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Background: Musculoskeletal injuries are prevalent among military trainees and certain occupations. Fitness and body mass index (BMI) have been associated with musculoskeletal conditions, including stress fractures. Hypothesis: The incidence of, and excess health care utilization for, stress fracture and non-stress fracture overuse musculoskeletal injuries during the first 6 months of service is higher among unfit female recruits. Those who exceeded body fat limits are at a greater risk of incident stress fractures, injuries, or health care utilization compared with weight-qualified recruits. Study Design: Cohort study; Level of evidence, 3. Methods: All applicants to the United States Army were required to take a preaccession fitness test during the study period (February 2005-September 2006). The test included a 5-minute step test scored as pass or fail. BMI was recorded at application. There were 2 distinct comparisons made in this study: (1) between weight-qualified physically fit and unfit women and (2) between weight-qualified physically fit women and those who exceeded body fat limits. We compared the incidence of, and excess health care utilization for, musculoskeletal injuries, including stress fractures and physical therapy visits, during the first 183 days of military service. Results: Among the weight-qualified women, unfit participants had a higher non-stress fracture injury incidence and related excess health care utilization rate compared with fit women, with rate ratios of 1.32 (95% CI, 1.14-1.53) and 1.18 (95% CI, 1.10-1.27), respectively. Among fit women, compared with the weight-qualified participants, those exceeding body fat limits had higher rate ratios for non-stress fracture injury incidence and related excess health care utilization of 1.27 (95% CI, 1.07-1.50) and 1.20 (95% CI, 1.11-1.31), respectively. Weight-qualified women who were unfit had a higher incidence of stress fractures and related excess health care utilization compared with fit women, with rate ratios of 1.62 (95% CI, 1.19-2.21) and 1.22 (95% CI, 1.10-1.36), respectively. Among fit women exceeding body fat limits, the stress fracture incidence and related excess health care utilization rate ratios were 0.79 (95% CI, 0.49-1.28) and 1.44 (95% CI, 1.20-1.72), respectively, compared with those who were weight qualified. Conclusion: The results indicate a significantly increased risk of musculoskeletal injuries, including stress fractures, among unfit recruits and an increased risk of non-stress fracture musculoskeletal injuries among recruits who exceeded body fat limits. Once injured, female recruits who were weight qualified but unfit and those who were fit but exceeded body fat limits had increased health care utilization. These findings may have implications for military accession and training policies as downsizing of military services will make it more important than ever to optimize the health and performance of individual service members. [ABSTRACT FROM AUTHOR]

Deals with a study which examined the characteristics of United States military personnel at entry who developed type 2 diabetes. Research design and methods; Results; Conclusions.

Abstract: The prevalence of antibodies to measles, mumps, and rubella in US military recruits is of importance to public health leaders. We performed ELISA testing using a commercially available product on samples from 537 recruits obtained in 1998, of which 437 were positive (81%). We then performed a validation study in a subsample of the population using plaque reduction neutralization (PRN) to assess misclassification error. This resulted in a corrected estimate of the prevalence of immunity to measles of 96% (95% CI: 92–100%). The military vaccinates a percentage of recruits who are likely to be immune if more sensitive testing, such as PRN, was used. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]

Background: During the conflicts in Iraq and Afghanistan, more than 52,000 U.S. military members were wounded in action. The battlefield mortality rate was lower than in past conflicts, however, those surviving often had complex soft tissue and bone injuries requiring multiple surgeries. This report describes the rates, types, and risks of infections complicating the care of combat casualties.Patients and Methods: Infection and microbiology data obtained from the Trauma Infectious Disease Outcomes Study (TIDOS), a prospective observational study of infections complicating deployment-related injuries, were used to determine the proportion of infection, types, and associated organisms. Injury and surgical information were collected from the Department of Defense Trauma Registry. Multivariable Cox proportional hazards and logistic regression models were used to evaluate potential factors associated with infection.Results: From 2009-2012, 1,807 combat casualties were evacuated to U.S. TIDOS-participating hospitals. Among the 1,807 patients, the proportion of overall infections from time of injury through initial U.S. hospitalization was 34% with half being skin, soft tissue, or bone infections. Infected wounds most commonly grew Enterococcus faecium, Pseudomonas aeruginosa, Acinetobacter spp. or Escherichia coli. In the multivariable model, amputation, blood transfusions, intensive care unit admission, injury severity scores, mechanical ventilation, and mechanism of injury were associated with risk of infection.Conclusions: One-third of combat casualties from Iraq and Afghanistan develop infections during their initial hospitalization. Amputations, blood transfusions, and overall injury severity are associated with risk of infection, whereas more easily modifiable factors such as early operative intervention or antibiotic administration are not. [ABSTRACT FROM AUTHOR]

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 refined 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 ~40%, among female subjects and ~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. [ABSTRACT FROM AUTHOR]

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 asthmalic 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 duly for recruits with mild asthma. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: To determine risk factors for osteomyelitis in US military personnel with combat-related, extremity long bone (humerus, radius, and ulna) open fractures., Design: Retrospective observational case-control study., Setting: US military regional hospital in Germany and tertiary care military hospitals in the United States (2003-2009)., Patients/participants: Sixty-four patients with open upper extremity fractures who met diagnostic osteomyelitis criteria (medical record review verification) were classified as cases. Ninety-six patients with open upper extremity fractures who did not meet osteomyelitis diagnostic criteria were included as controls., Intervention: Not applicable., Main Outcome Measurements: Multivariable odds ratios (ORs; 95% confidence interval [CI])., Results: Among patients with surgical implants, osteomyelitis cases had longer time to definitive orthopaedic surgery compared with controls (median: 26 vs. 11 days; P < 0.001); however, there was no significant difference with timing of radiographic union. Being injured between 2003 and 2006, use of antibiotic beads, Gustilo-Anderson [GA] fracture classification (highest with GA-IIIb: [OR: 22.20; CI: 3.60-136.95]), and Orthopaedic Trauma Association Open Fracture Classification skin variable (highest with extensive degloving [OR: 15.61; CI: 3.25-74.86]) were independently associated with osteomyelitis risk. Initial stabilization occurring outside of the combat zone was associated with reduced risk of osteomyelitis., Conclusions: Open upper extremity fractures with severe soft-tissue damage have the highest risk of developing osteomyelitis. The associations with injuries sustained 2003-2006 and location of initial stabilization are likely from evolving trauma system recommendations and practice patterns during the timeframe., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

We present extremity wound microbiology data from 250 combat casualties (2009-2012). Confirmed extremity wound infections (EWIs) were based on clinical and laboratory findings. Suspected EWIs had isolation of organisms from wound cultures with associated signs/symptoms not meeting clinical diagnostic criteria. Colonized wounds had organisms isolated without any infection suspicion. A total of 335 confirmed EWIs (131 monomicrobial and 204 polymicrobial) were assessed. Gram-negative bacteria were predominant (57% and 86% of monomicrobial and polymicrobial infections, respectively). In polymicrobial infections, 61% grew only bacteria, while 30% isolated bacteria and mold. Multidrug resistance was observed in 32% of isolates from first monomicrobial EWIs ±3 days of diagnosis, while it was 44% of isolates from polymicrobial EWIs. Approximately 96% and 52% of the suspected and colonized wounds, respectively, shared ≥1 organism in common with the confirmed EWI on the same patient. Understanding of combat-related EWIs can lead to improvements in combat casualty care., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To identify the risk factors for osteomyelitis development in US military personnel with combat-related, open femur fractures?, Design: Retrospective observational case-control study., Setting: US military regional hospital in Germany and tertiary care hospitals in United States (2003-2009)., Patients/participants: One hundred three patients with open femur fractures who met diagnostic osteomyelitis criteria (medical record review verification) were classified as cases. Sixty-four patients with open femur fractures who did not meet osteomyelitis diagnostic criteria were included as controls., Main Outcome Measurements: The main outcome measurements were multivariable odds ratios (ORs) and 95% confidence interval (CI)., Results: Among patients with surgical implants, osteomyelitis cases had significantly longer time to definitive orthopaedic surgery compared with controls (median: 21 vs. 13 days). Independent predictors for osteomyelitis risk were Gustilo-Anderson classification (transfemoral amputation OR: 19.3; CI: 3.0-123.0) and Orthopaedic Trauma Association Open Fracture Classification for muscle loss (OR: 5.7; CI: 1.3-25.1) and dead muscle (OR: 32.9; CI: 5.4-199.1). Being injured between 2003 and 2006, antibiotic bead use, and foreign body plus implant(s) at fracture site were also risk factors., Conclusions: Patients with open femur fractures resulting in significant muscle damage have the highest osteomyelitis risk. Foreign body contamination was only significant when an implant was present. Increased risk with antibiotic bead use is likely a surrogate for clinical suspicion of contamination with complex wounds. The timeframe association is likely due to changing trauma system patterns around 2006-2007 (eg, increased negative pressure wound therapy, reduced high-pressure irrigation, decreased crystalloid use, and delayed definitive internal fixations)., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: We assessed osteomyelitis risk factors in US military personnel with combat-related open tibia fractures (2003-2009)., Methods: Patients with open tibia fractures who met the diagnostic criteria of osteomyelitis were identified as cases using Military Health System data and verified through medical record review. Controls were patients with open tibia fractures who did not meet osteomyelitis criteria. The Gustilo-Andersen fracture classification scheme was modified to include transtibial amputations (TTAs) as the most severe level. Logistic regression multivariable odds ratios [ORs; 95% confidence intervals (CI)] were assessed., Results: A total of 130 tibia osteomyelitis cases and 85 controls were identified. Excluding patients with TTAs, osteomyelitis cases had significantly longer time to radiographic union compared with controls (median: 210 vs. 165 days). Blast injuries, antibiotic bead utilization, ≥ Gustilo-Andersen-IIIb fractures [highest risk with TTA (OR: 15.10; CI: 3.22-71.07)], and foreign body at the fracture site were significantly associated with developing osteomyelitis. In a separate model, the Orthopaedic Trauma Association Open Fracture Classification muscle variable was significant with increasing risk from muscle loss (OR: 5.62; CI: 2.21-14.25) to dead muscle (OR: 8.46; CI: 3.31-21.64). When TTAs were excluded, significant risk factors were similar and included sustaining an injury between 2003 and 2006., Conclusions: Patients with severe blast trauma resulting in significant muscle damage are at the highest risk for osteomyelitis. The period association coincides with a time frame when several trauma system practice changes were initiated (eg, increased negative pressure wound therapy, decreased high-pressure irrigation, and reduced crystalloid use)., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Opportunistic and other infections have declined since the introduction of highly active antiretroviral therapy (HAART) in developed countries but few studies have addressed the impact of HAART in HIV-infected children from developing countries. This study examines the prevalence and incidence of opportunistic and other infections in Latin America during the HAART era. Vertically HIV-infected children enrolled in a cohort study between 2002 and 2007 were followed for the occurrence of 29 targeted infections. Cross-sectional and longitudinal analyses were performed to calculate the prevalence of infections before enrollment and the incidence rates of opportunistic and other infections after enrollment. Comparisons were made with data from a U.S. cohort (PACTG 219C). Of the 731 vertically HIV-infected children 568 (78%) had at least one opportunistic or other infection prior to enrollment. The most prevalent infections were bacterial pneumonia, oral candidiasis, varicella, tuberculosis, herpes zoster, and Pneumocystis jiroveci pneumonia. After enrollment, the overall incidence was 23.5 per 100 person-years; the most common infections (per 100 person-years) were bacterial pneumonia (7.8), varicella (3.0), dermatophyte infections (2.9), herpes simplex (2.5), and herpes zoster (1.8). All of these incidence rates were higher than those reported in PACTG 219C. The types and relative distribution of infections among HIV-infected children in Latin America in this study are similar to those seen in the United States but the incidence rates are higher. Further research is necessary to determine the reasons for these higher rates.

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: 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.

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.

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.