The United States Department of Defense Blast Injury Research Program Coordinating Office organized the 2015 International State-of-the-Science meeting to explore links between blast-related head injury and the development of chronic traumatic encephalopathy (CTE). Before the meeting, the planning committee examined articles published between 2005 and October 2015 and prepared this literature review, which summarized broadly CTE research and addressed questions about the pathophysiological basis of CTE and its relationship to blast- and nonblast-related head injury. It served to inform participants objectively and help focus meeting discussion on identifying knowledge gaps and priority research areas. CTE is described generally as a progressive neurodegenerative disorder affecting persons exposed to head injury. Affected individuals have been participants primarily in contact sports and military personnel, some of whom were exposed to blast. The symptomatology of CTE overlaps with Alzheimer's disease and includes neurological and cognitive deficits, psychiatric and behavioral problems, and dementia. There are no validated diagnostic criteria, and neuropathological evidence of CTE has come exclusively from autopsy examination of subjects with histories of exposure to head injury. The perivascular accumulation of hyperphosphorylated tau (p-tau) at the depths of cortical sulci is thought to be unique to CTE and has been proposed as a diagnostic requirement, although the contribution of p-tau and other reported pathologies to the development of clinical symptoms of CTE are unknown. The literature on CTE is limited and is focused predominantly on head injuries unrelated to blast exposure (e.g., football players and boxers). In addition, comparative analyses of clinical case reports has been challenging because of small case numbers, selection biases, methodological differences, and lack of matched controls, particularly for blast-exposed individuals. Consequently, the existing literature is not sufficient to determine whether the development of CTE is associated with head injury frequency (e.g., single vs. multiple exposures) or head injury type (e.g., impact, nonimpact, blast-related). Moreover, the incidence and prevalence of CTE in at-risk populations is unknown. Future research priorities should include identifying additional risk factors, pursuing population-based longitudinal studies, and developing the ability to detect and diagnose CTE in living persons using validated criteria.

Mental health problems pose challenges for military veterans, returning service members, and military family members including spouses and children. Challenges to meeting mental health needs include improving access to care and improving quality of care. Mobile Health, or "mHealth," can help meet these needs in the garrison and civilian environments. mHealth brings unique capabilities to health care provision through the use of mobile device technologies. This report identifies high-priority mHealth technology development considerations in two categories. First, priority considerations specific to mental health care provision include safety, privacy, evidence-based practice, efficacy studies, and temperament. Second, priority considerations broadly applicable to mHealth include security, outcomes, ease of use, carrier compliance, hardware, provider perspectives, data volume, population, regulation, command policy, and reimbursement. Strategic planning for the advancement of these priority considerations should be coordinated with stated Department of Defense capability needs to maximize likelihood of adoption. This report also summarizes three leading, military programs focused on mHealth projects in mental health, The Telemedicine and Advanced Technology Research Center, The Military Operational Medicine Research Program, United States Army Medical Research and Materiel Command, and The National Center for Telehealth and Technology.

Leading practices, gaps, and research needs for technology-based strategies were identified and prioritized. This information can be used to provide a research and development road map for (1) leveraging technology to minimize barriers to enhancing health and (2) facilitating evidence-based techniques to create and sustain healthy behaviors.

Health-related technology, its relevance, and its availability are rapidly evolving. Technology offers great potential to minimize and/or mitigate barriers associated with achieving optimal health, performance, and readiness. In support of the U.S. Army Surgeon General's vision for a "System for Health" and its Performance Triad initiative, the U.S. Army Telemedicine and Advanced Technology Research Center hosted a workshop in April 2013 titled "Incentives to Create and Sustain Change for Health." Members of government and academia participated to identify and define the opportunities, gain clarity in leading practices and research gaps, and articulate the characteristics of future technology solutions to create and sustain real change in the health of individuals, the Army, and the nation. The key factors discussed included (1) public health messaging, (2) changing health habits and the environmental influence on health, (3) goal setting and tracking, (4) the role of incentives in behavior change intervention, and (5) the role of peer and social networks in change. This report summarizes the recommendations on how technology solutions could be employed to leverage evidence-based best practices and identifies gaps in research where further investigation is needed.

The potential relationship between chronic traumatic encephalopathy (CTE) and head injuries such as blast-related traumatic brain injury (TBI) is an important area of study, particularly for military and contact sports populations, yet little is known about this relationship. To address this topic, the Department of Defense (DoD) Blast Injury Research Program Coordinating Office organized the 2015 International State-of-the-Science Meeting, which brought together subject matter experts from the DoD, other federal agencies, academia, industry, foreign allies, and the sports community. Over the course of the meeting, this community of experts reached a consensus regarding the current body of knowledge and the future of the field. The overarching finding was that there is insufficient existing scientific evidence to link blast-related

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Skilled Nursing Facility Value-Based Purchasing (SNF-VBP) was a new Medicare payment program when COVID-19 began. SNF-VBP aims to improve care through payment bonuses and penalties. However, studies have shown that minority-serving nursing homes (NHs) tend to fare worse under SNF-VBP (more likely to receive penalties, less likely to receive bonuses). This study sought to examine whether SNF-VBP performance prior to the pandemic was associated with COVID-19 outcomes and whether associations varied in NHs where the majority of residents are Black/African American (majority-Black/AA). Using publicly available data on COVID-19 outcomes and vaccinations, SNF-VBP performance, and NH characteristics, we found that majority-Black/AA NHs were less likely to have zero infections; had higher case fatality rates; and had lower resident and staff vaccinations rates compared to NHs where the majority of residents are White. Across all NHs, worse SNF-VBP performance was associated with worse COVID-19 outcomes (the bottom quintile of SNF-VBP performers were more likely to experience COVID-19 infections and had lower vaccination rates; the highest performers had higher vaccination rates). However, in stratified analyses, SNF-VBP performance was not significantly associated with COVID-19 outcomes in majority-Black/AA NHs compared with majority-White NHs. The association between poor SNF-VBP performance and poor COVID-19 outcomes is concerning. Overall findings suggest that SNF-VBP performance prior to the pandemic is an important indicator of subsequent COVID-19 outcomes. However, it is unclear whether poor SNF-VBP performance is signaling overall poor quality or whether it is signaling a financial disadvantage caused by the program itself that in turn impacted COVID-19 outcomes.

This report is published in the interest of scientific and technical information exchange, and its publication does not constitute the Government's approval or disapproval of its ideas or findings.