Examining for gender differences in return to learn following sport-related concussion in high school student athletes.

OBJECTIVE: Prior studies have investigated associations between gender, symptom resolution, and time to return to play following sport-related concussion (SRC). However, there is a notable gap in research regarding the association between gender and return to learn (RTL) in adolescents. Therefore, this study 1) compared the patterns of RTL between boys and girls who are high school student athletes, and 2) evaluated the possible association between gender and time to RTL after adjusting for covariates. METHODS: A retrospective cohort study of a prospective surveillance program that monitored concussion recovery of athletes in high schools throughout the state of Maine between February 2015 and January 2023 was performed. The primary independent variable was gender, dichotomized as boys and girls. The primary outcome was time to RTL, defined by the number of days for an athlete to return to school without accommodations. Mann-Whitney U-tests were used to compare RTL between the boys and girls. Each athlete's RTL status was dichotomized (i.e., returned vs had not returned) at several time points following injury (i.e., 1, 2, 3, and 4 weeks), and chi-square tests were performed to compare the proportions who achieved RTL between groups. Multivariable linear regression analyses were performed to evaluate the predictive value of gender on RTL. Covariates included age, number of previous concussions, history of learning disability or attention-deficit disorder or attention-deficit/hyperactivity disorder, history of a psychological condition, history of headaches or migraines, initial Sport Concussion Assessment Tool (SCAT3/SCAT5) score, and days to evaluation. RESULTS: Of 895 high school athletes, 488 (54.5%) were boys and 407 (45.5%) were girls. There was no statistically significant difference in median [IQR] days to RTL between genders (6.0 [3.0-11.0] vs 6.0 [3.0-12.0] days; U = 84,365.00, p < 0.375). A greater proportion of boys successfully returned to learn without accommodations by 3 weeks following concussion (93.5% vs 89.4%; χ2 = 4.68, p = 0.030), but no differences were found at 1, 2, or 4 weeks. A multivariable model predicting days to RTL showed that gender was not a significant predictor of RTL (p > 0.05). Longer days to evaluation (ß = 0.10, p = 0.021) and higher initial SCAT3/SCAT5 scores (ß = 0.15, p < 0.001) predicted longer RTL. CONCLUSIONS: In a cohort of high school athletes, RTL did not differ between boys and girls following SRC. Gender was not a significant predictor of RTL. Longer days to evaluation and higher initial symptom scores were associated with longer RTL.

Subclinical, long-term psychological symptoms following sport-related concussion: are athletes more depressed than we think?

INTRODUCTION: In adolescent and collegiate athletes with sport-related concussion (SRC), we sought to evaluate the prevalence and predictors of long-term psychological symptoms. METHODS: A cohort study was conducted of athletes 12-24-year-old diagnosed with SRC between November 2017 and April 2022. Athletes/proxies were interviewed on psychological symptoms (i.e. anger, anxiety, depression, and stress). Participants who scored ≥75th percentile on one or more PROMIS (Patient-Reported Outcomes Measurement System) measures were operationalized to have subclinical, long-term psychological symptoms. Uni/multivariable regressions were used. RESULTS: Of 96 participants (60.4% male), the average age was 16.6 ± 2.6 years. The median time from concussion to interview was 286 days (IQR: 247-420). A total of 36.5% athletes demonstrated subclinical, long-term psychological symptoms. Univariate logistic regression revealed significant predictors of these symptoms: history of psychiatric disorder (OR = 7.42 95% CI 1.37,40.09), substance use (OR = 4.65 95% CI 1.15,18.81), new medical diagnosis since concussion (OR = 3.43 95% CI 1.27,9.26), amnesia (OR = 3.42 95% CI 1.02,11.41), other orthopedic injuries since concussion (OR = 3.11 95% CI 1.18,8.21), age (OR = 1.24 95% CI 1.03,1.48), days to return-to-play (OR = 1.02 95% CI 1.00,1.03), and psychiatric medication use (OR = 0.19 95% CI 0.05,0.74). Multivariable model revealed significant predictors: orthopedic injuries (OR = 5.17 95% CI 1.12,24.00) and return-to-play (OR = 1.02 95% CI 1.00,1.04). CONCLUSIONS: Approximately one in three athletes endorsed long-term psychological symptoms. Predictors of these symptoms included orthopedic injuries and delayed RTP.

Do academic accommodations help students recover following sport-related concussion? A retrospective study of 96 youth athletes.

OBJECTIVE: Many schools utilize academic accommodations to help athletes return-to-learn after sport-related concussion, yet little is known about the impact of accommodations on recovery. In a cohort of adolescent athletes with sport-related concussion, the authors sought to 1) describe academic accommodations, 2) determine predictors of receiving accommodations, and 3) determine how accommodations influenced recovery, as defined by days to return-to-learn, symptom resolution, and return-to-play. METHODS: A retrospective survey study was undertaken that included all athletes between the ages of 12 and 24 years who were seen at a regional sport-related concussion center from April 1, 2020, to April 1, 2022. Demographic characteristics, past medical history, injury characteristics, school-related factors, and recovery were collected via a telephone-based survey and from medical charts. The independent variable was the use of academic accommodations by students. The outcome variables included days to return-to-learn, symptom resolution, and return-to-play. Univariable and multivariable logistic regression analyses were performed. RESULTS: Of 300 athletes contacted, 96 consented to participate in this study (mean age ± SD 16.6 ± 2.6 years, 60.4% male). The mean return-to-learn was 9.0 ± 13.2 days. In total, 63.5% of athletes received some kind of school accommodation. The most common accommodations included extra time on tests (46/96 [47.9%] athletes) and extra time for assignments (43/96 [44.8%]), whereas preferential seating in class (0/96 [0.0%]) and reduced workloads (4/96 [4.2%]) were the least commonly used accommodations. Multivariable logistic regression revealed that White race (OR 0.17, 95% CI 0.02-0.71, p = 0.03) and higher initial Post-Concussion Symptom Scale (PCSS) score (OR 1.04, 95% CI 1.01-1.07, p = 0.02) were predictive of receiving accommodations. Univariable models showed that receiving accommodations was not predictive of return-to-learn (ß = 4.67, 95% CI -0.92 to 10.25, p = 0.10), symptom resolution (ß = 24.71, 95% CI -17.41 to 66.83, p = 0.26), or return-to-play (ß = 13.35, 95% CI -14.56 to 41.27, p = 0.35). Regarding other predictors of each outcome, several factors emerged irrespective of accommodations. Multivariable analysis revealed that longer time to return-to-learn was associated with a history of psychiatric illness (ß = 8.00, 95% CI 1.71-14.29, p = 0.02) and initial PCSS score (ß = 0.14, 95% CI 0.06-0.23, p < 0.01). Finally, predictors of days to return-to-play included school personnel who were knowledgeable of concussion (ß = -5.07, 95% CI -9.93 to -0.21, p = 0.04) and higher initial PCSS score (ß = 0.67, 95% CI 0.04-1.29, p = 0.03). CONCLUSIONS: The most common accommodation was extra time on tests/assignments, whereas reduced workload was the least common. White race and greater initial PCSS score were associated with receiving accommodations. Receiving accommodations did not significantly impact days to return-to-learn, symptom resolution, or return-to-play.

Symptoms of Traumatic Encephalopathy Syndrome are Common in Community-Dwelling Adults.

BACKGROUND AND OBJECTIVES: The consensus criteria for traumatic encephalopathy syndrome (TES), the possible in vivo clinical syndrome associated with significant repetitive head impacts, have only been minimally studied to date. This study examined the prevalence of the proposed core clinical features of TES in a sample of healthy adults. METHODS: A cross-sectional survey study was conducted through ResearchMatch, a national health volunteer registry. Participants were assessed for symptoms of TES based on the 2021 consensus criteria, including prior repetitive head impacts and core clinical features. Additional health information (e.g., concussion history, psychological health, sleep, chronic pain) was also evaluated. The consensus proposed research criteria for TES (i.e., reporting at least one progressive core clinical feature of TES, as in progressive difficulties with episodic memory, executive functioning, or neurobehavioral dysregulation) were applied to the sample. RESULTS: Out of 1100 participants (average age = 53.6 ± 17.7 years, 55% women), 34.6% endorsed one or more progressive core clinical features of TES. Participants with a significant history of contact sports (i.e., ≥ 5 years total, with ≥ 2 years in high school or beyond) had similar rates of endorsing a progressive core clinical feature of TES compared to those without significant histories of repetitive head impacts (36.4% vs 32.8%, respectively, χ2 = 0.52, p = 0.47). A significant history of repetitive head impacts in sports was not associated with endorsing a core clinical feature of TES in univariable or multivariable models (p > 0.47), whereas current depression/anxiety (odds ratio [OR] = 6.94), a history of psychiatric disorders (OR = 2.57), current sleep problems (OR = 1.56), and younger age (OR = 0.99) were significant predictors of TES status in a multivariable model. In a subsample of 541 participants who denied a lifetime history of contact sports, other forms of repetitive head impacts, and concussions, approximately 31.0% endorsed one or more progressive core clinical features of TES. Additionally, 73.5% of neurotrauma-naïve participants with current anxiety or depression reported at least one core progressive feature of TES, compared with 20.2% of those without clinically significant depression/anxiety symptoms. CONCLUSIONS: A considerable proportion of adults without a significant history of repetitive head impacts from sports endorsed core TES features, particularly those experiencing mental health symptoms. Having a significant history of contact sports was not associated with endorsing a core progressive clinical feature of TES, whereas other health factors were. These findings underscore the need for validating and refining TES criteria in samples with and without substantial neurotrauma histories.

Trends in non-focal neurological chief complaints and CT angiography utilization among adults in the emergency department.

Prudent imaging use is essential for cost reduction and efficient patient triage. Recent efforts have focused on head and neck CTA in patients with emergent concerns for non-focal neurological complaints, but have failed to demonstrate whether increases in utilization have resulted in better care. The objective of this study was to examine trends in head and neck CTA ordering and determine whether a correlation exists between imaging utilization and positivity rates. This is a single-center retrospective observational study at a quaternary referral center. This study includes patients presenting with headache and/or dizziness to the emergency department between January 2017 and December 2021. Patients who received a head and neck CTA were compared to those who did not. The main outcomes included annual head and neck CTA utilization and positivity rates, defined as the percent of scans with attributable acute pathologies. Among 24,892 emergency department visits, 2264 (9.1%) underwent head and neck CTA imaging. The percentage of patients who received a scan over the study period increased from 7.89% (422/5351) in 2017 to 13.24% (662/5001) in 2021, representing a 67.4% increase from baseline (OR, 1.14; 95% CI 1.11-1.18; P < .001). The positivity rate, or the percentage of scans ordered that revealed attributable acute pathology, dropped from 16.8% (71/422) in 2017 to 10.4% (69/662) in 2021 (OR, 0.86; 95% CI 0.79-0.94; P = .001), a 38% reduction in positive examinations. Throughout the study period, there was a 67.4% increase in head and neck CTA ordering with a concomitant 38.1% decrease in positivity rate.

International Hackathon as a Tool to Augment Education, Collaboration, and Innovation in Global Neurosurgery.

BACKGROUND AND OBJECTIVES: Health care providers' exposure to global surgical disparities is limited in current nursing and/or medical school curricula. For instance, global health is often associated with infectious diseases or maternal health without acknowledging the growing need for surgical care in low- and middle-income countries (LMICs). We propose an international virtual hackathon based on neurosurgical patient cases in under-resourced settings as an educational tool to bring awareness to global surgical disparities and develop relationships among trainees in different countries. METHODS: Participants were recruited through email listservs, a social media campaign, and prize offerings. A 3-day virtual hackathon event was administered, which included workshops, mentorship, keynote panels, and pitch presentations to judges. Participants were presented with real patient cases and directed to solve a barrier to their care. Surveys assessed participants' backgrounds and event experience. The hackathon was executed through Zoom at Harvard Innovation Lab in Boston, MA, on March 25 to 27, 2022. Participants included medical students, with additional participants from business, engineering, or current health care workers. RESULTS: Three hundred seven applications were submitted for 100 spots. Participants included medical students, physicians, nurses, engineers, entrepreneurs, and undergraduates representing 25 countries and 82 cities. Fifty-one participants previously met a neurosurgeon, while 39 previously met a global health expert, with no difference between LMIC and high-income countries' respondents. Teams spent an average of 2.75 hours working with mentors, and 88% of postevent respondents said the event was "very" or "extremely conducive" to networking. Projects fell into 4 categories: access, language barriers, education and training, and resources. The winning team, which was interdisciplinary and international, developed an application that analyzes patient anatomy while performing physical therapy to facilitate remote care and clinical decision-making. CONCLUSION: An international virtual hackathon can be an educational tool to increase innovative ideas to address surgical disparities in LMICs and establish early collaborative relationships with medical trainees from different countries.

Implication of nutritional status for adverse outcomes after surgery for metastatic spine tumors.

OBJECTIVE: Surgery for metastatic spinal tumors can have a substantial impact on patients' quality of life by alleviating pain, improving function, and correcting spinal instability when indicated. The decision to operate is difficult because many patients with cancer are frail. Studies have highlighted the importance of preoperative nutritional status assessments; however, little is known about which aspects of nutrition accurately inform clinical outcomes. This study investigates the interaction and prognostic importance of various nutritional and frailty measures in patients with spinal metastases. METHODS: A retrospective analysis of consecutive patients who underwent surgery for spinal metastases between 2014 and 2020 at the Massachusetts General Hospital was performed. Patients were stratified according to the New England Spinal Metastasis Score (NESMS). Frailty was assessed using the metastatic spinal tumor frailty index. Nutrition was assessed using the prognostic nutritional index (PNI), preoperative body mass index, albumin, albumin-to-globulin ratio, and platelet-to-lymphocyte ratio. Outcomes included postoperative survival and complication rates, with focus on wound-related complications. RESULTS: This study included 154 individuals (39% female; mean [SD] age 63.23 [13.14] years). NESMS 0 and NESMS 3 demonstrated the highest proportions of severely frail patients (56.2%) and nonfrail patients (16.1%), respectively. Patients with normal nutritional status (albumin-to-globulin ratio and PNI) had a better prognosis than those with poor nutritional status when stratified by NESMS. Multivariable regression adjusted for NESMS and frailty showed that a PNI > 40.4 was significantly associated with decreased odds of 90-day complications (OR 0.93, 95% CI 0.85-0.98). After accounting for age, sex, primary tumor pathology, physical function, nutritional status, and frailty, a preoperative nutrition consultation was associated with a decrease in postoperative wound-related complications (average marginal effect -5.00%; 95% CI -1.50% to -8.9%). CONCLUSIONS: The PNI was most predictive of complications and may be a key biomarker for risk stratification in the 90 days following surgery. Nutrition consultation was associated with a reduced risk of wound-related complications, attesting to the importance of this preoperative intervention. These findings suggest that nutrition plays an important role in the postsurgical course and should be considered when developing a treatment plan for spinal metastases.

Assessing the Relationship Between Race, Language, and Surgical Admissions in the Emergency Department.

INTRODUCTION: English proficiency and race are both independently known to affect surgical access and quality, but relatively little is known about the impact of race and limited English proficiency (LEP) on admission for emergency surgery from the emergency department (ED). Our objective was to examine the influence of race and English proficiency on admission for emergency surgery from the ED. METHODS: We conducted a retrospective observational cohort study from January 1-December 31, 2019 at a large, quaternary-care urban, academic medical center with a 66-bed ED Level I trauma and burn center. We included ED patients of all self-reported races reporting a preferred language other than English and requiring an interpreter or declaring English as their preferred language (control group). A multivariable logistic regression was fit to assess the association of LEP status, race, age, gender, method of arrival to the ED, insurance status, and the interaction between LEP status and race with admission for surgery from the ED. RESULTS: A total of 85,899 patients (48.1% female) were included in this analysis, of whom 3,179 (3.7%) were admitted for emergent surgery. Regardless of LEP status, patients identifying as Black (odds ratio [OR] 0.456, 95% CI 0.388-0.533; P<0.005), Asian [OR 0.759, 95% CI 0.612-0.929]; P=0.009), or female [OR 0.926, 95% CI 0.862-0.996]; P=0.04) had significantly lower odds for admission for surgery from the ED compared to White patients. Compared to individuals on Medicare, those with private insurance [OR 1.25, 95% CI 1.13-1.39; P <0.005) were significantly more likely to be admitted for emergent surgery, whereas those without insurance [OR 0.581, 95% CI 0.323-0.958; P=0.05) were significantly less likely to be admitted for emergent surgery. There was no significant difference in odds of admission for surgery between LEP vs non-LEP patients. CONCLUSION: Individuals without health insurance and those identifying as female, Black, or Asian had significantly lower odds of admission for surgery from the ED compared to those with health insurance, males, and those self-identifying as White, respectively. Future studies should assess the reasons underpinning this finding to elucidate impact on patient outcomes.

Novel methods for the quantification of toxic, residual phase transfer catalyst in fluorine-18 labeled radiotracers.

INTRODUCTION: Fluorine-18 labeled radiopharmaceuticals undergo quality control testing for residual phase-transfer-catalyst content. The almost universally used quality-control test is a silica plate spot-test comparison of the radiopharmaceutical beside a 50-ppm standard. Once developed by staining, the radiopharmaceutical spot must be of equal or less intensity to pass the test. There is currently a need for a quantitative, inexpensive, and less subjective quality control method that allows the automatic incorporation of the acquired measurement directly into electronic batch reports. RESULTS: In the developed method, a resazurin test solution is mixed with an aliquot of the radiopharmaceutical analyte along with dichloromethane (DCM). The mixture is vortexed. The potassium resazurin-phase transfer catalyst complex solubilizes into the DCM imparting a blue color. The organic layer is then removed for analysis. Three measurement methods were utilized: visual colorimetry against pre-prepared standards, spectrophotometric measurement of transmittance, and electrical conductance. A simple prototype spectrophotometer and an electrical test cell were constructed to acquire data. Sodium Resazurin dye was found to be a suitable test chromophore for residual phase transfer catalyst analysis of aqueous solutions. Quantitative spectrophotometric measurements are possible in the 0-100-ppm range (18-crown-6) and 0-150-ppm range (Kryptofix® or tetrabutylammonium). Electrical resistance measurements of the phase transfer-catalyst resazurin complex in DCM are also a viable method, allowing quantitative phase transfer catalyst measurements in the 0-100-ppm range. CONCLUSION: The methodologies developed are more quantitative alternatives to the current spot-test method. The spectrophotometric method was determined to be the most accurate method.