Concussion and long-term cognitive function among rugby players-The BRAIN Study.

OBJECTIVE: The BRAIN Study was established to assess the associations between self-reported concussions and cognitive function among retired rugby players. METHODS: Former elite-level male rugby union players (50+ years) in England were recruited. Exposure to rugby-related concussion was collected using the BRAIN-Q tool. The primary outcome measure was the Preclinical Alzheimer Cognitive Composite (PACC). Linear regressions were conducted for the association between concussion and PACC score, adjusting for confounders. RESULTS: A total of 146 participants were recruited. The mean (standard deviation) length of playing career was 15.8 (5.4) years. A total of 79.5% reported rugby-related concussion(s). No association was found between concussion and PACC (ß -0.03 [95% confidence interval (CI): -1.31, 0.26]). However, participants aged 80+ years reporting 3+ concussions had worse cognitive function than those without concussion (ß -1.04 [95% CI: -1.62, -0.47]). CONCLUSIONS: Overall there was no association between concussion and cognitive function; however, a significant interaction with age revealed an association in older participants.

Concussion and long-term cognitive impairment among professional or elite sport-persons: a systematic review.

INTRODUCTION: Understanding whether concussion in sport is associated with worsening cognitive function in later life will likely have immediate repercussion on sports concussion prevention and management policy and sporting rules and regulations. This systematic review aims to summarise the evidence on the association between concussion sustained by professional/elite athletes and long-term cognitive impairment. METHODS: Embase, PubMed and Web of Science were used to search for eligible studies. Studies including professional/elite athletes from any sport were considered. Three comparison groups were considered: internal comparison (concussed vs non-concussed athletes within the same sample); between-sport comparison (contact sport athletes vs non-contact sports ones); external comparison (athletes vs samples of the general population or population norms). RESULTS: 14 studies were included (rugby, American football, ice hockey players, boxers and marital art fighters). The general quality of the evidence was poor. The overall evidence, weighted for type of comparison and study quality, points towards an association between sustaining a sport-related concussion and poorer cognitive function later in life in rugby, American football and boxing, although it is unclear to what extent this is clinically relevant. Data on ice hockey and martial arts were too sparse to allow conclusions to be drawn. CONCLUSION: High-quality, appropriately designed and powered epidemiological studies are urgently needed to assess the association between sustaining a sport-related concussion and cognitive impairment later in life. Particular emphasis should be put on the clinical translational value of findings.

Perceptions of quality and safety and experience of adverse events in 27 European Union healthcare systems, 2009-2013.

OBJECTIVE: To assess trends in the perception of quality and safety between 2009 and 2013 in the European Union (EU). DESIGN: We analysed data from waves 72.2 and 80.2 of the Eurobarometer survey. Multilevel logistic regression models adjusted for sociodemographic factors and country-level health expenditure were fitted to assess changes between 2009 and 2013 in each of the assessed outcomes. SETTING: Twenty-seven EU member states. PARTICIPANTS: A total of n = 26 663 (2009) and n = 26 917 (2013) individuals aged ≥15 years. MAIN OUTCOME MEASURE(S): Outcomes included the perception of being harmed in hospital and non-hospital care; rating of the overall quality of the healthcare system; and personal or family experience of adverse events. RESULTS: Respondents in 2013 were more likely to think that it was likely to be harmed in hospital (Odds Ratio [OR] = 1.09; 95% Confidence Interval [CI]: 1.05-1.13; P < 0.001) and non-hospital care (OR = 1.11; 95% CI: 1.07-1.15; P < 0.001), compared to 2009. However, they were more likely to rate the quality of their country's healthcare system as good (OR = 1.26; 95% CI: 1.21-1.32; P < 0.001) and no significant change over time was identified in reported experience of adverse events (OR = 1.00; 95% CI: 0.95-1.05; P = 0.929). Lower health expenditure and decrease in health expenditure between the two waves were associated with worse outcomes in overall quality and perceptions of harm. There was significant variation between and within countries in all indicators. CONCLUSIONS: The public's perception of safety in European healthcare systems declined in recent years, which highlights that there are safety issues that could be addressed.

What is the suitability of clinical vignettes in benchmarking the performance of online symptom checkers? An audit study.

OBJECTIVE: Assess the suitability of clinical vignettes in benchmarking the performance of online symptom checkers (OSCs). DESIGN: Observational study using a publicly available free OSC. PARTICIPANTS: Healthily OSC, which provided consultations in English, was used to record consultation outcomes from two lay and four expert inputters using 139 standardised patient vignettes. Each vignette included three diagnostic solutions and a triage recommendation in one of three categories of triage urgency. A panel of three independent general practitioners interpreted the vignettes to arrive at an alternative set of diagnostic and triage solutions. Both sets of diagnostic and triage solutions were consolidated to arrive at a final consolidated version for benchmarking. MAIN OUTCOME MEASURES: Six inputters simulated 834 standardised patient evaluations using Healthily OSC and recorded outputs (triage solution, signposting, and whether the correct diagnostic solution appeared first or within the first three differentials). We estimated Cohen's kappa to assess how interpretations by different inputters could lead to divergent OSC output even when using the same vignette or when compared with a separate panel of physicians. RESULTS: There was moderate agreement on triage recommendation (kappa=0.48), and substantial agreement on consultation outcomes between all inputters (kappa=0.73). OSC performance improved significantly from baseline when compared against the final consolidated diagnostic and triage solution (p<0.001). CONCLUSIONS: Clinical vignettes are inherently limited in their utility to benchmark the diagnostic accuracy or triage safety of OSC. Real-world evidence studies involving real patients are recommended to benchmark the performance of OSC against a panel of physicians.

The BRAIN-Q, a tool for assessing self-reported sport-related concussions for epidemiological studies.

OBJECTIVES: The BRAIN-Q is a tool aimed at maximising the accuracy and minimising measurement error for retrospectively assessing concussions. This paper reports the agreement of the BRAIN-Q tool when compared to extant questionnaire questions, and its reproducibility when compared with its telephonic version (tBRAIN-Q). METHODS: The BRAIN-Q entails a 3-stage process: defining a concussion, creating a visual timeline with life events, and establishing detailed characteristics for each reported concussion. It was designed to be administered in-person by trained personnel, and was used in the BRAIN study. Its performance was compared with the MSK study, which previously collected a few questions in a broader self-administered questionnaire, and with the tBRAIN-Q Recall, its telephonic version. RESULTS: In total, 101 participants were included, of whom 9 were re-assessed with the tBRAIN-Q. The agreement of the BRAIN-Q with the muscle skeletal-questionnaire for rugby-related concussion was 86.7% (κ=0.6). Rugby-related concussion with loss of consciousness showed lower agreement (82.0%; κ=0.6). The comparison between the BRAIN-Q and the tBRAIN-Q showed good reproducibility. CONCLUSIONS: The BRAIN-Q is a relatively easy tool to administer in face-to-face assessments, and it showed optimal reproducibility. It includes a well-established definition of concussion, and is used to collect detailed information on each concussion, allowing for a number of subgroup analyses (e.g., by severity, age, or context). The BRAIN-Q is easily adaptable to other sporting settings.