BOLD signal variability as potential new biomarker of functional neurological disorders.

BACKGROUND: Functional neurological disorder (FND) is a common neuropsychiatric condition with established diagnostic criteria and effective treatments but for which the underlying neuropathophysiological mechanisms remain incompletely understood. Recent neuroimaging studies have revealed FND as a multi-network brain disorder, unveiling alterations across limbic, self-agency, attentional/salience, and sensorimotor networks. However, the relationship between identified brain alterations and disease progression or improvement is less explored. METHODS: This study included resting-state functional magnetic resonance imaging (fMRI) data from 79 patients with FND and 74 age and sex-matched healthy controls (HC). First, voxel-wise BOLD signal variability was computed for each participant and the group-wise difference was calculated. Second, we investigated the potential of BOLD signal variability to serve as a prognostic biomarker for clinical outcome in 47 patients who attended a follow-up measurement after eight months. RESULTS: The results demonstrated higher BOLD signal variability in key networks, including the somatomotor, salience, limbic, and dorsal attention networks, in patients compared to controls. Longitudinal analysis revealed an increase in BOLD signal variability in the supplementary motor area (SMA) in FND patients who had an improved clinical outcome, suggesting SMA variability as a potential state biomarker. Additionally, higher BOLD signal variability in the left insula at baseline predicted a worse clinical outcome. CONCLUSION: This study contributes to the understanding of FND pathophysiology, emphasizing the dynamic nature of neural activity and highlighting the potential of BOLD signal variability as a valuable research tool. The insula and SMA emerge as promising regions for further investigation as prognostic and state markers.

Transient resting-state salience-limbic co-activation patterns in functional neurological disorders.

BACKGROUND: Functional neurological disorders were historically regarded as the manifestation of a dynamic brain lesion which might be linked to trauma or stress, although this association has not yet been directly tested yet. Analysing large-scale brain network dynamics at rest in relation to stress biomarkers assessed by salivary cortisol and amylase could provide new insights into the pathophysiology of functional neurological symptoms. METHODS: Case-control resting-state functional magnetic resonance imaging study of 79 patients with mixed functional neurological disorders (i.e., functional movement disorders, functional seizures, persistent perceptual-postural dizziness) and 74 age- and sex-matched healthy controls. Using a two-step hierarchical data-driven neuroimaging approach, static functional connectivity was first computed between 17 resting-state networks. Second, dynamic alterations in these networks were examined using co-activation pattern analysis. Using a partial least squares correlation analysis, the multivariate pattern of correlation between altered temporal characteristics and stress biomarkers as well as clinical scores were evaluated. RESULTS: Compared to healthy controls, patients presented with functional aberrancies of the salience-limbic network connectivity. Thus, the insula and amygdala were selected as seed-regions for the subsequent analyses. Insular co-(de)activation patterns related to the salience network, the somatomotor network and the default mode network were detected, which patients entered more frequently than controls. Moreover, an insular co-(de)activation pattern with subcortical regions together with a wide-spread co-(de)activation with diverse cortical networks was detected, which patients entered less frequently than controls. In patients, dynamic alterations conjointly correlated with amylase measures and duration of symptoms. CONCLUSION: The relationship between alterations in insular co-activation patterns, stress biomarkers and clinical data proposes inter-related mechanisms involved in stress regulation and functional (network) integration. In summary, altered functional brain network dynamics were identified in patients with functional neurological disorder supporting previously raised concepts of impaired attentional and interoceptive processing.

Cortisol in functional neurological disorders: State, trait and prognostic biomarkers.

OBJECTIVE: Biological stress dysregulation, such as a flattened cortisol awakening response (CAR), has been identified in functional neurological disorder (FND). This longitudinal study aimed to explore whether CAR alterations in FND serve as state or trait biomarkers, assessing temporal changes in cortisol and clinical outcomes to test its prognostic value. METHODS: Salivary cortisol was measured in 53 patients with mixed FND at two visits separated by eight months (M0 and M8). CAR was calculated based on five consecutive samples, each taken with 15-min time intervals, collected upon awakening, whereas cortisol amplitude (CAmp) was calculated as the difference between the morning peak and the afternoon trough. Clinical outcome was assessed with the Functional Movement Disorder Rating Scale (S-FMDRS), Clinical global impression (CGI) scores for severity (CGI-S) and improvement (CGI-I) and the short-form health survey (SF-36). RESULTS: No differences in CAR levels were found between M0 and M8 regardless of clinical outcome (remained flattened). However, a good clinical outcome was associated with an earlier peak in the CAR (p = .013, odds ratio: 1.78; 95%-confidence interval: 0.095-1.13). A higher CAmp at M0 predicted a better outcome at M8 (ß = 1.14, 95%-confidence interval:0.15-2.13, p = .03). CONCLUSION: A flattened CAR might represent a trait marker for FND, when an earlier peak in the CAR may serve as a state biomarker. The CAmp demonstrates predictive power for clinical outcome, potentially representing a prognostic biomarker for FND. Further replication and follow-up studies are essential to confirm this suggested role of cortisol as a multifaceted biomarker of FND.

Non-invasive neuromodulation of the right temporoparietal junction using theta-burst stimulation in functional neurological disorder.

Background: Disrupted sense of agency (SoA)-the sense of being the agent of one's own actions-has been demonstrated in patients with functional neurological disorder (FND), and a key area of the corresponding neuronal network is the right temporoparietal junction (rTPJ). Several functional MRI (fMRI) studies have found hypoactivation as well as hyperactivation of the rTPJ in FND. In a proof-of-concept study, we tested whether repetitive transcranial magnetic stimulation (rTMS) over the rTPJ could restore this aberrant activity. Methods: In a randomised, crossover, single-blinded, sham-controlled study design, theta-burst stimulation (tb-rTMS) was applied over the rTPJ in 23 patients with FND and 19 healthy controls (HC), with each participant undergoing three stimulatory visits (inhibitory continuous TBS (cTBS), excitatory intermittent TBS (iTBS) and sham). During fMRI, participants played a visuomotor task artificially reducing their SoA (manipulated agency, MA), repeated after each neurostimulation. We compared brain activity and behavioural SoA as primary outcomes before and after tb-rTMS and investigated the feasibility of tb-rTMS over the rTPJ in FND as secondary outcome. Results: At baseline, patients showed decreased accuracy in detecting reduced agency compared with controls (p<0.001), paralleled by lower brain activation in the rTPJ during MA (p=0.037, volume of interest). A region of interest analysis on the rTPJ showed no effect of the sham condition in FND or HC (p=0.917; p=0.375) but revealed a significant effect of stimulation protocol (cTBS/iTBS, p=0.037) in patients with FND, with the excitatory protocol increasing the blood-oxygen-level-dependent (BOLD) signal, whereas this effect was not found in HC. In neither group, a behavioural effect of tb-rTMS was observed. Conclusion: Aberrant processing of agency in FND was confirmed at baseline, reflected in behavioural outcome and reduced activity in the rTPJ. Tb-rTMS over this key region elicited neuronal changes in patients, paving ways for future studies exploring TMS as neurobiologically informed intervention to restore SoA in FND. We critically discuss methodological intricacies and outline further steps in this research line.

Healthcare employment as a risk factor for functional neurological disorder: A case-control study.

BACKGROUND AND PURPOSE: Female gender, younger age and stressful life events are known predisposing factors for functional neurological disorders (FNDs). Employment in a healthcare profession has also been suggested to be a predisposing factor. We set out to conduct a large-scale case-control study to estimate the rate employment in a healthcare profession among people with FND. METHODS: We included 200 consecutive patients with a confirmed diagnosis of FND, referred to our clinic at University Hospital Bern Switzerland between October 1, 2016, and August 1, 2019. In addition, we included a control group of 200 patients with a confirmed neurological disorder, matched for age and gender, seen during the same period. The primary endpoint was to compare the prevalence of healthcare professionals between the groups. We also describe the clinical manifestations and concomitant psychiatric diagnoses in the FND cohort. RESULTS: Female gender was predominant (70%), and the participants' mean age was 37 years. The proportion of healthcare professionals in the FND patients was 18% (33/186), which was significantly higher than in the control group, in which it was 10.6% (17/189; p = 0.019, 95% confidence interval odds ratio 1.168-4.074). Most healthcare professionals in both cohorts were nurses (21/33 among FND patients, 10/17 among controls). Among FND patients, 140 (70%) had motor symptoms and 65 (32.5%) had a concomitant psychiatric diagnosis. CONCLUSION: This case-control study confirmed a higher rate of employment in healthcare professions in patients with FND, suggesting two potential mechanisms of FND: exposure to models/specific knowledge about neurological symptoms or stress-related professional factors. This warrants further studies on underlying mechanisms and prevention.

An Examination of Depression, Anxiety, and Self-Esteem in Collegiate Student-Athletes.

Mental health research exists for student-athletes in the areas of depression, anxiety, and self-esteem prevalence. However, updated prevalence rates and assessment of risks across sports, academic status, and genders are needed. Filling the gaps in research assists in the creation of patient-centered mental health screening and interventions designed for student-athletes. Therefore, the purpose is to examine the prevalence of depression, anxiety, and self-esteem in collegiate student-athletes and differences between sex, academic status, and sport type, and identify associations for risks. Using a cross-sectional design, collegiate student-athletes were surveyed to assess for risks of depression, anxiety, and self-esteem. With the use of SPSS, Chi-square analyses and multinomial logistic regressions were used. Student-athletes (22.3%) were at risk for depression, anxiety (12.5%), and low self-esteem (8%). No significant differences were found for sex, academic status, and sport type for depression or self-esteem; however, significant differences occurred for state and trait anxiety by sex. A significant association for depression and anxiety risk was found with females at risk. Depression and anxiety are present within student-athletes, regardless of sport type. Females are at a higher risk; however, all student-athletes would benefit from the creation of validated, patient-centered mental health screenings and psychotherapeutic interventions.

Multivariate classification provides a neural signature of Tourette disorder.

BACKGROUND: Tourette disorder (TD), hallmarks of which are motor and vocal tics, has been related to functional abnormalities in large-scale brain networks. Using a fully data driven approach in a prospective, case-control study, we tested the hypothesis that functional connectivity of these networks carries a neural signature of TD. Our aim was to investigate (i) the brain networks that distinguish adult patients with TD from controls, and (ii) the effects of antipsychotic medication on these networks. METHODS: Using a multivariate analysis based on support vector machine (SVM), we developed a predictive model of resting state functional connectivity in 48 patients and 51 controls, and identified brain networks that were most affected by disease and pharmacological treatments. We also performed standard univariate analyses to identify differences in specific connections across groups. RESULTS: SVM was able to identify TD with 67% accuracy (p = 0.004), based on the connectivity in widespread networks involving the striatum, fronto-parietal cortical areas and the cerebellum. Medicated and unmedicated patients were discriminated with 69% accuracy (p = 0.019), based on the connectivity among striatum, insular and cerebellar networks. Univariate approaches revealed differences in functional connectivity within the striatum in patients v. controls, and between the caudate and insular cortex in medicated v. unmedicated TD. CONCLUSIONS: SVM was able to identify a neuronal network that distinguishes patients with TD from control, as well as medicated and unmedicated patients with TD, holding a promise to identify imaging-based biomarkers of TD for clinical use and evaluation of the effects of treatment.

Identification of biopsychological trait markers in functional neurological disorders.

Stress is a well-known risk factor to develop a functional neurological disorder, a frequent neuropsychiatric medical condition in which patients experience a variety of disabling neurological symptoms. Only little is known about biological stress regulation, and how it interacts with predisposing biological and psychosocial risk factors. Dysregulation of the hypothalamic-pituitary-adrenal axis in patients with functional neurological disorders has been postulated, but its relationship to preceding psychological trauma and brain anatomical changes remains to be elucidated. We set out to study the hypothalamic-pituitary-adrenal axis analysing the cortisol awakening response and diurnal baseline cortisol in 86 patients with mixed functional neurological symptoms compared to 76 healthy controls. We then examined the association between cortisol regulation and the severity and duration of traumatic life events. Finally, we analysed volumetric brain alterations in brain regions particularly sensitive to psychosocial stress, acting on the assumption of the neurotoxic effect of prolonged cortisol exposure. Overall, patients had a significantly flatter cortisol awakening response (P < 0.001) and reported longer (P = 0.01) and more severe (P < 0.001) emotional neglect as compared to healthy controls. Moreover, volumes of the bilateral amygdala and hippocampus were found to be reduced in patients. Using a partial least squares correlation, we found that in patients, emotional neglect plays a role in the multivariate pattern between trauma history and hypothalamic-pituitary-adrenal axis dysfunction, while cortisol did not relate to reduced brain volumes. This suggests that psychological stress acts as a precipitating psychosocial risk factor, whereas a reduced brain volume rather represents a biological predisposing trait marker for the disorder. Contrarily, an inverse relationship between brain volume and cortisol was found in healthy controls, representing a potential neurotoxic effect of cortisol. These findings support the theory of reduced subcortical volumes representing a predisposing trait factor in functional neurological disorders, rather than a state effect of the illness. In summary, this study supports a stress-diathesis model for functional neurological disorders and showed an association between different attributes of trauma history and abnormalities in hypothalamus-pituitary-adrenal axis function. Moreover, we suggest that reduced hippocampal and amygdalar volumes represent a biological 'trait marker' for functional neurological disorder patients, which might contribute to a reduced resilience to stress.

Are flexibility and muscle-strengthening activities associated with functional limitation?

This retrospective cohort study examined the relationship between self-reported participation in flexibility and muscular strengthening activities and the development of functional limitation (i.e., once an individual has difficulty with or becomes unable to perform activities of daily living). Data were obtained from 1318 adults (mean age 49.5 â€‹± â€‹9.7 years; 98.7% Caucasian; 14.9% female) enrolled in the Aerobics Center Longitudinal Study from 1979 to 2004 and free of functional limitation at baseline. Mail-back health surveys were used to prospectively determine incident functional limitation. Participation in muscle-strengthening and flexibility activities was assessed via self-report. Adjusted logistic regression analyses were used to determine the odds ratios (OR) and corresponding 95% confidence intervals for developing functional limitation during follow-up based on participation in general and specific categories of flexibility ('Stretching', 'Calisthenics', or 'Exercise Class') and muscle-strengthening activities ('Calisthenics', 'Free Weights', 'Weight Training Machines', or 'Other'). Overall, 42.6% of the sample reported incident functional limitation. After adjusting for potential confounders (e.g., age, sex, cardiometabolic risk factors), those who reported performing muscle-strengthening activities in general (n â€‹= â€‹685) were at lower risk of developing functional limitation [OR â€‹= â€‹0.79 (0.63-1.00)]. In addition, the specific flexibility activities of stretching (n â€‹= â€‹491) and calisthenics (n â€‹= â€‹122) were associated with 24% and 38% decreased odds of incident functional limitation, respectively. General muscle-strengthening, stretching, and calisthenics activities are prospectively associated with decreased risk of incident functional limitation in generally healthy, middle-aged and older adults. Thus, both public health and rehabilitation programs should highlight the importance of flexibility and muscle-strengthening activities during adulthood to help preserve functional capacity.

Multi-centre classification of functional neurological disorders based on resting-state functional connectivity.

BACKGROUND: Patients suffering from functional neurological disorder (FND) experience disabling neurological symptoms not caused by an underlying classical neurological disease (such as stroke or multiple sclerosis). The diagnosis is made based on reliable positive clinical signs, but clinicians often require additional time- and cost consuming medical tests and examinations. Resting-state functional connectivity (RS FC) showed its potential as an imaging-based adjunctive biomarker to help distinguish patients from healthy controls and could represent a "rule-in" procedure to assist in the diagnostic process. However, the use of RS FC depends on its applicability in a multi-centre setting, which is particularly susceptible to inter-scanner variability. The aim of this study was to test the robustness of a classification approach based on RS FC in a multi-centre setting. METHODS: This study aimed to distinguish 86 FND patients from 86 healthy controls acquired in four different centres using a multivariate machine learning approach based on whole-brain resting-state functional connectivity. First, previously published results were replicated in each centre individually (intra-centre cross-validation) and its robustness across inter-scanner variability was assessed by pooling all the data (pooled cross-validation). Second, we evaluated the generalizability of the method by using data from each centre once as a test set, and the data from the remaining centres as a training set (inter-centre cross-validation). RESULTS: FND patients were successfully distinguished from healthy controls in the replication step (accuracy of 74%) as well as in each individual additional centre (accuracies of 73%, 71% and 70%). The pooled cross validation confirmed that the classifier was robust with an accuracy of 72%. The results survived post-hoc adjustment for anxiety, depression, psychotropic medication intake, and symptom severity. The most discriminant features involved the angular- and supramarginal gyri, sensorimotor cortex, cingular- and insular cortex, and hippocampal regions. The inter-centre validation step did not exceed chance level (accuracy below 50%). CONCLUSIONS: The results demonstrate the applicability of RS FC to correctly distinguish FND patients from healthy controls in different centres and its robustness against inter-scanner variability. In order to generalize its use across different centres and aim for clinical application, future studies should work towards optimization of acquisition parameters and include neurological and psychiatric control groups presenting with similar symptoms.

Creation of a Longitudinal Legal Data Set to Support Legal Epidemiology Studies of Mental Health Insurance Legislation.

OBJECTIVE: This article describes policy surveillance methodology used to track changes in the comprehensiveness of state mental health insurance laws over 23 years, resulting in a data set that supports legal epidemiology studies measuring effects of these laws on mental health outcomes. METHODS: Structured policy surveillance methods, including a coding protocol, blind coding of laws in 10% of states, and consensus meetings, were used to track changes in state laws from 1997 through 2019-2020. The legal database Westlaw was used to identify relevant statutes. The legal coding instrument included six questions across four themes: parity, mandated coverage, definitions of mental health conditions, and enforcement-compliance. Points (range 0-7) were assigned to reflect the laws' comprehensiveness and aid interpretation of changes over time. RESULTS: The search resulted in 147 coding time periods across 51 jurisdictions (50 states, District of Columbia). Intercoder consensus rates increased from 89% to 100% in the final round of blinded duplicate coding. Since 1997, average comprehensiveness scores increased from 1.31 to 3.82. In 1997, 41% of jurisdictions had a parity law, 28% mandated coverage, 31% defined mental health conditions, and 8% required state agency enforcement. In 2019-2020, 94% of jurisdictions had a parity law, 63% mandated coverage, 75% defined mental health conditions, and 29% required state enforcement efforts. CONCLUSIONS: Comprehensiveness of state mental health insurance laws increased from 1997 through 2019-2020. The State Mental Health Insurance Laws Dataset will enable evaluation research on effects of comprehensive legislation and cumulative impact.

Public Health Strategies: A Pathway for Public Health Practice to Leverage Law in Advancing Equity.

This article outlines a pathway for public health departments and practitioners to incorporate law into their efforts to advance equity in health outcomes. We assert that examining and applying law can accelerate public health efforts to mitigate structural and systemic inequities, including racism. Recent events such as the COVID-19 pandemic and the community impacts of policing have brought into sharp relief the inequities faced by many populations. These stark and explosive examples arise out of long-standing, persistent, and sometimes hidden structural and systemic inequities that are difficult to trace because they are embedded in laws and accompanying policies and practices. We emphasize this point with a case study involving a small, majority Black community in semirural Appalachia that spent almost 50 years attempting to gain access to the local public water system, despite being surrounded by water lines. We suggest that public health practitioners have a role to play in addressing these kinds of public health problems, which are so clearly tied to the ways laws and policies are developed and executed. We further suggest that public health practitioners, invoking the 10 Essential Public Health Services, can employ law as a tool to increase their capacity to craft and implement evidence-based interventions.

Behavioral Differences Across Theta Burst Stimulation Protocols. A Study on the Sense of Agency in Healthy Humans.

BACKGROUND: Theta burst stimulation (TBS) is a non-invasive brain stimulation method. Various stimulation protocols have been proposed, for instance, stimulation at 50 Hz with pattern at 5 Hz, or at 30 Hz with pattern at 6 Hz. To identify better stimulation parameters for behavioral applications, we investigated the effects of 50-Hz continuous TBS (cTBS) on the sense of agency (SoA), and compared them with a previously published study with 30-Hz cTBS. METHODS: Based on power analysis from a previous sample using two applications of 30-Hz cTBS, we recruited 20 healthy subjects in a single-blind, Vertex-controlled, randomized, crossover trial. Participants were stimulated with one application of 50-Hz cTBS over the right posterior parietal cortex (rPPC), a key area for agency processing, and the vertex, in a random order. A behavioral task targeting the SoA was done before and after stimulation. After controlling for baseline differences across samples, we studied the effect of stimulation in the two protocols separately. RESULTS: Compared to the previously published 30-Hz protocol, 50-Hz cTBS over the rPPC did not reveal significant changes in the SoA, similar to sham Vertex stimulation. CONCLUSION: One application of 50-Hz cTBS was not sufficient to elicit behavioral effects, compared to two applications of 30-Hz cTBS, as previously described. This may be due to a mechanism of synaptic plasticity, consolidated through consecutive stimulation cycles. Our results are relevant for future studies aiming at modulating activity of the rPPC in cognitive domains other than agency, and in patients affected by abnormal agency, who could benefit from treatment options based on TBS.

Core Body Temperatures in Collegiate Marching Band Artists During Rehearsals and Performances.

CONTEXT: To our knowledge, no researchers have investigated thermoregulatory responses and exertional heat illness (EHI) risk factors in marching band (MB) artists performing physical activity in high environmental temperatures. OBJECTIVE: To examine core temperature (Tc) and EHI risk factors in MB artists. DESIGN: Descriptive epidemiology study. SETTING: Three rehearsals and 2 football games for 2 National Collegiate Athletic Association Division I institution's MBs. PATIENTS OR OTHER PARTICIPANTS: Nineteen volunteers (females = 13, males = 6; age = 20.5 ± 0.9 years, height = 165.1 ± 7.1 cm, mass = 75.0 ± 19.1 kg) completed the study. MAIN OUTCOME MEASURE(S): We measured Tc, wet bulb globe temperature, and relative humidity preactivity, during activity, and postactivity. Other variables were activity time and intensity, body surface area, hydration characteristics (fluid volume, sweat rate, urine specific gravity, percentage of body mass loss), and medical history (eg, previous EHI, medications). The statistical analysis consisted of descriptive information (mean ± standard deviation), comparative analyses that determined differences within days, and correlations that identified variables significantly associated with Tc. RESULTS: The mean time for rehearsals was 102.8 ± 19.8 minutes and for games was 260.5 ± 47.7 minutes. Mean maximum Tc was 39.1 ± 1.1°C for games and 38.4 ± 0.7°C for rehearsals; the highest Tc (41.2°C) occurred during a game. Fluid consumption did not match sweat rates (P < .001). Participants reported to games in a hypohydrated state 63.6% of the time. The maximum Tc correlated with the maximum wet bulb globe temperature (r = 0.618, P < .001) and was higher in individuals using mental health medications (rpb = -0.254, P = .022) and females (rpb = 0.330, P = .002). Body surface area (r = -0.449, P < .001) and instrument mass (r = -0.479, P < .001) were negatively correlated with Tc. CONCLUSIONS: Marching band artists experienced high Tc during activity and should have access to athletic trainers who can implement EHI-prevention and -management strategies.

EXAMINING SOCIODEMOGRAPHIC DATA REPORTING REQUIREMENTS IN STATE DISEASE SURVEILLANCE SYSTEMS.

Law plays an important role in the collection of data related to disease and injury in a population. A robust system of laws sets out requirements for the collection, analysis, and dissemination of disease reporting data from local, state, territorial, and federal public health institutions. Occurrence of disease, including outbreaks of novel infectious agents like coronaviruses, influenza viruses, and others that have arisen in recent years, often require epidemiologists and others to understand not only the etiology and specific context of diseases and conditions, but also the trajectory of their spread among and across communities. Capturing sociodemographic data is critical to identifying the disproportionate impacts of diseases and conditions on diverse populations and determining an appropriate public health response. This Article discusses a legal epidemiological scan of state disease reporting laws that require the capture and reporting of sociodemographic information. Analyzing these state laws can serve as a potential starting point to assist in understanding why gaps in data exist and can help address these challenges in anticipation of future disease outbreaks or spread.

Collegiate Marching Band Artists Experience High Core Body Temperatures during Rehearsals and Performances.

CONTEXT: No research has investigated thermoregulatory responses and exertional heat illness (EHI) risk factors in marching band (MB) artists performing physical activity in high environmental temperatures. OBJECTIVE: Examine core temperature (Tc) and EHI risk factors in MB artists. DESIGN: Descriptive epidemiology study. SETTING: Three rehearsals and 2 football games for 2 NCAA Division I MBs. PARTICIPANTS: Nineteen volunteers completed the study (female = 13, males = 6; age = 20.5 ± 0.9 years; weight = 75.0 ± 19.1 kg; height = 165.1 ± 7.1 cm). MAIN OUTCOME MEASURES: We measured Tc pre-, post-, and every 15 minutes during activity and recorded wet-bulb globe temperature (WBGT) and relative humidity (RH) every 15 minutes. Other variables included activity time and intensity, ground surface, hydration characteristics (fluid volume, sweat rate, urine specific gravity, percent body mass loss [%BM]), and medical history (eg, previous EHI, medications). Statistical analysis included descriptives (mean ± standard deviation), comparative analyses determined differences within and between days, and linear regression identified variables that significantly explained Tc. RESULTS: Mean rehearsal time = 102.8 ± 19.8 minutes and game time = 260.5 ± 47.7 minutes. Max game Tc (39.1 ± 1.1°C) was significantly higher than rehearsal (38.4 ± 0.7°C, P = .003). The highest max game Tc = 41.2°C. Participants consumed significantly more fluid than their sweat rates (P < .003), which minimized %BM loss, particularly during rehearsals (-0.4 ± 0.6%). Mean game %BM loss = -0.9 ± 2.0%; however, 63.6% of the time, participants reported hypohydrated to game day. Max Tc was significantly predicted by max WBGT, max RH, ground surface, using mental health medications, and hours of sleep (adjusted R2 = 0.542, P < .001). CONCLUSIONS: Marching band artists experience high Tc during activity and should have access to athletic trainers who can implement EHI prevention and management strategies.

Civil Rights Law and the Determinants of Health: How Some States Have Utilized Civil Rights Laws to Increase Protections Against Discrimination.

One fundamental barrier to eliminating health disparities, particularly with regard to the determinants of health, is the persistence of discrimination. Civil rights law is the primary legal mechanism used to address discrimination. Federal civil rights laws have been the subject of wider analyses as a determinant of health as well as a tool to address health disparities. The research on state civil rights laws, while more limited, is growing. This article will highlight a few examples of how some states are using civil rights laws to combat discrimination, particularly in more expansive ways and in the interest of new populations, presenting tools that can target determinants and address the goal of reducing health disparities.