Fit Transitioning: When Can Transgender Airmen Fitness Test in Their Affirmed Gender?

INTRODUCTION: Transgender individuals have served openly in the U.S. Military since 2016. Official policies for transgender servicemembers continue to evolve, including approaches to physical fitness testing of transgender servicemembers. There is a paucity of scientific data regarding the effects of gender affirming hormone therapy (GAHT) on athletic performance for the past 24 months of treatment. Identification of expected trends in performance during and after gender transition is essential to allow for the development of appropriate military policy regarding when to assess servicemembers' fitness by standards of their affirmed gender. MATERIALS AND METHODS: We identified Department of the Air Force transgender patients using the Transgender Health Medical Evaluation Unit database and recorded dates of GAHT initiation through a retrospective chart review. We recorded performance values for the Air Force physical fitness test components 1 year before and up to 4 years after GAHT initiation. Performance measures were maximum sit-ups in 1 minute, push-ups in 1 minute, and 1.5-mile run time. Pre- and post-GAHT scores were compared using one-sample T-test to mean scores of Air Force-wide cisgender averages to assess for significant difference between affirmed transgender and cisgender airmen. We then performed the two one-sided test (TOST) procedure for equivalence with upper and lower bounds set at 1 SD from the means for cisgender airmen. Finally, using Z-scores, average transgender group scores were assigned a percentile rank with their respect to affirmed gender throughout the transition process. RESULTS: Following initiation of GAHT, transgender males demonstrated statistically significant worse performance than cisgender males in all events until 3 years of GAHT. Their average scores would have attained a comfortable passing score within 1 year of GAHT. Transgender females' performance showed statistically significantly better performance than cisgender females until 2 years of GAHT in run times and 4 years in sit-up scores and remained superior in push-ups at the study's 4-year endpoint. TOST confirmed equivalence at all points where statistical difference was not demonstrated. Servicemembers approximate their pre-GAHT assigned gender percentile ranking in their affirmed gender in a manner consistent with hypothesis and TOST testing in the push-up event for both transgender males and females and in the 1.5-mile run event for transgender males. CONCLUSIONS: In a sample of Air Force adult transgender patients, athletic performance measures demonstrate variable rates of change depending on the patients' affirmed gender and differ by physical fitness test component. Based on this study, transgender females should begin to be assessed by the female standard no later than 2 years after starting GAHT, while transgender males could be assessed by their affirmed standard no earlier than 3 years after initiating GAHT.

A different kind of battle: the effects of NICU admission on military parent mental health.

OBJECTIVE: To determine the incidence of mental health symptoms in military families after prolonged NICU admission. STUDY DESIGN: Prospective cohort study of military-affiliated NICU parents participating in serial electronic surveys, which included validated screening tools for acute stress (ASD), post-traumatic stress (PTSD), and depression disorders. RESULTS: Among 106 military parents surveyed after NICU admission, 24.5% screened positive for ASD and 28.3% for depression. 77 (72.6%) parents continued participation beyond discharge, with 7.8% screening positive for PTSD and 15.6% for late depression. Positive ASD correlated with later symptoms of PTSD (OR 8.4 [2.4-30]) and early depression with both PTSD symptoms (OR 5.7 [1.7-18.8]) and late depression (OR 8.4 [2.4-30]) after discharge. Secondary analysis determined these findings were independent of deployment and other military related factors. CONCLUSION: This study highlights the potential mental health burden experienced by military-affiliated NICU parents. Early ASD and depression screening may identify parents at risk for mental health symptoms after discharge.

A Pediatric Application of the STRAC Regional Hospital Trauma Registry Database: Pediatric Trauma Deaths in South Central Texas During 2004-2013.

The purpose of this study was to define the demographics of pediatric traumatic injuries and to understand the predictive value of injury type, prehospital, and emergency department (ED) data regarding the mortality of pediatric trauma patients (<14 years of age) in South Central Texas. We report a retrospective review of pediatric trauma patients presenting to Trauma Service Area P in South Central Texas during 2004-2013. The primary outcome was mortality; secondary outcomes were ventilator days, hospital days, and intensive care unit stay. Demographics, Abbreviated Injury Score (AIS) codes, ICD-9 codes, transport times, Emergency Medical Services (EMS) vital signs en route and on arrival to the emergency department (ED), and outcomes were evaluated. A total of 8004 traumatically injured children presented to EDs in South Central Texas during the study period; 4109 of these presented via EMS. Most patients were Hispanic and male. Distribution was even across age groups. Overall mortality was 2%, and the mortality of those arriving by EMS was 3.7%. Abnormal vital signs and Glasgow Coma Score upon presentation to both EMS and the ED were strongly associated with mortality. Increased Injury Severity Score, the need for transfusion in the ED, and increased maximal AIS were also strongly associated with mortality. African American race was associated with increased mortality, although transport time and age were not. Most injuries overall were caused by motor vehicle collisions; however, burns and falls were most common in infants. The most lethal injuries were caused by firearms (mostly seen in preteens) and assaults (mostly seen in infants). This analysis of injured children in Southwest Texas offers insight into areas of needed quality improvement in the trauma system and potential areas to focus prevention efforts.

Non-battle craniomaxillofacial injuries from U.S. military operations.

INTRODUCTION: Non-battle injuries (NBIs) can be a source of significant resource utilization for the armed forces in a deployed setting. While the incidence and severity of craniomaxillofacial (CMF) battle injuries (BIs) have reportedly increased in the ongoing U.S. military conflicts in Iraq and Afghanistan, the prevalence and the nature of NBIs are not well described. MATERIAL AND METHODS: The Joint Theater Trauma Registry was queried from October 2001 to February 2011, covering Operations Enduring Freedom and Iraqi Freedom, for both NBIs and BIs to the CMF region. Patient demographics, injury severity score, mechanism and type of injury were included in the query. Using ICD-9 diagnosis codes, CMF injuries were classified according to type (wounds, fractures, burns, vascular injuries, and nerve injuries). Statistical analysis was performed for comparative analysis. RESULTS: NBIs constituted 24.3% of all patients with CMF injuries evacuated to a regional combat support hospital (CMF BIs 75.4%). These injuries were characterized by blunt trauma, most commonly motor vehicle collisions (37%), and falls (20%). As compared to CMF BIs, CMF NBIs resulted in less mortality (1.3% vs. 3.1%, p < 0.0001), fewer injuries per patient (1.87 vs. 2.26, p = 0.055), and a decreased severity score (ISS) (8.38 vs. 12.98, p < 0.0001). However, a significant percentage of CMF NBIs still required evacuation out of theater (27.8% of NBIs vs. 42.2% of BIs, p < 0.0001), depleting the combat strength of the deployed forces. CONCLUSIONS: CMF NBIs accounted for a substantial portion of total CMF injuries. Though characterized predominantly by blunt trauma with an overall better prognosis, its burden to the limited resources of a deployment can be significant. This descriptive study highlights the need to allocate appropriate resources for treatment of these injuries as well as strategies to reduce both its incidence and severity. LEVEL OF EVIDENCE: IV Prognostic.

Resolution of LPS-induced airway inflammation and goblet cell hyperplasia is independent of IL-18.

BACKGROUND: The resolution of inflammatory responses in the lung has not been described in detail and the role of specific cytokines influencing the resolution process is largely unknown. METHODS: The present study was designed to describe the resolution of inflammation from 3 h through 90 d following an acute injury by a single intratracheal instillation of F344/N rats with LPS. We documented the inflammatory cell types and cytokines found in the bronchoalveolar lavage fluid (BALF), and epithelial changes in the axial airway and investigated whether IL-18 may play a role in the resolution process by reducing its levels with anti-IL-18 antibodies. RESULTS: Three major stages of inflammation and resolution were observed in the BALF during the resolution. The first stage was characterized by PMNs that increased over 3 h to 1 d and decreased to background levels by d 6-8. The second stage of inflammation was characterized by macrophage influx reaching maximum numbers at d 6 and decreasing to background levels by d 40. A third stage of inflammation was observed for lymphocytes which were elevated over d 3-6. Interestingly, IL-18 and IL-9 levels in the BALF showed a cyclic pattern with peak levels at d 4, 8, and 16 while decreasing to background levels at d 1-2, 6, and 12. Depletion of IL-18 caused decreased PMN numbers at d 2, but no changes in inflammatory cell number or type at later time points. CONCLUSION: These data suggest that IL-18 plays a role in enhancing the LPS-induced neutrophilic inflammation of the lung, but does not affect the resolution of inflammation.