Postpartum long-acting reversible contraceptive use among active-duty, female US Army soldiers.

BACKGROUND: Postpartum use of long-acting reversible contraception has been found to be effective at increasing interpregnancy intervals, reducing unintended pregnancies, and optimizing health outcomes for mothers and babies. Among female active-duty military service members, reproductive planning may be particularly important, yet little is known about postpartum long-acting reversible contraceptive use among active-duty soldiers. OBJECTIVE: This study aimed to (1) quantify postpartum uptake of long-acting reversible contraception among active-duty female US Army soldiers and (2) identify demographic and military-specific characteristics associated with use. STUDY DESIGN: This retrospective cohort study used longitudinal data of all digitally recorded health encounters for active-duty US Army soldiers from 2014 to 2017. The servicewomen included in our analysis were aged 18 to 44 years with at least one delivery and a minimum of 4 months of total observed time postdelivery within the study period. We defined postpartum long-acting reversible contraception use as initiation of use within the delivery month or in the 3 calendar months following delivery and identified likely immediate postpartum initiation via the proxy of placement recorded during the same month as delivery. We then evaluated predictors of postpartum long-acting reversible contraception use with multivariable logistic regression. RESULTS: The inclusion criteria were met by 15,843 soldiers. Of those, 3162 (19.96%) initiated the use of long-acting reversible contraception in the month of or within the 3 months following delivery. Fewer than 5% of these women used immediate postpartum long-acting reversible contraception. Among women who initiated postpartum long-acting reversible contraceptive use, 1803 (57.0%) received an intrauterine device, 1328 (42.0%) received an etonogestrel implant, and 31 received both (0.98%). Soldiers of younger age, self-reported White race, and those who were married or previously married were more likely to initiate long-acting reversible contraception in the postpartum period. Race-stratified analyses showed that self-reported White women had the highest use rates overall. When compared with these women, the adjusted odds of postpartum use among self-reported Black and Asian or Pacific Islander women were 18% and 30% lower, respectively (both P<.001). There was also a trend of decreasing postpartum use with increasing age within each race group. Differences observed between age groups and race identities could partially be attributed to differential use of permanent contraception (sterilization), which was found to be significantly more prevalent among both women aged 30 years or older and among women who identified as Black. CONCLUSION: Among active-duty US Army servicewomen, 1 in 5 used postpartum long-acting reversible contraception, and fewer than 5% of these women used an immediate postpartum method. Within this population with universal healthcare coverage, we observed relatively low rates of use and significant differences in the uptake of effective postpartum long-acting contraceptive methods across self-reported race categories.

Stressful Life Changes and Their Relationship to Nutrition-Related Health Outcomes Among US Army Soldiers.

Stressful life changes may tax people's adaptive capacity. We sought to determine if and when experiences of stressful life changes were associated with increased odds of adverse nutrition-related health outcomes among US Army soldiers relative to those who did not experience the same stressful life change. An additional aim was to determine which stressful life changes had the greatest association with these outcomes and if there were gender differences in the magnitude of the associations. Stressful life changes studied included: changes in marital status, combat deployment or return from deployment, relocation, adding a child, change in rank, change in occupation, and development of a physical limitation to duty. Using longitudinal data from the Stanford Military Data Repository, which represents all active-duty soldiers aged 17-62 between 2011 and 2014 (n = 827,126), we employed an event history analysis to examine associations between stressful life changes and a subsequent diagnosis of hyperlipidemia, substantial weight gain, and weight-related separation from the Army. Marriage was associated with an increase in the odds of substantial weight gain 3 months later for both men and women. Developing a physical duty limitation was associated with an increase in the odds of a hyperlipidemia diagnosis 2 months later for both men and women, as was substantial weight gain 2 months later. Stressful life changes were also associated with increased odds of nutrition-related health outcomes, although we found gender differences in the magnitude of the associations. Findings could be used to mitigate the effects of stress on health by health professionals.

Sickle cell trait and renal disease among African American U.S. Army soldiers.

Sickle cell trait and certain renal disorders are disproportionately prevalent among African American individuals, so a clear understanding of their association is important. We conducted a longitudinal study using the Stanford Military Data Repository to examine sickle cell trait in relation to the incidence of acute kidney injury (AKI) and chronic kidney disease (CKD). Our study population consisted of African American U.S. Army soldiers on active duty between January 2011 and December 2014. The cumulative incidence was 0·51% for AKI (236 cases out of 45 901 soldiers) and 0·56% for CKD (255 cases out of 45 882 soldiers). Discrete time logistic regression models adjusting for demographic-, military- and healthcare-related covariates showed that sickle cell trait was associated with significantly higher adjusted odds of both AKI [odds ratio (OR): 1·74; 95% confidence interval (CI): 1·17-2·59] and CKD (OR: 2·00; 95% CI: 1·39-2·88). Elevated odds of AKI and CKD were also observed in association with prior CKD and AKI, respectively, and with obesity and prior hypertension. Individuals with sickle cell trait and their providers should be aware of the possibility of increased risk of AKI and CKD to allow for timely intervention and possible prevention.

Sickle Cell Trait, Rhabdomyolysis, and Mortality among U.S. Army Soldiers.

BACKGROUND: Studies have suggested that sickle cell trait elevates the risks of exertional rhabdomyolysis and death. We conducted a study of sickle cell trait in relation to these outcomes, controlling for known risk factors for exertional rhabdomyolysis, in a large population of active persons who had undergone laboratory tests for hemoglobin AS (HbAS) and who were subject to exertional-injury precautions. METHODS: We used Cox proportional-hazards models to test whether the risks of exertional rhabdomyolysis and death varied according to sickle cell trait status among 47,944 black soldiers who had undergone testing for HbAS and who were on active duty in the U.S. Army between January 2011 and December 2014. We used the Stanford Military Data Repository, which contains comprehensive medical and administrative data on all active-duty soldiers. RESULTS: There was no significant difference in the risk of death among soldiers with sickle cell trait, as compared with those without the trait (hazard ratio, 0.99; 95% confidence interval [CI], 0.46 to 2.13; P=0.97), but the trait was associated with a significantly higher adjusted risk of exertional rhabdomyolysis (hazard ratio, 1.54; 95% CI, 1.12 to 2.12; P=0.008). This effect was similar in magnitude to that associated with tobacco use, as compared with no use (hazard ratio, 1.54; 95% CI, 1.23 to 1.94; P<0.001), and to that associated with having a body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) of 30.0 or more, as compared with a BMI of less than 25.0 (hazard ratio, 1.39; 95% CI, 1.04 to 1.86; P=0.03). The effect was less than that associated with recent use of a statin, as compared with no use (hazard ratio, 2.89; 95% CI, 1.51 to 5.55; P=0.001), or an antipsychotic agent (hazard ratio, 3.02; 95% CI, 1.34 to 6.82; P=0.008). CONCLUSIONS: Sickle cell trait was not associated with a higher risk of death than absence of the trait, but it was associated with a significantly higher risk of exertional rhabdomyolysis. (Funded by the National Heart, Lung, and Blood Institute and the Uniformed Services University of the Health Sciences.).

Gender differences in the associations of body mass index, physical fitness and tobacco use with lower extremity musculoskeletal injuries among new US Army soldiers.

BACKGROUND: Musculoskeletal (MSK) injuries are a leading cause of morbidity among US Army soldiers, especially among women and the newly enlisted. While extremes of body mass index (BMI), low physical fitness and tobacco use have been identified as risk factors, no prior studies have determined the combined effects of these risk factors or tested for gender differences in the associations. METHODS: We conducted a retrospective cohort study utilising the Stanford Military Data Repository to study all enlisted soldier accessions to the US Army between January 2011 and January 2014, with follow-up through December 2014 (n=238 772). We used discrete-time logistic regression to test for associations between demographic, socioeconomic and health behaviour-related predictors and incident lower extremity injuries. We included interaction terms to test for gender differences. RESULTS: Among men, there were greater adjusted odds of injury among underweight (OR 1.27), overweight (OR 1.14) and obese soldiers (OR 1.54) (all p<0.001) relative to normal-weight soldiers. No statistically significant differences in the odds of injury on the basis of BMI were observed for female soldiers. Physical fitness was a significantly stronger predictor of injury for female as compared with male soldiers, while the association between tobacco use and injury was stronger for men (OR 1.47) than for women (OR 1.30) (p<0.001 for both). CONCLUSION: This is the largest known study to simultaneously assess important, modifiable musculoskeletal injury risk factors and to test for gender differences in these associations. These findings provide critical gender-related nuances for clinicians and leaders seeking to reduce the risk of these problems.

Sickle Cell Trait and Heat Injury Among US Army Soldiers.

There is concern that sickle cell trait (SCT) increases risk of exertional collapse, a primary cause of which is heat injury. However, to our knowledge, no population-based studies among active individuals have addressed this, representing a critical evidence gap. We conducted a retrospective cohort study of SCT-tested African-American soldiers who were on active duty in the US Army anytime between January 2011 and December 2014. Using Cox proportional hazards models and adjusting for demographic and medical factors, we observed no significant associations between SCT and either mild heat injury (hazard ratio (HR) = 1.15, 95% confidence interval (CI): 0.84, 1.56; n = 45,999) or heat stroke (HR = 1.11, 95% CI: 0.44, 2.79; n = 46,183). Risk of mild heat injury was substantially higher among soldiers with recent prescriptions for antipsychotic agents (HR = 3.25, 95% CI: 1.33, 7.90). Risk of heat stroke was elevated among those with a prior mild heat injury (HR = 17.7, 95% CI: 8.50, 36.7) and among overweight and obese individuals (HR = 2.91 (95% CI: 1.38, 6.17) and HR = 4.04 (95% CI: 1.72, 9.45), respectively). In a setting where universal precautions are utilized to mitigate risk of exertion-related illnesses, SCT is not associated with either mild heat injury or heat stroke.

Deployment and Preterm Birth Among US Army Soldiers.

With increasing integration of women into combat roles in the US military, it is critical to determine whether deployment, which entails unique stressors and exposures, is associated with adverse reproductive outcomes. Few studies have examined whether deployment increases the risk of preterm birth; no studies (to our knowledge) have examined a recent cohort of servicewomen. We therefore used linked medical and administrative data from the Stanford Military Data Repository for all US Army soldiers with deliveries between 2011 and 2014 to estimate the associations of prior deployment, recency of deployment, and posttraumatic stress disorder with spontaneous preterm birth (SPB), adjusting for sociodemographic, military-service, and health-related factors. Of 12,877 deliveries, 6.1% were SPBs. The prevalence was doubled (11.7%) among soldiers who delivered within 6 months of their return from deployment. Multivariable discrete-time logistic regression models indicated that delivering within 6 months of return from deployment was strongly associated with SPB (adjusted odds ratio = 2.1, 95% confidence interval: 1.5, 2.9). Neither multiple past deployments nor posttraumatic stress disorder was significantly associated with SPB. Within this cohort, timing of pregnancy in relation to deployment was identified as a novel risk factor for SPB. Increased focus on servicewomen's pregnancy timing and predeployment access to reproductive counseling and effective contraception is warranted.

Objective Effects of Breast Reduction Surgery on Physical Fitness.

BACKGROUND: Reduction mammaplasty is known for excellent outcomes and patient satisfaction. Although patients report improvements in pain, weight loss, and exercise levels, objective data on physical fitness benefits are limited. METHODS: Using the Stanford Military Data Repository, we identified 89 US Army active duty women with at least 1 pre- and postoperative Army Physical Fitness Test (APFT) who underwent reduction mammaplasty during 2011 to 2014. We used paired t tests to compare pre- and postoperative APFT score means and raw values for push-ups, sit-ups, and the 2-mile run. RESULTS: There were 56 subjects (62.9%) who improved in total APFT scores. Total score means increased from 235.9 preoperatively to 243.4 postoperatively (P = 0.0065). Of 28 subjects with at least 2 APFT scores before and after surgery, 20 (71.4%) improved in total scores. The subgroup's mean total score increased from 237.8 to 251.3 (P = 0.0009). Comparing individual pre- and postprocedure APFTs, all subjects demonstrated a mean 3.9% (SD, 0.1) improvement in total scores, and the subpopulation of 28 improved by 6.3% (SD, 0.1). In all events, mean performance values trended toward better postoperative scores. Differences were statistically significant for the total population for the number of sit-ups (P = 0.035), and, for the subgroup of 28, differences were statistically significant for the total score (P = 0.0009), sit-ups (P = 0.0002), and push-ups (P = 0.0134). CONCLUSIONS: Reduction mammaplasty was associated with postoperative physical fitness improvements among US Army active duty women. Soldier data are useful for objectively assessing physical fitness effects of breast reduction surgery.

Prediction of all-cause occupational disability among US Army soldiers.

INTRODUCTION: Long-term occupational disability rates associated with eventual discharges from military service have risen sharply among active-duty US Army soldiers during the last three decades, with important implications for soldier health and national security alike. To address this problem, we built predictive models for long-term, all-cause occupational disability and identified disability risk factors using a very large, multisource database on the total active-duty US Army. METHODS: We conducted a cross-temporal retrospective cohort study and used mixed-effects logistic regression models to derive and validate disability risk assignments. The derivation cohort included 510 616 US Army soldiers on duty in December 2012, and the validation cohort included 483 197 soldiers on duty in December 2013. RESULTS: The predictive model yielded an overall c-statistic of 85.97% (95% CI 85.61% to 86.32%). Risk thresholds at the population's 75th and 95th centiles identified 80.53% and 42.08%, respectively, of the disability designations that occurred population wide during the subsequent 9 months. Frequent work excusals, high outpatient care utilisation and psychotropic medication use were the strongest independent predictors of later disability. CONCLUSIONS: These findings indicate that predictive models using diverse data types can successfully anticipate long-term occupational disability among US Army soldiers and could be used for disability risk screening.

Incidence of Ankylosing Spondylitis Among Male and Female United States Army Personnel.

OBJECTIVE: Incidence rates of ankylosing spondylitis (AS) among males versus females are poorly understood. Results of prior research have been mixed, including findings of a 3:1 incidence ratio for males versus females, but with increasing AS rates among females. The objective was to estimate the incidence of AS among members of the US military. METHODS: We estimated the incidence of AS in a retrospective cohort study of diverse, working-age US military service members during March 2014 to June 2017 (n = 728,556) who underwent clinical practice guideline-directed screening for chronic back pain. Incident AS cases were identified using diagnostic codes from electronic medical and administrative records. RESULTS: In contrast to some prior studies, AS incidence was similar among males and females (incidence rate ratio 1.16, P = 0.23; adjusted odds ratio [OR] 0.79 [95% confidence interval (95% CI) 0.61-1.02]; P = 0.072). AS rates increased approximately monotonically with age. Consistent with prior research, the AS incidence rate was greater in the White population than in the Black population (adjusted OR 1.39 [95% CI 1.01-1.66]; P = 0.04). CONCLUSION: In this study population, the incidence of AS was similar for the sexes. Previous observations of male predominance have typically been derived from clinic populations that are less representative of the US race/ethnicity distribution and based on disease ascertainment tools that may have identified subjects later in their disease course. Our study population also differed in being subject to organized screenings for musculoskeletal symptoms. Our findings suggest that sex may not predict AS incidence in the US population.

Physical Fitness in Relationship to Depression and Post-Traumatic Stress Disorder During Pregnancy Among U.S. Army Soldiers.

Background: Depression and post-traumatic stress disorder (PTSD) are prevalent in pregnancy, especially among military members. These conditions can lead to adverse birth outcomes, yet, there's a paucity of evidence for prevention strategies. Optimizing physical fitness is one understudied potential intervention. We explored associations between prepregnancy physical fitness and antenatal depression and PTSD in soldiers. Materials and Methods: This was a retrospective cohort study of active-duty U.S. Army soldiers with live births between 2011 and 2014, identified with diagnosis codes from inpatient and outpatient care. The exposure was each individual's mean Army physical fitness score from 10 to 24 months before childbirth. The primary outcome was a composite of active depression or PTSD during pregnancy, defined using the presence of a code within 10 months before childbirth. Demographic variables were compared across four quartiles of fitness scores. Multivariable logistic regression models were conducted adjusting for potential confounders selected a priori. A stratified analysis was conducted for depression and PTSD separately. Results: Among 4,583 eligible live births, 352 (7.7%) had active depression or PTSD during pregnancy. Soldiers with the highest fitness scores (Quartile 4) were less likely to have active depression or PTSD in pregnancy (Quartile 4 vs. Quartile 1 adjusted odds ratio 0.55, 95% confidence interval 0.39-0.79). Findings were similar in stratified analyses. Conclusion: In this cohort, the odds of active depression or PTSD during pregnancy were significantly reduced among soldiers with higher prepregnancy fitness scores. Optimizing physical fitness may be a useful tool to reduce mental health burden on pregnancy.

Post-Traumatic Stress Disorder Among U.S. Army Drone Operators.

INTRODUCTION: Exposure to traumatic events could increase post-traumatic stress disorder (PTSD) risk among enlisted U.S. Army drone operators. Published research on PTSD risk in this population is unavailable.METHODS: We used a combined medical and administrative longitudinal dataset to examine adjusted associations between drone operator service among U.S. Army enlisted members and three PTSD indicators: whether screened via the PTSD Checklist - Civilian (PCL-C); PCL-C scores; and incident PTSD diagnoses. We compiled summary statistics for and conducted tests of differences in independent variable distributions when comparing drone operators and others. Two multivariable survival regression models and an ordinary least squares model were used to estimate adjusted associations.RESULTS: There were 1.68 million person-years of observed time in the study population (N = 678,548; drone operator N = 2856). Compared to other servicemembers, the adjusted likelihood of undergoing PTSD screening was 35% lower [95% confidence interval (CI) for the adjusted hazard ratio (aHR): 0.56-0.76]. Among subjects who took the PCL-C, scores did not differ significantly on the basis of drone operator service (adjusted change: -1.26 points; CI: -3.41-0.89). The adjusted hazard of receiving a PTSD diagnosis was 34% lower among drone operators (CI: 0.54-0.80).DISCUSSION: These findings provide reassurance that enlisted U.S. Army drone operators are not at increased risk of PTSD. Further research is needed in order to identify the mechanisms of the decreased PTSD risk observed, and whether other or longer-term mental health risks are present among those in this occupation.Nelson DA, Wilson M, Kurina LM. Post-traumatic stress disorder among U.S. Army drone operators. Aerosp Med Hum Perform. 2022; 93(7):562-570.

Service discharges among US Army personnel with selected musculoskeletal and skin conditions: a retrospective cohort study.

OBJECTIVES: To determine the probability of discharge from military service among soldiers following an incident diagnosis of ankylosing spondylitis (AS), rheumatoid arthritis (RA), psoriasis or systemic lupus erythematous. METHODS: All soldiers on active duty in the US Army between January 2014 and June 2017 were included in a retrospective cohort analysis. Termination from service was ascertained using personnel records. Diagnostic codes were used to identify incident cases of the four musculoskeletal and skin diseases and, for comparison, diabetes mellitus (DM). Time to discharge was modelled using sex stratified multivariate survival analysis. RESULTS: The analysis included 657 417 individuals with a total of 1.2 million person-years of observation. An elevated risk of discharge was observed in association with each of the five chronic conditions studied. The increase in adjusted risk of discharge was highest among soldiers with AS (men, HR=2.5, 95% CI 2.1 to 3.0; women, HR=2.1, 95% CI 1.4 to 3.2) and with DM (men, HR=2.4, 95% CI 2.2 to 2.7; women, HR=2.2, 95% CI 1.8 to 2.5), followed by those with RA (men, HR=1.8, 95% CI 1.5 to 2.2; women, HR=1.8, 95% CI 1.4 to 2.4). CONCLUSIONS: Military discharges are consequential for the service and the service member. The doubling in risk of discharge for those with AS or RA was comparable to that for personnel with DM. Conditions that affect the spine and peripheral joints may often be incompatible with military readiness. Nevertheless, a substantial fraction of service members with these diagnoses continued in service.

Investigating Health Information Technology Usage by Sociodemographic Subpopulations to Increase Community Engagement in Healthcare: An Analysis of the Health Information National Trends Survey.

It is well known that the US is plagued by health inequities: unjust differences in morbidity and mortality rates by sociodemographic factors. A potential method to address such inequities lies in utilizing health information technologies (HIT) to reach under-resourced populations and increase their involvement in healthcare. Previous researchers have done just this, using HIT tools to engage under-resourced communities and improve outcomes. However, it is unclear how HIT usage varies by sociodemographic characteristics. This study investigated this question through analysis of the Health Information National Trends Survey (HINTS) and proposed tailored HIT interventions for specific subpopulations. Internet, smartphone, and wearable device usage were analyzed by age, race/ethnicity, educational attainment, and income; purposes of HIT usage were assessed; and logistic regression models were conducted to determine associations between purposes of HIT usage and sociodemographic predictors. Results showed that Black/African American, Latinx, and Asian populations all had significantly increased use of health videos, while participants with low educational attainment had significantly decreased use of many HIT tools. Thus, this study highlights effective interventions for specific racial/ethnic populations and showcases a need for HIT tools inclusive towards low education populations to increase their engagement in healthcare and reduce inequities.

An investigation of sickle cell trait, body mass index, and fitness in relation to venous thromboembolism among African American adults.

BACKGROUND: The relationships of sickle cell trait (SCT), body mass index (BMI), and physical fitness to venous thromboembolism (VTE) in young adults have received little attention. OBJECTIVES: To test for associations among SCT, BMI, fitness, and VTE. PATIENTS/METHODS: We conducted a retrospective cohort study of 48,316 SCT-tested, African American individuals in the US Army during 2011-14. We used Cox proportional hazards models to compute adjusted hazards of deep vein thrombosis (DVT) and pulmonary embolism (PE) associated with selected factors. RESULTS: Incidence rates of DVT and PE were 1.09 and 0.91 cases per 1000 person-years, respectively. Adjusted hazard ratios (aHRs) for DVT for men and women with SCT were 0.9 (95% confidence interval [CI]: 0.4-2.0; P = .711) and 1.51 (CI: 0.7-3.2; P = .274), respectively. aHRs for PE for SCT+ men and women were 1.1 (CI: 0.5-2.4; P = .773) and 1.2 (CI: 0.5-3.1; P = .650), respectively. Low physical fitness was associated with DVT and PE in women (DVT aHR =3.1; CI: 1.4-6.5; P = .004; PE aHR =4.6; CI: 2.1-9.9; P < .001) and DVT in men (aHR =2.2; CI: 1.0-4.6; P = .048). Recent weight gain of 1 or more BMI points was associated with DVT in men (aHR =1.8; CI: 1.1-2.8; P = .017). CONCLUSIONS: We found no evidence of increased VTE risk associated with SCT in this population. However, lower fitness levels and BMI increases were so associated.

Incidence of Pelvic Floor Disorders in US Army Female Soldiers.

OBJECTIVE: To determine the incidence of pelvic floor disorders (PFD) among active-duty US Army female soldiers. MATERIALS AND METHODS: We studied 102,015 women for incident PFD using the Stanford Military Data Repository, which comprises medical, demographic and service-related information on all soldiers on active duty in the US Army during 2011-2014. Cox proportional hazards estimated adjusted associations with PFD diagnoses. In the adjusted models, military-specific characteristics and fitness were evaluated alongside known PFD predictors. RESULTS: Among 102,015 subjects at risk there was a cumulative incidence of 6.4% over a mean of 27 months (median 29, range 1-42). In adjusted models, obese soldiers were more likely to have a PFD compared to those of normal weight (hazard ratio [HR] 1.23, confidence interval [CI] 1.14-1.34, P <0.001) and those with recent weight gain were more likely to have a PFD compared to those without (HR 1.32, CI 1.24-1.40, P <0.05). Women with the lowest physical fitness scores were more likely to have a PFD (HR 1.14, CI 1.04-1.25) compared to those with the highest scores. CONCLUSION: Over a median follow-up time of 29 months, 1 in 15 women in this active-duty cohort was diagnosed with a PFD. Optimizing risk factors including body mass index and physical fitness may benefit the pelvic health of female soldiers, independent of age, children, and years of service.

Health seeking behavior after the 2013-16 Ebola epidemic: Lassa fever as a metric of persistent changes in Kenema District, Sierra Leone.

BACKGROUND: The West African Ebola epidemic of 2013-2016 killed nearly 4,000 Sierra Leoneans and devastated health infrastructure across West Africa. Changes in health seeking behavior (HSB) during the outbreak resulted in dramatic underreporting and substantial declines in hospital presentations to public health facilities, resulting in an estimated tens of thousands of additional maternal, infant, and adult deaths per year. Sierra Leone's Kenema District, a major Ebola hotspot, is also endemic for Lassa fever (LF), another often-fatal hemorrhagic disease. Here we assess the impact of the West African Ebola epidemic on health seeking behaviors with respect to presentations to the Kenema Government Hospital (KGH) Lassa Ward, which serves as the primary health care referral center for suspected Lassa fever cases in the Eastern Province of Sierra Leone. METHODOLOGY/PRINCIPAL FINDINGS: Presentation frequencies for suspected Lassa fever presenting to KGH or one of its referral centers from 2011-2019 were analyzed to consider the potential impact of the West African Ebola epidemic on presentation patterns. There was a significant decline in suspected LF cases presenting to KGH following the epidemic, and a lower percentage of subjects were admitted to the KGH Lassa Ward following the epidemic. To assess general HSB, a questionnaire was developed and administered to 200 residents from 8 villages in Kenema District. Among 194 completed interviews, 151 (78%) of respondents stated they felt hospitals were safer post-epidemic with no significant differences noted among subjects according to religious background, age, gender, or education. However, 37 (19%) subjects reported decreased attendance at hospitals since the epidemic, which suggests that trust in the healthcare system has not fully rebounded. Cost was identified as a major deterrent to seeking healthcare. CONCLUSIONS/SIGNIFICANCE: Analysis of patient demographic data suggests that fewer individuals sought care for Lassa fever and other febrile illnesses in Kenema District after the West African Ebola epidemic. Re-establishing trust in health care services will require efforts beyond rebuilding infrastructure and require concerted efforts to rebuild the trust of local residents who may be wary of seeking healthcare post epidemic.

Military Occupational Disability Risk Surveillance: A Retrospective Cohort Study of Modifiable Risk Factors.

INTRODUCTION: Occupational disability among military service members is an important target for preventive screening. The specific aim of this study was to quantify disability risk levels among soldiers with selected risk factors (body mass index extremes, poor or absent physical fitness scores, and tobacco and opioid use) and combinations thereof, suggesting priorities for preventive actions. MATERIALS AND METHODS: This was a retrospective cohort study of 607,006 active-duty soldiers who served in the U.S. Army during 2011-2014. Official medical and administrative data were combined to produce a person-month-based panel dataset with identifiers removed. The subjects were observed longitudinally for incident disability (termed medical nonreadiness) during 1,305,618 person-years at risk. We employed Weibull parametric survival regression models to determine the adjusted medical nonreadiness hazard for selected variables. We then computed individual adjusted risk scores and the population proportions affected by risk factors and combinations thereof in postregression analyses. The project was approved by the Stanford University's Institutional Review Board and underwent secondary review by the Human Research Protections Office of the Defense Health Agency. RESULTS: During the observed time, 81,571 (13.4%) of subjects were found medically not ready. High or low body mass index, low or missing physical fitness test scores, tobacco use, and the highest levels of opioid use were each associated with increased adjusted hazards of medical nonreadiness. The hazards increased substantially when multiple risk factors were present, albeit while affecting reduced population proportions. CONCLUSIONS: We identified marked disability hazard increases, especially in association with opioid use and high body mass index. These factors, in addition to tobacco use and low physical fitness, are potential early prevention targets for clinicians who screen military service members.

Association of Nonsteroidal Anti-inflammatory Drug Prescriptions With Kidney Disease Among Active Young and Middle-aged Adults.

Importance: Concern about the renal effects of nonsteroidand al anti-inflammatory drugs (NSAIDs) among young, healthy adults has been limited, but more attention may be warranted given the prevalent use of these agents. Objective: To test for associations between dispensed NSAIDs and incident acute kidney injury and chronic kidney disease while controlling for other risk factors. Design, Setting, and Participants: This retrospective, longitudinal cohort study used deidentified medical and administrative data on 764 228 active-duty US Army soldiers serving between January 1, 2011, and December 31, 2014. Analysis was conducted from August 1 to November 30, 2018. All individuals new to Army service were included in the analysis. Persons already serving in January 2011 were required to have at least 7 months of observable time to eliminate those with kidney disease histories. Exposures: Mean total defined daily doses of prescribed NSAIDs dispensed per month in the prior 6 months. Main Outcomes and Measures: Incident outcomes were defined by diagnoses documented in health records and a military-specific digital system. Results: Among the 764 228 participants (655 392 [85.8%] men; mean [SD] age, 28.6 [7.9] years; median age, 27.0 years [interquartile range, 22.0-33.0 years]), 502 527 (65.8%) were not dispensed prescription NSAIDs in the prior 6 months, 137 108 (17.9%) were dispensed 1 to 7 mean total defined daily doses per month, and 124 594 (16.3%) received more than 7 defined daily doses per month. There were 2356 acute kidney injury outcomes (0.3% of participants) and 1634 chronic kidney disease outcomes (0.2%) observed. Compared with participants who received no medication, the highest exposure level was associated with significantly higher adjusted hazard ratios (aHRs) for acute kidney injury (aHR, 1.2; 95% CI, 1.1-1.4) and chronic kidney disease (aHR, 1.2; 95% CI, 1.0-1.3), with annual outcome excesses per 100 000 exposed individuals totaling 17.6 cases for acute kidney injury and 30.0 cases for chronic kidney disease. Conclusions and Relevance: Modest but statistically significant associations were noted between the highest observed doses of NSAID exposure and incident kidney problems among active young and middle-aged adults.