Level of perceived social support, and associated factors, in combat-exposed (ex-)military personnel: a systematic review and meta-analysis.

PURPOSE: Combat deployment increases exposure to potentially traumatic events. Perceived social support (PSS) may promote health and recovery from combat trauma. This systematic review and meta-analysis aimed to synthesize studies investigating the level of PSS and associated factors among (ex-)military personnel who served in the Iraq/Afghanistan conflicts. METHODS: Five electronic databases were searched in August 2023 and searches were restricted to the beginning of the Iraq/Afghanistan conflicts in 2001. The search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A quality assessment was carried out, and a meta-analysis and narrative synthesis were performed. RESULTS: In total, 35 papers consisting of 19,073 participants were included. Of these, 31 studies were conducted in the United States (US) and 23 were cross-sectional. The pooled mean PSS score was 54.40 (95% CI: 51.78 to 57.01). Samples with probable post-traumatic stress disorder had a lower mean PSS score (44.40, 95% CI: 39.10 to 49.70). Approximately half of the included studies (n = 19) investigated mental health in relation to PSS, whilst only four explored physical health. The most frequently reported risk factors for low PSS included post-traumatic stress disorder, depression and anxiety, whilst post-traumatic growth and unit support were protective factors. CONCLUSION: Higher levels of PSS were generally associated with more positive psychosocial and mental health-related outcomes following deployment. PSS should be targeted in psychosocial interventions and education programmes. Future research should investigate PSS in (ex-)military personnel across other countries and cultures, based on the lack of studies that focused on PSS in countries outside of the US.

How do people conceptualize self-harm recovery and what helps in adolescence, young and middle adulthood? A qualitative meta-synthesis.

OBJECTIVE: Self-harm can be understood as any behavior individuals use to harm themselves, irrespective of motive. Evidence has extensively examined the epidemiology and function of self-harm to the individual, but less is known about the subjective processes underpinning recovery. Such insights could inform therapeutic interventions to better support individuals. The present aim was to synthesize qualitative themes from eligible literature to identify how adolescents, young adults, and those in middle adulthood conceptualize self-harm recovery and the factors impacting this process. METHODS: Eleven studies were identified from a systematic search of five electronic research databases: PsycINFO, Embase, Medline, Global Health, and CINAHL. Studies were critically appraised using an adapted Critical Appraisal Skills Program tool for qualitative research. A meta-synthesis was conducted using reflexive thematic analysis to generate themes across the included studies. RESULTS: Themes depicted recovery as a multidimensional, nonlinear, and subjective process, characterized by a "push and pull" between states of (re-)engagement and cessation/reduction. Transition between these states was influenced by intrapersonal and interpersonal factors which were embedded in a wider milieu of the meaning of self-harm to the individual. CONCLUSION: Contemporary ideas of symptom eradication as the only marker of complete recovery may hinder individuals in the long-term, presenting an obstacle both to quality of life and therapeutic progress. Movement away from self-harm recovery as a uniform or singular phenomenon could enhance person-centered care.

Anger Among UK Ex-Service Military Personnel During the COVID-19 Pandemic.

ABSTRACT: Military service and ex-service personnel commonly experience difficulties with anger. The COVID-19 pandemic had several negative consequences upon social, economic, and health factors that influence anger. This study aimed to explore 1) levels of anger in an ex-serving military cohort during the COVID-19 pandemic; 2) self-reported changes in anger compared with prepandemic levels; and 3) identify sociodemographic characteristics, military characteristics, COVID-19 experiences, and COVID-19 stressors associated with anger. UK ex-service personnel ( n = 1499) completed the Dimensions of Anger Reactions 5-item measure within an existing cohort study. Overall, 14.4% reported significant difficulties with anger, and 24.8% reported their anger worsened during the pandemic. Anger was associated with factors such as financial difficulties, extra/new caring responsibilities, and COVID-19 bereavement. Endorsing more COVID-19 stressors was associated with higher odds of anger difficulties. This study highlights the impact of the pandemic on ex-service personnel, including a strain on family/social relationships and financial hardship, which affected anger.

Military veterans and civilians' mental health diagnoses: an analysis of secondary mental health services.

PURPOSE: Healthcare provision in the United Kingdom (UK) falls primarily to the National Health Service (NHS) which is free at the point of access. In the UK, there is currently no national marker to identify military veterans in electronic health records, nor a requirement to record it. This study aimed to compare the sociodemographic characteristics and recorded mental health diagnoses of a sample of veterans and civilians accessing secondary mental health services. METHODS: The Military Service Identification Tool, a machine learning computer tool, was employed to identify veterans and civilians from electronic health records. This study compared the sociodemographic characteristics and recorded mental health diagnoses of veterans and civilians accessing secondary mental health care from South London and Maudsley NHS Foundation Trust, UK. Data from 2,576 patients were analysed; 1288 civilians and 1288 veterans matched on age and gender. RESULTS: Depressive disorder was the most prevalent across both groups in the sample (26.2% veterans, 15.5% civilians). The present sample of veterans accessing support for mental health conditions were significantly more likely to have diagnoses of anxiety, depressive, psychosis, personality, and stress disorders (AORs ranging 1.41-2.84) but less likely to have a drug disorder (AOR = 0.51) than age- and gender-matched civilians. CONCLUSION: Veterans accessing secondary mental health services in South London had higher risks for many mental health problems than civilians accessing the same services. Findings suggest that military career history is a key consideration for probable prognosis and treatment, but this needs corroborating in other geographical areas including national population-based studies in the UK.

Golgi-Dependent Copper Homeostasis Sustains Synaptic Development and Mitochondrial Content.

Rare genetic diseases preponderantly affect the nervous system causing neurodegeneration to neurodevelopmental disorders. This is the case for both Menkes and Wilson disease, arising from mutations in ATP7A and ATP7B, respectively. The ATP7A and ATP7B proteins localize to the Golgi and regulate copper homeostasis. We demonstrate genetic and biochemical interactions between ATP7 paralogs with the conserved oligomeric Golgi (COG) complex, a Golgi apparatus vesicular tether. Disruption of Drosophila copper homeostasis by ATP7 tissue-specific transgenic expression caused alterations in epidermis, aminergic, sensory, and motor neurons. Prominent among neuronal phenotypes was a decreased mitochondrial content at synapses, a phenotype that paralleled with alterations of synaptic morphology, transmission, and plasticity. These neuronal and synaptic phenotypes caused by transgenic expression of ATP7 were rescued by downregulation of COG complex subunits. We conclude that the integrity of Golgi-dependent copper homeostasis mechanisms, requiring ATP7 and COG, are necessary to maintain mitochondria functional integrity and localization to synapses.SIGNIFICANCE STATEMENT Menkes and Wilson disease affect copper homeostasis and characteristically afflict the nervous system. However, their molecular neuropathology mechanisms remain mostly unexplored. We demonstrate that copper homeostasis in neurons is maintained by two factors that localize to the Golgi apparatus, ATP7 and the conserved oligomeric Golgi (COG) complex. Disruption of these mechanisms affect mitochondrial function and localization to synapses as well as neurotransmission and synaptic plasticity. These findings suggest communication between the Golgi apparatus and mitochondria through homeostatically controlled cellular copper levels and copper-dependent enzymatic activities in both organelles.

Association of psychological distress and religious coping tendencies in parents of children recently diagnosed with cancer: A cross-sectional study.

PURPOSE: Parents of children with cancer exhibit high levels of psychological distress. Parents of children with serious illness report religion and spirituality are important coping resources. We sought to describe characteristics of religion, religious coping, social support, and resiliency in parents of children newly diagnosed with cancer and examine associations between psychological distress and self-reported religious coping, religiosity, resiliency, and social support. PATIENTS AND METHODS: Cross-sectional observational study of 100 parents of 81 unique children recently diagnosed with cancer. Parents provided demographic information and completed measures of psychological distress, importance of religion, religious coping, resiliency, and social support. Patients' type of tumor and intensity of treatment were collected by medical record abstraction. RESULTS: Compared to nationally reported data for adults, parents of children with cancer reported high scores for psychological distress but similar levels of religiosity, religious coping, and resiliency. Negative religious coping (feelings of negativity related to the divine) was associated with higher levels of psychological distress. This effect was most prominent in parents who reported the highest levels of religiosity. Positive religious coping, religiosity, and social support were not associated with levels of psychological distress. DISCUSSION: Findings confirm high levels of distress for parents of children with cancer. Negative religious coping was associated with higher levels of psychological distress but positive religious coping, religiosity, and other coping factors were not found to be significantly associated with distress. Further assessment of negative religious coping to inform interventions to promote resiliency is warranted as they may impact parental decision-making and care.

A key metabolic integrator, coenzyme A, modulates the activity of peroxiredoxin 5 via covalent modification.

Peroxiredoxins (Prdxs) are antioxidant enzymes that catalyse the breakdown of peroxides and regulate redox activity in the cell. Peroxiredoxin 5 (Prdx5) is a unique member of Prdxs, which displays a wider subcellular distribution and substrate specificity and exhibits a different catalytic mechanism when compared to other members of the family. Here, the role of a key metabolic integrator coenzyme A (CoA) in modulating the activity of Prdx5 was investigated. We report for the first time a novel mode of Prdx5 regulation mediated via covalent and reversible attachment of CoA (CoAlation) in cellular response to oxidative and metabolic stress. The site of CoAlation in endogenous Prdx5 was mapped by mass spectrometry to peroxidatic cysteine 48. By employing an in vitro CoAlation assay, we showed that Prdx5 peroxidase activity is inhibited by covalent interaction with CoA in a dithiothreitol-sensitive manner. Collectively, these results reveal that human Prdx5 is a substrate for CoAlation in vitro and in vivo, and provide new insight into metabolic control of redox status in mammalian cells.

HCN channels segregate stimulation-evoked movement responses in neocortex and allow for coordinated forelimb movements in rodents.

KEY POINTS: The present study tested whether HCN channels contribute to the organization of motor cortex and to skilled motor behaviour during a forelimb reaching task. Experimental reductions in HCN channel signalling increase the representation of complex multiple forelimb movements in motor cortex as assessed by intracortical microstimulation. Global HCN1KO mice exhibit reduced reaching accuracy and atypical movements during a single-pellet reaching task relative to wild-type controls. Acute pharmacological inhibition of HCN channels in forelimb motor cortex decreases reaching accuracy and increases atypical movements during forelimb reaching. ABSTRACT: The mechanisms by which distinct movements of a forelimb are generated from the same area of motor cortex have remained elusive. Here we examined a role for HCN channels, given their ability to alter synaptic integration, in the expression of forelimb movement responses during intracortical microstimulation (ICMS) and movements of the forelimb on a skilled reaching task. We used short-duration high-resolution ICMS to evoke forelimb movements following pharmacological (ZD7288), experimental (electrically induced cortical seizures) or genetic approaches that we confirmed with whole-cell patch clamp to substantially reduce Ih current. We observed significant increases in the number of multiple movement responses evoked at single sites in motor maps to all three experimental manipulations in rats or mice. Global HCN1 knockout mice were less successful and exhibited atypical movements on a skilled-motor learning task relative to wild-type controls. Furthermore, in reaching-proficient rats, reaching accuracy was reduced and forelimb movements were altered during infusion of ZD7288 within motor cortex. Thus, HCN channels play a critical role in the separation of overlapping movement responses and allow for successful reaching behaviours. These data provide a novel mechanism for the encoding of multiple movement responses within shared networks of motor cortex. This mechanism supports a viewpoint of primary motor cortex as a site of dynamic integration for behavioural output.

Development, Implementation, and Evaluation of a Nurse Anesthesia Program in Belize.

Because of a critical shortage of anesthesia providers in Belize, the Belize Ministry of Health initiated support for the creation of a nurse anesthesia education program. Developed in collaboration with Health Volunteers Overseas and the University of Belize, the nurse anesthesia education program graduated 10 nurse anesthetists. This article describes the 24-month nurse anesthesia education program's design, implementation, and evaluation. Challenges and opportunities experienced during the program are outlined as lessons learned for planning similar programs.

Mental health, ethnicity and the UK armed forces: Historical lessons for research and policy.

BACKGROUND: UK armed forces have recruited from other races and ethnicities at times of crisis. To meet diversity targets, they have also recruited indigenous groups of non-White British heritage. Considered at greater risk of mental health problems generally, these populations are likely to suffer more in combat and in transition to civilian life. Yet, there is little data on how they fare. METHODS: A scoping review was conducted of peer-reviewed studies of psychological illnesses suffered by racial and ethnic minority soldiers from World War One to the present, together with research at the National Archives, Wellcome Trust Archives and the Imperial War Museum for unpublished studies. RESULTS: British commanders and psychiatrists argued that 'martial races' were protected against post-traumatic illnesses because of an innate resilience related to a rural heritage. Consequently, low morale and breakdown were interpreted as malingering to avoid combat. Indian troops received lower levels of psychiatric care than provided for British soldiers delivered with limited cultural understanding. Inferior terms and conditions were offered to Indian soldiers with lesser opportunities for promotion. These practices, established in both World Wars, continued for Gurkha and Commonwealth soldiers recruited to meet manpower and diversity targets. Disproportionate complaints of discrimination may explain why ethnic minority status is a risk factor for mental illness. CONCLUSION: Management patterns laid down during the Imperial era continue to influence current practice for ethnic minority service personnel. Yet, armed forces can play a positive role in fostering diversity and integration to provide protective factors against mental illness.

Patient and Family Outcomes of Community Neurologist Palliative Education and Telehealth Support in Parkinson Disease.

Importance: Parkinson disease and related disorders (PDRD) are the fastest growing neurodegenerative illness in terms of prevalence and mortality. As evidence builds to support palliative care (PC) for PDRD, studies are needed to guide implementation. Objective: To determine whether PC training for neurologists and remote access to a PC team improves outcomes in patients with PDRD in community settings. Design, Setting, and Participants: This pragmatic, stepped-wedge comparative effectiveness trial enrolled and observed participants from 19 community neurology practices supported by PC teams at 2 academic centers from March 8, 2017, to December 31, 2020. Participants were eligible if they had PDRD and moderate to high PC needs. A total of 612 persons with PDRD were referred; 253 were excluded. Patients were excluded if they had another diagnosis meriting PC, were receiving PC, or were unable or unwilling to follow study procedures. Patients received usual care or the intervention based on when their community neurologist was randomized to start the intervention. Data were analyzed from January 2021 to September 2023. Intervention: The intervention included (1) PC education for community neurologists and (2) team-based PC support via telehealth. Main Outcomes and Measures: The primary outcomes were differences at 6 months in patient quality of life (QOL; measured by the Quality of Life in Alzheimer Disease Scale [QOL-AD]) and caregiver burden (Zarit Burden Interview) between the intervention and usual care. Results: A total of 359 patients with PDRD (233 men [64.9%]; mean [SD] age, 74.0 [8.8] years) and 300 caregivers were enrolled. At 6 months, compared with usual care, participants receiving the intervention had better QOL (QOL-AD score, 0.09 [95% CI, -0.63 to 0.82] vs -0.88 [95% CI, -1.62 to -0.13]; treatment effect estimate, 0.97; 95% CI, 0.07-1.86; P = .03). No significant difference was observed in caregiver burden (Zarit Burden Interview score, 1.19 [95% CI, 0.16 to 2.23] vs 0.55 [95%, -0.44 to 1.54]; treatment effect estimate, 0.64; 95% CI, -0.62 to 1.90; P = .32). Advance directive completion was higher under the intervention (19 of 38 [50%] vs 6 of 31 [19%] among those without directives at the beginning of the study; P = .008). There were no differences in other outcomes. Conclusions and Relevance: PC education for community neurologists and provision of team-based PC via telehealth is feasible and may improve QOL and advance care planning. Overall treatment effects were small and suggest opportunities to improve both the intervention and implementation. Trial Registration: ClinicalTrials.gov Identifier: NCT03076671.

Anesthesia 101: everything you need to know.

Successful patient outcomes from an operative procedure require vigilance, diligence, and teamwork among the various providers involved with the surgical procedure. An understanding of the responsibilities and appreciation for the complexities of each healthcare provider's role in the operative process is essential to a harmonious relationship among the perioperative team to improve the working environment and provide safe patient care. The information provided in this article is based on commonly observed practices in the anesthesia community with the caveat that the choices can vary considerably and are influenced by patient presentation and surgical requirements.

The evolution of PTSD symptoms in serving and ex-serving personnel of the UK armed forces from 2004 to 16: A longitudinal examination.

Whilst most military personnel do not develop Post-Traumatic Stress Disorder (PTSD), ex-serving personnel exhibit higher levels compared to those in the military. The heterogeneity of symptom development for serving and ex-serving personnel has not yet been compared in the UK Armed Forces (UK AF). Latent class growth modelling was employed to estimate the trajectories of PTSD symptoms from three waves of data from the PTSD Checklist (PCL-C) from a UK AF sample (N = 7357). Regression mixture models were conducted to investigate covariates of class membership. Five trajectory classes were identified. Most of the sample reported no-low symptoms (71.3%). Of those reporting probable PTSD during the 12 year-period, 4.6% showed improvements, 4.9% worsened, and 1.8% displayed chronic symptoms. A class with subthreshold elevated symptoms (17.3%) was also identified. Trajectories of serving and ex-serving personnel were not substantially different, but more ex-serving personnel were symptomatic and those with chronic symptoms worsened over time. Chronic disorder was associated with lower rank, experiencing violent combat, and proximity to wounding/death on deployment. Worsening symptoms were associated with childhood stress/violence, lower rank, not being in a relationship, inconsistent post-deployment social support, proximity to wounding/death, and voluntary, or medical discharge. The present study found most UKAF personnel did not report PTSD symptoms between 2004 and 16 but, among those experiencing probable PTSD, more participants reported deteriorating/persistent symptoms than who improved. PTSD-onset was related to adversities across childhood and deployment, and lack of social support. Findings underscore the importance of addressing the through-life contributors of PTSD in order to prevent ingrained disorder.

Identifying Military Service Status in Electronic Healthcare Records from Psychiatric Secondary Healthcare Services: A Validation Exercise Using the Military Service Identification Tool.

Electronic healthcare records (EHRs) are a rich source of information with a range of uses in secondary research. In the United Kingdom, there is no pan-national or nationally accepted marker indicating veteran status across all healthcare services. This presents significant obstacles to determining the healthcare needs of veterans using EHRs. To address this issue, we developed the Military Service Identification Tool (MSIT), using an iterative two-staged approach. In the first stage, a Structured Query Language approach was developed to identify veterans using a keyword rule-based approach. This informed the second stage, which was the development of the MSIT using machine learning, which, when tested, obtained an accuracy of 0.97, a positive predictive value of 0.90, a sensitivity of 0.91, and a negative predictive value of 0.98. To further validate the performance of the MSIT, the present study sought to verify the accuracy of the EHRs that trained the MSIT models. To achieve this, we surveyed 902 patients of a local specialist mental healthcare service, with 146 (16.2%) being asked if they had or had not served in the Armed Forces. In total 112 (76.7%) reported that they had not served, and 34 (23.3%) reported that they had served in the Armed Forces (accuracy: 0.84, sensitivity: 0.82, specificity: 0.91). The MSIT has the potential to be used for identifying veterans in the UK from free-text clinical documents and future use should be explored.

Trajectories of alcohol misuse among the UK Armed Forces over a 12-year period.

AIM: To identify the main trajectories of alcohol misuse among UK military personnel from 12 years after the start of the Iraq war (2003) and the factors associated with each trajectory. DESIGN: Longitudinal cohort study with three phases of data collection (2004-06, 2007-09 and 2014-16). SETTING: United Kingdom. PARTICIPANTS: Serving and ex-serving personnel of the UK Armed Forces (n = 7111) participating at Phase 1 and at least one follow-up phase of the King's Centre for Military Health Research (KCMHR) cohort study. MEASUREMENTS: Trajectories of alcohol misuse were derived from scores using the Alcohol Use Disorders Identification Test (AUDIT-10) over three data collection phases. Demographic and military characteristics were collected and, among the key covariates, post-traumatic stress disorder (PTSD) was measured using the PTSD checklist (PCL-C) and childhood interpersonal stress and violence was measured using items from the Adverse Childhood Experiences questionnaire. FINDINGS: Five trajectories of alcohol misuse were identified, including 'no misuse' (n = 2249, 31.6%) and 'hazardous' (n = 3398, 47.8%), 'harmful' (n = 832, 11.7%), 'severe-to-hazardous' (n = 258, 5.3%) and 'severe' (n = 374, 3.6%) drinking. Substantial changes were evident only among severe drinkers, where more than half reduced over the study period. The factors most strongly associated with belonging to harmful/severe drinking classes were young age, male gender and childhood adversities and antisocial behaviour. Severe drinkers at Phase 1 were more likely to report probable PTSD and shorter military careers and were less likely to serve as Officers. Persistent severe drinkers were less likely to serve in the RAF compared to the Army and were more likely to be reserves. Not misusing alcohol was also associated with reserve status and having left service. CONCLUSIONS: In a cohort of approximately 7000 UK military personnel, trajectories of alcohol misuse appeared stable between 2004 and 2016. More than half of severe drinkers made substantial improvements over the period, but 68% of the cohort continued to drink hazardously or harmfully. Lack of change for the majority of the sample signals the need for strategies to address alcohol misuse and its cultural and psychosocial drivers.