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1.  Food and drinking water hygiene and intestinal protozoa in deployed German soldiers 
This report analyzes the occurrence of Cryptosporidium spp., E. histolytica, and G. intestinalis in stool of returnees from military deployments and the impact of hygiene precautions. Between 2007 and 2010, stool samples of 830 returnees that were obtained 8–12 weeks after military deployments in Afghanistan, Uzbekistan, the Balkans, Democratic Republic of the Congo/Gabonese Republic, and Sudan and 292 control samples from non-deployed soldiers were analyzed by PCR for Cryptosporidium spp., E. histolytica, G. intestinalis, and the commensal indicator of fecal contamination E. dispar. Data on hygiene precautions were available. The soldiers were questioned regarding gastrointestinal and general symptoms. Among 1122 stool samples, 18 were positive for G. intestinalis, 10 for E. dispar, and no-one for Cryptosporidium spp. and E. histolytica. An increased risk of acquiring chronic parasitic infections in comparison with non-deployed controls was demonstrated only for G. intestinalis in Sudan, where standardized food and drinking water hygiene precautions could not be implemented. Standard food and drinking water hygiene precautions in the context of screened military field camps proved to be highly reliable in preventing food-borne and water-borne chronic infections and colonization by intestinal protozoa, leading to detection proportions similar to those in non-deployed controls.
doi:10.1556/EuJMI.3.2013.1.8
PMCID: PMC3832084  PMID: 24265919
deployment, field camp, food hygiene, water hygiene, parasite, real-time PCR
2.  Posttraumatic Stress Symptoms Among National Guard Soldiers Deployed to Iraq: Associations with Parenting Behaviors and Couple Adjustment 
Objective
This article reports findings from a one-year longitudinal study examining the impact of change in PTSD symptoms following combat deployment on National Guard soldiers’ perceived parenting, and couple adjustment one year following return from Iraq.
Method
Participants were 468 Army National Guard fathers from a Brigade Combat Team (mean age 36 years; median deployment length 16 months; 89% European American, 5% African American, 6% Hispanic American). Participants completed an in-theater survey one month before returning home from OIF deployment (Time 1), and again, one year post-deployment (Time 2). The PTSD Checklist-Military Version (PCL-M; Weathers, Litz, Herman, Huska, & Keane, 1993) was gathered at both times, and two items assessing social support were gathered at baseline only. At Time 2, participants also completed self-report measures of parenting (Alabama Parenting Questionnaire—Short Form; Elgar, Waschbusch, Dadds, & Sigvaldason, 2007), couple adjustment (Dyadic Adjustment Scale-7; Sharpley & Rogers, 1984; Spanier, 1976), parent-child relationship quality (4 items from the Social Adjustment Scale-Self Report; Weissman & Bothwell, 1976), alcohol use (Alcohol Use Disorders Identification Test; Babor, Higgins-Biddle, Saunders, & Monteiro, 2001), and items assessing injuries sustained while deployed.
Results
Structural equation modeling analyses showed that increases in PTSD symptoms were associated with poorer couple adjustment and greater perceived parenting challenges at Time 2 (both at p<.001). Furthermore, PTSD symptoms predicted parenting challenges independent of their impact on couple adjustment.
Conclusions
Findings highlight the importance of investigating and intervening to support parenting and couple adjustment among combat-affected National Guard families.
doi:10.1037/a0020571
PMCID: PMC3073229  PMID: 20873896
parenting; couple adjustment; military personnel; posttraumatic stress symptoms
3.  Occupational Lung Diseases among Soldiers Deployed to Iraq and Afghanistan 
Occupational medicine & health affairs  2013;1:10.4172/2329-6879.1000117.
Military personnel deployed to Iraq and Afghanistan, from 2004 to the present, has served in a setting of unique environmental conditions. Among these are exposures to burning trash in open air “burn pits” lit on fire with jet fuel JP-8. Depending on trash burned--water bottles, styrofoam trays, medical waste, unexploded munitions, and computers--toxins may be released such as dioxins and n-hexane and benzene. Particulate matter air pollution culminates from these fires and fumes. Additional environmental exposures entail sandstorms (Haboob, Shamal, and Sharqi) which differ in direction and relationship to rain. These wars saw the first use of improvised explosive devices (roadside phosphate bombs),as well as vehicle improvised explosive devices (car bombs), which not only potentially aerosolize metals, but also create shock waves to induce lung injury via blast overpressure. Conventional mortar rounds are also used by Al Qaeda in both Iraq and Afghanistan. Outdoor aeroallergens from date palm trees are prevalent in southern Iraq by the Tigris and Euphrates rivers, while indoor aeroallergen aspergillus predominates during the rainy season. High altitude lung disease may also compound the problem, particularly in Kandahar, Afghanistan. Clinically, soldiers may present with new-onset asthma or fixed airway obstruction. Some have constrictive bronchiolitis and vascular remodeling on open lung biopsy - despite having normal spirometry and chest xrays and CT scans of the chest. Others have been found to have titanium and other metals in the lung (rare in nature). Still others have fulminant biopsy-proven sarcoidiosis. We found DNA probe–positive Mycobacterium Avium Complex in lung from a soldier who had pneumonia, while serving near stagnant water and camels and goats outside Abu Gharib. This review highlights potential exposures, clinical syndromes, and the Denver Working Group recommendations on post-deployment health.
doi:10.4172/2329-6879.1000117
PMCID: PMC3891866  PMID: 24443711
Burn pits; Aeroallergenaspergillus; Bronchiolitis; Mycobacterium avium complex
4.  Demographic, Physical, and Mental Health Factors Associated with Deployment of U.S. Army Soldiers to the Persian Gulf 
Military medicine  2000;165(10):762-772.
A total of 675,626 active duty Army soldiers who were known to be at risk for deployment to the Persian Gulf were followed from 1980 through the Persian Gulf War. Hospitalization histories for the entire cohort and Health Risk Appraisal surveys for a subset of 374 soldiers were used to evaluate prewar distress, health, and behaviors. Deployers were less likely to have had any prewar hospitalizations or hospitalization for a condition commonly reported among Gulf War veterans or to report experiences of depression/suicidal ideation. Deployers reported greater satisfaction with life and relationships but displayed greater tendencies toward risk-taking, such as drunk driving, speeding, and failure to wear safety belts. Deployed veterans were more likely to receive hazardous duty pay and to be hospitalized for an injury than nondeployed Gulf War-era veterans. If distress is a predictor of postwar morbidity, it is likely attributable to experiences occurring during or after the war and not related to prewar exposures or health status. Postwar excess injury risk may be explained in part by a propensity for greater risk-taking, which was evident before and persisted throughout the war.
PMCID: PMC2141685  PMID: 11050874
5.  Do soldiers seek more mental health care after deployment? Analysis of mental health consultations in the Netherlands Armed Forces following deployment to Afghanistan 
European Journal of Psychotraumatology  2014;5:10.3402/ejpt.v5.23667.
Background
Military deployment to combat zones puts military personnel to a number of physical and mental challenges that may adversely affect mental health. Until now, few studies have been performed in Europe on mental health utilization after military deployment.
Objective
We compared the incidence of mental health consultations with the Military Mental Health Service (MMHS) of military deployed to Afghanistan to that of non-deployed military personnel.
Method
We assessed utilization of the MMHS by the full cohort of the Netherlands Armed Forces enlisted between 2008 and 2010 through linkage of mental health and human resource information systems.
Results
The total population consisted of 50,508 military (18,233 deployed, 32,275 non-deployed), who accounted for 1,906 new consultations with the MMHS. The follow-up was limited to the first 2 years following deployment. We observed higher mental health care utilization in deployed vs. non-deployed military personnel; hazard ratio (HR), adjusted for sex, military branch and time in service, 1.84 [95% CI 1.61–2.11] in the first and 1.28 [1.09–1.49] in the second year after deployment. An increased risk of adjustment disorders (HR 2.59 [2.02–3.32] and 1.74 [1.30–2.32]) and of anxiety disorders (2.22 [1.52–3.25] and 2.28 [1.50–3.45]) including posttraumatic stress disorder (5.15 [2.55–10.40] and 5.28 [2.42–11.50]), but not of mood disorders (1.33 [0.90–1.97] and 1.11 [0.68–1.82]), was observed in deployed personnel in the first- and second-year post-deployment, respectively. Military personnel deployed in a unit with a higher risk of confrontation with potentially traumatic events had a higher HR (2.13 [1.84–2.47] and 1.40 [1.18–1.67]).
Conclusions
Though absolute risk was low, in the first and second year following deployment to Afghanistan there was an 80 and 30% higher risk for mental health problems resulting in a consultation with the Dutch MMHS compared to military never deployed to Afghanistan. These observations underscore the need for an adequate mental health infrastructure for those returning from deployment.
doi:10.3402/ejpt.v5.23667
PMCID: PMC4138709  PMID: 25206952
Military personnel; deployment; mental disorders; mental health care; service utilization; combat related stress disorders; hazard ratios
6.  Constrictive Bronchiolitis in Soldiers Returning from Iraq and Afghanistan 
The New England Journal of Medicine  2011;365(3):222-230.
Background
In this descriptive case series, 80 soldiers from Fort Campbell, Kentucky, with inhalational exposures during service in Iraq and Afghanistan were evaluated for dyspnea on exertion that prevented them from meeting the U.S. Army's standards for physical fitness.
Methods
The soldiers underwent extensive evaluation of their medical and exposure history, physical examination, pulmonary-function testing, and high-resolution computed tomography (CT). A total of 49 soldiers underwent thoracoscopic lung biopsy after noninvasive evaluation did not provide an explanation for their symptoms. Data on cardiopulmonary-exercise and pulmonary-function testing were compared with data obtained from historical military control subjects.
Results
Among the soldiers who were referred for evaluation, a history of inhalational exposure to a 2003 sulfur-mine fire in Iraq was common but not universal. Of the 49 soldiers who underwent lung biopsy, all biopsy samples were abnormal, with 38 soldiers having changes that were diagnostic of constrictive bronchiolitis. In the remaining 11 soldiers, diagnoses other than constrictive bronchiolitis that could explain the presenting dyspnea were established. All soldiers with constrictive bronchiolitis had normal results on chest radiography, but about one quarter were found to have mosaic air trapping or centrilobular nodules on chest CT. The results of pulmonary-function and cardiopulmonary-exercise testing were generally within normal population limits but were inferior to those of the military control subjects.
Conclusions
In 49 previously healthy soldiers with unexplained exertional dyspnea and diminished exercise tolerance after deployment, an analysis of biopsy samples showed diffuse constrictive bronchiolitis, which was possibly associated with inhalational exposure, in 38 soldiers.
doi:10.1056/NEJMoa1101388
PMCID: PMC3296566  PMID: 21774710
7.  The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
Psychiatry  2014;77(2):107-119.
Importance/Objective
Although the suicide rate in the U.S. Army has traditionally been below age-gender matched civilian rates, it has climbed steadily since the beginning of the Iraq and Afghanistan conflicts and since 2008 has exceeded the demographically matched civilian rate. The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent epidemiological and neurobiological study designed to generate actionable evidence-based recommendations to reduce Army suicides and increase knowledge about risk and resilience factors for suicidality and its psychopathological correlates. This paper presents an overview of the Army STARRS component study designs and of recent findings.
Design/Setting/Participants/Intervention
Army STARRS includes six main component studies: (1) the Historical Administrative Data Study (HADS) of Army and Department of Defense (DoD) administrative data systems (including records of suicidal behaviors) for all soldiers on active duty 2004–2009 aimed at finding administrative record predictors of suicides; (2) retrospective case-control studies of fatal and nonfatal suicidal behaviors (each planned to have n = 150 cases and n = 300 controls); (3) a study of new soldiers (n = 50,765 completed surveys) assessed just before beginning basic combat training (BCT) with self-administered questionnaires (SAQ), neurocognitive tests, and blood samples; (4) a cross-sectional study of approximately 35,000 (completed SAQs) soldiers representative of all other (i.e., exclusive of BCT) active duty soldiers; (5) a pre-post deployment study (with blood samples) of soldiers in brigade combat teams about to deploy to Afghanistan (n = 9,421 completed baseline surveys), with sub-samples assessed again one, three, and nine months after returning from deployment; and (6) a pilot study to follow-up SAQ respondents transitioning to civilian life. Army/DoD administrative data are being linked prospectively to the large-scale survey samples to examine predictors of subsequent suicidality and related mental health outcomes.
Main outcome measures
Measures (self-report and administratively recorded) of suicidal behaviors and their psychopathological correlates.
Results
Component study cooperation rates are comparatively high. Sample biases are relatively small. Inefficiencies introduced into parameter estimates by using nonresponse adjustment weights and time-space clustering are small. Initial findings show that the suicide death rate, which rose over 2004–2009, increased for those deployed, those never deployed, and those previously deployed. Analyses of administrative records show that those deployed or previously deployed were at greater suicide risk. Receiving a waiver to enter the Army was not associated with increased risk. However, being demoted in the past two years was associated with increased risk. Time in current deployment, length of time since return from most recent deployment, total number of deployments, and time interval between most recent deployments (known as dwell time) were not associated with suicide risk. Initial analyses of survey data show that 13.9% of currently active non-deployed regular Army soldiers considered suicide at some point in their lifetime, while 5.3% had made a suicide plan, and 2.4% had attempted suicide. Importantly, 47–60% of these outcomes first occurred prior to enlistment. Prior mental disorders, in particular major depression and intermittent explosive disorder, were the strongest predictors of these self-reported suicidal behaviors. Most onsets of plans-attempts among ideators (58.3–63.3%) occurred within the year of onset of ideation. About 25.1% of non-deployed U.S. Army personnel met 30-day criteria for a DSM-IV anxiety, mood, disruptive behavior, or substance disorder (15.0% an internalizing disorder; 18.4% an externalizing disorder) and 11.1% for multiple disorders. Importantly, three-fourths of these disorders had pre-enlistment onsets.
Conclusions
Integration across component studies creates strengths going well beyond those in conventional applications of the same individual study designs. These design features create a strong methodological foundation from which Army STARRS can pursue its substantive research goals. The early findings reported here illustrate the importance of the study and its approach as a model of studying rare events particularly of national security concern. Continuing analyses of the data will inform suicide prevention for the U.S. Army.
doi:10.1521/psyc.2014.77.2.107
PMCID: PMC4075436  PMID: 24865195
8.  Incidence of recurrent diagnoses of Chlamydia trachomatis genital infections among male and female soldiers of the US army 
Background/objectives: Few studies of Chlamydia trachomatis incidence, especially among men, and most studies of C trachomatis in US military populations are cross sectional prevalence surveys. A population based retrospective cohort was used to determine risk factors for repeat diagnoses of genital C trachomatis infections among male and female soldiers with previous C trachomatis infections.
Methods: All active duty soldiers diagnosed with C trachomatis genital infections between 1994 and 1998. Cohort members were passively followed until repeat diagnoses of C trachomatis infection, termination of army service, or the end of the study.
Results: Among 11 771 soldiers with initial diagnoses of chlamydia, the crude rate of repeat diagnoses was 52.0 per 1000 person years. Women and men aged 20–24 were at greatest unadjusted risk of reinfection. After adjustment, women aged 20–24 and men aged 25–29 were at higher risk than their younger or older counterparts.
Conclusions: Results of this study suggest that both male and female soldiers who are diagnosed with chlamydia infections have relatively high risks of reinfection through their 20s.
Key Words: epidemiology; military personnel; sexually transmitted diseases; United States
doi:10.1136/sti.77.1.33
PMCID: PMC1758309  PMID: 11158689
9.  Sexual Violence and Mental Health Symptoms Among National Guard and Reserve Soldiers 
ABSTRACT
BACKGROUND
Reserve and National Guard (NG) soldiers report disproportionate mental health problems relative to active duty military upon returning from the Iraq and Afghanistan conflicts. However, few studies have examined whether exposure to particular types of traumatic events (e.g., lifetime sexual violence) is associated with this increased burden of psychopathology.
OBJECTIVE
The current study examined the prevalence of lifetime sexual violence exposure as well as the adjusted odds and population attributable fraction of psychopathology associated with sexual violence in a large sample of male and female Reserve and NG soldiers.
DESIGN
Baseline structured telephone interviews were conducted in 2009.
PARTICIPANTS
1,030 Reserve (23 % female) and 973 NG (15 % female) soldiers.
MAIN MEASURES
Four items assessed lifetime and deployment-related sexual violence. Probable lifetime and past-year posttraumatic stress disorder (PTSD) and depression were assessed with the PTSD Checklist and the Patient Health Questionnaire, respectively.
KEY RESULTS
Lifetime sexual violence prevalence was 37.4 % and 27.6 % among Reserve and NG women, and 4.3 % and 3.7 % among Reserve and NG men, respectively. Recent deployment-related sexual violence ranged from 1.4 to 2.6 % for women and 0 % for men. Regression analyses indicated that the adjusted odds of probable past-year and lifetime PTSD and depression were 1.2 to 3.5 times greater among those reporting sexual violence relative to non-victims. The proportion of probable lifetime PTSD and depression attributable to sexual violence was 45.2 % and 16.6 %, respectively, in the Reserves, and 10.3 % and 6.2 %, respectively, in the NG.
CONCLUSIONS
Lifetime sexual violence prevalence was high among female soldiers, with approximately one-third of Reserve and National Guard women reporting a history. The majority of sexual violence was not related to the most recent deployment; however, sexual violence contributed to a high burden of psychopathology. Findings emphasize a need to screen for lifetime sexual violence and associated mental disorders in military samples.
doi:10.1007/s11606-013-2555-5
PMCID: PMC3889956  PMID: 23918158
reserve; national guard; sexual violence; PTSD; depression
10.  Multi-drug resistant Acinetobacter infections in critically injured Canadian forces soldiers 
Background
Military members, injured in Afghanistan or Iraq, have returned home with multi-drug resistant Acinetobacter baumannii infections. The source of these infections is unknown.
Methods
Retrospective study of all Canadian soldiers who were injured in Afghanistan and who required mechanical ventilation from January 1 2006 to September 1 2006. Patients who developed A. baumannii ventilator associated pneumonia (VAP) were identified. All A. baumannii isolates were retrieved for study patients and compared with A. baumannii isolates from environmental sources from the Kandahar military hospital using pulsed-field gel electrophoresis (PFGE).
Results
During the study period, six Canadian Forces (CF) soldiers were injured in Afghanistan, required mechanical ventilation and were repatriated to Canadian hospitals. Four of these patients developed A. baumannii VAP. A. baumannii was also isolated from one environmental source in Kandahar – a ventilator air intake filter. Patient isolates were genetically indistinguishable from each other and from the isolates cultured from the ventilator filter. These isolates were resistant to numerous classes of antimicrobials including the carbapenems.
Conclusion
These results suggest that the source of A. baumannii infection for these four patients was an environmental source in the military field hospital in Kandahar. A causal linkage, however, was not established with the ventilator. This study suggests that infection control efforts and further research should be focused on the military field hospital environment to prevent further multi-drug resistant A. baumannii infections in injured soldiers.
doi:10.1186/1471-2334-7-95
PMCID: PMC1988813  PMID: 17697345
11.  Mood symptoms contribute to working memory decrement in active-duty soldiers being treated for posttraumatic stress disorder 
Brain and Behavior  2012;2(4):357-364.
A significant proportion of military veterans of operations in Afghanistan and Iraq have been diagnosed with posttraumatic stress disorder (PTSD). Growing evidence suggests that neuropsychological deficits are a symptom of PTSD. The current study investigated neurocognitive functioning among soldiers diagnosed with PTSD. Specifically, active-duty soldiers with and without a diagnosis of PTSD were assessed for performance on tests of attention and working memory. In addition, factors such as combat experience, depression, anxiety, PTSD symptom severity, and alcohol consumption were explored as possible mediators of group differences in neurocognitive functioning. Twenty-three active-duty soldiers diagnosed with PTSD were matched with 23 healthy Soldier controls; all were administered the Attention Network Task (ANT), Backward Digit Span (BDS) task, Beck Depression Inventory, Beck Anxiety Inventory, PTSD Checklist—Military Version, Combat Exposure Scale, and Modified Drinking Behavior Questionnaire. Soldiers diagnosed with PTSD performed significantly worse on the working memory task (BDS) than healthy controls, and reported greater levels of PTSD symptoms, combat exposure, depression, and anxiety. However, after controlling for depression and anxiety symptoms, the relationship between PTSD and working memory was no longer present. The results indicate that PTSD is accompanied by deficits in working memory, which appear to be partially attributed to anxiety and depression symptoms.
doi:10.1002/brb3.53
PMCID: PMC3432958  PMID: 22950039
Anxiety; depression; digit span; memory; military; neurocognitive
12.  Comparison of HIV-related vulnerabilities between former child soldiers and children never abducted by the LRA in northern Uganda 
Conflict and Health  2013;7:17.
Background
Thousands of former child soldiers who were abducted during the prolonged conflict in northern Uganda have returned to their home communities. Programmes that facilitate their successful reintegration continue to face a number of challenges. Although there is increasing knowledge of the dynamics of HIV infection during conflict, far less is known about its prevalence and implications for population health in the post-conflict period. This study investigated the effects of abduction on the prevalence of HIV and HIV-risk behaviours among young people in Gulu District, northern Uganda. An understanding of abduction experiences and HIV-risk behaviours is vital to both the development of effective reintegration programming for former child soldiers and the design of appropriate HIV prevention interventions for all young people.
Methods
In 2010, we conducted a cross-sectional study of 2 sub-counties in Gulu District. A demographic and behavioural survey was interview-administered to a purposively selected sample of 384 transit camp residents aged 15–29. Biological specimens were collected for HIV rapid testing in the field and confirmatory laboratory testing. Descriptive statistics were used to describe characteristics of abduction. Additionally, a gender-stratified bivariate analysis compared abductees’ and non-abductees’ HIV risk profiles.
Results
Of the 384 participants, 107 (28%) were former child soldiers (61% were young men and 39% were young women). The median age of participants was 20 and median age at abduction was 13. HIV prevalence was similar among former abductees and non-abductees (12% vs. 13%; p = 0.824), with no differences observed by gender. With respect to differences in HIV vulnerability, our bivariate analysis identified greater risky sexual behaviours in the past year for former abductees than non-abductees, but there were no differences between the two groups’ survival/livelihood activities and food insufficiency experiences, both overall and by gender. The analysis further revealed that young northern Ugandans in general are in desperate need of education, skills development, and support for victims of sexual violence.
Conclusions
This study persuasively demonstrates that all young people in northern Ugandan have been similarly affected by HIV infection during war and displacement. Post-conflict programme planners must therefore abandon rudimentary targeting practices based on abductees as a high-profile category. Instead, they must develop evidence-based HIV interventions that are commensurate with young people’s specific needs. As such programmes will be less stigmatizing, more oriented to self-selection, and more inclusive, they will effectively reach the most vulnerable young people in northern Uganda.
doi:10.1186/1752-1505-7-17
PMCID: PMC3751706  PMID: 23919329
Child soldiers; HIV/AIDS; Post-conflict programming; Young people; Northern Uganda
13.  Genetic Polymorphisms and Drug Susceptibility in Four Isolates of Leishmania tropica Obtained from Canadian Soldiers Returning from Afghanistan 
Background
Cutaneous leishmaniasis (CL) is a vector-borne parasitic disease characterized by the presence of one or more lesions on the skin that usually heal spontaneously after a few months. Most cases of CL worldwide occur in Southwest Asia, Africa and South America, and a number of cases have been reported among troops deployed to Afghanistan. No vaccines are available against this disease, and its treatment relies on chemotherapy. The aim of this study was to characterize parasites isolated from Canadian soldiers at the molecular level and to determine their susceptibility profile against a panel of antileishmanials to identify appropriate therapies.
Methodology/Principal Findings
Parasites were isolated from skin lesions and characterized as Leishmania tropica based on their pulsed field gel electrophoresis profiles and pteridine reductase 1 (PTR1) sequences. Unusually high allelic polymorphisms were observed at several genetic loci for the L. tropica isolates that were characterized. The drug susceptibility profile of intracellular amastigote parasites was determined using an established macrophage assay. All isolates were sensitive to miltefosine, amphotericin B, sodium stibogluconate (Pentostam) and paromomycin, but were not susceptible to fluconazole. Variable levels of susceptibility were observed for the antimalarial agent atovaquone/proguanil (Malarone). Three Canadian soldiers from this study were successfully treated with miltefosine.
Conclusions/Significance
This study shows high heterogeneity between the two L. tropica allelic versions of a gene but despite this, L. tropica isolated from Afghanistan are susceptible to several of the antileishmanial drugs available.
Author Summary
Cutaneous leishmaniasis (CL) is a vector-borne parasitic disease transmitted by the bite of sandflies, resulting in sores on the skin. No vaccines are available, and treatment relies on chemotherapy. CL has been frequently diagnosed in military personnel deployed to Afghanistan and returning from duty. The parasites isolated from Canadian soldiers were characterized by pulsed field gels and by sequencing conserved genes and were identified as Leishmania tropica. In contrast to other Leishmania species, high allelic polymorphisms were observed at several genetic loci for the L. tropica isolates that were characterized. In vitro susceptibility testing in macrophages showed that all isolates, despite their genetic heterogeneity, were sensitive to most antileishmanial drugs (antimonials, miltefosine, amphotericin B, paromomycin) but were insensitive to fluconazole. This study suggests a number of therapeutic regimens for treating cutaneous leishmaniasis caused by L. tropica among patients and soldiers returning from Afghanistan. Canadian soldiers from this study were successfully treated with miltefosine.
doi:10.1371/journal.pntd.0001463
PMCID: PMC3260320  PMID: 22272366
14.  Supplement use by UK-based British Army soldiers in training 
The British Journal of Nutrition  2014;112(7):1175-1184.
The use of supplements is widespread at all levels of civilian sport and a prevalence of 60–90 % is reported among high-performance UK athletes, including juniors. The prevalence of supplement use among UK-based British Army personnel is not known. The aim of the present study was to establish the point prevalence of supplement use in UK-based British Army soldiers under training (SuTs) and associated staff. A cross-sectional anonymous survey was carried out in 3168 British Army SuTs and soldiers, equating to 3·1 % of regular Army strength, based at eleven Phase 1, 2 and 3 UK Army training sites. Overall, 38 % of the respondents reported current use of supplements, but prevalence varied according to the course attended by the respondents. The number of different supplements used was 4·7 (sd 2·9). Supplements most commonly used were protein bars, powders and drinks (66 %), isotonic carbohydrate–electrolyte sports drinks (49 %), creatine (38 %), recovery sports drinks (35 %), multivitamins (31 %) and vitamin C (25 %). A small proportion of respondents reported the use of amphetamines and similar compounds (1·6 %), cocaine (0·8 %), anabolic androgenic steroids (1·1 %), growth hormone (2·0 %), and other anabolic agents, e.g. testosterone (4·2 %). Logistic regression modelling indicated that, for current users, younger age, being female, smoking and undergoing Officer Cadet training were associated with greater supplement use. This is the first study to investigate the prevalence of dietary and training supplement use in UK-based British military personnel. Self-administration of a wide range of supplements is reported by British military personnel in training, which is at least as great as that reported by those on deployment, and has implications for Defence policy and educational needs.
doi:10.1017/S0007114514001597
PMCID: PMC4189117  PMID: 25119518
Supplements; Military; Training; Performance nutrition
15.  Personal values in soldiers after military deployment: associations with mental health and resilience 
European Journal of Psychotraumatology  2014;5:10.3402/ejpt.v5.22939.
Background
After military deployment, soldiers are at an increased risk of developing posttraumatic psychiatric disorders. The correlation of personal values with symptoms, however, has not yet been examined within a military context.
Method
Schwartz’s Portrait Values Questionnaire (PVQ), the Posttraumatic Stress Diagnostic Scale (PDS), and the 11-item version of the Resilience Scale (RS-11) were completed by 117 soldiers of the German Armed Forces who had recently been deployed to Afghanistan (n=40 undergoing initial psychiatric treatment, n=77 untreated).
Results
Logistic regression showed that the value types of hedonism (−), power (−), tradition (+), and universalism (+) were significantly correlated with the probability and severity of PTSD and whether the participant was in treatment or not. The effects were partially mediated by the RS-11 scale values.
Conclusions
Value types seem to be associated with psychiatric symptoms in soldiers after deployment. These results could contribute to the further development of therapeutic approaches.
doi:10.3402/ejpt.v5.22939
PMCID: PMC4012073  PMID: 24808938
Beliefs/values; war; logistic regression; treatment readiness; active duty soldiers
16.  Drinking and Spouse Abuse Among U.S. Army Soldiers 
Background
This study examines the relationship between typical weekly drinking and perpetration of spouse abuse as well as the relationship between the perpetrator’s typical weekly drinking and alcohol use during the abuse event among U.S. Army male soldiers.
Methods
Cases include all active duty, male, enlisted Army spouse abusers identified in the Army’s Central Registry who had also completed an Army Health Risk Appraisal Survey (HRA) between 1991 and 1998 (N = 9534). Cases were matched on sex, rank, and marital status with 21,786 control subjects who had also completed an HRA.
Results
In multivariate logistic regression models, heavy drinkers (22 or more drinks per week) were 66% more likely to be spouse abusers than were abstainers (odds ratio 1.66; 95% confidence interval 1.40–1.96). In addition, self-reported moderate and heavy drinkers were three times as likely and light drinkers (1–7 drinks per week) were twice as likely as nondrinkers to be drinking during the time of the abuse event.
Conclusion
Self-reported heavy drinking is an independent risk factor for perpetration of spouse abuse among male, enlisted Army soldiers. Even 5 years or more after ascertainment of typical drinking habits, there is a significant association between self-reported heavy drinking and alcohol involvement at the time of the spouse abuse event. Personnel who work with perpetrators and victims of spouse abuse should be trained carefully to query about current and typical drinking patterns.
doi:10.1097/01.ALC.0000148102.89841.9B
PMCID: PMC1351131  PMID: 15608606
Spouse Abuse; Violence; Alcohol; Injury; Military
17.  Hospitalizations for fall-related injuries among active-duty Army soldiers, 1980–1998 
Work (Reading, Mass.)  2002;18(2):161-170.
Data from the Total Army Injury and Health Outcomes Database (TAIHOD) were used to describe 28,352 fall-related hospitalizations among active-duty Army soldiers between 1980 and 1998. Soldiers who were younger than age 26, single, and had a high school education or less were at greatest risk. Falls from a height were more likely to be fatal than other types of falls, accounting for 88% of all fatalities. In cases where duty status was known, 64% of the falls took place while the soldier was on duty and half of these occurred during training. The most common type of fall during training was fall from a height (37%). Falls on stairs and ladders accounted for 49% of all off-duty falls. Future research should include identification of specific behavioral and occupational risk factors for falls, particularly those occurring during training activities, and falls occurring off duty.
PMCID: PMC2141687  PMID: 12441580
Accidental falls; Army; injuries and wounds; hospitalizations; database; military; free text
18.  Spouse Abuse and Alcohol Problems Among White, African American, and Hispanic U.S. Army Soldiers 
Background
Prior studies suggest racial/ethnic differences in the associations between alcohol misuse and spouse abuse. Some studies indicate that drinking patterns are a stronger predictor of spouse abuse for African Americans but not whites or Hispanics, while others report that drinking patterns are a stronger predictor for whites than African Americans or Hispanics. This study extends prior work by exploring associations between heavy drinking, alcohol-related problems, and risk for spouse abuse within racial/ethnic groups as well as variations associated with whether the perpetrator is drinking during the spouse abuse incident.
Methods
Cases (N = 7,996) were all active-duty male, enlisted Army spouse abusers identified in the Army’s Central Registry (ACR) who had also completed an Army Health Risk Appraisal (HRA) Survey between 1991 and 1998. Controls (N = 17,821) were matched on gender, rank, and marital and HRA status.
Results
We found 3 different patterns of association between alcohol use and domestic violence depending upon both the race/ethnicity of the perpetrator and whether or not alcohol was involved in the spouse abuse event. First, after adjusting for demographic and psychosocial factors, weekly heavy drinking (>14 drinks per week) and alcohol-related problems (yes to 2 or more of 6 alcohol-related problem questions, including the CAGE) were significant predictors of domestic violence among whites and Hispanics only. Also for the white soldiers, the presence of family problems mediated the effect of alcohol-related problems on spouse abuse. Second, alcohol-related problems predicted drinking during a spouse abuse incident for all 3 race groups, but this relation was moderated by typical alcohol consumption patterns in Hispanics and whites only. Finally, alcohol-related problems predicted drinking during a spouse abuse incident, but this was a complex association moderated by different psychosocial or behavioral variables within each race/ethnic group.
Conclusion
These findings suggest important cultural/social influences that interact with drinking patterns.
doi:10.1111/j.1530-0277.2006.00214.x
PMCID: PMC2141684  PMID: 17010139
Alcohol; Violence; Intimate Partner Violence; Ethnicity; Race; Army
19.  Incidence and Seroprevalence of Hepatitis A Virus Infections among Young Korean Soldiers 
Journal of Korean Medical Science  2007;22(3):546-548.
This study was performed to determine the incidence and seroprevalence of hepatitis A virus (HAV) infections in young soldiers in the Republic of Korea Army. From January 2000 through December 2004, a total of 147 hepatitis A cases were reported to the Armed Forces Medical Command. The annual incidence rates were 7.4 per 100,000 persons in 2000, 1.6 in 2001, 4.4 in 2002, 9.8 in 2003, and 6.2 in 2004, based on the reported cases among approximately 500,000 soldiers. All patients were males with a median age of 21 yr (range, 19-27). The most common symptom was nausea (86.5%), and all patients had recovered without complications. In addition, in order to evaluate the seroprevalence of HAV infection in young adults, serum samples were obtained from randomly selected young subjects among those who had been admitted to the Armed Forces Capital Hospital from September 2005 to February 2006. A total of 200 subjects were enrolled in the study to analyze the anti-HAV immune status. The overall anti-HAV IgG seropositive rate was 2% (4/200, 95% CI, 0.60-5.21%). Given the changing epidemiology of the disease and the associated increase in morbidity, it was suggested that the routine HAV vaccination for Korean military personnel might be necessary.
doi:10.3346/jkms.2007.22.3.546
PMCID: PMC2693652  PMID: 17596668
Hepatitis A; Incidence; Military Personnel; Seroprevalence
20.  Assessing the effect of community health nursing care management at home on war-worn soldiers’ physical problems suffering from spinal cord complications (urinary infection, bedsore) 
BACKGROUND:
Veterans are among the highly-susceptible and highly-esteemed groups of the society. there is no correct, principled, and comprehensive programming with respect to home-nursing care for them.
METHODS:
In this quasi-experimental study, 26 veterans with spinal cord complications, with a 70-percent damage who were resident of Najaf Abad, Iran were concluded. The data were gathered by a checklist consisted of two parts, the first part included the demographic data and the second part consisted of Para-clinical (clinical findings) assessment of the veterans suffering from urinary infection, laboratorial assessments, and assessing the bedsores. The researcher visited all the veterans and completed the checklist by interviewing them.
RESULTS:
The mean age of the veterans was 45 (5.1) years and the highest frequency (53.8%) belonged to the age range of 40-44 years. The mean number of the family members was 4.4 people. The veterans who had paraplegia damage included 88.6%. Considering the damage rate, the highest frequency (69.2%) belonged to thoracic vertebra level. all the 26 veterans had been suffering from urinal infection before the managerial intervention; however 20 subjects (76.9%) had urinal infection after the intervention.
CONCLUSIONS:
It can be stated that pressure wounds are preventable and these caring measures can be offered to susceptible groups of the community in a better and cheaper way if more studies are done with a closer contact and a higher number of samples in addition to have unison among the community-based systems.
PMCID: PMC3208931  PMID: 22069406
Veterans; spinal cord complications; community health nursing care
21.  Comparison of mental health between former child soldiers and children never conscripted by armed groups in Nepal 
JAMA : the journal of the American Medical Association  2008;300(6):10.1001/jama.300.6.691.
Context:
Despite child soldiers being considered in need of special mental health interventions, there is a lack of studies investigating the mental health of child soldiers compared with civilian children in armed conflicts.
Objective:
To compare the mental health status of former child soldiers with children who have never been conscripts of armed groups.
Design, Setting, and Participants:
A matched-pair cohort study conducted from March through April 2007 in Nepal compared the mental health of 141 former child soldiers to 141 never conscripted children matched on age, sex, education, and ethnicity.
Outcome Measures:
Depression symptoms were assessed via the Depression Self Rating Scale (DSRS), anxiety symptoms via the Screen for Child Anxiety Related Emotional Disorders (SCARED-5), symptoms of posttraumatic stress disorder (PTSD) via the Child PTSD Symptom Scale (CPSS), general psychological difficulties via the Strength and Difficulties Questionnaire (SDQ), daily functioning via the Function Impairment (FI) tool, and exposure to traumatic events via Kiddie-Schedule of Affective Disorders and Schizophrenia (KIDDIE-SADS) PTSD Traumatic Event Checklist.
Results:
Participants were a mean of 15.75 years at the time of this study and child soldiers ranged in age from 5 to 16 years at the time of conscription. All participants experienced at least 1 type of trauma. Number (%) of child soldiers meeting cutoff scores were 75 (53.2%) for depression, 65 (46.1%) for anxiety, 78 (55.3%) for PTSD, 55 (39.0%) for psychological difficulties, and 88 (62.4%) for function impairment. Child soldiers had greater odds of meeting cutoff for depression (OR=3.56, 95% CI 2.33—5.43), PTSD (for which we employed stratified analyses because of sex interaction: boys’ OR=3.85, 95% CI 1.77—8.39; girls’ OR=6.33, 95% CI 2.64—15.17), psychological difficulties (OR=2.91, 95% CI=1.53—5.51), and function impairment (OR=2.04, 95% CI 1.41—2.96), but no difference for anxiety (OR=1.46, 95% CI 0.72—2.68). After adjusting for traumatic exposures, soldier status was no longer associated with psychological difficulties or function impairment but remained significantly associated with depression (OR=2.69, 95% CI 1.48—4.89) and PTSD among girls (OR=5.98, 95% CI 1.86—19.27), but not PTSD among boys (OR=2.38, 95% CI 0.87—6.50).
Conclusions:
In Nepal, former child soldiers display greater severity of mental health problems compared with children never conscripted by armed groups, and this difference remains for depression and PTSD (the latter especially among girls) even after controlling for trauma exposure.
doi:10.1001/jama.300.6.691
PMCID: PMC3842355  PMID: 18698067
22.  Psychiatric distress among spouses of National Guard soldiers prior to combat deployment 
Mental Health in Family Medicine  2012;9(3):161-169.
Background The mental health functioning of military spouses and intimate partners prior to the combat deployments of their loved ones is poorly studied.
Aims Whereas service members and veterans often receive healthcare directly from the military or the Department of Veterans Affairs, family members may be more likely to present in family care settings. An understanding of mental health problems commonly occurring in this population is therefore important.
Method National Guard soldiers and their spouses or cohabitating partners (n = 223 couples) were surveyed about mental health symptoms, social functioning and mental health service utilisation one to two months prior to a combat deployment to Afghanistan.
Results Screening rates for partner post-traumatic stress disorder, depression, alcohol problems and social impairment were 2.4, 15.3, 3.7 and 10.7%, respectively, and were significantly higher for partners than soldiers with regards to depression and social impairment. The majority of partners screening positive for psychiatric distress did not report utilising mental health services or military support services (i.e. family readiness groups). Clinical implications are discussed.
PMCID: PMC3622908  PMID: 23997822
combat deployment; deployment cycle; depression; family well-being; PTSD
23.  What pre-deployment and early post-deployment factors predict health function after combat deployment?: a prospective longitudinal study of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) soldiers 
Background
Physical and mental function are strong indicators of disability and mortality. OEF/OIF Veterans returning from deployment have been found to have poorer function than soldiers who have not deployed; however the reasons for this are unknown.
Methods
A prospective cohort of 790 soldiers was assessed both pre- and immediately after deployment to determine predictors of physical and mental function after war.
Results
On average, OEF/OIF Veterans showed significant declines in both physical (t=6.65, p<.0001) and mental function (t=7.11, p<.0001). After controlling for pre-deployment function, poorer physical function after deployment was associated with older age, more physical symptoms, blunted systolic blood pressure reactivity and being injured. After controlling for pre-deployment function, poorer mental function after deployment was associated with younger age, lower social desirability, lower social support, greater physical symptoms and greater PTSD symptoms.
Conclusions
Combat deployment was associated with an immediate decline in both mental and physical function. The relationship of combat deployment to function is complex and influenced by demographic, psychosocial, physiological and experiential factors. Social support and physical symptoms emerged as potentially modifiable factors.
doi:10.1186/1477-7525-11-73
PMCID: PMC3704953  PMID: 23631419
Health function; Quality of life; Veterans; Military; Prospective; SF-36; Iraq; Afghanistan; Combat
24.  Health Care Response to CCHF in US Soldier and Nosocomial Transmission to Health Care Providers, Germany, 2009 
Emerging Infectious Diseases  2015;21(1):23-31.
Early recognition and implementation of appropriate infection control measures were effective in preventing further transmission.
In 2009, a lethal case of Crimean–Congo hemorrhagic fever (CCHF), acquired by a US soldier in Afghanistan, was treated at a medical center in Germany and resulted in nosocomial transmission to 2 health care providers (HCPs). After his arrival at the medical center (day 6 of illness) by aeromedical evacuation, the patient required repetitive bronchoscopies to control severe pulmonary hemorrhage and renal and hepatic dialysis for hepatorenal failure. After showing clinical improvement, the patient died suddenly on day 11 of illness from cerebellar tonsil herniation caused by cerebral/cerebellar edema. The 2 infected HCPs were among 16 HCPs who received ribavirin postexposure prophylaxis. The infected HCPs had mild or no CCHF symptoms. Transmission may have occurred during bag-valve-mask ventilation, breaches in personal protective equipment during resuscitations, or bronchoscopies generating infectious aerosols. This case highlights the critical care and infection control challenges presented by severe CCHF cases, including the need for experience with ribavirin treatment and postexposure prophylaxis.
doi:10.3201/eid2101.141413
PMCID: PMC4285246  PMID: 25529825
viral hemorrhagic fever; Crimean–Congo hemorrhagic Crimean–Congo hemorrhagic fever virus; fever; ribavirin; infection control; prophylaxis; CCHF; nosocomial infection; viruses; US soldier; health care providers; Germany
25.  Alcohol Use and Alcohol-Related Problems Before and After Military Combat Deployment 
Context
High rates of alcohol misuse after deployment have been reported among personnel returning from past conflicts, yet investigations of alcohol misuse after return from the current wars in Iraq and Afghanistan are lacking.
Objectives
To determine whether deployment with combat exposures was associated with new-onset or continued alcohol consumption, binge drinking, and alcohol-related problems.
Design, Setting, and Participants
Data were from Millennium Cohort Study participants who completed both a baseline (July 2001 to June 2003; n=77 047) and follow-up (June 2004 to February 2006; n=55 021) questionnaire (follow-up response rate=71.4%). After we applied exclusion criteria, our analyses included 48 481 participants (active duty, n=26 613; Reserve or National Guard, n=21 868). Of these, 5510 deployed with combat exposures, 5661 deployed without combat exposures, and 37 310 did not deploy.
Main Outcome Measures
New-onset and continued heavy weekly drinking, binge drinking, and alcohol-related problems at follow-up.
Results
Baseline prevalence of heavy weekly drinking, binge drinking, and alcohol-related problems among Reserve or National Guard personnel who deployed with combat exposures was 9.0%, 53.6%, and 15.2%, respectively; follow-up prevalence was 12.5%, 53.0%, and 11.9%, respectively; and new-onset rates were 8.8%, 25.6%, and 7.1%, respectively. Among active-duty personnel, new-onset rates were 6.0%, 26.6%, and 4.8%, respectively. Reserve and National Guard personnel who deployed and reported combat exposures were significantly more likely to experience new-onset heavy weekly drinking (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.36–1.96), binge drinking (OR, 1.46; 95% CI, 1.24–1.71), and alcohol-related problems (OR, 1.63; 95% CI, 1.33–2.01) compared with nondeployed personnel. The youngest members of the cohort were at highest risk for all alcohol-related outcomes.
Conclusion
Reserve and National Guard personnel and younger service members who deploy with reported combat exposures are at increased risk of new-onset heavy weekly drinking, binge drinking, and alcohol-related problems.
doi:10.1001/jama.300.6.663
PMCID: PMC2680184  PMID: 18698065

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