Prevalence of Cardiovascular and Cancer Risk Factors Among Rheumatoid Arthritis Patients Prescribed JAKi and TNFi: A MarketScan by Merative Cross-Sectional Study

OBJECTIVE

To determine the prevalence of baseline risk factors for cardiovascular outcomes and cancer among commercially insured rheumatoid arthritis (RA) patients during their first dispensed treatment for either TNFi or JAKi.

METHODS

Patients with RA from 8/16/2019-3/31/2022 were identified in the Merative MarketScan® Commercial and Medicare databases. The first dispensed TNFi or JAKi was the index date and baseline risk factors were assessed among patients continuously eligible for 12-months pre-index. Patients were stratified into "elevated" risk categories: age≥65 years, smoking, and/or a history of Major Adverse Cardiovascular Event (MACE), Venous Thromboembolism (VTE), or cancer. The prevalence of modifiable risk factors was also reported: hypertension, hyperlipidemia, obesity, and diabetes. The crude prevalence and prevalence difference (PD) were reported.

RESULTS

A total of 12,673 patients [TNFi (n=7,748; 61%) and JAKi (n=4,925; 39%)] met inclusion criteria. The prevalence of "elevated" risk was the same for all TNFi (n=2,051; 26%) and JAKi (n=1,262; 26%) patients. Compared to patients at low risk, patients with an elevated risk also had a higher prevalence of at least one primary modifiable risk factor for both JAKi [79% vs. 58%; PD: 21% (95%CI: 18%-24%)] and TNFi [81% vs. 60%; PD: 21% (95%CI: 19%-23%)] patients.

CONCLUSION

In recent years, JAKi and TNFi were used in similar proportions to treat RA among commercially insured patients at elevated cardiovascular and cancer risk. Because uncontrolled disease, modifiable comorbidities, and treatment with JAKi are associated with these adverse events, future studies evaluating how practice patterns may be affected by the emergence of safety data will be of value.

Comparison of Racial and Ethnic Mortality Disparities among Post-9/11 Veterans with and without Traumatic Brain Injury to the Total U.S. Adult Population

INTRODUCTION

The extent of racial/ethnic disparities and whether they are attenuated in the Veteran population compared to the total US population is not well understood. We aimed to assess racial/ethnic mortality disparities from all-cause, cardiovascular (CVD) and cancer among post-9/11 military Veterans with and without exposure to TBI, compared to the total US population.

METHODS

This cohort study included 2,502,101 US military Veterans (18,932,083 person-years) who served after 09/11/2001 with 3 or more years of care in the Military Health System (MHS); or had 3 or more years of care in the MHS and 2 or more years of care in the Veterans Health Administration. Mortality follow-up occurred from 01/01/2002 to 12/31/2020. Mortality rate ratios (MRR) from negative binomial regression models were reported for racial/ethnic groups compared to White non-Hispanic Veterans for all-cause, CVD and cancer mortality. Veteran MRR were compared to the total US population.

RESULTS

Mortality rates for Black Non-Hispanic Veterans were higher for all-cause (MRR = 1.21;95%CI: 1.13-1.29; p < 0.001), CVD (MRR = 1.78;95%CI: 1.62-1.96; p < 0.001) and cancer (MRR = 1.17;95%CI: 1.10-1.25; p < 0.001) than in White Non-Hispanic Veterans. Among Veterans with TBI, only Black Non-Hispanics had higher mortality than White Non-Hispanics and only for CVD (MRR = 1.32;95%CI: 1.12-1.54; p < 0.001), while CVD mortality was higher among Veterans without TBI (MRR = 1.77;95%CI: 1.63-1.93;p < 0.001). MRR for Black Non-Hispanics in the total US population, were consistently higher than those in the Veteran population for all-cause (MRR = 1.52;95%CI: 1.46-1.58; p < 0.001), CVD (MRR = 2.03;95%CI: 1.95-2.13; p < 0.001) and cancer (MRR = 1.26;95%CI: 1.22-1.30; p < 0.001).

CONCLUSION

This Veteran cohort experienced less racial/ethnic disparity in mortality than the total US population, especially among Veterans with TBI.

Real-world effectiveness of risankizumab in patients with moderate-to-severe psoriasis using the CorEvitas Psoriasis Registry

BACKGROUND

Psoriasis, an inflammatory skin disease, is often treated with biologic therapeutics.

OBJECTIVE

To determine the real-world treatment effectiveness of risankizumab, an interleukin-23 inhibitor, in the treatment of moderate-to-severe plaque psoriasis.

METHODS

A retrospective, observational study was conducted using the CorEvitas Psoriasis Registry for eligible adults with a diagnosis of moderate-to-severe psoriasis and persistent use of risankizumab at 12 (±3) months after initiation. Skin clearance measures and patient-reported outcomes were analyzed for the entire study population and by prior biologic treatment.

RESULTS

Among 287 patients with persistent risankizumab use at 1 year, most achieved clear or clear/almost clear skin and reported significant reductions in Dermatology Life Quality Index scores, psoriasis symptoms (fatigue, skin pain, and overall itch), and work and activity impairment.

LIMITATIONS

The CorEvitas Psoriasis Registry is not necessarily representative of all adults with psoriasis in the United States and Canada and does not measure patient adherence.

CONCLUSION

Patients treated with risankizumab, regardless of prior treatment, achieved high levels of clear and clear/almost clear skin, Dermatology Life Quality Index scores of 0/1, and significant reductions in psoriasis symptoms (fatigue, skin pain, and overall itch) and work and activity impairment 1 year after initiation.

Clinical Outcomes in Patients with Rheumatoid Arthritis After Switching Between Interleukin-6-Receptor Inhibitors and Janus Kinase Inhibitors: Findings from an Observational Study

INTRODUCTION

This observational study evaluated response in patients with rheumatoid arthritis (RA) who switched from an interleukin-6 receptor inhibitor (IL-6Ri) to a Janus kinase inhibitor (JAKi) and vice versa.

METHODS

Adult patients with RA, who initiated IL-6Ri or JAKi (following discontinuation of JAKi or IL-6Ri, respectively) during/after December 2012 and had a 6-month follow-up visit were enrolled. Clinical outcomes were evaluated at baseline and the follow-up visit. Continuous outcomes included Clinical Disease Activity Index (CDAI), Health Assessment Questionnaire (HAQ), pain, fatigue, tender joint count, swollen joint count, Physician Global Assessment (MDGA), Patient Global Assessment (PtGA), and morning stiffness duration. Categorical outcomes included the proportion of patients achieving CDAI low disease activity (LDA), remission, and minimal clinically important differences (MCIDs) for HAQ, pain, fatigue, MDGA, and PtGA. Continuous outcomes were summarized as mean changes from baseline, and categorical outcomes as response rates. Differences in the outcome measures between groups were evaluated using linear and logistic regression models.

RESULTS

Between IL-6Ri (n = 100) and JAKi initiators (n = 129), no significant differences were noted for continuous outcomes. Within both groups, a significant proportion of patients achieved LDA, remission, and MCIDs for other measures, although the odds of achieving LDA were higher among IL-6Ri (vs. JAKi) initiators with moderate-to-severe disease (adjusted odds ratio: 3.30 [1.01, 10.78]).

CONCLUSIONS

Patients with RA can achieve improvement in response when switching between IL-6Ri and JAKi. Although both therapies affect the IL-6 pathway, there are distinct mechanisms of action, which likely contribute to their clinical improvement, when reciprocally switched as follow-on treatments.

Trends in Suicide Rates Among Post-9/11 US Military Veterans With and Without Traumatic Brain Injury From 2006-2020

This cohort study examines trends in suicide rates for veterans with and without traumatic brain injury compared with the US adult population.

United States Military Fatalities During Operation Inherent Resolve and Operation Freedom's Sentinel

BACKGROUND

Military operations provide a unified action and strategic approach to achieve national goals and objectives. Mortality reviews from military operations can guide injury prevention and casualty care efforts.

METHODS

A retrospective study was conducted on all U.S. military fatalities from Operation Inherent Resolve (OIR) in Iraq (2014-2021) and Operation Freedom's Sentinel (OFS) in Afghanistan (2015-2021). Data were obtained from autopsy reports and other existing records. Fatalities were evaluated for population characteristics; manner, cause, and location of death; and underlying atherosclerosis. Non-suicide trauma fatalities were also evaluated for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement.

RESULTS

Of 213 U.S. military fatalities (median age, 29 years; male, 93.0%; prehospital, 89.2%), 49.8% were from OIR, and 50.2% were from OFS. More OIR fatalities were Reserve and National Guard forces (OIR 22.6%; OFS 5.6%), conventional forces (OIR 82.1%; OFS 65.4%), and support personnel (OIR 61.3%; OFS 33.6%). More OIR fatalities also resulted from disease and non-battle injury (OIR 83.0%; OFS 28.0%). The leading cause of death was injury (OIR 81.1%; OFS 98.1%). Manner of death differed as more homicides (OIR 18.9%; OFS 72.9%) were seen in OFS, and more deaths from natural causes (OIR 18.9%; OFS 1.9%) and suicides (OIR 29.2%; OFS 6.5%) were seen in OIR. The prevalence of underlying atherosclerosis was 14.2% in OIR and 18.7% in OFS. Of 146 non-suicide trauma fatalities, most multiple/blunt force injury deaths (62.2%) occurred in OIR, and most blast injury deaths (77.8%) and gunshot wound deaths (76.6%) occurred in OFS. The leading mechanism of death was catastrophic tissue destruction (80.8%). Most fatalities had non-survivable injuries (80.8%) and non-preventable deaths (97.3%).

CONCLUSIONS

Comprehensive mortality reviews should routinely be conducted for all military operation deaths. Understanding death from both injury and disease can guide preemptive and responsive efforts to reduce death among military forces.

Meaningful Improvement and Worsening in Patients Who Do Not Achieve Low Disease Activity and Switch Therapy to a New Biologic or Targeted Disease-Modifying Antirheumatic Drug: Results From the CorEvitas RA Registry

OBJECTIVE

The aim of this study was to assess the change in disease activity associated with switching from 1 biologic/targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD) to another in patients with rheumatoid arthritis who did not achieve low disease activity (LDA) after 6 to 12 months of their initial treatment.

METHODS

This observational study included patients from the CorEvitas Rheumatoid Arthritis Registry, who initiated a b/tsDMARD at the index visit (prebaseline), had any clinical disease activity index (CDAI) improvement but did not achieve LDA/remission at the subsequent visit (baseline), and switched therapy at baseline or between baseline and follow-up visits. Regardless of the preswitch CDAI value, 2 thresholds of CDAI change were used to define meaningful improvement and worsening for all patients: ≥6 units and ≥12 units; no meaningful change was defined as any change between -6 to +6 units and -12 to +12 units, based on respective thresholds.

RESULTS

Of 1226 patients fulfilling the inclusion criteria, 93 (7.6%) switched therapy at baseline or between baseline and follow-up, after an inadequate response at the baseline visit. At follow-up, meaningful worsening occurred in 30.1% and 12.9% of switchers, whereas the remaining switchers achieved meaningful improvement (34.4% and 20.4%) or had no meaningful change (35.5% and 66.7%), based on the thresholds of ≥6 and ≥12 units, respectively.

CONCLUSIONS

Rheumatoid arthritis patients, who had not achieved LDA and switched b/tsDMARD, were more likely to have meaningful improvement or no change, rather than meaningful worsening. These data may help some patients overcome their hesitancy to switch therapy, potentially improving clinical outcomes.

Comparative effectiveness of TNF inhibitor vs IL-6 receptor inhibitor as monotherapy or combination therapy with methotrexate in biologic-experienced patients with rheumatoid arthritis: An analysis from the CorEvitas RA Registry

OBJECTIVE

Randomized controlled trials (RCTs) in biologic-naïve rheumatoid arthritis (RA) patients with high disease activity and inadequate response/intolerance to methotrexate have shown interleukin-6 (IL-6) receptor inhibitors (IL-6Ri) to be superior to tumor necrosis factor inhibitors (TNFi) as monotherapy. This observational study aimed to compare the effectiveness of TNFi vs IL-6Ri as mono- or combination therapy in biologic/targeted synthetic (b/ts) -experienced RA patients with moderate/high disease activity.

METHODS

Eligible b/ts-experienced patients from the CorEvitas RA registry were categorized as TNFi and IL-6Ri initiators, with subgroups initiating as mono- or combination therapy. Mixed-effects regression models evaluated the impact of treatment on Clinical Disease Activity Index (CDAI), patient-reported outcomes, and disproportionate pain (DP). Unadjusted and covariate-adjusted effects were reported.

RESULTS

Patients initiating IL-6Ri (n = 286) vs TNFi monotherapy (n = 737) were older, had a longer RA history and higher baseline CDAI, and were more likely to initiate as third-line therapy; IL-6Ri (n = 401) vs TNFi (n = 1315) combination therapy initiators had higher baseline CDAI and were more likely to initiate as third-line therapy. No significant differences were noted in the outcomes between TNFi and IL-6Ri initiators (as mono- or combination therapy).

CONCLUSION

This observational study showed no significant differences in outcomes among b/ts-experienced TNFi vs IL-6Ri initiators, as either mono- or combination therapy. These findings were in contrast with the previous RCTs in biologic-naïve patients and could be explained by the differences in the patient characteristics included in this study. Further studies are needed to help understand the reasons for this discrepancy in the real-world b/ts-experienced population.

Long-Term Health Care Costs for Service Members Injured in Iraq and Afghanistan

INTRODUCTION

Over the last two decades, the conflicts in Iraq and Afghanistan have cost the United States significantly in terms of lives lost, disabling injuries, and budgetary expenditures. This manuscript calculates the differences in costs between veterans with combat injuries vs veterans without combat injuries. This work could be used to project future costs in subsequent studies.

MATERIALS AND METHODS

In this retrospective cohort study, we randomly selected 7,984 combat-injured veterans between February 1, 2002, and June 14, 2016, from Veterans Affairs Health System administrative data. We matched injured veterans 1:1 to noninjured veterans on year of birth (± 1 year), sex, and first service branch. We observed patients for a maximum of 10 years. This research protocol was reviewed and approved by the David Grant USAF Medical Center institutional review board (IRB), the University of Utah IRB, and the Research Review Committee of the VA Salt Lake City Health Care System in accordance with all applicable Federal regulations.

RESULTS

Patients were primarily male (98.1% in both groups) and White (76.4% for injured patients, 72.3% for noninjured patients), with a mean (SD) age of 26.8 (6.6) years for the injured group and 27.7 (7.0) years for noninjured subjects. Average total costs for combat-injured service members were higher for each year studied. The difference was highest in the first year ($16,050 compared to $4,135 for noninjured). These differences remained significant after adjustment. Although this difference was greatest in the first year (marginal effect $12,386, 95% confidence interval $9,736-$15,036; P < 0.001), total costs continued to be elevated in years 2-10, with marginal effects ranging from $1,766 to $2,597 (P < 0.001 for all years). More severe injuries tended to increase costs in all categories.

CONCLUSIONS

Combat injured patients have significantly higher long-term health care costs compared to their noninjured counterparts. If this random sample is extrapolated to the 53,251 total of combat wounded service members, it implies a total excess cost of $1.6 billion to date after adjustment for covariates and a median follow-up time of 10 years. These costs are likely to increase as injured veterans age and develop additional chronic conditions.

Characteristics of Patients with Crohn's Disease With or Without Perianal Fistulae in the CorEvitas Inflammatory Bowel Disease Registry

BACKGROUND

There are limited real-world data characterizing perianal fistulae in patients with Crohn's disease (CD).

AIM

To describe characteristics of patients with CD with and without perianal fistulae.

METHODS

In this cross-sectional study, characteristics, treatment history, and health outcomes of patients with CD enrolled in the CorEvitas IBD Registry were described according to perianal fistula status (current/previous or none).

RESULTS

Eight hundred and seventy-eight patients were included. Compared with patients with no perianal fistulae (n = 723), patients with current/previous perianal fistulae (n = 155) had longer disease duration since CD diagnosis (mean 16.5 vs 12.3 years; difference 4.3 years; 95% CI, 2.0, 6.6) and fewer had Harvey-Bradshaw Index scores indicative of remission (0-4, 56.8% vs 69.6%; difference - 12.9%; 95% CI, - 21.6, - 4.2). More patients with current/previous fistulae reported a history of IBD-related emergency room visits (67.7% vs 56.1%; difference 11.6%; 95% CI, 3.4, 19.8), hospitalizations (76.1% vs 58.4%; difference 17.7%; 95% CI, 10.1, 25.4), and surgeries (59.4% vs 27.7%; difference 31.7%; 95% CI, 23.3, 40.1), and a history of treatment with tumor necrosis factor inhibitors (81.3% vs 60.7%; difference 20.6%; 95% CI, 13.5, 27.7), immunosuppressants (51.6% vs 31.2%; difference 20.4%; 95% CI, 11.9, 29.0), and antibiotics (50.3% vs 23.7%; difference 26.6%; 95% CI, 18.2, 35.1) than patients without perianal fistulae.

CONCLUSIONS

Patients with CD with current/previous perianal fistulae have more symptomatic experiences of disease, higher medication use, hospitalization rates, and emergency room visits than patients without perianal fistulae. Interventions to prevent/reduce risk of developing fistulae may help improve outcomes in CD.

Suicide attempts and mental health diagnoses in combat-injured service members: A retrospective cohort study

INTRODUCTION

Examinations of risk factors for suicide attempt in United States service members at high risk of mental health diagnoses, such as those with combat injuries, are essential to guiding prevention and intervention efforts.

METHODS

Retrospective cohort study of 8727 combat-injured patients matched to deployed, non-injured patients utilizing Department of Defense and Veterans Affairs administrative records.

RESULTS

Combat injury was positively associated with suicide attempt in the univariate model (HR = 1.75, 95% CI 1.5-2.1), but lost significance after adjustment for mental health diagnoses. Utilizing Latent Transition Analysis in the combat-injured group, we identified five mental/behavioral health profiles: (1) Few mental health diagnoses, (2) PTSD and depressive disorders, (3) Adjustment disorder, (4) Multiple mental health comorbidities, and (5) Multiple mental health comorbidities with alcohol use disorder (AUD). Multiple mental health comorbidities with AUD had the highest suicide attempt rate throughout the study and more than four times that of Multiple mental health comorbidities in the first study year (23.4 vs. 5.1 per 1000 person years, respectively).

CONCLUSION

Findings indicate that (1) combat injury's impact on suicide attempt is attenuated by mental health and (2) AUD with multiple mental health comorbidities confers heightened suicide attempt risk in combat-injured service members.

Nonfatal Injuries From Falls Among U.S. Military Personnel Deployed for Combat Operations, 2001-2018

INTRODUCTION

Falls are a leading mechanism of injury. Hospitalization and outpatient clinic visits due to fall injury are frequently reported among both deployed and non-deployed U.S. Military personnel. Falls have been previously identified as a leading injury second only to sports and exercise as a cause for non-battle air evacuations.

MATERIALS AND METHODS

This retrospective study analyzed the Department of Defense Trauma Registry fall injury data from September 11, 2001 to December 31, 2018. Deployed U.S. Military personnel with fall listed as one of their mechanisms of injury were included for analysis.

RESULTS

Of 31,791 injured U.S. Military personnel captured by the Department of Defense Trauma Registry within the study time frame, a total of 3,101 (9.8%) incurred injuries from falls. Those who had fall injuries were primarily 21 to 30 years old (55.4%), male (93.1%), Army (75.6%), and enlisted personnel (56.9%). The proportion of casualties sustaining injuries from falls generally increased through the years of the study. Most fall injuries were classified as non-battle injury (91.9%). Falls accounted for 24.2% of non-battle injury hospital admissions with a median hospital stay of 2 days. More non-battle-related falls were reported in Iraq-centric military operations (62.7%); whereas more battle-related falls were reported in Afghanistan-centric military operations (58.3%).

CONCLUSIONS

This study is the largest analysis of deployed U.S. Military personnel injured by falls to date. Highlighted are preventive strategies to mitigate fall injury, reduce workforce attrition, and preserve combat mission capability.

LEVEL OF EVIDENCE

Level III Epidemiologic.

Post-Combat-Injury Opioid Prescription and Alcohol Use Disorder in the Military

INTRODUCTION

Previous studies have identified combat exposure and combat traumatic experience as problematic drinking risk factors. Increasing evidence suggests that opioid use increases the risk of alcohol use disorder. This study investigated the association between opioid prescription use after injury and (1) alcohol use disorder and (2) severity of alcohol use disorder among deployed military servicemembers.

METHODS

Deidentified health records data of 9,029 deployed servicemembers from a retrospective cohort study were analyzed. Data were randomly selected from the Department of Defense Trauma Registry and included servicemembers with combat injuries during deployment in Iraq or Afghanistan (2002-2016). Pharmacy records and International Classification of Diseases, Ninth and Tenth Revision diagnosis codes were used. Three groups were identified (no opioid prescription use, nonpersistent opioid prescription use, and persistent opioid prescription use) and were compared on the basis of alcohol use disorder risk using Cox proportional hazard models. Data analyses were performed in 2021.

RESULTS

Of the 9,029 servicemembers with combat injury, 2,262 developed alcohol use disorder (1,322 developed severe alcohol use disorder). Compared with no opioid prescription use, increased alcohol use disorder risk was associated with persistent opioid prescription use, with a hazard ratio of 1.13 (95% CI=1.02, 1.26). After covariate adjustment, increased risk remained statistically significant (hazards ratio=1.24; 95% CI=1.10, 1.39). There was no significant difference in alcohol use disorder risk between no opioid prescription use and nonpersistent opioid prescription use. The risk of severe alcohol use disorder did not vary by opioid use among servicemembers with alcohol use disorder diagnosis.

CONCLUSIONS

The findings of the study suggest that the incidence of alcohol use disorder was higher among injured servicemembers with persistent opioid prescription use than among those without opioid use. If replicated in prospective studies, the findings highlight the need for clinicians to consider the current and history of alcohol use of patients in initiating treatment involving opioids.

Association of Traumatic Brain Injury With Mortality Among Military Veterans Serving After September 11, 2001

IMPORTANCE

Emerging evidence suggests that harmful exposures during military service, such as traumatic brain injury (TBI), may contribute to mental health, chronic disease, and mortality risks.

OBJECTIVE

To assess the mortality rates and estimate the number of all-cause and cause-specific excess deaths among veterans serving after the September 11, 2001, terrorist attacks (9/11) with and without exposure to TBI.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed administrative and mortality data from January 1, 2002, through December 31, 2018, for a cohort of US military veterans who served during the Global War on Terrorism after the 9/11 terrorist attacks. Veterans who served active duty after 9/11 with 3 or more years of care in the Military Health System or had 3 or more years of care in the Military Health System and 2 or more years of care in the Veterans Health Administration were included for analysis. The study used data from the Veterans Affairs/Department of Defense Identity Repository database, matching health records data from the Military Health Service Management Analysis and Reporting tool, the Veterans Health Administration Veterans Informatics and Computing Infrastructure, and the National Death Index. For comparison with the total US population, the study used the Centers for Disease Control and Prevention WONDER database. Data analysis was performed from June 16 to September 8, 2021.

EXPOSURE

Traumatic brain injury.

MAIN OUTCOMES AND MEASURES

Multivariable, negative binomial regression models were used to estimate adjusted all-cause and cause-specific mortality rates for the post-9/11 military veteran cohort, stratified by TBI severity level, and the total US population. Differences in mortality rates between post-9/11 military veterans and the total US population were used to estimate excess deaths from each cause of death.

RESULTS

Among 2 516 189 post-9/11 military veterans (2 167 736 [86.2%] male; and 45 324 [1.8%] American Indian/Alaska Native, 160 178 [6.4%], Asian/Pacific Islander, 259 737 [10.3%] Hispanic, 387 926 [15.4%] non-Hispanic Black, 1 619 834 [64.4%] non-Hispanic White, and 43 190 [1.7%] unknown), 17.5% had mild TBI and 3.0% had moderate to severe TBI; there were 30 564 deaths. Adjusted, age-specific mortality rates were higher for post-9/11 military veterans than for the total US population and increased with TBI severity. There were an estimated 3858 (95% CI, 1225-6490) excess deaths among all post-9/11 military veterans. Of these, an estimated 275 (95% CI, -1435 to 1985) were not exposed to TBI, 2285 (95% CI, 1637 to 2933) had mild TBI, and 1298 (95% CI, 1023 to 1572) had moderate to severe TBI. Estimated excess deaths were predominantly from suicides (4218; 95% CI, 3621 to 4816) and accidents (2631; 95% CI, 1929 to 3333). Veterans with moderate to severe TBI accounted for 33.6% of total excess deaths, 11-fold higher than would otherwise be expected.

CONCLUSIONS AND RELEVANCE

This military veteran cohort experienced more excess mortality compared with the total US population than all combat deaths from 9/11/01 through 9/11/21, concentrated among individuals exposed to TBI. These results suggest that a focus on what puts veterans at risk for accelerated aging and increased mortality is warranted.

Obstructive sleep apnea among survivors of combat-related traumatic injury: a retrospective cohort study

STUDY OBJECTIVES

Obstructive sleep apnea is prevalent among military members despite fewer traditional risk factors. We sought to determine the incidence and longitudinal predictors of obstructive sleep apnea in a large population of survivors of combat-related traumatic injury and a matched control group.

METHODS

Retrospective cohort study of military service members deployed to conflict zones from 2002-2016 with longitudinal follow-up in the Veterans Affairs and Military Health Systems. Two cohorts of service members were developed: (1) those who sustained combat injuries and (2) matched, uninjured participants.

RESULTS

17,570 service members were retrospectively analyzed for a median of 8.4 years. After adjustment, traumatic brain injury (hazard ratio [HR] 1.39, 95% confidence interval [CI] 1.20-1.60), posttraumatic stress disorder (HR 1.24, 95% CI 1.05-1.46), depression (HR 1.52, 95% CI 1.30-1.79), anxiety (HR 1.40, 95% CI 1.21-1.62), insomnia (HR 1.71, 95% CI 1.44-2.02), and obesity (HR 2.40, 95% CI 2.09-2.74) were associated with development of obstructive sleep apnea. While combat injury was associated with obstructive sleep apnea in the univariate analysis (HR 1.25, 95% CI 1.17-1.33), the direction of this association was reversed in the multivariable model (HR 0.74, 95% CI 0.65-0.84). In a nested analysis, this was determined to be due to the effect of mental health diagnoses.

CONCLUSIONS

The incidence of obstructive sleep apnea is higher among injured service members (29.1 per 1,000 person-years) compared to uninjured service members (23.9 per 1,000 person-years). This association appears to be driven by traumatic brain injury and the long-term mental health sequelae of injury.

CITATION

Haynes ZA, Stewart IJ, Poltavskiy EA, et al. Obstructive sleep apnea among survivors of combat-related traumatic injury: a retrospective cohort study. J Clin Sleep Med. 2022;18(1):171-179.

Trends in Mortality Among Pregnant and Recently Pregnant Women in the US, 2015-2019

This study uses National Center for Health Statistics data to assess mortality rates and their annual percentage changes for pregnancy-related and other causes among pregnant and recently pregnant women from 2015 to 2019, compared with cause-specific mortality rates in the total US female population of childbearing age.

Prospective Evaluation of Health Outcomes in a Nationwide Sample of Aeromedical Evacuation Casualties: Methods From a Pilot Study

INTRODUCTION

Although retrospective analyses have found that combat-injured service members are at high risk for mental and physical health outcomes following injury, relatively little is known about the long-term health of injured service members. To better understand long-term health outcomes after combat injury, a large, prospective observational cohort collecting both subjective and objective health data is needed. Given that a study of this nature would be costly and face many logistical challenges, we first conducted a pilot to assess the feasibility of a larger, definitive study.

MATERIALS AND METHODS

We ran a prospective, observational pilot study of 119 combat-injured service members and veterans who completed (1) at least one set of laboratory measurements (blood and urine sample collection and vitals measurements) at Clinical Laboratory Improvement Amendment of 1988 compliant laboratory locations and (2) at least one online assessment for the Wounded Warrior Recovery Project (WWRP), a 15-year examination of patient-reported outcomes among service members injured on combat deployment. We recruited the pilot study cohort from WWRP participants who met eligibility criteria and indicated interest in additional research opportunities. We collected laboratory values and patient-reported outcomes at baseline and again 1 year later, and obtained demographic, injury, and military service data from the Expeditionary Medical Encounter Database. The David Grant USAF Medical Center Institution Review Board (IRB) and the Naval Health Research Center IRB reviewed and approved the study protocols.

RESULTS

During recruitment for the pilot study, 624 study candidates were identified from WWRP. Of the 397 candidates we contacted about the pilot study, 179 (45.1%) enrolled and 119 (66.4%) of those who enrolled completed the first year of participation. The second study year was suspended due to the coronavirus disease-2019 pandemic. At the time of suspension, 72 (60.5%) participants completed follow-up laboratory appointments, and 111 (93.3%) completed second-year WWRP assessments. Participants in the pilot study were predominately male (95.0%) and non-Hispanic White (55.5%), with a median (interquartile range) age of 38.3 (34.1-45.4) years.

CONCLUSIONS

Collection of patient-reported outcomes and laboratory samples in a geographically dispersed cohort of combat-injured service members is possible. While significant challenges exist, our pilot study results indicate that a larger, longitudinal, cohort study is feasible.

United States military fatalities during Operation New Dawn

BACKGROUND

Military operations vary by scope, purpose, and intensity, each having unique forces and actions to execute a mission. Evaluation of military operation fatalities guides current and future casualty care.

METHODS

A retrospective study was conducted of all US military fatalities from Operation New Dawn in Iraq, 2010 to 2011. Data were obtained from autopsies and other records. Population characteristics, manner of death, cause of death, and location of death were analyzed. All fatalities were evaluated for concomitant evidence of underlying atherosclerosis. Nonsuicide trauma fatalities were also reviewed for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement.

RESULTS

Of 74 US military Operation New Dawn fatalities (median age, 26 years; male, 98.6%; conventional forces, 100%; prehospital, 82.4%) the leading cause of death was injury (86.5%). The manner of death was primarily homicide (55.4%), followed by suicide (17.6%), natural (13.5%), and accident (9.5%). Fatalities were divided near evenly between combatants (52.7%) and support personnel (47.3%), and between battle injury (51.4%) and disease and nonbattle injury (48.6%). Natural and suicide death was higher (p < 0.01, 0.02) among support personnel who were older (p = 0.05) with more reserve/national guard personnel (p = 0.01). Total population prevalence of underlying atherosclerosis was 18.9%, with more among support personnel (64.3%). Of 46 nonsuicide trauma fatalities, most died of blast injury (67.4%) followed by gunshot wound (26.1%) and multiple/blunt force injury (6.5%). The leading mechanism of death was catastrophic tissue destruction (82.6%). Most had nonsurvivable injuries (82.6%) and nonpreventable deaths (93.5%).

CONCLUSION

Operation New Dawn fatalities were exclusively conventional forces divided between combatants and support personnel, the former succumbing more to battle injury and the latter to disease and nonbattle injury including self-inflicted injury. For nonsuicide trauma fatalities, none died from a survivable injury, and 17.4% died from potentially survivable injuries. Opportunities for improvement included providing earlier blood products and surgery.

LEVEL OF EVIDENCE

Therapeutic, level V and epidemiological, level IV.

Traumatic injury and atrial fibrillation among deployed service members

INTRODUCTION

Atrial fibrillation and atrial flutter (AF/AFL), the most common atrial arrhythmias, have never been examined in combat casualties. In this study, we investigated the impact of traumatic injury on AF/AFL among service members with deployment history.

METHODS

Sampled from the Department of Defense (DoD) Trauma Registry (n = 10,000), each injured patient in this retrospective cohort study was matched with a non-injured service member drawn from the Veterans Affairs/DoD Identity Repository. The primary outcome was AF/AFL diagnosis identified using ICD-9-CM and ICD-10-CM codes. Competing risk regressions based on Fine and Gray subdistribution hazards model with were utilized to assess the association between injury and AF/AFL.

RESULTS

There were 130 reported AF/AFL cases, 90 of whom were injured and 40 were non-injured. The estimated cumulative incidence rates of AF/AFL for injured was higher compared to non-injured patients (hazards ratio [HR] = 2.04; 95% confidence interval [CI] = 1.44, 2.87). After adjustment demographics and tobacco use, the association did not appreciably decrease (HR = 1.90; 95% CI = 1.23, 2.93). Additional adjustment for obesity, hypertension, diabetes, and vascular disorders, the association between injury and AF/AFL was no longer statistically significant (HR = 1.51; 95% CI = 0.99, 2.52).

CONCLUSION

Higher AF/AFL incidence rate was observed among deployed service members with combat injury compared to servicemembers without injury. The association did not remain significant after adjustment for cardiovascular-related covariates. These findings highlight the need for combat casualty surveillance to further understand the AF/AFL risk within the military population and to elucidate the potential underlying pathophysiologic mechanisms.

Longitudinal mental health outcomes of combat-injured service members

BACKGROUND

The relationship between traumatic injury and subsequent mental health diagnoses is not well understood and may have significant implications for patient screening and clinical intervention. We sought to determine the adjusted association between traumatic injury and the subsequent development of post-traumatic stress disorder (PTSD), depression, and anxiety.

METHODS

Using Department of Defense and Veterans Affairs datasets between February 2002 and June 2016, we conducted a retrospective cohort study of 7,787 combat-injured United States service members matched 1:1 to combat-deployed, uninjured service members. The primary exposure was combat injury versus no combat injury. Outcomes were diagnoses of PTSD, depression, and anxiety, defined by International Classification of Diseases 9th and 10th Revision Clinical Modification codes.

RESULTS

Compared to noninjured service members, injured service members had higher observed incidence rates per 100 person-years for PTSD (17.1 vs. 5.8), depression (10.4 vs. 5.7), and anxiety (9.1 vs. 4.9). After adjustment, combat-injured patients were at increased risk of development of PTSD (HR 2.92, 95%CI 2.68-3.17), depression (HR 1.47, 95%CI 1.36-1.58), and anxiety (HR 1.34, 95%CI 1.24-1.45).

CONCLUSIONS

Traumatic injury is associated with subsequent development of PTSD, depression, and anxiety. These findings highlight the importance of increased screening, prevention, and intervention in patients with exposure to physical trauma.

Telomere Shortening and Accelerated Aging in US Military Veterans

A growing body of literature on military personnel and veterans’ health suggests that prior military service may be associated with exposures that increase the risk of cardiovascular disease (CVD), which may differ by race/ethnicity. This study examined the hypothesis that differential telomere shortening, a measure of cellular aging, by race/ethnicity may explain prior findings of differential CVD risk in racial/ethnic groups with military service. Data from the first two continuous waves of the National Health and Nutrition Examination Survey (NHANES), administered from 1999–2002 were analyzed. Mean telomere length in base pairs was analyzed with multivariable adjusted linear regression with complex sample design, stratified by sex. The unadjusted mean telomere length was 225.8 base shorter for individuals with prior military service. The mean telomere length for men was 47.2 (95% CI: −92.9, −1.5; p < 0.05) base pairs shorter for men with military service after adjustment for demographic, socioeconomic, and behavioral variables, but did not differ significantly in women with and without prior military service. The interaction between military service and race/ethnicity was not significant for men or women. The results suggest that military service may contribute to accelerated aging as a result of health damaging exposures, such as combat, injury, and environmental contaminants, though other unmeasured confounders could also potentially explain the results.

How the Implementation of a Battlefield Clinical Practice Guideline Affects Documentation Practice and Informs Future Research Initiatives: Spinal Injuries and Cervical Collars

INTRODUCTION

In 2010, the Joint Trauma System published a clinical practice guideline (CPG) for providing care to patients with suspicion of spinal cord injury. The CPG advocated for liberal use of cervical collars and adequate documentation of the practice. This performance improvement project examined C-spine CPG adherence in both the prehospital and military treatment facility (MTF) settings. Understanding challenges in CPG adherence facilitates evaluation of future CPGs and their success at implantation of the clinical guidance.

MATERIALS AND METHODS

The Department of Defense Trauma Registry was used to identify US Military casualties meeting the criteria for cervical collar placement between January 1, 2007 and December 31, 2018. Criteria for cervical collar placement were defined as any patient who experienced a mechanism of injury relating to an explosion, fall, or motor-vehicle-related injury. Any patients with an AIS severity score greater than 1 to the head or having any ICD injury codes related to either upper spinal cord or head injury were also considered for inclusion. Adherence of cervical collar placement was defined by documented ICD codes or prehospital documentation of cervical collar placement as captured in the registry.

RESULTS

A total of 14,837 patients were identified for possible cervical collar placement and 3,317 had verifiable documentation of having a C-collar placed. Documented C-collar placement was higher after the publication of the clinical practice guideline in 2010 (29% vs. 15%, p < 0.0001). CPG publication was associated with cervical collar application (odds ratio: 2.50, 95% CI: 2.29-2.72).

CONCLUSION

Application of cervical collars has increased significantly, since the initial publication of the spine injury CPG. Current gaps include valid and reliable identification of patients warranting specific clinical interventions and documentation of patient care. Currently, lack of documentation is reported as nonadherence, but it remains unknown if these missing clinical data accurately portray nonadherence or adherence with lack of documentation. Future research and resources would benefit and expand the results collected in this paper, and cement the importance of CPG publication and adherence.

Use of Combat Casualty Care Data to Assess the US Military Trauma System During the Afghanistan and Iraq Conflicts, 2001-2017

Importance

Although the Afghanistan and Iraq conflicts have the lowest US case-fatality rates in history, no comprehensive assessment of combat casualty care statistics, major interventions, or risk factors has been reported to date after 16 years of conflict.

Objectives

To analyze trends in overall combat casualty statistics, to assess aggregate measures of injury and interventions, and to simulate how mortality rates would have changed had the interventions not occurred.

Design, Setting, and Participants

Retrospective analysis of all available aggregate and weighted individual administrative data compiled from Department of Defense databases on all 56 763 US military casualties injured in battle in Afghanistan and Iraq from October 1, 2001, through December 31, 2017. Casualty outcomes were compared with period-specific ratios of the use of tourniquets, blood transfusions, and transport to a surgical facility within 60 minutes.

Main Outcomes and Measures

Main outcomes were casualty status (alive, killed in action [KIA], or died of wounds [DOW]) and the case-fatality rate (CFR). Regression, simulation, and decomposition analyses were used to assess associations between covariates, interventions, and individual casualty status; estimate casualty transitions (KIA to DOW, KIA to alive, and DOW to alive); and estimate the contribution of interventions to changes in CFR.

Results

In aggregate data for 56 763 casualties, CFR decreased in Afghanistan (20.0% to 8.6%) and Iraq (20.4% to 10.1%) from early stages to later stages of the conflicts. Survival for critically injured casualties (Injury Severity Score, 25-75 [critical]) increased from 2.2% to 39.9% in Afghanistan and from 8.9% to 32.9% in Iraq. Simulations using data from 23 699 individual casualties showed that without interventions assessed, CFR would likely have been higher in Afghanistan (15.6% estimated vs 8.6% observed) and Iraq (16.3% estimated vs 10.1% observed), equating to 3672 additional deaths (95% CI, 3209-4244 deaths), of which 1623 (44.2%) were associated with the interventions studied: 474 deaths (12.9%) (95% CI, 439-510) associated with the use of tourniquets, 873 (23.8%) (95% CI, 840-910) with blood transfusion, and 275 (7.5%) (95% CI, 259-292) with prehospital transport times.

Conclusions and Relevance

Our analysis suggests that increased use of tourniquets, blood transfusions, and more rapid prehospital transport were associated with 44.2% of total mortality reduction. More critically injured casualties reached surgical care, with increased survival, implying improvements in prehospital and hospital care.

Exploring Disparities in Awarding VA Service-Connected Disability for Post-Traumatic Stress Disorder for Active Duty Military Service Members from Recent Conflicts in Iraq and Afghanistan

INTRODUCTION

We explore disparities in awarding post-traumatic stress disorder (PTSD) service-connected disability benefits (SCDB) to veterans based on gender, race/ethnicity, and misconduct separation.

METHODS

Department of Defense data on service members who separated from October 1, 2001 to May 2017 were linked to Veterans Administration (VA) administrative data. Using adjusted logistic regression models, we determined the odds of receiving a PTSD SCDB conditional on a VA diagnosis of PTSD.

RESULTS

A total of 1,558,449 (79% of separating service members) had at least one encounter in VA during the study period (12% female, 4.5% misconduct separations). Females (OR 0.72) and Blacks (OR 0.93) were less likely to receive a PTSD award and were nearly equally likely to receive a PTSD diagnosis (OR 0.97, 1.01). Other racial/ethnic minorities were more likely to receive an award and diagnosis, as were those with misconduct separations (award OR 1.3, diagnosis 2.17).

CONCLUSIONS

Despite being diagnosed with PTSD at similar rates to their referent categories, females and Black veterans are less likely to receive PTSD disability awards. Other racial/ethnic minorities and those with misconduct separations were more likely to receive PTSD diagnoses and awards. Further study is merited to explore variation in awarding SCDB.

Predicting and Planning for Musculoskeletal Service-Connected Disabilities in VA Using Disability for Active Duty OEF/OIF Military Service Members

INTRODUCTION

Musculoskeletal (MSK) conditions are commonly seen among military service members (SM) and Veterans. We explored correlates of award of MSK-related service-connected disability benefits (SCDB) among SM seeking care in Veterans Affairs (VA) hospitals.

MATERIALS AND METHODS

Department of Defense data on SM who separated from October 1, 2001 to May 2017 were linked to VA administrative data. Using adjusted logistic regression models, we determined the odds of receiving MSK SCDB.

RESULTS

A total of 1,558,449 (79% of separating SM) had at least one encounter in VA during the study period (7.8% disability separations). Overall, 51% of this cohort had at least one MSK SCDB (88% among disability separations, 48% among normal). Those with disability separations (as compared to normal separations) were significantly more likely to receive MSK SCDB (odds ratio 2.37) as were females (compared to males, odds ratio 1.15).

CONCLUSIONS

Although active duty SM with disability separations were more likely to receive MSK-related service-connected disability ratings in the VA, those with normal separations also received such awards. Identifying those at highest risk for MSK-related disability could lead to improved surveillance and prevention strategies in the Department of Defense and VA health care systems to prevent further damage and disability.

Comparison of Military and Civilian Methods for Determining Potentially Preventable Deaths: A Systematic Review

Importance

Military and civilian trauma experts initiated a collaborative effort to develop an integrated learning trauma system to reduce preventable morbidity and mortality. Because the Department of Defense does not currently have recommended guidelines and standard operating procedures to perform military preventable death reviews in a consistent manner, these performance improvement processes must be developed.

Objectives

To compare military and civilian preventable death determination methods to understand the existing best practices for evaluating preventable death.

Evidence Review

This systematic review followed the PRISMA reporting guidelines. English-language articles were searched from inception to February 15, 2017, using the following databases: MEDLINE (Ovid), Evidence-Based Medicine Reviews (Ovid), PubMed, CINAHL, and Google Scholar. Articles were initially screened for eligibility and excluded based on predetermined criteria. Articles reviewing only prehospital deaths, only inhospital deaths, or both were eligible for inclusion. Information on study characteristics was independently abstracted by 2 investigators. Reported are methodological factors affecting the reliability of preventable death studies and the preventable death rate, defined as the number of potentially preventable deaths divided by the total number of deaths within a specific patient population.

Findings

Fifty studies (8 military and 42 civilian) met the inclusion criteria. In total, 1598 of 6500 military deaths reviewed and 3346 of 19 108 civilian deaths reviewed were classified as potentially preventable. Among military studies, the preventable death rate ranged from 3.1% to 51.4%. Among civilian studies, the preventable death rate ranged from 2.5% to 85.3%. The high level of methodological heterogeneity regarding factors, such as preventable death definitions, review process, and determination criteria, hinders a meaningful quantitative comparison of preventable death rates.

Conclusions and Relevance

The reliability of military and civilian preventable death studies is hindered by inconsistent definitions, incompatible criteria, and the overall heterogeneity in study methods. The complexity, inconsistency, and unpredictability of combat require unique considerations to perform a methodologically sound combat-related preventable death review. As the Department of Defense begins the process of developing recommended guidelines and standard operating procedures for performing military preventable death reviews, consideration must be given to the factors known to increase the risk of bias and poor reliability.

Correction to: Description of trauma among French service members in the Department of Defense Trauma Registry: understanding the nature of trauma and the care provided

After publication of this article [1], it was brought to our attention that the Fig. 2 is incorrect. The correct Fig. 2 is as below.

US Military Service and Racial/Ethnic Differences in Cardiovascular Disease: An Analysis of the 2011-2016 Behavioral Risk Factor Surveillance System

Objective

To determine: 1) rates of cardiovascular disease (CVD) among individuals with and without prior US military service; and 2) variation in CVD outcomes by race/ethnicity.

Methods

We performed a cross-sectional study of the 2011-2016 Behavioral Risk Factor Surveillance System during 2018-2019. Groups with (n=369,844) and without (n=2,491,784) prior service were compared overall, and by race/ethnicity. CVD odds were compared using logistic regression. Rate-difference decomposition was used to estimate relative contributions of covariates to differences in CVD prevalence.

Results

CVD was associated with military service (OR=1.34; P<.001). Among non-Hispanic Blacks, prior service was associated with a lower odds of CVD (OR=.69; P<.001), fully attenuating the net difference in CVD between individuals with and without prior service. Non-Hispanic Whites who served had the highest odds of CVD, while Hispanics with prior service had the same odds of CVD as non-Hispanic Whites without prior service. After age, smoking and body mass index status were the largest contributors to CVD differences by race/ethnicity.

Conclusions

Results from this study support an association between prior military service and CVD and highlight differences in this association by race/ethnicity. Knowledge of modifiable health behaviors that contribute to differences in CVD outcomes could be used to guide prevention efforts.

Recommended medical and non-medical factors to assess military preventable deaths: subject matter experts provide valuable insights

Introduction

Historically, there has been variability in the methods for determining preventable death within the US Department of Defense. Differences in methodologies partially explain variable preventable death rates ranging from 3% to 51%. The lack of standard review process likely misses opportunities for improvement in combat casualty care. This project identified recommended medical and non-medical factors necessary to (1) establish a comprehensive preventable death review process and (2) identify opportunities for improvement throughout the entire continuum of care.

Methods

This qualitative study used a modified rapid assessment process that includes the following steps: (1) identification and recruitment of US government subject matter experts (SMEs); (2) multiple cycles of data collection via key informant interviews and focus groups; (3) consolidation of information collected in these interviews; and (4) iterative analysis of data collected from interviews into common themes. Common themes identified from SME feedback were grouped into the following subject areas: (1) prehospital, (2) in-hospital and (3) forensic pathology.

Results

Medical recommendations for military preventable death reviews included the development, training, documentation, collection, analysis and reporting of the implementation of the Tactical Combat Casualty Care Guidelines, Joint Trauma System Clinical Practice Guidelines and National Association of Medical Examiners autopsy standards. Non-medical recommendations included training, improved documentation, data collection and analysis of non-medical factors needed to understand how these factors impact optimal medical care.

Conclusions

In the operational environment, medical care must be considered in the context of non-medical factors. For a comprehensive preventable death review process to be sustainable in the military health system, the process must be based on an appropriate conceptual framework implemented consistently across all military services.

Rhabdomyolysis among Critically Ill Combat Casualties: Long-Term Outcomes

BACKGROUND

Although rhabdomyolysis has been associated with acute kidney injury and mortality in the short term, the long-term consequences of an episode of rhabdomyolysis remain unknown. We sought to identify the long-term outcomes of rhabdomyolysis, including mortality, renal function, and incidence of hypertension (HTN), among service members initially admitted to the intensive care unit after sustaining a combat injury in Iraq or Afghanistan between February 1, 2002 and February 1, 2011.

METHODS

Information on age, sex, injury severity score, mechanism of injury, serum creatinine, burn injury, presenting mean arterial pressure, and creatine kinase were retrospectively collected and analyzed for 2,208 patients. Standard descriptive tests were used to compare characteristics of patients with and without rhabdomyolysis. Competing risk Cox proportional hazards models were performed to assess the associated risk of rhabdomyolysis with both HTN and poor renal function.

RESULTS

While rhabdomyolysis was associated with HTN on univariate analysis (hazard ratio [HR] 1.30, 95% CI 1.03-1.64; p = 0.029), this difference did not persist on multivariable analysis (HR 1.27, 95% CI 0.99-1.62; p = 0.058). The median estimated glomerular filtration rate (eGFR) was 119 (interquartile range [IQR] 103-128) among those with rhabdomyolysis, compared with 108 (IQR 94-121) in the group without rhabdomyolysis (p < 0.001).

CONCLUSION

After adjustment, patients with rhabdomyolysis were not at an increased risk of HTN compared to patients without rhabdomyolysis. eGFR was paradoxically higher in patients with rhabdomyolysis. There was no association found between rhabdomyolysis and mortality.

Presenting hypertension, burn injury, and mortality in combat casualties

INTRODUCTION

The effect of presenting hypertension is poorly studied in combat casualties. We hypothesized that elevated mean arterial pressure (MAP) on presentation to combat hospitals would be associated with poor outcomes.

METHODS

Data was obtained from the Department of Defense Trauma Registry and the Armed Forces Medical Examiner System. Variables analyzed included presenting vital signs to Role II-III military theater hospital, demographic variables, injury severity score (ISS), location and mechanism of injury, presence of traumatic brain injury (TBI), acute kidney injury (AKI), and mortality. Patients were stratified by decile of MAP and logistic regression analysis was employed to adjust for confounders.

RESULTS

A total of 4072 subjects injured from February 2002 to February 2011 were identified. Compared to patients in the middle deciles of presenting MAP, patients in the highest and lowest MAP deciles were the only groups that demonstrated a higher mortality on univariate analysis (OR 2.06, 95% CI 1.16-2.31 and OR 2.86, 95% CI 1.76-4.67, respectively), and this relationship persisted after adjustment for ISS, HR, temperature, presence of burn injury, TBI, and AKI. Burn injury was associated with mortality in the full multivariate analysis. However, further analysis limited to patients without burn injury did not demonstrate an association between high MAP and mortality (OR 0.84, 95% CI 0.36-1.99; p=0.70). Conversely, when limited to patients with burn injury, high MAP was associated with mortality (OR 3.78, 95% CI 1.74-8.20; p=0.001).

CONCLUSION

The relationship between mortality and presenting MAP appears to be U-shaped, demonstrating increased mortality in the lowest and highest deciles. However, mortality in the highest MAP decile appears to be limited to casualties with associated burn injury, even after adjustment for TBI, AKI, and ISS, which takes into account the severity of the burn injury. Physicians should recognize that burn patients presenting with an elevated MAP are at an increased risk for poor outcomes.

LEVEL OF EVIDENCE

III.

U.S. military service and the prevalence of metabolic syndrome: Findings from a cross-sectional analysis of the Cooper Center Longitudinal Study, 1979-2013

U.S. military service confers both health benefits and risks potentially associated with a clustering of cardiovascular risk factors called metabolic syndrome. However, the association between prior military service and metabolic syndrome has not sufficiently been examined. The purpose of the study was to compare the prevalence of metabolic syndrome by prior military service status. Among 42,370 men (887 with prior military service) examined from 1979 to 2013 at the Cooper Clinic (Dallas, TX), we used a cross-sectional study design to examine the association between military service and metabolic syndrome. First, an unadjusted log binomial regression model was performed by regressing the prevalence of metabolic syndrome on prior service. This was followed by performing Kleinbaum's modeling strategy for assessing confounding. The same methodology was used to explore the association between individual metabolic syndrome risk factors and prior service. Prior military service was not significantly associated with the prevalence of metabolic syndrome (PR=0.98, 0.89-1.07). None of the variables explored were identified as confounders. Participants with prior military service had lower prevalence of both elevated levels of triglycerides (PR=0.89, 0.80-0.99) and low levels of high-density lipoprotein-cholesterol (PR=0.78, 0.70-0.88). They had a higher prevalence of elevated resting systolic blood pressure (PR=1.23, 1.12-1.35). However, none of these associations were significant after adjusting for identified confounders: age; cardiorespiratory fitness; and exam year. Study findings indicate that military service was not independently associated with the prevalence of metabolic syndrome or its components. Future research is warranted longitudinally assessing the impact of military service on long-term outcomes.

The association between physical fitness and academic achievement in Texas state house legislative districts: an ecologic study

BACKGROUND

The association of physical fitness with cognitive function in children and adolescents is unclear. The purpose of this ecological study was to describe the association between academic achievement, body mass index (BMI), and cardiovascular fitness (CVF) in a large sample of elementary, middle, and high school students in Texas.

METHODS

FITNESSGRAM(®) results for 2,550,144 students were matched with standardized composite academic test (TAKS) results from 2008 to 2009. Analyses were conducted on the percent of students meeting TAKS standards by BMI and CVF quintiles. Analyses of variance with Tukey adjustment examined differences between the most favorable 5th quintile (referent) and all other quintiles.

RESULTS

The prevalence of students meeting the TAKS standard was significantly higher in the highest fitness category for BMI and CVF compared to all other categories, regardless of sex or grade category (p < .05). Linear modeling suggested a 5% increase in the prevalence of students meeting healthy BMI and CVF standards would result in a 2.25% and 0.65% increase in the prevalence of students meeting the TAKS standard (both p < .05).

CONCLUSION

Findings suggest a healthy BMI and CVF are associated with higher academic achievement, and the need for additional research examining the role of potential confounders and/or effect modifiers longitudinally.