An Exploratory Analysis of Physical Examination Subtypes in Pediatric Athletes With Concussion.

OBJECTIVE: Pediatric athletes with concussion present with a variety of impairments on clinical assessment and require individualized treatment. The Buffalo Concussion Physical Examination is a brief, pertinent clinical assessment for individuals with concussion. The purpose of this study was to identify physical examination subtypes in pediatric athletes with concussion within 2 weeks of injury that are relevant to diagnosis and treatment. DESIGN: Secondary analysis of a published cohort study and clinician consensus. SETTING: Three university-affiliated sports medicine centers. PARTICIPANTS: Two hundred seventy children (14.9 ± 1.9 years). INDEPENDENT VARIABLES: Orthostatic intolerance, horizontal and vertical saccades, smooth pursuits, vestibulo-ocular reflex, near-point convergence, complex tandem gait, neck range of motion, neck tenderness, and neck spasm. MAIN OUTCOME MEASURES: Correlations between independent variables were calculated, and network graphs were made. k-means and hierarchical clustering were used to identify clusters of impairments. Optimal number of clusters was assessed. Results were reviewed by experienced clinicians and consensus was reached on proposed subtypes. RESULTS: Physical examination clusters overlapped with each other, and no optimal number of clusters was identified. Clinician consensus suggested 3 possible subtypes: (1) visio-vestibular (horizontal and vertical saccades, smooth pursuits, and vestibulo-ocular reflex), (2) cervicogenic (neck range of motion and spasm), and (3) autonomic/balance (orthostatic intolerance and complex tandem gait). CONCLUSIONS: Although we identified 3 physical examination subtypes, it seemed that physical examination findings alone are not enough to define subtypes that are both statistically supported and clinically relevant, likely because they do not include symptoms, assessment of mood or cognitive problems, or graded exertion testing.

Optimization of Advanced Molecular Genetic Testing Utilization in Hematopathology: A Goldilocks Approach to Bone Marrow Testing.

PURPOSE: This study investigated the effectiveness of algorithmic testing in hematopathology at the Brigham and Women's Hospital and Dana-Farber Cancer Institute (DFCI). The algorithm was predicated on test selection after an initial pathologic evaluation to maximize cost-effective testing, especially for expensive molecular and cytogenetic assays. MATERIALS AND METHODS: Standard ordering protocols (SOPs) for 17 disease categories were developed and encoded in a decision support application. Six months of retrospective data from application beta testing was obtained and compared with actual testing practices during that timeframe. In addition, 2 years of prospective data were also obtained from patients at one community satellite site. RESULTS: A total of 460 retrospective cases (before introduction of algorithmic testing) and 109 prospective cases (following introduction) were analyzed. In the retrospective data, 61.7% of tests (509 of 825) were concordant with the SOPs while 38.3% (316 of 825) were overordered and 30.8% (227 of 736) of SOP-recommended tests were omitted. In the prospective data, 98.8% of testing was concordant (244 of 247 total tests) with only 1.2% overordered tests (3 of 247) and 7.6% omitted tests (20 of 264 SOP-recommended tests; overall P < .001). The cost of overordered tests before implementing SOP indicates a potential annualized saving of $1,347,520 in US dollars (USD) in overordered testing at Brigham and Women's Hospital/DFCI. Only two of 316 overordered tests (0.6%) returned any additional information, both for extremely rare clinical circumstances. CONCLUSION: Implementation of SOPs dramatically improved test ordering practices, with a just right number of ancillary tests that minimizes cost and has no significant impact on acquiring key informative test results.

Identification of pre-race ultrasonographic abnormalities of the Achilles tendon and association with future injuries in runners.

OBJECTIVE: To determine if specific morphological changes in ultrasonographic images of Achilles tendons are associated with the development of pain in distance runners. METHODS: This study is a blinded, retrospective analysis of 276 Achilles tendon ultrasound images, which were used to determine if specific morphologic findings could positively or negatively predict future Achilles tendon pain development in distance runners. Pre-race ultrasound scans were performed on 138 asymptomatic half- and full marathon runners (276 tendons in total) who were followed for 12 months after their races. Specific patterns of morphologic abnormality were identified (location, size, and appearance of ultrasound abnormality within the tendon). Sonographic findings were blindly assessed by a medical student, a resident, and a physician who has significant sonographic imaging experience. These specific abnormalities were then compared to those who later did or did not develop tendon pain. RESULTS: Three findings were found to have significant odds of association with the development of pain: 1) focal deep midsubstance intratendinous hypoechogenicity, 2) focal superficial midsubstance intratendinous hypoechogenicity, and 3) linear hyperechogenicity extending into middle of tendon from calcaneus. CONCLUSION: These results suggest that the aforementioned specific morphologic abnormalities in the Achilles tendon may be associated with the future development of pain symptoms in distance runners in this cohort. Looking for these specific abnormalities may increase the specificity of identifying precursors to Achilles tendon pain development.

Guided, motor, and mental imagery adjuncts to teaching central venous access.

Background: Mental, motor, and guided imagery techniques are commonly used in sports psychology, but less often in medical education. Utilization of imagery-based techniques (IBTs) in combination with traditional teaching methods may provide a low-cost, innovative approach to improving outcomes in graduate medical education. Objective: The objective was to assess whether medical students demonstrate greater proficiency in the ability to obtain central venous access in simulation trainers following exposure to guided, mental, and motor imagery teaching methods in comparison to traditional methods. Methods: Volunteer fourth-year medical students during their emergency medicine rotation were randomly assigned to two groups, traditional plus imagery teaching or traditional teaching alone. The control group watched a video tutorial on central line placement methods. The study group watched the same video with the addition of imagery components. Participants filled out survey questions before and after the video and again after line placement. Proctors blinded to student group assignments then observed student placement of an internal jugular triple-lumen catheter on a simulation trainer and completed a standardized performance rubric. Results: Sixty medical students participated. Two were excluded for having performed five or more lines either clinically or in a previous simulation. There was no difference in self-perceived competence in line placement prior to watching the video or in the number of lines previously performed between groups. The imagery group (n = 25) averaged 1.3 errors/need for intervention compared to 2.2 errors/need for intervention in the control group (n = 33; p = 0.045, 95% confidence interval [CI] 0.02 to 1.61). Time to place the line was similar-8.9 min for the control group versus 8.6 min for the imagery group (p = 0.74, 95% CI -1.39 to 1.95). Conclusions: The use of IBTs may be a promising adjunct to traditional medical teaching of procedures in emergency medicine.

Sensitivity and Specificity of Exercise Intolerance on Graded Exertion Testing for Diagnosing Sport-Related Concussion: A Systematic Review and Exploratory Meta-Analysis.

Abstract There is no single gold standard test to diagnose sport-related concussion (SRC). Concussion-related exercise intolerance, that is, inability to exercise to the individual's appropriate level due to exacerbation of concussion-like symptoms, is a frequent finding in athletes early after SRC that has not been systematically evaluated as a diagnostic test of SRC. We performed a systematic review and proportional meta-analysis of studies that evaluated graded exertion testing in athletes after SRC. We also included studies of exertion testing in healthy athletic participants without SRC to assess specificity. Pubmed and Embase were searched in January 2022 for articles published since 2000. Eligible studies included those that performed graded exercise tolerance tests in symptomatic concussed participants (> 90% of subjects had an SRC, seen within 14 days of injury), at the time of clinical recovery from SRC, in healthy athletes, or both. Study quality was assessed using the Newcastle-Ottawa Scale. Twelve articles met inclusion criteria, most of which were of poor methodological quality. The pooled estimate of incidence of exercise intolerance in participants with SRC equated to an estimated sensitivity of 94.4% (95% confidence interval [CI]: 90.8, 97.2). The pooled estimate of incidence of exercise intolerance in participants without SRC equated to an estimated specificity of 94.6% (95% CI: 91.1, 97.3). The results suggest that exercise intolerance measured on systematic testing within 2 weeks of SRC may have excellent sensitivity for helping to rule in the diagnosis of SRC and excellent specificity for helping to rule out SRC. A prospective validation study to determine the sensitivity and specificity of exercise intolerance on graded exertion testing for diagnosing SRC after head injury as the source of symptoms is warranted.

Dual Component Passive Icephobic Coatings with Micron-Scale Phase-Separated 3D Structures.

A passive icephobic coating (τice < 20 kPa) is an enabling technology to many industries, including aerospace and energy and power generation, with recent efforts in materials research identifying strategies to achieve this low adhesion threshold. To better meet this need, we have combined low surface energy perfluoropolyether (PFPE) and hydrophilic poly(ethylene glycol) (PEG) species in a segmented polyurethane thermoplastic elastomer. Coating microstructure presents a segregated 3D morphology at the micron-scale (1-100 µm) with discrete PFPE and continuous PEG phases self-similar through the thickness. Spray application produces a solid, mechanically tough film free of additive fluids or sacrificial elements, demonstrating exceptional ice adhesion reduction up to 1000× lower versus aluminum (τice < 1 kPa), as measured under environmentally realistic accretion and centrifugal test shedding conditions. Finally, the modular nature of the synthetic system allows PEG and PFPE to be exchanged for poly(tetramethylene oxide) to investigate performance drivers.

htsget: a protocol for securely streaming genomic data.

Summary: Standardized interfaces for efficiently accessing high-throughput sequencing data are a fundamental requirement for large-scale genomic data sharing. We have developed htsget, a protocol for secure, efficient and reliable access to sequencing read and variation data. We demonstrate four independent client and server implementations, and the results of a comprehensive interoperability demonstration. Availability and implementation: http://samtools.github.io/hts-specs/htsget.html. Supplementary information: Supplementary data are available at Bioinformatics online.

Highly curved image sensors: a practical approach for improved optical performance.

The significant optical and size benefits of using a curved focal surface for imaging systems have been well studied yet never brought to market for lack of a high-quality, mass-producible, curved image sensor. In this work we demonstrate that commercial silicon CMOS image sensors can be thinned and formed into accurate, highly curved optical surfaces with undiminished functionality. Our key development is a pneumatic forming process that avoids rigid mechanical constraints and suppresses wrinkling instabilities. A combination of forming-mold design, pressure membrane elastic properties, and controlled friction forces enables us to gradually contact the die at the corners and smoothly press the sensor into a spherical shape. Allowing the die to slide into the concave target shape enables a threefold increase in the spherical curvature over prior approaches having mechanical constraints that resist deformation, and create a high-stress, stretch-dominated state. Our process creates a bridge between the high precision and low-cost but planar CMOS process, and ideal non-planar component shapes such as spherical imagers for improved optical systems. We demonstrate these curved sensors in prototype cameras with custom lenses, measuring exceptional resolution of 3220 line-widths per picture height at an aperture of f/1.2 and nearly 100% relative illumination across the field. Though we use a 1/2.3" format image sensor in this report, we also show this process is generally compatible with many state of the art imaging sensor formats. By example, we report photogrammetry test data for an APS-C sized silicon die formed to a 30° subtended spherical angle. These gains in sharpness and relative illumination enable a new generation of ultra-high performance, manufacturable, digital imaging systems for scientific, industrial, and artistic use.

Hierarchical carbon foams with independently tunable mesopore and macropore size distributions.

Hierarchical carbon foams with independently tunable mesopore and macropore size distributions were formed in a high internal phase emulsion (HIPE) template. The HIPE consists of an internal oil phase that controls the macropore dimensions and an aqueous resorcinol-formaldehyde precursor solution external phase that directs the mesopore size distribution. Once the emulsion is formed, the precursor solution is cured, fluid elements are extracted from the monolith via solvent exchange, and then the sample is pyrolyzed to create a hierarchical open-cell foam consisting of macropores with mesoporous carbon xerogel walls. Both mesopore and macropore size distributions may be independently tuned by changing the synthesis parameters. These samples have a peak in the mesopore size distribution that may be tuned to between 5 and 8 nm and macropore average diameters that may be tuned to between 0.7 and 2.1 microm. Furthermore, the 0.7 and 2.1 microm average diameter macropores have 0.18 and 0.53 microm diameter macropore windows between adjacent pores, respectively. Pore volumes up to 5.26 cm(3)/g and electrical conductivities as high as 0.34 S/cm are observed after 1200 degrees C carbonization of the framework. These foams may have potential applications as 3-D current collectors in batteries and as fuel cell catalyst supports.

Bacterial plaque retention on oral hard materials: effect of surface roughness, surface composition, and physisorbed polycarboxylate.

Bacterial adhesion to oral hard materials is dependent on various factors, for example, surface roughness and surface composition. In this study, bacteria retention on three oral hard substrates, hydroxyapatite (HAP), enamel, and polished enamel (p-enamel) were investigated. The surface morphology and roughness of the three substrates were measured by scanning probe microscopy. HAP had the roughest surface, followed by enamel and polished enamel. For each individual substrate type, the roughness was shown to increase with scan size up to 50 microm x 50 microm. For HAP and enamel, roughness decreased considerably after formation of a pellicle, while addition of polymer coating to the pellicle layer reduced roughness much less in comparison. Bacterial surface coverage was measured at 30 min, 3 h, and 24 h on both native and surface-modified substrates, which were coated with two different polycarboxylate-based polymers, Gantrez S97 and Carbopol 940. As a result, the polymer coated surfaces had reduced bacteria coverage compared with the native surfaces over all time points and substrates measured. The reduction is the combined effect of electrostatic repulsion and sequestering of Ca(2+) ions at the surface, which plays a key role in the initial adhesion of bacteria to enamel surfaces in models of plaque formation.

Biocompatibility of amphiphilic diblock copolypeptide hydrogels in the central nervous system.

Amphiphilic diblock copolypeptide hydrogels (DCHs) are synthetic materials whose properties can be varied readily and predictably by altering copolymer chain length or composition and which are of potential interest for biomaterial applications. We tested the biocompatibility in the central nervous system (CNS) of DCH composed of lysine, homoarginine or glutamate in combination with leucine. A range of DCH formulations with rheological properties similar to brain tissue were injected into mouse forebrain and examined after 1-8 weeks using light microscopy, immunohistochemistry and electron microscopy. DCH deposits elicited no more gliosis, inflammation, or toxicity to neurons, myelin or axons than did injections of physiological saline. The size, rigidity, and density of DCH deposits could be varied subtly by altering DCH composition and concentration. For any given DCH formulation, increased concentration correlated with increased gel strength in vitro and increased deposit size in vivo. DCHs of lysine and leucine (K(m)L(n)) were selected for detailed analyses because these formed deposits with desirable physical properties and since lysine is routinely used as a substrate for neural cell cultures. Deposits of unmodified K(180)L(20) exhibited time-dependent in-growth of blood vessels and of certain glial cells, and limited in-growth of nerve fibers. These findings show that DCHs are injectable, re-assemble in vivo to form 3-dimensional deposits, exhibit little or no detectable toxicity in the CNS, integrate well with brain tissue and represent a new class of synthetic biomaterials with potential for applications as depots or scaffolds in the CNS.

Effect of chemistry and morphology on the biofunctionality of self-assembling diblock copolypeptide hydrogels.

Amphiphilic, diblock copolypeptides of hydrophilic lysine or glutamic acid and hydrophobic leucine or valine have been observed to self-assemble into rigid hydrogels in aqueous solution at neutral pH and very low volume fraction of polymer, > or =0.5 wt % polypeptide. Laser scanning confocal microscopy and ultra small angle neutron scattering revealed a heterogeneous microstructure with distinct domains of hydrogel matrix and pure water pores. In situ nanoscale characterization, using cryogenic transmission electron microscopy, revealed a porous, interconnected membranous network of assembled polypeptides. At concentrations of polypeptide below gelation, diblocks containing lysine were cytotoxic to cells, whereas those containing glutamic acid were noncytotoxic. At higher polypeptide concentrations, within rigid gel scaffolds, both lysine and glutamic acid based diblocks were noncytotoxic but did not support cell attachment/proliferation. The cationic chemistry observed as cytotoxic in the fluid state was essentially inert in the intact, rigid hydrogel state.

Unusual salt stability in highly charged diblock co-polypeptide hydrogels.

The stability and properties of dilute solution hydrogels, synthesized by transition metal mediated polymerization of amino acid N-carboxyanhydrides (NCAs), have been studied in deionized (DI) water as well as various ionic media. These hydrogels are diblock amphiphilic copolymers of hydrophilic, charged segments of poly(l-lysine HBr) or poly(l-glutamic acid sodium salt), and helical, hydrophobic segments of poly(l-leucine). While many of these samples are able to form strong gels in deionized water at polymer concentrations as low as 0.25 wt %, stability in salt or buffer solutions was found to be only achieved at moderately higher polymer concentrations ( approximately 3.0 wt %). We have adjusted relative copolymer compositions and molecular weights to optimize hydrogel strength and polymer solubility in salt concentrations up to 0.5 M NaCl, as well as in cell growth media and aqueous buffers of varying pH. These materials are unique since they do not collapse in high ionic strength media, even though gel formation is contingent upon the presence of highly charged polyelectrolyte segments. The remarkable properties of these hydrogels make them excellent candidates for use as scaffolds in biomedical applications, such as tissue regeneration.

Rapidly recovering hydrogel scaffolds from self-assembling diblock copolypeptide amphiphiles.

Protein-based hydrogels are used for many applications, ranging from food and cosmetic thickeners to support matrices for drug delivery and tissue replacement. These materials are usually prepared using proteins extracted from natural sources, which can give rise to inconsistent properties unsuitable for medical applications. Recent developments have utilized recombinant DNA methods to prepare artificial protein hydrogels with specific association mechanisms and responsiveness to various stimuli. Here we synthesize diblock copolypeptide amphiphiles containing charged and hydrophobic segments. Dilute solutions of these copolypeptides would be expected to form micelles; instead, they form hydrogels that retain their mechanical strength up to temperatures of about 90 degrees C and recover rapidly after stress. The use of synthetic materials permits adjustment of copolymer chain length and composition, which we varied to study their effect on hydrogel formation and properties. We find that gelation depends not only on the amphiphilic nature of the polypeptides, but also on chain conformations--alpha-helix, beta-strand or random coil. Indeed, shape-specific supramolecular assembly is integral to the gelation process, and provides a new class of peptide-based hydrogels with potential for applications in biotechnology.