Early Identification and Management of Cervical Impairments in Pediatric Patients With Concussion May Reduce Risk of Delayed Recovery.

OBJECTIVE: Previous research, including high-quality systematic reviews, has found that cervical injury, which often accompanies concussive head injury, can delay recovery from concussion. One pilot randomized controlled trial found that focused cervical assessment and appropriate intervention in children and young adults with persisting postconcussive symptoms (PPCS) improved recovery outcomes. Our sports medicine clinics adopted this approach early (within 2 weeks) in children (aged 10-18 years) after concussion. This study describes our clinical management protocol and compares the recovery trajectories in children after concussion with and without a concomitant cervical injury. DESIGN: Prospective cohort study. SETTING: Three university-affiliated outpatient sports medicine clinics from September 2016 to December 2019. PATIENTS: One-hundred thirty-four concussed children with cervical impairment (mean age 14.9 years, 65% male, and 6.2 days since concussion) were compared with 130 concussed children without cervical impairment (mean age 14.9 years, 57% male, and 6.0 days since concussion). INDEPENDENT VARIABLES: Examination findings related to the cervical spine (range of motion, cervical spasm, and cervical tenderness). MAIN OUTCOME MEASURES: Recovery time (measured in days), concussion symptom burden (Postconcussion Symptom Scale), and incidence of PPCS. RESULTS: Children with cervical impairment reported a higher initial symptom burden; however, there were no differences in recovery time (33.65 [28.20-39.09] days vs 35.98 [27.50-44.45] days, P = 0.651) or incidence of PPCS (40.0% vs 34.3%, P = 0.340). CONCLUSIONS: We conclude that within this pediatric population, early identification and management of cervical injuries concomitant with concussion may reduce the risk of delayed recovery.

Environmental transmission of Pseudogymnoascus destructans to hibernating little brown bats.

Pathogens with persistent environmental stages can have devastating effects on wildlife communities. White-nose syndrome (WNS), caused by the fungus Pseudogymnoascus destructans, has caused widespread declines in bat populations of North America. In 2009, during the early stages of the WNS investigation and before molecular techniques had been developed to readily detect P. destructans in environmental samples, we initiated this study to assess whether P. destructans can persist in the hibernaculum environment in the absence of its conclusive bat host and cause infections in naive bats. We transferred little brown bats (Myotis lucifugus) from an unaffected winter colony in northwest Wisconsin to two P. destructans contaminated hibernacula in Vermont where native bats had been excluded. Infection with P. destructans was apparent on some bats within 8 weeks following the introduction of unexposed bats to these environments, and mortality from WNS was confirmed by histopathology at both sites 14 weeks following introduction. These results indicate that environmental exposure to P. destructans is sufficient to cause the infection and mortality associated with WNS in naive bats, which increases the probability of winter colony extirpation and complicates conservation efforts.

Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial.

Importance: Sport-related concussion (SRC) is a significant public health problem without an effective treatment. Objective: To assess the effectiveness of subsymptom threshold aerobic exercise vs a placebo-like stretching program prescribed to adolescents in the acute phase of recovery from SRC. Design, Setting, and Participants: This multicenter prospective randomized clinical trial was conducted at university concussion centers. Male and female adolescent athletes (age 13-18 years) presenting within 10 days of SRC were randomly assigned to aerobic exercise or a placebo-like stretching regimen. Interventions: After systematic determination of treadmill exercise tolerance on the first visit, participants were randomly assigned to a progressive subsymptom threshold aerobic exercise or a progressive placebo-like stretching program (that would not substantially elevate heart rate). Both forms of exercise were performed approximately 20 minutes per day, and participants reported daily symptoms and compliance with exercise prescription via a website. Main Outcomes and Measures: Days from injury to recovery; recovery was defined as being asymptomatic, having recovery confirmed through an assessment by a physician blinded to treatment group, and returning to normal exercise tolerance on treadmill testing. Participants were also classified as having normal (<30 days) or delayed (≥30 days) recovery. Results: A total of 103 participants were included (aerobic exercise: n = 52; 24 female [46%]; stretching, n = 51; 24 female [47%]). Participants in the aerobic exercise group were seen a mean (SD) of 4.9 (2.2) days after the SRC, and those in the stretching group were seen a mean (SD) of 4.8 (2.4) days after the SRC. There were no differences in age, sex, previous concussions, time from injury, initial symptom severity score, or initial exercise treadmill test and physical examination results. Aerobic exercise participants recovered in a median of 13 (interquartile range [IQR], 10-18.5) days, whereas stretching participants recovered in 17 (IQR, 13-23) days (P = .009 by Mann-Whitney test). There was a nonsignificant lower incidence of delayed recovery in the aerobic exercise group (2 participants [4%] in the aerobic group vs 7 [14%] in the placebo group; P = .08). Conclusions and Relevance: This is, to our knowledge, the first RCT to show that individualized subsymptom threshold aerobic exercise treatment prescribed to adolescents with concussion symptoms during the first week after SRC speeds recovery and may reduce the incidence of delayed recovery. Trial Registration: ClinicalTrials.gov identifier: NCT02710123.

Factors Associated With Problems for Adolescents Returning to the Classroom After Sport-Related Concussion.

The primary objective of this study was to determine factors in the clinic setting associated with concussion-related problems in the school setting. A total of 91 student athletes, 13 to 19 years old, completed the SCAT2 and computerized testing during their initial visit to the clinic. During a follow-up telephone interview, one-third reported problems with return to school. The presence of problems reported in school was associated with severity of concussion as represented by recovery time and the overall number of symptoms at the first clinic visit. Gender, age, and previous concussions were not associated with school problems. Athletes with computerized test scores below the ninth percentile were more likely to report school problems. The current study offers some descriptive information for clinicians and ideas for future research related to adolescent athletes with concussion and problems with return to the classroom.

Evaluation of the Zurich Guidelines and exercise testing for return to play in adolescents following concussion.

OBJECTIVE: To evaluate return to play (RTP) and return to classroom outcomes when the Zurich guidelines are combined with a standardized exercise treadmill test [Buffalo Concussion Treadmill Test (BCTT)] and computerized neuropsychological (cNP) testing in adolescent athletes after concussion. DESIGN: Retrospective chart review and follow-up. SETTING: University Sports Medicine Concussion Clinic. PARTICIPANTS: One hundred seventeen athletes (75% male) with sport concussion ages 13 to 19 years and telephone follow-up of 91 (77.8%) athletes and their parents. INTERVENTIONS: Concussed athletes who were asymptomatic at rest completed Automated Neuropsychological Assessment Metrics or Immediate Post-concussion Assessment and Cognitive Test cNP testing followed by the BCTT on the same day. Athletes then followed the Zurich consensus guidelines for RTP. MAIN OUTCOME MEASURES: The primary outcome measure was the degree of success in RTP, that is, RTP with or without return of concussive symptoms. Secondary outcome measure was return to school with or without symptoms. RESULTS: All athletes returned to sport without exacerbation of symptoms. Telephone follow-up revealed that 38.5% experienced new issues upon return to the classroom. Forty-eight percent of athletes had 1 or more cNP subtests below average (

Interannual Survival of Myotis lucifugus (Chiroptera: Vespertilionidae) near the Epicenter of White-Nose Syndrome.

Reduced populations of Myotis lucifugus (Little Brown Myotis) devastated by white-nose syndrome (WNS) persist in eastern North America. Between 2009 and 2013, we recaptured 113 marked individuals that survived between 1 and 6 winters in New England since the arrival of WNS. We also observed signs of reproductive success in 57 recaptured bats.

Frequent arousal from hibernation linked to severity of infection and mortality in bats with white-nose syndrome.

White-nose syndrome (WNS), an emerging infectious disease that has killed over 5.5 million hibernating bats, is named for the causative agent, a white fungus (Geomyces destructans (Gd)) that invades the skin of torpid bats. During hibernation, arousals to warm (euthermic) body temperatures are normal but deplete fat stores. Temperature-sensitive dataloggers were attached to the backs of 504 free-ranging little brown bats (Myotis lucifugus) in hibernacula located throughout the northeastern USA. Dataloggers were retrieved at the end of the hibernation season and complete profiles of skin temperature data were available from 83 bats, which were categorized as: (1) unaffected, (2) WNS-affected but alive at time of datalogger removal, or (3) WNS-affected but found dead at time of datalogger removal. Histological confirmation of WNS severity (as indexed by degree of fungal infection) as well as confirmation of presence/absence of DNA from Gd by PCR was determined for 26 animals. We demonstrated that WNS-affected bats aroused to euthermic body temperatures more frequently than unaffected bats, likely contributing to subsequent mortality. Within the subset of WNS-affected bats that were found dead at the time of datalogger removal, the number of arousal bouts since datalogger attachment significantly predicted date of death. Additionally, the severity of cutaneous Gd infection correlated with the number of arousal episodes from torpor during hibernation. Thus, increased frequency of arousal from torpor likely contributes to WNS-associated mortality, but the question of how Gd infection induces increased arousals remains unanswered.

Intentional versus unintentional contact as a mechanism of injury in youth ice hockey.

BACKGROUND: Youth ice hockey injury rates and mechanisms have been described by various classification systems. Intentional versus unintentional contact was used to classify mechanisms of injuries. All injuries (n=247) in one youth hockey programme over a 5-year period were recorded and included in the analysis. PURPOSE: To evaluate youth ice hockey injuries and compare programmes that allow body checking versus programmes that do not allow body checking. A primary goal was to determine whether programmes that allow body checking have increased injury rates from intentional body contact. Another goal was to describe the rates of injury across ages, levels of competitive play and during games versus practices. METHODS: Rates of injury were compared for three levels of competition (house, select and representative) for approximately 3000 boys aged 4-18 years over a 5-year period. This represents 13 292 player years. Data were collected prospectively in this cohort study. All injuries were reported prospectively by a designated team official and verified by a physician. The log injury rate (per 1000 player hours) was modelled via Poisson regression with log player hours used as an offset. Rate ratio was used to explain the covariate-adjusted injury rate for each of three groups (all injuries, intentional injuries, unintentional injuries). RESULTS: Unintentional contacts accounted for 66.0% of overall injuries (95% CI 60.0 to 72.0), compared with 34.0% from intentional contacts (p<0.001; Z=5.25). Serious injuries (fractures, dislocations, concussions) resulted more often from unintentional collisions (p=0.04). Players in more competitive leagues that allow body checking had a greater incidence of total injuries than less competitive leagues. CONCLUSIONS: Most injuries in the youth hockey programme studied were the result of unintentional contact, and were generally more severe. These findings were not expected given previously published research.

Bat white-nose syndrome: an emerging fungal pathogen?

White-nose syndrome (WNS) is a condition associated with an unprecedented bat mortality event in the northeastern United States. Since the winter of 2006*2007, bat declines exceeding 75% have been observed at surveyed hibernacula. Affected bats often present with visually striking white fungal growth on their muzzles, ears, and/or wing membranes. Direct microscopy and culture analyses demonstrated that the skin of WNS-affected bats is colonized by a psychrophilic fungus that is phylogenetically related to Geomyces spp. but with a conidial morphology distinct from characterized members of this genus. This report characterizes the cutaneous fungal infection associated with WNS.