An Association Between Herpes Zoster Vaccination and Stroke Reduction Among Elderly Individuals.

Herpes zoster (HZ, shingles) affects individuals (60+ years) by reactivation of varicella virus from primary infection. Approximately one-third of the general population will develop HZ and are at increased risk of stroke. Our objective was describing possible associations between self-reported HZ vaccination and stroke with the Centers for Disease Control and Prevention's Behavioral Risk Factors Surveillance System, a cross-sectional nationwide telephone survey. Non-institutionalized U.S. adults answered items concerning health risk behaviors. 2014 survey data were from 265,568 adults 50-79 years old. Multivariable Cox regressions adjusted for standard demographics, body mass index, and coronary heart disease showed that HZ-vaccinated individuals had lower risk of reporting stroke those not vaccinated (hazard ratio [HR] = 1.73). After stratification of participants into six 5-year age groups, adjusted weighted binary logistic regressions were conducted for each age group with stroke as outcome. The HZ-vaccinated group aged 65-69 years reported stroke approximately 50% less than those unvaccinated (adjusted Odds Ratio [aOR] = 1.51; 99% confidence interval [CI]:1.21,1.88). Secondary analyses indicated that this benefit was among HZ-vaccinated whites (aOR = 1.6, 95%CI:1.4,2.0), but not African Americans or Hispanics. These possible protective effects are not detected 10 years after recommended vaccine uptake. Limitations include not following participants longitudinally and that time between stroke and vaccination could not be determined.

Prediction of Insulin Resistance with Anthropometric and Clinical Laboratory Measures in Nondiabetic Teenagers.

BACKGROUND: Adolescent obesity is an important risk factor for cardiovascular disease in part due to its relationship to type 2 diabetes. Therefore, screening for type 2 diabetes is recommended. However, since insulin resistance (IR) is an early precursor of diabetes, it would be beneficial if IR predictors from routine assessments could identify those at greatest metabolic risk before diabetes has developed. METHODS: Adolescents aged 14-18 years with normal fasting plasma glucose (n = 252) were selected from the National Health and Nutrition Examination Survey 2013-2014. IR was estimated with homeostatic model assessment (HOMA). Multivariable linear/logistic regressions with demographic covariates assessed HOMA Index (HI)-determined IR associations with common clinical measurements. RESULTS: The constellation of body mass index (BMI) percentile (P < 0.0001), diastolic blood pressure (DBP, P = 0.0056), and serum alanine aminotransferase (ALT, P = 0.0295) predicted log-transformed HI; cholesterol, triglycerides, and high- and low-density lipoprotein cholesterol were not predictive. Secondary gender analyses indicated significant associations in males (BMI percentile, P = 0.0008; DBP, P = 0.0003; ALT, P = 0.0436), but only BMI percentile in females (P = 0.0001). After stratifying predictors at clinical thresholds, logistic regressions had increased specificity at HI's 85th percentile compared with its 75th [85th: area under curve (AUC) = 0.87, 75th: AUC = 0.80]. At the 85th HI percentile, IR was associated with these components [BMI percentile: adjusted odds ratio (aOR) = 34.31, 95% confidence interval (CI): 8.5-139.3; ALT: aOR = 11.36, 95% CI: 3.0-43.7; DBP: aOR = 7.73, 95% CI: 2.4-24.6]. In males, IR was associated with elevated BMI percentile (aOR 24.0) and ALT (aOR 23.9) and in females with elevated BMI percentile (aOR 45.8) and DBP (aOR 17.9). CONCLUSIONS: Three routine clinical assessments, BMI percentile, DBP, and ALT, predicted IR at HI's 75th and 85th percentiles in nondiabetic adolescents. Prospective validation may yield simple gender-specific screening identifying nondiabetic adolescents at greatest need of treatment intervention.

Painful Craniofacial/Cervical Surface Area and Continuous Headache After Military Concussion: A Morphometric Retrospective Cohort Study.

OBJECTIVE: In this retrospective study of active duty service members (ADSMs), possible relationships were examined between extent of headache pain depicted on head/neck diagrams and headache phenomenology. BACKGROUND: The signature injury of US military operations in Iraq and Afghanistan is mild traumatic brain injury (mTBI). Blast injury, especially from improvised explosive devices, was the most common cause during the height of the wars; the most persistent symptom remains posttraumatic headache (PTH). Neurologic patients were asked to draw pain diagrams/maps, a method of pain assessment in several clinical settings. METHODS: Thirty-four ADSMs attributing PTH to both blast and non-blast sources underwent clinical evaluations; diagnoses and headache characteristics were obtained. They completed 58 drawings depicting craniofacial/cervical headache pain on non-standardized templates. Drawings were of 29 continuous and 29 non-continuous headaches (CHA and NCHA, respectively). Surface area was calculated using a grid and expressed as a percentage. RESULTS: The sample was male (100%), primarily white (83%), with an average age of 30.3 years. Evidence for statistical independence of observations is provided (intra-class correlation = 0.004). Percent surface area was larger for CHA (median [mdn] = 35.2, interquartile range [IQR] = 9.0, 78.3) than NCHA (mdn = 9.1, IQR = 5.4, 34.1, P = .029). In those with blast injury, CHA percent surface areas (mdn = 45.9, IQR = 27.0, 100) were larger than NCHA (mdn = 11.6, IQR = 5.8, 28.9; P = .0012), a relationship not observed in patients with PTH from non-blasts (CHA: mdn = 26.8, IQR = 8.5, 52.0; NCHA: mdn = 9.1, IQR = 5.0, 47.6, P = .050). This pattern is observed after pooling at the median (blast, P < .012; non-blast: P = .264). CONCLUSION: Painful craniofacial/cervical surface area, as shown on patient drawings, is related to PTH phenomenology (continuous versus non-continuous headache). This relationship is stronger after blast injury.

Staying in service with posttraumatic headache: A retrospective cohort study of patient outcome.

OBJECTIVE: To predict the probability of a military outcome (medical discharge/retirement) in patients with mild traumatic brain injury from a clinical analysis of predetermined patient and headache characteristics. METHODS: This retrospective cohort study sampled all new patients referred for headache evaluation at the Brain Injury Clinic of the Womack Army Medical Center, Ft. Bragg, NC (August 2008-January 2010). Headache characteristics were extracted and analyzed. Multivariable binary logistic regressions were conducted to predict probability of medical discharge/retirement. RESULTS: Ninety-five soldiers (age 31.3 ± 7.4 years, male 93.7%) reported 166 headaches. The most common injury cited was a blast (53.7%). Patients with a continuous headache have almost 4 times the odds of a medically related discharge/retirement compared to patients without such a headache (continuous headache regression coefficient estimate: p < 0.042, odds ratio 3.98, 95% Wald confidence interval 1.05-15.07). Results suggest that, compared to service members who did not have a continuous headache, patients with headache histories with severe holocephalic pain who medicate to keep functioning had the highest probability of medical discharge/retirement. CONCLUSIONS: Certain headache characteristics may be predictive of military outcomes after mild traumatic brain injury, and we propose a profile that may be useful in that prediction. These data could be useful in future attempts to assess and treat patients with posttraumatic headache and to advise longer-term planning for return to duty or discharge.

Histological Diagnoses of Military Personnel Undergoing Lung Biopsy After Deployment to Southwest Asia.

INTRODUCTION: The current understanding of associations between lung disease and military deployment to Southwest Asia, including Iraq and Afghanistan, is both controversial and limited. We sought to clarify the relation between military deployment and biopsy-proven lung disease. METHODS: Retrospective data were analyzed for military personnel with non-neoplastic lung biopsies evaluated at the Armed Forces Institute of Pathology or Joint Pathology Center (January 2005 to December 2012). RESULTS: Of 391 subjects, 137 (35.0%) had deployed to Southwest Asia prior to biopsy. Compared to non-deployed subjects, those deployed were younger (median age 37 vs. 51 years) with higher representation of African Americans (30.0 vs. 16.9%). Deployed patients were more likely diagnosed with non-necrotizing granulomas (OR 2.4). Non-deployed subjects had higher frequency of idiopathic interstitial pneumonias, particularly organizing pneumonia. Prevalence of small airways diseases including constrictive bronchiolitis was low. CONCLUSIONS: This study provides a broader understanding of diversity of biopsy-proven non-neoplastic lung disease as it relates to military deployment to Southwest Asia and importantly did not show an increased prevalence of small airway disease to include constrictive bronchiolitis.

Which Matters More? A Retrospective Cohort Study of Headache Characteristics and Diagnosis Type in Soldiers with mTBI/Concussion.

OBJECTIVE: To describe the diagnostic types and characteristics of headaches in soldiers with mild traumatic brain injury during the wars in Afghanistan and Iraq. BACKGROUND: Persistent post-traumatic headache interferes with returns to activity or duty. The most commonly cited headache diagnosis after concussion is migraine. We hypothesize that headache diagnosis type, eg, migraine, is not sufficient to predict relationships with occupational outcomes after concussion. METHODS: The study sample consisted of all new patients referred for headache evaluation at the Brain Injury Center at Womack Army Medical Center over a 1-year time period. The design was retrospective and observational. Clinical data reported included demographics, causes of injury, headache characteristics, and headache diagnosis type. After reviewing records for retention or severance from military service, the primary occupational outcome measure was departure from service due to medical cause as determined by a Medical Evaluation Board (MEB). The primary outcome measure was to test the strength of association between leaving service for MEB and headache characteristics or diagnosis. RESULTS: A total of 95 patients (94% male) with concussion described 166 distinct headache types, the most common being migraine (60%) and trigeminal autonomic cephalalgia (24%). A total of 25% of all patients remained on active duty. A continuous headache of any type was present in 75% of patients and of these, 23% remained on active duty. Of the 51% of patients who had both a continuous and non-continuous headache, 17% remained on active duty (P < .001). Therefore, we report that a continuous headache, regardless of diagnosis type was associated with negative occupational outcomes. Regardless of headache duration, headache diagnosis type alone was not associated with soldiers' separations from service. CONCLUSIONS: Persistent post-traumatic headache is most likely to present with continuous pain. Migraine is the most common primary diagnosis type. The presence of a continuous headache was strongly associated with negative occupational outcomes. Primary headache diagnosis type was not. Headache characteristics, therefore, may be more important than diagnosis type when determining active duty status. Further prospective research is indicated.

Headache in military service members with a history of mild traumatic brain injury: A cohort study of diagnosis and classification.

Introduction Headaches after concussion are highly prevalent, relatively persistent and are being treated like primary headaches, especially migraine. Methods We studied all new patients seen between August 2008 and December 2009 assessed by a civilian headache specialist at the TBI Center at Womack Army Medical Center, Fort Bragg, NC. We report sample demographics, injuries and headache characteristics, including time from injury to headache onset, detailed descriptions and International Classification of Headache Disorders second edition primary headache diagnosis type. Results A total of 95 soldiers reported 166 headaches. The most common injury cited was a blast (53.7%). Most subjects (76.8%) recalled the onset of any headache within 7 days of injury. The most commonly diagnosed headache was a continuous type with migraine features ( n = 31 (18.7%)), followed by chronic migraine (type 1.5.1, n = 14 (8.4%)), migraine with aura (type 1.2.1, n = 10 (6.0%)), hemicrania continua (type 4.7, n = 12 (7.2%)), chronic cluster (type 3.1.2, n = 6 (3.6%)) and headaches not otherwise classifiable (type 14.1, n = 5 (3.0%)) also present. The most clinically important was a continuous headache with migraine features. Conclusion We present a series of patients seen in a military treatment facility for headache diagnosis after concussion in whom we found migraine, as well as uncommon primary headache types, at frequencies that were much higher than expected.