Andrew M. Johnson

Cumulative meta‐analysis of systemic antifungal agents for the treatment of onychomycosis

Background  Onychomycosis is a common nail disease that is often chronic, difficult to eradicate, and has a tendency to recur. The most common oral therapies for dermatophyte toenail onychomycosis include terbinafine, itraconazole and fluconazole.

Sublingual Atropine for sialorrhea secondary to parkinsonism: A pilot study

Sialorrhea is a relatively common symptom in idiopathic Parkinsons disease and related conditions for which most of the accepted treatments are either highly invasive or may cause substantial systemic side effects. This study describes an open‐label pilot study of sublingual atropine drops for the treatment of sialorrhea in 7 patients (6 with Parkinsons disease, 1 with progressive supranuclear palsy). Participants demonstrated statistically significant declines in saliva production, both objectively and subjectively. Self‐reported drooling severity showed a significant decline between baseline and 180 minutes, t(6) = 3.240 P < 0.025 (η2 = 0.636), and between baseline and 1 week, t(6) = 4.583 P < 0.005 (η2 = 0.778). Objectively measured saliva production decreased significantly between baseline and the 1‐week follow‐up, t(6) = 2.711 P < 0.05 (η2 = 0.551). Delirium occurred in 1 patient (concurrent with a urinary tract infection), and 2 patients experienced worsening of hallucinations (active hallucinosis was concealed by both individuals to allow participation in the trial). The remaining trial participants did not experience any anticholinergic side effects. This trial shows that, in selected patient populations, sublingual atropine is a simple and inexpensive treatment for sialorrhea associated with parkinsonism.

Validity of the Nintendo Wii® balance board for the assessment of standing balance in Parkinson’s disease

Background: Impaired postural stability places individuals with Parkinson’s at an increased risk for falls. Given the high incidence of fall-related injuries within this population, ongoing assessment of postural stability is important. Objective: To evaluate the validity of the Nintendo Wii® balance board as a measurement tool for the assessment of postural stability in individuals with Parkinson’s. Subjects: Twenty individuals with Parkinson’s participated. Intervention: Subjects completed testing on two balance tasks with eyes open and closed on a Wii® balance board and biomechanical force platform. Main Measures: Bland–Altman plots and a two-way, random-effects, single measure intraclass correlation coefficient model were used to assess concurrent validity of centre-of-pressure data. Results: Concurrent validity was demonstrated to be excellent across balance tasks (intraclass correlation coefficients = 0.96, 0.98, 0.92, 0.94). Conclusions: This study suggests that the Wii® balance board is a valid tool for the quantification of postural stability among individuals with Parkinson’s.

A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates.

OBJECT The objective of this study was to measure the incidence of concussion (scaled relative to number of athlete exposures) and recurrent concussion within 2 teams of fourth-tier junior ice hockey players (16-21 years old) during 1 regular season. METHODS A prospective cohort study called the Hockey Concussion Education Project was conducted during 1 junior ice hockey regular season (2009-2010) involving 67 male fourth-tier ice hockey players (mean age 18.2 ± 1.2 years, range 16-21 years) from 2 teams. Prior to the start of the season, every player underwent baseline assessments using the Sideline Concussion Assessment Tool 2 (SCAT2) and the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT). The study protocol also required players who entered the study during the season to complete baseline SCAT2 and ImPACT testing. If the protocol was not followed, the postinjury test results of a player without true baseline test results would be compared against previously established age and gender group normative levels. Each regular season game was observed by a qualified physician and at least 1 other neutral nonphysician observer. Players who suffered a suspected concussion were evaluated at the game. If a concussion diagnosis was made, the player was subsequently examined in the physicians office for a full clinical evaluation and the SCAT2 and ImPACT were repeated. Based on these evaluations, players were counseled on the decision of when to return to play. Athlete exposure was defined as 1 game played by 1 athlete. RESULTS Twenty-one concussions occurred during the 52 physician-observed games (incidence 21.5 concussions per 1000 athlete exposures). Five players experienced repeat concussions. No concussions were reported during practice sessions. A concussion was diagnosed by the physician in 19 (36.5%) of the 52 observed games. One of the 5 individuals who suffered a repeat concussion sustained his initial concussion in a regular season game that was not observed by a physician, and as a result this single case was not included in the total of 21 total concussions. This initial concussion of the player was identified during baseline testing 2 days after the injury and was subsequently medically diagnosed and treated. CONCLUSIONS The incidence of game-related concussions (per 100 [corrected] athlete exposures) in these fourth-tier junior [corrected] ice hockey players was 7 [corrected] times higher than [corrected] previously reported in the literature. This difference may be the result of the use of standardized direct physician observation, diagnosis, and subsequent treatment. The results of this study demonstrate the need for follow-up studies involving larger and more diverse sample groups to reflect generalizability of the findings. These follow-up studies should involve other contact sports (for example football and rugby) and also include the full spectrum of gender, age, and skill levels.

Comorbidity of rosacea and depression: an analysis of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey—Outpatient Department data collected by the U.S. National Center for Health Statistics from 1995 to 2002

Background  Psychogenic factors have been considered to be important in the exacerbation and possibly the onset of rosacea. However, there are very few studies that have reported conclusive findings.

A prospective study of physician-observed concussion during a varsity university hockey season: white matter integrity in ice hockey players. Part 3 of 4

OBJECT The aim of this study was to investigate the effect of repetitive head impacts on white matter integrity that were sustained during 1 Canadian Interuniversity Sports (CIS) ice hockey season, using advanced diffusion tensor imaging (DTI). METHODS Twenty-five male ice hockey players between 20 and 26 years of age (mean age 22.24 ± 1.59 years) participated in this study. Participants underwent pre- and postseason 3-T MRI, including DTI. Group analyses were performed using paired-group tract-based spatial statistics to test for differences between preseason and postseason changes. RESULTS Tract-based spatial statistics revealed an increase in trace, radial diffusivity (RD), and axial diffusivity (AD) over the course of 1 season. Compared with preseason data, postseason images showed higher trace, AD, and RD values in the right precentral region, the right corona radiata, and the anterior and posterior limb of the internal capsule. These regions involve parts of the corticospinal tract, the corpus callosum, and the superior longitudinal fasciculus. No significant differences were observed between preseason and postseason for fractional anisotropy. CONCLUSIONS Diffusion tensor imaging revealed changes in white matter diffusivity in male ice hockey players over the course of 1 season. The origin of these findings needs to be elucidated.

Hockey Concussion Education Project, Part 2. Microstructural white matter alterations in acutely concussed ice hockey players: a longitudinal free-water MRI study

OBJECT Concussion is a common injury in ice hockey and a health problem for the general population. Traumatic axonal injury has been associated with concussions (also referred to as mild traumatic brain injuries), yet the pathological course that leads from injury to recovery or to long-term sequelae is still not known. This study investigated the longitudinal course of concussion by comparing diffusion MRI (dMRI) scans of the brains of ice hockey players before and after a concussion. METHODS The 2011-2012 Hockey Concussion Education Project followed 45 university-level ice hockey players (both male and female) during a single Canadian Interuniversity Sports season. Of these, 38 players had usable dMRI scans obtained in the preseason. During the season, 11 players suffered a concussion, and 7 of these 11 players had usable dMRI scans that were taken within 72 hours of injury. To analyze the data, the authors performed free-water imaging, which reflects an increase in specificity over other dMRI analysis methods by identifying alterations that occur in the extracellular space compared with those that occur in proximity to cellular tissue in the white matter. They used an individualized approach to identify alterations that are spatially heterogeneous, as is expected in concussions. RESULTS Paired comparison of the concussed players before and after injury revealed a statistically significant (p < 0.05) common pattern of reduced free-water volume and reduced axial and radial diffusivities following elimination of free-water. These free-water-corrected measures are less affected by partial volumes containing extracellular water and are therefore more specific to processes that occur within the brain tissue. Fractional anisotropy was significantly increased, but this change was no longer significant following the free-water elimination. CONCLUSIONS Concussion during ice hockey games results in microstructural alterations that are detectable using dMRI. The alterations that the authors found suggest decreased extracellular space and decreased diffusivities in white matter tissue. This finding might be explained by swelling and/or by increased cellularity of glia cells. Even though these findings in and of themselves cannot determine whether the observed microstructural alterations are related to long-term pathology or persistent symptoms, they are important nonetheless because they establish a clearer picture of how the brain responds to concussion.

A prospective study of concussion education in 2 junior ice hockey teams: implications for sports concussion education.

OBJECT The aim of this study was to evaluate the effectiveness of an educational intervention on concussion knowledge within a sample of junior fourth-tier ice hockey players. METHODS A prospective cohort study, called the Hockey Concussion Education Project, was conducted during 1 junior ice hockey regular season (2009-2010) with 67 male fourth-tier ice hockey players (mean age 18.2 ± 1.2 years, range 16-21 years) from 2 teams. All participating players were randomized into 3 concussion education intervention groups (DVD group, interactive computer module [ICM] group, or control group) before the beginning of the season. Each individual received a preintervention knowledge test prior to the intervention. The DVD and ICM groups received a posttest after the completion of their intervention. All participants were offered the same knowledge test at 15 games (50 days) and 30 games (91 days) later. RESULTS In the concussion education intervention component no significant group differences were observed at baseline between individuals in the control group and between individuals within the interventional group. At the 15-game follow-up, however, the difference between groups approached significance (F [1, 30] = 3.91, p = 0.057). This group difference remained consistent at the 30-game follow-up. CONCLUSIONS This study demonstrates a positive trend concerning concussion education intervention and knowledge acquisition with either the ICMs or the educational DVD. Both forms of intervention produced a positive and sustainable improvement that approached statistical significance when compared with the control group. The control group demonstrated a negative longitudinal trend concerning concussion knowledge.

The Influence of Centre-Based Childcare on Preschoolers' Physical Activity Levels: A Cross-Sectional Study

The childcare environment represents an appropriate avenue to support physical activity among preschoolers. The aim of this study was two-fold: (1) to measure the physical activity levels of a sample of preschoolers during childcare hours; and (2) to assess which attributes (e.g., space, equipment, policies) within centre-based childcare environments influenced physical activity. Thirty-one preschoolers from 5 childcare centres across London, Canada participated. Actical accelerometers were worn by participants for one day during childcare hours to assess activity levels using a 15 second epoch length. The Environment and Policy Assessment and Observation instrument was used to conduct a full-day evaluation of the childcare environment. On average, participants engaged in 1.54 min/h of moderate-to-vigorous physical activity and 17.42 min/h of total physical activity. Sedentary opportunities, portable and fixed play equipment, and staff behaviour accounted for 49.3% of the variability in moderate-to-vigorous physical activity and 14.1% of the variability in total physical activity, with sedentary opportunities, fixed play equipment, and staff behaviours displaying an inverse relationship. Results emphasize the critical role the childcare environment plays in supporting physical activity among preschoolers.

Dual-Task Interference: The Effects of Verbal Cognitive Tasks on Upright Postural Stability in Parkinson's Disease

Although dual-task interference has previously been demonstrated to have a significant effect on postural control among individuals with Parkinsons disease, the impact of speech complexity on postural control has not been demonstrated using quantitative biomechanical measures. The postural stability of twelve participants with idiopathic Parkinsons disease and twelve healthy age-matched controls was evaluated under three conditions: (1) without a secondary task, (2) performing a rote repetition task and (3) generating a monologue. Results suggested a significant effect of cognitive load on biomechanical parameters of postural stability. Although both groups increased their postural excursion, individuals with Parkinsons disease demonstrated significantly reduced excursion as compared with that of healthy age-matched controls. This suggests that participants with Parkinsons disease may be overconstraining their postural adjustments in order to focus attention on the cognitive tasks without losing their balance. Ironically, this overconstraint may place the participant at greater risk for a fall.