Daniel Dyball

Background: Military personnel are at increased risk of traumatic brain injury (TBI). However, the late effects of injury on cognition, psychiatric symptoms and function remain unclear. The UK ADVANCE cohort, comprising 1144 male service personnel deployed to Afghanistan, of whom half were exposed to major combat-related physical trauma, was established to clarify long-term outcomes.Methods: Assessments performed on 1018/1144 participants a median of 13·7 years (IQR 12·5-15·0) post-injury included TBI ascertainment, neuropsychological testing, psychiatric and functional outcome questionnaires, and advanced brain MRI. Outcomes were related to injury severity, with voxel-based morphometry and diffusion tensor imaging quantifying brain morphometry and microstructure. Findings: Among 514 trauma-exposed participants, 306 (60%) sustained a battlefield TBI. 81 (15·8%) experienced moderate-severe (definite), 144 (28·0%) mild (probable), and 81 (15·8%) symptomatic (possible) TBI. Compared with Uninjured personnel (n=504), moderate-severe TBI was associated with multidomain cognitive deficits, including executive function (CWIT Inhibition/Switching: B=-5·44, 95% CI -8·86 to -2·07), attention (RBANS: B=-8·11, 95% CI -11·92 to -4·29), and delayed memory (RBANS: B=-4·0, 95% CI -7·42 to -0·91). Psychiatric symptoms and perceived health differed across injured groups. Unemployment risk was elevated across all injured groups and greatest after moderate-severe TBI (RR 10·74, 95% CI 5·86-19·68). Regional grey and white matter volume differed by injury severity, with modest differences in fractional anisotropy following moderate-severe TBI.Interpretation: TBI was common among combat trauma-exposed personnel. Moderate-severe TBI was associated with multidomain cognitive deficits, the largest unemployment risk, and structural brain changes persisting into the chronic phase post-injury. This highlights the need for targeted rehabilitation and long-term follow-up in service personnel.

Introduction: The consequences of serious physical traumatic injury may require pharmacological intervention, however long-term use and polypharmacy can increase risk of morbidity/mortality. This study aims to describe prescription medication use in a cohort of UK Armed Forces personnel who sustained physical combat injuries during the Afghanistan conflict (injured group) compared to demographically similar personnel without such injuries (uninjured group) a median of 11 years post injury. Methods: One thousand and fifty one participants of the ADVANCE cohort (injured group n = 526 uninjured group n = 525), including individuals with (n = 141) and without ( n = 384) limb loss or with (n = 226) and without ( n = 300) deployment-related Traumatic Brain Injury (TBI), reported medication use during a clinical interview. Overall incidence of prescribing any medication, specific anatomical/therapeutic classes (e.g., Central Nervous System (CNS), psychotropic or analgesic) and medications with pain or mental health indications were investigated. General (≥5 medications), CNS (≥5), psychotropic (≥2) and analgesic (≥2) polypharmacy was also investigated. Results: Compared to the uninjured group, the injured group reported a greater prevalence of prescription medication use (17.8% vs. 29.7%), including medications acting on the CNS (8.0% vs. 17.2%), psychotropics (6.3% vs. 11.8%) and analgesics (2.2% vs. 8.6%). Prevalence of polypharmacy was very low in the cohort (0%–4.4%). Incidence Rate Ratios (IRR) and 95% confidence intervals indicated that injured personnel were currently using on average over twice as many prescription medications as those in the uninjured group (IRR 2.15 (1.66, 2.92)), including medications acting on the CNS (IRR 2.67 (1.77, 4.08)), and psychotropics (IRR 2.03 (1.27, 3.25)). Similar elevations were present in those injured with and without limb loss and especially elevated in those with deployment-related TBI. Use of psychotropics amongst personnel injured with limb loss were predominantly for non-mental health indications (e.g., sleep, pain). Conclusion: Pharmacological intervention is not uncommon amongst UK Armed Forces personnel who sustained serious physical injuries, but the prevalence of polypharmacy is low. Effective prescribing practices should ensure optimal recovery whilst minimising the risk of adverse events.

Background: Given the burden and rising number of injuries from recent conflict zones such as Ukraine and the Middle East, understanding the long-term health outcomes of those with physical traumatic injuries is critical. This analysis investigates the psychosocial outcomes of UK Armed Forces personnel who sustained such injuries during deployments to Afghanistan and how traumatic amputation and Traumatic Brain Injury (TBI)) affect these outcomes. Methods: This analysis used data from a prospective cohort (ADVANCE), which consists of an injured group who sustained physical combat injuries (n=526) and a frequency-matched, demographically similar uninjured group (n=526), a median of 11 years following injury. The risk of reporting alcohol misuse, generalised anxiety, depression, Post-Traumatic Stress Disorder (PTSD) and mental health multimorbidity from validated questionnaires was determined relative to the uninjured group for injury profiles including with (n=141) and without (n=385) limb loss or with deployment-related TBI (n=222) of varying severity (mild TBI n=147; moderate-severe TBI n=75). Findings: Compared to being uninjured, sustaining a physical combat injury increased the risk of reporting generalised anxiety by 92% (Risk Ratio (RR) 1·92 (95% Confidence Interval (CI) 1·40, 2·95)), depression by 78% (RR 1·78 (CI 1·37, 2·44)), PTSD by 100% (RR 2·00 (CI 1·39, 3·00)) and mental health multimorbidity by 105% (RR 2·05 (CI 1·35, 3·16)). Being injured with associated limb loss resulted in small/inconclusive effects on mental health outcomes (24%-36% increased risk), whereas larger effects were observed in those injured without limb loss (95%-132% increased risk) and those who sustained a deployment-related TBI (108-156% increased risk; mild TBI 153%-174%; moderate-severe TBI 60%-123%). All injury types investigated were associated with only small/inconclusive risk ratios for reporting alcohol misuse. Interpretation: Specific injury profiles, namely deployment-related TBI or injuries without limb loss, elevated risk of poor mental health outcomes amongst UK Armed Forces personnel..

Purpose: Physical traumatic injuries are likely to impact on a person’s Health-Related Quality of Life (HRQOL). We present data on HRQOL, from which EQ-5D-5L index scores are derived, and overall perceived health in UK Armed Forces personnel who sustained serious physical combat injuries and compare them to demographically similar personnel without such injuries (uninjured group). To ensure that perception of HRQOL is similar between groups, we also assess for measurement bias through Differential Item Functioning (DIF). Methods: 577 personnel in an injured group (including subgroups of limb amputation injuries (n = 160) and non-amputation injuries (n = 417)) and 564 personnel in the uninjured group who sustained no such injuries were assessed in the ADVANCE cohort study. Health index values were derived from the EQ-5D-5L, overall perceived health from the EQ-visual analogue scale, and mobility from a Six-Minute Walk Test (6MWT). DIF was identified using multiple indicator multiple causes modelling. Results: Compared to the uninjured group, personnel injured with associated limb loss had significantly higher likelihood of reporting low health index scores (Relative Risk Ratio (RRR) 7.18 (95% Confidence Interval (CI) 4.25, 12.29; relative to high health index scores)), however no difference in the probability of reporting low or moderate overall perceived health, relative to high, was observed. Those injured without limb loss had a significantly higher probability of reporting low health index values (RRR 3.58 (95%CI 2.57, 5.03)) and low overall perceived health (RRR 1.91 (95%CI 1.34, 2.66)). Measurement bias was observed in items regarding mobility and anxiety/depression for those injured with associated limb loss and self-care for those with injured without. Differences in 6MWT only partially explained the bias observed in the mobility item. Conclusion: Personnel who experience serious traumatic injuries perceive aspects of HRQOL differently to personnel who experience no such injuries, with heterogenous biases expressed depending on presence of limb amputation. Researchers evaluating HRQOL in health interventions may need to account for this bias if comparing individuals with different traumatic injuries/conditions.

Objectives Over 600 UK Armed Forces personnel and civilians were seriously injured in the conflict in Afghanistan. We examined whether combat injury, and limb loss specifically, reduced the likelihood of employment after leaving the UK Armed Forces and to what extent this was mediated by pain and mobility. Methods Combat-injured participants who were aeromedically evacuated to a UK hospital while on deployment to Afghanistan and subsequently left the UK Armed Forces (n=406) and a comparison group of uninjured personnel who had left the military (n=107) were drawn from an existing cohort (the ADVANCE study). Current employment was determined by self-report questionnaire, and pain and mobility mediating variables were taken from the EuroQol EQ-5D 5-Level measure. Results 21.2% of the injured group were not in paid employment, compared with 14.3% of the uninjured comparison group; this difference was not statistically significant. Unmediated analyses showed that although those with amputation injuries had an increased risk of being unemployed compared with the comparison group, this was not statistically significant. For those who were injured without limb loss, compared with the comparison group, there were indirect effects on employment through both mobility (adjusted risk ratio (aRR) 1.32, 95% CI 1.11 to 1.69) and pain (aRR 1.10, 95% CI 1.01 to 1.31). Conclusions In this severely injured cohort, combat injury does not result in a significantly reduced rate of post-military employment. Any potential relationship between injury and employment for those injured without limb loss compared with the uninjured is due in part to the mediating effects of mobility and pain.

The ADVANCE cohort study is a prospective cohort study investigating the impact of sustaining a serious physical combat injury whilst on deployment to Afghanistan on long-term health outcomes. The cohort will provide essential data on medical/psychosocial risk factors and outcomes associated with combat injury and establish injury-specific mechanisms of disease. Participants include UK Armed Forces personnel who sustained serious physical combat injuries and a frequency-matched comparison group who sustained no such injuries (uninjured group). The cohort consists of 1145 participants, with a baseline response rate of 59.6% for the injured group ( n = 579) and 56.3% for the uninjured group ( n = 566). The first follow up of this cohort retained 92% of the sample ( n = 1053/1145). This cohort profile describes the baseline and first follow up demographics for ADVANCE, as well as details on published research projects spanning military epidemiology, physical health, including cardiovascular, respiratory, musculoskeletal and neurological, mental health and health-related behaviours. These projects comprise identification of early risk factors for disease and observed differences in health-characteristics between groups. Since baseline assessment of the cohort, ADVANCE has expanded investigations across physical and mental health domains, utilising advice from participant engagement and an international scientific advisory group. Researchers working on the ADVANCE cohort continue to engage with policy makers, clinicians and participants to ensure a wide-ranging impact from work conducted. Registration : The ADVANCE Study is registered at ISRCTN ID: ISRCTN57285353.

Introduction: Globally, millions of people are forced to flee their home nation due to war, conflict, political instability, natural disasters or persecution every year. The detrimental psychological issues that refugees experience are well established, whilst research on positive psychological well-being, such as Post-Traumatic Growth, is limited. This systematic review and meta-analysis aims to synthesise the peer-reviewed literature which quantitatively measured PTG in refugees and Internally Displaced Persons (IDP) and present factors associated with PTG in this population.Methods: The following electronic databases were searched in September 2024: PsycInfo, Embase, OVIDmedline, Global Health, PubMed and Web of Science Core Collection. Studies were retained if they used quantitative measures of PTG and were published after 2000. The database search produced 914 studies.Results: 45 studies were included in the review and 21 were included in the meta-analysis. Studies generally reported a moderate to high degree of PTG in this population, but considerable heterogeneity in PTG was observed. Demographic (e.g. age, gender, employment, education and displacement type), mental health (e.g. depression, Post-Traumatic Stress Disorder (PTSD), hope, optimism) and coping styles (e.g. adaptive, maladaptive, problem-focussed, emotion-focussed, cognitive, social support and religiosity) were investigated as factors associated with PTG. Strength of evidence for factors associated with PTG was generally very low based on study limitations, inconsistency of evidence, imprecision and reporting bias; the strongest endorsement was present for younger age, a non-linear association between PTSD and PTG, social support and religiosity.Discussion: PTG may be a possible outcome for refugees and IDP, but current survey-based methods to measure PTG do not account for cultural differences in perceptions of growth. Good quality longitudinal research accounting for these differences is required for a better understanding of PTG, and how to elicit PTG in these populations.