bluuebunny/crossref_metadata_2025 huggingface dataset:
Digital disconnection, digital inequality, and subjective well-being: a mobile experience sampling study
Authors: Nguyen Minh Hao , Hargittai Eszter
Published: November 2023

Drawing on theories of digital media (non-)use and well-being, this study examines how voluntary disconnection relates to subjective well-being and what role digital skills play in this relationship. We rely on mobile experience sampling methods to link nuanced disconnection practices throughout the day (e.g., putting screen devices away and muting notifications) with momentary experiences of well-being. We collected 4,028 responses from 105 mobile media users over the course of one week. Multilevel regression analyses revealed neither significant within-person effects of disconnection on affective well-being, social connectedness, or life satisfaction, nor a significant moderation effect of digital skills. Exploratory analyses, however, show that effects of disconnection on well-being vary greatly across participants, and that effects are dependent on whether one disconnects in the physical copresence of others. Our study offers a refined perspective on the consequences, or lack thereof, of deliberate non-use of technology in the digital age.
Symptom severity and trajectories among adolescent and young adult patients with cancer
Authors: Harper Andrew , Maseja Nicole , Parkinson Reilly , Pakseresht Mohammadreza , McKillop Sarah , Henning Jan-Willem , Watson Linda , Cuthbert Colleen , Cheung Winson , Fidler-Benaoudia Miranda M
Published: November 2023

Background

Patients with cancer experience significant symptom burden. We investigated symptom severity in adolescents and young adults (18- to 39-year-olds) during the year following a cancer diagnosis and made comparisons with older adult (those older than 40 years of age) patients with cancer.

Methods

All Albertan residents diagnosed with a first primary neoplasm at 18 years of age or older between April 1, 2018, and December 31, 2019, and who completed at least 1 electronic patient-reported outcome questionnaire were included. Symptom severity was assessed using the Edmonton Symptom Assessment System-revised. Descriptive statistics, multivariable logistic modeling, and mixed logistic regression modeling were used to describe symptom severity, identify risk factors, and assess symptom trajectories, respectively.

Results

In total, 473 and 322 adolescents and young adults completed a patient-reported outcomes questionnaire at diagnosis and 1 year after diagnosis, respectively. Adolescent and young adult patients with cancer reported high levels of tiredness, poor well-being, and anxiety. Important risk factors included metastatic disease, female sex, treatment types received, and age at diagnosis. Symptom severity varied by clinical tumor group, with those diagnosed with sarcoma having the worst scores for all symptoms at diagnosis and patients with intrathoracic or endocrine tumors having the worst scores for all symptoms at 1 year after diagnosis. Statistically significant differences in symptom severity over the 1-year period were observed between adolescents and young adults and older adults—specifically, the odds of having moderate to severe symptoms were statistically significantly greater among adolescents and young adults with respect to pain, tiredness, nausea, depression, anxiety, and poor well-being (all P < .01).

Conclusions

A substantial proportion of adolescents and young adults experience moderate to severe symptoms during the year following diagnosis. Modifying existing supportive services and developing interventions based on the needs of adolescent and young adult patients with cancer could aid symptom control.
A phase II clinical trial of frameless, fractionated stereotactic radiation therapy for brain metastases
Authors: Garg Amit K , Hernandez Mike , Schlembach Pamela J , Bowers John R , McAleer Mary F , Brown Paul D , Gopal Ramesh , Wiederhold Lee , Swanson Todd , Shah Shalin J , Li Jing , Ferguson Sherise D , Philip Nancy V , DeGracia Lilybeth , Bloom Elizabeth S , Chun Stephen G
Published: November 2023

Stereotactic radiation therapy yields high rates of local control for brain metastases, but patients in rural or suburban areas face geographic and socioeconomic barriers to its access. We conducted a phase II clinical trial of frameless, fractionated stereotactic radiation therapy for brain metastases in an integrated academic satellite network for patients 18 years of age or older with 4 or fewer brain metastases. Dose was based on gross tumor volume: less than 3.0 cm, 27 Gy in 3 fractions and 3.0 to 3.9 cm, 30 Gy in 5 fractions. Median follow-up was 10 months for 73 evaluable patients, with a median age of 68 years. Median intracranial progression-free survival was 7.1 months (95% confidence interval = 5.3 to not reached), and median survival was 7.2 months (95% confidence interval = 5.4 to not reached); there were no serious adverse events. Outcomes of this trial compare favorably with contemporary trials, and this treatment strategy provides opportunities to expand stereotactic radiation therapy access to underserved populations.
Black-White disparities in colorectal cancer outcomes: a simulation study of screening benefit
Authors: Rutter Carolyn M , Nascimento de Lima Pedro , Maerzluft Christopher E , May Folasade P , Murphy Caitlin C
Published: November 2023

The US Black population has higher colorectal cancer (CRC) incidence rates and worse CRC survival than the US White population, as well as historically lower rates of CRC screening. The Surveillance, Epidemiology, and End Results incidence rate data in people diagnosed between the ages of 20 and 45 years, before routine CRC screening is recommended, were analyzed to estimate temporal changes in CRC risk in Black and White populations. There was a rapid rise in rectal and distal colon cancer incidence in the White population but not the Black population, and little change in proximal colon cancer incidence for both groups. In 2014-2018, CRC incidence per 100 000 was 17.5 (95% confidence interval [CI] = 15.3 to 19.9) among Black individuals aged 40-44 years and 16.6 (95% CI = 15.6 to 17.6) among White individuals aged 40-44 years; 42.3% of CRCs diagnosed in Black patients were proximal colon cancer, and 41.1% of CRCs diagnosed in White patients were rectal cancer. Analyses used a race-specific microsimulation model to project screening benefits, based on life-years gained and lifetime reduction in CRC incidence, assuming these Black–White differences in CRC risk and location. The projected benefits of screening (via either colonoscopy or fecal immunochemical testing) were greater in the Black population, suggesting that observed Black–White differences in CRC incidence are not driven by differences in risk. Projected screening benefits were sensitive to survival assumptions made for Black populations. Building racial disparities in survival into the model reduced projected screening benefits, which can bias policy decisions.
Opportunities, challenges, and future directions for simulation modeling the effects of structural racism on cancer mortality in the United States: a scoping review
Authors: Jayasekera Jinani , El Kefi Safa , Fernandez Jessica R , Wojcik Kaitlyn M , Woo Jennifer M P , Ezeani Adaora , Ish Jennifer L , Bhattacharya Manami , Ogunsina Kemi , Chang Che-Jung , Cohen Camryn M , Ponce Stephanie , Kamil Dalya , Zhang Julia , Le Randy , Ramanathan Amrita L , Butera Gisela , Chapman Christina , Grant Shakira J , Lewis-Thames Marquita W , Dash Chiranjeev , Bethea Traci N , Forde Allana T
Published: November 2023

Purpose

Structural racism could contribute to racial and ethnic disparities in cancer mortality via its broad effects on housing, economic opportunities, and health care. However, there has been limited focus on incorporating structural racism into simulation models designed to identify practice and policy strategies to support health equity. We reviewed studies evaluating structural racism and cancer mortality disparities to highlight opportunities, challenges, and future directions to capture this broad concept in simulation modeling research.

Methods

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review Extension guidelines. Articles published between 2018 and 2023 were searched including terms related to race, ethnicity, cancer-specific and all-cause mortality, and structural racism. We included studies evaluating the effects of structural racism on racial and ethnic disparities in cancer mortality in the United States.

Results

A total of 8345 articles were identified, and 183 articles were included. Studies used different measures, data sources, and methods. For example, in 20 studies, racial residential segregation, one component of structural racism, was measured by indices of dissimilarity, concentration at the extremes, redlining, or isolation. Data sources included cancer registries, claims, or institutional data linked to area-level metrics from the US census or historical mortgage data. Segregation was associated with worse survival. Nine studies were location specific, and the segregation measures were developed for Black, Hispanic, and White residents.

Conclusions

A range of measures and data sources are available to capture the effects of structural racism. We provide a set of recommendations for best practices for modelers to consider when incorporating the effects of structural racism into simulation models.
Population simulation modeling of disparities in US breast cancer mortality
Authors: Mandelblatt Jeanne S , Schechter Clyde B , Stout Natasha K , Huang Hui , Stein Sarah , Hunter Chapman Christina , Trentham-Dietz Amy , Jayasekera Jinani , Gangnon Ronald E , Hampton John M , Abraham Linn , O’Meara Ellen S , Sheppard Vanessa B , Lee Sandra J
Published: November 2023

Background

Populations of African American or Black women have persistently higher breast cancer mortality than the overall US population, despite having slightly lower age-adjusted incidence.

Methods

Three Cancer Intervention and Surveillance Modeling Network simulation teams modeled cancer mortality disparities between Black female populations and the overall US population. Model inputs used racial group–specific data from clinical trials, national registries, nationally representative surveys, and observational studies. Analyses began with cancer mortality in the overall population and sequentially replaced parameters for Black populations to quantify the percentage of modeled breast cancer morality disparities attributable to differences in demographics, incidence, access to screening and treatment, and variation in tumor biology and response to therapy.

Results

Results were similar across the 3 models. In 2019, racial differences in incidence and competing mortality accounted for a net ‒1% of mortality disparities, while tumor subtype and stage distributions accounted for a mean of 20% (range across models = 13%-24%), and screening accounted for a mean of 3% (range = 3%-4%) of the modeled mortality disparities. Treatment parameters accounted for the majority of modeled mortality disparities: mean = 17% (range = 16%-19%) for treatment initiation and mean = 61% (range = 57%-63%) for real-world effectiveness.

Conclusion

Our model results suggest that changes in policies that target improvements in treatment access could increase breast cancer equity. The findings also highlight that efforts must extend beyond policies targeting equity in treatment initiation to include high-quality treatment completion. This research will facilitate future modeling to test the effects of different specific policy changes on mortality disparities.
Incidence of Suicidal Ideation and Suicide Attempt Based on Time in a Deployed Environment
Authors: Hall Andrew , Qureshi Iram , Meyer Eric G , Currier Glenn W , Castaneda Rebecca , Cardin Sylvain
Published: November 2023

Introduction

Knowing when suicidal ideation (SI) or suicide attempt (SA) is most likely to occur in a deployed environment would aid in focusing prevention efforts. This study aims to determine when evacuation for SA and SI is most likely to occur based on the absolute and relative number of months in a deployed setting.

Materials and Methods

This is a case–control study of active-duty military personnel evacuated from the U.S. Central Command area of responsibility for SI or an SA between April 1, 2020, and March 30, 2021. The arrival month and expected departure month were identified for all the included evacuees. The month of evacuation and proportion of completed deployment were compared. Secondary outcomes of mental health diagnosis or need for a waiver was also examined.

Results

A total of 138 personnel evacuated for SI or attempted suicide during the 12-month study period were included in the analysis. Evacuations occurring during month 3 of deployment were significantly higher (P < .0001) than those during other months. The 30% and 50% completion point of deployment had statistically higher frequencies of evacuations for SI/SA (<.0001). A secondary analysis revealed that 25.4% of the individuals had a documented preexisting behavioral health condition before deployment (P < .0001).

Conclusion

Specific points along a deployment timeline were significant predictors for being evacuated for SI and SA.
Portable Single-Exposure Dual-Energy X-ray Detector for Improved Point-of-Care Diagnostic Imaging
Authors: Karim Karim S , Tilley II Steven
Published: November 2023

Introduction

Dual-energy subtraction (DES) imaging is well known to reduce anatomical noise and enable material classification. The current approaches to DES imaging have trade-offs, such as motion artifacts, low sensitivity because of losses in a mid-filter, and lack of portability. Recently, a portable triple-layer flat-panel detector (FPD) was proposed for use in single-shot DES imaging that can provide improved sensitivity and removal of motion artifacts in a point-of-care setting. The purpose of this study is to evaluate the feasibility of such a detector. Various image quality metrics and clinical images are provided.

Materials and Methods

An FDA-cleared single-exposure DES FPD consisting of three stacked sensors was used for all measurements. This detector generates three images per exposure: A digital radiography (DR) image, i.e., as would be produced with a conventional detector, and two DES images, bone and soft tissue. To evaluate DR image quality, detective quantum efficiency (DQE) and modulation transfer function were measured for multiple radiation quality beams. Digital radiography and DES images obtained from this FPD were evaluated in previously reported fixed and portable clinical studies. Digital radiography and DES images from case studies are presented for qualitative assessment.

Results

Modulation transfer function and DQE were measured across multiple radiation quality beams for the DR image. The DES images showed good tissue separation and uniformity with no visible motion or alignment artifacts. The DES images, when read in conjunction with the DR image, resulted in increased reader confidence and revealed abnormalities or details that were sometimes overlooked in the DR image.

Conclusions

The proposed panel produces high-quality DR images as indicated by the DQE and modulation transfer function. The DES images have been shown to improve sensitivity in clinical applications and increase reader confidence. This detector can enable DES in portable or otherwise difficult applications, opening new doors for improved patient care.
Exposomic Signatures of Tinnitus and/or Hearing Loss
Authors: Maldonado Carlos J , White-Phillip Jessica A , Liu Yuliang , Erbele Isaac D , Choi Y. Sammy
Published: November 2023

Introduction

We evaluated the risk factors associated with tinnitus and/or hearing loss (THL) among active duty (AD) members of the U.S. Army and Marine Aviation Community (AMAC) using an exposomic approach. Specifically, we aimed to determine the factors associated with the reported THL in the Military Health System.

Methods

Longitudinal data were obtained from the Medical Assessment and Readiness System housed at Womack Army Medical Center, Fort Bragg, NC, for a retrospective cohort study that included 78,546 AD AMAC members from October 2015 to December 2019. Multivariable mixed-effects logistic regression was used to assess the relationship between THL and numerous variables to include rank, service time, deployment, tobacco use, alcohol use, age, gender, race, ethnicity, and body mass index.

Results

Our analysis included a total of 220,044 person-years of observations. The THL incidence rate was 6.7 per 100 person-years, with an 8.1% period prevalence. THL was associated with age, gender, body mass index, race, deployment, service time, marital status, and tobacco use (all P < .05). Service time greater than 16 years had the greatest odds ratio of THL (4.46, 95% CI: 3.58-5.55, P < .001).

Conclusions

Our assessment shows the utility of using an exposomic approach to create member-specific personalized clinical algorithms for health outcomes. We examined individuals with THL diagnoses and identified a combination of risk factors from biomedical, lifestyle, environmental, and stochastic sources. Taken together, the risk factors identified across the four exposomic domains could help understand the etiology of THL. Our exposomic methodology could be the foundation for generating predictive models. Finally, a specific evaluation of occupational risk factors may provide insight into aspects not readily available from civilian literature. In upcoming years, as the Medical Assessment and Readiness System matures, we will expand our analyses to include prospective, untargeted metabolites and biomarker data.
Trauma THOMPSON: Clinical Decision Support for the Frontline Medic
Authors: Birch Eleanor , Couperus Kyle , Gorbatkin Chad , Kirkpatrick Andrew W , Wachs Juan , Candelore Ross , Jiang Nina , Tran Oanh , Beck Jonah , Couperus Cody , McKee Jessica , Curlett Timothy , DeVane DeAnna , Colombo Christopher
Published: November 2023

Introduction

U.S. Military healthcare providers increasingly perform prolonged casualty care because of operations in settings with prolonged evacuation times. Varied training and experience mean that this care may fall to providers unfamiliar with providing critical care. Telemedicine tools with audiovisual capabilities, artificial intelligence (AI), and augmented reality (AR) can enhance inexperienced personnel’s competence and confidence when providing prolonged casualty care. Furthermore, implementing offline functionality provides assistance options in communications-limited settings. The intent of the Trauma TeleHelper for Operational Medical Procedure Support and Offline Network (THOMPSON) is to develop (1) a voice-controlled mobile application with video references for procedural guidance, (2) audio narration of each video using procedure mentoring scripts, and (3) an AI-guided intervention system using AR overlay and voice command to create immersive video modeling. These capabilities will be available offline and in downloadable format.

Materials and Methods

The Trauma THOMPSON platform is in development. Focus groups of subject matter experts will identify appropriate procedures and best practices. Procedural video recordings will be collected to develop reference materials for the Trauma THOMPSON mobile application and to train a machine learning algorithm on action recognition and anticipation. Finally, an efficacy evaluation of the application will be conducted in a simulated environment.

Results

Preliminary video collection has been initiated for tube thoracostomy, needle decompression, cricothyrotomy, intraosseous access, and tourniquet application. Initial results from the machine learning algorithm show action recognition and anticipation accuracies of 20.1% and 11.4%, respectively, in unscripted datasets “in the wild,” notably on a limited dataset. This system performs over 100 times better than a random prediction.

Conclusions

Developing a platform to provide real-time, offline support will deliver the benefits of synchronous expert advice within communications-limited and remote environments. Trauma THOMPSON has the potential to fill an important gap for clinical decision support tools in these settings.
Cognitive Task Analysis of Escharotomy
Authors: Lee Hanna , Rahul FNU , Makled Basiel , Parsey Conner , Norfleet Jack , De Suvranu
Published: November 2023

Introduction

With the Army’s emerging doctrine of prolonged field care, and with burns being a common injury among soldiers, non-expert providers must be trained to perform escharotomy when indicated. However, the existing physical simulators and training protocols are not sufficient for training non-experts for performing effective escharotomy. Hence, to provide guidance in developing realistic escharotomy simulators and effective training protocols suitable for prolonged field care, a cognitive task analysis (CTA) is needed. This work aims to obtain educative information from expert burn surgeons regarding escharotomy procedures via the CTA.

Materials and methods

The CTA was done by interviewing five subject matter experts with experience in performing escharotomy ranging from 20 to over 100 procedures and analyzing their responses. Interview questions were developed to obtain educative information from expert burn surgeons regarding the escharotomy procedure. A “gold standard protocol” was developed based on the CTA of each of the subject matter experts.

Results

The CTA helped identify general themes, including objectives, conditions that mandate escharotomy, signs of successful escharotomy, precautions, challenges, decisions, and performance standards, and specific learning goals such as the use of equipment, vital signs, performing the procedure, and preoperative and postoperative care. A unique aspect of this CTA is that it identifies the background information and preparations that could be useful to the practitioners at various levels of expertise.

Conclusions

The CTA enabled us to compile a “gold standard protocol” for escharotomy that may serve as a guide for practitioners at various levels of expertise. This information will provide a framework for escharotomy training systems and simulators.
Ruggedized Self-Propelling Hemostatic Gauze Delivers Low Dose of Thrombin and Systemic Tranexamic Acid and Achieves High Survival in Swine With Junctional Hemorrhage
Authors: Ali-Mohamad Nabil , Cau Massimo F , Wang Xu , Khavari Adele , Ringgold Kristyn , Naveed Asad , Sherwood Christopher , Peng Nuoya , Zhang Gao Han , Zhang Youjie , Semple Hugh , Peng Henry , Tenn Catherine , Baylis James R , Beckett Andrew , White Nathan J , Kastrup Christian J
Published: November 2023

Introduction

Hemorrhage is responsible for 91% of preventable prehospital deaths in combat. Bleeding from anatomic junctions such as the groin, neck, and axillae make up 19% of these deaths, and reports estimate that effective control of junctional hemorrhage could have prevented 5% of fatalities in Afghanistan. Hemostatic dressings are effective but are time-consuming to apply and are limited when proper packing and manual pressure are not feasible, such as during care under fire. CounterFlow-Gauze is a hemostatic dressing that is effective without compression and delivers thrombin and tranexamic acid into wounds. Here, an advanced prototype of CounterFlow-Gauze, containing a range of low thrombin doses, was tested in a lethal swine model of junctional hemorrhage. Outcomes were compared with those of Combat Gauze, the current dressing recommended by Tactical Combat Casualty Care.

Materials and Methods

CounterFlow-Gauze containing thrombin doses of 0, 20, 200, and 500 IU was prepared. Swine received femoral arteriotomies, and CounterFlow-Gauze was packed into wounds without additional manual compression. In a separate study using a similar model of junctional hemorrhage without additional compression, CounterFlow-Gauze containing 500 IU thrombin was tested and compared with Combat Gauze. In both studies, the primary outcomes were survival to 3 h and volume of blood loss.

Results

CounterFlow-Gauze with 200 and 500 IU had the highest 3-h survival, achieving 70 and 75% survival, respectively. CounterFlow-Gauze resulted in mean peak plasma tranexamic acid concentrations of 9.6 ± 1.0 µg/mL (mean ± SEM) within 3 h. In a separate study with smaller injury, CounterFlow-Gauze with 500 IU achieved 100% survival to 3 h compared with 92% in Combat Gauze animals.

Conclusions

An advanced preclinical prototype of CounterFlow-Gauze formulated with a minimized thrombin dose is highly effective at managing junctional hemorrhage without compression. These results demonstrate that CounterFlow-Gauze could be developed into a feasible alternative to Combat Gauze for hemorrhage control on the battlefield.
Seasonality of Microbiology of Combat-Related Wounds and Wound Infections in Afghanistan
Authors: Soderstrom Matthew A , Blyth Dana M , Carson M Leigh , Campbell Wesley R , Yabes Joseph M , Shaikh Faraz , Stewart Laveta , Tribble David R , Murray Clinton K , Kiley John L
Published: November 2023

Introduction

Battlefield-related wound infections are a significant source of morbidity among combat casualties. Seasonality of these infections was demonstrated in previous conflicts (e.g., Korea) but has not been described with trauma-related health care–associated infections from the war in Afghanistan.

Methods

The study population included military personnel wounded in Afghanistan (2009-2014) medevac’d to Landstuhl Regional Medical Center and transitioned to participating military hospitals in the United States with clinical suspicion of wound infections and wound cultures collected ≤7 days post-injury. Analysis was limited to the first wound culture from individuals. Infecting isolates were collected from skin and soft-tissue infections, osteomyelitis, and burn soft-tissue infections. Data were analyzed by season (winter [ December 1-February 28/29], spring [March 1-May 31], summer [June 1-August 31], and fall [September 1-November 30]).

Results

Among 316 patients, 297 (94.0%) sustained blast injuries with a median injury severity score and days from injury to initial culture of 33 and 3.5, respectively. Although all patients had a clinical suspicion of a wound infection, a diagnosis was confirmed in 198 (63%) patients. Gram-negative bacilli (59.5% of 316) were more commonly isolated from wound cultures in summer (68.1%) and fall (67.1%) versus winter (43.9%) and spring (45.1%; P < .001). Multidrug-resistant (MDR) Gram-negative bacilli (21.8%) were more common in summer (21.8%) and fall (30.6%) versus winter (7.3%) and spring (19.7%; P = .028). Findings were similar for infecting Gram-negative bacilli (72.7% of 198)—summer (79.5%) and fall (83.6%; P = .001)—and infecting MDR Gram-negative bacilli (27.3% of 198)—summer (25.6%) and fall (41.8%; P = .015). Infecting anaerobes were more common in winter (40%) compared to fall (11%; P = .036). Gram-positive organisms were not significantly different by season.

Conclusion

Gram-negative bacilli, including infecting MDR Gram-negative bacilli, were more commonly recovered in summer/fall months from service members injured in Afghanistan. This may have implications for empiric antibiotic coverage during these months.
Confidence and Utilization are Poorly Associated with Point-of-Care Ultrasound Competency among Internal Medicine Trainees
Authors: Elliott Brian P , Berglund Andrew , Markert Ronald , Burtson Kathryn
Published: November 2023

Introduction

Point-of-Care Ultrasound (POCUS) is the utilization of bedside ultrasound by clinicians. Its portable and rapid diagnostic capabilities make it an excellent tool for deployment and mobile military settings. However, formal and uniform POCUS training is lacking. Furthermore, the evaluation of these curricula often relies on confidence assessment. Our objective was to assess the relationships between confidence, frequency of utilization, and image interpretation knowledge among our Internal Medicine residents before and after the implementation of a formal curriculum.

Materials and Methods

In November 2020, we implemented a longitudinal, flipped-classroom, academic half-day curriculum, conducting a prospective before-after cohort evaluation of its implementation. The POCUS curriculum was implemented as a longitudinal, asynchronous, flipped-classroom activity with workshop sessions during one academic half-day per month. We measured confidence via a Likert scale and utilization frequency via a five-point scale. Six multiple-choice questions (MCQ) with ultrasound videos assessed image interpretation competency. The image interpretation score was reported as percent correct. We related confidence and utilization to the image interpretation score.

Results

Ninety-nine residents were eligible for participation. Fifty-four (55%) completed a pre-curriculum assessment and 45 (45%) completed a post-curriculum assessment. Average image interpretation scores were 41% pre-curriculum and 51% post-curriculum (P =0.02). Pre-curriculum residents were on average unconfident (mean=2.56), and post-curriculum residents were on average confident (mean=3.62). Pre-curriculum residents used POCUS occasionally (mean=2.02, count 13 (24%) never utilizing). Post-curriculum residents used POCUS occasionally (mean=2.42, count 4 (9%) never utilizing). Pre- and post-curriculum confidence were not significantly associated with image interpretation scores (pre-curriculum: r=−0.10, P =0.50; post-curriculum: r=0.24, P =0.11). Pre- and post-curriculum utilization were not significantly associated with image interpretation scores (pre-curriculum: r=0.15, P =0.28; post-curriculum: r=0.02, P =0.90). The number of curriculum sessions attended was significantly associated with higher image interpretation scores (r=0.30, P =0.003).

Conclusions

Our study suggests that POCUS confidence and informal utilization do not correlate with image interpretation knowledge on MCQs among Internal Medicine residents. These findings support assessing direct measures of knowledge, rather than confidence, as an endpoint in evaluating POCUS curricula among Internal Medicine residents.
Innovative Curriculum to Train Medical Students on Lateral Canthotomy and Cantholysis
Authors: McMurray Haana , Lewis Jason R , Brundridge Wesley L , Jeyarajah Theepica , Raiciulescu Sorana , Lopreiato Joseph , Chou Eva
Published: November 2023

Purpose

Orbital compartment syndrome (OCS) is an ocular emergency requiring prompt decompression with a lateral canthotomy and cantholysis (LCC) within 2 hours. This study evaluates the feasibility and effectiveness of a standardized LCC curriculum to train medical students to identify and treat OCS.

Methods

This was a prospective, non-randomized, non-comparative cohort study of 39 novice first-year medical students with no prior LCC training who underwent a standardized LCC curriculum incorporating both didactic and hands-on procedural training. Didactic knowledge of orbital anatomy and OCS was evaluated with written pre- and post-knowledge testing. Expert performance criteria were determined by expert consensus based on the performance of three oculoplastic surgeons and were defined as correctly performing all 12 critical checklist steps of an LCC within 3 minutes twice consecutively on a Sonalyst LCC training system eye model. Utilizing the principles of mastery learning, participants learned how to perform an LCC in a classroom environment and were evaluated on a final test of proficiency in a training lane designed to simulate an austere military environment.

Results

Participants required a median of 3.0 practice iterations to achieve expert performance in the classroom environment. During the testing phase, all participants correctly identified the eye with OCS, and 77% (n = 30) of learners successfully performed an LCC at the expert level within their first attempt. The median completion time of those who passed on their first testing was 130 seconds. The mean LCC knowledge test scores significantly improved from 48.7% to 71.2% (P < .001).

Conclusion

This study successfully developed a standardized LCC curriculum utilizing the principles of hands-on mastery learning to train novice learners to perform an LCC efficiently and effectively.
Subaxial Cervical Spine Motion With Different Sizes of Head-supported Mass Under Accelerative Forces
Authors: Choi Hoon , Purushothaman Yuvaraj , Gupta Bhavika , Banerjee Anjishnu , Yoganandan Narayan
Published: November 2023

Introduction

The evolution of military helmet devices has increased the amount of head-supported mass (HSM) worn by warfighters. HSM has important implications for spine biomechanics, and yet, there is a paucity of studies that investigated the effects of differing HSM and accelerative profiles on spine biomechanics. The aim of this study is to investigate the segmental motions in the subaxial cervical spine with different sizes of HSM under Gx accelerative loading.

Methods

A three-dimensional finite element model of the male head-neck spinal column was used. Three different size military helmets were modeled and incorporated into head–neck model. The models were exercised under Gx accelerative loading by inputting low and high pulses to the cervical vertebra used in the experimental studies. Segmental motions were obtained and normalized with respect to the non-HSM case to quantify the effect of HSM.

Results

Segmental motions increased with an increase in velocity at all segments of the spine. Increasing helmet size resulted in larger motion increases. Angulations ranged from 0.9° to 9.3° at 1.8 m/s and from 1.3° to 10.3° at 2.6 m/s without a helmet. Helmet increased motion between 5% to 74% at 1.8 m/s. At 2.6 m/s, the helmet increased segmental motion anywhere from 10% to 105% in the subaxial cervical spine. The greatest motion was seen at the C5-C6 level, followed by the C6-C7 level.

Conclusions

The subaxial cervical spine experiences motion increases at all levels at both velocity profiles with increasing HSM. Larger helmet and greater impact velocity increased motion at all levels, with C5-C6 demonstrating the largest range of motion. HSM should be minimized to reduce the risk of cervical spine injury to the warfighter.
Increasing Hearing Readiness Using Boothless Audiometry
Authors: Sheffield Benjamin , Kulinski Devon , Schurman Jaclyn , Sherlock LaGuinn , Bugtong Victoria , Spencer Michele , Caldwell Christopher , Brungart Douglas , Merkley John , Blank Amy
Published: November 2023

Introduction

U.S. Army regulations require all soldiers to undergo annual audiometric testing to maintain hearing readiness. The standard method of monitoring hearing in the DoD is via multi-person testing in sound-treated booths using the Defense Occupational and Environmental Health Readiness System—Hearing Conservation. COVID-19 significantly hindered the standard method, resulting in alarming declines in hearing readiness. In response, the Army Hearing Program initiated a pilot program to use boothless audiometers to supplement standard methods to increase hearing readiness.

Materials and Methods

Funding from the Coronavirus Aid, Relief, and Economic Security Act was used to purchase 169 boothless audiometers and increase staffing at dozens of Army Hearing Program clinics. Standard operating procedures were established for audiometric testing outside the booth using a process matching standard test parameters (i.e., test frequencies, tone characteristics, and interstimulus intervals). Additional capabilities developed to leverage this new technology during the annual hearing exam include the administration of automated contralateral masking, enhanced tinnitus screening, and hearing health education and training.

Results

Monitoring audiometry using boothless audiometers has been conducted for nearly 12,000 service members worldwide. Thresholds obtained via boothless audiometers are comparable to follow-up thresholds obtained from the standard test methods in the booth (mean difference 95% CI, −1.2, 0.9), and hearing readiness has returned to pre-pandemic levels at installations where this novel technology is being used regularly.

Conclusions

Significant reductions in patient encounters as a direct result of the COVID-19 pandemic have led to innovative solutions leveraging boothless audiometers. While this has aided the primary mission to maintain a medically ready force, innovations from this endeavor highlight several additional improvements relative to current standards of care that should be considered for permanent inclusion in DoD Hearing Conservation Programs.
Mitigation of Hearing Damage With Liraglutide Treatment in Chinchillas After Repeated Blast Exposures at Mild-TBI
Authors: Jiang Shangyuan , Sanders Sarah , Gan Rong Z
Published: November 2023

Introduction

Although hearing protection devices (HPDs) have been widely used during training and combat, over one million veterans experience service-connected hearing loss. Hearing damage has been reported to be associated with blast-induced mild traumatic brain injury (mTBI) and there is a lack of understanding and treatment. Liraglutide is a glucagon-like peptide-1 receptor agonist and a potential treatment for TBI-induced memory deficits. This study aims to investigate the function of the liraglutide to prevent damage and facilitate hearing restoration in chinchillas exposed to multiple high-intensity, mTBI-level blasts.

Materials and Methods

Chinchillas were divided into three treatment groups: blast control, pre-blast drug treatment, and post-blast drug treatment. On day 1, the chinchilla ears were protected by HPDs and exposed to three blasts with peak pressure levels of 15–25 psi. The auditory brainstem response (ABR), distortion product otoacoustic emission (DPOAE), and middle latency response (MLR) were recorded pre- and post-blast on day 1 and on days 4, 7, 14, and 28.

Results

Substantial acute damage was observed and progressively recovered in chinchillas after the blast exposures. The pre-blast treatment group exhibited the lowest elevation of the ABR threshold and reduction of the wave I amplitude on day 1 after blasts. The liraglutide treatment insignificantly facilitated the recovery of the DPOAE levels and ABR thresholds on days 14 and 28. The pre-blast treatment chinchillas showed reduced MLR amplitudes on days 4 and 7.

Conclusions

This study indicated that the pre-blast liraglutide administration provided damage protection against blasts in addition to the HPDs. Current evidence suggests that the effect of liraglutide is more prominent in the early phase of the experiment.
Opioid-Related Trends in Active Duty Service Members During the Coronavirus Disease 2019 Pandemic
Authors: Sorensen Ian S , Susi Apryl , Andreason Paul , Hisle-Gorman Elizabeth , Jannace Kalyn C , Krishnamurthy Jayasree , Chokshi Binny , Dorr Madeline , Wolfgang Aaron S , Nylund Cade M
Published: November 2023

Introduction

The USA is experiencing an opioid epidemic. Active duty service members (ADSMs) are at risk for opioid use disorder (OUD). The Coronavirus disease 2019 (COVID-19) pandemic has disrupted health care and introduced additional stressors.

Methods

The Military Healthcare System Data Repository was used to evaluate changes in diagnosis of OUD, medications for OUD (MOUD), opioid overdose (OD), and opioid rescue medication. ADSMs ages 18-45 years enrolled in the Military Healthcare System between February 2019 and April 2022 were included. Joinpoint Trend Analysis Software calculated the average monthly percent change over the study period, whereas Poisson regression compared outcomes over three COVID-19 periods: Pre-lockdown (pre-COVID-19 period 0) (February 2019-February 2020), early pandemic until ADSM vaccination initiation (COVID-19 period 1 [CP1]) (March 2020-November 2020), and late pandemic post-vaccination initiation (COVID-19 period 2 [CP2]) (December 2020-April 2022).

Results

A total of 1.86 million eligible ADSMs received care over the study period. Diagnoses of OUD decreased 1.4% monthly, MOUD decreased 0.6% monthly, diagnoses of opioid OD did not change, and opioid rescue medication increased 8.5% monthly.

Diagnoses of OUD decreased in both COVID-19 time periods: CP1 and CP2: Rate ratio (RR) = 0.74 (95% CI, 0.68-0.79) and RR = 0.72 (95% CI, 0.67-0.76), respectively. MOUD decreased in both CP1 and CP2: RR = 0.77 (95% CI, 0.68-0.88) and RR = 0.86 (95% CI, 0.78-0.96), respectively. Adjusted rates for diagnoses of opioid OD did not vary in either COVID-19 time period. Opioid rescue medication prescriptions increased in CP1 and CP2: RR = 1.09 (95% CI, 1.02-1.15) and RR = 6.02 (95% CI, 5.77-6.28), respectively.

Conclusions

Rates of OUD and MOUD decreased, whereas rates of opioid rescue medication increased during the study period. Opioid OD rates did not significantly change in this study. Changes in the DoD policy may be affecting rates with greater effect than COVID-19 pandemic effects.
Cohesion Assessment Team: A Multidisciplinary Unit Assessment Grounded in Army Doctrine
Authors: Crouch Coleen L , Teegarden Lisa A , Davis Jason , Adrian Amanda L , Knust Susannah K
Published: November 2023

Introduction

The Cohesion Assessment Team (CAT) provides battalion and brigade command teams with actionable insight into the climate of their unit and the presence of certain harmful behaviors. This assessment, initiated by the Vice Chief of Staff of the Army and initially managed by the Headquarters Department of the Army’s People First Task Force, employs a framework from the Center for Army Professional Leadership to structure data and findings.

Materials and Methods

This manuscript describes how to conduct a CAT assessment. To start, two battalions within the same brigade are selected or volunteer for observation based on various metrics. Data are collected from multiple sources including (1) army metrics, such as promotion rates and Uniformed Code of Military Justice actions, (2) subject matter expert in-person observations and interactions, (3) discussions with battalion and brigade staff, (4) survey data from approximately 90% of the soldiers in participating units, and (5) targeted interviews, focus groups, and listening sessions. Onsite data are collected and synthesized with the survey results within a week. Results are presented to battalion and brigade command teams. Briefs highlight key elements of the unit climate that should be maintained or improved. In addition, summarized results are presented to progressively higher echelons of leadership, culminating with the Vice Chief of Staff of the Army for consideration of army-wide changes.

Results and Conclusions

The CAT focuses on providing leaders at brigade and below with relevant and actionable information to help inform their internal decision-making to improve their unit’s climate. This capability is distinct in many ways, including its non-attributional systems focus and its methodical approach to quickly collecting and triangulating multiple data points. Additionally, the CAT helps leaders identify areas under their control that will impact unit climate, similar to the feedback that training events provide on unit readiness. Army leadership deemed the CAT pilot a success, and responsibility for future CATs was transferred to the Training and Doctrine Command (TRADOC) in October 2022.
Prompt gamma-ray burst emission from internal shocks – new insights
Authors: Rahaman S k Minhajur , Granot Jonathan , Beniamini Paz
Published: November 2023

Internal shocks are a leading candidate for the dissipation mechanism that powers the prompt γ-ray emission in gamma-ray bursts (GRBs). In this scenario a compact central source produces an ultra-relativistic outflow with varying speeds, causing faster parts or shells to collide with slower ones. Each collision produces a pair of shocks – a forward shock (FS) propagating into the slower leading shell and a reverse shock (RS) propagating into the faster trailing shell. The RS’s lab-frame speed is always smaller, while the RS is typically stronger than the FS, leading to different conditions in the two shocked regions that both contribute to the observed emission. We show that optically thin synchrotron emission from both (weaker FS + stronger RS) can naturally explain key features of prompt GRB emission such as the pulse shapes, time evolution of the νFν peak flux and photon energy, and the spectrum. Particularly, it can account for two features commonly observed in GRB spectra: (i) a sub-dominant low-energy spectral component (often interpreted as ‘photospheric’-like), or (ii) a doubly broken power-law spectrum with the low-energy spectral slope approaching the slow-cooling limit. Both features can be obtained while maintaining high-overall radiative efficiency without any fine tuning of the physical conditions.
SnapKin: a snapshot deep learning ensemble for kinase-substrate prediction from phosphoproteomics data
Authors: Xiao Di , Lin Michael , Liu Chunlei , Geddes Thomas A , Burchfield James G , Parker Benjamin L , Humphrey Sean J , Yang Pengyi
Published: November 2023

A major challenge in mass spectrometry-based phosphoproteomics lies in identifying the substrates of kinases, as currently only a small fraction of substrates identified can be confidently linked with a known kinase. Machine learning techniques are promising approaches for leveraging large-scale phosphoproteomics data to computationally predict substrates of kinases. However, the small number of experimentally validated kinase substrates (true positive) and the high data noise in many phosphoproteomics datasets together limit their applicability and utility. Here, we aim to develop advanced kinase-substrate prediction methods to address these challenges. Using a collection of seven large phosphoproteomics datasets, and both traditional and deep learning models, we first demonstrate that a ‘pseudo-positive’ learning strategy for alleviating small sample size is effective at improving model predictive performance. We next show that a data resampling-based ensemble learning strategy is useful for improving model stability while further enhancing prediction. Lastly, we introduce an ensemble deep learning model (‘SnapKin’) by incorporating the above two learning strategies into a ‘snapshot’ ensemble learning algorithm. We propose SnapKin, an ensemble deep learning method, for predicting substrates of kinases from large-scale phosphoproteomics data. We demonstrate that SnapKin consistently outperforms existing methods in kinase-substrate prediction. SnapKin is freely available at https://github.com/PYangLab/SnapKin.
Four decades of full-scale nitrous oxide emission inventory in China
Authors: Liang Minqi , Zhou Zheyan , Ren Peiyang , Xiao Han , Xu-Ri  , Hu Zhongmin , Piao Shilong , Tian Hanqin , Tong Qing , Zhou Feng , Wei Jing , Yuan Wenping
Published: November 2023

China is among the top nitrous oxide (N2O)-emitting countries, but existing national inventories do not provide full-scale emissions including both natural and anthropogenic sources. We conducted a four-decade (1980–2020) of comprehensive quantification of Chinese N2O inventory using empirical emission factor method for anthropogenic sources and two up-to-date process-based models for natural sources. Total N2O emissions peaked at 2287.4 (1774.8–2799.9) Gg N2O yr−1 in 2018, and agriculture-developed regions, like the East, Northeast, and Central, were the top N2O-emitting regions. Agricultural N2O emissions have started to decrease after 2016 due to the decline of nitrogen fertilization applications, while, industrial and energetic sources have been dramatically increasing after 2005. N2O emissions from agriculture, industry, energy, and waste represented 49.3%, 26.4%, 17.5%, and 6.7% of the anthropogenic emissions in 2020, respectively, which revealed that it is imperative to prioritize N2O emission mitigation in agriculture, industry, and energy. Natural N2O sources, dominated by forests, have been steadily growing from 317.3 (290.3–344.1) Gg N2O yr−1 in 1980 to 376.2 (335.5–407.2) Gg N2O yr−1 in 2020. Our study produces a Full-scale Annual N2O dataset in China (FAN2020), providing emergent counting to refine the current national N2O inventories.