Traumatic orbital encephalocele: Presentation and imaging.

OBJECTIVE: Traumatic orbital encephalocele is a rare but severe complication of orbital roof fractures. We describe 3 cases of orbital encephalocele due to trauma in children. METHODS: Retrospective case series from the University of Wisconsin - Madison and Medical College of Wisconsin. RESULTS: Three cases of traumatic orbital encephalocele in pediatric patients were found. The mechanism of injury was motor vehicle accident in 2 patients and accidental self-inflicted gunshot wound in 1 patient. All 3 patients sustained orbital roof fractures (4 mm to 19 mm in width) and frontal lobe contusions with high intracranial pressure. A key finding in all 3 cases was progression of proptosis and globe displacement 4 to 11 days after initial injury. On initial CT, all were diagnosed with extraconal hemorrhage adjacent to the roof fractures, with subsequent enlargement of the mass and eventual diagnosis of encephalocele. CONCLUSION: Orbital encephalocele is a severe and sight-threatening complication of orbital roof fractures. Post-traumatic orbital encephalocele can be challenging to diagnose on CT as patients with this condition often have associated orbital and intracranial hematoma, which can be difficult to distinguish from herniated brain tissue. When there is a high index of suspicion for encephalocele, an MRI of the orbits and brain with contrast should be obtained for additional characterization. Imaging signs that should raise suspicion for traumatic orbital encephalocele include an enlarging heterogeneous orbital mass in conjunction with a roof fracture and/or widening fracture segments.

Risk for broad-spectrum neuropsychiatric disorders after mild traumatic brain injury in a cohort of US Air Force personnel.

BACKGROUND: Military personnel are at increased risk for traumatic brain injury (TBI) from combat and non-combat exposures. Sequelae of moderate-to-severe TBI are well described, but the literature remains conflicted regarding whether mild TBI (mTBI) results in lasting brain injury and functional impairments. This study assessed risk for a range of neuropsychiatric disorders presenting after mTBI while adjusting for the potential confounds of depression and post-traumatic stress disorder (PTSD). METHODS: A historical prospective association study was conducted utilising electronic demographic, medical and military-specific data for over 49,000 active duty US Air Force service members (Airmen). This study utilised diagnostic codes considered by an expert panel to be indicative of mTBI to identify cases. Cox proportional hazards modelling calculated HRs for neuropsychiatric outcomes while controlling for varying lengths of follow-up and potentially confounding variables. RESULTS: Airmen with mTBI were at increased risk for specific neuropsychiatric disorders compared with a similarly injured non-mTBI control group. HRs for memory loss/amnesia, cognitive disorders, schizophrenia, PTSD, and depression were significantly elevated and remained so for at least 6 months post-mTBI, even after eliminating those with previous neuropsychiatric diagnoses. CONCLUSIONS: mTBI was positively associated with neuropsychiatric disorders in this population of primarily young adult males; with increased HRs 6 months post-mTBI. The results support that mTBI is distinguished from moderate-to-severe TBI in terms of risk for developing neuropsychiatric disorders. Further, these findings suggest the importance of screening for psychiatric and cognitive disorders post-mTBI in general medical practice.

Neurologically-related sequelae associated with mild traumatic brain injury.

OBJECTIVE: Mild traumatic brain injury (mTBI) accounts for more than 75% of traumatic brain injuries every year. This study examines the temporal association between non-blast mTBI and the onset of neurologic sequelae to illuminate risks of post-concussive syndrome, epilepsy and chronic pain. METHODS: A large historical prospective study was conducted utilizing electronically-recorded demographic, medical and military-specific data for over half a million active duty US Air Force Airmen. This study utilized diagnostic codes to identify mTBI exposures, two control groups and three post-mTBI time periods. Adjusted hazard ratios (HRs) were calculated using Cox proportional hazards modelling. RESULTS: HRs were higher when mTBI exposed Airmen were compared with the full cohort and lower when compared with the other injured group. When compared to the other injured group, mTBI was positively associated with epilepsy/recurrent seizure outcomes, post-concussive syndrome and pain disorders. HRs tended to be highest within the first 30 days and decreased over time. CONCLUSIONS: Findings support that mTBI may have a prolonged neurological impact. Findings are also likely generalizable to young adult populations with exposure to non-blast related mTBI, including civilians, as those included in this study were young adults with a high prevalence of recreational/sports and motor vehicle injuries.

Surgical timing and postoperative ocular motility in type B orbital blowout fractures.

PURPOSE: To determine whether patients with Type B orbital blowout fractures (soft-tissue distortion disproportionate to bone-fragment displacement) repaired within 7 days of injury have statistically greater postoperative vertical binocular fusion than similar patients who undergo later surgery. METHODS: Prospective and retrospective surgical case series. Inclusion criteria were orbital floor (with or without medial wall) blowout fracture repair, preoperative coronal orbital CT scans, and patient age of at least 12 years at time of postoperative binocular visual field. RESULTS: Twenty-five patients met inclusion criteria. Ten patients (group 1) had surgery within 7 days of injury, and 15 patients (group 2) had surgery more than 7 days after injury. The total cohort had a median postoperative vertical binocular fusion of 90°. Group 1 had postoperative vertical binocular fusion averaging 100°. Nine of 10 patients (90%) were above and 1 of 10 (10%) were below the median for the entire cohort. Group 2 had postoperative vertical binocular fusion averaging 70°. Three of 15 patients (20%) were above and 12 of 15 patients (80%) were below the median for the entire cohort. The difference between the average postoperative vertical binocular fusion of the 2 groups was statistically significant by two-tailed unpaired t test with p value 0.0022. CONCLUSIONS: Patients with Type B orbital blowout fractures (soft-tissue distortion disproportionate to bone-fragment displacement) have statistically greater average postoperative vertical binocular fusion if repaired within 7 days of injury than similar patients who undergo later surgery.

Hearing loss associated with US military combat deployment.

The objective of this study was to define the risk of hearing loss among US military members in relation to their deployment experiences. Data were drawn from the Millennium Cohort Study. Self-reported data and objective military service data were used to assess exposures and outcomes. Among all 48,540 participants, 7.5% self-reported new-onset hearing loss. Self-reported hearing loss showed moderate to substantial agreement (k = 0.57-0.69) with objective audiometric measures. New-onset hearing loss was associated with combat deployment (adjusted odds ratio [AOR] = 1.63, 95% confidence interval [CI] = 1.49-1.77), as well as male sex and older age. Among deployers, new-onset hearing loss was also associated with proximity to improvised explosive devices (AOR = 2.10, 95% CI = 1.62-2.73) and with experiencing a combat-related head injury (AOR = 6.88, 95% CI = 3.77-12.54). These findings have implications for health care and disability planning, as well as for prevention programs.

Listening to the nurse pays off: an integrated Nurse HealthLine programme was associated with significant cost savings.

AIM: To estimate the relationship between adherence to nurse recommendations about where to seek care and expenditures for health-care services received by callers to a Nurse HealthLine telephone-based triage programme. METHODS: Health-care utilization and claims data from callers to the Nurse HealthLine were included. Adherent callers were those who followed the nurse recommendations, while those who did not were classified as non-adherent. Programme-related savings were estimated using differences in downstream health-care expenditures between adherent and non-adherent callers after using multivariate modelling to adjust for between-group differences. RESULTS: Fifty-five per cent of callers were adherent. Nurses were over three times as likely (41% vs. 13%) to recommend seeking a higher level of care (e.g. emergency room vs. urgent care). Regression analyses showed that the impact of getting members to the appropriate place of care was associated with significant annual savings of $13.8 million (P < 0.05), attributable mostly to Medicare, generating a positive return on investment of $1.59. CONCLUSIONS: This is the first known Nurse HealthLine triage programme exclusively for Medicare beneficiaries with supplemental coverage. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers should consider promoting telephone-based triage programmes as complementary to clinical nursing, which has a direct impact on health-care utilization and costs.

The impact of prior deployment experience on civilian employment after military service.

OBJECTIVE: To determine if deployment to recent military operations or other health, demographic, or military-related characteristics were associated with employment after military service. METHODS: Former US active duty military service members participating in the Millennium Cohort Study, a population-based sample of US military personnel that began in July of 2001, were prospectively followed from the time of baseline health reporting to self-reported employment status after military separation. RESULTS: Of the 9099 separated personnel meeting inclusion criteria, 17% reported unemployment after military service. In multivariable modelling, prior deployment experiences, with or without reported combat, and post-traumatic stress disorder (PTSD) were not significantly associated with employment status postservice. Among those who routinely retired from service with a pension, positive screens for depression (OR, 1.67; 95% CI, 1.05 to 2.63) and panic/anxiety (OR, 1.63; 95% CI, 1.10 to 2.43) were significantly associated with subsequent unemployment. Poor physical health, female sex, black race, lower education and disabling illnesses/injuries were also predictive of postservice unemployment. CONCLUSIONS: After stratifying for reason for military separation, mental disorders like depression or panic/anxiety and poor physical health may have greater impact than prior deployment experiences or PTSD on the ability to find or maintain employment postservice. These findings may guide support for veterans most in need of job placement services after military service.

Prospective evaluation of mental health and deployment experience among women in the US military.

Previous research has shown that military women often experience potentially severe health outcomes following deployment. Data from the Millennium Cohort Study, a 21-year longitudinal study examining the health effects of military service, were used to examine this issue. In longitudinal analyses (2001-2008) carried out among US military women (n = 17,481), the authors examined positive screens for depression, anxiety, panic, and posttraumatic stress disorder in relation to deployment in support of the operations in Iraq and Afghanistan, while adjusting for relevant baseline and time-varying covariates. Women who were deployed and reported combat-related exposures had greater odds than nondeployed women of reporting symptoms of a mental health condition (odds ratio = 1.91, 95% confidence interval: 1.65, 2.20), after adjustment for demographic, military, and behavioral covariates. In addition, higher stress, problem drinking, and a history of mental illness were significantly associated with increased risk of later mental health conditions. In contrast, women in the Reserves or National Guard and those with higher education were at decreased risk of mental health conditions (all P 's < 0.01). As the roles and responsibilities of women in the military expand and deployments continue, designing better prevention and recovery strategies specifically for women are critical for overall force health protection and readiness.

Trajectories of trauma symptoms and resilience in deployed U.S. military service members: prospective cohort study.

BACKGROUND: Most previous attempts to determine the psychological cost of military deployment have been limited by reliance on convenience samples, lack of pre-deployment data or confidentiality and cross-sectional designs. AIMS: This study addressed these limitations using a population-based, prospective cohort of U.S. military personnel deployed in support of the operations in Iraq and Afghanistan. METHOD: The sample consisted of U.S. military service members in all branches including active duty, reserve and national guard who deployed once (n = 3393) or multiple times (n = 4394). Self-reported symptoms of post-traumatic stress were obtained prior to deployment and at two follow-ups spaced 3 years apart. Data were examined for longitudinal trajectories using latent growth mixture modelling. RESULTS: Each analysis revealed remarkably similar post-traumatic stress trajectories across time. The most common pattern was low-stable post-traumatic stress or resilience (83.1% single deployers, 84.9% multiple deployers), moderate-improving (8.0%, 8.5%), then worsening-chronic post-traumatic stress (6.7%, 4.5%), high-stable (2.2% single deployers only) and high-improving (2.2% multiple deployers only). Covariates associated with each trajectory were identified. CONCLUSIONS: The final models exhibited similar types of trajectories for single and multiple deployers; most notably, the stable trajectory of low post-traumatic stress preto post-deployment, or resilience, was exceptionally high. Several factors predicting trajectories were identified, which we hope will assist in future research aimed at decreasing the risk of post-traumatic stress disorder among deployers.

A comparison of mental health outcomes in persons entering U.S. military service before and after September 11, 2001.

It has been hypothesized that those who entered military service in the pre-September 11, 2001 era might have expectations incongruent with their subsequent experiences, increasing the risk for posttraumatic stress disorder (PTSD) or other mental disorders. A subset of Millennium Cohort Study participants who joined the military during 1995-1999 was selected and compared with a subset of members who joined the military in 2002 or later. Outcomes included new-onset symptoms of PTSD, depression, panic/anxiety, and alcohol-related problems. Multivariable methods adjusted for differences in demographic and military characteristics. More than 11,000 cohort members were included in the analyses. Those who entered service in the pre-September 11 era had lower odds of new-onset PTSD symptoms (odds ratio [OR] 0.74, 95% CI [0.59, 0.93]) compared with the post-September 11 cohort. There were no statistically significant differences in rates of new-onset symptoms of depression, panic/anxiety, or alcohol-related problems between the groups. The cohort who entered military service in the pre-September 11 era did not experience higher rates of new-onset mental health challenges compared with the cohort who entered service after September 11, 2001. Findings support the concept that the experience of war, and resulting psychological morbidity, is not a function of incongruent expectations.

Posttraumatic stress disorder and depression among U.S. military health care professionals deployed in support of operations in Iraq and Afghanistan.

Limited prospective studies exist that evaluate the mental health status of military health care professionals who have deployed. This study used prospective data from the Millennium Cohort Study with longitudinal analysis techniques to examine whether health care professionals deployed in support of the operations in Iraq and Afghanistan were more likely to screen positive for new-onset posttraumatic stress disorder (PTSD) or depression after deployment than individuals from other occupations. Of 65,108 subjects included, 9,371 (14.4%) reported working as health care professionals. The rates of new positive screens for PTSD or depression were similar for those in health care occupations (4.7% and 4.3%) compared with those in other occupations (4.6% and 3.9%) for the first and second follow-up, respectively. Among military personnel deployed with combat experience, health care professionals did not have increased odds for new-onset PTSD or depression over time. Among deployed health care professionals, combat experience significantly increased the odds: adjusted odds ratio = 2.01; 95% confidence interval [1.06, 3.83] for new-onset PTSD or depression. These results suggest that combat experience, not features specific to being a health care professional, was the key exposure explaining the development of these outcomes.

Two late complications of craniofacial trauma: case report and review of the literature.

Injuries after blunt and penetrating trauma to the face are a common occurrence and are managed by specialists from several disciplines. After short-term care and immediate recovery, long-term complications can develop including cosmetic deformity, unsightly scarring, problems with soft tissue healing, malunion or nonunion of bony segments, diplopia or other visual complaints, malocclusion, hardware failure, and mucocele formation. Here, we present a report of 2 late complications recognized and treated in a patient 40 years after an episode of craniofacial trauma: epistaxis with symptomatic nasal congestion from fixation wires and mucocele formation. Management of this patient accompanied by endoscopic photographs and computed tomographic images is presented, and discussion of these complications along with review of the literature is provided.

Prospectively assessed posttraumatic stress disorder and associated physical activity.

OBJECTIVES: We examined the association of physical activity with prospectively assessed posttraumatic stress disorder (PTSD) symptoms in a military cohort. METHODS: Using baseline and follow-up questionnaire data from a large prospective study of U.S. service members, we applied multivariable logistic regression to examine the adjusted odds of new-onset and persistent PTSD symptoms associated with light/moderate physical activity, vigorous physical activity, and strength training at follow-up. RESULTS: Of the 38,883 participants, 89.4% reported engaging in at least 30 minutes of physical activity per week. At follow-up, those who reported proportionately less physical activity were more likely to screen positive for PTSD. Vigorous physical activity had the most consistent relationship with PTSD. Those who reported at least 20 minutes of vigorous physical activity twice weekly had significantly decreased odds for new-onset (odds ratio [OR] = 0.58, 95% confidence interval [CI] 0.49, 0.70) and persistent (OR = 0.59, 95% CI 0.42, 0.83) PTSD symptoms. CONCLUSIONS: Engagement in physical activity, especially vigorous activity, is significantly associated with decreased odds of PTSD symptoms among U.S. service members. While further longitudinal research is necessary, a physical activity component may be valuable to PTSD treatment and prevention programs.

Health impact of US military service in a large population-based military cohort: findings of the Millennium Cohort Study, 2001-2008.

BACKGROUND: Combat-intense, lengthy, and multiple deployments in Iraq and Afghanistan have characterized the new millennium. The US military's all-volunteer force has never been better trained and technologically equipped to engage enemy combatants in multiple theaters of operations. Nonetheless, concerns over potential lasting effects of deployment on long-term health continue to mount and are yet to be elucidated. This report outlines how findings from the first 7 years of the Millennium Cohort Study have helped to address health concerns related to military service including deployments. METHODS: The Millennium Cohort Study was designed in the late 1990s to address veteran and public concerns for the first time using prospectively collected health and behavioral data. RESULTS: Over 150,000 active-duty, reserve, and National Guard personnel from all service branches have enrolled, and more than 70% of the first 2 enrollment panels submitted at least 1 follow-up survey. Approximately half of the Cohort has deployed in support of operations in Iraq and Afghanistan. CONCLUSION: The Millennium Cohort Study is providing prospective data that will guide public health policymakers for years to come by exploring associations between military exposures and important health outcomes. Strategic studies aim to identify, reduce, and prevent adverse health outcomes that may be associated with military service, including those related to deployment.

Mental health impact of the Iraq and Afghanistan conflicts: a review of US research, service provision, and programmatic responses.

Although documentation that war inflicts psychological casualties dates back to the American Civil War and earlier, most research began after the Vietnam conflict, when studies focused on post-traumatic stress disorder (PTSD). With ongoing conflicts in Iraq and Afghanistan, there has been significant research to illuminate the epidemiology of war-related psychological casualties. Significant findings include an appreciation for the role combat plays in the development of mental disorders, including PTSD and traumatic brain injury (TBI). Recent research has endeavoured to understand and improve psychological resilience to temper potentially adverse mental health effects of military service in the theatre of combat operations. Over 2 million US service members have now deployed and returned over 3 million times to the Iraq and Afghanistan conflicts. Mental health providers in the Departments of Defense and Veterans Affairs healthcare systems have consequently observed steep increases in mental health service use among these personnel. The Departments have responded aggressively to bolster staffing levels, increase capacity, improve available services, and anticipate future needs. Scientists and clinicians continue efforts to understand the determinants, prevention, recognition, and treatment of combat-related mental disorders.

Civil engineering airman at increased risk for injuries and injury-related musculoskeletal disorders.

BACKGROUND: With the advent of electronic records, the opportunity to conduct research on workplace-related injuries and musculoskeletal disorders has increased dramatically. The purpose of this study was to examine the United States Air Force Civil Engineering career field to determine if they are negatively impacted by their work environment. Specifically, the objective of this study was to determine if enlisted Civil Engineering Airmen (n = 25,385) were at increased risk for injury or injury-related musculoskeletal disorders compared to enlisted Information Management/Communications Airmen (n = 28,947). METHODS: Using an historical prospective design, electronic data were assembled and analyzed using Cox's proportional hazards modeling. Models were stratified by gender and adjusted for race/ethnicity, marital status, birth year, and deployment status. RESULTS: Male Civil Engineers were observed to be at greater risk for both inpatient injury-related musculoskeletal disorders (HR = 1.86; 95% CI = 1.54-2.26) and injuries (HR = 1.77; 95% CI = 1.48-2.11), while female Civil Engineers were more than double the risk for both inpatient injury-related musculoskeletal disorders (HR = 2.18; 95% CI = 1.28-3.73) and injuries (HR = 2.22; 95% CI = 1.27-3.88) compared to Information Management/Communications Airmen. CONCLUSIONS: Although analyses do not allow exploration of specific causes, they highlight the utility of using electronic data to identify occupations for further evaluation. Based on these results, additional resources were allocated to survey Civil Engineers on their physical work demands and job requirements to identify key problem areas for further study and mitigation.

Health care utilization among complementary and alternative medicine users in a large military cohort.

BACKGROUND: Complementary and Alternative Medicine use and how it impacts health care utilization in the United States Military is not well documented. Using data from the Millennium Cohort Study we describe the characteristics of CAM users in a large military population and document their health care needs over a 12-month period. The aim of this study was to determine if CAM users are requiring more physician-based medical services than users of conventional medicine. METHODS: Inpatient and outpatient medical services were documented over a 12-month period for 44,287 participants from the Millennium Cohort Study. Equal access to medical services was available to anyone needing medical care during this study period. The number and types of medical visits were compared between CAM and non-CAM users. Chi square test and multivariable logistic regression was applied for the analysis. RESULTS: Of the 44,287 participants, 39% reported using at least one CAM therapy, and 61% reported not using any CAM therapies. Those individuals reporting CAM use accounted for 45.1% of outpatient care and 44.8% of inpatient care. Individuals reporting one or more health conditions were 15% more likely to report CAM use than non-CAM users and 19% more likely to report CAM use if reporting one or more health symptoms compared to non-CAM users. The unadjusted odds ratio for hospitalizations in CAM users compared to non-CAM users was 1.29 (95% CI: 1.16-1.43). The mean number of days receiving outpatient care for CAM users was 7.0 days and 5.9 days for non-CAM users (p < 0.001). CONCLUSIONS: Our study found those who report CAM use were requiring more physician-based medical services than users of conventional medicine. This appears to be primarily the result of an increase in the number of health conditions and symptoms reported by CAM users.

Direct fixation of extraocular muscles to a silicone sphere: a cost-sensitive, low-risk enucleation procedure.

PURPOSE: To describe a simple, cost-sensitive enucleation technique and to evaluate it in the context of intended benefits and long-term outcomes of alternate methods. METHODS: A retrospective record review of patients who underwent enucleation using the described technique at a single institution by 2 surgeons. Surgery involved direct fixation of extraocular muscles to a solid silicone sphere, using nonabsorbable braided sutures with knots tied beneath the muscle insertions. Outcome measures included implant-related complications. RESULTS: Seventy-five patients meeting inclusion criteria ranged in age from 3 to 94 years (mean, 54 years; median, 56 years). Surgical indications included a blind painful or disrupted eye in 56 cases; uveal melanoma in 15 cases; retinoblastoma in 2 cases; and endophthalmitis in 2 cases. Follow-up intervals ranged from 3 to 57 months (mean, 27 months; median, 22 months). Complications requiring surgical revision of the implant occurred in 2 of the 75 cases (one luxation; one exposure). There were no instances of chronic socket discharge or implant infection. CONCLUSIONS: Nonabsorbable-suture attachment of muscles to a solid silicone implant offers an inexpensive enucleation option, with minimal risk of implant migration, exposure, or infection. In light of widespread disaffection with pegging of porous implants, and with no motility advantage of unpegged porous over nonporous implants, consideration should be given to techniques that are equally effective, less costly, and perhaps more reliable.

Racial differences in prostate cancer risk remain among US servicemen with equal access to care.

BACKGROUND: Prostate cancer is the most common cancer among US men, however, the etiology remains unclear. Yet, one consistency is that black non-Hispanic men are at increased risk for prostate cancer compared to white, non-Hispanic men. The goal of this study was to assess relations between demographic and other potential prostate cancer risk factors in the context of the US military healthcare system, which provides equal access to all US servicemen. METHODS: Military healthcare and demographic data were used to describe risk factors for prostate cancer in the US military from September 1993 to September 2003. Cox's proportional hazards regression was employed to model the time to prostate cancer hospitalization. RESULTS: Four hundred eight first prostate cancer hospitalizations were identified among 2,761,559 servicemen. The adjusted rate per 100,000 persons rose from 1.41 to 3.62 for white non-Hispanic men and 1.43 to 6.08 for black non-Hispanic men by the end of the study. The increasing incidence over time for combined race/ethnic groups was similar to trends reported in the Surveillance, Epidemiology, and End Results Program for the US civilian population. No association was observed between occupation and prostate cancer hospitalization. However, black non-Hispanic men were at increased risk compared with white non-Hispanic men (hazard ratio = 2.72, 95% confidence interval: 2.12, 3.49). CONCLUSIONS: No association was observed between occupation and prostate cancer hospitalization. In this relatively young cohort, black non-Hispanic race/ethnicity was found to be predictive of prostate cancer, and this association existed regardless of access to care and socioeconomic status.