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This article presents a brief history and literature review of chronic traumatic encephalopathy (CTE) in professional athletes that played contact sports. The hypothesis that CTE results from concussion or sub-concussive blows is based largely on several case series investigations with considerable bias. Evidence of CTE in its clinical presentation has not been generally noted in studies of living retired athletes. However, these studies also demonstrated limitation in research methodology. This paper aims to present a balanced perspective amidst a politically charged subject matter.

While the acute effects of concussion and mild traumatic brain injury (TBI) are well understood, the certainty in the medical literature regarding the long-term outcomes of sports-related concussion is limited. Long-term deficits that may result from single, repeated concussions, and possibly subconcussive impacts, include cognitive dysfunction, depression and executive dysfunction. Perhaps most troublingly, repetitive head impacts have been linked to neurodegenerative diseases, including chronic traumatic encephalopathy (CTE), although the precise risk of long-term consequences remains unknown. CTE represents a distinct tauopathy with an unknown incidence in athletic populations; however, a cause and effect relationship has not yet been demonstrated between CTE and concussions or between CTE and exposure to contact sports, as no prospective longitudinal studies have been performed to address that question. Studies of high-school sports exposure and long-term outcomes have not demonstrated consistent findings.Medical advice regarding return to play and the risk of acute and/or long-term consequences is therefore problematic. It is important that the individual’s right to make their own choices regarding their health is respected. Team, coach, parental, peer or financial pressures should not influence this decision. The choice to return to play after a concussion or mild TBI injury is the athlete’s decision once they have (1) recovered from their injury and have the legal capacity to make an informed decision; (2) been medically assessed and (3) been informed of any possible long-term risks in a language that they can understand.Given the current lack of certainty in relation to long-term outcomes from concussion, is it possible to provide a framework to inform players of current evidence, as part of a consent process, even if the information upon which the decision to return to sport is based remains uncertain and evolving?

OBJECTIVE: The recently published Centers for Disease Control and Prevention evidence-based guideline on pediatric mild traumatic brain injury (mTBI) was developed following an extensive review of the scientific literature. Through this review, experts identified limitations in existing pediatric mTBI research related to study setting and generalizability, mechanism of injury and age of cohorts studied, choice of control groups, confounding, measurement issues, reporting of results, and specific study design considerations. This report summarizes those limitations and provides a framework for optimizing the future quality of research conduct and reporting. RESULTS: Specific recommendations are provided related to diagnostic accuracy, population screening, prognostic accuracy, and therapeutic interventions. CONCLUSION: Incorporation of the recommended approaches will increase the yield of eligible research for inclusion in future systematic reviews and guidelines for pediatric mTBI.

The consensus definition of concussion was only agreed in 20011 which means that concussion has just turned 18. It must, therefore, be viewed as an unruly teenager, rebellious and changing, but finally beginning to mature. Along the way, there has been a book, a film, extensive litigation and legislation, millions of words written in the media, thousands of peer-reviewed articles, more consensus meetings, more books and the threat of still more litigation. Hardly a week goes by without another story about concussion hitting the headlines and the centre of the concussion maelstrom is the USA. In terms of global participation, volleyball leads the field with 998 million participants, followed by basketball (400 m), soccer (242 m), badminton (200 m) and tennis (60 m). Not the strongest line-up for sports involving concussion and in the USA, the list is only slightly …

Importance Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States. Objective To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI. Evidence Review The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015. Findings The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. Conclusions and Relevance This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

Through a partnership with the National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health, and Department of Defense, the development of Sport-Related Concussion (SRC) Common Data Elements (CDEs) was initiated. The aim of this collaboration was to increase the efficiency and effectiveness of clinical research studies and clinical treatment outcomes, increase data quality, facilitate data sharing across studies, reduce study start-up time, more effectively aggregate information into metadata results, and educate new clinical investigators. The SRC CDE Working Group consisted of 32 worldwide experts in concussion from varied fields of related expertise divided into three Subgroups: Acute (3 months post-concussion). To develop CDEs, the Subgroups reviewed various domains, then selected from, refined, and added to existing CDEs, case report forms and field-tested data elements from national registries and funded research studies. Recommendations were posted to the NINDS CDE Website for Public Review from February 2017 to April 2017. Following an internal Working Group review of recommendations, along with consideration of comments received from the Public Review period, the first iteration (Version 1.0) of the NINDS SRC CDEs was completed in June 2017. The recommendations include Core and Supplemental–Highly Recommended CDEs for cognitive data elements and symptom checklists, as well as other outcomes and end-points (e.g., vestibular, oculomotor, balance, anxiety, depression), and sample case report forms (e.g., injury reporting, demographics, concussion history) for domains typically included in clinical research studies. The NINDS SRC CDEs and supporting documents are publicly available on the NINDS CDE website www.commondataelements.ninds.nih.gov. Widespread use of CDEs by researchers and clinicians will facilitate consistent SRC clinical research and trial design, data sharing, and metadata retrospective analysis.

OBJECTIVE: To conduct a systematic review of the literature regarding assessment and treatment modalities in patients with persistent symptoms following sport-related concussion (SRC). DATA SOURCES: We searched Medline, Embase, SPORTSDiscus, PsycINFO, CINAHL, Cochrane library and ProQuest Dissertation & Theses Global electronic databases. STUDY ELIGIBILITY CRITERIA: Studies were included if they were original research, reported on SRC as the primary source of injury, included patients with persistent postconcussive symptoms (>10 days) and investigated the role of assessment or treatment modalities. RESULTS: Of 3225 articles identified in the preliminary search, 25 articles met the inclusion criteria. 11 articles were concerned with assessment and 14 articles with treatment of persistent symptoms following SRC. There were three randomised control trials and one quasi-experimental study. The remainder consisting of cross-sectional studies, historical cohorts and case series. SUMMARY: 'Persistent symptoms' following SRC can be defined as clinical recovery that falls outside expected time frames (ie, >10-14 days in adults and >4 weeks in children). It does not reflect a single pathophysiological entity, but describes a constellation of non-specific post-traumatic symptoms that may be linked to coexisting and/or confounding pathologies. A detailed multimodal clinical assessment is required to identify specific primary and secondary processes, and treatment should target specific pathologies identified. There is preliminary evidence supporting the use of symptom-limited aerobic exercise, targeted physical therapy and a collaborative approach that includes cognitive behavioural therapy. Management of patients with persistent symptoms is challenging and should occur in a multidisciplinary collaborative setting, with healthcare providers with experience in SRC.

Objective Systematic review of possible long-term effects of sports-related concussion in retired athletes. Data sources Ten electronic databases. Study selection Original research; incidence, risk factors or causation related to long-term mental health or neurological problems; individuals who have suffered a concussion; retired athletes as the subjects and possible long-term sequelae defined as >10 years after the injury. Data extraction Study population, exposure/outcome measures, clinical data, neurological examination findings, cognitive assessment, neuroimaging findings and neuropathology results. Risk of bias and level of evidence were evaluated by two authors. Results Following review of 3819 studies, 47 met inclusion criteria. Some former athletes have depression and cognitive deficits later in life, and there is an association between these deficits and multiple prior concussions. Former athletes are not at increased risk for death by suicide (two studies). Former high school American football players do not appear to be at increased risk for later life neurodegenerative diseases (two studies). Some retired professional American football players may be at increased risk for diminishment in cognitive functioning or mild cognitive impairment (several studies), and neurodegenerative diseases (one study). Neuroimaging studies show modest evidence of macrostructural, microstructural, functional and neurochemical changes in some athletes. Conclusion Multiple concussions appear to be a risk factor for cognitive impairment and mental health problems in some individuals. More research is needed to better understand the prevalence of chronic traumatic encephalopathy and other neurological conditions and diseases, and the extent to which they are related to concussions and/or repetitive neurotrauma sustained in sports.

Background:It has been previously shown that professional jockeys suffer high rates of fatal and non-fatal injuries in the pursuit of their occupation. Little is known, however, about differences in injury rates between countries.Aim:To determine the rate of fatal and non-fatal injuries in flat and jump jockeys in France and to compare the injury rates with those in Great Britain and IrelandMethod:Prospectively collected injury data on professional jockeys were used as the basis of the analysis.Results:Limb fractures occur four times more often in both flat and jump racing in France than in Great Britain. Similarly dislocations are diagnosed 20 times more often in flat and three times more often in jump racing. This difference is surprising given that French jockeys have fewer falls per ride than their British counterparts in flat racing, although they do have more falls than the British in jump racing. Similarly concussion rates seem to be higher in French jockeys, although there may be a difference in the diagnostic methods used in the different countries. By contrast, soft tissue injuries account for a far smaller percentage of injuries than in Great Britain.Conclusion:There are striking differences in injury rates between countries which may be explained in part by a difference in track conditions—for example, harder tracks in France—or different styles of racing—for example, larger fields of horses per race in France.

Professional horse racing is an exciting and demanding sport with high injury rates. Surprisingly few epidemiological studies have been published and no prospective studies have been reported. This paper reviews the literature and provides a detailed breakdown of injuries in Great Britain and the Republic of Ireland for 1992-2000. The introduction of protective equipment is discussed and evidence for its effectiveness put forward.

Background: It has been previously shown that professional jump and flat racing jockeys suffer a high incidence of injury as a consequence of their profession. This paper specifically examines career-ending injuries to professional jockeys in Great Britain. Aims: To investigate career-ending injuries in professional jockeys. Method: Analysis of prospectively collected injury database on professional jockeys. Results: The majority of injuries in this study occurred to the head, shoulder or torso. Fractures were the most common type of injury that led to a decision to end a career, followed by neurological injury to the head and/or spine. Conclusion: Injuries to the head are the most common career-ending injuries, and consideration of injury counter measures could be an important strategy in equestrian sports.

The growth of Escherichia coli in fed-batch and continuous culture is examined and results show that α-amylase production is strongly dependent on specific growth rate (dilution rate) of the culture and production is greatest at an intermediate rate. Using continuous culture, it has also been found that the presence of acetate above a certain concentration reduces both μmax, and the production of recombinant protein.

Objective. Vitamin D inadequacy is associated with medication refractory musculoskeletal pain and neuromuscular dysfunction. This vitamin deficiency could subsist as an unrecognized comorbid condition among patients with chronic pain. The primary objective of this study was to determine the prevalence and clinical correlates of vitamin D inadequacy in patients seeking treatment for chronic pain. Design. Retrospective case series. Setting. Multidisciplinary pain rehabilitation center at a tertiary referral medical center. Patients. The study involved 267 chronic pain patients admitted from February to December 2006. Intervention. Serum 25-hydroxyvitamin D (25[OH]D) was drawn at admission. Outcome Measures. Patients with serum 25[OH]D levels ≤20 ng/mL were considered to have inadequate levels and those with levels >20 ng/mL were considered to have adequate levels. Upon admission, opioid intake was documented and patients completed the Short Form-36 Health Status Questionnaire. Results. The prevalence of vitamin D inadequacy was 26% (95% confidence interval, 20.6–31.1%). Among patients using opioids, the mean morphine equivalent dose for the inadequate vitamin D group was 133.5 mg/day compared with 70.0 mg/day for the adequate group (P = 0.001). The mean duration of opioid use for the inadequate and adequate groups were 71.1 months and 43.8 months, respectively (P = 0.023). Opioid users with inadequate levels reported worse physical functioning (P = 0.041) and health perception (P = 0.003) than opioid users with adequate levels. Conclusion. The prevalence and clinical correlates identified in this pilot study provide the basis for the assertion that vitamin D inadequacy may represent an under-recognized source of nociception and impaired neuromuscular functioning among patients with chronic pain.

Little evidence exists to guide the selection of methods for teaching clinical diagnosis.To compare the efficacy, student preference, and cost of a Web-based (WB) program versus a standardized patient (SP) encounter for teaching clinical diagnosis skills to 2nd-year medical students.Randomized, controlled, crossover study comparing WB versus SP-based teaching for the clinical diagnosis of abdominal pain and headache. Outcome measures were performance on a 2-case SP examination (scored on the basis of a checklist completed by a faculty observer and an objective score on a postencounter subjective-objective assessment plan [SOAP] note), format preferences as assessed by end-of-course evaluations, and cost.Thirty students consented to participate. WB and SP training produced similar scores on both the Abdominal Pain checklist (66% vs. 62%; p = .17) and Headache checklist (56% vs. 63%; p = .07). WB training produced a higher score on the Abdominal Pain SOAP note (69% vs. 47%; p = .006), but not the Headache SOAP note (69% vs. 67%; p = .85). Students rated the SP format higher than the WB format on all 7 preference measures. Start-up costs were estimated at 2,190 dollars for the SP format and 2,250 dollars for the WB format. Ongoing costs per case per student were estimated to be 45 dollars for the SP format and 30 dollars for the WB format.WB and SP learning outcomes were comparable, but students preferred the SP format. Start-up costs were comparable, but the ongoing costs of the WB format were less expensive, suggesting that WB teaching may be a viable strategy.

At a lunchtime ceremony in Buckingham Palace on 15 October 2008, Professor Roald Bahr was presented with the Prince Philip Medal by His Royal Highness, The Duke of Edinburgh, KG, KT. The medal was awarded to Professor Bahr by the Institute of Sport and Exercise Medicine (ISEM), an organisation founded in 1958 and of which HRH The Duke of Edinburgh is an Honorary Fellow. The Institute was founded by Peter Sebastian and the first Chairman was Sir Arthur Porritt, President of the Royal College of Surgeons of England and later Governor-General of New Zealand. The ISEM, and its Honorary Fellow, played a significant role in the establishment of Sport and Exercise Medicine as a speciality in the UK. At a dinner hosted by HRH The Duke of Edinburgh, held at St James Palace in 1996, HRH urged the President of the Academy of the Medical Royal Colleges, Dame Fiona Caldicott, to revisit the establishment of sports medicine as a speciality after the Academy had …

This paper adds to the small body of literature available on horse-related injuries by clearly highlighting the need for …

The levels of ribonucleotide reductase activity (measured as the conversion of 3H-cytosine monophosphate to 3H-dCMP) in cell-free extracts of partially synchronized cultures of L cells were measured as the cells moved through the division cycle. A strict parallelism was found between the measured enzyme levels and the fractions of the population that were forming DNA. This relationship between enzyme level and ability to replicate DNA indicated that the reductase activity fell rapidly when cells emerged from the DNA synthetic period, suggesting a lability of the enzyme in vivo. The lability in vivo was confirmed by measuring enzyme levels in cultures where further protein synthesis had been blocked with cycloheximide. Under these conditions, an apparent half-life of less than 2 hours was observed for ribonucleotide reductase in the L cell.

The final stages in the biosynthesis of cephalosporin C are thought to involve the oxidation of desacetoxycephalosporin C to desacetylcephalosporin C (Fujisawa et al., 1975). Licrsch et al. (1976) showed that, in the presence of acetyl-CoA, cell-free extracts of Acremonium chrysogenum convert desacetoxycephalosporin C into cephalosporin C. They presented indirect evidence for an intermediate oxidation of the 3-methyl group on the cephalosporin nucleus by a mono-oxygenase dependent on NADH and MnZ+. Using an assay which measures the conversion of [3-Me-3H]desacetoxycephalosporin C into [3H]desacetylcephalosporin C, we now show that this oxidation is in fact catalysed by a 2-oxoglutarate-linked dioxygenase similar to the enzymes described by Abbott & Udenfrieiid (1 974). Desacetoxycephalosporin C was prepared by hydrogenolysis of cephalosporin C by using a large excess of palladium oxide on keiselguhr (Stedman et al., 1934). [3-Me-3H]Desacetoxycephalosporin C was prepared at The Radiochemical Centre (Amersham, Bucks., U.K.) by a similar procedure but with 3H. Chromatography on DEAE-cellulose eluted with acetic acid followed by preparative t.1.c. on cellulose (Eastman Kodak, type 13254) eluted with propan-1-ol/water/acetic acid (5: 2: 1, by vol.) yielded a product with a specific radioactivity of about 2Ci/mmol. A mutant of A. chrysogenum yielding high titres of cephalosporin C was grown on slopes containing 4% (w/v) maltose, 2.4% Oxoid malt extract, 1 % Oxoid peptone and 2% agar for 7 days at 28°C. Mycelium from half the slope was transferred to a 250ml flaskcontaining40ml of2.5 %corn steepliquor,0.55 %ammonium acetate, 2.5 %sucrose