# Military Medicine



## MedCorps

There are some good articles in the Sept volume of Military Medicine.  Take a look if you have the chance. 

Acanthamoeba Keratitis in a U.S. Army Soldier after Unauthorized Use of Contact Lenses in the Combat Theater

Bacteria Recovered from Patients Admitted to a Deployed U.S. Military Hospital in Baghdad, Iraq

Bacteriology of War Wounds at the Time of Injury

High Prevalence of Iron Deficiency and Anemia in Female Military Recruits

Humanitarian Assistance in Afghanistan: A Prospective Evaluation of Clinical Effectiveness

Job Stress, Depression, Work Performance, and Perceptions of Supervisors in Military Personnel

Noninvasive Hemodynamic Monitoring for Combat Casualties

Pelvic Pain Presenting in a Combat Environment

Prevalence of Glucose-6-Phosphate Dehydrogenase Deficiency in U.S. Army Personnel

Preventive Medicine in Task Force 1st Armored Division During Operation Iraqi Freedom

and lots of other neat stuff also... 

Cheers, 

MC


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## GINge!

This sounds like a good journal to have in the unit library. Does your unit have a subscription to it?


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## MedCorps

We have access via ProQuest.  Military Medicine is well worth having in my humble opinion, espcially if you are a bigger unit.  CFMGHQ has it is in the library also, and CFMSS might also.   

For a hard copy it works out to $165 USD / year.  

Here is a link for more information: http://www.amsus.org/journal/

Cheers, 

MC


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## Blackadder1916

Members of the Association of Military Surgeons of the United States (AMSUS) receive Military Medicine  by mail as one of the benefits of their membership.  Officers of the military medical services of other nations are eligible to join.  The current regular dues are $145 USD for three years or $50 USD annually .


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## MedCorps

Good stuff in this month (Oct) Military Medicine also: 

Canadian Forces Evaluation of the EPINATO Health Surveillance System in Bosnia-Herzegovina, from our own Ms. Wilson, Dr.  Carew, and Ms. Strauss at CFHSHQ / Force Health Protection.  

Sexually Transmitted Diseases in Operation Iraqi Freedom/Operation Enduring Freedom

The Military Physician as a Noncombatant: The Concept of Over Identification

Usefulness of Temazepam and Zaleplon to Induce Afternoon Sleep  (for forced rest pre night mission)

Lessons Learned from Indonesia: An Outline - Post Tsunami 

Medical Support to Sri Lanka in the Wake of Tsunamis: Planning Considerations and Lessons Learned

Rapid Assessment of Health Needs and Medical Response after the Tsunami in Thailand, 2004-2005

And lots of other good stuff. 

Cheers, 

MC


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## GINge!

excellent - appears I can access this through DWAN free of change via ingentaconnect.


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## RatCatcher

Link???

Alot of good PMed Info for units without PMed (mainly in the MO)


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## MedCorps

I do not have a link, as the ProQuest search engine requires a password.   GINge! might have a DWAN link to the source he has found free of change via ingentaconnect.

I cannot post the articles here due to copyright issues.  But, if you want to PM me to talk about <hint hint> the concepts, or the state of science behind of one or two of the articles please feel free to drop me a line  .  

Cheers, 

MC


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## GINge!

enjoy - it may only work through DWAN though

http://www.ingentaconnect.com/content/amsus/zmm


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## MedCorps

In this edition of Military Medicine... (June) that might be of interest... 

A Decade after the Tokyo Sarin Attack: A Review of Neurological Follow-Up of the Victims

Comparative Sporicidal Effects of Disinfectants after Release of a Biological Agent

Effects of Heavy Load Carriage during Constant-Speed, Simulated, Road Marching

How Satisfied Are Soldiers with Their Ballistic Helmets? A Comparison of Soldiers' Opinions about the Advanced Combat Helmet and the Personal Armor System for Ground Troops Helmet

Meralgia Paresthetica Due to Body Armor Wear in U.S. Soldiers Serving in Iraq: A Case Report and Review of the Literature

Nonconventional Uses of the Rocket-Propelled Grenade and Its Consequences

Metabolic Effects of Soldier Performance on a Simulated Graded Road March while Wearing Two Functionally Equivalent Military Ensembles

Psychological Guidelines for a Medical Team Debriefing after a Stressful Event

Enjoy, 

MC


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## MedCorps

Finally had a chance to read July... here is a list of the "good stuff" IMHO.  Let me know if you have questions.  

Application of the Mangled Extremity Severity Score in a Combat Setting

Blast Injury of the Ear: Clinical Update from the Global War on Terror

Developing an Effective Medication Soldier Readiness Process

Effects of Gender and Body Adiposity on Physiological Responses to Physical Work While Wearing Body Armor

Diagnosing Cutaneous Leishmaniasis: The Advantage of Forward Deployed Histology in Avoiding a Surgical Pitfall

Expeditionary Medicine in Africa: The French Experience

Psychiatric Medications for Deployment: An Update

Enjoy, 

MC


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## MedCorps

It was a little bit of a "thin" month for Military Medicine, but the highlights of the Aug issue of Military Medicine include: 

Comparison of M-16A2 and M-4 Wounding Potential  (M-16A2 had more tissue disruption)

Drowning Deaths of U.S. Service Personnel Associated with Motor Vehicle Accidents Occurring in Operation Iraqi Freedom and Operation Enduring Freedom, 2003-2005  (the US has had 71 of them)

Evaluation of a Combat Medic Skills Validation Test

Physiological Effects of Night Vision Goggle Counterweights on Neck Musculature of Military Helicopter Pilots

The Lessons Learned from the Canadian Forces Physiotherapy Experience during the Peacekeeping Operations in Bosnia

The Readiness Estimate and Deployability Index and Psychometric Properties in Army Reserve Nurses and Medics

Enjoy, 

MC


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## MedCorps

Once again the September issue was a little thin.  In fact you can read all the interesting stuff in about 10 minutes.  Let me know if anyone sees anything of interest.

Dehydration in Extreme Temperatures While Conducting Stability and Support Operations in a Combat Zone

Mobile Chemical Detector (AP2C+SP4E) as an Aid for Medical Decision Making in the Battlefield

Cheers, 

MC


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## MedCorps

Hello all... 

I don't think they came out with an Oct. issue of Military Medicine (or it did not make it to my desk).  Nonetheless the Nov. supplement makes up for it.  

The Supplement is called Tactical Combat Casualty Care 2007: Evolving concepts an battlefield experience by Capt Bulter, USN (Ret) and crew.  It covers the development of TCCC, a review of the 1996, 2003, and 2006 guidelines, updated information and recommendations on metrics, phases of care, tourniquets, hemostatic agents, NPA, surgical airways, tension pneumothorax, IV/IO access, fluid resuscitation, blood products, oxygen, patient monitoring, hypothermia, battlefield analgesia, and battlefield antibiotics. There is also a section on combining good medicine with good tactics, current challenges and future issues. 

Overall a fine piece of reading for all involved in the craft, with a solid set of references.  I highly recommend finding a copy of this and reading the 19-pages of goodness.  

The rest of Military Medicine this month...  meh... it is ok.  Some of the worth-while reads in IMHO are: 

Fatal Road Accidents among Finnish Military Conscripts: Fatigue-Impaired Driving
Giving Care in Iraq
Hepatitis E Virus Infection in Thai Troops Deployed with U.N. Peacekeeping Force
Wartime Burn Care in Iraq: 28th Combat Support Hospital, 2003

Cheers, 

MC


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## vincent.escanlar

There was an October edition (online, at least), it looked like this:



> *Volume 172, Number 10, October 2007*
> 
> Postdeployment Health Reassessment - A Sustainable Method for Brigade Combat Teams
> 
> Deaths Attributed to Suicide among Enlisted U.S. Armed Forces Recruits, 1980-2004
> 
> Evaluation of Data Obtained from Military Disability Medical Administrative Databases for Service Members with Schizophrenia or Bipolar Disorder
> 
> Does Compensation Status Influence Treatment Participation and Course of Recovery from Post-Traumatic Stress Disorder?
> 
> A Comparison of Experiences of Training Emergency Care in Military Exercises and Competences among Conscript Nurses with Different Levels of Education
> 
> Too Little Time to Teach? Medical Student Education and the Resident Work-Hour Restriction
> 
> Factors Associated with Health Care Professionals' Choice of Written Asthma Management Plans
> 
> Auditing and Benchmarking of Azithromycin Utilization in Primary Care Military Clinics
> 
> Gaining Experience with Military Medical Situational Awareness and Geographic Information Systems in a Simulated Influenza Epidemic
> 
> Premilitary Tobacco Use by Male Marine Corps Recruits
> 
> A Study of Cancer in the Military Beneficiary Population
> 
> Colonoscopy by a Family Physician: A Case Series Demonstrating Health Care Savings
> 
> Influenza Vaccine Refusal in Israeli Young Adults
> 
> War-Associated Cases of Typhoid Fever Imported to Split-Dalmatia County (Croatia)
> 
> Self-Reported Incidence of Snake, Spider, and Scorpion Encounters among Deployed U.S. Military in Iraq and Afghanistan
> 
> Outbreak of Query Fever among Argentinean Special Police Unit Officers during a United Nations Mission in Prizren, South Kosovo
> 
> Successful Treatment of a Septic Aneurysm Due to Salmonella enteritidis Complicated by the Rupture of the Pelvis of the Kidney
> 
> Severe Lung Contusion and Death after High-Velocity Behind-Armor Blunt Trauma: Relation to Protection Level
> 
> Prevention of Vaccinia Infection in a Laboratory Worker
> 
> Use of Surgisis for Abdominal Wall Reconstruction/Closure in Battlefield Casualties during Operation Iraqi Freedom
> 
> The Use of Rigid Sternal Fixation for Complex Poststernotomy Wounds and a Military-Unique Fracture at an Army Medical Center
> 
> Traumatic Arteriovenous Fistula Due to an Old Gunshot Injury - A Victim from the Afghanistan War



Unfortunately my university account only lets you access after they're 3mo old.  That supplement you mentioned with the guidelines sounds like a good read though, looking forward to it.

Speaking of trauma guidelines:  does anyone have a good clinical practice guidelines/protocols guide to share/recommend?  Especially if you're away from a tertiary care centre.  I'm using the Vancouver Coastal Health (2005) one which is great, but very dependent on having specialist referral (eg ENT, Neurosurg) and CT on-site.  (Eg the Blunt Neck Vascular Injury algorithm:  blunt force trauma -> (head injury c/ GCS <13, LeFort #, basal skull #, C-spine body #, major thoracic injury) -> CTA C-spine -> neurosurg +/- vascular consult.  But where I am I can't even get past the first box!)


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## RatCatcher

There is a good article in regards to Malaria prophylaxis in the Dec issue, written by the CF Entomolgist. I got the article sent to me... don't know if it is on line.


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## MedCorps

For some reason I did not get a Dec issue... I suspect it is because Dec is normally the Winter AMSUS Newsletter... Nov was volume 172, issue 11 and Jan was volume 173, issue 1...  The article you have form the CF Ento might be a pre-release copy.  I have found from the time I submit something for publication to the time it gets published is about 6 months (or a little longer).  

In this issue, was dental heavy.  Lots and lots of stuff on military dental issues.  One article of note from the Major Groves of the CFDS (he is/was the Director Dental Svcs Pol & Programs) was on Dental Fitness Classification in the Canadian Forces. Nice to see a CFHS'er publish in such a well respected international journal. 

One other short read of general interest was: The Impact of Retained Third Molars on the Deployed Airman.  It turns out 22% of all deployed dental problems in this study were from people who still had "wisdom" teeth. 

We will see what is next month...

Enjoy, 

MC


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## RatCatcher

Malaria Risk Assessment and Preventive Recommendations - A New Approach for the Canadian Military 
pp. 1250-1253(4) 
Authors: Schofield, Steve; Tepper, Martin; Tuck, Jeremy J. H. 

It's in the 12 Dec Issue...


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## Blackadder1916

MedCorps said:
			
		

> For some reason I did not get a Dec issue... I suspect it is because Dec is normally the Winter AMSUS Newsletter... Nov was volume 172, issue 11 and Jan was volume 173, issue 1...  The article you have form the CF Ento might be a pre-release copy.  I have found from the time I submit something for publication to the time it gets published is about 6 months (or a little longer).



AMSUS Journal Abstracts
December 2007, Vol 172, No 12



> Three-Step Emergency Cricothyroidotomy
> Allan MacIntyre, DO; Mark K. Markarian, MD; Dale Carrison, DO; Jay Coates, DO; Deborah Kuhls, MD; John J. Fildes, MD
> 
> Objective: Surgical cricothyroidotomy is the airway of choice in combat. It is too dangerous for combat medics to perform orotracheal intubation, because of the time needed to complete the procedure and the light signature from the intubation equipment, which provides an easy target for the enemy. The purpose of this article was to provide a modified approach for obtaining a surgical airway in complete darkness, with night-vision goggles. Methods: At our desert surgical skills training location at Nellis Air Force Base (Las Vegas, Nevada), Air Force para-rescue personnel received training in this technique using human cadavers. This training was provided during the fall and winter months of 2003-2006. Results: Through trial and error, we developed a "quick and easy" method of obtaining a surgical airway in complete darkness, using three steps. The steps involve the traditional skin and cricothyroid membrane incisions but add the use of an elastic bougie as a guide for endotracheal tube placement. We have discovered that the bougie not only provides an excellent guide for tube placement but also eliminates the use of additional equipment, such as tracheal hooks or dilators. Furthermore, the bevel of the endotracheal tube displaces the cricothyroid membrane laterally, which allows placement of larger tubes and yields a better tracheal seal. Conclusions: Combat medics can perform the three-step surgical cricothyroidotomy quickly and efficiently in complete darkness. An elastic bougie is required to place a larger endotracheal tube. No additional surgical equipment is needed.





> Malaria Risk Assessment and Preventive Recommendations: A New Approach for the Canadian Military
> Steve Schofield, PhD; Martin Tepper, MD; Col Jeremy J. H. Tuck, L/RAMC
> 
> Western militaries deploying to international locations are often confronted with the threat of malaria. For the Canadian military, the consequent response has been prescriptive- any risk of malaria warrants use of personal protective measures and chemoprophylaxis. In reality, however, malaria risk is highly variable and a one-size-fits-all strategy to mitigation may not be appropriate. In line with this, the Canadian military has revised its approach to malaria risk assessment and preventive response. More effort is now spent on predictive modeling and, where risk is deemed to be low, chemoprophylaxis may not be recommended. We describe here an application of the revised methodology to the recent Canadian military deployment to Kandahar province, Afghanistan.


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## MedCorps

Hmm... not sure why I did not get it.  Thanks for letting me know what I missed.  Need to make a phone call. 

I spoke with Steve Schofield about the article, a very good piece of work... we are very lucky to have him working for the CFHS.  

Cheers, 

MC


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## RatCatcher

We are lucky to have both him and Dr. Tepper. Although I still have a headache from staring into the microscope to type mosquitos....


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## PMedMoe

RatCatcher said:
			
		

> Although I still have a headache from staring into the microscope to type mosquitos....



What, you can't identify a female Anopheles without the microscope?    Just look for the black bands on the fore wings.  It's pretty obvious.  The sand flies were fun, though!


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## MedCorps

Interesting reads from the last issue of Military Medicine (Jan 2008. Vol. 173, Iss. 1).

Complications Associated with Prolonged Tourniquet Application on the Battlefield

Developing a Brucellosis Public Health Information and Awareness Campaign in Iraq

Management of Ectopic Pregnancy in the Military during Deployment to Southwest Asia

Standing By, Ready to Serve: The Case for Forensic Nurses in Uniform

Description of Risk and Resilience Factors among Military Medical Personnel before Deployment to Iraq

Enjoy, 

MC


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## Blackadder1916

MedCorps said:
			
		

> Interesting reads from the last issue of Military Medicine (Jan 2008. Vol. 173, Iss. 1).



A few interesting ones, I would add these to your list.

AMSUS Journal (Military Medicine) Abstracts  _(the link to the journal abstracts will open to the current issue only, no archive)_


> *Prediction of Simulated Battlefield Physical Performance from Field-Expedient Tests*
> Everett A. Harman, PhD; David J. Gutekunst, MS; Peter N. Frykman, MS; Marilyn A. Sharp, MS; Bradley C. Nindl, PhD; Joseph A. Alemany, BS; Robert P. Mello, MS
> 
> Predictive models of battlefield physical performance can benefit the military. To develop models, 32 physically trained men (mean ± SD: 28.0 ± 4.7 years, 82.1 ± 11.3 kg, 176.3 ± 7.5 cm) underwent (1) anthropometric measures: height and body mass; (2) fitness tests: push-ups, sit-ups, 3.2-km run, vertical jump, horizontal jump; (3) simulated battlefield physical performance in fighting load: five 30-m sprints prone to prone, 400-m run, obstacle course, and casualty recovery. *Although greater body mass was positively associated with better casualty recovery performance, it showed trends toward poorer performance on all the other fitness and military performance tests.* Regression equations well predicted the simulated battlefield performance from the anthropometric measures and physical fitness tests (r = 0.77-0.82). The vertical jump entered all four prediction equations and the horizontal jump entered one of them. The equations, using input from easy to administer tests, effectively predict simulated battlefield physical performance.





> *Complications Associated with Prolonged Tourniquet Application on the Battlefield*
> Lior Dayan, MD MSc; Chaim Zinmann, MD; Shalom Stahl, MD; Doron Norman, MD
> 
> The use of a tourniquet to control bleeding is a necessity in both surgical and prehospital settings. Tourniquet application, if performed properly, can be a lifesaving procedure, particularly in a traumatic setting such as the battlefield. A tourniquet is easily applied and requires the use of a relatively uncomplicated piece of equipment. However, improper or prolonged placement of a tourniquet because of poor medical training can lead to serious injuries, such as nerve paralysis and limb ischemia. Here we present five case reports of improper tourniquet applications on the battlefield that resulted in nerve damage. We conclude that there is a need for improved training among medical personnel in the use of tourniquets, as well as a need for an adjustable-pressure, commercial-type sphygmomanometer cuff with a large surface area that is appropriate for application to all limbs parts. We also recommend that, in cases requiring the use of a tourniquet, the caregiver remove the tourniquet every 2 hours and assess the bleeding; if the bleeding has stopped, then the tourniquet should be replaced with a pressure bandage to minimize tissue damage.





> *Effects of Commonly Used Topical Antimicrobial Agents on Acinetobacter baumannii: An In Vitro Study*
> Stephen C. Davis, BS; Franco Pisanni, BS; Ramon B. Montero, MS
> 
> Acinetobacter baumannii has recently emerged as an important pathogen among wounded soldiers in Iraq. Because of its ability to develop resistance to antimicrobial agents, wound infections with A. baumannii are difficult to treat and can lead to septicemia and even death. Use of appropriate topical antimicrobial agents in these circumstances could be one of the first steps in the prevention of A. baumannii wound infections. In this study, we present the in vitro effects of seven common topical antimicrobial creams and dressings on A. baumannii. A. baumannii was subjected to sensitivity tests with mupirocin, silver sulfadiazine, mafenide acetate, a double-antibiotic combination of polymyxin and bacitracin, a triple-antibiotic combination of neomycin, bacitracin, and polymyxin, and two silver-containing dressings. Zones of inhibition were measured after 24 hours of incubation. Of the evaluated antimicrobial agents, mafenide acetate was the most efficacious, followed by mupirocin and triple- and double-antibiotic combinations (in decreasing order). The silver-containing dressings yielded smaller zones of inhibition, compared to the previously mentioned agents, and no zone of inhibition was observed with silver sulfadiazine. Further in vivo studies on the effects of antimicrobial agents against A. baumannii are necessary to substantiate these findings and to determine the potential clinical relevance of these therapies.


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## PMedMoe

MedCorps said:
			
		

> Management of Ectopic Pregnancy in the Military during Deployment to Southwest Asia



Pregnancy?  On deployment?  So much for the non-frat rule.


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## MedCorps

I seldom get too excited by in vitro studies.... I will wait for the in vivo study.  

Cheers, 

MC


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## MedCorps

The lastest and greatest stuff worth reading from Military Medicine Vol.173, Iss.2... 

Infectious Diseases Investment Decision Evaluation Algorithm: A Quantitative Algorithm for Prioritization of Naturally Occurring Infectious Disease Threats to the U.S. Military  (this is neat stuff, but geeky as hell)

Should Asthmatics be enlisted? (If nothing else because it seems to be a topic here on army.ca)

The Emerging Role of Preventive Medicine in Health Diplomacy after the 2005 Earthquake in Pakistan

The Challenge of Controlling Lead and Silica Exposures from Firing Ranges in a Special Operations Force

Quick reads... 

Enjoy 

MC


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## david_wright

MedCorps said:
			
		

> Should Asthmatics be enlisted? (If nothing else because it seems to be a topic here on army.ca)



They are now allowed to enlist in the Australian Defence Force. I don't have the actual details in front of me, but the entry restrictions have been lifted slightly.


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## RatCatcher

Wow... I can't wait to see this article...



> The Emerging Role of Preventive Medicine in Health Diplomacy after the 2005 Earthquake in Pakistan


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## Blackadder1916

April 2008, Vol 173, No 4



> *A Survey of Deployed Foot Problems in a Desert Environment*
> Col John S. Cramer, USAF MC SFS; 1st Lt Kelly Forrest, NC NYANG
> 
> A casual comment made regarding the amount of "mole skin" being dispensed to airmen to handle blisters, pressure points, and foot pain led to the development of an impromptu voluntary survey in an attempt to quantify the number of personnel with foot care concerns and the spectrum of those problems. With only a small number of sick call visits related to foot and ankle problems, the amount of mole skin being dispensed was surprising. This survey represents the results of a comprehensive evaluation of a base population involved in support of the first 2 months of Operation Iraqi Freedom.  (Something to do with inproperly fitting footwear, maybe?  Justification, perhaps, for a footwear allowance or greater selection of authorized boots?)
> 
> *Seasonal Variations in Injury Rates in U.S. Army Ordnance Training*
> Sarah B. Jones, MPH; Joseph J. Knapik, ScD; Bruce H. Jones, MD
> 
> Objectives: This study assessed the effects of seasons and temperature on injury rates during U.S. Army ordnance advanced individual training. Methods: Injury data were collected each week at two clinics serving two geographically separated military training units. Weekly injury rates were calculated as the number of injured soldiers in each battalion (numerator) divided by the total number of soldiers in each battalion (denominator). A two-way analysis of variance examined weekly injury rates according to training unit and season of the year. Correlations between injury rates and average maximal temperatures were also examined. Results: Analysis of variance indicated significant differences in injury rates according to training unit (p = 0.04) and season (p < 0.01) but no significant interaction between unit and season (p = 0.16). Injury rates in the summer were higher than injury rates in the winter or autumn. Coefficients for correlations between weekly injury rates and weekly average maximal temperatures were 0.71 and 0.88 for the two training units. Conclusions: These data support previous work in U.S. Army basic combat training indicating a seasonal effect on injury rates. Higher environmental temperatures were associated with higher injury rates.
> 
> *Retention of Mild Asthmatics in the Navy (REMAIN): A Low-Risk Approach to Giving Mild Asthmatics an Opportunity for Military Service*
> MAJ Amy M. Millikan, MC USA; COL David W. Niebuhr, MC USA; Mary Brundage, MSc; Timothy E. Powers, MSc; COL Margot R. Krauss, MC USA (Ret.)
> 
> Objective: Rising U.S. asthma prevalence will be reflected in military applicants. We studied retaining mild asthmatics on active duty. Methods: A cohort study at Great Lakes Naval Training Center from 2000 to 2002 compared recruits diagnosed during basic training with mild asthma to matched comparison recruits on outpatient visits, hospitalizations, and discharge through August 2003. Results: A total of 136 asthmatic and 404 control subjects were enrolled. Overall attrition was greater among the asthma cohort (p < 0.01), largely during training. Asthmatics used more health care than controls during training (0.1 vs. 0.004 per person-month). No asthma-related hospitalizations or deaths occurred during the study. Conclusions: Although attrition during recruit training was higher in mild asthmatics, nearly 40% of recruits were retained on active duty without significant risk of hospitalization or excessive outpatient treatment after recruit training. These findings argue for consideration of a trial on active duty for recruits with mild asthma.  (As has been noted before, asthma is recurring topic, especially by those seeking to join)
> 
> *An Outbreak of Tuberculosis in a Bacillus Calmette-Guérin-Vaccinated Military Population*
> Jung-Chung Lin, MD PhD; Te-Yu Lin, MD; Wann-Cherng Perng, MD; Chang-Shang Mai, MD; Yeong-Hwang Chen, MD; Chih-Hung Ku, PhD; Feng-Yee Chang, MD PhD
> 
> The purpose of this study was to investigate an outbreak of tuberculosis (TB) in a bacillus Calmette-Guérin-vaccinated military population and propose an appropriate method of control. We divided 593 subjects into "close contacts" and "non-close contacts" of an index case and examined all subjects by chest X-radiography (CXR). For "close contacts," we performed several tests for patients with abnormal CXRs. "Non-close contacts" had no pulmonary infiltration and no evidence of TB. We administered tuberculin skin tests (TST) to 21 "close contacts" who had pulmonary infiltrations. Seven patients had a TST >= 18 mm, two of whom had active pulmonary TB. We administered antituberculous agents to all seven patients for 6 months. Fourteen subjects with TSTs < 18 mm had no evidence of TB during the 18-month follow-up period. Among the other 178 "close contact" subjects with no infiltrations evident on the initial CXR, one patient developed TB pleuritis. We conclude that it is important to use early treatment for "close contacts" of a TB index case by performing the TST and testing for pulmonary infiltration on CXRs.  (Maybe of interest due to potential for increased contact with foreign populations having an increased incidence of TB infection, however the number of BCG vaccinated CF members is probably a lot less than in the past.  Nflders, Quebecers and CF members posted to the North no longer get BCG vaccine.)
> 
> *Important Military Role for Medical Expulsion Therapy of Urolithiasis*
> LCDR Sean P. Stroup, MC USN; CDR Brian K. Auge, MC USN
> 
> Kidney stones are a major problem affecting military personnel and may lead to decreases in individual and unit readiness. Various medications, including steroids, calcium channel blockers, and |ga-adrenergic antagonists have been shown to aid in the spontaneous passage of ureteral calculi. Several recent randomized clinical trials have shown that selective |ga blockers improve stone passage rates. Although medical expulsion therapy has been the subject of a number of urologic investigations, to date there has been very little written about the acute medical management of urinary stones in the emergency medicine and primary care literature. Medical management of ureteral stones may offer forward-deployed forces a useful adjunct for the management of ureterolithiasis thereby greatly reducing the need for potentially hazardous evacuations out of theater. (Kidney stones is another of those topics that occasionally pops up from disappointed potential recruits)
> 
> *When the Envelope Pushes Back: A Combat Aviator Experiences Barotrauma after Descending with an Ear Block*
> LT Jason L. Henry, MC (FS) USN
> 
> While deployed to a war zone, an aviator displayed poor aeromedical judgment and flew with an upper respiratory infection and an ear block. This resulted in a tympanic membrane perforation and the medical grounding of the member for 10 days. The discussion involves the probable mechanism of injury and the requirements of the Naval Aerospace Medical Institute regarding perforations, as well as the reasoning behind the flight surgeon's choice of treatment.


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## MedCorps

Hmm... I guess I forgot the Mar 2008 edition; Vol.173, Iss.3.

It was a good month (that I am just getting around to reading).

Interesting articles included: 

Diagnostic Pelvic Computed Tomography in the Rectal-Injured Combat Casualty

Emergency Contraception Knowledge, Attitudes, Practices, and Barriers among Providers at a Military Treatment Facility

Helicopter Mishap Attributed to Single Seizure

Injury and Illness Casualty Distributions among U.S. Army and Marine Corps Personnel during Operation Iraqi Freedom

Intensive Coping Skills Training to Reduce Anxiety and Depression for Forward-Deployed Troops

Operation Aftershock: The U.S. Military Disaster Response to the Yogyakarta Earthquake May through June 2006

Risk Factors for Training Injuries among British Army Recruits

Reported Stress and Its Relationship to Tobacco Use among U.S. Military Personnel

Screening Tests Detect Knee Pain and Predict Discharge from Military Service

Sleep Disturbance during Military Deployment

What Procedural Skills Do Deployed US Navy Family Physicians Need?

Lots of good stuff. 

Enjoy, 

MC


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## MedCorps

I fell behind on my reading... 

May 2008 edition; Vol.173, Iss.5 - Stuff worth reading:

The Finnish Forward Surgical Team: Lessons from the European Union Forces Operation République Démocratique du Congo

Training and Equipping the Iraqi Army in Preventive Medicine: Part 2 - Overcoming Unexpected Challenges

June 2008 edition; Vol.173, Iss.6 - Stuff worth reading:

Field-Improvised War Surgery in Kosovo: Use of Kitchen Utensils as Surgical Instruments

The Use of Psychological Decompression in Military Operational Environments

Enjoy, 

MC


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## MedCorps

July 2008, Vol 173, No 7

IMHO material of interest... 

Acupuncture: A Useful Tool for Health Care in an Operational Medicine Environment

Comparison of Operation Iraqi Freedom and Patient Workload Generator Injury Distributions

Current and Future Cooling Technologies Used in Preventing Heat Illness and Improving Work Capacity for Battlefield Soldiers: Review of the Literature

Inhalational Diesel Exhaust Exposure in Submariners: Observational Study

Later Life Disability Status following Incarceration as a Prisoner of War

Surgical Management of Traumatic Strabismus after Combat-Related Injury

Suspected Pulmonary Tuberculosis Exposure at a Remote U.S. Army Camp in Northeastern Afghanistan, 2007

Enjoy, 

MC


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## Blackadder1916

August 2008, Vol 173, No 8      (some abstracts redacted to keep within size limit of post)

*Evidence of Greater Health Care Needs among Older Veterans of the Vietnam War*
LTC Matthew S. Brooks, MC USA; Sarah B. Laditka, PhD; James N. Laditka, PhD DA
This study examined self-rated health, impairments in activities of daily living, and treatment for eight health conditions among Vietnam War-era veterans, comparing those who served in Vietnam with those who served elsewhere. . . .  Among those ≥60 years of age, those who served in Vietnam had poorer self-rated health, higher cancer risk (odds ratio, 1.33; 95% confidence interval, 1.32-1.35), and more treatment for hypertension, lung conditions, stroke, and hearing loss. Results suggest greater resource use among older veterans who served in Vietnam. Clinicians and the Department of Veterans Affairs should especially note their substantially higher cancer risk.

*Suicide among Discharged Psychiatric Inpatients in the Department of Veterans Affairs*
Rani A. Desai, PhD; David Dausey, PhD; Robert A. Rosenheck, MD
Objective: The objective of this study was to explore correlates of the use of firearms to commit suicide.  . . .  Conclusions: Gun ownership rates, legislation, and levels of community cohesiveness are significantly associated with the likelihood of psychiatric patients committing suicide with a gun.

*The Financial Impact of Deployments on Reserve Health Care Providers*
MAJ Bruno Petinaux, MC USAR
This study retrospectively surveyed the financial impact of deployments on 17 U.S. Army Reserve health care providers. Due to multiple mobilizations, 29 separate deployments were reported. The deployments, mostly between 2001 and 2005, typically lasted 3 months during which 86% reported no civilian income and 76% reported no civilian benefits. Solo practice providers reported the greatest financial losses due to continuing financial responsibility related to their civilian practice despite being deployed. Overall, 2 deployments did not change, 9 increased, and 16 decreased the medical officer's income. Two were not reported. In this small retrospective convenience sample study, solo practice U.S. Army Reserve health care providers were found to be at highest risk of financial losses during military deployments. This being said, no price can be put on the privilege of serving our men and women in uniform.

*Mass Casualty in an Isolated Environment: Medical Response to a Submarine Collision*
CDR Christopher John Jankosky, MC USN
On January 8, 2005, the U.S.S. SAN FRANCISCO (SSN 711), a nuclear-powered submarine, collided with a seamount in a remote Pacific Ocean location. The high-speed impact resulted in injuries to 90% of the crew. Subsequent emergency medical response is described as well as the 3-month physical and psychological morbidity. Recommendations for medical training, equipment, and policy for workers in isolated environments are discussed.

*Physical Fitness Influences Stress Reactions to Extreme Military Training*<L2;&-2Q
LT Marcus K. Taylor, MSC USN; Amanda E. Markham, MPH; Jared P. Reis, PhD; Genieleah A. Padilla, BA; CDR Eric G. Potterat, MSC USN; Sean P. A. Drummond, PhD; Lilianne R. Mujica-Parodi, PhD
Background: Physical fitness and physical conditioning have long been valued by the military for their roles in enhancing mission-specific performance and reducing risk of injury in the warfighter. It is not known whether physical fitness plays a causal role in attenuating acute military stress reactions or the evolution of post-traumatic stress disorder. Objective: The objective of this study was to determine whether physical fitness influences the impact of stressful events during military survival training in 31 men. Methods: Participants self-reported their most recent Physical Readiness Test scores and completed a trait anxiety measure before survival training. Participants also completed the Impact of Events Scale (IES) 24 hours after training. Results: Aerobic fitness was inversely associated with the total IES score (p < 0.01, adjusted R2 = 0.19). When adjusted for trait anxiety, this relationship was substantially attenuated and no longer significant (p = 0.11). Trait anxiety was inversely associated with aerobic fitness (p < 0.05) and positively related to IES (p < 0.001). Conclusions: Physical fitness may buffer stress symptoms secondary to extreme military stress and its effects may be mediated via fitness-related attenuations in trait anxiety.

*Thermodynamic and Logistic Considerations for Treatment of Hypothermia*
Billy S. Gill, MD; Charles S. Cox, Jr., MD
Hypothermia increases mortality rates and should be treated aggressively in the forward echelons of care, but no practical solution exists to accomplish such treatment. The enormous energy burden for this task requires maximal thermodynamic efficiency for a practical portable solution. This review article presents an overview of the clinical and thermodynamic challenges related to the development of a successful system for treatment of hypothermia in the forward echelons. Specific issues addressed include (1) the clinical and logistical reasons why thermal resuscitation should be attempted at all in such a difficult environment, (2) the thermodynamic reasons why warm intravenous fluids, although helpful in not worsening hypothermia, cannot safely transmit enough energy to treat established hypothermia, (3) which among the various methods of rewarming are most likely to result in successful therapy, and (4) the energetic considerations that dictate that any practical portable solution to the treatment of hypothermia must use hydrocarbon combustion as the source of heat.

*Operation Sadbhavana: Winning Hearts and Minds in the Ladakh Himalayan Region*
LT COL Mudera P. Cariappa, Indian Army Medical Corps; Col Eugene V. Bonventre, USAF MC; MAJ GEN Bikash K. Mohanti, AVSM (Ret.)
"Sadbhavana" literally means "goodwill among people." The Indian Army has evolved a military strategy of winning hearts and minds, with this being just a phase in the broader war on terror. We have focused on actions to address the border regions of Ladakh in the Himalayas. The government of India strives against difficult conditions to provide essential services (including health care) to its population in an equitable manner; in remote areas with fragile security and hamstrung provincial government systems, the Indian Army fills this role. The Army's medical units have played a pivotal role in providing comprehensive health care as a keystone of the strategy. The endeavors of the doctors in uniform have succeeded in winning over an alienated population. A total of 163 medical camps were held in 2004, with attendance of 14,050 patients seeking medical attention and 264 patients seeking dental attention; in 2005, 87 camps were conducted, with attendance totals of 7,562 and 559, respectively. The Operation Sadbhavana military strategy has paid rich dividends in the form of changes in the perspective of the denizens of the remote and exotic locales of Ladakh. Planners must carefully analyze the target audiences and the messages delivered to those audiences at the onset of such projects. Future efforts would be enhanced by attempts to quantify the effects of medical missions on the health of the population and on population attitudes toward the Indian Army and the central government.

*Urinary and Serum Metal Levels as Indicators of Embedded Tungsten Alloy Fragments*
John F. Kalinich, PhD; Vernieda B. Vergara, BS; Christy A. Emond, BS
Novel metal formulations are being used with increasing frequency on the modern battlefield. In many cases the health effects of these materials are not known, especially when they are embedded as fragments. Imaging techniques, although useful for determining location, provide no information regarding the composition of embedded fragments. In this report, we show that laboratory rats implanted with weapons-grade tungsten alloy (tungsten, nickel, and cobalt) pellets demonstrate significant increases in both urinary and serum levels of tungsten, nickel, and cobalt, which indicates that such measurements can provide information on the composition of embedded fragments. We also propose that, in addition to the requirements promulgated by the recent directive on analysis of metal fragments removed from Department of Defense personnel (Health Affairs policy 07-029), urine and blood/serum samples should be collected from personnel and analyzed for metal content. Such measurements could yield information on the composition of retained fragments and provide the basis for further treatment options.

*Self-Assessment of Trauma Competencies among Army Family Nurse Practitioners*
MAJ Brad E. Franklin, ANC USA; MAJ Kate V. Carr, ANC USA; Diane L. Padden, PhD
The objective of this descriptive study was to determine whether Army family nurse practitioners perceive themselves as competent in providing trauma care. Using an adaptation of trauma competency outcomes from various trauma courses, all Army family nurse practitioners were asked to evaluate self-perceived level of trauma competence and self-perceived importance of trauma skills. Results (n = 96) indicate a general agreement that all skills identified in the questionnaire were important in the management of a trauma patient. The respondents considered themselves trained/somewhat competent or higher in 50% of the skills identified. Mann-Whitney U analysis was used to compare various groups within the sample. Significant differences on self-perceived competency were noted with intensive care/emergency room, Advanced Trauma Life Support, and deployment experience. Trauma Nursing Core Course experience was not significant to self-perceived trauma competency. Findings support the need for additional trauma training, such as Advanced Trauma Life Support and hands-on trauma experience.

*Morning Report in Military Family Medicine Residencies*
CPT Erin Drifmeyer, MC USA; MAJ Robert Oh, MC USA
Morning report is a standard component of residency training; however, little is written about this conference in family medicine. We emailed a survey to all 17 military family medicine residency directors. Descriptive statistics were used to calculate means and SDs. Twelve of 17 programs responded. All conducted morning report and all agreed that the main purpose of morning report is education. Its educational value ranked highly (mean, 4.2; SD = 0.78; with 1 = minimal educational value and 5 = very important educational value). Programs reported morning report being held four to five times a week (66%) for 30 minutes (92%) and using preprepared cases (75%) half the time or more. Most (75%) reported having no written goals and objectives; 77% did not track educational outcomes. Although military residencies appear to regard morning report as an important educational venue, most do not have goals or objectives nor formally evaluate effectiveness.

*Increasing Incidence and Severity of Coccidioidomycosis at a Naval Air Station*


*A Limited Measles Outbreak in U.S.-Born Children Living in a Military Community in Germany after Vaccine Refusal and Other Vaccination Delays*


*Dietary Intake of Pilots in the Israeli Air Force*
Aliza H. Stark, PhD; Neta Weis, BSc; Leah Chapnik, BSc; Erez Barenboim, MD; Ram Reifen, MD
The purpose of this study was to evaluate the dietary intake of pilots in the Israeli Air Force and to determine whether reported consumption met the Military Dietary Reference Intakes. Thirty-one pilots completed a 24-hour dietary recall and physical activity questionnaire. Blood parameter values were collected from medical records. Results showed that energy-adjusted sample mean intakes of nutrients met the military recommendations with the exceptions of dietary fiber (53% of the recommended level) and calcium (84% of the recommended level). Macronutrient distribution of energy was 17% from protein, 47% from carbohydrate, and 36% from fat. Although saturated fat consumption was not more than 10% of energy, cholesterol consumption was well above the 300 mg/d presently recommended. For all pilots, blood parameter values were in the normal range. Overall, the diet of Israeli pilots was found to be well balanced, but negative dietary patterns (i.e., high cholesterol intake and low fiber intake) characteristic of the general population were observed in this group.

*Establishment of the Royal Norwegian Navy Personnel Cohorts for Cancer Incidence and Mortality Studies*

*Battery Life of the "Four-Hour" Lithium Ion Battery of the LTV-1000 under Varying Workloads*

*Dermatomycosis, Hyperhydrosis, and Mechanical Injury to Skin of the Feet in Croatian Soldiers during War in Croatia 1991-1992*
Darko Biljan, MD PhD; Roman Pavic, MD PhD; Mirna Situm, MD PhD
During the War in Croatia from 1991 to 1992, we conducted an epidemiological study of the most frequent skin changes on the feet of 1,702 Croatian soldiers stationed in trenches and exposed to direct war activities. We saw significant increases in dermatomycosis, hyperhydrosis, and mechanical injury to the skin of the feet. Soldiers involved in this study did not have any specific medications or powders available as standard gear to prevent any of these foot diseases, but upon physical examination they received treatment. We can conclude that, in war situations, conditions are sufficient to cause an increased number of dermatomycosis, hyperhydrosis and chronic mechanical injuries of the foot. This study suggests the need for planned prevention to avoid these foot diseases in combat situations.

*Simultaneous Revascularization and Coverage of a Complex Volar Hand Blast Injury: Case Report Using a Contralateral Radial Forearm Flow-through Flap*
Navanjun S. Grewal, MD; LCDR Anand R. Kumar, MC USN; SSgt Christina K. Onsgard, USAF WF; CDR Bruce J. Taylor, MC USN
War wounds have created a unique reconstructive challenge for successful functional limb salvage. Various injury patterns related to improvised explosive devices (IEDs) occur and proper reconstruction goes a long way in reducing subsequent disfigurement and morbidity. One case in which a contralateral radial forearm flow-through flap is used for simultaneous revascularization and coverage of an IED hand blast injury is described. The advantages of this flap was its consistent arterial anatomy and long vascular pedicle. The thin skin paddle was used for soft tissue coverage of flexor tendon repair, median and ulnar nerve reconstruction, and metacarpal bone open reduction and internal fixation (ORIF). Recovery of motor function was satisfactory.

*A Case of Malignant Hyperthermia in a Child Encountered during a Humanitarian Assistance Mission to the Philippines*
CDR David Plurad, MC USN; CAPT Gregory Blaschke, MC USN; CDR Shari Jones, NC USN; Capt James Pfeiffer, USAF NC
Potentially fatal operating room events have become largely preventable with advances in anesthesia and surgical technique. Nonetheless, some lethal emergencies remain unpredictable and can occur whenever general anesthesia is given. We describe a case of malignant hyperthermia encountered and treated during surgical operations concurrent with an overseas humanitarian assistance mission. This case highlights the clinical diversity of malignant hyperthemia as well as the importance of preparation for any potential adverse event wherever trigger agents may be used from the mundane to exotic locales.

*Brugada Syndrome in an Active Duty Air Force Senior Pilot*
CAPT Dennis D. Walker, USAF MC; LT COL Monica L. Johnson, USAF MC; MAJ Robert W. Craig-Gray, USAF MC; MAJ Frank Loyd, USAFR MC
Introduction: Brugada syndrome describes a subgroup of patients at risk for polymorphic ventricular tachycardia, ventricular fibrillation, and sudden cardiac death and is likely underdiagnosed among aviators. Case Report: A 40-year-old male pilot presented to the clinic for his physical. He denied any symptoms on initial questioning. Subsequent electrocardiogram (ECG) revealed premature ventricular couplets with ST-segment elevation in V1 and V2 of the precordial leads with T-wave abnormalities. Discussion: Special care must be taken if ECG demonstrates a Brugada pattern—especially in patients with a history of syncope or a family history of sudden death. Recent studies have confirmed a significant risk reduction in symptomatic patients with type 1 Brugada to as low as 0.8% to 3% with an implantable cardioverter defibrillator. Conclusion: Symptomatic patients displaying type 1 Brugada ECG (spontaneous or after sodium channel blockade) should receive an implantable cardioverter defibrillator and must be permanently disqualified. The Aeromedical Consultation Service should review all cases of Brugada syndrome and render a return to fly for asymptomatic nondiagnostic Brugada types.

*Atypical Presentation of a Retrorectal Ancient Schwannoma: A Case Report and Review of the Literature*


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## Blackadder1916

September 2008, Vol 173, No 9    (some abstracts redacted to keep within size limit of post)

*Metabolic Demands of Body Armor on Physical Performance in Simulated Conditions*
COL Richard Ricciardi, NC USA; Patricia A. Deuster, PhD MPH; Col Laura A. Talbot, NC USAFR (Ret.)

The purpose of this study was to examine physical work performance, energy cost, and physiological fatigue in military personnel during simulated operational conditions. Using a within-subject, repeated-measures design, 34 military personnel volunteered to undergo two experimental conditions: with body armor (BA+) and without BA (BA-). Subjects walked on a treadmill for 30 minutes and completed a physical performance battery during each of two sessions, which were separated by >=5 days. Subjects with BA+ as compared with BA- had significantly greater increases in: oxygen uptake (VO2) at slow (16.8 ± 1.5 vs. 18.8 ± 1.7 mL · kg-1 · min-1) and moderate paces (34.8 ± 3.9 vs. 40.8 ± 5.0 mL · kg-1 · min-1); blood lactate at a moderate pace (4.0 ± 2.4 vs. 6.7 ± 2.6 mmol/L); heart rate at slow (107 ± 14 vs. 118 ± 16 beats per minute) and moderate paces (164 ± 16 vs. 180 ± 13 beats per minute); and ratings of perceived physical exertion at slow (8.4 ± 1.5 vs. 10.4 ± 1.8 ) and moderate paces (14.3 ± 2.3 vs. 16.7 ± 2.1). Physical tasks were significantly affected by BA: under BA+, men performed 61% fewer pull-ups and women's hang time was reduced by 63%; stair stepping was reduced by 16% for both men and women. BA significantly impacted the physical work capacity of militarily relevant tasks. Specifically, wearing BA significantly increased VO2 when walking at both slow and moderate paces. The potential for physical exhaustion is high and performance of physical tasks is markedly impaired when wearing BA.
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*U.S. Army Disease and Nonbattle Injury Model, Refined in Afghanistan and Iraq*
Barbara E. Wojcik, PhD; Rebecca J. Humphrey, MA; Bogdan Czejdo, PhD; L. Harrison Hassell, MD

Previous analysis of Operation Desert Shield/Operation Desert Storm data yielded a disease and nonbattle injury (DNBI) model using distinct 95th percentile daily admission rates during the three phases of a war-fighting operation to predict medical requirements. This study refines the model with data from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Inpatient health care records of U.S. Army soldiers deployed to OEF and OIF who were admitted with DNBI diagnoses were analyzed. DNBI admission rates for OEF and OIF were compared with rates for Operation Desert Shield/Operation Desert Storm. DNBI admission rates for OEF and OIF were lower than those for Operation Desert Shield/Operation Desert Storm. Rates among the phases of OIF were distinctly different. DNBI admission rates have been reduced during recent deployments. The concepts of the original model based on Operation Desert Shield/Operation Desert Storm data were validated by experiences during OEF and OIF. Continuous surveillance of DNBI admission rates is recommended.
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*Reference Data from the Automated Neuropsychological Assessment Metrics for Use in Traumatic Brain Injury in an Active Duty Military Sample*
Andrea S. Vincent, PhD; Joseph Bleiberg, PhD; Sam Yan, MS; Brian Ivins, MPS; CDR Dennis L. Reeves, MSC USN (Ret.); Karen Schwab, PhD; Kirby Gilliland, PhD; Robert Schlegel, PhD; Deborah Warden, MD

The current study examined the performance of active duty soldiers on the Automated Neuropsychological Assessment Metrics (ANAM) traumatic brain injury test battery, to expand the reference data for use in military settings. The effects of age and gender on cognitive performance also were explored. The ANAM traumatic brain injury battery, consisting of six performance tests and two subjective scales, was administered to a sample of healthy active duty soldiers (N = 5,247) as part of a concussion surveillance program. Performance means and SDs, stratified according to age and gender, are reported as reference data. In addition, the impact of age and gender on performance measures was analyzed. Because ANAM is rapidly being adopted for use in many military medical and research applications, the establishment of these reference values is invaluable, particularly for assisting with rapid accurate evaluation and treatment in clinical settings.
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*Acceptability of Adverse Childhood Experiences Questions for Health Surveillance in U.S. Armed Forces*
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*Establishing and Maintaining a Volunteer Victim Advocate Program to Assist Victims of Domestic Violence in the U.S. Army*
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*Characteristics of Domestic Violence Incidents Reported at the Scene by Volunteer Victim Advocates*
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*Referrals for Alcohol Use Problems in an Overseas Military Environment: Description of the Client Population and Reasons for Referral*
LT Adeline L. Ong, MSC USN; CDR Antony R. Joseph, MSC USN

Being stationed in an overseas installation has been associated with increased risk for alcohol use problems. Okinawa is a unique overseas environment that often challenges service members with separation from family and friends, limited resources and recreational activities, a high rate of deployment, and restrictive local laws. Single, young, male services members in the junior ranks are at increased risk for poor coping, particularly relying on alcohol use. Maladaptive alcohol use places them at increased risk for engaging in illegal behavior and other negative consequences that subsequently lead them to be referred for an evaluation for alcohol use problems. Alcohol use problems negatively affect health, safety, morale, and mission readiness. Findings from this study strongly suggest that prevention and wellness programs should target young service members in the junior ranks for training on responsible alcohol use, alcohol use problems, and basic coping for improved impact on health and mission readiness.
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*The Relation between Good Communication Skills on the Part of the Physician and Patient Satisfaction in a Military Setting*
Ohad Hochman, MD; Baruch Itzhak, MD; David Mankuta, MD; Shlomo Vinker, MD

Objective: The objective of this study was to assess the correlation between patients' view of the consultation and the assessment of an auditing physician on the same consultation. Methods: A prospective study in military clinics was conducted. A board-certified family physician made a real-time semistructured assessment of the medical consultation. At the end of it, the patient was asked to fill in the Consultation Satisfaction Questionnaire. The degree of correlation between patients' satisfaction from consultation and the scores given by the auditing physician was evaluated. Results: Twelve primary care physicians were evaluated. A total of 117 (76.5%) of 153 patients returned their questionnaires. A positive correlation was found between physician's communication skills and general satisfaction (r = 0.614), professional care (r = 0.367), and depth of relationship (r = 0.275) calculated from the Consultation Satisfaction Questionnaire. No correlation was found between patient satisfaction and other consultation skills. Conclusions: Good communication skills may enhance patient satisfaction. It may be advisable to investigate whether a training program to enhance the physician's communication skills can improve patient satisfaction.
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*Evaluation of Dermatologic Conditions by Primary Care Providers in Deployed Military Settings*
Maj Jason G. Arnold, USAF MC; Maj Michael D. Michener, USAF MC

Dermatologic illnesses have historically been a significant source of morbidity and resource utilization in fielded military forces. The impact of cutaneous diseases during U.S. military conflicts is reviewed, and recent data from Craig Joint Theater Hospital at Bagram Air Field in Afghanistan are presented, confirming previous experience. A discussion of the difficulties of diagnosing and treating dermatologic conditions for deployed primary care providers is provided, including recommendations to improve patient care and military unit readiness.
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*Changes in Maximum Muscle Strength and Rapid Muscle Force Characteristics after Long-Term Special Support and Reconnaissance Missions: A Preliminary Report*
Captain Peter A. Christensen, Special Operations Forces; Ole Jacobsen, MD; Jonas B. Thorlund, MSc; Thomas Madsen, MSc; Carsten Møller, WO1; Claus Jensen, WO1; Charlotte Suetta, MD PhD; Per Aagaard, PhD

Purpose: The purpose of the present study was to examine the impact of 8 days of immobilization during a Special Support and Reconnaissance mission (SSR) on muscle mass, contraction dynamics, maximum jump height/power, and body composition. Methods: Unilateral maximal voluntary contraction, rate of force development, and maximal jump height were tested to assess muscle strength/power along with whole-body impedance analysis before and after SSR. Results: Body weight, fat-free mass, and total body water decreased (4–5%) after SSR, along with impairments in maximal jump height (-8%) and knee extensor maximal voluntary contraction (-10%). Furthermore, rate of force development was severely affected (-15–30%). Conclusions: Eight days of immobilization during a covert SSR mission by Special Forces soldiers led to substantial decrements in maximal muscle force and especially in rapid muscle force capacity. This may negatively influence the ability for rapid exfiltration and redeployment, respectively.
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*Federally Employed Physician Assistants*
Roderick S. Hooker, PhD PA

The federal government is the largest single employer of clinically active physician assistants (PAs) in the United States, with >3,000 PAs in 2008. PAs are present within the Departments of Defense, Veterans Affairs, Health and Human Services, Justice, and Homeland Security. Most are civil servants or hold a commission in the uniformed services. Most employing agencies have expanding needs for PAs. This overview presents a framework of how PAs are being used and the critical roles they play in the federal health care system. Because civilian job opportunities for PAs are plentiful, the federal system is seeking strategies for recruitment and retention. A centralized plan may be one useful recommendation.
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*Health Indicators in Children from Meulaboh, Indonesia, following the Tsunami of December 26, 2004*
Jean-Baptiste Meynard, MD PhD; Antoine Nau, MD; Edouard Halbert, MD; Alain Todesco, MD MPH

The French Army medical service carried out an epidemiological survey to estimate health indicators in children living in Meulaboh, Indonesia, in the weeks following the tsunami of December 26, 2004, within a sample from refugee camps, schools, and quarters of the town. Thirty-four percent of the children in camps, 21.9% in schools, and 49.5% from quarters presented psychological trauma. Malnutrition affected 20.5% in camps and 34.4% in the town between 6 and 59 months, 11.3% in camps, and 7.6% in schools between 6 and 15 years. The children had suffered various symptoms since the tsunami; access to care was possible for 53.9% in the camps, 23.8% from schools, and 39.3% from the town. Those results have been subsequently used by the local health authorities to improve child health care. The method used for this survey could be applied for future disaster scenarios.
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*Military and Leisure-Time Noise Exposure and Hearing Thresholds of Finnish Conscripts*
Jaana Jokitulppo, MSc; Lt Col Markku Toivonen, Finnish Defence Forces (Med.); Rauno Pääkkönen, PhD; Col Seppo Savolainen, Finnish Defence Forces (Ret.); Erkki Björk, PhD; CAPT Kyösti Lehtomäki, Finnish Defence Forces (Navy)

This study presents an evaluation of the total cumulative noise exposure of Finnish conscripts (N = 416) during military service. All of the conscripts underwent a hearing screening and filled out a noise exposure questionnaire at the beginning and end of their military service. Eighty-nine percent of the conscripts were exposed weekly to military noise of over 85 dBA during the service. Eighteen percent of the conscripts had already reached at the end of their military service a cumulative noise dose corresponding to noise exposure of 85 dB for 40 years. During military service, permanent hearing loss of >20 dB in the frequency range of 0.5 to 8 kHz increased from 19 to 27% among the conscripts.
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*Distribution of Ametropia among Military Beneficiaries*
Lt Col Randall S. Collins, USAF BSC; Gregory E. Berg, PhD

In addition to active duty military members and their dependents, retired military members and the members of their immediate families are eligible for eye care in military medical treatment facilities. We recorded refractive errors, age, sex, and race for 4,595 individual beneficiaries visiting optometry clinics at two U.S. Air Force medical treatment facilities during 2005 to 2006. Evaluation revealed most patients requiring optical correction were myopic, or near-sighted, and there was an increase in the degree of myopia between ages 4 and 23. That trend is reversed at age 30 and, by age 60, most patients are hyperopic, or far-sighted. Both trends were true for both sexes and all ethnicities studied. The degree of astigmatism was distributed similarly between races and age groups. Presbyopia occurred at similar ages and progressed at similar rates in all ethnicities and both sexes.
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*ON-Q Anesthetic Pump in Gynecologic Oncology: Feasibility Study of a Novel Placement Technique at an Army Hospital*

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*Interlaminar Discectomy in Lumbar Disc Herniation: Shorten Postoperative Return to Work Period in Recruits Undergoing Military Training*
Lieutenant Haydar Celik, Turkish Armed Forces; Lieutenant Alihan Derincek, Turkish Armed Forces; Major Atilla Arslanoglu, Turkish Armed Forces

The operative treatment of lumbar disc disease has long challenged spine surgeons. In this study, we aimed to show that recruits with lumbar disc herniation managed by the interlaminar approach could return to work after 6 weeks. Forty male recruits were included in this study and interlaminar discectomy was adequate in 40 cases. Early postoperative rehabilitation had a positive effect on early return to work. We believe that interlaminar lumbar discectomy is an effective technique for treating patients with herniated lumbar discs; with early postoperative rehabilitation, recruits can return to work 6 weeks after surgery.
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*Successful Treatment of Vancomycin-Resistant Enterococcal Ventriculitis in a Pediatric Patient with Linezolid*

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*Polyp Inside the Concha Bullosa: Unusual Manifestation of Chronic Rhinosinusitis*


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## Blackadder1916

October 2008, Vol 173, No 10       (some abstracts redacted to keep within size limit of post)

*RESPECT-Mil: Feasibility of a Systems-Level Collaborative Care Approach to Depression and Post-Traumatic Stress Disorder in Military Primary Care*
COL Charles C. Engel, MC USA; Thomas Oxman, MD; MAJ Christopher Yamamoto, MC USA; MAJ Darin Gould, MC USA; Sheila Barry, BA; Patrice Stewart, PhD; COL Kurt Kroenke, MC USA (Ret.); John W. Williams, Jr., MD; Allen J. Dietrich, MD

Background: U.S. military ground forces report high rates of war-related traumatic stressors, post-traumatic stress disorder (PTSD), and depression following deployment in support of recent armed conflicts in Iraq and Afghanistan. Affected service members do not receive needed mental health services in most cases, and they frequently report stigma and significant structural barriers to mental health services. Improvements in primary care may help address these issues, and evidence supports the effectiveness of a systems-level collaborative care approach. Objective: To test the feasibility of systems-level collaborative care for PTSD and depression in military primary care. We named our collaborative care model "Re-Engineering Systems of Primary Care for PTSD and Depression in the Military" (RESPECT-Mil). Methods: Key elements of RESPECT-Mil care include universal primary care screening for PTSD and depression, brief standardized primary care diagnostic assessment for those who screen positive, and use of a nurse "care facilitator" to ensure continuity of care for those with unmet depression and PTSD treatment needs. The care facilitator assists primary care providers with follow-up, symptom monitoring, and treatment adjustment and enhances the primary care interface with specialty mental health services. We report assessments of feasibility of RESPECT-Mil implementation in a busy primary care clinic supporting Army units undergoing frequent Iraq, Afghanistan, and other deployments. Results: Thirty primary care providers (family physicians, physician assistants, and nurse practitioners) were trained in the model and in the care of depression and PTSD. The clinic screened 4,159 primary care active duty patient visits: 404 screens (9.7%) were positive for depression, PTSD, or both. Sixty-nine patients participated in collaborative care for 6 weeks or longer, and the majority of these patients experienced clinically important improvement in PTSD and depression. Even although RESPECT-Mil participation was voluntary for providers, only one refused participation. No serious adverse events were noted. Conclusions: Collaborative care is an evidence-based approach to improving the quality of primary care treatment of anxiety and depression. Our version of collaborative care for PTSD and depression, RESPECT-Mil, is feasible, safe, and acceptable to military primary care providers and patients, and participating patients frequently showed clinical improvements. Efforts to implement and evaluate collaborative care approaches for mental disorders in populations at high risk for psychiatric complications of military service are warranted.
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*Immunization against Haemophilus influenzae Type B Fails to Prevent Orbital and Facial Cellulitis: Results of a 25-Year Study among Military Children*
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*The Retrospective Prevalence of Community-Acquired Methicillin-Resistant Staphylococcus aureus in Soft Tissue Abscesses at Two Military Level I Trauma Centers*
MAJ Gary W. Dufresne, MC USA; Ryan D. Wells, MD; James A. Pfaff, MD

Study objective: Many studies have shown that community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) is a very prevalent organism. However, no data have been published to date with regard to CAMRSA prevalence in patients presenting to the emergency department (ED) of a military medical facility. Our objective is to estimate the period prevalence of CAMRSA in cases of soft tissue abscesses seen in the emergency departments of two major military hospitals. Methods: A retrospective review of electronic records was performed from January 1, 2004 to August 10, 2005. This database was used to identify patients with the diagnosis of abscess, the procedure code for incision and drainage, and culture of wound. After data were accumulated, standard prevalence calculations were applied to determine prevalence of CAMRSA in abscesses at our emergency departments. Antibiotic susceptibilities were then evaluated with regard to the CAMRSA bacteria. Results: The prevalence at our two emergency departments was 68% (751 abscesses, 220 cultured, 155 methicillin-resistant S. aureus (MRSA)-positive cultures). The prevalence at Brooke Army Medical Center and Wilford Hall Medical Center emergency departments was 70% (520 abscesses, 145 cultured, and 101 MRSA positive) and 65% (231 abscesses, 75 cultured, and 49 MRSA positive), respectively. Conclusion: The occurrence of CAMRSA is not isolated to the civilian population. The prevalence of CAMRSA in this population is significant, and may pose serious operational and deployment-related ramifications requiring the attention of military medical planners as well as forward medical care providers. The probability of CAMRSA infection should be considered when treating soft tissue abscesses in the military emergency department.
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*Outbreak of SandFly Fever in Central Iraq, September 2007*
MAJ Shannon B. Ellis, MC USA; LTC George Appenzeller, MC USA; LTC Heechoon Lee, MC USA; CPT Keri Mullen, MC USA; CPT Ricardo Swenness, SP USA; LCDR Guillermo Pimentel, MSC USN; Emad Mohareb, PhD; MAJ Christopher Warner, MC USA

An outbreak of nonspecific febrile illnesses occurred among U.S. Army troops in September 2007 at a remote, newly established, rural-situated patrol base, south of Baghdad, Iraq. Soldiers displayed an acute flu-like syndrome with symptoms of fever, headache, malaise, and myalgia. A total of 14 cases was identified and treated presumptively as query fever. Subsequent convalescent serum specimens confirmed 13 (92.9%) positive for sandfly Sicilian virus and 3 (21.4%) positive for Coxiella burnetii, with two positive for both. One sandfly Sicilian virus case tested positive for Brucella spp. This outbreak emphasizes the potential for multiple simultaneous disease exposures to endemic diseases in nonindigenous military personnel at remote military locations in Iraq. Recommendations include increased theater disease surveillance, medical training, and vector control.
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*Did You Just Ask If I Would Lead a Humanitarian Mission?*
Lt Col Stephanie M. Schaefer, USAF MC

This article is intended to help guide personnel chosen to lead military humanitarian missions. Suggestions for various stages of mission planning and execution are provided.
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*Military Community: A Privileged Site for Clinical Research: Epidemiological Study of Metabolic Syndrome Risk Factors in the Military Environment*
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*Ethics Training for Military Medical Trainees: The Brooke Army Medical Center Experience*
COL Kenneth R. Kemp, MC USA; LTC Jennifer C. Thompson, MC USA; COL Thomas Jefferson, MC USA; CPT Bruce Ong, MC USA; CPT Christine D. Sharkey, MC USA; MAJ Joseph Jeffries, CH USA; CPT Lara Nuñez, MC USA

Biomedical ethics training during graduate medical education programs is required by the Accreditation Council for Graduate Medical Education. Apart from this requirement, medical ethics education is an integral component of military medical practice. Although ethics education and training are required, tools to assess the effectiveness of ethics education are not well developed. Furthermore, although biomedical ethics education is mandated for new Army physician trainees, there has not been a systematic objective assessment of the effectiveness of that training. We report the concept underlying the design and implementation of a military biomedical ethics seminar for new Army physician trainees. Combining a didactic component and case analysis through small-group discussions, we emphasized providing tools to analyze ethical dilemmas both in the medical center environment and in the operational medicine environment. A total of 47 Army interns participated in the seminar. Eighty-nine percent of participants agreed or strongly agreed that the ethics orientation met expectations. Seventy-two percent agreed or strongly agreed that the information presented would affect their practice. Ninety-six percent thought that the small-group discussions were effective, and 80% thought that the presentations enhanced knowledge from medical school.
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*Supporting the Creation of New Institutional Review Boards in Developing Countries: The U.S. Naval Medical Research Center Detachment Experience*
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*Military Family Physician Attitudes toward Treating Obesity*
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*Advance and Retreat: Tobacco Control Policy in the U.S. Military*
Sarah R. Arvey, PhD; Ruth E. Malone, PhD

This archival study explored why military tobacco control initiatives have thus far largely failed to meet their goals. We analyzed more than 5,000 previously undisclosed internal tobacco industry documents made public via an online database and additional documents obtained from the U.S. military. In four case studies, we illustrate how pressures exerted by multiple political actors resulted in weakening or rescinding military tobacco control policy initiatives. Our findings suggest that lowering military smoking rates will require health policymakers to better anticipate and counter political opponents. The findings also suggest that effective tobacco control policies may require strong, explicit implementation instructions and high-level Department of Defense support. Finally, policy designers should also consider ways to reduce or eliminate existing perverse incentives to increase tobacco consumption, such as allowing exchange store tobacco sales to fund Morale, Recreation, and Welfare Programs.
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*Efficacy of the U.S. Army Policy on Hearing Conservation Programs*
Riedar K. Oestenstad, PhD; Melissa W. Norman, DrPH; Thomas E. Borton, PhD

Changes in U.S. Army hearing conservation policy require that many previous non-noise hazardous areas be reclassified as noise hazardous and that employees in these areas be included in hearing conservation programs. The purpose of this study was to determine if a group of employees affected by this policy suffered occupational hearing loss between 1987 and 2001 while working in previously classified noise hazardous areas. The 45 subjects included in the study were demographically similar to the 211 from which they were selected. Differences between measured and predicted hearing thresholds in 1987 and in 2001 did not change significantly over the 15 years. Predicted noise-induced thresholds in 2001 calculated from average noise exposures were not clinically significant. It was concluded that these subjects were adequately protected from hearing loss under the previous classification criteria and application of the new criteria provided no additional benefit.
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*The Effects of an Accelerated Triage and Treatment Protocol on Left Without Being Seen Rates and Wait Times of Urgent Patients at a Military Emergency Department*
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*Pitfalls in Aeromedical and Ground Crew Engagement: Lessons Learned*
Dagan Schwartz, MD; Meir T. Marmor, MD; Alex Geftler, MD; Erez Barenboim, MD

Aeromedical (AM) evacuation of trauma victims from action is an integral part of trauma care. The Israeli Air Force Rescue and Evacuation Unit is responsible for nearly all AM evacuations in Israel. We present three recent cases, within 1 year of operation, of engagement process failure during evacuations performed by the Rescue and Evacuation Unit. We then discuss possible pitfalls and lessons learned. In sum, we reveal that successful AM and ground crew engagement can save lives, as long as the engagement process is as short and efficient as possible.
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*Orthopedic Injuries in U.S. Casualties Treated on a Hospital Ship during Operation Iraqi Freedom*
CDR Jerome G. Enad, MC USN; CDR Jeff D. Headrick, MC USN (Ret.)

From March to May 2003, the USNS Comfort was deployed to the Persian Gulf in support of combat operations for Operation Iraqi Freedom. The onboard orthopedic service treated 58 U.S. casualties during that period. Eighty-seven percent of the injuries were to the appendicular skeleton. Twenty-four percent were battle injuries, and 72% were nonbattle injuries. Patients with battle injuries tended to be younger and required more orthopedic operations than did patients with nonbattle injuries. Moreover, all patients with battle injuries were evacuated to higher echelons for further care, whereas 19% of patients with nonbattle injuries returned to duty in the short term. Complications were few, with no infections, amputations, or deaths. A descriptive review of the types of injuries, orthopedic care, and eventual disposition is presented.
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*Army Dental Officer Retention*
LTC Jeffrey G. Chaffin, DC USA; COL Priscilla H. Hamilton, DC USA; MG Russell J. Czerw, DC USA

Objective: The objective of this article was to identify major factors associated with the retention of Army dentists. Methods: Customized survey instruments were designed. The 2006 survey was e-mailed to all Army Dental Corps captains and majors and the 2007 survey to all lieutenant colonels and colonels. Responses were returned by e-mail, fax, or traditional mail. Results: Response rates were 42% for the 2006 survey and 76% for the 2007 survey. More than one-half (53%) of junior officers responded as being highly unlikely or unlikely to remain on active duty, although the majority of senior officers reported being likely or very likely to remain in the Army until retirement. The results indicated that pay is a major driver for retention, because 72% of junior officers cited increases in bonuses as the first or second most important retention item. Sixty-nine percent of junior officers thought that a bonus of $30,000 to $40,000 per year would be influential in retention. Pay was important to senior officers, but quality of practice, quality of life, and less frequent moves were rated higher than pay. All respondents felt that both senior and local leaders were aware of the retention issues but only 41% of junior officers, compared with 75% of senior officers, felt that action was being taken to address the issues. Conclusions: Retention of Army Dental Corps officers is multifactorial in nature. Pay is a major retention factor, but retention initiatives need to be broader in scope.
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*Development and Testing of a Novel Forward-Deployable Dental Dressing*
David G. Charlton, DDS; Amer Tiba, PhD; CAPT James C. Ragain, Jr., DC USN

The purpose of this study was to measure select properties of four temporary filling materials suitable for use in treating minor dental emergencies in the field. Specimens were made of each of the following four materials: intermediate restorative material, Fuji IX GP Fast, Ketac-Molar Quick, and the forward-deployable dental dressing recently developed by the Naval Institute for Dental and Biomedical Research. Twenty-fours hours after specimen fabrication, five properties (hardness, compressive strength, diametral tensile strength, flexural strength, and flexural modulus) were measured for each of the materials and compared using analysis of variance and Tukey-Kramer tests to determine whether significant differences existed among the materials (α = 0.05). Data analysis revealed that significant differences existed among the products for all of the properties tested. The forward-deployable dental dressing's properties compared favorable with and, in many cases exceeded those of intermediate restorative material, Fuji IX GP Fast, and Ketac-Molar Aplicap Quick.
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*Comparison of Flexural Strength between Fiber-Reinforced Polymer and High-Impact Strength Resin*
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*Estimated Mental Health and Analysis of Relative Factors for New Chinese Recruits*
Jin Yan, MD, PhD; Li-Jie Wang, MD; Qi Cheng, MD; Dan-Min Miao, MD, PhD; Li-Yi Zhang, MD; Shui-Ping Yuan, MD; Ting An, MD; Yu Pan, MD

Objective: The primary aim of the present study was to quantitatively assess and analyze influential psychosocial factors in the mental health of new military recruits. Methods: A total of 2,734 army recruits were evaluated by using the Symptom Checklist-90 (SCL-90) and Trait Meta-Mood Scale. Results: In general, the army recruits were found to be in a good state of mental health. The SCL-90 scores of the new recruits were significantly higher than those of the normal civilian population (p < 0.01). The new recruits were similar to the normal army population, with notable exceptions in the following three scales: obsessive-compulsive, depression, and anxiety (p < 0.01 or p < 0.05). Factors that significantly influenced the SCL-90 scores included childhood environment, education level, and parental relationship. Results from the current study also revealed negative associations between the SCL-90 global severity index and the Trait Meta-Mood Scale subscale scores (p < 0.01). Conclusion: The mental health status of army recruits is closely related to their childhood environment, education level, parental relationship, and emotional intelligence. These factors should be considered by mental health workers, to help new army recruits adapt to the new environment.
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*Adaptation and Quality of Life among Long-Term Cervical Cancer Survivors in the Military Health Care System*
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*Rhabdomyolysis Associated with Bupropion Use as a Smoking Cessation Adjunct: Review of the Literature*
LT Anis Miladi, MC USN
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*A 31-Year-Old Army Specialist Presenting with Acute Oligoarthritis*
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*Two Successful Vaginal Births after Cesarean Section in a Patient with Hermansky-Pudlak Syndrome Who Was Treated with 1-Deamino-8-Arginine-Vasopression during Labor*


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## Blackadder1916

December 2008, Vol 173, No 12 

*Efficacy of a Cognitive-Behavioral Program to Improve Psychological Adjustment among Soldiers in Recruit Training*
LTCOL Andrew Cohn, Australian Army; Ken Pakenham, PhD
This study evaluated the efficacy of a brief cognitive-behavioral program in modifying causal attributions, expectancy of control, coping strategies, and psychological adjustment in a sample of Australian Army soldiers undergoing a 45-day recruit training program. Participants (N = 174) were randomly allocated within platoons to a treatment group (N = 101) or control group (N = 73). Data were collected before and after the intervention and 23 days later, at the end of training. Compared with the control group, those who received the intervention reported more temporary and specific attributions, less reliance on self-blame coping, greater positive states of mind, and lower psychological distress at the end of training.

*Post-Traumatic Stress Reactions before the Advent of Post-Traumatic Stress Disorder: Potential Effects on the Lives and Legacies of Alexander the Great, Captain James Cook, Emily Dickinson, and Florence Nightingale*
Philip A. Mackowiak, MD MBA MACP; Sonja V. Batten, PhD
Evidence is presented that Alexander the Great, Captain James Cook, Emily Dickinson, and Florence Nightingale each developed symptoms consistent with post-traumatic stress disorder in the aftermath of repeated potentially traumatizing events of differing character. Their case histories also varied with respect to background, premorbid personality style, risk factors, clinical presentation, and course of the illness, illustrating the pleomorphic character of the disorder, as well as the special problems in diagnosing it in historical figures.

*Evaluating Active Duty Risk-Taking: Military Home, Education, Activity, Drugs, Sex, Suicide, and Safety Method*
LTC Jeffrey W. Hutchinson, MC USA; LTC Jeffery P. Greene, MC USA; Capt Shana L. Hansen, USAF MC
Psychosocial screening tools are routinely used by adolescent medicine providers to evaluate risk-taking behaviors and resiliency. A large number of U.S. military service members are adolescents, and many engage in behaviors that cause morbidity and death, such as tobacco use and binge drinking. Health care providers should consider the regular use of a psychosocial screening method to evaluate risk-taking behavior. The Home, Education, Activity, Drugs, Sex, Suicide, and Safety method is used to evaluate the home environment, educational and employment situations, activities, drug use, sexual activity, suicide, and safety during health care visits. This technique, originally created for a civilian adolescent population, can be used with minimal adjustments to evaluate behaviors of military service members.

*Traumatic Brain Injury Risk While Parachuting: Comparison of the Personnel Armor System for Ground Troops Helmet and the Advanced Combat Helmet*
Brian J. Ivins, MPS; John S. Crowley, MD MPH; COL Jeffrey Johnson, MC USA; Deborah L. Warden, MD; Karen A. Schwab, PhD
Military paratroopers are inherently at risk for a variety of injuries when they jump, including traumatic brain injuries (TBIs). U.S. Army paratroopers rely on their ballistic helmets for protection against TBIs when jumping. Currently, two different helmets are available to Army paratroopers, that is, the personnel armor system for ground troops helmet and the advanced combat helmet. This study compared the incidence of self-reported, jump-related TBIs in a small sample of paratroopers (N = 585) using each type of helmet. Data were obtained from surveys of soldiers at Fort Bragg, North Carolina. The overall relative risk of sustaining a TBI while jumping was 2.3 times (95% confidence interval, 1.3-4.3) higher for personnel armor system for ground troops helmet users. Most of the increase in risk was accounted for by the most-minor TBIs (American Academy of Neurology grade 1 or 2 concussion).

*Changes in Cardiovascular Performance during an 8-Week Military Basic Training Period Combined with Added Endurance or Strength Training*
Matti Santtila, MSc; Häkkinen Keijo, PhD; Karavirta Laura, MSc; Kyröläinen Heikki, PhD
The purpose of the present study was to examine the changes in cardiovascular performance (VO2 max) and maximal strength development during an 8-week basic training (BT) combined with emphasized endurance training (ET) or strength training (ST) among 72 conscripts. The emphasized ST and ET programs combined with BT improved VO2 max by 12.0% (p < 0.01) and 8.5% (p < 0.05), while the increase in the control group (normal training) was 13.4% (p < 0.001). Body fat and waist circumference decreased in all groups. Normal training did not increase maximal strength of leg extensors but both ST (9.1%; p < 0.05) and ET (12.9%; p < 0.01) did. In conclusion, the current BT program including a high amount of endurance training improved cardiovascular performance. However, no further improvements in VO2 max were obtained by added endurance training for three times a week. BT positively influenced body composition but BT alone was not a sufficient stimulus to increase the maximal strength of leg extensors.

*Validation of Lower Limb Surrogates as Injury Assessment Tools in Floor Impacts due to Anti-Vehicular Land Mines*
Cynthia Bir, PhD; Ana Barbir, MS; Frank Dosquet; Marianne Wilhelm, PhD; Marike van der Horst, PhD; Greg Wolfe, MS
The aim of this study was to assess the ability of lower limb surrogates to predict injury due to floor/foot plate impact in military vehicles during anti-vehicular land mine explosions. Testing was conducted using two loading conditions simulated to represent those conditions created in the field. The lower condition was represented by a 24-kg mass impactor with a velocity of 4.7 m/s. The higher loading condition was represented by a 37-kg mass impactor with a velocity of 8.3 m/s. Two biomechanical surrogates were evaluated using the loading conditions: 50th percentile Hybrid III foot/ankle and Test Device for Human Occupant Restraint THOR-Lx. Comparisons of the force-time response were made to established corridors. Results show a better correlation to the corridors with the THOR-Lx; however, future improvements to the THOR-Lx are recommended.

*Orofacial Injuries and Mouth Guard Use in Elite Commando Fighters*
Major Yehuda Zadik, IDF; Liran Levin, DMD
The incidence, etiology, and consequences of orofacial injuries during service were evaluated among active duty elite commando fighters in the Israel Defense Forces. Male fighters (N = 280) were interviewed. Orofacial injuries were reported by 76 (27.1%) participants, with tooth injuries as the most common: 40 (52.6%) suffered from dental fracture and 6 (7.9%) from subluxation/luxation. Overall incidence was 85.5 cases per 1,000 fighter-years. Most injuries occurred in an isolated training or operational field. Overall, 162 participants (57.9%) received a boil-and-bite mouth guard during recruitment, but only 49 (30.2%) used it regularly during training and sport activities. The prevalence of injuries among fighters who reported regular mouth guard use was smaller than among fighters who reported of no regular use (20.4% vs. 28.6%, respectively; p < 0.001). Commando fighters are highly predisposed to dental trauma, resulting in the interference of their continuous daily activity. Military health care professionals and commanders should promote mouth protection devices for high-risk populations.

*Fever, Headache, and Myalgias after Deployment to the Philippines*
LCDR Frederick J. Trayers III, MC USN; John Simon, BM BCh; LCDR Steven P. Praske, MC USN; LCDR Kevi L. Christopher, MC
Classic dengue fever presents with a triad of fever, headache, and rash. A "saddleback" fever pattern, morbilliform rash with islets of sparing after apyrexia, and hematological/hepatic abnormalities are common findings. As the most common arbovirus infection, dengue is a significant health threat to deployed military forces worldwide. Preventive measures such as personal protective equipment and repellants should be employed by individuals and other preventive measures should be considered for units departing endemic areas. Due to the increased risk of severe or hemorrhagic syndromes in the case of reinfection, limiting redeployment of individuals who have been infected by dengue should be considered, and further research is needed in this area. Development of tetravalent or DNA-based vaccines should be a priority to improve health protection for deploying forces.

*Well-Tolerated Chemoprophylaxis Uniformly Prevented Swedish Soldiers from Plasmodium falciparum Malaria in Liberia, 2004-2006*
Håkan Andersson, MD; Helena H. Askling, MD; Björn Falck, MD; Lars Rombo, MD PhD
Background: Between 2004 and 2006, 1,170 Swedish soldiers were deployed to Liberia. They were prescribed mefloquine or atovaquone/proguanil as malaria chemoprophylaxis. Our study aims were to estimate the chemoprophylaxis effectiveness and adverse events. Methods: Cases of malaria were routinely reported during and after the mission. After return to Sweden, the soldiers filled in a questionnaire concerning type of accommodation, use of prophylaxis, and adverse events. Results: No cases of Plasmodium falciparum malaria were recorded during a total of ~7,000 person-months. Adverse events (AE) were reported by 57% in the mefloquine group and 34% in the atovaquone/proguanil group. In the mefloquine group, the soldiers reported more neuropsychological AE. Conclusions: Both drugs were safe and 100% effective as long-term prophylaxis for prevention of P. falciparum malaria. Atovaquone/proguanil was better tolerated with respect to self-reported AE.

*Identification, Evaluation, and Management of Pediatric Obesity in Military Academic and Nonacademic Settings*
LT John Podraza, MC USN; CDR Timothy A. Roberts, MC USN
Objective: The goal was to evaluate the recognition and management of pediatric obesity in an academic military medical treatment facility and an affiliated branch medical clinic.  . . .

*Suspected Child and Spouse Maltreatment Referral Sources: Who Reports Child and Spouse Maltreatment to the Air Force Family Advocacy Program?*
David J. Linkh, PhD; Leasley K. Besetsny, MA; Pamela S. Collins, MSW; Cynthia J. Thomsen, PhD; Mandy M. Rabenhorst, PhD; Alan Rosenbaum, PhD; Joel S. Milner, PhD
The present study describes the sources of Air Force (AF) Family Advocacy Program referrals (N = 42,389) for child and spouse maltreatment between 2000 and 2004.  . . . 

*A Pilot Study: Reports of Benefits from a 6-Month, Multidisciplinary, Shared Medical Appointment Approach for Heart Failure Patients*
LCDR Andrew Lin, MC USN; CDR Jeffrey Cavendish, MC USN (Ret.); CAPT Denise Boren, NC USN (Ret.); LCDR Trish Ofstad, NC USN; LCDR Daniel Seidensticker, MC USN
Heart failure continues to be the leading cause of hospitalization among older adults. Noncompliance with medications, dietary indiscretion, failure to recognize symptoms, and failed social support systems contribute to increased morbidity. Multidisciplinary medical approaches have proven successful for heart failure. In 2004, the Naval Medical Center San Diego started a multidisciplinary shared medical appointment for patients with complicated cases of heart failure.  . . .

*The Relationship of Vitamin D Deficiency to Health Care Costs in Veterans*
Alan N. Peiris, MD PhD MRCP; Beth A. Bailey, PhD; Todd Manning, BA
Vitamin D deficiency is often unrecognized and has been linked to many chronic diseases. Vitamin D supplementation has been shown to ameliorate these chronic diseases and may reduce the prevalence of some cancers. We analyzed the health care costs associated with vitamin D deficiency in Veterans in Northeast Tennessee.  . . . 

*Explaining and Forecasting Attrition in the Army Pharmacy Technician Course*
LTC Larry Fulton, MS USA; LTC William Starnes, MS USA; COL Marc Caouette, MS USA; COL Donna Whittaker, MS USA; Lana Ivanitskaya, PhD
The Army pharmacy technician (68Q) course trains ~260 students per year, with a mean graduation rate of 71.3%. In support of this course, a research team conducted a study using multiple analytical methods to evaluate, to explain, and potentially to forecast failures, because the 28.7% of students who do not graduate are associated with both opportunity and real costs. Results of this study indicated that largely uncontrollable population demographic characteristics, such as rank and enrollment status, along with controllable Armed Services Vocational Aptitude Battery skilled technical test scores, were related to graduation rates. The results of this study may be used to assist individuals at risk of failure or to establish additional admission criteria to increase the likelihood of success.

*A Pilot Study Evaluating Surfactant on Eustachian Tube Function in Divers*
LCDR Christopher Duplessis, USN; David Fothergill, PhD; LT Jeff Gertner, USN; Linda Hughes, MS; Derek Schwaller, BS
Background: Middle ear barotrauma (MEBT) is the most common medical complication in diving, aviation, and hyperbaric medicine. Eustachian tube dysfunction (ETD) quantifies the inability to open the eustachian tube (ET), risking MEBT. Surfactant administration improved ET function and efficaciously treated otitis media in a host of animal models. We performed a pilot study evaluating the efficacy of intranasal surfactant administration in reducing MEBT in repetitive diving. Methods: Eight divers participated in a subject-blinded, placebo-controlled, random order, multiarm (air and O2)-repeated measures trial investigating the relative efficacy of intranasally administered surfactant, acetylcysteine and oxymetazoline, and orally administered pseudoephedrine versus saline-placebo in middle ear equilibration during repetitive, multiday diving. Subjects were tested with the Nine-Step Inflation/Deflation Tympanometry Test (NSI/DT) and sonotubometry (testing eustachian tube opening pressure [ETOP]) before and immediately after each dive. Results: Significant interaction effects were found for drug-by-test (F8,668 = 4.05; p < 0.001) and the three-way interaction of drug-by-dive-by-test (F16, 668 = 2.47; p = 0.001) in sonotubometry testing. The ETOP revealed trends toward lowered (improved) values post- versus predive in all treatment arms, which was significant for oxymetazoline (p = 0.04). Only four of the eight subjects experienced any holds during diving. Statistical analysis of the NSI/DT data showed that none of the drug interventions resulted in improvements in ET function over that expected by chance. Conclusions: There is large intra- and intersubject variability in daily functioning of the ET as measured using the NSI/DT and sonotubomtery (ETOP). Sonotubometry engendered trends toward lowered (improved) values post- versus predive in all treatment arms. The repetitive dives did not result in a significant decrease in ET function as evidenced in the saline-placebo trials, circumventing an ability to detect superiority among the various treatment arms in our subject population. Additionally, since our study was underpowered to detect significant effects, we can only assert that various inhalational agents may improve middle ear ventilation in repetitive diving warranting further study. A larger subject population including subjects diagnosed with ET dysfunction may provide more statistical power to discern the benefit of inhaled agents as a useful prophylactic for preventing or reducing ET dysfunction during diving and/or hyperbaric/hypobaric pressure changes.

*Splenic Syndrome: A Rare Indication for Splenectomy*
Viswanadham Pothula, MD; Emi Saegusa, MD; Daisuke Takekoshi, MD; Theodore Edson, MD; Romeo Ignacio, MD
Splenic infarction due to sickle cell trait and high-altitude stress has been reported in the literature. Contributing factors leading to infarction are degree of altitude stress and status of physical condition. Medical therapy, which consists of evacuation from high altitude, intravenous fluids, supplemental oxygen, and pain control, has been the mainstay of treatment. However, some patients require surgical intervention. We describe six patients with sickle cell trait who sustained splenic infarctions due to high-altitude stress; two of these patients required splenectomy for near-total splenic necrosis and intractable pain. A review of the literature demonstrates that the common indications for splenectomy are splenic rupture, extensive splenic necrosis, or persistent abdominal pain.

*Paralabral Rupture of the Proximal Biceps Tendon from Light Weightlifting*
LT Kyle E. Miller, MC USN; CDR Daniel J. Solomon, MC USN
Rupture of the long head of the biceps is usually seen in older adults, in conjunction with rotator cuff tears or tenosynovitis secondary to chronic subacromial impingement; it is rarely seen as a result of trauma. We present the case of a young active patient who denied prodromal symptoms but ruptured the long head of the biceps brachii tendon (LHB) while performing 25-pound biceps curls. Upon examination, the patient was noted to have a readily apparent biceps defect and decreased strength. He was brought to the operating room, where open subpectoral tenodesis of the LHB was performed. At the 6-week follow-up evaluation, the patient had regained full range of motion. By 6 months, he had regained his previous strength. This case demonstrates an unusual presentation of a LHB rupture in a young healthy man with no prodromal symptoms


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