title: Retrospective Analysis of Long-Term Outcomes After Combat Injury: A Hidden Cost of War.
abstract: BACKGROUND
  During the conflicts in Iraq and Afghanistan, 52,087 service members have been wounded in combat. The long-term sequelae of these injuries have not been carefully examined. We sought to determine the relation between markers of injury severity and the subsequent development of hypertension, coronary artery disease, diabetes mellitus, and chronic kidney disease.
  
  
  RESULTS
  Retrospective cohort study of critically injured US military personnel wounded in Iraq or Afghanistan from February 1, 2002 to February 1, 2011. Patients were then followed until January 18, 2013. Chronic disease outcomes were assessed by International Classification of Diseases, 9th edition codes and causes of death were confirmed by autopsy. From 6011 admissions, records were excluded because of missing data or if they were for an individual's second admission. Patients with a disease diagnosis of interest before the injury date were also excluded, yielding a cohort of 3846 subjects for analysis. After adjustment for other factors, each 5-point increment in the injury severity score was associated with a 6%, 13%, 13%, and 15% increase in incidence rates of hypertension, coronary artery disease, diabetes mellitus, and chronic kidney disease, respectively. Acute kidney injury was associated with a 66% increase in rates of hypertension and nearly 5-fold increase in rates of chronic kidney disease.
  
  
  CONCLUSIONS
  In Iraq and Afghanistan veterans, the severity of combat injury was associated with the subsequent development of hypertension, coronary artery disease, diabetes mellitus, and chronic kidney disease.
authors.affiliation: From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.). ian.stewart@us.af.mil.
authors.forename: Ian J
authors.initials: IJ
authors.lastname: Stewart
authors.affiliation: From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.).
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Sosnov
authors.affiliation: From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.).
authors.forename: Jeffrey T
authors.initials: JT
authors.lastname: Howard
authors.affiliation: From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.).
authors.forename: Jean A
authors.initials: JA
authors.lastname: Orman
authors.affiliation: From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.).
authors.forename: Raymond
authors.initials: R
authors.lastname: Fang
authors.affiliation: From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.).
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Morrow
authors.affiliation: From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.).
authors.forename: David H
authors.initials: DH
authors.lastname: Zonies
authors.affiliation: From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.).
authors.forename: Mary
authors.initials: M
authors.lastname: Bollinger
authors.affiliation: From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.).
authors.forename: Caroline
authors.initials: C
authors.lastname: Tuman
authors.affiliation: From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.).
authors.forename: Brett A
authors.initials: BA
authors.lastname: Freedman
authors.affiliation: From the David Grant Medical Center, Travis AFB, CA (I.J.S.); Uniformed Services University of the Health Sciences, Bethesda, MD (I.J.S., J.A.S., B.D.M., K.K.C.); San Antonio Military Medical Center, TX (J.A.S., B.D.M.); U.S. Army Institute of Surgical Research, San Antonio, TX (J.T.H., J.A.O., K.K.C.); U.S. Air Force Center for Sustainment of Trauma and Readiness Skills, Baltimore, MD (R.F.); Oregon Health & Science University, Portland (D.H.Z.); South Texas Veterans Health Care System, San Antonio (M.B.); and Landstuhl Regional Medical Center, Landstuhl, Germany (C.T., B.A.F.).
authors.forename: Kevin K
authors.initials: KK
authors.lastname: Chung
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D015331:Cohort Studies; D003130:Combat Disorders / Q000175:diagnosis* / Q000453:epidemiology*; D017281:Cost of Illness; D005260:Female; D006801:Humans; D054542:Iraq War, 2003-2011; D008297:Male; D008889:Military Personnel; D012042:Registries; D012189:Retrospective Studies; D013997:Time Factors; D014728:Veterans; D000067398:War-Related Injuries / Q000175:diagnosis* / Q000453:epidemiology*; D014857:Warfare; D055815:Young Adult
keywords: coronary disease; diabetes mellitus; hypertension; kidney; mortality