What Engineering Technology Could Do for Quality of Life in Parkinson's Disease: A Review of Current Needs and Opportunities

Parkinson's disease (PD) involves well-known motor symptoms such as tremor, rigidity, bradykinesia, and altered gait, but there are also nonlocomotory motor symptoms (e.g., changes in handwriting and speech) and even nonmotor symptoms (e.g., disrupted sleep, depression) that can be measured, monitored, and possibly better managed through activity-based monitoring technologies. This will enhance quality of life (QoL) in PD through improved self-monitoring and also provide information that could be shared with a healthcare provider to help better manage treatment. Until recently, nonmotor symptoms ("soft signs") had been generally overlooked in clinical management, yet these are of primary importance to patients and their QoL. Day-to-day variability of the condition, the high variability in symptoms between patients, and the isolated snapshots of a patient in periodic clinic visits make better monitoring essential to the proper management of PD. Continuously monitored patterns of activity, social interactions, and daily activities could provide a rich source of information on status changes, guiding self-correction and clinical management. The same tools can be useful in earlier detection of PD and will improve clinical studies. Remote medical communications in the form of telemedicine, sophisticated tracking of medication use, and assistive technologies that directly compensate for disease-related challenges are examples of other near-term technology solutions to PD problems. Ultimately, a sensor technology is not good if it is not used. The Parkinson's community is a sophisticated early adopter of useful technologies and a group for which engineers can provide near-term gratifying benefits.

U.S. Army Research on Pharmacological Enhancement of Soldier Performance: Stimulants, Anabolic Hormones, and Blood Doping

The level playing field of competitive sports is an irrelevant concern in asymmetrical warfare. However, there is a common theme of pressure to use performance-enhancing drugs because athletic or military opponents may be using them to advantage. This interest is fueled by personal anecdotes, misconceptions, and myths, and decisions to use or not to use pharmacological interventions may ignore available scientific data. The U.S. Army has led research in this area, with an abundance of published data extending back to World War II. Behavioral effects have been a consistent concern. A key conclusion to be drawn from this research is that although there may be specialized applications for some of these interventions, the majority of soldiers will gain the greatest performance benefits from effective physical and mental training programs combined with good principles of rest and nutrition. Furthermore, the perceived need to improve human biology with drugs may be solving the wrong problem, trying to fit the human to the demands of poorly conceived tactics, tasks, and equipments instead of capitalizing on human capabilities.

Lifestyle and health-related risk factors and risk of cognitive aging among older veterans

Lifestyle and health-related factors are critical components of the risk for cognitive aging among veterans. Because dementia has a prolonged prodromal phase, understanding effects across the life course could help focus the timing and duration of prevention targets. This perspective may be especially relevant for veterans and health behaviors. Military service may promote development and maintenance of healthy lifestyle behaviors, but the period directly after active duty has ended could be an important transition stage and opportunity to address some important risk factors. Targeting multiple pathways in one intervention may maximize efficiency and benefits for veterans. A recent review of modifiable risk factors for Alzheimer's disease estimated that a 25% reduction of a combination of seven modifiable risk factors including diabetes, hypertension, obesity, depression, physical inactivity, smoking, and education/cognitive inactivity could prevent up to 3 million cases worldwide and 492,000 cases in the United States. Lifestyle interventions to address cardiovascular health in veterans may serve as useful models with both physical and cognitive activity components, dietary intervention, and vascular risk factor management. Although the evidence is accumulating for lifestyle and health-related risk factors as well as military risk factors, more studies are needed to characterize these factors in veterans and to examine the potential interactions between them.

Effects of traumatic brain injury and posttraumatic stress disorder on Alzheimer's disease in veterans, using the Alzheimer's Disease Neuroimaging Initiative

Both traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) are common problems resulting from military service, and both have been associated with increased risk of cognitive decline and dementia resulting from Alzheimer's disease (AD) or other causes. This study aims to use imaging techniques and biomarker analysis to determine whether traumatic brain injury (TBI) and/or PTSD resulting from combat or other traumas increase the risk for AD and decrease cognitive reserve in Veteran subjects, after accounting for age. Using military and Department of Veterans Affairs records, 65 Vietnam War veterans with a history of moderate or severe TBI with or without PTSD, 65 with ongoing PTSD without TBI, and 65 control subjects are being enrolled in this study at 19 sites. The study aims to select subject groups that are comparable in age, gender, ethnicity, and education. Subjects with mild cognitive impairment (MCI) or dementia are being excluded. However, a new study just beginning, and similar in size, will study subjects with TBI, subjects with PTSD, and control subjects with MCI. Baseline measurements of cognition, function, blood, and cerebrospinal fluid biomarkers; magnetic resonance images (structural, diffusion tensor, and resting state blood-level oxygen dependent (BOLD) functional magnetic resonance imaging); and amyloid positron emission tomographic (PET) images with florbetapir are being obtained. One-year follow-up measurements will be collected for most of the baseline procedures, with the exception of the lumbar puncture, the PET imaging, and apolipoprotein E genotyping. To date, 19 subjects with TBI only, 46 with PTSD only, and 15 with TBI and PTSD have been recruited and referred to 13 clinics to undergo the study protocol. It is expected that cohorts will be fully recruited by October 2014. This study is a first step toward the design and statistical powering of an AD prevention trial using at-risk veterans as subjects, and provides the basis for a larger, more comprehensive study of dementia risk factors in veterans.

Report of an EU-US symposium on understanding nutrition-related consumer behavior: strategies to promote a lifetime of healthy food choices

This report summarizes an EU-US Task Force on Biotechnology Research symposium on healthy food choices and nutrition-related purchasing behaviors. This meeting was unique in its transdisciplinary approach to obesity and in bringing together scientists from academia, government, and industry. Discussion relevant to funders and researchers centered on (1) increased use of public-private partnerships, (2) the complexity of food behaviors and obesity risk and multilevel aspects that must be considered, and (3) the importance of transatlantic cooperation and collaboration that could accelerate advances in this field. A call to action stressed these points along with a commitment to enhanced communication strategies.

Military risk factors for cognitive decline, dementia and Alzheimer's disease

Delayed neurological health consequences of environmental exposures during military service have been generally underappreciated. The rapidly expanding understanding of Alzheimer's disease (AD) pathogenesis now makes it possible to quantitate some of the likely long-term health risks associated with military service. Military risk factors for AD include both factors elevated in military personnel such as tobacco use, traumatic brain injury (TBI), depression, and post-traumatic stress disorder (PTSD) and other nonspecific risk factors for AD including, vascular risk factors such as obesity and obesity-related diseases (e.g., metabolic syndrome), education and physical fitness. The degree of combat exposure, Vietnam era Agent Orange exposure and Gulf War Illness may also influence risk for AD. Using available data on the association of AD and specific exposures and risk factors, the authors have conservatively estimated 423,000 new cases of AD in veterans by 2020, including 140,000 excess cases associated with specific military exposures. The cost associated with these excess cases is approximately $5.8 billion to $7.8 billion. Mitigation of the potential impact of military exposures on the cognitive function of veterans and management of modifiable risk factors through specifically designed programs will be instrumental in minimizing the impact of AD in veterans in the future decades.

Designing and using computer simulations in medical education and training: an introduction

Computer-based technologies informed by the science of learning are becoming increasingly prevalent in education and training. For the Department of Defense (DoD), this presents a great potential advantage to the effective preparation of a new generation of technologically enabled service members. Military medicine has broad education and training challenges ranging from first aid and personal protective skills for every service member to specialized combat medic training; many of these challenges can be met with gaming and simulation technologies that this new generation has embraced. However, comprehensive use of medical games and simulation to augment expert mentorship is still limited to elite medical provider training programs, but can be expected to become broadly used in the training of first responders and allied health care providers. The purpose of this supplement is to review the use of computer games and simulation to teach and assess medical knowledge and skills. This review and other DoD research policy sources will form the basis for development of a research and development road map and guidelines for use of this technology in military medicine.

Body composition and military performance--many things to many people

Soldiers are expected to maintain the highest possible level of physical readiness because they must be ready to mobilize and perform their duties anywhere in the world at any time. The objective of Army body composition standards is to motivate physical training and good nutrition habits to ensure a high state of readiness. Establishment of enforceable and rational standards to support this objective has been challenging even at extremes of body size. Morbidly obese individuals are clearly not suited to military service, but very large muscular individuals may be superbly qualified for soldier performance demands. For this reason, large individuals are measured for body fat using a waist circumference-based equation (female soldiers are also measured for hip circumference). The main challenge comes in setting appropriate fat standards to support the full range of Army requirements. Military appearance ideals dictate the most stringent body fat standards, whereas health risk thresholds anchor the most liberal standards, and physical performance associations fall on a spectrum between these 2 poles. Standards should not exclude or penalize specialized performance capabilities such as endurance running or power lifting across a spectrum of body sizes and fat. The full integration of women into the military further complicates the issue because of sexually dimorphic characteristics that make gender-appropriate standards essential and where inappropriately stringent standards can compromise both health and performance of this segment of the force. Other associations with body composition such as stress effects on intraabdominal fat distribution patterns and metabolic implications of a fat reserve for survival in extreme environments are also relevant considerations. This is a review of the science that underpins the U.S. Army body composition standards.

A standard telemental health evaluation model: the time is now

The telehealth field has advanced historic promises to improve access, cost, and quality of care. However, the extent to which it is delivering on its promises is unclear as the scientific evidence needed to justify success is still emerging. Many have identified the need to advance the scientific knowledge base to better quantify success. One method for advancing that knowledge base is a standard telemental health evaluation model. Telemental health is defined here as the provision of mental health services using live, interactive video-teleconferencing technology. Evaluation in the telemental health field largely consists of descriptive and small pilot studies, is often defined by the individual goals of the specific programs, and is typically focused on only one outcome. The field should adopt new evaluation methods that consider the co-adaptive interaction between users (patients and providers), healthcare costs and savings, and the rapid evolution in communication technologies. Acceptance of a standard evaluation model will improve perceptions of telemental health as an established field, promote development of a sounder empirical base, promote interagency collaboration, and provide a framework for more multidisciplinary research that integrates measuring the impact of the technology and the overall healthcare aspect. We suggest that consideration of a standard model is timely given where telemental health is at in terms of its stage of scientific progress. We will broadly recommend some elements of what such a standard evaluation model might include for telemental health and suggest a way forward for adopting such a model.

Cognitive change associated with self-reported mild traumatic brain injury sustained during the OEF/OIF conflicts

Traumatic brain injury (TBI) has received much attention due to high rates of this injury in Service Members returning from the Iraq/Afghanistan conflicts. This study examined cognitive performance in Service Members tested with ANAM prior to and following deployment. The sample was divided into a control group (n=400) reporting no TBI injury prior to or during most recent deployment, and a group who self-reported a TBI injury (n=502) during most recent deployment. This latter group was divided further based on self-report of post-concussion symptoms at post-deployment testing. All three groups performed similarly at pre-deployment. The group reporting TBI with active symptoms performed worst at post-deployment and included the highest percentage of individuals showing significant decline in cognitive performance over time (30.5%). A small sample of symptomatic individuals with a non-TBI reported injury did not demonstrate similar declines in performance, suggesting that active symptoms alone cannot account for these findings. Of those reporting a TBI injury during deployment, 70% demonstrated no significant change in cognitive performance compared with baseline. Although the exact etiology of observed declines is uncertain, findings indicate that individuals who self-report TBI during deployment with active symptomatology at post-deployment are at greatest risk for declines in cognitive performance. These individuals can be identified using self-report and brief computer-based testing. Importantly, the majority of active-duty individuals reporting TBI during deployment do not present with lasting significant cognitive impairment, a finding consistent with the civilian literature on mild TBI.

Nanotechnology research: applications in nutritional sciences

The tantalizing potential of nanotechnology is to fabricate and combine nanoscale approaches and building blocks to make useful tools and, ultimately, interventions for medical science, including nutritional science, at the scale of approximately 1-100 nm. In the past few years, tools and techniques that facilitate studies and interventions in the nanoscale range have become widely available and have drawn widespread attention. Recently, investigators in the food and nutrition sciences have been applying the tools of nanotechnology in their research. The Experimental Biology 2009 symposium entitled "Nanotechnology Research: Applications in Nutritional Sciences" was organized to highlight emerging applications of nanotechnology to the food and nutrition sciences, as well as to suggest ways for further integration of these emerging technologies into nutrition research. Speakers focused on topics that included the problems and possibilities of introducing nanoparticles in clinical or nutrition settings, nanotechnology applications for increasing bioavailability of bioactive food components in new food products, nanotechnology opportunities in food science, as well as emerging safety and regulatory issues in this area, and the basic research applications such as the use of quantum dots to visualize cellular processes and protein-protein interactions. The session highlighted several emerging areas of potential utility in nutrition research. Nutrition scientists are encouraged to leverage ongoing efforts in nanomedicine through collaborations. These efforts could facilitate exploration of previously inaccessible cellular compartments and intracellular pathways and thus uncover strategies for new prevention and therapeutic modalities.

Waist circumference threshold values for type 2 diabetes risk

Adult gains in body weight, excess adiposity, and intra-abdominal fat have each been associated with risk for type 2 diabetes mellitus (T2DM), forming the basis for preventive medicine guidelines and actuarial predictions using practical indices of weight (e.g., body mass index [BMI]) and waist circumference (WC). As obesity-related disease spreads beyond affluent western countries, application of WC thresholds to other populations has highlighted issues of their generalizability. For example, U.S. national health goals based on BMI < 25 kg/m(2) and WC < 89 cm (women) and <102 cm (men) differ considerably with a recent law in Japan mandating intervention for older adults with WC exceeding 90 cm (women) and 85 cm (men). The U.S. military has also faced issues of generalizability of WC-based adiposity standards that are fair and achievable. Data from many studies indicate that WC is a reliable biomarker for T2DM risk, suggesting that, for adult men and women, action thresholds should be more stringent than current U.S. guidelines, and it would not be harmful to set worldwide targets somewhere below 90 cm for men and women, regardless of weight status. Medical technology has provided many great insights into disease, including modern imaging technologies that have differentiated fat depots that have the greatest influence on T2DM, but ultimately, an inexpensive measuring tape provides the most useful and cost-effective preventive measure for T2DM today. At some point in the future, a Star Trek-like abdominal body fat "tricorder" noninvasive assessment of tissue composition may provide an advantage over abdominal girth.

Military services fitness database: development of a computerized physical fitness and weight management database for the U.S. Army

The Department of Defense (DoD) has mandated development of a system to collect and manage data on the weight, percent body fat (%BF), and fitness of all military personnel. This project aimed to (1) develop a computerized weight and fitness database to track individuals and Army units over time allowing cross-sectional and longitudinal evaluations and (2) test the computerized system for feasibility and integrity of data collection over several years of usage. The computer application, the Military Services Fitness Database (MSFD), was designed for (1) storage and tracking of data related to height, weight, %BF for the Army Weight Control Program (AWCP) and Army Physical Fitness Test (APFT) scores and (2) generation of reports using these data. A 2.5-year pilot test of the MSFD indicated that it monitors population and individual trends of changing body weight, %BF, and fitness in a military population.

Dietary reference intakes for vitamin D: justification for a review of the 1997 values

Recent Institute of Medicine (IOM) reviews of the process for deriving Dietary Reference Intakes (DRIs) suggest that determining the need for a new nutrient review should be evaluated against criteria set a priori. After selecting the criterion of significant new and relevant research, a working group of US and Canadian government scientists used results from a systematic review and 2 conferences on vitamin D and health to evaluate whether significant new and relevant scientific evidence had become available since the 1997 IOM publication of the DRIs for vitamin D. This working group concluded that there appears to be new research meeting the criteria for 4 key DRI questions. The new research is of larger quantity and quality for the elderly than for other groups, but overall 1) adds to the bone-related and status evidence available to the 1997 DRI Committee for several of the life-stage groups, 2) identifies new outcomes with respect to risk of falls and performance measures in the elderly and potential adverse effects, and 3) provides additional information on dose-response relations between intakes and circulating 25-hydroxyvitamin D concentrations and between 25-hydroxyvitamin D concentrations and several health outcomes (ie, bone-related outcomes for all ages and risk of falls and performance measures in older adults). Members of the working group concluded that significant new and relevant research was available for reviewing the existing DRIs for vitamin D while leaving the decision of whether the new research will result in changes to the current DRIs to a future IOM-convened DRI committee.

Stress fracture and military medical readiness: bridging basic and applied research

PURPOSE

Military recruits and distance runners share a special risk of stress fracture injury. Recent efforts by US and Israeli military-sponsored researchers have uncovered important mechanisms and practical low-cost interventions. This article summarizes key findings relevant to prevention of stress fracture, including simple strategies to identify and to mitigate risk.

METHODS

Published research supported through the Bone Health and Military Medical Readiness research program and related military bone research was analyzed for contributions to preventing stress fracture in military recruits and optimizing bone health.

RESULTS

Thousands of military recruits helped test hypotheses about predictors of risk, safer exercise regimens, and rest, nutrition, gait training, and technology interventions to reduce stress fracture risk. Concurrent cellular, animal, and human laboratory studies were used to systematically investigate mechanisms of mechanical forces acting on bone and interactions through muscle, hormonal and genetic influences, and metabolism. The iterative and sometimes simultaneous process of basic discovery and field testing produced new knowledge that will provide safer science-based physical training.

DISCUSSION

Human training studies evaluating effects on bone require special commitment from investigators and funders due to volunteer compliance and attrition challenges. The findings from multiple studies indicate that measures of bone elasticity, fragility, and geometry are as important as bone mineral density in predicting fracture risk, with applications for new measurement technologies. Risk may be reduced by high intakes of calcium, vitamin D, and possibly protein (e.g., milk products). Prostaglandin E2, insulin-like growth factor 1, and estrogens are important mediators of osteogenesis, indicating reasons to limit the use of certain drugs (e.g., ibuprofen), to avoid excessive food restriction, and to treat hypogonadism. Abnormal gait may be a correctable risk factor. Brief daily vibration may stimulate bone mineral accretion similar to weight-bearing exercise. Genetic factors contribute importantly to bone quality, affecting fracture susceptibility and providing new insights into fracture healing and tissue reengineering.

Physiological consequences of U.S. Army Ranger training

PURPOSE

Soldiers are expected to maintain a high degree of physical readiness as operational demands can severely degrade performance capabilities. This study examined the physiological consequences of U.S. Army Ranger training on strength, power, body composition, and somatotrophic hormones.

METHODS

In an intensive 8-wk military training course that included an average daily energy deficit of 1000 kcal.d, lower-body power output, maximal lifting strength, body composition, and serum concentrations of several somatotrophic hormones were measured in 50 male soldiers (24.6 +/- 4.4 y; 176.1 +/- 7.8 cm; 78.4 +/- 8.7 kg; 14.7 +/- 4.2% body fat) before and after the course.

RESULTS

Vertical jump height (-16%), explosive power output (-21%), maximal lifting strength. (-20%), body mass (-13%), fat-free mass (-6%), and fat mass (-50%) declined (P < 0.05) after the training course. Circulating total testosterone and insulin-like growth factor-I (IGF-I) experienced significant (P < 0.05) declines, and cortisol was significantly increased. Lower-body power output, but not maximal lifting strength, correlated with changes in fat-free mass. IGF-I and cortisol, but not total testosterone, were correlated with losses of tissue mass.

CONCLUSION

Lower-body power output, estimated from vertical jump height and body mass, is a sensitive and field expedient measure that can be used to assess the influence of caloric deficit on physical performance after 8 wk of U.S. Army Ranger training. With severe weight loss (>or=13% of body mass), IGF-I and cortisol correlate more closely with soft-tissue tissue adaptations than does testosterone.