Military Database Research Articles

Heart Rate Variability Biofeedback as a Treatment for Military PTSD: A Meta-Analysis.

Emerging research has provided tentative support for the use of heart rate variability biofeedback (HRVB) as a treatment for several psychological disorders, with meta-analyses providing compelling evidence for HRVB as a promising treatment for anxiety, depression, and PTSD. Given the prevalence of PTSD in military veterans and the comparatively lower benefit and higher attrition rate of traditional psychological treatment for PTSD relative to civilian counterparts, it is important to examine complementary and alternative treatment approaches such as HRVB in this population. Although studies of HRVB for PTSD have been conducted with military veterans, they have involved relatively small sample sizes, limiting interpretation. To address this, the current article presents a comprehensive meta-analysis, consolidating existing literature to more accurately evaluate the efficacy of HRVB in reducing PTSD symptoms within military populations. This meta-analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, and our protocol was registered with PROSPERO to increase review transparency. A literature search of HRVB interventions was conducted using PubMed, PsycINFO, Military Database, PTSDPubs, and EBSCO's Psychological and Behavioral Sciences Collection. Five studies met eligibility criteria, providing a combined sample size of 95 military services members. For all studies, effect sizes were negative, indicating a reduction in PTSD symptoms. Effect sizes ranged from -1.614 to -0.414, resulting in an overall moderate to large mean effect for HRVB (Hedges's g = -0.557; 95% confidence interval = -0.818 to -0.296; P < .001). Additionally, cumulative attrition was 5.8%, significantly lower than commonly reported rates for evidence-based treatments (16%-36%). The present study is the first meta-analysis to examine HRVB as a treatment for military service members with PTSD. Results indicate that HRVB may be a viable treatment approach to reduce PTSD symptomatology. Low attrition rates, ease of accessibility, and favorable participant outlook serve as additional benefits for the use of HRVB.

Creativity training needs assessment for homeland security enterprise: a case for creative thinking

ABSTRACT Creativity, specifically creative problem solving, is often excluded from Homeland Security Enterprise efforts to train and develop their workforces. To determine if this lack of training was a key knowledge gap in the communities, we drew on organisational creativity literature. Using the personnel databases O*NET and Careers in the Military Database, we conducted a training needs assessment by identifying relevant job tasks, knowledge, skills, and abilities (KSA) that align with the creative process. More specifically, we sought to identify the need for creative problem-solving training and designated creative thinking time (e.g. red teaming) to influence innovative intelligence capabilities. Based on our findings, we recommend creativity training to facilitate creative thinking and action. Moreover, we outline situational and individual factors that will affect the transfer of the training, such as organisation environment, leadership, and creative self-efficacy. The impact of these recommendations will aid security, counterterrorism, and intelligence communities to efficiently detect and prevent emerging threats, as well as develop intelligence products to further support the Homeland Security Enterprise mission.

Hybrid Hyper Chaotic Map with LSB for Image Encryption and Decryption

There are number of images that transmitted through the web for various usages like medical imaging, satellite images, military database, broadcasting, confidential enterprise, banking, etc. Thus, it is important to protect the images confidentially by securing sensitive information from an intruder. The present research work proposes a Hybrid Hyper Chaotic Mapping that considers a3D face Mesh model for hiding the secret image. The model has a larger range of chaotic parameters which are helpful in the chaotification approaches. The proposed system provides excellent security for the secret image through the process of encryption and decryption. The encryption of the secret image is performed by using chaos encryption with hyper hybrid mapping. The hyper hybrid mapping includes enhanced logistic and henon mapping to improve the computation efficiency for security to enhance embedding capacity. In the experiment Fingerprint and satellite image is used as secret image. The secret image is encrypted using a Least Significant Bit (LSB) for embedding an image. The results obtained by the proposed method showed better enhancements in terms of SNR for the 3D Mesh model dataset as 77.85 dB better compared to the existing models that achieved Reversible data hiding in the encrypted domain (RDH-ED) of 33.89 dB and Multiple Most Significant Bit (Multi-MSB) 40 dB. Also, the results obtained by the proposed Hybrid Hyper chaotic mapping showed PSNR of 65.73 dB better when compared to the existing Permutation Substitution and Boolean Operation that obtained 21.19 dB and 21.27 dB for the Deoxyribonucleic Acid (DNA) level permutation-based logistic map.

Therapeutic Interventions and Outcomes in Civilian and Military Isolated Gunshot Wounds to the Head: A Department of Defense Trauma Registry and ACS TQIP-matched Study.

The purpose of this study was to compare therapeutic strategies and outcomes, following isolated gunshot wounds of the head, between military and civilian populations. Recent military conflicts introduced new concepts in trauma care, including aggressive surgical intervention in severe head trauma. This was a cohort-matched study, using the civilian Trauma Quality Improvement Program (TQIP) database of the American College of Surgeons (ACS) and the Department of Defense Trauma Registry (DoDTR), during the period 2013 to 2016. Included in the study were patients with isolated gunshots to the head. Exclusion criteria were dead on arrival, civilians transferred from other hospitals, and patients with major extracranial associated injuries (body area Abbreviated Injury Scale >3). Patients in the military database were propensity score-matched 1:3 with patients in the civilian database. A total of 136 patients in the DoDTR database were matched for age, sex, year of injury, and head Abbreviated Injury Scale with 408 patients from TQIP. Utilization of blood products was significantly higher in the military population ( P <0.001). In the military group, patients were significantly more likely to have intracranial pressure monitoring (17% vs 6%, P <0.001) and more likely to undergo craniotomy or craniectomy (34% vs 13%, P <0.001) than in the civilian group. Mortality in the military population was significantly lower (27% vs 38%, P =0.013). Military patients are more likely to receive blood products, have intracranial pressure monitoring and undergo craniectomy or craniotomy than their civilian counterparts after isolated head gunshot wounds. Mortality is significantly lower in the military population. Level III-therapeutic.

Height as a risk factor in meningioma: a study of 2 million Israeli adolescents

BackgroundMeningiomas are the most common primary central nervous system tumors. Potential risk factors include obesity, height, history of allergy/atopy, and autoimmune diseases, but findings are conflicting. This study sought to assess the role of the different risk factors in the development of meningioma in adolescents/young adults.MethodsThe cohort included 2,035,915 Jewish men and women who had undergone compulsory physical examination between 1967 and 2011, at age 16 to 19 years, prior to and independent of actual military enlistment. To determine the incidence of meningioma, the military database was matched with the Israel National Cancer Registry. Cox proportional hazard models were used to estimate the hazard ratios for meningioma according to sex, body mass index (BMI), height, and history of allergic or autoimmune disease.ResultsA total of 480 subjects (328 females) were diagnosed with meningioma during a follow-up of 40,304,078 person-years. Median age at diagnosis was 42.1 ± 9.4 years (range 17.4–62.6). On univariate analysis, female sex (p < 0.01) and height (p < 0.01) were associated with risk of meningioma. When the data were stratified by sex, height remained a significant factor only in men. Spline analysis of the male subjects showed that a height of 1.62 m was associated with a minimum disease risk and a height of 1.85+ meters, with a significant risk.ConclusionsThis large population study showed that sex and adolescent height in males (> 1.85 m) were associated with an increased risk of meningioma in adulthood.

Burns in the military setting- analyzing 12,799 routine & combat cases.

Burns are a major trauma source in the civilian and military settings, with huge impact on patient's well-being, health system and operation status of the force in the military setting. The purpose of our study was to summarize characteristics of all burn cases seen by the Israel Defense Forces primary care physicians during the years 2008-2016. This can help understand what causes most burns, in what units, at which stages and settings and consequently will allow commanders to make decisions regarding safety-rules, protective-equipment and uniforms, medical educations for soldiers, etc.Data were collected from the military database system. All burn related visits were analyzed using a designated big data computerized algorithm that used keywords and phrases to retrieve data from the database. 12,799 burn injuries were found presented in 65,536 burn related visits were analyzed according to the demographics, burn mechanism and military unit.It was observed that most of the burns (70.7%) occurred during routine non-combat setting and there was a gradual decrease in burn injuries during the investigated period, from 17.6% of the cases in 2008 to 2.3% in 2016. Most of the burns occurred in the Air-Force (19.4%), and the leading etiology was Chemical (35%). Average Total Body Surface Area (TBSA) was 7.5%.Since most of the burns occurred in a routine setting and were occupational related, investment in education, and improving fire-protection has proven itself, leading to the decrease in burn prevalence, we recommend that more emphasis should be given on proper handling of chemicals.

Computed Tomographic Measures of Funnel-Shaped Lumbar Vertebral Canal and Articular Process Dysplasia Malformations Differ Between German Shepherd and Belgian Malinois Military Working Dogs.

Researchers who study the selection and breeding program criteria for military working dogs aim to help maximize the years of active duty service. Computed tomographic (CT) quantitative phenotyping has been previously described as a method for supporting these research studies. Funnel-shaped lumbar vertebral foramen malformations have been previously described in Labrador retriever military working dogs and proposed to be risk factors for impaired arterial perfusion of nerve tissues during exercise. Articular process dysplasia malformations have been previously described in varying dog breeds and proposed to be risk factors for articular process degenerative joint disease and vertebral foramen stenosis. Aims of this retrospective, cross-sectional study were to describe quantitative CT phenotyping methods for characterizing funnel-shaped lumbar vertebral foramina and articular process dysplasia malformations and to apply these methods in a comparison between groups of German shepherd and Belgian Malinois military working dogs. A military working dog hospital's database was searched for German shepherd and Belgian Malinois dogs aged <6 years that had CT scans of the lumbosacral region during the period of 2008–2016. Observers unaware of CT findings recorded available clinical data for each of the dogs. An observer unaware of clinical data recorded CT measures of funnel-shaped lumbar vertebral foramina and articular process dysplasia malformations for each of dogs and each of the lumbar vertebrae that were available in the scans. A total of 59 dogs were sampled: 41 German shepherd and 18 Belgian Malinois. Articular process dysplasia and funnel-shaped vertebral foramen phenotypic traits were present in both breeds in this sample, with the frequency and quantitative measure of these traits being greater in German shepherd dogs and heavier dogs. Lower weight dogs had a lesser degree of a funnel-shaped foramen at all sampled vertebral locations. A consistent relationship between articular process dysplasia measures and body weight was not seen. Computed tomography measures of funnel shaped vertebral foramina were greater in German shepherd vs. Belgian Malinois dogs at the L7 vertebra (P < 0.01). The CT measures of cranial articular process dysplasia were greater in German shepherd vs. Belgian Malinois dogs at the L4 (P < 0.01) and L5 (P < 0.05) vertebrae.

21 Racial Disparities in Outcomes After Burn Injury in a Universally Insured Military Population

Abstract Introduction In our healthcare system, racial disparities are estimated to account for more than 83,000 deaths and an average of more than $57 billion per year. These disparities have been well described in the surgical and trauma setting. Lack of insurance has frequently been blamed for the persistence of racial disparities in healthcare. The objective of the current study was to determine whether racial disparities in outcomes exist in a universally insured population of military-/civilian-dependent burn patients. Methods The 2006–2014 TRICARE military insurance database was queried for patients 18–64 years, who had a diagnosis of thermal burns. The Department of Defense Military Health System provides full insurance coverage for active/reserve/retired members of the Armed Services and their dependents. Basic demographic data and clinical characteristics were obtained. Our main outcome was in-hospital mortality. Multivariable logistic regression models were built to determine the association between race and the primary outcome. Results A total of 6,206 patients with diagnosis of burn injury were included: 69.7% white, 13.4% black, 6.8 % Hispanic, and 10% other. Median age was 29 years (IQR 23 - 40), and 63.1% were female. Overall mortality was 1.03%. In unadjusted analysis, there was no significant association between race and mortality (p=0.963). After multivariate analysis, no significant differences were found among racial minorities relative to racially white patients. Even though not significant, black patients had lower odds of mortality (OR 0.49, 95% CI 0.18 – 1.32) and Hispanic patients had higher odds (OR 1.33, 95% CI 0.39 – 4/52) when compared to white patients. Conclusions Risk-adjusted analysis did not show a significant difference in mortality among minority burn patients when compared to white patients. Our findings show that in a population with universal insurance and virtual equal access to care, racial disparities are mitigated. This data will help to the development of disparities interventions and its applicability nationwide. Applicability of Research to Practice The apparent mitigation of racial disparities among universally insured burn patients reinforces the association of insurance and access to care to outcomes in healthcare.

EPID-02. HEIGHT AND THE RISK OF MENINGIOMA

Abstract BACKGROUND Meningiomas are the most common primary central nervous system tumors. Risk factors for meningiomas including obesity, height, history of allergy/atopy or autoimmune diseases, have been previously assessed with conflicting results. We reviewed a large cohort of Israeli adolescents in order to assess potential risk factors for the development of meningiomas. METHODS This study analyzed a cohort of 2,035,915 Jewish men and women who underwent obligatory physical examination when aged 16 to 19 years, from 1967 to 2011. Meningioma incidence was identified by linkage to the national cancer registry. Cox proportional hazard models were used to estimate the hazard ratios for meningioma according to sex, body mass index (BMI), height, history of allergic and autoimmune disease. RESULTS Linkage of the adolescent military database with the Israeli cancer registry identified 480 cases (152 males and 328 females) of meningioma during a follow up of 40,304,078-person years. The median age at diagnosis of meningioma was 42.1 ± 9.4 (range 17.4–62.6). On univariate analysis, only female gender (p&lt; 0.01) and height (p&lt; 0.01) were associated with risk for meningioma in the total study population. When stratified by gender, height remained a significant risk factor only in men. Spline analysis in the men group showed the minimum risk at a height of 1.62 meters and a statistically significant increase in the risk for meningioma at heights taller than 1.85 meters. BMI, past medical history including asthma, diabetes, and atopic and autoimmune diseases, were not associated with meningioma risk. CONCLUSION in this large population study, we found that sex and taller height in adolescent males was associated with an increased risk of adult meningioma.

Risk of Dementia and Depression in Young and Middle-aged Men Presenting with Nonmetastatic Prostate Cancer Treated with Androgen Deprivation Therapy

BackgroundPrevious studies have found an association between androgen deprivation therapy (ADT) and an increased risk of dementia and depression in elderly men. This association remains controversial, and little is known about the effects of ADT in younger men. ObjectiveTo examine the association between the receipt of ADT and these outcomes in young men aged 40–64 yr presenting with nonmetastatic prostate cancer (PCa). Design, setting, and participantsFor this observational study, we identified 9117 men aged 40–64 yr diagnosed with localized PCa between 2007 and 2014, without a pre-existing neurocognitive diagnosis, using the TRICARE military database. Outcome measurements and statistical analysisKaplan-Meier curves were fitted to compare ADT versus no ADT. We also performed a subgroup analysis in patients undergoing ADT for ≥12 mo. The association between ADT and new-onset dementia or depression was evaluated using inverse-probability-of treatment-weight–adjusted Cox proportional hazards regression analysis. Results and limitationsPatients receiving ADT had a significantly higher incidence of depression (30.2 vs 15.8 per 1000 person years) and dementia (17.9 vs 7.5 per 1000 person years). The risk of developing either outcome was higher in the ADT cohort (depression: hazard ratio [HR] 2.07, p < 0.001; dementia: HR 1.70, p = 0.052). Additionally, there was a dose-response relationship between the duration of ADT and either outcome. ConclusionsIn our cohort of young men with PCa, the receipt of ADT was associated with an increased risk of developing dementia and depression. Long-term use of ADT was associated with the highest risk of neurocognitive outcomes. Patient summaryIn this study, we looked at the risk of dementia and depression in patients <65 yr of age undergoing androgen deprivation therapy (ADT) for prostate cancer. We found that these patients had a higher risk of dementia and depression than those who did not undergo ADT.

P09.06 Risk factors associated with Meningioma in a Cohort of 2 Million Israeli Adolescents

Abstract Background: Meningiomas are the most common primary central nervous system tumors. Risk factors including- obesity, height, history of allergy/atopy or autoimmune diseases, have been assessed with conflicting results. In this study, we reviewed the database of a large cohort of Israeli adolescents in order to assess potential risk factors for the development of meningiomas. Methods: This study analyzed a cohort of 2,035,915 Jewish men and women who underwent compulsory physical examination as part of screening for army drafting between the age of 16 to 19 from 1948 to 1991. Meningioma incidence was identified by linkage to the national cancer registry. Cox proportional hazard models were used to estimate the hazard ratios for meningioma according the several risk factors including sex, BMI, height, history of allergic and autoimmune disease. Results: Linkage of the adolescent military database with the Israeli cancer registry revealed 480 cases of meningioma. The median age at diagnosis of meningioma was 42.1 ± 9.4 (range 17.4–62.6). On univariate analysis, only gender (female) and height were significantly associated with the risk of meningioma for the whole study population (p&lt;0.01 for both variables). When analyzed separately for gender- height was significant only for men. Spline analysis in the men group showed the minimum risk at a height of 1.62 meters and a statistically significant increase in the risk for meningioma at heights taller than 1.85 meters. BMI was not associated with an elevated risk of meningioma even when analyzed separately for gender. Past medical history including asthma, diabetes, and other atopic and autoimmune diseases were not found to be associated with the risk of meningioma. Conclusion: In this large population study, we found that sex and taller height in adolescent males was associated with an increased risk of meningioma.

238 - The use of prostate-specific antigen screening in purchased versus direct care settings: Data from the TRICARE military database

238 - The use of prostate-specific antigen screening in purchased versus direct care settings: Data from the TRICARE military database

SIPRI’s New Long Data-set on Military Expenditure: The Successes and Methodological Pitfalls

SIPRI has collected data on military expenditure almost since its foundation in the 1960s, but various historical difficulties led to breaks in the consistency of the data series, so that until recently SIPRI’s consistent military expenditure database has only provided data from 1988 onwards. This paper describes recent efforts at SIPRI that have succeeded in extending these consistent series for most countries back to at least the 1960s, and in some cases to 1949. It describes the underlying difficulties involved in collecting military expenditure data and ensuring consistent series, the sources used in the reconstruction of the long data-set, the methodological choices made, and the results of the exercise. Overall, consistent constant price data series have been extended back as far as 1957 for half of the countries covered by the SIPRI database that existed at the time. Europe and the Americas generally have the best data coverage. One of the biggest problems with the extended data-set is the extensive use of estimates to splice together overlapping, but disagreeing series for the same country, adjusting the older series upwards or downwards by an appropriate ratio to give greater consistency with the later series. A number of case studies are investigated where parallel series exist for countries, suggesting that this approach may in some cases involve significant margins for error.

Abstract WP196: Can being Married Save the Healthcare System Money? A Retrospective Analysis of Stroke Admission in US Military Health Care System

Introduction: The role of gender and age is well documented with disparities noted in Duration of hospitalization, total Cost of hospitalization and Outcome in stroke patients. The military healthcare system database was reviewed to determine if marital status was risk factor for any of these three criteria. Hypothesis: We hypothesize that being unmarried would be correlated with an increase in Duration of hospitalization and total Cost of the hospitalization. Methods: Data was collected from the Defense Health Agency Military Mart (M2) database from fiscal year 2010 to 2016. The M2 database stores data including age, gender and marital status. Adult patients with a primary diagnosis of stroke at discharge (International Classification of Diseases, 9th Revision codes 434.91, 434.11 or 10 th Revision code I63.9) were reviewed. Age, Gender and Marital Status were compared for Duration of hospitalization, total Cost of hospitalization and Outcome using Multivariable Analysis. Results: A total of 3,910 patients discharged from Military hospitals were identified. The Marital status of this sample was: Married 67.1%, Widowed 12.4%, Single 4.7%, Legally Separated 0.5%, and Unknown/Not Reported 4.7%. There was a significant correlation between Marital Status and Duration of hospitalization (average of 1.2 fewer hospital days/patient, P-value &lt;0.01) and total Cost of hospitalization ($1,088 less/patient even after controlling for the shorter hospital stay (P-value &lt;0.05). There was no significant correlation for Marital Status with Outcome. There was a significant correlation between age and increased Duration of hospitalization and worse Outcome. There was no correlation of age with total Cost of hospitalization when we controlled for duration of hospitalizing. There was no correlation for gender with for Duration of hospitalization or total Cost of hospitalization. There was a small, statistically significant correlation of female gender and worse Outcomes (p-value &lt; 0.02). Conclusions: Unmarried status is an independent risk factor for increased Duration of hospitalization and total Cost of hospitalization. Older age is a risk factor for increased Duration of hospitalization and worse Outcome. Female gender is a risk factor for worse Outcomes.

A decision tree framework for understanding blast-induced mild Traumatic Brain Injury in a military medical database

Personalized medicine is a ubiquitous term that has come to be used to describe a medical model that proposes the customization of healthcare, such that decisions and/or treatments are tailored to each individual patient. Under this type of clinical practice model, diagnostic and prognostic decisions are often based upon selecting the most appropriate therapy based on a patient’s genetic, demographic, and/or other pertinent information. The primary aim of this paper is to use a personalized medicine framework to better understand the relationship between neuropsychological testing and the progression of symptoms in a blast-induced mild Traumatic Brain Injury (mTBI) patient population. In this paper, we extended our earlier work on Constrained Spectral Partitioning (CSP), a graph-based approach that incorporates additional information from separate graphs to help improve the clustering quality on both graphs simultaneously. While our previous work demonstrated the effectiveness of this algorithm in its ability to accurately classify whether symptoms improved or declined over time, that work did not provide any insights into the progression of symptoms. Therefore, this paper sought to identify, from a clinical perspective, whether symptoms increased/decreased over time. To accomplish this, we developed a decision tree classifier to classify symptom progression based on the outputs from our CSP algorithm. We present results from four separate decision tree classifiers that illustrate the adaptability of these algorithms for utilization as decision rules for the treatment of patients following blast-induced mTBI. Decision tree classifier models are useful in the healthcare setting because patient health data (e.g., diagnosis of a condition or a type of treatment) can be imput into the model and, based on the health data variables, a resulting outcome can be suggested, and providers can use this outcome as information to direct their clinical treatment.

IJARCCE - Computer and Communication Engineering

In the world of digitalization, security of image documents is bigger challenge particularly in era of image processing and analysing. Fast security system is most required in many applications like uploading private profile image, medical imaging system, and military database. And one of the ways to get higher security is encryption. Encryption is technique which convert original image to another image that is hard to understand and to keep the image confidential between users, in other word, it is essential that nobody could get to know the content without a key for decryption. In this paper, we survey many different encryption techniques through which we can easily hide or transfer our important document.

New Achievements in WWII Military Historical Reconstruction with GIS

Recently geoinformatics has become a well–known and widely applied discipline in different human sciences. There are several interesting examples of applying geographical information systems to manage the information of various time periods in military history and archaeology. Our research topic covers modern age military history, and so it is a very sensitive topic because of the recent dates. Therefore we always used objective data acquisition techniques and an applied engineering approach. The military historical GIS database, which was created in this way, can be handled as an objective and reliable basis for further research by scientists in object or even in event reconstructions. Firstly, we had to define a strategy, a methodology, which is suitable to achieve our aims — a uniform GIS database — considering the existing and currently accessible data sources. This methodology consists of three main parts: the reconstruction of the period’s environment, the military objects and finally the military historical events. According to this methodology we reconstructed particular sectors of the two major World War II defense lines (Attila– and Margit–line) in Hungary. Beside the GIS based reconstructions of the environment, the military objects and the events, we investigated further analytical and representational functions, which can also support these kinds of applications. The methods enable various spatial and attribute queries and animation possibilities that are also useful and sometimes necessary. The typical examples of these functions are also discussed in the paper.

On the Accuracy of Media-based Conflict Event Data

Empirical researchers of civil war rarely collect data on violence themselves and instead rely on other sources of information. One frequently used source is media reports, which serve as the basis for many ongoing data projects in the discipline. However, news reports rarely cover a conflict comprehensively and objectively and may therefore be prone to various reporting issues. This article provides an analysis of the accuracy of information given in news reports. In particular, if focuses on two types of “hard facts” that event data sets require: the location of an event and its severity. By linking media reports to firsthand accounts from a military database, the article does two things: (1) it analyzes the determinants of inaccuracy and confirms the expectation that events with a low number of observers tend to have higher reporting inaccuracies and (2) it assesses the magnitude of these inaccuracies and the implications for conducting empirical analyses with media-based event data.

Chronic Exertional Compartment Syndrome: Are Surgical Outcomes Worse in Soldiers Compared with Civilians?

Waterman et al. provide Level-IV evidence that outcomes of surgical treatment of chronic exertional compartment syndrome may be limited in the military population. This study revealed that members of the U.S. military treated surgically for chronic exertional compartment syndrome of the lower extremity had a 45% rate of symptom recurrence, a 28% chance of not being able to return to full activity, a 6% rate of revision surgery, and a 16% complication rate. Seventeen percent of the subjects in this cohort required a medical discharge from the military secondary to persistent symptoms of chronic exertional compartment syndrome. The information provided by this article allows military physicians to appropriately counsel their patients regarding appropriate expectations following surgical treatment of chronic exertional compartment syndrome. The strengths of this study include a large sample size and a homogeneous study cohort including only military subjects. However, this study was limited by a methodology that depended on retrospective review of a military database that included thirtytwo military centers. This database did not allow for detailed evaluation of inclusion and exclusion criterion, diagnostic approaches, surgical techniques, rehabilitation protocols, or follow-up. In addition, it did not include patient-determined outcome scores. These limitations must be considered when drawing conclusions from this article. The results of surgical treatment of chronic exertional compartment syndrome in this study were inferior to those in previous studies examining an athletic civilian population. Nevertheless, there were similarities between the results of this study and those reported by Almdahl and Samdal, who also examined only military subjects. After reviewing the results of the current study, one must ask the question: are they unique to the military or can they also be extrapolated to the civilian athletic population? If surgical treatment of chronic exertional compartment syndrome is actually less effective in the military population compared with the civilian population, the reasons remain unknown. One can hypothesize that (1) military personnel endure physical demands even greater than those experienced by civilian athletes, (2) military personnel have less ability to decrease their activity levels to accommodate postoperative persistence of symptoms compared with the civilian population, (3) there are unique psychological stressors in the military, and/or (4) there are potential secondary-gain issues that may be correlated with job dissatisfaction similar to those found in the Workers’ Compensation population. All of these factors may have contributed to the suboptimal outcomes found in this study. However, at this point, these theories are all a matter of conjecture. As part of the data analysis, the authors attempted to identify risk factors for surgical failure. However, instead they actually reported the characteristics of failure (i.e., persistence of preoperative pain, surgical complications, and postoperative activity limitations). Unfortunately, they did not find any modifiable preoperative risk factors for surgical failure that could be addressed to reduce the risk of failure in future treatment. This study also raises the question of whether the failures are technical or, instead, the nature of this disorder in this population does not reliably respond to current surgical treatments. Another concern is: are more patients in the military population, as compared with civilians, being misdiagnosed with chronic exertional compartment syndrome and, as a result, not responding to its surgical treatment? At this time, it is not well known if one, multiple, or all four compartments should be released when a patient is diagnosed with chronic exertional compartment syndrome. Waterman et al. evaluated four-compartment fasciotomy in a univariate analysis to determine if releasing all four compartments was either protective or detrimental in terms of rates of surgical failure. Although the reported odds ratio of 0.66 could represent a decreased risk of surgical failure, this odds ratio failed to reach significance. It is quite possible that patients have persistent postsurgical pain in unreleased compartments with elevated compartment pressures that were not initially diagnosed. Additionally, since only 14% of the patients in this study experienced complete resolution of symptoms after revision surgery, and only one revision was performed to release a compartment that had not been addressed at the initial surgery, one might consider releasing all four compartments in a revision setting. e48(1)

United States Counties with Low Black Male Mortality Rates

ObjectiveIn the United States, young and middle-aged black men have significantly higher total mortality than any other racial or ethnic group. We describe the characteristics of US counties with low non–Hispanic Black or African American male mortality (ages 25-64 years, 1999-2007). MethodsInformation was accessed through public data, the US Census, the US Compressed Mortality File, and the Native American Graves Repatriation Act military database. ResultsOf 1307 counties with black mortality rates classified as reliable by the National Center for Health Statistics (at least 20 deaths), 66 recorded lower mortality among black men than corresponding US whites. Most notable, 97% of the 66 counties were home to or adjacent a military installation versus 37% of comparable US counties (P<.001). Blacks in these counties had less poverty, higher percentages of elderly civilian veterans, and higher per capita income. Within these counties, national black:white disparities in mortality were eliminated for ischemic heart disease, accidents, diseases of the liver, chronic lower respiratory diseases, and mental disorder from psychoactive substance use. Application of age-, race-, ethnicity-, gender-, and urbanization-specific mortality rates from counties with relatively low mortality would reduce the black:white mortality rate ratio for black men aged 25 to 64 years from 1.67 to 1.20 nationally and to 1.00 in areas outside large central metropolitan areas. ConclusionsThese descriptive data demonstrate a small number of communities with low mortality rates among young and middle-aged black/African American men. Their characteristics may provide clinical and public health insights to reduce these higher mortality rates in the US population. Analytic epidemiologic studies are necessary to test these hypotheses.