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Kroshus E, Steiner MK, Chrisman SPD, Lion KC, Rivara F, Lowry SJ, Strelitz B, Klein EJ. Improving post-concussion discharge education for families seeking emergency department care: intervention development. Brain Inj 2024; 38:479-488. [PMID: 38441083 DOI: 10.1080/02699052.2024.2318595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 02/09/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Pediatric emergency departments (ED) are where many families receive post-concussion medical care and thus an important context for helping parents build skills to support their child after discharge. OBJECTIVE Develop a strategy for increasing parent provision of emotional and instrumental support to their child after discharge and conduct a pilot test of this strategy's acceptability. METHODS In a large pediatric ED in the United States, we partnered with parents (n = 15) and clinicians (n = 15) to understand needs and constraints related to discharge education and to operationalize a strategy to feasibly address these needs. This produced a brief daily text message intervention for parents for 10 days post-discharge. We used a sequential cohort design to assess the acceptability this intervention and its efficacy in changing parenting practices in the 2-weeks post-discharge (n = 98 parents). RESULTS Parents who received the messaging intervention rated it as highly acceptable and had meaningfully higher scores for emotionally supportive communication with their child in the two weeks post-discharge than parents in the control condition (Cohen's d = 0.65, p = 0.021). CONCLUSIONS This brief messaging intervention is a promising strategy for enhancing discharge education post-concussion that warrants further evaluation.
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Affiliation(s)
- Emily Kroshus
- Seattle Children's Research Institute, Center for Child Health, Behavior and Development, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Mary Kathleen Steiner
- Seattle Children's Research Institute, Center for Child Health, Behavior and Development, Seattle, WA, USA
| | - Sara P D Chrisman
- Seattle Children's Research Institute, Center for Child Health, Behavior and Development, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - K Casey Lion
- Seattle Children's Research Institute, Center for Child Health, Behavior and Development, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Frederick Rivara
- Seattle Children's Research Institute, Center for Child Health, Behavior and Development, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Sarah J Lowry
- Seattle Children's Research Institute, Center for Child Health, Behavior and Development, Seattle, WA, USA
| | - Bonnie Strelitz
- Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, WA, USA
| | - Eileen J Klein
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, WA, USA
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Sharma B, Obeid J, DeMatteo C, Noseworthy MD, Timmons BW. New Insights Into Accelerometer-Measured Habitual Physical Activity and Sedentary Time During Early Recovery in Pediatric Concussion. Pediatr Exerc Sci 2024; 36:58-65. [PMID: 37591503 DOI: 10.1123/pes.2023-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/26/2023] [Accepted: 05/25/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE Concussion management is shifting away from a rest-is-best approach, as data now suggest that exercise-is-medicine for this mild brain injury. Despite this, we have limited data on habitual physical activity following concussion. Therefore, our objective was to quantify accelerometer-measured physical activity and sedentary time in children with concussion (within the first month of injury) and healthy controls. We hypothesized that children with concussion would be less active than their healthy peers. METHODS We performed a secondary analysis of prospectively collected accelerometer data. Our sample included children with concussion (n = 60, 31 females) and historical controls (n = 60) matched for age, sex, and season of accelerometer wear. RESULTS Children with concussion were significantly more sedentary than controls (mean difference [MD], 38.3 min/d, P = .006), and spent less time performing light physical activity (MD, -19.5 min/d, P = .008), moderate physical activity (MD, -9.8 min/d, P < .001), and vigorous physical activity (MD, -12.0 min/d, P < .001); these differences were observed from 8:00 AM to 9:00 PM. Sex-specific analyses identified that girls with concussion were less active and more sedentary than both boys with concussion (P = .010) and healthy girls (P < .010). CONCLUSION There is an activity deficit observed within the first month of pediatric concussion. Physical activity guidelines should address this while considering sex effects.
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Affiliation(s)
- Bhanu Sharma
- Child Health and Exercise Medicine Program, Department of Pediatrics, McMaster University, Hamilton, ON,Canada
| | - Joyce Obeid
- Child Health and Exercise Medicine Program, Department of Pediatrics, McMaster University, Hamilton, ON,Canada
| | - Carol DeMatteo
- School of Rehabilitation Science, McMaster University, Hamilton, ON,Canada
- CanChild Center for Childhood Disability Research, McMaster University, Hamilton, ON,Canada
| | - Michael D Noseworthy
- Imaging Research Center, St. Joseph's Healthcare, Hamilton, ON,Canada
- Department of Electrical & Computer Engineering, McMaster University, Hamilton, ON,Canada
- McMaster School of Biomedical Engineering, McMaster University, Hamilton, ON,Canada
- Department of Radiology, McMaster University, Hamilton, ON,Canada
| | - Brian W Timmons
- Child Health and Exercise Medicine Program, Department of Pediatrics, McMaster University, Hamilton, ON,Canada
- CanChild Center for Childhood Disability Research, McMaster University, Hamilton, ON,Canada
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3
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Engel J, van Ierssel JJ, Osmond MH, Tsampalieros A, Webster R, Zemek R. Return to the Emergency Department Within 3 Months Following Pediatric Acute Concussion. J Head Trauma Rehabil 2023; 38:319-328. [PMID: 36854112 DOI: 10.1097/htr.0000000000000852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
OBJECTIVE To determine the proportion of concussed children returning to the emergency department (ED) for a concussion-related reason within 3 months of initial presentation and to determine which clinical composite score (5P or Post-Concussion Symptom Inventory) best predicts a return visit. SETTING, DESIGN, AND PARTICIPANTS We combined a secondary analysis of data from the prospectively collected 5P study with a retrospective medical record review of children aged 5 to 18 years who returned to the Children's Hospital of Eastern Ontario (CHEO) ED for a concussion-related reason within 3 months of an acutely diagnosed concussion. Among 770 eligible participants, 632 children (median age: 11.8 [interquartile range (IQR), 9.0-14.5] years; 58.9% male) were included in the study. MAIN MEASURES The primary outcome was the number of patients who returned to CHEO ED for a concussion-related reason within 3 months of an acute concussion diagnosed at CHEO ED. The secondary outcome was number of patients who returned within 14 days. RESULTS Forty-seven children (7.4%; 95% confidence interval [CI]: 5.6-9.7) had a concussion-related return to the ED within 3 months, the majority of which occurred in the first 14 days (29/47; 61.7%; 95% CI: 47.4-74.2). History of migraines (21.3% vs 9.7%; P = .03) were more common in those with a return visit. Headache was the most frequently reported symptom (87.2%) on revisit. Females aged 13 to 18 years had the highest return rate (survival rate: 85.8% [95% CI: 79.8-92.3]) compared with males and younger age groups. In multivariable Cox hazards regression modeling, inclusion of risk scores improved prognostication (pseudo R2 = 8%). The difference in pseudo R2 between 5P and Post-Concussion Symptom Inventory is small. CONCLUSION Most children and adolescents do not return to the ED following an acute concussion. Female youth with medium to high 5P scores at the index concussion visit may benefit from early referral to interdisciplinary specialty concussion care to guide treatment in anticipation of prolonged symptoms. By identifying these risk factors at the initial ED visit, healthcare and patient burden may be reduced.
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Affiliation(s)
- Jake Engel
- University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada (Mr Engel and Drs Osmond and Zemek); Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada (Drs van Ierssel, Osmond, Tsampalieros, Webster, and Zemek); and Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada (Drs Osmond and Zemek)
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Current Use and Future Considerations for Concussion Telemedicine Healthcare in Canada. Can J Neurol Sci 2023; 50:257-261. [PMID: 35272736 DOI: 10.1017/cjn.2022.18] [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: 11/06/2022]
Abstract
OBJECTIVE To examine the use of telemedicine among Canadian concussion providers and clinics before and after the COVID-19 pandemic onset and identify barriers and facilitators for future use. METHODS Ninety-nine concussion clinics and healthcare providers across Canada that offered one or more clinical concussion-related service were identified using standardized online searches and approached to complete a cross-sectional online survey. RESULTS Thirty clinics or providers completed the survey and two completed subsections of the survey (response rate of 32.3%). Only 28.1% of respondents indicated that they used telemedicine to provide care prior to the COVID-19 pandemic. Providers most commonly using telemedicine prior to the pandemic were occupational therapists and physicians, while the most commonly used services were in-person videoconferencing and eConsultation. Most respondents (87%) indicated their clinic's use of telemedicine changed following the onset of the COVID-19 pandemic including new use of in-person video-conferencing, telephone calls, and eConsultation. Ninety-three percent indicated that they would consider using telemedicine to provide care to their concussion patients once the pandemic was over. Barriers needed to be overcome to facilitate use or greater use of telemedicine-based services were the inability to conduct a complete physical examination, lack of appropriate reimbursement, lack of start-up, and maintenance funding and medico-legal risk. CONCLUSION Telemedicine was used by a minority of Canadian concussion clinics and providers prior to the COVID-19 pandemic but was rapidly adopted by many facilities. This study provides important insight into the factors that must be considered to optimize use of telemedicine in concussion care in the future.
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Sharma B, Nowikow C, DeMatteo C, Noseworthy MD, Timmons BW. Sex-specific differences in resting-state functional brain activity in pediatric concussion. Sci Rep 2023; 13:3284. [PMID: 36841854 PMCID: PMC9968337 DOI: 10.1038/s41598-023-30195-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/17/2023] [Indexed: 02/27/2023] Open
Abstract
Pediatric concussion has a rising incidence and can lead to long-term symptoms in nearly 30% of children. Resting state functional magnetic resonance imaging (rs-fMRI) disturbances are a common pathological feature of pediatric concussion, though no studies have explicitly examined sex-differences with respect to this outcome, precluding a sex-specific understanding of the functional neuropathology of pediatric concussion. Therefore, we performed a secondary data analysis of rs-fMRI data collected on children with concussion (n = 29) recruited from in a pediatric hospital setting, with greater than 12:1 matched control data accessed from the open-source ABIDE-II database. Seed-based and region of interest (ROI) analyses were used to examine sex-based rs-fMRI differences; threshold-free cluster enhancement (TFCE) and a family-wise error (FWE) corrected p-values were used to identify significantly different clusters. In comparing females with concussion to healthy females, groupwise differences were observed irrespective of seed selected. Notably, we observed (in order of largest effect) hypo-connectivity between the anterior cingulate cortex of the salience network and the thalamus and precuneus (TFCE = 1473.5, p-FWE < 0.001) and the cingulate gyrus (TFCE = 769.3, p-FWE = 0.009), and the seed (posterior cingulate cortex (PCC)) of the default mode network and the paracingulate gyrus (TFCE = 1275.7, p-FWE < 0.001), occipital pole right (TFCE = 1045.0, p-FWE = 0.001), and sub-callosal cortex (TFCE = 844.9, p-FWE = 0.005). Hyper-connectivity was observed between the salience network seed and the cerebellum (TFCE = 1719.3, p-FWE < 0.001) and the PCC and the thalamus (TFCE = 1198.3, p-FWE < 0.001), cuneal cortex (1070.9, p-FWE = 0.001), and lateral occipital cortex left (TFCE = 832.8, p-FWE = 0.006). ROI analyses showed 10 and 5 significant clusters of hypo- and hyper-connectivity in females, respectively. Only one cluster of difference was found between males with concussion and healthy males on seed-based analyses, and 3 clusters on ROI analyses. There are alterations in rs-fMRI in females with concussion at one-month post-injury that are minimally present in males, which provides further evidence that recovery timelines in pediatric concussion may differ by sex.
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Affiliation(s)
- Bhanu Sharma
- grid.25073.330000 0004 1936 8227Child Health and Exercise Medicine Program, Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, ON L8S4L8 Canada ,grid.416721.70000 0001 0742 7355Imaging Research Centre, St. Joseph’s Healthcare, Hamilton, ON Canada ,grid.25073.330000 0004 1936 8227Department of Electrical & Computer Engineering, McMaster University, Hamilton, Canada
| | - Cameron Nowikow
- grid.416721.70000 0001 0742 7355Imaging Research Centre, St. Joseph’s Healthcare, Hamilton, ON Canada ,grid.25073.330000 0004 1936 8227McMaster School of Biomedical Engineering, McMaster University, Hamilton, Canada
| | - Carol DeMatteo
- grid.25073.330000 0004 1936 8227School of Rehabilitation Science, McMaster University, Hamilton, Canada ,grid.25073.330000 0004 1936 8227CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Canada
| | - Michael D. Noseworthy
- grid.416721.70000 0001 0742 7355Imaging Research Centre, St. Joseph’s Healthcare, Hamilton, ON Canada ,grid.25073.330000 0004 1936 8227Department of Electrical & Computer Engineering, McMaster University, Hamilton, Canada ,grid.25073.330000 0004 1936 8227McMaster School of Biomedical Engineering, McMaster University, Hamilton, Canada ,grid.25073.330000 0004 1936 8227Department of Radiology, McMaster University, Hamilton, Canada
| | - Brian W. Timmons
- grid.25073.330000 0004 1936 8227Child Health and Exercise Medicine Program, Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, ON L8S4L8 Canada ,grid.25073.330000 0004 1936 8227CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Canada
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Tabor J, La P, Kline G, Wang M, Bonfield S, Machan M, Wynne-Edwards K, Emery C, Debert C. Saliva Cortisol as a Biomarker of Injury in Youth Sport-Related Concussion. J Neurotrauma 2023; 40:296-308. [PMID: 35906800 DOI: 10.1089/neu.2022.0190] [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: 02/04/2023] Open
Abstract
Increasing rates of sport-related concussion (SRC) in youth impose a significant burden on public health systems and the lives of young athletes. Accurate prediction for those likely to develop persistent post-concussion symptomology (PPCS) using a fluid biomarker, reflecting both acute injury and recovery processes, would provide the opportunity for early intervention. Cortisol, a stress hormone released through the hypothalamic-pituitary-adrenal (HPA) axis following injury, may provide a missing physiological link to clinical recovery. This cohort study investigated the change in saliva cortisol following SRC and the association between cortisol and symptom burden in pediatric ice hockey players. Further, the association between cortisol levels and medical clearance to return to play was explored. In total, cortisol samples from 233 players were included; 165 athletes (23.6% female) provided pre-injury saliva and 68 athletes (19.1% female) provided post-SRC saliva samples for cortisol analysis. Quantile (median) regressions were used to compare cortisol between pre-injury and post-SRC groups, and the association between total symptoms (/22) and symptom severity scores (/132) reported on the Sport Concussion Assessment Tool (SCAT)3/SCAT5 and post-SRC cortisol (adjusting for age, sex, history of concussion, and time from injury to sample collection). Results demonstrated significantly lower saliva cortisol in post-SRC athletes compared with the pre-injury group (β = -0.62, 95% confidence interval [CI; -1.08, -0.16], p = 0.009). Post-SRC cortisol was not significantly associated with the SCAT3/SCAT5 symptom totals or symptom severity scores; however, females were found to report more symptoms (β = 6.95, 95% CI [0.35, 13.55], p = 0.040) and greater symptom severity (β = 23.87, 95% CI [9.58, 38.15], p = 0.002) compared with males. Exploratory time-to-event analysis revealed a point estimate suggesting a potential association between low cortisol levels and days to medical clearance to return to play. Although preliminary, these findings suggest that the HPA axis may be dysregulated post-SRC. Further, our exploratory analysis and case presentation of post-injury outliers highlight the need to further research cortisol as a prognostic biomarker to inform individualized sex-specific care after SRC.
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Affiliation(s)
- Jason Tabor
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Parker La
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregory Kline
- Division of Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meng Wang
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephan Bonfield
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Machan
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Katherine Wynne-Edwards
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Carolyn Emery
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Chantel Debert
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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7
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Ramsay S, Dahinten VS, Ranger M, Babul S. Follow-up visits after a concussion in the pediatric population: An integrative review. NeuroRehabilitation 2023; 52:315-328. [PMID: 37005895 PMCID: PMC10200233 DOI: 10.3233/nre-220216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Concussions are a significant health issue for children and youth. After a concussion diagnosis, follow-up visits with a health care provider are important for reassessment, continued management, and further education. OBJECTIVE This review aimed to synthesize and analyse the current state of the literature on follow-up visits of children with a concussive injury and examine the factors associated with follow-up visits. METHODS An integrative review was conducted based on Whittemore and Knafl's framework. Databases searched included PubMed, MEDLINE, CINAHL, PsycINFO, and Google Scholar. RESULTS Twenty-four articles were reviewed. We identified follow-up visit rates, timing to a first follow-up visit, and factors associated with follow-up visits as common themes. Follow-up visit rates ranged widely, from 13.2 to 99.5%, but time to the first follow-up visit was only reported in eight studies. Three types of factors were associated with attending a follow-up visit: injury-related factors, individual factors, and health service factors. CONCLUSION Concussed children and youth have varying rates of follow-up care after an initial concussion diagnosis, with little known about the timing of this visit. Diverse factors are associated with the first follow-up visit. Further research on follow-up visits after a concussion in this population is warranted.
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Affiliation(s)
- Scott Ramsay
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - V Susan Dahinten
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | - Manon Ranger
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Shelina Babul
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- BC Injury and Research Prevention Unit, Vancouver, BC, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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8
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Davies J, Dinyarian C, Wheeler AL, Dale CM, Cleverley K. Traumatic Brain Injury History Among Individuals Using Mental Health and Addictions Services: A Scoping Review. J Head Trauma Rehabil 2023; 38:E18-E32. [PMID: 35452016 DOI: 10.1097/htr.0000000000000780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Traumatic brain injury (TBI) has been increasingly linked in population research to psychiatric problems as well as substance use and related harms, suggesting that individuals with TBI may also present more frequently to mental health and addictions (MHA) services. Little is known, however, about TBI history among MHA service users. The objectives of this review were to understand (i) the prevalence of TBI history among MHA service users; (ii) how TBI history is identified in MHA service settings; and (iii) predictors or outcomes of TBI that have been reported in MHA service users. METHODS A scoping review was conducted in accordance with PRISMA Scoping Review Extension guidelines. A search for relevant literature was conducted in MEDLINE, PsycINFO, SPORTDiscus, CINAHL, and Embase as well as various gray literature sources. RESULTS Twenty-eight relevant studies were identified. TBI was defined and operationalized heterogeneously between studies, and TBI history prevalence rates ranged considerably among the study samples. The included studies used varied methods to identify TBI history in MHA settings, such as clinical chart audits, single-item questions, or structured questionnaires (eg, Brain Injury Screening Questionnaire or Ohio State University TBI Identification Method). TBI history was most consistently associated with indicators of more severe substance use problems and mental health symptoms as well as increased aggression or risk to others. Studies reported less consistent findings regarding the relationship of TBI to physical health, cognitive impairment, functioning, risk to self, and type of psychiatric diagnosis. CONCLUSION Screening for TBI history in MHA settings may contribute important information for risk assessment and care planning. However, to be clinically useful, assessment of TBI history will require consistent operationalization of TBI as well as use of validated screening methods.
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Affiliation(s)
- Julia Davies
- Lawrence S. Bloomberg Faculty of Nursing (Mss Davies and Dinyarian and Drs Dale and Cleverley) and Faculty of Medicine (Drs Dale and Cleverley), University of Toronto, Toronto, Canada; Centre for Addiction and Mental Health, Toronto, Canada (Ms Davies and Dr Cleverley); Neuroscience and Mental Health Program, Hospital for Sick Children, Toronto, and Department of Physiology, University of Toronto, Toronto, Canada (Dr Wheeler); and Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, and University of Toronto Centre for the Study of Pain, Toronto, Canada (Dr Dale)
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9
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Wittevrongel K, Barrett O, Couloigner I, Bertazzon S, Hagel B, Schneider KJ, Johnson D, Yeates KO, Zwicker JD. Longitudinal trends in incidence and health care use for pediatric concussion in Alberta, Canada. Pediatr Res 2022; 93:1752-1764. [PMID: 36085365 PMCID: PMC10172117 DOI: 10.1038/s41390-022-02214-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 06/24/2022] [Accepted: 07/08/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND We described longitudinal trends in the incidence of episodes of care (EOC) and follow-up care for pediatric concussion in relation to age, sex, rurality of patient residence, point of care, and area-based socioeconomic status (SES) in Alberta, Canada. METHODS A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age who received a diagnosis of concussion, other specified injuries of head, unspecified injury of head, or post-concussion syndrome between April 1, 2004 and March 31, 2018. Data were geospatially mapped. RESULTS Concussion EOCs increased 2.2-fold over the study period, follow-up visits 5.1-fold. Care was increasingly received in physician office (PO) settings. Concussion diagnoses in rural and remote areas occurred in emergency department (ED) settings more often than in metro centres or urban areas (76%/75% vs. 52%/60%). Proportion of concussion diagnoses was positively related to SES and age. Diagnosis and point of care varied geographically. CONCLUSIONS The shift in care to PO settings, increased incidence of all diagnoses, and the higher use of the ED by some segments of the population all have important implications for appropriate clinical management and the efficient provision of health care for pediatric concussion. IMPACT This is the first study to use EOC to describe longitudinal trends in incidence and follow-up care for pediatric concussion in relation to age, sex, rurality, point of care, and area-based SES. We report increased incidence of concussion in both emergency and outpatient settings and the proportion of diagnoses was positively related to SES and age. Patients increasingly received care for concussion in PO over time. Geospatial mapping indicated that the incidence of concussion and unspecified injury of head varied geographically and temporally. Results have important implications for appropriate clinical management and efficient provision of health care following pediatric concussion.
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Affiliation(s)
| | | | | | - Stefania Bertazzon
- Department of Geography, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Brent Hagel
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Kathryn J Schneider
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada.,Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - David Johnson
- Alberta Health Services, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Keith O Yeates
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Psychology, University of Calgary, Calgary, AB, Canada
| | - Jennifer D Zwicker
- School of Public Policy, University of Calgary, Calgary, AB, Canada. .,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada. .,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada. .,Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada.
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10
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Sharma B, Obeid J, DeMatteo C, Noseworthy MD, Timmons BW. Exploring the relationship between resting state intra-network connectivity and accelerometer-measured physical activity in pediatric concussion: A cohort study. Appl Physiol Nutr Metab 2022; 47:1014-1022. [PMID: 35858484 DOI: 10.1139/apnm-2022-0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Our objective was to explore the association between resting state functional connectivity and accelerometer-measured physical activity in pediatric concussion. Fourteen children with concussion (aged 14.54 ± 2.39 years, 8 female) were included in this secondary data analysis of a larger study. Participants had neuroimaging at 15.3 ± 6.7 days post-injury and subsequently a mean of 11.1 ± 5.0 days of accelerometer data. Intra-network connectivity of the default mode network (DMN), sensorimotor network (SMN), salience network (SN), and fronto-parietal network (FPN) was computed using resting state functional MRI. We found that per general linear models, only intra-network connectivity of the DMN was associated with physical activity levels. More specifically, increased intra-network connectivity of the DMN was significantly associated with higher levels of subsequent accelerometer-measured light physical activity (F(2, 11) = 7.053, p = 0.011, Ra2 = 0.562; β = 0.469), moderate physical activity (F(2, 11) = 7.053, p = 0.011, Ra2 = 0.562; β = 0.725), and vigorous physical activity (F(2, 11) = 10.855, p = 0.002, Ra2 = 0.664; β = 0.79). Intra-network connectivity of the DMN did not significantly predict sedentary time. Therefore, these preliminary findings suggest that there is a positive association between the intra-network connectivity of the DMN and device-measured physical activity in children with concussion.
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Affiliation(s)
- Bhanu Sharma
- McMaster University, 3710, Department of Pediatrics, Hamilton, Canada;
| | - Joyce Obeid
- McMaster University, Kinesiology, Hamilton, Ontario, Canada;
| | | | - Michael D Noseworthy
- McMaster University, Electrical and Computer Engineering, Hamilton, Ontario, Canada;
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11
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Lyons TW, Mannix R, Tang K, Yeates KO, Sangha G, Burns EC, Beer D, Dubrovsky AS, Gagnon I, Gravel J, Freedman SB, Craig W, Boutis K, Osmond MH, Gioia G, Zemek R. Paediatric post-concussive symptoms: symptom clusters and clinical phenotypes. Br J Sports Med 2022; 56:785-791. [PMID: 35273038 DOI: 10.1136/bjsports-2021-105193] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the co-occurrence and clustering of post-concussive symptoms in children, and to identify distinct patient phenotypes based on symptom type and severity. METHODS We performed a secondary analysis of the prospective, multicentre Predicting and Preventing Post-concussive Problems in Pediatrics (5P) cohort study, evaluating children 5-17 years of age presenting within 48 hours of an acute concussion. Our primary outcome was the simultaneous occurrence of two or more persistent post-concussive symptoms on the Post-Concussion Symptom Inventory at 28 days post-injury. Analyses of symptom and patient clusters were performed using hierarchical cluster analyses of symptom severity ratings. RESULTS 3063 patients from the parent 5P study were included. Median age was 12.1 years (IQR: 9.2-14.6 years), and 1857 (60.6%) were male. Fatigue was the most common persistent symptom (21.7%), with headache the most commonly reported co-occurring symptom among patients with fatigue (55%; 363/662). Headache was common in children reporting any of the 12 other symptoms (range: 54%-72%). Physical symptoms occurred in two distinct clusters: vestibular-ocular and headache. Emotional and cognitive symptoms occurred together more frequently and with higher severity than physical symptoms. Fatigue was more strongly associated with cognitive and emotional symptoms than physical symptoms. We identified five patient groups (resolved/minimal, mild, moderate, severe and profound) based on symptom type and severity. CONCLUSION Post-concussive symptoms in children occur in distinct clusters, facilitating the identification of distinct patient phenotypes based on symptom type and severity. Care of children post-concussion must be comprehensive, with systems designed to identify and treat distinct post-concussion phenotypes.While I agree with the use of the british spelling of Paediatric throughout, this groups actual name is with the American English Spelling.
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Affiliation(s)
- Todd W Lyons
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA .,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rebekah Mannix
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ken Tang
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Keith Owen Yeates
- Department of Psychology, Hotchkiss Brain Institute, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Gurinder Sangha
- Department of Pediatrics, Children's Hospital of Western Ontario, London, Ontario, Canada.,Department of Pediatrics, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Emma Cm Burns
- Department of Emergency Medicine, IWK Health Centre, Halifax, Nova Scotia, Canada.,Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Darcy Beer
- Department of Pediatrics, Children's Hospital Foundation of Manitoba, Winnipeg, Manitoba, Canada
| | - Alexander S Dubrovsky
- UP Centre for Pediatric Emergencies, Montreal, Quebec, Canada.,Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| | - Isabelle Gagnon
- Division of Physical and Occupational Therapy, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jocelyn Gravel
- Department of Pediatrics, Saint Justine Hospital, Montreal, Quebec, Canada
| | - Stephen B Freedman
- Department of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - William Craig
- Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Kathy Boutis
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Martin H Osmond
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Gerard Gioia
- Division of Neuropsychology, Children's National Hospital, Washington, District of Columbia, USA
| | - Roger Zemek
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
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12
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Wittevrongel K, Barrett O, Hagel BE, Schneider KJ, Johnson DW, Yeates KO, Zwicker JD. Factors associated with follow-up care after pediatric concussion: A longitudinal population-based study in Alberta, Canada. Front Pediatr 2022; 10:1035909. [PMID: 36699293 PMCID: PMC9869116 DOI: 10.3389/fped.2022.1035909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Concussion is a common injury in children and adolescents. Current best practice guidelines indicate that recovery should be supervised through recurrent follow-up visits. A more detailed understanding of the system-level and individual factors that are associated with follow-up care is a critical step towards increasing evidence-based practice. The objective of this study was to identify predisposing, enabling, and need-based factors associated with follow-up care after pediatric concussion. MATERIALS AND METHODS A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age with a diagnosis of concussion, other specified injuries of the head, unspecified injury of head, or post-concussion syndrome (PCS) between April 1, 2004 and March 31, 2018 in Alberta, Canada. The association between predisposing, enabling, and need-based factors and the receipt of follow-up care within a defined episode of care (EOC) was analyzed using logistic regression models for the entire cohort and for EOC that began with a concussion diagnosis. Predisposing factors included age and sex. Enabling factors included the community type of patient residence, area-based socioeconomic status (SES), and visit year. Need-based factors included where the EOC began (outpatient vs. emergency settings) and history of previous concussion-related EOC. RESULTS 194,081 EOCs occurred during the study period but only 13% involved follow-up care (n = 25,461). Males and adolescents were more likely to receive follow-up care. Follow-up was less likely among patients who lived in remote communities or in areas of lower SES, while EOCs beginning in 2011 or later were more likely to involve follow-up care. Patients whose EOC began in outpatient settings, had more than one EOC, or a diagnosis of concussion were more likely to receive follow-up care. CONCLUSION Follow-up care for pediatric concussion has increased over time and is associated with patient age and sex, history of concussion-related EOC, where a patient lives (community type and area-based SES), and when and where the index visit occurs. A better understanding of which children are more likely to receive follow-up care, as well as how and when they do, is an important step in aligning practice with follow-up guidelines.
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Affiliation(s)
| | | | - Brent E Hagel
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Kathryn J Schneider
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada.,Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - David W Johnson
- Alberta Health Services, Calgary, AB, Canada.,Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Keith Owen Yeates
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Department of Psychology, University of Calgary, Calgary, AB, Canada
| | - Jennifer D Zwicker
- School of Public Policy, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
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13
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Dawson J, Reed N, Bauman S, Seguin R, Zemek R. Diagnosing and managing paediatric concussion: Key recommendations for general paediatricians and family doctors. Paediatr Child Health 2021; 26:402-407. [PMID: 34777657 DOI: 10.1093/pch/pxab024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/26/2021] [Indexed: 01/31/2023] Open
Abstract
Concussion in children and adolescents is an important health concern. Most paediatric patients fully recover in 1 month or less following an acute concussion. However, some experience prolonged or persistent concussion symptoms for months. Those with prolonged post-concussion-related symptoms may have impaired quality of life, and limited involvement in social, academic, and physical activities with associated mental health implications. In this review, we share key updated clinical recommendations from the Living Guideline for Diagnosing and Managing Pediatric Concussion that will improve the way general paediatricians and family doctors diagnose and manage paediatric patients with suspected concussion.
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Affiliation(s)
- Jennifer Dawson
- Children's Hospital of Eastern Ontario Research Institute (CHEO-RI), Ottawa, Ontario, Canada
| | - Nick Reed
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Shannon Bauman
- Concussion North, Royal Victoria Hospital, Barrie, Ontario, Canada.,Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ryan Seguin
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Roger Zemek
- Children's Hospital of Eastern Ontario Research Institute (CHEO-RI), Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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14
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Keenan HT, Clark AE, Holubkov R, Ewing-Cobbs L. Changing Healthcare and School Needs in the First Year After Traumatic Brain Injury. J Head Trauma Rehabil 2021; 35:E67-E77. [PMID: 31246877 PMCID: PMC6930363 DOI: 10.1097/htr.0000000000000499] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine children's unmet and unrecognized healthcare and school needs following traumatic brain injury (TBI). SETTING Two pediatric trauma centers. PARTICIPANTS Children with all severity of TBI aged 4 to 15 years. DESIGN Prospective cohort. MAIN MEASURES Caregivers provided child health and school service use 3 and 12 months postinjury. Unmet and unrecognized needs were categorized compared with norms on standardized physical, cognitive, socioemotional health, or academic competence measures in conjunction with caregiver report of needs and services. Modified Poisson models examined child and family predictors of unmet and unrecognized needs. RESULTS Of 322 children, 28% had unmet or unrecognized healthcare or school needs at 3 months, decreasing to 24% at 12 months. Unmet healthcare needs changed from primarily physical (79%) at 3 months to cognitive (47%) and/or socioemotional needs (68%) at 12 months. At 3 months, low social capital, preexisting psychological diagnoses, and 6 to 11 years of age predicted higher healthcare needs and severe TBI predicted higher school needs. Twelve months postinjury, prior inpatient rehabilitation, low income, and preexisting psychological diagnoses were associated with higher healthcare needs; family function was important for school and healthcare needs. CONCLUSIONS Targeted interventions to provide family supports may increase children's access to services.
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Affiliation(s)
- Heather T Keenan
- Division of Critical Care, Department of Pediatrics, The University of Utah, Salt Lake City (Drs Keenan and Holubkov and Ms Clark); and Department of Pediatrics and Children's Learning Institute, University of Texas McGovern Medical School, Houston (Dr Ewing-Cobbs)
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15
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Seegan PL, Tangella K, Seivert NP, Reynolds E, Young A, Ziegfeld S, Garcia A, Hodgman E, Parrish C. Factors Associated with Pediatric Burn Clinic Follow-up after Emergency Department Discharge. J Burn Care Res 2021; 43:207-213. [PMID: 33693681 DOI: 10.1093/jbcr/irab046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Attrition between emergency department discharge and outpatient follow-up is well documented across a variety of pediatric ailments. Given the importance of outpatient medical care and the lack of related research in pediatric burn populations, we examined sociodemographic factors and burn characteristics associated with outpatient follow-up adherence among pediatric burn patients. A retrospective review of medical records was conducted on patient data extracted from a burn registry database at an urban academic children's hospital over a 2-year period (January 2018-December 2019). All patients were treated in the emergency department and discharged with instructions to follow-up in an outpatient burn clinic within one week. A total of 196 patients (Mage=5.5 years; 54% male) were included in analyses. Average percent total body surface area was 1.9 (SD=1.5%). One-third of pediatric burn patients (33%) did not attend outpatient follow-up as instructed. Older patients (OR=1.00; 95% CI: [.99-1.00], p=.045), patients with superficial burns (OR=9.37; 95% CI: [2.50-35.16], p=.001), patients with smaller percent total body surface area (OR=1.37; 95% CI: [1.07-1.76], p=.014), and patients with Medicaid insurance (OR=.22; 95% CI: [.09-.57], p=.002) or uninsured/unknown insurance (OR=.07; 95% CI: [.02-.26], p=.000) were less likely to follow up, respectively. Patient gender, race, ethnicity, and distance to clinic were not associated with follow-up. Follow-up attrition in our sample suggests a need for additional research identifying factors associated with adherence to follow-up care. Identifying factors associated with follow-up adherence is an essential step in developing targeted interventions to improve health outcomes in this at-risk population.
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Affiliation(s)
- Paige L Seegan
- Johns Hopkins University School of Medicine, Division of Child and Adolescent Psychiatry
| | - Kavya Tangella
- Johns Hopkins University, Department of Psychological and Behavioral Sciences
| | - Nicholas P Seivert
- Children's Hospital of Philadelphia, Department of Child and Adolescent Psychiatry and Behavioral Sciences
| | - Elizabeth Reynolds
- Johns Hopkins University School of Medicine, Division of Child and Adolescent Psychiatry
| | - Andrea Young
- Johns Hopkins University School of Medicine, Division of Child and Adolescent Psychiatry
| | - Susan Ziegfeld
- Johns Hopkins University School of Medicine, Department of Surgery
| | - Alejandro Garcia
- Johns Hopkins University School of Medicine, Department of Surgery
| | - Erica Hodgman
- Johns Hopkins University School of Medicine, Department of Surgery
| | - Carisa Parrish
- Johns Hopkins University School of Medicine, Division of Child and Adolescent Psychiatry
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16
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Factors Influencing Primary Care Follow-Up After Pediatric Mild Traumatic Brain Injury. J Head Trauma Rehabil 2020; 34:E11-E19. [PMID: 30608309 DOI: 10.1097/htr.0000000000000461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify socioeconomic, demographic, and caregiver factors associated with children attending primary care provider (PCP) follow-up after emergency department (ED) evaluation for mild traumatic brain injury (mTBI). SETTING Pediatric trauma center ED. PARTICIPANTS Children 8 to 18 years of age sustaining mTBI less than 48 hours prior to an ED visit. Mean age of the 183 participants was 12 years with no significant differences between those who attended follow-up and those who did not in race, ethnicity, insurance provider, or PCP office setting. DESIGN Thirty-day longitudinal cohort study. MAIN MEASURES Insurance type, PCP practice setting, and a caregiver attitudes survey regarding mTBI recovery and management (5 questions each scored on a 5-point Likert scale). The primary outcome was attending a PCP follow-up visit within 1 month of injury. RESULTS Females were more likely than males to attend PCP follow-up (adjusted odds ratio: 2.27 [95% confidence interval: 1.00-5.18]). Increasing scores on the caregiver attitudes survey indicating greater concerns about recovery were significantly associated with attending PCP follow-up (adjusted odds ratio: 1.12 per unit increase in composite score [95% confidence interval: 1.02-1.23]). No other socioeconomic, demographic, or injury characteristics were associated with attending PCP follow-up. CONCLUSIONS The ED counseling regarding PCP follow-up of mTBI should stress the importance of follow-up care to monitor recovery and identify presence of lingering symptoms.
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17
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Northam WT, Cools MJ, Chandran A, Alexander A, Mihalik JP, Guskiewicz KM, Carneiro KA. Sports Medicine Fellowship Training Improves Sport-related Concussion Evaluation. Curr Sports Med Rep 2020; 19:272-276. [PMID: 32692063 DOI: 10.1249/jsr.0000000000000730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Evaluating acute sport-related concussion (SRC) differs among providers, who apply international consensus and national guidelines variably. Retrospective medical record review was completed for 889 outpatients aged 7 to 18 years, diagnosed with SRC from 2014 to 2017. Associations between board-certified sports medicine fellowship (SMF) training status and assessment of concussion-specific history and physical examination items were tested using nonparametric χ tests. Differential odds (by fellowship training status) of using history and physical examination items were assessed using multivariable logistic regression modeling. Each SRC history and physical examination items were assessed in higher proportions by SMFs, as compared with non-SMFs, statistically significant for all tested items with the exception of headache history. SMFs demonstrated higher odds of detailed neurologic examinations and clinical cognitive testing compared with non-SMFs, after adjusting for patient and physician characteristics. Physicians caring for concussed patients should seek continuing education opportunities aligning them with training provided to sports medicine fellows.
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Affiliation(s)
| | | | | | | | | | - Kevin M Guskiewicz
- Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Department of Exercise and Sport Science, University of North Carolina, Chapel Hill, NC
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18
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Association of Simple Step Test With Readiness for Exercise in Youth After Concussion. J Head Trauma Rehabil 2020; 35:E95-E102. [PMID: 31246885 DOI: 10.1097/htr.0000000000000512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We hypothesized that a submaximal step test would be associated with readiness to commence graded exercise in children and adolescents with concussion. METHODS Children and adolescents aged 8 to 18 years performed standard concussion clinical assessment for vestibular/ocular and balance impairment, and exercise examination utilizing the 3-minute Kasch Pulse Recovery test (KPR) and a symptom-limited graded exercise test (GXT). Outcome measures included activity readiness and symptom exacerbation. RESULTS Forty-five participants (mean age 13.2 ± 2.1 years, 76% male) had a confirmed concussion (73% sports-related). Some participants required follow-up testing giving 75 clinical presentations. Sensitivity and specificity of the KPR were 100% and 95.7%, respectively. Area under the receiver operating characteristics curve was 0.979. Activity readiness to GXT and KPR was strongly associated (χ = 21.672, P < .001), while symptom exacerbation showed a significant correlation between testing methods (r = 0.796, P < .001). Better exercise performance on GXT and KPR was significantly correlated with normal Vestibular/Ocular Motor Screening (rs = -0.380, P = .010, and rs = -0.281, P = .017, respectively) and Modified Balance Error Scoring System (rs = -0.452, P < .001, and rs = -0.301, P = .010, respectively). CONCLUSION The KPR is a simple and practical tool to determine whether it is appropriate for a child or adolescent with concussion to commence graded exercise.
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Povolo CA, Reid JN, Shariff SZ, Welk B, Morrow SA. Concussion in adolescence and the risk of multiple sclerosis: A retrospective cohort study. Mult Scler 2020; 27:180-187. [PMID: 32091315 DOI: 10.1177/1352458520908037] [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: 11/16/2022]
Abstract
BACKGROUND Physical trauma, specifically concussions sustained during adolescence, has been hypothesized to be a risk factor for multiple sclerosis (MS). OBJECTIVE To examine the association between adolescent concussions and future MS diagnosis. METHODS This retrospective study using linked administrative databases from Ontario, Canada, identified 97,965 adolescents (age 11-18 years) who sustained ⩾1 concussion and presented to an emergency department between 1992 and 2011. Cases were matched 1:3 with individuals who had not sustained a concussion based on age, sex, address, and index date. The primary outcome was MS diagnosis, using a validated MS diagnosis definition: ⩾1 hospitalization or ⩾5 physician billings within 2 years. RESULTS A concussion during adolescence was associated with a significantly increased risk of MS (hazard ratio (HR) = 1.29, p = 0.03). Sex-specific analysis revealed that only males who sustained a concussion in adolescence had a raised risk of MS (HR = 1.41, p = 0.04). CONCLUSION This study supports an association between concussions in adolescence and future MS diagnoses, highlighting the potentially serious long-term effects of concussions.
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Affiliation(s)
- Christopher A Povolo
- Department of Clinical Neurological Sciences, London Health Sciences Center, London, ON, Canada
| | - Jennifer N Reid
- Institute for Clinical Evaluative Sciences, London, ON, Canada
| | - Salimah Z Shariff
- Institute for Clinical Evaluative Sciences Western, Lawson Heath Research Institute and Arthur Labatt School of Nursing, Western University, London, ON, Canada
| | - Blayne Welk
- Institute for Clinical Evaluative Sciences and Department of Surgery and Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - Sarah A Morrow
- Department of Clinical Neurological Sciences, University Hospital, London Health Sciences Centre (LHSC), Western University, London, ON, Canada
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Abstract
Pediatric concussions are common and many children seek care in emergency departments. Providing concussion discharge instructions to patients and families is part of routine standard of care. The objective of this study was to determine whether the use of the Acute Concussion Evaluation-Emergency Department Discharge Instructions (ACE-ED DI) improves the caregiver's knowledge of injury management, specifics about returning to school and sports activities, and outpatient follow-up. This was a quasi-experimental study conducted in an urban Level 1 trauma center pediatric emergency department (PED). A convenience sample of caregivers of children aged 5-18 years who presented to the PED with a concussion was recruited and consented to participate. Caregivers completed a 16-item survey to assess overall understanding of concussion management after instructions were given. Caregivers received the standard discharge instructions (SDIs) in Phase 1 and SDIs plus the ACE-ED DI in Phase 2. Descriptive statistics were used for demographic variables and t-test to compare groups. Sixty-three of 68 (93%) caregivers participated; 30 in the SDI group and 33 in the SDI plus ACE-ED DI group. Demographic characteristics were similar between groups. Caregivers who received the ACE-ED DI reported a 24% increase in helpfulness of written materials (p < 0.001), a 25% increase in perceived understanding about concussion injury and management (p < 0.001), a 23% increase in understanding about returning to school activities (p < 0.001), and were 17% more likely to follow up with their primary care provider (p < 0.001). The ACE-ED DI used in a PED was found to be more effective at increasing caregivers' perceived knowledge of concussion management, specifics about returning to school and sports activities, and outpatient follow-up.
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21
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Keays G, Friedman D, Gagnon I, Beaudin M. Determining the accuracy of the Canadian Hospitals Injury Reporting and Prevention Program for the representation of the rates of mild traumatic brain injuries in Quebec. Health Promot Chronic Dis Prev Can 2019; 39:291-297. [PMID: 31729311 PMCID: PMC6876650 DOI: 10.24095/hpcdp.39.11.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The recent rise in mild traumatic brain injuries (mTBI) in the pediatric population has been documented by many studies in Canada and the United States. The objective of our study was to compare mTBI rates from the Canadian Hospital Injury Reporting and Prevention Program (CHIRPP) in Montréal with population-based rates (Quebec mTBI rates). METHODS We calculated CHIRPP's mTBI rates via two methods: (1) using all CHIRPP injuries as the denominator; and (2) using the number of children aged 0 to 17 years living within 5 km of either of two CHIRPP centres in Montréal as the denominator. We plotted CHIRPP's mTBI rates against the provincial rates and compared them according to sex and age. RESULTS Whether using all CHIRPP injuries or the number of children aged 0 to 17 years living within 5 km of either CHIRPP centre in Montreal as the denominator, CHIRPP paralleled the fluctuations seen in Quebec's rates between 2003 and 2016. When stratifying by sex and age, CHIRPP was better at estimating the population-based rates for the youngest (0 to 4 years) and the oldest (13 to 17 years) age groups. CONCLUSION CHIRPP in Montréal proved a valid tool for estimating the variations in rates of mTBI in the population. This suggests that CHIRPP could also be used to estimate population-based rates of other types of injuries.
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Affiliation(s)
- Glenn Keays
- Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), The Montreal Children's Hospital, McGill University Health Centre, Montréal, Quebec, Canada
- Montreal Children's Hospital Trauma Centre, McGill University Health Centre, Montréal, Quebec, Canada
| | - Debbie Friedman
- Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), The Montreal Children's Hospital, McGill University Health Centre, Montréal, Quebec, Canada
- Montreal Children's Hospital Trauma Centre, McGill University Health Centre, Montréal, Quebec, Canada
- Department of Pediatrics & Pediatric Surgery, Faculty of Medicine, McGill University, Montréal, Quebec, Canada
| | - Isabelle Gagnon
- Department of Pediatrics & Pediatric Surgery, Faculty of Medicine, McGill University, Montréal, Quebec, Canada
- School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Montréal, Quebec, Canada
| | - Marianne Beaudin
- Centre hospitalier universitaire mère-enfant Sainte-Justine, Montréal, Quebec, Canada
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22
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Reed N, Leeder K, Zemek R. Patient engagement in pediatric concussion research. CMAJ 2019; 190:S28-S30. [PMID: 30404847 DOI: 10.1503/cmaj.180450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Nick Reed
- Holland Bloorview Kids Rehabilitation Hospital (Reed, Leeder), Department of Occupational Science and Occupational Therapy, University of Toronto (Reed), Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (Zemek), Departments of Pediatrics and Emergency Medicine, University of Ottawa (Zemek), Ottawa, Ont.
| | - Kathy Leeder
- Holland Bloorview Kids Rehabilitation Hospital (Reed, Leeder), Department of Occupational Science and Occupational Therapy, University of Toronto (Reed), Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (Zemek), Departments of Pediatrics and Emergency Medicine, University of Ottawa (Zemek), Ottawa, Ont
| | - Roger Zemek
- Holland Bloorview Kids Rehabilitation Hospital (Reed, Leeder), Department of Occupational Science and Occupational Therapy, University of Toronto (Reed), Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (Zemek), Departments of Pediatrics and Emergency Medicine, University of Ottawa (Zemek), Ottawa, Ont
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Ellis MJ, Russell K. The Potential of Telemedicine to Improve Pediatric Concussion Care in Rural and Remote Communities in Canada. Front Neurol 2019; 10:840. [PMID: 31428043 PMCID: PMC6688625 DOI: 10.3389/fneur.2019.00840] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 07/19/2019] [Indexed: 12/15/2022] Open
Abstract
Concussion is a form of mild traumatic brain injury that affects thousands of Canadian children and adolescents annually. Despite national efforts to harmonize the recognition and management of pediatric concussion in Canada, timely access to primary and specialized care following this injury remains a challenge for many patients especially those who live in rural and remote communities. To address similar challenges facing patients with stroke and other neurological disorders, physicians have begun to leverage advances in telemedicine to improve the delivery of specialized neurological care to those living in medically underserved regions. Preliminary studies suggest that telemedicine may be a safe and cost-effective approach to assist in the medical care of select patients with acute concussion and persistent post-concussion symptoms. Here we provide an overview of telemedicine, teleneurology, the principles of concussion assessment and management, as well as the current state of concussion care in Canada. Utilizing preliminary evidence from studies of telemedicine in concussion and experience from comprehensive systems of care for stroke, we outline steps that must be taken to evaluate the potential of telemedicine-based concussion networks to improve the care of pediatric concussion patients living in underserved rural and remote communities in Canada.
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Affiliation(s)
- Michael J Ellis
- Department of Surgery, University of Manitoba, Winnipeg, MB, Canada.,Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada.,Section of Neurosurgery, University of Manitoba, Winnipeg, MB, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada.,Pan Am Concussion Program, Winnipeg, MB, Canada
| | - Kelly Russell
- Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
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Exploring Sex-Based Differences in Concussion Knowledge, Attitudes and Resources in Young First Nations Hockey Players: A Cross-Sectional Survey from Ontario, Canada. BRAIN IMPAIR 2019. [DOI: 10.1017/brimp.2019.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
AbstractObjective:Indigenous youth are vulnerable to concussion when playing hockey. A clear characterisation of sex differences among Indigenous youth could assist in tailoring future education programmes for prevention and management of concussion. The purpose of this study was to compare and contrast concussion knowledge, attitudes and resources in First Nations girls and boys playing recreational hockey.Method:The cross-sectional survey was conducted in partnership with a First Nations’ chief, other Indigenous community leaders and a tertiary care head injury clinic. In Canada, researchers engaging with Indigenous peoples are expected to adhere to principles of Ownership, Control, Access and Possessions. The study included Indigenous boys and girls between the ages of 10 and 18 years of age.Results:More girls attending the hockey tournament participated in the study as compared to boys (girlsn= 46, boysn= 29). More girls reported they had never experienced a concussion (73.9%), as compared to boys (58.6%) self-reports. Less than half of all study participants were able to identify some signs and symptoms of concussion such as vomiting/nausea, memory problems, fatigue and blurred vision and recognition of several concussion symptoms varied by sex.Conclusions:We created a unique partnership between Indigenous leaders and tertiary care clinic staff. Among Indigenous youth reasons for not reporting concussion symptoms to the coach varied by sex (although not reaching statistical significance), suggesting concussion education warrants tailoring for girls and boys.
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Sandhu H, Wilson K, Reed N, Mihailidis A. A Mobile Phone App for the Self-Management of Pediatric Concussion: Development and Usability Testing. JMIR Hum Factors 2019; 6:e12135. [PMID: 31152527 PMCID: PMC6658289 DOI: 10.2196/12135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 04/09/2019] [Accepted: 04/15/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Concussion is a common injury among Canadian children and adolescents that leads to a range of neurobehavioral deficits. However, noticeable gaps continue to exist in the management of pediatric concussion, with poor health outcomes associated with the inadequate application of best practice guidelines. OBJECTIVE The aim of this study was to describe the development and assess the usability of a mobile phone app to aid youth in the self-management of concussion. A secondary objective was to assess the usefulness of the app. METHODS An agile user-centered design approach was used to develop the technology, followed by a formative lab-based usability study for assessment and improvement proposals. Youths aged 10 to 18 years with a history of concussion and health care professionals involved in concussion management were recruited. This study included participants performing 12 tasks with the mobile phone app while using the think aloud protocol and the administration of the System Usability Scale (SUS), posttest questionnaire, and a semistructured interview. RESULTS A mobile phone app prototype called NeuroCare, an easily accessible pediatric concussion management intervention that provides easy access to expert-informed concussion management strategies and helps guide youth in self-managing and tracking their concussion recovery, was developed. A total of 7 youths aged between 10 and 18 years with a history of concussion and 7 health care professionals were recruited. The mean SUS score was 81.9, mean task success rates were greater than 90% for 92% (11/12) of the tasks, 92% (11/12) of tasks had a total error frequency of less than 11 errors, and mean task completion times were less than 2 min for 100% of the tasks. CONCLUSIONS Results suggest that participants rated this app as highly usable, acceptable to users, and that it may be useful in helping youth self-manage concussion.
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Affiliation(s)
- Harminder Sandhu
- Institute of Biomaterials & Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Katherine Wilson
- Concussion Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
| | - Nick Reed
- Concussion Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada.,Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alex Mihailidis
- Institute of Biomaterials & Biomedical Engineering, University of Toronto, Toronto, ON, Canada.,Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada
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Tarimala A, Singichetti B, Yi H, Huang L, Doerschuk R, Tiso M, Yang J. Initial Emergency Department Visit and Follow-Up Care for Concussions among Children with Medicaid. J Pediatr 2019; 206:178-183. [PMID: 30442410 DOI: 10.1016/j.jpeds.2018.10.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/17/2018] [Accepted: 10/10/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To describe the rates and patterns of initial emergency department (ED) encounters and follow-up care for concussions among Medicaid-insured children before and after the 2013 enactment of Ohio concussion law. STUDY DESIGN Using a time-series design, this study analyzed concussion claim data obtained from Partners for Kids, a pediatric accountable-care organization in Ohio. A total of 12 512 concussions and 48 238 associated claims for services between January 1, 2008, and June 30, 2017, with an initial ED encounter among Medicaid-insured children (ages 0-18 years) were analyzed. The effect of the law on the odds of follow-up care were assessed using generalized estimating equations models, adjusted for sex, age group, and residence location. RESULTS Of the total 12 512 concussions, 63.9% occurred in male patients, 70.1% in patients ages 10-18 years, and 65.2% in patients from urban areas. The rate of initial ED encounters for concussions increased from 2008 to 2014 (2.8 to 4.9 per 10 000 members), followed by a decrease in 2016 (4.2 per 10 000 members). A significant increase in follow-up care after the initial ED encounter was observed from pre-law to post-law (OR 1.73, 95% CI 1.61, 1.86). A shift in follow-up care was observed from radiology and ambulance services in pre-law to primary care providers in post-law. CONCLUSIONS The Ohio concussion law may have influenced the patterns of initial ED visit and follow-up care for concussions among Medicaid-insured children. Future studies evaluating the impact of the law should analyze the utilization patterns among children with various insurance/payment types.
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Affiliation(s)
- Anirudh Tarimala
- Nationwide Children's Hospital, Center for Injury Research and Policy, Columbus, OH; The Ohio State University College of Medicine, Columbus, OH
| | - Bhavna Singichetti
- Nationwide Children's Hospital, Center for Injury Research and Policy, Columbus, OH
| | - Honggang Yi
- Nationwide Children's Hospital, Center for Injury Research and Policy, Columbus, OH; Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Lihong Huang
- Nationwide Children's Hospital, Center for Injury Research and Policy, Columbus, OH
| | | | - Michael Tiso
- The Ohio State University College of Medicine, Columbus, OH
| | - Jingzhen Yang
- Nationwide Children's Hospital, Center for Injury Research and Policy, Columbus, OH; The Ohio State University College of Medicine, Columbus, OH.
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Kroshus E, Qu P, Chrisman SP, Schwien C, Herring SA, Rivara FP. Parental concern about concussion risk for their children. Soc Sci Med 2019; 222:359-366. [DOI: 10.1016/j.socscimed.2018.12.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 12/12/2018] [Accepted: 12/24/2018] [Indexed: 01/07/2023]
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Macartney G, Simoncic V, Goulet K, Aglipay M. Concussion Symptom Prevalence, Severity and Trajectory: Implications for Nursing Practice. J Pediatr Nurs 2018; 40:58-62. [PMID: 29776480 DOI: 10.1016/j.pedn.2018.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 03/08/2018] [Accepted: 03/09/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to describe the symptom severity and trajectory in concussed children who were followed during a one year period at a concussion clinic. DESIGN AND METHODS A retrospective chart review was completed to describe the symptom trajectory up to three months during the recovery. RESULTS One hundred and thirty-six patients were included (74 female, 62 male) with a median age of 15.4years (range 13-17). The most common mechanisms of injury included: falls (19.9%), hockey injuries (15.4%), soccer (14.0%) and football injuries (6.6%). Most concussion symptoms decreased in severity or improved over time. Four symptoms including fatigue/low energy, drowsiness, concentration difficulties and irritability had the highest symptoms scores at both 28 and 84days post-injury in patients with persistent symptoms. Emotionality and nervousness/anxiousness and nausea/vomiting scores were seen to increase over time in patients with persistent symptoms. IMPLICATIONS Clinical use of standardized assessment tools can help caregivers track and monitor concussion symptoms over time. Appropriate management strategies need to be devised for symptoms that are prevalent or increasing over time.
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Affiliation(s)
- Gail Macartney
- Children's Hospital of Eastern Ontario (CHEO), Canada; CHEO Research Institute, Canada.
| | | | - Kristian Goulet
- Children's Hospital of Eastern Ontario (CHEO), Canada; CHEO Research Institute, Canada
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