Literature Review

Head contact with other players, not with the ball, is the main source of concussions among high school soccer players, according to research published online ahead of print July 13 in JAMA Pediatrics.

Several studies have shown that heading the ball is responsible for many soccer-related concussions. Some people have called for banning heading, especially among children and adolescents, to make the sport safer. No large study, however, had examined the exact mechanism of head injuries among school-aged soccer players, so such prevention efforts could not be considered evidence-based, said R. Dawn Comstock, PhD, an epidemiologist at the University of Colorado Denver in Aurora.

Dr. Comstock and colleagues performed a retrospective analysis of data from a large, Internet-based sports injury surveillance study, focusing on concussions sustained during soccer practices or games that required medical attention and restricted the athlete’s participation for one or more days. The investigators assessed nationally representative samples of 100 high schools every year for nine years. There were 627 concussions during 1,393,753 athlete exposures among girls (4.50 per 10,000 exposures) and 442 concussions during 1,592,238 athlete exposures among boys (2.78 per 10,000 exposures).

The most common mechanism of concussion was player-to-player contact among boys (68.8%) and girls (51.3%). Contact with the ball accounted for 17% of concussions among boys and 29% among girls.

The number and types of concussion symptoms were the same, regardless of whether the concussion was caused by player-to-player contact or player-to-ball contact. However, symptom resolution time was slightly but significantly longer for both boys and girls when the concussion was caused by collision with a ball or goal post.

“We postulate that banning heading from soccer will have limited effectiveness as a primary prevention mechanism unless such a ban is combined with concurrent efforts to reduce athlete–athlete contact throughout the game,” Dr. Comstock and her associates said.

“It may be culturally more tolerable to the soccer community to attempt to reduce athlete–athlete contact across all phases of play through better enforcement of existing rules, enhanced education of athletes on the rules of the game, and improved coaching of activities such as heading,” rather than simply banning heading, said the researchers.

—Mary Ann Moon

Head contact with other players, not with the ball, is the main source of concussions among high school soccer players, according to research published online ahead of print July 13 in JAMA Pediatrics.

Several studies have shown that heading the ball is responsible for many soccer-related concussions. Some people have called for banning heading, especially among children and adolescents, to make the sport safer. No large study, however, had examined the exact mechanism of head injuries among school-aged soccer players, so such prevention efforts could not be considered evidence-based, said R. Dawn Comstock, PhD, an epidemiologist at the University of Colorado Denver in Aurora.

Dr. Comstock and colleagues performed a retrospective analysis of data from a large, Internet-based sports injury surveillance study, focusing on concussions sustained during soccer practices or games that required medical attention and restricted the athlete’s participation for one or more days. The investigators assessed nationally representative samples of 100 high schools every year for nine years. There were 627 concussions during 1,393,753 athlete exposures among girls (4.50 per 10,000 exposures) and 442 concussions during 1,592,238 athlete exposures among boys (2.78 per 10,000 exposures).

The most common mechanism of concussion was player-to-player contact among boys (68.8%) and girls (51.3%). Contact with the ball accounted for 17% of concussions among boys and 29% among girls.

The number and types of concussion symptoms were the same, regardless of whether the concussion was caused by player-to-player contact or player-to-ball contact. However, symptom resolution time was slightly but significantly longer for both boys and girls when the concussion was caused by collision with a ball or goal post.

“We postulate that banning heading from soccer will have limited effectiveness as a primary prevention mechanism unless such a ban is combined with concurrent efforts to reduce athlete–athlete contact throughout the game,” Dr. Comstock and her associates said.

“It may be culturally more tolerable to the soccer community to attempt to reduce athlete–athlete contact across all phases of play through better enforcement of existing rules, enhanced education of athletes on the rules of the game, and improved coaching of activities such as heading,” rather than simply banning heading, said the researchers.

—Mary Ann Moon

Head contact with other players, not with the ball, is the main source of concussions among high school soccer players, according to research published online ahead of print July 13 in JAMA Pediatrics.

Several studies have shown that heading the ball is responsible for many soccer-related concussions. Some people have called for banning heading, especially among children and adolescents, to make the sport safer. No large study, however, had examined the exact mechanism of head injuries among school-aged soccer players, so such prevention efforts could not be considered evidence-based, said R. Dawn Comstock, PhD, an epidemiologist at the University of Colorado Denver in Aurora.

Dr. Comstock and colleagues performed a retrospective analysis of data from a large, Internet-based sports injury surveillance study, focusing on concussions sustained during soccer practices or games that required medical attention and restricted the athlete’s participation for one or more days. The investigators assessed nationally representative samples of 100 high schools every year for nine years. There were 627 concussions during 1,393,753 athlete exposures among girls (4.50 per 10,000 exposures) and 442 concussions during 1,592,238 athlete exposures among boys (2.78 per 10,000 exposures).

The most common mechanism of concussion was player-to-player contact among boys (68.8%) and girls (51.3%). Contact with the ball accounted for 17% of concussions among boys and 29% among girls.

The number and types of concussion symptoms were the same, regardless of whether the concussion was caused by player-to-player contact or player-to-ball contact. However, symptom resolution time was slightly but significantly longer for both boys and girls when the concussion was caused by collision with a ball or goal post.

“We postulate that banning heading from soccer will have limited effectiveness as a primary prevention mechanism unless such a ban is combined with concurrent efforts to reduce athlete–athlete contact throughout the game,” Dr. Comstock and her associates said.

“It may be culturally more tolerable to the soccer community to attempt to reduce athlete–athlete contact across all phases of play through better enforcement of existing rules, enhanced education of athletes on the rules of the game, and improved coaching of activities such as heading,” rather than simply banning heading, said the researchers.

—Mary Ann Moon

Clinical question: What risk factors predict septic arthritis surgical debridement failure?

Background: Standard treatment of septic arthritis is debridement and antibiotics. Unfortunately, 23%-48% of patients fail single debridement. Data is limited on what factors correlate with treatment failure.

Study design: Retrospective, logistic regression analysis.

Setting: Billing database query of one academic medical center from 2000-2011.

Synopsis: After excluding patients with orthopedic comorbidities, multivariate logistic regression was performed on 128 patients greater than 18 years of age and treated operatively for septic arthritis, 38% of whom had failed a single debridement. Five significant independent clinical variables were identified as predictors for failure of a single surgical debridement:

• History of inflammatory arthropathy (OR, 7.3; 95% CI, 2.4 to 22.6; P<0.001);
• Involvement of a large joint (knee, shoulder, or hip; OR 7.0; 95% CI, 1.2-37.5; P=0.02);
• Synovial fluid nucleated cell count >85.0 x 109 cells/L (OR, 4.7; 95% CI, 1.8-17.7; P=0.002);
• S. aureus as an isolate (OR, 4.6; 95% CI, 1.8 to 11.9; P=0.002); and
• History of diabetes (OR, 2.6; 95% CI, 1.1 to 6.2; P=0.04).

Using these variables, a prognostic model was created with an ROC curve of 0.79.

The study’s limitations include its retrospective nature, reliance on coding and documentation, small sample size, and the fact that all patients were treated at a single center.

Bottom line: Risk factors for failing single debridement in septic arthritis include inflammatory arthropathy, large joint involvement, more than 85.0 x 109 nucleated cells, S. aureus infection, and history of diabetes.

Citation: Hunter JG, Gross JM, Dahl JD, Amsdell SL, Gorczyca JT. Risk factors for failure of a single surgical debridement in adults with acute septic arthritis. J Bone Joint Surg Am. 2015;97(7):558-564.

Clinical question: What risk factors predict septic arthritis surgical debridement failure?

Background: Standard treatment of septic arthritis is debridement and antibiotics. Unfortunately, 23%-48% of patients fail single debridement. Data is limited on what factors correlate with treatment failure.

Study design: Retrospective, logistic regression analysis.

Setting: Billing database query of one academic medical center from 2000-2011.

Synopsis: After excluding patients with orthopedic comorbidities, multivariate logistic regression was performed on 128 patients greater than 18 years of age and treated operatively for septic arthritis, 38% of whom had failed a single debridement. Five significant independent clinical variables were identified as predictors for failure of a single surgical debridement:

• History of inflammatory arthropathy (OR, 7.3; 95% CI, 2.4 to 22.6; P<0.001);
• Involvement of a large joint (knee, shoulder, or hip; OR 7.0; 95% CI, 1.2-37.5; P=0.02);
• Synovial fluid nucleated cell count >85.0 x 109 cells/L (OR, 4.7; 95% CI, 1.8-17.7; P=0.002);
• S. aureus as an isolate (OR, 4.6; 95% CI, 1.8 to 11.9; P=0.002); and
• History of diabetes (OR, 2.6; 95% CI, 1.1 to 6.2; P=0.04).

Using these variables, a prognostic model was created with an ROC curve of 0.79.

The study’s limitations include its retrospective nature, reliance on coding and documentation, small sample size, and the fact that all patients were treated at a single center.

Bottom line: Risk factors for failing single debridement in septic arthritis include inflammatory arthropathy, large joint involvement, more than 85.0 x 109 nucleated cells, S. aureus infection, and history of diabetes.

Citation: Hunter JG, Gross JM, Dahl JD, Amsdell SL, Gorczyca JT. Risk factors for failure of a single surgical debridement in adults with acute septic arthritis. J Bone Joint Surg Am. 2015;97(7):558-564.

Clinical question: What risk factors predict septic arthritis surgical debridement failure?

Background: Standard treatment of septic arthritis is debridement and antibiotics. Unfortunately, 23%-48% of patients fail single debridement. Data is limited on what factors correlate with treatment failure.

Study design: Retrospective, logistic regression analysis.

Setting: Billing database query of one academic medical center from 2000-2011.

Synopsis: After excluding patients with orthopedic comorbidities, multivariate logistic regression was performed on 128 patients greater than 18 years of age and treated operatively for septic arthritis, 38% of whom had failed a single debridement. Five significant independent clinical variables were identified as predictors for failure of a single surgical debridement:

• History of inflammatory arthropathy (OR, 7.3; 95% CI, 2.4 to 22.6; P<0.001);
• Involvement of a large joint (knee, shoulder, or hip; OR 7.0; 95% CI, 1.2-37.5; P=0.02);
• Synovial fluid nucleated cell count >85.0 x 109 cells/L (OR, 4.7; 95% CI, 1.8-17.7; P=0.002);
• S. aureus as an isolate (OR, 4.6; 95% CI, 1.8 to 11.9; P=0.002); and
• History of diabetes (OR, 2.6; 95% CI, 1.1 to 6.2; P=0.04).

Using these variables, a prognostic model was created with an ROC curve of 0.79.

The study’s limitations include its retrospective nature, reliance on coding and documentation, small sample size, and the fact that all patients were treated at a single center.

Bottom line: Risk factors for failing single debridement in septic arthritis include inflammatory arthropathy, large joint involvement, more than 85.0 x 109 nucleated cells, S. aureus infection, and history of diabetes.

Citation: Hunter JG, Gross JM, Dahl JD, Amsdell SL, Gorczyca JT. Risk factors for failure of a single surgical debridement in adults with acute septic arthritis. J Bone Joint Surg Am. 2015;97(7):558-564.

Clinical question: Does administration of prednisolone or pentoxifylline reduce mortality in patients hospitalized with severe alcoholic hepatitis?

Background: Alcoholic hepatitis is associated with high mortality. Studies have shown unclear mortality benefit with prednisolone and pentoxifylline. Despite multiple studies and meta-analyses, controversy about the use of these medications persists.

Study Design: Multicenter, double-blind, randomized trial with 2-by-2 design.

Setting: Sixty-five hospitals across the United Kingdom.

Synopsis: Approximately 1,100 patients with a clinical diagnosis of alcoholic hepatitis were randomized to four groups: placebo + placebo; prednisolone + pentoxifylline-matched placebo; prednisolone-matched placebo + pentoxifylline; or prednisolone + pentoxifylline. Groups received 28 days of treatment. The primary endpoint was 28-day mortality. Secondary endpoints were mortality or liver transplantation at 90 days and one year.

Neither intervention showed a significant reduction in 28-day mortality. Secondary analysis with adjustments for risk showed a reduction in 28-day mortality in the prednisolone groups. There was no difference between groups for mortality or liver transplantation at 90 days or one year.

Adverse events of death, infection, and acute kidney injury were reported in 42% of patients. Infection rates were higher in the prednisolone groups; however, attributable deaths were no different between groups.

Patients in this trial were younger, with a lower incidence of encephalopathy, infection, and acute kidney injury than those seen in similar trials, which could affect the rates of mortality seen here. Also, liver biopsy was not used, so patients may have been incorrectly included.

Bottom line: No difference was found in mortality or liver transplantation at 90 days and one year for prednisolone or pentoxifylline, although subanalysis showed there may be short-term benefit with prednisolone.

Citation: Thursz MR, Richardson P, Allison M, et al. Prednisolone or pentoxifylline for alcoholic hepatitis. New Engl J Med. 2015;372(17):1619-1628.

Clinical question: Does administration of prednisolone or pentoxifylline reduce mortality in patients hospitalized with severe alcoholic hepatitis?

Background: Alcoholic hepatitis is associated with high mortality. Studies have shown unclear mortality benefit with prednisolone and pentoxifylline. Despite multiple studies and meta-analyses, controversy about the use of these medications persists.

Study Design: Multicenter, double-blind, randomized trial with 2-by-2 design.

Setting: Sixty-five hospitals across the United Kingdom.

Synopsis: Approximately 1,100 patients with a clinical diagnosis of alcoholic hepatitis were randomized to four groups: placebo + placebo; prednisolone + pentoxifylline-matched placebo; prednisolone-matched placebo + pentoxifylline; or prednisolone + pentoxifylline. Groups received 28 days of treatment. The primary endpoint was 28-day mortality. Secondary endpoints were mortality or liver transplantation at 90 days and one year.

Neither intervention showed a significant reduction in 28-day mortality. Secondary analysis with adjustments for risk showed a reduction in 28-day mortality in the prednisolone groups. There was no difference between groups for mortality or liver transplantation at 90 days or one year.

Adverse events of death, infection, and acute kidney injury were reported in 42% of patients. Infection rates were higher in the prednisolone groups; however, attributable deaths were no different between groups.

Patients in this trial were younger, with a lower incidence of encephalopathy, infection, and acute kidney injury than those seen in similar trials, which could affect the rates of mortality seen here. Also, liver biopsy was not used, so patients may have been incorrectly included.

Bottom line: No difference was found in mortality or liver transplantation at 90 days and one year for prednisolone or pentoxifylline, although subanalysis showed there may be short-term benefit with prednisolone.

Citation: Thursz MR, Richardson P, Allison M, et al. Prednisolone or pentoxifylline for alcoholic hepatitis. New Engl J Med. 2015;372(17):1619-1628.

Clinical question: Does administration of prednisolone or pentoxifylline reduce mortality in patients hospitalized with severe alcoholic hepatitis?

Background: Alcoholic hepatitis is associated with high mortality. Studies have shown unclear mortality benefit with prednisolone and pentoxifylline. Despite multiple studies and meta-analyses, controversy about the use of these medications persists.

Study Design: Multicenter, double-blind, randomized trial with 2-by-2 design.

Setting: Sixty-five hospitals across the United Kingdom.

Synopsis: Approximately 1,100 patients with a clinical diagnosis of alcoholic hepatitis were randomized to four groups: placebo + placebo; prednisolone + pentoxifylline-matched placebo; prednisolone-matched placebo + pentoxifylline; or prednisolone + pentoxifylline. Groups received 28 days of treatment. The primary endpoint was 28-day mortality. Secondary endpoints were mortality or liver transplantation at 90 days and one year.

Neither intervention showed a significant reduction in 28-day mortality. Secondary analysis with adjustments for risk showed a reduction in 28-day mortality in the prednisolone groups. There was no difference between groups for mortality or liver transplantation at 90 days or one year.

Adverse events of death, infection, and acute kidney injury were reported in 42% of patients. Infection rates were higher in the prednisolone groups; however, attributable deaths were no different between groups.

Patients in this trial were younger, with a lower incidence of encephalopathy, infection, and acute kidney injury than those seen in similar trials, which could affect the rates of mortality seen here. Also, liver biopsy was not used, so patients may have been incorrectly included.

Bottom line: No difference was found in mortality or liver transplantation at 90 days and one year for prednisolone or pentoxifylline, although subanalysis showed there may be short-term benefit with prednisolone.

Citation: Thursz MR, Richardson P, Allison M, et al. Prednisolone or pentoxifylline for alcoholic hepatitis. New Engl J Med. 2015;372(17):1619-1628.

Clinical question: Does corticosteroid treatment shorten systemic illness in patients admitted to the hospital for community-acquired pneumonia (CAP)?

Background: Pneumonia is the third-leading cause of death worldwide. Studies have yielded conflicting data about the benefit of adding systemic corticosteroids for treatment of CAP.

Study design: Double-blind, multicenter, randomized, placebo-controlled trial.

Setting: Seven tertiary care hospitals in Switzerland.

Synopsis: Seven hundred eighty-four patients hospitalized for CAP were randomized to receive either oral prednisone 50 mg daily for seven days or placebo, with the primary endpoint being time to stable vital signs. The intention-to-treat analysis found that the median time to clinical stability was 1.4 days earlier in the prednisone group (hazard ratio 1.33, 95% CI 1.15-1.50, P<0.0001) and that length of stay and IV antibiotics were reduced by one day; this effect was valid across all PSI classes and was not dependent on age. Pneumonia-associated complications in the two groups did not differ at 30 days, though the prednisone group had a higher incidence of hyperglycemia requiring insulin.

Because all study locations were in a single, fairly homogenous northern European country, care should be taken when hospitalists apply these findings to their patient population, and the risks of hyperglycemia requiring insulin should be taken into consideration.

Bottom line: Systemic steroids may reduce the time to clinical stability in patients with CAP.

Citation: Blum CA, Nigro N, Briel M, et al. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicenter, double-blind, randomised, placebo-controlled trial. Lancet. 2015;385(9977):1511-1518.

Clinical question: Does corticosteroid treatment shorten systemic illness in patients admitted to the hospital for community-acquired pneumonia (CAP)?

Background: Pneumonia is the third-leading cause of death worldwide. Studies have yielded conflicting data about the benefit of adding systemic corticosteroids for treatment of CAP.

Study design: Double-blind, multicenter, randomized, placebo-controlled trial.

Setting: Seven tertiary care hospitals in Switzerland.

Synopsis: Seven hundred eighty-four patients hospitalized for CAP were randomized to receive either oral prednisone 50 mg daily for seven days or placebo, with the primary endpoint being time to stable vital signs. The intention-to-treat analysis found that the median time to clinical stability was 1.4 days earlier in the prednisone group (hazard ratio 1.33, 95% CI 1.15-1.50, P<0.0001) and that length of stay and IV antibiotics were reduced by one day; this effect was valid across all PSI classes and was not dependent on age. Pneumonia-associated complications in the two groups did not differ at 30 days, though the prednisone group had a higher incidence of hyperglycemia requiring insulin.

Because all study locations were in a single, fairly homogenous northern European country, care should be taken when hospitalists apply these findings to their patient population, and the risks of hyperglycemia requiring insulin should be taken into consideration.

Bottom line: Systemic steroids may reduce the time to clinical stability in patients with CAP.

Citation: Blum CA, Nigro N, Briel M, et al. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicenter, double-blind, randomised, placebo-controlled trial. Lancet. 2015;385(9977):1511-1518.

Clinical question: Does corticosteroid treatment shorten systemic illness in patients admitted to the hospital for community-acquired pneumonia (CAP)?

Background: Pneumonia is the third-leading cause of death worldwide. Studies have yielded conflicting data about the benefit of adding systemic corticosteroids for treatment of CAP.

Study design: Double-blind, multicenter, randomized, placebo-controlled trial.

Setting: Seven tertiary care hospitals in Switzerland.

Synopsis: Seven hundred eighty-four patients hospitalized for CAP were randomized to receive either oral prednisone 50 mg daily for seven days or placebo, with the primary endpoint being time to stable vital signs. The intention-to-treat analysis found that the median time to clinical stability was 1.4 days earlier in the prednisone group (hazard ratio 1.33, 95% CI 1.15-1.50, P<0.0001) and that length of stay and IV antibiotics were reduced by one day; this effect was valid across all PSI classes and was not dependent on age. Pneumonia-associated complications in the two groups did not differ at 30 days, though the prednisone group had a higher incidence of hyperglycemia requiring insulin.

Because all study locations were in a single, fairly homogenous northern European country, care should be taken when hospitalists apply these findings to their patient population, and the risks of hyperglycemia requiring insulin should be taken into consideration.

Bottom line: Systemic steroids may reduce the time to clinical stability in patients with CAP.

Citation: Blum CA, Nigro N, Briel M, et al. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicenter, double-blind, randomised, placebo-controlled trial. Lancet. 2015;385(9977):1511-1518.