Evaluation of a Medically Supervised Concussion Protocol for Youth Hockey in Canada.

OBJECTIVES: The objective of this study was to evaluate the feasibility and implementation of a standardized medically supervised concussion protocol established between a city-wide AAA hockey league and a multi-disciplinary concussion program. METHODS: We conducted a retrospective review of injury surveillance, clinical and healthcare utilization data from all athletes evaluated and managed through the Winnipeg AAA Hockey concussion protocol during the 2016-2017 season. We also conducted post-season email surveys of head coaches and parents responsible for athletes who competed in the same season. RESULTS: During the 2016-2017 season, 28 athletes were evaluated through the medically supervised concussion protocol, with two athletes undergoing evaluation for repeat injuries (a total of 30 suspected injuries and consultations). In all, 96.7% of the athletes managed through the concussion protocol were captured by the league-designated Concussion Protocol Coordinator and 100% of eligible athletes underwent complete medical follow-up and clearance to return to full hockey activities. Although 90% of responding head coaches and 91% of parents were aware of the concussion protocol, survey results suggest that some athletes who sustained suspected concussions were not managed through the protocol. Head coaches and parents also indicated that athlete education and communication between medical and sport stakeholders were other elements of the concussion protocol that could be improved. CONCLUSION: Successful implementation of a medically supervised concussion protocol for youth hockey requires clear communication between sport stakeholders and timely access to multi-disciplinary experts in traumatic brain and spine injuries. Standardized concussion protocols for youth sports may benefit from periodic evaluations by sport stakeholders and incorporation of national guideline best practices and resources.

Graduated driver licensing for reducing motor vehicle crashes among young drivers.

BACKGROUND: Graduated driver licensing (GDL) has been proposed as a means of reducing crash rates among novice drivers by gradually introducing them to higher risk driving situations. OBJECTIVES: To examine the effectiveness of GDL in reducing crash rates among young drivers. SEARCH STRATEGY: Studies were identified through searching MEDLINE, EMBASE, CINAHL, Healthstar, Web of Science, NTIS Bibliographic Database, TRIS Online, SIGLE, the World Wide Web, conference proceedings, consultation with experts and reference lists in relevant published literature. The searches were conducted from the time of inception to May 2009, and the Cochrane Injuries Group conducted an updated search of the TRANSPORT database in September 2009. SELECTION CRITERIA: Studies were included if: 1) they compared outcomes pre- and post-implementation of a GDL program within the same jurisdiction, 2) comparisons were made between jurisdictions with and without GDL, or 3) both. Studies had to report at least one objective, quantified outcome. DATA COLLECTION AND ANALYSIS: Results were not pooled due to substantial heterogeneity. Percentage change was calculated for each year after the intervention, using one year prior to the intervention as baseline. Results were adjusted by internal controls. Analyses were stratified by denominators (population, licensed drivers). Results were calculated for the different crash types and presented for 16 year-olds alone as well as all teenage drivers. MAIN RESULTS: We included 34 studies evaluating 21 GDL programs and 2 analyses of >40 US states. GDL programs were implemented in the US (n=16), Canada (n=3), New Zealand (n=1), and Australia (n=1) and varied in their restrictions during the intermediate stage. Based on the Insurance Institute for Highway Safety (IIHS) classification, eleven programs were good, four were fair, five were marginal, one was poor and two could not be assessed. Reductions in crash rates were seen in all jurisdictions and for all crash types. Among 16 year-old drivers, the median decrease in per population adjusted overall crash rates during the first year was 15.5% (range -27 to -8%, five studies). There was a decrease in per population adjusted injury crash rates (median -21%, range -46 to -2%, five studies). Results for all teenage drivers, rates per licensed driver, and rates adjusting for internal controls were generally reduced when comparing within jurisdictions. AUTHORS' CONCLUSIONS: GDL is effective in reducing crash rates among young drivers, although the magnitude of the effect varies. The conclusions are supported by consistent findings, temporal relationship, and plausibility of the association. Stronger GDL programs (i.e. more restrictions or higher quality based on IIHS classification) appear to result in greater fatality reduction. Future studies should focus on which components and combination of components yield the greatest reductions.

Glucocorticoids for croup.

BACKGROUND: Since the initial publication of this systematic review in 1997, several randomized trials examining the benefit of glucocorticoids have been published. The objective of this review is to provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas requiring future research. OBJECTIVES: To determine the effect of glucocorticoids for children with croup. SEARCH STRATEGY: We searched CENTRAL (2010, Issue 3), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July week 2, 2010) and EMBASE.com (1974 to July 2010). We also contacted authors of identified croup trials published in the last 10 years to inquire about additional published or unpublished trials. SELECTION CRITERIA: Randomised controlled trials (RCTs) that examine children with croup and objectively measure the effectiveness of glucocorticoids. DATA COLLECTION AND ANALYSIS: Two review authors identified studies for potential relevance based on the review of the title and abstract (when available). Two review authors independently reviewed studies for relevance using a priori inclusion criteria and assessed trial quality. Differences were resolved by consensus. One review author extracted data using a structured form and another review author checked the results for accuracy. We performed standard statistical analyses. MAIN RESULTS: Thirty-eight studies were included (n = 4299). Glucocorticoids were associated with an improved Westley score (maximum 17 points) at six hours with a mean difference of -1.2 (95% confidence interval (CI) -1.6 to -0.8) and at 12 hours -1.9 (95% CI -2.4 to -1.3); at 24 hours this improvement was no longer significant (-1.3, 95% CI -2.7 to 0.2). Fewer return visits and/or (re)admissions occurred in participants treated with glucocorticoids (risk ratio (RR) 0.5; 95% CI 0.3 to 0.7). Length of time spent in accident and emergency or hospital (mean difference 12 hours, five to 19 hours) was significantly decreased for participants treated with glucocorticoids. Use of epinephrine decreased for children treated with a glucocorticoid (risk difference 10%; 95% CI 1 to 20). AUTHORS' CONCLUSIONS: Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence.

Nebulized epinephrine for croup in children.

BACKGROUND: Croup is a common childhood illness characterized by barky cough, stridor, hoarseness and respiratory distress. Children with severe croup are at risk for intubation. Nebulized epinephrine (NE) may prevent intubation. OBJECTIVES: To evaluate the efficacy and safety of NE in children presenting to emergency department (ED) or admitted to hospital with croup. SEARCH STRATEGY: We searched CENTRAL (The Cochrane Library 2010, Issue 4), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (1966 to November Week 1, 2010), EMBASE (1980 to November 2010), Web of Science (1974 to November 2010), CINAHL (1982 to November 2010) and Scopus (1996 to November 2010). SELECTION CRITERIA: Randomized controlled trials (RCTs) or quasi-RCTs of children with croup evaluated in an ED or admitted to hospital. Comparisons were: NE versus placebo, racemic NE versus L-epinephrine (an isomer), and NE delivered by intermittent positive pressure breathing (IPPB) versus NE without IPPB. Primary outcome was change in croup score post-treatment. Secondary outcomes were rate and duration of intubation and hospitalization, croup return visit, parental anxiety and side effects. DATA COLLECTION AND ANALYSIS: Two authors independently identified potentially relevant studies by title and abstract (when available) and examined relevant studies using a priori inclusion criteria, followed by methodologic quality assessment. One author extracted data while the second checked accuracy. We performed standard statistical analyses. MAIN RESULTS: Eight studies (225 participants) were included. NE was associated with croup score improvement 30 minutes post-treatment (three RCTs, standardized mean difference (SMD) -0.94; 95% confidence interval (CI) -1.37 to -0.51; I(2) statistic = 0%). This effect was not significant two and six hours post-treatment. NE was associated with significantly shorter hospital stay than placebo (one RCT, mean difference -32.0 hours; 95% CI -59.1 to -4.9). Comparing racemic and L-epinephrine, no difference in croup score was found after 30 minutes (SMD 0.33; 95% CI -0.42 to 1.08). After two hours, L-epinephrine showed significant reduction compared with racemic epinephrine (one RCT, SMD 0.87; 95% CI 0.09 to 1.65). There was no significant difference in croup score between administration of NE via IPPB versus nebulization alone at 30 minutes (one RCT, SMD -0.14; 95% CI -1.24 to 0.95) or two hours (SMD -0.72; 95% CI -1.86 to 0.42). AUTHORS' CONCLUSIONS: NE is associated with clinically and statistically significant transient reduction of symptoms of croup 30 minutes post-treatment. Evidence does not favor racemic epinephrine or LE, or IPPB over simple nebulization. 

Tissue adhesives for traumatic lacerations: a systematic review of randomized controlled trials.

OBJECTIVE: To summarize the best available evidence for the effect of tissue adhesives (TAs) in managing traumatic lacerations in children and adults. METHODS: A search was conducted using the Cochrane Controlled Trials Register, Medline, and EMBase for relevant studies. The authors also searched the citations of selected studies and contacted relevant authors and manufacturers. The search included randomized controlled trials (RCTs) comparing a TA versus standard wound closure (sutures, staples, adhesive strips) (SWC) or two TAs for acute, linear, low-tension, traumatic lacerations in an emergency or primary care setting. Data were extracted by one reviewer and checked for accuracy by a second reviewer. Two reviewers independently assessed masked copies for quality. Outcomes of cosmesis (subgroups of age, wound location, and need for deep sutures), pain, procedure time, ease of use, and complications were analyzed separately for two comparisons: 1). TA versus SWC; and 2). TA versus TA. RESULTS: Eight studies compared a TA with SWC. No significant difference was found for cosmesis at any time point examined. Subgroup analysis was possible only for age; no significant difference was found. Pain scores [Parent Visual Analogue Scale weighted mean difference (VAS WMD) = -15.7 mm; 95% CI = -21.9 to -9.5] and procedure time (WMD = -5.7 minutes; 95% CI = -8.2 to -3.1) significantly favored TAs. Small, statistically significant risk differences were found for dehiscence [favoring SWC; number needed to harm (NNH) = 25; 95% CI = 14 to 100] and erythema (favoring TAs; NNH = 8; 95% CI = 4 to 100). Only one study compared two TAs (butylcyanoacrylate versus octylcyanoacrylate) for pediatric facial lacerations. No significant difference was found for cosmesis, pain, procedure time, or complications. CONCLUSIONS: TAs are an acceptable alternative to SWC for simple traumatic lacerations. No difference in cosmesis was found between TAs and SWC, or between different TAs. Tissue adhesives offer the benefits of decreased procedure time and less pain, compared with SWC. A small increased rate of dehiscence with TAs must be considered when choosing the closure method (NNH = 25).