Operation Enduring Freedom Research Articles

385 External Validation of a Massive Transfusion Protocol App-Based Algorithm in Military Combat Casualties

The most common cause of preventable death in US Military Service members is hemorrhagic shock, which is managed with tourniquets, blood administration, and damage control surgery. Administration of resuscitative blood products has been done by military providers since WWII and has since become common place in civilian hospitals. In the setting of limited resources while deployed, the use of a clinical decisionmaking calculator can help mitigate and expedite the decision of activating the massive transfusion protocol (MTP). The purpose of this research was to externally validate the ability of an app-based MTP algorithm developed by Mena et al. to predict the need for a massive transfusion (MT) in a military combat casualty dataset. Using casualty data from Operation Enduring Freedom (OEF), the Mena et al. MTP algorithm calculated the predicted probability of the need to receive a MT and was evaluated by calculating the area under the receiver operating characteristic curve (AUROC), specificity, and sensitivity. The AUROC for predicting MT was 0.84 (95% CI: 0.80-0.88) with specificity of 0.96 and sensitivity of 0.25 when assuming moderate and high categories (Pr > 0.070) is positive for MT. Using OEF casualty data, the MTP algorithm correctly categorized 96.4% of non-MT casualties ‘‘very low’’ or ‘‘low’’ and 3.0% moderate and 0.7% as high probability of MT. Alternatively,24.5% of MT casualties were categorized as ‘‘high’’ or ‘‘moderate,’’ with 31.6% and 43.9%categorized as “low” or “very low” probability of MT. The algorithm showed moderate ability in predicting the need for MT in combat casualties. With a specificity of 0.96, it is particularly useful in categorizing and ruling out the need for MT. With a sensitivity of 0.25, the algorithm lacks identification of those who will need MT, categorizing 76% in “very low” and “low” probabilities who ultimately required MT. The results suggest that especially with adjustments to mechanism of injury to aid in better prediction of the need for MTP.

Themes in experiences of PTSD symptoms and relationships among male veterans with risky sexual behavior.

United States veterans with posttraumatic stress disorder (PTSD) symptoms are at elevated risk for high-risk sexual behavior (HRSB). Although quantitative research has examined relationships between PTSD symptoms and HRSB, qualitative research to understand the lived experiences of veterans with PTSD symptoms and HRSB has not been conducted. Qualitative interviews were conducted with N = 29 male veterans of Operation Enduring Freedom or Operation Iraqi Freedom who had PTSD symptoms and reported recent HRSB. The interviews were analyzed using a phenomenological framework. Six themes emerged: (a) avoiding social contact due to feeling different since return from service; (b) effortful self-management; (c) supportive relationships; (d) sex as a means to an end; (e) sex, risk, and intimacy; and (f) responsibility and growth. Male veterans with PTSD symptoms and HRSB reported engagement in significant self-management to reengage in life, and still reported high levels of difficulty in relationships. They described both wanting to avoid perceived risk associated with intimate relationships and wanting to take risks that caused them to feel alive. Implications for treatment include increased efforts to facilitate coping, to recognize and moderate risk-taking urges, and to build intimacy and trust. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Ocular Trauma in Operation Iraqi Freedom and Operation Enduring Freedom from 2001 to 2011: A Bayesian Network Analysis

ABSTRACT Purpose To update the epidemiology of ocular injuries in soldiers admitted to Walter Reed Army Medical Center (WRAMC) from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Methods Data were collected in the Walter Reed Ocular Trauma Database. A Bayesian Network Analysis was completed to better understand the relationships between different ocular demographic variables, injuries, surgeries, ocular trauma scores (OTS) and visual outcomes. Results There were 890 consecutive globe or adnexal combat injuries, or both, sustained by 652 United States soldiers treated at WRAMC between 2001 and 2011.The primary mechanism of injury was improvised explosive device (62.47%). Many patients (62.0%) had final visual acuity (VA) grades of 1–2 (20/15 – 20/200), while 29.9% of patients had final VA grades of 3–5 (less than 20/200), and 8.1% had unknown final VA grades. Bayesian Network Analysis revealed that the injury variables of Retina (47.9%), Lens (44.6%), Posterior Segment (43.7%) and Anterior Segment (40.3%), and the surgical variables of Enucleation (97.6%) and cataract extraction and posterior capsule intraocular lens placement (CEPCIOL; 43.3%) all had probabilities greater than 40% for a poor final VA, while all other variables were less than 40%. Conclusion Modern-day combat trauma results in complicated ocular injuries causing 30% of patients to be left legally blind in their injured eye. It is critical to maintain a wide variety of deployable, specialty trained ophthalmologists to ensure the best visual outcomes for wounded warriors and to maintain mission readiness.

Military experience in the management of pelvic fractures from OIF/OEF

IntroductionPelvic fractures are a common occurrence in combat trauma. However, the fracture pattern and management within the most recent conflicts, i.e. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF),...

One Health and veterans' post-deployment health.

Since 2001, more than 3.3million US service members have been deployed to operations Iraqi Freedom, Enduring Freedom, New Dawn, Inherent Resolve and Freedom's Sentinel. Visible and invisible war wounds from direct combat experiences, coupled with environmental exposures to harmful substances, can complicate veterans' health throughout their lifespan. While promoting a holistic view of health, health professionals should be attentive for potential risks associated with environmental or animal exposures (One Health concept). During deployment, infectious and non-infectious environmental exposures and harmful substances in the air, on the land and in the water may result in immediate- or long-term health effects. Veterans can also face psychosocial health risks when home that may impact their concentration, emotional responses and social interactions. To strengthen health professions education, the authors recommend that curricula incorporate a comprehensive overview of veterans' physical and psychosocial health risks as a result of their deployment. They describe four specific curriculum topics, competencies and didactic methods that can reinforce veteran-specific content for clinical education and training. By applying the One Health concept, health professionals can document harmful environmental exposures during deployment, report gaps in clinical practice, and provide support for veterans' physical and psychosocial health needs when returning to civilian life.

Examining posttraumatic stress disorder as a key postinjury risk factor in OIF/OEF veterans with blast-induced mild traumatic brain injury.

To explore the neuropsychological sequelae of blast-induced mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD), several neuropsychological tests and self-reported measures of cognitive and emotional functioning were administered to 138 Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) veterans. We hypothesized that veterans affected by mTBI and PTSD would manifest differences in neuropsychological testing and self-report measures compared to a group of healthy veteran controls and to veterans with only PTSD. Participants included 3 groups of veterans: (a) healthy controls (n = 43); (b) PTSD only (n = 48); and (c) comorbid blast-induced mTBI and PTSD (n = 47). An exploratory factor analysis (EFA) was used to extract a smaller number of latent dimensions for group comparison. The EFA supported an 8-factor model. A multivariate analysis of variance on the 8 factor scores demonstrated 3 significant factor mean differences: (a) perceived cognitive complications (PCC), (b) perceived emotional distress (PED), and (c) processing speed (PS). Post hoc analyses showed significant group mean difference in PS between the comorbid and the control groups. In addition, the comorbid group presented with the highest levels of PCC and PED. Results suggest that among OIF/OEF veterans with blast-induced mTBI, PTSD with its accompanying emotional distress may be a significant determinant of subjective sense of well-being both cognitively and emotionally. The objective discrepancy in PS between the comorbid group and the healthy controls also appears largely due to PTSD more so than the remote blast-induced mTBI, as the group mean difference in PS became negligible after controlling for PTSD levels. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Longitudinal associations between negative urgency, symptoms of depression, cannabis and alcohol use in veterans.

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

A psychosocial mediational model of homelessness among U.S. male and female veterans who served in Iraq and Afghanistan.

Few studies have focused on homelessness among Operations Iraqi Freedom, Enduring Freedom and New Dawn (OEF/OIF/OND) veterans, especially female veterans. An explanatory model of homelessness was constructed and tested for each gender. Data collected in the United States from 833 OEF/OIF/OND veterans (41.5% female; Mage =35.22, SD=8.86) who completed the baseline assessment of the Survey of the Experiences of Returning Veterans between September 2011 and July 2014 were analysed. Path analysis was used to examine associations between risk factors and any lifetime homelessness, stratified by gender. Adverse childhood events (ACEs) and low social support were significantly associated with lifetime homelessness for both genders. Social support mediated associations between ACEs and homelessness, after controlling for sociodemographic factors. While sociodemographic risk factors are often considered in homeless prevention, these findings highlight the importance of social support among male and female OEF/OIF/OND veterans, underscoring the need to target this life domain in preventing homelessness.

Health Services Utilization, Health Care Costs, and Diagnoses by Mild Traumatic Brain Injury Exposure: A Chronic Effects of Neurotrauma Consortium Study

ObjectiveTo compare Veterans Health Administration (VHA) diagnoses, health services utilization, and costs by mild traumatic brain injury (mTBI) group (blast-related [BR] mTBI vs non–blast-related [NBR] mTBI vs no mTBI) among Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) veterans in the Chronic Effects of Neurotrauma Consortium multicenter observational study. DesignProspective cohort study. SettingFour Veterans Affairs Medical Centers. ParticipantsOEF/OIF/OND veterans (N=472) who used Veterans Affairs Medical Centers services between 2002-2017. InterventionsNot applicable. Lifetime mTBI history was assessed via semistructured interviews. Main Outcome MeasuresVHA diagnoses, health services utilization, and costs. ResultsRelative to NBR mTBI and no mTBI, veterans with BR mTBI were more likely to be male, have greater combat, and have controlled and uncontrolled detonations exposures (median BR, 15.0 vs NBR, 3.0 vs no mTBI, 3.0). They also had higher prevalence of headache, posttraumatic stress disorder, and anxiety diagnoses. Veterans with BR had the highest site-adjusted mean annual VHA utilization (26.31 visits; 95% confidence interval [CI], 26.01-26.61) relative to NBR (20.43 visits; 95% CI, 20.15-20.71) and no mTBI (16.62 visits; 95% CI, 16.21-17.04) and highest site adjusted mean annual VHA outpatient costs ($6480; 95% CI, $5842-$7187) relative to NBR ($4901; 95% CI, $4392-$5468) and no mTBI ($4069; 95% CI, $3404-$4864). ConclusionsVeterans with BR mTBI had higher exposure to combat and detonation. BR was associated with greater prevalence of select diagnoses and higher health services utilization and costs relative to NBR and no mTBI. The role of health care needs from mTBI polytrauma, other deployment-related exposures, and VHA access warrants future research.

Special Needs of and Promising Solutions for Incarcerated Veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn.

Over 2.5 million military service members have been deployed to Iraq and Afghanistan in Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND). Research indicates OEF/OIF/OND veterans, compared to veterans of other service eras, have elevated risks of mental health problems, suicide rates, homelessness, and problems in the criminal justice system. This article reviews the characteristics of, treatment needs of, and emerging criminal justice reentry initiatives for veterans of the Iraq and Afghanistan conflicts.

Characteristics and Distribution of Extremity Vascular Injuries in a Wartime Military Cohort

Combat-related extremity vascular injuries (EVI) in service members pose a significant challenge to clinicians due to the complex, long-term health care needs of these Veterans after repair and limb salvage. This study determined characteristics of service members, mechanisms of injury and distribution of vascular injuries in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans. Veterans with EVI undergoing an initial attempt at repair were identified using the Department of Defense Trauma Registry, validated by chart abstraction and merged with Veterans Administration data. Our cohort of 527 service members with EVI averaged 25.3 ± 6.5 years old (range, 18-56 years) at time of injury, >95% of the service members were male, and 30% were married. The distribution of race was 82% white, 6% African American and 3% Asian; independently, 10% were of Hispanic ethnicity. Cohort members were enlisted (95%) in the Army (68%) or Marines (28%), and most graduated from high school (84%) with 13% reporting some college. Service members were injured in Operation Iraqi Freedom/Operation New Dawn (66%) and Operation Enduring Freedom (33%). Explosive injury mechanism was most common (63%), with gunshot wounds accounting for 32%; 73% were penetrating versus 27% blunt injuries. The composite Injury Severity Score was 15.9 ± 9.2 (range, 1.0-59.0) with a distribution of 60% mild, 25% moderate, and 15% severe injuries. Abbreviated Injury Scale-Extremities distribution included 12% moderate, 67% serious, and 17% severe. The 527 service members experienced 741 vascular injuries: 246 arterial and 38 venous upper and 317 arterial and 140 venous lower extremity injuries with many Veterans also suffering concurrent soft tissue, bone and nerve injuries. Brachial (43%), radial (24%), and ulnar (21%) arteries and brachial (37%) veins were most frequently injured in the upper extremity (Table I). Superficial femoral (29%), tibial (25%), and popliteal (25%) arteries and superficial femoral (28%) and popliteal (23%) veins were the most common lower extremity injuries (Table II). All 527 service members were alive upon discharge with >99% surviving at 5 years of injury. Sixty-five percent were discharged/medically retired for disability, 52% were diagnosed with PTSD at 5 years of injury, and 82% had traumatic brain injury (TBI) including 14% with moderate, severe or penetrating TBI. EVI caused by explosive mechanism represents a large cause of morbidity with high rates of disability and TBI. Many service members undergo successful vascular repair and all survived their EVI, however, the overall health of this cohort requires complex and holistic care beyond initial surgical repair and stabilization.Table IDistribution of upper extremity vascular injuriesArterial injuriesVenous injuriesLeft132Left18Right114Right20Veterans: 227Veterans: 35Left only: 119Subclavian2Subclavian1Left only: 15Right only: 106Axillary15Axillary9Right only: 19Bilateral: 2Brachial106Brachial14Bilateral: 1Radial58Radial1Ulnar51Ulnar3Hand1Superficial7Unspecified13Unspecified324638 Open table in a new tab Table IIDistribution of lower extremity vascular injuriesArterial InjuriesVenous InjuriesLeft162Left71Right155Right69Veterans: 278Veterans: 119Left only: 134Common femoral11External iliac2Left only: 55Right only: 131Profunda femoral9Common femoral14Right only: 58Bilateral: 13Superficial femoral93Profunda femoral4Bilateral: 6Femoral branch2Superficial femoral39Femoral unspecified24Femoral branch1Popliteal78Femoral unspecified5Tibial/peroneal79Popliteal32Sural1Tibial/peroneal21Dorsalis pedis2Medial plantar1Medial plantar1Saphenous12Unspecified17Unspecified9317140 Open table in a new tab

Development of a Practice Tool for Primary Care Providers: Medication Management of Posttraumatic Stress Disorder in Veterans with Mild Traumatic Brain Injury.

Posttraumatic stress disorder (PTSD) and comorbid mild traumatic brain injury (mTBI) are highly prevalent in veterans who served in Iraq [Operation Iraqi Freedom/Operation New Dawn] and Afghanistan [Operation Enduring Freedom]. Complicated psychotropic medications are used for treatment of PTSD and comorbid mTBI symptoms lead to polypharmacy related complications. Primary care providers (PCPs) working in Community Based Outpatient Clinics (CBOCs) are usually burdened with the responsibility of managing this complicated medication regimen or relevant side effects. The PCPs do not feel equipped to provide this complicated psychopharmacological management. Thus, there is a need for a comprehensive yet concise tool for the medication management of PTSD in veterans with comorbid mTBI. (1) To conduct focus groups of interdisciplinary team of experts and other stake holders to assess need, (2) To carefully review current VA/Department of Defense practice guideline to identify content, (3) To develop an evidence based, user friendly, and concise pocket guide for the PCP's. Content was identified by review of current guidelines and available literature and was finalized after input from stakeholders, multidisciplinary team of experts, and review of qualitative data from focus groups/interviews of clinicians working in remote CBOCs. The pocket tool was formatted and designed by multimedia service. A pocket guide in the form of a bi-fold, 4″ × 5.5″ laminated card was developed. One thousand hard copies were distributed in the local VA medical center. This product is available online for download at the South-Central Mental Illness Research, Education, and Clinical Center website ( https://www.mirecc.va.gov/VISN16/ptsd-and-mtbi-pocket-card.asp ). This pocket card provides PCPs an easy to carry and user-friendly clinical decision-making tool to effectively treat veterans with PTSD and comorbid mTBI.

Comprehensive analysis of combat casualty outcomes in US service members from the beginning of World War II to the end of Operation Enduring Freedom.

Advances in combat casualty care have improved combat survivability over the past two decades. However, these outcomes remain incompletely framed in the broader context of combat casualty outcomes over the past eighty years. We hypothesized that starting with World War II, combat survival worsened at the beginning of each new conflict but then improved over time. To evaluate long-term trends in combat casualty outcomes, monthly combat injuries and deaths during World War II, the Korean conflict, the Vietnam conflict, Operation Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF) were collated. From these numbers, we calculated the monthly case fatality rate (CFR), the killed in action rate (%KIA), and the died of wounds rate (%DOW). We analyzed these metrics for significant trends during and between each conflict using linear and Loess regression. We then simulated alternate outcome scenarios by eliminating outcome variability. In this comprehensive analysis, CFR decreased over the study period in parallel with a decrease in %KIA. When examining individual conflicts, however, several unfavorable trends emerged including a spike in all fatality measures at the end of Vietnam and a rise in %DOW over the course of Korea and OIF. In comparing CFR at the beginning of each conflict to the best CFR from the prior conflict, high mortality outliers occurred in every conflict after a period of relative peace, and a clear peacetime effect occurred in both World War II and Vietnam. Eliminating these negative trends and the attendant preventable deaths would have reduced combat fatalities over the course of eighty years by 107,256 (39.7%). In summary, although combat mortality rates have generally improved since World War II, closer examination indicates several unfavorable trends both during and between conflicts. Identifying factors behind these trends will reveal further opportunities to improve combat casualty outcomes in the future. LEVEL OF EVIDENCE: III, Epidemiological.

A qualitative analysis of meaning-making and mental health among OIF/OEF veterans.

After combat, veterans may experience mental health symptomology and attempt to make meaning from their experiences. The present study qualitatively examined the mental health effects of deployment and meaning-making among Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) veterans. OIF/OEF veterans who were exposed to combat (N = 14) participated in semi-structured interviews to assess how their perspectives had changed post-deployment. Most participants (86%) were male, with a mean age of 30. Veterans described issues post-combat that caused psychological distress or promoted distancing from others. Veterans also discussed factors that could promote or hinder meaning-making, including perceptions of growth, changed global beliefs, and disillusionment. Finally, veterans described psychological reactions to death, which could be related to moral injury. Mental health concerns, meaning-making, and consideration of mortality appear to characterize veterans' experiences post-deployment. These constructs may be important for clinicians to consider when working with OIF/OEF veterans.

Adapting group interpersonal psychotherapy (IPT-G) for treating depression among military spouses at Naval Medical Center Portsmouth (NMCP): Formative qualitative phase

Introduction: Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq have resulted in the deployment of nearly 2,000,000 troops, of which nearly 60% were married, and nearly half had dependent children. While great attention is being paid to the mental health of returning Veterans, we cannot neglect the mental health of this substantial population of military family members. Studies have found that spouses exhibit similar rates of mental health problems as soldiers returning from combat. Whereas rates of anxiety have been shown to drop significantly post-deployment, depression in military spouses appears to persist following deployment. Although a number of psychosocial interventions tailored to military families have been developed, to the knowledge of the authors, no evidence-based interventions have been adapted to specifically target clinical depression in military spouses. Methods: This case study is part of a larger pilot study that sought to adapt, test, and evaluate Group Interpersonal Therapy (IPT-G), an evidence-based treatment for depression, for depressed military spouses. A formative qualitative assessment is crucial to the intervention’s long-term effectiveness, dissemination, and sustainability. This study aimed to understand military spouses’ unique mental health needs and their experience with mental health services. Three focus groups were conducted – two groups of military spouses and a group of mental health care providers – and transcripts were generated using verbatim note-taking. Five independent coders then coded the transcripts for themes that emerged as most salient using an inductive thematic analysis approach. Results: The results identified were clustered under three main themes: (1) psychosocial stressors for depressed military spouses; (2) barriers to mental health care for military spouses; and (3) proposed services. Discussion: When implementing an intervention for a specific population, optimization of its fit to the needs, priorities, and help-seeking patterns of the population should take place to ensure that it is meaningful, ecologically valid, and sensitive to context and culture. Our analysis showed that the military culture presents unique psychosocial stressors, barriers, demands, and needs to mental health provision that should be accounted for in the adaptation of evidence-based mental health intervention. The interpersonal nature of many of the challenges faced by military spouses lend themselves readily to the problem areas that are treatment targets of IPT, therefore increasing the patients’ potential for engagement and sense of compatibility with the treatment.

Relationship to Deployment on Sarcoidosis Staging and Severity in Military Personnel.

Ongoing studies are investigating the potential link between deployment to Operation Iraqi Freedom and Operation Enduring Freedom and relationship to increases in pulmonary disease. While increases in certain diseases such as asthma and airway hyperreactivity are well established, data on other chronic pulmonary diseases such as sarcoidosis have not been defined. A retrospective chart review was conducted of all active duty military personnel diagnosed with sarcoidosis from 2005 to 2010. Deployment dates and locations were obtained through the Armed Forces Health Surveillance Branch. Electronic medical records were reviewed to determine the following parameters: dates of diagnosis, temporal relationship of diagnosis and deployment, symptoms (pre- and/or post-deployment), spirometry, diffusing capacity, radiographic staging, and treatment course. Pulmonary sarcoidosis incidence rates were estimated using International Classification of Diseases (ICD-9) coded medical encounter data from the Defense Medical Surveillance System and compared between Army and nonArmy personnel, as well as between ever-deployed and never-deployed personnel. A cohort of 478 Army soldiers was identified with sarcoidosis based on ICD-9 codes and individual review of the medical records. The cohort was 80% male. 38.7% of soldiers with sarcoidosis never deployed. 11.7% were diagnosed prior to deployment, and 50.2% were diagnosed postdeployment. The diagnosis of sarcoidosis was established with a tissue diagnosis in 68% of the deployed cohort. Overall differences in spirometry were not identified. Obstructed spirometry was similar in all deployment groups (never, pre, and post) at 9.2%, 15.8% and 8.7%, respectively. Restrictive patterns based on total lung capacity (<70%) were similar at 9.2%, 12.5%, and 11.0%, respectively. Radiographic staging showed a similar distribution in the populations with the never/pre versus postdeployment groups having Stage 0=2.3 versus 3.5%, Stage I=43.8 versus 41.6%, Stage II=33.1 versus 41.0%, Stage III=15.1 versus 12.1%, and Stage IV=2.2 versus 1.7%, respectively. During 2005-2010, the estimated incidence rate of pulmonary sarcoidosis was low among active duty Army personnel (16.5 cases/100,000 person-years), and no trend in annual rates was observed, p=0.89. Based on overall Department of Defense medical data, estimated pulmonary sarcoidosis rates were lower among ever-deployed personnel, relative to nondeployed personnel. Based on this analysis of Army sarcoidosis patients, there was no difference in the rates of sarcoidosis diagnosis in deployed and nondeployed soldiers. Spirometry values, total lung capacity, and radiographic staging did not show significant differences between deployment groups.

Timing of evidence-based psychotherapy for posttraumatic stress disorder initiation among Iraq and Afghanistan war veterans in the Veterans Health Administration.

Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) were widely disseminated to treat posttraumatic stress disorder (PTSD) in the Veterans Health Administration (VHA). However, few Iraq and Afghanistan war veterans (Operation Enduring Freedom [OEF], Operation Iraqi Freedom [OIF], Operation New Dawn [OND]) diagnosed with PTSD have received CPT/PE and many initiate CPT/PE after substantial delay. Veterans who do not initiate CPT/PE or initiate CPT/PE after delay may have poorer treatment outcomes. This study aimed to identify predictors of CPT/PE initiation and timing. Participants included OEF/OIF/OND veterans diagnosed with PTSD who received psychotherapy between 2001 and 2017 in the VHA (n = 265,566). Logistic regression analysis was utilized to predict initiating CPT/PE (vs. no CPT/PE). Multinomial logistic regression analysis was utilized to predict not initiating or initiating delayed CPT/PE versus "early CPT/PE" (< 1 year after first mental health visit). Analyzed predictors included demographic, military, and clinical complexity variables (e.g., comorbidities, reported military sexual trauma [MST] history). Seventy-Seven percent of veterans did not initiate CPT/PE, with 7.4% initiating early and 15.4% initiating delayed CPT/PE. Reported MST history (odds ratio [OR] = 1.45, 95% CI [1.39, 1.51]) and history of suicidal ideation/attempt (OR = 1.42, 95% CI [1.38, 1.46]) were strong predictors of CPT/PE initiation versus no CPT/PE. Comorbid pain (relative risk ratio [RRR] = 1.35, 95% CI [1.30, 1.42]) and depressive disorders (RRR = 1.37, 95% CI [1.32, 1.43]) were associated with increased likelihood of delayed versus early CPT/PE. Most veterans in our study did not initiate CPT/PE. Generally, clinical complexity variables increased likelihood of initiating CPT/PE and initiating CPT/PE more than 1 year after first mental health visit. Additional research is needed to understand whether CPT/PE delay results from receipt of alternative intervention due to clinical complexity variables. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Neuro-Ophthalmic Injuries With Systemic Neurologic Injury or Traumatic Brain Injury in Operation Iraqi Freedom and Operation Enduring Freedom.

To analyze the final visual acuity (VA) of neuro-ophthalmologic injuries (NOI) in combat ocular trauma and to study the association of NOI with systemic neurologic injury (SNI) and traumatic brain injury (TBI). The Walter Reed Ocular Trauma Database was reviewed. Inclusion criteria were any US service member and Department of Defense civilians who suffered NOI, SNI, or TBI in Operation Iraqi Freedom or Operation Enduring Freedom. The primary outcome measure was the rate of poor final VA in patients with an NOI with secondary outcome measures the rate of SNI and TBI. in patients with NOI. One hundred seventy-eight (20.00%) of 890 eyes had an NOI. Optic nerve injury was observed in 79 (44.38%) eyes, other cranial nerve injury in 68 (38.20%), Horner syndrome in 4 (2.25%), diplopia in 45 (25.28%), and ptosis in 13 (7.30%). In patients with NOI, 76 (42.69%) eyes had a final VA less than 20/200. In injured eyes (n = 359) of patients (n = 251) with TBI, 154 eyes (34.26%) had a final VA less than 20/200. In multivariate analysis, optic nerve injury (P < 0.001), unlike TBI (P = 0.47), was associated with final VA less than 20/200. SNI (n = 229) had a statistically significant association (odds ratio 29.8, 95% confidence interval 19.2-47.8, P < 0.001) with NOI. Optic nerve injury and cranial nerve injury were associated with TBI and SNI (all, P < 0.001). Optic nerve injury and cranial nerve injury are associated with TBI and SNI. Optic nerve injury, but not TBI or cranial nerve injury, is associated with a poor final VA.

Sex differences in symptom presentation and functional outcomes: a pilot study in a matched sample of veterans with mild TBI

ABSTRACTPrimary Objective: Research focused on mild traumatic brain injury in active military and veteran populations details the psychological, neurological and functional outcomes of mTBI, in a primarily male (~95%) cohort. This may misrepresent female symptoms and outcomes. Here we assess for genuine sex differences in symptom presentation and functional outcomes.Research Design: We used matched pairs to preclude potential sex bias in outcome data.Methods and Procedures: We matched 49 female/male pairs on; 1) mechanism of injury, 2) time from injury to assessment and 3) age at assessment. Statistics were t-tests, chi-square, correlations and post hoc linear regression.Main outcomes and results: Outcome assessment revealed four significant (p < .05) sex differences; Living situation, Marital status, Vocation and Branch of service. Only the Neurobehavioral Symptom Inventory (NSI) composite cognitive domain factor was significantly different between females (mean: 10.26) and males (mean: 7.58). Linear regression confirmed a significant effect of sex for the cognitive composite (p = .002).Conclusion: We conclude that sex has a moderate effect on mTBI post-concussive symptom presentation. The significant sex difference in the NSI cognitive domain characterizes sex-related symptomology profiles providers can focus on for better rehabilitation management. Replication in the larger cohort would improve generalizability.Abbreviation: TBI: Traumatic Brain Injuries; mTBI: mild Traumatic Brain Injuries; OIF: Operation Iraqi Freedom; OEF: Operation Enduring Freedom; VA: Veterans Affairs Health Care System; PSC: Polytrauma System of Care; PRC: Polytrauma Rehabilitation Center; PTRP: Polytrauma Transitional Rehabilitation Program; PNS: Polytrauma Network Site; PTSD: Post Traumatic Stress Disorder; DoD: Department of Defense; NSI: Neurobehavioral Symptom Inventory; LOC: loss of consciousness; AOC: alteration of consciousness; PTA: posttraumatic amnesia; CPRS: computerized patient record system; CTBIE: Comprehensive TBI Evaluation; OCD: obsessive compulsive disorder; ETOH: alcohol abuse

Sleep Quality Moderates the Relationship between Anxiety Sensitivity and PTSD Symptoms in Combat-exposed Veterans

ABSTRACT Objective/Background: Posttraumatic stress disorder (PTSD) and related conditions (e.g., depression) are common in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) veterans. High anxiety sensitivity (AS), defined as fear of anxiety and anxiety-related consequences, is related to greater PTSD and depressive symptoms; however, few studies have identified possible modifiers of these associations. The current study examined the moderating role of sleep quality in the associations between AS and PTSD and depressive symptoms. Participants: Participants were 155 OEF/OIF/OND community veterans ages 21–40 (12.3% women). Methods: Participants completed a semi-structured clinical interview for DSM-IV PTSD symptoms (Clinician Administered PTSD Scale; CAPS) and self-report measures of anxiety sensitivity (Anxiety Sensitivity Index), sleep quality (Pittsburgh Sleep Quality Index global score; PSQI), and depressive symptoms (Beck Depression Inventory-II; BDI–II). Results: Results of hierarchical linear regression models indicated that the main effects of AS and global PSQI score were significantly associated with greater PTSD and depressive symptoms (both with sleep items removed), above and beyond the covariates of trauma load and military rank. Sleep quality moderated the relationship between AS and PTSD symptoms (but not depressive symptoms), such that greater AS was associated with greater PTSD symptoms for individuals with good sleep quality, but not poor sleep quality. Conclusions: Sleep quality and AS account for unique variance in PTSD and depressive symptoms in combat-exposed veterans. AS may be less relevant to understanding risk for PTSD among combat-exposed veterans experiencing poor sleep quality.