Influence of Postconcussion Sleep Duration on Concussion Recovery in Collegiate Athletes.

OBJECTIVE: To determine whether decreased sleep duration postconcussion influences days to asymptomatic and assessment of performance throughout recovery. DESIGN: Prospective. SETTING: Institutional Clinical Research Laboratory. PATIENTS: Four hundred twenty-three collegiate athletes were diagnosed with concussion. INTERVENTIONS: Multidimensional concussion assessment battery was conducted at baseline, within 24 to 48 hours, daily [2-4 days postinjury (PI); symptoms only], once asymptomatic, and after return-to-play. The battery included the following: 22-item symptom checklist, Standardized Assessment of Concussion (SAC), Balance Error Scoring System (BESS), and computerized neurocognitive test [Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)]. MAIN OUTCOME MEASURES: We subtracted baseline sleep duration from 24 to 48 hours postconcussion sleep duration and categorized athletes into the following groups: shorter sleep (≤-1 hour), no change (>-1 hour, <+1 hour), and longer sleep (≥+1 hour). A 1-way analysis of variance (ANOVA) was conducted to compare days to asymptomatic and separate mixed-model ANOVAs to compare total symptom scores, SAC total scores, BESS total error scores, and ImPACT composite scores between sleep categories across time points (α = 0.05). RESULTS: Sleep groups did not differ in days to asymptomatic. The shorter sleep group had greater symptom severity than no sleep change and longer sleep groups at 24 to 48 hours (shorter: 39.1 ± 20.7; no change: 25.1 ± 18.4, P = 0.007; longer: 25.7 ± 21.8, P = 0.004), and at 2 to 4 days PI (shorter: 21.8 ± 21.8; no change: 10.5 ± 10.8, P = 0.013; longer: 11.9 ± 14.2, P = 0.007), but did not differ at other time points (ie, asymptomatic and return-to-play). Participants with shorter sleep exhibited slower ImPACT reaction times at 24 to 48 hours (shorter: 0.68 ± 0.14; no change: 0.61 ± 0.09, P = 0.016; and longer: 0.62 ± 0.12, P = 0.028) and asymptomatic time points (shorter: 0.62 ± 0.11; no change: 0.56 ± 0.05; P = 0.015). CONCLUSION: Postinjury sleep declines may be associated with symptom severity and worsened reaction time during initial stages of recovery or may be the result of the concussion itself. Clinicians should be aware of alterations in sleep duration and manage appropriately to mitigate initial symptom burden postconcussion.

Performance Differences Between the Modified Star Excursion Balance Test and the Y-Balance Test in Individuals With Chronic Ankle Instability.

CONTEXT: The modified Star Excursion Balance Test (mSEBT) and Y-Balance Test (YBT) are common dynamic postural stability assessments for individuals with chronic ankle instability (CAI). However, the reach distance measurement technique and movement strategy used during the mSEBT and YBT differ. To date, no studies have compared task performance differences on these tests in CAI patients. OBJECTIVE: To determine whether individuals with CAI perform the mSEBT and YBT differently. DESIGN: Cross-sectional. SETTING: Biomechanics laboratory. PARTICIPANTS: Of 97 consented participants, 86 (43 females, 43 males; age 21.5 [3.3] y, height 169.8 [10.3] cm, mass 69.5 [13.4] kg), who reported ≤25 on the Cumberland Ankle Instability Tool, ≥11 on the Identification of Functional Ankle Instability, and had a history of a moderate to severe ankle sprain(s) participated. INTERVENTIONS: Participants were instructed to perform the mSEBT and YBT in a predetermined counterbalanced order. Three anterior, posteromedial, and posterolateral trials of each test were completed on the involved limb after 4 practice trials. Test direction order was randomized for each participant. MAIN OUTCOME MEASURES: Normalized (expressed in percentage) reach distance in each direction. Paired sample t tests were performed to compare each of the 3 directions between the mSEBT and YBT. RESULTS: Significantly shorter reach distances in the anterior (58.9% [5.8%] vs 61.4% [5.4%], P = .001) and the posteromedial (98.8% [8.6%] vs 100.8% [8.1%], P = .003) directions were noted on the mSEBT relative to the YBT. No differences in the posterolateral directions were observed. CONCLUSIONS: Within those with CAI, mSEBT and YBT normalized reach distances differ in the anterior and posteriomedial directions. As a result, clinicians and researchers should not directly compare the results of these tests.

Opportunities and challenges for electrochemistry in studying the electronic structure of nanocrystals.

We review the state-of-the-art of determining the electronic structure of nanocrystals in thin films by electrochemistry. Our core conclusion, the necessity of combining electrochemical with spectroscopic techniques, is illustrated with the holistic analysis of thin films of CdSe nanocrystals cross-linked with electroactive metal ß-tetraaminophthalocyanines by differential pulse voltammetry, optical spectroscopy and potential modulated absorption spectroscopy. We show that the same nanocrystals cross-linked with phthalocyanines of different metal centers exhibit rather similar electrochemical signatures, but behave distinctly different in spectroelectrochemical investigations. We argue that in one case, namely CdSe nanocrystals cross-linked with Co ß-tetraaminophthalocyanine, we find supporting evidence for the hybridization of energy levels at the organic/inorganic interface. This work suggests that spectroelectrochemistry is capable of revealing the electronic structure of complex nanomaterials, such as semiconductor nanocrystals functionalized with organic pi-systems.

Collegiate student-athlete sex, years of sport eligibility completed, and sport contact level influence on concussion reporting intentions and behaviours.

PRIMARY OBJECTIVE: The objective of this study was to determine whether sex, years of sport eligibility completed, and sport contact level influenced student-athletes' concussion reporting intentions and behaviours. RESEARCH DESIGN: Cross-sectional. METHODS AND PROCEDURES: Student-athletes (n = 828) reported their sex, years of sport eligibility completed, sport, and completed concussion reporting intentions and behaviours surveys. Nonparametric statistics were conducted to compare intentions and behaviours between groups (alpha = 0.05). MAIN OUTCOMES AND RESULTS: Females had higher indirect intentions to report concussion than males (p = 0.035), but did not differ in direct intentions (p = 0.258) or behaviours (indirect: p = 0.756; direct: p = 0.686). Intentions (indirect: p = 0.383; direct: p = 0.397) and behaviours (indirect: p = 0.154; direct: p = 0.999) did not differ between years of sport eligibility completed. Limited/non-contact sport student-athletes intended to report more concussions than those in collision/contact sports (indirect: p = 0.001; direct: p = 0.021), but did not differ in behaviours (indirect: p = 0.184; direct: p = 0.497). CONCLUSIONS: Data suggest that female and limited/non-contact sport student-athletes intended to report more concussions, however differences did not translate to reporting behaviours.

School Nurses' Management and Collaborative Practices for Student-Athletes Following Sport-Related Concussion.

The purpose of this study was to examine school nurses' management and collaboration with health-care providers (HCPs) for student-athletes following a concussion. Secondary school nurses accessed an online survey titled the Beliefs, Attitudes, and Knowledge of Pediatric Athletes with Concussions (access rate = 15.6%; n = 1,246/8,000). Approximately 40% of schools where nurses were employed administered baseline and postinjury concussion assessments. No significant differences were found between employment model (single vs. multiple sites) in regard to conducting baseline (p = .908) administration at their site; however, those employed at a single school more frequently offered postinjury assessments at their site than those at multiple sites (p = .019). School nurses most frequently reported relationships with an athletic trainer (38.8%, n = 483/1,246) compared to other HCPs. A concussion management team, including school nurses, and other recommended members should develop comprehensive concussion management plans. Plans should comprise of multiple concussion assessments to aid in the return-to-learn/play processes.

Metabolic and histological implications of intrahepatic triglyceride content in nonalcoholic fatty liver disease.

The cut-off point of intrahepatic triglyceride (IHTG) content to define nonalcoholic fatty liver disease (NAFLD) by proton magnetic resonance spectroscopy (1 H-MRS) was established based on the 95th percentile in a group of healthy individuals (i.e., ≥5.56%). Whether this threshold correlates with metabolic and histological changes and whether a further accumulation of IHTG is associated with worsening of these parameters has not been properly assessed in a large cohort of patients. In this cross-sectional study, 352 subjects were carefully characterized with the following studies: liver 1 H-MRS; euglycemic insulin clamp with measurement of glucose turnover; oral glucose tolerance test; and a liver biopsy. Hepatic insulin sensitivity (suppression of endogenous glucose production by insulin) was affected early on after IHTG content was ∼1.5% and remained uniformly impaired (∼40%-45%), regardless of further IHTG accumulation. Skeletal muscle insulin sensitivity showed a gradual impairment at low degrees of IHTG accumulation, but remained unchanged after IHTG content reached the ∼6 ± 2% threshold. A similar pattern was observed for metabolic changes typically associated with NAFLD, such as hypertriglyceridemia and low high-density lipoprotein cholesterol (HDL-C). In contrast, adipose tissue insulin sensitivity (suppression of free fatty acids by insulin) showed a continuous worsening across the spectrum of IHTG accumulation in NAFLD (r = -0.38; P < 0.001). Histological severity of liver disease (inflammation, ballooning, and fibrosis) was not associated with the amount of IHTG content. CONCLUSION: IHTG accumulation is strongly associated with adipose tissue insulin resistance (IR), supporting the current theory of lipotoxicity as a driver of IHTG accumulation. Once IHTG accumulation reaches ∼6 ± 2%, skeletal muscle IR, hypertriglyceridemia, and low HDL-C become fully established. Histological activity appears to have an early threshold and is not significantly influenced by increasing amounts of IHTG accumulation. (Hepatology 2017;65:1132-1144).

School nurses' perceptions and experiences with an interprofessional concussion management team in the secondary school setting.

Following a concussion, both cognitive and physical rest are imperative aspects of injury management. The inclusion of academic adjustments and the formation of an interprofessional concussion management team (ICMT) provide a mechanism to manage academic issues following a concussion. As one of the sole healthcare providers presents during school hours, the school nurse may offer unique insight regarding the infrastructure of an ICMT in the secondary school setting. The purpose of this study was to explore school nurses' perceptions of and experiences with an ICMT for adolescents following a concussion in the secondary school setting. The consensual qualitative research approach was used to guide this study. Semi-structured individual telephone interviews were conducted with 15 school nurses employed in the secondary school setting across the United States. During data analysis, themes and categories were established based on a consensus process by the research team. Study findings indicated that school nurses identified several stakeholders regarding the concussion management team that are essential to include in the concussion management process. In addition to the school nurse, participants perceived an ICMT should include a physician, athletic trainer, school counsellor, teachers, and other stakeholders such as the patient and their parents. Additionally, participants discussed their perceptions of their own role as a member of an ICMT in the secondary school setting. The inclusion of an ICMT to aid the recovery following a concussion is vital to ensure proper care for the adolescent patient. Furthermore, the school nurse and athletic trainer must effectively collaborate, when possible, to ensure that concussed adolescents are allowed sufficient cognitive rest via the incorporation of academic adjustments during the recovery process.

The role of liver fat and insulin resistance as determinants of plasma aminotransferase elevation in nonalcoholic fatty liver disease.

UNLABELLED: Plasma aminotransferases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) are usually increased in patients with nonalcoholic fatty liver disease (NAFLD). However, the factors behind their elevation remain unclear. The aim of this study was to assess the role of insulin resistance (IR) and liver triglyceride content in relation to histology in patients with NAFLD/nonalcoholic steatohepatitis (NASH) with normal or elevated ALT levels. To this end, we enrolled 440 patients, divided into three groups: no NAFLD (n = 60); NAFLD with normal ALT (n = 165); and NAFLD with elevated ALT (n = 215). We measured: (1) liver fat by proton magnetic resonance spectroscopy ((1)H-MRS); (2) severity of liver disease by biopsy (n = 293); and (3) insulin sensitivity in liver, muscle, and adipose tissue by a euglycemic hyperinsulinemic clamp with 3-(3)H-glucose. Patients with NAFLD and elevated ALT, even when well matched for body mass index to those with normal ALT, had worse adipose tissue insulin resistance (ATIR; P < 0.0001), higher liver triglyceride content (P < 0.0001), and lower plasma adiponectin (P < 0.05), but no differences in hepatic insulin resistance. Similar results were found when only patients with NASH were compared: both ATIR (P < 0.0001) and liver triglyceride content by (1)H-MRS (P < 0.0001) were worse in NASH with elevated ALT. Consistent with the (1)H-MRS data, steatosis on liver biopsy was also significantly increased in patients with NASH and elevated ALT levels (P < 0.0001). However, and most important, there were no differences in inflammation (P = 0.62), ballooning (P = 0.13), or fibrosis (P = 0.12). CONCLUSION: In patients with NAFLD or NASH, ATIR (but not HIR) and liver triglyceride content are major factors in the elevation of plasma aminotransferase levels. Patients with normal versus elevated ALT had similar severity of NASH, suggesting that plasma aminotransferase levels are misleading parameters for guiding clinical management.

Acetazolamide reduces postoperative pain following laparoscopic inguinal herniorrhaphy.

BACKGROUND: Carbonic acid accumulation, which results from CO2 insufflation, can produce visceral and referred pain in the postoperative setting. Acetazolamide inhibits carbonic anhydrase, an enzyme that accelerates carbonic acid formation. We hypothesized that preoperative administration of acetazolamide would decrease postoperative pain in patients undergoing laparoscopic inguinal herniorrhaphy. METHODS: A retrospective review was conducted of patients who underwent laparoscopic preperitoneal inguinal herniorrhaphy at the Medical College of Wisconsin between October 2012 and September 2014. Beginning in January 2014, patients began receiving 250 mg of acetazolamide preoperatively; patients prior to that time did not. The visual analog scale (range 0-10) was used to assess both preoperative pain and postoperative pain. RESULTS: A total of 66 patients underwent laparoscopic inguinal herniorrhaphy during the study interval. Of these, 22 (33 %) patients received acetazolamide preoperatively, and 44 (67 %) were included as controls. Overall mean pain scores were lower in the acetazolamide group (1.9 ± 1.45 vs 2.9 ± 1.5, p = 0.04). Specifically, patients who received acetazolamide reported lower pain scores immediately after surgery (0.6 ± 1.2 vs 1.9 ± 2.3, p = 0.01) and on post-op day one (2.3 ± 0.9 vs 4.0 ± 2.1, p = 0.04). Total morphine equivalents administered to manage postoperative pain were significantly less for the acetazolamide group (4.3 ± 4.8 mg) when compared to the control group (8.9 ± 8.4 mg), p = 0.04. Perioperative complications did not differ between the groups (p = 0.16). CONCLUSIONS: Acetazolamide appears to reduce pain in the immediate postoperative setting. Patients who received acetazolamide had lower pain scores postoperatively and required fewer narcotics for pain management prior to discharge.

School nurses' familiarity and perceptions of academic accommodations for student-athletes following sport-related concussion.

The purpose of this study was to evaluate school nurses' familiarity and perceptions regarding academic accommodations for student-athletes following sport-related concussion. School nurses (N = 1,246) accessed the survey School Nurses' Beliefs, Attitudes and Knowledge of Pediatric Athletes with Concussions (BAKPAC-SN). The BAKPAC-SN contained several questions pertaining to concussion management and academic accommodations. There were significant differences regarding personal experience as well as familiarity of academic accommodations (p < .001) between school nurses who work at a school that employs an athletic trainer and school nurses who work at a school that does not employ an athletic trainer. There were significant weak positive relationships between years of experience and familiarity with academic accommodations (r = .210, p < .001), 504 plans (r = .243, p < .001), and individualized education plans (r = .205, p < .001). School nurses employed at a single school were significantly more familiar with academic accommodations (p = .027) and 504 plans (p = .001) than school nurses employed at multiple schools. Health care professionals should collaborate to effectively manage a concussed patient and should consider academic accommodations to ensure whole-person health care.

A single ß adaptin contributes to AP1 and AP2 complexes and clathrin function in Dictyostelium.

The assembly of clathrin-coated vesicles is important for numerous cellular processes, including nutrient uptake and membrane organization. Important contributors to clathrin assembly are four tetrameric assembly proteins, also called adaptor proteins (APs), each of which contains a ß subunit. We identified a single ß subunit, named ß1/2, that contributes to both the AP1 and AP2 complexes of Dictyostelium. Disruption of the gene encoding ß1/2 resulted in severe defects in growth, cytokinesis and development. Additionally, cells lacking ß1/2 displayed profound osmoregulatory defects including the absence of contractile vacuoles and mislocalization of contractile vacuole markers. The phenotypes of ß1/2 null cells were most similar to previously described phenotypes of clathrin and AP1 mutants, supporting a particularly important contribution of AP1 to clathrin pathways in Dictyostelium cells. The absence of ß1/2 in cells led to significant reductions in the protein amounts of the medium-sized subunits of the AP1 and AP2 complexes, establishing a role for the ß subunit in the stability of the medium subunits. Dictyostelium ß1/2 could resemble a common ancestor of the more specialized ß1 and ß2 subunits of the vertebrate AP complexes. Our results support the essential contribution of a single ß subunit to the stability and function of AP1 and AP2 in a simple eukaryote.

Broad-range direct detection and identification of fungi by use of the PLEX-ID PCR-electrospray ionization mass spectrometry (ESI-MS) system.

The PLEX-ID system is a novel technology that couples PCR amplification and electrospray ionization-mass spectrometry to identify pathogens directly in clinical specimens. The analytical performance of the PLEX-ID Broad Fungal assay was compared with that of traditional culture identification by using 91 characterized fungal culture isolates (64 manufacturer-claimed and 27 nonclaimed organisms) and directly by using 395 respiratory specimens. Discordant results were resolved by D2 large-subunit ribosomal DNA fungal sequencing. Environmental studies were performed to monitor for potential contamination. The PLEX-ID Broad Fungal assay correctly identified 95.6% (87/91) and 81.3% (74/91) of the culture isolates to the genus and species levels, respectively. Of the manufacturer-claimed organisms, 100% (64/64) and 92.2% (59/64) were correctly identified to the genus and species levels, respectively. Direct analysis of respiratory specimens resulted in 67.6% (267/395) and 66.6% (263/395) agreement with culture results to the genus and species levels, respectively, with 16.2% (64/395) of the results discordant with culture and 16.2% (64/395) not detected by the system. The majority (>95%) of the isolates not detected directly by the PLEX-ID system ultimately grew in low quantities in culture (≤ 20 colonies). In 20.3% (35/172) of the respiratory specimens where no growth was observed in culture, the PLEX-ID system identified a fungus, suggesting a potential increase in sensitivity over culture in some instances. The PLEX-ID system provides a rapid method for the detection of a broad array of fungi directly in respiratory specimens and has the potential of impacting turnaround times and patient care by reducing the need to wait for the growth of an organism in culture.

A neutron scattering perspective on the structure, softness and dynamics of the ligand shell of PbS nanocrystals in solution.

Small-angle neutron and X-ray scattering, neutron backscattering and neutron time-of-flight spectroscopy are applied to reveal the structure of the ligand shell, the temperature-dependent diffusion properties and the phonon spectrum of PbS nanocrystals functionalized with oleic acid in deuterated hexane. The nanocrystals decorated with oleic acid as well as the desorbed ligand molecules exhibit simple Brownian diffusion with a Stokes-Einstein temperature-dependence and inhibited freezing. Ligand molecules desorbed from the surface show strong spatial confinement. The phonon spectrum of oleic acid adsorbed to the nanocrystal surface exhibits hybrid modes with a predominant Pb-character. Low-energy surface modes of the NCs are prominent and indicate a large mechanical softness in solution. This work provides comprehensive insights into the ligand-particle interaction of colloidal nanocrystals in solution and highlights its effect on the diffusion and vibrational properties as well as their mechanical softness.

Improving Concussion Reporting across National College Athletic Association Divisions Using a Theory-Based, Data-Driven, Multimedia Concussion Education Intervention.

Although a base level of knowledge is needed to recognize a concussion, knowledge-focused concussion educational materials ignore multifaceted barriers to concussion reporting. We compared student-athlete concussion reporting intentions and behaviors prior to and 1 year after exposure to an intervention or control treatment. We randomly assigned 891 collegiate student-athletes from three universities (Divisions I, II, III) to either the control group (National College Athletic Association [NCAA] Concussion Fact Sheet) or intervention group (theory-based, data-driven, multimedia, simulated concussion reporting module). A final sample of 520 student-athletes (control = 253, intervention = 267, expired eligibility = 189, left university = 182) completed intentions and behaviors surveys immediately prior to and 1 year after the educational intervention, and a second survey to assess the intervention effect. We compared intentions using 2 x 2 mixed model analyses of variance (ANOVAs). Behaviors and educational intervention effect were assessed using logistic regression models (α = 0.05). The intervention group had significantly improved concussion reporting intentions at 1-year follow-up relative to the control group (p = 0.009), but had similar odds for behaviors. The intervention group had 2.42 times greater odds of rating the module as "very effective," rather than "not effective" relative to the control group (95% confidence interval [CI]: 1.10,5.33). Relative to the control group, the intervention group had significantly greater odds of responding that the concussion education "greatly improved" rather than "did not improve" their knowledge (odds ratio [OR]: 2.49, 95% CI:1.25,4.96), attitudes (OR: 2.22, 95% CI: 1.23,4.03), self-efficacy (OR: 1.95,95% CI: 1.05,3.60), and intentions (OR: 1.86,95% CI: 1.03,3.35). The intervention was more effective at targeting elements of the overall sport culture in a way that substantively improved concussion reporting. We recommend use of this intervention in combination with other evidence-based educational materials.

Electron-Conducting PbS Nanocrystal Superlattices with Long-Range Order Enabled by Terthiophene Molecular Linkers.

PbS nanocrystals are surface-functionalized with the organic semiconductor 5,5″-dithiol-[2,2':5,2″-terthiophene] and assembled to afford hybrid nanostructured thin films with a large structural coherence and an electron mobility of 0.2 cm2/(V s). Electrochemistry, optical spectroscopy, and quantum mechanical calculations are applied to elucidate the electronic structure at the inorganic/organic interface, and it is established that electron injection into the molecule alters its (electronic) structure, which greatly facilitates coupling of the neighboring PbS 1Se states. This is verified by field-effect and electrochemically gated transport measurements, and evidence is provided that carrier transport occurs predominantly via the 1Se states. The presented material allows studying structure-transport correlations and exploring transport anisotropies in semiconductor nanocrystal superlattices.

School Nurses' Perceived Challenges With Concussion Management Procedures in the Secondary School Setting.

School nurses have an integral role in managing student health concerns throughout the school day, yet little is known about their specific role in concussion management. Therefore, the purpose of this study was to explore the challenges encountered by school nurses regarding concussion management in the secondary school setting. Twenty-two school nurses employed in the secondary school setting were interviewed via phone. We analyzed the data via the consensual qualitative research paradigm. Overall, we found school nurses face consistent challenges with their role on the concussion management team, specifically related to education of school personnel, parents, and community health-care providers. Challenging topics included the inconsistency of community health-care provider recommendations and others' perceptions of school nurses' preparation and training to be important members of the concussion management team. Efforts to increase concussion education and improve communication across all stakeholders of the concussion management team should be implemented.

Post-Concussion Driving Behaviors and Opinions: A Survey of Collegiate Student-Athletes.

Post-concussion driving restrictions are eminent, but we lack understanding of current behaviors and opinions about driving following concussion among populations at risk of concussion. We aimed to describe post-concussion driving behaviors and opinions among collegiate student-athletes. Student-athletes completed a survey (response rate = 45.3%, 223/492) regarding their post-concussion driving behaviors and opinions. Response frequencies and percentages are presented. Student-athletes self-reported a total of 169 lifetime concussions (0.76 ± 1.02 each). Of the 169 concussions, 52.1% (88/169) were diagnosed and 52.7% (89/169) occurred while the student-athlete possessed a valid driver's license. Student-athletes refrained from driving following 43.8% (39/89) of the concussive events. Student-athletes who refrained most commonly did so for only 24-48 h (20.5%, 8/39) and because a health care provider advised them to (33.3%, 13/39). Student-athletes most commonly reported that they would feel "very unsafe" driving a car immediately following injury (38.4%, 84/219). When asked whether driving restrictions would influence their decision to report the injury to a health care provider, 7.9% reported that it "definitely would" (17/214), 26.6% "probably would" (57/214), 17.8%"neutral" (38/214), 24.8% "probably would not" (53/214), and 22.9% "definitely would not" (49/214). Despite generally believing that driving immediately following a concussion is unsafe, a majority of student-athletes did not refrain from driving at any point following their previous concussions. Post-concussion driving restrictions may have some influence on student-athletes' decisions to report the injury to a health care provider. Health care providers play a critical role in post-concussion driving restriction, but lack standardized recommendations to guide their care.

Age at First Concussion Influences the Number of Subsequent Concussions.

BACKGROUND: Individuals who sustain their first concussion during childhood may be at greater risk of sustaining multiple concussions throughout their lifetime because of a longer window of vulnerability. This article aims to estimate the association between age at first concussion and number of subsequent concussions. PATIENTS AND METHODS: A total of 23,582 collegiate athletes from 26 universities and military cadets from three military academies completed a concussion history questionnaire (65% males, age 19.9 ± 1.4 years). Participants self-reported concussions and age at time of each injury. Participants with a history of concussion (n = 3,647, 15.5%) were categorized as having sustained their first concussion during childhood (less than ten years old) or adolescence (≥10 and ≤18 years old). Poisson regression was used to model age group (childhood, adolescence) predicting the number of subsequent concussions (0, 1, 2+). A second Poisson regression was developed to determine whether age at first concussion predicted the number of subsequent concussions. RESULTS: Participants self-reporting their first concussion during childhood had an increased risk of subsequent concussions (rate ratio = 2.19, 95% confidence interval: 1.82, 2.64) compared with participants self-reporting their first concussion during adolescence. For every one-year increase in age at first concussion, we observed a 16% reduction in the risk of subsequent concussion (rate ratio = 0.84, 95% confidence interval: 0.82, 0.86). CONCLUSIONS: Individuals self-reporting a concussion at a young age sustained a higher number of concussions before age 18. Concussion prevention, recognition, and reporting strategies are of particular need at the youth level.

Influences of Mental Illness, Current Psychological State, and Concussion History on Baseline Concussion Assessment Performance.

BACKGROUND: A student-athlete's mental state, including history of trait anxiety and depression, or current psychological state may affect baseline concussion assessment performance. PURPOSE: (1) To determine if mental illness (anxiety, depression, anxiety with depression) influences baseline scores, (2) to determine if psychological state correlates with baseline performance, and (3) to determine if history of concussion affects Brief Symptom Inventory-18 (BSI-18) subscores of state anxiety, depression, and somatization. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A sample of 8652 collegiate student-athletes (54.5% males, 45.5% females) participated in the Concussion Assessment, Research and Education (CARE) Consortium. Baseline assessments included a demographic form, a symptom evaluation, Standardized Assessment of Concussion, Balance Error Scoring System, a psychological state assessment (BSI-18), and Immediate Post-concussion Assessment and Cognitive Test. Baseline scores were compared between individuals with a history of anxiety (n = 59), depression (n = 283), and anxiety with depression (n = 68) and individuals without a history of those conditions (n = 8242). Spearman's rho correlations were conducted to assess the relationship between baseline and psychological state subscores (anxiety, depression, somatization) (α = .05). Psychological state subscores were compared between individuals with a self-reported history of concussions (0, 1, 2, 3, 4+) using Kruskal-Wallis tests (α = .05). RESULTS: Student-athletes with anxiety, depression, and anxiety with depression demonstrated higher scores in number of symptoms reported (anxiety, 4.3 ± 4.2; depression, 5.2 ± 4.8; anxiety with depression, 5.4 ± 3.9; no anxiety/depression, 2.5 ± 3.4), symptom severity (anxiety, 8.1 ± 9.8; depression, 10.4 ± 12.4; anxiety with depression, 12.4 ± 10.7; no anxiety/depression, 4.1 ± 6.9), and psychological distress in state anxiety (anxiety, 3.7 ± 4.7; depression, 2.5 ± 3.6; anxiety with depression, 3.8 ± 4.2; no anxiety/depression, 0.8 ± 1.8), depression (anxiety, 2.4 ± 4.0; depression, 3.2 ± 4.5; anxiety with depression, 3.8 ± 4.8; no anxiety/depression, 0.8 ± 1.8), and somatization (anxiety, 2.3 ± 2.9; depression, 1.8 ± 2.8; anxiety with depression, 2.2 ± 2.4; no anxiety/depression, 0.9 ± 1.7). A moderate positive relationship existed between all BSI-18 subscores and total symptom number (n = 8377; anxiety: rs = 0.43, P < .001; depression: rs = 0.42, P < .001; somatization: rs = 0.45, P < .001), as well as total symptom severity (anxiety: rs = 0.43, P < .001; depression: rs = 0.41, P < .001; somatization: rs = 0.45, P < .001). Anxiety, depression, and somatization subscores were greater among student-athletes that self-reported more concussions. CONCLUSION: Clinicians should be cognizant that student-athletes with a history of trait anxiety, depression, and anxiety with depression may report higher symptom score and severity at baseline. Individuals with extensive concussion history may experience greater state anxiety, depression, and somatization.

Delayed Imaging Presentation of a Symptomatic Insulinoma After Bariatric Surgery.

Many reports exist on hyperinsulinemic hypoglycemia after bariatric surgery, which can result in persistence of the metabolic syndrome in patients who have undergone these procedures. While the noninsulinoma pancreatogenous hypoglycemia syndrome, or nesidioblastosis, has garnered increased attention in these patients, its presentation is similar to patients with an insulinoma and this entity must therefore be evaluated and ruled out. Herein, we present a patient who developed symptoms of hypoglycemia 7 years after Roux-en-Y gastric bypass surgery. While a diagnosis of insulinoma was entertained, his laboratory values were indeterminate and imaging localization was inconclusive. Because of significant medical comorbidities, he was managed symptomatically until imaging ultimately localized a lesion in the pancreatic uncinate process consistent with an insulinoma. He subsequently underwent resection and remains disease and symptom free 1 year after surgery. This case demonstrates the diagnostic and imaging dilemma in patients with hypoglycemia after bariatric surgery and should be of interest to anyone who cares for these patients.