Angela K. Lumba-Brown

All Publications

• Using Machine Learning to Discover Traumatic Brain Injury Patient Phenotypes: National Concussion Surveillance System Pilot Waltzman, D., Daugherty, J., Peterson, A., Lumba-Brown, A. LIPPINCOTT WILLIAMS & WILKINS. 2024: E268-E269

  View details for Web of Science ID 001290640900036

• Anxiety and Mood Disruption in Collegiate Athletes Acutely Following Mild Traumatic Brain Injury. Diagnostics (Basel, Switzerland) Zhang, R., Martyna, M., Cornwell, J., Teramoto, M., Selfridge, M., Brown, A., Ghajar, J., Lumba-Brown, A. 2024; 14 (12)

  Abstract

  To report the symptom burden of anxiety and mood-related indicators following mTBI in collegiate student-athletes.Retrospective cohort study of varsity collegiate athletes.University sports medicine at a tertiary care center.Division I college varsity athletes diagnosed with mTBI at a single institution between 2016 and 2019.Pre- and post-injury.Comparisons between baseline testing and post-mTBI symptom scale assessments were made to determine changes in scores at the individual and group levels. The primary outcome was the prevalence of post-mTBI symptoms from within 72 h of injury through return to play. Associations with sport, sex, age, and return-to-play time were included.Compared to baseline, mood and anxiety symptom scores were significantly higher acutely following mTBI (2.1 ± 3.3 vs. 14.3 ± 12.2; p < 0.001). A family history of migraine was significantly associated with higher mood and anxiety symptom scores (20.0 ± 14.9 with history vs. 13.3 ± 11.3 without history; p = 0.042). Mood and anxiety symptom scores were highly correlated with non-mood and anxiety symptom scores for all athletes, including the subgroup with prolonged symptoms (r = 0.769; p < 0.001).Symptoms of anxiety or mood disruption are common during the acute period post-injury in varsity college athletes. Risk factors for higher symptom reports immediately following mTBI and for prolonged symptoms (>10 days) included female sex, those with a family history of migraine, and those with an overall higher symptom burden post-injury.

  View details for DOI 10.3390/diagnostics14121276

  View details for PubMedID 38928691

• Using machine learning to discover traumatic brain injury patient phenotypes: national concussion surveillance system Pilot. Brain injury Waltzman, D., Daugherty, J., Peterson, A., Lumba-Brown, A. 2024: 1-9

  Abstract

  The objective is to determine whether unsupervised machine learning identifies traumatic brain injury (TBI) phenotypes with unique clinical profiles.Pilot self-reported survey data of over 10,000 adults were collected from the Centers for Disease Control and Prevention (CDC)'s National Concussion Surveillance System (NCSS). Respondents who self-reported a head injury in the past 12 months (n = 1,364) were retained and queried for injury, outcome, and clinical characteristics. An unsupervised machine learning algorithm, partitioning around medoids (PAM), that employed Gower's dissimilarity matrix, was used to conduct a cluster analysis.PAM grouped respondents into five TBI clusters (phenotypes A-E). Phenotype C represented more clinically severe TBIs with a higher prevalence of symptoms and association with worse outcomes. When compared to individuals in Phenotype A, a group with few TBI-related symptoms, individuals in Phenotype C were more likely to undergo medical evaluation (odds ratio [OR] = 9.8, 95% confidence interval[CI] = 5.8-16.6), have symptoms that were not currently resolved or resolved in 8+ days (OR = 10.6, 95%CI = 6.2-18.1), and more likely to report at least moderate impact on social (OR = 54.7, 95%CI = 22.4-133.4) and work (OR = 25.4, 95%CI = 11.2-57.2) functioning.Machine learning can be used to classify patients into unique TBI phenotypes. Further research might examine the utility of such classifications in supporting clinical diagnosis and patient recovery for this complex health condition.

  View details for DOI 10.1080/02699052.2024.2352524

  View details for PubMedID 38722037

• Acute Eye-Tracking Changes Correlated With Vestibular Symptom Provocation Following Mild Traumatic Brain Injury. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine Uyeno, C., Zhang, R., Cornwell, J., Teramoto, M., Boo, M., Lumba-Brown, A. 2024

  Abstract

  To quantify norms and changes in eye-tracking proficiency, and determine vestibular symptom correlations in varsity college athletes following acute mild traumatic brain injury (mTBI). We hypothesized that mTBI impacts central coordination between the vestibular and oculomotor systems with resultant changes in eye-tracking proficiency that are correlated with vestibular symptom provocation.Retrospective cohort study.Sports medicine care at a single institution.One hundred and nineteen college athletes diagnosed with mTBI by a physician between 2013 and 2019.N/A.Standard deviation of tangential error, standard deviation of radian error, mean phase error, and horizontal gain from virtual reality-based, circular eye-tracking goggles used at baseline and within 72 hours post-mTBI. Headache, dizziness, nausea, and fogginess provocation after the Vestibular Ocular Motor Screening (VOMS) smooth pursuits subtest compared with pretest baseline, assessed within 72 hours post-mTBI.One hundred and nineteen college athletes (N = 56 women and 63 men) aged 18 to 24 years sustained a total of 177 mTBI. Forty-four percent of athletes displayed abnormal eye-tracking on at least 1 eye-tracking measure following acute mTBI compared with their baseline. From the VOMS, horizontal gain showed medium-sized to large-sized positive correlations with headache ( r = 0.34) and dizziness ( r = 0.54), respectively. Mean phase error showed a medium-sized negative correlation with nausea ( r = -0.32) on the VOMS.Eye-tracking proficiency was impaired and correlated with vestibular symptom provocation following acute mTBI in college athletes. Future research should examine eye-tracking proficiency testing in other acute care settings to support mTBI diagnosis.

  View details for DOI 10.1097/JSM.0000000000001223

  View details for PubMedID 38702871

• The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury. Archives of physical medicine and rehabilitation Silverberg, N. D., Iverson, G. L., ACRM Brain Injury Special Interest Group Mild TBI Task Force and the ACRM Mild TBI Definition Expert Consensus Group, A. B., Cogan, A., Dams-O'Connor, K., Delmonico, R., Graf, M. J., Iaccarino, M. A., Kajankova, M., Kamins, J., McCulloch, K. L., McKinney, G., Nagele, D., Panenka, W. J., Rabinowitz, A. R., Reed, N., Wethe, J. V., Whitehair, V., ACRM Mild TBI Diagnostic Criteria Expert Consensus Group, Anderson, V., Arciniegas, D. B., Bayley, M. T., Bazarian, J. J., Bell, K. R., Broglio, S. P., Cifu, D., Davis, G. A., Dvorak, J., Echemendia, R. J., Gioia, G. A., Giza, C. C., Hinds, S. R., Katz, D. I., Kurowski, B. G., Leddy, J. J., Sage, N. L., Lumba-Brown, A., Maas, A. I., Manley, G. T., McCrea, M., Menon, D. K., Ponsford, J., Putukian, M., Suskauer, S. J., van der Naalt, J., Walker, W. C., Yeates, K. O., Zafonte, R., Zasler, N. D., Zemek, R. 2023

  Abstract

  OBJECTIVE: To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings.DESIGN: Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus.PARTICIPANTS: The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations.RESULTS: The first two Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that 'the diagnostic label 'concussion' may be used interchangeably with 'mild TBI' when neuroimaging is normal or not clinically indicated.'CONCLUSIONS: New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care.

  View details for DOI 10.1016/j.apmr.2023.03.036

  View details for PubMedID 37211140

• Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition. Prehospital emergency care Lulla, A., Lumba-Brown, A., Totten, A. M., Maher, P. J., Badjatia, N., Bell, R., Donayri, C. T., Fallat, M. E., Hawryluk, G. W., Goldberg, S. A., Hennes, H. M., Ignell, S. P., Ghajar, J., Krzyzaniak, B. P., Lerner, E. B., Nishijima, D., Schleien, C., Shackelford, S., Swartz, E., Wright, D. W., Zhang, R., Jagoda, A., Bobrow, B. J. 2023: 1-32

  View details for DOI 10.1080/10903127.2023.2187905

  View details for PubMedID 37079803

• ACEP-SAEM Response to the National Institute of Health (NIH) proposal to simplify the review framework for research project grant applications. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Knack, S. K., Kim, H., Paxton, J., Garg, N., Brown, A. L., Levy, P., Puskarich, M., Silbergleit, R., D'Onofrio, G., Adeoye, O., Kang, C., Diercks, D., Neumar, R., Sharp, W. W. 2023

  View details for DOI 10.1111/acem.14730

  View details for PubMedID 36995344

• Neuroimaging for mild traumatic brain injury in children: cross-sectional study using national claims data. Pediatric radiology Waltzman, D., Miller, G. F., Patel, N., Sarmiento, K., Breiding, M., Lumba-Brown, A. 2023

  Abstract

  BACKGROUND: Current guidelines recommend healthcare professionals avoid routine use of neuroimaging for diagnosing mild traumatic brain injury (mTBI).OBJECTIVE: This study aimed to examine current use of CT and MRI among children and young adult patients with mTBI and factors that increase likelihood of neuroimaging in this population.MATERIALS AND METHODS: Data were analyzed using the 2019 MarketScan commercial claims and encounters database for the commercially insured population for both inpatient and outpatient claims. Descriptive statistics and logistic regression models for patients ≤24years of age who received an ICD-10-CM code indicative of a possible mTBI were analyzed.RESULTS: Neuroimaging was performed in 16.9% (CT; 95% CI=16.7-17.1) and 0.9% (MRI; 95% CI=0.8-0.9) of mTBI outpatient visits (including emergency department visits) among children (≤18years old). Neuroimaging was performed in a higher percentage of outpatient visits for patients 19-24years old (CT=47.1% [95% CI=46.5-47.6] and MRI=1.7% [95% CI=1.5-1.8]), and children aged 15-18years old (CT=20.9% [95% CI=20.5-21.2] and MRI=1.4% [95% CI=1.3-1.5]). Outpatient visits for males were 1.22 (95% CI=1.10-1.25) times more likely to include CT compared to females, while there were no differences by sex for MRI or among inpatient stays. Urban residents, as compared to rural, were less likely to get CT in outpatient settings (adjusted odds ratio [aOR]=0.55, 95% CI=0.53-0.57). Rural residents demonstrated a larger proportion of inpatient admissions that had a CT.CONCLUSIONS: Despite recommendations to avoid routine use of neuroimaging for mTBI, neuroimaging remained common practice in 2019.

  View details for DOI 10.1007/s00247-023-05633-6

  View details for PubMedID 36859687

• Multicentre evaluation of anxiety and mood among collegiate student athletes with concussion. BMJ open sport & exercise medicine Lumba-Brown, A., Teramoto, M., Zhang, R., Aukerman, D. F., Bohr, A. D., Harmon, K., Petron, D. J., Romano, R., Poddar, S. K., Ghajar, J. 2023; 9 (1): e001446

  Abstract

  Mental health problems are a premorbid and postinjury concern among college student athletes. Clinical phenotypes of anxiety and mood disruption are prevalent following mild traumatic brain injury, including concussion, a common sports injury. This work examined whether concussed student athletes with a history of mental health problems and higher symptoms of anxiety and mood disruption at baseline were more likely to have higher postinjury reports of mood and anxiety as well as prolonged resolution of postconcussive symptoms to near-baseline measures.This was a retrospective cohort study of a multi-institutional database of standardised baseline and postinjury assessments among college student athletes. Anxiety/mood evaluation data among varsity college athletes from four institutions over 1 year were measured and compared at baseline and postconcussion recovery using descriptive statistics and multilevel/mixed-effects analysis.Data from 2248 student athletes were analysed, with 40.6% reporting at least one symptom of anxiety and/or mood disruption at baseline. Of the 150 distinct concussions, 94.7% reported symptoms of anxiety/mood disruption during recovery (recovery time=0-96 days). Higher anxiety/mood scores at baseline were significantly associated with higher scores following concussion (p<0.001). Recovery trajectories of anxiety/mood scores showed different patterns by sex and prolonged recovery.Symptoms of anxiety and mood disruption are common at baseline among college student athletes. These students are at higher risk for symptomatology following injury, representing a screening cohort that may benefit from early counselling. Almost all student athletes will experience symptoms of anxiety and/or mood disruption following concussion.

  View details for DOI 10.1136/bmjsem-2022-001446

  View details for PubMedID 36756287

  View details for PubMedCentralID PMC9900064

• Firearm-Related Traumatic Brain Injury Homicides in the United States, 2000-2019. Neurosurgery Waltzman, D., Sarmiento, K., Daugherty, J., Lumba-Brown, A., Klevens, J., Miller, G. F. 2023

  Abstract

  BACKGROUND: Traumatic brain injury (TBI) is a leading cause of homicide-related death in the United States. Penetrating TBI associated with firearms is a unique injury with an exceptionally high mortality rate that requires specialized neurocritical trauma care.OBJECTIVE: To report incidence patterns of firearm-related and nonfirearm-related TBI homicides in the United States between 2000 and 2019 by demographic characteristics to provide foundational data for prevention and treatment strategies.METHODS: Data were obtained from multiple cause of death records from the National Vital Statistics System using Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database for the years 2000 to 2019. Number, age-adjusted rates, and percent of firearm and nonfirearm-related TBI homicides by demographic characteristics were calculated. Temporal trends were also evaluated.RESULTS: During the study period, there were 77602 firearm-related TBI homicides. Firearms were involved in the majority (68%) of all TBI homicides. Overall, men, people living in metro areas, and non-Hispanic Black persons had higher rates of firearm-related TBI homicides. The rate of nonfirearm-related TBI homicides declined by 40%, whereas the rate of firearm-related TBI homicides only declined by 3% during the study period. There was a notable increase in the rate of firearm-related TBI homicides from 2012/2013 through 2019 for women (20%) and nonmetro residents (39%).CONCLUSION: Firearm-related violence is an important public health problem and is associated with the majority of TBI homicide deaths in the United States. The findings from this study may be used to inform prevention and guide further research to improve treatment strategies directed at reducing TBI homicides involving firearms.

  View details for DOI 10.1227/neu.0000000000002367

  View details for PubMedID 36727717

• Journal update monthly top five. Emergency medicine journal : EMJ Saxena, M., Altamirano, J., Rose, C., Bennett, C., Govindarajan, P., Lumba-Brown, A., Hirst, R. 2022; 39 (7): 561-562

  View details for DOI 10.1136/emermed-2022-212603

  View details for PubMedID 35732304

• Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury. Neurotrauma reports Hawryluk, G. W., Selph, S., Lumba-Brown, A., Totten, A. M., Ghajar, J., Aarabi, B., Ecklund, J., Shackelford, S., Adams, B., Adelson, D., Armonda, R. A., Benjamin, J., Boone, D., Brody, D., Dengler, B., Figaji, A., Grant, G., Harris, O., Hoffer, A., Kitigawa, R., Latham, K., Neal, C., Okonkwo, D. O., Pannell, D., Rosenfeld, J. V., Rosenthal, G., Rubiano, A., Stein, D. M., Stippler, M., Talbot, M., Valadka, A., Wright, D. W., Davis, S., Bell, R. 2022; 3 (1): 240-247

  Abstract

  Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and healthcare costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries. A preliminary literature search revealed a need for updated guidelines, supported by the Brain Trauma Foundation. Methodologists experienced in TBI guidelines were recruited to support project development alongside two cochairs and a diverse steering committee. An expert multi-disciplinary workgroup was established and vetted to inform key clinical questions, to perform an evidence review and the development of recommendations relevant to pTBI. The methodological approach for the project was finalized. The development of up-to-date evidence- and consensus-based clinical care guidelines and algorithms for pTBI will provide critical guidance to care providers in the pre-hospital and emergent, medical, and surgical settings.

  View details for DOI 10.1089/neur.2022.0008

  View details for PubMedID 35919507

  View details for PubMedCentralID PMC9279118

• Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury NEUROTRAUMA REPORTS Hawryluk, G. J., Selph, S., Lumba-Brown, A., Totten, A. M., Ghajar, J., Aarabi, B., Ecklund, J., Shackelford, S., Adams, B., Adelson, D., Armonda, R. A., Benjamin, J., Boone, D., Brody, D., Dengler, B., Figaji, A., Grant, G., Harris, O., Hoffer, A., Kitigawa, R., Latham, K., Neal, C., Okonkwo, D. O., Pannell, D., Rosenfeld, J., Rosenthal, G., Rubiano, A., Stein, D. M., Stippler, M., Talbot, M., Valadka, A., Wright, D. W., Davis, S., Bell, R. 2022; 3 (1): 240-247

  View details for DOI 10.1089/neur.2022.0008

  View details for Web of Science ID 000813892800001

• Risk of Concussion After a Targeting Foul in Collegiate American Football. Orthopaedic journal of sports medicine Aukerman, D. F., Bohr, A. D., Poddar, S. K., Romano, R., Petron, D. J., Ghajar, J., Giza, C. C., Lumba-Brown, A., McQueen, M. B., Harmon, K. G. 2022; 10 (2): 23259671221074656

  Abstract

  Background: The targeting rule was adopted by the National Collegiate Athletic Association (NCAA) in 2008 to discourage dangerous contact during collegiate American football competition. Although targeting rules have been emphasized as a means to reduce concussion rates, there is currently no evidence that targeting plays are higher risk for concussion than other plays in American football.Purpose: To compare the rate of concussion occurring during targeting versus nontargeting plays in American collegiate football.Study Design: Cross-sectional study.Methods: Concussions occurring in games in the 2016-2019 Pac-12 Conference were classified as having occurred during either (1) a play where a targeting penalty was called or (2) all other plays. Targeting plays were further categorized to either those in which the call was upheld or those overturned by the on-field official after replay review. The number of targeting plays and the total number of plays during games were also recorded. Concussion incidence (per 1000 plays) and risk ratios were calculated.Results: Overall, 538 games with 68,670 plays were reviewed, during which 213 concussions occurred (15 during plays where targeting was called and 198 on other plays) and 141 targeting penalties were called. The incidence of concussion was 106.4/1000 plays for targeting plays (including 141.2/1000 upheld targeting fouls and 53.6/1000 overturned targeting fouls) and 2.9/1000 plays for nontargeting plays. The risk of concussion during targeting plays was 36.9 (95% CI, 22.4-60.7) times greater than that for all other plays. The risk of concussion during targeting plays upheld was 49.0 (95% CI, 28.5-84.2) times greater than that for all other plays.Conclusion: Concussion risk was significantly higher during plays in which targeting was called, especially those in which targeting fouls were upheld.Clinical Relevance: This study supports eliminating or reducing targeting from American football. The results of this study suggest that players should be screened for concussion after targeting plays are called.

  View details for DOI 10.1177/23259671221074656

  View details for PubMedID 35141342

• A Review of Implementation Concepts and Strategies Surrounding Traumatic Brain Injury Clinical Care Guidelines. Journal of neurotrauma Lumba-Brown, A., Prager, E. M., Harmon, N., McCrea, M., Bell, M. J., Ghajar, J., Pyne, S., Cifu, D. 2021

  Abstract

  Despite considerable efforts to advance the science surrounding traumatic brain injury (TBI), formal efforts supporting the current and future implementation of scientific findings within clinical practice and healthcare policy are limited. While many and varied guidelines inform the clinical management of TBI across the spectrum, clinicians and healthcare systems are not broadly adopting, implementing, and/or adhering to them. As part of the Brain Trauma Blueprint TBI State of the Science, an expert workgroup was assembled to guide this review article, which describes: 1) Possible etiologies of inadequate adoption and implementation; 2) Enablers to successful implementation strategies; and 3) Strategies to mitigate the barriers to adoption and implementation of future research.

  View details for DOI 10.1089/neu.2021.0067

  View details for PubMedID 34714147

• Sex Differences in Common Measures of Concussion in College Athletes. The Journal of head trauma rehabilitation Teramoto, M., Grover, E. B., Cornwell, J., Zhang, R., Boo, M., Ghajar, J., Lumba-Brown, A. 2021

  Abstract

  OBJECTIVE: Female athletes may be more likely to sustain a concussion and may vary in symptom presentation and neurocognitive impairments as compared with males. Scientific literature is limited by subjective assessments and underproportioned representation of women-the scope and etiology of sex-based differences are unknown. This study investigates sex-based differences in sports concussion assessments among college varsity athletes.DESIGN AND SETTING: Retrospective study of an institution's athletic head injury database.PARTICIPANTS: Acute postinjury and baseline data from 111 college athletes sustaining concussions between 2016 and 2018, diagnosed by a concussion specialist physician.MAIN OUTCOME MEASURES: Concussion assessments examined included the Sports Concussion Assessment Tool (SCAT5) and Vestibular Oculomotor Screening (VOMS) performed within 3 days (24-72 hours) of injury.RESULTS: No significant difference by sex was observed in the SCAT5 total symptom evaluation scores or severity scores, Standardized Assessment of Concussion, or Balance Error Scoring System (P > .05) within 3 days of head injury. Females did report more "pressure in the head" severity scores from baseline to postconcussion (2.7 ± 1.5 increased symptomatology in females vs 1.8 ± 1.3 increase in males, P = .007). The VOMS test resulted in significant sex differences in smooth pursuit [0.6 ± 1.4 increase in females (P < .001) vs 0.2 ± 0.6 increase in males (P = .364)], horizontal saccades [0.6 ± 1.2 increase in females (P < .001) vs 0.2 ± 0.5 increase in males (P = .149)], and vertical saccades [0.9 ± 1.9 increase in females (P < .001) vs 0.3 ± 0.7 increase in males (P = .206)].CONCLUSION: Our study did not show sex-based differences in baseline or acute postconcussive symptom reporting in most concussion assessment parameters, challenging previous research suggesting that females report more symptoms than males. Females did have significant differences in symptom provocation using the VOMS.

  View details for DOI 10.1097/HTR.0000000000000732

  View details for PubMedID 34698682

• The Other Side. Emergency medicine journal : EMJ Lumba-Brown, A. 2021

  View details for DOI 10.1136/emermed-2021-211939

  View details for PubMedID 34433616

• External Lumbar Drainage following Traumatic Intracranial Hypertension: A Systematic Review and Meta-Analysis. Neurosurgery Badhiwala, J., Lumba-Brown, A., Hawryluk, G. W., Ghajar, J. 2021

  Abstract

  BACKGROUND: Traumatic brain injury (TBI) often results in elevations in intracranial pressure (ICP) that are refractory to standard therapies. Several studies have investigated the utility of external lumbar drainage (ELD) in this setting.OBJECTIVE: To evaluate the safety and efficacy of ELD or lumbar puncture with regard to immediate effect on ICP, durability of the effect on ICP, complications, and neurological outcomes in adults with refractory traumatic intracranial hypertension.METHODS: A systematic review and meta-analysis were conducted beginning with a comprehensive search of PubMed/EMBASE. Two investigators reviewed studies for eligibility and extracted data. The strength of evidence was evaluated using GRADE methodology. Random-effects meta-analyses were performed to calculate pooled estimates.RESULTS: Nine articles detailing 6 studies (N=110) were included. There was moderate evidence that ELD has a significant immediate effect on ICP; the pooled effect size was -19.5mmHg (95% CI -21.0 to -17.9mmHg). There was low evidence to indicate a durable effect of ELD on ICP up to at least 24 h following ELD. There was low evidence to indicate that ELD was safe and associated with a low rate of clinical cerebral herniation or meningitis. There was very low evidence pertaining to neurological outcomes.CONCLUSION: Given preliminary data indicating potential safety and feasibility in highly selected cases, the use of ELD in adults with severe TBI and refractory intracranial hypertension in the presence of open basal cisterns and absence of large focal hematoma merits further high-quality investigation; the ideal conditions for potential application remain to be determined.

  View details for DOI 10.1093/neuros/nyab181

  View details for PubMedID 34171100

• Phenotyping the Spectrum of Traumatic Brain Injury: A Review and Pathway to Standardization. Journal of neurotrauma Pugh, M. J., Kennedy, E., Prager, E. M., Humpherys, J., Dams-O'Connor, K., Hack, D., McCafferty, M. K., Wolfe, J., Yaffe, K. C., McCrea, M., Ferguson, A. R., Lancashire, L., Ghajar, J., Lumba-Brown, A. 2021

  Abstract

  It is widely appreciated that the spectrum of traumatic brain injury (TBI), mild through severe, contains distinct clinical presentations, variably referred to as subtypes, phenotypes, and/or clinical profiles. As part of the Brain Trauma Blueprint TBI State of the Science, we review the current literature on TBI phenotyping with an emphasis on unsupervised methodological approaches, and describe five phenotypes that appear similar across reports. However, we also find the literature contains divergent analysis strategies, inclusion criteria, findings, and use of terms. Further, while some studies delineate phenotypes within a specific severity of TBI, others derive phenotypes across the full spectrum of severity. Together, these facts confound direct synthesis of findings. To overcome this, we introduce PhenoBench, a freely available code repository for the standardization and evaluation of raw phenotyping data. With this review and toolset, we provide a pathway towards robust, data-driven phenotypes that can capture the heterogeneity of TBI, enabling reproducible insights and targeted care.

  View details for DOI 10.1089/neu.2021.0059

  View details for PubMedID 33858210

• CDC Guideline on Mild Traumatic Brain Injury in Children: Important Practice Takeaways for Sports Medicine Providers CLINICAL JOURNAL OF SPORT MEDICINE Sarmiento, K., Waltzman, D., Lumba-Brown, A., Yeates, K. O., Putukian, M., Herring, S. 2020; 30 (6): 612–15

  View details for DOI 10.1097/JSM.0000000000000704

  View details for Web of Science ID 000587794700023

• Mentoring Pediatric Victims of Interpersonal Violence Reduces Recidivism JOURNAL OF INTERPERSONAL VIOLENCE Lumba-Brown, A., Batek, M., Choi, P., Keller, M., Kennedy, R. 2020; 35 (21-22): 4262–75

  View details for DOI 10.1177/0886260517705662

  View details for Web of Science ID 000561986300004

• Smooth Pursuit Eye-Movement Abnormalities Associated With Cervical Spine Whiplash: A Scientific Review and Case Report. Cureus Boo, M., Matheson, G., Lumba-Brown, A. 2020; 12 (8): e9872

  Abstract

  Whiplash injuries may disrupt normal cervical afferent and efferent projections. Oculomotor abnormalities have been reported in chronic whiplash cases, but there is limited knowledge of their presence in acute whiplash and how acute assessment may target early intervention. We present a literature review and case study of a 22-year-old female presenting with an acute concussion and whiplash secondary to a high-speed motor vehicle collision. Smooth pursuit eye-movement abnormalities were observed in relative cervical rotation in the setting of clinical examination of cervicogenic dysfunction. Treatment was focused on cervical manual therapy. While concussive symptoms resolved after seven days, eye-tracking showed a mild improvement and continued to exist in relationship with cervicogenic dysfunction. After completing physical therapy twice weekly for two weeks and in-home exercises, clinical signs and symptoms of whiplash-associated cervicogenic dysfunction and abnormal smooth pursuit eye-movement resolved across all cervical positions. This case highlights the need for ocular-motor impairment assessment following acute whiplash, specifically during cervical rotation. Early intervention should focus on cervical manual therapy and may be important in supporting altered cervical afferents causing oculomotor dysfunctions following acute whiplash.

  View details for DOI 10.7759/cureus.9872

  View details for PubMedID 32963912

  View details for PubMedCentralID PMC7500708

• Smooth Pursuit Eye-Movement Abnormalities Associated With Cervical Spine Whiplash: A Scientific Review and Case Report CUREUS Boo, M., Matheson, G., Lumba-Brown, A. 2020; 12 (8)

  View details for DOI 10.7759/cureus.9872

  View details for Web of Science ID 000560709500014

• Efficacy of levetiracetam, fosphenytoin, and valproate for established status epilepticus by age group (ESETT): a double-blind, responsive-adaptive, randomised controlled trial. Lancet (London, England) Chamberlain, J. M., Kapur, J., Shinnar, S., Elm, J., Holsti, M., Babcock, L., Rogers, A., Barsan, W., Cloyd, J., Lowenstein, D., Bleck, T. P., Conwit, R., Meinzer, C., Cock, H., Fountain, N. B., Underwood, E., Connor, J. T., Silbergleit, R. 2020; 395 (10231): 1217-1224

  Abstract

  Benzodiazepine-refractory, or established, status epilepticus is thought to be of similar pathophysiology in children and adults, but differences in underlying aetiology and pharmacodynamics might differentially affect response to therapy. In the Established Status Epilepticus Treatment Trial (ESETT) we compared the efficacy and safety of levetiracetam, fosphenytoin, and valproate in established status epilepticus, and here we describe our results after extending enrolment in children to compare outcomes in three age groups.In this multicentre, double-blind, response-adaptive, randomised controlled trial, we recruited patients from 58 hospital emergency departments across the USA. Patients were eligible for inclusion if they were aged 2 years or older, had been treated for a generalised convulsive seizure of longer than 5 min duration with adequate doses of benzodiazepines, and continued to have persistent or recurrent convulsions in the emergency department for at least 5 min and no more than 30 min after the last dose of benzodiazepine. Patients were randomly assigned in a response-adaptive manner, using Bayesian methods and stratified by age group (<18 years, 18-65 years, and >65 years), to levetiracetam, fosphenytoin, or valproate. All patients, investigators, study staff, and pharmacists were masked to treatment allocation. The primary outcome was absence of clinically apparent seizures with improved consciousness and without additional antiseizure medication at 1 h from start of drug infusion. The primary safety outcome was life-threatening hypotension or cardiac arrhythmia. The efficacy and safety outcomes were analysed by intention to treat. This study is registered in ClinicalTrials.gov, NCT01960075.Between Nov 3, 2015, and Dec 29, 2018, we enrolled 478 patients and 462 unique patients were included: 225 children (aged <18 years), 186 adults (18-65 years), and 51 older adults (>65 years). 175 (38%) patients were randomly assigned to levetiracetam, 142 (31%) to fosphenyltoin, and 145 (31%) were to valproate. Baseline characteristics were balanced across treatments within age groups. The primary efficacy outcome was met in those treated with levetiracetam for 52% (95% credible interval 41-62) of children, 44% (33-55) of adults, and 37% (19-59) of older adults; with fosphenytoin in 49% (38-61) of children, 46% (34-59) of adults, and 35% (17-59) of older adults; and with valproate in 52% (41-63) of children, 46% (34-58) of adults, and 47% (25-70) of older adults. No differences were detected in efficacy or primary safety outcome by drug within each age group. With the exception of endotracheal intubation in children, secondary safety outcomes did not significantly differ by drug within each age group.Children, adults, and older adults with established status epilepticus respond similarly to levetiracetam, fosphenytoin, and valproate, with treatment success in approximately half of patients. Any of the three drugs can be considered as a potential first-choice, second-line drug for benzodiazepine-refractory status epilepticus.National Institute of Neurological Disorders and Stroke, National Institutes of Health.

  View details for DOI 10.1016/S0140-6736(20)30611-5

  View details for PubMedID 32203691

  View details for PubMedCentralID PMC7241415

• Emergency department treatment of asthma in children: A review JACEP Open Lee, M. O., Sivasankar, S., Pokrajac, N., Smith, C., Lumba-Brown, A. 2020

  View details for DOI 10.1002/emp2.12224

• Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations. Neurosurgery Hawryluk, G. W., Rubiano, A. M., Totten, A. M., O'Reilly, C. n., Ullman, J. S., Bratton, S. L., Chesnut, R. n., Harris, O. A., Kissoon, N. n., Shutter, L. n., Tasker, R. C., Vavilala, M. S., Wilberger, J. n., Wright, D. W., Lumba-Brown, A. n., Ghajar, J. n. 2020

  Abstract

  When the fourth edition of the Brain Trauma Foundation's Guidelines for the Management of Severe Traumatic Brain Injury were finalized in late 2016, it was known that the results of the RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) randomized controlled trial of decompressive craniectomy would be public after the guidelines were released. The guideline authors decided to proceed with publication but to update the decompressive craniectomy recommendations later in the spirit of "living guidelines," whereby topics are updated more frequently, and between new editions, when important new evidence is published. The update to the decompressive craniectomy chapter presented here integrates the findings of the RESCUEicp study as well as the recently published 12-mo outcome data from the DECRA (Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury) trial. Incorporation of these publications into the body of evidence led to the generation of 3 new level-IIA recommendations; a fourth previously presented level-IIA recommendation remains valid and has been restated. To increase the utility of the recommendations, we added a new section entitled Incorporating the Evidence into Practice. This summary of expert opinion provides important context and addresses key issues for practitioners, which are intended to help the clinician utilize the available evidence and these recommendations. The full guideline can be found at: https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/.

  View details for DOI 10.1093/neuros/nyaa278

  View details for PubMedID 32761068

• Post-concussion symptom burden in children following motor vehicle collisions. Journal of the American College of Emergency Physicians open Lumba-Brown, A. n., Tang, K. n., Yeates, K. O., Zemek, R. n. 2020; 1 (5): 938–46

  Abstract

  Motor vehicle collisions generate considerable transmitted forces resulting in traumatic brain injury in children presenting to emergency departments (EDs). To date, no large study has examined post-concussive symptoms in children sustaining concussions in motor vehicle collisions. This study aimed to compare trends in acute post-concussive symptom burden in children with concussion following motor vehicle collisions as compared to other injury mechanisms.The study is a secondary analysis of the Predicting Persistent Post-concussive Problems in Pediatrics study, which prospectively recruited a multicenter cohort of 3029 children 5-17 years of age presenting to the ED with concussion from 2013-2015. Post-concussive symptom ratings were obtained at pre-specified time points for 12 weeks post-injury, using the validated Post-Concussion Symptom Inventory (PCSI). Symptom severity and recovery trajectories were measured using delta scores on the PCSI (mean post-injury symptom score minus perceived pre-injury score). A multivariable, longitudinal model evaluated the adjusted effect of mechanism of injury (motor vehicle collisions vs other mechanisms) on mean symptom scores, compared to perceived pre-injury reports, and the temporal change in mean scores over during recovery.Of 3029 study participants, 56 (1.8%) sustained concussion from motor vehicle collisions. Children sustaining concussion in a motor vehicle collision had lower post-concussive symptom scores upon ED presentation, measured as differences from their perceived pre-injury reports, as compared to other injury mechanisms (-0.36 [95% confidence interval (CI) = -0.58, -0.15]). However, the motor vehicle collisions group showed the smallest decline in symptom burden over 1 month following injury (-0.54 [95% CI = -0.81, -0.27]).Children sustaining concussions in motor vehicle collisions may have lower initial symptom burdens but slower symptom recovery at 1 month compared to other mechanisms of injury and may represent a distinct population for prognostic counseling in the ED requiring further research.

  View details for DOI 10.1002/emp2.12056

  View details for PubMedID 33145544

  View details for PubMedCentralID PMC7593496

• Sex-Related Differences in Neurosensory Alterations Following Blunt Head Injury. Frontiers in neurology Lumba-Brown, A. n., Niknam, K. n., Cornwell, J. n., Meyer, C. n., Ghajar, J. n. 2020; 11: 1051

  Abstract

  Background: There is heterogeneity in neurosensory alterations following mild traumatic brain injury. Commonly assessed neurosensory symptoms following head injury include symptom reports and measures of oculomotor impairment, auditory changes, and vestibular impairment. Hypothesis/Purpose: Neurosensory alterations are prevalent acutely following mild traumatic brain injury secondary to blunt head trauma during collegiate varsity sports and may vary by sex and sport. Study Design: Retrospective study of a large collegiate athletic database. Methods: Analyses were performed using an established single University dataset of 177 male and female collegiate varsity athletes who were diagnosed with concussion/mild traumatic brain injury between September 2013 and October 2019. Descriptive and comparative analyses were performed on individual and grouped acute concussion assessments pertaining to neurosensory alterations obtained within 72 h of injury using components of the Sports Concussion Assessment Tool Version 5 and Vestibular/Ocular-Motor Screening. Results: Females had significantly more abnormal smooth pursuit (p-value: 0.045), convergence (p-value: 0.031), and visual motion sensitivity tests results (p-value: 0.023) than males. There were no differences in neurosensory alterations when grouped by overall auditory, vestibular, or oculomotor impairments. The majority of sports-related concussions occurred during football (50, 28.25%), wrestling (21, 11.86%), water polo (15, 8.47%), and basketball (14, 7.91%). Abnormal vestibular assessments were high in these top four sports categories, but statistically significant differences in overall auditory, vestibular, or oculomotor impairments were not reached by individual sport. However, water polo players had higher abnormal individual assessments related to balance reports on the sideline (60.00%, p-value: 0.045) and in the clinic setting (57.14%, p-value: 0.038) as compared to all other sports. Conclusion: While neurosensory alterations are prevalent in both male and female athletes acutely post-concussion, females have a higher incidence of abnormalities in smooth pursuit, convergence, and visual motion sensitivity and may benefit from early rehabilitation.

  View details for DOI 10.3389/fneur.2020.01051

  View details for PubMedID 33041988

  View details for PubMedCentralID PMC7522405

• Emergency department implementation of abbreviated magnetic resonance imaging for pediatric traumatic brain injury. Journal of the American College of Emergency Physicians open Lumba-Brown, A. n., Lee, M. O., Brown, I. n., Cornwell, J. n., Dannenberg, B. n., Fang, A. n., Ghazi-Askar, M. n., Grant, G. n., Imler, D. n., Khanna, K. n., Lowe, J. n., Wang, E. n., Wintermark, M. n. 2020; 1 (5): 994–99

  Abstract

  Pediatric head injury is a common presenting complaint in the emergency department (ED), often requiring neuroimaging or ED observation for diagnosis. However, the traditional diagnostic neuroimaging modality, head computed tomography (CT), is associated with radiation exposure while prolonged ED observation impacts patient flow and resource utilization. Recent scientific literature supports abbreviated, or focused and shorter, brain magnetic resonance imaging (MRI) as a feasible and accurate diagnostic alternative to CT for traumatic brain injury. However, this is a relatively new application and its use is not widespread. The aims of this review are to describe the science and applications of abbreviated brain MRI and report a model protocol's development and ED implementation in the evaluation of children with head injury for replication in other institutions.

  View details for DOI 10.1002/emp2.12055

  View details for PubMedID 33145550

  View details for PubMedCentralID PMC7593499

• Emergency Department Implementation of the Brain Trauma Foundation's Pediatric Severe Brain Injury Guideline Recommendations. Pediatric emergency care Lumba-Brown, A., Totten, A., Kochanek, P. M. 2019

  Abstract

  The "Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines" published in Pediatric Critical Care Medicine in 2019 provides new and updated recommendations applicable to the emergency department management of children with severe traumatic brain injury. Practice-changing takeaways include specific recommendations for administration of 3% hypertonic saline, administration of seizure prophylaxis, and avoiding hyperventilation.

  View details for DOI 10.1097/PEC.0000000000001903

  View details for PubMedID 31804428

• Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. The New England journal of medicine Kapur, J., Elm, J., Chamberlain, J. M., Barsan, W., Cloyd, J., Lowenstein, D., Shinnar, S., Conwit, R., Meinzer, C., Cock, H., Fountain, N., Connor, J. T., Silbergleit, R. 2019; 381 (22): 2103-2113

  Abstract

  The choice of drugs for patients with status epilepticus that is refractory to treatment with benzodiazepines has not been thoroughly studied.In a randomized, blinded, adaptive trial, we compared the efficacy and safety of three intravenous anticonvulsive agents - levetiracetam, fosphenytoin, and valproate - in children and adults with convulsive status epilepticus that was unresponsive to treatment with benzodiazepines. The primary outcome was absence of clinically evident seizures and improvement in the level of consciousness by 60 minutes after the start of drug infusion, without additional anticonvulsant medication. The posterior probabilities that each drug was the most or least effective were calculated. Safety outcomes included life-threatening hypotension or cardiac arrhythmia, endotracheal intubation, seizure recurrence, and death.A total of 384 patients were enrolled and randomly assigned to receive levetiracetam (145 patients), fosphenytoin (118), or valproate (121). Reenrollment of patients with a second episode of status epilepticus accounted for 16 additional instances of randomization. In accordance with a prespecified stopping rule for futility of finding one drug to be superior or inferior, a planned interim analysis led to the trial being stopped. Of the enrolled patients, 10% were determined to have had psychogenic seizures. The primary outcome of cessation of status epilepticus and improvement in the level of consciousness at 60 minutes occurred in 68 patients assigned to levetiracetam (47%; 95% credible interval, 39 to 55), 53 patients assigned to fosphenytoin (45%; 95% credible interval, 36 to 54), and 56 patients assigned to valproate (46%; 95% credible interval, 38 to 55). The posterior probability that each drug was the most effective was 0.41, 0.24, and 0.35, respectively. Numerically more episodes of hypotension and intubation occurred in the fosphenytoin group and more deaths occurred in the levetiracetam group than in the other groups, but these differences were not significant.In the context of benzodiazepine-refractory convulsive status epilepticus, the anticonvulsant drugs levetiracetam, fosphenytoin, and valproate each led to seizure cessation and improved alertness by 60 minutes in approximately half the patients, and the three drugs were associated with similar incidences of adverse events. (Funded by the National Institute of Neurological Disorders and Stroke; ESETT ClinicalTrials.gov number, NCT01960075.).

  View details for DOI 10.1056/NEJMoa1905795

  View details for PubMedID 31774955

• Practice Variation in the Diagnosis of Aneurysmal Subarachnoid Hemorrhage: A Survey of US and Canadian Emergency Medicine Physicians NEUROCRITICAL CARE Kumar, A., Niknam, K., Lumba-Brown, A., Woodruff, M., Bledsoe, J. R., Kohn, M. A., Perry, J. J., Goyindarajan, P. 2019; 31 (2): 321–28

  View details for DOI 10.1007/s12028-019-00679-7

  View details for Web of Science ID 000487511700014

• Concussion Guidelines Step 2: Evidence for Subtype Classification. Neurosurgery Lumba-Brown, A., Teramoto, M., Bloom, O. J., Brody, D., Chesnutt, J., Clugston, J. R., Collins, M., Gioia, G., Kontos, A., Lal, A., Sills, A., Ghajar, J. 2019

  Abstract

  BACKGROUND: Concussion is a heterogeneous mild traumatic brain injury (mTBI) characterized by a variety of symptoms, clinical presentations, and recovery trajectories. By thematically classifying the most common concussive clinical presentations into concussion subtypes (cognitive, ocular-motor, headache/migraine, vestibular, and anxiety/mood) and associated conditions (cervical strain and sleep disturbance), we derive useful definitions amenable to future targeted treatments.OBJECTIVE: To use evidence-based methodology to characterize the 5 concussion subtypes and 2 associated conditions and report their prevalence in acute concussion patients as compared to baseline or controls within 3 d of injury.METHODS: A multidisciplinary expert workgroup was established to define the most common concussion subtypes and their associated conditions and select clinical questions related to prevalence and recovery. A literature search was conducted from January 1, 1990 to November 1, 2017. Two experts abstracted study characteristics and results independently for each article selected for inclusion. A third expert adjudicated disagreements. Separate meta-analyses were conducted to do the following: 1) examine the prevalence of each subtype/associated condition in concussion patients using a proportion, 2) assess subtype/associated conditions in concussion compared to baseline/uninjured controls using a prevalence ratio, and 3) compare the differences in symptom scores between concussion subtypes and uninjured/baseline controls using a standardized mean difference (SMD).RESULTS: The most prevalent concussion subtypes for pediatric and adult populations were headache/migraine (0.52; 95% CI=0.37, 0.67) and cognitive (0.40; 95% CI=0.25, 0.55), respectively. In pediatric patients, the prevalence of the vestibular subtype was also high (0.50; 95% CI=0.40, 0.60). Adult patients were 4.4, 2.9, and 1.7 times more likely to demonstrate cognitive, vestibular, and anxiety/mood subtypes, respectively, as compared with their controls (P<.05). Children and adults with concussion showed significantly more cognitive symptoms than their respective controls (SMD=0.66 and 0.24; P<.001). Furthermore, ocular-motor in adult patients (SMD=0.72; P<.001) and vestibular symptoms in both pediatric and adult patients (SMD=0.18 and 0.36; P<.05) were significantly worse in concussion patients than in controls.CONCLUSION: Five concussion subtypes with varying prevalence within 3 d following injury are commonly seen clinically and identifiable upon systematic literature review. Sleep disturbance, a concussion-associated condition, is also common. There was insufficient information available for analysis of cervical strain. A comprehensive acute concussion assessment defines and characterizes the injury and, therefore, should incorporate evaluations of all 5 subtypes and associated conditions.

  View details for DOI 10.1093/neuros/nyz332

  View details for PubMedID 31432081

• Reliable sideline ocular-motor assessment following exercise in healthy student athletes. Journal of science and medicine in sport Sundaram, V., Ding, V. Y., Desai, M., Lumba-Brown, A., Little, J. 2019

  Abstract

  OBJECTIVES: To assess the reliability and effect of exercise on sideline dynamic visual performance measures of ocular-motor function using a portable visual assessment system (EYE-SYNC).DESIGN: Prospective cohort study.METHODS: Healthy student athletes, ages 18-25 years, performed eye-tracking six times-three times consecutively prior to and after practice-using EYE-SYNC goggles. Ocular-motor performance was assessed by calculating five gaze error outcomes between target position and actual gaze position to inform dynamic visual synchronization. We assessed reliability by calculating the intraclass correlation coefficient (ICC) for each outcome (we defined the standard deviation of tangential error (SDTE) as our primary outcome) and calculated differences in mean pre- and post-practice scores.RESULTS: ICCs for the SDTE score were 0.86 (95% confidence interval, CI: 0.82-0.9) and 0.88 (0.84-0.91) at pre- and post-practice, respectively. 133 (89%) and 135 (90%) of 150 athletes had at least one measurement at pre- and post-practice, respectively. 117 (78%) and 122 (81%) athletes had more than one SDTE score at pre- and post-practice, respectively. The absolute mean (SD) differences between pre- and post-practice mean scores ranged from 0.02 (0.05) for horizontal gain to 0.1 (0.5) for SDTE.CONCLUSIONS: We observed high ICC scores indicating excellent reliability of visual synchronization measurements, suggesting that one measurement would be sufficient. Most athletes had similar scores before and after practice, indicating little change in visual performance following exercise. EYE-SYNC goggles have the potential for use in obtaining objective visual performance measures of ocular-motor function for sideline assessment of concussion and return to play decisions.

  View details for DOI 10.1016/j.jsams.2019.07.015

  View details for PubMedID 31445952

• Strengthening the Evidence Base: Recommendations for Future Research Identified Through the Development of CDC's Pediatric Mild TBI Guideline JOURNAL OF HEAD TRAUMA REHABILITATION Suskauer, S. J., Yeates, K., Sarmiento, K., Benzel, E. C., Breiding, M. J., Broomand, C., Haarbauer-Krupa, J., Turner, M., Weissman, B., Lumba-Brown, A. 2019; 34 (4): 215–23

  View details for DOI 10.1097/HTR.0000000000000455

  View details for Web of Science ID 000480754400010

• Practice Patterns in Pharmacological and Non-Pharmacological Therapies for Children with Mild Traumatic Brain Injury: A Survey of 15 Canadian and United States Centers JOURNAL OF NEUROTRAUMA Mannix, R., Zemek, R., Yeates, K., Arbogast, K., Atabaki, S., Badawy, M., Beauchamp, M. H., Beer, D., Bin, S., Burstein, B., Craig, W., Corwin, D., Doan, Q., Ellis, M., Freedman, S. B., Gagnon, I., Gravel, J., Leddy, J., Lumba-Brown, A., Master, C., Mayer, A. R., Park, G., Penque, M., Rhine, T., Russell, K., Schneider, K., Bell, M., Wisniewski, S. 2019

  View details for DOI 10.1089/neu.2018.6290

  View details for Web of Science ID 000472106400001

• Pediatric hypertonic saline use in emergency departments AMERICAN JOURNAL OF EMERGENCY MEDICINE Niknam, K., Mistry, R., Lumba-Brown, A. 2019; 37 (5): 981–83

  View details for DOI 10.1016/j.ajem.2018.09.040

  View details for Web of Science ID 000465499500040

• Practice Variation in the Diagnosis of Aneurysmal Subarachnoid Hemorrhage: A Survey of US and Canadian Emergency Medicine Physicians. Neurocritical care Kumar, A., Niknam, K., Lumba-Brown, A., Woodruff, M., Bledsoe, J. R., Kohn, M. A., Perry, J. J., Govindarajan, P. 2019

  Abstract

  BACKGROUND AND AIMS: Spontaneous subarachnoid hemorrhage (SAH) from a brain aneurysm, if untreated in the acute phase, leads to loss of functional independence in about 30% of patients and death in 27-44%. To evaluate for SAH, the American College of Emergency Physicians (ACEP) Clinical Policy recommends obtaining a non-contrast brain computed tomography (CT) scan followed by a lumbar puncture (LP) if the CT is negative. On the other hand, current evidence from prospectively collected data suggests that CT alone may be sufficient to rule out SAH in patients who present within 6h of symptom onset while anecdotal evidence suggests that CT angiogram (CTA) may be used to detect aneurysms, which are the probable cause of SAH. Since many different options are available to emergency physicians, we examinedtheirpractice pattern variation by observing their diagnostic approaches andtheir adherence to the ACEP Clinical Policy.METHODS: We developed, validated, and distributed a survey to emergency physicians at three practice sites: (1) Stanford Healthcare, California, (2) Intermountain Healthcare (five emergency departments), Utah, and (3) Ottawa General Hospital, Toronto. The survey questions examined physician knowledge on CT and LP's test performance and used case-based scenarios to assess diagnostic approaches, variation in practice, and adherence to guidelines. Results were presented as proportions with 95% CIs.RESULTS: Of the 216 physicians surveyed, we received 168 responses (77.8%). The responses by site were: (1) (n=38, 23.2%), (2) (n=70, 42.7%), (3) (n=56, 34.1%). To the CT and LP test performance question, most physicians indicated that CT alone detects>90% of SAH in those with a confirmed SAH [n=150 (89.3%, 95% CI 83.6-93.5]. To the case-based questions, most physicians indicated that they would perform a CTA along with a CT [n=110 (65.5%, 95% CI 57.8-72.6)], some indicated a LP along with a CT [n=57, 33.9% 95% CI 26.8-41.6)], and a few indicated both a CTA and a LP [n=16, 9.5%, 95% CI 5.5-15.0]. We also observed practice site variation in the proportion of physicians who indicated that they would use CTA: (1) (n=25, 65.8%), (2) (n=54, 77.1%), and (3) (n=28, 50.0%) (p=0.006).CONCLUSIONS: Survey responses indicate that physicians use some or all of the imaging tests, with or without LP to diagnose SAH. We observed variation in the use of CTA by site and academic setting and divergence from ACEP Clinical Policy.

  View details for PubMedID 30790225

• North American survey on the post-neuroimaging management of children with mild head injuries JOURNAL OF NEUROSURGERY-PEDIATRICS Greenberg, J. K., Jeffe, D. B., Carpenter, C. R., Yan, Y., Pineda, J. A., Lumba-Brown, A., Keller, M. S., Berger, D., Bollo, R. J., Ravindra, V. M., Naftel, R. P., Dewan, M. C., Shah, M. N., Burns, E. C., O'Neill, B. R., Hankinson, T. C., Whitehead, W. E., Adelson, P., Tamber, M. S., McDonald, P. J., Ahn, E. S., Titsworth, W., West, A. N., Brownson, R. C., Limbrick, D. D. 2019; 23 (2): 227–35

  Abstract

  OBJECTIVEThere remains uncertainty regarding the appropriate level of care and need for repeating neuroimaging among children with mild traumatic brain injury (mTBI) complicated by intracranial injury (ICI). This study's objective was to investigate physician practice patterns and decision-making processes for these patients in order to identify knowledge gaps and highlight avenues for future investigation.METHODSThe authors surveyed residents, fellows, and attending physicians from the following pediatric specialties: emergency medicine; general surgery; neurosurgery; and critical care. Participants came from 10 institutions in the United States and an email list maintained by the Canadian Neurosurgical Society. The survey asked respondents to indicate management preferences for and experiences with children with mTBI complicated by ICI, focusing on an exemplar clinical vignette of a 7-year-old girl with a Glasgow Coma Scale score of 15 and a 5-mm subdural hematoma without midline shift after a fall down stairs.RESULTSThe response rate was 52% (n = 536). Overall, 326 (61%) respondents indicated they would recommend ICU admission for the child in the vignette. However, only 62 (12%) agreed/strongly agreed that this child was at high risk of neurological decline. Half of respondents (45%; n = 243) indicated they would order a planned follow-up CT (29%; n = 155) or MRI scan (19%; n = 102), though only 64 (12%) agreed/strongly agreed that repeat neuroimaging would influence their management. Common factors that increased the likelihood of ICU admission included presence of a focal neurological deficit (95%; n = 508 endorsed), midline shift (90%; n = 480) or an epidural hematoma (88%; n = 471). However, 42% (n = 225) indicated they would admit all children with mTBI and ICI to the ICU. Notably, 27% (n = 143) of respondents indicated they had seen one or more children with mTBI and intracranial hemorrhage demonstrate a rapid neurological decline when admitted to a general ward in the last year, and 13% (n = 71) had witnessed this outcome at least twice in the past year.CONCLUSIONSMany physicians endorse ICU admission and repeat neuroimaging for pediatric mTBI with ICI, despite uncertainty regarding the clinical utility of those decisions. These results, combined with evidence that existing practice may provide insufficient monitoring to some high-risk children, emphasize the need for validated decision tools to aid the management of these patients.

  View details for PubMedID 30485194

• Practice Variation in the Management of Aneurysmal Subarachnoid Hemorrhage-A Survey of US and Canadian Emergency Medicine Physicians Kumar, A., NIknam, K., Lumba-Brown, A., Bledsoe, J., Woodruff, M., Kohn, M., Perry, J., Govindarajan, P. LIPPINCOTT WILLIAMS & WILKINS. 2019

  View details for Web of Science ID 000478733402016

• Strengthening the Evidence Base: Recommendations for Future Research Identified Through the Development of CDC's Pediatric Mild TBI Guideline. The Journal of head trauma rehabilitation Suskauer, S. J., Yeates, K. O., Sarmiento, K., Benzel, E. C., Breiding, M. J., Broomand, C., Haarbauer-Krupa, J., Turner, M., Weissman, B., Lumba-Brown, A. 2019

  Abstract

  OBJECTIVE: The recently published Centers for Disease Control and Prevention evidence-based guideline on pediatric mild traumatic brain injury (mTBI) was developed following an extensive review of the scientific literature. Through this review, experts identified limitations in existing pediatric mTBI research related to study setting and generalizability, mechanism of injury and age of cohorts studied, choice of control groups, confounding, measurement issues, reporting of results, and specific study design considerations. This report summarizes those limitations and provides a framework for optimizing the future quality of research conduct and reporting.RESULTS: Specific recommendations are provided related to diagnostic accuracy, population screening, prognostic accuracy, and therapeutic interventions.CONCLUSION: Incorporation of the recommended approaches will increase the yield of eligible research for inclusion in future systematic reviews and guidelines for pediatric mTBI.

  View details for PubMedID 30608306

• Practice Patterns in Pharmacologic and Non-pharmacologic Therapies for Children with Mild Traumatic Brain Injury: A survey of 15 Canadian and United States Centers. Journal of neurotrauma Mannix, R. n., Zemek, R. n., Yeates, K. O., Arbogast, K. B., Atabaki, S. n., Badawy, M. n., Beauchamp, M. H., Beer, D. n., Bin, S. n., Burstein, B. n., Craig, W. n., Corwin, D. n., Doan, Q. n., Ellis, M. n., Freedman, S. n., Gagnon, I. n., Gravel, J. n., Leddy, J. J., Lumba-Brown, A. n., Master, C. n., Mayer, A. n., Park, G. n., Penque, M. n., Rhine, T. n., Russell, K. n., Schneider, K. n., Bell, M. J., Wisniewski, S. R. 2019

  Abstract

  Given the lack of evidence regarding effective pharmacologic and non-pharmacologic interventions for pediatric mild traumatic brain injury (mTBI) and the resultant lack of treatment recommendations reflected in consensus guidelines, variation in the management of pediatric mTBI is to be expected. We therefore surveyed practitioners across 15 centers in the United States and Canada who care for children with pediatric mTBI to evaluate common-practice variation in the management of pediatric mTBI. The survey, developed by a panel of pediatric mTBI experts, consisted of a 10-item survey instrument regarding providers' perception of common pediatric mTBI symptoms and mTBI interventions. Surveys were distributed electronically to a convenience sample of local experts at each center. Frequencies and percentages (with confidence intervals) were determined for survey responses. One hundred and seven respondents (71% response rate) included specialists in pediatric Emergency Medicine, Sports Medicine, Neurology, Neurosurgery, Neuropsychology, Neuropsychiatry, Physical and Occupational Therapy, Physiatry/Rehabilitation and General Pediatrics. Respondents rated headache as the most prevalently reported symptom after pediatric mTBI, followed by cognitive problems, dizziness, and irritability. Of the 65 (61%; [95% CI: 51,70]) respondents able to prescribe medications, non-steroidal anti-inflammatory medications (55%; [95% CI:42,68]) and acetaminophen (59%; [95% CI:46,71]) were most commonly recommended. One in five respondents reported prescribing amitriptyline for headache management after pediatric mTBI, whereas topiramate (8%; [95% CI: 3,17]) was less commonly reported. For cognitive problems, methylphenidate (11%; [95% CI: 4,21]) was used more commonly than amantadine (2%; [95% CI:0,8]). The most common non-pharmacologic interventions were rest ("always" or "often" recommended by 83% [95% CI: 63,92] of the 107 respondents), exercise (59%; [95%CI: 49,69]), vestibular therapy (42% [95%CI:33,53]) and cervical spine exercises (29% [95%CI:21,39]). Self-reported utilization for common pediatric mTBI interventions varied widely across our Canadian and United States consortium. Future effectiveness studies for pediatric mTBI are urgently needed to advance the evidence-based care.

  View details for PubMedID 31025612

• Improving the Care of Young Patients with Mild Traumatic Brain Injury: CDC's Evidence-Based Pediatric Mild TBI Guideline LIFESTYLE MEDICINE, 3RD EDITION Sarmiento, K., Lumba-Brown, A., Breiding, M. J., Gordon, W., Paulk, D., Vitale, K., Sleet, D. A., Rippe, J. M. 2019: 1319-1326

  View details for Web of Science ID 000569702400119

• Representation of concussion subtypes in common postconcussion symptom-rating scales. Concussion (London, England) Lumba-Brown, A. n., Ghajar, J. n., Cornwell, J. n., Bloom, O. J., Chesnutt, J. n., Clugston, J. R., Kolluri, R. n., Leddy, J. J., Teramoto, M. n., Gioia, G. n. 2019; 4 (3): CNC65

  Abstract

  Postconcussion symptom-rating scales are frequently used concussion assessment tools that do not align directly with new expert, consensus-based concussion subtype classification systems. This may result in delays in concussion diagnosis, subspecialty referral and rehabilitative strategies.To determine the representation of subtype-directed symptomatology in common postconcussion symptom-rating scales.Literature review and expert consensus were used to compile commonly used concussion symptom-rating scales. Statistics were generated to describe the degree of representation of the consensus symptom set.The percentage of symptoms representing each subtype/associated condition is low overall (15-26%). The ocular-motor (11%) and vestibular subtypes (19%) and cervical strain (5%)-associated condition were the most under-represented and also had the greatest unmet needs.Concussion subtypes do not have equal representation on commonly used concussion symptom-rating scales. There is a need for a subtype-directed symptom assessment to allow for increased accuracy of diagnosis and to guide management.

  View details for DOI 10.2217/cnc-2019-0005

  View details for PubMedID 31827883

  View details for PubMedCentralID PMC6902310

• Concussion Subtype Identification With the Rivermead Post-concussion Symptoms Questionnaire. Frontiers in neurology Maruta, J., Lumba-Brown, A., Ghajar, J. 2018; 9: 1034

  Abstract

  Classifying concussion in key subtypes according to presenting symptomatology at an early post-injury stage is an emerging approach that may allow prediction of clinical trajectories and delivery of targeted treatments. The Rivermead Post-concussion Symptoms Questionnaire (RPQ) is a simple, freely available, and widely used tool for assessment of the presence and severity of various post-concussion symptoms. We aimed to probe the prevalence among athletes of symptom classes associated with identified concussion phenotypes using the RPQ at baseline and acutely after a concussion. Participants of organized sports aged 12-30 years were baseline-assessed with the expectation that some would experience a concussion during the study period. Concussed athletes were re-assessed within 2 weeks of their injuries. The RPQ was supplemented with three specific questions and reworded for baseline assessment. A binomial test was used to contrast the prevalence of an attribute in the concussed cohort against the probability established by the baseline observation. Three thousand and eighty-eight athletes were baseline-assessed and eighty-nine were re-assessed post-concussion. All concussed athletes endorsed having some elevated symptoms in the RPQ, and such endorsements were more prevalent than those among normal athletes. Moderate-to-severe post-concussion symptoms of specific classes tended to be endorsed with few additional symptoms of other classes of similar intensities. Elevated symptoms detected with the RPQ within as short as 2 weeks after a concussion may help delineate patients' clinical subtypes and guide their treatment. Further refinement of symptom questionnaires and use of objective measures will be needed to properly populate the concussion subtype classification.

  View details for DOI 10.3389/fneur.2018.01034

  View details for PubMedID 30559709

  View details for PubMedCentralID PMC6287109

• Concussion Subtype Identification With the Rivermead Post-concussion Symptoms Questionnaire FRONTIERS IN NEUROLOGY Maruta, J., Lumba-Brown, A., Ghajar, J. 2018; 9

  View details for DOI 10.3389/fneur.2018.01034

  View details for Web of Science ID 000451953400001

• CDC Guideline on Mild Traumatic Brain Injury in Children: Important Practice Takeaways for Sports Medicine Providers. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine Sarmiento, K., Waltzman, D., Lumba-Brown, A., Yeates, K. O., Putukian, M., Herring, S. 2018

  Abstract

  OBJECTIVES: The Centers for Disease Control and Prevention (CDC) published an evidence-based guideline on the diagnosis and management of pediatric mild traumatic brain injury (mTBI) in 2018. This commentary provides key practice takeaways for sports medicine providers outlined in the Guideline recommendations.DATA SOURCES: The CDC Pediatric mTBI Guideline was developed through a rigorous scientific process using a modified Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. A systematic review of the scientific literature published over a 25-year period for all causes of pediatric mTBI formed the basis of the Guideline.MAIN RESULTS: The key practice takeaways for sports medicine providers focus on preseason evaluations, neuroimaging, symptom-based assessment, managing recovery, monitoring for persistent symptoms, and return to activity, including sport and school.CONCLUSIONS: Sports medicine providers play an integral part in the implementation of evidence-based practices that promote appropriate diagnosis and management of mTBI in children. This commentary highlights key practice takeaways that sports medicine providers can implement.

  View details for PubMedID 30489330

• Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children JAMA PEDIATRICS Lumba-Brown, A., Yeates, K., Sarmiento, K., Breiding, M. J., Haegerich, T. M., Gioia, G. A., Turner, M., Benzel, E. C., Suskauer, S. J., Giza, C. C., Joseph, M., Broomand, C., Weissman, B., Gordon, W., Wright, D. W., Moser, R., McAvoy, K., Ewing-Cobbs, L., Duhaime, A., Putukian, M., Holshouser, B., Paulk, D., Wade, S. L., Herring, S. A., Halstead, M., Keenan, H. T., Choe, M., Christian, C. W., Guskiewicz, K., Raksin, P. B., Gregory, A., Mucha, A., Taylor, H., Callahan, J. M., DeWitt, J., Collins, M. W., Kirkwood, M. W., Ragheb, J., Ellenbogen, R. G., Spinks, T. J., Ganiats, T. G., Sabelhaus, L. J., Altenhofen, K., Hoffman, R., Getchius, T., Gronseth, G., Donnell, Z., O'Connor, R. E., Timmons, S. D. 2018; 172 (11)

  View details for DOI 10.1001/jamapediatrics.2018.2853

  View details for Web of Science ID 000449215800003

• Development of the CIDSS2 Score for Children with Mild Head Trauma without Intracranial Injury JOURNAL OF NEUROTRAUMA Greenberg, J. K., Yan, Y., Carpenter, C. R., Lumba-Brown, A., Keller, M. S., Pineda, J. A., Brownson, R. C., Limbrick, D. D. 2018; 35 (22): 2699–2707

  Abstract

  While most children with mild traumatic brain injury (mTBI) without intracranial injury (ICI) can be safely discharged home from the emergency department, many are admitted to the hospital. To support evidence-based practice, we developed a decision tool to help guide hospital admission decisions. This study was a secondary analysis of a prospective study conducted in 25 emergency departments. We included children under 18 years who had Glasgow Coma Scale score 13-15 head injuries and normal computed tomography scans or skull fractures without significant depression. We developed a multi-variable model that identified risk factors for extended inpatient management (EIM; defined as hospitalization for 2 or more nights) for TBI, and used this model to create a clinical risk score. Among 14,323 children with mTBI without ICI, 20% were admitted to the hospital but only 0.76% required EIM for TBI. Key risk factors for EIM included Glasgow Coma Scale score less than 15 (odds ratio [OR] = 8.1; 95% confidence interval [CI] 4.0-16.4 for 13 vs. 15), drug/alcohol Intoxication (OR = 5.1; 95% CI 2.4-10.7), neurological Deficit (OR = 3.1; 95% CI 1.4-6.9), Seizure (OR = 3.7; 95% CI 1.8-7.8), and Skull fracture (odds ratio [OR] 24.5; 95% CI 16.0-37.3). Based on these results, the CIDSS2 risk score was created. The model C-statistic was 0.86 and performed similarly in children less than (C = 0.86) and greater than or equal to 2 years (C = 0.86). The CIDSS2 score is a novel tool to help physicians identify the minority of children with mTBI without ICI at increased risk for EIM, thereby potentially aiding hospital admission decisions.

  View details for PubMedID 29882466

  View details for PubMedCentralID PMC6238605

• Emergency Department Implementation of the Centers for Disease Control and Prevention Pediatric Mild Traumatic Brain Injury Guideline Recommendations ANNALS OF EMERGENCY MEDICINE Lumba-Brown, A., Wright, D. W., Sarmiento, K., Houry, D. 2018; 72 (5): 581–85

  View details for DOI 10.1016/j.annemergmed.2018.03.045

  View details for Web of Science ID 000447612300019

• Diagnosis and Management of Mild Traumatic Brain Injury in Children A Systematic Review JAMA PEDIATRICS Lumba-Brown, A., Yeates, K., Sarmiento, K., Breiding, M. J., Haegerich, T. M., Gioia, G. A., Turner, M., Benzel, E. C., Suskauer, S. J., Giza, C. C., Joseph, M., Broomand, C., Weissman, B., Gordon, W., Wright, D. W., Moser, R., McAvoy, K., Ewing-Cobbs, L., Duhaime, A., Putukian, M., Holshouser, B., Paulk, D., Wade, S. L., Herring, S. A., Halstead, M., Keenan, H. T., Choe, M., Christian, C. W., Guskiewicz, K., Raksin, P. B., Gregory, A., Mucha, A., Taylor, H., Callahan, J. M., DeWitt, J., Collins, M. W., Kirkwood, M. W., Ragheb, J., Ellenbogen, R. G., Spinks, T. J., Ganiats, T. G., Sabelhaus, L. J., Altenhofen, K., Hoffman, R., Getchius, T., Gronseth, G., Donnell, Z., O'Connor, R. E., Timmons, S. D. 2018; 172 (11)

  View details for DOI 10.1001/jamapediatrics.2018.2847

  View details for Web of Science ID 000449215800002

• Pediatric hypertonic saline use in emergency departments. The American journal of emergency medicine Niknam, K., Mistry, R., Lumba-Brown, A. 2018

  View details for PubMedID 30274762

• Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA pediatrics Lumba-Brown, A., Yeates, K. O., Sarmiento, K., Breiding, M. J., Haegerich, T. M., Gioia, G. A., Turner, M., Benzel, E. C., Suskauer, S. J., Giza, C. C., Joseph, M., Broomand, C., Weissman, B., Gordon, W., Wright, D. W., Moser, R. S., McAvoy, K., Ewing-Cobbs, L., Duhaime, A., Putukian, M., Holshouser, B., Paulk, D., Wade, S. L., Herring, S. A., Halstead, M., Keenan, H. T., Choe, M., Christian, C. W., Guskiewicz, K., Raksin, P. B., Gregory, A., Mucha, A., Taylor, H. G., Callahan, J. M., DeWitt, J., Collins, M. W., Kirkwood, M. W., Ragheb, J., Ellenbogen, R. G., Spinks, T. J., Ganiats, T. G., Sabelhaus, L. J., Altenhofen, K., Hoffman, R., Getchius, T., Gronseth, G., Donnell, Z., O'Connor, R. E., Timmons, S. D. 2018: e182853

  Abstract

  Importance: Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States.Objective: To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI.Evidence Review: The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015.Findings: The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment.Conclusions and Relevance: This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

  View details for PubMedID 30193284

• Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review. JAMA pediatrics Lumba-Brown, A., Yeates, K. O., Sarmiento, K., Breiding, M. J., Haegerich, T. M., Gioia, G. A., Turner, M., Benzel, E. C., Suskauer, S. J., Giza, C. C., Joseph, M., Broomand, C., Weissman, B., Gordon, W., Wright, D. W., Moser, R. S., McAvoy, K., Ewing-Cobbs, L., Duhaime, A., Putukian, M., Holshouser, B., Paulk, D., Wade, S. L., Herring, S. A., Halstead, M., Keenan, H. T., Choe, M., Christian, C. W., Guskiewicz, K., Raksin, P. B., Gregory, A., Mucha, A., Taylor, H. G., Callahan, J. M., DeWitt, J., Collins, M. W., Kirkwood, M. W., Ragheb, J., Ellenbogen, R. G., Spinks, T. J., Ganiats, T. G., Sabelhaus, L. J., Altenhofen, K., Hoffman, R., Getchius, T., Gronseth, G., Donnell, Z., O'Connor, R. E., Timmons, S. D. 2018: e182847

  Abstract

  Importance: In recent years, there has been an exponential increase in the research guiding pediatric mild traumatic brain injury (mTBI) clinical management, in large part because of heightened concerns about the consequences of mTBI, also known as concussion, in children. The CDC National Center for Injury Prevention and Control's (NCIPC) Board of Scientific Counselors (BSC), a federal advisory committee, established the Pediatric Mild TBI Guideline workgroup to complete this systematic review summarizing the first 25 years of literature in this field of study.Objective: To conduct a systematic review of the pediatric mTBI literature to serve as the foundation for an evidence-based guideline with clinical recommendations associated with the diagnosis and management of pediatric mTBI.Evidence Review: Using a modified Delphi process, the authors selected 6 clinical questions on diagnosis, prognosis, and management or treatment of pediatric mTBI. Two consecutive searches were conducted on PubMed, Embase, ERIC, CINAHL, and SportDiscus. The first included the dates January 1, 1990, to November 30, 2012, and an updated search included December 1, 2012, to July 31, 2015. The initial search was completed from December 2012 to January 2013; the updated search, from July 2015 to August 2015. Two authors worked in pairs to abstract study characteristics independently for each article selected for inclusion. A third author adjudicated disagreements. The risk of bias in each study was determined using the American Academy of Neurology Classification of Evidence Scheme. Conclusion statements were developed regarding the evidence within each clinical question, and a level of confidence in the evidence was assigned to each conclusion using a modified GRADE methodology. Data analysis was completed from October 2014 to May 2015 for the initial search and from November 2015 to April 2016 for the updated search.Findings: Validated tools are available to assist clinicians in the diagnosis and management of pediatric mTBI. A significant body of research exists to identify features that are associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI, and long-term sequelae. However, high-quality studies of treatments meant to improve mTBI outcomes are currently lacking.Conclusions and Relevance: This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.

  View details for PubMedID 30193325

• Mentoring Pediatric Victims of Interpersonal Violence Reduces Recidivism. Journal of interpersonal violence Lumba-Brown, A., Batek, M., Choi, P., Keller, M., Kennedy, R. 2017: 886260517705662

  Abstract

  Pediatric interpersonal violence is a public health crisis resulting in morbidity and mortality and recidivism. St. Louis City and surrounding areas have the highest rates of youth interpersonal violence nationally. St. Louis Children's Hospital (SLCH) Social Work in conjunction with Pediatric Emergency Medicine established a novel emergency department (ED)-initiated program to determine whether co-location of services followed by outpatient mentoring reduced the rate of morbidity, mortality, and recidivism in youths experiencing interpersonal violence. SLCH developed the "Empowering Youth Through Interpersonal Violence Prevention Program," co-locating initial social work services and emergency medical services in the pediatric ED. Youths, ages 8 to 17 years, presenting for interpersonal violence were approached for immediate social work counseling and subsequent individualized outpatient mentoring, developed from national best practices and model programs. A prospective 2:1 randomized, controlled pilot study assessing for youth morbidity, mortality, and recidivism was conducted for program service feasibility from 2012 to 2014. The study was followed by a 1-year retrospective analysis of program service integration as a hospital standard-of-care evaluating the same outcome measures. Of the 24 youths who participated in the pilot study and received the intervention, there was a 4% rate of morbidity and recidivism. Conversely, there was a 3.4% rate of mortality, 6.7% rate of morbidity, and 11.8% recidivism rate in those who refused to participate in services. EYIPP was offered as a service from 2014 to 2015 and 57 youths participated with a 3.5% rate of both morbidity and recidivism. During this time, 78 eligible youths declined services with a 1.1% rate of morbidity, and 2.3% recidivism rate. This novelprogram reduces recidivism, morbidity, and mortality in youths presenting to SLCH for interpersonal violence-related injuries suggesting that co-location of social services in the ED, followed by individualized mentoring may be important for engagement.

  View details for PubMedID 29294791

• Development and Internal Validation of a Clinical Risk Score for Treating Children With Mild Head Trauma and Intracranial Injury. JAMA pediatrics Greenberg, J. K., Yan, Y., Carpenter, C. R., Lumba-Brown, A., Keller, M. S., Pineda, J. A., Brownson, R. C., Limbrick, D. D. 2017

  Abstract

  The appropriate treatment of children with mild traumatic brain injury (mTBI) and intracranial injury (ICI) on computed tomographic imaging remains unclear. Evidence-based risk assessments may improve patient safety and reduce resource use.To derive a risk score predicting the need for intensive care unit observation in children with mTBI and ICI.This retrospective analysis of the prospective Pediatric Emergency Care Applied Research Network (PECARN) head injury cohort study included patients enrolled in 25 North American emergency departments from 2004 to 2006. We included patients younger than 18 years with mTBI (Glasgow Coma Scale [GCS] score, 13-15) and ICI on computed tomography. The data analysis was conducted from May 2015 to October 2016.The primary outcome was the composite of neurosurgical intervention, intubation for more than 24 hours for TBI, or death from TBI. Multivariate logistic regression was used to predict the outcome. The C statistic was used to quantify discrimination, and model performance was internally validated using 10-fold cross-validation. Based on this modeling, the Children's Intracranial Injury Decision Aid score was created.Among 15 162 children with GCS 13 to 15 head injuries who received head computed tomographic imaging in the emergency department, 839 (5.5%) had ICI. The median ages of those with and without a composite outcome were 7 and 5 years, respectively. Among those patients with ICI, 8.7% (n = 73) experienced the primary outcome, including 8.3% (n = 70) who had a neurosurgical intervention. The only clinical variable significantly associated with outcome was GCS score (odds ratio [OR], 3.4; 95% CI, 1.5-7.4 for GCS score 13 vs 15). Significant radiologic predictors included midline shift (OR, 6.8; 95% CI, 3.4-13.8), depressed skull fracture (OR, 6.5; 95% CI, 3.7-11.4), and epidural hematoma (OR, 3.4; 95% CI, 1.8-6.2). The model C statistic was 0.84 (95% CI, 0.79-0.88); the 10-fold cross-validated C statistic was 0.83. Based on this modeling, we developed the Children's Intracranial Injury Decision Aid score, which ranged from 0 to 24 points. The negative predictive value of having 0 points (ie, none of these risk factors) was 98.8% (95% CI, 97.3%-99.6%).Lower GCS score, midline shift, depressed skull fracture, and epidural hematoma are key risk factors for needing intensive care unit-level care in children with mTBI and ICI. Based on these results, the Children's Intracranial Injury Decision Aid score is a potentially novel tool to risk stratify this population, thereby aiding management decisions.

  View details for DOI 10.1001/jamapediatrics.2016.4520

  View details for PubMedID 28192567

• Service Delivery in the Healthcare and Educational Systems for Children Following Traumatic Brain Injury: Gaps in Care. The Journal of head trauma rehabilitation Haarbauer-Krupa, J., Ciccia, A., Dodd, J., Ettel, D., Kurowski, B., Lumba-Brown, A., Suskauer, S. 2017

  Abstract

  To provide a review of evidence and consensus-based description of healthcare and educational service delivery and related recommendations for children with traumatic brain injury.Literature review and group discussion of best practices in management of children with traumatic brain injury (TBI) was performed to facilitate consensus-based recommendations from the American Congress on Rehabilitation Medicine's Pediatric and Adolescent Task Force on Brain Injury. This group represented pediatric researchers in public health, medicine, psychology, rehabilitation, and education.Care for children with TBI in healthcare and educational systems is not well coordinated or integrated, resulting in increased risk for poor outcomes. Potential solutions include identifying at-risk children following TBI, evaluating their need for rehabilitation and transitional services, and improving utilization of educational services that support children across the lifespan.Children with TBI are at risk for long-term consequences requiring management as well as monitoring following the injury. Current systems of care have challenges and inconsistencies leading to gaps in service delivery. Further efforts to improve knowledge of the long-term TBI effects in children, child and family needs, and identify best practices in pathways of care are essential for optimal care of children following TBI.

  View details for DOI 10.1097/HTR.0000000000000287

  View details for PubMedID 28060211

• 183 A Clinical Risk Score for Managing Children With Glasgow Coma Scale 13 to 15 Head Injuries and Intracranial Injury. Neurosurgery Greenberg, J. K., Yan, Y., Carpenter, C., Lumba-Brown, A., Keller, M. S., Pineda, J. A., Brownson, R. C., Limbrick, D. D. 2016; 63: 172-173

  Abstract

  Although rigorous decision tools exist to evaluate the need for commuted tomography (CT) imaging in children with Glasgow Coma Scale (GCS) score 13 to 15 head injuries, the appropriate management in children with intracranial injury (ICI) on CT remains unclear. The purpose of this study was to develop a risk score to predict neurosurgical intervention (NI), a concrete measure of neurological impairment or decline requiring intensive care unit observation.We included patients younger than 18 years with GCS score 13 to 15 that were enrolled in 1 of 25 hospitals participating in the prospective Pediatric Emergency Care Applied Research Network (PECARN) head injury study and had ICI identified on CT. We used multivariable logistic regression on 10 imputed data sets to identify independent predictors of NI, and used the model β-coefficients to develop a clinical risk score.Among 42 735 children with GCS 13 to 15 head injuries, 15 162 received a head CT scan and 846 had ICI. Among these patients, 8.3% required NI and no patients died. The most common type of ICI was subdural hematoma (24% of patients). Clinical variables independently associated with NI included palpable depressed skull fracture (odds ratio [OR] = 2.3) and GCS score of 13 (OR = 2.9) or 14 (OR = 1.2); radiological predictors included midline shift (OR = 7.2), epidural hematoma (OR = 1.3), and any skull fracture on CT (OR = 2.1). The model c-statistic was 0.81. Using the model's β-coefficients, the Children's Intracranial Injury Decision Aid (CHIIDA) score was created, which ranged from zero (2% risk of NI) to 27 (96% risk of NI) points.Midline shift, epidural hematoma, any radiological skull fracture, palpable depressed skull fracture, and GCS score accurately predict the risk of NI in children with GCS 13 to 15 head injury and ICI. Based on these results, the CHIIDA score is a novel clinical decision tool to aid physicians caring for these patients.

  View details for DOI 10.1227/01.neu.0000489752.67038.e7

  View details for PubMedID 27399462

• PEMNetwork Barriers and Enablers to Collaboration and Multimedia Education in the Digital Age PEDIATRIC EMERGENCY CARE Lumba-Brown, A., Tat, S., Auerbach, M. A., Kessler, D. O., Alletag, M., Grover, P., Schnadower, D., Macias, C. G., Chang, T. P. 2016; 32 (8): 565-569

  Abstract

  In January 2005, PEMFellows.com was created to unify fellows in pediatric emergency medicine. Since then, the website has expanded, contracted, and focused to adapt to the interests of the pediatric emergency medicine practitioner during the internet boom. This review details the innovation of the PEMNetwork, from the inception of the initial website and its evolution into a needs-based, user-directed educational hub. Barriers and enablers to success are detailed with unique examples from descriptive analysis and metrics of PEMNetwork web traffic as well as examples from other online medical communities and digital education websites.

  View details for PubMedID 27490735

• Essentials of PEM Fellowship Part 2: The Profession in Entrustable Professional Activities PEDIATRIC EMERGENCY CARE Hsu, D., Nypaver, M., Fein, D. M., McAneney, C., Santen, S., Nagler, J., Zuckerbraun, N., Roskind, C. G., Reynolds, S., Zaveri, P., Stankovic, C., House, J. B., Langhan, M., Titus, M. O., Dahl-Grove, D., Klasner, A. E., Ramirez, J., Chang, T., Jacobs, E., Chapman, J., Lumba-Brown, A., Thompson, T., Mittiga, M., Eldridge, C., Heffner, V., Herman, B. E., Kennedy, C., Madhok, M., Kou, M. 2016; 32 (6): 410-418

  Abstract

  This article is the second in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine (PEM) fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article describes the development of PEM entrustable professional activities (EPAs) and the relationship of these EPAs with existing taxonomies of assessment and learning within PEM fellowship. It summarizes the field in concepts that can be taught and assessed, packaging the PEM subspecialty into EPAs.

  View details for DOI 10.1097/PEC.0000000000000827

  View details for PubMedID 27253361

• Firearm injuries in the pediatric population: A tale of one city JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Choi, P. M., Hong, C., Bansal, S., Lumba-Brown, A., Fitzpatrick, C. M., Keller, M. S. 2016; 80 (1): 64-69

  Abstract

  Firearm-related injuries are a significant cause of morbidity and mortality in children. To determine current trends and assess avenues for future interventions, we examined the epidemiology and outcome of pediatric firearm injuries managed at our region's two major pediatric trauma centers.Following institutional review board approval, we conducted a 5-year retrospective review of all pediatric firearm victims, 16 years or younger, treated at either of the region's two Level 1 pediatric trauma centers, St. Louis Children's Hospital and Cardinal Glennon Children's Medical Center.There were 398 children treated during a 5-year period (2008-2013) for firearm-related injuries. Of these children, 314 (78.9%) were black. Overall, there were 20 mortalities (5%). Although most (67.6%) patients were between 14 years and 16 years of age, younger victims had a greater morbidity and mortality. The majority of injuries were categorized as assault/intentional (65%) and occurred between 6:00 pm and midnight, outside the curfew hours enforced by the city. Despite a regional decrease in the overall incidence of firearm injuries during the study period, the rate of accidental victims per year remained stable. Most accidental shootings occurred in the home (74.2%) and were self-inflicted (37.9%) or caused by a person known to the victim (40.4%).Despite a relative decrease in intentional firearm-related injuries, a constant rate of accidental shootings suggest an area for further intervention.Prognostic and epidemiologic study, level IV.

  View details for DOI 10.1097/TA.0000000000000893

  View details for Web of Science ID 000367544400009

  View details for PubMedID 26491805

• Emergency Neurological Life Support: Traumatic Brain Injury NEUROCRITICAL CARE Garvin, R., Venkatasubramanian, C., Lumba-Brown, A., Miller, C. M. 2015; 23: S143-S154

  Abstract

  Traumatic Brain Injury (TBI) was chosen as an Emergency Neurological Life Support topic due to its frequency, the impact of early intervention on outcomes for patients with TBI, and the need for an organized approach to the care of such patients within the emergency setting. This protocol was designed to enumerate the practice steps that should be considered within the first critical hour of neurological injury.

  View details for DOI 10.1007/s12028-015-0176-z

  View details for Web of Science ID 000367463100014

• Emergency Neurological Life Support: Traumatic Brain Injury. Neurocritical care Garvin, R., Venkatasubramanian, C., Lumba-Brown, A., Miller, C. M. 2015; 23 Suppl 2: S143-54

  Abstract

  Traumatic Brain Injury (TBI) was chosen as an Emergency Neurological Life Support topic due to its frequency, the impact of early intervention on outcomes for patients with TBI, and the need for an organized approach to the care of such patients within the emergency setting. This protocol was designed to enumerate the practice steps that should be considered within the first critical hour of neurological injury.

  View details for DOI 10.1007/s12028-015-0176-z

  View details for PubMedID 26438466

• Evidence-Based Assessment of Severe Pediatric Traumatic Brain Injury and Emergent Neurocritical Care SEMINARS IN PEDIATRIC NEUROLOGY Lumba-Brown, A., Pineda, J. 2014; 21 (4): 275-283

  Abstract

  Pediatric traumatic brain injury accounts for approximately 474,000 emergency department visits, 37,000 hospitalizations, and 3,000 deaths in children 14 years and younger annually in the United States. Acute neurocritical care in children has advanced with specialized pediatric trauma centers and emergency medical services. This article reviews pediatric-specific diagnosis, management, and medical decision making related to the neurocritical care of severe traumatic brain injury.

  View details for DOI 10.1016/j.spen.2014.11.001

  View details for Web of Science ID 000350996200006

  View details for PubMedID 25727509

• Hypertonic saline as a therapy for pediatric concussive pain: a randomized controlled trial of symptom treatment in the emergency department. Pediatric emergency care Lumba-Brown, A., Harley, J., Lucio, S., Vaida, F., Hilfiker, M. 2014; 30 (3): 139-145

  Abstract

  Three-percent hypertonic saline (HTS) is a hyperosmotic therapy used in pediatric traumatic brain injury to treat increased intracranial pressure and cerebral edema. It also promotes plasma volume expansion and cerebral perfusion pressure, immunomodulation, and anti-inflammatory response. We hypothesized that HTS will improve concussive symptoms of mild traumatic brain injury.The study was a prospective, double-blind, randomized controlled trial. Children, 4 to 7 years of age with a Glasgow Coma Scale score greater than 13, were enrolled from a pediatric emergency department following closed-head injury upon meeting Acute Concussion Evaluation criteria with head pain. Patients were randomized to receive 10 mL/kg of HTS or normal saline (NS) over 1 hour. Self-reported pain values were obtained using the Wong-Baker FACES Pain Rating Scale initially, immediately following fluids, and at 2 to 3 days of discharge. The primary outcome measure was change in self-reported pain following fluid administration. Secondary outcome measures were a change in pain and postconcussive symptoms within 2 to 3 days of fluid administration. We used an intention-to-treat analysis.Forty-four patients, ranging from 7 to 16 years of age with comparable characteristics, were enrolled in the study; 23 patients (52%) received HTS, and 21 (48%) received NS. There was a significant difference (P < 0.001) identified in the self-reported improvement of pain following fluid administration between the HTS group (mean improvement = 3.5) and the NS group (mean improvement = 1.1). There was a significant difference (P = 0.01) identified in the self-reported improvement of pain at 2 to 3 days after treatment between the HTS group (mean improvement = 4.6) and the NS group (mean improvement = 3.0). We were unable to determine a difference in other postconcussive symptoms following discharge.Three-percent HTS is more effective than NS in acutely reducing concussion pain in children.

  View details for DOI 10.1097/PEC.0000000000000084

  View details for PubMedID 24583571