Delayed care during pregnancy and postpartum linked to poor maternal mental health: evidence in the United States.

BACKGROUND: Mental health disorders are important prenatal and postpartum health complications. In the rapidly changing healthcare landscape, concerns have been raised about maternal mental well-being in the United States. This study aimed to investigate the relationship between delayed perinatal care and women's mental health during pregnancy and postpartum. METHODS: We conducted a cross-sectional survey from March through April, 2022, of women currently pregnant (n = 590) or one-year postpartum (n = 525). A generalised linear model examined the association of delayed care during pregnancy and postpartum with mental health outcomes, specifically Major Depressive Disorder (MDD) and Generalised Anxiety Disorder (GAD). RESULTS: Individuals who experienced delayed care tended to exhibit higher rates of mental health symptoms compared to those without delays, especially during postpartum (69.4% vs. 30.7% for MDD; 46.6% vs. 24.8% for GAD). The results from multivariable regression analysis were consistent, showing a greater prevalence of MDD (aPR [adjusted Prevalence Ratio] 2.25, 95%CI 1.82-2.79; p < .001) and GAD (aPR 2.00, 95%CI 1.53-2.61; p < .001), respectively, when delays in postpartum care occurred. Reasons for delayed care, such as financial and time issues, lack of transportation, nervousness about seeing a doctor, and rural residency, were associated with increased mental health symptoms. CONCLUSION: The current analysis highlights the significant adverse health impact of delayed care among pregnant and postpartum women. Continued, targeted efforts to reduce practical barriers to accessing prenatal and postpartum care are required to ensure maternal mental health.

Alcohol and Binge Drinking Frequency and Hypertension: a national cross-sectional study in the U.S.

INTRODUCTION: The relationship between alcohol consumption and hypertension is multifaceted and a major public health concern. The association becomes even more complicated when hypertension is undiagnosed. This study investigates how alcohol consumption patterns are linked to measured, diagnosed, undiagnosed, and composite hypertension (any indications of hypertension from blood pressure readings, professional diagnosis, or reported medication use) in the United States. METHODS: Data from the National Health and Nutrition Examination Survey (NHANES) 2015-2020, a nationally representative cross-sectional study, were analyzed in 2023-24. The final analytic sample was 12,950 participants. Complex-survey weighted multivariable linear and logistic regression models estimated the effect of different alcohol consumption levels on hypertension. RESULTS: Descriptive findings show that those who consumed alcohol more than three times weekly exhibited the highest prevalence of measured (52.5%), undiagnosed (27.0%), and composite hypertension (69.4%) compared to other levels of alcohol drinking. Multivariable linear regression analysis indicated a notable elevation in systolic (4.8 unit) and diastolic (2.46 unit) blood pressure among individuals with frequent binge drinking episodes compared to individuals with infrequent drinking. Logistic regression models estimated that drinking over three times weekly increases the odds of measured, undiagnosed, and composite hypertension by 64%, 70%, and 54%, respectively, while frequent binge drinking episodes raise these odds by 82%, 65%, and 47%. CONCLUSIONS: Contrary to some studies suggesting moderate alcohol intake has protective cardiovascular effects, the findings did not corroborate a "J-shaped" curve. This underscores the importance of regular blood pressure monitoring among individuals with binge drinking episodes and emphasizes the need for public health interventions to mitigate alcohol consumption and its associated hypertension risks.

Association of enterolactone with blood pressure and hypertension risk in NHANES.

The gut microbiome may affect overall cardiometabolic health. Enterolactone is an enterolignan reflective of dietary lignan intake and gut microbiota composition and diversity that can be measured in the urine. The purpose of this study was to examine the association between urinary enterolactone concentration as a reflection of gut health and blood pressure/risk of hypertension in a large representative sample from the US population. This analysis was conducted using data from the National Health and Nutrition Examination Survey (NHANES) collected from January 1999 through December 2010. Variables of interest included participant characteristics (including demographic, anthropometric and social/environmental factors), resting blood pressure and hypertension history, and urinary enterolactone concentration. 10,637 participants (45 years (SE = 0.3), 51.7% (SE = 0.6%) were female) were included in analyses. In multivariable models adjusted for demographic, socioeconomic and behavioral/environmental covariates, each one-unit change in log-transformed increase in enterolactone was associated with a 0.738 point (95% CI: -0.946, -0.529; p<0.001) decrease in systolic blood pressure and a 0.407 point (95% CI: -0.575, -0.239; p<0.001) decrease in diastolic blood pressure. Moreover, in fully adjusted models, each one-unit change in log-transformed enterolactone was associated with 8.2% lower odds of hypertension (OR = 0.918; 95% CI: 0.892, 0.944; p<0.001). Urinary enterolactone, an indicator of gut microbiome health, is inversely associated with blood pressure and hypertension risk in a nationally representative sample of U.S. adults.

Comparison of Racial and Ethnic Mortality Disparities among Post-9/11 Veterans with and without Traumatic Brain Injury to the Total U.S. Adult Population.

INTRODUCTION: The extent of racial/ethnic disparities and whether they are attenuated in the Veteran population compared to the total US population is not well understood. We aimed to assess racial/ethnic mortality disparities from all-cause, cardiovascular (CVD) and cancer among post-9/11 military Veterans with and without exposure to TBI, compared to the total US population. METHODS: This cohort study included 2,502,101 US military Veterans (18,932,083 person-years) who served after 09/11/2001 with 3 or more years of care in the Military Health System (MHS); or had 3 or more years of care in the MHS and 2 or more years of care in the Veterans Health Administration. Mortality follow-up occurred from 01/01/2002 to 12/31/2020. Mortality rate ratios (MRR) from negative binomial regression models were reported for racial/ethnic groups compared to White non-Hispanic Veterans for all-cause, CVD and cancer mortality. Veteran MRR were compared to the total US population. RESULTS: Mortality rates for Black Non-Hispanic Veterans were higher for all-cause (MRR = 1.21;95%CI: 1.13-1.29; p < 0.001), CVD (MRR = 1.78;95%CI: 1.62-1.96; p < 0.001) and cancer (MRR = 1.17;95%CI: 1.10-1.25; p < 0.001) than in White Non-Hispanic Veterans. Among Veterans with TBI, only Black Non-Hispanics had higher mortality than White Non-Hispanics and only for CVD (MRR = 1.32;95%CI: 1.12-1.54; p < 0.001), while CVD mortality was higher among Veterans without TBI (MRR = 1.77;95%CI: 1.63-1.93;p < 0.001). MRR for Black Non-Hispanics in the total US population, were consistently higher than those in the Veteran population for all-cause (MRR = 1.52;95%CI: 1.46-1.58; p < 0.001), CVD (MRR = 2.03;95%CI: 1.95-2.13; p < 0.001) and cancer (MRR = 1.26;95%CI: 1.22-1.30; p < 0.001). CONCLUSION: This Veteran cohort experienced less racial/ethnic disparity in mortality than the total US population, especially among Veterans with TBI.

Prevalence of Cardiovascular and Cancer Risk Factors Among Rheumatoid Arthritis Patients Prescribed Janus Kinase Inhibitors and Tumor Necrosis Factor Inhibitors: A Cross-Sectional Study.

OBJECTIVE: The study was to determine the prevalence of baseline risk factors for cardiovascular outcomes and cancer among commercially-insured patients with rheumatoid arthritis (RA) during their first dispensed treatment for either tumor necrosis factor inhibitors (TNFi) or JAK inhibitors (JAKi). METHODS: Patients with RA from August 16, 2019 to March 31, 2022 were identified in the Merative MarketScan Commercial and Medicare databases. The first date that a TNFi or JAKi was dispensed was the index date, and baseline risk factors were assessed among patients continuously eligible for 12 months before the index date. Patients who had the following were stratified into an elevated risk category: age ≥65 years, smoking, or a history of a major adverse cardiovascular event, venous thromboembolism, or cancer. The prevalence of modifiable risk factors was also reported: hypertension, hyperlipidemia, obesity, and diabetes. The crude prevalence and prevalence difference (PD) were reported. RESULTS: A total of 12,673 patients (TNFi [n = 7,748; 61%] and JAKi [n = 4,925; 39%]) met inclusion criteria. The prevalence of elevated risk was the same for all patients using TNFi (n = 2,051; 26%) and JAKi (n = 1,262; 26%). Compared with patients having low risk, patients with an elevated risk also had a higher prevalence of at least one primary modifiable risk factor for both patients using JAKi (79% vs 58%; PD 21%, 95% confidence interval [CI] 18%-24%) and TNFi (81% vs 60%; PD 21%, 95% CI 19%-23%). CONCLUSION: In recent years, JAKi and TNFi were used in similar proportions to treat RA among commercially-insured patients at elevated cardiovascular and cancer risk. Because uncontrolled disease, modifiable comorbidities, and treatment with JAKi are associated with these adverse events, future studies evaluating how practice patterns may be affected by the emergence of safety data will be of value.

Traumatic Brain Injury and Subsequent Risk of Brain Cancer in US Veterans of the Iraq and Afghanistan Wars.

Importance: While brain cancer is rare, it has a very poor prognosis and few established risk factors. To date, epidemiologic work examining the potential association of traumatic brain injury (TBI) with the subsequent risk of brain cancer is conflicting. Further data may be useful. Objective: To examine whether a history of TBI exposure is associated with the subsequent development of brain cancer. Design, Setting, and Participants: A retrospective cohort study was conducted from October 1, 2004, to September 20, 2019, and data analysis was performed between January 1 and June 26, 2023. The median follow-up for the cohort was 7.2 (IQR, 4.1-10.1) years. Veterans Affairs (VA) and Department of Defense (DoD) administrative data on 1 919 740 veterans from the Long-Term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium were included. Exposure: The main exposure of interest was TBI severity (categorized as mild, moderate or severe [moderate/severe], and penetrating). Main Outcomes and Measures: The outcome of interest was the development of brain cancer based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic codes in either the DoD/VA medical records or from the National Death Index. Results: After 611 107 exclusions (predominately for no encounter during the study period), a cohort including 1 919 740 veterans was included, most of whom were male (80.25%) and non-Hispanic White (63.11%). Median age at index date was 31 (IQR, 25-42) years. The cohort included 449 880 individuals with TBI (mild, 385 848; moderate/severe, 46 859; and penetrating, 17 173). Brain cancer occurred in 318 individuals without TBI (0.02%), 80 with mild TBI (0.02%), 17 with moderate/severe TBI (0.04%), and 10 or fewer with penetrating TBI (≤0.06%). After adjustment, moderate/severe TBI (adjusted hazard ratio [AHR], 1.90; 95% CI, 1.16-3.12) and penetrating TBI (AHR, 3.33; 95% CI, 1.71-6.49), but not mild TBI (AHR, 1.14; 95% CI, 0.88-1.47), were associated with the subsequent development of brain cancer. Conclusions and Relevance: In this cohort study of veterans of the Iraq and Afghanistan wars, moderate/severe TBI and penetrating TBI, but not mild TBI, were associated with the subsequent development of brain cancer.

EMS Treatment Guidelines in Major Traumatic Brain Injury With Positive Pressure Ventilation.

Importance: The Excellence in Prehospital Injury Care (EPIC) study demonstrated improved survival in patients with severe traumatic brain injury (TBI) following implementation of the prehospital treatment guidelines. The impact of implementing these guidelines in the subgroup of patients who received positive pressure ventilation (PPV) is unknown. Objective: To evaluate the association of implementation of prehospital TBI evidence-based guidelines with survival among patients with prehospital PPV. Design, Setting, and Participants: The EPIC study was a multisystem, intention-to-treat study using a before/after controlled design. Evidence-based guidelines were implemented by emergency medical service agencies across Arizona. This subanalysis was planned a priori and included participants who received prehospital PPV. Outcomes were compared between the preimplementation and postimplementation cohorts using logistic regression, stratified by predetermined TBI severity categories (moderate, severe, or critical). Data were collected from January 2007 to June 2017, and data were analyzed from January to February 2023. Exposure: Implementation of the evidence-based guidelines for the prehospital care of patient with TBI. Main Outcomes and Measures: The primary outcome was survival to hospital discharge, and the secondary outcome was survival to admission. Results: Among the 21 852 participants in the main study, 5022 received prehospital PPV (preimplementation, 3531 participants; postimplementation, 1491 participants). Of 5022 included participants, 3720 (74.1%) were male, and the median (IQR) age was 36 (22-54) years. Across all severities combined, survival to admission improved (adjusted odds ratio [aOR], 1.59; 95% CI, 1.28-1.97), while survival to discharge did not (aOR, 0.94; 95% CI, 0.78-1.13). Within the cohort with severe TBI but not in the moderate or critical subgroups, survival to hospital admission increased (aOR, 6.44; 95% CI, 2.39-22.00), as did survival to discharge (aOR, 3.52; 95% CI, 1.96-6.34). Conclusions and Relevance: Among patients with severe TBI who received active airway interventions in the field, guideline implementation was independently associated with improved survival to hospital admission and discharge. This was true whether they received basic airway interventions or advanced airways. These findings support the current guideline recommendations for aggressive prevention/correction of hypoxia and hyperventilation in patients with severe TBI, regardless of which airway type is used.

Investigating Racial and Ethnic Disparities in Maternal Care at the System Level Using Patient Safety Incident Reports.

BACKGROUND: Maternal mortality in the United States is high, and women and birthing people of color experience higher rates of mortality and severe maternal morbidity (SMM). More than half of maternal deaths and cases of SMM are considered preventable. The research presented here investigated systems issues contributing to adverse outcomes and racial/ethnic disparities in maternal care using patient safety incident reports. METHODS: The authors reviewed incidents reported in the labor and delivery unit (L&D) and the antepartum and postpartum unit (A&P) of a large academic hospital in 2019 and 2020. Deliveries associated with a reported incident were described by race/ethnicity, age group, method of delivery, and several other process variables. Differences across racial/ethnic group were statistically evaluated. RESULTS: Almost two thirds (64.8%) of the 528 reports analyzed were reported in L&D, and 35.2% were reported in A&P. Non-Hispanic white (NHW) patients accounted for 43.9% of reported incidents, non-Hispanic Black (NHB) patients accounted for 43.2%, Hispanic patients accounted for 8.9%, and patients categorized as "other" accounted for 4.0%. NHB patients were disproportionally represented in the incident reports, as they accounted for only 36.5% of the underlying birthing population. The odds ratio (OR) demonstrated a higher risk of a reported adverse incident for NHB patients; however, adjustment for cesarean section attenuated the association (OR 1.25, 95% confidence interval 1.01-1.54). CONCLUSION: Greater integration of patient safety and health equity efforts in hospitals are needed to promptly identify and alleviate racial and ethnic disparities in maternal health outcomes. Although additional systems analysis is necessary, the authors offer recommendations to support safer, more equitable maternal care.

¡Miranos! An 8-Month Comprehensive Preschool Obesity Prevention Program in Low-Income Latino Children: Effects on Children's Gross Motor Development.

Organized childcare is an ideal setting to promote gross motor development in young children from low-income minority families. A three-group clustered randomized controlled trial was conducted in Head Start centers serving low-income Latino children to evaluate the impact of an 8-month comprehensive obesity-prevention intervention on children's percentile scores for locomotive skills (LS pctl) and ball skills (BS pctl), and general motor quotient (GMQ). Trained Head Start staff delivered the center-based intervention (CBI) to modify center physical activity and nutrition policies, staff practices, and child behaviors, while the home-based intervention (HBI) offered training and support to parents for obesity prevention at home. Participants were 3-year-old children (n = 310; 87% Latino; 58% female) enrolled in Head Start centers in South Texas. Twelve centers were randomized (1:1:1 ratio) to receive CBI, CBI and HBI (CBI + HBI), or control treatment. Posttest data were collected from 79.1% of participants. All gross motor development measures improved significantly for children in CBI compared to the control, while children in CBI + HBI only showed improvement for GMQ (p = 0.09) and LS pctl (p < 0.001) compared to the control. A comprehensive and culturally competent intervention targeting childcare centers and children's homes was effective at improving children's gross motor development and reducing disparities in child development.

Age differences in Allostatic Load among adults in the United States by rural-urban residence.

•Rural residence is associated with allostatic load levels by age groups.•Allostatic load is higher among rural adults with the exception of the oldest age group.•Evidence of a rural-urban convergence in allostatic load levels among oldest old.•These rural disadvantages remained strong even when accounting for covariates.•The study of allostatic load can improve our understanding of rural disparities.

Trends in Suicide Rates Among Post-9/11 US Military Veterans With and Without Traumatic Brain Injury From 2006-2020.

This cohort study examines trends in suicide rates for veterans with and without traumatic brain injury compared with the US adult population.

A Review of 75th Ranger Regiment Battle-Injured Fatalities Incurred During Combat Operations From 2001 to 2021.

INTRODUCTION: The 75th Ranger Regiment is an elite U.S. military special operations unit that conducted over 20 years of sustained combat operations. The Regiment has a history of providing novel and cutting-edge prehospital trauma care, advancing and translating medical initiatives, and documenting and reporting casualty care performance improvement efforts. MATERIALS AND METHODS: A retrospective case fatality rate (CFR) review, mortality review, and descriptive analysis of fatalities were conducted for battle-injured personnel assigned or attached to the 75th Ranger Regiment from 2001 to 2021 during combat operations primarily in Afghanistan and Iraq. Fatalities were evaluated for population characteristics, cause of death, mechanism of death, injury severity, injury survivability, and death preventability. RESULTS: A total of 813 battle injury casualties, including 62 fatalities, were incurred over 20 years and 1 month of continuous combat operations. The Regiment maintained a zero rate of prehospital preventable combat death. Additionally, no fatalities had a mechanism of death because of isolated extremity hemorrhage, tension pneumothorax, or airway obstruction. When comparing the CFR of the Regiment to the U.S. military population as a whole, the Regiment had a significantly greater reduction in the cumulative CFR as measured by the difference in average annual percentage change. CONCLUSIONS: Documentation and analysis of casualties and care, mortality and casualty reviews, and other performance improvement efforts can guide combatant commanders, medical directors, and fighting forces to reduce preventable combat deaths and the CFR. Early hemorrhage control, blood product resuscitation, and other lifesaving interventions should be established and maintained as a standard prehospital practice to mitigate fatalities with potentially survivable injuries.

Beyond Being Insured: Insurance Coverage Denial as a Major Barrier to Accessing Care During Pregnancy and Postpartum.

This study investigates the association between insurance coverage denial and delays in care during pregnancy and postpartum. An online survey was administered in March and April 2022 to women who were either pregnant or within 1 year postpartum (n = 1,113). The outcome was delayed care, measured at four time points: during pregnancy and 1 week, 2 to 6 weeks, and after 7 weeks postpartum. The key covariate was insurance coverage denial by providers during pregnancy. Delayed care due to having an unaccepted insurance and being "out-of-network" was more pronounced at 1 week postpartum with 3.37 times and 3.47 times greater odds and in 2 to 6 weeks postpartum with 5.74 times and 2.97 times greater odds, respectively. The association between insurance denial and delays in care encapsulated transportation, rural residency, time issues, and financial constraints. The findings suggest that coverage denial is associated with significant delays in care, providing practical implications for effective perinatal care.

Long-Term Health Care Costs for Service Members Injured in Iraq and Afghanistan.

INTRODUCTION: Over the last two decades, the conflicts in Iraq and Afghanistan have cost the United States significantly in terms of lives lost, disabling injuries, and budgetary expenditures. This manuscript calculates the differences in costs between veterans with combat injuries vs veterans without combat injuries. This work could be used to project future costs in subsequent studies. MATERIALS AND METHODS: In this retrospective cohort study, we randomly selected 7,984 combat-injured veterans between February 1, 2002, and June 14, 2016, from Veterans Affairs Health System administrative data. We matched injured veterans 1:1 to noninjured veterans on year of birth (± 1 year), sex, and first service branch. We observed patients for a maximum of 10 years. This research protocol was reviewed and approved by the David Grant USAF Medical Center institutional review board (IRB), the University of Utah IRB, and the Research Review Committee of the VA Salt Lake City Health Care System in accordance with all applicable Federal regulations. RESULTS: Patients were primarily male (98.1% in both groups) and White (76.4% for injured patients, 72.3% for noninjured patients), with a mean (SD) age of 26.8 (6.6) years for the injured group and 27.7 (7.0) years for noninjured subjects. Average total costs for combat-injured service members were higher for each year studied. The difference was highest in the first year ($16,050 compared to $4,135 for noninjured). These differences remained significant after adjustment. Although this difference was greatest in the first year (marginal effect $12,386, 95% confidence interval $9,736-$15,036; P < 0.001), total costs continued to be elevated in years 2-10, with marginal effects ranging from $1,766 to $2,597 (P < 0.001 for all years). More severe injuries tended to increase costs in all categories. CONCLUSIONS: Combat injured patients have significantly higher long-term health care costs compared to their noninjured counterparts. If this random sample is extrapolated to the 53,251 total of combat wounded service members, it implies a total excess cost of $1.6 billion to date after adjustment for covariates and a median follow-up time of 10 years. These costs are likely to increase as injured veterans age and develop additional chronic conditions.

Correlation between prehospital and in-hospital hypotension and outcomes after traumatic brain injury.

BACKGROUND AND OBJECTIVE: Hypotension has a powerful effect on patient outcome after traumatic brain injury (TBI). The relative impact of hypotension occurring in the field versus during early hospital resuscitation is unknown. We evaluated the association between hypotension and mortality and non-mortality outcomes in four cohorts defined by where the hypotension occurred [neither prehospital nor hospital, prehospital only, hospital only, both prehospital and hospital]. METHODS: Subjects ≥10 years with major TBI were included. Standard statistics were used for unadjusted analyses. We used logistic regression, controlling for significant confounders, to determine the adjusted odds (aOR) for outcomes in each of the three cohorts. RESULTS: Included were 12,582 subjects (69.8% male; median age 44 (IQR 26-61). Mortality by hypotension status: No hypotension: 9.2% (95%CI: 8.7-9.8%); EMS hypotension only: 27.8% (24.6-31.2%); hospital hypotension only: 45.6% (39.1-52.1%); combined EMS/hospital hypotension 57.6% (50.0-65.0%); (p < 0.0001). The aOR for death reflected the same progression: 1.0 (reference-no hypotension), 1.8 (1.39-2.33), 2.61 (1.73-3.94), and 4.36 (2.78-6.84), respectively. The proportion of subjects having hospital hypotension was 19.0% (16.5-21.7%) in those with EMS hypotension compared to 2.0% (1.8-2.3%) for those without (p < 0.0001). Additionally, the proportion of patients with TC hypotension was increased even with EMS "near hypotension" up to an SBP of 120 mmHg [(aOR 3.78 (2.97, 4.82)]. CONCLUSION: While patients with hypotension in the field or on arrival at the trauma center had markedly increased risk of death compared to those with no hypotension, those with prehospital hypotension that was not resolved before hospital arrival had, by far, the highest odds of death. Furthermore, TBI patients who had prehospital hypotension were five times more likely to arrive hypotensive at the trauma center than those who did not. Finally, even "near-hypotension" in the field was strongly and independently associated the risk of a hypotensive hospital arrival (<90 mmHg). These findings are supportive of the prehospital guidelines that recommend aggressive prevention and treatment of hypotension in major TBI.

Evaluation of All-Cause and Cause-Specific Mortality by Race and Ethnicity Among Pregnant and Recently Pregnant Women in the US, 2019 to 2020.

This cross-sectional study examines all-cause and cause-specific mortality rates among pregnant and recently pregnant US women from 2019 to 2020 and compares mortality rates by race and ethnicity.

COVID-19 Concerns, Perceived Stress, and Increased Alcohol Use Among Adult Women in the United States.

The objective of this study was to assess the direct and indirect (via perceived stress) effects of different types of pandemic-related concerns and increased alcohol use among adult women in the United States (US). We conducted a secondary analysis of cross-sectional survey data from April 2020 for adult females in the US who use alcohol (n = 1,089). The indirect effect model accounted for 19% of the variance in perceived stress and 8% of the variance in reporting increased alcohol use compared to no change or decreased use. Path analysis results indicated that concerns about isolation (odds ratio [OR] = 1.027, 95% confidence interval [CI] = 1.013-1.046), job/finances (OR = 1.025, 95% CI = 1.007-1.065), basic needs (OR = 1.021, 95% CI = 1.008-1.047), and concerns about government (OR = 1.038, 95% CI = 1.014-1.179]) were significantly related to reporting increased alcohol use through perceived stress. These findings can inform timely public health interventions to minimize alcohol-related harm among women.

Suicide attempts and mental health diagnoses in combat-injured service members: A retrospective cohort study.

INTRODUCTION: Examinations of risk factors for suicide attempt in United States service members at high risk of mental health diagnoses, such as those with combat injuries, are essential to guiding prevention and intervention efforts. METHODS: Retrospective cohort study of 8727 combat-injured patients matched to deployed, non-injured patients utilizing Department of Defense and Veterans Affairs administrative records. RESULTS: Combat injury was positively associated with suicide attempt in the univariate model (HR = 1.75, 95% CI 1.5-2.1), but lost significance after adjustment for mental health diagnoses. Utilizing Latent Transition Analysis in the combat-injured group, we identified five mental/behavioral health profiles: (1) Few mental health diagnoses, (2) PTSD and depressive disorders, (3) Adjustment disorder, (4) Multiple mental health comorbidities, and (5) Multiple mental health comorbidities with alcohol use disorder (AUD). Multiple mental health comorbidities with AUD had the highest suicide attempt rate throughout the study and more than four times that of Multiple mental health comorbidities in the first study year (23.4 vs. 5.1 per 1000 person years, respectively). CONCLUSION: Findings indicate that (1) combat injury's impact on suicide attempt is attenuated by mental health and (2) AUD with multiple mental health comorbidities confers heightened suicide attempt risk in combat-injured service members.

Increased Self-Reported Mental Health Problems Among Asian-Americans During the COVID-19 Pandemic in the United States: Evidence from a Nationally Representative Database.

BACKGROUND: To investigate changes in mental health outcomes among racial groups between 2019 and 2020. METHODS: A retrospective cohort study was conducted using the third through fourth quarters of 2019-2020 longitudinal data from the National Health Interview Survey. Self-reports of diagnosed depression and anxiety disorder were key outcomes. We calculated the percentage of depression and anxiety disorder across baseline sample characteristics. Discrete-time hazard models stratified by race/ethnicity were conducted, with hazard ratios (HRs), 95% confidence intervals (CIs), and p-values reported. RESULTS: Of a total 10,415 individuals, 16.3 and 14.1% reported that they were diagnosed with depression and anxiety disorder in 2019, respectively. In the multivariable model, only Asian-Americans experienced a significant increase in the probability of receiving a diagnosis of depression by 104% between 2019 and 2020 (HR 2.04, 95%CI 1.19-3.52; p = 0.010). Also, Asian-Americans had a 97% (HR 1.97, 95%CI 1.23-3.15; p = 0.005) greater probability of being diagnosed with anxiety disorder in 2020 than in the previous year, while Hispanics and Whites had a relatively moderate increase of 40% (HR 1.40, 95%CI 1.01-1.76; p = 0.040) and 11% (HR 1.11, 95%CI 1.03-1.20; p = 0.007), respectively. CONCLUSIONS: Asian-Americans experienced a disproportionate increase in mental health conditions during the COVID-19 pandemic. Discriminatory behaviors against Asian-Americans may be important contributors. The study findings suggest the need for serious actions to address this issue.

United States Military Fatalities During Operation Inherent Resolve and Operation Freedom's Sentinel.

BACKGROUND: Military operations provide a unified action and strategic approach to achieve national goals and objectives. Mortality reviews from military operations can guide injury prevention and casualty care efforts. METHODS: A retrospective study was conducted on all U.S. military fatalities from Operation Inherent Resolve (OIR) in Iraq (2014-2021) and Operation Freedom's Sentinel (OFS) in Afghanistan (2015-2021). Data were obtained from autopsy reports and other existing records. Fatalities were evaluated for population characteristics; manner, cause, and location of death; and underlying atherosclerosis. Non-suicide trauma fatalities were also evaluated for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement. RESULTS: Of 213 U.S. military fatalities (median age, 29 years; male, 93.0%; prehospital, 89.2%), 49.8% were from OIR, and 50.2% were from OFS. More OIR fatalities were Reserve and National Guard forces (OIR 22.6%; OFS 5.6%), conventional forces (OIR 82.1%; OFS 65.4%), and support personnel (OIR 61.3%; OFS 33.6%). More OIR fatalities also resulted from disease and non-battle injury (OIR 83.0%; OFS 28.0%). The leading cause of death was injury (OIR 81.1%; OFS 98.1%). Manner of death differed as more homicides (OIR 18.9%; OFS 72.9%) were seen in OFS, and more deaths from natural causes (OIR 18.9%; OFS 1.9%) and suicides (OIR 29.2%; OFS 6.5%) were seen in OIR. The prevalence of underlying atherosclerosis was 14.2% in OIR and 18.7% in OFS. Of 146 non-suicide trauma fatalities, most multiple/blunt force injury deaths (62.2%) occurred in OIR, and most blast injury deaths (77.8%) and gunshot wound deaths (76.6%) occurred in OFS. The leading mechanism of death was catastrophic tissue destruction (80.8%). Most fatalities had non-survivable injuries (80.8%) and non-preventable deaths (97.3%). CONCLUSIONS: Comprehensive mortality reviews should routinely be conducted for all military operation deaths. Understanding death from both injury and disease can guide preemptive and responsive efforts to reduce death among military forces.