Gulf War and Health Volume 9: Long-Term Effects of Blast Exposures (2014) / Chapter Skim
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Explosions may cause five major patterns of injury -- primary, secondary, tertiary, quaternary, and quinary. Primary blast injury is caused by the blast wave itself, secondary injury is caused by fragments of debris propelled by the explosion, tertiary injury is due to the acceleration of the body or part of the body by the blast wave or blast wind, quaternary injuries include all other injuries directly caused by a blast but not classified by another mechanism (for example, burns, toxic-substance exposures, 1 Belmont, P
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hether improvements in collective and personal blast protection are W associated with diminished blast injury. In evaluating the long-term health effects of blast exposures among Gulf War Veterans, the committee should look broadly for relevant informa tion.
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The study was assigned to the IOM, and eight volumes have been published.4 The legislation did not preclude an IOM recommendation or a VA request for additional studies, particularly as subjects of concern arise. For example, VA's request that the IOM consider whether there is an increased risk of amyotrophic lateral sclerosis in all veteran populations resulted in the report Amyotrophic Lateral Sclerosis in Veterans; an examination of all health effects in veterans deployed to the 1991 Persian Gulf War irrespective of specific exposures resulted in Gulf War and Health, Volume 4: Health Effects of Serving in the Gulf War; and another VA request regarding the long-term effects of traumatic brain injury resulted in Gulf War and Health, Volume 7: Long-Term Consequences of Traumatic Brain Injury.
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Because of the inadequacy of epidemiologic literature that can inform understanding of long-term outcomes of exposure to blast, the committee relied heavily on the literature to assess the strength of the evidence on acute effects and on the collective clinical knowledge and expertise of the committee members to draw conclusions regarding the plausibility of the long-term outcomes. Some of the long-term outcomes are obvious and well documented as consequences of the acute injuries; others will require additional research studies to understand the long-term consequences of exposure specifically to blast.
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and satisfies several of the criteria used to assess causality: strength of association, dose–response relationship, consistency of association, temporal relationship, specificity of association, and biologic plausibility. Sufficient Evidence of an Association Evidence is sufficient to conclude that there is a positive association; that is, a consistent association has been observed between blast exposure and a specific health outcome in human studies in which chance and bias, including confounding, could be ruled out with reasonable confi dence as an explanation for the observed association.
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on long-term adverse health outcomes, particularly those not necessarily caused by a severe or obvious acute injury. Acute injuries to each organ system from exposure to blast are summarized in Chapter 4.
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Limited/Suggestive Evidence of an Association • Chronic traumatic encephalopathy with progressive cognitive and behavioral decline in cases of recurrent blast TBI. • Long-term effects on the tympanic membrane and auditory thresholds.
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• There is limited/suggestive evidence that diffuse brain injury with swelling may be more likely after blast than in relation to other mechanisms that lead to TBI. Blast Protection The committee was asked to consider whether improvements in collective and personal blast protection are associated with diminished blast injuries.
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The gaps include inadequately powered data sets, incomplete control populations, and poor study designs; an absence of combat-relevant expertise in blast on the research team; and a need to refine and advance preclinical models so that they can predict long-term multisystem effects of blast injuries in humans adequately. Greater collaboration within and among institutions will expand the expertise of research teams and help to fill the gaps, and this approach should be considered a strength, not a limitation, with respect to VA funding priorities.
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The Department of Veterans Affairs should cre ate a database that links Department of Defense records (particularly records that identify blast-injured service members) to records in the Veterans Health Administration, active-duty military treatment facili ties, and TRICARE (the Department of Defense health care program)
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The Department of Defense should determine whether existing screening tests administered during the physical exam ination conducted on enlistment can be used to measure susceptibility to blast injury, and if additional screening tests might be helpful in determining whether a service member has an increased susceptibility to blast injury. As part of its charge, the committee was asked to provide recommendations on disseminating information about the health effects of blast exposure throughout VA for the purpose of improving care and benefits provided to veterans.
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It should be a joint effort of the Department of Veter ans Affairs and the Department of Defense. • Use such mechanisms as the Patient Aligned Care Team, clini cal champions, and learning networks to educate Department of Veterans Affairs health care teams about the health effects of blast exposure.
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