United States Army War College

Abstract Background Squamous cell carcinoma (SCC) of the gallbladder is a rare and aggressive malignancy, accounting for 1–3% of all gallbladder cancers. It typically presents at an advanced stage due to nonspecific symptoms and is characterized by rapid local invasion. Surgical resection remains the primary treatment, though prognosis is poor, with most patients surviving less than one year. Case A 70-year-old woman presented with severe epigastric pain radiating to the right upper quadrant, worsened by fatty food intake, along with nausea, vomiting, and weight loss. On examination, she had epigastric tenderness and a positive Murphy’s sign. CTAP revealed obstructive hepatic duct dilatation. She underwent three ERCPs for CBD stones while awaiting cholecystectomy. Recurrent admissions with right upper quadrant pain prompted further imaging, which showed an ill-defined hypodense area in the gallbladder fossa extending into the adjacent liver, suspicious for malignancy. Ultrasound-guided biopsy and histopathology confirmed a malignant epithelial neoplasm composed of nests of atypical squamous cells with nuclear pleomorphism, keratin pearls, and desmoplastic stroma, consistent with metastatic squamous cell carcinoma. The case was discussed at MDT, and she was referred to a tertiary centre for further management. Discussion SCC of the gallbladder may arise from chronic inflammation and squamous metaplasia, often associated with gallstones. It mimics adenocarcinoma symptomatically but has more aggressive local invasion. Diagnosis is usually histological. Radical surgery is the mainstay, though often not feasible due to late detection. Conclusions This case highlights the need for early suspicion of gallbladder malignancy in high-risk patients with chronic biliary disease.

ABSTRACT The ability to adapt to a constantly evolving security environment has been critical to the success of NATO, yet this is being tested anew as the Alliance faces a second term of Donald Trump in the White House and re-embraces collective defence in light of Russia’s war on Ukraine. Despite notable solidarity and unity in the immediate aftermath of the Russian invasion and significant progress in rebuilding the Alliance’s defence and deterrence architecture, the list of challenges facing the NATO Alliance is significant. This paper focuses on four of the most critical gaps: in the fields of command structure, military capabilities, force posture, and asymmetric defence. It also offers actionable recommendations for progress in advance of NATO’s Hague Summit in June 2025.

Abstract The NATO defence planning process identifies the capabilities needed to meet the Alliance’s agreed tasks; force generation ensures those capabilities accord with NATO’s level of operational ambition. Uncertainty in the security environment along with NATO enlargement have complicated both these tasks. Complicating matters further is a familiar institutional logic: NATO is comprised of subgroups of allies whose interests diverge, alongside an organizational bureaucracy with robust institutional interests. Decision-making in NATO is inter-governmental in nature. And this poses a problem of collective action. The members of NATO aim to protect their national interests while bureaucratic actors strive to advance institutional concerns. This can result in a discrepancy between the levels and types of military capabilities that NATO needs and what actually materializes from NATO defence planning and force generation. Allies claim to want greater NATO efficiency but not, seemingly, at the cost of greater infringements upon national sovereignty.

PurposeResearchers piloted a problem-based learning (PBL) activity in a master’s degree-granting strategic studies program to explore how students apply knowledge and skills learned from the curriculum to their formulation of a strategy addressing a real-world global security scenario.Design/methodology/approachThis mixed-methods pilot study used ethnographic observation, participant feedback, document analysis and surveys to assess the learning and engagement of multinational postgraduate students in the context of a PBL environment.FindingsFindings revealed gaps in students’ causal logic and literacy, as well as student discomfort with ambiguity and reliance upon heuristic frameworks over willingness to conduct substantive, current and relevant research. Additionally, observed group dynamics represented a lack of inclusive collaboration in mixed gender and multinational teams. These findings suggest foundational issues with the curriculum, teaching methodologies and evaluation practices of the studied institution.Originality/valueThis study highlights the need to include explicit instruction in problem-solving and causal literacy (i.e. logical reasoning) in postgraduate programs for national and global security professionals, as well as authentic opportunities for those students to practice interpersonal communication.

ABSTRACT Military ethics seeks to provide practical guidance for the resolution of real ethical problems associated with the conduct of military operations. In doing so, it must reflect how actual persons give and take-up reasons when deliberating what actions to take. The Just War Tradition, for example, provides deontological and consequentialist considerations soldiers should take up when considering how to conduct operations. Sometimes, unfortunately, soldiers may find themselves in tragic situations where principles and consequences provide no clear guidance. To fill that gap, a full account of military ethics requires an account of virtue, which focuses more on the agent than the act and can provide resources necessary to avoid, or failing that, resolve, otherwise unresolvable ethical dilemmas that can arise during military operations. This point does not mean virtue ethics supersedes or assimilates other ethical approaches. Rather it means that in the context of a process aimed at establishing reflective equilibrium, it provides important beliefs, judgments, and ways of thinking about applied ethics that are critical not just to building a robust, maximally coherent equilibrium but also to maintain it. These resources are especially critical when one is faced with the kind of tragic situations soldiers confront in war.

The concept of soft power, that is the influence attained through the co-option of foreigners by the attractiveness of our values, ideas, and practices, understandably has great appeal.Soft power is much cheaper than the hard power of military force, and it is more compatible with the culture of a principally liberal American society.All too often, military force seems to fail as an instrument of policy and, as a consequence, it invites the view that it is becoming obsolescent and even anachronistic.Dr. Colin Gray subjects hard and soft power to close critical scrutiny and finds that the latter is significantly misunderstood and, as a consequence, misassessed as a substitute for the threat or use of military force.Each kind of power has its limitations, but the obvious and familiar challenges characteristic of military force do not mean that therefore soft power should be our policy instrument of choice.