Mortality among US veterans of the Persian Gulf War: 7-year follow-up

Longitudinal Patterns of Multimorbidity in Gulf War Era Veterans With and Without Gulf War Illness

Objectives: To examine whether severe Gulf War illness (SGWI) case status was associated with longitudinal multimorbidity patterns. Methods: Participants were users of the Veteran Health Administration Health Care System drawn from the Gulf War Era Cohort and Biorepository (n = 840). Longitudinal measures of multimorbidity were constructed using (1) electronic health records (Charlson Comorbidity Index; Elixhauser; and Veterans Affairs Frailty Index) from 10/1/1999 to 6/30/2023 and (2) self-reported medical conditions (Deficit Accumulation Index) since the war until the survey date. Accelerated failure time models examined SGWI case status as a predictor of time until threshold level of multimorbidity was reached, adjusted for age and sociodemographic and military characteristics. Results: Models, adjusted for covariates, revealed that (1) relative to the SWGI- group, the SGWI+ group was associated with an accelerated time for reaching each threshold and (2) the relationship between SGWI and each threshold was not moderated by age. Discussion: Findings suggest that veterans with SGWI experienced accelerated aging.

Accuracy of behavioral health variables in Oregon national violent death reporting system data: a linked cohort study

Background

The National Violent Death Reporting System (NVDRS) collects data on the circumstances of violent deaths, and all firearm-related deaths, across states and territories in the USA. This surveillance system is critical to understanding patterns and risk factors for these fatalities, thereby informing targets for prevention. NVDRS variables include behavioral health conditions among decedents, but the validity of the reported behavioral health data is unknown. Using Department of Veterans Affairs (VA) healthcare records as a criterion standard, we examined the accuracy of NVDRS-reported behavioral health variables for veteran decedents in a sample state (Oregon) between 2003 and 2017.

Methods

We linked Oregon NVDRS data to VA healthcare data to identify veteran decedents who used VA services within two years of death. Veterans’ VA diagnoses within this time frame, including depression, post-traumatic stress disorder (PTSD), anxiety, and substance use disorders, were compared to behavioral health variables identified in the Oregon NVDRS. Concordance, sensitivity, and correlates of sensitivity were examined over time and by decedent characteristics.

Results

We identified 791 VA-using veterans with violent and/or firearm-related fatal injuries documented in the Oregon NVDRS between 2003 and 2017. In this cohort, the Oregon NVDRS accurately identified only 49% of decedents who were diagnosed with depression, 45% of those diagnosed with PTSD, and 17% of those diagnosed with anxiety by the VA. Among 211 veterans diagnosed by the VA with a substance use disorder, the Oregon NVDRS coded only 56% as having a substance use problem. In general, the sensitivity of behavioral health variables in the Oregon NVDRS remained the same or decreased over the study period; however, the sensitivity of PTSD diagnoses increased from 21% in 2003–2005 to 54% in 2015–2017. Sensitivity varied by some decedent characteristics, but not consistently across behavioral health variables.

Conclusions

NVDRS data from one state missed more than half of behavioral health diagnoses among VA-using veterans who died from violence or from firearm injuries. This suggests that reports of behavioral health conditions among decedents nationally may be severely undercounted. Efforts to improve validity of these variables in state NVDRS data are needed.

Pooled analysis of all-cause and cause-specific mortality among Nordic military veterans following international deployment

OBJECTIVES

To investigate all-cause and cause-specific mortality risks, including deaths from external, cardiovascular and cancer causes, among deployed Nordic military veterans in comparison to the general population in each country.

DESIGN

Pooled analysis.

SETTING

Denmark, Norway, Finland and Sweden.

PARTICIPANTS

Military veterans deployed between 1990 and 2010 were followed via nationwide registers and compared with age-sex-calendar-year-specific rates in the general population using pooled standardised mortality ratios (SMRs).

MAIN OUTCOMES

All-cause and cause-specific mortality retrieved from each country's Causes of Death Register, including deaths from external, cardiovascular and cancer causes.

RESULTS

Among 83 584 veterans 1152 deaths occurred of which 343 were from external causes (including 203 suicides and 129 traffic/transport accidents), 134 from cardiovascular causes and 297 from neoplasms. Veterans had a lower risk of death from any cause (pooled SMR 0.58, 95% CI 0.52 to 0.64), external causes (0.71, 95% CI 0.64 to 0.79), suicide (0.77, 95% CI 0.67 to 0.89), cardiovascular causes (0.54, 95% CI 0.46 to 0.64) and neoplasms (0.78, 95% CI 0.70 to 0.88). There was no difference regarding traffic/transport accidents for the whole period (1.10, 95% CI 0.92 to 1.31) but the pooled point estimate was elevated, though not statistically significant, during the first 5 years (1.17, 95% CI 0.89 to 1.53) but not thereafter (1.01, 95% CI 0.77 to 1.34). For all other causes of death, except suicide, statistically significantly lower risk among veterans was observed both during the first 5 years and thereafter. For suicide, no difference was observed beyond 5 years. Judged from the country-specific SMR estimates, there was a high degree of consistency although statistically significant heterogeneity was found for all-cause mortality.

CONCLUSIONS

Nordic military veterans had lower overall and cause-specific mortality than the general population for most outcomes, as expected given the predeployment selection process. Though uncommon, fatal traffic/transport accidents were an exception with no difference between deployed military veterans and the general population.

Cause-Specific Mortality Among Norwegian Veterans Deployed to Afghanistan Between 2001 and 2019

INTRODUCTION

Norwegian military forces participated in the military campaign Operation Enduring Freedom in Afghanistan starting in 2001. Military personnel often show a "healthy soldier effect" in terms of lowered all-cause mortality when compared to the general population. However, military service in conflict areas is associated with an increased risk of death from external causes such as transport accidents and suicide after discharge. We aimed to investigate cause-specific mortality in a cohort of 9,192 Norwegian (7.5% women) veterans deployed to Afghanistan between 2001 and 2019.

MATERIALS AND METHODS

We followed cohort members from their first day of service in Afghanistan through 2019. We computed standardized mortality ratios (SMRs) with 95% CIs by comparing the observed number of deaths in our cohort with the expected number of deaths in the general population. Standardized mortality ratios were calculated for the full follow-up period among men and women separately, and among men only for two time periods: during deployment and after discharge from service in Afghanistan.

RESULTS

We observed 77 deaths (3 women and 74 men), 10 of which occurred during deployment (war casualties, 1 woman and 9 men); all others occurred after discharge. All-cause mortality in women did not differ from that in the general population (SMR = 0.52, 95% CI 0.11-1.53). For men, the observed all-cause mortality was lower than the expected rate for the full follow-up period (SMR = 0.55, 95% CI 0.43-0.69), during deployment, and after discharge, while deaths because of transport accidents after discharge (13 cases) were more than twice as high as expected rates (SMR = 2.36, 95% CI 1.26-4.04). The 11 observed suicides gave a nonstatistically significant, lower suicide risk compared to the expected rates (SMR = 0.66, 95% CI 0.33-1.18).

CONCLUSION

In accordance with the "healthy soldier effect," military service in Afghanistan was generally associated with a lower than expected risk of death both during deployment and after discharge. The risk of death from transport accidents was higher than expected after discharge, while the observed incidence of suicide did not differ from the expected rate in the general population.

Occupational Exposures and Environmental Health Hazards of Military Personnel

BACKGROUND

Military personnel are frequently exposed to environmental pollutants that can cause a variety of diseases.

METHODS

This review analyzed publications regarding epidemiological and biomonitoring studies on occupationally-exposed military personnel.

RESULTS

The exposures include sulfur mustard, organ chlorines, combustion products, fuel vapors, and ionizing and exciting radiations. Important factors to be considered are the lengths and intensities of exposures, its proximity to the sources of environmental pollutants, as well as confounding factors (cigarette smoke, diet, photo-type, healthy warrior effect, etc.). Assessment of environmental and individual exposures to pollutants is crucial, although often omitted, because soldiers have often been evaluated based on reported health problems rather than on excessive exposure to pollutants. Biomarkers of exposures and effects are tools to explore relationships between exposures and diseases in military personnel. Another observation from this review is a major problem from the lack of suitable control groups.

CONCLUSIONS

This review indicates that only studies which analyzed epidemiological and molecular biomarkers in both exposed and control groups would provide evidence-based conclusions on exposure and disease risk in military personnel.

Cause-specific mortality risks among U.S. veterans: 25 years after their service in the 1990-1991 gulf war

PURPOSE

There is concern about adverse health effects related to military service in the 1990-1991 Gulf War. This study assessed cause-specific mortality risks among Veterans who served in the war.

METHODS

The mortality of 621,244 veterans deployed to the Gulf War was compared to that of 745,704 Veterans who served during the war but were not deployed to the Gulf Theater. Cause-specific mortality of both deployed and nondeployed was also compared to that of the US general population.

RESULTS

There was no increased risk of disease-specific mortality among deployed Veterans compared to nondeployed. Deployed Veterans did have an increased risk of motor vehicle deaths compared to nondeployed Veterans, (hazard ratio, 1.12, 95% confidence interval, 1.04-1.21). Cause-specific mortality of both deployed and non-deployed Veterans was less than that of the US population. When stratified by gender, only female Veterans, both deployed and nondeployed, had increased risks of suicide compared to the female US population (standardized mortality ratio, 1.40; 95% confidence interval, 1.13-1.71 and standardized mortality ratio, 1.22; 95% confidence interval, 1.05-1.40, respectively).

CONCLUSION

There was no increased risk of disease mortality among Veterans of the 1990-1991 Gulf War. Both deployed and nondeployed female Veterans had increased risks of suicide compared to US female population.

Military service and related risk factors for amyotrophic lateral sclerosis

BACKGROUND

The cause of amyotrophic lateral sclerosis (ALS) is unknown, but occupations have been explored as a potential proxy measure of risk. There is a substantial body of literature connecting military service to ALS. We aimed to summarize and assess the quality of this evidence.

METHODS

Systematic review of the literature, including observational studies which explored one of the following exposures: general military service (army, air force, marines, or navy); or specific exposures associated with military service measured among military personnel. The outcome of interest was ALS incidence, which could include onset, diagnosis, or death from ALS.

RESULTS

A total of 2642 articles were screened. Following exclusion, 19 articles remained for inclusion in the systematic review, including 1 meta-analysis and 18 original observational studies. Most studies were of moderate quality. In general, the relationship between military service was suggestive of an increased risk, particularly among Gulf War and WWII veterans. Exposure to pesticides (including Agent Orange) certain chemicals (exhaust, burning agents), heavy metals, and head trauma appeared to increase the risk of ALS among military personnel.

CONCLUSIONS

There is a possible association between military service and the subsequent development of ALS; however, the evidence was limited. Studies were generally hindered by small sample sizes and inadequate follow-up time. Future studies should endeavor to objectively measure specific exposures, or combinations thereof, associated with military service, as this will be of vital importance in implementing preventative strategies into military organizations.

Study protocol for a prospective, longitudinal cohort study investigating the medical and psychosocial outcomes of UK combat casualties from the Afghanistan war: the ADVANCE Study

INTRODUCTION

The Afghanistan war (2003-2014) was a unique period in military medicine. Many service personnel survived injuries of a severity that would have been fatal at any other time in history; the long-term health outcomes of such injuries are unknown. The ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) study aims to determine the long-term effects on both medical and psychosocial health of servicemen surviving this severe combat related trauma.

METHODS AND ANALYSIS

ADVANCE is a prospective cohort study. 1200 Afghanistan-deployed male UK military personnel and veterans will be recruited and will be studied at 0, 3, 6, 10, 15 and 20 years. Half are personnel who sustained combat trauma; a comparison group of the same size has been frequency matched based on deployment to Afghanistan, age, sex, service, rank and role. Participants undergo a series of physical health tests and questionnaires through which information is collected on cardiovascular disease (CVD), CVD risk factors, musculoskeletal disease, mental health, functional and social outcomes, quality of life, employment and mortality.

ETHICS AND DISSEMINATION

The ADVANCE Study has approval from the Ministry of Defence Research Ethics Committee (protocol no:357/PPE/12) agreed 15 January 2013. Its results will be disseminated through manuscripts in clinical/academic journals and presentations at professional conferences, and through participant and stakeholder communications.

TRIAL REGISTRATION NUMBER

The ADVANCE Study is registered at ISRCTN ID: ISRCTN57285353.

Psychiatric disorders and cardiovascular diseases during the diagnostic workup of potential breast cancer: a population-based cohort study in Skåne, Sweden

Background

An increasing number of women are evaluated for potential breast cancer and may experience mental distress during evaluation. We aim to assess the risks of psychiatric disorders and cardiovascular diseases during the diagnostic workup of potential breast cancer.

Methods

All women with a new diagnosis of unspecified lump in breast (N = 15,714), benign tumor or breast cancer in situ (N = 4435), or breast cancer (N = 8512) during 2005–2014 in Skåne, Sweden, were considered as exposed to a breast diagnostic workup. We used multivariable Poisson regression to compare rates of psychiatric disorders and cardiovascular diseases during the 6 weeks before the date of diagnosis of these women with the corresponding rates of women not undergoing such workup. The commonest waiting time for breast cancer patients was 6 weeks during the study period. A within-individual comparison was performed to control for potential unmeasured time-stationary confounders.

Results

Compared to the reference, we found a higher rate of psychiatric disorders during the 6 weeks before diagnosis of benign tumor or breast cancer in situ (incidence rate ratio [IRR], 1.3; 95% confidence interval [CI], 1.1 to 1.5) and breast cancer (IRR, 1.4; 95% CI, 1.2 to 1.6). A higher rate was also noted for cardiovascular diseases (IRR, 1.3; 95% CI, 1.1 to 1.6 for benign tumor or breast cancer in situ, and IRR, 1.9; 95% CI, 1.8 to 2.0 for breast cancer). The rate increases for breast cancer were greater comparing a diagnostic workup due to symptoms to a workup due to screening. Little rate increase of neither psychiatric disorders nor cardiovascular diseases was noted during the 6 weeks before the diagnosis of unspecified lump in breast. The within-individual comparison largely confirmed these findings.

Conclusions

Women with benign and malignant breast tumor had increased rates of psychiatric disorders and cardiovascular diseases during the waiting for a final diagnosis.

Suicide in the Military: Understanding Rates and Risk Factors Across the United States’ Armed Forces

This paper presents data from the United States Department of Defense Suicide Event Report System for years 2012–2015 to detail descriptive, longitudinal rate data and risk factor profiles associated with military suicide. The annual findings were aggregated from all U.S. military suicide deaths and suicide attempts. Data elements included the most common method of suicide (firearms), most common behavioral health diagnoses (substance abuse/dependence), common life stressors (failed intimate–partner relationships), and an individual’s history of operational deployment. Age- and sex-adjusted rates for the Services were compared with rates for the U.S. adult population. Results showed that the current reporting period (2015) is similar to patterns that have been observed over the preceding years and to patterns reported in the overall U.S. adult population. Suicide rates remain elevated but stable for both the Active and Reserve Components of the Military Services compared to historical levels observed prior to 2003. Finally, we discuss common errors and misinterpretations that can occur when analyzing surveillance data.

Diagnosing Chronic Obstructive Pulmonary Disease Among Afghanistan and Iraq Veterans: Veterans Affair's Concordance With Clinical Guidelines for Spirometry Administration

BACKGROUND

Early diagnosis and treatment of chronic obstructive pulmonary disease (COPD) can slow disease progression. The Department of Veterans Affairs (VA)/Department of Defense Clinical Practice Guidelines (CPG), established to improve patient outcomes, recommend the use of spirometry in the COPD diagnostic process. The aims of this study were to assess VA health care providers' performance related to CPG-recommended spirometry administration in the evaluation of newly diagnosed COPD among veterans, determine the patient characteristics that may influence the adherence rate, and compare VA concordance rates to those of other health plans.

METHODS

Administrative health care data related to Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) veterans was used to identify newly diagnosed COPD cases and the proportion of cases receiving spirometry. Cases were defined as veterans who had their first medical encounter with a coded diagnosis of COPD ≥ 6 months after their initial VA health care evaluation. The relationship between prediagnostic and comorbid conditions and the administration of CPG-concordant spirometry was examined using regression analyses.

FINDINGS

Among the 923,646 OEF/OIF/OND veterans receiving VA health care between January 2002 and December 2014, 32,076 (3%) had a coded diagnosis of COPD. Among those, 22,156 (69%) were identified as newly diagnosed COPD cases; only 6,827 (31%) had CPG-concordant spirometry. Concordant spirometry was more likely to occur in veterans aged ≥40. A pre-existing tobacco use disorder marginally changed the concordance rate.

DISCUSSION

VA provider adherence to CPG-concordant spirometry would decrease the prevalence of false-positive COPD cases and lead to more targeted disease treatment. Future research should focus on such cases by assessing the association between COPD diagnosis and bronchodilator responsiveness.

Road traffic accidents in Scottish military veterans

Road traffic accidents (RTA) are recognised to be an important cause of death and injury in serving military personnel but little is known about the risk in veterans. We used data from the Scottish Veterans Health Study to examine the risk of RTA in a large national cohort of veterans, in comparison with people who had never served. We conducted a retrospective cohort study of 57,000 veterans and 173,000 non-veterans, followed up for up to 30 years, using survival analysis to compare risk of RTA injury. Subgroup analysis was used to explore trends by birth cohort and length of service. Overall, veterans had a higher risk of RTA (Cox proportional hazard ratio (HR) 1.17, 95% confidence intervals (CI) 1.14-1.20). The risk was highest in the veterans with the shortest service (early service leavers), including those who did not complete initial military training (HR 1.31, 95% CI 1.23-1.40). The mean age at first RTA was 34 years, irrespective of age at leaving service, and the greatest increase in risk was in veterans born in the 1960s, but veterans born after 1970 showed no increase in risk. We have therefore demonstrated that the increased risk of RTA observed in serving military personnel persists in veterans through the fourth decade of life. The high risk in early service leavers is likely to be related to risk factors other than military service, including previous childhood adversity. Recent Ministry of Defence road safety programmes may now be reducing the long-term risk of RTA injury.

Overall mortality of Canadian Armed Forces personnel enrolled 1976-2012

Background

Military personnel may be exposed to hazardous substances or environments, making health surveillance critical. However, surveillance is frequently handicapped by long lag times between exposure(s) and outcomes, which often manifest post-military release and are often not recorded.

Aims

To describe the burden of mortality in still serving and released Canadian Armed Forces (CAF) personnel.

Methods

The Canadian Forces Cancer and Mortality Study II (CF CAMS II) is an interdepartmental record linkage study using CAF pay data and Statistics Canada cancer and mortality data. The cohort included all Regular Force and class C Reservist men and women who first enrolled in the CAF between 1976 and 2012, inclusive. The anonymized linked data included death data, including cause and location of death. All-cause mortality (ACM) and International Classification of Disease (ICD)-10 chapter-level mortality (CLM) were quantified using standardized mortality ratios (SMRs), with the Canadian general population (CGP) as the reference population.

Results

Approximately 6870 deaths occurred during over 5 million person-years of observations. For ACM, the CAF risk of death was significantly lower than the CGP for both sexes (females: n = 540, SMR = 0.76 [95% CI 0.69-0.82]; males: n = 6330, SMR = 0.79 [95% CI 0.77-0.81]). In the CLM analysis, SMRs were significantly lower than, or not statistically different from, 1.0 for all ICD chapters.

Conclusions

Military service may have a protective effect that may be partly explained by the healthy soldier effect and the stringent selection process at enrolment.

Health Status and Clinical Diagnoses of 3000 UK Gulf War Veterans

Up to June 2001, 3000 British veterans of the Gulf War had sought advice from a special medical assessment programme established because of an alleged Gulf War syndrome. After assessment those attending were classified as completely well, well with symptoms, well with incidental diagnoses treated or controlled, or unwell (physically or mentally). Mental illness was confirmed by a psychiatrist. The first 2000 attenders have been reported previously. The present paper summarizes findings in all 3000.

2252 (75%) of those attending were judged ‘well’, of whom 303 were symptom-free. Medical diagnoses were those to be expected in such an age-group (mean age 34 years, range 21–63). No novel or unusual condition was found. In 604 of the 748 unwell veterans, a substantial element of the illness was psychiatric, the most common condition being post-traumatic stress disorder.

The healthcare requirements of the Gulf veterans seen in this programme can therefore be met by standard National Health Service provision.

A Review of Epidemiologic Studies of the Health of Gulf War Women Veterans

INTRODUCTION

In the 25 years since the 1990-1991 Gulf War (GW), studies have evaluated Gulf War Illness (GWI), sometimes referred to as medically unexplained multi symptom illness, and other medical and neurological conditions in women GW veterans.

MATERIALS AND METHODS

In this article, we review epidemiologic studies of the health of women who served in the 1990-1991 GW based upon bibliographic searches in PubMed and CINAHL with relevant search terms through September 2015.

RESULTS

A total of 56 articles were identified in the bibliographic searches. By screening abstracts or full-text articles, a total of 21 relevant studies were identified. Results from some studies, but not all, suggest that GWI is more common in women GW veterans than their male counterparts. Few studies of GW veterans focused on women's health. A small number of studies suggested excess rates of woman's health problems, e.g., breast cysts, abnormal Papanicolaou (Pap) smears, yeast infections, and bladder infections. Several studies have identified significantly elevated rates of birth defects and adverse reproductive outcomes among GW veterans. However, findings have varied with different study designs and sample sizes, with some studies showing elevated risks of stillbirths, miscarriages, and/or birth defects and others have not. In some studies, participants reported increased risks of ectopic pregnancies and spontaneous abortions.

CONCLUSION

Further research is needed to provide a comprehensive picture of the health of women GW veterans and to examine a broad range of women's health issues including adverse reproductive outcomes. Some deployment-related health problems only become apparent decades later and other conditions may worsen or improve over time. Assessments are needed of current health status, changes in health symptoms and conditions over time, and possible differences in health outcomes associated with specific experiences and exposures during the war. Future studies would be strengthened by assessing GWI symptom patterns that may be specific to women veterans, examine diagnosed medical conditions among women veterans, and evaluate changes in women's health over time, including changes potentially associated with menopause and age.

Risk of motor vehicle accident death among 1.3 million veterans of the Iraq and Afghanistan wars

OBJECTIVE

We conducted a cohort study of recent wartime veterans to determine the postservice mortality risk due to motor vehicle accidents (MVAs).

METHODS

Veterans were identified from the Defense Manpower Data Center records. Deployment to te Iraq or Afghanistan war zone was determined from the Contingency Tracking System. Vital status of 317,581 deployed and 964,493 nondeployed veterans was followed from their discharge dates between 2001 to 2007 until earlier of date of death or December 31, 2009. Underlying causes of death were obtained from the National Death Index Plus.

RESULTS

Based on 9,353 deaths (deployed, 1,650; nondeployed, 7,703), of which 779 were MVA deaths as drivers (166; 613), both cohorts had 25 to 24% lower mortality risk from all causes but had 44 to 45% higher risk of MVA deaths relative to the U.S. general population. The higher MVA mortality risk was not associated with deployment to the war zone. After controlling for age, sex, race, marital status, branch of service, and rank, the risk for deployed veterans was comparable to that of nondeployed veterans (hazard ratio = 0.91; 95% confidence interval, 0.77-1.09).

CONCLUSIONS

Veterans exhibit significantly higher risk of MVA deaths compared to the U.S. general population. However, deployment to the Iraq or Afghanistan war was not associated with the excess risk.

External-cause mortality among 21 609 Norwegian male military peacekeepers deployed to Lebanon between 1978 and 1998

OBJECTIVE

To investigate external-cause mortality among 21 609 Norwegian male military peacekeepers deployed to Lebanon during 1978-1998.

METHODS

The cohort was followed from the 1st day of deployment through 2013, and mortality during deployment and post discharge was assessed using SMRs calculated from national rates in Norway. Poisson regression was used to see the effect of high-conflict versus low-conflict exposure.

RESULTS

For the total cohort, external-cause mortality was within expected values during deployment (SMR=0.80) and post discharge (SMR=1.05). In the low-conflict exposure group, a lower mortality from all external causes (SMR=0.77), transport accidents (SMR=0.55) and accidental poisoning (SMR=0.53) was seen. The high-conflict exposure group showed an elevated mortality from all external causes (SMR=1.20), transport accidents (SMR=1.51) and suicide (SMR=1.30), but these risks were elevated only during the first 5 years after discharge. This group also showed elevated mortality from all external causes (rate ratio, RR=1.49), and for transport accidents (RR=3.30) when compared with the low-conflict exposure group.

CONCLUSIONS

Overall external-cause mortality among our peacekeepers was equal to national rates during deployment and post discharge. High-conflict exposure was associated with elevated mortality from all external causes, transport accidents and suicide during the first 5 years after discharge from service.

All-Cause Mortality Among US Veterans of the Persian Gulf War: 13-Year Follow-up

OBJECTIVE

We determined cause-specific mortality prevalence and risks of Gulf War deployed and nondeployed veterans to determine if deployed veterans were at greater risk than nondeployed veterans for death overall or because of certain diseases or conditions up to 13 years after conflict subsided.

METHODS

Follow-up began when the veteran left the Gulf War theater or May 1, 1991, and ended on the date of death or December 31, 2004. We studied 621   901 veterans who served in the 1990-1991 Persian Gulf War and 746   247 veterans who served but were not deployed during the Gulf War. We used Cox proportional hazard models to calculate rate ratios adjusted for age at entry to follow-up, length of follow-up, race, sex, branch of service, and military unit. We compared the mortality of (1) Gulf War veterans with non-Gulf War veterans and (2) Gulf War army veterans potentially exposed to nerve agents at Khamisiyah in March 1991 with those not exposed. We compared standardized mortality ratios of deployed and nondeployed Gulf War veterans with the US population.

RESULTS

Male Gulf War veterans had a lower risk of mortality than male non-Gulf War veterans (adjusted rate ratio [aRR] = 0.97; 95% confidence interval [CI], 0.95-0.99), and female Gulf War veterans had a higher risk of mortality than female non-Gulf War veterans (aRR = 1.15; 95% CI, 1.03-1.28). Khamisiyah-exposed Gulf War army veterans had >3 times the risk of mortality from cirrhosis of the liver than nonexposed army Gulf War veterans (aRR = 3.73; 95% CI, 1.64-8.48). Compared with the US population, female Gulf War veterans had a 60% higher risk of suicide and male Gulf War veterans had a lower risk of suicide (standardized mortality ratio = 0.84; 95% CI, 0.80-0.88).

CONCLUSION

The vital status and mortality risk of Gulf War and non-Gulf War veterans should continue to be investigated.

Predicting Self-Reported Exposure to Nerve Agents by Reserve Component Personnel during the First Persian Gulf War

Approximately 13% of 654 Reserve Component Gulf War veterans (18% women, 65% ground forces, between 24 and 61 years of age, average 40.2 yr.) surveyed in the Ohio Desert Storm Research Project reported that they had probably been exposed to nerve or mustard gas agents, while another 32% thought such exposures were possible. Reports of exposure were found, through ordinary least squares regression analysis, to be associated with membership in ground forces (Army/Marine Corps) ( b = .29), geographical location ( b = .17), ethnic minority status ( b = .07), education ( b = –.10), intrinsic religiosity ( b = .10), and also reporting having had physiological reactions to vaccines or pyridostigmine bromide pills ( b = .24). Reports were not associated significantly with subjective health before the war, age, or sex.

Military service, deployments, and exposures in relation to amyotrophic lateral sclerosis etiology

BACKGROUND

Factors underlying a possible excess of amyotrophic lateral sclerosis (ALS) among military veterans remain unidentified. Limitations of previous studies on this topic include reliance on ALS mortality as a surrogate for ALS incidence, low statistical power, and sparse information on military-related factors.

OBJECTIVES

We evaluated associations between military-related factors and ALS using data from a case-control study of U.S. military veterans.

METHODS

From 2005 to 2010, we identified medical record-confirmed ALS cases via the National Registry of Veterans with ALS and controls via the Veterans Benefits Administration's Beneficiary Identification and Records Locator System database. In total, we enrolled 621 cases and 958 frequency-matched controls in the Genes and Environmental Exposures in Veterans with Amyotrophic Lateral Sclerosis study. We collected information on military service and deployments and 39 related exposures. We used unconditional logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (CIs). We used inverse probability weighting to adjust for potential bias from confounding, missing covariate data, and selection arising from a case group that disproportionately included long-term survivors and a control group that may or may not differ from U.S. military veterans at large.

RESULTS

The odds of ALS did not differ for veterans of the Air Force, Army, Marines, and Navy. We found higher odds of ALS for veterans whose longest deployment was World War II or the Korean War and a positive trend with total years of all deployments (OR=1.27; 95% CI: 1.06, 1.52). ALS was positively associated with exposure to herbicides for military purposes, nasopharyngeal radium, personal pesticides, exhaust from heaters or generators, high-intensity radar waves, contaminated food, explosions within one mile, herbicides in the field, mixing and application of burning agents, burning agents in the field, and Agent Orange in the field, with ORs between 1.50 and 7.75.

CONCLUSIONS

Although our results need confirmation, they are potentially important given the large number of U.S. military veterans, and they provide clues to potential factors underlying the apparent increase of ALS in veteran populations.

Mortality in Italian veterans deployed in Bosnia-Herzegovina and Kosovo

BACKGROUND AND AIMS

The possible increase of cancer risk in military personnel deployed in Balkans during and after the 1992-1999 wars, mainly related to the depleted uranium, was addressed by several studies on European veterans of those war theatres. This article reports on the results of the mortality study on the Italian cohort of Bosnia and Kosovo veterans (Balkan cohort).

METHODS

Mortality rates for the Balkan cohort (71 144 persons) were compared with those of the Italian general population as well as to those of a comparable and unselected control cohort of not deployed military personnel (114 269 persons). Ascertainment of vital status during the period 1995-2008 of all the persons in the two cohorts has been carried out through deterministic record linkage with the national death records database, from information provided by the respective Armed Force General Staff, and through the civil registry offices of the veterans' residence or birth municipalities.

RESULTS

The Balkan cohort experienced a mortality rates lower than both the general population (SMR = 0.56; 95% CI 0.51-0.62) and the control group (SMR = 0.88; 95% CI 0.79-0.97). Cancer mortality in the deployed cohort group was half of that from the general population mortality rates (SMR = 0.50; 95% CI 0.40-0.62) and slightly lower if compared with the control group cancer mortality rates (SMR = 0.95; 95% CI 0.77-1.18).

CONCLUSION

Balkan veteran cohort did not show any increase in general mortality or in cancer mortality.

Risky driving among UK regular armed forces personnel: changes over time

OBJECTIVES

To compare the prevalence of self-reported risky driving in a sample of UK military personnel at 2 different time points (2004 and 2009), and to identify the incidence of new onset risky driving and possible determinants of becoming a new risky driver.

METHODS

Data were used from 2 phases of a military cohort study investigating the health and well-being of UK military personnel between 2004 and 2009. Participants were included if they were undertaking regular (rather than reserve) engagements, had completed both surveys and reported being a driver at both surveys. Univariable and multivariable logistic regression analyses were performed to examine the relationship between risky driving status and sociodemographic and military characteristics. Data analysis was conducted in 2011.

RESULTS

The prevalence of risky driving reduced from 18% to 14%, over an average of 3.3 years. The incidence of new onset risky driving was 7%. Predictors for becoming a new risky driver were: younger age, not being in a relationship at phase 2 and harmful alcohol use. Those deployed after 2007 were less likely to become risky drivers following deployment, compared with those deployed before 2007 (adjusted OR 0.62 (95% CI 0.40 to 0.95)).

CONCLUSIONS

The prevalence of becoming a risky driver appears to have reduced over time. This paper suggests a number of explanations for this reduction, including changes in the way that the UK military have dealt with road safety with the introduction of the road safety campaign (in 2007).

Health effects of occupational exposure to uranium: do physicochemical properties matter?

PURPOSE

Physicochemical properties of uranium, including isotopic composition and solubility, are determinants of its toxicity. We reviewed epidemiological studies in civilian and military workers known to be exposed to uranium with different physicochemical properties to investigate its long-term effects, such as cancerous and circulatory diseases.

MATERIALS AND METHODS

We systematically searched the Pubmed and the Scopus databases to identify studies of uranium- processing workers (published between 1980 and 2013) and veterans of the wars in the Persian Gulf and the Balkans (published between 1991 and 2013) in which defined outcomes, such as lung, lymphohematopoietic, kidney cancers, and circulatory diseases were examined. RESULTS from these studies in terms of risk of each health outcome (mortality or incidence) and analyses of dose-response relationship were examined to present the impact of uranium physicochemical properties on the observed results.

RESULTS

Twenty-seven articles were reviewed. There is some evidence for increased lung cancer risk among uranium-processing workers. The evidence is less strong for lymphohematopoietic cancer. We found that most of the studies insufficiently assessed the physicochemical properties of uranium and some of them used proxies for the exposure assessment and risk estimation analyses. Studies of veterans of the wars in the Persian Gulf and the Balkans are uninformative in respect to internal uranium exposure.

CONCLUSIONS

Existing epidemiological data on the physicochemical properties of uranium and associated health outcomes are inconclusive. Further studies among certain groups of uranium-processing workers (uranium-enrichment and fuel-fabrication workers) could contribute to our knowledge of the health effects of uranium with respect to its physicochemical properties.

Military service, deployments, and exposures in relation to amyotrophic lateral sclerosis etiology and survival

Rates of amyotrophic lateral sclerosis (ALS) have been reported to be higher among US military veterans, who currently number more than 21 million, but the causal factor(s) has not been identified. We conducted a review to examine the weight of evidence for associations between military service, deployments, and exposures and ALS etiology and survival. Thirty articles or abstracts published through 2013 were reviewed. Although the current evidence suggests a positive association with ALS etiology, it is too limited to draw firm conclusions regarding associations between military service and ALS etiology or survival. Some evidence suggests that deployment to the 1990-1991 Persian Gulf War may be associated with ALS etiology, but there is currently no strong evidence that any particular military exposure is associated with ALS etiology. Future studies should address the limitations of previous ones, such as reliance on mortality as a surrogate for incidence, a dearth of survival analyses, lack of clinical data, low statistical power, and limited exposure assessment. The Genes and Environmental Exposures in Veterans with Amyotrophic Lateral Sclerosis (GENEVA) Study is one such study, but additional research is needed to determine whether military-related factors are associated with ALS and to assess potential prevention strategies.

Deployment experiences and motor vehicle crashes among U.S. service members

BACKGROUND

Motor vehicle crashes (MVCs) continue to account for a third of service member fatalities each year. Sociodemographic factors associated with MVCs among service members have been evaluated, but whether deployment-specific experiences during the recent operations are associated with a higher risk of MVCs is unclear.

PURPOSE

Evaluate if military members with specific deployment experiences are at an increased risk of MVCs, while taking into account several potential confounders.

METHODS

Millennium Cohort Study participants who enrolled during 2001-2006 and were on active-duty service were evaluated. The Military Health System Data Repository (MDR) was used to investigate MVC-related injuries occurring 6 months postdeployment in relation to service-related factors, while adjusting for demographic, behavioral, and mental and physical health factors. Analysis conducted in 2012 used Cox proportional hazards modeling.

RESULTS

There were 13,620 deployed personnel included in this study. After adjusting for covariates, deployers with combat experiences (hazard ratio [HR]=1.86, 95% CI=1.33, 2.62) and those with more than one deployment (two deployments, HR=1.93, 95% CI=1.32, 2.83; three or more deployments, HR=2.83, 95% CI=1.71, 4.67) had an increased risk for an MVC within 6 months postdeployment. Enlisted rank and non-Hispanic black race/ethnicity were also associated with increased risk for MVCs.

CONCLUSION

Experiencing combat during deployment and multiple deployments are both strong predictors for MVCs within 6 months of returning home among U.S. military members. These data provide critical information for targeting prevention strategies to decrease MVCs among personnel postdeployment.

Suicide and substance use among female veterans: a need for research

BACKGROUND

The number of female veterans is increasing. Veterans Administration (VA) enrollment increased over 40% from past eras. However, little research has focused on their mental health. We reviewed literature to examine associations of substance use with suicide in female veterans, identify research gaps, and inform future studies.

METHODS

Google Scholar, Pub Med, and PsychINFO were searched using: substance use, female veteran, and suicide. Exclusion criteria (e.g., not discussing U.S. veterans) left 17 articles.

RESULTS

Nine studies examined completed suicide among veterans. In most recent years, rates of deaths were greater for veterans than nonveterans, including females. Completed suicide was associated with past trauma, young age, and a mental disorder. Studies have often not addressed substance use. Three studies examined completed suicide among VA treated veterans without examining substance use as an associated factor. Rates of completed suicides were also higher among veterans than nonveterans, including females. A large proportion of females also had a mental diagnosis. Five studies examined substance use and attempted or completed suicide among VA treated veterans. Veterans in poor mental health had increased odds of suicide mortality; women with a substance use disorder (SUD) had a higher hazard ratio for completed suicide than men with a SUD. Engagement in substance abuse treatment decreased odds of suicide attempt among veterans.

CONCLUSION

Available data suggest that suicide rates are higher among female veterans than women in the general population. Substance use may increase the likelihood of suicidal behaviors among female veterans, particularly those with a mental diagnosis.

Clinical perspective on oxidative stress in sporadic amyotrophic lateral sclerosis

Sporadic amyotrophic lateral sclerosis (ALS) is one of the most devastating neurological diseases; most patients die within 3 to 4 years after symptom onset. Oxidative stress is a disturbance in the pro-oxidative/antioxidative balance favoring the pro-oxidative state. Autopsy and laboratory studies in ALS indicate that oxidative stress plays a major role in motor neuron degeneration and astrocyte dysfunction. Oxidative stress biomarkers in cerebrospinal fluid, plasma, and urine are elevated, suggesting that abnormal oxidative stress is generated outside of the central nervous system. Our review indicates that agricultural chemicals, heavy metals, military service, professional sports, excessive physical exertion, chronic head trauma, and certain foods might be modestly associated with ALS risk, with a stronger association between risk and smoking. At the cellular level, these factors are all involved in generating oxidative stress. Experimental studies indicate that a combination of insults that induce modest oxidative stress can exert additive deleterious effects on motor neurons, suggesting that multiple exposures in real-world environments are important. As the disease progresses, nutritional deficiency, cachexia, psychological stress, and impending respiratory failure may further increase oxidative stress. Moreover, accumulating evidence suggests that ALS is possibly a systemic disease. Laboratory, pathologic, and epidemiologic evidence clearly supports the hypothesis that oxidative stress is central in the pathogenic process, particularly in genetically susceptive individuals. If we are to improve ALS treatment, well-designed biochemical and genetic epidemiological studies, combined with a multidisciplinary research approach, are needed and will provide knowledge crucial to our understanding of ALS etiology, pathophysiology, and prognosis.

Cognitive-behavioral group treatment for driving-related anger, aggression, and risky driving in combat veterans: a pilot study

The present study examined the preliminary effects of an 8-session group cognitive-behavioral treatment (CBT) designed to reduce driving-related anger, aggression, and risky driving behaviors in veterans. Participants (N = 9) with self-reported aggressive and risky driving problems completed self-report measures at pretreatment, posttreatment, and 1-month follow-up. Of those completing the treatment, 89% demonstrated reliable change in driving-related aggression and 67% evidenced reliable change in driving-related anger. Similar changes were found for secondary treatment targets.

The psychological costs of war: military combat and mental health

We exploit plausibly exogenous variation in overseas deployment assignment to estimate the effect of combat exposure on psychological well-being. Controlling for pre-deployment mental health, we find that active-duty soldiers deployed to combat zones are more likely to suffer from post-traumatic stress disorder (PTSD) than their counterparts deployed outside the United States in non-combat zones. Among those deployed to combat zones, those deployed to locales where they engage in enemy firefight or witness allied or civilian deaths are at an increased risk for suicidal ideation and PTSD relative to their active-duty counterparts deployed to combat zones without enemy firefight.

Suicidal behavior in war veterans

Military veterans represent a unique, heterogeneous population with suicide prevalence rates, risk factors and preventative management needs that differ from those of the rest of community. Veterans worldwide receive high proportions of their healthcare from community providers, and sensitivity to these distinct needs is required for optimized care. An overview of the recent prevalence-study literature, with a focus upon statistical design, is presented in order to provide a critical orientation within this field with high levels of popular media attention. Attention to psychiatric comorbidity, subthreshold symptomology, select signature disorders of contemporary conflicts (namely, post-traumatic stress disorder and traumatic brain injury), and veteran life narratives before, within and beyond military service will guide our review of risk factor assessment and management strategies. This critical review of the literature provides an overview of this active field of neuropsychiatric research with a select focus upon these topics of special interest.

Suicide among war veterans

Studies aiming to identify if war veterans are at higher risk of suicide have often produced inconsistent results; this could be due to the complexity of comparisons and different methodological approaches. It should be noted that this contingent has many risk factors, such as stressful exposures, wounds, brain trauma and pain syndrome. Most recent observations confirm that veterans are really more likely to die of suicide as compared to the general population; they are also more likely to experience suicidal ideation and suffer from mental health problems. Suicides are more frequent in those who develop PTSD, depression and comorbid states due to war exposure. Combat stress and its’ frequency may be an important factor leading to suicide within the frame of the stress-vulnerability model. According to this model, the effects of stress may interact with social factors, interpersonal relations and psychological variables producing suicidal tendencies. Modern understanding of stress-vulnerability mechanisms based on genetic predispositions, early life development, level of exposure to stress and stress-reactivity together with interpersonal aspects may help to build more effective suicide prevention programs based on universal/selective/indicated prevention principles.

Causes of death in patients with multiple sclerosis and matched referent subjects: a population-based cohort study

BACKGROUND AND PURPOSE

  Multiple sclerosis (MS) has been associated with increased mortality rates. However, influence of lifestyle parameters remains unknown, and inconsistencies exist regarding findings for causes of death.

METHODS

  We conducted a population-based cohort study using the General Practice Research Database, Hospital Episode Statistics, and national death certificates (January 2001 through March 2008). To each patient with MS (n = 1270), up to six referent subjects without MS were matched by age, gender, and practice. Cox proportional hazards models were used to estimate mortality rate ratios (HRs).

RESULTS

  Patients with MS had a 3.5-fold increased mortality rate for all-cause mortality, compared with referent subjects (HR 3.51, 95% CI 2.63-4.69). The rate further increased amongst current smokers (HR 6.72, 95% CI 4.16-10.87) (but not in ex-smokers) and subjects with a body mass index of <20 kg/m(2) (HR 6.67, 95% CI 3.50-12.73). The HR was highest for infectious/respiratory-related deaths (HR 7.69, 95% CI 4.92-12.02) and was significantly increased for deaths related to cardiovascular diseases (2.4-fold) and cancer (1.9-fold), but not for accidents and suicide related deaths.

CONCLUSION

  British patients with MS have a 3.5-fold increased mortality rate compared with the general population. Smoking and respiratory diseases are major (potentially preventable) factors related to increased mortality rate amongst patients with MS.

Veterans and suicide: a reexamination of the National Death Index-linked National Health Interview Survey

OBJECTIVES

We assessed the risk of suicide among veterans compared with nonveterans.

METHODS

Cox proportional hazards models estimated the relative risk of suicide, by self-reported veteran status, among 500,822 adult male participants in the National Death Index (NDI)-linked National Health Interview Survey (NHIS), a nationally representative cohort study.

RESULTS

A total of 482 male veterans died by suicide during 1,837,886 person-years of follow-up (76% by firearm); 835 male nonveterans died by suicide during 4,438,515 person-years of follow-up (62% by firearm). Crude suicide rates for veterans and nonveterans were, respectively, 26.2 and 18.8 per 100,000 person-years. The risk of suicide was not significantly higher among veterans, compared with nonveterans, after adjustment for differences in age, race, and survey year (hazard ratio = 1.11; 95% confidence interval = 0.96, 1.29).

CONCLUSIONS

Consistent with most studies of suicide risk among veterans of conflicts before Operation Iraqi Freedom/Operation Enduring Freedom, but in contrast to a previous study using the NDI-linked NHIS data, we found that male veterans responding to the NHIS were modestly, but not significantly, at higher risk for suicide compared with male nonveterans.

Predictors of posttraumatic stress disorder, depression, and suicidal ideation among Canadian Forces personnel in a National Canadian Military Health Survey

Despite efforts to elucidate the relationship between traumatic event exposure and adverse mental health outcomes, our ability to understand why only some trauma-exposed individuals become emotionally affected remains challenged. The aim of the current study is to determine the relations between social support, religiosity, and number of lifetime traumatic events experienced on past-12 month posttraumatic stress disorder (PTSD), depression, and suicidal ideation (SI) in a nationally representative sample of Canadian Forces personnel. The current study used data from the Canadian Community Health Survey Cycle 1.2 - Canadian Forces Supplement. The impact of a number of predictive and mediating factors was assessed using structural equation modeling. Social support and number of lifetime traumatic events experienced were significant predictors of past-year PTSD, depression, and SI; however PTSD did not mediate the relationship between number of traumatic events and SI nor between social support and SI. Conversely, depression mediated the relationship between number of traumatic events and SI. Possible mechanisms for these findings and their implications are discussed.

Predictors of suicide-related hospitalization among U.S. veterans receiving treatment for comorbid depression and substance dependence: who is the riskiest of the risky?

This study examined whether widely accepted suicide risk factors are useful in predicting suicide-related hospitalization, beyond history of a suicide attempt, in high-risk treatment-seeking veterans with depression and substance dependence. Negative mood regulation expectancies were the only significant predictor of hospitalization during 6-months of outpatient treatment. History of a suicide attempt was the only significant predictor of hospitalization during the one-year follow-up period. Results suggest that within high-risk populations, standard suicide risk factors may not identify individuals who will engage in suicidal behaviors resulting in hospitalization. Assessing negative mood regulation expectations may assist in identifying those most at risk.

History of military service and the risk of suicidal ideation: findings from the 2008 national survey on drug use and health

Studies of completed suicide by history of military service have produced inconsistent findings; no representative population-based study has compared the risk of nonfatal suicidal behavior among veterans with risk among nonveterans. The objective of this study was to examine whether male veterans of the U.S. military are at heightened risk of suicidal ideation, compared with males who never served in the U.S. military. A total of 17,641 adult men completed the 2008 National Survey on Drug Use and Health (NSDUH). Subjects provided information about history of ever having served in the U.S. armed forces, past suicidal ideation, alcohol and drug abuse and dependence, measures of psychological distress, and sociodemographic data. Overall, men who had ever served in the armed forces were no more likely than men who had never served to report having seriously considered suicide over the prior 12 months. Military status was not differentially associated with other known suicide risk factors assessed by NSDUH, including psychiatric disorders. Our findings suggest that evidence-based suicide prevention strategies applicable to the general population should be employed to reduce suicide risk among the veteran population as well.

Late-life coronary heart disease mortality of Finnish war veterans in the TAMRISK study, a 28-year follow-up

Background

Wartime stress has been associated with increased late-life mortality of all causes of death. We evaluated whether wounded Finnish World War II veterans who were alive at the age of 55 have increased long-term coronary heart disease (CHD) mortality.

Methods

Health survey data were recorded in 1980 from 667 men, aged 55 years. Of them 102 had been wounded or injured in action during 1939-1945. The remaining participants served as the comparison group. The death certificates during a 28-year follow-up were obtained from the national statistics centre. Statistical comparisons were done by Cox proportional hazard regression model.

Results

There were altogether 140 deaths from CHD. In men who had been wounded or injured in action the crude CHD mortality rate per 10,000 population was 2843, while in the comparison group the corresponding figure was 1961. Men who had been wounded or injured in action were 1.7 times (95% CI 1.1-2.5; p = 0.01) more likely to die from CHD than the comparison group.

Conclusions

Physical trauma at young adulthood may extend to lifelong effects on health. This study suggests that being physically wounded or injured in war may lead to increased CHD mortality in late adulthood in a Finnish population.

Are Canadian soldiers more likely to have suicidal ideation and suicide attempts than Canadian civilians?

Significant controversy exists as to whether soldiers are at increased risk for suicide and suicidal behaviors compared with civilians. Furthermore, little is known about whether risk factors for suicidal behaviors in civilian populations are generalizable to soldiers. The aim of the current study is to determine whether the prevalence and correlates of past-year suicidal ideation and suicide attempts differ in Canadian soldiers when compared with Canadian civilians. The current study utilized data from the Canadian Community Health Survey Cycle 1.2-Canadian Forces Supplement in conjunction with the 2001-2002 Canadian Community Health Survey Cycle 1.2. Logistic regression interaction models were used to explore differences between correlates of suicidal ideation and suicide attempts comparing Canadian soldiers with civilians. Although there was no significant difference between the 2 samples on prevalence of past-year suicidal ideation, the prevalence of past-year suicide attempts was significantly lower in the Canadian forces sample compared with the civilian population (odds ratio = 0.41, 95% confidence interval: 0.25, 0.67). Findings suggest that suicide attempts are less common in Canadian active military personnel than in the civilian population. Possible mechanisms for these differences are discussed.

War-related stress exposure and mortality: a meta-analysis

BACKGROUND

Domestic and international wars continue to be pervasive in the 21st century. This study summarizes the effects of war-related stress on all-cause mortality using meta-analyses and meta-regressions.

METHODS

A keyword search was performed, supplemented by extensive iterative hand-searches for observational studies of war-related stress and mortality. Two hundred and twenty mortality risk estimates from 30 studies were extracted, providing data on more than 9 million persons.

RESULTS

The mean hazard ratio (HR) was 1.05 [95% confidence interval (CI) 0.98-1.13] among HRs adjusted for age and additional covariates. The mean effect for men was 1.14 (CI 1.00-1.31), and for women it was 0.92 (CI 0.66-1.28). No differences were found for various follow-up durations or for various types of war stress. Neither civilians nor military personnel had an elevated mortality risk. Those exposed to a combat zone during the Vietnam War had a slightly higher chance of death (HR 1.11; 95% CI 1.00-1.23).

CONCLUSIONS

The results show that, over all, exposure to war-stress did not increase the risk of death when studies were well controlled. Effects were small when found. This lack of substantial effect may be the result of selection processes, developed resiliency and/or institutional support.

The use of electronic pharmacy data to investigate prescribed medications and fatal motor vehicle crashes in a military population, 2002-2006

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 (< 27 years) and history of deployment were reduced for MVC cases. Although results need to be considered in the context of data limitations, the association between prescribed antidepressants and fatal MVC may reflect unmeasured co-morbidities, such as combined effects of prescribed and over-the-counter medications and/or alcohol or other substance abuse. Younger individuals, representing new military accessions in training or returning from deployment with serious injuries, may have fewer opportunities to operate vehicles, or targeted efforts to reduce MVC following deployment may be showing a positive effect.

Neurological mortality among U.S. veterans of the Persian Gulf War: 13-year follow-up

BACKGROUND

This study focuses on long-term mortality, specifically brain cancer, amyotrophic lateral sclerosis (ALS), Parkinson's disease, and multiple sclerosis (MS) of 621,902 veterans who served in the 1990-1991 Persian Gulf War (GW), and 746,248 non-GW veterans.

METHODS

Follow-up began with the date the veteran left the GW theater or May 1, 1991 and ended with the date of death or December 31, 2004. Cox proportional hazard models were used for analyses.

RESULTS

Adjusted mortality rate ratios (aRR) of GW veterans compared to non-GW veterans were not statistically significant for brain cancer (aRR = 0.90, 95% confidence interval (CI): 0.73, 1.11), MS (aRR = 0.61, 95% CI: 0.23, 1.63), Parkinson's disease (aRR = 0.71, 95% CI: 0.17, 2.99), or ALS (aRR = 0.96, 95% CI: 0.56, 1.62). GW veterans potentially exposed to nerve agents for 2 or more days and GW veterans exposed to oil well fire smoke were at increased risk for brain cancer mortality (aRR = 2.71, 95% CI: 1.25, 5.87; aRR = 1.81, 95% CI: 1.00, 3.27; respectively).

CONCLUSIONS

The risk of death due to ALS, MS, Parkinson's disease, and brain cancer was not associated with 1991 GW service in general. However, GW veterans potentially exposed to nerve agents at Khamisiyah, Iraq, and to oil well fire smoke had an increased risk of mortality due to brain cancer.