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Lesnewich LM, Hyde JK, McFarlin ML, Bolton RE, Bayley PJ, Chandler HK, Helmer DA, Phillips LA, Reinhard MJ, Santos SL, Stewart RS, McAndrew LM. 'She thought the same way I that I thought:' a qualitative study of patient-provider concordance among Gulf War Veterans with Gulf War Illness. Psychol Health 2023:1-19. [PMID: 37654203 DOI: 10.1080/08870446.2023.2248481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 07/15/2023] [Accepted: 08/10/2023] [Indexed: 09/02/2023]
Abstract
Objective: Medically unexplained symptoms (MUS), such as chronic fatigue syndrome, irritable bowel syndrome, and Gulf War Illness (GWI), are difficult to treat. Concordance-shared understanding between patient and provider about illness causes, course, and treatment-is an essential component of high-quality care for people with MUS. This qualitative paper focuses on the experiences of United States military Veterans living with GWI who have endured unique healthcare challenges. Methods & Measures: Qualitative interviews were conducted with 31 Veterans with GWI to explore factors that contribute to and detract from concordance with their Veteran Affairs (VA) healthcare providers. In addition to being seen by VA primary care, over half of participants also sought care at a War Related Illness and Injury Study Center, which specializes in post-deployment health. Deductive and inductive codes were used to organize the data, and themes were identified through iterative review of coded data. Results: Major themes associated with patient-provider concordance included validation of illness experiences, perceived provider expertise in GWI/MUS, and trust in providers. Invalidation, low provider expertise, and distrust detracted from concordance. Conclusion: These findings suggest providers can foster concordance with MUS patients by legitimizing patients' experiences, communicating knowledge about MUS, and establishing trust.
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Affiliation(s)
- Laura M Lesnewich
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, East Orange, NJ, USA
| | - Justeen K Hyde
- Department of Medicine, Section General Internal Medicine, Boston University, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Bedford Healthcare System, Bedford, MA, USA
| | | | - Rendelle E Bolton
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Bedford Healthcare System, Bedford, MA, USA
- The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Peter J Bayley
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Helena K Chandler
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, East Orange, NJ, USA
| | - Drew A Helmer
- Center for Innovations in Quality, Effectiveness & Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - L Alison Phillips
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, East Orange, NJ, USA
- Department of Psychology, Iowa State University, IA, USA
| | - Matthew J Reinhard
- War Related Illness and Injury Study Center (WRIISC), Washington DC Veterans Affairs Medical Center, Washington, DC, USA high-quality
| | - Susan L Santos
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, East Orange, NJ, USA
| | - Rachel S Stewart
- War Related Illness and Injury Study Center (WRIISC), Washington DC Veterans Affairs Medical Center, Washington, DC, USA high-quality
| | - Lisa M McAndrew
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs New Jersey Health Care System, East Orange, NJ, USA
- University at Albany, State University of New York (SUNY), Albany, NY, USA
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Nkiliza A, Joshi U, Evans JE, Ait-Ghezala G, Parks M, Crawford F, Mullan M, Abdullah L. Adaptive Immune Responses Associated with the Central Nervous System Pathology of Gulf War Illness. Neurosci Insights 2021; 16:26331055211018458. [PMID: 34104887 PMCID: PMC8155779 DOI: 10.1177/26331055211018458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 04/26/2021] [Indexed: 11/17/2022] Open
Abstract
Gulf War Illness is a multisymptomatic condition which affects 30% of veterans
from the 1991 Gulf War. While there is evidence for a role of peripheral
cellular and humoral adaptive immune responses in Gulf War Illness, a potential
role of the adaptive immune system in the central nervous system pathology of
this condition remains unknown. Furthermore, many of the clinical features of
Gulf War Illness resembles those of autoimmune diseases, but the biological
processes are likely different as the etiology of Gulf War Illness is linked to
hazardous chemical exposures specific to the Gulf War theatre. This review
discusses Gulf War chemical–induced maladaptive immune responses and a potential
role of cellular and humoral immune responses that may be relevant to the
central nervous system symptoms and pathology of Gulf War Illness. The
discussion may stimulate investigations into adaptive immunity for developing
novel therapies for Gulf War Illness.
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Carpenter JM, Gordon HE, Ludwig HD, Wagner JJ, Harn DA, Norberg T, Filipov NM. Neurochemical and neuroinflammatory perturbations in two Gulf War Illness models: Modulation by the immunotherapeutic LNFPIII. Neurotoxicology 2019; 77:40-50. [PMID: 31866310 DOI: 10.1016/j.neuro.2019.12.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/12/2019] [Accepted: 12/19/2019] [Indexed: 01/06/2023]
Abstract
Gulf War Illness (GWI) manifests a multitude of symptoms, including neurological and immunological, and approximately a third of the 1990-1991 Gulf War (GW) veterans suffer from it. This study sought to characterize the acute neurochemical (monoamine) and neuroinflammatory profiles of two established GWI animal models and examine the potential modulatory effects of the novel immunotherapeutic Lacto-N-fucopentaose III (LNFPIII). In Model 1, male C57BL/6 J mice were treated for 10 days with pyridostigmine bromide (PB) and permethrin (PM). In Model 2, a separate cohort of mice were treated for 14 days with PB and N,N-Diethyl-methylbenzamide (DEET), plus corticosterone (CORT) via drinking water on days 8-14 and diisopropylfluorophosphate (DFP) on day 15. LNFPIII was administered concurrently with GWI chemicals treatments. Brain and spleen monoamines and hippocampal inflammatory marker expression were examined by, respectively, HPLC-ECD and qPCR, 6 h post treatment cessation. Serotonergic (5-HT) and dopaminergic (DA) dyshomeostasis caused by GWI chemicals was apparent in multiple brain regions, primarily in the nucleus accumbens (5-HT) and hippocampus (5-HT, DA) for both models. Splenic levels of 5-HT (both models) and norepinephrine (Model 2) were also disrupted by GWI chemicals. LNFPIII treatment prevented many of the GWI chemicals induced monoamine alterations. Hippocampal inflammatory cytokines were increased in both models, but the magnitude and spread of inflammation was greater in Model 2; LNFPIII was anti-inflammatory, more so in the apparently milder Model 1. Overall, in both models, GWI chemicals led to monoamine disbalance and neuroinflammation. LNFPIII co-treatment prevented many of these disruptions in both models, which is indicative of its promise as a potential GWI therapeutic.
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Affiliation(s)
- J M Carpenter
- Department of Physiology and Pharmacology, Athens, GA, United States
| | - H E Gordon
- Department of Physiology and Pharmacology, Athens, GA, United States
| | - H D Ludwig
- Department of Physiology and Pharmacology, Athens, GA, United States
| | - J J Wagner
- Department of Physiology and Pharmacology, Athens, GA, United States
| | - D A Harn
- Department of Infectious Diseases, Athens, GA, United States; Center for Tropical and Emerging Infectious Diseases, University of Georgia, Athens, GA, United States
| | - T Norberg
- Department of Chemistry, University of Uppsala, Uppsala, Sweden
| | - N M Filipov
- Department of Physiology and Pharmacology, Athens, GA, United States.
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4
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Abstract
Several studies have implicated immune system disruption in the pathophysiology of GWI. In addition, alterations in brain structure and functioning have been associated with specific exposures in theater, including pyridostigmine bromide and nerve gas agents. Recent studies conducted up to 25 years after the 1991 conflict have examined factors associated with the continuation or worsening of GWI. Drawing upon published studies of neural and immune system abnormalities in veterans with GWI, this paper proposes a model of GWI that takes into account neurologic and immunologic pathways, neuroimmune mechanisms of disease pathophysiology, individual predisposition due to sex and genetic background, and comorbid factors including neurological conditions such as neuritis/neuralgia and epilepsy that may occur along a continuum with GWI. The proposed neuroimmune model of GWI is likely to be useful for designing new research studies, clarifying factors involved in the continuation or worsening of GWI, and identifying biomarker screening algorithms for the illness. The proposed model goes beyond previously proposed frameworks for GWI by taking into account potential differences in risk based upon female vs. male sex, time elapsed since exposure to neurotoxicants, duration and severity of illness, comorbid conditions, and genotype.
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Affiliation(s)
- Steven S Coughlin
- Department of Clinical and Digital Health Sciences, Augusta University, Augusta, GA.,Research Service, Charlie Norwood VA Medical Center, Augusta, GA
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5
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Ikin JF, Kelsall HL, McKenzie DP, Gwini SM, Forbes AB, Glass DC, Mc Farlane AC, Clarke D, Wright B, Del Monaco A, Sim MR. Cohort Profile: The Australian Gulf War Veterans' Health Study cohort. Int J Epidemiol 2017; 46:31. [PMID: 27380794 DOI: 10.1093/ije/dyw025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2016] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jillian F Ikin
- Monash University, School of Public Health and Preventive Medicine, Centre for Occupational and Environmental Health, Clayton, VIC, Australia
| | - Helen L Kelsall
- Monash University, School of Public Health and Preventive Medicine, Centre for Occupational and Environmental Health, Clayton, VIC, Australia
| | - Dean P McKenzie
- Monash University, School of Public Health and Preventive Medicine, Centre for Occupational and Environmental Health, Clayton, VIC, Australia
| | - Stella M Gwini
- Monash University, School of Public Health and Preventive Medicine, Centre for Occupational and Environmental Health, Clayton, VIC, Australia
| | - Andrew B Forbes
- Monash University, School of Public Health and Preventive Medicine, Centre for Occupational and Environmental Health, Clayton, VIC, Australia
| | - Deborah C Glass
- Monash University, School of Public Health and Preventive Medicine, Centre for Occupational and Environmental Health, Clayton, VIC, Australia
| | | | - David Clarke
- Monash University, School of Clinical Sciences at Monash Health: Psychiatry, Clayton, VIC, Australia
| | - Breanna Wright
- Monash University, School of Public Health and Preventive Medicine, Centre for Occupational and Environmental Health, Clayton, VIC, Australia
| | - Anthony Del Monaco
- Monash University, School of Public Health and Preventive Medicine, Centre for Occupational and Environmental Health, Clayton, VIC, Australia
| | - Malcolm R Sim
- Monash University, School of Public Health and Preventive Medicine, Centre for Occupational and Environmental Health, Clayton, VIC, Australia
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White RF, Steele L, O'Callaghan JP, Sullivan K, Binns JH, Golomb BA, Bloom FE, Bunker JA, Crawford F, Graves JC, Hardie A, Klimas N, Knox M, Meggs WJ, Melling J, Philbert MA, Grashow R. Recent research on Gulf War illness and other health problems in veterans of the 1991 Gulf War: Effects of toxicant exposures during deployment. Cortex 2015; 74:449-75. [PMID: 26493934 PMCID: PMC4724528 DOI: 10.1016/j.cortex.2015.08.022] [Citation(s) in RCA: 292] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 08/19/2015] [Accepted: 08/28/2015] [Indexed: 11/01/2022]
Abstract
Veterans of Operation Desert Storm/Desert Shield - the 1991 Gulf War (GW) - are a unique population who returned from theater with multiple health complaints and disorders. Studies in the U.S. and elsewhere have consistently concluded that approximately 25-32% of this population suffers from a disorder characterized by symptoms that vary somewhat among individuals and include fatigue, headaches, cognitive dysfunction, musculoskeletal pain, and respiratory, gastrointestinal and dermatologic complaints. Gulf War illness (GWI) is the term used to describe this disorder. In addition, brain cancer occurs at increased rates in subgroups of GW veterans, as do neuropsychological and brain imaging abnormalities. Chemical exposures have become the focus of etiologic GWI research because nervous system symptoms are prominent and many neurotoxicants were present in theater, including organophosphates (OPs), carbamates, and other pesticides; sarin/cyclosarin nerve agents, and pyridostigmine bromide (PB) medications used as prophylaxis against chemical warfare attacks. Psychiatric etiologies have been ruled out. This paper reviews the recent literature on the health of 1991 GW veterans, focusing particularly on the central nervous system and on effects of toxicant exposures. In addition, it emphasizes research published since 2008, following on an exhaustive review that was published in that year that summarizes the prior literature (RACGWI, 2008). We conclude that exposure to pesticides and/or to PB are causally associated with GWI and the neurological dysfunction in GW veterans. Exposure to sarin and cyclosarin and to oil well fire emissions are also associated with neurologically based health effects, though their contribution to development of the disorder known as GWI is less clear. Gene-environment interactions are likely to have contributed to development of GWI in deployed veterans. The health consequences of chemical exposures in the GW and other conflicts have been called "toxic wounds" by veterans. This type of injury requires further study and concentrated treatment research efforts that may also benefit other occupational groups with similar exposure-related illnesses.
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Affiliation(s)
- Roberta F White
- Department of Environmental Health, Boston University School of Public Health, Boston, MA, United States.
| | - Lea Steele
- Baylor University Institute of Biomedical Studies, Waco, TX, United States.
| | - James P O'Callaghan
- Molecular Neurotoxicology, Toxicology & Molecular Biology Branch (MS-3014), Health Effects Laboratory Division, Centers for Disease Control and Prevention - NIOSH, Morgantown, WV, United States.
| | - Kimberly Sullivan
- Boston University School of Public Health, Department of Environmental Health, Boston, MA, United States.
| | - James H Binns
- Research Advisory Committee on Gulf War Veterans' Illnesses, Phoenix, AZ, United States.
| | | | - Floyd E Bloom
- Molecular & Integrative Neuroscience Department, The Scripps Research Institute, La Jolla, CA, United States.
| | - James A Bunker
- National Gulf War Resource Center, Topeka, KS, United States.
| | - Fiona Crawford
- Director, TBI Research Program, Roskamp Institute, Sarasota, FL, United States.
| | - Joel C Graves
- Captain, U.S. Army, Retired, Crestview, FL, United States.
| | - Anthony Hardie
- Veterans for Common Sense, Bradenton, FL, United States.
| | - Nancy Klimas
- Institute for Neuro-Immune Medicine, Nova Southeastern University, Miami, FL, United States.
| | - Marguerite Knox
- McEntire Joint National Guard Base, Eastover, SC, United States.
| | - William J Meggs
- Department of Emergency Medicine, 3ED311, The Brody School of Medicine, East Carolina University School of Medicine, Greenville, NC, United States.
| | - Jack Melling
- U.S. Government Accountability Office, Salisbury, Wiltshire, UK.
| | | | - Rachel Grashow
- Northeastern University, Department of Civil and Environmental Engineering, Boston, MA, United States.
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7
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McNeil RB, Thomas CM, Coughlin SS, Hauser E, Huang GD, Goldstein KM, Johnson MR, Dunn-Thomas T, Provenzale DT. An assessment of survey measures used across key epidemiologic studies of United States Gulf War I Era veterans. Environ Health 2013; 12:4. [PMID: 23302181 PMCID: PMC3599123 DOI: 10.1186/1476-069x-12-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 12/24/2012] [Indexed: 05/13/2023]
Abstract
Over the past two decades, 12 large epidemiologic studies and 2 registries have focused on U.S. veterans of the 1990-1991 Gulf War Era. We conducted a review of these studies' research tools to identify existing gaps and overlaps of efforts to date, and to advance development of the next generation of Gulf War Era survey tools. Overall, we found that many of the studies used similar instruments. Questions regarding exposures were more similar across studies than other domains, while neurocognitive and psychological tools were the most variable. Many studies focused on self-reported survey results, with a range of validation practices. However, physical exams, biomedical assessments, and specimen storage were not common. This review suggests that while research may be able to pool data from past surveys, future surveys need to consider how their design can yield data comparable with previous surveys. Additionally, data that incorporate recent technologies in specimen and genetic analyses would greatly enhance such survey data. When combined with existing data on deployment-related exposures and post-deployment health conditions, longitudinal follow-up of existing studies within this collaborative framework could represent an important step toward improving the health of veterans.
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Affiliation(s)
- Rebecca B McNeil
- Durham Epidemiologic Research and Information Center, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Catherine M Thomas
- Durham Epidemiologic Research and Information Center, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Steven S Coughlin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Elizabeth Hauser
- Durham Epidemiologic Research and Information Center, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - Grant D Huang
- Cooperative Studies Program, Office of Research and Development, Department of Veterans Affairs, Washington, DC, USA
| | | | - Marcus R Johnson
- Health Services Research and Development, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | | | - Dawn T Provenzale
- Durham Epidemiologic Research and Information Center, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
- Durham Veterans Affairs Medical Center, Durham, NC, USA
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8
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Organizational psychosocial factors and deployment-related exposure concerns in Afghanistan/Iraq War veterans. J Occup Environ Med 2012; 54:670-6. [PMID: 22684318 DOI: 10.1097/jom.0b013e318255ba57] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Environmental exposure concerns are associated with adverse health outcomes in soldiers deployed to South West Asia. There is little data on factors associated with the reporting of exposure concerns. We explored the relationship between deployment-related preparedness/support and exposure concerns. METHODS Retrospective chart review of 489 Afghanistan/Iraq veterans evaluated at a Veterans Affairs tertiary center for postdeployment health. RESULTS Virtually all subjects were concerned about environmental exposure(s). There were no significant demographic differences in exposure concerns, preparedness/support variables, or both. Preparedness/support correlated inversely with exposure concerns. Mental health function mediated the relationship between preparedness/support and exposure concerns. CONCLUSIONS Deployment-related preparedness/support is associated with exposure concerns and mental health functioning. Definitive studies will provide data and insight on how the military may better prepare/support soldiers to optimize their resilience and reduce deployment-related exposure concerns.
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Environmental Exposure and Health of Operation Enduring Freedom/Operation Iraqi Freedom Veterans. J Occup Environ Med 2012; 54:665-9. [DOI: 10.1097/jom.0b013e318255ba1b] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Dhillon K, Boyd KC. The Effect of War Stressors and Life Events on Gulf War Veterans With Chronic Fatigue Syndrome Symptoms. MILITARY PSYCHOLOGY 2010. [DOI: 10.1080/08995601003638892] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Brewer NT, Hallman WK, Kipen HM. The symmetry rule: a seven-year study of symptoms and explanatory labels among Gulf War veterans. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2008; 28:1737-1748. [PMID: 18795995 PMCID: PMC4049317 DOI: 10.1111/j.1539-6924.2008.01118.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Noticing medical symptoms can cause one to search for explanatory labels such as "ate bad food" or even "exposed to anthrax," and perhaps these labels may cause new symptom reports. The present study examined whether there is empirical support for this symptom-label "symmetry rule." We interviewed veterans (N= 362) from the Gulf War Registry in 1995 and 2002 about their medical symptoms and about their exposure to war-related hazards and stressors. Health symptom reports were strongly correlated between the two time periods and showed relatively stable mean levels, whereas recall of war-related exposures was notably unstable. Veterans starting with fewer medical symptoms recalled fewer war-related exposures seven years later. Initial recollection of chemical and biological warfare exposure (but not other exposures) longitudinally predicted novel medical symptoms. The findings generally support the symmetry rule hypotheses, although the evidence for the label to symptom link was less strong. The findings account for some variability in symptoms and exposure recall over time, but they do not, on their own, account for the Gulf War veterans' elevated number of unexplained medical symptoms.
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Affiliation(s)
- Noel T Brewer
- Department of Health Behavior and Health Education, University of North Carolina School of Public Health, Chapel Hill, NC 27516, USA.
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12
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Smith TC, Jacobson IG, Smith B, Hooper TI, Ryan MAK. The occupational role of women in military service: validation of occupation and prevalence of exposures in the Millennium Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2007; 17:271-84. [PMID: 17613091 DOI: 10.1080/09603120701372243] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
To better understand the US military's global peacekeeping and combat operations, which may expose a growing population of American service women to challenging occupations and environments. Concordance between self-reported and electronic occupation codes for female participants in the Millennium Cohort was measured using kappa statistics. Multivariable logistic regression modeling was used to assess the odds of five self-reported potentially toxic environmental exposures or disturbing experiences among different occupational categories, while adjusting for demographic and military characteristics, including deployment. Self-reported occupations were moderately to highly reliable when compared with electronic occupation data. Active-duty and Reserve/Guard females differentially reported witnessing death or trauma and exposure to chemical or biological warfare, depleted uranium, or pesticides. Findings suggest that self-reported occupation can be used with a high degree of confidence. Occupational groups with higher odds of reporting military exposures of concern will be followed longitudinally through 2022 and prospectively compared using baseline and follow-up evaluations.
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Affiliation(s)
- Tyler C Smith
- Department of Defense Center for Deployment Health Research, Naval Health Research Center, San Diego, California 92186, USA.
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13
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Iversen A, Chalder T, Wessely S. Gulf War Illness: lessons from medically unexplained symptoms. Clin Psychol Rev 2007; 27:842-54. [PMID: 17707114 DOI: 10.1016/j.cpr.2007.07.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Service in the Persian Gulf in 1991 is associated with increased reporting of symptoms and distress in a proportion of those who served there. Yet despite clear evidence of an increase in symptom burden and a decrease in well being, exhaustive clinical and laboratory based scientific research has failed to document many reproducible biomedical abnormalities in this group. Likewise, there has been no evidence of an increase in disease related mortality. Formal psychiatric disorders are twice as common in Gulf War veterans, as might be expected in the aftermath of any conflict, but this too is insufficient to explain the ill-health observed. Many service personnel who returned unwell believe that they have Gulf War Syndrome, and that their ill-health is due to exposures that they encountered in theatre. Research on multiple exposures to date has not generated a plausible aetiological mechanism for veterans' ill-health. Even if medical research has failed to provide a satisfactory explanation, it remains the case that many of those affected continue to be unwell and disabled some 15 years after returning from combat. For this reason, it is time that more attention is given to developing effective interventions to relieve their ill-health and distress. In this review we discuss the importance of the wider social context, individual illness beliefs and attributions and go on to outline a model of continuing ill-health in Gulf veterans. The review concludes with some suggestions for future research priorities, in particular the need for further qualitative studies to further our understanding of the illness, in order that better treatments may be developed.
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Affiliation(s)
- Amy Iversen
- King's Centre for Military Health Research, King's College London, Institute of Psychiatry, UK.
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14
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Ozakinci G, Hallman WK, Kipen HM. Persistence of symptoms in veterans of the First Gulf War: 5-year follow-up. ENVIRONMENTAL HEALTH PERSPECTIVES 2006; 114:1553-7. [PMID: 17035142 PMCID: PMC1626433 DOI: 10.1289/ehp.9251] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND During the 1990-1991 Gulf War, approximately 700,000 U.S. troops were deployed to the Persian Gulf theater of operations. Of that number, approximately 100,000 have presented medical complaints through various registry and examination programs. OBJECTIVES Widespread symptomatic illness without defining physical features has been reported among veterans of the 1991 Gulf War. We ascertained changes in symptom status between an initial 1995 symptom evaluation and a follow-up in 2000. METHODS We assessed mailed symptom survey questionnaires for 390 previously surveyed members of the U.S. Department of Veterans Affairs Gulf War Registry for changes over the 5-year interval in terms of number and severity of symptoms. RESULTS For the cohort as a whole, we found no significant changes in symptom number or severity. Those initially more symptomatic in 1995 showed some improvement over time, but remained much more highly symptomatic than those who had lesser initial symptomatology. CONCLUSIONS The symptom outbreak following the 1991 Gulf War has not abated over time in registry veterans, suggesting substantial need for better understanding and care for these veterans.
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Affiliation(s)
- Gozde Ozakinci
- Bute Medical School, University of St. Andrews, St. Andrews, Fife, Scotland, United Kingdom
| | - William K. Hallman
- Food Policy Institute, Cook College, Rutgers University, New Brunswick, New Jersey, USA
| | - Howard M. Kipen
- UMDNJ-Robert Wood Johnson Medical School, EOHSI–Clinical Research and Occupational Medicine Division, Piscataway, New Jersey, USA
- Address correspondence to H.M. Kipen, EOHSI–Clinical Research and Occupational Medicine Division, 170 Frelinghuysen Rd., Room 208, Piscataway, NJ 08854 USA. Telephone: (732) 445-0123, ext 629. Fax: (732) 445-3644. E-mail:
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15
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Abstract
The psychosocial issues related to deployment and combat duty are complex. Deployment may result in psychiatric casualties that are either the result of inadequate coping with the stressors of deployment or acute stress reactions caused by the trauma of battle, that is, combat stress reactions. Combat duty is associated with traumatic events, deprivation, and exposure to war atrocities that may result in acute, delayed or chronic psychosocial issues during and afer returning from deployment. Although protective and mediating factors ar in place, 11% to 17% of combat veterans are at risk for mental disorders in 3 to 4 months after return from combat duty. Combat veterans include service members directly involved in combat as well as those providing support to combatants, that is, nurses. All combat veterans are at risk for experiencing the negative effects of deployment. Frequent deployments of active duty, reserve, and National Guard members have become commonplace. This translates into a disruption of live for anyone associated with the military, as well as an increased focus on the psychosocial impact of combat across the nation. Modern warfare has resulted in multiple changes in policy that govern military operations. Initiatives that focus on the stabilization of service members and their families may impact mental health outcomes of service members returning from combat duty. An initiative toward decreasing the stigma of receiving mental health care is warranted. Mental health issues must be addressed before and during deployment to ensure optimum individual and unit functioning. Early identification and treatment of mental health problems may decrease the psychosocial impact of combat and thus prevent progression to more chronic and severe psychopathology such as depression and PTSD.
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Affiliation(s)
- Kathryn M Gaylord
- Psychiatric Mental Health Nurse Course, Walter Reed Army Medical Center, MCHL-N, 6900 Georgia Avenue, NW, Washington, DC 20307-5001, USA.
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16
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Glass DC, Sim MR. The challenges of exposure assessment in health studies of Gulf War veterans. Philos Trans R Soc Lond B Biol Sci 2006; 361:627-37. [PMID: 16687267 PMCID: PMC1569629 DOI: 10.1098/rstb.2006.1822] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A variety of exposures have been investigated in Gulf War veterans' health studies. These have most commonly been by self-report in a postal questionnaire but modelling and bio-monitoring have also been employed. Exposure assessment is difficult to do well in studies of any workplace environment. It is made more difficult in Gulf War studies where there are a number and variety of possible exposures, no agreed metrics for individual exposures and few contemporary records associating the exposure with an individual. In some studies, the exposure assessment was carried out some years after the war and in the context of media interest. Several studies have examined different ways to test the accuracy of exposure reporting in Gulf War cohorts. There is some evidence from Gulf War studies that self-reported exposures were subject to recall bias but it is difficult to assess the extent. Occupational exposure-assessment methodology can provide insights into the exposure-assessment process and how to do it well. This is discussed in the context of the Gulf War studies. Alternative exposure-assessment methodologies are presented, although these may not be suitable for widespread use in veteran studies. Due to the poor quality of and accessibility of objective military exposure records, self-assessed exposure questionnaires are likely to remain the main instrument for assessing the exposure for a large number of veterans. If this is to be the case, then validation methods with more objective methods need to be included in future study designs.
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Affiliation(s)
- Deborah C Glass
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, The Alfred Hospital, Melbourne, Victoria, Australia.
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Gray GC, Kang HK. Healthcare utilization and mortality among veterans of the Gulf War. Philos Trans R Soc Lond B Biol Sci 2006; 361:553-69. [PMID: 16687261 PMCID: PMC1569626 DOI: 10.1098/rstb.2006.1816] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The authors conducted an extensive search for published works concerning healthcare utilization and mortality among Gulf War veterans of the Coalition forces who served during the 1990-1991 Gulf War. Reports concerning the health experience of US, UK, Canadian, Saudi and Australian veterans were reviewed. This report summarizes 15 years of observations and research in four categories: Gulf War veteran healthcare registry studies, hospitalization studies, outpatient studies and mortality studies. A total of 149728 (19.8%) of 756373 US, UK, Canadian and Australian Gulf War veterans received health registry evaluations revealing a vast number of symptoms and clinical conditions but no suggestion that a new unique illness was associated with service during the Gulf War. Additionally, no Gulf War exposure was uniquely implicated as a cause for post-war morbidity. Numerous large, controlled studies of US Gulf War veterans' hospitalizations, often involving more than a million veterans, have been conducted. They revealed an increased post-war risk for mental health diagnoses, multi-symptom conditions and musculoskeletal disorders. Again, these data failed to demonstrate that Gulf War veterans suffered from a unique Gulf War-related illness. The sparsely available ambulatory care reports documented that respiratory and gastrointestinal complaints were quite common during deployment. Using perhaps the most reliable data, controlled mortality studies have revealed that Gulf War veterans were at increased risk of injuries, especially those due to vehicular accidents. In general, healthcare utilization data are now exhausted. These findings have now been incorporated into preventive measures in support of current military forces. With a few diagnostic exceptions such as amyotrophic lateral sclerosis, mental disorders and cancer, it now seems time to cease examining Gulf War veteran morbidity and to direct future research efforts to preventing illness among current and future military personnel.
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Affiliation(s)
- Gregory C Gray
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, 52242, USA.
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Brewer NT, Lillie SE, Hallman WK. Why people believe they were exposed to biological or chemical warfare: a survey of Gulf War veterans. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2006; 26:337-45. [PMID: 16573624 DOI: 10.1111/j.1539-6924.2006.00750.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
The study sought to understand better how people come to believe they have been exposed to biological and chemical warfare. We conducted telephone interviews with 1,009 American veterans (65% response rate) deployed and not deployed to the Gulf War, a conflict during which there were credible threats that such warfare could be used. Only 6% of non-Gulf War veterans reported exposure to biological or chemical warfare, but most of Gulf War veterans reported exposure (64%). The majority of these were unsure whether the exposure was chemical or biological in nature. The most commonly reported exposure indicators were receiving an alert from the military and having physical symptoms. Veterans who were certain of the type of exposure (biological or chemical) were more likely to recall having been told by the military and to recall physical symptoms. Future communications with soldiers and the general public about biological and chemical warfare may need to emphasize the uncertain nature of such risk information. Evaluations of exposure diagnostic technologies should take into account the problem of people initially believing, but not later discounting, false positive results.
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Affiliation(s)
- Noel T Brewer
- University of North Carolina at Chapel Hill, School of Public Health, Rosenau Hall 306, CB 7440, Chapel Hill, NC 27599, USA.
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Hausteiner C, Bornschein S, Hansen J, Zilker T, Förstl H. Self-reported chemical sensitivity in Germany: a population-based survey. Int J Hyg Environ Health 2005; 208:271-8. [PMID: 16078641 DOI: 10.1016/j.ijheh.2005.03.006] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Environmental clinics are frequented by patients with fears and complaints related to environmental triggers. A dose-independent overreaction to small doses of widely used and generally non-toxic chemicals is referred to as multiple chemical sensitivity (MCS), but no clearly defined clinical syndrome with objective physical findings has been delineated so far. We aimed to obtain information about symptoms, supposed environmental triggers, the frequency of self-reported chemical sensitivity, and of the diagnosis MCS in Germany. METHODS We conducted a representative survey among 2032 adult Germans. RESULTS We found self-reported chemical sensitivity in 9% and physician-diagnosed MCS in 0.5% of our representative sample. Physical complaints were common in the whole study population and in chemically sensitive individuals, but there was no clear-cut symptom constellation among the latter. The most common complaints were headache, fatigue, sleep disturbances, joint pain, mood changes and nervousness. A subjective connection between complaints and environmental triggers was denied by 67% of the whole group and by 35% of the self-reported chemically sensitive. Factor analysis of environmental triggers suggested that a specific exposure situation rather than chemical similarity is the basis for individual trigger combinations. CONCLUSIONS The prevalence of subjective sensitivity towards chemicals is similar to such rates reported from other countries. There is a relatively low awareness of the MCS-concept, and it appears to be diagnosed less frequently than, e.g., in the USA. Since symptoms and triggers in chemically sensitive individuals did not differ from the general population, our data do not suggest the existence of a widespread new syndrome related to chemical sensitivities in Germany. We outline the limitations of self-reported chemical sensitivity as the major criterion for such a contentious diagnosis as MCS.
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Affiliation(s)
- Constanze Hausteiner
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Germany.
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Sloan P, Arsenault L, Hilsenroth MJ. Impact of Event Scale Prediction of DSM-IV PTSD and Physical Symptoms in Gulf War Veterans. ACTA ACUST UNITED AC 2005. [DOI: 10.1080/15434610500406301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Hotopf M, Wessely S. Can epidemiology clear the fog of war? Lessons from the 1990-91 Gulf War. Int J Epidemiol 2005; 34:791-800. [PMID: 15911546 DOI: 10.1093/ije/dyi102] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Despite over US $200 million having been spent researching illnesses following the 1990-91 Persian Gulf War, the nature and cause of such illnesses remains controversial. In this narrative review, we discuss some of the methodological issues that have affected epidemiological studies on this topic. These include low-response rates, ascertainment bias, recall bias, problems identifying suitable control groups, and problems defining the outcomes to study. From this we argue that difficulties have arisen partly owing to the significant delay between the point at which illnesses were first identified by veterans and the reporting of epidemiological studies and that health surveillance should be routine following future deployments.
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Affiliation(s)
- Matthew Hotopf
- King's Centre for Military Health Research (KCMHR), King's College London, Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK.
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Hunt SC, Richardson RD, Engel CC, Atkins DC, McFall M. Gulf War Veterans’ Illnesses: A Pilot Study of the Relationship of Illness Beliefs to Symptom Severity and Functional Health Status. J Occup Environ Med 2004; 46:818-27. [PMID: 15300134 DOI: 10.1097/01.jom.0000135529.88068.04] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This investigation describes the illness beliefs of veterans regarding their Gulf War-related health concerns and investigates the relationship of these illness beliefs to physical and mental health functioning. Gulf War veterans (N = 583) presenting for evaluation at a Veteran's Affairs and Department of Defense facility completed self-report measures of symptom-related beliefs, psychosocial distress, and functional status. Hierarchical multiple regression analyses were performed to determine the extent that symptom-related beliefs impacted symptom-reporting and functional status independent of demographic factors and psychiatric illness. Several beliefs predicted physical symptom reporting and functional impairment in physical health and mental health domains after controlling for demographic variables and psychiatric illness. Gulf War veterans' illness beliefs may impact clinical outcomes. Discussing illness beliefs and providing accurate information is an important component of medical care for Gulf War veterans.
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Affiliation(s)
- Stephen C Hunt
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington 98108, USA.
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