Effectiveness of an outside-the-boot ankle brace in reducing parachuting related ankle injuries.

OBJECTIVES: To examine the efficacy of an outside-the-boot parachute ankle brace (PAB) in reducing risk of ankle injury to army paratrooper trainees and to identify inadvertent risks associated with PAB use. DESIGN: The authors compared hospitalization rates for ankle, musculoskeletal, and other traumatic injury among 223,172 soldiers trained 1985-2002 in time periods defined by presence/absence of PAB use protocols. Multiple logistic regression analysis estimated adjusted odds ratios (OR) and 95% confidence intervals for injury outcomes, comparing pre and post brace periods to the brace protocol period. SETTING: A research database consisting of training rosters from the US Army Airborne training facility (Fort Benning, GA) occupational, demographic, and hospitalization information. MAIN OUTCOME MEASURES: Injuries were considered training related if they occurred during a five week period starting with first scheduled static line parachute jump and a parachuting cause of injury code appeared in the hospital record. RESULTS: Of 939 parachuting related hospitalizations during the defined risk period, 597 (63.6%) included an ankle injury diagnosis, 198 (21.1%) listed a musculoskeletal (non-ankle) injury, and 69 (7.3%) cited injuries to multiple body parts. Risk of ankle injury hospitalization was higher during both pre-brace (adjusted OR 2.38, 95% CI 1.92 to 2.95) and post-brace (adjusted OR 1.72, 95% CI 1.27 to 2.32) periods compared with the brace protocol period. Odds of musculoskeletal (non-ankle) injury or injury to multiple body parts did not change between the brace and post-brace periods. CONCLUSION: Use of a PAB during airborne training appears to reduce risk of ankle injury without increasing risk of other types of traumatic injury.

Using narrative text and coded data to develop hazard scenarios for occupational injury interventions.

OBJECTIVE: To determine whether narrative text in safety reports contains sufficient information regarding contributing factors and precipitating mechanisms to prioritize occupational back injury prevention strategies.Design, setting, subjects, and MAIN OUTCOME MEASURES: Nine essential data elements were identified in narratives and coded sections of safety reports for each of 94 cases of back injuries to United States Army truck drivers reported to the United States Army Safety Center between 1987 and 1997. The essential elements of each case were used to reconstruct standardized event sequences. A taxonomy of the event sequences was then developed to identify common hazard scenarios and opportunities for primary interventions. RESULTS: Coded data typically only identified five data elements (broad activity, task, event/exposure, nature of injury, and outcomes) while narratives provided additional elements (contributing factor, precipitating mechanism, primary source) essential for developing our taxonomy. Three hazard scenarios were associated with back injuries among Army truck drivers accounting for 83% of cases: struck by/against events during motor vehicle crashes; falls resulting from slips/trips or loss of balance; and overexertion from lifting activities. CONCLUSIONS: Coded data from safety investigations lacked sufficient information to thoroughly characterize the injury event. However, the combination of existing narrative text (similar to that collected by many injury surveillance systems) and coded data enabled us to develop a more complete taxonomy of injury event characteristics and identify common hazard scenarios. This study demonstrates that narrative text can provide the additional information on contributing factors and precipitating mechanisms needed to target prevention strategies.

Risk factors for occupational knee related disability among enlisted women in the US Army.

AIMS: To identify sociodemographic and occupational determinants of knee related disability discharge from the US Army among enlisted women, and to investigate effect modification. METHODS: A case-control study of 692 cases of knee related disability discharge and 2080 incidence density matched controls nested within the population of all 244 000 enlisted women on active duty in the US Army, 1980-97. We used logistic regression to identify determinants of disability, stratified to explore effect modification by demographic and work characteristics. RESULTS: The risk of disability discharge was twice as high (odds ratio (OR) 2.4, 95% confidence interval (CI): 1.71 to 3.47) for the oldest (33-60 years) versus the youngest (17-21 years) women. Non-whites had lower risk than whites (OR 0.5, 95% CI: 0.41 to 0.60), as did married (OR 0.7, 95% CI: 0.54 to 0.81) relative to non-married women. Those of lower rank (pay grades E1-E3) were at five times the risk of disability discharge compared to those of higher ranks (pay grades E4-E9, OR 5.0, 95% CI: 2.86 to 8.33), while ORs were highest for those with longer duration of service compared to women on active duty for a year or less (OR 1.4, 95% CI: 0.8 to 2.55 after 12 years). Race modified several effects, including that of rank. Age, duration of service, and pay grade were too highly correlated to draw firm conclusions about their independent modifying effects on risk of disability discharge from the Army. CONCLUSIONS: Sociodemographic factors had larger effects than occupational characteristics on risk of knee related disability discharge from the US Army. Interactions suggest subgroups at differing risk levels that might be targeted for more detailed investigations.

Proposed explanations for excess injury among veterans of the Persian Gulf War and a call for greater attention from policymakers and researchers.

INTRODUCTION: Death rates among US veterans of the Persian Gulf War were lower than rates among non-deployed veterans and the US population at large, with the exception of injury deaths; returning veterans were at significantly greater risk of injury mortality. Similar patterns of excess injury mortality were documented among US and Australian veterans returning from Vietnam. In spite of these consistent findings little has been done to explain these associations and in particular to determine whether or not, and how, war related exposures influence injury risk among veterans returning home after deployments. HYPOTHESIZED PATHWAYS: Several potential pathways are proposed through which injury might be related to deployment. First, increases in injury mortality may be a consequence of depression, post-traumatic stress disorder, and symptoms of other psychiatric conditions developed after the war. Second, physical and psychological traumas experienced during the war may result in the postwar adoption of "coping" behaviors that also increase injury risk (for example, heavy drinking). Third, greater injury risk may be the indirect consequence of increased experiences of ill defined diseases and symptoms reported by many returning veterans. Fourth, veterans may experience poorer survivability for a given injury event resulting in greater mortality but not morbidity. Finally, the process that selects certain individuals for deployment may lead to a spurious association between deployment status and injury mortality by preferentially selecting individuals who are risk takers and/or exposed to greater hazards. CONCLUSIONS: More research and attention from policymakers is needed to clarify the link between deployment and postwar increased risk of injury.

Alcohol and other risk factors for drowning among male active duty U.S. army soldiers.

BACKGROUND: Risk factors for drowning are largely undocumented among military populations. HYPOTHESIS: Accident report narratives will provide important information about the role of alcohol use and other behaviors in drownings among active duty male U.S. Army soldiers. METHODS: Using a case series design, we describe drowning deaths reported to the U.S. Army Safety Center (1980-1997), documenting associated demographic factors, alcohol use, and other risk-taking behaviors. RESULTS: Drowning victims (n = 352) were disproportionately young, black, and single, with less time-in-service, and no college experience. Most drownings occurred off-duty (89%). Alcohol use was involved in at least 31% of the cases overall. Alcohol use was also associated with a 10-fold increase in reckless behavior (OR 9.6, 95% Cl 4.5-20.7) and was most common among drownings in Europe (OR = 4.3, 95% Cl 1.5-13.4). Most drownings occurred where no lifeguard was present (68%), but almost two-thirds occurred in the presence of others, with CPR initiated in less than one-third of these cases. Drownings involving minority victims were less likely to involve alcohol, but more likely to occur in unauthorized swimming areas. While most drownings did not involve violations of safety rules, over one-third of the cases involved some form of reckless behavior, particularly for those under age 21. CONCLUSIONS: Intervention programs should be tailored to meet the needs of the demographic subgroups at highest risk since behavioral risk factors vary by race and age. CPR training and skills maintenance can improve survival rates. Narrative data are important for developing hypotheses and understanding risk factors for injuries.

Short term effects of cigarette smoking on hospitalisation and associated lost workdays in a young healthy population.

OBJECTIVE: There are relatively few published studies conducted among people of younger ages examining short term outcomes of cigarette smoking, and only a small number with outcomes important to employers. The present study was designed to assess the short term effects of smoking on hospitalisation and lost workdays. DESIGN: Retrospective cohort study. SETTING: Military population. SUBJECTS: 87 991 men and women serving on active duty in the US Army during 1987 to 1998 who took a health risk appraisal two or more times and were followed for an average of 2.4 years. MAIN OUTCOME MEASURES: Rate ratios for hospitalisations and lost workdays, and fraction of hospitalisations and lost workdays attributable to current smoking (population attributable fraction). RESULTS: Compared with never smokers, men and women who were current smokers had higher short term rates of hospitalisation and lost workdays for a broad range of conditions. Population attributable fractions (PAFs) for outcomes not related to injury or pregnancy were 7.5% (men) and 5.0% (women) for hospitalisation, and 14.1% (men) and 3.0% (women) for lost workdays. Evidence suggests that current smoking may have been under reported in this cohort, in which case the true PAFs would be higher than those reported. CONCLUSIONS: In this young healthy population, substantial fractions of hospitalisations and lost workdays were attributable to current smoking, particularly among men.

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.

Progress toward attainment of the Healthy People 2000 objectives in the U.S. Army: measured by health risk appraisal results.

BACKGROUND: Healthy People 2000 (HP2000) is a national agenda of health promotion and disease prevention objectives, with specific health behavior goals in 22 priority areas. The U.S. Army Health Risk Appraisal (HRA) is a self-administered health-habits survey, inquiring about tobacco and alcohol use, physical activity, nutrition, and safety-related practices, given to more than 400,000 active-duty U.S. Army soldiers in the 1990s. This article compares the health behaviors of U.S. Army soldiers, as measured by the HRA, with the HP2000 objectives. METHODS: We compared cross-sectional analyses of self-reported health behaviors of active-duty Army personnel responding to HRA questionnaires in 1991 (n=78,256) and in 1997-1998 (n=59,771) with corresponding HP2000 objectives. We also calculated longitudinal changes for personnel who took more than one HRA (n=86,393). RESULTS: By 1997-1998, the Army exceeded HP2000 physical fitness goals by at least 50% and also exceeded goals for eating high-fiber foods and using bicycle helmets. The Army did not meet goals for nutrition, tobacco use, and seat-belt use. CONCLUSIONS: The Army has made good progress toward the HP2000 goals. However, improvement is needed to meet the tobacco, nutrition, and safety goals.

Cigarette smoking and suicide: a prospective study of 300,000 male active-duty Army soldiers.

The authors examined the relation between cigarette smoking and suicide by conducting a cohort study of 300,000 male US Army personnel followed prospectively from January 1987 through December 1996 for 961,657 person-years. They found that the risk of suicide increased significantly with the number of cigarettes smoked daily (p for trend < 0.001). In multivariable-adjusted analyses, smokers of more than 20 cigarettes a day, compared with never smokers, were more than twice as likely to commit suicide. For male active-duty army personnel, the dose-related association between smoking and suicide was not entirely explained by the greater tendency of smokers to be White, drink heavily, have less education, and exercise less often.

Hospitalization due to injuries in the military. Evaluation of current data and recommendations on their use for injury prevention.

INTRODUCTION: Injuries inflict the largest health impact on military populations in terms of hospitalization. Hospitalized injuries result in the largest direct costs of medical care and the most lost workdays, include the largest proportion of disabling injuries, and have the largest impact on troop readiness. Efforts are now beginning to focus on how injury surveillance data can be used to reduce the burden of injuries. This article examines the value of administrative hospital discharge databases in the military for routine injury surveillance, as well as investigation of specific injury problems, including musculoskeletal conditions that are frequently sequelae of old injuries. METHODS: Data on hospitalizations for injuries and musculoskeletal conditions were obtained from separate administrative agencies for the Army, Navy, and Air Force. Since 1989, a Standard Inpatient Data Record (SIDR) has been used to ensure uniformity in data collection across the services utilizing standard ICD-9 codes. Cause of injury was coded using special military cause codes (STANAG codes) developed by NATO. Data were analyzed on both nature and cause of injury. Denominator data on troop strength were obtained from the Defense Manpower Data Center (DMDC). RESULTS: Hospital records data indicate that injuries and musculoskeletal conditions have a bigger impact on the health of service members and military/combat readiness than any other ICD-9 Principal Diagnostic Group (higher incidence and higher noneffective rate or days not available for duty). Hospitalization rates for injury appeared to decline for all services from 1980 to 1992. In 1992, service-specific injury hospitalization rates per 1000 person-years were 15.6 for the Army, 8.3 for the Navy (enlisted only), and 7.7 for the Air Force, while the corresponding hospitalization rate for musculoskeletal conditions was higher in all three services: 28.1, 9.7, and 12.0, respectively. CONCLUSIONS: Military hospital discharge databases are an important source of information on severe injuries and are more comprehensive than civilian databases. They include detailed injury information that can be useful for injury prevention and surveillance purposes. Specifically, it can be used to identify high-risk groups or hazards for targeting prevention resources. These may vary widely by service, rank, and job tasks. Hospital discharge data can also be used to evaluate the effectiveness of interventions for reducing injury rates. Recommendations were submitted to further improve data collection and the use of hospital data for research and injury prevention.

Self-reported risk-taking behaviors and hospitalization for motor vehicle injury among active duty army personnel.

BACKGROUND: Motor vehicle crashes are a leading cause of injury in the Army. Behaviors increasing risk for motor vehicle crashes are also prevalent, but research has not linked these behaviors directly to injury outcomes (e.g., hospitalizations). METHODS: To evaluate the relationship between behavior and motor vehicle crash injuries, 99, 981 Army personnel who completed Health Risk Appraisal surveys in 1992 were followed for up to 6 years. Cox proportional hazards modeling was used to evaluate speeding, seat belt use, drinking patterns, and demographics. RESULTS: A total of 429 soldiers were hospitalized for motor vehicle injury. Unadjusted analyses revealed that heavy drinking, drinking and driving, speeding, low seat belt use, younger age, minority race/ethnicity, and enlisted rank were significantly associated with motor vehicle injury, but neither smoking nor gender was. Multivariate models showed a significant trend of increasing injury risk with younger ages. Soldiers under age 21 were injured almost five times more often than those over age 40 (HR 4.89, 2.56-9.33). Also associated with risk for hospitalizations were minority race (HR 1.78, 1.46-2.18), heaviest drinkers versus abstainers (HR 1.81, 1.11-2.94), and seat belt use of 50% or less versus 100% (HR 1.40, 1.07-1.85). Although nonsignificant, there was evidence of an age-drinking interaction where the difference in injury risk between those older and those younger than 21 was greatest at low alcohol consumption levels. CONCLUSIONS: Modifiable risk factors associated with motor vehicle injuries include heavy drinking and low seat belt use. Programs targeting these behaviors that meet the needs of young and minority soldiers are needed. The high density of young, at-risk soldiers residing in base housing may provide a unique opportunity for a residential intervention program.

Case-control study of discharge from the U.S. Army for disabling occupational knee injury: the role of gender, race/ethnicity, and age.

BACKGROUND: Occupational injuries are responsible for more lost time from work, productivity, and working years of life than any other health condition in either civilian or noncombat military sectors. Injuries, not illnesses, are the leading cause of morbidity and mortality among U.S. Army personnel. We examined the separate and joint roles of gender, race/ethnicity, and age in the odds of discharge from the Army for disabling knee injury. METHODS: A total of 860 women and 7868 men were discharged from the Army between 1980 and 1995 for knee-related disability and met all inclusion criteria for this study. All women and a subsample of 1005 men were included in these analyses, along with a simple random sample of three controls per case, stratified by gender, drawn from the population of all active-duty enlisted soldiers in each year from 1980 to 1995. We identified predictors of the occurrence or nonoccurrence of discharge from the Army for disabling knee injury using unconditional multiple logistic regression analyses. RESULTS: We found relations between the risk of knee-related disability and age and race, with marked effect modification by gender. Non-Caucasian men and women were at lower risk than Caucasians at all ages. At most ages, Caucasian women were at higher risk than Caucasian men, and non-Caucasian women were at lower risk than non-Caucasian men. Within race/ethnicity and gender, the risks for men showed an inverted "U" shape with increasing age, and the risks for women showed a "J" shape with increasing age. CONCLUSIONS: Age, race/ethnicity, and gender interactions are important in occupational injury. Differences in risk may be related to differences in work assignments, leisure activities, physical or physiological differences, or the ways in which disability compensation is granted.

High injury rates among female army trainees: a function of gender?

BACKGROUND: Studies suggest that women are at greater risk than men for sports and training injuries. This study investigated the association between gender and risk of exercise-related injuries among Army basic trainees while controlling for physical fitness and demographics. METHODS: Eight hundred and sixty-one trainees were followed during their 8-week basic training course. Demographic characteristics, body composition, and physical fitness were measured at the beginning of training. Physical fitness measures were taken again at the end of training. Multivariate logistic regression analysis was used to evaluate the association between gender and risk of injury while controlling for potential confounders. RESULTS: Women experienced twice as many injuries as men (relative risk [RR] = 2.1, 1.78-2.5) and experienced serious time-loss injuries almost 2.5 times more often than men (RR = 2.4, 1. 92-3.05). Women entered training at significantly lower levels of physical fitness than men, but made much greater improvements in fitness over the training period.In multivariate analyses, where demographics, body composition, and initial physical fitness were controlled, female gender was no longer a significant predictor of injuries (RR = 1.14, 0.48-2.72). Physical fitness, particularly aerobic fitness, remained significant. CONCLUSIONS: The key risk factor for training injuries appears to be physical fitness, particularly cardiovascular fitness. The significant improvement in endurance attained by women suggests that women enter training less physically fit relative to their own fitness potential, as well as to men. Remedial training for less fit soldiers is likely to reduce injuries and decrease the gender differential in risk of injuries.

Evaluating risk of re-injury among 1214 army airborne soldiers using a stratified survival model.

BACKGROUND: Many factors interact to influence an injured individual's risk of sustaining a second injury. However, the quantitative assessment of subsequent injury risk has been limited, primarily due to methodologic constraints. The purpose of this study is to present analytical methodology not previously employed in injury epidemiology to identify risk factors for subsequent injury. METHODS: Data were collected from a retrospective cohort of 1214 U.S. Army Airborne soldiers. Lower extremity and low-back musculoskeletal injuries were identified from outpatient medical records. The Prentice, Williams, and Peterson (PWP) model, stratified by injury event, was used to identify risk factors for initial and subsequent injuries. A Cox proportional hazards model to the time of last injury was used to determine the magnitude of the increased risk associated with having a previous injury history. RESULTS: Risk factors for initial injuries were similar to those seen in other epidemiologic studies of military populations. However, this study found that race/ethnicity, physical fitness, medical provider training, and initial injury types (traumatic versus other) were associated with subsequent injury risk. Additionally, the observed risk of injury was seven times greater among previously injured individuals. CONCLUSIONS: In this population, the risk factors for injury differed by event (initial or subsequent injury), and prior injury history was a risk factor for subsequent injury. The associations between demographic characteristics, the nature of the initial injury, and risk of subsequent injury suggest that changes in the evaluation and medical management of injured individuals may decrease the risk of subsequent injury.

Viewpoint: a comparison of cause-of-injury coding in U.S. military and civilian hospitals.

INTRODUCTION: Complete and accurate coding of injury causes is essential to the understanding of injury etiology and to the development and evaluation of injury-prevention strategies. While civilian hospitals use ICD-9-CM external cause-of-injury codes, military hospitals use codes derived from the NATO Standardization Agreement (STANAG) 2050. DISCUSSION: The STANAG uses two separate variables to code injury cause. The Trauma code uses a single digit with 10 possible values to identify the general class of injury as battle injury, intentionally inflicted nonbattle injury, or unintentional injury. The Injury code is used to identify cause or activity at the time of the injury. For a subset of the Injury codes, the last digit is modified to indicate place of occurrence. This simple system contains fewer than 300 basic codes, including many that are specific to battle- and sports-related injuries not coded well by either the ICD-9-CM or the draft ICD-10-CM. However, while falls, poisonings, and injuries due to machinery and tools are common causes of injury hospitalizations in the military, few STANAG codes correspond to these events. Intentional injuries in general and sexual assaults in particular are also not well represented in the STANAG. Because the STANAG does not map directly to the ICD-9-CM system, quantitative comparisons between military and civilian data are difficult. CONCLUSIONS: The ICD-10-CM, which will be implemented in the United States sometime after 2001, expands considerably on its predecessor, ICD-9-CM, and provides more specificity and detail than the STANAG. With slight modification, it might become a suitable replacement for the STANAG.

Qualitative assessment of cause-of-injury coding in U.S. military hospitals: NATO standardization agreement (STANAG) 2050.

BACKGROUND: Accurate injury cause data are essential for injury prevention research. U.S. military hospitals, unlike civilian hospitals, use the NATO STANAG system for cause-of-injury coding. Reported deficiencies in civilian injury cause data suggested a need to specifically evaluate the STANAG. METHODS: The Total Army Injury and Health Outcomes Database (TAIHOD) was used to evaluate worldwide Army injury hospitalizations, especially STANAG Trauma, Injury, and Place of Occurrence coding. We conducted a review of hospital procedures at Tripler Army Medical Center (TAMC) including injury cause and intent coding, potential crossover between acute injuries and musculoskeletal conditions, and data for certain hospital patients who are not true admissions. We also evaluated the use of free-text injury comment fields in three hospitals. RESULTS: Army-wide review of injury records coding revealed full compliance with cause coding, although nonspecific codes appeared to be overused. A small but intensive single hospital records review revealed relatively poor intent coding but good activity and cause coding. Data on specific injury history were present on most acute injury records and 75% of musculoskeletal conditions. Place of Occurrence coding, although inherently nonspecific, was over 80% accurate. Review of text fields produced additional details of the injuries in over 80% of cases. CONCLUSIONS: STANAG intent coding specificity was poor, while coding of cause of injury was at least comparable to civilian systems. The strengths of military hospital data systems are an exceptionally high compliance with injury cause coding, the availability of free text, and capture of all population hospital records without regard to work-relatedness. Simple changes in procedures could greatly improve data quality.