Concussion in Rugby Union and the Role of Biomechanics

Due to the physical and high-impact nature of rugby, head impacts can occur within the game which can result in concussion injuries as well as other moderate-to-severe head injuries 1. Concussion has been defined as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces”1 and was found to be one of the more common brain injuries throughout the world.2 This is particularly true in sport; it has been estimated that over half of all concussions are sports related.3 A systematic review of the incidence of concussion in contact sports found that rugby union has a higher incidence rate compared with other sports such as American football and soccer.4 Unlike other sports injuries, detecting a concussion is difficult as the neuropathological changes cannot be recognized on standard neuroimaging technology.5,6 \Therefore, if a player is suspected of having a concussion, they are removed from play for a Head Injury Assessment (HIA). The HIA is a standardized tool for the medical assessment of concussion injuries in rugby and aims to improve detection and patient education.7 The HIA assesses a range of degenerative concussive symptoms including memory, cognitive ability, balance and player discomfort. This concussion diagnosis protocol therefore relies heavily on side-line medical staff to identify if a player is exhibiting concussive symptoms. A major disadvantage to this is that concussion has a variable natural history, with transient, fluctuating, delayed and evolving signs or symptoms.8) This means that symptoms can take up to 48 hours to become apparent.8 It has therefore been acknowledged that the content of the HIA will be modified as the research around concussion diagnosis evolves.8 The reliance on side-line medical staff to accurately identify concussive symptoms means that there is a possibility a concussed player may remain on the field; this is one problem that biomechanical research into concussion is trying to overcome.  This study will give an overview of concussion in rugby union with a focus on incidence, severity and protection strategies. It will discuss current biomechanical research and further biomechanical research required in the area of concussion injuries in rugby union

The efficacy of statin administration prior to elective PCI in reducing the incidence of post-procedural myocardial infarction or all-cause mortality: a systematic review

Abstract  Background:   Observational studies show that statin-naïve patients presenting with acute coronary syndrome (ACS) undergoing elective percutaneous coronary intervention (PCI) have significantly higher rates of myocardial infarction (MI) and mortality.  We plan to review the evidence for giving statin naïve patients statins 24 hours pre-PCI, with the aim of reducing post-procedural MI and mortality. Objective: To critically evaluate and appraise primary and secondary literatures that investigate the efficacy of pre-treatment loading of a statin in improving outcome for patients with ACS undergoing percutaneous coronary intervention (PCI). Review Question: What is the efficacy of statin administration prior to elective PCI in reducing the incidence of post-MI or all-cause mortality? Methods: We searched the Cochrane Database of Systemic Reviews for systemic reviews and NICE CKS database for relevant NICE clinical guidelines. We then searched the MEDLINE database and Cochrane Central Register of Controlled Trial (CENTRAL) for relevant randomised control trials (RCTs). Our search was limited to peer reviewed papers published in the last 10 years, between 1st February 2006 to 1st February 2016. Our exclusion criteria were as follows: patients previously on statin therapy; statin administration outside 24 hours of PCI; unsuitable outcomes measured; papers not available in full and non-randomised trials. We conducted a systematic review on eligible papers acquired from this search. Results: Our literature search yielded 86 papers. After reviewing these papers, 80 papers were excluded. Six papers were included in the final review in which 2207 patients received either high-dose statin treatment (n=1111) or placebo/usual care (n=1096). The ARMYDA-ACS trial showed that short-term pre-treatment with atorvastatin reduces the incidence of major cardiac events in patients with acute coronary syndromes undergoing elective PCI (OR=0.12, CI: 0.05-0.50; p=0.004). These findings were consistent with NAPLES II Trial in which preloading with atorvastatin reduced the risk of MI (OR=0.56 CI: 0.35-0.89). On the other hand, the ALPACS trial showed atorvastatin preloading had no significant benefits over usual care. They found that preloading with atorvastatin was not statistically significant reducing for post-procedural MI (OR=0.92, CI: 0.50-1.69) or mortality (OR=1.06, CI: 0.07-17.01). Three papers reported that the use of rosuvastatin given prior to elective PCI was associated with a significant reduction in post-procedural MI in patients.  These were Yun KH. et al. (OR=0.50, CI: 0.25-0.98), Wang Z. et al. (OR=0.31, CI:  0.10-0.91) and Cay S. et al. (OR=0.05, CI: 0.01-0.41). Conclusion: 5 out of the 6 studies reviewed showed supported the effectiveness of pre-procedural statins use in reducing the risk of post-procedural major cardiac events in patients undergoing elective PCI. These findings support routine use of statins in patients with ACS undergoing elective PCI

Recurrent Aspergillus endocarditis in an immunocompetent patient: challenges in diagnosis and management

We describe an unusual case of recurrent Aspergillus endocarditis in an immunocompetent 64-year-old lady. Four weeks after aortic valve replacement surgery, she presented with an inferior ST elevation myocardial infarction. Coronary angiography demonstrated compromise of the ostium of the right coronary artery, which was successfully treated by primary angioplasty and stenting. Six weeks later, she suffered from a subarachnoid haemorrhage secondary to a mycotic aneurysm. A transoesphageal echocardiogram suggested a large aortic root vegetation. She underwent urgent aortic root replacement with removal of the vegetation, which was subsequently confirmed to be caused by Aspergillus. She was discharged on long term anti-fungal medication (Voriconazole), which she discontinued after seventeen weeks. Several years later, she presented with non-specific symptoms and was ultimately diagnosed with a recurrence of Aspergillus endocarditis. This case illustrates one of the many non-specific ways Aspergillus endocarditis can present. A high index of suspicion can prevent significant life-threatening complications.

Paediatric illness and care: more than just feeling poorly

The medical education curriculum in the UK includes a component on understanding and appreciating the psychosocial aspects of illness and care. Yet, children’s own experiences of illness and care are often overlooked. This article explores these neglected experiences and insights through an examination of paediatric epilepsy. The psychosocial implications of being diagnosed and living with epilepsy for children and their families are wide-ranging, affecting physical and emotional wellbeing and involvement in everyday activities, as well as being burdensome to manage and treat. As such, children and their families have to utilize various coping strategies in order to incorporate epilepsy into their lives. Obtaining and appreciating children’s own experiences and perspectives can highlight key challenges for healthcare professionals working with these patients and their families, including recognizing children’s autonomy, effective communication with them, and acknowledging the wider context of children’s lives

Henry Gray and John Fraser: Scottish surgeons of the Great War

Between 1914 and 1918, the British Expeditionary Force fighting in France and Flanders sustained 2.7 million battle casualties. Just over one quarter (26.1%) were never seen by the medical services. These were men who had been killed (14.2%), were missing (5.4%), or were prisoners of war (6.5%). Most of those who were missing had been killed and their bodies never recovered. Just under three-quarters of the wounded (73.9% or 1 988 969) were seen and treated by the medical services and 151 356 died.[i] The worst single day in British military history was Saturday 1 July 1916, the first day of the Battle of the Somme, when there were 57 470 casualties, of whom 20 000 were killed or died from their wounds. In nearly a quarter of a million admissions dealt with by the medical services, 58.5% of wounds were caused by high-explosive shellfire, 39% by bullets (mostly from machine guns), 2% were caused by grenades, and 0.5% from bayonets. &nbsp

SafeTALK suicide training: An evaluation of attitudes and actions among medical students

Background: SafeTALK is a half-day gatekeeper training program on recognizing persons at risk for suicide and intervening appropriately. Primary care clinicians have been increasingly targeted for suicide intervention training; however, evidence surrounding the effectiveness of safeTALK is lacking, particularly among medical learners. The aim of this study was to assess whether suicide literacy and intervention skills were enhanced by safeTALK training among medical learners.Methods: Undergraduate medical students from an Ontario university were invited to complete an online survey regardless if they had taken safeTALK training as part of their curriculum. Suicide literacy was measured with the Literacy of Suicide Scale (LOSS) and intervention skills were measured with the Suicide Intervention Response Inventory (SIRI).Results: The majority believed that suicide risk assessment training was very important to undergraduate medical education. Although limitations were noted, this study did not demonstrate that safeTALK training significantly improved medical students’ suicide literacy levels or suicide intervention skills.Conclusions: A more comprehensive program including the epidemiology of suicide and mental health disorders in addition to intervention skills is recommended to ensure medical learners are equipped to dispel the stigmas surrounding suicide and offer the appropriate care and follow up to their patients in future practice

Res Medica - RMS Conference Special Edition 2012

Abstracts from the 2012 RMS Conference