Detecting Atrial Fibrillation in the Emergency Department in Patients with Cardiac Implantable Electronic Devices.

BACKGROUND: Clinical guidelines emphasize identifying atrial fibrillation (AF) as a strategy to reduce stroke risk. Cardiac implantable electronic device (CIED) interrogation at the point of care may facilitate AF detection, increasing opportunities to identify patients at high risk for stroke. OBJECTIVES: This study sought to quantify AF prevalence and assess stroke risk in patients with a CIED who presented to the emergency department (ED). METHODS: This noninterventional, retrospective observational study included adult patients who presented at a single facility ED that incorporated device interrogation as a routine standard practice for all patients with a CIED. Interrogations were conducted in 494 unique patients, and relevant demographic/clinical information was captured from electronic medical records. RESULTS: AF was detected via CIED interrogation in 54.8% (271/494) of the unique patient population that presented to the ED. Device interrogation detected the presence of AF in 110 patients without a documented past history or current diagnosis of AF, representing 22.3% (110/494) of total unique patients. Based on CHA2DS2-VASc (Congestive heart failure, Hypertension, Age > 75 years, Diabetes mellitus, prior Stroke or transient ischemic attack or thromboembolism, Vascular disease, Age 65-74 years, Sex category [female]) risk scoring methodology, over three-quarters of these newly detected AF patients (78.2%, 86/110) were classified in a high stroke risk category that reflected a > 2.2% annualized risk, and over half (57.3%, 63/110) presented to the ED for reasons unrelated to cardiac/dysrhythmia problems. CONCLUSIONS: The use of technology-assisted device interrogation of CIEDs at the point of care has promise in identifying patients with asymptomatic AF. Results suggest consideration of routine device interrogation of CIEDs in the ED, regardless of reason for admission or history of AF.

Impact of combat deployment and posttraumatic stress disorder on newly reported coronary heart disease among US active duty and reserve forces.

BACKGROUND: The recent conflicts in Iraq and Afghanistan have exposed thousands of service members to intense stress, and as a result, many have developed posttraumatic stress disorder (PTSD). The role of military deployment experiences and PTSD in coronary heart disease (CHD) is not well defined, especially in young US service members with recent combat exposure. METHODS AND RESULTS: We conducted a prospective cohort study to investigate the relationships between wartime experiences, PTSD, and CHD. Current and former US military personnel from all service branches participating in the Millennium Cohort Study during 2001 to 2008 (n=60 025) were evaluated for newly self-reported CHD. Electronic medical record review for International Classification of Diseases, Ninth Revision, Clinical Modification codes for CHD was conducted among a subpopulation of active duty members (n=23 794). Logistic regression models examined the associations between combat experiences and PTSD with CHD with adjustment for established CHD risk factors. A total of 627 participants (1.0%) newly reported CHD over an average of 5.6 years of follow-up. Deployers with combat experiences had an increased odds of newly reporting CHD (odds ratio, 1.63; 95% confidence interval, 1.11-2.40) and having a diagnosis code for new-onset CHD (odds ratio, 1.93; 95% confidence interval, 1.31-2.84) compared with noncombat deployers. Screening positive for PTSD symptoms was associated with self-reported CHD before but not after adjustment for depression and anxiety and was not associated with a new diagnosis code for CHD. CONCLUSIONS: Combat deployments are associated with new-onset CHD among young US service members and veterans. Experiences of intense stress may increase the risk for CHD over a relatively short period among young adults.

Chronic multisymptom illness: a comparison of Iraq and Afghanistan deployers with veterans of the 1991 Gulf War.

Symptoms and illnesses reported by veterans of the 1991 Gulf War era are a cause of potential concern for those military members who have deployed to the Gulf region in support of more recent contingency operations in Iraq and Afghanistan. In the present study, we quantified self-reported symptoms from participants in the Millennium Cohort Study, a prospective study representing all US service branches, including both active duty and Reserve/National Guard components (2001-2008). Self-reported symptoms were uniquely compared with those in a cohort of subjects from the 1991 Gulf War to gain context for the present report. Symptoms were then aggregated to identify cases of chronic multisymptom illness (CMI) based on the case definition from the Centers for Disease Control and Prevention. The prevalence of self-reported CMI symptoms was compared with that collected in 1997-1999 from a study population of US Seabees from the 1991 Gulf War, as well as from deployed and nondeployed subgroups. Although overall symptom reporting was much less in the Millennium Cohort than in the 1991 Gulf War cohort, a higher prevalence of reported CMI was noted among deployed compared with nondeployed contemporary cohort members. An increased understanding of coping skills and resilience and development of well-designed screening instruments, along with appropriate clinical and psychological follow-up for returning veterans, might help to focus resources on early identification of potential long-term chronic disease manifestations.

Acupuncture for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial.

Importance: Current interventions for posttraumatic stress disorder (PTSD) are efficacious, yet effectiveness may be limited by adverse effects and high withdrawal rates. Acupuncture is an emerging intervention with positive preliminary data for PTSD. Objective: To compare verum acupuncture with sham acupuncture (minimal needling) on clinical and physiological outcomes. Design, Setting, and Participants: This was a 2-arm, parallel-group, prospective blinded randomized clinical trial hypothesizing superiority of verum to sham acupuncture. The study was conducted at a single outpatient-based site, the Tibor Rubin VA Medical Center in Long Beach, California, with recruitment from April 2018 to May 2022, followed by a 15-week treatment period. Following exclusion for characteristics that are known PTSD treatment confounds, might affect biological assessment, indicate past nonadherence or treatment resistance, or indicate risk of harm, 93 treatment-seeking combat veterans with PTSD aged 18 to 55 years were allocated to group by adaptive randomization and 71 participants completed the intervention protocols. Interventions: Verum and sham were provided as 1-hour sessions, twice weekly, and participants were given 15 weeks to complete up to 24 sessions. Main Outcomes and Measures: The primary outcome was pretreatment to posttreatment change in PTSD symptom severity on the Clinician-Administered PTSD Scale-5 (CAPS-5). The secondary outcome was pretreatment to posttreatment change in fear-conditioned extinction, assessed by fear-potentiated startle response. Outcomes were assessed at pretreatment, midtreatment, and posttreatment. General linear models comparing within- and between-group were analyzed in both intention-to-treat (ITT) and treatment-completed models. Results: A total of 85 male and 8 female veterans (mean [SD] age, 39.2 [8.5] years) were randomized. There was a large treatment effect of verum (Cohen d, 1.17), a moderate effect of sham (d, 0.67), and a moderate between-group effect favoring verum (mean [SD] Δ, 7.1 [11.8]; t90 = 2.87, d, 0.63; P = .005) in the intention-to-treat analysis. The effect pattern was similar in the treatment-completed analysis: verum d, 1.53; sham d, 0.86; between-group mean (SD) Δ, 7.4 (11.7); t69 = 2.64; d, 0.63; P = .01). There was a significant pretreatment to posttreatment reduction of fear-potentiated startle during extinction (ie, better fear extinction) in the verum but not the sham group and a significant correlation (r = 0.31) between symptom reduction and fear extinction. Withdrawal rates were low. Conclusions and Relevance: The acupuncture intervention used in this study was clinically efficacious and favorably affected the psychobiology of PTSD in combat veterans. These data build on extant literature and suggest that clinical implementation of acupuncture for PTSD, along with further research about comparative efficacy, durability, and mechanisms of effects, is warranted. Trial Registration: ClinicalTrials.gov Identifier: NCT02869646.

The impact of deployment experience and prior healthcare utilization on enrollment in a large military cohort study.

BACKGROUND: Longitudinal cohort studies are highly valued in epidemiologic research for their ability to establish exposure-disease associations through known temporal sequences. A major challenge in cohort studies is recruiting individuals representative of the targeted sample population to ensure the generalizability of the study's findings. METHODS: We evaluated nearly 350,000 invited subjects (from 2004-2008) of the Millennium Cohort Study, a prospective cohort study of the health of US military personnel, for factors prior to invitation associated with study enrollment. Multivariable logistic regression was utilized, adjusting for demographic and other confounders, to determine the associations between both deployment experience and prior healthcare utilization with enrollment into the study. RESULTS: Study enrollment was significantly greater among those who deployed prior to and/or during the enrollment cycles or had at least one outpatient visit in the 12 months prior to invitation. Mental disorders and hospitalization for more than two days within the past year were associated with reduced odds of enrollment. CONCLUSIONS: These findings suggest differential enrollment by deployment experience and health status, and may help guide recruitment efforts in future studies.

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.

Risk factors associated with suicide in current and former US military personnel.

IMPORTANCE: Beginning in 2005, the incidence of suicide deaths in the US military began to sharply increase. Unique stressors, such as combat deployments, have been assumed to underlie the increasing incidence. Previous military suicide studies, however, have relied on case series and cross-sectional investigations and have not linked data during service with postservice periods. OBJECTIVE: To prospectively identify and quantify risk factors associated with suicide in current and former US military personnel including demographic, military, mental health, behavioral, and deployment characteristics. DESIGN, SETTING, AND PARTICIPANTS: Prospective longitudinal study with accrual and assessment of participants in 2001, 2004, and 2007. Questionnaire data were linked with the National Death Index and the Department of Defense Medical Mortality Registry through December 31, 2008. Participants were current and former US military personnel from all service branches, including active and Reserve/National Guard, who were included in the Millennium Cohort Study (N = 151,560). MAIN OUTCOMES AND MEASURES: Death by suicide captured by the National Death Index and the Department of Defense Medical Mortality Registry. RESULTS: Through the end of 2008, findings were 83 suicides in 707,493 person-years of follow-up (11.73/100,000 person-years [95% CI, 9.21-14.26]). In Cox models adjusted for age and sex, factors significantly associated with increased risk of suicide included male sex, depression, manic-depressive disorder, heavy or binge drinking, and alcohol-related problems. None of the deployment-related factors (combat experience, cumulative days deployed, or number of deployments) were associated with increased suicide risk in any of the models. In multivariable Cox models, individuals with increased risk for suicide were men (hazard ratio [HR], 2.14; 95% CI, 1.17-3.92; P = .01; attributable risk [AR], 3.5 cases/10,000 persons), and those with depression (HR, 1.96; 95% CI, 1.05-3.64; P = .03; AR, 6.9/10,000 persons), manic-depressive disorder (HR, 4.35; 95% CI, 1.56-12.09; P = .005; AR, 35.6/10,000 persons), or alcohol-related problems (HR, 2.56; 95% CI, 1.56-4.18; P <.001; AR, 7.7/10,000 persons). A nested, matched case-control analysis using 20:1 control participants per case confirmed these findings. CONCLUSIONS AND RELEVANCE: In this sample of current and former military personnel observed July 1, 2001-December 31, 2008, suicide risk was independently associated with male sex and mental disorders but not with military-specific variables. These findings may inform approaches to mitigating suicide risk in this population.

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.

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.

The impact of key secular trends during the first three waves the COVID-19 pandemic.

IMPORTANCE: Patient age, comorbidity burden, and disease severity at presentation are the major factors associated with surviving COVID-19. Hospital-level factors including ICU occupancy may confer additional risk to individual patients, particularly at times of maximal stress on healthcare systems. The interaction of patient- and hospital-level factors over time during pandemic disease remains an area of active exploration. OBJECTIVE: To determine the impact of patient and hospital risk factors during episodic surges, characterize severity distribution between waves, and evaluate patient-level impact of ICU capacity on COVID-19 survivorship. DESIGN: Retrospective cohort study. SETTING: Four acute care hospitals within an integrated healthcare network in San Diego, California. PARTICIPANTS: All patients (18+ y.o.) admitted with a positive PCR test for SARS-CoV-2 or ICD-10 code for COVID-19 from March 1, 2020 through June 30, 2021. MAIN OUTCOME(S) AND MEASURE(S): Patient survivorship and length of stay. RESULTS: Six thousand eight hundred fifty-one patients were evaluated in this large cohort series. Patient level factors associated with mortality included: severity at admission (WHO Clinical Progression Score [WCPS]), age, gender, BMI, marital status, language preference, Elixhauser score, elevated laboratory (d-dimer, ferritin, LDH) or lower absolute lymphocyte count. When adjusting for patient age alone, survivorship during surges was also inversely associated with ICU occupancy, though this correlation was not present when adjusted for patient-level factors. CONCLUSIONS AND RELEVANCE: Patient age, comorbidity burden, and severity at the time of presentation are the major factors associated with surviving COVID-19. Hospital-level factors including ICU occupancy may confer additional risk to individual patients, particularly at times of maximal stress on healthcare systems.

Application of latent semantic analysis for open-ended responses in a large, epidemiologic study.

BACKGROUND: The Millennium Cohort Study is a longitudinal cohort study designed in the late 1990s to evaluate how military service may affect long-term health. The purpose of this investigation was to examine characteristics of Millennium Cohort Study participants who responded to the open-ended question, and to identify and investigate the most commonly reported areas of concern. METHODS: Participants who responded during the 2001-2003 and 2004-2006 questionnaire cycles were included in this study (n = 108,129). To perform these analyses, Latent Semantic Analysis (LSA) was applied to a broad open-ended question asking the participant if there were any additional health concerns. Multivariable logistic regression was performed to examine the adjusted odds of responding to the open-text field, and cluster analysis was executed to understand the major areas of concern for participants providing open-ended responses. RESULTS: Participants who provided information in the open-ended text field (n = 27,916), had significantly lower self-reported general health compared with those who did not provide information in the open-ended text field. The bulk of responses concerned a finite number of topics, most notably illness/injury, exposure, and exercise. CONCLUSION: These findings suggest generalized topic areas, as well as identify subgroups who are more likely to provide additional information in their response that may add insight into future epidemiologic and military research.

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.

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.

Factors Associated With Unplanned Acute Care Services for Patients With Newly Diagnosed Hematologic Malignancies.

PURPOSE: This study evaluated risk factors predicting unplanned 30-day acute service utilization among adults subsequent to hospitalization for a new diagnosis of leukemia, lymphoma, or myeloma. This study explored the prevalence of medical complications (aligned with OP-35 measure specifications from the Centers for Medicare & Medicaid Services [CMS] Hospital Outpatient Quality Reporting Program) and the potential impact of psychosocial factors on unplanned acute care utilization. METHODS: This study included 933 unique patients admitted to three acute care inpatient facilities within a nonprofit community-based health care system in southern California from 2012 to 2017. Integrated comprehensive data elements from electronic medical records and facility oncology registries were leveraged for univariate statistics, predictive models constructed using multivariable logistic regression, and further exploratory data mining, with predictive accuracy of the models measured with c-statistics. RESULTS: The mean age of study participants was 65 years, and 55.1% were male. Specific diagnoses were lymphoma (48.7%), leukemia (35.2%), myeloma (14.0%), and mixed types (2.1%). Approximately one fifth of patients received unplanned acute care services within 30 days postdischarge, and over half of these patients presented with one or more symptoms associated with the CMS medical complication measure. The predictive models, with c-statistics ranging from 0.7 and above for each type of hematologic malignancy, indicated good predictive qualities with the impact of psychosocial functioning on the use of acute care services (P values < .05), including lack of consult for social work during initial admission (lymphoma or myeloma), history of counseling or use of psychotropic medications (lymphoma), and past substance use (myeloma). CONCLUSION: This study provides insights into patient-related factors that may inform a proactive approach to improve health outcomes, such as enhanced care transition, monitoring, and support interventions.

Point prevalence survey to evaluate the seropositivity for coronavirus disease 2019 (COVID-19) among high-risk healthcare workers.

Among 1,770 healthcare workers serving in high-risk care areas for coronavirus disease 2019 (COVID-19), 39 (2.2%) were seropositive. Exposure to severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in the community was associated with being seropositive. Job or unit type and percentage of time working with COVID-19 patients were not associated with positive antibody tests.

Acupuncture for combat post-traumatic stress disorder: trial development and methodological approach for a randomized controlled clinical trial.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a significant public health problem, affecting approximately 7% of the general population and 13-18% of the combat Veteran population. The first study using acupuncture for PTSD in a civilian population showed large pre- to post-treatment effects for an empirically developed verum protocol, which was equivalent to group cognitive behavior therapy and superior to a wait-list control. The primary objective of this study is to determine both clinical and biological effects of verum acupuncture for combat-related PTSD in treatment-seeking US Veterans. METHODS: This is a two-arm, parallel-group, prospective randomized placebo-controlled clinical trial. The experimental condition is verum acupuncture and the placebo control is sham (minimal) acupuncture in 1-h sessions, twice a week for 12 weeks. Ninety subjects will provide adequate power and will be allocated to group by an adaptive randomization procedure. The primary outcome is change in PTSD symptom severity from pre- to post-treatment. The secondary biological outcome is change from pre- to post-treatment in psychophysiological response, startle by electromyographic (EMG) eyeblink. Assessments will be conducted at pre-, mid-, post-, and 1-month post-treatment, blind to group allocation. Intent-to-treat analyses will be conducted. DISCUSSION: The study results will be definitive because both clinical and biological outcomes will be assessed and correlated. Issues such as the number needed for recruitment and improvement, use of sham acupuncture, choice of biological measure, and future research need will be discussed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02869646 . Registered on 17 August 2016.

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.

Sleep patterns before, during, and after deployment to Iraq and Afghanistan.

STUDY OBJECTIVES: To determine the associations between deployment in support of the wars in Iraq and Afghanistan and sleep quantity and quality. DESIGN: Longitudinal cohort study SETTING: The Millennium Cohort Study survey is administered via a secure website or US mail. PARTICIPANTS: Data were from 41,225 Millennium Cohort members who completed baseline (2001-2003) and follow-up (2004-2006) surveys. Participants were placed into 1 of 3 exposure groups based on their deployment status at follow-up: nondeployed, survey completed during deployment, or survey completed postdeployment. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Study outcomes were self-reported sleep duration and trouble sleeping, defined as having trouble falling asleep or staying asleep. Adjusted mean sleep duration was significantly shorter among those in the deployed and postdeployment groups compared with those who did not deploy. Additionally, male gender and greater stress were significantly associated with shorter sleep duration. Personnel who completed their survey during deployment or postdeployment were significantly more likely to have trouble sleeping than those who had not deployed. Lower self-reported general health, female gender, and reporting of mental health symptoms at baseline were also significantly associated with increased odds of trouble sleeping. CONCLUSIONS: Deployment significantly influenced sleep quality and quantity in this population though effect size was mediated with statistical modeling that included mental health symptoms. Personnel reporting combat exposures or mental health symptoms had increased odds of trouble sleeping. These findings merit further research to increase understanding of temporal relationships between sleep and mental health outcomes occurring during and after deployment.

A prospective study of depression following combat deployment in support of the wars in Iraq and Afghanistan.

OBJECTIVE: We investigated relations between deployment and new-onset depression among US service members recently deployed to the wars in Iraq and Afghanistan. METHODS: We included 40 219 Millennium Cohort Study participants who completed baseline and follow-up questionnaires and met inclusion criteria. Participants were identified with depression if they met the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire criteria for depression at follow-up, but not at baseline. RESULTS: Deployed men and women with combat exposures had the highest onset of depression, followed by those not deployed and those deployed without combat exposures. Combat-deployed men and women were at increased risk for new-onset depression compared with nondeployed men and women (men: adjusted odds ratio [AOR]=1.32; 95% confidence interval [CI]=1.13, 1.54; women: AOR=2.13; 95% CI=1.70, 2.65). Conversely, deployment without combat exposures led to decreased risk for new-onset depression compared with those who did not deploy (men: AOR=0.66; 95% CI=0.53, 0.83; women: AOR=0.65; 95% CI=0.47, 0.89). CONCLUSIONS: Deployment with combat exposures is a risk factor for new-onset depression among US service members. Post-deployment screening may be beneficial for US service members exposed to combat.