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14 Νοε 2013 (πριν από 3 χρόνια και 6 μήνες)

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AMERICAN SOCIETY OF
ADDICTION MEDICINE
ANNUAL MEDICAL
-
SCIENTIFIC SYMPOSIUM


--
DR. MICHAEL KILPATRICK, MD


“Treatment of the Returning Military Veteran”

Friday, April 15, 2011

Treatment of the Returning Military
Veteran

Traumatic Brain Injury (TBI)

Traumatic Brain Injury

Data from Defense Veterans Brain Injury Center (DVBIC)

Blast

62%

Vehicular

13%

Fragment

11%

Fall

6%

Bullet

4%

Other

4%

TBI Injury Mechanism

Mild

62%

Moderate

18%

Severe

14%

Penetrating

5%

Unknown

1%

TBI Severity of Injury

Spectrum of TBI range from Mild to Severe

Mild

62%

Operational Breakout

OIF

96%

OEF

4%

Source: Defense Veterans Brain Injury Center 2006


2000

9000

10000

10,96
3

28,557

2000
0

6,282
(27%)

7,200
(25%)

(16%4
,442 )

2007

2008

2009

DoD Baseline

DoD

OIF/OEF

DoD

OIF/OEF

DoD

OIF/OEF

23,00
2

OVERALL TBI CASES HAVE MORE THAN
DOUBLED

27,86
2

DoD Total

Data Source: AFHSC

Deployed Forces

DoD TBI Numbers at www.dvbic.org & www.health.mil

Overall TBI Snapshot…

Policy Guidance for the Management of
Concussion/mTBI in the Deployed Setting


Directive
-
Type Memorandum (DTM) 09
-
033



Issued 21 June 2010 by DEPSECDEF



Involves commitment of line commanders and medical community


DCoE

coordination with FHP/R, JS, CENTCOM, JTAPIC, Service TBI POC’s



Describes mandatory processes for identifying those service members involved in
potentially concussive events


Exposed to blast, vehicle collision, witnessed loss of consciousness, other head trauma



DCoE

developed specific protocols for management of concussed service members
and those with recurrent concussion



Transition from symptom driven reporting to incident driven



DESIRED END STATE: the mitigation of the effects of potential concussive
events on both service member health, readiness and ongoing operations



Highlights from the DTM



Mandatory
event driven protocols
, for exposure to potentially concussive
events


剥煵楲e猠愠浥摩捡氠
evaluation

and

a rest
period


䅬氠獰潲瑳⁡o搠
activities with risk
of concussion are prohibited
until
medically cleared


Military Acute Concussion Evaluation (MACE) documentation will include
MACE 3
-
part score


Service Members diagnosed with mTBI will be given a
standardized
educational sheet


New
protocols

for anyone sustaining
3

or more mTBIs within 12 months

OASD(HA)
FHP&R

Data drivers:


inform
DoD

TBI

policy
updates and
MHS

Strategic
Communica
tions

ISAF

Tampa, FL


BECIR = Blast Exposure and Concussion Incident Report


CIDNE = Combined Information Data Network Exchange


JTAPIC = Joint Trauma Analysis and Prevention of Injury in Combat


OASD (HA) FHP&R = Office of the Assistant Secretary of Defense for
Health Affairs, Force Health Protection and Readiness


DDR&E = Director, Defense Research & Engineering


JIEDDO = Joint Improvised Explosive Device Defeat Organization


BIR PCO = Blast Injury Research Program Coordinating Office

End of
month
(
EoM
)

EoM

+
10 days

EoM

+ 15
days

EoM

+ ?
days

EoM

+ ?
days

USF
-
I

Monthl
y
BECIR

Data drivers:


Establish
procedures for
capturing and
reporting data


Quality
assurance

JIEDDO

DDR&E

Data drivers:


Medical/no
n
-
medical
RDT&E


Support
RDT&E

investment
decisions

JTAPIC

Fort Detrick

MD

Data drivers:


Develop event
-
specific
monitoring
summaries


Supplement
current
JTAPIC data
collection
efforts

DCoE

Data drivers:


Clinical Data
Analysis


Develop TBI CPG
recommendations


Provide DoD
leadership with
activity
summaries

Timeline

MTBI DTM Data Flow

Blast Injury
Research
PCO

Joint Staff

ISAF

Co
-
Morbidities Associated with
mTBI


Sleep disorders


Substance abuse


Psychiatric illness


Vestibular disorders


Visual disorders


Cognitive disorders

PTSD


N=232

68.2%


2.9%

16.5%

42.1%


6.8%

5.3%



10.3%


12.6%

TBI

N=227

66.8%

Chronic
Pain

N=277

81.5%

Lew, et al:

Prevalence of Chronic Pain, Posttraumatic Stress Disorder, and
Persistent Postconcussive Symptoms in OIF/OEF Veterans: Polytrauma Clinical
Triad

, Dept. of Veterans Affairs, Journal of Rehabilitative Research and
Development, Vol. 46, No. 6, 2009, pp. 697
-
702, Fig. 1

DoD TBI Research Initiatives

Blast Physics/

Blast Dosimetry

Force Protection Testing
& Fielding

Complementary
Alternative
Medicine

Field
Epidemiological
Studies (mTBI)

Rehabilitation
&
Reintegration:
Long Term
Effects of TBI

Neuroprotection
& Repair
Strategies:
Brain Injury
Prevention

Concussion: Rapid
field Assessment

Treatment & Clinical
Improvement


Close collaboration among the line, medical, and research communities


Key areas


Rapid field assessment of concussion (i.e., rapid eye movement tracking,
biomarkers)


Novel therapeutics (
i.e
, omega
-
3, progesterone, HBO2, cognitive rehabilitation)


Blast dynamics (i.e.,
neuroimaging
)

FY06

FY10: Over
$400M

for TBI
Research

Treatment of the Returning Military
Veteran

Surveillance

Psychological

Spiritual

Environmental

Social

Total

Fitness

Access

Immunizations

Screening

Prophylaxis

Dental

Heat/Cold

Altitude

Noise

Air Quality

Strength

Endurance

Flexibility

Mobility

Food quality

Nutrient requirements

Supplement Use

Food choices

Social support

Task cohesion

Social cohesion

Substance abuse

Hygiene

Risk mitigation


Service values


Positive beliefs


Meaning making

Ethical leadership

Accommodate diversity


Total

Force

Fitness

Coping

Awareness

Beliefs/appraisals

Decision making

Engagement

Total Force Fitness Model

Surveillance


2795 Predeployment Health Assessment (1998)



2796 Post Deployment Health Assessment (1998)


Modified April 2003


PTSD Screening


Modified late 2007


TBI



2900 Post Deployment Health Assessment (2005)


Modified late 2007



All being modified in 2011

December 2010 MSMR Data

The
inTransition

Program:
Maintaining Continuity of Care Across
Transitions


inTransition

is a Department of Defense (DoD) program created to
assist service members who are receiving mental health services
while transitioning between health care systems or providers



Developed in response to the DoD Mental Health Task Force
recommendation to “Maintain continuity of care across transitions”
(5.2.2)



Provides voluntary one
-
on
-
one coaching to service members



Designed as a bridge of support for service members when:


Relocating to another assignment


Returning from deployment


Transitioning from active duty to reserve, reserve to active duty, or
returning to civilian life





DoD PH Research Initiatives

Sleep Studies

Genetics and Biomarkers

Suicide
Prevention and
Screening

Pre/Peri/Post
-
Deployment
Behavioral
Skills Training
for Service
Members and
Spouses

Child and Family
Studies

Complementary
and Alternative
Medicine

Clinical Treatment:
Psychotherapy and
Pharmacotherapy


Key areas



Continued trials to treat deployment related PTSD, especially with co
-
morbidities


Novel therapeutics (e.g., virtual reality, mindfulness,
telehealth
,
pharmacotherapies
)


Establish validated models and measures of resilience

FY06

FY10:
Over $345M

for PH
Research

Co
-
morbidities
(TBI, Pain
Management,
Substance Use
Disorders, etc.)

Treatment of the Returning Military
Veteran

Millennium Cohort

Background

The Millennium Cohort Study is a longitudinal study designed to
evaluate long
-
term subjective health and chronic diagnosed
health problems, in relation to exposures of military concern,
especially deployments

>150,000 population
-
based with over
-
sampling for women,
previous
deployers
, and Reserve/National Guard

All services, active duty, Reserve/National Guard

Participants are re
-
surveyed at 3
-
year intervals, including after
service through 2022


Basic Methodology

DMDC Reference # 00
-
0019 * RCS # DD
-
HA(AR)2106 * OMB
Approval # 0720
-
0029

Survey refined based on focus group testing, pilot
study, and expert review


Questionnaire leverages standard instruments (PHQ,
PCL, SF
-
36V, others)


Includes measures of physical health, behavioral
health, mental health


Includes exposure questions, and other metrics
(deployment, sleep, etc.)


Participants respond via traditional paper, or over
secure website


Induction

Demographic Data

Immunization
Data

Deployment
Data

Mortality Data

Recruit Assessment
Program

Dept of Veterans
Affairs Data

Medical History

Survey Data, PDHA/RA

Exposure Data

Military Inpatient and
Outpatient Care

Civilian Inpatient and
Outpatient Care

Family Data

e.g., DoD Birth and

Infant Health Registry

DoD and VA Data

Sources

Environmental

DoD Serum Repository

Pharmacologic

Data

Current Status

2001: Study launched



77,047 enrolled in Panel 1

2004: Panel 2 enrollment and Panel 1 follow
-
up



31,110 enrolled / 55,021 followed
-
up



2007: Panel 3 enrollment and Panels 1
-
2 follow
-
up



43,440 enrolled / 71,942 followed
-
up



2010: Panel 4 enrollment (50,000) , Panels 1
-
3 follow
-
up, and


enrollment of Family Cohort

Of the current participants (N = 151,597) :


> 70% with at least 1 follow
-
up


~ 50% deployed in support of operations in Iraq and Afghanistan


~ 20% have left military service

Currently, 33 peer
-
reviewed publications and 190 scientific presentations with
many awards


Millennium Cohort

Environmental Exposure Support

Health outcomes among infants born to women deployed to US military
operations during pregnancy Birth defects research (Part A, In press)

Findings indicate that infants born to women who inadvertently
deployed to military operations during pregnancy were not at
increased risk of adverse birth or infant health outcomes

Newly reported respiratory symptoms and conditions among military
personnel deployed to Iraq and Afghanistan: a prospective population
-
based study (AJE, 2009)

Deployment associated with respiratory symptoms in Army and
Marine Corps personnel, independent of smoking status

Deployment length linearly associated with increased symptom
reporting in Army personnel, and elevated odds of symptoms were
associated with land
-
based deployment (vs. sea
-
based deployment)

Follow
-
up study in progress to assess
chronicity

of these findings

Burn Pit Studies

In progress are 4 burn pit studies that utilize 3 exposure measures: 1)
within 2, 3, or 5 miles of burn pit; 2) cumulative days of burn pit
exposure; and 3) base assigned (
Balad
/
Taji
/
Speicher
)

Analysis of birth outcomes for personnel assigned to locations with
burn pits and exposed before (women and men) and during pregnancy
(women)

Utilized DoD Birth and Infant Health Registry data

Compared live births for men and women deployed within 2, 3, or 5
miles of
Balad
/
Taji
/
Speicher

burn pits versus all other
deployers

Generally, no associations between burn pit exposure and birth
defects or preterm births in infants of active
-
duty personnel

However, infants born to men who were last exposed to a burn pit
area > 280 days prior to infant’s estimated date of conception had
an increased risk of birth defects (AOR = 1.31, 95% CI = 1.04, 1.64)