Diagnoses and factors associated with medical evacuation and return to duty among nonmilitary personnel participating in military operations in Iraq and Afghanistan

Background

Nonmilitary personnel play an increasingly critical role in modern wars. Stark differences exist between the demographic characteristics, training and missions of military and nonmilitary members. We examined the differences in types of injury and rates of returning to duty among nonmilitary and military personnel participating in military operations in Iraq and Afghanistan.

Methods

We collected data for nonmilitary personnel medically evacuated from military operations in Iraq and Afghanistan between 2004 and 2007. We compared injury categories and return-to-duty rates in this group with previously published data for military personnel and identified factors associated with return to duty.

Results

Of the 2155 medically evacuated nonmilitary personnel, 74.7% did not return to duty. War-related injuries in this group accounted for 25.6% of the evacuations, the most common causes being combat-related injuries (55.4%) and musculoskeletal/spinal injuries (22.9%). Among individuals with non–war-related injuries, musculoskeletal injuries accounted for 17.8% of evacuations. Diagnoses associated with the highest return-to-duty rates in the group of nonmilitary personnel were psychiatric diagnoses (15.6%) among those with war-related injuries and noncardiac chest or abdominal pain (44.0%) among those with non–war-related injuries. Compared with military personnel, nonmilitary personnel with war-related injuries were less likely to return to duty (4.4% v. 5.9%, p = 0.001) but more likely to return to duty after non–war-related injuries (32.5% v. 30.7%, p = 0.001).

Interpretation

Compared with military personnel, nonmilitary personnel were more likely to be evacuated with non–war-related injuries but more likely to return to duty after such injuries. For evacuations because of war-related injuries, this trend was reversed.In modern warfare, injuries sustained in combat have never been the leading source of attrition among soldiers. In World War I, World War II and the Korean War, respiratory and infectious diseases were the top reasons for hospital admissions among service members. By the Vietnam Conflict, non-battle injuries had supplanted respiratory illness as the leading cause of hospital admissions and have remained the leading cause ever since.^1,2The principal causes for medical evacuation of military personnel from US operations in Iraq and Afghanistan were recently described in a large four-year epidemiologic study.³ In descending order, the leading reasons were musculoskeletal conditions, combat-related injuries, neurologic symptoms and psychiatric disorders; the last category surpassed combat-related injuries as the number two reason in the latter half of both engagements. However, nonmilitary personnel were not included in that study. Over the past three years, nonmilitary members, including US Department of Defense civilians, private contractors and diplomats, have comprised about 50% of personnel serving in Iraq and about two-thirds of those serving in Afghanistan.^4,5Several reasons may explain why the types of injury and the return-to-duty rates differ between military and nonmilitary personnel. First, the motivations for overseas deployment might differ between the groups. Whereas some civilian personnel (e.g., diplomats) may be assigned to positions in Iraq and Afghanistan, virtually all private contractors volunteer for their jobs. In contrast, most military members have little choice in their deployment. Second, military and nonmilitary members assigned to war zones have different occupational specialties, living conditions and regulations to which they must adhere. Especially for junior military personnel, jobs tend to be more dangerous, living environments more austere and regulations more stringent. Finally, unlike military personnel, who are paid regardless of deployment status, most contractors’ pay is contingent upon continued employment in theatres of operation. In addition, nonmilitary personnel are generally compensated with higher salaries than service members in comparable occupational specialties.In civilian cohorts, many of these factors have been shown to influence return-to-work rates in a variety of contexts. Studies of the effect of financial compensation on work status after injury have generally shown a direct correlation between return-to-work rates and higher income levels.^6,7 Similar associations have also been found between return-to-work rates and job satisfaction and coping mechanisms, factors that may be influenced by work conditions and perceived control over one’s environment.^8–10The objectives of our study were threefold: to ascertain whether the reasons for medical evacuation from military operations differed between military and nonmilitary personnel; to determine whether return-to-duty rates differed between the two groups; and to identify factors that influence return-to-duty rates among nonmilitary members.     

Performance differences among ex situ native-provenance collections of Pinus radiata D. Don. 1: potential for infusion into breeding populations in Australia and New Zealand

Growth and form traits from a series of three provenance trials of Pinus radiata D. Don planted in New Zealand and Australia were analysed at age 9 years from planting. The trials included selections from three mainland California natural populations—A?o Nuevo, Monterey and Cambria. Monterey and Cambria performed better than A?o Nuevo at two New Zealand sites, but Monterey and A?o Nuevo were almost identical in growth, whereas Cambria grew less vigorously at the Australian site. We detected significant provenance differences for diameter at breast height (DBH) growth and stem straightness across countries (p < 0.001). Estimated heritability for DBH ranged from 0.19 to 0.26 within sites, while heritability estimates for stem straightness and branching frequency ranged from 0.10 to 0.24. Estimated type B genetic correlations for DBH were always higher between the two trials in New Zealand trials than between pairs of trials in New Zealand and the Australian site. The genetic coefficient of variation (CV_A) for DBH was around 8–10% compared to ca. 5% for the current breeding population. These results suggested that there is appreciable genetic variation in the native populations, and infusion of these materials would increase the genetic variation in current breeding populations. Ten unrelated parents ranked above control seedlots from the older open-pollinated seed orchard stock for DBH growth and would be potential candidates for infusion. The promising performance of the Cambria material is an important result because the genetic base of the present Australian and New Zealand plantations is principally derived from A?o Nuevo and Monterey.     

Cortical spreading depression modifies components of the inflammatory cascade

As more information becomes available regarding the role of inflammation following stroke, it is apparent that some inflammatory mediators are detrimental and others are beneficial to the progression of ischemic injury. Cortical spreading depression (CSD) is known to impart some degree of ischemic tolerance to the brain and to influence the expression of many genes. Many of the genes whose expression is altered by CSD are associated with inflammation, and it appears likely that modulation of the inflammatory response to ischemia by CSD contributes to ischemic tolerance. Understanding which inflammatory processes are influenced by CSD may lead to the identification of novel targets in the effort to develop an acute treatment for stroke.     

Flux and turnover of fixed carbon in soil microbial biomass of limed and unlimed plots of an upland grassland ecosystem

The influence of liming on rhizosphere microbial biomass C and incorporation of root exudates was studied in the field by in situ pulse labelling of temperate grassland vegetation with (13)CO(2) for a 3-day period. In plots that had been limed (CaCO(3) amended) annually for 3 years, incorporation into shoots and roots was, respectively, greater and lower than in unlimed plots. Analysis of chloroform-labile C demonstrated lower levels of (13)C incorporation into microbial biomass in limed soils compared to unlimed soils. The turnover of the recently assimilated (13)C compounds was faster in microbial biomass from limed than that from unlimed soils, suggesting that liming increases incorporation by microbial communities of root exudates. An exponential decay model of (13)C in total microbial biomass in limed soils indicated that the half-life of the tracer within this carbon pool was 4.7 days. Results are presented and discussed in relation to the absolute values of (13)C fixed and allocated within the plant-soil system.     

Multiple costimulatory modalities enhance CTL avidity

Recent studies in both animal models and clinical trials have demonstrated that the avidity of T cells is a major determinant of antitumor and antiviral immunity. In this study, we evaluated several different vaccine strategies for their ability to enhance both the quantity and avidity of CTL responses. CD8(+) T cell quantity was measured by tetramer binding precursor frequency, and avidity was measured by both tetramer dissociation and quantitative cytolytic function. We have evaluated a peptide, a viral vector expressing the Ag transgene alone, with one costimulatory molecule (B7-1), and with three costimulatory molecules (B7-1, ICAM-1, and LFA-3), with anti-CTLA-4 mAb, with GM-CSF, and combinations of the above. We have evaluated these strategies in both a foreign Ag model using beta-galactosidase as immunogen, and in a "self" Ag model, using carcinoembryonic Ag as immunogen in carcinoembryonic Ag transgenic mice. The combined use of several of these strategies was shown to enhance not only the quantity, but, to a greater magnitude, the avidity of T cells generated; a combination strategy is also shown to enhance antitumor effects. The results reported in this study thus demonstrate multiple strategies that can be used in both antitumor and antiviral vaccine settings to generate higher avidity host T cell responses.     

Evaluation of manometric temperature measurement (MTM), a process analytical technology tool in freeze drying, part III: Heat and mass transfer measurement

This article evaluates the procedures for determining the vial heat transfer coefficient and the extent of primary drying through manometric temperature measurement (MTM). The vial heat transfer coefficients (K_v) were calculated from the MTM-determined temperature and resistance and compared with K_v values determined by a gravimetric method. The differences between the MTM vial heat transfer coefficients and the gravimetric values are large at low shelf temperature but smaller when higher shelf temperatures were used. The differences also became smaller at higher chamber pressure and smaller when higher resistance materials were being freeze-dried. In all cases, using thermal shields greatly improved the accuracy of the MTM K_v measurement. With use of thermal shields, the thickness of the frozen layer calculated from MTM is in good agreement with values obtained gravimetrically. The heat transfer coefficient “error” is largely a direct result of the error in the dry layer resistance (ie, MTM-determined resistance is too low). This problem can be minimized if thermal shields are used for freeze-drying. With suitable use of thermal shields, accurate K_v values are obtained by MTM; thus allowing accurate calculations of heat and mass flow rates. The extent of primary drying can be monitored by real-time calculation of the amount of remaining ice using MTM data, thus providing a process analytical tool that greatly improves the freeze-drying process design and control.     

Investigating damselfly populations at springs in Banff National Park, Canada, with special focus on Argia vivida, Amphiagrion abbreviatum, and Ischnura cervula (Odonata: Coenagrionidae)

The objective of this study was to estimate Argia vivida (Odonata: Coenagrionidae) populations, identify breeding habitat, and investigate movement of adults within Banff National Park, Alberta, Canada, during the summer of 2003. Mark-recapture techniques and standardized dip-net surveys were used to monitor Argia vivida at various life stages. A reproductive index identified which sites Argia vivida recognized as suitable breeding habitat, and exuvia surveys confirmed breeding sites. The basic structure of emergent and surrounding vegetation was measured to investigate the importance of available ovipositing or roosting sites and the condition of the matrix habitat. Data was recorded for Amphiagrion abbreviatum and Ischnura cervula (both Odonata: Coenagrionidae) to determine if these spring-associated damselflies were successfully breeding within Banff National Park. Comparisons were made between the highly protected Middle Springs and the heavily altered Cave & Basin Springs. Additional surveys at the Vermilion Lake cool spring and Middle Springs Bog investigated their use as breeding habitat for Amphiagrion abbreviatum and Argia vivida, respectively. Results suggest the ecological value of thermal springs extends beyond their origin to outflows and downstream pools. Conservation of Argia vivida must recognize the value of unobstructed thermal outflows, and consider the condition of the forested habitat surrounding springs with regard to its potential use as nocturnal roosts and dispersal corridors. Amphiagrion abbreviatum was confirmed breeding within Banff National Park, while no sign of breeding activity was recorded for Ischnura cervula.     

Social status and availability of females determine patterns of sperm allocation in the fowl

Where sperm competition occurs, the number and quality of sperm males inseminate relative to rival males influences fertilization success. The number of sperm males produce, however, is limited, and theoretically males should allocate sperm according to the probability of gaining future reproductive opportunities and the reproductive benefits associated with copulations. However, the reproductive opportunities and value of copulations males obtain can change over their lifetime, but whether individuals respond to such changes by adjusting the way they allocate sperm is unclear. Here we show that, in the fowl, Gallus gallus, dominant males, which have preferential access to females, modulate the number of sperm they ejaculate according to the availability of females. When presented with two females, dominant males allocated more sperm to higher quality females, whereas when females were on their own, only copulation order had an affect on their sperm numbers. In contrast, subordinate males, whose mating activity is restricted by dominant males, allocated high numbers of sperm to initial copulations, irrespective of female availability. We further show, by manipulating male social status, that sperm allocation is both phenotypically plastic, with males adjusting their patterns of sperm allocation according to their dominance rank, and intrinsic, with males being consistently different in the way they allocate sperm, once the effects of social status are taken into account. This study suggests that males have evolved sophisticated patterns of sperm allocation to respond to frequent fluctuations in the value and frequency of reproductive opportunities.