Symptom Resolution Time Research Articles

Concussion Characteristics in High School Football by Helmet Age/Recondition Status, Manufacturer, and Model

Background: Football helmets used by high school athletes in the United States should meet the National Operating Committee on Standards for Athletic Equipment performance standards. Despite differences in interior padding and exterior shells, all football helmets should provide comparable protection against concussions. Yet, debate continues on whether differences in the rates or severity of concussions exist based on helmet age/recondition status, manufacturer, or model. Purpose: To investigate whether high school football concussion characteristics varied by helmet age/recondition status, manufacturer, and model. Study Design: Descriptive epidemiological study. Methods: High school football concussion and helmet data were collected from academic years 2008-2009 through 2012-2013 as part of the National High School Sports-Related Injury Surveillance Study. The certified athletic trainers of participating schools submitted athlete-exposure (AE) and injury information weekly. Results: Participating schools reported 2900 football concussions during 3,528,790 AEs for an overall rate of 8.2 concussions per 10,000 AEs. Concussion rates significantly increased from 2008-2009 through 2012-2013 overall (P = .006) as well as in competition (P = .027) and practice (P = .023). Characteristics of concussed football players (ie, mean number of symptoms, specific concussion symptoms, symptom resolution time, and time until return to play) were similar among players wearing new helmets when compared with reconditioned helmets. Fewer players wearing an old/not reconditioned helmet had concussion symptoms resolve within 1 day compared with players wearing a new helmet. Despite differences in the manufacturers and models of helmets worn by all high school football players compared with players who sustained a concussion, the mean number of concussion symptoms, specific concussion symptoms, symptom resolution time, and time until return to play were similar for concussions sustained by football players wearing the most common helmet manufacturers and models. Conclusion: Overall, for new and reconditioned football helmets, the most common helmet manufacturers and models on the market today appear to provide high school football players with similar protection against concussions. Clinical Relevance: Concussions can have serious acute and long-term effects. An understanding of concussion patterns in high school athletes can drive targeted preventive measures, including improvements to and/or better use of protective equipment, to reduce the incidence and/or severity of sports-related concussions.

Epidemiology of Sports-Related Concussions in National Collegiate Athletic Association Athletes From 2009-2010 to 2013-2014

Background: Limited data exist among collegiate student-athletes on the epidemiology of sports-related concussion (SRC) outcomes, such as symptoms, symptom resolution time, and return-to-play time. Purpose: This study used the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP) to describe the epidemiology of SRC outcomes in 25 collegiate sports. Study Design: Descriptive epidemiology study. Methods: SRC data from the NCAA ISP during the 2009-2010 to 2013-2014 academic years were analyzed regarding symptoms, time to resolution of symptoms, and time to return to play. Findings were also stratified by sex in sex-comparable sports (ie, ice hockey, soccer, basketball, lacrosse, baseball/softball) and whether SRCs were reported as recurrent. Results: Of the 1670 concussions reported during the 2009-2010 to 2013-2014 academic years, an average (±SD) of 5.29 ± 2.94 concussion symptoms were reported, with the most common being headache (92.2%) and dizziness (68.9%). Most concussions had symptoms resolve within 1 week (60.1%); however, 6.2% had a symptom resolution time of over 4 weeks. Additionally, 8.9% of concussions required over 4 weeks before return to play. The proportion of SRCs that required at least 1 week before return to play increased from 42.7% in 2009-2010 to 70.2% in 2013-2014 (linear trend, P < .001). Within sex-comparable sports analyses, the average number of symptoms and symptom resolution time did not differ by sex. However, a larger proportion of concussions in male athletes included amnesia and disorientation; a larger proportion of concussions in female athletes included headache, excess drowsiness, and nausea/vomiting. A total of 151 SRCs (9.0%) were reported as recurrent. The average number of symptoms reported with recurrent SRCs (5.99 ± 3.43) was greater than that of nonrecurrent SRCs (5.22 ± 2.88; P = .01). A greater proportion of recurrent SRCs also resulted in a long symptom resolution time (14.6% vs 5.4%, respectively; P < .001) and long return-to-play time (21.2% vs 7.7%, respectively; P < .001) compared with nonrecurrent SRCs. Conclusion: Trends in return-to-play time may indicate changing concussion management practices in which team medical staff members withhold players from participation longer to ensure symptom resolution. Concussion symptoms may differ by sex and recurrence. Future research should continue to examine the trends and discrepancies in symptom resolution time and return-to-play time.

Impact locations and concussion outcomes in high school football player-to-player collisions.

Little research has examined concussion outcomes in terms of impact location (ie, the area on the head in which the impact occurred). This study describes the epidemiology of concussions resulting from player-to-player collision in high school football by impact location. National High School Sports-Related Injury Surveillance Study data (2008/2009-2012/2013) were analyzed to calculate rates and describe circumstances of football concussion (eg, symptomology, symptom resolution time, return to play) resulting from player-to-player collisions by impact location (ie, front-, back-, side-, and top-of-the-head). Most concussions resulting from player-to-player collisions occurred from front-of-the-head (44.7%) and side-of-the-head (22.3%) impacts. Number of symptoms reported, prevalence of reported symptoms, symptom resolution time, and length of time to return to play were not associated with impact location. However, a larger proportion of football players sustaining concussions from top-of-the-head impacts experienced loss of consciousness (8.0%) than those sustaining concussions from impacts to other areas of the head (3.5%) (injury proportion ratio 2.3; 95% confidence interval 1.2-4.2; P = .008). Players had their head down at the time of impact in a higher proportion of concussions caused by top-of-the-head impacts (86.4%) than concussions from impacts to other areas of the head (24.0%) (injury proportion ratio 3.6; 95% confidence interval 3.2-4.0; P < .001). Among high school football players who sustained concussions due to player-to-player collisions, concussion outcomes were generally independent of impact location. Recommended strategies for reducing the proportion of top-of-the-head impacts include improved education regarding tackling with proper "head-up" technique.

Pediatric Concussion: Initial Symptom Severity Does Not Predict Persistent Symptoms

In a prospective study of children (age range, 8–18 years) presenting with concussion to a pediatric emergency department (ED), investigators examined whether symptom severity at time of injury predicted delayed symptom resolution (defined as 3 or more symptoms 1 month postinjury). Acute symptom severity was assessed using a …

Nutritional Therapy in Pediatric Crohn Disease

Crohn disease is characterized by chronic intestinal inflammation in the absence of a recognized etiology. Nutritional therapy in the form of exclusive enteral nutrition (EEN) has an established role within pediatric Crohn disease. Following exclusive enteral nutrition's success, many dietary therapies focusing on the elimination of specific complex carbohydrates have been anecdotally reported to be successful. Many of these therapies have not been evaluated scientifically; therefore, we reviewed the medical records of our patients with Crohn disease on the specific carbohydrate diet (SCD). Seven children with Crohn disease receiving the SCD and no immunosuppressive medications were retrospectively evaluated. Duration of the dietary therapy ranged from 5 to 30 months, with an average of 14.6±10.8 months. Although the exact time of symptom resolution could not be determined through chart review, all symptoms were notably resolved at a routine clinic visit 3 months after initiating the diet. Each patient's laboratory indices, including serum albumin, C-reactive protein, hematocrit, and stool calprotectin, either normalized or significantly, improved during follow-up clinic visits. This chart review suggests that the SCD and other low complex carbohydrate diets may be possible therapeutic options for pediatric Crohn disease. Further prospective studies are required to fully assess the safety and efficacy of the SCD, or any other low complex SCDs in pediatric patients with Crohn disease.

Decrease in N-Acetylaspartate Following Concussion May Be Coupled to Decrease in Creatine

To assess the time course changes in N-acetylaspartate (NAA) and creatine (Cr) levels in the brain of athletes who suffered a sport-related concussion. Eleven nonconsecutive athletes with concussive head injury and 11 sex- and age-matched control volunteers : At 3, 15, 30, and 45 days postinjury, athletes were examined by proton magnetic resonance spectroscopy for the determination of NAA, Cr, and choline (Cho) levels. Proton magnetic resonance spectroscopic data recorded for the control group were used for comparison. Compared with controls (2.18 ± 0.19), athletes showed an increase in the NAA/Cr ratio at 3 (2.71 ± 0.16; P < .01) and 15 (2.54 ± 0.21; P < .01) days postconcussion, followed by a decrease and subsequent normalization at 30 (1.95 ± 0.16, P < .05) and 45 (2.17 ± 0.20; P < .05) days postconcussion. The NAA/Cho ratio decreased at 3, 15, and 30 days postinjury (P < .01 compared with controls), with no differences observed in controls at 45 days postconcussion. Compared with controls, significant increase in the Cho/Cr ratio after 3 (+33%, P < .01) and 15 (+31.5%, P < .01) days postinjury was observed whereas no differences were recorded at 30 and 45 days postinjury. This cohort of athletes indicates that concussion may cause concomitant decrease in cerebral NAA and Cr levels. This provokes longer time for normalization of metabolism, as well as longer time for resolution of concussion-associated clinical symptoms.

Naturally Occurring Cutaneous Anthrax: Antibiotic Treatment and Outcome

Objectives: Cutaneous anthrax (CA) is the most common clinical presentation in human anthrax, but the duration of antibiotic therapy in naturally occurring CA is controversial. The aim of this study was to compare the clinical outcomes of patients receiving antibiotic treatment for either 3-5 days (group 1) or 7-10 days (group 2) in uncomplicated CA. Methods: A total of 66 patients were enrolled; 29 (44%) in group 1 and 37 (56%) in group 2. Infections were classified as mild (n = 22, 33%) or severe (n = 44, 67%) CA. Results: There were no significant differences between the groups in symptom resolution time, fever clearance time, healing of lesions, development and healing of eschars, requirement for surgical intervention or the development of complications. Both edema resolution time and duration of hospital stay were longer in group 2. There were no therapeutic failures, relapses or deaths in either group. Steroid therapy was used in 32% of patients with severe CA, but a beneficial effect on resolution of edema was not demonstrated. Conclusions: These results suggest that short-course antibiotic therapy is as effective as standard-duration therapy in uncomplicated CA and that steroid therapy may not be effective.

Meta-analysis of controlled studies on immunotherapy in severe scorpion envenomation

BackgroundDespite conflicting evidence, specific serotherapy is recommended for scorpion envenomation.MethodsA meta-analysis of prospective or observational controlled studies, comparing intravenous scorpion antivenin (SAV) with control, was performed. Binary outcomes are reported...

Sex Differences in Concussion Symptoms of High School Athletes

More than 1.6 million sport-related concussions occur every year in the United States, affecting greater than 5% of all high school athletes who participate in contact sports. As more females participate in sports, understanding possible differences in concussion symptoms between sexes becomes more important. To compare symptoms, symptom resolution time, and time to return to sport between males and females with sport-related concussions. Descriptive epidemiology study. Data were collected from 100 high schools via High School RIO (Reporting Information Online). Athletes from participating schools who sustained concussions while involved in interscholastic sports practice or competition in 9 sports (boys' football, soccer, basketball, wrestling, and baseball and girls' soccer, volleyball, basketball, and softball) during the 2005-2006 and 2006-2007 school years. A total of 812 sport concussions were reported (610 males, 202 females). Reported symptoms, symptom resolution time, and return-to-play time. No difference was found between the number of symptoms reported (P = .30). However, a difference was seen in the types of symptoms reported. In year 1, males reported amnesia (exact P = .03) and confusion/disorientation (exact P = .04) more frequently than did females. In year 2, males reported more amnesia (exact P = .002) and confusion/disorientation (exact P = .002) than did females, whereas females reported more drowsiness (exact P = .02) and sensitivity to noise (exact P = .002) than did males. No differences were observed for symptom resolution time (P = .40) or return-to-play time (P = .43) between sexes. The types of symptoms reported differed between sexes after sport-related concussion, but symptom resolution time and return-to-play timelines were similar.

The effects of walkers on lower limb kinematics of children with cerebral palsy

The tandem gait test has gained interest recently for assessment of concussion recovery. The purpose of our study was to determine the prognostic and diagnostic use of the single- and dual-task tandem gait test, alongside other clinical measures, within 10 days of pediatric concussion.We assessed 126 patients post-concussion (6.3 ± 2.3 days post-injury, mean ± SD) at a pediatric sports medicine clinic and compared them to 58 healthy controls (age: 15.6 ± 1.3 years; 43% female). We also compared the 31 patients with concussion who developed persistent post-concussion symptoms (PPCS) (age = 14.9 ± 2.0 years; 48% female) to the 81 patients with concussion who did not develop PPCS following the initial assessment (age: 14.1 ± 3.0 years; 41% female). All subjects completed a test battery, and concussion patients were monitored until they experienced concussion-symptom resolution. The test battery included tandem gait (single-task, dual-task (performing tandem gait while concurrently completing a cognitive test) conditions), modified Balance Error Scoring System (mBESS), and concussion symptom assessment (Health and Behavior Inventory). We defined PPCS as symptom resolution time > 28 days post-concussion for the concussion group. Measurement outcomes included tandem gait time (single- and dual-task), dual-task cognitive accuracy, mBESS errors (single/double/tandem stances), and symptom severity.The concussion group completed the single-task (mean difference = 9.1 s, 95% confidential interval (95%CI): 6.1–12.1) and dual-task (mean difference = 12.7 s, 95%CI: 8.7–16.8) tandem gait test more slowly than the control group. Compared to those who recovered within 28 days of concussion, the PPCS group had slower dual-task tandem gait test times (mean difference = 7.9 s, 95%CI: 2.0–13.9), made more tandem-stance mBESS errors (mean difference = 1.3 errors, 95%CI: 0.2–2.3), and reported more severe symptoms (mean difference = 26.6 Health and Behavior Inventory rating, 95%CI: 21.1–32.6).Worse dual-task tandem gait test time and mBESS tandem stance performance predicted PPCS in pediatric patients evaluated within 10 days of concussion. Tandem gait assessments may provide valuable information augmenting common clinical practices for concussion management.

Oral Vitamin A Enhances the Effectiveness of Formalin 8% in Treating Chronic Hemorrhagic Radiation Proctopathy

Chronic radiation proctopathy occurs in 5 to 20% of patients receiving radiation therapy, with rectal bleeding as its most common presentation. Although formalin treatment for rectal bleeding is promising, improvement is possible. Given the success of vitamin A in other radiation-induced treatments, we studied the efficacy of combining formalin with vitamin A in controlling bleeding symptoms of chronic radiation proctopathy. A retrospective review (1993-2007) was performed of patients presenting with features of chronic radiation proctopathy. Formalin 8% in a buffered solution was applied to the affected mucosa with use a tip applicator, and 10,000 units of vitamin A were given orally on a daily basis. Formalin treatments were repeated at three-week to four-week intervals until symptoms resolved. A comparison was made between patients who received formalin alone (n = 30) and those who received formalin in combination with vitamin A (n = 34). The 64 patients had a mean age of 79 years (range, 54-90 years). The combination group required fewer treatments (mean, 1.9) and a shorter time (11 weeks) for resolution of symptoms compared with the formalin-alone group (mean, 5.2 and 31 weeks, respectively) (P < 0.001). The overall success rate in controlling bleeding was only 64% in the formalin-alone group when compared with 94% in the combination group. When vitamin A was added to the regimen, a significant reduction was observed in the number of treatments and the time needed for resolution of symptoms, and there was an increased overall success rate. This combination represents a simple, effective, and well tolerated method of controlling hemorrhagic chronic radiation proctopathy.

Degenerative plantar fasciitis: A review of current concepts

Plantar fasciitis is a common cause for heel pain and is the result of a degenerative process of the plantar fascia at its calcaneal attachment. Age, obesity, excessive weight bearing and tight Achilles tendon are the common predisposing factors. Though this is a self-limiting condition, the time for resolution of symptoms is highly variable. Commonly used treatments are rest, analgesics, heat and cold application, stretching exercises, splints and orthoses. Local infiltration with steroids, radiotherapy, extracorporeal shock wave treatment and surgery are used in more resistant cases. We review the current understanding and concepts in the treatment of this condition.

Escalated Dosing of Tegasarod for the Treatment of Gastroparesis

Purpose: Gastroparesis (GP) is a common problem with a relatively poor selection of therapeutic agents. Tegaserod, a selective 5-hydroxytryptamine-4 (5HT4) receptor agonist, is known to stimulate gastrointestinal transit, particularly in constipation predominant irritable bowel syndrome. There are suggestions that tegaserod may likewise be useful in the treatment of GP, however there are few published data describing its use in this disorder. We report here, our experience using tegaserod, by means of a gradual dose escalation strategy, to treat GP. Methods: GP patients treated with tegaserod were included for review if: (1) they received a diagnosis of GP based both on symptoms and abnormal gastric emptying times and (2) they agreed to undergo repeat gastric emptying scans. Tegaserod was initiated at 6mg TID with step-wise dose increases of an additional 6mg TID (max. 24mg TID), as necessary based on persistent symptoms. Gastric emptying studies were performed at the time of the initial consultation, within one week of each dose adjustment, and upon resolution of GP symptoms. Results: The 33 patients reviewed consisted of 25 women and 8 men with an average age of 45.4 years. GP was identified as idiopathic (n = 23) or secondary to diabetes (n = 6), vagal injury (n = 2), or scleroderma (n = 2). At the time of the initial consultation, 5 patients were receiving tegaserod 6mg TID and 28 were receiving no therapy. Baseline gastric emptying scans found the mean gastric emptying at 60 mins. to be 12.7% (range 0–37%) with estimated T½ emptying times ranging from 100 mins. to “infinitity.” All patients achieved symptom resolution using dose escalation over an average of 3.3 months (range 7 days to 10 months). Doses required to achieve symptom resolution were 6mg TID (n = 19), 12mg TID (n = 12) and 24mg TID (n = 2). Gastric emptying scans at the time of symptom resolution found the mean gastric emptying at 60 mins. to be 53.2% (range 25–100%) with estimated T½ emptying times ranging from 14 mins. to 110 mins. Normalization of gastric emptying (T½ < 90 mins.) occurred in 78.8% (26/33) of patients. No significant side-effects were noted during treatment. Conclusions: Our results suggest that tegaserod can be successfully used in the treatment of GP, a disorder which otherwise has few satisfactory therapies. A strategy of dose escalation, beyond standard doses used for irritable bowel syndrome, resulted in symptom resolution in 100% of patients and normalization of gastric emptying times in 78.8% of patients.

Treatment and follow-up of referred otic symptomatology in 23 patients with diagnosed temporomandibular disorders

Reports of the cause and effect relationship between temporomandibular disorders and orofacial-otic symptoms are polemic. The current research had two aims: to explore the possible link between temporomandibular disorders and oticorofacial referred symptomatology and to emphasize their diagnostic importance. One hundred and sixty-five patients with temporomandibular dysfunction and otic symptoms but without ear, nose, paranasal sinuses and throat pathology, were referred from an otolaryngology clinic to an orofacial pain centre. Twenty-three patients (20 females and 3 males, age range 1466 years, median age 35 years) with otic symptoms and headache associated with temporomandibular disorders were selected as fulfilling the inclusion criteria for the research. In the follow-up, each patient received an intra-oral device and the treatment outcomes were evaluated monthly by visual analogue scales (VAS) for five months. During this time, a reduction of their symptomatology was observed with complete relief (headache and vertigo), partial symptom alleviation (tinnitus, otic fullness and otalgia) or without symptom alleviation (subjective hearing loss) in some patients. The time for resolution of symptoms varied with each patient. Team work (odontology-otolaryngology) and detailed evaluation criteria based on a completely structured interview and physical examination are necessary for the diagnosis and treatment of these symptoms, closing the wide breach existing between these health disciplines.

Chronic urticaria: Incidence of thyroiditis and response to medications

Rationale Chronic urticaria (CU) continues to be a vexing problem for the allergist. This study reports the clinical characteristics of CU patients in a large allergy practice, and their response to medications. Methods Retrospective chart review identified patients whose primary diagnosis was “urticaria” between October 1998 and June 2003. Patients who met diagnostic criteria for CU were included in this sample. Treatment included high-dose H1 and H2 histamine receptor antagonists, and additional medications if this combination failed. Outcome of treatment was evaluated by assessing the degree of improvement as well as the time for resolution of symptoms. A subset of patients with thyroiditis was identified and characterized. Results All 197 patients were identified and characterized by age, race, associated angioedema, anti-thyroid antibodies, physical examination, provocative triggers, laboratory findings, medication usage, clinical outcome and long term resolution. Twenty-four patients were lost to follow-up. One hundred sixty-one (94%) had substantial improvement of symptoms while 10 (6%) had no change. Twenty-two patients (only one male) were positive for antibodies to either thryoglobulin or peroxidase, or both. Conclusions The outcomes of the chronic urticaria patients seen in this allergy practice suggest that a combination of H1 and H2 antihistamines may be quite efficacious and that patients overwhelmingly improve. Hashimoto's thyroiditis was seen in a significant subset of patients.

Surgical treatment of recalcitrant plantar fasciitis.

Twenty-six patients (35 feet) underwent partial plantar fasciectomy with neurolysis of the nerve to the abductor digiti quinti muscle. Nonsurgical treatment for plantar fasciitis had been unsuccessful in these patients. Patients were followed after surgery for an average of 37.5 months. Six patients were male and 20 patients were female; the average age was 49 years. All patients had failed to respond to nonsurgical treatment for an average of 21.5 months. In addition to routine history and physical examination patients were evaluated before and after surgery with a subjective foot rating system, and a detailed questionnaire was used to assess post-operative functional outcome. Thirty-two patients (92%) had a satisfactory functional outcome, and three patients (8%) had an unsatisfactory result (21 excellent, 11 good, 3 fair, 0 poor). The Maryland Foot Score increased from a preoperative average of 74.8/100 points to a postoperative average of 90.6/100 points. Four patients (11%) had postoperative complications, including superficial wound infection (two patients), deep venous thrombosis (one patient), and superficial phlebitis (one patient), all of which resolved uneventfully with treatment. Ten patients (28.6%) reported some degree of heel pain after surgery. All 10 patients denied limitation in activity related to postoperative pain. The average period before return to daily activity and restricted work duty was 5.6 weeks and to full work duty without restriction was 8.7 weeks. Although the length of time for partial or complete resolution of symptoms is variable, a successful treatment outcome can be expected in most patients who are treated for recalcitrant plantar fasciitis.

A Randomized Trial for Outpatient Management of Peritonsillar Abscess

Two protocols for outpatient management of peritonsillar abscess were evaluated. One group of patients was treated with traditional incision and drainage, while the second group underwent simple aspiration with an 18-gauge needle. Both study groups received penicillin, or, if allergic, erythromycin, and both groups were seen at 24 to 48 hours for repetition of the initial procedure if the abscess had reaccumulated. These patients were interviewed seven to ten days after the initial visit for confirmation of the drainage procedure's efficacy and for subjective evaluation of the duration of pharyngeal discomfort following the procedure. Repetition of the initial drainage procedure was necessary in 20% of those patients treated with needle aspiration and in 10% of those patients undergoing incision and drainage. After needle aspiration, subjective improvement in swallowing discomfort occurred one to two days sooner, but there was no difference in the time for resolution of symptoms. S. P. Stringen