Naval Medical Center Portsmouth

Post-acute COVID-19 is a syndrome characterized by the persistence of clinical symptoms beyond 4 weeks from the onset of acute symptoms. Over 250,000 Department of Defense service members have recovered or are recovering from acute COVID-19, and the range of symptoms and physiological changes can impact the medical readiness of military service members. Understanding the chronic illness among some of the active-duty personnel with this virus is needed to begin finding treatments to reduce their symptoms and improve their health outcomes. This was a longitudinal, descriptive study designed to examine the prevalence and persistence of the symptoms of active-duty military persons who have post-COVID-19 syndrome. We obtained data from electronic health records (EHRs) of clinics and hospitals of the armed services from U.S. military bases. The de-identified data set came from the Department of Defense Military Health System Data Repository (MDR) which is a centralized data repository established to capture, archive, validate, integrate, and distribute Defense Health Agency (DHA) data worldwide. The most prevalent symptom was pulmonary related, affecting 22.4 % of individuals with post-COVID-19 syndrome. The second most prevalent symptom was neurological problems (14.6 %), followed by fatigue (13.5 %), digestive issues (12.5 %), and fever (11.5 %). Approximately 3.7 % of military personnel with post-COVID-19 experienced cognitive symptoms however, they had the greatest persistence, followed by pulmonary related, fatigue, and neurological symptoms. Based on the symptoms identified, finding treatments for post-COVID-19 syndrome is needed particularly for military personnel to maintain fitness and readiness.

Abstract Aims Free tissue transfer is a common plastic surgical procedure with a wide array of applications. There is limited consensus on how free flap ischaemia time impacts flap survival. This systematic review aims to evaluate the association between free flap ischaemia time and acute flap failure rate. Methods A systematic review and meta-analysis in compliance with PRISMA statement standards was conducted following registration on the PROSPERO Register (CRD420251052841). A search strategy was developed and the search conducted in September 2024. Studies eligible for inclusion reported length of ischaemia time for free flap surgery and acute flap failure rate. 78 articles were eligible for inclusion and were published between 1997 and 2024. Study populations ranged from 7 to 3926 patients, with a pooled total of 26 374 free flaps in 23 615 patients. The meta-analysis showed overall risk of flap failure was 3.5% (95% c.i. 3%–4.1%). Meta-regression using ischaemia time as a continuous variable showed an increasing risk of acute flap failure from 3% (2.3%–3.9%) at 30 min ischaemia time to 7.5% (4.4%–12.5%) at 240 min. The variables study type, flap type, indication and risk of bias did not account for between study heterogeneity which was substantial. Conclusions This study has systematically assessed existing literature to show a significant association between prolonged ischaemia time and acute free flap loss. This association can guide microsurgical training as carrying out microsurgery in a time efficient manner has a positive impact on free flap survival.

<title>Abstract</title> Purpose: Treatment fidelity is important for both research and clinical practice, including adapting new approaches for group delivery of Brief Cognitive Behavioral Therapy (G-BCBT) for suicide prevention. This study describes the development and preliminary field test of 12 fidelity assessment instruments (FAIs) for G-BCBT, for use in a non-inferiority trial comparing G-BCBT to Dialectical Behavioral Therapy (DBT) skills group. Method: This study included 141 active-duty service members (69 male, 72 female). Participants were randomized to one of two conditions with a total of 10 G-BCBT and 10 DBT group therapy cohorts. Twelve G-BCBT FAIs were developed (one per session) and used by two expert raters to evaluate G-BCBT fidelity. Results: Range of percent agreement was high among expert raters, with 86.3% of agreement scores exceeding 85%. Results for inter-rater reliability were mixed with several scores reflecting perfect agreement and others achieving fair to moderate levels of agreement. However, most inter-rater reliability metrics demonstrated less than chance levels of agreement, suggesting possible halo or ceiling effects. Conclusion: Initial field testing of G-BCBT FAIs provided mixed support for use. Recommendations to improve FAI use and inter-rater reliability metrics are discussed as well as directions for future research.

Operational experience from the Russo-Ukrainian War revealed frequent use of tourniquets that were not medically indicated and an increase in ischemic complications from prolonged tourniquet application as a consequence of extended evacuation times. In response to this, the Committee on Tactical Combat Casualty Care (CoTCCC) convened a working group to evaluate whether tourniquet reassessment and conversion practices should extend to the All Service Member (ASM) level. With input from NATO and partner nations, the Working Group developed a standardized, time-based algorithm that provides plain language guidance for reassessment, repositioning, and conversion. The proposed change replaces the term replacement with repositioning, affirms a reassessment window within 2 hours for nonmedical personnel, and limits conversion beyond 2 hours to medical personnel. These updates will expand lifesaving capability to nonmedical responders, reduce preventable morbidity and mortality from tourniquet use, and align TCCC principles with current operational realities.

Anterior cervical discectomy and fusion (ACDF) is a common procedure in the United States. Unanticipated postoperative reintubation after ACDF is a rare but serious complication associated with increased morbidity, mortality, and health care costs. This study identifies risk factors for reintubation after ACDF using a large, contemporary cohort. This retrospective cohort study examined demographic, clinical, and operative variables associated with unanticipated reintubation within 2 days of ACDF surgery using 2017 to 2022 data from the American College of Surgeons National Surgical Quality Improvement Program. Univariate analyses explored the relationship between variables and reintubation. Variables with P<0.15 were included in a multivariable model using logistic regression. Unanticipated reintubation occurred in 101 (0.2%) of 41,398 patients. Associated factors identified by univariate analysis included age, sex, race, operative time, corpectomy, number of vertebrae fused, posterior approach, ASA-PS, functional status, and select comorbidities. Using a multivariable model, independent risk factors for reintubation included older age (OR: 1.03, 95% CI: 1.01-1.06), male sex (OR: 1.59, 95% CI: 1.05-2.40), Black race (OR: 2.72, 95% CI: 1.73-4.30), longer operative time (OR per hour 1.20, 95% CI: 1.05-1.36), corpectomy (OR: 2.58, 95% CI: 1.67-3.98), procedures involving 3 or more levels (OR: 1.56, 95% CI: 1.00-2.44), and dependent functional status (OR: 2.99, 95% CI: 1.54-5.79). This study identified several surgical and nonmodifiable patient risk factors for reintubation after ACDF, which may aid in risk stratification to guide preoperative counseling, surgical planning, and patient disposition. Further research is needed to explore mitigation strategies and the association between race and reintubation.

Pseudohyponatremia is a laboratory artifact in which serum sodium levels appear falsely low despite normal serum osmolality. It typically occurs in the presence of hypertriglyceridemia or paraproteinemia, but this case highlights a rare etiology: inadvertent intravenous injection of an oil-diluted anabolic steroid. A 42-year-old healthy man presented to the emergency department with nausea, vomiting, and presyncope. He reported injecting trenbolone intramuscularly three days prior and noted blood aspiration before injection, suggesting possible intravenous administration. He denied other recent illnesses or exposures. On examination, he was afebrile, hemodynamically stable, and non-toxic, with an unremarkable physical exam. Initial laboratory results revealed a serum sodium level of 125 mmol/L. However, the measured serum osmolality was 289 mOsm/kg while the calculated osmolality was 259 mOsm/kg, revealing an osmolal gap. A point-of-care iSTAT revealed a sodium level of 137 mmol/L, indicating true normonatremia and supporting the diagnosis of pseudohyponatremia. Additional labs showed erythrocytosis, consistent with anabolic steroid use, and no evidence of hypertriglyceridemia or paraproteinemia. Nephrology was consulted due to concern for symptomatic hyponatremia. With a normal measured osmolality, normal lipid and protein levels, and a history of recent anabolic steroid injection, the low serum sodium level was attributed to a laboratory artifact resulting from nonaqueous solvent interference. The patient was admitted for observation and remained stable, with improving symptoms and normalizing labs. Serum sodium by main-lab indirect analysis was 136 mmol/L by the time of discharge on hospital day two. He was discharged with outpatient follow-up. In patients with unexplained hyponatremia and normal clinical status, pseudohyponatremia must be considered. Prompt recognition can prevent unnecessary treatments, reduce patient risk, and guide appropriate care.

PurposeFemoroacetabular impingement syndrome (FAIS) can lead to pain, decreased mobility, and difficulty in performing activities of daily living. Symptoms can improve with surgery, often hip arthroscopy with osteoplasty. Radiological parameters such as the alpha angle can be utilized to determine the degree of cam morphology and assess resection after surgery. This study sought to evaluate the relationship between pre-operative alpha angle and the change in alpha angle on patient satisfaction post-surgical correction using the 12-item International Hip Outcome Tool (iHOT-12).Patients and MethodsPatients that underwent primary or revision hip arthroscopy with osteoplasty for FAIS by a single fellowship-trained surgeon at a tertiary academic center from September 1, 2014 to April 1, 2024 were eligible for this retrospective cohort study. Data collected included type of operation, preoperative and postoperative alpha angle, 6-month iHOT-12 scores, and demographic data. Multivariate proportional odds regression analyses were conducted to assess whether preoperative alpha angle and the change in alpha angle from pre- to post-operative were predictive of 6-month iHOT-12 scores. Additionally, Pearson correlation coefficients were reported for 6-month iHOT-12 association with preoperative alpha angle and alpha angle delta.Results507 patients and 541 operative hips were identified during the study period. 99 (18%) hips were included in the final analysis. Mean alpha angle was 60.9 (SD = 9.8) preoperatively and 44.4 (SD = 6.1) postoperatively with a mean absolute change of 16.5 (SD = 8.6). The mean 6-month iHOT-12 score was 62.0 (SD = 26.9). Multivariate proportional odds regression analyses did not reveal significant predictors of 6-month iHOT-12 scores including preoperative alpha angle and alpha angle change.ConclusionThis study found no association between preoperative alpha angle or postoperative change in alpha angle and 6-month iHOT-12 scores. Future research on other factors such as three-dimensional morphology may be warranted.

BackgroundInjuries rank among the top 5 leading causes of death worldwide with 90% of all injury-related deaths occurring in low- and middle-income countries. Up to 70% of injuries are potentially preventable. One approach to inform strategies to reduce post-injury mortality is expert-led trauma death reviews. The objective of this study is to present the results of an expert review of decedent cases and the associated recommendations for health system improvement.MethodsA cohort of trauma decedents from 2023 was identified from an ongoing study in the Western Cape Province of South Africa. Demographics, injury details, time and location of death, and postmortem findings were collected. In April 2024, a multi-disciplinary expert panel determined preventability for each death and made actionable recommendations for improvements. Analysis of preventable and non-preventable cases was performed using Chi-square, Fisher’s exact, and Wilcoxon signed rank tests. A rapid qualitative analysis of recommendations was completed and descriptively summarized.Results210 deaths were reviewed by 30 expert panelists. The largest proportion of deaths were from assaults (39%), followed by gunshot injuries (29%). Overall, 33% of deaths were classified as preventable or potentially preventable. Of the 161 in-hospital and ambulance deaths, 64 (39%) were preventable or potentially preventable. The largest proportion of preventable deaths were from haemorrhage (27, 39%) and multi-organ failure or sepsis (25, 36%). The majority (100, 62.1%) of deaths occurred in an emergency centre. Top recommendations from the panel were: development of protocols for diagnosis and management of severe head injuries, context appropriate and accessible trauma training for all frontline providers particularly junior physicians, improved access to diagnostic CT imaging and operating theatres at non-tertiary facilities, and community initiatives to reduce interpersonal violence.ConclusionOne-third of deaths were preventable or potentially preventable, demonstrating a decrease from a review of 2021 trauma deaths in the same system which found 45% to be preventable. Findings highlight a continued need to increase training and strategic utilization of limited existing resources, such as CT and operating theatres, to improve the quality of trauma care. Preventable trauma death reviews are a powerful methodology to inform actionable change.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12889-025-25139-0.

The National Response Framework (NRF) provides a guideline on how the USA responds to disasters and emergencies.1 The NRF is designed as a tiered response such that incidents are handled at the lowest level. It states that it is built on scalable, flexible and adaptable concepts identified in the National Incident Management System.2 Globalisation, whether by its inherent structure or the effect of the disaster itself, no longer geographically limits the extent of today's disasters. Climate change, international economic integration, supply chain infrastructure, cyberattacks, infectious diseases, ease of travel and various national political interests change the way the NRF needs to address disaster preparedness, response, recovery and mitigation strategies. While the NRF approach begins at the lowest level, there needs to be simultaneous preparation at the highest levels, recognising that the impacts of disasters, as in much of the rest of the world, are no longer limited by borders. This article is also included in The Business & Management Collection which can be accessed at https://hstalks.com/ business/.

Youth with a parent in the U.S. military are more likely than their peers without a parent in the military to report suicidal ideation, plans, and attempts. Firearm access increases risk for suicide mortality among youth; yet, an understanding of firearm access and behaviors among military-connected youth is lacking. The objective of this study is to evaluate firearm access, carrying, and storage among military-connected youth and identify differences with non-military-connected youth. We conducted a systematic review of peer-reviewed articles and abstracts published through January 31, 2025, focusing on firearm access, carrying, and storage among military-connected youth. We searched Ovid MEDLINE(R), PsycInfo, Embase, Web of Science, Google Scholar, and the reference lists from the assembled articles. This study was approved by the Colorado Multiple Institutional Review Board. We identified 7 studies that examined firearm carrying among military-connected youths, 0 studies examining firearm access, and 0 studies examining firearm storage. Although findings were mixed, most studies indicated an increased risk of firearm carrying among military-connected youths compared with their peers, particularly in the context of parental deployment. Current evidence suggests that military-connected youth may be at increased risk for firearm carrying, which portends higher risk for firearm injury, including suicide. However, there are substantial gaps in the literature, particularly regarding firearm access and storage. Future study of military-connected youth should prioritize comprehensive data collection, to inform and optimize effective interventions designed to benefit military-connected youth.