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, Lisa J. Colpe, Pablo A. Aliaga, Nancy A. Sampson, Steven G. Heeringa, Murray B. Stein, , Carol S. Fullerton, Matthew K. Nock, Michael Schoenbaum, et al.
Published: 1 September 2016
Military Medicine, Volume 181, pp 1021-1032; https://doi.org/10.7205/milmed-d-15-00211

Abstract:
U.S. Army soldiers with mental disorders report a variety of barriers to initiating and continuing treatment. Improved understanding of these barriers can help direct mental health services to soldiers in need. A representative sample of 5,428 nondeployed Regular Army soldiers participating in the Army Study to Assess Risk and Resilience in Servicemembers completed a self-administered questionnaire and consented to linking self-administered questionnaire data with administrative records. We examined reported treatment barriers (perceived need, structural reasons, attitudinal reasons) among respondents with current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, mental disorders who either did not seek treatment in the past year (n = 744) or discontinued treatment (n = 145). About 82.4% of soldiers who did not initiate treatment and 69.5% of those who discontinued treatment endorsed at least two barriers; 69.8% of never-treated soldiers reported no perceived need. Attitudinal reasons were cited more frequently than structural reasons among never-treated soldiers with perceived need (80.7% vs. 62.7%) and those who discontinued treatment (71.0% vs. 37.8%). Multivariate associations with sociodemographic, Army career, and mental health predictors varied across barrier categories. These findings suggest most soldiers with mental disorders do not believe they need treatment and those who do typically face multiple attitudinal and, to a lesser extent, structural barriers.
Kenona H. Southwell, Shelley M. MacDermid Wadsworth
Published: 1 January 2016
Military Medicine, Volume 181, pp 70-79; https://doi.org/10.7205/milmed-d-15-00193

Abstract:
Female service members' family structures differ from the traditional male service member–female spouse composition of military families. Consequently, this mixed-methods study reviewed demographic data, empirical evidence, and presented findings from secondary analyses of the 2010 wave of the Military Family Life Project regarding structural differences in male and female service members' families and perceptions and experiences of military spouses. In addition, to gain an understanding of the influence of women's service on their family functioning, we conducted in-depth telephone interviews with 20 civilian husbands residing in 11 states around the United States. Empirical evidence suggests service women had higher rates or remarriage and divorce than service men. Women were also more likely than men to be part of nontraditional family forms. Civilian husbands of female service members, however, reported lower marital satisfaction, less support from the community, and less satisfaction with the military lifestyle than military wives. Husbands' accounts indicated that their families experienced both benefits and challenges from wives' service. Integration in the military community and separation presented major challenges for women's families. Implications of benefits and challenges of women's service for their families are discussed.
Judy L. Dye, , Victoria Tepe, Mary C. Clouser, Michael Galarneau
Published: 1 January 2016
Military Medicine, Volume 181, pp 92-98; https://doi.org/10.7205/milmed-d-15-00237

Abstract:
Although historically restricted from combat roles, women suffer from combat-related injuries, especially in recent conflicts where asymmetrical warfare erases distinctions between forward and rear operating areas. U.S. servicewomen who sustained combat-related injury in Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) between January 2003 and May 2014 were identified from the Expeditionary Medical Encounter Database. Injuries were characterized using Abbreviated Injury Scale and International Classification of Diseases, 9th Revision codes. Of the 844 combat-related injury episodes in women, 51% (n = 433) were OIF injuries and 49% (n = 411) were OEF injuries. Blast events were responsible for 90% of injuries. The average Injury Severity Score was 3, with no statistical difference in means between OIF and OEF. Of significance were increased head injuries in OEF compared with OIF (80% vs. 48%; p < 0.001). Although the majority of combat-related injuries suffered by women were mild, some women suffered life-threatening injuries, and nearly 65% of the injury episodes resulted in more than one injury. More research is needed as the roles of women in the military continue to expand. Future studies will investigate quality of life outcomes and gender differences in combat-related injuries.
Mady Wechsler Segal, Capt David G. Smith, David R. Segal, Lcdr Amy A. Canuso
Published: 1 January 2016
Military Medicine, Volume 181, pp 28-39; https://doi.org/10.7205/milmed-d-15-00342

Abstract:
This article analyzes how the behaviors of leaders and peers affect the performance and well-being of military women. Locating our analysis within the conceptual model in this issue, we summarize the empirical literature and make practice and policy recommendations. We synthesize results about unit integration, such as research on the conditions for successful integration of previously excluded groups and on the relationship between cohesion and performance. We apply lessons learned from the history of diversity integration in military and civilian organizations, analyzing the treatment of military personnel by race, gender, and sexual orientation. The opening of ground combat specialties and units to women is the latest step in personnel policy changes broadening the recruitment base. We analyze research on gender integration in contemporary armed forces, focusing on positive and negative effects on women of leader and peer behaviors. We discuss conditions for successfully integrating women and those that tend to lead to failure. We analyze military women's family issues, including the effects of deployments and how leaders and peers can help ameliorate problems—or exacerbate them with inappropriate or unsupportive behavior.
Bradley C. Nindl, Bruce H. Jones, Stephanie J. Van Arsdale, Karen Kelly, William J. Kraemer
Published: 1 January 2016
Military Medicine, Volume 181, pp 50-62; https://doi.org/10.7205/milmed-d-15-00382

Abstract:
This article summarizes presentations from a 2014 United States Department of Defense (DoD) Health Affairs Women in Combat symposium addressing physiological, musculoskeletal injury, and optimized physical training considerations from the operational physical performance section. The symposium was held to provide a state-of-the-science meeting on the U.S. DoD's rescinding of the ground combat exclusion policy opening up combat-centric occupations to women. Physiological, metabolic, body composition, bone density, cardiorespiratory fitness, and thermoregulation differences between men and women were briefly reviewed. Injury epidemiological data are presented within military training and operational environments demonstrating women to be at a higher risk for musculoskeletal injuries than men. Physical training considerations for improved muscle strength and power, occupational task performance, load carriage were also reviewed. Particular focus of this article was given to translating physiological and epidemiological findings from the literature on these topics toward actionable guidance and policy recommendations for military leaders responsible for military physical training doctrine: (1) inclusion of resistance training with special emphasis on strength and power development (i.e., activation of high-threshold motor units and recruitment of type II high-force muscle fibers), upper-body strength development, and heavy load carriage, (2) moving away from “field expediency” as the major criteria for determining military physical training policy and training implementation, (3) improvement of load carriage ability with emphasis placed on specific load carriage task performance, combined with both resistance and endurance training, and (4) providing greater equipment resources, coaching assets, and increased training time dedicated to physical readiness training.
Valerie A. Stander, Cynthia J. Thomsen
Published: 1 January 2016
Military Medicine, Volume 181, pp 20-27; https://doi.org/10.7205/milmed-d-15-00336

Abstract:
Recently, there has been increasing concern regarding the problem of sexual violence in the military. Because sexual harassment and assault are more closely intertwined in the military than in most civilian contexts, the military context affords a unique opportunity to study the interrelationships between these two types of sexual violence. In this review, we briefly summarize existing research on military sexual trauma prevalence rates, effects on victims, and risk factors, as well as prevention and response programs in the military context. In each of these topic areas, we emphasize issues unique to the complex interplay between sexual harassment and assault in the military and make recommendations for future research.
, , Pablo A. Aliaga, Nancy A. Sampson, Steven G. Heeringa, Murray B. Stein, , Carol S. Fullerton, Matthew K. Nock, Michael L. Schoenbaum, et al.
Published: 1 October 2015
Military Medicine, Volume 180, pp 1041-1051; https://doi.org/10.7205/milmed-d-14-00686

Abstract:
A representative sample of 5,428 nondeployed Regular Army soldiers completed a self-administered questionnaire (SAQ) and consented to linking SAQ data with administrative records as part of the Army Study to Assess Risk and Resilience in Service members. The SAQ included information about prevalence and treatment of mental disorders among respondents with current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) internalizing (anxiety, mood) and externalizing (disruptive behavior, substance) disorders. 21.3% of soldiers with any current disorder reported current treatment. Seven significant predictors of being in treatment were identified. Four of these 7 were indicators of psychopathology (bipolar disorder, panic disorder, post-traumatic stress disorder, 8+ months duration of disorder). Two were sociodemographics (history of marriage, not being non-Hispanic Black). The final predictor was history of deployment. Treatment rates varied between 4.7 and 71.5% depending on how many positive predictors the soldier had. The vast majority of soldiers had a low number of these predictors. These results document that most nondeployed soldiers with mental disorders are not in treatment and that untreated soldiers are not concentrated in a particular segment of the population that might be targeted for special outreach efforts. Analysis of modifiable barriers to treatment is needed to help strengthen outreach efforts.
John C. Dunn,
Published: 1 January 2015
Military Medicine, Volume 180; https://doi.org/10.7205/milmed-d-14-00232

Abstract:
A young active duty soldier underwent acromioclavicular reconstruction with hamstring autograft after sustaining a shoulder separation. At 3 months postoperatively, the patient fell and sustained a fracture of the coracoid process. The patient elected for nonoperative management of the coracoid fracture. Despite eventual nonunion of the fracture, the patient had excellent functional outcomes and returned to military duty without limitation. Although some authors advocate operative fixation, especially in a young and active cohort, excellent outcomes can be obtained with nonoperative management.
Published: 1 January 2015
Military Medicine, Volume 180, pp 32-37; https://doi.org/10.7205/milmed-d-14-00240

Abstract:
Skin is the most exposed organ of the body, and military personnel face many external skin threats. As a result, skin disease is an important source of morbidity among military personnel deployed on combat or peacekeeping operations. This article reviews the most common conditions seen by deployed military dermatologists. A PubMed search was used to identify articles in English, written between 1965 and 2014, using medical subject headings "military medicine" AND "skin disease" or "military personnel" AND "skin disease." The five most common reasons for physician consultation for skin conditions in wartime since the Vietnam War were warts (10.7%), fungal infections (10.4%), acne (9.0%), nonspecific eczematous conditions (7.1%), and sexually transmitted diseases (6.1%). There was a significant difference in the skin conditions seen in the hot and humid climates of Vietnam and East Timor, where bacterial and fungal infections were more common reasons for consultation, and the dry climates of Bosnia and Iraq, where eczematous conditions made up a larger part of the dermatologic caseload.
Michael McCrea, , Selina Doncevic, Katherine Helmick, Jan Kennedy, Cynthia Boyd, Sarah Asmussen, Kwang W. Ahn, Yanzhi Wang, James Hoelzle, et al.
Published: 1 September 2014
Military Medicine, Volume 179, pp 990-997; https://doi.org/10.7205/milmed-d-13-00349

Abstract:
The study investigated the clinical validity of the cognitive screening component of the Military Acute Concussion Evaluation (MACE) for the evaluation of acute mild traumatic brain injury (mTBI) in a military operational setting. This was a retrospective data study involving analysis of MACE data on Operation Enduring Freedom/Operation Iraqi Freedom deployed service members with mTBI. In total, 179 cases were included in analyses based on ICD-9 diagnostic codes and characteristics of mTBI, and availability of MACE data on day of injury. MACE data from the mTBI group was compared to a military sample without mTBI administered the MACE as part of a normative data project. On day of injury, the mTBI group performed worse than controls on the MACE cognitive test (d = 0.90), with significant impairments in all cognitive domains assessed. MACE cognitive score was strongly associated with established indicators of acute injury severity. Lower MACE cognitive performance on day of injury was predictive of lengthier postinjury recovery time and time until return to duty after mTBI. Findings from the current study support the use of the MACE as a valid screening tool to assess for cognitive dysfunction in military service members during the acute phase after mTBI.
Natalie E. Hundt, Terri L. Barrera, Andrew Robinson, Jeffrey A. Cully
Published: 1 September 2014
Military Medicine, Volume 179, pp 942-949; https://doi.org/10.7205/milmed-d-14-00128

Abstract:
Research conducted in the civilian population demonstrates that cognitive-behavioral therapies are effective for depression, but some evidence suggests that Veterans' treatment response may differ from civilians. This review examined cognitive-behavioral treatment (CBT) for depression in Veteran samples. A literature search for treatment outcome studies with Veteran samples was conducted using PsycInfo, PubMed, and SCOPUS databases. Nine studies met inclusion criteria and were assessed for methodological rigor (randomized controlled trials = 5; open trials = 4). Controlled effect sizes were compared for randomized controlled trials, and pre-post effect sizes were used to compare treatment groups across all studies. The open trials reviewed demonstrated large pre-post effect sizes, though these studies were of lower methodological quality. CBT performed better than control treatment in only two of five randomized controlled trials reviewed, a finding that contrasts with research in non-Veteran samples. Possible reasons for these findings are discussed, including psychosocial factors that may influence the course of depression treatment in Veterans. Additional high quality research is needed to conclusively determine if depression treatment outcomes differ for Veterans and, if so, what modifications to current CBT protocols might enhance response to treatment.
Eric K. O'Neal, Jared H. Hornsby, Kyle J. Kelleran
Published: 1 September 2014
Military Medicine, Volume 179, pp 950-954; https://doi.org/10.7205/milmed-d-14-00079

Abstract:
This article provides a synopsis of the limited investigations examining the impact of external load (EL) on performance of high-intensity tasks under load (HITL), EL training intervention effects on HITL performance, and injuries from EL training. Repetitive lifting tasks and initiation of locomotion, such as rapidly moving from a prone position to sprinting appear to be more hindered by EL than maximal sprinting velocity and may explain why training with EL does not improve obstacle course or prolonged (200-300 yard shuttle) drills. EL training appears to offer very little if any benefit for HITL in lesser trained populations. This contrast results of multiple studies incorporating ≥ 3 weeks of prolonged hypergravity interventions (wearing EL during daily activities) in elite anaerobic athletes, indicating EL training stimulus is likely only beneficial to well-trained soldiers. Women and lesser trained individuals appear to be more susceptible to increased injury with EL training. A significant limitation concerning current HITL knowledge is the lack of studies incorporating trained soldiers. Future investigations concerning the effects of HITL on marksmanship, repetitive lifting biomechanics, efficacy of hypergravity training for military personnel, and kinematics of sprinting from tactical positions with various EL displacements and technique training are warranted.
Gregory P. Beehler, Amy E. Rodrigues, Morgan A. Kay, Marc T. Kiviniemi, Lynn Steinbrenner
Published: 1 September 2014
Military Medicine, Volume 179, pp 998-1005; https://doi.org/10.7205/milmed-d-14-00027

Abstract:
This study aimed to identify barriers and facilitators to health behavior change related to body size in a sample of veteran cancer survivors. A qualitative study was conducted with a sample of 35 male and female cancer survivors receiving care at a Veterans Administration comprehensive cancer center. Participants completed individual interviews regarding barriers and facilitators to lifestyle change and responded to a brief questionnaire regarding current health behaviors. Participants reported suboptimal adherence to recommended health behavior goals and the majority were overweight or obese (80%). Qualitative analysis revealed numerous barriers and facilitators to health behavior change across six broad categories: environmental factors, health services delivery factors, health-related factors, factors related to attitudes toward change, factors related to enacting change, and motivational factors. Veteran cancer survivors were impacted by common barriers to change affecting the general population, cancer-specific factors related to personal diagnosis and treatment history, and health service delivery factors related to the Veterans Administration health care system. There are many barriers and facilitators that exist in diverse domains for veteran cancer survivors, each of which offers unique challenges and opportunities for improving engagement in behavior change following cancer diagnosis and treatment.
Alison L. Batig, Dawn Elliott, Harlan Rumjahn, Joren Keylock, Michael Chinn, Gregory E. Chow
Published: 1 September 2014
Military Medicine, Volume 179, pp 1030-1035; https://doi.org/10.7205/milmed-d-13-00569

Abstract:
To evaluate the utility of pipelle endometrial sampling as a diagnostic tool in the evaluation of abnormal first trimester gestations. Thirty-one women with abnormal first trimester pregnancies defined as gestations with abnormally rising or falling quantitative human chorionic gonadotropin (β-hCG) levels and ultrasound findings consistent with a nonviable or ectopic pregnancy were prospectively evaluated. Endometrial pipelle sampling was performed on each patient in a standardized fashion immediately before curettage and evaluated as a fixed, permanent specimen to assess for the presence of either chorionic villi, trophoblastic or fetal tissue. The sensitivity, specificity, positive predictive value, and negative predictive value for endometrial biopsy were 70.1%, 100%, 100%, and 33.3%, respectively. For curettage, the sensitivity, specificity, positive predictive value, and negative predictive value were 88.9%, 100%, 100%, and 57.1%, respectively. Curettage's overall sensitivity is superior to endometrial biopsy in detecting the presence of intrauterine products of conception in early abnormal pregnancies. However, in some clinical situations where the diagnosis of ectopic pregnancy is in question, particularly if the β-hCG is ≤ 2,000 mIU/mL, endometrial pipelle biopsy could be a useful tool in the evaluation algorithm.
Anne M. Gadermann, Steven G. Heeringa, Murray B. Stein, , Lisa J. Colpe, Carol S. Fullerton, , Michael J. Gruber, Matthew K. Nock, Anthony J. Rosellini, et al.
Military Medicine, Volume 179, pp 752-761; https://doi.org/10.7205/milmed-d-13-00446

Abstract:
Objectives: To derive job condition scales for future studies of the effects of job conditions on soldier health and job functioning across Army Military Occupation Specialties (MOSs) and Areas of Concentration (AOCs) using Department of Labor (DoL) Occupational Information Network (O*NET) ratings. Methods: A consolidated administrative dataset was created for the “Army Study to Assess Risk and Resilience in Servicemembers” (Army STARRS) containing all soldiers on active duty between 2004 and 2009. A crosswalk between civilian occupations and MOS/AOCs (created by DoL and the Defense Manpower Data Center) was augmented to assign scores on all 246 O*NET dimensions to each soldier in the dataset. Principal components analysis was used to summarize these dimensions. Results: Three correlated components explained the majority of O*NET dimension variance: “physical demands” (20.9% of variance), “interpersonal complexity” (17.5%), and “substantive complexity” (15.0%). Although broadly consistent with civilian studies, several discrepancies were found with civilian results reflecting potentially important differences in the structure of job conditions in the Army versus the civilian labor force. Conclusions: Principal components scores for these scales provide a parsimonious characterization of key job conditions that can be used in future studies of the effects of MOS/AOC job conditions on diverse outcomes.
Ronald J. Kembro, ,
Published: 1 November 2008
Military Medicine, Volume 173, pp 1057-1059; https://doi.org/10.7205/milmed.173.11.1057

Abstract:
Military physicians are using recombinant factor VIIa (rFVIIa) in Iraq and Afghanistan to help stop life-threatening hemorrhage in trauma patients. We constructed a questionnaire and surveyed Army general surgeons deployed to Iraq and/or Afghanistan about their predeployment experience, deployment experience, and projected postdeployment practice regarding rFVIIa usage. Most surgeons had rFVIIa available during their deployment (65%). The drug was used with varying frequency and subjective therapeutic effect. A majority of surgeons (79%) were unaware of any guideline or policy governing the use of rFVIIa. Seventy percent of respondents would use the drug in their future practice. Deployed surgeons generally have positive attitudes regarding the use of rFVIIa, but greater guidance and outcome measures are needed.
, David R. Tribble, Shannon D. Putnam, Timothy McGraw, John W. Sanders, Adam W. Armstrong, Mark S. Riddle
Published: 1 November 2008
Military Medicine, Volume 173, pp 1060-1067; https://doi.org/10.7205/milmed.173.11.1060

Abstract:
Background and Methods: Vector-borne diseases are known threats to deployed troops. We performed a cross-sectional study of troops deployed to Southwest Asia between January 2005 and February 2007 to evaluate practices of personal protective measures and their relationship to self-report of Old World cutaneous leishmaniasis (CL), a marker of vector-borne disease threat. Results: Regular or always N, N-diethyl-m-toluamide (DEET) use was low (2–5%). Associations for DEET use were command emphasis, branch of service, uniform treatment with permethrin, and duty station. Uniform treatment with permethrin was associated with branch of service, command emphasis, and use of DEET. We identified 22 cases of CL (incidence density of 1.8–3.7 per 100 person-years) with increased risk among Reserve/National Guard components, Air Force and Marine personnel. Conclusions: Commanders can influence the use of the military insect repellent system. Unit-based treatment of uniforms improves prevalence. CL incidence may be higher than previously reported.
Karen M. Eaton, Charles W. Hoge, Stephen C. Messer, Allison A. Whitt, Oscar A. Cabrera, Dennis McGurk, Anthony Cox, Carl A. Castro
Published: 1 November 2008
Military Medicine, Volume 173, pp 1051-1056; https://doi.org/10.7205/milmed.173.11.1051

Abstract:
Military spouses must contend with unique issues such as a mobile lifestyle, rules and regulations of military life, and frequent family separations including peacekeeping and combat deployments. These issues may have an adverse effect on the health of military spouses. This study examined the mental health status, rates of care utilization, source of care, as well as barriers and stigma of mental health care utilization among military spouses who were seeking care in military primary care clinics. The data show spouses have similar rates of mental health problems compared to soldiers. Spouses were more likely to seek care for their mental health problems and were less concerned with the stigma of mental health care than were soldiers. Services were most often received from primary care physicians, rather than specialty mental health professionals, which may relate to the lack of availability of mental health services for spouses on military installations.
Charles C. Engel, Thomas Oxman, Christopher Yamamoto, Darin Gould, Sheila Barry, Patrice Stewart, , John W. Williams, Allen J. Dietrich
Published: 1 October 2008
Military Medicine, Volume 173, pp 935-940; https://doi.org/10.7205/milmed.173.10.935

Abstract:
Background: U.S. military ground forces report high rates of war-related traumatic stressors, post-traumatic stress disorder (PTSD), and depression following deployment in support of recent armed conflicts in Iraq and Afghanistan. Affected service members do not receive needed mental health services in most cases, and they frequently report stigma and significant structural barriers to mental health services. Improvements in primary care may help address these issues, and evidence supports the effectiveness of a systems-level collaborative care approach. Objective: To test the feasibility of systems-level collaborative care for PTSD and depression in military primary care. We named our collaborative care model “Re-Engineering Systems of Primary Care for PTSD and Depression in the Military” (RESPECT-Mil). Methods: Key elements of RESPECT-Mil care include universal primary care screening for PTSD and depression, brief standardized primary care diagnostic assessment for those who screen positive, and use of a nurse “care facilitator” to ensure continuity of care for those with unmet depression and PTSD treatment needs. The care facilitator assists primary care providers with follow-up, symptom monitoring, and treatment adjustment and enhances the primary care interface with specialty mental health services. We report assessments of feasibility of RESPECT-Mil implementation in a busy primary care clinic supporting Army units undergoing frequent Iraq, Afghanistan, and other deployments. Results: Thirty primary care providers (family physicians, physician assistants, and nurse practitioners) were trained in the model and in the care of depression and PTSD. The clinic screened 4,159 primary care active duty patient visits: 404 screens (9.7%) were positive for depression, PTSD, or both. Sixty-nine patients participated in collaborative care for 6 weeks or longer, and the majority of these patients experienced clinically important improvement in PTSD and depression. Even although RESPECT-Mil participation was voluntary for providers, only one refused participation. No serious adverse events were noted. Conclusions: Collaborative care is an evidence-based approach to improving the quality of primary care treatment of anxiety and depression. Our version of collaborative care for PTSD and depression, RESPECT-Mil, is feasible, safe, and acceptable to military primary care providers and patients, and participating patients frequently showed clinical improvements. Efforts to implement and evaluate collaborative care approaches for mental disorders in populations at high risk for psychiatric complications of military service are warranted.
Gary W. Dufresne, Ryan D. Wells, James A. Pfaff
Published: 1 October 2008
Military Medicine, Volume 173, pp 945-948; https://doi.org/10.7205/milmed.173.10.945

Abstract:
Many studies have shown that community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) is a very prevalent organism. However, no data have been published to date with regard to CAMRSA prevalence in patients presenting to the emergency department (ED) of a military medical facility. Our objective is to estimate the period prevalence of CAMRSA in cases of soft tissue abscesses seen in the emergency departments of two major military hospitals. A retrospective review of electronic records was performed from January 1, 2004 to August 10, 2005. This database was used to identify patients with the diagnosis of abscess, the procedure code for incision and drainage, and culture of wound. After data were accumulated, standard prevalence calculations were applied to determine prevalence of CAMRSA in abscesses at our emergency departments. Antibiotic susceptibilities were then evaluated with regard to the CAMRSA bacteria. The prevalence at our two emergency departments was 68% (751 abscesses, 220 cultured, 155 methicillin-resistant S. aureus (MRSA)-positive cultures). The prevalence at Brooke Army Medical Center and Wilford Hall Medical Center emergency departments was 70% (520 abscesses, 145 cultured, and 101 MRSA positive) and 65% (231 abscesses, 75 cultured, and 49 MRSA positive), respectively. The occurrence of CAMRSA is not isolated to the civilian population. The prevalence of CAMRSA in this population is significant, and may pose serious operational and deployment-related ramifications requiring the attention of military medical planners as well as forward medical care providers. The probability of CAMRSA infection should be considered when treating soft tissue abscesses in the military emergency department.
Published: 1 September 2008
Military Medicine, Volume 173, pp 817-824; https://doi.org/10.7205/milmed.173.9.817

Abstract:
The purpose of this study was to examine physical work performance, energy cost, and physiological fatigue in military personnel during simulated operational conditions. Using a within-subject, repeated-measures design, 34 military personnel volunteered to undergo two experimental conditions: with body armor (BA+) and without BA (BA−). Subjects walked on a treadmill for 30 minutes and completed a physical performance battery during each of two sessions, which were separated by ≥5 days. Subjects with BA+ as compared with BA− had significantly greater increases in: oxygen uptake (VO2 ) at slow (16.8 ±1.5 vs. 18.8 ±1.7 mL . kg−1 . min−1) and moderate paces (34.8 ± 3.9 vs. 40.8 ± 5.0 mL . kg−1 . min−1); blood lactate at a moderate pace (4.0 ± 2.4 vs. 6.7 ± 2.6 mmol/L); heart rate at slow (107 ± 14 vs. 118 ± 16 beats per minute) and moderate paces (164 ± 16 vs. 180 ± 13 beats per minute); and ratings of perceived physical exertion at slow (8.4 ± 1.5 vs. 10.4 ± 1.8) and moderate paces (14.3 ± 2.3 vs. 16.7 ± 2.1). Physical tasks were significantly affected by BA: under BA+, men performed 61% fewer pull-ups and women's hang time was reduced by 63%; stair stepping was reduced by 16% for both men and women. BA significantly impacted the physical work capacity of militarily relevant tasks. Specifically, wearing BA significantly increased VO2 when walking at both slow and moderate paces. The potential for physical exhaustion is high and performance of physical tasks is markedly impaired when wearing BA.
John F. Kalinich, Vernieda B. Vergara, Christy A. Emond
Military Medicine, Volume 173, pp 754-758; https://doi.org/10.7205/milmed.173.8.754

Abstract:
Novel metal formulations are being used with increasing frequency on the modern battlefield. In many cases the health effects of these materials are not known, especially when they are embedded as fragments. Imaging techniques, although useful for determining location, provide no information regarding the composition of embedded fragments. In this report, we show that laboratory rats implanted with weapons-grade tungsten alloy (tungsten, nickel, and cobalt) pellets demonstrate significant increases in both urinary and serum levels of tungsten, nickel, and cobalt, which indicates that such measurements can provide information on the composition of embedded fragments. We also propose that, in addition to the requirements promulgated by the recent directive on analysis of metal fragments removed from Department of Defense personnel (Health Affairs policy 07-029), urine and blood/serum samples should be collected from personnel and analyzed for metal content. Such measurements could yield information on the composition of retained fragments and provide the basis for further treatment options.
, Gail D. Campbell-Gauthier, Amanda M. Mang-Lawson, A. David Mangelsdorff, Kenn Finstuen
Military Medicine, Volume 173, pp 641-646; https://doi.org/10.7205/milmed.173.7.641

Abstract:
The Military Health System (MHS) identified patient-centered care and satisfied beneficiaries as main objectives in their 2006 Strategic Plan. The objective of this study was to expand upon the previous MHS model to determine predictors of patient satisfaction behaviors based upon associated attitudes and beliefs in addition to determining the predictive qualities presented by continuity of care. A sample of 90,318 patient responses from 2002 to 2004 was drawn from the Customer Satisfaction Survey database. Hierarchical multiple linear regression analyses were conducted to assess the uniquely predictive effects of the independent variables on the outcome variable. Results indicated the constructs from previous studies of satisfaction within the MHS using an attitude model were consistent when tested in a behavioral model. Hypothesis tests also indicated continuity of care demonstrated uniquely predictive qualities suggesting inclusion in the model. The final satisfaction with visit model yielded F(29, 90,288) = 7062.37, p < 0.01 with R2 = 0.694.
Barbara E. Wojcik, Rebecca J. Humphrey, , Linda C. Psalmonds, L. Harrison Hassell
Military Medicine, Volume 173, pp 647-652; https://doi.org/10.7205/milmed.173.7.647

Abstract:
The Patient Workload Generator (PATGEN) simulation model is an important part of the Army Medical Department force requirement planning. The current version of the PATGEN model is based on historical major combat operations such as World War II and the Korean War. The purpose of this study was to determine whether there was a significant difference between injury distributions used in the PATGEN model and the injury distributions based on the data from Operation Iraqi Freedom (OIF). To make the comparison feasible, the PATGEN injury categories were created using the Barell Injury Matrix. Analyses were performed using two independent OIF data sources, the Joint Theater Trauma Registry and the Standard Inpatient Data Record. Based on χ2 test results, both analyses suggest a significant difference between PATGEN and OIF injury distributions. A major concern is the underestimation by PATGEN of battle injuries with multiple wounds. The findings support future use of data-driven diagnosis-based injury distributions for current operations and new more flexible simulation models that will allow for changes in injury probability distributions.
Seth C. Britch, Kenneth J. Linthicum, Assaf Anyamba, Compton J. Tucker, Edwin W. Pak, Francis A. Maloney, Kristin Cobb, Erin Stanwix, Jeri Humphries, Alexandra Spring, et al.
Military Medicine, Volume 173, pp 677-683; https://doi.org/10.7205/milmed.173.7.677

Abstract:
The United States faces many existing and emerging mosquito-borne disease threats, such as West Nile virus and Rift Valley fever. An important component of strategic prevention and control plans for these and other mosquito-borne diseases is forecasting the distribution, timing, and abundance of mosquito vector populations. Populations of many medically important mosquito species are closely tied to climate, and historical climate-population associations may be used to predict future population dynamics. Using 2003–2005 U.S. Army Center for Health Promotion and Preventive Medicine mosquito surveillance data, we looked at populations of several known mosquito vectors of West Nile virus, as well as possible mosquito vectors of Rift Valley fever virus, at continental U.S. military installations. We compared population changes with concurrent patterns for a satellite-derived index of climate (normalized difference vegetation index) and observed instances of population changes appearing to be direct responses to climate. These preliminary findings are important first steps in developing an automated, climate-driven, early warning system to flag regions of the United States at elevated risk of mosquito-borne disease transmission.
Charles Broy, Steven Bennett
Military Medicine, Volume 173, pp 523-524; https://doi.org/10.7205/milmed.173.6.523

Abstract:
Partial anomalous pulmonary venous return (PAPVR) is an uncommon congenital abnormality that occurs in 0.4 to 0.7% of postmortem examinations. Ninety percent of these anomalies are associated with an atrial septal defect. Partial anomalous pulmonary venous return occurs more commonly on the right than the left and is manifested by abnormal return of the pulmonary veins to the central venous circulation. Most patients are asymptomatic, but when symptoms are present they are due to shunting of oxygenated blood to the venous circulation. We submit the case of a recently activated solider who presented with dyspnea on exertion refractory to inhaled corticosteroids and an 8.5-mm solitary pulmonary nodule. Further diagnostic imaging revealed PAPVR. Our case appears to be the first report of a solitary pulmonary nodule as the initial presentation of a right upper lobe PAPVR with return to the superior vena cava in the absence of associated atrial septal defect.
Nathaniel Almond, Leila Kahwati, Linda Kinsinger, Deborah Porterfield
Military Medicine, Volume 173, pp 544-549; https://doi.org/10.7205/milmed.173.6.544

Abstract:
Overweight and obesity are increasingly contributing to disease burden among military populations. The purpose of this study was to calculate and examine the prevalence of overweight and obesity among the veteran population. Data were obtained from the 2004 Behavioral Risk Factor Surveillance System. Overweight (body mass index ≥25 kg/m2) prevalence in veterans was 73.3% (SE, 0.4%) for males and 53.6% (SE 1.7%) for females. Obesity (body mass index ≥30 kg/m2) prevalence in veterans was 25.3% (SE, 0.4%) for males and 21.2% (SE, 1.4%) for females. After adjusting for sociodemographics and health status, veterans were no more likely to be overweight (odds ratio, 1.05; 95% confidence interval, 0.99–1.11) or obese (odds ratio 0.99; confidence interval, 0.93–1.05) than nonveterans. Despite previous participation in a culture and environment that selects for and enforces body weight standards, veterans have a high prevalence of overweight and obesity that is similar to general population estimates.
Dana Perkins, Jacob S. Hogue, Mary Fairchok, LoRanée Braun, Helen B. Viscount
Military Medicine, Volume 173, pp 604-608; https://doi.org/10.7205/milmed.173.6.604

Abstract:
Mupirocin is an antibiotic used for eradication and infection control of methicillin-resistant Staphylococcus aureus (MRSA). Mupirocin binds to the bacterial isoleucyl tRNA synthetase, thus disrupting bacterial protein synthesis. Four hundred nine MRSA clinical isolates collected in 2006 and 2007 at Madigan Army Medical Center were screened for mupirocin resistance by E test and polymerase chain reaction; 7 MRSA isolates (1.7%) were found to be fully resistant to mupirocin (minimum inhibitory concentration [MIC] by E test: >1,024 µg/mL), 10 isolates (2.4%) had MIC values of 1 to 32 µg/mL, while 392 MRSA isolates (95.9%) had MIC values of <1 µg/mL. No trend of increased mupirocin resistance was found when compared with subsequent years. These results show that mupirocin remains a valid infection control measure due to its unique mechanism of action and the high susceptibility rate of MRSA isolates. In addition, rapid screening by polymerase chain reaction of MRSA shows promise in assessing the fully resistant mupirocin phenotype.
Linda Sohn, Nancy D. Harada
Military Medicine, Volume 173, pp 331-338; https://doi.org/10.7205/milmed.173.4.331

Abstract:
As the veteran population becomes ethnically diverse, it is important to understand complex interrelationships between racism and health. This study examined the association between perceptions of discrimination and self-reported mental and physical health for Asian/Pacific Islander, African American, and Hispanic veterans. The data for this study come from the 2001 Veteran Identity Program Survey, which measured utilization of outpatient care, discrimination, and health status across three minority veteran groups. Multivariate regression methods were used to model self-reported mental and physical health on perceptions of discrimination controlling for demographic and socioeconomic characteristics. Findings revealed that racial/ethnic discrimination during military service was significantly associated with lower physical, but not mental health. Satisfaction with health care provider's sensitivity toward racial/ethnic background was significantly associated with better mental health. Findings highlight the importance of developing policies that address racial/ethnic discrimination during military service while providing health care services for veterans.
Benjamin W. Lacy V, Thomas F. Ditzler, Raymond S. Wilson, Thomas M. Martin, Jon T. Ochikubo, Robert R. Roussel, Jose M. Pizarro-Matos, Raymond Vazquez
Military Medicine, Volume 173, pp 353-358; https://doi.org/10.7205/milmed.173.4.353

Abstract:
Substance use disorders constitute a serious and persistent threat to military readiness and to the health and safety of military personnel and their families. Methamphetamine is among the most addictive and damaging of commonly abused drugs; this is of great concern for military health providers in Hawaii due to the unusually high prevalence in the local community. The effect of regional drug use on active duty subpopulations has not been previously studied. This study includes a 6-year retrospective sample of laboratory-confirmed methamphetamine-, cocaine-, and marijuana-positive drug tests among Army soldiers stationed in Hawaii and western and eastern continental U.S. installations. The findings suggest that active duty members are significantly affected by the local drug climate. However, current military drug policies also deter use as evidenced by low absolute drug-positive rates even in regions of high civilian prevalence.
, Jeffrey L. Goodie, William A. Satterfield, William L. Brim
Military Medicine, Volume 173, pp 230-235; https://doi.org/10.7205/milmed.173.3.230

Abstract:
This preliminary investigation evaluated symptoms of sleep disturbance and insomnia in a group of 156 deployed military personnel. A 21-item Military Deployment Survey of Sleep was administered to provide self-reported estimates of a variety of sleep parameters. The results indicated that 74% of participants rated their quality of sleep as significantly worse in the deployed environment, 40% had a sleep efficiency of 30 minutes. Night-shift workers had significantly worse sleep efficiency and more problems getting to sleep and staying asleep as compared to day-shift workers. The results of the study indicate the need for programs to help deployed military members get more and better sleep.
Gillian K. SteelFisher, Alan M. Zaslavsky, Robert J. Blendon
Military Medicine, Volume 173, pp 221-229; https://doi.org/10.7205/milmed.173.3.221

Abstract:
This study examined problems pertaining to the health and well-being of Army spouses during deployment, comparing those whose experienced extensions of their partners' deployments with those whose partners returned home on time or early. It used data from a 2004 survey of 798 spouses of active duty personnel. Controlling for demographic and deployment characteristics, spouses who experienced extensions fared worse on an array of measures, including mental well-being (e.g., feelings of depression), household strains (e.g., problems with household and car maintenance), and some areas of their jobs (having to stop work or to work fewer hours). There were no statistically significant differences regarding problems pertaining to their overall health, marriage, other work issues, finances, relationships with Army families, or safety. However, spouses who experienced extensions were more likely to perceive the Army negatively during deployment. These findings suggest that deployment extensions may exacerbate certain problems and frustrations for Army spouses.
Helena Larsson, Matthias Larsson, Hanna Österberg, Karin Harms-Ringdahl
Military Medicine, Volume 173, pp 259-265; https://doi.org/10.7205/milmed.173.3.259

Abstract:
This study evaluated the capacity of a screening test to predict discharge from military training. When starting their training, 590 artillery and 258 ranger conscripts were tested in step-up, step-down, rising from a 0.40-m-high bench, and bilateral squat tests, with pain intensity ratings. Ranger conscripts who did not complete their training were noted. The rising test identified 82% and the step-down test 81% of artillery conscripts who reported pain at any level during any of the screening tests. Receiver operating characteristic curve analysis revealed that both the step-down test and the rising test were good in predicting discharge from military ranger training because of knee problems. The step-down test identified 80% of ranger conscripts who did not complete training because of knee disorders. The tests constitute a simple, time-saving, cost-effective tool in a systematic process for screening knee pain to identify high-risk groups, for prioritization of interventions.
, Marianne Cloeren, Lisa Michelle Firestone, Helen Christine Burch
Military Medicine, Volume 173, pp 253-258; https://doi.org/10.7205/milmed.173.3.253

Abstract:
This pilot study examined whether contract case managers are cost effective in reducing workers' compensation (WC) costs and preventing injuries. We placed contract medical case managers at four installations where they employed private industry best practices. A needs assessment was performed and site-specific targeted interventions were developed. Case managers improved WC program effectiveness by ensuring command support, and strengthening the case management process. They minimized lost work time and provided the WC team resources to review the oldest cases. Case managers cost $1.25 million and they generated $4.4 million in savings for a 3.52 return on investment. Case managers removed 73 workers from long-term rolls by making use of vocational rehabilitation, finding modified duty jobs, offering workers medical retirement, and terminating benefits when workers refused to work after being offered a job. This study of medical case managers demonstrates they can reduce WC costs.
Lance Sullenberger, Philip J. Gentlesk
Published: 1 February 2008
Military Medicine, Volume 173, pp 193-197; https://doi.org/10.7205/milmed.173.2.193

Abstract:
Background: No published data are available regarding cardiac evaluations in a forward military hospital setting. Methods: Two cardiologists deployed in support of Operation Iraqi Freedom identified all of their cardiac evaluations. Patient demographic data, evaluations performed, outcomes, and return-to-duty rates were determined. Results: Four hundred sixty-nine predominantly male patients were evaluated, with a mean age of 39 ± 10 years. The most common reasons for referral were ischemic evaluation (n = 283), arrhythmia/palpitations (n = 83), and syncope (n = 57). Of those referred with ischemia, the mean Framingham 10-year event risk calculated was low at 5.3 ± 3.1%; 86% of military patient evaluations revealed no identifiable cardiovascular pathological condition, and patients were returned to duty. Conclusions: Cardiology support, with the availability of echocardiography and stress testing in the theater of operations, was able to provide cardiovascular consultative evaluations and management and to reduce rates of medical evacuations out of the theater of operations.
, V. Grace Matheson, George A. Gaither, Nate Logan
Published: 1 February 2008
Military Medicine, Volume 173, pp 134-137; https://doi.org/10.7205/milmed.173.2.134

Abstract:
Stigma is known to have deleterious effects on individuals with psychiatric disorders as well as their family members. In this study, we examined stigma with regard to career concerns among active duty members of the Air Force with children who have psychiatric disorders. Albeit a weak relationship, a bivariate correlation confirmed a significant relationship between the child's mental health utilization (i.e., severity of illness) and participants concerns about the potential effects on their military (r = 0.423, p < 0.01), as well as civilian (r = 0.353, p < 0.01), careers. These findings indicate that among military members with children who have psychiatric disorders, illness severity significantly relates to concerns about the impact of stigma on careers, particularly military careers.
W. Neal Burnette, Charles H. Hoke, John Scovill, Kathryn Clark, Jerry Abrams, Lynn W. Kitchen, Kevin Hanson, Thomas J. Palys, David W. Vaughn
Published: 1 February 2008
Military Medicine, Volume 173, pp 174-181; https://doi.org/10.7205/milmed.173.2.174

Abstract:
Identification of the most significant infectious disease threats to deployed U.S. military forces is important for developing and maintaining an appropriate countermeasure research and development portfolio. We describe a quantitative algorithmic method (the Infectious Diseases Investment Decision Evaluation Algorithm) that uses Armed Forces Medical Intelligence Center information to determine which naturally occurring pathogens pose the most substantial threat to U.S. deployed forces in the absence of specific mitigating countermeasures. The Infectious Diseases Investment Decision Evaluation Algorithm scores the relative importance of various diseases by taking into account both their severity and the likelihood of infection on a country-by-country basis. In such an analysis, the top three endemic disease threats to U.S. deployed forces are malaria, bacteria-caused diarrhea, and dengue fever.
Jeff H. Feinberg, Charles B. Toner
Published: 1 February 2008
Military Medicine, Volume 173, pp 217-220; https://doi.org/10.7205/milmed.173.2.217

Abstract:
A 22-year-old African American U.S. sailor presented with an intermittent pruritic eruption precipitated by mild activity for the last 2 years. She developed an extremely pruritic papular rash that would quickly coalesce into larger wheals following any exercise, light activity such as vacuuming, or taking hot showers. This condition had been getting progressively worse, preventing her from successfully completing her physical readiness test and other required physical training for the last 2 years. Previous treatment with antihistamines and steroids had failed to control her symptoms. She was diagnosed with cholinergic urticaria, successfully controlled with a combination of cetirizine, montelukast, and propanolol. She has since been returned to full military duty and is able to exercise regularly.
, Sinil Kim, Denise Boren
Published: 1 January 2008
Military Medicine, Volume 173, pp 85-90; https://doi.org/10.7205/milmed.173.1.85

Abstract:
Objectives: Therapeutic alliance has been proposed as an ideal patient-provider relationship. The Kim Alliance Scale (KAS) measures the quality of therapeutic alliance, including patient empowerment. The objectives were to refine KAS and to measure the relationship between therapeutic alliance and patients' general satisfaction. Methods: A total of 601 evaluable patients was recruited, 304 patients in exploratory series and 297 patients in validation series. Patients completed a demographics questionnaire, the KAS, and Patient Satisfaction with Health Care Provider Scale. Results: Using the exploratory series, KAS was refined into a 16-item KAS-R consisting of collaboration, integration, empowerment, and communication subscales. Internal consistency reliability of KAS-R was 0.89. Hierarchical multiple regression analyses of the two series showed that KAS-R accounts for 35% to 36% of the variance in general satisfaction scores. Conclusions: Therapeutic alliance, as measured by KAS-R, predicted approximately one-third of patients' general satisfaction and empowerment was a significant predictor variable.
Wayne M. Deutsch
Published: 1 January 2008
Military Medicine, Volume 173, pp 29-37; https://doi.org/10.7205/milmed.173.supplement_1.29

Abstract:
Background: Planning of dental support for populations serving in isolation is essential. Many programs of national or scientific interest such as U.S. Navy submarine missions, the manned space program, and research in Antarctica require long periods where dental care is not available. Submariners make an excellent study population due to their relatively large numbers, good health, excellent dental screening, and professional status. Methods: This study examines dental events occurring while underway on 240 submarine patrols from January 1, 1997 to September 30, 2000. A health events database contains medical encounter notes, demographic information, crew rosters, and medical evacuation reports. A special survey database contains information from three surveys conducted aboard 1 submarine during a 101-day submergence. The evacuation database contains medical evacuation data from the Atlantic and Pacific submarine fleets from 1991 through 1999. Results: One hundred nine initial dental emergency visits and 45 revisits were recorded during these patrols. Of these visits, 48.6% were for an emergency related to an endodontic or caries problem. The incidence rate for all dental problems was 5.0 per 100,000 person-days at sea. Smoking was significantly associated with the occurrence of a periodontal-related emergency and also with the occurrence of any dental emergency. The rate of dental emergencies per 100,000 person-days decreased over time with the rate for the first 7 days being 7.5, days 8 through 14 being 5.5, and after day 14 being 4.6. Dental problems accounted for 6.9–9.3% of all medical evacuations from submarines between 1991 and 1999. The special survey of self-reported dental problems was designed to obtain information on minor conditions that might not be recorded in the medical encounter database. Of the problems reported, 13.1% had a dental problem during the 101-day submergence, 9.8% had a canker sore, and 4.1% had a gum problem.
Shira Maguen, Diane M. Turcotte, Alan L. Peterson, Theresa L. Dremsa, Howard N. Garb, Richard J. McNally,
Published: 1 January 2008
Military Medicine, Volume 173, pp 1-9; https://doi.org/10.7205/milmed.173.1.1

Abstract:
Military medical personnel preparing for deployment to Iraq (N = 328) participated in a survey concerning predeployment risk and resilience factors. Participants reported exposure to an average of 2.5 potentially traumatic events before deployment and 76% (n = 229) reported at least two current concerns about predeployment stressors. Military personnel also endorsed a series of positive appraisals of the military, the mission, and their unit. Fairly low levels of post-traumatic stress disorder symptoms before deployment were reported and positive affect was significantly higher than reported negative affect. Post-traumatic stress disorder symptoms that were present before deployment were most strongly associated with risk factors, whereas positive affect was most strongly associated with resilience factors. Predeployment negative affect was associated with a combination of risk and resilience factors. These findings have implications for possible interventions and preparation of medical personnel before military deployment. A better understanding of the factors related to risk and resilience in military medical personnel will allow for improved screening, educational, training, and clinical programs aimed at increasing resilience before military deployments.
Katie M. Heinrich, Nattinee Jitnarin, Richard R. Suminski, , Christine M. Hunter, Lisa Alvarez, Antionette R. Brundige, Alan L. Peterson, John P. Foreyt, C. Keith Haddock, et al.
Published: 1 January 2008
Military Medicine, Volume 173, pp 67-73; https://doi.org/10.7205/milmed.173.1.67

Abstract:
Objective: The purpose of this study was to evaluate obesity classifications from body fat percentage (BF%), body mass index (BMI), and waist circumference (WC). Methods: A total of 451 overweight/obese active duty military personnel completed all three assessments. Results: Most were obese (men, 81%; women, 98%) using National Institutes of Health (NIH) BF% standards (men, >25%; women, >30%). Using the higher World Health Organization (WHO) BF >35% standard, 86% of women were obese. BMI (55.5% and 51.4%) and WC (21.4% and 31.9%) obesity rates were substantially lower for men and women, respectively (p < 0.05). BMI/WC were accurate discriminators for BF% obesity (θ for all comparisons >0.75, p < 0.001). Optimal cutoff points were lower than NIH/WHO standards; WC = 100 cm and BMI = 29 maximized sensitivity and specificity for men, and WC = 79 cm and BMI = 25.5 (NIH) or WC = 83 cm and BMI = 26 (WHO) maximized sensitivity and specificity for women. Conclusions: Both WC and BMI measures had high rates of false negatives compared to BF%. However, at a population level, WC/BMI are useful obesity measures, demonstrating fair-to-high discriminatory power.
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