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Change-of-direction maneuvers (e.g., side-step cutting) are an important aspect of performance in multi-directional sports, but these maneuvers are also associated with anterior cruciate ligament (ACL) injury. Despite this, the impact of biomechanics on ACL injury risk and performance is often examined in isolation. The purpose of this review was to examine the alignment between biomechanical recommendations for ACL injury prevention and performance with regard to change-of-direction maneuvers. Several studies linking change-of-direction biomechanics to both ACL injury risk and performance were examined. A degree of overlap was identified between biomechanical strategies that could both reduce ACL injury risk and enhance performance during change-of-direction maneuvers. A fore-foot footfall pattern along with trunk rotation and lateral flexion in the intended cutting direction were identified as biomechanical strategies that could both reduce potentially hazardous knee joint moments and enhance change-of-direction speed. Minimizing knee valgus during change-of-direction maneuvers may also reduce ACL injury risk, with this biomechanical strategy found to have no impact on performance. Certain biomechanical strategies proposed to reduce ACL injury risk were linked to reduced change-of-direction performance. A narrow foot placement and “soft” landings with greater knee flexion were identified as ACL injury prevention strategies that could have a negative impact on performance. The findings of this review emphasize the need to consider both ACL injury risk and performance when examining the biomechanics of change-of-direction maneuvers.

Delirium and cognitive decline are linked to clinically relevant anesthetics in the vulnerable elderly population, prompting the need for new and safer anesthetic strategies. Most general anesthetics potentiate the activity of GABA A receptors. However, these drugs act on myriad other targets, causing unwanted effects. Dexmedetomidine (Dex), a selective α 2 adrenergic receptor agonist, is associated with reduced incidences of delirium and cognitive decline in the elderly. Unfortunately, despite its sedative effect, Dex is not suitable for general anesthesia when used alone. We previously demonstrated that enhancing Dex with low doses of either sevoflurane or propofol resulted in a potent general anesthetic that was rapidly reversible. In this study we assessed whether Dex enhanced by magnesium (Mg 2+ ) infusion could produce a general anesthetic. Mg 2+ is an essential ion in the body, possessing sedative effects attributable to antagonizing NMDA receptors and voltage-gated Ca 2+ channels and it may indirectly potentiate GABAergic signaling. Mg 2+ has been shown to be neuroprotective and safe to use even in pregnant women. Mg 2+ is a safer adjunct agent than either sevoflurane or propofol. For this study, rats of both sexes were anesthetized with a combination of Dex and Mg 2+ and then underwent procedures to determine the efficacy of the anesthetic. Dex with Mg 2+ produced an effective general anesthetic that was reversed by a combination of low dose atipamezole, an α 2 competitive antagonist, and caffeine. We compared Dex supplemented with Mg 2+ to Dex supplemented with midazolam, a selective positive GABA A modulator and found that immobility, antinociception, EEG signatures, and hemodynamic profiles were comparable. Our findings showed that activation of α 2 receptors by Dex, with blockade of NMDA receptors/ Ca 2+ channels by Mg 2+ produce an effective and reversible general anesthetic with possible neuroprotective properties that may be appropriate for cognitively vulnerable patients like the elderly.

Clinically useful anesthetics are associated with delirium and cognitive decline in the elderly. Dexmedetomidine (Dex), an α 2 adrenergic receptor agonist, is an intravenous sedative with analgesic properties. Dex is associated with a lower incidence of delirium in the elderly. In this study, we first assessed whether a high dose of Dex alone was a clinically useful anesthetic. Finding that it was not, we sought to determine whether supplementation of Dex with low doses of two common anesthetics, propofol or sevoflurane, created an effective general anesthetic. Rats were sedated with a bolus followed by a continuous infusion of Dex and a low dose of a second agent—propofol, or sevoflurane. A strong noxious stimulus was applied every 15 minutes while monitoring vital signs. A combination of the α 2 competitive antagonist, atipamezole, and caffeine was administered to reverse the anesthesia. Abdominal surgery was used to validate the efficacy of these dosing regimens. The animals responded to noxious stimuli when receiving Dex alone. Supplementing Dex with either a low dose of propofol or sevoflurane completely suppressed responses to the noxious stimulus and allowed the rats to tolerate abdominal surgery with complete immobility and no alterations in vital signs, suggesting that the drug combinations were effective anesthetics. EEG recordings showed suppression of high frequency activity suggesting that awareness and memory were impaired. Previously we found that combination of atipamezole and caffeine rapidly and completely reversed the sedation and bradycardia elicited by Dex. In this study, atipamezole and caffeine accelerated the time to emergence from unconsciousness by >95% in Dex supplemented with either propofol or sevoflurane.

Changing rules to promote scoring through more ‘high-risk’ play has become common in team sports. Australia’s national netball league (i.e. Suncorp Super Netball) has recently taken this approach–introducing a two-point shooting rule. Teams will be awarded two-points for shots made from an ‘outer circle’ 3.0m-4.9m from the goal in the final five minutes of quarters. We sought to answer a series of questions regarding the implementation and potential strategies surrounding the two-point rule in Suncorp Super Netball. We used video coded data from the 2018 Suncorp Super Netball season to identify the total number of made and missed shots from different distances across the season. We also used shooting statistics from recent Fast5 Netball World Series (a competition with a two-point shooting rule already in place) as a comparator. The reward of two-points is relatively well-aligned to the relative risk of missing shots from the proposed outer versus inner circle (2.22 [1.98, 2.48 95% CIs]) based on existing shooting data from Suncorp Super Netball teams. We found that the relative risk of missing shots from ‘long-’ (i.e. 3.5m-4.0m) versus ‘mid-range’ (i.e. 3.0–3.5m) was only slightly elevated (1.52 [1.21, 1.86 95% CIs])–suggesting teams should favour long- over mid-range shots when the two-point shot is available. Based on the typical number of shots a team receives in a five-minute period, we found that teams may be able to score ~3.51 extra points per quarter when taking all versus no-shots from the two-point outer circle. Analysis of the Fast5 versus Suncorp Super Netball data did, however, reveal that shooting accuracy from long-range may decrease when a two-point shot is available. Teams may need to consider situational factors (e.g. altered opposition defensive strategies) when developing their shooting strategy for taking advantage of the two-point shot.

Background Syringe services programs (SSPs) provide a spectrum of health services to people who use drugs, with many providing referral and linkage to substance use disorder (SUD) treatment, and some offering co-located treatment with medications for opioid use disorder (MOUD). The objective of this study was to review the evidence for SSPs as an entry point for SUD treatment with particular attention to co-located (onsite) MOUD. Methods We performed a scoping review of the literature on SUD treatment for SSP participants. Our initial query in PubMed led to title and abstract screening of 3587 articles, followed by full text review of 173, leading to a final total of 51 relevant articles. Most articles fell into four categories: (1) description of SSP participants’ SUD treatment utilization; (2) interventions to link SSP participants to SUD treatment; (3) post-linkage SUD treatment outcomes; (4) onsite MOUD at SSPs. Results SSP participation is associated with entering SUD treatment. Barriers to treatment entry for SSP participants include: use of stimulants, lack of health insurance, residing far from treatment programs, lack of available appointments, and work or childcare responsibilities. A small number of clinical trials demonstrate that two interventions (motivational enhancement therapy with financial incentives and strength-based case management) are effective for linking SSP participants to MOUD or any SUD treatment. SSP participants who initiate MOUD reduce their substance use, risk behaviors, and have moderate retention in treatment. An increasing number of SSPs across the United States offer onsite buprenorphine treatment, and a number of single-site studies demonstrate that patients who initiate buprenorphine treatment at SSPs reduce opioid use, risk behaviors, and have similar retention in treatment to patients in office-based treatment programs. Conclusions SSPs can successfully refer participants to SUD treatment and deliver onsite buprenorphine treatment. Future studies should explore strategies to optimize the implementation of onsite buprenorphine. Because linkage rates were suboptimal for methadone, offering onsite methadone treatment at SSPs may be an appealing solution, but would require changes in federal regulations. In tandem with continuing to develop onsite treatment capacity, funding should support evidence-based linkage interventions and increasing accessibility, availability, affordability and acceptability of SUD treatment programs.

Using synchronous kinematic and kinetic data in simulations of human running typically leads to dynamic inconsistencies. Minimizing residual forces and moments is subsequently important to ensure plausible model outputs. A variety of approaches suitable for residual reduction are available in OpenSim; however, a detailed comparison is yet to be conducted. This study compared OpenSim tools applicable for residual reduction in simulations of human running. Multiple approaches (i.e. Residual Reduction Algorithm, MocoTrack , AddBiomechanics ) designed to reduce residual forces and moments were examined using an existing dataset of treadmill running at 5.0 ms −1 . The computational time, residual forces and moments, and joint kinematics and kinetics from each approach were compared. A computational cost to residual reduction trade-off was identified, where lower residuals were achieved using approaches with longer computational times. The AddBiomechanics and MocoTrack approaches produced variable lower and upper body kinematics, respectively, versus the remaining approaches. Joint kinetics were similar between approaches; however, MocoTrack generated noisier upper limb joint torque signals. MocoTrack was the best-performing approach for reducing residuals to near-zero levels, at the cost of longer computational times. This study provides OpenSim users with evidence to inform decision-making at the residual reduction step of their workflow.

Background Hospital-based clinicians infrequently initiate medications for opioid use disorder (MOUD) for hospitalized patients. Our objective was to understand hospital-based clinicians’ knowledge, comfort, attitudes, and motivations regarding MOUD initiation to target quality improvement initiatives. Methods General medicine attending physicians and physician assistants at an academic medical center completed questionnaires eliciting barriers to MOUD initiation, including knowledge, comfort, attitudes and motivations regarding MOUD. We explored whether clinicians who had initiated MOUD in the prior 12 months differed in knowledge, comfort, attitudes, and motivations from those who had not. Results One-hundred forty-three clinicians completed the survey with 55% reporting having initiated MOUD for a hospitalized patient during the prior 12 months. Common barriers to MOUD initiation were: (1) Not enough experience (86%); (2) Not enough training (82%); (3) Need for more addiction specialist support (76%). Overall, knowledge of and comfort with MOUD was low, but motivation to address OUD was high. Compared to MOUD non-initiators, a greater proportion of MOUD initiators answered knowledge questions correctly, agreed or strongly agreed that they wanted to treat OUD (86% vs. 68%, p = 0.009), and agreed or strongly agreed that treatment of OUD with medication was more effective than without medication (90% vs. 75%, p = 0.022). Conclusions Hospital-based clinicians had favorable attitudes toward MOUD and are motivated to initiate MOUD, but they lacked knowledge of and comfort with MOUD initiation. To increase MOUD initiation for hospitalized patients, clinicians will need additional training and specialist support.

Post-release opioid-related overdose mortality is the leading cause of death among people released from jails or prisons (PRJP). Informed by the proximate determinants framework, this paper presents the Post-Release Opioid-Related Overdose Risk Model. It explores the underlying, intermediate, proximate and biological determinants which contribute to risk of post-release opioid-related overdose mortality. PRJP share the underlying exposure of incarceration and the increased prevalence of several moderators (chronic pain, HIV infection, trauma, race, and suicidality) of the risk of opioid-related overdose. Intermediate determinants following release from the criminal justice system include disruption of social networks, interruptions in medical care, poverty, and stigma which exacerbate underlying, and highly prevalent, substance use and mental health disorders. Subsequent proximate determinants include interruptions in substance use treatment, including access to medications for opioid use disorder, polypharmacy, polydrug use, insufficient naloxone access, and a return to solitary opioid use. This leads to the final biological determinant of reduced respiratory tolerance and finally opioid-related overdose mortality. Mitigating the risk of opioid-related overdose mortality among PRJP will require improved coordination across criminal justice, health, and community organizations to reduce barriers to social services, ensure access to health insurance, and reduce interruptions in care continuity and reduce stigma. Healthcare services and harm reduction strategies, such as safe injection sites, should be tailored to the needs of PRJP. Expanding access to opioid agonist therapy and naloxone around the post-release period could reduce overdose deaths. Programs are also needed to divert individuals with substance use disorder away from the criminal justice system and into treatment and social services, preventing incarceration exposure.

Currently no drugs are employed clinically to reverse the unconsciousness induced by general anesthetics. Our previous studies showed that caffeine, when given near the end of an anesthesia session, accelerated emergence from isoflurane anesthesia, likely caused by caffeine’s ability to elevate intracellular cAMP levels and to block adenosine receptors. These earlier studies showed that caffeine did not rouse either rats or humans from deep anesthesia (≥ 1 minimum alveolar concentration, MAC). In this current crossover study, we examined whether caffeine reversed the unconsciousness produced by light anesthesia (< 1 MAC) in the continued presence of isoflurane. The primary endpoint of this study was to measure isoflurane levels at the time of recovery of righting reflex, which was a proxy for consciousness. Rats were deeply anesthetized with 2% isoflurane (~1.5 MAC) for 20 minutes. Subsequently, isoflurane was reduced to 1.2% for 10 minutes, then by 0.2% every 10 min; animals were monitored until the recovery of righting reflex occurred, in the continued presence of isoflurane. Respiration rate, heart rate and electroencephalogram (EEG) were monitored. Our results show that caffeine-treated rats recovered their righting reflex at a significantly higher inspired isoflurane concentration, corresponding to light anesthesia, than the same rats treated with saline (control). Respiration rate and heart rate increased initially after caffeine injection but were then unchanged for the rest of the anesthesia session. Deep anesthesia is correlated with burst suppression in EEG recordings. Our data showed that caffeine transiently reduced the burst suppression time produced by deep anesthesia, suggesting that caffeine altered neuronal circuit function but not to a point where it caused arousal. In contrast, under light anesthesia, caffeine shifted the EEG power to high frequency beta and gamma bands. These data suggest that caffeine may represent a clinically viable drug to reverse the unconsciousness produced by light anesthesia.

Background Syringe services programs (SSPs) are critical healthcare access points for people with opioid use disorder (OUD) who face treatment utilization barriers. Co-locating care for common psychiatric comorbidities, like posttraumatic stress disorder (PTSD), at SSPs may reduce harms and enhance the health of individuals with OUD. To guide the development of onsite psychiatric care at SSPs, we collected quantitative survey data on the prevalence of PTSD, drug use patterns, treatment experiences associated with a probable PTSD diagnosis, and attitudes regarding onsite PTSD care in a convenience sample of registered SSP clients in New York City. Methods Study participants were administered the PTSD Checklist for the DSM-5 (PCL-5) and asked about sociodemographic characteristics, current drug use, OUD and PTSD treatment histories, and desire for future SSP services using a structured interview. Probable PTSD diagnosis was defined as a PCL-5 score  ≥  31. Results Of the 139 participants surveyed, 138 experienced at least one potentially traumatic event and were included in the present analysis. The sample was primarily male ( n  = 108, 78.3%), of Hispanic or Latinx ethnicity ( n  = 76, 55.1%), and middle-aged ( M  = 45.0 years, SD  = 10.6). The mean PCL-5 score was 35.2 ( SD  = 21.0) and 79 participants (57.2%) had a probable PTSD diagnosis. We documented frequent SSP utilization, significant unmet PTSD treatment need, and high interest in onsite PTSD treatment. Conclusions Study findings point to the ubiquity of PTSD in people with OUD who visit SSPs, large gaps in PTSD care, and the potential for harm reduction settings like SSPs to reach people underserved by the healthcare system who have co-occurring OUD and PTSD.