Enhancing behavioral sleep care with digital technology: study protocol for a hybrid type 3 implementation-effectiveness randomized trial.

BACKGROUND: Insomnia affects almost one in four military service members and veterans. The first-line recommended treatment for insomnia is cognitive-behavioral therapy for insomnia (CBTI). CBTI is typically delivered in-person or online over one-to-four sessions (brief versions) or five-to-eight sessions (standard versions) by a licensed doctoral or masters-level clinician with extensive training in behavioral sleep medicine. Despite its effectiveness, CBTI has limited scalability. Three main factors inhibit access to and delivery of CBTI including restricted availability of clinical expertise; rigid, resource-intensive treatment formats; and limited capacities for just-in-time monitoring and treatment personalization. Digital technologies offer a unique opportunity to overcome these challenges by providing scalable, personalized, resource-sensitive, adaptive, and cost-effective approaches for evidence-based insomnia treatment. METHODS: This is a hybrid type 3 implementation-effectiveness randomized trial using a scalable evidence-based digital health software platform, NOCTEM™'s Clinician-Operated Assistive Sleep Technology (COAST™). COAST includes a clinician portal and a patient app, and it utilizes algorithms that facilitate detection of sleep disordered patterns, support clinical decision-making, and personalize sleep interventions. The first aim is to compare three clinician- and system-centered implementation strategies on the reach, adoption, and sustainability of the COAST digital platform by offering (1) COAST only, (2) COAST plus external facilitation (EF: assistance and consultation to providers by NOCTEM's sleep experts), or (3) COAST plus EF and internal facilitation (EF/IF: assistance/consultation to providers by NOCTEM's sleep experts and local champions). The second aim is to quantify improvements in insomnia among patients who receive behavioral sleep care via the COAST platform. We hypothesize that reach, adoption, and sustainability and the magnitude of improvements in insomnia will be superior in the EF and EF/IF groups relative to the COAST-only group. DISCUSSION: Digital health technologies and machine learning-assisted clinical decision support tools have substantial potential for scaling access to insomnia treatment. This can augment the scalability and cost-effectiveness of CBTI without compromising patient outcomes. Engaging providers, stakeholders, patients, and decision-makers is key in identifying strategies to support the deployment of digital health technologies that can promote quality care and result in clinically meaningful sleep improvements, positive systemic change, and enhanced readiness and health among service members. TRIAL REGISTRATION: ClinicalTrials.gov NCT04366284 . Registered on 28 April 2020.

Association between exposure to o-chlorobenzylidene malononitrile (CS riot control agent) and urinary metabolite 2-chlorohippuric acid in U.S. Army Mask Confidence Training.

This study was conducted among U.S. Army soldiers to evaluate the association between exposure to o-chlorobenzylidene malononitrile (CS riot control agent) and urinary metabolite 2-chlorohippuric acid (CHA) detected in test subjects (n = 87) after completion of Mask Confidence Training. CS exposures ranged 0.086-4.9 mg/m³ ([Formula: see text] = 2.7 mg/m³). CHA levels (corrected for creatinine) at 2-, 8-, 24-, and 30-hr post-exposure resulted in ranges of 94.6-1120 µg/g-cr ([Formula: see text] = 389 µg/g-cr), 15.80-1170 µg/g-cr ([Formula: see text] = 341 µg/g-cr), 4.00-53.1 µg/g-cr ([Formula: see text] = 19.3 µg/g-cr), and 1.99-28.4 µg/g-cr ([Formula: see text] = 10.6 µg/g-cr), respectively. Spearman's correlation revealed CHA levels strongly correlated with time sampled (r = -0.748, p < 0.05) and weakly correlated with CS concentration (r = 0.270, p < 0.05). A linear relationship was observed between CHA, CS concentration, and time of urine sample according to the following regression equation: ln(CHA, µg/g-cr) = 5.423 + 0.316 (CS conc., mg/m³) - 0.002 (time sampled), (R = 0.910, R² = 0.827, p < 0.05). This relationship suggests that CHA has the potential to be an effective retrospective indicator of CS exposure in future biomarker developments.

O-chlorobenzylidene malononitrile (CS riot control agent) associated acute respiratory illnesses in a U.S. Army Basic Combat Training cohort.

Acute respiratory illnesses (ARIs) are among the leading causes for hospital visits in U.S. military training populations and historically peak during U.S. Army Basic Combat Training (BCT) following mandatory exposure to the riot control agent o-chlorobenzylidene malononitrile (CS). This observational prospective cohort studied the association between CS exposures and ARI-related health outcomes in 6,723 U.S. Army recruits attending BCT at Fort Jackson, South Carolina from August 1 to September 25, 2012 by capturing and linking the incidence of ARI before and after the mask confidence chamber to CS exposure data. Recruits had a significantly higher risk (risk ratio = 2.44; 95% confidence interval = 1.74, 3.43) of being diagnosed with ARI following exposure to CS compared to the period of training preceding exposure, and incidence of ARI after CS exposure was dependent on the CS exposure concentration (p = 0.03). There was a significant pre-/postexposure ARI difference across all CS concentration levels (p < 0.01), however, no significant differences were detected among these rate ratios (p = 0.72). As CS exposure is positively associated with ARI health outcomes in this population, interventions designed to reduce respiratory exposures could result in decreased hospital burden and lost training time in the U.S. Army BCT population.

O-chlorobenzylidene malononitrile (CS riot control agent) exposure in a U.S. Army basic combat training cohort.

All U.S. Army soldiers participate in mask confidence training during initial military training and periodically throughout their careers. Training is conducted by dispersing the riot control agent, o-chlorobenzylidene malononitrile (CS), in a relatively air-tight structure where soldiers enter and conduct a series of exercises that culminate with mask removal. The study described here quantified CS concentrations experienced by 6,723 trainees and seven chamber operators during U.S. Army basic combat training at Fort Jackson, South Carolina, from August 1 to September 25, 2012. All 6,723 trainees were potentially exposed to CS concentrations exceeding the American Conference of Governmental Industrial Hygienists threshold limit value-ceiling (TLV-C) (0.39 mg/m3), 6,589 of which were potentially exposed to concentrations exceeding the value deemed immediately dangerous to life and health (IDLH) (2.0 mg/m3) by the National Institute for Occupational Safety and Health. All chamber operators were exposed to concentrations exceeding both the TLV-C and the IDLH.

Evaluation of CS (o-chlorobenzylidene malononitrile) concentrations during U.S. Army mask confidence training.

All soldiers in the U.S. Army are required to complete mask confidence training with o-chlorobenzylidene malononitrile (CS). To instill confidence in the protective capability of the military protective mask, CS is thermally dispersed in a room where soldiers wearing military protective masks are required to conduct various physical exercises, break the seal of their mask, speak, and remove their mask. Soldiers immediately feel the irritating effects of CS when the seal of the mask is broken, which reinforces the mask's ability to shield the soldier from airborne chemical hazards. In the study described in this article, the authors examined the CS concentration inside a mask confidence chamber operated in accordance with U.S. Army training guidelines. The daily average CS concentrations ranged from 2.33-3.29 mg/m3 and exceeded the threshold limit value ceiling, the recommended exposure limit ceiling, and the concentration deemed immediately dangerous to life and health. The minimum and maximum CS concentration used during mask confidence training should be evaluated.

Association between barracks type and acute respiratory infection in a gender integrated Army basic combat training population.

BACKGROUND: Acute respiratory infections (ARIs) are the leading cause of acute morbidity and lost work time in the United States. Few studies have looked at building design and transmission of ARIs. OBJECTIVES: This study explores the association of ventilation design, room occupancy numbers, and training week with ARI rates in Army Basic Combat Training barracks. METHODS: This observational study captured the overall incidence of ARI in a cohort of 16,258 individuals attending basic combat training at Fort Jackson, South Carolina. RESULTS: ARI risk was higher among trainees living in the 60-person room barracks compared with those living in 8-person rooms, which increased rapidly for the first few weeks of training and then declined to baseline. CONCLUSIONS: Findings support direct contact as primary ARI transmission mode in this study population based on observed lower ARI risk in smaller room barracks and similar risk in large room barracks despite heating, ventilation, and air conditioning system variability.

Panel 5: educating leaders on identifying and mitigating environmental exposure risks.

Rapidly identifying and appropriately reacting to potentially hazardous environmental exposures could result in the mitigation of adverse health effects, accurate documentation of the exposures leading to reliable assessments of the risks associated with the exposures, and records of those actually exposed and the extent and duration of their exposures. As a panel, we addressed the questions of who should be educated, why they should be educated, what their education should consist of, and when the educational activities should occur. Our panel concluded that within the Department of Defense global community, education on potentially hazardous environmental exposures must start with and be grounded in the military Preventive Medicine (PM) professional community. Members of the military PM professional community must develop the skills needed to educate military non-PM medical and non-medical leaders, and they must actively assume their roles as educators. Panel 5 participants identified computer-based education as a means of disseminating teaching materials on environmental risks among military members as they move through the different phases of their careers.

Identification of compounds formed during low temperature thermal dispersion of encapsulated o-chlorobenzylidene malononitrile (CS riot control agent).

U.S. Army chemical mask confidence training is conducted in an enclosed chamber where airborne o-chlorobenzylidene malononitrile (also known as CS or "tear gas") is generated using a low temperature (150-300 degrees C) dispersal method. CS capsules are placed onto a flame-heated aerosol generator that melts the capsules and disperses CS into the chamber. To instill confidence in chemical protective equipment, trainees are required to break the seal of their chemical protective mask, resulting in the immediate irritation of their eyes, nose, throat, and lungs. Solid phase micro extraction (SPME) sample collection techniques were used inside the chamber, followed by gas chromatography and mass spectrometry (GC/MS) to identify unintended thermal degradation products created during the CS dispersal process. The temperature of the aerosol generator averaged 257 degrees C, and 17 thermal degradation products were identified. To characterize the relationship between temperature and the types of CS thermal degradation products formed, CS was dispersed in a tube furnace at controlled temperatures from 150-300 degrees C and analyzed using the same method. There was a graded response between temperature and the number of thermal degradation products formed, with one product formed at 150 degrees C and 15 products formed at 300 degrees C. Two additional products were identified in the chamber experiment when compared with the tube furnace experiment. These products are likely the result of molten CS dripping directly into the aerosol generator's flame, which averaged 652 degrees C. To prevent undesirable degradation products during thermal dispersion of CS, a delivery system designed to contain the molten CS and maintain a consistent temperature near 150 degrees C is recommended.