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Postpartum Depression in a Military Sample

INTRODUCTION

Postpartum depression Postpartum Depression Definition

Postpartum depression is a mood disorder that begins after childbirth and usually lasts beyond six weeks.
Description
 (PPD (1) (Parallel Presence Detect) The method used by earlier SIMM memory modules to communicate their capacity to the computer. A binary number coming from a parallel set of pins was read by the system, with each pin representing one bit. Contrast with SPD. ) is considered a type of major depressive disorder Major depressive disorder
A mood disorder characterized by profound feelings of sadness or despair.

Mentioned in: Conduct Disorder

major depressive disorder 
 occurring within the first 4 weeks after delivery.1 A meta-analysis of 59 studies reported an average rate of PPD of 13%,2 although some studies reported even higher rates.3 PPD has a negative impact on parenting ability4,5 and child development.6,7 Spouses of women with PPD have reported increased stress,8 may suffer psychological problems, and experience less marital satisfaction.9

There are many factors contributing to the development of PPD. Meta-analyses have identified 13 psychosocial psychosocial /psy·cho·so·cial/ (si?ko-so´shul) pertaining to or involving both psychic and social aspects.

psy·cho·so·cial
adj.
Involving aspects of both social and psychological behavior.
 risk factors for PPD.10,11 Ten of these variables, including prenatal prenatal /pre·na·tal/ (-na´tal) preceding birth.

pre·na·tal
adj.
Preceding birth. Also called antenatal.



prenatal

preceding birth.
 depression, self-esteem, child care stress, prenatal anxiety, life stress, social support, marital relationship Noun 1. marital relationship - the relationship between wife and husband
marital bed

family relationship, kinship, relationship - (anthropology) relatedness or connection by blood or marriage or adoption
, history of depression, infant temperament, and maternity blues Baby Blues is also the title of a comic strip by Rick Kirkman and Jerry Scott.
The maternity baby blues, maternity blues or baby blues is a condition that 75-80% of mothers can experience after childbirth with a wide variety of symptoms which generally involve mild
, had moderate effect sizes. The remaining three, that is, marital status marital status,
n the legal standing of a person in regard to his or her marriage state.
, socioeconomic status socioeconomic status,
n the position of an individual on a socio-economic scale that measures such factors as education, income, type of occupation, place of residence, and in some populations, ethnicity and religion.
, and unwanted/unplanned pregnancy, had small but significant effect sizes.

Transitioning into motherhood is a difficult task, and this role shift may be particularly challenging for employed women. It is estimated that >50% of women with infants < 1 year of age are employed.12 Employed women may have better mental health outcomes when they take longer maternity leaves and work fewer hours per week.13 Returning to work has been found to contribute to improved mood in the postpartum period The postpartum period is the period consisting of the months or weeks immediately after childbirth or delivery. Importance to health
The postpartum period is when the woman adjusts, both physically and psychologically, to the process of childbearing.
.14 des Rivieres-Pigeion et al.15 determined that social support could mediate the relationship between work status and depression, evidenced by the more isolated position of a homemaker. Professional identity may also be a source of protection against PPD,16 and employment may provide opportunities for more social support, positive feedback, fiscal autonomy, and stress management.17

Nearly 200,000 women are active duty (AD) members of the U.S. Armed Forces.18 This population has many protective factors, compared with the civilian working population. One study indicated that nearly 100% of military mothers attended check-ups during pregnancy.19 Additionally, military mothers have access to special health care services, such as diet, alcohol, and smoking counseling and infant care, exercise, and breastfeeding classes, at no cost.19

Although there are benefits to AD status, military mothers also experience unique stressors, compared with civilian mothers. A study noted that pregnant dependent spouses and AD military women reported low levels of stress but the AD women worked longer into their pregnancies and reported less support.20 They also reported more work hours per week and more weeks spent working throughout their pregnancies. Military mothers may feel especially torn between the demands of family and career.21 Additionally, struggling AD members may be hesitant to reveal emotional concerns because of fear of occupational repercussions repercussions nplrépercussions fpl

repercussions nplAuswirkungen pl 
.22,23 The difficulties inherent in disclosing mental health information may be considered a risk factor for this population, because depressive de·pres·sive
adj.
1. Tending to depress or lower.

2. Depressing; gloomy.

3. Of or relating to psychological depression.

n.
A person suffering from psychological depression.
 symptoms may be left unidentified and untreated.

Compared with the magnitude of research on PPD and civilian women, studies focusing on military women are lacking. Research found a rate of PPD among 26 AD women of 19%.24 Another study reported that 1 1% of 109 AD mothers were positive for PPD.25 New military mothers have reported increased parenting and occupational stress.26 Additional findings indicate that parental stress among military mothers may increase family-work conflict, which may then increase depression and decrease functioning.21 When military mothers were invested and involved in each of their roles (occupational, marital, and parental), however, distress was reduced, lessening depressive symptoms.

There have been positive findings related to civilian employment and decreased PPD symptoms,15,16 but military mothers do not necessarily have the protective characteristics correlated with employment. For example, enlisted military mothers in particular may have only high school diplomas A high school diploma is a diploma awarded for the completion of high school. In the United States and Canada, it is considered the minimum education required for government jobs and higher education. An equivalent is the GED. , be single, be younger, have less support, and have more unwanted pregnancies unwanted pregnancy Obstetrics A pregnancy that is not desired by one or both biologic parents. See Teen pregnancy. .27 Alternatively, some military mothers may be less susceptible to depression because of employment-related social support and well-timed pregnancies. At this time, the literature does not appear to thoroughly address frequency or contributing factors for PPD among AD military women. This exploratory study begins to bridge the gap in the literature by examining AD military mothers and the effects of their unique employment situation on postpartum postpartum /post·par·tum/ (post-pahr´tum) occurring after childbirth, with reference to the mother.

post·par·tum
adj.
Of or occurring in the period shortly after childbirth.
 mental health. The following questions are examined. (1) What is the prevalence rate of PPD in an AD military sample? (2) What psychosocial and demographic risk factors are associated witii PPD symptoms for military mothers? (3) Are these risk factors different from those identified in studies of civilian momers?

METHODS

Participants

All AD military women, including activated reservists and activated National Guard members, who gave birth at Wilford Hall Medical Center (WHMC WHMC Wilford Hall Medical Center
WHMC White House Millennium Council
) (Lackland Air Force Base Lackland Air Force Base (lăk`lənd), U.S. military installation, c.6,835 acres (2,766 hectares), S Tex., W of San Antonio; est. 1941. It is a major air force training center. , San Antonio, Texas “San Antonio” redirects here. For other uses, see San Antonio (disambiguation).
San Antonio is the second most populous city in Texas, the third most populous metropolitan area in Texas, and is the seventh most populous city in the United States. As of the 2006 U.S.
) were invited to participate in the study. The initial exclusion criterion was that participants complete the measures within the first 6 months after delivery. Additionally, letters were not sent to mothers who had poor delivery outcomes (low Agpar scores, fetal anomalies, or deliveries before 28 weeks). This step was taken to prevent study invitations being inadvertently sent to women who might have lost their babies.

Measures

The participants completed three measures, namely, the Edinburgh Postnatal Depression Postnatal depression is a form of clinical depression which can affect women, and less frequently men, after childbirth. It is widely considered to be treatable. Studies report prevalence rates from 5% to 25%, but methodological differences among the studies make the actual  Scale (EPDS EPDS Edinburgh Postnatal Depression Scale
EPDS Electrical Power & Distribution System
EPDS Electronic Processing and Dissemination System
EPDS Emergency Personnel Decontamination Station
EPDS Emergency Priority Dispatch System
),28 a modified Postpartum Depression Predictors Inventory-Revised (PDPIR)29 (Table I), and a demographic questionnaire (Table ?). The EPDS was developed by Cox et al.28 to aid primary care providers in detecting PPD. Its 10 items are related to PPD symptoms and requests patients to respond based on the past week. A score of 12 or 13 is a recommended cutoff value to indicate the presence of depression. A conservative cutoff value of 12 was used in this study, to avoid false-positive results and to achieve consistency with procedures in similar studies (e.g., the study by O'Boyle et al.24). The EPDS has solid reliability,30 as well as validity sensitivity and specificity.31

The PDPI-R was developed from meta-analytic findings10 as a clinician-administered interview.32 It was revised in 200229 on the basis of an updated meta-analysis" that identified 13 factors that place women at risk for PPD. Each of the statistically significant factors is represented in the original measure, that is, marital status, self-esteem, prenatal depression, prenatal anxiety, unplanned/unwanted pregnancy, history of previous depression, social support, marital satisfaction, life stress, child care stress, infant temperament, and maternity blues. The first 10 factors may be assessed both during and after pregnancy, whereas the last three are appropriate only in the postpartum period. Each question corresponds to a factor that has been found to be a statistically significant contributor to PPD.'0 " Although a recent study examined total score and cutoff value options,33 the PDPI-R was used in the present investigation to help identify exactly which risk factors may contribute to PPD in a military sample. The PDPI-R was designed for use as a clinical interview, but it has been used in a self-report format with positive results.34 We received permission from the developer (CT. Beck, personal communication) to further modify the instrument into a selfreport measure that is more amenable to statistical analyses. The modification was loyal to the original measure's 13 questions but altered the format from open-ended questions to Likert scale Likert scale A subjective scoring system that allows a person being surveyed to quantify likes and preferences on a 5-point scale, with 1 being the least important, relevant, interesting, most ho-hum, or other, and 5 being most excellent, yeehah important, etc  response options.

A 22-item, multiple-choice, background questionnaire was created to identify potential characteristics associated with PPD symptoms. The items focused on military-specific and demographic variables, such as deployment status, branch of service, and rank.

Procedure

Once each month, the WHMC Office of Clinical Investigations received, from the obstetrics/gynecology department chief, the names of all AD women who had given birth. Each new mother was sent an invitation letter through the Office of Clinical Investigations, informing her of the study. Informative posters and small printed materials were also displayed in the obstetrics/gynecology and pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children.

pe·di·at·ric
adj.
Of or relating to pediatrics.
 department waiting rooms. The letter and advertisements listed an Internet address There are two kinds of addresses that are widely used on the Internet. One is a person's e-mail address, and the other is the address of a Web site, which is known as a URL. Following is an explanation of Internet e-mail addresses only. For more on URLs, see URL and Internet domain name. , where the participants electronically gave informed consent and completed the measures. There was an option at the close of the survey to give an e-mail address See Internet address.

e-mail address - electronic mail address
 if the participants were interested in receiving an online-redeemable, $5 gift card to a well-known baby-needs store. The participants were aware that e-mail addresses were not linked to the data and would have no purpose other than communication of payment. Continuation to the debriefing de·brief·ing  
n.
1. The act or process of debriefing or of being debriefed.

2. The information imparted during the process of being debriefed.

Noun 1.
 page occurred for every participant, with or without an e-mail address. The debriefing page presented information on contacting the WHMC mental health clinic, a support hotline (Department of Defense Military OneSource Military OneSource (spelled in official publications as printed here, with the words One and Source merged into a single word with a capitalized O and S) is a government service provided by the Department of Defense through a contractor. ), and a special military resource number (Texas 211). Also presented were multiple methods for contacting the researchers.

Care was taken to ensure that, in this online study, proper informed consent was given, anonymity was provided, and effective debriefing was presented, as outlined by Kraut kraut  
n.
1. Sauerkraut.

2. often Kraut Offensive Slang Used as a disparaging term for a German.



[German; see sauerkraut.]

Noun 1.
 et al." This study was approved by the WHMC institutional review board, and Health Insurance Portability and Accountability Act The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the U.S. Congress in 1996.

According to the Centers for Medicare and Medicaid Services (CMS) website, Title I of HIPAA protects health insurance coverage for workers and their families when
 guidelines were followed. At no time did the authors have access to protected health information protected health information Health informatics Any individually identifiable health informatlon that is used or circulated by an entity that falls under the governance of HIPAA; the privacy regulations mandate safeguards for protected health information, and the , because the investigators and the Office of Clinical Investigations actively prevented disclosure of the participants' protected health information.

RESULTS

A total of 526 women were sent letters of invitation, and an unknown number viewed the study posters. Ninety-two responded and participated in the study. Four participants did not complete the measures, and one mother participated past the 6-month time period; these five women were excluded from analysis. A total of 87 participants were included in data analysis. Participants completed measures an average of 11 .7 weeks after delivery.

As noted in Table III, most participants were Caucasian and serving in the U.S. Air Force. The mean age of the participants was 30 years, with an average of 1.7 children; 54% of sample was multiparous mul·tip·a·rous
adj.
1. Relating to a multipara.

2. Giving birth to more than one offspring at a time.
. Participants had been in me military for an average of 8 years; 68% were first-term service members (defined as serving =4 years). Most (63%) were enlisted personnel, rather than officers. Married or partnered mothers composed 84% of the sample and, of those couples, 55% were dual-military. More than one-third (39%) of the participants reported medical complications of some type. Motiiers had an average of 46 days of maternity leave, consistent with the typical 42-day maternity leave allotted al·lot  
tr.v. al·lot·ted, al·lot·ting, al·lots
1. To parcel out; distribute or apportion: allotting land to homesteaders; allot blame.

2.
 to all military mothers.

A score of =12 on the EPDS (a cutoff value indicating the presence of significant PPD symptoms) was found for 19.5% of the participants,. The scores ranged from 0 to 22, with an average score of 6.4 (SD, 5.4).

Bivariate bi·var·i·ate  
adj.
Mathematics Having two variables: bivariate binomial distribution.

Adj. 1.
 nonparametric correlations were conducted to determine relationships between PDPI-R variables and EPDS scores. Because mese items are already established as being correlated wim PPD in me general population,10,11 me goal of this exploratory study was to determine whether these factors were correlated with PPD in a military sample. Because testing a model of factors was not justified in this exploratory study, multivariate The use of multiple variables in a forecasting model.  regression correlations were not conducted.

Twelve items on the modified PDPI-R are ordinal (mathematics) ordinal - An isomorphism class of well-ordered sets.  data, whereas one item (marital status) is nominal. Therefore, Spearman's ? analyses (two-tailed) were conducted with 12 of the 13 factors on the PDPI-R. Analyses indicated significant positive correlations between 10 of these items and scores on the EPDS (Table IV). Marital status was analyzed by using Pearson's ?^sup 2^ tests. The analysis showed that one cell had an expected count of <5; therefore, an exact significance test was selected. There was no relationship between marital status and EPDS scores (?^sup 2^ = 0.038, df = , exact p = 1.000).

Pearson's ?^sup 2^ analyses were also conducted for PPD symptoms and nominal military-specific variables. EPDS scores were coded dichotomously di·chot·o·mous  
adj.
1. Divided or dividing into two parts or classifications.

2. Characterized by dichotomy.



di·chot
, dividing patients with scores of = 12 and < 12. As displayed in Table V, analyses indicated no relationship between PPD symptoms and military factors.

DISCUSSION

This study found a rate of PPD in an AD military sample of nearly 20%. This value is consistent with findings in another military sample.24 Although the rate it is elevated in comparison with averages in the civilian population, it is within the range reported in various other studies.3 It is unclear what contributing factors might be responsible for an increased rate of PPD symptoms in this sample. Some studies have suggested that neither employment status36 nor occupation type2 is an important variable related to PPD. This sample was drawn from patients at a large hospital known for its treatment of complicated pregnancies; it is interesting to highlight that nearly 40% of this sample endorsed complications, a factor noted for its contribution to PPD.37 The elevated rate may also reflect a unique struggle AD mothers face; one study found that 51 % of military women indicated a belief that there is no ideal time to have both children and a military career.27 Other investigators reported that ~25% of women who chose to leave the military identified work-family conflict Work-family conflict is “a form of interrole conflict in which the role pressures from the work and family domains are mutually incompatible in some respect. That is participation in the work (family) role is made more difficult by virtue of participation in the family (work)  as a reason for separation.38 It is possible that our sample subjects struggled with such concerns, which were not directly assessed in this study.

Ten psychosocial factors were associated with PPD, including low self-esteem, prenatal anxiety, prenatal depression, history of previous depression, social support, poor marital satisfaction, life stress, child care stress, difficult infant temperament, and maternity blues. Three factors were not, including income level, marital status, and unplanned pregnancy, which is consistent with the meta-analysis by Beck," in which the same factors had only small effect sizes, whereas the other 10 had moderate effect sizes.

Particularly interesting is the lack of association between PPD and military-specific factors. Women who were in a dual-military relationship were not at higher risk for PPD. Additionally, women who were dealing with an impending im·pend  
intr.v. im·pend·ed, im·pend·ing, im·pends
1. To be about to occur: Her retirement is impending.

2.
 deployment or whose spouses were deployed were not more likely to report depressive symptoms. An upcoming military move, rank, and base housing were also unrelated to symptoms of PPD. One possibility is that differences were not detected because of the study being underpowered. Although none of the analyses detected a trend in the data, it is possible that a larger sample size might contribute to elucidation e·lu·ci·date  
v. e·lu·ci·dat·ed, e·lu·ci·dat·ing, e·lu·ci·dates

v.tr.
To make clear or plain, especially by explanation; clarify.

v.intr.
To give an explanation that serves to clarify.
 of potential relationships between military-specific variables and PPD. An alternative is that these findings are reasonable, because women who choose to join the armed services The Constitution authorizes Congress to raise, support, and regulate armed services for the national defense. The President of the United States is commander in chief of all the branches of the services and has ultimate control over most military matters.  may find the challenges and culture congruent con·gru·ent  
adj.
1. Corresponding; congruous.

2. Mathematics
a. Coinciding exactly when superimposed: congruent triangles.

b.
 with their lifestyle. Additionally, if pregnant enlisted members find the military environment incompatible with motherhood, they may request discharge.39 As previously stated, health care and supportive programs for military families during and after pregnancy are comprehensive and may actually serve as protective factors against PPD. However, military-specific environmental features that were not assessed could actually be affecting the 10 identified risk factors. Perhaps life stress could be accounted for by occupational stress, marital satisfaction might be affected by military lifestyle, or child care stress might be affected by long work hours.

This study has generated information that may help identify military mothers who have or are at risk for PPD. Although some military hospitals, such as this data collection site, assess and actively treat women with PPD, these results indicate it is imperative for other military bases to continue using, or consider adopting, such a protocol. It is interesting to note that all of the women in this study had already been given the EPDS during their obstetrics/gynecology visits and were automatically referred for treatment if they scored a 12. This sample's rate of PPD was nearly 1 in 5, despite the fact that each woman had already been screened for PPD. Other military health care facilities without this procedure could have particularly high rates of undiagnosed and untreated PPD.

Understanding factors that contribute to PPD in AD women can also lead to more effective prevention and intervention efforts. Although some military members are hesitant to disclose the presence of emotional distress emotional distress n. an increasingly popular basis for a claim of damages in lawsuits for injury due to the negligence or intentional acts of another. Originally damages for emotional distress were only awardable in conjunction with damages for actual physical harm.  because of stigma or fear of occupational consequences,22,23 knowing the risk factors can alert health providers to further assess the presence of PPD when a mother presents with significant factors. Identification and treatment of PPD could improve the quality of life and the quality of health care for military service members. Reduced costs to the government resulting from lost time and poor work quality may also be a positive result.

This study's method is an example of how technology can be used to gather data from special populations. Online data were collected while the primary investigator was residing thousands of miles away from the collection site, but the investigators were still able to safeguard the data until conclusion of the study (at which time it will be destroyed). Additionally, the completely anonymous nature of the method provided the opportunity for military women to disclose more information than they might be comfortable doing with their health care providers.22,23 This research displays a confidential methodological standard for gathering and safeguarding sensitive information.

There are several limitations in this work, largely attributable to the exploratory nature of the study. The psychosocial risk factors were measured only through single-question Likert scale items, and the presence or absence of risk factors was not fully assess. It was not feasible to investigate these factors with individual measures because of the time required and expense, as well as difficulty recruiting mothers with spare hours for study participation. Additionally, the PDPI-R was originally developed as a screening tool for identifying women at risk29 and was appropriate for rapid identification of risk factors in this sample. Furthermore, it is important to consider the correlational nature of this study, noting that causation cannot be inferred. Although "risk factors" are discussed, it is not clear whether these factors are present before PPD or arise as a result of the disorder. For example, poor marital satisfaction could occur after onset of PPD or contribute to its development.

It is also important to note that our sample may not accurately reflect the military population as a whole, because a single site was the source of all data collected and the sample size was relatively small. This sample also reflected over-representation of military officers (nearly 40%), compared with the female U.S. Air Force population of ~80% enlisted personnel and ~20% officers.40 As stated previously, rank did not statistically significantly distinguish depressed from nondepressed participants. More than one-half of the married/partnered women were in dual-military relationships. However, there were also no detectable differences related to spouse status. Approximately one-third of the sample subjects were serving their first term in the military, which also indicates greater participation of more seasoned military members than might be expected. It is also interesting to note that more than one-half of the participants were multiparous; some researchers have found that parity is important, because multiparous women may be more vulnerable to PPD.41 Although many women with medical complications participated, our letter-based advertising did exclude women with poor outcomes, which also could have biased our results. Finally, these participants were self-selected and might have chosen to respond to advertisements because of personal concerns related to the study topic.

Our response rate was -17.5%. It is not known whether mothers solicited in person would have been more participative than those solicited by letter. However, the burden of advertising/soliciting was greatly reduced by mailing a letter, rather than requesting military medical staff members to discuss the study witii women at the time of their delivery/ postpartum follow-up visits. Additionally, the primary investigator was residing thousands of miles away from the collection site. The completely anonymous nature of the study was also viewed as a benefit of letter-based recruitment.

Future studies should focus on multiple sites, larger sample sizes, and additional methods for assessing risk and protective factors. Expanded military-specific questions would better examine the effects of the military environment and wartime status on mothers' mental health. Work-family conflict should be considered in this population as well. It would helpful to identify any differences related to branch of service, as well as the unique circumstances that activated reservist re·serv·ist  
n.
A member of a military reserve.


reservist
Noun

a member of a nation's military reserve

Noun 1.
 and National Guard members face (e.g., distance from units, varying military-based supportive services, and different deployment tempos/situations). Length of time in service, parity, and adverse outcomes/pregnancy complications are also worthwhile factors to investigate. A prospective study would help clarify the directionality of correlated factors; consideration of current treatment status, such as psychotropic psychotropic /psy·cho·tro·pic/ (si?ko-tro´pik) exerting an effect on the mind; capable of modifying mental activity; said especially of drugs.

psy·cho·tro·pic
adj.
 medication or participation in psychotherapy psychotherapy, treatment of mental and emotional disorders using psychological methods. Psychotherapy, thus, does not include physiological interventions, such as drug therapy or electroconvulsive therapy, although it may be used in combination with such methods. , would also be helpful. An examination of anonymously reported EPDS scores and those endorsed during obstetric ob·stet·ric or ob·stet·ri·cal
adj.
Of or relating to the profession of obstetrics or the care of women during and after pregnancy.



obstetrical, obstetric

pertaining to or emanating from obstetrics.
 visits would also be useful; unfortunately such analyses were not feasible in mis study.

In conclusion, the reported findings of our study may allow for more targeted prevention and treatment of PPD in a military setting. There are identification and treatment protocols at certain military hospitals, such as WHMC. Such procedures involve screening all pregnant women before delivery (at 32-36 weeks) and 6 weeks after delivery and allowing doctors and nurses to make referrals to a behavioral health Behavioral health was first used in the 1980's to name the combination of the fields mental health and substance abuse. As an example, an organization serving both mental health and substance abuse clients might refer to its practice as behavioral health or  consultant in the obstetrics/gynecology department.42·43 Expanding specialized behavioral health consultant services, along with this knowledge of risk factors, could help increase effective identification and treatment delivery for military women at risk for PPD.

ACKNOWLEDGMENTS

Special thanks go to Lt Col Lt Col or LtCol
abbr.
lieutenant colonel
 Hryshko-Mullen, WHMC Clinical Health Psychology Service, Tammie Auton, WHMC Office of Special Investigations, and Lf Col Mike Gordon (Ret.) for meir invaluable support and assistance.

This study was funded by the 2005 American Psychological Association The American Psychological Association (APA) is a professional organization representing psychology in the US. Description and history
The association has around 150,000 members and an annual budget of around $70m.
 Division 19 (Society for Military Psychology) Student Research Grant Award.

© 2008 Association of Military Surgeons of the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area.  Provided by ProQuest LLC (Logical Link Control) See "LANs" under data link protocol.

LLC - Logical Link Control
. All Rights Reserved.
Copyright 2008 Military Medicine
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Author:Kathryn Kanzler USAF, BSC Appolonio and Randy PhD Fingerhut
Publication:Military Medicine
Date:Nov 1, 2008
Words:3475
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