Stratification of risk for emergent intracranial abnormalities in children with headaches: a Pediatric Emergency Care Applied Research Network (PECARN) study protocol.

INTRODUCTION: Headache is a common chief complaint of children presenting to emergency departments (EDs). Approximately 0.5%-1% will have emergent intracranial abnormalities (EIAs) such as brain tumours or strokes. However, more than one-third undergo emergent neuroimaging in the ED, resulting in a large number of children unnecessarily exposed to radiation. The overuse of neuroimaging in children with headaches in the ED is driven by clinician concern for life-threatening EIAs and lack of clarity regarding which clinical characteristics accurately identify children with EIAs. The study objective is to derive and internally validate a stratification model that accurately identifies the risk of EIA in children with headaches based on clinically sensible and reliable variables. METHODS AND ANALYSIS: Prospective cohort study of 28 000 children with headaches presenting to any of 18 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). We include children aged 2-17 years with a chief complaint of headache. We exclude children with a clear non-intracranial alternative diagnosis, fever, neuroimaging within previous year, neurological or developmental condition such that patient history or physical examination may be unreliable, Glasgow Coma Scale score<14, intoxication, known pregnancy, history of intracranial surgery, known structural abnormality of the brain, pre-existing condition predisposing to an intracranial abnormality or intracranial hypertension, head injury within 14 days or not speaking English or Spanish. Clinicians complete a standardised history and physical examination of all eligible patients. Primary outcome is the presence of an EIA as determined by neuroimaging or clinical follow-up. We will use binary recursive partitioning and multiple regression analyses to create and internally validate the risk stratification model. ETHICS AND DISSEMINATION: Ethics approval was obtained for all participating sites from the University of Utah single Institutional Review Board. A waiver of informed consent was granted for collection of ED data. Verbal consent is obtained for follow-up contact. Results will be disseminated through international conferences, peer-reviewed publications, and open-access materials.

Contribution of implicit memory to adaptation of movement extent during reaching against unpredictable spring-like loads: insensitivity to intentional suppression of kinematic performance.

We examined the extent to which intentionally underperforming a goal-directed reaching task impacts how memories of recent performance contribute to sensorimotor adaptation. Healthy human subjects performed computerized cognition testing and an assessment of sensorimotor adaptation, wherein they grasped the handle of a horizontal planar robot while making goal-directed out-and-back reaching movements. The robot exerted forces that resisted hand motion with a spring-like load that changed unpredictably between movements. The robotic test assessed how implicit and explicit memories of sensorimotor performance contribute to the compensation for the unpredictable changes in the hand-held load. After each movement, subjects were to recall and report how far the hand moved on the previous trial (peak extent of the out-and-back movement). Subjects performed the tests under two counter-balanced conditions: one where they performed with their best effort, and one where they intentionally sabotaged (i.e., suppressed) kinematic performance. Results from the computerized cognition tests confirmed that subjects understood and complied with task instructions. When suppressing performance during the robotic assessment, subjects demonstrated marked changes in reach precision, time to capture the target, and reaction time. We fit a set of limited memory models to the data to identify how subjects used implicit and explicit memories of recent performance to compensate for the changing loads. In both sessions, subjects used implicit, but not explicit, memories from the most recent trial to adapt reaches to unpredictable spring-like loads. Subjects did not "give up" on large errors, nor did they discount small errors deemed "good enough". Although subjects clearly suppressed kinematic performance (response timing, movement variability, and self-reporting of reach error), the relative contributions of sensorimotor memories to trial-by-trial variations in task performance did not differ significantly between the two testing conditions. We conclude that intentional performance suppression had minimal impact on how implicit sensorimotor memories contribute to adaptation of unpredictable mechanical loads applied to the hand.

The Effects of Rest on Concussion Symptom Resolution and Recovery Time: A Meta-analytic Review and Subgroup Analysis of 4329 Patients.

BACKGROUND: Numerous individual studies suggest that rest may have a negative effect on outcomes following concussion. PURPOSE: To perform a systematic meta-analysis of the effects of prescribed rest compared with active interventions after concussion. STUDY DESIGN: Meta-analysis; Level of evidence, 4. METHODS: A meta-analysis (using the Hedges g) of randomized controlled trials and cohort studies was conducted to evaluate the effects of prescribed rest on symptoms and recovery time after concussion. Subgroup analyses were performed for methodological, study, and sample characteristics. Data sources were obtained from systematic search of key terms using Ovid Medline, Embase, Cochrane Database of Systematic Reviews, APA PsycINFO, Web of Science, SPORTDiscus, and ProQuest dissertations and theses through May 28, 2021. Eligible studies were those that (1) assessed concussion or mild traumatic brain injury; (2) included symptoms or days to recovery for ≥2 time points; (3) included 2 groups with 1 group assigned to rest; and (4) were written in the English language. RESULTS: In total, 19 studies involving 4239 participants met criteria. Prescribed rest had a significant negative effect on symptoms (k = 15; g = -0.27; SE = 0.11; 95% CI, -0.48 to -0.05; P = .04) but not on recovery time (k = 8; g = -0.16; SE = 0.21; 95% CI, -0.57 to 0.26; P = .03). Subgroup analyses suggested that studies with shorter duration (<28 days) (g = -0.46; k = 5), studies involving youth (g = -0.33; k = 12), and studies focused on sport-related concussion (g = -0.38; k = 8) reported higher effect sizes. CONCLUSION: The findings support a small negative effect for prescribed rest on symptoms after concussion. Younger age and sport-related mechanisms of injury were associated with a greater negative effect size. However, the lack of support for an effect for recovery time and the relatively small overall numbers of eligible studies highlight ongoing concerns regarding the quantity and rigor of clinical trials in concussion. REGISTRATION: CRD42021253060 (PROSPERO).

Using Comic-Based Concussion Discharge Instructions to Address Caregiver Health Literacy in the Emergency Department.

INTRODUCTION: This study compared the effectiveness of comic-based with text-based concussion discharge instructions on improving caregiver knowledge. This study also examined the role of social determinants of health on comprehension instructions. METHODS: This was an observational study of the caregivers of pediatric concussion patients. Caregivers' health literacy and demographics related socioeconomic factors were obtained. After the patients' evaluation in the emergency department, caregivers were given printed comic-based concussion discharge instructions. Caregivers were contacted 3 days later and tested overall knowledge of discharge instructions' content. These survey results were compared with historical controls who received text-based instructions. RESULTS: A total of 120 participants were recruited, and 86 participants completed follow-up procedures. When comparing the caregivers' recall ability with a comic-based vs traditional text-based instructions, caregivers with comic-based content were more likely to accurately recall overall discharge instructions (77.5% vs 44%, P < .001), particularly physical rest and activity restrictions (86.5% vs 63%, P < .001). Caregivers also were less likely to misidentify a red flag symptom (7.5% vs 19%, P < .04). Comic-based instructions did not increase recall of cognitive rest instructions or postconcussive symptoms. When examining demographic factors, caregivers who could not recall 3 postconcussive symptoms were more likely to be Hispanic or Black, less likely to be college educated, and more likely to have low health literacy. DISCUSSION: Novel methods should be explored to adequately prepare caregivers for continuing postconcussive care at home. Discharge instructions must be tailored to address caregivers' baseline health literacy and how caregivers digest and retain information.

Concussion Referral and Practice Patterns by Pediatric Emergency Medicine Providers.

OBJECTIVES: Concussion is a commonly encountered diagnosis for pediatric emergency medicine (PEM) providers, yet little is known regarding referral patterns to specialists. Our goal was to assess PEM providers' referral patterns and current usage of standardized evaluation tools. METHODS: This study was conducted as cross-sectional survey of PEM providers recruited from the American Academy of Pediatrics Section on Emergency Medicine Listserv. Surveys were distributed at 3 time points between December 1, 2020, and February 28, 2021, and included multiple choice, Likert scale, and free text questions. Descriptive statistics and bivariate analyses were used to describe the sample and compare responses between those with variable experience and confidence in concussion management. RESULTS: In total, 162 of 491 Listserv members (33.0%) completed the survey. The factors most often reported to assist in referral decisions were history of severe (92.6%) or multiple (90.7%) prior concussions, prolonged symptom duration (89.5%), and severity of current symptoms (84.6%). Most providers reported having large experience (63.0%) and confidence (54.9%) in managing concussion. Standardized symptom scales (8.0%), vestibular (11.7%) and balance assessments (13.0%), and prognostic tools (6.8%) were infrequently used. Most (64.2%) providers felt specialty referral was important. More than 80% reported high likelihood to use an accurate risk stratification tool to facilitate referral. CONCLUSIONS: Although most PEM providers reported significant experience and confidence in managing pediatric concussion, standardized assessment tools were infrequently used. Most were likely to use a risk stratification tool to assist in specialty referral. Future studies should assess the ability of targeted referral strategies to improve recovery for concussed youth.

Five days of fever and myocardial inflammation.

Multisystem inflammatory syndrome in children is an emerging pediatric illness associated with severe acute respiratory syndrome coronavirus 2 infection. The syndrome is rare, and evidence-based guidelines are lacking. This report reviews a patient who presented for medical care multiple times early in the course of his illness, thus offering near-daily documentation of symptoms and laboratory abnormalities. The patient did not have thrombocytopenia, anemia, or myocardial inflammation until the fifth day of fever. These laboratory abnormalities coincided with the onset of rash, conjunctival injection, vomiting, and diarrhea: clinical signs that could serve as indicators for when to obtain blood tests. The timing of this patient's onset of multisystem involvement suggests that testing for multisystem inflammatory syndrome in children after only 24 h of fever, as the Centers for Disease Control and Prevention recommends, may yield false-negative results. Testing for multisystem inflammatory syndrome in children after 4 days of fever may be more reliable.

Contributions of implicit and explicit memories to sensorimotor adaptation of movement extent during goal-directed reaching.

We examined how implicit and explicit memories contribute to sensorimotor adaptation of movement extent during goal-directed reaching. Twenty subjects grasped the handle of a horizontal planar robot that rendered spring-like resistance to movement. Subjects made rapid "out-and-back" reaches to capture a remembered visual target at the point of maximal reach extent. The robot's resistance changed unpredictably between reaches, inducing target capture errors that subjects attempted to correct from one trial to the next. Each subject performed over 400 goal-directed reaching trials. Some trials were performed without concurrent visual cursor feedback of hand motion. Some trials required self-assessment of performance between trials, whereby subjects reported peak reach extent on the most recent trial. This was done by either moving a cursor on a horizontal display (visual self-assessment), or by moving the robot's handle back to the recalled location (proprioceptive self-assessment). Control condition trials performed either without or with concurrent visual cursor feedback of hand motion did not require self-assessments. We used step-wise linear regression analyses to quantify the extent to which prior reach errors and explicit memories of reach extent contribute to subsequent reach performance. Consistent with prior reports, providing concurrent visual feedback of hand motion increased reach accuracy and reduced the impact of past performance errors on future performance, relative to the corresponding no-vision control condition. By contrast, we found no impact of interposed self-assessment on subsequent reach performance or on how prior target capture errors influence subsequent reach performance. Self-assessments were biased toward the remembered target location and they spanned a compressed range of values relative to actual reach extents, demonstrating that declarative memories of reach performance systematically differed from actual performances. We found that multilinear regression could best account for observed data variability when the regression model included only implicit memories of prior reach performance; including explicit memories (self-assessments) in the model did not improve its predictive accuracy. We conclude therefore that explicit memories of prior reach performance do not contribute to implicit sensorimotor adaptation of movement extent during goal-directed reaching under conditions of environmental uncertainty.

Early Neurologic Recovery, Practice Pattern Variation, and the Risk of Endotracheal Intubation Following Established Status Epilepticus.

OBJECTIVE: To quantify the association between early neurologic recovery, practice pattern variation, and endotracheal intubation during established status epilepticus, we performed a secondary analysis within the cohort of patients enrolled in the Established Status Epilepticus Treatment Trial (ESETT). METHODS: We evaluated factors associated with the endpoint of endotracheal intubation occurring within 120 minutes of ESETT study drug initiation. We defined a blocked, stepwise multivariate regression, examining 4 phases during status epilepticus management: (1) baseline characteristics, (2) acute treatment, (3) 20-minute neurologic recovery, and (4) 60-minute recovery, including seizure cessation and improving responsiveness. RESULTS: Of 478 patients, 117 (24.5%) were intubated within 120 minutes. Among high-enrolling sites, intubation rates ranged from 4% to 32% at pediatric sites and 19% to 39% at adult sites. Baseline characteristics, including seizure precipitant, benzodiazepine dosing, and admission vital signs, provided limited discrimination for predicting intubation (area under the curve [AUC] 0.63). However, treatment at sites with an intubation rate in the highest (vs lowest) quartile strongly predicted endotracheal intubation independently of other treatment variables (adjusted odds ratio [aOR] 8.12, 95% confidence interval [CI] 3.08-21.4, model AUC 0.70). Site-specific variation was the factor most strongly associated with endotracheal intubation after adjustment for 20-minute (aOR 23.4, 95% CI 6.99-78.3, model AUC 0.88) and 60-minute (aOR 14.7, 95% CI 3.20-67.5, model AUC 0.98) neurologic recovery. CONCLUSIONS: Endotracheal intubation after established status epilepticus is strongly associated with site-specific practice pattern variation, independently of baseline characteristics, and early neurologic recovery and should not alone serve as a clinical trial endpoint in established status epilepticus. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov Identifier: NCT01960075.

Quantifying Activity Levels After Sport-Related Concussion Using Actigraph and Mobile (mHealth) Technologies.

CONTEXT: Interest in identifying the effects of physical and mental activity on recovery after sport-related concussion is growing. Clinical studies of concussed athletes' activities require well-validated methods for tracking their intensity and timing. OBJECTIVE: To develop and validate a novel multimodal approach to monitoring activity postconcussion using mobile (mHealth) technologies. DESIGN: Cohort study. SETTING: Translational research unit. PATIENTS OR OTHER PARTICIPANTS: A total of 40 high school and collegiate football players were evaluated at preseason and followed longitudinally after either concussion (n = 25; age = 17.88 ± 1.74 years, height = 182.07 ± 8.08 cm, mass = 98.36 ± 21.70 kg) or selection as a nonconcussed control (n = 15; age = 18.27 ± 1.83 years, height = 180.01 ± 7.19 cm, mass = 93.83 ± 24.56 kg). MAIN OUTCOME MEASURE(S): Participants wore a commercial actigraph and completed a daily mobile survey for 2 weeks. Analyses focused on comparisons between groups for actigraph-based physical activity and self-reported physical and mental activity during the follow-up period. RESULTS: For the first 2 days postinjury, objective measures showed fewer daily steps in concussed (6663 ± 2667 steps) than in control (11 148 ± 3381 steps) athletes (P < .001), and both objective and self-reported measures indicated less moderate to vigorous physical activity in concussed (27.6 ± 32.6 min/d and 25.0 ± 43.6 min/d, respectively) than in control (57.3 ± 38.6 min/d and 67.5 ± 40.1 min/d, respectively) athletes (both P values < .05). Correlations between objective and self-reported measures of moderate to vigorous physical activity were moderate across select 1-week and 2-week averages. We observed no group differences in self-reported mental activities. CONCLUSIONS: Physical activity after sport-related concussion varied widely across athletes but on average was reduced during the acute and early subacute postinjury periods for both objective and self-reported measures. The lack of differences in mental activities between groups may reflect limited change in mental exertion postconcussion or difficulty accurately measuring mental activities. Assessing concussed athletes' activities using actigraphy and self-reported scales may help monitor their compliance with activity recommendations and be useful in studies aimed at better understanding the effects of physical activity on concussion recovery.

Onychomadesis as a Late Complication of Hand-Foot-Mouth Disease: A Case Series Shedding Light on Nail Shedding.

Hand-foot-mouth disease is a viral illness frequently caused by enterovirus and coxsackievirus. Traditionally, this disease initially causes malaise, fever, and rash with vesicles in the mouth, as well as on the hands and feet. Occasionally, more severe presentations and late postinfectious sequelae occur, including onychomadesis, nail matrix arrest. We describe a series of 4 cases of onychomadesis and its evaluation following recent hand-foot-mouth disease during this current enteroviral season as a way to ensure appropriate clinician diagnosis and guidance.

The Effectiveness of Prescribed Rest Depends on Initial Presentation After Concussion.

OBJECTIVE: To evaluate if patients with signs of injury respond differently to prescribed rest after concussion compared with patients with symptoms only. STUDY DESIGN: Secondary analysis was completed of a prospective randomized controlled trial (NCT01101724) of pediatric concussion patients aged 11-18 years. Patients completed computerized neurocognitive testing and standardized balance assessment at the emergency department within 24 hours of injury and on follow-up (3 and 10 days). Patients were randomized to rest or usual care and completed activity and symptom diaries for 10 days after injury. A series of 2?×?2 ANOVAs with grouping factors of patient group (symptoms, signs) and treatment arm (prescribed rest, standard of care) were used to examine differences on clinical measures. Univariate nonparametric test (ie, ?2 with ORs and 95% CIs) was used to examine the association between treatment arm and symptom status 1-9 days after injury. RESULTS: A 2?×?2 factorial ANOVA revealed a significant patient group × treatment arm interaction for symptom score at 3 days after injury (F?=?6.31, P?=?.01, ?2?=?0.07). Prescribed rest increased the likelihood of still being symptomatic at days 1-6 and 8 (P?

Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015.

BACKGROUND: Conventional management for concussion involves prescribed rest and progressive return to activity. Recent evidence challenges this notion and suggests that active approaches may be effective for some patients. Previous concussion consensus statements provide limited guidance regarding active treatment. OBJECTIVE: To describe the current landscape of treatment for concussion and to provide summary agreements related to treatment to assist clinicians in the treatment of concussion. METHODS: On October 14 to 16, 2015, the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting was convened in Pittsburgh, Pennsylvania. Thirty-seven concussion experts from neuropsychology, neurology, neurosurgery, sports medicine, physical medicine and rehabilitation, physical therapy, athletic training, and research and 12 individuals representing sport, military, and public health organizations attended the meeting. The 37 experts indicated their agreement on a series of statements using an audience response system clicker device. RESULTS: A total of 16 statements of agreement were supported covering (1) Summary of the Current Approach to Treating Concussion, (2) Heterogeneity and Evolving Clinical Profiles of Concussion, (3) TEAM Approach to Concussion Treatment: Specific Strategies, and (4) Future Directions: A Call to Research. Support (ie, response of agree or somewhat agree) for the statements ranged from to 97% to 100%. CONCLUSION: Concussions are characterized by diverse symptoms and impairments and evolving clinical profiles; recovery varies on the basis of modifying factors, injury severity, and treatments. Active and targeted treatments may enhance recovery after concussion. Research is needed on concussion clinical profiles, biomarkers, and the effectiveness and timing of treatments. ABBREVIATIONS: ARS, audience response systemCDC, Centers for Disease Control and PreventionDoD, Department of DefensemTBI, mild traumatic brain injuryNCAA, National Collegiate Athletic AssociationNFL, National Football LeagueNIH, National Institutes of HealthRCT, randomized controlled trialRTP, return to playSRC, sport- and recreation-related concussionTBI, traumatic brain injuryTEAM, Targeted Evaluation and Active Management.

Activity-Related Symptom Exacerbations After Pediatric Concussion.

IMPORTANCE: Recovery from concussion generally follows a trajectory of gradual improvement, but symptoms can abruptly worsen with exertion. This phenomenon is poorly understood. OBJECTIVES: To characterize the incidence, course, and clinical significance of symptom exacerbations (spikes) in children after concussion. DESIGN, SETTING, AND PARTICIPANTS: This secondary analysis of clinical trial data analyzes 63 eligible participants prospectively recruited from an emergency department who were asked to complete a postconcussion symptom scale and record their activities in a structured diary for the next 10 days. They completed standardized assessments of symptoms (postconcussion symptom scale), cognition (Immediate Post-Concussion Assessment and Cognitive Testing), and balance (Balance Error Scoring System) 10 days following the injury. Eligible participants were aged 11 to 18 years and sustained a concussion (according to the Centers for Disease Control and Prevention criteria) that did not result in an abnormal computed tomography scan or require hospital admission. The trial was conducted from May 2010 to December 2012, and the analysis was conducted from November 2015 to February 2016. MAIN OUTCOME AND MEASURE: The occurrence of symptom spikes, defined as an increase of 10 or more points on the postconcussion symptom scale over consecutive days. RESULTS: Of the 63 participants, there were 41 boys (65.1%) and 22 girls (34.9%), and the mean (SD) age was 13.8 (1.8) years. Symptom spikes occurred in one-third of the sample (20 participants [31.7%]). Symptom spikes tended to partially resolve within 24 hours. An abrupt increase in mental activity (ie, returning to school and extracurricular activities) from one day to the next increased the risk of a symptom spike (relative risk, 0.81; 95% CI, 0.21-3.21), but most symptom spikes were not preceded by a documented increase in physical or mental activity. Patients with symptom spikes were initially more symptomatic in the emergency department and throughout the observation period but did not differ from the group without symptom spikes on cognition or balance 10 days following injury. CONCLUSIONS AND RELEVANCE: Certain patients appeared susceptible to high and variable symptom reporting. Symptom spikes may not themselves be detrimental to recovery. The present findings support clinical guidelines for adolescents to return to school and activities gradually after concussion. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01101724.

Identifying neurocognitive deficits in adolescents following concussion.

OBJECTIVES: This study of concussed adolescents sought to determine if a computer-based neurocognitive assessment (Immediate Postconcussion Assessment and Cognitive Test [ImPACT]) performed on patients who present to the emergency department (ED) immediately following head injury would correlate with assessments performed 3 to 10 days postinjury and if ED neurocognitive testing would detect differences in concussion severity that clinical grading scales could not. METHODS: A prospective cohort sample of patients 11 to 17 years of age presenting to the ED within 12 hours of a head injury were evaluated using two traditional concussion grading scales and neurocognitive testing. ED neurocognitive scores were compared to follow-up scores obtained at least 3 days postinjury. Postconcussive symptoms, outcomes, and complications were assessed via telephone follow-up for all subjects. RESULTS: Sixty patients completed phone follow-up. Thirty-six patients (60%) completed follow-up testing a median of 6 days postinjury. Traditional concussion grading did not correlate with neurocognitive deficits detected in the ED or at follow-up. For the neurocognitive domains of verbal memory, processing speed, and reaction time, there was a significant correlation between ED and follow-up scores trending toward clinical improvement. By 2 weeks postinjury, 23 patients (41%) had not returned to normal activity. At 6 weeks, six patients (10%) still had not returned to normal activity. CONCLUSIONS: Immediate assessment in the ED can predict neurocognitive deficits seen in follow-up and may be potentially useful to individualize management or test therapeutic interventions. Neurocognitive assessment in the ED detected deficits that clinical grading could not and correlated with deficits at follow-up.