Challenges in assessing change in autistic adults: scale limitations and discrepancies in reporting in clinical trials.

Autism Spectrum Disorder (ASD) is a developmental disorder marked by deficits in social communication and social interaction, together with restricted and/or repetitive patterns of behaviours, activities or interests. As more adults are being diagnosed with ASD, and more diagnosed children are aging into adulthood, the need for effective treatments and support services for autistic adults is quickly growing. As such, clinical research targeting autistic adults has emerged in recent years. Currently, caregiver ratings are commonly used as outcome measures in child treatment studies, but these scales present challenges when utilised to assess the autistic adult population. In this commentary, we seek to unveil the difficulties and obstacles in assessing change in clinical treatment trials for autistic adults. Specifically, this article uses case examples to explore the limitations of rating scales. Steps for improving the accuracy of ratings, and for developing novel self-rating scales for autistic adults are discussed. It is hoped that in exploring these difficulties in more depth, clinical research with adult ASD populations will continue to improve and that reliable, valid and sensitive outcome measures will be developed to ensure the highest quality treatments emerge.

A retrospective study of feline gastric lymphoma in 16 chemotherapy-treated cats.

The purposes of this study were to describe cases of feline gastric lymphoma with regards to signalment, clinical presentation, laboratory and ancillary study findings, response to therapy, and outcomes and to identify prognostic variables. Sixteen cats with stage I and II gastric lymphoma treated with chemotherapy were included in this study. Seventy-five percent of cats experienced remission. Overall, first remission duration was 108 days. Response to treatment was prognostic as in other types of feline lymphoma. Cats with a complete remission (CR) had longer survival times compared with cats with a partial remission (PR). Sex and treatment with a rescue protocol were found to be prognostic with castrated males having longer survivals than spayed females. Cats that received rescue chemotherapy had shorter first remission durations than those that did not. Prior treatment with steroids and stage were not found to be significant prognostic variables. This study characterizes gastric lymphoma treated with chemotherapy in cats. Further studies are needed to determine the comparative efficacy of surgical and chemotherapeutic treatments for feline gastric lymphoma.

A cluster of three extrapulmonary Mycobacterium abscessus infections linked to well-maintained water-based heater-cooler devices.

BACKGROUND: Various water-based heater-cooler devices (HCDs) have been implicated in nontuberculous mycobacteria outbreaks. Ongoing rigorous surveillance for healthcare-associated M. abscessus (HA-Mab) put in place following a prior institutional outbreak of M. abscessus alerted investigators to a cluster of 3 extrapulmonary M. abscessus infections among patients who had undergone cardiothoracic surgery. METHODS: Investigators convened a multidisciplinary team and launched a comprehensive investigation to identify potential sources of M. abscessus in the healthcare setting. Adherence to tap water avoidance protocols during patient care and HCD cleaning, disinfection, and maintenance practices were reviewed. Relevant environmental samples were obtained. Patient and environmental M. abscessus isolates were compared using multilocus-sequence typing and pulsed-field gel electrophoresis. Smoke testing was performed to evaluate the potential for aerosol generation and dispersion during HCD use. The entire HCD fleet was replaced to mitigate continued transmission. RESULTS: Clinical presentations of case patients and epidemiologic data supported intraoperative acquisition. M. abscessus was isolated from HCDs used on patients and molecular comparison with patient isolates demonstrated clonality. Smoke testing simulated aerosolization of M. abscessus from HCDs during device operation. Because the HCD fleet was replaced, no additional extrapulmonary HA-Mab infections due to the unique clone identified in this cluster have been detected. CONCLUSIONS: Despite adhering to HCD cleaning and disinfection strategies beyond manufacturer instructions for use, HCDs became colonized with and ultimately transmitted M. abscessus to 3 patients. Design modifications to better contain aerosols or filter exhaust during device operation are needed to prevent NTM transmission events from water-based HCDs.

Estimating fertility using adults: A method for under-enumerated pre-adult skeletal samples.

OBJECTIVES: Infant underrepresentation poses a great risk to accurate palaeodemographic findings when analyzing skeletal samples. Empirically derived palaeodemographic methods all require unbiased or minimally biased pre-adult representation for estimating demographic characteristics, including fertility. Currently, there are no reliable methods for estimating palaeodemographic parameters when pre-adults are underrepresented in skeletal samples, consequently such samples are often excluded from palaeodemographic analyses. The aim of this article is to develop a method for estimating total fertility rate (TFR) using reproductive aged adults, specifically for samples with suspected pre-adult under-enumeration. METHODOLOGY: United Nations mortality data and TFR from the World Population Prospects was utilized. The correlation between known fertility and the proportion of individuals in key reproductive years (15-49 years) to total adult sample (15+ years) was assessed as an indirect means to estimate fertility. RESULTS: It was determined that the proportion of reproductive aged adults is a reasonable proxy for fertility. A significant positive correlation was observed between the TFR and those who died aged 15-49 years of age as a proportion of those who died ≥15 years (D15-49/D15+). SE of the estimate revealed reasonable predictive accuracy. When applied to two modern non-agricultural populations, the method showed some variability in accuracy but good potential for an improved outcome over existing methods when pre-adults are underrepresented. CONCLUSION: This research has provided a new method for estimating fertility in archeological skeletal samples with pre-adult under-enumeration. In combination with a contextually focused approach, this provides a significant step toward further use of biased samples in palaeodemography.

Prevalence and Distribution of Refractive Errors Among Members of the U.S. Armed Forces and the U.S. Coast Guard, 2019.

During calendar year 2019, the estimated prevalence of myopia, hyperopia, and astigmatism were 17.5%, 2.1%, and 11.2% in the active component of the U.S. Armed Forces and 10.1%, 1.2%, and 6.1% of the U.S. Coast Guard, respectively. The prevalence of spectacle correction in the active component of the U.S. Armed Forces was 24.0%, which included single-vision distance (92.0%), multifocal (eg, bifocal, 6.0%), and single-vision reading (2.0%) spectacles. In comparison, the prevalence of spectacle correction was 14.6% in the U.S. Coast Guard. Additionally, among all U.S. Armed Forces service members who received spectacle correction for distance vision in 2019, service members of the reserve component, military academy cadets, and the National Guard were significantly more myopic (near-sightedness) than the active component or Coast Guard (p<.001). Within the active component, the Air Force was the most myopic and the Marine Corps followed it closely. These 2 military branches were not significantly different from each other (p=.46) but both were significantly more myopic than the Navy or the Army (p<.001). The Navy was more myopic than the Army (p=.01). The U.S. Coast Guard was significantly less myopic than any other military branch (p=.03).

The Montefiore-Einstein Rigidity Scale-Revised (MERS-R): Development, administration, reliability, and validity in child and adult Autism Spectrum Disorder (ASD).

BACKGROUND: Rigidity contributes to severity and functional impairment in autism spectrum disorder (ASD). There is an unmet need for a valid, reliable, and sensitive outcome measure to assess rigidity in ASD. OBJECTIVE: To develop and validate the Montefiore-Einstein Rigidity Scale-Revised (MERS-R) to assess the Behavioral Rigidity Domain (BRD), Cognitive Rigidity Domain (CRD), and Protest Domain (PD). MATERIALS AND METHODS: The MERS-R was administered to 93 individuals with ASD (children and adults, high and low IQ) at baseline, Week 2, and Week 12. Internal consistency was assessed for domain scores, Total Rigidity Composite (TRC = BRD + CRD), and Total Composite (TC = BRD + CRD + PD) with Cronbach's α. Intraclass correlation coefficients (ICCs) assessed test-retest reliability from baseline to weeks 2 and 12. Pearson's correlations assessed the relationship between the MERS-R and age, sex, and IQ. Convergent validity assessed the correlation of MERS-R scores to the Children's Yale-Brown Obsessive-Compulsive Scale-ASD (CY-BOCS-ASD). RESULTS: Good internal consistency was demonstrated for the BRD, PD, TRC and TC (Cronbach's α = 0.83, 0.88, 0.82, and 0.89, respectively) and adequate internal consistency for the CRD (α = .72). Good or excellent test-test reliability was demonstrated over two weeks (ICC: 0.66─.79), and fair or good reliability over 12 weeks (ICC: 0.56-66). MERS-R scores did not differ by age, sex, or IQ (p: 0.16─.99) with the exception that higher PD scores were associated with younger age (correlation = -0.25, p = 0.01). Significant convergent validity was demonstrated between all MERS-R scores and the CY-BOCS-ASD (p < 0.0001). DISCUSSION: The MERS-R demonstrated internal consistency, test-retest reliability, convergent validity and applicability to autistic children and adults of different sexes and IQ levels. It is a valid, sensitive, and reliable instrument to measure behavioral and cognitive rigidity in ASD.

Enhancement of infection prevention case review process to optimize learning from defects.

Hospitals continue to struggle with preventable healthcare-associated infections. Whereas the focus is generally on proactive prevention processes, performing retrospective case reviews of infections can identify opportunities for quality improvement and maximize learning from defects. This brief article provides practical information for structuring the case review process using readily available health system platforms. Using a structured approach for case reviews can help identify trends and opportunities for improvement.

Intranasal oxytocin versus placebo for hyperphagia and repetitive behaviors in children with Prader-Willi Syndrome: A randomized controlled pilot trial.

OBJECTIVE: The effects of intranasal oxytocin and placebo on hyperphagia and repetitive behaviors were compared in children and adolescents with Prader Willi Syndrome (PWS). METHODS: Children and adolescents with PWS were enrolled in an 8-week double-blind placebo-controlled intranasal oxytocin randomized trial. Twenty-three (23) subjects were assigned to oxytocin (N = 11) or placebo (N = 12). Hyperphagia was measured with the Hyperphagia Questionnaire (HQ), and repetitive behavior was measured with Repetitive Behavior Scale- Revised (RBS-R). RESULTS: There were modest significant treatment by-time interactions indicating reduction in hyperphagia and repetitive behaviors across time for placebo but no reduction for oxytocin. Total HQ score showed a greater average reduction of 1.81 points/week for the placebo group vs. oxytocin, with maximum reduction at week 4. There were also greater reductions on HQ-Drive and HQ-Behavior subscales on placebo vs. oxytocin. RBS-R subscales followed similar patterns to the HQ, with a significantly greater reduction in sameness subscale behaviors (average 0.825 points/week) in the placebo group compared to the oxytocin group. Oxytocin was well tolerated, and the only adverse event that was both more common and possibly related to oxytocin vs. placebo was nocturia (n = 1 vs 0). CONCLUSION: Placebo was associated with modest improvement in hyperphagia and repetitive behaviors in childhood PWS whereas intranasal oxytocin was not associated with improvement in these domains. More work is needed to understand the meaning and mechanism of these findings on hyperphagia and repetitive behaviors in PWS.

Behavioral features in Prader-Willi syndrome (PWS): consensus paper from the International PWS Clinical Trial Consortium.

Prader-Willi syndrome (PWS) is a rare neurodevelopmental genetic disorder associated with a characteristic behavioral phenotype that includes severe hyperphagia and a variety of other behavioral challenges such as temper outbursts and anxiety. These behaviors have a significant and dramatic impact on the daily functioning and quality of life for the person with PWS and their families. To date, effective therapies addressing these behavioral challenges have proven elusive, but several potential treatments are on the horizon. However, a limiting factor for treatment studies in PWS is the lack of consensus in the field regarding how to best define and measure the complex and interrelated behavioral features of this syndrome. The International PWS Clinical Trials Consortium (PWS-CTC, www.pwsctc.org ) includes expert PWS scientists, clinicians, and patient advocacy organization representatives focused on facilitating clinical trials in this rare disease. To address the above gap in the field, members of the PWS-CTC "Behavior Outcomes Working Group" sought to develop a unified understanding of the key behavioral features in PWS and build a consensus regarding their definition and description. The primary focus of this paper is to present consensus definitions and descriptions of key phenotypic PWS behaviors including hyperphagia, temper outbursts, anxiety, obsessive-compulsive behaviors, rigidity, and social cognition deficits. Patient vignettes are provided to illustrate the interrelatedness and impact of these behaviors. We also review some available assessment tools as well as new instruments in development which may be useful in measuring these behavioral features in PWS.

Single-institution experience with interhospital extracorporeal membrane oxygenation transport: A descriptive study.

OBJECTIVE: Patients with refractory cardiopulmonary failure may benefit from extracorporeal membrane oxygenation, but extracorporeal membrane oxygenation is not available in all medical centers. We report our institution's nearly 20-yr experience with interhospital extracorporeal membrane oxygenation transport. DESIGN: Retrospective review. SETTING: Quaternary care children's hospital. PATIENTS: All patients undergoing interhospital extracorporeal membrane oxygenation transport by the Arkansas Children's Hospital extracorporeal membrane oxygenation team. INTERVENTIONS: Data (age, weight, diagnosis, extracorporeal membrane oxygenation course, hospital course, mode of transport, and outcome) were obtained and compared with the most recent Extracorporeal Life Support Organization Registry report. RESULTS: Interhospital extracorporeal membrane oxygenation transport was provided to 112 patients from 1990 to 2008. Eight were transferred between outside facilities (TAXI group); 104 were transported to our hospital (RETURN group). Transport was by helicopter (75%), ground (12.5%), and fixed wing (12.5%). No patient died during transport. Indications for extracorporeal membrane oxygenation in RETURN patients were cardiac failure in 46% (48 of 104), neonatal respiratory failure in 34% (35 of 104), and other respiratory failure in 20% (21 of 104). Overall survival from extracorporeal membrane oxygenation for the RETURN group was 71% (74 of 104); overall survival to discharge was 58% (61 of 104). Patients with cardiac failure had a 46% (22 of 48) rate of survival to discharge. Neonates with respiratory failure had an 80% (28 of 35) rate of survival to discharge. Other patients with respiratory failure had a 62% (13 of 21) rate of survival to discharge. None of these survival rates were statistically different from survival rates for in-house extracorporeal membrane oxygenation patients or for survival rates reported in the international Extracorporeal Life Support Organization Registry (p > .1 for all comparisons). CONCLUSIONS: Outcomes of patients transported by an experienced extracorporeal membrane oxygenation team to a busy extracorporeal membrane oxygenation center are very comparable to outcomes of nontransported extracorporeal membrane oxygenation patients as reported in the Extracorporeal Life Support Organization registry. As has been previously reported, interhospital extracorporeal membrane oxygenation transport is feasible and can be accomplished safely. Other experienced extracorporeal membrane oxygenation centers may want to consider developing interhospital extracorporeal membrane oxygenation transport capabilities to better serve patients in different geographic regions.

Impact of 24-h high and low fermentable oligo-, di-, monosaccharide, and polyol diets on markers of exercise-induced gastrointestinal syndrome in response to exertional heat stress.

The study aimed to determine the effects of 24-h high (HFOD) and low (LFOD) fermentable oligo-, di-, monosaccharide, and polyol (FODMAP) diets before exertional heat stress on gastrointestinal integrity, function, and symptoms. Eighteen endurance runners consumed a HFOD and a LFOD (double-blind crossover design) before completing 2 h of running at 60% maximal oxygen uptake in 35 °C ambient temperature. Blood samples were collected before and after exercise to determine plasma cortisol and intestinal fatty acid binding protein (I-FABP) concentrations, and bacterial endotoxin and cytokine profiles. Breath hydrogen (H2) and gastrointestinal symptoms (GIS) were determined pre-exercise, every 15 min during, and in recovery. No differences were observed for plasma cortisol concentration between diets. Plasma I-FABP concentration was lower on HFOD compared with LFOD (p = 0.033). A trend for lower lipopolysaccharide binding protein (p = 0.088), but not plasma soluble CD14 (p = 0.478) and cytokine profile (p > 0.05), responses on HFOD was observed. A greater area under the curve breath H2 concentration (p = 0.031) was observed throughout HFOD (mean and 95% confidence interval: HFOD 2525 (1452-3597) ppm·4 h-1) compared with LFOD (1505 (1031-1978) ppm·4 h-1). HFOD resulted in greater severity of GIS compared with LFOD (pre-exercise, p = 0.017; during, p = 0.035; and total, p = 0.014). A 24-h HFOD before exertional heat stress ameliorates disturbances to epithelial integrity but exacerbates carbohydrate malabsorption and GIS severity in comparison with a LFOD. Novelty Twenty-four-hour high FODMAP diet ameliorated disturbances to gastrointestinal integrity. Twenty-four-hour high FODMAP diet results in greater carbohydrate malabsorption compared with low FODMAP diet. Incidence of GIS during exertional heat stress were pronounced on both low and high FODMAP diets, but greater GIS severity was observed with high FODMAP diet.

Randomized crossover feasibility trial of helminthic Trichuris suis ova versus placebo for repetitive behaviors in adult autism spectrum disorder.

Objectives: Inflammatory mechanisms are implicated in the aetiology of autism spectrum disorder (ASD), and use of the immunomodulator Trichuris suis Ova (TSO) is a novel treatment approach. This pilot study determined the effect sizes for TSO versus placebo on repetitive behaviours, irritability and global functioning in adults with ASD.Methods: A 28-week double-blind, randomised two-period crossover study of TSO versus placebo in ten ASD adults, aged 17-35, was completed, with a 4-week washout between each 12-week period at Montefiore Medical Center, Albert Einstein College of Medicine. Subjects with ASD, history of seasonal, medication or food allergies, Y-BOCS ≥6 and IQ ≥70 received 2,500 TSO ova or matching placebo every 2 weeks of each 12-week period.Results: Large effect sizes for improvement in repetitive behaviours (d = 1.0), restricted interests (d = 0.82), rigidity (d = 0.79) and irritability (d = 0.78) were observed after 12 weeks of treatment. No changes were observed in the social-communication domain. Differences between treatment groups did not reach statistical significance. TSO had only minimal, non-serious side effects.Conclusions: This proof-of-concept study demonstrates the feasibility of TSO for the treatment of ASD, including a favourable safety profile, and moderate to large effect sizes for reducing repetitive behaviours and irritability.Clinicaltrials.gov: NCT01040221.

Factors associated with motorcycle traffic crash fatalities among active duty U.S. Army personnel.

OBJECTIVE: Research on factors associated with motorcycle fatalities among active duty U.S. Army personnel is limited. This analysis describes motorcycle crash-related injuries from 1995 through 2014 and assesses the effect of alcohol use and helmet use on the risk of fatal injury among active duty U.S. Army motorcycle operators involved in a traffic crash, controlling for other factors shown to be potentially associated with fatality in this population. METHODS: Demographics, crash information, and injury data were obtained from safety reports maintained in the Army Safety Management Information System. Traffic crashes were defined as crashes occurring on a paved public or private roadway or parking area, including those on a U.S. Army installation. Analysis was limited to motorcycle operators. Odds ratios (ORs) and 95% confidence intervals (95% CIs) from a multivariable analysis estimated the effect of alcohol use and helmet use on the risk of a fatal injury given a crash occurred, controlling for operator and crash characteristics. RESULTS: Of the 2,852 motorcycle traffic crashes, most involved men (97%), operators aged 20-29 years of age (60%), and operators who wore helmets (95%) and did not use alcohol (92%). Two thirds of reported crashes resulted in injuries requiring a lost workday; 17% resulted in fatality. Controlling for operator and crash characteristics, motorcycle traffic crashes involving operators who had used alcohol had a 3.1 times higher odds of fatality than those who did not use alcohol (OR =3.14; 95% CI, 2.17-4.53). Operators who did not wear a helmet had 1.9 times higher odds of fatality than those who did wear a helmet (OR =1.89; 95% CI, 1.24-2.89). CONCLUSIONS: Among U.S. Army motorcycle operators, alcohol use and not wearing a helmet increased the odds of fatality, given that a crash occurred, and additional modifiable risk factors were identified. Results will help inform U.S. Army motorcycle policies and training.

Non-battle injuries among U.S. Army soldiers deployed to Afghanistan and Iraq, 2001-2013.

INTRODUCTION: Many non-battle injuries among deployed soldiers are due to occupational-related tasks. Given that non-battle injuries are a significant cause of morbidity and mortality, occupational safety and health are of great concern to the military. Some of the leading causes of non-battle injuries in the military are also common in non-military occupational settings. Nationally, falls and motor-vehicle accidents are leading causes of non-fatal occupational injuries in the civilian workforce. The objective of this research is to identify the leading causes, types, and anatomic locations of non-fatal non-battle injuries in Afghanistan and Iraq. METHODS: Non-battle injuries were identified from medical air evacuation records. Causes of air evacuated injuries were identified and coded using the diagnosis and narrative patient history in the air evacuation records. Descriptive statistics were used to report the air evacuated non-battle injury rates, causes, injury types, and anatomic locations. RESULTS: Between 2001 and 2013, there were 68,349 medical air evacuations from Afghanistan and Iraq. Non-battle injuries accounted for 31% of air evacuations from Afghanistan and 34% from Iraq. These injuries were the leading diagnosis category for air evacuations. The three leading causes of injury for Afghanistan and Iraq, respectively, were sports/physical training (23% and 24%), falls/jumps (19% and 16%), and military vehicle-related accidents (8% and 11%). The leading injury types were fractures (21%), overuse pain and inflammation (16%), and dislocations (11%). PRACTICAL APPLICATIONS: Given that over 30% of medical evacuations of soldiers result from non-battle injuries, prevention of such conditions would substantially enhance military readiness during combat.

Effect of Probiotics on Metabolic Outcomes in Pregnant Women with Gestational Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

The metabolic effects of probiotic administration in women with gestational diabetes mellitus (GDM) is unknown. The objective of this review was to investigate the effect of probiotics on fasting plasma glucose (FPG), insulin resistance (HOMA-IR) and LDL-cholesterol levels in pregnant women diagnosed with GDM. Seven electronic databases were searched for RCTs published in English between 2001 and 2017 investigating the metabolic effects of a 6-8 week dietary probiotic intervention in pregnant women following diagnosis with GDM. Eligible studies were assessed for risk of bias and subjected to qualitative and quantitative synthesis using a random effects model meta-analyses. Four high quality RCTs involving 288 participants were included in the review. Probiotic supplementation was not effective in decreasing FBG (Mean Difference = -0.13; 95% CI -0.32, 0.06, p = 0.18) or LDL-cholesterol (-0.16; 95% CI -0.45, 0.13, p = 0.67) in women with GDM. However, a significant reduction in HOMA-IR was observed following probiotic supplementation (-0.69; 95% CI -1.24, -0.14, p = 0.01). There were no significant differences in gestational weight gain, delivery method or neonatal outcomes between experimental and control groups, and no adverse effects of the probiotics were reported. Probiotic supplementation for 6-8 weeks resulted in a significant reduction in insulin resistance in pregnant women diagnosed with GDM. The use of probiotic supplementation is promising as a potential therapy to assist in the metabolic management of GDM. Further high quality studies of longer duration are required to determine the safety, optimal dose and ideal bacterial composition of probiotics before their routine use can be recommended in this patient group.

Psychomotor slowing as a predictor of fluoxetine nonresponse in depressed outpatients.

OBJECTIVE: This study examined the utility of baseline psychomotor speed, measured with neuropsychological tests, to predict fluoxetine response in moderately depressed outpatients. The authors hypothesized that since psychomotor slowing in depressed patients has been linked to reduced dopaminergic neurotransmission, patients with slowing would be unresponsive to fluoxetine, a selective serotonin reuptake inhibitor. METHOD: After baseline neuropsychological testing, patients were treated openly with fluoxetine for 12 weeks. Thirty-seven patients completed the trial. RESULTS: Compared to the 25 patients who responded, the 12 patients who did not respond to fluoxetine exhibited significantly poorer performance in verbal fluency on the Controlled Oral Word Association Test FAS and in color naming on the Stroop Color and Word Test. In addition, the nonresponders tended to perform worse than the responders on the Stroop Color and Word Test reading subtest and the WAIS-III digit symbol subtest. Differential treatment response was specific to psychomotor speed because responders and nonresponders did not perform differently on tasks of executive functioning, attention, visuospatial functioning, or verbal intelligence. CONCLUSIONS: Psychomotor slowing may identify a subgroup of depressed patients who have a dopaminergic deficit that is unresponsive to fluoxetine monotherapy and who should therefore receive an alternative treatment.

Planned missing data designs in psychological research.

The authors describe 2 efficiency (planned missing data) designs for measurement: the 3-form design and the 2-method measurement design. The 3-form design, a kind of matrix sampling, allows researchers to leverage limited resources to collect data for 33% more survey questions than can be answered by any 1 respondent. Power tables for estimating correlation effects illustrate the benefit of this design. The 2-method measurement design involves a relatively cheap, less valid measure of a construct and an expensive, more valid measure of the same construct. The cost effectiveness of this design stems from the fact that few cases have both measures, and many cases have just the cheap measure. With 3 brief simulations involving structural equation models, the authors show that compared with the same-cost complete cases design, a 2-method measurement design yields lower standard errors and a higher effective sample size for testing important study parameters. With a large cost differential between cheap and expensive measures and small effect sizes, the benefits of the design can be enormous. Strategies for using these 2 designs are suggested.

Surveillance of Disease and Nonbattle Injuries During US Army Operations in Afghanistan and Iraq.

Disease and nonbattle injury (DNBI) are the leading causes of morbidity during wars and military operations. However, adequate medical data were never before available to service public health centers to conduct DNBI surveillance during deployments. This article describes the process, results and lessons learned from centralized DNBI surveillance by the US Army Center for Health Promotion and Preventive Medicine, predecessor of the US Army Public Health Command, during operations in Afghanistan and Iraq (2001-2013).The surveillance relied primarily on medical evacuation records and in-theater hospitalization records. Medical evacuation rates (per 1,000 person-years) for DNBI were higher (Afghanistan: 56.7; Iraq: 40.2) than battle injury rates (Afghanistan: 12.0; Iraq: 7.7). In Afghanistan and Iraq, respectively, the leading diagnostic categories for medical evacuations were nonbattle injury (31% and 34%), battle injury (20% and 16%), and behavioral health (12% and 10%). Leading causes of medically evacuated nonbattle injuries were sports/physical training (22% and 24%), falls (23% and 26%) and military vehicle accidents (8% and 11%). This surveillance demonstrated the feasibility, utility, and benefits of centralized DNBI surveillance during military operations.

Behavioral phenotype in a child with Prader-Willi syndrome and comorbid 47, XYY.

We report a 12-year-old male with Prader-Willi syndrome (PWS) and 47, XYY syndrome. Genetic work up revealed 47, XYY karyotype. PWS diagnosis was made by polymerase chain reaction methylation and maternal uniparental disomy (mUPD) was determined to be the etiology. Review of distinct behavioral features, possible interplay between the two syndromes and considerations for diagnoses are presented. To our knowledge, this is the first report of behavioral features in PWS with comorbid 47, XYY.

Identification of specific activities associated with fall-related injuries, active component, U.S. Army, 2011.

Although falls continue to be a leading mechanism of serious injuries among military populations, interventions must target activities or hazards that can be controlled or managed. This project aimed to identify activities most frequently associated with Army soldier fall-related injuries to prioritize prevention strategies for this substantial health burden. Narrative data from Army safety, medical evacuation, and casualty reporting systems were reviewed to select incidents meeting inclusion criteria and assign established codes. Nondeployed (n=988) and deployed (n=254) injury rates were not statistically different (2.20 per 1,000 non-deployed person-years [p-yrs], 2.21 per 1,000 deployed p-yrs, respectively). More than 75% of injuries were temporarily disabling fractures, sprains, and strains, primarily to lower extremities. The most frequent activities associated with non-deployed fall injuries were sports (e.g., snowboarding and basketball; 22%), parachuting (20%), walking/marching (19%), and climbing (15%). Ice and snow were the leading hazard (43%). The most common associated activities among deployed soldiers were occupational tasks (53%), walking/patrolling (24%), climbing (23%), and sports (17%). Specific interventions that target the activities and hazards identified in this investigation are suggested as priorities to reduce Army fall-related injuries.