Baseline concussion assessment performance by sex in military service academy rugby players: findings from the CARE Consortium.

BACKGROUND: Normative student-athlete concussion assessment data may not be appropriate for service academy members (SAMs), particularly rugby players, because of the uniqueness of their academic/military training environment. Having accurate baseline data for this population is important because of their high risk for concussion and frequent lack of assigned sports medicine professional. The primary purpose of this study was to characterise baseline performance on a concussion assessment battery, with secondary purpose to determine effect of sex and concussion history on these measures among SAM rugby players. METHODS: 601 rugby-playing SAMs (19.3±1.5 years, 37.9% female) completed baseline concussion assessments: the Sport Concussion Assessment Tool (SCAT) Symptom and Symptom Severity Checklist, Standard Assessment of Concussion (SAC) and a neuropsychological test (either ImPACT (Immediate Post Concussion Assessment and Cognitive Testing) or ANAM (Automated Neuropsychological Assessment Metrics)). Groups were compared using an independent samples t-test or Mann-Whitney U test. A 2 (sex) × 2 (concussion history) ANOVA was conducted to determine the effects of sex and concussion history on outcomes. RESULTS: Women reported greater SCAT total symptoms (3.3 vs 2.8, p<0.001, r=0.143) and symptom severities (5.7 vs 4.3, p<0.001, r=0.139), and performed worse on ImPACT Visual Memory (79.3 vs 82.6, p=0.002, r=0.144) than men. Women performed better than men on SAC (28.0 vs 27.7, p=0.03, r=0.088), ImPACT Reaction Time Composite (0.59 vs 0.61, p=0.04, r=0.092) and ANAM Code Substitution Delayed (64.3 vs 61.5, p=0.04, d=0.433). Individuals with a history of concussion reported lower ImPACT Symptom Severity (2.6 vs 4.2, p=0.02, r=0.110). There was no interaction between concussion history and sex on outcomes. CONCLUSIONS: These findings provide reference data for SAM rugby players on baseline assessments and to help in clinical decision-making when managing sports-related concussion in absence of baseline data.

Implementation of active injury management (AIM) in youth with acute concussion: A randomized controlled trial.

BACKGROUND: Nearly 2 million youth seek acute medical care following concussion in the U.S. each year. Current standard of care recommends rest for the first 48 h after a concussion. However, research suggests that prolonged rest may lengthen recovery time especially for patients with certain risk profiles. Research indicates that physical activity and behavioral management interventions (sleep, stress management) may enhance recovery. To date, there is limited empirical evidence to inform acute (<72 h) concussion recommendations for physical activity and behavioral management in adolescents. OBJECTIVE: To determine the effectiveness of physical activity and behavioral management for acute concussion in adolescents and young adults, and to evaluate the role of patient characteristics on treatment response. METHODS: This multicenter prospective randomized controlled trial will determine which combination of physical activity and behavioral management is most effective for patients 11-24 years old who present to the emergency department or concussion clinic within 72 h of injury. Participants are randomized into: 1) rest, 2) physical activity, 3) mobile health application (mHealth) behavioral management, or 4) physical activity and mHealth app conditions. Assessments at enrollment, 3-5 days, 14 days, 1 month, and 2 months include: concussion symptoms, balance, vestibular-ocular and cognitive assessments, quality of life, and recovery time. Somatic symptoms and other risk factors are evaluated at enrollment. Compliance with treatment and symptoms are assessed daily using actigraph and daily self-report. The primary study outcome is symptoms at 14 days. CONCLUSION: Prescribed physical activity and behavioral management may improve outcomes in youth following acute concussion.

First Precision Measurement of the Parity Violating Asymmetry in Cold Neutron Capture on

We report the first precision measurement of the parity-violating asymmetry in the direction of proton momentum with respect to the neutron spin, in the reaction ^{3}He(n,p)^{3}H, using the capture of polarized cold neutrons in an unpolarized active ^{3}He target. The asymmetry is a result of the weak interaction between nucleons, which remains one of the least well-understood aspects of electroweak theory. The measurement provides an important benchmark for modern effective field theory and potential model calculations. Measurements like this are necessary to determine the spin-isospin structure of the hadronic weak interaction. Our asymmetry result is A_{PV}=[1.55±0.97(stat)±0.24(sys)]×10^{-8}, which has the smallest uncertainty of any hadronic parity-violating asymmetry measurement so far.

The evolution of white matter microstructural changes after mild traumatic brain injury: A longitudinal DTI and NODDI study.

Neuroimaging biomarkers that can detect white matter (WM) pathology after mild traumatic brain injury (mTBI) and predict long-term outcome are needed to improve care and develop therapies. We used diffusion tensor imaging (DTI) and neurite orientation dispersion and density imaging (NODDI) to investigate WM microstructure cross-sectionally and longitudinally after mTBI and correlate these with neuropsychological performance. Cross-sectionally, early decreases of fractional anisotropy and increases of mean diffusivity corresponded to WM regions with elevated free water fraction on NODDI. This elevated free water was more extensive in the patient subgroup reporting more early postconcussive symptoms. The longer-term longitudinal WM changes consisted of declining neurite density on NODDI, suggesting axonal degeneration from diffuse axonal injury for which NODDI is more sensitive than DTI. Therefore, NODDI is a more sensitive and specific biomarker than DTI for WM microstructural changes due to mTBI that merits further study for mTBI diagnosis, prognosis, and treatment monitoring.

Health-Related Quality of Life Following Concussion in Collegiate Student-Athletes With and Without Concussion History.

The purpose of this study was to compare global and specific health-related quality of life (HRQOL) throughout concussion recovery between those with and without concussion history. Student-athletes diagnosed with concussion completed global (Short Form-12v2; SF-12) and specific (Hospital Anxiety and Depression Scale: HADS) HRQOL assessments at baseline, 24-48 h, asymptomatic, return-to-play, and 6-months post-injury. Baseline scores were compared to post-injury time points for SF-12 subscores (physical and mental; PCS-12, MCS-12) and HADS subscores (depression and anxiety; HADS-D, HADS-A). We conducted a 2 × 5 mixed model ANOVA for group (with and without concussion history) and time (four post-injury assessments compared to baseline). We did not observe interaction or main effects for group, except those with concussion history had worse HADS-D subscores than those without concussion history. PCS-12 subscores were worse at 24-48 h, asymptomatic, and return-to-play compared to baseline, but returned to baseline 6-months post-injury. MCS-12 subscores did not differ at any time points. HADS-D subscores worsened 24-48 h post-injury, but improved for additional assessments compared to baseline. HADS-A improved post-injury compared to baseline at asymptomatic, return-to-play, and 6-month assessments, but was similar to baseline 24-48 h post-injury. HRQOL physical aspects slightly worsened post-injury and restored to baseline after returning to play.

Impact of Factors that Affect Reading Skill Level on King-Devick Baseline Performance Time.

The King-Devick (K-D) test is often used as part of a multimodal assessment to screen for sport-related concussion. However, the test involves reading numbers, and little is known about variation in baseline performance on the K-D by reading skill level. We conducted a cross-sectional study analyzing data from the Concussion Assessment, Research and Education (CARE) Consortium to assess differences in baseline performance on the K-D associated with factors that impact reading skill level (learning disorder [LD] and primary home language other than English [PHLOTE]), while controlling for covariates (gender, type of sport, attentional issues, history of concussion and modality of administration). We had a sample of 2311 student-athletes (47% female), and multivariate regression indicated an average K-D performance time of 40.4 s. Presence of LD was associated with a 3.3 s slower K-D time (95% CI 1.9-4.7, p < 0.001), and PHLOTE was associated with a 2.6 s slower K-D time (95% CI 1.2-4.0, p < 0.001), after controlling for other covariates. These results suggest caution in the use of normative data with the K-D. Future studies should explore the impact of factors associated with reading skill level on sensitivity of the K-D in detecting concussion.

Quantitative Susceptibility Mapping after Sports-Related Concussion.

BACKGROUND AND PURPOSE: Quantitative susceptibility mapping using MR imaging can assess changes in brain tissue structure and composition. This report presents preliminary results demonstrating changes in tissue magnetic susceptibility after sports-related concussion. MATERIALS AND METHODS: Longitudinal quantitative susceptibility mapping metrics were produced from imaging data acquired from cohorts of concussed and control football athletes. One hundred thirty-six quantitative susceptibility mapping datasets were analyzed across 3 separate visits (24 hours after injury, 8 days postinjury, and 6 months postinjury). Longitudinal quantitative susceptibility mapping group analyses were performed on stability-thresholded brain tissue compartments and selected subregions. Clinical concussion metrics were also measured longitudinally in both cohorts and compared with the measured quantitative susceptibility mapping. RESULTS: Statistically significant increases in white matter susceptibility were identified in the concussed athlete group during the acute (24 hour) and subacute (day 8) period. These effects were most prominent at the 8-day visit but recovered and showed no significant difference from controls at the 6-month visit. The subcortical gray matter showed no statistically significant group differences. Observed susceptibility changes after concussion appeared to outlast self-reported clinical recovery metrics at a group level. At an individual subject level, susceptibility increases within the white matter showed statistically significant correlations with return-to-play durations. CONCLUSIONS: The results of this preliminary investigation suggest that sports-related concussion can induce physiologic changes to brain tissue that can be detected using MR imaging-based magnetic susceptibility estimates. In group analyses, the observed tissue changes appear to persist beyond those detected on clinical outcome assessments and were associated with return-to-play duration after sports-related concussion.

First Observation of P-odd γ Asymmetry in Polarized Neutron Capture on Hydrogen.

We report the first observation of the parity-violating gamma-ray asymmetry A_{γ}^{np} in neutron-proton capture using polarized cold neutrons incident on a liquid parahydrogen target at the Spallation Neutron Source at Oak Ridge National Laboratory. A_{γ}^{np} isolates the ΔI=1, ^{3}S_{1}→^{3}P_{1} component of the weak nucleon-nucleon interaction, which is dominated by pion exchange and can be directly related to a single coupling constant in either the DDH meson exchange model or pionless effective field theory. We measured A_{γ}^{np}=[-3.0±1.4(stat)±0.2(syst)]×10^{-8}, which implies a DDH weak πNN coupling of h_{π}^{1}=[2.6±1.2(stat)±0.2(syst)]×10^{-7} and a pionless EFT constant of C^{^{3}S_{1}→^{3}P_{1}}/C_{0}=[-7.4±3.5(stat)±0.5(syst)]×10^{-11} MeV^{-1}. We describe the experiment, data analysis, systematic uncertainties, and implications of the result.

Sensitivity and specificity of standardized neurocognitive testing immediately following sports concussion.

Neuropsychology, with its emphasis on standardized and empirically based methods, has made a number of scientific contributions to address growing concerns about concussions resulting from sports injuries. This study employs a test-retest paradigm to determine the immediate effects of concussion in high-school and college athletes. The Standardized Assessment of Concussion (SAC) was administered to 1,313 male athletes prior to the beginning of the competitive season. Reliable change indices and multiple regression models were computed on retest scores obtained from 68 noninjured athletes who were readministered the SAC at either 60 or 120 days following baseline testing. Receiver operating characteristic (ROC) curve analyses were used to test these models with data obtained on 50 athletes tested immediately following concussion. The results indicate that a decline of I point on the SAC at retesting classified injured and noninjured participants with a level of 94% sensitivity and 76% specificity. The RCI and multiple regression models provided comparable levels of group classification, but provided cut-offs that are conservative for use with this population. The results support and extend previous research findings indicating that the SAC is a valid instrument for detecting the immediate effects of mild traumatic brain injury.

Standardized mental status assessment of sports concussion.

Neurocognitive status is often considered the domain of neurologic functioning most sensitive to change following concussion, but the effects are often subtle and difficult to detect on routine clinical examination. Recent efforts have focused on the development of brief, standardized methods of mental status assessment for use by sports medicine clinicians to quantify the acute neurocognitive effects of concussion and objectively track postinjury recovery. Research has demonstrated the reliability, validity, and sensitivity of these measures in detecting concussion in athletes and providing empirical data for consideration in the context of other examination findings, neuropsychologic test data, and neuroimaging results. Standardized measures of mental status and other postconcussive symptoms are valuable tools to assist clinicians in the assessment and management of concussion, but should not be used as a replacement for medical evaluation or viewed as a stand-alone means for determining readiness to return to competition after injury.

Personal reflections on early learning in shared leadership.

Shared leadership involves a process as well as a structure. Two key principles apply to all forms of shared leadership: a commitment to true partnership and a decision-making structure that allows for balance of power. In this article, the author shares her personal experience of facilitating a shared leadership model for staff on a unit level and also an executive model of shared leadership. The executive model was implemented during a transition after a traditional nursing leadership position was vacated. Lessons learned in facilitating a staff shared leadership model and participating in an executive model are discussed and contrasted. Relationships, dialogue, partnership, and an understanding of boundaries are essential elements for successful implementation of shared leadership at any level.

Standardized assessment of concussion (SAC): on-site mental status evaluation of the athlete.

OBJECTIVE: This study investigated the clinical utility of the Standardized Assessment of Concussion (SAC) in detecting concussion in athletes. METHOD: Athletic trainers administered the SAC to 568 nonconcussed high school and college football players prior to the 1995 and 1996 football seasons. Thirty-three of these players experienced concussion and were tested immediately following injury; 28 of the 33 underwent additional follow-up testing 48 hours after the injury. RESULTS: Concussed players scored significantly below nonconcussed controls on all SAC measures and significantly below their own pre-injury baseline performance. Follow-up testing documented return to preinjury baseline. CONCLUSION: These findings support the SAC's effectiveness in detecting concussion and tracking recovery in order to determine a player's fitness to return to play.

Standardized assessment of concussion in football players.

The recent formulation of guidelines for the management of concussion in sports adopted by the American Academy of Neurology specifically calls for the development of a standardized, systematic sideline evaluation for the immediate assessment of concussion in athletes. The present study involved the preliminary investigation of the feasibility and clinical validity of a standardized version of a brief sideline examination complied in accordance with these guidelines. This examination, intended for use by athletic trainers, was administered by three trainers to 141 nonconcussed high school football players at three separate schools. All players suspected of suffering a concussion (N = 6) during the fall 1995 season were also tested immediately following their injury. The examination was easily administered and scored. The concussed players as a group scored significantly below the nonconcussed controls and below their own baseline (pre-injury) performance, despite their all having been considered by the trainers to have suffered mild, grade 1 concussions. Although preliminary, these data suggest that a standardized sideline examination of this type can be useful in detecting concussion and determining fitness to return to play.

Neuropsychological characterization and detection of subclinical hepatic encephalopathy.

OBJECTIVE: To elucidate the nature of the neuropsychological deficits associated with subclinical hepatic encephalopathy. DESIGN: Prospective study comparing the performance of patients with liver disease and carefully matched normal controls on a short but comprehensive neuropsychological test battery. SETTING: A university medical center. PARTICIPANTS: Twenty patients with cirrhosis (10 alcoholic and 10 nonalcoholic) and 20 controls carefully matched on the basis of age, sex, education, and alcohol history. RESULTS: The cirrhotic patients exhibited relatively selective deficits in complex attentional and fine motor skills, with preservation of general intellectual ability, memory, language and visuospatial perception. CONCLUSIONS: This pattern of neuropsychological deficits suggests a subcortical pathophysiology, possibly reflecting involvement of the basal ganglia. These neuropsychological findings are consistent with recent neuroradiological, electrophysiological, and neurophysiological research implicating basal ganglia involvement in cirrhosis.

A mentoring relationship: two viewpoints.

A mentoring relationship can be a dynamic process for both participants, one filled with increased self-awareness, commitment, and mutual respect. The time spent with a mentor guides the transition of theory into practice while clearly expressing the humanistic and caring qualities of the nurse administrator.

Cocaine-induced rhabdomyolysis. Findings on bone scintigraphy.

During the examination of a young patient with acute renal failure, bone imaging was performed for evaluation of possible osteomyelitis. Marked soft tissue activity was seen on the bone scan. The patient admitted to recent intravenous cocaine use. Vasoconstriction from cocaine use was thought to induce rhabdomyolysis, which led to acute renal failure with myoglobulinuria.

Intercostal pulmonary/diaphragmatic hernia.

A case of post-traumatic herniation of the lung and diaphragm through the lateral thoracic wall is presented. The pathogenesis of lung hernias, their clinical signs and symptoms, as well as methods of radiographic diagnosis, are discussed.