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Background: SMS text messaging- and internet-based self-reporting systems can supplement existing vaccine safety surveillance systems, but real-world participation patterns have not been assessed at scale., Objective: This study aimed to describe the participation rates of a new SMS text messaging- and internet-based self-reporting system called the Kaiser Permanente Side Effect Monitor (KPSEM) within a large integrated health care system., Methods: We conducted a prospective cohort study of Kaiser Permanente Southern California (KPSC) patients receiving a COVID-19 vaccination from April 23, 2021, to July 31, 2023. Patients received invitations through flyers, SMS text messages, emails, or patient health care portals. After consenting, patients received regular surveys to assess adverse events up to 5 weeks after each dose. Linkage with medical records provided demographic and clinical data. In this study, we describe KPSEM participation rates, defined as providing consent and completing at least 1 survey within 35 days of COVID-19 vaccination., Results: Approximately, 8% (164,636/2,091,975) of all vaccinated patients provided consent and completed at least 1 survey within 35 days. The lowest participation rates were observed for parents of children aged 12-17 years (1349/152,928, 0.9% participation rate), and the highest participation was observed among older adults aged 61-70 years (39,844/329,487, 12.1%). Persons of non-Hispanic White race were more likely to participate compared with other races and ethnicities (13.1% vs 3.9%-7.5%, respectively; P<.001). In addition, patients residing in areas with a higher neighborhood deprivation index were less likely to participate (5.1%, 16,503/323,122 vs 10.8%, 38,084/352,939 in the highest vs lowest deprivation quintiles, respectively; P<.001). Invitations through the individual's Kaiser Permanente health care portal account and by SMS text message were associated with the highest participation rate (19.2%, 70,248/366,377 and 10.5%, 96,169/914,793, respectively), followed by email (19,464/396,912, 4.9%) and then QR codes on flyers (25,882/2,091,975, 1.2%). SMS text messaging-based surveys demonstrated the highest sustained daily response rates compared with internet-based surveys., Conclusions: This real-world prospective study demonstrated that a novel digital vaccine safety self-reporting system implemented through an integrated health care system can achieve high participation rates. Linkage with participants' electronic health records is another unique benefit of this surveillance system. We also identified lower participation among selected vulnerable populations, which may have implications when interpreting data collected from similar digital systems., (©Debbie E Malden, Julianne Gee, Sungching Glenn, Zhuoxin Li, Denison S Ryan, Zheng Gu, Cassandra Bezi, Sunhea Kim, Amelia Jazwa, Michael M McNeil, Eric S Weintraub, Sara Y Tartof. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 11.10.2024.)

Context: Primary hyperparathyroidism (PHPT) has initially been implicated in adverse maternal and neonatal outcomes, while subsequent population studies have failed to show an association., Objective: To compare maternal, pregnancy, and neonatal outcomes in patients with and without PHPT., Design: Retrospective matched-cohort study (2005-2020)., Setting: An integrated healthcare delivery system in Southern California., Patients: Women aged 18-44 years were included. Patients with biochemical diagnosis of PHPT were matched 1:3 with eucalcemic controls (non-PHPT)., Main Outcome Measures: Achievement of pregnancy, pregnancy outcomes (including rates of abortion, maternal complications), and neonatal outcomes (including hypocalcemia, need for intensive care)., Results: The cohort comprised 386 women with PHPT and 1158 age-matched controls. Pregnancy rates between PHPT and control groups were similar (10.6% vs 12.8%). The adjusted rate ratio of pregnancy was 0.89 (95% CI: 0.64-1.24) (PHPT vs non-PHPT). Twenty-nine pregnancies occurred in women with co-existing PHPT and 191 pregnancies occurred in controls, resulting in 23 (79.3%) and 168 (88.0%) live births, respectively (p=0.023). Neonatal outcomes were similar. Live birth rates were similar (86.4%, 80%, 79.2%) for those undergoing parathyroidectomy prior (n=22), during (n=5), or after pregnancy/never (n=24). Among patients who underwent parathyroidectomy during pregnancy, no spontaneous abortions occurred in women entering pregnancy with peak calcium <11.5 mg/dL [2.9 mmol/L]., Conclusions: We observed no difference in pregnancy rates between women with or without PHPT. Performing parathyroidectomy before pregnancy or during the second trimester appears to be a safe and successful strategy, and adherence to this strategy may be most critical for patients with higher calcium levels (≥11.5 mg/dL [2.9 mmol/L])., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com. See the journal About page for additional terms.)

Importance: People with HIV (PWH) may be at increased risk for severe outcomes with COVID-19 illness compared with people without HIV. Little is known about COVID-19 vaccination coverage and factors associated with primary series completion among PWH., Objectives: To evaluate COVID-19 vaccination coverage among PWH and examine sociodemographic, clinical, and community-level factors associated with completion of the primary series and an additional primary dose., Design, Setting, and Participants: This retrospective cohort study used electronic health record data to assess COVID-19 vaccination information from December 14, 2020, through April 30, 2022, from 8 health care organizations of the Vaccine Safety Datalink project in the US. Participants were adults diagnosed with HIV on or before December 14, 2020, enrolled in a participating site., Main Outcomes and Measures: The percentage of PWH with at least 1 dose of COVID-19 vaccine and PWH who completed the COVID-19 vaccine primary series by December 31, 2021, and an additional primary dose by April 30, 2022. Rate ratios (RR) and 95% CIs were estimated using Poisson regression models for factors associated with completing the COVID-19 vaccine primary series and receiving an additional primary dose., Results: Among 22 058 adult PWH (mean [SD] age, 52.1 [13.3] years; 88.8% male), 90.5% completed the primary series by December 31, 2021. Among 18 374 eligible PWH who completed the primary series by August 12, 2021, 15 982 (87.0%) received an additional primary dose, and 4318 (23.5%) received a booster dose by April 30, 2022. Receipt of influenza vaccines in the last 2 years was associated with completion of the primary series (RR, 1.17; 95% CI, 1.15-1.20) and an additional primary dose (RR, 1.61; 95% CI, 1.54-1.69). PWH with uncontrolled viremia (HIV viral load ≥200 copies/mL) (eg, RR, 0.90 [95% CI, 0.85-0.95] for viral load 200-10 000 copies/mL vs undetected or <200 copies/mL for completing the primary series) and Medicaid insurance (eg, RR, 0.89 [95% CI, 0.87-0.90] for completing the primary series) were less likely to be fully vaccinated. By contrast, greater outpatient utilization (eg, RR, 1.07 [95% CI, 1.05-1.09] for ≥7 vs 0 visits for primary series completion) and residence in counties with higher COVID-19 vaccine coverage (eg, RR, 1.06 [95% CI, 1.03-1.08] for fourth vs first quartiles for primary series completion) were associated with primary series and additional dose completion (RRs ranging from 1.01 to 1.21)., Conclusions and Relevance: Findings from this cohort study suggest that, while COVID-19 vaccination coverage was high among PWH, outreach efforts should focus on those who did not complete vaccine series and those who have uncontrolled viremia.

COVID-19 vaccinations protect against severe illness and death, but associations with post-COVID conditions (PCC) are less clear. We aimed to evaluate the association between prior COVID-19 vaccination and new-onset PCC among individuals with SARS-CoV-2 infection across eight large healthcare systems in the United States. This retrospective matched cohort study used electronic health records (EHR) from patients with SARS-CoV-2 positive tests during March 2021-February 2022. Vaccinated and unvaccinated COVID-19 cases were matched on location, test date, severity of acute infection, age, and sex. Vaccination status was ascertained using EHR and integrated data on externally administered vaccines. Adjusted relative risks (RRs) were obtained from Poisson regression. PCC was defined as a new diagnosis in one of 13 PCC categories 30 days to 6 months following a positive SARS-CoV-2 test. The study included 161,531 vaccinated COVID-19 cases and 161,531 matched unvaccinated cases. Compared to unvaccinated cases, vaccinated cases had a similar or lower risk of all PCC categories except mental health disorders (RR: 1.06, 95% CI: 1.02-1.10). Vaccination was associated with ≥10% lower risk of sensory (RR: 0.90, 0.86-0.95), circulatory (RR: 0.88, 0.83-0.94), blood and hematologic (RR: 0.79, 0.71-0.89), skin and subcutaneous (RR: 0.69, 0.66-0.72), and non-specific COVID-19 related disorders (RR: 0.53, 0.51-0.56). In general, associations were stronger at younger ages but mostly persisted regardless of SARS-CoV-2 variant period, receipt of ≥3 vs. 1-2 vaccine doses, or time since vaccination. Pre-infection vaccination was associated with reduced risk of several PCC outcomes and hence may decrease the long-term consequences of COVID-19., (© 2024. The Author(s).)

Background: Although previous studies found no-increased mortality risk after COVID-19 vaccination, residual confounding bias might have impacted the findings. Using a modified self-controlled case series (SCCS) design, we assessed the risk of non-COVID-19 mortality, all-cause mortality, and four cardiac-related death outcomes after primary series COVID-19 vaccination., Methods: We analyzed all deaths between December 14, 2020, and August 11, 2021, among individuals from eight Vaccine Safety Datalink sites. Demographic characteristics of deaths in recipients of COVID-19 vaccines and unvaccinated individuals were reported. We conducted SCCS analyses by vaccine type and death outcomes and reported relative incidences (RI). The observation period for death spanned from the dates of emergency use authorization to the end of the study period (August 11, 2021) without censoring the observation period upon death. We pre-specified a primary risk interval of 28-day and a secondary risk interval of 14-day after each vaccination dose. Adjusting for seasonality in mortality analyses is crucial because death rates vary over time. Deaths among unvaccinated individuals were included in SCCS analyses to account for seasonality by incorporating calendar month in the models., Results: For Pfizer-BioNTech (BNT162b2), RIs of non-COVID-19 mortality, all-cause mortality, and four cardiac-related death outcomes were below 1 and 95 % confidence intervals (CIs) excluded 1 across both doses and both risk intervals. For Moderna (mRNA-1273), RI point estimates of all outcomes were below 1, although the 95 % CIs of two RI estimates included 1: cardiac-related (RI = 0.78, 95 % CI, 0.58-1.04) and non-COVID-19 cardiac-related mortality (RI = 0.80, 95 % CI, 0.60-1.08) 14 days after the second dose in individuals without pre-existing cancer and heart disease. For Janssen (Ad26.COV2.S), RIs of four cardiac-related death outcomes ranged from 0.94 to 0.98 for the 14-day risk interval, and 0.68 to 0.72 for the 28-day risk interval and 95 % CIs included 1., Conclusion: Using a modified SCCS design and adjusting for temporal trends, no-increased risk was found for non-COVID-19 mortality, all-cause mortality, and four cardiac-related death outcomes among recipients of the three COVID-19 vaccines used in the US., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Understanding the long-term impact of the COVID-19 pandemic on health care utilization is important to health care organizations and policy makers for strategic planning, as well as to researchers when designing studies that use observational electronic health record data during the pandemic period., Objective: This study aimed to evaluate the changes in health care utilization across all care settings among a large, diverse, and insured population in the United States during the COVID-19 pandemic., Methods: We conducted a retrospective cohort study within 8 health care organizations participating in the Vaccine Safety Datalink Project using electronic health record data from members of all ages from January 1, 2017, to December 31, 2021. The visit rates per person-year were calculated monthly during the study period for 4 health care settings combined as well as by inpatient, emergency department (ED), outpatient, and telehealth settings, both among all members and members without COVID-19. Difference-in-difference analysis and interrupted time series analysis were performed to assess the changes in visit rates from the prepandemic period (January 2017 to February 2020) to the early pandemic period (April-December 2020) and the later pandemic period (July-December 2021), respectively. An exploratory analysis was also conducted to assess trends through June 2023 at one of the largest sites, Kaiser Permanente Southern California., Results: The study included more than 11 million members from 2017 to 2021. Compared with the prepandemic period, we found reductions in visit rates during the early pandemic period for all in-person care settings. During the later pandemic period, overall use reached 8.36 visits per person-year, exceeding the prepandemic level of 7.49 visits per person-year in 2019 (adjusted percent change 5.1%, 95% CI 0.6%-9.9%); inpatient and ED visits returned to prepandemic levels among all members, although they remained low at 0.095 and 0.241 visits per person-year, indicating a 7.5% and 8% decrease compared to pre-pandemic levels among members without COVID-19, respectively. Telehealth visits, which were approximately 42% of the volume of outpatient visits during the later pandemic period, were increased by 97.5% (95% CI 86.0%-109.7%) from 0.865 visits per person-year in 2019 to 2.35 visits per person-year in the later pandemic period. The trends in Kaiser Permanente Southern California were similar to those of the entire study population. Visit rates from January 2022 to June 2023 were stable and appeared to be a continuation of the use levels observed at the end of 2021., Conclusions: Telehealth services became a mainstay of the health care system during the late COVID-19 pandemic period. Inpatient and ED visits returned to prepandemic levels, although they remained low among members without evidence of COVID-19. Our findings provide valuable information for strategic resource allocation for postpandemic patient care and for designing observational studies involving the pandemic period., (©Lei Qian, Lina S Sy, Vennis Hong, Sungching C Glenn, Denison S Ryan, Jennifer C Nelson, Simon J Hambidge, Bradley Crane, Ousseny Zerbo, Malini B DeSilva, Jason M Glanz, James G Donahue, Elizabeth Liles, Jonathan Duffy, Stanley Xu. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 23.01.2024.)

Background: The safety of COVID-19 vaccines plays an important role in addressing vaccine hesitancy. We conducted a large cohort study to evaluate the risk of non-COVID-19 mortality after COVID-19 vaccination while adjusting for confounders including individual-level demographics, clinical risk factors, health care utilization, and community-level socioeconomic risk factors., Methods: The retrospective cohort study consisted of members from seven Vaccine Safety Datalink sites from December 14, 2020 through August 31, 2021. We conducted three separate analyses for each of the three COVID-19 vaccines used in the US. Crude non-COVID-19 mortality rates were reported by vaccine type, age, sex, and race/ethnicity. The counting process model for survival analyses was used to analyze non-COVID-19 mortality where a new observation period began when the vaccination status changed upon receipt of the first dose and the second dose. We used calendar time as the basic time scale in survival analyses to implicitly adjust for season and other temporal trend factors. A propensity score approach was used to adjust for the potential imbalance in confounders between the vaccinated and comparison groups., Results: For each vaccine type and across age, sex, and race/ethnicity groups, crude non-COVID-19 mortality rates among COVID-19 vaccinees were lower than those among comparators. After adjusting for confounders with the propensity score approach, the adjusted hazard ratios (aHRs) were 0.46 (95% confidence interval [CI], 0.44-0.49) after dose 1 and 0.48 (95% CI, 0.46-0.50) after dose 2 of the BNT162b2 vaccine, 0.41 (95% CI, 0.39-0.44) after dose 1 and 0.38 (95% CI, 0.37-0.40) after dose 2 of the mRNA-1273 vaccine, and 0.55 (95% CI, 0.51-0.59) after receipt of Ad26.COV2.S., Conclusion: While residual confounding bias remained after adjusting for several individual-level and community-level risk factors, no increased risk was found for non-COVID-19 mortality among recipients of three COVID-19 vaccines used in the US., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background and Objective: The goal of this study was to determine the anatomic outcome of traumatic retinal detachment (RD) from combat ocular trauma., Materials and Methods: Retrospective study of patients sustaining a traumatic RD in Operation Iraqi Freedom and Operation Enduring Freedom who were evacuated to Walter Reed Army Medical Center from 2001 to 2011. The Fisher exact test, Wilcoxon rank sum test, and Agresti and Coull methods were used for analyses., Results: There were 143 eyes of 134 patients in which a traumatic RD developed, of a total of 890 eyes of 652 patients in the Walter Reed Ocular Trauma Database. Based on our results, predictors for failure to reattach the retina include maculaoff status ( P = .0002), open-globe injury ( P = .03), proliferative vitreoretinopathy postoperatively ( P = .002), and presence of hyphema ( P = .02). Intraocular foreign body and time to initial retinal surgery did not increase risk for failure. Thirty-four percent (34%) of eyes failed to be reattached., Conclusions: Traumatic RD due to injury sustained in a combat zone resulted in poor prognosis, with 82.09% of eyes with RD having a best-corrected visual acuity worse than 20/200. The anatomic success of RD repair was shown to be 65.71%, likely owing to the severity of the injuries, concomitant systemic injuries, and delayed surgical intervention. [ Ophthalmic Surg Lasers Imaging Retina 2022;53:493-501.] .

Background: Shoulder injury related to vaccine administration (SIRVA) accounts for more than half of all claims received by the National Vaccine Injury Compensation Program. However, due to the difficulty of finding SIRVA cases in large health care databases, population-based studies are scarce., Objective: The goal of the research was to develop a natural language processing (NLP) method to identify SIRVA cases from clinical notes., Methods: We conducted the study among members of a large integrated health care organization who were vaccinated between April 1, 2016, and December 31, 2017, and had subsequent diagnosis codes indicative of shoulder injury. Based on a training data set with a chart review reference standard of 164 cases, we developed an NLP algorithm to extract shoulder disorder information, including prior vaccination, anatomic location, temporality and causality. The algorithm identified 3 groups of positive SIRVA cases (definite, probable, and possible) based on the strength of evidence. We compared NLP results to a chart review reference standard of 100 vaccinated cases. We then applied the final automated NLP algorithm to a broader cohort of vaccinated persons with a shoulder injury diagnosis code and performed manual chart confirmation on a random sample of NLP-identified definite cases and all NLP-identified probable and possible cases., Results: In the validation sample, the NLP algorithm had 100% accuracy for identifying 4 SIRVA cases and 96 cases without SIRVA. In the broader cohort of 53,585 vaccinations, the NLP algorithm identified 291 definite, 124 probable, and 52 possible SIRVA cases. The chart-confirmation rates for these groups were 95.5% (278/291), 67.7% (84/124), and 17.3% (9/52), respectively., Conclusions: The algorithm performed with high sensitivity and reasonable specificity in identifying positive SIRVA cases. The NLP algorithm can potentially be used in future population-based studies to identify this rare adverse event, avoiding labor-intensive chart review validation., (©Chengyi Zheng, Jonathan Duffy, In-Lu Amy Liu, Lina S Sy, Ronald A Navarro, Sunhea S Kim, Denison S Ryan, Wansu Chen, Lei Qian, Cheryl Mercado, Steven J Jacobsen. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 24.05.2022.)

Background: The COVID-19 pandemic caused an abrupt drop in in-person health care (inpatient, Emergency Department, outpatient) and an increase in telehealth care, which poses challenges in vaccine safety studies that identify outcomes from in-person encounters. We examined the changes in incidence rates of selected encounter-based outcomes during the COVID-19 pandemic., Methods: We assembled a cohort of members from 8 Vaccine Safety Datalink sites from January 1, 2017 through December 31, 2020. Using ICD-10 diagnosis codes or laboratory criteria, we identified 21 incident outcomes in traditional in-person settings and all settings. We defined 4 periods in 2020: January-February (pre-pandemic), April-June (early pandemic), July-September (middle pandemic), and October-December (late pandemic). We defined four corresponding periods in each year during 2017-2019. We calculated incidence rates, conducted difference in difference (DiD) analyses, and reported ratios of incidence rate ratios (RRR) to examine changes in rates from pre-pandemic to early, middle, and late pandemic in 2020, after adjusting for changes across similar periods in 2017-2019., Results: Among > 10 million members, regardless of setting and after adjusting for changes during 2017-2019, we found that incidence rates of acute disseminated encephalomyelitis, encephalitis/myelitis/encephalomyelitis/meningoencephalitis, and thrombotic thrombocytopenic purpura did not significantly change from the pre-pandemic to early, middle or late pandemic periods (p-values ≥ 0.05). Incidence rates decreased from the pre-pandemic to early pandemic period during 2020 for acute myocardial infarction, anaphylaxis, appendicitis, Bell's palsy, convulsions/seizures, Guillain-Barré syndrome, immune thrombocytopenia (ITP), narcolepsy/cataplexy, hemorrhagic stroke, ischemic stroke, and venous thromboembolism (p-values < 0.05). Incidence rates of Bell's palsy, ITP, and narcolepsy/cataplexy were higher in all settings than in traditional in-person settings during the three pandemic periods (p-values < 0.05)., Conclusion: Rates of some clinical outcomes during the pandemic changed and should not be used as historical background rates in vaccine safety studies. Inclusion of telehealth visits should be considered for vaccine studies involving Bell's palsy, ITP, and narcolepsy/cataplexy., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: JGD reports research support from Janssen for an unrelated study. LSS reports research support from Moderna, GlaxoSmithKline, Dynavax, and Seqirus for unrelated studies., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Although shoulder conditions have been reported as an adverse event after intramuscular vaccination in the deltoid muscle, epidemiologic data on shoulder conditions after vaccination are limited., Objective: To estimate the risk for shoulder conditions after vaccination and assess possible risk factors., Design: Retrospective cohort study., Setting: Kaiser Permanente Southern California, a large integrated health care organization., Participants: Kaiser Permanente Southern California members aged 3 years or older who had an intramuscular vaccination administered in the deltoid muscle between 1 April 2016 and 31 December 2017., Measurements: A natural language processing (NLP) algorithm was used to identify potential shoulder conditions among vaccinated persons with shoulder disorder diagnosis codes. All NLP-identified cases were manually chart confirmed on the basis of our case definition. The characteristics of vaccinated persons with and without shoulder conditions were compared., Results: Among 3 758 764 administered vaccinations, 371 cases of shoulder condition were identified, with an estimated incidence of 0.99 (95% CI, 0.89 to 1.09) per 10 000 vaccinations. The incidence was 1.22 (CI, 1.10 to 1.35) for the adult (aged ≥18 years) and 0.05 (CI, 0.02 to 0.14) for the pediatric (aged 3 to 17 years) vaccinated populations. In the adult vaccinated population, advanced age, female sex, an increased number of outpatient visits in the 6 months before vaccination, lower Charlson Comorbidity Index, and pneumococcal conjugate vaccine were associated with a higher risk for shoulder conditions. Among influenza vaccines, quadrivalent vaccines were associated with an increased risk for shoulder conditions. Simultaneous administration of vaccines was associated with a higher risk for shoulder conditions among elderly persons., Limitation: Generalizability to other health care settings, use of administrative data, and residual confounding., Conclusion: These population-based data suggest a small absolute risk for shoulder conditions after vaccination. Given the high burden of shoulder conditions, clinicians should pay attention to any factors that may further increase risks., Primary Funding Source: Centers for Disease Control and Prevention.

This study highlights an unmet need in osteoporosis management, suggesting that beyond bone mineral density and fracture history, gender, fracture type, and age should be considered for fracture risk assessment. Following fragility fracture, men, patients with a spine or hip fracture, and those aged ≥ 65 have a higher disease burden., Introduction: The objective of this study was to characterize osteoporosis-related fracture incidence and identify predictors of subsequent fractures and mortality., Methods: This retrospective cohort study, conducted within Kaiser Permanente Southern California, included patients aged ≥ 50 years with qualifying fractures from 1/1/2007 to 12/31/2016, identified from diagnosis/procedure codes. Rates for fracture incidence, mortality, and resource utilization in the year post-fracture are reported. Associations between index fracture types and demographic/clinical characteristics, and mortality, subsequent fracture, and rehospitalization outcomes were estimated., Results: Of 63,755 eligible patients, 66.7% were ≥ 65 years and 69.1% female. Index fractures included nonhip/nonspine (64.4%), hip (25.3%), and spine (10.3%). Age-adjusted subsequent fracture rate/100 person-years was higher for those with an index spine (14.5) versus hip fracture (6.3). Hospitalization rate/100 person-years was highest for patients ≥ 65 (31.8) and for spine fractures (43.5). Men (vs women) had higher age-adjusted rates of hospitalization (19.4; 17.7), emergency room visits (73.8; 66.3), and use of rehabilitation services (31.7; 27.2). The 30-day age-adjusted mortality rate/100 person-years was 46.7, 32.4, and 15.5 for spine, hip, and nonspine/nonhip fractures. The 1-year age-adjusted mortality rate/100 person-years was 14.7 for spine and 15.6 for hip fractures. In multivariable analyses, spine and hip fractures (vs nonhip/nonspine fractures) were significant predictors of 1-year mortality, all-cause and osteoporosis-related hospitalization, and nursing home use (all P-values < 0.0001)., Conclusion: Morbidity is high in the year following a fragility fracture and men, patients with a spine or hip fracture, and those aged ≥ 65 have a greater disease burden., (© 2021. The Author(s).)

Introduction: Traumatic brain injury (TBI) remains a significant source of disability for active duty service members in both deployed and training settings as well as those who have left active service. Service members with ocular trauma are at risk for a TBI and should be screened appropriately. Early detection results in treatment to minimize long-term sequelae which can often be debilitating. This study is the first to evaluate different combat-related ocular injuries and their associations with TBI., Materials and Methods: A secondary analysis of existing data was conducted from a prospective study of patients who sustained combat ocular trauma (COT) during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) between 2006 and 2020. Clinical data of a total of 88 participants were gathered and each case reviewed, including patient demographics, injury-related factors, history of TBI, and treatments rendered. All cases were then categorized to compare COT (n = 13) versus COT-T (Combat Ocular Trauma associated with TBI; n = 75). The Fisher's exact test was completed for each category to assess for predictive factors of TBI within the ophthalmic trauma cohort. Odds ratios were calculated with their 95% CI., Results: When compared to COT, COT-T was significantly associated with closed globe injuries (56%; OR 4.24, 95% CI 1.08-16.67), blast injuries (89.3%; OR 3.72, 95% CI 0.93-14.9), multiple surgeries (89%; OR 2.51, 95% CI 0.57-11.08), anterior segment injuries (69.3%; OR 1.41, 95% CI 0.42-4.79), optic nerve injuries (24%; OR 1.05, 95% CI 0.26-4.25), orbital fractures (48%; OR 2.08, 95% CI 0.59-7.34), enucleation (17.3%; OR 2.52, 95% CI 0.300-21.08), the use of eye protection (68.6%; OR 2.18, 95% CI 0.57-8.32), and the need to undergo plastic surgery (78.7%; OR 2.30, 95% CI 0.66-8.02). Significant factors associated with COT included penetrating injury (30.8%; OR 0.027, 95% CI 0.07-1.08), posterior segment injuries (92%; OR 0.264, 95% CI 0.032-2.17), bilateral injuries (76.9%; OR 0.678, 95% CI 0.17-2.69), and bilateral blindness (7.7%; OR 0.857, 95% CI 0.092-7.99)., Conclusions: Patients who have sustained combat-related ocular injuries, specifically blast injury, anterior segment injury, or an orbital fracture, were noted to be more likely to have also sustained a TBI. However, of the evaluated variables in predicting the co-occurrence of TBI, only closed globe injury was identified as statistically significant. Service members with injuries requiring multiple surgical procedures, reconstructive plastic surgery, or enucleation of an eye were also more likely to be diagnosed with a TBI, but these variables were not found to be predictive of TBI among ocular trauma patients. The presence of eye protection was not protective against TBI. Further studies are needed to find significant predictors of TBI in combat ocular trauma patients to assist in the early and accurate detection of TBI., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Purpose: The purpose of this study was to assess visual and health-related quality of life (QOL) among U.S. military service members who sustained combat ocular trauma (COT) with or without associated traumatic brain injury (TBI)., Methods: This was a single-center, prospective observational study of U.S. service members (n = 88) with COT who were treated at Walter Reed National Military Medical Center. Participants completed the National Eye Institute Visual Function Questionnaire (VFQ-25) at enrollment and at follow-up (>1 year) and supplemental surveys: Neurobehavioral Symptom Inventory, the Medical Outcomes 36-item Short Form Survey (SF-36), and Mayo-Portland Adaptability Inventory., Results: Initial and follow-up VFQ-25 showed a statistically significant increase in median scores for near activities (initial: 75.0, follow-up 83.3; P = .004) and peripheral vision (initial: 50.0, follow-up: 75.0; P = .009) and in composite scores (initial: 79.5, follow-up: 79.8; P = .022). Comparing those who did (n = 78) and did not (n = 8) have a TBI history, there were no significant differences in median change in VFQ-25 composite scores (with TBI: 2.3 vs. no TBI: 10.7; P = .179). Participants with a TBI history had a significantly lower median SF-36 General Health score (with TBI: 67.5 vs. no TBI: 92.5; P = .009)., Conclusions: Vision-related QOL of COT patients is generally good in the long term. However, those with both COT and a history of TBI conditions showed significantly worse functioning in several domains than those without TBI. As TBI is a common finding in COT, this association is an important factor impacting this population's overall clinical presentation and daily functions., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To determine the rates and types of open-globe wounds in soldiers admitted to Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries., Methods: Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were patients who suffered open-globe injuries. Open-globe injuries were classified by type of wound: corneal, corneo-scleral or scleral, or type of open-globe injury: perforating, rupture, penetrating or intraocular foreign body. The primary analysis assessed the effect on final visual acuity (VA) and the risk of enucleation., Results: In this study, 285 (32.02%) open-globe injuries were recorded in 890 eyes in the data set. Corneal wounds were noted in 127 (44.56%) eyes, corneo-scleral wounds in 78 (27.37%) and scleral wounds in 129 (45.26%) eyes. The involvement of both the corneal and sclera was associated with poorer visual outcome (BCVA < 20/200) compared to injuries with an injury confined to either the cornea or scleral alone (p = 0.038). At a wound length of greater than approximately 14 mm, patients had 75% chance of having a poor final VA. Enucleation was performed in 64 (22.46%) eyes of patients with wounds. The type of wound was not found to be predictive of enucleation in multivariate analysis, but rather the type of open-globe injury was predictive. Perforating (OR: 1.58, 95% CI: 1.43-1.72) and globe rupture injuries (OR: 1.49, 95% CI: 1.33-1.66) were more likely to undergo enucleation., Conclusions: Open-globe injuries occur frequently in combat ocular trauma. Poor final VA was noted most with corneo-scleral wounds with approximately 50% of patients having a final VA less than 20/200., (© 2021 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background/purpose: To characterize the nature of posterior segment ocular injuries in combat trauma., Methods: Eyes in the Walter Reed Ocular Trauma Database were evaluated for the presence of posterior segment injury. Final visual outcomes in open-globe versus closed-globe injuries and by zone of injury and the types of posterior segment injuries in open-globe versus closed-globe injuries were assessed., Results: Four hundred fifty-two of 890 eyes (50.8%) had at least one posterior segment injury. The mechanism of injury was most commonly an improvised explosive device in 280 (62.0%) eyes. Sixty-one patients (13.5%) had a Zone I injury, 50 (11.1%) a Zone II injury, and 341 (75.4%) a Zone III injury. Patients with Zone I injuries were more likely to have a final visual acuity of 20/200 or better compared with patients with either a Zone II (P < 0.001) or Zone III injury (P = 0.007). Eyes with a closed-globe injury were more likely to have a final visual acuity of 20/200 or better compared with those with an open-globe injury (P < 0.001). Furthermore, closed-globe injury compared with open-globe injury had a lower risk of vitreous hemorrhage (odds ratio 0.32, P < 0.001), proliferative vitreoretinopathy (odds ratio 0.14, P < 0.001), and retinal detachment (odds ratio 0.18, P < 0.001) but a higher risk of chorioretinal rupture (odds ratio 2.82, P < 0.001) and macular hole (odds ratio 3.46, P = 0.004)., Conclusion: Patients with combat ophthalmic trauma had similar posterior segment injury patterns to civilian trauma in open-globe versus closed-globe injuries. Zone II and III injuries were associated with a worse visual prognosis.

Purpose: To assess early visual outcomes and military task performance after small-incision lenticule extraction (SMILE) among U.S. military service members., Setting: Warfighter Refractive Eye Surgery Program and Research Center and Night Vision and Electronic Sensors Directorate, Fort Belvoir, Virginia., Design: Single-center, prospective, observational study., Methods: The study was composed of active duty service members (n = 37) electing to undergo SMILE for myopia or myopic astigmatism. Testing performed preoperatively and at 1 month and 3 months postoperatively included uncorrected (UDVA) and corrected (CDVA) distance visual acuities, wavefront aberrometry, low-contrast visual acuity (LCVA), contrast sensitivity, and vision-related questionnaire. 14 participants underwent rifle marksmanship with spectacle correction before and without correction at 6 to 8 weeks postoperatively., Results: At 3 months postoperatively, the efficacy index was 0.96 and the safety index was 1.03. UDVA was ≥20/20 in 69 (96%) of eyes. LCVA change from baseline was significant under night vision condition. Eye problems contributed to 10% work and 20% activity impairments, both of which decreased to 0% (P = .001). The overall satisfaction rating for SMILE was high at 90.9 (95% CI, 85.3 to 96.5), and 95% of participants would be willing to undergo the procedure again. The median scores between preoperative and 6 to 8 weeks postoperative firing performance were comparable (34 vs 35, with and without correction, respectively; P = .247)., Conclusions: After the early recovery period, SMILE seems to preserve quality of vision, which appears to facilitate the accomplishment of tasks related to their work as military service members as well as performing activities outside of work., (Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

By September 21, 2021, an estimated 182 million persons in the United States were fully vaccinated against COVID-19.* Clinical trials indicate that Pfizer-BioNTech (BNT162b2), Moderna (mRNA-1273), and Janssen (Johnson & Johnson; Ad.26.COV2.S) vaccines are effective and generally well tolerated (1-3). However, daily vaccination rates have declined approximately 78% since April 13, 2021 † ; vaccine safety concerns have contributed to vaccine hesitancy (4). A cohort study of 19,625 nursing home residents found that those who received an mRNA vaccine (Pfizer-BioNTech or Moderna) had lower all-cause mortality than did unvaccinated residents (5), but no studies comparing mortality rates within the general population of vaccinated and unvaccinated persons have been conducted. To assess mortality not associated with COVID-19 (non-COVID-19 mortality) after COVID-19 vaccination in a general population setting, a cohort study was conducted during December 2020-July 2021 among approximately 11 million persons enrolled in seven Vaccine Safety Datalink (VSD) sites. § After standardizing mortality rates by age and sex, this study found that COVID-19 vaccine recipients had lower non-COVID-19 mortality than did unvaccinated persons. After adjusting for demographic characteristics and VSD site, this study found that adjusted relative risk (aRR) of non-COVID-19 mortality for the Pfizer-BioNTech vaccine was 0.41 (95% confidence interval [CI] = 0.38-0.44) after dose 1 and 0.34 (95% CI = 0.33-0.36) after dose 2. The aRRs of non-COVID-19 mortality for the Moderna vaccine were 0.34 (95% CI = 0.32-0.37) after dose 1 and 0.31 (95% CI = 0.30-0.33) after dose 2. The aRR after receipt of the Janssen vaccine was 0.54 (95% CI = 0.49-0.59). There is no increased risk for mortality among COVID-19 vaccine recipients. This finding reinforces the safety profile of currently approved COVID-19 vaccines in the United States., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Runxin Huang reports support for attending meetings or travel from Dynavax Technologies. Nicola P. Klein reports institutional support from Pfizer, Sanofi Pasteur, Merck, GlaxoSmithKline, and Protein Science (now Sanofi Pasteur to support vaccine studies). Elizabeth G. Liles reports research contracts from the National Human Genome Research Institute and Pfizer. Kerresa Morrissette reports research contracts from the National Institutes of Health, GlaxoSmithKline, and Merck Sharp & Dohme Corporation, outside the submitted work. No other potential conflicts of interest were disclosed.

Background: Dramatic decreases in outpatient visits and sudden increases in telehealth visits were observed during the COVID-19 pandemic, but it was unclear whether these changes differed by patient demographics and socioeconomic status., Objective: This study aimed to assess the impact of the pandemic on in-person outpatient and telehealth visits (telephone and video) by demographic characteristics and household income in a diverse population., Methods: We calculated weekly rates of outpatient and telehealth visits by age, sex, race/ethnicity, and neighborhood-level median household income among members of Kaiser Permanente Southern California (KPSC) from January 5, 2020, to October 31, 2020, and the corresponding period in 2019. We estimated the percentage change in visit rates during the early pandemic period (March 22 to April 25, 2020) and the late pandemic period (October 4 to October 31, 2020) from the prepandemic period (January 5 to March 7, 2020) in Poisson regression models for each subgroup while adjusting for seasonality using 2019 data. We examined if the changes in visit rates differed by subgroups statistically by comparing their 95% CIs., Results: Among 4.56 million KPSC members enrolled in January 2020, 15.0% (n=682,947) were ≥65 years old, 51.5% (n=2,345,020) were female, 39.4% (n=1,795,994) were Hispanic, and 7.7% (n=350,721) lived in an area of median household income

Purpose: To update the epidemiology of ocular injuries in soldiers admitted to Walter Reed Army Medical Center (WRAMC) from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)., Methods: Data were collected in the Walter Reed Ocular Trauma Database. A Bayesian Network Analysis was completed to better understand the relationships between different ocular demographic variables, injuries, surgeries, ocular trauma scores (OTS) and visual outcomes., Results: There were 890 consecutive globe or adnexal combat injuries, or both, sustained by 652 United States soldiers treated at WRAMC between 2001 and 2011.The primary mechanism of injury was improvised explosive device (62.47%). Many patients (62.0%) had final visual acuity (VA) grades of 1-2 (20/15 - 20/200), while 29.9% of patients had final VA grades of 3-5 (less than 20/200), and 8.1% had unknown final VA grades. Bayesian Network Analysis revealed that the injury variables of Retina (47.9%), Lens (44.6%), Posterior Segment (43.7%) and Anterior Segment (40.3%), and the surgical variables of Enucleation (97.6%) and cataract extraction and posterior capsule intraocular lens placement (CEPCIOL; 43.3%) all had probabilities greater than 40% for a poor final VA, while all other variables were less than 40%., Conclusion: Modern-day combat trauma results in complicated ocular injuries causing 30% of patients to be left legally blind in their injured eye. It is critical to maintain a wide variety of deployable, specialty trained ophthalmologists to ensure the best visual outcomes for wounded warriors and to maintain mission readiness.

Background: The COVID-19 pandemic has caused an abrupt reduction in the use of in-person health care, accompanied by a corresponding surge in the use of telehealth services. However, the extent and nature of changes in health care utilization during the pandemic may differ by care setting. Knowledge of the impact of the pandemic on health care utilization is important to health care organizations and policy makers., Objective: The aims of this study are (1) to evaluate changes in in-person health care utilization and telehealth visits during the COVID-19 pandemic and (2) to assess the difference in changes in health care utilization between the pandemic year 2020 and the prepandemic year 2019., Methods: We retrospectively assembled a cohort consisting of members of a large integrated health care organization, who were enrolled between January 6 and November 2, 2019 (prepandemic year), and between January 5 and October 31, 2020 (pandemic year). The rates of visits were calculated weekly for four settings: inpatient, emergency department (ED), outpatient, and telehealth. Using Poisson models, we assessed the impact of the pandemic on health care utilization during the early days of the pandemic and conducted difference-in-deference (DID) analyses to measure the changes in health care utilization, adjusting for the trend of health care utilization in the prepandemic year., Results: In the early days of the pandemic, we observed significant reductions in inpatient, ED, and outpatient utilization (by 30.2%, 37.0%, and 80.9%, respectively). By contrast, there was a 4-fold increase in telehealth visits between weeks 8 (February 23) and 12 (March 22) in 2020. DID analyses revealed that after adjusting for prepandemic secular trends, the reductions in inpatient, ED, and outpatient visit rates in the early days of the pandemic were 1.6, 8.9, and 367.2 visits per 100 person-years (P<.001), respectively, while the increase in telehealth visits was 272.9 visits per 100 person-years (P<.001). Further analyses suggested that the increase in telehealth visits offset the reduction in outpatient visits by week 26 (June 28, 2020)., Conclusions: In-person health care utilization decreased drastically during the early period of the pandemic, but there was a corresponding increase in telehealth visits during the same period. By end-June 2020, the combined outpatient and telehealth visits had recovered to prepandemic levels., (©Stanley Xu, Sungching Glenn, Lina Sy, Lei Qian, Vennis Hong, Denison S Ryan, Steven Jacobsen. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 29.04.2021.)

Purpose  The aim of this study was to evaluate whether the simulated tissue models may be used in place of animal-based model for corneal laceration repair for surgical skills acquisition. Design  Prospective randomized controlled trial. Participants  Seventy-nine military and civilian 2nd- and 3rd-year ophthalmology residents and 16 staff ophthalmologists participating in the Tri-Service Ocular Trauma Skills Laboratory at the Uniformed Services University (Bethesda, MD). Methods  Resident ophthalmologists underwent preliminary evaluation of their ability to close a 5-mm linear, full-thickness corneal laceration involving the visual axis. They then were randomized to undergo 90 to 120 minutes of either simulator-based (SIM) or swine cadaveric-tissue-based (CADAVER) corneal laceration repair. The same evaluation was performed post training. On a more limited basis, the study was repeated for attending ophthalmologists to act as a pilot for future analysis and test efficacy for "refresher" training. Main Outcome Measures  Successful wound closure with secondary outcomes of suture length, tension, depth, and orientation, as graded by attending ophthalmologists. Results  No significant difference in CADAVER versus SIM groups in the primary outcome of watertight wound closure of the corneal laceration. CADAVER group performed better than SIM group for certain metrics (suture depth, p  = 0.009; length, p  = 0.003; and tension, p  = 0.043) that are associated with poor wound closure and increased amount of induced corneal astigmatism. For attending ophthalmologists, six of the eight in each group (SIM and CADAVER) retained or improved their skills. Conclusions  For resident ophthalmologists, SIM training is sufficient for achieving the primary outcome of watertight wound closure. However, CADAVER training is superior for wound metrics for the ideal closure. For attending ophthalmologists, SIM training may be useful for retention of skills., Competing Interests: Conflict of Interest No conflicting relationship exists for any author on this article., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Research has shown that compression of muscle can lead to a change in muscle force. Most studies show compression to lead to a reduction in muscle force, although recent research has shown that increases are also possible. Based on methodological differences in the loading design between studies, it seems that muscle length and the direction of transverse loading influence the effect of muscle compression on force production. Thus, in our current study we implement these two factors to influence the effects of muscle loading. In contrast to long resting length of the medial gastrocnemius (MG) in most studies, we use a shorter MG resting length by having participant seated with their knees at a 90° angle. Where previous studies have used unidirectional loads to compress the MG, in this study we applied a multidirectional load using a sling setup. Multidirectional loading using a sling setup has been shown to cause muscle force reductions in previous research. As a result of our choices in experimental design we observed changes in the effects of muscle loading compared to previous research. In the present study we observed no changes in muscle force due to muscle loading. Muscle thickness and pennation angle showed minor but significant increases during contraction. However, no significant changes occurred between unloaded and loaded trials. Fascicle thickness and length showed different patterns of change compared to previous research. We show that muscle loading does not result in force reduction in all situations and is possibly linked to differences in muscle architecture and muscle length., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Ryan, Stutzig, Helmer, Siebert and Wakeling.)

Lipids in complex, protein-enriched films at air/liquid interfaces reduce surface tension. In the absence of this benefit, the light refracting and immunoprotective tear film on eyes would collapse. Premature collapse, coupled with chronic inflammation compromising visual acuity, is a hallmark of dry eye disease affecting 7 to 10% of individuals worldwide. Although collapse seems independent of mutation (unlike newborn lung alveoli), selective proteome and possible lipidome changes have been noted. These include elevated tissue transglutaminase and consequent inactivation through C-terminal cross-linking of the tear mitogen lacritin, leading to significant loss of lacritin monomer. Lacritin monomer restores homeostasis via autophagy and mitochondrial fusion and promotes basal tearing. Here, we discover that lacritin monomer C-terminal processing, inclusive of cysteine, serine, and metalloproteinase activity, generates cationic amphipathic α-helical proteoforms. Such proteoforms (using synthetic peptide surrogates) act like alveolar surfactant proteins to rapidly bind and stabilize the tear lipid layer. Immunodepletion of C- but not N-terminal proteoforms nor intact lacritin, from normal human tears promotes loss of stability akin to human dry eye tears. Stability of these and dry eye tears is rescuable with C- but not N-terminal proteoforms. Repeated topical application in rabbits reveals a proteoform turnover time of 7 to 33 h with gradual loss from human tear lipid that retains bioactivity without further processing. Thus, the processed C-terminus of lacritin that is deficient or absent in dry eye tears appears to play a key role in preventing tear film collapse and as a natural slow release mechanism that restores epithelial homeostasis., Competing Interests: Conflict of interest G. W. L. is cofounder and CSO, and MGO is CMO of TearSolutions, Inc. G. A. G., M. S., J. R., K. D. T., C. S., D. S. R., R. K. S., J. P. K., J. M. H., K. L. H., A. L., T. S., R. L. M. declare no conflict of interest., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

In this study we examined how the strain energies within a muscle are related to changes in longitudinal force when the muscle is exposed to an external transverse load. We implemented a three-dimensional (3D) finite element model of contracting muscle using the principle of minimum total energy and allowing the redistribution of energy through different strain energy-densities. This allowed us to determine the importance of the strain energy-densities to the transverse forces developed by the muscle. We ran a series of in silica experiments on muscle blocks varying in initial pennation angle, muscle length, and external transverse load. As muscle contracts it maintains a near constant volume. As such, any changes in muscle length are balanced by deformations in the transverse directions such as muscle thickness or muscle width. Muscle develops transverse forces as it expands. In many situations external forces act to counteract these transverse forces and the muscle responds to external transverse loads while both passive and active. The muscle blocks used in our simulations decreased in thickness and pennation angle when passively compressed and pushed back on the load when they were activated. Activation of the compressed muscle blocks led either to an increase or decrease in muscle thickness depending on whether the initial pennation angle was less than or greater than 15°, respectively. Furthermore, the strain energy increased and redistributed across the different strain-energy potentials during contraction. The volumetric strain energy-density varied with muscle length and pennation angle and was reduced with greater transverse load for most initial muscle lengths and pennation angles. External transverse load reduced the longitudinal muscle force for initial pennation angles of β 0 = 0°. Whereas for pennate muscle (β 0 > 0°) longitudinal force changed (increase or decrease) depending on the muscle length, pennation angle and the direction of the external load relative to the muscle fibres. For muscle blocks with initial pennation angles β 0 ≤ 20° the reduction in longitudinal muscle force coincided with a reduction in volumetric strain energy-density., (Copyright © 2020 Ryan, Domínguez, Ross, Nigam and Wakeling.)

Background and Objective: To determine the risk factors associated with developing proliferative vitreoretinopathy (PVR) from combat ocular injuries in U.S. service members., Patients and Methods: Retrospective review of associated risk factors and outcomes of PVR within the Walter Reed Ocular Trauma Database. Ocular injuries in U.S. service members wounded during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2011 were assessed, and of these all cases of PVR were studied. Principal outcome measures were the risk factors associated with PVR development and rate of final visual acuity (VA) less than 20/200., Results: Eight hundred ninety eyes of 651 U.S. service members were evaluated. A total of 76 eyes (8.5%) of 66 patients developed PVR. Five patients had bilateral PVR. Nineteen patients had bilateral eye injuries. Sixty-one eyes (80.2%) had a final VA less than 20/200. PVR was found to be a significant risk factor for a poor final VA (P < .001). Retinal detachment (RD) was found in 52 eyes (68.4%) of patients. In patients with a RD, intraocular foreign bodies (IOFBs) (P < .001), unsuccessful repair (P = .002), and macular hemorrhage (P = .04) were significant risk factors for the development of PVR. Time to initial retina surgery was not found to be a risk factor for PVR development (P = .5). Time to initial retina surgery was available in 41 patients and the time to surgery on average was 22.56 days (range: 3 to 87 days)., Conclusions: PVR occurs frequently in combat trauma and is a significant cause of poor final VA. In patients with PVR and RD, injuries caused by an IOFB, macular hemorrhage, or unsuccessful repair were significant risk factors for the development of PVR. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:556-563.]., (Copyright 2020, SLACK Incorporated.)

Pregnant women might be at increased risk for severe coronavirus disease 2019 (COVID-19), possibly related to changes in their immune system and respiratory physiology* (1). Further, adverse birth outcomes, such as preterm delivery and stillbirth, might be more common among pregnant women infected with SARS-CoV-2, the virus that causes COVID-19 (2,3). Information about SARS-CoV-2 infection during pregnancy is rapidly growing; however, data on reasons for hospital admission, pregnancy-specific characteristics, and birth outcomes among pregnant women hospitalized with SARS-CoV-2 infections are limited. During March 1-May 30, 2020, as part of Vaccine Safety Datalink (VSD) † surveillance of COVID-19 hospitalizations, 105 hospitalized pregnant women with SARS-CoV-2 infection were identified, including 62 (59%) hospitalized for obstetric reasons (i.e., labor and delivery or another pregnancy-related indication) and 43 (41%) hospitalized for COVID-19 illness without an obstetric reason. Overall, 50 (81%) of 62 pregnant women with SARS-CoV-2 infection who were admitted for obstetric reasons were asymptomatic. Among 43 pregnant women hospitalized for COVID-19, 13 (30%) required intensive care unit (ICU) admission, six (14%) required mechanical ventilation, and one died from COVID-19. Prepregnancy obesity was more common (44%) among pregnant women hospitalized for COVID-19 than that among asymptomatic pregnant women hospitalized for obstetric reasons (31%). Likewise, the rate of gestational diabetes (26%) among pregnant women hospitalized for COVID-19 was higher than it was among women hospitalized for obstetric reasons (8%). Preterm delivery occurred in 15% of pregnancies among 93 women who delivered, and stillbirths (fetal death at ≥20 weeks' gestation) occurred in 3%. Antenatal counseling emphasizing preventive measures (e.g., use of masks, frequent hand washing, and social distancing) might help prevent COVID-19 among pregnant women, § especially those with prepregnancy obesity and gestational diabetes, which might reduce adverse pregnancy outcomes., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Denison S. Ryan reports grants from Amgen, Merck & Co., and Radius Health and other support from O.N. Diagnostics outside the submitted work. Allison L. Naleway reports grants from Pfizer outside the submitted work. Nicola P. Klein reports grants from Sanofi Pasteur, GlaxoSmithKline, Pfizer, Merck & Co., and Protein Science outside the submitted work. No other potential conflicts of interest were disclosed.

Background: To analyze the final visual acuity (VA) of neuro-ophthalmologic injuries (NOI) in combat ocular trauma and to study the association of NOI with systemic neurologic injury (SNI) and traumatic brain injury (TBI)., Methods: The Walter Reed Ocular Trauma Database was reviewed. Inclusion criteria were any US service member and Department of Defense civilians who suffered NOI, SNI, or TBI in Operation Iraqi Freedom or Operation Enduring Freedom. The primary outcome measure was the rate of poor final VA in patients with an NOI with secondary outcome measures the rate of SNI and TBI. in patients with NOI., Results: One hundred seventy-eight (20.00%) of 890 eyes had an NOI. Optic nerve injury was observed in 79 (44.38%) eyes, other cranial nerve injury in 68 (38.20%), Horner syndrome in 4 (2.25%), diplopia in 45 (25.28%), and ptosis in 13 (7.30%). In patients with NOI, 76 (42.69%) eyes had a final VA less than 20/200. In injured eyes (n = 359) of patients (n = 251) with TBI, 154 eyes (34.26%) had a final VA less than 20/200. In multivariate analysis, optic nerve injury (P < 0.001), unlike TBI (P = 0.47), was associated with final VA less than 20/200. SNI (n = 229) had a statistically significant association (odds ratio 29.8, 95% confidence interval 19.2-47.8, P < 0.001) with NOI. Optic nerve injury and cranial nerve injury were associated with TBI and SNI (all, P < 0.001)., Conclusion: Optic nerve injury and cranial nerve injury are associated with TBI and SNI. Optic nerve injury, but not TBI or cranial nerve injury, is associated with a poor final VA.

During contraction the energy of muscle tissue increases due to energy from the hydrolysis of ATP. This energy is distributed across the tissue as strain-energy potentials in the contractile elements, strain-energy potential from the 3D deformation of the base-material tissue (containing cellular and extracellular matrix effects), energy related to changes in the muscle's nearly incompressible volume and external work done at the muscle surface. Thus, energy is redistributed through the muscle's tissue as it contracts, with only a component of this energy being used to do mechanical work and develop forces in the muscle's longitudinal direction. Understanding how the strain-energy potentials are redistributed through the muscle tissue will help enlighten why the mechanical performance of whole muscle in its longitudinal direction does not match the performance that would be expected from the contractile elements alone. Here we demonstrate these physical effects using a 3D muscle model based on the finite element method. The tissue deformations within contracting muscle are large, and so the mechanics of contraction were explained using the principles of continuum mechanics for large deformations. We present simulations of a contracting medial gastrocnemius muscle, showing tissue deformations that mirror observations from magnetic resonance imaging. This paper tracks the redistribution of strain-energy potentials through the muscle tissue during fixed-end contractions, and shows how fibre shortening, pennation angle, transverse bulging and anisotropy in the stress and strain of the muscle tissue are all related to the interaction between the material properties of the muscle and the action of the contractile elements., (Copyright © 2020 Wakeling, Ross, Ryan, Bolsterlee, Konno, Domínguez and Nigam.)

Background: Bisphosphonates are effective in reducing hip and osteoporotic fractures. However, concerns about atypical femur fractures have contributed to substantially decreased bisphosphonate use, and the incidence of hip fractures may be increasing. Important uncertainties remain regarding the association between atypical femur fractures and bisphosphonates and other risk factors., Methods: We studied women 50 years of age or older who were receiving bisphosphonates and who were enrolled in the Kaiser Permanente Southern California health care system; women were followed from January 1, 2007, to November 30, 2017. The primary outcome was atypical femur fracture. Data on risk factors, including bisphosphonate use, were obtained from electronic health records. Fractures were radiographically adjudicated. Multivariable Cox models were used. The risk-benefit profile was modeled for 1 to 10 years of bisphosphonate use to compare associated atypical fractures with other fractures prevented., Results: Among 196,129 women, 277 atypical femur fractures occurred. After multivariable adjustment, the risk of atypical fracture increased with longer duration of bisphosphonate use: the hazard ratio as compared with less than 3 months increased from 8.86 (95% confidence interval [CI], 2.79 to 28.20) for 3 years to less than 5 years to 43.51 (95% CI, 13.70 to 138.15) for 8 years or more. Other risk factors included race (hazard ratio for Asians vs. Whites, 4.84; 95% CI, 3.57 to 6.56), height, weight, and glucocorticoid use. Bisphosphonate discontinuation was associated with a rapid decrease in the risk of atypical fracture. Decreases in the risk of osteoporotic and hip fractures during 1 to 10 years of bisphosphonate use far outweighed the increased risk of atypical fracture among Whites but less so among Asians. After 3 years, 149 hip fractures were prevented and 2 bisphosphonate-associated atypical fractures occurred in Whites, as compared with 91 and 8, respectively, in Asians., Conclusions: The risk of atypical femur fracture increased with longer duration of bisphosphonate use and rapidly decreased after bisphosphonate discontinuation. Asians had a higher risk than Whites. The absolute risk of atypical femur fracture remained very low as compared with reductions in the risk of hip and other fractures with bisphosphonate treatment. (Funded by Kaiser Permanente and others.)., (Copyright © 2020 Massachusetts Medical Society.)

Purpose: To assess the visual outcomes of small-incision lenticule extraction (SMILE) after the first year of treatments at a military refractive surgery center and compare with photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) outcomes during the same period., Setting: Warfighter Refractive Eye Surgery Program and Research Center, Fort Belvoir, VA., Design: Retrospective study., Methods: Records of service members who underwent SMILE, PRK, or LASIK for myopia from March 2017 to February 2018 were reviewed. Preoperative and up to 6-month postoperative data were collected. Visual outcomes were compared between treatments., Results: Of 563 treated eyes, 173 (30.7%) underwent SMILE, 304 (54.0%) PRK, and 86 (15.3%) LASIK. In comparing SMILE with PRK 1 month postoperatively, SMILE (145 eyes [87.9%]) attained uncorrected distance visual acuity (UDVA) ≥20/20 more vs PRK (214 eyes [73.8%]; P < .01). Similarly, SMILE (152 eyes [94.4%]) achieved more eyes with manifest spherical equivalent (MSE) within ±0.50 diopters (D) from intended target vs PRK (250 eyes [85.9%]; P = .01). None lost ≥1 line of corrected distance visual acuity in SMILE vs PRK (16 eyes [5.5%]; P < .01). Thereafter, there were no other significant differences except SMILE had 117 eyes (95.1%) vs PRK with 224 eyes (99.6%) achieving UDVA ≥20/20 at 3 months postoperatively (P = .01). In assessing SMILE vs LASIK, all parameters were comparable; however, 77 SMILE eyes (96.3%) had MSE within ±0.50 D from target vs 31 LASIK eyes (83.8%) at 6 months postoperatively (P = .02)., Conclusions: The first year after SMILE treatments in a U.S. military center demonstrated early postoperative outcomes superior to PRK. SMILE seemed more predictable compared with LASIK.

Introduction: The goal of this study is to update the incidence of hyphema in Operation Iraqi (OIF) and Enduring Freedom (OEF). We wanted to assess associated ocular injuries and final visual acuity (VA) in open-globe versus closed-globe injuries with a hyphema., Materials and Methods: We performed a retrospective review of the Walter Reed Ocular Trauma Database (WRTOD) to identify U.S. Service members and DoD civilians with hyphema who were evacuated to Walter Reed Army Medical Center between 2001 and 2011. Primary outcome measures were the final VA and differences in concomitant ocular injuries in open-globe hyphema and closed-globe hyphema., Results: 168 of 890 eyes (18.9%) in the WROTD had a hyphema. Closed-globe injuries were noted in 64 (38.1%) eyes and open-globe injuries in 104 (61.9%) eyes. A final VA of less than 20/200 was noted in 88 eyes (51.8%). Eyes with hyphema were more likely to have traumatic cataract formation (odds ratio (OR) 6.2, 95% confidence interval (CI) 4.2-9.2, P < 0.001), retinal detachment (OR 4.2, CI 2.8-6.4, P < 0.001), angle recession (OR 8.1, CI 2.9-24.3, P < 0.001), and final VA of less than 20/200 (OR 3.7, CI 2.6-5.4, P < 0.001). Traumatic cataract formation (OR 7.4, CI 2.9-18.7, P < 0.001), retinal detachment (OR 6.1, CI 2.1-17.5, P < 0.001), and a final VA less than 20/200 (OR 6.1, CI 2.4-15.4 P < 0.001) were statistically more likely to occur with an open-globe hyphema than with a closed-globe hyphema., Conclusions: Close follow-up in patients with hyphema is important due to the associated development of traumatic cataract and retinal detachment and poor final visual outcome., (© Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To assess whether densitometry analysis appropriately monitors the development of haze in myopic patients after photorefractive keratectomy (PRK) when compared to subjective slit-lamp haze grade examinations, and whether sutureless cryo-preserved amniotic membrane reduced postoperative haze development when compared to the standard bandage contact lens., Methods: In this retrospective cohort at the Center for Refractive Surgery, Walter Reed National Military Medical Center, a secondary analysis of prospectively collected data was performed. In the prospective study, participants underwent PRK for myopia. Postoperatively, a standard bandage contact lens was applied to the dominant eye and a sutureless cryo-preserved amniotic membrane graft to the nondominant eye. Participants were evaluated at 1, 3, and 6 months postoperatively for haze formation and corneal densitometry using slit-lamp biomicroscopy and Scheimpflug imaging, respectively., Results: Densitometry measurements at 6 months postoperatively were positively and significantly associated with the presence or absence of haze as assessed by slit-lamp examination in 39 patients (78 eyes; age range: 21 to 44 years). Eyes with increased densitometry measurements had 2.3 to 3.4 times the odds (P ⩽ .014) of having clinical haze on slit-lamp examination. Eyes with the amniotic membrane graft showed a positive correlation with increased corneal densitometry throughout most layers of the cornea., Conclusions: Densitometry analysis appears to be a useful tool to supplement slit-lamp examination in monitoring haze development after PRK. The amniotic membrane failed to show a reduction in corneal densitometry in myopic eyes after PRK. [J Refract Surg. 2020;36(5):293-299.]., (Copyright 2020, SLACK Incorporated.)

Background: This study evaluated the VIsion PERformance (VIPER) simulator's ability to assess the functional visual performance in warfighters conducting civilian and military tasks., Methods: Thirty service members, aged 25-35 years old with a best corrected distance visual acuity (VA) better than or equal to 20/20 or logarithm of the minimum angle of resolution (logMAR) 0.00, were randomized to locate and identify road signs and mock improvised explosive devices (IEDs) under either daytime conditions or with infrared imagery, with (cc) and without (sc) wearing their habitual correction. Participants also underwent binocular uncorrected (UDVA) and corrected (CDVA) visual assessment, refraction, contrast sensitivity testing and wavefront aberrometry., Results: The mean age was 28.47 years. The manifest spherical equivalent was - 3.16 ± 1.75 diopters (D), the UDVA in both eyes (OU) was logMAR 0.83 ± 0.47, and the CDVA OU was - 0.11 ± 0.06. For VIPER, the mean difference in the detection distance (DD) for road signs ccDD vs. scDD was 76.7 ± 52.8 m (P < 0.001). The average difference in identification distance (ID) ccID vs. scID was 13.9 ± 6.3 m (P < 0.001). The mean accuracies were 83.5 and 27.9% for cc and sc, respectively (P < 0.001). The regression analysis indicated that a 1.6 m change in the distance accounts for a 1% change in the accuracy (P = 0.002). Without correction, a 4.1 m change accounts for a 1% change in the accuracy (P < 0.001). The average IED ccDD was 29.9 ± 8.2 m, and that for scDD was 13.2 ± 13.6 m (P < 0.001). The average IED ccID was 32.2 ± 6.2 m and that for the scID was 7.4 ± 10.3 m (P < 0.001). The mean IED identification accuracy was 46.7 and 11.4% for cc and sc, respectively (P < 0.001)., Conclusions: The preliminary results reflect VIPER's ability to assess functional visual performance when detecting and identifying signs and IEDs. Furthermore, VIPER is able to detect performance changes with and without correction.

Purpose: To update the incidence of orbital fractures in U.S. Soldiers admitted to the former Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom., Methods: Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any U.S. Soldier or Department of Defense civilian with an orbital fracture injured in Operation Iraqi Freedom/Operation Enduring Freedom. Primary outcome measures were final visual acuity and the effect of orbital fracture, number of fractures, and anatomic location of fracture on final visual acuity., Results: Eight-hundred ninety eye injuries occurred in 652 patients evacuated to Walter Reed Army Medical Center between 2001 and 2011. Orbital fractures occurred in 304 eyes (34.2%). A single wall was fractured in 140 eyes (46.05%), 2 in 99 (32.6%) eyes, 3 in 31 (10.2%), 4 in 28 (9.2%), and unknown in 6 (1.9%) eyes. Roof fractures were found in 74 (24.34%), medial wall in 135 (44.41%), lateral wall in 109 (35.9%), and floor fractures in 217 (71.4%). Final visual acuity was analyzed and 140 (46.05%) eyes had greater than 20/40 vision, 17 (5.59%) were 20/50 to 20/200, 26 (8.5%) were count fingers to light perception, and 95 (31.3%) were no light perception. In logistic regression analysis, roof (p = 0.001), medial (p = 0.009), and lateral fractures (p = 0.016) were significantly associated with final visual acuity less than 20/200, while floor fractures were not (p = 0.874). Orbital fracture and all fracture subtypes were significantly associated with traumatic brain injury, retrobulbar hematoma, optic nerve injury, but not for vitreous hemorrhage, commotio, hyphema, and choroidal rupture. Fracture repair was noted in 45 (14.8%)., Conclusions: Orbital fractures occurred in a third of Operation Iraqi Freedom/Operation Enduring Freedom eyes of ocular trauma patients referred to one tertiary care military hospital. This resulted in approximately 40% of these eyes remaining legally blind after injury.Orbital fractures occur commonly during combat trauma and a significant number are legally blind despite appropriate treatment.

Purpose: To describe the demographics and clinical outcomes of patients who underwent posttraumatic enucleation or evisceration during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) from 2001 to 2011., Methods: The Walter Reed Ocular Trauma Database is a retrospective case series of US Servicemembers and Department of Defense civilians who had combat ocular injuries in OIF and OEF. Data regarding posttraumatic enucleations and eviscerations performed during OIF and OEF were extracted. The main outcomes analyzed were the number of enucleations and eviscerations performed, location of the surgery, laterality, and graft type. The secondary outcome measures included: mechanism of injury and Ocular Trauma Score classification., Results: One hundred nine enucleations and eviscerations were performed on the 890 eyes (12.24%). Sixty-three (57.80%) primary enucleations, 36 (33.03%) secondary enucleations, 5 (4.59%) postretinal detachment repair enucleations, and 5 (4.59%) primary eviscerations were completed. The surgeries were completed at a combat support hospital (57; 52.3%), or Walter Reed Army Medical Center (49; 45.0%). All surgeries were unilateral except in 2 patients. The most common graft type used was silicone (n = 56; 51.38%). Improvised explosive devices caused 76 (69.72%) eye injuries. Ocular Trauma Score were recorded as 56 (51.38%) between 0 and 44, 44 (40.37%) between 45 and 65, and unknown in 9 (8.26%)., Conclusion: Posttraumatic enucleation or evisceration due to devastating ocular trauma is required in about 15% of ophthalmic patients in modern combat trauma. The psychosocial impact on veterans who have required an enucleation or evisceration from combat trauma has been poorly studied and requires further review.

External forces from our environment impose transverse loads on our muscles. Studies in rats have shown that transverse loads result in a decrease in the longitudinal muscle force. Changes in muscle architecture during contraction may contribute to the observed force decrease. The aim of this study was to quantify changes in pennation angle, fascicle dimensions, and muscle thickness during contraction under external transverse load. Electrical stimuli were elicited to evoke maximal force twitches in the right calf muscles of humans. Trials were conducted with transverse loads of 2, 4.5, and 10 kg. An ultrasound probe was placed on the medial gastrocnemius in line with the transverse load to quantify muscle characteristics during muscle twitches. Maximum twitch force decreased with increased transverse muscle loading. The 2, 4.5, and 10 kg of transverse load showed a 9, 13, and 16% decrease in longitudinal force, respectively. Within the field of view of the ultrasound images, and thus directly beneath the external load, loading of the muscle resulted in a decrease in the muscle thickness and pennation angle, with higher loads causing greater decreases. During twitches the muscle transiently increased in thickness and pennation angle, as did fascicle thickness. Higher transverse loads showed a reduced increase in muscle thickness. Smaller increases in pennation angle and fascicle thickness strain also occurred with higher transverse loads. This study shows that increased transverse loading caused a decrease in ankle moment, muscle thickness, and pennation angle, as well as transverse deformation of the fascicles., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Purpose: To describe outcomes and associated ocular injuries of lateral canthotomy and cantholysis (LCC) as performed in combat ocular trauma., Methods: Data from the Walter Reed Ocular Trauma Database of patients requiring LCC during Operations Iraqi Freedom and Enduring Freedom was reviewed as a retrospective cohort. Primary outcome measures included final visual acuity (VA) and Ocular Trauma Score. Secondary outcome measures were associated injuries and timing of surgery., Results: Thirty-six LCCs were recorded on a total of 890 eyes (4.04 %) in the Walter Reed Ocular Trauma Database. Eighteen out of 36 eyes (50.00%) had a final VA of the affected eye of 20/200 or worse vision. From the initial available VA measured either at the time of injury or at Walter Reed Army Medical Center, 13 eyes (40.63%) had no change in VA, 15 eyes (46.88%) had improvement, and 4 (12.5%) had a decrease in VA (n = 32, data unavailable for 4 eyes). Ocular Trauma score 0-65 was noted in 14 (38.9%) and 66-100 (61.1%). Retinal detachment (6, 16.67%), optic nerve injuries (7, 19.44%), orbital fractures (20, 55.56%), and retrobulbar hematoma (25, 69.44%) were commonly associated injuries. Of the 36 LCC, 18 (50.00%) were performed as the first surgery performed at the combat support hospital, 13 (36.11%) as the second, 4 (11.11%) as the third, and 1 (2.78%) as the fourth., Conclusions: The largest subgroup of patients had an improvement in VA associated with performance of LCC; however, half of patients remained with a final VA of equal to or worse than 20/200 due to severe ocular trauma.

Purpose: We update the incidence of intraocular foreign bodies (IOFB) in soldiers admitted to Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom., Design: This consecutive retrospective case series included 890 eyes of 652 patients., Methods: Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any American soldier or Department of Defense civilian with an IOFB injured in Operation Iraqi Freedom/Operation Enduring Freedom. Closed globe injuries with orbital foreign bodies, injury outside of a combat zone, or non-Department of Defense civilian trauma were the exclusion criteria., Main Outcome Measures: Primary outcome measures were final visual outcome and the number, size, and location of IOFBs. Secondary outcome measures included surgical procedures, use of eye protection, associated complications, source of injury and Ocular Trauma Score., Results: There were 890 eye injuries in 652 patients evacuated to Walter Reed Army Medical Center between 2001 and 2011. IOFBs were found in 166 eyes of 149 patients (18.6%; 95% confidence interval [CI], 16.2%-21.3%). Most patients had a single IOFB (80.7%). An IOFB was positively associated with Ocular Trauma Score grade 1 or 2 (0-65) injuries (odds ratio [OR], 1.58; 95% CI, 1.07-2.38; P = 0.01). There were 130 eyes (78.33%) that had recorded time from initial visual acuity to final visual acuity and it ranged from 8 to 2421 days (mean, 433.24 days). Thirty-eight (25.16%; 95% CI, 18.89%-32.67%) eyes had no change in visual acuity, 98 (64.90%; 95% CI, 57.00%-72.07%) had improved visual acuity, and 15 (9.93%; 95% CI, 6.01%-15.84%) had decreased visual acuity. IOFB was not found to predict final visual acuity of <20/200 in multivariate analysis when other injury features were known (P = 0.1). Pars plana vitrectomy was completed on 124 eyes (74.70%). Removal of IOFB was performed in 118 eyes (71.08%; average of 31.67 days after initial injury) with a delayed procedure occurring after primary closure and antibiotics owing to a lack of surgical capacity in Iraq and Afghanistan. Retinal detachment occurred in 48 eyes (28.92%) and proliferative vitreoretinopathy in 44 eyes (26.5%)., Conclusions: IOFBs occur frequently in combat ocular trauma and are significantly associated with more severe injuries. However, IOFBs were not found to be a significant risk factor for visual acuity of <20/200., (Published by Elsevier Inc.)

Purpose: To compare contrast sensitivity among participants undergoing wavefront-guided or wavefront-optimized photorefractive keratectomy (PRK) or LASIK for the treatment of myopia or myopic astigmatism 12 months after surgery., Methods: In a prospective, randomized clinical trial, 215 participants with myopia ranging from -0.50 to -7.25 diopters (D) and less than -3.50 D of manifest astigmatism electing to undergo either LASIK or PRK were randomized to receive wavefront-guided or wavefront-optimized treatment. Corrected Super Vision Test (Precision Vision, La Salle, IL) high contrast and small letter contrast sensitivity, uncorrected postoperative contrast sensitivity function, and uncorrected and corrected distance visual acuity were measured preoperatively and at 1, 3, 6, and 12 months postoperatively., Results: There was a significant difference within each of the four groups over time when measuring high contrast visual acuity (P < .001) and small letter contrast sensitivity (P < .001), with the most significant decrease occurring 1 month postoperatively. However, there were no significant differences when comparing the four groups for high contrast sensitivity (P = .22) or small letter contrast sensitivity (P = .06). The area under the logarithm of contrast sensitivity function did not differ significantly over time (P = .09) or between groups (P = .16). A pairwise comparison of preoperative to 12-month CDVA showed a significant improvement in all groups (P < .017). The change in CDVA was also significantly different between groups as determined by one-way analysis of variance (P = .003)., Conclusions: Wavefront-guided and wavefront-optimized PRK and LASIK procedures maintained high contrast, small letter contrast sensitivity, and contrast sensitivity function 12 months postoperatively. Although the recovery period for visual performance was longer for PRK versus LASIK, there was no significant difference in treatment type or treatment profile at 12 months postoperatively. [J Refract Surg. 2018;34(9):590-596.]., (Copyright 2018, SLACK Incorporated.)

Purpose: To assess vision-related quality of life and military readiness and capabilities among active duty U.S. military service members undergoing refractive surgery., Methods: In this prospective, single-center, observational study, active duty U.S. military service members electing to undergo refractive surgery were asked to complete a military performance questionnaire and the National Eye Institute Refractive Error Quality of Life Instrument (NEI RQL-42) preoperatively and at 6 months postoperatively. On the military performance questionnaire, participants rated (1 = very bad to 5 = very good) how they felt their vision affected their military readiness and capabilities after refractive surgery., Results: Among 360 participants at 6 months postoperatively, the overall mean military performance score increased from 3.6 ± 0.8 to 4.8 ± 0.3, a change of 1.2, with 91.7% of the participants indicating an overall improvement in readiness and capability (P < .001). Scores measuring overall individual readiness, contribution to unit's mission, use of night vision goggles, function at night, weapons sighting ability, employment of personal masks, weather extreme environmental conditions, and optical support were significantly higher postoperatively (P < .001). For the NEI RQL-42, scores were significantly higher postoperatively for the subscales clarity of vision, expectations, near vision, far vision, diurnal fluctuations, activity limit, glare, dependence on correction, worry, appearance, and satisfaction with correction (all P < .001), but not for symptoms after refractive surgery (P = .403)., Conclusions: Refractive surgery significantly improves military readiness and capabilities and vision-related quality of life of active duty U.S. military service members with refractive error. [J Refract Surg. 2018;34(9):597-603.]., (Copyright 2018, SLACK Incorporated.)

It has been demonstrated that unidirectional transversal muscle loading induced by a plunger influences muscle shape and reduces muscle force. The interaction between muscle and transversal forces may depend on specific neuromuscular properties that change during a lifetime. Compression garments, applying forces from all directions in the transverse plane, are widely used in sports for example to improve performance. Differences in the loading direction (unidirectional vs. multidirectional) may have an impact on force generating capacity of muscle and, thus, on muscle performance. The aim of this study was to examine the effect of multidirectional transversal loads, using a sling looped around the calf, on the isometric force during plantarflexions. Young male adults (25.7 ± 1.5 years, n = 15) were placed in a prone position in a calf press apparatus. The posterior tibial nerve was stimulated to obtain the maximal double-twitch force of the calf muscles with (59.4 and 108.4 N) and without multidirectional transverse load. Compared to the unloaded condition, the rate of force development ( RFD ) was reduced by 5.0 ± 8.1% ( p = 0.048) and 6.9 ± 10.7% ( p = 0.008) for the 59.4 and 108.4 N load, respectively. No significant reduction (3.2 ± 4.8%, p = 0.141) in maximum muscle force ( F m ) was found for the lower load (59.4 N), but application of the higher load (108.4 N) resulted in a significant reduction of F m by 4.8 ± 7.0% ( p = 0.008). Mean pressures induced in this study (14.3 and 26.3 mm Hg corresponding to the 59.4 and 108.4 N loads, respectively) are within the pressure range reported for compression garments. Taking the results of the present study into account, a reduction in maximum muscle force would be expected for compression garments with pressures ≥26.3 mm Hg. However, it should be noted that the loading condition (sling vs. compression garment) differs and that compression garments may influence other mechanisms contributing to force generation. For example, wearing compression garments may enhance sport performance by enhanced proprioception and reduced muscle oscillation. Thus, superposition of several effects should be considered when analyzing the impact of compression garments on more complex sport performance.

Muscles undergo cycles of length change and force development during locomotion, and these contribute to their work and power production to drive body motion. Muscle fibers are typically considered to be linear actuators whose stress depends on their length, velocity, and activation state, and whose properties can be scaled up to explain the function of whole muscles. However, experimental and modeling studies have shown that a muscle's stress additionally depends on inactive and passive tissues within the muscle, the muscle's size, and its previous contraction history. These effects have not been tested under common sets of contraction conditions, especially the cyclic contractions that are typical of locomotion. Here we evaluate the relative effects of size, history-dependent, activation and three-dimensional effects on the work and power produced during cyclic contractions of muscle models. Simulations of muscle contraction were optimized to generate high power outputs: this resulted in the muscle models being largely active during shortening, and inactive during lengthening. As such, the history-dependent effects were dominated by force depression during simulated active shortening rather than force enhancement during active stretch. Internal work must be done to deform the muscle tissue, and to accelerate the internal muscle mass, resulting in reduced power and work that can be done on an external load. The effect of the muscle mass affects the scaling of muscle properties, with the inertial costs of contraction being relatively greater at larger sizes and lower activation levels.

Objectives: To describe the visual outlook and quality of life of service members after combat ocular trauma., Methods: In a single-center, prospective observational study of service members sustaining ocular trauma, participants underwent a series of ocular examinations and noninvasive tests, including the National Eye Institute Visual Functioning Questionnaire (VFQ-25)., Results: Of the 165 enrolled participants, 137 completed the VFQ-25. The mean VFQ-25 composite score was 74.4 ± 20.7 (range: 1.4-100). Among 118 participants with visual acuity assessment, 92% had best corrected visual acuity (BCVA) of 20/20 or better in at least one eye. Among participants with severe vision loss (BCVA ≤20/200), there was no statistically significant difference in self-reported general health compared to those without severe vision loss (p = 0.17). However, there was a significantly lower visual quality of life reported in the composite score and all of the 11 subscales of the VFQ-25., Conclusions: While this study provides evidence that combat ocular trauma is associated with a lower visual quality of life, limitations include the relatively small sample size and the limited documentation of the use of eye protection at time of injury among participants., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Objectives: To examine the incidence and the etiology of corneal and corneoscleral injuries in the setting of combat ocular trauma, and to determine what effect these injuries have on overall visual impairment from combat ocular trauma., Methods: Retrospective, noncomparative, interventional case series, analyzing U.S. service members who were evacuated to the former Walter Reed Army Medical Center (WRAMC). Primary outcome measures were types of corneal injuries, length of follow-up at WRAMC, globe survival, and anatomical causes of blindness. Secondary outcome measures included surgical procedures performed, use of eye protection, source of injury, and visual outcomes., Results: Between 2001 and 2011, there were 184 eyes of 134 patients with corneal or corneoscleral injuries. The average age was 26 years (range, 18-50); 99.3% were male, 31.9% had documented use of eye protection. The average follow-up was 428.2 days (3-2,421). There were 98 right-eye and 86 left-eye injuries. There were 169 open-globe and 15 closed-globe injuries with corneal lacerations occurring in 73 eyes with injuries to Zone I. Most injuries were attributable to an intraocular foreign body (IOFB; 48%), followed by penetrating (19.6%) and perforating (16.3%) injuries. The most common presenting visual acuity was hand motion/light perception (45.7%), yet, at the end of the study, visual acuity improved to 20/40 or better (40.8%). The majority of injuries in eyes with visual acuity worse than 20/200 involved the cornea and retina (58%). Injuries solely to the cornea accounted for only 19% of all injuries sustained., Conclusions: Ocular injuries in military combat have led to significant damage to ocular structures with a wide range of visual outcomes. The authors describe corneal and corneoscleral injuries in combat ocular trauma by classifying injuries by the anatomical site involved and identifying the main source of decreased visual acuity. In combat ocular trauma, corneal or corneoscleral injuries are not the sole etiology for poor vision. A cohesive approach among multiple ophthalmic subspecialties is needed when treating combat ocular trauma., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Purpose: To compare visual performance, marksmanship performance, and threshold target identification following wavefront-guided (WFG) versus wavefront-optimized (WFO) photorefractive keratectomy (PRK)., Methods: In this prospective, randomized clinical trial, active duty U.S. military Soldiers, age 21 or over, electing to undergo PRK were randomized to undergo WFG (n = 27) or WFO (n = 27) PRK for myopia or myopic astigmatism. Binocular visual performance was assessed preoperatively and 1, 3, and 6 months postoperatively: Super Vision Test high contrast, Super Vision Test contrast sensitivity (CS), and 25% contrast acuity with night vision goggle filter. CS function was generated testing at five spatial frequencies. Marksmanship performance in low light conditions was evaluated in a firing tunnel. Target detection and identification performance was tested for probability of identification of varying target sets and probability of detection of humans in cluttered environments., Results: Visual performance, CS function, marksmanship, and threshold target identification demonstrated no statistically significant differences over time between the two treatments. Exploratory regression analysis of firing range tasks at 6 months showed no significant differences or correlations between procedures. Regression analysis of vehicle and handheld probability of identification showed a significant association with pretreatment performance., Conclusions: Both WFG and WFO PRK results translate to excellent and comparable visual and military performance., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)