Leaning in to Address Sleep Disturbances and Sleep Disorders in Department of Defense and Defense Health Agency

Letter to the Editor, Military Medicine, 187, 5/6:155, 202217 USC 105 interim-entered record; under review.The article of record as published may be found at http://dx.doi.org/10.1177/0018720820906050In their article entitled, “Engaging Stakeholders to Optimize Sleep Disorders Management in the U.S. Military: A Qualitative Analysis,” Abdelwadoud and colleagues conducted focus groups of service members, primary care managers (PCMs), and administrative stakeholders about their perceptions, experiences, roles in sleep management, stated education needs, and management of sleep disorders.1 The qualitative methods are rigorous, and the findings reinforce and nuance prior results, especially regarding key requirements from PCMs. We feel compelled, however, to further nuance the authors’ conclusion that “current military sleep management practices are neither satisfactory nor maximally effective” and offer specific examples of actions taken by the Department of Defense (DoD) and Defense Health Agency (DHA) in recognition of the significance of optimal sleep in combat readiness and overall health of service members. We offer here a succinct list of concrete efforts to support and implement substantial clinical, operational, research, or educational efforts by the DoD or DHA to improve sleep in service members and associated clinical challenges in this unique population.Identified in text as U.S. Government work

Growing small solid nodules in lung cancer screening: safety and efficacy of a 200 mm3 minimum size threshold for multidisciplinary team referral

The optimal management of small but growing nodules remains unclear. The SUMMIT study nodule management algorithm uses a specific threshold volume of 200 mm3 before referral of growing solid nodules to the multidisciplinary team for further investigation is advised, with growing nodules below this threshold kept under observation within the screening programme. Malignancy risk of growing solid nodules of size >200 mm3 at initial 3-month interval scan was 58.3% at a per-nodule level, compared with 13.3% in growing nodules of size ≤200 mm3 (relative risk 4.4, 95% CI 2.17 to 8.83). The positive predictive value of a combination of nodule growth (defined as percentage volume change of ≥25%), and size >200 mm3 was 65.9% (29/44) at a cancer-per-nodule basis, or 60.5% (23/38) on a cancer-per-participant basis. False negative rate of the protocol was 1.9% (95% CI 0.33% to 9.94%). These findings support the use of a 200 mm3 minimum volume threshold for referral as effective at reducing unnecessary multidisciplinary team referrals for small growing nodules, while maintaining early-stage lung cancer diagnosis

Nightmares in United States Military Personnel With Sleep Disturbances

The article of record as published may be found at http://doi.org/10.5664/jcsm.6990The spectrum of sleep disorders in military personnel is varied and complicated by the presence of comorbidities and psychological disorders. Currently, little is known regarding nightmares, especially trauma-related nightmares. Study Impact: This is the first study to report on objective and subjective sleep attributes in a cohort of military personnel, determining the prevalence of nightmares and polysomnographic characteristics associated with nightmares. Clinically, this highlights the need for military and civilian health care providers to evaluate for nightmares in individuals with sleep disturbances after traumatic experiences. From a research perspective, these findings provide the basis to further address nightmares, which are associated with the pressing issues of sleep and behavioral medicine disorders and suicidality in military and veteran populations

The Role of Sleep in Human Performance and Well-Being

The article of record as published may be found at https://doi.org/10.1093/oso/9780190455132.003.0010This chapter explores the influence of sleep on human performance and well-being. A general discussion of the role of sleep in humans is followed by a description of the functions of various stages of sleep. The authors explore causal factors of insufficient sleep and inventory known effects of sleep restriction on human performance. They then describe the particular challenges of fatigue and sleep deprivation in military operational environments. The efficacy of fatigue countermeasures and alertness aids commonly used in military settings is presented. The chapter concludes with an argument for more deliberately protecting and promoting sleep, particularly in vulnerable populations such as shiftworkers

Notecarin D Binds Human Factor V and Factor V-a with High Affinity in the Absence of Membranes

Notecarin D (NotD) is a prothrombin (ProT) activator in the venom of the tiger snake, Notechis scutatus, and a factor Xa (FXa) homolog. NotD binds specifically to the FXa binding site expressed on factor V (FV) upon activation to factor Va (FVa) by thrombin. NotD active site-labeled with 5-fluorescein ([5F]FFR-NotD) binds FV and FVa with remarkably high affinity in the absence of phospholipids (K(D) 12 and ≤ 0.01 nm, respectively). In the presence of membranes, the affinity of [5F]FFR-NotD for FVa is similar, but increased ∼55-fold for FV. Binding of FXa active site-labeled with Oregon Green to FV and FVa in the presence of phospholipids is ∼5,000- and ∼80-fold weaker than [5F]FFR-NotD, respectively. NotD reports FVa and not FV binding by a 3-fold increase in tripeptide substrate hydrolysis, demonstrating allosteric regulation by FVa. The NotD·FVa·membrane complex activates ProT with K(m)((app)) similar to prothrombinase, and ∼85-fold weaker without membranes. Active site-blocked NotD exhibits potent anticoagulant activity in plasma thrombin generation assays, representing inhibition of productive prothrombinase assembly and possible disruption of FXa inhibition by the tissue factor pathway inhibitor. The results show that high affinity binding of NotD to FVa is membrane-independent, unlike the strict membrane dependence of FXa for high affinity FVa binding

Research on Youth and Young Adult Tobacco Use, 2013–2018, From the Food and Drug Administration–National Institutes of Health Tobacco Centers of Regulatory Science

The Tobacco Regulatory Science Program is a collaborative research effort between the National Institutes of Health (NIH) and the Food and Drug Administration (FDA). In 2013, the NIH funded 14 Tobacco Centers of Regulatory Science (TCORS), which serve as partners in establishing research, training, and professional development programs to guide FDA. Each of the fourteen TCORS, and two other NIH-funded research programs, the Center for the Evaluation of Nicotine in Cigarettes (CENIC) and the Consortium on Methods Evaluating Tobacco (COMET), pursued specific research themes relevant to FDA's priorities. A key mandate for FDA is to reduce tobacco use among young people. This article is a review of the peer-reviewed research, including published and in-press manuscripts, from the TCORS, CENIC, and COMET, which provides specific data or other findings on youth (ages 10-18 years) and/or young adults (ages 18-34 years), from 2013 to 2018. Citations of all TCORS, CENIC, and COMET articles from September 2013 to December 2017 were collected by the TCORS coordinating center, the Center for Evaluation and Coordination of Training and Research. Additional citations up to April 30, 2018 were requested from the principal investigators. A scoring rubric was developed and implemented to assess study type, primary theme, and FDA priority area addressed by each article. The major subareas and findings from each priority area are presented. There were 766 articles in total, with 258 (34%) focusing on youth and/or young adults. Findings relevant to FDA from this review concern impact analysis, toxicity, health effects, addiction, marketing influences, communications, and behavior.ImplicationsThe Tobacco Centers of Regulatory Science, CENIC, and COMET have had a high output of scientific articles since 2013. These Centers are unique in that the FDA supports science specifically to guide future regulatory actions. The 258 articles that have focused on youth and/or young adults are providing data for regulatory actions by the FDA related to the key priority areas such as the addictiveness of non-cigarette products, the effects of exposure to electronic cigarette marketing on initiation and cessation, and the impact of flavored products on youth and young adult tobacco use. Future regulations to reduce tobacco use will be guided by the cumulative evidence. These Centers are one innovative mechanism to promote important outcomes to advance tobacco regulatory science