"Who is the right patient?" Insights into decisions to transfer pediatric trauma patients.

OBJECTIVE: We aim to determine what variables may influence physician decision-making about transfer of pediatric patients from a Level III Trauma Center (L3TC) to a Pediatric Trauma Center (PTC). METHODS: Emergency L3TC physicians and PTC emergency physicians/TTLs were surveyed with clinical scenarios of children presenting to a L3TC with 5 injury parameters: age, hemodynamic status, GCS, intra-abdominal injury, femur/ pelvic fracture, and asked if the patient should be transferred to a PTC. Associations between parameters and physician demographics in the decision to transfer were examined. RESULTS: One hundred seven and 94 surveys were completed at L3TCs and PTCs, respectively. Parameters associated with decision to transfer: pelvic and GI tract injuries, GCS < 12, and age < 4 years. L3TCs were significantly less likely vs. PTCs to recommend transfer with femur fracture, solid organ / GI injury, or a GCS of <13. Increasing town size, access to an experienced surgeon, and formal training in emergency medicine among L3TC physicians were associated with a decision not to transfer. CONCLUSIONS: Injuries requiring potential surgery or critical care influenced the decision to transfer. For cases with lesser severity or older ages, input of L3TCs on developing triage criteria is vital to allow families to stay in their home communities while ensuring optimal clinical outcomes. TYPE OF STUDY: Prospective Cross Sectional Survey. LEVEL OF EVIDENCE: Level III.

Comorbid epilepsy in autism spectrum disorder: Implications of postnatal inflammation for brain excitability.

OBJECTIVE: In different cohorts, 5%-30% of individuals with autism spectrum disorder (ASD) also have epilepsy. The high co-occurrence of these disorders suggests that a common mechanistic link may exist. The underlying pathophysiology of this comorbidity remains unknown. To investigate the mechanism(s) involved in the pathogenesis of ASD and epilepsy, we developed and validated a novel mouse model that concurrently exhibits hallmark features of both disorders. METHODS: We utilized inbred BTBR T+ Itpr3tf/J (BTBR) mice that exhibit the core behavioral characteristics of ASD (ie, impaired sociability, altered vocalizations, and restricted interests). BTBR mice received a lipopolysaccharide (LPS) or sterile saline injection at postnatal day (P)7, P14, or P21. Cytokine expression was analyzed for interleukin (IL)-1ß, IL-10, IL-6, and tumor necrosis factor α in brain tissue of P7 and adult BTBR mice. Adult BTBR mice were behaviorally analyzed for seizure susceptibility, sociability, communication deficits, and motor stereotypies, and monitored using chronic video-electroencephalography (EEG). RESULTS: Adult male and female BTBR mice treated at P7-P14 with LPS were more sensitive to pentylenetetrazol-induced seizures than saline-treated controls. ASD-like behaviors and hippocampal cytokine levels were unchanged between P7 LPS-treated BTBR mice and controls. EEG recordings from the dorsal hippocampus revealed a significant increase in number and frequency of seizures over the 4-week recording period (P60-P88) in BTBR mice postnatally treated with LPS at P7. These results indicate the presence of a comorbid epileptic phenotype in BTBR mice. SIGNIFICANCE: These findings suggest that an early postnatal immune challenge can increase brain excitability in adult BTBR mice and reveal an underlying epilepsy phenotype. This novel animal model may enable the elucidation of specific molecular alterations that are associated with the concurrent presentation of ASD and epilepsy, which could facilitate the development of targeted therapies for individuals affected by this comorbidity.

Staying in the game: a pilot study examining the efficacy of protective headgear in an animal model of mild traumatic brain injury (mTBI).

PRIMARY OBJECTIVE: Rugby is one of the few contact sports that do not mandate protective headgear, possibly because studies have shown poor efficacy for protection related to concussion pathology with existing headguards. RESEARCH DESIGN: Following innovative material technology utilization to produce headgear believed to have protective capabilities, this study examined the effects of a soft-shell headgear constructed from a novel viscoelastic material, on both behaviour and serum biomarkers after high and average impact force mild traumatic brain injuries (mTBI). METHODS AND PROCEDURES: Seventy-five male Sprague Dawley rats were divided into five groups: control, average - 37G impact, with and without headgear, and high - 106G impact, with and without headgear. Rats were sacrificed at 3 or 48 hours and serum samples were analyzed for levels of TNF-α, NEF-L, and GFAP. Animals sacrificed at 48 hours also underwent testing for balance and motor coordination, and exploratory/locomotor behaviour. MAIN OUTCOMES AND RESULTS: The novel headgear offered significant protection against mTBI symptomology and biomarkers in the group that experienced an average impact force, but only moderated protection for the animals in the high impact group. CONCLUSIONS: This innovative headgear may prevent some of the negative sequel associated with concussion pathology.

Reducing the time interval between concussion and voluntary exercise restores motor impairment, short-term memory, and alterations to gene expression.

Despite the most common form of brain injury, there has been little progress in the prognosis and treatment of concussion/mild traumatic brain injury (mTBI). Current 'return-to-play' guidelines are conservative, deterring the initiation of physical and social activity until patients are asymptomatic; but the effects of post-injury exercise have not been adequately investigated. Therefore, this study examined the effects of voluntary exercise on concussion recovery. Using a translational rodent model of concussion, we examined the influence of exercise on injury-associated behaviours that comprise post-concussive syndrome (PCS) and gene expression changes (bdnf, dnmt1, Igf-1, pgc1-a, Tert) in prefrontal cortex and hippocampus. In addition, as we have previously demonstrated telomere length (TL) to be a reliable predictor of mTBI prognosis, TL was also examined. The results suggest that exercise initiated within 1-3 days post-concussion significantly improved motor and cognitive functioning, but had limited efficacy treating emotional impairments. What is more, when deprived of social interaction and exercise, a combination similar to clinical recommendations for rest until symptom resolution, animals did not recover and exhibited impairments similar to typical mTBI animals. Exercise aided in restoration of mTBI-induced modifications to gene expression in both brain regions. An inverse relationship between the exercise return interval and TL was identified, indicating greater recovery with acute exercise reinstatement. Although additional strategies may need to be employed for emotional functioning, these findings support re-evaluation of 'return-to-play' guidelines, suggesting that exercise is valuable for the treatment of concussion.