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1.
Hist Philos Life Sci ; 43(2): 62, 2021 Apr 26.
Artigo em Inglês | MEDLINE | ID: mdl-33900513

RESUMO

This article examines the relation between counting, counts and accountability. It does so by comparing the responses of the British government to deaths associated with Covid-19 in 2020 to its responses to deaths associated with the 2003 invasion of Iraq. Similarities and dissimilarities between the cases regarding what counted as data, what data were taken to count, what data counted for, and how data were counted provide the basis for considering how the bounds of democratic accountability are constituted. Based on these two cases, the article sets out the metaphors of leaks and cascades as ways of characterising the data practices whereby counts, counting and accountability get configured. By situating deaths associated with Covid-19 against previous experience with deaths from war, the article also proposes how claims to truth and ignorance might figure in any future official inquiry into the handling of the pandemic.


Assuntos
/mortalidade , Guerra do Iraque 2003-2011 , Mortalidade/história , Pandemias/estatística & dados numéricos , Responsabilidade Social , História do Século XXI , Humanos , Reino Unido
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
4.
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
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.
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
7.
J Affect Disord ; 282: 236-241, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33418372

RESUMO

BACKGROUND: Though sleep disturbance has shown to negatively affect outcomes related to post-deployment conditions, it is unclear whether and how sleep disturbance affects mental health symptoms beyond these conditions. We evaluated the independent and moderating effects of sleep quality on posttraumatic stress disorder (PTSD), depressive, and neurobehavioral symptoms beyond mild traumatic brain injury (TBI) and PTSD diagnosis. METHODS: Participants were 274 US combat veterans who deployed after 9/11. All completed diagnostic TBI and PTSD interviews and self-report measures of sleep quality, as well as PTSD, depressive, and neurobehavioral symptoms. Only those who passed symptom validity were included in analyses. Hierarchical regression evaluated the contribution of sleep quality to outcomes beyond PTSD and mild TBI. Moderation analyses evaluated interactions between mild TBI, PTSD, and sleep quality on symptom outcomes. RESULTS: Mild TBI was only significantly associated with PTSD (p = .006) and neurobehavioral (p = .003) symptoms. PTSD diagnosis was associated with PTSD (p < .001), depressive (p < .001), and neurobehavioral symptoms (p < .001) beyond mild TBI. Sleep quality explained additional significant variance in all three outcome measures (p < .001), and also significantly moderated the effects of PTSD diagnosis on neurobehavioral symptoms (ΔR2 = .01, p = .023). LIMITATIONS: Sleep was evaluated subjectively and therefore must be interpreted in this context. CONCLUSIONS: These results provide support that sleep quality is an independent contributing factor to health outcomes in post-deployment veterans and should be considered in etiology of complaints.


Assuntos
Concussão Encefálica , Transtornos do Sono-Vigília , Transtornos de Estresse Pós-Traumáticos , Veteranos , Humanos , Guerra do Iraque 2003-2011 , Sono , Transtornos do Sono-Vigília/epidemiologia , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/epidemiologia
8.
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
9.
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
10.
Arch Phys Med Rehabil ; 101(10): 1720-1730, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32653582

RESUMO

OBJECTIVE: To compare Veterans Health Administration (VHA) diagnoses, health services utilization, and costs by mild traumatic brain injury (mTBI) group (blast-related [BR] mTBI vs non-blast-related [NBR] mTBI vs no mTBI) among Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) veterans in the Chronic Effects of Neurotrauma Consortium multicenter observational study. DESIGN: Prospective cohort study. SETTING: Four Veterans Affairs Medical Centers. PARTICIPANTS: OEF/OIF/OND veterans (N=472) who used Veterans Affairs Medical Centers services between 2002-2017. INTERVENTIONS: Not applicable. Lifetime mTBI history was assessed via semistructured interviews. MAIN OUTCOME MEASURES: VHA diagnoses, health services utilization, and costs. RESULTS: Relative to NBR mTBI and no mTBI, veterans with BR mTBI were more likely to be male, have greater combat, and have controlled and uncontrolled detonations exposures (median BR, 15.0 vs NBR, 3.0 vs no mTBI, 3.0). They also had higher prevalence of headache, posttraumatic stress disorder, and anxiety diagnoses. Veterans with BR had the highest site-adjusted mean annual VHA utilization (26.31 visits; 95% confidence interval [CI], 26.01-26.61) relative to NBR (20.43 visits; 95% CI, 20.15-20.71) and no mTBI (16.62 visits; 95% CI, 16.21-17.04) and highest site adjusted mean annual VHA outpatient costs ($6480; 95% CI, $5842-$7187) relative to NBR ($4901; 95% CI, $4392-$5468) and no mTBI ($4069; 95% CI, $3404-$4864). CONCLUSIONS: Veterans with BR mTBI had higher exposure to combat and detonation. BR was associated with greater prevalence of select diagnoses and higher health services utilization and costs relative to NBR and no mTBI. The role of health care needs from mTBI polytrauma, other deployment-related exposures, and VHA access warrants future research.


Assuntos
Concussão Encefálica/epidemiologia , Gastos em Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Veteranos/estatística & dados numéricos , Adolescente , Adulto , Concussão Encefálica/economia , Doença Crônica , Feminino , Serviços de Saúde/economia , Serviços de Saúde/estatística & dados numéricos , Nível de Saúde , Humanos , Guerra do Iraque 2003-2011 , Masculino , Saúde Mental , Militares/psicologia , Militares/estatística & dados numéricos , Estudos Prospectivos , Fatores Sexuais , Fatores Socioeconômicos , Índices de Gravidade do Trauma , Estados Unidos , Veteranos/psicologia , Serviços de Saúde para Veteranos Militares/estatística & dados numéricos , Adulto Jovem
11.
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
12.
J Craniofac Surg ; 31(5): 1434-1437, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32502104

RESUMO

As the most prominent portion of the human body, the face embraces a multifaceted responsibility for functionality and survival while contributing to identity and self-image. Inopportunely, due to its distinctive anatomical location, the face as a unit is highly suspectable to trauma, particularly in warfare. As a result, facial injury creates a physical and psychological trauma that needs to be addressed immediately. In the following article, a detailed literature review was conducted to examine the interplay between facial injuries throughout multiple wars in Iraq and their management. The authors found a significant increase in facial injuries due to shell fragments corresponding with modern advances in warfare targeting mass casualties. The capacity to manage the magnitude and level of trauma observed in Iraq requires a substantial amount of resources and a systematic approach that unfortunately is unattainable in a country that is still struggling to rebuild after decades of oppression and war. Due to the circumstances, surgeons have to rely on training and experience to provide the best care for their patients and it is imperative that we continue to train our surgeons to rely on their skills and experience to ensure a high level of care with limited resources and lack of technology.


Assuntos
Traumatismos Craniocerebrais/terapia , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Iraque , Guerra do Iraque 2003-2011 , Masculino , Pessoa de Meia-Idade , Guerra , Adulto Jovem
14.
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
15.
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
16.
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
17.
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
18.
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
20.
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
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