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.

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.

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.

Assessment of clinical trial participant patient satisfaction: a call to action.

BACKGROUND: As patient satisfaction scores become increasingly relevant in today's health care market, we sought to evaluate satisfaction of the unique subset of patients enrolling in clinical trials in a research facility embedded within a community hospital system. METHODS: We developed and deployed a patient satisfaction survey tailored to clinical trial patients who consented to and/or completed a clinical trial in our research institute in the prior year. The survey was distributed to 222 patients. Likert scale responses were analyzed using top box and percentile rank procedures. Correlation analysis was used to evaluate associations between the clinical trial experience and intent to return to our system for routine care. RESULTS: Ninety surveys were returned in the 6 months following the mailing for a 41 % response rate; the bulk of these (N = 81) were returned within 6 weeks of the mailing. The questions with the highest ranking responses were related to interactions with staff (84th percentile or higher). Fifty-one point one percent of patients (64th percentile) strongly agreed that they would seek future care in our system. Patient intent to return to the provider seen during the clinical trial was most highly correlated with intent to seek future care within our system (r = 0.54, p < 0.0001). Reasons cited for clinical trial enrollment were generally altruistic. CONCLUSIONS: Querying this special patient population is feasible and yields valuable insight into their experience with healthcare system-based clinical trials and the relationship between clinical trial participation and perception of the healthcare system as a desirable resource for routine medical care. We argue that this work is invaluable to the research community and submit a call to action to our peers to begin systematic evaluation of clinical trial patient satisfaction.

Epidemiology of hospitalizations and deaths from heat illness in soldiers.

PURPOSE: Serious heat illness has received considerable recent attention due to catastrophic heat waves in the United States and Europe, the deaths of high-profile athletes, and military deployments. METHODS: This study documents heat illness hospitalizations and deaths for the U.S. Army from 1980 through 2002. Hospitalization data were obtained from the Total Army Injury Health Outcomes Database (TAIHOD) coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). North Atlantic Treaty Organization Standardization Agreement codes were searched for heat injuries in an effort to detect cases that were not found during the ICD-9-CM search. RESULTS: Five-thousand two-hundred forty-six soldiers were hospitalized, and 37 died due to heat illness. Our results indicate: 1) approximately 60% reduction in hospitalization rates (fewer heat exhaustion cases) over the 22-yr period; 2) fivefold increase in heat stroke hospitalization rates (1.8 per 100,000 in 1980 to 14.5 per 100,000 in 2001); 3) heat stroke cases were associated with dehydration (17%), rhabdomyolysis (25%), and acute renal failure (13%); 4) lower hospitalizations rates among African and Hispanic Americans compared with Caucasians (incidence density ratio, 0.76 [95% confidence interval, 0.71-0.82]; 5) greater rates of hospitalizations and heat strokes among recruits from northern than southern states (incidence density ratio, 1.69 [95% confidence interval, 1.42-1.90]; and 6) greater rates of hospitalizations and heat strokes among women than men (incidence density ratio, 1.18 [95% confidence interval, 1.09-1.27]). CONCLUSIONS: Exertional heat illness continues to be a military problem during training and operations. Whereas the hospitalization rate of heat illness is declining, heat stroke has markedly increased.

Does occupation explain gender and other differences in work-related eye injury hospitalization rates?

OBJECTIVE: We sought to determine whether demographic differences in eye injury rates persist after adjusting for occupational exposure. METHODS: On-duty eye injury hospitalizations were linked to occupation among active-duty US Army personnel. RESULTS: Eye injury rates were higher for white soldiers, men, and for younger soldiers, even after adjusting for occupational group and specific job titles using multivariate models. CONCLUSIONS: This finding contrasts with studies of other injuries, suggesting that occupation does not fully account for variations in eye injury risk. Because protective eye-wear can prevent most serious eye injuries, we hypothesize that differences in protective eye-wear use between men and women may contribute to differences in eye injury rates, although follow-up studies are needed to confirm this. Prevention efforts should consider targeting high-risk demographic groups in addition to high-risk occupations.

Quality improvement measures in pulse-oximetry newborn heart screening: a time series analysis.

BACKGROUND AND OBJECTIVES: The use of pulse-oximetry screening to detect critical congenital heart defects in newborns has gained national and international momentum in the past decade. Our hospital system began screening in 2008. Since then, our program has undergone leadership changes and multiple quality improvement interventions. The aims of this study are to evaluate the evolution of our pulse-oximetry program and to provide insights from lessons learned over the course of a long-standing program. METHODS: We reviewed 6 years of screening data and evaluated trends of missed screens, false-positives, protocol violations, and parental decline of screening. We implemented 3 quality improvement interventions (change in protocol, redesign of an electronic medical record documentation system to autocalculate results, and transition from research to standard-of-care) and reviewed the impact of a rigorous quality assurance review process. We used linear regression and statistical process control charts to evaluate the data. RESULTS: A total of 18,363 newborns were screened; we identified 5 critical cases. We observed a significant decrease in missed (P < .001) and false-positive (P = .03) screens over time but found no significant trend in the rate of percentage of protocol violations (P = .26) or decline of screening (P = .99). Each metric showed behavior attributable to at least 1 quality improvement intervention. CONCLUSIONS: We established a sustainable pulse-oximetry screening program in our community hospital system, and the screening has now become routine. The quality of our screening was influenced by choice of screening protocol, rigor of quality assurance reviews, and the process used to interpret screening results.