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INTRODUCTION: The War-Related Illness and Injury Study Center at the VA New Jersey Health Care System (WRIISC-VANJ) serves as one of the three tertiary referral centers for combat deployed Veterans of all eras with medically unexplained or difficult-to-diagnose conditions that may be related to deployment-related exposures. Many of the Veterans seen at the WRIISC experience chronic multisymptom illness (CMI), also known as Gulf War Illness (GWI). Given the complexity and interconnectedness of symptoms, Veterans with GWI are often unlikely to produce meaningful results when addressing single symptoms. Further, Veterans with GWI often have co-morbid cognitive and behavioral health conditions (e.g., TBI, PTSD, Depression), which further compromise their self-efficacy in following treatment recommendations. Thus, the WRIISC-NJ, in collaboration with Wellness Solutions Group, developed a virtual Functional Medicine-based Interdisciplinary and Integrative Intervention to improve the health of Veterans by assisting them in implementing lifestyle changes. METHODS: The 6-month telehealth program included functional medicine assessments, nutrition and adaptive exercise coaching, mindfulness meditation and yoga, guest health lectures, character strength coaching, and targeted nutritional supplements. Aspects of the program were tailored to the unique clinical needs of each Veteran. Participants completed baseline and 6 month follow-up assessments of physical and emotional symptoms and overall functioning. Follow-up scores were compared with baseline data. RESULTS: The program was well received by Veterans with attendance across all offered sessions ranging from 70 to 100%. Further, at the end of the clinical pilot program, improvements were demonstrated in physical and mental health symptoms, intentional weight loss/gain, functional movement, and sleep quality. CONCLUSIONS: These preliminary results demonstrate the possibility of creating positive health outcomes across multiple health indicators in medically complex combat-deployed Veterans. Our early success and participant enthusiasm for this clinical pilot program also illustrate an opportunity to provide individualized, innovative solutions for the evaluation and treatment of Veterans with GWI.

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This study evaluated risk factors of sarcoidosis among Airborne Hazards and Open Burn Pit Registry (AHOBPR) participants using a retrospective age and sex-matched case-control design of AHOBPR participants deployed to Afghanistan or Southwest Asia with and without sarcoidosis diagnosed in the Veterans Health Administration (VHA). Logistic regression models tested for associations between sarcoidosis and self-reported cumulative deployment-related exposures. 661 Veterans (0.37%) were diagnosed with sarcoidosis in VHA. Logistic regression demonstrated lower odds of sarcoidosis in Hispanic participants (OR 0.08, CI 0.04-0.15) and those who served in the Navy (OR 0.40, CI 0.21-0.72). African American veterans (OR 2.27, CI 1.66-3.11) and former smokers (OR 1.87, CI 1.33-2.62) were at elevated risk. Of the exposure variables, convoy activities had the highest odds of being associated with sarcoidosis and was marginally statistically significant (OR 1.16, CI 1.00-1.35). Sarcoidosis was an uncommon diagnosis among AHOBPR participants and was associated with only one of eight assessed cumulative deployment-related exposures.

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AIMS: We investigated whether the consumption of Concord grape juice (CGJ) was associated with increased bioavailability of serum metabolites and their potential impact on cognitive performance in Veterans with Gulf War Illness (GWI). MAIN METHODS: Twenty-six veterans were selected from a cohort of 36 enrolled in a 24-week randomized, double-blind, Phase I/IIA clinical trial exploring whether the consumption of Concord grape juice (CGJ) was tolerable and safe in Veterans with GWI and improved cognitive function and fatigue. These 26 veterans were selected based on their completion of the entire 24-week protocol and documented adherence to the study beverage ≥80%. Differences in serum metabolite levels between CGJ and placebo at midpoint and endpoint were evaluated using two-way repeated measures ANOVA with post hoc Sidak's multiple comparison test. Bivariate correlations to assess for possible relationships between change in serum metabolite levels and change in cognitive function as measured by the Halstead Category Test-Russell Revised Version (RCAT) were also conducted. KEY FINDINGS: Seventy-six metabolites were identified and quantified in this study, with three (cyanidin-glucuronide, me-cyanidin-glucuronide, and me-malvidin-glucuronide) found to be significantly higher (p < 0.05) in the CGJ group compared to placebo at 24 weeks. Significant associations between changes in cognitive function and changes in serum levels of epicatechin-sulphate (r = 0.48, p = 0.01) and petunidin-glucuronide (r = 0.53, p < 0.01) from baseline to 24 weeks were also observed. SIGNIFICANCE: Our data suggest that dietary supplementation with CGJ is associated with increased bioavailability of specific phenolic metabolites, some of which may be correlated with cognitive performance.

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Approximately 30 percent of U.S. veterans deployed during the Gulf War (1990-1991) have been diagnosed with Gulf War Illness (GWI), a chronic multi-symptom disorder without widely available specific treatments. We investigated whether the consumption of Concord grape juice (CGJ), rich in anti-inflammatory flavonoids, would be tolerated and safe in individuals with GWI and explored improvement in cognitive function and fatigue. Thirty-six veterans with GWI enrolled in a 24-week randomized, double-blind, Phase I/IIA clinical trial to explore safety, tolerability, and feasibility of 16 ounces daily of commercially available CGJ compared to placebo. Participants completed neurocognitive tests and self-reported surveys at baseline, 12 and 24 weeks. Thirty-one participants (86%) completed the study; no dropouts were related to side effects. Thirty participants (83%) documented ≥80% adherence. There were no statistically significant unadjusted differences between CGJ and placebo groups in change in efficacy measures from baseline to endpoint. We employed general linear regression models controlling for baseline differences between groups which indicated statistically significant improvement in the Halstead Category Test-Russell Revised Version (RCAT) at endpoint in the CGJ group compared to placebo (8.4 points, p = 0.04). Other measures of cognitive functioning did not indicate significant improvements in the adjusted analyses (p-values: 0.09-0.32), nor did the fatigue variable (p = 0.67). CGJ was safe and well-tolerated by veterans with GWI. Our data suggest high tolerability and potential benefit from CGJ in veterans with GWI and can be used to inform future studies of efficacy.

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BACKGROUND: Gulf War Illness (GWI) is a chronic condition involving symptoms across multiple body systems. Previous research has implicated the vestibular system as a potential underlying factor in the symptoms experienced by veterans with GWI, due in part to exposure to potentially ototoxic chemicals and events. PURPOSE: To characterize the presence of vertigo and dizziness symptoms in a sample of veterans with GWI using validated self-report instruments, accounting for mental health comorbidities. RESEARCH DESIGN: This is a case series, follow-up, prospective interview of clinical veterans; results presented are purely descriptive. STUDY SAMPLE: Our sample of 50 veterans was a follow-up to a case series of clinical Gulf War veterans evaluated at the War Related Illness and Injury Study Center. DATA COLLECTION AND ANALYSIS: Veterans participated in a 70-min phone interview where the following questionnaires were administered: Vertigo Symptom Scale (VSS), Patient Health Questionnaire (depression scale), Patient Health Questionnaire (somatization scale), Beck Anxiety Inventory, Posttraumatic Stress Disorder (PTSD) Checklist, Defense and Veterans Brain Injury Center Traumatic Brain Injury Questionnaire, and GWI (Kansas) Questionnaire. We used descriptive (mean/median, standard deviation, interquartile range, and percentage) statistics to describe our sample and illuminate possible relationships between measures. RESULTS: Our primary finding is a substantial report of vertigo symptoms in our sample, according to the VSS. Ninety percent of participants scored above the VSS threshold (>12), suggesting "severe dizziness." The most commonly endorsed symptom on the VSS was "headache or pressure in the head." CONCLUSIONS: We conclude that there is significant burden of vertigo symptoms in veterans with GWI, suggesting a need for objective tests of vestibular function in this population. Furthermore, the relationship between symptoms of vertigo and dizziness, vestibular function, and PTSD warrants further exploration using objective measures.

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PURPOSE: To evaluate the utility of the forced oscillation technique (FOT) among military veterans with preserved spirometry and chronic unexplained respiratory symptoms. METHODS: 178 veterans referred for evaluation of unexplained respiratory symptoms completed pulmonary function testing and FOT. Preserved spirometry was defined as FEV1/FVC, FEV1 and FVC ≥ 5th percentile. Frequency dependence of resistance (R4-R20) and reactance area (AX) were assessed via FOT, and R4-R20 ≥ 20% and AX ≥ 95th percentile were considered abnormal. RESULTS: Spirometry was preserved in 71.3%, of whom 124 had acceptable FOT data. 93 of 124 (75.0%) veterans with preserved spirometry had one or more abnormal findings on FOT. Veterans with abnormal R4-R20 and/or AX had reduced FVC, FEV1, FEF25-75, and diffusing capacity (% predicted) in comparison to those with Normal FOT (p = 0.030 to p < 0.001). CONCLUSIONS: In our referral sample, distal airway dysfunction in the presence of preserved spirometry appears common and may represent an at-risk group requiring closer surveillance.

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INTRODUCTION: We characterized the presence of autonomic symptoms in a sample of Veterans with Gulf War Illness (GWI) using the Composite Autonomic Symptom Scale (COMPASS-31). In addition, we examined the report of autonomic symptoms across comorbid mental health conditions in this sample. MATERIALS AND METHODS: Case-series follow-up of Gulf War veterans evaluated by the War Related Illness and Injury Study Center (WRIISC) between 2011 and 2016 (n = 153). Phone-based interview consisted of questionnaires designed to investigate autonomic symptoms, physical symptoms, mental health conditions, and GWI. Sixty-One Veterans agreed to participate in this follow-up arm of the study. We restricted our analysis to only those Veterans meeting CDC and/or Kansas criteria for GWI, leaving us with a sample of 56 Veterans. RESULTS: Veterans in our sample were, male (n = 55, 98%), 49 (±6.8) years old and used 8 (±6.6) medications. The mean COMPASS-31 score for our sample was 45.6 (±18.3). There were no differences in reports of autonomic symptoms between participants who screened positive or negative for depression or post-traumatic stress disorder, but COMPASS-31 scores were higher among those who screened positive for anxiety (49.6 (±16.0)) compared with those who screened negative (29.3 (±18.9)) (p < 0.001). CONCLUSIONS: The elevated COMPASS-31 scores suggest that there may be autonomic dysfunction present in our sample of Veterans with GWI, consistent with other published reports. Additionally, we believe that the high scores on the anxiety measure may reflect assessment of physiological symptoms that are not specific to anxiety, and may reflect GWI symptoms. Objective physiological tests of the autonomic nervous system are warranted to better characterize autonomic function and the clinical relevance of COMPASS-31 in this population.

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Introduction: Previous studies suggest that autonomic dysfunction may be an underlying factor in Gulf War Illness. This study examined self-reported symptoms of autonomic dysfunction and their relationship with physical functioning among veterans with Gulf War Illness. Materials and Methods: We abstracted medical records of Gulf War Veterans clinically evaluated at the New Jersey War Related Illness and Injury Study Center between 2010 and 2016. The outcome measure was the Veteran version of the Short Form Health Survey (VR-36) physical functioning scale. Autonomic function was assessed using a composite variable constructed from the chart abstraction to mimic the Composite Autonomic Symptom Scale (COMPASS-31). Results: Seventy-six veterans were included in the final analysis. The autonomic symptom burden score was 45 (±14). Increased autonomic symptom burden, greater mental health burden (PTSD/depression), and greater body mass index were individually associated with poorer physical functioning. A general linear regression containing these variables revealed that patients with both PTSD and depression (b = -15.2, p = 0.03) or either PTSD or depression (b = -22.7, p < 0.01) had lower physical functioning than those without; the other variables became not significant (body mass index: p = 0.07; autonomic function: p = 0.89). Conclusion: The average autonomic function score indicated significant burden in Gulf War Veterans, consistent with published research. We did not detect an independent association between autonomic symptom burden and physical functioning, likely due to the non-specific nature of the measure used to capture autonomic symptoms or the stronger association between mental health conditions and physical functioning. Future work utilizing valid and standardized instruments to clinically evaluate autonomic function is warranted.

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Following deployment to Iraq and Afghanistan ("post-9/11"), a spectrum of respiratory conditions has been reported; however, there are few published reports of objective physiologic data or later experience of symptoms and function. To better understand the post-deployment clinical presentation, we conducted a retrospective review of pulmonary function testing in 143 veterans referred to our tertiary care clinic for post-deployment health concerns. More than 75% of our sample had normal lung volumes and spirometry on pulmonary function testing; however, an isolated reduction in lung diffusing capacity (DLCO) was observed in 30% of our sample of post-9/11 veterans. An isolated reduction in DLCO is a rare pattern in primary-care seeking dyspneic patients, but is commonly associated with underlying pulmonary disease. Post-9/11 veterans with respiratory complaints and an isolated reduction in DLCO should undergo further evaluation.

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OBJECTIVE: The aim of this study was to determine the relationship between deployment length and indices of airflow obstruction in Iraq and Afghanistan veterans with airborne hazards exposure. METHODS: One hundred twenty-four post-9/11 veterans completed pulmonary function testing and questionnaires. We examined the association of airflow limitation [forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC)] and bronchodilator responsiveness (ΔFEV1 and ΔFVC) with deployment length, adjusting for smoking. RESULTS: Longer deployment length was associated with lower FEV1/FVC [ß = -0.19; 95% confidence interval (95% CI), -0.39 to 0.01], greater ΔFEV1 (ß = 0.27; 95% CI, 0.09 to 0.45) and ΔFVC (ß = 0.19; 95% CI, 0.05 to 0.33). In our model adjusted for smoking history, longer deployment length remained associated with greater ΔFEV1 and ΔFVC (P < 0.01), but not with FEV1/FVC (P = 0.059). CONCLUSION: In our sample of post-9/11 veterans, longer deployment lengths were associated with significant bronchodilator responsiveness and a trend toward airflow limitation independent of tobacco use.

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More than 2.6 million military personnel have been deployed to recent conflicts in Iraq and Afghanistan and were likely exposed to a variety of airborne hazards during deployment. Despite several epidemiologic reports of increased respiratory symptoms, whether or not these respiratory illnesses lead to reductions in lung function and/or specific pulmonary disease is unclear. We reviewed data published from 2001 to 2014 pertaining to respiratory health in military personnel deployed to Iraq and Afghanistan and found 19 unique studies. Study designs were primarily retrospective and observational in nature with patient symptom reporting and medical encounter data as primary outcome measures. Two case series reported on rare respiratory diseases, and one performed a standardized evaluation of new-onset respiratory symptoms. Respiratory outcomes in relation to proximity to a specific air pollution source (i.e., smoke from burning trash and sulfur mine fire) were described in 2 separate studies. Only 2 longitudinal investigations were identified comparing pre- and postdeployment measurement of exercise capacity. In summary, published data based on case reports and retrospective cohort studies suggest a higher prevalence of respiratory symptoms and respiratory illness consistent with airway obstruction. However, the association between chronic lung disease and airborne hazards exposure requires further longitudinal research studies with objective pulmonary assessments.

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OBJECTIVE: We characterized the prevalence of self-reported environmental exposures, concerns about exposures, and their relationships with somatic symptoms in Operation Enduring Freedom (Afghanistan) (OEF) and Operation Iraqi Freedom (Iraq) (OIF) veterans seeking treatment at a specialty Veterans Affairs (VA) clinic. Concerns about environmental exposures were expected to lead to more reporting of somatic symptom burden. METHODS: We conducted a chart review of 469 OEF/OIF veterans seen at a VA tertiary care clinic. RESULTS: OEF/OIF veterans reported a high level of environmental exposures and concerns about environmental exposures. Greater reported environmental exposures (ß = 0.13) and environmental exposure concerns (ß = 0.39) were associated with a greater somatic symptom burden. Exposure concerns accounted for some of the relationship of exposures on somatic symptom burden (confidence interval, 0.33-0.60). CONCLUSIONS: OEF/OIF veterans seeking treatment at a VA clinic reported a high prevalence of environmental exposures and exposure concerns. Both negatively impacted health outcomes.

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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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OBJECTIVE: The purpose of this study was to investigate relationships between environmental factors of odor, noise, light, and color and perceived stress, job satisfaction, and turnover intention. BACKGROUND: The physical work environment may positively or negatively influence nurses' stress, and stress may negatively impact their job satisfaction and intention to change jobs. METHODS: The research questions were answered using a descriptive, correlational design. The sample (n = 116) consisted of medical-surgical nurses working in acute-care settings. A 36-item questionnaire addressed odor, noise, light, color, perceived stress, job satisfaction, and turnover intention. RESULTS: Significant relationships were found between noise and perceived stress, perceived stress and job satisfaction, job satisfaction and turnover intention, and perceived stress and turnover intention. CONCLUSIONS: Nurses tend to overlook their physical environment and "do their job." Common environmental stressors in the work environment can be stressful to staff and influence job satisfaction and, ultimately, intention to change jobs. Mitigating or eliminating these environmental factors has the potential to improve staff satisfaction and retention. Stress influences nursing job satisfaction and, ultimately, intention to change jobs.

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OBJECTIVES: We propose a new theoretical model that integrates health interventions targeting multiple health behaviors around a common framework of enhancing life functioning. We then test an enhanced life functioning message against an enhanced physical health message in increasing participants' perceived importance of engaging in multiple health behaviors. METHODS: 94 undergraduate participants were exposed to either an enhanced life functioning message or an enhanced physical health message and then completed measures of health behavior importance and benefits associated with enhanced life functioning importance in the spring of 2008 at Rutgers University. RESULTS: Results indicate the efficacy of an enhanced life functioning message in increasing participants' perceived importance of engaging in multiple health behaviors. Moreover, the effect of an enhanced life functioning message on perceived health behavior importance is mediated by perceived importance of the benefits associated with enhanced life functioning. CONCLUSIONS: Emphasizing enhanced life functioning as an outcome of engaging in multiple health behaviors increases the perceived importance of performing multiple health behaviors, which may influence the performance of multiple health behaviors.

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OBJECTIVE: To assess if organizational factors are predictors of workers' health and productivity after the World Trade Center attacks. METHODS: We conducted a survey of 750 workers and compared those who had direct exposures to the World Trade Center attacks (south of Canal Street workers; primary victims) with those less directly exposed (north of Canal Street workers; other victims and non-victims). RESULTS: South of Canal Street workers reported headache more frequently than north of Canal Street workers did (P = 0.0202). Primary victims reported headache and cough more frequently than did other victims and non-victims (P = 0.0086 and 0.0043, respectively). Defensive organizational culture was an independent predictor of cough and job stress, and job stress was an independent predictor of on-the-job productivity losses. CONCLUSION: Organizational variables may modify health and productivity outcomes after a large-scale traumatic event in the workplace.

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BACKGROUND: The National Institutes of Health (NIH) consensus statement recommends adjuvant therapy for early breast cancer irrespective of age. However, the actual use of such therapy is not well documented among women over 65 years of age. METHODS: We studied the frequency of use of adjuvant therapy and report the receipt of this therapy among 200 women aged > or = 65 years diagnosed with early breast cancer who were identified from the New Jersey State Cancer Registry. RESULTS: In this population, 28% of patients received chemotherapy alone or in combination with hormonal therapy, whereas 42% received hormonal therapy alone. Less than half of the women with estrogen receptor-negative tumors received chemotherapy alone or in combination with hormonal treatment. Adjuvant therapy was not prescribed in 30% of patients. CONCLUSIONS: Despite NIH recommendations, the frequency of use of adjuvant therapy in New Jersey is low among women over 65 years of age, regardless of their receptor status.

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