Placing the keystone: the LIMBIC Military and Tactical Athlete Research Study.

OBJECTIVE: The LIMBIC Military and Tactical Athletic Research Study (MATARS) framework was established to confirm and extend understanding of concussion with initial studies driven by clinical data collected between 2015 and 2020 in a collegiate sports setting. The LIMBIC MATARS framework will be leveraged to apply gold-standard and innovative research designs to advance the science of concussion. This manuscript provides the background, methodology, and initial demographic data associated with the LIMBIC MATARS. METHODS: Consensus-based common data elements were used to conduct a retrospective chart review, specific to collegiate athletes diagnosed with concussions between 2015 and 2020 at 11 universities. RESULTS: A final sample of 1,311 (47.8% female) concussions were diagnosed during the five-year study period from athletes participating in a variety of National Collegiate Athlete Association (NCAA) sports. The LIMBIC MATARS demographic data, align with the NCAA and other pioneering multi-site concussion-related studies in terms of biological sex, race and ethnicity, and sport participation. CONCLUSION: This pragmatic, methodological approach was used to address several a priori hypotheses related to concussion, align with other multi-site studies of concussion, and establish a consortium for future investigations.

Racial identity and concussion diagnosis and recovery trajectories in collegiate athletes: a LIMBIC MATARS investigation.

OBJECTIVE: To determine if there were concussion diagnosis and recovery disparities between collegiate athletes with Black and White racial identities. DESIGN: Retrospective cohort study. METHODS: Concussion information was extracted from NCAA athlete medical files at LIMBIC MATARS member institutions from the 2015-16' to 2019-20' academic years. A total of 410 concussions from 9 institutions were included that provided all independent (i.e. racial identity of Black or White) and dependent variable information (i.e. dates of injury, diagnosis, symptom resolution, and return to sport) that were analyzed using Mann-Whitney U tests. The sample consisted of 114 (27.8%) concussions sustained by Black athletes and 296 (72.1%) sustained by White athletes. RESULTS: The overall sample had a median of 0 days between injury occurrence to diagnosis, 7 days to symptom resolution, and 12 days to return to sport. No significant timing differences were observed for concussion diagnosis (p = .14), symptom resolution (p = .39), or return to sport (p = 0.58) between collegiate athletes with Black versus White racial identities. CONCLUSIONS: These findings may reflect equitable access to onsite sports medicine healthcare resources that facilitate concussion management in the collegiate sport setting. Future work should explore these associations with a larger and more diverse sample of collegiate athletes.

Effects of bovine cytochrome P450 single-nucleotide polymorphism, forage type and body condition on production traits in cattle.

Relating single-nucleotide polymorphisms (SNP) to cows with acceptable productivity could benefit cattle breeders in areas where tall fescue is the predominant forage. This study aimed to (i) identify SNPs in bovine cytochrome P450 3A28 (CYP3A28) and (ii) determine the associations between SNP genotype, forage and cow body condition (BC). Genotype (CC, CG or GG) and forage [Kentucky-31 wild-type endophyte-infected tall fescue (KY+) vs. bermudagrass] effects on milk volume and quality were determined in Herd 1 cows (123 cows); in Herd 2 (99 cows), genotype and BC (low vs. moderate) effects on ovarian follicle size, calving date and calving per cent were determined; and in Herd 3 (114 cows), effects of genotype and fescue cultivar [KY+ vs. non-toxic endophyte-infected tall fescue (HiMag4)] were related to calving per cent, calving date and weaning weights of both cow and her calf. A cytosine (C) to guanine (G) transversion at base 994 (C994G) in CYP3A28 was identified. There was a genotype × forage type interaction (p < 0.05) on milk protein in Herd 1 cows; CC cows grazing bermudagrass had greater milk protein percentage in relation to other cows in the herd. In Herd 2, BC and genotype × BC tended (p < 0.10) to influence follicle size and Julian calving date respectively. Diameter of the largest follicle tended to be larger in moderate BC than in low-BC cows; whereas, CC and CG cows in moderate BC and homozygous (CC and GG) cows in low BC tended to calve 14 days earlier in relation to CG cows in low BC. In Herd 3, there was a genotype × forage type interaction (p < 0.05) on calving per cent, Julian calving date and calf weaning weight. In this study, genetic alterations (G allele at C994G) coupled with nutritional factors (low BC and toxic tall fescue) resulted in overall lower productivity in cows.

Electroporation-mediated delivery of a naked DNA plasmid expressing VEGF to the porcine heart enhances protein expression.

Gene therapy is an attractive method for the treatment of cardiovascular disease. However, using current strategies, induction of gene expression at therapeutic levels is often inefficient. In this study, we show a novel electroporation (EP) method to enhance the delivery of a plasmid expressing an angiogenic growth factor (vascular endothelial growth factor, VEGF), which is a molecule previously documented to stimulate revascularization in coronary artery disease. DNA expression plasmids were delivered in vivo to the porcine heart with or without coadministered EP to determine the potential effect of electrically mediated delivery. The results showed that plasmid delivery through EP significantly increased cardiac expression of VEGF compared with injection of plasmid alone. This is the first report showing successful intracardiac delivery, through in vivo EP, of a protein expressing plasmid in a large animal.

Symptom dimensions and cognitive-behavioural therapy outcome for pediatric obsessive-compulsive disorder.

OBJECTIVE: To examine whether obsessive-compulsive disorder (OCD) symptom subtypes are associated with response rates to cognitive-behavioural therapy (CBT) among pediatric patients. METHOD: Ninety-two children and adolescents with OCD (range = 7-19 years) received 14 sessions of weekly or intensive (daily psychotherapy sessions) family-based CBT. Assessments were conducted at baseline and post-treatment. Primary outcomes included scores on the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), remission status, and ratings on the Clinical Global Improvement (CGI) and Clinical Global Impression - Severity (CGI-Severity) scales. RESULTS: Seventy-six per cent of study participants (n = 70) were classified as treatment responders. Patients with aggressive/checking symptoms at baseline showed a trend (P = 0.06) toward improved treatment response and exhibited greater pre/post-treatment CGI-Severity change than those who endorsed only non-aggressive/checking symptoms. Step-wise linear regression analysis indicated higher scores on the aggressive/checking dimension were predictive of treatment-related change in the CGI-Severity index. Regression analysis with CY-BOCS score as the dependent variable showed no difference between OCD subtypes. CONCLUSION: Response to CBT in pediatric OCD patients does not differ substantially across subtypes.

Women, Co-occurring Disorders, and Violence Study: evaluation design and study population.

The Women, Co-occurring Disorders, and Violence Study (WCDVS) was a multi-site cooperative study to evaluate new service models for women with co-occurring mental health and substance use disorders and a history of physical and/or sexual abuse. Despite common features in the service interventions and evaluation procedures, diversity across the nine sites plus differences introduced by non-random assignment led to numerous methodological challenges. This article describes the design, measurement, and analysis decisions behind the WCDVS and lays the foundation for understanding participant-level outcomes and service costs. This article also describes the study population, as recruited and following attrition at the 6-month follow-up, in order to address the threat of selection bias to inferences drawn from this multi-site study.

Abuse, addiction, and depression as pathways to sexual risk in women and men with a history of substance abuse.

PURPOSE: In this paper, we develop and test a model for predicting sexual risk for HIV and other STDs. METHODS: Researchers interviewed 528 women and men with a history of substance abuse about their past experiences of physical and sexual abuse, symptoms, and sexual risk behavior (number of partners, trading sex for drugs or money, unprotected intercourse, and sexual orientation). The model explores direct and indirect associations of physical abuse and sexual abuse with sexual risk. RESULTS: Depression and severity of problems with drugs and alcohol were expected to mediate associations between abuse and sexual risk. However, analyses did not substantiate any indirect effects. Being female, more severe drug problems and, among men, past sexual abuse were significant predictors of sexual risk. CONCLUSION: Prevention interventions would do well to address not only drug addiction, but also past sexual abuse in men and depression in women.

Improving alcoholism treatment across the spectrum of services.

This article represents the proceedings of a symposium at the 2000 RSA Meeting in Denver, Colorado. The chair was Michael E. Hilton. The presentations were (1) The effects of brief advice and motivational enhancement on alcohol use and related variables in primary care, by Stephen A. Maisto, Joseph Conigliaro, Melissa McNiel, Kevin Kraemer, Mary E. Kelley, and Rosemarie Conigliaro; (2) Enhanced linkage of alcohol dependent persons to primary medical care: A randomized controlled trial of a multidisciplinary health evaluation in a detoxification unit, by Jeffrey H. Samet, Mary Jo Larson, Jacqueline Savetsky, Michael Winter, Lisa M. Sullivan, and Richard Saitz; (3) Cost-effectiveness of day hospital versus traditional alcohol and drug outpatient treatment in a health maintenance organization: Randomized and self-selected samples, by Constance Weisner, Jennifer Mertens, Sujaya Parthasarathy, Charles Moore, Enid Hunkeler, Teh-Wei Hu, and Joe Selby; and (4) Case monitoring for alcoholics: One year clinical and health cost effects, by Robert L. Stout, William Zywiak, Amy Rubin, William Zwick, Mary Jo Larson, and Don Shepard.

Cost-effectiveness of substance abuse services. Implications for public policy.

Cost-effectiveness analysis, a technique for allocating resources, examines the relationship between the cost of providing treatment and resulting improvement in health measured in a single, numerical scale. In applying this concept to substance abuse services, the authors expressed effectiveness in terms of additional "abstinent years." To control for differences in clients across modalities, the authors used multivariate cost-effectiveness analysis, estimating results for a typical client at each of three alternative severity levels.

Managed care of substance abuse disorders. Implications for generalist physicians.

Given the rapidly changing landscape of both private and public health plan programs, it is foolhardy to suggest that a definitive characterization of managed care and substance abuse issues can be made. Among other topics, this article discusses goals of managed care organizations, managed care models, and physicians' roles in managed care.

Can urinary nitrite results be used to guide antimicrobial choice for urinary tract infection?

Enterococcus is unable to reduce nitrates and is also considered clinically resistant to trimethoprim/sulfamethoxazole (TMP/SMX), the drug of choice for uncomplicated urinary tract infection (UTI). The purpose of this study was to determine whether urinalysis nitrite results can be used to guide antimicrobial therapy when treating UTI in the emergency department (ED). A retrospective chart review examined 159 university hospital ED outpatients who had signs or symptoms of UTI and had a urinalysis with positive culture. Patients were categorized into two groups based on nitrite results. The proportion of isolates sensitive to TMP/SMX in each group was compared by using a two-sample z-test. Eighty-six urinalyses were nitrite positive: 67 (78%) contained TMP/SMX-sensitive isolates. Seventy-three urinalyses were nitrite negative; 60 (82%) contained sensitive isolates. There was no statistically significant difference in the proportion of isolates sensitive to TMP/SMX. Thus, we conclude that emergency physicians should not adjust antibiotic therapy for UTI based on nitrite results.

Efficacy of a fibrin hemostatic bandage in controlling hemorrhage from experimental arterial injuries.

OBJECTIVE: To determine if a pressure dressing containing fibrinogen and thrombin could provide more effective control of arterial hemorrhage than a pressure dressing alone in an animal model of arterial injury. DESIGN: Randomized acute (nonsurvival) experiment in swine. SETTING: Federal biomedical research institute. ANIMALS: Six anesthetized Yorkshire swine. INTERVENTIONS: Uncontrolled arterial hemorrhage was induced in anesthetized swine by creating femoral artery lacerations. Hemorrhage was controlled by a gauze bandage containing fibrinogen and thrombin, applied with 1 minute of 3.5-kg pressure. The dressings were left in place for 1 hour after the pressure was removed. The contralateral limbs received identical treatment with plain gauze dressings. MAIN OUTCOME MEASURES: Total blood loss, mean arterial pressure, and mortality were measured after 1 hour. RESULTS: After 1 hour, blood loss in the fibrin bandage group was 123 +/- 48 mL, compared with 734 +/- 134 mL in the control group (P = .0022). In the group treated with the fibrin bandages, there was no significant decrease in the mean arterial pressure after arterial laceration. In contrast, there was a decrease of 30 mm Hg in the group treated with gauze dressings alone. There was no animal mortality during the study period. CONCLUSIONS: Bandages containing fibrinogen and thrombin significantly reduced the amount of blood loss and allowed mean arterial pressures to be maintained in animals with uncontrolled hemorrhage from femoral artery lacerations. A hemostatic bandage may be an important adjuvant for controlling severe extremity hemorrhage in the prehospital setting.

Mental health/substance abuse treatment in managed care: the Massachusetts Medicaid experience.

Massachusetts was the first state to introduce a statewide specialty mental health managed care plan for its Medicaid program. This study assesses the impact of this program on expenditures, access, and relative quality. Over a one-year period, expenditures were reduced by 22 percent below predicted levels without managed care, without any overall reduction in access or relative quality. Reduced lengths-of-stay, lower prices, and fewer inpatient admissions were the major factors. However, for one population segment--children and adolescents--readmission rates increased slightly, and providers for this group were less satisfied than they were before managed care was adopted. Less costly types of twenty-four-hour care were substituted for inpatient hospital care. This experience supports the usefulness of a managed care program for mental health and substance abuse services, and the applicability of such a program to high-risk populations.

Chronic sepsis following intramedullary nailing of femoral fractures.

We reviewed 12 patients with chronic drainage after intramedullary nailing of a femoral shaft fracture. The fractures tended to be the result of high-speed trauma and were frequently comminuted. Six were open fractures and six were closed injuries. All but one had been managed initially with the open nailing technique, exposing the fracture site. In six cases we left the nail in place until bone union occurred, an average of 33 months after injury, removing the hardware thereafter. The remaining six patients, each with bone sequestra at the fracture site, underwent nail removal, debridement of nonviable bone, and external fixation followed by bone grafting; this group took 37 months to heal. There was one persistent nonunion in each group. Drainage did not cease in either group until the nail and all sequestra had been removed. There was an average of 4.3 cm of shortening, but no angulation greater than 10 degrees. Six patients were left with less than 45 degrees of knee flexion and only five had 100 degrees or more of knee flexion.

Funeral mania in recurrent bipolar affective disorders: reports of three cases.

Anniversary reactions as precipitants of manic episodes are reported to be relatively common, while manic onset within a week of bereavement ("funeral mania") has been considered rare. Three cases of funeral mania are described to illustrate that this phenomenon may be more frequent than has been thought.