Publications by authors named "Allen K Sills"

57 Publications

Observed Versus Expected COVID-19 Infections Among National Football League Players During the 2020 Season.

Epidemiology 2021 Sep 2. Epub 2021 Sep 2.

National Football League, New York, NY Department of Mathematics and Statistics, Skidmore College IQVIA, Real World Solutions, Durham, NC Department of Epidemiology, University of North Carolina-Chapel Hill, Chapel Hill, NC Allergy and Infectious Diseases, University of Washington, Seattle, WA MD2 McLean, Virginia Hospital Center Center for Infectious Disease Research and Policy, University of Minnesota, Minneapolis, MN In_Q-Tel, Arlington, Virginia NFL Players Association, Washington, DC.

Background: The National Football League (NFL) and National Football League Players Association (NFLPA) implemented a set of strict protocols for the 2020 season with the intent to mitigate COVID-19 risk among players and staff. In that timeframe, the league's 32 teams completed 256 regular season games and several thousand meetings and practices. In parallel, community cases of COVID-19 were highly prevalent. We assess the risk of holding a 2020 NFL season by comparing community and player COVID-19 infections.

Methods: We used county-level COVID-19 test data from each team to establish baseline distributions of infection rates expected to occur in a population similar in age and sex to NFL players. We used a binomial distribution to simulate expected infections in each community cohort and compared these findings with observed COVID-19 infections in players.

Results: Over a 5-month period (1 August 2020 to 2 January 2021), positive NFL player infections (n = 256) were 55.7% lower than expected when compared to simulations from NFL community cohorts. For 30 of 32 teams (94%), observed counts fell at or below expectation, including 28 teams (88%) for which rates were lower. Two teams fell above baseline expectation.

Conclusions: The NFL/NFLPA protocols that governed team facilities, travel, gameday, and activities outside of the workplace were associated with lower infection rates among NFL players compared to the surrounding community. The NFL's 2020-2021 season are consistent with the hypothesis that robust testing and behavioral protocols support a safe return to sport and work.
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http://dx.doi.org/10.1097/EDE.0000000000001416DOI Listing
September 2021

Validity of Research Based on Public Data in Sports Medicine: A Quantitative Assessment of Anterior Cruciate Ligament Injuries in the National Football League.

Am J Sports Med 2021 Jun 24:3635465211015435. Epub 2021 Jun 24.

Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA.

Background: Numerous researchers have leveraged publicly available Internet sources to publish publicly obtained data (POD) studies concerning various orthopaedic injuries in National Football League (NFL) players.

Purpose: To provide a comprehensive systematic review of all POD studies regarding musculoskeletal injuries in NFL athletes and to use anterior cruciate ligament (ACL) injuries in NFL players to quantify the percentage of injuries identified by these studies.

Study Design: Systematic review; Level of evidence, 4.

Methods: A systematic review was conducted to identify all published studies utilizing POD regarding ACL injury in NFL athletes from 2000 to 2019. Data regarding player demographics were extracted from each publication. These results were compared with prospectively collected data reported by the teams' medical staff to the NFL Injury Surveillance System database linked to the League's electronic health record. An ACL "capture rate" for each article was calculated by dividing the number of ACL injuries in the POD study by the total number of ACL injuries in the NFL injury database occurring in the study period of interest.

Results: A total of 42 studies were extracted that met the definition of a POD study: 28 evaluated a variety of injuries and 14 dealt specifically with ACL injuries, with 35 (83%) of the 42 studies published during or since 2015. POD studies captured a mean of 66% (range, 31%-90%) of ACL injuries reported by the teams' medical staff. This inability to capture all injury rates varied by position, with 86% capture of ACL injuries in skill athletes, 72% in midskill athletes, and 61% in linemen. POD studies captured 35% of injuries occurring during special teams play.

Conclusion: The frequency of studies leveraging publicly obtained injury data in NFL players has rapidly increased since 2000. There is significant heterogeneity in the degree to which POD studies correctly identify ACL injuries from public reports. Sports medicine research relying solely on publicly obtained sources should be interpreted with an understanding of their inherent limitations and biases. These studies underreport the true incidence of injuries, with a bias toward capturing injuries in more popular players.
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http://dx.doi.org/10.1177/03635465211015435DOI Listing
June 2021

Sport-Related Structural Brain Injury and Return to Play: Systematic Review and Expert Insight.

Neurosurgery 2021 05;88(6):E495-E504

Department of Neurosurgery, Johns Hopkins University Medical Center, Baltimore, Maryland, USA.

Background: Sport-related structural brain injury (SRSBI) is intracranial pathology incurred during sport. Management mirrors that of non-sport-related brain injury. An empirical vacuum exists regarding return to play (RTP) following SRSBI.

Objective: To provide key insight for operative management and RTP following SRSBI using a (1) focused systematic review and (2) survey of expert opinions.

Methods: A systematic literature review of SRSBI from 2012 to present in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a cross-sectional survey of RTP in SRSBI by 31 international neurosurgeons was conducted.

Results: Of 27 included articles out of 241 systematically reviewed, 9 (33.0%) case reports provided RTP information for 12 athletes. To assess expert opinion, 31 of 32 neurosurgeons (96.9%) provided survey responses. For acute, asymptomatic SRSBI, 12 (38.7%) would not operate. Of the 19 (61.3%) who would operate, midline shift (63.2%) and hemorrhage size > 10 mm (52.6%) were the most common indications. Following SRSBI with resolved hemorrhage, with or without burr holes, the majority of experts (>75%) allowed RTP to high-contact/collision sports at 6 to 12 mo. Approximately 80% of experts did not endorse RTP to high-contact/collision sports for athletes with persistent hemorrhage. Following craniotomy for SRSBI, 40% to 50% of experts considered RTP at 6 to 12 mo. Linear regression revealed that experts allowed earlier RTP at higher levels of play (β = -0.58, 95% CI -0.111, -0.005, P = .033).

Conclusion: RTP decisions following structural brain injury in athletes are markedly heterogeneous. While individualized RTP decisions are critical, aggregated expert opinions from 31 international sports neurosurgeons provide key insight. Level of play was found to be an important consideration in RTP determinations.
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http://dx.doi.org/10.1093/neuros/nyab041DOI Listing
May 2021

Prevalence of Inflammatory Heart Disease Among Professional Athletes With Prior COVID-19 Infection Who Received Systematic Return-to-Play Cardiac Screening.

JAMA Cardiol 2021 07;6(7):745-752

Division of Cardiology, Columbia University Irving Medical Center, New York, New York.

Importance: The major North American professional sports leagues were among the first to return to full-scale sport activity during the coronavirus disease 2019 (COVID-19) pandemic. Given the unknown incidence of adverse cardiac sequelae after COVID-19 infection in athletes, these leagues implemented a conservative return-to-play (RTP) cardiac testing program aligned with American College of Cardiology recommendations for all athletes testing positive for COVID-19.

Objective: To assess the prevalence of detectable inflammatory heart disease in professional athletes with prior COVID-19 infection, using current RTP screening recommendations.

Design, Setting, And Participants: This cross-sectional study reviewed RTP cardiac testing performed between May and October 2020 on professional athletes who had tested positive for COVID-19. The professional sports leagues (Major League Soccer, Major League Baseball, National Hockey League, National Football League, and the men's and women's National Basketball Association) implemented mandatory cardiac screening requirements for all players who had tested positive for COVID-19 prior to resumption of team-organized sports activities.

Exposures: Troponin testing, electrocardiography (ECG), and resting echocardiography were performed after a positive COVID-19 test result. Interleague, deidentified cardiac data were pooled for collective analysis. Those with abnormal screening test results were referred for additional testing, including cardiac magnetic resonance imaging and/or stress echocardiography.

Main Outcomes And Measures: The prevalence of abnormal RTP test results potentially representing COVID-19-associated cardiac injury, and results and outcomes of additional testing generated by the initial screening process.

Results: The study included 789 professional athletes (mean [SD] age, 25 [3] years; 777 men [98.5%]). A total of 460 athletes (58.3%) had prior symptomatic COVID-19 illness, and 329 (41.7%) were asymptomatic or paucisymptomatic (minimally symptomatic). Testing was performed a mean (SD) of 19 (17) days (range, 3-156 days) after a positive test result. Abnormal screening results were identified in 30 athletes (3.8%; troponin, 6 athletes [0.8%]; ECG, 10 athletes [1.3%]; echocardiography, 20 athletes [2.5%]), necessitating additional testing; 5 athletes (0.6%) ultimately had cardiac magnetic resonance imaging findings suggesting inflammatory heart disease (myocarditis, 3; pericarditis, 2) that resulted in restriction from play. No adverse cardiac events occurred in athletes who underwent cardiac screening and resumed professional sport participation.

Conclusions And Relevance: This study provides large-scale data assessing the prevalence of relevant COVID-19-associated cardiac pathology with implementation of current RTP screening recommendations. While long-term follow-up is ongoing, few cases of inflammatory heart disease have been detected, and a safe return to professional sports activity has thus far been achieved.
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http://dx.doi.org/10.1001/jamacardio.2021.0565DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934073PMC
July 2021

Consensus Recommendations on the Prehospital Care of the Injured Athlete With a Suspected Catastrophic Cervical Spine Injury.

Clin J Sport Med 2020 07;30(4):296-304

University of Georgia, Athens, Georgia.

Introduction: Sports participation is among the leading causes of catastrophic cervical spine injury (CSI) in the United States. Appropriate prehospital care for athletes with suspected CSIs should be available at all levels of sport. The goal of this project was to develop a set of best-practice recommendations appropriate for athletic trainers, emergency responders, sports medicine and emergency physicians, and others engaged in caring for athletes with suspected CSIs.

Methods: A consensus-driven approach (RAND/UCLA method) in combination with a systematic review of the available literature was used to identify key research questions and develop conclusions and recommendations on the prehospital care of the spine-injured athlete. A diverse panel of experts, including members of the National Athletic Trainers' Association, the National Collegiate Athletic Association, and the Sports Institute at UW Medicine participated in 4 Delphi rounds and a 2-day nominal group technique (NGT) meeting. The systematic review involved 2 independent reviewers and 4 rounds of blinded review.

Results: The Delphi process identified 8 key questions to be answered by the systematic review. The systematic review comprised 1544 studies, 49 of which were included in the final full-text review. Using the results of the systematic review as a shared evidence base, the NGT meeting created and refined conclusions and recommendations until consensus was achieved.

Conclusions: These conclusions and recommendations represent a pragmatic approach, balancing expert experiences and the available scientific evidence.
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http://dx.doi.org/10.1097/JSM.0000000000000869DOI Listing
July 2020

Best Practices and Current Care Concepts in Prehospital Care of the Spine-Injured Athlete in American Tackle Football March 2-3, 2019; Atlanta, GA.

J Athl Train 2020 Jun;55(6):545-562

Piedmont Physicians Neurosurgery Athens, GA.

Sport-related spine injury can be devastating and have long-lasting effects on athletes and their families. Providing evidence-based care for patients with spine injury is essential for optimizing postinjury outcomes. When caring for an injured athlete in American tackle football, clinicians must make decisions that involve unique challenges related to protective equipment (eg, helmet and shoulder pads). The Spine Injury in Sport Group (SISG) met in Atlanta, Georgia, March 2-3, 2019, and involved 25 health care professionals with expertise in emergency medicine, sports medicine, neurologic surgery, orthopaedic surgery, neurology, physiatry, athletic training, and research to review the current literature and discuss evidence-based medicine, best practices, and care options available for the prehospital treatment of athletes with suspected cervical spine injuries.1,2 That meeting and the subsequent Mills et al publication delineate the quality and quantity of published evidence regarding many aspects of prehospital care for the athlete with a suspected cervical spine injury. This paper offers a practical treatment guide based on the experience of those who attended the Atlanta meeting as well as the evidence presented in the Mills et al article. Ongoing research will help to further advance clinical treatment recommendations.
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http://dx.doi.org/10.4085/1062-6050-430-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7319739PMC
June 2020

Consensus Recommendations on the Prehospital Care of the Injured Athlete With a Suspected Catastrophic Cervical Spine Injury.

J Athl Train 2020 Jun;55(6):563-572

University of Georgia, Athens.

Introduction: Sports participation is among the leading causes of catastrophic cervical spine injury (CSI) in the United States. Appropriate prehospital care for athletes with suspected CSIs should be available at all levels of sport. The goal of this project was to develop a set of best-practice recommendations appropriate for athletic trainers, emergency responders, sports medicine and emergency physicians, and others engaged in caring for athletes with suspected CSIs.

Methods: A consensus-driven approach (RAND/UCLA method) in combination with a systematic review of the available literature was used to identify key research questions and develop conclusions and recommendations on the prehospital care of the spine-injured athlete. A diverse panel of experts, including members of the National Athletic Trainers' Association, the National Collegiate Athletic Association, and the Sports Institute at UW Medicine participated in 4 Delphi rounds and a 2-day nominal group technique meeting. The systematic review involved 2 independent reviewers and 4 rounds of blinded review.

Results: The Delphi process identified 8 key questions to be answered by the systematic review. The systematic review comprised 1544 studies, 49 of which were included in the final full-text review. Using the results of the systematic review as a shared evidence base, the nominal group technique meeting created and refined conclusions and recommendations until consensus was achieved.

Conclusions: These conclusions and recommendations represent a pragmatic approach, balancing expert experiences and the available scientific evidence.
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http://dx.doi.org/10.4085/1062-6050-0434.19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7319738PMC
June 2020

Sensitivity and Specificity of On-Field Visible Signs of Concussion in the National Football League.

Neurosurgery 2020 09;87(3):530-537

Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: On-field visible signs (VS) are used to help identify sport-related concussion (SRC) in the National Football League (NFL). However, the predictive utility of a VS checklist for SRC is unknown.

Objective: To report the frequency, sensitivity, specificity, and predictive value of VS in a cohort of NFL athletes.

Methods: On-field VS ratings from 2 experts who independently reviewed video footage of a cohort of 251 injury plays that resulted in an SRC diagnosis (n = 211) and no diagnosis (n = 40) from the 2017 NFL season were examined. The frequency, sensitivity, specificity, and a receiver operating characteristic (ROC) curve with area under the curve (AUC) were calculated for each VS.

Results: Slow to get up (65.9%) and motor incoordination (28.4%) were the most frequent VS in concussed athletes, and slow to get up (60.0%) was the most common VS among nonconcussed athletes. The most sensitive VS was slow to get up (66%); the most specific signs in concussed NFL athletes were blank/vacant look and impact seizure (both 100%). Approximately 26% of concussed NFL players did not exhibit a VS, and the overall sensitivity and specificity for the VS checklist to detect SRC were 73% and 65%, respectively. The VS checklist demonstrated "poor" ability to discriminate between SRC and non-SRC groups (AUC = 0.66).

Conclusion: In the NFL, the diagnosis of concussion cannot be made from on-field VS alone. The VS checklist is one part of the comprehensive sideline/acute evaluation of concussion, and the diagnosis remains a multimodal clinical decision.
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http://dx.doi.org/10.1093/neuros/nyaa072DOI Listing
September 2020

Concussion Guidelines in National and International Professional and Elite Sports.

Neurosurgery 2020 08;87(2):418-425

Major League Baseball, New York, New York.

The Berlin statement on sport-related concussion was published in 2017 using evidence-based recommendations. We aimed to examine (1) the implementation of, distribution and education based on the Berlin recommendations, and the development of sport-specific protocols/guidelines among professional and elite sports, (2) the implementation of guidelines at the community level, (3) translation of guidelines into different languages, and (4) research activities. Senior medical advisers and chief medical officers from Australian Football League, All Japan Judo Federation, British Horseracing Authority, Cricket Australia, Fédération Equestre Internationale, Football Association, Gaelic Athletic Association, International Boxing Association, Irish Horseracing Regulatory Board, Major League Baseball, National Football League, National Hockey League, National Rugby League, and World Rugby completed a questionnaire. The results demonstrated that all 14 sporting organizations have published concussion protocols/guidelines based on the Berlin recommendations, including Recognize, Removal from play, Re-evaluation, Rest, Recovery, and Return to play. There is variable inclusion of Prolonged symptoms. Prevention and Risk reduction and Long-term effects are addressed in the guidelines, rules and regulations, and/or sport-specific research. There is variability in education programs, monitoring compliance with guidelines, and publication in other languages. All sporting bodies are actively involved in concussion research. We conclude that the Berlin recommendations have been included in concussion protocols/guidelines by all the sporting bodies, with consistency in the essential components of the recommendations, whilst also allowing for sport- and regional-specific variations. Education at the elite, community, and junior levels remains an ongoing challenge, and future iterations of guidelines may consider multiple language versions, and community- and junior-level guidelines.
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http://dx.doi.org/10.1093/neuros/nyaa057DOI Listing
August 2020

Concussions in the National Football League: the evolution of video review for assessing the frequency and reliability of visible signs.

Phys Sportsmed 2020 11 23;48(4):424-429. Epub 2020 Feb 23.

Vanderbilt Sports Concussion Center, Vanderbilt University Medical Center , Nashville, TN, USA.

: The use of video review to document visible signs (VS) of sport-related concussion in the National Football League (NFL) is a novel method to recognize head injuries. : The current pilot studies used varying methodologies to (1) examine the frequency of VS in concussed NFL players using the Australian Football League's (AFL) checklist, and (2) assess the reliability of VS between non-expert and expert raters. : Cohort study : In the first pilot study, two rated VS of SRC occurring in the 2015 NFL season (96) using a single VS from the AFL checklist. Based on this pilot study, two then rated VS of SRC during the 2017 NFL season (211) using all VS from the AFL checklist. The frequency, total percent agreement (TPA), and reliability (kappa coefficients) were calculated for all VS of concussion for the two seasons. Kappa agreement was classified as fair (.41-.60), moderate (.61-.80), or substantial (.81-1.00). Significance was set at .05. : The most frequent VS of concussion identified by both non-expert and expert raters were . The least frequent VS were , the average TPA for VS ranged from 84% to 100% and kappa coefficients ranged from .52 to .68. For , the average TPA ranged from 83% to 100%, and kappa coefficients ranged from .56 to .86. : In these preliminary analyses, use of multiple VS was a superior methodology, and the reliability of VS rating was stronger for experts. Due to the inherent differences in gameplay and protective equipment used in the NFL compared to other professional sports, it is our hope these data can generate new ways to improve existing practices and identify potentially novel VS of SRC.
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http://dx.doi.org/10.1080/00913847.2020.1731379DOI Listing
November 2020

International consensus definitions of video signs of concussion in professional sports.

Br J Sports Med 2019 Oct 6;53(20):1264-1267. Epub 2019 Apr 6.

Melbourne Brain Centre, Florey Institute of Neuroscience and Mental Health-Austin Campus, Heidelberg, Victoria, Australia.

Background: The use of video to assist professional sporting bodies with the diagnosis of sport-related concussion (SRC) has been well established; however, there has been little consistency across sporting codes with regards to which video signs should be used, and the definitions of each of these signs.

Aim: The aims of this study were to develop a consensus for the video signs considered to be most useful in the identification of a possible SRC and to develop a consensus definition for each of these video signs across the sporting codes.

Methods: A brief questionnaire was used to assess which video signs were considered to be most useful in the identification of a possible concussion. Consensus was defined as >90% agreement by respondents. Existing definitions of these video signs from individual sports were collated, and individual components of the definitions were assessed and ranked. A modified Delphi approach was then used to create a consensus definition for each of the video signs.

Results: Respondents representing seven sporting bodies (Australian Football League, Cricket Australia, Major League Baseball, NFL, NHL, National Rugby League, World Rugby) reached consensus on eight video signs of concussion. Thirteen representatives from the seven professional sports ranked the definition components. Consolidation and refinement of the video signs and their definitions resulted in consensus definitions for six video signs of possible concussion: and .

Conclusions: These video signs and definitions have reached international consensus, are indicated for use by professional sporting bodies and will form the basis for further collaborative research.
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http://dx.doi.org/10.1136/bjsports-2019-100628DOI Listing
October 2019

International study of video review of concussion in professional sports.

Br J Sports Med 2019 Oct 27;53(20):1299-1304. Epub 2018 Sep 27.

Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.

Background: Video review has become an important tool in professional sporting codes to help sideline identification and management of players with a potential concussion.

Aim: To assess current practices related to video review of concussion in professional sports internationally, and compare protocols and diagnostic criteria used to identify and manage potential concussions.

Methods: Current concussion management guidelines from professional national and international sporting codes were reviewed. Specific criteria and definitions of video signs associated with concussion were compared between codes. Rules and regulations adopted across the codes for processes around video review were also assessed.

Results: Six sports with specific diagnostic criteria and definitions for signs of concussion identified on video review participated in this study (Australian football, American football, world rugby, cricket, rugby league and ice hockey). Video signs common to all sports include and . The video signs considered by the majority of sports as most predictive of a diagnosis of concussion include and Regulatory requirements, sideline availability of video, medical expertise of video reviewers and use of spotters differ across sports and geographical boundaries. By and large, these differences reflect a pragmatic approach from each sport, with limited underlying research and development of the video review process in some instances.

Conclusions: The use of video analysis in assisting medical staff with the diagnosis or identification of potential concussion is well established across different sports internationally. The diagnostic criteria used and the expertise of the video review personnel are not clearly established, and research efforts would benefit from a collaborative harmonisation across sporting codes.
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http://dx.doi.org/10.1136/bjsports-2018-099727DOI Listing
October 2019

NCCN Guidelines Insights: Central Nervous System Cancers, Version 1.2017.

J Natl Compr Canc Netw 2017 11;15(11):1331-1345

For many years, the diagnosis and classification of gliomas have been based on histology. Although studies including large populations of patients demonstrated the prognostic value of histologic phenotype, variability in outcomes within histologic groups limited the utility of this system. Nonetheless, histology was the only proven and widely accessible tool available at the time, thus it was used for clinical trial entry criteria, and therefore determined the recommended treatment options. Research to identify molecular changes that underlie glioma progression has led to the discovery of molecular features that have greater diagnostic and prognostic value than histology. Analyses of these molecular markers across populations from randomized clinical trials have shown that some of these markers are also predictive of response to specific types of treatment, which has prompted significant changes to the recommended treatment options for grade III (anaplastic) gliomas.
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http://dx.doi.org/10.6004/jnccn.2017.0166DOI Listing
November 2017

Factors associated with post-concussion syndrome in high school student-athletes.

J Sci Med Sport 2018 May 14;21(5):447-452. Epub 2017 Sep 14.

Department of Athletic Training, Lebanon Valley College, USA.

Objectives: To identify factors associated with post-concussion syndrome (PCS) among a national sample of high school student-athletes from the 2011/12-2013/14 academic years.

Design: Ambispective cohort study from sports injury surveillance data.

Methods: Sport-related concussion data originated from the National Athletic Treatment, Injury and Outcomes Network (NATION) surveillance program, consisting of 27 sports from a convenience sample of 196 high schools across 26 states. All SRCs were reported by certified athletic trainers. The PCS and non-PCS groups consisted of concussed individuals with symptoms resolution time of >4 weeks and ≤2 weeks, respectively. Logistic regression estimated the association of athlete and concussion characteristics on the odds of PCS, and calculated adjusted odds ratios (OR) and 95% confidence intervals (CI).

Results: Overall, 1334 concussed high school athletes met inclusion criteria: 215 in the PCS group and 1119 in the non-PCS group. In the multivariable analysis, concussion symptoms associated with increased odds of PCS included: retrograde amnesia (OR=3.01, 95%CI: 1.31-6.91), difficulty concentrating (OR=2.72, 95%CI: 1.56-4.77), disorientation (OR=1.86; 95%CI: 1.04-3.33), insomnia (OR=2.79; 95%CI: 1.62-4.80), loss of balance (OR=1.76; 95%CI: 1.00-3.10), sensitivity to noise (OR=1.80; 95%CI: 1.02-3.17), and visual disturbance (OR=2.21; 95%CI: 1.23-3.97). Sex and recurrent concussion were not associated with PCS.

Conclusions: As in previous research, somatic and cognitive symptoms were associated with PCS. The identification of factors associated with PCS may assist clinicians in identifying concussed athletes at greater risk of having longer symptom resolution time.
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http://dx.doi.org/10.1016/j.jsams.2017.08.025DOI Listing
May 2018

Factors Associated With Playing Through a Sport-Related Concussion.

Neurosurgery 2017 09;64(CN_suppl_1):211-216

Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tennessee.

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http://dx.doi.org/10.1093/neuros/nyx294DOI Listing
September 2017

Predictors of clinical recovery from concussion: a systematic review.

Br J Sports Med 2017 Jun;51(12):941-948

Departments of Neurological Surgery, Orthopaedic Surgery & Rehabilitation, and Psychiatry & Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.

Objective: A systematic review of factors that might be associated with, or influence, clinical recovery from sport-related concussion. Clinical recovery was defined functionally as a return to normal activities, including school and sports, following injury.

Design: Systematic review.

Data Sources: PubMed, PsycINFO, MEDLINE, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus and Web of Science.

Eligibility Criteria For Selecting Studies: Studies published by June of 2016 that addressed clinical recovery from concussion.

Results: A total of 7617 articles were identified using the search strategy, and 101 articles were included. There are major methodological differences across the studies. Many different clinical outcomes were measured, such as symptoms, cognition, balance, return to school and return to sports, although symptom outcomes were the most frequently measured. The most consistent predictor of slower recovery from concussion is the severity of a person's acute and subacute symptoms. The development of subacute problems with headaches or depression is likely a risk factor for persistent symptoms lasting greater than a month. Those with a preinjury history of mental health problems appear to be at greater risk for having persistent symptoms. Those with attention deficit hyperactivity disorder (ADHD) or learning disabilities do not appear to be at substantially greater risk. There is some evidence that the teenage years, particularly high school, might be the most vulnerable time period for having persistent symptoms-with greater risk for girls than boys.

Conclusion: The literature on clinical recovery from sport-related concussion has grown dramatically, is mostly mixed, but some factors have emerged as being related to outcome.
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http://dx.doi.org/10.1136/bjsports-2017-097729DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466929PMC
June 2017

The Sport Concussion Assessment Tool 5th Edition (SCAT5): Background and rationale.

Br J Sports Med 2017 Jun 26;51(11):848-850. Epub 2017 Apr 26.

Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.

This paper presents the Sport Concussion Assessment Tool 5th Edition (SCAT5), which is the most recent revision of a sport concussion evaluation tool for use by healthcare professionals in the acute evaluation of suspected concussion. The revision of the SCAT3 (first published in 2013) culminated in the SCAT5. The revision was based on a systematic review and synthesis of current research, public input and expert panel review as part of the 5th International Consensus Conference on Concussion in Sport held in Berlin in 2016. The SCAT5 is intended for use in those who are 13 years of age or older. The Child SCAT5 is a tool for those aged 5-12 years, which is discussed elsewhere.
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http://dx.doi.org/10.1136/bjsports-2017-097506DOI Listing
June 2017

The Concussion Recognition Tool 5th Edition (CRT5): Background and rationale.

Br J Sports Med 2017 Jun 26;51(11):870-871. Epub 2017 Apr 26.

Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine, and Neurological Surgery, Seattle, Washington, USA.

The Concussion Recognition Tool 5 (CRT5) is the most recent revision of the Pocket Sport Concussion Assessment Tool 2 that was initially introduced by the Concussion in Sport Group in 2005. The CRT5 is designed to assist non-medically trained individuals to recognise the signs and symptoms of possible sport-related concussion and provides guidance for removing an athlete from play/sport and to seek medical attention. This paper presents the development of the CRT5 and highlights the differences between the CRT5 and prior versions of the instrument.
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http://dx.doi.org/10.1136/bjsports-2017-097508DOI Listing
June 2017

Socioeconomic status and outcomes after sport-related concussion: a preliminary investigation.

J Neurosurg Pediatr 2017 Jun 24;19(6):652-661. Epub 2017 Mar 24.

Vanderbilt Sports Concussion Center and.

OBJECTIVE A significant proportion of patients experience long-term symptoms after sport-related concussion (SRC), and several factors have been associated with this protracted recovery. Limited data exist on the role of socioeconomic status (SES) on SRC outcomes. The objective in this study was to conduct a preliminary investigation to determine the effect of SES on outcomes after SRC in student-athletes treated at a regional sports concussion center. METHODS A retrospective cohort study of 282 middle school, high school, and collegiate student-athletes was conducted. An attempt was made to contact all patients seen at a comprehensive SRC center between January 2012 and May 2015 for in-depth interviews. Subsequent demographic data were collected. The SES was defined as follows: cost of living percentile, median income percentile, percentage of college graduates, percentage of homeowners, county type, and insurance status. Outcomes after SRC were defined as follows: days of symptom duration, days of missed school, and days of missed practice. Statistically controlled covariates included sex, race, age, body mass index, concussion history, neuropsychiatric history, and type of sport. RESULTS A total of 282 student-athletes consented and were studied. The median age was 15.8 years (range 11.6-22.2 years) and 61.4% of student-athletes were male. A previous concussion was incurred by 34.0% of student-athletes. Football was the most common sport (32.3%), followed by soccer (16.3%), and basketball (15.6%). The median symptom duration was 21 days (range 1-365 days); the median missed school days was 2 (range 0-90 days); and median for days of missed practice was 10 (range 0-150 days). After multivariate Cox regression analysis, no relationship between any of the 6 SES variables and symptom duration or missed practice was seen. However, individuals with private insurance had more missed days of school than those with public insurance (hazard ratio 0.46, 95% CI 0.26-0.83, p = 0.009). CONCLUSIONS In a preliminary study of middle school, high school, and collegiate student-athletes, SES had no impact on the outcomes of symptom duration and missed practice. However, for individuals with private insurance, the return to school was slower than for those with public insurance. This pilot study reveals the complex relationship between SES and SRC recovery, which demands further study with more accurate and validated assessments of SES.
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http://dx.doi.org/10.3171/2017.1.PEDS16611DOI Listing
June 2017

In Reply to: Medical Student Recruitment into Neurosurgery: Maximizing the Pool of Talent.

World Neurosurg 2017 02;98:860

Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

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http://dx.doi.org/10.1016/j.wneu.2016.11.098DOI Listing
February 2017

Balance Assessment in Sports-Related Concussion: Evaluating Test-Retest Reliability of the Equilibrate System.

J Surg Orthop Adv 2016 ;25(2):93-8

Vanderbilt University School of Medicine, Nashville, Tennessee.

This study evaluated the test-retest reliability of a novel computer-based, portable balance assessment tool, the Equilibrate System (ES), used to diagnose sports-related concussion. Twenty-seven students participated in ES testing consisting of three sessions over 4 weeks. The modified Balance Error Scoring System was performed. For each participant, test-retest reliability was established using the intraclass correlation coefficient (ICC). The ES test-retest reliability from baseline to week 2 produced an ICC value of 0.495 (95% CI, 0.123-0.745). Week 2 testing produced ICC values of 0.602 (95% CI, 0.279-0.803) and 0.610 (95% CI, 0.299-0.804), respectively. All other single measures test-retest reliability values produced poor ICC values. Same-day ES testing showed fair to good test-retest reliability while interweek measures displayed poor to fair test-retest reliability. Testing conditions should be controlled when using computerized balance assessment methods. ES testing should only be used as a part of a comprehensive assessment.
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January 2017

Obesity and neurocognitive recovery after sports-related concussion in athletes: a matched cohort study.

Phys Sportsmed 2016 09 8;44(3):217-22. Epub 2016 Aug 8.

c Department of Neurosurgery , Vanderbilt University Medical Center , Nashville , TN , USA.

Objectives: Sports-related concussions (SRCs) are a significant public health concern in athletes. Data exist suggesting a link between obesity and decreased neurocognitive function, yet the effect of body mass index (BMI) on neurocognitive function and recovery after a SRC is unknown. The goal of our study was to discern the effect of BMI on recovery after SRC.

Methods: This study was a retrospective observational cohort study. Between 2013 and 2014, 7,606 athletes between the ages of 13-20 years valid baseline neurocognitive testing performed at multiple regional concussion centers sustained a concussion. Out of these athletes, 711 normal weight athletes and 711 obese athletes were matched by age, gender, number of previous concussions, and sport. The proportions of athletes returning to baseline within two weeks between the groups were defined by using 80% confidence reliable change index (RCI) criteria and were compared using Fisher's Exact Test. Kaplan-Meier survival curve analysis with log-rank test was used to compare the median time to neurocognitive recovery between groups.

Results: Fewer obese athletes returned to baseline within 2 weeks on measures of verbal memory, visual motor speed, reaction time, postconcussion symptom scale (PCSS), and overall recovery compared to normal weight athletes. Obese athletes also had greater median time of return to baseline with respect to reaction time, PCSS, and overall recovery.

Conclusion: Using RCI methodology, there exists an association between obesity and increased time to return to neurocognitive and symptom baseline after SRC in athletes, specifically reaction time, symptom scores, and overall recovery.
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http://dx.doi.org/10.1080/00913847.2016.1216718DOI Listing
September 2016

Sport-related structural brain injury associated with arachnoid cysts: a systematic review and quantitative analysis.

Neurosurg Focus 2016 Apr;40(4):E9

Vanderbilt Sports Concussion Center, and.

OBJECTIVE Arachnoid cysts (ACs) are congenital lesions bordered by an arachnoid membrane. Researchers have postulated that individuals with an AC demonstrate a higher rate of structural brain injury after trauma. Given the potential neurological consequences of a structural brain injury requiring neurosurgical intervention, the authors sought to perform a systematic review of sport-related structural-brain injury associated with ACs with a corresponding quantitative analysis. METHODS Titles and abstracts were searched systematically across the following databases: PubMed, Embase, CINAHL, and PsycINFO. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Peer-reviewed case reports, case series, or observational studies that reported a structural brain injury due to a sport or recreational activity (hereafter referred to as sport-related) with an associated AC were included. Patients were excluded if they did not have an AC, suffered a concussion without structural brain injury, or sustained the injury during a non-sport-related activity (e.g., fall, motor vehicle collision). Descriptive statistical analysis and time to presentation data were summarized. Univariate logistic regression models to assess predictors of neurological deficit, open craniotomy, and cystoperitoneal shunt were completed. RESULTS After an initial search of 994 original articles, 52 studies were found that reported 65 cases of sport-related structural brain injury associated with an AC. The median age at presentation was 16 years (range 4-75 years). Headache was the most common presenting symptom (98%), followed by nausea and vomiting in 49%. Thirteen patients (21%) presented with a neurological deficit, most commonly hemiparesis. Open craniotomy was the most common form of treatment (49%). Bur holes and cyst fenestration were performed in 29 (45%) and 31 (48%) patients, respectively. Seven patients (11%) received a cystoperitoneal shunt. Four cases reported medical management only without any surgical intervention. No significant predictors were found for neurological deficit or open craniotomy. In the univariate model predicting the need for a cystoperitoneal shunt, the odds of receiving a shunt decreased as age increased (p = 0.004, OR 0.62 [95% CI 0.45-0.86]) and with male sex (p = 0.036, OR 0.15 [95% CI 0.03-0.88]). CONCLUSIONS This systematic review yielded 65 cases of sport-related structural brain injury associated with ACs. The majority of patients presented with chronic symptoms, and recovery was reported generally to be good. Although the review is subject to publication bias, the authors do not find at present that there is contraindication for patients with an AC to participate in sports, although parents and children should be counseled appropriately. Further studies are necessary to better evaluate AC characteristics that could pose a higher risk of adverse events after trauma.
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http://dx.doi.org/10.3171/2016.1.FOCUS15608DOI Listing
April 2016

The Sport Concussion Assessment Tool: a systematic review.

Neurosurg Focus 2016 Apr;40(4):E6

Vanderbilt Sports Concussion Center, and.

OBJECTIVE Over the last 2 decades, sport-related concussion (SRC) has garnered significant attention. Even with increased awareness and athlete education, sideline recognition and real-time diagnosis remain crucial. The need for an objective and standardized assessment of concussion led to the eventual development of the Sport Concussion Assessment Tool (SCAT) during the Second International Conference on Concussion in Sport in 2004, which is now in its third iteration (SCAT3). In an effort to update our understanding of the most well-known sideline concussion assessment, the authors conducted a systematic review of the SCAT and the evidence supporting its use to date. METHODS English-language titles and abstracts published between 1995 and October 2015 were searched systematically across 4 electronic databases and a review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines adapted for the review of a heterogeneous collection of study designs. Peer-reviewed journal articles were included if they reported quantitative data on any iteration of the SCAT, Standardized Assessment of Concussion (SAC), or modified Balance Error Scoring System (mBESS) data at baseline or following concussion in an exclusively athlete population with any portion older than 13 years of age. Studies that included nonathletes, only children less than 13 years old, exclusively BESS data, exclusively symptom scale data, or a non-SCAT-related assessment were excluded. RESULTS The database search process yielded 549 abstracts, and 105 full-text articles were reviewed with 36 meeting criteria for inclusion. Nineteen studies were associated with the SAC, 1 was associated with the mBESS exclusively, and 16 studies were associated with a full iteration of the SCAT. The majority of these studies (56%) were prospective cohort studies. Male football players were the most common athletes studied. An analysis of the studies focused on baseline differences associated with age, sex, concussion history, and the ability to detect an SRC. CONCLUSIONS Looking toward the upcoming Concussion in Sport Group meeting in fall 2016, one may expect further revision to the SCAT3. However, based on this systematic review, the authors propose further, in-depth study of an already comprehensive concussion test, with acute, diagnostic, as well as long-term use.
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April 2016

Predictors of postconcussion syndrome in collegiate student-athletes.

Neurosurg Focus 2016 Apr;40(4):E13

Datalys Center for Sports Injury Research and Prevention, Indianapolis, Indiana.

OBJECTIVE Sport-related concussion (SRC) has emerged as a public health problem, especially among student-athletes. Whereas most concussions resolve by 2 weeks, a minority of patients experience postconcussion syndrome (PCS), in which symptoms persist for months. The objective of this study was to elucidate factors predictive of PCS among a sample of National Collegiate Athletic Association (NCAA) student-athletes in the academic years 2009-2010 to 2014-2015. METHODS The SRC data originated from the NCAA Injury Surveillance Program (ISP) in the 2009-2010 to 2014-2015 academic seasons. The NCAA ISP is a prospective database made up of a convenience sample of schools across all divisions. All SRCs are reported by certified athletic trainers. The PCS group consisted of concussed student-athletes with concussion-related symptoms that lasted ≥ 4 weeks. The non-PCS group consisted of concussed student-athletes with symptom resolution in ≤ 2 weeks. Those with symptoms that resolved in the intermediate area of 2-4 weeks were excluded. Odds ratios (ORs) were estimated using logistic regression. RESULTS During the 2009-2010 to 2014-2015 seasons, 1507 NCAA student-athletes sustained an SRC, 112 (7.4%) of whom developed PCS (i.e., concussion-related symptoms that lasted ≥ 4 weeks). Men's ice hockey contributed the largest proportion of concussions to the PCS group (28.6%), whereas men's football contributed the largest proportion of concussions in the non-PCS group (38.6%). In multivariate analysis, recurrent concussion was associated with increased odds of PCS (OR 2.08, 95% CI 1.28-3.36). Concussion symptoms that were also associated with increased odds of PCS included retrograde amnesia (OR 2.75, 95% CI 1.34-5.64), difficulty concentrating (OR 2.35, 95% CI 1.23-4.50), sensitivity to light (OR 1.97, 95% CI 1.09-3.57), and insomnia (OR 2.19, 95% CI 1.30-3.68). Contact level, sex, and loss of consciousness were not associated with PCS. CONCLUSIONS Postconcussion syndrome represents one of the most impactful sequelae of SRC. In this study of exclusively collegiate student-athletes, the authors found that recurrent concussions and various concussion-related symptoms were associated with PCS. The identification of initial risk factors for the development of PCS may assist sports medicine clinicians in providing timely interventions and treatments to prevent morbidity and shorten recovery time after SRC.
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http://dx.doi.org/10.3171/2016.1.FOCUS15593DOI Listing
April 2016

Participation in Pre-High School Football and Neurological, Neuroradiological, and Neuropsychological Findings in Later Life: A Study of 45 Retired National Football League Players.

Am J Sports Med 2016 May 17;44(5):1106-15. Epub 2016 Feb 17.

Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

Background: A recent study found that an earlier age of first exposure (AFE) to tackle football was associated with long-term neurocognitive impairment in retired National Football League (NFL) players.

Purpose: To assess the association between years of exposure to pre-high school football (PreYOE) and neuroradiological, neurological, and neuropsychological outcome measures in a different sample of retired NFL players.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: Forty-five former NFL players were included in this study. All participants prospectively completed extensive history taking, a neurological examination, brain magnetic resonance imaging, and a comprehensive battery of neuropsychological tests. To measure the associations between PreYOE and these outcome measures, multiple regression models were utilized while controlling for several covariates.

Results: After applying a Bonferroni correction for multiple comparisons, none of the neurological, neuroradiological, or neuropsychological outcome measures yielded a significant relationship with PreYOE. A second Bonferroni-corrected analysis of a subset of these athletes with self-reported learning disability yielded no significant relationships on paper-and-pencil neurocognitive tests but did result in a significant association between learning disability and computerized indices of visual motor speed and reaction time.

Conclusion: The current study failed to replicate the results of a prior study, which concluded that an earlier AFE to tackle football might result in long-term neurocognitive deficits. In 45 retired NFL athletes, there were no associations between PreYOE and neuroradiological, neurological, and neuropsychological outcome measures.
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http://dx.doi.org/10.1177/0363546515626164DOI Listing
May 2016

Central Nervous System Cancers, Version 1.2015.

J Natl Compr Canc Netw 2015 Oct;13(10):1191-202

From University of Alabama at Birmingham Comprehensive Cancer Center; City of Hope Comprehensive Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Yale Cancer Center/Smilow Cancer Hospital; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; The University of Texas MD Anderson Cancer Center; UCSF Helen Diller Family Comprehensive Cancer Center; University of Washington/Seattle Cancer Care Alliance; Roswell Park Cancer Institute; Duke Cancer Institute; UC San Diego Moores Cancer Center; University of Michigan Comprehensive Cancer Center; Memorial Sloan Kettering Cancer Center; St. Jude Children's Research Hospital/University of Tennessee Health Science Center; Massachusetts General Hospital Cancer Center; American Brain Tumor Association; Vanderbilt-Ingram Cancer Center; Mayo Clinic Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Stanford Cancer Institute; Fred & Pamela Buffet Cancer Center; Huntsman Cancer Institute at the University of Utah; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; Moffitt Cancer Center; Fox Chase Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; National Comprehensive Cancer Network.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Central Nervous System (CNS) Cancers provide interdisciplinary recommendations for managing adult CNS cancers. Primary and metastatic brain tumors are a heterogeneous group of neoplasms with varied outcomes and management strategies. These NCCN Guidelines Insights summarize the NCCN CNS Cancers Panel's discussion and highlight notable changes in the 2015 update. This article outlines the data and provides insight into panel decisions regarding adjuvant radiation and chemotherapy treatment options for high-risk newly diagnosed low-grade gliomas and glioblastomas. Additionally, it describes the panel's assessment of new data and the ongoing debate regarding the use of alternating electric field therapy for high-grade gliomas.
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http://dx.doi.org/10.6004/jnccn.2015.0148DOI Listing
October 2015

Post-concussion syndrome (PCS) in a youth population: defining the diagnostic value and cost-utility of brain imaging.

Childs Nerv Syst 2015 Dec 29;31(12):2305-9. Epub 2015 Sep 29.

Department of Neurological Surgery, Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Medical Center North T-4224, 37212, Nashville, TN, USA.

Purpose: Approximately 90% of concussions are transient, with symptoms resolving within 10-14 days. However, a minority of patients remain symptomatic several months post-injury, a condition known as post-concussion syndrome (PCS). The treatment of these patients can be challenging. The goal of our study was to assess the utility and cost-effectiveness of neurologic imaging two or more weeks post-injury in a cohort of youth with PCS.

Methods: We conducted a retrospective study of 52 pediatric patients with persistent post-concussion symptoms after 3 months. We collected demographics and neuroimaging results obtained greater than 2 weeks post-concussion. Neuroimaging ordered in the first 2 weeks post-concussion was excluded, except to determine the rate of re-imaging. Descriptive statistics and corresponding cost data were collected.

Results: Of 52 patients with PCS, 23/52 (44%) had neuroimaging at least 2 weeks after the initial injury, for a total of 32 diagnostic studies. In summary, 1/19 MRIs (5.3%), 1/8 CTs (13%), and 0/5 x-rays (0%) yielded significant positive findings, none of which altered clinical management. Chronic phase neuroimaging estimated costs from these 52 pediatric patients totaled $129,025. We estimate the cost to identify a single positive finding was $21,000 for head CT and $104,500 for brain MRI.

Conclusions: In this cohort of pediatric PCS patients, brain imaging in the chronic phase (defined as more than 2 weeks after concussion) was pursued in almost half the study sample, had low diagnostic yield, and had poor cost-effectiveness. Based on these results, outpatient management of pediatric patients with long-term post-concussive symptoms should rarely include repeat neuroimaging beyond the acute phase.
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http://dx.doi.org/10.1007/s00381-015-2916-yDOI Listing
December 2015

Neurosurgery Elective for Preclinical Medical Students: Early Exposure and Changing Attitudes.

World Neurosurg 2016 Feb 7;86:120-6. Epub 2015 Sep 7.

Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Objective: Exposure to surgical subspecialties is limited during the preclinical years of medical school. To offset this limitation, the authors created a neurosurgery elective for first- and second-year medical students. The objective was to provide each student with early exposure to neurosurgery by combining clinical experience with faculty discussions about the academic and personal realities of a career in neurosurgery.

Methods: From 2012 to 2013, the authors offered a neurosurgery elective course to first- and second-year medical students. Each class consisted of the following: 1) peer-reviewed article analysis; 2) student presentation; 3) faculty academic lecture; 4) faculty personal lecture with question and answer period.

Results: Thirty-five students were enrolled over a 2-year period. After completing the elective, students were more likely to: consider neurosurgery as a future career (P < 0.0001), perceive the personalities of attending physicians to be more collegial and friendly (P = 0.0002), perceive attending quality of life to be higher (P < 0.0001), and believe it was achievable to be a neurosurgeon and have a family (P < 0.0001). The elective did not alter students' perceived difficulty of training (P = 0.7105).

Conclusions: The neurosurgery elective course significantly increased student knowledge across several areas and changed perceptions about collegiality, quality of life, and family-work balance, while not altering the students' views about the difficulty of training. Adopting a neurosurgery elective geared towards preclinical medical students can significantly change attitudes about the field of neurosurgery and has potential to increase interest in pursuing a career in neurosurgery.
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http://dx.doi.org/10.1016/j.wneu.2015.08.081DOI Listing
February 2016
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