The discriminative power of STOP-Bang as a screening tool for suspected obstructive sleep apnea in clinically referred patients: considering gender differences.

PURPOSE: Obstructive sleep apnea (OSA) is the most commonly seen clinical sleep disorder. STOP-Bang, a widely used screening tool, yields a composite score based on eight dichotomized items including male gender. This study was designed to validate STOP-Bang among clinically referred patients and tested alternative scoring designs on tool performance, with a focus on gender differences in OSA. METHOD: STOP-Bang was administered to 403 female and 532 male subjects, followed by comprehensive sleep evaluation that included measurement of apnea-hypopnea indexes. Gender differences in STOP-Bang scores, OSA diagnosis, and severities were explored, and gender-specific alternative score cutoffs evaluated. Optimal operating points (OOP) were tested for female body mass index (BMI) and male neck circumference to inform STOP-Bang threshold refinement. Receiver operating characteristic curves were used to compare conventional and modified STOP-Bang. RESULTS: STOP-Bang performance by gender showed extremely low specificity in males at the recommended cutoff of ≥3. Better utility was presented at a cutoff of 4 or 5 among clinically referred patients irrespective of gender differences. Screening performance was improved by modifying BMI and/or neck circumference thresholds using gender-triaged OOP estimation. Three gender-based model revisions outperformed conventional STOP-Bang. CONCLUSION: Our study suggests that gender-specific consideration needs to be incorporated into the application of STOP-Bang in a clinically referred patient population with a higher risk of OSA. Alternative scoring systems may improve predictive performance of STOP-Bang.

Development of a systematic protocol to identify victims of non-accidental trauma.

PURPOSE: Each year, nearly 1 million children in the USA are victims of non-accidental trauma (NAT). Missed diagnosis or poor case management often leads to repeat/escalation injury. Victims of recurrent NAT are at higher risk for severe morbidity and mortality resulting from abuse. The objective of this review is to describe the evolution and implementation of this tool and evaluate our institutional response to NAT prior to implementation. METHODS: A systematic guideline for the evaluation of pediatric patients in which NAT is suspected or confirmed was developed and implemented at a level II pediatric trauma hospital. To understand the state of our institution prior to implementation of the guideline, a review of 117 confirmed NAT cases at our hospital over the prior 4 years was conducted. RESULTS: In the absence of a systematic management guideline, important and relevant social and family history red flags were often missing in the initial evaluation. Patients with perineal bruising experienced significantly higher mortality than patients without perineal bruising (27.3 vs. 5.7%; p = 0.03) and were significantly more likely to require surgery (45.5 vs. 14.2%; p = 0.02). CONCLUSION: Development and implementation of a standardized tool for the differentiation and diagnosis of NAT and creation of a structured electronic medical record note should improve the description and documentation of child abuse cases in a community hospital setting. A retrospective analysis demonstrated that in the absence of such a tool, management of NAT may be inconsistent or incomplete. Perineal injury is an especially ominous red flag finding.

Fructose intolerance/malabsorption and recurrent abdominal pain in children.

OBJECTIVES: The purpose of the present study was to ascertain whether pediatric patients with chronic abdominal pain had concurrent fructose intolerance as determined by a standardized dose breath hydrogen test (BHT), and whether symptoms would improve with a low-fructose diet. METHODS: The fructose BHT test was administered to patients evaluated in clinic with unexplained chronic abdominal pain alone or associated with constipation, gas or bloating, and/or diarrhea. The patients were given a standard dose of 1 g/kg fructose to maximum of 25 g. Hydrogen and methane were measured at 8 time points. The test was presumed positive if breath hydrogen exceeded 20 ppm above baseline. If positive, patients were given a dietitian-prescribed low-fructose diet. RESULTS: A total of 222 patients were part of the study. Ages ranged from 2 to 19 years with a mean of 10.5. BHT for fructose was performed in all of the patients and it was positive for fructose intolerance in 121 of 222 patients (54.5%). A total of 101 of 222 (45.5%) patients had negative BHT for fructose intolerance. All BHT-positive patients had a nutrition consult with a registered dietitian and were placed on a low-fructose diet. Using a standard pain scale for children, 93 of 121 patients (76.9%) reported resolution of symptoms on a low-fructose diet (P < 0.0001). Furthermore, 55 of 101 patients (54.4%) with negative BHT for fructose reported resolution of symptoms without a low-fructose diet (P = 0.37). CONCLUSIONS: Fructose intolerance/malabsorption is common in children with recurrent/functional abdominal pain and a low-fructose diet is an effective treatment.

Application of latent semantic analysis for open-ended responses in a large, epidemiologic study.

BACKGROUND: The Millennium Cohort Study is a longitudinal cohort study designed in the late 1990s to evaluate how military service may affect long-term health. The purpose of this investigation was to examine characteristics of Millennium Cohort Study participants who responded to the open-ended question, and to identify and investigate the most commonly reported areas of concern. METHODS: Participants who responded during the 2001-2003 and 2004-2006 questionnaire cycles were included in this study (n = 108,129). To perform these analyses, Latent Semantic Analysis (LSA) was applied to a broad open-ended question asking the participant if there were any additional health concerns. Multivariable logistic regression was performed to examine the adjusted odds of responding to the open-text field, and cluster analysis was executed to understand the major areas of concern for participants providing open-ended responses. RESULTS: Participants who provided information in the open-ended text field (n = 27,916), had significantly lower self-reported general health compared with those who did not provide information in the open-ended text field. The bulk of responses concerned a finite number of topics, most notably illness/injury, exposure, and exercise. CONCLUSION: These findings suggest generalized topic areas, as well as identify subgroups who are more likely to provide additional information in their response that may add insight into future epidemiologic and military research.

Effectiveness of an external ankle brace in reducing parachuting-related ankle injuries.

Outside-the-boot parachute ankle braces (PABs) worn during US Army paratrooper training have been shown to reduce the risk of severe ankle injuries. In spite of evidence to the contrary, anecdotal reports continue to suggest increases in risk of other types of injury, and the cost of obtaining and periodically replacing the PAB has been used to justify its discontinued use. The authors identified inpatient and outpatient treatment for injuries during US Army paratrooper training. Those undergoing training during two periods when PAB use was mandated had 40% lower risks of ankle injury (brace I, RR=0.60 (95% CI 0.47 to 0.75); brace II, RR=0.62 (95% CI 0.49 to 0.78)), with no difference in risks of other types of injury. There were no differences in risk of ankle injury during periods when brace use was not mandated. The PAB is safe, effective and cost effective.

Health impact of US military service in a large population-based military cohort: findings of the Millennium Cohort Study, 2001-2008.

BACKGROUND: Combat-intense, lengthy, and multiple deployments in Iraq and Afghanistan have characterized the new millennium. The US military's all-volunteer force has never been better trained and technologically equipped to engage enemy combatants in multiple theaters of operations. Nonetheless, concerns over potential lasting effects of deployment on long-term health continue to mount and are yet to be elucidated. This report outlines how findings from the first 7 years of the Millennium Cohort Study have helped to address health concerns related to military service including deployments. METHODS: The Millennium Cohort Study was designed in the late 1990s to address veteran and public concerns for the first time using prospectively collected health and behavioral data. RESULTS: Over 150,000 active-duty, reserve, and National Guard personnel from all service branches have enrolled, and more than 70% of the first 2 enrollment panels submitted at least 1 follow-up survey. Approximately half of the Cohort has deployed in support of operations in Iraq and Afghanistan. CONCLUSION: The Millennium Cohort Study is providing prospective data that will guide public health policymakers for years to come by exploring associations between military exposures and important health outcomes. Strategic studies aim to identify, reduce, and prevent adverse health outcomes that may be associated with military service, including those related to deployment.

Assessing nonresponse bias at follow-up in a large prospective cohort of relatively young and mobile military service members.

BACKGROUND: Nonresponse bias in a longitudinal study could affect the magnitude and direction of measures of association. We identified sociodemographic, behavioral, military, and health-related predictors of response to the first follow-up questionnaire in a large military cohort and assessed the extent to which nonresponse biased measures of association. METHODS: Data are from the baseline and first follow-up survey of the Millennium Cohort Study. Seventy-six thousand, seven hundred and seventy-five eligible individuals completed the baseline survey and were presumed alive at the time of follow-up; of these, 54,960 (71.6%) completed the first follow-up survey. Logistic regression models were used to calculate inverse probability weights using propensity scores. RESULTS: Characteristics associated with a greater probability of response included female gender, older age, higher education level, officer rank, active-duty status, and a self-reported history of military exposures. Ever smokers, those with a history of chronic alcohol consumption or a major depressive disorder, and those separated from the military at follow-up had a lower probability of response. Nonresponse to the follow-up questionnaire did not result in appreciable bias; bias was greatest in subgroups with small numbers. CONCLUSIONS: These findings suggest that prospective analyses from this cohort are not substantially biased by non-response at the first follow-up assessment.

Early mortality experience in a large military cohort and a comparison of mortality data sources.

BACKGROUND: Complete and accurate ascertainment of mortality is critically important in any longitudinal study. Tracking of mortality is particularly essential among US military members because of unique occupational exposures (e.g., worldwide deployments as well as combat experiences). Our study objectives were to describe the early mortality experience of Panel 1 of the Millennium Cohort, consisting of participants in a 21-year prospective study of US military service members, and to assess data sources used to ascertain mortality. METHODS: A population-based random sample (n = 256,400) of all US military service members on service rosters as of October 1, 2000, was selected for study recruitment. Among this original sample, 214,388 had valid mailing addresses, were not in the pilot study, and comprised the group referred to in this study as the invited sample. Panel 1 participants were enrolled from 2001 to 2003, represented all armed service branches, and included active-duty, Reserve, and National Guard members. Crude death rates, as well as age- and sex-adjusted overall and age-adjusted, category-specific death rates were calculated and compared for participants (n = 77,047) and non-participants (n = 137,341) based on data from the Social Security Administration Death Master File, Department of Veterans Affairs (VA) files, and the Department of Defense Medical Mortality Registry, 2001-2006. Numbers of deaths identified by these three data sources, as well as the National Death Index, were compared for 2001-2004. RESULTS: There were 341 deaths among the participants for a crude death rate of 80.7 per 100,000 person-years (95% confidence interval [CI]: 72.2,89.3) compared to 820 deaths and a crude death rate of 113.2 per 100,000 person-years (95% CI: 105.4, 120.9) for non-participants. Age-adjusted, category-specific death rates highlighted consistently higher rates among study non-participants. Although there were advantages and disadvantages for each data source, the VA mortality files identified the largest number of deaths (97%). CONCLUSIONS: The difference in crude and adjusted death rates between Panel 1 participants and non-participants may reflect healthier segments of the military having the opportunity and choosing to participate. In our study population, mortality information was best captured using multiple data sources.

Demographic, physical, and mental health factors associated with deployment of U.S. Army soldiers to the Persian Gulf.

A total of 675,626 active duty Army soldiers who were known to be at risk for deployment to the Persian Gulf were followed from 1980 through the Persian Gulf War. Hospitalization histories for the entire cohort and Health Risk Appraisal surveys for a subset of 374 soldiers were used to evaluate prewar distress, health, and behaviors. Deployers were less likely to have had any prewar hospitalizations or hospitalization for a condition commonly reported among Gulf War veterans or to report experiences of depression/suicidal ideation. Deployers reported greater satisfaction with life and relationships but displayed greater tendencies toward risk taking, such as drunk driving, speeding, and failure to wear safety belts. Deployed veterans were more likely to receive hazardous duty pay and to be hospitalized for an injury than nondeployed Gulf War-era veterans. If distress is a predictor of postwar morbidity, it is likely attributable to experiences occurring during or after the war and not related to prewar exposures or health status. Postwar excess injury risk may be explained in part by a propensity for greater risk taking, which was evident before and persisted throughout the war.

Feasibility of connecting regional research programs to national multisite trials emanating from the CTSA Trial Innovation Network.

A collaborative research model was developed and tested to enable regional healthcare systems to join multisite clinical trials emanating from the Clinical and Translational Science Award (CTSA) Trial Innovation Network (TIN) by the Institute of Translational Health Sciences at the University of Washington and the Northwest Participant and Clinical Interactions (NW PCI) Network. The NW PCI is a collaborative group of regional research programs located at medical centers, healthcare systems, and universities across Washington, Wyoming, Alaska, Montana, and Idaho. This article describes the purpose, development, barriers, and initial experience with feasibility assessment for TIN-supported studies in the NW PCI. The tools and processes of the NW PCI Network were adapted to enable network sites to assess studies for clinical relevance and feasibility. Seven of seventeen TIN-supported studies were reviewed for consideration; three of which resulted in successful completion of study documentation for site selection by NW PCI sites. The NW PCI/TIN model can be adapted by other CTSAs to increase involvement of regional research programs in national multisite clinical research studies. Barriers to expanding TIN-supported trials to regional networks include short timelines for study document submissions, insufficient site reimbursement rates, and non-feasible study designs.

Disordered eating and weight changes after deployment: longitudinal assessment of a large US military cohort.

The effect of military deployments to combat environments on disordered eating and weight changes is unknown. Using longitudinal data from Millennium Cohort Study participants who completed baseline (2001-2003) and follow-up (2004-2006) questionnaires (n=48,378), the authors investigated new-onset disordered eating and weight changes in a large military cohort. Multivariable logistic regression was used to compare these outcomes among those who deployed and reported combat exposures, those who deployed but did not report combat exposures, and those who did not deploy in support of the wars in Iraq and Afghanistan. Deployment was not significantly associated with new-onset disordered eating in women or men, after adjustment for baseline demographic, military, and behavioral characteristics. However, in subgroup comparison analyses of deployers, deployed women reporting combat exposures were 1.78 times more likely to report new-onset disordered eating (95% confidence interval: 1.02, 3.11) and 2.35 times more likely to lose 10% or more of their body weight compared with women who deployed but did not report combat exposures (95% confidence interval: 1.17, 4.70). Despite no significant overall association between deployment and disordered eating and weight changes, deployed women reporting combat exposures represent a subgroup at higher risk for developing eating problems and weight loss.

Identifying modifiable causes of fall-related injury: an analysis of U.S. Army safety data.

Details on fall-related circumstances, a leading cause of occupational injury, are scarce. This study aimed to identify modifiable causes of falls using data from safety reports. Coded and narrative data on injured persons, event locations, and circumstances associated with falls sustained by U.S. Army personnel were obtained from safety reports dated September 1994-September 2002. Descriptive statistics are presented for injury outcomes and risk factors, with a focus on falls from elevation. On average, 59 fall-related injuries/100,000 person-years were reported. Higher rates occurred among whites, single persons, and 20-24 year-olds. Falls from elevation resulted in more severe outcomes, longer hospitalizations, and more lost work time compared to falls from the same level. Most falls from elevation occurred in training (32%) and housing (18%) areas. Leading causes included routine activities (e.g., walking, entering/exiting vehicles) (35%), physical training (12%), and sports (12%). Interventions to prevent falls from elevation in this population should focus on reducing risks from routine activities, specifically in training and housing areas. Safety reports provided details necessary for prioritizing and planning fall prevention efforts that are not available from other sources.

Delay in Treatment After Cancer Diagnosis in Adolescents and Young Adults: Does Facility Transfer Matter?

Background: Timeliness is one of the fundamental yet understudied quality metrics of cancer care. Little is known about cancer treatment delay among adolescent and young adult (AYA) cancer patients. This study assessed cancer treatment delay, with a specific focus on facility transfer and diagnosis/treatment interval. Methods: Based on MultiCare Health System's (MHS's) institutional cancer registry data of AYA patients diagnosed during 2006-2015, this study analyzed patient demographics, insurance, clinical characteristics, and time of diagnosis and treatment initiation. Chi-squared tests, cumulative hazard estimates, and Cox proportional regression were used for univariable analysis. Multivariate regression models were used to test the association between care transfer and days of interval or prolonged delay, controlling for baseline parameters. Results: Of 840 analytic AYA cases identified, 457 (54.5%) were both diagnosed and treated within MHS. A total of 45.5% were either diagnosed or treated elsewhere. Mean and median intervals for treatment initiation were 27.03 (95% CI = 21.94-33.14) and 8.00 days (95% CI = 5.00-11.00), respectively, with significant differences between patients with and without facility transfer. Transfer was significantly correlated with longer length of diagnosis-to-treatment interval. Treatment delay, ≥1 week, was associated with transfer, female sex, older age, no surgery involvement, and more treatment modalities. Treatment delay, ≥4 weeks, was associated with transfer, female sex, no insurance, and no surgery involvement. Conclusion: In a community care setting, the diagnosis-to-treatment interval is significantly longer for transferred AYA cancer patients than for patients without a transfer. Future studies are warranted to explore the prognostic implications and the reasons for delays within specific cancer types.

Challenges of self-reported medical conditions and electronic medical records among members of a large military cohort.

BACKGROUND: Self-reported medical history data are frequently used in epidemiological studies. Self-reported diagnoses may differ from medical record diagnoses due to poor patient-clinician communication, self-diagnosis in the absence of a satisfactory explanation for symptoms, or the "health literacy" of the patient. METHODS: The US Department of Defense military health system offers a unique opportunity to evaluate electronic medical records with near complete ascertainment while on active duty. This study compared 38 self-reported medical conditions to electronic medical record data in a large population-based US military cohort. The objective of this study was to better understand challenges and strengths in self-reporting of medical conditions. RESULTS: Using positive and negative agreement statistics for less-prevalent conditions, near-perfect negative agreement and moderate positive agreement were found for the 38 diagnoses. CONCLUSION: This report highlights the challenges of using self-reported medical data and electronic medical records data, but illustrates that agreement between the two data sources increases with increased surveillance period of medical records. Self-reported medical data may be sufficient for ruling out history of a particular condition whereas prevalence studies may be best served by using an objective measure of medical conditions found in electronic healthcare records. Defining medical conditions from multiple sources in large, long-term prospective cohorts will reinforce the value of the study, particularly during the initial years when prevalence for many conditions may still be low.

Alcohol use and alcohol-related problems before and after military combat deployment.

CONTEXT: High rates of alcohol misuse after deployment have been reported among personnel returning from past conflicts, yet investigations of alcohol misuse after return from the current wars in Iraq and Afghanistan are lacking. OBJECTIVES: To determine whether deployment with combat exposures was associated with new-onset or continued alcohol consumption, binge drinking, and alcohol-related problems. DESIGN, SETTING, AND PARTICIPANTS: Data were from Millennium Cohort Study participants who completed both a baseline (July 2001 to June 2003; n=77,047) and follow-up (June 2004 to February 2006; n=55,021) questionnaire (follow-up response rate = 71.4%). After we applied exclusion criteria, our analyses included 48,481 participants (active duty, n = 26,613; Reserve or National Guard, n = 21,868). Of these, 5510 deployed with combat exposures, 5661 deployed without combat exposures, and 37 310 did not deploy. MAIN OUTCOME MEASURES: New-onset and continued heavy weekly drinking, binge drinking, and alcohol-related problems at follow-up. RESULTS: Baseline prevalence of heavy weekly drinking, binge drinking, and alcohol-related problems among Reserve or National Guard personnel who deployed with combat exposures was 9.0%, 53.6%, and 15.2%, respectively; follow-up prevalence was 12.5%, 53.0%, and 11.9%, respectively; and new-onset rates were 8.8%, 25.6%, and 7.1%, respectively. Among active-duty personnel, new-onset rates were 6.0%, 26.6%, and 4.8%, respectively. Reserve and National Guard personnel who deployed and reported combat exposures were significantly more likely to experience new-onset heavy weekly drinking (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.36-1.96), binge drinking (OR, 1.46; 95% CI, 1.24-1.71), and alcohol-related problems (OR, 1.63; 95% CI, 1.33-2.01) compared with nondeployed personnel. The youngest members of the cohort were at highest risk for all alcohol-related outcomes. CONCLUSION: Reserve and National Guard personnel and younger service members who deploy with reported combat exposures are at increased risk of new-onset heavy weekly drinking, binge drinking, and alcohol-related problems.

Parachute ankle brace and extrinsic injury risk factors during parachuting.

INTRODUCTION: This study examined the injury prevention effectiveness of the parachute ankle brace (PAB) while controlling for known extrinsic risk factors. METHODS: Injuries among airborne students who wore the PAB during parachute descents were compared with injuries among those who did not. Injury risk factors from administrative records included wind speed, combat loads, and time of day (day/night). Injuries were collected in the drop zone. RESULTS: A total of 596 injuries occurred in 102,784 parachute descents. In univariate analysis, students not wearing the PAB (Controls) were 2.00 [95% confidence interval (95% CI) = 1.32-3.02] times more likely to experience an ankle sprain, 1.83 (95% CI = 1.04-3.24) times more likely to experience an ankle fracture, and 1.92 (95% CI = 1.38-2.67) times more likely to experience an ankle injury of any type. PAB wearers and Controls had a similar incidence of lower body injuries exclusive of the ankle [risk ratio (Control/PAB) = 0.92, 95% CI = 0.65-1.30]. After accounting for known extrinsic injury risk factors, Controls were 1.90 (95% CI = 1.24-2.90) times more likely than PAB wearers to experience an ankle sprain, 1.47 (95% CI = 0.82- 2.63) times more likely to experience an ankle fracture, and 1.75 (95% CI = 1.25-2.48) times more likely to experience an ankle injury of any type. The incidence of parachute entanglements that persisted until the jumpers reached the ground were similar among PAB wearers and Controls IRR (Control/PAB) = 1.17, 95% CI = 0.61-2.29]. CONCLUSION: After controlling for known injury risk factors, the PAB protected against ankle injuries, and especially ankle sprains, while not influencing parachute entanglements or lower body injuries exclusive of the ankle.

Injury risk factors in parachuting and acceptability of the parachute ankle brace.

INTRODUCTION: This investigation examined risk factors for injuries during military parachute training and solicited attitudes and opinions regarding a parachute ankle brace (PAB) that has been shown to protect against ankle injuries. METHODS: Male Army airborne students (N = 1677) completed a questionnaire after they had successfully executed 4 of the 5 jumps necessary for qualification as a military paratrooper. The questionnaire asked about injuries during parachute descents, demographics, lifestyle characteristics, physical characteristics, physical fitness, airborne recycling (i.e., repeating airborne training because of failure to qualify on a previous attempt), PAB wear, problems with aircraft exits, and injuries in the year before airborne school. A final section of the questionnaire solicited open-ended comments about the PAB. RESULTS: Increased risk of a parachute-related injury occurred among students who had longer time in service, were older, taller, heavier, performed fewer push-ups, ran slower, were airborne recycles, did not wear the PAB, had an aircraft exit problem, and/or reported an injury in the year prior to jump school. Among students who wore the brace, most negative comments about the PAB had to do with design, comfort, and difficulties during parachute landing falls. CONCLUSIONS: This study supported some previously identified injury risk factors (older age, greater body weight, and not using a PAB) and identified a number of new risk factors. To address PAB design and comfort issues, a strap is being added over the dorsum of the foot to better hold the PAB in place.

Millennium Cohort: enrollment begins a 21-year contribution to understanding the impact of military service.

OBJECTIVE: In response to health concerns of military members about deployment and other service-related exposures, the Department of Defense (DoD) initiated the largest prospective study ever undertaken in the U.S. military. STUDY DESIGN AND SETTING: The Millennium Cohort uses a phased enrollment strategy to eventually include more than 100,000 U.S. service members who will be followed up through the year 2022, even after leaving military service. Subjects will be linked to DoD and Veterans Affairs databases and surveyed every 3 years to obtain objective and self-reported data on exposures and health outcomes. RESULTS: The first enrollment phase was completed in July 2003 and resulted in 77,047 consenting participants, well representative of both active-duty and Reserve/Guard forces. This report documents the baseline characteristics of these Cohort members, describes traditional, postal, and Web-based enrollment methods; and describes the unique challenges of enrolling, retaining, and following such a large Cohort. CONCLUSION: The Millennium Cohort was successfully launched and is becoming especially relevant, given current deployment and exposure concerns. The Cohort is representative of the U.S. military and promises to provide new insight into the long-term effects of military occupations on health for years to come.

Occupational and non-occupational injuries in the United States Army: focus on gender.

BACKGROUND: The differences in occupational and non-occupational injuries between military men and women have not been documented. This study compares occupational and non-occupational injuries between male and female United States Army soldiers by examining injury hospitalization rates and characteristics. METHODS: The U.S. Army's Total Army Injury and Health Outcomes Database was searched for hospitalizations with ICD-9-CM codes for injury (800-959.9) between 1992 and 2002. Injury rates were calculated using yearly U.S. Army population data and compared using rate ratios. Injury characteristics were compared among categories of the Trauma Code (on duty; off duty; scheduled training, schemes, and exercises), stratified by gender. RESULTS: Included in this analysis were 792 women for an injury hospitalization rate of 11.0 per 1000 individuals (95% confidence interval [CI]=8.5-13.5) and 4879 men for a rate of 15.5 per 1000 individuals (95% CI=14.0-16.9). While women had significantly more injuries during scheduled training, schemes, and exercises than men (p<0.0001), there were few differences in the cause of those injuries. Women had longer average hospital stays compared to men due to these injuries (9.3 days vs 7.4 days, p=0.002), although these injuries were not more severe (average Injury Severity Score=3.5 for men vs average ISS for women=3.5, p=0.79). There was no difference between the genders in the percent of injuries that occurred off duty; however, men were more likely to get injured due to sports and athletics (p=0.001) and due to fighting (p=0.017) while off duty compared to women. CONCLUSIONS: Injury prevention messages for military personnel should focus on reducing risk factors for both on- and off-duty injuries.

Functional electrical stimulation improves quality of life by reducing intermittent claudication.

OBJECTIVE: To determine if Functional Electrical Stimulation (FES) would improve ischemic pain, walking distance, and quality of life of patients with intermittent claudication. DESIGN: Single blind, randomized block, two factorial design. PATIENTS: Patients diagnosed with Peripheral Artery Disease (PAD) and intermittent claudication (IC). Ankle Brachial Index ranged 0.4-0.9 on at least one leg. Patients were randomly assigned to experimental (FES+Walk, N=13) or control (WALK, N=14) groups. INTERVENTION: Experimental group patients received FES to the dorsiflexor and plantarflexor muscles while walking for 1h/day, six days/week for eight weeks. Control group patients received similar intervention without FES. A Follow-up period of both groups lasted eight weeks. OUTCOME MEASURES: Outcome measures were taken at baseline (T0), after intervention (T1), and after follow-up (T2). Primary measures included Perceived Pain Intensity (PPI), Six minute walk (6MW), and Peripheral Arterial Disease Quality of Life (PADQOL). Secondary measures included Intermittent Claudication Questionnaire (ICQ) and Timed Up and Go (TUG). RESULTS: Group by time interactions in PPI were significant (P<0.001) with differences of 27.9 points at T1 and 36.9 points at T2 favoring the FES+Walk group. Groups difference in Symptoms and Limitations in Physical Function of the PADQOL reached significance (T1=8.9, and T2=8.3 improvements; P=0.007). ICQ was significant (T1=9.3 and T2=13.1 improvements; P=0.003). Improvement in 6MW and TUG tests were similar between groups. CONCLUSIONS AND RELEVANCE: Walking with FES markedly reduced ischemic pain and enhanced QOL compared to just walking. FES while walking may offer an effective treatment option for the elderly with PAD and Intermittent Claudication. TRIAL REGISTRATION: NIH-NIA 1R21AG048001 https://projectreporter.nih.gov/project_info_description.cfm?aid=8748641&icde=30695377&ddparam=&ddvalue=&ddsub=&cr=1&csb=default&cs=ASC. https://clinicaltrials.gov/ct2/show/NCT02384980?term=David+Embrey&rank=1.