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This cohort study assessed all reported injuries experienced by the personnel of a U.S. Navy aircraft carrier during two consecutive 6-month deployments. These nondisease injury cases were collected by the ship's Safety Department from ship's Medical Department reports and showed 291 total injuries (3.05 injuries per 10,000 person-days) and 412 total injuries (4.39 injuries per 10,000 person-days) among 5,101 personnel during two cruises, slightly higher than the recordable mishap rate for general U.S. industry (which uses a different metric). Junior personnel experienced one-half of the mishaps but represented only 31% of the manpower. Slips, trips, and falls were the most common causes of accidents on the ship, similar to general industry. The incidence densities and causes reported should be similar to and representative of those for other large deck ships in the U.S. Navy and can be used in developing risk-reduction strategies for targeted populations, to meet the Secretary of Defense requirement to reduce injuries by 50% in the next 2 years. [ABSTRACT FROM AUTHOR]

Objectives: To investigate reticulocyte hemglobin content (CHr) as a primary screening test to detect iron deficiency (ID) in healthy toddlers. Demographic and dietary risk factors associated with ID were studied for an association with low CHr.Methods: This was a prospective cross-sectional study of healthy toddlers aged 12 to 36 months coming to well-child visits at two military pediatric ambulatory clinics in the Washington, DC, area from August 2006 to November 2007. Data were collected on medical, demographic, and dietary intake by parental questionnaire. A sample of blood was drawn from each subject for complete blood count and CHr. A logistic regression model was used to determine which factors may be predictive of ID.Results: A total of 144 children were studied. An abnormal low CHr of 27.5 was identified in 18.8% of our toddler population. Two variables were determined to be independent predictors of low CHr; an age of 12 to 23 months and black race.Conclusions: Used alone as a primary screening marker, CHr identified a high prevalence of ID in our population of toddlers. Black race and younger age were associated with a lower CHr. Larger studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

The medical literature is replete with case reports of thromboembolic events related to high altitude exposure. Studies have shown an increased risk of thromboembolic events at high and very high altitudes. Most of these case reports and studies have been documented at altitudes between 3,000 m and 8,000 m (9,843-26,247 ft). The U.S. Air Force Academy (USAFA) rests at moderate altitude of 7,250 ft (2,210 m). This study was designed to quantify the incidence of thromboembolic events in USAFA cadets over a 5-year period and then compare the incidence of events to those in the age-matched, similarly screened midshipmen and cadet populations of the U.S. Naval and U.S. Military Academies living at sea level. Our study showed an increased incidence of thromboemoblic events in USAFA cadet outpatients compared with that in the U.S. Military Academy cadets and U.S. Naval Academy midshipmen. This implicates moderate altitude as a potential risk factor for thrombosis. [ABSTRACT FROM AUTHOR]

Individual health status assessment upon completion of U.S military deployments was standardized in 1999 with a brief health assessment questionnaire. This cohort study analyzed health status responses and their relationship to postdeployment health outcomes among 16,142 military personnel who completed a health questionnaire after a deployment ending in 1999. Respondents were Army and Air Force personnel returning from Europe or Southwest Asia. Fourteen percent documented at least one health concern and 1.8% had fair/poor self-rated health. In the 6 months after deployment, 1.4% were hospitalized, 25% made five or more outpatient visits, and 4% separated from military service. Deployers with fair/poor self-rated health were at a significantly increased risk for high use of outpatient services (risk ratio, men 1.8, women 1.7) but not for hospitalization or separation. Self-report of low health status or other health concerns may help identify deployers with higher health care needs after future deployments. [ABSTRACT FROM AUTHOR]

Introduction: The high frequency and number of ankle inversion injuries and meniscal injuries in military populations is an area of concern due to the debilitating effects and cumulative consequences of these particular injuries on the soldiers sustaining injury and the consequences on the operational effectiveness of the Israeli Defense Force (IDF). This study examines the possible relationship between ankle inversion injury and potential for subsequent meniscal injury in infantry soldiers in the IDF., Material and Methods: All 89,069 infantry combat soldiers (including special units), recruited to the IDF between 2007 and 2017 were included in this study. A historical cohort study was conducted. The cohort was divided into two groups: The exposure group included all participants that had suffered at least one ankle sprain in the past and the unexposed group that included all participants who did not suffer an ankle sprain in the past. A Cox proportional-hazards model (COX) model was used in order to obtain the adjusted to confounders association between exposure and outcome expressed in hazard ratio (HR)., Results: The crude association between ankle sprain in the past and the development of meniscal injury in this study was 0.87 (Relative risk = 0.87, P = 0.007). After adjusting for unit type, Body Mass Index (BMI), previous fracture of the lower limb, and the use of eyeglasses, using a COX model, the adjusted association between ankle sprain in the past and the development of meniscal injury was 0.8 (HR = 0.8, P = 0.001, confidence interval (95%) 0.74, 0.88)., Conclusion: The results of this study indicate ankle sprains to be a protective factor for meniscal injury. Our main conclusion from the results of this study is that the assumption that those with previous leg injuries are at a greater risk for further leg injuries is questionable and cannot be generalized. Hence, the association between different types of injuries should be investigated separately., (© The Association of Military Surgeons of the United States. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Severe upper limb injuries (SULI) may pose a significant public health challenge for the military; however, SULI has not been previously defined or studied in the US military. Objective: Determine SULI incidence, risk factors, and outcomes., Materials and Methods: Active Component (AC) U.S. military personnel who served during January 1, 2003 to December 31, 2012 who met the case definition for SULI (N = 213,745) and a random sample from the same population without SULI were included. Data from the Defense Medical Surveillance System and Defense Medical Epidemiology Database was used to calculate incidence. Multiple logistic regression and Cox proportional hazards models were used to analyze SULI risk factors and attrition., Results: SULI incidence was 15/1,000 person-years. Higher SULI risk was observed in men (OR 1.25; 95% CI 1.22-1.27), age 25-29 (OR 1.07; 95% CI 1.05-1.09) compared to age 20-24, E5-E9 (OR 1.14; 95% CI 1.12-1.17) compared to E1-E4, serving in Coast guard (OR 1.62; 95% CI 1.56-1.68) and Air Force (OR 1.17; 95% CI 1.14-1.19) relative to Army and with a deployment history (OR 2.16, 95% CI 2.12-2.19) while SULI risk was lower for blacks (OR 0.91; 95% CI 0.90-0.93) and those in the "other race" category (HR 0.81; 95% CI 0.80-0.84) compared to whites. SULI was associated with 23% increased risk of attrition (HR 1.23; 95% CI 1.22-1.24)., Conclusion: The study findings provide preliminary evidence on the incidence, natural history and distribution of SULI in this population. The findings indicate SULI may impact readiness and result in premature military separation., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Integration of females in combat units poses a unique challenge for army commanders around the world. The purpose of this study is to provide a detailed up-to-date situation report regarding overuse injuries among combat female warriors in the IDF (Israeli Defense Forces) in order to enable evidence-based decision-making, prevention policy, and further research of this highly significant military public health issue., Methods: A cross-sectional descriptive study was conducted including 2,519 females recruited to combat duties during the year of 2013. The main data source was the IDF's computerized medical consultation records package (CPR). Descriptive statistics was performed and some results were compared with males using data from other reports and studies of the IDF., Results: The overall injury rate was 28.3%. Of all injuries, 86% were in the ankle and calf (41%), the lower back (23%), and the knee (22%) regions. The average lost training days was 11 d for females as compared with 8 d for males. The overall rates of stress fractures and the rates of femur and femoral neck stress fractures were significantly higher among females as compared with males (11.2% vs. 2.5%, p = 0.0032, and 7.8% vs. 1.6% p = 0.00001, respectively)., Conclusions: The overuse injury rates among females in the IDF are high and may be considered a significant military public health problem. In order to reduce the numbers of overuse injuries, which is expected to significantly increase after the IDF's policy change regarding to combat duties open for females, we recommend planning and implementation of policies and intervention programs and further research regarding to overuse injuries among female combat warriors with special focus on the calf and ankle, lower back, and knee regions and femoral stress fractures.

Introduction: Attrition from training is associated with substantial financial and personnel loss. There is a plethora of medical literature and research of attrition rates related to initial/phase 1 training (basic combat training); however, the analysis of second phase training (commanders training, consisting of schools that qualify junior commanders and officers for infantry and non-infantry combat units) is limited. The purpose of this study is to perform a comprehensive survey regarding to medical attrition from commanders training in the IDF (Israeli Defense Forces) in order to present the commanders of the IDF a detailed situation report that will serve as an evidence-based platform for future policy planning and implementation., Methods: A cross-sectional study including all soldiers (23,841) who participated in commanders training in the IDF in the period of 2012-2015 was performed. Soldiers for whom the attrition reason (medical or not medical) was missing were excluded from this study. Data were collected from the adjutancy-computerized system as well as the IDF's computerized medical consultation records package (CPR). Descriptive statistics were performed using mean, standard deviation, and median in order to express results. For the determination of statistical significance, chi-square test, Student's t-test, and Poisson regression models were used., Results: Out of 23,841 soldiers that participated in this study, 75% (17,802) were males and 25% (6,039) were females. The overall attrition rate was 0.7% (164). The attrition rate for males was 0.86% (148 out of 17,082 males) and 0.26% (16 out of 6,039 females) for females. After adjusting for training unit, age, and BMI, the risk for attrition was 1.6 (160%) times higher for males as compared with females, and this result was statistically significant (IRR = 1.6, p = 0.01, CI 1.1, 2.2). The re-injury rate was 41% (68 out of 164 soldiers). The three most frequent diagnoses for attrition were orthopedics (66%), general surgery diagnoses (12%), and diagnoses related to internal medicine (11%). Out of 107 soldiers that attired due to orthopedic reasons, 36 (34%) suffered from calf and ankle injuries, 22 (21%) attired due to diagnoses related to the lower back, and 22 (21%) attired due to diagnoses related to the knee region. The highest attrition rate was encountered in the school for infantry junior command (2.2%) and the lowest rate was encountered in the officer training school for non-infantry units (0.11%). After adjusting for age and BMI, the risk for ankle injury was 2.55 (255%) times higher for soldiers in the school for infantry junior command as compared with soldiers in the officer school for infantry units (IRR = 2.55 p = 0.017, CI 1.18, 5.47)., Conclusion: The attrition rate from commanders training in the IDF is low, and at this point, however, due to lack of uniform criteria for attrition, it cannot serve as an objective measure. We suggest measuring and discussing overuse injury rates (which is the most frequent cause of attrition), instead. Based on our results, we recommend an implementation of a better medical screening policy in order to reduce the re-injury rates during commanders training., (© Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Overuse injuries are responsible for most lost training days and attrition from combat training in the Israeli Defense Forces (IDF) as in armies around the world. The purpose of this study is to understand the rates, types, and mechanism of occurrence of overuse injuries in the IDF in order to provide the IDF's commanders a detailed updated situation report in order to enable commanders decision-making, prevention policy, and further research of this highly significant military public health issue., Methods: A cross-sectional study including 20,000 soldiers recruited to combat units during the year of 2013 was performed. Most of the data were collected from the IDF's computerized medical consultation records package. Descriptive statistics (percent, mean, standard deviation, and median) were used in order to express results. The study was approved by the IDF's institutional review board., Results: The overall injury rate was 24.5%. The total number of injuries was 6,393 with an average of 1.32 ± 0.22 injuries per injured soldier. The injury rate was 18.4% in the infantry units and 36.1% in non-infantry units. Of all injuries, 87% occurred in the lower back and lower limb regions. The most frequent injury sites were the calf and ankle (34%), the knee region (22%), and the lower back (19%). Of all injuries, 74% occurred during running (45%) or long-distance walking (29%). The average lost training days due to injuries was 9 d per soldier and 6.5 d per injury. The total number of stress fractures was 494-2.5% of all soldiers (four fractures per 100 person years). The calf and ankle region was the most frequent site of stress fractures and accounted for 84% of all stress fractures, the vast majority of them (95%) were fractures of the distal tibia. The average number of lost training days due to stress fractures was 16 ± 6.1 per fracture., Conclusions: As in other armies around the world, overuse injuries in the IDF are a major public health problem and poses a significant challenge to the IDF's commanders and the medical corps policy leaders. Further studies should be performed in order to identify the risk factors for these injuries especially in the lower back and the lower limb regions as part of the effort to try and reduce the rates of these injuries as much as possible. This study emphasizes the need for a continuous surveillance and monitoring system for overuse injuries as a significant and integral component of any intervention plan in the domain of overuse injuries., (© Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Many medical institutions have moved forward with curricular objectives aimed at teaching professionalism, but the question remains: are we teaching the most appropriate content at the most opportune times to maximize sustained learning? The students' point of view of professionalism is helpful in addressing this question., Aim: To describe the views of professionalism held by students and faculty at the Uniformed Services University of the Health Sciences., Methods: In e-mailed surveys, students and faculty free-texted the three most important characteristics of a professional. Qualitative analysis was used to analyze the results. Data were compared on the basis of the percentage of each group affirming one of the characteristics., Results: Fourteen characteristics of professionalism were found. There were significant differences across all participant groups in the characteristics that each indicated were most important., Conclusion: Differences emerge between definitions of professionalism that appear to relate to training and experience. Students' views of professionalism reflect the immediate context of their educational environment. Curricula targeted to the students' foci are relevant in teaching professionalism., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

Introduction: The role of testosterone in health and quality of life has become increasingly visible and overtly marketed to the public. Some evidence suggests that testosterone levels in men may be low because of a variety of reasons, including stress and environmental exposures., Objective: This study examines trends in testosterone prescriptions dispensed by military treatment facilities (MTFs)., Methods: We examined data from the Department of Defense Pharmacy Data Transaction Service to determine the nature of androgen prescriptions dispensed through MTFs from 2007 through 2011., Results: The number of androgen prescriptions increased more than two-fold across the military from 19,494 in 2007 to 45,270 in 2011. Most prescriptions (99%) were for men. Androgen prescription rates rose 23% per year from 2007 through 2011 (p < 0.001, CI 23-24%). The prescription rate for 35- to 44-year-olds increased more than any other age group, with annual increases averaging 33% (p < 0.001, CI 32-34%)., Conclusion: The number of androgen prescriptions within MTFs rose significantly from 2007 through 2011. This is similar to rises in androgen prescriptions seen in civilian medical systems. Clinical indications for the sharp increase in testosterone prescriptions are unknown, and the indications for clinically appropriate testosterone replacement need further clarification., (Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.)

Introduction: Mineral supplements such as calcium and iron are readily available over the counter and are some of the most frequently consumed dietary supplements. Health care providers also prescribe mineral supplements for treatment of certain conditions and to maintain health., Objective: This study examines trends in mineral-supplement prescriptions dispensed by military treatment facilities., Methods: We examined data from the DoD Pharmacy Data Transaction Service to determine the nature of mineral-supplement prescriptions dispensed by MTFs from 2007 through 2011., Results: Overall, 1,785,158 calcium, 844,655 iron, 166,207 magnesium, and 23,297 zinc prescriptions were dispensed over this 5-year period. Although the number of zinc prescriptions decreased considerably by an average of 30% across the 5-year period, calcium and magnesium prescriptions increased by 3% and 8%, respectively. The number of iron prescriptions dispensed was relatively stable across the 5 years., Conclusions: Patterns of mineral-supplement prescriptions in the military changed over the 5-year period examined. However, the patterns within the DoD medical system may or may not represent those of the civilian medical system. Because we could not determine the reasons why the mineral supplements were prescribed, we cannot report whether the supplements were effective for the intended uses., (Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.)

Background: Eczema affects 3.5% of the global population, with peak prevalence during infancy. Eczema has no cure, but probiotics have been suggested as a preventative measure., Objective: To comprehensively analyze the impact of prenatal and postnatal probiotic supplementation on the prevention of infantile and childhood eczema., Methods: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and PubMed were searched for randomized controlled trials regarding probiotic usage and eczema development from 1945 to 2013. Participants included were 7 years old or younger with probiotic exposure in utero or below 6 months of age and who was not diagnosed previously., Results: 27 publications describing 16 studies assessing 10 probiotics in 2,797 participants met our criterion. The pooled relative risk of all the studies, 0.74 (95% confidence interval 0.67, 0.82), indicated that probiotic supplementation in the first several years of life did have a significant impact on development of eczema. During evaluation of the studies, heterogeneity of terms and definitions for similar primary and secondary outcomes were identified., Conclusion: The use of probiotic supplements during pregnancy and/or during infancy creates a statistically significant decline in the incidence of eczema. The heterogeneity of terms and definitions regarding eczema is the major limitation of these studies., (Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.)

Few studies have explored the effects of various occupations on venous thromboembolism occurrence. We examined idiopathic venous thromboembolism (IVTE) occurrence by occupation, body size, and age in the U.S. military. To capture idiopathic cases, exclusion criteria included recognized venous thromboembolism risk factors. Each case was matched to three controls on branch of service, sex, rank/grade, race, and education level. Body mass index, age, and occupation were analyzed with chi2 and logistic regression. Of 2,167 cases, most were male (87%), white (69%), enlisted (78%), averaging 36 years old. IVTE odds increased with age (p < 0.001). Every occupation showed greater odds than pilots/aircrew (p < 0.001), especially infantry/artillery/combat arms, which showed twice the odds, followed by health care workers. Normal weight was protective, especially in pilots/aircrew (OR 0.52, p = 0.03) and repair/engineering (OR 0.72, p < 0.001). Our analysis found a lower risk of IVTE among pilots and aircrew compared to other military occupations. Body size had less impact than expected in aircraft and vehicle operators. Greater odds in health care workers and infantry/artillery/combat arms than in pilots/aircrew and armor/motor transport occupational groups may reflect prolonged standing. Limitations include potential miscoding of health records and potential misclassification. Future IVTE research should explore job functions and worker characteristics.