From the Defense Health Board: Military Accessions and the Continuum of Mental Health Research.

The Defense Health Board conducted a year-long examination of mental health accession screening and related issues. In its August 2020 report, Examination of Mental Health Accession Screening: Predictive Value of Current Measures and Processes, the Board recommends a paradigm shift in how mental health impacts on readiness are understood and addressed. This shift can only occur with the development and implementation of a research plan that follows cohorts of military personnel from recruitment through their military career. The following article describes this research plan as an excerpt of the larger report.

A Career Life-Cycle Perspective on Women's Health and Safety: Insights From the Defense Health Board Report on Military Women's Health.

OBJECTIVE: Women's health has demanded more attention from employers as women integrated into the workforce. Traditionally male-dominant fields and occupations require special attention to workplace design, physical standards for entry, employment practices, equipment, and health monitoring. This editorial summarizes the Defense Health Board's (DHB) review of Active Duty Women's Health and its recommendations grounded in a woman's career life-cycle. METHODS: The DHB reviewed the Department of Defense and foreign militaries' current women's health services, relevant policies and practices, peer-reviewed scientific literature, and subject matter expert interviews. RESULTS: The DHB's recommendations centered on a comprehensive approach to education, health care access and treatment, professional workforce development, workplace standards and equipment, and accountable outcomes metrics to guide improvement. CONCLUSIONS: Employers can learn how to reduce morbidity, leading to a healthier and more productive female workforce.

Urine Single-Cell RNA Sequencing in Focal Segmental Glomerulosclerosis Reveals Inflammatory Signatures.

INTRODUCTION: Individuals with focal segmental glomerular sclerosis (FSGS) typically undergo kidney biopsy only once, which limits the ability to characterize kidney cell gene expression over time. METHODS: We used single-cell RNA sequencing (scRNA-seq) to explore disease-related molecular signatures in urine cells from subjects with FSGS. We collected 17 urine samples from 12 FSGS subjects and captured these as 23 urine cell samples. The inflammatory signatures from renal epithelial and immune cells were evaluated in bulk gene expression data sets of FSGS and minimal change disease (MCD) (The Nephrotic Syndrome Study Network [NEPTUNE] study) and an immune single-cell data set from lupus nephritis (Accelerating Medicines Partnership). RESULTS: We identified immune cells, predominantly monocytes, and renal epithelial cells in the urine. Further analysis revealed 2 monocyte subtypes consistent with M1 and M2 monocytes. Shed podocytes in the urine had high expression of marker genes for epithelial-to-mesenchymal transition (EMT). We selected the 16 most highly expressed genes from urine immune cells and 10 most highly expressed EMT genes from urine podocytes as immune signatures and EMT signatures, respectively. Using kidney biopsy transcriptomic data from NEPTUNE, we found that urine cell immune signature and EMT signature genes were more highly expressed in FSGS biopsies compared with MCD biopsies. CONCLUSION: The identification of monocyte subsets and podocyte expression signatures in the urine samples of subjects with FSGS suggests that urine cell profiling might serve as a diagnostic and prognostic tool in nephrotic syndrome. Furthermore, this approach may aid in the development of novel biomarkers and identifying personalized therapies targeting particular molecular pathways in immune cells and podocytes.

Mobilizing the U.S. Military's TRICARE Program for Value-Based Care: A Report From the Defense Health Board.

The U.S. Military Health System spends about $50 billion annually to provide care to 9.6 million active duty service members, retirees, and their families through its TRICARE health plans. TRICARE follows the predominant payment model in the USA-fee-for-service-although the Department of Defense (DoD) and Congress encourage and mandate a move toward alternative payment models-mainly, fee-for-value. For the next TRICARE contracts which will begin in 2023, the DoD asked its health-focused federal advisory committee, the Defense Health Board (DHB), to recommend how best to assess and prioritize leading value-based healthcare initiatives identified from private, public, and employer-based health plans. The November 2020 report, 'Modernization of the TRICARE Benefit', specifies a rubric to evaluate these value-based care initiatives not only in traditional measures of effectiveness but also in terms of the Defense Health Agency's Quadruple Aim with its focus on readiness. The goal of TRICARE's move toward value-based care is to leverage its size and focus on prevention of disease and injury to maintain the readiness of the U.S. Armed Forces in addition to delivering great outcomes and value to the DoD's nearly 10 million beneficiaries. The DHB emphasizes that TRICARE's size and focus on providing quality care at lower cost will incentivize providers to participate in the shift toward value-based care despite the potential challenges in transitioning to this system. This shift also aims to motivate other large government and private payors to accelerate the adoption of value-based care through TRICARE's example.

Impact of parental injury on adolescent sleep.

STUDY OBJECTIVES: The aim of this study was to determine the impact of serious parental injury on adolescent sleep disorder diagnoses, outpatient care, and medication use. METHODS: U.S. military personnel who sustained a serious injury and were parents of adolescents aged 10-18 years were identified. Included adolescents were enrolled in the Military Health System for 2 years before their parent's injury and 2 years after the injury. We used logistic regression clustered by adolescents to compare the odds of having a sleep diagnosis and negative binomial regression analysis clustered by adolescents to compare outpatient sleep disorder visits and sleep medication days before and after parental injury. RESULTS: There were 96,318 parents seriously injured during 2004-2014 who had 117,577 children aged 10-18 years in 2002-2016. Approximately 2% of adolescents had a sleep disorder diagnosis, both before and after their parent's injury or illness. Outpatient sleep disorder visits increased 36% after a parent's injury (incidence rate ratio 1.36 [1.24-1.50]), with a twofold increase in insomnia visits (incidence rate ratio 2.35 [2.08-2.64]). Increases in sleep visits were most pronounced in adolescents of parents with traumatic brain injury, comorbid traumatic brain injury and posttraumatic stress disorder, battle injury, and those who were medically discharged from the military. The number of adolescents using sleep medications increased, but sleep medication days did not increase. CONCLUSIONS: Adolescents in our study used more outpatient medical care for sleep disorders; sleep medication use increased after parental injury. Sleep disorders should be considered in the care of adolescents with injured parents.

Brief Report: Association of Complicated Appendicitis in Children with Autism Spectrum Disorders.

Appendicitis is the most common surgical emergency in children and can lead to significant complications. The aim of our study was to determine whether children with autism spectrum disorders (ASD) are at increased risk for appendicitis and its complications compared to neurotypical (NT) peers. From 2000 to 2013, 292,572 children were included (n = 48,762 ASD). ASD children exhibited an incidence of 8.66 appendicitis cases per 10,000 person-years, P > 0.05. There was an increased risk of perforation in ASD children age 15-17 years-old (OR 2.25; 95% CI 1.15-4.42) as well as an increased odds of sepsis (OR 3.44, 95% CI 1.43-8.27). Providers should display heightened awareness for the risk of complicated appendicitis in children with ASD.

The Impact Of Military Parents' Injuries On The Health And Well-Being Of Their Children.

Parental injuries and illnesses affect child and family life. We hypothesized that military parental injury would adversely affect children's preventive care, injuries, maltreatment, mental health care, and psychiatric medication prescriptions. Visit and prescription data of 485,002 military-connected children ages 2-16 were tracked for two years before and two years after the injury of a parent in the period 2004-14. Adjusted negative binomial regression compared pre- and post-injury visit and prescription rates. Children with injured parents had decreased rates of preventive care visits and increased rates of visits for injuries, maltreatment, and mental health care, as well as increased psychiatric medication use, following their parent's injury. Across all categories of care, children of parents with posttraumatic stress disorder (PTSD), both alone and with traumatic brain injury, appeared to have more pronounced changes in care patterns. Parental injury and illness are associated with changes in children's health care use, and PTSD in a parent increases the effect.

Mental Health Trends in Military Pediatrics.

OBJECTIVE: Childhood psychiatric disorders affect current functioning and predispose individuals to more severe adult mental health problems. Provider survey research has suggested that children's mental health problems are increasing; observed changes may be due to increased illness or improved access to care. The authors sought to quantify trends in the prevalence of diagnosed and treated mental health conditions, outpatient treatment, and psychiatric medication prescriptions in a large population of children who were continuously insured. METHODS: The authors performed a retrospective trend study of diagnosed mental health conditions, treatment, and psychiatric medication prescriptions from 2003 to 2015 in children ages 2-18 who were military dependents (N=1,798,530). Poisson regression analyses and Cochran-Armitage tests determined trends in the prevalence of treated psychiatric diagnoses overall and by subcategory, rates of outpatient mental health visits, and psychiatric medication use overall and by specific class. RESULTS: From 2003 to 2015, the prevalence of children with diagnosed mental health conditions increased from 9.2% to 15.2% (rate ratio=1.04, 95% confidence interval=1.04-1.05, p<0.001). Identified suicidal ideation prevalence increased by 20% a year. Mental health care visits increased by 2% a year, and psychiatric medication prescriptions increased by 3% a year between 2003 and 2015, with larger increases seen among older children. Prescriptions for children with identified mental health conditions did not increase. CONCLUSIONS: Diagnosed mental health conditions, pharmaceutical treatment, and outpatient visits all increased across a diverse U.S. pediatric population from 2003 to 2015. Results suggest that use of psychiatric medications kept pace with the increased number of diagnoses and that older children are most affected.

Gender Dysphoria in Children with Autism Spectrum Disorder.

PURPOSE: While gender dysphoria (GD) and autism spectrum disorder (ASD) are generally identified in isolation, research on individuals who are gender-referred or have autism suggests a possible overrepresentation of ASD in persons with GD and GD in persons with ASD. We investigated diagnosed GD in patients formally diagnosed with ASD and matched controls in the Military Health System. METHODS: We performed a retrospective case-cohort study of GD diagnoses in children aged 2-18 years with and without ASD utilizing health care records from 2000 to 2013. Cases were formally diagnosed with ASD and matched to five controls by date of birth, gender marker, and enrollment time. Outpatient visits for GD were identified by relevant International Classification of Diseases, Ninth Revision codes. Logistic regression analysis determined odds ratios (ORs) and 95% confidence intervals (95% CIs) of GD diagnoses by ASD. RESULTS: A total of 48,762 children with diagnosed ASD were identified, and each matched to five controls, for a total of 292,572 children. Cases and controls were each 80% assigned male at birth. The median end age of included children was 11.6 years. Of included children, 66 (0.02%) had diagnosed GD. Children with ASD were over four times as likely to be diagnosed with a condition indicating GD (OR 4.38 [95% CI 2.64-7.27], p < 0.001) compared with matched controls. CONCLUSION: This study corroborates previous research indicating an overrepresentation of GD in children with ASD. Further research is needed to understand the association and to demonstrate approaches to providing optimal care to these children.

Association Between Use of Acid-Suppressive Medications and Antibiotics During Infancy and Allergic Diseases in Early Childhood.

Importance: Allergic diseases are prevalent in childhood. Early exposure to medications that can alter the microbiome, including acid-suppressive medications and antibiotics, may influence the likelihood of allergy. Objective: To determine whether there is an association between the use of acid-suppressive medications or antibiotics in the first 6 months of infancy and development of allergic diseases in early childhood. Design, Setting, and Participants: A retrospective cohort study was conducted in 792 130 children who were Department of Defense TRICARE beneficiaries with a birth medical record in the Military Health System database between October 1, 2001, and September 30, 2013, with continued enrollment from within 35 days of birth until at least age 1 year. Children who had an initial birth stay of greater than 7 days or were diagnosed with any of the outcome allergic conditions within the first 6 months of life were excluded from the study. Data analysis was performed from April 15, 2015, to January 4, 2018. Exposures: Exposures were defined as having any dispensed prescription for a histamine-2 receptor antagonist (H2RA), proton pump inhibitor (PPI), or antibiotic. Main Outcomes and Measures: The main outcome was allergic disease, defined as the presence of food allergy, anaphylaxis, asthma, atopic dermatitis, allergic rhinitis, allergic conjunctivitis, urticaria, contact dermatitis, medication allergy, or other allergy. Results: Of 792 130 children (395 215 [49.9%] girls) included for analysis, 60 209 (7.6%) were prescribed an H2RA, 13 687 (1.7%) were prescribed a PPI, and 131 708 (16.6%) were prescribed an antibiotic during the first 6 months of life. Data for each child were available for a median of 4.6 years. Adjusted hazard ratios (aHRs) in children prescribed H2RAs and PPIs, respectively, were 2.18 (95% CI, 2.04-2.33) and 2.59 (95% CI, 2.25-3.00) for food allergy, 1.70 (95% CI, 1.60-1.80) and 1.84 (95% CI, 1.56-2.17) for medication allergy, 1.51 (95% CI, 1.38-1.66) and 1.45 (95% CI, 1.22-1.73) for anaphylaxis, 1.50 (95% CI, 1.46-1.54) and 1.44 (95% CI, 1.36-1.52) for allergic rhinitis, and 1.25 (95% CI, 1.21-1.29) and 1.41 (95% CI, 1.31-1.52) for asthma. The aHRs after antibiotic prescription in the first 6 months of life were 2.09 (95% CI, 2.05-2.13) for asthma, 1.75 (95% CI, 1.72-1.78) for allergic rhinitis, 1.51 (95% CI, 1.38-1.66) for anaphylaxis, and 1.42 (95% CI, 1.34-1.50) for allergic conjunctivitis. Conclusions and Relevance: This study found associations between the use of acid-suppressive medications and antibiotics during the first 6 months of infancy and subsequent development of allergic disease. Acid-suppressive medications and antibiotics should be used during infancy only in situations of clear clinical benefit.

Lower Preterm Birth Rates but Persistent Racial Disparities in an Open-Access Health Care System.

BACKGROUND: The Military Health System (MHS) provides universal access to medical care to active duty service members, retirees, and their dependents. Observational data from small studies suggest lower preterm birth rates in the MHS compared with U.S. national averages. The objectives of this study are to determine the rate of preterm birth in the MHS from 2006 to 2012 compared with national rates and to analyze the impact of demographic factors on preterm birth in a universal access health care system. METHODS: A cohort of infants born in 2006-2012 was formed from the MHS M2 database. International Classification of Disease - Ninth Revision (ICD-9) codes were used to define prematurity. Preterm births were linked to military parent's demographic data. Calculated MHS preterm birth rates were compared with U.S. national data using the Pearson chi-square test and comparison via standardized differences. Logistic regression analyses were used to determine the impact of demographic factors on prematurity. FINDINGS: From 2006 to 2012, 564,920 infants were born in the MHS; 45,445 (8%) were born preterm. The preterm birth rate in the MHS peaked at 8.34% in 2008 and declined to 7.67% in 2012, which is significantly lower than the U.S. national average preterm birth rate over the same time period. In the 2008-2012 cohort, the odds of preterm birth were increased with Black race (adjusted odds ratio 1.30; 95% confidence interval 1.26-1.33) and with a parent of junior enlisted rank (adjusted odds ratio 1.08; 95% confidence interval 1.05-1.06), a surrogate for lower socioeconomic status. Odds of preterm birth were decreased in families with married parents and with an active duty mother. DISCUSSION: Preterm birth rates in the MHS have been consistently lower than national rates from 2006 to 2012, potentially due to universal access to health care. Black race increased odds of preterm birth despite universal access to health care. These findings support the need for further research examining racial disparities in health care outcomes related to preterm birth.

Association of Autism Spectrum Disorders and Inflammatory Bowel Disease.

Autism spectrum disorders (ASD) and inflammatory bowel disease (IBD) both have multifactorial pathogenesis with an increasing number of studies demonstrating gut-brain associations. We aim to examine the association between ASD and IBD using strict classification criteria for IBD. We conducted a retrospective case-cohort study using records from the Military Health System database with IBD defined as having one encounter with an ICD-9-CM diagnostic code for IBD and at least one outpatient prescription dispensed for a medication to treat IBD. Children with ASD were more likely to meet criteria for Crohn's disease (CD) and Ulcerative colitis (UC) compared to controls. This higher prevalence of CD and UC in children with ASD compared to controls confirms the association of ASD with IBD.

Association of Inflammatory Bowel Disease and Urolithiasis in Hospitalized Pediatric Patients.

BACKGROUND: Urolithiasis is rare in pediatric patients. All patients with inflammatory bowel disease (IBD) have an increased risk of urolithiasis, but this risk is poorly quantified in children. The objective of this study is to evaluate the association of IBD with urolithiasis, assess surgical outcomes, and analyze the financial burden for children hospitalized with urolithiasis and comorbid IBD. METHODS: The triennial Healthcare Cost and Utilization Project Kids' Inpatient Database for years 1997 to 2012 was used to evaluate the association between urolithiasis and IBD in hospitalized, nonpregnant children ages 5 to 20 years old. Billing codes were used to define conditions. Logistic regression analysis quantified the association between IBD types and urolithiasis. Length of hospital stay, costs, procedures, and complications were compared between urolithiasis patients with and without IBD. RESULTS: Among 8,828,522 hospital admissions, we identified 36,771 admissions with a primary diagnosis of urolithiasis. Of these cases, 230 were associated with Crohn's disease (odds ratios, 1.99; 95% confidence interval, 1.74-2.27) and 102 with ulcerative colitis (odds ratio, 1.63; 95% confidence interval, 1.34-1.99). Urolithiasis patients with ulcerative colitis, but not Crohn's disease, had significantly increased length of stay and costs. Patients with either IBD had a decreased number of urologic procedures. CONCLUSIONS: The diagnosis of urolithiasis in pediatric patients is associated with IBD, and those with ulcerative colitis have longer hospital stays and greater costs. Patients with IBD have fewer urologic procedures associated with their urolithiasis diagnosis.

Autism Spectrum Disorders and Metabolic Complications of Obesity.

OBJECTIVES: To assess for an increased risk of obesity, type 2 diabetes mellitus, hypertension, hyperlipidemia, and nonalcoholic fatty liver disease/nonalcoholic steatohepatitis in children with autism spectrum disorders (ASD). Additionally, to determine the rates of prescribed treatment for obesity-related metabolic disorders and to determine whether treatment with psychotropic medications is associated with the development of obesity for children with ASD. STUDY DESIGN: A retrospective 1:5 case-control study was performed by use of the Military Health System database from October 2000 to September 2013. For children with ASD and matched controls, International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes for obesity, type 2 diabetes mellitus, hypertension, hyperlipidemia, nonalcoholic fatty liver disease/nonalcoholic steatohepatitis, and prescriptions were obtained. Conditional logistic regression determined ORs and 95% CIs. RESULTS: A total of 48 762 individuals with ASD and 243 810 matched controls were identified. Children with ASD had significantly greater odds of having obesity (OR 1.85; 95% CI 1.78-1.92), having obesity-related disorders, and being prescribed a medication when they had these diseases. In children with ASD, mood stabilizers, antipsychotics, antiepileptic drugs, and selective serotonin reuptake inhibitors were associated with obesity. CONCLUSIONS: Children with ASD have an increased risk of obesity and obesity-related metabolic disorders. They are more likely to be prescribed medications to treat these complications, suggesting they may have more severe disease. There is a significant association between the use of some psychotropic categories and a diagnosis of obesity, suggesting that obesity in children with ASD may be partially iatrogenic.

Primary renal magnesium wasting: an unusual clinical picture of exercise-induced symptoms.

Magnesium is one of the most abundant cations in the human body and plays a key role as a metabolic enzyme cofactor and regulatory ion for neurons and cardiomyocytes. Hypomagnesemia due to isolated primary renal magnesium wasting is a rare clinical condition typically associated with neurological hyperexcitability. Exercise-related gastrointestinal symptoms are caused by ischemic, mechanical, or neurohormonal changes. The role of hypomagnesemia in gastrointestinal symptoms is not well understood. We present a case of a 15-year-old male who presented with exercise-induced abdominal pain, nausea, and vomiting, who was found to have profound hypomagnesemia and inappropriately elevated fractional excretion of magnesium (FEMg). Testing for multiple intrinsic and extrinsic etiologies of renal magnesium wasting was inconclusive. He was diagnosed with primary renal magnesium wasting and his symptoms resolved acutely with intravenous magnesium sulfate and with long-term oral magnesium chloride. Primary renal magnesium wasting is a rare clinical entity that can cause extreme hypomagnesemia. It has not been associated previously with exercise-induced gastrointestinal symptoms. The effects of hypomagnesemia on the human gastrointestinal tract are not well established. This case offers unique insights into the importance of magnesium homeostasis in the gastrointestinal tract. Exercise-induced splanchnic hypoperfusion may contribute to gastrointestinal symptoms observed in this chronically hypomagnesemic patient.

Prevalence of Diagnosed Sleep Disorders and Related Diagnostic and Surgical Procedures in Children with Autism Spectrum Disorders.

OBJECTIVE: Sleep disorders are common and important comorbid conditions in children with autism spectrum disorder (ASD) and can contribute to cognitive and behavioral problems. Sleep-disordered breathing (SDB) is a diagnosable and treatable cause of behavioral problems in children. We aimed to quantify the relative risk for children with ASD versus controls of being diagnosed with sleep disorders including SDB and undergoing related diagnostic and surgical procedures. METHOD: This retrospective case-cohort study included 48,762 children with ASD aged 2 to 18 years enrolled in the military health system (MHS) from 2000 to 2013. Children with ASD were matched 1:5 by birthdate, sex, and enrollment time to children without an ASD diagnosis. The MHS database was queried for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for sleep disorders or ICD-9-CM and Current Procedural Terminology codes for diagnostic and surgical procedures. Relative risks (RR) and 95% confidence intervals (CI) were determined with binary Poisson regression conditional on the match and adjusting for confounders. RESULTS: Children with ASD were at higher risk of receiving any sleep disorder diagnosis (RR: 1.97 [95% CI, 1.91-2.02]) including SDB (RR: 1.96 [95% CI, 1.88-2.05]). Children with ASD also were at increased risk of undergoing polysomnography (RR: 3.74 [95% CI, 3.56-3.93]) and sleep disorder-related surgery (RR: 1.50 [95% CI, 1.46-1.54]). CONCLUSION: Children with ASD are more likely to be given a sleep disorder diagnosis including SDB and are more likely to undergo related diagnostic and surgical procedures compared with controls without ASD.

In Pursuit of Meaningful Use of Learning Goals in Residency: A Qualitative Study of Pediatric Residents.

PURPOSE: Medical education aims to equip physicians for lifelong learning, an objective supported by the conceptual framework of self-regulated learning (SRL). Learning goals have been used to develop SRL skills in learners across the medical education continuum. This study's purpose was to elicit residents' perspectives on learning goal use and to develop explanations suggesting how aspects of the learning environment may facilitate or hinder the meaningful use of learning goals in residency. METHOD: Resident focus groups and program director interviews were conducted in 2012-2013, audio-recorded, and transcribed. Programs were selected to maximize diversity of size, geographic location, type of program, and current use of learning goals. Data were analyzed using the constant comparative method associated with grounded theory. Further analysis compared themes frequently occurring together to strengthen the understanding of relationships between the themes. Through iterative discussions, investigators built a grounded theory. RESULTS: Ninety-five third-year residents and 12 program directors at 12 pediatric residency programs participated. The analysis identified 21 subthemes grouped into 5 themes: program support, faculty roles, goal characteristics and purposes, resident attributes, and accountability and goal follow-through. Review of relationships between the themes revealed a pyramid of support with program support as the foundation that facilitates the layers above it, leading to goal follow-through. CONCLUSIONS: Program support facilitates each step of the SRL process that leads to meaningful use of learning goals in residency. A strong foundation of program support should include attention to aspects of the implicit curriculum as well as the explicit curriculum.

Impact of parents' wartime military deployment and injury on young children's safety and mental health.

OBJECTIVE: Children are at risk for adverse outcomes during parental military deployments. We aim to determine the impact of parental deployment and combat injury on young children's postdeployment mental health, injuries, and maltreatment. METHOD: This is a population-based, retrospective cohort study of young children of active duty military parents during fiscal years (FY) 2006 to 2007, a high deployment period. A total of 487,460 children, 3 to 8 years of age, who received Military Health System care, were included. The relative rates of mental health, injury, and child maltreatment visits of children whose parents deployed and children of combat-injured parents were compared to children unexposed to parental deployment. RESULTS: Of the included children, 58,479 (12%) had a parent deploy, and 5,405 (1%) had a parent injured during deployment. Relative to children whose parents did not deploy, children of deployed and combat-injured parents, respectively, had additional visits for mental health diagnoses (incidence rate ratio [IRR] = 1.09 [95% CI = 1.02-1.17], IRR = 1.67 [95% CI = 1.47-1.89]), injuries (IRR = 1.07 [95% CI = 1.04-1.09], IRR = 1.24 [95% CI = 1.17-1.32]), and child maltreatment (IRR = 1.21 [95% CI = 1.11-1.32], IRR 2.30 = [95% CI 2.02-2.61]) postdeployment. CONCLUSION: Young children of deployed and combat-injured military parents have more postdeployment visits for mental health, injuries, and child maltreatment. Mental health problems, injuries, and maltreatment after a parent's return from deployment are amplified in children of combat-injured parents. Increased preventive and intervention services are needed for young children as parents return from deployments. Child health and mental health providers are crucial to effective identification of these at-risk children to ensure effective care provision.

Association of Autism Spectrum Disorders With Neonatal Hyperbilirubinemia.

Autism spectrum disorders (ASD) are a common neurodevelopmental disorder of unknown etiology. Studies suggest a link between autism and neonatal jaundice. A 1:3 matched case-control study was conducted with children enrolled in the Military Health System born between October 2002 and September 2009. Diagnostic and procedure codes were used for identifying ASD and hyperbilirubinemia. Two definitions for hyperbilirubinemia were evaluated: an inpatient admission with a diagnosis of jaundice and treatment with phototherapy. A total of 2917 children with ASD and 8751 matched controls were included in the study. After adjustment, there remained an association between ASD in children and an admission with a diagnosis of jaundice (odds ratio = 1.18; 95% confidence interval = 1.06-1.31; P = .001) and phototherapy treatment (odds ratio = 1.33; 95% confidence interval = 1.04-1.69; P = .008). Children who develop ASD are more likely to have an admission with a diagnosis of jaundice in the neonatal period and more likely to require treatment for this jaundice.