The Portable Warrior Test of Tactical Agility: A Novel Functional Assessment That Discriminates Service Members Diagnosed With Concussion From Controls.

INTRODUCTION: Return-to-duty (RTD) readiness assessment for service members (SM) following concussion requires complex clinical considerations. The Portable Warrior Test of Tactical Agility (POWAR-TOTAL) is a functional assessment which improves on previous laboratory-based RTD assessments. METHODS: Sixty-four SM diagnosed with concussion and 60 healthy control (HC) SM participated in this study. Group differences were analyzed to validate the POWAR-TOTAL. The High-level Mobility Assessment Test (HiMAT) was used to examine concurrent construct validity. An exploratory logistic regression analysis examined predictive validity. RESULTS: The groups were demographically well-matched except for educational level. POWAR-TOTAL measures were statistically significantly different between the groups with moderate to large effect sizes. Concussed participants were less likely to be able to complete all trials of the POWAR-TOTAL. Motor scores correlated highly with HiMAT scores. POWAR-TOTAL motor task performance and membership in the control group was significantly associated with self-reported physical readiness to deploy. CONCLUSION: The POWAR-TOTAL is a clinically feasible, military relevant assessment that is sensitive to differences between concussed and HC SM. This analysis supports the discriminant and construct validity of the POWAR-TOTAL, and may be useful for medical providers evaluating RTD readiness for SM who have sustained a concussion.

Contribution of socio-economic factors in the spread of antimicrobial resistant infections in Australian primary healthcare clinics.

OBJECTIVES: To effectively contain antimicrobial-resistant (AMR) infections, we must better understand the social determinates of health that contribute to transmission and spread of infections. METHODS: We used clinical data from patients attending primary healthcare clinics across three jurisdictions of Australia (2007-2019). Escherichia coli (E. coli), Klebsiella pneumoniae (K. pneumoniae), Pseudomonas aeruginosa (P. aeruginosa) and Staphylococcus aureus (S. aureus) isolates and their corresponding antibiotic susceptibilities were included. Using multivariable logistic regression analysis, we assessed associations between AMR prevalence and indices of social disadvantage as reported by the Australian Bureau of Statistics (i.e., remoteness, socio-economic disadvantage and average person per household). RESULTS: This study reports 12 years of longitudinal data from 43 448 isolates from a high-burden low-resource setting in Australia. Access to health and social services (as measured by remoteness index) was a risk factor for increased prevalence of third-generation cephalosporin-resistant (3GC) E. coli (odds ratio 5.05; 95% confidence interval 3.19, 8.04) and methicillin-resistant S. aureus (MRSA) (odds ratio 5.72; 95% confidence interval 5.02, 6.54). We did not find a positive correlation of AMR and socio-economic disadvantage or average person per household indices. CONCLUSION: Remoteness is a risk factor for increased prevalence of 3GC-resistant E. coli and MRSA. We demonstrate that traditional disease surveillance systems can be repurposed to capture the broader social drivers of AMR. Access to pathogen-specific and social data early and within the local regional context will fill a significant gap in disease prevention and the global spread of AMR.

The price tag of a potential cure for chronic hepatitis B infection: A cost threshold analysis for USA, China and Australia.

BACKGROUND & AIMS: We aim to capture the economic impact of a potential cure for chronic hepatitis B infection (CHB) in three countries (USA, China and Australia) with different health systems and epidemics to estimate the threshold drug prices below which a CHB cure would be cost-saving and/or highly cost-effective. METHODS: We simulated patients' hepatitis B progression, under three scenarios: current long-term suppressive antiviral therapy, functional cure defined as sustained undetectable HBsAg and HBV DNA, and partial cure defined as sustained undetectable HBV DNA only after a finite, 48-week treatment. RESULTS: Compared with current long-term antiviral therapy, a 30% effective functional cure among patients with and without cirrhosis in the USA, China and Australia would yield 17.50, 17.32 and 20.42 QALYs per patient, and 20.61, 20.42 and 20.62 QALYs per patient respectively. In financial terms, for CHB patients with and without cirrhosis, this would be cost-saving at a one-time treatment cost under US$11 944 and US$6694, respectively, in the USA, US$1744 and US$1001 in China, and US$12 063 and US$10 983 in Australia. CONCLUSION: We show that in purely economic terms, a CHB cure will be highly cost-effective even if effective in only 30% of treated patients. The threshold price for cure is largely determined by the current antiviral drug costs, since it will replace a daily antiviral pill that is inexpensive and effective, although not curative. The likely need for combination therapies to achieve cure will also present cost challenges. While cost-effectiveness is important, it cannot be the only consideration, as cure will provide many benefits in addition to reduced liver disease and HCC, including eliminating the need for a long-term daily pill and reducing stigma often associated with chronic viral infection.

A pilot study on exertional tasks with physiological measures designed for the assessment of military concussion.

BACKGROUND: Guidelines for clinicians treating military concussion recommend exertional testing before return-to-duty, yet there is currently no standardized task or inclusion of an objective physiological measure like heart rate variability (HRV). METHODOLOGY & RESULTS: We pilot-tested two clinically feasible exertional tasks that include HRV measures and examined reliability of a commercially available heart rate monitor. Testing healthy participants confirmed that the 6-min step test and 2-min pushup test evoked the targeted physiological response, and the Polar H10 was reliable to the gold-standard electrocardiogram. CONCLUSION: Both tasks are brief assessments that can be implemented into primary care setting including the Polar H10 as an affordable way to access HRV. Additional research utilizing these tasks to evaluate concussion recovery can validate standardized exertional tasks for clinical use.

Enhancing the hepatitis B care cascade in Australia: A cost-effectiveness model.

If Australia is to successfully eliminate hepatitis B as a public health threat, it will need to enhance the chronic hepatitis B (CHB) care cascade. This study used a Markov model to assess the impact, cost and cost-effectiveness of scaling up CHB diagnosis, linkage to care and treatment to reach national and international elimination targets for hepatitis B in Australia. Compared to continued current trends, the model calculated the difference in care cascade projection, disability-adjusted life years (DALYs), costs and the incremental cost-effectiveness ratio (ICER), of scaling up CHB diagnosis, linkage to care and treatment to reach: (a) Australia's 2022 national targets and (b) the WHO's 2030 global targets. Achieving the national and WHO targets had ICERs of A$13 435 (A$10 236-A$21 165) and A$14 482 (A$13 031-A$25 641) per DALY averted between 2016 and 2030 in Australia, respectively. However, this excluded implementation and demand generation costs. The ICER for the National Strategy and WHO Strategy remained under A$50 000 per DALY averted if Australia spent up to A$328 or A$538 million, respectively, per annum (for 2016-2030) on implementation and demand generation activities. Sensitivity analysis showed that cost-effectiveness was predominately driven by the cost of CHB treatment and influenced by disease progression rates. Hence for Australia to reach the National Hepatitis B Strategy 2022 targets and WHO Strategy 2030 targets, it requires an improvement in the CHB care cascade. We estimated it is cost-effective to spend up to A$328 million or A$538 million per year to reach the National and WHO Strategy targets, respectively.

This girl can #jointhemovement: Effectiveness of physical functionality-focused campaigns for women's body satisfaction and exercise intent.

We tested the effectiveness of exposure to two functionality-focused media campaigns, This Girl Can and #jointhemovement, in improving state appearance and physical functionality satisfaction, exercise intent, and protecting against exposure to idealised imagery. Across two studies, 339 (Mage=24.94, SD=4.98) and 256 (Mage=26.46, SD=5.50) women viewed the campaign or control video, followed by images of models who were posed or physically active, or images of landscapes. State satisfaction and exercise intent was measured at pre-test, post-video, post-images, and 1-week follow-up. Social comparison was measured at post-images. Viewing either campaign produced higher appearance satisfaction and exercise intentions than the control video. Effects weren't maintained after viewing idealised imagery or 1 week later. Further, the campaigns did not decrease social comparisons when viewing idealised imagery. Results can inform agencies about campaign effectiveness and suggest that women benefit from campaigns that feature non-idealised depictions of women exercising.

Further Development of the Assessment of Military Multitasking Performance: Iterative Reliability Testing.

The Assessment of Military Multitasking Performance (AMMP) is a battery of functional dual-tasks and multitasks based on military activities that target known sensorimotor, cognitive, and exertional vulnerabilities after concussion/mild traumatic brain injury (mTBI). The AMMP was developed to help address known limitations in post concussive return to duty assessment and decision making. Once validated, the AMMP is intended for use in combination with other metrics to inform duty-readiness decisions in Active Duty Service Members following concussion. This study used an iterative process of repeated interrater reliability testing and feasibility feedback to drive modifications to the 9 tasks of the original AMMP which resulted in a final version of 6 tasks with metrics that demonstrated clinically acceptable ICCs of > 0.92 (range of 0.92-1.0) for the 3 dual tasks and > 0.87 (range 0.87-1.0) for the metrics of the 3 multitasks. Three metrics involved in recording subject errors across 2 tasks did not achieve ICCs above 0.85 set apriori for multitasks (0.64) and above 0.90 set for dual-tasks (0.77 and 0.86) and were not used for further analysis. This iterative process involved 3 phases of testing with between 13 and 26 subjects, ages 18-42 years, tested in each phase from a combined cohort of healthy controls and Service Members with mTBI. Study findings support continued validation of this assessment tool to provide rehabilitation clinicians further return to duty assessment methods robust to ceiling effects with strong face validity to injured Warriors and their leaders.

Military-Civilian Collaborations for mTBI Rehabilitation Research in an Active Duty Population: Lessons Learned From the Assessment of Military Multitasking Performance Project.

This article describes lessons learned in the planning, development, and administration of a collaborative military-civilian research project, the Assessment of Military Multitasking Performance, which was designed to address a gap in clinical assessment for active duty service members with mild traumatic brain injury who wish to return to active duty. Our team worked over the course of multiple years to develop an assessment for military therapists to address this need. Insights gained through trial and error are shared to provide guidance for civilian researchers who may wish to collaborate with active duty researchers.

Development and preliminary reliability of a multitasking assessment for executive functioning after concussion.

OBJECTIVES. Executive functioning deficits may result from concussion. The Charge of Quarters (CQ) Duty Task is a multitask assessment designed to assess executive functioning in servicemembers after concussion. In this article, we discuss the rationale and process used in the development of the CQ Duty Task and present pilot data from the preliminary evaluation of interrater reliability (IRR). METHOD. Three evaluators observed as 12 healthy participants performed the CQ Duty Task and measured performance using various metrics. Intraclass correlation coefficient (ICC) quantified IRR. RESULTS. The ICC for task completion was .94. ICCs for other assessment metrics were variable. CONCLUSION. Preliminary IRR data for the CQ Duty Task are encouraging, but further investigation is needed to improve IRR in some domains. Lessons learned in the development of the CQ Duty Task could benefit future test development efforts with populations other than the military.

Returning service members to duty following mild traumatic brain injury: exploring the use of dual-task and multitask assessment methods.

Within the last decade, more than 220,000 service members have sustained traumatic brain injury (TBI) in support of military operations in Iraq and Afghanistan. Mild TBI may result in subtle cognitive and sensorimotor deficits that adversely affect warfighter performance, creating significant challenges for service members, commanders, and clinicians. In recent conflicts, physical therapists and occupational therapists have played an important role in evaluating service member readiness to return to duty (RTD), incorporating research and best practices from the sports concussion literature. Because premorbid (baseline) performance metrics are not typically available for deployed service members as for athletes, clinicians commonly determine duty readiness based upon the absence of postconcussive symptoms and return to "normal" performance on clinical assessments not yet validated in the military population. Although practices described in the sports concussion literature guide "return-to-play" determinations, resolution of symptoms or improvement of isolated impairments may be inadequate to predict readiness in a military operational environment. Existing clinical metrics informing RTD decision making are limited because they fail to emphasize functional, warrior task demands and they lack versatility to assess the effects of comorbid deficits. Recently, a number of complex task-oriented RTD approaches have emerged from Department of Defense laboratory and clinical settings to address this gap. Immersive virtual reality environments, field-based scenario-driven assessment programs, and militarized dual-task and multitask-based approaches have all been proposed for the evaluation of sensorimotor and cognitive function following TBI. There remains a need for clinically feasible assessment methods that can be used to verify functional performance and operational competence in a variety of practice settings. Complex and ecologically valid assessment techniques incorporating dual-task and multitask methods may prove useful in validating return-to-activity requirements in civilian and military populations.

Lessons learned in participant recruitment and retention: the EXCITE trial.

Participant recruitment is considered the most difficult aspect of the research process. Despite the integral role of recruitment in randomized clinical trials, publication of data defining the recruitment effort is not routine in rehabilitation initiatives. The recruitment process for the Extremity Constraint-Induced Therapy Evaluation (EXCITE) trial illustrates obstacles to and strategies for participant accrual and retention that are inherent in rehabilitation clinical trials. The purpose of this article is to increase awareness of the multiple facets of recruitment necessary for successful clinical trials, thus supporting the continued development of evidence-based practice in physical therapy. The Recruitment Index is presented as a variable to measure recruitment efficacy. In addition, ethical aspects of recruitment are explored, including informed consent and the concept of therapeutic misconception.