Study protocol for a prospective, longitudinal cohort study investigating the medical and psychosocial outcomes of UK combat casualties from the Afghanistan war: the ADVANCE Study

Bennett, Alexander N.; Dyball, Daniel; Boos, Christopher J.; Fear, Nicola T.; Schofield, Susan; Bull, Anthony M.J.; Cullinan, Paul; Study, Advance

doi:10.1136/bmjopen-2020-037850

Cited by 32 publications

(63 citation statements)

References 131 publications

(124 reference statements)

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“…Details of the study design, sampling and protocol have been previously published. 5 The primary outcomes were the relative prevalence of MetS and large artery stiffness (using cAIx) among injured versus uninjured servicemen.…”

Section: Methodsmentioning

confidence: 99%

“…Between March 2016 and August 2020, male UK military personnel (≥18 years) who had sustained CRTI (sufficient to require aeromedical evacuation) were compared with a frequency-matched comparison group (by age, service, rank, regiment, deployment period and role-in-theatre) of on March 13, 2022 Participants with established CVD (history of stroke or transient ischaemic attack, ischaemic heart disease (IHD), peripheral vascular disease) prior to their injury/deployment of interest or evidence of active acute infection at baseline survey were excluded. 5 Patients and the public were engaged, and continue to be so, in the study design, research questions, outcome measures, conduct and logistics of the study via focus groups, feedback questionnaires, newsletters and via the ADVANCE study website (https:// www. advancestudydmrc.…”

Section: Study Populationmentioning

confidence: 99%

“…The severity of the original CRTI was quantified using the New Injury Severity Score (NISS), 15 provided by the UK Joint Theatre Trauma Registry, which is a prospectively collected database of every service casualty admitted to a deployed UK medical facility. 5 Socioeconomic status (SEC) was classified by military rank at the time of deployment using the three-tier National Statistics Socio-Economic Classification (NS-SEC): senior rank (commissioned officers), NS-SEC group 1; mid-rank (senior non-commissioned officers), NS-SEC group 2; and junior rank…”

Section: Assessment Of Injury Severity and Socioeconomic Classmentioning

confidence: 99%

“…4 There is a need for a contemporary prospective cohort study examining the relationship between CRTI and its severity to earlier markers of cardiovascular risk, which if established would prompt prevention strategies to mitigate the risk. 5 Metabolic syndrome (MetS) and arterial stiffness are two recognised markers of cardiovascular risk. MetS affects up to 30% of Western adults, with a prevalence that is rapidly rising.…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Association between combat-related traumatic injury and cardiovascular risk

Boos

Schofield

Cullinan

et al. 2021

Heart

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ObjectiveThe association between combat-related traumatic injury (CRTI) and cardiovascular risk is uncertain. This study aimed to investigate the association between CRTI and both metabolic syndrome (MetS) and arterial stiffness.MethodsThis was a prospective observational cohort study consisting of 579 male adult UK combat veterans (UK-Afghanistan War 2003–2014) with CRTI who were frequency-matched to 565 uninjured men by age, service, rank, regiment, deployment period and role-in-theatre. Measures included quantification of injury severity (New Injury Severity Score (NISS)), visceral fat area (dual-energy X-ray absorptiometry), arterial stiffness (heart rate-adjusted central augmentation index (cAIx) and pulse wave velocity (PWV)), fasting venous blood glucose, lipids and high-sensitivity C reactive protein (hs-CRP).ResultsOverall the participants were 34.1±5.4 years, with a mean (±SD) time from injury/deployment of 8.3±2.1 years. The prevalence of MetS (18.0% vs 11.8%; adjusted risk ratio 1.46, 95% CI 1.10 to 1.94, p<0.0001) and the mean cAIx (17.61%±8.79% vs 15.23%±8.19%, p<0.0001) were higher among the CRTI versus the uninjured group, respectively. Abdominal waist circumference, visceral fat area, triglycerides, estimated insulin resistance and hs-CRP levels were greater and physical activity and high-density lipoprotein-cholesterol lower with CRTI. There were no significant between-group differences in blood glucose, blood pressure or PWV. CRTI, injury severity (↑NISS), age, socioeconomic status (SEC) and physical activity were independently associated with both MetS and cAIx.ConclusionsCRTI is associated with an increased prevalence of MetS and arterial stiffness, which are also influenced by age, injury severity, physical activity and SEC. The longitudinal impact of CRTI on clinical cardiovascular events needs further examination.

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Section: Methodsmentioning

confidence: 99%

Section: Study Populationmentioning

confidence: 99%

Section: Assessment Of Injury Severity and Socioeconomic Classmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Association between combat-related traumatic injury and cardiovascular risk

Boos

Schofield

Cullinan

et al. 2021

Heart

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Association Between Combat‐Related Traumatic Injury and Skeletal Health: Bone Mineral Density Loss Is Localized and Correlates With Altered Loading in Amputees: the Armed Services Trauma Rehabilitation Outcome (ADVANCE) Study

McMenemy

Behan

Kaufmann

et al. 2023

J of Bone & Mineral Res

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The association between combat‐related traumatic injury (CRTI) and bone health is uncertain. A disproportionate number of lower limb amputees from the Iraq and Afghanistan conflicts are diagnosed with osteopenia/osteoporosis, increasing lifetime risk of fragility fracture and challenging traditional osteoporosis treatment paradigms. The aim of this study is to test the hypotheses that CRTI results in a systemic reduction in bone mineral density (BMD) and that active traumatic lower limb amputees have localized BMD reduction, which is more prominent with higher level amputations. This is a cross‐sectional analysis of the first phase of a cohort study comprising 575 male adult UK military personnel with CRTI (UK‐Afghanistan War 2003 to 2014; including 153 lower limb amputees) who were frequency‐matched to 562 uninjured men by age, service, rank, regiment, deployment period, and role‐in‐theatre. BMD was assessed using dual‐energy X‐ray absorptiometry (DXA) scanning of the hips and lumbar spine. Femoral neck BMD was lower in the CRTI than the uninjured group (T‐score −0.08 versus −0.42 p = .000). Subgroup analysis revealed this reduction was significant only at the femoral neck of the amputated limb of amputees (p = 0.000), where the reduction was greater for above knee amputees than below knee amputees (p < 0.001). There were no differences in spine BMD or activity levels between amputees and controls. Changes in bone health in CRTI appear to be mechanically driven rather than systemic and are only evident in those with lower limb amputation. This may arise from altered joint and muscle loading creating a reduced mechanical stimulus to the femur resulting in localized unloading osteopenia. This suggests that interventions to stimulate bone may provide an effective management strategy. © 2023 Crown copyright and The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). This article is published with the permission of the Controller of HMSO and the King's Printer for Scotland.

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Influence of traumatic lower‐limb amputation on physical activity, body composition, and cardiometabolic risks: A descriptive preliminary study

Ladlow

Nightingale

McGuigan

et al. 2023

PM&R

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Background Following traumatic lower‐limb amputation (LLA), humans are predisposed to numerous unfavorable changes in health, including the development of secondary chronic health conditions such as metabolic disorders and cardiovascular disease. Objective To determine within and between group differences in cardiometabolic component risks, body composition, and physical activity (PA) in individuals with traumatic unilateral and bilateral LLA, compared to noninjured controls. Design Prospective observational cohort study. Setting A military complex trauma rehabilitation center. Participants Sixteen males with traumatic LLA (8 unilateral, mean age 30 ± 5 years and 8 bilateral, mean age 29 ± 3 years). Thirteen active age‐matched males with no LLA (28 ± 5 years) acted as controls and performed habitual activities of daily living. Intervention Participants with LLA attended two 4‐week periods of inpatient rehabilitation, separated by two 6‐week periods of home‐based recovery. Main Outcome Measures Venous blood samples were taken prior to and following a 75 g oral glucose load, for determination of biomarkers, including insulin and glucose, at baseline and 20 weeks. Body composition (dual X‐ray absorptiometry) was measured at baseline, 10 weeks, and 20 weeks. Daily PA was recorded using a triaxial accelerometer for 7 days during inpatient rehabilitation and while at home. Energy expenditure was estimated using population‐specific equations. Results Individuals with bilateral LLA demonstrated more unfavorable mean body composition values, lower PA, and increased cardiometabolic health risk compared to controls. Cardiometabolic syndrome was identified in 63% of individuals with bilateral LLA. No statistically significant differences in cardiometabolic component risk factors, body composition, and estimated daily PA were reported between unilateral LLA and control groups (p > .05). While at home, mean PA counts.day−1 reduced by 17% (p = .018) and 42% (p = .001) in the unilateral and bilateral LLA groups, respectively. Conclusions Despite extensive inpatient rehabilitation, cardiometabolic component risks are elevated in individuals with bilateral LLA but are comparable between unilateral LLA and active noninjured control groups. Innovative strategies that improve/support the long‐term PA and cardiometabolic health of severely injured individuals with bilateral LLA are warranted.

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Study protocol for a prospective, longitudinal cohort study investigating the medical and psychosocial outcomes of UK combat casualties from the Afghanistan war: the ADVANCE Study

Cited by 32 publications

References 131 publications

Association between combat-related traumatic injury and cardiovascular risk

Association between combat-related traumatic injury and cardiovascular risk

Association Between Combat‐Related Traumatic Injury and Skeletal Health: Bone Mineral Density Loss Is Localized and Correlates With Altered Loading in Amputees: the Armed Services Trauma Rehabilitation Outcome (ADVANCE) Study

Influence of traumatic lower‐limb amputation on physical activity, body composition, and cardiometabolic risks: A descriptive preliminary study

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