Previously published studies have found that concussion symptoms are underreported in youth athletics. This study evaluated the likelihood high school soccer players would identify themselves as having concussion related symptoms during game situations. A questionnaire inquiring about past concussion education and the likelihood of notifying their coach of concussion symptoms was administered to 183 high school soccer players. Of the 60 (33%) who completed the survey, 18 (72%) athletes who had acknowledged receiving concussion training responded that they would always notify their coach of concussion symptoms, as compared with 12 (36%) of the players who reported having no such training (P = .01). The results of this study suggest that athletes with past concussion training are more likely to notify their coach of concussion symptoms, potentially reducing their risk for further injury. Concussion education should be considered for all high school soccer players.
To assess the accuracy and physiological relevance of circulating microRNA (miRNA) as a biomarker of pediatric concussion, we compared changes in salivary miRNA and cerebrospinal fluid (CSF) miRNA concentrations after childhood traumatic brain injury (TBI). A case-cohort design was used to compare longitudinal miRNA concentrations in CSF of seven children with severe TBI against three controls without TBI. The miRNAs "altered" in CSF were interrogated in saliva of 60 children with mild TBI and compared with 18 age- and sex-matched controls. The miRNAs with parallel changes (Wilcoxon rank sum test) in CSF and saliva were interrogated for predictive accuracy of TBI status using a multivariate regression technique. Spearman rank correlation identified relationships between miRNAs of interest and clinical features. Functional analysis with DIANA mirPath identified related mRNA pathways. There were 214 miRNAs detected in CSF, and 135 (63%) were also present in saliva. Six miRNAs had parallel changes in both CSF and saliva (miR-182-5p, miR-221-3p, mir-26b-5p, miR-320c, miR-29c-3p, miR-30e-5p). These miRNAs demonstrated an area under the curve of 0.852 for identifying mild TBI status. Three of the miRNAs exhibited longitudinal trends in CSF and/or saliva after TBI, and all three targeted mRNAs related to neuronal development. Concentrations of miR-320c were directly correlated with child and parent reports of attention difficulty. Salivary miRNA represents an easily measured, physiologically relevant, and accurate potential biomarker for TBI. Further studies assessing the influence of orthopedic injury and exercise on peripheral miRNA patterns are needed.
IMPORTANCE Approximately one-third of children who experience a concussion develop prolonged concussion symptoms. To our knowledge, there are currently no objective or easily administered tests for predicting prolonged concussion symptoms. Several studies have identified alterations in epigenetic molecules known as microRNAs (miRNAs) following traumatic brain injury. No studies have examined whether miRNA expression can detect prolonged concussion symptoms. OBJECTIVE To evaluate the efficacy of salivary miRNAs for identifying children with concussion who are at risk for prolonged symptoms. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study at the Penn State Medical Center observed 52 patients aged 7 to 21 years presenting for evaluation of concussion within 14 days of initial head injury, with follow-up at 4 and 8 weeks. EXPOSURES All patients had a clinical diagnosis of concussion. MAIN OUTCOMES AND MEASURES Salivary miRNA expression was measured at the time of initial clinical presentation in all patients. Patients with a Sport Concussion Assessment Tool (SCAT3) symptom score of 5 or greater on self-report or parent report 4 weeks after injury were designated as having prolonged symptoms. RESULTS Of the 52 included participants, 22 (42%) were female, and the mean (SD) age was 14 (3) years. Participants were split into the prolonged symptom group (n = 30) and acute symptom group (n = 22). Concentrations of 15 salivary miRNAs spatially differentiated prolonged and acute symptom groups on partial least squares discriminant analysis and demonstrated functional relationships with neuronal regulatory pathways. Levels of 5 miRNAs (miR-320c-1, miR-133a-5p, miR-769-5p, let-7a-3p, and miR-1307-3p) accurately identified patients with prolonged symptoms on logistic regression (area under the curve, 0.856; 95% CI, 0.822-0.890). This accuracy exceeded accuracy of symptom burden on child (area under the curve, 0.649; 95% CI, 0.388-0.887) or parent (area under the curve, 0.562; 95% CI, 0.219-0.734) SCAT3 score. Levels of 3 miRNAs were associated with specific symptoms 4 weeks after injury; miR-320c-1 was associated with memory difficulty (R, 0.55; false detection rate, 0.02), miR-629 was associated with headaches (R, 0.47; false detection rate, 0.04), and let-7b-5p was associated with fatigue (R, 0.45; false detection rate, 0.04). CONCLUSIONS AND RELEVANCE Salivary miRNA levels may identify the duration and character of concussion symptoms. This could reduce parental anxiety and improve care by providing a tool for concussion management. Further validation of this approach is needed.
Sleep disturbance is a common problem following concussion. A retrospective chart review was conducted at a regional concussion clinic on patients 13 to 18 years of age between 2005 and 2011. Statistical analysis evaluated sleep disturbance and duration of concussion, as well as the use and effectiveness of melatonin. A total of 417 patients met inclusion criteria. One hundred twenty-three (34%) reported disturbance in sleep. There was no difference in sleep disturbance based on age, gender, or past number of concussions. Sleep disturbance was associated with a 3- to 4-fold increase in recovery time. Non-sport-related concussions were more likely to be associated with sleep disturbance compared to sport-related concussions (45% vs 29%, P = .01). Melatonin improved sleep disturbance in 67% of the patients. Evaluating sleep disorders following concussion is an important part of the assessment. These findings will help clinicians provide anticipatory guidance and treatment for adolescents recovering from concussion.
Ensuring that schools have policies established for a student's return to learning, having specific guidelines to provide an individualized approach to return to learning based on postconcussion signs/symptoms, training school nurses in the recognition and management of concussions, and involving school nurses in the re-entry process are identified areas for improvement. Schools in the United States should be aware of these recommendations to guide a student's postconcussion graduated academic re-entry process.
Ice hockey is a high-risk sport for concussion. It is important that coaches have an understanding of concussion, although previous studies have demonstrated poor knowledge of concussion recognition and management by youth coaches. A cross-sectional survey with 7 case scenarios was completed by 314 youth hockey coaches. Each case scenario described a player with a concussion during a game, and scores reflected how the coach would respond to each scenario. Although most coaches would not allow a player to continue participating in a game after suffering a concussion, there was a small percentage that would. Statistical analysis found an inverse relationship between the coaches' age and consideration of continued participation. This places athletes at significant risk for further injury and is not consistent with current concussion guidelines. USA Hockey should provide additional concussion training for their coaches as well as mandatory health care clearance following a concussion.
To determine the preferences for and satisfaction with communication between pediatric primary care physicians (PCPs) and hospitalists, 2 surveys (PCP and hospitalist versions with matching questions) were developed. Overall, PCPs were less satisfied than hospitalists with communication (P < .01). The 2 provider types had differing opinions on responsibility for care after hospital discharge, with hospitalists more likely than PCPs to assign responsibility to the PCP for pending labs (65% vs 49%; P < .01), adverse events (85% vs 67%; P < .01), or status changes (85% vs 69%; P < .01). Whereas satisfaction with and preferences for patient-related communication differed between hospitalists and PCPs, the incongruent views on the responsibility for care after patient discharge have major implications for safety particularly if poor communication occurs at discharge. Successful transitions from the hospital to primary care require communication between hospitalists and PCPs to be consistent, timely, and informative with responsibility for care discussed at discharge.
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