We evaluated the moderating effect of preinjury psychosocial function on postconcussion symptoms for children with mild traumatic brain injury (mTBI).
We conducted a prospective cohort study of ...children ages 8.0 to 16.9 years with mTBI ( n = 633) or orthopedic injury (OI; n = 334), recruited from 5 pediatric emergency departments from September 2016 to December 2018.
Participants completed baseline assessments within 48 hours of injury, and postconcussion symptoms assessments at 7 to 10 days, weekly to 3 months, and biweekly to 6 months post-injury. Preinjury psychosocial function was measured using parent ratings on the Pediatric Quality of Life Inventory (PedsQL) and the Strengths and Difficulties Questionnaire (SDQ), retrospectively evaluating their child's status prior to the injury. Parent and child ratings on the Health and Behavior Inventory (HBI) (cognitive and somatic subscales) and the Post-Concussion Symptom Interview (PCS-I) were used as measures of postconcussion symptoms. We fitted 6 longitudinal regression models, which included 747 to 764 participants, to evaluate potential interactions between preinjury psychosocial function and injury group as predictors of child- and parent-reported postconcussion symptoms.
Preinjury psychosocial function moderated group differences in postconcussion symptoms across the first 6 months post-injury. Higher emotional and conduct problems were significantly associated with more severe postconcussion symptoms among children with mTBI compared with OI. Wald's χ 2 for interaction terms (injury group × SDQ subscales) ranged from 6.3 to 10.6 ( P values <.001 to .043) across parent- and child-reported models. In contrast, larger group differences (mTBI > OI) in postconcussion symptoms were associated with milder hyperactivity (Wald's χ 2 : 15.3-43.0, all P < .001), milder peer problems (Wald's χ 2 : 11.51, P = .003), and higher social functioning (Wald's χ 2 : 12.435, P = .002).
Preinjury psychosocial function moderates postconcussion symptoms in pediatric mTBI, highlighting the importance of assessing preinjury psychosocial function in children with mTBI.
Background
Adolescents and young adults with cancer (AYA) are a complex group of patients. The development of fever and neutropenia (FN) is a potentially lethal complication of chemotherapy. Risk ...stratification of patients with FN has become increasingly valuable allowing for early intervention and to guide treatment type and duration appropriately. There are risk stratification guidelines that exist, but most are validated in young children with cancer (YCWC). AYA are frequently shown to have more numerous and severe side effects from chemotherapy.
Aims
This study aimed to identify whether age contributes to the incidence and severity of FN.
Methods and Results
Patients diagnosed with a malignancy in a 5‐year period at our institution were included from ages 0–18 years. We reviewed details of their FN events, including duration of hospital admission, source (bacterial/fungal), PICU admission and duration, positive blood cultures and mortality. Adolescents with cancer (AWC) had a trend of being 1.56 times more likely to have FN events (CI 95% 0.936–2.622, p = 0.087). Assessment of the duration of PICU stay showed that AWC were 4.9 times more likely to have longer admissions (CI 95% 0.998–24.067, p = 0.050). There was no significant difference between the two groups in the rate of PICU admission, positive cultures, identification of a bacterial or fungal source, hospital admission duration or mortality from FN.
Conclusion
This study demonstrated a trend towards AWC being more likely to develop FN events. When such events occur in this group, the severity of them may be heightened as evidenced by longer duration of PICU admission.
Objective
Motor vehicle collisions generate considerable transmitted forces resulting in traumatic brain injury in children presenting to emergency departments (EDs). To date, no large study has ...examined post‐concussive symptoms in children sustaining concussions in motor vehicle collisions. This study aimed to compare trends in acute post‐concussive symptom burden in children with concussion following motor vehicle collisions as compared to other injury mechanisms.
Methods
The study is a secondary analysis of the Predicting Persistent Post‐concussive Problems in Pediatrics study, which prospectively recruited a multicenter cohort of 3029 children 5–17 years of age presenting to the ED with concussion from 2013–2015. Post‐concussive symptom ratings were obtained at pre‐specified time points for 12 weeks post‐injury, using the validated Post‐Concussion Symptom Inventory (PCSI). Symptom severity and recovery trajectories were measured using delta scores on the PCSI (mean post‐injury symptom score minus perceived pre‐injury score). A multivariable, longitudinal model evaluated the adjusted effect of mechanism of injury (motor vehicle collisions vs other mechanisms) on mean symptom scores, compared to perceived pre‐injury reports, and the temporal change in mean scores over during recovery.
Results
Of 3029 study participants, 56 (1.8%) sustained concussion from motor vehicle collisions. Children sustaining concussion in a motor vehicle collision had lower post‐concussive symptom scores upon ED presentation, measured as differences from their perceived pre‐injury reports, as compared to other injury mechanisms (−0.36 95% confidence interval (CI) = −0.58, −0.15). However, the motor vehicle collisions group showed the smallest decline in symptom burden over 1 month following injury (−0.54 95% CI = −0.81, −0.27).
Conclusions
Children sustaining concussions in motor vehicle collisions may have lower initial symptom burdens but slower symptom recovery at 1 month compared to other mechanisms of injury and may represent a distinct population for prognostic counseling in the ED requiring further research.
Placental histopathology provides insights, or "snapshots", into relevant antenatal factors that could elevate the risk of perinatal brain injury. We present a systematic review and meta-analysis ...comparing frequencies of adverse neurological outcomes in infants born to women with placental abruption versus without abruption. Records were sourced from MEDLINE, Embase, and the CENTRAL Trials Registry from 1946 to December 2019. Studies followed the PRISMA guidelines and compared frequencies of neurodevelopmental morbidities in infants born to pregnant women with placental abruption (exposure) versus women without placental abruption (comparator). The primary endpoint was cerebral palsy. Periventricular and intraventricular (both severe and any grades of IVH) and any histopathological neuronal damage were the secondary endpoints. Study methodologic quality was assessed by the Ottawa-Newcastle scale. Estimated odds ratios (OR) and hazards ratio (HR) were derived according to study design. Data were meta-analyzed using a random effects model expressed as pooled effect sizes and 95% confidence intervals. We included eight observational studies in the review, including 1245 infants born to women with placental abruption. Results of the random effects meta-analysis show that the odds of infants born to pregnant women with placental abruption who experience cerebral palsy is higher than in infants born to pregnant women without placental abruption (OR 5.71 95% CI (1.17, 27.91);
= 84.0%). There is no statistical difference in the odds of infants born to pregnant women with placental abruption who experience severe IVH (grade 3+) (OR 1.20 95% CI (0.46, 3.11);
= 35.8%) and any grade of IVH (OR 1.20 95% CI (0.62, 2.32);
= 32.3%) vs. women without placental abruption. There is no statistically significant difference in the odds of infants born to pregnant women with placental abruption who experience PVL vs. pregnant women without placental abruption (OR 6.51 95% CI (0.94, 45.16);
= 0.0%). Despite our meta-analysis suggesting increased odds of cerebral palsy in infants born to pregnant women with placental abruption versus without abruption, this finding should be interpreted cautiously, given high heterogeneity and overall poor quality of the included studies.
Although there is significant variability in the manifestations of persisting post-concussive symptoms (PPCS), autonomic dysfunction has been reported to contribute to PPCS and could serve as a ...biomarker of recovery. The objective of this study was to evaluate cardiac autonomic reflexes and autonomic function after concussion injury comparing those with prolonged concussion symptoms to those without. This is a case-control study where a non-referred population of concussed children or adolescent participants were enrolled from the Emergency Department (ED) of the Stollery Children's Hospital, a tertiary pediatric hospital in Edmonton, Alberta, Canada. Children and adolescents 8 through <18 years of age who presented with mild traumatic brain injury were diagnosed with concussion. Our study reported concussion symptoms and standardized clinical cardiac autonomic reflex testing at 4 and 12 weeks after injury. Our findings showed that 28 participants with concussion completed the 4-week follow-up questionnaires, and that 17 (61%) were diagnosed with PPCS. Difficulty concentrating, fatigue, noise sensitivity, light sensitivity, and headache were most commonly reported at baseline among those who were later diagnosed with PPCS. The mean change in heart rate (HR) with head-up tilt was 44.2 bpm (standard deviation SD 9.1) in the non-PPCS group and 46.6 bpm (SD 14.1) in the PPCS group at 4 weeks and was not significant in the unadjusted (p = 0.2) or adjusted analysis for age and female sex (p = 0.2). Overall, 70% (19/27) had significant orthostatic tachycardia >40 bpm, but PPCS and non-PPCS groups were similar. Similar results were observed among 23 participants at 12-week follow-up. The median maximum decrease in systolic blood pressure (SBP) with head-up tilt was -26.9 mm Hg (interquartile range IQR -32.6, -22.3) in the non-PPCS group and -25.1 mm Hg (IQR -32.2, -18.2) in the PPCS group, and was not significantly different in the unadjusted (p = 0.8) or adjusted (p = 0.8) analysis. Overall, 19 of 26 participants (73%) demonstrated orthostatic hypotension (SBP change >20 mm Hg) with no significant difference between the PPCS and non-PPCS groups. Similar results were observed at 12-week follow-up. In conclusion, cardiac autonomic reflex responses are abnormal in most children and adolescents with a concussion injury at 4- and 12-week follow-up and may reflect ongoing autonomic dysfunction. However, autonomic function did not differentiate PPCS, indicating that reported symptoms are not sensitive to autonomic abnormalities.
Puberty onset and development contribute substantially to adolescents' bone mass and body composition. Our objective with this study was to examine the effects of gonadotropin-releasing hormone ...agonists (GnRHa) on these puberty-induced changes among youth with gender dysphoria (GD).
Medical records of the endocrine diversity clinic in an academic children's hospital were reviewed for youth with GD seen from January 2006 to April 2017 with at least 1 baseline dual-energy radiograph absorptiometry measurement.
At baseline, transgender females had lower lumbar spine (LS) and left total hip (LTH) areal bone mineral density (aBMD) and LS bone mineral apparent density (BMAD)
scores. Only 44.7% of transgender youth were vitamin D sufficient. Baseline vitamin D status was associated with LS, LTH aBMD, and LS BMAD
scores. Post-GnRHa assessments revealed a significant drop in LS and LTH aBMD
scores (transgender males and transgender females) without fractures and LS BMAD (transgender males), an increase in gynoid (fat percentage), and android (fat percentage) (transgender males and transgender females), and no changes in BMI
score.
GnRHa monotherapy negatively affected bone mineral density of youth with GD without evidence of fractures or changes in BMI
score. Transgender youth body fat redistribution (android versus gynoid) were in keeping with their affirmed gender. The majority of transgender youth had vitamin D insufficiency or deficiency with baseline status associated with bone mineral density. Vitamin D supplementation should be considered for all youth with GD.
ObjectiveTo compare the association between mouthguard-use and symptom score stratified by sex at acute presentation, and 1-, 2-, and 4-weeks after pediatric sport-related concussion.DesignSecondary ...analysis of 5P multicenter, prospective, cohort study.SettingNine Canadian pediatric Emergency Departments (ED).ParticipantsChildren aged 5–18 years presenting ≤48 hours of concussion sustained during collision or contact sport.Assessment of Risk FactorsSymptom score (0–6) was measured using the Post-Concussion Symptom Inventory.Outcome MeasuresAssociation of mouthguard use on symptoms was estimated using a fitted generalized least squares multivariable model.Main ResultsOf 1019 children (73% male; mean age=13.02SD=2.82), 42% wore mouthguards at time of injury. After adjusting for covariates, post-model fitting revealed no significant group by sex by time interaction for symptoms (χ2 3=0.27; p=.965). Males who wore mouthguards reported similar symptom scores in ED (diff=-0.07; 95%CI:-0.23,0.09), at week-1 (diff=-0.02; 95%CI:-0.18,0.14; p=.793), week-2 (diff=-0.03; 95%CI:-0.19,0.13), and week-4 (diff=-0.13; 95%CI:-0.29,0.04) compared with males who didn’t wear mouthguards. In contrast, female mouthguard wearers reported higher symptom scores at week-1 compared with non-mouthguard users (diff=0.29; 95%CI:0.01,0.56). Symptom scores were not significantly different for females who wore a mouthguard and those who didn’t in the ED (diff=0.22; 95%CI:-0.04,0.48; p=.098), at week-2 (diff=0.22; 95%CI:-0.06,0.51; p=.128), or week-4 (diff=0.08; 95%CI:-0.20,0.36; p=.581).ConclusionsWearing a mouthguard at time of injury is not associated with reduced symptoms after sport-related concussion in youth compared with non-mouthguard wearers. Mouthguards remain important to prevent dental injury and may play a role in concussion prevention.
ObjectiveTo characterize symptom burden, school functioning, and physical-activity outcomes in youth 1-year following acute concussion and those with subsequent repeat concussion.DesignSecondary ...analysis of 5P prospective, multicenter cohort study.SettingNine Canadian pediatric emergency departments (ED).ParticipantsYouth presenting ≤48-hours of concussion and agreed to participate in a post-hoc electronic survey at 1-year following injury.Assessment of Risk FactorsStandardized 25-question symptom scale derived from the Post-Concussion Symptom Inventory-Parent; school and physical-activity outcomes.Outcome MeasuresPrimary outcome was total symptom score at 1-year following concussion, defined as the number of symptoms experienced more than before injury.Main ResultsOf 3063 youth enrolled in the 5P study, 441 (median IQR age, 11.45 8.86–14.04 years; 272 61.7% male) completed the 1-year survey; 37 respondents reported repeat concussion. Following acute concussion, youth were more likely to be symptom-free than following repeat concussion (74%vs.54%; difference=20%95%CI:6,37; p=.005) and to have fully recovered (91%vs.76%; difference=15%95%CI:4, 3; p=.005) at 1-year. Although physical symptoms were lower at 1-year than ED presentation for both groups (p<.001), more youth with repeat concussion reported headache persistence (24%vs.12%; difference=12%95%CI:0,28; p=.04). Both groups returned to normal school routines (100%vs.95%; difference=5%95%CI:-5,8; p=.59). Youth without repeat concussion more frequently returned to normal physical activities (98%vs.87%; difference=12%95%CI:4,26; p<.001) and sport (95%vs.84%; difference=11%95%CI:23,27; p=.02).ConclusionsMost youth are symptom-free and fully recovered 1-year following concussion. Youth with repeat concussion have worse outcomes and delays in returning to normal school routines and sport.
ContextCurrent evidence regarding the protective effect of mouthguard use on symptom severity in children and adolescents who sustain sport-related concussions is insufficient to make clinical ...recommendations.ObjectiveTo compare the association between mouthguard-use and symptoms stratified by sex in the first 4-weeks after pediatric sport-related concussion. We hypothesized that mouthguard-use would be associated with lower symptoms.DesignProspective cohort studySettingNine Canadian pediatric emergency departments (EDs).PatientsChildren aged 5–18 years presenting ≤48 hours of concussion sustained during a collision or contact sport.Main Outcome MeasuresInjury characteristics were collected using the Acute Concussion Evaluation. Primary outcome measure was symptom score (0–6), measured using age-appropriate versions (5–7 years; 8–12 years; 13–18 years) of the Post-Concussion Symptom Inventory. Independent variable was time postconcussion (at initial assessment, 1-, 2-, 4, weeks).ResultsOf 1019 children (73% male; median IQR age=13.4311.01,15.27 years), 42% wore a mouthguard at time of injury. There was no significant group by sex by time interaction for symptoms (χ23=0.27; p=.965). Male mouthguard users reported similar symptom scores in the ED (diff=-0.07; 95%CI:-0.23,0.09), at week-1 (diff=−0.02; 95%CI:−0.18,0.14), week-2 (diff=-0.03; 95%CI:−0.19,0.13), and week-4 (diff=-0.13; 95%CI:-0.29,0.04) compared with males who didn't wear a mouthguard. Female mouthguard users reported minimally higher symptom scores at week-1 compared with non-mouthguard users (diff=0.29; 95%CI:0.01,0.56). Symptom scores were not significantly different for females who wore a mouthguard and those who didn't in the ED (diff=0.22; 95%CI:-0.04,0.48), at week-2 (diff=0.22; 95%CI:-0.06,0.51), or week-4 (diff=0.08; 95%CI:-0.20,0.36).ConclusionWearing a mouthguard at time of injury is not associated with reduced acute and subacute symptoms after sport-related concussion in either males or females who were treated in the ED compared with those who did not wear a mouthguard. Athletes are still encouraged to wear a mouthguard during sports since overwhelming evidence supports their use in preventing dental injuries.
Seasonal variations of water exchange in the Luzon Strait are studied numerically using the improved Princeton Ocean Model (POM) with a consideration of the effects of connectivity of South China Sea ...(SCS) and monsoons. The numerical simulations are carried out with the strategy of variable grids, coarse grids for the Pacific basin and fine grids for the SCS. It is shown that the Mindoro Strait plays an important role in adjusting the water balance between the Pacific and the SCS. The SCS monsoon in summer seasons hinders the entrance of the Pacific water into the SCS through the Luzon Strait while the SCS monsoon in winter seasons promotes the entrance of Pacific water into the SCS through the Luzon Strait. However, the SCS monsoon does not affect the annual mean Luzon Strait transport, as is mainly determined by the Pacific basin wind.
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