Health Phenotypes and Neurobehavioral Symptom Severity Among Post-9/11 Veterans With Mild Traumatic Brain Injury: A Chronic Effects of Neurotrauma Consortium Study

OBJECTIVE

To evaluate whether neurobehavioral symptoms differ between groups of veterans with mild traumatic brain injury (mTBI) classified by health characteristics.

PARTICIPANTS

A total of 71 934 post-9/11 veterans with mTBI from the Chronic Effects of Neurotrauma Consortium Epidemiology warfighter cohort.

DESIGN

Cross-sectional analysis of retrospective cohort.

MAIN MEASURES

Health phenotypes identified using latent class analysis of health and function over 5 years. Symptom severity measured using Neurobehavioral Symptom Inventory; domains included vestibular, somatic, cognitive, and affective.

RESULTS

Veterans classified as moderately healthy had the lowest symptom burden while the polytrauma phenotype group had the highest. After accounting for sociodemographic and injury characteristics, polytrauma phenotype veterans had about 3 times the odds of reporting severe symptoms in each domain compared with moderately healthy veterans. Those veterans who were initially moderately healthy but whose health declined over time had about twice the odds of severe symptoms as consistently healthier Veterans. The strongest associations were in the affective domain. Compared with the moderately healthy group, veterans in other phenotypes were more likely to report symptoms substantially interfered with their daily lives (odds ratio range: 1.3-2.8).

CONCLUSION

Symptom severity and interference varied by phenotype, including between veterans with stable and declining health. Ameliorating severe symptoms, particularly in the affective domain, could improve health trajectories following mTBI.

Impacts of a web-based educational program for veterans who read their mental health notes online

Objective

This study evaluates whether a web-based educational program for patients who read their mental health notes online improves patient-clinician communication and increases patient activation.

Methods

The web-based educational program, developed with end-user input, was designed to educate patients on the content of mental health notes, provide guidance on communicating with clinicians about notes, and facilitate patients' safe and purposeful use of their health information. Eligible patients were engaged in mental health treatment (≥1 visit in the prior 6 months) and had logged into the Veterans Health Administration (VHA) patient portal at least twice. Participants completed measures of patient activation, perceived efficacy in healthcare interactions, patient trust in their clinicians, and patient assessment of the therapeutic relationship before and after participating in the program. A total of 247 participants had complete data and engaged with the program for 5 minutes or more, comprising the analytic sample. Multivariate analysis using mixed effects models were used to examine pre-post changes in outcomes.

Results

In bivariate analyses, patient activation, perceived efficacy in healthcare interactions, and trust in clinicians increased significantly between pre- and post-training assessments. In fully adjusted models, changes in patient activation [b = 2.71 (1.41, 4.00), P < 0.01] and perceived efficacy in healthcare interactions [b = 1.27 (0.54, 2.01), P < 0.01)] remained significant.

Conclusions

Findings suggest that this educational program may help empower mental health patients who read their notes online to be active participants in their care, while also providing information and tools that may facilitate better relationships with their clinicians.

Vitreous traction and epiretinal membranes in diabetic macular oedema using spectral-domain optical coherence tomography

PURPOSE

The purpose of this study was to present an association between diabetic macular oedema (DME) and vitreoretinal interface abnormalities using 3D spectral domain optical coherence tomography (SD-OCT).

METHODS

In a retrospective study, charts and SD-OCT of consecutive patients with diffuse or focal DME were reviewed. Only one randomly chosen eye per patient with DME was included, and eyes that had another retinopathy that could affect the study analysis or that underwent vitreoretinal surgery were excluded.

RESULTS

Out of 58 eyes (58 patients) with DME, 11 eyes (19.0%) had vitreofoveal traction (Group A), either unifocally (n=6) or multifocally; that is, associated with additional extrafoveal traction site(s). Group B comprised 20 eyes (34.5%) that had sole extrafoveal vitreous traction, at either retinal and/or papillary sites. In each, the retinal oedema underlying extrafoveal traction was in continuum in at least one site with that at the central macula, as verified by the macular maps, thus presented as diffuse macular oedema. In Group C, 13 eyes (22.4%) had an epiretinal membrane (ERM), 1.5 × 3 mm to ≥6 × 6 mm in size that overlaid diffuse oedematous macula. Group D included 14 eyes (24.1%) that had neither vitreous traction nor ERM; 12 (20.7%) of them had DME secondary to leaking microaneurysms with or without leaking capillary beds, and the remaining two had leakage from non-microaneurysms sources.

CONCLUSIONS

DME was detected by the SD-OCT to be associated with sole extrafoveal vitreous traction in one-third of the patients. Further studies are required to evaluate the clinical consequences of these observations.

Enzymatic activity of endogenous telomerase associated with intact nuclei from human leukemia CEM cells

Telomerase, a telomere-specific DNA polymerase and novel target for chemotherapeutic intervention, is found in many types of cancers. Telomerase activity is typically assayed using an exogenous primer and cellular extracts as the source of enzyme. Since the nuclear organization might affect telomerase function, we developed a system in which telomerase in intact nuclei catalyzes primer extension. Telomerase activity in isotonically isolated nuclei from human CEM cells shows low processivity (addition of up to four TTAGGG repeats). In contrast, telomerase activity which leaks into a 500 g postnuclear supernatant and the activity in a CHAPS extract are highly processive. The nucleotide inhibitor, 7-deaza-dGTP, seems to be more inhibitory against the nuclei-associated enzyme compared to telomerase from cytoplasmic extracts. However, 7-deaza-dATP and ddGTP are less inhibitory against nuclei-associated telomerase. The results suggest that the association of telomerase with the nuclear chromatin affects telomerase activity. Examination of telomerase activity in a more natural nuclear environment may shed new light on the telomerase function and provide a useful system for the evaluation of new telomerase inhibitors.

Reduced efficacy of 8-OH-DPAT's inhibition of lordosis behavior by prior estrogen treatment

The effects of bilateral VMN infusion with the 5-HT1A receptor agonist, (+/-)-8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT; 200, 1000, or 2000 ng), on lordosis behavior were examined in hormonally primed ovariectomized rats. When rats were given a single injection with 25 microg estradiol benzoate followed 48 h later with 500 microg progesterone, inhibition of lordosis behavior was evident at all doses of 8-OH-DPAT. However, when rats were treated with 25 microg estradiol benzoate followed 7 days later with a second injection of 25 microg estradiol benzoate and then progesterone, none of the doses of 8-OH-DPAT effectively inhibited lordosis behavior. In some rats, cannulae were located near the most rostral portion of the VMN. In these rats, there was no effect of the second estrogen treatment on the response to 8-OH-DPAT. Therefore, a second experiment was performed to specifically evaluate the effects of two estradiol benzoate treatments on the response to bilateral 8-OH-DPAT infusion in the rostral VMN. In contrast to the reduced effectiveness of the 8-OH-DPAT infusion in the mid to caudal VMN in rats given two injections with estradiol benzoate, 2000 ng 8-OH-DPAT continued to effectively inhibit lordosis behavior following the 5-HT1A receptor agonist's infusion into the more rostral areas. These findings are discussed in relation to earlier studies in which the potency, but not the efficacy, of 8-OH-DPAT was reduced following systemic treatment with the 5-HT1A receptor agonist.

Attenuation of the lordosis-inhibiting effects of 8-OH-DPAT by TFMPP and quipazine

Regularly cycling, proestrous female rats received infusions of 200 ng of the serotonin (5-HT) 1A receptor agonist, (+/-) 8-hydroxy 2-(di-n-propylamino) tetralin-HBr (8-OH-DPAT), or 200 ng 8-OH-DPAT and 1000 or 2000 ng of N-(3-trifluoro-methylphenyl) piperazine hydrochloride (TFMPP) or 2-(1-piperazinyl) quinoline dimaleate (quipazine). Infusions were made bilaterally into the ventromedial nucleus of the hypothalamus (VMN). Animals receiving 200 ng 8-OH-DPAT exhibited a decline in lordosis behavior following infusion. Rats receiving 8-OH-DPAT and 1000 or 2000 ng quipazine or TFMPP were protected from the lordosis-inhibiting effects of 8-OH-DPAT, alone. Although both quipazine and TFMPP act on multiple 5-HT receptors, they overlap in their agonist action at 5-HT2 receptors. Consequently, these results provide further evidence supporting the contention that within the VMN, both 5-HT1A and 5-HT2 receptor subtypes contribute to the modulation of lordosis behavior in the female rat. The data are discussed in terms of the relative potency of 5-HT at 5-HT receptors mediating inhibition and facilitation of lordosis behavior.

Central nervous system DNA fragmentation induced by the inhibition of nuclear factor kappa B

Ageing of the central nervous system (CNS) is characterized by a progressive apoptotic loss of neurons that may be in part due to impaired neurotrophin signaling mediated by such elements as the transcription factor nuclear factor kappa B (NFkappaB). To support this hypothesis, we inhibited nuclear translocation of NFkappaB in vivo by injecting a proteasome inhibitor (PSI) directly in the CNS lateral ventricle of rats and then measured fragmented DNA in various CNS areas as an index of ongoing apoptosis. Our results show that after PSI injection there was a significant inhibition of NFkappaB activity in vivo that resulted in the appearance of fragmented (apoptotic) DNA in the CNS of rats. These results suggest that alteration of NFkappaB may cause apoptotic cell death in the rat CNS during ageing.

Street heroin potency and deaths from overdose in San Antonio

Disagreement over the mechanism of death in so-called heroin overdose has been noted in the medical literature for more than a decade. We studied the relationship between the potency of street heroin and the frequency of heroin overdose deaths in San Antonio in order to test the "pharmacologic overdose" hypothesis. We found a small, nonsignificant correlation (r=+.13) between monthly mean heroin dose and monthly number of heroin overdose deaths over a 5-year period. This low correlation contradicts findings of previous studies in Washington, D.C. and Atlanta, conducted over shorter periods of time, in which high positive correlations were found. The low correlation does not support the pharmacologic overdose hypothesis. Since there were confounding variables, the data do not refute the hypothesis. These variables include the use of alcohol and other depressants, hidden suicide, and reduced opioid drug tolerance due to institutional treatment.

Normal renin uremic hypertension. Study of cardiac hemodynamics, plasma volume, extracellular fluid volume, and the renin angiotensin system

Studies were undertaken in 33 uremic patients with or without hypertension, 11 normal subjects, and 15 essential hypertensive patients to assess cardiac hemodynamics, plasma volume, extracellular fluid volume, and peripheral renin levels. Cardiac output and intraarterial blood pressure were measured and peripheral vascular resistance index calculated. These studies suggest that uremic hypertension with normal renin values and hypervolemia is hemodynamically sustained by an increase in peripheral resistance rather than by an increased cardiac output. The renin angiotensin system plays a secondary role as compared to overexpansion in the genesis of hypertension in normoreninemic uremic hypertension.