Health-related quality of life in Persian Gulf War Veterans.

OBJECTIVE: The objective of this investigation is to describe the health-related quality of life of Persian Gulf War (GW) veterans and to examine the effects of current chronic medical conditions and psychiatric status on physical functioning. METHODS: To measure health-related quality of life, the Medical Outcomes Short Form Survey (SF36) was administered approximately 4 years after the GW to a stratified, random sample of New England-area GW-deployed veterans and a group of military personnel deployed to Germany during the GW. The SF36 scores for the GW-deployed study population (N = 141) were compared with those for the Germany-deployed group (N = 46) and with published U.S. population norms. Multiple linear regression analyses were performed to identify risk factors associated with lower physical health functioning in the GW-deployed study group. RESULTS: Functional health status was significantly lower in the GW-deployed group compared with the Germany-deployed group for each of the SF36 subscales and the two summary scores (Physical Component Summary [PCS] and Mental Component Summary). Compared with the general U.S. population, the GW-deployed group median was between the 25th and 50th percentile for the Physical Functioning subscale and the PCS score. Within the GW-deployed group, lower education, psychological symptomatology, and a higher number of chronic self-reported medical conditions were significant predictors of the PCS score. CONCLUSION: GW-deployed veterans report lower functional health status compared with a group of Germany-deployed veterans and published general U.S. population norms. Within the group of GW-deployed veterans, several current medical and psychological conditions predictive of lower physical functioning levels were identified.     

War crimes during the Persian Gulf War.

Evidence of violations of the 1949 Geneva Conventions by Iraq's military personnel during Desert Shield and Desert Storm are described and adverse effects on the Kuwaiti health care delivery system are discussed. New diplomatic and military initiatives that include education and accountability are needed to ensure better compliance with international conventions designed to protect victims of war.     

Evaluation of chronic gastrointestinal symptoms following Persian Gulf War exposure

This was a prospective study performed in a Department of Veterans Affairs Medical Center. The aim of this study was to use endoscopic and histological examinations to determine the potential diagnostic origins of chronic gastrointestinal symptoms among patients who were part of the deployment of troops to the Persian Gulf after August 1990. Twenty-four (8%) male patients (mean age, 42 years) of 308 patients in the Persian Gulf War Registry agreed to undergo endoscopic examination of chronic symptoms, including heartburn (29%), dyspepsia (33%), dysphagia (8%), diarrhea (63%), Hemoccult-positive stool (21%), and rectal bleeding (17%). There were 17 upper endoscopies, 18 colonoscopies, and 4 flexible sigmoidoscopies performed, all with biopsies. Five (33%) of 15 patients had positive serological findings for Helicobacter pylori. With upper endoscopy, major findings included esophagitis (12%), Schatzki's ring (12%), hiatal hernia (47%), antral erythema (59%), and duodenal erythema (29%). With lower endoscopy, major findings included ileitis (5%), lymphoid hyperplasia (9%), polyps (27%), diverticulosis (23%), and hemorrhoids (23%). Major histopathological findings included microscopic esophagitis (24%), gastritis with H. pylori (35%), gastritis without H. pylori (18%), Crohn's disease (5%), tubular adenoma (5%), hyperplastic polyps (18%), and melanosis coli (5%). Most patients with chronic heartburn or dyspepsia have evidence of esophagitis or H. pylori. Individuals with these chronic symptoms should undergo evaluation.     

Medical follow-up of Persian Gulf War Veterans with severe medically unexplained fatigue: a preliminary study.

An important question for researchers interested in long-term consequences of military service is the health outcome of symptomatic Persian Gulf War Veterans. From an original group of 76 Gulf War Veterans who received the diagnosis of severe fatiguing illness, we attempted to get 58 veterans to return to our center for a second evaluation. Thirteen returned. Two had recovered by the time of revisit, but the rest remained ill; however, only one was so ill as to be unable to work. The data suggest that the medical consequences of serving in the Persian Gulf are not transient. The difficulty in getting veterans to return to our center suggests potential problems in the proposed nation-wide longitudinal health outcome study of Persian Gulf War Veterans.     

A comparison of postdeployment hospitalization incidence between active duty Vietnam and Persian Gulf War Veterans

Post-conflict hospitalization rates of active duty Marines deployed to the Persian Gulf War were compared with hospitalization rates of similar Marine Corps units returning from the Vietnam conflict. The aggregated Gulf War units exhibited lower hospitalization rates than their Vietnam counterparts. Examined separately, infantry and service support units deployed to the Persian Gulf had lower postdeployment hospitalization rates than similar units returning from Vietnam; no significant rate differences existed for the combat engineer and artillery units. The Vietnam veterans had higher percentages of hospital admissions for infective and parasitic diseases and genitourinary disorders than Gulf War veterans, whereas Gulf War veterans had a higher proportion of their hospitalizations in the musculoskeletal disorder category. The types of individual musculoskeletal disorders incurred by the two cohorts were not substantially different.     

Human leukocyte antigens in Gulf War veterans with chronic unexplained multiple symptoms

Several articles have suggested that immune dysregulation related to Gulf War deployment may be involved in chronic illnesses with an unclear etiology among Gulf War veterans. To determine whether genetic susceptibility related to the human leukocyte antigen (HLA) system might play a role in development of the veterans' illnesses, we examined the frequency distribution of HLA A, B, DR, and DQ antigens from symptomatic veterans residing in south-central Pennsylvania compared with a local healthy population database. Only HLA-A28 demonstrated statistical significance. A28 was present in 7 (21.9%) of 32 of the veterans and 15 (6.9%) of 217 of the healthy population (p = 0.01, Fisher's exact test). This accounts for a minority of the ill veterans tested and is not statistically significant when corrected for the number of antigens determined. We conclude that specific HLA antigens are not strongly associated with the illnesses of Gulf War veterans.     

Predicting costs of Veterans Affairs health care in Gulf War veterans with medically unexplained physical symptoms

Measures of post-traumatic stress disorder (PTSD) and depression were used to predict Veterans Affairs outpatient treatment costs among Persian Gulf War veterans with medically unexplained physical symptoms. Patients (N = 206) enrolled in a Veterans Affairs primary care clinic for Persian Gulf War veterans completed study assessments at the initial appointment or at a proximal follow-up visit. Costs of care for mental health, medical, and pharmacy services for these veterans were computed for the subsequent 6-month period. Depression and PTSD symptoms explained a significant share of variance in costs of mental health care and pharmacy services, after adjustment for covariates. None of the mental status measures was significantly related to costs of medical care. Models using global measures of mental health status were as robust as models using disorder-specific measures of PTSD and depression in predicting mental health care and pharmacy costs. The implications of these findings for anticipating costs of care for Persian Gulf War veterans are discussed.     

Evaluation of Persian Gulf veterans with symptoms of peripheral neuropathy

BACKGROUND: Persian Gulf syndrome is a set of symptoms that do not fit into well-understood diagnostic categories. Among these symptoms, there are some that could suggest a generalized neuropathic process. OBJECTIVE: Correlate neurological symptoms with objective electrodiagnostic findings. METHODS: A randomized sample of 176 Persian Gulf veterans (PGV) evaluated at the San Juan Veterans Administration Medical Center was obtained. The subjects completed a questionnaire, and those who met the inclusion criteria underwent electrodiagnostic evaluation. RESULTS: Of the 176 PGV selected, 162 completed the questionnaire. The next step was to perform electrodiagnostic studies on those who described symptoms suggesting peripheral neuropathy and met the inclusion criteria. Twelve individuals met the inclusion criteria for electro-diagnostic studies. All studies were normal except that two subjects were found to have bilateral carpal tunnel syndrome. CONCLUSIONS: Although this is a relatively small sample of PGV, the findings are in accordance with other studies in which no definite generalized neuropathic pattern has been described.     

No evidence of increase in birth defects and health problems among children born to Persian Gulf War Veterans in Mississippi

The Department of Veterans' Affairs, Jackson, Mississippi, and the Mississippi State Department of Health conducted a collaborative investigation of an apparent increase in the numbers of birth defects and other health problems among children born to veterans of two Mississippi National Guard units who had served in the Persian Gulf War. The medical records of all children conceived by and born to veterans of the two units after deployment were reviewed; observed numbers of birth defects and other health problems were compared with expected numbers using rates from birth defect surveillance systems and previous surveys. The total number of all types of birth defects was not greater than expected, but whether the number of specific birth defects was greater than expected could not be determined. The frequency of premature birth, low birth weight, and other health problems appeared similar to that in the general population.     

The Department of Defense's Persian Gulf War registry year 2000: an examination of veterans' health status

This study examined the health status of 46,633 Persian Gulf War theater veterans who received full clinical evaluations in the Department of Defense's Gulf War Comprehensive Clinical Evaluation Program (CCEP) as of spring 2000. Clinical data analyzed included demographic information, 15 health symptoms, 19 wartime exposures, and primary and secondary physician-determined medical diagnoses based on International Classification of Diseases, 9th Revision, Clinical Modification, criteria. Findings and discussions are arrayed, by gender, with comparative 1996 data from the Department of Veterans Affairs Health Examination Registry Program. Many veterans reported fewer physical symptoms now than during the time of the Gulf War. Many endorsed symptoms of joint pain, fatigue, weight change, and sleep disturbances. Most reported exposure to diesel fuel and the nerve agent antidote pyridostigmine bromide; far fewer female veterans reported combat involvement. The most frequent primary or secondary diagnosed medical conditions were musculoskeletal/connective tissue diseases, ill-defined conditions, and mental disorders. Female veterans were diagnosed more frequently with mental disorders. Symptom endorsement and diagnosis rates between the CCEP and the Department of Veterans Affairs registry were not dissimilar. Overall, the self-reported general health of veterans with symptoms was much poorer (females had higher rates of "fair to poor" health than males) than that of veterans with no reported symptoms.     

The health status of Gulf War veterans: lessons learned from the Department of Veterans Affairs Health Registry.

OBJECTIVE: To describe the demographic characteristics and postwar health status of U.S. Gulf War veterans who participated in the Department of Veterans Affairs health examination registry program. DESIGN: Case records of 52,835 veterans who participated in a standardized health examination program were reviewed. SETTING: Participants volunteered for physical examinations at a Department of Veterans Affairs medical treatment facility from August 1992 to September 1996. SUBJECTS: U.S. Gulf War veterans deployed to southwest Asia between August 1990 and 1996. MAIN OUTCOME MEASURE: Demographic, military, symptom, and International Classification of Diseases, Ninth Revision, Clinical Modification, diagnostic categories. RESULTS: A wide variety of symptoms and diagnoses were reported without apparent internal variation by military characteristics (branch and service component). The frequency of symptoms (fatigue, skin rash, headache, muscle and joint pain, and memory loss) reported increased over time, whereas the proportion of individuals with physician-diagnosed illnesses remained fairly constant. No single category of disease increased or decreased substantially over time. CONCLUSIONS: Veterans have experienced a wide variety of health problems since their Gulf War service. These problems, in aggregate, are different from what has been seen in other armed conflicts. The Department of Veterans Affairs registry is a very large case series and has failed to identify a single, unique syndrome or new illness after Gulf War service. An epidemiologic study would better define the prevalence of specific symptoms and medical conditions among Gulf War veterans and to what extent any of the conditions identified are associated with Gulf War military service. The knowledge provided by such studies would be important to development of preventive measures and future deployment medical surveillance planning.     

Training resident surgeons in combat: an experience during the Persian Gulf War.

The Persian Gulf War necessitated the activation of many Army Reserve and National Guard physicians, including a number in residency training. No prototype existed for the continued training of resident surgeons in a combat setting. The 159th Mobile Army Surgical Hospital (MASH) deployed in support of the Allied invasion of Iraq. A structured training program for two general surgery residents attached to the 159th MASH was developed and implemented. This program combined supervised operating room experience, perioperative management, morbidity and mortality conferences, and orthopedic grand rounds, all with careful professional documentation. A planned reading program could not be realized, due to the physical setting of wartime. Residents and attending staff interacted positively and the residents were able to continue their formal training as an integral part of the hospital. The model developed by the 159th MASH is a practical method of continuing structured resident training in a combat setting.     

Factors associated with depression on a hospital ship deployed during the Persian Gulf War

Investigators surveyed health care providers (N = 250) deployed to the Persian Gulf on the USNS Comfort hospital ship days before the beginning of the Persian Gulf War in 1990. In this article, we identify factors associated with the development of depression during deployment. Age, gender, negative life events, stress from trauma-related work demands, and occupational experience with the dying and the dead were significant predictors of depression. Military training, although not associated with the experience of depression, was negatively correlated with concern about injury.     

Ambulatory health care needs of women deployed with a heavy armor division during the Persian Gulf War.

A study was undertaken to assess the health care needs of women in a combat deployment. During a 6-month period during the Persian Gulf War, 10,165 ambulatory visits from an armor division were studied. The results demonstrate that the health care needs of women can be managed by competently and broadly trained practitioners. Referral sites should provide for gynecologic consultants along with equipment and resources needed to manage pregnancy complications, pelvic pain, and abnormal cervical cytology. It is unlikely that women deployed in this setting pose a significant health care burden attributable solely to their gynecologic needs.     

Clinical management of Gulf War veterans with medically unexplained physical symptoms

Veterans of the Persian Gulf War have increased rates of medically unexplained physical symptoms (MUPS). This article describes a model for the clinical management of MUPS in Gulf War veterans. Predisposing, precipitating, and perpetuating factors contribute to the emergence and clinical course of MUPS. Predisposing factors include biologically and psychosocially determined vulnerabilities that render individuals more susceptible to MUPS and related morbidity. Precipitating factors promote the onset of MUPS. These factors are triggering events that serve to initiate episodes of MUPS. Perpetuating factors sustain illness. They maintain, exacerbate, or prolong MUPS and associated distress and disability. Intervention involves identifying and addressing all relevant predisposing, precipitating, and perpetuating factors. A representative patient vignette is presented to illustrate the clinical utility of the model for a Gulf War veteran with MUPS.     

Spouses of Persian Gulf War I veterans: medical evaluation of a U.S. cohort

Ten years after the 1991 Persian Gulf War (GW I), a comprehensive evaluation of a national cohort of deployed veterans (DV) demonstrated a higher prevalence of several medical conditions, in comparison to a similarly identified cohort of nondeployed veterans (NDV). The present study determined the prevalence of medical conditions among nonveteran spouses of these GW I DV and NDV. A cohort of 490 spouses of GW I DV and 537 spouses of GW I NDV underwent comprehensive face-to-face examinations. No significant differences in health were detected except that spouses of DV were less likely to have one or more of a group of six common skin conditions. We conclude that, 10 years after GW I, the general physical health of spouses of GW I DV is similar to that of spouses of NDV.     

Pyridostigmine bromide intake during the Persian Gulf War is not associated with postwar handgrip strength

Many Persian Gulf War veterans took pyridostigmine bromide (PB) during the Persian Gulf War. Previous research suggests that PB intake and insecticide exposure may reduce muscular strength. During 1994 and 1995, we examined the relationships between self-reported PB intake, self-reported exposures, and handgrip strength among 527 Gulf War veterans (GWVs) and 969 nondeployed veterans of that era (NDVs). We found that 25.4% and 6.7% of the GWVs and NDVs, respectively, reported generalized musucle weakness (for 1 month or longer) since the Gulf War (July 1990). Many veterans also reported exposure to insecticide during the war. Dominant handgrip strength was measured three times with a hand-held dynamometer in subjects standing with the elbow bent at a right angle. Multiple linear regression revealed that handgrip strength was negatively associated with age (p = 0.001) and female gender (p < 0.001). Handgrip strength was also found to be positively associated with height (p < 0.001), but it was not associated with PB intake (p = 0.558). Exposure to insecticides had no major effect on handgrip strength. These data suggest no association between PB intake and postwar handgrip strength.