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1.
Br Dent J ; 230(7): 466-472, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33837346

RESUMO

Operation Herrick was the British military operation in Afghanistan that occurred between 2002 and 2014; the most recent, large-scale and publicly conducted war in British history. During this time, over 60 British military dental teams deployed as part of the UK Medical Group, their primary role being the treatment of dental emergencies in UK Armed Forces. There are numerous publications citing statistics regarding the rates and nature of dental casualties on operations, their management and how this affects operational capability. This article instead aims to give a more generalised insight into the lived experience of an Army dentist deployed on Operation Herrick.


Assuntos
Militares , Campanha Afegã de 2001- , Afeganistão , Odontólogos , Humanos
2.
JAMA Netw Open ; 4(2): e2036065, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33528551

RESUMO

Importance: There is uncertainty about the role that military deployment experiences play in suicide-related outcomes. Most previous research has defined combat experiences broadly, and a limited number of cross-sectional studies have examined the association between specific combat exposure (eg, killing) and suicide-related outcomes. Objective: To prospectively examine combat exposures associated with suicide attempts among active-duty US service members while accounting for demographic, military-specific, and mental health factors. Design, Setting, and Participants: This cohort study analyzed data from the Millennium Cohort Study, an ongoing prospective longitudinal study of US service members from all military branches. Participants were enrolled in 4 phases from July 1, 2001, to April 4, 2013, and completed a self-administered survey at enrollment and every 3 to 5 years thereafter. The population for the present study was restricted to active-duty service members from the first 4 enrollment phases who deployed in support of the wars in Iraq and Afghanistan. Questionnaire data were linked with medical encounter data through September 30, 2015. Data analyses were conducted from January 10, 2017, to December 14, 2020. Exposures: Combat exposure was examined in 3 ways (any combat experience, overall combat severity, and 13 individual combat experiences) using a 13-item self-reported combat measure. Main Outcomes and Measures: Suicide attempts were identified from military electronic hospitalization and ambulatory medical encounter data using the International Classification of Diseases, Ninth Revision codes. Results: Among 57 841 participants, 44 062 were men (76.2%) and 42 095 were non-Hispanic White individuals (72.8%), and the mean (SD) age was 26.9 (5.3) years. During a mean (SD) follow-up period of 5.6 (4.0) years, 235 participants had a suicide attempt (0.4%). Combat exposure, defined broadly, was not associated with suicide attempts in Cox proportional hazards time-to-event regression models after adjustments for demographic and military-specific factors; high combat severity and certain individual combat experiences were associated with an increased risk for suicide attempts. However, these associations were mostly accounted for by mental disorders, especially posttraumatic stress disorder. After adjustment for mental disorders, combat experiences with significant association with suicide attempts included being attacked or ambushed (hazard ratio [HR], 1.55; 95% CI, 1.16-2.06), seeing dead bodies or human remains (HR, 1.34; 95% CI, 1.01-1.78), and being directly responsible for the death of a noncombatant (HR, 1.81; 95% CI, 1.04-3.16). Conclusions and Relevance: This study suggests that deployed service members who experience high levels of combat or are exposed to certain types of combat experiences (involving unexpected events or those that challenge moral or ethical norms) may be at an increased risk of a suicide attempt, either directly or mediated through a mental disorder.


Assuntos
Transtorno Depressivo/epidemiologia , Homicídio/estatística & dados numéricos , Militares/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Tentativa de Suicídio/estatística & dados numéricos , Exposição à Guerra/estatística & dados numéricos , Adulto , Campanha Afegã de 2001- , Transtorno Depressivo/psicologia , Feminino , Homicídio/psicologia , Humanos , Guerra do Iraque 2003-2011 , Masculino , Militares/psicologia , Questionário de Saúde do Paciente , Modelos de Riscos Proporcionais , Transtornos de Estresse Pós-Traumáticos/psicologia , Tentativa de Suicídio/psicologia , Estados Unidos/epidemiologia , Lesões Relacionadas à Guerra/epidemiologia , Lesões Relacionadas à Guerra/psicologia , Adulto Jovem
3.
Mil Med ; 186(Suppl 1): 559-566, 2021 01 25.
Artigo em Inglês | MEDLINE | ID: mdl-33499440

RESUMO

INTRODUCTION: Deployment-related mild traumatic brain injury (mTBI) affects a significant proportion of those who served in Post-9/11 combat operations. The prevalence of head injuries, including those that lead to mTBI, is often reported quantitatively. However, service member (SM) and Veteran firsthand accounts of their potential concussive events (PCEs) and mTBIs can serve as a rich resource for better understanding the nuances and context of these exposures. MATERIALS AND METHODS: Post-9/11 SMs and Veterans with a history of combat deployment were recruited through the Chronic Effects of Neurotrauma Consortium's observational study of deployment-related mTBI. During a comprehensive assessment, participants completed the Virginia Commonwealth University retrospective Concussion Diagnostic Interview, a specialized validated interview measure which obtains detailed narratives of deployment-incurred blast and non-blast-related PCEs. Qualitative thematic analysis was used to identify and code recurring themes within the narratives. RESULTS: Among the sample of 106 SMs and Veterans, deployment-related mTBI was highly prevalent (67.0%). Over half (50.9%) of the participants identified a blast as the cause of their worst PCE, frequently with accompanying themes of self-reported acute neurological symptoms, intense physical blast forces, and tertiary head impact. Exposure to blast at close range, such as driving directly over an improvised explosive device, occurred in 24.7% of all blast-related narratives and in 59.3% of narratives where blast was identified as causing the worst PCE. Themes of potentially preventable head impacts experienced during noncombat circumstances were also frequent, accounting for 35% of all non-blast-related head injuries in the sample. CONCLUSIONS: Prevalence of deployment-related close-range blast exposure, non-blast impact PCEs, and mTBIs among this Post-9/11 combatant sample was substantial, and in many cases potentially preventable. The use of detailed semi-structured interviews may help health care providers and policymakers to better understand the context and circumstances of deployment-related PCEs and mTBIs.


Assuntos
Concussão Encefálica , Veteranos , Campanha Afegã de 2001- , Concussão Encefálica/epidemiologia , Humanos , Guerra do Iraque 2003-2011 , Testes Neuropsicológicos , Estudos Retrospectivos , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Transtornos de Estresse Pós-Traumáticos/etiologia , Virginia
4.
Med Care ; 59: S42-S50, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33438882

RESUMO

OBJECTIVE: To examine sex differences in risk for administratively documented suicide attempt (SA) among US Army soldiers during the Iraq/Afghanistan wars. METHOD: Using administrative person-month records of Regular Army enlisted soldiers from 2004 to 2009, we identified 9650 person-months with a first documented SA and an equal-probability control sample (n=153,528 person-months). Person-months were weighted to the population and pooled over time. After examining the association of sex with SA in a logistic regression analysis, predictors were examined separately among women and men. RESULTS: Women (an estimated 13.7% of the population) accounted for 25.2% of SAs and were more likely than men to attempt suicide after adjusting for sociodemographic, service-related, and mental health diagnosis (MHDx) variables (odds ratio=1.6; 95% confidence interval, 1.5-1.7). Women with increased odds of SA in a given person-month were younger, non-Hispanic White, less educated, in their first term of enlistment, never or previously deployed (vs. currently deployed), and previously received a MHDx. The same variables predicted SA among men. Interactions indicated significant but generally small differences between women and men on 6 of the 8 predictors, the most pronounced being time in service, deployment status, and MHDx. Discrete-time survival models examining risk by time in service demonstrated that patterns for women and men were similar, and that women's initially higher risk diminished as time in service increased. CONCLUSIONS: Predictors of documented SAs are similar for US Army women and men. Differences associated with time in service, deployment status, and MHDx require additional research. Future research should consider stressors that disproportionately affect women.


Assuntos
Militares/estatística & dados numéricos , Tentativa de Suicídio/estatística & dados numéricos , Adulto , Campanha Afegã de 2001- , Estudos de Coortes , Sistemas de Gerenciamento de Base de Dados , Feminino , Humanos , Guerra do Iraque 2003-2011 , Estudos Longitudinais , Masculino , Estudos Retrospectivos , Fatores Sexuais , Estados Unidos , United States Department of Defense , Adulto Jovem
5.
Artigo em Inglês | MEDLINE | ID: mdl-33498982

RESUMO

Prior research on the relationship between veterans' mental health and psychosocial functioning has primarily relied on male samples. Here, we investigated prospective longitudinal relationships between mental health and psychosocial functioning in 554 female Iraq and Afghanistan War veterans who were surveyed three times between two- and seven-years following separation from service. Mixed effects modeling revealed that increasing depression and posttraumatic stress disorder (PTSD) severity predicted declines in work functioning. Increasing PTSD severity predicted declining parental functioning and worsening depression predicted a decline in relationship functioning. In turn, decreased work and intimate relationship functioning predicted increased PTSD and depression symptom severity suggesting bi-directional effects between mental health and psychosocial functioning. An examination of the effect of deployment stressors on psychosocial functioning revealed that deployment sexual harassment was the strongest predictor of decreased psychosocial functioning across all domains. Evidence for the reciprocal nature of relationships between mental health and psychosocial functioning underscore the need for treatment targeted at PTSD and depression, as well as work and relationship functioning to improve outcomes for women veterans.


Assuntos
Saúde Mental , Transtornos de Estresse Pós-Traumáticos , Veteranos , Campanha Afegã de 2001- , Afeganistão , Feminino , Humanos , Iraque , Guerra do Iraque 2003-2011 , Estudos Prospectivos , Transtornos de Estresse Pós-Traumáticos/epidemiologia
6.
J Spec Oper Med ; 20(3): 76-80, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32969008

RESUMO

BACKGROUND: The United States (US) military utilizes combat wound medication packs (CWMP) to provide analgesia and wound prophylaxis in casualties who are still able to fight. We compared characteristics of combat casualties receiving CWMP to those not receiving CWMP. We also describe the proportions of casualties with injury patterns consistent with Tactical Combat Casualty Care (TCCC) guideline indications for CWMP use who received this intervention. METHODS: This is a secondary analysis of Department of a Defense Trauma Registry (DODTR) dataset of US military personnel from January 2007 to August 2016. We searched for all subjects with documented use of at least one medication from the CWMP (acetaminophen, meloxicam, moxifloxacin). RESULTS: Within our dataset, 11,665 casualties were US military Servicemembers. Overall, <1% (84) of our study population received the CWMP. The median age and mechanism of injuries were similar between CWMP nonrecipients versus recipients. Median composite injury scores were higher for nonrecipients than recipients (6 versus 4, P < .001). Proportions of casualties with injury patterns meeting TCCC guideline CWMP indications who received this intervention were low: gunshot wound, <1% (14 of 1805), tourniquet applied, <1% (11 of 1912), major amputation, <1% (5 of 803), and open fracture, <1% (10 of 2425). Based on serious injuries by body region, we had similar findings for the thorax (<1%; 3 of 1122), abdomen (<1%; 1 of 736), and extremities (<1%; 11 of 2699). CONCLUSIONS: Subjects receiving the CWMP were less severely injured compared to those who did not receive this intervention. The CWMP had very infrequent use among those casualties with injury patterns meeting indications specified in the TCCC Guidelines for use of this intervention.


Assuntos
Serviços Médicos de Emergência , Medicina Militar , Militares , Ferimentos por Arma de Fogo , Campanha Afegã de 2001- , Afeganistão/epidemiologia , Humanos , Iraque/epidemiologia , Guerra do Iraque 2003-2011 , Sistema de Registros , Estados Unidos/epidemiologia
8.
BMC Public Health ; 20(1): 1076, 2020 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-32641028

RESUMO

BACKGROUND: Posttraumatic stress disorder (PTSD) and hearing loss are hallmark public health issues related to military service in Iraq and Afghanistan. Although both are significant individual contributors to disability among veterans, their co-occurrence has not been specifically explored. METHODS: A total of 1179 male U.S. military personnel who sustained an injury between 2004 and 2012 during operations in Iraq or Afghanistan were identified from clinical records. Pre- and postinjury audiometric data were used to define new-onset hearing loss, which was categorized as unilateral or bilateral. Diagnosed PTSD was abstracted from electronic medical records. Logistic regression analysis examined the relationship between hearing loss and PTSD, while adjusting for age, year of injury, occupation, injury severity, injury mechanism, and presence of concussion. RESULTS: The majority of the study sample were aged 18-25 years (79.9%) and sustained mild-moderate injuries (94.6%). New-onset hearing loss was present in 14.4% of casualties (10.3% unilateral, 4.1% bilateral). Rates of diagnosed PTSD were 9.1, 13.9, and 29.2% for those with no hearing loss, unilateral hearing loss, and bilateral hearing loss, respectively. After adjusting for covariates, those with bilateral hearing loss had nearly three-times higher odds of PTSD (odds ratio = 2.92; 95% CI, 1.47-5.81) compared to those with no hearing loss. Unilateral hearing loss was not associated with PTSD. CONCLUSIONS: Both PTSD and hearing loss are frequent consequences of modern warfare that adversely affect the overall health of the military. Bilateral, but not unilateral, hearing loss was associated with a greater burden of PTSD. This has implications for warfighter rehabilitation and should encourage collaboration between audiology and mental health professionals.


Assuntos
Perda Auditiva/epidemiologia , Militares/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Adolescente , Adulto , Campanha Afegã de 2001- , Fatores Etários , Concussão Encefálica/epidemiologia , Humanos , Guerra do Iraque 2003-2011 , Masculino , Estudos Retrospectivos , Índices de Gravidade do Trauma , Estados Unidos/epidemiologia , Guerra , Adulto Jovem
9.
Surgery ; 168(4): 662-670, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32600883

RESUMO

BACKGROUND: Post-traumatic acute kidney injury has occurred in every major military conflict since its initial description during World War II. To ensure the proper treatment of combat casualties, early detection is critical. This study therefore aimed to investigate combat-related post-traumatic acute kidney injury in recent military conflicts, used machine learning algorithms to identify clinical and biomarker variables associated with the development of post-traumatic acute kidney injury, and evaluated the effects of post-traumatic acute kidney injury on wound healing and nosocomial infection. METHODS: We conducted a retrospective clinical cohort review of 73 critically injured US military service members who sustained major combat-related extremity wounds and had collected injury characteristics, assayed serum and tissue biopsy samples for the expression of protein and messenger ribonucleic acid biomarkers. Bivariate analyses and random forest recursive feature elimination classification algorithms were used to identify associated injury characteristics and biomarker variables. RESULTS: The incidence of post-traumatic acute kidney injury was 20.5%. Of that, 86% recovered baseline renal function and only 2 (15%) of the acute kidney injury group required renal replacement therapy. Random forest recursive feature elimination algorithms were able to estimate post-traumatic acute kidney injury with the area under the curve of 0.93, sensitivity of 0.91, and specificity of 0.91. Post-traumatic acute kidney injury was associated with injury severity score, serum epidermal growth factor, and tissue activin A type receptor 1, matrix metallopeptidase 10, and X-C motif chemokine ligand 1 expression. Patients with post-traumatic acute kidney injury exhibited poor wound healing and increased incidence of nosocomial infections. CONCLUSION: The occurrence of acute kidney injury in combat casualties may be estimated using injury characteristics and serum and tissue biomarkers. External validations of these models are necessary to generalize for all trauma patients.


Assuntos
Lesão Renal Aguda/diagnóstico , Citocinas/sangue , Inflamação/sangue , Lesões Relacionadas à Guerra/complicações , Lesão Renal Aguda/sangue , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/etiologia , Adulto , Campanha Afegã de 2001- , Algoritmos , Biomarcadores/sangue , Infecção Hospitalar/complicações , Diagnóstico Precoce , Feminino , Humanos , Incidência , Escala de Gravidade do Ferimento , Guerra do Iraque 2003-2011 , Aprendizado de Máquina , Masculino , Militares , Estudos Retrospectivos , Fatores de Risco , Cicatrização , Adulto Jovem
10.
Artigo em Inglês | MEDLINE | ID: mdl-32397395

RESUMO

During their deployment to Iraq in support of Operation Iraqi Freedom (OIF), many Veterans were exposed to a wide array of toxic substances and psychologic stressors, most notably airborne/environmental pollutants from open burn pits. Service members do not deploy whilst unhealthy, but often they return with a multitude of acute and chronic symptoms, some of which only begin to manifest years after their deployment. Our findings, while preliminary in nature, suggest that Iraq War Veterans who participated in our survey reported a decrease in overall physical fitness and increased respiratory clinical symptoms compared with pre-deployment periods. The objective of this report is to provide information that will benefit how combat Veterans are cared for post-deployment. Strategies for a wider and more comprehensive assessment and medical screening process post-deployment are recommended.


Assuntos
Campanha Afegã de 2001- , Substâncias Perigosas , Nível de Saúde , Estresse Psicológico , Veteranos , Adulto , Feminino , Substâncias Perigosas/toxicidade , Humanos , Iraque , Masculino , Aptidão Física , Projetos Piloto
11.
Am J Physiol Endocrinol Metab ; 319(1): E48-E66, 2020 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-32315214

RESUMO

Although glucocorticoid resistance contributes to increased inflammation, individuals with posttraumatic stress disorder (PTSD) exhibit increased glucocorticoid receptor (GR) sensitivity along with increased inflammation. It is not clear how inflammation coexists with a hyperresponsive hypothalamic-pituitary-adrenal (HPA) axis. To understand this better, we developed and analyzed an integrated mathematical model for the HPA axis and the immune system. We performed mathematical simulations for a dexamethasone (DEX) suppression test and IC50-dexamethasone for cytokine suppression by varying model parameters. The model analysis suggests that increasing the steepness of the dose-response curve for GR activity may reduce anti-inflammatory effects of GRs at the ambient glucocorticoid levels, thereby increasing proinflammatory response. The adaptive response of proinflammatory cytokine-mediated stimulatory effects on the HPA axis is reduced due to dominance of the GR-mediated negative feedback on the HPA axis. To verify these hypotheses, we analyzed the clinical data on neuroendocrine variables and cytokines obtained from war-zone veterans with and without PTSD. We observed significant group differences for cortisol and ACTH suppression tests, proinflammatory cytokines TNFα and IL6, high-sensitivity C-reactive protein, promoter methylation of GR gene, and IC50-DEX for lysozyme suppression. Causal inference modeling revealed significant associations between cortisol suppression and post-DEX cortisol decline, promoter methylation of human GR gene exon 1F (NR3C1-1F), IC50-DEX, and proinflammatory cytokines. We noted significant mediation effects of NR3C1-1F promoter methylation on inflammatory cytokines through changes in GR sensitivity. Our findings suggest that increased GR sensitivity may contribute to increased inflammation; therefore, interventions to restore GR sensitivity may normalize inflammation in PTSD.


Assuntos
Citocinas/imunologia , Glucocorticoides/imunologia , Receptores de Glucocorticoides/imunologia , Transtornos de Estresse Pós-Traumáticos/imunologia , Hormônio Adrenocorticotrópico/imunologia , Hormônio Adrenocorticotrópico/metabolismo , Adulto , Campanha Afegã de 2001- , Proteína C-Reativa/imunologia , Estudos de Casos e Controles , Ritmo Circadiano , Metilação de DNA , Dexametasona , Glucocorticoides/metabolismo , Humanos , Hidrocortisona/imunologia , Hidrocortisona/metabolismo , Sistema Hipotálamo-Hipofisário/imunologia , Sistema Hipotálamo-Hipofisário/metabolismo , Inflamação , Concentração Inibidora 50 , Interleucina-6/imunologia , Guerra do Iraque 2003-2011 , Masculino , Modelos Teóricos , Testes de Função Adreno-Hipofisária , Sistema Hipófise-Suprarrenal/imunologia , Sistema Hipófise-Suprarrenal/metabolismo , Regiões Promotoras Genéticas , Receptores de Glucocorticoides/genética , Receptores de Glucocorticoides/metabolismo , Transtornos de Estresse Pós-Traumáticos/metabolismo , Fator de Necrose Tumoral alfa/imunologia , Veteranos
12.
BMC Public Health ; 20(1): 578, 2020 Apr 28.
Artigo em Inglês | MEDLINE | ID: mdl-32345277

RESUMO

BACKGROUND: Blast injury emerged as a primary source of morbidity among US military personnel during the recent conflicts in Iraq and Afghanistan, and led to an array of adverse health outcomes. Multimorbidity, or the presence of two or more medical conditions in an individual, can complicate treatment strategies. To date, there is minimal research on the impact of multimorbidity on long-term patient-reported outcomes. We aimed to define multimorbidity patterns in a population of blast-injured military personnel, and to examine these patterns in relation to long-term quality of life (QOL). METHODS: A total of 1972 US military personnel who sustained a blast-related injury during military operations in Iraq and Afghanistan were identified from clinical records. Electronic health databases were used to identify medical diagnoses within the first year postinjury, and QOL was measured with a web-based assessment. Hierarchical cluster analysis methods using Ward's minimum variance were employed to identify clusters with related medical diagnosis categories. Duncan's multiple range test was used to group clusters into domains by QOL. RESULTS: Five distinct clusters were identified and grouped into three QOL domains. The lowest QOL domain contained one cluster with a clinical triad reflecting musculoskeletal pain, concussion, and mental health morbidity. The middle QOL domain had two clusters, one with concussion/anxiety predominating and the other with polytrauma. The highest QOL domain had two clusters with little multimorbidity aside from musculoskeletal pain. CONCLUSIONS: The present study described blast-related injury profiles with varying QOL levels that may indicate the need for integrated health services. Implications exist for current multidisciplinary care of wounded active duty and veteran service members, and future research should determine whether multimorbidity denotes distinct post-blast injury syndromes.


Assuntos
Traumatismos por Explosões/psicologia , Militares/psicologia , Multimorbidade , Traumatismos Ocupacionais/psicologia , Qualidade de Vida , Adulto , Campanha Afegã de 2001- , Traumatismos por Explosões/epidemiologia , Concussão Encefálica/epidemiologia , Concussão Encefálica/psicologia , Análise por Conglomerados , Feminino , Humanos , Guerra do Iraque 2003-2011 , Masculino , Transtornos Mentais/epidemiologia , Transtornos Mentais/psicologia , Pessoa de Meia-Idade , Dor Musculoesquelética/epidemiologia , Dor Musculoesquelética/psicologia , Traumatismos Ocupacionais/epidemiologia , Medidas de Resultados Relatados pelo Paciente , Estudos Retrospectivos , Estados Unidos/epidemiologia
13.
JAMA Netw Open ; 3(3): e200287, 2020 03 02.
Artigo em Inglês | MEDLINE | ID: mdl-32119096

RESUMO

Importance: In response to the national opioid public health crisis, there is an urgent need to develop nonopioid solutions for effective pain management. Neurosteroids are endogenous molecules with pleotropic actions that show promise for safe and effective treatment of chronic low back pain. Objective: To determine whether adjunctive pregnenolone has therapeutic utility for the treatment of chronic low back pain in Iraq- and Afghanistan-era US military veterans. Design, Setting, and Participants: Randomized, double-blind, placebo-controlled clinical trial that enrolled for 42 months, from September 2013 to April 2017. Participants were Iraq- and Afghanistan-era veterans aged 18 to 65 years with chronic low back pain who received treatment in the Durham VA Health Care System in Durham, North Carolina, over 6 weeks. Data analysis began in 2018 and was finalized in March, 2019. Interventions: Following a 1-week placebo lead-in, participants were randomized to pregnenolone or placebo for 4 weeks. Pregnenolone and placebo were administered at fixed, escalating doses of 100 mg for 1 week, 300 mg for 1 week, and 500 mg for 2 weeks. Main Outcomes and Measures: The primary outcome measure was the change in mean pain intensity ratings from a daily pain diary (numerical rating scale, 0-10) between visit 3 (baseline) and visit 6. Secondary outcomes included pain interference scores (Brief Pain Inventory, Short Form). Preintervention and postintervention neurosteroid levels were quantified by gas chromatography with tandem mass spectrometry. Hypotheses tested were formulated prior to data collection. Results: A total of 94 participants (84 [89.4%] male; mean [SD] age, 37.5 [9.8] years; 53 [56.4%] of self-reported Caucasian race and 31 [33.0%] of self-reported African American race) were included. Forty-eight participants were randomized to pregnenolone and 52 to placebo, of whom 45 and 49, respectively, were included in baseline demographic characteristics secondary to noncompliance with medications as per protocol. Veterans randomized to pregnenolone reported significant reductions in low back pain relative to those randomized to placebo. Baseline unadjusted mean (SE) pain diary ratings were 4.83 (0.23) and 5.24 (0.22) for the placebo- and pregnenolone-treated groups, respectively (baseline unadjusted mean [SE] ratings for pain recall were 4.78 [0.24] and 5.15 [0.23], respectively). Unadjusted mean (SE) ratings following treatment (visit 6) were 4.74 (0.26) in the placebo group and 4.19 (0.30) in the pregnenolone-treated group. Unadjusted mean (SE) ratings for pain recall following treatment were 4.86 (0.27) for placebo and 4.18 (0.29) for pregnenolone. Least-square mean (LSM) analysis showed that pain scores significantly improved in the pregnenolone-treated group compared with placebo (LSM [SE] change in pain diary rating, -0.56 [0.25]; P = .02; LSM [SE] change in pain recall, -0.70 [0.27]; P = .01). Pain interference scores for work (LSM [SE] change, 0.71 [0.12]; P = .04) and activity (LSM [SE] change, 0.71 [0.11]; P = .03) were also improved in veterans randomized to pregnenolone compared with placebo. Pregnenolone was well tolerated. Conclusions and Relevance: Participants receiving pregnenolone reported a clinically meaningful reduction in low back pain and 2 pain interference domains compared with those receiving placebo. Pregnenolone may represent a novel, safe, and potentially efficacious treatment for the alleviation of chronic low back pain in Iraq- and Afghanistan-era veterans. Trial Registration: ClinicalTrials.gov Identifier: NCT01898013.


Assuntos
Dor Crônica/tratamento farmacológico , Dor Lombar/tratamento farmacológico , Pregnenolona/uso terapêutico , Veteranos , Adulto , Campanha Afegã de 2001- , Método Duplo-Cego , Feminino , Cromatografia Gasosa-Espectrometria de Massas , Humanos , Guerra do Iraque 2003-2011 , Análise dos Mínimos Quadrados , Masculino , Pessoa de Meia-Idade , Medição da Dor , Pregnanolona/sangue , Pregnenolona/sangue , Autorrelato , Espectrometria de Massas em Tandem , Estados Unidos
14.
Arch Clin Neuropsychol ; 35(5): 491-505, 2020 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-32128559

RESUMO

OBJECTIVE: The purpose of this study was to evaluate relationships between multiple mild traumatic brain injuries (mTBIs) and objective and subjective clinical outcomes in a sample of combat-exposed Veterans, adjusting for psychiatric distress and combat exposure. METHOD: In this cross-sectional study, 73 combat-exposed Iraq/Afghanistan Veterans were divided into three groups based on mTBI history: 0 mTBIs (n = 31), 1-2 mTBIs (n = 21), and 3+ mTBIs (n = 21). Veterans with mTBI were assessed, on average, 7.78 years following their most recent mTBI. Participants underwent neuropsychological testing and completed self-report measures assessing neurobehavioral, sleep, and pain symptoms. RESULTS: MANCOVAs adjusting for psychiatric distress and combat exposure showed no group differences on objective measures of attention/working memory, executive functioning, memory, and processing speed (all p's > .05; ηp2 = .00-.06). In contrast, there were significant group differences on neurobehavioral symptoms (p's = < .001-.036; ηp2 = .09-.43), sleep difficulties (p = .037; ηp2 = .09), and pain symptoms (p < .001; ηp2 = .21). Pairwise comparisons generally showed that the 3+ mTBI group self-reported the most severe symptoms, followed by comparable symptom reporting between the 0 and 1-2 mTBI groups. CONCLUSIONS: History of multiple, remote mTBIs is associated with elevated subjective symptoms but not objective neuropsychological functioning in combat-exposed Veterans. These results advance understanding of the long-term consequences of repetitive mTBI in this population and suggest that Veterans with 3+ mTBIs may especially benefit from tailored treatments aimed at ameliorating specific neurobehavioral, sleep, and pain symptoms.


Assuntos
Lesões Encefálicas Traumáticas , Transtornos de Estresse Pós-Traumáticos , Veteranos , Campanha Afegã de 2001- , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/epidemiologia , Estudos Transversais , Humanos , Guerra do Iraque 2003-2011 , Testes Neuropsicológicos , Transtornos de Estresse Pós-Traumáticos/complicações , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Resultado do Tratamento
15.
J Trauma Acute Care Surg ; 88(6): 832-838, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32176176

RESUMO

BACKGROUND: Pelvic trauma has emerged as one of the most severe injuries to be sustained by the victim of a blast insult. The incidence and mortality due to blast-related pelvic trauma is not known, and no data exist to assess the relative risk of clinical or radiological indicators of mortality. METHODS: The UK Joint Theater Trauma Registry was interrogated to identify those sustaining blast-mediated pelvic fractures during the conflicts in Iraq and Afghanistan, from 2003 to 2014, with subsequent computed tomography image analysis. Casualties that sustained more severe injuries remote to the pelvis were excluded. RESULTS: One hundred fifty-nine casualties with a 36% overall mortality rate were identified. Pelvic vascular injury, unstable pelvic fracture patterns, traumatic amputation, and perineal injury were higher in the dismounted fatality group (p < 0.05). All fatalities sustained a pelvic vascular injury. Pelvic vascular injury had the highest relative risk of death for any individual injury and an associated mortality of 56%. Dismounted casualties that sustained unstable pelvic fracture patterns, traumatic amputation, and perineal injury were at three times greater risk (relative risk, 3.00; 95% confidence interval, 1.27-7.09) to have sustained a pelvic vascular injury than those that did not sustain these associated injuries. Opening of the pubic symphysis and at least one sacroiliac joint was significantly associated with pelvic vascular injury (p < 0.001), and the lateral displacement of the sacroiliac joints was identified as a fair predictor of pelvic vascular injury (area under the receiver operating characteristic curve, 0.73). CONCLUSION: Dismounted blast casualties with pelvic fracture are at significant risk of a noncompressible pelvic vascular injury. Initial management of these patients should focus upon controlling noncompressible pelvic bleeding. Clinical and radiological predictors of vascular injury and mortality suggest that mitigation strategies aiming to attenuate lateral displacement of the pelvis following blast are likely to result in fewer fatalities and a reduced injury burden. LEVEL OF EVIDENCE: Prognostic, level III.


Assuntos
Traumatismos por Explosões/epidemiologia , Fraturas Ósseas/epidemiologia , Técnicas Hemostáticas , Ossos Pélvicos/lesões , Lesões do Sistema Vascular/mortalidade , Adolescente , Adulto , Campanha Afegã de 2001- , Traumatismos por Explosões/complicações , Traumatismos por Explosões/diagnóstico , Traumatismos por Explosões/terapia , Fraturas Ósseas/complicações , Fraturas Ósseas/diagnóstico , Fraturas Ósseas/terapia , Humanos , Escala de Gravidade do Ferimento , Guerra do Iraque 2003-2011 , Masculino , Pessoa de Meia-Idade , Militares/estatística & dados numéricos , Ossos Pélvicos/irrigação sanguínea , Ossos Pélvicos/diagnóstico por imagem , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Falha de Tratamento , Reino Unido/epidemiologia , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/terapia , Adulto Jovem
16.
Exp Clin Psychopharmacol ; 28(4): 426-437, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32134284

RESUMO

There is a high comorbidity between symptoms of depression and cannabis and alcohol use in civilian and veteran populations. Prospective studies attempting to clarify the directionality of these comorbidities have yielded mixed results. Further, the relations between these constructs and impulsive personality, particularly negative urgency (NU, the tendency to act rashly when experiencing emotional distress) warrants further attention, as NU relates to symptoms of depression and alcohol and cannabis use. Importantly, NU partially accounts for the association between symptoms of depression and cannabis and alcohol problems in cross-sectional studies. This study examined alternative theories of directionality in order to better understand the longitudinal associations between symptoms of depression, NU, and cannabis or alcohol use. Three semiannual waves of data (baseline, 6-month, and 12-month) were collected in parallel assessments from a sample of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (N = 361). Autoregressive cross-lagged panel models were used to test four alternative theory-driven models about the longitudinal associations between the interaction of symptoms of depression and NU and cannabis or alcohol use. Models revealed unique direction of effects specific to each substance, such that the interaction between symptoms of depression and NU at 6 months postbaseline predicted more alcohol use at 12 months postbaseline, whereas more cannabis use at 6 months postbaseline predicted more severe symptoms of depression at 12 months postbaseline. Results suggests alternate directions of effect for cannabis and alcohol use. Future research should examine these patterns over wider assessment periods in order to see more variability and change over time. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


Assuntos
Consumo de Bebidas Alcoólicas/psicologia , Depressão/psicologia , Fumar Maconha/epidemiologia , Veteranos/psicologia , Adolescente , Adulto , Campanha Afegã de 2001- , Comorbidade , Estudos Transversais , Feminino , Humanos , Guerra do Iraque 2003-2011 , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Adulto Jovem
17.
Mil Med ; 185(Suppl 1): 413-419, 2020 01 07.
Artigo em Inglês | MEDLINE | ID: mdl-32074349

RESUMO

INTRODUCTION: Musculoskeletal (MSK) conditions are commonly seen among military service members (SM) and Veterans. We explored correlates of award of MSK-related service-connected disability benefits (SCDB) among SM seeking care in Veterans Affairs (VA) hospitals. MATERIALS AND METHODS: Department of Defense data on SM who separated from October 1, 2001 to May 2017 were linked to VA administrative data. Using adjusted logistic regression models, we determined the odds of receiving MSK SCDB. RESULTS: A total of 1,558,449 (79% of separating SM) had at least one encounter in VA during the study period (7.8% disability separations). Overall, 51% of this cohort had at least one MSK SCDB (88% among disability separations, 48% among normal). Those with disability separations (as compared to normal separations) were significantly more likely to receive MSK SCDB (odds ratio 2.37) as were females (compared to males, odds ratio 1.15). CONCLUSIONS: Although active duty SM with disability separations were more likely to receive MSK-related service-connected disability ratings in the VA, those with normal separations also received such awards. Identifying those at highest risk for MSK-related disability could lead to improved surveillance and prevention strategies in the Department of Defense and VA health care systems to prevent further damage and disability.


Assuntos
Avaliação da Deficiência , Pessoas com Deficiência/reabilitação , Previsões/métodos , Militares/estatística & dados numéricos , Doenças Musculoesqueléticas/complicações , Adulto , Campanha Afegã de 2001- , Pessoas com Deficiência/estatística & dados numéricos , Feminino , Humanos , Guerra do Iraque 2003-2011 , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Doenças Musculoesqueléticas/epidemiologia , Estados Unidos , United States Department of Veterans Affairs/organização & administração , United States Department of Veterans Affairs/estatística & dados numéricos , Veteranos/estatística & dados numéricos
18.
Mil Med ; 185(Suppl 1): 50-56, 2020 01 07.
Artigo em Inglês | MEDLINE | ID: mdl-32074359

RESUMO

INTRODUCTION: There is mounting evidence of respiratory problems related to military service in the Middle East in the past two decades due to environmental exposures during deployment (eg, sand storms and burn pits). This pilot study tests the hypothesis that regional lung function in subjects with prior deployment in Iraq and/or Afghanistan with suspected War Lung Injury (WLI) would be worse than subjects with normal lung function. MATERIALS AND METHODS: Five subjects meeting the inclusion and exclusion criteria were recruited for this pilot study. All subjects underwent spirometry, high-resolution chest computed tomography imaging, and 19F MRI. RESULTS: While the WLI subjects had normal pulmonary function tests and normal high-resolution chest computed tomography evaluations, their regional lung function from 19F MRI was abnormal with compartments with poor function showing slower filling time constants for ventilation. The scans of suspected WLI subjects show higher fractional lung volume with slow filling compartments similar to patients with chronic obstructive pulmonary disease in contrast to normal subjects. CONCLUSIONS: This is consistent with our premise that WLI results in abnormal lung function and reflects small airways dysfunction and suggests that we may be able to provide a more sensitive tool for evaluation of WLI suspected cases.


Assuntos
Imagem por Ressonância Magnética de Flúor-19/métodos , Lesão Pulmonar/diagnóstico por imagem , Adulto , Campanha Afegã de 2001- , Feminino , Imagem por Ressonância Magnética de Flúor-19/instrumentação , Imagem por Ressonância Magnética de Flúor-19/estatística & dados numéricos , Humanos , Guerra do Iraque 2003-2011 , Masculino , Pessoa de Meia-Idade , Oxigenoterapia/métodos , Projetos Piloto , Sistema de Registros/estatística & dados numéricos , Inquéritos e Questionários , Estados Unidos
19.
Mil Med ; 185(Suppl 1): 73-76, 2020 01 07.
Artigo em Inglês | MEDLINE | ID: mdl-32074367

RESUMO

BACKGROUND: Infectious complications of war wounds are a significant source of mortality and morbidity. Tactical Combat Casualty Care (TCCC) guidelines recommend prehospital moxifloxacin, ertapenem, or cefotetan for "all open combat wounds." We describe the prehospital administration of antibiotics to pediatric trauma patients. METHODS: We queried the Department of Defense Trauma Registry for all pediatric subjects admitted to United States and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. RESULTS: During this time, there were 3,439 pediatric encounters which represented 8.0% of all admissions. Prehospital providers administered a total of 216 antibiotic doses to 210 subjects. Older children received antibiotics more frequently than younger children, were more likely to be male, located in Afghanistan, and injured by explosive with the majority surviving to hospital discharge. Cefazolin and ceftriaxone were the most frequently utilized antibiotics. CONCLUSIONS: The most frequently administered antibiotics were cephalosporins. TCCC recommended agents for adult prehospital wound prophylaxis were infrequently administered to pediatric casualties. Administration rates of pediatric prehospital wound prophylaxis may be improved with pediatric-specific TCCC guidelines recommending cephalosporins as first-line agents, fielding of a TCCC-oriented Broselow tape, and training prehospital providers on administration of antimicrobials.


Assuntos
Antibioticoprofilaxia/normas , Pediatria/métodos , Ferimentos e Lesões/tratamento farmacológico , Adolescente , Campanha Afegã de 2001- , Afeganistão , Antibioticoprofilaxia/classificação , Antibioticoprofilaxia/estatística & dados numéricos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Iraque , Guerra do Iraque 2003-2011 , Masculino , Pediatria/normas , Pediatria/estatística & dados numéricos
20.
Mil Med ; 185(Suppl 1): 296-302, 2020 01 07.
Artigo em Inglês | MEDLINE | ID: mdl-32074380

RESUMO

INTRODUCTION: We explore disparities in awarding post-traumatic stress disorder (PTSD) service-connected disability benefits (SCDB) to veterans based on gender, race/ethnicity, and misconduct separation. METHODS: Department of Defense data on service members who separated from October 1, 2001 to May 2017 were linked to Veterans Administration (VA) administrative data. Using adjusted logistic regression models, we determined the odds of receiving a PTSD SCDB conditional on a VA diagnosis of PTSD. RESULTS: A total of 1,558,449 (79% of separating service members) had at least one encounter in VA during the study period (12% female, 4.5% misconduct separations). Females (OR 0.72) and Blacks (OR 0.93) were less likely to receive a PTSD award and were nearly equally likely to receive a PTSD diagnosis (OR 0.97, 1.01). Other racial/ethnic minorities were more likely to receive an award and diagnosis, as were those with misconduct separations (award OR 1.3, diagnosis 2.17). CONCLUSIONS: Despite being diagnosed with PTSD at similar rates to their referent categories, females and Black veterans are less likely to receive PTSD disability awards. Other racial/ethnic minorities and those with misconduct separations were more likely to receive PTSD diagnoses and awards. Further study is merited to explore variation in awarding SCDB.


Assuntos
Avaliação da Deficiência , Disparidades em Assistência à Saúde/estatística & dados numéricos , Militares/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/terapia , United States Department of Veterans Affairs/estatística & dados numéricos , Adulto , Campanha Afegã de 2001- , Feminino , Humanos , Guerra do Iraque 2003-2011 , Masculino , Pessoa de Meia-Idade , Militares/psicologia , Transtornos de Estresse Pós-Traumáticos/psicologia , Estados Unidos , United States Department of Veterans Affairs/organização & administração
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