Little research has described the long-term health outcomes of patients who had combat-related amputations or leg-threatening injuries. We conducted retrospective analysis of Department of Defense ...and Department of Veterans Affairs health data for lower extremity combat-injured patients with (1) unilateral amputation within 90 days postinjury (early amputation, n = 440), (2) unilateral amputation more than 90 days postinjury (late amputation, n = 78), or (3) leg-threatening injuries without amputation (limb salvage, n = 107). Patient medical records were analyzed for four years postinjury. After adjusting for group differences, early amputation was generally associated with a lower or similar prevalence for adverse physical and psychological diagnoses (e.g., pain, osteoarthritis, posttraumatic stress disorder) versus late amputation and/or limb salvage. By contrast, early amputation was associated with an increased likelihood of osteoporosis during the first year postinjury. The prevalence of posttraumatic stress disorder increased for all patient groups over four years postinjury, particularly in the second year. The different clinical outcomes among combat extremity injured patients treated with early amputation, late amputation, or limb salvage highlight their different healthcare requirements. These findings can inform and optimize the specific treatment pathways that address the physical and psychological healthcare needs of such patients over time.
Abstract Background We sought to determine the incidence, risk factors, and time course for deep vein thrombosis and pulmonary embolism (DVT/PE) after combat-related major limb amputations. Methods ...Patients with amputation in Iraq or Afghanistan from 2009 through 2011 were eligible. Details of postinjury care, date of diagnosis of DVT/PE, and injury specific data were collected. Military databases and chart reviews were used. Results In 366 patients, 103 (28%) had DVT/PE; PE was diagnosed in 59 (16%) and DVT in 59 (16%). Most DVT (69%) and PE (66%) occurred within 10 days. Increasing ventilator days (odds ratio OR, 1.97; 95% CI, 1.16 to 3.37) and units of blood transfused (OR, 1.72; 95% CI, 1.11 to 2.68) were associated with DVT. Increasing units of fresh-frozen plasma were associated with PE (OR, 1.31; 95% CI, 1.10 to 1.55). Conclusions The incidence of DVT/PE is high after combat-related amputation. Most DVT/PE occur early and prophylaxis is indicated.
Treatment of military combatants who sustain leg-threatening injuries remains one of the leading challenges for military providers. The present study provides systematic health outcome data to inform ...decisions on the definitive surgical treatment, namely amputation versus limb salvage, for the most serious leg injuries.
This was a retrospective analysis of health records for patients who sustained serious lower-extremity injuries in the Iraq and Afghanistan conflicts, 2001 to 2008. Patients had (1) amputation during the first 90 days after injury (early amputees, n = 587), (2) amputation more than 90 days after injury (late amputees, n = 84), or (3) leg-threatening injuries without amputation (limb salvage LS, n = 117). Injury data and health outcomes were followed up to 24 months.
After adjusting for group differences, early amputees and LS patients had similar rates for most physical complications. Early amputees had significantly reduced rates of psychological diagnoses (posttraumatic stress disorder, substance abuse) and received more outpatient care, particularly psychological, compared with LS patients. Late amputees had significantly higher rates of many mental and physical health diagnoses, including prolonged infections and pain issues, compared with early amputees or LS patients.
Early amputation was associated with reduced rates of adverse health outcomes relative to late amputation or LS in the short term. Most evident was that late amputees had the poorest physical and psychological outcomes. These findings can inform health care providers of the differing clinical consequences of early amputation and LS. These results indicate the need for separate health care pathways for early and late amputees and LS patients.
Abstract
Introduction
Little population-based research has described the transition from Department of Defense (DoD) to Department of Veterans Affairs (VA) healthcare following combat related ...amputations. The objectives were to describe (1) to what extent patients used either DoD only facilities, both DoD and VA facilities, or VA only facilities during the first 5 years postinjury, (2) which specific clinics were used and (3) clinic use among patients with different levels of amputation (upper versus lower), and among patients with early or late amputation.
Materials and Methods
This was a retrospective analysis of health data extracted from the expeditionary medical encounter database (EMED) and national DoD and VA databases. Patients were 649 US service members who sustained a single major limb amputation following injuries in the Iraq and Afghanistan conflicts, 2001–2008. We compared yearly DoD and VA clinic use by patient groups with different levels of amputation (upper limb: above versus below elbow or lower limb: above versus below knee), different timing of amputation (early: within 90 days postinjury versus late: more than 90 days postinjury), military component (Active Duty versus National Guard/Reserve) and race (White versus Black). For all groups, we calculated the percentage of patients using: (1) DoD only, (2) both DoD and VA or 3) VA only clinics during each of postinjury years 1 through 5. We also calculated the percentage of patients who used specific clinics (e.g., social work, prosthetics, mental health) during each postinjury year.
Results
During postinjury year 1, over 98% of patients used DoD only or both DoD and VA clinics. Most individuals (70% to 78%) used both DoD and VA clinics during postinjury year 1. Use of VA only clinics increased gradually between postinjury year 2 (15% to 30% of patient groups) and year 5 (75% to 88%). This gradual transition to use of VA only clinics was seen consistently across patient groups with different anatomical levels or timing of amputation, military component or race. Patients with lower levels of amputation (versus higher levels) and individuals with early amputations (versus late) transitioned earlier to VA only care. Overall, clinic use was high as 91% to 100% of all patient groups used one or more clinics (DoD or VA) during each of the first 5 years. For specific clinics, most patients used DoD facilities related to rehabilitation (physical therapy, prosthetics) or transitional care (social work) particularly during postinjury year 1. Use of most VA clinics studied (social work, primary care, prosthetics, mental health) showed a modest increase primarily after postinjury year 1 and remained stable through postinjury year 5. The results indicated apparent underuse of psychiatric/mental health and prosthetics between postinjury year 1 and 2.
Conclusions
The present study indicated a gradual transition from DoD to VA only healthcare which extended across 5 years following combat related amputations. Patients with lower levels of amputation or early amputation generally transitioned earlier to VA only healthcare. These results can inform medical planning to support a timely and clinically effective transition from DoD to VA healthcare.
Previous studies have shown that veterans with lower limb amputation have a higher risk for cardiovascular disease (CVD) compared with population-based controls. American veterans who have served in ...Iraq and Afghanistan with lower limb amputation may be at a similarly higher risk.
The Navel Health Research Center (NHRC) maintains the Expeditionary Medical Encounter Database (EMED) of military personnel who have sustained combat limb amputation or serious limb injury during the conflicts in Iraq and Afghanistan. Department of Veterans Affairs data from 2003 to April 2015 was used to analyze CVD risk factors in this cohort. Veterans with either unilateral (n=442) or bilateral (n
146) lower limb amputation were compared to those with serious lower limb trauma without amputation (n=184). Multivariate regression was used to measure associations between lower limb amputation and CVD risk factors over an average of 8 years of follow-up. Outcomes included mean arterial pressure (MAP), low-density lipoprotein, high-density lipoprotein (HDL), and serum triglycerides (TG).
Compared with the limb injury group, those with unilateral lower limb amputation had significantly lower HDL (
<0.05) and higher TG (
<0.05). Those with bilateral lower limb amputation had significantly higher MAP (
<0.05), lower HDL (
<0.01), and higher TG (
<0.001). The prevalence of metabolic syndrome, defined as type 2 diabetes or a constellation of blood pressure and lipid changes consistent with metabolic syndrome, was 8.7%, 14.9%, and 21.9% for limb injury, unilateral amputation, and bilateral amputation groups, respectively. Veterans with bilateral lower limb amputation had a 2.25-increased odds ratio (95% confidence interval 1.19-5.05) of type 2 diabetes or blood pressure and lipid changes consistent with metabolic syndrome compared to those with limb injury.
Results suggest that veterans with lower limb amputation have a higher risk for metabolic syndrome. Primary care interventions to manage weight, blood pressure, and lipid levels are fundamental in order to reduce cardiac risk in this relatively young cohort.
Abstract
Introduction
Limited research has analyzed the full range of outpatient medication prescription activity following serious combat injury. The objectives of this study were to describe (1) ...outpatient medication prescriptions and refills during the first 12 months after serious combat injury, (2) longitudinal changes in medication prescriptions during the first-year postinjury, and (3) patient characteristics associated with outpatient prescriptions.
Materials and methods
This was a retrospective analysis of existing health and pharmacy data for a random sample of U.S. service members who sustained serious combat injuries in the Iraq and Afghanistan conflicts, 2010–2013 (n = 381). Serious injury was defined by an Injury Severity Score (ISS) of 9 or greater. These patients typically participate in military rehabilitation programs (eg, amputation care) where prescription medications are essential. Data sources were the Expeditionary Medical Encounter Database for injury-specific data, the Pharmacy Data Transaction Service for outpatient medication prescriptions and refills, and the Military Health System Data Repository for diagnostic codes of pain and psychological disorders. Military trauma nurses reviewed casualty records to identify types of injuries. Using the American Hospital Formulary Service Pharmacologic-Therapeutic Classification system, clinicians identified 13 categories of prescription medications (eg, opioid, psychotherapeutic, immunologic) for analysis. Multivariable negative binomial and logistic regression analyses evaluated significant associations between independent variables (eg, blast injury, traumatic brain injury TBI, ISS, limb amputation, diagnoses of chronic pain, or psychological disorders) and prescription measures (ie, number or category of medication prescriptions). We also describe longitudinal changes in prescription activity postinjury across consecutive quarterly intervals (91 days) during the first-year postinjury.
Results
During the first-year postinjury, patients averaged 61 outpatient prescriptions, including all initial prescriptions and refills. They averaged eight different categories of medications, primarily opioid, immunologic, gastrointestinal/genitourinary, central nervous system (CNS), nonopioid analgesic, and psychotherapeutic medications (representing 82% of prescriptions) during the first year. Prescription activity generally declined across quarters. There was still substantial prescription activity during the fourth quarter, as 79% of patients had at least one prescription. From 39 to 49% of patients had fourth-quarter prescriptions for opioid, CNS, or psychotherapeutic medications. Longitudinally, we found that 24–34% of patients had an opioid, CNS, or psychotherapeutic prescription during each of the final three quarters. In multivariable analysis, ISS, limb amputation (particularly bilateral amputation), and diagnoses of chronic pain and post-traumatic stress disorder (PTSD) were associated with significantly higher counts of individual and multiple medication prescriptions. TBI was associated with significantly lower numbers of prescriptions for certain medications.
Conclusions
This is one of the first studies to provide a systematic analysis of outpatient medication prescriptions following serious combat injury. The results indicate substantial prescription activity from multiple medication categories throughout the first-year postinjury. Diagnoses of chronic pain, PTSD, and limb amputation and ISS were associated with significantly higher counts of prescriptions overall and more prescription medication categories. This study provides initial evidence to better understand medication prescription activity following serious combat injury. The results inform future research on medication prescription practices and planning for rehabilitation.
BACKGROUNDPrescription medications are an essential element of military amputation care programs.OBJECTIVESTo analyze (1) outpatient prescription medications following combat-related amputations, (2) ...longitudinal changes in prescription activity during the first year postinjury, and (3) patient characteristics associated with prescription medications.DESIGNRetrospective study of military casualty records and outpatient prescription medications. Clinicians identified 13 medication categories based on American Hospital Formulary Service classifications.SETTINGMilitary amputation rehabilitation program.PATIENTS1651 service members who sustained major limb amputations during 2001-2017.MAIN OUTCOMES MEASURESPrescription medication category, days' supply, opioid dosage.RESULTSDuring the first year postinjury, patients averaged 65 outpatient prescriptions (new or refills, SD = 43.3) and 8 (SD = 1.9) of 13 medication categories. Nearly all patients (99%) had opioid prescriptions averaging high dosages with variation by patient characteristics and postinjury time. At least 84% of patients had prescriptions for one or more central nervous system, gastrointestinal, psychotherapeutic, immune/anti-infective and/or nonopioid analgesic medications. Prescriptions declined from the first (92%) to fourth (73%) quarter postinjury. Many patients had prescription opioids (51%), central nervous system medications (43%), or psychotherapeutic medications (32%) during the fourth quarter. In regression models, multiple factors including White race/ethnicity (relative risk RR = 1.16; 95% confidence interval CI: 1.06-1.28, p = .001), injury severity, traumatic brain injury, upper limb amputation (RR = 0.90; CI: 0.83-0.99, p = .020), multiple amputation (RR = 1.12 CI: 1.03-1.22, p = .008), phantom limb syndrome, chronic pain, and posttraumatic stress disorder were significantly associated with prescriptions (p's < .05).CONCLUSIONSAmputation care providers manage a high volume and wide range of prescription medications including multiple central nervous system drugs. The results show significant variation in prescription practices by patient characteristics and time postinjury. These findings can help optimize the benefits and reduce the risks of prescription medications and indicate areas for future research.
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