Utility of neurocognitive testing of mild traumatic brain injury in children treated and released from the emergency department.

PRIMARY OBJECTIVE: To assess feasibility and utility of neurocognitive testing of children evaluated and discharged from the ED with mild traumatic brain injury (MTBI). METHODS: Paediatric blunt trauma patients (aged 11-18 years) evaluated in the ED for MTBI and control patients with isolated lower extremity injury were prospectively enrolled. All patients were administered a validated neurocognitive test (ImPACT(©)). Wilcoxon sign rank tests were used to compare reported symptoms and neurocognitive performance between subjects and controls, as well as to matched normative data. RESULTS: Thirty-nine subjects and 46 controls were enrolled. The MTBI patients had a mean age of 13.9 years (53.8% male). An abnormal symptom score was reported in 89.7% of MTBI subjects (mean score = 29.4, normal ≤ 8), differing significantly (p < 0.05) from controls, in whom 39.1% demonstrated an abnormal score (mean score = 8.7). In all neurocognitive test domains, visual motor speed and reaction time, MTBI patients demonstrated lower scores than normative data (p < 0.05). CONCLUSIONS: Patients with MTBI were more likely than control subjects to have scores on any or all neurocognitive domains below the 25th percentile and 10th percentile. In the ED setting, acute neurocognitive testing of MTBI in children is feasible. This highlights the importance of structured follow-up for this treated and released population.

Behavioural characteristics associated with dog bites to children presenting to an urban trauma centre.

Children are the most frequent victims of dog bites presenting to hospital emergency departments (ED), but there are gaps in understanding of the circumstances of such bites. The objective of this study was to characterise the behavioural circumstances of dog bites by interviewing children ≤17 years (or parent proxies for children ≤6 years) presenting with dog bite injuries to The Children's Hospital of Philadelphia about the bite incident, its setting and associated interactions. Of 203 children enrolled, 51% were <7 years old and 55% were male. 72% of children knew the biting dog. Most bites to younger children occurred during positive interactions, initiated by the child, with stationary, familiar dogs, indoors. Most older bitten children had been active (eg, outdoors), unfamiliar with the dog and not interacting. Whereas face bites predominated (70%) in the younger group (<7 years), bites to extremities predominated (72%) in the older group. Recognition of the two distinctive behavioural and circumstantial subgroups of dog bites that emerged can lead to more effective prevention strategies.

Comparison of telephone with World Wide Web-based responses by parents and teens to a follow-up survey after injury.

OBJECTIVE: To identify sociodemographic factors associated with completing a follow-up survey about health status on the web versus by telephone, and to examine differences in reported health-related quality of life by method of response. DATA SOURCES/STUDY SETTINGS: Survey about child health status of 896 parents of children aged 0-17 years treated in a hospital emergency department or admitted for a traumatic brain injury or arm injury, and 227 injured adolescents aged 14-17 years. STUDY DESIGN: The main outcomes were characteristics of those who completed a follow-up survey on the web versus by telephone and health-related quality of life by method of response. PRINCIPAL FINDINGS: Email addresses were provided by 76.9 percent of parents and 56.5 percent of adolescents at baseline. The survey was completed on the web by 64.9 percent of parents and 40.2 percent of adolescents through email. Parents with email access who were Blacks, Hispanics, had lower incomes, and those who were not working were less likely to choose the web mode for completing the survey. Unlike adolescents, the amount of time for parents to complete the survey online was significantly shorter than completion by telephone. Differences by survey mode were small but statistically significant in some of the six functional outcome measures examined. CONCLUSIONS: Survey mode was associated with several sociodemographic characteristics. Sole use of web surveys could provide biased data.

Postconcussive symptoms in hospitalized pediatric patients after mild traumatic brain injury.

BACKGROUND: Mild traumatic brain injury (MTBI) is common in the pediatric population. The symptom complex that might be expected in children after MTBI is not well documented. We sought to clarify the frequency and severity of concussive symptoms reported by children who required hospitalization for MTBI. METHODS: Pediatric blunt trauma patients (age, 11-17 years) admitted for treatment of MTBI (GCS 14-15) were prospectively enrolled over a 2-year period. Consented patients were administered a 22-question Likert-based concussion symptom scale (normal, total score 0-8). The symptom scale was repeated at the time of routine follow-up trauma clinic visit. The frequency and severity of concussive symptoms were analyzed at both time-points. RESULTS: For the 2-year period, 116 children participated in the study including 63 who returned for clinic follow-up. The overall population had mean age of 14.1 years (median 14) and was 69.8% male. The mean symptom score (sum of Likert scores [scale 0-6] for 22 questions) was 27.9 (median, 23.5) at hospitalization and 9.2 (median, 4.0) at follow-up. An abnormal symptom score (>8) was reported in 83.6% of hospitalized patients and 38.1% at follow-up. Girls had a significantly higher mean symptom score at initial testing than boys (33.9 vs 25.3, respectively; P < .05). This difference disappeared by the time of follow-up (girls 9.2 vs boys 9.1, P = .98) The most common initial symptom was headache (71.5% of patients) and most severe (highest mean score) was fatigue (mean, 2.0; median, 2.0). At follow-up, the most common symptom was excess sleep (38.1%) and most severe symptom falling asleep (mean, 1.0; median, 0). There were no significant differences in initial scores based on reported loss of consciousness, prior concussion history, or GCS 14 vs 15. CONCLUSIONS: Symptoms after MTBI are quite common at the time of hospitalization. Symptom scores improve to near normal for most by outpatient follow-up. The most common symptom was headache, but the most severe was fatigue, in this hospitalized pediatric population. Thoughtful assessment and follow-up of this patient population are warranted.

The health-related quality of life of children with an extremity fracture: a one-year follow-up study.

PURPOSE: To document the health-related quality of life (HRQOL) of children with an extremity fracture at 3 and 12 months postinjury and to determine whether it varies significantly by fracture region and site. METHODS: Children hospitalized for an extremity fracture at 4 pediatric trauma centers were studied. A baseline, 3-month, and 12-month telephone interview were completed by a primary caregiver to measure the child's HRQOL using the Pediatric Quality of Life Inventory (PedsQL). HRQOL was modeled as a function of injury, patient, and family characteristics using a longitudinal regression model. RESULT: Of the 100 children enrolled, 52 sustained a lower extremity fracture (LEF) and 48 an upper extremity fracture (UEF). Postinjury HRQOL scores were significantly poorer than preinjury scores for all subjects (P = 0.05). In addition, a significant proportion of subjects reported impaired physical and psychosocial HRQOL at 3 (44% and 46%, respectively) and 12 months (23% and 33%, respectively) postinjury. At 3 months postinjury, children with an LEF had significantly poorer HRQOL outcomes compared to children with a UEF. By 12 months postinjury, the physical function of children with a tibia and/or fibula fracture remained significantly lower than children with a UEF (P < or = 0.05). CONCLUSIONS: Children hospitalized for an extremity fracture suffered dramatic declines in physical and psychosocial well-being during the first 3 months postinjury. By 1 year postinjury, most children recovered; however, children with a tibia and/or fibula fracture still reported significantly poorer physical functioning.

Effective radiation dose from radiologic studies in pediatric trauma patients.

Evaluation of the pediatric trauma patient frequently requires radiologic studies. Although low-dose radiation from diagnostic radiology is considered safe, lifetime risks per unit dose of radiation are increased in children compared to adults. The total effective dose of radiation to a typical pediatric trauma patient is unknown. We sought to estimate the total effective dose of radiation related to the radiologic assessment of injured children admitted to a pediatric Level I trauma center. We reviewed the radiology records of all children admitted directly to a trauma center in 2002 and tabulated all plain films, computed tomograms, angiographic/fluoroscopic studies, and nuclear medicine studies. Using age-adjusted effective doses (which incorporate biologic effects of radiation), we computed each patient's total effective dose of radiation. Of 506 admitted patients, 394 (78%) underwent at least one radiologic study. The mean total effective dose per patient was 14.9 mSv (median: 7.2 mSv; interquartile range: 2.2-27.4 mSv). On average, computed tomography accounted for 97.5% of total effective dose. Age and injury severity score did not predict total effective dose. We conclude that in pediatric trauma patients, the estimated total effective dose of radiation varied widely. Computed tomography contributed virtually the entire total effective dose. Regarding radiographic evaluation of pediatric trauma patients, the risks and benefits of current practices should continue to be evaluated critically, because lifetime risks associated with radiation exposure are inversely proportional to age at exposure.