Comparing return to play protocols after sports-related concussion among international sporting organisations

BACKGROUND

Return to play (RTP) protocols are an important part of recovery management following a sport-related concussion (SRC) and can prevent athletes from returning to competition too early and thereby avoid prolonged recovery times. To assist sporting organizations in the development of RTP guidelines, the Concussion in Sports Group (CISG) provides scientific-based recommendations for the management of SRC in its consensus statement on concussion in sport.

OBJECTIVES

This study investigates commonalities and differences among current RTP protocols of international sporting organizations and examines the implementation of the most recent CISG recommendations.

METHODS

Concussion guidelines and medical rules of 12 international sporting organizations from contact, collision and combat sports were accessed via the organizations websites and compared regarding the management of SRC and the RTP decision.

RESULTS

Only six of the included organizations developed and published their own concussion guidelines, which included an RTP protocol on their website. The number of steps until RTP was similar across the different protocols. Each protocol required at least one medical examination before clearing an athlete to RTP. A high variation among organizations was found for initial resting period after injury, the implementation of sport-specific training drills and the time needed to complete the protocol before returning to competition. At the date of this study (9 September 2023), none of the accessible RTP protocols were updated to include the latest version of the CISG consensus statement.

CONCLUSION

To improve the safety of athletes after a head injury, sporting organizations should develop sport-specific guidelines according to the latest CISG consensus statement, and this should be updated regularly. Implementation is especially important in combat sports, where there is a high incidence of head injury. Thus, there is a requirement for the most up-to-date concussion management protocols in these sports.

Non-adiabatic conformation distortion charge transfer enables dual emission of thermally activated delayed fluorescence and room temperature phosphorescence

In this work, we report for the first time that thiophenol-substituted naphthalimide can achieve thermally activated delayed fluorescence (TADF) and room temperature phosphorescence (RTP) simultaneously through non-conjugated flexible connection. Herein, we explain that the enhancement of intersystem crossing (ISC) between the singlet excited state and triplet excited states in NISPh is mainly caused by the non-adiabatic conformation distortion charge transfer (CDCT) of the excited states. More precisely, CDCT results in the conformation matching and energy barrier decrease between the excited states. In addition, the electronic and vibration coupling is further enhanced in NISPh. Our work substantiates a rational design strategy for the development of simple purely organic materials to achieve dual emission of TADF and RTP.

Phosphorescence Properties of Boron/Bismuth Hybrid Conjugated Materials

By introducing main-group elements such as boron and bismuth to π-conjugated systems, it is possible to modify the optical properties of π-conjugated materials through orbital interactions between the orbital on the elements and π/π*-orbitals, and the heavy atom effect. Moreover, bismuth, which is the heaviest stable element, induces a significant heavy atom effect, making organobismuth compounds promising for applications as phosphorescent materials. In this study, we synthesized new room-temperature phosphorescent materials by incorporating bismuth into thiophene units. The phosphorescence properties of these materials, such as emission lifetime and wavelength, could be further controlled by combining tricoordinate boron with the thienylbismuth structures. The synthesized bismuth- and boron-containing thiophene compounds exhibited phosphorescence at room temperature in both solution and solid states. Furthermore, the introduction of boron raised the energy of the triplet state in the π-conjugated system, resulting in a blue shift of the phosphorescence wavelength. The analysis of photoluminescence properties and TD-DFT calculations revealed that the introduction of bismuth enhances phosphorescence properties, whereas the introduction of boron further promotes intersystem crossing.

Modulating Aryl Azide Photolysis: Synthesis of a Room-Temperature Phosphorescent Carboline in Cucurbit[7]uril Host

Cucurbit[7]uril (CB7), a supramolecular host, is employed to control the pathway of photolysis of an aryl azide in an aqueous medium. Normally, photolysis of aryl azides in bulk water culminates predominantly in the formation of azepine derivatives via intramolecular rearrangement. Remarkably, however, when this process unfolds within the protective confinement of the CB7 cavity, it results in a carboline derivative, as a consequence of a C─H amination reaction. The resulting carboline caged by CB7 reveals long-lived room temperature phosphorescence (RTP) in the solid state, with lifetimes extending up to 2.1 s. These findings underscore the potential of supramolecular hosts to modulate the photolysis of aryl azides and to facilitate novel phosphorescent materials.

Clinical feasibility of a commercially available MRI-only method for radiotherapy treatment planning of the brain

BACKGROUND

Advancements in deep-learning based synthetic computed tomography (sCT) image conversion methods have enabled the development of magnetic resonance imaging (MRI)-only based radiotherapy treatment planning (RTP) of the brain.

PURPOSE

This study evaluates the clinical feasibility of a commercial, deep-learning based MRI-only RTP method with respect to dose calculation and patient positioning verification performance in RTP of the brain.

METHODS

Clinical validation of dose calculation accuracy was performed by a retrospective evaluation for 25 glioma and 25 brain metastasis patients. Dosimetric and image quality of the studied MRI-only RTP method was evaluated by a direct comparison of the sCT-based and computed tomography (CT)-based external beam radiation therapy (EBRT) images and treatment plans. Patient positioning verification accuracy of sCT images was evaluated retrospectively for 10 glioma and 10 brain metastasis patients based on clinical cone-beam computed tomography (CBCT) imaging.

RESULTS

An average mean dose difference of Dmean = 0.1% for planning target volume (PTV) and 0.6% for normal tissue (NT) structures were obtained for glioma patients. Respective results for brain metastasis patients were Dmean = 0.5% for PTVs and Dmean =1.0% for NTs. Global three-dimensional (3D) gamma pass rates using 2%/2 mm dose difference and distance-to-agreement (DTA) criterion were 98.0% for the glioma subgroup, and 95.2% for the brain metastasis subgroup using 1%/1 mm criterion. Mean distance differences of <1.0 mm were observed in all Cartesian directions between CT-based and sCT-based CBCT patient positioning in both subgroups.

CONCLUSIONS

In terms of dose calculation and patient positioning accuracy, the studied MRI-only method demonstrated its clinical feasibility for RTP of the brain. The results encourage the use of the studied method as part of a routine clinical workflow.

Achieving White-Light Emission Using Organic Persistent Room Temperature Phosphorescence

Artificial lighting currently consumes approximately one-fifth of global electricity production. Organic emitters with white persistent RTP have potential for applications in energy-efficient lighting technologies, due to their ability to harvest both singlet and triplet excitons. Compared to heavy metal phosphorescent materials, they have significant advantages in cost, processability, and reduced toxicity. Phosphorescence efficiency can be improved by introducing heteroatoms, heavy atoms, or by incorporating luminophores within a rigid matrix. White-light emission can be achieved by tuning the ratio of fluorescence to phosphorescence intensity or by pure phosphorescence with a broad emission spectrum. This review summarizes recent advances in the design of purely organic RTP materials with white-light emission, describing single-component and host-guest systems. White phosphorescent carbon dots and representative applications of white-light RTP materials are also introduced.

Return to Play and Performance After Anterior Cruciate Ligament Reconstruction in the National Women's Soccer League

Background

The anterior cruciate ligament (ACL) is commonly injured in elite-level female athletes, which usually requires ACL reconstruction (ACLR).

Purpose

To analyze return to play (RTP) and changes in performance of players in the National Women's Soccer League (NWSL) after ACLR.

Study Design

Descriptive epidemiology study.

Methods

NWSL players who sustained an ACL tear and underwent surgery between the 2013 and 2020 seasons were identified by multiple online resources. Players were classified as forwards, defenders, midfielders, and goalkeepers. RTP was assessed according to games played, games started, percentage of minutes played, plus/minus net per 90 minutes (a measure of a player's contribution to their team's performance while on the field), goals scored, and assists. A subanalysis was performed based on the median age at the time of the injury (≤24 vs ≥25 years). Nonparametric testing methods were used throughout the analysis.

Results

A total of 30 NWSL athletes were included. Midfielders had the highest percentage of injuries (n = 11; 36.7%), followed by forwards (n = 10; 33.3%). Overall, 27 players returned to the NWSL at a median of 12.1 months (IQR, 10.9-14.3 months), constituting a 90.0% RTP rate. There was a significant decrease in the percentage of minutes played from 1 year before the injury to 1 year after the injury (median, 87.9% [IQR, 80.7%-90.6%] vs 25.1% [IQR, 16.3%-57.2%], respectively; P = .031). Forwards and midfielders had a significant decrease in the number of assists from 1 year before the injury to 1 year after the injury (median, 3.0 [IQR, 1.0-3.0] vs 0.0 [IQR, 0.0-1.0], respectively; P = .037) as well as the number of goals scored when averaging across 2 seasons before the injury to 2 seasons after the injury (median, 3.0 [IQR, 1.5-5.5] vs 1.0 [IQR, 0.5-3.5], respectively; P = .031). On subanalysis, older players started in significantly more games (median, 12.0 [IQR, 3.8-18.5] vs 3.0 [IQR, 0.5-6.0], respectively; P = .048) and had a higher percentage of minutes played (median, 63.0% [IQR, 18.8%-77.3%] vs 14.9% [IQR, 2.0%-21.2%], respectively; P = .046) at 1 year after the injury versus younger players.

Conclusion

There was a 90.0% RTP rate after ACLR in the NWSL. Players who returned to the NWSL had a lower percentage of minutes played in their first year after RTP, with older players starting in more games and having a greater percentage of minutes played. Compared with preinjury performance, forwards and midfielders had a significant decrease in the number of assists at 1 year after the injury as well as the number of goals scored at 2 years after the injury.

High-level soccer players have a low rate of return to performance after hip arthroscopy for femoroacetabular impingement syndrome

PURPOSE

Femoroacetabular impingement syndrome (FAIS) is a known cause of impaired sports performance in athletes and the relationship between FAIS and soccer players has previously been described. Hip arthroscopy is a viable treatment option that can facilitate athletes' return to sport (RTS). The aim of this study was to evaluate the RTS and return to performance (RTP) with objective measurements in high-level soccer players after hip arthroscopy for FAIS.

METHOD

Soccer players, with a hip sports activity scale (HSAS) level of 7 or 8 before symptom onset and undergoing hip arthroscopy for FAIS between 2011 and 2019 were identified in the Gothenburg hip arthroscopic registry. A total of 83 high-level soccer players, with a mean age of 23.9 (SD 4.4) years at surgery, were included. To verify the activity level and further stratify players as elite or sub-elite, player statistics were collected from soccer-specific scout webpages and the Swedish national soccer association. The return to sport was defined as return to one game of soccer. Return to performance was defined as playing at the same level, or higher, and participating in at least 80% of the number of games played the season before symptom onset or the season before surgery either the first or second season after hip arthroscopy.

RESULTS

In total, 71 (85.5%, 95% confidence interval (CI) 76.1-92.3%) of the players returned to sport the first or second season after surgery. Compared to the season before symptom onset, 31 (37.3%, 95% CI 27.0-48.7%) players returned to performance the first or second season after surgery, and 32 (38.6%, 95% CI 28.1-49.9%) players returned to performance the first or second season after surgery compared to the season before surgery.

CONCLUSION

A high rate of elite and sub-elite soccer players return to soccer after hip arthroscopy for FAIS. However, less than half of the players RTP when evaluating performance through level of play and number of games played.

LEVEL OF EVIDENCE

Level IV.

Beginning With the End in Mind: Implementing Backward Design to Improve Sports Injury Rehabilitation Practices

SYNOPSIS: Current injury-specific return-to-performance rehabilitation programs are not comprehensive, lack intensity, and need better tailoring to the demands of sport. The vast number of rehabilitation and return to sport protocols also reflects a lack of consensus about what the best program looks like, which hinders beginning practitioners from implementing best practices across the spectrum of injuries and sports. Backward design, which has underpinnings in educational research, can facilitate implementation by encouraging practitioners to begin with the end in mind before logically and intentionally working backwards to design transferable and context-specific rehabilitation plans that improve sports injury rehabilitation practices. We discuss and illustrate using case examples how clinicians can apply backward design in best practice sports injury rehabilitation. J Orthop Sports Phys Ther 2022;52(12):770-776. Epub: 7 October 2022. doi:10.2519/jospt.2022.11440.

Psychological readiness to return to sports practice and risk of recurrence: Case studies

Returning to sport after the sports injury is a difficult decision because it's multicausal and the fact that a rash decision can result in numerous negative consequences. Given the importance of psychological variables for the correct rehabilitation of the injured athlete and his or her optimal return to sports practice, there seems to be little information on this subject. In this sense, the objective is to determine the relationship between the subjective psychological disposition of the athlete in the process of Return to Play (RTP) with the type of mood profile and his mental health. This is based on the fact that each athlete evaluates his or her recovery differently and has different levels of anxiety, depression, and stress. For this purpose, four athletes participated in the study. Two males and two females from the sports of indoor soccer and soccer, who had just returned to sports after a moderate or severe injury. The average age was 24.25 years. Various measurements were taken after practices and after matches, to assess mood, psychological readiness, anxiety, stress, and depression. The results confirm Morgan's iceberg profile and the influence that subjective psychological perceptions and assessed emotional states have on athletes' incorporation into their sports practice with a guarantee of success.

Cardiac involvement in athletes infected by SARS COV-2 disease

Objectives

The aim of the present study was to conduct a review of the current literature evaluating the available evidence to date in terms of epidemiology, pathophysiology and clinical presentation of COVID-19 in relation to cardiovascular involvement, with a special focus on the myocarditis model, in the population of athletes (professional and recreational) who are preparing to return to competitions, with the ultimate aim of guaranteeing maximum safety for resuming sports activities.

News

The COVID-19 pandemic has resulted in the inevitable cancellation of most sports activities, practiced at both a professional and amateur level, in order to minimize the risk of spreading the infection. Since the number of athletes who tested positive was rather high, the potential cardiac involvement in this peculiar population of subjects contracting the disease in a mild (asymptomatic, slightly symptomatic) or moderate form, has recently raised concerns following the observation of cases of recorded myocardial damage, myocarditis, arrhythmias and a first reported case of Sudden Cardiac Death (SCD) in a 27-year-old professional basketball player. Several studies even seem to confirm the possibility of permanent impairment of the cardiorespiratory system following the infection. Medical history, biomarkers, electrocardiographical and cardiac imaging features appear to be crucial in distinguishing cardiovascular alterations related to COVID-19 infection from typical adaptations to exercise related to athletes' heart.

Prospects and Projects

Clarifications and prospective data based on long-term follow-ups on larger populations of athletes are still needed to exclude the development of myocardial damage capable of negatively affecting prognosis and increasing cardiovascular risk in athletes recovered from COVID-19 in asymptomatic (simple positivity to SARS-COV-2) or in a mild form.

Conclusion

From a clinical point of view extreme caution is necessary when planning the return to sport (Return To Play-RTP) of athletes recovered from a mild or asymptomatic form of COVID-19: a careful preliminary medical-sports evaluation should be carried out in order to assess the potential development of myocardial damage that would increase their cardiovascular risk.

A Framework for Clinicians to Improve the Decision-Making Process in Return to Sport

Return-to-sport (RTS) decisions are critical to clinical sports medicine and are often characterised by uncertainties, such as re-injury risk, time pressure induced by competition schedule and social stress from coaches, families and supporters. RTS decisions have implications not only for the health and performance of an athlete, but also the sports organisation. RTS decision-making is a complex process, which relies on evaluating multiple biopsychosocial factors, and is influenced by contextual factors. In this narrative review, we outline how RTS decision-making of clinicians could be evaluated from a decision analysis perspective. To begin with, the RTS decision could be explained as a sequence of steps, with a decision basis as the core component. We first elucidate the methodological considerations in gathering information from RTS tests. Second, we identify how decision-making frameworks have evolved and adapt decision-making theories to the RTS context. Third, we discuss the preferences and perspectives of the athlete, performance coach and manager. We conclude by proposing a framework for clinicians to improve the quality of RTS decisions and make recommendations for daily practice and research.

Greatness in Simplicity: Efficient Red Room-Temperature Phosphorescence from Simple Halogenated Maleimides with a 2D Layered Structure

Herein, two maleimide derivatives substituted by Br (DBM) and I (DIM) with a two-dimensional (2D) layered structure are found to have highly efficient red room-temperature phosphorescence (RTP) at 660 nm in solid state, which is independent of their morphology (crystal, powder, and film). The red RTP of DBM and DIM is closely related to the synergism of n_π-ct-π* transitions and the 2D halogen-bonded network. Interestingly, the red RTP can be excited by visible light of 500 nm, which should be ascribed to the forbidden absorption from the ground state to the triplet state activated in the layered halogen-bonded framework. Due to the rich intermolecular interactions in the rigid layered structure, the red RTP of DBM is very stable under water or external force stimulation. Notably, Hg(II) and Cd(II) ions in a pure aqueous solution result in an opposite change in the RTP intensity of the DBM film. The detection limit of Hg(II) ion is as low as 2.5 × 10^-5 nM, lesser than all reported values. The above results not only provide a new idea for the design of simple and efficient red RTP materials but also make it possible to develop solid-state phosphorescent probes for toxic heavy metal ions in environmental sewage with high sensitivity and selectivity.

High-Speed and Continuous-Wave Programmable Luminescent Tags Based on Exclusive Room Temperature Phosphorescence (RTP)

Most materials recently developed for room temperature phosphorescence (RTP) lack in practical relevance due to their inconvenient crystalline morphology. Using amorphous material systems instead, programmable luminescent tags (PLTs) based on organic biluminescent emitter molecules with easy processing and smooth sample shapes are presented recently. Here, the effective quenching of the emitter's RTP by molecular oxygen (O₂ ) and the consumption of the excited singlet O₂ through a chemical reaction represent the central features. With customized activation schemes, high-resolution content can be written and later erased multiple times into such films, providing a versatile yet simple photonic platform for information storage. However, two important limitations remain: The immutable fluorescence of the emitters outshines the phosphorescent patterns by roughly one order of magnitude, allowing readout of the PLTs only after the excitation source is turned off. The programming of these systems is a rather slow process, where lowest reported activation times are still >8 s. Here, a material-focused approach to PLTs with fast activation times of 120 ± 20 ms and high-contrast under continuous-wave illumination is demonstrated, leading to accelerated programming on industry relevant time scales and a simplified readout process both by eye and low cost cameras.

Long-standing pubic-related groin pain in professional academy soccer players: a prospective cohort study on possible risk factors, rehabilitation and return to play

Background

Despite being a common overuse entity in youth soccer, scientific data on risk factors, rehabilitation and return to play for long-standing pubic-related groin pain is still rare. The current prospective cohort study aims to evaluate potential risk-factors, propose a criteria-based conservative rehabilitation protocol and assess return-to-play outcomes among professional youth soccer players suffering from long-standing pubic-related groin pain.

Methods

Male soccer players with long-standing (> 6 weeks) pubic-related groin pain from a professional soccer club’s youth academy were analyzed for possible risk factors such as age, team (U12 - U23), younger/older age group within the team, position and preinjury Functional movement score. All injured players received a conservative, standardized, supervised, criteria-based, 6-level rehabilitation program. Outcome measures included time to return to play, recurrent groin pain in the follow-up period and clinical results at final follow-up two years after their return to play.

Results

A total of 14 out of 189 players developed long-standing pubic-related groin pain in the 2017/2018 season (incidence 7.4%). The average age of the players at the time of the injury was 16.1 ± 1.9 years. Risk factor analysis revealed a significant influence of the age group within the team (p = .007). Only players in the younger age group were affected by long-standing pubic-related groin pain, mainly in the first part of the season. Injured players successfully returned to play after an average period of 135.3 ± 83.9 days. Only one player experienced a recurrence of nonspecific symptoms (7.1%) within the follow-up period. The outcome at the 24-month follow-up was excellent for all 14 players.

Conclusions

Long-standing pubic-related groin pain is an overuse entity with a markedly high prevalence in youth soccer players, resulting in a relevant loss of time in training and match play. In particular, the youngest players in each team are at an elevated risk. Applying a criteria-based rehabilitation protocol resulted in an excellent return-to-play rate, with a very low probability of recurrence.

Trial registration

The trial was retrospectively registered under DRKS00016510 in the German Clinical Trials Register on 19.04.2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04837-x.

Return to Play Following COVID-19 Infection-A Systematic Review of Current Evidence

CONTEXT

The COVID-19 pandemic has had catastrophic impact on a global scale, affecting people from all walks of life including elite athletes.

OBJECTIVES

The purpose of this study was to evaluate the reported rates of return to play (RTP) in conjunction with the expert-derived guidelines previously recommended to enable safe RTP post COVID-19 infection.

EVIDENCE ACQUISITION

Two independent reviewers searched the literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, utilizing the MEDLINE, Embase, and Scopus databases. Only studies that reported rates of RTP and/or recommended guidelines for safe RTP were included.

EVIDENCE SYNTHESIS

Overall, 17 studies (3 level III and 14 level V) were included. A total of 3 studies reported rates of RTP in a total of 1255 athletes and 623 officials; 72 (30 symptomatic) were infected with COVID-19, 100% of whom were able to RTP post COVID-19 infection. Of the 14 studies recommending guidelines for safe RTP, 3 and 9 studies recommended 7 and 14 days of rest in isolation respectively for asymptomatic patients with COVID-19 infection, prior to safe RTP. In contrast, 7 studies recommended 3 to 6 months of rest (following 14 d isolation) in cases of COVID-19-induced myocarditis as a safe timeframe for safe RTP. Of the 11 studies reporting on whether blanket testing prior to RTP was recommended, only 7 studies recommended a negative test result as mandatory prior to RTP for athletes previously infected with COVID-19.

CONCLUSIONS

Although excellent rates of RTP have been reported for elite athletes post COVID-19 infection, discrepancies in recommended rest periods, requirement for mandatory negative test results, and the magnitude of screening investigations required continue to exist in the literature, with a need for further standardized international guidelines required in future.

LEVEL OF EVIDENCE

Level V; systematic review of all forms of evidence.

Return-to-Play for Athletes With Long QT Syndrome or Genetic Heart Diseases Predisposing to Sudden Death

BACKGROUND

Within the last 5 years, cardiac society guidelines have begun to acknowledge shared decision making (SDM) for the athlete with sudden cardiac death-predisposing genetic heart diseases (GHDs), such as long QT syndrome (LQTS), and the possibility for that athlete's return to play. Previously, international guidelines embraced a de facto disqualification for all such athletes including athletes with solely a positive genetic test in Europe.

OBJECTIVES

This study sought to examine the prevalence and outcomes of athletes with sudden cardiac death-predisposing GHDs, particularly LQTS, after their return to play.

METHODS

A retrospective review of the electronic medical record was performed on all athletes with GHD, with a primary analysis for those with LQTS, who were evaluated, risk stratified, and treated in Mayo Clinic's Windland Smith Rice Genetic Heart Rhythm Clinic by a single genetic cardiologist between July 1, 2000, and July 31, 2020.

RESULTS

There were 672 athletes with GHD overall including 494 athletes with LQTS (231 female athletes [46.8%]; mean age at diagnosis 14.8 ± 10.5 years; mean follow-up 4.2 ± 4.8 years) who were given return-to-play approval. Overall, 79 of 494 athletes with LQTS (16.0%) were symptomatic before diagnosis, and 58 (11.7%) had an implantable cardioverter-defibrillator. In 2,056 combined years of follow-up, there was no GHD-sports associated mortality. Instead, 29 patients (5.9%) had ≥1 nonlethal, LQTS-associated breakthrough cardiac event. Of those, 15 (3.0%) were athletes at the time of the breakthrough cardiac event, with 3 (0.6%) experiencing a sports-related breakthrough cardiac event, and 12 (2.4%) a non-sports-related event. Overall, the event rate was 1.16 nonlethal events per 100 athlete-years of follow-up.

CONCLUSIONS

This 20-year single center experience challenges the status quo of disqualification for all athletes with LQTS and provides additional observational evidence, albeit from a single center, in support of the more contemporary SDM approaches to this complex issue.

Persistent Room Temperature Phosphorescence from Triarylboranes: A Combined Experimental and Theoretical Study

Achieving highly efficient phosphorescence in purely organic luminophors at room temperature remains a major challenge due to slow intersystem crossing (ISC) rates in combination with effective non-radiative processes in those systems. Most room temperature phosphorescent (RTP) organic materials have O- or N-lone pairs leading to low lying (n, π*) and (π, π*) excited states which accelerate kisc through El-Sayed's rule. Herein, we report the first persistent RTP with lifetimes up to 0.5 s from simple triarylboranes which have no lone pairs. RTP is only observed in the crystalline state and in highly doped PMMA films which are indicative of aggregation induced emission (AIE). Detailed crystal structure analysis suggested that intermolecular interactions are important for efficient RTP. Furthermore, photophysical studies of the isolated molecules in a frozen glass, in combination with DFT/MRCI calculations, show that (σ, B p)→(π, B p) transitions accelerate the ISC process. This work provides a new approach for the design of RTP materials without (n, π*) transitions.

Assessment of MRI-Based Attenuation Correction for MRI-Only Radiotherapy Treatment Planning of the Brain

Magnetic resonance imaging-only radiotherapy treatment planning (MRI-only RTP) and positron emission tomography (PET)-MRI imaging require generation of synthetic computed tomography (sCT) images from MRI images. In this study, initial dosimetric evaluation was performed for a previously developed MRI-based attenuation correction (MRAC) method for use in MRI-only RTP of the brain. MRAC-based sCT images were retrospectively generated from Dixon MR images of 20 patients who had previously received external beam radiation therapy (EBRT). Bone segmentation performance and Dice similarity coefficient of the sCT conversion method were evaluated for bone volumes on CT images. Dose calculation accuracy was assessed by recalculating the CT-based EBRT plans using the sCT images as the base attenuation data. Dose comparison was done for the sCT- and CT-based EBRT plans in planning target volume (PTV) and organs at risk (OAR). Parametric dose comparison showed mean relative differences of <0.4% for PTV and <1.0% for OARs. Mean gamma index pass rates of 95.7% with the 2%/2 mm agreement criterion and 96.5% with the 1%/1 mm agreement criterion were determined for glioma and metastasis patients, respectively. Based on the results, MRI-only RTP using sCT images generated from MRAC images can be a feasible alternative for radiotherapy of the brain.

Associations Between Initial Clinical Examination and Imaging Findings and Return-to-Sport in Male Athletes With Acute Adductor Injuries: A Prospective Cohort Study

BACKGROUND

Time to return-to-sport (RTS) after acute adductor injuries varies among athletes, yet we know little about which factors determine this variance.

PURPOSE

To investigate the association between initial clinical and imaging examination findings and time to RTS in male athletes with acute adductor injuries.

STUDY DESIGN

Cohort study (Prognosis); Level of evidence, 2.

METHODS

Male adult athletes with an acute adductor injury were included within 7 days of injury. Standardized patient history and clinical and magnetic resonance imaging (MRI) examinations were conducted for all athletes. Athletes performed a supervised standardized criteria-based exercise treatment program. Three RTS milestones were defined: (1) clinically pain-free, (2) completed controlled sports training, and (3) first full team training. Univariate and multiple regression analyses were performed to determine the association between the specific candidate variables of the initial examinations and the RTS milestones.

RESULTS

We included 81 male adult athletes. The median duration for the 3 RTS milestones were 15 days (interquartile range, 12-28 days), 24 days (16-32 days), and 22 days (15-31 days), respectively. Clinical examination including patient history was able to explain 63%, 74%, and 68% of the variance in time to RTS. The strongest predictors for longer time to RTS were pain on palpation of the proximal adductor longus insertion or a palpable defect. The addition of MRI increased the explained variance with 7%, 0%, and 7%. The strongest MRI predictor was injury at the bone-tendon junction. Post hoc multiple regression analyses of players without the 2 most important clinical findings were able to explain 24% to 31% of the variance, with no added value of the MRI findings.

CONCLUSION

The strongest predictors of a longer time to RTS after acute adductor injury were palpation pain at the proximal adductor longus insertion, a palpable defect, and/or an injury at the bone-tendon junction on MRI. For athletes without any of these findings, even extensive clinical and MRI examination does not assist considerably in providing a more precise estimate of time to RTS.

Return to Sport After Criteria-Based Rehabilitation of Acute Adductor Injuries in Male Athletes: A Prospective Cohort Study

Background:

Despite being one of the most common sports injuries, there are no criteria-based rehabilitation programs published for acute adductor injuries.

Purpose:

To evaluate return-to-sport (RTS) outcomes and reinjuries after criteria-based rehabilitation for athletes with acute adductor injuries.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

Male adult athletes with an acute adductor injury underwent a supervised, standardized criteria-based exercise rehabilitation program. Magnetic resonance imaging (MRI) was used to grade the injury extent from 0 (negative finding) to 3 (complete tear/avulsion). There were 3 milestones used to evaluate the RTS continuum: (1) clinically pain-free, (2) completion of controlled sports training, and (3) return to full team training. Subsequent injuries were registered within the first year.

Results:

We included 81 athletes with an acute adductor injury (MRI grade 0: n = 14; grade 1: n = 20; grade 2: n = 30; grade 3: n = 17). Of these, 61 (75%) athletes achieved RTS milestone 1, 50 (62%) achieved RTS milestone 2, and 75 (93%) achieved RTS milestone 3. There were no statistical differences in the RTS duration between MRI grade 0, 1, and 2 at any RTS milestone; thus, these were grouped together as grade 0-2. The median time (interquartile range [IQR]) for athletes with grade 0-2 injuries to become clinically pain-free was 13 days (IQR, 11-21 days), to complete controlled sports training was 17 days (IQR, 15-27 days), and to return to full team training was 18 days (IQR, 14-27 days). For athletes with a grade 3 injury, median times were 55 days (IQR, 31-75 days), 68 days (IQR, 51-84 days), and 78 days (IQR, 68-98 days), respectively. The overall 1-year reinjury rate was 8%. Athletes who achieved RTS milestone 1 had a statistically significantly lower reinjury rate than athletes who did not (5% vs 21%, respectively; ϕ = –0.233; P = .048). Athletes who achieved RTS milestone 2 had a nonstatistically significantly lower reinjury rate than athletes who did not (6% vs 13%, respectively; ϕ = –0.107; P = .366).

Conclusion:

We analyzed the results of a criteria-based rehabilitation protocol for athletes with acute adductor injuries. Athletes with an MRI grade 0-2 adductor injury were clinically pain-free after approximately 2 weeks and returned to full team training after approximately 3 weeks. Most athletes with an MRI grade 3 adductor injury were pain-free and returned to full team training within 3 months. Meeting the clinically pain-free criteria resulted in fewer reinjuries compared with not meeting the criteria.

Unanticipated jump-landing after anterior cruciate ligament reconstruction: Does unanticipated jump-landing testing deliver additional return to sport information to traditional jump performance tests?

BACKGROUND

We aimed to delineate if unanticipated jump-landing assessments delivers complementary information to those of commonly used hop and jump tests after anterior cruciate ligament reconstruction.

METHODS

Eleven participants (5 males) performed a series of unanticipated jump-landings and traditional hop and jump performance tests (single leg hops for distance, triple crossover hops for distance and drop jumps). The number of mistrials, time to stabilization and peak ground reaction force (pGRF) at landing and jump/hop distance were measured. Pearson correlations to find potential associations between the unanticipated jump-landing-values and the traditional jump/hop performance tests were calculated twice: once for the affected and once for the unaffected legs. t-Tests for dependent samples were used to detect differences between affected and unaffected leg within each test condition.

FINDINGS

The pGRF at unanticipated landing significantly correlated to the pGRF at drop jump landing (r = 0.68) and the hopping distance after the triple crossover hops (r = 0.71, each p < .05). No other significant correlation occurred (p > .05). Hopping distance after single leg hops (mean: 110.2 cm vs. 95.5 cm) and triple crossover hops for distance (mean: 315.3 cm vs. 294.2 cm) showed significant differences between the unaffected and the reconstructed leg (p < .05). Other parameters showed no significant between-legs differences (p > .05).

INTERPRETATION

Both, the reconstructed and the contralateral leg seems to be affected. Unanticipated jump landing tasks deliver information beyond those of commonly used jump and hop tests, the thereby assessed abilities may thus be a complementary aspect of dynamic knee function than those assessed with classic tests.

Development of underwater radiography scanner for reactor-pool experiment at the TRIGA PUSPATI reactor

This paper describes the development of a custom-designed underwater scanner to support the experimental works for characterizing irradiated fuel stored in the TRIGA PUSPATI pool by means of radiography technique. Materials used to build the scanner are aluminum 6061, lead and teflon. Three main units that make up the scanner are rig structure, arm block and collimator. Collimator is designed to control radiation exposure by opening and closing the shutter. The experimental works were conducted underwater at 5-m depth hence water tightness is one of the main design criteria. Radiation in terms of gamma energy is captured by radiography film which after development and processing revealed the image of the radiation impact in terms of pixel and gray value. The film size used is 4in x 8in which was slot in the collimator. To validate the scanner, fuel element containing 8.5 wt% and 12 wt% enriched Uranium 235 were used. It was found that the experimental output is consistent with the fuel type and confirmed that the scanner is viable for fuel characterization study.

Conversion of Carbon Dots from Fluorescence to Ultralong Room-Temperature Phosphorescence by Heating for Security Applications

Stimuli-responsive optical materials have received tremendous interest in the last several decades due to their numerous promising applications. Here, fluorescence emissive polymer carbon dots (F-CDs), prepared with a simple heating treatment from ethylenediamine and phosphoric acid, are found to produce unexpected ultralong room-temperature phosphorescence (URTP), which lasts for about 10 s with a lifetime of 1.39 s. This is the first example to achieve the conversion of a fluorescence material to URTP by means of an external heating stimulus. Further investigations reveal that the doping of N and P elements and self-immobilization of the excited triplet species are likely mainly responsible for the observed URTP after the heating treatment, due to the facilitation of the intersystem crossing and formation of more compact cores for effective intraparticle hydrogen bonds, respectively. Importantly, this study also demonstrates the potential for aqueous dispersion of the F-CDs as an advanced security ink for information encryption and anticounterfeiting; this is a feature that has not been reported before. This study is believed to open possibilities to extend stimuli-responsive optical materials to rarely exploited phosphorescence-relevant systems and applications, and also to provide a novel strategy to easily prepare URTP materials.

Zero TE-based pseudo-CT image conversion in the head and its application in PET/MR attenuation correction and MR-guided radiation therapy planning

PURPOSE

To describe a method for converting Zero TE (ZTE) MR images into X-ray attenuation information in the form of pseudo-CT images and demonstrate its performance for (1) attenuation correction (AC) in PET/MR and (2) dose planning in MR-guided radiation therapy planning (RTP).

METHODS

Proton density-weighted ZTE images were acquired as input for MR-based pseudo-CT conversion, providing (1) efficient capture of short-lived bone signals, (2) flat soft-tissue contrast, and (3) fast and robust 3D MR imaging. After bias correction and normalization, the images were segmented into bone, soft-tissue, and air by means of thresholding and morphological refinements. Fixed Hounsfield replacement values were assigned for air (-1000 HU) and soft-tissue (+42 HU), whereas continuous linear mapping was used for bone.

RESULTS

The obtained ZTE-derived pseudo-CT images accurately resembled the true CT images (i.e., Dice coefficient for bone overlap of 0.73 ± 0.08 and mean absolute error of 123 ± 25 HU evaluated over the whole head, including errors from residual registration mismatches in the neck and mouth regions). The linear bone mapping accounted for bone density variations. Averaged across five patients, ZTE-based AC demonstrated a PET error of -0.04 ± 1.68% relative to CT-based AC. Similarly, for RTP assessed in eight patients, the absolute dose difference over the target volume was found to be 0.23 ± 0.42%.

CONCLUSION

The described method enables MR to pseudo-CT image conversion for the head in an accurate, robust, and fast manner without relying on anatomical prior knowledge. Potential applications include PET/MR-AC, and MR-guided RTP.

Challenges surrounding return-to-play (RTP) for the sports clinician: a case highlighting the need for a thorough three-step RTP model

Return-to-play (RTP) is a multifactorial process of retuning an injured athlete back to competition when risk for re-injury is minimized. Traditionally, these decisions are made by medical practitioners based on experience or anecdotal evidence. RTP decisions continue to be a challenging task for the medical practitioner. In the interest of advancing sports medicine for the betterment of athletes, improving the RTP decision-making process with a new paradigm has been suggested.1 It stands to clarify the intricacies used by clinicians when making RTP decisions by providing insight into the multiple factors that must be considered; not only by the athlete and medical practitioner, but all relevant parties (i.e., coaches, trainers, and organizations). This case describes a 19-year-old Ontario Junior Hockey League (OJHL) player who fractured his left clavicle during game play and consequently, suffered a more severe injury to the same clavicle 5½ weeks later by returning to competition against medical advice. This case highlights the potential issues that present when a RTP protocol is poorly executed and addresses the need to adopt a thorough decision-based RTP model proposed by Creighton et al.1 Further, the discussion will draw on current literature and issues surrounding RTP, and the potential legal implications associated with premature return to competition. Given the lack of consensus among sport medicine experts in regards to RTP criteria, the presented model stands to provide a pivotal framework upon which future research can be conducted, while improving the current criteria in place when returning an athlete to competition to aid medical practitioners.

[Mobile laboratories for rapid deployment and their contribution to the containment of emerging diseases in Sub-Saharan Africa, illustrated by the example of Ebola virus disease]

The Ebola virus, which became a global health concern in 2014, is an example of an emerging pathogen. Ebola virus disease can only be diagnosed in biosafety level 3 and 4 laboratories, which provide the security required to avoid exposure of both the staff and the environment to the pathogen. These laboratories are often far from the site of outbreaks, which may occur in rural areas or border regions (when the disease is imported from a neighboring country). Rapidly deployable laboratory units can bring the diagnosis closer to the outbreak site and thus significantly shorten the time to delivery of results, thus facilitating epidemic containment. Here we report our experience from the first months of implementation in Mali of a mobile laboratory unit of the same type as the European mobile labs and we describe the workflow in the laboratory as well as the training of its Malian staff. Based on our experience and the reports of other projects, we propose a framework in which these mobile laboratory units can strengthen epidemiological surveillance and contribute to containing outbreaks of emerging diseases in sub-Saharan Africa.

Micrometer-Scale Ordering of Silicon-Containing Block Copolymer Thin Films via High-Temperature Thermal Treatments

Block copolymer (BCP) self-assembly is expected to complement conventional optical lithography for the fabrication of next-generation microelectronic devices. In this regard, silicon-containing BCPs with a high Flory-Huggins interaction parameter (χ) are extremely appealing because they form high-resolution nanostructures with characteristic dimensions below 10 nm. However, due to their slow self-assembly kinetics and low thermal stability, these silicon-containing high-χ BCPs are usually processed by solvent vapor annealing or in solvent-rich ambient at a low annealing temperature, significantly increasing the complexity of the facilities and of the procedures. In this work, the self-assembly of cylinder-forming polystyrene-block-poly(dimethylsiloxane-random-vinylmethylsiloxane) (PS-b-P(DMS-r-VMS)) BCP on flat substrates is promoted by means of a simple thermal treatment at high temperatures. Homogeneous PS-b-P(DMS-r-VMS) thin films covering the entire sample surface are obtained without any evidence of dewetting phenomena. The BCP arranges in a single layer of cylindrical P(DMS-r-VMS) nanostructures parallel-oriented with respect to the substrate. By properly adjusting the surface functionalization, the heating rate, the annealing temperature, and the processing time, one can obtain correlation length values larger than 1 μm in a time scale fully compatible with the stringent requirements of the microelectronic industry.

A community return-to-play mTBI clinic: results of a pilot program and survey of high school athletes

BACKGROUND

High school athletes who sustain a mild traumatic brain injury (mTBI) or concussion are required to be removed from play until clearance by a provider. A regional pediatric trauma center offered an mTBI clinic to evaluate students for return to play (RTP).

METHODS

An mTBI clinic was developed in collaboration with a high school district containing three schools. This program evaluated students suffering from sports-related head trauma, specifically football injuries. Community mTBI education was performed, a standardized RTP algorithm was developed, and a postseason survey was administered to football players.

RESULTS

Twenty-eight students playing football were seen by the mTBI clinic. The average time until RTP for clinic patients was 16.9 days. Four hundred five players were surveyed. Of players responding to the survey, 40 (15%) reported sustaining an mTBI during the football season. Of those sustaining an mTBI, 9 (22.5%) did not report their symptoms.

CONCLUSION

Although the mTBI rate is similar to reported rates, the unreported mTBI episodes were lower (22.5%) than previously published self-reported mTBI rates. The RTP algorithm was successful in returning athletes in 16.9 days. The algorithm and data can be utilized by other organizations in establishment of an mTBI clinic and RTP program.

REEP1 and REEP2 proteins are preferentially expressed in neuronal and neuronal-like exocytotic tissues

The six members of the Receptor Expression Enhancing Protein (REEP) family were originally identified based on their ability to enhance heterologous expression of olfactory receptors and other difficult to express G protein-coupled receptors. Interestingly, REEP1 mutations have been linked to neurodegenerative disorders of upper and lower motor neurons, hereditary spastic paraplegia (HSP) and distal hereditary motor neuropathy type V (dHMN-V). The closely related REEP2 isoform has not demonstrated any such disease linkage. Previous research has suggested that REEP1 mRNA is ubiquitously expressed in brain, muscle, endocrine, and multiple other organs, inconsistent with the neurodegenerative phenotype observed in HSP and dHMN-V. To more fully examine REEP1 expression, we developed and characterized a new REEP1 monoclonal antibody for both immunoblotting and immunofluorescent microscopic analysis. Unlike previous RT-PCR studies, immunoblotting demonstrated that REEP1 protein was not ubiquitous; its expression was restricted to neuronal tissues (brain, spinal cord) and testes. Gene expression microarray analysis demonstrated REEP1 and REEP2 mRNA expression in superior cervical and stellate sympathetic ganglia tissue. Furthermore, expression of endogenous REEP1 was confirmed in cultured murine sympathetic ganglion neurons by RT-PCR and immunofluorescent staining, with expression occurring between Day 4 and Day 8 of culture. Lastly, we demonstrated that REEP2 protein expression was also restricted to neuronal tissues (brain and spinal cord) and tissues that exhibit neuronal-like exocytosis (testes, pituitary, and adrenal gland). In addition to sensory tissues, expression of the REEP1/REEP2 subfamily appears to be restricted to neuronal and neuronal-like exocytotic tissues, consistent with neuronally restricted symptoms of REEP1 genetic disorders.

A novel method of teaching surgical techniques to residents--computerized enhanced visual learning (CEVL) with simulation to certify mastery of training: a model using newborn clamp circumcision

OBJECTIVE

To assess the learning process of combining a web-based video of a simulated surgical procedure with a step-by-step checklist of the same procedure in achieving competency of the simulated technique, in this case a newborn clamp circumcision. Fundamental to this particular learning process is immediate mentor step-by-step feedback which specifically follows the procedure's step-by-step checklist.

MATERIALS AND METHODS

Pediatric residents naïve to newborn circumcision were enrolled (n = 7). A circumcision simulator, instruments, and web access to the learning module were provided. Residents trained independently and then performed two simulations with the mentor. The first simulation was completed with formative scored feedback. The learner then performed a second scored simulation.

RESULTS

All learners showed improvement between the first and second simulation (mean 85.3-97.4). All residents achieved competency (96/100 or greater) by the second simulation. On post-procedure surveys, learners demonstrated increased comfort and reduced apprehension in performing the procedure.

CONCLUSION

Combining a web-accessible video of a procedure, a checklist, and a simulator followed by a single mentor session with immediate formative feedback which follows the steps of the checklist is a useful method to teach the simulation technique of circumcision. We plan to study if this paradigm is transferable to clinical circumcision.