INTRODUCTION:Remotely piloted aircraft systems (RPAS) are integral to military operations. Although geographically removed from the battlefield, RPAS personnel are exposed to operational, organisational and moral stressors. This review synthesises evidence on the mental health and well-being of military RPAS personnel. METHODS:This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Cochrane methodology. The protocol was preregistered on PROSPERO. Searches were conducted in MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science, ScienceDirect and PILOTS for studies from January 2002 to June 2025. Peer-reviewed studies examining mental health outcomes among military RPAS personnel were included while grey literature and technical repositories were screened for context. Study quality was assessed using NICE (National Institute for Health and Care Excellence) public health guidance checklists. Given variation in study designs and outcome measures, findings were synthesised narratively. RESULTS:Fourteen studies met the inclusion criteria, comprising nine cross-sectional surveys, two retrospective record analyses, one cohort study, one physiological experiment and one qualitative study. The prevalence of probable post-traumatic stress disorder (PTSD) ranged from 3.3% to 6.7%, which is broadly comparable to other military populations. Psychological distress was reported in 13.0%-16.0% of personnel, and high emotional exhaustion in 25.0%-37.0%. Suicidal ideation ranged from 4.4% to 8.0%. Subthreshold PTSD symptoms, sleep disturbance and functional impairment were frequently reported. The identified risk factors were predominantly organisational rather than combat-related, including long working hours, shift instability, understaffing, role conflict and sleep disruption. Protective factors included leadership support, team cohesion, adequate sleep and positive help-seeking attitudes. CONCLUSIONS:RPAS personnel do not show significantly higher rates of diagnosable mental disorder than other military groups. However, they do experience considerable occupational strain. Across the literature, adverse outcomes were more often linked to chronic organisational stressors than to direct battlefield exposure. Future research should prioritise longitudinal designs, comparative cohorts and the evaluation of targeted occupational interventions. PROSPERO REGISTRATION NUMBER:CRD42022329937.
INTRODUCTION:Adequate nutrition and regular meal patterns are essential for maintaining metabolic health as well as optimal physical and cognitive function. Military conscripts represent a particularly vulnerable population due to the high physical and cognitive demands placed on them during basic combat training (BCT). We sought to identify the relationship between nutrition and dietary patterns before and during BCT and health-related variables. METHODS:A total of 96 female and 129 male conscripts completed questionnaires at baseline and after 5 months, assessing dietary habits and general health. Haemoglobin and ferritin were measured both at baseline and after 5 months of BCT. Physical work capacity was assessed at baseline, including an incremental multistage shuttle run test and a neuromuscular multitest. RESULTS:Vegetarian dietary patterns were associated with lower baseline ferritin (β=-20.5, p=0.011) but a greater increase in haemoglobin during BCT (β=4.50, p=0.026). Less frequent breakfast consumption was associated with lower baseline physical work capacity (β=-0.32, p=0.015). Over a 5-month period, conscripts reporting less frequent consumption of full meal portions had lower baseline physical work capacity (β=-0.33, p=0.019) and higher odds of injury or overuse symptoms (OR 2.33, p=0.015) and missed training (OR 1.85, p=0.047). Not eating enough in relation to individual needs was associated with a smaller increase in haemoglobin (β=-7.38, p<0.001). Poor self-rated physical health was associated with higher odds of injury or overuse symptoms (OR 1.80, p=0.035). CONCLUSIONS:Irregular meal patterns and insufficient food intake were associated with lower physical work capacity and increased risk of adverse outcomes during BCT. Dietary behaviours may represent modifiable factors relevant to performance, health and resilience in military training.
The Recovery, Readjustment and Reintegration Programme (R3P) is a structured, meaning-based psychological support tool that offers peers the opportunity to meet and discuss their shared experiences to enable better coping. Since its inception in 2020, the tool has been adopted nationally by the UK National Health Service and by international military partners. R3P is a leader-led, non-medical initiative, which navigates participants through group discussions focussing on five themes that are acknowledged to cause distress and to linger in a person's mind long after their occurrence. The five themes, namely morally injurious events, death and suffering, vulnerability, personal and professional challenge, and unrealistic expectations, might be experienced on military deployments but apply equally to everyday life and the occupational environment in the home nation. This paper aims to provide a simple guide of how and when to implement R3P, with considerations for providing a psychologically safe space to optimise fruitful engagement. It will also dispel the myths that have emerged since its inception.
INTRODUCTION:G-induced loss of consciousness (G-LOC) remains a significant hazard in high-performance aviation. Although protective equipment and anti-G straining manoeuvres improve tolerance to high +Gz acceleration, individual physiological and operational factors may influence susceptibility to G-LOC during flight. The aim of this study was to characterise in-flight G-LOC cases and to identify potential factors associated with these events. METHODS:This retrospective case-control study analysed all in-flight G-LOC events reported among Israeli Air Force cadets and fighter aircrew between 2015 and 2025. For each case, four controls matched for age and squadron were randomly selected without a history of G-LOC. Variables included anthropometric characteristics, resting blood pressure, operational role during the manoeuvre, flight training stage, G-levels at the time of G-LOC, incapacitation duration and preceding symptoms. RESULTS:Fifteen in-flight G-LOC events occurring in 13 individuals were identified. The mean age at the time of the event was 23.4±5.6 years. The mean incapacitation duration was 19.6±9.9 s. Visual symptoms preceded loss of consciousness in 73% of events. G-LOC cases were significantly taller than matched controls (183.8±6.3 cm vs 176.8±3.3 cm, 95% CI 2.89 to 11.01, p=0.003). Within the G-LOC cohort, higher G-levels at the time of G-LOC were observed during events in which the affected pilot was directly controlling the aircraft. Among cadets, G-level at the time of G-LOC was positively correlated with training stage (Spearman ρ=0.74, p=0.014). CONCLUSIONS:These findings provide observational data suggesting that anthropometric and operational factors may influence the conditions under which G-LOC occurs during flight.
Introduction Since the full-scale Russian invasion of Ukraine in February 2022, the Ukrainian Women, Peace and Security National Action Plan (NAP) has become extremely important in creating conditions for the participation of both women and men in conflict resolution, peacebuilding, recovery, in addressing security challenges and systemic responses to conflict-related violence including sexual violence, in alignment with United Nations Security Council Resolution (UNSCR) 1325. NAPs are more effective when they have broad population acceptance. This paper introduces a structured method for evaluating progress towards the NAP via measurement of public opinion and creates baseline measures for that progress. Methods We conducted a population-based, cross-sectional household quantitative study in 20 of 24 oblasts in Ukraine during a 2-month period from 01 May to 29 June 2025 to assess public opinion related to the progress of Ukraine’s NAP across four pillars consistent with UNSCR 1325 to include participation, protection, prevention, and rehabilitation and recovery, which relate to indicators in the Ukrainian NAP. Results Of the 4385 households surveyed, respondents from 4228 households completed the study (96%). The majority of the NAP indicators assessed were either met or somewhat met. Only one of the indicators scored low enough to be considered ‘not met’. However, there were significant differences in agreement levels between sex and between civilians and former military. Conclusions Despite the ongoing conflict, Ukraine continues to make significant progress towards its NAP goals, which are vital for long-term recovery, reintegration and resilience. Moving forward, shifting mindsets, particularly among males, to support female leadership and peacebuilding roles will be essential to securing lasting peace.
Large-scale combat operations (LSCO) are increasingly shaped by persistent surveillance, precision strike capability, electronic warfare, contested mobility and repeated attacks on healthcare personnel and facilities. These conditions challenge a core assumption of military medical planning: that casualties can be moved rapidly and predictably through a linear evacuation chain. This article asks how commanders and medical planners should treat medical timelines when evacuation, protection, logistics and information are themselves contested. Drawing on a directed qualitative content analysis of doctrinal, empirical, institutional and clinical sources, it identifies three linked mechanisms: evacuation becomes a contested operational activity rather than a predictable transport function; clinical responsibility shifts forward across an extended continuum of care and survivability depends on interdependence among mobility, protection, logistics, command-and-control, information and clinical capability. The implication is not that rapid evacuation has become obsolete, but that fixed evacuation timelines are brittle planning assumptions in transparent LSCO—a battlespace in which persistent, multi-domain surveillance makes concealment, massing and uncontested evacuation difficult. Military medicine should therefore be planned as a coupled operational capability that shapes course of action development, command risk assessment, wargaming and force generation. The policy challenge is to design medical systems that preserve combat power when movement, visibility, capacity and information are contested.
INTRODUCTION:Maintaining the activity of pharmaceuticals and preventing the accumulation of harmful degradation products during storage are essential for efficacy and safety, particularly for non-titrated medications such as antibiotics. Although manufacturers' storage instructions usually specify a target controlled temperature, military operations often occur in extreme environments with substantial temperature variability. No manufacturer provides data to guide decisions under such circumstances. This study assessed the stability of 10 medications commonly used in the Australian Defence Force (ADF) prehospital setting when subjected to operationally relevant temperatures. METHODS:10 medications (pseudoephedrine, cefazolin, tranexamic acid, ceftriaxone, hydrocortisone, benzylpenicillin, promethazine, ketorolac, amiodarone and metoclopramide) were stored for 14 or 28 days under five conditions: -20°C, 30°C, 50°C, 30°C-50°C diurnal cycling and ambient control (24°C±1°C). Stability was assessed by recording pH, visual appearance, subvisible particle count distribution and intact content using validated physicochemical and chromatographic methods. Changes exceeding the coefficient of variation (CV) of ambient control replicates were flagged as signs of potential instability. RESULTS:Nine of the 10 medications retained ≥90% of original content across all conditions and met criteria for stability according to visual appearance, pH and subvisible particle formation. However, after 14 days at 50°C, cefazolin content fell below this threshold (87.7%), and the CV in pH failed the acceptance criterion. Minor fluctuations above control CV were also noted for tranexamic acid, promethazine and pseudoephedrine, but no significant degradation trends emerged. CONCLUSIONS:Most of the medications tested retained acceptable physicochemical characteristics over 28 days under conditions simulating field exposure. These findings provide preliminary support that some medications may remain suitable for use when manufacturer-recommended temperatures cannot be maintained, and resupply is unlikely. However, the single sample (n=1) study design limits confidence in the findings. Further replicated studies are required before these results should inform medicines management policy.
Small military medical teams are increasingly required to deliver advanced clinical capability in remote and austere environments. They are structurally fragile because expertise is concentrated in a small number of individuals who cannot be replaced or rotated. Redundancy is minimal and the organisational depth that absorbs interpersonal dysfunction in larger systems is absent. When dysfunction occurs, the consequences may propagate directly into patient care and operational capability. Dysfunction in these teams is not primarily a product of technical deficit. It arises from a combination of maladaptive behavioural responses to psychological stress caused by environmental and team factors. Resource constraint, compromised standards, eligibility restrictions, moral strain and sustained underload are all predictable sources. Because they are predictable, they are trainable. Human factors approaches, effective in complicated and reproducible clinical environments, are insufficient for the complex, non-linear dynamics of austere deployment where errors arise through the interaction of individuals under strain rather than through system failures. Establishment of an effective team can often be seen as part of a clinical process rather than a stand-alone objective. This paper argues that structured, team-centric pre-deployment preparation, in which behavioural alignment and psychological safety are established before clinical simulation training begins, should be a core readiness requirement. Adaptive behaviours must be established before the team is tested clinically, in training or on operations, otherwise maladaptive behaviours will propagate and become difficult to displace. Preparing small medical teams as cohesive performance units is a patient safety intervention that protects deployed medical capability.
INTRODUCTION:The incidence of anterior knee pain (AKP) in female military personnel is twice that of their male counterparts. However, whether AKP affects functional outcomes differently in females remains unclear. The objective of this study was to identify differences in AKP-associated functional outcomes between male and female combatants. METHODS:This was a cross-sectional secondary analysis by biological sex (male/female) of active combat soldiers of the Israel Defense Forces and Israel Border Police personnel with AKP due to overuse, using screening data originally collected for a registered interventional study. Outcome measures included Kujala AKP scores by functional domain, anatomical mapping of pain location (by tenderness on palpation) and pain level measured using a Visual Analogue Scale (VAS). RESULTS:The cohort comprised 27 females, 45 males and 112 knees. Females were younger (20.1 ± 1.3 vs 22.9 ± 6.3 years, p< 0.001), had lower body mass index (23.0 ± 3.2 vs 24.6 ± 3.2 kg/m², p=0.006) and reported less premilitary physical activity (67% vs 89%, p=0.021). In female combatants, tenderness on palpation was more frequent over the patellar ligament (PL) versus the patella (P) itself (PL vs P: females, 59% vs 32%, p=0.016; males, 51% vs 48%, p=0.74). Females reported significantly higher pain levels than males (VAS: 54±23 vs 45±23 mm on scale, p=0.046) and significantly lower overall functionality and symptoms (Kujala: 67±12 vs 73±11, p=0.030). The frequencies of affected performance from AKP were significantly greater in females for running and ascending/descending stairs (running: 30% vs 9%, p=0.022 and stairs: 82% vs 56%, p=0.025, respectively). CONCLUSIONS:Female combatants suffer more from AKP, report higher pain levels and have greater functional disability compared with their male counterparts. This study points to the important need for a sex-specific approach for evaluation of AKP-related functional disabilities in order to optimise treatment protocols and reduce the time to return to active service or performance in physically demanding settings. TRIAL REGISTRATION NUMBER:NCT02845869.
Introduction The US Defense Health Agency (DHA) maintains five Institutional Review Boards (IRBs) within the Office of Human Research Protection Human Research Protection Program (HRPP) to oversee the research portfolio. DHA researchers completed the IRB Researcher Assessment Tool (IRB-RAT) to share their perceptions of IRB performance and identify areas where future process improvement efforts can be focused. Methods This study was a cross-sectional programme evaluation and IRB determination was received. Participants were asked to complete the IRB-RAT. The primary outcome was the performance gap score, calculated for each item as Actual minus Ideal. Linear mixed-effects models were used to analyse responses and to evaluate institutional variability. Results An electronic invitation to complete the IRB-RAT was sent to 5960 registered DHA Electronic IRB system (EIRB) users between May and October 2025. Of those, 473 responded. Analysis identified the most important Ideal characteristics as (Q1) timeliness , (Q4) providing complete explanations for changes and (Q25) not using its power to suppress research . The largest performance gap scores were (Q1) timeliness, (Q24) being an ally rather than a hurdle and (Q15) accountability for errors or delays . Items identified for process improvement were (Q1) timeliness , (Q4) providing complete explanations for changes, (Q24) being an ally rather than a hurdle and (Q22) understanding and acting within their scope of function . There were significant differences across the five IRBs. Performance was not uniform across the DHA. Conclusions The IRB-RAT effectively captured respondents’ perceptions of DHA IRB performance. Timeliness was a universal concern and improvements within IRB scope of function and providing explanations for changes should help minimise delays. Additional work is needed to understand why DHA researchers view the IRB as a hurdle, not an ally. The DHA IRBs must harmonise best practices across the five IRBs and develop future process improvement projects to address researchers’ concerns.
INTRODUCTION:Musculoskeletal injuries are a major concern in military populations, particularly during basic training, when up to one in four soldiers require medical attention. Traditional surveillance systems based on medical records underestimate the true burden as many injuries go unreported. Self-reporting tools, such as the validated Oslo Sports Trauma Research Center Questionnaire on Health Problems (OSTRC-H2), provide a more comprehensive overview by capturing injuries of all severities. This study evaluated the feasibility of implementing a large-scale self-reporting injury surveillance system using the OSTRC-H2 across basic training schools in different branches and locations of the Norwegian Armed Forces. METHOD:A total of 1521 conscripts from the Norwegian Army, the Royal Norwegian Navy and the Royal Norwegian Air Force completed weekly questionnaires over 6 weeks during military training in basic training schools, using a modified version of the OSTRC-H2. Participants reported all injuries, regardless of medical attention, along with information on injury type, anatomical location and severity. Weekly prevalence and incidence rates were calculated. RESULTS:The mean weekly response rate was 54%, with variation across weeks and platoons. 796 injuries were reported, corresponding to an annualised incidence of 5.1 injuries per recruit, including 4.1 overuse and 1.0 acute injuries per recruit per year. The average weekly injury prevalence was 17%, including 9% with substantial injuries, moderately or severely restricting military activity and/or performance. Most injuries involved the lower limbs (71%), and the average time loss per injury was 1.2 days. CONCLUSION:Implementation of a self-report injury surveillance system using the OSTRC-H2 across basic training schools in multiple branches and locations of the Norwegian Armed Forces proved feasible, with consistent participation and the ability to capture detailed injury patterns across units. This approach provides a robust foundation for monitoring and comparing injury burden and supports targeted prevention efforts within military training environments.
Introduction The sinking of the warship IRIS Dena by a torpedo attack on 4 March 2026 represents a rare maritime mass-casualty event. Because such events are relatively uncommon, the clinical outcomes of torpedo-related trauma remain poorly documented. This study describes the injury patterns among surviving crew members of a ship following a torpedo attack. Method A retrospective study was conducted including all 32 survivors admitted to the National Hospital Galle, Sri Lanka. Data regarding patient demographics, injury characteristics, initial investigations and management were extracted from medical records and analysed. Results All 32 survivors were male, with a mean age of 31.7 years. Eighteen patients (56.2%) reported only mild pain requiring standard analgesia. The remaining 14 patients (43.8%) sustained a total of 18 major traumatic injuries. Of these injuries, 10 (55.6%) were vertebral compression wedge fractures. Most vertebral fractures were concentrated at the thoracolumbar junction, with 6 (60%) involving T11 and L1 vertebrae. Five (27.8%) limb fractures were reported, including two scaphoid fractures, one femur fracture and two ankle fractures involving the lateral malleolus. One patient sustained severe chest trauma complicated with haemopneumothorax. The most used radiological imaging modality was spinal X-rays (n=15, 46.9%). Conclusion Injuries among survivors of a torpedo attack predominantly consisted of thoracolumbar vertebral compression fractures. This specific injury pattern is likely attributable to the violent upward displacement of the ship, known as the “deck-slap” effect. Clinicians should use spinal immobilisation and subsequent spinal imaging in survivors of maritime explosions.
BACKGROUND:Major trauma and polytrauma are leading causes of mortality, driven by haemorrhagic shock and a dysregulated inflammatory response. Vitamin C, which has a role in vasopressor synthesis, endothelial function and antioxidant defence, is rapidly depleted in critical illness. Vitamin C has been highlighted as a promising therapeutic opportunity in trauma patients. This systematic review evaluates the evidence of vitamin C use in adult trauma patients. METHODS:The systematic review was registered on PROSPERO (International Prospective Register of Systematic Reviews) and is reported according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Embase, Medline, CINAHL, SCOPUS, ClinicalTrials.gov, and Cochrane Central were searched up to December 2025. Studies evaluating intravenous vitamin C in adult trauma patients were included, with studies screened and quality assessed in duplicate by two blinded authors. Meta-analysis was not possible due to heterogeneous outcome reporting. RESULTS:Six studies, including three randomised controlled trials (RCTs) and three cohort studies, met the inclusion criteria. The included studies suggest patients receiving high-dose vitamin C may have a significantly lower mortality with significantly reduced intensive care unit and hospital stays. There were also lower rates of sepsis and organ failure in the vitamin C cohorts. These findings derive from a small number of methodologically heterogeneous studies, resulting in a limited certainty of evidence. CONCLUSIONS:This review identifies the potential benefit of intravenous high-dose vitamin C in trauma patients, supported by a strong biological rationale. The studies included are heterogeneous, which limits their strength and results in low certainty of our presented evidence. High-quality, adequately powered RCTs with standardised protocols, including dosing regimen and timing, are needed before routine clinical use can be recommended.
INTRODUCTION:Ejections from combat aircraft pose a significant risk of head injury, and the primary protective measure against such injuries is the aircrew helmet. Internationally, aircrew helmets are typically certified against motorcycle or motorcycle-derived helmet standards, which may not reflect the injury mechanisms experienced during aircraft ejections. METHODS:The objective of this study was to identify the historical risk of head injury associated with combat aircraft ejections. All UK combat aircraft ejections from 1972 to 2025 were analysed to determine common brain pathologies, head injury mechanisms and helmet damage characteristics. RESULTS:In total, 268 aircraft ejections were recorded, with 12% resulting in a head injury. Two primary head injury mechanisms were identified: headbox impact (58%) and parachute landing (27%). The findings indicate that aircrew helmets provide protection against skull fracture as no cases were recorded following in-envelope ejections. This outcome is likely attributable to existing aircrew helmet standards, which assess helmet performance based on peak translational acceleration, a parameter closely linked to skull fracture. A key finding is that loss of consciousness associated with head rotation was the most prevalent pathology, comprising 76% of all head injuries. CONCLUSIONS:These results inform potential improvements in aircrew helmet standards. Even a brief incapacitation, such as a loss of consciousness, can impair aircrew escape and evasion capabilities, thereby affecting survivability. Consequently, this study recommends that future aircrew helmet standards expand their test methods to include assessments of rotational injury, with the aim of mitigating the risk of loss of consciousness.
Introduction Tourniquet (TQ) application is a key component of extremity haemorrhage control in high-resource military and civilian trauma systems. In settings with prolonged evacuation times, TQs can cause complications including limb loss, rhabdomyolysis, or death, yet limited data exist on the scope and impact of this problem. Methods We conducted a single-centre prospective observational analysis at the largest military hospital in Burkina Faso to describe injury epidemiology, TQ application practices and early outcomes among casualties with conflict-related injuries who underwent prehospital TQ application from January to July 2025. Results 100 casualties (N) were included in the analysis. Mean prehospital time was 11.9 hours. The most common mechanism of injury was gunshot wound (64.0%, n=64) followed by explosion (36.0%, n=36). 114 TQs were placed. 5.3% (n=6) of TQs were both medically necessary and appropriately placed. Of 24 amputations, 54.2% (n=13) were performed at an anatomical level more proximal than otherwise indicated due to TQ application and 50.0% (n=12) were associated with TQs that were not medically necessary. Mortality was 5.0% (n=5), three of which were attributable to TQ-associated complications (eg, rhabdomyolysis, cardiac arrest). Conclusions TQs can reduce preventable death from extremity haemorrhage but can also have harmful consequences in settings with prolonged evacuation times. In our sample from the Sahel, a low proportion of prehospital TQs were medically necessary and appropriately placed, with substantial TQ-associated morbidity and mortality. Context-appropriate clinical algorithms and training programmes are needed to reduce these complications while upholding the role of appropriate TQ use for haemorrhage control in conflict.
