Quantifying head impact biomechanical differences between commonly employed cleaning levels: a critical research interpretation consideration.

INTRODUCTION: Wearable accelerometry devices quantify on-field frequency and severity of head impacts to further improve sport safety. Commonly employed post-data collection cleaning techniques may affect these outcomes. OBJECTIVE: Our purpose was to compare game impact rates and magnitudes between three different cleaning levels (Level-1: impacts recorded within start and end times, Level-2: impacts during pauses/breaks removed, Level-3: video verified) for male youth tackle football. METHODS: Participants (n = 23, age = 10.9 ± 0.3 yrs, height = 150.0 ± 8.3 cm, mass = 41.6 ± 8.4 kg) wore Triax SIM-G sensors throughout Fall 2019. Impact rates, ratios (IRRs), and 95% confidence intervals (95%CI) were used to compare levels. Random-effects general linear models were used to compare peak linear acceleration (PLA;g) and angular velocity (PAV;rads/s). RESULTS: Level-1 resulted in higher impact rates (4.57; 95%CI = 4.14-5.05) compared to Level-2 (3.09; 95%CI = 2.80-3.42; IRR = 1.48; 95%CI = 1.34-1.63) and Level-3 datasets (2.56; 95%CI = 2.30-2.85; IRR = 1.78; 95%CI = 1.60-1.98). Level-2 had higher impact rates compared to Level-3 (1.21; 95%CI = 1.08-1.35). Level-1 resulted in higher PAV than Level-2 and Level-3 (p < 0.001) datasets. PLA did not differ across datasets (p = 0.296). CONCLUSIONS: Head impact data should be filtered of pauses/breaks, and does not substantially differ outcome estimates compared to time-intensive video verification.

Youth Tackle Football Head-Impact Estimation by Players and Parents: Is the Perception the Reality?

CONTEXT: With growing concerns surrounding exposure to head impacts in youth tackle football, players and parents must understand the exposure level when assenting and consenting to participate. OBJECTIVE: To determine whether youth football players and parents could estimate on-field head-impact frequency, severity, and location. DESIGN: Prospective cohort study. SETTING: Football field. PATIENTS OR OTHER PARTICIPANTS: We administered a 10-question head-impact estimation tool to parents (n = 23; mean age = 36.5 years [95% CI = 31.7, 37.3 years]) and players (n = 16 boys; mean age = 11.1 years [95% CI = 10.3, 11.8 years]). MAIN OUTCOME MEASURE(S): Player on-field head-impact exposure was captured using the Triax SIM-G system. We determined the accuracy between player and parent estimates relative to on-field head-impact exposures using κ and weighted κ values. RESULTS: Youth tackle football players and parents did not accurately estimate on-field head-impact frequency (κ range = -0.09 to 0.40), severity (κ range = -0.05 to 0.34), or location (κ range = -0.30 to 0.13). Players and parents overestimated head-impact frequency in practices but underestimated the frequency in games. Both groups overestimated head-impact severity, particularly in games. Most players and parents underestimated the number of head impacts to the top of the head, particularly during practices. CONCLUSIONS: Underestimations of head-impact frequency in games and to the top of the head suggest that informed consent processes aimed at educating players and parents should be improved. Overestimations of head-impact frequency in practices and severity may explain declining rates of youth tackle football participation.

King-Devick Sensitivity and Specificity to Concussion in Collegiate Athletes.

CONTEXT: The King-Devick (K-D) test is used to identify oculomotor impairment after concussion. However, the diagnostic accuracy of the K-D test over time has not been evaluated. OBJECTIVES: To (1) examine the sensitivity and specificity of the K-D test at 0 to 6 hours postinjury, 24 to 48 hours postinjury, the beginning of a return-to-play (RTP) protocol (asymptomatic), unrestricted RTP, and 6 months postconcussion and (2) compare outcomes between athletes with and those without concussion across confounding factors (sex, age, sport contact level, academic year, learning disorder, attention-deficit/hyperactivity disorder, migraine history, concussion history, and test administration mode). DESIGN: Retrospective, cross-sectional design. SETTING: Multiple institutions in the Concussion Assessment, Research and Education Consortium. PATIENTS OR OTHER PARTICIPANTS: A total of 320 athletes with a concussion (162 men, 158 women; age = 19.80 ± 1.41 years) were compared with 1239 total collegiate athletes without a concussion (646 men, 593 women; age = 20.31 ± 1.18 years). MAIN OUTCOME MEASURE(S): We calculated the K-D test time difference (in seconds) by subtracting the baseline from the most recent time. Receiver operator characteristic (ROC) curve and area under the curve (AUC) analyses were used to determine the diagnostic accuracy across time points. We identified cutoff scores and corresponding specificity at both the 80% and 70% sensitivity levels. We repeated ROC with AUC analyses using confounding factors. RESULTS: The K-D test predicted positive results at the 0- to 6-hour (AUC = 0.724, P < .001), 24- to 48-hour (AUC = 0.701, P < .001), RTP (AUC = 0.640, P < .001), and 6-month postconcussion (AUC = 0.615, P < .001) tim points but not at the asymptomatic time point (AUC = 0.513, P = .497). The 0- to 6-hour and 24- to 48-hour time points yielded 80% sensitivity cutoff scores of -2.6 and -3.2 seconds (ie, faster), respectively, but 46% and 41% specificity, respectively. The K-D test had a better AUC when administered using an iPad (AUC = 0.800, 95% CI = 0.747, 0.854) compared with the spiral-bound card system (AUC = 0.646, 95% CI = 0.600, 0.692; P < .001). CONCLUSIONS: The diagnostic accuracy of the K-D test was greatest at 0 to 6 hours and 24 to 48 hours postconcussion but declined across subsequent postconcussion time points. The AUCs did not differentiate between groups across confounding factors. Our negative cutoff scores indicated that practice effects contributed to improved performance, requiring athletes to outperform their baseline scores.

Influence of Society for Academic Emergency Medicine Foundation's Research Training Grant on postaward academic federal funding.

OBJECTIVES: The objective was to measure the impact of the Society for Academic Emergency Medicine Foundation's (SAEMF) Research Training Grant (RTG) by comparing academic success in grant recipients versus non-recipient applicants. Our primary outcome was subsequent federal funding as a principal investigator (PI) or multiple principal investigator (MPI). Our secondary outcomes included subsequent K-award funding, R-series funding, R01 funding, and academic productivity measured by first author peer-reviewed publications. METHODS: The authors examined all SAEMF RTG applicants from 2002 through 2019 (n = 109). Data were collected using the National Institutes of Health RePORTER database, a literature search using PubMed, and an online survey sent to all RTG applicants. Relative risks (RRs) with 95% confidence intervals (95% CI) were calculated. RESULTS: Over 18 years, 18 of 109 (16.5%) RTG applicants were awarded by SAEMF. Subsequent federal funding as PI or MPI was obtained by 11 of the 18 RTG recipients compared to 29 of the 91 nonrecipients (61% vs. 33%, RR = 1.9; 95% CI = 1.2-3.1). The RTG award was also associated with increased probability of receiving a federal Career Development Award (K-series) (RR 2.0; 95% CI 1.1-3.9) and R-series award (RR 2.0; 95% CI 1.1-3.9) but not an R01 award (RR 2.1; 95% CI 0.8-5.3). The median number of first-authored peer reviewed manuscripts did not differ between RTG award recipients (14, IQR 8,44) and nonrecipients (14, IQR 6,30) (p = 0.5) though RTG recipients had a higher percentage of their publications as a first author (49% vs. 33%, p = 0.04). CONCLUSIONS: SAEMF RTG awards were associated with increased probability of future federal funding, including career development awards and R-series awards but not R01 awards. RTG recipients also had a higher percentage of their peer reviewed publications as first author.

Safe Triage of STEMI Patients to General Telemetry Units After Successful Primary Percutaneous Coronary Intervention.

OBJECTIVE: To analyze outcomes of patients with ST-segment elevation myocardial infarction (STEMI) after successful primary percutaneous coronary intervention (PCI) triaged to the cardiac intensive care unit (CICU) vs a general telemetry unit by a Zwolle risk score-based algorithm. METHODS: We introduced a quality improvement protocol in 2014 encouraging admission of STEMI patients with Zwolle score of 3 or less to general telemetry units unless they were hemodynamically unstable. We subsequently conducted a retrospective single-center cohort study of consecutive STEMI patients who had undergone primary PCI from January 1, 2014, to December 31, 2018. Outcomes studied include immediate complications, need for urgent unplanned intervention, need for CICU care, length of hospitalization, and survival. RESULTS: We identified 547 patients, 406 with a Zwolle score of 3 or less. Of these, 192 (47.3%) were admitted to general telemetry and 214 (52.7%) to the CICU. Reasons for CICU admission included persistent chest pain, late presentation, and procedural complications. The average hospital length of stay was 2.1±1.4 days for non-CICU patients and 3.3±2.8 days for low-risk CICU patients (P<.001). Two patients initially admitted to general telemetry required transfer to the CICU. There were 26 patients who required unplanned cardiovascular intervention within 30 days, 5 from the general telemetry unit; 540 patients survived to discharge. One in-hospital death occurred among those initially triaged to the general telemetry unit, and this was due to a noncardiac cause. CONCLUSION: A Zwolle score-based algorithm can be used to safely triage post-PCI STEMI patients to a general telemetry unit.

Head Impact Biomechanics in Youth Flag Football: A Prospective Cohort Study.

BACKGROUND: Youth flag football participation has rapidly grown and is a potentially safer alternative to tackle football. However, limited research has quantitatively assessed youth flag football head impact biomechanics. PURPOSE: To describe head impact biomechanics outcomes in youth flag football and explore factors associated with head impact magnitudes. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We monitored 52 player-seasons among 48 male flag football players (mean ± SD; age, 9.4 ± 1.1 years; height, 138.6 ± 9.5 cm; mass, 34.7 ± 9.2 kg) across 3 seasons using head impact sensors during practices and games. Sensors recorded head impact frequencies, peak linear (g) and rotational (rad/s2) acceleration, and estimated impact location. Impact rates (IRs) were calculated as 1 impact per 10 player-exposures; IR ratios (IRRs) were used to compare season, event type, and age group IRs; and 95% CIs were calculated for IRs and IRRs. Weekly and seasonal cumulative head impact frequencies and magnitudes were calculated. Mixed-model regression models examined the association between player characteristics, event type, and seasons and peak linear and rotational accelerations. RESULTS: A total of 429 head impacts from 604 exposures occurred across the study period (IR, 7.10; 95% CI, 4.81-10.50). Weekly and seasonal cumulative median head impact frequencies were 1.00 (range, 0-2.63) and 7.50 (range, 0-21.00), respectively. The most frequent estimated head impact locations were the skull base (n = 96; 22.4%), top of the head (n = 74; 17.2%), and back of the head (n = 66; 15.4%). The combined event type IRs differed among the 3 seasons (IRR range, 1.45-2.68). Games produced greater IRs (IRR, 1.24; 95% CI, 1.01-1.53) and peak linear acceleration (mean difference, 5.69g; P = .008) than did practices. Older players demonstrated greater combined event-type IRs (IRR, 1.46; 95% CI, 1.12-1.90) and increased head impact magnitudes than did younger players, with every 1-year age increase associated with a 3.78g and 602.81-rad/s2 increase in peak linear and rotational acceleration magnitude, respectively (P≤ .005). CONCLUSION: Head IRs and magnitudes varied across seasons, thus highlighting multiple season and cohort data are valuable when providing estimates. Head IRs were relatively low across seasons, while linear and rotational acceleration magnitudes were relatively high.

On-field Characteristics and Head Impact Magnitude in Youth Tackle Football.

BACKGROUND: This study determined the effect of video-verified collision characteristics on head impact magnitudes in male youth tackle football. METHODS: Participants (n = 23, age = 10.9 ± 0.3 years, height = 150.0 ± 8.3 cm, mass = 41.6 ± 8.4 kg) wore Triax Sim-G sensors throughout the fall 2019 season. Ten filmed games were used to identify nine different collision characteristics: mechanism, preparedness, head direction, struck versus striking activity, stance, play type, closing distance, penalty, and quarter. Random-effects general linear models and Cohen d effect sizes were used to examine differences in log-transformed peak linear (PLA; g) and rotational (PRA; rad/s2) accelerations across characteristics. The 10 games produced 533 total video-verified impacts and 23.2 ± 7.2 impacts per athlete. RESULTS: PLA (P range: 0.107 to 0.923) and PRA (P range: 0.057 to 0.768) did not differ across characteristics. Struck players (3370 rads/s2, 95% confidence interval [CI] = 2986 to 3808) had a small effect for higher PRA compared with striking players (3037 rads/s2, 95% CI = 2713 to 3404, d = 0.251), but negligible effect for simultaneous struck-striking players (3340 rad/s2, 95% CI = 2945 to 3792, d = 0.018). Fourth quarter impacts (3490 rads/s2, 95% CI = 3083 to 3951) had a small effect for higher PRA compared with first (2945 rads/s2, 95% CI = 2596 to 3337, d = 0.404), second (3196 rads/s2, 95% CI = 2832 to 3604, d = 0.219), and third quarters (3241 rads/s2, 95% CI = 2841 to 3699, d = 0.144). CONCLUSION: Youth tackle football characteristics did not significantly affect head impact magnitudes during games. More research is needed to explore additional factors that could be modified for sport safety rather than mitigating impact mechanism.

The Effects of On-Field Heat Index and Altitude on Concussion Assessments and Recovery Among NCAA Athletes.

BACKGROUND: Recent literature has indicated altitude may be a protective factor for concussion but it is unknown whether altitude or heat index affects recovery. OBJECTIVE: To examine whether on-field heat index and altitude at the time of injury alter acute (< 48 h) concussion assessments, days-to-asymptomatic, and days-to-return-to-play in collegiate athletes following concussion. METHODS: Collegiate athletes (n = 187; age = 19.7 ± 1.4 years; male = 70.6%) underwent baseline assessments across 30 universities and experienced a concussion in this retrospective cohort study. Altitude (m) and heat index (°C) at the time and location of injury were determined using valid online database tools. Acute concussion assessments included the Sport Concussion Assessment Tool (SCAT) symptom inventory, Balance Error Scoring System (BESS), and the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). We used multiple linear regression models to determine whether heat index and altitude predicted each acute assessment outcome, days-to-asymptomatic, and days-to-return-to-play. RESULTS: Collegiate athletes were concussed at a 181.1 m (range - 0.6 to 2201.9 m) median altitude and 17.8 °C (range - 6.1 to 35.6 °C) median heat index. Altitude did not predict (p ≥ 0.265) any outcomes. Every one-degree increase in heat index reduced days-to-asymptomatic (p = 0.047; R2 = 0.06) and days-to-return-to-play (p = 0.006; R2 = 0.09) by 0.05 and 0.14 days, respectively. Heat index and altitude did not explain significant variance in SCAT, BESS, and ImPACT composite scores (p's = 0.20-0.922). CONCLUSION: Our findings suggest that on-field altitude and heat index at the time of injury do not contribute to clinically meaningful changes on acute assessments or concussion recovery. On-field altitude and heat index do not appear to significantly alter assessment outcomes or clinical recovery, suggesting that environmental factors at altitudes below < 2500 m are negligible outcomes for researchers and clinicians to consider post-concussion.

A Case of Hyperkalemia Versus Pseudohyperkalemia in Chronic Lymphocytic Leukemia.

INTRODUCTION: Both hyperkalemia and pseudohyperkalemia occur in the emergency department. True hyperkalemia necessitates emergent treatment while pseudohyperkalemia requires recognition to prevent inappropriate treatment. It is imperative that the emergency physician (EP) have an understanding of the causes and clinical presentations of both phenomena. CASE REPORT: We present a case of an 88-year-old male with chronic lymphocytic leukemia (CLL) and suspected blast crisis who was found to have elevated serum potassium levels without other manifestations of hyperkalemia and eventually was determined to have pseudohyperkalemia due to white cell fragility. DISCUSSION: Differentiation of hyperkalemia and pseudohyperkalemia is a critical skill for the EP. We discuss multiple causes of hyperkalemia and pseudohyperkalemia in an effort to broaden the knowledge base. CONCLUSION: We present a case of CLL as an unusual cause of pseudohyperkalemia and review common causes of pseudohyperkalemia.

Clinical Outcomes of Various Management Strategies for Symptomatic Bradycardia.

OBJECTIVE: To determine clinical outcomes of various management strategies for reversible and irreversible causes of symptomatic bradycardia in the inpatient setting. DESIGN: Retrospective observational study. SETTING: Emergency room and inpatient. PARTICIPANTS: Patients presenting to the emergency department with symptomatic bradycardia. METHODS: We retrospectively reviewed electronic health records of 518 patients from two Mayo Clinic campuses (Rochester and Phoenix) who presented to the emergency department with symptomatic bradycardia (heart rate ≤50 beats/minute) from January 1, 2010 through December 31, 2015. Sinus bradycardia was excluded. The following management strategies were compared: observation, non-invasive management (medications with/without transcutaneous pacing), early permanent pacemaker (PPM) implantation (≤2 days), and delayed PPM implantation (≥3 days). Study endpoints included length of stay and adverse events related to bradycardia (syncope, central line-associated bloodstream infections, cardiac arrest, and in-hospital mortality). Patients who received a PPM were further stratified by weekend hospital admission. RESULTS: Heart block occurred in 200 (38.6%) patients, and atrial arrhythmias with slow ventricular response occurred in 239 (46.1%) patients. Reversible causes of bradycardia included medication toxicity in 22 (4.2%) patients and hyperkalemia in 44 (8.5%) patients. Adverse events were similar in patients who underwent early compared to delayed PPM implantation (6.6% vs 12.5%, P=.20), whereas adverse events were higher in patients who received temporary transvenous pacing (19.1% vs 3.4%, P<.001). Weekend admissions were associated with increased temporary transvenous pacing, prolonged median time to PPM implantation by 1 day, and prolonged median length of stay by 2 days. CONCLUSIONS: Delayed PPM implantation was not associated with an increase in adverse events. Weekend PPM implantation should be considered to reduce temporary transvenous pacing and shorten length of stay.

Sex differences in mechanisms of head impacts in collegiate soccer athletes.

BACKGROUND: There has been growing interest in head impacts related to sports participation due to potential long- and short-term consequences of head injuries. Our purpose was to compare head impact magnitude and frequency between men's and women's intercollegiate soccer players based on head impact mechanism. METHODS: 28 collegiate soccer players (16 women: age = 19.94 (1.06) years, height = 163.75 (5.15) cm, mass = 61.21 (5.09) kg; 12 men: age = 20.25 (1.14) years, height = 180.34 (6.03) cm, mass = 74.09 (9.32) kg) wore xPatch (X2 Biosystems, Seattle, WA) head impact sensors. Each practice and game was video recorded in order to confirm head impacts. The independent variable was impact mechanism (head to head, head to body (other than head), head to ground, ball to head, goal to head, and combination). Sensors collected linear and rotational accelerations and frequency of head impacts per 1000 athlete exposures. FINDINGS: Men were more likely to sustain head impacts than women (IRR = 1.74, CI95 = 1.59-1.92). The highest head impact incidence rate for men was head to body (IR = 611.68, CI95 = 553.11-670.25) while the highest impact incidence rate for women was ball to head (IR = 302.29, CI95 = 270.93-333.64). The interaction between sex and mechanism was significant for rotational accelerations (F4, 1720 = 3.757, P = .005, ω2 = 0.013) but not for linear accelerations (F4,1720 = 0.680, P = .606, ω2 < 0.001, 1 - ß = 0.223). INTERPRETATION: To reduce the frequency of head impacts in men, perhaps rules governing player to player contact should be more strictly enforced as these data confirm frequent player-to-head contact during soccer practices and games. Prevention efforts for women should be focused on limiting the amount of purposeful heading (planned contact between the head and ball) occurring during play especially since these impacts had higher magnitudes compared to men.

Artificial Light Increases Local Predator Abundance, Predation Rates, and Herbivory.

Human activity is rapidly increasing the radiance and geographic extent of artificial light at night (ALAN) leading to alterations in the development, behavior, and physiological state of many organisms. A limited number of community-scale studies investigating the effects of ALAN have allowed for spatial aggregation through positive phototaxis, the commonly observed phenomenon of arthropod movement toward light. We performed an open field study (without restricted arthropod access) to determine the effects of ALAN on local arthropod community composition, plant traits, and local herbivory and predation rates. We found strong positive phototaxis in 10 orders of arthropods, with increased (159% higher) overall arthropod abundance under ALAN compared to unlit controls. The arthropod community under ALAN was more diverse and contained a higher proportion of predaceous arthropods (15% vs 8%). Predation of immobilized flies occurred 3.6 times faster under ALAN; this effect was not observed during the day. Contrary to expectations, we also observed a 6% increase in herbivory under ALAN. Our results highlight the importance of open experimental field studies in determining community-level effects of ALAN.

Thrombocytopenia independently predicts death in idiopathic PAH.

BACKGROUND: Pulmonary arterial hypertension (PAH) is a progressive vascular disorder with a high mortality. Clinical experience and small case series suggest thrombocytopenia may be frequent in this population and associated with a poor prognosis. We sought to estimate the prevalence of thrombocytopenia in patients with PAH and characterize its association with disease characteristics and patient outcome. METHODS: Single center cohort study of 714 incident adult patients with Group 1 PH who were evaluated for baseline platelet count at the time of diagnosis. Pts were stratified into three groups: normal platelet count (>150 × 109/L), Grade 1 thrombocytopenia (75-149 × 109/L) and Grade 2-4 thrombocytopenia (<75 × 109/L). RESULTS: The median platelet count was 209 × 109/L (IQR 163, 264). There were 572 (80%) pts without thrombocytopenia, 107 (15%) with Grade 1 and 35 (5%) with Grade 2-4 thrombocytopenia. The median pt age was 55 years (IQR 44-65) with no difference between platelet groups (p = 0.85). Men were more likely to have thrombocytopenia (62, 34%) than women (80, 15%, p < 0.0001). Thrombocytopenia was frequent with portopulmonary PAH (84%) as opposed to idiopathic PAH (iPAH; 14%) or connective tissue disease associated PAH (12%). Platelet counts were not associated with functional class symptoms, the degree of right ventricular enlargement or dysfunction or tricuspid regurgitation by echocardiography. Invasive hemodynamics of right atrial pressure, mean pulmonary artery pressure and pulmonary vascular resistance were also similar between platelet groups. Thrombocytopenia was associated with higher mortality in iPAH patients (age- and sex-adjusted 5 year mortality [HR 1.95 (1.20, 3.08) p = 0.008] but not in other etiology groups. In a multivariate model of iPAH patients (adjusted for age, sex, DLCO, PVR, creatinine and 6MW distance) thrombocytopenia was most predictive of 5-year mortality [HR 1.68 (1.32, 2.12), p < 0.0001]. CONCLUSION: Thrombocytopenia in the context of iPAH portends a poor prognosis and is a simple independent factor to consider in judging severity of disease.

Differences in the Mechanism of Head Impacts Measured Between Men's and Women's Intercollegiate Lacrosse Athletes.

BACKGROUND: Lacrosse is a rapidly growing sport in the United States. Comparing the magnitude and frequency of head impact mechanisms between sexes will provide data for injury prevention techniques and risk reduction of head injuries. PURPOSE: To compare sex-specific differences in the magnitude and frequency of head impact mechanisms in National Collegiate Athletic Association (NCAA) Division III intercollegiate lacrosse athletes. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 31 NCAA Division III intercollegiate lacrosse athletes (16 men [mean age, 21 ± 1 years; mean height, 179.70 ± 5.82 cm; mean weight, 80.71 ± 6.33 kg] and 15 women [mean age, 20 ± 1 years; mean height, 165.43 ± 5.25 cm; mean weight, 64.08 ± 7.59 kg]) voluntarily participated in this study. Participants wore xPatch sensors at every event during the 2015 spring season. Sensors recorded the magnitude, frequency, and location of head impacts over 10g. Linear (g) and rotational (deg/s2) acceleration determined impact magnitudes. We calculated incidence rates (IRs; per 1000 athlete-exposures [AEs]) and incidence rate ratios (IRRs) with 95% CIs to determine frequency differences. Film footage from each event was synchronized with the time of each head impact for verification and mechanism coding. Sex and impact mechanism served as the independent variables. RESULTS: A significant interaction was found between impact mechanism and sex (P < .001) and main effects for impact mechanism (P < .001) and sex (P < .001). The most common mechanism in men's lacrosse was head to body (IR, 970.55/1000 AEs [95% CI, 266.14-331.98]), and in women's lacrosse, stick to head (IR, 289.87/1000 AEs [95% CI, 124.32-184.55]) was most common. Only 9 of 419 impermissible head impacts in men's lacrosse games were classed as penalties (2%); 7 of 25 impermissible head impacts in women's lacrosse games were called as penalties (28%). CONCLUSION: The impact mechanisms of head to body in men's lacrosse and stick to head in women's lacrosse are penalties but occur frequently, suggesting that a focus on stressing rule enforcement is warranted. Because mechanism and sex affect the magnitude of head impacts, proper offensive and defensive techniques against opponents should be encouraged to reduce head impacts.

Monitoring opioid and benzodiazepine use and abuse: Is oral fluid or urine the preferred specimen type?

BACKGROUND: Oral fluid (OF) has become an increasingly popular matrix to assess compliance in pain management and addiction settings as it reduces the likelihood of adulteration. However, drug concentrations and windows of detection are not as well studied in OF as in urine (UR). We compared the clinical utility and analytical performance of OF and UR as matrices for detecting common benzodiazepines and opioids. METHODS: OF and UR concentrations of 5 benzodiazepines and 7 opioids were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) in 263 paired OF and UR specimens. UR creatinine was measured and prescription medications were reviewed. RESULTS: The benzodiazepines 7-aminoclonazepam, lorazepam, and oxazepam exhibited statistically higher detection rates in UR. For opioids, 6-AM was statistically more likely to be detected in OF, while hydromorphone and oxymorphone were statistically more likely to be detected in UR. Chemical properties including glucuronidation explain preferential detection in each matrix, not UR creatinine nor prescription status. CONCLUSION: We found that OF is the preferred matrix for 6-AM, while UR is preferred for 7-aminoclonazepam, lorazepam, oxazepam, hydromorphone, and oxymorphone. However, OF should be considered if the risk of adulteration is high and use and/or misuse of benzodiazepines, hydromorphone, and oxymorphone is low.

The prognostic significance of tricuspid valve regurgitation in pulmonary arterial hypertension.

INTRODUCTION: Tricuspid valve regurgitation (TR) is a frequent finding in patients with pulmonary arterial hypertension (PAH). However, its prognostic significance and relation to PAH, while suspected, are poorly understood. We assessed 727 consecutive patients with newly diagnosed PAH who underwent transthoracic echocardiographic evaluation of tricuspid valve function. OBJECTIVES: The study objective was to determine the association of TR presence and severity with patient characteristics, pulmonary artery hemodynamics and outcome. METHODS: Consecutive patients with newly diagnosed PAH (N = 727 with group 1 pulmonary hypertension) underwent transthoracic echocardiographic evaluation of tricuspid valve function at diagnosis. The primary study end point was all-cause mortality or lung transplantation. RESULTS: In this population, 702 patients (96.5%) had TR; in 165 patients (23%), TR was severe. Compared with those with no or mild TR by echocardiography criteria, patients with severe TR had shorter mean (SD) 6-minute walk distances (285 [125] m vs 360 [121] m; P = .02) and higher levels of B-type natriuretic peptide (695 [672] pg/dL vs 328 [300] pg/dL; P < .05). Severe TR was associated with greater right atrial dilatation (91% vs 47%; P = .004) and right ventricular (RV) dilatation (92% vs 51%; P = .008), greater right atrial pressure (mean [SD] 15 [7] mm Hg vs 10 [6] mm Hg; P < .001) and lower cardiac index (mean [SD], 2.2 [0.7] L/min/m2 vs 2.8 [0.9] L/min/m2; P < .001). Severe TR was strongly predictive of greater 5-year mortality risk after adjustment for age, sex, functional class, 6-minute walk distance, diffusing capacity, RV size and pulmonary vascular resistance index (adjusted hazard ratio, 1.83; 95% CI, 1.38-2.41; P < .001). CONCLUSIONS: Severe TR was a significant predictor of long-term mortality rate in PAH, and TR severity correlated with PAH severity.

Multimodal Imaging of Anomalous Left Coronary Artery from the Pulmonary Artery in a 75-Year-Old Woman.

Anomalous origin of the left coronary artery from the pulmonary artery is rare and typically results in mitral regurgitation, ventricular arrhythmias, heart failure, and sudden death. The condition most often manifests itself in early childhood, but some individuals are diagnosed much later. We describe the case of a 75-year-old woman with heart failure in whom stepwise multimodal imaging revealed anomalous origin of the left coronary artery from the pulmonary artery.

Side Effects of CV Medications Following Hospitalization for ACS Are Associated With More Frequent Health-Care Contacts.

BACKGROUND: Patients hospitalized for first acute coronary syndrome (ACS) are frequently discharged on multiple new medications. The short-term tolerability of these medications is unknown. METHODS: This single-center cohort study assessed 30-day health-care utilization and how it may be impacted by medication prescribing trends. We included Olmsted County patients presenting with ACS and previously undiagnosed coronary artery disease in 2008 to 2009. All health-care contacts were reviewed 30 days after index hospital discharge for potential adverse medication effects including documented hypotension or bradycardia, or symptoms likely attributed to the medications. RESULTS: The study included 86 patients; their mean age was 63 (standard deviation: 15.5 years). Antianginal or antihypertensive cardiovascular (CV) medications were prescribed to 98% of patients at discharge; 76% were prescribed 2 or more. There were 233 health-care contacts in 30 days; 90 (39%) of these contacts were unscheduled. More CV medications tended to be prescribed to patients with unscheduled contacts, both pre-ACS ( P = .045) and upon hospital discharge ( P = .051). Hypotension and/or bradycardia at follow-up occurred in 52 patients (60%). Surprisingly, there was no association between hypotension and/or bradycardia at follow-up and increased health-care utilization ( P = .12). Potential adverse drug effects were reported in 34 (40%) patients. These patients had significantly more total health-care contacts ( P < .001) and unscheduled health-care contacts (median 0 vs 1.5; P < .001). CONCLUSIONS: Symptoms of adverse drug effects were associated with more frequent health-care utilization after ACS. Clinicians need to consider this while striving to increase patient compliance with post-ACS medications and optimize care transitions.

Significant Reduction in Preanalytical Errors for Nonphlebotomy Blood Draws After Implementation of a Novel Integrated Specimen Collection Module.

OBJECTIVES: Most preanalytical errors at our institution occur during nonphlebotomy blood draws. We implemented an electronic health record (EHR), interfaced the EHR to the laboratory information system, and designed a new specimen collection module. We studied the effects of the new system on nonphlebotomy preanalytical errors. METHODS: We used an electronic database of preanalytical errors and calculated the number and type of the most common errors in the emergency department (ED) and inpatient nursing for 3-month periods before (August-October 2014) and after (August-October 2015) implementation. The level of staff compliance with the new system was also assessed. RESULTS: The average monthly preanalytical errors decreased significantly from 7.95 to 1.45 per 1,000 specimens in the ED (P < 0001) and 11.75 to 3.25 per 1,000 specimens in inpatient nursing (P < 0001). The rate of decrease was similar for mislabeled, unlabeled, wrong specimen received and no specimen received errors. Most residual errors (80% in the ED and 67% in inpatient nursing) occurred when providers did not use the new system as designed. CONCLUSIONS: Implementation of a customized specimen collection module led to a significant reduction in preanalytical errors. Improved compliance with the system may lead to further reductions in error rates.