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Introduction: We examined antibiotic management of combat-related extremity wound infections (CEWI) among wounded U.S. military personnel (2009-2012)., Methods: Patients were included if they sustained blast injuries, resulting in ≥1 open extremity wound, were admitted to participating U.S. hospitals, developed a CEWI (osteomyelitis or deep soft-tissue infections) within 30 days post-injury, and received ≥3 days of relevant antibiotic (s) for treatment., Results: Among 267 patients, 133 (50%) had only a CEWI, while 134 (50%) had a CEWI plus concomitant non-extremity infection. In the pre-diagnosis period (4-10 days prior to CEWI diagnosis), 95 (36%) patients started a new antibiotic with 28% of patients receiving ≥2 antibiotics. During CEWI diagnosis week (±3 days of diagnosis), 209 (78%) patients started a new antibiotic (71% with ≥2 antibiotics). In the week following diagnosis (4-10 days after CEWI diagnosis), 121 (45%) patients started a new antibiotic with 39% receiving ≥2 antibiotics. Restricting to ±7 days of CEWI diagnosis, patients commonly received two (35%) or three (27%) antibiotics with frequent combinations involving carbapenem, vancomycin, and fluoroquinolones., Conclusions: Substantial variation in antibiotic prescribing patterns related to CEWIs warrants development of combat-related clinical practice guidelines beyond infection prevention, to include strategies to reduce the use of unnecessary antibiotics and improve stewardship., (Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2020.)

We examined risk factors for combat-related extremity wound infections (CEWI) among U.S. military patients injured in Iraq and Afghanistan (2009-2012). Patients with ≥1 combat-related, open extremity wound admitted to a participating U.S. hospital (≤7 days postinjury) were retrospectively assessed. The population was classified based upon most severe injury (amputation, open fracture without amputation, or open soft-tissue injury defined as non-fracture/non-amputation wounds). Among 1271 eligible patients, 395 (31%) patients had ≥1 amputation, 457 (36%) had open fractures, and 419 (33%) had open soft-tissue wounds as their most severe injury, respectively. Among patients with traumatic amputations, 100 (47%) developed a CEWI compared to 66 (14%) and 12 (3%) patients with open fractures and open soft-tissue wounds, respectively. In a Cox proportional hazard analysis restricted to CEWIs ≤30 days postinjury among the traumatic amputation and open fracture groups, sustaining an amputation (hazard ratio: 1.79; 95% confidence interval: 1.25-2.56), blood transfusion ≤24 hours postinjury, improvised explosive device blast, first documented shock index ≥0.80, and >4 injury sites were independently associated with CEWI risk. The presence of a non-extremity infection at least 4 days prior to a CEWI diagnosis was associated with lower CEWI risk, suggesting impact of recent exposure to directed antimicrobial therapy. Further assessment of early clinical management will help to elucidate risk factor contribution. The wound classification system provides a comprehensive approach in assessment of injury and clinical factors for the risk and outcomes of an extremity wound infection., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019.)

Background: Many resource-limited countries rely on clinical and immunological monitoring without routine virological monitoring for human immunodeficiency virus (HIV)-infected children receiving highly active antiretroviral therapy (HAART). We assessed whether HIV load had independent predictive value in the presence of immunological and clinical data for the occurrence of new World Health Organization (WHO) stage 3 or 4 events (hereafter, WHO events) among HIV-infected children receiving HAART in Latin America., Methods: The NISDI (Eunice Kennedy Shriver National Institute of Child Health and Human Development International Site Development Initiative) Pediatric Protocol is an observational cohort study designed to describe HIV-related outcomes among infected children. Eligibility criteria for this analysis included perinatal infection, age <15 years, and continuous HAART for ≥6 months. Cox proportional hazards modeling was used to assess time to new WHO events as a function of immunological status, viral load, hemoglobin level, and potential confounding variables; laboratory tests repeated during the study were treated as time-varying predictors., Results: The mean duration of follow-up was 2.5 years; new WHO events occurred in 92 (15.8%) of 584 children. In proportional hazards modeling, most recent viral load >5000 copies/mL was associated with a nearly doubled risk of developing a WHO event (adjusted hazard ratio, 1.81; 95% confidence interval, 1.05-3.11; P = .033), even after adjustment for immunological status defined on the basis of CD4 T lymphocyte value, hemoglobin level, age, and body mass index., Conclusions: Routine virological monitoring using the WHO virological failure threshold of 5000 copies/mL adds independent predictive value to immunological and clinical assessments for identification of children receiving HAART who are at risk for significant HIV-related illness. To provide optimal care, periodic virological monitoring should be considered for all settings that provide HAART to children.

Background: The Assessment of Recruit Motivation and Strength (ARMS) study was designed to pilot-test the use of a physical fitness screening tool for Army applicants before basic training., Methods: The ARMS test consists of two components, namely, a 5-minute step test and push-ups. Attrition among 7,612 recruits who underwent preaccession ARMS testing and began service between May 2004 and December 2005 was studied., Results: ARMS test performance was found to be significantly related to risk of attrition within 180 days; the hazard ratios for failing relative to passing the ARMS test were 2.27 (95% confidence interval, 1.70-3.04) among female subjects and 1.36 (95% confidence interval, 1.13-1.64) among male subjects. The attributable risk of attrition associated with failing the ARMS test was approximately 40% among female subjects and approximately 30% among male subjects., Discussion: The ARMS study is the first prospective study conducted in the U.S. Army to assess physical fitness before accession. Physical fitness and motivation to serve were shown to correlate with attrition during initial entry training.

Objective: Rising U.S. asthma prevalence will be reflected in military applicants. We studied retaining mild asthmatics on active duty., Methods: A cohort study at Great Lakes Naval Training Center from 2000 to 2002 compared recruits diagnosed during basic training with mild asthma to matched comparison recruits on outpatient visits, hospitalizations, and discharge through August 2003., Results: A total of 136 asthmatic and 404 control subjects were enrolled. Overall attrition was greater among the asthma cohort (p < 0.01), largely during training. Asthmatics used more health care than controls during training (0.1 vs. 0.004 per person-month). No asthma-related hospitalizations or deaths occurred during the study., Conclusions: Although attrition during recruit training was higher in mild asthmatics, nearly 40% of recruits were retained on active duty without significant risk of hospitalization or excessive outpatient treatment after recruit training. These findings argue for consideration of a trial on active duty for recruits with mild asthma.

Background: Hearing deficiency is the condition for which accession medical waivers are most commonly granted. The retention of individuals entering service with a waiver for hearing deficiency has not been previously studied., Methods: Military retention among new enlistees with a medical waiver for hearing deficiency was compared with that among a matched comparison group of fully qualified enlistees. Comparisons according to branch of service over the first 3 years of service were performed with the Kaplan-Meier product-limit method and proportional-hazards model., Results: Army subjects had significantly lower retention rates than did their fully qualified counterparts. In the adjusted model, Army and Navy enlistees with a waiver for hearing deficiency had a significantly lower likelihood of retention than did their matched counterparts., Discussion: The increased likelihood of medical attrition in enlistees with a waiver for hearing loss provides no evidence to make the hearing accession standard more lenient and validates a selective hearing loss waiver policy.

Background: Recurrent headaches are disqualifying for military service if they are of sufficient severity or frequency to interfere with normal function in the past 3 years. The occupational impact of waiving this standard is evaluated., Methods: A retrospective cohort study of enlistees from January 1, 1995, through December 31, 2000, was performed. Enlistees with a waiver for recurrent headaches were compared with fully qualified enlistees (matched 3:1) for retention in the military, headache-related discharges, and hospitalizations., Results: The 174 individuals with waivers for a history of recurrent headaches were retained on active duty at the same rate as the 522 matched control subjects (log rank test, p = 0.91). Medical record review of waivers documented no debilitating headaches within 1 year before the medical examination., Conclusions: These results validate the current headache waiver criteria from the perspective of retention and suggest a more lenient medical accession standard. Future studies should evaluate the morbidity and occupational impact of headaches in the U.S. military.

Background: Military service requires physical fitness, including vision within set standards. Premature attrition inflicts a considerable manpower and fiscal burden upon the military., Methods: We conducted a retrospective cohort survival analysis of newly enlisted military personnel who entered active duty with a medical waiver for myopia between January 1, 1999, and December 31, 2001. Premature attrition rates, both medical and overall, were compared with those for a matched, fully qualified, comparison group., Results: New enlistees with a waiver for myopia had the same probability of remaining on active duty through the first 2 years of service as did fully qualified peers. Enlistees with a waiver for myopia also had a low probability of an early medical discharge for myopia., Conclusion: The results of this study tend to validate the current branch-specific myopia waiver processes. They also provide evidence that current myopia accession criteria may be too restrictive and in need of policy review.

Objective: This study examines the extent to which discharges from Initial Entry Training can be adequately characterized by the current policy of a single descriptive category., Methods: Service records of each trainee discharged from Fort Leonard Wood in 2003 were examined. Discharged trainee's counseling and outpatient clinic visit records were reviewed for evidence of multiple reasons for discharge., Results: Evidence of medical involvement was found by record review in 13% of administrative discharges. Among discharges classified as being for medical or physical conditions that did not exist before service, 17% had clear evidence of preexisting chronic conditions., Conclusion: The policy of allowing only one categorization code to describe reasons for an Initial Entry Training discharge frequently resulted in incomplete characterization of factors leading to discharge. Pre-existing medical and mental health conditions were found in a much greater percentage of discharges than indicated by a simple review of discharge codes.

A retrospective cohort study was conducted to evaluate the Department of Defense practice of allowing some individuals with a history of attention-deficit/hyperactivity disorder (ADHD) to enter military service (waiving for ADHD). Enlisted recruits who entered active duty with a waiver for academic problems related to ADHD were compared with control subjects who did not reveal health problems before entry, in terms of retention, promotion, and mental health-related outcomes. A total of 539 recruits with a history of ADHD were retained at the same rate as 1,617 control subjects, with no differences in promotion rates, comorbid diagnoses, or mental health-related discharges. On the basis of these findings, the Department of Defense medical accession standards have been changed to allow applicants who reveal a history of ADHD but did not require medication to finish high school or to hold a job for at least 1 year the opportunity to enter active duty without going through the current waiver process.

Background: Several investigators have found that Chlamydia pneumoniae and cytomegalovirus infections may be risk factors for coronary heart disease. However, the data remain controversial. To address this hypothesis, data and specimens were collected from a well-established prospective cohort of active-duty personnel from the US military., Methods: A nested case-control study was conducted with 300 case patients and 300 matched control subjects. Case patients were men (age, 30-50 years) with a medically documented, first-time hospitalization for acute myocardial infarction (MI) and from whom a serum specimen had been drawn >or=1 year before the time of the acute MI. Population-based control subjects were chosen from the same cohort and were individually matched by age, race, and time of specimen collection. Evidence of past infections with C. pneumoniae and cytomegalovirus were measured by microimmunofluorescence assay and enzyme-linked immunosorbent assay, respectively., Results: Significant risk was associated with high titer (>or=1 : 64) to C. pneumoniae immunoglobulin A (IgA) (adjusted relative risk [RR(adj)], 1.67; 95% confidence interval [CI], 1.04-2.70). This increased risk was greatest when specimens were collected 1-5 years before the event (RR(adj), 2.11; 95% CI, 1.06-4.21). High titer (>or=1 : 256) to C. pneumoniae immunoglobulin G (IgG) was also associated with an elevated risk (RR(adj), 1.74; 95% CI, 0.90-3.34) after full adjustment for cardiovascular risk factors, whereas no independent risk for acute MI was associated with cytomegalovirus IgG seropositivity., Conclusions: This study demonstrates a significant association between high titers to C. pneumoniae IgG and IgA and acute MI in a cohort of young men and suggests that recent or chronic active infections could be associated with an increased risk for MI.

Among the 1.4 million active duty U.S. military service members, 6% receive outpatient treatment for a mental disorder each year. Over 25% of these service members leave military service within 6 months, a rate that is more than two times higher than the rate following treatment for any other illness category. There is clearly a need to define psychiatric research priorities and an unprecedented opportunity to enhance the field of psychiatric research in general using the well-characterized military population. The first priority is to better define the burden of mental disorders in terms of incidence, prevalence, severity, risk factors, and health care use. The impact of mental disorders on occupational functioning, particularly among new recruits, needs to be better characterized. Suicide research should include efforts to validate mortality data, define the normal level of rate variability, and establish surveillance for clusters. The highly structured occupational environment of the military lends itself to studies of preventive interventions designed to reduce disability or occupational attrition resulting from mental/behavioral problems.