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Cook NE, Gaudet CE, Zafonte R, Berkner PD, Iverson GL. Acute effects of concussion among adolescents with attention-deficit/hyperactivity disorder. Child Neuropsychol 2022:1-24. [PMID: 36510369 DOI: 10.1080/09297049.2022.2144815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Adolescents with ADHD have a greater lifetime history of concussion and experience concussion-like symptoms in the absence of a concussion, complicating concussion assessment and management. It is well established that individuals who experience greater acute symptoms following concussion are at risk for slower recovery and persistent symptoms. We examined whether youth with ADHD experience worse acute effects, within the first 72 h following concussion, compared to youth without ADHD. We hypothesized that youth with ADHD would perform worse on neurocognitive testing and endorse more severe symptoms acutely following injury, but the magnitude of change from pre injury to post injury would be similar for both groups, and thus comparable to baseline group differences. The sample included 852 adolescents with pre-injury and post-injury ImPACT results (within 72 h); we also conducted supplementary case-control analyses on a subset of youth with and without ADHD matched on demographics and pre-injury health history. For both samples, there were significant interaction effects for the Verbal Memory and Visual Motor Speed composites (p < 0.01, η2=.01-.07, small-medium effect), such that youth with ADHD showed a greater magnitude of diminished cognitive functioning from pre-injury to post-injury testing. There were no significant differences in the magnitudes of changes from pre injury to post injury with regard to overall symptom reporting (i.e., total symptom severity scores, total number of symptoms endorsed); however, there were group differences in endorsement rates for several individual symptoms. Further research is needed to determine whether such differential acute effects are associated with recovery time in youth with ADHD.
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Affiliation(s)
- Nathan E Cook
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.,Sports Concussion Program, MassGeneral Hospital for Children, Waltham, MA, USA.,Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Charles E Gaudet
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.,Sports Concussion Program, MassGeneral Hospital for Children, Waltham, MA, USA.,Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Paul D Berkner
- College of Osteopathic Medicine, University of New England, Biddeford, ME, USA
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.,Sports Concussion Program, MassGeneral Hospital for Children, Waltham, MA, USA.,Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, USA.,Department of Physical Medicine and Rehabilitation, Schoen Adams Research Institute at Spaulding Rehabilitation, Charlestown, MA, USA
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Raikes AC, Hernandez GD, Mullins VA, Wang Y, Lopez C, Killgore WDS, Chilton FH, Brinton RD. Effects of docosahexaenoic acid and eicosapentaoic acid supplementation on white matter integrity after repetitive sub-concussive head impacts during American football: Exploratory neuroimaging findings from a pilot RCT. Front Neurol 2022; 13:891531. [PMID: 36188406 PMCID: PMC9521411 DOI: 10.3389/fneur.2022.891531] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Context Repetitive sub-concussive head impacts (RSHIs) are common in American football and result in changes to the microstructural integrity of white matter. Both docosahexaenoic acid (DHA) and eicosapentaoic acid (EPA) supplementation exerted neuroprotective effects against RSHIs in animal models and in a prior study in football players supplemented with DHA alone. Objective Here, we present exploratory neuroimaging outcomes from a randomized controlled trial of DHA + EPA supplementation in American football players. We hypothesized that supplementation would result in less white matter integrity loss on diffusion weighted imaging over the season. Design setting participants We conducted a double-blind placebo-controlled trial in 38 American football players between June 2019 and January 2020. Intervention Participants were randomized to the treatment (2.442 g/day DHA and 1.020 g/day EPA) or placebo group for five times-per-week supplementation for 7 months. Of these, 27 participants were included in the neuroimaging data analysis (n = 16 placebo; n = 11 DHA + EPA). Exploratory outcome measures Changes in white matter integrity were quantified using both voxelwise diffusion kurtosis scalars and deterministic tractography at baseline and end of season. Additional neuroimaging outcomes included changes in regional gray matter volume as well as intra-regional, edge-wise, and network level functional connectivity. Serum neurofilament light (NfL) provided a peripheral biomarker of axonal damage. Results No voxel-wise between-group differences were identified on diffusion tensor metrics. Deterministic tractography using quantitative anisotropy (QA) revealed increased structural connectivity in ascending corticostriatal fibers and decreased connectivity in long association and commissural fibers in the DHA+EPA group compared to the placebo group. Serum NfL increases were correlated with increased mean (ρ = 0.47), axial (ρ = 0.44), and radial (ρ = 0.51) diffusivity and decreased QA (ρ = -0.52) in the corpus callosum and bilateral corona radiata irrespective of treatment group. DHA + EPA supplementation did preserve default mode/frontoparietal control network connectivity (g = 0.96, p = 0.024). Conclusions These exploratory findings did not provide strong evidence that DHA + EPA prevented or protected against axonal damage as quantified via neuroimaging. Neuroprotective effects on functional connectivity were observed despite white matter damage. Further studies with larger samples are needed to fully establish the relationship between omega-3 supplementation, RSHIs, and neuroimaging biomarkers. Trial registration ClinicalTrials.gov-NCT04796207.
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Affiliation(s)
- Adam C. Raikes
- Center for Innovation in Brain Science, University of Arizona, Tucson, AZ, United States
| | - Gerson D. Hernandez
- Center for Innovation in Brain Science, University of Arizona, Tucson, AZ, United States
| | - Veronica A. Mullins
- Department of Nutritional Sciences, University of Arizona, Tucson, AZ, United States
| | - Yiwei Wang
- Center for Innovation in Brain Science, University of Arizona, Tucson, AZ, United States
| | - Claudia Lopez
- Center for Innovation in Brain Science, University of Arizona, Tucson, AZ, United States
| | - William D. S. Killgore
- Social, Cognitive, and Affective Neuroscience Lab, Department of Psychiatry, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Floyd H. Chilton
- Department of Nutritional Sciences, University of Arizona, Tucson, AZ, United States
| | - Roberta D. Brinton
- Center for Innovation in Brain Science, University of Arizona, Tucson, AZ, United States
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Exploring Vestibular/Ocular and Cognitive Dysfunction as Prognostic Factors for Protracted Recovery in Sports-Related Concussion Patients Aged 8 to 12 Years. Clin J Sport Med 2022; 32:408-414. [PMID: 34516435 DOI: 10.1097/jsm.0000000000000975] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/10/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To explore the prognostic ability of the vestibular/ocular motor screening (VOMS), King-Devick (K-D) Test, and C3 Logix Trails A and B to identify protracted recovery from sports-related concussion (SRC) in patients aged 8 to 12 years. DESIGN Retrospective cohort analysis. SETTING Specialty pediatric sports concussion clinic. PARTICIPANTS A total of 114 youth athletes aged 8 to 12 years who were diagnosed with an SRC within 7 days of injury. INDEPENDENT VARIABLES A positive screen on the VOMS, K-D, and C3 Logix Trails A and Trails B. Combined positive screens on multiple tests (ie, 2, 3, or all 4 positive screens of 4 possible). MAIN OUTCOME MEASURES Recovery time in days and protracted recovery (recovery time ≥30-days) were the primary outcomes of interest. RESULTS A positive VOMS screen was associated with 1.31 greater days to SRC recovery ( P = 0.02) than a negative VOMS screen. The K-D and C3 Logix tests were not significantly associated with recovery time, nor were any combinations of tests ( P > 0.05). The VOMS demonstrated moderate prognostic ability to predict normal recovery (negative predictive value = 80.78% [95% CI = 63.73-90.95]). Overall predictive accuracy of normal versus protracted recovery was strongest when a participant screened positive on all 4 tests (Accuracy = 76.32% [95% CI = 67.45-83.78]). CONCLUSIONS The VOMS was associated with overall recovery time and proved to be a useful test to identify those who would experience a normal recovery time. Combining the 4 tests improved the prognostic accuracy of the protocol in predicting protracted versus normal recovery. These findings suggest that combining multiple, varied assessments of cognition and vestibular/ocular functions may better explain factors contributing to protracted recovery.
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Abstract
Objective Current clinical guidelines provide a unitary approach to manage sport-related concussion (SRC), while heterogeneity in the presentation of symptoms suggests that subtypes of SRC may exist. We systematically reviewed the available evidence on SRC subtypes and associated clinical outcomes. Data Sources Ovid Medline, Embase, PsycINFO, and SPORTDiscus Eligibility Criteria for Selecting Studies Electronic databases were searched for studies: (i) identifying SRC symptom clusters using classification methodology; or (ii) associating symptom clusters to clinical outcome variables. A total of 6,146 unique studies were identified, of which 75 full texts were independently assessed by two authors for eligibility. A total of 22 articles were included for systematic review. Data Extraction Two independent authors performed data extraction and risk of bias analysis using the Cochrane Collaboration tool. Data Synthesis Six studies found evidence for existence of SRC symptom clusters. Combining the available literature through Multiple Correspondence Analysis (MCA) provided evidence for the existence of a migraine cluster, a cognitive–emotional cluster, a sleep–emotional cluster, a neurological cluster, and an undefined feelings cluster. Nineteen studies found meaningful associations between SRC symptom clusters and clinical outcomes. Clusters mapping to the migraine cluster were most frequently reported in the literature and were most strongly related to aspects of clinical outcome. Conclusions The available literature provides evidence for the existence of at least five subtypes in SRC symptomatology, with clear relevance to clinical outcome. Systematically embedding the differentiation of SRC subtypes into prognosis, clinical management, and intervention strategies may optimize the recovery from SRC. Electronic supplementary material The online version of this article (10.1007/s40279-020-01321-9) contains supplementary material, which is available to authorized users.
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A Review of Analytical Methods Used for Evaluating Clustering in Concussion-Related Symptoms. CURR EPIDEMIOL REP 2020. [DOI: 10.1007/s40471-020-00254-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Brett BL, Kramer MD, McCrea MA, Broglio SP, McAllister T, Nelson LD, Hazzard JB, Kelly LA, Ortega J, Port N, Pasquina PF, Jackson J, Cameron KL, Houston MN, Goldman JT, Giza C, Buckley T, Clugston JR, Schmidt JD, Feigenbaum LA, Eckner JT, Master CL, Collins MW, Kontos AP, Chrisman SPD, Duma SM, Miles CM, Susmarski A. Bifactor Model of the Sport Concussion Assessment Tool Symptom Checklist: Replication and Invariance Across Time in the CARE Consortium Sample. Am J Sports Med 2020; 48:2783-2795. [PMID: 32809856 PMCID: PMC7484253 DOI: 10.1177/0363546520946056] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Identifying separate dimensions of concussion symptoms may inform a precision medicine approach to treatment. It was previously reported that a bifactor model identified distinct acute postconcussion symptom dimensions. PURPOSE To replicate previous findings of a bifactor structure of concussion symptoms in the Concussion Assessment Research and Education (CARE) Consortium sample, examine measurement invariance from pre- to postinjury, and evaluate whether factors are associated with other clinical and biomarker measures. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 2. METHODS Collegiate athletes were prospectively evaluated using the Sport Concussion Assessment Tool-3 (SCAT-3) during preseason (N = 31,557); 2789 were followed at <6 hours and 24 to 48 hours after concussion. Item-level SCAT-3 ratings were analyzed using exploratory and confirmatory factor analyses. Bifactor and higher-order models were compared for their fit and interpretability. Measurement invariance tested the stability of the identified factor structure across time. The association between factors and criterion measures (clinical and blood-based markers of concussion severity, symptom duration) was evaluated. RESULTS The optimal structure for each time point was a 7-factor bifactor model: a General factor, on which all items loaded, and 6 specific factors-Vestibulo-ocular, Headache, Sensory, Fatigue, Cognitive, and Emotional. The model manifested strict invariance across the 2 postinjury time points but only configural invariance from baseline to postinjury. From <6 to 24-48 hours, some dimensions increased in severity (Sensory, Fatigue, Emotional), while others decreased (General, Headache, Vestibulo-ocular). The factors correlated with differing clinical and biomarker criterion measures and showed differing patterns of association with symptom duration at different time points. CONCLUSION Bifactor modeling supported the predominant unidimensionality of concussion symptoms while revealing multidimensional properties, including a large dominant General factor and 6 independent factors: Headache, Vestibulo-ocular, Sensory, Cognitive, Fatigue, and Emotional. Unlike the widely used SCAT-3 symptom severity score, which declines gradually after injury, the bifactor model revealed separable symptom dimensions that have distinct trajectories in the acute postinjury period and different patterns of association with other markers of injury severity and outcome. CLINICAL RELEVANCE The SCAT-3 total score remains a valuable, robust index of overall concussion symptom severity, and the specific factors identified may inform management strategies. Because some symptom dimensions continue to worsen in the first 24 to 48 hours after injury (ie, Sensory, Fatigue, Emotional), routine follow-up in this time frame may be valuable to ensure that symptoms are managed effectively.
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Affiliation(s)
- Benjamin L. Brett
- Departments of Neurosurgery & Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | | | - Michael A. McCrea
- Departments of Neurosurgery & Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | - Steven P. Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI USA
| | - Thomas McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN USA
| | - Lindsay D. Nelson
- Departments of Neurosurgery & Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | | | - Joseph B Hazzard
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Louise A Kelly
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Justus Ortega
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nicholas Port
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Paul F Pasquina
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jonathan Jackson
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kenneth L Cameron
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Megan N Houston
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Joshua T Goldman
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christopher Giza
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Thomas Buckley
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - James R Clugston
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Julianne D Schmidt
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Luis A Feigenbaum
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - James T Eckner
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christina L Master
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael W Collins
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Anthony P Kontos
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sara P D Chrisman
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stefan M Duma
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christopher M Miles
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Adam Susmarski
- Investigation performed at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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McKeithan L, Hibshman N, Yengo-Kahn AM, Solomon GS, Zuckerman SL. Sport-Related Concussion: Evaluation, Treatment, and Future Directions. Med Sci (Basel) 2019; 7:medsci7030044. [PMID: 30884753 PMCID: PMC6473667 DOI: 10.3390/medsci7030044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/11/2019] [Accepted: 03/11/2019] [Indexed: 01/16/2023] Open
Abstract
Sport-related concussion (SRC) is a highly prevalent injury predominantly affecting millions of youth through high school athletes every year. In recent years, SRC has received a significant amount of attention due to potential for long-term neurologic sequelae. However, the acute symptoms and possibility of prolonged recovery account for the vast majority of morbidity from SRC. Modifying factors have been identified and may allow for improved prediction of a protracted course. Potential novel modifying factors may include genetic determinants of recovery, as well as radiographic biomarkers, which represent burgeoning subfields in SRC research. Helmet design and understanding the biomechanical stressors on the brain that lead to concussion also represent active areas of research. This narrative review provides a general synopsis of SRC, including relevant definitions, current treatment paradigms, and modifying factors for recovery, in addition to novel areas of research and future directions for SRC research.
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Affiliation(s)
- Lydia McKeithan
- Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
| | - Natalie Hibshman
- Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
| | - Aaron M Yengo-Kahn
- Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Gary S Solomon
- Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Scott L Zuckerman
- Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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Yakoub KM, O'Halloran P, Davies DJ, Bentley C, Watson CN, Forcione M, Scarpa U, Bishop JRB, Toman E, Hammond D, Cross MJ, Stokes KA, Kemp SPT, Menon DK, Di Pietro V, Belli A. Study of Concussion in Rugby Union through MicroRNAs (SCRUM): a study protocol of a prospective, observational cohort study. BMJ Open 2018; 8:e024245. [PMID: 30478124 PMCID: PMC6254405 DOI: 10.1136/bmjopen-2018-024245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The diagnosis of mild traumatic brain injury or sports-related concussion is a challenge for all clinicians, players, coaches and parents involved in contact sports. Currently, there is no validated objective biomarker available to assess the presence or severity of concussion in sport, and so it is necessary to rely on subjective measures like self-reporting of symptoms which depend on the cooperation of the athlete. There is a significant health risk associated with repetitive injury if the diagnosis is missed, and so there is great value in an objective biomarker to assist diagnostic and prognostic decisions. OBJECTIVE To establish a panel of non-invasive MicroRNA biomarkers in urine and saliva for the rapid diagnosis of sports-related concussion and investigate the kinetics and clinical utility of these biomarkers in assisting diagnostic, prognostic and return-to-play decisions. METHODS AND ANALYSIS Observational, prospective, multicentre cohort study recruiting between the 2017-2018 and 2018-2019 Rugby Union seasons. Professional rugby players in the two highest tiers of senior professional domestic rugby competition in England will be recruited prospectively to the study. During the season, three groups will be identified: athletes entering the World Rugby Head Injury Assessment (HIA) protocol, uninjured control athletes and control athletes with musculoskeletal injuries. Saliva and urine will be collected from these athletes at multiple timepoints, coinciding with key times in the HIA protocol and return-to-play process. ETHICS AND DISSEMINATION Ethics approval has been obtained. The compiled and analysed results will be presented at national and international conferences concerning the care of patients with traumatic brain injury. Results will also be submitted for peer review and publication in the subject journals/literature.
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Affiliation(s)
- Kamal M Yakoub
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Neurotrauma and Ophthalmology Research Group, Institute of Inflammation and Aging, University of Birmingham, Birmingham, UK
| | - Patrick O'Halloran
- Neurotrauma and Ophthalmology Research Group, Institute of Inflammation and Aging, University of Birmingham, Birmingham, UK
| | - David J Davies
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Neurotrauma and Ophthalmology Research Group, Institute of Inflammation and Aging, University of Birmingham, Birmingham, UK
| | - Conor Bentley
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Callum N Watson
- Neurotrauma and Ophthalmology Research Group, Institute of Inflammation and Aging, University of Birmingham, Birmingham, UK
| | - Mario Forcione
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Neurotrauma and Ophthalmology Research Group, Institute of Inflammation and Aging, University of Birmingham, Birmingham, UK
| | - Ugo Scarpa
- Neurotrauma and Ophthalmology Research Group, Institute of Inflammation and Aging, University of Birmingham, Birmingham, UK
| | - Jonathan R B Bishop
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Emma Toman
- Head Injury Management Research Group, Faculty of Clinical and Biomedical Science, School of Dentistry, University of Central Lancashire, Preston, UK
| | - Douglas Hammond
- Head Injury Management Research Group, Faculty of Clinical and Biomedical Science, School of Dentistry, University of Central Lancashire, Preston, UK
| | - Matthew J Cross
- Department for Health, University of Bath, Bath, UK
- Premiership Rugby, Twickenham, London, UK
| | - Keith A Stokes
- Department for Health, University of Bath, Bath, UK
- Rugby Football Union, Twickenham, London, UK
| | | | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Valentina Di Pietro
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Neurotrauma and Ophthalmology Research Group, Institute of Inflammation and Aging, University of Birmingham, Birmingham, UK
- The Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana Champaign, Illinois, USA
| | - Antonio Belli
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Neurotrauma and Ophthalmology Research Group, Institute of Inflammation and Aging, University of Birmingham, Birmingham, UK
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