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Studer M, Heussler M, Romano F, Lidzba K, Bigi S. Processing speed and its association with working memory and episodic memory 3-6 months after pediatric mild traumatic brain injury. Brain Inj 2024; 38:928-937. [PMID: 38819316 DOI: 10.1080/02699052.2024.2361626] [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: 05/08/2023] [Revised: 05/01/2024] [Accepted: 05/27/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVE Following mild traumatic brain injury (mTBI), children show reduced processing speed (PS). Evidence suggests that slowed PS after TBI is associated with working memory deficits. Our aim was to investigate several forms of PS and to examine its impact on working and episodic memory performance in children after mTBI. METHOD We included data of 64 children after mTBI and 57 healthy control children aged 8-16 years. PS (Color Naming, Coding, Symbol Search, Alertness) was compared between groups 1 week (T1) and 3-6 months (T2) after the injury; working and episodic memory outcome was compared between groups at T2. RESULTS Alertness at T1 and Color Naming at T1 and T2 were significantly reduced following mTBI compared to controls, although most group differences in PS disappeared when patients with previous impairments and mTBI were excluded. PS was predictive for episodic and working memory performance 3-6 months after injury, whereas group was a significant predictor of working memory. CONCLUSIONS Compared to healthy controls, children after mTBI showed reduced performance in verbal PS, which was associated with working memory. In children who are symptomatic after mTBI, diagnostic screening of PS could be helpful in identifying patients that could profit from speed-improving strategies.
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Affiliation(s)
- Martina Studer
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital Basel UKBB, Basel, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Milena Heussler
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Fabrizio Romano
- Division of Paediatric Emergency Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Karen Lidzba
- Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Sandra Bigi
- Division of Pediatric Neurology, Department of Pediatrics, Children's Hospital of Central Switzerland, Lucerne, Switzerland
- Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Ewing-Cobbs L, Clark A, Keenan H. Long-term Participation and Functional Status in Children Who Experience Traumatic Brain Injury. J Head Trauma Rehabil 2024; 39:E162-E171. [PMID: 38032836 DOI: 10.1097/htr.0000000000000917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
OBJECTIVE To evaluate the effect of child and family factors on children's participation outcomes 2 to 3 years following traumatic brain injury (TBI). SETTING Two level 1 pediatric trauma centers. PARTICIPANTS Children aged 0 to 15 years with TBI at all severity levels or an orthopedic injury. DESIGN Prospective cohort. MAIN MEASURES Caregivers completed the Child and Adolescent Scale of Participation (CASP) at 2- and 3-year follow-ups. The CASP was categorized as more than 90 or 90 or less on a 100-point scale, with 90 or less representing the 10th percentile and below in this sample. Modified Poisson regression models were used to describe relative risk of the CASP at 90 or less at 2 to 3 years postinjury, adjusting for preinjury family environment variables and injury group. A secondary analysis only included children who were 31 months or older at injury ( n = 441) to determine whether changes in functional outcome (Pediatric Injury Functional Outcome Scale, PIFOS) and executive functions (Behavior Rating Inventory of Executive Function, BRIEF) from preinjury to 1 year after injury predicted CASP scores at the 2- or 3-year follow-up. RESULTS Seventy-eight percent (596/769) of children who had a completed preinjury survey had a completed CASP. In the adjusted model, children with severe TBI had a nearly 3 times higher risk (RR = 2.90; 95% CI, 1.43-5.87) of reduced participation than children with an orthopedic injury. In the secondary analysis, lower functional skills (5-point increase in 1-year postinjury PIFOS score) (RR = 1.36; 95% CI, 1.18-1.57) and less favorable family function (RR = 1.46; 95% CI, 1.02-2.10) were associated with reduced participation in both girls and boys. CONCLUSION Participation in home, school, and community activities after TBI is related to multiple biopsychosocial factors. Participation-focused interventions are needed to reduce barriers to involvement and assist children and families to close the participation gap across settings.
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Affiliation(s)
- Linda Ewing-Cobbs
- Department of Pediatrics and Children's Learning Institute, McGovern Medical School, University of Texas Health Science Center at Houston (Dr Ewing-Cobbs); and Division of Critical Care, Department of Pediatrics, University of Utah (Ms Clark and Dr Keenan)
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3
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Dahl HM, Holthe IL, Andelic N, Løvstad M, Myhre MC. Unmet health care needs over the first 2 years after pediatric traumatic brain injury. Eur J Paediatr Neurol 2024; 49:73-81. [PMID: 38430714 DOI: 10.1016/j.ejpn.2024.01.002] [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: 05/30/2023] [Revised: 12/04/2023] [Accepted: 01/09/2024] [Indexed: 03/05/2024]
Abstract
AIM Few studies have addressed how children and adolescents with traumatic brain injuries (TBIs) access health care and educational services. This study aimed to investigate the course of symptoms during the first two years after TBI, whether symptoms implied a need for health care and/or educational services, and the extent of unmet needs. The association between unmet needs and health-related quality of life was also explored. METHODS This prospective cohort study was conducted at Oslo University Hospital, Norway, from 2015 to 2018. Forty-nine patients aged 1-15 years hospitalized due to TBI were included and followed for 24 months. Registration of symptoms and identification of unmet needs was based on clinical assessment, self-reports and interviews with patients and parents during the acute phase and at 6 and 24 months postinjury. RESULTS Twenty-five percent of the sample presented with unmet needs at 24 months. Compared to the group with no needs and met needs, these patients reported lasting cognitive and emotional symptoms affecting school and social interaction and scored lower on health-related quality of life. CONCLUSION Pediatric patients with TBI may have long-term symptom burden affecting school and social functioning, leading to unmet needs if targeted services are not provided.
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Affiliation(s)
- Hilde Margrete Dahl
- Dept. of Clinical Neurosciences for Children, Section for Child Neurology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Ingvil Laberg Holthe
- Dept. of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway; Dept. of Research, Sunnaas Rehabilitation Hospital Trust, Nesoddtangen, Norway
| | - Nada Andelic
- Dept. of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway; Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Marianne Løvstad
- Dept. of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway; Dept. of Research, Sunnaas Rehabilitation Hospital Trust, Nesoddtangen, Norway
| | - Mia C Myhre
- Norwegian Centre for Violence and Traumatic Stress Studies, Nydalen, Oslo, Norway; Dept. of Neonatal Intensive Care, Oslo University Hospital, Oslo, Norway
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4
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Linden MA, McKinlay A, Hawley C, Aaro-Jonsson C, Kristiansen I, Meyer-Heim A, Ewing-Cobbs L, Wicks B, Beauchamp MH, Prasad R. Further recommendations of the International Paediatric Brain Injury Society (IPBIS) for the post-acute rehabilitation of children with acquired brain injury. Brain Inj 2024; 38:151-159. [PMID: 38329039 DOI: 10.1080/02699052.2024.2309252] [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: 08/11/2022] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Paediatric acquired brain injury is a life-long condition which impacts on all facets of the individual's lived experience. The existing evidence base continues to expand and new fields of enquiry are established as clinicians and researchers uncover the extent of these impacts. PRIMARY OBJECTIVE To add to recommendations described in the International Paediatric Brain Injury Society's 2016 paper on post-acute care for children with acquired brain injury and highlight new areas of enquiry. REVIEW OF INFORMATION Recommendations were made based on the opinions of a group of experienced international clinicians and researchers who are current or past members of the board of directors of the International Paediatric Brain Injury Society. The importance of each recommendation was agreed upon by means of group consensus. OUTCOMES This update gives new consideration to areas of study including injuries which occur in pre-school children, young people in the military, medical referral, young offenders and the use of technology in rehabilitation.
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Affiliation(s)
- Mark A Linden
- School of Nursing & Midwifery, Queen's University Belfast, Belfast, UK
| | | | - Carol Hawley
- Warwick Medical School - Mental Health and Wellbeing, University of Warwick, UK
| | | | - Ingela Kristiansen
- Department of Pediatric Neurology, Uppsala University Hospital, Uppsala, Sweden
| | - Andreas Meyer-Heim
- Rehabilitation Centre, University Children's Hospital Zürich, Zurich, Switzerland
| | - Linda Ewing-Cobbs
- Department of Pediatrics, UTHealth Houston, McGovern Medical School, USA
| | | | - Miriam H Beauchamp
- Department of Psychology, University of Montréal, Montréal, Québec, Canada
| | - Rajendra Prasad
- Department of Neurosurgery, Indraprastha Apollo Hospitals, New Delhi, India
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Duquette-Laplante F, Macaskill M, Jutras B, Jemel B, Koravand A. Brain functional connectivity in children with a mild traumatic brain injury: A scoping review. APPLIED NEUROPSYCHOLOGY. CHILD 2023:1-12. [PMID: 38100747 DOI: 10.1080/21622965.2023.2293248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
INTRODUCTION The occurrence of mild traumatic brain injury(mTBI) is estimated at 0,2-0,3% cases annually. Following a mTBI, some children experience persistent symptoms, and functional connectivity(FC) changes may be implicated. However, characteristics of FC have not been widely described in this population. This scoping review aimed to identify and understand the impacts of mTBI on EEG-measured FC in children, provide an overview of the available literature, detail analysis techniques, and describe gaps in the research. METHODS PubMed, Web of Science, Medline, Embase, ProQuest and CINAHL were searched up to June 25, 2023, with the terms child, mTBI, EEG, FC, and their synonyms. Ten studies were identified. RESULTS Five studies reported significant differences between the mTBI group and controls. In addition to group differences, six studies reported significant variation over time. Brain Network Analysis(BNA), utilized in seven studies, was the primary FC analysis recorded. Two of the five studies that reported significant differences following mTBI utilized the BNA. The other three applied alternative analysis methods. DISCUSSION FC assessment based on EEG can identify some differences in children with mTBI. BNA was more useful in following changes over time. Further research is suggested, considering the limited age range and number of retrieved studies.
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Affiliation(s)
- F Duquette-Laplante
- Audiology and Speech Pathology Program, School of Rehabilitation Sciences, University of Ottawa, Ottawa, Canada
- School of Speech-Language Pathology and Audiology, Université de Montréal, Montreal, Canada
- Research Center, CHU Sainte-Justine, Montreal, Canada
| | - M Macaskill
- Centre de Recherche en Audiologie pédiatrique, Hôpital Necker, Paris, France
| | - B Jutras
- School of Speech-Language Pathology and Audiology, Université de Montréal, Montreal, Canada
- Research Center, CHU Sainte-Justine, Montreal, Canada
| | - B Jemel
- School of Speech-Language Pathology and Audiology, Université de Montréal, Montreal, Canada
- Research Laboratory in Neurosciences and Cognitive Electrophysiology, Research Center CIUSS-NIM, Hôpital Rivière des Prairies, Montréal, Canada
| | - A Koravand
- Audiology and Speech Pathology Program, School of Rehabilitation Sciences, University of Ottawa, Ottawa, Canada
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Shenoy S, Patil S, Samaga VV, HS I. Correlation of clinical features with neuroimaging in children with mild head injury. J Neurosci Rural Pract 2023; 14:650-654. [PMID: 38059221 PMCID: PMC10696321 DOI: 10.25259/jnrp_246_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/25/2023] [Indexed: 12/08/2023] Open
Abstract
Objectives Mild head injury is defined as a pediatric Glasgow Coma Scale (GCS) score of 13-15 at admission following head trauma. There are no clear indications for neuroimaging in such children. The aim of our study was to analyze the correlation of symptoms commonly encountered following mild head injury with any abnormality on the computed tomography (CT) scan. Materials and Methods This is a retrospective and observational study done in a tertiary care hospital. Records of all the children fulfilling the inclusion criteria were retrieved. Demographic details such as age, gender, and type of injury (hit by a blunt object, fall from height, and road traffic accident), symptoms such as presence and number of episodes of vomiting, presence and duration of loss of consciousness (LOC), presence of drowsiness, headache, giddiness, seizures, focal deficits and the GCS score, and CT scan findings were noted in a predesigned proforma. A CT scan with any of the following abnormalities such as skull fracture, cerebral edema, intracranial bleed (epidural hematoma, subdural hematoma, intracerebral hematoma, and subarachnoid hemorrhage), and cerebral contusion was considered as abnormal. Any neurosurgical intervention done was also noted. Results A total of 134 children in the age group of 1 month to 18 years with mild head injury were included in this study. The median (interquartile range) age of the children was 5 (2, 8) years, with majority being males. Road traffic accidents (34.3%) were the most common cause of injury, followed by fall from lesser than 3 feet height (31.3%). The most common symptoms were vomiting (43.6%), scalp/facial abrasions (37.2%), and LOC (31.9%). CT scan was abnormal in 53.7% of the cases, with skull fracture (35.1%) being the most common finding, followed by cerebral edema (13.4%). Among all the symptoms, ear/nosebleed or cerebrospinal fluid (CSF) otorrhea/rhinorrhea had a statistically significant association with a positive CT scan with P = 0.05 and an odds ratio of 1.4 (95% confidence interval, 1-1.9). Conclusion Children with mild head injury presenting with clinical features such as bleeding from the ear or nose and CSF otorrhea/rhinorrhea are more likely to have an abnormal CT scan. Hence, such children require close neurological observation and prompt intervention if necessary. However, abnormality on CT scan cannot be reliably ruled out based on the symptoms alone.
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Affiliation(s)
- Sangeetha Shenoy
- Department of Pediatrics, MS Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Shruti Patil
- Department of Pediatrics, MS Ramaiah Medical College, Bengaluru, Karnataka, India
| | | | - Ila HS
- Department of Pediatrics, MS Ramaiah Medical College, Bengaluru, Karnataka, India
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Cook NE, Kissinger-Knox A, Iverson IA, Liu BC, Gaudet CE, Norman MA, Iverson GL. Social Determinants of Health and Health Equity in the Diagnosis and Management of Pediatric Mild Traumatic Brain Injury: A Content Analysis of Research Underlying Clinical Guidelines. J Neurotrauma 2023; 40:1977-1989. [PMID: 37071186 PMCID: PMC10541940 DOI: 10.1089/neu.2023.0021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
We conducted a content analysis of the literature underlying the Centers for Disease Control and Prevention (CDC) Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children (i.e., the "Guideline") to determine the extent to which social determinants of health (SDoH) were examined or addressed. The systematic review forming the basis for the Guideline included 37 studies addressing diagnosis, prognosis, and treatment/rehabilitation. We examined those studies to identify SDoH domains derived from the U.S. Department of Health and Human Services' Healthy People 2020 and 2030 websites. No study explicitly mentioned "social determinants of health," by name, and few studies addressed SDoH domains as a primary focus (ranging from 0% to 27% of studies across SDoH domains). The most frequently represented SDoH domains, described in an inferential or a descriptive manner, were Education Access and Quality (29.7% of studies), Social and Community Context (27.0% of studies), and Economic Stability (21.6% of studies). Health Care Access (13.5% of studies) was less well represented and no studies (0%) examined Neighborhood and Built Environment. In terms of the CDC clinical questions, SDoH were only examined as predictors of outcome (prognosis) and no studies examined SDoH in relation to diagnosis or treatment/rehabilitation. The Guideline includes some commentary on health literacy and socioeconomic status. Overall, social determinants of health are largely unrepresented as important or meaningful variables influencing the Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children, or in the studies that informed the Guideline.
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Affiliation(s)
- Nathan E. Cook
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- MassGeneral Hospital for Children Sports Concussion Program, Waltham, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Alicia Kissinger-Knox
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Ila A. Iverson
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian C. Liu
- MassGeneral Hospital for Children Sports Concussion Program, Waltham, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Charles E. Gaudet
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- MassGeneral Hospital for Children Sports Concussion Program, Waltham, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Marc A. Norman
- Department of Psychiatry, UC San Diego School of Medicine, San Diego, California, USA
| | - Grant L. Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- MassGeneral Hospital for Children Sports Concussion Program, Waltham, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Shoen Adams Research Institute at Spaulding Rehabilitation, Charlestown, Massachusetts, USA
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8
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Hansen C, Teramoto M, Gardner JE, Capizzi AN. Sport participation among children with complicated mild traumatic brain injury. PM R 2023; 15:943-953. [PMID: 36459541 DOI: 10.1002/pmrj.12928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 10/07/2022] [Accepted: 11/14/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Complicated mild traumatic brain injury (C-mTBI) represents mTBI with positive trauma-related radiographic findings, such as hematoma. It is estimated that 7.5% of all pediatric mTBIs meet these criteria. There is a paucity of research on return to sports in children with C-mTBI. OBJECTIVE To examine children with C-mTBI, mTBI with skull fracture (mTBI-SF) only and mTBI in relation to sport participation and factors associated with repeated injury. DESIGN Cross-sectional survey. SETTING Level I pediatric trauma center. PARTICIPANTS Parents of children who were 5-18 years of age at the time of injury who sustained C-mTBI or mTBI from 2010 to 2013. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Sports participation characteristics before and after injury in children with C-mTBI and mTBI as a function of degree and length of recovery. Repeat mTBI after the index injury was also examined. RESULTS Of 247 children who participated in sports preinjury (27.5% with C-mTBI and 9.7% with mTBI-SF), 95.1% returned to sports. There was no significant difference by mTBI type regarding participation in any sports (p = .811) nor with high-risk sports (p = .128). C-mTBI but not mTBI-SF (versus mTBI) was associated with lower odds of sustaining a repeat mTBI (odds ratio = 0.30, p = .045). Waiting longer (>3 months compared to <1 month) to return to contact sports was associated with lower odds of sustaining a repeat mTBI (odds ratio = 0.23, p < .05). CONCLUSIONS Children with C-mTBI and mTBI-SF resume similar sports as children with mTBI. Those with C-mTBI and those who take longer to return to play may have lower risk of repeat mTBIs. Prospective research is needed to inform the development of evidence-based guidelines for children with C-mTBI and mTBI-SF.
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Affiliation(s)
- Colby Hansen
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, United States
| | - Masaru Teramoto
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, United States
| | - James E Gardner
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Allison N Capizzi
- Department of Physical Medicine & Rehabilitation, VA Palo Alto Polytrauma System of Care, Palo Alto, California, United States
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Steiner M, Lidzba K, Bigi S. Processing Speed in Children with Traumatic Brain Injury. ZEITSCHRIFT FÜR NEUROPSYCHOLOGIE 2023. [DOI: 10.1024/1016-264x/a000370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Abstract: Traumatic brain injury (TBI) is a common cause of childhood morbidity and mortality. Information processing speed (IPS) is a central construct of neuropsychology and a mediator for a range of cognitive functions. In adults, the negative effects of TBI on IPS are well documented. This review qualitatively describes the impact of TBI on IPS in children and adolescents and examines various influencing factors. We included a total of 37 studies in the review that explored IPS using various clinical assessments. These clinical assessments often examine other neuropsychological functions besides IPS. In 29 of these studies, we found a negative effect of TBI on IPS. While injury severity has small but consistent effects on IPS, the effects of age at injury, time since injury, and gender were less evident. Because it is a central construct of neuropsychological functions, IPS should be assessed after TBI.
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Affiliation(s)
- Michelle Steiner
- Department of Pediatrics, Division of Neuropediatrics, Development, and Rehabilitation, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Karen Lidzba
- Department of Pediatrics, Division of Neuropediatrics, Development, and Rehabilitation, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Sandra Bigi
- Department of Pediatrics, Division of Neuropediatrics, Development, and Rehabilitation, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Department of Neurology, Bern University Hospital, University of Bern, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
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10
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Riemann L, Mikolic A, Maas A, Unterberg A, Younsi A. Computed Tomography Lesions and Their Association with Global Outcome in Young People with Mild Traumatic Brain Injury. J Neurotrauma 2023. [PMID: 36578216 DOI: 10.1089/neu.2022.0055] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Mild traumatic brain injury (mTBI) can be accompanied by structural damage to the brain. Here, we investigated how the presence of intracranial traumatic computed tomography (CT) pathologies relates to the global functional outcome in young patients one year after mTBI. All patients with mTBI (Glasgow Coma Scale: 13-15) ≤24 years in the multi-center, prospective, observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study were included. Patient demographics and CT findings were assessed at admission, and the Glasgow Outcome Scale Extended (GOSE) was evaluated at 12 months follow-up. The association between a "positive CT" (at least one of the following: epidural hematoma, subdural hematoma, traumatic subarachnoid hemorrhage (tSAH), intraventricular hemorrhage, subdural collection mixed density, contusion, traumatic axonal injury) and functional outcome (GOSE) was assessed using multi-variable mixed ordinal and logistic regression models. A total of 462 patients with mTBI and initial brain CT from 46 study centers were included. The median age was 19 (17-22) years, and 322 (70%) were males. CT imaging showed a traumatic intracranial pathology in 171 patients (37%), most commonly tSAH (48%), contusions (40%), and epidural hematomas (37%). Patients with a positive CT scan were less likely to achieve a complete recovery 12 months post-injury. The presence of any CT abnormality was associated with both lower GOSE scores (odds ratio [OR]: 0.39 [0.24-0.63]) and incomplete recovery (GOSE <8; OR: 0.41 [0.25-0.68]), also when adjusted for demographical and clinical baseline factors. The presence of intracranial traumatic CT pathologies was predictive of outcome 12 months after mTBI in young patients, which might help to identify candidates for early follow-up and additional care.
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Affiliation(s)
- Lennart Riemann
- Department of Neurosurgery, University Hospital Heidelberg, Germany
| | - Ana Mikolic
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | | | - Alexander Younsi
- Department of Neurosurgery, University Hospital Heidelberg, Germany
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11
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Kooper CC, van der Zee CW, Oosterlaan J, Plötz FB, Königs M. Prediction Models for Neurocognitive Outcome of Mild Traumatic Brain Injury in Children: A Systematic Review. J Neurotrauma 2023. [PMID: 36472215 DOI: 10.1089/neu.2022.0369] [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: 12/12/2022] Open
Abstract
Mild traumatic brain injury (mTBI) is highly prevalent in children. Recent literature suggests that children with mTBI are at considerable risk of persisting neurocognitive deficits, threatening post-injury child development. Nevertheless, clinical tools for early identification of children at risk are currently not available. This systematic review aims to describe the available literature on neurocognitive outcome prediction models in children with mTBI. Findings are highly relevant for early identification of children at risk of persistent neurocognitive deficits, allowing targeted treatment of these children to optimize recovery. The electronic literature search was conducted in PubMed, EMBASE, CINAHL, Cochrane, PsychINFO and Web of Science on February 9, 2022. We included all studies with multi-variate models for neurocognitive outcome based on original data from only children (age <18 years) with mTBI. Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, two authors independently performed data extraction and risk of bias analysis using the Prediction model Risk of Bias Assessment Tool (PROBAST). This systematic review identified eight original studies (nine articles) reporting prediction models for neurocognitive outcome, representing a total of 1033 children diagnosed with mTBI (mean age at injury = 10.5 years, 37.6% girls). Neurocognitive outcome assessment took place between 1 month and 7 years post-injury. Models were identified with significant predictive value for the following outcomes: memory, working memory, inhibition, processing speed, and general neurocognitive functioning. Prediction performance of these models varied greatly between weak and substantial (R2 = 10.0%-54.7%). The best performing model was based on demographic and pre-morbid risk factors in conjunction with a subacute neurocognitive screening to predict the presence of a deficit in general neurocognitive functioning at 12 months post-injury. This systematic review reflects the absence of robust prediction models for neurocognitive outcome of children with mTBI. The findings indicate that demographic factors, pre-morbid factors as well as acute and subacute clinical factors have relevance for neurocognitive outcome. Based on the available evidence, evaluation of demographic and pre-morbid risk factors in conjunction with a subacute neurocognitive screening may have the best potential to predict neurocognitive outcome in children with mTBI. The findings underline the importance of future research contributing to early identification of children at risk of persisting neurocognitive deficits.
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Affiliation(s)
- Cece C Kooper
- Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Department of Pediatrics, Amsterdam, the Netherlands.,Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Emma Neuroscience Group, Amsterdam, the Netherlands.,Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Carlijn W van der Zee
- Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Department of Pediatrics, Amsterdam, the Netherlands
| | - Jaap Oosterlaan
- Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Department of Pediatrics, Amsterdam, the Netherlands.,Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Emma Neuroscience Group, Amsterdam, the Netherlands.,Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Follow-Me Program, Amsterdam, the Netherlands.,Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Frans B Plötz
- Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Department of Pediatrics, Amsterdam, the Netherlands.,Tergooi Hospital, Department of Pediatrics, Blaricum, the Netherlands
| | - Marsh Königs
- Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Department of Pediatrics, Amsterdam, the Netherlands.,Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Emma Neuroscience Group, Amsterdam, the Netherlands.,Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Follow-Me Program, Amsterdam, the Netherlands.,Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
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12
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Keenan HT, Clark A, Holubkov R, Ewing-Cobbs L. Longitudinal Developmental Outcomes of Infants and Toddlers With Traumatic Brain Injury. JAMA Netw Open 2023; 6:e2251195. [PMID: 36648943 PMCID: PMC9856699 DOI: 10.1001/jamanetworkopen.2022.51195] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
IMPORTANCE Among children, infants and toddlers have some of the highest rates of traumatic brain injury (TBI), but longitudinal information on their developmental outcomes to guide postinjury surveillance is sparse. OBJECTIVE To evaluate infants' and toddlers' development over 3 years following TBI compared with those with orthopedic injury (OI). DESIGN, SETTING, AND PARTICIPANTS A longitudinal observational cohort study was conducted at 2 level 1 pediatric trauma centers from January 20, 2013, to September 30, 2015; data analysis was performed from May 12 to October 20, 2021. Participants included children injured when younger than 31 months with TBI or OI who received emergency department care. EXPOSURES Mild, moderate, or severe TBI or OI. MAIN OUTCOMES AND MEASURES Parents completed baseline measures representing preinjury status and 3-, 12-, 24-, and 36-month postinjury status, using the Ages & Stages Questionnaire-3 (ASQ-3), with a mean reference value of 50 and higher scores indicating more advanced development. Linear mixed models characterized children's outcomes for each ASQ-3 domain after adjustment for baseline ASQ-3, injury severity and group, age, injury mechanism (abuse or not), sex, prematurity, family function, social capital, and time. Interactions with time were evaluated. RESULTS Consent for participation was provided for 195 children; 184 parents (94%) completed a baseline survey. The cohort included 168 children who completed at least 1 follow-up survey: 48 (29%) mild; 54 (32%) complicated mild/moderate; 21 (13%) severe TBI; and 45 (27%) orthopedic injury. The cohort included 95 boys (57%), 49% injured before age 1 year; and 13% injured by abuse. Mean (SD) age at the time of injury was 13.9 (9.4) months. At 36 months, children with mild or complicated mild/moderate TBI performed similarly to children with OI across ASQ-3 domains. Children with severe TBI performed poorly as shown by negative mean differences in communication (-8.8; 95% CI, -13.8 to -3.8); gross motor (-10.1; 95% CI, -15.1 to -5.1); problem solving (-6.6; 95% CI, -11.2 to -1.9), and personal social (-6.3; 95% CI, -10.4 to -2.1) domains with little recovery over time. Children with abusive injury experienced decrements in ability over time in fine motor and personal social skills. Social capital was protective in communication (mean, 1.5; 95% CI, 0.3-2.7) and problem solving (mean, 1.2; 95% CI, 0.1-2.3) domains. CONCLUSIONS AND RELEVANCE In this cohort study of children with TBI, children with severe injury showed little recovery. These findings suggest that early childhood intervention is needed, while children with milder injury remained on their developmental track and should continue routine developmental surveillance.
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Affiliation(s)
- Heather T. Keenan
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Amy Clark
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Rich Holubkov
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Linda Ewing-Cobbs
- Department of Pediatrics and Children’s Learning Institute, McGovern Medical School, University of Texas Health Science Center at Houston
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13
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A model for estimating the brainstem volume in normal healthy individuals and its application to diffuse axonal injury patients. Sci Rep 2023; 13:33. [PMID: 36593347 PMCID: PMC9807567 DOI: 10.1038/s41598-022-27202-x] [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: 09/08/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023] Open
Abstract
Diffuse axonal injury (DAI) is a subtype of traumatic brain injury that causes acute-phase consciousness disorders and widespread chronic-phase brain atrophy. Considering the importance of brainstem damage in DAI, a valid method for evaluating brainstem volume is required. We obtained volume measurements from 182 healthy adults by analyzing T1-weighted magnetic resonance images, and created an age-/sex-/intracranial volume-based quantitative model to estimate the normal healthy volume of the brainstem and cerebrum. We then applied this model to the volume measurements of 22 DAI patients, most of whom were in the long-term chronic phase and had no gross focal injury, to estimate the percentage difference in volume from the expected normal healthy volume in different brain regions, and investigated its association with the duration of posttraumatic amnesia (which is an early marker of injury severity). The average loss of the whole brainstem was 13.9%. Moreover, the percentage loss of the whole brainstem, and particularly of the pons and midbrain, was significantly negatively correlated with the duration of posttraumatic amnesia. Our findings suggest that injury severity, as denoted by the duration of posttraumatic amnesia, is among the factors affecting the chronic-phase brainstem volume in patients with DAI.
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14
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Hageman G, Nihom J. A Child Presenting with a Glasgow Coma Scale Score of 13: Mild or Moderate Traumatic Brain Injury? A Narrative Review. Neuropediatrics 2022; 53:83-95. [PMID: 34879424 DOI: 10.1055/s-0041-1740455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The objective of this article was to compare children with traumatic brain injury (TBI) and Glasgow Coma Scale score (GCS) 13 with children presenting with GCS 14 and 15 and GCS 9 to 12. DATA SOURCE We searched PubMed for clinical studies of children of 0 to 18 years of age with mild TBI (mTBI) and moderate TBI, published in English language in the period of 2000 to 2020. STUDY SELECTION We selected studies sub-classifying children with GCS 13 in comparison with GCS 14 and 15 and 9 to 12. We excluded reviews, meta-analyses, non-U.S./European population studies, studies of abusive head trauma, and severe TBI. DATA SYNTHESIS Most children (>85%) with an mTBI present at the emergency department with an initial GCS 15. A minority of only 5% present with GCS 13, 40% of which sustain a high-energy trauma. Compared with GCS 15, they present with a longer duration of unconsciousness and of post-traumatic amnesia. More often head computerized tomography scans show abnormalities (in 9-16%), leading to neurosurgical intervention in 3 to 8%. Also, higher rates of severe extracranial injury are reported. Admission is indicated in more than 90%, with a median length of hospitalization of more than 4 days and 28% requiring intensive care unit level care. These data are more consistent with children with GCS 9 to 12. In children with GCS 15, all these numbers are much lower. CONCLUSION We advocate classifying children with GCS 13 as moderate TBI and treat them accordingly.
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Affiliation(s)
- Gerard Hageman
- Department of Neurology, Medical Spectrum Enschede, Hospital Enschede, Enschede, The Netherlands
| | - Jik Nihom
- Department of Neurology, Medical Spectrum Enschede, Hospital Enschede, Enschede, The Netherlands
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15
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Hansen C, Waller LC, Brady D, Teramoto M. Relationship Between CT Head Findings and Long-term Recovery in Children with Complicated Mild Traumatic Brain Injury. Brain Inj 2022; 36:77-86. [PMID: 35129405 DOI: 10.1080/02699052.2022.2034947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
PRIMARY OBJECTIVE Complicated mild traumatic brain injury (C-mTBI) refers to CT positive patients with clinically mild TBI. This study investigates the association between CT head findings at time of injury and recovery of paediatric patients with C-mTBI. RESEARCH DESIGN Retrospective survey and chart review. METHODS For paediatric patients with C-mTBI (N = 77), CT findings associated with corresponding degree and lengths of recovery from C-mTBI using logistic regression analysis. RESULTS There was a trend that the odds of incomplete recovery at the time of survey was higher for older children than for younger children (OR = 1.14, 95% CI = 0.98-1.32, p = 0.072). There was a trend that the odds of incomplete recovery (OR = 6.26, 95% CI = 0.97-40.57, p = 0.054) and longer duration for recovery (OR = 8.14, 95% CI = 0.78-84.46, p = 0.079) was higher for children with multiple haemorrhagic contusions than those with single haemorrhagic contusion. No other imaging patterns predicted degree or length of recovery with statistical significance (p > 0.05). CONCLUSIONS Other than the presence of multiple haemorrhagic contusions, no other pattern of imaging abnormality in paediatric C-mTBI appears to be associated with degree or length of recovery. Further studies with larger cohorts are encouraged.
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Affiliation(s)
- Colby Hansen
- Department of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Laura C Waller
- Department of Rehabilitation Medicine, Essentia Health, Duluth, Minnesota, USA
| | - Dalton Brady
- Department of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Masaru Teramoto
- Department of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, Utah, USA
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16
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Hanalioglu S, Hanalioglu D, Elbir C, Sahin O, Sahin B, Turkoglu M, Kertmen H. Clinical course and outcomes of complicated mild traumatic brain injury in children: A single-center series of 124 cases. NEUROL SCI NEUROPHYS 2022. [DOI: 10.4103/nsn.nsn_35_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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17
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Fisher ER, Montroy JJ, Duque G, Cox CS, Ewing-Cobbs L. Post-Concussion and Post-Traumatic Stress Symptoms after Pediatric Traumatic Brain Injury: Shared Vulnerability Factors? J Neurotrauma 2021; 38:2600-2609. [PMID: 33899522 PMCID: PMC8403207 DOI: 10.1089/neu.2020.7541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Following pediatric traumatic brain injury (TBI), post-concussion symptoms (PCS) and post-traumatic stress symptoms (PTSS) occur commonly; however, it is unknown to what degree they overlap. The study examined PCS and PTSS persisting 7 weeks after injury in children and adolescents ages 8-15 years with TBI (n = 89) or extracranial injury (EI; n = 40) after vehicle collisions. TBI was divided into mild, complicated-mild/moderate, and severe groups. Parents retrospectively rated children's pre-injury symptoms and behavior problems, and children completed self-report measures after injury. PCS and PTSS total scores were significantly correlated in TBI and EI groups, respectively, for child (rs = 0.75; rs = 0.44), and adolescent (rs = 0.61; rs = 0.67) cohorts. Generalized linear models examined whether injury type and severity, age, sex, and pre-injury symptom ratings predicted PCS and PTSS total scores and factor scores. Specific PCS and PTSS factor scores were elevated in different TBI severity groups, with most frequent problems following mild or severe TBI. PCS did not differ by age; however, girls had more emotional symptoms than boys. Only PTSS were predicted by pre-injury externalizing behavior. Significant age by sex interactions indicated that adolescent girls had more total, avoidance, and hyperarousal PTSS symptoms than younger girls or all boys. PCS and PTSS significantly overlapped in both TBI and EI groups, highlighting shared persistent symptoms after injury. Shared vulnerability factors included female sex, milder TBI, and poorer pre-injury adjustment. Older age was a unique vulnerability factor for PTSS. Psychological health interventions after injury should be customized to address comorbid symptoms.
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Affiliation(s)
- Emily R. Fisher
- Children's Learning Institute and Department of Pediatrics, McGovern School of Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Janelle J. Montroy
- Children's Learning Institute and Department of Pediatrics, McGovern School of Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Gerardo Duque
- Children's Learning Institute and Department of Pediatrics, McGovern School of Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles S. Cox
- Department of Pediatric Surgery, McGovern School of Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Linda Ewing-Cobbs
- Children's Learning Institute and Department of Pediatrics, McGovern School of Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
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18
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Quinn de Launay K, Martino A, Riggs L, Reed N, Beal DS. Pediatric concussion working memory outcomes: a scoping review. Brain Inj 2021; 35:1121-1133. [PMID: 34506212 DOI: 10.1080/02699052.2021.1972148] [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: Characterize the working memory (WM) profile of children and youth who have experienced concussion by systematically synthesizing existing literature on the neuropsychological outcomes of these injuries.Methods: Implemented a peer-reviewed search strategy combining key concepts of concussion/mild traumatic brain injury (mTBI), WM, and pediatrics across MedLine, Embase, PsycINFO, and CINAHL. Included studies written in English with extractable results on a WM outcome measure in individuals aged 21 and under who experienced concussion. Applied narrative synthesis to identify trends in the literature. Assessed risk of bias and quality using the NHLBI's Quality Assessment of Observational Cohort and Cross-Sectional Studies.Results: 40 articles met inclusion criteria. 34/40 studies compared WM performance in children or youth with concussion to healthy controls, pre-injury performance, or normative values, of which 15 reported significantly lower WM performance in the concussion sample. Visual/spatial WM was more consistently impacted than verbal WM. Cognitive demanding dual-task conditions were also reliably impacted.Conclusion: Literature indicated that WM is vulnerable to negative outcomes following pediatric concussion, yet the nature of outcomes is variable. Clinicians and researchers should implement comprehensive and theoretically motivated WM assessments to better understand the WM components impacted by injury.
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Affiliation(s)
- Keelia Quinn de Launay
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
| | - Amanda Martino
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
| | - Lily Riggs
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
| | - Nick Reed
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada.,Department of Occupational Science and Occupational Therapy, Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
| | - Deryk S Beal
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada.,Department of Speech-Language Pathology, Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
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19
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Jones KM, Starkey N, Barker-Collo S, Ameratunga S, Theadom A, Pocock K, Borotkanics R, Feigin VL. Parent and Teacher-Reported Child Outcomes Seven Years After Mild Traumatic Brain Injury: A Nested Case Control Study. Front Neurol 2021; 12:683661. [PMID: 34367050 PMCID: PMC8342814 DOI: 10.3389/fneur.2021.683661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 06/16/2021] [Indexed: 11/19/2022] Open
Abstract
Background: Increasing evidence suggests potential lifetime effects following mild traumatic brain injury (TBI) in childhood. Few studies have examined medium-term outcomes among hospitalized and non-hospitalized samples. Study aims were to describe children's behavioral and emotional adjustment, executive function (EF), quality of life, and participation at 7-years following mild TBI using parents' and teachers' reports. Methods: Nested case control study of 86 children (68% male, mean age at assessment = 11.27 years; range 7-17 years) who sustained a mild TBI 7-years previously, identified from a prospective, population-based study. They were compared to 69 children free from TBI (61% male, mean age at assessment = 11.12 years; range 5-17 years). In addition to parent-reported socio-demographic details, parents (mild TBI n = 86, non-TBI n = 69) completed age-appropriate standardized questionnaires about children's health-related quality of life, behavioral and emotional adjustment, EF, and social participation. Parents own mood was assessed using the Hospital Anxiety and Depression Scale. Teachers (mild TBI n = 53, non-TBI n = 42) completed questionnaires about children's behavioral and emotional adjustment, and EF. Results: Parent reports showed median group-level scores for cases were statistically significantly greater than controls for emotional symptoms, conduct problems, hyperactivity/inattention, total behavioral difficulties, inhibitory control, shifting, planning/organizing, and Global Executive Composite (total) EF difficulties (p-values 0.001-0.029). Parent reports of child quality of life and social participation were similar, as were teacher reports of child behavioral and emotional adjustment, and EF (p > 0.05). When examining clinical cut-offs, compared to controls, cases had a higher risk of parent-reported total EF difficulties (odds ratio = 3.00) and, to a lesser extent, total behavior problems (odds ratio = 2.51). Conclusions: As a group, children with a history of mild TBI may be at elevated risk for clinically significant everyday EF difficulties in the medium-term compared to non-TBI controls, as judged by their parents. Further multi-informant longitudinal research is required, following larger samples. Aspects requiring particular attention include pre-injury characteristics, such as sleep disturbances and comorbidities (e.g., headaches), that may act as potential confounders influencing the association between mild TBI and child behavioral problems.
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Affiliation(s)
- Kelly M. Jones
- School of Clinical Sciences, National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
| | - Nicola Starkey
- Division of Arts, Law, Psychology & Social Sciences, School of Psychology, University of Waikato, Hamilton, New Zealand
| | - Suzanne Barker-Collo
- Faculty of Science, School of Psychology, The University of Auckland, Auckland, New Zealand
| | - Shanthi Ameratunga
- Faculty of Science, School of Psychology, The University of Auckland, Auckland, New Zealand
- UCL Research Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Alice Theadom
- School of Clinical Sciences, National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
| | - Katy Pocock
- School of Clinical Sciences, National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
| | - Robert Borotkanics
- Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Valery L. Feigin
- School of Clinical Sciences, National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
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20
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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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21
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Ewing-Cobbs L, Montroy JJ, Clark AE, Holubkov R, Cox CS, Keenan HT. As Time Goes by: Understanding Child and Family Factors Shaping Behavioral Outcomes After Traumatic Brain Injury. Front Neurol 2021; 12:687740. [PMID: 34290664 PMCID: PMC8287068 DOI: 10.3389/fneur.2021.687740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/25/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To model pre-injury child and family factors associated with the trajectory of internalizing and externalizing behavior problems across the first 3 years in children with pediatric traumatic brain injury (TBI) relative to children with orthopedic injuries (OI). Parent-reported emotional symptoms and conduct problems were expected to have unique and shared predictors. We hypothesized that TBI, female sex, greater pre-injury executive dysfunction, adjustment problems, lower income, and family dysfunction would be associated with less favorable outcomes. Methods: In a prospective longitudinal cohort study, we examined the level of behavior problems at 12 months after injury and rate of change from pre-injury to 12 months and from 12 to 36 months in children ages 4-15 years with mild to severe TBI relative to children with OI. A structural equation model framework incorporated injury characteristics, child demographic variables, as well as pre-injury child reserve and family attributes. Internalizing and externalizing behavior problems were indexed using the parent-rated Emotional Symptoms and Conduct Problems scales from the Strengths and Difficulties questionnaire. Results: The analysis cohort of 534 children [64% boys, M (SD) 8.8 (4.3) years of age] included 395 with mild to severe TBI and 139 with OI. Behavior ratings were higher after TBI than OI but did not differ by TBI severity. TBI, higher pre-injury executive dysfunction, and lower income predicted the level and trajectory of both Emotional Symptoms and Conduct Problems at 12 months. Female sex and poorer family functioning were vulnerability factors associated with greater increase and change in Emotional Symptoms by 12 months after injury; unique predictors of Conduct Problems included younger age and prior emotional/behavioral problems. Across the long-term follow-up from 12 to 36 months, Emotional Symptoms increased significantly and Conduct Problems stabilized. TBI was not a significant predictor of change during the chronic stage of recovery. Conclusions: After TBI, Emotional Symptoms and Conduct Problem scores were elevated, had different trajectories of change, increased or stayed elevated from 12 to 36 months after TBI, and did not return to pre-injury levels across the 3 year follow-up. These findings highlight the importance of addressing behavioral problems after TBI across an extended time frame.
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Affiliation(s)
- Linda Ewing-Cobbs
- Department of Pediatrics and Children's Learning Institute, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Janelle J. Montroy
- Department of Pediatrics and Children's Learning Institute, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Amy E. Clark
- Department of Pediatrics, Division of Critical Care, School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Richard Holubkov
- Department of Pediatrics, Division of Critical Care, School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Charles S. Cox
- Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Heather T. Keenan
- Department of Pediatrics, Division of Critical Care, School of Medicine, University of Utah, Salt Lake City, UT, United States
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22
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Sarmiento K, Daugherty J, Haarbauer-Krupa J. Healthcare Providers' Self-Reported Pediatric Mild Traumatic Brain Injury Diagnosis, Prognosis, and Management Practices: Findings From the 2019 DocStyles Survey. J Head Trauma Rehabil 2021; 36:282-292. [PMID: 33656487 PMCID: PMC8249309 DOI: 10.1097/htr.0000000000000671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess adherence to 5 key recommendations in the Centers for Disease Control and Prevention evidence-based guideline on pediatric mild traumatic brain injury, this article presents results from the 2019 DocStyles survey. STUDY DESIGN Cross-sectional, web-based survey of 653 healthcare providers. RESULTS Most healthcare providers reported adhering to the recommendations regarding the use of computed tomography and providing education and reassurance to patients and their families. However, less than half reported routinely examining their patients with mild traumatic brain injury (mTBI) using age-appropriate, validated symptom scales, assessing for risk factors for prolonged recovery, and advising patients to return to noncontact, light aerobic activities within 2 to 3 days. Self-reported mTBI diagnosis, prognosis, and management practices varied by specialty. Only 3.8% of healthcare providers answered all 7 questions in a way that is most consistent with the 5 recommendations examined from the Centers for Disease Control and Prevention Pediatric mTBI Guideline. CONCLUSION This study highlights several important information gaps regarding pediatric mTBI diagnosis and management. Further efforts to improve adoption of guideline recommendations may be beneficial to ensure optimal outcomes for children following an mTBI.
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Affiliation(s)
- Kelly Sarmiento
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Injury Prevention, Atlanta, GA
| | - Jill Daugherty
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Injury Prevention, Atlanta, GA
| | - Juliet Haarbauer-Krupa
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Injury Prevention, Atlanta, GA
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23
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Madaan P, Gupta D, Agrawal D, Kumar A, Jauhari P, Chakrabarty B, Sharma S, Pandey RM, Paul VK, Misra MC, Gulati S. Neurocognitive Outcomes and Their Diffusion Tensor Imaging Correlates in Children With Mild Traumatic Brain Injury. J Child Neurol 2021; 36:664-672. [PMID: 33624545 DOI: 10.1177/0883073821996095] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This study aimed to assess the neurocognitive outcomes and their diffusion tensor imaging correlates in children (aged 6-16 years) with mild traumatic brain injury. This prospective analysis included 74 children with mild traumatic brain injury (52 boys; mean age: 9.5 [±2.7] years). Wechsler Intelligence Scale for Children-Indian adaptation (WISC-IV), Child Behavior Checklist, and Children's Sleep Habits Questionnaire were administered for 57 cases (at 3 months postinjury) and 51 controls of similar age. The findings of diffusion tensor imaging (done within 7 days of injury) were correlated with various WISC-IV indices. The presenting features at the time of injury were loss of consciousness (53%), confusion or disorientation (47%), and post-traumatic amnesia (10%). Other features in the acute phase included drowsiness (86%), headache (78%), balance problems (62%), nausea (47%), fatigue (45%), vomiting (35%), nasal or ear bleed (12%), sensitivity to sound and light (12%), etc. At 3 months postinjury, the children with mild traumatic brain injury performed poorly in terms of Intelligence Quotient, perceptual reasoning index, and processing speed index as compared to controls. Based on the Child Behavior Checklist, 17% of children with mild traumatic brain injury had internalizing behavioral problems in comparison with 4% of controls. Prevalence of poor sleepers in the mild traumatic brain injury cohort and controls was 12.3% and 2% respectively. Headache, reduced attention span, and fatigue were common postconcussion symptoms. There was a positive correlation between right uncinate fasciculus fractional anisotropy and verbal comprehension index (r = 0.32; P < .05).
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Affiliation(s)
- Priyanka Madaan
- Child Neurology Division, Center of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, 29751All India Institute of Medical Sciences, New Delhi, India.,Pediatric Neurology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Gupta
- Department of Neurosurgery, 29751All India Institute of Medical Sciences and Jai Prakash Narayan Apex Trauma Centre, New Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery, 29751All India Institute of Medical Sciences and Jai Prakash Narayan Apex Trauma Centre, New Delhi, India
| | - Atin Kumar
- Department of Radiodiagnosis, 29751All India Institute of Medical Sciences and Jai Prakash Narayan Apex Trauma Centre, New Delhi, India
| | - Prashant Jauhari
- Child Neurology Division, Center of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, 29751All India Institute of Medical Sciences, New Delhi, India
| | - Biswaroop Chakrabarty
- Child Neurology Division, Center of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, 29751All India Institute of Medical Sciences, New Delhi, India
| | - Shobha Sharma
- Child Neurology Division, Center of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, 29751All India Institute of Medical Sciences, New Delhi, India
| | - Ravindra M Pandey
- Department of Biostatistics, 29751All India Institute of Medical Sciences, New Delhi, India
| | - Vinod K Paul
- Department of Pediatrics, 29751All India Institute of Medical Sciences, New Delhi, India
| | - Mahesh C Misra
- Department of General Surgery, 29751All India Institute of Medical Sciences and Jai Prakash Narayan Apex Trauma Centre, New Delhi, India
| | - Sheffali Gulati
- Child Neurology Division, Center of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, 29751All India Institute of Medical Sciences, New Delhi, India
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Prus R, Appelhans O, Logash M, Pokotylo P, Nowicki GJ, Ślusarska B. A Histological and Morphometric Assessment of the Adult and Juvenile Rat Livers after Mild Traumatic Brain Injury. Cells 2021; 10:cells10051121. [PMID: 34066539 PMCID: PMC8148537 DOI: 10.3390/cells10051121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/23/2021] [Accepted: 04/27/2021] [Indexed: 11/28/2022] Open
Abstract
Traumatic brain injury (TBI) is one of the most severe problems of modern medicine that plays a dominant role in morbidity and mortality in economically developed countries. Our experimental study aimed to evaluate the histological and morphological changes occurring in the liver of adult and juvenile mildly traumatized rats (mTBI) in a time-dependent model. The experiment was performed on 70 adult white rats at three months of age and 70 juvenile rats aged 20 days. The mTBI was modelled by the Impact-Acceleration Model-free fall of weight in the parieto-occipital area. For histopathological comparison, the samples were taken on the 1st, 3rd, 5th, 7th, 14th, and 21st days after TBI. In adult rats, dominated changes in the microcirculatory bed in the form of blood stasis in sinusoidal capillaries and veins, RBC sludge, and adherence to the vessel wall with the subsequent appearance of perivascular and focal leukocytic infiltrates. In juvenile rats, changes in the parenchyma in the form of hepatocyte dystrophy prevailed. In both groups, the highest manifestation of the changes was observed on 5–7 days of the study. On 14–21 days, compensatory phenomena prevailed in both groups. Mild TBI causes changes in the liver of both adult and juvenile rats. The morphological pattern and dynamics of liver changes, due to mild TBI, are different in adult and juvenile rats.
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Affiliation(s)
- Ruslan Prus
- Department of Normal and Pathological Clinical Anatomy, Odessa National Medical University, UA-65000 Odessa, Ukraine; (R.P.); (O.A.)
| | - Olena Appelhans
- Department of Normal and Pathological Clinical Anatomy, Odessa National Medical University, UA-65000 Odessa, Ukraine; (R.P.); (O.A.)
| | - Maksim Logash
- Department of Normal Anatomy, Lviv National Medical University, UA-79010 Lviv, Ukraine;
- Correspondence: ; Tel.: +48-814-486-810
| | - Petro Pokotylo
- Department of Normal Anatomy, Lviv National Medical University, UA-79010 Lviv, Ukraine;
| | - Grzegorz Józef Nowicki
- Department of Family Medicine and Community Nursing, Medical University of Lublin, PL-20-081 Lublin, Poland; (G.J.N.); (B.Ś.)
| | - Barbara Ślusarska
- Department of Family Medicine and Community Nursing, Medical University of Lublin, PL-20-081 Lublin, Poland; (G.J.N.); (B.Ś.)
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Hardin KY. Prospective Exploration of Cognitive-Communication Changes With Woodcock-Johnson IV Before and After Sport-Related Concussion. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2021; 30:894-907. [PMID: 33784181 PMCID: PMC8702850 DOI: 10.1044/2020_ajslp-20-00110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/13/2020] [Accepted: 12/21/2020] [Indexed: 06/12/2023]
Abstract
Purpose The purpose of this study was to evaluate changes in cognitive-communication performance using Woodcock-Johnson IV Tests (WJIV) from pre-injury baseline to post sport-related concussion. It was hypothesized that individual subtest performances would decrease postinjury in symptomatic individuals. Method This prospective longitudinal observational nested cohort study of collegiate athletes assessed cognitive-communicative performance at preseason baseline and postinjury. Three hundred and forty-two male and female undergraduates at high risk for sport-related concussion participated in preseason assessments, and 18 individuals met criteria post injury. WJIV subtest domains included Word Finding, Speeded Reading Comprehension, Auditory Comprehension, Verbal Working Memory, Story Retell, and Visual Processing (letter and number). The power calculation was not met, and therefore data were conservatively analyzed with descriptive statistics and a planned subgroup analysis based on symptomatology. Results Individual changes from baseline to postinjury were evaluated using differences in standard score performance. For symptomatic individuals, mean negative decreases in performance were found for Retrieval Fluency, Sentence Reading Fluency, Pattern Matchings, and all cluster scores postinjury. Individual performance declines also included decreases in story retell, verbal working memory, and visual processing. Conclusions This study identified within-subject WJIV performance decline in communication domains post sport-related concussion and reinforces that cognitive-communication dysfunction should be considered in mild traumatic brain injury. Key cognitive-communication areas included speeded naming, reading, and verbal memory, though oral comprehension was not sensitive to change. Future clinical research across diverse populations is needed to expand these preliminary findings.
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Affiliation(s)
- Kathryn Y. Hardin
- Department of Speech, Language, and Hearing Sciences, University of Colorado Boulder
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Keenan HT, Clark AE, Holubkov R, Cox CS, Ewing-Cobbs L. Trajectories of Children's Executive Function After Traumatic Brain Injury. JAMA Netw Open 2021; 4:e212624. [PMID: 33739432 PMCID: PMC7980098 DOI: 10.1001/jamanetworkopen.2021.2624] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Executive functions are critical for school and social success. Although these functions are adversely affected by pediatric traumatic brain injury (TBI), recovery patterns are not well established. OBJECTIVE To examine 3-year trajectories of selected children's executive functions after TBI. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was conducted from January 22, 2013, to September 30, 2015, with 3-year follow-up at the level I pediatric trauma centers Primary Children's Hospital in Salt Lake City, Utah and Children's Memorial Hermann Hospital in Houston, Texas. Study participants included children aged 2 to 15 years with TBI or orthopedic injury (OI) who were treated at the participating hospitals. Children were consecutively recruited and stratified by injury severity and age group. A total of 625 children consented and completed a baseline survey; 559 (89%) children completed at least 1 follow-up and composed the analysis cohort. It was hypothesized that recovery would differ by injury severity, age at injury, and sex. Data analyses were performed from June to October 2019. MAIN OUTCOMES AND MEASURES Growth curve models examined the pattern of change in the Emotional Control, Inhibit, Working Memory, and Plan-Organize subscales of the Behavior Rating Inventory of Executive Function (BRIEF) or BRIEF-Preschool. For all BRIEF subscales, higher scores indicate worse symptoms, and a score of 65 or greater represents clinical impairment. RESULTS A total of 559 children (mean [SD] age, 8.6 [4.4] years; 356 boys [64%], 328 non-Hispanic White children [59%]) were included in the study: 155 (28%) children had mild TBI, 162 (29%) had complicated mild or moderate TBI, 90 (16%) had severe TBI, and 152 (27%) had OI. Growth curve trajectories varied by BRIEF subscale and injury severity. Overall, children with TBI did not return to their preinjury baseline, with a stepwise worsening of each outcome at 36 months by TBI severity compared with OI. Among children with severe TBI, trajectories accelerated fastest, indicating increased problems, from injury to 12 months for the Emotional Control (9.0 points; 95% CI, 6.0-11.9 points), Inhibit (3.6 points; 95% CI, 1.6-5.6 points), and Working Memory (7.0 points; 95% CI, 4.1-9.9 points) subscales. Their trajectories plateaued, with a secondary acceleration before 36 months for the Emotional Control and Working Memory subscales. Children with mild TBI had worse 36-month scores on all subscales except Inhibit compared with OI. Recovery patterns were similar for boys and girls. CONCLUSIONS AND RELEVANCE In this longitudinal cohort study of children with TBI, trajectory analysis revealed that some children worsen after a recovery plateau, suggesting a need for longitudinal reassessment beyond 1 year postinjury.
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Affiliation(s)
- Heather T. Keenan
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City
| | - Amy E. Clark
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City
| | - Richard Holubkov
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City
| | - Charles S. Cox
- Department of Pediatric Surgery, McGovern Medical School at Houston, The University of Texas Health Science Center at Houston, Houston
| | - Linda Ewing-Cobbs
- Department of Pediatrics and Children’s Learning Institute, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston
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Karr JE, Iverson GL, Williams MW, Huang SJ, Yang CC. Complicated versus uncomplicated mild traumatic brain injuries: A comparison of psychological, cognitive, and post-concussion symptom outcomes. J Clin Exp Neuropsychol 2020; 42:1049-1058. [PMID: 33161877 DOI: 10.1080/13803395.2020.1841118] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION A complicated mild traumatic brain injury (MTBI) is defined as mild by all clinical severity indicators but is complicated due to a traumatic intracranial abnormality visible on neuroimaging. Researchers have reported mixed findings regarding whether neuropsychological and functional outcomes following complicated MTBI are worse than, or similar to, outcomes following uncomplicated MTBI. This study examined patients referred from a Taiwanese emergency department to a neurosurgical outpatient clinic. Participants with complicated MTBI, uncomplicated MTBI, and those who did not undergo head computed tomography (CT) were compared on psychological, neuropsychological, and post-concussion symptom outcomes within 21 days of injury. METHOD Participants with complicated MTBI (n = 42), uncomplicated MTBI (n = 77), and no head CT (n = 172) completed the Paced Auditory Serial Attention Test, Taiwanese Word Sequence Learning Test, a semantic Verbal Fluency Test, the Checklist of Post-Concussion Symptoms, and the Beck Depression and Anxiety Inventories. RESULTS No significant differences were observed between groups on any measure. For individual post-concussion symptoms, dizziness, anxiety, and attention difficulty were endorsed more often after uncomplicated MTBIs, but these group differences were not significant after controlling for multiple comparisons. CONCLUSIONS Participants with complicated MTBIs did not have worse acute or subacute outcomes than participants with uncomplicated MTBIs or no head CT. These results are consistent with many studies finding comparable outcomes between those with complicated and uncomplicated MTBIs. This study is limited by small sample size and minimal information on intracranial abnormalities, broadly categorizing groups based on positive or negative neuroimaging as opposed to specific lesion types and locations.
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Affiliation(s)
- Justin E Karr
- Department of Psychology, University of Kentucky , Lexington, KY, USA
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School , Boston, MA, USA.,Spaulding Rehabilitation Hospital , Charlestown, MA, USA.,Spaulding Research Institute , Charlestown, MA, USA.,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program , Charlestown, MA, USA
| | | | | | - Chi-Cheng Yang
- Department of Psychology, National Chengchi University , Taipei, Taiwan.,Holistic Mental Health Center, Taipei City Hospital , Taipei, Taiwan
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Bartnik-Olson B, Holshouser B, Ghosh N, Oyoyo UE, Nichols JG, Pivonka-Jones J, Tong K, Ashwal S. Evolving White Matter Injury following Pediatric Traumatic Brain Injury. J Neurotrauma 2020; 38:111-121. [PMID: 32515269 DOI: 10.1089/neu.2019.6574] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
This study is unique in that it examines the evolution of white matter injury very early and at 12 months post-injury in pediatric patients following traumatic brain injury (TBI). Diffusion tensor imaging (DTI) was acquired at two time-points: acutely at 6-17 days and 12 months following a complicated mild (cMild)/moderate (mod) or severe TBI. Regional measures of anisotropy and diffusivity were compared between TBI groups and against a group of age-matched healthy controls and used to predict performance on measures of attention, memory, and intellectual functioning at 12-months post-injury. Analysis of the acute DTI data using tract based spatial statistics revealed a small number of regional decreases in fractional anisotropy (FA) in both the cMild/mod and severe TBI groups compared with controls. These changes were observed in the occipital white matter, anterior limb of the internal capsule (ALIC)/basal ganglia, and corpus callosum. The severe TBI group showed regional differences in axial diffusivity (AD) in the brainstem and corpus callosum that were not seen in the cMild/mod TBI group. By 12-months, widespread decreases in FA and increases in apparent diffusion coefficient (ADC) and radial diffusivity (RD) were observed in both TBI groups compared with controls, with the overall number of regions with abnormal DTI metrics increasing over time. The early changes in regional DTI metrics were associated with 12-month performance IQ scores. These findings suggest that there may be regional differences in the brain's reparative processes or that mechanisms associated with the brain's plasticity to recover may also be region based.
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Affiliation(s)
- Brenda Bartnik-Olson
- Department of Radiology, Loma Linda University Health, Loma Linda, California, USA
| | - Barbara Holshouser
- Department of Radiology, Loma Linda University Health, Loma Linda, California, USA
| | - Nirmalya Ghosh
- Department of Pediatrics, Loma Linda University Health, Loma Linda, California, USA
| | - Udochukwu E Oyoyo
- Department of Radiology, Loma Linda University Health, Loma Linda, California, USA
| | - Joy G Nichols
- Department of Pediatrics, Loma Linda University Health, Loma Linda, California, USA
| | - Jamie Pivonka-Jones
- Department of Pediatrics, Loma Linda University Health, Loma Linda, California, USA
| | - Karen Tong
- Department of Radiology, Loma Linda University Health, Loma Linda, California, USA
| | - Stephen Ashwal
- Department of Pediatrics, Loma Linda University Health, Loma Linda, California, USA
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Stenberg J, Karr JE, Terry DP, Saksvik SB, Vik A, Skandsen T, Silverberg ND, Iverson GL. Developing Cognition Endpoints for the CENTER-TBI Neuropsychological Test Battery. Front Neurol 2020; 11:670. [PMID: 32765400 PMCID: PMC7379151 DOI: 10.3389/fneur.2020.00670] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/05/2020] [Indexed: 12/18/2022] Open
Abstract
Background: Measuring cognitive functioning is common in traumatic brain injury (TBI) research, but no universally accepted method for combining several neuropsychological test scores into composite, or summary, scores exists. This study examined several possible composite scores for the test battery used in the large-scale study Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI). Methods: Participants with mild traumatic brain injury (MTBI; n = 140), orthopedic trauma (n = 72), and healthy community controls (n = 70) from the Trondheim MTBI follow-up study completed the CENTER-TBI test battery at 2 weeks after injury, which includes both traditional paper-and-pencil tests and tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB). Seven composite scores were calculated for the paper and pencil tests, the CANTAB tests, and all tests combined (i.e., 21 composites): the overall test battery mean (OTBM); global deficit score (GDS); neuropsychological deficit score-weighted (NDS-W); low score composite (LSC); and the number of scores ≤5th percentile, ≤16th percentile, or <50th percentile. Results: The OTBM and the number of scores <50th percentile composites had distributional characteristics approaching a normal distribution. The other composites were in general highly skewed and zero-inflated. When the MTBI group, the trauma control group, and the community control group were compared, effect sizes were negligible to small for all composites. Subgroups with vs. without loss of consciousness at the time of injury did not differ on the composite scores and neither did subgroups with complicated vs. uncomplicated MTBIs. Intercorrelations were high within the paper-and-pencil composites, the CANTAB composites, and the combined composites and lower between the paper-and-pencil composites and the CANTAB composites. Conclusion: None of the composites revealed significant differences between participants with MTBI and the two control groups. Some of the composite scores were highly correlated and may be redundant. Additional research on patients with moderate to severe TBIs is needed to determine which scores are most appropriate for TBI clinical trials.
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Affiliation(s)
- Jonas Stenberg
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Justin E Karr
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States.,Spaulding Rehabilitation Hospital, Charlestown, MA, United States.,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, MA, United States.,Spaulding Research Institute, Charlestown, MA, United States
| | - Douglas P Terry
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Spaulding Rehabilitation Hospital, Charlestown, MA, United States.,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, MA, United States
| | - Simen B Saksvik
- Department of Psychology, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne Vik
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Toril Skandsen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Noah D Silverberg
- Department of Psychology, University of British Columbia, Vancouver, BC, Canada.,Division of Physical Medicine & Rehabilitation, University of British Columbia, Vancouver, BC, Canada.,Rehabilitation Research Program, GF Strong Rehabilitation Centre, Vancouver, BC, Canada
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Spaulding Rehabilitation Hospital, Charlestown, MA, United States.,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, MA, United States.,Spaulding Research Institute, Charlestown, MA, United States
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Humphries TJ, Ingram S, Sinha S, Lecky F, Dawson J, Singh R. The effect of socioeconomic deprivation on 12 month Traumatic Brain Injury (TBI) outcome. Brain Inj 2020; 34:343-349. [DOI: 10.1080/02699052.2020.1715481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Thomas Jackson Humphries
- Sheffield Institute of Translational Neuroscience (Sitran), University of Sheffield, Sheffield, UK
- University of Sheffield (Medical School), Sheffield, UK
- Department of Neurosurgery, Sheffield Teaching Hospitals, Sheffield, UK
| | - Sarah Ingram
- Sheffield Institute of Translational Neuroscience (Sitran), University of Sheffield, Sheffield, UK
- University of Sheffield (Medical School), Sheffield, UK
| | - Saurabh Sinha
- Department of Neurosurgery, Sheffield Teaching Hospitals, Sheffield, UK
| | - Fiona Lecky
- Health Services Research, School of Health and Related Research (Scharr), Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK
| | - Jeremy Dawson
- Health Services Research, School of Health and Related Research (Scharr), Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK
| | - Rajiv Singh
- Health Services Research, School of Health and Related Research (Scharr), Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK
- Osborn Neurorehabilitation Unit, Department of Rehabilitation Medicine, Sheffield Teaching Hospitals, Sheffield, UK
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Gardner JE, Teramoto M, Hansen C. Factors Associated With Degree and Length of Recovery in Children With Mild and Complicated Mild Traumatic Brain Injury. Neurosurgery 2019; 85:E842-E850. [PMID: 31058994 DOI: 10.1093/neuros/nyz140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 12/25/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND A complicated mild traumatic brain injury (C-mTBI) is an mTBI with some form of intracranial abnormality identified radiographically. The lack of knowledge in recovery patterns and no clear guidelines on return to activity in children with C-mTBI provide unique challenges to physicians. OBJECTIVE To examine recovery patterns among three cohorts: mTBI, mTBI with skull fracture only (mTBI-SF), and C-mTBI via a cross-sectional survey. METHODS Caregivers of children with mTBI (from hospital database queries 2010-2013) were mailed a questionnaire on preinjury health, postinjury recovery, and activity patterns before and after injury. We examined degree (0-10 with 10 being complete recovery) and length (in months) of recovery in children with mTBI, and associations of potential risk factors to these variables. RESULTS Of the 1777 surveyed, a total of 285 complete responses were analyzed for this study. Data included 175 (61.4%) children with mTBI, 33 (11.6%) children with mTBI-SF, and 77 (27.0%) children with C-mTBI. Older age and C-mTBI (vs mTBI) were significantly associated with a lower degree and longer period of recovery (P < .05). Predicted probabilities of complete recovery for children with mTBI, those with mTBI-SF, and those with C-mTBI were 65.5%, 52.7%, and 40.0%, respectively. Predicted probabilities of not yet completely recovered after more than a year since injury for these groups were 11.3%, 24.4%, and 37.6%, respectively. CONCLUSION These results demonstrate significant differences in children with different forms of mTBI, and argue for further investigation of treatment plans individualized for each form of mTBI.
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Affiliation(s)
- James E Gardner
- School of Medicine, University of Utah, Salt Lake City, Utah
| | - Masaru Teramoto
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Colby Hansen
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, Utah
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Fischer JT, Hannay HJ, Alfano CA, Swank PR, Ewing-Cobbs L. Sleep disturbances and internalizing behavior problems following pediatric traumatic injury. Neuropsychology 2019. [PMID: 29528681 DOI: 10.1037/neu0000420] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE This prospective longitudinal study investigated sleep disturbance (SD) and internalizing problems after traumatic injury, including traumatic brain injury (TBI) or extracranial/bodily injury (EI) in children and adolescents, relative to typically developing (TD) children. We also examined longitudinal relations between SD and internalizing problems postinjury. METHOD Participants (N = 87) ages 8-15 included youth with TBI, EI, and TD children. Injury groups were recruited from a Level 1 trauma center after sustaining vehicle-related injuries. Parent-reported SD and internalizing problems were assessed at preinjury/baseline, and 6 and 12 months postinjury. Linear mixed models evaluated the relation of group and time of assessment on outcomes. RESULTS Controlling for age, the combined traumatic injury group experienced significantly higher postinjury levels of SD (p = .042) and internalizing problems (p = .024) than TD children; however, TBI and EI injury groups did not differ from each other. Injury severity was positively associated with SD in the EI group only, but in both groups SD was associated with additional postinjury sequelae, including fatigue and externalizing behavior problems. Internalizing problems predicted subsequent development of SD but not vice versa. The relation between injury and SD 1 year later was consistent with mediation by internalizing problems at 6 months postinjury. CONCLUSIONS Children with both types of traumatic injury demonstrated higher SD and internalizing problems than healthy children. Internalizing problems occurring either prior to or following pediatric injury may be a risk factor for posttraumatic SD. Consequently, internalizing problems may be a promising target of intervention to improve both SD and related adjustment concerns. (PsycINFO Database Record
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Affiliation(s)
| | - H Julia Hannay
- Texas Institute For Measurement, Evaluation, And Statistics, University of Houston
| | | | - Paul R Swank
- School of Public Health, University of Texas Health Science Center at Houston
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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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King DJ, Ellis KR, Seri S, Wood AG. A systematic review of cross-sectional differences and longitudinal changes to the morphometry of the brain following paediatric traumatic brain injury. Neuroimage Clin 2019; 23:101844. [PMID: 31075554 PMCID: PMC6510969 DOI: 10.1016/j.nicl.2019.101844] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 04/26/2019] [Accepted: 04/29/2019] [Indexed: 01/27/2023]
Abstract
Paediatric traumatic brain injury (pTBI) is a leading cause of disability for children and young adults. Children are a uniquely vulnerable group with the disease process that occurs following a pTBI interacting with the trajectory of normal brain development. Quantitative MRI post-injury has suggested a long-term, neurodegenerative effect of TBI on the morphometry of the brain, in both adult and childhood TBI. Changes to the brain beyond that of anticipated, age-dependant differences may allow us to estimate the state of the brain post-injury and produce clinically relevant predictions for long-term outcome. The current review synthesises the existing literature to assess whether, following pTBI, the morphology of the brain exhibits either i) longitudinal change and/or ii) differences compared to healthy controls and outcomes. The current literature suggests that morphometric differences from controls are apparent cross-sectionally at both acute and late-chronic timepoints post-injury, thus suggesting a non-transient effect of injury. Developmental trajectories of morphometry are altered in TBI groups compared to patients, and it is unlikely that typical maturation overcomes damage post-injury, or even 'catches up' with that of typically-developing peers. However, there is limited evidence for diverted developmental trajectories being associated with cognitive impairment post-injury. The current review also highlights the apparent challenges to the existing literature and potential methods by which these can be addressed.
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Affiliation(s)
- D J King
- School of Life and Health Sciences & Aston Brain Centre, Aston University, Birmingham, UK
| | - K R Ellis
- School of Life and Health Sciences & Aston Brain Centre, Aston University, Birmingham, UK
| | - S Seri
- School of Life and Health Sciences & Aston Brain Centre, Aston University, Birmingham, UK
| | - A G Wood
- School of Life and Health Sciences & Aston Brain Centre, Aston University, Birmingham, UK; Child Neuropsychology, Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia.
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Early Elementary School Outcome in Children With a History of Traumatic Brain Injury Before Age 6 Years. J Head Trauma Rehabil 2019; 34:111-121. [DOI: 10.1097/htr.0000000000000414] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Healthcare Utilization and Missed Workdays for Parents of Children With Traumatic Brain Injury. J Head Trauma Rehabil 2019; 34:257-267. [PMID: 30608307 DOI: 10.1097/htr.0000000000000458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND We enrolled patients in a prospective study in which we obtained estimates of the direct and indirect burden for families of children with traumatic brain injury (TBI) relative to a control group of families of children with orthopedic injury (OI). METHODS Parents were surveyed at 3 time points following injury: 3, 6, and 12 months. At each follow-up contact, we asked parents to list the number of workdays missed, number of miles traveled, amount of travel-related costs, and whether their child had an emergency department (ED) visit, hospital admission, any over-the-counter (OTC) medications, and any prescription medications during that time period. We assessed the difference in these outcomes between the TBI and OI groups using multivariable logistic and 2-part regression models to account for high concentrations of zero values. RESULTS Children with TBI had significantly greater odds of having an ED visit (3.04; 95% CI, 1.12-8.24), OTC medications (1.98; 95% CI, 1.34-2.94), and prescription medications (2.34; 95% CI, 1.19-4.59) than those with OI. In addition, parents of children with TBI missed significantly more days of work (19.91 days; 95% CI, 11.64-28.17) overall during the 12 months following injury than their OI counterparts. CONCLUSION Extrapolating our results to the entire country, we estimate that pediatric TBI is associated with more than 670 000 lost workdays annually over the 12 months following injury, which translates into more than $150 million in lost productivity. These missed workdays and lost productivity may be prevented through safety efforts to reduce pediatric TBI.
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Hansen C, Battikha M, Teramoto M. Complicated Mild Traumatic Brain Injury at a Level I Pediatric Trauma Center: Burden of Care and Imaging Findings. Pediatr Neurol 2019; 90:31-36. [PMID: 30415875 DOI: 10.1016/j.pediatrneurol.2018.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 09/07/2018] [Accepted: 09/28/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aims of this study were: (1) to characterize mild traumatic brain injury (mTBI), mTBI with skull fracture, and complicated mTBI in school-aged children seen at a Level I pediatric trauma center and (2) to examine the nature of imaging findings seen in children with mTBI with skull fracture and those with complicated mTBI. METHODS A total of 1777 pediatric patients (male: 1193 or 67.1%; age = 11.1 ± 3.5 years) sustaining mTBI who presented to the Emergency Department or directly to the trauma service in the years 2010 to 2013 were identified and classified into mTBI (n = 1,319 or 74.2%), mTBI with skull fracture (n = 127 or 7.2%), and complicated mTBI (n = 331 or 18.6%). Patient characteristics and imaging findings were analyzed using descriptive statistics, Pearson's χ2 test, Fisher's exact test, and logistic regression analysis. RESULTS In children with complicated mTBI, subdural hematoma (36.9%) was the most common finding. Of the 331 children with complicated mTBI, 241 (72.8%) had multiple findings compared with one (0.8%) of 127 children having mTBI with skull fracture (Fisher's exact P < 0.001), with logistic regression analysis revealing younger age as a potential risk factor (P < 0.01). Children sustaining a depressed or complex skull fracture were nearly twice as likely as those with simple, linear skull fracture to have intracranial abnormality. CONCLUSIONS Multiple radiographic findings in children sustaining mTBI with skull fracture or complicated mTBI are prevalent (72.8%), with younger age as a potential risk factor.
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Affiliation(s)
- Colby Hansen
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, Utah
| | | | - Masaru Teramoto
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, Utah.
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Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskauer SJ, Giza CC, Joseph M, Broomand C, Weissman B, Gordon W, Wright DW, Moser RS, McAvoy K, Ewing-Cobbs L, Duhaime AC, Putukian M, Holshouser B, Paulk D, Wade SL, Herring SA, Halstead M, Keenan HT, Choe M, Christian CW, Guskiewicz K, Raksin PB, Gregory A, Mucha A, Taylor HG, Callahan JM, DeWitt J, Collins MW, Kirkwood MW, Ragheb J, Ellenbogen RG, Spinks TJ, Ganiats TG, Sabelhaus LJ, Altenhofen K, Hoffman R, Getchius T, Gronseth G, Donnell Z, O'Connor RE, Timmons SD. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr 2018; 172:e182853. [PMID: 30193284 PMCID: PMC7006878 DOI: 10.1001/jamapediatrics.2018.2853] [Citation(s) in RCA: 297] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States. Objective To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI. Evidence Review The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015. Findings The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. Conclusions and Relevance This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.
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Affiliation(s)
| | | | - Kelly Sarmiento
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Matthew J Breiding
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Tamara M Haegerich
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Gerard A Gioia
- Children's National Health System, George Washington University School of Medicine, Washington, DC
| | | | | | - Stacy J Suskauer
- Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher C Giza
- The University of California, Los Angeles (UCLA) Steve Tisch BrainSPORT Program, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles
| | | | - Catherine Broomand
- Center for Neuropsychological Services, Kaiser Permanente, Roseville, California
| | | | - Wayne Gordon
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Karen McAvoy
- Rocky Mountain Hospital for Children, Denver, Colorado
| | - Linda Ewing-Cobbs
- Children's Learning Institute, Department of Pediatrics, University of Texas (UT) Health Science Center at Houston
| | | | - Margot Putukian
- University Health Services, Princeton University, Princeton, New Jersey
| | | | | | - Shari L Wade
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | - Meeryo Choe
- The University of California, Los Angeles (UCLA) Steve Tisch BrainSPORT Program, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles
| | - Cindy W Christian
- Children's Hospital of Philadelphia, Raymond and Ruth Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - P B Raksin
- John H. Stroger, Jr Hospital of Cook County (formerly Cook County Hospital), Chicago, Illinois
| | - Andrew Gregory
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Anne Mucha
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
| | - H Gerry Taylor
- Nationwide Children's Hospital Research Institute, Columbus, Ohio
| | - James M Callahan
- Children's Hospital of Philadelphia, Raymond and Ruth Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - John DeWitt
- Jameson Crane Sports Medicine Institute, School of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus
| | - Michael W Collins
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
| | | | - John Ragheb
- Nicklaus Children's Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Theodore J Spinks
- Department of Pediatric Neurosurgery, St Joseph's Children's Hospital, Tampa, Florida
| | | | | | | | | | - Tom Getchius
- American Academy of Neurology, Minneapolis, Minnesota
| | | | - Zoe Donnell
- Social Marketing Group, ICF, Rockville, Maryland
| | | | - Shelly D Timmons
- Penn State University Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Ewing-Cobbs L, Cox CS, Clark AE, Holubkov R, Keenan HT. Persistent Postconcussion Symptoms After Injury. Pediatrics 2018; 142:e20180939. [PMID: 30323108 PMCID: PMC6317768 DOI: 10.1542/peds.2018-0939] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 12/25/2022] Open
Abstract
: media-1vid110.1542/5828371885001PEDS-VA_2018-0939Video Abstract OBJECTIVES: We examined whether preinjury, demographic, and family factors influenced vulnerability to postconcussion symptoms (PCSs) persisting the year after mild traumatic brain injury (mTBI). METHODS Children with mTBI (n = 119), complicated mild traumatic brain injury (cmTBI) (n = 110), or orthopedic injury (OI) (n = 118), recruited from emergency departments, were enrolled in a prospective, longitudinal cohort study. Caregivers completed retrospective surveys to characterize preinjury demographic, child, and family characteristics. PCSs were assessed using a validated rating scale. With multivariable general linear models adjusted for preinjury symptoms, we examined predictors of PCSs 3, 6, and 12 months after injury in children ages 4 to 8, 9 to 12, and 13 to 15 years at injury. With logistic regression, we examined predictors of chronic PCSs 1 year after traumatic brain injury. RESULTS Postinjury somatic, emotional, cognitive, and fatigue PCSs were similar in the mTBI and cmTBI groups and significantly elevated compared with the OI group. PCS trajectories varied with age and sex. Adolescents had elevated PCSs that improved; young children had lower initial symptoms and less change. Despite similar preinjury PCSs, girls had elevated symptoms across all time points compared with boys. PCS vulnerability factors included female sex, adolescence, preinjury mood problems, lower income, and family discord. Social capital was a protective factor. PCSs persisted in 25% to 31% of the traumatic brain injury group and 18% of the OI group at 1 year postinjury. The odds of chronic PCSs were almost twice as high in girls as in boys and were >4 times higher in young children with cmTBI than in those with mTBI. CONCLUSIONS A significant minority of children with mTBI and OI have PCSs that persisted 1 year after injury.
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Affiliation(s)
| | - Charles S Cox
- Pediatric Surgery, John P. and Katherine G. McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; and
| | - Amy E Clark
- Department of Pediatrics, The University of Utah, Salt Lake City, Utah
| | - Richard Holubkov
- Department of Pediatrics, The University of Utah, Salt Lake City, Utah
| | - Heather T Keenan
- Department of Pediatrics, The University of Utah, Salt Lake City, Utah
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Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskauer SJ, Giza CC, Joseph M, Broomand C, Weissman B, Gordon W, Wright DW, Moser RS, McAvoy K, Ewing-Cobbs L, Duhaime AC, Putukian M, Holshouser B, Paulk D, Wade SL, Herring SA, Halstead M, Keenan HT, Choe M, Christian CW, Guskiewicz K, Raksin PB, Gregory A, Mucha A, Taylor HG, Callahan JM, DeWitt J, Collins MW, Kirkwood MW, Ragheb J, Ellenbogen RG, Spinks TJ, Ganiats TG, Sabelhaus LJ, Altenhofen K, Hoffman R, Getchius T, Gronseth G, Donnell Z, O'Connor RE, Timmons SD. Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review. JAMA Pediatr 2018; 172:e182847. [PMID: 30193325 DOI: 10.1001/jamapediatrics.2018.2847] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In recent years, there has been an exponential increase in the research guiding pediatric mild traumatic brain injury (mTBI) clinical management, in large part because of heightened concerns about the consequences of mTBI, also known as concussion, in children. The CDC National Center for Injury Prevention and Control's (NCIPC) Board of Scientific Counselors (BSC), a federal advisory committee, established the Pediatric Mild TBI Guideline workgroup to complete this systematic review summarizing the first 25 years of literature in this field of study. OBJECTIVE To conduct a systematic review of the pediatric mTBI literature to serve as the foundation for an evidence-based guideline with clinical recommendations associated with the diagnosis and management of pediatric mTBI. EVIDENCE REVIEW Using a modified Delphi process, the authors selected 6 clinical questions on diagnosis, prognosis, and management or treatment of pediatric mTBI. Two consecutive searches were conducted on PubMed, Embase, ERIC, CINAHL, and SportDiscus. The first included the dates January 1, 1990, to November 30, 2012, and an updated search included December 1, 2012, to July 31, 2015. The initial search was completed from December 2012 to January 2013; the updated search, from July 2015 to August 2015. Two authors worked in pairs to abstract study characteristics independently for each article selected for inclusion. A third author adjudicated disagreements. The risk of bias in each study was determined using the American Academy of Neurology Classification of Evidence Scheme. Conclusion statements were developed regarding the evidence within each clinical question, and a level of confidence in the evidence was assigned to each conclusion using a modified GRADE methodology. Data analysis was completed from October 2014 to May 2015 for the initial search and from November 2015 to April 2016 for the updated search. FINDINGS Validated tools are available to assist clinicians in the diagnosis and management of pediatric mTBI. A significant body of research exists to identify features that are associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI, and long-term sequelae. However, high-quality studies of treatments meant to improve mTBI outcomes are currently lacking. CONCLUSIONS AND RELEVANCE This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.
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Affiliation(s)
| | | | - Kelly Sarmiento
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew J Breiding
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tamara M Haegerich
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gerard A Gioia
- Children's National Health System, George Washington University School of Medicine, Washington, DC
| | | | | | - Stacy J Suskauer
- Kennedy Krieger Institute, Johns Hopkins University , Baltimore, Maryland.,Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher C Giza
- UCLA Steve Tisch BrainSPORT Program, University of California, Los Angeles, Mattel Children's Hospital, Los Angeles.,David Geffen School of Medicine at University of California, Los Angeles
| | | | - Catherine Broomand
- Kaiser Permanente, Center for Neuropsychological Services, Roseville, California
| | | | - Wayne Gordon
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Karen McAvoy
- Rocky Mountain Hospital for Children, Denver, Colorado
| | - Linda Ewing-Cobbs
- Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston
| | | | - Margot Putukian
- Princeton University, University Health Service, Princeton, New Jersey
| | | | - David Paulk
- Kaiser Permanente, Center for Neuropsychological Services, Roseville, California
| | - Shari L Wade
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | - Meeryo Choe
- UCLA Steve Tisch BrainSPORT Program, University of California, Los Angeles, Mattel Children's Hospital, Los Angeles.,David Geffen School of Medicine at University of California, Los Angeles
| | - Cindy W Christian
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | - P B Raksin
- John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | - Andrew Gregory
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Anne Mucha
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
| | - H Gerry Taylor
- Nationwide Children's Hospital Research Institute, Columbus, Ohio
| | - James M Callahan
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - John DeWitt
- Jameson Crane Sports Medicine Institute and School of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus
| | - Michael W Collins
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
| | | | - John Ragheb
- Nicklaus Children's Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | | | - T J Spinks
- St. Joseph's Children's Hospital, Department of Pediatric Neurosurgery, Tampa, Florida
| | | | | | | | | | - Tom Getchius
- American Academy of Neurology, Minneapolis, Minnesota
| | | | - Zoe Donnell
- ICF, Social Marketing Group, Rockville, Maryland
| | | | - Shelly D Timmons
- Penn State University, Milton S. Hershey Medical Center, Hershey
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Long-term cognitive outcomes in male and female athletes following sport-related concussions. Int J Psychophysiol 2018; 132:3-8. [DOI: 10.1016/j.ijpsycho.2018.03.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 03/15/2018] [Accepted: 03/19/2018] [Indexed: 11/24/2022]
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The long-term outcomes of sport-related concussion in pediatric populations. Int J Psychophysiol 2018; 132:14-24. [DOI: 10.1016/j.ijpsycho.2018.04.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 03/08/2018] [Accepted: 04/04/2018] [Indexed: 12/14/2022]
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Keenan HT, Presson AP, Clark AE, Cox CS, Ewing-Cobbs L. Longitudinal Developmental Outcomes after Traumatic Brain Injury in Young Children: Are Infants More Vulnerable Than Toddlers? J Neurotrauma 2018; 36:282-292. [PMID: 30019631 DOI: 10.1089/neu.2018.5687] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Children under 4 years of age have the highest incidence of traumatic brain injury (TBI) among the non-elderly and may be at high risk of poor developmental outcomes. We prospectively enrolled a cohort of children injured before 31 months old with TBI or orthopedic injury (OI), from 2013 to 2015 at two pediatric level 1 trauma centers to study very young children's developmental outcomes after injury. We used Ages & Stages-3 and Ages & Stages: Social-Emotional screening tools to measure children's development at pre-injury and 3 and 12 months post-injury. The cohort included 123 children with TBI categorized as mild (n = 48), complicated-mild or moderate (n = 54), and severe (n = 21) and 45 children with OI. Generalized linear models examined effects of injury severity and age at injury controlling for pre-injury ratings. Children with mild or complicated-mild/moderate TBI generally remained on developmental track. Compared to OI, children with severe TBI tended to have a negative developmental trajectory with decrements in communication (-7.07; 95% confidence interval [CI], -13.7, -0.48), gross motor (-15.2; 95% CI, -21.1, -9.19), problem solving (-11.6; 95% CI, -17.9, -5.29), personal-social (-16.8; 95% CI, -22.8, -10.8), and social-emotional (21.0; 95% CI, 7.32, 34.7) domains 12 months post-injury. Developmental effects from TBI differed by age at injury: Infants had more difficulties than older children in communication and problem-solving domains. Despite low developmental scores in 28% of the cohort, only 5% were receiving Early Childhood Intervention (ECI) services 12 months after injury. Early age at injury is a vulnerability factor after TBI. Young age and severe injury should prompt evaluation for ECI.
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Affiliation(s)
- Heather T Keenan
- 1 Department of Pediatrics and Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Angela P Presson
- 1 Department of Pediatrics and Department of Internal Medicine, University of Utah, Salt Lake City, Utah.,2 Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Amy E Clark
- 1 Department of Pediatrics and Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Charles S Cox
- 3 Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, Texas
| | - Linda Ewing-Cobbs
- 4 Department of Pediatrics and Children's Learning Institute, University of Texas Health Science Center at Houston, Houston, Texas
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Pediatricians' Knowledge, Attitudes, and Behaviors to Screening Children After Complicated Mild TBI: A Survey. J Head Trauma Rehabil 2018; 32:385-392. [PMID: 28489701 DOI: 10.1097/htr.0000000000000265] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To understand pediatricians' attitudes, knowledge, and behaviors about the care of children with complicated mild traumatic brain injury (TBI). PARTICIPANTS A total of 3500 pediatricians randomly selected from the American Medical Association Master File. DESIGN It was a cross-sectional survey. MAIN MEASURES A survey developed to assess pediatricians' attitudes toward following children with complicated mild TBI for cognitive and behavioral sequelae; their knowledge of TBI sequelae; and their usual evaluation and management of children after TBI. RESULTS There were 576 (16.5%) completed responses. Most pediatricians (51%) see 1 or 2 patients with complicated mild TBI annually. Most do not think that pediatricians are the correct clinician group to be primarily responsible for following children with complicated mild TBI for cognitive (74%) or behavioral sequelae (54%). Pediatricians report difficulty referring children for cognitive (56%) and behavioral (48%) specialty services. Pediatricians have good knowledge of short-term complications of complicated mild TBI. CONCLUSION Pediatricians do not think they are the clinicians that should primarily care for children after hospitalization for complicated mild TBI; however, other clinicians are frequently not accessible. Pediatricians need educational and referral support to provide surveillance for injury sequelae in this group of children.
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Evans E, Asuzu D, Cook NE, Caruso P, Townsend E, Costine-Bartell B, Fortes-Monteiro C, Hotz G, Duhaime AC. Traumatic Brain Injury-Related Symptoms Reported by Parents: Clinical, Imaging, and Host Predictors in Children with Impairments in Consciousness Less than 24 Hours. J Neurotrauma 2018; 35:2287-2297. [PMID: 29681226 DOI: 10.1089/neu.2017.5408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study examined the relationship between acute neuroimaging, host and injury factors, and parent-reported traumatic brain injury (TBI)-related symptoms in children with noncritical head injury at two weeks and three months after injury. Data were collected prospectively on 45 subjects aged three to 16 years old enrolled in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study. Subjects had rapid recovery of mental status (Glasgow Coma Score [GCS] = 15 within 24 h), and had no clinical need for neurosurgical intervention. Intra- or extra-axial magnetic resonance imaging (MRI) lesions were categorized using Common Data Elements (CDE) definitions. Host and acute injury factors including neurobehavioral history, race, extracranial injuries, loss of consciousness (LOC), and GCS were analyzed while controlling for pre-injury symptoms, age, sex, and socioeconomic status. Parent-reported cognitive and somatic symptoms were measured by the Health and Behavior Inventory (HBI). Forty-nine percent of children had MRI lesions, most of which were relatively small. LOC predicted increased cognitive and somatic symptoms at two weeks. At three months, pre-injury neurobehavioral history predicted increased cognitive and somatic symptoms. Neuroimaging findings did not predict parent-reported symptom severity, except at three months where extra-axial lesions were associated with less severe cognitive symptoms. While structural MRI lesions do not predict increased parent-reported symptoms in this population, age-specific child performance measures may be more sensitive outcome measures and require further study. Children with pre-injury neurobehavioral problems have more severe symptoms at three months and thus may benefit from longer follow-up and monitoring after traumatic brain injury.
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Affiliation(s)
- Emily Evans
- 1 MGH-Institute of Health Professions , Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David Asuzu
- 2 Yale School of Medicine , North Haven, Connecticut
| | - Nathan E Cook
- 3 Department of Physical Medicine and Rehabilitation, Harvard Medical School; Spaulding Rehabilitation Hospital; MassGeneral Hospital for Children™ Sport Concussion Program , Boston, Massachusetts
| | - Paul Caruso
- 4 Department of Radiology, Massachusetts General Hospital , Boston, Massachusetts
| | - Elise Townsend
- 5 Department of Physical Therapy, MGH Institute of Health Professions , Boston, Massachusetts
| | - Beth Costine-Bartell
- 6 Department of Neurosurgery, Massachusetts General Hospital , Harvard Medical School, Boston, Massachusetts
| | - Carla Fortes-Monteiro
- 7 Department of Neurosurgery, Massachusetts General Hospital , Boston, Massachusetts
| | - Gillian Hotz
- 8 KiDZ Neuroscience Center, Department of Neurosurgery, University of Miami Miller School of Medicine , Lois Pope Life Center, Miami, Florida
| | - Ann-Christine Duhaime
- 9 Department of Neurosurgery, Massachusetts General Hospital , Harvard Medical School, Boston, Massachusetts
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Long-Term School Outcomes of Children and Adolescents With Traumatic Brain Injury. J Head Trauma Rehabil 2018; 32:E24-E32. [PMID: 26828713 DOI: 10.1097/htr.0000000000000218] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To better understand the impact of age at injury, severity of injury, and time since injury on long-term school outcomes of children with traumatic brain injury (TBI). PARTICIPANTS Four groups of children: complicated mild/moderate TBI (n = 23), severe TBI (n = 56), orthopedic injury (n = 35), and healthy controls (n = 42). Children with TBI were either 2 years postinjury or 6 years postinjury. DESIGN Cross-sectional design. MEASURES School records as well as parental ratings of functional academic skills and school competency. RESULTS Children with severe TBI had consistently high usage of school services and low school competency ratings than children with orthopedic injuries and healthy controls. In contrast, children with complicated-mild/moderate TBI were significantly more likely to receive school support services and have lower competence ratings at 6 years than at 2 years postinjury. Students injured at younger ages had lower functional academic skill ratings than those injured at older ages. CONCLUSIONS These findings highlight the increasing academic challenges faced over time by students with complicated-mild/moderate TBI and the vulnerability of younger children to poorer development of functional academic skills.
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Crowe LM, Hearps S, Anderson V, Borland ML, Phillips N, Kochar A, Dalton S, Cheek JA, Gilhotra Y, Furyk J, Neutze J, Lyttle MD, Bressan S, Donath S, Molesworth C, Oakley E, Dalziel SR, Babl FE. Investigating the Variability in Mild Traumatic Brain Injury Definitions: A Prospective Cohort Study. Arch Phys Med Rehabil 2018; 99:1360-1369. [PMID: 29407521 DOI: 10.1016/j.apmr.2017.12.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 12/11/2017] [Accepted: 12/14/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To prospectively compare the proportion of traumatic brain injuries (TBIs) that would be classified as mild by applying different published definitions of mild TBI to a large prospectively collected dataset, and to examine the variability in the proportions included by various definitions. DESIGN Prospective observational study. SETTING Hospital emergency departments. PARTICIPANTS Children (N=11,907) aged 3 to 16 years (mean age, 8.2±3.9y). Of the participants, 3868 (32.5%) were girls, and 7374 (61.9%) of the TBIs were the result of a fall. Median Glasgow Coma Scale score was 15. MAIN OUTCOME MEASURES We applied 17 different definitions of mild TBI, identified through a published systematic review, to children aged 3 to 16 years. Adjustments and clarifications were made to some definitions. The number and percentage identified for each definition is presented. RESULTS Adjustments had to be made to the 17 definitions to apply to the dataset: none in 7, minor to substantial in 10. The percentage classified as mild TBI across definitions varied from 7.1% (n=841) to 98.7% (n=11,756) and varied by age group. CONCLUSIONS When applying the 17 definitions of mild TBI to a large prospective multicenter dataset of TBI, there was wide variability in the number of cases classified. Clinicians and researchers need to be aware of this variability when examining literature concerning children with mild TBI.
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Affiliation(s)
- Louise M Crowe
- Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Melbourne School of Psychological Science, University of Melbourne, Melbourne, VIC, Australia; Psychology Department, Royal Children's Hospital, Melbourne, VIC, Australia.
| | - Stephen Hearps
- Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Vicki Anderson
- Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Melbourne School of Psychological Science, University of Melbourne, Melbourne, VIC, Australia; Psychology Department, Royal Children's Hospital, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Meredith L Borland
- Emergency Department, Princess Margaret Hospital for Children, Perth, WA, Australia; Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Natalie Phillips
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, QLD, Australia
| | - Amit Kochar
- Emergency Department, Women's & Children's Hospital, Adelaide, SA, Australia
| | - Sarah Dalton
- Emergency Department, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - John A Cheek
- Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Emergency Department, Royal Children's Hospital, Melbourne, VIC, Australia; Monash Medical Centre, Melbourne, VIC, Australia
| | - Yuri Gilhotra
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, QLD, Australia
| | - Jeremy Furyk
- Emergency Department, The Townsville Hospital, Townsville, QLD, Australia
| | - Jocelyn Neutze
- Emergency Department, Kidzfirst Middlemore Hospital, Auckland, New Zealand
| | - Mark D Lyttle
- Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Bristol Royal Hospital for Children, Bristol, United Kingdom; Academic Department of Emergency Care, University of the West of England, Bristol, United Kingdom
| | - Silvia Bressan
- Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Susan Donath
- Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Charlotte Molesworth
- Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Ed Oakley
- Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Emergency Department, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Stuart R Dalziel
- Starship Children's Health, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Franz E Babl
- Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Emergency Department, Royal Children's Hospital, Melbourne, VIC, Australia
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DeMaster D, Johnson C, Juranek J, Ewing‐Cobbs L. Memory and the hippocampal formation following pediatric traumatic brain injury. Brain Behav 2017; 7:e00832. [PMID: 29299377 PMCID: PMC5745237 DOI: 10.1002/brb3.832] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 08/15/2017] [Indexed: 12/20/2022] Open
Abstract
Introduction Previous research indicates disruption of learning and memory in children who have experienced traumatic brain injury (TBI). Objective This research evaluates the impact of pediatric TBI on volumetric differences along the long axis of the hippocampus, a region of the brain that is critical for explicit memory. Methods Structural brain data and behavioral measures were collected 6 weeks following TBI or extracranial injury (EI), in children aged 8-15 years and from a group of age matched typically developing controls (TDC). Total hippocampal volume and hippocampal subregion volumes corresponding to hippocampal head, body, and tail were compared across groups and were examined in relation to verbal and visual memory. Results Group differences were evident such that hippocampal body volume was found to be smaller for TBI and EI groups compared to the TDC group. Analysis restricted to the TBI group indicated that hippocampal head volume was associated with severity of injury. The relation between severity of injury and hippocampal head volume is particularly important considering results from our investigation of hippocampal volume-to-memory performance relations indicating positive correlations between hippocampal head volume and performance on memory measures for both the TBI group and the TDC group. Significant negative correlations between hippocampal body volume and memory were evident for the TBI group but not EI or TDC groups. Correlations between memory performance and hippocampal tail volume were not significant for the TBI or TDC groups, although for the EI group, a positive correlation was found between hippocampal tail volume and memory. Conclusion Together these results underscore an important relation between hippocampal structure and memory function during the subacute stage of recovery from pediatric TBI.
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Affiliation(s)
- Dana DeMaster
- Department of PediatricsChildren's Leaning InstituteUniversity of Texas McGovern Medical SchoolHoustonTXUSA
| | - Chad Johnson
- Department of PediatricsChildren's Leaning InstituteUniversity of Texas McGovern Medical SchoolHoustonTXUSA
| | - Jenifer Juranek
- Department of PediatricsChildren's Leaning InstituteUniversity of Texas McGovern Medical SchoolHoustonTXUSA
| | - Linda Ewing‐Cobbs
- Department of PediatricsChildren's Leaning InstituteUniversity of Texas McGovern Medical SchoolHoustonTXUSA
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Keenan HT, Clark AE, Holubkov R, Cox CS, Ewing-Cobbs L. Psychosocial and Executive Function Recovery Trajectories One Year after Pediatric Traumatic Brain Injury: The Influence of Age and Injury Severity. J Neurotrauma 2017; 35:286-296. [PMID: 28854841 DOI: 10.1089/neu.2017.5265] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Time since traumatic brain injury (TBI) and developmental stage at injury may affect the trajectory of outcomes associated with adjustment and school success. We prospectively enrolled a cohort of 519 children with either TBI or orthopedic injury (OI) age 2.5-15 years to examine children's psychosocial and executive function outcomes at 3- and 12-months post-injury. Outcome measures included the Child Behavior Checklist (CBCL), Strengths and Difficulties Questionnaire (SDQ), and Behavior Rating Inventory of Executive Function (BRIEF) ratings. Controlling for pre-injury ratings and using the OI group as the reference, children with TBI, regardless of age or injury severity, had affective, anxiety, and attention-deficit/hyperactivity disorder (ADHD) problems on the CBCL. Symptom trajectories differed both by injury severity and age at injury. Children with mild and complicated mild TBI had a decreasing anxiety trajectory, whereas children with severe TBI had increasing symptoms. Children 6-11 years of age had high ADHD and affective scores; however, the youngest children had increasing symptoms over time. On the SDQ, peer relationships and prosocial behaviors were not significantly affected by TBI but were associated with family environment. Children with severe TBI had the worst executive function scores; however, mild and complicated mild/moderate TBI groups had clinically important working memory deficits. Hispanic ethnicity and strong social capital were positively associated with multiple outcomes. Children's recovery trajectories differed by injury severity, time since injury, and developmental stage when injured. Schools need to reassess children's skills over time as new problems in behavior and learning may emerge.
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Affiliation(s)
- Heather T Keenan
- 1 Department of Pediatrics, University of Utah , Salt Lake City, Utah
| | - Amy E Clark
- 1 Department of Pediatrics, University of Utah , Salt Lake City, Utah
| | - Richard Holubkov
- 1 Department of Pediatrics, University of Utah , Salt Lake City, Utah
| | - Charles S Cox
- 2 Department of Pediatric Surgery, University of Texas Medical School at Houston , Houston, Texas
| | - Linda Ewing-Cobbs
- 3 Department of Pediatrics and Children's Learning Institute, University of Texas Health Science Center at Houston , Houston, Texas
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