Altered Oculomotor and Vestibulo-ocular Function in Children and Adolescents Postconcussion.

OBJECTIVE: To document (1) oculomotor (OM) and vestibulo-ocular (VO) function in children with concussion who were symptomatic at the time of assessment and to compare it with that in children with concussion who were clinically recovered (asymptomatic) and in children with no concussive injury, and (2) the extent to which OM and VO function relates to postconcussion symptom severity in injured children. SETTING: Participants were recruited from a concussion clinic or the community. PARTICIPANTS: A total of 108 youth with concussion (72 symptomatic; 36 recovered) and 79 healthy youth (aged 9-18 years). Youth with concussion were included if aged 9 to 18 years, had no previous concussion within the last 12 months, less than 90 days since injury, and no known existing visual disorders or learning disabilities. STUDY DESIGN: A prospective cross-sectional study. MAIN MEASURES: All participants were tested for OM and VO function with a commercial virtual reality (VR) eye-tracking system (Neuroflex®, Montreal,Québec, Canada). Participants in the concussion group who completed the postconcussion symptoms were scored with the Post-Concussion Symptom Inventory. RESULTS: There was a significant group effect for vergence during smooth pursuit (F2,176 = 10.90; P < .05), mean latency during saccades (F2,171 = 5.99; P = .003), and mean response delay during antisaccades (F2,177 = 9.07; P < .05), where children with symptomatic concussion showed poorer performance than clinically recovered and healthy children. Similar results were found in VO for average vestibular ocular reflex gain in the horizontal leftward (F2,168 = 7; P = .001) and rightward directions (F2,163 = 13.08; P < .05) and vertical upward (F2,147 = 7.60; P = .001) and downward directions (F2,144 = 13.70; P < .05). Mean saccade error was positively correlated to total Post-Concussion Symptom Inventory scores in younger clinically recovered children. CONCLUSION: VR eye tracking may be an effective tool for identifying OM and VO deficits in the subacute phase (<90 days) postconcussion.

Feasibility of Early Active Rehabilitation for Concussion Recovery in Youth: A Randomized Trial.

OBJECTIVE: The primary objective is to evaluate the feasibility (safety and acceptability) of implementing early active rehabilitation (AR) for concussion management in youth with symptoms persisting 2 weeks after injury. A secondary and exploratory objective was to estimate the potential efficacy of early AR compared with standard AR. We hypothesize that AR at 2-weeks postconcussion will be safe and acceptable to patients. DESIGN: Randomized clinical trial. SETTING: The Montreal Children's Hospital of the McGill University Health Center (MCH-MUHC), a tertiary care pediatric teaching hospital affiliated with McGill University in Montreal, Canada. PARTICIPANTS: Twenty youth aged 9 to 17 years old with postconcussion symptoms for at least 2 weeks. INTERVENTION: Active rehabilitation (aerobic exercise, coordination drills, visualization, and education/reassurance) was administered by physiotherapists in-person, and then continued as a home program. METHODS: Twenty participants were randomized to either early AR (initiated 2 weeks after injury) or standard AR (initiated 4 weeks after injury). RESULTS: Two adverse events (one in each group) were identified through an online survey more than one-month postconcussion. Postconcussion symptoms decreased over time for both groups. CONCLUSIONS: The results from this pilot study indicate that a full clinical trial estimating the efficacy of early AR (starting 2 weeks after injury) is feasible. Further study is needed to determine the superiority of this strategy over current treatment approaches.

Effectiveness of an Exercise-Based Active Rehabilitation Intervention for Youth Who Are Slow to Recover After Concussion.

OBJECTIVE: (1) To determine the impact of providing participants aged 8 to 17 years who are slow to recover after a concussion with a well-developed active rehabilitation intervention (ARI), compared with receiving standard care alone, on postconcussion symptoms (PCS) at 2 and 6 weeks after the initiation of ARI; and (2) to investigate functional recovery 6 weeks after initiation of ARI. DESIGN: A multicenter prospective quasi-experimental control group design. SETTING: Tertiary care pediatric trauma center and community health care providers. PARTICIPANTS: Forty-nine youth were enrolled (experimental n = 36; control n = 13). PROCEDURES: Participants were assessed on 3 different occasions: (1) initial visit (baseline); (2) 2 weeks; and (3) 6 weeks after enrollment. MAIN OUTCOME MEASURES: Child- and parent-reported PCS were obtained by the PCS Inventory Scale (primary outcome). Secondary outcomes included: (1) mood and anxiety; (2) quality of life; (3) energy level; (4) coordination and balance; (5) neurocognition; (6) parental anxiety; and (7) satisfaction with intervention. RESULTS: Both groups reported decrease of PCS over time (child: P = 0.01; parent: P = 0.03). Children in the experimental group presented higher quality of life (P = 0.04) and less anger (P = 0.02). A trend toward significance was observed for better tandem gait (P = 0.07) and for less general fatigue on self-reported PCS (P = 0.09) in the experimental group. CONCLUSIONS: Active rehabilitation intervention does not affect the PCS beyond the usual management, but it increases their quality of life, decreases anger, and potentially increases energy level and balance.

Effect of Sex on Recovery From Persistent Postconcussion Symptoms in Children and Adolescents Participating in an Active Rehabilitation Intervention.

OBJECTIVE: To estimate the extent to which biologic sex contributes to the severity of postconcussion symptoms (PCSs) in concussed youth, who are slow to recover and who receive an active rehabilitation intervention (ARI) as part of their standard care. SETTING: The concussion clinic of a pediatric trauma center in Canada. PARTICIPANTS: A total of 355 youth with persistent PCS (188 girls and 167 boys) as per the following criteria: (1) diagnosed with a concussion (or mild traumatic brain injury) as per the 2004 World Health Organization definition; (2) aged 8 to 17 years (mean = 14.34, standard deviation [SD] = 2.22 years); (3) presenting with at least 1 PCS interfering with daily activities (mean total PCS score at initial assessment = 24.50, SD = 18.88); and (4) on ARI 4 weeks postinjury (mean = 30.46, SD = 3.74 days). DESIGN: A retrospective analysis of a prospective cohort. MAIN MEASURES: PCS severity, measured by the PCS Scale (PCSS) included in the Sports Concussion Assessment Tool-3, was the dependent variable. PCSs were assessed 3 times over a 4-week period. RESULTS: Boys presented with significantly fewer symptoms than girls 4 weeks postinjury, at initiation of the ARI (PCSS total score mean: ♂ = 19.9, ♀ = 28.5, P < .001, confidence interval = -14.8 to -6.4), at 2 and 4 weeks of follow-up, but the rate of recovery was slightly faster for girls over the follow-up period. CONCLUSION: Despite differences between the PCSS score reduction after 4 weeks of intervention, our results favored to a slightly faster recovery for girls over the follow-up period. Although our findings are not strong enough to suggest distinct sex-specific intervention, both boys and girls benefit from participating in an ARI.

Is There an Optimal Time to Initiate an Active Rehabilitation Protocol for Concussion Management in Children? A Case Series.

OBJECTIVE: To estimate the time frame during which initiating an active rehabilitation intervention (aerobic exercise, balance, and sport specific skills) after concussion contributed to improvement in symptoms at follow-up in children and adolescents who are slow to recover (symptoms persisting beyond 2 weeks) from concussion. SETTING: Concussion clinic at a tertiary care pediatric teaching hospital. PARTICIPANTS: A total of 677 children and adolescents with concussion aged 7 to 18 years. DESIGN: Case series of participants starting active rehabilitation less than 2, 2, 3, 4, 5, or 6 or more weeks postconcussion. MAIN MEASURE: Symptom severity measured by the 22-item Post-Concussion Scale (PCS)-revised. RESULTS: All patients experienced significant improvement of symptoms while participating in active rehabilitation, irrespective of the start time postonset. Patients initiating active rehabilitation at 2 (P < .001) or 3 (P = .039) weeks postinjury demonstrated lower symptom severity at follow-up than those starting at 6 weeks or later. Patients starting at 2 weeks had lower symptom severity than patients starting less than 2 (P = .02), 4 (P = .20), or 5 weeks postinjury (P = .04). Lastly, patients starting less than 2 and 6 weeks or more postinjury yielded equivalent outcomes. CONCLUSIONS: The findings support the use of active rehabilitation in children and adolescents who are slow to recover from concussion. Participants starting active rehabilitation less than 2 weeks and up to 6 or more weeks postconcussion demonstrated significant symptom improvements, but improvement was observed in all groups, regardless of the time to start active rehabilitation.

An evaluation of the impact of FIFA World Cup on soccer emergency department injuries among Montreal adolescents.

AIM: The 'trickle-down effect', or how major sports events have a positive impact on sports participation, has been the subject of many studies, but none produced conclusive results. We took a different approach and rather than look at sports participation, we used injuries as a proxy and see if injuries increased, or remained the same, after the International Federation of Association Football World Cup. METHODS: Using a retrospective cohort design, we looked at the injuries suffered by males and females (13-16 years old) while playing team sports in Montreal, that occurred in May to July, from 1999 to 2014. Information reported by the Canadian Hospitals Injury Reporting Prevention Program (CHIRPP) was limited to the two CHIRPP centres in Montreal: the Montreal Children's Hospital and Hopital Sainte-Justine. RESULTS: In females, no significant trends were noticed. In males who played non-organised soccer, the percent changes between FIFA World Cup (WC) (June) and pre-FIFA WC (May) was always highest during FIFA WC years: 17.2% more injuries in years when FIFA WC was held compared to 1.3% less injuries during non-FIFA WC years. In non-organised soccer, male players suffered less strains/sprains (11.9% vs. 30.1%; P = 0.015), suffered more severe injuries (59.7% vs. 43.1%; P = 0.049) and more of their injuries were the results of direct contact with another player (26.8% vs. 13.3%; P = 0.028) during FIFA WC. CONCLUSION: FIFA WC seems to have an impact on the injuries of teenage boys when playing non-organised soccer. The impact was short-lived, only lasting during the FIFA WC event.

Evaluation of an active rehabilitation program for concussion management in children and adolescents.

OBJECTIVE: To estimate the extent to which post-concussion symptoms were influenced by participation in an Active Rehabilitation (AR) program (aerobic exercise, coordination drills, visualization and education) for children and adolescents who are slow to recover from concussion. A secondary exploratory objective included examining the influence of sex on symptom evolution. METHODS: Analysis of prospectively collected data was performed on 277 youth who initiated an AR program, between three and four weeks post-injury at a Concussion Clinic in a tertiary care paediatric teaching hospital. MAIN OUTCOME MEASURE: Post-concussion symptom scale (PCSS) from Sport Concussion Assessment Tool-3 (SCAT 3). RESULTS: Children and adolescents participating in an active rehabilitation program displayed improved post-concussion symptom severity at follow-up (median = 9.5) compared to pre-intervention (median = 18) (p < .05). Patients demonstrated improved physical, cognitive, emotional and sleep-related post-concussion symptoms (p < .05). Female sex was associated with an increased post-concussion symptom severity at follow-up. CONCLUSIONS: Youth experiencing persisting symptoms three to four weeks post-concussion demonstrated improved post-concussion symptoms scores (physical, cognitive, emotional and sleep related) with participation in an active rehabilitation program.

Pediatric post-traumatic headaches and peripheral nerve blocks of the scalp: a case series and patient satisfaction survey.

OBJECTIVE: This study's objective is to characterize the therapeutic effect of peripheral nerve blocks of the scalp for children and adolescents with post-traumatic headaches. BACKGROUND: Headaches are the most frequently reported persistent symptoms following a pediatric mild traumatic brain injury, may be challenging to treat, and can transform into debilitating chronic headaches. The beneficial use of peripheral nerve blocks of the scalp has been reported for adults with post-traumatic headaches. METHODS: Retrospective case series on all patients <18 years of age treated between January 2012 and June 2013 in the mild traumatic brain injury clinic with a nerve block. The main outcome measure was the proportion of patients with a good therapeutic effect, defined by the duration of the block being >24 hours and/or repeat blocks requested. A data extractor blinded to main outcome measures performed the chart review. A patient satisfaction survey was also sent to all patients to assess the recalled experience with the interventions received. RESULTS: A total of 62 nerve blocks were performed on 28 patients for 30 injuries that led to post-traumatic headaches. The mean (standard deviation) age was 14.6 (1.7) years. The first nerve blocks were performed a mean (standard deviation) of 70 (54.2) days post-injury. The therapeutic effect was good in 93% of patients with 71% reporting immediate complete relief of their headaches; the mean percent headache reduction was 94%. Most (91%) would recommend a nerve block for post-traumatic headaches. CONCLUSION: The ease with which peripheral nerve blocks of the scalp can be performed combined with the immediate relief experienced by patients makes them a potential addition to the armamentarium of headache management strategies for children and adolescent with post-traumatic headaches.

Ringette-related injuries in young female players.

OBJECTIVE: To document the injuries sustained during organized ringette games. DESIGN: Retrospective data. SETTING: Canadian Children's Hospital Emergency Department. PATIENTS: Information reported by the Canadian Hospitals Injury Reporting Prevention Program on the injuries of 494 female ringette players (age, 10-17 years) between 2004 and 2010. ASSESSMENT OF RISK FACTORS: The injuries (types, body part, and mechanisms) presenting to emergency departments were compared between the 4 levels of minor organized ringette. MAIN OUTCOME MEASURES: Proportions of injuries by diagnosis, body site, and mechanisms. RESULTS: The common injuries noted were contusions and head injuries, fractures of the upper extremities, and contusions to both lower and upper extremities. Hospitalizations after injury were rare (1.0%). Body contacts, intentional or incidental, accounted for 63% of all injuries. The actual ringette (rubber ring) was not involved in any injury. CONCLUSIONS: Even though all types of contact are forbidden in ringette, our research showed that in minor leagues, a significant proportion of the injuries were caused by body contact. As with regular ice hockey, enforcing policies regarding contacts, use of proper equipment, good maintenance (ice conditions should be checked regularly), and proper skill training should help diminish these types of injuries.

Definitive Care for Severely Injured Children in Quebec.

INTRODUCTION: Injury is the leading cause of death in children over the age of one in Canada, and remains the most common cause of death in Quebec pediatric patients. Indigenous communities are 3-4 times more likely to be affected by injuries than the national average. In Quebec, health centres can range from 30 to 1000 km away from the closest level I trauma center. METHODS: Descriptive analysis and multiple logistic regression were performed for severely injured pediatric trauma patients received at the Montreal Children's Hospital (MCH) over a ten-year period. Outcomes were compared between regional groups in Quebec using forward sortation areas. RESULTS: Two hundred and forty four pediatric patients presented to the MCH with major trauma between 2006 and 2016. Of those, 42% of patients resided in Montreal, 42% off-island, and 16% in Northern Quebec. Admission to the Intensive Care Unit (ICU) was required for 60% of off-island patients and 58% of Northern residents. The median length of hospital stay (LOS) was 5 days for off-island and 15 days for Northern patients. Most patients (78% off-island vs. 76% Northern Quebec) were discharged home. The overall mortality was 5%. In multiple regression analysis, residence in Northern Quebec was associated with increased incidence of longer than median length of stay compared to off-island patients (OR 2.78, 95%CI (1.12-7.29)) after adjusting for injury severity, operative intervention, age, and sex. CONCLUSION: ICU admission rate was similar among Northern and off-island populations. Patients from Northern Quebec appeared to have longer-than-median hospital length of stay. In-hospital mortality was infrequent and limited to on-island and off-island populations. A further exploration of this data is required to identify the "trauma deserts" and advocate for children involved in trauma in all areas of Quebec.

Tracking postural stability of children and adolescents after a concussion: sport-related versus non-sport-related concussion.

BACKGROUND: Although postural impairments have long been reported following a concussion in the pediatric population, we still know very little about who is more at risk of presenting those balance problems and how the mechanism of injury (sport vs non-sport) could influence balance problems after concussions. The purpose of this study was to compare balance function in children having sustained a sport-related (SRC) or non-sport-related (NSRC) concussion, to that of children with an orthopedic injury (OI) and to non-injured (NI), over a one-year period. METHODS: One-hundred and twelve participants were included in this study. Among them, 38 were concussed, with 27 having sustained a SRC; and 11 an NSRC, as well as 38 NI, and 36 OI. Balance function was evaluated at 2 weeks, 3 months, 6 months, and 12 months after a concussion, and at the same time intervals for the control groups. The balance subtest of the Bruininks-Oseretsky Test of Motor Proficiency (BOT2) and Timed Foam Test was used to measure postural instability. Concussion related symptoms were measured by the Post Concussion Symptom Scale (PCSS). RESULTS: There was an improvement in tandem standing on the balance beam (P=.02) and in single-leg standing (SL) on foam surface (P=.02) for all groups over a year. At the 2nd week, NSRC had more postural instability than NI during SL on the balance beam when eyes were closed (P =.01), and performed significantly worse than SRC (P =.01) and NI (P =.01) during SL on the foam surface. NSRC also reported more symptoms than SRC on PCSS (P < 0.001). In the 3rd month, NSRC still had lower performance than SRC in SL on foam surface (P =.01). CONCLUSIONS: Children sustaining a concussion outside of a sport seem to have higher levels of postural instability up to 3 months post-injury when compared to those injured in sport.

Lifetime History of Concussion Among Youth With ADHD Presenting to a Specialty Concussion Clinic.

Child and adolescent student athletes with attention-deficit/hyperactivity disorder (ADHD) report a greater lifetime history of concussion than those without ADHD. This case-control study compared youth with and without ADHD presenting for care at a specialty concussion clinic on their lifetime history of concussion. We hypothesized that a greater proportion of youth with ADHD would report a history of prior concussion. Archival clinical data from patients presenting to a specialty concussion clinic in Montreal, Québec, Canada between September 2015 and August 2019 were analyzed. The sample included 2,418 children and adolescents (age: M = 13.6, SD = 2.7, range 5-18 years; 50.9% girls), including 294 (12.2%) with ADHD and 2,124 (87.8%) without ADHD. The proportion with prior concussion among youth with ADHD (43.9%) was significantly greater than youth without ADHD [37.5%, χ2 = 4.41, p = 0.04, OR = 1.30, 95% confidence interval (CI): 1.02-1.67]. A significantly higher proportion of boys with ADHD had a prior concussion history (48.1%) than boys without ADHD [38.4%, χ2 = 5.33, p = 0.02, OR = 1.48 (95% CI: 1.06-2.09)], but this difference was not observed for girls (χ2 = 0.31, p = 0.58). Youth with ADHD did not differ with regard to their estimated longest duration of symptoms from a prior concussion (Z = 1.52, p = 0.13) and the proportion who reported taking longer than 28 days to recover from a prior concussion did not differ between those with ADHD (15.3%) and without ADHD (12.2%), χ2 = 2.20, p = 0.14. Among youth presenting to a specialty clinic, ADHD was associated with greater lifetime history of concussion but not a greater duration of symptoms from a prior injury.

Pediatric mock code curriculum: improving resident resuscitations.

OBJECTIVES: Resuscitation of the acutely ill child is a necessary skill for pediatric residents. The effects of a hospital-wide mock code program on involvement, anxiety, and leadership have not been studied. We hypothesized that after 1 year of mock codes, pediatric residents would report (1) increased participation, (2) decreased anxiety and increased comfort with knowledge, and (3) increased likelihood of leading and feeling capable of running a code. METHODS: In this cross-sectional study of pediatric residents, anonymous surveys evaluated involvement, comfort, and leadership in codes before and 1 year after a monthly mock code curriculum was incorporated into the resident educational curriculum. The survey measured residents' involvement in actual and mock codes and levels of anxiety, knowledge, and leadership ability during codes. RESULTS: Approximately 60 residents returned completed survey forms each year. Attendance and participation at actual codes were not significantly changed between years. For mock codes, there was a significant change (P < 0.001) in both observation and participation. After 1 year, residents reported a statistically significant increase in their comfort with knowledge during a code (odds ratio, 2.5; 95% confidence interval, 1.2-5.2). They also reported a decrease in anxiety and felt more capable of running a code, although these numbers were not statistically significant. CONCLUSIONS: One year after starting a mock code program, residents attended more mock codes and reported more comfort with knowledge in codes. A continued monthly mock code program will provide residents with critical skills training and experience and may translate into active participation, increased leadership, and decreased anxiety in actual codes.

Injuries in the time of COVID-19. / Les blessures au temps de la COVID-19.

INTRODUCTION: Research has shown that during the 2003 SARS pandemic, emergency department (ED) visits among the pediatric population decreased. We set out to investigate if this was also true for injury-related ED visits during the COVID-19 pandemic. METHODS: Using data from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), we looked at 28 years of injury-related ED visits at the Montreal Children's Hospital, a provincially designated Pediatric Trauma Centre. We compared data from a two-month period during the COVID-19 lockdown (16 March to 15 May) to the same period in previous years (1993-2019) to determine whether the 2020 decrease in ED visit numbers was unprecedented (i.e. a similar decrease had never occurred) for different age groups, nature of injuries, mechanisms and severity. RESULTS: The 2020 decrease was unprecedented across all age groups between 1993 and 2019. When compared with the 2015 to 2019 average, the decrease was smallest in children aged 2 to 5 years (a 35% decrease), and greatest in the group aged 12 to 17 years (83%). Motor vehicle collisions and sports-related injuries practically vanished during the COVID-19 lockdown. Surprisingly, more children aged 6 to 17 years presented with less urgent injuries during the COVID-19 lockdown than in previous years. CONCLUSION: As was the case with SARS in 2003, COVID-19 acted as a deterrent for pediatric ED visits. The lockdown in particular had a profound impact on injury-related visits. The de-confinement period will be monitored to determine the impact in both the short and the long term.

Active rehabilitation for children who are slow to recover following sport-related concussion.

PRIMARY OBJECTIVE: To present an innovative approach to the management of children who are slow to recover after a sport-related concussion. RESEARCH DESIGN: The article describes the underlying principles and the development of specific interventions for a new rehabilitation programme as well as preliminary data on pre- and post-rehabilitation changes in outcome measures. METHODS AND PROCEDURES: Development of the intervention was done using multiple perspectives including that of the literature, of experts in the field of traumatic brain injury and of experienced clinicians involved with the paediatric and adolescent MTBI clientele. A logic model was developed providing sound theoretical background to the intervention. The intervention was implemented and evaluated with a sample of 16 children and adolescents. MAIN OUTCOMES AND RESULTS: The presented cases suggest that involvement in controlled and closely monitored rehabilitation in the post-acute period may promote recovery in children and adolescents who present with atypical recovery following a concussion. All 16 of the children and adolescents who participated in the programme experienced a relatively rapid recovery and returned to their normal lifestyles and sport participation. CONCLUSIONS: A gradual, closely-supervised active rehabilitation programme in the post-acute period (i.e. after 1 month post-injury) appears promising to improve the care provided to children who are slow to recover.

Determining the accuracy of the Canadian Hospitals Injury Reporting and Prevention Program for the representation of the rates of mild traumatic brain injuries in Quebec. / Évaluation de l'exactitude du Système canadien hospitalier d'information et de recherche en prévention des traumatismes dans la représentation des taux de traumatismes crâniens légers au Québec.

INTRODUCTION: The recent rise in mild traumatic brain injuries (mTBI) in the pediatric population has been documented by many studies in Canada and the United States. The objective of our study was to compare mTBI rates from the Canadian Hospital Injury Reporting and Prevention Program (CHIRPP) in Montréal with population-based rates (Quebec mTBI rates). METHODS: We calculated CHIRPP's mTBI rates via two methods: (1) using all CHIRPP injuries as the denominator; and (2) using the number of children aged 0 to 17 years living within 5 km of either of two CHIRPP centres in Montréal as the denominator. We plotted CHIRPP's mTBI rates against the provincial rates and compared them according to sex and age. RESULTS: Whether using all CHIRPP injuries or the number of children aged 0 to 17 years living within 5 km of either CHIRPP centre in Montreal as the denominator, CHIRPP paralleled the fluctuations seen in Quebec's rates between 2003 and 2016. When stratifying by sex and age, CHIRPP was better at estimating the population-based rates for the youngest (0 to 4 years) and the oldest (13 to 17 years) age groups. CONCLUSION: CHIRPP in Montréal proved a valid tool for estimating the variations in rates of mTBI in the population. This suggests that CHIRPP could also be used to estimate population-based rates of other types of injuries.

Identifying the specific needs of adolescents after a mild traumatic brain injury: a service provider perspective.

PRIMARY OBJECTIVE: To identify the specific service needs of adolescents with mild traumatic brain injury (MTBI) and those of their parents through the perspective of expert service providers as well as to compare it to the perspective of adolescents and their parents obtained in a prior study. STUDY DESIGN: Qualitative design including a focus group held with experts in the field of adolescent TBI and a validation survey of other professionals. METHODS AND PROCEDURES: Eight experts from a variety of disciplines participated in a focus group where important needs of adolescents were discussed. Results were then validated through a questionnaire to 33 professionals. MAIN OUTCOMES AND RESULTS: Experts questioned through both methods are generally in agreement and acknowledge that adolescents are unique, but they often find them challenging. Like adolescents themselves, experts identify the need for information as the most important but are wary of offering too much detail and fear that this could encourage malingering of symptoms and problems. Service providers also recognize the importance of supporting adolescents and parents when returning to activities (school and physical activities). CONCLUSIONS: The notion that teens represent a specific group of consumers of healthcare services is supported by findings in this study. These results provide important information to those involved in the structuring of service provision to adolescents following MTBI.

Rates of concussions and minor head injuries in Quebec, 2003 and 2016, in children under 18 years old, and comparisons with Ontario's rates of mild traumatic brain injuries.

OBJECTIVES: Increases of mild traumatic brain injuries in children have been reported in the USA and Ontario over the past decade. The main objective of this study is to calculate the pediatric rates of mild traumatic brain injury in Quebec, and our second objective is to compare them with those in Ontario. METHODS: Analysts from the Régie de l'Assurance Maladie du Québec (RAMQ, Quebec Health Insurance Board) compiled tables, by age and sex, of all medical services for mild traumatic brain injuries (concussions and minor head injuries) between 2003 and 2016. Quebec's population rates were calculated and yearly graphs were plotted by age and sex. RESULTS: In Quebec, there were statistically significant increases in rates of mild traumatic brain injury (concussion and minor head injury) in older children: a 2.0-fold increase for those aged 13-17 years, and 1.4-fold increase for those aged 9-12 years. When only considering concussions, girls (13-17 years) had more concussions than boys in 2015 and 2016. The increase in the rates of concussion was significantly higher in Ontario than in Quebec: 4.4- vs. 2.2-fold increase. CONCLUSIONS: The recent increase in rates of mild traumatic brain injuries reported in the scientific literature has also been observed in Quebec. The fact that the rate of visits for mild traumatic brain injury, per person, remained the same from 2003 to 2016 suggests that the increase was not the result of parents seeking more medical services, but that more of them consulted when their child injured his/her head.

The Canadian Pediatric Mild Traumatic Brain Injury Common Data Elements Project: Harmonizing Outcomes to Increase Understanding of Pediatric Concussion.

A critical component for accelerating the clinical uptake of research data in the area of pediatric concussion or mild traumatic brain injury (MTBI) pertains to the establishment and utilization of common databases. The objective of the first phase of our CanPedCDE initiative was to agree upon pediatric common data elements (CDEs) that could best characterize children with MTBI over their recovery period. The selection of CDEs for our framework aimed to balance factors such as the comprehensiveness of outcomes collected, their applicability to diverse settings, as well as the costs associated with their use. Selection began by identifying relevant domains of functioning (e.g., post-concussion symptoms, attention, and balance). Two sources were used to make this process more efficient: 1) the World Health Organization International Classification of Functioning (ICF) Traumatic Brain Injury Core Set, and the U.S. National Institute of Neurological Disorders and Stroke Traumatic Brain Injury Common Data Elements, both of which had already suggested relevant domains to include in TBI research. The process was completed in two phases: 1) using an online survey of experts and 2) through an in-person consensus meeting. Measurement tools were also proposed that were best felt to capture these domains. Forty experts in MTBI in children from multiple health-related perspectives (e.g., emergency medicine, pediatrics, neurosurgery, nursing, physiotherapy, and neuroscience), as well as knowledge users, participated in the selection process. The final list of CDEs included 77 distinct areas of functioning, covering all categories of the ICF model. Outcome measures were attached to each element, when applicable. The CanPedCDE initiative addresses a significant limitation in MTBI research to date and may help both researchers and clinicians to organize and standardize their assessment of children and youth post-MTBI in order to move the field in promising directions.

Ecteinascidin-743 inhibits activated but not constitutive transcription.

Ecteinascidin-743 (ET-743) is a promising chemotherapeutic agent currently in Phase III clinical trials. Previous studies indicated a novel spectrum of activity for this agent, including transcriptional inhibition. Initially hypothesized to target a single transcription factor (NF-Y), we now show that ET-743 is a more general inhibitor of activated transcription. Induction of the Sp1-regulated p21 gene by Trichostatin A (TSA) was blocked by ET-743 at concentrations that had minimal effect on uninduced (constitutive) expression. Moreover, ET-743 blocked induction of Gal4 fusion proteins by TSA without affecting activation mediated by the fusion proteins in the absence of the inducer. Finally, microarray analysis of SW620 cells treated with TSA and/or ET-743 indicated that activation of TSA-responsive promoters was blocked by ET-743 with little affect on nonresponsive promoters. These results, taken together with previous reports, leads us to suggest a mechanism whereby ET-743 is a novel, potent, and general inhibitor of activated but not uninduced transcription.