Testosterone replacement therapy (TRT) has been used in millions of men worldwide to treat diminished libido and erectile dysfunction, and to improve strength and physical function. The estimated likelihood of adverse effects of long-term TRT is still essentially unknown, as overall high-quality evidence based upon prospective randomized trials to recommend for or against its use in most men with testosterone deficiency (TD) is lacking. Evidence to suggest that TRT increases cardiovascular morbidity and mortality risks is poor, as results vary across study populations and their baseline comorbidities. While TRT may increase serum prostate-specific antigen levels in some men, it often remains within clinically acceptable ranges, and has not been shown to increase the risk of prostate cancer. Current literature supports that TRT does not substantially worsen lower urinary tract symptoms, and may actually improve symptoms in some men. Limited evidence suggests that TRT may initially worsen obstructive sleep apnea in some men, but that this is not a longstanding effect. TRT may result in erythrocytosis in some men, however long-term studies have not reported significant adverse events (e.g. cerebrovascular accident, vascular occlusive events, venous thromboembolisms). Future research will require dedicated focus on evaluation of large, multiethnic cohorts of men through prospective trials to better elucidate both risk and hazard ratios of TRT as it relates to cardiovascular disease, prostate cancer, lower urinary tract symptoms, obstructive sleep apnea, erythrocytosis, and other to-bedetermined theoretical risks in men both with and without cardiovascular risk equivalents.
IMPORTANCE Concussion on university campuses is a significant health problem. Characterizing the incidence of concussion on college campuses may inform education and resource allocation policy at student health care centers. OBJECTIVES To establish a measure of concussion incidence among collegiate undergraduate students and to describe characteristics associated with concussion incidence, including sex, cause, and month. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study included data from 3 academic years from August 2015 to April 2018 at a large, public university in the United States. Participants included any undergraduate student or varsity athlete who was diagnosed with at least 1 concussion during the academic year. EXPOSURES Sport-and non-sport-related activities of undergraduate students. MAIN OUTCOMES AND MEASURES Concussion diagnosis. RESULTS Among 954 undergraduate students from the general undergraduate population with at least 1 concussion, including 502 men and 452 women, 1020 concussions were diagnosed in 3 academic years. During 2 academic years, a total of 80 concussions occurred among the varsity athlete population, including 26 men and 54 women. Overall, concussion incidence among both the general undergraduate population and varsity athletes was 132.4 (95% CI, 123.2-142.0) concussions per 10 000 students. Men sustained concussions at a rate of 126.1 (95% CI, 114.1-139.0) concussions per 10 000 students and women sustained concussions at a rate of 140.0 (95% CI, 126.2-155.3) concussions per 10 000 students for the 2016 to 2017 and 2017 to 2018 academic years. Concussion incidence peaked in August at the start of the academic year and the rate of non-sport-related concussions (81.0 [95% CI, 73.9-88.7] concussions per 10 000 students for academic years 2016-2017 and 2017-2018) was higher than the rate of sport-related concussions (51.5 [95% CI, 49.5-57.7] concussions per 10 000 students for academic years 2016-2017 and 2017-2018). CONCLUSIONS AND RELEVANCE This cohort study found concussions to be common among this US collegiate population. While concussion is often associated with sport, the incidence of non-sport-related concussion was higher than that of sport-related concussion throughout the academic year. Additional research is warranted to determine if this incidence measure among undergraduate students is generalizable to other university populations.
In studies of the rhetorical forms present in biblical writings there exists today a certain confusion regarding the way various patterns are identified. Chiasmus should be clearly distinguished from direct, inverted and antithetical parallelism, in order to stress its characteristic focus upon a thematic center or "pivot" about which other elements of the literary unit are developed. Several key passages, from the psalms, epistles, and gospels, are shown to be structured according to the chiastic patterns A B A'or A B C B' A'. By revealing the conceptual center of the passage in question, these examples demonstrate that recognition and analysis of chiasmus is indispensable for a proper understanding of the theological message the biblical writer intended to communicate.
Intracranial hypotension can be a common sequela of a cerebrospinal fluid (CSF) leak. However, evidence of such a condition related to an injury in American football is currently lacking in the literature. While a positional or orthostatic headache is the most classic symptom of headaches due to intracranial hypotension, a variety of nonspecific symptoms such as neck pain, nausea, vomiting, photophobia, phonophobia, and visual changes can also be present. We present two cases where collegiate American football players developed protracted headaches after a concussive injury and were subsequently diagnosed with intracranial hypotension thought secondary to spinal CSF leaks. Both players underwent multiple procedures of fluoroscopic-guided autologous blood patching, with improvement in their headaches. Recovery varied between the athletes. Case 1 achieved full resolution of his headaches and returned to full activity. Case 2 continued to have intermittent headaches after blood patching, but the positional nature had resolved and he was cleared for full participation in football and was closely followed during the remainder of his collegiate career. Both these cases emphasize the importance of including CSF leak as a cause of post-traumatic headache in an American football player.
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