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Rogan A, Sik A, Dickinson E, Patel V, Peckler B, McQuade D, Larsen PD. Diagnostic performance of S100B as a rule-out test for intracranial pathology in head-injured patients presenting to the emergency department who meet NICE Head Injury Guideline criteria for CT-head scan. Emerg Med J 2023; 40:159-166. [PMID: 36323496 DOI: 10.1136/emermed-2022-212549] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 09/27/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Traumatic brain injury is a common ED presentation. CT-head utilisation is escalating, exacerbating resource pressure in the ED. The biomarker S100B could assist clinicians with CT-head decisions by excluding intracranial pathology. Diagnostic performance of S100B was assessed in patients meeting National Institute of Health and Clinical Excellence Head Injury Guideline (NICE HIG) criteria for CT-head within 6 and 24 hours of injury. METHODS This multicentre prospective observational study included adult patients presenting to the ED with head injuries between May 2020 and June 2021. Informed consent was obtained from patients meeting NICE HIG CT-head criteria. A venous blood sample was collected and serum was tested for S100B using a Cobas Elecsys-S100 module; >0.1 µg/mL was the threshold used to indicate a positive test. Intracranial pathology reported on CT-head scan by the duty radiologist was used as the reference standard to review diagnostic performance. RESULTS This study included 265 patients of whom 35 (13.2%) had positive CT-head findings. Within 6 hours of injury, sensitivity of S100B was 93.8% (95% CI 69.8% to 99.8%) and specificity was 30.8% (22.6% to 40.0%). Negative predictive value (NPV) was 97.3% (95% CI 84.2% to 99.6%) and area under the curve (AUC) was 0.73 (95% CI 0.61 to 0.85; p=0.003). Within 24 hours of injury, sensitivity was 82.9% (95% CI 66.4% to 93.44%) and specificity was 43.0% (95% CI 36.6% to 49.7%). NPV was 94.29% (95% CI 88.7% to 97.2%) and AUC was 0.65 (95% CI 0.56 to 0.74; p=0.046). Theoretically, use of S100B as a rule-out test would have reduced CT-head scans by 27.1% (95% CI 18.9% to 36.8%) within 6 hours and 37.4% (95% CI 32.0% to 47.2%) within 24 hours. The risk of missing a significant injury with this approach would have been 0.75% (95% CI 0.0% to 2.2%) within 6 hours and 2.3% (95% CI 0.5% to 4.1%) within 24 hours. CONCLUSION Within 6 hours of injury, S100B performed well as a diagnostic test to exclude significant intracranial pathology in low-risk patients presenting with head injury. In theory, if used in addition to NICE HIGs, CT-head rates could reduce by one-quarter with a potential miss rate of <1%.
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Affiliation(s)
- Alice Rogan
- Department of Surgery and Anaesthesia, University of Otago Wellington, Wellington, New Zealand .,Emergency Department, Wellington Regional Hospital, Newtown, New Zealand
| | - Annabelle Sik
- Department of Surgery and Anaesthesia, University of Otago Wellington, Wellington, New Zealand
| | - Emily Dickinson
- Emergency Department, Wellington Regional Hospital, Newtown, New Zealand
| | - Vimal Patel
- Emergency Department, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - Brad Peckler
- Emergency Department, Wellington Regional Hospital, Newtown, New Zealand
| | - David McQuade
- Department of Surgery and Anaesthesia, University of Otago Wellington, Wellington, New Zealand.,Emergency Department, Wellington Regional Hospital, Newtown, New Zealand
| | - Peter D Larsen
- Department of Surgery and Anaesthesia, University of Otago Wellington, Wellington, New Zealand
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Merezhinskaya N, Mallia RK, Park D, Millian-Morell L, Barker FM. Photophobia Associated with Traumatic Brain Injury: A Systematic Review and Meta-analysis. Optom Vis Sci 2021; 98:891-900. [PMID: 34354013 DOI: 10.1097/opx.0000000000001757] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE This study reports the prevalence and relative risk of photophobia in patients with traumatic brain injury (TBI). OBJECTIVES This study aimed to conduct a systematic review and meta-analysis to determine the prevalence and relative risk of photophobia in patients with TBI. DATA SOURCES Three databases were used for literature search: PubMed, EMBASE, and Cochrane Library. STUDY APPRAISAL AND SYNTHESIS METHODS Publications reporting the prevalence of photophobia after TBI in patients of any age were included. A series of meta-regression analyses based on a generalized linear mixed model was performed to identify potential sources of heterogeneity in the prevalence estimates. RESULTS Seventy-five eligible publications were identified. The prevalence of photophobia was 30.46% (95% confidence interval [CI], 20.05 to 40.88%) at 1 week after the injury. Prevalence decreased to 19.34% (95% CI, 10.40 to 28.27%) between 1 week and 1 month after TBI and to 13.51% (95% CI, 5.77 to 21.24%) between 1 and 3 months after the injury. The rapid decrease in the prevalence of photophobia in the first 3 months after a TBI injury was significant (P < .001). Three months post-TBI, the prevalence of photophobia leveled off to a near plateau with nonsignificant variability, increasing between 3 and 6 months (17.68%; 95% CI, 9.05 to 26.32%) and decreasing between 6 and 12 months since TBI (14.85%; 95% CI, 6.80 to 22.90%). Subgroup analysis of 14 publications that contained control data showed that the estimated risk ratio for photophobia was significantly higher in the TBI than in the control group during the entire 12 months after TBI. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS This study demonstrates that photophobia is a frequent complaint after TBI, which largely resolves for many individuals within 3 months after the injury. For some patients, however, photophobia can last up to 12 months and possibly longer. Developing an objective quantitative methodology for measuring photophobia, validating a dedicated photophobia questionnaire, and having a specific photophobia International Classification of Diseases, Tenth Revision code would greatly improve data gathering and analysis.
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Affiliation(s)
- Natalya Merezhinskaya
- Department of Defense/Veterans Affairs Vision Center of Excellence, Bethesda, Maryland
| | - Rita K Mallia
- Department of Defense/Veterans Affairs Vision Center of Excellence, Bethesda, Maryland
| | - DoHwan Park
- University of Maryland, Baltimore County, Maryland
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3
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Rashid H, Mishra S, Dobbin N. Management of sport-related concussion in emergency departments in England: a multi-center study. Brain Inj 2021; 35:1035-1042. [PMID: 34288793 DOI: 10.1080/02699052.2021.1945146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To establish the current knowledge of sport-related concussion (SRC) management of clinicians in emergency departments in the North West of England. METHODS A cross-sectional, multi-center study design was used and included emergency department clinicians (EDCs) across 15 centers in the North West of England. A 22-question survey was issued with questions focused on the 5th International Conference on Concussion Consensus Statement. Absolute and percentages were presented, and comparisons in knowledge of guidelines and confidence between EDCs were made using the Kruskal-Wallis test. RESULTS Of an estimated 300 EDCs, 111 (37%) responded. Thirty (27%) were aware of the guidelines, whilst 63 (57%) had heard of a graduated return-to-sport protocol. Physical rest was advised by 106 (95%) respondents, with 68 (61%) advising cognitive rest and 47 (42%) providing written advice. There was no difference (p > .05) in awareness of SRC guidelines or confidence between clinician grade, with most receiving no SRC training. CONCLUSIONS There is a lack of knowledge amongst EDCs in the North West of England in managing and providing discharge advice to patients with SRC. This is likely due to the limited awareness of guidelines and training, and therefore further education delivery on SRC management guidelines is required.
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Affiliation(s)
- Haroon Rashid
- Department of Emergency Medicine, Manchester Royal Infirmary, Manchester, UK.,Department of Health Professions, Manchester Metropolitan University, Manchester, UK
| | - Smarak Mishra
- Department of Health Professions, Manchester Metropolitan University, Manchester, UK
| | - Nick Dobbin
- Department of Health Professions, Manchester Metropolitan University, Manchester, UK
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4
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Gaudet LA, Eliyahu L, Beach J, Mrazik M, Cummings G, Voaklander DC, Rowe BH. Workers' recovery from concussions presenting to the emergency department. Occup Med (Lond) 2020; 69:419-427. [PMID: 31340019 DOI: 10.1093/occmed/kqz089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The emergency department (ED) is the first point of care for many patients with concussion, and post-concussion syndrome can impact vocational outcomes like successful return to work. Evaluation of concussion in general adult populations is needed. AIMS To document the occurrence and outcomes of work-related concussion presenting to the ED for treatment. METHODS This study enrolled adults presenting with concussion to three urban Canadian EDs. Baseline ED interviews, physician questionnaires and patient phone interviews at 30 and 90 days documented work-related events, ED management, discharge advice, patient adherence and symptom severity. Work-related injury and return to work were modelled using logistic or linear regression, as appropriate. RESULTS Overall, 172 enrolled workers completed at least one follow-up. Work-related concussions were uncommon (n = 28). Most employees (80%) missed at least 1 day of work (median = 7; interquartile range: 3-14). Most (91%) employees returned to work within 90 days, while 41% reported persistent symptoms. Manual labour and self-reported history of attention deficit hyperactivity disorder were associated with work-related concussion, while days of missed work increased with marital status (divorced), history of sleep disorder and physician's advice to avoid work. CONCLUSION Work-related concussions are infrequent; however, most workers who sustain a concussion will miss work, and many return while still experiencing symptoms. Work-related concussion and days of missed work are mainly affected by non-modifiable factors. Workers, employers and the workers' compensation system should take necessary precautions to ensure that workers return to work safely and successfully following a concussion.
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Affiliation(s)
- L A Gaudet
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - L Eliyahu
- Department of Family Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - J Beach
- College of Physicians & Surgeons of Alberta, Edmonton, Alberta, Canada.,Division of Preventive Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - M Mrazik
- Department of Educational Psychology, University of Alberta, Edmonton, Alberta, Canada
| | - G Cummings
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - D C Voaklander
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - B H Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
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5
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Recommendations for the Emergency Department Prevention of Sport-Related Concussion. Ann Emerg Med 2019; 75:471-482. [PMID: 31326205 DOI: 10.1016/j.annemergmed.2019.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 12/31/2022]
Abstract
Sport-related concussion refers to the subset of concussive injuries occurring during sport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion. This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.
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Brown AM, Twomey DM, Wong Shee A. Evaluating mild traumatic brain injury management at a regional emergency department. Inj Prev 2018; 24:390-394. [PMID: 29866717 DOI: 10.1136/injuryprev-2018-042865] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/14/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND Emergency departments (EDs) are usually the first point of contact, and often the only medical service available, for patients with mild traumatic brain injury (mTBI) in rural and regional areas. Clinical practice guidelines (CPGs) have been created to ensure best practice management of mTBI in EDs. Adherence to mTBI CPGs has rarely been evaluated in rural and regional areas. AIM The aim of this paper was to assess a regional health service's adherence to their mTBI CPG. METHODS This was a 12-month retrospective audit of 1280 ED records of patients ≥16 years presenting with mTBI to a regional Australian ED. Case selection used the Victorian Admitted Episodes Dataset codes for suspected head injury: principal diagnosis codes (S00-T98), concussive injury recorded in diagnosis codes (S06.00-S06.05) and unintentional external cause code (V00-X59). The data were collected to determine 4-hour observation rates, CT scan rates, safe discharge and appropriate referral documentation. RESULTS Fewer people received a CT scan than qualified (n=245, 65.3%), only 45% had 4-hour observations recorded, safe discharge was documented in 74.1% of cases and 33% received educational resources. DISCUSSION/CONCLUSION Several key elements for the management of mTBI were under-recorded, particularly 4-hour observations, safe discharge and education. Acquired brain injury clinic referrals were received in overwhelmingly fewer cases than had a CT scan (n=19, 6.3%). Overall, this study suggests that the regional health service does not currently fully adhere to the CPG and that the referral services are potentially underutilised.
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Affiliation(s)
- Ashlee Maree Brown
- School of Health Sciences and Psychology, Federation University Australia, Ballarat, Victoria, Australia
| | - Dara M Twomey
- School of Health Sciences and Psychology, Federation University Australia, Ballarat, Victoria, Australia
| | - Anna Wong Shee
- School of Medicine, Deakin Rural Health, Deakin University, Warrnambool, Victoria, Australia
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Baron Shahaf D, Bar S, Leiba R, Dvir V, Shavit I. Unscheduled adolescents return to the emergency department following acute concussion. Brain Inj 2018; 32:331-334. [PMID: 29341786 DOI: 10.1080/02699052.2018.1425914] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Emergency department (ED) visits due to concussion have increased over recent years. We aimed to identify variables associated with unscheduled adolescents return to the ED. METHODS A retrospective cohort study was conducted. All children aged 11 to 18 years who were admitted to the ED due to concussion between 2011 and 2016 were included. Multivariable logistic regression was performed to identify predictors of ED return. RESULTS Overall, 616 adolescents were admitted to the ED due to concussion. Within the first week from discharge, 37/616 (6%) patients returned unscheduled to the ED, 21 (3.4%) during the first 48 hours and 16 (2.6%) during the following 3-7 days. Age, gender, ethnicity, diagnosis of concussion on first visit and length-of-stay in the ED were not associated with unscheduled ED returns. Variables that were independently associated with increased odds for an unscheduled ED return included two or more symptoms of concussion [odds ratio (OR): 2.81; 95% confidence interval (CI): (1.16-6.82)], bicycle or motor vehicle accident (OR: 3.48; 95% CI: 1.29-9.4), and performance of CT scan on first visit (OR: 2.47; 95% CI: 1.12-5.48). CONCLUSIONS The findings suggest that certain variables on the first ED visit can predict an unscheduled return visit in adolescents. ABBREVIATIONS Emergency department (ED); Length of stay (LOS); computerised tomography (CT).
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Affiliation(s)
- Dana Baron Shahaf
- a Department of Anesthesiology , Rambam Health Care Campus , Haifa , Israel
| | - Sapir Bar
- b Rappaport faculty of Medicine , Technion-institute of technology , Haifa , Israel
| | - Ronit Leiba
- c Quality of Care Unit , Rambam Health Care Campus , Haifa , Israel
| | - Vered Dvir
- a Department of Anesthesiology , Rambam Health Care Campus , Haifa , Israel
| | - Itai Shavit
- d Emergency Department , Ruth Children's Hospital, Rambam Health Care Campus , Haifa , Israel
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8
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Brown AM, Twomey DM, Wong Shee A. Are patients with concussion getting optimal discharge advice at a regional emergency department? Aust J Rural Health 2017; 26:134-135. [PMID: 29105939 DOI: 10.1111/ajr.12397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Ashlee M Brown
- School of Health Sciences & Psychology, Federation University Australia, Ballarat, Victoria, Australia
| | - Dara M Twomey
- School of Health Sciences & Psychology, Federation University Australia, Ballarat, Victoria, Australia
| | - Anna Wong Shee
- Ballarat Health Services, Drummond Street North, Ballarat, Victoria, Australia
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9
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Lasry O, Liu EY, Powell GA, Ruel-Laliberté J, Marcoux J, Buckeridge DL. Epidemiology of recurrent traumatic brain injury in the general population: A systematic review. Neurology 2017; 89:2198-2209. [PMID: 29070664 DOI: 10.1212/wnl.0000000000004671] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 09/05/2017] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To comprehensively assess recurrent traumatic brain injury (rTBI) risk and risk factors in the general population. METHODS We systematically searched MEDLINE, EMBASE, and the references of included studies until January 16, 2017, for general population observational studies reporting rTBI risk or risk factors. Estimates were not meta-analyzed due to significant methodologic heterogeneity between studies, which was evaluated using meta-regression. RESULTS Twenty-two studies reported recurrence risk and 11 reported on 27 potential risk factors. rTBI risk was heterogeneous and varied from 0.43% (95% confidence interval [CI] 0.19%-0.67%) to 41.92% (95% CI 34.43%-49.40%), with varying follow-up periods (3 days-55 years). Median time to recurrence ranged from 0.5 to 3.8 years. In studies where cases were ascertained from multiple points of care, at least 5.50% (95% CI 4.80%-6.30%) of patients experienced a recurrence after a 1-year follow-up. Studies that used administrative data/self-report surveys to ascertain cases tended to report higher risk. Risk factors measured at time of index traumatic brain injury (TBI) that were significantly associated with rTBI in more than one study were male sex, prior TBI before index case, moderate or severe TBI, and alcohol intoxication. Risk factors reported in a single study that were significantly associated with rTBI were epilepsy, not seeking medical care, and multiple factors indicative of low socioeconomic status. CONCLUSIONS rTBI is an important contributor to the general population TBI burden. Certain risk factors can help identify individuals at higher risk of these repeated injuries. However, higher quality research that improves on rTBI surveillance methodology is needed.
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Affiliation(s)
- Oliver Lasry
- From the Department of Epidemiology, Biostatistics and Occupational Health (O.L., E.Y.L., G.A.P., D.L.B.), and Department of Neurology and Neurosurgery, McGill University Health Centre (O.L., J.M.), McGill University, Montreal; and Faculty of Medicine (J.R.-L.), Université Laval, Canada.
| | - Erin Y Liu
- From the Department of Epidemiology, Biostatistics and Occupational Health (O.L., E.Y.L., G.A.P., D.L.B.), and Department of Neurology and Neurosurgery, McGill University Health Centre (O.L., J.M.), McGill University, Montreal; and Faculty of Medicine (J.R.-L.), Université Laval, Canada
| | - Guido Antonio Powell
- From the Department of Epidemiology, Biostatistics and Occupational Health (O.L., E.Y.L., G.A.P., D.L.B.), and Department of Neurology and Neurosurgery, McGill University Health Centre (O.L., J.M.), McGill University, Montreal; and Faculty of Medicine (J.R.-L.), Université Laval, Canada
| | - Jessica Ruel-Laliberté
- From the Department of Epidemiology, Biostatistics and Occupational Health (O.L., E.Y.L., G.A.P., D.L.B.), and Department of Neurology and Neurosurgery, McGill University Health Centre (O.L., J.M.), McGill University, Montreal; and Faculty of Medicine (J.R.-L.), Université Laval, Canada
| | - Judith Marcoux
- From the Department of Epidemiology, Biostatistics and Occupational Health (O.L., E.Y.L., G.A.P., D.L.B.), and Department of Neurology and Neurosurgery, McGill University Health Centre (O.L., J.M.), McGill University, Montreal; and Faculty of Medicine (J.R.-L.), Université Laval, Canada
| | - David L Buckeridge
- From the Department of Epidemiology, Biostatistics and Occupational Health (O.L., E.Y.L., G.A.P., D.L.B.), and Department of Neurology and Neurosurgery, McGill University Health Centre (O.L., J.M.), McGill University, Montreal; and Faculty of Medicine (J.R.-L.), Université Laval, Canada
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10
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Postconcussion Symptoms as a Marker of Delayed Recovery in Children and Youth Who Recently Sustained a Concussion: A Brief Report. Clin J Sport Med 2017; 27:325-327. [PMID: 27347856 DOI: 10.1097/jsm.0000000000000355] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To identify predictors of delayed recovery in children who sustained a concussion and sought care in a pediatric hospital. DESIGN Retrospective cohort study design. SETTING Montreal Children's Hospital Concussion Clinic database. PATIENTS Children who sustained a concussion and sought care within 10 days of the injury, with complete medical history and Postconcussion Symptom Scale (PCSS) score available. INDEPENDENT VARIABLES Total symptom score on the PCSS, sex, age, history of concussion, sleep disturbances, anxiety, learning disabilities, attention problems, and depression. MAIN OUTCOME MEASURE Delayed recovery (28 days or more). RESULTS A total of 213 children (F = 76, M = 138) with a mean age of 13.89 ± 2.55 years were included. Only total PCSS score at 10 days postinjury was identified as a significant predictor of delayed recovery (odds ratio: 1.019, P = 0.01). CONCLUSIONS This study demonstrates the potential for clinicians to identify, with the sole use of the PCSS, children at risk of experiencing symptoms for longer periods of time.
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11
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Persistent problems 1 year after mild traumatic brain injury: a longitudinal population study in New Zealand. Br J Gen Pract 2017; 66:e16-23. [PMID: 26719482 DOI: 10.3399/bjgp16x683161] [Citation(s) in RCA: 154] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Mild traumatic brain injury (mTBI) is a common problem in general practice settings, yet previous research does not take into account those who do not attend hospital after injury. This is important as there is evidence that effects may be far from mild. AIM To determine whether people sustain any persistent effects 1 year after mTBI, and to identify the predictors of health outcomes. DESIGN AND SETTING A community-based, longitudinal population study of an mTBI incidence cohort (n = 341) from a mixed urban and rural region (Hamilton and Waikato Districts) of the North Island of New Zealand (NZ). METHOD Adults (>16 years) completed assessments of cognitive functioning, global functioning, post-concussion symptoms, mood, and quality of life over the year after injury. RESULTS Nearly half of participants (47.9%) reported experiencing four or more post-concussion symptoms 1 year post-injury. Additionally, 10.9% of participants revealed very low cognitive functioning. Levels of anxiety, depression, or reduced quality of life were comparable with the general population. Having at least one comorbidity, history of brain injury, living alone, non-white ethnic group, alcohol and medication use, and being female were significant predictors of poorer outcomes at 12 months. CONCLUSION Although some people make a spontaneous recovery after mTBI, nearly half continue to experience persistent symptoms linked to their injury. Monitoring of recovery from mTBI may be needed and interventions provided for those experiencing persistent difficulties. Demographic factors and medical history should be taken into account in treatment planning.
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Eliyahu L, Kirkland S, Campbell S, Rowe BH. The Effectiveness of Early Educational Interventions in the Emergency Department to Reduce Incidence or Severity of Postconcussion Syndrome Following a Concussion: A Systematic Review. Acad Emerg Med 2016; 23:531-42. [PMID: 26825870 DOI: 10.1111/acem.12924] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 12/30/2015] [Accepted: 01/04/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Concussions or mild traumatic brain injury are a major public health concern accounting for 85% of all brain injuries. Postconcussion syndrome (PCS) has been found to affect between 15 and 25% of patients with concussion 1 year after the initial injury. The goal of this review is to assess the effectiveness of early educational information or interventions provided in the emergency department on the onset and/or severity of PCS. METHODS A comprehensive literature search strategy involving seven electronic databases was developed. A grey literature search of Google Scholar, recent conference proceedings in emergency medicine, bibliographies of included studies, and clinical trial registries was also performed. The citation list was reviewed independently by two reviewers; no restrictions on publication status or language of publication were applied. The Cochrane risk-of-bias tool and the Newcastle-Ottawa scale were used to assess quality. RESULTS From 1,325 citations retrieved, four RCTs and one controlled clinical trial met inclusion criteria. Interventions identified in these studies included: educational information sheets, with or without telephone or in-person follow-up, and one study on bed rest. While rarely requested, one study offered referrals and additional treatment, if needed. None of the studies were deemed to be high quality. Heterogeneity among outcome reporting, follow-up dates and interventions used precluded a pooled analysis. Overall, only two of the five included studies involving adult patients receiving early educational interventions reported a significant improvement in PCS symptoms. No reduction in PCS symptoms was found in the study on bed rest interventions. CONCLUSION Limited evidence exists regarding the effectiveness of early educational interventions following concussion. Standardization of the interventions, outcome measures, and follow-up periods would make quantitative comparisons more valid. Moreover, higher-quality research in the field of early interventions for patients in the acute care setting is urgently required.
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Affiliation(s)
- Leeor Eliyahu
- Department of Emergency Medicine; University of Alberta; Edmonton Alberta Canada
- School of Public Health; University of Alberta; Edmonton Alberta Canada
| | - Scott Kirkland
- Department of Emergency Medicine; University of Alberta; Edmonton Alberta Canada
| | - Sandy Campbell
- J. W. Scott Health Sciences Library; University of Alberta; Edmonton Alberta Canada
| | - Brian H. Rowe
- Department of Emergency Medicine; University of Alberta; Edmonton Alberta Canada
- School of Public Health; University of Alberta; Edmonton Alberta Canada
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13
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Post-concussive syndrome after mild head trauma: epidemiological features in Tunisia. Eur J Trauma Emerg Surg 2016; 43:747-753. [DOI: 10.1007/s00068-016-0656-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 03/01/2016] [Indexed: 10/22/2022]
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14
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Fralick M, Thiruchelvam D, Tien HC, Redelmeier DA. Risk of suicide after a concussion. CMAJ 2016; 188:497-504. [PMID: 26858348 DOI: 10.1503/cmaj.150790] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Head injuries have been associated with subsequent suicide among military personnel, but outcomes after a concussion in the community are uncertain. We assessed the long-term risk of suicide after concussions occurring on weekends or weekdays in the community. METHODS We performed a longitudinal cohort analysis of adults with diagnosis of a concussion in Ontario, Canada, from Apr. 1, 1992, to Mar. 31, 2012 (a 20-yr period), excluding severe cases that resulted in hospital admission. The primary outcome was the long-term risk of suicide after a weekend or weekday concussion. RESULTS We identified 235,110 patients with a concussion. Their mean age was 41 years, 52% were men, and most (86%) lived in an urban location. A total of 667 subsequent suicides occurred over a median follow-up of 9.3 years, equivalent to 31 deaths per 100,000 patients annually or 3 times the population norm. Weekend concussions were associated with a one-third further increased risk of suicide compared with weekday concussions (relative risk 1.36, 95% confidence interval 1.14-1.64). The increased risk applied regardless of patients' demographic characteristics, was independent of past psychiatric conditions, became accentuated with time and exceeded the risk among military personnel. Half of these patients had visited a physician in the last week of life. INTERPRETATION Adults with a diagnosis of concussion had an increased long-term risk of suicide, particularly after concussions on weekends. Greater attention to the long-term care of patients after a concussion in the community might save lives because deaths from suicide can be prevented.
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Affiliation(s)
- Michael Fralick
- Department of Medicine (Fralick, Redelmeier), University of Toronto; Evaluative Clinical Sciences (Fralick, Thiruchelvam, Tien, Redelmeier), Sunnybrook Research Institute; Institute for Clinical Evaluative Sciences (Thiruchelvam); Canadian Forces Health Services (Tien), Toronto, Ont
| | - Deva Thiruchelvam
- Department of Medicine (Fralick, Redelmeier), University of Toronto; Evaluative Clinical Sciences (Fralick, Thiruchelvam, Tien, Redelmeier), Sunnybrook Research Institute; Institute for Clinical Evaluative Sciences (Thiruchelvam); Canadian Forces Health Services (Tien), Toronto, Ont
| | - Homer C Tien
- Department of Medicine (Fralick, Redelmeier), University of Toronto; Evaluative Clinical Sciences (Fralick, Thiruchelvam, Tien, Redelmeier), Sunnybrook Research Institute; Institute for Clinical Evaluative Sciences (Thiruchelvam); Canadian Forces Health Services (Tien), Toronto, Ont
| | - Donald A Redelmeier
- Department of Medicine (Fralick, Redelmeier), University of Toronto; Evaluative Clinical Sciences (Fralick, Thiruchelvam, Tien, Redelmeier), Sunnybrook Research Institute; Institute for Clinical Evaluative Sciences (Thiruchelvam); Canadian Forces Health Services (Tien), Toronto, Ont.
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15
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de Guise E, Bélanger S, Tinawi S, Anderson K, LeBlanc J, Lamoureux J, Audrit H, Feyz M. Usefulness of the rivermead postconcussion symptoms questionnaire and the trail-making test for outcome prediction in patients with mild traumatic brain injury. APPLIED NEUROPSYCHOLOGY-ADULT 2015; 23:213-22. [DOI: 10.1080/23279095.2015.1038747] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Elaine de Guise
- Psychology Department, University of Montreal, Montreal, Quebec, Canada
- Neurology and Neurosurgery Department, McGill University, Montreal, Quebec, Canada
| | - Sara Bélanger
- Traumatic Brain Injury Program, McGill University Health Centre-Montreal General Hospital, Montreal, Quebec, Canada
| | - Simon Tinawi
- Rehabilitation Medicine Department, McGill University Health Centre-Montreal General Hospital, Montreal, Quebec, Canada
| | - Kirsten Anderson
- Psychology Department, University of Montreal, Montreal, Quebec, Canada
| | - Joanne LeBlanc
- Traumatic Brain Injury Program, McGill University Health Centre-Montreal General Hospital, Montreal, Quebec, Canada
| | - Julie Lamoureux
- Social and Preventive Medicine Department, University of Montreal, Montreal, Quebec, Canada
| | - Hélène Audrit
- Psychology Department, University of Montreal, Montreal, Quebec, Canada
| | - Mitra Feyz
- Traumatic Brain Injury Program, McGill University Health Centre-Montreal General Hospital, Montreal, Quebec, Canada
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16
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Norris JN, Smith S, Harris E, Labrie DW, Ahlers ST. Characterization of acute stress reaction following an IED blast-related mild traumatic brain injury. Brain Inj 2015; 29:898-904. [PMID: 25955118 DOI: 10.3109/02699052.2015.1022879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVE To characterize an acute stress reaction (ASR) following an improvised explosive device (IED) blast-related mild traumatic brain injury (mTBI). RESEARCH DESIGN Participants were male, US military personnel treated in Afghanistan within 4 days following an IED-related mTBI event (n = 239). METHODS AND PROCEDURES Demographics, diagnosis of ASR, injury history and self-reported mTBIs, blast exposures and psychological health histories were recorded. MAIN OUTCOMES AND RESULTS In total, 12.5% of patients met ASR criteria. Patients with ASR were significantly younger and junior in rank (p < 0.05). Patients with ASR were more likely to experience the IED-blast while dismounted, report a loss of consciousness (LOC) and higher pain levels (p < 0.05). Adjusting for age and rank, multivariate logistic regression showed an association between mTBI history and ASR (AOR = 1.405; 95% CI = 1.105-1.786, p < 0.01). Adjusting for mechanism of injury (dismounted vs. mounted), LOC and pain, multivariate logistic regression showed an association between mTBI history and ASR (AOR = 1.453; 95% CI = 1.132-1.864, p < 0.01). Prior blast exposure and past psychological health issues were not associated with ASR. CONCLUSIONS A history of multiple mTBIs is associated with increased risk of ASR. Future research is warranted.
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Affiliation(s)
- Jacob N Norris
- Neurotrauma Department, Naval Medical Research Center , Silver Spring, MD , USA
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17
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Williams RM, Welch CE, Parsons JT, McLeod TCV. Athletic trainers' familiarity with and perceptions of academic accommodations in secondary school athletes after sport-related concussion. J Athl Train 2015; 50:262-9. [PMID: 25562456 PMCID: PMC4477921 DOI: 10.4085/1062-6050-49.3.81] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Sport-related concussion can affect athletes' sport participation and academic success. With the recent emphasis on cognitive rest, student-athletes may benefit from academic accommodations (AA) in the classroom; however, athletic trainers' (ATs') perceived familiarity with, and use of, AA is unknown. OBJECTIVE To assess secondary school ATs' perceived familiarity with, attitudes and beliefs about, and incorporation of AA for student-athletes after sport-related concussion. A secondary purpose was to determine whether employment status altered familiarity and use of AA. DESIGN Cross-sectional study. SETTING Online survey. PATIENTS OR OTHER PARTICIPANTS Of 3286 possible respondents, 851 secondary school ATs accessed the survey (response rate = 25.9%; 308 men [36.2%], 376 women [44.2%], 167 respondents [19.6%] with sex information missing; age = 37.3 ± 10.1 years). MAIN OUTCOME MEASURE(S) Participants were solicited via e-mail to complete the Beliefs, Attitudes and Knowledge Following Pediatric Athlete Concussion among Athletic Trainers employed in the secondary school setting (BAKPAC-AT) survey. The BAKPAC-AT assessed ATs' perceived familiarity, perceptions, and roles regarding 504 plans, Individualized Education Programs (IEPs), and returning student-athletes to the classroom. Independent variables were employment status (full time versus part time), employment model (direct versus outreach), years certified, and years of experience in the secondary school setting. The dependent variables were participants' responses to the AA questions. Spearman rank-correlation coefficients were used to assess relationships and Mann-Whitney U and χ(2) tests (P < .05) were used to identify differences. RESULTS Respondents reported that approximately 41% of the student-athletes whose sport-related concussions they managed received AA. Respondents employed directly by the school were more familiar with 504 plans (P < .001) and IEPs (P < .001) and had a greater belief that ATs should have a role in AA. Both the number of years certified and the years of experience at the secondary school were significantly correlated with perceived familiarity regarding 504 plans and IEPs. CONCLUSIONS The ATs employed directly by secondary schools and those with more experience as secondary school ATs were more familiar with AA. Understanding AA is important for all ATs because cognitive rest and "return to learn" are becoming more widely recommended in concussion management.
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18
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Norris JN, Sams R, Lundblad P, Frantz E, Harris E. Blast-related mild traumatic brain injury in the acute phase: Acute stress reactions partially mediate the relationship between loss of consciousness and symptoms. Brain Inj 2014; 28:1052-62. [DOI: 10.3109/02699052.2014.891761] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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19
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Wojcik SM. Predicting mild traumatic brain injury patients at risk of persistent symptoms in the Emergency Department. Brain Inj 2014; 28:422-30. [PMID: 24564636 DOI: 10.3109/02699052.2014.884241] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To identify factors that can predict which emergency department (ED) patients with mTBI are likely to develop persistent post-concussion symptoms (PPCS). DESIGN A matched case-control study was conducted at a Level 1 trauma centre between June 2006 and July 2009. Patients diagnosed with mTBI in the ED and diagnosed at a concussion management programme with at least one PPCS (85 cases) were compared to patients diagnosed with mTBI in the ED (340 controls) to determine if factors assessed at the time of ED presentation could predict patients likely to develop persistent symptoms. RESULTS Multivariable hierarchical logistic regression with variables indicating increased risk for PPCS (prior mTBI, history of depression, history of anxiety, multiple injury, forgetfulness/poor memory, noise sensitivity, or light sensitivity) resulted in a final predictive model including prior mTBI, history of anxiety, forgetfulness/poor memory and light sensitivity. The final model had a specificity of 87.9% and a sensitivity of 69.9%. CONCLUSIONS A strong prediction model to identify those ED patients with mTBI at risk for PPCS was developed and could be easily implemented in the ED; therefore, helping to target those patients who would potentially benefit from close follow-up.
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Affiliation(s)
- Susan M Wojcik
- Department of Emergency Medicine, Upstate Medical University , Syracuse, NY , USA
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Reuben A, Sampson P, Harris AR, Williams H, Yates P. Postconcussion syndrome (PCS) in the emergency department: predicting and pre-empting persistent symptoms following a mild traumatic brain injury. Emerg Med J 2013; 31:72-7. [DOI: 10.1136/emermed-2012-201667] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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21
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Harris AW, Jones CA, Rowe BH, Voaklander DC. A population-based study of sport and recreation-related head injuries treated in a Canadian health region. J Sci Med Sport 2012; 15:298-304. [DOI: 10.1016/j.jsams.2011.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 11/28/2011] [Accepted: 12/02/2011] [Indexed: 10/14/2022]
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Chittiboina P, Banerjee AD, Nanda A. Do concomitant cranium and axis injuries predict worse outcome? A trauma database quantitative analysis. Skull Base 2012; 21:249-54. [PMID: 22470268 DOI: 10.1055/s-0031-1280679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We performed a trauma database analysis to identify the effect of concomitant cranial injuries on outcome in patients with fractures of the axis. We identified patients with axis fractures over a 14-year period. A binary outcome measure was used. Univariate and multiple logistic regression analysis were performed. There were 259 cases with axis fractures. Closed head injury was noted in 57% and skull base trauma in 14%. Death occurred in 17 cases (6%). Seventy-two percent had good outcome. Presence of abnormal computed tomography head findings, skull base fractures, and visceral injury was significantly associated with poor outcome. Skull base injury in association with fractures of the axis is a significant independent predictor of worse outcomes, irrespective of the severity of the head injury. We propose that presence of concomitant cranial and upper vertebral injuries require careful evaluation in view of the associated poor prognosis.
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Affiliation(s)
- Prashant Chittiboina
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
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