Randomized, controlled clinical trial of acoustic stimulation to reduce postconcussive symptoms

OBJECTIVE

Effective interventions are needed to address postconcussive symptoms. We report the results of randomized, sham-controlled trial of Cereset Research™ Standard Operating Procedures (CR-SOP), a noninvasive, closed-loop, allostatic, acoustic stimulation neurotechnology previously shown to improve insomnia.

METHODS

Military service members, veterans, or their spouses with persistent symptoms (Neurobehavioral Symptom Inventory [NSI] Score ≥23) after mTBI 3 months to 10 years ago, were randomized to receive 10 sessions of engineered tones linked to brainwaves (LB, intervention), or random engineered tones not linked to brainwaves (NL, sham control). The primary outcome was change in NSI, with secondary outcomes of heart rate variability and self-report measures of sleep, mood, and anxiety.

RESULTS

Participants (n = 106, 22% female, mean age 37.1, 2.8 deployments, 3.8 TBIs) were randomized 1:1 to LB or NL, with no significant differences between groups at baseline. Among all study participants, the NSI declined from baseline 41.0 to 27.2 after (P < 0.0001), with gains largely sustained at 3 months (31.2) and 6 months (28.4). However, there were no significant differences between the LB (NSI declined from 39.9 at baseline to 28.2 post-intervention, 31.5 at 3 months, and 29.4 at 6 months) and NL (NSI declined from 41.5 at baseline to 26.2, 29.9, and 27.3, respectively. Similar patterns were observed for the PCL5 and PHQ-9 and there was no difference in HRV between groups.

INTERPRETATION

Ten hours of acoustic stimulation while resting in a zero-gravity chair improves postconcussive symptoms. However, linking tones to brain electrical activity did not reduce symptoms more than random tones.

REGISTRATION

ClinicalTrials.gov - NCT03649958.

Sequence differences between BAX and BAK core domains manifest as differences in their interactions with lipids

The B-cell lymphoma 2 (BCL2) family members, BCL2-associated protein X (BAX) and BCL2 homologous antagonist killer (BAK), are required for programmed cell death via the mitochondrial pathway. When cells are stressed, damaged or redundant, the balance of power between the BCL2 family of proteins shifts towards BAX and BAK, allowing their transition from an inactive, monomeric state to a membrane-active oligomeric form that releases cytochrome c from the mitochondrial intermembrane space. That oligomeric state has an essential intermediate, a symmetric homodimer of BAX or BAK. Here we describe crystal structures of dimers of the core domain of BAX, comprising its helices α2-α5. These structures provide an atomic resolution description of the interactions that drive BAX homo-dimerisation and insights into potential interaction between core domain dimers and membrane lipids. The previously identified BAK lipid-interacting sites are not conserved with BAX and are likely to determine the differences between them in their interactions with lipids. We also describe structures of heterodimers of BAK/BAX core domains, yielding further insight into the differences in lipid binding between BAX and BAK.

Beliefs and Perceived Barriers Regarding Psychedelic-assisted Therapy in a Pilot Study of Service Members and Veterans With a History of Traumatic Brain Injury

INTRODUCTION

Posttraumatic stress disorder (PTSD) and depression are common in service members and veterans, and the response to currently available treatments is often modest at best. Recent studies suggest potential benefit with psychedelic-assisted therapies (PATs), particularly 3,4-methylenedioxymethamphetamine-assisted therapy for PTSD and psilocybin-assisted therapy for depression. This study examined beliefs and perceived barriers regarding PAT among service members and veterans to inform the delivery of these treatments if they are approved by the FDA.

MATERIALS AND METHODS

Twenty-one service members and veterans (67% male, 81% White, and 43% active duty) with a history of traumatic brain injury and co-occurring cognitive and psychological symptoms completed a measure assessing baseline knowledge and views of PAT, read a brief psychoeducation regarding PAT, and then responded to questions related to their beliefs and perceived barriers to PAT.

RESULTS

Before psychoeducation, participants reported a neutral view of psychedelic drugs (M = 2.76; range: 1-5), PAT (M = 3.33), and interest in PAT (M = 3.10). After psychoeducation, participants reported a significantly more positive view of psychedelic drugs (M = 3.24, P = .014) and interest in PAT (M = 3.67, P = .016). Overall, participants indicated that they would support PAT availability in medical settings if proven beneficial (M = 4.52; 5 = "agree strongly") and they would support a loved one engaging in PAT (M = 4.29). The most frequently reported health concerns were concern of long-term effects (43%), fear of losing their mind (33%), fear of personality changes (33%), and fear of traumatic brain injury complications (24%). The most frequently endorsed barriers were time commitment, transportation, financial concerns, work, and childcare (33%-19%), with 48% reporting no barriers.

CONCLUSIONS

This is the first study to explore beliefs and perceived barriers regarding PAT among service members and veterans. These results indicate that military populations may be interested in PAT, particularly if psychoeducation and outreach regarding these treatments occurred. If FDA approved, it will be important to facilitate command support and address logistical barriers to ensure appropriate access within military contexts.

Structural mapping of PEAK pseudokinase interactions identifies 14-3-3 as a molecular switch for PEAK3 signaling

PEAK pseudokinases regulate cell migration, invasion and proliferation by recruiting key signaling proteins to the cytoskeleton. Despite lacking catalytic activity, alteration in their expression level is associated with several aggressive cancers. Here, we elucidate the molecular details of key PEAK signaling interactions with the adapter proteins CrkII and Grb2 and the scaffold protein 14-3-3. Our findings rationalize why the dimerization of PEAK proteins has a crucial function in signal transduction and provide biophysical and structural data to unravel binding specificity within the PEAK interactome. We identify a conserved high affinity 14-3-3 motif on PEAK3 and demonstrate its role as a molecular switch to regulate CrkII binding and signaling via Grb2. Together, our studies provide a detailed structural snapshot of PEAK interaction networks and further elucidate how PEAK proteins, especially PEAK3, act as dynamic scaffolds that exploit adapter proteins to control signal transduction in cell growth/motility and cancer.

Common health assets protocol: a mixed-methods, realist evaluation and economic appraisal of how community-led organisations (CLOs) impact on the health and well-being of people living in deprived areas

INTRODUCTION

This research investigates how community-led organisations' (CLOs') use of assets-based approaches improves health and well-being, and how that might be different in different contexts. Assets-based approaches involve 'doing with' rather than 'doing to' and bring people in communities together to achieve positive change using their own knowledge, skills and experience. Some studies have shown that such approaches can have a positive effect on health and well-being. However, research is limited, and we know little about which approaches lead to which outcomes and how different contexts might affect success.

METHODS AND ANALYSIS

Using a realist approach, we will work with 15 CLOs based in disadvantaged communities in England, Scotland and Northern Ireland. A realist synthesis of review papers, and a policy analysis in different contexts, precedes qualitative interviews and workshops with stakeholders, to find out how CLOs' programmes work and identify existing data. We will explore participants' experiences through: a Q methodology study; participatory photography workshops; qualitative interviews and measure outcomes using a longitudinal survey, with 225 CLO participants, to assess impact for people who connect with the CLOs. An economic analysis will estimate costs and benefits to participants, for different contexts and mechanisms. A 'Lived Experience Panel' of people connected with our CLOs as participants or volunteers, will ensure the appropriateness of the research, interpretation and reporting of findings.

ETHICS AND DISSEMINATION

This project, research tools and consent processes have been approved by the Glasgow Caledonian University School of Health and Life Sciences Ethics Committee, and affirmed by Ethics Committees at Bournemouth University, Queen's University Belfast and the University of East London. Common Health Assets does not involve any National Health Service sites, staff or patients.Findings will be presented through social media, project website, blogs, policy briefings, journal articles, conferences and visually in short digital stories, and photographic exhibitions.

Perceptions of Health and Wellbeing Among Employees in a Work Integration Social Enterprise in Sweden

Background

Work Integration Social Enterprises (WISEs) constitute an important vehicle for providing employment opportunities for disadvantaged groups.

Objective

The goal of this qualitative case study is to explore perceptions of health and wellbeing among employees working in a WISE located in the Gävleborg region, in east central Sweden.

Methods

Data were gathered using 16 in-depth, semi-structured interviews with the social enterprise employees.

Results

Findings were categorized into three main categories: the importance of financial independence and societal benefits; team spirit and a sense of belonging; and improved quality of life and wellbeing.

Conclusion

The participants perceived that working in the WISE gave them a feeling of freedom and increased their self-esteem because of the possibility to earn an income. Also, they were satisfied with their job (e.g., with regard to work quality and flexibility) and believed that their work contributed to society. Moreover, through working in a WISE, the participants felt a sense of belonging and togetherness through interaction with co-workers and managers, and an improved quality of life for themselves and their families.

Methodology of the INVestigating traIning assoCiated blasT pAthology (INVICTA) study

BACKGROUND

Subconcussive blast exposure during military training has been the subject of both anecdotal concerns and reports in the medical literature, but prior studies have often been small and have used inconsistent methods.

METHODS

This paper presents the methodology employed in INVestigating traIning assoCiated blasT pAthology (INVICTA) to assess a wide range of aspects of brain function, including immediate and delayed recall, gait and balance, audiologic and oculomotor function, cerebral blood flow, brain electrical activity and neuroimaging and blood biomarkers.

RESULTS

A number of the methods employed in INVICTA are relatively easy to reproducibly utilize, and can be completed efficiently, while other measures require greater technical expertise, take longer to complete, or may have logistical challenges.

CONCLUSIONS

This presentation of methods used to assess the impact of blast exposure on the brain is intended to facilitate greater uniformity of data collection in this setting, which would enable comparison between different types of blast exposure and environmental circumstances, as well as to facilitate meta-analyses and syntheses across studies.

A selective and orally bioavailable VHL-recruiting PROTAC achieves SMARCA2 degradation in vivo

Targeted protein degradation offers an alternative modality to classical inhibition and holds the promise of addressing previously undruggable targets to provide novel therapeutic options for patients. Heterobifunctional molecules co-recruit a target protein and an E3 ligase, resulting in ubiquitylation and proteosome-dependent degradation of the target. In the clinic, the oral route of administration is the option of choice but has only been achieved so far by CRBN- recruiting bifunctional degrader molecules. We aimed to achieve orally bioavailable molecules that selectively degrade the BAF Chromatin Remodelling complex ATPase SMARCA2 over its closely related paralogue SMARCA4, to allow in vivo evaluation of the synthetic lethality concept of SMARCA2 dependency in SMARCA4-deficient cancers. Here we outline structure- and property-guided approaches that led to orally bioavailable VHL-recruiting degraders. Our tool compound, ACBI2, shows selective degradation of SMARCA2 over SMARCA4 in ex vivo human whole blood assays and in vivo efficacy in SMARCA4-deficient cancer models. This study demonstrates the feasibility for broadening the E3 ligase and physicochemical space that can be utilised for achieving oral efficacy with bifunctional molecules.

Protein degraders are an emerging drug modality; however, their properties lie beyond typical drug-like space. Here the authors report optimisation via structure-based exit vector and linker design towards the VHL-recruiting PROTAC ACBI2, an orally bioavailable and selective degrader of SMARCA2.

Enhancing exposure therapy for posttraumatic stress disorder (PTSD): a randomized clinical trial of virtual reality and imaginal exposure with a cognitive enhancer

Posttraumatic stress disorder (PTSD) is a significant public health issue. Yet, there are limited treatment options and no data to suggest which treatment will work for whom. We tested the efficacy of virtual reality exposure (VRE) or prolonged imaginal exposure (PE), augmented with D-cycloserine (DCS) for combat-related PTSD. As an exploratory aim, we examined whether brain-derived neurotrophic factor (BDNF) and fatty acid amide hydrolase (FAAH) moderated treatment response. Military personnel with PTSD (n = 192) were recruited into a multisite double-blind randomized controlled trial to receive nine weeks of VRE or PE, with DCS or placebo. Primary outcome was the improvement in symptom severity. Randomization was stratified by comorbid depression (MDD) and site. Participants in both VRE and PE showed similar meaningful clinical improvement with no difference between the treatment groups. A significant interaction (p = 0.45) suggested VRE was more effective for depressed participants (CAPS difference M = 3.51 [95% CI 1.17-5.86], p = 0.004, ES = 0.14) while PE was more effective for nondepressed participants (M = -8.87 [95% CI -11.33 to -6.40], p < 0.001, ES = -0.44). The main effect of DCS vs. placebo was not significant. Augmentation by MDD interaction (p = 0.073) suggested that depressed participants improved more on placebo (M = -8.43 [95% CI -10.98 to -5.88], p < 0.001, ES = -0.42); DCS and placebo were equally effective for nondepressed participants. There was an apparent moderating effect of BDNF Val66Met polymorphism on DCS augmentation (ES = 0.67). Met66 allele carriers improved more on DCS (ES = -0.25). FAAH 385 A carriers improved more than non-carriers (ES = 0.33), particularly those with MDD (ES = 0.62). This study provides a step toward precision therapeutics for PTSD by demonstrating that comorbid MDD and genetic markers may help guide treatment selection.ClinicalTrials.gov Identifier: NCT01352637.

The Redesign and Validation of Multimodal Motion-Assisted Memory Desensitization and Reconsolidation Hardware and Software: Mixed Methods, Modified Delphi-Based Validation Study

BACKGROUND

In recent years, the delivery of evidence-based therapies targeting posttraumatic stress disorder (PTSD) has been the focus of the Departments of Defense in countries such as Canada, the Netherlands, and the United States. More than 66% of military members continue to experience symptoms of PTSD that significantly impact their daily functioning and quality of life after completing evidence-based treatments. Innovative, engaging, and effective treatments for PTSD are needed. Multimodal motion-assisted memory desensitization and reconsolidation (3MDR) is an exposure-based, virtual reality-supported therapy used to treat military members and veterans with treatment-resistant PTSD. Given the demonstrated efficacy of 3MDR in recently published randomized control trials, there is both an interest in and a need to adapt the intervention to other populations affected by trauma and to improve accessibility to the treatment.

OBJECTIVE

We aimed to further innovate, develop, and validate new and existing hardware and software components of 3MDR to enhance its mobility, accessibility, feasibility, and applicability to other populations affected by trauma, including public safety personnel (PSP), via international collaboration.

METHODS

This study used a modified Delphi expert consultation method and mixed methods quasi-experimental validation with the purpose of software validation among PSP (first responders, health care providers) participants (N=35). A team of international experts from the Netherlands, the United States, and Canada met on the web on a weekly basis since September 2020 to discuss the adoption of 3MDR in real-world contexts, hardware and software development, and software validation. The evolution of 3MDR hardware and software was undertaken followed by a mixed methods software validation study with triangulation of results to inform the further development of 3MDR.

RESULTS

This study resulted in the identification, description, and evolution of hardware and software components and the development of new 3MDR software. Within the software validation, PSP participants widely acknowledged that the newly developed 3MDR software would be applicable and feasible for PSP affected by trauma within their professions. The key themes that emerged from the thematic analysis among the PSP included the desire for occupationally tailored environments, individually tailored immersion, and the applicability of 3MDR beyond military populations.

CONCLUSIONS

Within the modified Delphi consultation and software validation study, support for 3MDR as an intervention was communicated. PSP participants perceived that 3MDR was relevant for populations affected by trauma beyond military members and veterans. The resulting hardware and software evolution addressed the recommendations and themes that arose from PSP participants. 3MDR is a novel, structured, exposure-based, virtual reality-supported therapy that is currently used to treat military members and veterans with PTSD. Going forward, it is necessary to innovate and adapt 3MDR, as well as other trauma interventions, to increase effectiveness, accessibility, cost-effectiveness, and efficacy among other populations affected by trauma.

Production and purification of the PEAK pseudokinases for structural and functional studies

The PEAK family of pseudokinases, which comprises PEAK1, PEAK2 and PEAK3, are newly identified scaffolds that dynamically assemble oncogenic signaling pathways known to contribute to the development of several aggressive cancers. A striking feature of this unique family of pseudokinase scaffolds is their large multi-domain structure, which allows them to achieve protein complex assemblies through their structural plasticity and functional versatility. Recent structural advances have begun to reveal the critical regulatory elements that control their function. Specifically, the dimer-dependent scaffolding activity of PEAK pseudokinases is emerging as a critical mechanism for their signaling function, in addition to their ability to hetero-associate to form higher-order regulatory networks to diversify and amplify their signaling output. Here, we present a suite of techniques that enable the efficient expression and purification of PEAK proteins for functional characterization.

Distinct PEAK3 interactors and outputs expand the signaling potential of the PEAK pseudokinase family

The pseudokinase scaffolds PEAK1 and PEAK2 are implicated in cancer cell migration and metastasis. We characterized the regulation and role of the third family member PEAK3 in cell signaling. Similar to PEAK1 and PEAK2, PEAK3 formed both homotypic and heterotypic complexes. In addition, like PEAK1, it bound to the adaptors Grb2 and CrkII. However, unlike PEAK1 and PEAK2, homodimerized PEAK3 also interacted with the ARF GTPase-activating protein ASAP1, the E3 ubiquitin ligase Cbl, and the kinase PYK2. Dimerization and subsequent phosphorylation on Tyr²⁴, likely by a Src family kinase, were required for the binding of PEAK3 to Grb2 and ASAP1. Interactions with Grb2, CrkII, ASAP1, Cbl, and PYK2 exhibited contrasting dynamics upon cell stimulation with epidermal growth factor (EGF), in part due to PEAK3 dephosphorylation mediated by the phosphatase PTPN12. Overexpressing PEAK3 in mesenchymal-like MDA-MB-231 breast cancer cells enhanced cell elongation in a manner dependent on PEAK3 dimerization, and manipulation of PEAK3 expression demonstrated a positive role for this scaffold in regulating cell migration. Overexpressing PEAK3 in PEAK1/2 double-knockout MCF-10A breast epithelial cells enhanced acinar growth, impaired basement membrane integrity, and promoted invasion in three-dimensional cultures, with the latter two effects dependent on the binding of PEAK3 to Grb2 and ASAP1. PEAK1 and PEAK2 quantitatively and temporally influenced PEAK3 function. These findings characterize PEAK3 as an integral, signal-diversifying member of the PEAK family with scaffolding roles that promote cell proliferation, migration, and invasion.

Combat-Related Post-traumatic Stress Disorder: A Case Report of Virtual Reality Graded Exposure Therapy With Physiological Monitoring in a U.S. Navy Officer and a U.S. Army Officer

The U.S. Department of Defense (DoD) and the Department of Veterans Affairs (DVA) seek to enhance the efficacy of treatments for warriors with post-traumatic stress disorder (PTSD) secondary to their combat deployments to Iraq and/or Afghanistan. Virtual Reality Graded Exposure Therapy (VR-GET) with arousal control has shown particular promise in reducing the symptom severity of PTSD in combat veterans. In this report, we describe the outcome of VR-GET for the treatment of combat-related PTSD in two combat veterans, neither of whom had received treatment for PTSD in the initial years after their return from combat duty.

Sex Differences in Behavioral Symptoms and the Levels of Circulating GFAP, Tau, and NfL in Patients With Traumatic Brain Injury

Traumatic brain injury (TBI) affects millions of Americans each year and has been shown to disproportionately impact those subject to greater disparities in health. Female sex is one factor that has been associated with disparities in health outcomes, including in TBI, but sex differences in biomarker levels and behavioral outcomes after TBI are underexplored. This study included participants with both blunt and blast TBI with majority rating their TBI as mild. Time since injury was 5.4 (2.0, 15.5) years for females and 6.8 (2.4, 11.3) years for males. The aim of this cross sectional study is to investigate the relationship between postconcussive, depression, and post-traumatic stress disorder (PTSD) symptoms, as well as health related quality of life (HRQOL), and the levels of glial fibrillary acidic protein (GFAP), total tau (t-tau), neurofilament light chain (NfL), and ubiquitin C-terminal hydrolase-L1 (UCH-L1). Behavioral outcomes were evaluated with the Neurobehavioral Symptom Inventory (NSI), Patient Health Questionnaire-9 (PHQ-9), PTSD Checklist- Civilian Version (PCL-C), short form (SF)-36, and plasma levels of total tau, GFAP, NfL, and UCHL-1 measured with the Simoa-HDX. We observed that females had significantly higher levels of GFAP and tau (ps < 0.05), and higher PHQ-9 scores, NSI total scores, NSI- vestibular, NSI-somatosensory, NSI-affective sub-scale scores (ps < 0.05)), than males. In addition, females had lower scores in HRQOL outcomes of role limitations due to emotional problems, vitality, emotional well-being, social functioning, and pain compared to males (ps < 0.05). Correlation analysis showed positive associations between levels of tau and the NSI-total and NSI-cognitive sub-scale scores (ps < 0.05) in females. No significant associations were found for NfL or GFAP with NSI scores. For female participants, negative correlations were observed between tau and NfL concentrations and the SF-36 physical function subscale (ps < 0.05), as well as tau and the social function subscale (p < 0.001), while GFAP levels positively correlated with role limitations due to emotional problems (p = 0.004). No significant associations were observed in males. Our findings suggest that sex differences exist in TBI-related behavioral outcomes, as well as levels of biomarkers associated with brain injury, and that the relationship between biomarker levels and behavioral outcomes is more evident in females than males. Future studies are warranted to corroborate these results, and to determine the implications for prognosis and treatment. The identification of candidate TBI biomarkers may lead to development of individualized treatment guidelines.

Synthesis of C-Mannosylated Glycopeptides Enabled by Ni-Catalyzed Photoreductive Cross-Coupling Reactions

The biological functions of tryptophan C-mannosylation are poorly understood, in part, due to a dearth of methods for preparing pure glycopeptides and glycoproteins with this modification. To address this issue, efficient and scalable methods are required for installing this protein modification. Here, we describe unique Ni-catalyzed cross-coupling conditions that utilize photocatalysis or a Hantzsch ester photoreductant to couple glycosyl halides with (hetero)aryl bromides, thereby enabling the α-C-mannosylation of 2-bromo-tryptophan, peptides thereof, and (hetero)aryl bromides more generally. We also report that 2-(α-d-mannopyranosyl)-L-tryptophan undergoes facile anomerization in the presence of acid: something that must be considered when preparing and handling peptides with this modification. These developments enabled the first automated solid-phase peptide syntheses of C-mannosylated glycopeptides, which we used to map the epitope of an antibody, as well as providing the first verified synthesis of Carmo-HrTH-I, a C-mannosylated insect hormone. To complement this approach, we also performed late-stage tryptophan C-mannosylation on a diverse array of peptides, demonstrating the broad scope and utility of this methodology for preparing glycopeptides.

Structure-Guided Development of Potent Benzoylurea Inhibitors of BCL-XL and BCL-2

The BCL-2 family of proteins (including the prosurvival proteins BCL-2, BCL-X_L, and MCL-1) is an important target for the development of novel anticancer therapeutics. Despite the challenges of targeting protein-protein interaction (PPI) interfaces with small molecules, a number of inhibitors (called BH3 mimetics) have entered the clinic and the BCL-2 inhibitor, ABT-199/venetoclax, is already proving transformative. For BCL-X_L, new validated chemical series are desirable. Here, we outline the crystallography-guided development of a structurally distinct series of BCL-X_L/BCL-2 inhibitors based on a benzoylurea scaffold, originally proposed as α-helix mimetics. We describe structure-guided exploration of a cryptic "p5" pocket identified in BCL-X_L. This work yields novel inhibitors with submicromolar binding, with marked selectivity toward BCL-X_L. Extension into the hydrophobic p2 pocket yielded the most potent inhibitor in the series, binding strongly to BCL-X_L and BCL-2 (nanomolar-range half-maximal inhibitory concentration (IC₅₀)) and displaying mechanism-based killing in cells engineered to depend on BCL-X_L for survival.

Excessive daytime sleepiness is associated with altered gene expression in military personnel and veterans with posttraumatic stress disorder: an RNA sequencing study

STUDY OBJECTIVES

Posttraumatic stress disorder (PTSD) is a common condition for military personnel and veterans. PTSD has been shown to impact gene expression, however, to date no study has examined comorbid conditions which may also impact gene expression, for example, excessive daytime sleepiness (EDS). As such, this study sought to examine gene expression using RNA sequencing across three group comparisons of military personnel and veterans: (1) PTSD with EDS (PTSDwEDS) versus PTSD without EDS (PTSDw/outEDS), (2) Controls (no PTSD or EDS) versus PTSDwEDS, and (3) Controls versus PTSDw/outEDS.

METHODS

We performed experimental RNA-seq using Illumina's HiSeq 2500 Sequencing System. We also used Ingenuity Pathway Analysis (IPA), a bioinformatics application, to identify gene pathways and networks which may be disrupted.

RESULTS

There were only two genes that were significantly dysregulated between the Controls and PTSDw/outEDS, therefore IPA analysis was not conducted. However, comparisons revealed that there was significant gene dysregulation between Controls and the PTSDwEDS (251 genes), and the PTSDwEDS versus the PTSDw/outEDS (1,873 genes) groups. Four candidate networks were identified via the IPA software for analysis. Significantly dysregulated genes across the four candidate networks were associated with sleep and circadian function, metabolism, mitochondrial production and function, ubiquitination, and the glutamate system.

CONCLUSIONS

These results suggest that PTSD with concurrent EDS is associated with gene dysregulation. This dysregulation may present additional biological and health consequences for these military personnel and veterans. Further research, to track these gene changes over time and to determine the cause of the EDS reported, is vital.

0024 PTSD with Concurrent Excessive Daytime Sleepiness Alters Gene Expression in Military Personnel and Veterans; An RNA-Sequencing Study

Introduction

Up to 91% of military personnel and veterans with posttraumatic stress disorder (PTSD) report co-occurring sleep disturbances, including. insomnia and excessive daytime sleepiness (EDS). Sleep disturbances have been shown not only to increase the risk of developing PTSD, but to exacerbate and maintain PTSD symptomology. The aim of this study was to examine gene expression in active duty military personnel and veterans with PTSD, with and without EDS. Participants were categorized into three groups; 1) PTSD with EDS (PTSDwEDS; n=21), 2) PTSD without EDS (PTSDnoEDS; n=25), or 3) Controls (no PTSD and no EDS; n=57).

Methods

Participants were 79% male, mean age of 37.6years (SD=11.2years). PTSD symptoms were measured using the PTSD checklist for civilians (PCL-C); participants were classified as PTSD-present using DSM-IV-TR criteria of “moderate-to-severe”. Daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS), high sleepiness was indicated by an ESS score &gt;13. We performed RNA-seq with Illumina’s HiSeq 2500 in paired-end. We conducted quality control using FastQC and aligned to GRCh38 reference genome using STAR (v2.5.3a). Differentially expressed genes identified using DESeq2 (v1.20.0) with False Discovery Rate of 0.10. Finally, Ingenuity Pathway Analysis (IPA) was conducted to identify dysregulated gene networks.

Results

Between the Controls and PTSDnoEDS groups, two genes were significantly dysregulated. In controls and PTSDwEDS groups, 251 genes were dysregulated. The IPA networks showed that genes associated with inflammation were significantly dysregulated. Finally, between PTSDwEDS and PTSDnoEDS there were 1,873 significantly dysregulated genes. The IPA networks identified dysregulation of genes related to sleep, fatigue, circadian, and mitochondrial function.

Conclusion

Taken together this data indicates that EDS that is co-morbidly experienced with PTSD is associated with significant gene dysregulation, above and beyond that observed in participants with PTSD without significant EDS and controls. Treating EDS in military personnel and veterans with PTSD is important.

Support

This work was supported by the Center for Neuroscience and Regenerative Medicine (CNRM)

Enhanced exposure therapy for combat-related Posttraumatic Stress Disorder (PTSD): Study protocol for a randomized controlled trial

BACKGROUND

PTSD, which has been identified in up to 23% of post-9-11 veterans, often results in a chronic, pernicious course. Thus, effective treatments are imperative. The Institute of Medicine (IOM) concluded that the only intervention for PTSD with sufficient evidence to conclude efficacy is exposure therapy. This Phase III trial compares the efficacy of exposure therapy for combat-related PTSD delivered in two different formats- via virtual reality exposure therapy (VRE) or prolonged exposure therapy (PE)- combined with D-Cycloserine (DCS), a cognitive enhancer shown to facilitate the extinction of fear.

METHODS/DESIGN

Military personnel of any duty status and civilians deployed to Iraq and Afghanistan were eligible. Participants were randomly assigned to 9 sessions of exposure therapy (VRE or PE) and medication (50 mg DCS or placebo). Participants were treated at three geographically diverse sites. Participants were re-assessed at 3-months post-treatment. The co-primary hypotheses are that (1) DCS will augment response to exposure therapy (both VRE and PE) on PTSD symptoms; (2) VRE will be associated with greater improvement than PE. Genetic and psychophysiological markers will be evaluated as potential moderators and mediators of treatment outcomes as well as secondary outcomes.

DISCUSSION

This study is the first to compare the relative efficacy of DCS-augmented VRE versus PE on PTSD symptoms. The design has several advantages: participants received an active, effective treatment and predictors of response to treatment included genetic and psychobiological measures. The results may directly influence the future delivery of services, and contribute to the development of a standardized treatment protocol.

TRIAL REGISTRATION

NCT01352637.

The PEAK family of pseudokinases, their role in cell signalling and cancer

The study of pseudokinases has uncovered that catalysis-independent functions play a critical role in cell signalling regulation. However, how pseudokinases dynamically assemble and regulate oncogenic signalling pathways remains, in most cases, unclear due to a limited knowledge of the structural determinants that are critical for their functions. Here, we review the recent progress made to unravel the role of the PEAK family of pseudokinases, which comprises SgK269, SgK223 and the recently identified PEAK3, in assembling specific oncogenic signalling pathways that contribute to the progression of several aggressive cancers. We focus on recent structural advances revealing that SgK269 and SgK223 can homo- and heteroassociate via a unique dimerisation domain, comprising conserved regulatory helices directly surrounding the pseudokinase domain, which is also conserved in PEAK3. We also highlight a potential oligomerisation mechanism driven by the pseudokinase domain. While it is likely that homo- or heterodimerisation and oligomerisation mechanisms contribute to the assembly of complex signalling hubs and provide a means to spatially and temporally modulate and diversify signalling outputs, the exact role that these oncogenic scaffolds play in regulating cell migration, invasion and morphology remains unclear. Here, we attempt to link their structural characteristics to their cellular functions by providing a thorough analysis of the signalling transduction pathways they are known to modulate.

Single-Trial Mechanisms Underlying Changes in Averaged P300 ERP Amplitude and Latency in Military Service Members After Combat Deployment

Attenuation in P300 amplitude has been characterized in a wide range of neurological and psychiatric disorders such as dementia, schizophrenia, and posttraumatic stress disorder (PTSD). However, it is unclear whether the attenuation observed in the averaged event-related potential (ERP) is due to the reduction of neural resources available for cognitive processing, the decreased consistency of cognitive resource allocation, or the increased instability of cognitive processing speed. In this study, we investigated this problem by estimating single-trial P300 amplitude and latency using a modified Woody filter and examined the relation between amplitudes and latencies from the single-trial level to the averaged ERP level. ERPs were recorded from 30 military service members returning from combat deployment at two time points separated by 6 or 12 months. A conventional visual oddball task was used to elicit P300. We observed that the extent of changes in the within-subject average P300 amplitude over time was significantly correlated with the amount of change in three single-trial measures: (1) the latency variance of the single-trial P300 (r = -0.440, p = 0.0102); (2) the percentage of P300-absent trials (r = -0.488, p = 0.005); and (3) the consistent variation of the single-trial amplitude (r = 0.571, p = 0.0022). These findings suggest that there are multiple underlying mechanisms on the single-trial level that contribute to the changes in amplitudes seen at the averaged ERP level. The changes between the first and second assessments were quantified with the intraclass correlation coefficient, the standard error of measurement and the minimal detectable difference. The unique population, the small sample size and the large fraction of participants lost to follow up precludes generalizations of these measures of change to other populations.

BAF complex vulnerabilities in cancer demonstrated via structure-based PROTAC design

Targeting subunits of BAF/PBAF chromatin remodeling complexes has been proposed as an approach to exploit cancer vulnerabilities. Here we develop PROTAC degraders of the BAF ATPase subunits SMARCA2 and SMARCA4 using a bromodomain ligand and recruitment of the E3 ubiquitin ligase VHL. High-resolution ternary complex crystal structures and biophysical investigation guided rational and efficient optimization towards ACBI1, a potent and cooperative degrader of SMARCA2, SMARCA4 and PBRM1. ACBI1 induced antiproliferative effects and cell death caused by SMARCA2 depletion in SMARCA4 mutant cancer cells, and in acute myeloid leukemia cells dependent on SMARCA4 ATPase activity. These findings exemplify a successful biophysics- and structure-based PROTAC design approach to degrade high profile drug targets and pave the way towards new therapeutics for the treatment of tumors sensitive to the loss of BAF complex ATPases.

Conceptualizing the health and well-being impacts of social enterprise: a UK-based study

Social enterprises-businesses that work for social benefit rather than for the maximization of financial returns to shareholders or owners-could potentially prove to be an innovative and sustainable way of tackling 'upstream' social determinants of health. However, empirical work focusing upon how, and to what extent, social enterprise-led activity may impact upon health and well-being is still relatively scarce. This study examines how social enterprises portray their impact, and how such impacts may be considered in health and well-being terms. Through analysing evaluative reports of the work of social enterprises in Scotland (n = 17) utilizing a 'process coding' method, we investigate both the self-reported impacts of the work of social enterprises and the mechanisms by which these are said to be derived. Revisiting previous conceptualizations in the extant literature, this work allows us to present an 'empirically-informed' conceptual model of the health and well-being impacts of social enterprise-led activity, and thus presents a significant advance on previous hypothetical, theoretically-based conceptualizations. It is considered that these findings further improve our overall knowledge of ways in which social enterprise and other parts of the third sector could be considered as potentially valuable 'non-obvious' public health actors.

Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE): A pilot clinical trial for chronic traumatic brain injury

BACKGROUND

Virtual reality (VR) technology may provide an effective means to integrate cognitive and functional approaches to TBI rehabilitation. However, little is known about the effectiveness of VR rehabilitation for TBI-related cognitive deficits. In response to these clinical and research gaps, we developed Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE), an intervention designed to improve cognitive performance, driving safety, and neurobehavioral symptoms.

OBJECTIVE

This pilot clinical trial was conducted to examine feasibility and preliminary efficacy of NeuroDRIVE for rehabilitation of chronic TBI.

METHODS

Eleven participants who received the intervention were compared to six wait-listed participants on driving abilities, cognitive performance, and neurobehavioral symptoms.

RESULTS

The NeuroDRIVE intervention was associated with significant improvements in working memory and visual search/selective attention- two cognitive skills that represented a primary focus of the intervention. By comparison, no significant changes were observed in untrained cognitive areas, neurobehavioral symptoms, or driving skills.

CONCLUSIONS

Results suggest that immersive virtual environments can provide a valuable and engaging means to achieve some cognitive rehabilitation goals, particularly when these goals are closely matched to the VR training exercises. However, additional research is needed to augment our understanding of rehabilitation for driving skills, cognitive performance, and neurobehavioral symptoms in chronic TBI.

Increased cognitive control and reduced emotional interference is associated with reduced PTSD symptom severity in a trauma-exposed sample: A preliminary longitudinal study

Individuals with posttraumatic stress disorder (PTSD) show deficits in recruiting neural regions associated with cognitive control. In contrast, trauma exposed individuals (TEIs) show increased recruitment of these regions. While many individuals who experience a trauma exhibit some PTSD symptoms, relatively few develop PTSD. Despite this, no work has examined the relationship between changes in PTSD symptoms and changes in neural functioning in TEIs longitudinally. This study examined the neural correlates of changing PTSD symptom levels in TEIs. Twenty-one military service members completed the affective stroop task while undergoing fMRI within 2 months of returning from deployment and a second scan 6-12 months later. Participants with PTSD or depression at baseline were excluded. PTSD symptom improvement was associated with greater increase in response to incongruent relative to congruent negative stimuli in dorsal anterior cingulate cortex and inferior frontal gyrus/anterior insula and increased BOLD response over time to emotional relative to neutral stimuli in inferior parietal cortex. Improvement in PTSD symptoms were not associated with changes in amygdala responsiveness to emotional stimuli. In short, the current data indicate that TEIs who become more able to recruit regions implicated in cognitive control show greater reductions in PTSD symptom levels.

Utility of P300 ERP in monitoring post-trauma mental health: A longitudinal study in military personnel returning from combat deployment

Military service members (SMs) returning from combat are at high risk of developing neuropsychiatric conditions such as posttraumatic stress disorder (PTSD) and major depression. Symptom dynamics following reintegration into civilian life may be magnified over time such that some SMs present with delayed onset and may not reach a diagnostic threshold for months to years. Monitoring the trajectory of mental health in the aftermath of combat trauma can therefore be particularly important in enhancing diagnosis. In this study, we investigated the possible utility of the P300 event-related potential (ERP) as an objective marker for monitoring post-trauma mental health. SMs recently returned from a combat deployment were recruited to undergo a baseline assessment, with subsequent follow-up assessment at 6 or 12 months later. At each assessment, ERPs were recorded using a conventional visual oddball task and a set of psychological scores assessing PTSD, depression, and psychosocial functioning were obtained. We observed that the individuals with overall improved psychological scores at follow-up had increased P300 amplitude and shortened P300 latency, and the individuals with overall worsened psychological scores at follow-up had prolonged P300 latency. The degree of change in aggregate psychological score was significantly correlated with the magnitude of change in P300 amplitude (r = -0.72, p < 0.0001) and latency (r = 0.42, p = 0.0201). These findings suggest that the P300 may be utilized as a quantitative biomarker for tracking the changes of mental health longitudinally. It may offer clinicians an objective tool for the assessment of the dynamics of mental health following trauma, and perhaps also for monitoring recovery during treatment.

Differentiating the effect of social enterprise activities on health

An emerging stream of literature has focused on the ways in which social enterprises might act on the social determinants of health. However, this previous work has not taken a sufficiently broad account of the wide range of stakeholders involved in social enterprises and has also tended to reduce and simplify a complex and heterogeneous set of organisations to a relatively homogenous social enterprise concept. In an attempt to address these gaps, we conducted an empirical investigation between August 2014 and October 2015 consisting of qualitative case studies involving in-depth semi-structured interviews and a focus group with a wide variety of stakeholders from three social enterprises in different regions of Scotland. We found that different forms of social enterprise impact on different dimensions of health in different ways, including through: engendering a feeling of ownership and control; improving environmental conditions (both physical and social); and providing or facilitating meaningful employment. In conclusion, we highlight areas for future research.

Disrupted Gamma Synchrony after Mild Traumatic Brain Injury and Its Correlation with White Matter Abnormality

Mild traumatic brain injury (mTBI) has been firmly associated with disrupted white matter integrity due to induced white matter damage and degeneration. However, comparatively less is known about the changes of the intrinsic functional connectivity mediated via neural synchronization in the brain after mTBI. Moreover, despite the presumed link between structural and functional connectivity, no existing studies in mTBI have demonstrated clear association between the structural abnormality of white matter axons and the disruption of neural synchronization. To investigate these questions, we recorded resting state EEG and diffusion tensor imaging (DTI) from a cohort of military service members. A newly developed synchronization measure, the weighted phase lag index was applied on the EEG data for estimating neural synchronization. Fractional anisotropy was computed from the DTI data for estimating white matter integrity. Fifteen service members with a history of mTBI within the past 3 years were compared to 22 demographically similar controls who reported no history of head injury. We observed that synchronization at low-gamma frequency band (25–40 Hz) across scalp regions was significantly decreased in mTBI cases compared with controls. The synchronization in theta (4–7 Hz), alpha (8–13 Hz), and beta (15–23 Hz) frequency bands were not significantly different between the two groups. In addition, we found that across mTBI cases, the disrupted synchronization at low-gamma frequency was significantly correlated with the white matter integrity of the inferior cerebellar peduncle, which was also significantly reduced in the mTBI group. These findings demonstrate an initial correlation between the impairment of white matter integrity and alterations in EEG synchronization in the brain after mTBI. The results also suggest that disruption of intrinsic neural synchronization at low-gamma frequency may be a characteristic functional pathology following mTBI and may prove useful for developing better methods of diagnosis and treatment.

An App a Day Keeps the Doctor Away: Guided Education and Training via Smartphones in Subthreshold Post Traumatic Stress Disorder

Post traumatic stress disorder (PTSD) symptoms are common in military service members (SMs), but stigma can impede treatment initiation. Smartphone applications (apps) are available anywhere, anytime, with the potential to both mitigate the impact of stigma and reduce PTSD symptom severity. We provided 144 SMs or family members, with subthreshold PTSD symptoms (PTSD Checklist [PCL] scores of 28-49), with apps promoting psychoeducation, social engagement, and relaxation and randomized them to 6 weeks of resilience enhancement (brief cognitive-behavioral session, followed by daily text messages directing app use) or a control group (daily text messages of inspirational quotes). Participants (54 percent males, 87 percent SMs) in both groups reported reductions in PTSD, anxiety, and depression symptoms during the 6-week intervention, which were sustained at 3 months, but exhibited partial rebound at 6-12 months. Our preliminary results suggest that app use, with or without specific direction, feasibly and effectively reduces symptom severity. Future studies should consider a longer intervention, enhanced compliance tracking, or boosters to sustain benefits.

Streamlining Participant Recruitment for TBI and PTSD Research Studies

OBJECTIVES

Recruitment of participants for traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) studies is a major challenge, causing delays in study timelines and even study failures. To address this challenge, the Center for Neuroscience and Regenerative Medicine (CNRM) Recruitment Core developed procedures for identification, screening, and referral of participants from screening studies to a broad range of TBI and PTSD studies.

METHODS

Participants were recruited from civilian hospitals, Military Treatment Facilities, and through various events and presentations. Enrolled participants were referred to other studies during initial enrollment, follow-up visits, or ad hoc as new CNRM studies became active. A centralized online database was used to streamline the eligibility and referral process.

RESULTS

As of October 25, 2016, 1,040 enrolled participants from the two screening studies have been assessed for eligibility for active CNRM studies. Referrals have led to 197 total enrollments into other CNRM studies. Common reasons for exclusion from studies included age, date of injury, injury severity, contraindication to Magnetic Resonance Imaging, state of residence, and military status.

CONCLUSION

Collaborative work with multiple disciplines and institutions, and the use of diverse media, was critical to augmenting participant enrollment, and significantly diversified the demographics of the participant population. Streamlining the referral process helps studies meet their timelines and target enrollment.

Identifying Electrophysiological Prodromes of Post-traumatic Stress Disorder: Results from a Pilot Study

The objective of this research project is the identification of a physiological prodrome of post-traumatic stress disorder (PTSD) that has a reliability that could justify preemptive treatment in the sub-syndromal state. Because abnormalities in event-related potentials (ERPs) have been observed in fully expressed PTSD, the possible utility of abnormal ERPs in predicting delayed-onset PTSD was investigated. ERPs were recorded from military service members recently returned from Iraq or Afghanistan who did not meet PTSD diagnostic criteria at the time of ERP acquisition. Participants (n = 65) were followed for up to 1 year, and 7.7% of the cohorts (n = 5) were PTSD-positive at follow-up. The initial analysis of the receiver operating characteristic (ROC) curve constructed using ERP metrics was encouraging. The average amplitude to target stimuli gave an area under the ROC curve of greater than 0.8. Classification based on the Youden index, which is determined from the ROC, gave positive results. Using average target amplitude at electrode Cz yielded Sensitivity = 0.80 and Specificity = 0.87. A more systematic statistical analysis of the ERP data indicated that the ROC results may simply represent a fortuitous consequence of small sample size. Predicted error rates based on the distribution of target ERP amplitudes approached those of random classification. A leave-one-out cross validation using a Gaussian likelihood classifier with Bayesian priors gave lower values of sensitivity and specificity. In contrast with the ROC results, the leave-one-out classification at Cz gave Sensitivity = 0.65 and Specificity = 0.60. A bootstrap calculation, again using the Gaussian likelihood classifier at Cz, gave Sensitivity = 0.59 and Specificity = 0.68. Two provisional conclusions can be offered. First, the results can only be considered preliminary due to the small sample size, and a much larger study will be required to assess definitively the utility of ERP prodromes of PTSD. Second, it may be necessary to combine ERPs with other biomarkers in a multivariate metric to produce a prodrome that can justify preemptive treatment.

Conceptualising the public health role of actors operating outside of formal health systems: The case of social enterprise

This paper focuses on the role of actors that operate outside formal health systems, but nevertheless have a vital, if often under-recognised, role in supporting public health. The specific example used is the 'social enterprise', an organisation that seeks, through trading, to maximise social returns, rather than the distribution of profits to shareholders or owners. In this paper we advance empirical and theoretical understanding of the causal pathways at work in social enterprises, by considering them as a particularly complex form of public health 'intervention'. Data were generated through qualitative, in depth, semi-structured interviews and a focus group discussion, with a purposive, maximum variation sample of social enterprise practitioners (n = 13) in an urban setting in the west of Scotland. A method of analysis inspired by critical realism - Causation Coding - enabled the identification of a range of explanatory mechanisms and potential pathways of causation between engagement in social enterprise-led activity and various outcomes, which have been grouped into physical health, mental health and social determinants. The findings then informed the construction of an empirically-informed conceptual model to act as a platform upon which to develop a future research agenda. The results of this work are considered to not only encourage a broader and more imaginative consideration of what actually constitutes a public health intervention, but also reinforces arguments that actors within the Third Sector have an important role to play in addressing contemporary and future public health challenges.

The assets-based approach: furthering a neoliberal agenda or rediscovering the old public health? A critical examination of practitioner discourses

The 'assets-based approach' to health and well-being has, on the one hand, been presented as a potentially empowering means to address the social determinants of health while, on the other, been criticised for obscuring structural drivers of inequality and encouraging individualisation and marketisation; in essence, for being a tool of neoliberalism. This study looks at how this apparent contestation plays out in practice through a critical realist-inspired examination of practitioner discourses, specifically of those working within communities to address social vulnerabilities that we know impact upon health. The study finds that practitioners interact with the assets-based policy discourse in interesting ways. Rather than unwitting tools of neoliberalism, they considered their work to be about mitigating the worst effects of poverty and social vulnerability in ways that enhance collectivism and solidarity, concepts that neoliberalism arguably seeks to disrupt. Furthermore, rather than a different, innovative, way of working, they consider the assets-based approach to simply be a re-labelling of what they have been doing anyway, for as long as they can remember. So, for practitioners, rather than a 'new' approach to public health, the assets-based public health movement seems to be a return to recognising and appreciating the role of community within public health policy and practice; ideals that predate neoliberalism by quite some considerable time.

Functional neuroimaging correlates of thinking flexibility and knowledge structure in memory: Exploring the relationships between clinical reasoning and diagnostic thinking

BACKGROUND

Diagnostic reasoning involves the thinking steps up to and including arrival at a diagnosis. Dual process theory posits that a physician's thinking is based on both non-analytic or fast, subconscious thinking and analytic thinking that is slower, more conscious, effortful and characterized by comparing and contrasting alternatives. Expertise in clinical reasoning may relate to the two dimensions measured by the diagnostic thinking inventory (DTI): memory structure and flexibility in thinking.

AIM

Explored the functional magnetic resonance imaging (fMRI) correlates of these two aspects of the DTI: memory structure and flexibility of thinking.

METHODS

Participants answered and reflected upon multiple-choice questions (MCQs) during fMRI. A DTI was completed shortly after the scan. The brain processes associated with the two dimensions of the DTI were correlated with fMRI phases - assessing flexibility in thinking during analytical clinical reasoning, memory structure during non-analytical clinical reasoning and the total DTI during both non-analytical and analytical reasoning in experienced physicians.

RESULTS

Each DTI component was associated with distinct functional neuroanatomic activation patterns, particularly in the prefrontal cortex.

CONCLUSION

Our findings support diagnostic thinking conceptual models and indicate mechanisms through which cognitive demands may induce functional adaptation within the prefrontal cortex. This provides additional objective validity evidence for the use of the DTI in medical education and practice settings.

Predictors of Neurocognitive Syndromes in Combat Veterans

Traumatic brain injury, depression and posttraumatic stress disorder (PTSD) are neurocognitive syndromes often associated with impairment of physical and mental health, as well as functional status. These syndromes are also frequent in military service members (SMs) after combat, although their presentation is often delayed until months after their return. The objective of this prospective cohort study was the identification of independent predictors of neurocognitive syndromes upon return from deployment could facilitate early intervention to prevent disability. We completed a comprehensive baseline assessment, followed by serial evaluations at three, six, and 12 months, to assess for new-onset PTSD, depression, or postconcussive syndrome (PCS) in order to identify baseline factors most strongly associated with subsequent neurocognitive syndromes. On serial follow-up, seven participants developed at least one neurocognitive syndrome: five with PTSD, one with depression and PTSD, and one with PCS. On univariate analysis, 60 items were associated with syndrome development at p < 0.15. Decision trees and ensemble tree multivariate models yielded four common independent predictors of PTSD: right superior longitudinal fasciculus tract volume on MRI; resting state connectivity between the right amygdala and left superior temporal gyrus (BA41/42) on functional MRI; and single nucleotide polymorphisms in the genes coding for myelin basic protein as well as brain-derived neurotrophic factor. Our findings require follow-up studies with greater sample size and suggest that neuroimaging and molecular biomarkers may help distinguish those at high risk for post-deployment neurocognitive syndromes.

Biomarkers of post-deployment resilience among military service members

The development of PTSD after military deployment is influenced by a combination of biopsychosocial risk and resilience factors. In particular, physiological factors may mark risk for symptom progression or resiliency. Research in civilian populations suggests elevated catecholamines after trauma are associated with PTSD months following the trauma. However, less is known regarding physiological markers of PTSD resilience among post-deployment service members (SM). We therefore assessed whether catecholamines obtained shortly after deployment were associated with combat-related PTSD symptoms three months later. Eighty-seven SMs completed the Clinician-Administered PTSD Scale for DSM-IV and blood draws within two months after return from deployment to Iraq or Afghanistan ("Time 1" or "T1") and three months later ("Time 2" or "T2"). Linear regression analyses demonstrated that lower norepinephrine at T1 was associated with lower PTSD symptoms at T2. In particular, T1 norepinephrine was positively associated with T2 symptom intensity and avoidance symptoms. The present findings represent a biologically-informed method of assessing PTSD resilience after deployment, which may aid clinicians in providing tailored treatments for those in the greatest need. Further research is needed to validate these findings and incorporate physiological measures within an assessment battery.

A Comparison of the Pathogenesis of Marburg Virus Disease in Humans and Nonhuman Primates and Evaluation of the Suitability of These Animal Models for Predicting Clinical Efficacy under the 'Animal Rule'

Marburg virus outbreaks are sporadic, infrequent, brief, and relatively small in terms of numbers of subjects affected. In addition, outbreaks most likely will occur in remote regions where clinical trials are not feasible; therefore, definitive, well-controlled human efficacy studies to test the effectiveness of a drug or biologic product are not feasible. Healthy human volunteers cannot ethically be deliberately exposed to a lethal agent such as Marburg virus in order to test the efficacy of a therapy or preventive prior to licensure. When human efficacy studies are neither ethical nor feasible, the US Food and Drug Administration may grant marketing approval of a drug or biologic product under the 'Animal Rule,' through which demonstration of the efficacy of a product can be 'based on adequate and well-controlled animal efficacy studies when the results of those studies establish that the drug is reasonably likely to produce clinical benefit in humans.' This process requires that the pathogenic determinants of the disease in the animal model are similar to those that have been identified in humans. After reviewing primarily English-language, peer-reviewed journal articles, we here summarize the clinical manifestations of Marburg virus disease and the results of studies in NHP showing the characteristics and progression of the disease. We also include a detailed comparison of the characteristics of the human disease relative to those for NHP. This review reveals that the disease characteristics of Marburg virus disease are generally similar for humans and 3 NHP species: cynomolgus macaques (Macaca fascicularis), rhesus macaques (Macaca mulatta), and African green monkeys (Chlorocebus aethiops).

Relationship of Neuroimaging to Typical Sleep Times During a Clinical Reasoning Task: A Pilot Study

Background: Sleep deprivation and fatigue have been associated with medical errors, clinical performance decrements, and reduced quality of life for both practicing physicians and medical students. Greater understanding of the impact of sleep quantity on clinical reasoning could improve patient care. The purpose of our pilot study was to examine relationships between clinical reasoning (assessed by functional magnetic resonance imaging) and sleep time (measured in different ways by actigraphy) while answering multiple-choice questions (MCQs) from licensing agencies. Methods: Residents and faculty were administered a clinical reasoning exercise (MCQs from licensing bodies) during functional magnetic resonance imaging. Usual sleep patterns were sampled with actigraphy. Covariate analysis was used to examine the relationship between sleep duration (mean sleep, minimum sleep, maximum sleep) and brain activity during clinical reasoning (solving MCQs from licensing bodies). Results: The mean sleep time over the duration of monitoring for the group was 7.19 hours (SD 0.66) with a range of 6.1 to 8.1 hours (internal medicine faculty 7.1 hours, SD 0.41; internal medicine residents 7.27 hours, SD 0.92). There was a negative relationship between activation in the prefrontal cortex and minimum sleep time while reflecting on MCQs. Conclusion: Our findings provide evidence that the quantity of sleep can modulate brain activity while completing a clinically meaningful task that should be confirmed in larger studies. Our findings suggest that the construct of sleepiness may be more complex than appreciated by many and that the most important of these sleep measures in terms of outcomes remains to be determined.

Catecholamine responses to virtual combat: implications for post-traumatic stress and dimensions of functioning

Posttraumatic stress disorder (PTSD) symptoms can result in functional impairment among service members (SMs), even in those without a clinical diagnosis. The variability in outcomes may be related to underlying catecholamine mechanisms. Individuals with PTSD tend to have elevated basal catecholamine levels, though less is known regarding catecholamine responses to trauma-related stimuli. We assessed whether catecholamine responses to a virtual combat environment impact the relationship between PTSD symptom clusters and elements of functioning. Eighty-seven clinically healthy SMs, within 2 months after deployment to Iraq or Afghanistan, completed self-report measures, viewed virtual-reality (VR) combat sequences, and had sequential blood draws. Norepinephrine responses to VR combat exposure moderated the relationship between avoidance symptoms and scales of functioning including physical functioning, physical-role functioning, and vitality. Among those with high levels of avoidance, norepinephrine change was inversely associated with functional status, whereas a positive correlation was observed for those with low levels of avoidance. Our findings represent a novel use of a virtual environment to display combat-related stimuli to returning SMs to elucidate mind-body connections inherent in their responses. The insight gained improves our understanding of post-deployment symptoms and quality of life in SMs and may facilitate enhancements in treatment. Further research is needed to validate these findings in other populations and to define the implications for treatment effectiveness.

Neural basis of nonanalytical reasoning expertise during clinical evaluation

INTRODUCTION

Understanding clinical reasoning is essential for patient care and medical education. Dual-processing theory suggests that nonanalytic reasoning is an essential aspect of expertise; however, assessing nonanalytic reasoning is challenging because it is believed to occur on the subconscious level. This assumption makes concurrent verbal protocols less reliable assessment tools.

METHODS

Functional magnetic resonance imaging was used to explore the neural basis of nonanalytic reasoning in internal medicine interns (novices) and board-certified staff internists (experts) while completing United States Medical Licensing Examination and American Board of Internal Medicine multiple-choice questions.

RESULTS

The results demonstrated that novices and experts share a common neural network in addition to nonoverlapping neural resources. However, experts manifested greater neural processing efficiency in regions such as the prefrontal cortex during nonanalytical reasoning.

CONCLUSIONS

These findings reveal a multinetwork system that supports the dual-process mode of expert clinical reasoning during medical evaluation.

If You Build It, They Will Come, But What Will Wounded Warriors Experience? Presence in the CAREN

Military service members (SMs) are surviving complex battlefield injuries at higher rates than ever before. Cutting-edge technologies are increasingly being employed to improve assessment and treatment of these complex injuries. The Computer Assisted Rehabilitation Environment (CAREN) is a comprehensive immersive environment, featuring a treadmill, curved panoramic screen, audio array, and infrared cameras to capture movement. While the CAREN has been progressively incorporated in treatment and research, little has been reported regarding participants' subjective experiences, particularly in relation to the signature wounds of the Iraq and Afghanistan wars, traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). Here we report participant presence, in a cohort of SMs with complex, frequently dual-diagnosis injuries (N=148; 95% TBI; 58% PTSD) engaging in CAREN-driven treatment. Using a presence questionnaire, participants rated aspects of the CAREN on a 7-point Likert scale and a presence score was calculated. The average presence score was 46.83 (SD=6.04; possible score range 7-63), with 95% of participants reporting scores &gt;36. Those with motion sickness and eye discomfort reported lower presence, whereas those with PTSD reported higher presence. Presence did not vary according to TBI severity. Overall, SMs with complex injuries experience presence in the CAREN. However, presence may be adversely affected by CAREN-associated symptoms such as motion sickness.

GETSmart: Guided Education and Training via Smart Phones to Promote Resilience

Posttraumatic stress disorder (PTSD) is common in U.S. military service members (SMs) returning from Afghanistan and Iraq. SMs with PTSD symptoms that fall short of meeting full diagnostic criteria also experience devastating effects on their quality of life and daily functioning. Though evidence based treatments are indicated for those meeting diagnostic criteria, less attention has been given to interventions for those with subthreshold symptoms. The advent of novel technologies affords a unique opportunity to meet these intervention needs. Here we describe the feasibility and preliminary findings testing a smartphone-based intervention program to reduce PTSD symptoms in post-deployment SMs. Participants were randomized to a control or intervention condition. Those in the intervention condition engaged in one Skype session and six weeks of daily directive text messages guiding application (app) use. Apps primarily included those developed by the Department of Defense or VA. Participants completed the PTSD Checklist online at baseline, post-intervention, and 3-month follow-up. Overall, participant feedback was positive, regardless of treatment condition. Preliminary findings (with 10% of the overall target population having enrolled) indicate PCL scores decrease significantly from baseline to post-intervention, and these effects are maintained at 3-month follow-up. Additional analyses will be performed upon completion of the study. The present findings demonstrate the feasibility and acceptability of a smartphone-based resiliency training program for those with subthreshold PTSD.