Demographics and Comorbidities of United States Service Members with Combat-Related Lower Extremity Limb Salvage.

INTRODUCTION: This retrospective study describes the demographics and injury characteristics of a recently identified cohort of US Service members with combat-related lower extremity limb salvage (LS). METHODS: US Service members with combat trauma were identified from the Expeditionary Medical Encounter Database and Military Health System Data Repository and stratified into primary amputation (PA), LS, and non-threatened limb trauma (NTLT) cohorts based on ICD-9 codes. Disparities in demographic factors and injury characteristics were investigated across cohorts and within the LS cohort based on limb retention outcome. RESULTS: Cohort demographics varied by age but not by sex, branch, or rank. The mechanism of injury and injury characteristics were found to be different between the cohorts, with the LS cohort exhibiting more blast injuries and greater injury burden than their peers with NTLT. A sub-analysis of the LS population revealed more blast injuries and fewer gunshot wounds in those that underwent secondary amputation. Neither demographic factors nor total injury burden varied with limb retention outcome, despite slight disparities in AIS distribution within the LS cohort. CONCLUSIONS: In accordance with historic dogma, the LS population presents high injury severity. Demographics and injury characteristics are largely invariant with respect to limb retention outcomes, despite secondary amputation being moderately more prevalent in LS patients with blast-induced injuries. Further study of this population is necessary to better understand the factors that impact the outcomes of LS in the Military Health System.

A Data-Driven Method to Discriminate Limb Salvage from Other Combat-Related Extremity Trauma.

INTRODUCTION: The aim of this study was to address and enhance our ability to study the clinical outcome of limb salvage (LS), a commonly referenced but ill-defined clinical care pathway, by developing a data-driven approach for the identification of LS cases using existing medical code data to identify characteristic diagnoses and procedures, and to use that information to describe a cohort of US Service members (SMs) for further study. METHODS: Diagnosis code families and inpatient procedure codes were compiled and analyzed to identify medical codes that are disparately associated with a LS surrogate population of SMs who underwent secondary amputation within a broader cohort of 3390 SMs with lower extremity trauma (AIS > 1). Subsequently, the identified codes were used to define a cohort of all SMs who underwent lower extremity LS which was compared with the opinion of a panel of military trauma surgeons. RESULTS: The data-driven approach identified a population of n = 2018 SMs who underwent LS, representing 59.5% of the combat-related lower extremity (LE) trauma population. Validation analysis revealed 70% agreement between the data-driven approach and gold standard SME panel for the test cases studied. The Kappa statistic (κ = 0.55) indicates a moderate agreement between the data-driven approach and the expert opinion of the SME panel. The sensitivity and specificity were identified as 55.6% (expert range of 51.8-66.7%) and 87% (expert range of 73.9-91.3%), respectively. CONCLUSIONS: This approach for identifying LS cases can be utilized to enable future high-throughput retrospective analyses for studying both short- and long-term outcomes of this underserved patient population.

Burn injuries in US service members: 2001-2018.

INTRODUCTION: Burns are an important cause of battlefield injury, accounting for 5-20% of the combat injury burden. To date, no report has examined the full range of burns, from mild to severe, resulting from post-9/11 conflicts. The present study leverages the Expeditionary Medical Encounter Database (EMED), a Navy-maintained health database describing all service member medical encounters occurring during deployment, to capture, quantify and characterize burn-injured service members and the injuries they sustained while deployed in support of post-9/11 operations. METHODS: The EMED was queried for all surviving service members with at least one burn injury, identified using injury-specific Abbreviated Injury Scale codes. Demographic and additional injury information were also obtained from the EMED. RESULTS: From 2001 through 2018, 2507 deployed service members sustained 5551 burns. Blasts accounted for 82% of injuries, largely attributed to the use of improvised explosive devices. Concurrent injury was common, with 30% sustaining a traumatic brain injury and 10% sustaining inhalation injury. Most burns were small, with 92% involving< 20% TBSA; 85% of burns involved< 10% TBSA. The head and the hands were the most commonly affected areas, accounting for 48% of all burns, with 80% of service members sustaining at least one burn to these areas. CONCLUSION: The majority of burns tend to be small in size, with the head and hands most commonly affected. As these areas are often left uncovered by the uniform, prevention measures, particularly improvement in and increased usage of personal protective gear, may help reduce these injuries and their consequences.

Differences in quality-of-life scores across injury categories by mental health status among injured U.S. military service members and veterans.

PURPOSE: Posttraumatic stress disorder (PTSD) and depression are strong predictors of poor health-related quality of life (HRQOL) among injured U.S. military service members (SMs). Patterns of HRQOL between injury categories and injury categories stratified by mental health (MH) symptoms have not been examined. Among deployment-injured SMs and veterans (n = 4353), we examined HRQOL and screening data for PTSD and/or depression within specific injury categories. METHODS: Participants included those enrolled in the Wounded Warrior Recovery Project with complete data for HRQOL (SF-36) from June 2017 to May 2020. Injuries were categorized using the Barell Injury Diagnosis Matrix (Barell Matrix). Mean physical component summary (PCS) and mental component summary (MCS) scores were calculated for each injury category and stratified by the presence or absence of probable PTSD and/or depression. RESULTS: The average follow-up time that participants were surveyed after injury was 10.7 years. Most participants were male, non-Hispanic White, served in the Army, and enlisted rank. Mechanism of injury for 77% was blast-related. Mean PCS and MCS scores across the entire sample were 43.6 (SD = 10.3) and 39.5 (SD = 13.3), respectively; 50% screened positive for depression and/or PTSD. PCS and MCS scores were significantly lower within each injury category among individuals with probable PTSD and/or depression than those without. CONCLUSION: Among deployment-injured SMs, those with probable PTSD and/or depression reported significantly lower HRQOL within injury categories and HRQOL component (i.e., physical or mental) than those without. Findings are consistent with prior reports showing mental health symptoms to be strongly associated with lower HRQOL and suggest integration of mental health treatment into standard care practices to improve long-term HRQOL.

Postinjury Care and Complications Among U.S. Military Women With Combat-Related Major Limb Traumatic Amputation.

BACKGROUND: U.S. servicewomen may be at greater risk of injury in future conflicts as they integrate into combat occupations. More than 1,000 servicewomen were wounded during military conflicts in Iraq and Afghanistan. Some women sustained traumatic amputations, and research on their postinjury health is needed. OBJECTIVE: To describe acute care, complications, and health care utilization among servicewomen with combat-related amputations, comparing them with injured men. METHODS: In this retrospective matched-pairs study, women were identified from the Expeditionary Medical Encounter Database between 2003 and 2012 and matched with men on amputation injuries, injury severity, and age. Differences were assessed with nonparametric tests for paired data. RESULTS: Of 20 women identified for analysis, 13 received tourniquets, three were administered procoagulants, and six had massive transfusions. Women averaged 3.4 (SD = 1.6) postinjury complications, and the most frequent were heterotopic ossification (n = 17), posthemorrhagic anemias (n = 13), and bacterial wound infections (n = 10). Acute care and complications were similar among men. Women averaged more acute care days (M = 49.8, SD = 30.6) than men (M = 46.1, SD = 27.4) but fewer intensive care unit days (women: M = 2.6, SD = 4.0; men: M = 4.4, SD = 8.3). No statistical differences were observed. CONCLUSION: Postinjury care among servicewomen with combat-related amputations was comparable with servicemen, and complications were common. This information can aid providers and nursing staff in the management of these injuries.

The relationship between self-reported physical functioning, mental health, and quality of life in Service members after combat-related lower extremity amputation.

PURPOSE: Service members with amputations experience numerous challenges, yet few studies have examined patient-reported outcomes, including physical functional status, mental-health screening status, and quality of life (QOL) or the relationship between these outcomes. MATERIALS AND METHODS: Service members with combat-related lower extremity amputations (N = 82) and participants in the Wounded Warrior Recovery Project were included. Patient-reported outcomes of physical functional status, posttraumatic stress disorder (PTSD), depression screening status, and QOL were compared, while accounting for amputation level. Linear regression assessed relationships between physical functional status and QOL, as well as mental-health screening status. RESULTS: Higher physical functioning scores were associated with better QOL, and lower physical functioning scores were associated with screening positive for PTSD or depression. When stratified by mental-health screening, a significant relationship was observed between mean physical functioning scores and amputation level with a negative PTSD or depression screen only. Additionally, those with bilateral amputation reported lower physical functioning. CONCLUSIONS: Physical functioning was associated with patient-reported outcomes, including QOL and mental-health screening. Screening positive for PTSD or depression was associated with worsened self-reported physical function and may outweigh the impact of amputation severity on physical functioning. Successful rehabilitation requires the integration of physical and mental health domains in order to achieve optimal functioning.Implications for rehabilitationThe current study shows that physical functioning in participants with combat-related amputation is related to the amputation level, quality of life, and mental-health symptom screening.Good mental health is crucial to optimal functioning, as presence of adverse mental-health symptoms may exacerbate physical functional limitations among those with combat-related amputations.Assessing variables related to adverse mental-health symptoms and ultimate physical functioning outcomes is critical for clinicians to optimize rehabilitative strategies and outcomes.

A Focus on Non-Amputation Combat Extremity Injury: 2001-2018.

INTRODUCTION: Extremity injuries have comprised the majority of battlefield injuries in modern U.S. conflicts since World War II. Most reports have focused on serious injuries only and, to date, no reports have described the full extent of combat extremity injuries, from mild to severe, resulting from post-9/11 conflicts. This study aims to identify and characterize the full spectrum of non-amputation combat-related extremity injury and extend the findings of previous reports. METHODS: The Expeditionary Medical Encounter Database was queried for all extremity injured service members (SMs) deployed in support of post-9/11 conflicts through July 2018. Only injuries incurred during combat operations were included in this report. Major amputations were excluded as well as SMs killed in action or who died of wounds. Extremity injuries were categorized by body region, nature of injury, and severity. Demographics and injury event characteristics are also presented. RESULTS: A total of 17,629 SMs sustained 42,740 extremity injuries during 18,004 separate injury events. The highest number of SMs were injured in 2004 (n = 3,553), 2007 (n = 2,244), and 2011 (n = 2,023). Injured SMs were mostly young (78% under 30 years), male (97%), junior- to mid-level enlisted (89%), in the Army (69%) or Marine Corps (28%), active duty (84%), serving as infantry and gun crew (59%), and injured in support of Operation Iraqi Freedom (60%). Blast weaponry was responsible for 75% of extremity injuries. Injuries were similarly distributed between the lower (52%) and upper (48%) extremities. The most common sites of lower extremity injury were the lower leg/ankle complex (40%) and thigh (26%). The most common upper extremities sites were the shoulder and upper arms (37%), and the hand, wrist, and fingers (33%). Nearly half (48%) of all extremity injuries were open wounds (48%), followed by fractures (20%) and contusions/superficial injuries (16%). SMs sustained an average of 2.4 extremity injuries per event and 56% of injuries were considered mild, with a median Injury Severity Score (ISS) of 3. CONCLUSION: This study is the first publication to capture, review, and characterize the full range, from mild to severe, of non-amputation combat-related extremity injuries resulting from post-9/11 conflicts. The high prevalence of extremity injury, particularly in such a young population, and associated short- and long-term health outcomes, will impact military health care systems for decades to come.

Prosthesis satisfaction and quality of life in US service members with combat-related major lower-limb amputation.

BACKGROUND: Military amputee patient care programs offer extensive services, including advanced prosthetic devices, to restore function and improve quality of life (QOL) among veterans and service members with combat-related limb loss, but research on satisfaction with these devices is limited. OBJECTIVE: To assess prosthesis satisfaction and QOL in US service members and veterans with combat-related major lower-limb amputation. STUDY DESIGN: Cross-sectional study. METHODS: Eighty-six participants with combat-related major lower-limb amputation completed the Orthotics and Prosthetics Users' Survey (OPUS) Satisfaction with Device scale and Quality of Well-Being Scale, Self-Administered, for the Wounded Warrior Recovery Project. RESULTS: Most participants (62%-88%) responded Agree or Strongly Agree to OPUS Satisfaction with Device items on the fit, weight, comfort, ease of donning, appearance, and durability of their prosthesis. By contrast, the majority of participants (55%-79%) responded Disagree or Strongly Disagree to items on clothes being free of wear and tear, skin free of abrasions and irritations, and the affordability of their prosthesis. In linear regression analysis, total OPUS Satisfaction with Device score was positively associated with Quality of Well-Being Scale, Self-Administered score (ß = 0.0058; P = 0.004). CONCLUSIONS: Findings indicate the majority of participants were satisfied with the overall functionality of their prosthesis, but dissatisfied with the effect of their prosthesis on clothing and skin, as well as expenses related to their prosthesis. Additionally, prosthesis satisfaction was positively associated with QOL.

Mental and physical health, and long-term quality of life among service members injured on deployment.

BACKGROUND: More than 52,000 casualties have been documented in post-9/11 conflicts. Service members with extremity injuries (EIs) or traumatic brain injury (TBI) may be at particular risk for long-term deficits in mental and physical health functioning compared with service members with other injuries. METHODS: The present study combined medical records with patient reports of mental health and health-related quality of life (HRQOL) for 2,537 service members injured in overseas contingency operations who participated in the Wounded Warrior Recovery Project. Combined parallel-serial mediation models were tested to examine the pathways through which injury is related to mental and physical health conditions, and long-term HRQOL. RESULTS: Results revealed that injury was indirectly related to long-term HRQOL via its associations with physical health complications and mental health symptoms. Relative to TBI, EI was associated with a higher likelihood for a postinjury diagnosis for a musculoskeletal condition, which were related to lower levels of later posttraumatic stress disorder (PTSD) symptoms, and higher levels of physical and mental HRQOL. Similarly, EI was related to a lower likelihood for a postinjury PTSD diagnosis, and lower levels of subsequent PTSD symptoms, and therefore higher physical and mental HRQOL relative to those with TBI. Despite this, the prevalence of probable PTSD among those with EI was high (35%). Implications for intervention, rehabilitation, and future research are discussed.

The Relationships Between Self-reported Pain Intensity, Pain Interference, and Quality of Life Among Injured U.S. Service Members With and Without Low Back Pain.

Low back pain is a prevalent military and veteran health problem and individuals injured on deployment may be at particularly high risk of pain conditions. Given that increasing numbers of active duty and veteran military personnel are seeking care in community settings, it is critical that health care providers are aware of military health issues. The current study examined the prevalence of low back pain among individuals with deployment-related injuries, compared their self-reported pain intensity and interference ratings, and assessed the relationship between low back pain, self-reported pain ratings, and quality of life. Almost half of participants had low back pain diagnoses, and individuals with low back pain reported significantly higher intensity and interference due to their pain than individuals without low back pain. Finally, the relationship between low back pain and quality of life was explained by self-reported pain indices, underscoring the importance of patient-centered metrics in pain treatment.

Risk of post-traumatic knee osteoarthritis after knee injury in military service members.

PURPOSE: The aims of the present study were: (a) to identify the incidence of osteoarthritis (OA) after a traumatic knee injury; (b) identify the risk of post-traumatic osteoarthritis (PTOA) based on the type of injury; and (c) identify the time from injury to OA diagnosis. PATIENTS AND METHODS: The Expeditionary Medical Encounter Database, containing healthcare utilization for all deployment injuries sustained by military service members, was queried for traumatic knee injuries between 2001 and 2016. Subsequent diagnosis of knee OA was identified, defined as PTOA. Time to knee PTOA diagnosis was determined and logistic regression was used to obtain odds ratios (ORs) (95% confidence interval [CI]) between knee injury type and development of PTOA. RESULTS: A total of 345 (9.57%) of the 3,605 subjects were diagnosed with PTOA. The median time to diagnosis was 4.10 years. Four primary diagnoses remained significantly associated with PTOA after adjusting for age and injury severity score: fracture (adjusted OR [aOR] = 1.36; 95% CI 1.02, 1.82), sprain (aOR = 1.59; 95% CI 1.23, 2.06), dislocation (aOR = 3.70; 95% CI 2.09, 6.55) and derangement (aOR = 2.38; 95% CI 1.33, 4.28). Subjects were significantly less likely to develop PTOA after a soft-tissue injury (aOR = 0.44; 95% CI 0.41, 0.75). CONCLUSIONS: A substantial number of individuals with a traumatic knee injury developed early PTOA (9.6%). Certain knee injuries have a greater association with PTOA. Future studies should implement longer surveillance periods and identify other healthcare variables associated with the risk of developing PTOA, to include appropriate and timely interventions.

Self-reported Functional Status in US Service Members After Combat-Related Amputation.

The objective of this study was to describe the functional status of US service members after combat-related amputation. This was a cross-sectional analysis of data from a subsample of the Wounded Warrior Recovery Project, an ongoing, web-based, longitudinal examination of patient-reported outcomes of injured service members. The study sample included 82 Wounded Warrior Recovery Project participants with a combat-related lower extremity amputation who reported using a prosthetic device and completed the Orthotics and Prosthetics Users' Survey Lower Extremity Functional Status, which measures self-reported functional status in participants with a prosthetic device. Basic activities, such as walking indoors, getting on and off the toilet, and getting up from a chair, were reported by the majority of participants as "very easy/easy," whereas higher-level activities, such as climbing stairs, walking long distances, or running, were more often reported as "slightly difficult/very difficult" or "cannot do this activity." Functional status varied significantly by amputation site (unilateral below knee, unilateral above knee, or bilateral; P = 0.004), with significantly better function reported in those with unilateral below knee than bilateral amputation (P < 0.05). These findings highlight deficits in the functional status of US service members with combat-related amputation. Self-reported functional status of daily activities may help target important activities for patient-centered goals.

Association of Specific Lower Extremity Injuries With Delayed Amputation.

INTRODUCTION: Despite medical interventions to preserve viability and functionality of injured limb(s) among combat-injured service members, delayed amputations may occur. The goal of this study was to determine whether specific lower extremity (LE) injuries were associated with delayed amputations. METHODS: The Expeditionary Medical Encounter Database was queried for combat-related LE injuries between 2003 and 2015. The Abbreviated Injury Scale (AIS) was used to categorize LE injuries by severity. Injury episodes with a maximum LE AIS of 1 or amputation on the day of injury were excluded. The final sample included 2,996 service members with at least one LE injury with an AIS ≥2. The frequencies of specific LE fractures and nerve and vessel injuries were determined. Logistic regression with paired independent variables was performed to examine the impact of multiple LE injuries on the odds of delayed amputation. RESULTS: Delayed LE amputation was identified in 308 (10.3%) service members in the sample. The delayed and no amputation groups did not differ in age and service branch. The majority of injury episodes were blast-related and with an Injury Severity Score ≥9. The most frequent fractures were tibia (34.4%) and fibula (29.3%), but the highest rates of delayed amputation were in those with navicular (36.2%), talus (30.0%), or calcaneus (28.1%) fractures. Odds of amputation were highest among service members with the calcaneus fracture and LE nerve injury (odds ratio [OR]: 41.74; 95% confidence interval [CI], 14.70, 118.55; p < 0.001), calcaneal fracture and LE vessel injury (OR: 17.99; 95% CI: 10.53, 30.74; p < 0.001), and calcaneus and tibia fractures (OR: 15.12; 95% CI: 9.54, 23.96; p < 0.001) combinations. CONCLUSIONS: Odds of delayed amputation increased substantially with specific injury combinations. These findings may guide clinical decision-making in the acute care period.

Descriptive Characteristics and Amputation Rates With Use of Intrepid Dynamic Exoskeleton Orthosis.

Advancements in ankle-foot orthotic devices, such as the Intrepid Dynamic Exoskeletal Orthosis (IDEO), are designed to improve function and reduce pain of the injured lower extremity. There is a paucity of research detailing the demographics, injury patterns and amputation outcomes of patients who have been prescribed an IDEO. The purpose of this study was to describe the demographics, presenting diagnosis and patterns of amputation in patients prescribed an IDEO at the Center for the Intrepid (CFI). The study population was comprised of 624 service members who were treated at the CFI and prescribed an IDEO between 2009 and 2014. Data were extracted from the Expeditionary Medical Encounter Database, Defense Manpower Data Center, Military Health System Data Repository, and CFI patient records for demographic and injury information as well as an amputation outcome. The most common injury category that received an IDEO prescription was injuries at or surrounding the ankle joint (25.0%), followed by tibia injuries (17.5%) and nerve injuries below the knee (16.4%). Over 80% of the sample avoided amputation within a one year time period using this treatment modality. Future studies should longitudinally track IDEO users for a longer term to determine the long term viability of the device.

Characterization and Comparison of Combat-Related Injuries in Women During OIF and OEF.

Although historically restricted from combat roles, women suffer from combat-related injuries, especially in recent conflicts where asymmetrical warfare erases distinctions between forward and rear operating areas. U.S. servicewomen who sustained combat-related injury in Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) between January 2003 and May 2014 were identified from the Expeditionary Medical Encounter Database. Injuries were characterized using Abbreviated Injury Scale and International Classification of Diseases, 9th Revision codes. Of the 844 combat-related injury episodes in women, 51% (n = 433) were OIF injuries and 49% (n = 411) were OEF injuries. Blast events were responsible for 90% of injuries. The average Injury Severity Score was 3, with no statistical difference in means between OIF and OEF. Of significance were increased head injuries in OEF compared with OIF (80% vs. 48%; p < 0.001). Although the majority of combat-related injuries suffered by women were mild, some women suffered life-threatening injuries, and nearly 65% of the injury episodes resulted in more than one injury. More research is needed as the roles of women in the military continue to expand. Future studies will investigate quality of life outcomes and gender differences in combat-related injuries.

Combat blast injuries: injury severity and posttraumatic stress disorder interaction on career outcomes in male servicemembers.

The purpose of this study was to describe career performance outcomes after combat blast injury and to examine the relationship between the injury severity and type of military discharge. A retrospective cohort study of 4,255 male servicemembers injured in a combat blast as a part of Operation Iraqi Freedom was completed. In the total sample, 37.8% experienced a normal discharge and 8.3% had an early discharge. Of the 2,229 members who had a discharge code, 29.8% experienced a disability discharge. Both early attrition and disability discharge proportions were higher in those with posttraumatic stress disorder (PTSD) than in those without PTSD. There was a significant interaction between PTSD and injury severity in the discharge disability outcome. In those without PTSD, there was a dose-response relationship between injury severity and disability discharge. In those with PTSD, injury severity predicted disability discharge. The relationship between injury severity and disability discharge was less striking in servicemembers with PTSD than without PTSD. The effect of PTSD and injury severity on career performance outcomes after blast injuries should be factored into outcome planning.

Influence of combat blast-related mild traumatic brain injury acute symptoms on mental health and service discharge outcomes.

Assessment of acute mild traumatic brain injury (mTBI) symptoms after a combat blast could aid diagnosis and guide follow-up care. Our objective was to document acute mTBI symptoms following a combat blast and to examine associations between acute symptoms and mental health and service discharge outcomes. A retrospective cohort study was conducted with 1656 service personnel who experienced a combat blast-related mTBI in Iraq. Acute mTBI symptoms were ascertained from point-of-injury medical records. The associations between acute symptoms and posttraumatic stress disorder (PTSD), postconcussion syndrome (PCS), and type of service discharge were examined. Disability discharge occurred in 11% of patients, while 36% had a non-disability discharge and 52% had no recorded discharge. A PTSD and PCS diagnosis was made in 19% and 15% of the sample, respectively. The most common acute mTBI symptoms were headache (62.8%), loss of consciousness (LOC) (34.5%), and tinnitus (33.2%). LOC was predictive of PTSD (odds ratio [OR] 1.54; 95% confidence interval [CI] 1.18, 2.00) and PCS (OR 2.08; 95% CI 1.56, 2.77), while altered mental status (OR 1.53; 95% CI 1.07, 2.17) and previous blast history (OR 1.83; 95% CI 1.15, 2.90) also were predictive of PCS. While no acute mTBI symptoms were associated with discharge outcomes, injury severity was associated with disability discharge. LOC after blast-related mTBI was associated with PTSD and PCS, and injury severity was predictive of disability discharge. The assessment of cognitive status immediately after a blast could assist in diagnosing mTBI and indicate a need for follow-up care.

Injuries from combat explosions in Iraq: injury type, location, and severity.

INTRODUCTION: Explosions have caused a greater percentage of injuries in Iraq and Afghanistan than in any other large-scale conflict. Improvements in body armour and field medical care have improved survival and changed the injury profile of service personnel. This study's objective was to determine the nature, body region, and severity of injuries caused by an explosion episode in male service personnel. MATERIALS AND METHODS: A descriptive analysis was conducted of 4623 combat explosion episodes in Iraq between March 2004 and December 2007. The Barell matrix was used to describe the nature and body regions of injuries due to a combat explosion. RESULTS: A total of 17,637 International Classification of Diseases, Ninth Revision (ICD-9) codes were assigned to the 4623 explosion episodes, with an average of 3.8 ICD-9 codes per episode. The most frequent single injury type was a mild traumatic brain injury (TBI; 10.8%). Other frequent injuries were open wounds in the lower extremity (8.8%) and open wounds of the face (8.2%), which includes tympanic membrane rupture. The extremities were the body regions most often injured (41.3%), followed by head and neck (37.4%) and torso (8.8%). CONCLUSION: The results of this study support previous observations of TBI as a pre-eminent injury of the wars in Iraq and Afghanistan, with mild TBI as the most common single injury in this large cohort of explosion episodes. The extremities had the highest frequency of injuries for any one body region. The majority of the explosion episodes resulted in more than one injury, and the variety of injuries across nearly every body region and injury type suggests a complex nature of explosion injuries. Understanding the constellation of injuries commonly caused by explosions will assist in the mitigation, treatment, and rehabilitation of the effects of these injuries.

Estrogen therapy and bone mineral density in African-American and Caucasian women.

Controlling for body size and composition, the authors examined the association between estrogen therapy and bone mineral density in older African-American and Caucasian women. In 1992-1998, 443 African-American and 989 Caucasian women aged 45-87 years were assessed for medication use, laboratory variables, behavioral characteristics, and bone mineral density. The mean age was 61.3 (95% confidence interval: 60.3, 62.3) years in African Americans and 71.0 (95% confidence interval: 70.4, 71.7) years in Caucasians (P < 0.001). All measures of body size and composition were significantly greater in the African-American women compared with Caucasian women (P < 0.001). As expected, African Americans had significantly higher bone mineral density at all 4 sites independent of age, weight, body composition, estrogen use, and lifestyle factors. Although Caucasians were significantly more likely to currently use estrogen (48.9% vs. 33.9%; P < 0.001), African Americans not using estrogen had significantly higher bone mineral density at all sites except the spine than Caucasians who were using estrogen. Regression models including age and lean mass explained the most variation in bone mineral density (R(2) range = 0.13-0.37). Results suggest that higher levels of bone mineral density in African-American women were not due to estrogen use.