Relapse of concussion symptoms in the context of premature return to learn and return to play: Comparative analysis of 2006 to 2011 and 2011 to 2016.

OBJECTIVE: To determine whether the proportion of sport-related concussion (SRC) cases among student athletes that resulted in a relapse of their symptoms due to premature return to play (RTP) or premature return to learn (RTL) has changed compared with a prior (2006 to 2011) study. DESIGN: Retrospective cohort study of electronic medical record charts from a 5-year period (2011 to 2016) compared with previous data. SETTING: A sport and exercise medicine physician's office-based practice in Ontario. PARTICIPANTS: Two-hundred forty-one students who had 258 distinct cases of SRC diagnosed. MAIN OUTCOME MEASURES: Premature RTP and RTL were defined as chart records documenting the relapse, recurrence, or worsening of concussion symptoms that accompanied the patient's RTP or RTL. RESULTS: Between 2011 and 2016, premature RTP and RTL resulted in a relapse of symptoms in 26.7% and 42.6% of cases, respectively. When compared with data from the 2006 to 2011 chart review, the incidence of premature RTP decreased by 38.6%. However, the rate of the relapse of symptoms associated with premature RTL decreased by only 4.7%. There was a relapse of symptoms in 43.4% of the cases involving female students and 29.7% of the cases involving male students, indicating that female patients are more likely to experience a relapse of symptoms. Cases involving female athletes also resulted in much later RTP clearance compared with those involving male athletes, with a median duration that was almost double that of male athletes' cases (49 days vs 25 days). CONCLUSION: An important decrease in the relapse of symptoms in the context of premature RTP occurred over the 2006 to 2016 period. However, this decrease was minimal for RTL. This may reflect the fact that efforts to implement structured RTP strategies arose earlier than those to implement RTL strategies. Efforts are needed to find the best method of implementing a coordinated plan for the postconcussion athlete who is returning to school.

Acute Hemorrhagic Encephalitis Related to COVID-19.

PURPOSE OF REVIEW: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the most critical public health challenge in recent history. In this report, we present a case of suspected acute hemorrhagic encephalitis with bilateral intracranial hemorrhages associated with coronavirus disease 2019 (COVID-19) infection. RECENT FINDINGS: A 48-year-old female COVID-19-positive patient developed acute changes in her neurologic status. A head CT with CT angiography demonstrated extensive bilateral parietal and occipital intraparenchymal hemorrhage with intraventricular extension and acute hydrocephalus. The patient was treated with an external ventricular drain, and a CSF sample was tested for SARS-CoV-2 but was found to be negative. SUMMARY: The underlying mechanism for developing acute hemorrhagic encephalitis in viral illnesses may be autoimmune in nature and warrants further investigation. The initial neurologic presentation of COVID-19-related hemorrhagic encephalitis is altered level of consciousness, which may prompt further neurologic examination and imaging to exclude this feature.

The effects of obstacle proximity on aperture crossing behaviours.

Affordance theory and behavioural dynamics have been used as theoretical constructs to explain how individuals interact with the environment in order to avoid obstacles. Features of obstacle distance and multiple obstacle avoidance have been discussed in unique studies, yet the interactions of these environmental features have yet to be explored. The purpose of this study was to asses the effects of obstacle distance, relative to the goal, on aperture crossing strategies. Kinematics and gaze behaviours were assessed in a cohort of female young adults (N = 24, 21.3 ± 1.4 years). Results identified that participants chose to navigate through gaps of 1.3× shoulder width or greater, regardless of obstacle distance. However, safety margin in the anterior-posterior direction was found to increase with increased obstacle distance, suggesting unique environmental affordances for each obstacle distance. Therefore, although decision making on whether to navigate through, or around, the aperture appears to be unaffected by obstacle location, specific environmental features result in unique kinematic behaviours. Such behaviours fit within, and add merit to, the tenets of both affordance theory and behavioural dynamics.

Visuomotor deficits during locomotion in previously concussed athletes 30 or more days following return to play.

Current protocols for returning athletes to play (RTP) center around resolution of physical symptoms of concussion. However, recent research has identified that balance and cognitive deficits persist beyond physical symptom recovery. Protocols that involve testing dynamic balance and visuomotor integration have been recommended as potential tools for better understanding of length of impairment following concussion. A dynamic, visuomotor paradigm was undertaken in the current study to assess decision making in athletes who had sustained a concussion >30 days before study participation and had been cleared to RTP (N = 10). Two obstacles created a gap that varied between 0.6 and 1.8× participants' individual shoulder width in open space. Participants made decisions to navigate through or deviate around the gap created by the two obstacles. The results revealed that previously concussed athletes were highly variable in their decision making and demonstrated variable Medial-Lateral (ML) center of mass (COM) control when approaching the obstacles, when compared with nonconcussed, age-matched controls. As such, they showed poor visuomotor control and decision making, as well as poor dynamic stability compared to controls. Visuomotor deficits were persistent in the sample of previously concussed individuals, well beyond deficits identified by current RTP standards. This study suggests that dynamic, visuomotor integration tasks may be of benefit to increase rigor in RTP protocols and increase safety of athletes returning to sport.

Perspective on reconstruction after mastectomy.

BACKGROUND: We sought to evaluate the factors influencing our patients to receive or forego reconstruction after mastectomy and their subsequent satisfaction with their decision. METHODS: A questionnaire was sent to 819 patients who underwent mastectomy from 1994 to 1998 in a community-based health system. RESULTS: Response rate was 50% (408 of 819). Overall, 92% (n = 243) of women who did not have reconstruction and 89% (n = 152) of women who did proceed with reconstruction were happy with their decision. Fifty-five (17%) respondents were not offered reconstruction. For this group, age was a significant factor as 64% of them were 60 years or older (P < 0.0001). Dissatisfied patients were disappointed with their cosmetic, sensory, or functional outcome. Their result did not meet their expectations. There were no significant differences noted on the basis of marital status. CONCLUSION: Ninety percent of patients adjust well to mastectomy whether or not they receive reconstruction if they make informed decisions with realistic expectations. Surgeons should offer reconstruction to women of all ages although patients over 60 years old are less likely to proceed with, and complete, reconstruction.