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ObjectiveTo characterise the obstetrical management and outcomes in a series of women with a history of Kawasaki disease (KD) in childhood.DesignRetrospective case series.SettingTertiary healthcare setting in the USA.PopulationWomen with a history of KD in childhood.MethodsWomen completed a detailed health questionnaire and participated in research imaging studies as part of the San Diego Adult KD Collaborative Study.Main outcome measuresObstetrical management, complications during pregnancy and delivery, and infant outcomes.ResultsTen women with a history of KD in childhood carried a total of 21 pregnancies to term. There were no cardiovascular complications during labour and delivery despite important cardiovascular abnormalities in four of the ten subjects. Pregnancy was complicated by pre-eclampsia and the post-partum course was complicated by haemorrhage in one subject each. Two of the 21 progeny subsequently developed KD.ConclusionsWomen with important cardiovascular sequelae from KD in childhood should be managed by a team that includes both a maternal-fetal medicine specialist and a cardiologist. Pre-pregnancy counselling should include delineation of the woman's current functional and structural cardiovascular status and appropriate adjustment of medications, but excellent outcomes are possible with appropriate care. Review of the English and Japanese literature on KD and pregnancy revealed the occurrence of myocardial infarction during pregnancy in women with missed KD and aneurysms that were not diagnosed until their acute event. Our study highlights the need for counselling with regard to the increased genetic risk of KD in offspring born to these mothers.

This case study describes a patient who presented with vague visual complaints in the right eye, decreased visual acuity in the affected eye, and a difficult initial eye evaluation, including fundoscopic and slit lamp examinations, in the emergency department (ED). The preliminary finding included a darkened-appearing area of the retina on fundoscopic exam. The patient subsequently had bedside sonography of the eyes done by an emergency medicine (EM) intern which revealed a thin and serpentine strip appearing as a hyperechoic representation of the retina floating freely into the vitreous from the superior-lateral section of the posterior globe.

This case study describes a pregnant patient with vaginal bleeding who had a bedside endovaginal ultrasound in the emergency department (ED). The emergency physician identified a live intra-uterine pregnancy (IUP) with another structure that appeared to be a second gestational sac. The patient subsequently had an endovaginal ultrasound in the radiology department 46 minutes later. The attending radiologist described one live IUP and a subchorionic hemorrhage. Comparison of the ED and radiology ultrasound showed that the second structure, identified as a subchorionic hemorrhage, had significantly decreased in size. Endovaginal ultrasound in the evaluation of possible ectopic pregnancy is a useful bedside tool in the ED. We discuss a pitfall that can occur with endocavitary ultrasound when a twin gestation is presumed.

Background: Giant coronary artery aneurysms and myocardial fibrosis after Kawasaki disease may lead to devastating cardiovascular outcomes. We characterised the vascular and myocardial outcomes in five selected Kawasaki disease patients with a history of giant coronary artery aneurysms that completely regressed., Methods: Five patients were selected who had giant coronary artery aneurysm in early childhood that regressed when studied 12-33 years after Kawasaki disease onset. Coronary arteries were imaged by coronary CT angiography, and coronary artery calcium volume scores were determined. We used endocardial strain measurements from CT imaging to assess myocardial regional wall function. Calprotectin and galectin-3 (gal-3) as biomarkers of inflammation and myocardial fibrosis were measured by enzyme-linked immunosorbent assay., Results: The five selected patients with regressed giant coronary artery aneurysms had calcium scores of zero, normal levels of calprotectin and gal-3, and normal appearance of the coronary arteries by coronary computed tomography angiography. CT strain demonstrated normal peak systolic and diastolic strain patterns in four of five patients. In one patient with a myocardial infarction at the time of Kawasaki disease diagnosis at the age of 10 months, CT strain showed altered global longitudinal strain, reduced segmental peak strain, and reduced diastolic relaxation patterns in multiple left ventricle segments., Conclusions: These patients illustrate that regression of giant aneurysms after Kawasaki disease is possible with no detectable calcium, normal biomarkers of inflammation and fibrosis, and normal myocardial function. Individuals with regressed giant coronary artery aneurysm still require longitudinal surveillance to assess the durability of this favourable outcome.

Purpose: We evaluated T- and B-cell receptor (TCR and BCR) repertoire diversity and 38 serum cytokines in pre- and post-treatment peripheral blood of 66 patients with triple-negative breast cancer (TNBC) who received neoadjuvant chemotherapy plus durvalumab and assessed associations with pathologic response and immune-related adverse events (irAEs) during treatment., Methods: Genomic DNA was isolated from buffy coat for TCR and BCR clonotype profiling using the Immunoseq platform and diversity was quantified with Pielou's evenness index. MILLIPLEX MAP Human Cytokine/Chemokine Magnetic Bead Panel was used to measure serum cytokine levels, which were compared between groups using moderated t-statistic with Benjamini-Hochberg correction for multiple testing., Results: TCR and BCR diversity was high (Pielou's index > 0.75) in all samples. Baseline receptor diversities and change in diversity pre- and post-treatment were not associated with pathologic response or irAE status, except for BCR diversity that was significantly lower post-treatment in patients who developed irAE (unadjusted p = 0.0321). Five cytokines increased after treatment in patients with pathologic complete response (pCR) but decreased in patients with RD, most prominently IL-8. IFNγ, IL-7, and GM-CSF levels were higher in pre-treatment than in post-treatment samples of patients who developed irAEs but were lower in those without irAEs., Conclusion: Baseline peripheral blood cytokine levels may predict irAEs in patients treated with immune checkpoint inhibitors and chemotherapy, and increased post-treatment B-cell clonal expansion might mediate irAEs., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background and Objectives: Recovery after sport-related concussion is variable, and potential differences between team vs individual sport athletes are not fully understood. In a cohort of athletes with concussions, we sought to compare these groups across (1) symptom severity score, (2) individual symptom cluster scores, and (3) recovery metrics., Methods: A retrospective, cohort study of 13 to 23-year-old athletes treated at a regional sport concussion center between November 2017 and April 2022 was conducted. Athletes were categorized into team vs individual sport athletes, with additional classification of individual sports based on strong vs minimal team elements (ie, the degree of interdependence displayed by athletes). The primary outcomes were symptom severity score, measured by either the Sport Concussion Assessment Tool-5th Edition or the Immediate Post-Concussion Assessment and Cognitive Testing, and physical, cognitive, emotional, and sleep symptom cluster scores. Secondary outcomes were recovery metrics, including time to return-to-learn, symptom resolution, and return-to-play., Results: Of the 1051 athletes, 954 (90.8%) were in team sports and 97 (9.2%) in individual sports. In multivariable linear regression, individual sport athletes had higher emotional symptom severity compared with team sport athletes (β = 0.09 [0.01, 0.17], P = .034) when adjusting for sex, attention-deficit/hyperactivity disorder, psychological disorders, time to clinic, on-field evaluation, and Immediate Post-Concussion Assessment and Cognitive Testing vs Sport Concussion Assessment Tool-5th Edition scale. There were no significant differences in return-to-learn (P = .104), symptom resolution (P = .941), or return-to-play (P = .279) on univariate regressions., Conclusion: In the current single-center, pilot study of athletes with a sport-related concussion, individual sport athletes exhibited more emotional symptoms than team sport athletes. These preliminary data lend early support that individual sport athletes may be more at risk of emotional symptoms than team sport athletes after a sport-related concussion. Clinicians may use these findings to identify athletes who may be particularly vulnerable to emotional symptoms., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Objective: Despite the growing literature on sport-related concussion (SRC) in high school and collegiate athletes, the understanding of how outcomes can vary in child athletes younger than 12 years of age remains limited. Therefore, the authors sought to compare injury characteristics and recovery in 8- to 12-year-old athletes with those of 13- to 17-year-old athletes following SRC., Methods: A single-institution retrospective cohort study was undertaken including 8- to 12-year-old and 13- to 17-year-old athletes seen at a regional SRC between November 2017 and January 2022. Demographic information, injury characteristics, Post-Concussion Symptom Scale (PCSS) scores, and recovery (i.e., return to learn [RTL], symptom resolution, and return to play [RTP]) were compared between 8- to 12-year-old and 13- to 17-year-old athletes using the Mann-Whitney U-test and chi-square test., Results: A total of 147 athletes (8- to 12-year-old athletes: n = 49; 13- to 17-year-old athletes: n = 98) were included. The mean ages for the younger and older groups were 10.9 ± 0.9 and 15.7 ± 1.3 years, respectively. Athletes aged 8-12 years and 13-17 years had similar median times to initial healthcare presentation (1 vs 2 days, p = 0.37). Athletes aged 8-12 years were more likely to present to the emergency department (ED) (44.9% vs 25.5%, p = 0.02) and receive head imaging (36.7% vs 19.4%, p = 0.02). Initial PCSS scores were similar between the groups (21.5 vs 22.0, p = 0.99). Athletes aged 8-12 years took longer to RTL (median 6.0 [IQR 4.0-13.0] days vs median 4.0 [IQR 2.0-8.0] days, p = 0.04). However, time to symptom resolution (median 16.0 [IQR 7.0-42.0] days vs median 13.5 [IQR 6.3-22.5] days, p = 0.34) and RTP (median 22.5 [IQR 10.0-54.8] days vs median 15.0 [IQR 10.0-24.0] days, p = 0.17) were not significantly different., Conclusions: Comparing 8- to 12-year-old with 13- to 17-year-old concussed athletes, the authors found that the initial PCSS score did not differ, although the younger group was more likely to present to the ED and receive head imaging. The 8- to 12-year-old athletes took more time to RTL, although no differences were found in time to symptom resolution or RTP.

Background: Extracting phenotype-representative flow patterns and their associated numerical metrics is a bottleneck in the clinical translation of advanced cardiac flow imaging modalities. We hypothesized that reduced-order models (ROMs) are a suitable strategy for deriving simple and interpretable clinical metrics of intraventricular flow suitable for further assessments. Combined with machine learning (ML) flow-based ROMs could provide new insight to help diagnose and risk-stratify patients., Methods: We analyzed 2D color-Doppler echocardiograms of 81 non-ischemic dilated cardiomyopathy (DCM) patients, 51 hypertrophic cardiomyopathy (HCM) patients, and 77 normal volunteers (Control). We applied proper orthogonal decomposition (POD) to build patient-specific and cohort-specific ROMs of LV flow. Each ROM aggregates a low number of components representing a spatially dependent velocity map modulated along the cardiac cycle by a time-dependent coefficient. We tested three classifiers using deliberately simple ML analyses of these ROMs with varying supervision levels. In supervised models, hyperparameter grid search was used to derive the ROMs that maximize classification power. The classifiers were blinded to LV chamber geometry and function. We ran vector flow mapping on the color-Doppler sequences to help visualize flow patterns and interpret the ML results., Results: POD-based ROMs stably represented each cohort through 10-fold cross-validation. The principal POD mode captured >80 % of the flow kinetic energy (KE) in all cohorts and represented the LV filling/emptying jets. Mode 2 represented the diastolic vortex and its KE contribution ranged from <1 % (HCM) to 13 % (DCM). Semi-unsupervised classification using patient-specific ROMs revealed that the KE ratio of these two principal modes, the vortex-to-jet (V2J) energy ratio, is a simple, interpretable metric that discriminates DCM, HCM, and Control patients. Receiver operating characteristic curves using V2J as classifier had areas under the curve of 0.81, 0.91, and 0.95 for distinguishing HCM vs. Control, DCM vs. Control, and DCM vs. HCM, respectively., Conclusions: Modal decomposition of cardiac flow can be used to create ROMs of normal and pathological flow patterns, uncovering simple interpretable flow metrics with power to discriminate disease states, and particularly suitable for further processing using ML., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Computational fluid dynamics can compute fractional flow reserve (FFR) accurately. However, existing models are limited by either the intravascular hemodynamic phenomarkers that can be captured or the fidelity of geometries that can be modeled., Methods and Results: This study aimed to validate a new coronary angiography-based FFR framework, FFR HARVEY , and examine intravascular hemodynamics to identify new biomarkers that could augment FFR in discerning unrevascularized patients requiring intervention. A 2-center cohort was used to examine diagnostic performance of FFR HARVEY compared with reference wire-based FFR (FFR INVASIVE ). Additional biomarkers, longitudinal vorticity, velocity, and wall shear stress, were evaluated for their ability to augment FFR and indicate major adverse cardiac events. A total of 160 patients with 166 lesions were investigated. FFR HARVEY was compared with FFR INVASIVE by investigators blinded to the invasive FFR results with a per-stenosis area under the curve of 0.91, positive predictive value of 90.2%, negative predictive value of 89.6%, sensitivity of 79.3%, and specificity of 95.4%. The percentage ofdiscrepancy for continuous values of FFR was 6.63%. We identified a hemodynamic phenomarker, longitudinal vorticity, as a metric indicative of major adverse cardiac events in unrevascularized gray-zone cases., Conclusions: FFR HARVEY had high performance (area under the curve: 0.91, positive predictive value: 90.2%, negative predictive value: 89.6%) compared with FFR INVASIVE . The proposed framework provides a robust and accurate way to compute a complete set of intravascular phenomarkers, in which longitudinal vorticity was specifically shown to differentiate vessels predisposed to major adverse cardiac events.

Objective: The aim of this study was to compare clinical and craniometric outcomes of patients treated for hydrocephalus following fetal myelomeningocele repair (fMMR) via a ventriculoperitoneal shunt (VPS) or endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC)., Methods: This was a retrospective cohort study of children who were treated for hydrocephalus following fMMR via VPS or ETV with or without CPC (ETV ± CPC) at Vanderbilt between 2012 and 2021. The primary outcomes were treatment failure and time to failure (TTF). Secondary outcomes included changes in hydrocephalus metrics (fronto-occipital horn ratio [FOHR] and head circumference measurements) and healthcare resource utilization (number of hospital admissions, clinic visits, and neuroimaging findings)., Results: Among 88 patients who underwent fMMR, 37 (42%) required permanent CSF diversion, of whom 19 received treatment at the authors' institution. Twelve patients underwent ETV ± CPC, and 7 underwent VPS placement at a median corrected age of 23 weeks versus 1 week (p = 0.002). The preoperative median head circumference percentiles and z-scores for patients in the ETV ± CPC cohort were similar to those of the VPS cohort (percentiles: 98.5 vs 94.0, p = 0.064; z-scores: 2.32 vs 1.60, p = 0.111). There was no difference in preoperative median FOHR measurements between the two cohorts (0.57 vs 0.59, p = 0.53). At 6 months postoperatively, the median head circumference percentile and z-score for the ETV ± CPC cohort remained similar between the two cohorts (percentiles: 98.0 vs 67.5, p = 0.315; z-scores: 2.12 vs 0.52, p = 0.307). There was no difference in the change in FOHR (-0.06 vs -0.09, p = 0.37) and change in head circumference percentile (-1.33 vs -28.6, p = 0.058) between the cohorts 6 months after the index CSF diversion procedure. One patient in the ETV ± CPC cohort experienced a seizure and a nonoperative subdural hemorrhage postoperatively; no other complications were observed. Six of the 7 patients in the VPS cohort required shunt revision with a median TTF of 9.8 months while 2 of the 12 ETV ± CPC patients required a repeat ETV at a median of 17.5 months (86% vs 17%, p = 0.013). The median number of hydrocephalus-related hospital readmissions was significantly lower in the ETV ± CPC cohort than in the VPS cohort (0 vs 1, p = 0.006). The ETV ± CPC cohort had fewer CT scans (0 vs 2, p = 0.004) and radiographs (0 vs 2, p < 0.001) than the VPS cohort., Conclusions: In a single-center cohort, hydrocephalic fMMR patients treated via ETV ± CPC remained shunt free, while a majority of patients receiving an upfront shunt required revision. This is the first study comparing ETV ± CPC with VPS in the fMMR hydrocephalus population. While larger, multicenter studies are needed, these results suggest that ETV/CPC may be a preferred means of CSF diversion following fMMR.

The management of brain metastases, a potentially devastating complication of advanced cancers, has become increasingly complex with advancements in local and systemic therapies. Improved outcomes and extended survival for patients with metastatic solid tumors have led to a surge in the prevalence and possibly incidence of brain metastases, affecting up to 40% of individuals with solid tumors. Enhanced imaging technologies contribute to more accurate and early detection, shaping the understanding of the intricate landscape of this condition. Traditionally, surgery and radiation stood as the mainstays of treatment because of the limited efficacy of systemic therapies within the brain. However, emerging clinical data, particularly in melanoma, lung, and breast cancers, reveal promising results with novel systemic treatments such as immunotherapy and targeted therapies. Despite the historical exclusion of patients with active brain metastases from clinical trials, a shift is occurring toward a more inclusive approach. This chapter delves into the multifaceted challenges associated with managing brain metastases, with a focus on the evolving landscape of systemic approaches as well as the intricacies of shared decision making, providing a comprehensive overview of the current state and future directions in navigating the complexities of brain metastases management.

Prospective and between trial comparisons indicate that first-line treatment with immune checkpoint inhibitors improves survival outcomes compared to first-line therapy with combined BRAF and MEK inhibitors in metastatic melanoma containing BRAFV600E/K mutations. Long-term outcomes for BRAF/MEK inhibition after progression on immunotherapy have not been reported. Moreover, clinical variables associated with outcome from treatment with combined BRAF/MEK inhibition were previously identified in the first-line setting but have not been investigated when targeted therapies are administered after progression on immune therapy. We performed a retrospective single institution analysis of 40 metastatic melanoma patients receiving combined BRAF/MEK inhibitors after progression on an anti-PD-1 or ipilimumab plus nivolumab to assess response rate by RECIST 1.1, progression-free and overall survival (PFS and OS). Pretreatment clinical variables were analyzed for association with OS. Ipilimumab/nivolumab was the first-line immunotherapy regimen in 39 patients (97.5%), and BRAFV600E/K mutations were present in 33 (83%) and 7 (17%) patients, respectively. The median OS from start of BRAF/MEK inhibitors was 20.3 months (1.73-106.4+, 95% CI of median 13.3-30.7). Clinical characteristics associated with worse survival prior to starting BRAF/MEK inhibitors included age > 60 years (median OS 14 vs. 28 months; HR 2.5; 95% CI 0.91-6.87, P = .023), ECOG-PS > 2 (median OS 7 vs. 33 months; HR 2.89; 95% CI 0.78-10.76, P = .018), and presence of bone metastases (median OS 9 vs. 52 months; HR 3.17; 95% CI 1.33-7.54, P = .002). These associations with shorter survival maintained their significance on multivariate analysis. If confirmed in larger cohorts, the identified prognostic variables can be used for stratification of patients in future randomized trials., (© The Author(s) 2023. Published by Oxford University Press.)

Objective: Sport-related concussion (SRC) is an evolving public health concern among youth athletes. Despite emerging evidence that race and ethnicity are important factors in determining concussion outcomes, studies examining race and ethnicity are limited. We conducted a systematic review to (1) determine the prevalence of SRC studies in which participants' race or ethnicity is reported, (2) describe how race and ethnicity are used within each study, and (3) assess predictive factors for the reporting of race and ethnicity., Data Sources: PubMed, Embase, PsycINFO, and CINAHL databases., Study Selection: Study inclusion criteria were (1) primary and peer-reviewed research; (2) related to the diagnosis, treatment, or recovery of SRC; (3) involving school-aged athletes (ages 5 to 25); and (4) with 25 or more participants. The search was performed in March 2021 and included only studies published after March 2013., Data Extraction: For each article, we looked at whether race and ethnicity were reported, and if so, which races or ethnicities were mentioned. For each race or ethnicity mentioned, we extracted the corresponding sample size and how they were used as variables in the study., Data Synthesis: Of 4583 studies screened, 854 articles met inclusion criteria. Of the included articles, 132 (15.5%) reported race, and 65 (7.6%) reported ethnicity, whereas 721 (84.4%) reported neither. When examining the demographic characteristics of the 132 studies that reported race, 69.8% of athletes were White. Additionally, 79.5% of these studies used race solely as a demographic descriptor as opposed to a main exposure or covariate of interest. Studies published more recently were more likely to report race. Further, studies in specific study or journal topics and specific geographic locations of the authors were more likely to report race., Conclusions: Reporting of race and ethnicity is limited in current SRC literature. Future authors should improve the reporting of race and ethnicity, diversify study samples by focusing on enrolling athletes from underrepresented groups, and consider the potential effect of race and ethnicity as social determinants of health on risk factors, recovery, and long-term sequelae after SRC., (© by the National Athletic Trainers’ Association, Inc.)

Introduction: Repeat sport-related concussion (SRC) is anecdotally associated with prolonged recovery. Few studies have examined repeat concussion within the same athlete. We sought to explore differences in symptom burden and recovery outcomes in an individual athlete's initial and repeat SRC., Methods: A retrospective within-subject cohort study of athletes aged 12-23 years diagnosed with two separate SRCs from 11/2017-10/2020 was conducted. Primary outcomes were initial symptom severity and time-to-symptom-resolution. Secondary outcomes included return-to-learn (RTL) and return-to-play (RTP) duration., Results: Of 868 athletes seen, 47 athletes presented with repeat concussions. Median time between concussions was 244 days (IQR 136-395). Comparing initial to repeat concussion, no differences were observed in time-to-clinic (4.3 ± 7.3vs.3.7 ± 4.6 days, p  = 0.56) or initial PCSS (26.2 ± 25.3 vs. 30.5 ± 24.1, p  = 0.32). While a difference was observed in time-to-symptom resolution between initial/repeat concussion (21.2 ± 16.3 vs. 41.7 ± 86.0 days, p  = 0.30), this did not reach statistical significance. No significant differences were observed in time-to-RTL (17.8 ± 60.6 vs. 6.0 ± 8.3 days, p  = 0.26) and RTP (33.2 ± 44.1 vs. 29.4 ± 39.1 days, p  = 0.75). Repeat concussion was not associated with symptom resolution on univariate (HR 1.64, 95% CI 0.96-2.78, p  = 0.07) and multivariable (HR 0.85, 95% CI 0.49-1.46, p  = 0.55) Cox regression., Conclusion: No significant differences in symptom duration and RTP/RTL were seen between initial/repeat concussion.

Context: People with diabetes mellitus (DM) are at increased risk for adverse health events and complications throughout their lifetime. Whether DM significantly affects collegiate athletes' concussion baseline testing performance remains unclear., Objectives: To (1) describe the prevalence of DM and associated comorbidities and (2) compare concussion baseline testing performance between student-athletes with DM and student-athletes without DM (NoDM)., Design: Retrospective, cross-sectional study., Setting: University., Patients or Other Participants: Using the Concussion, Assessment, Research and Education (CARE) Consortium research database, we matched athletes with self-reported DM (N = 229) by institution, sex, age, sport, position, testing year, and concussion history to athletes with NoDM (N = 229; total sample mean age = 19.6 ± 1.4 years, women = 42%)., Main Outcome Measure(s): Descriptive statistics and χ2 tests of independence with subsequent odds ratios were calculated. Independent-samples t tests compared baseline symptoms, neurocognitive testing, and balance performance between athletes with DM and athletes with NoDM. Effect sizes were determined for significant group differences., Results: At baseline, athletes with DM had higher rates of self-reported pre-existing balance disorders, sleep disorders, seizure disorders, motion sickness, learning disorders, vision and hearing problems, psychiatric disorders, depression, bipolar disorder, nonmigraine headaches, and meningitis than athletes with NoDM (P values < .05). We found balance differences between groups (P = .032, Cohen d = 0.17) such that, on average, athletes with DM had 1 additional error on the Balance Error Scoring System (DM = 13.4 ± 6.5; NoDM = 12.1 ± 5.9). No other comparisons yielded significant results., Conclusions: Although athletes with DM had high rates of self-reported balance disorders, sleep disorders, seizures, and meningitis, their baseline neurocognitive testing results were largely identical to those of athletes with NoDM. Our findings suggested that nonclinically meaningful differences were present in concussion baseline balance testing but no significant differences were noted in cognitive testing; however, the effect of DM on concussion recovery remains unknown., (© by the National Athletic Trainers' Association, Inc.)

Objective: Most studies regarding sport-related concussion (SRC) focus on high school and collegiate athletes; however, little has been published on children younger than 12 years of age. In a cohort of children aged 8-12 years with SRC, the authors sought to describe demographics, initial presentation, and recovery in this understudied population., Methods: A retrospective cohort study of children aged 8-12 years who sustained an SRC between November 2017 and April 2022 and were treated at a regional sports concussion center was conducted. Demographic information, injury characteristics, traditional Sport Concussion Assessment Tool 5 (SCAT5) and Child/Parent SCAT5 scores, and outcomes, defined as days to return to learn (RTL), symptom resolution, and return to play (RTP), were reported. Outcomes in boys and girls were compared using effect size analyses given sample size constraints., Results: Forty-seven athletes were included. The mean age was 11.0 ± 0.8 years, and the majority were male (34, 72.3%). A sizable proportion of patients visited an emergency department (19, 40.4%), and many received head imaging (16, 34.0%), mostly via CT (n = 13). The most common sport for boys was football (15, 44.1%), and the most common sports for girls were soccer (4, 30.8%) and cheerleading (4, 30.8%). These athletes reported a variety of symptoms on presentation. It took a mean of 8.8 ± 10.8 days to RTL, 27.3 ± 38.3 days to reach symptom resolution, and 35.4 ± 41.9 days to RTP. When comparing boys versus girls, there appeared to be moderate differences in symptom severity scores (Cohen's d = 0.44 for SCAT5, 0.13 for Child SCAT5, and 0.38 for Parent SCAT5) and minimal differences in recovery (Cohen's d = 0.11 for RTL, n = 35; 0.22 for symptom resolution, n = 22; and 0.12 for RTP, n = 21)., Conclusions: In this cohort of concussed athletes aged 8-12 years, a little less than half of the athletes initially presented to the emergency department, and approximately one-third received acute head imaging. Across all athletes, the mean RTL was slightly more than a week and the mean symptom resolution and RTP were both approximately 1 month; however, much of the cohort is missing recovery outcome measures. This study demonstrated a strong positive correlation between Child SCAT5 and Parent SCAT5 symptom reporting. Future efforts are needed to evaluate differences in clinical presentation and outcomes following SRC between children and older populations.

Objectives: 1) Evaluate the frequency of same-year, repeat concussions; (2) assess predictors of sustaining a repeat concussion; and (3) compare outcomes of athletes with repeat concussions with athletes with single concussion., Design: A retrospective, case-control study., Setting: Regional sports concussion center., Patients: Adolescents sustaining a sport-related concussions (SRC) from November 2017 to October 2020., Independent Variables: Participants were dichotomized into 2 groups: (1) athletes with a single concussion; and (2) athletes with repeat concussions., Main Outcome Measures: Between group and within group analyses were completed to look for differences in demographics, personal and family history, concussion history, and recovery metrics between the 2 groups., Results: Of 834 athletes with an SRC, 56 (6.7%) sustained a repeat concussion and 778 (93.3%) had a single concussion. Between group: Personal history of migraines (19.6% vs 9.5%, χ 2 = 5.795, P = 0.02), family history of migraines (37.5% vs 24.5%, χ 2 = 4.621, P = 0.03), and family history of psychiatric disorders (25% vs 13.1%, χ 2 = 6.224, P = 0.01) were significant predictors of sustaining a repeat concussion. Within group: Among those with a repeat concussion, initial symptom severity was greater (Z = -2.422; P = 0.02) during the repeat concussion and amnesia was more common (χ 2 = 4.775, P = 0.03) after the initial concussion., Conclusions: In a single-center study of 834 athletes, 6.7% suffered a same-year, repeat concussion. Risk factors included personal/family migraine history and family psychiatric history. For athletes with repeat concussions, initial symptom score was higher after the second concussion, yet amnesia was more common after the initial concussion., Competing Interests: S.L. Zuckerman serves as an unaffiliated neurotrauma consultation for the U.S. National Football League. A.M. Yengo-Kahn receives honoraria from BlinkTBI. Douglas Terry receives honoraria from REACT Neuro, Inc as well as HitIQ and has a consulting practice in forensic neuropsychology. For remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The objectives of this study are to 1) describe collegiate student-athlete (SA) race and household income and 2) evaluate time to normal academic performance (i.e., return to learn (RTL)), initiation of the return to play (iRTP) protocol, RTP protocol duration, and time to unrestricted RTP (URTP) after sustaining sport-related concussion (SRC)., Methods: Data were collected between 2014 and 2020 by the Concussion Assessment, Research, and Education Consortium. Baseline data were used to characterize participant demographics ( N = 22,819) and post-SRC outcomes ( n = 5485 SRC) in time to RTL ( n = 1724) and RTP outcomes ( n = 2646) by race. Descriptive statistics and nonparametric tests examined differences across race by demographic and injury characteristics. Kaplan-Meier curves estimated median days to RTL, iRTP protocol, RTP protocol completion, and URTP by race and covariate measures. Multivariable Cox proportional hazards regression assessed the effect of race on risk of RTL and RTP recovery time points., Results: SA largely identified as White (75%) followed by Black (14%), multiracial (7%), and Asian (3%). More than half (53%) of all SA reported a household income of >$120,000, whereas 41% of Black SA reported a household income <$60,000. Race was not associated with relative risk of RTL or iRTP but was associated with RTP protocol completion and URTP. Non-Black/non-White SA were 17% less likely (adjusted hazard ratio = 0.83; 95% confidence interval = 0.71, 0.97) to complete the RTP protocol, and Black SA were 17% more likely (adjusted hazard ratio = 1.17; 95% confidence interval = 1.05, 1.31) to reach the URTP time point compared with White SA., Conclusions: The present findings suggest collegiate SA enrolled in the Concussion Assessment, Research, and Education Consortium are primarily White and come from household incomes well above the US median. Race was not associated with RTL or iRTP but was associated with RTP protocol duration and total time to URTP. Clinicians should be conscientious of how their implicit or preconceived biases may influence SRC management among National Collegiate Athletic Association SA., (Copyright © 2023 by the American College of Sports Medicine.)

Background: Frequent neurological examinations in patients with traumatic brain injury (TBI) disrupt sleep-wake cycles and potentially contribute to the development of delirium., Objective: To evaluate the risk of delirium among patients with TBI with respect to their neuro-check frequencies., Methods: A retrospective study of patients presenting with TBI at a single level I trauma center between January 2018 and December 2019. The primary exposure was the frequency of neurological examinations (neuro-checks) assigned at the time of admission. Patients admitted with hourly (Q1) neuro-check frequencies were compared with those who received examinations every 2 (Q2) or 4 (Q4) hours. The primary outcomes were delirium and time-to-delirium. The onset of delirium was defined as the first documented positive Confusion Assessment Method for the Intensive Care Unit score., Results: Of 1552 patients with TBI, 458 (29.5%) patients experienced delirium during their hospital stay. The median time-to-delirium was 1.8 days (IQR: 1.1, 2.9). Kaplan-Meier analysis demonstrated that patients assigned Q1 neuro-checks had the greatest rate of delirium compared with the patients with Q2 and Q4 neuro-checks ( P < .001). Multivariable Cox regression modeling demonstrated that Q2 neuro-checks (hazard ratio: 0.439, 95% CI: 0.33-0.58) and Q4 neuro-checks (hazard ratio: 0.48, 95% CI: 0.34-0.68) were protective against the development of delirium compared with Q1. Other risk factors for developing delirium included pre-existing dementia, tobacco use, lower Glasgow Coma Scale score, higher injury severity score, and certain hemorrhage patterns., Conclusion: Patients with more frequent neuro-checks had a higher risk of developing delirium compared with those with less frequent neuro-checks., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Clot formation is a crucial process that prevents bleeding, but can lead to severe disorders when imbalanced. This process is regulated by the coagulation cascade, a biochemical network that controls the enzyme thrombin, which converts soluble fibrinogen into the fibrin fibers that constitute clots. Coagulation cascade models are typically complex and involve dozens of partial differential equations (PDEs) representing various chemical species' transport, reaction kinetics, and diffusion. Solving these PDE systems computationally is challenging, due to their large size and multi-scale nature. We propose a multi-fidelity strategy to increase the efficiency of coagulation cascade simulations. Leveraging the slower dynamics of molecular diffusion, we transform the governing PDEs into ordinary differential equations (ODEs) representing the evolution of species concentrations versus blood residence time. We then Taylor-expand the ODE solution around the zero-diffusivity limit to obtain spatiotemporal maps of species concentrations in terms of the statistical moments of residence time, [Formula: see text], and provide the governing PDEs for [Formula: see text]. This strategy replaces a high-fidelity system of N PDEs representing the coagulation cascade of N chemical species by N ODEs and p PDEs governing the residence time statistical moments. The multi-fidelity order (p) allows balancing accuracy and computational cost providing a speedup of over N/p compared to high-fidelity models. Moreover, this cost becomes independent of the number of chemical species in the large computational meshes typical of the arterial and cardiac chamber simulations. Using a coagulation network with N = 9 and an idealized aneurysm geometry with a pulsatile flow as a benchmark, we demonstrate favorable accuracy for low-order models of p = 1 and p = 2. The thrombin concentration in these models departs from the high-fidelity solution by under 20% (p = 1) and 2% (p = 2) after 20 cardiac cycles. These multi-fidelity models could enable new coagulation analyses in complex flow scenarios and extensive reaction networks. Furthermore, it could be generalized to advance our understanding of other reacting systems affected by flow., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Guerrero-Hurtado et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The literature on athletes with positive head computed tomography (HCT) findings in the setting of sport head injuries remains sparse., Objective: To report the proportions of athletes with a positive HCT and compare acute injury characteristics and recovery between those with and without a positive HCT., Methods: A retrospective, single-institution, cohort study was performed with all athletes aged 12 to 23 years seen at a regional concussion center from 11/2017 to 04/2022. The cohort was dichotomized into positive vs negative HCT (controls). Acute injury characteristics (ie, loss of consciousness and amnesia) and recovery, as measured by days to return-to-learn (RTL), symptom resolution, and return-to-play (RTP) were compared. χ 2 and Mann-Whitney U tests were performed., Results: Of 2061 athletes, 226 (11.0%) received an HCT and 9 (4.0%) had positive findings. HCT findings included 4 (44.4%) subdural hematomas, 1 (11.1%) epidural hematoma, 2 (22.2%) facial fractures, 1 (11.1%) soft tissue contusion, and 1 (11.1%) cavernous malformation. All 9 (100.0%) athletes were treated nonoperatively and successfully returned-to-play at a median (IQR) of 73.0 (55.0-82.0) days. No differences in loss of consciousness or amnesia were seen between positive HCT group and controls. The Mann-Whitney U test showed differences in RTL (17.0 vs 4.0 days; U = 45.0, P = .016) and RTP (73.0 vs 27.0 days; U = 47.5, P = .007) but not in symptom resolution. Our subanalysis showed no differences across all recovery metrics between acute hemorrhages and controls., Conclusion: Among athletes seen at a regional concussion center who underwent an acute HCT, positive findings were seen in 4%. Although athletes with a positive HCT had longer RTL and RTP, symptom resolution was similar between those with a positive and negative HCT. All athletes with a positive HCT successfully returned to play. Despite a more conservative approach to athletes with a positive HCT, clinical outcomes are similar between those with and without a positive HCT., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Current treatments for patients with coronary aneurysms caused by Kawasaki disease (KD) are based primarily on aneurysm size. This ignores hemodynamic factors influencing myocardial ischemic risk. We performed patient-specific computational hemodynamics simulations for 15 KD patients, with parameters tuned to patients' arterial pressure and cardiac function. Ischemic risk was evaluated in 153 coronary arteries from simulated fractional flow reserve (FFR), wall shear stress, and residence time. FFR correlated weakly with aneurysm [Formula: see text]-scores (correlation coefficient, [Formula: see text]) but correlated better with the ratio of maximum-to-minimum aneurysmal lumen diameter ([Formula: see text]). FFR dropped more rapidly distal to aneurysms, and this correlated more with the lumen diameter ratio ([Formula: see text]) than [Formula: see text]-score ([Formula: see text]). Wall shear stress correlated better with the diameter ratio ([Formula: see text]), while residence time correlated more with [Formula: see text]-score ([Formula: see text]). Overall, the maximum-to-minimum diameter ratio predicted ischemic risk better than [Formula: see text]-score. Although FFR immediately distal to aneurysms was nonsignificant, its rapid rate of decrease suggests elevated risk., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Programmed death-ligand 1 (PD-L1) expression is required for benefit from immune checkpoint inhibitors in metastatic triple negative breast cancer (TNBC). In contrast, in the neoadjuvant setting patients benefited regardless of PD-L1 expression. We hypothesized that, in stages II-III breast cancers, low levels of PD-L1 expression may be sufficient to confer sensitivity to therapy and focal expression could be missed by a biopsy., Methods: In this study, we examined intratumor spatial heterogeneity of PD-L1 protein expression in multiple biopsies from different regions of breast cancers in 57 primary breast tumors (n = 33 TNBC, n = 19 estrogen receptor-positive [ER-positive], n = 5 human epidermal receptor 2-positive [HER2 +]). E1L3N antibody was used to assess PD-L1 status and staining was scored using the combined positivity score (CPS) with PD-L1 positive defined as CPS ≥ 10., Results: Overall, 19% (11/57) of tumors were PD-L1 positive based on positivity in at least 1 biopsy. Among TNBC, PD-L1 positivity was 27% (9/33). The discordance rate, defined as the same tumor yielding PD-L1 positive and negative samples in different regions, was 16% (n = 9) in the whole study population and 23% (n = 7) in TNBC. Cohen's kappa coefficient of agreement was 0.214 for the whole study and 0.239 for TNBC, both of which falling into a non-statistically significant fair agreement range. Among all PD-L1 positive cases, 82% (n = 9/11) had positivity in only one of the tissue assessments., Conclusion: These results indicate that the overall 84% concordance is driven by concordant negative results. In PD-L1 positive cancers, within-tumor heterogeneity in PD-L1 expression exists., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Disruptions to left atrial (LA) blood flow, such as those caused by atrial fibrillation (AF), can lead to thrombosis in the left atrial appendage (LAA) and an increased risk of systemic embolism. LA hemodynamics are influenced by various factors, including LA anatomy and function, and pulmonary vein (PV) inflow conditions. In particular, the PV flow split can vary significantly among and within patients depending on multiple factors. In this study, we investigated how changes in PV flow split affect LA flow transport, focusing for the first time on blood stasis in the LAA, using a high-fidelity patient-specific computational fluid dynamics (CFD) model. We use an Immersed Boundary Method, simulating the flow in a fixed, uniform Cartesian mesh and imposing the movement of the LA walls with a moving Lagrangian mesh generated from 4D Computerized Tomography images. We analyzed LA anatomies from eight patients with varying atrial function, including three with AF and either a LAA thrombus or a history of Transient Ischemic Attacks (TIAs). Using four different flow splits (60/40% and 55/45% through right and left PVs, even flow rate, and same velocity through each PV), we found that flow patterns are sensitive to PV flow split variations, particularly in planes parallel to the mitral valve. Changes in PV flow split also had a significant impact on blood stasis and could contribute to increased risk for thrombosis inside the LAA, particularly in patients with AF and previous LAA thrombus or a history of TIAs. Our study highlights the importance of considering patient-specific PV flow split variations when assessing LA hemodynamics and identifying patients at increased risk for thrombosis and stroke. This knowledge is relevant to planning clinical procedures such as AF ablation or the implementation of LAA occluders., Competing Interests: Declaration of Competing Interest None Declared, (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objective: Following sport-related concussion (SRC), early studies have demonstrated racial differences in time to clinical recovery; however, these differences have not been fully explained. We sought to further explore these associations by considering possible mediating/moderating factors., Methods: Data from patients aged 12-18 years diagnosed with SRC from November 2017 to October 2020 were analyzed. Those missing key data, lost to follow-up, or missing race were excluded. The exposure of interest was race, dichotomized as Black/White. The primary outcome was time to clinical recovery (days from injury until the patient was either deemed recovered by an SRC provider or symptom score returned to baseline or zero.) RESULTS: A total of 389 (82%) White and 87 (18%) Black athletes with SRC were included. Black athletes more frequently reported no SRC history (83% vs. 67%, P = 0.006) and lower symptom burden at presentation (median total Post-Concussion Symptom Scale 11 vs. 23, P < 0.001) than White athletes. Black athletes achieved earlier clinical recovery (hazard ratio [HR] = 1.35, 95% CI 1.03-1.77, P = 0.030), which remained significant (HR = 1.32, 95% CI 1.002-1.73, P = 0.048) after adjusting for confounders associated with recovery but not race. A third model adding the initial Post-Concussion Symptom Scale score nullified the association between race/recovery (HR = 1.12, 95% CI 0.85-1.48, P = 0.410). Adding prior concussion history further reduced the association between race/recovery (HR = 1.01, 95% CI 0.77-1.34, P = 0.925)., Conclusions: Overall, Black athletes initially presented with fewer concussion symptoms than White athletes, despite no difference in time to clinic. Black athletes achieved earlier clinical recovery following SRC, a difference explained by differences in initial symptom burden and self-reported concussion history. These crucial differences may stem from cultural/psychologic/organic factors., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction  The middle fossa craniotomy (MFCs) is commonly utilized for spontaneous cerebrospinal fluid (CSF) leaks, encephaloceles, and superior semicircular canal dehiscence (SSCD). This study compares postoperative outcomes of MFCs with and without LD use. Methods  A retrospective cohort study of adults over the age of 18 years presenting for the repair of nonneoplastic CSF leak, encephalocele, or SSCD via MFC from 2009 to 2021 was conducted. The main exposure of interest was the placement of an LD. The primary outcome was the presence of postoperative complications (acute/delayed neurologic deficit, meningitis, intracranial hemorrhage, and stroke). Secondary outcomes included operating room (OR) time, length of stay, recurrence, and need for reoperation. Results  In total, 172 patients were included, 96 of whom received an LD and 76 who did not. Patients not receiving an LD were more likely to receive intraoperative mannitol ( n  = 24, 31.6% vs. n  = 16, 16.7%, p  = 0.02). On univariate logistic regression, LD placement did not influence overall postoperative complications (OR: 0.38, 95% confidence interval [CI]: 0.05-2.02, p  = 0.28), CSF leak recurrence (OR: 0.75, 95% CI: 0.25-2.29, p  = 0.61), or need for reoperation (OR: 1.47, 95% CI: 0.48-4.96, p  = 0.51). While OR time was shorter for patients not receiving LD (349 ± 71 vs. 372 ± 85 minutes), this difference was not statistically significant ( p  = 0.07). Conclusion  No difference in postoperative outcomes was observed in patients who had an intraoperative LD placed compared to those without LD. Operative times were increased in the LD cohort, but this difference was not statistically significant. Given the similar outcomes, we conclude that LD is not necessary to facilitate safe MCF for nonneoplastic skull base pathologies., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Objective: Accurately predicting early (≤ 14 days) versus typical (15-27 days) or delayed (≥ 28 days) recovery from sport-related concussion (SRC) may allow for improved resource utilization and precision in planning and carrying out rehabilitation. In this study, the authors sought to develop an algorithm that enables accurate differentiation of recovery periods and duration after SRC. The authors hypothesized that data regarding initial symptom burden as quantified by a Post-Concussion Symptom Scale (PCSS) score, time to presentation, and number of prior concussions would be the most useful for analyzing predictive factors for concussion recovery duration., Methods: A retrospective case-control study was conducted to assess the primary outcome of days to clinical recovery following SRC in pediatric patients. Data from patients 12-18 years old presenting within 28 days of injury to an SRC clinic between November 11, 2017, and October 10, 2020, were analyzed. Patients with positive evidence of injury on head imaging or incomplete records were excluded. The primary outcome was duration of clinical recovery, grouped as early (≤ 14 days), typical (15-27 days), or delayed (≥ 28 days). Recovery was defined as follows: 1) symptom resolution or return to baseline, or 2) initiation of graduated return to play. CHAID (chi-square automatic interaction detection) analysis was used to optimize a decision tree based on 16 input factors, including age, sex, initial PCSS score, time to clinic presentation, number of prior concussions, and presence of defined symptom clusters. The cohort was randomized into training (70%) and test (30%) samples for algorithm validation., Results: A total of 493 patients met the inclusion criteria (mean age 15.7 ± 1.5 years, 68.2% male, 70.0% White). The median time to presentation was 5 days (IQR 2-10 days). Most patients (52.3%) recovered within 14 days of injury, 21.5% recovered within 15-27 days, and 26.2% had a recovery period of 28 days or longer. The variables most predictive of recovery were initial PCSS score (cutoffs ≤ 6, 7-28, or ≥ 29), time to presentation (≤ 7 vs > 7 days), or prior concussions (0 vs ≥ 1). The model accurately discriminated between early versus typical or delayed recovery duration groupings (area under the curve 0.80, Youden index 0.44), and correctly classified > 90% of patients who recovered early., Conclusions: This novel three-factor predictive tool enabled accurate discrimination of early versus typical or delayed SRC recovery to better allocate resources, counsel patients, and make timely referrals.

Purpose: To investigate whether endocardial regional shortening computed from four-dimensional (4D) CT angiography (RS CT ) can be used as a decision classifier to detect the presence of left ventricular (LV) wall motion abnormalities (WMAs)., Materials and Methods: One hundred electrocardiographically gated cardiac 4D CT studies (mean age, 59 years ± 14 [SD]; 61 male patients) conducted between April 2018 and December 2020 were retrospectively evaluated. Three experts labeled LV wall motion in each of the 16 American Heart Association (AHA) segments as normal or abnormal; they also measured peak RS CT across one heartbeat in each segment. The data set was split evenly into training and validation groups. During training, interchangeability of RS CT thresholding with experts to detect WMA was assessed using the individual equivalence index (γ), and an optimal threshold of the peak RS CT (RS CT *) that achieved maximum agreement was identified. RS CT * was then validated using the validation group, and the effect of AHA segment-specific thresholds was evaluated. Agreement was assessed using κ statistics., Results: The optimal threshold, RS CT * of -0.19, when applied to all AHA segments, led to high agreement (agreement rate = 92.17%, κ = 0.82) and interchangeability with experts (γ = -2.58%). The same RS CT * also achieved high agreement in the validation group (agreement rate = 90.29%, κ = 0.76, γ = -0.38%). The use of AHA segment-specific thresholds (range: 0.16 to -0.23 across AHA segments) slightly improved agreement (1.79% increase)., Conclusion: RS CT thresholding was interchangeable with expert visual analysis in detecting segmental WMA from 4D CT and may be used as an objective decision classifier. Keywords: CT, Left Ventricle, Regional Endocardial Shortening, Wall Motion Abnormality Supplemental material is available for this article. © RSNA, 2023., Competing Interests: Disclosures of conflicts of interest: Z.C. National Heart, Lung, and Blood Institute. F.C. Research support from GE Healthcare unrelated to this work. A.M.K. No relevant relationships. S.K. Deputy editor of Radiology: Cardiothoracic Imaging. H.K.N. No relevant relationships. A.M. American Heart Association predoctoral fellowship. E.M. National Institutes of Health grants; founder shares in Clearpoint Neuro Inc., (© 2023 by the Radiological Society of North America, Inc.)

Limited evidence exists concerning how a diagnosis of attention-deficit hyperactivity disorder and/or learning disabilities (ADHD/LD) modifies recovery and behavior following sport-related concussion (SRC). To understand how ADHD/LD modifies the post-SRC experience, we conducted a retrospective cohort study of concussed young athletes through phone interviews with patients and guardians. Outcomes included time until symptom resolution (SR) and return-to-learn (RTL), plus subjective changes in post-SRC activity and sports behavior. Multivariate Cox and logistic regression was performed, adjusting for biopsychosocial characteristics. The ADHD/LD diagnosis was independently associated with worse outcomes, including lower likelihood to achieve SR (hazard ratio [HR] = 0.62, 95% confidence interval [CI] = [0.41-0.94]; P = .02) and RTL (HR = 0.55, 95% CI = [0.36-0.83]; P < .01) at any time following injury, and increased odds of changing sport behavior after concussion (odds ratio [OR] = 3.26, 95% CI = [1.26-8.42], P = .02), often to a safer style of play (62.5% vs 39.6%; P = .02) or retiring from the sport (37.5% vs 18.5%; P = .02). These results provide further evidence of the unique needs for athletes with ADHD/LD following SRC.

Introduction: 4D cardiac CT (cineCT) is increasingly used to evaluate cardiac dynamics. While echocardiography and CMR have demonstrated the utility of longitudinal strain (LS) measures, measuring LS from cineCT currently requires reformatting the 4D dataset into long-axis imaging planes and delineating the endocardial boundary across time. In this work, we demonstrate the ability of a recently published deep learning framework to automatically and accurately measure LS for detection of wall motion abnormalities (WMA)., Methods: One hundred clinical cineCT studies were evaluated by three experienced cardiac CT readers to identify whether each AHA segment had a WMA. Fifty cases were used for method development and an independent group of 50 were used for testing. A previously developed convolutional neural network was used to automatically segment the LV bloodpool and to define the 2, 3, and 4 CH long-axis imaging planes. LS was measured as the perimeter of the bloodpool for each long-axis plane. Two smoothing approaches were developed to avoid artifacts due to papillary muscle insertion and texture of the endocardial surface. The impact of the smoothing was evaluated by comparison of LS estimates to LV ejection fraction and the fractional area change of the corresponding view., Results: The automated, DL approach successfully analyzed 48/50 patients in the training cohort and 47/50 in the testing cohort. The optimal LS cutoff for identification of WMA was -21.8, -15.4, and -16.6% for the 2-, 3-, and 4-CH views in the training cohort. This led to correct labeling of 85, 85, and 83% of 2-, 3-, and 4-CH views, respectively, in the testing cohort. Per-study accuracy was 83% (84% sensitivity and 82% specificity). Smoothing significantly improved agreement between LS and fractional area change ( R 2 : 2 CH = 0.38 vs. 0.89 vs. 0.92)., Conclusion: Automated LV blood pool segmentation and long-axis plane delineation via deep learning enables automatic LS assessment. LS values accurately identify regional wall motion abnormalities and may be used to complement standard visual assessments., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Li, Chen, Kahn, Kligerman, Narayan and Contijoch.)

Objective: The objective of this study was to determine the effects of in utero bipedicle flaps on maternal-fetal morbidity/mortality, the need for CSF diversion, and long-term functional outcomes., Methods: Eighty-six patients who underwent fetal myelomeningocele repair from 2011 to 2021 at a single institution were reviewed. Primary outcomes included intrauterine fetal demise, postnatal death, postnatal myelomeningocele repair dehiscence, and CSF diversion by final follow-up., Results: The cohorts were no different with regard to race, ethnicity, maternal age at fetal surgery, body mass index, gravidity, parity, gestational age at fetal surgery, estimated fetal weight at fetal surgery, or fetal lesion level. Of the 86 patients, 64 underwent primary linear repair and 22 underwent bipedicle flap repair. There were no significant differences in rates of intrauterine fetal demise, postnatal mortality, midline repair site dehiscence, or the need for CSF diversion by final follow-up. Operative times were longer (32.5 vs 18.7 minutes, p < 0.001) and gestational age at delivery was lower (232 vs 241 days, p = 0.01) in the bipedicle flap cohort, but long-term functional outcomes were not different., Conclusions: Analysis of the total cohort affirms the long-term benefits of fetal myelomeningocele repair. In utero bipedicle flaps are safe and can be used for high-tension lesions without increasing perioperative risks to the mother or fetus. In utero flaps preserve the long-term benefits seen with primary linear repair and may expand inclusion criteria for fetal repair, providing life-changing care for more patients.

Objective: To evaluate the variables associated with additional concussion clinic visits before discharge to athletic trainer (AT)., Design: Retrospective cohort study., Setting: Multidisciplinary Sports Concussion Center., Patients: Patients ages 12 to 23 years presenting with a sport-related concussion between January 11, 2017, and January 10, 2020, and were discharged to an AT., Methodology: Our main outcome variable was being discharged to AT after the initial clinic visit versus those who attended additional clinic visits before AT discharge. We examined the influence of age, sex, initial visit symptom score, family and personal history of psychiatric disorders and migraines, history of prior concussions, and other variables on this outcome., Results: Of 524 patients, 236 were discharged to AT after the initial clinic visit, while 288 patients required additional clinic visits. The additional visit group had higher initial visit symptom scores ( P = 0.002), head imaging performed more frequently ( P < 0.02), a family history of psychiatric disorders and/or migraines ( P < 0.001, P < 0.001), more often reported a prior concussion ( P = 0.02), and was younger ( P = 0.014) compared with the one visit group. In a multiple variable model, the family history of psychiatric disorders [odds ratio (OR), 3.12 (95% CI, 1.531-6.343), P = 0.002], prior concussions [OR, 1.39 (95% CI, 1.020-1.892), P = 0.037], greater initial symptom score [OR, 1.05 (95% CI, 1.031-1.058), P < 0.001], and younger age [OR, 0.87 (95% CI, 0.773-0.979), P = 0.021] were strongly associated with additional visits., Conclusions: Among athletes treated at a regional sports concussion center, family history of psychiatric disorders, increased symptom score at initial visit, prior concussions, and younger age were each uniquely associated with needing additional clinic visits at the time of initial assessment. Understanding these variables may guide treatment protocols for optimal care., Competing Interests: The authors report no conflicts of interest. Douglas Terry, Ph.D., serves as a scientific advisor for HitIQ. He previously consulted for REACT Neuro, Inc. He has a consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild TBIs (including former athletes)., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Vein grafts, the most commonly used conduits in multi-vessel coronary artery bypass grafting surgery, have high intermediate- and long-term failure rates. The abrupt and marked increase in hemodynamic loads on the vein graft is a known contributor to failure. Recent computational modeling suggests that veins can more successfully adapt to an increase in mechanical load if the rate of loading is gradual. Applying an external wrap or support at the time of surgery is one way to reduce the transmural load, and this approach has improved performance relative to an unsupported vein graft in several animal studies. Yet, a clinical trial in humans has shown benefits and drawbacks, and mechanisms by which an external wrap affects vein graft adaptation remain unknown. This study aims to elucidate such mechanisms using a multimodal experimental and computational data collection pipeline. We quantify morphometry using magnetic resonance imaging, mechanics using biaxial testing, hemodynamics using computational fluid dynamics, structure using histology, and transcriptional changes using bulk RNA-sequencing in an ovine carotid-jugular interposition vein graft model, without and with an external biodegradable wrap that allows loads to increase gradually. We show that a biodegradable external wrap promotes luminal uniformity, physiological wall shear stress, and a consistent vein graft phenotype, namely, it prevents over-distension, over-thickening, intimal hyperplasia, and inflammation, and it preserves mechanotransduction. These mechanobiological insights into vein graft adaptation in the presence of an external support can inform computational growth and remodeling models of external support and facilitate design and manufacturing of next-generation external wrapping devices. STATEMENT OF SIGNIFICANCE: External mechanical support is emerging as a promising technology to prevent vein graft failure following coronary bypass graft surgery. While variants of this technology are currently under investigation in clinical trials, the fundamental mechanisms of adaptation remain poorly understood. We employ an ovine carotid-jugular interposition vein graft model, with and without an external biodegradable wrap to provide mechanical support, and probe vein graft adaptation using a multimodal experimental and computational data collection pipeline. We quantify morphometry using magnetic resonance imaging, mechanics using biaxial testing, fluid flow using computational fluid dynamics, vascular composition and structure using histology, and transcriptional changes using bulk RNA sequencing. We show that the wrap mitigates vein graft failure by promoting multiple adaptive mechanisms (across biological scales)., Competing Interests: Declaration of Competing Interest All authors report no conflict of interest related to this project. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier Ltd.)

Objective: Standardized letters of recommendation (SLORs) were introduced during the 2020-2021 neurosurgery residency application cycle, but suffered from poor interrater reliability and grade inflation. Changes were made to the SLOR template and utilization patterns in response to these shortcomings. The authors examined the second year of SLOR utilization. They hypothesized that grade inflation and interrater reliability would be improved from the first iteration. They also hypothesized that increased numbers of letters by single writers would correlate with broader rating distributions., Methods: This cross-sectional study analyzed all SLORs submitted to a single neurosurgery residency program over the 2021-2022 cycle. Data from 7 competency domains and the overall rating were recorded and stratified by academic category of the letter writer. Interrater reliability was evaluated using Krippendorff's alpha. The frequency of letters written was evaluated using the Kruskal-Wallis H test., Results: Ninety percent of SLORs rated applicants among the top 25%, but there was a significant decrease in the usage of the top 1% and top 2%-5% ratings. Interrater reliability was poor across all competencies. Writers who completed 1 SLOR rated applicants higher and had a narrower range than those who completed multiple SLORs., Conclusions: Changes in the format and subsequent utilization patterns of SLORs have slightly decreased grade inflation; however, interrater reliability remains poor. The most wide-ranging evaluators submitted the highest number of SLORs, suggesting that future evaluation and usage of SLORs should emphasize letter-writer characteristics and numbers of SLORs written. Overall, SLORs have been well and broadly accepted with subtle improvements in the second year of utilization.

Objective: Pediatric spinal injuries in all-terrain vehicle (ATV) and dirt bike crashes are relatively uncommon but may be associated with significant morbidity. There are no recent studies examining these injuries, their management, and outcomes. Therefore, a retrospective study was performed to characterize pediatric spinal injuries related to ATV and dirt bike crashes over the last decade., Methods: Data on all patients involved in ATV or dirt bike crashes evaluated at a regional level 1 pediatric trauma center over a 10-year period (2010-2019) were analyzed. Descriptive statistics were analyzed and chi-square, Fisher exact, and Mann-Whitney U-tests were performed comparing the demographics, injury characteristics, and clinical outcomes in patients with versus those without spinal injuries., Results: Of 680 patients evaluated, 35 (5.1%) were diagnosed with spinal injuries. Over the study period, both spinal injuries and emergency department visits related to ATV or dirt bike crashes increased in frequency. All spinal injuries were initially diagnosed on CT scans, and 57.9% underwent spinal MRI. Injuries were most commonly thoracic (50%), followed by cervical (36.8%). The injuries of most patients were classified as American Spinal Injury Association (ASIA) grade E on presentation (86.8%), while 2 (5.3%) had complete spinal cord injuries (ASIA grade A) and 3 patients (8.6%) were ASIA grade B-D. Operative management was required for 13 patients (28.9%). Nonoperative management was used in 71.1% of injuries, including bracing in 33% of all injuries. Patients with spinal injuries were older than those without (13.4 ± 3.35 vs 11.5 ± 3.79 years, p = 0.003). Spinal injuries occurred via similar crash mechanisms (p = 0.48) and in similar locations (p = 0.29) to nonspinal injuries. Patients with spinal injuries more frequently required admission to the intensive care unit (ICU; 34.2% vs 14.6%, p = 0.011) and had longer hospital stays (mean 4.7 ± 5.5 vs 2.7 ± 4.0 days, p = 0.0025)., Conclusions: Although infrequent among young ATV and dirt bike riders, spinal injuries are associated with longer hospital stays, increased ICU use, and required operative intervention in 29%. Increasing awareness among ATV and dirt bike riders about the severity of riding-related injuries may encourage safer riding behaviors.

Background: Following aneurysmal subarachnoid hemorrhage (SAH), patients are monitored closely for vasospasm in the intensive care unit. Conditional vasospasm-free survival describes the risk of future vasospasm as a function of time elapsed without vasospasm. Conditional survival has not been applied to this clinical scenario but could improve patient counseling and intensive care unit use. The objective of this study was to characterize conditional vasospasm-free survival following SAH., Methods: This was a single institution, retrospective cohort study of patients treated for aneurysmal SAH between 1/1/2000-6/1/2020. The primary outcome was the development of vasospasm defined by the first instance of either radiographic vasospasm on computed tomography angiography, Lindegaard Index > 3.0 by transcranial doppler ultrasonography, or vasospasm-specific intraarterial therapy. Multivariable Cox regression was performed, and conditional vasospasm-free survival curves were constructed., Results: A total of 528 patients were treated for aneurysmal SAH and 309 (58.5%) developed vasospasm. Conditional survival curves suggest patients who survive to postbleed day 10 without vasospasm have a nearly 90% chance of being discharged without vasospasm. The median onset of vasospasm was postbleed day 6. Age more than 50 years was associated with a lower risk (hazard ratio [HR] = .76; 95% confidence interval [CI] 0.64-0.91; p < 0.001). Higher initial systolic blood pressure (HR = 1.18; 95% CI 1.046-1.350; p = .008), Hunt-Hess grades 4 or 5 (HR = 1.304; 95% CI 1.014-1.676), and modified Fisher scale score of 4 (HR = 1.808; 95% CI 1.198-2.728) were associated with higher vasospasm than the respective lower grades., Conclusion: Conditional survival provides a useful framework for counseling patients and making decisions around vasospasm risk for patients with aneurysmal SAH, while risk factor-stratified plots facilitate a patient-centric, evidence-based approach to these conversations and decisions., (© 2022. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

Objective: Adolescents sustaining sport-related concussion often experience difficulties with the return-to-learn (RTL) process. Whereas the initial symptom burden has predicted prolonged RTL, no studies have established a relationship between acute cognitive symptoms and RTL duration. The authors sought to evaluate the relationship between initial cognitive symptoms and RTL duration., Methods: A retrospective single-institution cohort study of adolescent athletes aged 12-23 years who were evaluated within 5 days of a diagnosed sport-related concussion between November 2017 and October 2020 was conducted. Athletes missing cognitive symptom ratings and RTL data were excluded. The primary exposure variable was the Cognitive Symptom Ratio (CSR), defined as total cognitive symptom cluster score divided by total Post-Concussion Symptom Scale (PCSS) score from the initial clinic visit. Primary and secondary outcomes were time to RTL and total length of care, respectively. Multivariable Cox proportional hazards modeling was used to assess the effect of CSR on RTL duration., Results: Of 653 athletes evaluated within 5 days of injury, 346 patients were included in the final cohort. Athletes reported a median initial PCSS score of 21 (interquartile range [IQR] 6-37) and a median cognitive symptom score of 4 (IQR 0-9). Most patients endorsed some degree of difficulty concentrating (n = 212, 61.3%). The median CSR was 0.18 (IQR 0.00-0.27). On multivariable regression analysis, a higher CSR was associated with prolonged RTL duration (HR 0.30, 95% CI 0.13-0.69, p = 0.004). When initial PCSS score was added to the model, the previously significant association between CSR and RTL was no longer significant (HR 0.67, 95% CI 0.29-1.59, p = 0.367). When dichotomized based on frequency distribution, a higher proportion of patients with low CSR achieved RTL by 7 days postinjury (82.2% vs 69.9%, p = 0.007), a difference not seen at 14 days (92.2% vs 87.3%, p = 0.133)., Conclusions: An acute ratio of cognitive symptoms may predict patients at increased risk for prolonged RTL and those with normal PCSS scores who may experience difficulties once resuming school activities.