The Convergent Validity of the SWAY Balance Application to Assess Postural Stability in Military Cadets Recovering from Concussion

Background

Concussions are often accompanied by balance disturbances. Clinically accurate evaluation systems are often expensive, large, and inaccessible to most clinicians. The Sway Balance Mobile Application (SWAY) is an accessible method to quantify balance changes.

Purpose

To determine the known groups and convergent validity of the SWAY to assess balance after a concussion.

Study Design

Case-Control Study.

Methods

Twenty participants with acute concussion and twenty controls were recruited. At initial, one-week, and final return to activity (RTA) evaluations, all participants completed the Sports Concussion Assessment Tool (SCAT-5), and balance control measured by SWAY mBESS and NeuroCom Balance Master Sensory Organization Test (SOT). Mixed model ANOVAs were used to detect differences in SWAY mBESS and NeuroCom SOT scores with time (initial, one-week, final RTA) as the within-subjects factor and group (concussed, healthy) as the between-subjects factor. Spearman's Rho correlations explored the associations between NeuroCom SOT scores, SWAY scores, SCAT-5 symptom scores, and time in days to final RTA.

Results

The sampled population was predominantly male and age (20 ± 1), and BMI differences were insignificant between groups. The SWAY did not detect differences between healthy and concussed participants and did not detect change over time [F(2,40) = .114, p = 0.89; F(2,40)= .276, p =0.60]. When assessing the relationship between the SWAY and the SOT, no correlation was found at any time point (r = -0.317 to -0.062, p > 0.05). Time to RTA demonstrated a moderate correlation with both SCAT-5 symptom severity score (r = .693, p < 0.01) and SCAT-5 total symptom score (r = .611, p < 0.01) at the one-week follow-up.

Conclusion

The SWAY mBESS does not appear to be a valid balance assessment for the concussed patient. The SWAY mBESS in patients with concussion failed to demonstrate convergent validity and did not demonstrate an ability to validate known groups. When assessing the time to final RTA, the one-week post-initial assessment SCAT-5 symptom severity and total scores may help determine the length of recovery in this population.

Level of Evidence

Level 3.

Core and Whole Body Vibration Exercise Influences Muscle Sensitivity and Posture during a Military Foot March

Military foot marches account for 17-22% of Army musculoskeletal injuries (MSI), with low back pain (LBP) being a common complaint. Core-exercise and whole-body vibration (WBV) have been shown to decrease LBP in patients with chronic low back MSI. This study investigated if WBV and/or core-exercise influenced LBP or posture associated with a military ruck march. A randomized control trial with three groups: (1) WBV and core-exercise (WBVEx); (2) core-exercise alone (Ex); and (3) control evaluated the effects of core-exercise and WBV on LBP during/after a two 8 K foot marches with a 35 lb rucksack. The intervention groups completed three weeks of core-exercise training with/without WBV. Outcome measurements included visual analog scale (VAS), algometer, posture and electromyography (EMG). LBP, pressure threshold, and posture were elevated throughout the foot march regardless of group. LBP remained elevated for 48 h post foot march (p = 0.044). WBVEx and Ex did not have a significant effect on LBP. WBVEx and Ex both decreased muscle sensitivity and increased trunk flexion (p < 0.001) during the second foot march (FM2). The 8 K foot marches significantly increased LBP. Core-exercise training with/without WBV decreases low back muscle sensitivity. WBV and core-exercise increases trunk flexion which may help improve performance and may influence LBP.

Seasonal Trends for Environmental Illness Incidence in the U.S. Army

INTRODUCTION

The incidence of and risk factors for exertional heat illness (EHI) and cold weather injury (CWI) in the U.S. Army have been well documented. The "heat season", when the risk of EHI is highest and application of risk mitigation procedures is mandatory, has been arbitrarily defined as May 1 through September 30, while the "cold season" is understood to occur from October 1 to April 30 each year. The proportions of EHI and CWI that occur outside of the traditional heat and cold seasons are unknown. Additionally, it is unknown if either of the seasonal definitions are appropriate. The primary purpose of this study was to determine the proportion of EHI and of CWI that occur within the commonly accepted seasonal definitions. We also report the location-specific variability, seasonal definitions, and the demographic characteristics of the populations.

METHODS

The U.S. Army installations with the highest frequency of EHI and of CWI from 2008 to 2013 were identified and used for analysis. In total there were 15 installations included in the study, with five installations used for analysis in both the EHI and CWI projects. In- and out-patient EHI and CWI data (ICD-9-CM codes 992.0 to 992.9 and ICD codes 991.0 to 991.9, respectively) were obtained from the Defense Medical Surveillance System. Installation-specific denominator data were obtained from the Defense Manpower Data Center, and incidence rates were calculated by week, for each installation. Segmental (piecewise) regression analysis was used to determine the start and end of the heat and cold seasons.

RESULTS

Our analysis indicates that the heat season starts around April 22 and ends around September 9. The cold season starts on October 3 and ends on March 24. The majority (n = 6,445, 82.3%) of EHIs were diagnosed during the "heat season" of May 1 to September 30, while 10.3% occurred before the heat season started (January1 to April 30) and 7.3% occurred after the heat season ended (October 1 to December 31). Similar to EHI, 90.5% of all CWIs occurred within the traditionally defined cold season, while 5.7% occurred before and 3.8% occurred after the cold season. The locations with the greatest EHI frequency were Ft Bragg (n = 2,129), Ft Benning (n = 1,560), and Ft Jackson (n = 1,538). The bases with the largest proportion of CWI in this sample were Ft Bragg (17.8%), Ft Wainwright (17.2%), and Ft Jackson (12.7%). There were considerable inter-installation differences for the start and end dates of the respective seasons.

CONCLUSIONS

The present study indicates that the traditional heat season definition should be revised to begin  ∼3 weeks earlier than the current date of May 1; our data indicate that the current cold season definition is appropriate. Inter-installation variability in the start of the cold season was much larger than that for the heat season. Exertional heat illnesses are a year-round problem, with ∼17% of all cases occurring during non-summer months, when environmental heat strain and vigilance are lower. This suggests that EHI mitigation policies and procedures require greater year-round emphasis, particularly at certain locations.

Narrowband ultraviolet B (UVB) phototherapy in children

BACKGROUND

While narrowband ultraviolet B (UVB) phototherapy is a well-established treatment for a range of skin conditions in adults, there is little in the literature about its use in children and data regarding its long-term carcinogenic potential are lacking.

AIM

We undertook a retrospective review of the use of narrowband UVB phototherapy in a paediatric population attending two Glasgow Hospitals.

METHODS

Phototherapy case notes for all children aged 16 years and under at time of treatment were reviewed at two hospital sites between 1996 and 2002.

RESULTS

In total, 77 children had been treated (median age 12 years, range 4-16). The conditions treated most frequently were psoriasis (45%) and atopic eczema (32%). Other dermatoses treated included alopecia areata, acne, hydroa vacciniforme and polymorphic light eruption. Treatment courses for atopic conditions were longer than those required for psoriatic conditions: median number of treatments 24 for atopic eczema (range 3-46), and 17.5 for psoriasis (range 9-35). By the end of treatment, 68% of the atopic patients and 63% of the patients with psoriasis had cleared. The adverse event profile was similar to that in adults, with erythema, herpes simplex reactivation and PLE all recorded. Anxiety was a problem for five patients.

CONCLUSION

We conclude that narrowband UVB phototherapy is a useful and well-tolerated treatment for children with severe or intractable inflammatory skin disease, but concerns remain regarding long-term side-effects.

Nodular presentation of eosinophilic cellulitis (Wells' syndrome)

Eosinophilic cellulitis is a rare condition of unknown aetiology. The classical presentation is of a tender or mildly pruritic cellulitis-like eruption, that has typical histology characterized by tissue eosinophilia, oedema and "flame" figures. Other reported clinical presentations include papular and nodular eruptions. It may be recurrent, and preceded at a variable time by a pruritic papular eruption. We describe a patient with the rare nodular variant of eosinophilic cellulitis affecting the palms of the hands, which occurred 2 years after a nonspecific pruritic papular eruption, without an obvious precipitant and in the absence of the more typical cellulitis-like plaques.

Nail dystrophy due to lichen sclerosus?

Lichen sclerosus (LS) affects anogenital skin alone in 80% of cases. When extragenital disease occurs, it usually affects the trunk, neck, axillae and wrist flexures. Nail involvement with LS is rare. In contrast, lichen planus (LP) commonly affects extragenital skin. Mucosal lesions occur in 50% of cases, affecting the mouth and genitalia. Nail disease in LP is common, and, if severe, can lead to destruction of the nail bed. LS and LP can coexist. We report two cases of LS with nail involvement. In the Case 1 disease was confined to the nail, and nail biopsy confirmed LS. In the Case 2, the nail changes formed part of the widespread genital and extragenital LS, confirmed histologically. We review existing literature on nail disease in LS and discuss the possible aetiology of the nail changes.

Long-term patient satisfaction with cosmetic outcome of minor cutaneous surgery

We evaluated our patients' own assessment of the cosmetic outcome of minor dermatological surgery procedures. A postal questionnaire was sent to patients who had undergone surgery between 12 and 18 months previously. Patient satisfaction was correlated with variables, including age, sex, lesion size and site, indication for excision, histological diagnosis and operator. Two hundred and seven excisional procedures were identified in 193 patients. Seventy-nine per cent of the questionnaires (163/207) were returned. Seventy per cent of patients reported that the scar was invisible or better than expected and 9% rated it to be worse than expected. Ninety per cent of patients said they would undergo the procedure again. Patient dissatisfaction was associated significantly and independently with excisions from the back, younger age and benign histology.

Interactions with the pharmaceutical industry: a survey of family medicine residents in Ontario

OBJECTIVE

To determine the attitudes, knowledge and practices of family medicine residents relating to the pharmaceutical industry and to assess the effectiveness of existing guidelines on appropriate interactions with the pharmaceutical industry.

DESIGN

Survey by mailed questionnaire.

SETTING

Ontario.

PARTICIPANTS

All 262 second-year family medicine residents in Ontario (seven centres); 226 (86.3%) responded.

RESULTS

Fifty-two (23.0%) of the residents who responded stated that they had read the CMA policy statement on appropriate interactions between physicians and the pharmaceutical industry. A total of 124 (54.9%) stated that they would attend a private dinner paid for by a pharmaceutical representative; the proportion was not significantly reduced among those who had read the CMA guidelines, which prohibit the acceptance of personal gifts. In all, 186 (82.3%) reported that they would like the opportunity to interact with pharmaceutical representatives in an educational setting, even though several programs now discourage these interactions. Approximately three quarters (172/226 [76.1%]) of the residents indicated that they plan to see pharmaceutical representatives in their future practice. Residents at Centre 2 were significantly more critical of the pharmaceutical industry than those from the other centres. Overall, being aware of, and familiar with, departmental policy or CMA policy on interactions with the pharmaceutical industry did not affect the residents' attitudes or intended future practices.

CONCLUSION

The presence of guidelines concerning physicians' interactions with the pharmaceutical industry does not appear to have a significant impact on family medicine residents in Ontario.

Naevi in schoolchildren in Scotland and Australia

To test the hypothesis that children living in subtropical and tropical environments have more naevi than those of similar ethnicity living in temperature countries, a comparative study of melanocytic naevi in 111 schoolchildren from Brisbane, Australia, and 222 from Glasgow, Scotland, was carried out. All children were aged 13-15 years, of European ancestry, and had spent most of their lives at latitudes of less than 30 degrees S (Australia) or greater than 30 degrees N (Scotland). Using an identical protocol, all naevi of 2 mm or more in diameter occurring on the right arm were counted by either a highly experienced research nurse in Brisbane, or a dermatologist in Glasgow. Hair and eye colour, and facial freckling, were assessed by the examiner, and axillary skin colour of children in both cities was measured using the same reflectance spectrophotometer. Children in Brisbane had significantly more naevi than those in Glasgow (P < 0.05), after adjusting for complexion variables. The difference in the geometric mean number of naevi on the arm was much greater among boys (7.7 vs. 4.4, in Brisbane and Glasgow, respectively) than among girls (7.3 vs. 6.7). This has parallels with the sex differences in melanoma at later ages in the two countries. Besides country of residence, freckles and innate skin colour were the most significant predictors of large numbers of naevi, whereas red hair had a significant protective effect. Overall, these data on prevalence of naevi in children from contrasting environments provide some evidence in support of the theory that naevus development is related to the level of sun exposure in childhood and adolescence.

Relationship of urinary pyridinium crosslinks to disease extent and activity in osteoarthritis

Urinary crosslinks, pyridinoline and deoxypyridinoline, have been shown to be elevated in RA and OA. This study confirmed this elevation, with levels in patients with predominantly knee OA higher than those with nodal OA and hip OA. Intra-articular corticosteroid injection was followed by a significant fall in urinary crosslinks, which was associated with a corresponding improvement in articular index and pain score, although there was no overall correlation between crosslink levels and the clinical indices studied. Collagen crosslinks may be of value as markers of disease activity in OA.

Accelerated detection with prospective surveillance for cutaneous malignant melanoma in high-risk groups

In 1983 a classification scheme was proposed for patients with atypical naevi, according to their personal and family history of melanoma and atypical naevi. To assess the predictive value of these features we undertook prospective surveillance of patients at high risk of primary melanoma. We followed up 116 patients each with 3 or more clinically atypical naevi for at least 5 years. Patients are examined and naevi are photographed every 3-6 months; lesions showing disturbing change are excised for histopathology. Among 85 patients with no personal or family history of melanoma, 5 invasive (level 2 or deeper) melanomas developed during 583 person-years of follow up. The expected number of invasive melanomas in this population would be 0.054; the increased risk is significant (p < 0.001; relative risk 92 [95% CI 30-216]). There was a similarly increased risk of new melanoma also among 24 patients with atypical naevi plus a history of previous melanoma (observed 2, expected 0.022, p < 0.001; relative risk 91 [11-328]). By comparison, no second melanoma developed among 25 patients with previous melanoma but a normal naevus pattern during 213 person-years of similarly intensive follow-up. The risk of melanoma was highest among 7 patients with atypical naevi and a family history of melanoma (observed 6, expected 0.009, p < 0.001; relative risk 444 [121-1138]). The median thickness of surveillance-detected melanomas was 0.75 mm (range 0.40-1.05 mm) in this group. This study shows the value of clinical follow-up of high-risk patients to detect early thin melanomas.

Exercise-induced left bundle branch block and its relation to coronary artery disease

The records of 2,584 consecutive patients who underwent both treadmill exercise testing and coronary cineangiography were reviewed to determine the relation between exercise-induced, acceleration-dependent left bundle branch block (LBBB) and the presence of coronary artery disease (CAD). Rate-dependent LBBB during exercise was identified in 28 patients (1.1%), who were categorized according to their presenting symptoms: classic angina pectoris, atypical chest pain, symptomatic cardiac arrhythmia and asymptomatic. Asymptomatic patients underwent a screening exercise test. CAD was present in 7 of 10 patients who presented with classic angina pectoris, but 12 of 13 patients presenting with atypical chest pain had normal coronary arteries. All 10 patients in whom LBBB developed at a heart rate of 125 beats/min or higher were free of CAD, whereas 9 of 18 patients in whom LBBB developed at a heart rate of less than 125 beats/min had CAD. Normal coronary arteries were present in 3 patients who presented with angina and in whom both chest pain and LBBB developed during exercise. It is concluded that patients who present with atypical chest pain in whom rate-dependent LBBB develops on the treadmill are significantly less likely to have CAD than patients who present with classic angina; the onset of LBBB at a heart rate of 125 beats/min or higher is highly correlated with the presence of normal coronary arteries, regardless of patient presentation; and patients with angina in whom both chest pain and LBBB develop during exercise may have normal coronary arteries.