Qualitative Analysis of Bystander Intervention Among Young Adult Male Soldiers Who Engage in At-Risk Drinking.

Bystander intervention-when someone intervenes to help in situations that pose a risk for harm-is a promising strategy for sexual violence prevention. In the current study, a sample of U.S. Army male soldiers (N = 10; ages 18-24) who engaged in at-risk drinking completed a 90-min individual semi-structured interview to understand the ways in which soldiers intervene to address risk for sexual violence. Two independent raters coded soldier responses using thematic analysis and identified eight main themes: (a) recognizing risk for sexual violence; (b) labeling situations as problematic and taking responsibility; (c) facilitators of intervention; (d) barriers to intervention; (e) intervention strategies; (f) reactions and consequences to intervention; (g) alcohol's influence on intervention; and (h) using bystander intervention to shift cultural norms. As soldiers reported noticing more extreme risks for violence, prevention interventions may help service members identify situations earlier in the continuum of harm. Soldiers anticipated intervening in a way that was physical and aggressive, which could facilitate physical altercation and result in collateral misconduct. Results from the present study reveal ways that bystander intervention programs for civilians can be tailored to address the unique individual, situational, and contextual factors relevant to the military. These findings also highlight the importance of teaching soldiers indirect and nonaggressive strategies for intervention.

Prevalence of Neck Pain in Soldiers as a Result of Mild Traumatic Brain Injury-Associated Trauma.

INTRODUCTION: Many of the injury mechanisms that cause mild traumatic brain injury (mTBI) also create forces commonly associated with whiplash, resulting in cervical pain injury. The prevalence of associated neck pain with mTBI is not well established. There is a strong indication that injury to the cervical spine may aggravate, cause, and/or impact recovery of symptoms and impairments associated with the concussive event and its primary effect on the brain. The purpose of this study is to help identify the prevalence of ensuing cervical pain within 90 days of a previously documented mTBI and to examine the role of neck pain during concurrent concussive symptoms, in a military population stationed at a large military installation. MATERIALS AND METHODS: This retrospective design utilized a de-identified dataset using predetermined search and filter criteria, which included male active duty service members (SMs), 20 to 45 years of age, who received medical care at any clinic on Fort Liberty (Fort Bragg, NC) during fiscal year (FY) 2012 to FY 2019, with documented cervicalgia and mTBI (via the International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes), verified using electronic medical records. The final dataset served as the basis for subject sampling and was analyzed to determine the total number of documented cervicalgia and mTBI diagnoses. Results are presented as descriptive statistics. Approval for this study was received from the Andrews University Office of Research (18-097) and the Womack Army Medical Center Human Protections Office. RESULTS: Between FY 2012 and FY 2019, 14,352 unique SMs accessed a Fort Bragg, NC health care facility, at least once (Table I). Overall, 52% of SMs diagnosed with cervicalgia were found to have a previously diagnosed mTBI during the 90 days before the cervicalgia diagnosis. In contrast, the prevalence of same-day cervicalgia and mTBI diagnosis was <1% (Table IV). The prevalence of isolated cervicalgia diagnosis at any time during the reporting period was 3%, whereas isolated mTBI diagnosis was 1% (Table III). CONCLUSIONS: Over 50% of SMs diagnosed with cervicalgia had sustained a documented mTBI within 90 days prior, whereas less than 1% were diagnosed with cervicalgia at the time of initial primary care or emergency room encounter following the mTBI event. This finding suggests that the close anatomical and neurophysiological connections between the head and the cervical spine are both likely to be impacted through the same mechanism of injury. Delayed evaluation (and treatment) of the cervical spine may contribute to lingering post-concussive symptoms. Limitations of this retrospective review include the inability to assess the causality of the relationship between neck pain and mTBI, as only the existence and strength of the prevalence relationship can be identified. The outcome data are exploratory and intended to identify relationships and trends that may suggest further study across installations and across mTBI populations.

The Intersection between Alcohol use and Sexual Activity among Young Adult Male U.S. Service Members.

Aims: The current study explores drinking habits, preferences for alcohol use before sexual activity, and alcohol-related sexual behavior among young adult male active duty service members in the United States. Background: Hazardous alcohol use is a significant problem among United States military service members. Whereas the association between alcohol use and sexual assault is well documented in civilian samples, less is known regarding the intersection of alcohol use and sexual activity among soldiers. Objective: Descriptive statistics were utilized to summarize drinking habits, preferences for alcohol use before sexual activity, and alcohol-related sexual behavior. Methods: A sample of 338 active-duty male service members between the ages of 18 and 24 were recruited from a large military post in the Southeastern United States. Constructs were assessed using self-report surveys. Results: Participants reported consuming alcohol, on average, 5.6 times over the prior month. Average alcohol consumption was reported to be 7.8 beverages per drinking occasion. Participants reported engaging in heavy drinking an average of 2.9 times over the past 30 days. On average, service members reported a preference for 1.3 drinks before sexual activity. Furthermore, 75.2% of participants preferred to be sober during sex, and 82.1% preferred to engage in sexual activity with a sober partner. Approximately 14% of the sample reported using alcohol to improve their chances of having sex. Conclusion: These findings highlight high rates of alcohol use among soldiers. Nonetheless, young adult male soldiers report a preference for sexual activity while sober. Understanding the co-occurrence of alcohol use and sexual activity has the potential to inform the development of integrated alcohol and sexual assault prevention programs for service members.

An Application of the Confluence Model of Sexual Aggression Among Young Adult Male Soldiers.

Sexual violence in the U.S. military is a serious concern. Whereas numerous studies document the prevalence of sexual violence among service members, far less research has examined etiological risk factors for sexual aggression perpetration among service members. The present study sought to evaluate the applicability of the Confluence Model of Sexual Aggression among a sample of young adult men engaged in active-duty military service within the U.S. Army. Anonymous surveys were completed by 326 male soldiers between the ages of 18 and 24 at a large military installation in the Southeastern region of the United tStates. Men's likelihood to engage in sexual aggression was operationalized as men's perceived likelihood to persist with sexual activity despite a partner's resistance. Aligning with the Confluence Model of Sexual Aggression, two composite variables reflecting hostile masculinity and tendency toward impersonal sex were created. A linear regression indicated that the main effects of hostile masculinity and impersonal sex were significantly associated with greater perceived likelihood of sexual aggression perpetration. Results also revealed that while the interaction term between hostile masculinity and impersonal sex was significant, the direction of the relationship suggests that the effect of impersonal sex is weaker at higher levels of hostile masculinity. These findings lend evidence to help identify those at elevated risk for perpetrating sexual aggression, as well as informing programmatic efforts to prevent sexual assault within the military.

Attention deficit hyperactivity disorder medications and bone mineral density of adults in the United States.

Introduction: Several medications used to treat attention deficit hyperactivity disorder (ADHD) have been associated with diminished bone mineral density (BMD) in children. The objective of this study was to determine if evidence exists for a similar association among adults. Materials and methods: A retrospective cross-sectional analysis was conducted using data collected by the National Health Nutrition Examination Survey 2013-2018. Data from 7961 individuals aged 18 to 50, 79 of whom were taking medications to treat ADHD. Dual-energy X-ray absorptiometry scans provided measure of body composition. Linear regression models were used to examine associations between ADHD medication use and body composition. Results: Stimulant ADHD medication usage was found to be associated with decreased BMD in both the skull (-6.6%; 95% CI 5.9-7.2) (P < 0.05) and thoracic spine (-6.0%; 95% CI 5.1-7.0) (P < 0.05). No difference in BMD was seen in any other skeletal region based on stimulant ADHD medication use (P > 0.05). We found no evidence to suggest that duration of use affected the observed decreases in BMD, P > 0.05. Conclusion: This study using a nationally representative sample assessed whether stimulant medication use in adults with ADHD was associated with decreased BMD. The overall results are inconclusive. Further study is needed to better evaluate if ADHD and/or stimulant medication use is independently associated with bone health.

U.S. military implantable collamer lens surgical outcomes: 11-year retrospective review.

PURPOSE: To examine the long-term efficacy and safety of myopic implantable collamer lens (ICL) implantation in active duty personnel of U.S. military. SETTING: Hospital practice. DESIGN: Retrospective longitudinal observational study. METHODS: 1485 patients (median age 25, interquartile range 22 to 29) underwent ICL surgery. Patients received a preoperative examination including uncorrected distance visual acuity (UDVA), intraocular pressure (IOP), manifest refraction measuring corrected distance visual acuity (CDVA), corneal topography and tomography, qualitative grading of perceived ectatic risk, ophthalmic biometry, and baseline endothelial cell counts (ECCs). Outcome measures included UDVA, IOP, vault size, manifest refraction, CDVA, and ECCs. The long-term follow-up data ware drawn from the U.S. military medical record system. RESULTS: A total of 3105 eyes were evaluated. Patients received ICLs because of either abnormal topography (2111 eyes [68%]) or high myopia (994 eyes [32%]). 94 eyes (80%) maintained UDVA of 20/25 or better up to 8 years postoperatively. The rate of achieving the desired refractive correction was 97% (503 eyes) at 1 year and 90% (81 eyes) at 8 years. Stability of these outcomes was also shown by minimal change in manifest refraction. Documented mean ECC loss was 22% at postoperative year 5. The overall rate of adverse events was 1.2% (36 eyes) including visually significant cataract formation, glaucoma, retinal detachment, and traumatic incision opening. A removal or replacement rate of 4.5% (135 eyes) was observed. CONCLUSIONS: ICL implantation was found to be effective and safe. Vault sizes decreased over time, suggesting an increased risk of cataract formation after 7 years. Further study is necessary to assess long-term clinical significance of ECC decline.

Prevalence of Hepatic Steatosis and Fibrosis in the United States.

Introduction: Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease in the world. We evaluated vibration-controlled transient elastography (VCTE) data to determine the prevalence of two principle manifestations of NAFLD, hepatic steatosis and hepatic fibrosis. Methods: Data were sourced from the 2017 to 2018 National Health and Nutrition Examination Survey, which provides a representative cross-section of the noninstitutionalized U.S. population. Participants 18 years of age and older were examined using sera and VCTE. Sociodemographic and medical history information were gathered through self-report. Logistic regression models assessed relationships between steatosis, fibrosis, and variables of interest. Prevalence estimates are reported as weighted percentages with 95% Wald confidence intervals (CIs). Results: A total of 4083 participants representing 187 million U.S. adults were included in our analysis. We estimate the prevalence of steatosis (controlled attenuation parameter ≥302 dB/m, ≥S1) at 27.3% (95% CI: 25.3-29.4) and significant fibrosis (liver stiffness ≥8.2 kPa, ≥F2) at 7.7% (95% CI: 6.1-9.6). Both were independently associated with age, gender, body mass index (BMI), and diabetes (all P < 0.05). The greatest predictor of both steatosis and fibrosis was BMI. Steatosis was present in 3.6%, 18.7%, and 49.4% of those in the normal or underweight, overweight, or obese categories, respectively. Significant fibrosis was present in 2.1%, 3.2%, and 14.7% of those in the normal or underweight, overweight, or obese categories, respectively. Conclusions: Clinically significant steatosis and/or fibrosis are highly prevalent among the U.S. adult population. The greatest predictor of both steatosis and fibrosis is obesity.

Enhanced Submentoplasty as an Adjunct to Orthognathic Surgery for the Improvement of the Neck-Throat Point.

Orthognathic surgery has been used to enhance the function of the maxillomandibular complex with numerous positive effects on facial esthetics, as it can profoundly alter the skeletal architecture of the face. Numerous adjunctive surgical techniques are used to enhance the overall cosmetic results of orthognathic surgery to include the following: genioplasty, midface augmentation, rhinoplasty, fillers, and liposuction. Mandibular advancement, submental liposuction and genioplasty are all techniques that help to define the neck throat point (NTP), minimize submental sagging, and enhance throat length (TL) in order to establish a more harmonious facial profile. However, these procedures may still be insufficient to define the NTP in the low hyoid, retrognathic patient. This report presents the case of an adult male, with a non-existent NTP and retrognathia, who underwent corrective orthognathic surgery with the novel enhanced submentoplasty and a suture assisted resuspension of the platysma in order to establish the NTP, increase TL, minimize submental sagging, and enhance mandibular border definition.

Wound Management of a Pediatric Spina Bifida Patient Secondary to a Canine-Inflicted Fifth-Digit Amputation: A Case Report.

We present a case of a pediatric patient with a history of spina bifida who presented to the emergency department of a large Army medical treatment facility with a partially amputated right fifth digit she sustained while sleeping with the family canine. There are several reports in the popular press that suggest that an animal, particularly a dog, can detect human infection, and it is hypothesized that the toe chewing was triggered by a wound infection. This case provides an opportunity to provide further education in caring for foot wounds in patients with spina bifida.

Normative formaldehyde-hemoglobin adduct levels among the US Population: Analysis of the 2013-2016 National Health and Nutrition Examination Survey.

INTRODUCTION: Formaldehyde (FA) is currently classified as a known carcinogen. In addition to being a ubiquitous compound with many common exogenous exposure sources, it is also part of multiple metabolic pathways and present in every living cell. The objectives of this study were to determine normative levels of FA as measured by FA-Hemoglobin (Hb) adducts in the United States (US) and to determine if FA-Hb levels differ based on a variety of demographic factors. METHODS: Data collected between 2013 and 2016 by the National Health and Nutrition Examination Survey were assessed from 4521 participants representing approximately 244 million individuals living in the US. General linear models were used to examine associations between FA-Hb adducts and sample characteristics. FA-Hb levels were summarized using geometric mean concentrations (GMC) and associated 95% confidence intervals (CI). RESULTS: The overall GMC was 131.10 nmol/g Hb (95% CI 129.39-132.83). Analyses revealed no evidence to support associations between FA-Hb levels and age, gender, income, or nicotine use. Among adults, non-Hispanic Black race was associated with lower FA-Hb levels compared to all other race/ethnicity groups, P < 0.01. CONCLUSION: The study provides the first normative values for FA in adults and children. These data could be a tool to assess the body's response to acute and chronic exposure.

Conceptualizations of Hooking Up Among Male Soldiers: A Qualitative Analysis.

INTRODUCTION: Hooking up is an impersonal sexual interaction, differing from sexual activity that occurs in the context of a committed relationship. Hookup behavior has been widely studied among college populations; however, this type of sexual behavior has yet to be explored in a military population. METHODS: The current study conducted semi-structured interviews with 10 male soldiers with high-risk drinking habits to explore conceptualizations of hooking up. Interviews were systematically coded and analyzed via thematic analysis. RESULTS: Five themes emerged: (1) definitions of hookups, (2) descriptions of why hookups occur, (3) how hookups occur (ie, the social context of hookups), (4) factors that facilitate hookups, and (5) differences between hookups and relationships. CONCLUSIONS: Findings suggest that perceptions of hookups among participants who were male soldiers are generally consistent with college populations, with some varying aspects.

Sliding Hip Screw for Fixation of Fracture Through a Previously Arthrodesed Hip.

Hip arthrodesis is a treatment option for painful chronic hip conditions. Hip fractures through a previously arthrodesed hip are relatively uncommon as indications for hip arthrodesis are rare. The following case reports on the use of a sliding hip screw and a pelvic reconstruction plate to address arthrodesed hip fracture in an 81-year-old man. The use of a dynamic hip screw in this setting gave us a stable fixed-angle construct with compression across the fracture site, and the addition of a trochanteric side plate added to the stability. The dynamic compression plate with limited bone contact was used to neutralize the construct. This case describes the successful treatment of such an injury in a way not previously described in the literature with the intent of giving the orthopaedic traumatologist another method to approach this rare injury.

Dysphoric Milk Ejection Reflex: A Descriptive Study.

Introduction: Dysphoric milk ejection reflex (D-MER) is emerging as a recognized phenomenon to describe an abrupt dysphoria, or undesirable feeling that occurs with the milk ejection reflex (MER) and then goes away after a few minutes. The purpose of this study was to determine the prevalence of D-MER among breastfeeding women and to describe the experience of symptoms associated with D-MER. Materials and Methods: To determine the prevalence of D-MER, a retrospective chart review was conducted over a 12-month period on women presenting for their 6- to 8-week postpartum visit. To describe the experience of D-MER, an anonymous cross-sectional survey consisting of 36 items was made accessible through a link to an online survey management platform. Participants were recruited through both paper and electronic posters at a variety of venues. Results: A prevalence rate of 9.1% was found. The respondents described similarities in their experiences with D-MER, to include feelings coming on suddenly and lasting for <5 minutes. The respondents described feeling anxious, sad, irritable, panicky, agitated, oversensitive, and tearful most often. Conclusion: This is the first study to quantify a prevalence rate and describe suspected experiences of D-MER. It provides the groundwork for future research to explore other contributing factors or relationships that may be relevant to D-MER. The findings support that the experience of D-MER is different from that of postpartum depression. Future research exploring the behavior of hormones and neurotransmitters within the context of lactation could contribute to the knowledge regarding D-MER.

Evaluation of Clinical Nurse Transition Program at US Army Hospitals.

INTRODUCTION: The purpose of this evaluation was to determine the effectiveness of the clinical nurse transition program (CNTP) for newly commissioned Army nurses. This is one of the first evaluations conducted to document the outcomes of the Army Nurse Corps (ANC) transition-to practice residency program. MATERIALS AND METHODS: This project was a prospective pre-test/post-test design evaluation of newly licensed registered nurses (RNs) entering the military health system from Fall 2017 to Fall 2018 using Casey-Fink Readiness for Practice Survey and the New Graduate RN Transition Program Competency Assessment Tool. Data were analyzed using SAS 9.4. All tests were two-tailed as applicable and p-values less than 0.05 were considered significant. Missing data were treated as missing for individual items; their values were not imputed. No participant was excluded due to missing items. This evaluation was determined to be exempt from human subject protection regulations by the Human Protections Administrator at Womack Army Medical Center. RESULTS: A total of 92 pre-test surveys were sent to the nine CNTP training sites which actively trained RNs during the study timeframe. Due to a shipping error, 6 of the 92 completed pre-test surveys from one CNTP site were not received, for an overall response rate of 93.4% (86/92), from eight CNTP sites. Of the 86 participants from whom pre-tests were received, all 86 successfully returned their post-test survey, for a 100% response rate pre- to post- survey. The participants were predominately white (73.3%) and female (70.9%) with a median age of 23 years (IQR: 22-24 years) and an undergraduate GPA of 3.5 (IQR: 3.4-3.7, Table II). Quantitative data analysis revealed that after the training, all participants reported a significant improvement in providing safe (p < 0.0001) and quality care (p < 0.0001) for an average workload of in-patient patients. It also showed a significant improvement in team leading (p < 0.0001), effective decision making (p < 0.0001), incorporating evidence into practice (p < 0.0001), and demonstrated professionalism (p < 0.0001). The overall clinical competence and readiness to practice (p < 0.0001) also improved. Data shows that participants perceive significant improvement in all the objectives set by the ANC for the transition program. CONCLUSION: The results of this program evaluation provide evidence that the CNTP has been a success in meeting the intended objectives. Participants showed a significant improvement in their perceived readiness and level of competency in clinical, technical, and leadership skills performance at the end of the program, as well as improved communication and teamwork. The CNTP experience provides an effective means to facilitate the development of newly licensed Army nurses' clinical competence and confidence in practice. The study limitation includes the Casey-Fink Readiness for Practice Survey had relatively low reliability, but it was chosen as it was better aligned to the specified CNTP objectives. And also, with any self-reported evaluation, there is potential bias regarding the accuracy of participants' self-perception. Follow-up study may include examining the demographics of the incoming nurses, such as their source of commission. To determine if and how the comfort and confidence self-reported by the new graduate nurses is reflective of actual ability, nurse preceptors may be asked to complete skills assessments or simulations with objective measurements may be used.

Temporomandibular Joint Pain Presentation of Myocardial Ischemia.

Cardiovascular disease is a leading cause of death worldwide. We report a case of myocardial infarction for which temporomandibular joint (TMJ) pain was the sole presenting initial symptom. A 28-year-old man presented to a dental clinic reporting TMJ pain. He was an active duty infantry solider in the US Army who was otherwise healthy and in excellent physical condition. He reported a 3-week history of intense throbbing to his left TMJ, specifically during physical activities and weight lifting. On examination by his general dentist, his blood pressure, heart rate, respiratory rate, and temperature were unremarkable. His maximal incisal opening was more than 45 mm without pain and demonstrated deviation, crepitus, and a full range of excursive movements without restrictions or provocation of pain. A hard night guard appliance was fabricated, and muscular physical therapy instructions were given, because his symptoms were thought to be related to muscle-related pain, possibly related to bruxism. He was referred to the oral and maxillofacial surgery (OMS) department for further evaluation and a second opinion. Before his appointment, he collapsed during physical training in cardiac arrest. He was brought to the emergency department and successfully resuscitated. He was found to have an 80% occlusion of his left anterior descending artery that was treated with a 1-vessel coronary artery bypass graft. After his cardiac surgery, he was seen and evaluated by OMS, and his TMJ symptoms had completely resolved. During the differential diagnosis of orofacial pain, clinicians should consider nonfacial sources of pain, especially referred cardiac pain that can mimic TMJ, odontogenic, and myofascial pain.

Evaluations of Sexual Assault Prevention Programs in Military Settings: A Synthesis of the Research Literature.

The prevention of sexual assault (SA) in the U.S. military is a significant priority. This study applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to a literature search that identified research evaluating SA prevention programs conducted within military settings. Only six studies published between 2005 and 2016 met criteria for inclusion in the review. Studies demonstrated high heterogeneity in the: (1) conceptual framework of the prevention approach; (2) target population and timing of administration; (3) study recruitment methods; (4) methodological design; (5) method of delivery, program dosage and theory of change; and (6) outcome administration and efficacy. Scientific rigor according to the Oxford Center for Evidence-based Medicine was also variable. Several gaps in the research base were identified. Specifically, research evaluating SA prevention programs have only been conducted among U.S. Army and U.S. Navy samples. Most studies did not examine whether program participation was associated with reductions in rates of sexual violence. Studies also lacked utilization of a long-term follow-up period. Additionally, studies did not reflect the types of SA prevention programs currently being implemented in military settings. Taken together, further research is needed to enhance the evidence base for SA prevention in the military, and to evaluate the effectiveness of the approaches currently being conducted with service members.

Dysphoric Milk Ejection Reflex: A Case Series.

BACKGROUND: Dysphoric milk ejection reflex (D-MER) is characterized by an abrupt dysphoria, or undesirable feeling that occurs with the MER and continues for no more than a few minutes. After milk ejection, the dysphoria vanishes. CASE SERIES: This case series provides a report of three women who have experienced D-MER. All three women described the sudden onset of negative feelings at the initiation of each breastfeeding session. The dysphoria vanished after each milk ejection. DISCUSSION: Literature on D-MER is limited to one published qualitative research study and two published case reports. As a result, lactation professionals and other providers in the healthcare setting rarely recognize this condition. CONCLUSIONS: The case studies presented here provide evidence for the presence of D-MER. Research is needed to better understand its pathophysiology, incidence, and treatment options.

Invasive Reduction of Paraphimosis in an Adolescent Male While in a Deployed Austere Environment.

Paraphimosis is a urologic emergency resulting in tissue necrosis and partial amputation, if not reduced. Paraphimosis occurs when the foreskin of the uncircumcised or partially circumcised male is retracted behind the glans penis, develops venous and lymphatic congestion, and cannot be returned to its normal position. Invasive reduction of paraphimosis requires minimal instruments and can be accomplished by experienced providers. This case describes a 10-year-old local national with paraphimosis over 10 days that required invasive reduction in a deployed austere environment in Africa.

Severe Hiatal Hernia as a Cause of Failure to Thrive Discovered by Transthoracic Echocardiogram.

A newborn infant with failure to thrive presented for murmur evaluation on day of life three due to a harsh 3/6 murmur. During the evaluation, a retrocardiac fluid filled mass was seen by transthoracic echocardiogram. The infant was also found to have a ventricular septal defect and partial anomalous pulmonary venous return. Eventually, a large hiatal hernia was diagnosed on subsequent imaging. The infant ultimately underwent surgical repair of the hiatal hernia at a tertiary care facility. Hiatal hernias have been noted as incidental extracardiac findings in adults, but no previous literature has documented hiatal hernias as incidental findings in the pediatric population.