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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_245"
                     title="Accidents, Illness Cause Most War-Zone Casualties (CME/CE)"
                     score="-0.002"
                     href="http://www.medpagetoday.com/PublicHealthPolicy/MilitaryMedicine/tb/18100?impressionId=1265789099214"
                     
      &lt;p&gt;More than 85% of American military medical evacuations from the Middle East were not the direct result of enemy action, but the result of non-battle injuries and disease, researchers said.&lt;/p&gt;
&lt;p&gt;Of some 34,000 military personnel in Iraq and Afghanistan who shipped out for medical reasons from 2004 to 2007, only 14% had been wounded or injured in combat, according to Steven P. Cohen, MD, of Johns Hopkins, and colleagues.&lt;/p&gt;
&lt;p&gt;The most common reasons for medical evacuation were non-battle related musculoskeletal and connective tissue disorders, accounting for 24% of evacuations, the researchers wrote in the Jan. 23 issue of &lt;em&gt;The Lancet&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Combat injuries were the second most common, followed by neurological disorders (10%) and psychiatric illnesses (9%).&lt;/p&gt;
&lt;p&gt;&quot;Non-battle related injuries continue to be the leading cause of medical evacuation in modern warfare, and medical officers should be prepared for this burden in subsequent conflicts,&quot; Cohen and colleagues wrote.&lt;/p&gt;
&lt;p&gt;&quot;To reduce the number of evacuees, preventive medicine programmes and educational initiatives need to target health-care providers, non-commissioned officers, and combat soldiers.&quot;&lt;/p&gt;
&lt;p&gt;They also warned that &quot;the burden of psychiatric illness&quot; will increase with the duration of conflict and reliance on reserve units.&lt;/p&gt;
&lt;p&gt;Cohen and colleagues obtained data kept by the U.S. military on all medical evacuations from Iraq and Afghanistan spanning 2004 to 2007.&lt;/p&gt;
&lt;p&gt;In addition to describing the medical reasons for evacuation, the data included the individuals&apos; ranks, service affiliations, active-duty or reserve status, and whether personnel returned to duty.&lt;/p&gt;
&lt;p&gt;Any injury sustained during combat missions, including those not caused directly by enemy fire such as back strains, was counted as battle-related.&lt;/p&gt;
&lt;p&gt;The number of evacuations each year fell from 2004 to 2006  --  from 10,290 to 6,778  --  but abruptly rose in 2007 to 8,444 with the Iraq surge and the reinvigorated Afghan Taliban resistance.&lt;/p&gt;
&lt;p&gt;Not surprisingly, as these conflicts evolved over time, the balance of combat and non-combat injuries and illnesses changed and the characteristics of evacuated soldiers changed as well.&lt;/p&gt;
&lt;p&gt;The proportion of evacuations related to combat injuries climbed steadily in Afghanistan, from 10% in 2004 to 19% in 2007. Injuries from combat also increased over time in Iraq but not as much: from 24% of evacuations to 28% during the study period.&lt;/p&gt;
&lt;p&gt;But by 2007, combat wounds had become only the fourth most common reason for evacuation in both regions.&lt;/p&gt;
&lt;p&gt;Musculoskeletal and connective tissue disorders held steadily as the number one reason throughout the study period, ranging from 21% to 28%.&lt;/p&gt;
&lt;p&gt;But non-combat neurological and psychiatric disorders both increased substantially, especially the latter.&lt;/p&gt;
&lt;p&gt;Evacuations for psychiatric conditions soared from 5% to 6% of the total in 2004 to about 13% in 2007. Neurological disorders accounted for about 10% of evacuations early in the conflicts, rising to more than 12% in 2007. These figures did not differ substantially between Iraq and Afghanistan.&lt;/p&gt;
&lt;p&gt;Most of the evacuees did not return to duty: about 80% of those shipped from Iraq and 75% from Afghanistan.&lt;/p&gt;
&lt;p&gt;Although overall return-to-duty rates changed little with time, evacuations for some types of illness did increase or decrease.&lt;/p&gt;
&lt;p&gt;Personnel evacuated because of infectious disease became more likely to see service again  --  37% returned to active duty in 2007, compared with 8% in 2004. Cohen and colleagues identified better control of leishmaniasis as at least partly responsible for the increase.&lt;/p&gt;
&lt;p&gt;More significantly, the researchers indicated, return-to-duty rates declined progressively after 2004 for psychiatric evacuees, Cohen and colleagues reported.&lt;/p&gt;
&lt;p&gt;By 2007, only 7% of psychiatric evacuees from Iraq and 4% of those from Afghanistan were returning to duty.&lt;/p&gt;
&lt;p&gt;The researchers also found that, among particular types of psychiatric illness, personnel with stress reactions, depression, and bipolar disorder were least likely to return to duty.&lt;/p&gt;
&lt;p&gt;They also found that individuals with back pain were also more unlikely than most evacuees to return to duty.&lt;/p&gt;
&lt;p&gt;In their report, Cohen and colleagues said these latter trends were potentially related.&lt;/p&gt;
&lt;p&gt;&quot;The parallels between emotional distress and spinal pain are intriguing. Findings from several studies in patients presenting with back or neck pain have established that the major risk factors for disability and persistence are psychosocial (e.g., anxiety, depression, poor coping skills, and low job satisfaction),&quot; they wrote.&lt;/p&gt;
&lt;p&gt;&quot;As survival rates of combat injuries increase, and the burden of non-battle-related injuries and psychiatric disorders continues to soar, society must be prepared to deal with the aftermath of these injuries,&quot; Cohen and colleagues concluded.&lt;/p&gt;
&lt;p&gt;In an accompanying commentary, J. Don Richardson, MD, of St. Joseph&apos;s Health Care in London, Ontario, and colleagues also found the results on psychiatric evacuees most striking in the study.&lt;/p&gt;
&lt;p&gt;&quot;The low rate of return to duty in service personnel evacuated for psychiatric conditions warrants further study, and [the] article points out the importance of cumulative stress in repeated deployments and the physical and mental demands on the military member and their family,&quot; Richardson and colleagues wrote.&lt;/p&gt;
&lt;p&gt;&quot;The low rate of return to duty might be related to the nature of the combat operation for which military commanders might be reluctant to deploy an individual with a psychiatric diagnosis to a combat zone,&quot; they speculated.&lt;/p&gt;
&lt;p&gt;&quot;Early intervention becomes crucial to help promote recovery because military members often experience substantial stigma disclosing symptoms of PTSD and other psychiatric problems,&quot; Richardson and colleagues added.&lt;/p&gt;
&lt;p&gt;They also suggested that military doctors &quot;should have a high index of suspicion&quot; for PTSD when soldiers present with spinal pain or other somatic complaints, &quot;especially if there is a physical injury.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the federally funded John P. Murtha Neuroscience and Pain Institute and the U.S. Army.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported by study authors or the editorialists.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_156"
                     title="Research Fraud Probe Leads to Criminal Charge"
                     score="-0.007"
                     href="http://www.medpagetoday.com/PublicHealthPolicy/Ethics/tb/17985?impressionId=1265789099214"
                     
      &lt;p&gt;A Massachusetts anesthesiologist accused of fabricating data in studies of pain drugs will plead guilty to federal criminal charges under an agreement with prosecutors.&lt;/p&gt;
&lt;p&gt;Scott Reuben, MD, a well-known pain researcher at Baystate Medical Center in Springfield, Mass., was charged with one count of healthcare fraud.&lt;/p&gt;
&lt;p&gt;Early last year, the hospital announced that an internal audit had revealed that Reuben had made up research data out of whole cloth, affecting at least 21 published studies over a 15-year period. (See &lt;a href=&quot;http://www.medpagetoday.com/Surgery/Anesthesiology/13592&quot; mce_href=&quot;http://www.medpagetoday.com/Surgery/Anesthesiology/13592&quot; target=&quot;_blank&quot;&gt;Special Report: Few Gaps in Analgesic Practice After Reuben Retractions&lt;/a&gt;) The criminal charge arose from one of those studies, funded by Pfizer and published in &lt;em&gt;Anesthesia &amp;amp; Analgesia&lt;/em&gt; in 2007.&lt;/p&gt;
&lt;p&gt;According to the U.S. Attorney&apos;s office in Boston, Pfizer had given some $74,000 to Reuben for a placebo-controlled study of celecoxib (Celebrex) as part of a &quot;multimodal&quot; painkiller regimen for outpatient knee ligament surgery. The study was to enroll 100 patients.&lt;/p&gt;
&lt;p&gt;Reuben subsequently reported to Pfizer and in the journal article that 200 patients entered the trial and that the celecoxib regimen was effective.&lt;/p&gt;
&lt;p&gt;&quot;In fact, Reuben had not enrolled any patients into that study, and the results reported both to Pfizer and to &lt;em&gt;Anesthesia &amp;amp; Analgesia&lt;/em&gt; and, in turn, to the public were wholly made up by Reuben and therefore false,&quot; prosecutors wrote in a court filing.&lt;/p&gt;
&lt;p&gt;Reuben could receive up to 10 years of jail time, to be followed by three years of supervised release and a $250,000 fine, but prosecutors agreed in the plea deal to recommend penalties at the low end of the range allowed in sentencing guidelines.&lt;/p&gt;
&lt;p&gt;The agreement also requires Reuben to pay a total of about $362,000 in restitution to Pfizer and other pharmaceutical companies, plus $55,000 in fines and forfeitures.&lt;/p&gt;
&lt;p&gt;Last year, after Baystate announced its findings on Reuben, the 21 articles it identified as tainted were retracted by the journals publishing them.&lt;/p&gt;
&lt;p&gt;The National Library of Medicine&apos;s PubMed system lists more than 70 articles published since 1991 with Reuben as an author. The 21 retracted articles all listed Reuben as first author.&lt;/p&gt;
&lt;p&gt;The editor of one journal that had published Reuben&apos;s research, &lt;em&gt;Regional Anesthesia and Pain Medicine&lt;/em&gt;, contacted other investigators on six studies in which Reuben was a secondary author.&lt;/p&gt;
&lt;p&gt;They all attested to the truthfulness of the reported data, according to the journal editor, Joseph M. Neal, MD. The journal ended up retracting only the one paper which had Reuben as lead author.&lt;/p&gt;
&lt;p&gt;Reuben&apos;s contract with Baystate was terminated last March, at which time he reportedly also agreed with the state&apos;s medical board to voluntarily withdraw from practice.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_124"
                     title="Morphine Cuts Both Pain and PTSD (CME/CE)"
                     score="-0.008"
                     href="http://www.medpagetoday.com/PublicHealthPolicy/MilitaryMedicine/tb/17938?impressionId=1265789099214"
                     
      The use of morphine may prevent the development of post-traumatic stress disorder (PTSD) in military personnel injured in combat, an observational study showed.&lt;br&gt;
&lt;br&gt;Those who received the drug during resuscitation or trauma care were about half as likely to later develop PTSD (OR 0.47, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001), according to Troy Lisa Holbrook, PhD, of the Naval Health Research Center in San Diego, and colleagues.&lt;br&gt;
&lt;br&gt;&quot;Our findings suggest that the use of morphine after serious injury may be a first-line defense against the development of PTSD,&quot; they wrote in the Jan. 14 issue of the &lt;em&gt;New England Journal of Medicine&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;They said that any benefits, if causal, would likely be seen with other opiates as well.&lt;/p&gt;
&lt;p&gt;Previous studies have found that pharmacotherapy following trauma may be effective for secondary prevention of PTSD, with the primary goal of interfering with memory consolidation and the associated conditioned response to fear, according to the researchers.&lt;/p&gt;
&lt;p&gt;And a small study found a protective effect from morphine specifically in children with burn injuries.&lt;/p&gt;
&lt;p&gt;To evaluate the drug&apos;s effect in adults, Holbrook and her colleagues turned to a U.S. Navy-Marine Corps combat trauma database that included information on medications administered after injury.&lt;/p&gt;
&lt;p&gt;They analyzed data for 696 military personnel who were hurt during Operation Iraqi Freedom but who did not have serious traumatic brain injury.&lt;/p&gt;
&lt;p&gt;Nearly all of the injured personnel were male and the mean age was about 24.&lt;/p&gt;
&lt;p&gt;The most common mechanisms of injury were improvised explosive devices, gunshots, mortar fire, and rocket-propelled grenades.&lt;/p&gt;
&lt;p&gt;About one-third (35%) of the injured personnel developed PTSD. Those who did were less likely to have been administered morphine shortly after their injury (60% versus 76%).&lt;/p&gt;
&lt;p&gt;The use of morphine was associated with a significantly lower risk of PTSD (ORs ranging from 0.48 to 0.66, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.05 for all) in models adjusting for several factors, including severity and mechanism of injury, need for amputation, resuscitation, and the presence of mild traumatic brain injury.&lt;/p&gt;
&lt;p&gt;Morphine dose had no effect on the relationship.&lt;/p&gt;
&lt;p&gt;Although causality could not be established, any beneficial effect morphine might have on PTSD risk might involve pain reduction; previous studies have identified associations between lower pain levels after serious injury and a reduced risk of developing the disorder.&lt;/p&gt;
&lt;p&gt;&quot;The logical conclusion to be made on the basis of these data is that a reduction in perceived pain levels through the use of morphine or other opiates as part of trauma care may lower the rate of PTSD onset after major trauma,&quot; Holbrook and her colleagues wrote.&lt;/p&gt;
&lt;p&gt;In an accompanying editorial, Matthew Friedman, MD, PhD, of the National Center for PTSD at the VA Medical Center in White River Junction, Vt., said, &quot;This finding adds to a small but growing body of observational and experimental studies that have reported similar results.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Since physical injury from a traumatic event (especially injury that is associated with severe pain) is a risk factor for the later development of PTSD, such findings suggest a potential for prophylactic use of rapid pain reduction among injured, traumatized persons in both military and civilian acute care settings,&quot; he said.&lt;/p&gt;
&lt;p&gt;He noted, however, that use of opioids would likely not be an acceptable treatment for individuals exposed to trauma who had not suffered major, painful injuries.&lt;/p&gt;
&lt;p&gt;The findings of the current study, he wrote in his editorial, are consistent with theories about the adrenergic mediation of fear-conditioned traumatic memories.&lt;/p&gt;
&lt;p&gt;&quot;These results should motivate researchers to redouble efforts to test adrenergic antagonists such as propranolol and clonidine (an &amp;#945;&lt;sub&gt;2&lt;/sub&gt;-adrenergic agonist) in the search for a morning-after pill to prevent the later development of PTSD among persons after major trauma.&quot;&lt;/p&gt;
&lt;p&gt;Holbrook and her colleagues acknowledged that the study was limited by its observational design, missing or incomplete data on medication for patients who were ultimately excluded from the study, and the inability to thoroughly address the question of a dose-response relationship.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the U.S. Navy Bureau of Medicine and Surgery under the Wounded, Ill, and Injured-Psychological Health-Traumatic Brain Injury Program.&lt;/p&gt;&lt;p&gt;Neither the study authors nor the editorialist reported any conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_123"
                     title="Army Wives Pay Price in Long Wars (CME/CE)"
                     score="-0.008"
                     href="http://www.medpagetoday.com/PublicHealthPolicy/MilitaryMedicine/tb/17942?impressionId=1265789099214"
                     
      &lt;p&gt;The longer that U.S. Army soldiers spent in Iraq and Afghanistan, the greater the likelihood that their wives would seek psychiatric treatment, researchers said.&lt;/p&gt;
&lt;p&gt;The risk that a woman would receive a new mental illness diagnosis during her husband&apos;s deployment was significantly higher when he was overseas for a year or more, compared with tours of duty of 11 months or less, according to Alyssa J. Mansfield, PhD, MPH, of RTI International in Research Triangle Park, N.C., and colleagues.&lt;/p&gt;
&lt;p&gt;Some individual diagnoses were as much as tripled among wives of soldiers with long deployments, Mansfield and colleagues reported in the Jan. 14 issue of the &lt;em&gt;New England Journal of Medicine&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The researchers also found that the number of outpatient mental health visits by Army wives correlated significantly with the length of their husbands&apos; deployments.&lt;/p&gt;
&lt;p&gt;&quot;Overall, our data suggest that the mental health effects of current operations are extending beyond soldiers and into their immediate families,&quot; Mansfield and colleagues wrote.&lt;/p&gt;
&lt;p&gt;The researchers based their findings on records for 250,626 wives of active-duty, regular Army personnel sent to Iraq and Afghanistan from 2003 to 2006.&lt;/p&gt;
&lt;p&gt;Initially, Mansfield and colleagues had also included husbands of female personnel deployed to these areas, but the results &quot;were highly unstable,&quot; the researchers indicated.&lt;/p&gt;
&lt;p&gt;&quot;Without persuasive evidence that male spouses had a similar pattern of effects, it was not appropriate to generalize these results to husbands and wives. Therefore, we opted to be conservative and restrict our analyses to wives (approximately 95% of the complete sample); this limited the generalizability of our results accordingly,&quot; Mansfield and colleagues wrote.&lt;/p&gt;
&lt;p&gt;About 173,000 women in the sample had husbands deployed to the two combat areas; the others&apos; husbands were not deployed and they served as controls.&lt;/p&gt;
&lt;p&gt;Among those whose spouses were not deployed, 30.5% received some mental health diagnosis. That percentage rose to 36.6% among those whose husbands were serving in the Middle East.&lt;/p&gt;
&lt;p&gt;Among the specific disorders that appeared more common among those whose spouses were deployed were alcohol and drug use, depression, sleep problems, and stress disorders.&lt;/p&gt;
&lt;p&gt;And the length of deployment increased the risk and apparent severity of psychiatric problems.&lt;/p&gt;
&lt;p&gt;Compared with the nondeployed sample, the adjusted number of &quot;excess&quot; mental health diagnoses per 1,000 women was 41.3 (95% CI 35.6 to 47.1) for deployments lasting one to 11 months, compared with 60.7 (95% CI 53.8 t0 67.7) for deployments of one year or more.&lt;/p&gt;
&lt;p&gt;Rates of excess cases, per 1,000 women, for certain specific diagnoses were as follows:&lt;ul&gt; &lt;li&gt;Depression: 27.4 (95% CI 22.4 to 32.3) for short deployments, 39.3 (95% CI 33.2 to 45.4) for long deployments&lt;/li&gt; &lt;li&gt;Drug use: 0.8 (95% CI -0.3 to 1.9) for short deployments, 2.6 (95% CI 1.2 to 4.0) for long deployments&lt;/li&gt; &lt;li&gt;Sleep disorder: 11.6 (95% CI 8.3 to 14.8) for short deployments, 23.5 (95% CI 19.4 to 27.6) for long deployments&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Other categories of diagnosis  --  specifically neurotic stress disorder, impulse control disorder, and personality disorder  --  showed nonsignificant trends toward increased frequency with long spousal deployments.&lt;/p&gt;
&lt;p&gt;Mansfield and colleagues noted that a woman&apos;s age and her husband&apos;s total number of deployments also were correlated with increased risk of psychiatric illness. Those factors were included in the adjustments taken in calculating excess-case rates.&lt;/p&gt;
&lt;p&gt;Use of mental health services was also more intense with longer deployments.&lt;/p&gt;
&lt;p&gt;The researchers found that the average number of outpatient mental health visits was 19% greater (95% CI 15% to 22%) among wives of personnel deployed for one to 11 months, and 27% higher (95% CI 22% to 32%) among wives of troops with longer deployments  --  both relative to wives of nondeployed personnel.&lt;/p&gt;
&lt;p&gt;In an accompanying editorial, Matthew J. Friedman, MD, PhD, of the VA Medical Center in White River Junction, Vt., noted that the researchers lacked data on the exact timing of the husbands&apos; deployments, leaving it unclear when the wives&apos; psychiatric problems emerged  --  before, during, or after the deployments.&lt;/p&gt;
&lt;p&gt;&quot;In other words, was the presence or absence of the soldier more likely to be associated with mental health problems in the wife?&quot; Friedman asked rhetorically, noting that the likely causes would differ considerably.&lt;/p&gt;
&lt;p&gt;He also indicated other factors that were unaddressed in the study including the possible roles of intensity of husbands&apos; combat experiences, presence of post-traumatic stress disorder or physical injury, or problems involving children.&lt;/p&gt;
&lt;p&gt;Nevertheless, Friedman indicated that the study&apos;s findings had public health implications.&lt;/p&gt;
&lt;p&gt;&quot;Besides the obvious importance of developing appropriate programs to fortify wellness and resilience among spouses and children, such programs might also be expected to prevent psychiatric morbidity among the troops themselves,&quot; he wrote.&lt;/p&gt;
&lt;p&gt;Mansfield and colleagues identified several limitations to the study, in addition to the exclusion of male spouses of female soldiers. They included the reliance on administrative records, the possibility that some wives received mental health treatment without a corresponding diagnostic code, and the exclusion of reserve and National Guard personnel.&lt;ul&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The researchers said the impacts of deployments could be greater on spouses of reserve and Guard personnel.&lt;/p&gt;
&lt;p&gt;&quot;Spouses in our sample probably had at least five years of continuous Army life,&quot; during which they would have had &quot;substantial opportunities for networking, shared experience, and military services associated with life in and around most active-duty communities,&quot; according to Mansfield and colleagues.&lt;/p&gt;
&lt;p&gt;Such exposure, generally lacking for families of reserve and Guard personnel, might help wives of Army regulars cope more effectively with their husbands&apos; deployments, the researchers suggested.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;No corporate funding for the study was reported.&lt;/p&gt;&lt;p&gt;One author reported consulting fees and/or research funding from Bristol-Myers Squibb and Novartis and serving as an expert witness for Phillips Lytle in litigation involving paroxetine, which did not go to trial. No other potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_705"
                     title="IDSA: Wounded Soldiers Back From Iraq With Multidrug-Resistant Acinetobacter"
                     score="-0.008"
                     href="