Cerebral blood flow is associated with matrix metalloproteinase levels during the early symptomatic phase of concussion

Concussion is associated with disrupted cerebral blood flow (CBF), although there appears to be substantial inter-individual variability in CBF response. At present, the mechanisms of variable CBF response remain incompletely understood, but one potential contributor is matrix metalloproteinase (MMP) expression. In more severe forms of acquired brain injury, MMP up-regulation contributes to CBF impairments via increased blood-brain barrier permeability. A similar relationship is hypothesized for concussion, where recently concussed individuals with higher MMP levels have lower CBF. To test this hypothesis, 35 concussed athletes were assessed longitudinally at early symptomatic injury (median: 5 days post-injury) and at medical clearance (median: 24 days post-injury), along with 71 athletic controls. For all athletes, plasma MMPs were measured and arterial spin labelling was used to measure CBF. Consistent with our hypothesis, higher concentrations of MMP-2 and MMP-3 were correlated with lower global CBF. The correlations between MMPs and global CBF were also significantly diminished for concussed athletes at medical clearance and for athletic controls. These results indicate an inverse relationship between plasma MMP levels and CBF that is specific to the symptomatic phase of concussion. Analyses of regional CBF further showed that correlations with MMP levels exhibited some spatial specificity, with greatest effects in occipital, parietal and temporal lobes. These findings provide new insights into the mechanisms of post-concussion cerebrovascular dysfunction.

Controversies Surrounding Medical Clearance in Psychiatry Patients: evidence, recommendations, and potential approach

Background: Despite the evidence and guidelines recommending otherwise, routine testing remains pervasive in the management of patients presenting to the Emergency Department (ED) for behavioral complaints, under the guise of medical clearance (MC). The aim of this review is to highlight the evidence available concerning routine laboratory testing in psychiatry patients presenting to the ED, underline available guidelines, list possible reasons for over-testing, and propose a possible approach based on all the evidence and recommendations. Methods: Electronic database searches were carried out in Medline/PubMed and Google Scholar with the period set from January 1, 1990 to March 1, 2021. The search process was focused on studies where MC was evaluated in the management of patients presenting for psychiatric complaints to the ED. The references listed in each identified article were also screened and manually searched. Results: 14 relevant studies were found with the majority evaluating the impact of routine laboratory testing on the management and disposition of adults in the ED presenting for an acute psychiatric condition. Two studies investigated the use of a screening tool to rule out the presence of acute medical illness. Conclusion: While ED physicians are faced with many challenges such as litigation and fear of diagnostic uncertainty, few solutions have been proposed. A suggested approach relies on history taking, physical examination, and assessment of mentation to evaluate for the presence of an organic etiology requiring further testing. Adequate communication between the ED physician and psychiatrist, along with shared decision-making are also key to optimizing care.

POST-CONCUSSION PHYSICAL THERAPY REFERALS

Background: Treating a concussion is complex, requiring a multi-disciplinary patient-centered approach for optimal outcomes. Physical therapy (PT) is a treatment utilized to facilitate concussion recovery, however little is known about those patients referred to PT. Purpose/Hypothesis: The purpose of this study was to report the demographics and other outcome measures of patients referred to PT from an attached specialty concussion clinic. Methods: Retrospective data were extracted from medical records for patients who were referred for physical therapy (PT) from its specialty concussion clinic. Patients included in this study were aged 8-18, diagnosed with a concussion, and referred to PT. Demographic data (age, gender, ethnicity, race) were patient reported. Other patient outcome measures (total injury recovery in days, total number of PT visits, total days between the first and last PT visit, positive VOMS score (symptom increase of 2 from baseline on any symptom and/or convergence on any trial >6cm). Statistical analyses included summary statistics and were reported appropriately as proportions, medians (interquartile range [IQR]), and means (± standard deviation [SD]). Results: Of the 88 patients referred to PT, the mean (± SD) age was 14.31 (± 2.58), 27.3% were children (8-12 years), 72.7% were adolescents (13-18 years), 65.9% were female, 87.5% were white race, 6.8% were black race, and 12.5% were Hispanic in ethnicity. A total of 84.1% patients had a positive VOMS, 9.1% had a negative VOMS, and 6.8% had an invalid VOMS. On average, patients were seen for 4 (± 2.60) total visits, spanning across an average of 18 (± 14.83) days between initial and last PT visits, with the median recovery between date of injury and medical clearance being 48 days (SD=175). Conclusions: This is the first study to provide preliminary demographics of post-concussive PT patients referred from its specialty concussion clinic. These results will be useful in establishing future protocols for future studies to examine the effect of early PT intervention on pediatric concussion recovery.

THE CLINICAL UTILITY OF THE VESTIBULAR AND OCULAR MOTOR SCREENING FOR PROTRACTED RECOVERY IN PEDIATRIC CONCUSSION PATIENTS

Background: Sports-related concussions (SRCs) are a concern for youth athletes and their subsequent healthy development into adulthood. Protracted recovery (>28 days) from a SRC may lead to long-term complications resultant of persistent symptoms. There is a current lack in understanding of the factors contributing to protracted recovery from SRC in children, and in particular no tools exist to identify those SRC patients that may be more likely have a protracted recovery in an acute clinical setting. Hypothesis/Purpose: To examine the relationship between initial Vestibular and Ocular Motor Screening (VOMS) and protracted recovery from concussion in youth. Methods: Children aged 8-12 years old, who were diagnosed with a SRC and seen in a concussion specialty clinic within 7-days of injury were included in the analysis. VOMS was administered during the initial visit. A positive VOMS score was defined as any 2-point increase from baseline in patient reported symptom severity on dizziness, fogginess, headache, and nausea, or any convergence measure greater than 6 centimeters. Recovery time (days) was the interval between date of injury and date of medical clearance. Multivariable logistic regressions were used to determine the odds of protracted recovery based on an initial positive VOMS. Results: A total of 108 males (mean age=10.8, sd=1.3) and 66 females (mean age=10.8, sd=1.4), took a median (IQR) 20.0 (15.0-28.5) and 22.0 (15.0-34.0) days to recover, respectively. After controlling for age and days since injury, those with a positive VOMS were 3.92 (95% CI = 1.58-9.71, p=0.003) times more likely to have a protracted recovery compared to those with a negative VOMS. When stratified by sex, observed effects were more amplified among males (OR=5.92, 95% CI=1.59-21.96, p=0.008), than among females (OR=2.44, 95% CI=0.61-9.71, p=0.21). Conclusion: There is a need to determine the relationship between SRC assessment measures and recovery time to improve clinical management and outcomes. In this sample of pediatric concussion patients aged 8-12 years, the VOMS displayed potential as a tool to screen for delayed recovery among males. Future studies should confirm these findings in other, larger samples, while taking into consideration other factors that may influence recovery time.

White Matter Abnormalities Associated With Prolonged Recovery in Adolescents Following Concussion

Background: Concussion symptoms in adolescents typically resolve within 4 weeks. However, 20 – 30% of adolescents experience a prolonged recovery. Abnormalities in tracts implicated in visuospatial attention and emotional regulation (i.e., inferior longitudinal fasciculus, ILF; inferior fronto-occipital fasciculus, IFOF; uncinate fasciculus; UF) have been consistently reported in concussion; yet, to date, there are no objective markers of prolonged recovery in adolescents. Here, we evaluated the utility of diffusion MRI in outcome prediction. Forty-two adolescents (12.1 – 17.9 years; female: 44.0%) underwent a diffusion Magnetic Resonance Imaging (dMRI) protocol within the first 10 days of concussion. Based on days of injury until medical clearance, adolescents were then categorized into SHORT (<28 days; N = 21) or LONG (>28 days; N = 21) recovery time. Fractional anisotropy (FA) in the ILF, IFOF, UF, and/or concussion symptoms were used as predictors of recovery time (SHORT, LONG). Forty-two age- and sex-matched healthy controls served as reference. Higher FA in the ILF (left: adjusted odds ratio; AOR = 0.36, 95% CI = 0.15 – 0.91, P = 0.030; right: AOR = 0.28, 95% CI = 0.10 – 0.83, P = 0.021), IFOF (left: AOR = 0.21, 95% CI = 0.07 – 0.66, P = 0.008; right: AOR = 0.30, 95% CI = 0.11 – 0.83, P = 0.020), and UF (left: AOR = 0.26, 95% CI = 0.09 – 0.74, P = 0.011; right: AOR = 0.28, 95% CI = 0.10 – 0.73, P = 0.010) was associated with SHORT recovery. In additional analyses, while adolescents with SHORT recovery did not differ from HC, those with LONG recovery showed lower FA in the ILF and IFOF (P < 0.014). Notably, inclusion of dMRI findings increased the sensitivity and specificity (AUC = 0.93) of a prediction model including clinical variables only (AUC = 0.75). Our findings indicate that higher FA in long associative tracts (especially ILF) might inform a more objective and accurate prognosis for recovery time in adolescents following concussion.

Predicting risks of physical health deterioration in a place of safety

AimsHealthcare triage for those subject to section 136 powers (MHA 1983/2007) remains challenging. Camden and Islington NHS Foundation Trust opened a dedicated Health-Based Place of Safety (HBPOS) in 2020, situated separately from an emergency department (ED). There was concern that this may lead to physical health problems going unrecognised. We aimed to design a simple, efficient algorithm to be used by non-medically-trained staff to identify those who are subject to s.136 powers who would benefit from medical clearance before being admitted to the HBPOSMethodWe chaired a consensus meeting with nursing staff, police and emergency medicine consultants when designing the algorithm. Case notes of those presenting under s.136 to the POS over 1 calendar-month in 2019 were reviewed, and the proportion of those who the algorithm would have diverted for medical clearance was calculated. We then reviewed the proportion of cases sent for medical clearance during a single calendar month in 2020, after the HBPOS had opened, to see whether there was a significant difference.Result37 patients were admitted to the ED-based POS in July 2019, of which 36 records were analysed. 9 patients (25%) were referred for medical clearance, with 2 (6%) requiring medical admission. 8.6% were identified as needing medical clearance when the algorithm was applied retrospectively (positive predictive value 66%, negative predictive value = 79%).Review of records over 1 calendar-month after the HBPOS was established showed 30.6% of patients had been diverted for medical clearance prior to entering the HBPOS. Of the 65 patients, 1 (2%) required transfer to ED within 48 hours of entry. No statistical difference in the proportion of patients sent for medical clearance was observed since the formation of the HBPOS away from the ED (Chi-squared = 0.549, p = 0.458), suggesting the algorithm successfully identified those patients who needed medical clearance prior to admission.We observed high rates of intoxication amongst those admitted (30–40%).ConclusionThe algorithm showed high specificity and negative predictive value, allowing for a degree of confidence when admitting those deemed at low-risk of physical deterioration, though it does not eliminate the need for clinical judgement. Interpretation of the results is complicated by the COVID19 pandemic in 2020, which was not accounted for in the algorithm, which possibly led to deviations from the algorithm in real-world clinical practice.

Utility and acceptability of the EXCEEDS algorithm for oncology stakeholders: Results of a Delphi study.

e13538 Background: The Exercise in Cancer Decision Support (EXCEEDS) algorithm is an evidence-based, risk stratified framework. This framework allows for enhanced decision making for exercise pre-participation medical clearance and triage to cancer rehabilitation or exercise services across the cancer continuum. We conducted a Delphi study to examine utility and acceptability of the EXCEEDS algorithm for oncology stakeholders. Methods: Delphi study participants were randomized to two case studies, then made pre-participation medical clearance (yes/no) and intervention triage recommendations (cancer rehabilitation, clinically-supervised exercise, cancer-specific community-based exercise, and unsupervised exercise) in two conditions: independent (IND) and using EXCEEDS. Immediately following, participants rated algorithm acceptability in four domains using 4-point Likert scales (1- strongly disagree, to 4- strongly agree). We dichotomously coded accuracy (correct/incorrect) for each medical clearance and triage recommendation, then calculated the proportion of correct answers for each case to determine accuracy. We compared triage decision time (seconds) between conditions (IND vs. EXCEEDS) using paired-samples t-tests. We calculated the proportion of participants who ‘agreed’ (i.e., score ≥3) with each acceptability domain. Results: Oncology stakeholders (N=33) were mostly female (69.7%), 35-44 years old (42.4%), located in the United States (60.6%), and had at least 10 years of experience (60.6%). When using EXCEEDS, accuracy for medical clearance decisions improved in 3 of 4 cases (75%), triage decision accuracy improved in 4 of 4 (100%) cases, and triage time (seconds) improved significantly in 3 of 4 cases (75%, p<.05). Table shows average improvement in decision accuracy and triage time for each case study. Most participants agreed that the algorithm was acceptable in each domain: “meets my approval” (n=21, 63.6%), “is appealing” (n=29, 87.9%), “enjoyable to use” (n=19, 57.6%), and “welcomed in my discipline or practice” (n=24, 72.7%). Conclusions: Accuracy and efficiency of decision-making for medical clearance and triage to cancer rehabilitation or exercise services was enhanced when using the EXEECDS algorithm. Most participants agreed the algorithm was acceptable. Future research is needed to validate the tool and explore avenues for dissemination and clinical implementation. % difference between EXCEEDS and Individual condition (EXCEEDS – IND) for medical clearance decision, triage decision and mean (M) and standard deviation (SD) of triage decision time.[Table: see text]

Covid-19 y cetoacidosis diabética erróneamente diagnosticadas como ansiedad primaria: Reporte de un caso acerca de causas médicas versus psiquiátricas de ansiedad.

Los trastornos de ansiedad tienen gran importancia en la psiquiatría de urgencias, tanto por la frecuencia con la que se presentan, como por la relevancia de las enfermedades somáticas que pueden subyacer a un cuadro ansioso. Resulta imperativo determinar desde el abordaje diagnóstico inicial si los signos y síntomas de la ansiedad constituyen una plena respuesta a situaciones de estrés, son manifestaciones de una patología somática subyacente, o se pueden explicar como síntomas de un trastorno psiquiátrico primario específico. En el momento actual, la pandemia de COVID-19 –en la que el Perú ha llegado a tener la mayor tasa de mortalidad mundial-- desborda los servicios de salud con abigarrados cuadros en los que se combinan tanto los síntomas de la infección viral por sí misma, como los de reacciones ansiosas y respuestas al estrés. A propósito de un caso ilustrativo, en el que el proceso de tamizaje médico fue deficitario y se etiquetó al paciente como un caso primario de “ansiedad”, con un desenlace lamentablemente ominoso, se revisa brevemente la literatura acerca del proceso de medical clearance (o descarte de condiciones médicas) y se reafirma concluyentemente la importancia de una consideración diagnóstica inicial abarcadora, no sesgada, y basada en criterios clínicos sólidamente elaborados y sustentados. Es evidente, por otro lado, que el psiquiatra requiere estar permanentemente actualizado sobre las formas de presentación psicopatológica asociadas a la sintomatología de COVID-19.