Military medicine
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Nerve agents have emerged as a global threat since their discovery in the 1930s, posing severe risks due to their inhibition of acetylcholinesterase and the subsequent accumulation of acetylcholine in nerve synapses. Despite the enforcement of the Chemical Weapon Convention to control chemical weapons, including nerve agents, recent events, such as the Novichok attacks on Sergei Skripal and Alexei Navalny, have highlighted the persistent threat. Novichok, a distinct class of nerve agents, raises specific concerns regarding its management due to limited understanding. This article aims to comprehensively analyze existing literature. ⋯ This review highlights the significant uncertainties and knowledge gaps surrounding the management of patients poisoned with Novichok. While some aspects align with other nerve agents, limited research likely due to safety and ethical challenges leads to assumptions and uncertainties in patient care. The review identifies areas with ongoing research, such as decontamination and biomarker recognition, while other aspects remain understudied. The possible inefficacy of current treatment options and the need for further research on oximes, bioscavengers, and long-term effects emphasize the necessity for increased research to optimize patient outcomes. More studies are essential to clarify the actual threat and toxicity of Novichok. Moreover, raising awareness among medical staff is crucial for early diagnosis, prompt treatment, and safety. This review offers valuable insights into managing Novichok-poisoned patients and calls for increased research and awareness in this critical area.
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Multicenter Study
Implementation of an International Severe Infection Point-of-Care Ultrasound Research Network.
Point-of-care ultrasound (POCUS) is a rapid, readily available, and cost-effective diagnostic and prognostic modality in a range of clinical settings. However, data to support its clinical application are limited. This project's main goal was to assess the effectiveness of standardizing lung ultrasound (LUS) training for sonographers to determine if universal LUS adoption is justified. ⋯ POCUS training and implementation proved feasible in diverse research settings among a range of providers. Standardization across ongoing cohort protocols affords opportunities for increased statistical power and generalizability of results. These results potentially support care delivery by enabling military medics to provide care at the point of injury, as well as aiding frontline clinicians in both austere and highly resourced critical care settings.
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Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in both adult civilian and military populations. Currently, diagnostic and prognostic methods are limited to imaging and clinical findings. Biomarker measurements offer a potential method to assess head injuries and help predict outcomes, which has a potential benefit to the military, particularly in the deployed setting where imaging modalities are limited. We determine how biomarkers such as ubiquitin C-terminal hydrolase-L1 (UCH-L1), glial fibrillary acidic protein (GFAP), S100B, neurofilament light chain (NFL), and tau proteins can offer important information to guide the diagnosis, acute management, and prognosis of TBI, specifically in military personnel. ⋯ TBI occurs frequently in the military and civilian settings with limited methods to diagnose and prognosticate outcomes. We highlighted several promising biomarkers for these purposes including S100B, UCH-L1, NFL, GFAP, and tau proteins. S100B and UCH-L1 appear to have the strongest data to date, but further research is necessary. The robust data that explain the optimal timing and, more importantly, trending of these biomarker measurements are necessary before widespread application.
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Combat-related wound infections complicate the recovery of wounded military personnel, contributing to overall morbidity and mortality. Wound infections in combat settings present unique challenges because of the size and depth of the wounds, the need to administer emergency care in the field, and the need for subsequent treatment in military facilities. Given the increase in multidrug-resistant pathogens, a novel, broad-spectrum antibiotic is desired across this continuum of care when the standard of care fails. Omadacycline was FDA-approved in 2018 for treatment of adults with acute bacterial skin and skin structure infections (ABSSSI), as well as community-acquired bacterial pneumonia (CABP). It is a broad-spectrum antibiotic with activity against gram-positive, gram-negative, and atypical bacterial pathogens, including multidrug-resistant species. Omadacycline can overcome commonly reported tetracycline resistance mechanisms, ribosomal protection proteins, and efflux pumps, and is available in once-daily intravenous or oral formulations. In this review, we discuss the potential role of omadacycline, which is included in the Department of Defense Formulary, in the context of combat wound infections. ⋯ Omadacycline has broad-spectrum activity, the option to be orally administered and an established safety profile, making it a potentially attractive replacement for moxifloxacin in the military individual first aid kit, especially when accounting for the increasing resistance to fluoroquinolones. Further studies and clinical evaluation are warranted to support broader use of omadacycline to treat combat wound infections in the military healthcare system.
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Exertional heat stroke (EHS), which presents with extreme hyperthermia and alteration to the central nervous system, disproportionately affects the military, where warfighters are expected to perform in all types of environmental conditions. Because of an incomplete understanding of individualized recovery from EHS, there are several shortcomings with the current guidance on return to duty (RTD) following an EHS. The purpose of this manuscript is to provide an updated literature review of best practices for return to duty following EHS to guide decision making regarding EHS and explore areas of future research for medical staff who work with warfighters. ⋯ EHS has a high morbidity and mortality rate if not treated rapidly. Because the extent of end-organ damage is dependent on the amount of time that the individual is hyperthermic, rapid diagnosis via rectal thermometry, and efficient cooling methods are imperative to the wellbeing of EHS patients. Following EHS, gradual RTD recommendations within the limits of operational demand should be implemented to reduce the risk for a subsequent heat injury event. While many versions of HTT, most notably the Israeli Defense Force (IDF) protocol, have been created to guide RTD recommendations, a universal assessment for heat tolerance has yet to be adopted. As such, medical personnel should apply a multifactorial approach to ensure safe RTD.