Length of Recovery From Sports-Related Concussions in Pediatric Patients Treated at Concussion Clinics.

OBJECTIVES: We quantified the length of recovery time by week in a cohort of pediatric sports-related concussion patients treated at concussion clinics, and examined patient and injury characteristics associated with prolonged recovery. DESIGN: A retrospective, cohort design. SETTING: Seven concussion clinics at a Midwest children's hospital. PATIENTS: Patients aged 10 to 17 years with a diagnosed sports-related concussion presenting to the clinic within 30 days of injury. MAIN OUTCOME MEASURES: Length of recovery by week. METHODS: Unadjusted and adjusted multinomial logistic regression analyses were used to model the effect of patient and injury characteristics on length of recovery by week. RESULTS: Median length of recovery was 17 days. Only 16.3% (299/1840) of patients recovered within one week, whereas 26.4% took longer than four weeks to recover. By 2 months postinjury, 6.7% of patients were still experiencing symptoms. Higher symptom scores at injury and initial visit were significantly associated with prolonged symptoms by week. Patients who presented to the clinic more than 2 weeks postinjury or who had 2 or more previous concussions showed increased risk for prolonged recovery. Females were at greater risk for prolonged recovery than males (odds ratio = 2.08, 95% confidence interval = 1.49-2.89). Age was not significantly associated with recovery length. CONCLUSIONS: High symptom scores at injury and initial visit, time to initial clinical presentation, presence of 2 or more previous concussions, and female sex are associated with prolonged concussion recovery. Further research should aim to establish objective measures of recovery, accounting for treatment received during the recovery. CLINICAL RELEVANCE: The median length of recovery is 17 days among pediatric sports-related concussion patients treated at concussion clinics. Only 16.3% of patients recovered within one week, whereas 26.4% took longer than 4 weeks to recover.

Injuries and Illnesses Occurring on a Recreational Bicycle Tour: The Great Ohio Bicycle Adventure.

OBJECTIVE: Recreational multiday cycling events have grown popular in the United States; however, little has been published regarding the injuries and illnesses that occur during these events. The objective of this study was to describe injuries and illnesses that occur in the Great Ohio Bicycle Adventure (GOBA) and to examine associated risk factors. METHODS: Injury and illness data collected from an on-site medical clinic during the 2013 and 2014 GOBA tours were merged with rider registration data for analysis. Diagnoses were classified as acute injury, overuse injury, or medical illness. The odds ratios of sustaining at least 1 injury/illness, as well as sustaining an acute injury, were assessed adjusting for riders' demographics. RESULTS: A total of 4005 (2172 in 2013 and 1833 in 2014) cyclists participated in GOBA, with an an age of 50.7±17.6 (2-86) years (mean±SD [range]), of whom 59.8% were male. During the tours, 143 (3.6%) riders reported at least 1 injury/illness, which resulted in 220 clinical diagnoses, including 114 (51.8%) acute injuries, 27 (12.3 %) overuse injuries, and 79 (35.9%) medical illnesses. The lower extremities were the most commonly injured body site (n=71, 50.4%). "Superficial/Abrasions/Contusions" was the most common injury/illness type (n=68, 30.9%). Riders who had no previous tour experience or who were at least 50 years old had a greater risk of injury/illness than their counterparts. CONCLUSIONS: The prevalence of injury and illness is relatively low in multiday recreational cycling events. Our findings provide important data for planning and preparing for medical coverage at mass recreational cycling events.

Orthostatic Intolerance and Autonomic Dysfunction in Youth With Persistent Postconcussion Symptoms: A Head-Upright Tilt Table Study.

OBJECTIVE: To explore head-upright tilt table (HUT) signs of autonomic dysfunction in a cohort of youth with persistent postconcussion symptoms (PCSs) that include light-headedness and to correlate repeat tilt table results with symptom improvements for those patients found to have postural tachycardia syndrome (POTS) on initial testing. DESIGN: Prospective cohort design. SETTING: Nationwide Children's Hospital, Neurology Clinic. PARTICIPANTS: Thirty-four patients (13-18 years of age) with persistent PCSs. MAIN OUTCOME MEASURES: All patients underwent at least 1 tilt table test. The PCS Interview (PCS-I) and patient ratings of light-headedness and vertigo were used to measure symptom burden. Patients found to have POTS were asked to repeat tilt table testing when PCSs improved or 3 to 6 months after the initial test if symptoms persisted. RESULTS: Twenty-four of the 34 (70.6%) patients had abnormal tilt table results with patients categorized as normal (n = 10), isolated syncope (n = 10), and POTS (n = 14). Patients with POTS had higher PCS-I scores than normal patients (P < 0.001) and higher ratings of light-headedness than both normal patients (P = 0.015) and syncope patients (P = 0.04). Twelve POTS patients underwent repeat tilt table testing, and 9 of 12 (75%) no longer met POTS diagnostic criteria. All patients with resolution of POTS had corresponding improvements in PCSs, including light-headedness and vertigo. CONCLUSIONS: Our study demonstrates a high rate of tilt table abnormalities among youth with persistent PCSs. Several patients with POTS had normalization of tilt table testing when PCSs improved. These findings warrant further research of autonomic dysfunction related to concussion. CLINICAL RELEVANCE: Our study is the first to prospectively characterize autonomic dysfunction in patients with persistent PCSs using HUT testing and to show that the tilt test abnormalities normalize in some patients as PCSs improve.

Salivary miRNA Expression in Children With Persistent Post-concussive Symptoms.

Background: Up to one-third of concussed children develop persistent post-concussive symptoms (PPCS). The identification of biomarkers such as salivary miRNAs that detect concussed children at increased risk of PPCS has received growing attention in recent years. However, whether and how salivary miRNA expression levels differ over time between concussed children with and without PPCS is unknown. Aim: To identify salivary MicroRNAs (miRNAs) whose expression levels differ over time post-concussion in children with vs. without PPCS. Methods: We conducted a prospective cohort study with saliva collection at up to three timepoints: (1) within one week of injury; (2) one to two weeks post-injury; and (3) 4-weeks post-injury. Participants were children (ages 11 to 17 years) with a physician-diagnosed concussion from a single hospital center. We collected participants' daily post-concussion symptom ratings throughout their enrollment using the Post-concussion Symptom Scale, and defined PPCS as a total symptom score of ≥ 5 at 28 days post-concussion. We extracted salivary RNA from the saliva samples and measured expression levels of 827 salivary miRNAs. We then compared the longitudinal expression levels of salivary miRNAs in children with vs. without PPCS using linear models with repeated measures. Results: A total of 135 saliva samples were collected from 60 children. Of the 827 miRNAs analyzed, 91 had expression levels above the calculated background threshold and were included in the differential gene expression analyses. Of these 91 miRNAs, 13 had expression levels that differed significantly across the three timepoints post-concussion between children with and without PPCS (i.e., hsa-miR-95-3p, hsa-miR-301a-5p, hsa-miR-626, hsa-miR-548y, hsa-miR-203a-5p, hsa-miR-548e-5p, hsa-miR-585-3p, hsa-miR-378h, hsa-miR-1323, hsa-miR-183-5p, hsa-miR-200a-3p, hsa-miR-888-5p, hsa-miR-199a-3p+hsa-miR-199b-3p). Among these 13 miRNAs, one (i.e., hsa-miR-203a-5p) was also identified in a prior study, with significantly different expression levels between children with and without PPCS. Conclusion: Our results from the longitudinal assessment of miRNAs indicate that the expression levels of 13 salivary miRNAs differ over time post-injury in concussed children with vs. without PPCS. Salivary miRNAs may be a promising biomarker for PPCS in children, although replication studies are needed.

Dislocation/separation injuries among US high school athletes in 9 selected sports: 2005-2009.

OBJECTIVE: To investigate the epidemiology of dislocations/separations in a nationally representative sample of high school student-athletes participating in 9 sports. DESIGN: Descriptive epidemiologic study. SETTING: Sports injury data for the 2005-2009 academic years were collected using an Internet-based injury surveillance system, Reporting Information Online (RIO). PARTICIPANTS: A nationally representative sample of 100 US high schools. ASSESSMENT OF RISK FACTORS: Injuries sustained as a function of sport and gender. MAIN OUTCOME MEASURES: Dislocation/separation rates, body site, outcome, surgery, and mechanism. RESULTS: Dislocations/separations represented 3.6% (n = 755) of all injuries. The most commonly injured body sites were the shoulder (54.9%), wrist/hand (16.5%), and knee (16.0%); 18.4% of dislocations/separations were recurrences of previous injuries at the same body site; 32.3% of injuries were severe (ie, student-athletes unable to return to play within 3 weeks of the injury date), and 11.8% required surgical repair. The most common mechanisms of injury were contact with another player (52.4%) and contact with the playing surface (26.4%). Injury rates varied by sport. In gender-comparable sports, few variations in patterns of injury existed. Rates were highest in football (2.10 per 10 000 athletic exposures) and wrestling (1.99) and lowest in baseball (0.24) and girls' soccer (0.27). CONCLUSIONS: Although dislocation/separation injuries represent a relatively small proportion of all injuries sustained by high school student-athletes, the severity of these injuries indicates a need for enhanced injury prevention efforts. Developing effective targeted preventive measures depends on increasing our knowledge of dislocation/separation rates, patterns, and risk factors among high school athletes.

Erythropoietin and other blood-boosting methods.

Dating back to the earliest Olympics, athletes have been searching for a performance edge. Recombinant human erythropoietin was made commercially available in 1987 to treat various diseases associated with anemia. Within a few years, elite endurance athletes capitalized on its potential as an undetectable performance-enhancing agent. Although antidoping agencies have developed a test to detect its use, there are pitfalls. More importantly, athletes continue to add more sophisticated doping practices to their armamentarium, challenging regulatory agencies, putting their health at great risk, and tainting the spirit of fair competition.

Ankle and foot injuries in pediatric and adult athletes.

Foot and ankle injuries are among the most common in athletes.Differential diagnosis, imaging decisions, and treatment plan should be influenced by the age of the athlete. A thorough history and physical examination, with an understanding of the anatomy of the foot and ankle anatomy and the mechanism of injury, will give the best opportunity to make the correct diagnosis. For most athletes, the prognosis for returning to play after a foot or ankle injury is very good. The recipe for keeping our athletes healthy includes early intervention, undergoing proper rehabilitation, applying braces or orthotics when indicated, and preventing injuries when appropriate.

Direct medical charges of pediatric traumatic brain injury in multiple clinical settings.

BACKGROUND: Data limited to emergency department and inpatient visits undoubtedly underestimate the medical charges associated with traumatic brain injury. The objective of this study was to estimate the direct medical charges of pediatric traumatic brain injuries across all clinical settings in one large, pediatric hospital in the United States. METHODS: Traumatic brain injuries sustained by children ≤20 years of age treated across all clinical settings at one large pediatric hospital from August 1, 2010-July 31, 2011 were identified using ICD-9-CM codes 310.2, 800-801.9, 803-804.9, 850-854.16, and 959.01. RESULTS: 3,971 individuals ≤20 years of age were seen during 5,429 traumatic brain injury-related visits. Total medical charges for pediatric traumatic brain injury-related visits were $13,131,547. Inpatient (68.7%) and emergency department (16.1%) visits accounted for the highest proportion of TBI-related charges; however, >15% of all charges were associated with visits to clinic outpatient, urgent care, and diagnostic/therapy outpatient settings. Fracture of the vault or base of the skull (37.1%) and brain injury with contusion, laceration, or hemorrhage (27.1%) accounted for the largest proportion of total charges. Although unspecified head injuries made up almost half of all TBI-related visits (47.4%), they accounted for only 12.6% of total charges. Mild traumatic brain injuries accounted for 92.0% of all traumatic brain injury-related visits but only 44.7% of all traumatic brain injury-related charges. Mild traumatic brain injuries treated in the emergency department had a higher median total charge than those treated in urgent care (p < 0.0001) or clinic outpatient setting (p < 0.001). CONCLUSIONS: This study, the first to evaluate the direct medical charges of pediatric traumatic brain injury across all clinical settings at one large pediatric hospital, found that pediatric traumatic brain injuries present to a wide variety of clinical settings, and differences exist in total charges by diagnosis, severity of the injury, and clinical site/setting. Investigating traumatic brain injuries across the full spectrum of clinical care is needed for a better understanding of the true medical cost and public health burden of pediatric traumatic brain injury.

Overuse injuries in adolescents.

The incidence of overuse injuries in young athletes is on the rise and accounts for a significant number of visits to the primary care office. There are distinctive intrinsic and extrinsic factors that place young athletes at risk for overuse injuries. These injuries vary in severity from being a temporary inconvenience to having potential lifelong morbidity. An understanding of the young athlete and their unique injuries is important for enabling early recognition and treatment. Prevention strategies are also discussed.

Septic Arthritis of the Shoulder.

In brief A wrestler developed septic arthritis in his glenohumeral joint. His case is unusual because septic arthritis most commonly affects weight-bearing joints and is usually seen in the very young, the very old, and people who are immunocompromised. Other risk factors include concurrent infection, endocarditis, invasive procedures, and intra-articular corticosteroid injection. Disease onset is usually insidious. Nonspecific findings include restricted motion, mild pain, and joint effusions; systemic signs of toxicity are often mild or absent. Diagnosis is confirmed with joint aspiration and analysis and culture of synovial fluids; definitive treatment often involves arthroscopic debridement followed by 2 to 6 weeks of antibiotics.

Primary immunodeficiencies.

Primary immunodeficiencies include a variety of disorders that render patients more susceptible to infections. If left untreated, these infections may be fatal. The disorders constitute a spectrum of more than 80 innate defects in the body's immune system. Primary immunodeficiencies generally are considered to be relatively uncommon. There may be as many as 500,000 cases in the United States, of which about 50,000 cases are diagnosed each year. Common primary immunodeficiencies include disorders of humoral immunity (affecting B-cell differentiation or antibody production), T-cell defects and combined B- and T-cell defects, phagocytic disorders, and complement deficiencies. Major indications of these disorders include multiple infections despite aggressive treatment, infections with unusual or opportunistic organisms, failure to thrive or poor growth, and a positive family history. Early recognition and diagnosis can alter the course of primary immunodeficiencies significantly and have a positive effect on patient outcome.