Multidisciplinary Management of Collegiate Sports-Related Concussions.

PURPOSE: Collegiate varsity athletes are at risk for sustaining a sports-related concussion, which can negatively impact performance during academic, social, work, and athletic endeavors. Because of the complex nature of concussions and high rates of underreporting by athletes, concussion education, identification, and postinjury care require a collaborative, multidisciplinary approach. Therefore, the purpose of this paper is to describe the specific responsibilities of the team members along with the established pre- and postconcussion procedures of one of the oldest university-based multidisciplinary concussion management programs that is coordinated by speech-language pathology. METHOD: The authors provide a theoretical review of current best practices for the multidisciplinary team along with a discussion of baseline and postconcussion neurocognitive assessment and management procedures directly involving speech-language pathology. Included is a case example illustrating the postinjury procedures utilized by the team. CONCLUSION: Management of the complex sequelae of sports-related concussion for the varsity collegiate athlete necessitates implementation of a multidisciplinary, collaborative approach. Speech-language pathologists' training in the assessment and treatment of brain injury provides the team with an objective perspective in the evaluation and postinjury management of the injured student athlete. While our understanding of concussions has improved greatly over the past two decades, researchers and clinicians on the front lines of care recognize that continued voids exist in our knowledge, with the need to continually explore new methods to identify and manage the complex immediate and potentially long-term ramifications of concussion.

HR-MAS NMR tissue metabolomic signatures cross-validated by mass spectrometry distinguish bladder cancer from benign disease.

Effective diagnosis and surveillance of bladder cancer (BCa) is currently challenged by detection methods that are of poor sensitivity, particularly for low-grade tumors, resulting in unnecessary invasive procedures and economic burden. We performed HR-MAS NMR-based global metabolomic profiling and applied unsupervised principal component analysis (PCA) and hierarchical clustering performed on NMR data set of bladder-derived tissues and identified metabolic signatures that differentiate BCa from benign disease. A partial least-squares discriminant analysis (PLS-DA) model (leave-one-out cross-validation) was used as a diagnostic model to distinguish benign and BCa tissues. Receiver operating characteristic curve generated either from PC1 loadings of PCA or from predicted Y-values resulted in an area under curve of 0.97. Relative quantification of more than 15 tissue metabolites derived from HR-MAS NMR showed significant differences (P < 0.001) between benign and BCa samples. Noticeably, striking metabolic signatures were observed even for early stage BCa tissues (Ta-T1), demonstrating the sensitivity in detecting BCa. With the goal of cross-validating metabolic signatures derived from HR-MAS NMR, we utilized the same tissue samples to analyze 8 metabolites through gas chromatography-mass spectrometry (GC-MS)-targeted analysis, which undoubtedly complements HR-MAS NMR-derived metabolomic information. Cross-validation through GC-MS clearly demonstrates the utility of a straightforward, nondestructive, and rapid HR-MAS NMR technique for clinical diagnosis of BCa with even greater sensitivity. In addition to its utility as a diagnostic tool, these studies will lead to a better understanding of aberrant metabolic pathways in cancer as well as the design and implementation of personalized cancer therapy through metabolic modulation.

Team Approach: Treatment of Traumatic Dislocations of the Knee.

¼: Traumatic knee dislocations are complex injuries that can be associated with compromise of the neurovascular structures about the knee. ¼: Various classification systems for knee dislocations exist in the literature but should be used with caution as a prognostic tool because many knee dislocations fit into more than 1 category. ¼: Special populations of knee dislocations, such as obese patients and high-velocity mechanism injuries, require additional caution during the initial evaluation for possible vascular injuries.

Hospital design and construction: song of the sirens.

Hospital and health system executives charged with overseeing a facility design-and-build project should follow the examples of organizations that have successfully completed such projects. Here are just a few lessons learned from fruitful projects: Simplistic cost comparisons do not define value. Alternative design solutions offer a hospital the opportunity to test the value of its original design thinking. Functional designs reflect proven best practices.

Can a transient exertion-related carotid (TERC) murmur heard during a symptom-limited exercise test be used as a means for managing sports concussion?

We hypothesize that a transient exertion-related carotid (TERC) murmur flow murmur similar in nature to a "bruit" heard best at the carotid artery during exercise in healthy individuals can be used as a means for assessing post-concussion injury exertion tolerance. Typically there are no arterial sounds heard at the carotid artery in healthy individuals. Bruit, heard at rest, is an indicator of cardiovascular disease. Listening for a flow murmur or bruit-like sounds during exercise may indicate brain blood flow autoregulation and that this audible change in brain blood flow autoregulation could be used to assess exercise tolerance. We present very preliminary evidence supporting our hypothesis in that a transient exertion-related carotid (TERC) murmur is heard at a HR (HR) of approximately 150 beats per minute (bpm) in healthy individuals and 120bpm in concussion patients. Future prospective clinical studies to validate this hypothesis and these methods may aid clinicians who manage concussion patients by using this method to help guide exertion protocols.

Complications associated with single-dose, perioperative mitomycin-C for patients undergoing bladder tumor resection.

OBJECTIVES: To better understand the risk of short-term complications associated with perioperative intravesical mitomycin-C (MMC) therapy for patients undergoing endoscopic management of non-muscle invasive bladder cancer. METHODS AND MATERIALS: Using an institutional database of patients with bladder cancer, we performed a retrospective case-control study of patients receiving perioperative MMC after tumor resection (2008-2012). MMC cases were matched by clinical stage to controls receiving endoscopic resection alone. Demographic information, clinicopathologic details, and outcomes were compared between groups. Outcomes of interest included overall, genitourinary, and major complications. Chi-square tests and multivariable logistic regression were used to evaluate associations among patient characteristics, clinical factors, exposure to MMC, and outcomes of interest. RESULTS: One-hundred sixteen patients treated with MMC were matched to 116 controls. Patients receiving MMC were younger (P = 0.04) and more likely to have invasive disease (i.e. T1 or greater) (23% vs. 15%, P = 0.02). Complications were more frequent among patients who were treated with MMC (34.5% vs. 19.8%, Odds Ratio 2.89, 95% Confidence Interval 1.43-5.81). The most common complication among MMC patients that required medical management was dysuria (17%). Major complications were more common among MMC patients (5.2% vs. 0.9%), but this difference did not reach statistical significance (P = 0.11). CONCLUSIONS: Use of MMC is associated with a greater odds of complications compared with controls. Patients should be counseled regarding both the benefits and potential risks of perioperative intravesical MMC. Continued research is required to understand the safety implications associated with the use of perioperative, intravesical MMC.

Health-related quality of life outcomes after robot-assisted and open radical cystectomy using a validated bladder-specific instrument: a multi-institutional study.

OBJECTIVE: To evaluate health-related quality of life (HRQL) using validated bladder-specific Bladder Cancer Index (BCI) and European Organization for Research and Treatment of Cancer Body Image scale (BIS) between open radical cystectomy (ORC) and robot-assisted radical cystectomy (RARC). METHODS: This was a retrospective case series of all patients who underwent radical cystectomy. Patients were grouped based on surgical approach (open vs robot assisted) and diversion technique (extracorporeal vs intracorporeal). Patients completed BCI and BIS preoperatively and at standardized postoperative intervals (at least 2). The primary exposure variable was surgical approach. The primary outcome measure was difference in interval and baseline BCI and BIS scores in each group. The Fisher exact, Wilcoxon rank-sum, and Kruskal-Wallis tests were used for comparisons. RESULTS: Eighty-two and 100 patients underwent RARC and ORC, respectively. Compared with RARC, more patients undergoing ORC had an American Society of Anesthesiology score≥3 (66% vs 45.1% RARC; P=.007) and shorter median operative time (350 vs 380 minutes; P=.009). Baseline urinary, bowel, sexual function, and body image were not different between both the groups (P=1.0). Longitudinal postoperative analysis revealed better sexual function in ORC group (P=.047), with no significant differences between both the groups in the other 3 domains (P=.11, .58, and .93). Comparisons regarding diversion techniques showed similar findings in baseline and postoperative HRQL data, with no significant differences in the HRQL and body image domains. CONCLUSION: RARC has comparable HRQL outcomes to ORC using validated BCI and BIS. The diversion technique used does not seem to affect patients' quality of life.

An in vitro study comparing the effects of Hextend, Hespan, normal saline, and lactated ringer's solution on thrombelastography and the activated partial thromboplastin time.

OBJECTIVE: The purpose of this study was to determine if 6% HES 450/0.7 (hydroxyethyl starch 450/0.7) in normal saline (Hespan) and 6% HES 450/0.7 in lactated Ringer's solution (Hextend) have the same inhibition of the intrinsic coagulation pathway and platelet function. Multiple studies have suggested that 6% Hespan inhibits coagulation and increases chest tube drainage and transfusion requirements in cardiac surgical patients. There have been few studies of the effects of 6% Hextend, a relatively new plasma volume expander, on coagulation and the results thus far have been mixed. DESIGN: A prospective in vitro study. SETTING: A large academic medical center. PARTICIPANTS: Blood was collected from 30 healthy volunteers. Interventions : The blood was fractionated and diluted by 30% with Hextend, Hespan, normal saline, and lactated Ringer's solutions, with a native sample for a control. MEASUREMENTS AND MAIN RESULTS: Primary outcome measures were thromboelastography and activated partial thromboplastin time (APTT). For each of the TEG parameters, there was no difference between samples diluted with Hextend compared with Hespan (p > or = 0.112 in all cases). APTT did not differ significantly between samples diluted with Hextend compared with Hespan (p = 0.562). CONCLUSIONS: This prospective in vitro study suggests that Hextend and Hespan, hydroxyethyl starch 450/0.7 in different base solutions, exhibit the same effect on platelet function as measured by the TEG.

Anesthesia for the Injured Hand.

In brief When an active patient sustains a hand or finger injury, a digital nerve block is often the appropriate anesthetic technique. A thorough knowledge of the area's anatomy, the materials needed, the proper technique, and the potential complications can help the primary care physician perform the procedure smoothly.

Head Injuries in Soccer.

In brief Two soccer goalies, a 20-year-old woman and a 28-year-old man, sustained head injuries as they fielded shots on goal. One was kicked, the other kneed by another player. The female goalie suffered a mild concussion. The male goalie lost consciousness and was transported to a hospital where he scored a 7 of 15 on the Glasgow Coma Scale. Three months after the injury, he still suffered from decreased concentration and hearing loss and had not returned to work.