Historical approaches to post-combat disorders

Almost every major war in the last century involving western nations has seen combatants diagnosed with a form of post-combat disorder. Some took a psychological form (exhaustion, combat fatigue, combat stress reaction and post-traumatic stress disorder), while others were characterized by medically unexplained symptoms (soldier's heart, effort syndrome, shell shock, non-ulcer dyspepsia, effects of Agent Orange and Gulf War Syndrome). Although many of these disorders have common symptoms, the explanations attached to them showed considerable diversity often reflected in the labels themselves. These causal hypotheses ranged from the effects of climate, compressive forces released by shell explosions, side effects of vaccinations, changes in diet, toxic effects of organophosphates, oil-well fires or depleted-uranium munitions. Military history suggests that these disorders, which coexisted in the civilian population, reflected popular health fears and emerged in the gaps left by the advance of medical science. While the current Iraq conflict has yet to produce a syndrome typified by medically unexplained symptoms, it is unlikely that we have seen the last of post-combat disorders as past experience suggests that they have the capacity to catch both military planners and doctors by surprise.     

THE NEW MILITARY MEDICAL ETHICS: LEGACIES OF THE GULF WARS AND THE WAR ON TERROR

United States military medical ethics evolved during its involvement in two recent wars, Gulf War I (1990–1991) and the War on Terror (2001–). Norms of conduct for military clinicians with regard to the treatment of prisoners of war and the administration of non‐therapeutic bioactive agents to soldiers were set aside because of the sense of being in a ‘new kind of war’. Concurrently, the use of radioactive metal in weaponry and the ability to measure the health consequences of trade embargos on vulnerable civilians occasioned new concerns about the health effects of war on soldiers, their offspring, and civilians living on battlefields. Civilian medical societies and medical ethicists fitfully engaged the evolving nature of the medical ethics issues and policy changes during these wars. Medical codes of professionalism have not been substantively updated and procedures for accountability for new kinds of abuses of medical ethics are not established. Looking to the future, medicine and medical ethics have not articulated a vision for an ongoing military‐civilian dialogue to ensure that standards of medical ethics do not evolve simply in accord with military exigency.     

加强军队医院非现役编制医务人员卫生勤务保障能力的重要性

目的:调查军队医院非现役编制医务人员的军事素质和卫勤保障意识,探讨提升该群体卫勤保障能力的重要性和必要性,为军队医院卫勤管理提供参考。方法:采用问卷调查的方式对我院154名非现役编制医务人员进行调查,主要包括军事理论、卫生勤务、突发事件应急管理及战伤急救等,分析非现役编制医务人员缺乏的基本军事素质,并提出针对性的加强军队医院文职人员卫生勤务保障能力的可行性培训计划,在培训结束时对医护人员的军事素质进行测评。结果:问卷调查结果:非现役文职人员的军事素质评分为(3.70±0.46)、卫生勤务能力评分为(2.48±0.91)、突发事件应急管理评分为(2.61±0.53)、战伤急救技能评分为(2.42±1.02)。测评结果:军事理论知识评分为(4.11±1.04)、卫生勤务能力评分为(4.78±1.37)、突发事件应急意识评分为(4.56±0.56)、战伤急救技能评分为(4.68±0.91)。培训后,非现役医务人员的卫勤保障能力显著提高,差异具有统计学意义(P0.05)。结论:非现役文职作为军队医院的聘用制人员已成为医务工作的主要力量,因此军队医院应加强非现役医务人员的卫生勤务保障能力,提高我军后勤医疗保障的坚固力量。     

The injured mind in the UK Armed Forces

The mental health of the UK Armed Forces is a topic much debated by healthcare professionals, politicians and the media. While the current operations in Afghanistan, and the recent conflict in Iraq, are relevant to this debate, much of what is known about the effects of war upon the psyche still derives from the two World Wars. This paper will examine the historical and contemporary evidence about why it is that some Service personnel suffer psychological injuries during their military service and others do not. The paper will also consider some of the strategies that today's Armed Forces have put in place to mitigate the effects of sending military personnel into danger.     

The black citizen-subject: black single mothers in US military recruitment material

This article examines how the US military uses race inequalities to mobilize black single mothers for enlistment of their children in the Armed Forces. Through an analysis of military recruitment materials during the height of the US War on Terrorism, I demonstrate how the military disproportionately shows black single mothers going through a process of reacting to their child's enlistment (with fear and worry), welcoming the military institution as the co-parent, and accepting enlistment as a venue for education and career opportunities (productive citizenship). The military models a citizen-mother who supports their child's enlistment, while unquestionably supporting the war. This exploits the obligations of citizenship for black single mothers, whose citizenship is already under scrutiny. By targeting the children of these mothers for recruitment, the military encourages a higher burden of military participation on an already underprivileged segment of the population.     

Traumatic brain injury

There is an increasing incidence of military traumatic brain injury (TBI), and similar injuries are seen in civilians in war zones or terrorist incidents. Indeed, blast-induced mild TBI has been referred to as the signature injury of the conflicts in Iraq and Afghanistan. Assessment involves schemes that are common in civilian practice but, in common with civilian TBI, takes little account of information available from modern imaging (particularly diffusion tensor magnetic resonance imaging) and emerging biomarkers. The efficient logistics of clinical care delivery in the field may have a role in optimizing outcome. Clinical care has much in common with civilian TBI, but intracranial pressure monitoring is not always available, and protocols need to be modified to take account of this. In addition, severe early oedema has led to increasing use of decompressive craniectomy, and blast TBI may be associated with a higher incidence of vasospasm and pseudoaneurysm formation. Visual and/or auditory deficits are common, and there is a significant risk of post-traumatic epilepsy. TBI is rarely an isolated finding in this setting, and persistent post-concussive symptoms are commonly associated with post-traumatic stress disorder and chronic pain, a constellation of findings that has been called the polytrauma clinical triad.     

Influence of prolonged stress on cerebral hemodynamics

The author has investigated the impact of psychological and socio-economic factors on cerebral hemodynamics and development of cerebrovascular disease (CVD). A group of 120 war sufferers with signs of post-traumatic stress disorder and adaptation disturbances, and 120 persons of the control group with no traumatic war experience have been studied. The blood flow velocity and various parameters of spectral frequency analysis have been measured, using the method of transcranial doppler sonography (TCD). A greater number of hemodynamical changes has been found in the group of subjects than in the control group (p < 0.05), in which increase of vasospasm is statistically significant probably as a result of predomination of the sympathetic system stimulation and nicotinic effect on the brain blood vessels. Flow disturbances are relatively more frequent in older subjects, which suggests the rapid development of the atherosclerotic process. The results suggest that exposure to prolonged stress and bad socio-economic factors, through different neurobiological mechanisms, increased the risk for stroke.     

The effects of chronic psychological and physical stress on feather replacement in European starlings (Sturnus vulgaris).

Corticosterone (CORT) is seasonally modulated in many passerines, with plasma CORT concentrations lowest during the prebasic molt, when all feathers are replaced. Recent evidence indicating that CORT implants slow the rate of feather regrowth in molting birds suggests that plasma CORT concentrations are downregulated during molt in order to avoid the inhibition of feather growth caused by the protein catabolic activity of CORT. To further test this hypothesis, we examined whether endogenous CORT release, stimulated by exposure to either psychological stress or physical stress (food restriction), could inhibit feather regrowth rates or decrease feather quality in birds undergoing an induced molt (feather replacement after plucking). European starlings (Sturnus vulgaris) were exposed to chronic psychological stress or food restriction for three weeks of the feather regrowth period. Throughout this time, the length of growing primary, secondary, and tail feathers was measured and blood samples were collected to measure baseline and stress-induced CORT concentrations. Upon completion of growth, feather quality was analyzed via measurements of mass, rachis length, feather area, and presence of fault bars. Both psychological and physical stress protocols elevated circulating plasma CORT but significantly less than implants from an earlier study did. Psychological stress had no effect on feather regrowth rates or feather quality. Food restriction had no effect on feather growth rate but caused asynchronous feather replacement. When combined with psychological stress, physical stress also resulted in smaller feather area. Results indicate that CORT implants may not accurately represent chronic stress physiology. Additionally, the purpose for downregulating CORT concentrations during molt appears to be more complicated than simply protecting feather production from CORT's catabolic effects.     

The effects of chronic psychological and physical stress on feather replacement in European starlings (Sturnus vulgaris)

Corticosterone (CORT) is seasonally modulated in many passerines, with plasma CORT concentrations lowest during the prebasic molt, when all feathers are replaced. Recent evidence indicating that CORT implants slow the rate of feather regrowth in molting birds suggests that plasma CORT concentrations are downregulated during molt in order to avoid the inhibition of feather growth caused by the protein catabolic activity of CORT. To further test this hypothesis, we examined whether endogenous CORT release, stimulated by exposure to either psychological stress or physical stress (food restriction), could inhibit feather regrowth rates or decrease feather quality in birds undergoing an induced molt (feather replacement after plucking). European starlings (Sturnus vulgaris) were exposed to chronic psychological stress or food restriction for three weeks of the feather regrowth period. Throughout this time, the length of growing primary, secondary, and tail feathers was measured and blood samples were collected to measure baseline and stress-induced CORT concentrations. Upon completion of growth, feather quality was analyzed via measurements of mass, rachis length, feather area, and presence of fault bars. Both psychological and physical stress protocols elevated circulating plasma CORT but significantly less than implants from an earlier study did. Psychological stress had no effect on feather regrowth rates or feather quality. Food restriction had no effect on feather growth rate but caused asynchronous feather replacement. When combined with psychological stress, physical stress also resulted in smaller feather area. Results indicate that CORT implants may not accurately represent chronic stress physiology. Additionally, the purpose for downregulating CORT concentrations during molt appears to be more complicated than simply protecting feather production from CORT's catabolic effects.     

Toward Innovative,Cost-Effective,and Systemic Solutions to Improve Outcomes and Well-Being of Military Families Affected by Autism Spectrum Disorder

The burdens faced by military families who have a child with autism are unique. The usual challenges of securing diagnostic, treatment, and educational services are compounded by life circumstances that include the anxieties of war, frequent relocation and separation, and a demand structure that emphasizes mission readiness and service. Recently established military autism-specific health care benefits set the stage for community-viable and cost-effective solutions that can achieve better outcomes for children and greater well-being for families. Here we argue for implementation of evidence-based solutions focused on reducing age of diagnosis and improving access to early intervention, as well as establishment of a tiered menu of services, individualized to the child and family, that fit with the military ethos and system of health care. Absence of this new model of care could compromise the utility and sustainability of the autism-specific benefit.     

部队疗养院非现役文职护理人员的现状分析

目的:分析部队疗养院非现役文职护理人员的现状并给出相应对策。方法:采用不记名问卷形式对92名非现役文职护理人员进行调查。结果:部分非现役文职护理人员在业务能力、军事素质、身心健康等方面存在不足。结论:应采取有效措施提升非现役文职护理人员的综合素质,提高护理质量。     

部队疗养院非现役文职护理人员的现状分析

目的：分析部队疗养院非现役文职护理人员的现状并给出相应对策。方法：采用不记名问卷形式对92名非现役文职护理人员进行调查。结果：部分非现役文职护理人员在业务能力、军事素质、身心健康等方面存在不足。结论：应采取有效措施提升非现役文职护理人员的综合素质,提高护理质量。     

Role of vaccinations as risk factors for ill health in veterans of the Gulf war: cross sectional study

ObjectivesTo explore the relation between ill health after the Gulf war and vaccines received before or during the conflict. To test the hypothesis that such ill health is limited to military personnel who received multiple vaccines during deployment and that pesticide use modifies any effect.DesignCross sectional study of Gulf war veterans followed for six to eight years after deployment.Setting UK armed forces.ParticipantsMilitary personnel who served in the Gulf and who still had their vaccine records.Results The response rate for the original survey was 70.4% (n=3284). Of these, 28% (923) had vaccine records. Receipt of multiple vaccines before deployment was associated with only one of the six health outcomes (post-traumatic stress reaction). By contrast five of the six outcomes (all but post-traumatic stress reaction) were associated with multiple vaccines received during deployment. The strongest association was for the multisymptom illness (odds ratio 5.0; 95% confidence interval 2.5 to 9.8).ConclusionAmong veterans of the Gulf war there is a specific relation between multiple vaccinations given during deployment and later ill health. Multiple vaccinations in themselves do not seem to be harmful but combined with the “stress” of deployment they may be associated with adverse health outcomes. These results imply that every effort should be made to maintain routine vaccines during peacetime.     

Military Veterans and Service Dogs: A Qualitative Inquiry Using Interpretive Phenomenological Analysis

There are over 18.8 million veterans of the United States of America's Armed Forces. After military service veterans may find it difficult transitioning back to civilian life. Veterans reintegrating may experience physical and psychological challenges related to their military service. For many, a successful role change takes considerable time and determination. In order to ease their transition, veterans are using the assistance of service dogs to aid in symptom management and assist with positive reintegration into civilian life. Service dogs are highly trained animals that help individuals perform life tasks to assist with physical and psychological challenges. The purpose of this qualitative study was to give voice to the experiential viewpoints of veterans who utilize service dogs. Guided by the theoretically informed method of interpretation— interpretive phenomenological analysis (IPA)—the researchers uncovered the veterans’ perspectives, which provided meaningful insight into their lives with a service dog. Semi-structured interviews were conducted with veterans (n = 21) who utilized a service dog. The interviews lasted approximately one hour and were video or audio recorded. The most salient themes that emerged from the interviews were grouped into four superordinate themes: Procurement, psychosocial functioning, value, and detriments. Results suggest that service dogs improved veterans’ physical and psychological health, provided a coping resource and a form of social support, and supported sustaining their independence. Veterans’ right to privacy and the public's lack of knowledge and understanding of legal accommodation requirements via the Americans with Disabilities Act (ADA) were perceptible. Implications for policy, practice, and research, are discussed.     

Inching toward Armageddon: a psychiatric view

The existence of thermonuclear arsenals capable of destroying much of humanity takes its origins from, and has an influence on, processes that are largely psychological. The threat to use a single nuclear bomb to resolve contemporary conflict is an anathema in part because complex nation-states did not evolve with surviving a nuclear war in mind. The atomic arms race has proceeded apace because of maladaptive psychological mechanism including denial, distortion, projection, and, most relevantly, the need to enhance bonding within groups by creating stereotypes. One consequence of the arms race is a climate of fear and hopelessness, and especially destructive effect of which is seen in children. The physician's role in the prevention of nuclear war is critical, but divided between contradictory roles. On one hand, the physician is traditionally identified as a non-political advocate of the sick; on the other, as an advocate for the public health. It is this second model that enables physicians most legitimately to work for the prevention of nuclear war and to deal with the psychiatric concomitants of a planet drifting toward disaster.     

Alimentary infections during war conditions: Mostar and Tomislavgrad, Bosnia and Herzegovina, 1992-1995

The aim of this study was to assess the outcome of sanitary and epidemiologic measures undertaken in relation to alimentary infections in the military corps of the Croatian Defense Council (Hrvatsko vje?e obrane) and civilian population in Mostar and Tomislavgrad regions during the 1992-1995 War in Bosnia and Herzegovina. A total of 25 (4.8%) of soldiers and 7 (7.1%) of non-military personnel were not being granted medical clearance to be employed in the food provision services. We recorded a total of 68 alimentary infections cases in military personnel (with an incidence of 536.2 per 100,000 persons), and 436 in civilian population (573.9 per 100,000 person), without significant difference between them (p=0.647). We did not record any alimentary infection outbreak in the military personnel, while two smaller epidemics of the abdominal typhus were recorded among civilian populations, but without lethal outcomes. The results of this study suggest that even the most basic adherence to the principle of standard sanitary and epidemiologic preventive measures may substantially reduce the probability of alimentary infections outbreaks, even in the highly disruptive, warfare environment.     

Experiences and psycosocial impact on soldier boys and girls from the civil war in El Salvador

Exploratory research with 293 excombatants who participated as child soldiers in the El Salvador civil war as FMLN (Marti Front for National Liberation) members or as Armed Forces soldiers was conducted to examine their current living conditions and the impact of past military experience. Although nearly ten years have passed since the peace accords were signed, the excombatant exhibited signs of emotional disturbance. Current underprivileged living conditions and social marginalization were decisive factors which inhibited reentry into civilian life and constituted an important psychosocial impact by placing at risk their integration at the family, community and society levels.     

Birth defects prevalence among infants of Persian Gulf War veterans born in Hawaii, 1989-1993

BACKGROUND: Gulf War veterans (GWVs) have expressed concern about possible teratogenic exposures. However, epidemiologic studies on birth defects prevalence among their progeny have been limited to military hospitals, anomalies diagnosed among newborns, or self-reported data. To measure the prevalence of selected birth defects among infants of GWVs and nondeployed veterans (NDVs) in Hawaii, using birth defects surveillance records. METHODS: Personal identifiers of 684,645 GWVs and 1,587,102 NDVs and their families were matched against birth certificate records of 99,545 live births reported to the State of Hawaii Department of Health between 1989 and 1993 to identify births to military personnel. These births were matched with records from the Hawaii Birth Defects Program. RESULTS: A total of 17,182 military infants (3,717 GWV infants and 13,465 NDV infants) were identified. Of these, 367 infants (2.14/100 live births) were identified with one or more of 48 major birth defects diagnoses. The prevalence of the 48 birth defects were similar for GWV and NDV infants during the prewar and postwar periods, and among GWV infants who were conceived before and after the Gulf war. CONCLUSIONS: The results must be interpreted with caution because of the small number of affected infants in each birth defects category. This study demonstrated the feasibility of measuring birth defects prevalence among military infants through multiple data linkage. Further, it included live births to parents who had separated from the military, births in civilian hospitals, and birth defects diagnosed through the first year of life.     

部队医院文职人员管理的探索与研究

随着部队医疗机构人事编制的调整,军队医院及疗养院为缓解人员严重短缺的问题,通过公开考核面向社会招聘具有专业资格的非现役文职人员。文职人员作为军队疗养院的聘用制人员已成为医护工作的主要力量。因此,完善文职人员的管理工作是提高医院医疗质量的重点。本文通过分析文职人员聘用、教育、生活福利待遇及公务事业、社会保险等文职人员管理制度,探讨各项管理制度的特点及作用,提出适合我院推行的文职人员管理制度,即充分利用社会人才资源,建立健全文职人员管理评价体系,提高文职人员献身部队、服务军队的积极性和创造性。