bluuebunny/crossref_metadata_2025 huggingface dataset:
Preliminary Data of Neck Muscle Morphology With Head-Supported Mass in Male and Female Volunteers
Authors: Yoganandan Narayan , Baisden Jamie , Varghese Vicky , Vedantam Aditya , Stemper Brian , Banerjee Anjishnu , Jebaseelan Davidson
Published: November 2023

Introduction

This study quantified parameters related to muscle morphology using a group of upright seated female and male volunteers with a head-supported mass.

Materials and Methods

Upright magnetic resonance images (MRIs) were obtained from 23 healthy volunteers after approval from the U.S. DoD. They were asymptomatic for neck pain, with no history of injury. The volunteers were scanned using an upright MRI scanner with a head-supported mass (army combat helmet). T1 and T2 sagittal and axial images were obtained. Measurements were performed by an engineer and a neurosurgeon. The cross-sectional areas of the sternocleidomastoid and multifidus muscles were measured at the inferior endplate in the sub-axial column, and the centroid angle and centroid radius were quantified. Differences in the morphology by gender and spinal level were analyzed using a repeated measures analysis of variance model, adjusted for multiple corrections.

Results

For females and males, the cross-sectional area of the sternocleidomastoid muscle ranged from 2.3 to 3.6 cm2 and from 3.4 to 5.4 cm2, the centroid radius ranged from 4.1 to 5.1 cm and from 4.7 to 5.7 cm, and the centroid angle ranged from 75° to 131° and from 4.8° to 131.2°, respectively. For the multifidus muscle, the area ranged from 1.7 to 3.9 cm2 and from 2.4 to 4.2 cm2, the radius ranged from 3.1 to 3.4 cm and from 3.3 to 3.8 cm, the angle ranged from 15° to 24.4° and 16.2° to 24.4°, respectively. Results from all levels for both muscles and male and female spines are given.

Conclusions

The cross-sectional area, angulation, and centroid radii data for flexor and extensor muscles of the cervical spine serve as a dataset that may be used to better define morphologies in computational models and obtain segmental motions and loads under external mechanical forces. These data can be used in computational models for injury prevention, mitigation, and readiness.
Correlation of Impulse Oscillometry with Spirometry in Deployed Military Personnel with Airway Obstruction
Authors: Houle Mateo C , Cavacece Christian T , Gonzales Michael A , Anderson Jess T , Hunninghake John C , Holley Aaron B , Morris Michael J
Published: November 2023

Introduction

Evaluation of chronic respiratory symptoms in deployed military personnel has been conducted at Brooke Army Medical Center as part of the Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures III study. Although asthma and airway hyperreactivity have been the most common diagnoses, the clinical findings in these patients may be multifactorial. This study aims to evaluate the utility of impulse oscillometry (IOS) in diagnosing airway obstruction in patients undergoing multiple pulmonary function testing (PFT) studies.

Methods

Military personnel referred for deployed-related pulmonary symptoms underwent a standardized evaluation at Brooke Army Medical Center and Walter Reed National Military Medical Center over a 5-year span. Initial studies included laboratory tests, high-resolution computed tomography imaging, cardiac evaluation with electrocardiogram, and echocardiography. PFT consisted of full PFTs, forced inspiratory/expiratory pressures, post-spirometry bronchodilator testing, IOS, exhaled nitric oxide, and methacholine challenge testing.

Results

A total of 360 patients have completed an evaluation to date. In this cohort, 108 patients (30.0%) have evidence of obstruction by spirometry, whereas 74 (20.6%) had IOS values of both an R5 > 150% and X5 < −1.5. Only 32 (8.9%) had evidence of obstruction by both spirometry and IOS, whereas 210 (57.3%) had neither. A comparison among R5 (resistance at 5 Hz), R20 (resistance at 20 Hz), and X5 (reactance at 5 Hz) was performed in those individuals with and without spirometric obstruction. R5 (% predicted) was 156.2 ± 57.4% (obstruction) vs. 129.1 ± 39.6% (no obstruction) (P < .001); R20 (% predicted) was 138.1 ± 37.7% (obstruction) vs. 125.3 ± 31.2% (no obstruction) (P = .007); and X5 (cmH2O/L/s) was −1.62 ± 1.28 (obstruction) vs. −1.25 ± 0.55 (no obstruction) (P < .001).

Discussion

Impulse oscillometry has been advocated as a supplemental pulmonary function test to aid in the diagnosis of airway obstruction. The use of IOS has been primarily used in pediatrics and elderly populations as a validated tool to establish a diagnosis of airway obstruction but is limited in the adult population because of a well-validated set of reference values. Prior studies in adults have most often demonstrated a correlation with an elevated R5 > 150%, elevated resonant frequency, and a negative X5 < −1.5 or a decrease of 30 to 35% in R5 post-bronchodilator.

Conclusion

Impulse oscillometry may serve as an adjunct to diagnosis but likely cannot replace a standard spirometric evaluation. Our study highlights the future utility for diagnosing early obstructive disease in the symptomatic individual.
Local Antibiotic Therapy for Open Long Bone Fractures: Appropriate Prophylaxis or Unnecessary Exposure for the Orthopedic Trauma Patient?
Authors: Bhogadi Sai Krishna , Stewart Collin , El-Qawaqzeh Khaled , Colosimo Christina , Hosseinpour Hamidreza , Nelson Adam , Castanon Lourdes , Spencer Audrey L , Magnotti Louis J , Joseph Bellal
Published: November 2023

Introduction

Prophylactic local antibiotic therapy (LAbT) to prevent infection in open long bone fracture (OLBF) patients has been in use for many decades despite lack of definitive evidence confirming a beneficial effect. We aimed to evaluate the effect of LAbT on outcomes of OLBF patients on a nationwide scale.

Materials and Methods

In this retrospective analysis of 2017-2018 American College of Surgeons-Trauma Quality Improvement Program database, all adult (≥18 years) patients with isolated OLBF (non–extremity-Abbreviated Injury Scale < 3) were included. We excluded early deaths (<24 h) and those who had burns or non–extremity surgery. Outcomes were infectious complications (superficial surgical site infection, deep superficial surgical site infection, osteomyelitis, or sepsis), unplanned return to operating room, and hospital and intensive care unit length of stay (LOS). Patients were stratified into two groups: those who received LAbT and those who did not receive LAbT (No-LAbT). Propensity score matching (1:3) and chi-square tests were performed.

Results

A total of 61,337 isolated OLBF patients were identified, among whom 2,304 patients were matched (LAbT: 576; No-LAbT: 1,728). Both groups were similar in terms of baseline characteristics. Mean age was 43 ± 17 years, 75% were male, 14% had penetrating injuries, and the median extremity-Abbreviated Injury Scale was 1 (1-2). Most common fracture locations were tibia (66%), fibula (49%), femur (24%), and ulna (11%). About 52% of patients underwent external fixation, 79% underwent internal fixation, and 86% underwent surgical debridement. The median time to LAbT was 17 (5-72) h, and the median time to debridement was 7 (3-15) h (85% within 24 h). The LAbT group had similar rates of infectious complications (3.5% vs. 2.5%, P = 0.24) and unplanned return to the operating room (2.3% vs. 2.0%, P = 0.74) compared to the No-LAbT group. Patients who received LAbT had longer hospital LOS (16 [10-29] vs. 14 [9-24] days, P < 0.001) but similar intensive care unit LOS (4 [3-9] vs. 4 [2-7] days, P = 0.19).

Conclusions

Our findings indicate that prophylactic LAbT for OLBF may not be beneficial over well-established standards of care such as early surgical debridement and systemic antibiotics. Prospective studies evaluating the efficacy, risks, costs, and indications of adjuvant LAbT for OLBF are warranted.
Regional Strain Response of an Anatomically Accurate Human Finite Element Head Model Under Frontal Versus Lateral Loading
Authors: Rooks Tyler F , Chancey Valeta Carol , Baisden Jamie L , Yoganandan Narayan
Published: November 2023

Introduction

Because brain regions are responsible for specific functions, regional damage may cause specific, predictable symptoms. However, the existing brain injury criteria focus on whole brain response. This study developed and validated a detailed human brain computational model with sufficient fidelity to include regional components and demonstrate its feasibility to obtain region-specific brain strains under selected loading.

Methods

Model development used the Simulated Injury Monitor (SIMon) model as a baseline. Each SIMon solid element was split into 8, with each shell element split into 4. Anatomical regions were identified from FreeSurfer fsaverage neuroimaging template. Material properties were obtained from literature. The model was validated against experimental intracranial pressure, brain–skull displacement, and brain strain data. Model simulations used data from laboratory experiments with a rigid arm pendulum striking a helmeted head–neck system. Data from impact tests (6 m/s) at 2 helmet sites (front and left) were used.

Results

Model validation showed good agreement with intracranial pressure response, fair to good agreement with brain–skull displacement, and good agreement for brain strain. CORrelation Analysis scores were between 0.72 and 0.93 for both maximum principal strain (MPS) and shear strain. For frontal impacts, regional MPS was between 0.14 and 0.36 (average of left and right hemispheres). For lateral impacts, MPS was between 0.20 and 0.48 (left hemisphere) and between 0.22 and 0.51 (right hemisphere). For frontal impacts, regional cumulative strain damage measure (CSDM20) was between 0.01 and 0.87. For lateral impacts, CSDM20 was between 0.36 and 0.99 (left hemisphere) and between 0.09 and 0.93 (right hemisphere).

Conclusions

Recognizing that neural functions are related to anatomical structures and most model-based injury metrics focus on whole brain response, this study developed an anatomically accurate human brain model to capture regional responses. Model validation was comparable with current models. The model provided sufficient anatomical detail to describe brain regional responses under different impact conditions.
The Association Between Glasgow Coma Scale Scores and PTSD in Military Trauma Casualties: Does Mental Status Following Injury Play a Role in PTSD Development?
Authors: Bulis Shir , Talmy Tomer , Radomislensky Irina , Gelman Daniel , Bushinsky Shir , Nachum Dikla , Tomer Gaia , Tsur Avishai M , Paulman Omer , Gendler Sami , Almog Ofer , Benov Avi
Published: November 2023

Background

Posttraumatic stress disorder (PTSD) is prevalent among military personnel and may arise following a wide range of traumatic exposures. Consciousness level following traumatic injury may play a role in the development of PTSD, but its effects have been primarily investigated in the context of traumatic brain injury.

Methods

Registry-based study surveying three databases documenting care from point of injury to long-term rehabilitation of traumatic injuries among military personnel. The study population was divided according to Glasgow Coma Scale (GCS) scores upon emergency department admission (GCS scores 15, 13 and 14, 9–12, and 3–8), with PTSD diagnoses being determined according to disability claim records. Multivariable logistic regression was utilized to determine the association between GCS score at admission and PTSD.

Results

Overall, 3,376 military personnel hospitalized following traumatic injuries between 1997 and 2020 were included. The majority were male (92.3%), with a median age of 20 (interquartile range 19–22) at the injury time. Of these, 569 (16.9%) were diagnosed with PTSD according to disability claims, with a median follow-up time of 10.9 years. PTSD diagnosis was most prevalent (30.3% of patients), with a GCS score of 13 and 14. In the adjusted multivariable model, a GCS score of 13 and 14 was associated with significantly higher odds of PTSD diagnosis when compared to a GCS score of 15 (odds ratio 2.19, 95% CI, 1.21–3.88). The associations of other GCS groupings with PTSD diagnosis were nonsignificant.

Conclusions

Minimally impaired consciousness following traumatic injuries is associated with increased odds of PTSD. The role of patient awareness, analgesia, and sedation following an injury in developing PTSD warrants further investigation and could guide early diagnosis and preventive interventions.
Utilization of the En Route Aeromedical Patient Movement Form by Critical Care Air Transport Teams
Authors: Valdez-Delgado Krystal K , Medellin Kimberly L , Arana Allyson A , Hare Jonathan , Maddry Joseph K , Ng Patrick C , Mann-Salinas Elizabeth A , Davis William T
Published: November 2023

Introduction

Understanding usage patterns of current paper-based documentation can inform the development of electronic documentation forms for en route care. The primary objective was to analyze the frequency of use of each field within the 3899 L Patient Movement Record documented by en route Critical Care Air Transport Teams. Secondary objectives were to identify rarely utilized form fields and to analyze the proportion of verifiable major events documented within the 3899 L form.

Materials and methods

We performed a retrospective review of 3899 L patient movement records for patients transported via Critical Care Air Transport Teams from January 2019 to December 2019. Scanned 3899 L forms were manually transcribed into a Microsoft Access database for evaluation and analysis. Proportions were calculated for completed fields. Major vital sign event frequency was compared for checkbox fields versus the vital sign flow sheet for each patient. We performed descriptive analyses for the proportion of charts with completed documentation in each evaluated field and the proportion of flow sheet events documented in major event fields.

Results

We analyzed 130 records. Fourteen of 18 (77.8%) demographic fields had a 75% or greater completion ratio. Sections with the largest proportion of rarely or never utilized fields (<1.5% completed) were procedures (77.8% of fields) and major events (63.9% of fields). Major event checkboxes had low sensitivity for documented events in the flow sheet: Change in heart rate greater than 20% (1 of 28 patients); increase in the fraction of inspired oxygen requirement of greater than 10% (6 of 23 patients); decrease in mean arterial pressure of greater than 20% (1 in 12 patients); and temperature less than 35.6°C (1 in 13 patients).

Conclusions

Many of the current 3899 L fields are highly utilized, but some 3899 L sections contain high proportions of rarely utilized fields. Major event checkboxes did not consistently capture events documented within the in-flight vital sign flow sheet.
Impact of the COVID-19 Pandemic on Indicators of Psychological Health and Suicidal Ideation Within an Active Duty U.S. Military Population
Authors: Baker Justin C , Bhola Simran , Tabares Jeffrey V , Beckman Derek , Martin Christiana , Khazem Lauren R , Bryan AnnaBelle O , Bryan Craig J
Published: November 2023

Introduction

The COVID-19 pandemic has had a significant impact on the psychological health of individuals. The pandemic has contributed to increased anxiety, elevated rates of depression, and worsening suicidal ideation among civilians. Reported rates of burnout are also elevated as employees and employers adapted to ever-changing work environments, finding it increasingly difficult to maintain a work-life balance. The objective of this study is to determine how the COVID-19 pandemic impacted the psychological health and rates of suicidal ideation of active duty military personnel in the USA.

Materials and Methods

A total of 2055 military personnel and military-adjacent employees stationed at a U.S. Air Force base completed a self-report survey that was administered six times from January 2020 to December 2021. Validated scales assessed measures of psychological health and suicidal ideation. General Estimating Equations were used to examine how indicators of time and psychological health predicted suicidal ideation in a military population.

Results

Life satisfaction, happiness, feeling life is worthwhile, depression severity, and suicidal ideation did not statistically change across the six time points. Worry (P < .01) and depression (P < .001) did decrease significantly, while burnout (P = .01) significantly increased across these time points. Feeling life is worthwhile significantly predicted reduced suicidal ideation (B = -.19; SE = 0.05), while depression (B = 0.11; SE = 0.03), depression severity (B = 0.24; SE = 0.05), worry (B = 0.06; SE = 0.02), and burnout (B = 0.15; SE = 0.07) predicted increased suicidal ideation.

Conclusions

The rates of depression and worry decreased throughout the pandemic for those in the study while rates of suicidal ideation remained constant, demonstrating the potential resilience of military personnel and military-adjacent employees in response to the COVID-19 pandemic. However, burnout increased and significantly predicted elevated rates of suicidal ideation, highlighting the importance of focusing on reducing workplace stressors for military personnel.
Adaptive Human-Robotic Interaction for Robotic-assisted Surgical Settings
Authors: Yang Jing , Layadi Iris Charlene , Wachs Juan P , Yu Denny
Published: November 2023

Introduction

Increased complexity in robotic-assisted surgical system interfaces introduces problems with human–robot collaboration that result in excessive mental workload (MWL), adversely impacting a surgeon’s task performance and increasing error probability. Real-time monitoring of the operator’s MWL will aid in identifying when and how interventions can be best provided to moderate MWL. In this study, an MWL-based adaptive automation system is constructed and evaluated for its effectiveness during robotic-assisted surgery.

Materials and Methods

This study recruited 10 participants first to perform surgical tasks under different cognitive workload levels. Physiological signals were obtained and employed to build a real-time system for cognitive workload monitoring. To evaluate the effectiveness of the proposed system, 15 participants were recruited to perform the surgical task with and without the proposed system. The participants’ task performance and perceived workload were collected and compared.

Results

The proposed neural network model achieved an accuracy of 77.9% in cognitive workload classification. In addition, better task performance and lower perceived workload were observed when participants completed the experimental task under the task condition supplemented with adaptive aiding using the proposed system.

Conclusions

The proposed MWL monitoring system successfully diminished the perceived workload of participants and increased their task performance under high-stress conditions via interventions by a semi-autonomous suction tool. The preliminary results from the comparative study show the potential impact of automated adaptive aiding systems in enhancing surgical task performance via cognitive workload-triggered interventions in robotic-assisted surgery.
The Military Health System: Minimizing Disparities in Breast Cancer Treatment
Authors: Liggett Jedson R , Norris Emily A , Rush Toni M , Sicignano Nicholas M , Oxner Christopher
Published: November 2023

Background

The Military Health System (MHS) is a universal health care system, in which health care disparities are theoretically minimized. This study aimed to identify disparities and assess their impact on the initiation of timely treatment for breast cancer within a universally insured population.

Methods

A retrospective cohort study was performed to evaluate the treatment of female breast cancer patients ≥18 years of age within the MHS from January 1, 2014, to December 31, 2018. Incident breast cancer was defined as ≥2 breast cancer diagnoses without a prior diagnosis of breast cancer during the three continuous years before index diagnosis. Time from index diagnosis to initial treatment was calculated and dichotomized as receiving treatment within a clinically acceptable time course. Poisson regression was used to estimate relative risk (RR) with 95% CIs.

Results

Among the 30,761 female breast cancer patients identified in the MHS, only 6% of patients had a prolonged time to initial treatment. Time to initial treatment decreased during the study period from a mean (SD) of 63.2 (152.0) days in 2014 to 37.1 (28.8) days in 2018 (P < 0.0001). Age, region, and military characteristics remained significantly associated with receiving timely treatment even after the adjustment of confounders. Patients 70-79 years old were twice as likely as 18-39 years olds to receive timely treatment (RR: 2.0100, 95% CI, 1.52-2.6563, P < 0.0001). Senior officers and their dependents were more likely to receive timely initial treatment compared to junior enlisted patients and their dependents (RR: 1.5956, 95% CI, 1.2119-2.1005, P = 0.004).

Conclusions

There have been significant improvements in the timely initiation of breast cancer treatment within the MHS. However, demographic and socioeconomic disparities can be identified that affect the timely initiation of therapy.
Protocol for the Implementation of Psychologically Informed Physical Therapy to Prevent Chronification in Service Members With Musculoskeletal Disorders
Authors: Campello Marco , Ziemke Gregg , Hair Leslie C , Oh Cheongeun , Mowery Hope , Hope Timothy , Weiser Sherri
Published: November 2023

Introduction

Musculoskeletal disorders (MSDs) are a primary cause of separation and long-term disability in active duty service members (ADSMs). Psychologically informed physical therapy (PiPT) is designed to identify and address modifiable psychological risk factors early in an MSD episode and has been proven effective in preventing chronicity in civilian populations. We developed a course to train military physical therapy (PT) personnel in PiPT for treating ADSM with MSD. This study tests the feasibility and effectiveness of our training.

Objective

Establish the feasibility of implementing PiPT and its effectiveness in the U.S. military.

Specific Aims

Materials and Methods

An observational, prospective, comparative cohort study will test implementation and effectiveness. First, we will observe clinical outcomes in a cohort of ADSM with MSD receiving usual PT care at a military outpatient PT clinic. Next, we will train all PT staff in PiPT. Finally, PiPT will be implemented in a second cohort of ADSM. Data will be collected from each cohort at pre-treatment, fourth PT visit, 6 months post enrollment, and 12 months post enrollment. The primary outcomes are pain interference and psychological risk for chronicity.

Results and Conclusions

Data collection is ongoing. Findings will identify the factors associated with PiPT outcomes in ADSM, inform the implementation of PiPT across health care settings, and allow us to document the prevalence of risk factors for chronicity in ADSM. Findings can help to prevent chronification from MSD, thereby reducing lost man-hours and enhancing military readiness, contribute to the development of a highly skilled workforce for the provision of health services to ADSM, and enhance the efficiency of health care delivery through optimal allocation of PT resources, resulting in significant cost savings for the military.
Prevalence and Risk Factors of Self-reported Dizziness in Post-9/11 Service Members and Veterans
Authors: Sonstroem Anneka , Thapa Samrita , Pigott Kaylee , Henry James A , Schultz James , Esquivel Carlos , Carlson Kathleen F , Hullar Timothy E , Reavis Kelly M
Published: November 2023

Introduction

Dizziness is prevalent in the general population, but little is known about its prevalence in the U.S. military population. Dizziness is commonly associated with blast exposure and traumatic brain injury (TBI), but the potential independent contributions of blast and TBI have yet to be evaluated. This study’s goal was to estimate the prevalence of dizziness among post-9/11 service members and Veterans and to examine independent and joint associations between military TBI history, blast exposure, and self-reported dizziness.

Materials and Methods

The study sample consisted of service members (n = 424) and recently separated (< ∼2.5 years) Veterans (n = 492) enrolled in the Noise Outcomes in Service members Epidemiology (NOISE) Study. We examined associations between self-reported history of probable TBI and blast exposure and recent dizziness using logistic regression. Models were stratified by service member versus Veteran status and adjusted to account for potentially confounding demographic and military characteristics.

Results

Overall, 22% of service members and 31% of Veterans self-reported dizziness. Compared to those with neither TBI nor blast exposure history, both service members and Veterans with TBI (with or without blast) were three to four times more likely to self-report dizziness. Those with blast exposure but no TBI history were not more likely to self-report dizziness. There was no evidence of an interaction effect between blast exposure and a history of TBI on the occurrence of dizziness.

Conclusion

Self-reported dizziness was prevalent in this sample of service members and Veterans. Probable TBI history, with or without blast exposure, was associated with dizziness, but blast exposure without TBI history was not. This suggests that treatment guidelines for TBI-related dizziness may not need to be tailored to the injury mechanism. However, future efforts should be directed toward the understanding of the pathophysiology of TBI on self-reported dizziness, which is fundamental to the design of treatment strategies.
Measurement of Head Kinematics Using Instrumented Mouthguards During Introductory Boxing Courses in U.S. Military Academy Cadets
Authors: Fetchko Travis J , Hart Gerald J , Aderman Michael J , Ross Jeremy D , Malvasi Steven R , Roach Megan H , Cameron Kenneth L , Rooks Tyler F
Published: November 2023

Introduction

Use of wearable impact sensor devices to quantitatively measure head impact exposure remains largely unstudied in military-style martial arts training and combat sports, particularly at the beginner levels. The baseline frequency and severity of head impact exposure during introductory military-style martial arts trainings, such as combatives training, is valuable information for developing future programs of instruction and exposure monitoring programs. The purpose of this study was to describe head impact exposures experienced during introductory combatives training (a boxing course) at U.S. Military Academy.

Methods

This study used instrumented mouthguards to measure head impact exposure in U.S. Military Academy cadets during a compulsory boxing course. Summary exposures from a preliminary dataset are presented.

Results

Twenty-two male subjects (19.9 ± 1.1 years, 86.6 ± 11.7 kg) participated in 205 analyzed player-bouts (full contact sparring sessions) with 809 video verified impacts (average 3.9 impacts per player-bout). The mean peak linear acceleration was 16.5 ±7.1 G, with a maximum of 70.8 G. There was a right-skewed distribution, with 640/809 (79.1%) events falling between 10 and 20 G. The mean peak angular acceleration was 1.52 ± 0.96 krad/s2, with a maximum of 8.85 krad/s2.

Conclusions

Compared to other high-risk sports at Service Academies, head impacts from beginner boxing were of similar magnitude to those reported for Service Academy football and slightly lower than those reported for Service Academy rugby. Based on these preliminary data, the risk profile for introductory military-style martial arts training, such as boxing or combatives, may be similar to other contact sports like football and rugby, but further research is required to confirm these findings and understand the effects of the exposures in a shorter duration.
Robust Multi-View Fracture Detection in the Presence of Other Abnormalities Using HAMIL-Net
Authors: Lu Xing , Chang Eric Y , Du Jiang , Yan An , McAuley Julian , Gentili Amilcare , Hsu Chun-Nan
Published: November 2023

Introduction

Foot and ankle fractures are the most common military health problem. Automated diagnosis can save time and personnel. It is crucial to distinguish fractures not only from normal healthy cases, but also robust against the presence of other orthopedic pathologies. Artificial intelligence (AI) deep learning has been shown to be promising. Previously, we have developed HAMIL-Net to automatically detect orthopedic injuries for upper extremity injuries. In this research, we investigated the performance of HAMIL-Net for detecting foot and ankle fractures in the presence of other abnormalities.

Materials and Methods

HAMIL-Net is a novel deep neural network consisting of a hierarchical attention layer followed by a multiple-instance learning layer. The design allowed it to deal with imaging studies with multiple views. We used 148K musculoskeletal imaging studies for 51K Veterans at VA San Diego in the past 20 years to create datasets for this research. We annotated each study by a semi-automated pipeline leveraging radiology reports written by board-certified radiologists and extracting findings with a natural language processing tool and manually validated the annotations.

Results

HAMIL-Net can be trained with study-level, multiple-view examples, and detect foot and ankle fractures with a 0.87 area under the receiver operational curve, but the performance dropped when tested by cases including other abnormalities. By integrating a fracture specialized model with one that detecting a broad range of abnormalities, HAMIL-Net’s accuracy of detecting any abnormality improved from 0.53 to 0.77 and F-score from 0.46 to 0.86. We also reported HAMIL-Net’s performance under different study types including for young (age 18–35) patients.

Conclusions

Automated fracture detection is promising but to be deployed in clinical use, presence of other abnormalities must be considered to deliver its full benefit. Our results with HAMIL-Net showed that considering other abnormalities improved fracture detection and allowed for incidental findings of other musculoskeletal abnormalities pertinent or superimposed on fractures.
A Novel Paradigm to Develop Regional Thoracoabdominal Criteria for Behind Armor Blunt Trauma Based on Original Data
Authors: Yoganandan Narayan , Shah Alok , Somberg Lewis , Baisden Jamie , Stemper Brain D , Bass Cameron , Salzar Robert S , Chancey Valeta Carol , McEntire Joseph
Published: November 2023

Introduction

For behind armor blunt trauma (BABT), recent prominent BABT standards for chest plate define a maximum deformation distance of 44 mm in clay. It was developed for soft body armor applications with limited animal, gelatin, and clay tests. The legacy criterion does not account for differing regional thoracoabdominal tolerances to behind armor-induced injury. This study examines the rationale and approaches used in the legacy BABT clay criterion and presents a novel paradigm to develop thoracoabdominal regional injury risk curves.

Materials and Methods

A review of the original military and law enforcement studies using animals, surrogates, and body armor materials was conducted, and a reanalysis of data was performed. A multiparameter model analysis describes survival–lethality responses using impactor/projectile (mass, diameter, and impact velocity) and specimen (weight and tissue thickness) variables. Binary regression risk curves with ±95% confidence intervals (CIs) and peak deformations from simulant tests are presented.

Results

Injury risk curves from 74 goat thorax tests showed that peak deflections of 44.7 mm (±95% CI: 17.6 to 55.4 mm) and 49.9 mm (±95% CI: 24.7 to 60.4 mm) were associated with the 10% and 15% probability of lethal outcomes. 20% gelatin and Roma Plastilina #1 clay were stiffer than goat. The clay was stiffer than 20% gelatin. Penetration diameters showed greater variations (on a test-by-test basis, difference 36-53%) than penetration depths (0-12%) across a range of projectiles and velocities.

Conclusions

While the original authors stressed limitations and the importance of additional tests for refining the 44 mm recommendation, they were not pursued. As live swine tests are effective in developing injury criteria and the responses of different areas of the thoracoabdominal regions are different because of anatomy, structure, and function, a new set of swine and human cadaver tests are necessary to develop scaling relationships. Live swine tests are needed to develop incapacitation/lethal injury risk functions; using scaling relationships, human injury criteria can be developed.
The Design and Application of a Health Behavioral Change (HBC) Roadmap
Authors: Schulz Theresa , Hammill Tanisha , Zapata Tracy , Betancourt Jose , Edwards-Stewart Amanda
Published: November 2023

Introduction

To assist in addressing medical readiness challenges, the DOD has established various Centers of Excellence to focus efforts to protect, treat, train, and educate service members concerning risks and potential injuries. Using the hearing health domain as a pilot, this effort used DOD methods to evaluate all facets of successful health behavior change (HBC) practices within a military environment and developed a framework and pathway for HBC.

Methods

The DOD uses the Joint Capabilities Integration and Development System (JCIDS) to ensure new DOD capabilities are identified and fielded in a manner that is interoperable, resilient, and supportables. The study sponsor for the Health Behavioral Change Framework study is the Defense Health Agency Deputy Assistant Director for Research and Engineering (R&E). The main objective of this group was to ensure that final products would both meet the requirements as defined by the JCIDS process, as well as be used by the operational force in addressing HBCs that improve readiness of the joint force.

Results

The Health Behavior Change Guidebook applies to all organizations across the DOD and military health system that may participate in or support specific tasks related to the design, conduct, and assessment of the HBC campaign. The advantage of the process is the ability to define gaps and solutions at an enterprise level. The HBC framework can be applied to a variety of health domains to include behavioral health.

Conclusions

Use of the “Guidebook for Design, Conduct and Assessment of Health Behavior Change Campaign Within the DOD” and DOTMLPF-P analysis will move Defense Health Agency toward more disciplined use of the JCIDS. The HBC framework allowed the Hearing Center of Excellence to lead the hearing health community to create a capability-based assessment for hearing HBC.
Developing a Comparative Effective Methodology for Technology Usability During a Simulated Casualty Event
Authors: Schmidt Patricia M , Ortman Holly , Gaudaen James C , Markins Larry , Manemeit Carl , Knisely Benjamin , Pamplin Jeremy C
Published: November 2023

Introduction

Future combat environments will be complex, making effective care for multi-domain battlefield injuries more challenging. Technology and resources are essential to reduce provider burden enabling more accurate assessments, decision-making support, expanded treatment, and outcome improvements. Experimentation exercises to evaluate concepts and technologies to incorporate into the Army’s future force ensure rapid and continuous integration across air, land, sea, space, and cyberspace domains to overmatch adversaries. A medical lane was first integrated on the communications networks for experimentation in 2022. We describe a project to develop a method for empirically comparing devices intended to support combat casualty care through high-fidelity simulation in preparation for an Army experimentation exercise.

Methods

Six medics participated in a series of high-fidelity simulation medical casualty injury scenarios with and without technology devices. The participants provided usability information about their care delivery experiences using the System Usability Scale and Adapted Telehealth Usability Questionnaire-Telemedicine and Advanced Technology Research Command and qualitative feedback.

Results

A comparative effectiveness design compared the devices regarding their usability, size, weight, and power with the addition of cost, connectivity, and cyber security, and the qualitative feedback this methodology holistically assessed the technologies as they were applied in the combat casualty care scenario.

Conclusions

Results were used by decision makers to determine technology inclusion in experimentation exercise, develop proof of concept methodology to scale for the exercise, and provide technology developers feedback for iterative updates of their devices before participation in experimentation exercise. This project supports the body of simulation studies conducted to understand combat casualty care. It is one of few empirical medical technology assessments with medical personnel end user input that has been reported. The methodology incorporates a user-centered design for rapid technology improvements before fielding.
Medical Evaluation Readiness Information Toolset (MERIT): Developing a Data-driven Decision Support Tool to Augment Complex Clinical Decisions
Authors: Tang Huang , Lipman Drew , Armstrong Rachel , Dempsey Dennis
Published: November 2023

Introduction

Medical readiness continues to be a significant concern for the military. DoD policy directs medical authorities to refer service members to the Disability Evaluation System (DES) when the course of further recovery is relatively predictable or within 1 year of diagnosis, whichever is sooner. The Medical Evaluation Readiness Information Toolset (MERIT) is an application that leverages artificial intelligence within a clinical decision support tool to provide clinicians with predictions of a service member’s likelihood of referral to the DES for the top 24 medical conditions that result in separation from the service, which represent more than 90% of all referral cases to the DES since 2000.

Materials and Methods

Data spanned 19 years and contained records for over 3 million army service members. The MERIT team incorporated a novel approach using a Gamma window function to weight recent medical data more than older medical data in the creation of a “Disease Severity Index” (DSI) that summarized the progression of a health deterioration process per medical condition code. Time-dependent medical encounter data were aggregated into an individual-level DSI. The identified features including the DSI were used in logistic regression and random forest models to predict whether a service member is likely to be referred to the DES. Models were constructed for each of the top 24 unfitting medical conditions.

Results

MERIT produced a set of high-performing classification models with area under the receiver operating characteristics curves across all conditions exceeding 0.919 using logistic regression for all conditions.

Conclusions

This project demonstrated with a high degree of accuracy that MERIT, using a combination of ICD codes and personnel records, can be used to develop an individual risk profile for each service member.
TCCC Decision Support With Machine Learning Prediction of Hemorrhage Risk, Shock Probability
Authors: Nemeth Christopher , Amos-Binks Adam , Rule Gregory , Laufersweiler Dawn , Keeney Natalie , Flint Isaac , Pinevich Yuliya , Herasevich Vitaly
Published: November 2023

Introduction

Expected future delays in evacuation during near-peer conflicts in remote locales are expected to require extended care including prolonged field care over hours to days. Such delays can increase potential complications, such as insufficient blood flow (shock), bloodstream infection (sepsis), internal bleeding (hemorrhage), and require more complex treatment beyond stabilization. The Trauma Triage Treatment and Training Decision Support (4TDS) system is a real-time decision support system to monitor casualty health and identify such complications. The 4TDS software prototype operates on an Android smart phone or tablet configured for use in the DoD Nett Warrior program. It includes machine learning models to evaluate trends in six vital signs streamed from a sensor placed on a casualty to identify shock probability, internal hemorrhage risk, and need for a massive transfusion.

Materials and Methods

The project team used a mixed methods approach to create and evaluate the system including literature review, rapid prototyping, design requirements review, agile development, an algorithm “silent test,” and usability assessments with novice to expert medics from all three services.

Results

Both models, shock (showing an accuracy of 0.83) and hemorrhage/massive transfusion protocol, were successfully validated using externally collected data. All usability assessment participants completed refresher training scenarios and were able to accurately assess a simulated casualty’s condition using the phone prototype. Mean responses to statements on evaluation criteria [e.g., fit with Tactical Combat Casualty Care (TCCC), ease of use, and decision confidence] fell at five or above on a 7-point scale, indicating strong support.

Conclusions

Participatory design ensured 4TDS and machine learning models reflect medic and clinician mental models and work processes and built support among potential users should the system transition to operational use. Validation results can support 4TDS readiness for FDA 510k clearance as a Class II medical device.
Acute Hearing Deficits associated with Weapons Exposure in Section 734 Blast Overpressure Study (BOS)
Authors: Kulinski Devon , Carr Walter , Garfield Bradley A , Salib Jonathan , Dirks Coral , Sheffield Benjamin , Brungart Douglas S
Published: November 2023

Introduction

This prospective, multi-site, observational study describes ongoing efforts in support of the Fiscal Year 2018 National Defense Authorization Act (NDAA) Section 734 Blast Overpressure Study (BOS) to identify the acute effects impulse and blast exposure have on hearing abilities of the Warfighter in various military training environments.

Materials and Methods

Hearing thresholds, a binaural tone detection task, and auditory symptoms were collected before and immediately following weapons exposure across nine military training environments from January 2020 to October 2022. An additional 25 non-exposed control participants also completed the behavioral test battery. A boothless audiometer was used to measure hearing ability in the field. Sound level meters were attached on-body to record the exposure environment throughout training.

Results

Mean threshold change for the blast-exposed group was worse than the control group. Of the 188 blast-exposed participants, 23 experienced a temporary threshold shift (TTS) acutely after exposure. A decrease in binaural tone detection performance and increased symptom severity was found when comparing blast-exposed participants with a TTS versus those without a significant change in hearing. A complex but consistent relationship between measured exposure level (LAeq8hr) and the magnitude of the resulting TTS is suggested in the available data.

Conclusions

Recent discussions on Section 734 studies examining the effects of repetitive blast exposure have indicated that hearing-related issues were a critical problem that needed additional research. Study outcomes provide highly repeatable results across various weapons systems with hazardous blast exposure. This standardized set of hearing assessment tools for evaluating acute effects of noise under field conditions has been critically important in improving our understanding of TTS in prospective human subject research.
US Soldiers’ Individual and Unit-level Factors Associated with Perceptions of Disinformation in the Military Context
Authors: Duffy Farifteh Firoozmand , McDonnell Gerald P , Auslander Margeaux V , Bricault Stephanie A , Kim Paul Y , Rachlin Nicholas W , Quartana Phillip J
Published: November 2023

Introduction

Although the US Government considers threats of misinformation, disinformation, and mal-information to rise to the level of terrorism, little is known about service members’ experiences with disinformation in the military context. We examined soldiers’ perceptions of disinformation impact on the Army and their units. We also investigated associations between disinformation perceptions and soldiers’ sociodemographic characteristics, reported use of fact-checking, and perceptions of unit cohesion and readiness

Methods

Active-duty soldiers (N = 19,465) across two large installations in the Southwest US completed an anonymous online survey

Results

Sixty-six percent of soldiers agreed that disinformation has a negative impact on the Army. Thirty-three percent of soldiers perceived disinformation as a problem in their unit. Females were more likely to agree that disinformation has a negative impact on the Army and is a problem in their unit. Higher military rank was associated with lower odds of agreeing that disinformation is a problem in units. Most soldiers were confident about their ability to recognize disinformation (62%) and reported using fact-checking resources (53%), and these factors were most often endorsed by soldiers who agreed that disinformation is a problem for the Army and their unit. Soldiers’ perceptions of unit cohesion and readiness were negatively associated with the perception that disinformation is a problem in their unit

Conclusion

While the majority of soldiers viewed disinformation as a problem across the Army, fewer perceived it as problematic within their units. Higher levels of reported fact-checking were most evident among those who perceived disinformation as a problem, suggesting that enhancing awareness of the problem of disinformation alone could help mitigate its deleterious impact. Perceptions of disinformation problems within units were associated with soldiers’ perceptions of lower unit cohesion and readiness, highlighting misinformation, disinformation, and mal-information’s impact on force readiness. Limitations and future directions are discussed.
The Adoption Problem and the Epistemology of Logic
Authors: Birman Romina
Published: November 2023

After introducing the adoption problem (AP) as the claim that certain basic logical principles cannot be adopted, I offer a characterization of this notion as a two-phase process consisting in (1) the acceptance of a basic logical principle, and (2) the development, in virtue of Phase 1, of a practice of inferring in accordance with that principle. The case of a subject who does not infer in accordance with universal instantiation is considered in detail. I argue that the AP has deep and wide implications for the epistemology of logic, extending well beyond Kripke’s original target, viz. Putnam’s proposal for the empirical revision of logic and its background Quinean epistemology. In particular, the AP questions whether basic logical principles could have a fundamental role in our inferential practices, drawing our attention to the nature of basic inferences and the need to have a clearer conception of them before taking a stand on the matter of the epistemic justification of the logical principles.