Systematic Review Examining the Reporting of Race and Ethnicity in Sport-Related Concussion Studies

OBJECTIVE

Sport-related concussion (SRC) is an evolving public health concern among youth athletes. Despite emerging evidence that race and ethnicity are important factors in determining concussion outcomes, studies examining race and ethnicity are limited. We conducted a systematic review to (1) determine the prevalence of SRC studies in which participants' race or ethnicity is reported, (2) describe how race and ethnicity are used within each study, and (3) assess predictive factors for the reporting of race and ethnicity.

DATA SOURCES

PubMed, Embase, PsycINFO, and CINAHL databases.

STUDY SELECTION

Study inclusion criteria were (1) primary and peer-reviewed research; (2) related to the diagnosis, treatment, or recovery of SRC; (3) involving school-aged athletes (ages 5 to 25); and (4) with 25 or more participants. The search was performed in March 2021 and included only studies published after March 2013.

DATA EXTRACTION

For each article, we looked at whether race and ethnicity were reported, and if so, which races or ethnicities were mentioned. For each race or ethnicity mentioned, we extracted the corresponding sample size and how they were used as variables in the study.

DATA SYNTHESIS

Of 4583 studies screened, 854 articles met inclusion criteria. Of the included articles, 132 (15.5%) reported race, and 65 (7.6%) reported ethnicity, whereas 721 (84.4%) reported neither. When examining the demographic characteristics of the 132 studies that reported race, 69.8% of athletes were White. Additionally, 79.5% of these studies used race solely as a demographic descriptor as opposed to a main exposure or covariate of interest. Studies published more recently were more likely to report race. Further, studies in specific study or journal topics and specific geographic locations of the authors were more likely to report race.

CONCLUSIONS

Reporting of race and ethnicity is limited in current SRC literature. Future authors should improve the reporting of race and ethnicity, diversify study samples by focusing on enrolling athletes from underrepresented groups, and consider the potential effect of race and ethnicity as social determinants of health on risk factors, recovery, and long-term sequelae after SRC.

Acute Sport-Related Concussion Management and Return to Sport Time in High School Athletes

BACKGROUND

The current evidence for acute management practices of sport-related concussion (SRC) is often limited to in-clinic visits, with limited studies identifying professionals in early SRC care and the association with prolonged recovery outcomes.

PURPOSE

To describe acute SRC management practices (ie, the personnel in the initial evaluations, removal from activity) and test the association with prolonged return to sport (RTS) time.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

We conducted a retrospective cohort study of 17,081 high school SRCs accrued between the 2015-2016 and 2020-2021 academic years. We reported acute management practices and RTS time as frequencies stratified by sex, sport, and event type and compared athletic trainer (AT) access in initial evaluation with chi-square tests (P < .05). Separate logistic regressions estimated odds ratios (ORs) and 95% CIs for removal from activity and prolonged RTS >21 days by acute management practices.

RESULTS

Most SRCs (n = 12,311 [72.1%]) had complete initial evaluation by an AT. Boys had an AT evaluation in 75.5% (n = 2860/3787) of practice-related and 74.8% (n = 5551/7423) of competition-related events. Girls had an AT evaluation in 61.3% (n = 1294/2110) of practice-related and 69.3% (n = 2606/3761) of competition-related events. In sex-comparable sports (n = 6501), there was no difference between boys (n = 1654/2455 [67.4%]) and girls (n = 2779/4046 [68.7%]) having an AT involved in the first evaluation (χ2 = 1.21; P = .27). Notably, 25.3% of girls' SRCs were evaluated by a coach alone, and we observed differences in personnel in initial evaluations by sport. The odds of immediate removal were higher when an AT made the initial evaluation (OR, 2.8 [95% CI, 2.54-3.08]). The odds of prolonged RTS >21 days was lower for those with an AT in the initial evaluation (OR, 0.74 [95% CI, 0.65-0.84]) adjusting for significant factors from univariate analyses, boys relative to girls (OR, 0.85 [95% CI, 0.76-0.96]), specialty care relative to PCP (OR, 2.16 [95% CI, 1.90-2.46]), specialty care relative to urgent or ready care (OR, 0.99 [95% CI, 0.82-1.22]) concussion history (OR, 1.41 [95% CI, 1.22-1.63]), and removal from activity (OR, 0.90 [95% CI, 0.78-1.05]).

CONCLUSION

This study found variability in personnel involved in initial SRC evaluations, with higher percentages of athletes with SRCs having ATs make the initial evaluation during competitive events. There was no association between sex and AT involvement in comparable sports. There was an association between prolonged RTS and AT involvement, sex, concussion history, and location of follow-up care.

Consistently High Frequency of Scooter Injuries in Children-Retrospective Data Analysis in a Level I Trauma Centre

The aim of this retrospective study was to present an epidemiological overview of paediatric nonelectric-scooter-related injuries, focusing on changes in injury mechanism and frequency. A retrospective, descriptive data analysis at a Level I trauma centre, including patients aged from 0 to 18 years injured by riding nonelectric scooters, was performed. The observation period ranged from January 2015 to December 2022. The total study population consisted of 983 (mean age: 7.9 ± 4.0 years) children and adolescents, with most patients being male (800/983; 81.4%). The frequency of nonelectric scooter injuries was relatively consistent over the observation period. Patients sustained mostly minor injuries (lacerations, bone contusions, sprains) (527/983; 53.6%), followed by head injuries (238/983; 24.5%), limb fractures (166/983; 16.9%) and trunk injuries (52/983; 5.3%). However, a few patients sustained severe injuries, including skull fractures (7/238; 2.9%), intracranial haematoma (4/238; 1.7%) or lacerations of abdominal organs (4/52; 7.7%). This study presented a consistently high frequency of scooter injuries in children. Children under 15 years were the most affected by scooter-related injuries. Although most injuries were minor, serious injuries occurred that should not be underestimated. Hence, we emphasise the use of protection gear and recommend raising awareness among parents and children.

Hard-Headed Decisions: Intrapersonal Factors Underlying Concussion Reporting in University Athletes

Most of the research investigating sports concussion (SC) disclosure has been conducted using questionnaires with a pre-determined set of questions. Hence, significant gaps remain in our understanding of which factors weight in the decision-making process underlying SC disclosure and how they contribute to it. This present study aims to fill some of these gaps using qualitative methods to identify intrapersonal determinants of SC disclosure and describe their influence on an athlete's decision-making process. Our results are based on in-depth, semistructured interviews (range, 56-79 min; total = 587 min) with 9 university athletes (5 females, 4 males) from three team sports (soccer, rugby, and cheerleading). Using constant comparative analysis guided by Straussian grounded theory, we identified 13 concepts, across three major intrapersonal categories (i.e., attitudes and behaviors; concussion knowledge; and subjective evaluation of the concussion), contributing to SC disclosure, including novel determinants such as prioritization of athletic versus intellectual activities and maturity level. Our results suggest that a comparison between experiential knowledge and severity of the injury plays a major role in determining an athlete's disclosure behaviors. Athletes with a history of concussion seem to adopt a non-disclosure default strategy and are inclined to disclose their concussion symptoms only if they judge their current concussion to be worse than their previous most severe injury. Other concepts identified appear to contribute to the decisional process by modulating the adoption of this non-disclosure default strategy. Our work highlights the benefits and necessity of using qualitative methods to study the decision-making process underlying concussion disclosure.

Incidence of traumatic brain injuries in head-injured children with seizures

OBJECTIVE

Incidence and short-term outcomes of clinically important traumatic brain injury (ciTBI) in head-injured children presenting to ED with post-traumatic seizure (PTS) is not described in current literature.

METHODS

Planned secondary analysis of a prospective observational study undertaken in 10 Australasian Paediatric Research in Emergency Departments International Collaborative (PREDICT) network EDs between 2011 and 2014 of head-injured children <18 years with and without PTS. Clinical predictors and outcomes were analysed by attributable risk (AR), risk ratios (RR) and 95% confidence interval (CI), including the association with Glasgow Coma Scale (GCS) scores.

RESULTS

Of 20 137 head injuries, 336 (1.7%) had PTS with median age of 4.8 years. Initial GCS was 15 in 268/336 (79.8%, AR -16.1 [95% CI -20.4 to -11.8]), 14 in 24/336 (7.1%, AR 4.4 [95% CI 1.6-7.2]) and ≤13 in 44/336 (13.1%, AR 11.7 [95% CI 8.1-15.3]) in comparison with those without PTS, respectively. The ciTBI rate was 34 (10.1%) with PTS versus 219 (1.1%) without PTS (AR 9.0 [95% CI 5.8-12.2]) with 5/268 (1.9%), 6/24 (25.0%) and 23/44 (52.3%) with GCS 15, 14 and ≤13, respectively. In PTS, rates of admission ≥2 nights (34 [10.1%] AR 9.0 [95% CI 5.8-12.3]), intubation >24 h (9 [2.7%] AR 2.5 [95% CI 0.8-4.2]) and neurosurgery (8 [2.4%] AR 2.0 [95% CI 0.4-3.7]), were higher than those without PTS. Children with PTS and GCS 15 or 14 had no neurosurgery, intubations or death, with two deaths in children with PTS and GCS ≤13.

CONCLUSIONS

PTS was uncommon in head-injured children presenting to the ED but associated with an increased risk of ciTBI in those with reduced GCS on arrival.

Comparison of Head Strike Incidence under K1 Rules of Kickboxing with and without Helmet Protection-A Pilot Study

BACKGROUND

Kickboxing is a combat sport that encompasses various forms of competition. K1 kickboxing is conducted without any restrictions on the force of strikes, and the bout can end prematurely through a knockout. Headgear has been introduced in amateur kickboxing to safeguard the head. However, scientific studies have shown that despite their use, serious head injuries can still occur. The aim of this study was to evaluate the temporal structure of the bout by calculating the number of head strikes in K1 kickboxing bouts with and without headgear.

METHODS

Thirty K1 kickboxing bouts were analyzed, with 30 participants included in the study. The fights were conducted according to the World Association Kickboxing Organization (WAKO) rules. The bouts consisted of three rounds of 2 min each, with a 1 min break between rounds. Sparring pairs were arranged according to weight categories. The first bouts were conducted without headgear, and two weeks later, the fights were repeated with WAKO-approved headgear. The number of head strikes was assessed retrospectively by analyzing video recordings of the bouts, categorizing strikes as hand or foot strikes, and differentiating between strikes that hit the head directly or indirectly.

RESULTS

The results showed statistically significant differences between bouts with and without headgear in terms of the number of strikes to the head (p = 0.002), strikes directly to the head (p < 0.001), all hand strikes to the head (p = 0.001), hand strikes directly to the head (p = 0.003), and foot strikes directly to the head (p = 0.03). Higher values were observed in bouts with headgear.

CONCLUSIONS

Headgear increases the probability of direct strikes to the head. Therefore, it is important to familiarize kickboxers with the use of headgear in their sport to minimize head injuries.

Head Injuries Related to Birth Trauma in Low Birthweight Neonates During Vacuum Extraction

Introduction Preterm delivery (gestational age < 34 w) is a relative contraindication to vacuum extraction. Current data do not differentiate clearly between preterm delivery and low birthweight. We aimed to evaluate the impact of non-metal vacuum cup extraction on neonatal head injuries related to birth trauma in newborns with low birthweights (< 2500 g). Materials and Methods A retrospective cohort of 3377 singleton pregnancies delivered by vacuum extraction from 2014 to 2019. All were gestational age ≥ 34 w. We compared 206 (6.1%) neonates with low birthweights < 2500 g to 3171 (93.9%) neonates with higher birthweights, divided into 3 subgroups (2500-2999 g, 3000-3499 g, and ≥ 3500 g). A primary composite outcome of neonatal head injuries related to birth trauma was defined. Results The lowest rates of subgaleal hematoma occurred in neonates < 2500 g (0.5%); the rate increased with every additional 500 g of neonatal birthweight (3.5%, 4.4% and 8.0% in the 2500-2999 g, 3000-3499 g, and ≥ 3500 g groups, respectively; p = 0.001). Fewer cephalohematomas occurred in low birthweight neonates (0.5% in < 2500 g), although the percentage increased with every additional 500 g of birthweight (2.6%, 3.3% and 3.7% in the 2500-2999 g, 3000-3499 g, and ≥ 3500 g groups, respectively, p = 0.020). Logistic regression found increasing birthweight to be a significant risk factor for head injuries during vacuum extraction, with adjusted odds ratios of 8.12, 10.88, and 13.5 for 2500-2999 g, 3000-3499 g, and ≥ 3500 g, respectively (p = 0.016). NICU hospitalization rates were highest for neonates weighing < 2500 g (10.2%) compared to the other groups (3.1%, 1.7% and 3.3% in 2500-2999 g, 3000-3499 g, ≥ 3500 respectively, p < 0.001). Conclusions Vacuum extraction of neonates weighing < 2500 g at 34 w and beyond seems to be a safe mode of delivery when indicated, with lower rates of head injury related to birth trauma, compared to neonates with higher birthweights.

Injuries among Canadian children and youth: an analysis using the 2019 Canadian Health Survey on Children and Youth

This work provides an overview of injury patterns in Canadian children and youth aged 1 to 17 years. Self-reported data from the 2019 Canadian Health Survey on Children and Youth were used to calculate estimates for the percentage of Canadian children and youth who experienced a head injury or concussion, broken bone or fracture, or serious cut or puncture within the last 12 months, overall and by sex and age group. Head injuries and concussions (4.0%) were the most commonly reported, but the least likely to be seen by a medical professional. Injuries most frequently occurred while engaging in sports, physical activity or playing.

The Influence of Protective Headgear on the Visual Field of Recreational-Level Skiers

The benefit of protective headgear for recreational skiers is an ongoing debate in the snow sports industry, and there are a lot of opposing opinions. Due to the dynamic conditions in which winter sports are performed, athletes demand rapid and constant processing of visual information. A sufficient level of anticipation helps athletes to properly position themselves to reduce the forces transferred to the head or even move to avoid a collision. To objectively identify the impact of protective headgear on the visual field when skiing, it is necessary to conduct suitable measurements. The sample consisted of 43 recreational-level skiers (27 M, 16 F; age 31.6 ± 8.23 years). A predefined testing protocol on an ortoreter was used to assess the visual field for three conditions of wearing protective headgear. Differences in perceived visual stimuli between the three conditions were evaluated by repeated measures analysis of variance (ANOVA). Based on the observed results, it can be concluded that the combination of wearing a ski helmet and ski goggles significantly negatively influences visual performance in a way that the visual field is narrowed, for both helmet users and non-users, only when comparing the tested conditions. When comparing helmet users and non-users, there are no differences in the amount of visual impairment; therefore, the habit of wearing a helmet does not influence the ability of perceiving visual stimuli.

Documentation of paediatric head injuries in a mixed metropolitan emergency department

OBJECTIVE

Head injuries are a common presentation of children to Australian EDs. Healthcare documentation is an important tool for enhancing patient care. In our study, we aimed to assess the adequacy of paediatric head injury documentation in a mixed ED.

METHODS

A retrospective analysis of presentations to a mixed ED between 2017 and 2018. Children aged <16 years old with a primary diagnosis of head injury were included. Documentation items based on local head injury guidelines were assessed in both medical and nursing documentation. We compared cases aged <1 and ≥1 year.

RESULTS

There were 427 presentations that met the case definition. Medical documentation was present in 422 cases and nursing documentation in 310 cases. In combined medical and nursing documentation, items poorly documented include blood pressure (BP; 21.3%) and secondary survey (16.9%). In solely medical documentation, least commonly documented items are high-risk bony injuries (22.5%), high-risk soft tissue injuries (22.3%), seizure (22.0%) and non-accidental injury (3.6%). Glasgow Coma Scale (GCS) was poorly documented in cases aged <1 year (10.9%, P < 0.001).

CONCLUSIONS

The largest gaps in the documentation of paediatric head injuries were BP and paediatric GCS in infants. Future audits and educational strategies should focus on targeting clinically relevant items that are predictive of serious outcomes.

Association of frontal and maxillary bone fractures and concomitant craniocerebral injuries in patients presenting with head trauma

Background

Maxillofacial fractures and craniocerebral injuries are common in patients with head trauma. These are injuries with high mortality and morbidity. Therefore, patients with head trauma should be evaluated early with a multidisciplinary approach.

Aim

The association between frontal and maxillary bone fractures and concurrent craniocerebral injuries were investigated in patients presenting with head trauma in this study. The data of the patients were analyzed retrospectively.

Methods and Material

Age and gender distributions were evaluated in frontal and maxillary fractures. Concomitant craniocerebral injuries were investigated. Craniocerebral injuries were grouped as pneumocephalus, extra-axial, intra-axial injuries and brain edema. Craniocerebral injuries in frontal and maxillary fractures were compared statistically.

Results

Frontal bone and maxillary bone fractures were detected in 24% and 95% of the patients. Coexistence of pneumocephalus and intra-axial injuries in frontal bone fracture was statistically significant. The association of frontal posterior wall fractures with pneumocephalus and parenchymal contusion was found to be statistically significant. In addition, the association of craniocerebral injuries were evaluated and statistically significant ones were determined.

Conclusion

The presence of maxillofacial fractures in patients presenting with head trauma increases mortality and morbidity. Craniocerebral injuries can be life-threatening and delay the treatment of facial fractures. Upper facial bone fractures are significantly more common in craniocerebral injuries.

Prof. B. Ramamurthi - A Glimpse into his Contributions to Neuroscience

Prof B Ramamurthi was a pioneer of Indian neurosurgery and a major force in the development of Indian neuroscience. Founding the Madras Institute of Neurology and later the A Lakshmipathi Neurosurgical Centre (ALNC), both at Madras (or Chennai as it is now called), he developed centres of excellence in his career that spanned over five decades. During this period of time he made Madras, a destination for neurosurgery and neuroscience. Along with his colleagues a large number of publications were produced which influenced the world. Notable among his contributions were those in Stereotaxy for movement disorders, epilepsy, pain and psychiatric illness. He also had notable contributions in brain tumours especially acoustic neurinomas and pituitary tumours. His papers on the low incidence of aneurysms is still quoted widely. Head injuries formed a major part of the neurosurgical work and major contributions were made in that field too. As a developing country with socio-economic issues, infections of the nervous system were seen commonly. His publications on tuberculomas of the brain are noteworthy. He was intrigued by the neurophysiological basis of consciousness. He writings on the subject reflect his attempt to bring together ancient eastern thoughts and concepts of consciousness and life and western science. In the later part of his career he spoke on ethics in and the changing milieu of neurosurgery. While contributions to spinal surgery were not seen in the first half of his career, he along with his colleagues from ALNC published original articles on spinal surgery especially tumours and OPLL. Prof B Ramamurthi, has not only influenced, taught and mentored, during his lifetime, a great many neuroscientists, but he also continues to do so through his publications which continue to be relevant in todays world. A glimpse into his contributions show us how without the technology of today a lot was achieved - and we need to see that, to inspire us to achieve more and to strive for greater heights.

Assessment of Neuropsychological Function in Veterans With Blast-Related Mild Traumatic Brain Injury and Subconcussive Blast Exposure

Objective: The majority of combat-related head injuries are associated with blast exposure. While Veterans with mild traumatic brain injury (mTBI) report cognitive complaints and exhibit poorer neuropsychological performance, there is little evidence examining the effects of subconcussive blast exposure, which does not meet clinical symptom criteria for mTBI during the acute period following exposure. We compared chronic effects of combat-related blast mTBI and combat-related subconcussive blast exposure on neuropsychological performance in Veterans. Methods: Post-9/11 Veterans with combat-related subconcussive blast exposure (n = 33), combat-related blast mTBI (n = 26), and controls (n = 33) without combat-related blast exposure, completed neuropsychological assessments of intellectual and executive functioning, processing speed, and working memory via NIH toolbox, assessment of clinical psychopathology, a retrospective account of blast exposures and non-blast-related head injuries, and self-reported current medication. Huber Robust Regressions were employed to compare neuropsychological performance across groups. Results: Veterans with combat-related blast mTBI and subconcussive blast exposure displayed significantly slower processing speed compared with controls. After adjusting for post-traumatic stress disorder and depressive symptoms, those with combat-related mTBI exhibited slower processing speed than controls. Conclusion: Veterans in the combat-related blast mTBI group exhibited slower processing speed relative to controls even when controlling for PTSD and depression. Cognition did not significantly differ between subconcussive and control groups or subconcussive and combat-related blast mTBI groups. Results suggest neurocognitive assessment may not be sensitive enough to detect long-term effects of subconcussive blast exposure, or that psychiatric symptoms may better account for cognitive sequelae following combat-related subconcussive blast exposure or combat-related blast mTBI.

Sport Concussion Assessment Tool-5th Edition (SCAT5): Normative Reference Values for the National Rugby League Women's Premiership

Objective: To establish normative reference values for the Sport Concussion Assessment Tool-5th Edition (SCAT5) for the new National Rugby League Women's Premiership. Methods: Preseason SCAT5 baseline testing was administered individually to all National Rugby League Women's Premiership players (N = 117). Testing was completed by the medical staff. Normative reference values were calculated for the components of the SCAT5, including the Standardized Assessment of Concussion, modified Balance Error Scoring System, and the Symptom Scale. A small case series of players who sustained concussions were included to illustrate the use of the new normative data. Results: The median Standardized Assessment of Concussion total score was 27.0 (M = 26.9, SD = 2.1). The median modified Balance Error Scoring System score was 2.0 (M = 2.4, SD = 2.2). The median number of symptoms score was 1.0 (M = 3.2, SD = 4.7) and the median symptom severity score was 2.0 (M = 5.4, SD = 8.2). The most common baseline symptom was fatigue or low energy (33%), followed by trouble sleeping (24%), headache (23%), neck pain (22%), and difficulty remembering (21%). In the total sample, 41% reported no symptoms. The clinical interpretation of these new normative data to a case series of women with concussions is provided. Conclusions: Normative reference values are provided for the SCAT5 for women who are professional rugby league players. Using these normative data will improve clinical interpretation of SCAT5 scores following a concussion.

Prevalence and Characteristics of Earthquake-Related Head Injuries: A Systematic Review

OBJECTIVE

We conducted a systematic review to determine the prevalence and characteristics of earthquake-associated head injuries for better disaster preparedness and management.

METHODS

We searched for all publications related to head injuries and earthquakes from 1985 to 2018 in MEDLINE and other major databases. A search was conducted using "earthquakes," "wounds and injuries," and "cranio-cerebral trauma" as a medical subject headings.

RESULTS

Included in the analysis were 34 articles. With regard to the commonly occurring injuries, earthquake-related head injury ranks third among patients with earthquake-related injuries. The most common trauma is lower extremity (36.2%) followed by upper extremity (19.9%), head (16.6%), spine (13.1%), chest (11.3%), and abdomen (3.8%). The most common earthquake-related head injury was laceration or contusion (59.1%), while epidural hematoma was the most common among inpatients with intracranial hemorrhage (9.5%) followed by intracerebral hematoma (7.0%), and subdural hematoma (6.8%). Mortality rate was 5.6%.

CONCLUSION

Head injuries were found to be a commonly occurring trauma along with extremity injuries. This knowledge is important for determining the demands for neurosurgery and for adequately managing patients, especially in resource-limited conditions.

Characterizing changes in network connectivity following chronic head trauma in special forces military personnel: a combined resting-fMRI and DTI study

BACKGROUND

Soldiers are exposed to significant repetitive head trauma, which may disrupt functional and structural brain connectivity patterns.

PURPOSE/HYPOTHESIS

Integrate resting-state functional MRI (rs-fMRI) and diffusion tensor imaging (DTI) to characterize changes in connectivity biomarkers within Canadian Special Operations Forces (CANSOF), hypothesizing that alterations in architectural organization of cortical hubs may follow chronic repetitive head trauma.

METHODS

Fifteen CANSOFs with a history of chronic exposure to sub-concussive head trauma and concussive injuries (1.9 ± 2.0 concussions (range: [0-6])), as well as an equal age-matched cohort of controls (CTLs) were recruited. BOLD-based rs-fMRI was combined with DTI to reconstruct functional and structural networks using independent component analyses and probabilistic tractography. Connectivity markers were computed based on the distance between functional seeds to assess for possible differences in injury susceptibility of short- and long-range connections.

RESULTS/DISCUSSION

Significant hyper- and hypo-connectivity differences in cortical connections were observed suggesting that chronic head trauma may predispose soldiers to changes in the functional organization of brain networks. Significant structural alterations in axonal fibers directly connecting disrupted functional nodes were specific to hyper-connected long-range connections, suggesting a potential relationship between axonal injury and increases in neural recruitment following repetitive head trauma from high-exposure military duties.

Examining Batting Performance After a Sports-Related Concussion Among Major League Baseball Position Players

BACKGROUND

An ongoing challenge in sports-related concussion (SRC) is determining full recovery. This study examines performance metrics in baseball after an SRC and provides a template for assessment of return-to-performance parameters.

PURPOSE

To determine whether batting performance returns to baseline after an SRC.

STUDY DESIGN

Descriptive epidemiological study.

METHODS

Participants were all Major League Baseball (MLB) position players with confirmed SRCs that occurred during the 2011-2015 seasons. A retrospective review and assessment of performance metrics before and after injury were conducted as defined relative to the number of plate appearances (PAs) to yield reliable performance statistics. Seven batting metrics were considered as outcomes in longitudinal regressions: batting average, on-base percentage, slugging percentage, on-base plus slugging, bases on balls, strikeouts, and home runs. Metrics were calculated for each player 60, 30, and 14 days before their SRCs, as well as for the 14, 30, and 60 days after returning to play. Other variables controlled for included defensive position, player age at the time of SRC, number of days missed, mechanism of injury, whether the player completed a rehabilitation stint, and year in which the mild traumatic brain injury (MTBI) occurred (2011-2015).

RESULTS

A total of 77 MTBI case events occurred in MLB position players over 5 seasons. These injuries resulted in a mean 11.4 days lost to injury. For all performance metrics using 60 or 30 days before MTBI as baseline, no statistically significant differences were found in batting performance. In total, 63 events met PA criteria before injury. Varying the PA cutoff thresholds to be more inclusive or more restrictive yielded similar regression results. For the 48 events that met PA criteria before and after injury, most performance metrics showed no significant performance change after MTBI and, in some events, a slight though mostly nonsignificant performance improvement after MTBI.

CONCLUSIONS

MLB position players who are medically cleared to return to play after an SRC perform at the same offensive performance levels as their preinjury statistics when an adequate number of PAs is used to compare performance before and after injury.

Collegiate Athletes' Concussion Awareness, Understanding, and -Reporting Behaviors in Different Countries With Varying Concussion Publicity

CONTEXT

Concussions are a global public health concern, and education on the importance of self-reporting may not reach all athletes to the same degree around the world.

OBJECTIVE

To determine if differences were present in the concussion awareness, understanding, and -reporting behaviors of collegiate athletes' in 3 countries with varied degrees of concussion publicity.

DESIGN

Cross-sectional survey.

SETTING

Collegiate sports medicine clinics.

PATIENTS OR OTHER PARTICIPANTS

Collegiate athletes in the United States (n = 964; high publicity), Ireland (n = 302; moderate publicity), and Jordan (n = 129; low publicity). The degree of concussion publicity was categorized based on the extent of national public health awareness initiatives, care guidelines, research publications, and mass media coverage.

MAIN OUTCOME MEASURE(S)

Participants completed a 10- to 15-minute survey on concussion awareness, understanding, and -reporting behaviors. The main outcome measures were concussion education (awareness; 21 options; select all sources of concussion information), concussion knowledge (understanding; maximum score of 49), and diagnosed/nondisclosed concussion history (reporting behaviors; self-report yes/no items).

RESULTS

A higher proportion of Jordanian athletes reported never having received concussion information previously (73.6%) than Irish (24.2%) or US athletes (9.4%). Knowledge differed among countries (P < .0001, η2 = .28), with US athletes displaying higher total knowledge scores (40.9 ± 4.5) than Jordanian (35.1 ± 5.6) and Irish (32.1 ± 3.5) athletes. Greater percentages of Irish and US athletes reported a history of a diagnosed concussion (31.8% and 29.6%, respectively) and history of concussion nondisclosure (25.2% and 15.5%, respectively) than Jordanian athletes (2.3% and 0.0% for history of a diagnosed concussion and history of concussion nondisclosure, respectively).

CONCLUSIONS

In the United States, where concussion publicity is high, formal legislation exists, and sports medicine resources and concussion awareness and understanding were increased. More culturally appropriate concussion initiatives are needed globally to ensure that athletes around the world can identify concussive injuries and understand the dangers of continued sport participation while concussed.

Antiplatelet therapy is associated with a high rate of intracranial hemorrhage in patients with head injuries

Background

Antiplatelet agents are increasingly used in cardiovascular treatment. Limited research has been performed into risks of acute and delayed traumatic intracranial hemorrhage (ICH) in these patients who sustain head injuries. Our goal was to assess the overall odds and identify factors associated with ICH in patients on antiplatelet therapy.

Methods

A retrospective observational study was conducted at two level I trauma centers. Adult patients with head injuries on antiplatelet agents were enrolled from the hospitals’ trauma registries. Acute ICH was diagnosed by head CT. Observation and repeat CT to evaluate for delayed ICH was performed at clinicians’ discretion. Patients were stratified by antiplatelet type and analyzed by ICH outcome.

Results

Of 327 patients on antiplatelets who presented with blunt head trauma, 133 (40.7%) had acute ICH. Three (0.9%) had delayed ICH on repeat CT, were asymptomatic and did not require neurosurgical intervention. One with delayed ICH was on clopidogrel and two were on both clopidogrel and aspirin. Patients with delayed ICH compared with no ICH were older (94 vs 74 years) with higher injury severity scores (15.7 vs 4.4) and trended towards lower platelet counts (141 vs 216). Patients on aspirin had a higher acute ICH rate compared with patients on P2Y12 inhibitors (48% vs 30%, 18% difference, 95% CI 4 to 33; OR 2.18, 95% CI 1.15 to 4.13). No other group comparison had significant differences in ICH rate.

Conclusions

Patients on antiplatelet agents with head trauma have a high rate of ICH. Routine head CT is recommended. Patients infrequently developed delayed ICH. Routine repeat CT imaging does not appear to be necessary for all patients.

Level of evidence

Level III, prognostic.

Upper Limb Strikes Reactive Forces in Mix Martial Art Athletes during Ground and Pound Tactics

Athletes of mixed martial arts use a ground and pound strategy with the strikes in the dominant ground position. The aim of this study was to compare the average peak force (F_peak) among three punches and to estimate the probability of achieving a skull bone fracture force of 5.1 kN for each type of strike in male and female athletes. A total of 60 males and 31 females (26 ± 8 years, 75 ± 20 kg, 177 ± 11 cm) practicing professional self-defense at the advanced and professional levels performed 15 strikes on a force plate. The analyses of 1360 trials showed significant differences among the strikes F_peak in females (p < 0.01) and males (p < 0.01). Straight punches had lower F_peak than palm strikes and elbow strikes in both genders, and palm strikes had higher F_peak than elbow strikes in females. No difference was observed between palm strikes and elbow strikes in males (p = 0.09). The ground and pound strikes resulted in higher impacts than previously reported strikes in the standing position. Male athletes can deliver a F_peak above 5.1 kN with a probability of 36% with elbow and palm strikes. Such forces can cause head injury; therefore, the use of these strikes in competition should be carefully considered.

Pediatric Head Injuries in Summer Camps

Summer camps have a unique supervisory environment that may lead to increased head injury risk for children. The epidemiology of head injuries in camps is unclear. We partnered with CampDoc.com to review head injury reports from camp nurses in 2016 from 197 camps in 36 states. A total of 4290 (92%) reports were coded as definite head injuries, 47% (n = 2002) in female campers, with median camper age of 10 years. Head injury severity was coded as mild (94%, n = 4040), moderate (6%, n = 248), or severe (<1%, n = 2). Only 3% (n = 134) were medically evaluated, and 29% (n = 1221) were sports-related. Head injuries were categorized as definite (3%, n = 137) and probable (13%, n = 572) concussions, with 39% (n = 277) being sports-related and 61% (n = 83) of definite concussions incurred by female campers. Summer camps, while an important location of head injury risk, appear to be a safe environment for youth.

[Treatment of contusion of moderate severity in children in outpatient clinics]

OBJECTIVE

To determine the efficacy of cortexin in treatment of traumatic brain injuries with contusion of moderate severity in children in an outpatient clinics.

MATERIALS AND METHODS

Seventy-four patients, aged 6-13 years, with a traumatic brain injury and a moderate brain contusion were examined. A comprehensive clinical examination, including neurological and ophthalmological examinations, EEG, brain CT scan, testing using a set of experimental psychological techniques, was performed. Children of the main group received standard therapy and cortexin. Children of the control group received similar treatment without cortexin. Re-examination was carried out 30 days after the start of treatment.

RESULTS

After the treatment, a positive dynamics was noted in both groups. There were a decrease in the severity of subjective symptoms (p<0,01) and focal neurological symptoms (p <0,001) as well as absence of acute waves to physical activity according to EEG results in the main group compared with the control group. Also, EEG showed that cortical electrogenesis corresponded to the age of the patient, hypertensive/hydrocephalic signs were stopped (p <0,05), positive changes in cognitive functions occurred.

CONCLUSION

The study showed the positive dynamics in the recovery of cognitive functions, the normalization of EEG parameters and stopping of hypertension-hydrocephalic symptoms in children with traumatic brain injuries with contusion of moderate severity a month after the start of treatment with cortexin.

Penetrating Orbital Injury; a Case Report and Treatment Algorithm

Penetrating orbital trauma (POT) consists of high and low velocity penetrating injuries that may lead to severe consequences such as visual impairment and globe tearing. It has been reported to make up 30% to 50% of all orbital injuries. POT requires a multidisciplinary approach due to complex orbital injury, which involves eye function, brain injury, and facial aesthetics. In this report, we presented a case of POT due to knife injury in which the knife blade was removed and bleeding was controlled, the patient's general condition after surgery was good, but the vision of the right eye was lost.

Reporting of Concussion-Like Symptoms After Cycling Crashes: A Survey of Competitive and Recreational Cyclists

CONTEXT

Cycling crashes are common among recreational and competitive riders and may result in head and bodily trauma. Information is limited regarding the signs and symptoms of head injury (HI) after cycling crashes, medical treatment, and recovery.

OBJECTIVES

To evaluate concussion-like symptom reporting after cycling crashes with or without HI in recreational and competitive cyclists and to assess crash characteristics and follow-up medical care.

DESIGN

Cross-sectional study.

SETTING

Voluntary online survey.

PATIENTS OR OTHER PARTICIPANTS

A convenience sample of 780 cyclists residing in the United States: 528 males, 249 females, 2 gender queer/nonbinary, and 1 transgender female.

MAIN OUTCOME MEASURE(S)

Survey-based, self-reported signs and symptoms of HI, including the third edition of the Sport Concussion Assessment Tool (SCAT3) symptom checklist, loss of consciousness, posttraumatic amnesia, and helmet damage.

RESULTS

Of the participants, 403 reported crashes in the previous 2 years. Cyclists who self-reported no significant injury after their crash were excluded, leaving 77 HI reporters (HI group) and 260 trauma controls (TC group). The HI group more frequently reported experiencing 17 of the 22 symptoms on the SCAT3 symptom checklist. The HI group described a 4-fold higher incidence of loss of consciousness (HI = 13/77 [16.9%] versus TC = 11/2600 [4.2%]) and memory loss immediately after the crash (HI = 44/77 [57.1%] versus TC = 37/260 [14.2%]). The HI group reported major, noncosmetic helmet damage 2.5 times more frequently than the TC group (HI = 49/77 [63.6%] versus TC = 67/260 [25.8%]).

CONCLUSIONS

The findings suggest that a standardized concussion assessment is needed for cyclists who experience major trauma.

The Effect of Game Importance on Concussion Incidence in the National Football League: An Observational Study

Introduction Concussion incidence in the National Football League (NFL) has been shown to generally increase as the season progresses. Yet, there is evidence that suggests that the incidence stagnates or decreases in the final quarter of the season in comparison to the third quarter. This anomaly cannot be explained by any of the known modulators of concussion incidence. However, the fact that the teams start getting eliminated from playoff contention in the fourth quarter of the season may explain this pattern in concussion incidence. This study tests whether there is a difference in concussion incidence in games between teams who are still in the playoff hunt [in the hunt (IH) games] versus games where both teams have had their playoff fate already determined (non-IH games). Methods We obtained details of 166 documented concussions from weeks 13-16 of each of the four NFL seasons from 2012 to 2015 from Public Broadcasting Service's (PBS) Frontline Concussion Watch and matched them to the games in which they occurred. Each game was categorized based on the playoff status [clinched (CL), eliminated (EL), or IH] of the teams playing in the game. Concussion incidence of the game types was compared to each other using a one-way analysis of variance (ANOVA) test and student t-tests. Additionally, concussion incidences at six different player positions in important games were compared to the corresponding incidences in unimportant games. An ordinary least squares regression was used to examine the effects of game importance and plays per game on concussion incidence. Results Concussion incidence in important games (mean = 0.651 ±0.055) did not differ significantly (p: 0.890) from the incidence in unimportant games (mean = 0.623 ±0.143). Instead, plays per game was found to be the primary driver of concussion in the regression analysis (β = 0.01605; p: 0.025). At the position-specific level, running backs (RB) were the only position to demonstrate a significant increase in concussion incidence (p: 0.004) in important games (mean = 0.049 ±0.017) compared to unimportant games (mean = 0.00 ±0.00). Conclusions The results suggest that, in general, players are not more likely to suffer concussions in IH games than in non-IH games. However, RBs may have an increased risk of concussion in games with playoff implications than in games without.

Motor vehicle accident is a risk factor for traumatic head injury among children in Abuja: analysis of the first trauma registry in Nigeria

Introduction

Pediatric traumatic injury is a major public health concern that is poorly documented in lower and middle-income countries. This study analyzed data on pediatric injuries from a unique hospital trauma registry in Abuja, Nigeria.

Methods

Data were analyzed on 220 traumatically injured patients aged 21 years/less to describe injury characteristics and to determine the association between mechanism of injury and pediatric head injuries in Abuja, Nigeria, between 2014 and 2015. Bivariate analysis using Pearson's chi-square and adjusted logistic regression were conducted to characterize the population and identify risk factors for head injury. P-values<0.05 were considered statistically significant. All statistical analyses were performed using STATA v.15.1.

Results

The majority of patients were male (60.9%) with a mean age (SD) of 12.5±6.9 years. Head injuries were most common (49.6%), followed by chest (14.1%), abdomen (12.3%) and back (7.7%). The mechanism of injury was statistically significantly associated with head injury (p=0.027) with 63% of children in a motor vehicle accident sustaining a head injury. After adjusting for covariates, the odds of head injury were 3.8 times higher for children injured in a motor vehicle accidents (MVA) compared to those with falls (95%CI 1.40-10.40).

Conclusion

This analysis reveals that motor vehicle accident is a risk factor for traumatic head injury among children in Nigeria. Therefore, efforts should be made to address motor vehicle accidents involving children. These data will help to inform age-related prevention and treatment strategies. The results of this study highlight the importance of collecting pediatric trauma data in developing countries.

Repair of the superior sagittal sinus following penetrating intracranial injury caused by nail gun accident: case report and technical note

We report a 45-year-old man who suffered a penetrating nail gun injury resulting in damage to the lateral edge of the superior sagittal sinus. The injury was successfully treated via a parasagittal craniotomy that enabled removal of the nail under direct vision, allowing for rapid suturing of the sagittal sinus. Two neurosurgeons worked together; one carefully withdrew the tip of the nail back into the sinus itself while the second rapidly sutured the hole in the inner superior sagittal sinus leaflet. Postoperatively, the patient made a rapid recovery without neurological deficit.

Musculoskeletal and head injuries in the Ultimate Fighting Championship (UFC)

OBJECTIVES

Mixed martial arts (MMA) has witnessed a surge in popularity worldwide. This study explores the musculoskeletal and head injuries sustained in the professional fights of the Ultimate Fighting Championship (UFC), and establishes associations between injury profiles and impactful contributory factors.

METHODS

The Nevada State Athletic Commission database was screened for ringside physician reports of UFC fights between January 2016 and July 2018. Information on the fighter's gender, weight, injury, way of finish, and match result were collected. Injury rates were calculated and statistical analyses were conducted to determine significant associations among variables. P-values <0.05 were considered significant (95% CI).

RESULTS

A total of 291 injuries were recorded in 285 fights from nine weight divisions. The overall injury rate was 51 per 100 athletic exposures (AE). Males predominantly partook in 249 matches (87%) and had higher injury rates (54 injuries per 100 AE) than females (30 injuries per 100 AE). Decision was the most common way a match ended. Knockouts (KOs) were significantly higher in males (36%) than in females (14%, P = 0.0007). Submissions were significantly higher in females (36%) than in males (16%, P = 0.001). Head injuries (67%) were the most common injuries reported with a rate of 34 per 100 AE. Upper limb injuries were significantly higher in females (40%) than in males (14%, P = 0.0003). Lower limb injuries were significantly higher in males (19%) than in females (5%, P = 0.01). Head injuries were significantly associated with KOs (P < 0.0001). Upper limb injuries (P = 0.032) and lower limb injuries (P = 0.034) were significantly associated with matches that ended with Decision. Trend-line analyses showed that as weight division increases, overall injury rates, head injuries, lower limb injuries, and KOs' frequency increase, whereas upper limb injuries, Submission frequency, and Decision frequency decrease.

CONCLUSION

MMA has a high injury rate. Gender, way of finish, and weight play an important role in predicting fight outcomes and injury profiles. Injury prevention policies must be entertained to limit injury risk in MMA.

How Well Do EMS Providers Predict Intracranial Hemorrhage in Head-Injured Older Adults?

Objective: To evaluate the accuracy of emergency medical services (EMS) provider judgment for traumatic intracranial hemorrhage (tICH) in older patients following head trauma in the field. We also compared EMS provider judgment with other sets of field triage criteria. Methods: This was a prospective observational cohort study conducted with five EMS agencies and 11 hospitals in Northern California. Patients 55 years and older who experienced blunt head trauma were transported by EMS between August 1, 2015 and September 30, 2016, and received an initial cranial computed tomography (CT) imaging, were eligible. EMS providers were asked, "What is your suspicion for the patient having intracranial hemorrhage (bleeding in the brain)?" Responses were recorded as ordinal categories (<1%, 1-5%, >5-10%, >10-50%, or >50%) and the incidences of tICH were recorded for each category. The accuracy of EMS provider judgment was compared to other sets of triage criteria, including current field triage criteria, current field triage criteria plus multivariate logistical regression risk factors, and actual transport. Results: Among the 673 patients enrolled, 319 (47.0%) were male and the median age was 75 years (interquartile range 64-85). Seventy-six (11.3%) patients had tICH on initial cranial CT imaging. The increase in EMS provider judgment correlated with an increase in the incidence of tICH. EMS provider judgment had a sensitivity of 77.6% (95% CI 67.1-85.5%) and a specificity of 41.5% (37.7-45.5%) when using a threshold of 1% or higher suspicion for tICH. Current field triage criteria (Steps 1-3) was poorly sensitive (26.3%, 95% CI 17.7-37.2%) in identifying tICH and current field trial criteria plus multivariate logistical regression risk factors was sensitive (97.4%, 95% CI 90.9-99.3%) but poorly specific (12.9%, 95% CI 10.4-15.8%). Actual transport was comparable to EMS provider judgment (sensitivity 71.1%, 95% CI 60.0-80.0%; specificity 35.3%, 95% CI 31.6-38.3%). Conclusions: As EMS provider judgment for tICH increased, the incidence for tICH also increased. EMS provider judgment, using a threshold of 1% or higher suspicion for tICH, was more accurate than current field triage criteria, with and without additional risk factors included.

The Epidemiology of Injuries in Middle School Football, 2015-2017: The Advancing Healthcare Initiatives for Underserved Students Project

BACKGROUND

Although data exist on injuries in youth football leagues, there are limited recent data on injury incidence in middle school football. Updated injury incidence estimates can help drive the development of injury prevention strategies.

PURPOSE

Describe the epidemiology of injuries in middle school football during school years 2015-2016 to 2017-2018.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Data originated from 9 public middle schools in Virginia during school years 2015-2016 to 2017-2018. Certified athletic trainers collected injury and athlete-exposure (AE) data from school-sanctioned games and practices in boys', football. Injury counts and rates per 1000 AEs were calculated. Injury rate ratios with 95% CIs compared rates between games and practices.

RESULTS

Overall, 664 middle school boys', football injuries were reported, leading to an overall injury rate of 20.54 per 1000 AEs (95% CI, 18.98-22.11). The time loss injury rate (inclusive of injuries with participation restriction time ≥24 hours) was 9.28 per 1000 AEs (95% CI, 8.23-10.33). The injury rate was higher in competition than practice (36.19 vs 17.97 per 1000 AEs; injury rate ratio, 2.01; 95% CI, 1.69-2.40). Most injuries were to the head/face (competition, 20.6%; practice, 15.8%) and hand/wrist (competition, 18.8%; practice, 16.4%) and were diagnosed as contusions (competition, 30.9%; practice, 25.9%) and sprains (competition, 19.4%; practice, 12.6%). Competitions also had a large proportion of concussions (10.3%). Overall, 80.0% and 66.9% of injuries were due to contact in competition and practice, respectively; of these contact-related injuries, 62.1% and 41.6% were specifically player contact.

CONCLUSION

Injury distributions parallel those found in previous research from middle school and other sport settings. Injury rates in middle school football were higher than those reported in previous findings in high school and college. However, caution must be taken when interpreting findings in relation to other surveillance systems with varying methodologies. Still, the findings highlight the need for injury prevention strategies within middle school football, particularly as related to contact-related mechanisms.

Head Trauma Exposure in Mixed Martial Arts Varies According to Sex and Weight Class

BACKGROUND

Brain injury arising from head trauma is a major concern in mixed martial arts (MMA) because knockout (KO) and technical knockout (TKO) are frequent fight outcomes. Previous studies have shown a high incidence of matches ending due to strikes to the head but did not consider weight categories and female fights. This study aimed at analyzing match stoppages in MMA and the exposure to head trauma distinguished by sex and weight categories.

HYPOTHESIS

The heavier the weight class, the greater the risk and incidence of head trauma will be, regardless of sex.

STUDY DESIGN

Descriptive epidemiology study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Publicly available data of 167 MMA events from 1903 fights between 2014 and 2017 were assessed, comprising 8 male and 2 female weight categories.

RESULTS

The combined KO/TKO rates per 100 athlete-exposures in the middleweight (19.53), light heavyweight (20.8), and heavyweight (26.09) divisions were greater than previously reported for MMA. While stoppage via KO/TKO occurred in 7.9% of combats in the female strawweight division, it occurred in 52.1% of the male heavyweight fights. The male middleweight ( P = 0.001), light heavyweight ( P < 0.001), and heavyweight divisions ( P < 0.001) had an increased risk of KO/TKO due to strikes to the head by 80%, 100%, and 206%, respectively. The risk in the flyweight division decreased 62% ( P = 0.001). All categories were compared with the lightweight division. The female bantamweight category presented a 221% increased risk in matches ending due to KO/TKO compared with the strawweight division ( P = 0.012). Punches to the head were the major technique used to end a combat via KO/TKO, regardless of sex and weight class.

CONCLUSION

Head injury risk and incidence varies considerably according to sex and weight category in MMA.

CLINICAL RELEVANCE

The analysis of head trauma exposure in MMA athletes should be distinguished according to sex and weight category.

The Incidence of Traumatic Intracranial Hemorrhage in Head-Injured Older Adults Transported by EMS with and without Anticoagulant or Antiplatelet Use

Field triage guidelines recommend transport of head-injured patients on anticoagulants or antiplatelets to a higher-level trauma center based on studies suggesting a high incidence of traumatic intracranial hemorrhage (tICH). We compared the incidence of tICH in older adults transported by emergency medical services (EMS) with and without anticoagulation or antiplatelet use and evaluated the accuracies of different sets of field triage criteria to identify tICH. This was a prospective, observational study at five EMS agencies and 11 hospitals. Older adults (≥55 years) with head trauma and transported by EMS from August 2015 to September 2016 were eligible. EMS providers completed standardized data forms and patients were followed through emergency department (ED) or hospital discharge. We enrolled 1304 patients; 1147 (88%) received a cranial computed tomography (CT) scan and were eligible for analysis. Four hundred thirty-four (33%) patients had anticoagulant or antiplatelet use and 112 (10%) had tICH. The incidence of tICH in patients with (11%, 95% confidence interval [CI] 8%-14%) and without (9%, 95% CI 7%-11%) anticoagulant or antiplatelet use was similar. Anticoagulant or antiplatelet use was not predictive of tICH on adjusted analysis. Steps 1-3 criteria alone were not sensitive in identifying tICH (27%), whereas the addition of anticoagulant or antiplatelet criterion improved sensitivity (63%). Other derived sets of triage criteria were highly sensitive (>98%) but poorly specific (<11%). The incidence of tICH was similar between patients with and without anticoagulant or antiplatelet use. Use of anticoagulant or antiplatelet medications was not a risk factor for tICH. We were unable to identify a set of triage criteria that was accurate for trauma center need.

In-vivo measurement of tri-axial loading at the head during the rugby tackle

To investigate the anatomical distribution of linear and rotational forces during the tackle scenario, male rugby players performed a total of 48 trials, as ball carrier or tackler. Participants wore headgear accommodating three global positioning system units measuring uniaxial acceleration at the occipital region (OR), left tempero-parietal (LT-PR) and right tempero-parietal region (RT-PR). An additional unit was located at the cervico-thoracic spinal region in a custom vest. There was a significant main effect for tackle condition (P < 0.001), with the tackler exposed to significantly greater load than the ball carrier, supporting epidemiological observations. A repeated measure general linear model also revealed a significant (P < 0.001) main effect for unit location upon 3D load, with significantly higher load at the CSR (1.63 ± 0.54 a.u.) and OR (1.67 ± 0.94 a.u.) units when compared to the LT-PR (1.23 ± 0.39 a.u.) and RT-PR (1.21 ± 0.44 a.u.) units. The anatomical specificity in loading supports epidemiological observations and provides an insight into potential concussion aetiology.

Reliability of Computerized Neurocognitive Tests for Concussion Assessment: A Meta-Analysis

OBJECTIVE

  Although widely used, computerized neurocognitive tests (CNTs) have been criticized because of low reliability and poor sensitivity. A systematic review was published summarizing the reliability of Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores; however, this was limited to a single CNT. Expansion of the previous review to include additional CNTs and a meta-analysis is needed. Therefore, our purpose was to analyze reliability data for CNTs using meta-analysis and examine moderating factors that may influence reliability.

DATA SOURCES

  A systematic literature search (key terms: reliability, computerized neurocognitive test, concussion) of electronic databases (MEDLINE, PubMed, Google Scholar, and SPORTDiscus) was conducted to identify relevant studies.

STUDY SELECTION

  Studies were included if they met all of the following criteria: used a test-retest design, involved at least 1 CNT, provided sufficient statistical data to allow for effect-size calculation, and were published in English.

DATA EXTRACTION

  Two independent reviewers investigated each article to assess inclusion criteria. Eighteen studies involving 2674 participants were retained. Intraclass correlation coefficients were extracted to calculate effect sizes and determine overall reliability. The Fisher Z transformation adjusted for sampling error associated with averaging correlations. Moderator analyses were conducted to evaluate the effects of the length of the test-retest interval, intraclass correlation coefficient model selection, participant demographics, and study design on reliability. Heterogeneity was evaluated using the Cochran Q statistic.

DATA SYNTHESIS

  The proportion of acceptable outcomes was greatest for the Axon Sports CogState Test (75%) and lowest for the ImPACT (25%). Moderator analyses indicated that the type of intraclass correlation coefficient model used significantly influenced effect-size estimates, accounting for 17% of the variation in reliability.

CONCLUSIONS

  The Axon Sports CogState Test, which has a higher proportion of acceptable outcomes and shorter test duration relative to other CNTs, may be a reliable option; however, future studies are needed to compare the diagnostic accuracy of these instruments.

St Hugh's Military Hospital (Head Injuries), Oxford 1940-1945

Despite being open for only five years, St Hugh's Military Hospital (Head Injuries) has a seminal place in the history of neurology, neurosurgery and rehabilitation medicine. At its peak, during the Normandy campaign of 1944, it provided 430 beds for the treatment of service personnel. Between 1940 and 1945, 13,000 patients were referred to St Hugh's providing a unique opportunity for ground-breaking research into the management of head injuries. The doctors at St Hugh's collaborated with research scientists at Oxford University in many areas of fundamental research including the treatment of infection, the mechanics of brain injury, brain surgery, neuropsychiatry and rehabilitation, and the use of electroencephalograms. This paper documents these scientific advances and considers their influence on the practice of neurology and neurosurgery in the UK.

Computed tomography of the head for adult patients with minor head injury: are clinical decision rules a necessary evil?

INTRODUCTION

This study aimed to evaluate compliance with and performance of the Canadian Computed Tomography Head Rule (CCHR), and its applicability to the Singapore adult population with minor head injury.

METHODS

We conducted a retrospective study over six months of consecutive patients who presented to the adult emergency department (ED) with minor head injury. Data on predictor variables indicated in the CCHR was collected and compliance with the CCHR was assessed by comparing the recommendations for head computed tomography (CT) to its actual usage.

RESULTS

In total, 349 patients satisfied the inclusion criteria. Common mechanisms of injury were falls (59.3%), motor vehicle crashes (16.9%) and assault (12.0%). 249 (71.3%) patients underwent head CT, yielding 42 (12.0%) clinically significant findings. 1 (0.3%) patient required neurosurgical intervention. According to the CCHR, head CT was recommended for 209 (59.9%) patients. Compliance with the CCHR was 71.3%. Among the noncompliant group, head CT was overperformed for 20.1% and underperformed for 8.6% of patients. Multivariate logistic regression analysis revealed that absence of retrograde amnesia (odds ratio [OR] 4.1, 95% confidence interval [CI] 1.8-9.7) was associated with noncompliance to the CCHR. Factors associated with underperformance were absence of motor vehicle crashes as a mechanism of injury (OR 6.6, 95% CI 1.2-36.3) and absence of headache (OR 10.8, 95% CI 1.3-87.4).

CONCLUSION

Compliance with the CCHR for adult patients with minor head injury remains low in the ED. A qualitative review of physicians' practices and patients' preferences may be carried out to evaluate reasons for noncompliance.

Ball-Contact Injuries in 11 National Collegiate Athletic Association Sports: The Injury Surveillance Program, 2009-2010 Through 2014-2015

CONTEXT

  Surveillance data regarding injuries caused by ball contact in collegiate athletes have not been well examined and are mostly limited to discussions of concussions and catastrophic injuries.

OBJECTIVE

  To describe the epidemiology of ball-contact injuries in 11 National Collegiate Athletic Association (NCAA) sports during the 2009-2010 through 2014-2015 academic years.

DESIGN

  Descriptive epidemiology study.

SETTING

  Convenience sample of NCAA programs in 11 sports (men's football, women's field hockey, women's volleyball, men's baseball, women's softball, men's and women's basketball, men's and women's lacrosse, and men's and women's soccer) during the 2009-2010 through 2014-2015 academic years.

PATIENTS OR OTHER PARTICIPANTS

  Collegiate student-athletes participating in 11 sports.

MAIN OUTCOME MEASURE(S)

  Ball-contact-injury rates, proportions, rate ratios, and proportion ratios with 95% confidence intervals were based on data from the NCAA Injury Surveillance Program during the 2009-2010 through 2014-2015 academic years.

RESULTS

  During the 2009-2010 through 2014-2015 academic years, 1123 ball-contact injuries were reported, for an overall rate of 3.54/10 000 AEs. The sports with the highest rates were women's softball (8.82/10 000 AEs), women's field hockey (7.71/10 000 AEs), and men's baseball (7.20/10 000 AEs). Most ball-contact injuries were to the hand/wrist (32.7%) and head/face (27.0%) and were diagnosed as contusions (30.5%), sprains (23.1%), and concussions (16.1%). Among sex-comparable sports (ie, baseball/softball, basketball, and soccer), women had a larger proportion of ball-contact injuries diagnosed as concussions than men (injury proportion ratio = 2.33; 95% confidence interval = 1.63, 3.33). More than half (51.0%) of ball-contact injuries were non-time loss (ie, participation-restriction time <24 hours), and 6.6% were severe (ie, participation-restriction time ≥21 days). The most common severe ball-contact injuries were concussions (n = 18) and finger fractures (n = 10).

CONCLUSION

  Ball-contact-injury rates were the highest in women's softball, women's field hockey, and men's baseball. Although more than half were non-time-loss injuries, severe injuries such as concussions and fractures were reported.

Prevalence of head injury and medically diagnosed concussion in junior-level community-based Australian Rules Football

AIM

For junior-level Australian Rules Football there is a paucity of head injury and concussion surveillance data; thus, the primary aim was to document head injury and concussion incidence in participants aged 9-17 years with a secondary aim to identify the mechanism-of-injury.

METHODS

A prospective cohort study in which a designated representative for each of the 41 teams recorded on a weekly basis the number of head injuries suspected of being a concussion, diagnosed concussions and the mechanism-of-injury during competition games over the course of a 12-game season. For analysis three groups were formed - number of Player-Seasons, Athlete-Exposures, head injury and concussion incidence per 1000 Athlete-Exposures - and were calculated. Narrative data was categorised.

RESULTS

There was 13 reported head injuries resulting in seven concussions in the sample population (n = 976). The incidence rates for head injury and concussion were 1.1 (95% confidence interval: 0.5-1.7) and 0.59 (95% confidence interval: 0.2-1.0) per 1000 Athlete-Exposures. There were four head injuries resulting in two concussions in the 12-13-year-old group and nine head injuries and five concussions in the 14-17-year-old group. Two categories emerged for mechanism-of-injury: player-to-surface and player-to-player, with 9 of the 13 head injuries resulting from player-to-player contact.

CONCLUSIONS

The incidence rates were similar in the two older groups and lower in comparison with American football and rugby. The data collected have advanced our knowledge of head injury incidence and established baseline data which to compare in future years and may assist in development of preventative measures.

Predictive Factors of Survival and 6-Month Favorable Outcome of Very Severe Head Trauma Patients; a Historical Cohort Study

INTRODUCTION

Very severe head trauma cases, defined as Glasgow Coma Scale (GCS) scores of less than 6, have a higher mortality rate and poorer outcome. The purpose of this study was to recognize factors associated with survival and 6-month favorable outcome of very severe head trauma patients presenting to emergency department.

METHODS

In this historical cohort study, the authors retrospectively reviewed medical records of head trauma patients who were admitted to the emergency department with post-resuscitation GCS scores of less than 6. Both univariate and multivariate analyses were used to test the association between various parameters with survival and 6-month outcome.

RESULTS

103 cases with the mean age of 39 ± 16.5 years were studied (80% male). The overall survival rate was 41.7% and the rate of 6-month favorable outcome was 28.2%. In multivariate analysis, brisk pupil light reaction on admission and patent basal cistern on brain computed tomography (CT) scan were significant factors associated with both survival (OR 5.20, 95% CI 1.57-17.246, p = 0.007 and OR 3.65, 95% CI 1.22-10.91, p=0.02 respectively) and favorable outcome (OR 4.07, 95% CI 1.35-12.24, p=0.01 and OR 3.54, 95% CI 1.22-10.26, p 0.02), respectively.

CONCLUSION

Based on the results of present study, the survival rate of patients with very severe head trauma (GCS < 6) was 41.7%. The strong predictors of survival and 6-month favorable outcome of these patients were brisk pupillary reactivity and patent cistern on brain CT scan. It seems that very severe head trauma patients still have a reasonable chance to survive and aggressive management should be continued.

Exploration of Pedestrian Head Injuries-Collision Parameter Relationships through a Combination of Retrospective Analysis and Finite Element Method

There are a very limited number of reports concerning the relationship between pedestrian head injuries and collision parameters through a combination of statistical analysis methods and finite element method (FEM). This study aims to explore the characteristics of pedestrian head injuries in car–pedestrian collisions at different parameters by using the two means above. A retrospective analysis of pedestrian head injuries was performed based on detailed investigation data of 61 car–pedestrian collision cases. The head damage assessment parameters (head injury criterion (HIC), peak stress on the skull, maximal principal strain for the brain) in car–pedestrian simulation experiments with four contact angles and three impact velocities were obtained by FEM. The characteristics of the pedestrian head injuries were discussed by comparing and analyzing the statistical analysis results and finite element analysis results. The statistical analysis results demonstrated a significant difference in skull fractures, contusion and laceration of brain and head injuries on the abbreviated injury scale (AIS)3+ was found at different velocities (p < 0.05) and angles (p < 0.05). The simulation results showed that, in pedestrian head-to-hood impacts, the values of head damage assessment parameters increased with impact velocities. At the same velocity, these values from the impact on the pedestrian’s back were successively greater than on the front or the side. Furthermore, head injury reconstruction and prediction results of two selected cases were consistent with the real injuries. Overall, it was further spelled out that, for shorter stature pedestrians, increased head impact velocity results in greater head injury severity in car–pedestrian collision, especially in pedestrian head-to-hood impacts. Under a back impact, the head has also been found to be at greater damage risk for shorter stature pedestrians, which may have implications on automotive design and pedestrian protection research if prevention and treatment of these injuries is to be prioritized over head injuries under a front or side impact.

Accident or crime? About the meaning of face injuries inflicted by blunt force

Injuries caused by blunt force are seen frequently in daily forensic casework. Sometimes, especially when there is less information about the surrounding circumstances, it might become difficult to figure out the cause and background of injuries: accident, criminal violence or self-infliction? In the study presented, face injuries caused by blunt force in 694 cases were analyzed comparing the injury patterns in accidents to those in crimes. It turned out injuries of the ear and retroauricular region clearly indicate a crime. Also, soft tissue injuries of nose, upper jaw, and lower jaw point towards a criminal violence, whereas tooth injuries occur with a similar frequency in both crimes and accidents.

Epidemiology and clinical characteristics of traumatic brain injury in Lebanon: A systematic review

BACKGROUND

Traumatic brain injury (TBI) is a debilitating medical and emerging public health problem that is affecting people worldwide due to a multitude of factors including both domestic and war-related acts. The objective of this paper is to systematically review the status of TBI in Lebanon - a Middle Eastern country with a weak health system that was chartered by several wars and intermittent outbursts of violence - in order to identify the present gaps in knowledge, direct future research initiatives and to assist policy makers in planning progressive and rehabilitative policies.

METHODS

OVID/Medline, PubMed, Scopus databases and Google Scholar were lastly searched on April 15, 2016 to identify all published research studies on TBI in Lebanon. Studies published in English, Arabic or French that assessed Lebanese patients afflicted by TBI in Lebanon were warranting inclusion in this review. Case reports, reviews, biographies and abstracts were excluded. Throughout the whole review process, reviewers worked independently and in duplicate during study selection, data abstraction and methodological assessment using the Downs and Black Checklist.

RESULTS

In total, 11 studies were recognized eligible as they assessed Lebanese patients afflicted by TBI on Lebanese soils. Considerable methodological variation was found among the identified studies. All studies, except for two that evaluated domestic causes such as falls, reported TBI due to war-related injuries. Age distribution of TBI victims revealed two peaks, young adults between 18 and 40 years, and older adults aged 60 years and above, where males constituted the majority. Only three studies reported rates of mild TBI. Mortality, rehabilitation and systemic injury rates were rarely reported and so were the complications involved; infections were an exception.

CONCLUSION

Apparently, status of TBI in Lebanon suffers from several gaps which need to be bridged through implementing more basic, epidemiological, clinical and translational research in this field in the future.

Validation of CRASH Model in Prediction of 14-day Mortality and 6-month Unfavorable Outcome of Head Trauma Patients

INTRODUCTION

To date, many prognostic models have been proposed to predict the outcome of patients with traumatic brain injuries. External validation of these models in different populations is of great importance for their generalization. The present study was designed, aiming to determine the value of CRASH prognostic model in prediction of 14-day mortality (14-DM) and 6-month unfavorable outcome (6-MUO) of patients with traumatic brain injury.

METHODS

In the present prospective diagnostic test study, calibration and discrimination of CRASH model were evaluated in head trauma patients referred to the emergency department. Variables required for calculating CRASH expected risks (ER), and observed 14-DM and 6-MUO were gathered. Then ER of 14-DM and 6-MUO were calculated. The patients were followed for 6 months and their 14-DM and 6-MUO were recorded. Finally, the correlation of CRASH ER and the observed outcome of the patients was evaluated. The data were analyzed using STATA version 11.0.

RESULTS

In this study, 323 patients with the mean age of 34.0 ± 19.4 years were evaluated (87.3% male). Calibration of the basic and CT models in prediction of 14-day and 6-month outcome were in the desirable range (P < 0.05). Area under the curve in the basic model for prediction of 14-DM and 6-MUO were 0.92 (95% CI: 0.89-0.96) and 0.92 (95% CI: 0.90-0.95), respectively. In addition, area under the curve in the CT model for prediction of 14-DM and 6-MUO were 0.93 (95% CI: 0.91-0.97) and 0.93 (95% CI: 0.91-0.96), respectively. There was no significant difference between the discriminations of the two models in prediction of 14-DM (p = 0.11) and 6-MUO (p = 0.1).

CONCLUSION

The results of the present study showed that CRASH prediction model has proper discrimination and calibration in predicting 14-DM and 6-MUO of head trauma patients. Since there was no difference between the values of the basic and CT models, using the basic model is recommended to simplify the risk calculations.

Validation and calibration of HeadCount, a self-report measure for quantifying heading exposure in soccer players

The long-term effects of repetitive head impacts due to heading are an area of increasing concern, and exposure must be accurately measured; however, the validity of self-report of cumulative soccer heading is not known. In order to validate HeadCount, a 2-week recall questionnaire, the number of player-reported headers was compared to the number of headers observed by trained raters for a men's and a women's collegiate soccer teams during an entire season of competitive play using Spearman's correlations and intraclass correlation coefficients (ICCs), and calibrated using a generalized estimating equation. The average Spearman's rho was 0.85 for men and 0.79 for women. The average ICC was 0.75 in men and 0.38 in women. The calibration analysis demonstrated that men tend to report heading accurately while women tend to overestimate. HeadCount is a valid instrument for tracking heading behaviour, but may have to be calibrated in women.

Functional outcomes of motor vehicle crash head injuries in pediatric and adult occupants

OBJECTIVE

The objective of the study was to develop a disability-based metric for motor vehicle crash (MVC) injuries, with a focus on head injuries, and compare the functional outcomes between the pediatric and adult populations.

METHODS

Disability risk (DR) was quantified using Functional Independence Measure (FIM) scores within the National Trauma Data Bank-Research Data System (NTDB-RDS) for the top 95% most frequently occurring Abbreviated Injury Scale (AIS) 3, 4, and 5 head injuries in NASS-CDS 2000-2011. Pediatric (ages 7-18), adult (19-45), middle-aged (46-65), and older adult (66+) patients with an FIM score available who were alive at discharge and had an AIS 3, 4, or 5 injury were included in the study. The NTDB-RDS contains a truncated form of the FIM instrument, including 3 items (self-feed, locomotion, and verbal expression), each graded on a scale of 1 (full functional dependence) to 4 (full functional independence). Patients within each age group were classified as disabled or not disabled based on the FIM scale. The DR was calculated for each age group by dividing the number of patients who sustained a specific injury and were disabled by the number of patients who sustained the specific injury. To account for the impact of more severe associated coinjuries, a maximum AIS (MAIS) adjusted DR (DRMAIS) was also calculated for each injury. DR and DRMAIS ranged from 0 (0% disability risk) to 1 (100% disability risk).

RESULTS

An analysis of the most frequent FIM components associated with disabling MVC head injuries revealed that disability across all 3 items (self-feed, locomotion, and expression) was the most frequent for pediatric and adult patients. Only locomotion was the most frequent for middle-aged and older adults. The mean DRMAIS for MVC head injuries was 35% for pediatric patients, 36% for adults, 38% for middle-aged adults, and 44% for older adults. Further analysis was conducted by grouping the head injuries into 8 groups based on the structure of injury and injury type. The pediatric population possessed higher DRMAIS values for brain stem injuries as well as loss of consciousness injuries. Older adults possessed higher DRMAIS values for contusion/hemorrhage injuries, epidural hemorrhage, intracerebral hemorrhage, skull fracture, and subdural/subarachnoid hemorrhage.

CONCLUSION

At-risk populations such as pediatric and older adult patients possessed higher DRMAIS values for different head injuries. Disability in pediatric patients is critical due to loss of quality life years. Disability risk can supplement severity metrics to improve the ability of such metrics to discriminate the severity of different injuries that do not lead to death. Understanding of age-related differences in injury outcomes when compared to adults could inform future age-specific modifications to the AIS.

Headaches in patients with previous head injuries: A population-based historical cohort study (HUNT)

Background Headache attributed to head injury is claimed to be among the most common secondary headache disorders, yet available epidemiological evidence is scarce. We evaluated the prevalence of headache among individuals previously exposed to head injury by a comparison to an uninjured control group. Methods This population-based historical cohort study used data from hospital records on previous exposure to head injury linked to a large epidemiological survey with data on headache occurrence. Participants without head injury, according to hospital records, were used as controls. The head injuries were classified according to the Head Injury Severity Scale (HISS) and the International Classification of Headache Disorders (ICHD-3 beta). Binary logistic regression was performed to investigate the association between headache and head injury, controlling for potential confounders. Results The exposed group consisted of 940 individuals and the control group of 38,751 individuals. In the multivariate analyses, adjusting for age, sex, anxiety, depression and socioeconomic status, there were significant associations between mild head injury and any headache, migraine, chronic daily headache and medication overuse headache. Conclusion Headache was more likely among individuals previously referred to a hospital for a mild head injury compared to uninjured controls.

[Treatment methods of atypical gunshot wounds to the head--case reports]

Due to a high mortality rate, headshot injuries pose serious diagnostic and clinical problems. In this work, we wanted to describe four atypical headshot injuries. The first patient with a headshot injury using a nail gun mishap; the second one after a headshot injury, as a result of attempted murder (the bullet came to a parasagittal halt in the left parietal area); the third victim, after a suicide attempt (the bullet was removed from clivus area, below the pituitary gland); in the case of the fourth patient, after shooting himself with a self-constructed weapon in the chin, the metal body was surgically removed - a bearing pellet from the corpus callosum. Males dominate among victims of headshot injuries. Alcohol is one of the elements that facilitate suicidal behaviour. Anti-spasm, antibacterial, anti-tetanus prophylaxes are incredibly important. In some cases, the metallic body does not have to be removed from the brain. Pulmonary embolism can be a cause of death after 7 days from injury.

[Minor head trauma - trivial matter or sirious diagnostic and therapeutic problem? The role of Infrascanner in the diagnostic process]

Head injuries in children, especially minor head injuries, still constitute a important diagnostic and therapeutic problem. Despite progress in medical sciences, there is no definition of minor head injury or standards of the management of children with a minor head injury. In consequence, the diagnostic procedure in the child who does not show any signs of central nervous system damage as a result of head injury is individual and depends on the experience and knowledge of the aid provider and as well as procedures established in a given ward. Therefore, a problem which requires to be urgently solved is to determine the justification and indications for imaging investigations (justification for skull X-ray, performance indications for carrying out computed tomography of the head) as well as indications for inpatient observation in such cases. The study presents currently existing definitions and proposals for the management of children presenting with a minor head injury. On the basis of own investigation we would stress that there is an opportunity to use in the initial diagnostics of head injuries in children, a modern non-invasive method already available in Poland, utilising the near-infrared NIR technology in order to detect intracranial haemorrhages by means of the Infrascanner.

The Ability of American Football Helmets to Manage Linear Acceleration With Repeated High-Energy Impacts

CONTEXT

Football players can receive up to 1400 head impacts per season, averaging 6.3 impacts per practice and 14.3 impacts per game. A decrease in the capacity of a helmet to manage linear acceleration with multiple impacts could increase the risk of traumatic brain injury.

OBJECTIVE

To investigate the ability of football helmets to manage linear acceleration with multiple high-energy impacts.

DESIGN

Descriptive laboratory study.

SETTING

Laboratory.

MAIN OUTCOME MEASURE(S)

We collected linear-acceleration data for 100 impacts at 6 locations on 4 helmets of different models currently used in football. Impacts 11 to 20 were compared with impacts 91 to 100 for each of the 6 locations.

RESULTS

Linear acceleration was greater after multiple impacts (91-100) than after the first few impacts (11-20) for the front, front-boss, rear, and top locations. However, these differences are not clinically relevant as they do not affect the risk for head injury.

CONCLUSIONS

American football helmet performance deteriorated with multiple impacts, but this is unlikely to be a factor in head-injury causation during a game or over a season.