Different fetal effects on fingers from exposure to phenytoin, phenobarbital, and carbamazepine.

Exposure at conception to phenytoin (PHT), phenobarbital (PB), and carbamazepine (CBZ) has been associated with several different effects on the fetus, including hypoplasia of the distal phalanges, dysmorphic facial features, and structural abnormalities such as oral clefts and neural tube defects. One question is whether each of these antiepileptic drugs (AEDs) has the same effects or just similar effects. A systematic examination of the fingers of children exposed at conception to PHT, PB, or CBZ, as monotherapy, has been used to address this question. The findings in the examinations of the fingers of 115 AED-exposed children (40, PHT; 34, PB; 41, CBZ) and their parents were compared to the findings in 111 age- and sex-matched children and their parents. The evaluations used were both subjective assessments and objective measurements. Shortening and narrowing of the fifth fingernail and an increased frequency of arch patterns in the dermal ridges were more common in PHT-exposed children. A significant decrease in the length of the nail, but not width, occurred in the PB-exposed children. Stiffness of the interphalangeal joints was more common in the CBZ-exposed children. The findings in children exposed to PHT, PB, or CBZ, as monotherapy, showed that all three exposures in early pregnancy affected the fingers, but the effects were not the same. The most striking effects were present in PHT-exposed children.

Facial dysmorphology in children exposed in pregnancy to anticonvulsant medications correlates with deficits in IQ.

Some children exposed at conception to the antiepileptic drugs (AEDs) phenytoin (PHT), phenobarbital (PB), and carbamazepine (CBZ) have changes in their midface and fingers. It has been suggested that the anticonvulsant-exposed child with these subtle changes in facial features (the "anticonvulsant face") has a greater likelihood of having deficits in IQ in comparison with children exposed to the same anticonvulsants who do not have these features. 115 AED-exposed children (40, PHT; 34, PB; and 41, CBZ) between 6.5 and 16 years of age and 111 unexposed children matched by sex, race, and year in school were evaluated. The evaluations were (WISC-III), physical examination with measurements of facial features and digits and photographs. The AED-exposed children had cephalometric radiographs, but not the unexposed. Each parent had a similar examination of face and hands plus tests of intelligence. These AED-exposed children showed an increased frequency of a short nose and anteverted nares, features of the "anticonvulsant face." Lateral skull radiographs showed a decrease in the angle between the anterior cranial base and nasal bone, which produces anteverted nares. Mean IQs were significantly lower on one or more IQ measures for the children with these facial features. Shortening of the distal phalanges and small fingernails correlated with the presence of a short nose in that child. The findings in 115 children exposed at conception to either phenytoin, phenobarbital, or carbamazepine, as monotherapy, confirmed the hypothesis that those with a short nose and anteverted nares had a lower IQ than exposed children without those features.

Contextual factors of financial capability and financial well-being for adults living with brain injury: a qualitative photovoice study.

OBJECTIVE: To identify the contextual factors related to financial capability and financial well-being for adults living with acquired brain injury (ABI). DESIGN & METHOD: We conducted a qualitative descriptive study using photovoice and included 17 adults who live with ABI in Manitoba, Canada. Over 3-to-5 weeks, participants took photos of their financial capability (i.e. knowledge, skills, and behaviors related to managing finances) or their financial well-being (i.e. subjective and objective financial outcomes). Participants were interviewed about their photos. Five researchers iteratively and thematically analyzed interview transcripts. MAIN OUTCOMES/RESULTS: Analysis identified the importance of the economic, social, technology, and physical or sensory context. Subthemes related to: (i) hard times finding financial resources; (ii) processes not making sense; (iii) getting help from the right person; and (iv) invisible disability bias and stigma. CONCLUSIONS: There is decreased literature about financial capability or financial well-being after ABI. The results of this study highlight the salience of finance to living with ABI and the importance of the context to addressing financial-related life participation for people living with ABI. Information about contextual factors related to finance can improve rehabilitation assessment and intervention practice as well as emphasize needed accessibility changes to financial environments.

Evaluating the usefulness of a wordless picture book for adults with intellectual disabilities about the COVID-19 vaccination programme using co-production: The CAREVIS study.

AIM: To explore the usefulness of a co-designed wordless book showing processes of receiving COVID-19 vaccines designed by, and for, adults with intellectual disabilities. METHODS: A qualitative evaluation of the resource using mixed methods. Semi-structured interviews were conducted with people with intellectual disabilities, carers and health professionals about resource content, and use. This was analysed thematically. A survey was circulated to intellectual disabilities networks to understand resource need, use, sharing and content. RESULTS: Understanding the COVID-19 vaccine was a process, not a single event using one resource. A visual resource had a place in facilitating conversations about vaccines between people with intellectual disabilities and carers. Differing perspectives were expressed regarding personal needs, existing awareness of vaccine programmes and communication preferences. Changes were suggested to improve the suggested storyline and relevance around COVID-19 restrictions changing. CONCLUSION: A visual resource may help conversations about the COVID-19 vaccine for people with intellectual disabilities.

Pediatric acquired brain injury resources for educators: a multi-year scan of Canadian-relevant internet resources.

BACKGROUND: Acquired Brain Injury (ABI) is the leading cause of death and disability in children, yet educators report a lack of knowledge about ABI and supporting students with ABI. With no formal learning about ABI, education professionals may turn to the internet for information. OBJECTIVES: To find online resources about supporting students with ABI, in any format, available freely and publicly, aimed toward elementary educators and that could be applied in a Canadian context. METHODS: We performed an environmental scan using keyword Google searches, key websites, and expert recommendations. The search was performed twice: 2018 and 2021. RESULTS: 96 resources were included after screening. The resources were published by organizations in the United States (n = 57), Canada (n = 19), United Kingdom (n = 16), Australia (n = 3) and New Zealand (n = 1). Traumatic brain injury and concussion were the most commonly addressed type of ABI, and Short Fact/Information sheets were the most common resource format. Between 2018 and 2021, 13 previously included resource links were no longer accessible. CONCLUSIONS: This scan suggests that there are many online resources available to educators in a variety of formats, and that information online can be transient. Future studies should evaluate the accuracy and quality of the resources available.

Adolescent and parent experiences with Tele-Active Rehabilitation for concussion: an exploratory qualitative study.

PURPOSE: To explore the experiences of adolescents with concussion and their parents who participated in a novel remotely delivered Tele-Active Rehabilitation (Tele-AR) intervention involving sub-symptom threshold exercise, education, and support. Specifically, we aimed to elicit perspectives regarding the remote delivery approach, valued aspects of the program, and perceived benefits of the intervention. METHODS: This qualitative study took place within the context of a larger mixed-methods project exploring the feasibility of the Tele-AR intervention. A descriptive qualitative design was utilized. Semi-structured interviews were conducted with adolescents (n = 3; ages 14-17 years) with concussion and one of their parents (n = 3) within one week of completing the six-week Tele-AR intervention. Data were analyzed using thematic analysis. RESULTS: Four themes were identified that capture participant experiences in the intervention: (1) Enabling access to active rehabilitation; (2) Focusing on individual needs; (3) Learning to take responsibility for recovery; and (4) Convenience and comfort of engaging in rehabilitation from home. CONCLUSIONS: A small sample of 3 adolescents with concussion and their parents were satisfied with the Tele-AR intervention and appreciated the convenience and comfort of engaging in rehabilitation from home, which facilitated adolescents taking responsibility for their own recovery. Findings support continued study of Tele-AR, which may be an accessible intervention to facilitate recovery in adolescents with concussion.

Sensitivity and Specificity of a Multimodal Approach for Concussion Assessment in Youth Athletes.

CONTEXT: Current international consensus endorses a multimodal approach to concussion assessment. However, the psychometric evaluation of clinical measures used to identify postconcussion performance deficits once an athlete is asymptomatic remains limited, particularly in the pediatric population. OBJECTIVE: To describe and compare the sensitivity and specificity of a multimodal assessment battery (balance, cognition, and upper and lower body strength) versus individual clinical measures at discriminating between concussed youth athletes and noninjured controls when asymptomatic. DESIGN: Prospective cohort study. SETTING: Hospital laboratory setting. PARTICIPANTS: A total of 32 youth athletes with a concussion and 32 matched (age and sex) noninjured control participants aged 10-18 years. INTERVENTION(S): Participants were administered preinjury (baseline) assessments of cognition (Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT]), balance (BioSway), and upper and lower body strength (grip strength and standing long jump). Assessments were readministered when concussed participants reported symptom resolution (asymptomatic time point). Noninjured control participants were reassessed using the same time interval as their concussion matched pair. Sensitivity and specificity were calculated using standardized regression-based methods and receiver operating characteristic curves. MAIN OUTCOME MEASURES: Outcome measures included baseline and postinjury ImPACT, BioSway, grip strength, and standing long jump scores. RESULTS: When asymptomatic, declines in performance on each individual clinical measure were seen in 3% to 22% of the concussion group (sensitivity = 3%-22%) compared with 3% to 13% of the noninjured control group (specificity = 87%-97%) (90% confidence interval). The multimodal battery of all combined clinical measures yielded a sensitivity of 41% and a specificity of 77% (90% confidence interval). Based on discriminative analyses, the multimodal approach was statistically superior compared with an individual measures approach for balance and upper and lower body strength, but not for cognition. CONCLUSIONS: Results provide a foundation for understanding which domains of assessment (cognition, balance, and strength) may be sensitive and specific to deficits once symptoms resolve in youth athletes. More work is needed prior to clinical implementation of a preinjury (baseline) to postinjury multimodal approach to assessment following concussion in youth athletes.

Rehabilitation interventions in Rett syndrome: a scoping review.

AIM: To summarize existing interventions and their outcomes in Rett syndrome (RTT) rehabilitation and identify gaps in the literature. METHOD: Five databases (Ovid MEDLINE, Ovid Embase Classic, Ovid PsycINFO, EBSCO CINAHL Plus, and ProQuest ERIC) were systematically searched up to 23rd July 2018 for studies describing rehabilitation interventions. Data on study participants, design, and outcomes were extracted. RESULTS: Sixty-two articles were included in the final review. Evidence consistently demonstrated that females with RTT can improve their gross motor, fine motor, and communicative skills with rehabilitation. All 11 interventions targeting gross motor function, namely ambulation, achieved functional improvements. Twenty of 24 articles describing fine motor rehabilitation studies succeeded in decreasing stereotypies, improving functional hand use, and/or reducing self-injurious behaviors. Twenty-one of 22 studies describing communication interventions succeeded in training choice-making, communicative language, or socialization behavior. Other key findings include the positive interplay between physical and communicative rehabilitation outcomes, and the ability of females with RTT to improve their cognitive abilities during intervention. INTERPRETATION: Rehabilitation can impact the daily lives of females with RTT and their caregivers in clinically meaningful ways.

Mood-related changes in children and adolescents with persistent concussion symptoms following a six-week active rehabilitation program.

PRIMARY OBJECTIVE: The purpose of this study is to explore changes in mood in youth with persistent post-concussion symptoms following participation in a six-week active rehabilitation program. RESEARCH DESIGN: A pre-post test design was used. METHODS AND PROCEDURES: Participants (N = 40 children and adolescents with concussion symptoms >2 weeks post-injury) were recruited from the concussion services at an urban children's rehabilitation hospital and the community. The program consisted of individualized low-intensity aerobic exercise, sport-specific drills, relaxation exercises and comprehensive education and support. The 6 week program was completed by participants in their home or local community with weekly check-ins with the research team. Data were analyzed using descriptive statistics and linear regressions. MAIN OUTCOMES AND RESULTS: Outcome measures included the Beck Youth Inventories (youth), and the Child Behavior Checklist (parents). Results indicated significant improvements in anger and anxiety post-intervention with anger reduction being more pronounced in girls. CONCLUSIONS: Active rehabilitation interventions may have positive effects on mood in youth recovering from concussion. Clinicians may wish to consider addressing anxiety and anger management strategies as part of comprehensive concussion management in youth.

Feasibility and Effects of the CO-OP Approach™ in Postconcussion Rehabilitation.

OBJECTIVE: We determined the feasibility and effects of the Cognitive Orientation to daily Occupational Performance (CO-OP) ApproachTM on activity performance and satisfaction, symptoms, and mood of adolescents with persistent postconcussion symptoms. METHOD: In a prospective case series, 3 participants with persistent symptoms 3 mo after concussion and difficulties resuming activities were taught to use a metacognitive strategy (Goal-Plan-Do-Check) to work toward occupation-based goals in a 7-wk intervention (10 sessions, 30-60 min each). Participants were assessed pre- and postintervention and at 3-mo follow-up. Feasibility was determined by positive changes on study measures, ease of administration, and acceptability to participants. RESULTS: Clinically significant, positive changes were found in participants' activity performance and satisfaction. All participants had decreases in symptoms and improved mood scores at posttest. CONCLUSION: The CO-OP Approach to rehabilitation for youth postconcussion is feasible and may make a positive contribution to recovery.

Research Priorities for Optimizing Long-term Community Integration after Brain Injury.

OBJECTIVE: This paper reports on a funded summit, which convened a multidisciplinary group of experts to provide consensus on the research priorities necessary for improving long-term community integration of individuals with traumatic brain injury (TBI) and their caregivers. METHODS: The 2-day summit was directed using the World Café Methodology, to engage stakeholders and collaboratively arrive at a consensus on the problems to be targeted in research. Participants (n=54), drawn from two Canadian provinces, included an interdisciplinary group of researchers, clinicians, representatives from brain injury associations, individuals with TBI, and caregivers. In small groups, participants discussed challenges to long-term community integration and potential initiatives that would address these barriers. Field notes from the discussions were analyzed using qualitative content analysis. RESULTS: The consensus on prioritized research directions included developing interventions to optimize the functioning and participation of individuals with TBI, reducing caregiver burden, and evaluating how emerging technology can facilitate delivery of care. CONCLUSIONS: The World Café Methodology was an effective method for developing research priorities. The breadth of expertise of participants and the collegial environment allowed for the identification of a broad perspective on important future research directions with potential to enhance the long-term community integration of individuals with brain injury.

Key ingredients to an active rehabilitation programme post-concussion: perspectives of youth and parents.

OBJECTIVE: To identify key ingredients in a six-week active rehabilitation intervention from the perspectives of youth recovering from concussion and their parents. METHODS: Surveys with open- and closed-ended questions were administered to youth (N = 38) ages 10-18 years (average = 14.5 years) and their parents (n = 36) immediately post intervention. Descriptive statistics and thematic analysis were used to analyse data. RESULTS: One hundred percent (N = 38) of youth and 100% (N = 36) of parents reported that the active rehabilitation intervention was helpful. The most helpful ingredients according to youth were: energy management strategies (47.4%, N = 18), aerobic exercise (31.6%, N = 12) and sport coordination drills (21.1%, N = 8). Qualitative analysis of youth survey questions resulted in three themes: (1) learning energy management; (2) engaging in physical activity and (3) seeking help. Themes emerging from the parent survey were: (1) encouraging recovery and confidence through structured activity; (2) recognizing youth's accountability and (3) learning to be patient and to accept uncertain timelines. CONCLUSIONS: Education about energy management is an important ingredient of the active rehabilitation intervention for youth with concussion. Parents benefit from learning how their child can be more accountable for their own rehabilitation and to be more accepting of unclear recovery timelines.

Grip Strength in Youth Ice Hockey Players: Normative Values and Predictors of Performance.

Toong, T, Wilson, KE, Urban, K, Paniccia, M, Hunt, AW, Keightley, M, and Reed, N. Grip strength in youth ice hockey players: Normative values and predictors of performance. J Strength Cond Res 32(12): 3503-3511, 2018-Grip strength is a simple, valid, and reliable tool for estimating overall muscular strength, a key component of health-related fitness and sport performance. To date, there is a paucity of up-to-date and developmentally sensitive grip strength norms specific to youth-athlete populations. The objectives of this study are to (a) establish normative grip strength values in youth ice hockey players, (b) descriptively compare these values with existing Canadian pediatric norms, and (c) explore the relationship between age, sex, body mass, and hockey playing level on grip strength performance. A sample of 690 male and female youth ice hockey players between the ages of 10 and 16 years were included. Participants completed assessments of maximal grip strength using a hand dynamometer on both hands. In addition, age, sex, body mass, and hockey playing level were collected. Maximal absolute grip strength, stratified by age and sex, was higher than previously published Canadian pediatric norms. Grip strength increased with age in both sexes. Males and females performed similarly until 12 years of age, after which point males had greater strength. Individuals with greater body mass had greater strength. For the nondominant hand, competitive players had greater strength than those playing house league or select. This study describes normative grip strength values in youth ice hockey players according to age, sex, body mass, and playing level. These athlete-specific norms may be used to help evaluate and monitor changes in grip strength over time in youth ice hockey players.

Impact of elective termination on the occurrence of severe birth defects identified in a hospital-based active malformations surveillance program (1999 to 2002).

BACKGROUND: The number of affected infants and the types of malformations identified by a malformation surveillance programs can be impacted if elective terminations for malformations are not included. METHODS: The occurrence of malformations in all newborn infants was determined in a daily review of the findings in the pediatricians' examinations and those of all consultants. In addition, the findings in autopsies of all elective terminations were reviewed to identify all fetuses with structural abnormalities. A severity scale was used to subdivide the malformations. To establish the impact of elective termination, the malformed infants identified in the Active Malformations Surveillance Program at Brigham and Women's Hospital in Boston were analyzed for the 2 years before and after the hospital decreased significantly the number of elective terminations temporarily (1999-2000 vs. 2001-2002). The effect on the number of malformations identified at birth, as well as malformations of greater severity, was determined. RESULTS: The number of terminated fetuses with malformations decreased dramatically after termination services were interrupted (p < 0.0001). There were no differences in the prevalence rates of all malformations in the 2 years before and after the change in access to elective terminations. However, there were significant decreases in the number of infants identified with lethal/life-limiting and severe/handicapping malformations. CONCLUSION: In the surveillance for malformations among newborn infants, the inclusion of malformed fetuses from elective terminations had a significant effect on the number of infants with the more severe malformations identified. Birth Defects Research (Part A) 106:659-666, 2016. © 2016 Wiley Periodicals, Inc.

Oculomotor-Based Vision Assessment in Mild Traumatic Brain Injury: A Systematic Review.

OBJECTIVE: The purpose of this article is to synthesize and appraise the evidence regarding the use of oculomotor-based vision assessment to identify and monitor recovery from mild traumatic brain injury (mTBI). Specific objectives are to (1) identify changes in oculomotor-based vision following mTBI; (2) distinguish methods of assessment; (3) appraise the level and quality of evidence; and, if warranted, (4) determine clinical recommendations for assessment. METHODS: A systematic review was undertaken to identify and appraise relevant literature. A search was conducted of 7 databases of peer-reviewed literature from January 1990 to January 2015. Articles were included if study populations were clearly identified as having mTBI and used an assessment of oculomotor-based vision. Articles with pooled data (eg, mTBI and stroke), addressing afferent visual function (eg, visual field deficits) or using single case designs, were excluded. RESULTS: Twenty articles were selected for inclusion. Exploratory findings suggest that measurements of saccades, smooth pursuit, and vergence are useful in detecting changes associated with mTBI. Assessment methods included eye tracker protocols, optometric assessment, and the King-Devick test. CONCLUSION: The strength of this evidence is not yet sufficient to warrant clinical recommendations. Research using rigorous methods is required to develop reliable, valid, and clinically useful assessment protocols.

Development and feasibility of an evidence-informed self-management education program in pediatric concussion rehabilitation.

BACKGROUND: Concussion is a considerable public health problem in youth. However, identifying, understanding and implementing best evidence informed recovery guidelines may be challenging for families given the vast amount of information available in the public domains (e.g. Internet). The objective of this study was to develop, implement and evaluate the feasibility of an evidence-informed self-management education program for concussion recovery in youth. METHODS: Synthesis of best evidence, principles of knowledge translation and exchange, and expert opinion were integrated within a self-management program framework to develop a comprehensive curriculum. The program was implemented and evaluated in a children's rehabilitation hospital within a universal health care system. A retrospective secondary analysis of anonymous data from a program evaluation survey was used to evaluate program feasibility, to identify features of importance to program participants and to assess changes in participants' knowledge. RESULTS: The program, "Concussion & You" includes a comprehensive, evidence informed, population specific curriculum that teaches participants practical strategies for management of return to school and play, sleep, nutrition, relaxation and energy conservation. A 'wheel of health' is used to facilitate participants' self-management action plan. Results from eighty-seven participant surveys indicate that the program is feasible and participant knowledge increased in all areas of the program with the highest changes reported in knowledge about sleep hygiene, rest and energy conservation. CONCLUSION: Findings indicate that "Concussion & You" is a feasible program that is acceptable to youth and their families, and fills a health system service gap.

Inhalation of Polychlorinated Biphenyls (PCB) Produces Hyperactivity in Rats.

Attention deficit hyperactivity disorder (ADHD) is a serious behavioral syndrome seen in children, and more common in males than females. There is increasing evidence that prenatal and/or early life exposure to persistent organic pollutants (POP) such as polychlorinated biphenyls (PCB) is associated with increased risk of ADHD occurrence. While PCB exposure is usually attributed to ingestion of contaminated food, recent reports of elevated PCB concentrations in indoor air, especially in schools, raised concern regarding inhalation as an important route of exposure to PCB with consequent effects on neurobehavior. The effects of exposure to air contaminated with Aroclor 1248 or contaminated sediment (SED) from the St. Lawrence River were examined on operant behavior of male and female Sprague-Dawley rats. Data showed that relative to controls, vapor-phase inhalation of PCB, whether from blowing air over Aroclor 1248 or from blowing air over sediment contaminated with PCB, resulted in hyperactivity and impatience in rats, more pronounced in males than females. These results are consistent with the hypothesis that inhalation of PCB may contribute to behavioral abnormalities in children.

Elucidating a Goal-Setting Continuum in Brain Injury Rehabilitation.

For individuals with brain injury, active participation in goal setting is associated with better rehabilitation outcomes. However, clinicians report difficulty engaging these clients in goal setting due to perceived or real deficits (e.g., lack of awareness). We conducted a study using grounded theory methods to understand how clinicians from occupational therapy facilitate client engagement and manage challenges inherent in goal setting with this population. Through constant comparative analysis, a goal-setting continuum emerged. At one end of the continuum, therapists embrace client-determined goals and enable clients to decide their own goals. At the other, therapists accept preset organization-determined goals (e.g., "the goal is discharge") and pay little attention to client input. Although all participants aspired to embrace client-determined goal setting, most felt powerless to do so within perceived organizational constraints. Views of advocacy and empowerment help to explain our findings and inform more inclusive practice.

Exploring the perceived met and unmet need of life-limited children, young people and families.

This article presents an original study commissioned by the UK charity, Together for Short Lives which explored children and young people up to 25 years of age with life-threatening/limiting conditions and their families. Using Appreciative Inquiry and framework analysis, qualitative work sought to explore perceived met and unmet needs of services and care. Fifty-one families were interviewed from one UK area, 18 of which were children/young people up to 25 years old. Findings indicated that children and their families felt medical/nursing needs were well met but provision was needed for broader financial, social and emotional support alongside more responsive specialist therapies.

An occupation-based strategy training approach to managing age-related executive changes: a pilot randomized controlled trial.

OBJECTIVE: To determine the feasibility of recruitment and retention of healthy older adults and the effectiveness of an intervention designed to manage age-related executive changes. DESIGN: A pilot randomized controlled trial. SETTING: Research centre and participants' homes. PARTICIPANTS: Nineteen healthy, community dwelling older adults with complaints of cognitive difficulties and everyday problems, but no evidence of mild cognitive impairment, dementia or depression on objective testing. INTERVENTIONS: Seventeen hours of group and individual training. Participants in the experimental arm received education about self-management, successful aging and an occupation-based meta-cognitive strategy-training program. Participants in the control arm received education about brain health and participated in cognitively stimulating exercises. MAIN MEASURES: Changes on untrained, everyday life goals were identified using the Canadian Occupational Performance Measure. Generalization of benefits was measured using the Stanford Chronic Disease Questionnaire, general self-efficacy and changes in executive function (Delis-Kaplan Executive Function System Tower Test, Word Fluency and Trail-Making Test). RESULTS: 20% (19/96) of healthy older adults approached were eligible, consented and were enrolled in the study, 90% (17/19) were retained to three-month follow-up. Participants in the experimental arm reported significantly more improvement on untrained goals (11/22 compared with 9/46, χ(2)=4.92, p<0.05), maintenance of physical activity (p<0.05) and better preparation for doctors' visits (p<0.05) relative to the control group. There were no significant between group differences on objective measures of executive function. CONCLUSIONS: These data support the feasibility of a larger trial where a sample of 72 (36 participants in each arm) would be required to confirm or refute these findings.