What is the effect of a decision aid in potentially vulnerable parents? Insights from the head CT choice randomized trial.

OBJECTIVE: To test the hypotheses that use of the Head CT Choice decision aid would be similarly effective in all parent/patient dyads but parents with high (vs low) numeracy experience a greater increase in knowledge while those with low (vs high) health literacy experience a greater increase in trust. METHODS: This was a secondary analysis of a cluster randomized trial conducted at seven sites. One hundred seventy-two clinicians caring for 971 children at intermediate risk for clinically important traumatic brain injuries were randomized to shared decision making facilitated by the DA (n = 493) or to usual care (n = 478). We assessed for subgroup effects based on patient and parent characteristics, including socioeconomic status (health literacy, numeracy and income). We tested for interactions using regression models with indicators for arm assignment and study site. RESULTS: The decision aid did not increase knowledge more in parents with high numeracy (P for interaction [Pint ] = 0.14) or physician trust more in parents with low health literacy (Pint  = 0.34). The decision aid decreased decisional conflict more in non-white parents (decisional conflict scale, -8.14, 95% CI: -12.33 to -3.95; Pint  = 0.05) and increased physician trust more in socioeconomically disadvantaged parents (trust in physician scale, OR: 8.59, 95% CI: 2.35-14.83; Pint  = 0.04). CONCLUSIONS: Use of the Head CT Choice decision aid resulted in less decisional conflict in non-white parents and greater physician trust in socioeconomically disadvantaged parents. Decision aids may be particularly effective in potentially vulnerable parents.

Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury.

Importance: Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI. Objective: To determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI. Design, Setting, and Participants: Multicenter, double-blinded, randomized clinical trial at 20 trauma centers and 39 emergency medical services agencies in the US and Canada from May 2015 to November 2017. Eligible participants (N = 1280) included out-of-hospital patients with TBI aged 15 years or older with Glasgow Coma Scale score of 12 or less and systolic blood pressure of 90 mm Hg or higher. Interventions: Three interventions were evaluated, with treatment initiated within 2 hours of TBI: out-of-hospital tranexamic acid (1 g) bolus and in-hospital tranexamic acid (1 g) 8-hour infusion (bolus maintenance group; n = 312), out-of-hospital tranexamic acid (2 g) bolus and in-hospital placebo 8-hour infusion (bolus only group; n = 345), and out-of-hospital placebo bolus and in-hospital placebo 8-hour infusion (placebo group; n = 309). Main Outcomes and Measures: The primary outcome was favorable neurologic function at 6 months (Glasgow Outcome Scale-Extended score >4 [moderate disability or good recovery]) in the combined tranexamic acid group vs the placebo group. Asymmetric significance thresholds were set at 0.1 for benefit and 0.025 for harm. There were 18 secondary end points, of which 5 are reported in this article: 28-day mortality, 6-month Disability Rating Scale score (range, 0 [no disability] to 30 [death]), progression of intracranial hemorrhage, incidence of seizures, and incidence of thromboembolic events. Results: Among 1063 participants, a study drug was not administered to 96 randomized participants and 1 participant was excluded, resulting in 966 participants in the analysis population (mean age, 42 years; 255 [74%] male participants; mean Glasgow Coma Scale score, 8). Of these participants, 819 (84.8%) were available for primary outcome analysis at 6-month follow-up. The primary outcome occurred in 65% of patients in the tranexamic acid groups vs 62% in the placebo group (difference, 3.5%; [90% 1-sided confidence limit for benefit, -0.9%]; P = .16; [97.5% 1-sided confidence limit for harm, 10.2%]; P = .84). There was no statistically significant difference in 28-day mortality between the tranexamic acid groups vs the placebo group (14% vs 17%; difference, -2.9% [95% CI, -7.9% to 2.1%]; P = .26), 6-month Disability Rating Scale score (6.8 vs 7.6; difference, -0.9 [95% CI, -2.5 to 0.7]; P = .29), or progression of intracranial hemorrhage (16% vs 20%; difference, -5.4% [95% CI, -12.8% to 2.1%]; P = .16). Conclusions and Relevance: Among patients with moderate to severe TBI, out-of-hospital tranexamic acid administration within 2 hours of injury compared with placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. Trial Registration: ClinicalTrials.gov Identifier: NCT01990768.

The effects of prehospital TXA on mortality and neurologic outcomes in patients with traumatic intracranial hemorrhage: a subgroup analysis from the prehospital TXA for TBI trial.

BACKGROUND: In the Prehospital Tranexamic Acid (TXA) for TBI Trial, TXA administered within two hours of injury in the out-of-hospital setting did not reduce mortality in all patients with moderate/severe traumatic brain injury (TBI). We examined the association between TXA dosing arms, neurologic outcome, and mortality in patients with intracranial hemorrhage (ICH) on computed tomography (CT). METHODS: This was a secondary analysis of the Prehospital Tranexamic Acid for TBI Trial (ClinicalTrials.gov [NCT01990768]) that randomized adults with moderate/severe TBI (Glasgow Coma Scale<13) and systolic blood pressure > =90 mmHg within two hours of injury to a 2-gram out-of-hospital TXA bolus followed by an in-hospital saline infusion, a 1-gram out-of-hospital TXA bolus/1-gram in-hospital TXA infusion, or an out-of-hospital saline bolus/in-hospital saline infusion (placebo). This analysis included the subgroup with ICH on initial CT. Primary outcomes included 28-day mortality, 6-month Glasgow Outcome Scale-Extended (GOSE) < = 4, and 6-month Disability Rating Scale (DRS). Outcomes were modeled using linear regression with robust standard errors. RESULTS: The primary trial included 966 patients. Among 541 participants with ICH, 28-day mortality was lower in the 2-gram TXA bolus group (17%) compared to the other two groups (1-gram bolus/1-gram infusion 26%, placebo 27%). The estimated adjusted difference between the 2-gram bolus and placebo groups was -8·5 percentage points (95% CI, -15.9 to -1.0) and between the 2-gram bolus and 1-gram bolus/1-gram infusion groups was -10.2 percentage points (95% CI, -17.6 to -2.9). DRS at 6 months was lower in the 2-gram TXA bolus group than the 1-gram bolus/1-gram infusion (estimated difference -2.1 [95% CI, -4.2 to -0.02]) and placebo groups (-2.2 [95% CI, -4.3, -0.2]). Six-month GOSE did not differ among groups. CONCLUSIONS: A 2-gram out-of-hospital TXA bolus in patients with moderate/severe TBI and ICH resulted in lower 28-day mortality and lower 6-month DRS than placebo and standard TXA dosing. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level II.

Immediate post-resection diabetes mellitus after pancreaticoduodenectomy: incidence and risk factors.

BACKGROUND: New-onset diabetes mellitus after a pancreaticoduodenectomy (PD) remains poorly defined. The aim of this study was to define the incidence and predictive factors of immediate post-resection diabetes mellitus (iPRDM). METHODS: Retrospective review of patients undergoing PD from January 2004 through to July 2010. Immediate post-resection diabetes mellitus was defined as diabetes requiring pharmacological treatment within 30 days post-operatively. Logistic regression was conducted to identify factors predictive of iPRDM. RESULTS: Of 778 patients undergoing PD, 214 were excluded owing to pre-operative diabetes (n= 192), declined research authorization (n= 14) or death prior to hospital discharge (n= 8); the remaining 564 patients comprised the study population. iPRDM occurred in 22 patients (4%) who were more likely to be male, have pre-operative glucose intolerance, or an increased creatinine, body mass index (BMI), pre-operative glucose, operative time, tumour size or specimen length compared with patients without iPRDM (P < 0.05). On multivariate analysis, pre-operative impaired glucose intolerance (P < 0.001), pre-operative glucose ≥ 126 (P < 0.001) and specimen length (P= 0.002) were independent predictors of iPRDM. A predictive model using these three factors demonstrated a c-index of 0.842. DISCUSSION: New-onset, post-resection diabetes occurs in 4% of patients undergoing PD. Factors predictive of iPRDM include pre-operative glucose intolerance, elevated pre-operative glucose and increased specimen length. These data are important for patient education and predicting outcomes after PD.

Incidence and risk of attention-deficit/hyperactivity disorder and learning disability by adulthood after traumatic brain injury in childhood: a population-based birth cohort study.

The aim of this study was to understand the risk of developing attention-deficit/hyperactivity disorder (ADHD) or learning disability (LD) after childhood traumatic brain injury (TBI) in a population-based birth cohort. Cases of TBI for children from birth to 10 years were confirmed and stratified by severity of injury. For each TBI case, two age-matched and sex-matched referents without TBI were identified from the same birth cohort. Presence of ADHD and LD before age 19 were confirmed using medical and/or school records. Associations between TBI exposure and subsequent ADHD or LD were assessed in multivariable Cox regression models, adjusting for maternal age, education, and race. The incidence rate of TBI before age 10 was 1,156 per 100,000 person-years. Children who had a TBI before age 10 were more likely to have met the research criteria for ADHD (hazard ratio [HR], 1.68; 95% CI, 1.15-2.45) or LD (HR, 1.29; 95% CI, 1.00-1.68) by age 19. No statistically significant associations were shown between TBI and ADHD or LD when restricted to definite and probable TBI cases (consistent with moderate to severe and mild TBI, respectively) and their referents. Significant associations were shown when the analysis was confined to possible TBI cases (consistent with concussive TBI) and their referents (ADHD: HR, 2.05; 95% CI, 1.31-3.20; and LD: HR, 1.42; 95% CI, 1.05-1.91). Increased risk for developing ADHD and LD by adulthood was shown particularly for children with the least-severe injuries, indicating that factors other than trauma-related altered brain function likely contribute to this risk.

Tension pneumothorax decompression with colorimetric capnography: pilot case series.

Tension pneumothorax is a life-threatening condition that can develop when either the visceral pleura is disrupted, or with injury to the tracheobronchial tree. Rapid, accurate diagnosis and appropriate management are required to prevent significant atelectasis, hypoxia, circulatory arrest, and ultimate patient demise. Needle decompression is the current standard of care for the management of tension pneumothorax. Healthcare providers struggle to assess the success of decompression due to a lack of any immediate objective feedback. The gaseous composition of tension pneumothorax is similar to that of end respiratory gas. This includes an increased partial pressure of carbon dioxide in comparison to atmospheric air, which makes colorimetric capnography an ideal confirmatory test. This colorimetric capnography device may help the healthcare providers to make an objective and accurate assessment of the success of the needle decompression, in particular in prehospital environments.

"Decompression of tension pneumothorax in a trauma patient -first use of a novel decompression colorimetric capnography device in human patient".

Tension pneumothorax is a common cause of mortality in trauma. Tension pneumothorax is the confinement of respired gases within the pleural cavity at increasing pressure resulting in hemodynamic collapse. Decompression is crucial in management. Emergency needle thoracostomy is a life-saving maneuver that allows atmospheric pressure equilibration and partial restoration of cardiac filling. Needle decompressions are usually performed under noisy, tense, and stressful circumstances, and objective assessment of success is difficult in the field. A device which is simple that objectively informs operators of successful decompression would be clinically useful. In previous work, we have demonstrated end-expiratory gas and gaseous composition of tension pneumothorax are similar due to increased carbon dioxide partial pressure relative to atmospheric gas composition. Therefore, a simple solution to objective needle decompression may be colorimetric capnography.We report a case of 58-year-old male treated by EMS following a motorcycle accident with left-sided chest pain, hypoxia, hypotension, and clinical findings of tension pneumothorax. Needle decompression with colorimetric capnography using the device indicated decompression of his tension pneumothorax, with appropriate temporizing success.

Exploring the utility of a novel point-of-care whole blood thrombin generation assay following trauma: A pilot study.

INTRODUCTION: Plasma thrombin generation kinetics as measured by the calibrated automated thrombogram (CAT) assay is a predictor of symptomatic venous thromboembolism after trauma. We hypothesized that data from a new prototype assay for measurement of thrombin generation kinetics in fresh whole blood (near patient testing of thrombin generation), will correlate with the standard CAT assay in the same patients, making it a potential tool in the future care of trauma patients. METHODS: Patients were enrolled from June 2018 to February 2020. Within 12 hours of injury, blood samples were collected simultaneously for both assays. Variables compared and correlated between assays were lag time, peak height, time to peak, and endogenous thrombin potential. Data are presented as median with interquartile range (IQR). Spearman and Pearson correlations were estimated and tested between both assays; a P value of <0.05 was considered to be significant. RESULTS: A total of 64 trauma patients had samples analyzed: injury severity score = 17 (IQR), 10-26], hospital length of stay = 7.5 (IQR), 2-18) days, age = 52 (IQR, 35-63) years, 71.9% male, and 42.2% of patients received a transfusion within 24 hours of injury. Thrombin generation parameters between plasma and whole blood were compared and found that all parameters of the two assays correlate in trauma patients. CONCLUSION: In this pilot study, we have found that a novel point-of-care whole blood thrombin generation assay yields results with modest but statistically significant correlations to those of a standard plasma thrombin generation assay. This finding supports studying this device in a larger, adequately powered study.

Euglobulin clot lysis time reveals a high frequency of fibrinolytic activation in trauma.

Activation of the fibrinolytic system plays a central role in the host response to trauma. There is significant heterogeneity in the degree of fibrinolysis activation at baseline that is usually assessed by whole blood thromboelastography (TEG). Few studies have focused on plasma markers of fibrinolysis that could add novel insights into the frequency and mechanisms of fibrinolytic activation in trauma. Global fibrinolysis in plasma was assessed using a modified euglobulin clot lysis time (ECLT) assay in 171 major trauma patients and compared to commonly assessed analytes of fibrinolysis. The median ECLT in trauma patients was significantly shorter at 8.5 h (IQR, 1.3-19.5) compared to 19.9 h (9.8-22.6) in healthy controls (p < 0.0001). ECLT values ≤2.5th percentile of the reference range were present in 83 (48.5%) of trauma patients, suggesting increased fibrinolytic activation. Shortened ECLT values were associated with elevated plasmin-antiplasmin (PAP) complexes and free tissue plasminogen activator (tPA) levels in plasma. Sixteen (9.2%) individuals met the primary outcome for massive transfusion, here defined as the critical administration threshold (CAT) of 3 units of packed red cells in any 60-minute period within the first 24 h. In a univariate screen, plasma biomarkers associated with CAT included D-dimer (p < 0.001), PAP (p < 0.05), free tPA (p < 0.05) and ECLT (p < 0.05). We conclude that fibrinolytic activation, measured by ECLT, is present in a high proportion of trauma patients at presentation. The shortened ECLT is partially driven by high tPA levels and is associated with high levels of circulating PAP complexes. Further studies are needed to determine whether ECLT is an independent predictor of trauma outcomes.

Heat Policy Revision for Georgia High School Football Practices Based on Data-Driven Research.

CONTEXT: Interscholastic heat policies for football have not been evidence based. Therefore, their effectiveness in mitigating exertional heat illness has not been assessed. OBJECTIVE: To discuss the development of the Georgia High School Association heat policy and assess the effectiveness of revised guidelines. DESIGN: Descriptive epidemiology study. SETTING: Georgia high schools. PATIENTS OR OTHER PARTICIPANTS: Interscholastic football players in grades 9 through 12. MAIN OUTCOME MEASURE(S): Heat syncope and heat exhaustion (HS/HE) illness rates (IRs) were calculated per 1000 athlete-exposures (AEs), and relative risk (RR) was calculated as a ratio of postpolicy (POST) IR divided by prepolicy (PRE) IR. RESULTS: A total of 214 HS/HE cases (172 PRE, 42 POST) and 341 348 AEs (178 230 PRE, 163 118 POST) were identified. During the first 5 days of the PRE period, approximately 50% of HS/HE illnesses occurred; HS/HE IRs doubled when practice sessions increased from 2 to 2.5 hours and tripled for practices ≥3 hours. The HS/HE IRs in the PRE period increased from 0.44/1000 AEs for wet-bulb globe temperatures (WBGTs) of <82°F (<27.8°C) to >2.0/1000 AEs for WBGTs from 87°F (30.6°C) to 89.9°F (32.2°C). The RRs comparing PRE and POST policy periods were 0.29 for WBGTs of <82.0°F (<27.80°C), 0.65 for WBGTs from 82.0°F (27.8°C) to 86.9°F (30.5°C), and 0.23 for WBGTs from 87.0°F (30.6°C) to 89.9°F (32.2°C). No HS/HE illnesses occurred in the POST period for WBGTs at >90°F (>32.3°C). CONCLUSIONS: Results from the PRE period guided the Georgia High School Association to revise its heat and humidity policy to include a mandated 5-day acclimatization period when no practices may exceed 2 hours and the use of WBGT-based activity-modification categories. The new policy reduced HS/HE IRs by 35% to 100%, depending on the WBGT category. Our results may be generalizable to other states with hot and humid climates similar to that of Georgia.

The relationship of athlete-reported concussion symptoms and objective measures of neurocognitive function and postural control.

OBJECTIVE: Concussed athlete evaluations often include symptoms, balance, and neurocognitive assessments. We sought to identify the relationship between subjective symptom reports and objective clinical measures. DESIGN: A retrospective assessment. SETTING: A research laboratory. PATIENTS: Concussed collegiate-level athletes (N = 32, 19.7 years) evaluated pre- and postinjury (less than 48 hours). INTERVENTION: Each athlete completed an inventory of concussion-related symptoms, the NeuroCom Sensory Organization Test (SOT), and ImPACT neurocognitive assessment. Spearman correlations between balance symptoms and SOT scores and cognitive symptoms and ImPACT scores were completed. MAIN OUTCOME MEASURES: Symptoms related to balance and cognitive deficits, SOT composite balance and visual, vestibular, and somatosensory ratios, and ImPACT output scores. RESULTS: Significant Spearman correlations were noted between reports of "dizziness" and the SOT composite balance (rs = -0.55) and vestibular ratio (rs = -0.50). Similarly, "balance problems" were significantly correlated with composite balance (rs = -0.52) and the somatosensory (rs = -0.41), visual (rs = -0.39), and vestibular ratios (rs = -0.57). The cognitive symptom of "feeling mentally foggy" and ImPACT variables of reaction time (rs = 0.36) and "difficulty concentrating" and verbal memory score (rs = -0.41) were significantly related. Finally, reports of "difficulty remembering" were significantly related to the verbal memory score (rs = -0.48) and reaction time (rs = 0.36). CONCLUSIONS: These findings indicate self-report symptoms are associated with athlete deficits in postural control and cognitive function. The moderate relationship between the symptom reports and the objective measures warrants the continued use of all measures. A reduction in the number of symptoms concussed athletes respond to may be justified to reduce redundancy.

The reliability of the modified Balance Error Scoring System.

OBJECTIVE: Study 1 investigated the intraclass reliability and percent variance associated with each component within the traditional Balance Error Scoring System (BESS) protocol. Study 2 investigated the reliability of subsequent modifications of the BESS. DESIGN: Prospective cross-sectional examination of the traditional and modified BESS protocols. SETTING: Schools participating in Georgia High School Athletics Association. INTERVENTION: The modified BESS consisted of 2 surfaces (firm and foam) and 2 stances (single-leg and tandem-leg stance) repeated for a total of three 20-second trials. PARTICIPANTS: Participants consisted of 2 independent samples of high school athletes aged 13 to 19 years. MAIN OUTCOME MEASURES: Percent variance for each condition of the BESS was obtained using GENOVA 3.1. An intraclass reliability coefficient and repeated measures analysis of variance were calculated using SPSS 13.0. RESULTS: Study 1 obtained an intraclass correlation coefficient (r = 0.60) with stance accounting for 55% of the total variance. Removing the double-leg stance increased the intraclass correlation coefficient (r = 0.71). Study 2 found a statistically significant difference between trials 1 and 2 (F(1.65,286) = 4.890, P = 0.013) and intraclass reliability coefficient of r = 0.88 for 3 trials of 4 conditions. CONCLUSIONS: The variance associated with the double-leg stance was very small, and when removed, the intraclass reliability coefficient of the BESS increased. Removal of the double-leg stance and addition of 3 trials of 4 conditions provided an easily administered, cost-effective, time-efficient tool that provides reliable objective information for clinicians to base clinical decisions upon.

Effects of backpack load on balance and decisional processes.

A dual-task method was employed to assess the effects of backpack carriage weight on 20 young adults' balance and rapid decision making. During two separate sessions, participants' balance was perturbed during 18, 60-second trials by altering visual and/or somatosensory conditions. Concurrent balance control and auditory choice-reaction task performance were assessed. Each participant wore an all-purpose, lightweight, individual, carrying equipment (ALICE) backpack containing a load equal to 30% of his/her body weight throughout one session. Within-subjects analyses revealed that carriage load disrupted balance control and degraded cognitive processes but only on trials that required executive, higher-level, mental processing. The magnitude of the effects of the backpack load on balance and cognitive performance was similar over 22 minutes of testing. Carriage load degrades both balance control and situational awareness of ROTC cadets.

Principles and Strategies for Effective Teaching: A Workshop for Pre- and Postdoctoral Trainees in the Biomedical Sciences.

The 2012 National Institutes of Health (NIH) Biomedical Workforce Working Group Report documented that graduate training in the biomedical sciences predominantly prepares people for academic research positions. The report recommended that NIH provide funds for institutions to develop broader career development opportunities, including training related to teaching. Indeed, teaching is not only a required component of any faculty position, it is the primary task for trainees who seek employment at small liberal arts colleges and other primarily undergraduate institutions. NIH funding for the BEST (Broadening Experiences in Scientific Training) programs allowed us to develop a six-week training workshop for bioscience trainees to introduce participants to research-based, student-centered pedagogies and instructional design techniques and to inspire them to view teaching as an intellectual endeavor. The methods and outcomes of our case study should be applicable in a variety of programs and organizations, especially those with a separate health science campus, where faculty mentors often do not teach many classes and there are few, if any, apprenticeship-teaching opportunities for trainees.

A helmetless-tackling intervention in American football for decreasing head impact exposure: A randomized controlled trial.

OBJECTIVES: To evaluate a behavioral intervention to reduce head impact exposure in youth playing American football. DESIGN: Nested randomized controlled trial. METHODS: Participants, ages 14-17 years, wore head impact sensors (SIM-G™) during two seasons of play. Those randomized to the intervention group underwent weekly tackling/blocking drills performed without helmets (WoH) and shoulder pads while the control group trained as normal, matching frequency and duration. Research personnel provided daily oversight to maintain fidelity. Head impact frequency (≥10g) per athlete exposure (ImpAE) was analyzed over time (two 11-week seasons) using mixed effect models or ANCOVA. Secondary outcomes included exposure-type (training, game) and participation level (entry-level versus upper-level secondary education). RESULTS: One-hundred fifteen participants (59 WoH, 56 control) met compliance criteria, contributing 47,382 head impacts and 10,751 athlete exposures for analysis. WoH had fewer ImpAE during games compared to control participants at weeks 4 (p=0.0001 season 1, p=0.0005 season 2) and 7 (p=0.0001 both seasons). Upper-level WoH participants had less ImpAE during games than their matched controls at weeks 4 (p=0.017 and p=0.026) and 7 (p=0.037 and p=0.014) in both seasons, respectively. Upper-level WoH also had fewer ImpAE during training at week 7 (p=0.015) in season one. CONCLUSIONS: Tackling and blocking drills performed without a helmet during training reduced the frequency of head impacts during play, especially during games. However, these differences disappeared by the end of the season. Future research should explore the frequency of behavioral intervention and a dose-response relationship considering years of player experience. TRIAL REGISTRATION: ClinicalTrials.gov # NCT02519478.

Cognitive and motor function are associated following mild traumatic brain injury.

Mild traumatic brain injury (mTBI) causes deficits in motor and cognitive function. There is a dearth of research examining the association between these deficits. The purpose of this investigation was to examine the effect of mTBI on the association between cognitive and motor function. Thirty-six individuals completed a neurocognitive test battery and postural control assessment at baseline and were retested 24-h post mTBI. Reaction time and accuracy to various cognitive tasks was assessed. Postural control was indexed with the somatosenory organization test. This test allows for the decomposition of postural control resulting from the integration of visual, somatosensory and vestibular information. The association between cognitive and motor function was assessed with correlational analyses. Overall, it was found that mTBI resulted in increased simple and choice reaction time as well as deficits in verbal and visual memory. mTBI was also found to reduce overall postural control, especially when visual information was utilized. Prior to injury there was no association between cognitive and motor function-indicating minimal association between cognitive and motor function. After injury there were significant positive correlations between cognitive and motor function. The findings suggest that transient neural insults resulting from mTBI lead to increased cognitive-motor association. It is speculated that a shared neural process, such as visuospatial attention is damaged resulting in similar deficits in cognitive and motor function.

Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head Trauma: A Cluster Randomized Trial.

Importance: The Pediatric Emergency Care Applied Research Network prediction rules for minor head trauma identify children at very low, intermediate, and high risk of clinically important traumatic brain injuries (ciTBIs) and recommend no computed tomography (CT) for those at very low risk. However, the prediction rules provide little guidance in the choice of home observation or CT in children at intermediate risk for ciTBI. Objective: To compare a decision aid with usual care in parents of children at intermediate risk for ciTBI. Design, Settings, and Participants: This cluster randomized trial was conducted in 7 geographically diverse US emergency departments (EDs) from April 1, 2014, to September 30, 2016. Eligible participants were emergency clinicians, children ages 2 to 18 years with minor head trauma at intermediate risk for ciTBI, and their parents. Interventions: Clinicians were randomly assigned (1:1 ratio) to shared decision-making facilitated by the Head CT Choice decision aid or to usual care. Main Outcomes and Measures: The primary outcome, selected by parent stakeholders, was knowledge of their child's risk for ciTBI and the available diagnostic options. Secondary outcomes included decisional conflict, parental involvement in decision-making, the ED CT rate, 7-day health care utilization, and missed ciTBI. Results: A total of 172 clinicians caring for 971 children (493 decision aid; 478 usual care) with minor head trauma at intermediate risk for ciTBI were enrolled. The patient mean (SD) age was 6.7 (7.1) years, 575 (59%) were male, and 253 (26%) were of nonwhite race. Parents in the decision aid arm compared with the usual care arm had greater knowledge (mean [SD] questions correct: 6.2 [2.0] vs 5.3 [2.0]; mean difference, 0.9; 95% CI, 0.6-1.3), had less decisional conflict (mean [SD] decisional conflict score, 14.8 [15.5] vs 19.2 [16.6]; mean difference, -4.4; 95% CI, -7.3 to -2.4), and were more involved in CT decision-making (observing patient involvement [OPTION] scores: mean [SD], 25.0 [8.5] vs 13.3 [6.5]; mean difference, 11.7; 95% CI, 9.6-13.9). Although the ED CT rate did not significantly differ (decision aid, 22% vs usual care, 24%; odds ratio, 0.81; 95% CI, 0.51-1.27), the mean number of imaging tests was lower in the decision aid arm 7 days after injury. No child had a missed ciTBI. Conclusions and Relevance: Use of a decision aid in parents of children at intermediate risk of ciTBI increased parent knowledge, decreased decisional conflict, and increased involvement in decision-making. The intervention did not significantly reduce the ED CT rate but safely decreased health care utilization 7 days after injury. Trial Registration: ClinicalTrials.gov Identifier: NCT02063087.

Concussion does not impact intraindividual response time variability.

This investigation examined the effect of concussion on intraindividual variability in 5 processing speed tasks. Forty-four adults, including 22 concussed and 22 healthy age- and gender-matched participants, completed the Headminder Concussion Resolution Index (D. M. Erlanger, D. J. Feldman, K. C. Kutner,& M. McCrea, 2001) twice. The test consists of a series of tasks including 25 trials of simple response time task, 70 trials of cued response time task (CuRT), 60 trials each for 2 visual recognition tasks, and 30 trials of symbol scanning task. Concussed participants completed a preinjury baseline assessment and were retested within 48 hours of injury diagnosis. The nonconcussed participants were retested 45 days after initial assessment. Average response time (RT), standard deviation, and response accuracy were calculated for each individual. Overall, concussed individuals had increased RTs across all tasks and were less accurate in the CuRT. RT variability for all tasks was elevated in concussed individuals, but controlling for mean RT at follow-up eliminated group differences. These findings indicate that response-time-variability increases in concussed individuals are proportional to processing-time increases. As such, RT variability is not a unique identifier of cognitive dysfunction following concussion. These results highlight that transient brain injury has significantly different neurobiological consequences than chronic conditions have.

The effect of effort on baseline neuropsychological test scores in high school football athletes.

OBJECTIVE: Poor effort on baseline neuropsychological tests is expected to influence interpretation of post-concussion assessment scores. Our study examined effort in an athletic population to determine if poor effort effects neuropsychological test performance. METHODS: High school athletes (N=199) were administered a brief neuropsychological test battery, which included the Dot Counting Test (DCT) and the Rey 15-Item Test with recognition trial. One-way analyses of variance were used to compare groups with adequate and poor effort test performance. RESULTS: Most athletes (N=177; 89%) exerted adequate effort while a number of athletes (N=22; 11%) exerted poor effort on the DCT. Statistically significant differences existed between effort groups (p<0.05) on several of the neuropsychological tests. CONCLUSIONS: Poor effort was observed in the athletic population during baseline testing and athletes with poor effort displayed statistically significant differences in performance on neuropsychological tests. Adding an effort test to baseline examinations may improve post-concussion test score interpretations.

Thrombin generation profiles as predictors of symptomatic venous thromboembolism after trauma: A prospective cohort study.

BACKGROUND: Reliable biomarkers predictive of venous thromboembolism (VTE) after acute trauma are uncertain. The objective of the study was to identify risk factors for symptomatic VTE after trauma, including individual plasma coagulome characteristics as reflected by thrombin generation. METHODS: In a prospective, case-cohort study, trauma patients were enrolled over the 4.5-year period, 2011 to 2015. Blood was collected by venipuncture into 3.2% trisodium citrate at 0, 6, 12, 24, and 72 hours after injury and at hospital discharge. Platelet poor plasma was stored at -80 °C until analysis. Thrombin generation, as determined by the calibrated automated thrombogram (CAT) using 5 pM tissue factor (TF)/4 µM phospholipid (PS), was reported as peak height (nM thrombin) and time to peak height (ttPeak [minutes]). Data are presented as median [IQR] or hazard ratio with 95% CI. RESULTS: Among 453 trauma patients (injury severity score = 13.0 [6.0, 22.0], hospital length of stay = 4.0 [2.0, 10.0] days, age = 49 [28, 64] years, 71% male, 96% with blunt mechanism, mortality 3.2%), 83 developed symptomatic VTE within 92 days after injury (35 [42%] after hospital discharge). In a weighted, multivariate Cox model that included clinical and CAT characteristics available within 24 hours of admission, increased patient age (1.35 [1.19,1.52] per 10 years, p < 0.0001), body mass index ≥30 kg/m (4.45 [2.13,9.31], p < 0.0001), any surgery requiring general anesthesia (2.53 [1.53,4.19], p = 0.0003) and first available ttPeak (1.67 [1.29, 2.15], p < 0.00001) were independent predictors of incident symptomatic VTE within 92 days after trauma (C-statistic = 0.799). CONCLUSION: The individual's plasma coagulome (as reflected by thrombin generation) is an independent predictor of VTE after trauma. Clinical characteristics and ttPeak can be used to stratify acute trauma patients into high and low risk for VTE. LEVEL OF EVIDENCE: Prognostic, level III.