Lia LasCasas

October 26th, 2017

Period 6
Annotated Source List

American Academy of Pediatrics. www.aap.org/en-us/Pages/Default.aspx. Accessed 20 Oct.

2017.

The American Academy of Pediatrics is a website recommended by my mother, Lauren

LasCasas. It has five main tabs including Professional Resources, Professional education,
advocacy and policy, shop AAP, and about the AAP. The website contains several subscriptions
to medical journals and accurate news stories. In their search engine, you can search just about
any medical topic you wish. For example, when I searched concussions it pulled up seven
different reliable news stories that were current and well as included information one must know
regarding concussions. In addition to new stories were studies relating to your topic of interest as
well as videos to go along with them.
This website was incredibly helpful for me. It was easy to read and navigate through.
There was a visible home button that would help to guide you through the website. Everything
was sectioned properly and the information included was very dense and wordy but able to grasp
a good bit of it without a medical background. At KinderMender, I know I will be using this
website as a resource when I do not understand a certain diagnosis, prescription, medicine,
disease, or word my mentor uses or says to me.

Black, Lisa. "Saliva test predicts prolonged concussion symptoms in children." Saliva
test predicts prolonged concussion symptoms in children. Accessed 20 Oct. 2017.

In this study, it is revealed that brain scans can show impact of contact sports even on
young, healthy athletes. The study looked at athletes, from three different sports groups: collision
sports, which involve body-to-body contact, such as football and rugby; contact sports, where
contact is allowed, but is not an integral part of the game, such as soccer and basketball; and non-
contact sports, where there is no contact allowed, such as swimming or golf. The study looked at
the effect sports of different levels of contact had on the athletes' brains. "These differences do
suggest that although these athletes report as healthy and don't have significant health problems,
there are still some biological consequences to collision," "It's all pointing to the same direction:
that people with more contact exposure show changes in many different aspects of the brain that
look a little bit like a concussion," Dr. Churchill said.
Significantly, the more contact in a sport, the greater the effect on the structure, function
and chemical markers of the brain. People in sports with higher levels of contact showed
decreased brain activity and signs of reduced communication between brain areas, particularly in
regions involved in vision and motor function. This makes sense because contact related sports
make kids stress and strive for perfection to satisfy their coach. At KinderMender, it is important
to point out those qualities found on children because that could help better distinguish their
concussion level.
Benson, Brian W., et al. "A prospective study of concussions among National Hockey League
players during regular season games: the NHL-NHLPA Concussion Program." CMAJ:
Canadian Medical Association Journal, 17 May 2011, p. 905+. Accessed 20 Oct. 2017.

Sports are the primary reason why high school athletes have concussions. A study was
conducted among National Hockey League players during regular season games: the NHL-
NHLPA Concussion Program. The National Hockey League (NHL) and NHL Players'
Association (NHLPA) started a concussion program to improve the understanding of this injury.
The study held prospective case series of concussions over seven NHL regular seasons (1997-
2004) using players as test subjects. The primary outcome was concussion and the secondary
outcome was time loss. NHL team physicians documented post-concussion clinical
manifestations and recorded the date when a player was medically cleared to return to play. The
results were that team physicians reported 559 concussion during regular season games. On
average, time loss increased by 2.25 times for every subsequent concussion.
Interpreting this, post-concussion headache, fatigue, amnesia, and abnormal neurologic
examination were considered significant predictors of time losses among the hockey players. At
KinderMender, I know now that I need to focus more on what the patients are saying. It is
important to hear their opinion on their own head or brain injuries because it will ultimately help
me to better understand what they are experiencing. Although I am just an intern, I can make
personal assumptions to try to conclude what the problem by analyzing the information I am
given first-hand from the victim.

Clark, Joseph, et al. "Colored Glasses to Mitigate Photophobia Symptoms Posttraumatic

Brain Injury." Journal of Athletic Training, vol. 52, no. 8, Aug. 2017, pp.
725-29. Accessed 20 Oct. 2017.

A study was conducted based off the fact that colored glasses mitigate photophobia
symptoms posttraumatic brain injury. The purpose of the study was to provide the athletic trainer
with a means and method to assess whether an athlete is suffering from photophobia after
concussion and to determine if colored glasses provide relief. It was a cross-sectional study
located at a Rehabilitation clinic where fifty-one patients were being treated after concussions.
The experiment consisted of assessing post-concussion patients for visual symptoms including
photophobia and photosensitivity. Off-the-shelf glasses were used to determine whether specific
colors provided relief from photophobia. Screening was done using a penlight and multiple pairs
of colored glasses. Out of the 39 of the patients studied who had visual symptoms, 76%
complained of photophobia. Using glasses of different colors provided relief such as blue, green,
red, and purple.
It’s interesting to me that colored glasses can translate to a concussion. So many new
innovative technologies are in our world now, however, they relate more to entertainment rather
than vital medical solutions. This study was fairly recent, conducted in August 2017. The use of
color filters for other neurologic and ophthalmologic conditions is not new. For example, a
migraine with visual aura; light mitigation can alleviate the migraine and is a practical
intervention. This discovery that to ultimately helps with detecting brain injury is the new aspect.
Paired with the information already known, it ultimately reflects the fact that the glasses are safe
to use.
Doucette, Mitchell L., et al. "The Massachusetts school sports concussions law: a qualitative
study of local implementation experiences." Journal of Law, Medicine & Ethics, Fall
2016, p. 503+. Accessed 20 Oct. 2017.

A qualitative study of local implementation experiences took place in a school in

Massachusetts due to the sports concussions law. The article starts off with a vital statistic, where
evidence suggests that between 1.6 and 3.8 million sport and recreation-related concussions
occur per year in the United States. This concussions law came about due to all 50 states and the
District of Columbia passing legislation to address the issue of concussions in high school sports.
“Massachusetts was an early adopter of concussion-prevention legislation.” The law says that all
public middle and high schools subject to official rules of the Massachusetts Interscholastic
Athletic Association (MIAA), a private nonprofit association organized to govern, coordinate,
and promote athletic activity among Massachusetts high school athletes. Interviews and
questions took place in order to get a better understanding as to why this law was vital. The
results were that overwhelmingly, cases relied on independent physicians for concussion
diagnosis and medical clearance. Participants said that physicians provide concussion diagnoses,
medical clearance for student-athletes, and academic accommodations. If a student-athlete is
suspected of having a concussion and is removed from athletic activity, participants explained
the athlete is responsible for securing a visit with a physician, presumably with the help of a
parent or legal guardian.
This journal study is ultimately very eye opening to the importance of concussion
evaluations. Even though this study takes place in Maryland, the same law applies in 50 of the
United States, revealing that most of the country is on the same page in this subject. Knowing
this law helps me to better understand the true causes of not being evaluated both medically and
eventually financially. The study consisted of interviews and questions asked to a realm of
participants. The results were that all cases have made athletic trainers the ultimate decision-
making authority for those decisions.

Gillooly, Diane. "Current recommendations on management of pediatric concussions." Pediatric

Nursing, Sept.-Oct. 2016, p. 217+. Professional Collection. Accessed 20 Oct. 2017.

This article consists of Current recommendations on management of pediatric

concussions. An introduction to concussions is provided where statistics are given as well as the
basic information regarding the subject. Two tables are provided one of which presenting the
annual traumatic brain injury related emergency department visits, hospitalizations, and deaths
from 2002-2006. While the ladder presents annual traumatic brain injury related emergency
department visits by age group and gender 2002-2006. Screening and diagnosis is also provided
where the physical signs and symptoms of concussions are included. A key concept related to
concussions and emphasized in this article is the management of concussions. “Proper
management of concussion is essential in ensuring adequate recovery and prevention of
complications, such as re-injury or second impact syndrome (SIS).” They explain that post-
concussions all physical activity should be put off in addition to the recommended adequative
cognitive rest activities.
 In this article the two tables were very significant to the entirety of it and certainly
coordinate with my internship at KnderMender. For example, Table I, annual traumatic brain
injury related emergency department visits, hospitalizations, and deaths from 2002-2006,
provides information in age groups of children (0-4, 5-9, 10-14, and 15-19). From this, I know at
KinderMender Emergency department visits will be seen most commonly in 0-4 year olds and
hospitalizations and deaths will most likely reside in the 15-19 age group. In Table 2, annual
traumatic brain injury related emergency department visits by age group and gender 2002-2006,
is also given in children statistics. Emergency department visits will more commonly be seen in
males significantly in 0-4 year olds, becoming less significant until reaching the 15-19 year old
range.

Giza CC, et al. Neurology. 2013. 20 Oct. 2017.

This is an evidence-based review article written to update practice guidelines for the
treatment of concussion in sports. It was published in Neurology, The Official Journal of the
American Academy of Neurology in June 2013. For this review article, the authors analyzed all
of the literature from 1955 to 2012 on the subject of concussions. The purpose of the article was
to update the practice guidelines from 1997 focusing on the following questions 1) what factors
increase or decrease the chance of getting a concussion, 2) what diagnostic tools are helpful in
identifying patients with concussion and who will be at greater risk for severe/prolonged
impairments, 3) what signs or symptoms help determine which patients are at increased risk for
severe/prolonged impairments, 4) what treatments help recovery, reduce chance of concussion
recurrence, and reduce long-term effects. There have been a large number of tests developed to
help identify concussions, and this article analyzes the effectiveness of these tools. The authors
recommend the Standardized Assessment of Concussion, neuropsychological assessments, and
the Balance Error Scoring System. Factors that made people at greater risk for long term
symptoms were ongoing symptoms, specific aspects of the concussion, younger age, and
recurrent concussion, especially within 10 days. The study also found that there were no
interventions that help to speed along recovery or decrease long term negative effects. Finally,
the article outlines specific guidelines health care providers should follow for pre-participation
counseling as well as management of concussion diagnosis and treatment.
This is an excellent review article on the subject of concussion identification and
management, and provides specific recommendations for health care providers. Review articles
are specifically helpful because they accumulate all the recent relevant studies on the subject.
This article would be useful for my research for a number of reasons. First, it is interesting to see
how concussion management and guidelines have changed since 1997. Second, it would be
interesting to see if the scored diagnostic checklists are used in the urgent care in which I am
doing my internship. Third, it would be interesting to see if the guidelines are also followed at
the school/sideline level.
Glatter, Robert. "New Eye Tracking Technology Can Detect Concussions." Forbes Pharma &
Healthcare, 29 Jan. 2015. Accessed 20 Oct. 2017.

A recent discovery in 2015 has been found inn that a new eye tracking technology can
detect concussions. This article discusses even though imaging studies such as CT or MRI can
reveal fractures of bleeding in the brain, they cannot diagnose a concussion, which is broadly
defined as a complex pathophysiological process induced by biomechanical forces leading to
changes in brain function, characterized by changes in orientation, memory as well as balance.
Researchers from NYU have developed a new approach using an eye tracking technology that
can reveal abnormalities in eye movements revealing concussion signs. Since eyes are a “marker
for head trauma” abnormal eye movements may be an early sign of disrupted neurologic
function which can ultimately show a concussion exists in the brain. Applications for this eye
tracking device include evaluation of neurodegenerative diseases, including Alzheimer’s disease
and other forms of dementia.
With this new eye tracking technology comes the hope of spotting more concussions
resulting in less brain injuries to be overlooked. Unfortunately, this eye tracking device is not
available at the KinderMender Columbia Office however if a patient is asked to visit a local
medical center that has one, I will be able to understand where he/she is going and how that
operation is going to take place. X-ray scanning is harsh on the human body, especially in the
children and elderly people, so it is vital that this new form of signifying concussions becomes
more popular and ultimately takes the place of harmful X-ray scans.

Gulli, Cathy. "Blindsided: mounting research shows concussion rates are a lot higher in female
than male athletes--even in 'safer' sports." Maclean's, 27 June 2011, p. 50+. Accessed 20
Oct. 2017.

This article makes the argument that concussion rates are a lot higher in female than male
athletes--even in 'safer' sports. The article states in the introduction that "What we know right
now is that females are about two to three times more likely to have a concussion than males."
The present this as a problem. The problem is widespread: high rates of concussion in females
are occurring at both the youth and adult levels, and across the sports spectrum. Recent studies
have found that in gender-comparable sports such as soccer and basketball, which have the same
rules and equipment for both sexes, females are far more likely to receive a concussion per
number of" athlete exposures." For example, females have a considerably higher rate of
concussion in ice hockey even though “body checking” is prohibited in women’s leagues.
This was an excellent article, but it was biased. Even though I am a woman I still felt the
tension building up through her writing. Regardless, the article is structured precisely and gives
the right amount of explanations for each section. From my first few trips to my internship I hve
noticed that more girls are seen each day for mainly head-related issues whether it be headaches,
dizziness, migraines, concussions, etc. This could be a probable answer as to why so many girls
show up at KinderMender.
Halstead, Mark, and Kevin Walter. "Sport-Related Concussion in Children and Adolescents."
AAP News & Journals Gateway. Accessed 20 Oct. 2017.

This article primarily focuses on sports related concussions in both children and
adolescents. It is mentioned that even though football players have the highest incidence of
concussions, girls have higher concussion rates than boys do looking at similar sports types. The
article goes on to describe the birth of concussion studies in that young athletes have a unique
challenge, because their brains are still developing and are more susceptible to the effects of a
concussion. A brief and easy reading paragraph is entitled “definition” where a consensus of the
definition of a concussion was made: “a complex pathophysiological process affecting the brain,
induced by traumatic biomechanical forces.” In addition to this they also provide five major
features of a concussion including the following: may be caused either by a direct blow to the
head, face, or neck or elsewhere on the body, results in the rapid onset of short-lived impairment
of neurologic function, may result in neuropathological changes, results in a graded set of
clinical symptoms, and no abnormality on standard structural neuroimaging studies is seen in
concussion.
The purpose of this article was to discuss what concussion are and how they primarily
relate to sports related injuries. The article is written in a very kid-friendly, easy to read way so I
was able to understand what they were talking about from the beginning. Structurally it was also
pleasing, breaking the article into easy to follow categories such as introduction, definition, and
epidemiology of concussion. The definition subtitle was very thorough with its information and
provided me with five feathers of a concussion which will benefit me in my time shadowing at
KinderMender.

KinderMender, www.kindermender.com. Accessed 13 Oct. 2017.

The KinderMender Website gives an overview of the four medical center offices located
in Glen Burnie, Columbia, Laurel, and Timonium. It is a user-friendly website due to its clear
and easily accessible tabs at the top of the screen labeled [home symbol], Why Choose Us,
Services, Our staff, Contact Us, Locations, News/Blog, FAQs, Videos, and En Espanol. The
website opens to a home screen providing the recent diagnoses from today, this week, and last
week allowing web-surfers to see the types of treatments offered. For example, Otitis Media- Ear
Infection was shown as treated in all three time frames indicating it’s a common infection seen at
KinderMender. Additionally, the homepage includes directions to their four office locations as
well as a brief description of the KinderMender Pediatric Walk in Clinic, giving the reader
background information about clinic. The Why Choose Us tab offers a helpful side bar that
indicates the wait time for each of the offices, with, for example, Glen Burnie being an eight
minute at 9:03am on October 8th, 2017. Next, the Services tab is divided into four subsections:
urgent care, primary care, sports and school physicals, and immunizations. The urgent care
categorizes the general injuries and infections, the primary care provides information needed for
physicians prior to the appointment and the hours of each office, the sports and school physicals
gives web users information on the importance of sports physical check and how to schedule it,
and the immunizations tab allows you to check if your children are up-to-date with their
immunizations. The Our staff tab allows the web user to learn more about the KinderMender
team. Specifically, founder and manager Dr. Keyvan Rafei provided the website with
background information about himself including his schooling, accomplishments, and fun
miscellaneous information. The Contact Us tab gives the who, what, when, where, why of
KinderMender, as well as a phone number with hours listed and optional email outline.
Locations, although already listed in several other places, go more into depth here providing a
map, which is easily accessible in the GPS system of smart phones. The News/Blog tab provides
the web-user with different accomplishments and awards KinderMender has received. The FAQs
tab offers the web-user a possibly easier way to get the answer to a question they are confused
about. User-friendly videos are provided in the Videos tab, such as Cold versus Flu, What Is
Asthma?, and Allergy Treatments. Lastly the En Espanol tab converts the general information
about KinderMender to Spanish.
This website is very helpful, because it is the website of the clinic I intern at. It allows me
to read more about the background knowledge about the site as well as help me to get a better
grasp of the place I am interning at. A specific feature of the website that was most helpful to me
was the Videos tab where user-friendly videos covering a vast number of different illnesses are
shown. These videos not only help web-users but also helped me to get a better understanding of
certain things to look out for and observe while interning. Additionally, the website included
directions to the offices in several different places. The repetitiveness of the website allows the
website to connect and ultimately make more sense to people. The staff provide detailed
backgrounds of each other as well as their contact information, which could be an easy way to
schedule an interview.

Kirkwood, Michael W., et al. "Pediatric sport-related concussion: a review of the clinical
management of an oft-neglected population." Pediatrics, Apr. 2006, p. 1359+. Accessed
20 Oct. 2017.

This review is a pediatric sports related concussion regarding the clinical management of
an oft-neglected population. It is stated that Athletic concussion is a growing focus of attention
for pediatricians. Sequentially, background information of the subject is mentioned as well as the
topic of epidemiology. They included that a concussion is a type of mild traumatic brain injury
(mTBI) that is caused by an impact or jolt to the head. “The American Academy of Neurology
straightforwardly defines concussion as a trauma-induced alteration in mental status that may or
may not involve a loss of consciousness.” Next the topic of concussion effects is mentioned
which includes the subtopics of biomechanical properties, pathophysiological response,
neurobehavioral outcome, and contextual expectations. To conclude, clinical management is
stressed severely as being “individualized” and matched to the particular person and his or her
own unique circumstances to ensure that medical, cognitive, emotional, social, athletic, school,
and family issues are all addressed adequately.
This article primarily stresses the important that no two concussions will be exactly alike
regardless of age, the specific symptom pattern will depend on innumerable injury, personal, and
contextual factors (eg, severity and location of injury forces, genetic make-up, gender, learning
and previous injury history, psychiatric status). At KinderMender, no treatment will be the same
especially relating to concussions. Although the actual testing will be the same the main point the
article is stressing is that no two concussion will happen in the same way and there is no real way
to compare the brain injury of one person to another.
LasCasas, Lauren Beth. Interview. 7 Oct. 2017.

Dr. Lauren Beth LasCasas, my mother, is a (not practicing at the moment) pediatrician, at
Nigthtime Pediatrics in Columbia Maryland. In her career path, the medical field was not at first
what she wanted to do. She attended Wilde Lake High School, graduating first in her class with a
4.0 GPA. Then she attended Duke University and worked as a math major, receiving her first
high-paying job as a governmental accountant. But she wasn’t enjoying her job and thought, “I
like to help people. I need to do something in my life that helps people.” So, she quit her steady
job to attend UMBC medical school where she ultimately received her doctorate and became a
pediatrician. Some struggles she had as a pediatrician were that she would always be worrying
about the patients. LasCasas says, “I would always try to call them when I got home asking how
they were feeling. It was mentally-draining but all a patient can ask for, right?”
This interview with my mother helped me to gain the true knowledge of becoming a pediatrician
or physician’s assistant. Even though she warns me that the medical field is a lot of work and she
probably would have done something less extreme than a doctor, she still encourages me to
follow my dreams. My take on the interview is that my mother really cared about her job and the
patients surrounding her. She has taught me to not become worrisome when treating patients, but
to become cautious and taken seriously. These are the skills I need to become a better intern, and
later a better doctor. She provided me with the information I need for an everyday trip at my
internship including what I should look out for, things I should pay close attention to, questions I
should ask, etc. She similarly had interned during her residency and gave me helpful tips that she
learned from. Ultimately, she gave me the best approach I should take in this internship as well
as guide me in the right direction for my career path.

Master, Christina, et al. "Pediatricians take front line in management of

concussions." Healio, Sept. 2016, www.healio.com/pediatrics/adolescent-
medicine/news/print/infectious-diseases-in-children/%7Bd1789384-d949-4a8f-92f1-
51680ceb6870%7D/pediatricians-take-front-line-in-management-of-concussions?page=2.
Accessed 20 Oct. 2017.

In this article, it discusses the biased opinion that Pediatricians take front line in
management of concussions. In a recent study, Alan L. Zhang, MD, associate professor of the
orthopedic department at the University of California, and her colleagues looked at data from
administrative health records of several patients diagnosed with concussions. Statistics were also
brought into the article, where, during this time, here was a 160% increase in the incidence of
concussion in the general population; 32% of the individuals diagnosed with concussion were
aged 10 to 19 years with the largest increase in incidence occurring from 2007 to 2014 in that
age group. The article suggests that high school athletes are one of the largest contributors to
head and neck injuries. Danger is posed by sports-related concussions primary among children.
Due to all 50 states, as well as the District of Columbia, having passed similar “return-to-play”
legislation, requiring schools to follow specific protocols for allowing students to return to sports
after a concussion.
This article sums up a lot of some of the other articles I have read in that “return-to-play”
legislation has had immense impact on athletic trainers, doctors, coaches, patients, etc. “The rates
at which concussions are rising may be in part due to the rise in youth sports participation and
also better diagnostic skills and training for coaches and sports medicine professionals,” Zhang
and colleagues wrote. At KinderMender, it is important that children are being reported for their
concussions and can get the help they need and deserve. Keeping a count of hoe many children
actually do have reported concussions from their school can be a good indicator as to if this law
is actually obeyed in Maryland.

McLeod, Tamara C. Valovich, et al. "Rest and return to activity after sport-related concussion: a
systematic review of the literature." Journal of Athletic Training, vol. 52, no. 3, 2017, p.
262+. Accessed 20 Oct. 2017.

This study consists of the Rest and return to activity after sport-related concussion: a
systematic review of the literature. The objective of the study was to review literature regarding
before and after activities of concussions. It was conducted in several medical offices including
Cochrane Central Register of Controlled Trials, PubMed, SPORTDiscus, etc. Articles were
grouped into sections based on their abilities to address particular clinical questions of interest:
“use of rest, rest effectiveness, compliance with recommendations, or outcome after graded
return-to-activity progression.” It was considered a qualitative study.
Conclusively, the findings reveela that rest is underused by doctors, nurses, and health
providers where recommendations for rest are not specific to individual patients like they should
be. It is something I should look out for at KinderMender as a sort of test to my doctors whom I
am shadowing. It is vital that they focus primarily on management and physical rest after a
sports-related concussion. The brain may still be vulnerable from the initial concussing
preventing second-impact syndrome in younger patients. Ultimately, even though I am not
allowed to suggest or recommend any type of treatment I can still tell patients to rest their body
because that is something anyone can benefit from.

Meckler, Sydney. "Clinical Management of Sports-related pediatric Concussions." Physicians

Assistant Review Panel. Accessed 20 Oct. 2017.

This article, entitled Clinical Management of Sports-related pediatric Concussions,

provides a clinical review discussing the challenges of diagnosis and treatment of pediatric
concussive injuries, focusing specifically on the effects of a concussion on the brain. The term
concussion is defined as a mild traumatic brain injury (mTBI). The article goes on to describe
that an injury to the brain is made up of several pathophysiologic components that are a
consequence of biomechanical forces. A diagram is shown that explains that in order
concussions occur, nerve cell’ adaptability or homeostasis must be interrupted. The pictures and
labeled diagrams are provided to help the reader better understand these complex processes. The
article then goes into explaining the importance of the crucial developmental years where the
brain is progressing and becoming more complex. The crucial years exist from ages 5 to 12 and
the evolving neurocognitive functioning of the brain must be taken into account. The article
explains these to be the “critical skills” such as language, emotion, memory, problem solving,
and motor dexterity, emerge during childhood, and a disturbance during this time could have
substantial consequences. Lastly, tables are included to help the reader better understand
concussions. For example, Table I included a list of all the areas in the brain that may be affected
by the concussions such as the frontal lobe, temporal lobe, parietal lobe, occipital lobe,
Hypothalamus, trigeminal system, basal ganglia, cerebellum, etc.
 This article covers an immense number of topics each vital to concussions and also
relatable to my internship. The material covered will reflect with situations I will encounter at
KinderMender and I will use this as a study tool in order more prepared at my internship. The
first day of at the office, I had no idea what my main focus would be or which patients I would
want to observe. After coming to the conclusion wanting to study concussion testing, I will need
to fam familiarize myself with critical concussion-related information in order to better
understand the patient visits I am observing which is provided directly in this article.

"Saliva test predicts prolonged concussion symptoms in children." Medical Laboratory

Observer, June 2017, p. 11. Accessed 20 Oct. 2017.

A recent finding in the medical world is that a saliva test can predict prolonged
concussion symptoms in children. The objective was to assess the utility of salivary miRNA in
predicting prolonged pediatric concussion symptoms relative to the SCAT-3. The designs and
methods of this experiments consist of the following: Fifty children (ages 7-18) with mild
traumatic brain injury were enrolled in the study. Injury mechanism and demographic features
were recorded. Concussion symptoms were assessed with parental and child SCAT-3 surveys
administered within 14 days of injury and again four weeks post-concussion. Expectorated saliva
was collected at the time of enrollment and miRNA content was assessed with high-throughput
RNA sequencing. Participants with SCAT-3 scores ≥ 5 at four weeks were considered to have
prolonged concussion symptoms. Mann Whitney testing assessed differences in SCAT-3 scores
and miRNA expression between acute- and prolonged-concussion groups. A logistic regression
analysis with 10-fold Monte Carlo cross-validation was used to assess predictive utility of
SCAT-3 and miRNA components. The study resulted in no differences in injury mechanism or
demographic variables between acute- and prolonged-concussion groups.
Conclusively, Salivary miRNA has prognostic utility for identifying prolonged
concussion symptoms in pediatric patients that exceeds the SCAT-3. As mentioned before, this
discovery is huge in the medical world. It could easily be brought to KinderMender where there
would be an array of test subjects to try it on. It could help parents to better understand their
child’s level of concussion. “We believe that saliva-based RNA testing holds great promise as an
accurate and non-invasive method for evaluating pediatric concussions and giving patients and
families a more solid prognosis," Dr. Hicks said.

"Saliva, An Indicator of Concussions,” Medical Laboratory Observer, June 2017. Accessed 20

Oct. 2017.

A significantly recent finding that saliva test predicts prolonged concussion symptoms in
children was just discovered in July o 2017. A statistic begins the article by stating that most of
the three million concussions diagnosed in the U.S. each year occur in children. A simple saliva
test may yield to answers. Colleagues from Penn State College of Medicine presented an abstract
of the study "Peripheral microRNA patterns predict prolonged concussion symptoms in pediatric
patients" at the conference. Previous studies suggest that altered miRNA levels in the saliva of
children with mild concussions. This mirrored similar miRNA changes in cerebrospinal fluid of
patients with severe brain injury. The researchers studied 50 children between the ages of 7 and
18 years with mild traumatic brain injury. Spit samples were collected and tested for miRNA
levels. Surveys were taken within 14 days of injury and again four weeks post-concussion. This
resulted in the 29 children with prolonged concussion symptoms had higher scores for
headaches, fatigue, and difficulties concentrating.
A discovery so recent, means that many more are to come. The usage of saliva to detect
the severity of a concussion is incredible. At KinderMender, I still think its amazing how a
simple sample from the back of the throat can tell you whether you have strep or not. Saliva is
taking it to the next level and it is kid friendly. It’s a very strategical way to get a double check
answer and to help doctors to decide how to diagnose, treat, react, prescribe patients better now
that this information is available. I hope to see this new type of indicator during my time
interning.

O'Connor, Kathryn L., et al. "Epidemiology of sport-related concussions in high school athletes:
National Athletic Treatment, injury and outcomes network (NATION), 2011-2012
through 2013-2014." Journal of Athletic Training, vol. 52, no. 3, 2017, p. 175+. Accessed
20 Oct. 2017.

This article focuses on an Epidemiology study relating to sports-related concussions in

high school athletes. National Athletic Treatment, Injury and Outcomes Network (NATON)
conducted this study where patients and other participants that participated in high school
athletics certain questions. They were asked Sport-related concussion counts, percentages, rates
per 10000 athlete-exposures (AEs), rate ratios (RRs), and injury proportion ratios (IPRs) were
reported with 95% confidence intervals (CIs). Rate ratios and IPRs with 95% CIs not containing
1.0 were considered significant. “Overall, 2004 SRCs were reported among 27 high school
sports, for a rate of 3.89 per 10 000 AEs. Football had the highest SRC rate (9.21/10000 AEs),
followed by boys' lacrosse (6.65/10000 AEs) and girls' soccer (6.11/10 000 AEs).” With the data
from this study it is clear that concussions are present in all sports, primarily in soccer and
especially girls.
This study gathers data from actual high school athletes where almost all of them have
had some type of brain or head injury throughout their years playing. It is interesting to know
that girls’ soccer is the most common place concussions are seen. As a soccer player, I have
never had a severe head injury, but just recently a girl on the Centennial High School team just
had a terrible brain injury that may cost her this season. It does surprise me that men’s football is
not nearly as susceptible to concussions compared to other girls’ sports. At KinderMender, I tend
to see more female patients rather than male and this article might explain my confusion of this.

Perriello, Vito A., and Jeffrey T. Barth. "Sports concussions: Coming to the right conclusions."
Contemporary Pediatrics, Feb. 2000, p. 132. Accessed 20 Oct. 2017.

This article covers concussions regarding sports and how to “come to the right conclusion.” The
introduction includes the importance of concussions in that in order to determine the severity of a
head injury, an evaluation needs to occur. They go on to say that head trauama in sports
commonly seen and that an estimated 300,000 mild to moderate head injuries that could be
classified as concussions. The article goes on to describe the process of a sideline evaluation as
well as the office evaluation. A sideline evaluation consists of a coach’s or athletic trainer’s
evaluation while an office evaluation consists of a doctor’s evaluation of a head injury. A second
impact syndrome is also mentioned as a crucial aspect to look out of during the post-concussion
stage. Conclusively, helpful key questions that readers may ask are answered thoroughly,
readable for adults unaware of the subject.
Sports concussions are going to be the main type of concussion I will be witnessing in
children at KinderMender. This article provides detailed information on the subject of
concussions which will be useful in being educated during my time shadowing. The information
regarding the two types of evaluations is also something I should consider because there
certainly are cases where “the sideline evaluation” does not always take place. At KinderMender,
I will get to experience the doctor’s office evaluation of a concussion which consists of an
observation for classic signs and symptoms of concussion and testing for deficits in cognition,
mental status, and coordination. The use of X-rays was also mentioned as a possible indicator for
concussions, which is also provided at the KinderMender Columbia office.

Piazza, Stephen. "Why is it so hard to stop sports concussions?" American Scientist, vol. 102, no.
5, 2014, p. 346+. Accessed 20 Oct. 2017.

`This article discusses hence why it is so hard to stop sports concussions. It is told in the voice of
a high school physics teacher where the mechanics of brain injury are thoroughly emphasized.
Physics-related laws are significantly stressed as being the true explanation for concussions. For
example, to help readers better understand, the author provided a discussion of a simple model to
illustrate how inertial forces might injure the brain despite the surrounding fluid. A second point
that this teacher stresses is that the most vital thing to do before and after a concussion to protect
the brain. A study is mentioned where the highest helmet accelerations recorded using HITS
were about 100 g, or 100 times the acceleration due to Earth's gravity, clearly a dangerous level
of acceleration for the human head. However, the heads of woodpeckers undergo accelerations
of 1,200g as they hammer into trees which suggests that hope that researchers will find evidence
to prevent conditions in humans such as detachment of the retina and shaken baby syndrome, or
lead to biologically inspired helmet.
Even though my main focus is not related to the physics of concussions it was interesting
to learn about how and why certain situations cause our bodies to act a certain way. This article
helped me to actually relate previous topics I learned at school in my Physics I AP class with
what I already know about concussions. Certain speeds cause a centripetal force our head cannot
handle and the response to it is a concussion. The study, conducted by Greenwald was interesting
in that helmets at certain accelerations are at a farther lower acceleration level of the average
woodpecker’s pecking rate. This discovery allows for a chance of our bodies to somehow exist at
higher accelerations of gravity as well as the decreasing of concussions per year.

Reynolds, Gretchen. "Concussions in Teenagers Tied to Multiple Sclerosis Risk." New York
Times, 18 Oct. 2017. Accessed 20 Oct. 2017.

Concussions in teenagers now fall into the pool of people at risk for multiple Sclerosis.
the new study, which was published last month in Annals of Neurology, scientists at Orebro
University and the Karolinska Institute in Sweden and other institutions decided to look at the
medical histories of every person in Sweden who had been given a multiple sclerosis diagnosis
since 1964, when the diagnosis began to be reported to a national medical database. They found
7,292 men and women who had been given M.S. diagnoses through the end of 2012. They found
that symptoms of M.S. often begin to affect people years before a diagnosis and can include
clumsiness and falls. If people had stumbled and incurred head injuries because they had early
M.S., then their disease might be contributing to their concussions and not the other way around,
a statistical issue known as reverse causation.
Several medical issues can come about when concussions come into the picture. Broken
bones are just one cause of concussion leading to a disease. At KinderMender it is good to catch
things early on in the processs so no huge medical issues get overlooked and not treated. It is
important that I agree and understand everything the doctor that I am shadowing is saying so that
I become better aware of the things to look out for. In this case, a medical record would need too
be looked at which would be done by the doctor.

Ropper, Allan, and Kenneth Gorson. "Concussion." The New England Journal of Medicine,
11 Jan. 2007, pp. 166-72. Accessed 20 Oct. 2017.

The famous and widely known professional journal of The New England Journal of
Medicine, discusses both the observations and causes of concussions. To begin, a short story is
provided of a 64-year-old woman who slipped on an icy walk, describing the process of her
concussion. Her symptoms consisted of unresponsiveness for less than one minute, headaches
and nausea, and unable to recall the previous hours. This unfortunate lesson is a great transition
to the topic of concussions management. The journal stresses the importance of managing
concussions and how other causes can arise if not taken care of properly. Additionally, it also
includes the clinical problems of concussions, strategies and evidence for the evaluation of
concussions, observations after concussions, Post-concussion Syndrome, and specifically
concussions from athletics. Furthermore, areas of uncertainty are included where the effects of
concussions are not always considered black and white, or clear. Conclusively a brief summary
is included to wrap up the article with recommendations and suggestions during concussion
incidents.
“Concussion,” in The New England Journal of Medicine, is a great source for my specific
area of study. Working at KinderMender will allow me to witness several minor concussions, as
my mentors have told me. This journal provides a perfect overview of the subject. The brief
grabber that was provided helped me to better understand the importance of concussions.
Important statistics that were emphasized included the following: 1) concussions affect about
128 people per 100,000 population in the United States yearly and 2) sports and bicycle
accidents account for the majority of cases among 5- to 14-year-olds, whereas falls and vehicular
accidents are the most common causes of concussion in adults. With this information, I am now
aware that concussions are very common in the United States and the majority of concussions
witnessed at KinderMender will be due to sports and bicycle accidents. Strategies are also
provided in this article, allowing me to become more aware with the suggestions a doctor could
give to a patient. These include to keep the airway clear, be attentive to a possible accompanying
neck injury, and in certain circumstances be prepared to take the victim to an emergency
department for evaluation. These are helpful tips anyone should know regarding how to deal
with concussions. Lastly, a discussion of a Post-Concussion Syndrome known as Posttraumatic
Nervous Instability was provided which named the common symptoms to look out for at my
internship. The symptoms include mainly headaches, dizziness, and trouble concentrating, in the
days and weeks following a concussion.
Rafei, Kenyan, Dr. interview. 1 Oct. 2017.

This interview/ speech by Dr. Kenyan Rafei was given at my informational meeting for
KinderMender. Even though I did not formally meet or interview Dr. Rafei, his speech inspired
me and has certainly made an impact on my interning experience. Dr Kenyan Rafei is the
manager director and founder of the KinderMender Walk-In Pediatric Center. He has 11 years of
schooling in pediatrics attending Pennsylvania State University, Medical College of
Pennsylvania, and completed his residency at the Baylor College of Medicine Affiliated
Hospitals in Texas.
In the video clip, Dr. Rafei goes on to explain what it takes to become an intern at
KinderMender. He explained what types of things we would be dealing with at the office such as
greeting patients, cleaning tables, and simply being kind. He significantly harped on the point of
being kind in that he believes it is just as important as the care given. He explained that people
remember the care they are given with how they were feeling during the whole experience. He
helped me to realize that this is a business and needs to be taken seriously. At my internship,
when I am greeting people I will try to make patients feel safe and happy even when times are
tough. Dr. Rafei is an incredible man and has forever inspired me now and in my later medical
field paths.

Swich, Susan, and Micharl Jellinek. “Depression in Adolescence.” Pediatric News, Aug. 2017.
Accessed 20 Oct. 2017.

This article, entitled “Depression in Adolescence” talks about teenagers with psychiatric illnesses
such as the mostly common, depression. They talk about how this illness is treatable. And that
Psychotherapy is the answer. “psychotherapy usually works over several months, and even
effective treatments takes time.” It is the first line treatment for depression, along with additional
medications for severe episodes. A factor associated with depression is sleep. Sleep can disrupt
your attention and concentration and worse anxiety and depressive systems. It is critical you get
enough sleep and avoid taking just the simple daytime nap. Exercises are vital to your health and
“has shown to be as effective as antidepressants in treating mild to moderate episodes of
depression.
This article provides me with the knowledge I need for depression. Depression, being
most common in teenagers, is unfortunately a probable cause of self-harm and self-suicide. It is a
serious problem that needs to be addressed early on and a statistic rate that needs to decrease.
This article helps me look out for certain behaviors at my office that may correlate with
depression. Even simply providing patients with the importance of sleep and exercise can be
helpful advice for someone in need of it. The treatment of depression is also great knowledge to
hold onto that could be used in emergency cases. For example, the psychological therapy is a
recommended treatment by professionals. Even though I am not allowed to formal diagnose any
patient I can still give them helpful guidance provided in this article.
 Teel, Elizabeth F., et al. "Predicting recovery patterns after sport-related concussion."
Journal of Athletic Training, vol. 52, no. 3, 2017, p. 288+. Accessed 20 Oct. 2017.

This study consists of predicting recovery patterns after-sport-related concussions. This is

a Cohort study that looks at seven sports at 26 colleges and 201 schools totaling 8905 collegiate
and high school athletes. “The Graded Symptom Checklist, Standardized Assessment of
Concussion, and Balance Error Scoring System were administered to all athletes during the
preseason. To allow us to track recovery patterns, athletes diagnosed with a concussion (n = 375)
repeated these assessments immediately after the injury, 3 hours post injury, 1 day post injury,
and at 2, 3, 5, 7, and 90 days after injury.” Athletes who had amnesia had greater deficits in and
slower recovery relating to cognition and balance. Athletes with two or more prior
concussiosdemonstrat3ed poorer balance than those with no previous history. Greater deficits in
balance scores were observed in athletes with all symptom types. Recovery time for most of the
athletes was within 7 to 10 days.
This study ultimately made me realize that there are patterns relating to sports-related
concussions. Based off of the data, some conclusions can be made. Athletes who experienced
amnesia had more symptoms and greater deficits in cognition and balance Symptoms and
cognitive or balance deficits were not consistently associated with LOC or concussion history.
Acute symptoms had a strong influence on balance scores and, to a lesser extent, on cognition.
However, group recovered occurred within normal timelines.

Vojdani, Aristo. "Blood-Brain barrier damage and neuroautoimmunity." Townsend Letter, Oct.
2014, p. 58+. Accessed 20 Oct. 2017.

This article focuses on the blood-brain barrier damage and neuroautoimmunity. The
article gives an easy explanation of what occurs when the blood-brain barrier is damaged. For
example, they describe that “circulating antibodies that cross-react with neurological tissues can
infiltrate the brain and nervous system, with the potential destruction of neurologic tissues.”
Additionally, they allude to “new breakthroughs” in order to make it possible to identify BBB
permeability. For example, testing for key antibodies makes it possible to diagnose many of
these conditions at a preclinical stage, before frank symptoms of injury or disease are present.
Increased permeability can manifest as CNS symptoms of neurotoxicity, autoimmunity, or even
cancer. Lastly, secondary disorders are mentioned. Chronic inflammation and deterioration.
Chronic inflammation in the brain can be caused by environmental triggers such as infection or
toxic chemicals that activate neurons, astrocytes, and microglia to produce cytokines.
It is important to consider the factors of blood-brain-barrier damage under the topic of
concussions. Concussions have so many other terrible causes to consider in the brain that it is
hard to keep track of all of them. Blood-brain-barrier damage is a more critical cause that should
be watched and managed as would the symptom of slight dizziness. All symptoms are critical
and all symptoms need to be monitored. Knowing these symptoms can be helpful in identifying
how critical a certain concussion might be for a given patent a KinderMender.
Wallace, Jessica, et al. "Knowledge of concussion and reporting behaviors in high school
athletes with or without access to an athletic trainer." Journal of Athletic Training, vol.
52, no. 3, 2017, p. 228+. Accessed 20 Oct. 2017.

This study is mainly focused on the knowledge of concussion and reporting behaviors in
high school athletes with or without access to an athletic trainer. The objective of this study was
to evaluate knowledge of concussion and reporting behaviors in high school athletes who did or
did not have access to an AT. A total of 438bathletes were survey consisting of 83 items
addressing “concussion history, concussion knowledge, scenario questions, signs and symptoms
of a concussion, and reasons why an athlete would not report a concussion.” Proportions of
athletes were made comparing the athletes who correctly identified knowledge of concussion,
signs and symptoms of concussion, and reasons why high school student-athletes would not
disclose a potential concussive injury by access to an AT. The underreporting of concussions
was a shocking 55%. Athletes with access to an AT had more knowledge of concussion than did
athletes without such access.
From this study, the main take-away is that athletic trainers do not report concussions. It
is interesting to me that this is where the problem stands and it’s not because the law is enforcing
strict concussion reports. High school athletes with access to an AT had more concussion
knowledge, but they did not report suspected concussions to an authority figure more frequently
than athletes without access to an AT. At KinderMender, there are doctors, and hopefully I will
see reporting of concussions being followed through with and taken into consideration.

Williamson, John. "Unique Helmet Design Could Reduce Concussions." Design News, 1 May
2009, p. M14. Accessed 20 Oct. 2017.

This article suggests a discovery in 2009 of a design of a helmet that could reduce
concussions. Background information is provided on the subject of concussions where they
described as a type of traumatic brain injury resulting from the sudden violent movement of the
head during impact. Any alert movement of the head causes the brain to move inside the skull,
which may result in disrupted brain function, leading to the signs and symptoms of concussion.
Football is the sport primarily related to concussions. The helmets were tested in a crash test
dummy head which measures the movements in units of G or SI. “The dummy head registers an
acceleration curve, representing the force the head experiences. The lower the peak, the lower
the G or SI. A lower, flatter curve indicates a more gradual movement and less likelihood of an
injury. However, performance on standards does not necessarily correlate with the risk of
concussion.” The result of this helmet came up with the name Xenith where comfort and
concussing reducing factors were both considered.
With interning at an urgent care comes several sports injuries. Football being the primary
sport for injuries specifically regarding concussions. Although players wear helmets, they aren’t
enough to withstand the blood battles happening on the field. A new type of helmet could be the
solution to, at least, this type of injury. At KinderMender, I will be more educated with the most
recent gadgets sports players are using in order to prevent concussions. It is also a suggestion I
can make to both patients and their parents/guardians.
Wilson, Robert F., et al. "Sports concussion: Implications of the exam after head injury. (Primary
Care Update)." Consultant, Feb. 2002, p. 230+. Accessed 20 Oct. 2017.

This article centers on the idea that there are post-concussion causes that need to be
carefully watched. It is recommended that exams should be made after head injuries. A
significant statistic is made in that “As many as 300,000 sports-related concussions are
diagnosed each year in the United States.” It is mentioned that Most sports-related concussions
occur among amateur and recreational athletes in settings where sophisticated diagnostic
techniques are not readily available. Not until recently, there had been no way to measure the
severity or recovery of brain injury. Now we are provided with useful methods. For example,
McGill Concussion Protocol, which ultimately enables doctors to objectively evaluate the
severity of an injury and to gauge the progress of recovery. The presentation and severity of a
concussion are touched on where there is one grading system based on signs and symptoms from
a concussion.
Post-concussion causes are just and if not more sever than the causes of the concussion
itself. The causes are categorized into a grading system from grades one to three. Grade one
consists of the mildest form of concussion, but also the easiest to overlook. It lasts for less than
30 minutes with no LOC. Grade 2 is defined as a moderate concussion and has LOC with a
recovery in less than 5 minutes, transient confusion lasting more than 15 minutes, and PTA
lasting more than 3 minutes. Grade 3 is the most severe concussion type where there is any LOC
and PTA lasts more than a day. With this information I will better understand what the doctor I
am shadowing is talking about when she uses the grading scale to describe a concussion level.