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Context Conflict between athletic trainers (ATs) and other stakeholders can occur because of competing interests over medical decisions regarding concussion. However, we are unaware of any studies specifically exploring these situations across various collegiate athletic affiliations. Objective To investigate the challenges faced by ATs when treating concussed student-athletes. Design Qualitative study. Setting Online questionnaire. Patients or Other Participants A total of 434 ATs (267 women, 166 men, 1 missing data; age = 27.73 ± 3.24 years, experience = 5.17 ± 2.67 years) completed the questionnaire (response rate = 14.47%). Our participants represented multiple employment settings within intercollegiate athletics. Data Collection and Analysis We sent an online questionnaire to 3000 ATs working in the collegiate and university setting across the United States. A survey expert verified face, content, and construct validity of the questionnaire in 2 rounds of review, and 3 ATs completed a content-validity tool before we finalized the survey. We analyzed the qualitative data using a general inductive approach and ensured trustworthiness through multiple-analyst triangulation and peer review. Results When we examined the responses from our participants regarding their work with student-athletes who had sustained concussions, we found 2 major themes, each with subthemes. First, educational efforts appeared to be only modestly effective because of a lack of honesty, noncompliant actions, and coach interference. Second, return to learn was challenging because of a lack of communication among stakeholders, athletes being anxious about needing accommodations, and difficulty convincing faculty to provide reasonable accommodations. Conclusions Based on our findings, we recommend continued efforts to improve the culture surrounding concussion in collegiate athletes. Athletic trainers should include key stakeholders such as coaches, student-athletes, parents, faculty, and other educational administrators in their educational efforts to improve the policies and culture surrounding concussion treatment.

In 2015, new practice recommendations to remove equipment prior to transport when cervical spine injury is suspected were released. The purpose of this study was to determine current emergency management practices and perceptions of the new practice recommendation. We received completed mixed-method surveys from 143 athletic trainers practicing in the Mid-Atlantic region (response rate = 10.11%). The majority of respondents stated that the number of personnel required, along with the training and time to practice equipment removal, were barriers to implementation. Requiring assistance from emergency medical services (EMS) was common, but many failed to practice with local EMS. Emergency management procedures should be appropriate given the resources (personnel and training) available. Collaboration between athletic trainers and EMS is needed.

The diagnosis and management of concussion is hindered by its diverse clinical presentation and assessment tools reliant on subjectively experienced symptoms. The biomechanical threshold of concussion is also not well understood, and asymptomatic concussion or "subconcussive impacts" of variable magnitudes are common in contact sports. Concerns have risen because athletes returning to activity too soon have an increased risk of prolonged recovery or long-term adverse health consequences. To date, little is understood on a molecular level regarding concussion and subconcussive impacts. Recent research suggests that neuroinflammatory mechanisms may serve an important role subsequent to concussion and possibly to subconcussive impacts. These studies suggest that autoantibodies may be a valuable tool for detection of acute concussion and monitoring for changes caused by cumulative exposure to subconcussive impacts. Hence, we aimed to profile the immunoglobulin (Ig)A autoantibody repertoire in saliva by screening a unique sport-related head trauma biobank. Saliva samples (

Background Sports-related concussions are prevalent in the United States. Various diagnostic tools are utilized in order to monitor deviations from baseline in memory, reaction time, symptoms, and balance. Evidence indicates that dehydration may also alter the results of diagnostic tests. Purpose The purpose was to determine the effect of exercise-induced dehydration on performance related to concussion examination tools. Study Design Repeated measures design. Methods Seventeen recreationally competitive, non-concussed participants (age: 23.1±3.1 years, height:168.93±10.71 cm, mass: 66.16 ± 6.91 kg) performed three thermoneutral, counterbalanced sessions (rested control, euhydrated, dehydrated). Participants were either restricted (0.0 L/hr) or provided fluids (1.0 L/hr) while treadmill running for 60 min at an intensity equal to 65-70% age-predicted maximum heart rate (APMHR). The Sport Concussion Assessment Tool 3 (SCAT3) was utilized to assess symptoms, memory, balance, and coordination. Results Statistically significant differences were seen among sessions for symptom severity and symptom total. The rested control session had significantly lower values when compared to the dehydrated session. Additionally, the symptom total in the rested control was significantly lower than the euhydrated condition as well. No statistically significant differences were seen for the BESS or memory scores. Conclusions Mild exercise-induced dehydration results in increased self-reported symptoms associated with concussions. Clinicians tasked with monitoring and accurately diagnosing head trauma should take factors such as hydration status into account when assessing patients for concussion with the SCAT3. Clinicians should proceed with caution and not assume concussion as primary cause for symptom change. Level of evidence Level 3

Quantifying head impacts is a vital component to understanding and preventing head trauma in sport. Our objective was to establish the frequency and magnitude of head impact mechanisms in men’s lacrosse athletes. Eleven male lacrosse athletes wore xPatch sensors during activity. Video footage of practices and games was analyzed to verify impacts and code them with impact mechanisms. The authors calculated incidence rates (IRs) per 1000 exposures with corresponding 95% confidence intervals (CIs) and used multivariate analysis of variances to compare the linear (g) and rotational (rad/s2) accelerations between mechanisms. A total of 167 head impacts were successfully verified and coded with a mechanism using video footage during 542 total exposures. The highest IR was head to body (IR = 118.08; 95% CI, 89.15–147.01), and the lowest was head to ball (IR = 3.69; 95% CI, 0–8.80) (incidence rate ratio = 32.00; 95% CI, 67.83–130.73). Analysis indicated that impact mechanism failed to significantly alter the combined dependent variables (multivariate F10,306 = 1.79, P = .06, η2 = .06, 1−β = 0.83). While head to head, body to head, and stick to head mechanisms are penalty-inducing offenses in men’s lacrosse, head to ground, head to ball, and combination impacts have similar head accelerations. If penalties and rules are created to protect players from traumatic head injury, the authors recommend stricter enforcement.

Objective Regulation of fatty acid (FA) metabolism is central to adipocyte dysfunction during diet-induced obesity (DIO). Long-chain acyl-CoA synthetase-4 (ACSL4) has been hypothesized to modulate the metabolic fates of polyunsaturated FA (PUFA), including arachidonic acid (AA), but the in vivo actions of ACSL4 are unknown. The purpose of our studies was to determine the in vivo role of adipocyte ACSL4 in regulating obesity-associated adipocyte dysfunction. Methods We developed a novel mouse model with adipocyte-specific ablation of ACSL4 (Ad-KO) using loxP Cre recombinase technology. Metabolic phenotyping of Ad-KO mice relative to their floxed littermates (ACSL4floxed) was performed, including body weight and body composition over time; insulin and glucose tolerance tests; and energy expenditure, activity, and food intake in metabolic cages. Adipocytes were isolated for ex vivo adipocyte oxygen consumption by Clark electrode and lipidomics analysis. In vitro adipocyte analysis including oxygen consumption by Seahorse and real-time PCR analysis were performed to confirm our in vivo findings. Results Ad-KO mice were protected against DIO, adipocyte death, and metabolic dysfunction. Adipocytes from Ad-KO mice fed high-fat diet (HFD) had reduced incorporation of AA into phospholipids (PL), free AA, and levels of the AA lipid peroxidation product 4-hydroxynonenal (4-HNE). Additionally, adipocytes from Ad-KO mice fed HFD had reduced p53 activation and increased adipocyte oxygen consumption (OCR), which we demonstrated are direct effects of 4-HNE on adipocytes in vitro. Conclusion These studies are the first to elucidate ACSL4's in vivo actions to regulate the incorporation of AA into PL and downstream effects on DIO-associated adipocyte dysfunction. By reducing the incorporation of AA into PL and free fatty acid pools in adipocytes, Ad-KO mice were significantly protected against HFD-induced increases in adipose and liver fat accumulation, adipocyte death, gonadal white adipose tissue (gWAT) inflammation, and insulin resistance (IR). Additionally, deficiency of adipocyte ACSL4 expression in mice fed a HFD resulted in increased gWAT adipocyte OCR and whole body energy expenditure (EE)., Highlights • ACSL4 expression is upregulated in murine white adipocytes during diet-induced obesity. • Mice with adipocyte-specific ablation of ACSL4 (Ad-KO) are protected against diet-induced obesity, adipocyte death and metabolic dysfunction. • Lipidomics profiling of isolated adipocytes from Ad-KO mice fed a high-fat diet (HFD) had reduced arachidonic acid (AA) in phospholipids. • Adipocytes from Ad-KO mice fed HFD had reduced free AA and levels of the AA lipid peroxidation product 4-hydroxynonenal (4-HNE). • Adipocytes from Ad-KO mice fed HFD had reduced p53 activation and increased adipocyte oxygen consumption (OCR). • P53 activation and inhibited adipocyte OCR are direct effects of 4-HNE on adipocytes in vitro.

Background Head impacts have been studied extensively in football, but little similar research has been conducted in men's lacrosse. It is important to understand the location and magnitude of head impacts during men's lacrosse to recognize the risk of head injury. Methods Descriptive epidemiology study set on collegiate lacrosse fields. Eleven men's lacrosse players (age=20.9±1.13years, mass=83.91±9.04kg, height=179.88±5.99cm) volunteered to participate. We applied X2 sensors behind the right ear of participants for games and practices. Sensors recorded data on linear and rotational accelerations and the location of head impacts. We calculated incidence rates per 1000 exposures with 95% confidence intervals for impact locations and compared the effect of impact location on linear and rotational accelerations with Kruskal-Wallis tests. Findings We verified 167 head impacts (games=112; practices=55). During games, the incidence rate was 651.16 (95% confidence interval=530.57–771.76). The high and low incidence rates for head impact locations during games were: side=410.7 (95% confidence interval=292.02–529.41) and top=26.79 (95% confidence interval=3.53–57.10). For games and practices combined, the impact locations did not significantly affect linear ( χ 2 3 =6.69, P =0.08) or rotational acceleration ( χ 2 3 =6.34, P =0.10). Interpretation We suggest further research into the location of head impacts during games and practices. We also suggest player and coach education on head impacts as well as behavior modification in men's lacrosse athletes to reduce the incidence of impacts to the side of the head in an effort to reduce potential injury.

Objective: To describe the challenges of service coordination through the National Disaster Medical System (NDMS) for Hurricane Maria evacuees, particularly those on dialysis.Design: Public health report.Setting: Georgia.Report: On November 25, 2017, there were 208 patients evacuated to Georgia in response to Hurricane Maria receiving NDMS support. Most were evacuated from the US Virgin Islands (97 percent) and the remaining from Puerto Rico (3 percent); 73 percent of these patients were on dialysis, all from the US Virgin Islands. From the beginning of the evacuation response through November 25, 2017, there were 282 patients evacuated to Georgia via NDMS, with a median length of coverage through NDMS for those on and not on dialysis of 60 and 16 days, respectively. Conclusion: The limited capacity and capability of dialysis centers currently in the US Virgin Islands are delaying the return to home of many Hurricane Maria evacuees who are on dialysis.

Objective The family of acyl-CoA synthetase enzymes (ACSL) activates fatty acids within cells to generate long chain fatty acyl CoA (FACoA). The differing metabolic fates of FACoAs such as incorporation into neutral lipids, phospholipids, and oxidation pathways are differentially regulated by the ACSL isoforms. In vitro studies have suggested a role for ACSL5 in triglyceride synthesis; however, we have limited understanding of the in vivo actions of this ACSL isoform. Methods To elucidate the in vivo actions of ACSL5 we generated a line of mice in which ACSL5 expression was ablated in all tissues (ACSL5−/−). Results Ablation of ACSL5 reduced ACSL activity by ∼80% in jejunal mucosa, ∼50% in liver, and ∼37% in brown adipose tissue lysates. Body composition studies revealed that ACSL5−/−, as compared to control ACSL5loxP/loxP, mice had significantly reduced fat mass and adipose fat pad weights. Indirect calorimetry studies demonstrated that ACSL5−/− had increased metabolic rates, and in the dark phase, increased respiratory quotient. In ACSL5−/− mice, fasting glucose and serum triglyceride were reduced; and insulin sensitivity was improved during an insulin tolerance test. Both hepatic mRNA (∼16-fold) and serum levels of fibroblast growth factor 21 (FGF21) (∼13-fold) were increased in ACSL5−/− as compared to ACSL5loxP/loxP. Consistent with increased FGF21 serum levels, uncoupling protein-1 gene (Ucp1) and PPAR-gamma coactivator 1-alpha gene (Pgc1α) transcript levels were increased in gonadal adipose tissue. To further evaluate ACSL5 function in intestine, mice were gavaged with an olive oil bolus; and the rate of triglyceride appearance in serum was found to be delayed in ACSL5−/− mice as compared to control mice. Conclusions In summary, ACSL5−/− mice have increased hepatic and serum FGF21 levels, reduced adiposity, improved insulin sensitivity, increased energy expenditure and delayed triglyceride absorption. These studies suggest that ACSL5 is an important regulator of whole-body energy metabolism and ablation of ACSL5 may antagonize the development of obesity and insulin resistance., Graphical abstract, Highlights • Role of acyl CoA synthetase 5 (ACSL5) in systemic metabolism was studied in an ACSL5 deficient mouse. • ACSL5 deficiency reduced total ACSL activity in liver, intestine, and brown adipose tissue. • ACSL5 deficient mice had increased hepatic and circulating FGF21 expression and energy expenditure. • ACSL5 deficient mice demonstrated delayed triglyceride absorption.

Context: Retaining athletic training students has been identified as problematic by approximately half of athletic training program (ATP) directors. It is unknown what ATP directors do to improve athletic training student retention.Objective: To identify initiatives that ATP directors use to improve the retention rates of athletic training students in their programs.Design: Qualitative study.Setting: Undergraduate ATPs.Patients or Other Participants: We asked directors of ATPs across the nation to complete an Internet questionnaire. We obtained responses from 171 out of 343 ATP directors (51.6%). In addition, we completed follow-up interviews with 16 randomly selected ATP directors.Main Outcome Measure(s): During the online questionnaire, we asked ATP directors to describe any specific initiatives they or their ATP used that were aimed at retaining athletic training students and ideally what they would like to do to improve athletic training student retention at their institution. During the follow-up telephone interviews, we asked participants to further describe their retention strategies and other techniques not already mentioned in their questionnaire responses to gain further insight. We used a general inductive approach to analyze the data and performed multiple-analyst triangulation, member checks, and a peer review to ensure the trustworthiness of the analysis and results.Results: During data analysis, we identified 3 themes that highlight the ATP directors' initiatives to retain athletic training students. Directors discussed fostering a family atmosphere, strategic planning, and having resources available to support students as ways to improve retention.Conclusions: Athletic training program directors are encouraged to integrate students into their programs early through informal and formal participation opportunities, evaluate student potential prior to formal admissions, plausibly through an interview process, and educate students on scholarship opportunities to help offset tuition and fees associated with program completion.

Carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) regulates insulin sensitivity by promoting hepatic insulin clearance. Liver-specific inactivation or global null-mutation of Ceacam1 impairs hepatic insulin extraction to cause chronic hyperinsulinemia, resulting in insulin resistance and visceral obesity. In this study we investigated whether diet-induced insulin resistance implicates changes in hepatic CEACAM1. We report that feeding C57/BL6J mice a high-fat diet reduced hepatic CEACAM1 levels by >50% beginning at 21 days, causing hyperinsulinemia, insulin resistance, and elevation in hepatic triacylglycerol content. Conversely, liver-specific inducible CEACAM1 expression prevented hyperinsulinemia and markedly limited insulin resistance and hepatic lipid accumulation that were induced by prolonged high-fat intake. This was partly mediated by increased hepatic β-fatty acid oxidation and energy expenditure. The data demonstrate that the high-fat diet reduced hepatic CEACAM1 expression and that overexpressing CEACAM1 in liver curtailed diet-induced metabolic abnormalities by protecting hepatic insulin clearance.

Context Choosing to pursue an advanced degree in athletic training appears to indicate professional commitment and passion for the profession. Currently, there is a paucity of information regarding why some athletic trainers pursue enrollment in a postprofessional athletic training program (PPATP), indicating commitment to the profession, but later depart for another primary role outside of athletic training. Objective To understand why athletic trainers invested in advanced training via a PPATP but then decided to leave the profession. Design Qualitative study. Setting Online data collection. Patients or Other Participants Twelve graduates (8 women [67%], 4 men [33%], age = 31.58 ± 3.06 years) from PPATPs who no longer had primary employment as an athletic trainer. Data Collection and Analysis Recruits responded to an e-mail invitation to participate by completing a confidential online questionnaire. We analyzed data using a general inductive approach and secured trustworthiness using multiple-analyst triangulation, peer review, and member checks. Results Two higher-order themes emerged regarding the career commitment of former athletic trainers who were PPATP graduates: (1) departure from an athletic training career and (2) partial continuance in athletic training. Two second-order themes emerged from the reasons for departure: (1) decreased recognition of value and (2) work-life imbalance. Finally, we identified 2 third-order themes from the participants' reasons for departure because of a perceived lack of value: (1) low salary and (2) long, inconsistent hours worked. Conclusions Most of our participants intended to stay in the profession when they chose to attend a PPATP. However, during role inductance in either the clinical experience of the PPATP they attended or early in their careers, they began to have thoughts of leaving mainly because of inadequate financial compensation, challenging work schedules, or both.

ContextAthletic training programs (ATPs) are charged with meeting an increased demand for athletic trainers with adequate graduates. Currently, the retention rate of athletic training students in ATPs nationwide and the programmatic factors associated with these retention rates remain unknown.ObjectiveDetermine the retention rate for athletic training students nationwide and the programmatic factors associated with retention.DesignCross-sectional online survey.SettingUndergraduate ATPs.Patients or Other ParticipantsProgram directors (PDs) of all Commission on Accreditation of Athletic Training Education–accredited undergraduate ATPs were surveyed. We obtained responses from 177 of the 343 PDs (51.6%).Intervention(s)The survey asked PDs for information about their institution, ATP, and themselves.Main Outcome Measure(s)Self-reported retention rate.ResultsThe participants reported an average retention rate of 81.0% ± 17.9%. We found a significant prediction equation (F4,167 = 16.39, R2 = 0.282, P < .001), using the perceptions of student success factor (P < .001, R2 = 0.162), the timing of formal admission (P < .001, R2 = 0.124), the number of years the ATPs had been accredited (P = .001, R2 = 0.039), the number of students admitted to the ATP annually (P = .001, R2 = 0.037), and the number of years the PDs had held their position at their current institution (P = .03, R2 = 0.018).ConclusionsProgram directors should work to provide a stimulating atmosphere to motivate students. Delaying the formal admission of prospective students may allow athletic training students to make an informed decision to enter an ATP. A rich history of success and consistent leadership can provide an ATP environment that fosters retention. Program directors should carefully consider how many students to admit into the ATP annually, as individual attention may alter retention decisions of athletic training students.

Fat-induced hepatic insulin resistance plays a key role in the pathogenesis of type 2 diabetes in obese individuals. Although PKC and inflammatory pathways have been implicated in fat-induced hepatic insulin resistance, the sequence of events leading to impaired insulin signaling is unknown. We used Wistar rats to investigate whether PKCδ and oxidative stress play causal roles in this process and whether this occurs via IKKβ- and JNK-dependent pathways. Rats received a 7-h infusion of Intralipid plus heparin (IH) to elevate circulating free fatty acids (FFA). During the last 2 h of the infusion, a hyperinsulinemic-euglycemic clamp with tracer was performed to assess hepatic and peripheral insulin sensitivity. An antioxidant, N-acetyl-l-cysteine (NAC), prevented IH-induced hepatic insulin resistance in parallel with prevention of decreased IκBα content, increased JNK phosphorylation (markers of IKKβ and JNK activation, respectively), increased serine phosphorylation of IRS-1 and IRS-2, and impaired insulin signaling in the liver without affecting IH-induced hepatic PKCδ activation. Furthermore, an antisense oligonucleotide against PKCδ prevented IH-induced phosphorylation of p47phox(marker of NADPH oxidase activation) and hepatic insulin resistance. Apocynin, an NADPH oxidase inhibitor, prevented IH-induced hepatic and peripheral insulin resistance similarly to NAC. These results demonstrate that PKCδ, NADPH oxidase, and oxidative stress play a causal role in FFA-induced hepatic insulin resistance in vivo and suggest that the pathway of FFA-induced hepatic insulin resistance is FFA → PKCδ → NADPH oxidase and oxidative stress → IKKβ/JNK → impaired hepatic insulin signaling.

The cytoplasmic lipid droplet (CLD) protein perilipin-2 (Plin2) is expressed in multiple nonadipose tissues, where it is thought to play a role in regulating their lipid storage properties. However, the extent to which Plin2 functions in nutrient utilization and metabolism, or how it influences the consequences of over-feeding, remains unclear. In this study, we demonstrate that the absence of Plin2 prevents high-fat diet(HFD)-induced obesity in male and female mice. This response is associated with increased formation of subcutaneous beige adipocyte cells with uncoupling protein 1 expression, and amelioration of inflammatory foci formation in white adipose tissue and steatosis in the liver. Experiments demonstrate that Plin2 loss results in reduced energy intake and increased physical activity in response to HFD feeding. Our study provides the first evidence that Plin2 contributes to HFD-induced obesity by modulating food intake, and that its absence prevents obesity-associated adipose tissue inflammatory foci and liver steatosis.

Impairment of insulin clearance is being increasingly recognized as a critical step in the development of insulin resistance and metabolic disease. The carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) promotes insulin clearance. Null deletion or liver-specific inactivation of Ceacam1 in mice causes a defect in insulin clearance, insulin resistance, steatohepatitis, and visceral obesity. Immunohistological analysis revealed reduction of hepatic CEACAM1 in obese subjects with fatty liver disease. Thus, we aimed to determine whether this occurs at the hepatocyte level in response to systemic extrahepatic factors and whether this holds across species. Northern and Western blot analyses demonstrate that CEACAM1 mRNA and protein levels are reduced in liver tissues of obese individuals compared to their lean age-matched counterparts. Furthermore, Western analysis reveals a comparable reduction of CEACAM1 protein in primary hepatocytes derived from the same obese subjects. Similar to humans, Ceacam1 mRNA level, assessed by quantitative RT-PCR analysis, is significantly reduced in the livers of obese Zucker (fa/fa, ZDF), and Koletsky (f/f) rats relative to their age-matched lean counterparts. These studies demonstrate that the reduction of hepatic CEACAM1 in obesity occurs at the level of hepatocytes and identify the reduction of hepatic CEACAM1 as a common denominator of obesity across multiple species.

The carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) promotes insulin clearance. Mice with global null mutation (Cc1 −/−) or with liver-specific inactivation (L-SACC1) of Cc1 (also known as Ceacam1) gene display hyperinsulinaemia resulting from impaired insulin clearance, insulin resistance, steatohepatitis and obesity. Because increased lipolysis contributes to the metabolic phenotype caused by transgenic inactivation of CEACAM1 in the liver, we aimed to further investigate the primary role of hepatic CEACAM1-dependent insulin clearance in insulin and lipid homeostasis. To this end, we examined whether transgenic reconstitution of CEACAM1 in the liver of global Cc1 −/− mutant mice reverses their abnormal metabolic phenotype. Insulin response was assessed by hyperinsulinaemic–euglycaemic clamp analysis and energy balance was analysed by indirect calorimetry. Mice were overnight-fasted and refed for 7 h to assess fatty acid synthase activity in the liver and the hypothalamus in response to insulin release during refeeding. Liver-based rescuing of CEACAM1 restored insulin clearance, plasma insulin level, insulin sensitivity and steatohepatitis caused by global deletion of Cc1. It also reversed the gain in body weight and total fat mass observed with Cc1 deletion, in parallel to normalising energy balance. Mechanistically, reversal of hyperphagia appeared to result from reducing fatty acid synthase activity and restoring insulin signalling in the hypothalamus. Despite the potential confounding effects of deleting Cc1 from extrahepatic tissues, liver-based rescuing of CEACAM1 resulted in full normalisation of the metabolic phenotype, underscoring the key role that CEACAM1-dependent hepatic insulin clearance pathways play in regulating systemic insulin sensitivity, lipid homeostasis and energy balance.

The pathogenesis of human non-alcoholic fatty liver disease (NAFLD) remains unclear, in particular in the context of its relationship to insulin resistance and visceral obesity. Work on the carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) in mice has resolved some of the related questions. CEACAM1 promotes insulin clearance by enhancing the rate of uptake of the insulin-receptor complex. It also mediates a negative acute effect of insulin on fatty acid synthase activity. This positions CEACAM1 to coordinate the regulation of insulin and lipid metabolism. Fed a regular chow diet, global null mutation of Ceacam1 manifest hyperinsulinemia, insulin resistance, obesity, and steatohepatitis. They also develop spontaneous chicken-wire fibrosis, characteristic of non-alcoholic steatohepatitis. Reduction of hepatic CEACAM1 expression plays a significant role in the pathogenesis of diet-induced metabolic abnormalities, as bolstered by the protective effect of hepatic CEACAM1 gain-of-function against the metabolic response to dietary fat. Together, this emphasizes that loss of hepatic CEACAM1 links NAFLD to insulin resistance and obesity.

Aims: Examine the incidence of clinical events after utilization of the TAXUS® Express® paclitaxel-eluting stent (PES) in multivessel and bifurcation coronary stenting in an unselected patient population. Methods and Results: The ARRIVE Program compiled data on 7,492 patients receiving ≥1 TAXUS Express PES, including patients with multivessel stenting (MVS; n = 1,208) and bifurcation stenting (n = 575). Patients were enrolled at procedure start with no mandated inclusion/exclusion criteria; all cardiac events were monitored with independent adjudication of end-points. Compared to simple use (single vessel/single stent) patients undergoing native intervention (N = 2,698), MVS patients had significantly more baseline comorbidities. Both groups had higher 2-year rates of mortality (7.3%[MVS] and 7.5%[bifurcation] vs. 4.2%[simple-use], P < 0.001), myocardial infarction (5.5% and 4.6% vs. 2.2%, P < 0.001 and P = 0.002), target vessel revascularization (15.5% and 14.8% vs. 7.7%, P < 0.001), and Academic Research Consortium definite/probable stent thrombosis (4.3% and 4.4% vs. 1.4%, P < 0.001) than the simple-use group. Conclusions: ARRIVE multivessel and bifurcation stenting patients have significantly higher clinical risk through 2 years compared to simple-use patients. In the absence of large randomized controlled trials in these populations, ARRIVE provides important insight into clinical outcomes over an extended period of time. (J Interven Cardiol 2011;24:342–350)

Aims: To examine the incidence of clinical events after implantation of the TAXUS Express paclitaxel-eluting stent (PES) in chronic total occlusions (CTO) in an unselected patient population. Methods and Results: The TAXUS ARRIVE registries compiled data on 7,492 patients, including 113 patients with CTO (TIMI flow 0). Patients enrolled at procedure start with no mandated inclusion/exclusion criteria; all cardiac events were monitored with independent end-point adjudication. Two-year follow-up was 89% (101/113) for CTO patients who had significantly more baseline comorbidities/complex disease than simple-use patients undergoing native coronary intervention (N = 2,698) and significantly longer lesions/smaller vessels than other expanded-use patients (N = 4,681 without CTO). Among CTO patients the rate of 2-year major cardiac events (MCE, including cardiac death, myocardial infarction, and target vessel revascularization) was 22.3%, significantly higher than in simple-use patients (10.3%, P < 0.001). CTO MCE was similar to that for other expanded-use patients (16.5%, P = 0.14) but target lesion revascularization was significantly higher in year 2 (6.9% vs. 2.7%, P = 0.02). Academic Research Consortium definite/probable stent thrombosis through 2 years was 5.7%, significantly higher than simple-use patients but similar to other expanded-use cases. Conclusion: In a “real-world” setting, PES use in CTO was associated with increased MCE compared to simple- use patients, but achieved long-term outcomes similar to that observed in other complex patient/lesion cases. (J Interven Cardiol 2011;24:232–240)

Objectives The aim of this study was to examine the incidence of clinical events after implantation of the TAXUS Express (Boston Scientific Corporation, Natick, Massachusetts) paclitaxel-eluting stent in saphenous vein graft (SVG) lesions in an unselected patient population. Background Saphenous vein grafts have 1-year occlusion rates of 12% to 20%, with >50% failure by 7 to 10 years. Many diseased SVGs are treated by percutaneous coronary intervention to avoid higher-risk reoperation, but bare-metal stents have 35% to 40% historical SVG restenosis rates by 18 months. Reported outcomes of drug-eluting stents in SVG lesions are limited and mainly retrospective. Methods The ARRIVE (TAXUS Peri-Approval Registry: A Multicenter Safety Surveillance) program compiled data on 7,492 patients receiving ≥1 TAXUS Express (Boston Scientific) stent, including 474 patients with SVG. All cardiac events were monitored with independent adjudication of end points. Patients enrolled at procedure start with no mandated inclusion/exclusion criteria. Results The ARRIVE SVG patient 2-year follow-up was 96% complete (457 of 474). The SVG patients had significantly more baseline comorbidities/complex disease than simple-use patients (n = 2,698) undergoing native coronary intervention or other expanded-use patients (n = 4,320 without SVG patients). They had higher 2-year rates of mortality (10.9% vs. 4.2%, p Conclusions The ARRIVE SVG patients have significantly different baseline risk and higher clinical risk through 2 years than simple-use and other expanded-use patients. Nonetheless, compared with historical SVG revascularization rates, treatment with paclitaxel-eluting stent seems to offer a reasonable therapeutic option in this high-risk group. (TAXUS ARRIVE: TAXUS Peri-Approval Registry: A Multicenter Safety Surveillance Program; NCT00569491 ) and (TAXUS ARRIVE 2: A Multicenter Safety Surveillance Program; NCT00569751 )

Although FK506-binding protein 52 (FKBP52) is an established positive regulator of glucocorticoid receptor (GR) activity, an in vivo role for FKBP52 in glucocorticoid control of metabolism has not been reported. To address this question, FKBP52(+/-) mice were placed on a high-fat (HF) diet known to induce obesity, hepatic steatosis, and insulin resistance. Tissue profiling of wild-type mice showed high levels of FKBP52 in the liver but little to no expression in muscle or adipose tissue, predicting a restricted pattern of FKBP52 effects on metabolism. In response to HF, FKBP52(+/-) mice demonstrated a susceptibility to hyperglycemia and hyperinsulinemia that correlated with reduced insulin clearance and reduced expression of hepatic CEACAM1 (carcinoembryonic antigen-related cell adhesion molecule 1), a mediator of clearance. Livers of HF-fed mutant mice had high lipid content and elevated expression of lipogenic genes (peroxisome proliferator-activated receptor gamma, fatty acid synthase, and sterol regulatory element-binding protein 1c) and inflammatory markers (TNFalpha). Interestingly, mutant mice under HF showed elevated serum corticosterone, but their steatotic livers had reduced expression of gluconeogenic genes (phosphoenolpyruvate carboxy kinase, glucose 6 phosphatase, and pyruvate dehydrogenase kinase 4), whereas muscle and adipose expressed normal to elevated levels of glucocorticoid markers. These data suggest a state of glucocorticoid resistance arising from liver-specific loss of GR activity. Consistent with this hypothesis, reduced expression of gluconeogenic genes and CEACAM1 was observed in dexamethasone-treated FKBP52-deficient mouse embryonic fibroblast cells. We propose a model in which FKBP52 loss reduces GR control of gluconeogenesis, predisposing the liver to steatosis under HF-diet conditions attributable to a shunting of metabolism from glucose production to lipogenesis.

Objective Physical activity has been associated with lower diabetes risk, but several prospective studies among women found that activity only slightly attenuated the diabetes risk associated with high body mass index (BMI). We investigated the independent and joint associations between vigorous activity and BMI on diabetes risk in men. Methods This was a prospective cohort design within the Physicians' Health Study, using Cox proportional hazards models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) of incident diabetes in 20,757 men without diabetes at baseline. Models were based on self-reported BMI and exercise frequency at baseline, first separately and then with a 6-category joint variable combining World Health Organization BMI category (normal/overweight/obese) with activity status (active/inactive) using weekly vigorous activity as the threshold. Results After a median follow-up of 23.1 years, there were 1836 cases of incident diabetes. Compared with active participants with normal BMIs, active but overweight and obese men had multivariable-adjusted HRs of 2.39 (95% CI, 2.11-2.71) and 6.22 (95% CI, 5.12-7.56). Inactive men with normal, overweight, or obese BMIs had multivariable-adjusted HRs of 1.41 (95% CI, 1.19-1.67), 3.14 (95% CI, 2.73-3.62), and 6.57 (95% CI, 5.25-8.21). Conclusion Active men with normal and overweight BMIs had lower diabetes hazards than their inactive counterparts, but no difference by weekly activity was seen in obese men. Elevated BMI is a key driver of diabetes risk, with relatively modest attenuation by activity.

Objectives The pivotal TAXUS IV (TAXUS IV-SR: Treatment of De Novo Coronary Disease Using a Single Paclitaxel-Eluting Stent) trial evaluated the long-term safety and effectiveness of the paclitaxel-eluting stent (PES) compared with an otherwise identical bare-metal stent (BMS) in a relatively uncomplicated population of patients with a single de novo lesion in a native coronary vessel, treated between March and July 2002. Background Long-term follow-up is required to determine whether the early safety and efficacy of drug-eluting stents are maintained. Methods The primary end point of this prospective, randomized, double-blind trial was 9-month ischemia-driven target vessel revascularization (TVR) for PES versus the BMS control. Follow-up was complete in 1,230 (95.1%) of 1,294 randomized evaluable patients at 5 years. Results Compared with BMS, PES significantly reduced TVR at 9 months (12.1% vs. 4.7%; p Conclusions These 5-year results demonstrate the long-term safety and sustained efficacy of PES compared with BMS in patients with noncomplex lesions. (TAXUS IV-SR: Treatment of De Novo Coronary Disease Using a Single Paclitaxel-Eluting Stent; NCT00292474 )

The association between change in high-density lipoprotein cholesterol (HDL-C) and risk of subsequent coronary heart disease (CHD) remains unclear. We calculated the change in HDL-C in a prospective cohort of 4501 male physicians enrolled in the Physician's Health Study I (PHS I) who had HDL-C levels measured in 1982-1983 and again approximately 14 years later. Subjects were divided into categories: those with a decrease (of -2.5 mg/dL or more), those with no change in HDL-C (change between -2.5 mg/dL and 2.5 mg/dL), those with a small increase in HDL-C of 2.5 to 12.5 mg/dL, and those with a large increase in HDL-C of ≥12.5 mg/dL. We used Cox proportional hazards to examine the association between change in HDL-C and incident CHD (confirmed acute myocardial infarction or cardiac death). Hazard ratios were adjusted for age, initial HDL-C level, diabetes mellitus, hypertension, non-HDL cholesterol, and history of cholesterol medication. Compared to subjects with a decrease in HDL-C, multivariable-adjusted hazard ratios (HR, 95% confidence interval, CI) for CHD were 0.66(0.40-1.09) in subjects with no change in HDL-C, 0.56 (0.35-0.89) for subjects with an increase in HDL-C between 2.5 mg/dL and 12.5 mg/dL, and 0.43 (0.23-0.83) for subjects with HDL-C increase of ≥12.5 mg/dL. In conclusion, our findings are consistent with an inverse, graded relation between 14-year increase in HDL-C and risk of subsequent CHD.

OBJECTIVE—Liver-specific inactivation of carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) by a dominant-negative transgene (l-SACC1 mice) impaired insulin clearance, caused insulin resistance, and increased hepatic lipogenesis. To discern whether this phenotype reflects a physiological function of CEACAM1 rather than the effect of the dominant-negative transgene, we characterized the metabolic phenotype of mice with null mutation of the Ceacam1 gene (Cc1−/−). RESEARCH DESIGN AND METHODS—Mice were originally generated on a mixed C57BL/6x129sv genetic background and then backcrossed 12 times onto the C57BL/6 background. More than 70 male mice of each of the Cc1−/− and wild-type Cc1+/+ groups were subjected to metabolic analyses, including insulin tolerance, hyperinsulinemic-euglycemic clamp studies, insulin secretion in response to glucose, and determination of fasting serum insulin, C-peptide, triglyceride, and free fatty acid levels. RESULTS—Like l-SACC1, Cc1−/− mice exhibited impairment of insulin clearance and hyperinsulinemia, which caused insulin resistance beginning at 2 months of age, when the mutation was maintained on a mixed C57BL/6x129sv background, but not until 5–6 months of age on a homogeneous inbred C57BL/6 genetic background. Hyperinsulinemic-euglycemic clamp studies revealed that the inbred Cc1−/− mice developed insulin resistance primarily in liver. Despite substantial expression of CEACAM1 in pancreatic β-cells, insulin secretion in response to glucose in vivo and in isolated islets was normal in Cc1−/− mice (inbred and outbred strains). CONCLUSIONS—Intact insulin secretion in response to glucose and impairment of insulin clearance in l-SACC1 and Cc1−/− mice suggest that the principal role of CEACAM1 in insulin action is to mediate insulin clearance in liver.

Objective:To present the case of an 18-year-old collegiate decathlete with a Salter-Harris type I epiphyseal plate fracture of the proximal humerus.Background:A collegiate decathlete was playing flag football and fell on an outstretched arm. He was taken to the emergency room and diagnosed with a type I epiphyseal plate fracture.Differential Diagnosis:AC sprain, dislocation or subluxation, rotator cuff tear, labral tear.Treatment:Active and passive range of motion exercises were completed after two days of immobilization. He then started strengthening exercises and returned to competitive activity in 10 weeks.Uniqueness:Proximal humeral epiphyseal plate fractures are uncommon injuries, especially in athletes over the age of 15.Conclusions:If an accurate diagnosis is made, an appropriate conservative rehabilitation program can be implemented to safely return an athlete to participation without permanent deformity following a type I Salter-Harris fracture.

Background. High blood pressure (BP) has been associated with a decrease in kidney function. However, it remains unclear which BP measure best predicts impaired kidney function. Methods. We compared systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP) and mean arterial pressure (MAP) in predicting risk of chronic kidney disease (CKD). We prospectively followed 8093 male participants in the Physicians' Health Study, without a known history of kidney disease at baseline, who provided BP values on the baseline and 24-month questionnaires, and for whom we had creatinine measures after 14 years of follow-up. Reported BP was averaged from both questionnaires. The main outcome was CKD, defined as an estimated glomerular filtration rate

Context The debate over what the entry-level degree should be for athletic training has heightened. A comparison of retention and career-placement rates between bachelor's and master's degree professional athletic training programs may inform the debate. Objective To compare the retention rates and career-placement rates of students in bachelor's and master's degree professional programs. Design Cross-sectional study. Setting Web-based survey. Patients or Other Participants A total of 192 program directors (PDs) from bachelor's degree (n = 177) and master's degree (n = 15) professional programs. Intervention(s) The PDs completed a Web-based survey. Main Outcome Measure(s) We instructed the PDs to provide a retention rate and career-placement rate for the students in the programs they lead for each of the past 5 years. We also asked the PDs if they thought retention of students was a problem currently facing athletic training education. We used independent t tests to compare the responses between bachelor's and master's degree professional programs. Results We found a higher retention rate for professional master's degree students (88.70% ± 9.02%, 95% confidence interval [CI] = 83.71, 93.69) than bachelor's degree students (80.98% ± 17.86%, 95% CI = 78.30, 83.66) (t25 = −2.86, P = .008, d = 0.55). Similarly, PDs from professional master's degree programs reported higher career-placement percentages (88.50% ± 10.68%, 95% CI = 82.33, 94.67) than bachelor's degree professional PDs (71.32% ± 18.47%, 95% CI = 68.54, 74.10) (t20 = −5.40, P < .001, d = 1.14). Finally, we observed no difference between groups regarding whether retention is a problem facing athletic training (χ21 = 0.720, P = .40, Φ = .061). Conclusions Professional master's degree education appears to facilitate higher retention rates and greater career-placement rates in athletic training than bachelor's degree education. Professional socialization, program selectivity, and student commitment and motivation levels may help to explain the differences noted.

CEACAM1 promotes insulin extraction, an event that occurs mainly in liver. Phenocopying global Ceacam1 null mice (Cc1–/–), C57/BL6J mice fed a high-fat diet exhibited reduced hepatic CEACAM1 levels and impaired insulin clearance, followed by hyperinsulinemia, insulin resistance and visceral obesity. Conversely, forced liver-specific expression of CEACAM1 protected insulin sensitivity and energy expenditure, and limited gain in total fat mass by high-fat diet in L-CC1 mice. Because CEACAM1 protein is barely detectable in white adipose tissue, we herein investigated whether hepatic CEACAM1-dependent insulin clearance pathways regulate adipose tissue biology in response to dietary fat. While high-fat diet caused a similar body weight gain in L-CC1, this effect was delayed and less intense relative to wild-type mice. Histological examination revealed less expansion of adipocytes in L-CC1 than wild-type by high-fat intake. Immunofluorescence analysis demonstrated a more limited recruitment of crown-like structures and qRT-PCR analysis showed no significant rise in TNFα mRNA levels in response to high-fat intake in L-CC1 than wild-type mice. Unlike wild-type, high-fat diet did not activate TGF-β in white adipose tissue of L-CC1 mice, as assessed by Western analysis of Smad2/3 phosphorylation. Consistently, high-fat diet caused relatively less collagen deposition in L-CC1 than wild-type mice, as shown by Trichome staining. Coupled with reduced lipid redistribution from liver to visceral fat, lower inflammation and fibrosis could contribute to protected energy expenditure against high-fat diet in L-CC1 mice. The data underscore the important role of hepatic insulin clearance in the regulation of adipose tissue inflammation and fibrosis.

Obesity is a risk factor for colorectal cancer (CRC), and alterations in the colonic microbiome and metabolome may be mechanistically involved in this relationship. The relative contribution of diet and obesity per se are unclear. We compared the effect of diet- and genetically-induced obesity on the intestinal microbiome and metabolome in a mouse model of CRC. Apc1638N mice were made obese by either high fat (HF) feeding or the presence of the Leprdb/db (DbDb) mutation. Intestinal tumors were quantified and stool microbiome and metabolome were profiled. Genetic obesity, and to a lesser extent HF feeding, promoted intestinal tumorigenesis. Each induced distinct microbial patterns: taxa enriched in HF were mostly Firmicutes (6 of 8) while those enriched in DbDb were split between Firmicutes (7 of 12) and Proteobacteria (5 of 12). Parabecteroides distasonis was lower in tumor-bearing mice and its abundance was inversely associated with colonic Il1b production (p

Objective: To evaluate which blood pressure measure is the best predictor of risk of total, ischemic, and hemorrhagic stroke. Methods: The authors used a prospective cohort study among 11,466 men followed for incident stroke during a median of 19.4 years in the Physicians9 Health Study. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were self-reported. They calculated relative risks (RRs) and 95% CIs for total, ischemic, and hemorrhagic stroke using Cox proportional hazards models. Model fit was compared using the χ 2 test statistic from likelihood ratio tests. Results: During follow-up, 508 strokes occurred (411 ischemic, 89 hemorrhagic, and eight of unknown etiology). For each 10-mm Hg increase in SBP, the multivariable RRs were 1.31 (95% CI: 1.20 to 1.42) for total stroke, 1.28 (95% CI: 1.16 to 1.40) for ischemic stroke, and 1.38 (95% CI: 1.13 to 1.68) for hemorrhagic stroke. Although DBP, pulse pressure, and mean arterial pressure were all significant predictors of stroke risk, none was a significantly better predictor than SBP alone. Adding DBP did not significantly improve the model fit of SBP alone for any stroke type. Conclusion: In this large cohort of initially healthy men, systolic blood pressure was a consistent and significant predictor of total, ischemic, and hemorrhagic stroke. Systolic blood pressure alone was the only measure necessary to predict risk of total stroke or its major subtypes.

Background and Purpose— Large epidemiological studies have not established cholesterol levels as a risk factor for ischemic stroke, but recent clinical trials have demonstrated a reduction in the ischemic stroke rate for patients taking HMG-CoA reductase inhibitors (“statins”). The goal of this study was to evaluate whether total cholesterol (TC), high-density lipoprotein (HDL), triglycerides, and the TC:HDL ratio are risk factors for ischemic stroke in apparently healthy men enrolled in the Physicians’ Health Study. Methods— We used a nested case-control study design and matched 296 ischemic stroke cases with an equal number of controls on age, tobacco use, and follow-up time. At baseline, TC, HDL, and triglyceride levels were measured. We calculated odds ratios (ORs) and their 95% confidence intervals (CIs) using conditional logistic regression, adjusting for major risk factors for ischemic stroke. Results— Compared with the reference lowest quartile, the highest quartile for TC had an adjusted OR of 1.56 (95% CI, 0.84 to 2.92), the highest quartile of HDL had an adjusted OR of 0.75 (95% CI, 0.43 to 1.30), and the highest quartile of triglycerides had an adjusted OR of 1.07 (95% CI, 0.63 to 1.82). Although the highest quartile of the TC:HDL ratio had an adjusted OR of 1.62 (95% CI, 0.93 to 2.82), the risk of ischemic stroke was not a linear relationship. Conclusions— After adjustment, TC, HDL, and triglycerides were not significantly associated with ischemic stroke risk, and for the TC:HDL ratio, a suggestion of increased risk of ischemic stroke was limited to those with the highest levels.

Objective For both subconcussive impacts and traditionally-defined concussion, neither the number of head impacts nor the magnitude has had a strong correlation to the incidence or severity of injury. Recent modelling work has suggested that impulse may be an important biomechanical factor, and therefore it is hypothesised that it may be a good predictor of subconcussive neurophysiological changes. Design Observational study. Setting American high school football team. Participants Nine male high school football athletes (mean age=16.4, range=15–17) volunteered. All participants were enrolled with parental consent. Assessment of risk factors Head impacts were monitored at all practices and games with the Head Impact Telemetry System. Baseline neurophysiology was measured prior to contact activity using a functional magnetic resonance imaging (fMRI) visual n-back task protocol. Subjects returned throughout the season and were re-evaluated according to the same protocol. Outcome measures Kinematic impulse was computed from head impact telemetry. Changes in neurophysiology were determined as the difference in the 2 vs. 1-back contrast. This contrast was determined for 116 anatomically defined regions of interest (ROI). Main results Stepwise regressions (P=0.05) relating kinematic impulse to ROI-specific changes in neurophysiology yielded significant correlations for 57/116 ROIs. 22/116 ROIs had an R2 value greater than 0.70. Correlations were found bilaterally for 16 anatomical ROIs, including the executive pre-frontal regions, basal ganglia, and thalamus. Conclusions The relationship between kinematic impulse and fMRI changes reported here are the strongest correlations to subconcussive changes reported to date. Correlations were observed bilaterally in regions associated with concussion symptoms. Competing interests None.

Objective Neurocognitive changes have been found in football players without documented concussion raising concerns regarding the long term consequences of subconcussive head impacts in sport. It remains unknown if similar neurocognitive changes are found in female soccer athletes without concussion. Females have been found to have higher concussion rates compared to males and soccer is the most popular sport internationally providing a compelling area of study. Design Observational study. Setting American collegiate women’s soccer team. Participants 16 National Collegiate Athletic Association Division III women’s soccer athletes (19.88±1.1 years old, 163.7±4.9 cm, 61.2±4.9 kg) volunteered and provided consent for the study. Assessment of risk factors We measured head impacts during practices and games throughout the 15 week season with the xPatch (X2 Biosystems, Seattle, WA, USA). All participants completed ImPACT and the Sport Concussion Assessment Tool – 3rd Edition (SCAT3) prior to the season’s start and at the end of the season. Outcome measures The xPatch stored location, frequency, and magnitude (linear and rotational accelerations) of head impacts. Event film was used to verify each head impact. Changes in neurocognitive function were determined by comparing the baseline ImPACT and SCAT3 scores with the post-season scores. Main results A stepwise regression found a significant relationship between weekly head impact frequency during practices and the ImPACT measures of Visual Motor Speed (P=0.03) and Symptom Score (P=0.03). Conclusions Soccer activity may lead to lower visual motor speed and higher symptom scores. Future studies should use additional screening tools to verify these preliminary findings. Competing interests None.

In response to adrenergic stimulation, adipocytes undergo protein kinase A (PKA)‐stimulated lipolysis. A key PKA target in this context is perilipin 1, a major regulator of lipolysis on lipid droplets (LDs). A study published in this issue of The EMBO Journal (Pidoux et al , 2011) identifies optic atrophy 1 (OPA1), a protein that regulates mitochondrial dynamics, as perilipin 1 interaction partner and the A‐kinase anchoring protein (AKAP) on LDs that is involved in the induction of stimulated lipolysis.

Context: The average retention rate for students enrolled in undergraduate athletic training programs (ATPs) nationwide has been reported to be 81%, and slightly more than half of program directors (PDs) have indicated that retention of athletic training students (ATSs) is a problem. However, why PDs do or do not believe ATS retention is problematic is unknown. Objective: To determine why PDs do or do not believe ATS retention is problematic. Design: Qualitative study. Setting: Undergraduate ATPs. Patients or Other Participants: We obtained responses from 177 of the 343 PDs (51.6%). Using data saturation as a guide, we randomly selected 16 PDs from the survey responses to participate in follow-up telephone interviews; 8 believed retention was a problem and 8 did not. Data Collection and Analysis: During audio-recorded telephone interviews, we asked PDs why they thought retention was or was not a problem for athletic training education. Following verbatim transcription, we used grounded theory to analyze the interview data and maintained trustworthiness by using intercoder agreement, member checks, and peer review. Results: Program directors believed that retaining ATSs was a problem because students lack information regarding athletic training and the rigor of the ATP. Program directors were consistent in their perception that ATPs do not have a retention challenge because of the use of a secondary admissions process. This finding was likely based on personal use of a secondary admissions process in the ATPs these PDs lead. Conclusions: Program directors who lead ATPs that struggle to retain ATSs should consider using a secondary admissions process. During the preprofessional phase of the ATP, faculty and staff should work to socialize students to the demands of the ATP and the professional lives of athletic trainers.

Aims: To examine the incidence of clinical events after implantation of the TAXUS Express paclitaxel-eluting stent (PES) for in-stent restenosis (ISR) in an unselected patient population. Implantation of bare metal stents in native coronary vessels can result in ISR rates exceeding 50%. PES significantly reduces ISR-lesion restenosis and improves event-free survival versus vascular brachytherapy. Methods and results: The 7,492-patient ARRIVE registry enrolled patients receiving ≥1 TAXUS Express stent at procedure initiation with no inclusion/exclusion criteria, including 489 patients with ISR. Endpoints were independently adjudicated. All major cardiac events were monitored plus a 10-20% sample per site. ISR patient 2-year follow-up was 94% complete (462/489). Compared to simple-use patients undergoing native coronary intervention (N=2698) or other, non-ISR expanded-use cases (N=4305), ISR patients had significantly more baseline comorbidities/complex disease. They had higher 2-year rates for mortality (8.6% vs. 4.2%, P

Aims: Examine the incidence of clinical events after utilization of the TAXUS® Express® paclitaxel-eluting stent (PES) in multivessel and bifurcation coronary stenting in an unselected patient population. Methods and Results: The ARRIVE Program compiled data on 7,492 patients receiving ≥1 TAXUS Express PES, including patients with multivessel stenting (MVS; n = 1,208) and bifurcation stenting (n = 575). Patients were enrolled at procedure start with no mandated inclusion/exclusion criteria; all cardiac events were monitored with independent adjudication of end-points. Compared to simple use (single vessel/single stent) patients undergoing native intervention (N = 2,698), MVS patients had significantly more baseline comorbidities. Both groups had higher 2-year rates of mortality (7.3%[MVS] and 7.5%[bifurcation] vs. 4.2%[simple-use], P < 0.001), myocardial infarction (5.5% and 4.6% vs. 2.2%, P < 0.001 and P = 0.002), target vessel revascularization (15.5% and 14.8% vs. 7.7%, P < 0.001), and Academic Research Consortium definite/probable stent thrombosis (4.3% and 4.4% vs. 1.4%, P < 0.001) than the simple-use group. Conclusions: ARRIVE multivessel and bifurcation stenting patients have significantly higher clinical risk through 2 years compared to simple-use patients. In the absence of large randomized controlled trials in these populations, ARRIVE provides important insight into clinical outcomes over an extended period of time. (J Interven Cardiol 2011;24:342–350)

The vocalizations of eight infants with Down syndrome were recorded longitudinally in relation to different social and non-social contexts. The infants were observed biweekly from 8 to 24 weeks and monthly up to 40 weeks. At each visit the infants were presented with their mother, a female stranger, and a rattle puppet, each alternately active and passive. Each condition lasted 60 sec. The results showed that by 4 months of age, the infants produced different types of vocal sounds in relation to environmental contexts. They produced significantly more melodic (speechlike) sounds, vocalic (non-speechlike) sounds, and emotional (crying, laughing and fussing) sounds when facing people than objects. By 6 months of age, these utterances began to be distinguished between mother and female stranger and active and passive adults. However, within the communicative context the overall amount of vocalic (non-speechlike) sounds produced was larger than the amount of melodic (speechlike) sounds. It is suggested that this low output of melodic sounds in the overall vocal production of these infants may adversely affect the development of more appropriate vocal behaviour.

Background Elevated blood pressure (BP) is a risk factor for cardiovascular disease (CVD), but it remains unclear which component—alone or in combination—is the best predictor. We sought to determine which BP parameters are important predictors of CVD death across a wide age range. Methods We used a prospective cohort study design with 53,163 men followed for cause-specific death during a median of 5.7 years in the Physicians’ Health Study enrollment cohort. Baseline age, systolic BP and diastolic BP were collected. We calculated relative risks (RRs) and their 95% confidence intervals using Cox proportional hazard models adjusting for major risk factors for CVD, and then stratified by age (39 to 49, 50 to 59, 60 to 69, and 70 to 84 years). Results There were 459 CVD deaths during follow-up. For each 10 mm Hg increase in systolic BP, the multivariable RRs by ascending age group were 1.46, 1.43, 1.24, and 1.13. The multivariable RRs for each 10 mm Hg increase in diastolic BP were 1.25, 1.20, 1.28, and 1.07. Compared with systolic BP, pulse pressure and mean arterial pressure were not consistent predictors across age ranges, and combining systolic BP with another parameter did not improve the model compared with using systolic BP alone in any age group (all P > .05). Conclusions In this large cohort of healthy men with no history of hypertension, systolic BP was the most consistent and significant predictor of CVD death across all ages. Diastolic BP was not as strongly associated with risk. Our results support the continuing emphasis on using systolic BP in predicting cardiovascular risk.

Sumona Ghosh1,2,*, Meenakshi Kaw1,2,*, Payal R Patel1,2, Kelly J Ledford1,2, Thomas A Bowman1,2, Marcia F McInerney1,4, Sandra K Erickson5, Raymond E Bourey1,3, Sonia M Najjar1,21Center for Diabetes and Endocrine Research, 2Departments of Physiology and Pharmacology, and of 3Medicine at the University of Toledo College of Medicine, Health Science Campus, Toledo, OH, USA; 4Department of Medicinal and Biological Chemistry at the College of Pharmacy, University of Toledo, Main Campus, Toledo, OH, USA; 5Department of Medicine, University of California, and Veterans Affairs Medical Center, San Francisco, CA, USA; *These authors contributed equally to this workAbstract: Transgenic liver-specific inactivation of the carcinoembryonic antigen-related cell adhesion molecule (CEACAM1) impairs hepatic insulin clearance and causes hyperinsulinemia, insulin resistance, elevation in hepatic and serum triglyceride levels, and visceral obesity. It also predisposes to nonalchoholic steatohepatitis (NASH) in response to a high-fat diet. To discern whether this phenotype reflects a physiological function of CEACAM1 rather than the effect of the dominant-negative transgene, we investigated whether Ceacam1 (gene encoding CEACAM1 protein) null mice with impaired insulin clearance also develop a NASH-like phenotype on a prolonged high-fat diet. Three-month-old male null and wild-type mice were fed a high-fat diet for 3 months and their NASH phenotype was examined. While high-fat feeding elevated hepatic triglyceride content in both strains of mice, it exacerbated macrosteatosis and caused NASH-characteristic fibrogenic changes and inflammatory responses more intensely in the null mouse. This demonstrates that CEACAM1-dependent insulin clearance pathways are linked with NASH pathogenesis.Keywords: nonalcoholic steatohepatitis, CEACAM1, high-fat diet, inflammation, apoptosis, fibrosis

The distress level of parents who had infants with Down syndrome (study parents) was compared to that of control parents of infants without disability (infants were all less than 2 years of age). Data were collected in two independent surveys. We matched subjects case-by-case on socioeconomic status. Analysis of pooled data indicated significantly greater depression for the study parents. However, effect sizes were small, and the prevalence of clinical depression was 5.56% (n = 108) among matched study parents and 4.26% (n = 188) among unmatched study parents. Parenting an infant with Down syndrome may cause less distress than previously thought.

Event-related potentials (ERPs) were recorded during a visual discrimination task from nine elderly individuals (mean=68.1 years), diagnosed as having major depressive disorder, and nine age-matched controls (mean=68.0 years). During the task, subjects pressed a switch to targets (the number 9) and ignored background (the number 6) and novel stimuli (random designs). Novel and target stimuli were both interspersed infrequently in the sequence of background stimuli. Scalp electrical activity was recorded from midline frontal (Fz), central (Cz), and parietal (Pz) sites. Depressives were characterized by lengthened response times and increased number of errors across the session. Speed of response was also found to vary directly with clinical status. Additionally, ERP correlates of depression in the elderly were found: N1 was more prolonged for target than non-target stimuli in the depressed group; P2 was larger for all conditions; N2 was uniformly small across the scalp, whereas the controls showed small N2 amplitudes only at Fz; large P3s appeared in trials following the novel stimuli in the depressed but not in the control group. These results are interpreted in terms of the symptomatology associated with depression (i.e., distractability, impaired short-term memory or concentration, indecisiveness) and possible age-related changes in the ERP scalp distribution.

The behavior of eight infants with Down syndrome was observed biweekly from 8 to 24 weeks and monthly up to 48 weeks. At each visit the infants were presented with their mother, a female stranger, and a rattle puppet that were alternately active and passive. Each condition lasted 60 s. The results showed that by 4 months of age the infants began to differentiate, in the proportion of time they looked, smiled, and vocalized, between people and the toy. They did not discriminate, however, between mother and female stranger and between the active and passive adults until the second half of the first year. In particular, whereas normal infants usually show distress toward passive or “still-face” adults, the infants in this study continued to vocalize, at times even with smiling faces. The implications of these atypical aspects of the social development of infants with Down syndrome for their subsequent nonverbal communicative development are discussed.