April 2008, Vol 173, No 4
Effects of Racial/Ethnic Discrimination on the Health Status of Minority Veterans
Linda Sohn, MD MPH; Nancy D. Harada, PhD
As the veteran population becomes ethnically diverse, it is important to understand complex interrelationships between racism and health. This study examined the association between perceptions of discrimination and self-reported mental and physical health for Asian/Pacific Islander, African American, and Hispanic veterans. The data for this study come from the 2001 Veteran Identity Program Survey, which measured utilization of outpatient care, discrimination, and health status across three minority veteran groups. Multivariate regression methods were used to model self-reported mental and physical health on perceptions of discrimination controlling for demographic and socioeconomic characteristics. Findings revealed that racial/ethnic discrimination during military service was significantly associated with lower physical, but not mental health. Satisfaction with health care provider's sensitivity toward racial/ethnic background was significantly associated with better mental health. Findings highlight the importance of developing policies that address racial/ethnic discrimination during military service while providing health care services for veterans.
Collaborative Intervention: A Model for Coordinated Treatment of Mental Health Issues within a Ground Combat Unit
LT Michael D. Howard, CHC USN; Ruth P. Cox, PhD
Involvement in combat imposes a psychological burden that affects all combatants, not only those who are vulnerable to emotional disorders or those who sustain physical wound distress. This burden of combat is also carried by the families of those who go to war. Although most ground combat units have a medical officer as well as a chaplain assigned to them, they do not have a mental health counselor or psychologist. Traditionally, the medical officer focuses on the treatment of physical symptoms, diseases, and physical injuries, whereas the chaplain treats spiritual and adjustment issues that may affect how well an individual service member functions personally and/or professionally. Located between these two points is a void, the treatment of psychological or emotional issues. By using the collaborative intervention model presented here, unit medical officers and chaplains can work together to treat these issues, thus reducing the number of service members needing referral to mental health agencies, decreasing the number of mental health-related medical separations, and increasing overall mission readiness. This article presents a model whereby medical officers and chaplains can enter this void together, treating these emotional issues collaboratively.
Soldiers' Experience with Medical Hold: The Case of Fort Bragg
Cristóbal S. Berry-Cabán, PhD; CPT Steven Lynch, MC FS USA
Soldiers' treatment in medical hold has been controversial due in part to a series of articles that appeared in the popular press. The purpose of this study was to explore soldiers' satisfaction as an indicator of the quality of health and treatment care received while in medical hold at Womack Army Medical Center (Fort Bragg, North Carolina). Data came from a survey of 17 questions that was administered on a point prevalence date and analyzed using descriptive statistics. A total of 47 of 164 soldiers on medical hold on March 1, 2007 responded. The overall patient satisfaction averaged 81.57%, based on a 5-point Likert rating scale for the soldier case sample. However, the survey also showed areas where Womack can improve.
Regional Methamphetamine Use among U.S. Army Personnel Stationed in the Continental United States and Hawaii: A Six-Year Retrospective Study (2000-2005)
CPT(P) Benjamin W. Lacy V, MC USA; Thomas F. Ditzler, PhD FRIPH; CPT(P) Raymond S. Wilson, MC USA; MAJ Thomas M. Martin, USA; Jon T. Ochikubo, BS; LTC Robert R. Roussel, USA; MAJ Jose M. Pizarro-Matos, USA; MAJ Raymond Vazquez, USA
Substance use disorders constitute a serious and persistent threat to military readiness and to the health and safety of military personnel and their families. Methamphetamine is among the most addictive and damaging of commonly abused drugs; this is of great concern for military health providers in Hawaii due to the unusually high prevalence in the local community. The effect of regional drug use on active duty subpopulations has not been previously studied. This study includes a 6-year retrospective sample of laboratory-confirmed methamphetamine-, cocaine-, and marijuana-positive drug tests among Army soldiers stationed in Hawaii and western and eastern continental U.S. installations. The findings suggest that active duty members are significantly affected by the local drug climate. However, current military drug policies also deter use as evidenced by low absolute drug-positive rates even in regions of high civilian prevalence.
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.
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.
Postdeployment Evaluation of Health Risk Communication after Exposure to a Toxic Industrial Chemical
MAJ James D. Mancuso, MC USA; Margaret Ostafin, MPH; COL Mark Lovell, MC USA
Increasing emphasis is being placed on the appropriate communication of deployment-related risks among military service members. This report validates risk communication on the postdeployment health assessment (PDHA), in the context of a known, low-level exposure to a toxic industrial chemical. In late 2003, 245 soldiers were exposed to hexavalent chromium at an industrial site in Iraq; of those, 227 had completed PDHAs on file for review. Despite being directed to document this exposure upon redeployment, only 55 soldiers (24.2%) specifically reported chromium exposure. Increasing age and time at the industrial site were associated with increased reporting of exposure. Although providers documented deployment exposure concerns for only 65.4% of this population, this was much more often than for other redeploying service members. The PDHA is a risk assessment and risk communication tool that has sources of misclassification, and results must be interpreted with caution when individual or population occupational and environmental risks resulting from deployment are assessed.
Variability in Interpretation among B-Readers in the U.S. Navy Asbestos Medical Surveillance Program
John G. Muller, MD MPH; LCDR Jonathan M. Lieske, MC USN; Jose E. Hernandez, MS CIH (Ret.); Gosia Kubiak, MSc; CAPT W. Garry Rudolph, MC USN; CAPT Moore H. Jan, MC USN
U.S. Navy Asbestos Medical Surveillance Program B-reading reports were analyzed for variability in identifying pneumoconiosis in 278,944 chest radiographs done from 1990 to 2004 using commercial database and statistical software. Reported presence of pneumoconiosis by 33 B-readers ranged from 1.85 to 32.28%. The reported presence of parenchymal abnormalities ranged from 0.11 to 15.07%; increased profusion (to 1/0 or greater) of small parenchymal opacities ranged from 0.10 to 17.70%; presence of large opacities ranged from 0.00 to 0.67%; and presence of pleural abnormalities ranged from 1.08 to 23.93%. Ranges appear to be decreasing slightly as rates of abnormal findings are diminishing. Differences between U.S. East Coast, West Coast, and midcontinent were not statistically significant.
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
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.
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.
Complications after the Surgical Treatment of Malignant Thyroid Disease
Capt Samuel A. Spear, USAF MC; CPT Jared Theler, MC USA; LTC Douglas M. Sorensen, MC USA
Objectives: Our objectives were to document the complication rates after total thyroidectomy or lobectomy for malignant thyroid disease and to compare these rates with previously documented complication rates after operations for benign thyroid disease. Methods: This is a retrospective chart review of patients diagnosed with thyroid carcinoma at a tertiary military medical center from 1996 to 2000. Results: Eighty-two patients were identified with thyroid carcinoma, of which 81 underwent surgical treatment. Nine patients had complications related to their treatment, four were permanent. This included two cases of permanent postoperative hypoparathyroidism, one case of phrenic nerve injury, and one case of unilateral vocal cord paralysis. There is a statistically significant higher overall complication rate of this series (10%) in comparison to a similar series of patients surgically treated for benign thyroid disease (2%) when comparing only recurrent laryngeal nerve injury and hypoparathyroidism (p = 0.02). There is also a higher overall complication rate (11% vs. 4.9%); however, this does not reach statistical significance (p = 0.16). Conclusion: Recurrent laryngeal nerve injury and hypoparathyroidism complication rates after operations for malignant thyroid disease are statistically higher in this series than complication rates after operations for benign thyroid disease. Overall complication rates are also higher for malignant thyroid disease as compared to benign thyroid disease. Before surgical treatment for malignant thyroid disease, patients should be counseled accordingly.
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.
Metastatic Malignant Teratoma Arising from Mediastinal Nonseminomatous Germ Cell Tumor: A Case Report
CPT(P) Jacob Collen, MC USA; MAJ Mark Carmichael, MC USA; MAJ Tanya Wroblewski, MC USA
Primary mediastinal nonseminomatous germ cell tumors (NSGCT) have a worse prognosis than gonadal germ cell tumors (GCTs). Malignant transformation of teratomatous components of GCT to a somatic malignancy is rare. We present a case of primary mediastinal NSGCT with malignant transformation of a teratoma in an active duty airman who presented with a 12-cm anterior mediastinal mass and vertebral body lesion. Pathology confirmed NSGCT with yolk sac and teratomatous components. Chemotherapy for GCT normalized serum tumor markers with little effect on the mediastinal mass. Incomplete resection of the residual tumor revealed high-grade mixed sarcoma. Serum tumor markers rose 3 months following resection with metastatic disease to bone and liver. Chemotherapy targeting sarcoma induced a partial response, but the patient developed acute myeloid leukemia refractory to chemotherapy. We discuss our approach to management of this complicated patient.