United States Military Fatalities During Operation Inherent Resolve and Operation Freedom\u27s Sentinel.

BACKGROUND: Military operations provide a unified action and strategic approach to achieve national goals and objectives. Mortality reviews from military operations can guide injury prevention and casualty care efforts. METHODS: A retrospective study was conducted on all U.S. military fatalities from Operation Inherent Resolve (OIR) in Iraq (2014-2021) and Operation Freedom\u27s Sentinel (OFS) in Afghanistan (2015-2021). Data were obtained from autopsy reports and other existing records. Fatalities were evaluated for population characteristics; manner, cause, and location of death; and underlying atherosclerosis. Non-suicide trauma fatalities were also evaluated for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement. RESULTS: Of 213 U.S. military fatalities (median age, 29 years; male, 93.0%; prehospital, 89.2%), 49.8% were from OIR, and 50.2% were from OFS. More OIR fatalities were Reserve and National Guard forces (OIR 22.6%; OFS 5.6%), conventional forces (OIR 82.1%; OFS 65.4%), and support personnel (OIR 61.3%; OFS 33.6%). More OIR fatalities also resulted from disease and non-battle injury (OIR 83.0%; OFS 28.0%). The leading cause of death was injury (OIR 81.1%; OFS 98.1%). Manner of death differed as more homicides (OIR 18.9%; OFS 72.9%) were seen in OFS, and more deaths from natural causes (OIR 18.9%; OFS 1.9%) and suicides (OIR 29.2%; OFS 6.5%) were seen in OIR. The prevalence of underlying atherosclerosis was 14.2% in OIR and 18.7% in OFS. Of 146 non-suicide trauma fatalities, most multiple/blunt force injury deaths (62.2%) occurred in OIR, and most blast injury deaths (77.8%) and gunshot wound deaths (76.6%) occurred in OFS. The leading mechanism of death was catastrophic tissue destruction (80.8%). Most fatalities had non-survivable injuries (80.8%) and non-preventable deaths (97.3%). CONCLUSIONS: Comprehensive mortality reviews should routinely be conducted for all military operation deaths. Understanding death from both injury and disease can guide preemptive and responsive efforts to reduce death among military forces

Comparative effectiveness of TNF inhibitor vs IL-6 receptor inhibitor as monotherapy or combination therapy with methotrexate in biologic-experienced patients with rheumatoid arthritis: An analysis from the CorEvitas RA Registry

Objective Randomized controlled trials (RCTs) in biologic-naïve rheumatoid arthritis (RA) patients with high disease activity and inadequate response/intolerance to methotrexate have shown interleukin-6 (IL-6) receptor inhibitors (IL-6Ri) to be superior to tumor necrosis factor inhibitors (TNFi) as monotherapy. This observational study aimed to compare the effectiveness of TNFi vs IL-6Ri as mono- or combination therapy in biologic/targeted synthetic (b/ts) -experienced RA patients with moderate/high disease activity. Methods Eligible b/ts-experienced patients from the CorEvitas RA registry were categorized as TNFi and IL-6Ri initiators, with subgroups initiating as mono- or combination therapy. Mixed-effects regression models evaluated the impact of treatment on Clinical Disease Activity Index (CDAI), patient-reported outcomes, and disproportionate pain (DP). Unadjusted and covariate-adjusted effects were reported. Results Patients initiating IL-6Ri (n = 286) vs TNFi monotherapy (n = 737) were older, had a longer RA history and higher baseline CDAI, and were more likely to initiate as third-line therapy; IL-6Ri (n = 401) vs TNFi (n = 1315) combination therapy initiators had higher baseline CDAI and were more likely to initiate as third-line therapy. No significant differences were noted in the outcomes between TNFi and IL-6Ri initiators (as mono- or combination therapy). Conclusion This observational study showed no significant differences in outcomes among b/ts-experienced TNFi vs IL-6Ri initiators, as either mono- or combination therapy. These findings were in contrast with the previous RCTs in biologic-naïve patients and could be explained by the differences in the patient characteristics included in this study. Further studies are needed to help understand the reasons for this discrepancy in the real-world b/ts-experienced population

Telomere Shortening and Accelerated Aging in US Military Veterans

A growing body of literature on military personnel and veterans’ health suggests that prior military service may be associated with exposures that increase the risk of cardiovascular disease (CVD), which may differ by race/ethnicity. This study examined the hypothesis that differential telomere shortening, a measure of cellular aging, by race/ethnicity may explain prior findings of differential CVD risk in racial/ethnic groups with military service. Data from the first two continuous waves of the National Health and Nutrition Examination Survey (NHANES), administered from 1999–2002 were analyzed. Mean telomere length in base pairs was analyzed with multivariable adjusted linear regression with complex sample design, stratified by sex. The unadjusted mean telomere length was 225.8 base shorter for individuals with prior military service. The mean telomere length for men was 47.2 (95% CI: −92.9, −1.5; p < 0.05) base pairs shorter for men with military service after adjustment for demographic, socioeconomic, and behavioral variables, but did not differ significantly in women with and without prior military service. The interaction between military service and race/ethnicity was not significant for men or women. The results suggest that military service may contribute to accelerated aging as a result of health damaging exposures, such as combat, injury, and environmental contaminants, though other unmeasured confounders could also potentially explain the results

Establishing an enduring Military Trauma Mortality Review: Misconceptions and lessons learned.

Under direction from the Defense Health Agency, subject matter experts (SMEs) from the Joint Trauma System, Armed Forces Medical Examiner System, and civilian sector established the Military Trauma Mortality Review process. To establish the most empirically robust process, these SMEs used both qualitative and quantitative methods published in a series of peer-reviewed articles over the last 3 years. Most recently, the Military Mortality Review process was implemented for the first time on all battle-injured service members attached to the United States Special Operations Command from 2001 to 2018. The current Military Mortality Review process builds on the strengths and limitations of important previous work from both the military and civilian sector. To prospectively improve the trauma care system and drive preventable death to the lowest level possible, we present the main misconceptions and lessons learned from our 3-year effort to establish a reliable and sustainable Military Trauma Mortality Review process. These lessons include the following: (1) requirement to use standardized and appropriate lexicon, definitions, and criteria; (2) requirement to use a combination of objective injury scoring systems, forensic information, and thorough SME case review to make injury survivability and death preventability determinations; (3) requirement to use nonmedical information to make reliable death preventability determinations and a comprehensive list of opportunities for improvement to reduce preventable deaths within the trauma care system; and (4) acknowledgment that the military health system still has gaps in current infrastructure that must be addressed to globally and continuously implement the process outlined in the Military Trauma Mortality Review process in the future. LEVEL OF EVIDENCE: Level III

Nonfatal motor vehicle related injuries among deployed US Service members: Characteristics, trends, and risks for limb amputations.

BACKGROUND: Motor vehicle-related (MVR) incidents are important causes of morbidity among deployed US service members (SMs). Nonbattle MVR injuries are usually similar to civilian MVR injuries, while battle MVR injuries are often unique due to the blast effects from precipitating explosive mechanisms. Our primary objective was to describe the characteristics and trends of nonfatal MVR injuries sustained by deployed US SMs. A second objective was to assess the association between mechanism of injury (i.e., explosive vs. nonexplosive) and limb amputation. METHODS: We conducted a retrospective cross-sectional analysis using data from the Department of Defense Trauma Registry collected from October 2001 to December 2018. Descriptive statistics were reported stratified by mechanism of injury (explosive vs. nonexplosive). The association between mechanism of injury and limb amputation was assessed using logistic regression models. RESULTS: There were 3,119 US casualties who sustained nonfatal MVR injuries, 2,380 (76.3%) SMs sustained nonexplosive MVR injuries while 739 (23.7%) sustained explosive MVR injuries. Of all MVR casualties, 2,085 (66.9%) were in Iraq or Syria and 1034 (33.1%) in Afghanistan. The annual prevalence of nonfatal MVR battle casualties was highest in Iraq and Syria from 2003 to 2009 and Afghanistan from 2009 to 2014, ranging overall 15 to 50 MVR casualties per 1,000 wounded in action. There were 92 limb amputations associated with MVR incidents. Compared with nonexplosive MVR mechanisms, explosive MVR mechanisms had higher association with limb amputation (adjusted odds ratio, 2.6; confidence interval, 1.7-3.9), even after adjusting for injury year and Injury Severity Score (AOR, 2.1; confidence interval: 1.4-3.4). CONCLUSION: Motor vehicle-related incidents are an important cause of injury in US military operations. Compared with nonexplosive MVR incidents, explosive MVR incidents result in more severe injuries, and have a higher associated risk of limb amputation. Continued efforts to improve injury prevention through protective equipment and medical training specific to MVR injuries are needed. LEVEL OF EVIDENCE: Prognostic and epidemiological study, Level III

Nonfatal motor vehicle related injuries among deployed US Service members: Characteristics, trends, and risks for limb amputations

BACKGROUND: Motor vehicle-related (MVR) incidents are important causes of morbidity among deployed US service members (SMs). Nonbattle MVR injuries are usually similar to civilian MVR injuries, while battle MVR injuries are often unique due to the blast effects from precipitating explosive mechanisms. Our primary objective was to describe the characteristics and trends of nonfatal MVR injuries sustained by deployed US SMs. A second objective was to assess the association between mechanism of injury (i.e., explosive vs. nonexplosive) and limb amputation. METHODS: We conducted a retrospective cross-sectional analysis using data from the Department of Defense Trauma Registry collected from October 2001 to December 2018. Descriptive statistics were reported stratified by mechanism of injury (explosive vs. nonexplosive). The association between mechanism of injury and limb amputation was assessed using logistic regression models. RESULTS: There were 3,119 US casualties who sustained nonfatal MVR injuries, 2,380 (76.3%) SMs sustained nonexplosive MVR injuries while 739 (23.7%) sustained explosive MVR injuries. Of all MVR casualties, 2,085 (66.9%) were in Iraq or Syria and 1034 (33.1%) in Afghanistan. The annual prevalence of nonfatal MVR battle casualties was highest in Iraq and Syria from 2003 to 2009 and Afghanistan from 2009 to 2014, ranging overall 15 to 50 MVR casualties per 1,000 wounded in action. There were 92 limb amputations associated with MVR incidents. Compared with nonexplosive MVR mechanisms, explosive MVR mechanisms had higher association with limb amputation (adjusted odds ratio, 2.6; confidence interval, 1.7-3.9), even after adjusting for injury year and Injury Severity Score (AOR, 2.1; confidence interval: 1.4-3.4). CONCLUSION: Motor vehicle-related incidents are an important cause of injury in US military operations. Compared with nonexplosive MVR incidents, explosive MVR incidents result in more severe injuries, and have a higher associated risk of limb amputation. Continued efforts to improve injury prevention through protective equipment and medical training specific to MVR injuries are needed. LEVEL OF EVIDENCE: Prognostic and epidemiological study, Level III

United States military fatalities during Operation New Dawn

BACKGROUND: Military operations vary by scope, purpose, and intensity, each having unique forces and actions to execute a mission. Evaluation of military operation fatalities guides current and future casualty care. METHODS: A retrospective study was conducted of all US military fatalities from Operation New Dawn in Iraq, 2010 to 2011. Data were obtained from autopsies and other records. Population characteristics, manner of death, cause of death, and location of death were analyzed. All fatalities were evaluated for concomitant evidence of underlying atherosclerosis. Nonsuicide trauma fatalities were also reviewed for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement. RESULTS: Of 74 US military Operation New Dawn fatalities (median age, 26 years; male, 98.6%; conventional forces, 100%; prehospital, 82.4%) the leading cause of death was injury (86.5%). The manner of death was primarily homicide (55.4%), followed by suicide (17.6%), natural (13.5%), and accident (9.5%). Fatalities were divided near evenly between combatants (52.7%) and support personnel (47.3%), and between battle injury (51.4%) and disease and nonbattle injury (48.6%). Natural and suicide death was higher (p \u3c 0.01, 0.02) among support personnel who were older (p = 0.05) with more reserve/national guard personnel (p = 0.01). Total population prevalence of underlying atherosclerosis was 18.9%, with more among support personnel (64.3%). Of 46 nonsuicide trauma fatalities, most died of blast injury (67.4%) followed by gunshot wound (26.1%) and multiple/blunt force injury (6.5%). The leading mechanism of death was catastrophic tissue destruction (82.6%). Most had nonsurvivable injuries (82.6%) and nonpreventable deaths (93.5%). CONCLUSION: Operation New Dawn fatalities were exclusively conventional forces divided between combatants and support personnel, the former succumbing more to battle injury and the latter to disease and nonbattle injury including self-inflicted injury. For nonsuicide trauma fatalities, none died from a survivable injury, and 17.4% died from potentially survivable injuries. Opportunities for improvement included providing earlier blood products and surgery. LEVEL OF EVIDENCE: Therapeutic, level V and epidemiological, level IV

Patterns of Anatomic Injury in Critically Injured Combat Casualties: A Network Analysis.

A mortality review of death caused by injury requires a determination of injury survivability prior to a determination of death preventability. If injuries are nonsurvivable, only non-medical primary prevention strategies have potential to prevent the death. Therefore, objective measures are needed to empirically inform injury survivability from complex anatomic patterns of injury. As a component of injury mortality reviews, network structures show promise to objectively elucidate survivability from complex anatomic patterns of injury resulting from explosive and firearm mechanisms. In this network analysis of 5,703 critically injured combat casualties, patterns of injury among fatalities from explosive mechanisms were associated with both a higher number and severity of anatomic injuries to regions such as the extremities, abdomen, and thorax. Patterns of injuries from a firearm were more isolated to individual body regions with fatal patterns involving more severe injuries to the head and thorax. Each injury generates a specific level of risk as part of an overall anatomic pattern to inform injury survivability not always captured by traditional trauma scoring systems. Network models have potential to further elucidate differences between potentially survivable and nonsurvivable anatomic patterns of injury as part of the mortality review process relevant to improving both the military and civilian trauma care systems

Use of Combat Casualty Care Data to Assess the US Military Trauma System During the Afghanistan and Iraq Conflicts, 2001-2017.

IMPORTANCE: Although the Afghanistan and Iraq conflicts have the lowest US case-fatality rates in history, no comprehensive assessment of combat casualty care statistics, major interventions, or risk factors has been reported to date after 16 years of conflict. OBJECTIVES: To analyze trends in overall combat casualty statistics, to assess aggregate measures of injury and interventions, and to simulate how mortality rates would have changed had the interventions not occurred. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of all available aggregate and weighted individual administrative data compiled from Department of Defense databases on all 56 763 US military casualties injured in battle in Afghanistan and Iraq from October 1, 2001, through December 31, 2017. Casualty outcomes were compared with period-specific ratios of the use of tourniquets, blood transfusions, and transport to a surgical facility within 60 minutes. MAIN OUTCOMES AND MEASURES: Main outcomes were casualty status (alive, killed in action [KIA], or died of wounds [DOW]) and the case-fatality rate (CFR). Regression, simulation, and decomposition analyses were used to assess associations between covariates, interventions, and individual casualty status; estimate casualty transitions (KIA to DOW, KIA to alive, and DOW to alive); and estimate the contribution of interventions to changes in CFR. RESULTS: In aggregate data for 56 763 casualties, CFR decreased in Afghanistan (20.0% to 8.6%) and Iraq (20.4% to 10.1%) from early stages to later stages of the conflicts. Survival for critically injured casualties (Injury Severity Score, 25-75 [critical]) increased from 2.2% to 39.9% in Afghanistan and from 8.9% to 32.9% in Iraq. Simulations using data from 23 699 individual casualties showed that without interventions assessed, CFR would likely have been higher in Afghanistan (15.6% estimated vs 8.6% observed) and Iraq (16.3% estimated vs 10.1% observed), equating to 3672 additional deaths (95% CI, 3209-4244 deaths), of which 1623 (44.2%) were associated with the interventions studied: 474 deaths (12.9%) (95% CI, 439-510) associated with the use of tourniquets, 873 (23.8%) (95% CI, 840-910) with blood transfusion, and 275 (7.5%) (95% CI, 259-292) with prehospital transport times. CONCLUSIONS AND RELEVANCE: Our analysis suggests that increased use of tourniquets, blood transfusions, and more rapid prehospital transport were associated with 44.2% of total mortality reduction. More critically injured casualties reached surgical care, with increased survival, implying improvements in prehospital and hospital care

The effect of prehospital transport time, injury severity, and blood transfusion on survival of US military casualties in Iraq.

BACKGROUND: Reducing time from injury to care can optimize trauma patient outcomes. A previous study of prehospital transport of US military casualties during the Afghanistan conflict demonstrated the importance of time and treatment capability for combat casualty survival. METHODS: A retrospective descriptive analysis was conducted to analyze battlefield data collected on US military combat casualties during the Iraq conflict from March 19, 2003, to August 31, 2010. All casualties were analyzed by mortality outcome (killed in action, died of wounds, case fatality rate) and compared with Afghanistan conflict. Detailed data for those who underwent prehospital transport were analyzed for effects of transport time, injury severity, and blood transfusion on survival. RESULTS: For the total population, percent killed in action (16.6% vs. 11.1%), percent died of wounds (5.9% vs. 4.3%), and case fatality rate (10.0 vs. 8.6) were higher for Iraq versus Afghanistan (p \u3c 0.001). Among 1,692 casualties (mean New Injury Severity Score, 22.5; mortality, 17.6%) with detailed data, the injury mechanism included 77.7% from explosions and 22.1% from gunshot wounds. For prehospital transport, 67.6% of casualties were transported within 60 minutes, and 32.4% of casualties were transported in greater than 60 minutes. Although 97.0% of deaths occurred in critical casualties (New Injury Severity Score, 25-75), 52.7% of critical casualties survived. Critical casualties were transported more rapidly (p \u3c 0.01) and more frequently within 60 minutes (p \u3c 0.01) than other casualties. Critical casualties had lower mortality when blood was received (p \u3c 0.01). Among critical casualties, blood transfusion was associated with survival irrespective of transport time within or greater than 60 minutes (p \u3c 0.01). CONCLUSION: Although data were limited, early blood transfusion was associated with battlefield survival in Iraq as it was in Afghanistan. LEVEL OF EVIDENCE: Performance improvement and epidemiological, level IV