The current state of training in pain medicine fellowships: An Association of Pain Program Directors (APPD) survey of program directors.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) approved the first pain medicine fellowship programs over three decades ago, designed around a pharmacological philosophy. Following that, there has been a rise in the transition of pain medicine education toward a multidisciplinary interventional model based on a tremendous surge of contemporaneous literature in these areas. This trend has created variability in clinical experience and education amongst accredited pain medicine programs with minimal literature evaluating the differences and commonalities in education and experience of different pain medicine fellowships through Program Director (PD) experiences. This study aims to gather insight from pain medicine fellowship program directors across the country to assess clinical and interventional training, providing valuable perspectives on the future of pain medicine education. METHODS: This study involved 56 PDs of ACGME-accredited pain fellowship programs in the United States. The recruitment process included three phases: advanced notification, invitation, and follow-up to maximize response rate. Participants completed a standard online questionnaire, covering various topics such as subcategory fields, online platforms for supplemental education, clinical experience, postgraduate practice success, and training adequacy. RESULTS: Surveys were completed by 39/56 (69%) standing members of the Association of Pain Program Directors (APPD). All PDs allowed fellows to participate in industry-related and professional society-related procedural workshops, with 59% encouraging these workshops. PDs emphasized the importance of integrity, professionalism, and diligence for long-term success. Fifty-four percent of PDs expressed the need for extension of fellowship training to avoid supplemental education by industry or pain/spine societies. CONCLUSION: This study highlights the challenge of providing adequate training in all Pain Medicine subtopics within a 12-month pain medicine fellowship. PDs suggest the need for additional training for fellows and discuss the importance of curriculum standardization.

Association Between First Attempt Buffalo Concussion Treadmill Test and Days to Recovery in 855 Children With Sport-Related Concussion: A Historical Cohort Study and Prognostic Factors Analysis.

OBJECTIVE: Little is known about the prognostic value of the Buffalo Concussion Treadmill Test (BCTT) after the acute phase of sport-related concussion (SRC). We examined the added prognostic value of the BCTT performed 10 to 21 days after SRC in children, in addition to participant, injury, and clinical process characteristics on days to recovery. DESIGN: Historical clinical cohort study. SETTING: Network of approximately 150 Canadian multidisciplinary primary-care clinics. PARTICIPANTS: 855 children (mean age 14 years, range 6-17 years, 44% female) who presented between January 2016, and April 2019 with SRC. ASSESSMENT OF RISK FACTORS: Participant, injury, and clinical process characteristics, with focus on BCTT exercise intolerance assessed 10 to 21 days after injury. OUTCOME: Days to clinical recovery. RESULTS: Children who were exercise intolerant experienced an increase of 13 days to recovery (95% CI, 9-18 days). Each additional day between SRC and first BCTT was associated with a recovery delay of 1 day (95% CI, 1-2 days), and prior history of concussion was associated with a recovery delay of 3 days (95% CI, 1-5 days). Participant, injury, and clinical process characteristics, and the first attempt BCTT result explained 11% of the variation in recovery time, with 4% accounted for by the BCTT. CONCLUSION: Exercise-intolerance assessed 10 to 21 days after SRC was associated with delayed recovery. However, this was not a strong prognostic factor for days to recovery.

Meta-Regression to Develop Predictive Equations for Urinary Nitrogen Excretion of Lactating Dairy Cows.

Dairy cows' urinary nitrogen (N) excretion (UN; g/d) represents a significant environmental concern due to their contribution to nitrate leaching, nitrous oxide (a potent greenhouse gas), and ammonia emissions (contributor to N deposition). The first objective of the current study was to determine the adequacy of existing models to predict UN from total mixed ration (TMR)-fed and fresh forage (FF)-fed cows. Next, we aimed to develop equations to predict UN based on animal factors [milk urea nitrogen (MUN; mg/dL) and body weight (BW, kg)] and to explore how these equations are improved when dietary factors, such as diet type, dry matter intake (DMI), or dietary characteristics [neutral detergent fiber (NDF) and crude protein (CP) content], are considered. A dataset was obtained from 51 published experiments composed of 174 treatment means. The whole dataset was used to evaluate the mean and linear biases of three existing equations including diet type as an interaction term; all models had significant linear and mean biases and two of the three models had poor predictive capabilities as indicated by their large relative prediction error (RPE; root mean square error of prediction as a percent of the observed mean). Next, the complete data set was split into training and test sets, which were used to develop and to evaluate new models, respectively. The first model included MUN and BW, and there was a significant interaction between diet type and the coefficients. This model had the worst 1:1 agreement [Lin's concordance correlation coefficient (CCC) = 0.50] and largest RPE (24.7%). Models that included both animal and dietary factors performed the best, and when included in the model, the effect of diet type was no longer significant (p > 0.10). These models all had very good agreement (CCC ≥ 0.86) and relatively low RPE (≤13.1%). This meta-analysis developed precise and accurate equations to predict UN from dairy cows in both confined and pasture-based systems.

Causes of Industrial Protein A Column Degradation, Explored Using Raman Spectroscopy.

Monoclonal antibodies (mAbs) are used extensively as biotherapeutics for chronic and acute conditions. Production of mAbs is lengthy and expensive, with protein A affinity capture the most costly step, due both to the nature of the resin and its marked reduction in binding capacity with repeated use. Our previous studies using in situ ATR-FTIR spectroscopy indicated that loss in protein A binding capacity is not the result of leaching or degradation of protein A ligand, suggesting fouling is the principal cause. Here we explore binding behavior and resin capacity loss using Raman spectroscopy. Our data reveal a distinct Raman spectral fingerprint for mAb bound to the protein A ligand of MabSelect SuRe. The results show that the drop in static binding capacity (SBC) previously observed for used protein A resin is discernible by Raman spectroscopy in combination with partial least-squares regression. The SBC is lowest (35.76 mg mL-1) for used inlet resin compared to used outlet (40.17 mg mL-1) and unused resin samples (70.35 mg mL-1). Depth profiling by Raman spectroscopy indicates that at below saturating concentrations (∼18 mg mL-1), binding of mAb is not homogeneous through used resin beads with protein binding preferentially to the outer regions of the bead, in contrast to fully homogeneous distribution through unused control MabSelect SuRe resin beads. Analysis of the Raman spectra indicates that one foulant is irreversibly bound mAb. The presence of irreversibly bound mAb and host cell proteins was confirmed by mass spectrometric analysis of used resin beads.

Dietary and Animal Strategies to Reduce the Environmental Impact of Pastoral Dairy Systems Result in Altered Nutraceutical Profiles in Milk.

The objective of this study was to evaluate and provide further insights into how dairy cows genetically divergent for milk urea N breeding values [MUNBV, high (2.21 ± 0.21) vs. low (−1.16 ± 0.21); µ ± SEM], consuming either fresh cut Plantain (Plantago lanceolata L., PL) or Ryegrass (Lolium perenne L., RG) herbage, impacted the nutraceutical profile of whole milk by investigating amino and fatty acid composition and applying metabolomic profiling techniques. Both diet and MUNBV, and their interaction term, were found to affect the relative abundance of alanine, glycine, histidine, and phenylalanine in the milk (p < 0.05), but their minor absolute differences (up to ~0.13%) would not be considered biologically relevant. Differences were also detected in the fatty acid profile based on MUNBV and diet (p < 0.05) with low MUNBV cows having a greater content of total unsaturated fatty acids (+16%) compared to high MUNBV cows and cows consuming PL having greater content of polyunsaturated fatty acids (+92%), omega 3 (+101%) and 6 (+113%) compared to RG. Differences in the metabolomic profile of the milk were also detected for both MUNBV and dietary treatments. Low MUNBV cows were found to have greater abundances of choline phosphate, phosphorylethanolamine, N-acetylglucosamine 1-phosphate, and 2-dimethylaminoethanol (p < 0.05). High MUNBV cows had a greater abundance of methionine sulfoxide, malate, 1,5-anhydroglucitol (1,5-AG), glycerate, arabitol/xylitol, 3-hydroxy-3-methylglutarate, 5-hydroxylysine and cystine (p < 0.05). Large differences (p < 0.05) were also detected as a result of diet with PL diets having greater abundances of the phytochemicals 4-acetylcatechol sulfate, 4-methylcatechol sulfate, and p-cresol glucuronide whilst RG diets had greater abundances of 2,6-dihydroxybenzoic acid, 2-acetamidophenol sulfate, and 2-hydroxyhippurate. The results of this study indicate the potential to alter the nutraceutical value of milk from dietary and genetic strategies that have been previously demonstrated to reduce environmental impact.

Examining how time from sport-related concussion to initial assessment predicts return-to-play clearance.

OBJECTIVE: (i) To analyze data of adolescents who have sustained a sport-related concussion (SRC) through the use of Complete Concussion Management Inc. (CCMI) concussion database system; and (ii) to determine an optimal time to assess and manage an athlete with an SRC by prospectively analyzing data from CCMI concussion database system. METHOD: A cohort of patients, ages 8-18 years, who sustained an SRC, assessed 30 days or less from injury and were treated at partnered CCMI clinics across Canada were prospectively followed. The primary outcome measure was recovery, defined as CCMI discharge, which includes an athlete having completed all return-to-school and return-to-play steps and passed the Gapski-Goodman test without symptom exacerbation. RESULTS: 1213 athletes (482 female) were included for analysis. Days between injury and initial assessment (p = 0.00), male sex (p = 0.00), and previous concussion history (p = 0.00) were significant predictors of time to discharge. A log-rank test revealed a significant difference (p = 0.00) in time to discharge with athletes assessed <10 days of injury discharged at a mean of 23.5 days (95% CI, 22.5, 24.5) and those assessed at day 10 to 30 were discharged at a mean of 37.1 days (95% CI, 33.7, 40.5). Athletes who were assessed at 0 to 9 days from injury were two times more likely to be discharged sooner compared to those athletes assessed 10 to 30 days from injury (HR 2.03, p = 0.00). CONCLUSION: Time from SRC to initial assessment significantly predicted time to discharge, with those being evaluated earlier experiencing a faster discharge. The results aid in establishing recommended timelines for evaluation following an SRC in order to prevent or mitigate athletes experiencing a prolonged recovery and encourage timely access to care and a quicker return to life post-concussive injury.

Varied diets: implications for lamb performance, rumen characteristics, total antioxidant status, and welfare.

Intensive pastoral systems have moved away from diverse and varied diets towards overly simple monotonous diets. Feed choice through time is an obsolete way of providing forage to animals, as intensive management schemes generally allocate a single herbage or a dyad mixed sward. Monotonous feeding regimes impose nutritional repetition, which may impair animal performance and welfare. The objective of this experiment was to determine the impact of a diverse diet [DIV; free choice from perennial ryegrass (Lolium perenne L.), plantain (Plantago lanceolata L.), alfalfa (Medicago sativa L.), and chicory (Cichorium intybus L.) at all times], a varied diet [VAR; choice from ryegrass and plantain in the AM (0700-1600 h), and chicory and alfalfa in PM (1600-0700 h)], and a single forage diet of alfalfa [SFA; alfalfa at all times], on DMI, performance, and welfare of lambs. Six-month-old Coopworth ram lambs (n = 21) were offered their respective fresh-forage treatment (n = 7) diet indoors for 20 d. The DIV lambs consumed 1.64 ± 0.03 kg DM/d (mean ± SEm), which was 6% more (P < 0.05; 1.54 ± 0.03 kg DM/d) than the SFA and were not different (P > 0.05; 1.59 ± 0.03 kg DM/d) to the VAR lambs. Average daily gain (ADG) of DIV (296 g/d) and VAR (378 g/d) was 30% and 67% greater (P < 0.05) than that in the SFA lambs (227 g/d), respectively. The VAR lambs had 28% greater (P < 0.05) ADG than the DIV lambs. Differences among treatments were detected (P < 0.05) for the proportion of the day spent conducting the following behaviors: eating, ruminating, idling, lying, and standing. In addition, the number of bouts of stereotypic behaviors recorded from the SFA lambs (13.2 ± 2.2) was 150% greater (P < 0.05) than the DIV (5.1 ± 1.0) and VAR (5.5 ± 1.0) lambs. Our results suggest that the varied diet offered can improve animal performance and welfare compared to a monotonous SFA diet. Feeding management to provide a varied diet can improve performance relative to giving lambs free choice from taxonomically diverse forage options. Moreover, performance is affected by more than the primary chemical composition of the diet consumed, but how the diet is presented through time and the herbage species and quantities of each that are consumed to reach that chemical composition.

Nitrogen Balance of Dairy Cows Divergent for Milk Urea Nitrogen Breeding Values Consuming Either Plantain or Perennial Ryegrass.

Inefficient nitrogen (N) use from pastoral dairy production systems has resulted in environmental degradation, as a result of excessive concentrations of urinary N excretion leaching into waterways and N2O emissions from urination events into the atmosphere. The objectives of this study were to measure and evaluate the total N balance of lactating dairy cows selected for milk urea N concentration breeding values (MUNBVs) consuming either a 100% perennial ryegrass (Lolium perenne L.) or 100% plantain (Plantago lanceolata L.) diet. Sixteen multiparous lactating Holstein-Friesian × Jersey cows divergent for MUNBV were housed in metabolism crates for 72 h, where intake and excretions were collected and measured. No effect of MUNBV was detected for total N excretion; however, different excretion characteristics were detected, per urination event. Low MUNBV cows had a 28% reduction in the concentration of urinary urea nitrogen (g/event) compared to high MUNBV cows when consuming a ryegrass diet. Cows consuming plantain regardless of their MUNBV value had a 62% and 48% reduction in urinary urea nitrogen (g/event) compared to high and low MUNBV cows consuming ryegrass, respectively. Cows consuming plantain also partitioned more N into faeces. These results suggest that breeding for low MUNBV cows on ryegrass diets and the use of a plantain diet will reduce urinary urea nitrogen loading rates and therefore estimated nitrate leaching values, thus reducing the environmental impact of pastoral dairy production systems.

Functional diversity vs. monotony: the effect of a multiforage diet as opposed to a single forage diet on animal intake, performance, welfare, and urinary nitrogen excretion.

The objective of this study was to determine the effect of offering animals a multiforage choice (MF) of fresh herbages on dry matter intake (DMI), live weight gain, and animal welfare, in comparison with a monotonous diet of ryegrass (Lolium perenne L.). Twenty ram lambs (30.5 ± 0.9 kg initial live weight; mean ± SEM), were randomly allocated to either a diet consisting of diverse MF choice or a single forage ryegrass (SF) diet (n = 10 per treatment) for 35 d. Both diets were fed ad libitum; however, the MF diet was composed of set dry matter ratios of 24% chicory (Cichorium intybus L.), 30% lucerne (Medicago sativa L.), 25% plantain (Plantago lanceolata L.), and 21% ryegrass. The DMI of the MF lambs was 48% greater (P < 0.01) and the within animal day-to-day coefficient of variation (CV) of intake was 26% lower (P < 0.01) than the SF lambs. The average daily gain (ADG) of lambs offered the MF diet was 92% greater (P < 0.01) than the lambs offered the SF diet. The within-animal day-to-day CV of intake was negatively related to ADG (r = -0.59; P < 0.01). The MF lamb's urinary N concentration was 30% lower (P < 0.01) than that of the SF lambs. The SF lambs spent more time (P < 0.05) exhibiting stereotypic behaviors in the afternoon and spent more time observing other animals than the MF. Overall, allocating an MF choice of fresh herbages as opposed to a single forage diet of ryegrass increases DMI and thereby animal performance, while potentially reducing urinary N excretion.

Characteristics of adolescent athletes seeking early versus late care for sport-related concussion.

OBJECTIVES: 1) To determine which characteristics of adolescent athletes with SRC are associated with 'early' versus 'late' presentation for multimodal treatment; 2) to build a propensity score to investigate the effects of treatment timing during the management of SRCs. METHODS: Associations between early (0-7 days) versus late (8-28 days) presentation for treatment and pre-specified sociodemographic, pre-injury and injury characteristics were investigated in a historical cohort study of 2949 multi-sport athletes across Canada aged 12-18 years diagnosed with a SRC in community-based healthcare clinics. RESULTS: Early presentation was associated with being male, completing a pre-injury baseline assessment, and responding 'yes' or 'no' to having a diagnosed learning disability. Older athletes who reported previous SRCs were less likely to present early. The propensity score demonstrated an area under the curve of 0.71 (95% CI, 0.69 to 0.73). CONCLUSIONS: Male athletes with a completed baseline assessment were more likely to seek early treatment following a SRC, and older athletes who reported a greater number of previous SRCs were less likely to present early. External validation of the propensity score is needed before examining the impact of treatment timing on adolescent athlete recovery outcomes.

OBJECTIFS: 1) Trouver les caractéristiques des athlètes adolescents ayant subi une CCLS qui sont associées à la consultation précoce et à une consultation tardive; 2) établir un score de propension pour étudier les effets du moment du traitement pendant la prise en charge de la CCLS. MÉTHODOLOGIE: Les liens entre la consultation précoce (de 0 à 7 jours) et la consultation tardive (de 8 à 28 jours) et les caractéristiques sociodémographiques, les caractéristiques avant la blessure et les caractéristiques après des blessure prédéterminées ont été examinés au cours d'une étude de cohorte historique menée auprès de 2 949 adolescents multisports répartis dans toutes les régions du Canada, âgés de 12 à 18 ans, chez lesquels une CCLS avait été diagnostiquée dans des cliniques de santé communautaires. RÉSULTATS: La consultation précoce a été associée au sexe masculin, à une évaluation de départ avant la blessure et à la présence ou à l'absence d'un trouble de l'apprentissage. Les athlètes plus âgés ayant signalé des CCLS antérieures étaient moins susceptibles de consulter précocement. Le score de propension a démontré une aire sous la courbe de 0,71 (IC à 95 %: 0,69 à 0,73). CONCLUSIONS: Les athlètes masculins ayant subi une évaluation de départ étaient plus susceptibles de consulter précocement après une CCRS alors que les athlètes âgés ayant déclaré un plus grand nombre de CCRS antérieures étaient moins susceptibles de consulter précocement. Une validation externe du score de propension serait nécessaire avant d'examiner l'effet du moment de la consultation sur les résultats de récupération chez les athlètes adolescents.

Predictors of Concussion Outcomes in Individuals With ADHD.

OBJECTIVES: To describe and delineate the epidemiological profile of concussion injuries in individuals with attention-deficit/hyperactivity disorder (ADHD) by identifying characteristics associated with poorer outcomes. SETTING: One hundred forty-four multidisciplinary concussion-specialized clinics across Canada. PARTICIPANTS: Two hundred twenty-two individuals with a diagnosis of ADHD aged 7 to 53 years who sustained a concussion within the last year. DESIGN: Multicenter cohort study. MAIN MEASURES: Candidate predictor variables (ie, age, sex, concussion history, loss of consciousness, and internalized and learning disorder comorbidities) were collected through oral interviews. Concussion outcomes (ie, symptom severity and total number of symptoms experienced) were assessed with the Sport Concussion Assessment Tool. RESULTS: Older age, female sex, and the presence of an internalized disorder predicted poorer concussion outcomes in individuals with ADHD. Males with ADHD reported significantly worse concussion outcomes with increasing age, while outcomes remained fairly stable across age in females. CONCLUSION: The current findings represent a promising step toward the optimization of concussion management in individuals with ADHD. With a more thorough understanding of the demographic and comorbidity variables, clinical care decisions and intervention strategies can be developed to help individuals with ADHD who might be at a higher risk of poorer outcomes following a concussion.

Multi-modal management of sport and non-sport related concussion by chiropractic sports specialists: a case series.

This case series describes the multi-modal treatment plans delivered by two chiropractic sports specialists for the management of post-concussive symptoms (PCS). Three concussion cases are presented each with different mechanisms of injury (two sportrelated and one non-sport-related) and each within a different stage of recovery (acute, sub-acute, and chronic). Treatment plans included patient education, sub-symptom threshold exercise, soft-tissue therapy, spinal manipulation, and cervical spine as well as visual/vestibular rehabilitation exercises. This series highlights three important observations: (1) the efficacy of individualized, multi-modal treatment plans based on suggested clinical profiles for patients with PCS of various stages; (2) that the delineation of concussion literature based on mechanism of injury (i.e. sport- vs. non-sport-related) may be unnecessary; and (3) these cases provide encouraging evidence to support the inclusion of manual therapists with advanced knowledge of concussion treatment, such as chiropractors, as part of the interdisciplinary healthcare team when managing patients with PCS.

Cette série de cas sert à présenter les plans multimodaux utilisés par deux spécialistes de la chiropratique sportive pour traiter des symptômes postcommotionnels (SPC). Trois cas de commotion cérébrale pour chaque type de mécanisme de lésion (deux cas de blessure liée au sport et un cas de blessure non liée au sport), chacun avec un stade différent (aigu, subaigu et chronique). Les plans de traitement englobaient l'information au patient, la réduction du seuil nociceptif par des exercices, le traitement des tissus mous, des manipulations vertébrales, des manipulations cervicales et des exercices de rééducation visuelle et/ou vestibulaire. Cette série de cas met en relief trois importantes observations, à savoir : 1)l'efficacité des plans multimodaux personnalisés élaborés selon les profils cliniques suggérés de patients présentant des SPC de divers stades sont efficaces; 2) la segmentation de la littérature sur la commotion cérébrale selon le mécanisme de la blessure (commotion liée au sport et commotion non liée au sport) pourrait s'avérer superflue; et 3) ces cas fournissent des preuves encourageantes qu'il est pertinent d'inclure un thérapeute manuel possédant des connaissances poussées en matière de traitement des commotions cérébrales, comme le chiropraticien, à l'équipe interdisciplinaire de soins de santé prenant soin du patient ayant des SPC.

Lifetime prevalence of concussion among Canadian ice hockey players aged 10 to 25 years old, 2014 to 2017.

BACKGROUND: The primary objective of this study was to identify the self-reported lifetime prevalence of diagnosed concussions among Canadian ice hockey players aged 10 to 25 years old. METHOD: Medical records were identified for n=5223 athletes whom completed comprehensive baseline assessments with a Canada-wide network of private concussion management clinics. Variables extracted included: sex, age, diagnosed history of and number of prior concussions, diagnosed health condition(s), and Post-Concussion Symptom Scale scores. RESULTS: Approximately 22% of all athletes, 21.7% of females and 21.8% of males reported that they had sustained at least one diagnosed concussion. Age was significantly associated with history of concussion as was having an additional health condition. Sex was not significantly associated with a history of concussion. CONCLUSION: Lifetime history of concussion prevalence estimates aligned closely with estimates previously published. Future investigations should seek to establish the prevalence of concussions that occur during ice hockey games and practices alone.

CONTEXTE: L'objectif principal de cette étude était de déterminer la prévalence autodéclarée au cours de la vie des commotions cérébrales diagnostiquées chez les joueurs canadiens de hockey sur glace âgés de 10 à 25 ans. MÉTHODE: Des dossiers médicaux ont été identifiés pour 5223 athlètes qui ont effectué des évaluations de base complètes avec un réseau pancanadien de cliniques privées de gestion des commotions cérébrales. Les variables extraites comprenaient : le sexe, l'âge, les antécédents diagnostiqués et le nombre de commotions cérébrales antérieures, le ou les problèmes de santé diagnostiqués et les scores de l'échelle des symptômes après la commotion cérébrale. RÉSULTATS: Environ 22 % de tous les athlètes, 21,7 % des femmes et 21,8 % des hommes ont déclaré avoir reçu au moins un diagnostic de commotion cérébrale. L'âge était associé de façon significative aux antécédents de commotion cérébrale tout comme le fait d'avoir un autre problème de santé. Le sexe n'était pas associé de façon significative à des antécédents de commotion cérébrale. CONCLUSION: Les estimations de la prévalence des antécédents de commotion cérébrale au cours de la vie concordent étroitement avec les estimations publiées antérieurement. Les enquêtes futures devraient chercher à établir la prévalence des commotions cérébrales qui surviennent uniquement pendant les parties et les pratiques de hockey sur glace.

Interaction between Age, Sex, and Mental Health Status as Precipitating Factors for Symptom Presentation in Concussed Individuals.

Concussions are among the most common neurological conditions, with emergency departments and sports injury clinics seeing hundreds of patients each year. The consideration of risk factors such as age, sex, and comorbid conditions are very important when looking at individual physiological and psychological outcomes after a concussion. The purpose of this study was to look at four comorbid conditions (depression, anxiety, behavioural disorder, or learning disability) and identify any interactions with age and sex in symptom presentation after suffering a concussion. A total of 4,865 participants from the CCMI (Complete Concussion Management Inc.) dataset were used with 1,577 self-identified with a diagnosis of anxiety, depression, a behavioural disorder, or a learning disability. Fixed-factor analyses of variance were used with age and sex as fixed, grouping factors and symptom total and severity as dependent measures. For the individuals who did not have one of the 4 mental health conditions (3,288 control participants), symptom total and symptom severity increased with age (p < 0.05), and females showed more symptoms and a higher symptom severity than males across all ages (p < 0.05). A diagnosis of anxiety or depression exacerbated total symptoms and symptom severity from 25-50% above control levels in the 19 and under age groups, while depression or anxiety exacerbated total symptoms and severity by 10-15% in males more than females over 20. A diagnosis of a behavioural disorder or a learning disability exacerbated symptom severity by approximately 50% above control levels in 13-19-year-old females and in males of 30 years and older. This study highlights how the presence of a mental health condition may alter concussion symptom presentation dependent on age and sex. The identification of risk factors and how they may interact can be of great value to health care providers who manage concussion symptoms and recovery.

Pubic stress fracture presenting as a strain of adductor longus in a 16-year-old elite soccer player with Crohn's disease: a case report.

BACKGROUND: Adductor strains are the most commonly reported muscle injuries in adolescent soccer players and the second most common muscle injuries in adult players. Health practitioners should be aware of possible differential diagnoses, such as a pubic stress fracture or pubic apophysitis when athletes present with chronic groin pain. PURPOSE: To present a rare case of a unilateral pelvic stress fracture of a 16-year old elite soccer player with a history of Crohn's disease. STUDY DESIGN: Retrospective case report (n=1). METHODS: Case notes of two sports-based practitioners were reviewed and compiled retrospectively. RESULTS: Following activity restriction, a period of rest, conservative care, and progressive rehabilitation, this athlete was able to achieve a pain-free state with near equal iso-kinetic strength bilaterally as measured by Cybex 6000 (Cybex International Inc., Medway, MA, USA) muscle testing. Full activity was resumed 10 months after initial presentation and the athlete was able to return to playing professional soccer. SUMMARY: This case report presents a rare diagnosis of a unilateral pubic stress fracture presenting as a strain of adductor longus. Although quite rare, differential diagnoses such as a potential underlying stress fracture should be considered when presented with chronic or recurrent groin pain.

CONTEXTE: Les entorses des adducteurs sont les blessures musculaires les plus fréquemment signalées chez les joueurs de soccer adolescents et les deuxièmes blessures musculaires les plus fréquentes chez les joueurs adultes. Les professionnels de la santé devraient connaitre les diagnostics différentiels possibles, comme une fracture de stress du pubis ou une apophysite pubienne lorsque les athlètes présentent des douleurs chroniques à l'aine. OBJECTIF: Présenter un cas rare de fracture de stress pelvien unilatéral chez un joueur de soccer d'élite de 16 ans ayant des antécédents de maladie de Crohn. PLAN D'ÉTUDE: Cas clinique rétrospectif (n=1). MÉTHODOLOGIE: Les notes de cas de deux praticiens du sport ont été examinées et compilées rétrospectivement. RÉSULTATS: Après une période de restriction d'activité, une période de repos, des soins conservateurs et une rééducation progressive, cet athlète a pu atteindre un état indolore avec une force isocinétique bilatérale presque égale, mesurée par le test musculaire Cybex 6000 (Cybex International Inc., Medway, MA, USA). L'activité sportive complète a repris 10 mois après la présentation initiale et l'athlète a pu recommencer à jouer au soccer à un niveau professionnel. RÉSUMÉ: Ce cas clinique présente un diagnostic rare de fracture de stress pubien unilatéral se présentant sous la forme d'une lésion du moyen adducteur. Bien qu'ils soient assez rares, les diagnostics différentiels tels qu'une fracture de stress sousjacente potentielle devraient être pris en considération dans le cas d'une douleur chronique ou récurrente à l'aine.

The use of an intensive physical exertion test as a final return to play measure in concussed athletes: a prospective cohort.

OBJECTIVES: To examine the utility of a novel physical exertion test developed by the Chicago Blackhawks medical staff as a final return to play (RTP) clearance test in youth and young adult athletes, and to determine the relationship between participant and test variables on RTP within asymptomatic athletes diagnosed with concussion. METHODS: Once asymptomatic and following completion of all RTP steps, concussed athletes underwent the Gapski-Goodman Test (GGT) or modified GGT (mGGT) at partnered Complete Concussion Management Inc. (CCMI) clinics as part of RTP decision-making. Prospective data was collected electronically by trained CCMI clinicians utilizing the CCMI Concussion Database System. A review was conducted to examine data collected between January 2016 and February 2017. Participant and test variables were analyzed to determine relationships with pass/fail rate of the GGT/mGGT. RESULTS: A total of 759 athletes performed the GGT/mGGT in the study period. Although all asymptomatic, 14.6% of concussed athletes failed the GGT/mGGT while attempting to achieve RTP clearance. Statistically significant relationships were found between failure of the test and symptom severity score on initial presentation and self-reported history of pre-morbid anxiety. When taken together, sex, age, and pre-morbid anxiety significantly predicted the length of time between injury and RTP clearance. CONCLUSION: The GGT may identify individuals who are not ready to RTP despite a self-reported asymptomatic status and completion of all RTP steps. These results illustrate that RTP clearance decisions based on self-reported asymptomatic status at rest may be inadequate. Instead, monitored, intensive, sport-specific, physical exertion testing should be utilized to inform clinical RTP decisions.

Absence of Tumor Necrosis Factor Supports Alternative Activation of Macrophages in the Liver after Infection with Leishmania major.

The absence of tumor necrosis factor (TNF) causes lethal infection by Leishmania major in normally resistant C57BL/6J (B6.WT) mice. The underlying pathogenic mechanism of this fatal disease has so far remained elusive. We found that B6.WT mice deficient for the tnf gene (B6.TNF-/-) displayed not only a non-healing cutaneous lesion but also a serious infection of the liver upon L. major inoculation. Infected B6.TNF-/- mice developed an enlarged liver that showed increased inflammation. Furthermore, we detected an accumulating monocyte-derived macrophage population (CD45+F4/80+CD11bhiLy6Clow) that displayed a M2 macrophage phenotype with high expression of CD206, arginase-1, and IL-6, supporting the notion that IL-6 could be involved in M2 differentiation. In in vitro experiments, we demonstrated that IL-6 upregulated M-CSF receptor expression and skewed monocyte differentiation from dendritic cells to macrophages. This was countered by the addition of TNF. Furthermore, TNF interfered with the activation of IL-6-induced gp130-signal transducer and activator of transcription (STAT) 3 and IL-4-STAT6 signaling, thereby abrogating IL-6-facilitated M2 macrophage polarization. Therefore, our results support the notion of a general role of TNF in the inflammatory activation of macrophages and define a new role of IL-6 signaling in macrophage polarization downstream of TNF.

The role of the cervical spine in post-concussion syndrome.

While much is known regarding the pathophysiology surrounding concussion injuries in the acute phase, there is little evidence to support many of the theorized etiologies to post-concussion syndrome (PCS); the chronic phase of concussion occurring in ∼ 10-15% of concussed patients. This paper reviews the existing literature surrounding the numerous proposed theories of PCS and introduces another potential, and very treatable, cause of this chronic condition; cervical spine dysfunction due to concomitant whiplash-type injury. We also discuss a short case-series of five patients with diagnosed PCS having very favorable outcomes following various treatment and rehabilitative techniques aimed at restoring cervical spine function.

Sports-related concussion: A narrative review of the literature.

Sports-related concussion has gained widespread interest and media attention in recent years due to the potential dangers and long-term consequences. Despite several international consensus statements there remains a great deal of uncertainty surrounding these injuries. This paper is a review of recent literature on the topic of concussion, consisting of: biomechanics, pathophysiology, diagnosis and sideline management.