The "value added" of neurocognitive testing after sports-related concussion

Background: Neurocognitive testing has been endorsed as a "cornerstone" of concussion management by recent Vienna and Prague meetings of the Concussion in Sport Group. Neurocognitive testing is important given the potential unreliability of athlete self-report after injury. Relying only on athletes' reports of symptoms may result in premature return of athletes to contact sport, potentially exposing them to additional injury. Hypothesis: Use of computer-based neurocognitive testing results in an increased capacity to detect postconcussive abnormalities after injury. Study Design. Case control study; Level of evidence, 3. Methods: High school and college athletes with a diagnosed concussion were tested 2 days after injury. Postinjury neurocognitive performance (immediate Postconcussion Assessment and Cognitive Testing) and symptom (postconcussion symptom) scores were compared with preinjury (baseline) scores and with those of an age- and education-matched noninjured athlete control group. "Abnormal" test performance was determined statistically with Reliable Change Index scores. Results: Sixty-four percent of concussed athletes reported a significant increase in symptoms, as judged by postconcussion symptom scores, compared with preinjury baseline at 2 days after injury. Eighty-three percent of the concussed sample demonstrated significantly poorer neurocognitive test results relative to their own baseline performance. The addition of neurocognitive testing resulted in a net increase in sensitivity of 19%. Ninety-three percent of the sample had either abnormal neurocognitive test results or a significant increase in symptoms, relative to their own baseline; 30% of a control group demonstrated either abnormalities in neurocognitive testing or elevated symptoms, as judged by postconcussion symptom scores. For the concussed group, use of symptom and neurocognitive test results resulted in an increased yield of 29% overreliance on symptoms alone. In contrast, 0% of the control group had both symptoms and abnormal neurocognitive testing. Conclusion: Reliance on patients' self-reported symptoms after concussion is likely to result in underdiagnosis of concussion and may result in premature return to play. Neurocognitive testing increases diagnostic accuracy when used in conjunction with self-reported symptoms

The responsiveness and minimal important change of the western Ontario shoulder instability index and oxford shoulder instability score

BACKGROUND: Patient-reported outcome measurements (PROMs) are widely used to evaluate functional limitations. Considering PROMs for shoulder instability, information is lacking with regard to what constitutes a relevant change from baseline scores. OBJECTIVES: To evaluate the responsiveness of the Western Ontario Shoulder Instability Index (WOSI) and the Oxford Shoulder Instability Score (OSIS) and estimate their minimal important change (MIC). METHODS: One hundred five consecutive patients with shoulder instability completed 5 PROMs at baseline and at 6-month follow-up. The PROMs included the WOSI and OSIS, the Simple Shoulder Test, the Oxford Shoulder Score, and the Disabilities of the Arm, Shoulder and Hand assessment. Patients also rated their functional change on an anchor question at follow-up. Responsiveness was evaluated by testing 9 hypotheses regarding predefined correlations between the changes in PROM scores, by calculating the area under the receiver operating characteristic curve and by calculating the standardized response mean and effect size statistics. The MIC was determined by identifying the optimal cutoff on the receiver operating characteristic curve. RESULTS: Seven out of 9 hypotheses (78%) were confirmed; as expected, a high correlation (0.77) was found between change scores of the WOSI and OSIS, whereas the correlations of the change scores of the WOSI and OSIS with those of general shoulder PROMs were slightly lower (0.61-0.75). The area under the curve was 0.83 (95% confidence interval: 0.75, 0.91) for the OSIS and 0.82 (95% confidence interval: 0.74, 0.90) for the WOSI. The MIC was about 6 points for the OSIS and about 14 points for the WOSI. CONCLUSION: Both the WOSI and OSIS are able to measure change in shoulder function in patients with shoulder instability. The estimated MIC is 6 points for the OSIS (on a scale from 0 to 48) and 14 points for the WOSI (on a scale from 0 to 100)

Aspects and Intensity of Pediatric Palliative Case Management Provided by a Hospital-Based Case Management Team: A Comparative Study Between Children With Malignant and Nonmalignant Disease

Objectives: Anticipating case management is considered crucial in pediatric palliative care. In 2012, our children's university hospital initiated a specialized pediatric palliative care team (PPCT) to deliver inbound and outbound case management for children with life-shortening disease. The aim of this report is to gain insight in the first 9 months of this PPCT. Methods: Aspects of care during the first 9 months of the PPCT are presented, and comparison is made between patients with malignant disease (MD) and nonmalignant disease (NMD) in a retrospective study design. Insight in the aspects of care of all patients with a life-shortening disease was retrieved from web-based files and the hour registrations from the PPCT. Results: Forty-three children were supported by the PPCT during the first 9 months: 22 with MD with a median of 50 (1-267) days and 29 minutes (4-615) of case management per patient per day and 21 patients with NMD with a median of 79.5 (5-211) days and 16 minutes of case management per day (6-64). Our data show significantly more interprofessional contacts for patients with MD and more in-hospital contacts for patients with NMD. The median number of admission days per patient was 11 (0-22) for MD (44% for anticancer therapy) and 44 (0-303) for NMD (36% for infectious diseases). Significance of Results: This overview of aspects of pediatric palliative case management shows shorter but more intensive case management for MD in comparison with NMD. This insight in palliative case management guides the design of a PPC

A prospective study on the characteristics and subjects of pediatric palliative care case management provided by a hospital based palliative care team

BACKGROUND: Case management is a subject of interest within pediatric palliative care. Detailed descriptions of the content of this type of case management are lacking. We aim to describe the contents of care provided, utilization of different disciplines, and times of usage of a pediatric palliative care case management program compared for patients with malignant disease (MD) and non-malignant disease (NMD). METHODS: A three-month prospective study, with questionnaires filled in by members of a pediatric palliative care team (PPCT) for each contact with parents. RESULTS: Four hundred fifty-five contacts took place with parents of 70 patients (27MD, 43NMD). Sixty-two percent of all contacts were with the specialized nurse. The child life specialists, psychologist and social worker were also regularly consulted, the chaplain was not consulted. Ninety-five percent of all contacts took place between 8 am and 6 pm during weekdays, a limited number between 6 pm and 9 pm. Twenty-five percent of all contacts were proactively initiated by the PPCT, 25 % were initiated by parents. In these care characteristics, no differences were seen for MD and NMD patients. Psychosocial topics were addressed most frequently. MD patients consulted the PPCT more often about school and NMD patients about socio-economic issues. CONCLUSIONS: All different disciplines of the PPCT were regularly consulted, except for the chaplain. With an easy accessible team with a highly pro-active approach, availability from 8 am to 9 pm seems sufficient to accommodate patient's and parent's needs. More anticipation seems required for socio-economic topics. This insight in pediatric palliative case management can provide guidance in the development of a new PPCT

Direct and indirect costs associated with nonoperative treatment for shoulder instability:an observational study in 132 patients

Background: Shoulder instability is associated with decreased functioning. The associated costs could be substantial and interesting to clinicians, researchers, and policy makers. This prospective observational study aims to (1) estimate productivity losses and healthcare expenses following the nonoperative treatment of shoulder instability and (2) identify patient characteristics that influence societal costs. Methods: One hundred and thirty-two patients completed a questionnaire regarding production losses and healthcare utilization following consecutive episodes of shoulder instability. Productivity losses were calculated using the friction cost approach. Healthcare utilization was evaluated using standard costs. analysis of variance test was used to assess which patient characteristics are related to productivity losses and healthcare expenses. Societal costs were assessed using multilevel analyses. Bootstrapping was used to estimate statistical uncertainty. Results: Mean productivity losses are €1469, €881, and €728 and mean healthcare expenses are €3759, €3267, and €2424 per patient per dislocation for the first, second, and third dislocation. Productivity losses decrease significantly after the second (mean difference €−1969, 95%CI= −3680 to −939) and third (mean difference €−2298, 95%CI= −4092 to −1288) compared to the first dislocation. Conclusions: Nonoperative treatment of shoulder instability has substantial societal costs. Level of Evidence: III, economic analysis

Appendix -Supplemental material for Direct and indirect costs associated with nonoperative treatment for shoulder instability: an observational study in 132 patients

<p>Supplemental material, Appendix for Direct and indirect costs associated with nonoperative treatment for shoulder instability: an observational study in 132 patients by Just A van der Linde, Judith E Bosmans, Dirk P ter Meulen, Derk A van Kampen, Derek FP van Deurzen, Robert Haverlag, Daniel BF Saris and Michel PJ van den Bekerom in Shoulder & Elbow</p