Introduction by Brenda L. Mooney, Editorial Director, U.S. Medicine

by U.S. Medicine

June 18, 2013

“An army is a minature of the society which produces it.”
– C.L.R. James

Brenda L. Mooney, Editorial Director

On a recent road trip to enjoy the spring weather, my husband and I stopped at a convenience store near the Georgia-South Carolina state line to fill up our car with gas. When we walked in, we found the store was a sea of green — a group of soldiers had just completed basic training at Fort Benning, GA, and were stocking up on snacks and soft drinks as they headed up I-85 to a new posting in Virginia.

We struck up a conversation with some of the young men and were impressed by their confidence and maturity. They told us about their training and their plans for the future; one announced excitedly that he would be moving on to military police school soon. They were proud young men, ready and willing to do what was necessary to protect their country.

As we got in the car and drove away, I looked back and watched the young soldiers, who had been so serious and polite with us. Outside the store, they were now play-wrestling with their buddies, guzzling Red Bull drinks and laughing too loudly at each other’s jokes. If you disregarded the high-and-tight haircuts and the fatigues, they looked just like any other teenagers or 20-somethings.

Military healthcare providers understand that fundamental truth about the admirable young men and women who make up the active-duty military: While they are brave soldiers, sailors, Marines and airmen who take seriously their mission to protect the United States, they also are, in many cases, youngsters not that far removed from high school and hanging out at the mall.

Like their civilian counterparts, young servicemembers don’t always make the best choices when it comes to their health and well-being. As detailed in U.S. Medicine over the last year, military medical leadership has had to grapple with such issues as overuse of energy drinks, ingestion of risky body-building supplements, experimentation with “designer” drugs and lack of sleep among troops.

Prevention and health training of young troops is essential to maintain their fitness and readiness for duty, and the 2013 Compendium of Federal Medicine discusses some of those issues. One article describes preventive efforts by the Air Force to ensure that airmen wear headgear and use sunscreen to prevent skin cancer and its most dangerous manifestation — melanoma. The successful program has driven down melanoma rates among young airmen, even though military personnel spend more time outdoors and exposed to the sun.

Another article deals with an even more disturbing issue: the soaring rates of unintended pregnancy among active-duty troops. Even though contraceptives are available free of charge to military personnel, the rates are already 50% higher than among civilians. The Navy, which is facing some of the highest increases among sailors and Marines, has a new program to address the issue.

Unplanned pregnancies are not only the result of lack of knowledge or planning related to contraceptives, but also are associated with the alarmingly high rate of military sexual assault, which has been a critical focus of military leadership and a challenge for behavioral health providers.

That situation underscores another reality faced by military healthcare providers: While the medical issues faced by active-duty troops might be similar to the civilian world, conditions unique to wartime or the military often make them far more complex.

For example, battlefield conditions ranging from sun exposure to crowded living conditions to chafing and sweating caused by body armor can create hard-to-manage dermatologic issues. This year’s Compendium discusses the unexpectedly high rate of medical evacuations of troops from war zones because of skin problems, and how a tri-service program brought that under control. The solution was to use telemedicine to transport the expertise of dermatologists to the frontlines so skin conditions could be diagnosed remotely, with only the most serious being evacuated.

War zone situations also produce other medical conditions that, because of how they are intertwined with psychological issues, make them especially hard to diagnose. Are lower urinary tract symptoms a result of harsh battlefield conditions that make bathroom breaks difficult, or are they related to the post-traumatic stress disorder (PTSD) and depression that beset so many servicemembers in the aftermath of their Iraq and Afghanistan experiences? An article in this issue discusses how VA researchers are trying to answer that question.

PTSD and traumatic brain injury (TBI) also are contributors to the increasing number of patients with psychogenic nonepileptic seizures (PNES). On these pages, authors from the Veterans Healthcare Administration Southeast Epilepsy Centers of Excellence (ECoE) discuss how patients with PNES represent a new population that must be evaluated in the ECoEs to ensure the best treatment for war-injured veterans.

Another VA Center for Excellence network, the one overseeing treatment of multiple sclerosis, also is facing new challenges. As discussed in the 2013 Compendium, the MSCoE is grappling with some troubling questions raised by new research: Why are incidence rates for multiple sclerosis increasing in African-Americans compared with other racial backgrounds, and why is the disease more severe in that population?

Research raising those issues was done by VA clinicians, as was another effort that has created a lot of buzz, a study finding that contralateral prophylactic mastectomies are unnecessary in most cases where the surgery is performed. The article in this issue raises concerns about whether healthcare providers are doing enough to educate and advise breast cancer patients about their options.

Like the breast cancer feature, other articles in the 2013 Compendium of Federal Medicine discuss issues primarily affecting the population at the other end of the spectrum: veterans coping with diseases of aging.

The Compendium discusses how recommendations against prostate-specific antigen (PSA) screening for prostate cancer are getting some pushback, with researchers suggesting that screening methodology be revised and not abandoned. Those discussions are having a significant effect on the VA, which diagnoses more than 12,000 new cases of prostate cancer each year.

Another article is on newer anticoagulants and how they offer options for veterans with atrial fibrillation who are ineligible to take warfarin or prefer not to be on it. The drugs bring their own risks, however, but VA experts explain how they might be in a unique position to mitigate those.

Just as military and veteran patients are both alike and different from their compatriots who never served, so are federal healthcare providers. Military and VA clinicians have the unique experience of dealing with patients at every age and in sometimes less-than-favorable conditions.

I’ve thought a lot about the young men we met at the convenience store and what the future holds for them. As the war in Afghanistan winds down, will they be peacetime warriors or will they be frontline fighters in another distant land, such as Syria or South Korea?

We all pray that won’t be necessary. One thing I know for sure, however: No matter where they go as servicemembers or veterans, they will be well cared for by healthcare systems that provide quality of care unrivaled in any setting.

It is my privilege to work with the many healthcare professionals who are so gracious in providing information to U.S. Medicine. Thank you for your commitment and patriotism.

Brenda L. Mooney

Editorial Director

U.S. Medicine

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