Omowunmi Y. Osinubi

Environmental exposure and health of Operation Enduring Freedom/Operation Iraqi Freedom veterans.

Objective: We characterized the prevalence of self-reported environmental exposures, concerns about exposures, and their relationships with somatic symptoms in Operation Enduring Freedom (Afghanistan) (OEF) and Operation Iraqi Freedom (Iraq) (OIF) veterans seeking treatment at a specialty Veterans Affairs (VA) clinic. Concerns about environmental exposures were expected to lead to more reporting of somatic symptom burden. Methods: We conducted a chart review of 469 OEF/OIF veterans seen at a VA tertiary care clinic. Results: OEF/OIF veterans reported a high level of environmental exposures and concerns about environmental exposures. Greater reported environmental exposures (&bgr; = 0.13) and environmental exposure concerns (&bgr; = 0.39) were associated with a greater somatic symptom burden. Exposure concerns accounted for some of the relationship of exposures on somatic symptom burden (confidence interval, 0.33–0.60). Conclusions: OEF/OIF veterans seeking treatment at a VA clinic reported a high prevalence of environmental exposures and exposure concerns. Both negatively impacted health outcomes.

Use of Adjuvant Systemic Therapy for Early Breast Cancer Among Women 65 Years of Age and Older

BACKGROUND The National Institutes of Health (NIH) consensus statement recommends adjuvant therapy for early breast cancer irrespective of age. However, the actual use of such therapy is not well documented among women over 65 years of age. METHODS We studied the frequency of use of adjuvant therapy and report the receipt of this therapy among 200 women aged > or = 65 years diagnosed with early breast cancer who were identified from the New Jersey State Cancer Registry. RESULTS In this population, 28% of patients received chemotherapy alone or in combination with hormonal therapy, whereas 42% received hormonal therapy alone. Less than half of the women with estrogen receptor-negative tumors received chemotherapy alone or in combination with hormonal treatment. Adjuvant therapy was not prescribed in 30% of patients. CONCLUSIONS Despite NIH recommendations, the frequency of use of adjuvant therapy in New Jersey is low among women over 65 years of age, regardless of their receptor status.

Organizational Factors and Office Workers' Health After the World Trade Center Terrorist Attacks : Long-Term Physical Symptoms, Psychological Distress, and Work Productivity

Objective: To assess if organizational factors are predictors of workers’ health and productivity after the World Trade Center attacks. Methods: We conducted a survey of 750 workers and compared those who had direct exposures to the World Trade Center attacks (south of Canal Street workers; primary victims) with those less directly exposed (north of Canal Street workers; other victims and non-victims). Results: South of Canal Street workers reported headache more frequently than north of Canal Street workers did (P = 0.0202). Primary victims reported headache and cough more frequently than did other victims and non-victims (P = 0.0086 and 0.0043, respectively). Defensive organizational culture was an independent predictor of cough and job stress, and job stress was an independent predictor of on-the-job productivity losses. Conclusion: Organizational variables may modify health and productivity outcomes after a large-scale traumatic event in the workplace.

Bronchodilator Responsiveness and Airflow Limitation Are Associated With Deployment Length in Iraq and Afghanistan Veterans.

Objective: The aim of this study was to determine the relationship between deployment length and indices of airflow obstruction in Iraq and Afghanistan veterans with airborne hazards exposure. Methods: One hundred twenty-four post-9/11 veterans completed pulmonary function testing and questionnaires. We examined the association of airflow limitation [forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC)] and bronchodilator responsiveness (&Dgr;FEV1 and &Dgr;FVC) with deployment length, adjusting for smoking. Results: Longer deployment length was associated with lower FEV1/FVC [&bgr; = −0.19; 95% confidence interval (95% CI), −0.39 to 0.01], greater &Dgr;FEV1 (&bgr; = 0.27; 95% CI, 0.09 to 0.45) and &Dgr;FVC (&bgr; = 0.19; 95% CI, 0.05 to 0.33). In our model adjusted for smoking history, longer deployment length remained associated with greater &Dgr;FEV1 and &Dgr;FVC (P < 0.01), but not with FEV1/FVC (P = 0.059). Conclusion: In our sample of post-9/11 veterans, longer deployment lengths were associated with significant bronchodilator responsiveness and a trend toward airflow limitation independent of tobacco use.

Organizational psychosocial factors and deployment-related exposure concerns in Afghanistan/Iraq War veterans.

Objective: Environmental exposure concerns are associated with adverse health outcomes in soldiers deployed to South West Asia. There is little data on factors associated with the reporting of exposure concerns. We explored the relationship between deployment-related preparedness/support and exposure concerns. Methods: Retrospective chart review of 489 Afghanistan/Iraq veterans evaluated at a Veterans Affairs tertiary center for postdeployment health. Results: Virtually all subjects were concerned about environmental exposure(s). There were no significant demographic differences in exposure concerns, preparedness/support variables, or both. Preparedness/support correlated inversely with exposure concerns. Mental health function mediated the relationship between preparedness/support and exposure concerns. Conclusions: Deployment-related preparedness/support is associated with exposure concerns and mental health functioning. Definitive studies will provide data and insight on how the military may better prepare/support soldiers to optimize their resilience and reduce deployment-related exposure concerns.

Blast Injury and Cardiopulmonary Symptoms in U.S. Veterans: Analysis of a National Registry

Background: Recent epidemiologic studies have reported an increased risk for respiratory conditions in service members deployed to Iraq or Afghanistan (1) since 2001 and an increasing prevalence of chronic lung disease in this population (2). Reports of dyspnea and exercise intolerance have mostly been attributed to exposure to airborne hazards, such as burn-pit smoke and particulate matter. Exposure to blast waves during military deployment has been recognized as the hallmark injury of the wars in Iraq and Afghanistan, and considerable efforts have been made to understand the associated neurologic sequelae. However, less attention has been paid to the lungs, which may be particularly susceptible to blast waves given tissue-density gradients. The exact relationship between blast lung injury and long-term sequelae is unknown; however, animal models show long-term, persistent elevations in oxidative stress and vascular abnormalities after blast exposure (3), which may contribute to respiratory symptoms. Associations between blast exposure and chronic lung diseases in this cohort have recently been suggested (2). Objective: To study the association between blast exposure and current cardiopulmonary symptoms. Methods and Findings: In June 2014, the U.S. Department of Veterans Affairs and Department of Defense launched the Airborne Hazards and Open Burn Pit Registry (AHOBPR) to ascertain and monitor health effects and health care in approximately 3 million veterans and service members deployed to southwest Asia, Djibouti, or Afghanistan since July 1990. The major domains of this voluntary online survey include deployment history, symptoms and medical health, and occupational and environmental exposures. Between June 2014 and 31 July 2015, a total of 42558 registry participants who were deployed after 7 October 2001 completed the AHOBPR questionnaire (Table). The outcome of interest was self-reported current dyspnea and/or decreased ability to exercise in response to the question, Do you currently have any of the following symptoms? Exposure to a blast was determined by an affirmative response to the question, Were you ever close enough to feel the blast from an IED (improvised explosive device) or other explosive device? Table. Characteristics of Registry Participants Deployed After 7 October 2001* All statistical analyses were performed using SAS Enterprise Guide, version 7.1 (SAS Institute). Most participants (61.0%) reported dyspnea or decreased exercise tolerance; 59.1% reported both. Time from last deployment to start of the survey was a mean of 62.2 months (SD, 37.2) and a median of 57.0 months (range, 0 to 162.0 months). Self-reported exposure to blast was 73.7% overall but was higher among those with symptoms (20512 [79.0%]) than those without symptoms (10860 [65.5%]). To further explore the hypothesized relationship between blast exposure and cardiopulmonary symptoms, we used a multivariate model, controlling for the following potential self-reported confounders: age; sex; branch of service; body mass index; smoking status; exposure to burn-pit smoke; nonmilitary occupational exposure to dust, gas, smoke, chemical vapors, or fumes; and time since deployment. Missing data for burn-pit smoke exposure (17% of records) were estimated using multiple imputation (PROC MI FCS discriminant method [SAS Institute], with 25 imputed data sets and 2 auxiliary variables associated with burn-pit exposure included in the imputation model). We observed an association between current symptoms and self-reported blast exposure (adjusted odds ratio, 1.66 [95% CI, 1.5 to 1.7]), controlling for the covariates. Conclusion: We found a moderate, independent association between self-reported blast exposure and current symptoms of dyspnea and/or decreased exercise tolerance in U.S. military service members who were deployed after 7 October 2001 and had completed the AHOBPR. Our findings are biologically plausible and supported by animal studies showing impaired cardiopulmonary function secondary to blast injury (4). Further, this study corroborates a report of increased risk for chronic lung disease among deployed veterans of the wars in Iraq and Afghanistan with a history of traumatic brain injurya potential proxy for blast exposure (2). The results of this study are intended to generate hypotheses and must be confirmed by more rigorous epidemiologic and clinical studies. The voluntary nature of the AHOBPR is associated with a lack of generalizability of the findings because of the nonrepresentative sample. In addition, the self-reported responses raise the possibility of exaggerated reporting of symptoms and exposure and of incomplete or inaccurate recall (5). Despite the lack of information on the number, timing, or severity of blast exposure or nature of acute symptoms, the independent association between self-reported blast and current symptoms suggests a robust relationship. Our findings indicate that blast exposure may have a discernable effect on symptoms and exercise capacity even several years after the exposure. If these findings are confirmed, clinicians should consider and document blast exposure as a possible contributing factor in patients with persistent or latent cardiopulmonary symptoms after deployment. In parallel, a focus on burn-pit smoke exposure as the cause of adverse cardiopulmonary effects may be incomplete and misattributed in some cases. Recognizing the possible importance of blast-related lung injury may accelerate research that can clarify the relevance of such injuries.

Report of Autonomic Symptoms in a Clinical Sample of Veterans with Gulf War Illness

Introduction Previous studies suggest that autonomic dysfunction may be an underlying factor in Gulf War Illness. This study examined self-reported symptoms of autonomic dysfunction and their relationship with physical functioning among veterans with Gulf War Illness. Materials and Methods We abstracted medical records of Gulf War Veterans clinically evaluated at the New Jersey War Related Illness and Injury Study Center between 2010 and 2016. The outcome measure was the Veteran version of the Short Form Health Survey (VR-36) physical functioning scale. Autonomic function was assessed using a composite variable constructed from the chart abstraction to mimic the Composite Autonomic Symptom Scale (COMPASS-31). Results Seventy-six veterans were included in the final analysis. The autonomic symptom burden score was 45 (±14). Increased autonomic symptom burden, greater mental health burden (PTSD/depression), and greater body mass index were individually associated with poorer physical functioning. A general linear regression containing these variables revealed that patients with both PTSD and depression (b = -15.2, p = 0.03) or either PTSD or depression (b = -22.7, p < 0.01) had lower physical functioning than those without; the other variables became not significant (body mass index: p = 0.07; autonomic function: p = 0.89). Conclusion The average autonomic function score indicated significant burden in Gulf War Veterans, consistent with published research. We did not detect an independent association between autonomic symptom burden and physical functioning, likely due to the non-specific nature of the measure used to capture autonomic symptoms or the stronger association between mental health conditions and physical functioning. Future work utilizing valid and standardized instruments to clinically evaluate autonomic function is warranted.

Autonomic Symptoms in Gulf War Veterans Evaluated at the War Related Illness and Injury Study Center

INTRODUCTION We characterized the presence of autonomic symptoms in a sample of Veterans with Gulf War Illness (GWI) using the Composite Autonomic Symptom Scale (COMPASS-31). In addition, we examined the report of autonomic symptoms across comorbid mental health conditions in this sample. MATERIALS AND METHODS Case-series follow-up of Gulf War veterans evaluated by the War Related Illness and Injury Study Center (WRIISC) between 2011 and 2016 (n = 153). Phone-based interview consisted of questionnaires designed to investigate autonomic symptoms, physical symptoms, mental health conditions, and GWI. Sixty-One Veterans agreed to participate in this follow-up arm of the study. We restricted our analysis to only those Veterans meeting CDC and/or Kansas criteria for GWI, leaving us with a sample of 56 Veterans. RESULTS Veterans in our sample were, male (n = 55, 98%), 49 (±6.8) years old and used 8 (±6.6) medications. The mean COMPASS-31 score for our sample was 45.6 (±18.3). There were no differences in reports of autonomic symptoms between participants who screened positive or negative for depression or post-traumatic stress disorder, but COMPASS-31 scores were higher among those who screened positive for anxiety (49.6 (±16.0)) compared with those who screened negative (29.3 (±18.9)) (p < 0.001). CONCLUSIONS The elevated COMPASS-31 scores suggest that there may be autonomic dysfunction present in our sample of Veterans with GWI, consistent with other published reports. Additionally, we believe that the high scores on the anxiety measure may reflect assessment of physiological symptoms that are not specific to anxiety, and may reflect GWI symptoms. Objective physiological tests of the autonomic nervous system are warranted to better characterize autonomic function and the clinical relevance of COMPASS-31 in this population.

Isolated diffusing capacity reduction is a common clinical presentation in deployed Iraq and Afghanistan veterans with deployment‐related environmental exposures

Following deployment to Iraq and Afghanistan (“post‐9/11”), a spectrum of respiratory conditions has been reported; however, there are few published reports of objective physiologic data or later experience of symptoms and function. To better understand the post‐deployment clinical presentation, we conducted a retrospective review of pulmonary function testing in 143 veterans referred to our tertiary care clinic for post‐deployment health concerns. More than 75% of our sample had normal lung volumes and spirometry on pulmonary function testing; however, an isolated reduction in lung diffusing capacity (DLCO) was observed in 30% of our sample of post‐9/11 veterans. An isolated reduction in DLCO is a rare pattern in primary‐care seeking dyspneic patients, but is commonly associated with underlying pulmonary disease. Post‐9/11 veterans with respiratory complaints and an isolated reduction in DLCO should undergo further evaluation.