Personality Disorders as a Basis for Discharge and Denial of Benefits in the Military: Logical or Abusive?

ABSTRACT: The US Department of Defense specifically states that intellectual disability and personality disorders are not diseases for compensation purposes, and disabilities from them may not be service connected absent a superimposed mental disorder. In addition, the diagnosis of a personality disorder led to the discharge of 31,000 troops during the years 2001 to 2010. I review the history of these developments, and how the Diagnostic and Statistical Manual of Mental Disorders enabled these actions. In contrast, the United Kingdom and Canada do not allow such actions. Whether our approach is logical seems highly questionable, especially given the significant problems with the DSM's definitions of personality disorders, definitions at odds with the literature.

US Department of Defense Warfighter Brain Health Initiative: Maximizing performance on and off the battlefield.

The US Department of Defense (DoD) recognizes the importance of warfighter brain health with the establishment of the Warfighter Brain Health Initiative and Strategy. For a warfighter, also known as a service member, to perform at their highest level, cognitive and physical capabilities must be optimized. This initiative addresses brain health, brain exposures, to include blast overpressure exposures from weapons and munitions, traumatic brain injury (TBI), and long-term or late effects of TBI. The DoD's pursuit of maximal strength hinges on the speed of decisions (neurocognitive) and detection of brain injury when it occurs. The strategy creates a framework for deliberate, prioritized, and rapid development of end-to-end solutions for warfighter brain health. Through this strategy, DoD is addressing the needs of our service members, their families, line leaders/commanders, and their communities at large. The implications of this initiative and strategy are noteworthy for practitioners because the DoD Warfighter Brain Health construct lends itself to nurse practitioner engagement in clinical practice, patient education, policy development, and emerging research.

Racial Disparities in Prenatal Care Utilization and Infant Small for Gestational Age Among Active Duty US Military Women.

OBJECTIVES: To examine racial disparities in prenatal care (PNC) utilization and infant small for gestational age (SGA) among active duty US military women, a population with equal access to health care and known socioeconomic status. METHODS: Department of Defense Birth and Infant Health Research program data identified active duty women with singleton live births from January 2003 through August 2015. Administrative claims data were used to define PNC utilization and infant SGA, and log-binomial regression models estimated associations with race/ethnicity. To examine whether associations between maternal race/ethnicity and infant SGA were subject to effect measure modification, respective analyses were stratified by demographic and health characteristics. RESULTS: Overall, 12.2% of non-Hispanic White women initiated PNC after the first trimester, compared with 14.8% of American Indian/Alaska Native, 15.1% of Asian/Pacific Islander, 14.2% of non-Hispanic Black, and 13.0% of Hispanic women. Infant SGA prevalence was 2.4% and 1.6% among non-Hispanic Black and White women, respectively (aRR 1.52, 95% CI 1.40-1.64). This disparity persisted across stratified analyses, particularly among non-Hispanic Black versus White women with a preeclampsia or hypertension diagnosis in pregnancy (RR 1.96, 95% CI 1.67-2.29) and those aged 35 + years at infant birth (RR 2.04, 95% CI 1.56-2.67). CONCLUSIONS FOR PRACTICE: In multiple assessments of PNC utilization and infant SGA, non-Hispanic Black military women had consistently worse outcomes than their non-Hispanic White counterparts. This suggests that equal access to health care does not eliminate racial disparities in outcomes or utilization; additional research is needed to elucidate the underlying etiology of these disparities.

Breaching the Department of Defense's Biotech Bottleneck.

The global biotechnology revolution offers a profusion of promising innovations for the US Department of Defense (DoD). As with other emerging technologies, the commercial market, rather than defense, is driving the evolution of biotechnology products, and the ability to harness biotechnology for defense benefits has been hampered by strategic confusion in DoD. Here we describe a set of high-level challenges and a set of potential solutions that could bring innovative biotechnology closer to reality for the warfighter and DoD writ large.

The Effectiveness of the DoD/VA Mobile Device Outcomes-Based Rehabilitation Program for High Functioning Service Members and Veterans with Lower Limb Amputation.

INTRODUCTION: The objective was to determine if the Mobile Device Outcomes-based Rehabilitation Program (MDORP) improved strength, mobility, and gait quality in service members (SMs) and Veterans with lower limb amputation (LLA). METHODS: Seven SMs and 10 Veterans with LLA enrolled and were trained to use a mobile sensor system, called Rehabilitative Lower Limb Orthopedic Analysis Device (ReLOAD). ReLOAD provided participants with real-time assessment of gait deviations, subsequent corrective audio feedback, and exercise prescription for normalizing gait at home and in the community. After baseline testing, prosthetic gait and exercise training, participants took ReLOAD home and completed an 8-week walking and home exercise program. Home visits were conducted every 2 weeks to review gait training and home exercises. RESULTS: Significant improvements in hip extensor strength, basic and high-level mobility, musculoskeletal endurance, and gait quality (P < 0.05) were found at the completion of the 8-week intervention. CONCLUSION: Preliminary MDORP results are promising in its ability to improve basic and high-level mobility, lower limb strength, and gait quality in a group of SMs and Veterans with LLA. In addition, "booster" prosthetic training may be justified in an effort helps maintain an active lifestyle, promotes prosthetic use, and mitigates secondary health effects.

US Department of Defense Support of Civilian Vector Control Operations Following Natural Disasters.

The United States Department of Defense (DoD) employs advanced-degreed entomologists as Preventive Medicine and Public Health Officers in the Army, Navy, and Air Force. While the primary objective of military entomologists is service member health and readiness ("force health protection"), military entomology resources can provide support to civil authorities as directed by the President or Secretary of Defense through Department of Defense Directive 3025.18, Defense Support of Civil Authorities (DSCA). The employment of DSCA is complex and involves the consideration of such factors as the proper request process, funding, legality, risk, appropriateness, and readiness. Once approved and mobilized, however, military preventive medicine assets can be of significant help to civil authorities when dealing with emergency vector control. This paper will address some of the policy issues surrounding the use of DSCA, outline the resources available from the individual military services, and provide examples of DoD contingency vector control support to civil authorities.

The Acute Respiratory Infection Consortium: A Multi-Site, Multi-Disciplinary Clinical Research Network in the Department of Defense.

INTRODUCTION: Acute respiratory infections (ARI) result in substantial annual morbidity among military personnel and decrease operational readiness. Herein, we summarize the research efforts of the Infectious Disease Clinical Research Program (IDCRP) related to ARIs. METHODS: The ARI Research Area of the IDCRP was established in response to the 2009 emergence of pandemic influenza A/H1N1. That year, IDCRP investigators deployed the ARI Consortium Natural History Study (ARIC NHS), a multi-centered, longitudinal observational study to assess etiology, epidemiology, and clinical characteristics of influenza-like illness (ILI) and severe acute respiratory infections (SARI) in the U.S. military. The success of this initial effort spurred implementation of several new initiatives. These include the FluPlasma trial, designed to evaluate the efficacy of hyperimmune anti-influenza plasma for the treatment of severe influenza; the self-administered live-attenuated influenza vaccine (SNIF) trial, which assessed the immunogenicity and acceptance of a self-administered live-attenuated influenza vaccine in military personnel; the Study to Address Threats of ARI in Congregate Military Populations (ATARI), a prospective study of ILI transmission, etiology and epidemiology in recruits; and the Flu Breath Test (FBT) study, a preliminary study of exhaled volatile organic compounds (VOC) in influenza patients. In addition, the InFLUenza Patient-Reported Outcome (FLU-PRO) survey, a daily diary to measure influenza symptoms during clinical trials, was developed. Lastly, the Pragmatic Assessment of Influenza Vaccine Effectiveness in the DoD (PAIVED) study, a two-year randomized trial designed to compare the effectiveness of the three types of licensed vaccines, launched in Fall 2018. RESULTS: The on-going ARIC NHS has enrolled over 2000 ILI and SARI cases since its inception, providing data on burden and clinical manifestations of ARI in military personnel and their families. The FluPlasma 2 trial concluded subject enrollment in 2018. Preliminary results from ATARI study show a high frequency of respiratory viruses circulating during the first two weeks of recruit training. Based on assessment of FLU-PRO responses, which were found to be reliable and reproducible, the survey may be a useful tool in clinical trials and epidemiological studies. The Flu Breath Study will complete enrollment in 2019. Findings from PAIVED are intended to provide evidence needed for assessing influenza vaccination policy in the military. CONCLUSIONS: The ARI burden in the armed services remains significant every year and the threat is dynamic given emergent and evolving threats, such as influenzas. With strong successes to date, future initiatives of the ARI Research Area will focus on interventional studies, ARI transmission dynamics in congregate military settings, and determinants of risk of pandemic influenza and other emergent respiratory viruses.

Status of Robotic-Assisted Surgery (RAS) in the Department of Defense (DoD).

INTRODUCTION: Since inception of robotic-assisted surgery (RAS) in 1999, there has been an exponential rise in RAS in both number and complexity of surgical cases performed. The majority of these cases are gynecologic surgery in nature, with only a quarter of them labeled as general surgery. The purpose of this study is to determine if RAS in the Department of Defense (DoD) mirrors these trends. METHODS: A total of 6,204 RAS cases from across the DoD were reviewed between 01 January 2015 and 30 September 2017 from every Military Treatment Facility (MTF) that employs a robotic surgical device (various models of the da Vinci robotic surgical system by Intuitive Surgical). Specialty, number, and surgeon were recorded for each case. These end points were also examined for trends overtime and compared to similar civilian data. RESULTS: The number of MTFs performing robotic surgery and the number of cases performed increased significantly. An average of 373 cases per quarter-year were performed in 2015, 647 in 2016, and 708 in 2017. The number of RAS cases increased by about 10% every quarter-year during this time period. RAS was most commonly performed by general surgery in 10 of the 14 MTFs examined. CONCLUSIONS: MTFs implemented RAS much later than the civilian world. However, since its implementation, the frequency of RAS use has increased at a faster rate in the DoD than in the civilian world. Possible reasons for this are a younger pool of surgeons in the military and less demands on cost-effective productivity, allowing these younger surgeons to focus on emerging technology rather than maximizing surgical cost efficiency. General surgery constitutes the majority of RAS cases in the DoD. It is unclear why this difference from the civilian world exists.

Injury and Illness Surveillance During the 2016 Department of Defense Warrior Games: Review of Methods and Results.

INTRODUCTION: Surveillance systems have become a valuable tool to capture epidemiological data at multi-sport events, with findings serving to predict and prevent injury, reduce illness, and guide efficient utilization of medical resources. In 2016, the first injury and illness surveillance tool for the Department of Defense (DoD) Warrior Games was established to inform the required medical footprint. The purpose of this paper is to describe the methods and findings from the 2016 DoD Warrior Games surveillance system, which included a database of injuries and illness. MATERIALS AND METHODS: A total of 245 wounded warrior (WW) athletes were followed over 19 days, to include train-up and competition periods, as they competed for their respective teams of Army, Navy, Air Force, Marines, Special Operations, and United Kingdom. Medical personnel recorded injuries and illnesses treated utilizing a standardized surveillance form and data were entered into a daily tracker to examine patterns or areas for prevention. Reports included sex, age, event discipline, previous injury or illness, reason for presentation, and treatment provided. RESULTS: From June 3 to June 21, 2016, 114 individual encounters were recorded on the standard form and entered into the surveillance database. Athletes accounted for 67% of all encounters. Illness accounted for 30.7% of all visits, while injuries accounted for 69.2%. The incident proportion of injuries in athletes was 23.3 injuries per 100 athletes (95% CI 17.6, 30.1) and incident rate of 12.2 injuries per 1000 athlete days. Integrative medicine treatments including acupuncture, osteopathic manipulative treatment (OMT), massage therapy, and gua sha accounted for the largest forms of treatment (31%). CONCLUSIONS: From the surveillance data, staff levels and treatment supplies can be adjusted. In addition an improved surveillance tool can be created. Continuous surveillance is required to provide information on trends in injury and illness to support prevention strategies.

The Prevalence of Faculty Physician Burnout in Military Graduate Medical Education Training Programs: A Cross-Sectional Study of Academic Physicians in the United States Department of Defense.

INTRODUCTION: In military populations, physician burnout has potential to adversely affect medical readiness to deploy in support of joint operations. Burnout among Graduate Medical Education (GME) faculty may further threaten the welfare of the medical force given the central role these officers have in training and developing junior physicians. The primary aim of this investigation was to estimate the prevalence of burnout among faculty physicians in United States (US) Army, Navy, and Air Force GME programs. MATERIALS AND METHODS: We conducted a cross-sectional study of faculty physicians at US military GME training programs between January 2018 and July 2018. Through direct coordination with Designated Institutional Officials, we administered the Maslach Burnout Inventory Health Services Survey (MBI-HSS) via online web link to faculty physicians listed in Accreditation Data System at each sponsoring institution. In addition to the MBI-HSS, we collected demographic data and queried physicians about common occupational stressors in order to assist institutional leaders with identifying at-risk physicians and developing future interventions to address burnout. RESULTS: Sixteen of 21 institutions that currently sponsor military GME programs agreed to distribute the MBI-HSS survey to core faculty. We received completed assessments from 622 of the 1,769 (35.1%) reported physician core faculty at these institutions. Of the 622 physician respondents, 162 demonstrated high levels of emotional exhaustion and depersonalization for an estimated 26% prevalence of burnout. We identified only one independent risk factor for burnout: increasing numbers of deployments (OR 1.38, 95% CI 1.07-1.77). Physicians in our cohort who reported a desire to stay beyond their initial active duty service obligation were less likely to be classified with burnout (OR 0.45, 95% CI 0.26-0.77). The most common drivers of occupational distress were cumbersome bureaucratic tasks, insufficient administrative support, and overemphasis on productivity metrics. CONCLUSIONS: We estimate that 26% of physician faculty in military GME programs are experiencing burnout. No specialty, branch of service, or specific demographic was immune to burnout in our sample. Institutional leaders in the MHS should take action to address physician burnout and consider using our prevalence estimate to assess effectiveness of future interventions.

Mental Health Care for Service Members and Their Families Across the Globe.

The U.S. Defense Department partnered with the International Initiative for Mental Health Leadership on effective leadership and operational practices for delivery of mental health (MH) as well as addiction services throughout the world for Service Members (SM) and beneficiaries. A Military Issues Work Group (MIWG) was established in 2011 to focus on challenges experienced by military SM and beneficiaries among countries. The MIWG found common concerns related to MH care delivery to rural and remote beneficiaries. Gaps in access to care were identified and prioritized to explore. This led to better collaboration and understanding of telemental health (TMH) practices and technology applications (apps) which increase access to care for rural and remote SMs and beneficiaries. An assessment of the number of SMs and dependents distant from MH care services in the USA was conducted, as well as an environmental scan for psychological health-focused mobile apps and TMH services geared toward SM, veterans, and beneficiaries. The MIWG is developing a compendium of existing military TMH programs and apps that address MH concerns and extant literature on use of technology to extend global access to care for military members and their families across the world.

Description of trauma among French service members in the Department of Defense Trauma Registry: understanding the nature of trauma and the care provided.

BACKGROUND: Since 2001, the French Armed Forces have sustained many casualties during the Global War on Terror; however, even today, there is no French Military trauma registry. Some French service members (SMs) were treated in US Military Medical Treatment Facilities (MTFs) and were recorded in the US Department of Defense Trauma Registry (DoDTR). Our objective was to conduct a descriptive analysis of the injuries sustained by French SMs reported in the DoDTR and subsequent care provided to them to assist in understanding the importance of building a French Military trauma registry. METHODS: Using DoDTR data collected from 2001 to 2017, a retrospective descriptive analysis was conducted. We identified 59 French SMs treated in US MTFs. The characteristics of the SMs' demographics, injuries, care provided to them, and discharge outcomes were summarized. RESULTS: Among the 59 French SMs identified, 46 (78%) sustained battle injuries (BIs) and 13 (22%) sustained nonbattle injuries (NBIs). There were 47 (80%) SMs injured in Afghanistan (Opération Pamir), while 12 (20%) were injured in Opération Chammal in Iraq and Syria. Explosives accounted for 52.5% of injuries, while 25.4% were due to gunshot wounds; all were BIs. The majority of reported injuries were penetrating (59.3%), most of which were BIs (71.7%). The mean Injury Severity Score for BIs was 12 (SD = 8.9) compared to 6 (SD = 1.7) for NBIs. Around half of SMs (n = 30; 51%) were injured in Afghanistan between the years 2008-2010. Among a total of 246 injuries sustained by 59 patients, extremities were the body part most prone to BIs followed by the head and face. Four SMs died after admission (6.8%). CONCLUSIONS: The DoDTR provides extensive data on trauma injuries that can be used to inform injury prevention and clinical care. The majority of injuries sustained by French SMs were BIs, caused by explosives, and predominantly occurring to the extremities; these findings are similar to those of other studies conducted in combat zones. There is a need to establish a French Military trauma registry to improve the combat casualty care provided to French SMs, and its creation may benefit from the DoDTR model.

Impact of Fire Arms Training in a Virtual Reality Environment on Occupational Performance (Marksmanship) in a Polytrauma Population.

INTRODUCTION: Polytrauma, to include major limb amputation, in a military population presents unique rehabilitation challenges with the overarching goal of restoring function leading to the primary question, "Is this Service Member (SM) capable of returning to duty following rehabilitation?" The US military has a vested interest in maximizing injured SMs occupational performance to allow for return to duty. The purpose of this report is to describe marksmanship (shot grouping and weapon qualification) and return to duty outcomes following a course of VRE-based firearm training in a polytrauma patient population. METHODS: The medical records, stored in the Armed Forces Health Longitudinal Technology Application (AHLTA), of all patients who received rehabilitative care at the Center for the Intrepid (CFI) to include VRE-based firearms training between 01OCT2015 and 01AUG2016 were manually reviewed for inclusion. Subjects included all adult (18 years and older) SMs (active duty at time of admission) with a diagnosis of polytrauma who had been referred to and treated (received additional services such as physical and or occupational therapy) at the CFI. Approval for this research was received from the Brooke Army Medical Center Department of Clinical Investigation Office of the Institutional Review Board. RESULTS: Medical records of 30 SMs with a polytrauma diagnosis met the inclusion criteria. Mean shot group sizes for the M9 and M4 weapon decreased between initial and post training time points for the M9 zero (p = 0.009) and M4 zero (p = 0.020). There was no significant difference between initial and post training time points at the other shooting distances with either weapon. There was an 89% qualification rate for both the M9 (n = 18) and M4 (n = 19) weapons for those who attempted qualification; 43% of the population (n = 13) did not attempt qualification with either weapon. CONCLUSION: SMs with polytrauma demonstrated a high rate of weapon qualification (accuracy) following VRE-based firearm training. Shot group size (precision) at short distances with a M9 pistol and M4 rifle also improved with training. While overall marksmanship appeared to improve, high return to duty rates were not directly related to firearm training or marksmanship. Future efforts need to focus on consistent clinical documentation of firearm training procedure and the establishment of psychometric properties for marksmanship outcome measures.

A Descriptive Analysis of Causalities Undergoing CASEVAC from the Point-of-Injury in the Department of Defense Trauma Registry.

INTRODUCTION: The recent conflicts in Iraq and Afghanistan entail an asymmetric battlefield without clearly defined forward lines of troops as seen in previous wars. Accordingly, the United States military medical services have increasingly adopted casualty evacuation (CASEVAC) platforms. We describe CASEVAC events reported within the Department of Defense Trauma Registry (DODTR). MATERIALS AND METHODS: This is a secondary analysis of previously published data from two datasets spanning from 2007 through 2017. We isolated casualties within our dataset that had a documented evacuation method from the point-of-injury other than dedicated medical evacuation platforms (e.g., MEDEVAC, etc.). RESULTS: During OPERATION IRAQI FREEDOM, three casualties underwent CASEVAC. The median age was 30 and all were male. Most sustained injuries from explosives (67%) and the median composite injury scores were low (10). The most frequent seriously injured body region was the thorax (67%). All survived to hospital discharge. During operations in Afghanistan (OPERATION ENDURING FREEDOM, OPERATION FREEDOMS SENTINEL, OPERATION NEW DAWN), 248 casualties underwent CASEVAC. The median age was 28 and most (96%) were male. Most sustained injuries from explosives (58%) and the median injury score was low (9). The most frequent seriously injured body region was the extremities (24%). Most (97%) survived to hospital discharge. During OPERATION INHERENT RESOLVE, 247 casualties underwent CASEVAC. The median age was 21 and most (96%) were male. The majority sustained injuries from explosives (61%) and the median injury score was low (9). The most frequent seriously injury body region was the extremities (27%). Most survived to hospital discharge (94%). CONCLUSIONS: In our dataset, CASEVAC events most frequently involved US military personnel service members with most surviving to hospital discharge. Developing new terminology that distinguishes different types of CASEVAC would allow for more accurate future analyses of casualty evacuation and outcomes - such as those transports that are truly in a non-medical versus the various medical platforms that do not fall with into the confines of the MEDEVAC platforms.