brain

Importance: Concussion is a mild traumatic brain injury with associated abnormalities in brain function, rather than structural injury. An estimated 1.1 million to 1.9 million pediatric concussions occur annually in the US.

Objective: To determine the accuracy of clinical history and physical examination findings for identifying concussion in children and adolescents who have had a plausible mechanism of injury.

Data sources and study selection: PubMed, Embase, ClinicalTrials.gov, Cochrane Library, CINAHL, Web of Science, and Google Scholar were searched from January 2002 through December 2025 without language restrictions. Observational studies including patients aged 2 to 18 years evaluated for concussion in outpatient, emergency, or inpatient settings were included.

Data extraction and synthesis: Four reviewers independently extracted study characteristics and diagnostic accuracy data and assessed study quality with the Rational Clinical Examination levels of evidence.

Main outcomes and measures: Sensitivity, specificity, and likelihood ratios (LRs) for symptoms and physical signs associated with concussion were calculated using random-effects meta-analysis when summary measures were appropriate.

Results: Of 7110 screened abstracts, 23 studies (level 4 evidence; case-control design) met inclusion criteria. The presence of mental fog (LR, 11.8-12.0; specificity, 0.96), noise sensitivity (LR, 6.9; 95% CI, 3.6-13.1; specificity, 0.94), nausea (LR, 6.7; 95% CI, 3.1-14.6; specificity, 0.93), and light sensitivity (LR, 6.4; 95% CI, 2.1-19.7; specificity, 0.93) were most useful for increasing the likelihood of a concussion diagnosis. The absence of headache was the most useful symptom for decreasing the likelihood of concussion (LR, 0.20; 95% CI, 0.10-0.39; sensitivity, 0.74). Signs that increased the likelihood of concussion were abnormal near-point convergence, which is the inability to maintain ocular convergence on a near target (LR, 7.0; 95% CI, 2.0-24.9; specificity, 0.97); abnormal smooth pursuits, which are jerky, irregular eye movements when tracking a target (LR, 6.5; 95% CI, 2.4-17.5; specificity, 0.96); and saccades, which are inaccurate or slow eye movements with overshooting or undershooting when looking between 2 or more targets (LR, 4.8; 95% CI, 1.8-13.1; specificity, 0.92); however, none of these findings had a sensitivity of more than 0.40. A consensus statement by the International Conference on Concussion in Sport recommends the Sport Concussion Assessment Tool to systematize the comprehensive evaluation of patients with symptoms concerning for concussion.

Conclusions and relevance: While no single finding was sufficient to confirm or exclude concussion, the presence of mental fog, noise and light sensitivity, nausea, or ocular abnormalities were most useful to identify patients more likely to have had a concussion, while absence of a headache made a concussion less likely. These symptoms and signs are integrated into structured clinical assessments to support the clinical diagnosis and management of pediatric concussion.

Author/s:

Sonal N. Shah, Haley M. Chizuk, Hiu-Fai Fong

Pharmacologic Treatment of Perinatal Depression

Megan George — Fri, 21 Nov 2025 19:44:10 +0000

Date Added:

November 21, 2025

Journal/Publication:

JAMA Insights

Publication Date:

November 19, 2025

URL:

Pharmacologic Treatment of Perinatal Depression

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2025.17250

Keywords

Pharmacology

Perinatal Depression

Major Depressive Disorder

abuse

depression

PMID (1):

41259042

A review of the treatment of patients with perinatal depression with an emphasis on pharmalogic therapy. James W. Mold, MD, MPH

View

Approximately 1 in 7 individuals are affected by perinatal depression, defined as a depressive episode occurring during pregnancy or within 12 months after delivery. Although the diagnostic criteria are similar to those of major depressive disorder, perinatal depression may also include symptoms such as difficulty forming an emotional attachment with the fetus or infant, persistent doubts about parenting abilities, and intrusive thoughts of harm to self or infant.1 Mental health conditions are leading contributors to maternal mortality in the US; among reporting states, the rate of death from perinatal suicide ranges from 4.2 to 21.4 per 100 000 pregnancies.2 Untreated or undertreated perinatal depression increases other maternal risks, including limited engagement in care, impaired relationships, substance use, preeclampsia, and suicide, as well as fetal or neonatal risks, including preterm birth, low birth weight, and disrupted attachment with long-term developmental consequences.3 Individuals from marginalized communities, such as those who are non–English speaking, uninsured, or geographically isolated, experience a higher prevalence of perinatal depression and are at increased risk of underdiagnosis and undertreatment.3

Risk factors for perinatal depression include a personal or family history of depression, abuse, stressful life events, low socioeconomic status, adolescent or single parenthood, and pregnancy complications, such as preterm birth or pregnancy loss. Each factor individually confers only a small increase in risk, making accurate prediction based on clinical factors challenging.4 Therefore, to facilitate early identification and treatment, universal screening during and after pregnancy is recommended. The American College of Obstetricians and Gynecologists (ACOG) recently issued 2 Clinical Practice Guidelines on perinatal mental health, 1 on screening and diagnosis5 and 1 on treatment and management,3 highlighting opportunities for obstetricians to address existing health gaps.

Author/s:

Emily S. Miller, S. Karlene Cunningham, Lauren M. Osborne

Frontotemporal dementia

Erin Blanchette — Wed, 13 Dec 2023 17:01:01 +0000

Date Added:

December 13, 2023

Journal/Publication:

Canadian Medical Association Journal

Publisher:

Canadian Medical Association

Publication Date:

December 10, 2023

Issue:

Volume:

195

Pages:

E1660

URL:

Frontotemporal dementia

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1503/cmaj.230407

Keywords

Frontotemporal Dementia

neurology

dementia

Alzheimer Disease

PMID (1):

38081627

MeSH

Frontotemporal Dementia

alzheimer disease

Pick Disease of the Brain

Cognition

brain

Temporal Lobe

Behavioral Symptoms/diagnosis

Magnetic Resonance Imaging

A concise review of fronto-temporal dementia. James W. Mold, MD, MPH

Free full text

View

Frontotemporal dementia should be considered in adults aged 50–75 years presenting with behavioural or language changes. After Alzheimer disease, it is the second most common cause of dementia among adults younger than 65 years.1 Frontal and temporal lobe degeneration results in behavioural or language impairment.

Author/s:

Raul Medina-Rioja, Gina Gonzalez-Calderon, Mario Masellis

APOE ɛ4 Allele Testing and Risk of Alzheimer Disease

Devin Evans — Thu, 21 Jan 2021 06:00:00 +0000

Date Added:

January 21, 2021

Journal/Publication:

The Journal of the American Medical Association

Publication Date:

January 14, 2021

URL:

APOE ɛ4 Allele Testing and Risk of Alzheimer Disease

Type:

Clinical Decision Aids

Format:

Article

DOI (1):

10.1001/jama.2020.15085

Keywords

PMID (1):

33443531

MeSH

A brief review of the interpretation of APOE tests for diagnosing and predicting dementia of the Alzheimer’s type. James W. Mold, MD, MPH

Free full text

View

A 64-year-old man presented with concern about an abnormal genetic test result for apolipoprotein E (APOE) obtained through his primary care physician. He reported forgetfulness and word-finding difficulties for 3 years but performed all activities of daily living independently and was generally healthy. His father and maternal great aunt developed dementia in their 70s. Physical (including neurologic) examination, basic laboratory studies, and brain magnetic resonance imaging results were normal. The Short Test of Mental Status (STMS) score was 33 (maximal attainable score of 38 indicates best performance). Neuropsychological assessment showed average to above-average performance in all cognitive domains, accounting for age and education. Results of his genetic testing for APOE were reported as follows: “This individual possesses an apolipoprotein E genotype (3 and 4) that indicates, with high specificity, that Alzheimer’s disease is the cause of or a contributor to the observed dementia.”

Author/s:

Choudhury, Parichita, Ramanan, Vijay K., Boeve, Bradley F.

Preoperative Cardiac Risk Assessment

John Bayhi — Thu, 27 Feb 2020 15:22:21 +0000

Date Added:

February 27, 2020

Journal/Publication:

Mayo Clinic Proceedings

Publisher:

Elsevier B.V. / Mayo Foundation for Medical Education and Research

Publication Date:

February 24, 2020

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.mayocp.2019.08.013

Keywords

cardiac

preoperative assessment

MeSH

acute coronary syndrome

Cost-Benefit Analysis

This is a review of the latest recommendations regarding the cardiac assessment of patients needing surgery. James W. Mold, MD, MPH

Free full text

View

Major adverse cardiac events are common causes of perioperative mortality and major morbidity. Preventing these complications requires thorough preoperative risk assessment and postoperative monitoring of at-risk patients. Major guidelines recommend assessment based on a validated risk calculator that incorporates patient- and procedure-specific factors. American and European guidelines define when stress testing is needed on the basis of functional capacity assessment. Favoring cost-effectiveness, Canadian guidelines instead recommend obtaining brain natriuretic peptide or N-terminal prohormone of brain natriuretic peptide levels to guide postoperative screening for myocardial injury or infarction. When conditions such as acute coronary syndrome, severe pulmonary hypertension, and decompensated heart failure are identified, nonemergent surgery should be postponed until the condition is appropriately managed. There is an evolving role of biomarkers and myocardial injury after noncardiac surgery to enhance risk stratification, but the effect of interventions guided by these strategies is unclear.

Author/s:

Raslau, D, Bierle, DM, Stephenson, CR, Mikhail, MA, Kebede, EB, Mauck, KF

Subconcussive Football Hits May Leave a Telltale Signature of Brain Damage

John Bayhi — Fri, 04 Oct 2019 13:19:44 +0000

Date Added:

October 4, 2019

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

October 3, 2019

URL:

Subconcussive Football Hits May Leave a Telltale Signature of Brain Damage

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jama.2019.15361

Keywords

PMID (1):

31580382

MeSH

Humans

male

football

Chronic Traumatic Encephalopathy

Diffuse Axonal Injury

White Matter

Diffusion Magnetic Resonance Imaging

Head Protective Devices

brain concussion

brain

Craniocerebral Trauma

Soccer

retrospective studies

cohort studies

Even sub-concussive head injuries can injure the brains of football players. James W. Mold, MD, MPH

Free full text

View

College football players in the United States endure over 1000 head hits every season. Although many don’t produce symptoms such as dizziness or blurred vision that often accompany frank concussion, these “clinically silent” hits are associated with the same type of brain damage as concussion, according to a recent Science Advances study.

Author/s:

Sancar, F

Randomized Controlled Trial of Iron-Fortified versus Low-Iron Infant Formula: Developmental Outcomes at 16 Years

Brian Desmarais — Mon, 19 Aug 2019 15:00:24 +0000

Date Added:

August 19, 2019

Journal/Publication:

Journal of Pediatrics

Publication Date:

June 25, 2019

URL:

Randomized Controlled Trial of Iron-Fortified versus Low-Iron Infant Formula: Developmental Outcomes at 16 Years

Type:

Clinical Research Results

Format:

Article

Keywords

MeSH

Anemia, Iron-Deficiency

infants

Perhaps we are overprescribing iron fortified formulas for infants without iron deficiency anemia. James W. Mold, MD, MPH

Free full text

View

OBJECTIVES:

To test differences in cognitive outcomes among adolescents randomly assigned previously as infants to iron-fortified formulaor low-iron formula as part of an iron deficiency anemia prevention trial.

STUDY DESIGN:

Infants were recruited from community clinics in low- to middle-income neighborhoods in Santiago, Chile. Entrance criteria included term, singleton infants; birth weight of ≥3.0 kg; and no major congenital anomalies, perinatal complications, phototherapy, hospitalization >5 days, chronic illness, or iron deficiency anemia at 6 months. Six-month-old infants were randomized to iron-fortified(12 mg/L) or low-iron (2.3 mg/L) formula for 6 months. At 16 years of age, cognitive ability, visual perceptual ability, visual memory, and achievement in math, vocabulary, and comprehension were assessed, using standardized measures. We compared differences in developmental test scores according to randomization group.

RESULTS:

At the follow-up assessment, the 405 participants averaged 16.2 years of age and 46% were male. Those randomized to iron-fortified formula had lower scores than those randomized to low-iron formula for visual memory, arithmetic achievement, and reading comprehension achievement. For visual motor integration, there was an interaction with baseline infancy hemoglobin, such that the iron-fortified group outperformed the low-iron group when 6-month hemoglobin was low and underperformed when 6-month hemoglobin was high.

CONCLUSIONS:

Adolescents who received iron-fortified formula as infants from 6 to 12 months of age at levels recommended in the US had poorer cognitive outcomes compared with those who received a low-iron formula. The prevention of iron deficiency anemia in infancy is important for brain development. However, the optimal level of iron supplementation in infancy is unclear.

TRIAL REGISTRATION:

Clinicaltrials.gov: NCT01166451.

Author/s:

Gahagan, S., Delker, E., Blanco, E., Burrows, R., Lozoff, B.

Some benefits from donepezil in Alzheimer’s disease

Brian Desmarais — Thu, 20 Jun 2019 12:57:52 +0000

Date Added:

June 20, 2019

Journal/Publication:

British Journal of General Practice

Publication Date:

March 1, 2013

Issue:

Volume:

608

Pages:

150

URL:

Some benefits from donepezil in Alzheimer’s disease

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.3399/bjgp13X664333

Keywords

MeSH

Cholinesterase Inhibitors

Synaptic Transmission

brain

RPR Commentary: This is a summary of the data available to date on the effectiveness of donepezil for treatment of patients with Alzheimer’s Disease. I told patients and their families that if a small improvement in functional abilities would make a huge difference in quality of life (e.g. could remain at home 6 months longer), it is probably worth trying donepezil. Otherwise the expense and side effects are not worth the very small benefit. 5 to 10mg seems to be enough. James W. Mold, MD, MPH

Free full text

View

CLINICAL QUESTION

How effective is exercise-based cardiac rehabilitation on mortality, morbidity, and health-related quality of life (QOL) in patients with coronary heart disease (CHD)?

BOTTOM LINE

Compared to usual care, in medium to longer-term follow-up (≥12 months) exercise-based cardiac rehabilitation was found to be effective in reducing overall and cardiovascular mortality in patients with CHD, and appeared to reduce the risk of hospital admissions in the shorter term (<12 months follow-up). There was no reduction seen in the risk of total myocardial infarction, coronary artery bypass graft, or percutaneous transluminal coronary angioplasty.

Author/s:

McAvoy, B.R.