Effects of prior concussion on symptom severity and recovery time in acute youth concussion.

OBJECTIVE: Many studies have identified factors associated with increased symptom burden and prolonged recovery after pediatric and adolescent concussion. Few have systematically examined the effects of prior concussion on these outcomes in patients with concussion due to any mechanism. An improved understanding of the short- and long-term effects of a multiple concussion history will improve counseling and management of this subgroup of patients. METHODS: A retrospective review of adolescent and young adult acute concussion patients presenting to the multidisciplinary concussion clinic between 2018 and 2019 was conducted at a single center. Patient demographic data, medical history including prior concussion, initial symptom severity score (SSS), injury mechanisms, and recovery times were collected. Univariate and multivariable analyses were conducted to identify associations of history of prior concussion and patient and injury characteristics with symptom score and recovery time. RESULTS: A total of 266 patients with an average age of 15.4 years (age range 13-27 years) were included. Prior concussion was reported in 35% of patients. The number of prior concussions per patient was not significantly associated with presenting symptom severity, recovery time, or recovery within 28 days. Male sex and sports-related concussion (SRC) were associated with lower presenting SSS and shorter recovery time on univariate but not multivariable analysis. However, compared to non-sport concussion mechanisms, SRC was associated with 2.3 times higher odds of recovery within 28 days (p = 0.04). A history of psychiatric disorders was associated with higher SSS in univariate analysis and longer recovery time in univariate and multivariable analyses. Multivariable log-linear regression also demonstrated 5 times lower odds of recovery within 28 days for those with a psychiatric history. CONCLUSIONS: The results of this study demonstrated that an increasing number of prior concussions was associated with a trend toward higher presenting SSS after youth acute concussion but did not show a significant association with recovery time or delayed (> 28 days) recovery. Presence of psychiatric history was found to be significantly associated with longer recovery and lower odds of early (≤ 28 days) recovery. Future prospective, long-term, and systematic study is necessary to determine the optimal counseling and management of adolescent and young adult patients with a history of multiple concussions.

Socioeconomic and demographic considerations of pediatric concussion recovery.

The objective of this study was to investigate predictors of concussion recovery in children (5-12) versus adolescents (13-18) while identifying economic and demographic disparities in post-concussion care at a tertiary referral concussion clinic versus emergency department (ED). Race and insurance status were recorded for patients presenting to the concussion clinic (724) and ED (1,160) with an ICD-10 concussion diagnosis between 2018 and 2019. Secondly, a subset of patients from the concussion clinic group were included for retrospective cohort review based on documented recovery data. Overall, the concussion clinic saw more Caucasian patients (66.7%) than the ED (56.8%). Concussion clinic patients were more likely to have Private insurance than ED patients (67.2% vs. 55.3%) and less likely to have Medicaid and Self pay (p < 0.001). Children were more likely to be hospitalized after concussion diagnosis than adolescents (40.8% vs. 24.4%, p = 0.006). Attending public school was associated with a 1.8 times greater hazard ratio (HR) for shorter time to recovery compared to attending private school. Additionally, presence of a diagnosed psychiatric disorder was associated with a HR of 0.5, indicating a longer time to recovery (p < 0.001) than patients without a disorder. The present findings may support limitations on contact sports participation in young children given their higher hospitalization rate after concussion. Additionally, the study highlights potential barriers to care amongst youth concussion patients with those seen in specialized concussion clinics more likely to be White and have private insurance.

Exercise prehabilitation during neoadjuvant chemotherapy may enhance tumour regression in oesophageal cancer: results from a prospective non-randomised trial.

BACKGROUND: There is increasing evidence for the use of exercise in cancer patients and data supporting enhanced tumour volume reduction following chemotherapy in animal models. To date, there is no reported histopathological evidence of a similar oncological benefit in oesophageal cancer. METHODS: A prospective non-randomised trial compared a structured prehabilitation exercise intervention during neoadjuvant chemotherapy and surgery versus conventional best-practice for oesophageal cancer patients. Biochemical and body composition analyses were performed at multiple time points. Outcome measures included radiological and pathological markers of disease regression. Logistic regression calculated ORs with 95% CI for the likelihood of pathological response adjusting for chemotherapy regimen and chemotherapy delivery. RESULTS: Comparison of the Intervention (n=21) and Control (n=19) groups indicated the Intervention group had higher rates of tumour regression (Mandard TRG 1-3 Intervention n=15/20 (75%) vs Control n=7/19 (36.8%) p=0.025) including adjusted analyses (OR 6.57; 95% CI 1.52 to 28.30). Combined tumour and node downstaging (Intervention n=9 (42.9%) vs Control n=3 (15.8%) p=0.089) and Fat Free Mass index were also improved (Intervention 17.8 vs 18.7 kg/m2; Control 16.3 vs 14.7 kg/m2, p=0.026). Differences in markers of immunity (CD-3 and CD-8) and inflammation (IL-6, VEGF, INF-y, TNFa, MCP-1 and EGF) were observed. CONCLUSION: The results suggest improved tumour regression and downstaging in the exercise intervention group and should prompt larger studies on this topic. TRIAL REGISTRATION NUMBER: NCT03626610.

Efficacy of outpatient infusion therapy in pediatric patients with postconcussive headaches.

PURPOSE: To determine the relative efficacy of intravenous therapy for postconcussive headaches in a pediatric population, as compared to oral therapy. METHODS: Pediatric patients treated for postconcussive headaches at an outpatient infusion clinic from 2016 to 2018 were selected for inclusion in the study. Of the 95 patients who were treated in clinic, 53 patients were selected for a retrospective chart review. Clinic visits before and after infusions were reviewed to determine changes in headache score (HA), symptom severity score (SSS), and self-reported symptom relief. An age-matched and SSS-matched group served as a control. The control group received only oral therapy for their headaches. The infusion consisted of parenteral ketorolac, compazine, diphenhydramine, and a normal saline bolus (20 mg/kg). RESULTS: Following infusion therapy, overall mean HA and SSS scores were both reduced (p < 0.0001). Oral therapy demonstrated a similar mean overall reduction in HA and SS scores (p < 0.0001). While both groups achieved a reduction in HA and SS scores, there was not a statistically significant difference in reduction of symptoms scores between the oral and infusion groups. CONCLUSION: Infusion therapy is as effective at reducing HA and SSS as established oral therapies. Infusion therapy may have a shorter time to headache abortion than oral therapy based on pharmacokinetics. Further, some physicians are unwilling to allow an athlete to return to play while taking suppressive medication. Future studies may show that an infusion could allow a more rapid return to play and resolution of symptoms.

SHP: 50 years and counting.

This essay contributes to the celebration of the 50th anniversary of the founding of the Society for the History of Psychology (SHP) in its earlier form (Division 26 of the American Psychological Association). Ronald Mayer's history of the division is updated by providing a description of some of the noteworthy events and changes in the organization since his publication. (PsycINFO Database Record

Acute pulmonary edema after pericardial drainage for cardiac tamponade.

Pericardial effusions with tamponade may present a clinical challenge in management for the cardiothoracic surgeon. We report a case of acute pulmonary edema secondary to the rapid release of a chronic traumatic pericardial effusion that resulted in the death of the patient.

Bilateral central retinal artery occlusion in a patient with acute pancreatitis.

PURPOSE: To illustrate a case of bilateral simultaneous central retinal artery occlusion in a patient with acute pancreatitis. METHODS: This patient presented to the emergency room with a 4-day history of acute painless bilateral loss of vision and was then immediately referred to the on-call ophthalmologist. PATIENT: This patient is a 47-year-old white man with a chronic history of alcohol abuse. RESULTS: Laboratory workup and computed tomography abdominal imaging were diagnostic of acute pancreatitis. DISCUSSION: It is postulated that the resultant complement activation with subsequent leukoembolization along with the combined effect of other variables led to microvascular damage resulting in bilateral central retinal artery occlusion.

Comparison of spinal cord protection utilizing left atrial-femoral with femoral-femoral bypass in patients with traumatic rupture of the aortic isthmus.

INTRODUCTION: Postoperative paraplegia remains a dreaded complication of repair of traumatic rupture of the aortic isthmus. Claims have been made that left atrial-femoral bypass provides better spinal cord protection. To test the hypothesis that left atrial-femoral bypass is better than femoral vein-to-femoral artery bypass in regard to postoperative paraplegia, we concurrently compared the two techniques. METHODS: We compared the occurrence of paraplegia in 18 patients whose ruptures were repaired utilizing left atrial-femoral bypass with 10,000 units of systemic heparin (group A) and 72 patients with femoral-femoral bypass with heparin 300 units/kg and an oxygenator (group B) operated on between January 1995 and July 2004. RESULTS: The mortality rate was 5.6% (5/90), with no statistical difference between the two groups. Postoperative paraplegia was present in three (16.7%) group A patients and five group B (6.9%) patients. However, the specific etiology of the neurologic defect was not clear, as one patient's paraplegia was transient following a period of cardiac arrest, and four others had had neurologic injuries prior to the aortic repair. Median aortic cross-clamp times were shorter in group A (34 minutes vs. 49 minutes). No patient required reexploration for bleeding, and no patient developed a graft infection. CONCLUSIONS: Paraplegia rates were higher in the left atrial-femoral group, but the difference was not statistically significant. This occurred despite the decreased cross-clamp times in this group. In patients undergoing repair of traumatic rupture of the aortic isthmus, left atrial-femoral bypass does not provide better spinal cord protection than femoral-femoral bypass.

Wedge resection for non-small cell lung cancer in patients with pulmonary insufficiency: prospective ten-year survival.

BACKGROUND: Possibility of curative resection by lobectomy for non-small cell lung cancer is often denied patients with compromised pulmonary reserve. Analysis of survival of such patients treated by wedge resection was compared with that of patients treated by standard resection, with both groups followed for 10 years. DESIGN: A prospective 5-year cohort study. METHODS: From 1988 to 1992, an observational cohort of 127 consecutive resected patients at Memphis VA Medical Center was divided into those receiving lobectomy in 81 cases and pneumonectomy in 15 cases (group I) versus 31 patients with compromised pulmonary reserve (group II), who had complete tumor excision by wedge resection. Preoperative clinical staging was corrected to surgical-pathological staging after demonstration of its superiority. Survival estimates were obtained by Kaplan-Meier method with curves compared by log rank tests, with all-cause mortality calculated from date of surgery. RESULTS: Extent of disease in group I was 58% stage I, 19% stage II, and 23% stage III. In group II, extent of disease was 84% stage I, 3% stage II, and 14% stage III. Group I median survival was 26 months with 30% 5-year survival; for group II, median survival was 30 months and 32%. Kaplan-Meier survival plots showed similar curves in groups I and II. Realizing less extent of disease in group II, another Kaplan-Meier plot restricted to stage I and II patients showed overlapping survival curves for groups I and II. CONCLUSION: Survival during 10-year observation was similar for patients with pulmonary insufficiency treated by wedge resection to that of patients receiving standard resection in this single-institution consecutive cohort.

Sequential responding and planning in chimpanzees (Pan troglodytes) and rhesus macaques (Macaca mulatta).

Chimpanzees (Pan troglodytes) and rhesus macaques (Macaca mulatta) selected either Arabic numerals or colored squares on a computer monitor in a learned sequence. On shift trials, the locations of 2 stimuli were interchanged at some point. More errors were made when this interchange occurred for the next 2 stimuli to be selected than when the interchange was for stimuli later in the sequence. On mask trials, all remaining stimuli were occluded after the 1st selection. Performance exceeded chance levels for only 1 selection after these masks were applied. There was no difference in performance for either stimulus type (numerals or colors). The data indicated that the animals planned only the next selection during these computerized tasks as opposed to planning the entire response sequence.

Uncertainty monitoring may promote emergents.

We suggest that the phenomenon of uncertainty monitoring in nonhuman animals contributes richly to the conception of nonhuman animals' self-monitoring. We propose that uncertainty may play a role in the emergence of new forms of behavior that are adaptive. We recommend that Smith et al. determine the extent to which the uncertain response transfers immediately to other test paradigms.