Department Of Defense Research Articles

Comparison of Tobacco Product Prices at Fort Liberty Army Installation and Surrounding Community Areas, 2021.

High rates of tobacco use persist in the U.S. military, with 18.4% of service members smoking cigarettes in 2018. The Department of Defense's (DoD) 2017 policy required that tobacco retailers on military installations set tobacco product prices equal to the most common community price, including tax, but there is limited evidence confirming whether local retailers are adhering to this policy. We examined tobacco product pricing in tobacco retailers on- and off-post at the largest U.S. Army installation, Fort Liberty, and Cumberland County, North Carolina. Between June-August 2021, we collected data on tobacco product availability, price, and promotions from retailers on Fort Liberty (n=14) and a random sample of off-post retailers within 10-miles of installation gates (n=52). We calculated the mode, mean, and median price of each product, plus the difference in these prices at on- and off-post retailers. We used Welch's t-test to test differences in mean prices between on- vs. off-post retailers. The mode, mean, and median prices of cigarette packs and cartons were lower on-post than off-post (e.g., $0.51-$0.55 cheaper for Marlboro cigarette packs on-post). However, the mode, mean, and median prices of smokeless tobacco products and little cigars were higher on-post than off-post (e.g., $0.82-$0.89 more costly for Swisher Sweets 2-packs on-post). Results highlight the need for continued enforcement to ensure compliance with the 2017 DoD policy. Comprehensive policy action to reduce tobacco price disparities on- and off-post is critical to reducing high rates of tobacco use among service members. Despite the implementation of the 2017 DoD pricing policy, some tobacco products remain cheaper at tobacco retailers on-post compared to off-post retailers. Our results highlight the need for greater routine surveillance to increase implementation of the policy-particularly for cigarettes-to reduce high rates of tobacco use among service members.

Challenges and opportunities on the horizon of post-quantum cryptography

Large quantum computers have the potential to break many cryptographic systems, e.g., Rivest–Shamir–Adleman, Diffie–Hellman key exchange, and the elliptical curve cryptosystem. The Department of Defense (DoD) is aware of this threat, and the National Institute of Standards and Technology is preparing a set of approved encryption and signature schemes that are not susceptible to these attacks by quantum computers, the so-called Post-Quantum Cryptography (PQC). The task of substituting older encryption and signature schemes raises a number of questions, to which there are not yet clear answers. In this research, we investigate the transition to PQC on existing networks, explain the approved PQC schemes, describe the likely path to an adaptation of PQC, and offer forward guidance on challenges and threats that may be encountered in the process of transition to PQC. This paper discusses the impacts of the new PQC schemes on network performance and speculates on possible side-channel attacks on the new encryption scheme. This paper offers hardware/software solutions based on the Split-protocol.

Exploring over a decade of systems engineering research center: A community detection and text analytics approach

AbstractThe Systems Engineering Research Center (SERC) is a University Affiliated Research Center (UARC) of the US Department of Defense (DoD) formed in 2008 with more than 20 collaborator universities in the United States. Over the last decade, SERC has conducted research with Principal Investigators from universities within the SERC network, as reflected in technical reports (TR). These reports describe detailed information and analysis of the conducted research for every project under SERC support, such as written records of experiments or results of a scientific project. We analyzed the TRs from 2009 to early 2023 to identify research streams, topics, and evolution in systems engineering (SE) research using text mining and network analysis techniques, such as Louvain Community Detection and word similarity. As a result, we identified four major research streams over a decade of research projects, along with insights about topics and the evolution of SE within this time frame. Finally, we distinguished most profile authors and their most significant collaborations and networks.

The biopolitics of algorithmic governmentality: How the US military imagines war in the age of neurobiology and artificial intelligence

With the objective to predict and pre-empt the emergence of political violence, the US Department of Defence (DoD) has devoted increasing attention to the intersection between neurobiology and artificial intelligence. Concepts such as ‘cognitive biotechnologies’, ‘digital biosecurity’ and large-scale collection of ‘neurodata’ herald a future in which neurobiological intervention on a global scale is believed to come of age. This article analyses how the relationship between neurobiology and AI – between the human and the machine – is conceived, made possible, and acted upon within the SMA programme, an interdisciplinary research programme sponsored by the DoD. By showcasing the close intersection between the computer sciences and the neurosciences within the US military, the article questions descriptions of algorithmic governmentality as decentring the human, and as juxtaposed to biopolitical techniques to regulate processes of subjectivity. The article shows that within US military discourse, new biotechnologies are seen to engender algorithmic governmentality a biopolitical dimension, capable of monitoring and regulating emotions, thoughts, beliefs, and subjectivity on population level, particularly targeting the minds and brains of ‘vulnerable’ populations in the global South.

Health Care Utilization During the First 5½ Years of Authorized Service by Transgender U.S. Service Members (2016-2021).

Purpose: This study examined the utilization of gender-affirming health care by active-duty service members during the initial 5½ years that transgender and gender-diverse (TGD) individuals were authorized to serve in the U.S. military. The aim of this study was to inform policy discussions regarding inclusion of TGD individuals in the military. Methods: We conducted a retrospective cohort study using administrative health care data from the Military Data Repository (MDR). We assessed the association of demographic factors with the utilization of gender-affirming medical and surgical care. We calculated the incidence rate of initial TGD-related encounters and new prescriptions for gender-affirming hormones among Defense Department Service members between July 2016 and December 2021. Results: We identified 2481 service members with an initial health care encounter with an associated TGD-related diagnosis. More than half (53%) of these service members started gender-affirming hormones, and 14% underwent gender-affirming surgery. Mastectomies and hysterectomies accounted for more than 70% of surgeries. Service members made 3.22 initial encounters with a TGD-related diagnosis per 10,000 service members per year, with an overrepresentation of service members who were designated female in the MDR (8.62), junior enlisted (4.98), and young (4.64). Individuals designated female in the MRD comprised 17% of all service members but accounted for 46% of initial encounters, 51% of new prescriptions, and 73% of surgeries. Conclusion: The study revealed a higher-than-expected number of service members seeking gender-affirming care, particularly among service members designated female in the MDR. Military Health System clinicians provided most of this care, which may mitigate the cost of delivering this essential medical care.

Abstract PO5-27-02: A Tumor Emboli Platform for Morphometric Analysis, Drug screening and for Intravital Optical Imaging in a Murine Model to Simulate Clinicopathological Features of Inflammatory Breast Cancer

Abstract Background: Inflammatory breast cancer (IBC) is distinguished by the presence of tumor emboli, clusters of tumor cells, found within breast parenchyma and dermal lymphatic vessels. These emboli serve as a crucial clinicopathological hallmark, believed to underlie the characteristic diffuse growth pattern and aggressive progression observed in IBC patients, with nearly 30% of patients presenting with metastatic disease at diagnosis. However, the rarity of this cancer and the absence of a solid tumor mass pose challenges in obtaining biospecimens, particularly those with evidence of tumor emboli. To address this pressing need for preclinical models that replicate this distinctive tumor growth pattern, we describe a tumor emboli culture platform that facilitates live imaging, enables compound screening by assessing various phenotypes of the emboli, and permits evaluation of emboli in an in vivo murine model. Methods: The tumor emboli culture system was evaluated for physiological measurements corresponding to dermal lymphatic vessels and subsequently employed to generate tumor emboli from diverse patient-derived cell lines and PDX. Confocal microscopy was employed to characterize cellular information across multiple slices of the tumor emboli. This provided a comprehensive, multi-parametric analysis of single-cell and spheroid phenotypes, including measurements of number, size, shape, and viability of the organoids. Furthermore, we developed imaging algorithms to evaluate phenotypic changes in tumor emboli in response to anti-cancer drug treatment. We also optimized a technique that allows for in vivo tumor emboli implantation including in a transgenic mice with red fluorescent lymphatic vasculature that were surgically implanted with a dorsal skin window chamber. This allowed for intravital optical imaging of the local tumor microenvironment and adjacent skin. Results: Our culture platform enables live imaging of the tumor emboli generated over a span of 7-10 days, maintaining key parameters including kinematic and dynamic viscosity, density along with sheer wall stress within the reported physiological range for lymphatics. Through higher resolution confocal image acquisition and multi-parametric analysis, we conducted particle counting and classification, providing statistically significant insights into the integrity of tumor emboli over time. Additionally, the developed algorithms allowed for quantitative analysis of images from tumor emboli cultures subjected to anti-cancer drugs, revealing disparities in drug efficacy on tumor emboli integrity and dispersion including inter-cluster space within the emboli. Intravital optical imaging, coupled with quantitative analysis of dispersion characteristics of the tumor emboli implanted in the murine model over 5-6 days, demonstrated a diffuse spread reminiscent of observations in IBC patients. Furthermore, immunohistochemistry staining showed marked Ki67, CD45, F4-80 revealing a proliferative tumor microenvironment with high levels of macrophage infiltration. Conclusions: As of now specific targeted therapies for IBC patients remain elusive. Our culture platform for tumor emboli, when combined with advanced imaging techniques both in vitro and in vivo and traditional approaches like immunohistochemistry and genomic evaluation, forms a powerful toolkit for assessing the phenotype and dispersion characteristics of this unique pathological feature in IBC. This preclinical model offers crucial insights, potentially paving the way for precision medicine strategies in the treatment of this understudied cancer. Funding in part from American Cancer Society Mission Boost MBG-20-141-01-MBG grant (GRD), Department of Defense W81XWH-20-1-0153 (GRD), Duke Consortium for Inflammatory Breast Cancer Education (AB, CW, RE). Citation Format: Dorababu Sannareddy, Theresa Charity, Alexandra Bennion, Caroline Way, Edwin Yu, Ralph Erdmann, Gregory M Palmer, Gayathri R Devi. A Tumor Emboli Platform for Morphometric Analysis, Drug screening and for Intravital Optical Imaging in a Murine Model to Simulate Clinicopathological Features of Inflammatory Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-27-02.

Abstract PO2-17-12: Phase I Trial of alpha-lactalbumin vaccine in high risk operable triple negative breast cancer (TNBC) and patients at high genetic risk for TNBC

Abstract Background: Triple-negative breast cancer (TNBC) has a poor prognosis and may be associated with germline mutations. α-Lactalbumin (aLA) is expressed in lactating breasts but not at other times or in other tissues. Expression of aLA is found in 70% of TNBC (PMID: 27322324) so could be an immunologic target for TNBC based on the “retired protein hypothesis” (PMID: 31926646). In pre-clinical studies, vaccination with aLA provided protection from development of autochthonous tumors in transgenic murine models of breast cancer and inhibited growth of established 4T1 transplantable breast tumors in BALB/c mice (PMID: 20512124). Methods: To determine the safety and immunogenicity of aLA, patients with early stage TNBC are being entered in a Phase I trial of aLA with GMP-grade zymosan adjuvant in Montanide ISA 51 VG vehicle. Subjects receive 3 vaccinations given once every 2 weeks. Events of Common Terminology Criteria for Adverse Events (CTCAE) grade ≥ 2 are considered dose-limiting toxicities (DLTs). Results: CTCAE toxicity by dose level is summarized below. All DLTs were injection site reactions, with ulceration and need for incisional drainage representing the grade 3 events. Seven (7) of 10 patients assayed to date have met protocol specified definitions of an immune response based on ELISpot assays to determine frequencies of T cells producing IFNγ and IL-17 in response to recombinant aLA. Assays for an additional 6 patients will be available in September 2023. Conclusion: Dose level ≤ 2 appears to be the maximum tolerated dose. Based on immune response, additional intermediate dose levels may be studied. An additional cohort of patients receiving concurrent anti-PD1 treatment is being accrued. Accrual of patients with BRCA1/2 or PALB2 mutations planning to undergo prophylactic mastectomy is beginning in order to define the toxicity and immunologic effects in this group and to determine whether inflammatory changes from occult lactational foci will be produced. Funding Source: Department of Defense (W81XWH-17-1-0592 and W81XWH-17-1-0593) Table 1 Worst Toxicity by Dose Level Citation Format: Justin Johnson, Emily Rhoades, Holly Levengood, Halle Moore, Megan Kruse, Erin Roesch, Jame Abraham, Brenna Elliott, Rachel Swartz, Holly Pederson, Elena Haury, Azka Ali, Tiffany Onger, Andrew Sciallis, Zahraa Al-Hilli, Wei Wei, Thaddeus Stappenbeck, George Budd. Phase I Trial of alpha-lactalbumin vaccine in high risk operable triple negative breast cancer (TNBC) and patients at high genetic risk for TNBC [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-17-12.

Cost-benefit analysis with return on investment of clinical pharmacists in the Military Health System.

The Defense Health Agency comprises more than 700 military medical, dental, and veterinary facilities and provides care to more than 9.6 million beneficiaries. As medication experts, pharmacists identify opportunities to optimize medication therapy, reduce cost, and increase readiness to support the Defense Health Agency's mission. The Tripler Pilot Project and the Army Polypharmacy Program were used to establish a staffing model of 1 clinical pharmacist for every 6,500 enrolled beneficiaries. No large-scale cost-benefit study within the military health care system has been done, which documents the number of clinical interventions and uses established cost-avoidance (CA) data, to determine the cost-benefit and return on investment (ROI) for clinical pharmacists working in the medical treatment facilities. To validate the patient-centered medical home staffing model across the military health care system using the Tripler Pilot Project results to provide a cost-benefit analysis with an ROI. The secondary goal is to describe the interventions, staffing levels, and US Department of Defense-specific requirements impacting the provision of clinical pharmacy. A retrospective analysis of 3 years of encounters by clinical pharmacists in which an intervention was documented in the Tri-Service Workflow (TSWF) form as part of the electronic health record was completed. The analysis used 6 steps to assign CA intervention types and to prevent duplication and overestimation of the ROI. The absolute number of clinical pharmacists was determined using workload criteria defined as at least 20 encounters per month for at least 3 months of each calendar year. The number of clinical pharmacist full-time employees (FTEs) was determined by dividing the number of total active months by 12 months. Attrition was calculated comparing the presence of a unique provider identification between calendar years. The ROI range was calculated by dividing the CA by the total cost of clinical pharmacists using the variables' raw and extrapolated CA based on percentage of documentation template usage and the active clinical pharmacist calculation (absolute and FTE-based). Between January 1, 2017, and December 31, 2019, a total of 1,069,846 encounters by clinical pharmacists were documented in the electronic health record. The TSWF Alternative Input Method form was used by pharmacists to document 616,942 encounters. Forty-three percent of TSWF documented encounters had at least 1 CA intervention. The absolute number of clinical pharmacists associated with a documented encounter in any medical treatment facility ranged from 404 in 2017 to 374 in 2018 and the clinical pharmacist FTEs ranged from 324 in 2017 to 314 in 2019. Annual attrition rates for clinical pharmacists ranged from 15% to 20% (58 to 81 clinical pharmacists) annually. The total CA range was $329,166,543-$534,014,494. The ROI range was between $2 and $4 per dollar spent. This analysis demonstrated that ambulatory care clinical pharmacists in the Military Health System bring value through a positive ROI. Our study also identified a potential shortage of clinical pharmacists within the Air Force and Navy branches impacting medication management. This can have a negative impact on the readiness of service members, one of the leading priorities of the US Department of Defense.

Partnership building for scale-up in the Veteran Sponsorship Initiative: Strategies for harnessing collaboration to accelerate impact in suicide prevention.

To evaluate the implementation and trust-building strategies associated with successful partnership formation in scale-up of the Veteran Sponsorship Initiative (VSI), an evidence-based suicide prevention intervention enhancing connection to U.S. Department of Veterans Affairs (VA) and other resources during the military-to-civilian transition period. Scaling VSI nationally required establishing partnerships across VA, the U.S. Department of Defense (DoD), and diverse public and private Veteran-serving organizations. We assessed partnerships formalized with a signed memorandum during pre- and early implementation periods (October 2020-October 2022). To capture implementation activities, we conducted 39 periodic reflections with implementation team members over the same period. We conducted a qualitative case study evaluating the number of formalized VSI partnerships alongside directed qualitative content analysis of periodic reflections data using Atlas.ti 22.0. We first independently coded reflections for implementation strategies, following the Expert Recommendations for Implementing Change (ERIC) taxonomy, and for trust-building strategies, following the Theoretical Model for Trusting Relationships and Implementation; a second round of inductive coding explored emergent themes associated with partnership formation. During this period, VSI established 12 active partnerships with public and non-profit agencies. The VSI team reported using 35 ERIC implementation strategies, including building a coalition and developing educational and procedural documents, and trust-building strategies including demonstrating competence and credibility, frequent interactions, and responsiveness. Cultural competence in navigating DoD and VA and accepting and persisting through conflict also appeared to support scale-up. VSI's partnership-formation efforts leveraged a variety of implementation strategies, particularly around strengthening stakeholder interrelationships and refining procedures for coordination and communication. VSI implementation activities were further characterized by an intentional focus on trust-building over time. VSI's rapid scale-up highlights the value of partnership formation for achieving coordinated interventions to address complex problems.

U.S. military installations and extreme weather: an Oklahoma case study on preparation

ABSTRACT The readiness and execution of national security missions by The United States Department of Defense (DoD) hinges on military installations being equipped with infrastructure that can support the actions needed to protect the U.S., including extreme weather responses. Extreme weather threatens human lives, property, and military operations nationally. Thus, it is paramount to mitigate these impacts and improve preparedness. Oklahoma is home to five federal military installations, all of which are susceptible to hazardous weather, such as severe thunderstorms, tornadoes, and flooding. At a local level, hazardous weather events can be quite costly in a variety of ways, including disrupting operations, causing economic losses, and leading to injuries. This case study examines the preparedness and impacts of extreme weather events as well as climate change considerations at two Oklahoma military installations (Tinker Air Force Base and Fort Sill). Interviews and a focus group revealed weather-related decisions at these installations were unit-specific and dependent on the weather event. These installations have both short- and long-term preparedness plans for different weather scenarios. The impacts of these weather events ranged from delays/cancellations of training to installation closures. Lastly, climate considerations from DoD have been, and continue to be, included in planning. This study highlights the nuances across different military installations as a function of their differing roles; there is not a ‘one size fits all’ preparedness plan that will work across the board. Further, there is much room to improve military-civilian collaboration to mitigate the effects of extreme weather events and climate change on military installations and their operations.

Deployment to Military Bases With Open Burn Pits and Respiratory and Cardiovascular Disease

Many veterans who served in Afghanistan and Iraq during Operations Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) were deployed to military bases with open burn pits and exposed to their emissions, with limited understanding of the long-term health consequences. To determine the association between deployment to military bases where open burn pits were used for waste disposal and the subsequent risk of developing respiratory and cardiovascular diseases. This retrospective observational cohort study used Veterans Health Administration medical records and declassified deployment records from the Department of Defense to assess Army and Air Force veterans who were deployed between 2001 and 2011 and subsequently received health care from the Veterans Health Administration, with follow-up through December 2020. Data were analyzed from January 2023 through February 2024. Duration of deployment to military bases with open burn pits. Diagnosis of asthma, chronic obstructive pulmonary disease, interstitial lung disease, hypertension, myocardial infarction, congestive heart failure, ischemic stroke, and hemorrhagic stroke. The study population included 459 381 OEF and OIF veterans (mean [SD] age, 31.6 [8.7] years; 399 754 [87.0%] male). Median (IQR) follow-up from end of deployment was 10.9 (9.4-12.7) years. For every 100 days of deployment to bases with burn pits, veterans experienced increased adjusted odds for asthma (adjusted odds ratio [aOR], 1.01; 95% CI, 1.01-1.02), chronic obstructive pulmonary disease (aOR, 1.04; 95% CI, 1.02-1.07), hypertension (aOR, 1.02; 95% CI, 1.02-1.03), and ischemic stroke (aOR, 1.06; 95% CI, 0.97-1.14). Odds of interstitial lung disease, myocardial infarction, congestive heart failure, or hemorrhagic stroke were not increased. Results based on tertiles of duration of burn pit exposures were consistent with those from the continuous exposure measures. In this cohort study, prolonged deployment to military bases with open burn pits was associated with increased risk of developing asthma, COPD, and hypertension. The results also point to a possible increased risk in ischemic stroke. The novel ability to use integrated data on deployment and health outcomes provides a model for additional studies of the health impact of environmental exposures during military service.

The long-term association between exposure to wartime bombing earlier in life and post-traumatic stress later in life among today's older Vietnamese population

This analysis examines the relationship between exposure to American wartime bombardments earlier in life and later-life PTSD among current surviving Vietnamese aged 59+. It also assesses whether the relationship varies by military status during the war - formal military, informal military, or civilian - and whether associations are explained by exposure to violence and malevolent conditions. Data link survey responses from the 2018 Vietnam Health and Aging Study to provincial-wide level bombing intensity using U.S. Department of Defense records from the Theater History of Operations Vietnam database. PTSD measured using nine items from the PTSD Checklist. Analyses employ multivariate logistic quantile regression. Findings examined for a sample of 2290 Vietnamese survivors and a subsample of 736 Vietnamese that moved at least once during wartime. Results show a robust and significant positive association between province-wide bombing intensity and later-life PTSD scores. Interaction effects indicate civilians have overall lower levels of PTSD than those that were in the formal or informal military, but the association between bombing and PTSD is stronger among civilians. Much of the association is a function of exposure to violence and less is a function of exposure to malevolent conditions. Findings confirm earlier studies that have shown severe deleterious impacts of war trauma, and arial bombardments particularly, on long-term psychological health, while extending extant literature to civilian populations living in Vietnam during intense aerial bombing episodes.

The Walter Reed Project, Kisumu Field Station: Impact of Research on Malaria Policy, Management, and Prevention.

The Walter Reed Project is a collaboration between the Walter Reed Army Institute of Research of the United States Department of Defense and the Kenya Medical Research Institute. The Kisumu field station, comprising four campuses, has until recently been devoted primarily to research on malaria countermeasures. The Kombewa Clinical Research Center is dedicated to conducting regulated clinical trials of therapeutic and vaccine candidates in development. The center's robust population-based surveillance platform, along with an active community engagement strategy, guarantees consistent recruitment and retention of participants in clinical trials. The Malaria Diagnostic Center, backed by WHO-certified microscopists and a large malaria blood film collection, champions high-quality malaria diagnosis and strict quality assurance through standardized microscopy trainings. The Malaria Drug Resistance Laboratory leverages cutting-edge technology such as real-time Polymerase Chain Reaction (qPCR) to conduct comprehensive research on resistance markers and obtain information on drug efficacy. The laboratory has been working on validating artemisinin resistance markers and improving tracking methods for current and future antimalarial compounds. Finally, the Basic Science Laboratory employs advanced genomic technology to examine endpoints such as immunogenicity and genomic fingerprinting for candidate drugs and vaccine efficacy. Herein, we examine the site's significant contributions to malaria policy, management, and prevention practices in Kenya and around the world.

Explainable AI in the military domain

Artificial intelligence (AI) has become nearly ubiquitous in modern society, from components of mobile applications to medical support systems, and everything in between. In societally impactful systems imbued with AI, there has been increasing concern related to opaque AI, that is, artificial intelligence where it is unclear how or why certain decisions are reached. This has led to a recent boom in research on “explainable AI” (XAI), or approaches to making AI more explainable and understandable to human users. In the military domain, numerous bodies have argued that autonomous and AI-enabled weapon systems ought not incorporate unexplainable AI, with the International Committee of the Red Cross and the United States Department of Defense both explicitly including explainability as a relevant factor in the development and use of such systems. In this article, I present a cautiously critical assessment of this view, arguing that explainability will be irrelevant for many current and near-future autonomous systems in the military (which do not incorporate any AI), that it will be trivially incorporated into most military systems which do possess AI (as these generally possess simpler AI systems), and that for those systems with genuinely opaque AI, explainability will prove to be of more limited value than one might imagine. In particular, I argue that explainability, while indeed a virtue in design, is a virtue aimed primarily at designers and troubleshooters of AI-enabled systems, but is far less relevant for users and handlers actually deploying these systems. I further argue that human–machine teaming is a far more important element of responsibly using AI for military purposes, adding that explainability may undermine efforts to improve human–machine teamings by creating a prima facie sense that the AI, due to its explainability, may be utilized with little (or less) potential for mistakes. I conclude by clarifying that the arguments are not against XAI in the military, but are instead intended as a caution against over-inflating the value of XAI in this domain, or ignoring the limitations and potential pitfalls of this approach.

CSF β-Amyloid and Tau Biomarker Changes in Veterans With Mild Traumatic Brain Injury.

Moderate-to-severe traumatic brain injuries (TBI) have been reported to increase the risk of Alzheimer disease (AD). Whether mild TBI (mTBI) in veterans confers a similar increased risk of AD is less known. This study investigated early AD changes using CSF biomarkers in veterans with blast mTBI. This was a cross-sectional case-control study of veterans with mTBI and non-mTBI veterans and civilians from 2 study sources. Blast-mTBI veterans had at least 1 war zone blast or combined blast/impact mTBI meeting Veterans Affairs (VA) and Department of Defense (DoD) criteria for mTBI. Non-mTBI participants had no lifetime history of TBI. All participants underwent standardized clinical and neuropsychological assessments and lumbar puncture for collection of the CSF. CSF biomarkers were measured using MesoScale Discovery assays for Aβ40 and Aβ42 and INNOTEST ELISAs for phosphorylated tau181 (p-tau181) and total tau (t-tau). Our sample comprised 51 participants with mTBI and 85 non-mTBI participants with mean (SD) ages 34.0 (10.1) and 33.5 years (8.9), respectively. All participants but 1 (99%) were male. Differences in CSF AD biomarkers between mTBI and non-mTBI groups were age dependent and most pronounced at older ages (omnibus test p ≤ 0.08). At age 50 years, the mTBI group had lower mean [95% CI] CSF Aβ42 and Aβ40 than the non-mTBI group by 154 [-12 to 319] and 1864 [610-3,118] pg/mL, respectively. By contrast, CSF p-tau181 and t-tau mean levels remained relatively constant with age in participants with mTBI, while tending to be higher at older ages for the non-mTBI group. The mTBI group also demonstrated poorer cognitive performance at older ages (omnibus p < 0.08): at age 50 years, the mean TMT-B time was higher by 34 seconds [10-58] and the mean CVLT-II short-delay recall was lower by 4.2 points [1.9-6.6]. Poorer verbal memory and verbal fluency performance were associated with lower CSF Aβ42 (p ≤ 0.05) in older participants. CSF Aβ levels decreased in middle-aged veterans with blast-related mTBI. These data suggest that chronic neuropathologic processes associated with blast mTBI share properties in common with pathogenic processes known to portend AD onset, thus raising concern that veterans with blast-related mTBI may develop a dementing disorder later in life.

Insider Threats to the Military Health System: A Systematic Background Check of TRICARE West Providers.

To address the pandemic, the Defense Health Agency (DHA) expanded its TRICARE civilian provider network by 30.1%. In 2022, the DHA Annual Report stated that TRICARE's provider directories were only 80% accurate. Unlike Medicare, the DHA does not publicly reveal National Provider Identification (NPI) numbers. As a result, TRICARE's 9.6 million beneficiaries lack the means to verify their doctor's credentials. Since 2013, the Department of Health and Human Services' (HHS) Office of Inspector General (OIG) has excluded 17,706 physicians and other providers from federal health programs due to billing fraud, neglect, drug-related convictions, and other offenses. These providers and their NPIs are included on the OIG's List of Excluded Individuals and Entities (LEIE). Patients who receive care from excluded providers face higher risks of hospitalization and mortality. We sought to assess the extent to which TRICARE screens health care provider names on their referral website against criminal databases. Between January 1-31, 2023, we used TRICARE West's provider directory to search for all providers within a 5-mile radius of 798 zip codes (38 per state, ≥10,000 residents each, randomly entered). We then copied and pasted all directory results' first and last names, business names, addresses, phone numbers, fax numbers, degree types, practice specialties, and active or closed statuses into a CSV file. We cross-referenced the search results against US and state databases for medical and criminal misconduct, including the OIG-LEIE and General Services Administration's (GSA) SAM.gov exclusion lists, the HHS Office of Civil Rights Health Insurance Portability and Accountability Act (HIPAA) breach reports, 15 available state Medicaid exclusion lists (state), the International Trade Administration's Consolidated Screening List (CSL), 3 Food and Drug Administration (FDA) debarment lists, the Federal Bureau of Investigation's (FBI) list of January 6 federal defendants, and the OIG-HHS list of fugitives (FUG). Our provider search yielded 111,619 raw results; 54 zip codes contained no data. After removing 72,156 (64.65%) duplicate entries, closed offices, and non-TRICARE West locations, we identified 39,463 active provider names. Within this baseline sample group, there were 2398 (6.08%) total matches against all exclusion and sanction databases, including 2197 on the OIG-LEIE, 2311 on the GSA-SAM.gov list, 2 on the HIPAA list, 54 on the state Medicaid exclusion lists, 69 on the CSL, 3 on the FDA lists, 53 on the FBI list, and 10 on the FUG. TRICARE's civilian provider roster merits further scrutiny by law enforcement. Following the National Institute of Standards and Technology 800, the DHA can mitigate privacy, safety, and security clearance threats by implementing an insider threat management model, robust enforcement of the False Claims Act, and mandatory security risk assessments. These are the views of the author, not the Department of Defense or the US government.

Decoupling in hybrid arrangements: Insights from the Australian defence industry

AbstractThe Australian Industry Capability (AIC) program presents an example of hybridity where national security interests are served through a complex partnership between the Department of Defence, global prime contractors, and small and medium‐sized Australian companies. Through a qualitative interview study of stakeholders in the defence industry by and triangulating findings from publicly available defence industry documents, this study aims to document the decoupling associated with the AIC program. We find that complexity and opacity, stemming from hybridity, create decoupling in the implementation of the AIC program. We also find that a lack of accountability and monitoring contributes to decoupling. We advance the literature on hybridity into the context of multi‐organisational arrangements in a unique industry and identify how decoupling can impede the achievement of policy objectives in the context of complex hybrid arrangements.Points for practitioners The Australian Industry Capability (AIC) program represents a case of complex hybrid arrangement in public sector management involving the defence industry. Hybridity of AIC arrangements creates challenges of complexity and opacity, creating conditions that give rise to decoupling. Lack of accountability and monitoring exacerbates these challenges. Potential for coupling is identified with recommendations provided.

Review of mental healthcare provision by primary care physicians in the Department of Defense (DoD)

Abstract Aim Primary care visits in the United States increasingly involve the treatment of mental health concerns, and the Military Health System (MHS) is no exception. The authors characterize treatment trends of mental healthcare in military primary care. Subject and methods A retrospective analysis of 110 million primary care visits and 27 million behavioral healthcare visits from an MHS database evaluated frequencies and proportions of mental health-related care in both military and civilian healthcare facilities for the years 2017–2021. Prevalence ratios were compared with Poisson regression models by year and by characteristic, with potential linear trends evaluated. Results A notable amount of behavioral healthcare provision transitioned from military to civilian healthcare facilities during this period. A comparison showed that psychotropic medication prescriptions from primary care prescribers with primary care visits coded for psychiatric diagnoses were similar for dependents (16.5% vs. 15.5%) but nearly doubled for military (7.7% vs. 3.9%). Active-duty personnel seen by primary care providers in purchased care (PC) were more than twice as likely to have a behavioral health diagnosis as those seen in direct care (DC) (8.4% vs. 3.9%). Conclusion To the best of the authors’ knowledge, this study is the first to use a comprehensive database to evaluate behavioral healthcare provision trends in the MHS. This provides a baseline of healthcare burden numbers useful for determining the training needed for primary care clinicians to feel comfortable appropriately treating mental health conditions. Future research should focus on diagnostic differences between civilian and military healthcare facilities as well as prescription discrepancies for service members.

Abstract 4861: Incidence rates of bladder and kidney cancers among U.S. military servicemen: Comparison with the rates in the general U.S. population

Abstract Background: The military population may differ from the general population in factors related to the incidence of bladder and kidney cancers. However, incidence rates of these cancers have not been systematically compared between the two populations. This study compared incidence rates of bladder and kidney cancers and their trends between active-duty servicemen and men in the general U.S. population. Methods: Data were obtained from the Department of Defense’s (DoD) Automated Central Tumor Registry (ACTUR) and the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) database. Patients were active-duty servicemen in ACTUR and men in SEER who were diagnosed with malignant bladder and kidney cancers and 18-59 years at diagnosis from 1990-2013. Age-adjusted rates, incidence rate ratios (IRR), and their 95% confidence intervals (95% CI) were compared between the two populations by age, race, and cancer stage. Trends in the incidence were also compared. Results: Incidence rates were lower in ACTUR than SEER for bladder cancer overall (IRR=0.55, 95% CI=0.48-0.62) and by age, race, or tumor stage. However, for 50-59-year-old men, the rates did not differ between the populations. Trend analysis showed bladder cancer incidence decreased more in ACTUR than SEER over the study period. Kidney cancer incidence rates were marginally lower overall (IRR=0.92, 95% CI=0.84-1.00) and significantly lower for 30-49-year-old Black men in the military than the general population. For kidney cancer, the trends were similar between the two populations with increased incidence from 1999 to 2013. Conclusion: Lower bladder and kidney cancer incidence in ACTUR, notably in younger individuals, may be primarily associated with healthier status and better health care. The lack of differences in bladder or kidney cancer incidence among 50-59-year-old men between the populations might result from more cumulative military-related exposures in this age group, which effects were offset by healthier status and better medical care. Disclaimer: The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, opinions or policies of NCI, USUHS, HJF, the DoD or the Departments of the Army, Navy or Air Force. Mention of trade names, commercial products or organizations does not imply endorsement by the US Government. Citation Format: Julie A. Bytnar, Katherine A. McGlynn, Sean Q. Kern, Craig D. Shriver, Kangmin Zhu. Incidence rates of bladder and kidney cancers among U.S. military servicemen: Comparison with the rates in the general U.S. population [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4861.

Abstract 4944: Divergent proteogenomic gene expression is driven by microenvironment across tumor types

Abstract Solid tumors develop through a complex series of genome and downstream expression alterations that interact with the local tissue microenvironment, leading to a transformed cell and malignant phenotype. With massive multi-omic data, recent proteogenomics studies have jointly analyzed RNA and protein expression to uncover new gene regulatory relationships; however, many of these studies focused on single tumor types and lack a generalizable view of joint RNA and protein expression. Here, we present the first pan-cancer analysis of sample-wise RNA to protein correlation (SRPC). We re-analyzed over 1,000 tumors across 10 tumor types from published proteogenomic data from the Clinical Proteomic Tumor Analysis Consortium (CPTAC) and the Applied Proteogenomics OrganizationaL Learning and Outcomes (APOLLO) Research Network. We identified a wide range of SRPC across all tumors (ρ range: -0.08 to 0.70, median: 0.45). We then analyzed tumor pathologic and molecular characteristics versus the range of SRPC. High SRPC tumors had high tumor purity by pathology review, by somatic DNA whole exome sequencing, and by RNA and protein purity scores. In contrast, low SRPC tumors had high immune cell and stromal cell expression scores as inferred by either protein or RNA based signatures. We observed marked differences in cell type populations estimated by expression in different SRPC tumor tranches (low SRPC: macrophages, endothelial cells, cancer-associated fibroblasts; high SRPC: CD4+ Th2 cells). Tumors expressed signaling pathways depending on their SRPC (low SRPC: hypoxia, inflammatory response, and KRAS signaling; high SRPC: DNA repair and E2F targets). SRPC also stratifies tumors with distinct somatic DNA alterations (low SRPC: HRAS and NF2; high SRPC: TP53, MEN1, high Tumor Mutational Burden and high DNA chromosomal instability). Finally, we found that cancer driver genes displayed divergent gene-wise RNA to protein correlations (GRPC) among tumor types with a median absolute deviation interquartile range of 0.1 - 0.2, suggesting tumor-type-specific regulation. In summary, divergent RNA and protein expression is driven, in part, by tumor microenvironment composition across tumor types. Tumors with a diverse cellular microenvironment display a summation of RNA and protein expression resulting from this cell type diversity leading to a low SRPC, while tumors predominated by tumor cells display coordinated RNA and protein expression levels resulting from a pure clonal or cell type leading to a high SRPC. This first deep analysis into sample-wise RNA to protein correlation represents a large proteogenomic community resource for informing biomarker analysis by modality and by tranches of tumor microenvironment. The views expressed in this abstract are solely of the authors and do not reflect the official policy of the Departments of Army/Navy/Air Force, Department of Defense, USUHS, HJF, or U.S. Government. Citation Format: Joseph LaMorte, Nicholas Bateman, Thomas Conrads, Robert F. Browning, Craig D. Shriver, Robert L. Kortum, Matthew D. Wilkerson. Divergent proteogenomic gene expression is driven by microenvironment across tumor types [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4944.