Self-reported concussions in Canada: A cross-sectional study.

Background: Traumatic brain injuries (TBIs) are a major public health concern impacting the lives of many Canadians. Among all TBIs, concussions are the most common. However, to date, the incidence of concussions among the Canadian population, has remained unknown. To address this data surveillance gap, this study presents national estimates on the percentage of Canadians aged 12 years or older (excluding those living in the territories) who sustained one or more concussions in 2019. Data and methods: This study used data collected from the Traumatic Brain Injury Rapid Response (TBIRR) module of the 2020 Canadian Community Health Survey, a cross-sectional health survey. Descriptive statistics and logistic regressions were conducted to summarize the information in the TBIRR module. Results: This study found that approximately 1.6% of Canadians aged 12 years or older reported sustaining one or more concussions in 2019. Age was significantly associated with concussion incidence after controlling for sex and annual household income, and the locations and activities surrounding respondents' most serious concussions varied by age group. Over one-third of respondents sustained multiple concussions. Interpretation: The results suggest that certain populations, particularly younger individuals, may be more affected by concussions. While circumstances surrounding concussions vary by age group, the most important contributing factors were sports or physical activities among youth and falls among the adult population. Monitoring concussions among the national population is an important activity in injury surveillance, as it can help evaluate the efficacy of injury prevention intervention and better understand knowledge gaps and the burden of this injury.

Canadians Reporting Sport-Related Concussions: Increasing and Now Stabilizing.

BACKGROUND: Canada is currently engaged in a national harmonization of strategies to prevent and manage sport-related concussions. OBJECTIVE: To examine the annual incidence rates of reported sport-related concussions or other brain injuries by participants in the Canadian Community Health Survey, a national public health survey which provides nearly 2 decades of serial data using consistent methodology. DESIGN: Serial cross-sectional survey. SETTING: Population-based Canadian survey from 2000 to 2018 that collects data on "concussions or other brain injuries." PARTICIPANTS: Respondents 12 years and older. INDEPENDENT VARIABLES: Sex and age categorized 12 to 14 years, 15 to 19 years, 20 to 29 years, and 30+ years. OUTCOME MEASURES: National incidence rates of participants reporting concussions or other brain injuries occurring within the previous year while engaged in "organized sports/leisure sports or physical exercise." RESULTS: Data were available for 2000/01, 2003, 2005/6, 2009/10, 2013/4, and 2017/8 (N = 757 383). A previously stable annual incidence of reported sport-related concussions or other brain injuries increased nearly 2 and a half-fold from 2005/06 through 2013/14 (P < 0.0001) but seems to have stabilized recently (2013/14 vs 2017/8, P = 0.35). This trend is similar for both men and women but is manifest primarily within youth (12-19 years) as opposed to adults (>19 years). Approximately 1 in 450 Canadians 12 years and older report sport-related concussions or other brain injuries as their most significant injury associated with disability in the previous year (2017-2018: 221 per 100 000 population, 95% confidence interval: 179-264). CONCLUSIONS: In Canada, the annual incidence rates of reported sport-related concussions or other brain injuries is changing and may reflect improved reporting and recognition.

The Silent Minority: Insights into Who Fails to Present for Medical Care Following a Brain Injury.

BACKGROUND: The WHO and Center for Disease Control have identified that current estimates of brain injury incidence miss individuals who do not seek medical attention for their injury. METHODS: The Canadian Community Health Survey is a nationally representative health survey. Respondents aged 12 years and above reporting "concussion or other brain injury" occurring within the previous year also reported whether they had received any medical attention from a health professional within 48 h of their injury. RESULTS: Nationally representative data were available biennially from 2000/2001 through 2013/2014 with the exception of 2007/2008 and 2011/2012. In all, 1,749 respondents reported concussion or other brain injury with disability in the previous 12 months. Of these, 21.9% (95% CI 19.0-24.7) reported not having received medical attention from a health professional within 48 h following their injury. Within a multivariable model, those who are more likely not to receive medical care with 48 h of incurring a brain injury are more likely to be younger (<20 years) or older (>24 years), have an injury incurred through sports exposure or in or around their home, do not identify as immigrant, and are currently smokers. The area under the ROC was modest at 0.58. CONCLUSIONS: Within a nationally representative sample of individuals reporting concussion or other brain injury, we found that those reporting medical non-attendance and those reporting medical attendance within 48 h of their injury were remarkably similar. This outcome suggests that brain injury surveillance based on point of care may produce relatively unbiased samples of the brain injured population.

'Reported concussion' time trends within two national health surveys over two decades.

BACKGROUND: An 'epidemic' of concussions has been widely reported. We examined the annual incidence of reported concussion or other brain injury, over 20 years within Canada in order to explore the magnitude of this reported epidemic. METHODS: Two Canadian nationally representative health surveys have serially collected injury data associated with disability. The National Population Health Survey (NPHS) collected data on 'concussion' (1994-1999), and the Canadian Community Health Survey (CCHS) collects data on 'concussion or other brain injury' (2000-current). Respondents 12 years and older reporting concussion or other brain injury occurring within the previous year were used to produce serial incidence data. RESULTS: Nationally representative data were available biennially from 1994/95 through 2013/14 with the exception of 2007/08 and 2011/12. Reported incidence of concussions, or concussions and other brain injury has been stable until 2005/06 when the reported annual incidence started an upward slope to levels 250% higher without any apparent stabilization by 2013/14, at which time approximately 1 in 200 Canadians 12 years and older reported concussion or other brain injury as their most significant injury associated with disability in the previous year. CONCLUSIONS: The current pandemic of reported brain injury in Canada will have implications for health-care delivery.

Validation of 'reported concussion' within a national health survey.

SETTING: The Canadian Community Health Survey (CCHS) is a national cross-sectional health survey, which has collected information on injuries serious enough to limit normal activity. OBJECTIVE: To assess the construct and discriminant validity of reporting 'concussion or other brain injury' in the CCHS as the respondents' most serious injury. METHODS: Construct validity was assessed by describing the injury profile. Discriminant validity was assessed by examining differences between those reporting concussion or other brain injury, and either: respondents not reporting brain injury (population control); or respondents reporting orthopaedic injuries (orthopaedic control). RESULTS: In total, 1,852 of the 682,455 eligible CCHS respondents (≥12 years) reported a concussion or other brain injury within the prior year, a population annual incidence of 0.29%. Those reporting concussion or other brain injury were younger and male (p < 0.001), with an injury acquired by falling (p < 0.001) or sport or physical exercise (p < 0.001). Most (78.4%) who reported concussions or other brain injuries received medical attention from a health professional within 48 hours of their injury. The reported injury profiles appear to differ from the population controls and those reporting orthopaedic injuries. CONCLUSIONS: The report of 'concussion or other brain injury' in the CCHS may be a valid source of population-based traumatic brain injury epidemiological data.

Stuttering as a Symptom of Concussion: Confirmation of Association Using Nontraditional Information Sources.

OBJECTIVE: A 12-year-old girl presented to our pediatric emergency department after a head injury with symptoms of concussion and acute stuttering. A PubMed search identified only 1 similar pediatric case. We investigated whether new-onset stuttering may be seen in the presence of acute concussive symptoms using an infodemiologic approach. METHODS: We conducted a search with a metabrowser search engine (www.dogpile.com) using the free-text words "concussion" and "stuttering." The first 100 hits were scanned specifically for forum posts, extracting reports of concussions that were followed by new-onset stuttering. Duplicates were minimized by cross-referencing user name, location, date, and reported age and sex. RESULTS: Of the first 100 hits, we identified 17 unique posts that described an injury leading to a concussion followed within a short interval by new-onset stuttering. Posts were primarily by the affected individual (76%) and 64% involved female individuals. Sports and falls/injury accounted for most injuries (71%). Forty-one percent of posts explicitly stated that the concussion had been formally diagnosed. For those that reported the timing of stuttering onset (47%), the stuttering was documented within 1 hour of the injury (4/8) or between 1 and 24 hours (4/8). CONCLUSIONS: The ease with which we found so many reports of stuttering after head injury with concussive symptoms confirms that new-onset stuttering may be a symptom of concussion. Our experience highlights both a failure of using conventional medical literature and a success of using nontraditional information sources in identifying uncommonly associated symptoms of frequently encountered conditions.

Perceived need for restrictions on activity for children with epilepsy.

BACKGROUND: Children and youth with epilepsy have long been subjected to excessive restrictions on extracurricular activities due to concerns over risk of injury. Over time physicians and medical regulatory associations have liberalized the advice given for people with epilepsy to promote independence, self-esteem and general health benefits of physical activity. Current evidence suggests that few restrictions are needed for children with epilepsy beyond water-related precautions and avoidance of very high-risk activities. However, more stringent restrictions on daily activities may be imposed by caregivers. This study was aimed at exploring current perceptions of parents regarding restrictions on activity for children with epilepsy and the child's perspective on restrictions related to the diagnosis. METHODS: A self-administered questionnaire was offered to a sample of parent-child dyads of children/youth with epilepsy attending summer camp for children with epilepsy age 8-18years. A 10-item validated HARCES Parent Scale of Childhood Epilepsy was completed by the parent/guardian and a modified-HARCES completed by the child. The primary objective was to assess the degree of restrictions placed on children with epilepsy from the perspective of child and parent assessed independently. Agreement of perceived restrictions between parent-child dyads was also determined. RESULTS: 21 parent/guardian-child pairs were recruited with mean age of children/youth 12.7years (range 9-16years). Total HARCES scores for parents and guardians ranged from 11-26 (x=16.5; SD 4.9) while total scores for children with epilepsy similarly ranged from 10-25 (x=15.2; SD 4.9). There were no differences in total parent scores when analyzed by child's age (<13 or >13years), gender, age of seizure onset, seizure frequency or seizure type. Total HARCES scores showed no agreement between parent and child pairs with correlation of 0.2798 (95% CI -0.173-0.635). CONCLUSIONS: Children and youth with epilepsy often face activity restrictions based on fear of perceived risk of injury. This small sample shows evidence that even more permissive parents and his/her children still feel limited by such restrictions. Parents and children do not perceive these restrictions in the same way despite similar education by physicians highlighting an important secondary role of epilepsy camps in targeting misperceptions and educating families on appropriate precautions.

Combination therapy in a xenograft model of glioblastoma: enhancement of the antitumor activity of temozolomide by an MDM2 antagonist.

OBJECTIVE Improvement in treatment outcome for patients with glioblastoma multiforme (GBM) requires a multifaceted approach due to dysregulation of numerous signaling pathways. The murine double minute 2 (MDM2) protein may fulfill this requirement because it is involved in the regulation of growth, survival, and invasion. The objective of this study was to investigate the impact of modulating MDM2 function in combination with front-line temozolomide (TMZ) therapy in GBM. METHODS The combination of TMZ with the MDM2 protein-protein interaction inhibitor nutlin3a was evaluated for effects on cell growth, p53 pathway activation, expression of DNA repair proteins, and invasive properties. In vivo efficacy was assessed in xenograft models of human GBM. RESULTS In combination, TMZ/nutlin3a was additive to synergistic in decreasing growth of wild-type p53 GBM cells. Pharmacodynamic studies demonstrated that inhibition of cell growth following exposure to TMZ/nutlin3a correlated with: 1) activation of the p53 pathway, 2) downregulation of DNA repair proteins, 3) persistence of DNA damage, and 4) decreased invasion. Pharmacokinetic studies indicated that nutlin3a was detected in human intracranial tumor xenografts. To assess therapeutic potential, efficacy studies were conducted in a xenograft model of intracranial GBM by using GBM cells derived from a recurrent wild-type p53 GBM that is highly TMZ resistant (GBM10). Three 5-day cycles of TMZ/nutlin3a resulted in a significant increase in the survival of mice with GBM10 intracranial tumors compared with single-agent therapy. CONCLUSIONS Modulation of MDM2/p53-associated signaling pathways is a novel approach for decreasing TMZ resistance in GBM. To the authors' knowledge, this is the first study in a humanized intracranial patient-derived xenograft model to demonstrate the efficacy of combining front-line TMZ therapy and an inhibitor of MDM2 protein-protein interactions.

EUS and EUS-Guided Interventions Alter Clinical Management in Children With Digestive Diseases.

OBJECTIVES: Endoscopic ultrasound (EUS) ± fine needle aspiration (FNA) is a useful tool to evaluate gastrointestinal tract disorders in adults because of its established feasibility and safety. Its role in children has not been well established and continues to evolve. Our objective was to evaluate the utility and impact on clinical management of EUS and EUS-guided interventions in the pediatric population at our institution. METHODS: Retrospective, single-center study including 43 patients undergoing EUS and EUS-FNA between August 2005 and January 2012. RESULTS: Fifty-one EUS procedures were performed in 43 patients, 30 girls, median age 14.5 (range 4-18). The most common indications were suspected biliary obstruction in 11 of 51 (22%), pancreatic cysts in 10 of 51 (20%), acute or recurrent pancreatitis in 9 of 51 (18%), and abdominal pain in 8 of 51 (16%). The most common findings of EUS included normal 11 of 51 (22%), pancreas cyst 6 of 51 (12%), pancreatic pseudocyst 5 of 51 (10%), biliary system sludge or stones 9 of 51 (18%), and acute and chronic pancreatitis 5 of 51 (10%). EUS-FNA was performed in 13 cases: 7 solid masses or nodes, 4 pancreatic pseudocyst, 1 pancreatic cyst, and 1 celiac plexus block. FNA cyst drainage was successful in resolving all 4 pancreatic pseudocysts. EUS prompted a surgical procedure in 13 cases (25%), ERCP in 5 cases (10%), and repeat EUS in 5 cases (10%). EUS led to a new diagnosis in 34 of 43 (79%) patients and prompted further intervention in 24 of 51 (47%) procedures. CONCLUSIONS: In this large cohort study, we found that EUS and EUS-guided interventions assist in diagnosing and altering clinical management in pediatric patients and should be considered in cases with vexing pancreaticobiliary disorders.

Food insecurity and migraine in Canada.

AIM: The aim of this study was to examine the prevalence of household food insecurity in individuals reporting migraine within a large population-based sample of Canadians. METHODS: The Canadian Community Health Survey (CCHS) uses a stratified cluster sample design to obtain information on Canadians ≥12 years of age. Data on household food insecurity were assessed for individuals who reported having migraine or not, providing a current point prevalence. This was assessed for stability in two CCHS datasets from four and eight years earlier. Factors associated with food insecurity among those reporting migraine were examined and a logistic regression model of food insecurity was developed. We also examined whether food insecurity was associated with other reported chronic health conditions. RESULTS: Of 48,645 eligible survey respondents, 4614 reported having migraine (weighted point prevalence 10.2%). Food insecurity was reported by 14.8% who reported migraine compared with 6.8% of those not reporting migraine, giving an odds ratio of 2.4 (95% confidence interval 2.0-2.8%). This risk estimate was stable over the previous eight years. The higher risk for food insecurity was not unique to migraine and was seen with some, but not all, chronic health conditions reported in the CCHS. CONCLUSIONS: Food insecurity is more frequent among individuals reporting migraine in Canada.

Food insecurity and epilepsy in a nationally representative sample.

BACKGROUND: Food insecurity amongst patients with epilepsy has not been previously studied. The aim of this study was to compare the presence of food insecurity within a nationally representative sample of individuals reporting epilepsy with that within the general population. METHODS: The Canadian Community Health Survey, Cycle 3.1, is a cross-sectional survey that uses a stratified cluster sample design to obtain information on Canadians 12years of age or older. Data on food insecurity were compared for those who reported having epilepsy and the remainder of the population. RESULTS: Of the 102,927 eligible survey respondents, 654 reported having epilepsy. Food insecurity was considerably more likely to be reported amongst those also reporting epilepsy with a rate of 10.8% compared with those not reporting epilepsy with a rate of 5.2% (odds ratio=2.2, (95% CI=1.6, 3.0)). Binary bivariate prediction of food insecurity within the population of respondents reporting epilepsy included the following: education, income, family size, and home ownership. CONCLUSIONS: The experience of food insecurity appears to be more frequent amongst persons living with epilepsy. Whether this is related directly to epilepsy or factors within the epilepsy experience is unclear.

Information-Seeking Behaviors of Medical Students: A Cross-Sectional Web-Based Survey.

BACKGROUND: Medical students face an information-rich environment in which retrieval and appraisal strategies are increasingly important. OBJECTIVE: To describe medical students' current pattern of health information resource use and characterize their experience of instruction on information search and appraisal. METHODS: We conducted a cross-sectional web-based survey of students registered in the four-year MD Program at Dalhousie University (Halifax, Nova Scotia, and Saint John, New Brunswick, sites), Canada. We collected self-reported data on information-seeking behavior, instruction, and evaluation of resources in the context of their medical education. Data were analyzed using descriptive statistics. RESULTS: Surveys were returned by 213 of 462 eligible students (46.1%). Most respondents (165/204, 80.9%) recalled receiving formal instruction regarding information searches, but this seldom included nontraditional tools such as Google (23/107, 11.1%), Wikipedia, or social media. In their daily practice, however, they reported heavy use of these tools, as well as EBM summaries. Accessibility, understandability, and overall usefulness were common features of highly used resources. Students identified challenges managing information and/or resource overload and source accessibility. CONCLUSIONS: Medical students receive instruction primarily on searching and assessing primary medical literature. In their daily practice, however, they rely heavily on nontraditional tools as well as EBM summaries. Attention to appropriate use and appraisal of nontraditional sources might enhance the current EBM curriculum.

Alice in wonderland and other migraine associated phenomena-evolution over 30 years after headache diagnosis.

BACKGROUND: The International Classification of Headache Disorders-III beta includes a number of episodic syndromes associated with migraine. Those who treat pediatric headaches are aware of a number of other phenomena (such as the Alice in Wonderland syndrome) which are thought to occur as precursors of migraine. There is no available data on the course of these phenomena over the decades following childhood headache diagnosis. METHODS: Patients who were observed by one of the authors in 1983 were contacted by telephone in 1993, 2003, and 2013. Details were gathered regarding the presence and characteristics of ongoing headaches and about the presence of sleepwalking, motion sickness, and distortions of either time or space perceptions. RESULTS: Twenty-eight patients were monitored in 1993, 2003, and 2013. Ongoing headaches were reported by 71%. Sleepwalking was only present in one patient in 2013. More than a third still complained of motion sickness, and more than one quarter still experienced distortions of time. Distortions of space were still reported by nearly 20%. Reporting any of these phenomena was not consistent over time, with some patients reporting distortions for the first time in adulthood. There was no clear correlation with migraine, and patients with tension-type headaches also reported the phenomena. CONCLUSIONS: Motion sickness and distortions of both space and time persist into the fifth decade for many patients initially observed with headaches in childhood. The correlation with migraine is less clear than previously thought.

What do patients and families want from a child neurology consultation?

Understanding what patients and their parents want is essential to plan appropriate patient-centered care. Questionnaires were distributed to 500 consecutive children and parents seen for their first pediatric neurology consultation. Both patients and their families answered questions about their expectations of the consultation, their level of worry, and the Penn State Worry Questionnaire. The 5 most important issues for the parents were to get information, to work with the doctor to manage the problem, to have questions answered, to find out what was wrong, and to discuss the impact on the child's life. The children had very similar priorities. The 5 least important concerns for parents were to get a prescription, blood tests, to talk to others with similar problems, to get a radiograph/computed tomography/magnetic resonance imaging (MRI) and to be told nothing is wrong. The pediatric neurologists did well in anticipating these priorities but had more difficulty appreciating parent and patient level of worry.

Concussion management by paediatricians: a national survey of Canadian paediatricians.

OBJECTIVE: To assess the use of concussion/mild traumatic brain injury (mTBI) guidelines, criteria used in the initiation of return-to-play (RTP) and management of RTP for brain injured children and youth by Canadian paediatricians. METHODS: A cross-sectional survey was mailed through the Canadian Paediatric Surveillance Program to ∼2600 paediatric specialists and sub-specialists. RESULTS: Of 809 respondents (31%), 503 encountered newly diagnosed paediatric concussion/mTBI within the past 12 months, reporting ∼6900 cases. Of the respondents, 96.7% (95% CI = 94.7-98.6%) reported using one or more of the presented concussion/mTBI guidelines in the management of their patients. The most frequently reported criteria (>50%) used to determine asymptomatic status were: free from all concussion symptoms, by patient report (92%), by proxy report (76%), normal physical examination (65%), in school full-time, with usual school performance (53%). Most respondents (84.9%) did not initiate RTP immediately after their patients became asymptomatic. The median time waiting before initiating RTP was 7 days. The median duration of the RTP sequence was 7 days, with considerable variation reported. CONCLUSIONS: Canadian paediatricians frequently encounter patients with concussion/mTBI. Their concussion/mTBI care appears to be consistent with current guidelines, but also shows practice variation, particularly when current guidelines become less proscriptive.

Syndrome of hepatic cirrhosis, dystonia, polycythemia, and hypermanganesemia caused by mutations in SLC30A10, a manganese transporter in man.

Environmental manganese (Mn) toxicity causes an extrapyramidal, parkinsonian-type movement disorder with characteristic magnetic resonance images of Mn accumulation in the basal ganglia. We have recently reported a suspected autosomal recessively inherited syndrome of hepatic cirrhosis, dystonia, polycythemia, and hypermanganesemia in cases without environmental Mn exposure. Whole-genome mapping of two consanguineous families identified SLC30A10 as the affected gene in this inherited type of hypermanganesemia. This gene was subsequently sequenced in eight families, and homozygous sequence changes were identified in all affected individuals. The function of the wild-type protein and the effect of sequence changes were studied in the manganese-sensitive yeast strain Δpmr1. Expressing human wild-type SLC30A10 in the Δpmr1 yeast strain rescued growth in high Mn conditions, confirming its role in Mn transport. The presence of missense (c.266T>C [p.Leu89Pro]) and nonsense (c.585del [p.Thr196Profs(∗)17]) mutations in SLC30A10 failed to restore Mn resistance. Previously, SLC30A10 had been presumed to be a zinc transporter. However, this work has confirmed that SLC30A10 functions as a Mn transporter in humans that, when defective, causes Mn accumulation in liver and brain. This is an important step toward understanding Mn transport and its role in neurodegenerative processes.

Manganese toxicity in a child with iron deficiency and polycythemia.

A previously healthy 5-year-old girl presented with pica, emotional lability, and marked gait abnormalities. She had concurrent severe iron deficiency and polycythemia. Her magnetic resonance imaging (MRI) scan showed increased signal in the basal ganglia on T1-weighted images consistent with manganese neurotoxicity. Manganism was subsequently confirmed as her blood manganese levels were extremely elevated. Chelation therapy resulted in improvement in her mobility but she continues to have significant gait impairment. An epidemiological investigation identified well water as the potential source of manganese exposure for our patient, but to date, we have been unable to identify the nature of her neurotoxic susceptibility.

Impact of bisphosphonates on survival for patients with Duchenne muscular dystrophy.

OBJECTIVE: In this article we describe the association of bisphosphonate therapy on survival within a regional cohort of patients with Duchenne muscular dystrophy (DMD) who received steroid therapy and were managed in a single center. PATIENTS AND METHODS: The records of all patients with confirmed DMD who were born between 1963 and 2006 and who had received at least 1 year of steroid therapy were reviewed from birth until they reached the study end points (death, loss to follow-up, or the last follow-up was in 2009). A survival analysis was used to account for the variable follow-up duration within this cohort. RESULTS: Forty-four boys from this cohort with DMD were exposed to continuous steroid use. Bisphosphonate therapy was initiated for 16 patients (36%) between 1997 and 2007 at a median age of 12.5 years (range: 7-23 years). At the time of the last follow-up in 2009, 13 patients had died (30%) at a median age of 16 years (range: 14-27 years). Survival curves demonstrate that the prescription of bisphosphonates was associated with a significant improvement in survival rate (P = .005, log-rank test). Furthermore, a possible therapy-duration effect could be shown for bisphosphonate use (P = .007, log-rank test). CONCLUSIONS: The treatment of patients with DMD with steroids and bisphosphonates seems to be associated with significantly improved survival compared with treatment with steroids alone.