Heat exhaustion and heat stroke among active component members of the U.S. Armed Forces, 2019-2023.

The most serious types of heat illnesses, heat exhaustion and heat stroke, are occupational hazards associated with many of the military's training and operational environments. These illnesses can typically be prevented by appropriate situational awareness, risk management strategies, along with effective countermeasures. In 2023, the crude incidence of heat stroke and heat exhaustion were 31.7 and 172.7 cases per 100,000 person-years, respectively. The rates of incident heat stroke declined during the 2019 to 2023 surveillance period, but rates of incident heat exhaustion increased over the same period. In 2023, higher rates of heat stroke were observed among male service members compared to their female counterparts, and female service members experienced higher rates of heat exhaustion compared to male personnel. Heat illness rates were also higher among those younger than age 20, Marine Corps and Army service members, non-Hispanic Black service members, and recruits. Leaders, training cadres, and supporting medical and safety personnel must inform their subordinate and supported service members of heat illness risks, preventive measures, early signs and symptoms of illness, and appropriate interventions.

Healthcare team resilience during COVID-19: a qualitative study.

BACKGROUND: Resilience, in the field of Resilience Engineering, has been identified as the ability to maintain the safety and the performance of healthcare systems and is aligned with the resilience potentials of anticipation, monitoring, adaptation, and learning. In early 2020, the COVID-19 pandemic challenged the resilience of US healthcare systems due to the lack of equipment, supply interruptions, and a shortage of personnel. The purpose of this qualitative research was to describe resilience in the healthcare team during the COVID-19 pandemic with the healthcare team situated as a cognizant, singular source of knowledge and defined by its collective identity, purpose, competence, and actions, versus the resilience of an individual or an organization. METHODS: We developed a descriptive model which considered the healthcare team as a unified cognizant entity within a system designed for safe patient care. This model combined elements from the Patient Systems Engineering Initiative for Patient Safety (SEIPS) and the Advanced Team Decision Making (ADTM) models. Using a qualitative descriptive design and guided by our adapted model, we conducted individual interviews with healthcare team members across the United States. Data were analyzed using thematic analysis and extracted codes were organized within the adapted model framework. RESULTS: Five themes were identified from the interviews with acute care professionals across the US (N = 22): teamwork in a pressure cooker, consistent with working in a high stress environment; healthcare team cohesion, applying past lessons to present challenges, congruent with transferring past skills to current situations; knowledge gaps, and altruistic behaviors, aligned with sense of duty and personal responsibility to the team. Participants' described how their ability to adapt to their environment was negatively impacted by uncertainty, inconsistent communication of information, and emotions of anxiety, fear, frustration, and stress. Cohesion with co-workers, transferability of skills, and altruistic behavior enhanced healthcare team performance. CONCLUSION: Working within the extreme unprecedented circumstances of COVID-19 affected the ability of the healthcare team to anticipate and adapt to the rapidly changing environment. Both team cohesion and altruistic behavior promoted resilience. Our research contributes to a growing understanding of the importance of resilience in the healthcare team. And provides a bridge between individual and organizational resilience.

Insights for precision oncology from the integration of genomic and clinical data of 13,880 tumors from the 100,000 Genomes Cancer Programme.

The Cancer Programme of the 100,000 Genomes Project was an initiative to provide whole-genome sequencing (WGS) for patients with cancer, evaluating opportunities for precision cancer care within the UK National Healthcare System (NHS). Genomics England, alongside NHS England, analyzed WGS data from 13,880 solid tumors spanning 33 cancer types, integrating genomic data with real-world treatment and outcome data, within a secure Research Environment. Incidence of somatic mutations in genes recommended for standard-of-care testing varied across cancer types. For instance, in glioblastoma multiforme, small variants were present in 94% of cases and copy number aberrations in at least one gene in 58% of cases, while sarcoma demonstrated the highest occurrence of actionable structural variants (13%). Homologous recombination deficiency was identified in 40% of high-grade serous ovarian cancer cases with 30% linked to pathogenic germline variants, highlighting the value of combined somatic and germline analysis. The linkage of WGS and longitudinal life course clinical data allowed the assessment of treatment outcomes for patients stratified according to pangenomic markers. Our findings demonstrate the utility of linking genomic and real-world clinical data to enable survival analysis to identify cancer genes that affect prognosis and advance our understanding of how cancer genomics impacts patient outcomes.

Active Surveillance for Acute Respiratory Disease Detected No Outbreaks at Four U.S. Army Basic Training Installations in 2022.

Abstract: A total of 254 febrile acute respiratory disease (ARD) cases were identified among Army basic trainees in 2022. No Army basic training installations met the definition for an ARD or Group A Beta-Hemolytic Streptococcus outbreak in 2022. The inclusion of afebrile ARD data in the surveillance program identified an additional 1,696 cases in which a trainee met the criteria for a case of ARD, except for an oral temperature of 100.5°F or higher. While including afebrile cases in the ARD rate calculation did result in an overall increase in weekly ARD rates, no basic training installations met the MEDCOM definition for an ARD outbreak. The continued surveillance and implementation of interventions such as chemoprophylaxis, vaccination, and non-pharmacologic interventions (e.g. hand-washing, head-to-toe sleeping bunk arrangement, etc.) helped identify and potentially prevent ARD outbreaks. What are the new findings?: In 2022, no ARD outbreaks were identified at any U.S. Army basic training installations, according to the U.S. Army's Medical Com-mand (MEDCOM) definition. This marks the third consecutive year without an ARD outbreak at these installations. Vaccination, chemoprophylaxis, and active disease surveillance are cornerstones of the Army's program to protect the health and readiness of basic trainees, utilizing support from the Defense Health Agency's Defense Centers for Public Health. What is the impact on readiness and force health protection?: U.S. Army basic training provides an ideal environment for the development of respiratory disease outbreaks because of sustained high stress combined with close trainee living and training quarters. Disease outbreaks degrade force readiness by increasing training time or potentially reducing numbers of trainees who graduate. The data from 2020 through 2022 demonstrate that no ARD outbreaks occurred in this population.

Identifying and Treating Vulnerable Atherosclerotic Plaques.

Acute coronary syndromes and, in particular, ST-elevation myocardial infarction are usually caused by coronary thrombosis in which the thrombus develops either on a disrupted plaque (usually a thin-capped fibroatheroma) or an eroded atherosclerotic plaque. These thrombus-prone plaques are vulnerable or high-risk. Although, traditionally, cardiologists have concentrated on treating significant coronary obstruction, there has been great interest over the last 2 decades in possibly preventing the thrombotic causes of myocardial infarction/sudden coronary death by mostly identifying and stabilizing these asymptomatic vulnerable or high-risk plaques, which, at least on invasive angiography, are mostly nonobstructive. Computed tomographic angiography and intravascular imaging during invasive coronary angiography have now been shown to identify a majority of these vulnerable or high-risk plaques before symptoms, thus opening up new preventive strategies. In conclusion, this article discusses the identification and management of these thrombus-prone lesions and patients with these lesions either with noninvasive techniques and systemic therapies or possibly through a new and bold interventional paradigm.

Estimates of Direct Medical and Indirect Costs Associated With COVID-19 Among U.S. Active Duty Army Soldiers.

INTRODUCTION: This study estimated the direct medical and indirect costs associated with coronavirus disease 2019 (COVID-19) diagnoses among U.S. active duty (AD) Army service members (SMs). These cost estimates provide the U.S. Military with a better understanding of the financial burden of COVID-19 and provide a foundation for cost-effectiveness estimates. MATERIALS AND METHODS: The study was approved as Public Health Practice (#17-605) by the U.S. Army Public Health Center, Public Health Review Board. U.S. AD Army SMs with COVID-19 were identified using an Army COVID-19 testing and surveillance database. Encounters for these SMs were captured from medical record where International Classification of Disease Tenth Revision, Clinical Modification code U07.1 was in the first or second diagnostic position. Analyses were conducted on SMs with COVID-19 who either had no healthcare encounters in the Military Health System (MHS); at least one MHS COVID-19 inpatient hospitalization; or at least one MHS outpatient COVID-19 encounter. Coronavirus disease 2019 (COVID-19) costs captured from the encounters were used to develop direct medical cost estimates. Literature on COVID-19 recovery post-hospitalization, along with the number of COVID-19 hospitalizations and outpatient visits from encounters were used to describe the intensity of COVID-19 care. Estimates of the indirect cost of lost duty were based on SMs salary information, along with recovery time, bed days, or outpatient visit time. The indirect cost of limited duty was estimated using the time associated with the Department of Defense (DoD) COVID-19 pandemic mitigation strategies in place when these SMs were identified as positive for COVID-19. RESULTS: Coronavirus disease 2019 (COVID-19) cost estimates were developed for the Army using data from 19,086 SMs identified as positive for COVID-19 between June 1, 2020, and December 31, 2020. Direct medical costs, or the amount paid by the DoD to facilities for COVID-19 care, averaged $606 per SM with an encounter. Indirect costs for lost duty or the cost for recovery and the time taken to seek care for COVID-19 averaged $319 per SM, while indirect costs for limited duty or isolation associated with COVID-19 averaged $4,111 per SM or $411 per day. Service members (SMs) with an inpatient hospitalization averaged 4.8 bed days (range 1-43) and 266 recovery hours while SMs who sought outpatient care for COVID-19 averaged two outpatient visits (range 1-60 visits). CONCLUSIONS: The direct medical costs of a COVID-19 encounter in the MHS ($606) are a small portion of the costs for a SM with COVID-19. Indirect costs of lost and limited duty associated with COVID-19 averaged seven times higher ($4,331) and accounted for the vast majority of costs. Recognition of these costs is important especially given that soldiers in the hospital or in quarters being quarantined are complete losses of manpower to the Army. While the COVID-19 pandemic is ongoing and prevention, treatment, and mitigation efforts continue to evolve, having reliable estimates of direct medical and indirect costs from this study allows the U.S. Army and MHS to better account for the cost of this pandemic for its population.

Suicide behavior among heterosexual, lesbian/gay, and bisexual active component service members in the U.S. Armed Forces.

Lesbian, gay, and bisexual (LGB) individuals are at a particularly high risk for suicidal behavior in the general population of the United States. This study aims to determine if there are differences in the frequency of lifetime suicide ideation and suicide attempts between heterosexual, lesbian/gay, and bisexual service members in the active component of the U.S. Armed Forces. Self-reported data from the 2015 Department of Defense Health-Related Behaviors Survey were used in the analysis. Multivariable logistic regression demonstrated that lesbian/gay and bisexual service members were more likely to report past suicide ideation when compared to heterosexual service members (adjusted odds ratio [AOR] for lesbian/gay: 1.79; 95% CI:1.14-2.82; AOR for bisexual: 2.33; 95% CI: 1.56-3.49). Similar results were observed for past suicide attempt for lesbian/gay (AOR: 2.29; 95% CI: 1.15-4.57) and bisexual SMs (AOR: 2.04; 95% CI: 1.24-3.38). Despite disparities in suicide ideation and attempt by sexual orientation, a majority of service members' behavioral health questionnaires do not assess sexual orientation. Clinical screenings of suicide risk in military settings should factor in sexual orientation to more comprehensively assess association between sexual orientation and suicidal behavior in this population.

Comparison and imputation-aided integration of five commercial platforms for targeted DNA methylome analysis.

Targeted bisulfite sequencing (TBS) has become the method of choice for the cost-effective, targeted analysis of the human methylome at base-pair resolution. In this study, we benchmarked five commercially available TBS platforms-three hybridization capture-based (Agilent, Roche and Illumina) and two reduced-representation-based (Diagenode and NuGen)-across 11 samples. Two samples were also compared with whole-genome DNA methylation sequencing with the Illumina and Oxford Nanopore platforms. We assessed workflow complexity, on/off-target performance, coverage, accuracy and reproducibility. Although all platforms produced robust and reproducible data, major differences in the number and identity of the CpG sites covered make it difficult to compare datasets generated on different platforms. To overcome this limitation, we applied imputation and show that it improves interoperability from an average of 10.35% (0.8 million) to 97% (7.6 million) common CpG sites. Our study provides guidance on which TBS platform to use for different methylome features and offers an imputation-based harmonization solution that allows comparative, integrative analysis.

A systematic concept analysis of healthcare team resilience in times of pandemic disasters.

BACKGROUND: The concept of resilience has been used as a descriptor for individuals and organizations with the dominant themes of bouncing back and moving forward. AIMS: To examine the concept of resilience in providers and healthcare teams during pandemic disasters. RESEARCH DESIGN: Walker and Avant's eight-step concept analysis method. DATA SOURCE: CINAHL, EBSCO Host, PubMed, and SCOPUS were searched using the combined terms "resilience" or "resiliency" or "resilient" and "healthcare professionals," or "healthcare worker" or "healthcare team" or "physician" or "nurse" or "doctor" and "pandemic" or "disaster." METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Checklist was used to review the literature and apply findings using the eight-step Walker and Avant method for concept analysis. RESULTS: Three clusters emerged as attributes of individual resilience that may be applied to healthcare teams in times of pandemic disasters: (1) resilience is a dynamic contextual process, (2) resilience stabilizes the team to maintain a routine level of function, and (3) resilience is a catalyst for the actualization of innate or acquired skills and ability within the healthcare team. CONCLUSION: This analysis suggests that resilience enhances the healthcare team's ability to maintain function during acute changes created by pandemic disasters. Resilience in healthcare teams during pandemics requires future research to explore the phenomenon.

In Search of Coronary Thrombosis as the Cause of Myocardial Infarction: Unraveling a 20th-Century Mystery.

For the greater part of the 20th century, the pathophysiology of acute myocardial infarction regarding whether thrombosis was either present or primary was debated until 1973 when pathologists and clinicians met and by consensus, finally decided that the data supported that transmural infarction (what we now refer to as ST elevation myocardial infarction or STEMI) was caused by thrombus in the vessel supplying the infarcted territory. As the data for this consensus came from pathological analysis, it took another 7 years until angiographic and interventional data in humans with acute presentations of transmural infarction convincingly indicated that thrombus was indeed responsible. Subsequently, in patients presenting with either syndromes of unstable angina or nontransmural (later called non-ST elevation) myocardial infarction, it was established through angiographic and other interventional approaches that thrombus formation was also causative in a substantial proportion of these patients. This article reviews the history and this search for causation of myocardial infarction that now has resulted in present therapies that have saved innumerable lives over the last 30 to 40 years.

New Precordial T Wave Inversions in Hospitalized Patients.

BACKGROUND: The incidence of precordial T changes has been described in athletes and in specific populations, while the etiology in a large patient population admitted to the hospital has not previously been reported. METHODS: All electrocardiograms (ECGs) read by the same physician with new (compared to prior ECGs) or presumed new (no prior ECGs) precordial T wave inversions of >1 mm (0.1 mV) in multiple precordial leads were retrospectively reviewed and various ECG, patient-related, and imaging parameters assessed. A total of 226 patients and their ECGs were initially selected for analysis. Of these, 35 were eliminated leaving 191 for the final analysis. RESULTS: Patients and their ECGs were divided into 5 groups based on diagnosis and incidence including Wellens syndrome, takotsubo, type 2 myocardial infarction, other (including multiple diagnoses), and unknown. Although subtle differences including number of T inversion leads, depth of T waves, QTc intervals, and other variables were present between some groups, diagnosis in individual cases required appropriate clinical, laboratory, or imaging studies. For example, although Wellens syndrome was identified in <20% of cases, a presenting history of chest discomfort with precordial T changes either on the admission or next-day ECG was highly sensitive and specific for this diagnosis. In some cases, type 2 myocardial infarction can also have a Wellens-like ECG phenotype without significant left anterior descending disease. CONCLUSIONS: Precordial T wave changes in hospitalized patients have various etiologies, and in individual cases, the changes on the ECG alone cannot easily distinguish the presumptive diagnosis and additional data are required.

Integration of Multiple Surveillance Systems to Track COVID-19 in the U.S. Army Population.

INTRODUCTION: The coronavirus disease (COVID-19) pandemic presented unique challenges for surveillance of the military population, which include active component service members and their family members. Through integrating multiple Department of Defense surveillance systems, the Army Public Health Center can provide near real-time case counts to Army leadership on a daily basis. MATERIALS AND METHODS: The incidence of COVID-19 was tracked by incorporating data from the Disease Reporting System Internet, laboratory test results, Commanders' Critical Incidence Reports, reports from the Centers for Disease Control and Prevention military liaison, and media reports. Cases were validated via a medical record review for all Army beneficiaries. Descriptive analyses were performed using Microsoft Excel and SAS 9.4 to measure demographic frequencies. RESULTS: In the first year of the pandemic from February 1, 2020 to February 28, 2021, a total of 96,315 COVID-19 cases were reported to the Disease Reporting System internet, the Army's passive surveillance system, of which 95,429 (99%) were confirmed and 886 (1%) were probable. A total of 76 outbreak reports were submitted from 14 Army installations. The proportion of Army beneficiaries with severe illness was low: 2,271 (2.4%) individuals required hospitalization and 269 (0.3%) died. Installations in Texas reported the highest proportion of confirmed-not hospitalized cases (n = 19,246, 20.7%), confirmed-hospitalized cases (n = 1,037, 45.7%), and deaths (n = 137, 50.9%) as compared to other states with Army installations. CONCLUSIONS: The pandemic has demonstrated the need for a robust public health enterprise with a focus on data collection, validation, and analysis, allowing leaders to make informed decisions that may impact the health of the Army.

A Qualitative Protocol to Examine Resilience Culture in Healthcare Teams during COVID-19.

Resilience allows teams to function at their optimal capacity and skill level in times of uncertainty. The SARS-CoV-2 (COVID-19) pandemic created a perfect opportunity to study resilience culture during a time of limited healthcare team experience, protocols, and specific personal protective equipment (PPE) needed. Little is known about healthcare team resilience as a phenomenon; existing definitions and empiric referents do not capture the nature of healthcare team resilience, as the traditional focus has been placed on individual resilience. This qualitative research protocol provides the rationale and methodology to examine this phenomenon and builds a bridge between resilience engineering and individual resilience. The sample is composed of healthcare team members from the US. This research may add to the body of knowledge on resilience culture in healthcare teams during the COVID-19 pandemic. This qualitative research protocol paper outlines the rationale, objective, methods, and ethical considerations entailed in this research.

Surveillance of spotted fever rickettsioses at Army installations in the U.S. Central and Atlantic regions, 2012-2018.

Spotted fever rickettsioses (SFR) are emerging in the Atlantic and Central regions of the U.S., though cases have been reported across the contiguous U.S. Military populations may be at increased risk for SFR because of residence in these regions and frequent field training in tick habitats. Surveillance for Rocky Mountain spotted fever in the Army began in 1998 and was expanded to include all SFR in 2017. Between 2016 and 2017, the rate of active component cases reported from Army installations in the Atlantic and Central regions of the U.S. increased nearly five-fold from 2016 (0.55 per 100,000 person-years [p-yrs]) to 2017 (2.65 per 100,000 p-yrs). The majority of SFR cases were reported from Fort Leonard Wood, MO, and Fort Bragg, NC. Most reported cases had no documented symptoms consistent with SFR and could not be confirmed as "cases" by standard case-defining methods. SFR surveillance and control efforts in military populations can be improved by better adherence to guidelines for SFR diagnosis and through the use of available advanced laboratory techniques.

Effects of horse riding simulator on sitting motor function in children with spastic cerebral palsy.

BACKGROUND: Horse riding simulator (HRS) is an electronic horse, working under the principles of hippotherapy. It is one of the advanced therapeutic methods to improve postural control and balance in sitting, which could be recommended in the rehabilitation of cerebral palsy if real horses are unavailable. OBJECTIVE: To investigate the therapeutic effects of HRS on sitting motor function in children with spastic diplegia and evaluate the changes in sitting motor function at different periods of time (4, 8 and 12 weeks). METHODS: This study is a randomized controlled trial conducted over a period of 12 weeks. Thirty children with spastic diplegia age between 2 and 4 years with Gross Motor Function Classification System (GMFCS) Level I-III were included and divided into two groups. The control group received the conventional physiotherapy while the experimental group received HRS along with conventional physiotherapy. Sitting motor function was assessed by Gross Motor Function Measure (GMFM)-88 (sitting dimension B) at baseline, 4, 8 and 12 weeks. Pre- and post-intervention scores were measured and analysed. RESULTS: The baseline characteristics were similar in both groups before the intervention with p > .01. The observed mean value of GMFM in both groups improved over a period of 12 weeks. The results denote that the sitting motor function gradually improved over a period of time in both groups and the experimental group showed significant improvement (p < .01) than the control group in all the weeks. CONCLUSION: The study results confirmed that gradual improvement in sitting motor function was observed in both groups. Children exposed to HRS show better improvement than the children in the control group. It was concluded that HRS is effective in improving the sitting motor function in children with spastic diplegia and the continuous provision of HRS in longer duration provide more benefits than the shorter duration.

Prevalence of selected underlying health conditions among active component Army service members with coronavirus disease 2019, 11 February-6 April 2020.

The novel coronavirus (severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) is exhibiting widespread community transmission throughout most of the world. Previous reports have evaluated the risk of serious illness in civilians diagnosed with COVID-19; however, similar reports have not been compiled for the Army active component (AC) population. COVID-19 has been a reportable condition for the Department of Defense since 5 February 2020, and, as of the morning of 6 April, a total of 873 cases were reported to the Disease Reporting System internet from Army installations. Of these cases, a total of 219 (25.1%) were identified as Army AC service members. The majority of these cases did not require hospitalization (n=207; 94.5%). The most common comorbidities present in nonhospitalized cases included other chronic illnesses (43.5%), neurologic disorders (24.6%), and obesity (21.7%). Overall, 12 cases (5.5%) required hospitalization. Hospitalized cases had a history of obesity (58.3%), neurologic disorder (50.0%), other chronic illnesses (41.7%), and hypertension (25.0%). No comorbidities were present among 27.1% (n=56) of nonhospitalized cases and 25.0% (n=3) of hospitalized cases.