Partnering With Patients, Caregivers, and Clinicians to Determine Research Priorities for Concussion.

Importance: Identifying research priorities of patients with concussion, their caregivers, and their clinicians is important to ensure future concussion research reflects the needs of those who will benefit from the research. Objective: To prioritize concussion research questions from the perspectives of patients, caregivers, and clinicians. Design, Setting, and Participants: This cross-sectional survey study used the standardized James Lind Alliance priority-setting partnership methods (2 online cross-sectional surveys and 1 virtual consensus workshop using modified Delphi and nominal group techniques). Data were collected between October 1, 2020, and May 26, 2022, from people with lived concussion experience (patients and caregivers) and clinicians who treat concussion throughout Canada. Exposures: The first survey collected unanswered questions about concussion that were compiled into summary questions and checked against research evidence to ensure they were unanswered. A second priority-setting survey generated a short list of questions, and 24 participants attended a final priority-setting workshop to decide on the top 10 research questions. Main Outcomes and Measures: Top 10 concussion research questions. Results: The first survey had 249 respondents (159 [64%] who identified as female; mean [SD] age, 45.1 [16.3] years), including 145 with lived experience and 104 clinicians. A total of 1761 concussion research questions and comments were collected and 1515 (86%) were considered in scope. These were combined into 88 summary questions, of which 5 were considered answered following evidence review, 14 were further combined to form new summary questions, and 10 were removed for being submitted by only 1 or 2 respondents. The 59 unanswered questions were circulated in a second survey, which had 989 respondents (764 [77%] who identified as female; mean [SD] age, 43.0 [4.2] years), including 654 people who identified as having lived experience and 327 who identified as clinicians (excluding 8 who did not record type of participant). This resulted in 17 questions short-listed for the final workshop. The top 10 concussion research questions were decided by consensus at the workshop. The main research question themes focused on early and accurate concussion diagnosis, effective symptom management, and prediction of poor outcomes. Conclusions and Relevance: This priority-setting partnership identified the top 10 patient-oriented research questions in concussion. These questions can be used to provide direction to the concussion research community and help prioritize funding for research that matters most to patients living with concussion and those who care for them.

Identifying research priorities with children, youth, and families: A scoping review.

Increased patient advocacy has resulted in a shift toward more active patient engagement in the research. A scoping review was conducted to explore the literature on healthcare research priority settings wherein children, youths, or their families were involved in the priority-setting process. Six databases including MEDLINE, CINAHL, PsycINFO, Embase, Web of Science, and Global Health and the James Lind Alliance website were searched up until September 2019. All primary studies involving children (<18 years of age) or families in developing research priorities in health care were included. All retrieved references were uploaded into Covidence, and two independent reviewers screened the search results. Descriptive thematic analysis was used to identify common themes. A total of 30 studies with 4247 participants were included. Less than half of the participants (n = 1237, (33%) were pediatric patients and their families. A total of 455 research priorities were identified. Three common themes emerged: (i) quality of care delivery, (ii) self-efficacy in health behaviors, and (iii) community engagement in care. This scoping review revealed priority research health topics from the perspectives of children, youths, or their families. The findings may be used as a foundation for future research to improve the health outcomes of children, youths, or their families according to their identified priorities.

Symptom Burden, School Function, and Physical Activity One Year Following Pediatric Concussion.

OBJECTIVES: To characterize symptom burden, school function, and physical activity in youth 1 year following acute concussion and those with subsequent repeat concussion. STUDY DESIGN: Secondary analysis of Predicting Persistent Postconcussive Problems in Pediatrics prospective, multicenter cohort study conducted in 9 Canadian emergency departments. Participants were children between ages 5 and 18 years who presented consecutively ≤48 hours of concussion and agreed to participate in a post hoc electronic survey 1 year after injury. Outcomes were assessed using a standardized 25-question symptom scale derived from the Post-Concussion Symptom Inventory-Parent; school function and physical activity outcomes were queried. The primary outcome was total symptom score 1 year following concussion, defined as the number of symptoms experienced more than before injury. RESULTS: Of 3052 youth enrolled in the Predicting Persistent Postconcussive Problems in Pediatrics study, 432 (median [IQR] age, 11.5 [9,14] years; 266 [62%] male) completed the 1-year survey; 34 respondents reported a repeat concussion. Following acute concussion, youth were more likely to be symptom-free than following repeat concussion (75% vs 50%; difference = 25% [95% CI 8-41]; P = .002) and to have recovered fully (90% vs 74%; difference = 17% [95% CI 5-34]; P = .002) after 1 year. Although physical symptoms were less 1 year after initial emergency department presentation for both groups (P < .001), youth with a repeat concussion reported greater headache persistence (26% vs 13%; difference = 13% [95% CI 1,31]; P = .024). Both groups returned to their normal school routine (100% vs 95%; difference = 5% [95% CI -5 to 8; P = .618). Youth without repeat concussion more frequently returned to normal physical activities (98% vs 85%; difference = 13% [95% CI 4-28]; P < .0001) and sport (95% vs 82%; difference = 13% [95% CI 3-29]; P = .009). CONCLUSIONS: Most youth are symptom-free and fully recovered 1 year following concussion. Some children with repeat concussion have worse outcomes and have delays in returning to normal school routines and sport.

Validation and refinement of a clinical decision rule for the use of computed tomography in children with minor head injury in the emergency department.

BACKGROUND: There is uncertainty about which children with minor head injury need to undergo computed tomography (CT). We sought to prospectively validate the accuracy and potential for refinement of a previously derived decision rule, Canadian Assessment of Tomography for Childhood Head injury (CATCH), to guide CT use in children with minor head injury. METHODS: This multicentre cohort study in 9 Canadian pediatric emergency departments prospectively enrolled children with blunt head trauma presenting with a Glasgow Coma Scale score of 13-15 and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. Phys icians completed standardized assessment forms before CT, including clinical predictors of the rule. The primary outcome was neurosurgical intervention and the secondary outcome was brain injury on CT. We calculated test characteristics of the rule and used recursive partitioning to further refine the rule. RESULTS: Of 4060 enrolled patients, 23 (0.6%) underwent neurosurgical intervention, and 197 (4.9%) had brain injury on CT. The original 7-item rule (CATCH) had sensitivities of 91.3% (95% confidence interval [CI] 72.0%-98.9%) for neurosurgical intervention and 97.5% (95% CI 94.2%-99.2%) for predicting brain injury. Adding "≥ 4 episodes of vomiting" resulted in a refined 8-item rule (CATCH2) with 100% (95% CI 85.2%-100%) sensitivity for neurosurgical intervention and 99.5% (95% CI 97.2%-100%) sensitivity for brain injury. INTERPRETATION: Among children presenting to the emergency department with minor head injury, the CATCH2 rule was highly sensitive for identifying those children requiring neurosurgical intervention and those with any brain injury on CT. The CATCH2 rule should be further validated in an implementation study designed to assess its clinical impact.

Scalp Hematoma Characteristics Associated With Intracranial Injury in Pediatric Minor Head Injury.

OBJECTIVES: Minor head trauma accounts for a significant proportion of pediatric emergency department (ED) visits. In children younger than 24 months, scalp hematomas are thought to be associated with the presence of intracranial injury (ICI). We investigated which scalp hematoma characteristics were associated with increased odds of ICI in children less than 17 years who presented to the ED following minor head injury and whether an underlying linear skull fracture may explain this relationship. METHODS: This was a secondary analysis of 3,866 patients enrolled in the Canadian Assessment of Tomography of Childhood Head Injury (CATCH) study. Information about scalp hematoma presence (yes/no), location (frontal, temporal/parietal, occipital), and size (small and localized, large and boggy) was collected by emergency physicians using a structured data collection form. ICI was defined as the presence of an acute brain lesion on computed tomography. Logistic regression analyses were adjusted for age, sex, dangerous injury mechanism, irritability on examination, suspected open or depressed skull fracture, and clinical signs of basal skull fracture. RESULTS: ICI was present in 159 (4.1%) patients. The presence of a scalp hematoma (n = 1,189) in any location was associated with significantly greater odds of ICI (odds ratio [OR] = 4.4, 95% confidence interval [CI] = 3.06 to 6.02), particularly for those located in temporal/parietal (OR = 6.0, 95% CI = 3.9 to 9.3) and occipital regions (OR = 5.6, 95% CI = 3.5 to 8.9). Both small and localized and large and boggy hematomas were significantly associated with ICI, although larger hematomas conferred larger odds (OR = 9.9, 95% CI = 6.3 to 15.5). Although the presence of a scalp hematoma was associated with greater odds of ICI in all age groups, odds were greatest in children aged 0 to 6 months (OR = 13.5, 95% CI = 1.5 to 119.3). Linear skull fractures were present in 156 (4.0%) patients. Of the 111 patients with scalp hematoma and ICI, 57 (51%) patients had a linear skull fracture and 54 (49%) did not. The association between scalp hematoma and ICI attenuated but remained significant after excluding patients with linear skull fracture (OR = 3.3, 95% CI = 2.1 to 5.1). CONCLUSIONS: Large and boggy and nonfrontal scalp hematomas had the strongest association with the presence of ICI in this large pediatric cohort. Although children 0 to 6 months of age were at highest odds, the presence of a scalp hematoma also independently increased the odds of ICI in older children and adolescents. The presence of a linear skull fracture only partially explained this relation, indicating that ruling out a skull fracture beneath a hematoma does not obviate the risk of intracranial pathology.

Reduction of radial-head subluxation in children by triage nurses in the emergency department: a cluster-randomized controlled trial.

BACKGROUND: Radial-head subluxation is an easily identified and treated injury. We investigated whether triage nurses in the emergency department can safely reduce radial-head subluxation at rates that are not substantially lower than those of emergency department physicians. METHODS: We performed an open, noninferiority, cluster-randomized control trial. Children aged 6 years and younger who presented to the emergency department with a presentation consistent with radial-head subluxation and who had sustained a known injury in the previous 12 hours were assigned to either nurse-initiated or physician-initiated treatment, depending on the day. The primary outcome was the proportion of children who had a successful reduction (return to normal arm usage). We used a noninferiority margin of 10%. RESULTS: In total, 268 children were eligible for inclusion and 245 were included in the final analysis. Of the children assigned to receive physician-initiated care, 96.7% (117/121) had a successful reduction performed by a physician. Of the children assigned to receive nurse-treatment care, 84.7% (105/124) had a successful reduction performed by a nurse. The difference in the proportion of successful radial head subluxations between the groups was 12.0% (95% confidence interval [CI] 4.8% to 19.7%). Noninferiority of nurse-initiated radial head subluxation was not shown. INTERPRETATION: In this trial, the rate of successful radial-head subluxation performed by nurses was inferior to the physician success rate. Although the success rate in the nurse-initiated care group did not meet the non-inferiority margin, nurses were able to reduce radial head subluxation for almost 85% of children who presented with probable radial-head subluxation. TRIAL REGISTRATION: Clinical Trials.gov, no. NCT00993954.

Triage nurse initiation of corticosteroids in pediatric asthma is associated with improved emergency department efficiency.

OBJECTIVE: To assess the effectiveness of nurse-initiated administration of oral corticosteroids before physician assessment in moderate to severe acute asthma exacerbations in the pediatric ED. METHODS: A time-series controlled trial evaluated nurse initiation of treatment with steroids before physician assessment in children with Pediatric Respiratory Assessment Measure score ≥4. One-to-one periods (physician-initiated and nurse-initiated) were analyzed from September 2009 through May 2010. In both phases, triage nurses initiated bronchodilator therapy before physician assessment, per Pediatric Respiratory Assessment Measure score. We reviewed charts of 644 consecutive children aged 2 to 17 years for the following outcomes: admission rate; times to clinical improvement, steroid receipt, mild status, and discharge; and rate of return ED visit and subsequent admission. RESULTS: Nurse-initiated phase children improved earlier compared to physician-initiated phase (median difference: 24 minutes; 95% confidence interval [CI]: 1-50; P = .04). Admission was less likely if children received steroids at triage (odds ratio = 0.56; 95% CI: 0.36-0.87). Efficiency gains were made in time to steroid receipt (median difference: 44 minutes; 95% CI: 39-50; P < .001), time to mild status (median difference: 51 minutes; 95% CI: 17-84; P = .04), and time to discharge (median difference: 44 minutes; 95% CI: 17-68; P = .02). No differences were found in return visit rate or subsequent admission. CONCLUSIONS: Triage nurse initiation of oral corticosteroid before physician assessment was associated with reduced times to clinical improvement and discharge, and reduced admission rates in children presenting with moderate to severe acute asthma exacerbations.

Cost-effectiveness of epinephrine and dexamethasone in children with bronchiolitis.

OBJECTIVE: Using data from the Canadian Bronchiolitis Epinephrine Steroid Trial we assessed the cost-effectiveness of treatments with epinephrine and dexamethasone for infants between 6 weeks and 12 months of age with bronchiolitis. METHODS: An economic evaluation was conducted from both the societal and health care system perspectives including all costs during 22 days after enrollment. The effectiveness of therapy was measured by the duration of symptoms of feeding problems, sleeping problems, coughing, and noisy breathing. Comparators were nebulized epinephrine plus oral dexamethasone, nebulized epinephrine alone, oral dexamethasone alone, and no active treatment. Uncertainty around estimates was assessed through nonparametric bootstrapping. RESULTS: The combination of nebulized epinephrine plus oral dexamethasone was dominant over the other 3 comparators in that it was both the most effective and least costly. Average societal costs were $1115 (95% credible interval [CI]: 919-1325) for the combination therapy, $1210 (95% CI: 1004-1441) for no active treatment, $1322 (95% CI: 1093-1571) for epinephrine alone, and $1360 (95% CI: 1124-1624) for dexamethasone alone. The average time to curtailment of all symptoms was 12.1 days (95% CI: 11-13) for the combination therapy, 12.7 days (95% CI: 12-13) for no active treatment, 13.0 days (95% CI: 12-14) for epinephrine alone, and 12.6 days (95% CI: 12-13) for dexamethasone alone. CONCLUSION: Treating infants with bronchiolitis with a combination of nebulized epinephrine plus oral dexamethasone is the most cost-effective treatment option, because it is the most effective in controlling symptoms and is associated with the least costs.

CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury.

BACKGROUND: There is controversy about which children with minor head injury need to undergo computed tomography (CT). We aimed to develop a highly sensitive clinical decision rule for the use of CT in children with minor head injury. METHODS: For this multicentre cohort study, we enrolled consecutive children with blunt head trauma presenting with a score of 13-15 on the Glasgow Coma Scale and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. For each child, staff in the emergency department completed a standardized assessment form before any CT. The main outcomes were need for neurologic intervention and presence of brain injury as determined by CT. We developed a decision rule by using recursive partitioning to combine variables that were both reliable and strongly associated with the outcome measures and thus to find the best combinations of predictor variables that were highly sensitive for detecting the outcome measures with maximal specificity. RESULTS: Among the 3866 patients enrolled (mean age 9.2 years), 95 (2.5%) had a score of 13 on the Glasgow Coma Scale, 282 (7.3%) had a score of 14, and 3489 (90.2%) had a score of 15. CT revealed that 159 (4.1%) had a brain injury, and 24 (0.6%) underwent neurologic intervention. We derived a decision rule for CT of the head consisting of four high-risk factors (failure to reach score of 15 on the Glasgow coma scale within two hours, suspicion of open skull fracture, worsening headache and irritability) and three additional medium-risk factors (large, boggy hematoma of the scalp; signs of basal skull fracture; dangerous mechanism of injury). The high-risk factors were 100.0% sensitive (95% CI 86.2%-100.0%) for predicting the need for neurologic intervention and would require that 30.2% of patients undergo CT. The medium-risk factors resulted in 98.1% sensitivity (95% CI 94.6%-99.4%) for the prediction of brain injury by CT and would require that 52.0% of patients undergo CT. INTERPRETATION: The decision rule developed in this study identifies children at two levels of risk. Once the decision rule has been prospectively validated, it has the potential to standardize and improve the use of CT for children with minor head injury.

Epinephrine and dexamethasone in children with bronchiolitis.

BACKGROUND: Although numerous studies have explored the benefit of using nebulized epinephrine or corticosteroids alone to treat infants with bronchiolitis, the effectiveness of combining these medications is not well established. METHODS: We conducted a multicenter, double-blind, placebo-controlled trial in which 800 infants (6 weeks to 12 months of age) with bronchiolitis who were seen in the pediatric emergency department were randomly assigned to one of four study groups. One group received two treatments of nebulized epinephrine (3 ml of epinephrine in a 1:1000 solution per treatment) and a total of six oral doses of dexamethasone (1.0 mg per kilogram of body weight in the emergency department and 0.6 mg per kilogram for an additional 5 days) (the epinephrine-dexamethasone group), the second group received nebulized epinephrine and oral placebo (the epinephrine group), the third received nebulized placebo and oral dexamethasone (the dexamethasone group), and the fourth received nebulized placebo and oral placebo (the placebo group). The primary outcome was hospital admission within 7 days after the day of enrollment (the initial visit to the emergency department). RESULTS: Baseline clinical characteristics were similar among the four groups. By the seventh day, 34 infants (17.1%) in the epinephrine-dexamethasone group, 47 (23.7%) in the epinephrine group, 51 (25.6%) in the dexamethasone group, and 53 (26.4%) in the placebo group had been admitted to the hospital. In the unadjusted analysis, only the infants in the epinephrine-dexamethasone group were significantly less likely than those in the placebo group to be admitted by day 7 (relative risk, 0.65; 95% confidence interval, 0.45 to 0.95, P=0.02). However, with adjustment for multiple comparisons, this result was rendered insignificant (P=0.07). There were no serious adverse events. CONCLUSIONS: Among infants with bronchiolitis treated in the emergency department, combined therapy with dexamethasone and epinephrine may significantly reduce hospital admissions. (Current Controlled Trials number, ISRCTN56745572.)

The appropriateness of referrals to a pediatric emergency department via a telephone health line.

OBJECTIVE: We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial telephone health line-referral, by self- or parent-referral, and by physician-referral. METHODS: A cohort of patients younger than 18 years of age who presented to a pediatric ED during any of four 1-week study periods were prospectively enrolled. The cohort consisted of all patients who were referred to the ED by a provincial telephone health line or by a physician. For each patient referred by the health line, the next patient who was self- or parent-referred was also enrolled. The primary outcome was visit appropriateness, which was determined using previously published explicit criteria. Secondary outcomes included the treating physician's view of appropriateness, disposition (hospital admission or discharge), treatment, investigations and the length of stay in the ED. RESULTS: Of the 578 patients who were enrolled, 129 were referred from the health line, 102 were either self- or parent-referred, and 347 were physician-referred. Groups were similar at baseline for sex, but health line-referred patients were significantly younger. Using explicitly set criteria, there was no significant difference in visit appropriateness among the health line-referrals (66%), the self- or parent-referrals (77%) and the physician-referrals (73%) (p = 0.11). However, when the examining physician determined visit appropriateness, physician-referred patients (80%) were deemed appropriate significantly more often than those referred by the health line (56%, p < 0.001) or by self- or parent-referral (63%, p = 0.002). There was no significant difference between these latter 2 referral routes (p = 0.50). In keeping with their greater acuity, physician-referred patients were significantly more likely to have investigations, receive some treatment, be admitted to hospital and have longer lengths of stay. Patients who were self- or parent-referred, and those who were health line-referred were similar to each other in these outcomes. CONCLUSION: There was no significant difference in visit appropriateness based on the route of referral when we used set criteria; however, there was when we used treating physician opinion, triage category and resource use.

Prospective evaluation of the MET-AP system providing triage plans for acute pediatric abdominal pain.

BACKGROUND: Children with acute abdominal pain (AP) are frequently assessed in the Emergency Department (ED). Though the majority of patients have benign causes, uncertainty during the physician's initial assessment may result in unnecessary tests and prolonged observation before a definitive disposition decision can be made. A rule-based mobile clinical decision support system, Mobile Emergency Triage-Abdominal Pain (MET-AP), has been developed to recommend an appropriate triage plan (discharge, consult surgery or observe/investigate) early in the ED visit, with the goal of promoting ED efficiencies and improved patient outcomes. OBJECTIVE: To prospectively evaluate the accuracy of MET-AP to recommend the correct triage plan when used during the initial assessment by staff emergency physicians (EPs) and residents in a tertiary care pediatric ED. DESIGN: Prospective cohort study. Staff EPs and/or residents examined children, aged 1-16 years, with acute, non-traumatic AP of less than 10 days duration. Details of their initial assessment, along with their blinded prediction of the correct triage plan, were recorded electronically. Inter-observer assessments were collected, where possible. Telephone and chart follow-up at 10-14 days was conducted to determine the patient's outcome/diagnosis, and thus the gold standard triage plan appropriate for the patient's visit. MEASUREMENTS: Accuracy of MET-AP to recommend the correct triage plan (i.e., to match the gold standard plan); accuracy of physicians to predict the correct triage plan; inter-observer agreement between staff EPs and residents for each clinical attribute recorded within MET-AP. RESULTS: Over 8 months, 574 patients with AP completed follow-up (10% appendicitis, 13% other pathology, 77% benign/resolving conditions). For patient assessments by the staff EP (n=457), the MET-AP recommendation was correct for 72% of patients (95% CI's: 67.9-76.1), while the physician's prediction was correct in 70% of cases (65.9-74.2) (p=0.518). However, staff EP triage plans were more conservative than those generated by MET-AP, and a small number of patients whose triage plan should have been "consult surgery" would have been "discharged" by MET-AP. For resident assessments (n=339), MET-AP and physician accuracies were slightly lower, but not statistically different from staff results or from each other. Inter-observer agreement on most attributes was moderate to near perfect. CONCLUSION: MET-AP shows promise in recommending the correct triage plan with similar overall accuracy to experienced pediatric EPs, but requires further research to improve accuracy and safety. MET-AP can be used on all pediatric ED patients with AP and is capable of producing a triage plan recommendation without requiring a complete set of patient information.

Radial head subluxation: how long do children wait in the emergency department before reduction?

OBJECTIVE: To describe the current emergency department (ED) wait times and treatment characteristics of children with radial head subluxation (RHS). METHODS: We performed a 2-year retrospective medical record review (April 1, 2004, to March 31, 2006) of all children who presented to our tertiary care pediatric ED with a discharge diagnosis of RHS, pulled elbow, dislocated elbow or nursemaid's elbow. RESULTS: We identified 501 cases of RHS in 427 children over a 2-year period. The mean age was 2.4 years (range 22 d-9.7 yr) and the injury was caused by a pull in 314 (62.8%) cases, a fall in 91 (18.2%) cases and a twist in 20 (4.0%) of the cases. The median time from triage to physician assessment was 1.3 hours, with 112 (23.5%) patients waiting > 2 hours and 33 (6.9%) waiting > 3 hours. The median time from triage to ED discharge was 1.7 hours, with 193 (41.2%) staying > 2 hours, 85 (18.1%) staying > 3 hours and 30 (6.4%) staying > 4 hours. Overall, 490 (99.2%) of these injuries were reduced in the ED: 98 (19.8%) were reduced prior to physician assessment and 309 (89.6%) were reduced on the first attempt. The technique used was pronation in 138 (52.7%), supination in 100 (38.2%), and pronation and supination in 24 (9.2%) cases. CONCLUSION: This large cohort indicates that children with RHS often have long ED waits before reduction and discharge. The majority of children with RHS are treated successfully with 1 reduction attempt. The data from this study will be used in planning a prospective study to shorten ED visits for patients with RHS.

A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma.

OBJECTIVE: Our goal was to determine which of 3 analgesics, acetaminophen, ibuprofen, or codeine, given as a single dose, provides the most efficacious analgesia for children presenting to the emergency department with pain from acute musculoskeletal injuries. PATIENTS AND METHODS: Children 6 to 17 years old with pain from a musculoskeletal injury (to extremities, neck, and back) that occurred in the preceding 48 hours before presentation in the emergency department were randomly assigned to receive orally 15 mg/kg acetaminophen, 10 mg/kg ibuprofen, or 1 mg/kg codeine. Children, parents, and the research assistants were blinded to group assignment. The primary outcome was change in pain from baseline to 60 minutes after treatment with study medication as measured by using a visual analog scale. RESULTS: A total of 336 patients were randomly assigned, and 300 were included in the analysis of the primary outcome (100 in the acetaminophen group, 100 in the ibuprofen group, and 100 in the codeine group). Study groups were similar in age, gender, final diagnosis, previous analgesic given, and baseline pain score. Patients in the ibuprofen group had a significantly greater improvement in pain score (mean decrease: 24 mm) than those in the codeine (mean decrease: 11 mm) and acetaminophen (mean decrease: 12 mm) groups at 60 minutes. In addition, at 60 minutes more patients in the ibuprofen group achieved adequate analgesia (as defined by a visual analog scale <30 mm) than the other 2 groups. There was no significant difference between patients in the codeine and acetaminophen groups in the change in pain score at any time period or in the number of patients achieving adequate analgesia. CONCLUSIONS: For the treatment of acute traumatic musculoskeletal injuries, ibuprofen provides the best analgesia among the 3 study medications.

A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children.

OBJECTIVE: Wrist buckle fractures are a frequent reason for emergency department visits. Although textbooks recommend 2 to 4 weeks of immobilization in a short arm cast, management varies. Treatment with both casts and splints is common, and length of immobilization varies. The objective was to determine if children with distal radius and/or ulna buckle fractures treated with a removable splint have better physical functioning than those treated with a short arm cast for 3 weeks. METHODS: This was a randomized, controlled trial in the emergency department of an academic, tertiary care children's hospital. Participants were children 6 to 15 years of age with distal radius and/or ulna buckle fractures who were randomly assigned to treatment with a short arm cast for 3 weeks or a removable splint. Cast removal was at 3 weeks. A validated self-reported outcome tool, the Activities Scales for Kids performance version (ASKp), was used to measure physical functioning over a 4-week period. The main outcome was the ASKp score at 14 days postinjury. RESULTS: We randomly assigned 113 patients, and 87 were included in the final analysis: 42 in the splint group and 45 in the cast group. Study groups were similar in age, gender, bone fractured, and dominant hand injured. There were significant differences in ASKp score at day 14 and change in ASKp from baseline at days 14 and 20, indicating better functioning in the splint group. Splinted children had less difficulty with bathing throughout the entire study. There were no significant differences in pain between groups as measured by visual analog scale. There were no refractures. CONCLUSIONS: Children treated with removable splinting have better physical functioning and less difficulty with activities than those treated with a cast.

Factors influencing childhood influenza immunization.

Following the launch of a publicly funded influenza immunization program for all residents of Ontario over the age of 6 months, we evaluated 203 parents of children who presented to our emergency department between January and March of the following year (2001). Overall, 54 (27%) of the children had been vaccinated. Parents of non-immunized children were more likely to believe that immunization resulted in a flu-like illness (42% v. 17%; p = 0.001), caused side effects that were more severe than having influenza (36% v. 17%; p = 0.010) and weakened the immune system (52% v. 24%; p < 0.001). Parents of both immunized and non-immunized children incorrectly identified gastrointestinal symptoms as symptoms of influenza. The primary reason for deciding against immunization was the belief that their child was not at risk. After adjustment, children with a chronic disease were more likely than those without a chronic disease to be immunized (adjusted odds ratio [OR] 4.7, 95% confidence interval [CI] 1.8-12.6). Children of parents who discussed immunization with a physician were more likely to be immunized than those who had not discussed immunization with a physician (OR 6.8, 95% CI 2.4-19.2).