Operations Enduring Freedom And Iraqi Freedom Research Articles

Enucleations and Eviscerations for Combat Ocular Trauma Performed During Operations Iraqi and Enduring Freedom: 2001 to 2011.

To describe the demographics and clinical outcomes of patients who underwent posttraumatic enucleation or evisceration during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) from 2001 to 2011. The Walter Reed Ocular Trauma Database is a retrospective case series of US Servicemembers and Department of Defense civilians who had combat ocular injuries in OIF and OEF. Data regarding posttraumatic enucleations and eviscerations performed during OIF and OEF were extracted. The main outcomes analyzed were the number of enucleations and eviscerations performed, location of the surgery, laterality, and graft type. The secondary outcome measures included: mechanism of injury and Ocular Trauma Score classification. One hundred nine enucleations and eviscerations were performed on the 890 eyes (12.24%). Sixty-three (57.80%) primary enucleations, 36 (33.03%) secondary enucleations, 5 (4.59%) postretinal detachment repair enucleations, and 5 (4.59%) primary eviscerations were completed. The surgeries were completed at a combat support hospital (57; 52.3%), or Walter Reed Army Medical Center (49; 45.0%). All surgeries were unilateral except in 2 patients. The most common graft type used was silicone (n = 56; 51.38%). Improvised explosive devices caused 76 (69.72%) eye injuries. Ocular Trauma Score were recorded as 56 (51.38%) between 0 and 44, 44 (40.37%) between 45 and 65, and unknown in 9 (8.26%). Posttraumatic enucleation or evisceration due to devastating ocular trauma is required in about 15% of ophthalmic patients in modern combat trauma. The psychosocial impact on veterans who have required an enucleation or evisceration from combat trauma has been poorly studied and requires further review.

Urinary Tract Infections After Combat-related Genitourinary Trauma

BackgroundGenitourinary (GU) trauma accounted for 5% of combat-related injuries sustained by U.S. military personnel during Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF). Incidence and risk factors for long-term infectious complications, including urinary tract infections (UTI), have not been described in this unique population.MethodsDemographics, injury patterns, initial and long-term medical care, urologic complications, and infectious complications involving the urinary tract for enrollees within the Trauma Infectious Disease Outcomes Study (TIDOS) were collected from Department of Defense (DOD) and Department of Veterans Affairs (VA) data sources. Statistical analyses were conducted to identify candidate predictors for UTIs after GU trauma.ResultsAmong the 530 TIDOS enrollees who entered VA care, 90 (17%) sustained GU trauma. Blast injury (93.3%), injury during dismounted operations (56.7%), and lower extremity amputation (56.7%) were common characteristics among those with GU trauma. Higher median injury severity scores (ISS) were associated with GU trauma vs. non-GU trauma [33 (IQR: 21–38) vs. 17 (IQR: 9–26), P < 0.001]. Of those with GU trauma, 21 (23.3%) had ≥1 UTI (range 1–9) during DOD-VA care. A total of 42 unique UTI episodes were identified, with 11 (26.2%) occurring during initial DOD care, 19 (45.2%) during subsequent DOD care after initial hospital discharge, and 12 (28.6%) during VA care. The median time to first UTI episode was 49 days (IQR: 40.5–171.8). Having an UTI was associated with bladder (P = 0.002) and posterior urethral injury (P = 0.002), pelvic fracture (P < 0.001), urinary catheterization (P = 0.001), and urologic complications, including urinary retention or incontinence (P = 0.001) and stricture (P = 0.007). Pseudomonas aeruginosa (61.5%) was commonly isolated in urine cultures obtained within 6 months of the initial injury.ConclusionUTIs are a common infectious complication after combat genitourinary trauma, particularly in the setting of severe injury and urologic sequelae. Episodes of UTIs typically occur early on after the initial injury while in DOD care; however, recurrent infections may continue well into long-term VA care.Disclosures All authors: No reported disclosures.

PD63-01 SEVERE PENILE INJURIES SUSTAINED DURING OPERATIONS IRAQI AND ENDURING FREEDOM: EVALUATING THE TOUGH COHORT FOR PENILE TRANSPLANTATION

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) II1 Apr 2017PD63-01 SEVERE PENILE INJURIES SUSTAINED DURING OPERATIONS IRAQI AND ENDURING FREEDOM: EVALUATING THE TOUGH COHORT FOR PENILE TRANSPLANTATION Steven Hudak, Judson Janak, Jean Orman, and Michael Davis Steven HudakSteven Hudak More articles by this author , Judson JanakJudson Janak More articles by this author , Jean OrmanJean Orman More articles by this author , and Michael DavisMichael Davis More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2925AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In our initial review of the Trauma Outcomes and Urogenital Health (TOUGH) cohort, we identified 423 male US service members (SMs) who sustained penile injuries (PI) while deployed in support of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF). Conventional penile reconstruction is challenged by the unique structure and function of the penile tissues. Thus, penile transplantation is being investigated as a potential means for penile replacement after severe PI. We have made the clinical observation that many SMs who sustained severe PI during OIF/OEF presented with complex polytrauma which may have excluded them from enrollment in existing penile transplantation protocols. The objective of this study was to evaluate the injury patterns among members of the TOUGH cohort who sustained PI with a focus on comorbid conditions which may impact candidacy for penile transplantation. METHODS The previously identified members of the TOUGH cohort who sustained PI were further characterized based on injury severity as well as the presence of comorbid conditions which may impact eligibility for penile transplantation. Severe PI was defined as an Abbreviated Injury Scale severity of 3 or greater (cutaneous avulsion, laceration through glans/cavernosum/urethra, or partial/total penectomy). Five comorbid conditions were identified which may negatively impact penile transplant candidacy: traumatic brain injury (TBI), massive blood transfusion, colorectal injury, pelvic fracture, and extremity amputation(s). SMs with severe PI were stratified by the number of comorbid conditions diagnosed. RESULTS Among the 423 men with PI identified in the TOUGH cohort, 86 (20.3%) sustained severe PI. SMs with severe PI were largely young (median age: 23) and injured during battle (n=81; 94%) by explosive mechanisms (n=77; 90%) resulting in severe polytrauma (median ISS=29). Comorbid conditions which could impact penile transplantation candidacy were common, including massive transfusion (n=56; 65%), lower extremity amputation(s) (n=55; 64%), TBI (n=34; 40%), colorectal injury (n=29; 34%), and pelvic fracture (n=27; 31%). Overall, 83% of SMs (n=71) had at least one of these conditions and 47% (n=41) had ≥ 3. CONCLUSIONS Severe PI was relatively rare during OIF/OEF. Life-threatening polytrauma was common and nearly all SMs with severe PI had comorbid immunologic, physical, and/or neurologic diagnoses which could disqualify them from penile transplantation given the current restrictions identified in existing transplant protocols. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1254 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Steven Hudak More articles by this author Judson Janak More articles by this author Jean Orman More articles by this author Michael Davis More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Firing a weapon and killing in combat are associated with suicidal ideation in OEF/OIF veterans.

Combat veterans are at risk for several adverse outcomes such as posttraumatic stress disorder (PTSD), depression, hazardous alcohol use, and most critically, suicidal behaviors. The high rate of suicide in veterans has been understood as a correlate of PTSD and depression, but it is possible that certain specific types of combat experiences may lead to suicidal behaviors. Acts committed by veterans in the context of war such as killing may evoke a "moral injury," which leads to thoughts of ending one's life. The present exploratory research examined relationships between combat experiences and suicidal ideation (SI) and PTSD in a sample of 68 Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans (91% male, mean age = 32.31 years) who had screened positive for alcohol misuse. We examined firing a weapon/killing in combat (Firing/Killing) and killing in combat (Killing) alone as predictors of SI and PTSD severity in both the full sample and men only. Firing/Killing were associated with SI for the full sample and men only, and Killing showed a trend toward significance in predicting SI. Hierarchical regression analyses suggested that Firing/Killing did not predict PTSD for the full sample or men only, but Killing was predictive of PTSD for both samples. These results indicate that there may be differences in Firing/Killing and Killing alone in OEF/OIF veterans who screened positive for alcohol misuse. Thorough screening of combat experiences and addressing moral injury in returning combat veterans may help reduce high rates of suicide and PTSD. (PsycINFO Database Record

Mild Traumatic Brain Injury, PTSD, and Psychosocial Functioning Among Male and Female U.S. OEF/OIF Veterans.

This study examined the unique and combined relationship between mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) with psychosocial functioning in a cohort of 1,312 U.S. male and female veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) enrolled in the Veterans After-Discharge Longitudinal Registry (Project VALOR). We assessed mTBI with structured screening questions reflective of current TBI classification standards and PTSD via the SCID-IV PTSD module; all other variables were assessed by self-report questionnaires. We identified significant diagnostic group differences in psychosocial functioning for both sexes. Individuals with PTSD, with or without a history of mTBI, reported significantly worse psychosocial functioning than individuals with mTBI alone or neither mTBI nor PTSD (males, η(2) p = .11, p < .001; females, η(2) p = .14, p < .001), even after adjusting for demographics and severity of chronic pain. The results suggested that veterans experiencing PTSD, regardless of whether they had a history of mTBI, were at increased risk for long-term psychosocial impairment. Further research examining possible benefits from improved access to resources and treatment to address these needs would be valuable.

Management of Battlefield Injuries to the Skull Base

High velocity skull base injuries on the battlefield are unique in comparison to most civilian sector trauma. With more than 43,000 United States military personnel injuries during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF), the most recent conflicts in Iraq and Afghanistan have significantly expanded the understanding of the physiology of modern battlefield trauma and how to appropriately address these injuries. The acute care principles of effective triage, airway management, and hemorrhage control in these injuries can be life saving and are reviewed here. Specific injury patterns and battlefield examples are reviewed as well, with a review of some of the lessons learned while providing care in a deployed setting. Utilization of the knowledge learned in Iraq and Afghanistan, which have improved casualty care of deployed service members, can be used both in future military conflicts and in civilian trauma care.

Static and dynamic postural stability in veterans with combat-related mild traumatic brain injury

Persistent post-concussive symptoms are reported by 10–15% of individuals who suffer mild traumatic brain injury (mTBI), but their basis is often uncertain. One such symptom is disequilibrium, a sensation of impaired balance during standing and walking. The hypothesis for this study was that this subjective symptom is associated with objective and measurable deficits in static and dynamic postural stability. An infrared motion tracking system was used to record body motion during quiet standing and in response to waist perturbations in fourteen veterans (age 22–40 years, 13 male) of the Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF), who had a history of mTBI that occurred 7 months to 7 years prior to testing. We compared body sway between veterans with mTBI reporting persistent disequilibrium (TD, n=8) and those with no vestibular symptoms (n=6), as well as to a group of non-veterans with no balance symptoms (n=10). Static postural stability was reduced in TD veterans in comparison to each of the other two groups (p<0.0002), most notably on a compliant surface with eyes closed. The TD group also had decreased dynamic stability of the upper trunk (p<0.05) and enhanced postural oscillations (p<0.02) following waist perturbations. Our findings support a physiological basis for persistent disequilibrium after mTBI and are consistent with impaired vestibular processing. Disruption of semicircular canal inputs is unlikely to be the cause, as head impulse responses were normal in all groups. The unexpected finding of dynamic postural oscillations requires further study but may indicate enhanced instability in sensorimotor networks responsible for postural control.

Military Sexual Trauma Among Recent Veterans: Correlates of Sexual Assault and Sexual Harassment.

Military sexual trauma (MST) includes sexual harassment or sexual assault that occurs during military service and is of increasing public health concern. The population prevalence of MST among female and male veterans who served during Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) has not been estimated to our knowledge. The purpose of this study is to assess the population prevalence and identify military correlates of MST, sexual harassment, and sexual assault among OEF/OIF veterans. MST was assessed in the 2009-2011 National Health Study for a New Generation of U.S. Veterans, a survey of 60,000 veterans who served during the OEF/OIF eras (response rate, 34%, n=20,563). Weighted prevalence estimates and AORs of MST, sexual harassment, and sexual assault among women and men were calculated. Gender-stratified logistic regression models controlled for military and demographic characteristics. Data analyses were conducted in 2013-2014. Approximately 41% of women and 4% of men reported experiencing MST. Deployed men had lower risk for MST compared with non-deployed men, though no difference was found among women. However, veterans reporting combat exposure during deployment had increased risk for MST compared with those without, while controlling for OEF/OIF deployment. Among women, Marines and Navy veterans had increased risk for MST compared with Air Force veterans. MST was significantly higher among veterans who reported using Veterans Affairs healthcare services. These prevalence estimates underscore the importance of public awareness and continued investigation of the public health impact of MST.

Emotion Regulatory Brain Function and SSRI Treatment in PTSD: Neural Correlates and Predictors of Change.

Posttraumatic stress disorder (PTSD)-a chronic, debilitating condition, broadly characterized by emotion dysregulation-is prevalent among US military personnel who have returned from Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF). Selective serotonin reuptake inhibitors (SSRIs) are a first-line treatment for PTSD, but treatment mechanisms are unknown and patient response varies. SSRIs may exert their effects by remediating emotion regulatory brain activity and individual differences in patient response might be explained, in part, by pre-treatment differences in neural systems supporting the downregulation of negative affect. Thirty-four OEF/OIF veterans, 17 with PTSD and 17 without PTSD underwent 2 functional magnetic resonance imaging scans 12 weeks apart. At each scan, they performed an emotion regulation task; in the interim, veterans with PTSD were treated with the SSRI, paroxetine. SSRI treatment increased activation in both the left dorsolateral prefrontal cortex (PFC) and supplementary motor area (SMA) during emotion regulation, although only change in the SMA over time occurred in veterans with PTSD and not those without PTSD. Less activation of the right ventrolateral PFC/inferior frontal gyrus during pre-treatment emotion regulation was associated with greater reduction in PTSD symptoms with SSRI treatment, irrespective of pre-treatment severity. Patients with the least recruitment of prefrontal emotion regulatory brain regions may benefit most from treatment with SSRIs, which appear to augment activity in these regions.

MP27-05 SEVERE WAR-RELATED GENITOURINARY INJURIES AMONG MALE SERVICE MEMBERS IN OPERATIONS ENDURING FREEDOM AND IRAQI FREEDOM

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality of Life1 Apr 2015MP27-05 SEVERE WAR-RELATED GENITOURINARY INJURIES AMONG MALE SERVICE MEMBERS IN OPERATIONS ENDURING FREEDOM AND IRAQI FREEDOM Jud Janak, Steven Hudak, Douglas Soderdahl, Jean Orman, Kristy Pottol, and Wendy Dean Jud JanakJud Janak More articles by this author , Steven HudakSteven Hudak More articles by this author , Douglas SoderdahlDouglas Soderdahl More articles by this author , Jean OrmanJean Orman More articles by this author , Kristy PottolKristy Pottol More articles by this author , and Wendy DeanWendy Dean More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1167AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Severe genitourinary (GU) injuries among service members (SMs) from Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) are of great concern for military and VA urologists because of both the physical and psychological complexity of the injuries, as well as the challenges of restoration. Growing interest in applying the most effective approaches to treat these injuries has raised questions about the number of SMs with severe GU injuries. No previous reports have addressed either the number or types of such injuries; therefore, the objective of this study was to describe the epidemiology of severe war-related GU injuries in this population. METHODS Data for US male SMs injured in OEF/OIF during the years 2001-2013 were obtained from the Department of Defense Trauma Registry (DoDTR). The DoDTR includes data for SMs wounded in theater who survived to be admitted to a combat support hospital. Severe GU injury was defined as any injury with at least one Abbreviated Injury Scale code for a “serious” injury OR at least one code for a major/massive laceration to the GU tract. Patients who died of wounds were excluded. Basic demographic and injury characteristics were analyzed. RESULTS Among 1291 male US SMs deployed to OIF/OEF who sustained one or more GU injuries, 482 (37.3%) were classified as severe. This subset of severely GU-injured males were largely young (median age: 24, IQR 21-27) and injured during battle (n=437; 90.7%). The most common injury type and mechanism were penetrating (n=364; 75.5%) and explosive injuries (n=368; n=76.4%); respectively. Regarding the severity of their overall injuries, the median Injury Severity Score (ISS) was in the severe range (ISS = 25; IQR 17-35). Two important associated injuries included amputation(s) of the upper and/or lower extremity (n=202; 41.9%) and colorectal injuries (n=141; 29.3%). The most common severe GU injuries were: renal (n=78; 16.2%); scrotum (n=87; 18.1%); testes (n=275; 57.1%); and penis injuries (n=84; 17.4%). 19 SMs had a complete loss of penis and/or testis(es). CONCLUSIONS A substantial number of SMs have sustained severe GU injury during OIF/OEF. In general, conventional reconstructive surgical techniques have allowed for restoration of form and function in less severe GU injuries. However, these data indicate that some SMs have sustained more severe injuries such as penile amputation and/or orchiectomy which could potentially benefit from advanced restorative approaches. Further studies are needed to determine what types of restorative techniques are most feasible in this population. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e303-e304 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jud Janak More articles by this author Steven Hudak More articles by this author Douglas Soderdahl More articles by this author Jean Orman More articles by this author Kristy Pottol More articles by this author Wendy Dean More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Homecoming of soldiers who are citizens: Re-employment and financial status of returning Army National Guard soldiers from Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF)

This study examined civilian employment among Army National Guard soldiers who had recently returned from Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF). Of specific interest were relationships of re-employment and financial difficulties to several conditions, such as amount of social support during and after deployment, combat exposure, negative feelings during and after deployment, and postdeployment adjustment symptoms. Survey data from the Army's Reintegration Unit Risk Inventory were used (4,546 soldiers in 50 units who were deployed during 2010). Few soldiers reported financial difficulties during deployment (7.1% of the sample) and after having returned (11.8%). Of those who reported postdeployment financial difficulties, nearly one-half had reported such difficulties during deployment, and not having resumed the predeployment job was associated with more postdeployment financial difficulties. Logistic regression analyses showed the relative contribution of the study variables to changed financial status, from deployment to postdeployment. Reported deployment support (e.g., trust in the unit chain-of-command and available support) was associated with decreased financial difficulties. In contrast, increased financial difficulties were associated with having seen others wounded or killed in combat. Other postdeployment experiences, such as feelings of anger and frustration and available support, were associated with increased financial difficulties, in addition to alcohol use, trouble sleeping and suicidal thoughts. Implications of results for policy and practice to lessen financial hardships and job loss associated with deployment are discussed.

Mental health utilization of new-to-care Iraq and Afghanistan Veterans following suicidal ideation assessment

We evaluated the impact of brief structured suicidal ideation (SI) assessments on mental health care among new-to-care Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans. National datasets provided military, demographic, and clinical information. For all new-to-care OEF/OIF veterans administered depression screens (PHQ-2: Patient Health Questionnaire-2) and structured SI assessments in primary care or ambulatory mental health settings of three Veterans Affairs (VA) Medical Centers between April 2008 and September 2009 (N=465), generalized estimating equations were used to examine associations between SI and number of subsequent-year specialty mental health visits and antidepressant prescriptions. Approximately one-third of the veterans reported SI. In multivariate models, PTSD and anxiety diagnoses, severe depression symptoms, being married, and SI assessment by a mental health clinician were associated with more mental health visits in the subsequent year. Depression, PTSD, and anxiety diagnoses, and SI assessment by a mental health clinician were associated with receiving antidepressants. Presence of SI did not significantly affect subsequent year mental health utilization when adjusting for diagnostic and clinician variables, but inaugural visits involving mental health clinicians were consistently associated with subsequent mental health care.

A Survey of Perceived Barriers and Attitudes Toward Mental Health Care Among OEF/OIF Veterans at VA Outpatient Mental Health Clinics

In an effort to improve our understanding of perceived treatment barriers among veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) relative to other era veterans, the current study examined veteran attitudes and beliefs about mental health treatment and treatment-seeking, and perceived patient and institution-level logistical barriers to care. A survey was conducted among 434 Combat veterans seeking care in nine Veterans Affairs mental health care outpatient clinics. When compared to Vietnam and Gulf War veterans, OEF/OIF veterans were significantly more likely to endorse negative treatment attitudes as possible barriers to care. OEF/OIF veterans were also more likely than Vietnam veterans to endorse conflicting work demands as a potential barrier, although this was the only logistical barrier for which OEF/OIF veterans' responses differed significantly from those of veterans of other eras. Among OEF/OIF veterans, older veterans were more likely than younger veterans to endorse barriers related to cost and time commitments. These findings suggest an important role for outreach and engagement strategies that address attitudinal barriers to treatment utilization among veteran populations.

Psychosocial Concerns of Veterans of Operation Enduring Freedom/Operation Iraqi Freedom

U.S. veterans present with complex medical and psychosocial concerns postdeployment. Identification of psychosocial concerns is necessary for appropriate and targeted social work interventions to improve delivery and receipt of health care through the U.S. Department of Veterans Affairs. The purpose of this article is to identify specific psychosocial concerns of veterans of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) presenting at the War Related Illness and Injury Study Center. A retrospective chart review of psychosocial concerns from all OIF/OEF veterans seen fromJune 2008 toJune 2010 provided data for this mixed methods study. Veterans in the sample (N= 356) reported an average of 5.2 psychosocial concerns (SD = 2.32, range = 0 to 11). The most commonly reported concerns were pain (72 percent), sleep (62 percent), cognition (61 percent), vocational issues (53 percent), education (49 percent), finances (42 percent), relationships (37 percent), anger (30 percent), substance abuse (23 percent), and social support (20 percent), though these categories were not exclusive and many veterans endorsed more than one category. Multiple psychosocial concerns reported by veterans suggest the need for targeted social work intervention.

Treatment utilization among OEF/OIF veterans referred for psychotherapy for PTSD.

Despite high levels of positive screening for mental health complaints, research indicates that veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) seek mental health care at low rates. The purpose of this study was to examine treatment utilization in 200 consecutive OEF/OIF referrals to a PTSD specialist for psychotherapy. This study also examined the relationships between treatment engagement/completion and numerous demographic and clinical variables. This chart-review study identified whether referrals were seen at all and whether they completed psychotherapy (as defined by documented mutual agreement between therapist and referral). Chi-square analyses and t tests were performed to determine whether engagement and completion were related to gender, age, marital status, race, employment, school enrollment, branch of service, time since most recent deployment, number of deployments, service-connection rating, medication prescription, substance use and depressive disorder comorbidity, referral source, TBI screening results, and presence of pain problems and legal issues. Of 200 consecutively referred OEF/OIF veterans, 75 were never seen, 86 were seen at least once without completing, and 24 completed psychotherapy. Being married and employed and older age were associated with higher likelihood of completing therapy. Completers received significantly more sessions of psychotherapy than those who were seen without completing, but the 2 groups did not differ in the types of therapy received.

Sleep disturbance is common among servicemembers and veterans of Operations Enduring Freedom and Iraqi Freedom.

Sleep routines that develop as an adaptation or reaction to deployment can persist upon return stateside. Sleep problems intensify and are intensified by psychiatric distress. This research presents the findings of a comprehensive survey of sleep impairment in relation to demographic data, military history, combat exposure, and mental illness symptoms among a general sample of 375 servicemembers and veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) at a wide range of times postdeployment. Sleep impairment was assessed with the Pittsburgh Sleep Quality Index (PSQI) and the Addendum for PTSD. Posttraumatic stress disorder (PTSD), depression, and anxiety symptoms were evaluated, with the PTSD Checklist-Military, the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7. Sleep problems were common across the sample, with 45.4% of participants reporting sleep onset greater than 30 minutes, 21.4% typically achieving less than 4.5 hours of total sleep time, and 56% reporting being awake in bed more than 15% of the night. Global PSQI scores classified 89% of the sample as "poor sleepers." Sleep problems were more severe among servicemembers with less education, from lower ranks (E1-E3), with greater combat exposure, and greater depression, anxiety, and PTSD symptoms. These findings suggest the need for routine screening of sleep problems among veterans and increased professional training in interventions for insomnia and nightmares. For individuals experiencing sleep problems with concurrent psychiatric symptoms, addressing sleep concerns may be one less-stigmatizing way to transition servicemembers and veterans into needed mental health services.

Extent of Cerebrovascular Disruption Following Blast Exposure is Influenced by the Duration of the Positive Phase in Addition to Peak Overpressure

Blast-induced traumatic brain injury (bTBI) has been described as the defining injury of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). Although there has been a significant amount of research characterizing the brain injury produced by blast, greater understanding of the contribution of each component of the shockwave to the injury is needed. Large animal models of bTBI utilize chemical explosives as their shockwave source while small animal models predominantly utilize compressed air-driven membrane rupture as their shockwave source. We previously designed and built a multi-mode shock tube capable of utilizing air-driven membrane rupture or chemical explosives (oxyhydrogen: A 2:1 mixture of hydrogen and oxygen gasses to produce a shockwave. Compressed airdriven shockwaves exhibited longer duration positive phases than compressed oxyhydrogen-driven shockwaves of similar peak overpressure. The longer duration of compressed air-driven shockwaves results in greater energy being imparted on a test subject than would be impacted by shockwaves of identical peak overpressures from the other sources. Animals exposed to compressed air-driven shockwaves exhibited more extensive brain surface hematoma and more blood-brain barrier compromise than did animals exposed to oxyhydrogen-driven shockwaves of even greater peak overpressure. Taken together, these data suggest that compressed air-driven shockwaves contain more energy than their chemical explosive-derived counterparts of equal peak overpressure and can result in greater injury in an experimental animal model. Additionally, these data suggest that exposure to longer duration shockwaves can result in more severe bTBI. The results of this study are relevant to the design of blast wave mitigation technology and future clinical intervention

Neural Activation during Response Inhibition Differentiates Blast from Mechanical Causes of Mild to Moderate Traumatic Brain Injury

Military personnel involved in Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) commonly experience blast-induced mild to moderate traumatic brain injury (TBI). In this study, we used task-activated functional MRI (fMRI) to determine if blast-related TBI has a differential impact on brain activation in comparison with TBI caused primarily by mechanical forces in civilian settings. Four groups participated: (1) blast-related military TBI (milTBI; n=21); (2) military controls (milCON; n=22); (3) non-blast civilian TBI (civTBI; n=21); and (4) civilian controls (civCON; n=23) with orthopedic injuries. Mild to moderate TBI (MTBI) occurred 1 to 6 years before enrollment. Participants completed the Stop Signal Task (SST), a measure of inhibitory control, while undergoing fMRI. Brain activation was evaluated with 2 (mil, civ)×2 (TBI, CON) analyses of variance, corrected for multiple comparisons. During correct inhibitions, fMRI activation was lower in the TBI than CON subjects in regions commonly associated with inhibitory control and the default mode network. In contrast, inhibitory failures showed significant interaction effects in the bilateral inferior temporal, left superior temporal, caudate, and cerebellar regions. Specifically, the milTBI group demonstrated more activation than the milCON group when failing to inhibit; in contrast, the civTBI group exhibited less activation than the civCON group. Covariance analyses controlling for the effects of education and self-reported psychological symptoms did not alter the brain activation findings. These results indicate that the chronic effects of TBI are associated with abnormal brain activation during successful response inhibition. During failed inhibition, the pattern of activation distinguished military from civilian TBI, suggesting that blast-related TBI has a unique effect on brain function that can be distinguished from TBI resulting from mechanical forces associated with sports or motor vehicle accidents. The implications of these findings for diagnosis and treatment of TBI are discussed.

Cognitive-Behavioral Conjoint Therapy for PTSD: Initial Findings for Operations Enduring and Iraqi Freedom Male Combat Veterans and Their Partners

Posttraumatic stress disorder (PTSD) and partner relationship difficulties commonly co-occur among Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF-OIF). This study reports upon results for six male OEF-OIF Veterans with PTSD and their female relationship partners who completed cognitive-behavioral conjoint therapy for PTSD (CBCT for PTSD), which is a treatment that targets reductions in PTSD and couple distress. Case- and group-level data supported reductions in Veterans' PTSD symptoms and female partners' relationship distress. These findings suggest that CBCT for PTSD may be a promising intervention for OEF-OIF Veterans' PTSD and their partners.

Challenges in the Development of Rodent Models of Mild Traumatic Brain Injury

Approximately 75% of traumatic brain injuries (TBI) are classified mild (mTBI). Despite the high frequency of mTBI, it is the least well studied. The prevalence of mTBI among service personnel returning from Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) and the recent reports of an association between repeated mTBI and the early onset of Alzheimer's and other types of dementias in retired athletes has focused much attention on mTBI. The study of mTBI requires the development and validation of experimental models and one of the most basic requirements for an experimental model is that it replicates important features of the injury or disease in humans. mTBI in humans is associated with acute symptoms such as loss of consciousness and pre- and/or posttraumatic amnesia. In addition, many mTBI patients experience long-term effects of mTBI, including deficits in speed of information processing, attention and concentration, memory acquisition, retention and retrieval, and reasoning and decision-making. Although methods for the diagnosis and evaluation of the acute and chronic effects of mTBI in humans are well established, the same is not the case for rodents, the most widely used animal for TBI studies. Despite the magnitude of the difficulties associated with adapting these methods for experimental mTBI research, they must be surmounted. The identification and testing of treatments for mTBI depends of the development, characterization and validation of reproducible, clinically relevant models of mTBI.