CONNECTing Concussion Care with Research Across Ontario.

Common data elements (CDEs) for concussion, as established by international bodies, are not being widely used in Ontario, resulting in significant variability in the data being assessed and collected across clinics. CDEs support standardization of care as well as large-scale data sharing for high impact research. A collaborative network - Concussion Ontario Network: Neuroinformatics to Enhance Clinical care and Translation (CONNECT) - comprised of health care professionals, researchers, members from advocacy groups, and patients was formed to establish and implement CDEs for concussion care and research. While the seeds have been planted and initial effectiveness demonstrated, future challenges exist.

Feasibility of Concussion Rehabilitation Approaches Tailored to Psychological Coping Styles: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the feasibility of a clinical trial involving participants with concussion randomized to treatments designed to address fear avoidance or endurance coping, which are risk factors for disability. A secondary objective was to evaluate whether each treatment could affect selective change on targeted coping outcomes. DESIGN: Randomized controlled trial. SETTING: Outpatient concussion clinics. PARTICIPANTS: Adults (N=73, mean age=42.5y) who had persistent postconcussion symptoms and high avoidance or endurance behavior were enrolled at a mean of 12.9 weeks post injury. Ten participants did not complete treatment. INTERVENTIONS: Participants were randomized to an interdisciplinary rehabilitation program delivered via videoconferencing and tailored to avoidance coping (graded exposure therapy [GET]) or endurance coping (operant condition-based pacing strategies plus mindfulness training [Pacing+]). MAIN OUTCOME MEASURES: Feasibility outcomes included screening efficiency, accrual, credibility, treatment fidelity, adherence, and retention. Avoidance was measured with the Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire and endurance behavior with the Behavioral Response to Illness Questionnaire. RESULTS: Screening efficiency, or the proportion of clinic patients who were assessed for eligibility, was 44.5% (275 of 618). A total of 65.8% (73 of 111) of eligible patients were randomized (37 to GET, 36 to Pacing+), meeting accrual targets; 91.7% (55 of 60) of participants perceived treatment as credible. Therapists covered a mean of 96.8% of essential prescribed elements, indicating excellent fidelity. The majority (71.2%; 47 of 66) of participants consistently attended treatment sessions and completed between-session homework. Retention was strong, with 65 of 73 (89%) randomized participants completing the outcome assessment. GET was associated with greater posttreatment reductions in avoidance behavior compared with Pacing+ (Cohen's drepeated measures, 0.81), whereas the treatment approach-specific effect of Pacing+ on endurance behavior was less pronounced (Cohen's drepeated measures, 0.39). CONCLUSIONS: These findings support a future efficacy-focused clinical trial. GET has the potential to selectively reduce fear avoidance behavior after concussion, and, via this mechanism, to prevent or reduce disability.

Normative Data for the Fear Avoidance Behavior After Traumatic Brain Injury Questionnaire in a Clinical Sample of Adults With Mild TBI.

OBJECTIVE: Fear avoidance behavior after a concussion or mild traumatic brain injury (mTBI) is associated with a number of adverse outcomes, such as higher symptom burden, emotional distress, and disability. The Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI) is a recently developed and validated self-report measure of fear avoidance after mTBI. The objective of this study was to derive clinical normative data for the FAB-TBI. To determine whether demographic stratification was necessary and to further support clinical interpretation, we also explored associations between fear avoidance behavior and demographic and injury variables. SETTING: Five concussion clinics in Canada. PARTICIPANTS: Adults who sustained an mTBI (N = 563). DESIGN: Cross-sectional. MAIN MEASURES: Participants completed the Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI) and measures of postconcussion symptom burden (Rivermead Postconcussion Symptoms Questionnaire, Sport Concussion Assessment Tool-5) at clinic intake. RESULTS: Generalized linear modeling revealed that females reported more fear avoidance than males (95% CI = 0.66 to 2.75), indicating that FAB-TBI normative data should be stratified by sex. Differences between recruitment sites on FAB-TBI scores were reduced but not eliminated by controlling for potential confounds. Loss of consciousness (95% CI =0.61 to 2.76) and higher postconcussion symptom burden (95% CI = 0.79 to 1.03) were also associated with higher FAB-TBI scores, but time since injury was not (95% = CI -0.4 to 0.03). Tables to convert FAB-TBI raw scores to Rasch scores to percentiles are presented. CONCLUSION: These findings support clinical interpretation of the FAB-TBI and further study of fear avoidance after mTBI.

Mapping Stakeholder Perspectives on Engagement in Concussion Research to Theory.

BACKGROUND: Involving stakeholders has been acknowledged as a way to improve quality and relevance in health research. The mechanisms that support effective research engagement with stakeholders have not been studied in the area of concussion. Concussion is a large public health concern worldwide with billions of dollars spent on health care services and research with improvements in care and service delivery not moving forward as quickly as desired. Enabling effective stakeholder engagement could improve concussion research and care. OBJECTIVE: The aim of the study was to identify potential benefits, challenges, and motivators to engaging in research by gathering the perspectives of adults with lived experience of concussion. METHODS: A thematic analysis of qualitative responses collected from a convenience sample attending a provincial brain injury conference (n = 60) was undertaken using open coding followed by axial coding. RESULTS: Four themes regarding benefits to engagement emerged: first-hand account, meaningful recovery, research relevance, and better understanding of gaps. Three forces inhibited engagement: environmental barriers, injury-related constraints, and personal deterrents. Four enablers supported engagement: focus on positive impact, build connections, create a supportive environment, and provide financial assistance. CONCLUSIONS: Understanding stakeholder's perspectives on research engagement is an important issue that may serve to improve research quality. There may be unique nuances at play with injury-specific stakeholders that require researchers to consider a balance between reducing inhibitors while supporting enablers. These findings are preliminary and limited. Nevertheless, they provide needed insight and guidance for ongoing investigation regarding improvement of stakeholder engagement in concussion research.

Quality of life measures in older adults after traumatic brain injury: a systematic review.

BACKGROUND: On average older adults experiencing TBI are hospitalized four times as often, have longer hospital stays, and experience slower recovery trajectories and worse functional outcomes compared to younger populations with the same injury severity. A standard measure of Qol for older adults with TBI would facilitate accurate and reliable data across the individual patient care continuum and across clinical care settings, as well as support more rigorous research studies of metadata. PURPOSE: The aim of this systematic review was to investigate patient reported Qol measures in studies with older adults post TBI. METHOD: A systematic review was carried out focusing on the various tools to measure Qol in older adults, ≥ 65 years of age with a diagnosis of TBI. Data bases searched included Medline, Embase, PubMed, CINAHL, and PsychInfo from date of inception to September 25, 2017. RESULTS: A total of 20 articles met the inclusion criteria. Nine different tools were identified. CONCLUSIONS: Findings based on the comparison of reliability and construct validity of the Qol measures reported in this review suggest that no single instrument is superior to all others for our study population. Future research in this field should include the enrollment of larger study samples of older adults. Without these future efforts, the ability to detect an optimal Qol measure will be hindered.

Knowledge, Attitudes and Concussion Information Sources Among First Nations in Ontario.

OBJECTIVE: Hockey is a popular sport played by many First Nation youth. Concussion frequently goes unrecognized and unreported in youth hockey. Unintentional injuries among Indigenous youth occur at rates three to four times the national Canadian average. The study sought to examine knowledge, attitudes and sources of concussion information among First Nations people attending a provincial hockey tournament. METHODS: A cross-sectional survey was undertaken. The survey by Mzazik et al. were modified to use in this study. Participants included youth (6-18 years) hockey players (n=75), parents (n=248) and coaches (n=68). The main outcome measure was total knowledge index (TKI) which consisted of the sum of correct responses to 15 multiple choice questions. Additional data gathered included demographics, concussion history, attitudes toward concussion and sources of information. Descriptive statistics included proportion comparisons. Variables were tested using χ 2 and analysis of variance. RESULTS: Overall TKI scores (out of a total of 15) were low; players (5.9±2.8), parents (7.5±2.6) and coaches (7.9±2.6). Participants with higher knowledge scores reported more appreciation of the seriousness of concussion. Sources of information about concussion differed by study group, suggesting the need for multiple knowledge translation strategies to reach youth, parents and coaches. CONCLUSIONS: Future initiatives are urgently needed to improve education and prevention of concussion in First Nations youth hockey. Collaborating and engaging with communities can help to ensure an Indigenous lens for culturally safe interventions.

Exploring concussion awareness in hockey with a First Nations community in Canada.

OBJECTIVE: The purpose of this pilot study was twofold: (1) to begin to understand concussion in youth hockey in a First Nations community in Canada and (2) to determine the impact of a novel concussion education workshop. DESIGN: A one-group quasiexperimental time series study was undertaken. SAMPLE: A total of 41 participants consented, with 71% (n = 29) completing data collection at all three study time points. MEASUREMENT AND INTERVENTIONS: Two nurses one from the First Nations community and one from the tertiary care center collaborated to develop and deliver the intervention on concussion specifically general, hockey and symptom knowledge. The primary outcome was Total Knowledge Score (TKS), whereby correct responses to a self-reported questionnaire were summed and then converted to a percentage. RESULTS: The TKS were similar across study time points; preworkshop 71.7%, postworkshop 71.8%, and 6-month follow-up 72%. CONCLUSIONS: Nurses worked collaboratively with cultural experts from a First Nations community to integrate Indigenous ways of knowing into concussion awareness and safety for First Nations youth playing hockey.

Is Age Associated With the Severity of Post-Mild Traumatic Brain Injury Symptoms?

BACKGROUND: Mild traumatic brain injury (mTBI) is a significant public health concern. Research has shown that mTBI is associated with persistent physical, cognitive, and behavioural symptoms, leading to significant direct and indirect medical costs. Our objective was to determine if age impacts the type and severity of post-mTBI symptoms experienced. METHODS: Retrospective analysis of prospectively collected data at a level 1 tertiary care outpatient head injury clinic. Participants (N=167) were patients seen at the clinic following an mTBI. The Rivermead Post-Concussion Symptoms Questionnaire was used to assess symptom severity. RESULTS: In our sample, the mean age was 44±16 years with 51% males. Compared with other age groups, patients >66 years of age were significantly more likely to report an mTBI between 6 AM to 12 PM (69%). Middle-aged patients (36-55 years) were more likely to report higher severity of certain post-mTBI symptoms (headache, nausea and vomiting, irritability, poor concentration, sleep disturbance, blurry vision, light sensitivity, and taking longer to think) compared with patients >66 years of age. CONCLUSIONS: In general, middle-aged patients reported higher severity of post-mTBI symptoms compared with the oldest patients. Thus, there was a significant association between age and the severity of specific mTBI symptoms, which highlights the need for targeted management. Additional research is needed to understand the mechanisms that could be contributing to the higher symptom severity experienced by the middle-aged group.

Common Data Elements for Concussion in Tertiary Care: Phase One in Ontario.

BACKGROUND: Standardized data collection for traumatic brain injury (TBI) (including concussion) using common data elements (CDEs) has strengthened clinical care and research capacity in the United States and Europe. Currently, Ontario healthcare providers do not collect uniform data on adult patients diagnosed with concussion. OBJECTIVE: The Ontario Concussion Care Strategy (OCCS) is a collaborative network of multidisciplinary healthcare providers, brain injury advocacy groups, patient representatives, and researchers with a shared vision to improve concussion care across the province, starting with the collection of standardized data. METHODS: The International Framework of Functioning Disability and Health was selected as the conceptual framework to inform the selection of CDEs. The CDEs recommended by the OCCS were identified using key literature, including the National Institute of Neurological Disorders and Stroke-Zurich Consensus Statements for concussion in sport and the Ontario Neurotrauma Foundation Concussion/mTBI clinical guidelines. RESULTS: The OCCS has recommended and piloted CDEs for Ontario that are readily available at no cost, clinically relevant, patient friendly, easy to interpret, and recognized by the international scientific community. CONCLUSIONS: The implementation of CDEs can help to shift Ontario toward internationally recognized standard data collection, and in so doing yield a more comprehensive evidence-based approach to care while also supporting rigorous research.

Graded Exposure Therapy for Fear Avoidance Behaviour After Concussion (GET FAB): protocol for a multisite Canadian randomised controlled trial.

INTRODUCTION: Persistent symptoms after mild traumatic brain injury (mTBI) negatively affect daily functioning and quality of life. Fear avoidance behaviour, a coping style in which people avoid or escape from activities or situations that they expect will exacerbate their symptoms, maybe a particularly potent and modifiable risk factor for chronic disability after mTBI. This study will evaluate the efficacy of graded exposure therapy (GET) for reducing persistent symptoms following mTBI, with two primary aims: (1) To determine whether GET is more effective than usual care; (2) to identify for whom GET is the most effective treatment option, by evaluating whether baseline fear avoidance moderates differences between GET and an active comparator (prescribed aerobic exercise). Our findings will guide evidence-based care after mTBI and enable better matching of mTBI patients to treatments. METHODS AND ANALYSIS: We will conduct a multisite randomised controlled trial with three arms. Participants (n=220) will be recruited from concussion clinics and emergency departments in three Canadian provinces and randomly assigned (1:2:2 ratio) to receive enhanced usual care, GET or prescribed aerobic exercise. The outcome assessment will occur remotely 14-18 weeks following baseline assessment, after completing the 12-week treatment phase. The primary outcome will be symptom severity (Rivermead Post-concussion Symptoms Questionnaire). ETHICS AND DISSEMINATION: Informed consent will be obtained from all participants. All study procedures were approved by the local research ethics boards (University of British Columbia Clinical Research Ethics Board, University of Calgary Conjoint Health Research Ethics Board, University Health Network Research Ethics Board-Panel D). Operational approvals were obtained for Vancouver Coastal Health Research Institute and Provincial Health Services Authority. If GET proves effective, we will disseminate the GET treatment manual and present instructional workshops for clinicians. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov #NCT05365776.

Characterizing the profiles of patients with acute concussion versus prolonged post-concussion symptoms in Ontario.

Identifying vulnerability factors for developing persisting concussion symptoms is imperative for determining which patients may require specialized treatment. Using cross-sectional questionnaire data from an Ontario-wide observational concussion study, we compared patients with acute concussion (≤ 14 days) and prolonged post-concussion symptoms (PPCS) (≥ 90 days) on four factors of interest: sex, history of mental health disorders, history of headaches/migraines, and past concussions. Differences in profile between the two groups were also explored. 110 patients with acute concussion and 96 patients with PPCS were included in our study. The groups did not differ on the four factors of interest. Interestingly, both groups had greater proportions of females (acute concussion: 61.1% F; PPCS: 66.3% F). Patient profiles, however, differed wherein patients with PPCS were significantly older, more symptomatic, more likely to have been injured in a transportation-related incident, and more likely to live outside a Metropolitan city. These novel risk factors for persisting concussion symptoms require replication and highlight the need to re-evaluate previously identified risk factors as more and more concussions occur in non-athletes and different risk factors may be at play.

Enhanced education for adult patients with persistent post-concussion headaches: a randomized controlled trial.

Aim & Patients: We conducted a randomized clinical trial to determine if an e-learning intervention can enhance recovery in adult patients with persistent post-concussion headaches (PPCH). Materials & Methods: The intervention consisted of three e-learning modules administered at baseline, 6 and 12 weeks. Data were collected on symptoms, community integration, quality of life and healthcare utilization at baseline and 12-week follow-up. ANCOVA was conducted to compare changes. Results: No statistically significant difference was observed on symptoms although we observed a trend toward reduced healthcare utilization and improved quality of life in the intervention group. Conclusion: E-learning modules for patients experiencing PPCH warrant further investigation with data on participant compliance and measures focusing on simpler short-term outcomes.Clinical Trial Registration: NCT03391583 (ClinicalTrials.gov).

Psychological mediators of avoidance and endurance behavior after concussion.

OBJECTIVE: The avoidance-endurance model (AEM) proposes multiple pathways from acute to chronic pain, with distinct cognitive and behavioral components in each pathway. The AEM may also be applicable to persistent symptoms after concussion. In this study, we tested the AEM as an explanatory framework for concussion outcomes, by using mediation analyses through the proposed psychological mechanisms. Based on the AEM, we hypothesized that postconcussion symptoms would significantly predict avoidance behavior through catastrophizing, and endurance behavior through thought suppression and self-distraction. PARTICIPANTS AND METHODS: We recruited 84 adults seeking treatment at 2 outpatient concussion clinics (M = 41.8 years old, 63% female) who completed measures of postconcussion symptoms, catastrophizing, thought suppression, "self-distraction" (Five Factor Mindfulness Questionnaire "Act with Awareness" Scale reverse-scored), avoidance behavior, and endurance behavior at an average of 17.8 weeks postconcussion. We conducted 3 mediation analyses to assess each of the AEM pathways. RESULTS: We found a significant indirect effect of postconcussion symptoms on avoidance behavior through catastrophizing (ab = .113 (.036), 95% CI [.053, .195]). The indirect effects of postconcussion symptoms on endurance behavior through thought suppression (ab = .011 (.012), 90% CI [.002, .035]) and "self-distraction" (ab = .003 (.009), 90% CI [.008, .022]) were not statistically significant. CONCLUSIONS: Results supported the catastrophizing-avoidance pathway in concussion, but not the thought-suppression-endurance or self-distraction-endurance pathways. Therefore, catastrophic thinking about concussion symptoms may be an appropriate treatment target for individuals who exhibit fear-avoidance behavior. Further research is needed to establish whether thought suppression and self-distraction are relevant for interventions aimed at reducing excessive endurance behavior. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Noncanonical Hippo Pathway Regulates Spindle Disassembly and Cytokinesis During Meiosis in Saccharomyces cerevisiae.

Meiosis in the budding yeast Saccharomyces cerevisiae is used to create haploid yeast spores from a diploid mother cell. During meiosis II, cytokinesis occurs by closure of the prospore membrane, a membrane that initiates at the spindle pole body and grows to surround each of the haploid meiotic products. Timely prospore membrane closure requires SPS1, which encodes an STE20 family GCKIII kinase. To identify genes that may activate SPS1, we utilized a histone phosphorylation defect of sps1 mutants to screen for genes with a similar phenotype and found that cdc15 shared this phenotype. CDC15 encodes a Hippo-like kinase that is part of the mitotic exit network. We find that Sps1 complexes with Cdc15, that Sps1 phosphorylation requires Cdc15, and that CDC15 is also required for timely prospore membrane closure. We also find that SPS1, like CDC15, is required for meiosis II spindle disassembly and sustained anaphase II release of Cdc14 in meiosis. However, the NDR-kinase complex encoded by DBF2/DBF20MOB1 which functions downstream of CDC15 in mitotic cells, does not appear to play a role in spindle disassembly, timely prospore membrane closure, or sustained anaphase II Cdc14 release. Taken together, our results suggest that the mitotic exit network is rewired for exit from meiosis II, such that SPS1 replaces the NDR-kinase complex downstream of CDC15.

Kinetic isotope effects of nucleoside hydrolase from Escherichia coli.

rihC is one of a group of three ribonucleoside hydrolases found in Escherichia coli (E. coli). The enzyme catalyzes the hydrolysis of selected nucleosides to ribose and the corresponding base. A family of Vmax/Km kinetic isotope effects using uridine labeled with stable isotopes, such as 2H, 13C, and 15N, were determined by liquid chromatography/mass spectrometry (LC/MS). The kinetic isotope effects were 1.012+/-0.006, 1.027+/-0.005, 1.134+/-0.007, 1.122+/-0.008, and 1.002+/-0.004 for [1'-13C], [1-15N], [1'-2H], [2'-2H], and [5'-2H2] uridine, respectively. A transition state based upon a bond-energy bond-order vibrational analysis (BEBOVIB) of the observed kinetic isotope effects is proposed. The main features of this transition state are activation of the heterocyclic base by protonation of/or hydrogen bonding to O2, an extensively broken C-N glycosidic bond, formation of an oxocarbenium ion in the ribose ring, C3'-exo ribose ring conformation, and almost no bond formation to the attacking nucleophile. The proposed transition state for the prokaryotic E. coli nucleoside hydrolase is compared to that of a similar enzyme isolated from Crithidia fasciculata (C. fasciculata).

Identification of hidden health utilization services and costs in adults awaiting tertiary care following mild traumatic brain injury in Toronto, Ontario, Canada.

AIM: The cognitive, emotional, behavioral and physical impairments experienced by adults after mild traumatic brain injury (mTBI) can produce substantial disability, with 15-20% requiring referral to tertiary care (TC) for persistent symptoms. METHODS: A convenience sample of 201 adult patients referred to TC as a result of mTBI was studied. Self-reported data were collected at first TC visit, on average 10 months postinjury. Patients reported the type and intensity of healthcare provider visit(s) undertaken while awaiting TC. RESULTS: On average males reported 37 and females 30 healthcare provider visits, resulting in over $500,000 Canadian dollars spent on potentially excess mTBI care over 1 year. DISCUSSION: Based on conservative estimate of 15% of mTBI patients receiving TC, this finding identifies a possible excess in care of $110 million for Ontario. Accurate diagnosis of mTBI and early coordination of follow-up care for those needing TC could increase cost-effectiveness.

Incivility in the practice environment: a perspective from clinical nursing teachers.

This paper advances a notion of incivility as a precursor to a continuum of antisocial acts culminating in bullying behaviour. Clinical teachers (CTs), working with undergraduate nursing students in a variety of clinical settings from a large urban centre, were studied. Using a mixed method design, CTs were asked to define and describe the nature, type and frequency of uncivil encounters. Data was collected across four practice settings, which included, acute care, maternal child, community and mental health. To unpack the complex nature of incivility we applied a conceptual model based on bullying behaviour which permitted us to analyze CTs narratives for both form (i.e., direct vs. indirect incivility) and function (i.e., reactive vs. proactive). The results suggest that indirect incivility was the most prevalent subtype narrative reported. One of the implications of this study is that nurse educators can help new clinical students recognize the different subtypes of in/civility in the practice environment as an essential first step before targeted intervention programs can be developed and implemented to create civil learning and safer working environments.

A journey towards a healthy collaborative nursing program: a case study.

In Canada, collaborative college-university nursing programs have emerged in response to professional education changes and nursing shortages. Developing a collaborative nursing education program between two provinces, each with a distinct academic culture, independent practice, unique governance and separate administration, was not an easy undertaking. The authors used a theoretical approach to implement a collaborative nursing program. Integrating leadership theory with an existing framework for multiple interventions from community health, the authors articulate developmental stages for collaborative education and share their own collaborative journey. This case study demonstrates that healthy, sustainable collaborative education does exist. The paper introduces a developmental model for collaborative education and serves as both a pathway for new collaborations and a reflective tool for existing ones.