Iraqi Freedom Research Articles

B - 30 Influence of Military Blast Exposure on Subjective Post-Concussion Symptom Reporting

Abstract Objective Repeated subconcussive blast exposure associated with explosive breaching, mortars, and shoulder-fired artillery weapons is commonly seen in the military/veteran population and has been found to contribute to adverse neurological outcomes; however, the extent is not fully understood. The aim of this study was to assess the effects of blast exposure during military or other training exercises on neurobehavioral symptom endorsement. Method Cross-sectional data from 48 nonclinical post-deployment Operation Enduring Freedom/Operation Iraqi Freedom veterans prospectively-recruited for a study examining posttraumatic stress and cognitive correlates at an urban VA Medical Center were examined (M age = 36.02; SD = 6.12; M years of education = 14.94; SD = 1.84). The sample was 96% male, 41% White, 39% Black, 4% Asian, and 16% Other. The Neurobehavioral Symptom Inventory (NSI) was used to assess self-reported vestibular, somatosensory, cognitive, and affective post-concussion symptoms, and the Boston Assessment of Traumatic Brain Injury-Lifetime semi-structured clinical interview assessed military-related blast exposure. Results There was a significant difference in neurobehavioral symptoms based on blast exposure, F(4,43) = 3.49, p = 0.015; Wilk’s Λ = 0.755, partial η2 = 0.25. Follow-up analyses showed that veterans with history of blast exposure endorsed significantly higher levels of somatosensory (F(1,47) = 7.69, p = 0.008, η2 = 0.143); affective (F(1,47) = 12.66, p < 0.001, η2 = 0.216); cognitive (F(1,47) = 5.97, p = 0.018, η2 = 0.115); and vestibular (F(1,47) = 7.21, p = 0.010, η2 = 0.136) post-concussive symptoms on the NSI compared to those without history of military blast exposure. Conclusion Veterans with blast exposure during military service reported significantly greater levels of post-concussion symptoms. This demonstrates the need to assess history of blast exposure, implement prevention measures through safeguards and decreased exposure when possible, and establish treatment modalities to improve outcomes.

All-cause mortality among United States military personnel: Findings from the Millennium Cohort Study, 2001–2021

PurposeThe goal of this study was to estimate all-cause mortality among Operations Enduring Freedom, Iraqi Freedom, and New Dawn era service members and veterans and to identify protective and risk factors for mortality. MethodsUsing 20 years of longitudinal data from the Millennium Cohort Study (2001–2021), sequential Cox proportional hazard models were conducted to examine demographic, military, and health-related characteristics associated with all-cause mortality among service members and veterans. ResultsAmong 201,619 participants, 3806 (1.9 %) were deceased by the end of the observation period, with an age- and sex-adjusted incidence of 37.6 deaths per 100,000 person-years. Deployed service members had lower all-cause mortality risk than those who did not deploy. Personnel who experienced combat had higher mortality risk compared with those who did not in unadjusted models; this association was nonsignificant after accounting for health-related factors. Enlisted and Army personnel both had a higher mortality risk, while women and Hispanic individuals had a lower risk. Stressful life events, lower physical health related quality of life, problem drinking, and smoking were also associated with greater mortality risk. ConclusionThese profiles may be useful for developing preventive education and intervention efforts in military and veteran populations to reduce premature mortality.

"Doing the right thing": Moral conflicts and ethical issues experienced by military nurses during wartime.

The War on Terrorism, which included Operation Enduring Freedom (OEF) in Afghanistan from 2001 to 2014 and the concurrent Operation Iraqi Freedom (OIF) from 2003 to 2011, exposed military nurses to situations and challenges for which many reported feeling unprepared. Clinically, nurses faced multi-trauma injuries and devastating wounds suffered by military troops and civilians alike. Cultural issues and harsh living conditions added further complications to the care environment. The purpose of this study was to address the research question: How do military nurses identify, assess, manage, and personally resolve ethical issues occurring in nursing practice during wartime deployments? Qualitative grounded theory provided the design for this study. Using the constant comparative method, data collection, and data analysis occurred simultaneously to build a theory of ethical issues management during wartime. Using a focused interview guide responsive to emerging themes and developing theory, interviews were conducted until theoretical saturation was achieved. Participants represented primarily Army (55%) active duty (83%) female nurses (71%) who had deployed to Iraq (52%), Afghanistan (32%), or both (16%). A sampling grid was used to recruit nurses representative of the demographics deployed in support of OIF and OEF. Data analysis usedgrounded theory methods to identify a core construct to detail proposed relationships and concepts. Rigor was maintained in study methods and analysis using established tenets to support trustworthiness. The nurses shared stories regarding their experiences during deployment. Many struggled to find internal resolutions regarding the care of detainees, cultural differences, end-of-life decision-making, pain management, and care of civilian casualties. The study described the ethical issues military nurses encountered during wartime and the strategies used to mitigate moral conflict. By better understanding how nurses define, assess, and manage ethical situations, we can better prepare our deploying nurses for future conflicts. Military nurses returning from wars with unresolved moral conflicts are at risk for moral distress. Moral distress has been associated with burnout, dissatisfaction with and leaving the nursing profession, compassion fatigue, and disinterest in the provision of quality patient care. In the interest of preserving the health of military nurses, steps need to be taken to provide resources for helping them prepare for, encounter, and cope with the ethical situations inherent in wartime nursing care.

Outpatient Prescriptions for Insomnia Medications During the First Year Following Combat-Related Amputations.

Sleep-related disorders are associated with pain, fatigue, and deficits in cognitive performance, which may interfere with successful rehabilitation. The study objectives were to (1) quantify outpatient prescriptions for insomnia medications during the first year following combat-related amputations, (2) examine longitudinal changes in prescriptions for insomnia medications, and (3) analyze patient characteristics associated with prescriptions for insomnia medications. This was a retrospective study of DoD casualty records from the Expeditionary Medical Encounter Dataset and prescriptions for outpatient medications from the Pharmacy Data Transaction Service. Patients were a total of 1,651 U.S. service members who sustained major limb amputations in Operations Iraqi and Enduring Freedom from 2001 through 2017 and had outpatient prescriptions for any medication during the first year postinjury. Prescriptions for medications recommended for insomnia were low-dose antidepressants, anxiolytic sedatives, benzodiazepines, melatonin receptor agonist, and low-dose quetiapine. These prescription medications were analyzed by medication type, postinjury time, and patient characteristics during the first year postinjury. During the first year postinjury, 78% of patients (1,291 of 1,651) had outpatient prescriptions for insomnia medications, primarily anxiolytic sedative drugs (e.g., zolpidem), averaging a total of 86 prescription days (median = 66). The prevalence of these prescriptions declined substantially during the first year, from 57% of patients during the first quarter to 28% during the fourth quarter postinjury. In univariate analyses, multiple patient characteristics, including high Injury Severity Score, continued opioid and non-opioid analgesic prescriptions, and diagnoses of chronic pain, mood disorder, and posttraumatic stress disorder, were significantly associated with higher prevalence and duration of outpatient prescriptions for insomnia medications. The present results indicate a high prevalence of outpatient prescriptions for insomnia medications following combat-related amputations, a prevalence that is substantially higher than previously reported among active duty personnel. These findings can inform DVA/DoD guidelines for amputation care and insomnia among military subpopulations. The results highlight the need for more research on the treatment of insomnia during early postinjury rehabilitation among patients who sustained serious combat injuries.

Who needs a tourniquet? And who does not? Lessons learned from a review of tourniquet use in the Russo-Ukrainian war.

Extremity tourniquets have proven to be lifesaving in both civilian and military settings and should continue to be used by first responders for trauma patients with life-threatening extremity bleeding. This is especially true in combat scenarios in which both the casualty and the first responder may be confronted by the imminent threat of death from hostile fire as the extremity hemorrhage is being treated. Not every extremity wound, however, needs a tourniquet. One of the most important aspects of controlling life-threatening extremity bleeding with tourniquets is to recognize what magnitude of bleeding requires this intervention and what magnitude of bleeding does not. Multiple studies, both military and civilian, have shown that tourniquets are often applied when they are not medically indicated. Overuse of extremity tourniquets has not caused excess morbidity in either the recent conflicts in Iraq and Afghanistan or in the US urban civilian setting. In the presence of prolonged evacuation, however, applying a tourniquet when it is not medically indicated changes tourniquet application from being a lifesaving intervention to one that may cause an avoidable amputation and the development of an array of metabolic derangements and acute kidney injury collectively called prolonged tourniquet application syndrome. The recent literature was reviewed for papers that documented the complications of tourniquet use resulting from the prolonged casualty evacuation times being seen in the current Russo-Ukrainian war. The literature was also reviewed for the incidence of tourniquet application that was found to not be medically indicated, in both the US civilian setting and from Ukraine. Finally, an in-person meeting of the US/Ukraine Tourniquet Working Group was held in Warsaw, Poland, in December of 2023. Unnecessary loss of extremities and life-threatening episodes of prolonged tourniquet application syndrome are currently occurring in Ukrainian combat forces because of nonindicated tourniquet use combined with the prolonged evacuation time seen in the Russo-Ukrainian war. Specific numbers of the complications experienced as a result of tourniquet use by Ukrainian forces in the current conflict are treated as classified information and are not available, but multiple sources from the Ukrainian military medical personnel and from the US advisors providing medical assistance to Ukraine have all agreed that the problem is substantial. Unnecessary tourniquet morbidity might also occur in US forces in a variety of potential future combat scenarios in which evacuation to surgical care is delayed. Prehospital trauma training programs, including but not limited to tactical combat casualty care, place insufficient emphasis on the need to avoid leaving tourniquets in place when they are not medically indicated. This aspect of training should receive emphasis in future Tactical Combat Casualty Care (TCCC) and civilian first responder curriculum development. An interim ad hoc training solution on this topic is available at the websites noted in this articles. Additional training modalities may follow in the near future. Therapeutic/Care Management; Level V.

What is the Case Volume of Orthopaedic Trauma Surgeons in the Military Health System? An Assessment of Wartime Readiness and Skills Sustainment.

Complex, high-energy extremity trauma secondary to explosive mechanisms has been increasingly common in modern warfare, accounting for a majority of combat wounds throughout the conflicts in Iraq and Afghanistan. Fellowship-trained orthopaedic trauma surgeons treated many of these complex injuries; however, as the number of casualties continue to decrease during a period of relative peace, a growing concern over maintaining military trauma readiness exists. The Military Health System Data Repository was queried for all Common Procedural Terminology (CPT) codes associated with 18 fellowship-trained orthopaedic trauma surgeons from 2013 to 2019. The codes were further analyzed and categorized based on common trauma subspecialty procedures such as fracture fixation of the pelvic ring, acetabulum, upper and lower extremity, peri-articular, and nonunion/malunion surgery. We used descriptive statistics to quantify both the average number of cases per surgeon per year in each of the subcategories and case volume among Military Treatment Facilities (MTFs) during the study period. We identified 7,769 CPT codes for surgical procedures throughout the study period. The most common surgical procedures performed were: removal of implant (n = 836, 11%), knee arthroscopy (n = 507, 7%), and debridement of devitalized tissue (n = 345, 4%). The total trauma subspecialty procedural codes and average cases per surgeon per year were as follows: pelvic ring (n = 54, <1 case/year), acetabulum (n = 90, 1 case/year), upper extremity (n = 1,314, 15 cases/year), lower extremity (n = 2,286, 25 cases/year), peri-articular (n = 675, 8 cases/year), and nonunion/malunion (n = 288, 3 cases/year). San Antonio Military Medical Center (SAMMC) accounted for the most fracture-related CPT codes overall (35%), while all other MTFs contributed approximately 10% or less of all fracture-related codes. These results highlight the lack of orthopaedic trauma volume at other MTFs outside of SAMMC, raising concern for maintaining military readiness during an inter-war period of relative peace. The DoD continues to make concerted efforts to maintain readiness through civilian partnerships and subsequently increase surgical case volume for military trauma surgeons. Future efforts should include an in-depth analysis of caseloads of military trauma surgeons providing care at both MTFs and civilian institutions to optimize preparedness in future conflicts.

The principle of cascadic prosilience—Assessment of territorial recovery strategies after disrupted regional infrastructure systems in Iraq

This paper presents an assessment approach to fostering socioeconomic re-development and resilience in Iraqi regions emerging from the destruction and instability, in the aftermath of the war conflict in Iraq. Focusing on the intricate interplay of logistics infrastructure and economic recovery, the present study proposes a novel framework that integrates general resilience insights, data analytics, infrastructure systems, and decision support from Data Envelopment Analysis (DEA). We draw inspiration also from historical cases on “creative destruction” or “Blessing in Disguise” (BiD) phenomena, like the post-WWII reconstruction of Rotterdam, so as to develop the notion of stepwise or cascadic prosilience, analyzing how innovative logistics systems may in various stages contribute to economic rejuvenation. Our approach recognizes the multifaceted nature of regional resilience capacity, encompassing both static (conserving resources, rerouting, etc.) and dynamic (accelerating recovery through innovative strategies) dimensions. The logistics aspect spans both the supply side (new infrastructure, ICT facilities) and the demand side (changing transportation flows and product demands), culminating in an integrated perspective for sustainable growth of Iraqi regions. In our study, we explore several forward-looking strategic future options (scenarios) for recovery and reconstruction policy factors in the context of regional development in Iraq, regarding them as crucial strategic elements for effective post-conflict rebuilding and regeneration. Given that such assets and infrastructures typically extend beyond a single city or area, their geographic scope is broader, calling for a multi-region approach. By leveraging the extended DEA approach by an incorporation of a super-efficiency (SE) DEA approach so as to better discriminate among efficient Decision-Making Units (DMUs)—in this case, regions in Iraq—our research aims to present actionable and effective insights for infrastructure investment strategies at regional-governorate scale in Iraq, that optimize efficiency, sustainability and resilience. This approach may ultimately foster prosperous and stable post-conflict regional economies that display—by means of a cascadic change—a new balanced prosilient future.

Impact of an internet-based insomnia intervention on suicidal ideation and associated correlates in veterans at elevated suicide risk.

Improving public health approaches to suicide prevention requires scalable evidence-based interventions that can be easily disseminated. Given empirical data supporting the association between insomnia and suicide risk, internet-delivered insomnia interventions are promising candidates to meet this need. The purpose of this study was to examine whether an unguided internet-delivered cognitive-behavioral therapy for insomnia (iCBT-I) improved insomnia severity, suicidal ideation (SI), and suicide risk correlates (depression, post-traumatic stress disorder, anxiety, hostility, belongingness, hopelessness, agitation, irritability, concentration) in a sample of veterans. Secondary data analysis of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (n = 50) with clinically significant insomnia and elevated SI drawn from a larger randomized controlled trial (RCT) of an iCBT-I, Sleep Healthy Using the Internet (SHUTi). Two-sample t-tests or Wilcoxon rank sum tests were used to evaluate between-group differences (SHUTi vs. Insomnia Education Website control) in symptom improvement from baseline to post-intervention. SHUTi participants experienced a significant improvement in insomnia severity (P < .001; d = -1.08) and a non-significant with small (subthreshold medium) effect size reduction of SI (P = .17, d = 0.40), compared to control participants. Significant improvement in hopelessness was observed (medium effect size), with non-significant small to medium effect size reductions in most remaining suicide risk correlates. Self-administered iCBT-I was associated with improvements in insomnia severity in veterans at elevated risk for suicide. These preliminary findings suggest that SI and suicide risk correlates may improve following an iCBT-I intervention, demonstrating the need for future well-powered iCBT-I RCTs targeted for populations at elevated suicide risk.

Combat-Genital Injury in UK Male Military Veterans: A Pilot and Feasibility Study Exploring Long-Term Psychosocial and Sexual Experiences and Support Needs

During the most recent conflicts in Iraq and Afghanistan, genital injuries were reported among male personnel at rates higher than previous conflicts. To date, research has focused predominantly on immediate medical management with limited published research exploring the long-term psychosocial and sexual impacts of combat-genital injury. This pilot study, therefore, aimed to explore the psychosocial and sexual health outcomes, experiences and support needs of military veterans who sustained combat-genital injuries and to assess the feasibility of conducting further research on this topic. A cross-sectional online survey design was used, comprising open and closed questions. Recruited through opportunity and snowball sampling, 11 eligible male UK veterans who had sustained a combat-genital injury completed the survey between March and July 2021. The results indicate that participants experienced long-term challenges related to their genital injury including low self-esteem, sexual function difficulties, and fertility concerns. The findings provide preliminary evidence of unmet long-term psychosocial, sexual, and fertility support needs among UK veterans with combat-genital injury. Further research is required to better understand the psychosexual wellbeing of combat veterans who have sustained physical injuries more broadly and to determine how best to provide psychosexual support to those who may benefit.

Sex Differences in Screening Positive for Post-Traumatic Stress Disorder After Combat Injury.

U.S. military women were at risk of combat exposure and injury from asymmetric warfare during the conflicts in Iraq and Afghanistan. Previous research has yielded mixed results when examining sex differences in PTSD following operational deployment. To date, no study has explored sex differences in PTSD after combat injury. This retrospective study included U.S. military service men and women who experienced a combat injury in Iraq or Afghanistan (March 2003 to March 2013) and completed a Post-Deployment Health Assessment (PDHA) within 1 year of injury. The PDHA is administered at the end of deployment and includes the 4-item Primary Care PTSD Screen. The prevalence of screening positive for PTSD was evaluated by sex using a chi-square test. Multivariable logistic regression was used to assess the association between sex and PTSD while adjusting for covariates. The study sample included 16,215 injured military personnel (666 women and 15,549 men). The average time between injury and PDHA was 132 days (SD = 91.0). Overall, women had a higher prevalence of screening positive for PTSD than men (48.3% vs. 40.9%, P < .001). In multivariable regression, women had higher odds than men of screening positive for PTSD (odds ratio, 1.34; 95% confidence interval, 1.14-1.57). Psychiatric history was the strongest predictor of screening positive for PTSD regardless of sex (odds ratio, 1.59; 95% confidence interval, 1.45-1.74). In this novel study of military service members, women were more likely to screen positive for PTSD than men after combat injury. Strategies to mitigate PTSD, enhance resiliency, and incorporate psychological care into injury rehabilitation programs for women may be needed for future U.S. military conflicts where they will play a larger role in combat operations.

Injuries in Fatalities of Dismounted Blast: Identification of Four Mechanisms of Head and Spine Injury.

Blast is the most common injury mechanism in conflicts of this century due to the widespread use of explosives, confirmed by recent conflicts such as in Ukraine. Data from conflicts in the last century such as Northern Ireland, the Falklands, and Vietnam up to the present day show that between 16% and 21% of personnel suffered a traumatic brain injury. Typical features of fatal brain injury to those outside of a vehicle (hereafter referred to as dismounted) due to blast include the presence of hemorrhagic brain injury alongside skull fractures rather than isolated penetrating injuries more typical of traditional ballistic head injuries. The heterogeneity of dismounted blast has meant that analysis from databases is limited and therefore a detailed look at the radiological aspects of injury is needed to understand the mechanism and pathology of dismounted blast brain injury. The aim of this study was to identify the head and spinal injuries in fatalities due to dismounted blast. All UK military fatalities from dismounted blast who suffered a head injury from 2007-2013 in the Iraq and Afghanistan conflicts were identified retrospectively. Postmortem computerized tomography images (CTPMs) were interrogated for injuries to the head, neck, and spine. All injuries were documented and classified using a radiology brain injury classification (BIC) tool. Chi-squared (χ2) and Fisher's exact tests were used to investigate correlations between injuries, along with odds ratios for determining the direction of correlation. The correlations were clustered. There were 71 fatalities from dismounted blast with an associated head injury with a CTPM or initial CT available for analysis. The results showed the heterogeneity of injury from dismounted blast but also some potential identifiable injury constellations. These were: intracranial haemorrhage, intracranial deep haemorrhage, spinal injury, and facial injury. These identified injury patterns can now be investigated to consider injury mechanisms and so develop mitigation strategies or clinical treatments. Level of Evidence: Observational. Study type: cohort observational.

Water for Food in the Tigris–Euphrates River System

Water scarcity is an important threat to food security in the Tigris–Euphrates river system. Water scarcity is a huge worldwide problem that results from the rapid increase in water demand, which exceeds the amount of available water. The most significant problems currently affecting countries are food insecurity water scarcity. The Tigris–Euphrates river system countries suffer from different political issues, such as the Syrian war and internal civil conflicts in Iraq. In addition, this area consists of only three countries: Iraq, Syria, and Turkey, but it affects the entire Middle East. Turkey has established many irrigation projects compared to Iraq, which still suffers from the previous American invasion. Therefore, this study examines the Tigris–Euphrates river system (using two countries) to examine the relationship between water scarcity and food security from 1992 to 2020. This study will be conducted using a fixed and random regression approach over 18 years. The results show a negative relationship between water scarcity and food security in the short run, at a 10% significance level, and a long-term positive relationship of 1%. Thus, the use of research and development and the encouragement of investments will help policymakers to develop a nexus between water scarcity and food security.

Efficacy of a Single Day Extracorporeal Membrane Oxygenation Training Course for Critical Care Air Transport Team Eligible Personnel.

Extracorporeal membrane oxygenation (ECMO) is an advanced medical technology that is used to treat respiratory and heart failure. The U.S. military has used ECMO in the care of combat casualties during Operation Enduring Freedom and Operation Iraqi Freedom as well as in the treatment of patients during the recent Coronavirus Disease 2019 pandemic. However, few Military Health System personnel have training and experience in the use of ECMO therapy. To address this dearth of expertise, we developed and evaluated an accelerated ECMO course for military medical personnel. To compare the efficacy of an accelerated ECMO course for Military Health System critical care teams. Seventeen teams, each consisting of a physician and nurse, underwent a 5-h accelerated ECMO course. Similar to our previous live-tissue ECMO training program (phases I and II), each team watched prerecorded ECMO training lectures. Subjects then practiced priming the ECMO circuit, cannulating ECMO, initiating ECMO, and correcting common complications on an ECMO simulation model. An added component to this phase III project included transportation and telemedicine consultation availability. Training success was evaluated via knowledge and confidence assessments, and observation of each team attempting to initiate ECMO on a Yorkshire swine patient model, transport the patient model, and troubleshoot complications with the support of telemedicine consultation when desired. Seventeen teams successfully completed the course. All seventeen teams (100%) successfully placed the swine on veno-arterial ECMO. Of those, 15 teams successfully transitioned to veno-arterial-venous ECMO. The knowledge assessments of physicians and nurses increased by 12.2% from pretest (mean of 62.1%, SD 10.4%) to posttest (mean of 74.4%, SD 8.2%), P < .0001; their confidence assessments increased by 41.1% from pretest (mean of 20.1%, SD 11.8%) to posttest (mean of 61.2%, SD 18.6%). An abbreviated 1-day lecture and hands-on task-trainer-based ECMO course resulted in a high rate of successful skill demonstration and improvement of physicians' and nurses' knowledge assessments and confidence levels, similar to our previous live-tissue training program. When compared to our previous studies, the addition of telemedicine and patient transportation to this study did not affect the duration or performance of procedures.

Deployment to Military Bases With Open Burn Pits and Respiratory and Cardiovascular Disease

Many veterans who served in Afghanistan and Iraq during Operations Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) were deployed to military bases with open burn pits and exposed to their emissions, with limited understanding of the long-term health consequences. To determine the association between deployment to military bases where open burn pits were used for waste disposal and the subsequent risk of developing respiratory and cardiovascular diseases. This retrospective observational cohort study used Veterans Health Administration medical records and declassified deployment records from the Department of Defense to assess Army and Air Force veterans who were deployed between 2001 and 2011 and subsequently received health care from the Veterans Health Administration, with follow-up through December 2020. Data were analyzed from January 2023 through February 2024. Duration of deployment to military bases with open burn pits. Diagnosis of asthma, chronic obstructive pulmonary disease, interstitial lung disease, hypertension, myocardial infarction, congestive heart failure, ischemic stroke, and hemorrhagic stroke. The study population included 459 381 OEF and OIF veterans (mean [SD] age, 31.6 [8.7] years; 399 754 [87.0%] male). Median (IQR) follow-up from end of deployment was 10.9 (9.4-12.7) years. For every 100 days of deployment to bases with burn pits, veterans experienced increased adjusted odds for asthma (adjusted odds ratio [aOR], 1.01; 95% CI, 1.01-1.02), chronic obstructive pulmonary disease (aOR, 1.04; 95% CI, 1.02-1.07), hypertension (aOR, 1.02; 95% CI, 1.02-1.03), and ischemic stroke (aOR, 1.06; 95% CI, 0.97-1.14). Odds of interstitial lung disease, myocardial infarction, congestive heart failure, or hemorrhagic stroke were not increased. Results based on tertiles of duration of burn pit exposures were consistent with those from the continuous exposure measures. In this cohort study, prolonged deployment to military bases with open burn pits was associated with increased risk of developing asthma, COPD, and hypertension. The results also point to a possible increased risk in ischemic stroke. The novel ability to use integrated data on deployment and health outcomes provides a model for additional studies of the health impact of environmental exposures during military service.

Predictive modeling of initiation and delayed mental health contact for depression

BackgroundDepression is prevalent among Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) Veterans, yet rates of Veteran mental health care utilization remain modest. The current study examined: factors in electronic health records (EHR) associated with lack of treatment initiation and treatment delay; the accuracy of regression and machine learning models to predict initiation of treatment.MethodsWe obtained data from the VA Corporate Data Warehouse (CDW). EHR data were extracted for 127,423 Veterans who deployed to Iraq/Afghanistan after 9/11 with a positive depression screen and a first depression diagnosis between 2001 and 2021. We also obtained 12-month pre-diagnosis and post-diagnosis patient data. Retrospective cohort analysis was employed to test if predictors can reliably differentiate patients who initiated, delayed, or received no mental health treatment associated with their depression diagnosis.Results108,457 Veterans with depression, initiated depression-related care (55,492 Veterans delayed treatment beyond one month). Those who were male, without VA disability benefits, with a mild depression diagnosis, and had a history of psychotherapy were less likely to initiate treatment. Among those who initiated care, those with single and mild depression episodes at baseline, with either PTSD or who lacked comorbidities were more likely to delay treatment for depression. A history of mental health treatment, of an anxiety disorder, and a positive depression screen were each related to faster treatment initiation. Classification of patients was modest (ROC AUC = 0.59 95%CI = 0.586–0.602; machine learning F-measure = 0.46).ConclusionsHaving VA disability benefits was the strongest predictor of treatment initiation after a depression diagnosis and a history of mental health treatment was the strongest predictor of delayed initiation of treatment. The complexity of the relationship between VA benefits and history of mental health care with treatment initiation after a depression diagnosis is further discussed. Modest classification accuracy with currently known predictors suggests the need to identify additional predictors of successful depression management.

Study protocol: Identifying transcriptional regulatory alterations of chronic effects of blast and disturbed sleep in United States Veterans.

Injury related to blast exposure dramatically rose during post-911 era military conflicts in Iraq and Afghanistan. Mild traumatic brain injury (mTBI) is among the most common injuries following blast, an exposure that may not result in a definitive physiologic marker (e.g., loss of consciousness). Recent research suggests that exposure to low level blasts and, more specifically repetitive blast exposure (RBE), which may be subconcussive in nature, may also impact long term physiologic and psychological outcomes, though findings have been mixed. For military personnel, blast-related injuries often occur in chaotic settings (e.g., combat), which create challenges in the immediate assessment of related-injuries, as well as acute and post-acute sequelae. As such, alternate means of identifying blast-related injuries are needed. Results from previous work suggest that epigenetic markers, such as DNA methylation, may provide a potential stable biomarker of cumulative blast exposure that can persist over time. However, more research regarding blast exposure and associations with short- and long-term sequelae is needed. Here we present the protocol for an observational study that will be completed in two phases: Phase 1 will address blast exposure among Active Duty Personnel and Phase 2 will focus on long term sequelae and biological signatures among Veterans who served in the recent conflicts and were exposed to repeated blast events as part of their military occupation. Phase 2 will be the focus of this paper. We hypothesize that Veterans will exhibit similar differentially methylated regions (DMRs) associated with changes in sleep and other psychological and physical metrics, as observed with Active Duty Personnel. Additional analyses will be conducted to compare DMRs between Phase 1 and 2 cohorts, as well as self-reported psychological and physical symptoms. This comparison between Service Members and Veterans will allow for exploration regarding the natural history of blast exposure in a quasi-longitudinal manner. Findings from this study are expected to provide additional evidence for repetitive blast-related physiologic changes associated with long-term neurobehavioral symptoms. It is expected that findings will provide foundational data for the development of effective interventions following RBE that could lead to improved long-term physical and psychological health.

Migraine Prevalence, Environmental Risk, and Comorbidities in Men and Women Veterans

Migraine is a prevalent and debilitating condition that substantially impacts quality of life. Investigating migraine prevalence, associated comorbidities, and potential military service exposures in veterans, focusing on gender differences, is crucial for targeted interventions and management strategies. To determine the prevalence of migraine, associated health comorbidities, and potential military service and environmental exposures among men and women US veterans using a large-scale epidemiological sample from the Million Veteran Program (MVP). This cross-sectional study analyzed self-report survey data from the MVP, a large epidemiological sample of US veterans that was started in 2011 and has ongoing enrollment. Eligible participants were selected from the MVP database in 2023. The study included 491 604 veterans to examine migraine prevalence, health comorbidities, demographic characteristics, military service history, and environmental exposures. Data were analyzed from December 2022 to July 2023. Military service and environmental factors, such as chemical or biological warfare exposure, were considered. The primary outcome was migraine prevalence among men and women veterans, assessed through self-reported diagnoses. Secondary outcomes included the association between migraine and health comorbidities, demographic characteristics, military service history, and environmental exposures. Of the 491 604 veterans included in this study, 450 625 (91.8%) were men and 40 979 (8.2%) were women. The lifetime prevalence of migraine was significantly higher in women (12 324 of 40 979 [30.1%]) than in men (36 816 of 450 625 [8.2%]). Migraine prevalence varied by race and ethnicity, with the highest prevalence in Hispanic or Latinx women (1213 of 3495 [34.7%]). Veterans with migraine reported worse general health, higher levels of pain, increased pain interference with work, a higher likelihood of psychiatric and neurological health conditions, and greater lifetime opioid use. Specific aspects of military service, including service post-September 2001 and deployment in Operation Enduring Freedom and Operation Iraqi Freedom, and environmental factors, including Agent Orange, chemical and biological welfare, and antinerve agent pills history, were significantly associated with migraine prevalence. In this cross-sectional study of migraine, the results highlighted gender differences in migraine prevalence and associated health comorbidities among US veterans. The findings emphasized the need for interdisciplinary approaches to migraine management, increased awareness and education efforts, and population-based screening strategies, particularly for women and Hispanic veterans who are at greater risk. Our findings encourage further research into tailored interventions for specific subpopulations and the impact of military service and environmental exposures on migraine and related health conditions.

The top-cited military relevant spine articles

IntroductionHistorically musculoskeletal injury has substantially affected United States (US) service members. Lumbosacral spine injuries are among the most common sites of injury for service members across all US military branches and usually presents with pain in the lower back and extremities. The aim of this study is to identify and describe the 50 most-cited articles relevant to military medicine on the subject of the spine. MethodsIn April 2020 Web of Science was used to search the key words: spinal cord injury, spine, thoracic spine, lumbar spine, cervical spine, sacrum, sacral, cervical fusion, lumbar fusion, sacral fracture, combat, back pain, neck pain, and military. Articles published from 1900 to 2020 were evaluated for relevance to military spine orthopaedics and ranked based on citation number. The 50 most-cited articles were characterized based on country of origin, journal of publication, affiliated institution, topic, military branch, and conflict. Results1900 articles met search criteria. The 50 most-cited articles were cited 24 to 119 times and published between 1993 and 2017. 30 articles (60%) originated in the United States. Aviation, Space, and Environmental Medicine accounted for the most frequent (n = 10) destination journal followed by Spine (n = 8). 37 institutions contributed to the top 50 most-cited articles. The most common article type was clinically focused retrospective analysis 36% (n = 18), clinically focused cohort study 10% (n = 5), and clinically focused cohort questionnaire, cross-sectional analysis, and randomized study 8% each (n = 4). 90% of articles were non-surgical (n = 45). The US Army had the greatest number of associated articles. Operation Iraqi Freedom and Operation Enduring Freedom were the most-cited conflicts. ConclusionThe 50 most-cited articles relevant to military spine orthopaedics are predominantly clinically focused, arising from the US, and published in Aviation, Space, and Environmental Medicine, Spine, and The Spine Journal.

Impact of PTSD treatment on postconcussive symptoms in veterans: A comparison of sertraline, prolonged exposure, and their combination

Many Veterans who served in Iraq and Afghanistan struggle with posttraumatic stress disorder (PTSD) and the effects of traumatic brain injuries (TBI). Some people with a history of TBI report a constellation of somatic, cognitive, and emotional complaints that are often referred to as postconcussive symptoms (PCS). Research suggests these symptoms may not be specific to TBI. This study examined the impact of PTSD treatment on PCS in combat Veterans seeking treatment for PTSD. As part of a larger randomized control trial, 198 Operation Iraqi Freedom, Operation Enduring Freedom, Operation New Dawn (OIF/OEF/OND) Veterans with PTSD received Prolonged Exposure Therapy, sertraline, or the combination. Potential deployment related TBI, PCS, PTSD and depression symptoms were assessed throughout treatment. Linear mixed models were used to predict PCS change over time across the full sample and treatment arms, and the association of change in PTSD and depression symptoms on PCS was also examined. Patterns of change for the full sample and the subsample of those who reported a head injury were examined. Results showed that PCS decreased with treatment. There were no significant differences across treatments. No significant differences were found in the pattern of symptom change based on TBI screening status. Shifts in PCS were predicted by change PTSD and depression. Results suggest that PCS reduced with PTSD treatment in this population and are related to shift in depression and PTSD severity, further supporting that reported PCS symptoms may be better understood as non-specific symptoms.

Aerosolized Particulate Matter and Blunting of Ciliary Dynamic Responses: Implications for Veterans and Active Duty Military in Southwest Asia.

Respiratory diseases such as chronic rhinosinusitis and asthma are observed at increased rates in active duty and veteran military members, and they are especially prevalent in individuals who have been deployed in Southwest Asia during Operation Iraqi Freedom and Operation Enduring Freedom. Particulate matter, specifically the fine-grain desert sand found in the Middle East, may be a key source of this pathology because of deleterious effects on mucociliary clearance. With IRB approval, human sinonasal tissue was grown at an air-liquid interface and cultures were exposed to different types and sizes of particulate matter, including sand from Afghanistan and Kuwait. Ciliary dynamic responses to mechanical stimulation and ATP application were assessed following particulate exposure. Particle size of the commercial sand was substantially larger than that of the sand of Afghan or Kuwaiti origin. Following exposure to particulate matter, normal dynamic ciliary responses to mechanical stimulation and ATP application were significantly decreased (P < .01), with corresponding decreases in ATP-induced calcium flux (P < .05). These changes were partially reversible with apical washing after a 16-h period of exposure. After 36 h of exposure to Middle Eastern sand, ciliary responses to purinergic stimulation were completely abolished. There is a neutralization of the dynamic ciliary response following chronic particulate matter exposure, similar to ciliary pathologies observed in patients with chronic rhinosinusitis. Aerosolized particulate matter endured by military personnel in the Southwest Asia may cause dysfunctional mucociliary clearance; these data help to explain the increased prevalence of respiratory pathology in individuals who are or have been deployed in this region.