A systematic review of cognition in idiopathic intracranial hypertension

Background: Cognitive disturbance is not pathognomonic of idiopathic intracranial hypertension (IIH), and therefore is not routinely assessed unless it presents as a major complaint. Consequently, cognition has been slow to gain substantial traction in IIH-related research, despite its notable impact on a subset of patients. We completed a systematic review of the literature examining the neurocognitive profile of patients with IIH. Methods: A PRISMA compliant literature search was conducted in Ovid Medline, PubMed, PsycInfo, Embase, Web of Science, Cochrane, Cinahl, and Scopus databases. The initial query yielded 1376 unique articles. These articles were narrowed to those including empirical analyses of cognitive assessment in adult patients with IIH. Results: A final cohort of nine articles resulted, comprising the findings from 309 patients with IIH and 153 healthy control subjects. Although there was considerable variability in methodology particularly with respect to cognitive assessment, fairly consistent deficits were observed across studies in the domains of processing speed, working memory, sustained and complex attention, set-shifting, and confrontation naming. Body mass index and body weight were not associated with cognitive performance. Pertinent limitations of the literature were identified, most notably failure to report trial-level cognitive testing data, the need for more comprehensive testing batteries with less reliance on screening tools, and not controlling for variables that may impact cognition. Conclusions: A more complete understanding of the cognitive profile in patients with idiopathic intracranial hypertension could lead to the increased -relevance of cognitive screening in disease management, and therefore more appropriate neuropsychological referral, earlier identification of functional limitations, and targeted neurorehabilitation.

Association of Win-Loss Record With Neuropsychiatric Symptoms and Brain Health Among Professional Fighters

OBJECTIVE

Repetitive head impacts in professional fighting commonly lead to head injuries. Increased exposure to repetitive head trauma, measured by the number of professional fights and years of fighting, has been associated with slower processing speed and smaller brain volumes. The impact of win-loss outcomes has been investigated in other sports, with several studies suggesting that individuals on losing teams experience more head injuries. Here, the authors hypothesized that fighters with a worse fight record would exhibit poorer brain health outcomes.

METHODS

The Professional Fighters Brain Health Study examined changes in neuropsychiatric symptoms, regional brain volume, and cognition among professional boxers and mixed martial arts fighters. These data were used to evaluate the relationship between win-loss ratios and brain health outcomes among professional fighters (N=212) by using validated neuropsychiatric symptom and cognitive measures and MRI data.

RESULTS

Retired fighters with a better record demonstrated more impulsiveness (B=0.21, df=48) and slower processing speed (B=-0.42, df=31). More successful fighters did not perform better than fighters with worse records on any neuropsychiatric or cognitive test. Retired fighters with better fight records had smaller brain volumes in the subcortical gray matter, anterior corpus callosum, left and right hippocampi, left and right amygdala, and left thalamus. More successful active fighters had a smaller left amygdala volume.

CONCLUSIONS

These findings suggest that among retired fighters, a better fight record was associated with greater impulsiveness, slower processing speed, and smaller brain volume in certain regions. This study shows that even successful fighters experience adverse effects on brain health.

Sparring and the Brain: The Associations between Sparring and Regional Brain Volumes in Professional Mixed Martial Arts Fighters

BACKGROUND

Mixed martial arts (MMA) fighters, due to exposure to repetitive head impacts, are at risk for brain atrophy and neurodegenerative sequelae. Simultaneously, motor skills training and cognition-rich activities have been linked with larger regional brain volumes. The majority of an MMA fighter's sporting activity occurs during practice (e.g., sparring) rather than formal competition. This study, therefore, aims to be the first to explore regional brain volumes associated with sparring in MMA fighters.

METHODS

Ninety-four active, professional MMA fighters from the Professional Fighters Brain Health Study met inclusion criteria for this cross-sectional analysis. Adjusted multivariable regression analyses were utilized to examine the relationship between the number of sparring practice rounds per week during typical training and a select number of regional brain volumes (i.e., caudate, thalamus, putamen, hippocampus, amygdala).

RESULTS

A higher number of weekly sparring rounds during training was significantly associated with larger left (beta = 13.5 µL/round, 95% CI 2.26-24.8) and right (beta = 14.9 µL/round, 95% CI 3.64-26.2) caudate volumes. Sparring was not significantly associated with left or right thalamus, putamen, hippocampus, or amygdala volumes.

CONCLUSIONS

More weekly rounds of sparring was not significantly associated with smaller volumes in any of the brain regions studied in active, professional MMA fighters. Sparring's significant association with larger caudate volume raises questions about whether fighters who spar more experience attenuated trauma-related decreases in caudate volume relative to fighters who spar less, whether fighters who spar more experience minimal or even positive changes to caudate volume, whether baseline differences in caudate size may have mediated results, or whether some other mechanism may be at play. Given limitations inherent to the cross-sectional study design, more research is needed to further explore the brain effects of sparring in MMA.

Effect of traumatic brain injury on mild behavioral impairment domains prior to all-cause dementia diagnosis and throughout disease progression

Introduction

Traumatic brain injury (TBI) may alter dementia progression, although co-occurring neuropsychiatric symptoms (NPS) have received less attention. Originally designed to evaluate behavioral disruption prior to dementia diagnosis, the mild behavioral impairment (MBI) construct relates NPS to underlying neural circuit disruptions, with probable relevance across the progression of neurodegenerative disease. Therefore, the MBI construct may represent a valuable tool to identify and evaluate related NPS both preceding diagnosis of all-cause dementia throughout the progression of disease, representing an important area of inquiry regarding TBI and dementia. This investigation sought to evaluate the effect of TBI on NPS related by the MBI construct in participants progressing from normal cognitive status to all-cause dementia.

Methods

Using National Alzheimer's Coordinating Center data, individuals progressing from normal cognition to all-cause dementia (clinician diagnosed) over 7.6 ± 3.0 years were studied to estimate prevalence of MBI domains in 124 participants with prior TBI history (57 with loss of consciousness [LOC] <5 minutes, 22 with LOC >5 min, 45 unknown severity) compared to 822 without. MBI domain prevalence was evaluated (1) prior to dementia onset (including only time points preceding time at dementia diagnosis, as per MBI's original definition) and (2) throughout dementia progression (evaluating all available time points, including both before and after dementia diagnosis).

Results

More severe TBI (LOC >5 minutes) was associated with the social inappropriateness MBI domain (adjusted odds ratio = 4.034; P = 0.024) prior to dementia onset, and the abnormal perception/thought content domain looking across dementia progression (adjusted hazard ratio [HR_adj] = 3.703; P = 0.005). TBI (all severities) was associated with the decreased motivation domain looking throughout dementia progression (HR_adj. = 1.546; P = 0.014).

Discussion

TBI history is associated with particular MBI profiles prior to onset and throughout progression of dementia. Understanding TBI's impact on inter-related NPS may help elucidate underlying neuropathology with implications for surveillance, detection, and treatment of behavioral concerns in aging TBI survivors.

Highlights

The mild behavioral impairment (MBI) construct links related neuropsychiatric symptoms (NPS) by probable underlying neural network dysfunction.Traumatic brain injury (TBI) with loss of consciousness (LOC) > 5 minutes was associated with pre-dementia social inappropriateness.TBI was associated with decreased motivation looking across dementia progression.TBI with LOC > 5 minutes was associated with abnormal perception/thought content.The MBI construct may be useful for examining related NPS across dementia progression.

Neuroimaging Correlates of Post-Traumatic Stress Disorder in Traumatic Brain Injury: A Systematic Review of the Literature

Neuroimaging is widely utilized in studying traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). The risk for PTSD is greater after TBI than non-TBI trauma, and PTSD is associated with worse outcomes after TBI. Studying the neuroimaging correlates of TBI-related PTSD may provide insights into the etiology of both conditions and help identify those TBI patients most at risk of developing persistent symptoms. The objectives of this systematic review were to examine the current literature on neuroimaging in TBI-related PTSD, summarize key findings, and highlight strengths and limitations to guide future research. A PRISMA compliant literature search was conducted in PubMed (MEDLINE), PsychINFO, EMBASE, and Scopus databases prior to January 2022. The database query yielded 4486 articles, which were narrowed based on specified inclusion criteria to a final cohort of 16 studies, comprised of 854 participants with TBI. There was no consensus regarding neuroimaging correlates of TBI-related PTSD among the included articles. A small number of studies suggest that TBI-related PTSD is associated with white matter tract changes, particularly in frontotemporal regions, as well as changes in whole-brain networks of resting-state connectivity. Future studies hoping to identify reliable neuroimaging correlates of TBI-related PTSD would benefit from ensuring consistent case definition, preferably with clinician diagnosed TBI and PTSD, selection of comparable control groups, and attention to imaging timing post-injury. Prospective studies are needed and should aim to further differentiate predisposing factors from sequelae of TBI-related PTSD.

Neuroimaging correlates of syndromal depression following traumatic brain injury: A systematic review of the literature

Objective

To complete a systematic review of the literature examining neuroimaging findings unique to co-occurring syndromal depression in the setting of TBI.

Methods

A PRISMA compliant literature search was conducted in PubMed (MEDLINE), PsychINFO, EMBASE, and Scopus databases for articles published prior to April of 2022. The database query yielded 4447 unique articles. These articles were narrowed based on specific inclusion criteria (e.g., clear TBI definition, clear depression construct commenting on the syndrome of major depressive disorder, conducted empirical analyses comparing neuroimaging correlates in TBI subjects with depression versus TBI subjects without depression, controlled for the time interval between TBI occurrence and acquisition of neuroimaging).

Results

A final cohort of 10 articles resulted, comprising the findings from 423 civilians with brain injury, 129 of which developed post-TBI depression. Four articles studied mild TBI, three mild/moderate, one moderate/severe, and two all-comers, with nine articles focusing on single TBI and one including both single and recurrent injuries. Spatially convergent structural abnormalities in individuals with TBI and co-occurring syndromal depression were identified primarily in bilateral frontal regions, particularly in those with damage to the left frontal lobe and prefrontal cortices, as well as temporal regions including bilateral temporal lobes, the left superior temporal gyrus, and bilateral hippocampi. Various parietal regions and the nucleus accumbens were also implicated. EEG studies showed supporting evidence of functional changes in frontal regions.

Conclusion

Additional inquiry with attention to TBI without depression control groups, consistent TBI definitions, previous TBI, clinically diagnosed syndromal depression, imaging timing post-injury, acute prospective design, functional neuroimaging, and well-defined neuroanatomical regions of interest is crucial to extrapolating finer discrepancies between primary and TBI-related depression.

Patient-reported outcomes after operative versus nonoperative treatment of pediatric lateral humeral condyle fractures

Lateral humeral condyle fractures in children are treated with several approaches, yet it is unclear which has the best treatment outcomes. We hypothesized that functional outcomes would be equivalent between treatment types, reduction approaches, and fixation types. Our purpose was to assess patient-reported outcomes and complications by treatment type (operative versus nonoperative), reduction approach (open versus percutaneous), and fixation type (cannulated screws versus Kirschner wires).We retrospectively reviewed data from acute lateral humeral condyle fractures treated at our level-1 pediatric trauma center from 2008 to 2017. Patients were included if they were 8 years or older and had completed clinical follow-up. Fractures were categorized by fracture severity as mild (<2-mm displacement), moderate (isolated, 2- to 5-mm displacement), or severe (isolated, >5-mm displacement or >2-mm displacement with concomitant elbow dislocation or other elbow fracture). We extracted data on patient age, sex, treatment type, reduction approach, fixation type, patient-reported outcomes (shortened Disabilities of the Arm, Shoulder, and Hand and Patient Reported Outcome Measurement Information System upper extremity), treatment complications, and follow-up duration. Patients in the operative versus nonoperative group and across fracture severity subgroups did not differ significantly by age, sex, or follow-up duration. Bivariate analysis was performed to determine whether outcomes differed by intervention. Alpha = 0.05.No differences were observed in patient-reported outcomes between operative versus nonoperative groups for the mild and severe fracture subgroups. No differences were observed between approach (open versus percutaneous) or instrumentation (cannulated screw versus Kirschner wire fixation) for any outcome measure within the operative group. Patients whose fractures were stabilized with screws versus wires had significantly higher rates of return to the operating room (94% versus 8.3%, P < .001). The overall complication rate for our cohort was low, with no differences by treatment type or fracture severity.In our cohort, patient-reported outcomes were similar across fracture severity categories, irrespective of treatment or fixation type. Patients who underwent internal fixation with cannulated screws experienced significantly higher rates of return to the operating room compared with those treated with Kirschner wires but otherwise had similar complication rates and patient-reported outcomes.Level of Evidence: 3.

Neuroimaging Correlates of Syndromal Anxiety Following Traumatic Brain Injury: A Systematic Review of the Literature

BACKGROUND

Traumatic brain injury (TBI) can precipitate new-onset psychiatric symptoms or worsen existing psychiatric conditions. To elucidate specific mechanisms for this interaction, neuroimaging is often used to study both psychiatric conditions and TBI. This systematic review aims to synthesize the existing literature of neuroimaging findings among patients with anxiety after TBI.

METHODS

We conducted a Preferred Reporting Items for Systematic Review and Meta-Analyses-compliant literature search via PubMed (MEDLINE), PsychINFO, EMBASE, and Scopus databases before May, 2019. We included studies that clearly defined TBI, measured syndromic anxiety as a primary outcome, and statistically analyzed the relationship between neuroimaging findings and anxiety symptoms.

RESULTS

A total of 5982 articles were retrieved from the systematic search, of which 65 studied anxiety and 13 met eligibility criteria. These studies were published between 2004 and 2017, collectively analyzing 764 participants comprised of 470 patients with TBI and 294 non-TBI controls. Imaging modalities used included magnetic resonance imaging, functional magnetic resonance imaging, diffusion tensor imaging, electroencephalogram, magnetic resonance spectrometry, and magnetoencephalography. Eight of 13 studies presented at least one significant finding and together reflect a complex set of changes that lead to anxiety in the setting of TBI. The left cingulate gyrus in particular was found to be significant in 2 studies using different imaging modalities. Two studies also revealed perturbances in functional connectivity within the default mode network.

CONCLUSIONS

This is the first systemic review of neuroimaging changes associated with anxiety after TBI, which implicated multiple brain structures and circuits, such as the default mode network. Future research with consistent, rigorous measurements of TBI and syndromic anxiety, as well as attention to control groups, previous TBIs, and time interval between TBI and neuroimaging, are warranted. By understanding neuroimaging correlates of psychiatric symptoms, this work could inform future post-TBI screening and surveillance, preventative efforts, and early interventions to improve neuropsychiatric outcomes.

Neurology trial registrations on ClinicalTrials.gov between 2007 and 2018: A cross-sectional analysis of characteristics, early discontinuation, and results reporting

BACKGROUND

Increasing neurological disease burden and advancing treatment options require clinical trials to expand the evidence base of clinical care. We aimed to characterize neurology clinical trials registered between October 2007 and April 2018 and identify features associated with early discontinuation and results reporting.

METHODS

We compared 16,994 neurology (9.4%) and 163,714 non-neurology comparison trials registered to ClinicalTrials.gov. Trials therapeutic focus within neurology was assigned via combination programmatic and manual review. We performed descriptive analyses of trial characteristics, cox regression of early discontinuation, and multivariable logistic regression for results reporting within 3 years of completion.

RESULTS

Most neurology trials were academic-funded (58.5%) followed by industry (31.9%) and US-government (9.6%). Neurology trials focused more on treatment than prevention compared to non-neurology studies. Of neurology trials, 11.3% discontinued early, and 32.2% of completed trials reported results by April 30, 2018. In multivariable analysis accounting for time-to-event, neurology trials were at lower risk of discontinuation than non-neurology trials (adjusted hazard 0.83, p < 0.0001). Both academic and government-funded trials had greater risk of discontinuation than industry (adjusted hazard 0.57 and 0.46, respectively). Among completed trials, government-funded studies (adjusted odds ratio 2.12, p < 0.0001) had highest odds of results reporting while academic trials reported less (adjusted odds ratio 0.51, p < 0.0001).

CONCLUSIONS

Funding source is associated with trial characteristics and outcomes in neurology. Improvements in trial completion and timely dissemination of results remain urgent goals for the field.

Effect of Weight Class on Regional Brain Volume, Cognition, and Other Neuropsychiatric Outcomes among Professional Fighters

Traumatic brain injury (TBI) is a common source of functional impairment among athletes, military personnel, and the general population. Professional fighters in both boxing and mixed martial arts (MMA) are at particular risk for repetitive TBI and may provide valuable insight into both the pathophysiology of TBI and its consequences. Currently, effects of fighter weight class on brain volumetrics (regional and total) and functional outcomes are unknown. Fifty-three boxers and 103 MMA fighters participating in the Professional Fighters Brain Health Study (PRBHS) underwent volumetric magnetic resonance imaging (MRI) and neuropsychological testing. Fighters were divided into lightweight (≤139.9 lb), middleweight (140.0–178.5 lb), and heavyweight (>178.5 lb). Compared with lightweight fighters, heavyweights displayed greater yearly reductions in regional brain volume (boxers: bilateral thalami; MMA: left thalamus, right putamen) and functional performance (boxers: processing speed, simple and choice reaction; MMA: Trails A and B tests). Lightweights suffered greater reductions in regional brain volume on a per-fight basis (boxers: left thalamus; MMA: right putamen). Heavyweight fighters bore greater yearly burden of regional brain volume and functional decrements, possibly related to differing fight dynamics and force of strikes in this division. Lightweights demonstrated greater volumetric decrements on a per-fight basis. Although more research is needed, greater per-fight decrements in lightweights may be related to practices of weight-cutting, which may increase vulnerability to neurodegeneration post-TBI. Observed decrements associated with weight class may result in progressive impairments in fighter performance, suggesting interventions mitigating the burden of TBI in professional fighters may both improve brain health and increase professional longevity.

Medical Student Research Productivity: Which Variables are Associated with Matching to a Highly Ranked Orthopaedic Residency Program?

OBJECTIVE

Little is known about the importance of an applicant's research productivity in terms of matching into a highly-ranked orthopaedic residency. We characterized the research of orthopaedic residents who matched in 2017 to determine whether 1) program tiers differed by their residents' research; and 2) discrete increases in applicants' research were associated with matching into higher-ranked programs.

DESIGN

We searched Scopus for resident publications accepted before 2017 or published through January 2017. Using an established ranking system, programs were ranked (tier-1, highest; tier-5, lowest) by their department's number of citations from 2005 to 2015. We compared resident research productivity among these 5 tiers. We then categorized residents by discrete levels of research productivity (0, 1, or ≥2 publications) and compared the differences in matched program rank.

SETTING

Data collection and analysis performed at Johns Hopkins Hospital, a tertiary care center in Baltimore, MD.

PARTICIPANTS

We obtained our sample from allopathic orthopaedic program websites, excluding military programs and international students, for a total of 111 programs (565 of 726 matched residents [78%]).

RESULTS

Tier-1 and tier-2 programs differed significantly in their residents' publications, h-index, and citations. Programs of other tiers did not differ significantly. Applicants with 1 publication matched to higher-ranked residency programs than those with 0 publications. When comparing residents with 1 publication versus residents with more than 1 publication, we found no significant differences in program rank matched.

CONCLUSIONS

Our results suggest that higher-tier orthopaedic residency programs match residents with greater research productivity than do lower-tier programs. Having 1 publication was associated with matching into a higher-ranked program but no significant associations were observed beyond the first publication.

Traumatic brain injury alters neuropsychiatric symptomatology in all-cause dementia

INTRODUCTION

Traumatic brain injury (TBI) may alter the course of neuropsychiatric symptom (NPS) onset during dementia development. The connection among TBI, NPS, and dementia progression is of increasing interest to researchers and clinicians.

METHODS

Incidence of NPS was examined in participants with normal cognition who progressed to all-cause dementia based on whether TBI history was present (n = 130) or absent (n = 849). Survival analyses were used to examine NPS incidence across 7.6 ± 3.0 years of follow-up.

RESULTS

Participants with TBI history had increased prevalence and incidence of apathy (44.7% vs 29.9%, P = .0062; HR_adj. = 1.708, P = .0018) and motor disturbances (17.2% vs 9.5%, P = .0458; HR_adj. = 2.023, P = .0168), controlling for demographics and type of dementia diagnosis. Earlier anxiety onset was associated with TBI (692 days prior to dementia diagnosis vs 161 days, P = .0265).

DISCUSSION

History of TBI is associated with increased risk for and earlier onset of NPS in the trajectory of dementia development.

Bioengineering lungs - current status and future prospects

INTRODUCTION

Once pulmonary disease progresses to end-stage pulmonary disease, treatment options are very limited. An important advance in the field is the development of a bioartificial lung derived from a generic matrix scaffold populated with patients' own cells. Significant progress has already been made in the engineering of bioartificial lungs.

AREAS COVERED

This review explains how previous and current research contributes to the goal of creating a successful bioartificial lung, and the barriers faced in doing so. We will also highlight some of the design considerations being explored to optimize bioartificial lungs and considerations for clinical translation.

EXPERT OPINION

While current bioartificial lungs are able to provide short-term gas exchange in large-animal studies, much work is still required to combine the disciplines of cell biology, materials science, and tissue engineering to create such clinically useful and functioning artificial lungs.

Opioid use after adult spinal deformity surgery: patterns of cessation and associations with preoperative use

OBJECTIVE

The objectives of the study were to determine, among patients with adult spinal deformity (ASD), the following: 1) how preoperative opioid use, dose, and duration of use are associated with long-term opioid use and dose; 2) how preoperative opioid use is associated with rates of postoperative use from 6 weeks to 2 years; and 3) how postoperative opioid use at 6 months and 1 year is associated with use at 2 years.

METHODS

Using a single-center, longitudinally maintained registry, the authors identified 87 patients who underwent ASD surgery from 2013 to 2017. Fifty-nine patients reported preoperative opioid use (37 high-dose [≥ 90 morphine milligram equivalents daily] and 22 low-dose use). The duration of preoperative use was long-term (≥ 6 months) for 44 patients and short-term for 15. The authors evaluated postoperative opioid use at 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. Multivariate logistic regression was used to determine associations of preoperative opioid use, dose, and duration with use at each time point (alpha = 0.05).

RESULTS

The following preoperative factors were associated with opioid use 2 years postoperatively: any opioid use (adjusted odds ratio [aOR] 14, 95% CI 2.5-82), high-dose use (aOR 7.3, 95% CI 1.1-48), and long-term use (aOR 17, 95% CI 2.2-123). All patients who reported high-dose opioid use at the 2-year follow-up examination had also reported preoperative opioid use. Preoperative high-dose use (aOR 247, 95% CI 5.8-10,546) but not long-term use (aOR 4.0, 95% CI 0.18-91) was associated with high-dose use at the 2-year follow-up visit. Compared with patients who reported no preoperative use, those who reported preoperative opioid use had higher rates of use at each postoperative time point (from 94% vs 62% at 6 weeks to 54% vs 7.1% at 2 years) (all p < 0.001). Opioid use at 2 years was independently associated with use at 1 year (aOR 33, 95% CI 6.8-261) but not at 6 months (aOR 4.3, 95% CI 0.95-24).

CONCLUSIONS

Patients' preoperative opioid use, dose, and duration of use are associated with long-term use after ASD surgery, and a high preoperative dose is also associated with high-dose opioid use at the 2-year follow-up visit. Patients using opioids 1 year after ASD surgery may be at risk for long-term use.

History of traumatic brain injury interferes with accurate diagnosis of Alzheimer's dementia: a nation-wide case-control study

Traumatic brain injury (TBI) and Alzheimer's disease (AD) bear a complex relationship, potentially increasing risk of one another reciprocally. However, recent evidence suggests post-TBI dementia exists as a distinct neurodegenerative syndrome, confounding AD diagnostic accuracy in clinical settings. This investigation sought to evaluate TBI's impact on the accuracy of clinician-diagnosed AD using gold standard neuropathological criteria. In this preliminary analysis, data were acquired from the National Alzheimer's Coordinating Centre (NACC), which aggregates clinical and neuropathologic information from Alzheimer's disease centres across the United States. Modified National Institute on Aging-Reagan criteria were applied to confirm AD by neuropathology. Among participants with clinician-diagnosed AD, TBI history was associated with misdiagnosis (false positives) (OR = 1.351 [95% CI: 1.091-1.674], p = 0.006). Among participants without clinician-diagnosed AD, TBI history was not associated with false negatives. TBI moderates AD diagnostic accuracy. Possible AD misdiagnosis can mislead patients, influence treatment decisions, and confound research study designs. Further work examining the influence of TBI on dementia diagnosis is warranted.

The effect of age of first exposure to competitive fighting on cognitive and other neuropsychiatric symptoms and brain volume

It has long been established that fighting sports such as boxing and mixed martial arts can lead to head injury. Prior work from this group on the Professional Fighters Brain Health Study found that exposure to repetitive head impacts is associated with lower brain volumes and decreased processing speed in fighters. Current and previously licensed professional fighters were recruited, divided into active and retired cohorts, and matched with a control group that had no prior experience in sports with likely head trauma. This study examined the relationship between age of first exposure (AFE) to fighting sports and brain structure (MRI regional volume), cognitive performance (CNS Vital Signs, iComet C3), and clinical neuropsychiatric symptoms (PHQ-9, Barratt Impulsiveness Scale). Brain MRI data showed significant correlations between earlier AFE and smaller bilateral hippocampal and posterior corpus callosum volumes for both retired and active fighters. Earlier AFE in active fighters was correlated with decreased processing speed and decreased psychomotor speed. Retired fighters showed a correlation between earlier AFE and higher measures of depression and impulsivity. Overall, the results help to inform clinicians, governing bodies, parents, and athletes of the risks associated with beginning to compete in fighting sports at a young age.

Exosomes function in antigen presentation during an in vivo Mycobacterium tuberculosis infection

Mycobacterium tuberculosis-infected macrophages and dendritic cells are limited in their ability to present antigen to CD4+ T cells suggesting that other mechanism of antigen presentation are driving the robust T cell response observed during an M. tuberculosis infection. These mechanisms could include antigens present in apoptotic bodies, necrotic debris, exosomes or even release of non-vesicular antigen from infected cells. However, there is limited data to support any of these mechanisms as important in driving T cell activation in vivo. In the present study we use Rab27a-deficient mice which show diminished trafficking of mycobacterial components to exosomes as well as M. tuberculosis strains that express recombinant proteins which traffic or fail to traffic to exosomes. We observed that exosomes released during a mouse M. tuberculosis infection contribute significantly to its T cell response. These finding imply that exosomes function to promote T cell immunity during a bacterial infection and are an important source of extracellular antigen.

Acute hepatic necrosis and death in a subadult southern white rhinoceros (Ceratotherium simum) associated with exposure to sterigmatocystin in forage contaminated with Aspergillus nidulans

A young male southern white rhinoceros (Ceratotherium simum), which was resident in a zoo as part of a multi-rhinoceros group, died suddenly. Necropsy and histopathological findings supported a diagnosis of death from acute hepatic necrosis. The microscopic distribution of liver lesions was suggestive of hepatotoxicosis. Further investigation revealed potential exposure to a mycotoxin, sterigmatocystin, present in spoiled lucerne hay contaminated with Aspergillus nidulans. It was concluded that mycotoxicosis was the likely cause of the hepatic necrosis and death in this animal.

Seminoma in a southern black rhinoceros (Diceros bicornis minor): diagnosis, surgical management and effect on fertility

A testicular mass was identified by ultrasonography performed during a routine reproductive evaluation of an adult male southern black rhinoceros (Diceros bicornis minor). Histological examination of a testicular biopsy supported a presumptive diagnosis of testicular neoplasia. Hemi-castration was performed to excise the affected testis and a pathological diagnosis of a seminoma was made. Assessment of semen suggested reduced fertility as a consequence of the neoplastic process, but hemi-castration prevented further growth and metastasis of the tumour and ensured the animal's breeding potential. This is the second documented case of a seminoma in a rhinoceros species and the first case in a black rhinoceros.

Ovarian superstimulation, transrectal ultrasound-guided oocyte recovery, and IVF in rhinoceros

Numerous reports on reproductive pathology in all rhinoceros species illustrate the abundance of female infertility in captive populations. In infertile rhinoceroses, oocyte collection and embryo production could represent the best remaining option for these animals to reproduce and to contribute to the genetic pool. We report here on superstimulation, repeated oocyte recovery, and attempted in vitro fertilization (IVF) in white and black rhinoceroses. Four anestrous rhinoceroses (two white, two black) with unknown follicular status were treated with gonadotropin-releasing hormone analogue, deslorelin acetate, for 6 to 7 d. Number and size of follicles in superstimulated females was significantly higher and larger compared with those in nonstimulated anestrous females (n=9). Ovum pick-up was achieved by transrectal ultrasound-guided follicle aspiration. Up to 15 follicles were aspirated per ovary. During six ovum pick-ups, a total of 29 cumulus-oocyte complexes (COCs) were harvested with a range of 2 to 9 COCs per collection. No postsurgical complications were noted on the rhinoceros ovaries using this minimally invasive approach. Various in vitro maturation (IVM) and IVF protocols were tested on the collected COCs. Despite the low total number of COCs available for IVM and IVF in this study, we can report the first rhinoceros embryo ever produced in vitro. The production of a 4-cell embryo demonstrated the potential of transrectal ultrasound-guided oocyte recovery as a valuable tool for in vitro production of rhinoceros embryos from otherwise infertile females.

Pleomorphic lobular carcinoma: morphology, immunohistochemistry, and molecular analysis

Infiltrating pleomorphic lobular carcinoma (PLC) is an aggressive variant of infiltrating lobular carcinoma. Recently, in situ changes identical to PLC (PLCIS) have been described. The role of prognostic markers and their correlation with therapeutics, clinical outcome, and genetic changes is not well established in PLC. The authors examined 38 cases of this entity to understand better this tumor's biology. Immunohistochemical (IHC) analysis was performed in 21 specimens for estrogen and progesterone steroid receptors, p53, Her 2 (p185), and GCDFP-15. Genomic deoxyribonucleic acid was obtained from microdissected tumor as well as normal control cells, and loss of heterozygosity was investigated at the ESR (16q24), p53 (TP53 17p), Her 2 (17q 11-12), and BRCA 1 (17q12-25) loci. In this series, the average patient age was 57.5 years (age range, 24-92 years). Twenty-seven women were postmenopausal. Tumor size ranged from 1.2 to 25 cm. Six patients were a pathologic stage I; 19, stage II; 12, stage III; and one, stage IV. Histologically, multifocal nodular aggregates of discohesive pleomorphic tumor cells were seen interspersed in dense and fibrotic breast parenchyma. Twenty-nine percent of the specimens demonstrated associated signet ring cells. The remainder had dishesive, globoid, plasmacytoid cells with high-grade nuclear features. PLCIS was identified in 17 of 38 patients (45%), and lobular carcinoma in situ (LCIS) was noted in 8 patients (21%). IHC analysis showed estrogen immunoreactivity in 81%, progesterone in 67%, GCDFP-15 in 71%, and Her 2 in 81% (2+ to 3+ membranous staining) of specimens. Antibodies to p53 stained the tumor cell nuclei in 48% of the tumors. Loss of heterozygosity was identified in 52% of the specimens at the p53 locus, 18% at the ESR locus, 19% to 24% at the Her 2 loci, and 27% to 32% at the BRCA 1 locus. Follow-up was available in 19 patients and ranged from 12 months to 15 years (mean, 73 months). Seven patients had no evidence of disease at last examination (range, 1-15 years), three patients were alive with disease (range, 2-14 years), and nine patients were dead of disease (range, 2 months-9 years). Six patients had subsequent diagnoses of tumor in the contralateral breast. Analysis shows that PLC tends to appear in older postmenopausal women who present with locally advanced disease. PLCIS was found to be associated with PLC 45% of the time. The aggressive clinical course of patients with PLC is supported by tumor immunoreactivity with unfavorable markers Her 2 and p53. Overexpression of Her 2 in PLC may be therapeutically relevant, enabling the use of novel chemotherapeutic drugs like Herceptin. Interestingly, tumors that were Her 2 immunoreactive also maintained estrogen hormone immunoreactivity.

Characteristic behaviors of students with LD who have teacher-identified math weaknesses

Mathematics learning disabilities (LD) have gained increased attention over the last decade from both researchers and practitioners. A large percentage of students receiving learning disability services experience difficulties with mathematics, but little research has examined the specific mathematics behaviors of students with LD who have teacher-identified math weaknesses. This study examines the literature on mathematics LD and identifies specific behaviors from that body of research for the purpose of determining the extent to which those behaviors are observed in students with LD. Data are presented from observations of 391 special education professionals on 1724 students with LD, 870 of whom had identified math weaknesses and 854 of whom did not. Our results validate the existing literature and provide implications for teachers, researchers, and others interested in studying mathematics LD.

The Tall cell variant of papillary carcinoma of the thyroid: cytologic features and loss of heterozygosity of metastatic and/or recurrent neoplasms and primary neoplasms

BACKGROUND

The Tall cell variant of papillary carcinoma of the thyroid (TCV) is characterized by the proliferation of oxyphilic, tall, columnar cells with a height-to-width ratio of at least 2:1. TCV exhibits more aggressive clinical behavior than conventional thyroid papillary carcinoma (CPC). Cytologic features suggestive of TCV have been described in fine-needle aspiration material from primary tumors. Similarly, loss of heterozygosity (LOH) for chromosome 1 (D1S243) and the p53 gene (TP53) have been reported in TCV but not in CPC, thus making exploitation of this genetic feature a potential tool for molecular discrimination between these two neoplasms.

METHODS

Cytology samples of metastatic and/or recurrent neoplasms (M/R) (12 cases) and 7 cases of primary TCV obtained from 12 patients were evaluated. The cytologic findings of these cases were compared with previously published findings. Microdissection and polymerase chain reaction for LOH for chromosome 1 and p53 (D1S243 and TP53 markers) were performed on cytologic smears from 6 cases of M/R tumors and 3 cases of primary tumors.

RESULTS

More then 50% of M/R showed atypical follicular cells with enlarged nuclei, granular chromatin, nuclear grooves, pseudoinclusions, and abundant finely granular cytoplasm. Cells were disposed in monolayers (58%) and papillary clusters (50%). Similar findings were present in cases of primary TCV. LOH studies showed that 4 of 6 M/R were noninformative and 2 of 3 cases of primary TCV were informative for the D1S243 marker; however, in contrast with previously published reports, no LOH was detected for the markers evaluated.

CONCLUSIONS

M/R and primary TCV have similar cytologic features. Additional studies of larger series of M/R and primary TCV should be performed to delineate further any potential application of LOH for chromosome 1 and the p53 gene as a tool for diagnosing TCV with cytologic preparations. Cancer (Cancer Cytopathol)

Infiltrating micropapillary carcinoma of the breast

Infiltrating micropapillary carcinoma of the breast is a recently described and poorly recognized aggressive variant of infiltrating ductal carcinoma for which the clinical significance and role of prognostic markers are not fully described. In 14 cases of infiltrating micropapillary carcinoma, we studied histologic characteristics; immunohistochemical expression of c-erbB-2, p53, and MIB-1; hormonal expression of these tumors; and genetic alterations on the p53 locus. We correlated these results with clinical outcome. Patient ages ranged from 37 to 58 years (mean, 50 yr). Nine patients presented with a palpable tumor, one with an axillary mass. Three patients had abnormal mammograms. Five patients (36%) presented with Stage II disease, eight (57%) with Stage III, and one (7%) with Stage IV. The tumors were a modified Bloom-Richardson Grade II in nine cases (64%) and Grade III in 5 (36%). Mitoses ranged from 1 to 12 per 10 high power fields. Necrosis was uniformly absent. Psammoma bodies were present in 9 cases (64%) and lymphatic invasion in 10 (71%). In all of the cases, c-erbB-2 was identified immunohistochemically, and MIB-I was positive, staining 30 to 60% of the tumor cells. The cells were immunoreactive for p53 in six (75%) of eight cases, and, when present, stained 20 to 50% of the tumor cells. Loss of heterozygosity on locus 17p13.1 (p53) was identified in 4 of 5 informative samples. Molecular and immunohistochemical analyses had an 80% concordance. Follow-up was available in 11 patients, of whom 9 had recurrence in the skin and chest wall (average time of recurrence, 24 mo). Recognition of this distinctive and aggressive variant of infiltrating carcinoma is important because of its unfavorable prognosis and specific pattern of local recurrence. Its aggressive nature is supported by its advanced stage at presentation and expression of unfavorable prognostic markers.

Using assistive technology adaptations to include students with learning disabilities in cooperative learning activities

Cooperative learning (CL) is a common instructional arrangement that is used by classroom teachers to foster academic achievement and social acceptance of students with and without learning disabilities. Cooperative learning is appealing to classroom teachers because it can provide an opportunity for more instruction and feedback by peers than can be provided by teachers to individual students who require extra assistance. Recent studies suggest that students with LD may need adaptations during cooperative learning activities. The use of assistive technology adaptations may be necessary to help some students with LD compensate for their specific learning difficulties so that they can engage more readily in cooperative learning activities. A process for integrating technology adaptations into cooperative learning activities is discussed in terms of three components: selecting adaptations, monitoring the use of the adaptations during cooperative learning activities, and evaluating the adaptations' effectiveness. The article concludes with comments regarding barriers to and support systems for technology integration, technology and effective instructional practices, and the need to consider technology adaptations for students who have learning disabilities.

The Technology-Related Assistance to Individuals with Disabilities Act: relevance to individuals with learning disabilities and their advocates

Assistive technology (AT) was recognized by Congress as a viable need for people with disabilities when it passed the Tech Act in 1988. The legislation, which was reauthorized in 1994, has resulted in numerous programs and services that have helped people with disabilities access and use AT devices. The Tech Act's implications for people with learning disabilities is discussed in this article.

Educational assessment of mathematics skills and abilities

Mathematics assessments play a valuable role in identifying students' strengths and weaknesses and in developing and monitoring instructional practice. Over the last century, mathematics assessment has been refined as math content has changed as a result of curriculum reform. Today, researchers and practitioners use various assessment techniques to (a) identify students who have mathematics learning disabilities (LD), (b) target individual strengths and weaknesses across mathematics areas, (c) document the effects of mathematics instruction in a remedial or special program, (d) identify strategies that students employ during math activities, (e) conduct research about the characteristics of students with math LD, and (f) examine the technical characteristics of mathematics tests. This article provides an historical overview of the development of mathematics assessment and a description of specific strategies for conducting math evaluations.

Genetic analysis of synchronous mucinous tumors of the ovary and appendix

The coexistence of mucinous ovarian and appendiceal tumors in association with pseudomyxoma peritonei (PP) is well established. However, it has not been determined whether they represent independent or metastatic neoplasms. The authors analyzed microsatellites on chromosome 17q 21.3-22 (nm23), 3p 25-26 (von Hippel Lindau disease [VHL] gene), and 5q 21-22 (D5S346 locus) in 12 synchronous ovarian and appendiceal mucinous lesions. Loss of heterozygosity (LOH) at the nm23 locus has been shown previously in ovarian carcinomas, and genetic alterations at both the 3p and 5q loci have been reported in colorectal carcinomas. The ovarian lesions consisted of nine mucinous tumors of low malignant potential and three invasive adenocarcinomas, and the appendiceal lesions consisted of eight carcinomas without invasion, two invasive carcinomas, and two mucosal hyperplasias. DNA was extracted from microdissected cells obtained from formalin-fixed, paraffin-embedded tissue sections and amplified by polymerase chain reaction. In three specimens, genetic alterations occurred at 17q 21.3-22 in only the ovarian tumors. One of these cases showed LOH on chromosome 5q 21-22 in only the appendiceal tumor. In three other specimens, LOH at the same locus was found in both tumors. Six specimens did not show LOH at any locus. These results suggest that a subset of synchronous mucinos ovarian and appendiceal lesions showing different LOH patterns in both sites most likely represent patients with two separate primary lesions. Another group of specimens with the same allelic loss in both tumors most likely represent patients with a single primary and metastatic spread. Thus, genetic analysis of these lesions may be useful in investigating the origin of histologically similar synchronous tumors.