Utilization of the Progressive Return to Activity Following Acute Concussion Clinical Recommendations

Purpose: Since 2000, almost 300,000 concussions have been reported in the military population. Concussions were labeled the signature injury of the wars in Iraq and Afghanistan. Prevalence of concussions and implications for service members prompted the Defense Centers of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury to introduce the Progressive Return to Activity Progression Following Acute Concussion/Mild Traumatic Brain Injury clinical recommendations in 2014 to guide cognitive and physical rehabilitation of concussion. The purpose of this study was to identify utilization rates of the DCoE clinical practice recommendations and to identify barriers to implementation that affect clinician adherence. Subjects: Subjects included military healthcare providers at Joint Base-Lewis McChord, WA and Fort Wainwright, AK who treat patients with concussions. 79 survey responses were received. Methods: Primary service line providers who treat concussion in service members at Joint Base-Lewis McChord, WA and Fort Wainwright, AK were sent an online survey. The survey examined utilization of the clinical recommendations, ease of use, barriers to implementation, recommendations for increased adherence, and use of other return to activity protocols. Results: While 76% of respondents treat service members with concussions and 70% are familiar with the DCOE clinical recommendations, only 31% reported unwavering adherence to the recommendations. Primary reasons for deviating from the protocol included patient compliance (30%) and need to individualize treatment (35%). No significant correlations were found between provider type or experience and protocol use. Significant differences were found between provider and PT/OT rating of the protocol. Conclusions: Responses suggest that the DCOE recommendations are underutilized. Utilization of the protocols could be improved through factors including provider education, ease of application, a more interdisciplinary approach, and the ability to individualize treatment within the parameters of the protocol. Clinical Relevance: The results may inform recommendations to commanders or the Defense and Veteran’s Brain Injury Center for procedural or educational changes to facilitate improved adherence to the clinical recommendations. The study identifies areas for potential protocol modification based on provider feedback and may improve post-concussion outcomes. References: 1. DoD Worldwide Numbers for TBI | DVBIC. http://dvbic.dcoe.mil/dod-worldwide-numbers-tbi. Accessed September 11, 2017. 2. Snell FI, Halter MJ. A signature wound of war: mild traumatic brain injury. J Psychosoc Nurs Ment Health Serv. 2010;48(2):22-28 7p. doi:10.3928/02793695-20100108-02. 3. McCulloch KL, Goldman S, Lowe L, et al. Development of clinical recommendations for progressive return to activity after military mild traumatic brain injury: guidance for rehabilitation providers. J Head Trauma Rehabil. 2015;30(1):56-67. doi:10.1097/HTR.0000000000000104. 4. http://www.dtic.mil/dtic/tr/fulltext/u2/a592497.pdf. Accessed September 15, 2017. 5. http://www.dtic.mil/dtic/tr/fulltext/u2/a592691.pdf. Accessed September 15, 2017

A case of acute extensive viral sinusitis secondary to acute Epstein Barr virus

Infectious mononucleosis (IM), the most common presentation of acute Epstein Barr virus (EBV) infection, typically presents with fever, pharyngitis and lymphadenopathy. We describe an unusual case of IM presenting as acute sinusitis. A 25 year-old male presented to the emergency department with worsening right frontal sinus pain along with fever, chills, and greenish nasal discharge for 3 weeks. Laboratory workup showed leukocytosis with high lymphocyte counts as well as transaminitis. Facial computerized tomography (CT) showed extensive right frontal, ethmoidal and maxillary sinusitis and antrochoanal polyp. The patient underwent endoscopy with drainage of purulent material and polyp removal. Unfortunately, cultures of the sample were not sent and bacterial infection could not be ruled out. Broad spectrum antibiotics were continued. Pathology of redundant tissue revealed large atypical lymphocytes with positive EBV-encoded RNA and lack of evidence of extranodal natural killer/T-cell (NK/T-cell) type lymphoma (ENKTCL). Tests for serum EBV IgM antibodies and EBV early Antigen antibodies were positive, indicating acute EBV infection. Lymphocytosis resolved along with significant clinical improvement at the 10-day follow up visit. Even though patient did receive antibiotics, multiple factors including isolated lymphocytosis, pathology positive for EBV with no neutrophilia were more suggestive of sinusitis caused by viral infection, EBV in this case. Lymphocytosis with fever and sore throat should prompt physicians to consider IM. There are no known reports in the literature of EBV as a causal organism for acute viral sinusitis. There are some studies relating EBV with ENKTCL. It is unknown whether this particular patient with a history of EBV sinusitis will be at high risk for nasal type lymphoma in the future. Further studies should be conducted to understand the pathogenesis and relationship between EBV and ENKTCL

Estrogen Depletion Results in Nanoscale Morphology Changes in Dermal Collagen

Tissue cryo-sectioning combined with atomic force microscopy imaging reveals that the nanoscale morphology of dermal collagen fibrils, quantified using the metric of D-periodic spacing, changes under the condition of estrogen depletion. Specifically, a new subpopulation of fibrils with D-spacings in the region between 56 and 59nm is present 2 years following ovariectomy in ovine dermal samples. In addition, the overall width of the distribution, both values above and below the mean, was found to be increased. The change in width due to an increase in lower values of D-spacings was previously reported for ovine bone; however, this report demonstrates that the effect is also present in non-mineralized collagen fibrils. A nonparametric Kolmogorov–Smirnov test of the cumulative density function indicates a statistical difference in the sham and OVX D-spacing distributions (P<0.01)

The Refederalization of American Health Care

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/69090/2/10.1177_107755878704400103.pd

Nonmalarial Infant Deaths and DDT Use for Malaria Control

Although dichlorodiphenyl trichloroethane (DDT) is being banned worldwide, countries in sub-Saharan Africa have sought exemptions for malaria control. Few studies show illness in children from the use of DDT, and the possibility of risks to them from DDT use has been minimized. However, plausible if inconclusive studies associate DDT with more preterm births and shorter duration of lactation, which raise the possibility that DDT does indeed have such toxicity. Assuming that these associations are causal, we estimated the increase in infant deaths that might result from DDT spraying. The estimated increases are of the same order of magnitude as the decreases from effective malaria control. Unintended consequences of DDT use need to be part of the discussion of modern vector control policy

Tradable Pollution Permits and the Regulatory Game

This paper analyzes polluters\u27 incentives to move from a traditional command and control (CAC) environmental regulatory regime to a tradable permits (TPP) regime. Existing work in environmental economics does not model how firms contest and bargain over actual regulatory implementation in CAC regimes, and therefore fail to compare TPP regimes with any CAC regime that is actually observed. This paper models CAC environmental regulation as a bargaining game over pollution entitlements. Using a reduced form model of the regulatory contest, it shows that CAC regulatory bargaining likely generates a regulatory status quo under which firms with the highest compliance costs bargain for the smallest pollution reductions, or even no reduction at all. As for a tradable permits regime, it is shown that all firms are better off under such a regime than they would be under an idealized CAC regime that set and enforced a uniform pollution standard, but permit sellers (low compliance cost firms) may actually be better off under a TPP regime with relaxed aggregate pollution levels. Most importantly, because high cost firms (or facilities) are the most weakly regulated in the equilibrium under negotiated or bargained CAC regimes, they may be net losers in a proposed move to a TPP regime. When equilibrium costs under a TPP regime are compared with equilibrium costs under a status quo CAC regime, several otherwise paradoxical aspects of firm attitudes toward TPP type reforms can be explained. In particular, the otherwise paradoxical pattern of allowances awarded under Phase II of the 1990 Clean Air Act\u27s acid rain program, a pattern tending to favor (in Phase II) cleaner, newer generating units, is explained by the fact that under the status quo regime, a kind of bargained CAC, it was the newer cleaner units that were regulated, and which therefore had higher marginal control costs than did the largely unregulated older, plants. As a normative matter, the analysis here implies that the proper baseline for evaluating TPP regimes such as those contained in the Bush Administration\u27s recent Clear Skies initiative is not idealized, but nonexistent CAC regulatory outcomes, but rather the outcomes that have resulted from the bargaining game set up by CAC laws and regulations