Neuropsychological, Neurocognitive, Vestibular, and Neuroimaging Correlates of Exposure to Repetitive Low-Level Blast Waves: Evidence From Four Nonoverlapping Samples of Canadian Breachers.

INTRODUCTION: We assessed the utility of a battery of neuropsychological, neurocognitive, physiological (balance, ataxia, postural tremor), and neuroimaging measures for studying the effects of blast waves in breachers-a population repeatedly exposed to low-level blast during military training and operations. MATERIALS AND METHODS: Data were collected from four nonoverlapping samples, in the course of similarly structured 4-day breacher training exercises in successive years involving a combination of indoor and outdoor blast events. In all cases, self-report and neuropsychological measures were administered once at baseline (i.e., 1 day before the start of training). In years 1-2, neurocognitive and physiological measures were administered daily before and after training. In years 3-4, neurocognitive data were collected once at baseline. In Year 4, we introduced 3 modifications to our design. First, in addition to breachers, we also collected data from sex-and age-matched military controls at the same time points. Second, we assessed balance, ataxia, and postural tremor immediately following blast exposure "in the field," enabling us to quantify its acute effects. Third, structural magnetic resonance imaging (MRI) scans were acquired before and after the 4-day training exercise to explore differences between breachers and controls at baseline, as well as possible training-related changes using voxel-based morphometry. These design modifications were made to enable us to test additional hypotheses in the context of the same training exercise. RESULTS: At baseline, scores on the "Rivermead Post Concussion Symptoms Questionnaire," "RAND SF-36" (physical functioning, role limitation due to physical health, social functioning, energy/fatigue, general health), and "Short Musculoskeletal Function Questionnaire" distinguished breachers from controls. Also at baseline, the MRI data revealed that there was greater regional gray matter volume in controls compared to breachers in the right superior frontal gyrus. Balance, ataxia, and postural tremor did not exhibit sensitivity to the acute effects of blast in the field, nor did neurocognitive measures to its cumulative or daily effects. CONCLUSION: Our exploratory results suggest that self-report neuropsychological measures and structural MRI hold promise as sensitive measures for quantifying the long-term, cumulative effects of blast exposure in breachers. We discuss the limitations of our study and the need for prospective longitudinal data for drawing causal inferences regarding the impact of blast exposure on breachers' health and performance.

Changes in mood, fatigue, sleep, cognitive performance and stress hormones among instructors conducting stressful military captivity survival training.

Numerous studies have examined the effects of captivity survival training on psychological and physiological function in trainees. In the present study we shifted the focus to instructors, and measured the effects that the delivery of training exerts on their levels of stress and performance. Because instructors are called upon to perform difficult duties (e.g., mock interrogations) under extreme conditions, we hypothesized that significant increases in psychological and physiological indices of stress would occur due to training. In addition, as part of their job tasking, the instructors conducted courses in consecutive weeks. This offered a unique and ecologically valid opportunity to assess carryover of stress from one week to the next. We hypothesized stress levels would be higher in the second than the first week of training. Our first hypothesis was supported: Delivering training was associated with impairments in mood, fatigue, and sleep, as well as a reduction in the ratio of testosterone/cortisol level in blood. Our second hypothesis was largely not supported as a 3-day break separating consecutive courses appeared sufficient for restoring psychological and physiological function. Our results demonstrate that although the delivery of training exerts negative effects on instructors' levels of stress, the 3-day recovery period separating consecutive courses is sufficient to return psychological and physiological function to baseline levels.

Framework for advancing improvement in primary care.

A consistent feature of effective healthcare delivery systems is a strong and well-integrated primary care sector. This paper presents a framework that describes the key elements of high-performing primary care and the supports required to attain it. The framework was developed by the Quality Improvement and Innovation Partnership in Ontario (now part of Health Quality Ontario) to guide the process of primary care transformation. The first section of this paper presents and describes the framework, the second proposes implementation strategies and the third identifies system-level structures and policies needed to support primary care transformation. The framework has three components: (1) the major constituencies that primary care serves ­ patients, families and their local communities; (2) the desired outcomes of primary care (better health, better care, better value); and (3) the attributes that will enable primary care organizations to attain these outcomes. These attributes are a population focus, patient engagement, partnerships with health and community services, innovation, performance measurement and quality improvement and team-based care.Proposed transformation strategies include building system capacity and capability, ensuring access to resources, providing support from coaches and employing effective spread and sustainability strategies. Broader system-level structures and policies necessary to support and sustain a high-performing and continually improving primary care sector include clear goals; a comprehensive approach to performance measurement; systematic evaluation of innovation; funding incentives aligned with quality outcomes; a system of local primary care organizations; support for inter-professional teams; funding for research to inform primary care policy, management and practice; patient enrolment with primary care providers; and mechanisms to support coordination and integration.

Use of a program logic model to guide the development of a strategic plan for Wellington County Hospitals Network.

This article describes how the Wellington County Hospitals Network successfully used a program logic model as a decision-making framework to guide the development of the Network's first strategic plan. The advantages and disadvantages of this approach to the development of a strategic plan and identification of short-term priorities for action by the Network are discussed.