Vitamin D is critically important to numerous physiologic functions, including bone health. Poor vitamin D status is a common but underrecognized problem that predisposes the military population to stress fracture and completed fracture. This has significant implications for force health protection, warfighter readiness, attrition, and cost. Despite this, vitamin D deficiency is still underdiagnosed and undertreated in the military. This is a major hindrance to military readiness and one that could easily be modified with awareness, prevention, and early treatment. In this commentary, we review the literature on vitamin D deficiency and critically examine the current status of policies and clinical practice related to vitamin D in the military health system. We offer several practical recommendations to increase awareness and readiness while decreasing musculoskeletal injury and the associated costs.

Background Intestinal and multivisceral transplantations are treatment options for patients with intestinal failure. Transplantation is often complicated by abdominal and/or bloodstream infections in the post‐operative period. Methods A retrospective chart review of all adults who underwent intestinal or multivisceral transplantation at our institution from 2003 to 2015 was performed. Data were collected for 2 years post transplant. Results A total of 106 intestinal or multivisceral transplants were performed in 103 patients. The median age at the time of transplant was 44 (IQR: 34‐52) with 55% (n = 58) male and 45% (n = 48) female. There were 46 (43%) intra‐abdominal infections post transplant among the 103 patients, and six transplant recipients (13%) developed concurrent bloodstream infections. The median time to first intra‐abdominal infection was 23 days (IQR: 10‐48). For those with organisms isolated in culture, forty‐seven percent of the isolates were gram negative, 39% gram positive, 7% anaerobes, and 7% yeast. The most common isolates were enterococci at 28%, E. coli at 14%, and Klebsiella spp at 13%. Sixty‐three percent of the enterococci were vancomycin‐resistant enterococci (VRE), and 22% of the gram‐negative isolates were extended spectrum beta‐lactamases (ESBLs). Patients with intra‐abdominal infections had longer hospital post‐transplant length of stays at a median of 35 days (IQR: 25‐48) vs 23 days (IQR: 17‐33) for those without infections, P = .0012. There was no difference in all‐cause mortality in patients with or without intra‐abdominal infections, P = .654. Conclusions Intra‐abdominal infections are common in intestinal or multivisceral transplant recipients, but despite this complication, we found no increased risk of mortality. These transplant recipients are also at risk for infection with drug‐resistant organisms.

doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

Background: The objective of this study was to evaluate sex differences in the incidence and risk of ankle–foot complex (AFC) stress fractures among U.S. military personnel, which could assist in developing management strategies as females assume a greater role in U.S. military operations. Methods: The Defense Medical Epidemiological Database was used to identify all diagnosed AFC stress fractures in military personnel from 2006 to 2015. Cumulative incidence of AFC stress fractures was calculated and compared by year, service branch, and military rank. Sex differences in the risk of AFC stress fractures by occupation were examined, and integrated (i.e., male and female) occupations were compared with non-integrated (i.e., male–only) occupations. Results: A total of 43,990 AFC stress fractures were identified. The overall incidence rate was 2.76 per 1,000 person-years for males and 5.78 per 1,000 person-years for females. Females consistently had higher incidence of AFC stress fractures across all subgroups, particularly among enlisted personnel. Female enlisted service members had the highest risk of AFC stress fractures in aviation [relative risk (RR) = 5.74; 95% confidence interval [CI] 4.80–6.87] and artillery/gunnery (RR = 5.15; 95% CI 4.62–5.75) occupations. Females in integrated occupations had significantly higher rates of AFC stress fractures than males in both integrated and non-integrated occupations (i.e., special forces, infantry, and mechanized/armor). Conclusions: Females in the U.S. military have a higher risk of AFC stress fractures than males. As integration of females into previously sex-restricted occupations continues, focused prevention efforts may be needed to reduce injury burden and maximize medical readiness.