Injuries in combat from 1982–2005 with particular reference to those to the head and neck: A review

The aim of this review was to examine the range of combat injuries with particular reference to those of the head and neck. We evaluated 10 retrospective studies selected from the period 1982-2005 that covered war injuries from Vietnam, Lebanon, Slovenia, Croatia, Iraq, Somalia, and Afghanistan. We found differences in the causes of injuries. Injuries from fragments were more common during the 90s than during the Vietnam War, where shooting injuries predominated. Injuries to the trunk were reduced in conflicts from 1991 onwards as military personal armour systems including protective vests were used. However, the mortality of wounded soldiers in all conflicts was consistently between 10% and 14%. There was a high incidence of injuries to the head and neck (up to 40%) though they affected only 12% of the body surface area. Though the data from the different military conflicts are not totally comparable, there are trends in the type of injuries and mortality, which may lead to changes in existing systems of medical care.

Does education affect smoking behaviors? Evidence using the Vietnam draft as an instrument for college education

This paper tests the hypothesis that education improves health and increases people's life expectancy. It does so by analyzing the effect of education on smoking behaviors. To account for the endogeneity of smoking, the analysis develops an instrumental variable approach which relies on the fact that during the Vietnam War college attendance provided a strategy to avoid the draft. The results indicate that education does affect smoking decisions: educated individuals are less likely to smoke, and among those who initiated smoking, they are more likely to have stopped.

Education and smoking: were Vietnam war draft avoiders also more likely to avoid smoking?

We use the Vietnam war draft avoidance behavior documented by Card and Lemieux [Card, D., Lemieux, T., May 2001. Did draft avoidance raise college attendance during the Vietnam war? American Economic Review 91 (2), 97-102] as a quasi experiment to infer causation from education to smoking and find strong evidence that education, whether measured in years of completed schooling or in educational attainment categories, reduces the probability of smoking at the time of the interview, more particularly the probability of smoking regularly. However, while we find that more education substantially increases the probability of never smoking, our instrumental procedure yields imprecise estimates of the effect of education on smoking cessation. Potential mechanisms linking education and smoking are also explored.

A twin study of post-traumatic stress disorder symptoms and asthma

RATIONALE

Studies have suggested heightened anxiety among adults with asthma; the mechanism of this association is not known.

OBJECTIVES

To determine the association between post-traumatic stress disorder (PTSD) symptoms and asthma among adults, and to examine if this association is due to confounding by environmental and genetic factors.

METHODS

Data were obtained from twins in the Vietnam Era Twin Registry, which includes male veteran twin pairs born between 1939 and 1956 who served during the Vietnam era (1965-1975). Measurements included a symptom scale for PTSD, history of a doctor diagnosis of asthma, and sociodemographic and health confounding factors. Co-twin control analytic methods used mixed-effects logistic regression to account for the paired structure of the twin data and to examine the association between PTSD symptoms and asthma in all twins. Separate analyses were conducted within twin pairs and according to zygosity.

MEASUREMENTS AND MAIN RESULTS

PTSD symptoms were associated with a significantly increased likelihood of asthma (P(trend) < 0.001) even after adjustment for confounding factors. Among all twins, those in the highest quartile of PTSD symptoms were 2.3 times as likely (95% confidence interval, 1.4-3.7) to have asthma compared with those in the lowest quartile. These findings persist when examined within twin pairs and when stratified by zygosity.

CONCLUSIONS

Symptoms of PTSD were associated with an elevated prevalence of asthma. Even after careful adjustment for familial/genetic factors and other potential confounding factors, an association between PTSD symptoms and asthma remains. Efforts to understand this comorbidity may be useful in identifying modifiable environmental risk factors contributing to this pattern and therefore in developing more effective prevention and intervention strategies.

Confounding the critics: the Dohrenwend and colleagues reexamination of the National Vietnam Veteran Readjustment Study

The National Vietnam Veteran Readjustment Study (NVVRS; R. A. Kulka et al., 1988) has been highly influential, but critics argue that the study had several flaws. In this article, the author addresses how the recent NVVRS reevaluation (B. P. Dohrenwend et al., 2006) refutes most of the critic's major concerns including that self-report of exposure to war-zone stressors could not be verified, that PTSD did not require functional impairment, and that PTSD prevalence was too high for a low-intensity war in which relatively few veterans were assigned to combat military operation specialties. The author also addresses misleading statements made by critics discussing the NVVRS, the reevaluation, and related articles. The proper role of science and public policy, the importance of reporting findings accurately, and placing findings in proper perspective are discussed.

Circumstances of service and gender differences in war-related PTSD: findings from the National Vietnam Veteran Readjustment Study

Data from the National Vietnam Veteran Readjustment Study (NVVRS) revealed a prevalence of current posttraumatic stress disorder (PTSD) in female Vietnam Theater veterans half the size of the prevalence in their male counterparts. This stands in contrast to the elevated prevalence of PTSD in women obtained in general population surveys. This study undertakes further analyses of gender differences in the NVVRS and how these differences might be specified by the amount and type of exposure to war-zone stress. The findings indicate that male elevations in PTSD are limited to men who served under circumstances of high probable severity of war-zone stress exposure. When prewar demographic differences are controlled, male veterans in low-exposure circumstances display a level of PTSD prevalence substantially lower than female veterans.

Continuing controversy over the psychological risks of Vietnam for U.S. veterans

In 1988, the National Vietnam Veterans Readjustment Study (NVVRS) reported 30.9% lifetime and 15.2% current rates of posttraumatic stress disorder (PTSD), and a strong dose/response relationship with retrospective reports of combat exposure. Skeptics argued that recall bias and other flaws inflated the results. Using a new record-based exposure measure and diagnoses in an NVVRS subsample, the authors addressed this controversy in a recent issue of Science (B. P. Dohrenwend et al., 2006). They found little evidence of falsification, an even stronger dose/response relationship and, when fully adjusted for impairment and evidence of exposure, 18.7% onset and 9.1% current rates of war-related PTSD. The fact that these rates are lower than the original NVVRS rates has stimulated continuing controversy that has tended to obscure the more important implications of the study's results.

The psychological risks of Vietnam: the NVVRS perspective

In recent years, controversy concerning the psychological consequences of service in the Vietnam war has rearisen. In this article, the Co-Principal Investigators of the National Vietnam Veterans Readjustment Study (NVVRS) provide a perspective on new findings reported by B. P. Dohrenwend et al. (2006) that addresses criticisms of the NVVRS PTSD (posttraumatic stress disorder) prevalence findings, and on a perspective that was provided by R. J. McNally (2006) in an accompanying commentary. They find that Dohrenwend et al.'s study, which evaluated empirically a variety of the critics' alternative explanations and found little support for any of them, represents a landmark contribution to the trauma field. However, they found that McNally's commentary misrepresented the history and context of the NVVRS, and then misinterpreted Dohrenwend et al.'s findings and their importance.

Revisiting Dohrenwend et al.'s revisit of the National Vietnam Veterans Readjustment Study

Critics of the National Vietnam Veterans Readjustment Study (NVVRS) suspect that the NVVRS overestimated the prevalence of posttraumatic stress disorder (PTSD) among Vietnam veterans. Dohrenwend et al. (2006) confirmed this suspicion. Dohrenwend et al.'s reanalysis of the NVVRS data resulted in a prevalence estimate 40% lower than the original NVVRS estimate. Furthermore, had they required clinically significant functional impairment, the prevalence rate would have been 65% lower than the original NVVRS rate. That is, the current (late 1980s) prevalence estimates for PTSD are 15.2% (original NVVRS), 9.1% (Dohrenwend et al.), and 5.4% (clinically significant functional impairment). The policy implications of these findings are discussed.

Genetic influence on contrast sensitivity in middle-aged male twins

Contrast sensitivity is strongly associated with daily functioning among older adults, but the genetic and environmental contributions to this ability are unknown. Using the classical twin method, we addressed this issue by examining contrast sensitivity at five spatial frequencies (1.5-18 cycles per degree) in 718 middle-aged male twins from the Vietnam Era Twin Study of Aging (VETSA). Heritability estimates were modest (14-38%), whereas individual-specific environmental influences accounted for 62-86% of the variance. Identifying the types of individual-specific events that impact contrast sensitivity may suggest interventions to modulate this ability and thereby improve overall quality of life as adults age.

Pretrauma cognitive ability and risk for posttraumatic stress disorder: a twin study

CONTEXT

Cognitive deficits are associated with posttraumatic stress disorder (PTSD), but whether such deficits reflect sequelae or risk factors is not fully resolved.

OBJECTIVE

To determine, in a representative sample, whether preexposure cognitive ability is associated with risk for PTSD, and whether that risk is genetically mediated.

DESIGN, SETTING, AND PARTICIPANTS

The co-twin-control study involved 2386 male Vietnam-era twin veterans with a mean (SD) age of 41.9 (2.7) years, a population-based sample of men who were in military service during this era. Cognitive ability scores were obtained just before military induction at a mean (SD) age of 19.7 (1.5) years. Participants included only individuals who were exposed to potentially traumatic events and underwent preexposure cognitive testing.

MAIN OUTCOME MEASURES

Armed Forces Qualification Test (of cognitive ability) percentile scores and PTSD diagnosed by means of structured interviews.

RESULTS

We found a significant dose-response relationship between preexposure cognitive ability and risk for PTSD. After controlling for confounders, the highest cognitive ability quartile had a 48% lower risk than the lowest ability quartile (P<.001). Non-PTSD-concordant pairs had the highest scores; PTSD-concordant pairs had the lowest scores; and PTSD-discordant pairs had intermediate scores. Differences in Armed Forces Qualification Test scores within twin pairs were significant only in PTSD-discordant pairs (P=.04) and were accounted for specifically by the discordant dizygotic pairs (P=.002). Genetic influences on preexposure cognitive ability explained 5% of the variation in PTSD, but 100% of that relationship was explained by common genes.

CONCLUSIONS

Preexposure cognitive ability is a risk or a protective factor for PTSD. The variance in PTSD explained by preexposure cognitive ability is accounted for entirely by common genetic factors. Lower cognitive ability may be a marker of less adaptive coping against adverse mental health consequences of exposure to potentially traumatic events. Further study of the potential mechanisms through which cognitive ability confers risk is needed.

Cardiovascular manifestations of posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) involves the onset of psychiatric symptoms after exposure to a traumatic event. PTSD has an estimated lifetime prevalence of 7.8% among adult Americans, and about 15.2% of the men and 8.5% of the women who served in Vietnam suffered from posttraumatic stress disorder (PTSD) > or =15 years after their military service. Physiological responses (increase in heart rate, blood pressure, tremor and other symptoms of autonomic arousal) to reminders of the trauma are a part of the DSM-IV definition of PTSD. Multiple studies have shown that patients suffering from PTSD have increased resting heart rate, increased startle reaction, and increased heart rate and blood pressure as responses to traumatic slides, sounds and scripts. Some researchers have studied the sympathetic nervous system even further by looking at plasma norepinephrine and 24-hour urinary norepinephrine and found them to be elevated in veterans with PTSD as compared to those without PTSD. PTSD is associated with hyperfunctioning of the central noradrenergic system. Hyperactivity of the sympathoadrenal axis might contribute to cardiovascular disease through the effects of the catecholamines on the heart, the vasculature and platelet function. A psychobiological model based on allostatic load has also been proposed and states that chronic stressors over long durations of time lead to increased neuroendocrine responses, which have adverse effects on the body. PTSD has also been shown to be associated with an increased prevalence of substance abuse. With this review, we have discussed the effects of PTSD on the cardiovascular system.

Field Expediency

In the early years of the Vietnam War, when resources were in short supply, nurses improvised in the field to provide care to the sick and wounded under extremely adverse conditions. This "field expediency" was the result of nursing knowledge as well as flexibility, creativity, audacity, and pragmatism. Nurses in other settings--for example, those practicing in remote areas, in developing nations, or during natural disasters--may also find themselves facing severe shortages or too few essential supplies or a lack of equipment. Familiarity with the methods associated with field expediency will help nurses adapt quickly--on the battlefield and off.

Consistent association between mixed lateral preference and PTSD: confirmation among a national study of 2490 US Army Vietnam veterans

OBJECTIVE

To evaluate the research-based association between mixed lateral preference for handedness and risk for posttraumatic stress disorder (PTSD) in a large-scale sample of US Army Vietnam veterans exposed to war zone stressors.

METHOD

We used a national sample of 2490 male US Army veterans, who completed the Edinburgh Handedness Inventory (EHI), a measure ranging from -100 (pure left-handedness) to +100 (pure right-handedness). We developed several classifications representing levels of mixed laterality: a) an EHI -70 to +70 (EHI 70, moderate mixed); b) an EHI -50 to +50 (EHI 50, consistent mixed); and c) an EHI 0, plus reports of using either hand on > or =50% of the tasks assessed (EHI 0+, extreme mixed). We controlled for intelligence, race, Army entry age, and Army volunteer status, and we assessed the impact of combat exposure.

RESULTS

Although all three handedness measures were associated with current PTSD in bivariate analyses, only Edinburgh 0+ was associated with PTSD in the multivariate model (odds ratio (OR) = 2.1; p = .021). However, when we classified handedness by high combat exposure, all three measures were associated with PTSD, with ORs = 2.5, 2.8, and 4.7 for EHI 70, EHI 50, and EHI 0+, respectively (all p < .001). Veterans with mixed laterality and high combat exposure also had significantly increased PTSD symptoms (all p < .001).

CONCLUSION

Our study confirmed findings reported among mostly smaller clinical samples and suggested that mixed lateral preference was associated with PTSD, especially among those individuals exposed to more severe psychological trauma.

Can we solve the mysteries of the National Vietnam Veterans Readjustment Study?

The National Vietnam Veterans Readjustment Study (NVVRS) researchers reported that 30.9% of all men who served in that conflict developed posttraumatic stress disorder (PTSD) even though only about 15% had been assigned to combat units. Scholars, mainly historians, have questioned the accuracy of the PTSD prevalence rate. The purpose of this article is to evaluate the merits of several hypotheses adduced to explain the high apparent PTSD prevalence in the NVVRS. Empirical and conceptual analysis suggests that malingering is unlikely to account for many cases. Also, deployment to Vietnam in the absence of exposure to classic traumatic stressors is likewise unlikely to account for many cases. There are three plausible explanations for the high prevalence rate of PTSD in the NVVRS. First, DSM-III-R PTSD criteria, used in the NVVRS, did not require that symptoms produce impairment. Accordingly, some PTSD-positive cases may actually have been leading productive lives, despite occasional nightmares, or other stress responses. Second, some men assigned to non-combat duty (e.g., medics) may have been exposed to PTSD-inducing stressors. Third, some respondents may have invoked the Vietnam-PTSD narrative to make sense of postwar psychological difficulties having diverse causes unrelated to their military service. These three factors likely contribute to the high PTSD prevalence rate in the NVVRS.

Elevated sister chromatid exchange frequencies in New Zealand Vietnam War veterans

From July 1965 until November 1971, New Zealand Defence Force Personnel fought in the Vietnam War. During this time more than 76,500,000 litres of phenoxylic herbicides were sprayed over parts of Southern Vietnam and Laos, the most common being known as 'Agent Orange'. The current study aimed to ascertain whether or not New Zealand Vietnam War veterans show evidence of genetic disturbance arising as a consequence of their now confirmed exposure to these defoliants. A sample group of 24 New Zealand Vietnam War veterans and 23 control volunteers were compared using an SCE (sister chromatid exchange) analysis. The results from the SCE study show a highly significant difference (P < 0.001) between the mean of the experimental group (11.05) and the mean of a matched control group (8.18). The experimental group also has an exceptionally high proportion of HFCs (cells with high SCE frequencies) above the 95th percentile compared to the controls (11.0 and 0.07%, respectively). We conclude that the New Zealand Vietnam War veterans studied here were exposed to a clastogenic substance(s) which continues to exert an observable genetic effect today, and suggest that this is attributable to their service in Vietnam.

Genes, environment, and time: the Vietnam Era Twin Study of Aging (VETSA)

The Vietnam Era Twin Study of Aging (VETSA) is a large-scale investigation of cognitive aging from middle to later age. The intended sample of 1440 twin subjects is recruited from the Vietnam Era Twin Registry (VETR), a registry of middle-aged male-male twin pairs who both served in the military during the Vietnam conflict (1965-1975). VETSA employs a multitrait multimethod approach to cognitive assessment to focus on the genetic and environmental contributions to cognitive processes over time, as well as the relative contributions to cognitive aging from health, social, personality, and other contextual factors. The cognitive domains of episodic memory, working memory, abstract reasoning, and inhibitory executive functioning are assessed through neuropsychological testing. In addition, VETSA obtains the participant's score on the Armed Forces Qualification Test, taken at the time of induction into the military around age 20 years, and re-administers the test. Two other projects--VETSA Cortisol and VETSA Magnetic Resonance Imaging--are also in progress using subsamples of the VETSA twins. Prior waves of data collection by VETSA investigators using the VETR have provided historical data on physical and mental health, while future waves of VETSA data collection are planned every 5 years. These methods will provide data on multiple phenotypes in the same individuals with regard to genetic and environmental contributions to cognitive functioning over time, personality and interpersonal risk and protective factors, stress and cortisol regulation, and structural brain correlates of aging processes.

Contemporary Group Treatment of Combat-Related Posttraumatic Stress Disorder

The contemporary group treatment of veterans from the Vietnam War to the present who suffer from combat-related PTSD is reviewed in light of the dynamic understanding of combat trauma developed during and since World War II. Both dynamic and cognitive behavioral group therapies are explored. The common features of all group treatments of combat PTSD involve the development of trust and the communalization of trauma within a cohesive group. Further research is needed to increase our understanding of effectiveness, mediating factors, and relationships between childhood experience and combat trauma.

Mortality, length of life, and physical examination attendance in participants of the Air Force Health Study

Begun in 1982, the Air Force Health Study (AFHS) has assessed the mortality of veterans of Operation Ranch Hand, the unit responsible for aerially spraying herbicides in Vietnam. A comparison group of other Air Force veterans involved with aircraft missions in Southeast Asia during the same period, but not involved with spraying herbicides, was included in the study. Among 18,082 veterans, this report examined whether attendance at AFHS physical examinations from 1982 to 1999 played a role in mortality experience and potential lengthening of life relative to veterans who did not attend. The years of potential life lost for 1173 veterans who died before age 65 was calculated. No statistically significant difference in risk of death was found from all causes, cancer, or circulatory disease between attendees and nonattendees. No evidence was found to suggest that attending physical examinations decreased mortality or substantially lengthened life in AFHS participants.

Conduct disorder, war zone stress, and war-related posttraumatic stress disorder symptoms in American Indian Vietnam veterans

This study examined whether conduct disorder (CD) was associated with war zone stress and war-related post-traumatic stress disorder (PTSD) symptoms in American Indian (AI) Vietnam veterans. Cross-sectional lay-interview data was analyzed for 591 male participants from the American Indian Vietnam Veterans Project. Logistic regression evaluated the association of CD with odds of high war zone stress and linear regression evaluated the association of CD and PTSD symptom severity. Childhood CD was not associated with increased odds of high war zone stress. Conduct disorder was associated with elevated war-related PTSD symptoms among male AI Vietnam Veterans independent of war zone stress level and other mediators. Future efforts should examine reasons for this association and if the association exists in other AI populations.

Epidermal inclusion cyst in the foot of a Vietnam Veteran

Epidermal inclusion cysts are soft-tissue lesions that result from traumatic implantation of epidermal cells into the dermis. A case report is presented involving a large recurrent plantar inclusion cyst secondary to trauma sustained in the Vietnam War. The patient reported that the initiating trauma was the result of stepping on a punji stake in Vietnam. Punji stakes, sharpened spikes typically made of bamboo and dipped in poison or excrement, were used by the Vietnamese soldiers to wound enemy soldiers. Careful excision of the lesion is imperative to prevent recurrence.

Anthropometric and metabolic factors and risk of benign prostatic hyperplasia: a prospective cohort study of Air Force veterans

OBJECTIVES

The relationship between anthropometric and metabolic factors and benign prostatic hyperplasia (BPH) is poorly understood. We investigated the associations of BPH with anthropometric and metabolic parameters in this prospective study of Vietnam War veterans.

METHODS

A total of 1206 participants in the comparison arm of the Air Force Health Study with a median follow-up of 15.6 years were included in this study. The "Ranch Hand" group, occupationally exposed to herbicides, was excluded to eliminate any confounding from exposure to herbicides. BPH was determined by medical record review using the International Classification of Diseases and Related Problems, Ninth Revision. We used Cox proportional hazards regression models for the statistical analysis.

RESULTS

The median age for BPH diagnosis was 58.6 years. On multivariate analyses, increasing age (relative risk [RR] 1.14, 95% confidence interval [CI] 1.12 to 1.17), height (RR 1.02, 95% CI 1.004 to 1.03), and fasting blood glucose (RR 1.004, 95% CI 1.001 to 1.007) were associated with increased risk. The effect of age varied with the duration of follow-up. A greater systolic blood pressure (RR 0.992, 95% CI 0.986 to 0.997) was associated with decreased risk of BPH. A dose-response effect was seen for age, height, and systolic blood pressure. No effect was seen for weight, body mass index, change in weight or body mass index, lipids, thyroid hormone status, or the metabolic syndrome.

CONCLUSIONS

The risk of BPH increased with increasing age, height, and fasting blood glucose levels. The risk was decreased with a greater systolic blood pressure. No relationship was seen between BPH and metabolic syndrome, weight, body mass index, lipid level, or thyroid hormone status.

Acute respiratory distress syndrome in combat casualties: military medicine and advances in mechanical ventilation

Military medicine has made numerous enduring contributions to the advancement of pulmonary medicine. Acute respiratory distress syndrome was first recognized as a complication in battlefield casualties in World War I and continued to play a significant role in the treatment of casualties through the Vietnam War. Innovative surgeons during World War II devised methods to assist their patients with positive pressure breathing. This concept was later adopted and applied to the development of mechanical ventilation in the late 1940s and early 1950s. The continued treatment of acute respiratory distress syndrome in combat casualties by military physicians has provided a major impetus for advances in modern mechanical ventilation and intensive care unit medicine.

Nicotine dependence subtypes: association with smoking history, diagnostic criteria and psychiatric disorders in 5440 regular smokers from the Vietnam Era Twin Registry

Studies suggest empirically derived subtypes of nicotine dependence exist in young adult populations with short smoking careers. It is not known if classes of dependence exist in middle aged smokers with longer smoking careers and whether these classes reflect quantitative or qualitative differences. It is not known if psychiatric disorders are associated with classes of nicotine dependence. Nicotine dependence symptoms were obtained from a 1992 administration of the Diagnostic Interview Schedule. Latent Class Analyses (LCA) was computed using data from 5440 members of the Vietnam Era Twin Registry. LCA was used to derive significantly different classes of nicotine dependence, which were assessed for their association with smoking history, nicotine dependence, and other psychiatric disorders. The LCA model which best fit the data was a 4 class solution characterized by severity. Age onset of regular smoking decreased with more severe classes. Cigarette consumption, failed cessation and psychiatric disorders were associated with more severe classes. Empirically derived subtypes of nicotine dependence are mostly characterized by increasing severity. Suggestions for refinement of nicotine dependence diagnostic criteria are discussed.

Upper extremity arterial combat injury management

Traumatic hemorrhage and vascular injury management have been concerns for both civilian and military physicians. During the 20th century, advances in technique allowed surgeons to focus on vascular repair, restoration of perfusion, limb salvage, and life preservation. Military surgeons such as Makins, DeBakey, Hughes, Rich, and others made significant contributions to the field of surgery in general and vascular surgery in particular. Casualties from combat in Afghanistan and Iraq confront physicians and surgeons with devastating injuries. The current generation of providers is challenged with applying contemporary care while expanding upon the lessons taught by our predecessors. The objective of this report is to review the historical experience with managing military upper extremity arterial injuries and compare that experience with current management.

External-cause mortality after psychologic trauma: the effects of stress exposure and predisposition

Research suggests that exposure to psychologic trauma is associated with mortality from external causes, including homicide, suicide, drug overdoses, and unintended injury. However, the etiology of this association is unclear. We examined the survival time and cause of death among a national sample of 15288 US Army veterans by posttraumatic stress disorder (PTSD) status 30 years after military service. In these analyses, we included demographic (age, race, marital status, service entry age, and birthplace), predisposing (army volunteer status, discharge status, history of drug abuse, early-age alcohol use, and intelligence), and combat exposure variables. After adjusting for demographic and predisposing factors, all-cause mortality was associated with PTSD for all veterans combined (hazards ratio [HR] = 2.1, P < .001), as well as for era veterans without Vietnam service (HR = 2.0, P = .001) and theater veterans with Vietnam service (HR = 2.1, P < .001). For theater veterans, PTSD remained significant for all-cause mortality, even after controlling for demographic, predisposition, and combat exposure measures (HR = 2.1, P < .001). For external mortality, the adjusted results indicated that PTSD was associated with death for all veterans combined (HR = 2.3, P < .001) and for theater veterans separately (HR = 2.2, P = .002). For era veterans, the adjusted external mortality results also approached statistical significance (HR = 2.2, P = .068). Among theater veterans, PTSD remained significant for external mortality, even after controlling for all variables and combat exposure (HR = 2.2, P = .002). Combat exposure was not associated with external mortality once all variables were controlled. In addition, theater veterans who volunteered for Vietnam and those with dishonorable discharges were at increased risk for external-cause mortality.

Serum dioxin, testosterone, and subsequent risk of benign prostatic hyperplasia: a prospective cohort study of Air Force veterans

BACKGROUND

Operation Ranch Hand veterans were involved in spraying herbicides, including Agent Orange, during the Vietnam War in 1962-1971; Agent Orange was contaminated with 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). It has been hypothesized that dioxins may be partially responsible for an increase of male reproductive tract disorders such as testicular cancer, cryptorchidism, and hypospadias.

OBJECTIVES

In this study, our objective was to assess the effect of serum TCDD concentration on the risk of development of benign prostatic hyperplasia (BPH) and on serum testosterone levels.

METHODS

This study was a longitudinal, prospective cohort study made up of U.S. Air Force veterans involved in Operation Ranch Hand. Other Air Force veterans who did not spray herbicides were included as comparisons. BPH was determined by medical record review and by medical examinations conducted during the study. Data were available for 971 Ranch Hand and 1,266 comparison veterans. We investigated the relationship between BPH and serum TCDD level using the Cox proportional hazards models adjusted for testosterone levels, body mass index (BMI), and the percentage change in BMI per year.

RESULTS

In univariate and multivariate analyses, the risk of BPH decreased with increasing serum TCDD in the comparison group. The multivariate risk ratio for BPH in the comparison group was 0.84 (95% confidence interval, 0.73-0.98). Excluding men with prostate cancer, inflammatory or other prostatic diseases did not substantially alter the association. Serum testosterone levels were inversely associated with serum TCDD levels in both Ranch Hand and comparison groups.

CONCLUSIONS

TCDD exposure at general population levels is associated with a decreasing risk of BPH with higher exposure levels. TCDD exposure is also negatively associated with serum testosterone levels.

Health status of Army Chemical Corps Vietnam veterans who sprayed defoliant in Vietnam

BACKGROUND

U.S. Army Chemical Corps veterans handled and sprayed herbicides in Vietnam resulting in exposure to Agent Orange and its contaminant 2,3,7, 8-tetrachlorodibenzo-p-dioxin (TCDD or dioxin). This study examined the long-term health effects associated with herbicide exposure among these Vietnam veterans.

METHODS

A health survey of these 1,499 Vietnam veterans and a group of 1,428 non-Vietnam veterans assigned to chemical operations jobs was conducted using a computer-assisted telephone interview (CATI) system. Exposure to herbicides was assessed by analyzing serum specimens from a sample of 897 veterans for dioxin. Logistic regression analyses were used to estimate the risk of selected medical outcomes associated with herbicide exposure.

RESULTS

Odds ratios for diabetes, heart disease, hypertension, and chronic respiratory disease were elevated, but not significantly (P>0.05) for those who served in Vietnam. However, they were significantly elevated among those Vietnam veterans who sprayed herbicides: diabetes, odds ratio (OR)=1.50 (95% confidence interval [95%CI]=1.15-1.95); heart disease, OR=1.52 (1.18-1.94); hypertension, OR=1.32 (1.08-1.61); and chronic respiratory condition, OR=1.62 (1.28-2.05). Hepatitis was associated with Vietnam service, but not with herbicide application.

CONCLUSIONS

Vietnam veterans who were occupationally exposed to herbicide experienced a higher risk of several chronic medical conditions relative to other non-Vietnam veterans. A potential selection bias is of concern. However, there were relatively high participation rates in both the Vietnam and non-Vietnam veteran groups, and the prevalence rates of some of these medical conditions among non-Vietnam veterans were comparable to general populations. Therefore, self-selection factors are considered unlikely to have biased the study results.

Molecular epidemiologic evidence for diabetogenic effects of dioxin exposure in U.S. Air force veterans of the Vietnam war

BACKGROUND

One of the outcomes positively associated with dioxin exposure in humans is type 2 diabetes.

OBJECTIVES

This study was conducted in order to find the molecular biological evidence for the diabetogenic action of dioxin in adipose samples from Vietnam veterans.

METHODS

We obtained 313 adipose tissue samples both from Vietnam veterans who were exposed to dioxin (Operation Ranch Hand) and from comparison veterans who served in Southeast Asia with no record of dioxin exposure. We conducted quantitative reverse-transcribed polymerase chain reaction studies on selected marker mRNAs from these samples.

RESULTS

We found the most sensitive and reliable molecular indicator of dioxin-induced diabetes to be the ratio of mRNA of glucose transporter 4 (GLUT4) and nuclear transcription factor kappa B (NFkappaB), a marker of inflammation. This ratio showed significant correlations to serum dioxin residues and to fasting glucose among those in the Ranch Hand group and, surprisingly, even in the comparison group, who have low levels of dioxin comparable to the general public. Such a correlation in the comparison group was particularly significant among those with known risk factors such as obesity and family history of diabetes.

CONCLUSIONS

These results show that the GLUT4:NFkappaB ratio is a reliable marker for the diabetogenic action of dioxin, particularly at very low exposure levels that are not much higher than those found in the general public, implying a need to address current exposure levels.

Covariation of psychological attributes and incident coronary heart disease in U.S. Air Force veterans of the Vietnam war

OBJECTIVE

The purpose of the present investigation was to examine the prospective associations of hostility, anger, depression, and anxiety, alone and in combination, to incident coronary heart disease (CHD).

METHODS

Subjects were 2105 men who participated in the Air Force Health Study, a 20-year study designed to evaluate the effects of herbicide exposure on various health outcomes in Air Force veterans of Operation Ranch Hand. Psychological attributes were assessed in 1985 using scales constructed from the Minnesota Multiphasic Personality Inventory. Participants were followed for an average of 15 years for evidence of ischemic heart disease (International Classification of Diseases codes 410-414, 428.4, or 36). The relation between psychological attributes and CHD was examined with Cox proportional hazard models.

RESULTS

Adjusting for CHD risk factors, depression, anxiety, hostility, and trait anger were significant predictors of incident CHD. In addition, a factor analytically derived psychological risk factor composite score was the strongest predictor of CHD.

CONCLUSIONS

These results suggest that the covariation of hostility, anger, depression, and anxiety accounts for the increased risk of CHD associated with each individual factor. The results of this study challenge the conventional approach of examining these psychological attributes in isolation.

Treatment for combat-related posttraumatic stress disorder: two-year follow-up

This study reports on outcomes 2 years following completion of specialist veteran posttraumatic stress disorder (PTSD) treatment programs in 2,223 (reduced to 1,508 at 24 months) consecutive admissions. Self-report measures of PTSD, anxiety, depression, anger, alcohol use, and general functioning were obtained at admission, 6, 12, and 24 months after admission. Significant improvements were demonstrated at 6 months, with smaller gains continuing through to 24-month assessment. Within subject effect sizes of around 0.8 were obtained for PTSD and around 0.5 for anxiety and depression. Although lack of a control group limits the extent to which improvements can be attributed to the treatment program, the data suggest that specialized treatment programs for combat-related PTSD continue to be of value.

Gender and psychotherapy with traditional men

Therapists who are accustomed to operating in a world where gender roles are becoming increasingly androgynous may underestimate how foreign the experience of psychotherapy can be to "traditional" men. This paper describes the occurrence of transference and resistance encountered by female therapists when seeing male patients at a Veterans Administration (V.A.) Medical Center who identify with traditional American male gender roles. The discussion is informed by recent advances in the theory of male gender identity development and yields new insights into the typical defenses men may bring to the early phases of psychotherapy. Case examples from the authors' practices illustrate strategies for intervening with resistance and enhancing the therapeutic alliance. Common countertransference issues encountered by therapists working with "traditional" men are also discussed.

The psychological risks of Vietnam for U.S. veterans: a revisit with new data and methods

In 1988, the National Vietnam Veterans Readjustment Study (NVVRS) of a representative sample of 1200 veterans estimated that 30.9% had developed posttraumatic stress disorder (PTSD) during their lifetimes and that 15.2% were currently suffering from PTSD. The study also found a strong dose-response relationship: As retrospective reports of combat exposure increased, PTSD occurrence increased. Skeptics have argued that these results are inflated by recall bias and other flaws. We used military records to construct a new exposure measure and to cross-check exposure reports in diagnoses of 260 NVVRS veterans. We found little evidence of falsification, an even stronger dose-response relationship, and psychological costs that were lower than previously estimated but still substantial. According to our fully adjusted PTSD rates, 18.7% of the veterans had developed war-related PTSD during their lifetimes and 9.1% were currently suffering from PTSD 11 to 12 years after the war; current PTSD was typically associated with moderate impairment.