Initial Consideration of the Feasibility and Optimal Application of Tactile Sway Cueing to Improve Balance Among Persons Suffering from Disequilibrium

http://www.usaarl.army.mil/TechReports/2011-01.pdf
Initial Consideration of the Feasibility and Optimal Application of Tactile Sway Cueing to Improve Balance Among Persons Suffering from Disequilibrium

Angus H. RupertBenton D. Lawson

USAARL 2011-01
This report explores the use of tactual sway cueing as a compensatory strategy for patients suffering disequilibrium. Sway feedback systems have the potential to aid Soldiers with traumatic brain injury (TBI) and other patients whose balance has been disrupted by concussions, labyrinthine diseases, or aging. Several sway feedback approaches are considered and recommendations are made concerning the steps necessary for the successful transition of promising approaches.

Cognition-Enhancing Drugs and Their Appropriateness for Aviation and Ground Troops: A Meta-Analysis

Cognition-Enhancing Drugs and Their Appropriateness for Aviation and Ground Troops: A Meta-Analysis
http://www.usaarl.army.mil/TechReports/2011-06.pdf
Amanda Kelley, Catherine Webb, Jeremy, Athy Sanita Ley, Steven Gaydos
USAARL 2011-06

Currently, there are a number of pharmaceuticals available that have potential to enhance cognitive functioning which will inevitably be considered for use in military operations for enhancement purposes. Some drugs such as modafinil and caffeine have already been tested for use in military operations and some drugs used for cognition enhancement are already included in Army policy in terms of their approved use. There is considerable research available on these drugs. However, military policy regarding use must be based on high-quality research studies. The goal of this study was to review the literature and conduct a meta-analysis to determine quality of the research available and to synthesize the current state of knowledge of these potentially cognition enhancing drugs. A meta-analysis of the 3 studies that met all inclusion criteria revealed a relatively weak pooled effect of modafinil on some aspects of cognitive performance in normal, rested adults. While the results of this study support the efficacy of modafinil, the main finding is the large literature gap evaluating the short and long term effects of these drugs in healthy adults.

Decision Making Under Uncertainty

http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA534878&Location=U2&doc=GetTRDoc.pdf


Decision Making Under Uncertainty


This report introduces concepts, principles, and approaches for addressing uncertainty in decision making. The sources of uncertainty in decision making are discussed, emphasizing the distinction between uncertainty and risk, and the characterization of uncertainty and
risk. The report provides a brief overview of decision theory and presents a practical method for modeling decisions under uncertainty and selecting decision alternatives that optimize the decision maker’s objectives. The decision modeling methods introduced in this paper are suitable for both data rich and data poor decision environments. This report describes how to analyze the sensitivity of a decision model to improve understanding of the decision problem and build confidence in the conclusions of an analysis. Principles of adaptive management and adaptive engineering are discussed from a decision analysis perspective. Examples are provided to
demonstrate how these methods could be applied within the U.S. Army Corps of Engineers.

Standardizing Data Collection in Traumatic Brain Injury

http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA534620&Location=U2&doc=GetTRDoc.pdf


Standardizing Data Collection in Traumatic Brain Injury

Walter Reed Army Institute of Research,Washington,DC,20307

Andrew I.R. Maas M.D., Cynthia L. Harrison-Felix PhD, David Menon, M.D., P. David Adelson,
M.D., Tom Balkin, PhD., Ross Bullock, M.D., Doortje C. Engel, M.D., PhD, Wayne Gordon,
PhD., Jean Langlois-Orman, ScD., Henry L. Lew, M.D., PhD.1, Claudia Robertson, M.D.,
Nancy Temkin,PhD., Alex Valadka M.D., Mieke Verfaellie,PhD., Mark Wainwright, M.D., David W. Wright, M.D. and Karen Schwab, PhD



Collaboration among investigators, centers, countries and disciplines is essential to advancing the care for traumatic brain injury (TBI). It is then important that we ?speak the same language?. Great variability, however exists in data collection and coding of variables in TBI studies, confounding comparisons between and analysis across different studies. Randomized controlled trials can never address the many uncertainties around treatment approaches in TBI. Pooling data from different clinical studies and high-quality observational studies combined with Comparative Effectiveness Research may provide excellent alternatives in a cost-efficient way. Standardization of data collection and coding is essential to this purpose. Common Data Elements are presented for demographics and clinical variables applicable across the broad spectrum of TBI. Most recommendations represent a consensus, derived from clinical practice. Some recommendations concern novel approaches, for example towards assessing the intensity of
therapy in severely injured patients. Up to three levels of detail for coding data elements were developed: basic, intermediate, and advanced, with the greatest level of detail in the advanced version. More detailed codings can be collapsed into the basic version. Templates were produced to summarize coding formats explanation of choices and recommendations for procedures. Endorsement of the recommendations has been obtained from many authoritative organisations. The development of Common Data Elements for TBI should be viewed as a continuing process: As more experience is gained, refinement and amendments will be required. This proposed process of standardization will facilitate Comparative Effectiveness Research and encourage high-quality meta-analysis of individual patient data.

Management of Circadian Desynchrony (Jetlag and Shiftlag) in CF Air Operations

http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA534917&Location=U2&doc=GetTRDoc.pdf


Management of Circadian Desynchrony
(Jetlag and Shiftlag) in CF Air Operations


Background: In response to operational difficulties resulting from the effects of fatigue
(secondary to jetlag and shiftlag) on performance of Air Force personnel, the Air Force funded a
4-year project to optimize Canadian Forces (CF) ability to manipulate circadian rhythms forwards or backwards to counter jetlag and shiftlag. This report presents the highlights of that work and offers recommendation for exploitation of this new capability to sustain operational readiness.
Methods: The project consisted of 7 studies. Four studies involved light treatment, 2 studies
involved efficacy comparisons of 3 melatonin formulations to produce a phase advance and a
phase delay, and the final study involved a combination of melatonin and light treatment.
Results: We identified the best 2 of 4 light treatment devices, confirmed optimal melatonin doses
and determined the correct treatment times with light and melatonin for circadian phase advance and phase delay. Discussion: We can now develop circadian treatments using light and melatonin along with shifting sleep/wake times and avoidance of light at key times across a broad range of operational scenarios. We are therefore in a position to exploit circadian phase shifting to counterjetlag and shiftlag. Recommendations: 1. That this knowledge-base be translated into an operational implementation plan through an interface with Air Force operational personnel. This should include the development of appropriate directives, and training of squadron personnel on the use of scheduling tools such as FAST™ (Fatigue Avoidance Scheduling Tool) for fatigue management. 2. That the Air Force aerospace medical community develop medical doctrine in the utilization of circadian interventions to improve and sustain operational readiness. This should include training Bioscience Officers in circadian physiology and how to generate circadian phaseshift protocols, and Flight Surgeons in the pharmaceutical management of circadian phase shifting with melatonin, light therapy, and sleep medications. 3. That the Surgeon General acquires several different melatonin dose sizes and formulations for the CF formulary, along with light treatment devices for use at squadron/wing level.


management of jetlag and shiftlag; melatonin; light treatment; circadian phase shifting;
circadian phase advance; circadian phase delayme

Sleep and Fatigue Issues in Continuous Operations: A Survey of U.S Army Officers

http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA534777&Location=U2&doc=GetTRDoc.pdf

Sleep and Fatigue Issues in Continuous Operations: A Survey of U.S.
Army Officers


A group of 49 US Army Officers recently returned from combat and attending the Infantry Officers Advanced Course at FT Benning, GA were surveyed to assess the sleep hygiene of their units and to determine the tactics, techniques, and procedures (TTPs) they used to reduce the effects of sleep deprivation in their units. Results indicate that despite Army policy, nearly 80% of the study participants had not received a sleep management plan during their most recent deployment. Over half (55%) of respondents reported that fatigue was a problem in their unit. The majority of respondents who received a sleep plan briefing indicated that their unit had done a good job of managing sleep routines (66% with vs. 25% without sleep plan briefing). Attention to the importance of sleep and fatigue management, manifested by sleep plan briefings, seems to be an important means by which units can mitigate fatigue in continuous combat operations. Respondents reported that during their most recent combat deployment,
they spent nearly half (46.7%) of their time at high operational tempo (OPTEMPO). This factor becomes especially important when considering that survey respondents report receiving only four hours of sleep per day during periods when their units are at high OPTEMPO, just over half the amount the report when at low OPTEMPO (4.0 vs. 7.8 hours). The vast majority of respondents (82.6%) report feeling sleep-deprived occasionally, sometimes or all the time while they are at high OPTEMPO.

Workplace Clinics: A Sign of Growing Employer Interest in Wellness

http://www.rwjf.org/files/research/71564.pdf


Workplace Clinics: A Sign of Growing Employer Interest in Wellness

BY HA T. TU, ELLYN R. BOUKUS AND GENNA R. COHEN


Findings From HSC NO. 17, DECEMBER 2010
Workplace Clinics: A Sign of Growing Employer Interest in Wellness
BY HA T. TU, ELLYN R. BOUKUS AND GENNA R. COHEN
Interest in workplace clinics has intensified in recent years, with employers moving well beyond traditional niches of occupational health and minor acute care to offering clinics that provide a full range of wellness and primary care services. Employers view workplace clinics as a tool to contain medical costs, boost productivity and enhance companies’ reputations as employers of choice. The potential for clinics to transform primary care delivery through the trusted clinician model holds promise, according to experts interviewed for a new qualitative research study from the Center for Studying Health System Change (HSC). Achieving that model is dependent on gaining employee trust in the clinic, as well as the ability to recruit and retain clinicians with the right qualities—a particular challenge in communities with provider shortages. Even when clinic operations are outsourced to vendors, initial employer involvement—including the identification of the appropriate scope and scale of clinic services—and sustained employer attention over time are critical to clinic success. Measuring the impact of clinics is difficult, and credible evidence on return on investment (ROI) varies widely, with very high ROI claims made by some vendors lacking credibility. While well-designed, well-implemented workplace clinics are likely to achieve positive returns over the long term, expecting clinics to be a game changer in bending the overall health care cost curve may be unrealistic.

The Economics of Air Force Medical Service Readiness

http://www.rand.org/content/dam/rand/pubs/technical_reports/2010/RAND_TR859.pdf

The Economics of Air Force Medical Service Readiness


John C. Graser, Daniel Blum, Kevin Brancato,
James J. Burks, Edward W. Chan, Nancy Nicosia,
Michael J. Neumann, Hans V. Ritschard,
Benjamin F. Mundell

Prepared for the United States Air Force


The Air Force Medical Service (AFMS) has three major missions: keeping the Air Force active duty population healthy and deployable for their wartime mission; maintaining the readiness
of AFMS personnel to perform their wartime health-care mission; and providing health-care
services for Air Force and other Department of Defense (DoD) retirees, dependents, and other
categories of eligible beneficiaries. To accomplish these missions, AFMS has a full-time force
of about 40,000 military and civilian personnel who operate 74 military treatment facilities
(MTFs) throughout the world and provide health care to about 2.6 million eligible beneficiaries.
In addition, the Air National Guard and Air Force Reserve have about 20,000 medical
personnel.
Since 2001, as part of the global war on terror, AFMS and the medical departments of the
Army and Navy have been tasked with supporting combat operations in Afghanistan and Iraq.
Specialists providing critical care, specifically surgeons and operating room nurses and technicians,as well as mental health professionals, have been in high demand. In addition to the
problem of filling these in-theater requirements with highly trained specialists, deployments
present another problem to AFMS: how to provide for the home-station health care these specialists would normally accomplish if they were not deployed. Their absence means that some
beneficiaries must find alternative sources of medical care. In addition, current funding methodologies mean that the resulting decreases in workloads (number of medical procedures performed) at the home station can adversely affect the portions of the AFMS budget that depend on these workloads to generate that funding. A final complication in the AFMS operating
environment is the reduction in the number of inpatient facilities and overall inpatient workload,
which has decreased opportunities for training critical-care specialists for wartime duties.
Under a project entitled “Economics of Air Force Medical Service Readiness,” the project
sponsor, then–Deputy Surgeon of the Air Force, Maj Gen C. Bruce Green, asked RAND
Project AIR FORCE to assess the AFMS operation by
• evaluating how AFMS functions as a health plan, a health-care provider, and a payer for
services, as well as how it relates to other DoD organizations
• examining how resource decisions are made and how the Medical Expense and Performance
Reporting System and other systems and processes affect resource allocation
within the U.S. Military Health System
• analyzing the effects of resource decisions on system incentives and medical readiness
• examining alternative methodologies for solving problems that are discovered.
iv The Economics of Air Force Medical Service Readiness
The research was conducted within the Resource Management Program of RAND Project
AIR FORCE. Data collection and analysis were performed between January 2008 and
September 2008, and a final project update was provided to the sponsor in September 2008,
with frequent updates in between.
This report should be of interest to government personnel with a stake in military healthcare
operations and resourcing issues. Related documents include the following:
• Christine Eibner, Maintaining Military Medical Skills During Peacetime: Outlining and
Assessing a New Approach, Santa Monica, Calif.: RAND Corporation, MG-638-OSD,
2008.
• Edward G. Keating, Marygail K. Brauner, Lionel A. Galway, Judith D. Mele, James J.
Burks, and Brendan Saloner, Air Force Physician and Dentist Multiyear Special Pay: Current
Status and Potential Reforms, Santa Monica, Calif.: RAND Corporation, MG-866-AF,
2009.
• Edward G. Keating, Hugh G. Massey, Judith D. Mele, and Benjamin F. Mundell, An
Analysis of the Populations of the Air Force’s Medical and Professional Officer Corps, Santa
Monica, Calif.: RAND Corporation, TR-782-AF, 2010.
• Don Snyder, Edward W. Chan, James J. Burks, Mahyar A. Amouzegar, and Adam C.
Resnick, How Should Air Force Expeditionary Medical Capabilities Be Expressed? Santa
Monica, Calif.: RAND Corporation, MG-785-AF, 2009.

Visual Dysfunction Following Blast-Related Traumatic Brain Injury form the Battlefield

http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA533219&Location=U2&doc=GetTRDoc.pdf
Visual Dysfunction Following Blast-Related Traumatic Brain Injury
From The Battlefield


To assess the occurrence of ocular and visual disorders following blast-related traumatic brain injury (TBI) in Operation Iraqi Freedom.

Research design: Retrospective cohort study.
Methods and procedures: A total of 2254 US service members with blast-related combat injuries were identified for analysis from the Expeditionary Medical Encounter Database. Medical record information near the point of injury was used to assess factors associated with the diagnosis of ocular/visual disorder within 12 months after injury, including severity of TBI.
Main outcomes and results: Of 2254 service members, 837 (37.1%) suffered a blast-related TBI and 1417 (62.9%) had other blast-related injuries. Two-hundred and one (8.9%) were diagnosed with an ocular or visual disorder within 12 months after blast injury. Compared with service members with other injuries, odds of ocular/visual disorder were significantly higher for
service members with moderate TBI (odds ratio (OR)¼1.58, 95% confidence interval (CI)¼1.02–2.45) and serious to critical TBI (OR¼14.26, 95% CI¼7.00–29.07).
Conclusions: Blast-related TBI is strongly associated with visual dysfunction within 1 year after injury and the odds of disorder appears to increase with severity of brain injury. Comprehensive vision examinations following TBI in theatre may be necessary.