Symptom Recovery and Return to Participation Timelines of Patients With Concussion at a Community Physiotherapy Clinic Based on Injury Mechanism

ObjectiveTo compare patient demographics, injury phase (IP; time-to-assessment), total symptom severity score (TSS) changes and return to participation (RTP; cognitive/physical) to mechanism of injury (MOI).BackgroundSecondary concussion prevention includes timely assessment and treatment to decrease TSS and maximize RTP.Design/MethodsOne community physiotherapy clinic. Retrospective chart review (September 1, 2016–August 8, 2018). Two hundred thirty-four patients with concussion (male: n = 85; female: n = 149) from various MOIs. Age groups (years): children 8–12, youth 13–17, young adult 18–29, adult 30–64, senior 65+. IP: acute (<72 hours), subacute (72 hours-2 weeks adults, 72 hours-4 weeks children/youth), persistent (2 weeks-3 months adults, 4 weeks-3 months children/youth), chronic (>3 months). Intervention: multimodal physiotherapy (cervico-vestibular, exertion, education), referral to specialist, psychology and/or neuropsychology. Outcome measures: treatment (number, timeframe) and weeks to recovery (WTR) vs MOI; TSS changes and RTP rates.ResultsAll acute IP had sport MOI, with WTR consistent with current literature. For all others, WTR was longer regardless of age or MOI. MVC and other MOIs were primarily patients in persistent or chronic IP (80% and 71%, respectively). MVC had the longest recovery (12.28 ± 8.21 treatments over 21.03 weeks 95% CI [17.05, 25.01], 44.94 WTR 95% CI [36.38, 53.51]); p < 0.05). Sport MOI received 5.50 ± 3.62 treatments over 7.49 (95% CI [5.59, 9.40]) weeks and 19.07 (95% CI [13.72, 24.42]) WTR. No significant statistical difference was observed between sport and other MOI recovery. TSS decreased in 85% of all patients. Full cognitive RTP was achieved by 75% of patients, and full physical RTP by 68%.ConclusionsConcussion patients experienced symptom and participation recovery, with IP and MOI related to WTR. Treatment/recovery timeframes were longer than previously reported for subacute, persistent, and chronic IPs. These results will inform secondary prevention strategies and knowledge translation underscoring the need for timely assessment and treatment. It also draws attention to RTP in MOIs other than sport.

Evaluation of treatment with two weeks of doxycycline on macrolide-resistant strains of Mycoplasma genitalium: a retrospective observational study

Background Increasing macrolide resistance makes treatment of Mycoplasma genitalium infections challenging. The second-line treatment is moxifloxacin, an antibiotic drug best avoided due to the potential of severe side effects and interactions. This study evaluates the effects of treatment with doxycycline 100 mg twice daily for 2 weeks as an alternative to moxifloxacin. Methods This retrospective observational study examined the medical records of patients testing positive for macrolide resistant Mycoplasma genitalium from January 1st, 2016 to September 1st, 2019 in Trondheim, Norway. Information regarding symptoms as well as clinical and microbiological cure was collected. Results 263 infections from 259 patients (161 females/98 males) were examined. 155 (58.9%) had a negative test of cure following treatment. 34.7% of symptomatic patients not achieving microbiological cure experienced symptom relief or clearance. There was no statistical difference between bacterial loads in symptomatic versus asymptomatic patients. The mean difference was 1.6 × 105 copies/ml (95% CI − 1.4 × 105–4.8 × 105, p = 0.30) for women and 1.4 × 106 copies/ml (95% CI -4.0 × 105–3.2 × 106, p = 0.12) for men. Conclusions The cure rate of doxycycline in this study is higher than previously reported. This adds support to doxycycline’s role in treatment before initiating treatment with less favorable drugs such as moxifloxacin.

Harnessing Inflammation Resolution in Arthritis: Current Understanding of Specialized Pro-resolving Lipid Mediators’ Contribution to Arthritis Physiopathology and Future Perspectives

The concept behind the resolution of inflammation has changed in the past decades from a passive to an active process, which reflects in novel avenues to understand and control inflammation-driven diseases. The time-dependent and active process of resolution phase is orchestrated by the endogenous biosynthesis of specialized pro-resolving lipid mediators (SPMs). Inflammation and its resolution are two forces in rheumatic diseases that affect millions of people worldwide with pain as the most common experienced symptom. The pathophysiological role of SPMs in arthritis has been demonstrated in pre-clinical and clinical studies (no clinical trials yet), which highlight their active orchestration of disease control. The endogenous roles of SPMs also give rise to the opportunity of envisaging these molecules as novel candidates to improve the life quality of rhematic diseases patients. Herein, we discuss the current understanding of SPMs endogenous roles in arthritis as pro-resolutive, protective, and immunoresolvent lipids.

Leukocytoclastic vasculitis in patients with IL12B or IL12RB1 deficiency: case report and review of the literature

Background Mendelian susceptibility to mycobacterial disease (MSMD) is an inborn error of immunity, resulting in susceptibility to weakly virulent mycobacteria and other intramacrophagic pathogens. Rheumatologic manifestations and vasculitis are considered rare manifestations in MSMD patients. Case presentation In this study, we reported a 20-year-old female who was presented with recurrent lymphadenitis following bacillus Calmette-Guérin (BCG) vaccination and a history of recurrent disseminated rash diagnosed as leukocytoclastic vasculitis (LCV). A slight reduction in lymphocyte subsets including CD4+, CD19+, and CD 16 + 56 T-cell count, as well as an elevation in immunoglobulins level (IgG, IgA, IgM, IgE), were observed in the patient. Whole exome sequencing revealed a homozygous Indel-frameshift mutation, c.527_528delCT (p. S176Cfs*12), at the exon 5 of the IL12B gene. She experienced symptom resolution after treatment with anti-mycobacterial agents and subcutaneous IFN-γ. We conducted a manual literature search for MSMD patients reported with vasculitis in PubMed, Web of Science, and Scopus databases. A total of 18 MSMD patients were found to be affected by a variety of vasculitis phenotypes mainly including LCV and Henoch-Schönlein purpura (HSP) with often skin involvement. Patients were all involved with vasculitis at the median age of 6.8 (2.6–7.7) years, nearly 6.1 years after the initial presentations. Sixteen patients (88.9%) had IL12RB1 defects and concurrent Salmonella infection was reported in 15 (88.2%) patients. Conclusion The lack of IL-12 and IL-23 signaling/activity/function and salmonella infection may be triggering factors for the development of leukocytoclastic vasculitis. IL12B or IL12RB1 deficiency and salmonellosis should be considered in MSMD patients with vasculitis.

Identifying Patterns of Symptom Distress in Pregnant Women: A Pilot Study

During pregnancy, a woman’s enlarged uterus and the developing fetus lead to symptom distress; in turn, physical and psychological aspects of symptom distress are often associated with adverse prenatal and birth outcomes. This study aimed to identify the trends in the trajectory of these symptoms. This longitudinal study recruited 95 pregnant women, with a mean age of 32 years, from the prenatal wards of two teaching hospitals in northern Taiwan. Symptom distress was measured by a 22-item scale related to pregnancy-induced symptoms. The follow-up measurements began during the first trimester and were taken every two to four weeks until childbirth. More than half of the pregnant women experienced symptom distress manifested in a pattern depicted to be “Decreased then Increased” (56.8%). Other noticeable patterns were “Continuously Increased” (28.4%), “Increased then Decreased” (10.5%) and “Continuously Decreased” (4.2%), respectively. It is worth noting that most pregnant women recorded a transit and increase in their symptom distress, revealed by their total scores, at the second trimester (mean 22.02 weeks) of pregnancy. The participants’ major pregnancy-related distress symptoms were physical and included fatigue, frequent urination, lower back pain, and difficulty sleeping. The mean scores for individual symptoms ranged from 2.32 to 3.61 and were below the “moderately distressful” level. This study provides evidence that could be used to predict women’s pregnancy-related symptom distress and help healthcare providers implement timely interventions to improve prenatal care.

Calcium Electroporation for Keloids: A First-in-Man Phase I Study

<b><i>Background:</i></b> Keloid scarring is a pathologic proliferation of scar tissue that often causes pruritus, pain, and disfigurement. Keloids can be difficult to treat and have a high risk of recurrence. Recent studies have shown promising results in the treatment of cutaneous metastases with intralesional calcium combined with electroporation (calcium electroporation). As calcium electroporation has shown limited side effects it has advantages when treating benign keloid lesions, and on this indication we performed a phase I study. <b><i>Methods:</i></b> Patients with keloids were treated with at least 1 session of calcium electroporation and followed up for 2 years. Calcium was administered intralesionally (220 mM) followed by the application of eight 100-µs pulses (400 V) using linear-array electrodes and Cliniporator (IGEA, Italy). Treatment efficacy was evaluated clinically (size, shape, erythema), by patient self-assessment (pruritus, pain, other) and assessed histologically. <b><i>Results:</i></b> Six patients were included in this small proof of concept study. Treatment was well tolerated, with all patients requesting further treatment. Two out of 6 patients experienced a decrease in keloid thickness over 30%. A mean reduction of 11% was observed in volume size, and a mean flattening of 22% was observed (not statistically significant). Five out of 6 patients reported decreased pain and pruritus. No serious adverse effects or recurrences were observed over a mean follow-up period of 338 days. <b><i>Conclusion:</i></b> In this first phase I clinical study on calcium electroporation for keloids, treatment was found to be safe with minor side effects. Overall, patients experienced symptom relief, and in some patients keloid thickness was reduced.

A study on symptom improvement and efϑicacy of formoterol plus budesonide in the asthma management in northern parts of Tamil Nadu

The purpose is to study the asthma symptom improvement and efficacy of formoterol (LABA) and Budesonide (ICS) combination in the asthma management in northern districts of Tamilnadu. It is a multicentric, non-comparative, questionnaire and random sampling study was conducted in 145 mild to severe asthmatic patients. They were in Formoterol plus budesonide combination inhalation drugs available in DPI and pMDI. Among the 145 asthmatic patients, 45 patients, 6 patients and 94 patients were in DPI, nebuliser and pMDI devices respectively. During drug initiation, The Asthmatics were in mild (27%), Moderate (57%) and Severe (16%) stages. After one year of follow-up, the number of patients in the mild is 84%, moderate 14% and severe 2%. Among 45 DPI Asthmatic patients, 29 patients, 15 patients and 1 patient have reported the handling the devices as easy, medium and hard respectively. On the other hand, 94 pMDI asthmatic patients, 38 patients, 48 patients and 8 patients have reported the handling of devices as easy, medium and hard respectively. The treatment resulted in 77 patients as good, 65 as satisfactory and 3 as same. After one year, all the 145 asthmatic patients adhered with the treatment and experienced symptom improvement with 53% patients as good, 45% patients as satisfactory and 2% patients as same. The treatment of formoterol and budesonide combination in the northern districts of Tamilnadu have effectively controlled the asthmatic symptoms and improved the quality of life in asthmatics. Moreover, the patient's adherence to the treatment is good in the northern parts of Tamilnadu.

Symptom Provocation During Aerobic and Dynamic Supervised Exercise Challenges in Adolescents With Sport-Related Concussion

Context Supervised exercise challenges (SECs) have been shown to be safe and beneficial in the early symptomatic period after concussion. Thus far, most in-clinic SECs studied have included a form of basic aerobic exercise only. An SEC that also includes dynamic forms of exercise mimics all steps of a standard return-to-play progression and may enhance the detection of concussion symptoms to guide in-clinic management decisions. Objective To determine whether an SEC that includes a dynamic SEC (DSEC) uncovered symptoms that would not have been identified by an SEC involving an aerobic SEC (ASEC) alone in adolescent patients with sport-related concussion. Design Retrospective case series. Setting Multidisciplinary sport concussion clinic at a tertiary care center. Patients or Other Participants A total of 65 adolescent athletes (mean age = 14.9 ± 2.0 years, 72.3% males) who underwent an in-clinic SEC within 30 days of concussion. Main Outcome Measure(s) Presence of pre-exercise symptoms and symptom provocation during the SEC were recorded, with exercise-provoked symptoms categorized as occurring during ASEC or DSEC. Results Of the total patient sample, 69.2% (n = 45/65) experienced symptom provocation at some point during the SEC. Symptoms were provoked in 20 patients during the ASEC, whereas 25 completed the ASEC without symptom provocation before becoming symptomatic during the subsequent DSEC and 20 completed the SEC without any symptom provocation. Of the 65 patients in the total sample, 46 were asymptomatic immediately before the SEC. Of these previously asymptomatic patients, 23.9% (n = 11/46) experienced symptom provocation during the ASEC, and an additional 37.0% (n = 17/46) remained asymptomatic during the ASEC but then developed symptoms during the DSEC. Conclusions The ASEC alone may not detect symptom provocation in a significant proportion of concussion patients who otherwise would develop symptoms during a DSEC.

The Patient Experienced Symptom State (PESS): a patient-reported global outcome measure that may better reflect disease remission status

Objectives In RA, Patient Acceptable Symptom State assesses disease from the patient’s perspective, which does not correspond either to disease remission or to full control of disease impact. This study aims to explore the properties of a novel multilevel Patient Experienced Symptom State (PESS). Methods This was a cross-sectional analysis of two datasets of patients with RA. PESS was assessed through the question: ‘Consider how your RA has affected you. If you remain in the coming months as you have been the last week, how would you rate your condition?’, with five levels (from ‘very bad’ to ‘very good’). Construct validity of PESS was assessed against validated disease activity [DAS28, Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI)] and impact measures [RA Impact of Disease (RAID) and modified HAQ]. Multiple pairwise comparisons between groups and receiver-operating characteristic curves with Youden Index were performed. Results A total of 1407 patients [74% female, mean (S.d.) age 53.5 (13.4) years, mean disease duration 14.3 (12.0) years and mean DAS28 3.0 (1.5)] were analysed. Overall, 16.3% considered themselves as being in ‘very good’, 21.6% in ‘good’ and 31.9% in ‘acceptable’ state. Disease activity and impact measures differed significantly across the five levels (P &lt; 0.01). Cut-off values corresponding to ‘good’ and ‘very good’ PESS states were in the range of low disease activity/remission (for ‘good’ and ‘very good’: DAS28-ESR-4v ≤2.6/≤2.3; CDAI ≤5.0/≤3.1; SDAI ≤5.1/≤3.8, respectively) and very low disease impact (RAID domains all ≤1). Conclusion PESS ‘very good’ status corresponds to currently recommended targets for RA management and reflects full control of disease impact. PESS appears to be an easy-to-use and relevant measure in the evaluation of patients with RA.

Symptom Provocation Patterns During Supervised Exercise in Adolescent Athletes with Concussion

ObjectiveTo understand which exercises provoke symptoms, as well as the type and frequency of symptoms, during supervised exercise (SE) following concussion, and to better understand how to interpret and utilize findings during SE.BackgroundExercise is increasingly used in the management of sport-related concussion, and SE has been shown to be associated with faster clearance to return to sport. However, the optimal use of exercise following concussion is not known, and findings during SE have not been studied.Design/MethodsThis study is a retrospective review of patients seen at a sport concussion clinic. Participants were concussed athletes under age 18 who underwent SE within 30 days of concussion. A typical SE session began with a basic cardiovascular exercise followed by dynamic exercise challenges. Data recorded included exercise type, pre-exercise symptoms, symptom exacerbation scores, and maximum heart rate during exercise. A symptom was considered provoked if a new symptom developed or if an existing symptom increased by ≥3 points on a 10 point scale. Outcome measures were referral to vestibular physical therapy and the number of days from concussion until clearance for return to sport. Data were analyzed using two-sample t tests, linear and logistic regression models.Results66.2% of patients experienced symptom provocation during SE. Symptom provocation did not occur until the dynamic challenge portion of the workout in 55.6% of those symptomatic. Dizziness was the most common symptom (48.5%), and medicine ball exercises (50.0%) the most common provoking exercise. Dizziness provoked during SE predicted referral to vestibular physical therapy (OR 5.90, p = 0.015). Provocation of symptoms during basic cardiovascular exercises predicted a greater number of days until clearance for return to sport (p = 0.015).ConclusionsSymptom provocation during SE provides useful information in return to play decision making, guidance for physical thearpy treatments, and prognostication of recovery time following concussion.