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Fatigue, a common complaint in individuals with postpolio syndrome (PPS), is defined as an overwhelming sustained feeling of exhaustion and diminished capacity for physical and mental work. A comprehensive medical work-up is needed to rule out all other causes of fatigue. A sleep study should be considered for individuals with PPS who complain of fatigue. Self-reported outcome measures, such as the Fatigue Severity Scale, are reliable and valid tools to measure fatigue in this population. Fatigue management consists of individualized treatment of underlying medical conditions, energy conservation, pacing techniques, and lifestyle modifications.

Background Literature indicates that individuals with long-term residual lower extremity (LE) weakness after polio have decreased bone mineral density (BMD) deficiencies related to muscle weakness. Where weakness is asymmetrical, bone densitometry (BDt) measured only on the stronger LE may misclassify BMD. Objective To determine (1) whether femoral neck BMD differed from side to side in individuals with asymmetrical LE muscle weakness, and (2) the proportion of individuals at risk for underdiagnosis of low bone density or osteoporosis given unilateral assessment of the femoral neck. Design Retrospective study. Setting Outpatient postpolio center. Participants Patients >18 years old with complete relevant data. Main Outcome Measures BDt T scores, BMD categories based on standard T-score ranges, and side of LE weakness determined by a strength score. Results Forty-three subjects had at least 1 femoral neck T score and bilateral LE strength scores. Fourteen (32.5%) had BDt only on their weaker LE and 14 (32.5%) had BDt only on their stronger LE. Of the 15 subjects with BDt done on both femoral necks, T scores (mean [standard deviation]) were lower in the weaker LE (–1.73 [1.09]) than the stronger LE (–0.88 [1.0]) (P = .001). Classification of low bone density or osteoporosis was more frequent based on T scores taken on a weaker LE (48.3% and 24.1%, respectively) than from T scores from a stronger LE (41.4% and 6.9%, respectively). Conclusions In this small sample, using strong-limb T scores resulted in fewer individuals categorized as having low bone density or osteoporosis than when weak-limb T scores were used. Underestimating BMD loss may lead to undertreatment and increased risk of morbidity, mortality, and costs associated with femoral neck fractures in this high-fall-risk group. Level of Evidence III

Historically, insurgency is one of the most prevalent forms of armed conflict and it is likely to remain common in the foreseeable future. Recent experiences with counterinsurgency in Iraq and Afghanistan offer many lessons for future counterinsurgents, but the discourse on the subject continues to be mired in a traditional dichotomy pitting population-centric approaches to counterinsurgency against enemy-centric approaches. Historical analysis suggests that this traditional dichotomy is not a sufficiently nuanced way to understand or plan for such operations. Instead, discussions of counterinsurgency should focus on two dimensions: actions (use of physical force vs. political or moral actions) and targets (active insurgents vs. insurgent support). This perspective divides the space of possible counterinsurgency efforts into four quadrants, suggesting that effective counterinsurgency campaigns find a balance of effort across the four quadrants that is well matched to the specific context.

Border management hinges on the tension between the need to prevent undesirable people and goods from crossing borders and the economic vitality gained through trade and travel. Building on lessons learned from Jordan, Saudi Arabia, Niger, and Morocco, this Perspective proposes opportunities to strengthen security while simultaneously improving the flow of licit travelers and goods through national policies and programs.

Security cooperation is an important mission of the U.S. Air Force. This report reviews two core Air Force decisionmaking processes — the strategy, planning, and programming process and the concept development and acquisition process — to determine the extent to which decisionmakers consider security cooperation impact and to recommend ways to make such considerations systematic and explicit.

Supporting Tunisia as it builds its counterterrorism institutions and preventing the flow of foreign fighters across its borders remain core objectives of U.S. assistance programs. This report offers recommendations that could improve Tunisia's border management capabilities at ground, sea, and air ports and crossings, with the goal of addressing security concerns while improving the licit flow of people and commerce.