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There are conflicting reports on the efficacy of exercise in chronic venous insufficiency (CVI). Exercise in water or aquatic activity (AA) can have additional advantages. We sought to evaluate the clinical effects of AA in CVI in a randomized prospective open label fashion.A total of 201 patients with advanced CVI were randomized to receive AA vs no such treatment. In the Aquatic Group (AG), 91 patients reached the 24-month follow-up point, and in the Control Group (CG), 90 patients did. The primary efficacy end point was a predefined reduction of ≥4 points in the modified Venous Clinical Severity Score (VCSS) at 3 months. Instruments of venous disease severity and quality of life were compared at baseline, 3 months, and 24 months between and within the two groups. These included the modified VCSS, Villalta score, leg and thigh circumference, the Physical Health Component of the 36-Item Short Form Health Survey, and the Venous Insufficiency Epidemiological and Economic Study Quality of Life/Symptom scores. Aquatic activity consisted of a minimum of 15 minutes of walking in a swimming pool at 1 m/s, 3 times/wk for 3 months.The primary end point of 4-point reduction in the modified VCSS at 3 months was reached in 28% of AG and 3% of CG (odds ratio = 12.08; 95% confidence interval: 3.51, 41.59; P .001). Comparison of changes in secondary end points from baseline to 24 months between AG and CG demonstrated the following: modified VCSS -4.08 ± 2.08 vs -1.15 ± 1.26, Villalta score -4.00 ± 2.68 vs -1.01 ± 1.34, thigh circumference -3.40 ± 1.78 cm vs -1.40 ± 2.55 cm, leg circumference -1.27 ± 1.34 cm vs -0.49 ± 1.21 cm, Physical Health Component of the 36-Item Short Form Health Survey 3.82 ± 2.36 vs 1.16 ± 1.18, Venous Insufficiency Epidemiological and Economic Study Quality of Life 3.35 ± 1.67 vs 1.30 ± 1.43, and Venous Insufficiency Epidemiological and Economic Study Symptom 3.53 ± 1.71 vs 1.23 ± 1.26 (P .001 for all comparisons; ± denotes mean ± standard deviation).The addition of AA to the treatment of patients with advanced CVI is safe and effective, leading to a significant improvement in clinical status and quality of life. These beneficial changes occur rapidly within 3 months of initiation of AA and are continued at a slower rate of improvement from 3 months to 2 years.

Context: Concussions are shown to hinder multiple health dimensions, including health-related quality of life (HRQOL), suggesting a need for a whole-person approach to assessment and treatment. Patient-reported outcome measures are one method to gather the patient’s perspective regarding their HRQOL. Objective: To evaluate perceived HRQOL using the Patient-Reported Outcomes Measurement Information System Pediatric-25 subscale in patients throughout concussion recovery. Design: Prospective cohort, descriptive survey. Setting: There were 9 high school athletic training facilities. Participants: A total of 70 patients with diagnosed concussions (51 males, 7 females, 12 unreported; age = 15.7 [0.9] y, height = 174.6 [8.4] cm, mass = 72.8 [14.8] kg, grade = 10.0 [0.9] level). Interventions: Patient-Reported Outcomes Measurement Information System Pediatric-25 was administered at 3 days, 10 days postconcussion, and return to play (RTP). Main Outcome Measures: Patient-Reported Outcomes Measurement Information System Pediatric-25 subscale T scores and self-reported concussion history (yes/no). Results: A total of 70 patients completed the study. For the Pediatric-25 subscales, the severity of problems associated with Physical Function Mobility, Anxiety, Depression, Fatigue, and Pain Interference were highest 3 days postconcussion, decreasing at 10 days and RTP (all p p p > .05). Ceiling and floor effects were present in all subscales throughout each timepoint, except for Physical Function Mobility (14.7%), and pain interference (11.8%) at day 3 postinjury. Conclusions: Patients who had suffered a concussion improved from day 3 through RTP on multiple health domains as demonstrated through the Pediatric-25 subscales. These findings highlight the need for health care professionals to serially monitor HRQOL and social factors that may affect the patient postconcussion as part of a multifactorial assessment. Ceiling effects in high functioning adolescent athletes were present; thus, efforts should be made to identify appropriate scales for use in managing recovery in athletic populations.

Identifying risk factors for prolonged recovery following concussion can assist clinicians with appropriate management strategies. It is thought that athletes who continue to participate following a hit to the head or body may take longer to recover following a concussion diagnosis. To systematically review the body of literature regarding the effect of delayed reporting and delayed presentation to medical providers on concussion recovery times. Systematic review with meta-analysis. PubMed, Ovid Medline, SPORTDiscus, Cochrane Central Register of Controlled Trials and hand searches of reference lists. All the searches were performed in April 2020. Studies included an investigation of immediate versus delayed reporting or early versus late presentation following a concussion, were published in the past ten years, and were level 4 evidence or higher. 12 studies were included. Patients who continued play or delayed reporting their concussion had significantly longer recovery times (standardized mean difference = 0.36 days (95%CI 0.066, 0.662) than those who immediately reported or were removed from play (p = 0.017). Expressed in raw scores, those who immediately reported recovered in 5.4 days (95% CI − 10.14, − 0.75) fewer than delayed reporters. Comparable results were found for post-concussion symptom scores (p = 0.034) with immediate reporters demonstrating lower symptom severity scores. Our qualitative synthesis found patients who presented earlier to a concussion specialist tended to recover faster than those who presented later. Patients who delayed reporting or continued play had longer recovery times compared to their immediately-reporting peers. Providers should ask concussion patients approximately how long they waited to report their injury, and also focus educational efforts on encouraging immediate reporting of concussion.

PURPOSE The purpose of this study was to evaluate potential benefits of use of an abdominal binder after cesarean birth. STUDY DESIGN AND METHODS A randomized controlled trial was conducted at a Magnet-designated, academic medical center in the southwest United States. English- and Spanish-speaking adult women scheduled for an elective cesarean birth were randomized to the intervention or control group. Outcomes were measured for the first 48 hours postoperatively, including pain, medication use, and self-reported symptom distress. RESULTS Randomization resulted in balanced groups. Women who used the abdominal binder after cesarean birth reported a decrease in pain after ambulation, whereas women in the control group reported an increase in pain after ambulation (p < .001). Women in the binder group reported less distress on the Breathe and Cough items of the Symptom Distress Scale than those in the control group. On postoperative day 2, women in the binder group used more ibuprofen (p = .002) and acetaminophen (p = .027) than the control group. CLINICAL IMPLICATIONS Use of an abdominal binder by women after cesarean birth can decrease pain, potentially enhancing speed of postoperative recovery. As a nursing intervention, abdominal binders may offer women a safe nonpharmacologic option to provide postoperative comfort.

OBJECTIVE Our purpose was to determine the association between concussion recovery and health-related quality of life (HRQOL). SETTING Secondary school athletic training facilities. PARTICIPANTS Patients (N = 122) with a concussion. STUDY DESIGN Prospective, longitudinal cohort. MAIN MEASURES The Pediatric Quality-of-Life Inventory (PedsQL), PedsQL Multidimensional Fatigue Scale (MFS), and Headache Impact Test-6 (HIT-6) were completed at preseason and days 3 (D3), 10 (D10), and 30 (D30) postconcussion. The independent variable was the recovery group. RESULTS Interactions between group and time (P < .001) were noted for all PedsQL subscales, except Social Functioning (P = .75). Significantly lower scores were found among Prolonged than in Short on D3 (P < .05). Significant interactions (P < .001) were also noted for all MFS subscales. Pairwise comparisons for General and Sleep subscales revealed Prolonged had lower scores than Short and Moderate on D3 and D10. A group by time interaction was found for the HIT-6 (P < .001), with scores being higher (P < .01) in Prolonged than in Short on D3 and D10. CONCLUSIONS Adolescents with a prolonged recovery demonstrated lower HRQOL in the immediate days postinjury, particularly in physical and school functioning, fatigue, and headache. There was a strong association between recovery length and school functioning. Additional research is needed to understand how to minimize the impact of concussion on HRQOL.

Concussion symptoms are important self-reported indicators of recovery. The purpose of this study was to describe the symptom burden in the first 3 weeks postconcussion and estimate the strength of relationship between symptomatology and days postconcussion. Headache was the most commonly endorsed symptom during weeks 1 (71.1%), 2 (37.6%), and 3 (32.6%). Severity scores were negatively correlated with days postconcussion, p

We aimed to assess whether perceived pressure predicts concussion reporting intentions and behavior in youth, high school, and collegiate ice hockey athletes, and, secondarily, whether perceived pressure from stakeholders differed between sex or level of play.Online survey.One hundred fifty-two ice hockey athletes (males: n = 96, 63.2%; females: n = 55, 36.2%; missing: n = 1, 0.7%; age = 14.04 ± 3.6 years).Cross-sectional.Respondents answered a survey that elicited information about demography, perceived pressure from 6 stakeholders, and concussion reporting intentions and behavior. For the first aim, we used a generalized linear model to determine whether perceived pressure from any stakeholder predicted intention (symptom reporting, concussion reporting, and intention beliefs) or behavior ("all concussions," "not obvious concussions"; α.05) while controlling for level of play. To determine whether pressure from any stakeholder predicted symptom reporting behavior, we used logistic regression while controlling for level of play. For the second aim, to examine sex differences in perceived pressure from each stakeholder, we employed Mann-Whitney tests and to examine level of play differences, we used Kruskal-Wallis tests.Controlling for level of play, a 1-point increase in perceived pressure from parents and athletic administrators decreased concussion reporting intentions by 0.92 (P = .004) and 1.09 (P = .005) points, respectively. Perceived pressure from a sports medicine professional decreased intention beliefs by 0.17 (P = .029) points. Perceived pressure from stakeholders did not predict symptom reporting (P = .440) or "not obvious concussion" reporting (P = .655) behavior. We observed no difference in perceived pressure across stakeholders (all P values.05); however, collegiate ice hockey respondents perceived greater pressure from coaches than youth or high school athletes (P.001). We noted no other differences in perceived pressure across levels of play (all P values.05).Concussion reporting intentions were negatively influenced by perceived pressure from parents, athletic administrators, and sports medicine professionals, but these findings did not translate to reporting behavior.

Postural control deficits are a key component to injury assessment and, more specifically, following concussion. However, these assessments are often administered in a serial manner to track deficits and recovery, thus the stability or test-retest reliability of these measures is important. With the advent of mobile applications to assess postural control, it is important to evaluate the reliability of these tools; therefore our purpose was to estimate reliability for the Sway Balance™ mobile application, a portable device for postural control assessment. Postural control assessment of males between ages 7–22 showed good-to-excellent reliability in the overall composite score of the Sway Balance™. Sway Balance™ is a reliable tool for measuring postural control.

This study builds upon a project that developed clinical criteria to identify undiagnosed hypertension patients "hiding in plain sight" (HIPS) by examining patient characteristics to understand whether there are disparities in hypertension diagnosis. We examined electronic health record demographic data for patients identified by the HIPS criteria and subgroups at 3 Missouri health centers. Identified patients who returned for a follow-up visit and were subsequently diagnosed with hypertension tended to be older, black/African American, uninsured, and classified as having obesity. Younger, white, healthy weight females were less likely to be diagnosed. These findings point to exploring possible biases/other nonclinical factors in hypertension diagnosis.

Previous randomized controlled trials evaluating the efficacy of mycophenolate mofetil (MMF) in patients with immunoglobulin A nephropathy (IgAN) have produced varying results.Double-blind placebo-controlled randomized controlled trial.52 children, adolescents, and adults with biopsy-proven IgAN in 30 centers in the United States and Canada. Entry criteria: age older than 7 to younger than 70 years; urine protein-creatinine ratio (UPCR), ≥0.6g/g (males) or ≥0.8g/g (females); and estimated glomerular filtration rate ≥ 50mL/min/1.73m(2) (≥40mL/min/1.73m(2) if receiving angiotensin-converting enzyme inhibitor). Mean age, 32±12 (SD) years; 62% men; and 73% white.Lisinopril (or losartan) plus a highly purified omega-3 fatty acid (Omacor [Pronova Biocare]) was given to 94 patients for 3 months; 52 of the patients with persistent UPCR≥0.6g/g (males) and ≥0.8g/g (females) were randomly assigned to MMF or placebo (target dose, 25-36mg/kg/d) in addition to lisinopril/losartan plus Omacor.Change in UPCR after 6 and 12 months treatment with MMF/placebo and 12 months after the end of treatment.UPCR measured on 24-hour urine samples. Glomerular filtration rate estimated with the Schwartz (age 18 years) or Cockcroft-Gault (age ≥ 18 years) formula.44 patients completed 6 months of treatment with MMF (n=22) or placebo (n=22). The trial was terminated early at the recommendation of the Data Monitoring Committee because of the lack of benefit. No patient achieved a complete remission (UPCR0.2g/g). Mean UPCRs at randomization and after 6 months were 1.45 (95% CI, 1.16-1.75) and 1.40 (95% CI, 1.09-1.70) for MMF and 1.41 (95% CI, 1.17-1.65) and 1.58 (95% CI, 1.13-2.04) for placebo, respectively. The mean difference in UPCR change between these groups (MMF minus placebo) was -0.22 (95% CI, -0.75 to 0.31; P=0.4). Adverse events were rare apart from nausea (MMF, 8.7%; placebo, 3.7%); one of these MMF patients withdrew.Low patient enrollment and short follow-up.MMF did not reduce proteinuria significantly in patients with IgAN who had persistent proteinuria after lisinopril/losartan plus Omacor.

Background. Geographical location, socioeconomic status, and logistics surrounding transportation impede access of poststroke individuals to comprehensive rehabilitative services. Robotic therapy may enhance telerehabilitation by delivering consistent and state-of-the art therapy while allowing remote monitoring and adjusting therapy for underserved populations. The Hand Mentor Pro (HMP) was incorporated within a home exercise program (HEP) to improve upper-extremity (UE) functional capabilities poststroke. Objective. To determine the efficacy of a home-based telemonitored robotic-assisted therapy as part of a HEP compared with a dose-matched HEP-only intervention among individuals less than 6 months poststroke and characterized as underserved. Methods. In this prospective, single-blinded, multisite, randomized controlled trial, 99 hemiparetic participants with limited access to UE rehabilitation were randomized to either (1) the experimental group, which received combined HEP and HMP for 3 h/d ×5 days ×8 weeks, or (2) the control group, which received HEP only at an identical dosage. Weekly communication between the supervising therapist and participant promoted compliance and progression of the HEP and HMP prescription. The Action Research Arm Test and Wolf Motor Function Test along with the Fugl-Meyer Assessment (UE) were primary and secondary outcome measures, respectively, undertaken before and after the interventions. Results. Both groups demonstrated improvement across all UE outcomes. Conclusions. Robotic + HEP and HEP only were both effectively delivered remotely. There was no difference between groups in change in motor function over time. Additional research is necessary to determine the appropriate dosage of HMP and HEP.

Background: While the assessment of symptoms, cognition, balance, and oculomotor function is common among sports medicine clinicians, there has been increased attention on assessing the patient’s perception of their health status following concussion. Recent recommendations suggest the use of patient-report outcome instruments (PROs) as part of the concussion evaluation to assess health-related quality of life (HRQOL) to aid in managing the injury. At present, there is not a concussion-specific PRO developed for the assessment of HRQOL in the pediatric population. Therefore, our purpose was to develop and assess the readability of a concussion-specific HRQOL measure, the Concussion Quality of Life Scale-Youth (CQOL-Y), using a mixed method approach. Methods: For instrument development and initial item generation, we analyzed prospectively collected data from three prior studies of HRQOL that used the Pediatric Quality of Life Inventory, Multidimensional Fatigue Scale, Headache Impact Test, and Patient-Reported Outcomes Measurement Information System outcome scales. Additionally, categories and themes from a prospective qualitative study of HRQOL following concussion were analyzed. Item themes were included in the initial item generation if the item was endorsed by greater than 15% of participants at day 3 or day 10 post-injury. As part of the gap analysis, a review of the literature was also conducted for studies of HRQOL following concussion to determine domains affected after injury and to review individual items on the PROs utilized in those studies. For readability assessment, we used two approaches: participant-based and computer-based assessments. For participant-based assessment of readability sixteen participants (7 children; 10.3±1.4 years, 5.4±1.5 grade level; 9 adolescents 14.2±1.7 years, 9.4±1.6 grade level) were recruited. The San Diego Quick Assessment of Reading Ability was used to determine each participant’s reading grade level. Participants then read each item of the CQOL-Y and circled words that they did not understand. Frequency counts were determined for each word identified by participants, for each item, domain, and the total CQOL-Y. For computer-based assessment of readability, the Flesch Reading Ease (FRE) and Flesch-Kincaid Reading Level (FK) scores were calculated for each item, domain, and the total CQOL-Y. The FRE is scored 0-100, with lower scores indicating more difficult reading material. The FRE score is converted to the FK, an approximate reading level, ranging from pre-primer (12), with higher reading level indicating more difficult reading material. Summary statistics were used to report scores for each item, domain, and the total CQOL-Y. Independent t-tests were used to determine whether differences existed between children (7-12 years) and adolescents (13-18 years) on the San Diego Quick Assessment of Reading Ability and the word difficulty endorsement. Results: For instrument development, after eliminating items that were endorsed by fewer than 15% of patients, we had a total of 27 items from the established PROs related to school and cognition, social, sleep and fatigue, activities of daily living, and sport participation that were reworded to be more specific to the athletic population. The gap analysis also identified a lack of emotion or mood related items. The initial item generation phase resulted in 50 HRQOL items and 3 single-item questions in the following domains identified as important to adolescents following concussion: cognitive and school (12 items), social (11 items), mood and emotions (13 items), sleep (8 items), and activities of daily living and sport participation (6 items). For participant-based assessment of readability, the average reading levels of the participants was 6.14±1.07 (range 5-8) in children and 8.78±1.40 (range 6-10) in adolescents, which was significantly different between groups (p=.001). For the total CQOL-Y scale, children identified difficulty with .44±.73 words (range 0-4) and adolescents identified 0.33±0.71 (range 0-2 words), which was not different between groups (p=.263). Among children, difficulty was noted with irritable, errands, isolated, and occurred, whereas adolescents identified irritable and cognitive. The computer-based readability analysis of the FRE for items ranged from 34.5 to 100. The FRE of the scale as a whole was 67.6 with domains ranging from 75.4-95.3. The FK reading level ranged from 0 to 9.8 across items with a total FK score of 5.6 and domain scores ranging from 2.2-5.6. Conclusion and Significance: Using a mixed methods approach to scale development, including context identification, concept elicitation, and item pool development, we have identified a 50-item scale to assess HRQOL following concussion. The initial analysis of readability suggests the overall scale was written at an appropriate reading level for children and adolescents. Future steps of scale development, including an expert panel review, item response theory model selection, item reduction, and field-testing will be conducted to improve readability of individual items and the patient acceptability of the CQOL-Y.

Little is known about the relationship between post-concussion impairments and health-related quality-of-life (HRQoL). The primary purpose of this study was to determine the relationship between traditional concussion assessments and HRQoL in adolescent athletes post-concussion. The secondary purpose was to determine the association between HRQoL deficits and time lost.In total, 1134 athletes completed a baseline assessment battery. HRQoL measures included the Pediatric Quality of Life Inventory (PedsQL), Multidimensional Fatigue Scale (MFS) and Headache Impact Test-6. In total, 122 athletes sustained a concussion and underwent follow-up testing at 3 and 10 days post-injury.The strongest relationships were between symptom severity and HRQoL. For concurrent regression analyses at Day 3, PedsQL-Physical accounted for 17.9% of the variance in time lost beyond that accounted for by traditional measures. At Day 10, PedsQL-School accounted for 15.2% and symptom severity for 7.1% of this variance. In predictive analyses, at Day 3, PedsQL-Physical accounted for 3.9% and MFS-General for 3.3% of the variance in time lost beyond that accounted for by traditional measures. At Day 10, MFS-Cognitive accounted for 12.0% of this variance.HRQoL appears to play a role in time lost post-concussion and should be measured in combination with traditional concussion assessments.

Purpose The purpose of this study was to evaluate the efficacy of peanut ball use on duration of first stage labor and pushing time in women who were scheduled for elective induction of labor at ≥39 weeks gestation and planning an epidural. Study design and methods In this randomized controlled trial, women having labor induction and planning a labor epidural were assigned (1:1) to one of two groups: one group used a peanut ball and one group did not. Outcome variables were time spent in first stage labor and time spent pushing. Factors included group assignment (peanut ball, no peanut ball), parity (primiparous, multiparous), and race. Age and maximum oxytocin dose served as covariates. Results Among women having elective induction with epidural analgesia, use of a peanut ball reduced first stage labor duration for primiparous patients significantly more than multiparous patients, p = 0.018. There was no significant difference in the reduction of length of first stage labor for multiparous women, p = 0.057 with use of the peanut ball. Peanut ball use did not alter length of pushing time for either group, p > 0.05. Clinical implications Use of peanut balls may reduce total labor time to a greater degree in primiparous patients than multiparous patients having elective induction at ≥39 weeks with epidural analgesia.

Background: To improve and standardize the sideline evaluation of sports-related concussion, the Sport Concussion Assessment Tool 2 (SCAT2) was developed. This tool assesses concussion-related signs and symptoms, cognition, balance, and coordination. This newly published assessment tool has not established representative baseline data on adolescent athletes. Hypothesis: Representative baseline SCAT2 scores in adolescent athletes will differ by gender, grade in school, and self-reported concussion history. Study Design: Descriptive epidemiology study. Methods: Interscholastic athletes were administered the SCAT2 during a preseason concussion baseline testing session. The SCAT2 total score ranges from 0 to 100 points, with lower scores indicating poorer performance. Overall, representative values were calculated using descriptive statistics. Separate independent-samples t tests, with gender and concussion history as the independent variables, and a 1-way analysis of variance, with grade as the independent variable, were conducted to assess differences in SCAT2 total score ( P < .05). Results: There were 1134 high school athletes (872 male and 262 female) who participated. The SCAT2 total score across all participants was 88.3 ± 6.8 (range, 58-100); skewness was −0.86 ± 0.07, and kurtosis was 0.73 ± 0.14. Male athletes scored significantly lower on the SCAT2 total score ( P = .03; 87.7 ± 6.8 vs 88.7 ± 6.8), and 9th graders (86.9 ± 6.8) scored significantly lower than 11th (88.7 ± 7.0) and 12th (89.0 ± 6.6) graders ( P < .001). Athletes with a self-reported concussion history scored significantly lower on the SCAT2 total score than those with no concussion history ( P < .001; 87.0 ± 6.8 vs 88.7 ± 6.5). Conclusion: These data provide representative scores on the SCAT2 in adolescent athletes and show that male athletes, 9th graders, and those with a self-reported concussion history scored significantly lower than their female, upperclassmen, or nonconcussed peers. Clinical Relevance: These results suggest that healthy adolescent athletes display variability on the SCAT2 at baseline. Therefore, clinicians should administer baseline assessments of the SCAT2 because assuming a perfect baseline score of 100 points is not appropriate in an adolescent athlete population.

ObjectiveThe purpose of this study was to evaluate test-retest reliability and practice effects of the Dynavision D2 in active adolescents.BackgroundFollowing sport-related concussion, assessment of oculomotor function and vision is important. While clinical tests are recommended, computerized devices, such as the Dynavision D2, are emerging as viable tools for vision assessment. As with all concussion assessments, understanding test-retest reliability and susceptibility to practice effects is important for appropriate interpretation of serial assessments post-injury.Design/methodsParticipants included 20 female adolescents (age = 16.6 ± 1.10 years, mass = 62.0 ± 5.9 kg, height = 169.2 ± 5.1 cm). Participants completed 2 test sessions 1 week apart using the Dynavision D2. The Dynavision D2 includes a one-minute drill task where a single light illuminates, and participants hit the light as quickly as possible, completing 3 drills per trial. Participants completed 3 trials during the first session and 2 during the second. Independent variables were day (day 1, day 2) and drills (15 drills). Dependent variables were the number of hits per minute (Hits/min) and average reaction time (AvgRT). Within-day and between-day test-retest reliabilities were analyzed using two-way random effects intraclass correlation coefficients for consistency. Practice effects were analyzed with repeated measures analysis of variance and Helmert contrasts (p = 0=.05).ResultsModerate-to-strong reliability was demonstrated for Hits/min (within-day 1 [ICC = 0.74; 95% CI: 0.53, 0.87]; within-day 2 [ICC = 0.91; 95% CI. 77.97]; between-days [ICC = 0.86; 95% CI. 65.95]). Moderate-to-strong reliability was demonstrated for AvgRT (within-day 1 [ICC = 0.70, 95% CI. 48.86], within-day 2 [ICC = 0.92; 95% CI. 78.97]; between-days [ICC = 0.85; 95% CI: 0.64.94]). Practice effects were noted for Hits/Min (p = 0.001) and AvgRT (p < 0.001). Helmert contrasts suggested that the practice effect plateaued at drill 11 for Hits/min and drill 12 for AvgRT.ConclusionsModerate-to-excellent test-retest reliability was found for the one-minute task drill with better reliability noted on day 2 and between days, compared to day 1. This task is susceptible to practice effects, highlighting the need for familiarization or practice trials prior to documenting patient scores.

Assessing the awareness and recognition of concussion is im- portant at all levels of athletics, especially youth sports. This study assessed the knowledge base of youth athletes and their parents regarding concussion and their ability to recognize it. Seventy-three youth athletes (age range, 10-14 years) and 100 parents responded to the survey. An athlete or parent version of a previously published survey about concussion was complet- ed by each participant. Athletes and parents did not differ ( P = .94) in their ability to recognize concussion symptoms. Youth athletes who reported having their "bell rung" did no better (P = .36) in recognizing concussion symptoms than those who had not. Parents with first aid certification or general medical train - ing recognized significantly more symptoms ( P = .01 and .01, respectively) than those without training. A knowledge deficit exists regarding symptom recognition and issues about sport- related concussion among youth athletes and their parents.

Objective The purpose of this study was to investigate factors influencing the success rate of orthodontic microimplants (OMIs) using panoramic radiographs (PRs). Methods We examined 160 OMIs inserted bilaterally in the maxillary buccal alveolar bone between the second premolars and first molars of 80 patients (51 women, 29 men; mean age, 18.0 ± 6.1 years) undergoing treatment for malocclusion. The angulation and position of OMIs, as well as other parameters, were measured on PRs. The correlation between each measurement and the OMI success rate was then evaluated. Results The overall success rate was 85.0% (136/160). Age was found to be a significant predictor of implant success (p < 0.05), while sex, side of placement, extraction, and position of the OMI tip were not significant predictors (p > 0.05). The highest success rate was observed for OMIs with tips positioned on the interradicular midline (IRML; central position). Univariate analyses revealed that the OMI success rate significantly increased with an increase in the OMI length and placement height of OMI (p = 0.001). However, in simultaneous analyses, only length remained significant (p = 0.027). Root proximity, distance between the OMI tip and IRML, interradicular distance, alveolar crest width, distance between the OMI head and IRML, and placement angle were not factors for success. Correlations between the placement angle and all other measurements except root proximity were statistically significant (p < 0.05). Conclusions Our findings suggest that OMIs positioned more apically with a lesser angulation, as observed on PRs, exhibit high success rates.

Context:Clinicians often rely on the self-report symptoms of patients in making clinical decisions; hence it is important that these scales be reliable.Objective:To determine the test-retest reliability of healthy youth in completing a graded symptom scale (GSS), modified from the Head Injury Scale Self-Report Concussion Symptoms Scale (HIS).Design:Repeated-measures.Setting:Middle school classroom.Patients or Other Participants:126 middle school students.Intervention:A survey consisting of a demographic and life events questionnaire and a GSS asking about symptom severity and duration.Main Outcomes Measures:Score for each symptom on the severity and duration scale and a total symptom score (TSS) and the total number of symptoms endorsed (TSE) from the severity scale. Responses on a life events questionnaire were also recorded.Results:We found excellent reliability for TSS (ICC = .93) and TSE (ICC = .88) for the severity scale. We found moderate to excellent reliability on the individual symptoms of both the severity (ICC = .65-.89) and duration (ICC =.56-.96) scales.Conclusions:Healthy youth can reliably self-report symptoms using a GSS. This patient-oriented outcome measure should be incorporated into more investigations in this age group.

Serious burn injuries are a potential threat to patients with seizure disorder. There are limited studies addressing this issue. Therefore, a retrospective study was undertaken with two goals: one to develop better understanding of this potential threat and two to create a prevention message regarding seizure-related burns. The burn center registry was reviewed to ascertain the number of patients who sustained burn injury during or directly after a seizure from 2000 to 2005. Thirty-two patients were admitted (44% female, 56% male) with mean age of 39 years (SD +/- 10.4) after sustaining a burn during or after a seizure. Average TBSA was 8.3% (SD +/- 4.8) with 72% of patients experiencing full-thickness burns. The three most prevalent etiologies were falling into a stove while cooking (34%; n = 11), falling on hot pavement (31%; n = 10), and falling into a campfire (9%; n = 3). A full 88% of patients (n = 28) reported a previous diagnosis of seizure disorder, whereas the other 9% (n = 3) reported seizures related to alcohol consumption. Laboratory reports revealed 20 patients (63%) had subtherapeutic levels of antiseizure medication, 1 patient (3%) had toxic levels, and 5 patients (16%) were not being treated for seizures. Upon discharge, 23 patients went home with family, 5 were discharged to skilled nursing, 1 to a homeless shelter, 1 died, and 2 patients were lost to follow-up. Because of the severe burns observed in epileptic burn patients, a burn-prevention brochure was developed and is being distributed to seizure patients and their families.

To determine the longitudinal and concurrent validity of single-item patient-rated outcomes (PROs) in adolescent football athletes with concussion.Longitudinal.Athletic training facilities.Convenience sample of male adolescent interscholastic athletes (n=94; mean age, 15.7±1.1y; mean grade, 10.1±1.1) from a larger investigation who suffered a sport-related concussion during football and had at least 3 follow-up assessments at 3, 10, and 30 days postinjury (N=249).Not applicable.Participants were administered 3 global rating questions (1 generic, 1 for daily activities, and 1 for athletic activities) along with the Pediatric Quality of Life Inventory (PedsQL), Multidimensional Fatigue Scale (MFS), and Headache Impact Test-6 (HIT-6) at 3, 10, and 30 days postconcussion. Longitudinal validity was determined through a mixed linear model with random effects for subjects, with pairwise differences assessed using Bonferroni correction (P.05). Concurrent validity was determined by examining Spearman ρ correlations between the single-item PROs and multi-item PROs.All 3 single-item PROs improved over time, demonstrating longitudinal validity (P.001), except day 10 versus day 30 for global change (P=.072). Fair to moderate correlations were identified between the single-item PROs and the PedsQL, MFS, and HIT-6.The improvement of single-item PRO scores over a postinjury time period of 30 days suggests that these PROs respond as expected to patient recovery. The correlations identified between the single-item PROs and common multi-item PROs used in athletes with concussion demonstrate concurrent validity. Therefore, single-item PROs appear to measure patient progress in adolescent football athletes postconcussion.

Methods We performed a cross-sectional survey of 357 reproductive-aged women, mostly Hispanic (81.8%), presenting for ambulatory and hospital reproductive care in Phoenix, AZ, about their interest in natural family planning (NFP). Participants completed questionnaires, and responses were analyzed to determine predictors of interest in NFP. Results Sixty-one percent stated that they were likely or very likely to use NFP to avoid pregnancy, and 50% would use NFP to achieve pregnancy. Of factors studied, Hispanic ethnicity, lower level of acculturation, less education and recent use of condoms or withdrawal were independently associated with interest in using NFP to avoid pregnancy. Younger age and desire for future pregnancy were independently predictive of potential NFP use to achieve pregnancy. Conclusion This study suggests that Hispanic women find NFP to be an appealing family planning alternative.

Objective The purpose of this study was to determine if cesarean delivery is a risk factor for respiratory distress syndrome (RDS) and if this risk is modified by labor before cesarean. Study design This population-based case-control study compared 4778 cases of RDS to 5 times as many controls. Results Unadjusted, cesarean delivery was associated with RDS, odds ratio (OR) 3.5 (95% CI 3.2–3.8). After controlling for potential confounding variables, cesarean remained an independent risk factor, OR 2.3 (95% CI 2.1–2.6). Labor modified this risk significantly ( P =.02)—with labor, cesarean delivery had an OR of 1.9 (95% CI 2.2–2.9), without labor, the OR was 2.6 (95% CI 1.3–2.8). Conclusion Cesarean delivery was an independent risk factor for RDS. The risk was reduced with labor before cesarean, but still elevated. This supports the importance of being certain of fetal lung maturity before cesarean delivery, particularly when done before labor.

Glioblastoma multiforme is extraordinarily aggressive due to the propensity of cells to migrate away from the tumor core into the surrounding normal brain. In this report, we investigated the role of proline-rich tyrosine kinase 2 (Pyk2) and FAK with regard to influencing glioma cell phenotypes. Expression of Pyk2 stimulated glioma cell migration, whereas expression of FAK inhibited glioma cell migration and stimulated cell cycle progression. Pyk2 autophosphorylation was necessary, but not sufficient, to stimulate cellular migration. The N-terminal domain of Pyk2 is required for stimulation of migration as an N-terminally deleted variant of Pyk2 failed to stimulate migration, whereas expression of an autonomous Pyk2 N-terminal domain inhibited cell migration. Substitution of the C-terminal domain of Pyk2 with the corresponding domain of FAK stimulated cell migration as effectively as wild-type Pyk2; however, substitution of the N-terminal domain of Pyk2 with that of FAK inhibited cell migration, substantiating that the N-terminal domain of Pyk2 was required to stimulate migration. Silencing of Pyk2 expression by RNA interference significantly inhibited glioma migration. Cell migration was restored on reexpression of Pyk2, but expression of FAK in Pyk2 knockdown cells failed to restore migration. We conclude that Pyk2 plays a central role in the migratory behavior of glioblastomas.

The objective of this study was to evaluate knowledge regarding folic acid among postpartum Mexican-American patients. A survey regarding folate was administered to postpartum women at a public hospital serving primarily Mexican-Americans (n = 393). English and Spanish speakers were compared. Fifty eight percent cited prevention of birth defects as a reason to take folate. English speakers were less likely to know this than Spanish speakers (p = 0.005). Fifty-one percent of women stated they had learned about folate from radio or television. Of these, 83% knew that folic acid prevents birth defects and that it should be taken prior to pregnancy. Only 16% learned about folate from a health care provider. Compared to previous research, Mexican-American women have increased awareness of the association between folate consumption and birth defects, especially Spanish speakers. Patients citing radio/television as a source of information tended to answer questions correctly, suggesting that media efforts in this area have been effective.

•Objective To test the simultaneous effect of various established predictors of breast and cervical cancer screening (breast self-examination, clinical breast examination by a physician, Papanicolaou [Pap] smear, and pelvic examination) in a low-income, Mexican-American sample. •Material and Methods A total of 188 Mexican-American women participated in a face-to-face structured interview in their preferred language. We tested a model with four established predictors of breast and cervical cancer screening—communication skills, knowledge of cancer, access to health care (finances and availability of care), and anxiety about cancer. Simultaneous structural equations analysis was used to form latent variables and to control for the effect of all predictors concurrently. •Results Screening behavior was inversely associated with anxiety about cancer when all other predictors were statistically controlled. In addition, anxiety substantially affected the relationship between communication skills and screening behavior. Unexpectedly, knowledge of cancer was positively, rather than negatively, associated with anxiety about cancer. Predictors in the model demonstrated an excellent fit of the proposed model to the data. •Conclusion Successful cancer screening programs for Mexican-American women must address not only access barriers but also communication skills, knowledge, and, perhaps most importantly, anxiety.

This study aimed to determine the prevalence of long-term anxiety disorder in burn-injured youth. It is well documented that inpatient pediatric burn patients experience heightened anxiety. However, the prevalence of anxiety disorder in pediatric burn survivors warrants further investigation. Participants completed the Screen for Anxiety Related Disorders, a 41-item self-report measuring anxiety disorder symptomatology. Respondents included 197 pediatric burn survivors, 105 boys, 92 girls, who were between 8 and 18 years of age; the mean age was 12.4 ± 2.4 years. Mean age at time of injury was 5.8 ± 3.7 years, with 79% of youth reporting visible scars. There were 77 participants (39%) who screened positive for a possible anxiety disorder with a total anxiety score ≥25, and 28% with a total mean score of ≥30, more specific to the likely presence of anxiety disorder. Nearly half of the participants (44%) reported symptoms indicating the presence of separation anxiety with a mean score of ≥5, and 28% had symptoms indicating the presence of panic disorder and school avoidance disorder. Significant sex differences were observed for anxiety, with girls scoring significantly higher than boys on total anxiety P ≤ .001 and on all four subscales. Youth attending burn camps for ≥5 years reported significantly lower anxiety scores. This study supports the screening of burn-injured youth for anxiety disorder and highlights the importance of educating parents and burn care professionals regarding the symptoms of anxiety disorders. This can help to ensure that pediatric burn survivors receive treatment when anxiety disorder symptoms are present. Screening appears to be especially important for girls.

Objective And Study Design: Ovarian needle diathermy was used in the treatment of clomiphene-resistant polycystic ovarian syndrome (PCOS). Factors predictive of pregnancy in our study group included younger age, lower body weight, and surgery before 1998. Results And Conclusion: Insulin resistance and adhesions at surgery were negatively associated with pregnancy. Sixty-six percent of the study group cycled spontaneously after surgery and 50% became pregnant. (Am J Obstet Gynecol 2003;188:1171-3.)

A causal role of mutations in multiple general transcription factors in neurodevelopmental disorders including autism suggested that alterations in global levels of gene expression regulation might also relate to disease risk in sporadic cases of autism. This premise can be tested by evaluating for changes in the overall distribution of gene expression levels. For instance, in mice, variability in hippocampal-dependent behaviors was associated with variability in the pattern of the overall distribution of gene expression levels, as assessed by variance in the distribution of gene expression levels in the hippocampus. We hypothesized that a similar change in variance might be found in children with autism. Gene expression microarrays covering greater than 47,000 unique RNA transcripts were done on RNA from peripheral blood lymphocytes (PBL) of children with autism (n = 82) and controls (n = 64). Variance in the distribution of gene expression levels from each microarray was compared between groups of children. Also tested was whether a risk factor for autism, increased paternal age, was associated with variance. A decrease in the variance in the distribution of gene expression levels in PBL was associated with the diagnosis of autism and a risk factor for autism, increased paternal age. Traditional approaches to microarray analysis of gene expression suggested a possible mechanism for decreased variance in gene expression. Gene expression pathways involved in transcriptional regulation were down-regulated in the blood of children with autism and children of older fathers. Thus, results from global and gene specific approaches to studying microarray data were complimentary and supported the hypothesis that alterations at the global level of gene expression regulation are related to autism and increased paternal age. Global regulation of transcription, thus, represents a possible point of convergence for multiple etiologies of autism and other neurodevelopmental disorders.

To determine the understanding of sport-related concussion among youth sports coaches.Cross-sectional survey.The survey was administered at coaches' meetings, following practices, and via mail.156 active youth sports coaches, with 5.88 +/- 3.16 years (range 1-22) of coaching experience.An original survey instrument developed to assess concussion knowledge. Internal validity of the instrument was established prior to the study (Cronbach's alpha = 0.83).Scores on the survey instrument reflecting symptom recognition and management knowledge.For the 16 items comprising the symptom recognition survey, the mean number of correct responses was 9.78 +/- 2.07. Previous coaching education was predictive of better symptom recognition. On the true/false portion, between 49.4% and 61.5% of coaches correctly answered the 4 statements.This investigation revealed that, among youth sports coaches, coaching education was predictive of the ability to recognize signs and symptoms of sport-related concussion. However, several misconceptions about concussion still exist, highlighting that education regarding concussion is necessary. The presence of qualified health care personnel, such as an athletic trainer, at the youth organization level may enhance early recognition, treatment, and referral of concussions.

Objective This study was undertaken to determine whether the association of intimate partner violence with urinary tract infection and pyelonephritis in pregnancy is due to a higher rate of asymptomatic bacteriuria in those suffering intimate partner violence. Study Design Women enrolling in prenatal care had urine collected for quantitative culture (n = 342) and completed 2 scales with a computer-based survey system: The Conflict Tactics Scale for verbal and physical abuse and the Castro survey for sexual abuse. Results The prevalence of verbal abuse during pregnancy was 46.9%, physical abuse, 7.6%, sexual abuse 5.8%. No significant associations were seen between quantitative culture of uropathogens and verbal, physical, or sexual abuse. Conclusion It is unlikely that the reason for the association of urinary tract infection and intimate partner violence is due to a higher number of uropathogens present in the urine of women with verbal, physical, or sexual abuse.

Objective This study was undertaken to identify risk factors for prolonged neonatal intensive care unit (NICU) stay in macrosomic (≥ 4000 g) neonates. Study design A population-based case-control study in which 799 cases of macrosomic neonates with a prolonged NICU stay were compared with macrosomic neonates without a prolonged stay (n = 1598). Results Significant risk factors included: 5-minute Apgar score less than 7: odds ratio (OR) = 43.1; fetal distress: OR = 3.0; birth length less than 20 inches: OR = 2.2; birth weight more than 5000 g: OR = 2.6; maternal diabetes: OR = 3.0; gestational age 37 to 38 weeks: OR = 2.2; cephalopelvic disproportion: OR = 2.5; primary cesarean: OR = 2.6; forceps/vacuum: OR = 1.7. No significant association was seen with labor induction/augmentation or dysfunctional/prolonged labor. Conclusion Prolonged stay in macrosomic neonates was related to fetal distress measures and less to factors related to prolonged labor. Attention to intrapartum fetal status during labor with suspected macrosomia appears to be especially warranted.

Background Breast cancer incidence and survival varies by race and ethnicity. There are limited data regarding breast cancer in Native American women. Methods A retrospective chart review was performed of 139 women diagnosed with breast cancer and treated at Phoenix Indian Medical Center in Phoenix, AZ between January 1, 1982 and December 31, 2003. Data points included tribal affiliation, and quantum (percentage American Indian Heritage) along with patient, tumor, and treatment characteristics. Results Most patients (79%) presented initially with physical symptoms. There were no significant differences based on tribal affiliation; however, higher quantum predicted both larger tumor size and more advanced stage at diagnosis. Obesity also significantly correlated with larger tumor size and more advanced stage. Treatment was inadequate in 21%; this was attributed to traditional beliefs, patient refusal, or financial issues. Conclusions When compared to national averages, Native American women presented at a later stage, underutilized screening, and had greater delays to treatment.

Objective To investigate changes in SCAT2 scores in high school athletes in the first 10 days post-concussion. Design Within subjects, repeated measures. Setting High school athletic facilities. Patients 119 high school athletes who sustained a sport-related concussion diagnosed by their athletic trainer (102 males, 15 females, and 2 missing, age=15.8±1.2, grade=10.0±1.0 level). Interventions The SCAT2 was administered during a preseason baseline, day of injury (DOI), and days 3 (D3) and 10 (D10) post-concussion. The SCAT2 total score is calculated by summing each component score, and has a maximum of 100 points. Main Outcome Measures Day of testing served as the independent variable and the dependent variable was SCAT2 total score. Analyses were conducted using a generalised estimating equations approach to accommodate repeated measures of the same participants. An inverse Gaussian distribution and identity link were specified, along with robust variance estimators. Follow-up pairwise tests employed a Bonferroni correction. Results The omnibus test was significant (p Conclusions SCAT2 scores decreased significantly during the first 3 days post-concussion, demonstrating impairments in a composite score that includes symptoms, mental status, and balance. Deficits in the SCAT2 recovered to levels above baseline by D10, indicating a resolution of concussion related impairments. Acknowledgements This study was funded by a grant from the National Operating Committee for Standards on Athletic Equipment (NOCSAE). Competing interests None.

Objective Determine school absence and accommodation frequency, accommodation type, and relationship to health-related quality of life (HRQOL), following concussion. Design Repeated measures. Setting Secondary schools. Patients or Other Participants Athletes with diagnosed concussion (n=149; males=130, females=19, age=15.7±1.1, grade=10.0±1.0). Interventions Sport-Concussion Assessment Tool-2 (SCAT2), a general survey, paediatric Quality of Life Inventory (PedsQL), Multidimensional Fatigue Scale, and Headache Impact Test (HIT-6) were administered on date of injury (DOI), and days 3(D3), 10(D10), and 30(D30) post-injury. The general survey captured academic absence and accommodation occurrences and accommodation type. Main Outcome Measures Dependent variables: school absence; academic accommodation; and, type of accommodation received. Descriptive and Mann-Whitney U analyses were employed. Results Of 143 patients: 28% (n=40) missed school, 16.1% (n=23) received academic accommodations, and 7.7% (n=11) experienced both. The most frequent accommodation was shorter school day (n=9 (39%)). Those requiring accommodations: missed more school, had lower D3 physical, psychosocial, and school functioning, and PedsQL total score; and had higher D30 HIT6 score (all p Conclusions Results suggest that SRC-induced school absence and accommodations are related to declines in DOI and D3 HRQOL and increased symptom severity. Further research should explore the predictive value of these measures to future academic disruption. Acknowledgements This study was funded by a grant from the National Operating Committee for Standards on Athletic Equipment (NOCSAE). Competing interests None.

Objective To determine the impact of concussion on general, fatigue-specific, and headache-specific Health-related quality of life (HRQOL). Design Repeated measures. Setting High school athletic facilities. Patients Two hundred and fifty-nine adolescent athletes who sustained a concussion diagnosed by their athletic trainer (218 males, 41 females, age=15.9±1.2 years, grade=10.0±1.1). Interventions Participants completed the paediatric Quality of Life Inventory (PedsQL), PedsQL Multidimensional Fatigue Scale (MFS), and Headache Impact Test (HIT-6) during a preseason baseline (BL) and on days 3 (D3), 10 (D10) and 30 (D30) post-concussion. Main Outcome Measures Dependent variables included: 4 PedsQL subscale scores (physical (PF), emotional (EF), social (SOF), school (SCF) functioning), 3 MFS subscale scores (general (GF), sleep (SLF), cognitive (CF) fatigue), and the HIT-6 total score. Higher scores on the HIT-6 and lower scores on the PedsQL and MFS indicate lower HRQOL. Analyses were conducted using generalised estimating equations with follow-up Bonferroni corrections. Results All omnibus tests were significant (p Conclusions Concussed athletes demonstrated lower general, fatigue-specific, and headache-specific HRQOL in the immediate days post-injury. These findings corroborate reports of the symptoms experienced acutely post-concussion and align with a time when athletes are often restricted from participating in physical and cognitive activities. The effects of concussion on HRQOL appear short-lived, with recovery by 10 days post-injury. Acknowledgements This study was funded by a grant from the National Operating Committee for Standards on Athletic Equipment (NOCSAE). Competing interests None.

Undertook a goal systems analysis in order to elucidate the nature of diabetic children's cognitive representations of their health-related activities. Using a modified version of Little's (1983) Personal Projects Analysis methodology, youngsters with Type I diabetes were asked to sort health-care goals into self-selected versus imposed categories. Goal dimension differences were compared via t tests, revealing that children make clear evaluative distinctions among types of diabetes-care activities. Factor analyses further revealed distinct conceptualizations for "told to do" versus "want to do" goals. When metabolic control (as measured by glycosolated hemoglobin assays) was regressed on the derived factors for selected and imposed self-care goals, none of the self-selected (want to do) factors, but two of the three imposed (told to do) factors, contributed significantly to variance in HbAlc. Implications and design limitations are discussed.