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Objectives Regular vigorous physical activity (PA) and high levels of physical fitness (PF) confer health benefits. Conversely, sedentary time is a risk factor for chronic illness, independent of PA. We evaluated associations between self-reported PA, sedentary time, and objective PF measures in military Service members. Design Cross-sectional study including 10,105 Air Force Millennium Cohort participants with a valid physical fitness assessment (PFA). Methods Linear regression assessed associations between self-report PA, screen time, and usual activity and abdominal circumference (AC) and VO2 max; logistic regression was used for PFA failure. We stratified by age and sex. Results Men who self-reported high versus low levels of PA had greater AC (19–29 years: β = 0.23 in., 95% CI 0.07, 0.39; 30–39 years: β = 0.45 in., 95% CI 0.17, 0.72). High versus low self-reported PA was also associated with greater VO2Max (β =: 0.81–1.41 mL/kg/min). Self-reported strength training for ≥2 days/week was associated with greater VO2Max in 19–29 year old men (β = 0.84 mL/kg/min, 95% CI 0.09, 0.60) and 30–39 year old women (β = 0.74 mL/kg/min, 95% CI 0.02, 1.46). For younger men and women, Conclusions Self-reported PA and screen time were associated with some objective PF measures, including VO2Max and AC. However, screen time alone was associated with PFA failure.

Board of nursing (BON) approval of registered nurse (RN) education programs is vital for protecting the public. The purpose of BON program approval is to ensure the program comprehensively covers the knowledge and skills that students will need to be licensed as an RN and to practice safely and competently as new graduate nurses. Most states require BONs to approve a nursing program before it is open for enrollment and then monitor all programs on an ongoing basis. This article presents key regulatory components of RN education programs, discusses the BON approval process of RN education programs, and identifies challenges and ideas for future consideration.

Twenty-seven vocational and 61 professional nursing education programs in Texas were required to write self-study reports (SSRs) during 3 years based on the 2013, 2014, and 2015 National Council Licensing Examination pass rates. The comprehensive self-analysis of each SSR resulted in potential factors that may have contributed to the pass rates and program-directed plans for correction and quality improvement. Texas Board of Nursing (BON) staff summarized findings from the 88 SSRs. They identified common program factors and planned interventions for improvement. The most frequently mentioned areas for improvement included revising admission and readmission criteria, identifying at-risk students and providing remediation, revising and enforcing program policies, updating curriculum, basing decisions on program evaluation data, and evaluating the use of standardized examinations in the program. At the end of the 3 years, as a part of program monitoring, Texas BON staff surveyed the 88 programs to determine which interventions were most effective. Upon comparing findings from the vocational, associate degree, and baccalaureate degree nursing programs, three common interventions were deemed "extremely effective" for all program types: identifying at-risk students earlier, providing timely remediation for at-risk students, and enforcing program policies.

Smoking rates among U.S. Service members and veterans have been consistently higher than in civilian populations. While much has been published about tobacco use in both military and veteran populations, smoking patterns during transition from military to veteran status remains unclear. We studied military members participating in the Millennium Cohort Study, who separated from their respective Services between baseline and first follow-up survey ( N = 5,510). Two generalized estimating equation models were used to examine any association between smoking status and time to military separation (days between baseline survey and separation), as well as smoking during transition and reason for separation. Reason for separation was categorized into three groups: (1) not meeting military standards or judicial-related reasons, (2) drugs-/alcohol-related misconduct, and (3) other types of separation including retirement, pregnancy, and so on. Statistical models accounted for baseline smoking and demographic/military/health behavioral/mental health characteristics. Overall, we observed a decline in smoking prevalence over time (19.5%, 16.7%, 15.2%, and 12.6%, respectively). However, we found a 22% increase in the odds of smoking among those who stayed in the military between 3 months and 1 year, compared to those who stayed 2+ years. Additionally, participants separating for standard/judicial reason(s) showed 69% increased smoking compared to those with other reasons for separation. The time period immediately prior to Service separation and certain types of separation were associated with increased odds of smoking. Thus, smoking cessation interventions should target Service members during this transition period to potentially reduce smoking prevalence after separation.

Sexual harassment (SH) and sexual assault (SA) continue to be a focus of prevention efforts in the U.S. military because of the prevalence and potential to affect the health and readiness of service members. Limited research exists on the association of SH and SA with coping behaviors, such as physical activity, within the military. Data including self-reported SA, SH, and physical activity were obtained from the Millennium Cohort Study, a longitudinal cohort study designed to examine the impact of military service on the health and well-being of service members. A hierarchical regression approach was applied to examine the association between SH or SA and subsequent physical activity levels. Hierarchical regression showed that, among those self-reporting recent SA, the odds of medium-high (300-449 min/week) and high physical activity levels (≥450 min/week) were significantly increased. Although the magnitude of these associations was attenuated with an increasing amount of adjustment, the odds of high physical activity levels remained statistically significant in the fully adjusted model (medium-high: odds ratio [OR] = 1.72, 95% confidence interval [CI] = [1.08, 2.73]; high: OR = 1.58, 95% CI = [1.02, 2.44]). We observed statistically significant negative associations between recent SH and medium-high physical activity levels in adjusted models (OR = 0.70, 95% CI = [0.54, 0.91]). The current results demonstrate that SA is generally associated with increased levels of physical activity among military service members. Analyzing the relationship between sexual trauma and physical activity is valuable because of the high prevalence of SH and SA in the military, long-term health implications including physical and emotional well-being, and potential impact on military readiness.

SummaryBackground Crohn's disease (CD) and ulcerative colitis (UC) are two pathotypes of inflammatory bowel disease (IBD) with unique pathology, risk factors and significant morbidity. Aim To estimate incidence and identify IBD risk factors in a US military population, a healthy subset of the US population, using information from the Millennium Cohort Study. Methods Incident IBD was identified from medical encounters from 2001 to 2009 or by self-report. Our primary risk factor of interest, infectious gastroenteritis, was identified from medical encounters and self-reported post-deployment health assessments. Other potential risk factors were assessed using self-reported survey responses and military personnel files. Hazard ratios were estimated using Cox proportional hazards analysis. Results We estimated 23.2 and 21.9 diagnoses per 100 000 person-years, respectively, for CD and UC. For CD, significant risk factors included [adjusted hazard ratio (aHR), 95% confidence interval]: current smoking (aHR: 2.7, 1.4–5.1), two life stressors (aHR: 2.8, 1.4–5.6) and prior irritable bowel syndrome (aHR: 4.7, 1.5–15.2). There was no significant association with prior infectious gastroenteritis. There was an apparent dose–response relationship between UC risk and an increasing number of life stressors. In addition, antecedent infectious gastroenteritis was associated with almost a three-fold increase in UC risk (aHR: 2.9, 1.4–6.0). Moderate alcohol consumption (aHR: 0.4, 0.2–0.6) was associated with lower UC risk. Conclusions Stressful conditions and the high risk of infectious gastroenteritis in deployment operations may play a role in the development of IBD in military populations. However, observed differences in risk factors for UC and CD warrant further investigation.

Study Design. A prospective cohort study. Objective. Activities performed during military operations vary in complexity and physical demand. The risk for mental illness following military combat deployment has been well documented. However, information regarding the possible contribution of back pain to decreased mental and functional health is scarce. To our knowledge, this is the first study to prospectively assess deployment and self-reported recent back pain in a population-based U.S. military cohort. Summary of Background Data. The study consisted of Millennium Cohort participants who were followed for the development of back pain for an average of 3.9 years. Methods. Descriptive statistics and longitudinal analyses were used to assess the temporal relationship of deployment with self-reported recent back pain at follow-up (N = 53,933). Results. Recent back pain was self-reported by 8379 (15.5%) participants at follow-up. After adjusting for covariates, deployers with combat experiences had higher odds [odds ratio (OR) = 1.38, 95% confidence interval (95% CI): 1.28–1.50] of recent back pain than noncombat deployers. There was no association between recent back pain and nondeployers compared with noncombat deployers. Service support/supply handlers were at an increased odds of reporting recent back pain (OR = 1.11, 95% CI: 1.02–1.21) than functional support/administration occupations. Occupations associated with a physically demanding work environment had a higher risk of back pain. Conclusion. Deployers with combat experiences were more likely to report back pain postdeployment. This well-defined group of military personnel may potentially benefit from integrated prevention efforts. Level of Evidence: 3

Introduction The Texas Board of Nursing charged a task force with studying the growth of nursing programs and developing a guideline to assist programs with the associated challenges. Methods The task force distributed a survey to 214 nursing programs across the state to solicit responses from faculty members, students, and clinical partners about the current environment for clinical instruction. Results The 1,251 responses provided data on areas of satisfaction and areas for improvement in clinical instruction. Conclusion Recommendations in the resulting guideline suggest that programs should use more simulation experiences and a variety of clinical sites to relieve the congestion in acute-care settings.

OBJECTIVES: Functional gastrointestinal disorders occur more frequently among deployed veterans, although studies evaluating the relative impact of risk factors, including stress and antecedent infectious gastroenteritis (IGE), are limited. We examined risk factors for new-onset irritable bowel syndrome (IBS) among active duty participants in the military's Millennium Cohort Study. METHODS: Medical encounter data from 2001 to 2009, limited to Cohort members on active duty, were used to identify incident IBS cases (any and highly probable). IGE was identified using medical encounter or self-report. Covariate data were obtained from the Millennium Cohort Study surveys and analyzed using Cox proportional hazards methods. RESULTS: Overall, 41,175 Cohort members met the eligibility criteria for inclusion and 314 new-onset cases of IBS were identified among these. Significant risk factors (adjusted hazard ratio, 95% confidence interval) included antecedent IGE (2.05, 1.53–2.75), female gender (1.96, 1.53–2.52), number of life stressors (1: 1.82, 1.37–2.41; 2: 2.86, 2.01–4.06; 3+: 6.69, 4.59–9.77), and anxiety syndrome (1.74, 1.17–2.58). Limited to highly probable IBS, a stronger association with antecedent IGE was observed, particularly when based on medical encounter records (any IGE: 2.20, 1.10–4.43; medical encounter IGE only: 2.84, 1.33–6.09). Precedent anxiety or depression and IGE interacted with increased IBS risk compared with IGE alone. CONCLUSIONS: These results confirm previous studies on the association between sociodemographic or life stressors and IBS. IGE was significantly associated with IBS risk. Whether deployed or not, US service members often encounter repeated exposure to high levels of stress, which, combined with other environmental factors such as IGE, may result in long-term debilitating functional gastrointestinal disorders.

The National Council of State Boards of Nursing (NCSBN) published the results of the largest, most comprehensive study to date concerning the use of simulation as a substitute for traditional clinical experience. Results of the study, which were published in 2014, demonstrated that high-quality simulation experiences could be substituted for up to 50% of traditional clinical hours across the prelicensure nursing curriculum. An expert panel convened by NCSBN evaluated the data gathered through this study, examined previous research and the International Nursing Association for Clinical Simulation and Learning Standards of Best Practice: SimulationSM, and used their collective knowledge to develop national simulation guidelines for prelicensure nursing programs. This article presents those guidelines, evidence to support the use of simulation, and information for faculty and program directors on preparation and planning for using simulation successfully in their nursing programs.

The objective of this study was to define the risk of hearing loss among US military members in relation to their deployment experiences. Data were drawn from the Millennium Cohort Study. Self-reported data and objective military service data were used to assess exposures and outcomes. Among all 48,540 participants, 7.5% self-reported new-onset hearing loss. Self-reported hearing loss showed moderate to substantial agreement (k = 0.57-0.69) with objective audiometric measures. New-onset hearing loss was associated with combat deployment (adjusted odds ratio [AOR] = 1.63, 95% confidence interval [CI] = 1.49-1.77), as well as male sex and older age. Among deployers, new-onset hearing loss was also associated with proximity to improvised explosive devices (AOR = 2.10, 95% CI = 1.62-2.73) and with experiencing a combat-related head injury (AOR = 6.88, 95% CI = 3.77-12.54). These findings have implications for health care and disability planning, as well as for prevention programs.

Background Potential adverse mental health effects of deployment, including depression, are an ongoing concern. Although a previous study assessed under-reporting of depression on post-deployment health assessments compared to anonymous surveys, those results were not examined at the individual level to identify demographic or military factors that may be associated with unwillingness to report depression symptoms. Purpose To compare self-reported depression symptoms on post-deployment health assessments with responses to the same depression questions on a research survey. Methods This cross-sectional study analyzed depression screening responses from 2001 to 2008 from participants of the Millennium Cohort Study, a longitudinal military cohort study, who completed a post-deployment health assessment within 30 days of a research survey. Kappa statistics and percent positive and negative agreement were calculated. Demographic and military characteristics associated with discordant screening results were examined. Initial analyses were performed in 2011, with additional analyses in 2013. Results Moderate agreement (κ=0.464) was observed between paired survey responses. A higher proportion of active duty members, the unmarried, and new accessions into military service endorsed depression symptoms on the research survey but not the military-linked survey. In stratified analyses, agreement was higher in Reserve/National Guard members than active duty (κ=0.561 vs 0.409). New active duty accessions showed lower agreement (κ=0.388), as did unmarried active duty participants (κ=0.304). Conclusions Deployment health surveys are important tools for identifying returning service members experiencing depression symptoms. However, these findings suggest that ongoing stigma and barriers to appropriate follow-up mental health care remain to be addressed in the military setting.

This article presents the educational preparation of licensed vocational (practical) nurses (LVNs) in Texas and the boundaries of the LVN scope of practice before describing the case against an LVN for violating those boundaries. The recounting of the case includes the actions of the LVN during a home health visit, the basis of the complaint filed against her for practicing outside her scope of practice, the subsequent hearing before an administrative law judge (ALJ), and the conflicting findings by the ALJ and the board of nursing.

Norovirus (NoV) has been identified as a significant cause of acute gastrointestinal illness among deployed military troops. We conducted a cost-effectiveness analysis for the use of a NoV vaccine in the military using a previously developed model that evaluated vaccines for ETEC, Campylobacter, and Shigella for prevention of non-outbreak associated travelers' diarrhea. Under conservative assumptions, acquisition of a NoV vaccine by the Department of Defense is estimated to result in a cost-effectiveness ratio per duty day lost to illness (CERDDL) of $1344 compared to a CERDDL of $776, $800, and $1275 for ETEC, Campylobacter sp., and Shigella sp., respectively compared to current management strategies. The absolute value of avoiding a duty day lost is likely to vary under different scenarios, and further study is needed to evaluate how improved diagnostics and prevention of outbreaks may impact the relative value of this vaccine. Overall, this study demonstrates the utility of a previously established evidence-based decision tool for prioritization of vaccine acquisition in an important target population.

OBJECTIVE Research has suggested that a higher risk of type 2 diabetes associated with sleep characteristics exists. However, studies have not thoroughly assessed the potential confounding effects of mental health conditions associated with alterations in sleep. RESEARCH DESIGN AND METHODS We prospectively assessed the association between sleep characteristics and self-reported incident diabetes among Millennium Cohort Study participants prospectively followed over a 6-year time period. Surveys are administered approximately every 3 years and collect self-reported data on demographics, height, weight, lifestyle, features of military service, sleep, clinician-diagnosed diabetes, and mental health conditions assessed by the PRIME-MD Patient Health Questionnaire and the PTSD Checklist–Civilian Version. Statistical methods for longitudinal data were used for data analysis. RESULTS We studied 47,093 participants (mean 34.9 years of age; mean BMI 26.0 kg/m2; 25.6% female). During 6 years of follow-up, 871 incident diabetes cases occurred (annual incidence 3.6/1,000 person-years). In univariate analyses, incident diabetes was significantly more likely among participants with self-reported trouble sleeping, sleep duration CONCLUSIONS Trouble sleeping and sleep apnea predict diabetes risk independent of mental health conditions and other diabetes risk factors.

To evaluate predeployment sleep duration and insomnia symptoms in relation to the development of mental health symptoms.Longitudinal cohort study.The Millennium Cohort Study survey is administered via a secure website or US mail.Data were from 15,204 participants who completed their first deployment between the submissions of 2 consecutive Millennium Cohort questionnaires (2001-2008).N/A.Using self-reported data from the Millennium Cohort Study we evaluated the association of predeployment sleep duration and insomnia symptoms on the development of new-onset mental disorders among deployers. Multivariable logistic regression was used to estimate the odds of developing posttraumatic stress disorder (PTSD), depression, and anxiety, while adjusting for relevant covariates including combat-related trauma. The study outcomes were assessed using validated instruments, including the PTSD checklist-civilian version, and the PRIME-MD Patient Health Questionnaire. We identified 522 people with new-onset PTSD, 151 with anxiety, and 303 with depression following deployment. In adjusted models, combat-related trauma and predeployment insomnia symptoms were significantly associated with higher odds of developing posttraumatic stress disorder, depression, and anxiety postdeployment.Sleep characteristics, especially insomnia symptoms, are related to the development of mental disorders following military deployments. Assessment of insomnia symptoms predeployment may help to better identify those at highest risk for subsequent adverse mental health outcomes.Gehrman P; Seelig AD; Jacobson IG; Boyko EJ; Hooper TI; Gackstetter GD; Ulmer CS; Smith TC; for the Millennium Cohort Study Team. Predeployment sleep duration and insomnia symptoms as risk factors for new-onset mental health disorders following military deployment.

The number and size of RN-to-BSN programs have grown rapidly since the Institute of Medicine's recommendation that the proportion of registered nurses (RNs) with BSNs be increased to 80% by 2020. Although recognition of the importance of a BSN is welcome, the rapid expansion in the number and size of these programs raises questions about how to define program content and ensure quality in the absence of national benchmarks. Additionally, questions have been raised about what outcomes and competencies should be expected from graduates of these programs. As a source that explicitly outlines expected competencies based on level of nursing education, the Differentiated Essential Competencies of Graduates of Texas Nursing Programs is suggested as a starting place to address these questions. This article describes and recommends a national metric of quality indicators of excellence in RN-to-BSN programs.

Maternal depression is a common condition among new mothers that can be associated with poor maternal health and negative consequences on infant health. Little research has been conducted to examine maternal depression, especially among military mothers, where unique conditions often exist. Using data from a large military cohort, this study prospectively examined the relationship between deployment experience before and after childbirth and maternal depression among U.S. service women.The study included 1,660 female Millennium Cohort participants who gave birth during active duty service and completed baseline and follow-up questionnaires between 2001 and 2008. Maternal depression was assessed at follow-up using Primary Care Evaluation of Mental Disorders Patient Health Questionnaire criteria.Deployment before childbirth, regardless of combat experience, and deployment without combat experience after childbirth did not increase the risk of maternal depression. Women who deployed and reported combat experience after childbirth were at increased risk for maternal depression compared with nondeployed women who gave birth (adjusted odds ratio [OR] 2.01, 95% confidence interval [CI] 1.17-3.43). Among the subgroup of female combat deployers, however, women who gave birth did not have a significantly increased risk for depression compared with those who did not give birth.Military women who deployed with combatlike experiences after childbirth were at increased risk for postdeployment maternal depression. The risk, however, appeared primarily related to combat rather than childbirth-related experiences.

Previous research has shown that military women often experience potentially severe health outcomes following deployment. Data from the Millennium Cohort Study, a 21-year longitudinal study examining the health effects of military service, were used to examine this issue. In longitudinal analyses (2001-2008) carried out among US military women (n = 17,481), the authors examined positive screens for depression, anxiety, panic, and posttraumatic stress disorder in relation to deployment in support of the operations in Iraq and Afghanistan, while adjusting for relevant baseline and time-varying covariates. Women who were deployed and reported combat-related exposures had greater odds than nondeployed women of reporting symptoms of a mental health condition (odds ratio = 1.91, 95% confidence interval: 1.65, 2.20), after adjustment for demographic, military, and behavioral covariates. In addition, higher stress, problem drinking, and a history of mental illness were significantly associated with increased risk of later mental health conditions. In contrast, women in the Reserves or National Guard and those with higher education were at decreased risk of mental health conditions (all P 's < 0.01). As the roles and responsibilities of women in the military expand and deployments continue, designing better prevention and recovery strategies specifically for women are critical for overall force health protection and readiness.

Concerns about social work students' writing are well documented, but the cost of specialized writing programs leaves budget-stressed programs confronting a problem they may feel they have few means to address. However, a valuable resource is already available: faculty expertise in social work writing. The challenge is helping faculty realize their knowledge is not transparent to students; it must be taught, intentionally and explicitly, in undergraduate social work classrooms. Engaging faculty in a process of articulating their expectations will help them elicit more effective student writing and change their attitudes toward student writing from frustrated to excited and optimistic.

In the United Kingdom and United States, these two independent cohort studies have been instituted to prospectively study the health of service personnel and veterans. From comparisons with baseline information, these studies are designed to better inform the military and the public on how best to protect the health of their armed forces and better understand the long-term risks of some occupational exposures that extend beyond military communities. In order to do this, these studies consider: 1) The underlying physical and mental health of the military populations before, during, and after military service; and 2) The specific effects of deployment, deployment-related exposures, and other occupational exposures upon personnel compared with unexposed subgroups. Whilst previous studies have attempted to address these topics, they have often been limited in their generalisability to all service branches and components of the military, or previous population-based methodologies have been largely limited to cross-sectional or retrospective methods. Although follow-up to the National Vietnam Veterans Readjustment Survey, called the National Vietnam Veterans Longitudinal Study, is still ongoing, this study is focused on a single deployment. Similarly, the Air Force Health study, a 20-year longitudinal study of approximately 20,000 Vietnam veterans, assessed potential health effects associated with exposure to aerial spraying of dioxins. Here, we present two prospective, longitudinal, multi-service studies of active duty and Reserve/National Guard personnel that will continue to follow participants even after they have left military service. We describe these two studies in detail, comparing study populations, methodology, and the published literature so far. Potential areas for future collaboration are also explored. By understanding the inherent similarities and differences between these two cohorts and leveraging each study?s unique strengths and strategies to minimize

(Headache 2011;51:1098-1111) Objective.— Characterize migraine and other headache disorders within a large population-based US military cohort, with an emphasis on the temporal association between military deployment and exposure to combat. Background.— Little research has been published on the prevalence of headache disorders in the US military population, especially in relation to overseas deployments and exposure to combat. A higher than expected prevalence of migraine has previously been reported among deployed US soldiers in Iraq, suggesting an association. Headache disorders, including migraine, could have important effects on the performance of service members. Methods.— A total of 77,047 US active-duty, Reserve, and National Guard members completed a baseline questionnaire between July 2001 to June 2003 for the Millennium Cohort Study. Headache disorders were assessed using the following survey-based measures: self-reported history of provider-diagnosed migraine, recurrent severe headache within the past year, and recent headaches/bothered a lot within the past 4 weeks. Follow-up surveys were completed on average 3 years after baseline (mean = 2.7 years; range = 11.4 months to 4.5 years). Results.— The overall male and female prevalence of self-reported headache conditions at baseline were: provider-diagnosed migraine, 6.9% and 20.9%, respectively; recurrent severe headache, 9.4% and 22.3%, respectively; and bothered a lot by headaches, 3.4% and 10.4%, respectively. Combat deployers had significantly higher odds of any new-onset headache disorders than non-deployers (adjusted odds ratios = 1.72 for men, 1.84 for women; 95% confidence intervals, 1.55-1.90 for men, 1.55-2.18 for women), while deployers without combat exposure did not. Conclusions.— Deployed personnel with reported combat exposure appear to represent a higher risk group for new-onset headache disorders. The identification of populations at higher risk of development of headache provides support for targeted interventions.

Objective: We estimated the prevalence of children with life-threatening conditions (LTC) cared for in the military health system (MHS) in response to a Congressional inquiry and to inform program planning. Methods: We developed a case definition of LTC, using the concept ‘‘death trajectory’’1,2 to define our cases. We conducted an unduplicated count of children with LTC in the MHS database during FY 2001/FY 2002 using selected ICD-9 codes based on our case definition. We then surveyed the literature for reported prevalence of LTC among children with similar case definitions. The concept of ‘‘death trajectory’’ describes non-categorical life-threatening conditions of four types: progressive decline to death (e.g., spinal muscular atrophy); intermittent periods of intensive care to maintain quality-of-life (e.g., cystic fibrosis); curative treatment is possible but may fail (e.g., childhood cancers); and severe but non-progressive disability with extreme health vulnerability (e.g., spastic quadriplegia with tracheotomy). Results: There were 3,976 children identified with LTC in a population of 2.6 million children, for a prevalence of 0.15%. Conclusion: A prevalence of 0.15% for children with LTC in the MHS population agrees closely with that derived for similar case definitions by other authors among populations of children in other single-payer health care systems (i.e., United Kingdom). The method used here may apply to similar health care systems with ICD 9 codes in a searchable database.

ACCORDING TO A 2008 REPORT FROM THE NATIONAL SLEEP FOUNDATION, AMERICANS ARE WORKING MORE AND SLEEPING LESS, WITH THE AVERAGE work day lasting 9 hours 28 minutes and time in bed only 6 hours 55 minutes.1 The US military is at particularly high risk for sleep disturbances due to hazardous working conditions, inconsistent work hours, harsh environments, routine exposure to loud noises, and crowded sleeping spaces.2,3 Exposures to these adverse working conditions are often intensified during deployments, including the current increased operational tempo, with lengthy and frequent deployments, as well as demanding training exercises. Deployment-related factors may lead to sleep complaints, including circadian desynchronosis, total or partial sleep deprivation, lengthy sleep latency, and wakening after sleep onset that may, in turn, exacerbate mental and physical health symptoms following deployment.2,3 The quantity and quality of sleep affect many aspects of physical and mental health.4–12 Military personnel deployed in support of Operation Iraqi Freedom and Operation Enduring Freedom may be at increased risk for chronic sleep loss, as well as many other adverse physical and mental conditions, compared with nondeployed military personnel.13–15 Sleep deprivation has been studied extensively and is associated with many physical and psychological effects, including increased risk-taking behavior,7,11 decreased threat detection,10 impaired decision making,7,11,12 performance degradation,4,8,9 mood disturbances,8 and tunnel vision.6 Short sleep duration has also been associated with obesity, weight gain, and heart disease.5,16,17 A recent cross-sectional study of 156 deployed US Air Force Airmen found that 40% of respondents suffered from at least 1 sleep disturbance, and 75% of respondents reported diminished sleep quality while deployed when compared to sleep quality at home.3 The purpose of this study was to determine any association between deployment in support of the operations in Iraq and Afghanistan and sleep quantity and quality in a large military population. We hypothesized that military personnel who had deployed would have more trouble sleeping and sleep less than those who have not deployed. The Millennium Cohort Study18 includes all Service branches of the US military, active-duty, Reserve, and National Guard personnel. A substantial proportion (22%) of cohort members were deployed in support of the operations in Iraq and Afghanistan between baseline and follow-up surveys. This population provided valuable information on sleep patterns, as well as behavioral, occupational, and demographic characteristics among participants who completed their survey during and after deployment.

OBJECTIVE Few prospective data exist on the risk of diabetes in individuals serving in the U.S. military. The objectives of this study were to determine whether military deployment, combat exposures, and mental health conditions were related to the risk of newly reported diabetes over 3 years. RESEARCH DESIGN AND METHODS Data were from Millennium Cohort Study participants who completed baseline (July 2001–June 2003) and follow-up (June 2004–February 2006) questionnaires (follow-up response rate = 71.4%). After exclusion criteria were applied, adjusted analyses included 44,754 participants (median age 36 years, range 18–68 years). Survey instruments collected demographics, height, weight, lifestyle, military service, clinician-diagnosed diabetes, and other physical and mental health conditions. Deployment was defined by U.S. Department of Defense databases, and combat exposure was assessed by self-report at follow-up. Odds of newly reported diabetes were estimated using logistic regression analysis. RESULTS Occurrence of diabetes during follow-up was 3 per 1,000 person-years. Individuals reporting diabetes at follow-up were significantly older, had greater baseline BMI, and were less likely to be Caucasian. After adjustment for age, sex, BMI, education, race/ethnicity, military service characteristics, and mental health conditions, only baseline posttraumatic stress disorder (PTSD) was significantly associated with risk of diabetes (odds ratio 2.07 [95% CI 1.31–3.29]). Deployments since September 2001 were not significantly related to higher diabetes risk, with or without combat exposure. CONCLUSIONS In this military cohort, PTSD symptoms at baseline but not other mental health symptoms or military deployment experience were significantly associated with future risk of self-reported diabetes.

The authors examined the association between prescribed medications and fatal motor vehicle crashes (MVCs) in an active duty military population between 2002 and 2006. Using a case-control design, MVC deaths were ascertained using a military mortality registry, and an integrated health system database provided information on health system eligibility, pharmacy transactions, and medical encounters. Cases and controls were matched on comparable observation time outside periods of deployment. Among selected categories, only one, antidepressant medications, was an independent predictor of fatal MVC (odds ratio, 3.19; 95% confidence interval, 1.01-10.07). Male gender, Black race, enlisted rank, service branch (Navy and Marine Corps), and selected co-morbidities were also independent predictors. Unexpectedly, the odds of younger age quartiles (

Background: To sustain progress toward injury reduction and other health promotion goals, public health organizations need a systematic approach based on data and an evaluation of existing scientific evidence on prevention. This paper describes a process and criteria developed to system- atically and objectively define prevention program and policy priorities. Methods: Military medical surveillance data were obtained and summarized, and a working group of epidemiology and injury experts was formed. After reviewing the available data, the working group used predefined criteria to score leading military unintentional injury causes on five main criteria that assessed factors contributing to program and policy success: (1) importance of the problem, (2) effectiveness of existing prevention strategies, (3) feasibility of establishing programs and policies, (4) timeliness of implementation and results, and (5) potential for evaluation. Injury problems were ranked by total median score. Results: Causes with the highest total median scores were physical training (34 points), military parachuting (32 points), privately-owned vehicle crashes (31 points), sports (29 points), falls (27 points), and military vehicle crashes (27 points). Conclusions: Using a data-driven, criteria-based process, three injury causes (physical training, military parachuting, and privately owned-vehicle crashes) with the greatest potential for successful program and policy implementation were identified. Such information is useful for public health practitioners and policymakers who must prioritize among health problems that are competing for limited resources. The process and criteria could be adapted to systematically assess and prioritize health issues affecting other communities.

Infectious diarrhea is one of the many threats to the deployed military, and given limited resources, a decision to pursue a vaccine acquisition strategy should be based on best evidence that weighs costs and benefits compared to alternatives. An economic model was developed to estimate the marginal cost to avert a duty day lost due to diarrhea for a vaccine acquisition strategy compared to current clinical management, for both multiplex and pathogen-specific vaccines. Vaccines against Campylobacter and enterotoxigenic Escherichia coli appeared to be more favorable than a Shigella vaccine. This model provides an evidence-based decision tool to support prioritization in vaccine development.

The Joint Medical Work Station (JMeWS) is a theater medical surveillance system that integrates information from three separate health data collection systems for the Army, Navy, Air Force, and Marines. Our objective was to characterize JMeWS data during its first year of implementation in 2003. We conducted a descriptive analysis of health events documented in JMeWS among military personnel deployed to Operations Enduring Freedom and Iraqi Freedom. Among the 38,498 individuals (7.8%) with a JMeWS record, women, college-educated, older individuals, and Reserve/Guard personnel were over-represented. There was wide variability by service (Air Force, 25%; Army, 5.5%; Marine Corps, 1.2%; and Navy, 0.6%). The most common diagnoses were in the categories of injury and poisoning, respiratory conditions, and musculoskeletal disorders. Differences in distribution of the various patient encounter modules in theater likely resulted in variable data capture across services. System enhancements should improve future applications.

Objective: We examined common factors in vehicular drowning deaths that might lead to changes in equipment or training. Methods: Drowning deaths among service members deployed to Operations Iraqi Freedom or Enduring Freedom, 2003 to 2005, were ascertained using the Armed Forces Medical Examiner Tracking System database. Cases were linked to Army and Navy safety and investigative files. Results: Fifty-two cases of vehicular drowning deaths were identified. These occurred mostly at night, were almost always the result of a rollover, and were most frequently associated with a high-mobility medium-weight vehicle. Seat belts were rarely worn, but the majority of injuries should not have been severe enough to affect egress from the vehicle. These drowning deaths seldom occurred while engaged with the enemy and were rarely associated with bad road conditions or bad weather. Conclusions: Effective preventive strategies might focus on training and equipment to reduce rollover events and on the expeditious...

Objective In response to health concerns of military members about deployment and other service-related exposures, the Department of Defense (DoD) initiated the largest prospective study ever undertaken in the U.S. military. Study Design and Setting The Millennium Cohort uses a phased enrollment strategy to eventually include more than 100,000 U.S. service members who will be followed up through the year 2022, even after leaving military service. Subjects will be linked to DoD and Veterans Affairs databases and surveyed every 3 years to obtain objective and self-reported data on exposures and health outcomes. Results The first enrollment phase was completed in July 2003 and resulted in 77,047 consenting participants, well representative of both active-duty and Reserve/Guard forces. This report documents the baseline characteristics of these Cohort members, describes traditional, postal, and Web-based enrollment methods; and describes the unique challenges of enrolling, retaining, and following such a large Cohort. Conclusion The Millennium Cohort was successfully launched and is becoming especially relevant, given current deployment and exposure concerns. The Cohort is representative of the U.S. military and promises to provide new insight into the long-term effects of military occupations on health for years to come.

Motor vehicle crashes (MVCs) are an important cause of morbidity and premature loss of life among military personnel during peacetime and particularly following combat. A nested case-control study of fatal MVC occurring between 1991 and 1995 was conducted in a cohort of Gulf War era veterans. Cases were validated MVC deaths in the Fatality Analysis Reporting System. Controls were selected using risk set sampling by gender and year of case ascertainment in a 10:1 ratio. Preliminary results, consistent with previous reports of increased fatal MVC risk among returning combat veterans, showed a crude odds ratio of 1.45 (95% confidence interval 1.27-1.65). Multivariable logistic regression modeling was used to identify important independent predictors, as well as to quantify the influence of deployment on a risk profile for fatal MVC. Because of significant interaction between deployment and inpatient diagnosis of substance abuse, the final model was stratified by deployment status. Results suggest that demographic, military, and behavioral characteristics of deployed healthy warriors are similar to the risk profile for fatal MVC. In addition to young, single, high school-educated, enlisted male personnel, those who served during times of ground combat, particularly in infantry, gun crews, or seamanship occupations, should be targeted for preventive interventions.

Our objective was to describe fatal motor vehicle crashes (MVC) among veterans of the 1991 Gulf War era and to compare the distribution of crash and individual characteristics between those deployed to the Gulf War (GWV) and those not deployed (NDV).We compared individual characteristics, crash mechanisms, and crash circumstances between 765 GWV and 553 NDV who died from MVC within the first five years of the war, between May 1991 and December 1995.Overall, GWV and NDV who died from a MVC were more likely to be enlisted males (97%), 21-30 years old (72%), have a high school education or less (91%), drive a passenger car (52%), and not use restraints (60%). The overall annual rate of motor vehicle fatalities for GWV (23.6 per 100,000; 95% confidence interval: 21.9-25.3) was significantly greater than the rate for NDV (15.9, 95% CI: 14.6-17.3). GWV with the highest motor vehicle fatality rates include males (24.8, 95% CI: 23.0-26.6), 17-20 year olds (105.0, 95% CI: 78.2-138.1), and those not married (27.3, 95% CI: 25.1-30.1). Adjusting for differences in age distribution across GWV and NDV did not account for the difference in rates. Characteristics of MVC fatalities that were over-represented among GWV include serving as regular active duty (p = 0.001), having a high school education or less (p = 0.01), being involved in a single-vehicle crash (p = 0.008), and dying within the first hour following the crash (p = 0.004). Also, we identified a greater proportion of alcohol-related crashes among GWV during the late night and early morning hours.The highest rates of motor vehicle fatality among young, single males in the military mirror the experience of the general population. Further research is necessary to determine modifiable risk factors that can be targeted for specific interventions and whether the elevated late night alcohol-related crash rate among GWV is an effect of deployment or an inherent population bias among those selected for operational deployments.

BACKGROUND: A proposed explanation for the observed higher risk of fatal motor vehicle crashes (MVC) among 1991 Gulf War-deployed veterans is neurocognitive deficits resulting from nerve agent exposure at Khamisiyah, Iraq. Our objective was to assess any association between postwar fatal MVC and possible nerve agent exposure based on 2000 modeled plume data. METHODS: Cases were defined as MVC deaths with a record in the Department of Transportation Fatality Analysis Reporting System through 1995. Cases (n = 282) and controls (n = 3,131) were derived from a larger nested case-control study of Gulf War-era veterans and limited to Army, male, deployed personnel. Exposure and cumulative dose by case-control status were analyzed using multivariate techniques. RESULTS: Exposure status was not associated with fatal MVC (OR 0.96, 95% CI 0.72-1.26), nor were tertiles of cumulative dose. CONCLUSIONS: Findings do not support an association between possible exposures at Khamisiyah and postwar fatal MVC among Gulf War veterans.

The aim of this article is to share our experiences from an international collaborative effort to study health outcomes among Saudi Arabian National Guard (SANG) soldiers following the 1991 Gulf War. By paying particular attention to distinct social and religious customs, geopolitical differences, and unique aspects of the health care system, we achieved a successful international collaboration in health research.

Attrition among medical students is a concern for the institution, the individual, and the profession. Disenrollment has an impact on the institution, in terms of academic reputation and resources expended, and the individual, in terms of self-esteem, personal finances, and opportunity costs. This study summarizes the results of an epidemiologic study of student attrition conducted at the only federal medical school in the United States--the Uniformed Services University of the Health Sciences in Bethesda, Maryland--and describes the association between demographic and selected quantitative variables for those students who graduated or remained enrolled and those who disenrolled. Both sex (female) and a decelerated curriculum were predictive of attrition in this medical student population. The records of the students who left Uniformed Services University of the Health Sciences without graduating were examined to ascertain the presence of noncognitive issues surrounding disenrollment; over one-half of the students who disenrolled left voluntarily and for nonacademic reasons.

SUMMARY Family practices related to hygiene, affection behavior, and privacy were studied using a sample of mental health and child welfare professionals. The professionals were asked to use their own experience to state up to what age it was acceptable for parents and children of the same gender and mixed gender to engage in certain family practices. For virtually all family practices, respondents reported lower appropriate ages for mixed gender pairs. Family practices were acceptable for mothers with their daughters up to older ages than fathers with their sons. Results indicate high variability in the responses regarding appropriate ages, as well as whether the behavior was ever acceptable. The implications of these substantial differences among professionals who often assess these practices as “soft signs” related to abuse are discussed.

Since the Gulf War, investigation continues of symptoms and illnesses among its veterans. Yet, identifying a specific "Gulf War Syndrome" remains elusive. With new disease entities, causal associations are relatively easily established when the condition is serious, verifiable, and has excess disease rates in specific groups. In common conditions, many excess cases are required to establish association with a specific exposure. Establishing causality in syndromes with variable symptoms is difficult because specific diagnostic algorithms must be established before causal factors can be properly investigated. Searching for an environmental cause is futile in the absence of an operational disease case definition. Common subjective symptoms (without objective physical or laboratory findings) account for over one-half of all medical outpatient visits, yet these symptoms lack an identified physical cause at least one-third of the time. Our medical care system has difficulty dealing with disorders where there is no identified anatomic abnormality or documented metabolic/physiological dysfunction.

There has been much concern among the public and veterans that specific environmental exposures incurred during the Gulf War were the cause of subsequent illness among Gulf War veterans. In this historical cohort study, the authors compared the postwar morbidity of US military personnel exposed to smoke from the 1991 Kuwaiti oil well fires with that of unexposed personnel. Complete exposure and demographic data were available for 405,142 active-duty Gulf War veterans who did not remain in the region after the war. The authors used data from all Department of Defense hospitals for the period August 1, 1991-July 31, 1999 to estimate rates of hospitalization due to any cause, hospitalization due to a diagnosis in one of 15 major categories, and hospitalization due to one of nine diagnoses likely to be manifestations of smoke exposure. Exposures to particulate matter from oil-well-fire smoke were based on the integration of meteorologic data, diffusion modeling, and troop location data. The authors constructed seven exposure groups combining duration and amount of exposure. In Cox modeling, three of the 25 models showed an increased adjusted risk of hospitalization. However, there was no evidence of a dose-response relation. Despite some limitations, these data do not support the hypothesis that Gulf War veterans have an increased risk of postwar morbidity from exposure to Kuwaiti oil-well-fire smoke.

Symptoms and illnesses reported by veterans of the 1991 Gulf War era are a cause of potential concern for those military members who have deployed to the Gulf region in support of more recent contingency operations in Iraq and Afghanistan. In the present study, we quantified self-reported symptoms from participants in the Millennium Cohort Study, a prospective study representing all US service branches, including both active duty and Reserve/National Guard components (2001-2008). Self-reported symptoms were uniquely compared with those in a cohort of subjects from the 1991 Gulf War to gain context for the present report. Symptoms were then aggregated to identify cases of chronic multisymptom illness (CMI) based on the case definition from the Centers for Disease Control and Prevention. The prevalence of self-reported CMI symptoms was compared with that collected in 1997-1999 from a study population of US Seabees from the 1991 Gulf War, as well as from deployed and nondeployed subgroups. Although overall symptom reporting was much less in the Millennium Cohort than in the 1991 Gulf War cohort, a higher prevalence of reported CMI was noted among deployed compared with nondeployed contemporary cohort members. An increased understanding of coping skills and resilience and development of well-designed screening instruments, along with appropriate clinical and psychological follow-up for returning veterans, might help to focus resources on early identification of potential long-term chronic disease manifestations.

Accidents and injuries, the most common cause of morbidity in military populations, result in a significant number of work days lost each year and account for 75% of all active duty deaths. Rates of accidents and injuries during U.S. Navy submarine deployments have not been evaluated previously. A database designed to monitor the health of submarine crew-members was used to examine the rates and causes of accidents among deployed crewmembers aboard 196 submarine patrols between 1997 and mid 1999. The most common category of injuries was open wounds, followed by sprains and strains, contusions, superficial injuries, burns, and others. Rates of accidents and injuries decreased with increasing age and duration of military service. Among submariners working in supply departments, the rates were more than two times those of crewmembers working in other departments. Based on these data, among a submarine crew of 100 men at sea for 100 days, approximately four to five accidents or injuries might be expected and would result in an average of about 2 days of light or no duty per injury. Rates of accidents and injuries were very low; however, focused safety training could reduce rates among younger and less experienced crewmembers as well as among those working in particular areas of the submarine.

Beginning in 2005, the incidence of suicide deaths in the US military began to sharply increase. Unique stressors, such as combat deployments, have been assumed to underlie the increasing incidence. Previous military suicide studies, however, have relied on case series and cross-sectional investigations and have not linked data during service with postservice periods.To prospectively identify and quantify risk factors associated with suicide in current and former US military personnel including demographic, military, mental health, behavioral, and deployment characteristics.Prospective longitudinal study with accrual and assessment of participants in 2001, 2004, and 2007. Questionnaire data were linked with the National Death Index and the Department of Defense Medical Mortality Registry through December 31, 2008. Participants were current and former US military personnel from all service branches, including active and Reserve/National Guard, who were included in the Millennium Cohort Study (N = 151,560).Death by suicide captured by the National Death Index and the Department of Defense Medical Mortality Registry.Through the end of 2008, findings were 83 suicides in 707,493 person-years of follow-up (11.73/100,000 person-years [95% CI, 9.21-14.26]). In Cox models adjusted for age and sex, factors significantly associated with increased risk of suicide included male sex, depression, manic-depressive disorder, heavy or binge drinking, and alcohol-related problems. None of the deployment-related factors (combat experience, cumulative days deployed, or number of deployments) were associated with increased suicide risk in any of the models. In multivariable Cox models, individuals with increased risk for suicide were men (hazard ratio [HR], 2.14; 95% CI, 1.17-3.92; P = .01; attributable risk [AR], 3.5 cases/10,000 persons), and those with depression (HR, 1.96; 95% CI, 1.05-3.64; P = .03; AR, 6.9/10,000 persons), manic-depressive disorder (HR, 4.35; 95% CI, 1.56-12.09; P = .005; AR, 35.6/10,000 persons), or alcohol-related problems (HR, 2.56; 95% CI, 1.56-4.18; P.001; AR, 7.7/10,000 persons). A nested, matched case-control analysis using 20:1 control participants per case confirmed these findings.In this sample of current and former military personnel observed July 1, 2001-December 31, 2008, suicide risk was independently associated with male sex and mental disorders but not with military-specific variables. These findings may inform approaches to mitigating suicide risk in this population.

OBJECTIVE Research has suggested that a higher risk of type 2 diabetes associated with sleep characteristics exists. However, studies have not thoroughly assessed the potential confounding effects of mental health conditions associated with alterations in sleep. RESEARCH DESIGN AND METHODS We prospectively assessed the association between sleep characteristics and self-reported incident diabetes among Millennium Cohort Study participants prospectively followed over a 6-year time period. Surveys are administered approximately every 3 years and collect self-reported data on demographics, height, weight, lifestyle, features of military service, sleep, clinician-diagnosed diabetes, and mental health conditions assessed by the PRIME-MD Patient Health Questionnaire and the PTSD Checklist–Civilian Version. Statistical methods for longitudinal data were used for data analysis. RESULTS We studied 47,093 participants (mean 34.9 years of age; mean BMI 26.0 kg/m2; 25.6% female). During 6 years of follow-up, 871 incident diabetes cases occurred (annual incidence 3.6/1,000 person-years). In univariate analyses, incident diabetes was significantly more likely among participants with self-reported trouble sleeping, sleep duration

The fur gene product, Fur, of Escherichia coli is a repressor when it binds Fe(II). Since heme and iron metabolism are closely linked and Fur is rich in histidine, a ligand for heme, the binding of heme to Fur was investigated. The oxidized Fur-heme complex is stable and low spin with a Soret maximum at 404 nm and no 620-nm band. CO coordinates with the reduced heme-Fur complex, causing a shift from 412 nm to 410 nm, and stabilizes it, increasing the half-life from 5 to 15 min. Circular dichroism (CD) spectra in the Soret region show heme bound in an asymmetric environment in Fur, both in the oxidized and reduced-CO forms. Quenching of tyrosine fluorescence by heme revealed rapid, tight binding (Kd1 microM) with an unusual stoichiometry of 1 heme:1 Fur dimer. Fur binds Mn(II), a model ligand for the endogenous Fe(II), much more weakly (Kd80 microM). Far-ultraviolet CD spectroscopy showed that the alpha-helix content of apo-Fur decreases slightly with heme binding, but increases with Mn(II) binding. Competition experiments indicated that heme interacts with Fur dimers at the same site as Mn(II) and can displace the metal. In contrast to Mn(II), Zn(II) did not quench the tyrosine fluoroescence of Fur, affected the CD spectrum less than Mn(II), but did bind in a manner which prevented heme from binding. In sum, Fur not only binds heme and Zn(II) with sufficient affinity to be biologically relevant, but the interactions that occur between these ligands and their effects on Mn(II) binding need to be taken into account when addressing the biological function of Fur.