bluuebunny/crossref_metadata_2025 huggingface dataset:
One voice: the 1st international symposium on paediatricpediatric concussion
Authors: Provvidenza Christine , Greenspoon Dayna , McFarland Stephanie , Hickling Andrea , Fait Phil , Reed Nick
Published: November 2017

Objective

One Voice: the 1st International Symposium on Paediatric Concussionis a knowledge sharing event dedicated to translating research generated by the paediatric concussion community. The objective of this study was to evaluate the effectiveness of pre-symposium webinars and collaborative workshops as part of the symposium.

Design

Quantitative, cross sectional, one-group survey design

Setting

Paediatric rehabilitation hospital.

Participants

Sixty international paediatric concussion leaders representing various stakeholder groups.

Intervention

Knowledge sharing webinars and action plan development through facilitated workshops

Outcome measures

Surveys were designed to assess: the effectiveness of the webinars as a knowledge sharing strategy; and the experiences of the stakeholders participating in action planning workshops.

Results

Participants found the webinars to be effective in highlighting international research (93%) and education initiatives (91%). There was agreement that the symposium provided participants with the opportunity to engage (97%) and network (96%) with others, as well as co-create an action plan (95%) with three strategic directions: 1) connecting kids to care; 2) moving facts forward; and 3) driving big change.

Conclusions

One Voice was developed to support the paediatric concussion community to best help children with concussion do the things they want, need and love to do. One Voice enabled the development of a collaborative international action plan in paediatric concussion. Findings will inform the development and delivery of future symposia and action planning events specific to paediatric concussion to meet the needs of this population. Moving the strategic directions forward will help guide the future of paediatric concussion care globally.

Competing interests

None.
Perception and practice of prescribed rest following concussion in primary and secondary schools
Authors: Taylor Alex M , Blackwell Laura S , Robinson Anna F , Proctor Mark R
Published: November 2017

Objective

The purpose of our study was to characterise return-to-learn practices following concussion in primary and secondary schools, particularly with regard to prescribed cognitive rest.

Design

Cross-sectional survey.

Setting

Massachusetts.

Participants

Nine hundred member of the Massachusetts School Nurse Research Network (MASNRN) employed full or part-time at a public, private, or charter school serving pre-school through the 12th grade.

Outcome measures

Prescribed rest (actual) versus perceived benefit of rest.

Main results

A majority of respondents expressed the opinion that more prolonged cognitive rest benefits recovery, with 53.6% endorsing 4–10 days as beneficial compared to 44.3% endorsing 3 days or less. Only 2.1% felt no benefit to cognitive rest following concussion. The average number of medically advised rest (actual) was equal for older and younger students (4.5 days). School nurses perceived less benefit to prolonged cognitive rest (>4 days) for high school students relative to students in elementary school [2 (4, n=97)=11.05, p<0.05], but provided academic accommodations to high school students for comparatively longer periods of time (10–14 days vs. 6–10 days) [F(2,89)=4.74, p=0.011].

Conclusions

Counter to the practice of administering accommodations for fewer days in younger students, school nurses perceived greater benefit to shorter periods of cognitive rest (3 days or less) for older children (high school age) relative to elementary school and middle school children. In all settings, schools rest is overprescribed in light of recent finding indicating that prolonged rest (beyond two to three days) may delay recovery.

Competing interests

None.
Tracking developmental trajectories on neurocognitive testing in young athletes ages 5–12
Authors: Schatz Philip , Ferris Charles
Published: November 2017

Objective

Despite increased attention to sports-related concussion, there is a lack of research on younger athletes. The purpose of this study was to establish developmental trajectories on neurocognitive testing in younger athletes ages 5 to 12.

Design

Pre-Test Only Design.

Setting

Multi-site study from numerous locations in the Eastern USA and Canada.

Participants

A total of 788 youth athletes, 73% male, assigned to groups on the basis of age: Ages 5–6 (N=128), Ages 7–8 (N=282), Ages 9–10 (N=284), Ages 11–12 (N=94).

Intervention

An iPad-based Paediatric version of the ImPACT test was administered individually to participants in a quiet office setting.

Outcome measures

Accuracy scores were documented on: Word List Learning (Immediate, Delayed, Recognition); and accuracy and timing scores on Design Rotation, Choice Reaction Time, Visual Sequencing and Visual Memory.

Main results

One-way ANOVAs with Bonferroni correction for multiple comparisons, and Scheffé post-hoc comparisons were conducted between age groups on the dependent measures. All measures showed statistically significant changes (p< 0.001) across the developmental age groups, with better performance in older participants and lower performance in younger participants.

Conclusions

Youth athletes between the ages of 5 and 12 are underrepresented with respect to age-appropriate assessment measures, and these results document the need for developmentally- and age-appropriate measures and normative data, in order to capture neurocognitive change across developmental stages.

Competing interests

Dr. Schatz serves on the ImPACT Scientific Advisory Board.

None.
Vestibular and vision deficits following concussion in children under 12
Authors: Master Christina L , Curry Allison E , Kessler Ronni , Pfeiffer Melissa R , Grady Matthew F , Robinson Roni , Arbogast Kristy B
Published: November 2017

Objective

Vestibular and oculomotor visual (VOM) deficits are emerging as key characteristics of youth concussion. However, since most studies of paediatric concussion focus on adolescents, little is known about the extent to which younger children experience this deficit. To address this gap, we used an electronic health record (EHR) system across a large paediatric healthcare network to quantify the presence of VOM deficits following concussion in patients under age 12.

Design

Descriptive epidemiology.

Setting

Data were collected from all primary (n=31) and relevant specialty care (n=4) network settings.

Participants

We identified all patients aged 5–11 years who had ≥1 clinical visit for concussion at a network primary or specialty care site from 7/1/2014 through 6/30/2015. We included the 82% of these patients for whom a concussion electronic clinical decision support tool within the EHR was used during their initial visit.

Outcome measures

The proportion who demonstrated each VOM deficit – balance, saccades, gaze stability, and convergence – was calculated among all who were assessed for that deficit.

Main results

871 patients were included (median [IQR]: 10 [8, 11] years). On physical examination, 58% had at least one VOM deficit. 44% had balance abnormalities, 39% had saccadic dysfunction, 28% had deficits in gaze stability, and 10% convergence insufficiency.

Conclusions

In this sample, vestibular oculomotor visual deficits following concussion in young children were common. Improved recognition of the deficits will lead to timely diagnosis and appropriate management, including school accommodations for oculomotor visual challenges and vestibular therapy for motion sensitivity issues.

Competing interests

None.

KB, Arbogast serves as a consultant to the National Football League Players Association on head injury topics.
Epidemiology of head and neck injuries in elite football – a prospective survey of fifa tournaments between 1998 and 2015
Authors: Prien Annika , Dvorak Jiri , Junge Astrid
Published: November 2017

Objective

Recently the potential long-term effect of sports-related head injuries has been discussed. To develop effective injury prevention strategies, epidemiological information is required. The aim of this study was to analyse the incidence and characteristics of head and neck match injuries.

Design

Prospective cohort study.

Setting

FIFA tournaments and Olympic Games.

Participants

All football teams participating in FIFA tournaments and Olympic Games between 1998 and 2015 were included in the study. The team physicians reported injuries from 2106 matches from 65 outdoor tournaments (20 women’s and 45 men’s). The average response rate was 96%.

Outcome measures

Incidence rates per match and a variety of injury characteristics (type, severity, cause, gender) of head/neck injuries compared to other football injuries were analysed.

Main results

4756 injuries (2.4 injuries/match) were reported. Most injuries affected the lower extremity (70%), followed by the head/neck (15%), trunk (8%) and upper extremity (7%). Head injuries (n=674; 14.4%) were more frequent than neck injuries (n= 34;0.7%), and the incidence was higher in female (18%) than in male (14%) players. Most head/neck injuries were contusions (n=362; 50.3%) and non-time-loss injuries (n= 164;22.8%). Of the 108 (15%) reported concussions, 62% resulted in time-loss. Only one head injury (fracture) had an estimated time-loss of more than four weeks.

Conclusion

While neck injuries are rare, head injuries are more frequent, and particularly concussions often result in time-loss. No career-ending injuries of the head or neck were reported. Potential long-term effects of head/neck injuries warrant further evaluation in clinical studies.

Competing interests

None.
Incidence of head impacts at elite-level male and female cricket in australia
Authors: Kountouris Alex , Orchard John
Published: November 2017

Objective

To document the incidence of head impacts at the elite level in the sport of cricket, where there currently is very little epidemiological data regarding concussion.

Design

Prospective registry of head impacts reported by medical and physiotherapy staff and/or discovered by Chief Medical Officer from clinical record-keeping systems and media reports

Setting

Elite-level male and female cricket in Australia for one season (2015–16)

Main results

There were 64 head impacts on the registry for season 2015–16, with 20 of these occurring in List A/First Class men’s matches and 6 occurring in List A women’s matches. The match incidence rates were 3.9 head impacts/1000 player days in elite male cricket and 3.1 head impacts/1000 player days in elite female cricket. The vast majority were caused by ball-helmet(head) impact, with a majority in batters (strikers). The next most common players affected were wicketkeepers and close-in fielders. An incidence rate for concussion is not presented as there were a number of ambiguous head impact cases (clinically not diagnosed as concussion on the field but with symptoms or abnormal Cogsport tests after the match)

Conclusions

The rate of head impact in cricket is perhaps higher than previously appreciated (as it has been traditionally considered a low-risk sport for concussion), although lower than the football codes. Definition of concussion in this sport is quite subjective and problematic, perhaps as it is the only team sport in which injury substitution is not permitted, which may influence the reporting of symptoms by players during the match.

Competing interests

Chief Medical Officer, Cricket Australia.
Comparison of inertial sensors and bess in balance testing of professional football players with respect to concussion
Authors: Bockisch Christopher , Mani Karin , Weber Konrad , Tarnutzer Alexander , Straumann Dominik , Nina Feddermann
Published: November 2017

Objective

Balance problems are a frequent symptom after head trauma including concussion, and the Balance Error Scoring System (BESS) is routinely used as a subjective screening test. Low-cost inertial sensors are an attractive objective alternative to elaborative force plates in objective testing balance in athletes.

Design

Case series.

Setting

Training area of professional players.

Participants

310 professional male and female football players from highest league in Switzerland (19/20 (95%) teams).

Intervention

Subjects were scored on their ability to maintain posture while standing in the six BESS conditions. Errors were counted by a test administrator, while an IPOD worn in a waist belt recorded linear acceleration and rotational velocity.

Outcome measures

A variety of measures of stability (e.g., area of 2D surface plot, normalised path length (NPL)) were computed. In order to determine which measure was most sensitive to changes in balance, receiver operating characteristic (ROC) curves were created comparing firm to foam surfaces, and then the area under the ROC was calculated.

Main results

BESS and inertial measures correlated well overall (>0.7). Inertial measurements perform well in easier conditions (ROC area >0.95 for double stance), whereas BESS is insensitive to subtle changes in balance (ROC area=0.5). BESS, however, performs better on difficult conditions (ROC area >0.9 for single stance).

Conclusions

Accelerometer assisted balance tests are a useful laboratory test in assessing balance problems. Normative values for athletes should be established.

Competing interests

None.
History of multiple sport-related concussions alters variability of heart rate response to activity
Authors: Wright Alexander D , Grewal Harjas S , Smirl Jonathan D , Bryk Kelsey , Donkelaar Paul van
Published: November 2017

Objective

To examine the effect of multiple previous concussions on heart rate variability (HRV) in contact-sport athletes.

Design

Retrospective Cohort.

Setting

Laboratory.

Participants

136 male elite contact-sport (hockey and football) athletes were recruited for this study. Forty-one had no previous concussion history (Hx-), while nineteen had a history of three or more concussions (Hx+). All testing was preformed prior to the start of the competitive season

Interventions

HRV was assessed during 5-minutes of quiet stance, and while actively squatting at 0.10 Hz via a 3-lead electrocardiogram, using Kubios software. Independent variables included condition (rest vs active) and group (Hx+ vs Hx-)

Outcome measures

Time-Domain: square root of mean squared differences of successive R-R intervals (RMSSD), percentage of successive R-R intervals that differ by more than 50 milliseconds (pNN50). Frequency-Domain: total power.

Main results

Mixed ANOVA revealed repeated squat-stand manoeuvres challenged the autonomic system, increasing total power by 2477 milliseconds2(95% CI: 1153–3801, p<0.001). A significant interaction effect was observed for RMSSD (p=0.031) and pNN50 (p=0.012), characterised by a greater increase in HRV in the Hx+ group than in Hx- from rest to squatting (95%CIs for group differences, RMSSD: 13.2–26.3 ms, p=0.006; pNN50: 3.6–15.1%, p=0.002)

Conclusions

A history of multiple sport-related concussions impairs the ability of the autonomic system to respond to an everyday stressor applied to the cardiovascular system (squatting and standing). This is an important finding, as it reveals that cumulative concussions may impart long-term impairments in the ability to accurately regulate the autonomic system.

Competing interests

None.
Is concussion a risk factor for epilepsy?
Authors: Wennberg Richard , Hiploylee Carmen , Tator Charles H
Published: November 2017

Objective

It has been stated that concussion is a risk factor for the development of post-traumatic epilepsy, but few data exist to support or refute this statement. We analysed the incidence and prevalence of epilepsy in a large cohort of post-concussion patients.

Design

Retrospective cohort study.

Setting

Academic tertiary care centre.

Participants

330 consecutive post-concussion patients followed by one concussion specialist (CHT). Exclusion criteria: abnormal brain CT/MRI, GCS ≤ 12 >1 hr post-injury, hospitalisation>48 hrs. Mean number of concussions/patient 3.3 (±2.5), mean age at first clinic visit 28 years (±14.7), mean follow-up after first concussion 7.6 years (±10.8).

Assessment of risk factor

Independent variable, concussion.

Outcome measures

Epilepsy incidence (dependent variable); prevalence.

Main results

Eight patients had medical record documentation of seizures or convulsions or epilepsy. Upon detailed review by an epilepsy specialist (RW) none met criteria for a definite diagnosis of epilepsy: 4 had episodic symptoms incompatible with epileptic seizures (multifocal paraesthesiae, multimodality hallucinations, classic migraine) and normal EEG/MRI investigations; 4 had clear histories of syncopal (n=2) or concussive (n=2) convulsions. Compared to epilepsy prevalence (6.6/1000 individuals) and annual incidence (0.5/1000 individuals) in the general population, there was no difference in this post-concussion cohort (Chi-square=0.218, d.f.1, corr.cont., p=0.64).

Conclusions

In this large cohort of post-concussion patients we found no evidence of an increased incidence of epilepsy, and the prevalence of epilepsy was lower than in the general population. Concussion is not a significant risk factor for the development of post-traumatic epilepsy, at least in the first decade post-injury.

Competing interests

None.
Depth perception differences in athletes reporting a concussion history
Authors: Mihalik Jason P , Wasserman Erin B
Published: November 2017

Objective

Vision testing is becoming more commonplace in concussion assessment. The purpose of our study was to determine vision domain deficits in athletes reporting a concussion history.

Design

Cross-sectional.

Setting

Clinical research centre.

Subjects

High school and college student-athletes (n=224; 183 males) completed a multi-modal vision and sensory performance assessment.

Intervention

Participants completed a valid and reliable visual performance evaluation (Nike SPARQ Sensory Station). Participants were categorised by self-reported concussion history: no history (n=158) vs. 1 or more concussions (n=66).

Outcome measures

The Nike SPARQ Sensory Station measures visual acuity, contrast sensitivity, depth perception, near-far quickness, target capture, perception span, eye-hand coordination, go/no-go, and reaction time. We employed Wilcoxon two-sample nonparametric analyses comparing concussion history groups for each outcome.

Results

Student-athletes with a concussion history (median=1553 ms) responded more slowly to primary gaze depth perception tasks than student-athletes with no concussion history (median=1363 ms;P=0.02). Left gaze depth perception also yielded significant differences between those with concussion history (median=1383 ms) and those without concussion history (median=1162 ms;P=0.03), but not right gaze depth perception (P=0.07). No other significant differences were observed (P>0.05).

Conclusions

Depth perception is worse in student-athletes with concussion history, suggesting the eyes’ ability to work in tandem may be compromised following concussion. It is also possible that observed visual performance differences may have previously existed and subsequently placed those athletes at a higher risk for concussion. Future prospective studies should explore the predictive value of visual performance screening in reducing concussion risk.

Competing interests

Wasserman – None.

Dr. Mihalik has an equity interest in Senaptec LLC, a licensee of the intellectual property employed in this study.
Exposure to rotational acceleration over the course of one athletic season is related to impairments in an index of dynamic cerebral autoregulation
Authors: Wright Alexander D , Smirl Jonathan D , Jakovac Michael , Fraser Sarah K , Bryk Kelsey , Grewal Harjas S , Dierijck Jill , Donkelaar Paul van
Published: November 2017

Objective

To examine the relationship between cerebral autoregulation changes and impact exposuresthroughout a season of contact sports (hockey or football).

Design

Prospective Cohort.

Setting

Laboratory.

Participants

40 male contact sport athletes (19.4±1.2 years); to date, 3 cross-country athletes (20.0±1.0 years) have completed testing (non-contact controls).

Intervention

Participants completed testing prior to the start of their athletic seasons (T1), and again after the conclusion of each season (T2). Blood pressure (BP) oscillations were driven by stand-squat manoeuvres at 0.05 and 0.10 Hz. BP and cerebral blood velocity (CBV) in the middle cerebral artery were indexed non-invasively using finger photoplethysmography and transcranial Doppler ultrasound, respectively. RM-ANOVA independent variables included time (2) and frequency (2).

Outcome measures

Point-estimates ofcoherence(correlation),phase(synchronisation), andgain(amplitude buffer) transfer function analysis metrics were calculated. Biomechanical data on head-impact exposure was estimated in a subset of contact-sport athletes (n=29) using the xPatch (X2 Biosystems), affixed to the right mastoid.

Results

Significant frequency-time interaction forgainin contact-sport athletes (p=0.048) but not controls (p=0.213). Simple effects analysis revealed a time effect at 0.10 Hz (p<0.001), wherebygainincreased at T2 (95% CI: 0.070–0.229%/%). The ΔgainT2-T1at 0.10 Hz was correlated withestimated cumulativerotational acceleration exposure (r=0.462, p=0.015).

Conclusions

These findings suggest cumulative exposure to the rotational component of sustained head-impactsduring participation in a season of contact-sport (hockey or football) impairs the ability of the cerebrovasculature to buffer BP challenges experienced during everyday activities.

Competing interests

None.
Heart rate variability reductions following a season of sub-concussive head hits are related to the magnitude of impacts experienced
Authors: Smirl Jonathan D , Wright Alexander D , Grewal Harjas S , Jakovac Michael , Bryk Kelsey , Donkelaar Paul van
Published: November 2017

Objective

To examine the effect of repetitive contact sport-related head trauma on indices ofheart rate variability (HRV).

Design

Prospective Cohort.

Setting

Laboratory.

Participants

Forty-ninemale contact-sport (hockey or football) and four non-contact control athletes (age range: 17–22).

Intervention

Prior to (T1) and upon completion of (T2) the competitive athletic season, a three-lead electrocardiogram and Kubios software (Kuopio, Finland) were used to assess heart rate variability during 5-minutes of quiet stance and while actively squatting at 0.10 Hz. Independent variables included condition (rest-vs-active) and time (T1-vs-T2).

Outcome measures

Time-Domain: square root of mean squared differences of successive R-R intervals (RMSSD), percentage of successive R-R intervals that differ by more than 50 milliseconds (pNN50); Non-Linear: approximateentropy (ApEn). In a subset of participants (n=29) biomechanical head-impact exposure data was estimated usingthe xPatch (X2 Biosystems), affixed to the right mastoid.

Main results

RM-ANOVA indicateda significant main effect of timein contact sport but not control athletes (all p>0.133). HRV metrics were decreased post-season relative to baseline (95% CI:s for differences: MeanRR4–48 ms, p=0.045; RMSSD 1–9 ms, p=0.018; pNN50 0.689–5.98, p=0.010; ApEn 0.022–0.163, p=0.044). Significant correlations were observed between the average peak linear acceleration per hit experienced and the change in MeanRR(R²=0.1382), and RMSSD (R²=0.1525).

Conclusions

Exposure to repetitive subconcussive impacts overone season of contact-sport leads to decreases in heart rate variability. The magnitude of HRV reduction is related to the average magnitude of the linear component of hits to the head experienced during play

Competing interests

None.
Descriptive analysis of head impact kinetics in a simulated rugby union tackle: preliminary findings
Authors: Danielle Salmon , Pinfold Jayden , Sullivan S John , Andrew Gray , Lodge Ed , Hamish Osborne , Darryl Tong
Published: November 2017

Objective

The tackle is a key component in rugby union and carries some of the highest risk for concussions. The purpose this study was to observe the acceleration profile of the head during a simulated tackle and to determine if these forces vary by playing position.

Design

Observational.

Setting

Laboratory.

Participants

Male rugby players (n=41) age 21.8±3.4 years.

Protocol

Participants were asked to perform 5 tackles with each shoulder. For each tackle the 50 kg bag was released on a pendulum and the players completed a 3 m run-up to make contact with the bag at its peak speed (4.3 ±.13 m/s). For each tackle the linear and rotational acceleration were captured using a head positioning system (HPS) anchored over the mastoid bone.

Outcome measures

The magnitude and variability of the mean resultant linear and rotational acceleration forces over the 10 tackles were examined using the peak acceleration values and were compared with Mann-Whitney-Wilcoxon tests.

Main results

The overall mean peak linear force was 82.9 Gz with a range of 20.1–236.6 Gz. For the forwards (n=23) the peak linear and rotational accelerations were 83.0±36.3 Gz and 2537.8±477.7 m/s2, while for the backs (n=18) were 77.6±33.8 Gz and 2501.9±519.6 m/s2. There were no significant differences between forwards/backs, or those with a history of concussion (p≥0.054).

Conclusions

With growing evidence implicating the importance of sub-concussive impacts in later brain health, understanding the exposure load of players during trainings and games is essential. This is the first study to document the impact forces recorded at the head during a simulated rugby tackle.

Competing interests

None.

Ed Lodge is CEO of CSx Concussion Management Systems, who developed and provided the Head positioning system that was used to measure head impact kinetics in real time.
The effect of prior concussion history on dual-task gait following a concussion
Authors: Howell David R , Beasley Michael , Vopat Lisa , Meehan William P
Published: November 2017

Objective

To examine gait characteristics among patients following their first lifetime concussion, second or greater lifetime concussion, and individuals with no concussion history.

Design

Prospective observational study.

Setting

Regional sport-concussion clinic.

Participants

Fourteen patients presented following their first lifetime concussion (57% female; 15.6 [95% CI:=13.0, 17.2] years of age; 11.1 [8.3, 13.9] days post-concussion), 21 following their second or greater lifetime concussion (52% female; 16.9 [15.5, 18.4] years of age; 8.6 [6.2, 11.1] days post-concussion), and thirty-one controls without a concussion history (65% female; 15.0 [14.2, 15.8] years of age). Exclusion criteria included a current lower extremity injury or diagnosed learning disability.

Interventions/independent variables

Participants completed gait evaluations and medical history questionnaires. MANCOVAs evaluated between-group gait differences; correlations were calculated between the number of lifetime concussions and gait.

Outcome measures

Participants recorded their number of prior concussions. Three inertial sensors quantified single and dual-task gait; variables included average gait speed, cadence, and stride length.

Main results

During dual-task gait, patients reporting for their ≥ second lifetime concussion walked significantly slower (0.81 [0.75, 0.89] m/s vs. 0.92 [0.86, 0.97] m/s;p=0.009) and with smaller stride lengths (0.98 [0.92, 1.04] m vs. 1.08 [1.04, 1.13] m;p=0.02) compared to controls. A moderate correlation was detected between dual-task gait speed and the number of prior concussions (ρ= 0.44,p= 0.04).

Conclusions

Patients with a prior concussion history demonstrated altered dual-task gait strategies relative to controls. Dual-task gait velocity and number of prior concussions were moderately correlated, suggesting a worsening effect from multiple concussions across the lifetime.

Competing interests

None.

Dr. Meehan receives royalties from ABC-Clio publishing for the sale of his book,Kids, Sports, and Concussion: A guide for coaches and parents, and royalties from Wolters Kluwer for working as an author forUpToDate. He is under contract with ABC-Clio publishing for a future book entitled,Concussions, and with Springer International publishing for a future book entitled,Head and Neck Injuries in Young Athletes. His research is funded, in part, by a grant from the National Football League Players Association and by philanthropic support from the National Hockey League Alumni Association through the Corey C. Griffin Pro-Am Tournament. Drs. Howell, Beasley, and Vopat have no conflicts of interest to report.
Association between initial post-concussion presentation and persistent symptoms at 1–month post-concussion
Authors: Register-Mihalik Johna , Herzog Mackenzie , Bloom O Josh , Fonseca Janna , Phillips Kristen , De Maio Valerie
Published: November 2017

Objective

To examine associations between acute post-concussion measures and 1-month persistent symptom presence among paediatric concussion patients.

Design

Prospective cohort.

Setting

Three family medicine clinics, from the same practice, in an urban/suburban area of the USA.

Subjects

Paediatric concussion patients (n=179); ages 8-18 years (median age=15; IQR: 13-16) presenting within three days of injury.

Intervention

Participants completed a systematic evaluation during their initial visit and a 4-6 week follow-up survey (80% follow-up; n=144). The initial visit variables included age, gender, previous head injury, total symptom severity, Immediate Postconcussion Assessment and Cognitive Test (ImPACTTM) composite scores, and near point convergence (NPC).

Outcome measures

The primary outcome was 1-month follow-up persistent symptom presence, determined using the Rivermead Postconcussion Symptoms Questionnaire. We assessed univariate relationships for each variable with persistent symptoms. Variables significant in univariable analyses (p<0.10) were included in a multivariable logistic regression model.

Results

Persistent symptoms were reported for 27.1% (n=39) of participants. Females were more likely to have persistent symptoms (OR=1.9; 95% CI: 0.9, 4.0; p=0.086). Initial visit total symptom severity (Z=4.2; p<0.001) was higher in those with persistent symptoms. Initial visit verbal memory (Z=−1.7; p=0.083), processing speed (Z=−1.7; p=0.093), and reaction time (Z=2.8; p=0.001) were worse in those with persistent symptoms. Total symptom severity was the only factor significant in the multivariable model (OR=1.04; 95% CI=1.02–1.07).

Conclusions

Gender, acute symptom burden and post-concussion neurocognitive deficits have significant relationships with persistent symptom presence. Clinicians should be mindful of these factors when considering treatment.

Competing interests

The current study was funded in part by the National Operating Committee on Standards for Athletic Equipment.

Dr. Bloom is employed at the study setting.

Ms. Fonseca is employed at the study setting.

Ms. Phillips is employed at the study setting.
Feasibility of exercise for adolescents with persisting symptoms following a sport-related concussion: a randomized controlled trial
Authors: Chan Catherine , Silverberg Noah , Purtzki Jacqueline , Wong Kathy , Iverson Grant , Gagnon Isabelle
Published: November 2017

Objective

To describe the feasibility and safety of a randomised controlled trial (RCT) comparing active rehabilitation (AR) to treatment as usual (TAU) in adolescents with persistent symptoms following a sport-related concussion.

Design

Partially blinded, pilot RCT.

Setting

Outpatient Rehabilitation Hospital.

Participants

13 adolescents enrolled and completed the study (10 girls, 3 boys). All were between the ages of 12–18 and were symptomatic for greater than 4 weeks. Participants were excluded if they had more than 1 concussion in the last year, any active mental health disorder, or if their concussion occurred more than 1 year from enrolment.

Intervention

Participants were randomly allocated to TAU (occupational therapy and school recommendations) or AR. AR included aerobic exercise, positive visualisation techniques, and sport-specific exercises. AR sessions were supervised by a physiotherapist, and a blinded assessor monitored all participants weekly.

Outcome measures

Investigators monitored symptoms using the Post-Concussion Symptom Inventory. Secondary outcome measures included activity level, balance, mood, fatigue, and return to school.

Main results

125 individuals were screened over a 1.25 year period. Of the 22% of individuals deemed eligible, 15 declined to participate. Most commonly, individuals were excluded due to being unreachable, uninterested, or having more than one concussion. No drop outs occurred. An external committee reviewed two adverse events in TAU and 1 adverse event in the AR group. All adverse events were unrelated to the intervention and study procedures.

Conclusions

Based on this small pilot study, exercise appeared safe in this sample of youth with persistent symptoms.

Competing interests

None.
The effect of persistent post-concussive symptoms on cognitive performance after sport concussion
Authors: Su Zhangjie , Davies David , Bhavsar Amar , Hammond Douglas , Hacker David , Evans Shaun , Grey Michael , Belli Antonio
Published: November 2017

Objective

We aim to study the effect of persistent post-concussive symptoms on cognitive performance of elite athletes, based on the hypothesis that persistent symptoms could impair athletes’ cognitive performances and functional outcomes.

Design

Prospective observational and longitudinal case control study.

Setting

University research centre, single centre.

Participants

7 athletes with persistent symptoms (>2 weeks, assessed at median 31 days post-concussion), 10 athletes with brief symptoms (<3 days, assessed within a week, median 3.5 days), and 9 age-matched healthy volunteers. Inclusion criteria: male/female athletes (aged 18–40) in contact sports who sustained concussion(s) recently, being symptomatic with normal neuro-radiological findings at enrolment.

Intervention

Independent variables: post-concussive symptom scores and duration of symptoms.

Outcome measures

Multi-dimensional scores from Sport Concussion Assessment Tool III, Immediate Post-concussion Assessment and Cognitive Testing, WAIS symbol search and digit span backward tests.

Main results

Patients with persistent symptoms scored less in the symbol search test than those with brief symptoms and the healthy volunteers (grouping effect p=0.006; post hoc tests p=0.039 and 0.004, respectively). In all 17 patients, symptom scores correlated with reaction time (ρ=−0.61, p=0.009), and visual motor speed correlated with symbol search scores (ρ=0.59, p=0.013). 6 patients who completed follow-up assessments when symptom-free showed improvement in their symbol search scores (p=0.042) and visual memory (p=0.028).

Conclusions

Concussed athletes with persistent symptoms performed poorly in visual perception/analysis and information processing. Persistent post-concussive symptoms could affect athletes’ visual memory, perception/analysis, reaction time and information processing speed, thus precipitating them to further injuries should they return to play prematurely.

Competing interests

None.
Acute sport-related concussion suppresses heart rate variability beyond clinical recovery
Authors: Wright Alexander D , Smirl Jonathan D. , Grewal Harjas S. , Bryk Kelsey , van Donkelaar Paul
Published: November 2017

Objective

To examine the effect of acute sport-related concussion on heart rate variability (HRV) in contact-sport athletes over 1 month post-injury.

Design

Prospective Cohort.

Setting

Laboratory.

Participants

136 male contact-sport athletes (19.1±1.4 years) were recruited and a subset of 14 athletes sustained concussions (19±1.4 years) and were included in the current analyses.

Intervention

Participants completed baseline (T0) and post-injury testing at 72-hours (T1), 2-weeks (T2), and 1-month (T3). A three-lead electrocardiogram was recorded to assess HRV during 5-minutes of quiet stance and while actively squatting at 0.10 Hz (6 squats per minute). Recordings were analysed using Kubios software (Kuopio, Finland). Independent variables included condition (resting versus active) and time (4).

Outcome measures

Time-Domain: square root of mean squared differences of successive R-R intervals (RMSSD), percentage of successive R-R intervals that differ by more than 50 milliseconds (pNN50). Non-linear: approximate entropy (ApEn).

Main results

RM-ANOVA revealed a significant main effect of time for ApEn only (p=0.016). ApEn was reduced at T2 (−0.126, 95% CI: 0.029–0.222, p=0.015) and T3 (−0.068, 95% CI: 0.009–0.128, p=0.027) compared to T0. Median return-to-play duration was 14.5 days.

Conclusions

Acute sport-related concussions induce a delayed reduction in heart rate variability that does not manifest until near-clinical recovery, and persists until at least 1-month post-injury. This is an important finding, indicating that concussions impair regulation of the autonomic nervous system for a duration persisting well beyond clinical recovery.

Competing interests

None.
Muscle injury rate in professional football is higher in matches played within 5 days since the previous match: a 14-year prospective study with more than 130 000 match observations
Authors: Bengtsson Håkan , Ekstrand Jan , Waldén Markus , Hägglund Martin
Published: November 2017

Background

The association between match congestion and injury rates in professional football has yielded conflicting results.

Aim

To analyse associations between match congestion on an individual player level and injury rates during professional football matches.

Methods

Data from a prospective cohort study of professional football with 133 170 match observations were analysed with Poisson regressions. Associations between short-term match congestion, defined as number of days between two match exposures (≤3, 4, 5, 6 and 7–10 days) and injury rates were analysed. To analyse the influence of long-term match congestion, defined as individual match exposure hours in the 30 days preceding a match, observations were categorised into three groups (low, ≤4.5; medium, >4.5 to ≤7.5; and high, >7.5 hours).

Results

No differences in total match injury rates were found between the reference category (≤3 days) and the other categories of short-term congestion. Muscle injury rates were significantly lower in matches preceded by 6 (rate ratio (RR) 0.79; 95% CI 0.65 to 0.95) or 7–10 days (RR 0.81; 95% CI 0.71 to 0.93) compared with ≤3 days since the last match exposure. No differences in total and muscle injury rates between the three long-term match congestion groups were found.

Conclusions

In this study of male professional football players, there were no match congestion-related differences in total match injury rates, but muscle injury rates during matches were lower when players were given at least 6 days between their match exposures.
Incidence of patient safety events and process-related human failures during intra-hospital transportation of patients: retrospective exploration from the institutional incident reporting system
Authors: Yang Shu-Hui , Jerng Jih-Shuin , Chen Li-Chin , Li Yu-Tsu , Huang Hsiao-Fang , Wu Chao-Ling , Chan Jing-Yuan , Huang Szu-Fen , Liang Huey-Wen , Sun Jui-Sheng
Published: November 2017

Background

Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited.

Objective

To perform a retrospective analysis of IHT-related events, human failures and unsafe acts.

Setting

A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan.

Participants

All eligible IHT-related patient safety events between January 2010 to December 2015 were included.

Main outcome measures

Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts.

Results

There were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (p<0.001). Of the events with human failures (n=186), the most common related process step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, p<0.001) was associated with increased patient harm, whereas the presence of omission (OR 0.12, p<0.001) was associated with less patient harm.

Conclusions

This study shows a need to reduce human failures to prevent patient harm during intra-hospital transportation. We suggest that the transportation team pay specific attention to the sub-process at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted.
Mortality of hospitalised internal medicine patients bedspaced to non-internal medicine inpatient units: retrospective cohort study
Authors: Bai Anthony D , Srivastava Siddhartha , Tomlinson George A , Smith Christopher A , Bell Chaim M , Gill Sudeep S
Published: November 2017

Objective

To compare inhospital mortality of general internal medicine (GIM) patients bedspaced to off-service wards with GIM inpatients admitted to assigned GIM wards.

Method

A retrospective cohort study of consecutive GIM admissions between 1 January 2015 and 1 January 2016 was conducted at a large tertiary care hospital in Canada.

Inhospital mortality was compared between patients admitted to off-service wards (bedspaced) and assigned GIM wards using a Cox proportional hazards model and a competing risk model. Sensitivity analyses included propensity score and pair matching based on GIM service team, workload, demographics, time of admission, reasons for admission and comorbidities.

Results

Among 3243 consecutive GIM admissions, more than a third (1125, 35%) were bedspaced to off-service wards with the rest (2118, 65%) admitted to assigned GIM wards. In hospital, 176 (5%) patients died: 88/1125 (8%) bedspaced patients and 88/2118 (4%) assigned GIM ward patients. Compared with assigned GIM wards patients, bedspaced patients had an HR of 3.42 (95% CI 2.23 to 5.26; P<0.0001) for inhospital mortality at admission, which then decreased by HR of 0.97 (95% CI 0.94 to 0.99; P=0.0133) per day in hospital. Competing risk models and sensitivity analyses using propensity scores and pair matching yielded similar results.

Conclusions

Bedspaced patients had significantly higher inhospital mortality than patients admitted to assigned GIM wards. The risk was highest at admission and subsequently declined. The results of this single centre study may not be generalisable to other hospitals and may be influenced by residual confounding. Despite these limitations, the relationship between bedspacing and patient outcomes requires investigation at other institutions to determine if this common practice represents a modifiable patient safety indicator.
Butyrate reduces appetite and activates brown adipose tissue via the gut-brain neural circuit
Authors: Li Zhuang , Yi Chun-Xia , Katiraei Saeed , Kooijman Sander , Zhou Enchen , Chung Chih Kit , Gao Yuanqing , van den Heuvel José K , Meijer Onno C , Berbée Jimmy F P , Heijink Marieke , Giera Martin , Willems van Dijk Ko , Groen Albert K , Rensen Patrick C N , Wang Yanan
Published: November 2017

Objective

Butyrate exerts metabolic benefits in mice and humans, the underlying mechanisms being still unclear. We aimed to investigate the effect of butyrate on appetite and energy expenditure, and to what extent these two components contribute to the beneficial metabolic effects of butyrate.

Design

Acute effects of butyrate on appetite and its method of action were investigated in mice following an intragastric gavage or intravenous injection of butyrate. To study the contribution of satiety to the metabolic benefits of butyrate, mice were fed a high-fat diet with butyrate, and an additional pair-fed group was included. Mechanistic involvement of the gut-brain neural circuit was investigated in vagotomised mice.

Results

Acute oral, but not intravenous, butyrate administration decreased food intake, suppressed the activity of orexigenic neurons that express neuropeptide Y in the hypothalamus, and decreased neuronal activity within the nucleus tractus solitarius and dorsal vagal complex in the brainstem. Chronic butyrate supplementation prevented diet-induced obesity, hyperinsulinaemia, hypertriglyceridaemia and hepatic steatosis, largely attributed to a reduction in food intake. Butyrate also modestly promoted fat oxidation and activated brown adipose tissue (BAT), evident from increased utilisation of plasma triglyceride-derived fatty acids. This effect was not due to the reduced food intake, but explained by an increased sympathetic outflow to BAT. Subdiaphragmatic vagotomy abolished the effects of butyrate on food intake as well as the stimulation of metabolic activity in BAT.

Conclusion

Butyrate acts on the gut-brain neural circuit to improve energy metabolism via reducing energy intake and enhancing fat oxidation by activating BAT.
Genome-wide DNA methylation analysis reveals a prognostic classifier for non-metastatic colorectal cancer (ProMCol classifier)
Authors: Gündert Melanie , Edelmann Dominic , Benner Axel , Jansen Lina , Jia Min , Walter Viola , Knebel Phillip , Herpel Esther , Chang-Claude Jenny , Hoffmeister Michael , Brenner Hermann , Burwinkel Barbara
Published: November 2017

Objective

Pathological staging used for the prediction of patient survival in colorectal cancer (CRC) provides only limited information.

Design

Here, a genome-wide study of DNA methylation was conducted for two cohorts of patients with non-metastatic CRC (screening cohort (n=572) and validation cohort (n=274)). A variable screening for prognostic CpG sites was performed in the screening cohort using marginal testing based on a Cox model and subsequent adjustment of the p-values via independent hypothesis weighting using the methylation difference between 34 pairs of tumour and normal mucosa tissue as auxiliary covariate. From the 1000 CpG sites with the smallest adjusted p-value, 20 CpG sites with the smallest Brier score for overall survival (OS) were selected. Applying principal component analysis, we derived a prognostic methylation-based classifier for patients with non-metastatic CRC (ProMCol classifier).

Results

This classifier was associated with OS in the screening (HR 0.51, 95% CI 0.41 to 0.63, p=6.2E−10) and the validation cohort (HR 0.61, 95% CI 0.45 to 0.82, p=0.001). The independent validation of the ProMCol classifier revealed a reduction of the prediction error for 3-year OS from 0.127, calculated only with standard clinical variables, to 0.120 combining the clinical variables with the classifier and for 4-year OS from 0.153 to 0.140. All results were confirmed for disease-specific survival.

Conclusion

The ProMCol classifier could improve the prognostic accuracy for patients with non-metastatic CRC.