Stimulus-Elicited Involuntary Cognition: Boundary Conditions and Systematic Effects.

For decades, researchers have been presenting participants with stimuli and instructing the participants not to respond to the stimuli in some way. Today, researchers are studying the effects that such stimuli have, not only on behavior, but on conscious experience. To this end, researchers have used several laboratory tasks, including the reflexive imagery task (RIT). In the RIT, participants are instructed not to respond in a specific way to stimuli. Participants often cannot suppress such responses. Knowledge of the conditions under which RIT effects fail to arise can illuminate the limitations of involuntary processes. We observed that the RIT effect can survive with brand symbols (Experiment 1, n = 30), which are different from everyday objects in interesting ways. In addition, we investigated systematic effects. Systematic effects are unlikely to be due to experimental demand. In Experiment 2 (n = 48), we observed that RIT effects could arise from associations learned, not across the participant's lifetime, but only in the laboratory. Participants studied nonsense shapes that were associated with pseudowords that preceded or followed the shapes. Afterward, these new associations led to RIT effects. In addition, RIT effects were more likely for pseudowords that preceded the shapes rather than for the pseudowords that followed the shapes (a systematic effect). In Experiment 3 (n = 46), systematic effects involving two sensory modalities were observed: olfactory stimuli were more likely to elicit involuntary visual imagery than visual stimuli were to elicit involuntary olfactory imagery. We discuss the theoretical implications of these effects.

Insuppressible cognitions in the reflexive imagery task: Insights and future directions.

In 1959, Neal Miller made the bold claim that the Stimulus-Response, Behaviorist models of that era were describing the way in which stimuli lead to the entry of contents into consciousness ("entry," for short). Today, researchers have begun to investigate the link between external stimuli and involuntary entry, using paradigms such as the reflexive imagery task (RIT), the focus of our review. The RIT has revealed that stimuli can elicit insuppressible entry of high-level cognitions. Knowledge of the boundary conditions of the RIT effect illuminates the limitations of involuntary processes and the role of consciousness in the regulation of behavior. We review the boundary conditions of this paradigm as well as its systematic effects. Systematic effects are unlikely to be due to experimental demand. While reviewing each effect, we consider its theoretical implications. In addition, throughout our review, we discuss future directions for the study of insuppressible entry using the RIT. Last, we discuss a theoretical development (passive frame theory) that stems from the RIT and illuminates how involuntary entry and encapsulation, though at times disadvantageous for the actor, are essential for adaptive action selection during the course of ontogeny.

The impact of combat deployment on asthma diagnosis and severity.

OBJECTIVES: Environmental exposures during military deployments to Iraq and Afghanistan may lead to higher rates of respiratory complaints and diagnoses. This study investigates whether there is a relationship between rates of asthma diagnosis and severity associated with military deployment. METHODS: Retrospective review of active duty Army personnel underwent fitness for duty evaluation (Medical Evaluation Board) for asthma. The electronic medical record was reviewed for onset of diagnosis (pre- or post-deployment), disease severity, screening spirometry, bronchodilator response and bronchoprovocation testing. We compared patients with and without a history of combat deployment to Operations Iraqi Freedom/Enduring Freedom. RESULTS: Four hundred consecutive Army personnel with a clinical diagnosis of asthma were evaluated. Equal numbers of patients had deployed (48.5%) versus never deployed (51.5%). Of those who deployed, 98 (24.5%) were diagnosed post-deployment. The diagnosis of asthma was objectively confirmed in 74.8% of patients by obstructive screening spirometry, bronchodilator response, and/or methacholine challenge testing. There were no significant differences in spirometry between deployers and non-deployers or based on pre- and post-deployment diagnosis. Similarly, asthma severity classification did not differ between deployed and non-deployed service members, or by pre- and post-deployment diagnosis status. CONCLUSIONS: Among active duty military personnel with career limiting asthma, there is no significant relationship between rates of diagnosis or severity based on history of deployment to Southwest Asia.

The impact of deployment on COPD in active duty military personnel.

PURPOSE: To identify trends in chronic obstructive pulmonary disease (COPD) diagnoses among active duty U.S. military personnel based on deployment history and whether International Classification of Disease, 9th edition (ICD-9) coding meet criteria for the diagnosis of COPD. METHODS: A retrospective chart review using the electronic medical system was conducted for military personnel diagnosed with COPD based on ICD-9 codes for emphysema or chronic obstructive lung disease with at least three qualifying outpatient COPD-coded encounters. Clinical symptoms, smoking history, pulmonary function testing, and radiographs obtained during the diagnostic workup were reviewed. The established diagnosis of COPD was analyzed in relation to deployment. RESULTS: A total of 371 patients were identified during the study period (2005-2009). Of these patients, 194 (52.3%) deployed, whereas 177 (47.7%) did not deploy to Southwest Asia since 2003. Thirty-four percent had no documented smoking history despite the diagnosis of COPD. Airway obstruction was identified by spirometry in only 67% of individuals diagnosed with COPD. No statistically significant differences in pulmonary function testing values were identified between those deployed and nondeployed individuals. CONCLUSION: Despite evidence of increased respiratory symptoms in deployed military personnel, the impact of deployment on increased diagnosis of COPD or severity of disease appears minimal.

Military service and lung disease.

OBJECTIVE: Lung diseases associated with military service are often a reflection of the conditions seen in the local civilian population, and with a few notable exceptions, are often related to unique environmental and occupational exposures. METHODS: This article reviews important pulmonary diseases that have been associated with military service in the past 100 years in a question-and-answer format. RESULTS: Traditionally, bacterial and viral pneumonias were the most common sources of military morbidity and mortality. With improved preventive medicine and antimicrobial therapy, other diseases related to battlefield injuries or inhalational exposures have assumed greater importance. CONCLUSIONS: The etiology of military morbidity and mortality has evolved over the past century. Many of the discoveries related to vaccine efficacy, trauma resuscitation, interstitial lung disease, and even carcinomas have a strong military association.

Study of active duty military for pulmonary disease related to environmental deployment exposures (STAMPEDE).

RATIONALE: Because of increased levels of airborne particulate matter in Southwest Asia, deployed military personnel are at risk for developing acute and chronic lung diseases. Increased respiratory symptoms are reported, but limited data exist on reported lung diseases. OBJECTIVES: To evaluate new respiratory complaints in military personnel returning from Southwest Asia to determine potential etiologies for symptoms. METHODS: Returning military personnel underwent a prospective standardized evaluation for deployment-related respiratory symptoms within 6 months of returning to their duty station. MEASUREMENTS AND MAIN RESULTS: Prospective standardized evaluation included full pulmonary function testing, high-resolution chest tomography, methacholine challenge testing, and fiberoptic bronchoscopy with bronchoalveolar lavage. Other procedures including lung biopsy were performed if clinically indicated. Fifty patients completed the study procedures. A large percentage (42%) remained undiagnosed, including 12% with normal testing and an isolated increase in lavage neutrophils or lymphocytes. Twenty (40%) patients demonstrated some evidence of airway hyperreactivity to include eight who met asthma criteria and two with findings secondary to gastroesophageal reflux. Four (8%) additional patients had isolated reduced diffusing capacity and the remaining six had other miscellaneous airway disorders. No patients were identified with diffuse parenchymal disease on the basis of computed tomography imaging. A significant number (66%) of this cohort had underlying mental health and sleep disorders. CONCLUSIONS: Evaluation of new respiratory symptoms in military personnel after service in Southwest Asia should focus on airway hyperreactivity from exposures to higher levels of ambient particulate matter. These patients may be difficult to diagnose and require close follow-up.

Prevalence of supranormal pulmonary function test values between a military and nonmilitary cohort.

BACKGROUND: The study objective was to determine differences in the proportion of supranormal pulmonary function tests (PFTs) between active duty (AD) military personnel and a similar non-active duty (non-AD) population. Given the emphasis on cardiovascular fitness in the military, it has been hypothesized that regular exercise in this cohort leads to an increased proportion of supranormal PFTs. We hypothesized that a comparison of PFTs would identify no differences in the ratio of supranormal to normal PFTs between the AD and non-AD populations. METHODS: A retrospective chart review was conducted of all PFT studies at the Brooke Army Medical Center from 2006 to 2011. Studies were included with either an FVC or FEV1 > 110% of predicted, with both values > 100% of predicted. A comparative analysis was performed for patients between 18 and 50 years of age based on AD status. Further analysis was performed on all ages to determine the distribution of supranormal findings in the entire study population. RESULTS: A total of 16,600 interpreted PFTs were queried. Of those, 4,303 (31.6%) were AD patients, and 9,306 (68.4%) were non-AD patients. From all of the PFTs reviewed, a total of 912 (6.7%) were identified as supranormal. When further analyzed, 381 (9.4%) of AD patients 18-50 years old were supranormal, 175 (12.4%) of non-AD patients 18-50 years old were supranormal, and 356 (4.7%) of non-AD patients older than 50 years were supranormal. CONCLUSIONS: This study revealed no significant difference in the proportion of supranormal-to-normal PFTs in an AD versus non-AD duty population of the same age range. Based on these findings, no assumption should be made that supranormal PFTs are more common in military personnel. Interpretation of normal PFTs in AD personnel undergoing evaluation should not differ from that in any typical patient.

Diagnosis and management of chronic lung disease in deployed military personnel.

Military personnel are a unique group of individuals referred to the pulmonary physician for evaluation. Despite accession standards that limit entrance into the military for individuals with various pre-existing lung diseases, the most common disorders found in the general population such as asthma and chronic obstructive pulmonary disease remain frequently diagnosed. Military personnel generally tend to be a more physically fit population who are required to exercise on a regular basis and as such may have earlier presentations of disease than their civilian counterparts. Exertional dyspnea is a common complaint; establishing a diagnosis may be challenging given the subtle nature of symptoms and lack of specificity with pulmonary function testing. The conflicts over the past 10 years in Iraq and Afghanistan have also given rise to new challenges for deployed military. Various respiratory hazards in the deployed environment include suspended geologic dusts, burn pits, vehicle exhaust emissions, industrial air pollution, and isolated exposure incidents and may give rise to both acute respiratory symptoms and chronic lung disease. In the evaluation of deployed military personnel, establishing the presence of actual pulmonary disease and the relationship of existing disease to deployment is an ongoing issue to both military and civilian physicians. This paper reviews the current evidence for chronic lung disease in the deployed military population and addresses any differences in diagnosis and management.

Overview and recommendations for medical screening and diagnostic evaluation for postdeployment lung disease in returning US warfighters.

OBJECTIVE: To review inhalational exposures and respiratory disease risks in US military personnel deployed to Iraq and Afghanistan and to develop consensus recommendations for medical screening and diagnostic referral. METHODS: A Working Group of physicians and exposure scientists from academia and from the Departments of Defense and Veterans Affairs was convened in February 2010. RESULTS: Despite uncertainty about the number of people affected and risk factors for adverse pulmonary outcomes in this occupational setting, the Working Group recommended: (1) standardized approaches to pre- and postdeployment medical surveillance; (2) criteria for medical referral and diagnosis; and (3) case definitions for major deployment-related lung diseases. CONCLUSIONS: There is a need for targeted, practical medical surveillance for lung diseases and for a standardized diagnostic approach for all symptomatic deployed personnel.

Investigating the respiratory health of deployed military personnel.

Recent news media articles have implied a direct relationship between environmental exposures such as burn pits during current deployments and the development of serious and debilitating chronic pulmonary disease. These articles suggest that the military is superficially investigating evidence that establishes a link between deployment and development of chronic lung disease. Anecdotal cases of military personnel with lung disease are detailed to suggest a systemic problem with undiagnosed and untreated pulmonary disease in deployed service members. Despite these contentions, the U.S. Army Medical Department and other agencies have been actively pursuing numerous scientific investigations into deployment-related lung disease to define the severity and prevalence of the issue. This article will review relevant research efforts by the U.S. military in the existing medical literature and address the current efforts planned by the services to systematically investigate the possibility of deployment-related pulmonary disease.

Intensive education on evidence-based evaluation of syncope increases sudden death risk stratification but fails to reduce use of neuroimaging.

BACKGROUND: We sought to determine whether aggressive education on evidence-based guidelines would affect the use of resources. Specifically, we sought to educate providers about the role of neuroimaging as well as sudden death risk stratification. METHODS: We reviewed 1092 consecutive cases involving patients who were admitted for syncope. We retrospectively reviewed 30 months of admissions for baseline characteristics and then initiated an intensive monthly education campaign directed toward internal medicine physicians-in-training focusing on evidence-based guidelines for a 13-month period. RESULTS: There were 721 patients (66.0%) evaluated before the education intervention and 371 patients (34.0%) evaluated after the education intervention. After the intervention, there was no change in the use of computed tomography (52.3% vs 55.5%; P = .31) or magnetic resonance imaging (20.2% vs 16.7%; P = .16) of the head or carotid ultrasonography (4.7% vs 6.2%; P = .30). The referral rate for electrophysiologic study significantly increased from 6.4% at baseline to 11.3% (P = .006) after intervention, with an overall diagnostic yield of 28.4%. Of those with identified structural heart disease, the referral rate went from 5.7% to 19.0% (P = .03). Only 66 of 1092 patients who presented with syncope ultimately required a pacemaker or defibrillator implantation during hospitalization. CONCLUSIONS: With intensive education, there was no decrease in neuroimaging, despite a low diagnostic yield. We were able to increase sudden death risk stratification using electrophysiologic studies without evidence of overuse of implantable device-based therapy. Intensive education allows increased adherence to guidelines for mortality reduction; however, further attempts to reduce the lower yield imaging will require methods other than education of hospital-based physicians.

Determination of the internal medicine service's role in emergency department length of stay at a military medical center.

OBJECTIVES: Increasing numbers of emergency department (ED) visits and higher leaving-without-being-seen rates resulted in an evaluation of the contribution of the internal medicine service to the admission process. METHODS: Standardized ED encounter sheets were completed by the medicine physician on duty (MOD) assessing various admission and consultative parameters. RESULTS: 304 patient encounters revealed a 44-minute mean time from MOD consultation to order submission; 49% in under 30 minutes and 76% in under an hour. There was no difference in time among MOD shifts, staff and residents, or admission diagnoses. Reasons for delays were receiving multiple consults at a time (36%) and needing further specialty consultation or additional workup (30%). CONCLUSIONS: Most medicine admissions took less than an hour from time of MOD consultation to time orders were written. Areas of improvement include expediting discussion with specialists and timely but appropriate ED workup before consultation.

The prevalence and impact of respiratory symptoms in asthmatics and nonasthmatics during deployment.

OBJECTIVE: The purpose of this study was to compare the prevalence, severity, and impact of respiratory symptoms in asthmatics and nonasthmatics during Operation Enduring Freedom and Operation Iraqi Freedom. METHODS: A survey was given to 1,250 active duty soldiers and Department of Defense contractors returning from Operation Enduring Freedom/Operation Iraqi Freedom. Subjects were asked about demographics, smoking habits, respiratory symptoms, and impact on job performance before and during deployment. Patients with a history of asthma were asked method of diagnosis, current symptoms, and asthma therapy. RESULTS: A total of 1,193 subjects returned the completed questionnaire (95% response rate). Mean age of respondents was 38 +/- 11 years, 83% (n = 977) were male, and 31% (n = 375) were past or present smokers. Sixty-one subjects (5%) reported a previous diagnosis of asthma. Both asthmatics and nonasthmatics had increased respiratory symptoms of wheezing, cough, sputum production, chest pain/tightness, and allergy symptoms during deployment compared to predeployment (p < 0.05 for all). When compared to nonasthmatics, asthmatic subjects reported more wheezing, sputum production, and chest pain/tightness during deployment (p < 0.0001, 0.05, 0.05 respectively), had more difficulty with military duties (p < 0.05), and were more likely to seek medical attention and receive duty restrictions (p < 0.0001). Twenty-six percent (n = 16) of asthmatics reported poor baseline symptom control, and this group had significantly increased symptoms, functional limitations, and health care utilization when compared to asthmatics who were symptom-controlled at baseline. CONCLUSIONS: Respiratory symptoms were common among both asthmatics and nonasthmatics during deployment. Differences in symptoms and health care utilization in this group of asthmatics were primarily due to subjects with poor baseline control.

The demonstration of pulmonary neuroendocrine cell hyperplasia with tumorlets in a patient with chronic cough and a history of multiple medical problems.

A 58-year-old woman presented with chronic cough felt to be multifactorial secondary to asthma, gastroesophageal reflux disease, and chronic sinusitis. Additional medical history included obstructive sleep apnea, type 2 diabetes, and hypertension. She had a 40- year history of tobacco use, but quit 10 years ago. Her examination was significant for obesity and cobble stoning of the oropharynx. Pulmonary function testing and arterial blood gases were unrevealing. Chest films were normal. High-resolution computed tomography revealed multiple focal lucencies in a mosaic pattern consistent with air trapping and small airways disease. Bronchoscopy revealed normal airways and a noninflammatory bronchoalveolar lavage. Transbronchial biopsies revealed inflammatory infiltrates of the peribronchiolar interstitium. Lung biopsy revealed pulmonary neuroendocrine cell hyperplasia with tumorlets that stained positive for neuroendocrine tissue. We present the case of a woman with chronic cough, multiple medical problems, and pulmonary neuroendocrine cell hyperplasia with tumorlets.