Protracted Recovery Research Articles

The role of family burden on informant discrepancies between parents and youths with protracted recovery from mild traumatic brain injury

ABSTRACT Previous literature shows that family burden can lead to symptom-report discrepancies between parents and children. The present study sought to extend this research by investigating the influence of family burden factors, including socioeconomic status (SES) and family stress on informant discrepancies between parents and youths with mild traumatic brain injury (mTBI). Participants were clinically referred youths with mTBI ages 8–17, consecutively seen in a hospital-based neuropsychology concussion clinic (N = 81; females = 54.3%). Parents and children completed the Behavioral Assessment for Children System (BASC) and the Postconcussive Symptom Scale (PCSS). Parents rated changes in family stress related to the mTBI (categorized as “no change,” “minor change,” or “major change”) and provided information to calculate SES. Results revealed that family stress but not SES influenced parent-child report discrepancies for the BASC Internalizing Symptoms Index (F = 8.72(2, 79), p <.000), and that the discrepancies were independent of postconcussive symptom severity. Clinical implications of these findings are discussed.

A multiple levels of analysis examination of the performance goal model of depression vulnerability in preadolescent children.

If performance goals (i.e., motivation to prove ability) increase children's vulnerability to depression (Dykman, 1998), why are they overlooked in the psychopathology literature? Evidence has relied on self-report or observational methods and has yet to articulate how this vulnerability unfolds across levels of analysis implicated in stress-depression linkages; for example, hypothalamic-pituitaryadrenal axis (HPA), sympathetic nervous system (SNS). Utilizing a multiple-levels-of-analysis approach (Cicchetti, 2010), this experimental study tested Dykman's goal orientation model of depression vulnerability in a community sample of preadolescents (N = 121, Mage = 10.60 years, Range = 9.08-12.00 years, 51.6% male). Self-reports of performance goals, attachment security, and subjective experience of internalizing difficulties were obtained in addition to objective behavioral (i.e., task persistence) and physiologic arousal (i.e., salivary cortisol, skin conductance level) responses to the Trier Social Stress Test (TSST) and two randomly assigned coping conditions: avoidance, distraction. Children with performance goals reported greater internalizing difficulties and exhibited more dysregulated TSST physiologic responses (i.e., HPA hyperreactivity, SNS protracted recovery), yet unexpectedly displayed greater TSST task persistence and more efficient physiologic recovery during avoidance relative to distraction. These associations were stronger and nonsignificant in the context of insecure and secure attachment, respectively. Findings illustrate a complex matrix of in-the-moment, integrative psychobiological relationships linking performance goals to depression vulnerability.

Concussion Symptom Cutoffs for Identification and Prognosis of Sports-Related Concussion: Role of Time Since Injury

Background: Symptom reporting with scales such as the Post-Concussion Symptom Scale (PCSS) is one of the most sensitive markers of concussed status and/or recovery time, It is known that time from injury until initial clinic visit affects symptom presentation and recovery outcomes, but no study to date has evaluated changes in clinical cutoff scores for the PCSS based on earlier versus later clinical presentation postconcussion. Purpose: To evaluate if time since injury after sports-related concussion (SRC) affects clinical cutoff scores for total PCSS and PCSS factors in differentiating athletes with SRC from healthy controls and predicting prolonged recovery (>30 days) after SRC. Study Design: Cohort study; Level of evidence, 3. Methods: A chart review was conducted of clinical data from patients with SRC (age, 13-25 years; n = 588; female, n = 299) who presented to concussion specialty clinics. Participants were categorized on the basis of time from injury: early (≤7 days; n = 348) and late (8-21 days; n = 240). Outcomes were total symptom severity (ie, total PCSS score) and total score for each of 4 symptom factors (cognitive/migraine/fatigue [CMF], affective, sleep, and somatic). Area under the curve (AUC) analyses were conducted using the Youden index to optimize sensitivity and specificity cutoffs. Results: In the early group, the CMF factor (cutoff, ≥7; AUC = 0.944), affective factor (cutoff, ≥1; AUC = 0.614), and total PCSS (cutoff, ≥7; AUC = 0.889) differentiated athletes with SRC from controls. In the late group, the CMF factor cutoff was reduced (cutoff, ≥4; AUC = 0.945), while the total PCSS score (cutoff, ≥7; AUC = 0.892), affective factor (cutoff, ≥1; AUC = 0.603), and sleep factor (cutoff, ≥1; AUC = 0.609) remained the same. In the early cohort, the CMF factor was the strongest predictor of protracted recovery (cutoff, ≥23; AUC = 0.717), followed by the total PCSS (cutoff, ≥39; AUC = 0.695) and affective factor (cutoff, ≥2; AUC = 0.614). The affective factor (cutoff, ≥1; AUC = 0.642) and total PCSS (cutoff, ≥35; AUC = 0.592) were significant predictors in the late cohort, but the cutoff threshold was reduced. Conclusion: The findings indicate that PCSS symptom clinical cutoffs for identifying injury and recovery prognosis change on the basis of time since injury. Specifically, the combination of CMF, affective, and sleep factors is the best differentiator of athletes with SRC from controls regardless of time since injury. Furthermore, the CMF factor is the most robust predictor of prolonged recovery if the patient is within 1 week of SRC, whereas the affective factor is the most robust predictor of prolonged recovery if the patient is within 2 to 3 weeks of SRC.

Predicting Protracted Concussion Recovery To Inform Proactive Care: A Genetic Fuzzy Machine Learning Approach

Poor prognostic accuracy of sport-related concussion (SRC) recovery times has limited proactive clinical care. Currently, clinicians consolidate a battery of assessments and combine their own practical knowledge to develop prognosis and treatment plans. Machine learning may provide a useful method to augment clinicians’ prognostic decision making: a critical first step to enhance proactive care. PURPOSE: Determine utility of a novel genetic fuzzy system (GFS) machine learning approach, FuzzyBolt, to predict protracted recovery after SRC. METHOD: Data from 76 pediatric patients (age 14.44 ± 2.54 years; 28 F) were obtained from 186 combined clinic visits following initial SRC. Recovery time was indexed from the physician-recorded full clearance to return to play date in the medical record and then classified as less than or equal to 28 days (N=88) vs. greater than 28 days (N=98)—the consensus pediatric threshold for persistent symptoms. A GFS model classified protracted recovery on patients that were less than 28 days in recovery. GFS uses fuzzification, rule-inference and defuzzification to make decisions, and FuzzyBolt provides an efficient method of optimizing model parameters via genetic algorithms. The model used 36 inputs, including ordinal and binary variables related to patient demographics, standardized Post-Concussion Symptom Inventory responses, and self-reported responses from a clinic-based Head Injury Questionnaire. RESULTS: Data were split, via stratified sampling, into a training set (80%; 61 athletes with 151 visits) and a hold-out validation set (20%; 15 athletes with 35 visits). Each patient visit was considered a unique case, with visits from the same patient never part of both the training and validation sets to reduce the risk of over-fitting and inflation of non-generalizable prediction accuracy. The FuzzyBolt model correctly predicted 12 of 16 protracted (and 16 of 19 typical) recovery cases, for an overall classification accuracy of 80%. CONCLUSION: This is the highest prediction accuracy, to date, for any published prognostic model of concussion recovery. It is a first step toward promoting early allocation of resources for patients at high-risk for protracted recovery, and demonstrates a novel technique to empower a data-driven solution to improve outcomes in these athletes.

Removal From Activity Following Sport-related Concussion In Sex-comparable Sports

As sport-related concussion (SRC) awareness has increased, timely reporting and immediate removal from play have become a focal point of proper management. Delayed removal may result in additional injury and protracted recovery. Research has demonstrated that girls are more honest and likely to report their concussion symptoms compared to boys. However, it is unknown if these reporting behaviors correspond with immediate removal from play in girls compared to boys in sex-comparable sports. PURPOSE: To compare the incidence of high school athletes not removed from activity following SRC in sex-comparable sports in Michigan. METHODS: An epidemiological study of athletes diagnosed with SRC participating in Michigan High School Athletic Association-sponsored basketball, baseball/softball, and soccer from 2016-2019 was performed. All SRCs were recorded in a Head Injury Reporting System by certified athletic trainers, administrators, or coaches. Removal from activity indicated the athlete was removed from play at the time of an injury event. Lack of removal does not indicate mismanagement at the time of the event, but that the injury was not reported. Incidence was calculated by dividing SRCs not removed by total SRCs in each sport. Risk ratios were calculated by dividing the incidence of girls not removed by boys not removed in each sport. RESULTS: A total of 3696 (2425 female, 1271 male) SRCs were reported, with the most occurring in girls’ soccer (n = 1024). Overall, 442 girls and 182 boys were not removed from activity, resulting in incidences of 0.18 (95% CI, 0.17-0.20) and 0.14 (95% CI, 0.12-0.16), respectively. Across all sports, girls were 1.27 (95% CI, 1.09-1.49) times as likely to not be removed from activity compared to boys. Girls had 1.16 (95% CI, 0.91-1.50), 1.19 (95% CI, 0.77-1.84), and 1.41 (95% CI, 1.12-1.78) times the risk of not being removed from basketball, softball, and soccer, respectively, when compared to the equivalent boy sports. CONCLUSIONS: Girls were at greater risk of not being removed from activity compared to boys in sex-comparable sports. Although girls are more likely to report symptoms of SRC, there is still a gap in their removal from play, potentially due to a delayed onset or recognition of symptoms. Future research and initiatives should target reporting and removal in female sports.

Examining the effects of atopic disease on concussion recovery: a preliminary investigation to inform personalized care

Background: Predicting time-to-recovery in pediatric concussion patients is key to advancing the treatment paradigm of pediatric concussion from a reactive to proactive precision and personalized medicine approach. Recent epidemiologic research indicates a possible mechanistic overlap between concussion and atopic disease (i.e., allergic rhinitis, asthma, and eczema) via pathways implicated in the inflammatory response. The purpose of this study was to examine patients with concussion and atopic disease comorbidity to better elucidate mechanisms that underlie protracted recovery and better predict return to play (RTP) timelines following concussion injury. Method: Data from …

A-33 VOMS Scores Relationship to C3 Logix Trail Scores in Females

Abstract Objective Burkhart and colleagues (2020) showed that positive screening on the Vestibular Ocular Motor Screening (VOMS) and slower C3 Logix Trails (C3LT) were predictive of protracted recovery in female adolescents. The purpose of this study was to see if there was a relationship between positive screening on the VOMS and slower C3LT times in a similar population. Method 220 females aged 10–18 were administered the VOMS and C3LT between 2017–2019. We hypothesized that positive screening on the VOMS (i.e. symptom provocation of +2, convergence of &amp;gt; 6 mm) would be related to slower speeds on C3LT A and B. Odds ratios were calculated to estimate the likelihood of screening positive on the VOMS based on C3LT times. Results Slower times on C3LT A and B, one to two standard deviations (SD) above the mean, was not related to a positive screening on the VOMS. However, performing a faster C3LT A time, one SD below the mean, was 68% less likely to screen positively on the VOMS (OR = 0.32, 95%CI = 0.16–0.62, p = 0.001) compared to those not 1 SD below the mean. Conclusions Though C3LT has a visual scanning component, positive screening on the VOMS was not related to slower processing speeds on the C3LT in females age 10–18.

A-17 Psychological Resilience and Concussion Recovery in Athletes

Abstract Objective Psychological resilience has been positively associated with sport achievement and psychological well-being, while being negatively associated with psychological distress. Lower psychological resilience may also increase the risk of protracted recovery from concussion. The purpose of this study is to examine the relationship between psychological resilience and clinical outcomes among adolescent and young adult athletes. Method Fifty-seven patients (11–22 years; m = 15.2, SD = 2.76) were diagnosed with a sport-related concussion (SRC) within two weeks of injury. Patients completed the Conner-Davidson Resilience Scale (CD-RISC-10) and the Depression Anxiety and Stress Scales (DASS-21) at first visit in addition to neurocognitive screening (ImPACT) and vestibular/oculomotor screening (VOMS). Participants were divided into “Low”, “Moderate” and “High” resilience using CD-RISC-10 tertiles. A series of one-way ANOVAS with pairwise comparisons (Tukey post-hoc test) were used to compare groups across outcomes measures. Results Significant differences were present between the High Resilience (m = 15.22 days; SD = 8.87) and Low Resilience (m = 30.95 days; SD = 23.76) groups in Days to Clearance (p = .032), DASS-21 Total score (p = 0.01), DASS-21 Depression subscale (p = 0.022), DASS-21 Anxiety subscale (p = 0.01), and DASS-21 Stress subscale (p = 0.002). No significant relationships were observed between resilience and ImPACT, VOMS, or PCSS score for any group. Conclusions Athletes with low psychological resilience immediately following concussion had a recovery time twice that of athletes with high resilience. All groups in the study exhibited recovery times within a normal time frame (i.e., ≤ 30 days), but high psychological resiliency may serve as a protective factor for recovery outcomes among athletes experiencing concussion.

A-42 Incremental Utility of Visual Assessment in Predicting Concussion Recovery Time Among Adolescents

Abstract Objective Sports-related concussions (SRC) often affect vision function and cognition, two components frequently assessed as part of a multimodal post-injury evaluation. The purpose of the study was to examine contributions of measures of vision function and cognition toward understanding recovery time. Method Participants were 593 (37.6% female) adolescents ages 10–18 (M = 14.7, SD = 1.7) who were evaluated and diagnosed with a concussion within 10 days of injury. Participants were administered the King-Devick (KD) test via KD cards to assess rapid number naming speed and the ImPACT test to assess post-concussion symptoms and neurocognitive test performance. The primary outcome was number of weeks (M = 3.2, SD = 1.9) until participants were cleared to return to play by the treating physician based on a standardized protocol. Results Poorer performance on the King-Devick test was significantly correlated with higher symptom severity (r = .41, p &amp;lt; .001), and poorer performance on ImPACT Verbal Memory (r = −.46, p &amp;lt; .001), Visual Memory (r = −.39, p &amp;lt; .001), Visual Motor Speed (r = −55, p &amp;lt; .001), and Reaction Time (r = .47, p &amp;lt; .001) composites. Poorer KD scores were also significantly correlated with a longer time to recovery (r = .23, p &amp;lt; .001). Importantly, poorer KD scores continued to significantly predict protracted recovery time after controlling for age, gender, time to initial physician evaluation, prior history of concussion, post-concussion symptom severity, and neurocognitive test performance (β = .12, p &amp;lt; .05). Conclusions Performance on King-Devick testing predicted recovery time, even after controlling for important demographic/injury characteristics and cognitive testing. Evaluation of vision function is an important component of post-injury assessment for SRC.

A-08 VOMS Scores Relationship to King-Devick Scores in Males

Abstract Objective Burkhart and colleagues (2020) showed that positive screening on the Vestibular Ocular Motor Screening (VOMS) and slower King Devick scores were predictive of protracted recovery in male adolescents. The purpose of this study was to examine the relationship between positive VOMS screening and King-Devick Trial 1 scores in a similar population. Method 300 male participants age 10–18 were administered VOMS and King-Devick Trial 1 within 7-days of their injury at a specialty concussion clinic between 2017–2019. We hypothesized that slower speeds on King-Devick Trial 1 would be related to a positive screening on the VOMS (i.e. symptom provocation of +2, convergence of &amp;gt; 6 mm). Odds ratios were calculated to estimate the likelihood of screening positive on the VOMS among those with a King-Devick Trial 1 score above the median compared to those with a score below the median. Results Those scoring above the median on King-Devick Trial 1 (i.e. slower times) were 74% more likely to have a positive screening on the VOMS, OR = 1.74, 95% CI [1.10–2.78], p = 0.02, relative to those with a King-Devick Trial 1 above the median. Conclusions The VOMS was created to be a symptom provocation tool sensitive to concussion. However, this study demonstrated that the VOMS is also related to performance on objective visual scanning task. Specifically, adolescent males with slower scores on the King-Devick Trial 1 were more likely to have a positive screening on the VOMS.

Protracted and incomplete language recovery from SMART syndrome: a case report

ABSTRACT Background: Stroke-like migraine attacks after radiation therapy – also known as SMART syndrome – constitute a rare condition characterised by headache, seizures, vision abnormalities, hemiparesis, and aphasia. The condition usually resolves within a few days or weeks with little to no residual impairment; however, recovery in some cases is protracted and incomplete. Aims: The purpose of this case report was to describe the one-year progression of language in a person, GB, with slow recovery from SMART syndrome. Methods & Procedures: GB was diagnosed with SMART syndrome at 39 years of age. Formal and informal assessments occurred at six, 11, 18, 29, and 52 weeks post-onset of SMART syndrome. Standardised assessment involved administration of portions of the Western Aphasia Battery – Revised, and informal assessment took the form of written and spoken language sample analyses. Outcomes & Results: Initial evaluation at two weeks post-onset revealed global aphasia. This evolved into severe Wernicke’s aphasia by six weeks post-onset. Repeated evaluation over subsequent months revealed gradual improvement but continuing and substantial language impairment. At one-year post-onset, GB displayed anomic aphasia and persistent reading and writing deficits. Conclusions: Substantial language recovery from SMART syndrome can occur beyond the initial few months post-onset. Documentation of the nature and extent of language impairment provides a starting point for developing and refining efficacious treatment protocols.

Amplifying Factors in the Proposed Relationship between Sleep-Wake Dysfunction and Post-Concussion Syndrome Pathogenesis

Objective: Examine factors contributing to the relationship between sleep-wake dysfunction and subacute post-concussion syndrome. Setting: Data collection online via Qualtrics survey. Participants: Forty seven adults reporting recent TBI recruited via Facebook and Reddit. Design: Moderation analysis via hierarchical multiple regression procedure. Main Measures: Neurobehavioral Symptom Inventory, Epworth Sleepiness Scale, Patient Health Questionnaire, General Anxiety Disorder Scale, and a General Health Questionnaire. Results: A relationship between sleep-wake dysfunction and symptoms of subacute post-concussion syndrome was observed. While premorbid mental health did not interact with this relationship, recent endorsement of depression and anxiety symptoms moderated the association. Exploratory analysis also suggested duration of posttraumatic amnesia inflated this relationship. Conclusion: These findings suggest that patients reporting post-concussive sleep dysfunction may benefit from mental health support. They also provide insight in to which early factors may be associated with the development of a sleep-related protracted recovery profile following a traumatic brain injury.

Percutaneous Transforaminal Endoscopic Lumbar Interbody Fusion for Degenerative Lumbar Diseases: A Consecutive Case Series with Mean 2-Year Follow-Up

Conventional open surgical procedures may cause massive dissections of the spine, higher perioperative complications, prolonged hospitalization, protracted rehabilitation programs and recovery. Percutaneous endoscopic lumbar interbody fusion (PELIF) is an evolving treatment option. To present the detailed procedure and preliminary clinical and radiologic results of PELIF for degenerative lumbar diseases. A retrospective cohort study. A university affiliated tertiary hospital. The medical records of patients with degenerative lumbar diseases who underwent PELIF between January 2016 and December 2017 were retrospectively reviewed. Surgical level, surgical time, blood loss, hospital length of stay, and perioperative complications were discussed. Patients were also evaluated for pain by the Visual Analog Scale (VAS), and functional assessment by the Oswestry Disability Index (ODI) and the 36-Item Short Form Health Survey (SF-36), including Physical Component Summary (PCS) and Mental Component Summary (MCS) preoperatively, postoperatively, and during the follow-up period. Thirty-nine consecutive patients (25 men and 14 women) with a mean age of 59.0 years (range, 39-77 years) were enrolled. The average surgical time was 213.8 ± 31.7 minutes (range, 185-324 minutes). Mean estimated blood loss was 25.0 ± 12.6 mL (range, 15-50 mL). At the latest follow-up visit, the VAS scores for back pain, leg pain, ODI, and SF-36 (MCS/PCS) scores improved 89.5%, 95.0%, 71.2%, and 37.5%/58%, respectively. Reoperations were performed in one patient for residual disc mass and one for misplacement of pedicle screw. Fusion was achieved in all patients. The presented results are preliminary and should be interpreted taking the limitations into account, including nonrandomized design, relatively small sample size, and less intensive follow-up period. The presented PELIF technique seems to be a promising surgical alternative for the treatment of patients with specific degenerative lumbar diseases. Randomized studies with larger sample size and long-term follow-up duration are needed to validate the superiorities of this versatile surgery. Endoscopic, minimally invasive spine surgery, lumbar interbody fusion, disc herniation, spondylolisthesis.

Sex, race, ADHD, and prior concussions as predictors of concussion recovery in adolescents

ABSTRACT Objective Concussions in adolescents are a growing public health concern as the popularity of high school sports increases. The aim of this study was to identify clinical (e.g., prior concussion, migraine history, learning disabilities/attention deficit hyperactivity disorders [ADHD]) and demographic factors (e.g., sex, race, health insurance, mechanism of injury/sport, education) that predict concussion recovery times. Design In a retrospective cohort study of adolescents 13–19 years old evaluated for an acute concussion (≤ 10 days from injury), recovery times were calculated from the date of concussive injury to the date of clearance to return to play or normal activities. Results The sample (N = 227) was primarily male (75%), and the median age was 15 years. Predictors of protracted recovery were ADHD (hazard ratio [HR] =.449, 95% confidence interval [CI] =.272-.741, p = .002) and prior concussion (HR =.574, 95% CI =.397-.828, p = .003) in all sex and race groups, while shorter recovery times were predicted by Hispanic and African American race (HR = 2.12, 95% CI = 1.30–3.46, p = .003), with White females as the reference group. Conclusions Further research is needed to examine the role of sex, race, ADHD, and concussion history on concussion outcomes.

Pediatric empyema thoracis: roles and outcomes of surgery in advanced disease.

Aim Empyema thoracis has become increasingly common in the pediatric population. Antibiotics and thoracostomy have been the cornerstones of management of stage 1 empyema, whereas management of stage 2 and 3 empyema remains controversial. Surgical intervention is perceived to be associated with high morbidity and protracted recovery. We aimed to review the role and outcome of surgical decortication, and provide data for comparison with other treatment modalities. Methods The medical records and clinical outcomes of 30 children (median age 5.2 years) with stage 2 or 3 empyema, who underwent surgical decortication from September 2017 to September 2019, were reviewed. Results Most children were referred for decortication by day 8.8 ± 4 of admission, and the median time from referral to surgery was 2.2 ± 2 days. All patients had tube thoracostomy, and 5 (17%) underwent fibrinolysis prior to surgery. Twenty-one (70%) patients required pediatric intensive care unit admission preoperatively. Postoperatively, most patients were extubated on day 2.5 (range 1–4 days), with chest tubes removed on day 3.8 (range 1–7 days). Most were discharge by day 6.2 (range 4–10 days). Postoperative air leak occurred in one (3%) patient. There was no mortality or reoperation. Conclusion Surgical decortication remains an excellent modality for managing stage 2 and 3 pediatric empyema. The procedure has a low morbidity and provides rapid resolution of symptoms with good clinical outcomes if performed promptly. Delayed referral may result in a more protracted clinical course.

A Pilot Randomized Controlled Trial of Cognitive-Behavioral Therapy for Insomnia in Adolescents With Persistent Postconcussion Symptoms.

Cognitive-behavioral therapy for insomnia (CBT-I) is an effective insomnia treatment but has yet to be applied to adolescents with sleep disruption following concussion. This pilot study evaluated CBT-I to improve insomnia in adolescents with protracted concussion recovery. Tertiary pediatric hospital. Participants (N = 24) were 12 to 18 years old (M = 15.0, SD = 1.4), 15.1 weeks (SD = 9.2) postinjury, and presenting with sleep disruption and persistent postconcussion symptoms. A single-blind, parallel-group randomized controlled trial (RCT) design comparing 6 weeks of CBT-I and a treatment-as-usual control group. Outcomes were measured before treatment, at treatment completion, and 4 weeks after completion. Primary outcome was Insomnia Severity Index. Secondary outcomes included Pittsburgh Sleep Quality Index, Dysfunctional Beliefs and Attitudes about Sleep Scale, 7-night sleep diary, PROMIS Depression, PROMIS Anxiety, and Health and Behavior Inventory. Adolescents who received CBT-I demonstrated large and clinically significant improvements in insomnia ratings at posttreatment that were maintained at follow-up. They also reported improved sleep quality, fewer dysfunctional beliefs about sleep, better sleep efficiency, shorter sleep-onset latency, and longer sleep time compared with those with treatment as usual. There was also a modest reduction in postconcussion symptoms. In this pilot RCT, 6 weeks of CBT-I produced significant improvement in sleep in adolescents with persistent postconcussion symptoms. A larger trial is warranted.

Preliminary Evidence of a Dose-Response for Continuing to Play on Recovery Time After Concussion.

To investigate a dose-response relationship between continuing to play following concussion and outcomes. A total of 130 athletes (age 11-19 years). Repeated-measures design comparing symptoms, neurocognitive performance, and recovery time between 52 athletes immediately removed from play (Removed), 24 who continued to play for 15 minutes or less (Short-Play), and 32 who continued to play for more than 15 minutes (Long-Play). Recovery was the number of days from injury to clearance. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) measured neurocognitive outcomes and the Post-Concussion Symptom Scale (PCSS) measured symptom severity. Long-Play (44.09 ± 27.01 days) took longer to recover than Short-Play (28.42±12.74 days) and Removed (18.98 ± 13.76 days). Short-Play was 5.43 times more likely, and Long-Play 11.76 times more likely, to experience protracted recovery relative to Removed. Both Play groups had worse neurocognitive performance and higher symptom scores than Removed at days 1 to 7, with Long-Play demonstrating worse reaction time than Short-Play. At days 8 to 30, both Play groups performed worse than Removed on visual memory and visual motor speed, while only Long-Play performed worse on verbal memory and reaction time. Results provide initial evidence of a dose-response effect for continuing to play on recovery from concussion, highlighting the importance of removal from play.

Paediatric Empyema Thoracis: Roles and Outcomes of Surgical Intervention in Advanced Disease

Empyema thoracis has become increasingly common in paediatric population. Antibiotics and thoracostomy have been the cornerstones in managing stage 1 empyema, where as management of stage 2-3 empyema remains controversial. Surgical intervention is perceived to be associated with high morbidity and protracted recovery. This paper reviews the roles and outcomes of surgical decortication, and to provide data for comparison with other treatment modalities.

Muscle Homeostasis Is Disrupted in Burned Adults.

Severe burn leads to substantial skeletal muscle wasting that is associated with adverse outcomes and protracted recovery. The purpose of our study was to investigate muscle tissue homeostasis in response to severe burn. Muscle biopsies from the right m. lateralis were obtained from 10 adult burn patients at the time of their first operation. Patients were grouped by burn size (total body surface area of <30% vs ≥30%). Muscle fiber size and factors of cell death and muscle regeneration were examined. Muscle cell cross-sectional area was significantly smaller in the large-burn group (2174.3 ± 183.8 µm2 vs 3687.0 ± 527.2 µm2, P = .04). The expression of ubiquitin E3 ligase MuRF1 and cell death downstream effector caspace 3 was increased in the large-burn group (P < .05). No significant difference was seen between groups in expression of the myogenic factors Pax7, MyoD, or myogenin. Interestingly, Pax7 and proliferating cell nuclear antigen (PCNA) expression in muscle tissue were significantly correlated to injury severity only in the smaller-burn group (P < .05). In conclusion, muscle atrophy after burn is driven by apoptotic activation without an equal response of satellite cell activation, differentiation, and fusion.

Assets for Alimentation? The Nutritional Impact of Assets-based Programming in Niger

A recent strand of aid programming aims to develop household assets by removing the stresses associated with meeting basic nutritional needs. In this study, the authors posit that such nutrition-sensitive programmes can reduce malnourishment by encouraging further investment in diet. To test this hypothesis, they analyse the World Food Programme’s (WFP) Protracted Relief and Recovery Operation (PRRO), in Niger, a conflict-affected, low-income country with entrenched food insecurity. Under the PRRO, a household falls into one of three groups at end line: receiving no assistance, receiving nutrition-specific assistance, or receiving nutrition-specific assistance and nutrition-sensitive food for assets-based programming. If provided alone, food aid has no nutritional impact relative to receiving no assistance. However, the study observes pronounced positive effects if food aid is paired with assets-based programming. The authors conclude, first, that certain forms of food aid function well in complex, insecure environments; second, that assets-based programmes deliver positive nutritional spillovers; and, third, that there are theoretical grounds to believe that assets-based nutrition-sensitive programmes interact positively with nutrition-specific programming.