Occurrence of amyotrophic lateral sclerosis among Gulf War veterans.

BACKGROUND: In response to Gulf War veterans' concerns of high rates of ALS, this investigation sought to determine if Gulf War veterans have an elevated rate of ALS. METHODS: A nationwide epidemiologic case ascertainment study design was used to ascertain all occurrences of ALS for the 10-year period since August 1990 among active duty military and mobilized Reserves, including National Guard, who served during the Gulf War (August 2, 1990, through July 31, 1991). The diagnosis of ALS was confirmed by medical record review. Risk was assessed by the age-adjusted, average, annual 10-year cumulative incidence rate. RESULTS: Among approximately 2.5 million eligible military personnel, 107 confirmed cases of ALS were identified for an overall occurrence of 0.43 per 100,000 persons per year. A significant elevated risk of ALS occurred among all deployed personnel (RR = 1.92; 95% CL = 1.29, 2.84), deployed active duty military (RR = 2.15, 95% CL = 1.38, 3.36), deployed Air Force (RR = 2.68, 95% CL = 1.24, 5.78), and deployed Army (RR = 2.04; 95% CL = 1.10, 3.77) personnel. Elevated, but nonsignificant, risks were observed for deployed Reserves and National Guard (RR = 2.50; 95% CL = 0.88, 7.07), deployed Navy (RR = 1.48, 95% CL = 0.62, 3.57), and deployed Marine Corps (RR = 1.13; 95% CL = 0.27, 4.79) personnel. Overall, the attributable risk associated with deployment was 18% (95% CL = 4.9%, 29.4%). CONCLUSIONS: Military personnel who were deployed to the Gulf Region during the Gulf War period experienced a greater post-war risk of ALS than those who were not deployed to the Gulf.

VA Stroke Study: neurologist care is associated with increased testing but improved outcomes.

OBJECTIVE: VA Stroke Study (VASt) data were analyzed to determine whether neurologist management affected the process and outcome of care of patients with ischemic stroke. METHODS: VASt prospectively identified patients with stroke admitted to nine VA hospitals (April 1995 to March 1997). Demographics, stroke severity (Canadian Neurologic Score), stroke subtype (Trial of ORG 10172 in Acute Stroke Treatment [TOAST] classification), tests/procedures, and discharge status (independent, Rankin < or = 2, vs dead or dependent, Rankin 3 through 5) were compared between patients who were or were not cared for by a neurologist. RESULTS: Of 1,073 enrolled patients, 775 (neurologist care, n = 614; non-neurologist, n = 161) with ischemic stroke were admitted from home. Stroke severity (Canadian Neurologic Score 8.7 +/- 0.1 vs 8.4 +/- 0.2; p = 0.44), TOAST subtype (p = 0.55), and patient age (71.4 +/- 0.4 vs 72.4 +/- 0.7; p = 0.23) were similar for neurologists and non-neurologists. Neurologists more frequently obtained MRI (44% vs 16%; p < 0.001), transesophageal echocardiograms (12% vs 2%; p < 0.001), carotid ultrasounds (65% vs 57%; p = 0.05), cerebral angiography (8% vs 1%; p = 0.001), speech (35% vs 18%; p < 0.001), and occupational therapy (46% vs 33%; p = 0.005) evaluations. Brain CT, transthoracic echocardiogram, 24-hour ambulatory ECG use, and hospitalization durations (18.2 +/- 0.8 vs 19.7 +/- 4.1 days; p = 0.725) were similar. Neurologists' patients were less likely to be dead (5.6% vs 13.5%; OR = 0.38; 95% CI 0.22, 0.68; p = 0.001) and less likely to be dead or dependent (46.1% vs 57.1%; OR = 0.64; 95% CI 0.45, 0.92; p = 0.019) at the time of discharge. The benefit remained after controlling for stroke severity and comorbidity (OR = 0.63; 95% CI 0.42, 0.94; p = 0.025). CONCLUSION: Neurologist care was associated with more extensive testing, but similar lengths of hospitalization and improved outcomes.