A healthy breakfast each and every day is important for students' motivation and achievement.

Breakfast is often cited as the most important meal of the day and vital for students' academic functioning at school. Although much research has linked students' breakfast consumption to better achievement, there has been debate about why and how breakfast has academic benefits. The present study of 648 Australian high school students investigated (a) the role of breakfast consumption and breakfast quality in students' self-reported motivation and their achievement in a science test, (b) the role of motivation in mediating the link between breakfast consumption and quality and students' achievement, and (c) the extent to which breakfast consumption effects are moderated by the quality of breakfast (e.g., more vegetables, fruit, dairy/protein, wholegrains, cereals, water; less sugary drinks, processed meat, fast take-away, unhealthy snack foods). Findings indicated that beyond the effects of personal, home, and classroom factors, breakfast consumption predicted higher adaptive motivation (p < .05), breakfast quality predicted lower maladaptive motivation (p < .05), and in turn, students' adaptive (positively, p < .01) and maladaptive (negatively, p < .01) motivation predicted their achievement. Moreover, adaptive motivation significantly mediated the relationship between breakfast consumption and achievement (p < .05). The effect of breakfast consumption was moderated by the quality of breakfast such that consuming a high-quality breakfast in the morning was associated with the highest levels of adaptive motivation (p < .01) and achievement (p < .05) later in the day. Findings have implications for educational practice and policy seeking to promote a healthy start to the school day to optimize students' motivation and achievement.

Association Between Early Return to School Following Acute Concussion and Symptom Burden at 2 Weeks Postinjury.

Importance: Determining how the timing of return to school is related to later symptom burden is important for early postinjury management recommendations. Objective: To examine the typical time to return to school after a concussion and evaluate whether an earlier return to school is associated with symptom burden 14 days postinjury. Design, Setting, and Participants: Planned secondary analysis of a prospective, multicenter observational cohort study from August 2013 to September 2014. Participants aged 5 to 18 years with an acute (<48 hours) concussion were recruited from 9 Canadian pediatric emergency departments in the Pediatric Emergency Research Canada Network. Exposure: The independent variable was the number of days of school missed. Missing fewer than 3 days after concussion was defined as an early return to school. Main Outcomes and Measures: The primary outcome was symptom burden at 14 days, measured with the Post-Concussion Symptom Inventory (PCSI). Symptom burden was defined as symptoms status at 14 days minus preinjury symptoms. Propensity score analyses applying inverse probability of treatment weighting were performed to estimate the relationship between the timing of return to school and symptom burden. Results: This cohort study examined data for 1630 children (mean age [SD] 11.8 [3.4]; 624 [38%] female). Of these children, 875 (53.7%) were classified as having an early return to school. The mean (SD) number of days missed increased across age groups (5-7 years, 2.61 [5.2]; 8-12 years, 3.26 [4.9]; 13-18 years, 4.71 [6.1]). An early return to school was associated with a lower symptom burden 14 days postinjury in the 8 to 12-year and 13 to 18-year age groups, but not in the 5 to 7-year age group. The association between early return and lower symptom burden was stronger in individuals with a higher symptom burden at the time of injury, except those aged 5 to 7 years. Conclusions and Relevance: In this cohort study of youth aged 5 to 18 years, these results supported the growing belief that prolonged absences from school and other life activities after a concussion may be detrimental to recovery. An early return to school may be associated with a lower symptom burden and, ultimately, faster recovery.

What self-regulation strategies do elementary students utilize while learning online?

Little is known about the strategies elementary school students use to self-regulate their learning while in a hypermedia environment. This exploratory study investigated the self-regulatory strategies that young students (N = 48, M age = 10.75) utilized while individually completing a 20-min online research task about space. Video data was coded using Azevedo et al.'s (2004) established coding scheme for analyzing self-regulatory behavior in hypermedia environments. Results showed that young students spent the majority of their time using cognitive strategies (M = 75.26%) to read and summarise information to complete the task. Little time was taken to plan (M = 6.99%) or monitor (M = 5.92%) their work or learning processes, which are key attributes of effective self-regulation. The study reveals the disparity between the ability to navigate within a hypermedia environment and utilizing planning and monitoring processes to enhance learning while using digital tools. This study highlights the need for the explicit teaching of planning and monitoring strategies in order for young students to develop the full range of self-regulation skills they need when using technology, for instance while learning from home during COVID-19. Implications for curriculum policy and teacher practice are discussed.

Positive, complicated, distant, and negative: How different teacher-student relationship profiles relate to students' science motivation.

INTRODUCTION: Researchers note a consistent decline in adolescents' motivation and participation in science. It is important to examine factors vital to students' motivation in science, such as teacher-student relationships (TSRs). Limited research in science has examined TSRs from a multidimensional or person-centered perspective. The present investigation adopts Ang's tripartite relational framework to examine three dimensions of TSRs: socio-emotional support, instrumental help, and conflict. Such research is needed to better understand the diversity of relationships that exist within a science classroom and their impact on science motivation. METHODS: This study examined N = 2669 Australian high school students (66% girls; Mage = 15.11 years; SD = 0.69). Data were collected via online sampling in the final quarter of 2020. The data are cross-sectional. Latent profile analysis was used to (1) determine if distinct student profiles based on the three dimensions of TSRs existed and (2) the extent to which these profiles were associated with varying levels of science motivation: self-efficacy, intrinsic value, utility value, and cost. RESULTS: Four distinct profiles were identified: Positive, Complicated, Distant, and Negative. Students in the Negative TSR profile reported the lowest adaptive motivation and highest cost. The associations between profile membership and motivation were more varied for the Positive, Complicated, and Distant TSR profiles. CONCLUSIONS: Findings indicate that dichotomous perspectives (positive vs. negative) may be insufficient to describe the diversity of relationships within science classrooms. Results also suggest that concurrent attendance to all dimensions of TSRs is needed to improve relationships.

Paediatric post-concussive symptoms: symptom clusters and clinical phenotypes.

OBJECTIVE: To assess the co-occurrence and clustering of post-concussive symptoms in children, and to identify distinct patient phenotypes based on symptom type and severity. METHODS: We performed a secondary analysis of the prospective, multicentre Predicting and Preventing Post-concussive Problems in Pediatrics (5P) cohort study, evaluating children 5-17 years of age presenting within 48 hours of an acute concussion. Our primary outcome was the simultaneous occurrence of two or more persistent post-concussive symptoms on the Post-Concussion Symptom Inventory at 28 days post-injury. Analyses of symptom and patient clusters were performed using hierarchical cluster analyses of symptom severity ratings. RESULTS: 3063 patients from the parent 5P study were included. Median age was 12.1 years (IQR: 9.2-14.6 years), and 1857 (60.6%) were male. Fatigue was the most common persistent symptom (21.7%), with headache the most commonly reported co-occurring symptom among patients with fatigue (55%; 363/662). Headache was common in children reporting any of the 12 other symptoms (range: 54%-72%). Physical symptoms occurred in two distinct clusters: vestibular-ocular and headache. Emotional and cognitive symptoms occurred together more frequently and with higher severity than physical symptoms. Fatigue was more strongly associated with cognitive and emotional symptoms than physical symptoms. We identified five patient groups (resolved/minimal, mild, moderate, severe and profound) based on symptom type and severity. CONCLUSION: Post-concussive symptoms in children occur in distinct clusters, facilitating the identification of distinct patient phenotypes based on symptom type and severity. Care of children post-concussion must be comprehensive, with systems designed to identify and treat distinct post-concussion phenotypes.

Assessing Instructional Cognitive Load in the Context of Students' Psychological Challenge and Threat Orientations: A Multi-Level Latent Profile Analysis of Students and Classrooms.

To better understand instructional cognitive load, it is important to operationalize and assess it in novel ways that can reveal how different students perceive and experience this load as either challenging or threatening. The present study administered a recently developed instruction assessment tool-the Load Reduction Instruction Scale-Short (LRIS-S)-to N = 2,071 students in 188 high school science classrooms. Multilevel latent profile analysis (LPA) was used to identify student and classroom profiles based on students' reports of instructional cognitive load (load reduction instruction, LRI; using the LRIS-S) and their accompanying psychological challenge orientations (self-efficacy and growth goals), and psychological threat orientations (anxiety and failure avoidance goals). In phase 1 of analyses (investigating students; Level 1), we identified 5 instructional-psychological student profiles that represented different presentations of instructional load, challenge orientation, and threat orientation, ranging from the most maladaptive profile (the Instructionally-Overburdened & Psychologically-Resigned profile) to the most adaptive profile (Instructionally-Optimized & Psychologically-Self-Assured profile). The derived profiles revealed that similar levels of perceived instructional load can be accompanied by different levels of perceived challenge and threat. For example, we identified two profiles that were both instructionally-supported but who varied in their accompanying psychological orientations. Findings also identified profiles where students were dually motivated by both challenge and threat. In turn, these profiles (and their component scores) were validated through their significant associations with persistence, disengagement, and achievement. In phase 2 of analyses (investigating students and classrooms; Levels 1 and 2), we identified 3 instructional-psychological classroom profiles that varied in instructional cognitive load, challenge orientations, and threat orientations: Striving classrooms, Thriving classrooms, and Struggling classrooms. These three classroom profiles (and their component scores) were also validated through their significant associations with classroom-average persistence, disengagement, and achievement-with Struggling classrooms reflecting the most maladaptive outcomes and Thriving classrooms reflecting the most adaptive outcomes. Taken together, findings show that considering instructional cognitive load (and new approaches to empirically assessing it) in the context of students' accompanying psychological orientations can reveal unique insights about students' learning experiences and about important differences between classrooms in terms of the instructional load that is present.

A future time perspective of secondary school students' academic engagement and disengagement: A longitudinal investigation.

Students' conceptions of their academic futures, such as completing secondary school, have been found to play a significant role in their current behavior. Indeed, research regarding future time perspectives (FTP) indicates that students with extended FTPs are likely to be more engaged and less disengaged over time. Extended FTPs comprise two critical motivating elements: the cognitive (i.e., importance value) and the dynamic (i.e., school completion aspirations). Although these elements are hypothetically reciprocally related and without temporal limitation to their motivational effects, these claims have largely gone untested. These claims were examined via longitudinal structural equation modelling with cross-lagged panel analysis and invariance testing in a sample of 1327 Australian secondary school students. Findings indicated that importance value is directionally salient over school completion aspirations (such that it may precede school completion aspirations), both are associated with higher engagement and lower disengagement over time, and evidence of temporal limitations on the motivational benefits of the elements of extended FTPs was not found. School-based interventions that focus on improving importance value and school completion aspirations are discussed.

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.

Factors that support high school completion: A longitudinal examination of quality teacher-student relationships and intentions to graduate.

INTRODUCTION: Stage-environment fit theory (SEF) posits that students leave school when their environments do not meet their needs. Quality teacher-student relationships (QTSRs) are a critical element of students' environments. Moreover, QTSRs help students internalize positive intentions to graduate. QTSRs and intentions to graduate have both been identified as separate determinants of high school completion. These factors may also form a longitudinal socio-motivational process that supports graduation. However, few studies have examined such processes. METHODS: This investigation examined data from N = 4691 Australian secondary students (43% female) included in the Longitudinal Survey of Australian Youth (LSAY) 2009 cohort. Participants were in grade 10 at Time 1 (Mage = 15.74; SD = 0.28), with a total of four annual time points examined. Longitudinal probit regression was used to examine the extent to which grade 10 QTSRs predicted students' intentions to graduate (in grades 10 and 11), and QTSRs and intentions to graduate predicted high school completion. Multi-class analysis and indirect effects testing were also conducted. RESULTS: Grade 10 QTSRs are positively associated with grade 10 intentions to graduate and grade 11 intentions to graduate (beyond the effects of grade 10 intentions to graduate). QTSRs and intentions to graduate were also positively associated with increased chances of high school completion. QTSRs were found to play a stronger role for low-achieving students over time. CONCLUSIONS: Overall, QTSRs and intentions to graduate appear to be significantly associated with intentions to graduate and high school completion, especially for low-achieving students. Intervention implications are signalled.

Codesigning discharge communication interventions with healthcare providers, youth and parents for emergency practice settings: EDUCATE study protocol.

INTRODUCTION: Discharge communication is an important aspect of patient care but frequently has shortcomings in emergency departments (EDs). In a paediatric context, youth or parents with young children often leave the ED with minimal opportunity to ask questions or to ensure comprehension of important information. Strategies for improving discharge communication have primarily targeted patients and/or parents, although neither group has been engaged in intervention design or implementation. Furthermore, ED healthcare providers (HCPs), important actors in discharge communication practice, are rarely consulted regarding intervention design decisions. We will generate evidence to enhance discharge communication by engaging youth, parents and HCPs in the codesign of ED discharge communication strategies (EDUCATE) for asthma and minor head injury. METHODS AND ANALYSIS: This mixed methods study will take place at two academic paediatric EDs in Canada. The study will occur in two phases: (A) codesign and refinement of the intervention prototypes; and (B) usability testing of the prototypes. During the first phase, two codesign teams (one for each condition) will follow a series of structured design meetings based on the Behavior Change Wheel to develop the EDUCATE interventions. Each codesign team (composed of youth, parents, HCPs and study researchers) will collaborate to identify priority target behaviours and acceptable components to include in the interventions. During the second phase, we will conduct usability testing in two EDs with a group of youth, parents and HCPs to refine the interventions. Two cycles of usability testing will be conducted with intervention refinement occurring at the end of each cycle. ETHICS AND DISSEMINATION: Informed consent will be obtained from all participants. Ethics approval for this study has been obtained from the Research Ethics Board, IWK Health Centre. Results from this study will form the basis of a future effectiveness implementation trial. Key findings will be presented at national and international conferences and published within peer-reviewed journals.

Early versus delayed emergency department presentation following mild Traumatic Brain Injury and the presence of symptom at 1, 4 and 12 weeks in children.

OBJECTIVES: We evaluated the association between timing of presentation and postconcussive symptoms (PCS) at 1, 4 and 12 weeks after injury. METHODS: This was a secondary analysis of a prospective cohort study conducted in nine Canadian paediatric EDs in 2013-2015 (5P study). Participants were children who suffered a head injury within the preceding 48 hours and met Zurich consensus concussion diagnostic criteria. The exposure was the time between head injury and ED presentation. The primary outcome was the presence of PCS at 1 week defined by the presence of at least three symptoms on the Post-Concussion Symptom Inventory (PCSI). Secondary outcomes evaluated PCS at 4 and 12 weeks. Multivariable logistic regression analyses were adjusted for ED PCSI and other potential confounders. RESULTS: There were 3041 patients with a concussion in which timing of the injury was known. 2287 (75%) participants sought care in the first 12 hours, 388 (13%) 12-24 hours after trauma and 366 (12%) between 24 and 48 hours. Compared with children who sought care >24 hours after trauma, children who sought care in the first 12 hours had a significantly lower incidence of PCS at 1 week (OR: 0.55 (95% CI 0.41 to 0.75)) and 4 weeks (OR: 0.74 (95% CI 0.56 to 0.99)) but not at 12 weeks (OR: 0.88 (95% CI 0.63 to 1.23)). CONCLUSIONS: Patients who present early after a concussion appear to have a shorter duration of PCS than those presenting more than 12 hours later. Patients/families should be informed of the higher probability of PCS in children with delayed presentation.

Boarding and Day School Students: A Large-Scale Multilevel Investigation of Academic Outcomes Among Students and Classrooms.

Boarding school is a major educational option for many students (e.g., students living in remote areas, or whose parents are working interstate or overseas, etc.). This study explored the motivation, engagement, and achievement of boarding and day students who are educated in the same classrooms and receive the same syllabus and instruction from the same teachers (thus a powerful research design to enable unique comparisons). Among 2,803 students (boarding n = 481; day n = 2,322) from 6 Australian high schools and controlling for background attributes and personality, we found predominant parity between boarding and day students in their motivation, engagement, and achievement. We also found that classroom-average motivation, engagement, and achievement was not significantly affected by the number of boarders (relative to day students) in the classroom. In addition, the effects of boarding were generally not moderated by students' background or personality attributes. We conclude that boarders have academic opportunities and outcomes that are comparable to their day student counterparts. Implications for students, teachers, and parents are discussed.

Managing uncertainty in movement knowledge for environmental decisions.

Species' movements affect their response to environmental change but movement knowledge is often highly uncertain. We now have well-established methods to integrate movement knowledge into conservation practice but still lack a framework to deal with uncertainty in movement knowledge for environmental decisions. We provide a framework that distinguishes two dimensions of species' movement that are heavily influenced by uncertainty: knowledge about movement and relevance of movement to environmental decisions. Management decisions can be informed by their position in this knowledge-relevance space. We then outline a framework to support decisions around (1) increasing understanding of the relevance of movement knowledge, (2) increasing robustness of decisions to uncertainties and (3) improving knowledge on species' movement. Our decision-support framework provides guidance for managing movement-related uncertainty in systematic conservation planning, agri-environment schemes, habitat restoration and international biodiversity policy. It caters to different resource levels (time and funding) so that species' movement knowledge can be more effectively integrated into environmental decisions.

Understanding Girls' Disengagement: Identifying Patterns and the Role of Teacher and Peer Support using Latent Growth Modeling.

Previous work has established a significant increase in disengagement as students progress through secondary school. This work has also established that rates of disengagement appear to be higher among boys, leading to an increased focus on the underlying causes and factors associated with disengagement within this population. However, less is known about the patterns of disengagement exhibited by girls. Given that disengagement is consistently associated with negative personal and academic outcomes, it is important to more closely examine the disengagement trajectories of girls. Moreover, it critical to identify factors that buffer the effects of disengagement that are the most effective for girls. Classroom interpersonal support from teachers and peers have been identified as factors that are likely to mitigate disengagement among girls. The present investigation examined longitudinal data from Australian adolescent girls (N = 302, age range 12-16 years old). Latent growth modeling was used to examine the extent to which disengagement was increasing among secondary school girls in Australia, as well as the effects of teacher and peer social support in slowing this increase. The results showed that disengagement significantly increased across 3 years and that teacher support (but not peer support) was associated with a reduction in girls' upward disengagement trajectories. The results of the current study provide much-needed insight about the developmental trajectories of disengagement among adolescent girls and the role of teachers in buffering these problematic trajectories.

Derivation and Initial Validation of Clinical Phenotypes of Children Presenting with Concussion Acutely in the Emergency Department: Latent Class Analysis of a Multi-Center, Prospective Cohort, Observational Study.

The identification of clinical phenotypes may help parse the substantial heterogeneity that characterizes children with concussion. This study used latent class analysis (LCA) to identify discernible phenotypes among children with acute concussion and examine the association between phenotypes and persistent post-concussive symptoms (PPCS) at 4 and 12 weeks post-injury. We conducted LCA of variables representing pre-injury history, clinical presentation, and parent symptom ratings, derived from a prospective cohort, observational study that recruited participants from August 2013 until June 2015 at nine pediatric emergency departments within the Pediatric Emergency Research Canada network. This substudy included 2323 children from the original cohort ages 8.00-17.99 years who had data for at least 80% of all variables included in each LCA. Concussion was defined according to Zurich consensus statement diagnostic criteria. The primary outcome was PPCS at 4 and 12 weeks after enrollment. Participants were 39.5% female and had a mean age of 12.8 years (standard deviation = 2.6). Follow-up was completed by 1980 (85%) at 4 weeks and 1744 (75%) at 12 weeks. LCA identified four groups with discrete pre-injury histories, four groups with discrete clinical presentations, and seven groups with discrete profiles of acute symptoms. Clinical phenotypes based on the profile of group membership across the three LCAs varied significantly in their predicted probability of PPCS at 4 and 12 weeks. The results indicate that children with concussion can be grouped into distinct clinical phenotypes, based on pre-injury history, clinical presentation, and acute symptoms, with markedly different risks of PPCS. With further validation, clinical phenotypes may provide a useful heuristic for clinical assessment and management.

The Diagnosis of Concussion in Pediatric Emergency Departments: A Prospective Multicenter Study.

BACKGROUND: The accurate identification of children with a concussion by emergency physicians is important to initiate appropriate anticipatory guidance and management. OBJECTIVES: We compared the frequency of persistent concussion symptoms in children who were provided the diagnosis of concussion by an emergency physician versus those who met Berlin/Zurich international criteria for this diagnosis. We also determined the clinical variables independently associated with a physician-diagnosed concussion. METHODS: This was a planned secondary analysis of a prospective, multicenter cohort study. Participants were 5-17 years of age and met the Zurich/Berlin International Consensus Statement criteria for concussion. RESULTS: There were 2946 enrolled children. In those with physician-diagnosed concussion vs. no concussion, the frequency of persistent symptoms was 62.5% vs. 38.8% (p < 0.0001) at 1 week, 46.3% vs. 25.8% (p < 0.0001) at 2 weeks, and 33.0% vs. 23.0% (p < 0.0001) at 4 weeks. Of those meeting international criteria, 2340 (79.4%) were diagnosed with a concussion by an emergency physician and 12 variables were associated with this diagnosis. Five had an odds ratio (OR) > 1.5: older age (13-17 vs. 5-7 years, OR 2.9), longer time to presentation (≥16 vs. <16 h, OR 2.1), nausea (OR 1.7), sport mechanism (OR 1.7), and amnesia (OR 1.6). CONCLUSIONS: Relative to international criteria, the more selective assignment of concussion by emergency physicians was associated with a greater frequency of persistent concussion symptoms. In addition, while most children meeting international criteria for concussion were also provided this diagnosis for concussion by an emergency physician, the presence of 5 specific variables made this diagnosis more likely.

Biodiversity responds to increasing climatic extremes in a biome-specific manner.

An unprecedented rate of global environmental change is predicted for the next century. The response to this change by ecosystems around the world is highly uncertain. To address this uncertainty, it is critical to understand the potential drivers and mechanisms of change in order to develop more reliable predictions. Australia's Long Term Ecological Research Network (LTERN) has brought together some of the longest running (10-60years) continuous environmental monitoring programs in the southern hemisphere. Here, we compare climatic variables recorded at five LTERN plot network sites during their period of operation and place them into the context of long-term climatic trends. Then, using our unique Australian long-term datasets (total 117 survey years across four biomes), we synthesize results from a series of case studies to test two hypotheses: 1) extreme weather events for each plot network have increased over the last decade, and; 2) trends in biodiversity will be associated with recent climate change, either directly or indirectly through climate-mediated disturbance (wildfire) responses. We examined the biodiversity responses to environmental change for evidence of non-linear behavior. In line with hypothesis 1), an increase in extreme climate events occurred within the last decade for each plot network. For hypothesis 2), climate, wildfire, or both were correlated with biodiversity responses at each plot network, but there was no evidence of non-linear change. However, the influence of climate or fire was context-specific. Biodiversity responded to recent climate change either directly or indirectly as a consequence of changes in fire regimes or climate-mediated fire responses. A national long-term monitoring framework allowed us to find contrasting species abundance or community responses to climate and disturbance across four of the major biomes of Australia, highlighting the need to establish and resource long-term monitoring programs across representative ecosystem types, which are likely to show context-specific responses.

Essential Content for Discharge Instructions in Pediatric Emergency Care: A Delphi Study.

OBJECTIVE: The aim of this study was to identify the 5 most essential discharge instruction content elements that should be communicated to all caregivers of children who present to the emergency department (ED) with asthma, vomiting/diarrhea, abdominal pain, fever, minor head injury, or bronchiolitis. METHODS: A discharge information content list was developed for each illness presentation following a review of the literature. Using a modified Delphi technique, 6 lists were distributed to a panel of experts from EDs across Canada using a secure online survey tool with the goal of achieving the 5 most essential discharge instruction elements. RESULTS: A total of 37 emergency clinicians completed all 4 rounds of the Delphi. Consensus for the final 30 content items ranged from 51.4% to 100%. Items pertaining to diarrhea/vomiting, abdominal pain, fever, and bronchiolitis obtained relatively high levels of consensus for all top 5 items. The majority of items (n = 19 [63.3%]) that reached consensus across the illness presentations were associated with instructions intended to educate caregivers on instances when they should return to the ED department. CONCLUSIONS: Findings from this study provide a better understanding of what should be communicated to caregivers of children who present to the ED with a number of different illness presentations. Results from this study suggest that health care providers agree on the importance of providing information to caregivers regarding when to return to the ED with their child. Reaching consensus among all experts in this study provides insight into the difficulty of standardizing discharge communication in the absence of widely accepted guidelines.

The Response of the Primary Motor Cortex to Neuromodulation is Altered in Chronic Low Back Pain: A Preliminary Study.

Objective: Neuromodulation is increasingly investigated for the treatment of low back pain (LBP). However, the neurophysiological effects of common neuromodulatory techniques (anodal transcranial direct current stimulation [tDCS] and peripheral electrical stimulation [PES]) have not been investigated in people with chronic LBP. Here we aimed to compare the effect of three neuromodulatory protocols (anodal tDCS, high intensity PES, and a priming protocol of combined tDCS/PES) on primary motor cortex (M1) excitability in people with and without chronic LBP. Design: Cross-sectional. Setting: University laboratory. Participants: Ten individuals with chronic LBP and 10 pain-free controls. Methods: Participants received four interventions in random order across separate sessions: 1) anodal tDCS to M1 + PES to the back muscles; 2) tDCS + sham PES; 3) sham tDCS + PES; or 4) sham tDCS + sham PES. Motor cortical excitability (map volume, discrete map peaks, and cortical silent period [CSP]) was measured before and after each intervention. Results: Anodal tDCS increased M1 excitability (increased map volume and reduced CSP) in controls but had no effect in the LBP group. PES reduced M1 excitability in both groups. The combined tDCS + PES treatment increased M1 excitability in the LBP group but had no effect in controls. Conclusions: The neurophysiological response to common neuromodulatory treatments differs between people with and without LBP. This has relevance for the design and tailoring of neuromodulation in pain. Further, if the goal of treatment is to increase M1 excitability, a priming protocol (e.g., combined tDCS + PES) may be more effective than tDCS alone.