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The largest percentage of sports-related injuries requiring medical attention are from overuse injuries. Ultra-endurance athletes, such as triathletes, commonly experience overuse injuries, making them a useful group to study in order to understand overuse injuries among endurance athletes. Competitors in the World Triathlon Championship were studied to assess the type and incidence of overuse injuries experienced in training. Over 90 percent of the triathletes studied in the year prior to this major competitive event reported one or more injuries. The back was reported as the most frequent site of injury, although a high percentage of athletes also sustained knee, thigh, ankle, and foot injuries. Over 70 percent of the athletes covered in the study experienced multiple injuries during the year of intense training, yet the vast majority continued to workout at high levels of intensity in spite of injury. Although study results indicate no apparent relationship between training habits and overuse injuries, experts advocate a gradual increase in the duration, intensity, or frequency of training in order to avoid overuse injuries. The majority of overuse syndromes (pain, weakness, muscle tightness) did not lead to permanent impairment of athletic performance, and most of the conditions responded to medical treatment in combination with a lighter training schedule. Additional research is needed to study changes in posture and running gait which may be useful predictors of injury. Furthermore, among triathletes, investigation into the long term effect of overuse injury on the development of osteoarthritis is needed.

The effect of prolonged daily electrical stimulation (ES) on quadriceps strength in 22 patients during the 6 weeks following anterior cruciate reconstruction was investigated. Patients were randomly assigned to re ceive either a combination of ES and exercise or exer cise alone. Isometric quadriceps strength was meas ured at the 7th, 8th, and 9th postoperative weeks. No significant difference in strength existed between the groups as a result of ES. A significant difference in strength did exist between competitive and recreational athletes regardless of treatment. Further research is needed to determine if the addition of ES to isometric exercise during immobilization can significantly retard strength loss after anterior cruciate reconstructive sur gery. [ABSTRACT FROM PUBLISHER]

Triathlons (races involving consecutive swimming, bi cycling, and running) have become commonplace in the United States. These races may involve from 30 min utes to 36 hours of continuous exercise, usually in warm or hot environments. Little has been published regarding the medical and physiological aspects of these events. This paper represents the first large study to date on the subject, including both an analysis of medical complications at six triathlons as well as a prospective electrolyte study conducted at two of these races.Medical records were kept and examined for all ath letes requiring treatment during a typical United States Triathlon Series (USTS) race in 1986 (1,000 starters; finish times, 2 to 4 hours), a typical Ironman Qualifier (IQ) race in 1986 (622 starters; finish times, 4 to 8 hours), and the 1982 through 1985 Hawaii lronman World Championships (4,583 starters; finish times, 9 to 17 hours). At the USTS race, fewer than 2% (17/1,000) of the starters required aid, at the IQ, approximately 10% (61 /622) of the starters were treated, and at the Ironman, an average of 17% (794/4,583) received med ical attention. The most common diagnoses at the USTS and IQ were dehydration and heat exhaustion. At the lronman, dehydration and heat problems were complicated by hyponatremia.Because hyponatremia has been reported as a com plication of ultraendurance events, a prospective study was performed on 36 athletes during a USTS race and 64 athletes at the 1984 lronman race. Prerace and postrace blood samples showed that no athletes were hyponatremic following the shorter USTS race, but 27% (17/64) of the athletes studied were hyponatremic fol lowing the lronman race.Medical personnel should be prepared to treat a minimum of 2% and up to 10% of the athletes in races lasting up to 4 hours, 10% to 20% of those in races lasting 4 to 8 hours, and at least 20% of starters in races lasting between 9 and 17 hours. For races less than 4 hours, the IV fluid of choice should be D5 1/2 NSS (normal saline solution). For races longer than 4 hours, D5NSS should be used for IV resuscitation. [ABSTRACT FROM PUBLISHER]

Many studies concerning the injuries occuring in high school and intercollegiate football have been re ported, including those emphasizing the number and type of injuries, geographic distribution of injuries, and the rate of injury compared to position, condition ing, officiating, equipment, and type of playing sur face. This report focuses on the individual player involved in a sports program for four or five years and emphasizes the statistical probability of that individual sustaining an injury during his playing career.Conclusions, drawn from statistics compiled at Memphis State University from 1975 through 1979, involved 265 athletes. These 265 athletes sustained 283 injuries during this period. Of these 283 injuries, 69% were mild, 20% were moderate, and 11% were severe. The knee was most often involved and suf fered the most severe injuries. Ankle injuries ac counted for the second highest incidence of injury, but these were primarily mild or moderate injuries. The defensive line, especially the defensive ends, received the greatest percentage of injuries. The prob ability of injury for the individual player was found to be 106.7% for a five-year participant, 99.1% for a four-year participant, and 46.6% for a one-year par ticipant. [ABSTRACT FROM PUBLISHER]

Introduction: Fetal echocardiograms (F-echo) are recommended in all pregnancies when maternal congenital heart disease (CHD) is present, even if there was a prior level II ultrasound (LII-US) that was normal. The goal of this study was to evaluate if any diagnosis of a critical CHD was missed in a fetus with maternal CHD who had a normal LII-US., Methods: A retrospective chart review of all F-echoes where the indication was maternal CHD between 1/1/2015 to 12/31/2022 was performed. Fetuses were included if they had a LII-US that was read as normal and had an F-echo. Critical CHD was defined as CHD requiring catheterization or surgical intervention < 1 month of age., Results: A total of 296 F-echoes on fetuses with maternal CHD were evaluated, of which 175 met inclusion criteria. LII-US was performed at 19.8 ± 2.9 weeks gestational age and F-echo was performed at 24.2 ± 2.8 weeks gestational age. No patient with a normal LII-US had a diagnosis of a critical CHD by F-echo (negative predictive value = 100%). Evaluating those patients that had a negative LII-US, ten patients were diagnosed with non-critical CHD postnatally (negative predictive value = 94.3%). F-echo correctly diagnosed two of the ten missed LII-US CHD., Conclusions: Critical CHD was not missed with a normal LII-US in this at risk population. F-echo also missed the majority of CHD when a LII-US was read as normal. A cost-benefit analysis of screening F-echo in fetuses with maternal CHD should be conducted if a normal LII-US has been performed., (© 2024. The Author(s).)

Background: Data on the use of implanted hemodynamic monitoring (IHM) in patients with Fontan circulation are limited. This study reports our experience using the CardioMEMS HF system in adults with Fontan circulation., Methods and Results: This single-center, retrospective study evaluated heart failure hospitalizations, procedural complications, and device-related complications in patients with Fontan circulation referred for IHM placement (2015-2022). The association of pulmonary artery pressure (by most recent catheterization and median IHM pressure within 30 days of placement) with both death and follow-up Model for End-Stage Liver Disease Excluding International Normalized Ratio score were evaluated. Of 18 patients referred for IHM placement, 17 were successful (median age, 30 [range 21-48] years, 6 women). Procedural complications (access site hematomas, pulmonary artery staining) occurred in 3 patients, without device-related procedural complications. In follow-up (median, 35 [range, 6-83] months), 1 patient developed a pulmonary embolism (possibly device-related). Heart failure hospitalizations/year were similar before and after IHM (median, 1 [interquartile range, 0-1.0] versus 0.6 [0-2.3]; P =0.268), though only 46% of heart failure hospitalizations had associated IHM transmissions. IHM pressures were associated with Model for End-Stage Liver Disease Excluding International Normalized Ratio scores ( R 2 =0.588, P <0.001), though catheterization pressures were not ( R 2 =0.140, P =0.139). The long-term mortality rate was 53% in this cohort. On unadjusted survival analysis, IHM pressures ≥18 mm Hg were associated with mortality (log rank P =0.041), which was not reproduced with catheterization pressures (log rank P =0.764)., Conclusions: In patients with Fontan circulation, IHM did not reduce heart failure hospitalizations, though patient adherence to transmission was low. Device-related complications were low. IHM pressures may better represent real-life conditions compared with catheterization given associations with mortality and Model for End-Stage Liver Disease Excluding International Normalized Ratio score.

Introduction: The COVID-19 pandemic has resulted in increased use of telemedicine. There are limited data on patient experience with telemedicine in adults with congenital heart disease (ACHD). We hypothesized that due to their complex medical history, ACHD would prefer in-person clinic visits over telemedicine. Methods: We conducted a nurse-administered telephone survey based on Agency for Healthcare Research and Quality recommendations to assess patient experience after ACHD telemedicine visits in the early part of the pandemic from March 2020 to June 2020. Results: Of 216 ACHD who had telemedicine visits, 136 (63%) agreed to participate in the survey. Mean age was 45 ± 18 years, majority (65%) being video encounters. Most (98%) patients expressed that the telemedicine visit was successful in addressing their health care needs. Only 21 (15%) patients reported technical issues. Most patients (76%) preferred telemedicine given testing was provided separately, 25 (18%) preferred in-person clinic visits, and 8 (6%) had no preference. Of the 25 patients over 65 years, 19 (76%) would choose telemedicine over the in-person clinic, and only 1 patient reported technical difficulties. Conclusion: ACHD reported a positive experience with telemedicine. Technical limitations were infrequent even among the elderly. The majority of patients felt that their health care needs were addressed and would consider telemedicine over clinic visits. These data are important as payors move away from supporting telemedicine and hospitals restructure, with and without ongoing COVID-19 concerns.

A central challenge in the study of intrinsically disordered proteins is the characterization of the mechanisms by which they bind their physiological interaction partners. Here, we utilize a deep learning based Markov state modeling approach to characterize the folding-upon-binding pathways observed in a long-time scale molecular dynamics simulation of a disordered region of the measles virus nucleoprotein N TAIL reversibly binding the X domain of the measles virus phosphoprotein complex. We find that folding-upon-binding predominantly occurs via two distinct encounter complexes that are differentiated by the binding orientation, helical content, and conformational heterogeneity of N TAIL . We do not, however, find evidence for the existence of canonical conformational selection or induced fit binding pathways. We observe four kinetically separated native-like bound states that interconvert on time scales of eighty to five hundred nanoseconds. These bound states share a core set of native intermolecular contacts and stable N TAIL helices and are differentiated by a sequential formation of native and non-native contacts and additional helical turns. Our analyses provide an atomic resolution structural description of intermediate states in a folding-upon-binding pathway and elucidate the nature of the kinetic barriers between metastable states in a dynamic and heterogenous, or "fuzzy", protein complex.

Grasslands managed for grazing are the largest land-use category globally, with a significant proportion of these grasslands occurring in semiarid and arid regions. In such dryland systems, the effect of grazing on native plant diversity has been equivocal, some studies suggesting that grazing reduces native plant diversity, others that grazing increases or has little impact on diversity. One impediment toward generalizing grazing effects on diversity in this region is that high levels of interannual variation in precipitation may obfuscate vegetative response patterns. By analyzing a long-term data set collected over a 20-yr period in a semiarid grassland, we explicitly evaluated the role of climate in regulating the effect of cattle grazing on plant communities, finding that climate interacted with grazing intensity to shape grassland communities. Community composition of plots that were intensively grazed varied considerably in response to climatic variation and native species richness was low relative to ungrazed and moderately grazed plots. Following a severe drought in 2002, exotic species richness rapidly increased in the high-intensity grazing plots. While this pattern was mirrored in the other treatments, exotic species richness increased to a greater extent and was slower to return to pre-drought levels in the high-intensity grazing plots. Overall, moderate grazing, even compared to grazing cessation, stabilized grassland communities through time, increased resilience to drought, and maintained the highest levels of native plant diversity and lowest levels of exotic diversity. These findings suggest that grazing, at moderate levels, may support grassland resilience to climate change in semiarid regions. However, grazing that exceeds tolerances, particularly in combination with extreme climatic events, like drought, can alter plant composition over relatively long timescales and possibly increase invasibility by nonnative species., (© 2019 by the Ecological Society of America.)

Objectives: Left heart obstruction in pregnancy is associated with higher rates of morbidity/mortality. The primary aim of this study was to evaluate maternal cardiovascular, obstetric, and fetal/infant events in pregnant women with left heart obstruction., Study Design: Pregnant women with current or repaired left heart obstruction were retrospectively analyzed (2000-2014): mitral stenosis, left ventricular outflow tract obstruction (subvalvar, valvar, supravalvar), and coarctation of the aorta. Maternal cardiovascular events were defined as: heart failure, arrhythmia, urgent/emergent cardiac surgery or percutaneous transcatheter intervention, transient ischemic attack/cerebrovascular accident, and death up to 6 months postpartum., Results: There were 90 pregnancies in 67 women (29±7 years old) who had 15 maternal cardiovascular events. Isolated mitral stenosis (n=6) or >1 serial left heart obstructive lesion (n=6) were the source of the event in the majority pregnancies. Women with isolated mitral stenosis had increased cardiovascular events compared to other single left heart obstructive lesions (OR 18.6, 95% CI: 3.8-91.1). If >1 serial obstructive lesion was present, there was also an increased risk of maternal cardiovascular events (OR 6.8, 95% CI: 1.6-29.1), however isolated mitral stenosis carried similar risk to serial left heart obstructive lesions (OR 2.7, 95% CI: 0.7-11.2). Baseline characteristics associated with events included: New York Heart Association functional class >2 (27% vs. 0, p<0.001), any current left heart obstruction (73% vs. 36%, p=0.01), severe left heart obstruction (40% vs. 29%, p<0.001), and higher Cardiac Disease in Pregnancy ("CARPREG") score (1.2±0.7 vs. 0.5±0.7, p=0.01). There was no difference in rate of obstetric/fetal/infant complications in women with cardiovascular events; however, term birth weight was lower (2.7±0.5 vs. 3.1±0.6kg, p=0.01). There was no maternal mortality., Conclusions: Isolated mitral stenosis and serial (>1) left heart obstructive lesions carry the highest risk of maternal cardiovascular events. We are the first to show higher event rates in women with serial left heart obstructive lesions. The data supports the need for specialized and experienced high-risk obstetric-cardiac teams to care for women with left heart obstruction, and demonstrates excellent outcomes in a complex cohort of pregnant women with all types of left heart obstruction., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Atrial switch operations for D-Transposition of the great arteries (D-TGA) were performed until the late 20th century. These patients have substantial rates of re-operation, particularly for baffle related complications. This study sought to analyze the efficacy of percutaneous transcatheter intervention (PTI) for baffle leak and/or stenosis in adult atrial switch patients. Adult patients with a prior atrial switch operation who underwent heart catheterization (2002-2014) at a tertiary adult congenital heart disease referral center were retrospectively analyzed. In 58 adults (30 ± 8 years, 75% men, 14% New York Heart Association (NYHA) functional class ≥2) who underwent 79 catheterizations, PTI was attempted in 50 (baffle leak (n = 10, 20%), stenosis (n = 27, 54%), or both (n = 13, 26%)). PTI was successful in 45 and 5 were referred for surgery due to complex anatomy. A total of 40 bare metal stents, 18 covered stents, 16 occlusion devices, 2 angioplasties, and 1 endovascular graft were deployed. In isolated stenosis, there was improvement in NYHA functional class after PTI (8 vs. 0 patients were NYHA FC > 2, p = 0.004), which was matched by improvement in maximal oxygen consumption on exercise testing (VO 2 ) (25.1 ± 5.4 mL/kg/min vs. 27.9 ± 9 mL/kg/min, p = 0.03). There were no procedure-related deaths or emergent surgeries in this cohort. This single-center cohort is the largest reported series of adult atrial switch operation patients who have undergone PTI for baffle stenosis and/or leak. We demonstrate that PTI with an expert multi-disciplinary team is a safe and effective alternative to surgery in adult patients with an atrial switch operation.

Major adverse maternal cardiovascular-related events (MAMCRE) in aortopathy patients undergoing pregnancy are poorly defined. The aim was to assess for MAMCRE in pregnant patients with aortopathy or aortic enlargement in conotruncal defects (CTD), and determine if there are differences between groups. We conducted a single-center retrospective review of pregnant women (2000-2013) with hereditary vascular disease (HVD: BAV, COA), heritable fibrillinopathies (HF: MFS, EDS, LDS, FTAAS), and CTD with aortic dilatation (TOF, d-TGA, DORV). MAMCRE included: aortic dissection/surgery, therapeutic abortion, change in mode of delivery, and aortic growth > 0.5 cm within 1 year. We identified 73 patients/97 pregnancies (39/50 HVD, 15/20 HF, and 19/27 CTD). There were 14 MAMCRE (14%); 85% (n = 12) occurred in HV and HF patients and was associated with higher baseline cross-sectional-to-height (CSA/Ht) ratio (6.6 [Symbol: see text] 2.5 vs. 5.1 [Symbol: see text] 1.3, p = 0.005). There was more aortic surgery in the HF (vs. HV) (RR 3.9, p = 0.12). Only 2 MAMCRE (aortic growth) occurred in CTD. Overall and emergent C-section was higher than the general population (52% vs. 29%, p < 0.001 and 16% vs. 3%, p < 0.001) as was postpartum hemorrhage (PPH) (6% vs. 1.5%, p < 0.001). We describe the largest series of pregnant women with aortopathy and found a substantial incidence of MAMCRE, which was associated with higher pre-pregnancy CSA/Ht ratio. Rates of C-section and PPH were higher than the general population. Our data suggest that larger, multi-center studies are needed to define risks that predict MAMCRE/obstetric events in women with aortopathies, allowing optimal medical care during pregnancy., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

The management of landscapes for biological conservation and ecologically sustainable natural resource use are crucial global issues. Research for over two decades has resulted in a large literature, yet there is little consensus on the applicability or even the existence of general principles or broad considerations that could guide landscape conservation. We assess six major themes in the ecology and conservation of landscapes. We identify 13 important issues that need to be considered in developing approaches to landscape conservation. They include recognizing the importance of landscape mosaics (including the integration of terrestrial and aquatic areas), recognizing interactions between vegetation cover and vegetation configuration, using an appropriate landscape conceptual model, maintaining the capacity to recover from disturbance and managing landscapes in an adaptive framework. These considerations are influenced by landscape context, species assemblages and management goals and do not translate directly into on-the-ground management guidelines but they should be recognized by researchers and resource managers when developing guidelines for specific cases. Two crucial overarching issues are: (i) a clearly articulated vision for landscape conservation and (ii) quantifiable objectives that offer unambiguous signposts for measuring progress.

The major histocompatibility complex (MHC) class II transactivator (CIITA) regulates the expression of genes involved in the immune response, including MHC class II genes and the interleukin-4 gene. Interactions between CIITA and sequence-specific, DNA-binding proteins are required for CIITA to function as an activator of MHC class II genes. CIITA also interacts with the coactivators CBP (also called p300), and this interaction leads to synergistic activation of MHC class II promoters. Here, we report that CIITA forms complexes with itself and that a central region, including the GTP-binding domain is sufficient for self-association. Additionally, this central region interacts with the C-terminal leucine-rich repeat as well as the N-terminal acidic domain. LXXLL motifs residing in the GTP-binding domain are essential for self-association. Finally, distinct differences exist among various CIITA mutant proteins with regard to activation function, subcellular localization, and association with wild-type protein and dominant-negative potential.

The MHC class II transactivator (CIITA) is a critical transcription factor that regulates genes involved in antigen presentation function. At least three functional forms of CIITA gene products are transcribed from three different promoters. The CIITA gene expressed in dendritic cells (DC-CIITA) has a unique first exon encoding an extended N-terminal region of CIITA. Here, we show that the N terminus of DC-CIITA has high homology to a caspase recruitment domain (CARD) found in components of apoptosis and nuclear factor-kappaB signaling pathways. However, DC-CIITA does not regulate cell death, nor does it induce nuclear factor-kappaB activity. Instead, DC-CIITA is transcriptionally a more potent activator of the MHC class II gene than the form expressed in B cells. A single amino acid substitution in the CARD of DC-CIITA, predicted to disrupt CARD-CARD interactions, diminished the transactivation potential of DC-CIITA. These results indicate that the CARD in the context of CIITA serves as a regulatory domain for transcriptional activity and may function to selectively enhance MHC class II gene expression in dendritic cells.

The MHC class II transactivator (CIITA) activates the expression of multiple genes involved in Ag presentation, but inhibits Th2-type cytokine production, including IL-4, during Th1 cell differentiation. Th1 cells derived from CIITA-deficient mice produce both Th1- and Th2-type cytokines, and the introduction of CIITA to Th2 cells down-regulates Th2-type cytokine gene transcription. Here we show that the IL-4 promoter is regulated by multiple protein-protein interactions among CIITA, NF-AT, and coactivator CBP/p300. The introduction of CBP/p300 and NF-AT enhances the IL-4 promoter activity, and this activation was repressed by CIITA. Furthermore, our data show that CIITA competes with NF-AT to bind CBP/p300 and that this competition dramatically influences transcriptional activation of the IL-4 promoter. We identified two domains of CIITA that interact with two distinct domains of CBP/p300 that are also recognized by NF-AT. CIITA mutants that retain the ability to interact with CBP/p300 are sufficient to inhibit NF-AT-mediated IL-4 gene expression.

Treatment of ruptures of the proximal biceps tendon has been based on clinical observations, with little objective data to substantiate treatment guidelines. Evaluation of 25 patients (all > 40 years of age) at an average of 7.9 years after injury found few objective or subjective differences between those treated nonoperatively and those treated operatively. Only 1 patient (treated nonoperatively) was dissatisfied with the result, and her dissatisfaction was with a cosmetic defect. Objective manual muscle testing and Cybex II (Cybex Corporation, Ronkonkoma, New York) evaluation of 19 patients found no significant differences in supination or elbow flexion strength in the two groups.

The mechanoreceptor innervation of fibular collateral ligaments from human knee joints is described. While a small number of 'non-Paciniform' endings were identified in 5 optimally-stained ligaments, 'Paciniform' endings were not identified. These 'non-Paciniform endings' were variable in shape, but each consisted of an encapsulated arborisation of neurites embedded in a granular matrix. The significance of these findings is discussed as they relate to (i) discrepancies of the extent to which certain periarticular tissues are innervated, and (ii) the role of periarticular mechanoreceptors in initiating protective muscular reflexes.

The immobilization of fracture fragments by the insertion of pins connected externally by plaster, metal devices, or other appliances is not a new concept. In the past two centuries external fixation has enjoyed long periods of enthusiastic use alternating with intervals of total disrepute.