bluuebunny/crossref_metadata_2025 huggingface dataset:
Vaccination with the Recombinant Major Outer Membrane Protein Elicits Antibodies to the Constant Domains and Induces Cross-Serovar Protection against Intranasal Challenge with Chlamydia trachomatis
Authors: Tifrea Delia F. , Ralli-Jain Pooja , Pal Sukumar , de la Maza Luis M.
Published: March 2013

To determine the ability of the major outer membrane protein (MOMP) to elicit cross-serovar protection, groups of mice were immunized by the intramuscular (i.m.) and subcutaneous (s.c.) routes with recombinant MOMP (rMOMP) fromChlamydia trachomatisserovars D (UW-3/Cx), E (Bour), or F (IC-Cal-3) orChlamydia muridarumstrain Nigg II using CpG-1826 and Montanide ISA 720 VG as adjuvants. Negative-control groups were immunized i.m. and s.c. withNeisseria gonorrhoeaerecombinant porin B (Ng-rPorB) or i.n. with Eagle's minimal essential medium (MEM-0). Following vaccination, the mice developed antibodies not only against the homologous serovar but also against heterologous serovars. The rMOMP-vaccinated animals also mounted cell-mediated immune responses as assessed by a lymphoproliferative assay. Four weeks after the last immunization, mice were challenged i.n. with 104inclusion-forming units (IFU) ofC. muridarum. The mice were weighed for 10 days and euthanized, and the number of IFU in their lungs was determined. At 10 days postinfection (p.i.), mice immunized with the rMOMP ofC. muridarumorC. trachomatisD, E, or F had lost 4%, 6%, 8%, and 8% of their initial body weight, respectively, significantly different from the negative-control groups (Ng-rPorB, 13%; MEM-0, 19%;P< 0.05). The median number of IFU recovered from the lungs of mice immunized withC. muridarumrMOMP was 0.13 × 106. The median number of IFU recovered from mice immunized with rMOMP from serovars D, E, and F were 0.38 × 106, 7.56 × 106, and 11.94 × 106IFU, respectively. All the rMOMP-immunized animals had significantly less IFU than theNg-rPorB (40 × 106)- or MEM-0 (70 × 106)-immunized mice (P< 0.05). In conclusion, vaccination with rMOMP can elicit protection against homologous and heterologousChlamydiaserovars.
Down syndrome masked by Marfan syndrome in a neonate
Authors: Eayrs Katie , Shettihalli Naveen , Adwani Satish
Published: March 2013

A male neonate with maternally inherited Marfan syndrome was also diagnosed with Down syndrome at 3 weeks of age. To our knowledge this is the first described case in the literature of the co-occurrence of Down syndrome and Marfan syndrome in a neonate. The diagnosis of Down syndrome was delayed and we hypothesise that Marfan syndrome had masked the usual phenotypic features of Down syndrome. The phenotype of this child is intriguing and has lead to speculation of the possible interaction of the two syndromes.
Does changing policy to disallow body checking reduce the risk of concussion in 11 and 12-year-old ice hockey players?
Authors: Emery C A , Macpherson A , Kang J , Hagel B , Black A , Romiti M , Meeuwisse W H
Published: March 2013

Objective

The objective of this study was to determine if the risk of concussion differed for non-elite Pee Wee ice hockey players (ages 11–12) in leagues where Body Checking (BC) is permitted (Alberta, Canada) versus leagues where policy no longer permits BC (Ontario, Canada).

Design

Cohort study.

Setting

Community ice rinks and sport medicine clinics during the 2011/12 season.

Participants

Forty-four teams from Alberta (n=658) and 32 from Ontario (n=258) participated. Players were from non-elite Pee Wee teams (lower 70% of divisions of play).

Assessment of Risk Factors

Non-elite Pee Wee ice hockey leagues where BC is permitted (Alberta) compared to leagues where policy no longer permits BC (Ontario).

Main Outcome Measurements

Players with a suspected concussion were identified by a team therapist or safety designate and referred to a sport medicine physician.

Results

There were 83 concussions (Incidence Proportion (IP)=12.61 (95% CI; 10.17 to 15.4)) in Alberta and 11 concussions (IP=4.26 (95% CI; 2.15 to 7.5)) in Ontario. The Concussion Risk Ratio was 2.96 (95% CI; 1.6 to 5.46). Overall, 76% of players identified with a concussion were assessed by a physician.

Conclusions

There was a 3-fold increased risk of concussion in non-elite Pee Wee ice hockey players in leagues where BC is permitted compared to a cohort where BC is no longer permitted. These findings have important implications for further BC policy change to reduce the public health burden of injury and concussion in youth ice hockey.

Acknowledgements

The University of Calgary Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We also acknowledge the support of Max Bell Foundation, Alberta Innovates Health Solutions and the Alberta Children's Hospital Institute for Child and Maternal Health (Alberta Children's Hospital Foundation).
Effectiveness of the particle repositioning maneuver for benign positional vertigo following traumatic brain injury
Authors: Ouchterlony Donna , Michalak Alicja , Topolovec-Vranic Jane , Rutka John A , Masanic Cheryl
Published: March 2013

Objective

The purpose of this pilot project was to explore the clinical presentation of benign positional vertigo (BPV) in patients with mild or moderate traumatic brain injury (TBI) and to determine if a non-invasive bedside intervention, the Particle Repositioning Maneuver (PRM) would be effective in treating BPV.

Design

Observational, cohort prospective study, with repeated measures of three groups of patients diagnosed with TBI.

Setting

Subjects were recruited from an out-patient clinic specialising in the management of TBI in a large, urban, academic hospital.

Participants

56 subjects with mild to moderate TBI: 21 patients with BPV, 23 with non-specific dizziness, and 12 without any form of dizziness.

Intervention

Patients were assessed at baseline and at 1, 5, 9 weeks and 3 months post-enrollment. BPV was confirmed by the administration of the Dix-Hall Pike Maneuver to patients with dizziness at each assessment and those positive for BPV received PRM treatment.

Outcome Measures

Demographic and injury-related data were collected and the Dizziness Handicap Inventory (DHI) and Short-Form Health Survey (SF-36) were administered at each assessment. Mean difference in DHI scores between baseline and follow-ups were assessed.

Results

DHI scores were significantly reduced in the BPV group (20.6; p<0.01) and dizziness symptoms had resolved in 52% of patients. A significant improvement on the SF-36 physical component scores was found for the BPV group (increasing from 38.1 at baseline to 45.7 at 3 months; p<0.01)

Conclusions

Our pilot study demonstrated both significantly improved dizziness symptoms and physical wellbeing for BPV patients who received PRM treatment.

Competing interestsNone.
What factors increase the risk of concussion in elite youth ice hockey players?
Authors: Blake Tracy A , Kang Jian , Meeuwisse Willem H , Lemke Nicole , Schneider Kathryn J , Taylor Kirsten A , Emery Carolyn A
Published: March 2013

Objective

To examine the risk of concussion amongst elite youth male and female ice hockey players.

Design

Prospective cohort study.

Setting

Community ice rinks and sport medicine clinics.

Participants

764 Bantam (12–14 years) and Midget (15–17 years) ice hockey players. Assessment of Risk Factors: 743 players completed baseline SCAT2 testing (2011/2012 season). Age group, sex, previous concussion history, Total Symptoms Score (TSS), Balance Error Score (BES), Standardised Assessment of Concussion (SAC) Score and SCAT2 Total Score at baseline were evaluated as potential risk factors. Higher scores indicate greater impairment or symptoms.

Main Outcome Measurements

Players with a suspected concussion were assessed by a team therapist and referred to a sport medicine physician.

Results

Multivariate Poisson Regression analyses, adjusted for cluster by team, were used to estimate concussion risk ratios (RR). The RR for Bantam players with previous concussion history was 1.15 (95% CI 0.69 to 1.90) and for Midget players with previous concussion history was 2.83 (95% CI 1.69 to 4.72) compared to players in the same age group with no previous concussion history. The RR for players with baseline TSS and SCAT2 Total Score in the lowest 25%ile were 1.54 (95% CI 1.07 to 2.20) and 1.40 (95% CI 1.03 to 1.90), respectively, compared to those in the upper 75%ile. Sex, BES and SAC score were not predictive of concussion.

Conclusions

There is a greater risk of concussion in elite ice hockey players 15–17 years old with a previous history of concussion. Baseline TSS and SCAT2 Total Score in the lowest 25%ile are also predictive of concussion.

Acknowledgements

The University of Calgary Sport Injury Prevention Research Centre is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. We also acknowledge the support of Alberta Innovates Health Solutions, the Alberta Children's Hospital Institute for Child and Maternal Health (Alberta Children's Hospital Foundation) and Talisman Energy for their generous support.
The effect of multiple sub-concussive blows on brain structural and functional integrity: combined virtual reality and neuroimaging study
Authors: Slobounov Semyon , Sebastianelli Wayne
Published: March 2013

Objective

To determine the differential sensitivity of subjects, with and without prior history of concussion, towards multiple sub-concussive impacts. We hypothesised that previous concussions may increase the athletes' vulnerability to repetitive blows leading to brain metabolic, structural and/or functional compromised integrity.

Design

A set of Virtual Reality (VR) tests and MRI scans (fMRI, DTI, MRS) before and within 3 h after a competition was implemented. The number and type of sub-concussive blows was documented via observational charts incorporated with reconstruction of impacts captured on video.

Setting

Subjects were recruited from Penn State collegiate football and rugby teams.

Subjects

12 football and rugby players (with n=6 and without n=6 history of concussion) often experiencing multiple blows during practices and games were recruited for this study.

Outcome Measures

Spatial working memory, balance, and speed of information processing were assessed by VR testing using Head Mounted Display. Brain metabolic profile (MRS NAA/Cho; NAA/CR of the corpus callosum), functional connectivity (DMN during rs-fMRI) and white matter tracks integrity (DTI, FA) were the primary neuroimaging measures.

Results

We observed decreased interhemispheric functional connectivity (rs-fMRI, left-right hippocampus; r=0.82/0.55), reduced FA (DTI in Genu, 0.7/0.4), and reduced NAA/Cho ratio (MRS measures) at frontal (2.21/1.72) ROI after the competition only in subjects with prior history of concussion. These subjects also experienced deficient balance and spatial memory problems assessed by VR.

Conclusions

This study provides a solid foundation to begin improving the current understanding of the neural substrate(s) differential response(s) to sub-concussive blows occurring in athletics.

Competing interests

None.
Do family physicans, emergency physicians and paediatricians give consistent sport-related concussion management advice?
Authors: Stoller Jacqueline , Carson James , Purcell Laura , Davidson Bruce , Garel Alisha , Bell Margaret , Snow Catherine , Law Marcus
Published: March 2013

Objective

To identify differences and gaps in the recommendations to patients for the management of sport-related concussion among family physicians (FPs), emergency physicians (ERs) and paediatricians (Peds).

Design

A self-administered multiple-choice survey, which had been validated for content validity.

Setting

Toronto East General Hospital and Markham Stouffville Hospital, both in Ontario, Canada.

Subjects

270 physicians were invited to participate; 104 surveys were completed (39%).

Intervention

The survey link was emailed to FPs, ERs and Peds from the above hospitals. Data were analysed using SPSS. Frequencies and percentages were calculated with cross-tabulation of data by specialty.

Outcome Measures

Key survey questions identified sources of concussion management information, usefulness of concussion diagnosis strategies, and whether physicians use common terminology when explaining cognitive rest strategies to patients after a sport-related concussion.

Results

For making a diagnosis of concussion, 54% of FPs, 86% of ERs and 78% of Peds never used the SCAT2; 49% of FPs, 57% of ERs and 36% of Peds always advised cognitive rest, the mainstay of early management for post-concussion symptoms; 65% of FPs, 71% of ERs and 55% of Peds always advised physical rest; and 49% of FPs, 52% of ERs and 27% of Peds reported no knowledge of any consensus statements on concussion in sport.

Conclusions

We identified large gaps in the implementation of recommendations for sport-related concussion patients. Although some physicians are recommending physical and cognitive rest, a large proportion fail to consistently advise this strategy. Better knowledge translation efforts should target all three groups of physicians.

Acknowledgements

Thank you to Babak Aliarzadeh for the statistical analysis. Special thanks go to Paul Krueger, Leigh Hayden and the other 18 participants in the validation of our survey.

Competing interests

None.
Academic accommodation for post concussion student athletes: can physicians do better?
Authors: Carson James , Snow Catherine , Lawrence David , Kraft Sari , Chatterjee Ananda , MacKenzie Heather , Moineddin Rahim , Frémont Pierre
Published: March 2013

Objective

To determine the barriers and facilitators to the implementation of concussion related medical recommendations in a sport and school environment.

Design

Retrospective longitudinal chart review and structured telephone interviews.

Setting

A sport medicine physician's office in Ontario, Canada.

Subjects

159 students with a sport-related concussion.

Intervention

The data collection involved a review of 170 charts of patients seen for concussion over a 5-year period (2006–2010). Two blinded authors independently reviewed each chart and SCAT or SCAT2 symptom self report form. In situations where there was discrepancy between the two reviewers results, a third author reviewed the charts. The telephone interviews supported the data collection.

Outcome Measures

Our primary outcome measures were (1) whether the patient returned to their sport too soon, or before they had fully recovered, and (2) whether the patient returned to school too soon, or before they had adequately recovered. The phone interview was structured to collect outcome measures providing insight into the patients' post-concussion course and recovery process. This will assist in determining what factors they believe improved their condition, or what slowed the recovery process.

Results

In terms of the primary outcomes, 43.53% of students returned to sport too soon and 44.71% returned to school too soon.

Conclusions

Currently, physicians advise restricted mental and physical activity, but no clear guideline exists explaining exactly what cognitive rest entails for post-concussion student athletes. Efforts are needed to find the best method of implementing a coordinated plan for the post-concussion athlete who is returning to school.

Competing interests

None.
Diffusion tensor and susceptibility-weighted imaging in concussion assessment of national football league players
Authors: Luther Neal , Niogi Sumit , Kutner Kenneth , Rodeo Scott , Shetty Teena , Warren Russell , Weiss Leigh , Barnes Ronnie , Zimmerman Robert , Tsiouris Apostolos , Hartl Roger
Published: March 2013

Introduction

Standard MRI is normal following the vast majority of concussions. Diffusion tensor imaging (DTI) and susceptibility-weighted imaging (SWI) are advanced MRI techniques hypothesized to be more sensitive in detecting subtle evidence of structural brain injury. Using DTI and SWI in National Football League (NFL) players, we aim to elucidate and localise the presence of such injury following concussions.

Methods

This ongoing prospective study has recruited active NFL players with and without history of concussion within 6 months prior to entry. Neurological and neurocognitive examination, DTI, and SWI were performed on each subject. Blinded neuroradiologists performed radiographic analysis. Fractional anisotropy (FA) values were measured for 11 distinct white matter tracts on DTI. A global FA value was calculated. SWI was utilised to assess for microhemorrhage. Statistical comparisons between players with and without recent concussion, and to civilian controls, were made.

Results

Seven of eighteen evaluated players to date had a concussion within 6 months of entry. On DTI, of the 11 tracts evaluated, a significant decrease in FA for concussed players was seen in one tract. There was no significant difference in global FA assessment between players with and without recent concussions. Civilian control comparisons are ongoing. SWI was negative in all players.

Conclusions

To our knowledge this is the largest prospective brain imaging study, and the first utilising DTI and SWI to assess anatomical injury secondary to concussion, in NFL players. Minimal changes have been observed in players with recent concussion. The clinical significance of these findings remains under investigation.

Learning Objectives

By the conclusion of the session, participants should be able to (1) understand the role of DTI and SWI in the evaluation of mild traumatic brain injury (2) discuss to what degree long-term football play poses risk in terms of structural brain injury.

References

Concussion, football, MRI, NFL.

How will your Research Improve Patient Care

There is no reliable objective test to evaluate the severity of brain injury suffered secondary to concussion, and concussion is a growing area of concern in football and other contact sports. This study evaluates to what degree brain injury as detected by highly sensitive MR technologies (DTI and SWI) is suffered by those who have had long-term, high-level participation in football and now play at the professional level. Information from this study could play an important role in establishing neurological risks of football.
Effects of exercise on symptoms, cognitive and motor performance tasks using the sport concussion assessment tool (SCAT2) in healthy young adults and children
Authors: Boutros Nour , Norcia Mary Catherine , Sammouda Jamila , Tran Chi-Lan , Pearson Isabelle , Gagnon Isabelle
Published: March 2013

Objective

To document the effect of high intensity exercise on the Sport Concussion Assessment Tool 2 (SCAT2) scores in healthy young adults and children.

Design

Repeated measures design.

Setting

McGill University Athletics Department (adults) and Elementary School in the Montreal area (children).

Participants

Seventy six healthy young adults (45 women and 31 men, mean age 22.5±1.9 years) and 13 children (6 girls and 7 boys, mean age 10.7±0.4 years) participated in this study.

Intervention

Participants performed the Léger Test, a maximal multistage 20 m shuttle run test, to their perceived volitional exhaustion.

Main Outcome Measurements

The SCAT2 was used to evaluate participants at rest, 2 min and 25 min post-exercise.

Results

In adults, total SCAT2 scores were significantly decreased immediately after high intensity exercise (p<0.001) and returned to baseline after the allocated rest period (p=0.350). Individual components of the SCAT2 also reflected this for symptom severity (p<0.001), and total balance score (p<0.001). High intensity exercise had no effect on delayed recall memory (p=0.242). Children in our small sample revealed a tendency for a similar impact of high intensity exercise on SCAT2 scores although statistical significance was not reached.

Conclusions

High intensity exercise, such as that achieved during a sporting event, has an impact on aspects of functioning assessed by the SCAT2.

Clinical Relevance

In order to eliminate the effects of exercise when testing individuals on the field immediately post-injury, professionals should allow for proper rest before using the SCAT2.

Acknowledgements

Participants and their families, Gardenview Elementary School for allowing testing within their institutions, Fonds de recherche du Québec-Santé, School of Physical and Occupational Therapy McGill University.

Competing interests

None.
Persistent differences in patterns of brain activation after sports- related concussion: a longitudinal fMRI study
Authors: Dettwiler Annegret , Murugavel Murali , Putukian Margot , Echemendia Ruben , Cubon Valerie , Furtado John , Osherson Daniel
Published: March 2013

Objective

To define neural correlates of SRC during the 2 month post-injury period using a working memory (WM) task and fMRI and correlate these to clinical measures.

Design

Longitudinal fMRI study assessing subject's brain activation as they perform a N-back task (N=1 to 3) consisting of 30 randomised blocks.

Setting

Varsity collegiate athletes were recruited from high-risk sports teams. Images were acquired on a 3T Siemens Skyra scanner.

Subjects

All athletes were evaluated prospectively within 48 h, 2, 8 weeks postinjury on SCAT2 and hybrid NP battery (ImPACT, paper and pencil tests). 15 right-handed, varsity contact sport athletes who sustained a SRC were scanned at 72 h, 2 and 8 weeks post injury. 15 uninjured control athletes were scanned at baseline and 2 weeks.

Outcome Measures

Post-hoc, whole brain t tests of the 2–1 contrast were performed using FSL-FEAT (mixed effects modelling, z>2.3, corrected p=0.05).

Results

Across all 3 sessions, concussed athletes demonstrated significantly increased activation in the right dorsolateral prefrontal cortex (DLPFC). In session 1, concussed subjects demonstrated increased activation in additional areas: left DLPFC and bilateral inferior parietal. In all 3 sessions, no significant between group differences were observed in subjects performance for all 3 N-back task conditions.

Conclusions

Functional brain activation differences persist at 8 weeks post injury in concussed athletes, despite the fact that their performance on a WM task is comparable to normal controls and normalisation of clinical/hybrid NP tests. These results might indicate a delay between neural and behaviorally-assessed recovery.

Acknowledgements

This research was supported by NJBIR Grant 10-3217-BIR-E-0 AMSSM Grant 005548 Goldstein Family Fund.
Another look at active rehabilitation for slow-to-recover sport-related concussion in children and adolescents: further evidence to support its effectiveness
Authors: Gagnon Isabelle
Published: March 2013

Objective

To explore and impact of a previously developed active rehabilitation intervention for children who are slow-to-recover after concussion.

Design

Prospective repeated measures design.

Setting

The Montreal Children's Hospital Concussion Clinic.

Participants

Ten children (three girls and seven boys, mean age 14.4±1.3 years) participated in this study.

Intervention

Participants who were still symptomatic 4 weeks after the injury were involved in the active rehabilitation intervention (mean time since injury=47 days). It involves gradual, closely monitored light aerobic exercise, general coordination exercises, mental imagery, as well as reassurance and stress/anxiety reduction strategies. The program continued until complete symptom resolution at rest, at which time children and adolescents were eligible to resume the standard return to sports protocol.

Main Outcome Measurements

Primary outcome was evolution of post-concussion symptoms. Secondary outcomes included mood and energy level as well as balance and cognitive function. Those were assessed at initiation and at the end of the rehabilitation.

Results

Change in functioning was found in all domains assessed including Symptoms, Balance, Fatigue and Depressive Symptoms. Cognitive function was within normal limits at the initiation of the intervention and remained unchanged. Average duration of the intervention was 45 days (range 14–72 days).

Conclusions

Although no control group was used in this pilot study, children's functioning is improved after participation in the active rehabilitation intervention.

Clinical Relevance

The introduction of graded light intensity exercise in the post-acute period post-concussion is feasible and appears to have benefits on children's functioning.

Acknowledgements

Participants and their families, Trauma Programs of the Montreal Children's Hospital-McGill University Health Center, Fonds de la recherche du Québec-Santé; Réseau provincial de recherche en adaptation-réadaptation.

Competing interests

None.
Concussion education and awareness support group: the value of a pilot clinical program as an essential Knowledge Transfer and Exchange (KTE) strategy
Authors: Provvidenza Christine , Kissick James , Purcell Laura , Johnston Karen
Published: March 2013

Objective

To pilot test a concussion education and support workshop as a Knowledge Transfer and Exchange (KTE) intervention for enhancing knowledge and education post-concussion.

Design

Prospective, pre-post design to pilot test a KTE intervention.

Setting

Sport Concussion Clinic patients and their parents.

Subjects

Five concussed athletes (4 males; 1 female) ages 10–39 years (mean=29±10 years) and their parents (N=4).

Intervention

An education presentation based on 2008 Concussion in Sport Meeting content (Zurich, Switzerland) consisting of case studies, discussion questions and a workbook.

Outcome Measures

A survey was designed to examine baseline and changes in concussion knowledge and attitudes, and was administered pre and post intervention. A workshop evaluation assessed preferred learning methods and workshop satisfaction.

Results

Knowledge improvements regarding the return-to-play protocol (RTP; 22%), when to RTP (11%) and start rehabilitation (45%) were seen. Knowledge gaps were associated with the role of CT/MRI and protective equipment. Athletes acknowledged the seriousness of concussion and felt relief that they were not alone. The workshop was considered a successful form of peer support for the athletes and overall support for the parents.

Conclusions

This intervention is a potentially effective KTE strategy for optimising concussion knowledge and education post-injury, and providing support throughout the concussion recovery process. Participants indicated they wanted to learn more about recovery techniques and coping, and would like to receive information electronically. The limited sample size reinforces the need to continue examining the role of such workshops using a larger group design. Establishing online peer support and education workshops in a webinar format would be an appropriate next step.

Acknowledgements

Alternative Funding Program Innovation Funds, Ontario Ministry of Health and Long-Term Care.

Competing interests

None.
A sample of headache incidence in post concussive patients
Authors: Ouchterlony Donna , Johnson Patricia , Wong Amy , Michalak Alicja , Topolovec-Vranic Jane , Masanic Cheryl , Waseem Zeesham
Published: March 2013

Objective

Headache is one of the most common and debilitating symptoms after traumatic brain injury (TBI) and may persist months to years after the initial injury. The purpose of this pilot project was to determine the incidence and characteristics of headaches within the TBI population.

Design

Descriptive study.

Setting

Data were collected from an out-patient clinic specialising in the management of TBI.

Participants

42 patients (24 male, 18 female) with headache symptoms.

Intervention

Treating physicians collected data on only one appointment for each patient. Of the 160 patients visiting the clinic in May 2012, 30% complained of headaches. Headache symptoms were defined by the International Headache Society Classification ICHD-II criteria.

Outcome Measures

Measures relating to gender, time since head injury, type of headache, severity of headache, frequency of headaches, location of headache and current medication were recorded.

Results

Fifty-seven percent of the population was male. Almost 40% of patients had sustained a head injury over a year prior to data collection. Half of the subjects suffered from tension-type headaches, 14% of patients from migraines, and 7% from both migraine and tension-type headaches. One third reported headaches to occur on a daily basis and 81% percent suffered from headaches that were at least moderate in severity. Thirty-six percent of patients were taking either Advil or Tylenol at the time of data collection.

Conclusions

The pilot data confirmed clinical belief of the necessity to conduct large-scale trials to implement and evaluate interventions for the management of headaches in the TBI population.

Competing interests

None.
Acute clinical signs and outcome of concussion in National Hockey League (NHL) players
Authors: Comper Paul , Hutchison Michael
Published: March 2013

Objectives

To describe and quantify the acute clinical signs of concussion in National Hockey League (NHL) players.

Setting

National Hockey League (NHL).

Design

Prospective case series of concussions over a 5 year period of regular season NHL games (2006–2011).

Subjects

Digital video images of 341 NHL players diagnosed with concussions.

Outcome Measures

Primary outcome measures were mechanism of contact (direct vs indirect trauma), observable acute clinical signs (eg, disorientation, loss of consciousness, balance difficulties, ‘slow to get up’), and time loss that is, time between the injury and medical clearance by the physician to return to competitive play).

Results

Approximately 20% of players diagnosed with concussions showed no on-ice clinical signs. Most frequent on-ice clinical signs were: (1) slow to get up; (2) clutching of the head/helmet; and (3) disorientation/dazed. The number of players with observable on-ice clinical signs, particularly for those who either sustained ‘Possible/Probable Loss of Consciousness’ declined following the 2009 season. None of the clinical signs predicted poor outcome (eg, greater than 21 days of time loss).

Conclusions

Concussion can produce a spectrum of acute on-ice clinical signs. Most commonly observed with the 5 year sample of NHL players were ‘slow to get up’, ‘clutching of the head/helmet’, and ‘disorientation/dazed’. Length of time to recovery was not predicted on the basis of acute observable signs.

Competing interests

One of the authors (PC) is a paid consultant for the National Hockey League Players' Association (NHLPA).
The University of Toronto Concussion Symptom Scale: do initial symptoms predict outcome?
Authors: Richards Doug , Hutchison Michael , Ekhtiari Seper , Comper Paul
Published: March 2013

Objective

To explore symptoms during initial physician evaluation and time to return-to-play experienced by university level athletes.

Design

Prospective case series of concussions during three athletic seasons (2009–2012).

Setting

University of Toronto, Ontario, Canada.

Subjects

Athletes who sustained concussions while involved in inter-university sports (practice or competition) in the following sports: volleyball, fencing, rugby, basketball, track, hockey, soccer, cheerleading, football, lacrosse, field hockey, and figure skating. A total of 85 concussions were reported from 68 athletes (37 males, 31 females)

Intervention

David L. Macintosh Sport Medicine Clinic physicians documented athletes' post-concussion symptoms and recorded the date when a player was medically cleared to return to play.

Main Outcome Measures

Symptoms as measured by the University of Toronto Concussion Symptom Scale (UTCSS) scores, time loss from competition, loss of consciousness, amnesia, and history of concussion.

Results

90.6% of athletes reported at least one symptom on the UTCSS at the first office-visit, with somatic symptoms most frequently reported. The average UTCSS score at 3 days following injury was 13.1 (range, 0–51), with female athletes reporting significantly more symptoms than males (p<0.01). Time loss was not significantly different between males and females. The only factor that predicted poor outcome (>14 days out) was endorsement of cognitive symptoms of the UTCSS (OR 1.30, 95% CI 1.03 to 1.68).

Conclusions

Female athletes reported significantly more symptoms than male athletes following concussion. Cognitive symptoms of the UTCSS were significant predictors of time loss among university level athletes.

AcknowledgementsThe authors wish to acknowledge the David L. Macintosh Sport Medicine Clinic, The University of Toronto Varsity Blues athletes, therapists, and support staff.

Competing interests

None.
Concussion management by paediatricians: a national survey of Canadian paediatricians
Authors: Gordon Kevin , Do Minh T , Thompson Wendy , McFaull Steven
Published: March 2013

Objective

To determine: (a) concussion/mTBI guideline use, (b) criteria used in initiating return to play (RTP), and (c) the management of RTP by Canadian paediatricians.

Design

Cross-sectional survey.

Subjects

Sample of 2599 Canadian paediatric specialists and subspecialists.

Methods

The Canadian Paediatric Surveillance Program provided the sampling frame and survey management. Potential participants were sent a seven-item survey inquiring whether they managed children with concussion, and if so, which guidelines they used, and their initiating RTP criteria and duration.

Results

809 paediatricians responded (31%), with 503 eligible for the study by indicating that they managed children/youth with newly diagnosed with concussion/mTBI. They reported collectively managing approximately 6700 children/youth within the last 12 months (2010–2011). They reported using many concussion/mTBI guidelines: Canadian Paediatric Society (n=244), American Academy of Paediatrics (n=101), Concussion in Sport Group (n=68), Canadian Academy of Sport and Exercise Medicine (n=58), and the American Academy of Neurology (n=25). Similarly, different criteria were used to determine asymptomatic status. Most common were: free from all concussion symptoms, by patient report (n=323), by proxy report (parent/other) (n=269), and free from continuous daily (unremitting) headache (n=162). Of those reporting, most (∼85%) indicated that theydid notinitiate RTP immediately after their patients became asymptomatic. The median recommend time before initiating RTP was 7 days.

Conclusions

Concussions/mTBI are frequently encountered by Canadian paediatricians. There is heterogeneity in the guidelines used and the criteria used to determine when patients become asymptomatic with most recommending asymptomatic time before starting RTP.

Competing interests

None.
Epidemiology and age comparisons of patients presenting to a dedicated community concussion clinic
Authors: Register-Mihalik Johna K , Maio Valerie J De , Tibbo-Valeriote Holly , Lanier Brian , Jackson Thomas , Wooten John D
Published: March 2013

Objective

To describe the epidemiology of student-athletes presenting to a community concussion clinic and to compare post-concussive outcomes between younger and older patients.

Design

Retrospective cohort.

Setting

Community concussion clinic.

Patients

Student-athletes (10–18 years) presenting to a concussion clinic August 2009–July 2011 (n=280).

Interventions

The independent variable was age (10–14 vs 15–18 years).

Main Outcome Measurements

Outcome measures included Immediate Post Concussion Assessment and Cognitive Test (ImPACT) composite (COMP) and percentile-rank (PR) scores, symptom scores, and Balance Error Scoring System (BESS) score. Univariate statistics were used for age comparisons.

Results

Characteristics of patients were: male (76%), mean age (14.6±2.3 years), previous head trauma (61%), migraine family history (25%), initially evaluated in the emergency department (ED) (55%), loss of consciousness (24%), anterograde amnesia (21%). Common sport and injury mechanisms were American football (42%) and person-to-person contact (41%). Common symptoms included: headache (67%), fatigue (45%), difficulty concentrating (44%), and drowsiness (44%). At initial visit, younger (n=135) compared to older (n=145) patients had lower processing speed PR (30.5±27.8 vs 38.1±29.7*) and COMP (29.9±6.5 vs 35.2±8.1*), slower reaction time COMP (0.67±0.14 vs 0.61±0.09*), and lower cognitive symptom severity (2.8±3.9 vs 4.6±6.0*). Older patients were more likely to report time-of-injury dizziness (OR=2.0; 95% CI 1.1 to 3.8*) and fogginess (OR=2.0; 95% CI 1.2 to 3.4*) and being dazed (OR=2.3; 95% CI 1.2 to 4.2*) and foggy (OR=2.3; 95% CI 1.3 to 4.3*) at initial visit. (*p<0.05) No BESS differences were observed.

Conclusions

Patients presenting to concussion clinics are often ED referrals and may represent a unique group with complicated post-injury patterns. Clinicians should be mindful of age and cognitive differences in post-concussion evaluations.

Competing interests

None.
School absence, academic accommodation and health-related quality of life in adolescents with sport-related concussion
Authors: Parsons John T , Curtis Bay R , Valovich McLeod Tamara C
Published: March 2013

Objective

Determine school absence and accommodation frequency, accommodation type, and relationship to health-related quality of life (HRQOL), following concussion.

Design

Repeated measures.

Setting

Secondary schools.

Patients or Other Participants

Athletes with diagnosed concussion (n=149; males=130, females=19, age=15.7±1.1, grade=10.0±1.0).

Interventions

Sport-Concussion Assessment Tool-2 (SCAT2), a general survey, paediatric Quality of Life Inventory (PedsQL), Multidimensional Fatigue Scale, and Headache Impact Test (HIT-6) were administered on date of injury (DOI), and days 3(D3), 10(D10), and 30(D30) post-injury. The general survey captured academic absence and accommodation occurrences and accommodation type.

Main Outcome Measures

Dependent variables: school absence; academic accommodation; and, type of accommodation received. Descriptive and Mann-Whitney U analyses were employed.

Results

Of 143 patients: 28% (n=40) missed school, 16.1% (n=23) received academic accommodations, and 7.7% (n=11) experienced both. The most frequent accommodation was shorter school day (n=9 (39%)). Those requiring accommodations: missed more school, had lower D3 physical, psychosocial, and school functioning, and PedsQL total score; and had higher D30 HIT6 score (all p<0.05). Those with school absences had: more problems with DOI balance, slowness, fatigue, confusion, drowsiness, sleep, irritability, symptom severity and endorsement (all p<0.05); lower (all p<0.05) DOI SCAT2 total score D3 physical, psychosocial, and school functioning, PedsQL total score and sleep fatigue and higher D10 HIT6 total.

Conclusions

Results suggest that SRC-induced school absence and accommodations are related to declines in DOI and D3 HRQOL and increased symptom severity. Further research should explore the predictive value of these measures to future academic disruption.

Acknowledgements

This study was funded by a grant from the National Operating Committee for Standards on Athletic Equipment (NOCSAE).

Competing interests

None.
Neuroimaging dual task performance in youth after sports-related concussion: an fMRI study
Authors: Keightley Michelle L , Sinopoli Katia , Wells Greg , Chen Jen-Kai , Taha Tim , Ptito Alain
Published: March 2013

Objective

To identify the neural substrates of a dual-task paradigm and evaluate performance in concussed versus non-concussed youth 3–6 months post-injury.

Design

Standard structural (T1, T2, FLAIR, DTI) and functional (single-shot T2*-weighted pulse sequence with in-out spiral readout images) were collected using a 3 Tesla imaging system. fMRIstat was used to analyse the data.

Setting

Male participants 9–15 years of age were recruited from The Greater Toronto Hockey League and The Hospital for Sick Children via poster advertising.

Subjects

13 concussed youth (mean age=12.61+1.55 years) and 14 control subjects (mean age 12.59±1.55 years).

Intervention

None.

Outcome Measures

Accuracy (ACC) and reaction time (RT) during (1) a 0–3 back visuospatial working memory task; (2) a two finger button pressing motor task and (3) dual-task cost associated with simultaneously performing the working memory and motor tasks.

Results

There were no significant group differences across single and dual-task conditions. Although both groups activated similar brain regions across tasks, concussed youth demonstrated significantly less percent BOLD change in the prefrontal cortex across all working memory task comparisons. Similar results were found during the 1 vs 0 back and 2 vs 0 back dual task conditions, but not for the 3 vs 0 back dual task condition.

Conclusions

Differences in brain function can be observed in youth who have sustained a single injury 3–6 months earlier. Further research is needed to identify the clinical correlates of these atypical activation patterns.

Acknowledgements

Canadian Institute of Health Research (CIHR) and Ontario Neurotrauma Foundation (ONF).

Competing interests

None.
Balance testing of concussion patients using dual-task interference
Authors: Valentine Verle D , Dorman Jason C , Munce Thayne A , Nelson Hannah K , Kindt Shanna L , Joel Tjarks B , Bergeron Michael F
Published: March 2013

Objective

To compare the diagnostic utility of balance testing (BT) with a dual-task cognitive challenge to concussion symptom scores (SS).

Design

Observational clinical trial.

Setting

Concussion clinic, Sioux Falls, SD, USA.

Subjects

18 subjects (12–20 years) diagnosed with a concussion, examined within 10 days of injury and seen for ≥4 visits; 26 healthy, age- and gender-matched controls (BT evaluated 2X).

Outcome Measures

SS and BT from each clinical visit. Postural stability (AMTI force platform) assessed by velocity (V) of movement and 95% ellipse area (EA) during four BT conditions: eyes open (O), eyes open+cognitive challenge (recite the months of the year backwards; OC), eyes closed (C), and eyes closed+cognitive challenge (CC).

Results

Concussed group: all tests were abnormal at visit one, with progressive improvement of SS over four visits (mean=35.7, 31.4, 18.5, 10.6) and progressive resolution of postural stability (1.0 SD±normative mean). By visit two, V had resolved in all four conditions; however, all four conditions were still abnormal when measured as EA. By visit three, EA for O, OC, and C tasks returned to normal, while the CC task remained abnormal. By visit four, all BT means had returned to normal.

Conclusions

Improvements in postural stability coincide (though resolve earlier) with reductions in SS. Although more variable, SS and EA were, more sensitive to abnormality than V. Further validation of this novel methodology may help to establish BT as an effective tool in concussion management and research.

Competing interests

None.
Republished: A systematic literature review of strategies promoting early referral and reducing delays in the diagnosis and management of inflammatory arthritis
Authors: Villeneuve Edith , Nam Jackie L , Bell Mary J , Deighton Christopher M , Felson David T , Hazes Johanna M , McInnes Iain B , Silman Alan J , Solomon Daniel H , Thompson Andrew E , White Patience H P , Bykerk Vivian P , Emery Paul
Published: March 2013

Background

Despite the importance of timely management of patients with inflammatory arthritis (IA), delays exist in its diagnosis and treatment.

Objective

To perform a systematic literature review to identify strategies addressing these delays to inform an American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) taskforce.

Methods

The authors searched literature published between January 1985 and November 2010, and ACR and EULAR abstracts between 2007–2010. Additional information was obtained through a grey literature search, a survey conducted through ACR and EULAR, and a hand search of the literature.

Results

(1) From symptom onset to primary care, community case-finding strategies, including the use of a questionnaire and autoantibody testing, have been designed to identify patients with early IA. Several websites provided information on IA but were of varying quality and insufficient to aid early referral. (2) At a primary care level, education programmes and patient self-administered questionnaires identified patients with potential IA for referral to rheumatology. Many guidelines emphasised the need for early referral with one providing specific referral criteria. (3) Once referred, early arthritis clinics provided a point of early access for rheumatology assessment. Triage systems, including triage clinics, helped prioritise clinic appointments for patients with IA. Use of referral forms standardised information required, further optimising the triage process. Wait times for patients with acute IA were also reduced with development of rapid access systems.

Conclusions

This review identified three main areas of delay to care for patients with IA and potential solutions for each. A co-ordinated effort will be required by the rheumatology and primary care community to address these effectively.
Perceived lactose intolerance in adult Canadians: a national survey
Authors: Barr Susan I.
Published: March 2013

Although double-blind studies show that lactose-intolerant individuals can consume moderate quantities of milk products without perceptible symptoms, many who perceive that they are lactose intolerant limit or avoid milk products, potentially compromising calcium and vitamin D intakes. Adult Canadians are at risk of inadequate intakes of these nutrients, but no data exist on the prevalence, correlates, and potential impact of perceived lactose intolerance among Canadians. To address this, a Web-based survey of a population-representative sample of 2251 Canadians aged ≥19 years was conducted. Overall, 16% self-reported lactose intolerance. This was more common in women (odds ratio (OR), 1.84; 95% CI, 1.46–2.33) and in nonwhites (OR, 1.79; 95% CI, 1.24–2.58) and less common in those >50 years of age (OR, 0.71; 95% CI, 0.56–0.90) and in those completing the survey in French (OR, 0.74; 95% CI, 0.56–0.99). Those with self-reported lactose intolerance had lower covariate-adjusted milk product and alternative intakes (mean ± SE; 1.40 ± 0.08 servings·day−1 vs. 2.33 ± 0.03 servings·day−1, p < 0.001). A greater proportion used supplements containing calcium (52% vs. 37%, p < 0.001) and vitamin D (58% vs. 46%, p < 0.001), but calcium intakes from the combination of milk products, alternatives, and supplements were lower (739 ± 30 mg·day−1 vs. 893 ± 13 mg·day−1, p < 0.0001). Variation in self-reported lactose intolerance by sex, age, and language preference was unexpected and suggests that some groups may be more vulnerable to the perception that they are lactose intolerant. Regardless of whether lactose intolerance is physiologically based or perceptual, education is required to ensure that calcium intakes are not compromised.