Testing the role of aerobic exercise in the treatment of posttraumatic stress disorder (PTSD) symptoms in U.S. active duty military personnel: a pilot study.

The purpose of this pilot study was to determine if the efficacy of imaginal exposure for symptoms of posttraumatic stress disorder (PTSD) could be improved by adding aerobic exercise. We hypothesized that aerobic exercise would enhance the efficacy of exposure therapy. Active duty service members with clinically significant symptoms of posttraumatic stress (PTSD Checklist-Stressor-Specific Version, [PCL-S], ≥25) were randomized into one of four conditions: exercise only; imaginal exposure only; imaginal exposure plus exercise; no exercise/no exposure therapy (control). Participants (N = 72) were primarily male, Army, noncommissioned officers ranging in age from 22 to 52. PTSD symptom severity decreased over time (p < .0001); however, there were no significant differences between the experimental conditions. The prediction that imaginal exposure augmented with aerobic exercise would be superior to either imaginal exposure alone or aerobic exercise alone was not supported, suggesting that engaging in exercise and imaginal exposure simultaneously may not be any better than engaging in either activity alone. A better understanding of individually administered and combined exercise and exposure therapy interventions for PTSD is warranted.

The impact of symptom burden on the health status of service members with extremity trauma.

BACKGROUND: Service members injured in combat undergo repeated surgeries and long recoveries following a traumatic injury that produce a myriad of physical and psychological symptoms. PURPOSE: To describe the severity of pain, sleep disturbance, depression, and anxiety in service members with extremity trauma sustained during combat operations at the time of discharge from the hospital and to evaluate for differences in health status between those with and without symptom burden. METHOD: Descriptive study of 130 United States Army service members. DISCUSSION: More than 80% of the service members were classified as having symptom burden. Service members who reported one or more clinically meaningful levels of pain, sleep disturbance, depression, or anxiety reported significantly worse health status compared to those without symptom burden. CONCLUSIONS: Service members with extremity trauma experience clinically significant levels of pain, sleep disturbance, depression, and/or anxiety at the time of discharge from the hospital. The greater the service members' symptom burden, the worse their reported health status.

The association of shift-level nurse staffing with adverse patient events.

OBJECTIVE: The objective of this study was to demonstrate the association between nurse staffing and adverse events at the shift level. BACKGROUND: Despite a growing body of research linking nurse staffing and patient outcomes, the relationship of staffing to patient falls and medication errors remains equivocal, possibly due to dependence on aggregated data. METHODS: Thirteen military hospitals participated in creating a longitudinal nursing outcomes database to monitor nurse staffing, patient falls and medication errors, and other outcomes. Unit types were analyzed separately to stratify patient and nurse staffing characteristics. Bayesian hierarchical logistic regression modeling was used to examine associations between staffing and adverse events. RESULTS: RN skill mix, total nursing care hours, and experience, measured by a proxy variable, were associated with shift-level adverse events. CONCLUSIONS: Consideration must be given to nurse staffing and experience levels on every shift.

Implementing a unit-level intervention to reduce the probability of ventilator-associated pneumonia.

BACKGROUND: Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection and is associated with high morbidity and mortality rates for mechanically ventilated patients in the intensive care unit. Routine nursing interventions have been shown to reduce VAP rates. OBJECTIVES: The purpose of this study was to evaluate the effectiveness of a unit-specific education intervention that emphasized hand hygiene, head-of-the-bed elevation, and oral care. The goals were to improve staff compliance with hand washing, head-of-the-bed elevation, and oral care; to decrease VAP rates, and to decrease number of ventilator days. METHODS: Two-hour observations were conducted on a convenience sample of 100 ventilated patients not diagnosed with VAP and the clinical staff that interacted with them. Instrumentation included a compliance checklist, a demographic patient survey, and the Acute Physiology and Chronic Health Evaluation AEIV tool. Unit-specific educational interventions were designed and implemented on each participating unit. RESULTS: : The VAP and the ventilator day rates did not improve significantly. There were no significant changes in clinician adherence to hand hygiene, provision of oral care, or patient positioning. DISCUSSION: Despite implementation of both structured and creative education, team-based approach, and frequent staff reminders, patient outcomes and staff compliance did not improve significantly. Unit-based education interventions may not be the best strategy to facilitate change. Organizations with frequent changes in personnel and leadership may not have the unit-level infrastructure necessary to attain and sustain change.

Mass casualty care in an expeditionary environment: developing local knowledge and expertise in context.

To discover new experience-based clinical and care delivery knowledge learned in the Iraq and Afghanistan combat zones, 107 Air Force, Army, and Navy nurses were interviewed. Eight areas of experiential knowledge were identified in the new care delivery system that featured rapid transport, early trauma and surgical care, and expeditious aeromedical evacuation: (1) organizing for mass casualties, (2) uncertainty about incoming casualties, (3) developing systems to track patients, (4) resource utilization, (5) ripple effects of a mass casualty event, (6) enlarging the scope of nursing practice, (7) operating medical facilities under attack, and (8) nurse emotions related to mass casualties.

Obesity and cholesterol in Japanese, French, and U.S. children.

The number of children at risk for overweight/obesity has increased dramatically in the last decade worldwide. This study compares measures of obesity (body mass index [BMI] and body fat percentage) and total cholesterol in 4,013 fourth-grade students from three countries, France, Japan, and the United States. Data were analyzed using t test, chi-square, and analysis of variance to determine differences between groups and by multiple linear regression. All variables differed significantly by group. BMI was highest in U.S. children. Body fat percentage was also highest in U.S. children and lowest in French children. Total cholesterol was highest in French children and lowest in U.S. White children. There were modest but significant associations between BMI and cholesterol in all groups except French children; associations varied by gender. Results indicate there was great variation in measures of obesity and cholesterol by country. The association between obesity and cholesterol may vary by culture, ethnicity, and gender.

Soldiers with musculoskeletal injuries.

PURPOSE: To describe Soldiers' (e.g., U.S. Army personnel) perspectives of the effect of musculoskeletal injuries. DESIGN: Data were collected in the summer of 2003 using a prospective survey design. The survey was mailed to active duty Soldiers on modified work plans because of musculoskeletal injuries. These Soldiers were assigned to one Army installation in the US. METHODS: Responses to the survey questions were analyzed using descriptive statistics. The numerous handwritten comments were evaluated qualitatively. FINDINGS: Injuries most often involved the back and knees (18% each). At least 47% of the injuries were work related. Injuries interfered with Soldiers' abilities to perform military tasks such as road marching (80%) and organized physical training (69%). Although many respondents indicated they were not experiencing pain, at least some Soldiers reported mild pain for each of 19 anatomic locations. Severe pain was reported most often for the lower back (21%). In their written comments, Soldiers expressed a sense of frustration with their injuries, the healthcare system and providers, and their unit leaders. CONCLUSIONS: Healthcare personnel are challenged to better manage Soldiers with musculoskeletal injuries and expedite their return to full duty. Unit leaders are challenged to create work environments that focus on injury prevention and allow injured Soldiers time to heal. CLINICAL RELEVANCE: The Soldiers in this study were often engaged in physically challenging work or sports activities when injured. Because people outside the Army engage in similar activities (e.g., construction workers, endurance athletes), the findings from this study might be applicable to nonmilitary communities. Additionally, with the number of Reserve and National Guard Soldiers currently on active duty, civilian nurses might be caring for Soldiers with musculoskeletal injuries.

Effectiveness of prediabetes nutrition shared medical appointments: prevention of diabetes.

PURPOSE: The purpose of this study is to evaluate the effectiveness of a nutrition-based shared medical appointment (SMA) intervention in the treatment of prediabetes compared to the individualized counseling standard of care. METHODS: A randomized controlled trial design comparing health outcomes in patients with prediabetes attending either an individualized counseling (control group) or three 90-minute nutrition SMA (intervention group) sessions. Demographic, anthropometric (weight and body mass index), clinical (blood pressure), and biochemical (lipid profile, fasting blood sugar, glycated hemoglobin, albumin-to-creatinine ratio) measures were obtained from all participants at baseline, at 3 months, and at 1 year. RESULTS: Ninety-four participants were randomized into the 2 study groups with a 69% completion rate at 1 year (n = 34 SMA, n = 31 control). The average participant was Caucasian (64%), male (54%), 58.3 ± 9.6 years, had a BMI of 30.8 ± 4.9 kg/m(2) (obese), and fasting blood glucose of 109 ± 9.5 mg/dL. The SMA and control participants lost a mean of 6.6 pounds and 3.6 pound, respectively; neither group met the 5% modest weight loss expected. The SMA and control group experienced a mean drop in fasting blood glucose of 6 mg/dL. CONCLUSIONS: As demands on health care providers continue to rise, finding innovative ways to manage the patient load while providing quality health care is increasingly important. SMA health outcomes were equivalent to individual counseling outcomes, while increasing the provider's productivity by treating 6 to 8 people with prediabetes in 90 minutes compared to 1 patient in 60 minutes.

Military nurses and combat-wounded patients: a qualitative analysis of psychosocial care.

PURPOSE: The aims were to explore the lived experience of combat-wounded patients and the military nurses who care for them. DESIGN AND METHODS: The study was a qualitative phenomenological design, and focus groups were conducted with 20 nurses and 8 combat-wounded patients. FINDINGS: Themes common to nurses and patients were coping, shared experiences, finding meaning, psychosocial nursing care, families, and bureaucratic structure. Thematic differences were the patients' perspectives "changed self" while nurses described "professional boundaries." PRACTICE IMPLICATIONS: The importance of finding meaning presents ideas that could help nurses and patients cope better with stressful situations regardless of the setting.

Transition from military to VHA care: psychiatric health services for Iraq/Afghanistan combat-wounded.

OBJECTIVE: Veterans from the wars in Afghanistan and Iraq (OEF/OIF) report high rates of mental distress especially affective disorders. Ensuring continuity of care across institutions is a priority for both the Department of Defense (DoD) and the Veterans Health Administration (VHA), yet this process is not monitored nor are medical records integrated. This study assessed transition from DoD to VHA and subsequent psychiatric care of service members traumatically injured in OEF/OIF. METHODS: Inpatients at a DoD trauma treatment facility discharged in FY02-FY06 (n=994) were tracked into the VHA via archival data (n=216 OEF/OIF veterans). Mental health utilization in both systems was analyzed. RESULTS: VHA users were 9% female, 15% Hispanic; mean age 32 (SD=10; range 19-59). No DoD inpatients received diagnoses of post-traumatic stress disorder (PTSD); 21% had other mental health diagnoses, primarily drug abuse. In the VHA, 38% sought care within 6 months of DoD discharge; 75% within 1 year. VHA utilization increased over time, with 88-89% of the transition cohort seeking care in FY07-FY09. Most accessed VHA mental health services (81%) and had VHA psychiatric diagnoses (71%); half met criteria for depression (27%) or PTSD (38%). Treatment retention through FY09 was significantly greater for those receiving psychiatric care: 98% vs 62% of those not receiving psychiatric care (x(2)=53.3; p<.001). LIMITATIONS: DoD outpatient data were not available. The study relied on administrative data. CONCLUSIONS: Although physical trauma led to hospitalization in the DoD, high rates of psychiatric disorders were identified in subsequent VHA care, suggesting delay in development or recognition of psychiatric problems.