Identification and Treatment of TBI and Co-occurring Psychiatric Symptoms Among OEF/OIF/OND Veterans Seeking Mental Health Services Within the State of Colorado: Establishing Consensus for Best Practices

This paper highlights the results of a consensus meeting regarding best practices for the assessment and treatment of co-occurring traumatic brain injury (TBI) and mental health (MH) problems among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans seeking care in non-Veterans Affairs Colorado community MH settings. Twenty individuals with expertise in TBI screening, assessment, and intervention, as well as the state MH system, convened to establish and review questions and assumptions regarding care for this Veteran population. Unanimous consensus regarding best practices was achieved. Recommendations for improving care for Veterans seeking care in community MH settings are provided.     

Poor Performance Validity Predicts Clinical Characteristics and Cognitive Test Performance of OEF/OIF/OND Veterans in a Research Setting

This study examined the performance of 198 Veteran research participants deployed during Operation Enduring Freedom, Operation Iraqi Freedom, and/or Operation New Dawn (OEF/OIF/OND) on four measures of performance validity: the Medical Symptom Validity Test (MSVT), California Verbal Learning Test: Forced Choice Recognition (FCR), Reliable Digit Span (RDS), and TOVA Symptom Exaggeration Index (SEI). Failure on these performance validity tests (PVTs) ranged from 4% to 9%. The overall base rate of poor performance validity, as measured by failure of the MSVT in conjunction with an embedded PVT (FCR, RDS, SEI), was 5.6%. Regression analyses revealed that poor performance validity predicted cognitive test performance and self-reported psychological symptom severity. Furthermore, a greater prevalence of traumatic brain injury (TBI), Post-Traumatic Stress Disorder (PTSD), co-morbid TBI/PTSD, and other Axis I diagnoses, was observed among participants with poor effort. Although poor performance validity is relatively uncommon in a research setting, these findings demonstrate that clinicians should be cautious when interpreting psychological symptoms and neuropsychological test performance of Veteran participants who fail effort measures.     

Military Psychodynamics

High rates of attrition occur in outpatient and inpatient evidence-based treatments (EBTs) targeting newly returning veterans from Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) with posttraumatic stress disorder (PTSD). Traditionally, research has examined attrition as a dichotomous variable (i.e., noncompleters vs. completers) and focused almost exclusively on outpatient EBTs for PTSD. These studies have provided little information to inpatient psychiatric providers about timing-related predictors of treatment discontinuation. The present study attempted to mend these gaps by examining attrition as a continuous variable and investigated predictors of length of stay (LOS) among 282 OEF/OIF/OND male veterans, 69 of which did not complete the full 25-day intensive, multimodal inpatient PTSD EBT program. At admission, participants completed a series of clinician-rated, biological, and self-report assessments. Linear regression analyses were used to identify predictors of shorter LOS. The results demonstrated that less improvement in symptom reduction, overall functioning, and greater number of drugs used at admission were significant and unique predictors of shorter LOS. Overall, these findings reveal clinically relevant, timing-related predictors of attrition and provide generalizable clinical information to inpatient psychiatric providers.     

1例颅内巨大脑膜瘤手术治疗体会

患者,男性,4l岁,主因“睡眠增多20余天,头痛伴左下肢麻木10余天”于2012年3月23日人院。既往体健,人院查体：T：36．0℃,P：72次／min,R：18次／min,BP：130／80mmHg（1mmHg=0．133kPa）,神志清楚,言语流利,遵嘱动作,神经系统体查未见明显阳性体征。辅助检查：头颅核磁平扫＋增强提示后顶枕巨大占位病变,大小约7cm×8．5cm×8．0cm,肿瘤分叶状,侵犯矢状窦,大脑镰,颅骨,长至皮下,压迫周围脑组织,肿瘤内较大血管留空影,增强明显（见图1,2,3）。     

Symptom responses of female Vietnam veterans to Operation Desert Storm.

OBJECTIVE: This study examined the status of symptoms of posttraumatic stress disorder (PTSD) in a cohort of women after the onset of Operation Desert Storm. METHOD: Seventy-six non-treatment-seeking Vietnam veterans were obtained from lists of those who recently had participated in other research projects conducted at the National Center for Post-Traumatic Stress Disorder. Before the onset of Operation Desert Storm, subjects had completed a set of psychometrically valid instruments measuring general psychological symptoms and PTSD symptoms (e.g., SCL-90-R, Mississippi Scale for Combat-Related Posttraumatic Stress Disorder). On the basis of the latter scale, subjects were divided into groups with and without PTSD symptoms. At the height of the military conflict, subjects were recontacted and asked to complete the SCL-90-R and the Veterans Update Form, a measure assessing changes in PTSD symptoms. RESULTS: Multivariate analyses indicated that while most female Vietnam veterans experienced some intensification of stress-related symptoms during Operation Desert Storm, those who had previously reported high levels of PTSD were significantly more susceptible to greater distress. CONCLUSIONS: Results of this survey indicate that female Vietnam veterans with prior wartime exposure are an at-risk population for the intensification of stress symptoms after the recurrence of a military conflict.     

Neuropathology of Explosive Blast Traumatic Brain Injury

During the conflicts of the Global War on Terror, which are Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF), there have been over a quarter of a million diagnosed cases of traumatic brain injury (TBI). The vast majority are due to explosive blast. Although explosive blast TBI (bTBI) shares many clinical features with closed head TBI (cTBI) and penetrating TBI (pTBI), it has unique features, such as early cerebral edema and prolonged cerebral vasospasm. Evolving work suggests that diffuse axonal injury (DAI) seen following explosive blast exposure is different than DAI from focal impact injury. These unique features support the notion that bTBI is a separate and distinct form of TBI. This review summarizes the current state of knowledge pertaining to bTBI. Areas of discussion are: the physics of explosive blast generation, blast wave interaction with the bony calvarium and brain tissue, gross tissue pathophysiology, regional brain injury, and cellular and molecular mechanisms of explosive blast neurotrauma.     

An expanded view of self-management: patients' perceptions of education and support in an intervention for chronic musculoskeletal pain

Objectives. Chronic pain is prevalent, costly, and is associated with profound psychological effects. Although pain is prevalent in returning veterans of the recent military conflicts in Afghanistan and Iraq (Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn [OEF/OIF/OND] Veterans), little is known about chronic pain in these patients. This study's objective was to ascertain perceptions of a multicomponent intervention tested in a randomized controlled trial for OEF/OIF/OND veterans with chronic musculoskeletal pain (Evaluation of Stepped Care for Chronic Pain [ESCAPE]). Design. Qualitative interviews were conducted with 26 patients in the intervention arm of ESCAPE (21% of total intervention patients) to determine patients' experiences with and perceptions of the intervention. Patients were purposefully sampled to include treatment responders (defined as ≥30% reduction in pain-related disability or pain severity), nonresponders, and noncompleters (completed <50% of trial). Qualitative analysis was guided by grounded theory. Results. Both responders and nonresponders discussed the importance of the self-management education they received. Of particular significance, patients identified the nurse care manager who administered the intervention as being integral to patients' ability to self-manage their chronic pain. Patients described important ways in which the nurse facilitated their self-management, reported under three themes: 1) helping patients find what works for their pain; 2) holding patients accountable for their pain management; 3) motivating and providing emotional support to patients. Conclusions. Results corroborate previous work and suggest that current conceptualizations of self-management are incomplete. A model is proposed that not only depicts self-management as involving more than activities and strategies, but also acknowledges the central role of relationships and support in pain self-management.     

Healing the Wounds of War: The Vietnam Veteran After Operation Desert Storm

topic . How Operation Desert Storm, and the positive response of the public to this crisis, seemed to stimulate and heighten unresolved feelings for many Vietnam veterans.
purpose . To show that understanding the lived experiences of Vietnam veterans, at time when men and women returning from Operation Desert Storm were welcomed back by their country, would allow for the development of more effective treatment approaches in working with Vietnam veterans.
methods . Personal interviews, during and immediately following Operation Desert Storm, with 12 men who served in Vietnam.
findings . Themes identified and described by Vietnam veterans included repressed fear, shame, isolation and loneliness, disillusionment, permanence of memories, and acceptance.
conclusion . Further exploration and analysis of these themes is recommended.     

Examining an emotion enhancement effect in working memory: Evidence from age-related differences

The aim of the present study was to examine age-related differences between young, young–old and old–old adults in an affective version of the classical Working Memory Operation Span Test. The affective version of the Working Memory Operation Span Test included neutral words (as in the classical version) as well as negative and positive ones. Results showed that while young adults performed better than the young–old and old–old with neutral words, age-related differences between young and young–old with positive words were no longer significant, and age-related differences were nullified with negative ones. Altogether, results indicate that emotional words can reduce age-related decline when maintenance and manipulation of information in working memory in older adults are required.     

Project VALOR: design and methods of a longitudinal registry of post-traumatic stress disorder (PTSD) in combat-exposed veterans in the Afghanistan and Iraqi military theaters of operations

Few studies have investigated the natural history of post-traumatic stress disorder (PTSD). Project VALOR (Veterans' After-discharge Longitudinal Registry) was designed as a longitudinal patient registry assessing the course of combat-related PTSD among 1600 male and female Veterans who served in Operation Enduring Freedom (OEF) in Afghanistan or Operation Iraqi Freedom (OIF). Aims of the study include investigating patterns and predictors of progression or remission of PTSD and treatment utilization. The study design was based on recommendations from the Agency for Healthcare Quality and Research for longitudinal disease registries and used a pre-specified theoretical model to select the measurement domains for data collection and interpretation of forthcoming results. The registry will include 1200 male and female Veterans with a recent diagnosis of PTSD in the Department of Veteran Affairs (VA) electronic medical record and a comparison group of 400 Veterans without a medical record-based PTSD diagnosis, to also allow for case-control analyses. Data are collected from administrative databases, electronic medical records, a self-administered questionnaire, and a semi-structured diagnostic telephone interview. Project VALOR is a unique and timely registry study that will evaluate the clinical course of PTSD, psychosocial correlates, and health outcomes in a carefully selected cohort of returning OEF/OIF Veterans.     

Examining the relation between posttraumatic stress disorder and suicidal ideation in an OEF/OIF veteran sample

This study examined the relation between posttraumatic stress disorder (PTSD) and suicidal ideation among U.S. military veterans deployed during Operation Enduring Freedom and/or Operation Iraqi Freedom. Specific aims included investigation of (1) whether PTSD was associated with suicidal ideation after controlling for combat exposure and history of suicide attempt(s), (2) whether PTSD was associated with suicidal ideation absent a co-occurring depressive disorder (MDD) or alcohol use disorder (AUD), (3) whether co-occurring MDD or AUD increased risk of suicidal ideation among those with PTSD and (4) whether PTSD/MDD symptom clusters were differentially associated with suicidal ideation. Results pointed to unique effects associated with prior suicide attempt(s), PTSD and MDD. PTSD-diagnosed participants with co-occurring MDD or AUD were not significantly more likely to endorse suicidal ideation than PTSD-diagnosed participants without such comorbidity. The ‘emotional numbing’ cluster of PTSD symptoms and the ‘cognitive-affective’ cluster of MDD symptoms were uniquely associated with suicidal ideation.     

Neurology in Operation Iraqi Freedom: risk factors for referral, clinical presentations and incidence of disease

Six hundred and sixteen patients were referred for consultation to the author who served as the neurologist on the 252nd Neurosurgical Team in Kuwait in support of Operation Iraqi Freedom between April and October, 2003. Demographic and military data were collected. The cohort of neurologic patients showed significant differences from the total population of the United States Army contemporarily deployed to Operation Iraqi Freedom. Versus the deployed personnel, the neurologic cohort was older in age (p<0.001), had a greater percentage of females (p<0.00001), had an excessive representation for the military rank of sergeant (p<0.00001), with a deficit of other ranks (junior enlisted and officers), and were more likely to soldiers from the Reserves (p<0.00001) and National Guard (p=0.0021) than from the Regular Army. Seven categories of chief complaints and ten categories of diagnoses constituted some 80% of patients. The incidence of neurologic disease was calculated to be 634 per 100,000 people/year. This information provides valuable information for military neurologists concerning their anticipated duties in future deployments and for non-neurologists by focusing their skills in the evaluation of common neurologic presentations, yet further research is needed to optimize the neurologist's role in a field environment.     

Language and cultural barriers in the assessment of enemy prisoners of war and other foreign nationals

The authors describe difficulties encountered in the assessment and treatment of enemy prisoners of war and foreign civilians during Operation Enduring Freedom and Operation Iraqi Freedom. Of prime concern was the complexity of evaluating and working with patients through translators. Secondary concerns included self-protective behaviors of and fears experienced by patients, which complicated the patient-provider relationship. Future difficulties could be reduced by training translators in medical interviewing, training providers in the skills used by translators, informing providers of command and political policy, and producing concrete, portable information in written or other forms for enemy prisoners to reduce inherent mistrust.     

The contributions of self-reported injury characteristics and psychiatric symptoms to cognitive functioning in OEF/OIF veterans with mild traumatic brain injury

Mild traumatic brain injury (mTBI) affects a significant number of combat veterans returning from Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF). Although resolution of mTBI symptoms is expected over time, some individuals continue to report lingering cognitive difficulties. This study examined the contributions of self-reported mTBI injury characteristics (e.g., loss of consciousness, post-traumatic amnesia) and psychiatric symptoms to both subjective and objective cognitive functioning in a sample of 167 OEF/OIF veterans seen in a TBI clinic. Injury characteristics were not associated with performance on neuropsychological tests but were variably related to subjective ratings of cognitive functioning. Psychiatric symptoms were highly prevalent and fully mediated most of the relationships between injury characteristics and cognitive ratings. This indicates that mTBI characteristics such as longer time since injury and loss of consciousness or post-traumatic amnesia can lead to increased perceived cognitive deficits despite having no objective effects on cognitive performance. Psychiatric symptoms were associated with both cognitive ratings and neuropsychological performance, illustrating the important role that psychiatric treatment can potentially play in optimizing functioning. Finally, subjective cognitive ratings were not predictive of neuropsychological performance once psychiatric functioning was statistically controlled, suggesting that neuropsychological assessment provides valuable information that cannot be gleaned from self-report alone.     

Neuropsychological Effects of Self-Reported Deployment-Related Mild TBI and Current PTSD in OIF/OEF Veterans

Current combat veterans are exposed to many incidents that may result in mild traumatic brain injury (mTBI) and/or posttraumatic stress disorder (PTSD). While there is literature on the neuropsychological consequences of PTSD only (PTSD-o) and mTBI alone (mTBI-o), less has been done to explore their combined (mTBI+PTSD) effect. The goal of this study was to determine whether Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans with mTBI+PTSD have poorer cognitive and psychological outcomes than veterans with PTSD-o, mTBI-o, or combat exposure-only. The final sample included 20 OIF/OEF veterans with histories of self-reported deployment mTBI (mTBI-o), 19 with current PTSD (PTSD-o), 21 with PTSD and self-reported mTBI (mTBI+PTSD), and 21 combat controls (CC) (no PTSD and no reported mTBI). Groups were formed using structured interviews for mTBI and PTSD. All participants underwent comprehensive neuropsychological testing, including neurocognitive and psychiatric feigning tests. Results of cognitive tests revealed significant differences in performance in the mTBI+PTSD and PTSD-o groups relative to mTBI-o and CC. Consistent with previous PTSD literature, significant differences were found on executive (switching) tasks, verbal fluency, and verbal memory. Effect sizes tended to be large in both groups with PTSD. Thus, PTSD seems to be an important variable affecting neuropsychological profiles in the post-deployment time period. Consistent with literature on civilian mTBI, the current study did not find evidence that combat-related mTBI in and of itself contributes to objective cognitive impairment in the late stage of injury.     

Die Behandlung des Phantomschmerzes durch postzentrale Topectomie

Zusammenfassung Verff. berichten über den Krankheitsverlauf von 2 an Phantomschmerz leidenden, durch postzentrale Topectomie behandelten Kranken. Einer der Pat. ist seit 5Jahren beschwerdefrei und dies stellt unseres Wissens die zweitlängste, einer Topectomie folgende schmerzlose Periode der Literatur dar (Lenshoek). Die nach vorübergehender Besserung eingetretene Verschlechterung des anderen Kranken kann teils mit der im Stumpf nach der Operation eingetretenen Entzündung (als ein peripherer Reiz), teils mit der zu spät erfolgten Operation des an Alkoholund Alkaloidmißbrauch Leidenden in Zusammenhang gebracht werden. Es wird aufgrund der Literaturfälle wie auch an Hand der eigenen Fälle betont, daß das Wesen des Ph.schm. vorwiegend in dem zutage tretenden ungewöhnlichen, unangenehmen Erlebnis des gestörten Körperschemas besteht, das entscheidender als der Einfluß peripherer pathologischer Reize ist. Es wird im Falle von erfolgloser konservativer Behandlung oder eines solchen peripheren Eingriffs die Ausführung einer frühzeitigen, das gestörte Körperschema behebenden corticalen oder subcorticalen Operation empfohlen.     

视神经损伤后睫状神经营养因子的神经保护效应

目的 研究睫状神经营养因子(CNTF)不同给药途径对猫视神经不全损伤后的神经保护效应.方法 完成猫视神经不全损伤模型的制作;实验组和空白对照组分别给予静脉、前房、玻璃体内CNTF注射和生理盐水玻璃体注射;术后15 d双侧上丘、外侧膝状体显微注射DiI逆行神经示踪;不同时间点行视觉诱发电位(PVEP)检测;术后30 d原位心脏灌注;视网膜铺片,视网膜神经节细胞计数;取术侧视神经组织,光镜和电镜观察各组视神经形态变化.结果 空白对照组术侧眼PVEPP100较实验各组振幅明显减低,潜伏期明显延长,差异有统计学意义(P＜0.01);与空白对照组比较,实验组视网膜神经节细胞存活数量明显增加(P＜0.01),神经结构更加完整.结论 视神经不全损伤后CNTF不同途径给药具有视神经保护效应,但效应存在差异.

Abstract：

Objective To research the nerve protective effect of ciliary neurotrophic factor (CNTF) after cat optic nerve not entire injury.Methods Completes the cat optic nerve not entire damage model.The experimental group gives CNTF by in the vein,the anterior chambe,the intravitreal to inject separately,the control group gives the physiological saline.Operation latter 15 days of two-sided anterior colliculi,lateral geniculate body microinjection DiI retrogradation nerve tracing.The different time spot completes the examination of visual evoked potential (PVEP).Operation latter 30 days complete the situ heart dabbling;Retina stretched preparation,retina ganglion cell counting.Takes the optic nerve of operation side,the light microscope and the electron microscope observation morphologic change of optic nerve.Result Controlled group PVEP compares the experimental groups oscillation amplitude of P100 to decrease obviously,incubation period of P100 obvious extension,difference remarkable (P ＜ 0.0l ).Compares with the controlled group,the survival number of retina ganglion cell of experimental groups increases obviously(P＜0.01 ),the nerve structure is more complete.Conclusion After optic nerve not entire damage,the CNTF different way injection has the optic nerve protective effect,but effect existence difference.     

Stereotaktische Strahlentherapie am adaptierten Linearbeschleuniger bei Patienten mit Hirnmetastasen

Ziel der Studie war es, die klinischen Ergebnisse nach stereotaktischer Strahlentherapie (Radiochirurgie und stereotaktischer fraktionierter Strahlentherapie) am adaptierten Linearbeschleuniger bei Patienten mit Hirnmetastasen zu evaluieren. Dabei wurden folgende Parameter untersucht: Tumorkontrolle, überlebenszeit und Nebenwirkungen. Die Vor- und Nachteile dieser Behandlungstechnik im Vergleich zu traditionellen Behandlungsmethoden (Operation und Ganzsch?delbestrahlung) wurden auf der Basis der Literaturdaten und der eigenen Erfahrung analysiert.     

Demographics of and diagnoses in Operation Enduring Freedom and Operation Iraqi Freedom personnel who were psychiatrically evacuated from the theater of operations

OBJECTIVE: The objective of this study was to characterize the demographic and clinical information of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) military personnel who were psychiatrically evacuated from the theater of operations. METHOD: Records of 1264 consecutive OEF/OIF patients who were medically evacuated for primarily psychiatric reasons between November 4, 2001, and July 30, 2004, were reviewed to collect demographic information and psychiatric diagnoses. RESULTS: When compared with all returned OEF/OIF veterans (N=213,150), psychiatric evacuees were more likely to be: female, under the age of 31 years, African-American or Hispanic, enlisted and National Guard/Reserve. Over 80% of patients were evacuated during the first 6 months, compared with 17% during the second 6 months of deployment. The most common diagnostic categories were adjustment disorders (37.6%), mood disorders (22.1%), personality disorders (15.7%) and anxiety disorders (15.4%); 16.5% received no psychiatric diagnosis. Only 5% of evacuees were returned to OEF/OIF duty. CONCLUSION: Almost half of evacuated patients received no diagnosis or no adjustment disorder diagnosis, suggesting clinical improvement since a decision for evacuation was made. Potential areas of focus for preventing psychiatric evacuations are identifying service members who are at risk during early stages of deployment and studying whether there are gender-specific deployment stressors.     

Elevated rates of memory impairment in military service-members and veterans with posttraumatic stress disorder

Introduction: Studies investigating the neurocognitive effects of posttraumatic stress disorder (PTSD) routinely find “deficits” in various cognitive domains. However, the rate of cognitive impairment in individuals with PTSD remains unclear, as studies have focused on null hypothesis testing (NHT) and inferring patterns of impairment rather than empirically determining the rate of cognitive impairment in this sample. Method: This study examined rates of cognitive impairment using a domain-specific approach in non-treatment-seeking Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn service members and veterans with (n = 92) and without (n = 79) PTSD and without substance abuse/dependence who passed a performance validity measure and were matched on age, education, estimated IQ, and ethnicity. Chi-square analyses were used to compare the rate of cognitive impairment across groups based on normative scores using three cutoffs (?1, ?1.5, and ?2 SDs). NHT was also used to compare performances across groups. Results: Individuals with PTSD showed higher rates of impairment in memory (?1-SD cutoff) than controls, but equivalent rates of impairment in attention, processing speed, and executive functioning; no significant differences were found on NHT. Impairment in any domain was also more prevalent in PTSD (?1-, ?1.5-, and ?2-SD cutoffs). No differences were found on NHT or rates of impairment in individuals with PTSD with (n = 34) and without (n = 58) depression. Conclusions: Patients with PTSD were more likely to meet criteria for memory impairment and to show impairment in any domain than controls. Patients with PTSD and comorbid depression were no more likely to be impaired in any cognitive domain or to have lower scores on individual cognitive tasks than patients with PTSD alone. Clinicians noting cognitive impairment in individuals with PTSD should exercise caution before ascribing that impairment to another etiology if deficits are limited to memory.