There’s safety in numbers

Predictors of Likelihood and Intensity of Past-Year Mental Health Service Use in an Active Canadian Military Sample

Objectives:Shoulder instability is endemic in military and young athletic populations. Anteriorshoulder instability is the most prevalent instability in civilian populations, but theunique physical demands placed upon military service members shoulders likely result ina different injury pattern. The purpose of the current investigation was to examine thedistribution of labral tears across multiple military medical centers. We hypothesizedthere would be a higher incidence of posterior and combined labral tears treatedoperatively as compared to the civilian literature.Methods:The Military Orthopaedics Tracking Injuries and Outcomes Network’s (MOTION) prospectiveWounded Ill and Injured Registry (WIIR) was queried for all patients who had undergone asurgical stabilization procedure (CPT 29806, 23455, 23462) from October 2016 to January2019. Patients with isolated superior labral repairs were excluded. Labral tear locationwas abstracted from intraoperative data collection forms. Chi-Square analyses (X2)compared the percentage of patients with isolated anterior, isolated posterior, isolatedinferior, or combined labral tears between individuals in the current study cohort witha previously reported civilian Norway shoulder instability registry, a reportedprevalence at the National Football League scouting combine, and with operative shoulderinstability patients at a single military treatment facility. Chi-square analyses alsocompared differences in labral tear location between males and females. Statisticalsignificance was set a priori at α ≤ 0.05.Results:Three hundred fourteen patients (n=314) were identified who had undergone primaryshoulder stabilization during the study period. Three patients were excluded due toinsufficient data. Of the 311 remaining patients, 41 (13%) were female, 269 (87%) weremale, 1 patient did not report a gender. All 311 patients’ military status was eitheractive duty or active reserve (301 and 10, respectively). Ninety-four patients (30.23%)had isolated anterior labral tears (21 female, 73 male), 76 patients (24.44%) hadisolated posterior labral tears (7 female, 69 male), 5 patients (1.61%) had isolatedinferior tears, and 136 patients (43.73%) had combined labral tears. The number ofposterior and combined labral tears in our data differed from previously reportedpercentages in the civilian literature (9.90% and 6.93%, respectively; X2(2)=208.94,p<0.00001). We also observed a higher percentage of combined tears than waspreviously reported from a military institution (18.61%; X2(2)=48.20, p<0.00001). TheNFL combine cohort had 31% of players with anterior, 35% of players with posterior, and35% with combined anterior/posterior labral tears (X2(2)=9.54, p=0.0085). Significantlymore females (51.22%) had an isolated anterior labral tear, as compared to males(25.65%; X2(2)=9.25, p=0.009).Conclusion:The rate of posterior and combined labral tears in a military population with shoulderinstability is higher than what is reported in the civilian literature, which is inkeeping with a previous study at one Army medical treatment facility, although the rateof combined tears was even higher in the current cohort than previously reported ineither population. The distribution of tear location is most similar tothat of an NFLcombine population, supporting the thought that the military population should bethought of and treated as a population of athletes. Labral tears in females were moreconsistent with the civilian literature in that they had significantly more isolatedanterior tears than posterior orcombined, which significantly differed from males.Military shoulder surgeons should be prepared to address multiple labral tears at thetime of shoulder stabilization and be aware of the difference in tear location infemales versus males.

To assess the prevalence of self-reported symptoms and illnesses among military personnel deployed during the Persian Gulf War (PGW) and to compare the prevalence of these conditions with the prevalence among military personnel on active duty at the same time, but not deployed to the Persian Gulf (non-PGW).Cross-sectional telephone interview survey of PGW and non-PGW military personnel. The study instrument consisted of validated questions, validated questionnaires, and investigator-derived questions designed to assess relevant medical and psychiatric conditions.Population-based sample of military personnel from Iowa.A total of 4886 study subjects were randomly selected from 1 of 4 study domains (PGW regular military, PGW National Guard/Reserve, non-PGW regular military, and non-PGW National Guard/Reserve), stratifying for age, sex, race, rank, and branch of military service.Self-reported symptoms and symptoms of medical illnesses and psychiatric conditions.Overall, 3695 eligible study subjects (76%) and 91% of the located subjects completed the telephone interview. Compared with non-PGW military personnel, PGW military personnel reported a significantly higher prevalence of symptoms of depression (17.0% vs 10.9%; Cochran-Mantel-Haenszel test statistic, P<.001), posttraumatic stress disorder (PTSD) (1.9% vs 0.8%, P=.007), chronic fatigue (1.3% vs 0.3%, P<.001), cognitive dysfunction (18.7% vs 7.6%, P<.001), bronchitis (3.7% vs 2.7%, P<.001), asthma (7.2% vs 4.1%, P=.004), fibromyalgia (19.2% vs 9.6%, P<.001), alcohol abuse (17.4% vs 12.6%, P=.02), anxiety (4.0% vs 1.8%, P<.001), and sexual discomfort (respondent, 1.5% vs 1.1%, P=.009; respondent's female partner, 5.1% vs 2.4%, P<.001). Assessment of health-related quality of life demonstrated diminished mental and physical functioning scores for PGW military personnel. In almost all cases, larger differences between PGW and non-PGW military personnel were observed in the National Guard/Reserve comparison. Within the PGW military study population, compared with veterans in the regular military, veterans in the National Guard/Reserve only reported more symptoms of chronic fatigue (2.9% vs 1.0%, P=.03) and alcohol abuse (19.4% vs 17.0%, P=.004).Military personnel who participated in the PGW have a higher self-reported prevalence of medical and psychiatric conditions than contemporary military personnel who were not deployed to the Persian Gulf. These findings establish the need to further investigate the potential etiologic, clinical, pathogenic, and public health implications of the increased prevalence of multiple medical and psychiatric conditions in populations of military personnel deployed to the Persian Gulf.

In this issue of the Journal, Metzgar et al. [1] report a significant addition to the adenovirus (Ad) types infecting US military recruits with acute respiratory disease (ARD). Their ongoing epidemiological studies, which use rapid molecular diagnostic procedures, enabled the detection and identification of a species B2 Ad, type 14 (Ad14), that had not been previously observed in US military recruits. This virus was originally recovered 50 years ago from Dutch recruits [2], with only 2 subsequent reports of ARD associated with Ad14 [1, 3]. In contrast to the B1 Ads (i.e., types 3, 7, and 21) that often infect the respiratory tract, Ad14 respiratory infections have been very rarely observed in adult military and civilian populations [4]. At present, studies are under way at military training centers to field test replacements for the live oral Ad4 and Ad7 vaccines that had been used for 25 years but were lost when production ceased in the 1990s [5–7]. The recent recovery of Ad14 raises new questions as to whether Ad14 will take hold as a respiratory disease agent in civilian and military populations and whether the candidate Ad4 and Ad7 vaccines will protect against Ad14. The absence of identified Ad14 respiratory infections in the United States suggests that we have highly susceptible civilian and military populations. Review of past experience with the live oral Ad vaccines may be of value in assessing the long-term threat of Ad14 to recruits. Previous observation of responses to the Ad4 and Ad7 vaccines indicated that they were highly effective against homologous viruses and Ad3 [6, 7]. Vaccines responses to Ad3 were attributed to some level of Ad3 occurring naturally and to Ad3 being antigenically related to Ad7, both being species B1 viruses. Therefore, after exposure to the Ad7 vaccine virus, heterotypic responses to Ad3 occurred [8]. In contrast to Ad3, naturally occurring background infections with Ad21, also a species B1 virus, have been considered rare. Recent studies of recruits with ARD found only small numbers infected with Ad21 [1]. Only a few additional Ad21 infections were identified via antibody testing, suggesting that the virus currently is not highly communicable [9, 10]. However, in 1975–1976, Ad21 was recovered from large numbers of recruits with ARD who had been vaccinated against Ad4 and Ad7. ARD-associated Ad21 infections continued for months at most training facilities, resulting in the testing of an experimental live oral vaccine [11, 12]. However, long-term observation revealed that Ad21 did not persist as a significant cause of ARD, even though outbreaks occurred in the 1970s and again in 1985 [13]. Thus, there has been no interest in renewing studies of an Ad21 vaccine. It is possible that Ad14 and other Ads could cause significant ARD morbidity among military recruits for a limited period and then disappear as an important cause of respiratory disease. It is also possible that some protection against emerging Ads could be provided as a result of heterotypic antibody responses to other viruses, including the Ad7 vaccine virus. Past studies in The Netherlands found that Ad14-associated ARD did not persist in their recruits [2, 14]. Additionally, the development of heterotypic antibody to Ad14 after Ad7 immunization was reported in 1960 [15]. Contemporary serologic surveys of new US military recruits will provide important information on their susceptibility. Testing archival serum-bank specimens from recruits vaccinated against Ad4 and Ad7 and from recruits with ARD who had laboratory confirmation of a specific Ad type could provide data on the occurrence of heterotypic antibody reReceived 4 June 2007; accepted 4 June 2007; electronically published 31 October 2007. Potential conflicts of interest: none reported. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the true views of the Department of the Army or the Department of Defense. Reprints or correspondence: Dr. Leonard N. Binn, Div. of Viral Diseases, Walter Reed Army Institute of Research, 503 Robert Grant Ave., Silver Spring, MD 20910 (leonard.binn@na.amedd.army.mil). The Journal of Infectious Diseases 2007; 196:1436 –7 This article is in the public domain, and no copyright is claimed. 0022-1899/2007/19610-0003$15.00 DOI: 10.1086/522969 E D I T O R I A L C O M M E N T A R Y

The authors review traffic safety in the United States, with specific reference to military personnel, focusing on safety interventions and attempts to change driver behavior and decisions. Overall, driving has become safer over the last 20 years: A variety of factors seem to have contributed to this increased safety-better vehicle safety features, better road safety features, decreases in teenage drunk driving, more seat belt use, and at least recently, fewer vehicle miles traveled. In contrast, motorcycle riding, a topic of particular interest to the military, is becoming more dangerous. The main difference between the military and civilian population is the proportion of military crash fatalities on motorcycles-the U.S. rate is currently about 15 percent of fatalities, while in some military branches the rate is on average 35-40 percent. This review shows that the following safety interventions tend to help in the reduction of vehicle crashes and that some in particular may be useful in the military setting: (1) better enforcement of underage drinking laws and continuation of alcohol deglamorization campaigns (Department of Defense regulations exist, but underage drinking seems to be relatively common); (2) high-visibility enforcement techniques for sobriety checkpoints; (3) high-visibility enforcement techniques for seat belt use; (4) adoption of a lower blood alcohol concentration level (such as 0.05) for motorcyclists, since the evidence shows that motorcyclists' ability to drive safely begins declining at lower levels than those for car drivers; (5) screening-perhaps as part of military medical assessment-and brief intervention with a trained counselor for at-risk drinkers, since they are at higher risk for drinking and driving; (6) media campaigns that are paired with community activities that also emphasize driver safety, such as workshops or fairs and with enforcement of driving regulations, and targeted at the drivers at highest risk (men in their teens and early 20s); (7) requirements that motorcyclists be licensed and own their vehicles.

ObjectivesRecurrent instability is common after shoulder dislocation in the young, particularly those engaged in physical jobs or sport. The management of recurrent traumatic shoulder instability is predominantly operative. However, the...

ObjectivesSLAP (superior labrum anterior and posterior) lesions are a recognised cause of shoulder pain and instability. They can occur following a direct blow, biceps traction and compression injuries, and are...

Section one reports on a quantitative systematic literature review examining the relationship between post-traumatic stress disorder and eating disorders within a military population. Six academic databases were systematically searched using key words related to the concepts of post-traumatic stress disorder, eating disorders, and military personnel and veterans. The findings suggested that there is a significant positive association between post-traumatic stress disorder and eating disorders within a military population. Females were at a greater likelihood than males of experiencing co-occurring post-traumatic stress disorder and eating disorders. Furthermore, longitudinal studies suggested a directional relationship wherein military personnel and veterans experiencing post-traumatic stress disorder were later more likely to engage in disordered eating behaviours. However, the majority of research reviewed was cross-sectional and related to US military veterans, therefore the area would benefit from additional studies, particularly those examining international active military service members and veterans. Section two reports on an empirical study examining the effect of fear of compassion on the relationship between self-criticism and disordered eating within an adult population. Individuals across the spectrum of disordered eating took part in an online survey. A series of mediation models were employed in order to explore the relationships between self-criticism, fear of compassion, and disordered eating. Findings indicated that the relationships between two forms of self-criticism, namely self-critical rumination and self-criticism in relation to a sense of personal inadequacy, and disordered eating were mediated by fear of both showing compassion to oneself and receiving compassion from others. These results highlight a need for the assessment of fear of compassion within therapeutic interventions for people who experience disordered eating, particularly in clients who experience high levels of self-criticism. Section three includes a critical appraisal of the thesis. It includes a summary of overall findings in addition to reflections upon key decision-making points.

Annually 1.2 million deaths occur globally due to road traffic injuries; additionally, 20-50 million are injured or disabled ("Global status report", 2013). Concomitant with rapid socioeconomic growth, infrastructure development and increased vehicle ownership, injury, disability and mortality due to road traffic collisions are high in the Gulf Cooperation Council countries. This is also true for Qatar where road traffic collisions are one of the leading causes of premature mortality (Bener et al., 2012). Road traffic mortality in Qatar (2010) is 14 per 100,000 population. Young adult males are disproportionately affected ("Global status report", 2013). Laws pertaining to seat belt and mobile phone use exist; however, there is a lack of enforcement. We collected data regarding seat belt and mobile phone use while driving in college students, majority of whom were in the age group 18-24 years. The data was collected via a self-administered survey in two colleges. The total sample consisted of 419 students but 321 admitted to driving a vehicle. Overall seat belt use among drivers was reported at 51% “always”, 41% “sometimes”, and 8% “never”. Overall mobile phone use was reported at 23% “always”, 64% “sometimes”, and 13% “never”. Females were significantly more likely than males to use seat belt and less likely to use mobile phone while driving. Additionally, drivers at or below the age of 25 were significantly more likely to use seat belt and less likely to use mobile phone than those over 25 years old (Table 1). The results give us reliable estimates of seat belt and mobile phone use prevalence in young adult drivers in Qatar. Increased awareness and enforcement of road safety laws are required to control this epidemic of road traffic injury, disability and fatality. These findings are of public health importance and deserve our attention.

BackgroundDiarrhea remains a major public health problem for both civilian and military populations. This study describes the prevalence of acute diarrheal illness etiological agents, their antibiotic resistance distribution patterns, the resulting impact upon military force health protection, and potential prevention and treatment strategies.ResultsForty-eight acute diarrhea stool samples from US military personnel deployed to Thailand from 2013–2017 were screened for enteric pathogens using ELISA, the TaqMan Array Card (TAC), and conventional microbiological methods. These isolates were also evaluated using antimicrobial susceptibility testing (AST) against ampicillin (AMP), azithromycin (AZM), ceftriaxone (CRO), ciprofloxacin (CIP), nalidixic acid (NA), erythromycin (ERY), and trimethoprim-sulfamethoxazole (SXT) using commercial methodology. Susceptibility results were interpreted following the CLSI and NARM guidelines. Questionnaire data obtained from 47/48 volunteers indicated that 89.4% (42/47) reported eating local food and the most common clinical symptoms were nausea and abdominal pain (51%; 24/47). Multiple bacterial species were identified from the 48 stool samples with diarrhea etiological agents being detected in 79% (38/48) of the samples distributed as follows: 43.8% (21/48) Campylobacter jejuni and Campylobacter species, 42% (20/48) diarrheagenic Escherichia coli, and 23% (11/48) Salmonella. Co-infections were detected in 46% (22/48) of the samples. All C. jejuni isolates were resistant to CIP and NA. One C. jejuni isolate exhibited resistance to both AZM and ERY. Lastly, an association between exposure to poultry and subsequent detection of the diarrhea-associated pathogens E. coli and P. shigelloides was significant (p < 0.05).ConclusionThe detection of Campylobacter isolates with CIP, AZM and ERY resistance has critical force health protection and public health implications, as these data should guide effective Campylobacteriosis treatment options for deployed military members and travelers to Southeast Asia. Additional research efforts are recommended to determine the association of pathogen co-infections and/or other contributing factors towards diarrheal disease in military and traveler populations. Ongoing surveillance and AST profiling of potential disease-causing bacteria is required for effective disease prevention efforts and treatment strategies.

Purpose: This study estimated the annual count of spinal cord injuries (SCIs) in motor vehicles crashes by type and seat belt use using 18 years of NASS-CDS data. It determined the rate for SCI and fracture-dislocation of the spine.Methods: 1994–2011 NASS-CDS was used to estimate the annual occurrence of spinal injuries in front seat occupants involved in motor vehicle crashes. Crashes were grouped by front, side, rear, and rollovers, and the effects of belt use were investigated. Light vehicles were included with model year 1994+. Spinal injuries were classified as minor (Abbreviated Injury Scale [AIS] 1), moderate (AIS 2), serious (AIS 3), fracture-dislocations, and SCI (AIS 4+). The annual count and rate for different types of spinal injury were estimated along with standard errors. The results were compared to estimates of head injuries. NASS-CDS electronic cases of SCIs in rear impacts were investigated.Results: There were 5,592 ± 1,170 fracture-dislocations of the spine and 1,046 ± 193 AIS 4+ SCI per year in motor vehicle crashes. Most of the injuries occurred in rollovers and frontal crashes and the least occurred in rear impacts. The rate of SCI was 0.054 ± 0.010%. The highest rate was 0.220 ± 0.056% in rollover crashes and the lowest rate was 0.032 ± 0.009% in frontal crashes. The highest rate for spinal fracture-dislocation was 1.552 ± 0.455% in rollovers and the lowest was 0.065 ± 0.021% in rear impacts. The rate for SCI was 0.027 ± 0.005% in belted and 0.145 ± 0.028% in unbelted occupants giving 81% effectiveness of belt use in reducing SCI. The cervical spine was associated with 66.3 ± 11.3% of the AIS 4+ SCI with 30.5 ± 7.4% in the thoracic spine and 3.2 ± 1.3% in the lumbar spine. Severe head injuries occurred 13.3 times more often than SCIs.Conclusions: Spinal cord injury occurred in one out of 1,860 front seat occupants in tow-away crashes. The rate was highest in rollover crashes and was reduced by seat belt use. Fracture-dislocation of the spine occurred about 5.3 times more often than SCIs and was also prevented by seat belt use.

Motor vehicle crashes are a leading cause of death among children. Age- and size-appropriate restraint use is an effective way to prevent motor vehicle-related injuries and deaths. However, children are not always properly restrained while riding in a motor vehicle, and some are not restrained at all, which increases their risk for injury and death in a crash. 2005-2008. The Crash Outcome Data Evaluation System (CODES) is a multistate program facilitated by the National Highway Traffic Safety Administration to probabilistically link police crash reports and hospital databases for traffic safety analyses. Eleven participating states (Connecticut, Georgia, Kentucky, Maryland, Minnesota, Missouri, Nebraska, New York, Ohio, South Carolina, and Utah) submitted data to CODES during the reporting period. Descriptive analysis was used to describe drivers and child passengers involved in motor vehicle crashes and to summarize crash and medical outcomes. Odds ratios and 95% confidence intervals were used to compare a child passenger's likelihood of sustaining specific types of injuries by restraint status (optimal, suboptimal, or unrestrained) and seating location (front or back seat). Because of data constraints, optimal restraint use was defined as a car seat or booster seat use for children aged 1-7 years and seat belt use for children aged 8-12 years. Suboptimal restraint use was defined as seat belt use for children aged 1-7 years. Unrestrained was defined as no use of car seat, booster seat, or seat belt for children aged 1-12 years. Optimal restraint use in the back seat declined with child's age (1 year: 95.9%, 5 years: 95.4%, 7 years: 94.7%, 8 years: 77.4%, 10 years: 67.5%, 12 years: 54.7%). Child restraint use was associated with driver restraint use; 41.3% of children riding with unrestrained drivers also were unrestrained compared with 2.2% of children riding with restrained drivers. Child restraint use also was associated with impaired driving due to alcohol or drug use; 16.4% children riding with drivers suspected of alcohol or drug use were unrestrained compared with 2.9% of children riding with drivers not suspected of such use. Optimally restrained and suboptimally restrained children were less likely to sustain a traumatic brain injury than unrestrained children. The 90th percentile hospital charges for children aged 4-7 years who were in motor vehicle crashes were $1,630.00 and $1,958.00 for those optimally restrained in a back seat and front seat, respectively; $2,035.91 and $3,696.00 for those suboptimally restrained in a back seat and front seat, respectively; and $9,956.60 and $11,143.85 for those unrestrained in a back seat and front seat, respectively. Proper car seat, booster seat, and seat belt use among children in the back seat prevents injuries and deaths, as well as averts hospital charges. However, the number, severity, and cost of injuries among children in crashes who were not optimally restrained or who were seated in a front seat indicates the need for improvements in proper use of age- and size-appropriate car seats, booster seats, and seat belts in the back seat. Effective interventions for increasing proper child restraint use could be universally implemented by states and communities to prevent motor vehicle-related injuries among children and their resulting costs.

Racial/Ethnic Differences in Limited English Proficiency (LEP) and Associations with Regular Seat Belt Use

M R Smallman-Raynor and A D Cliff, War epidemics: an historical geography of infectious diseases in military conflict and civil strife, 1850–2000, Oxford University Press, 2004, pp. xxxv, 805, illus., £100 (hardback 0-19-823364-7). - Volume 50 Issue 3

Objective. Low seat belt use rate among car occupants is one of the main problems contributing to low driver and passenger safety in Turkey, where injury and fatality rates of car occupants are very high in traffic crashes. The present article consists of two observation studies, which were conducted in Ankara. The first study aimed at investigating environmental factors and occupant characteristics affecting seat belt use among front-seat occupants, and the objective of the second study was to investigate the relationship between driver and front-seat passenger seat belt use. Method. In the first study, 4, 227 front-seat occupants (drivers or front seat passengers) were observed on four different road sides and, in the second study 1, 398 front seat occupants were observed in car parks of five different shopping centers in Ankara. In both observations, front-seat occupants' seat bet use (yes, no), sex (male, female), and age (< 30 years, 30–50 years, > 50 years) were recorded. Results. The data were analyzed using chi-square statistics and binary logistic regression techniques. Results of the first study showed that seat belt use proportion among observed front seat occupants was very low (25%). Being female and traveling on intercity roads were two main factors positively related to use a seat belt among front-seat occupants. High correlations between seat belt use of the drivers and front-seat passengers were found in the second study. Conclusions. Overall, low seat belt use rate (25%) among the front-seat occupants should be increased urgently for an improved driver and passenger safety in Turkey. Seat belt campaigns especially tailored for male front-seat occupants and for the front-seat occupants traveling on city roads are needed to increase seat belt use rates among them. Also, both drivers and passengers may have an important role in enforcing seat belt use among themselves.