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Wrist fractures are common injuries associated with high disability in the early recovery period. The impact of wrist fractures on safe return to drive is not understood. (1) To compare the proportion of adults who were drivers in car crashes before and after wrist fracture; (2) To examine potential factors (demographic and/or clinical) associated with increased odds of being a driver in a car crash following wrist fracture. Retrospective cohort study. Three state-wide government datasets (MainRoads Western Australia [WA], Hospital Morbidity Data Collection and the Emergency Department Data Collection) were used to obtain and link demographic, clinical and car crash information relating to adults with a wrist fracture sustained between 2008 and 2017. McNemar's tests were used to compare the proportion of drivers in a car crash within the 2 years prior to and following the fracture date. Multivariable logistic regressions were used to identify if any variables were associated with increased odds of crashing in the post-fracture period. Data relating to 37,107 adults revealed a 3.3% (95% CI 3.0%–3.6%, p < 0.05) decrease in the proportion of drivers in a car crash following wrist fracture, persisting for the entire 2 years post-fracture, when compared to the proportion who crashed before their fracture. Those with more severe wrist fracture injury patterns had 79%(95% CI 1.07–3.0, p = 0.03) higher odds of having a crash in the first 3 months following their injury, compared to those with isolated wrist fracture injuries. These results inform and update return to drive recommendations. The reduced proportion of drivers involved in crashes following wrist fracture persisted for 2 years; longer than the expected physical recovery timeframe. It is important that hand therapists actively educate the sub-group of adults with more severe wrist fracture injury patterns of the increased likelihood of car crash for the 3 months following their fracture. • This the first paper to report on car crashes following wrist fracture. • We provide much needed information to assist with return to drive decision-making. • Those with severe injury had 79% higher odds of crashing in the initial 3-months. • Education is recommended for the sub-group with 3-months of increased crash risk. [ABSTRACT FROM AUTHOR]

Perinatal stroke causes hemiparetic cerebral palsy (HCP) and lifelong disability. Constraint-induced movement therapy (CIMT) and neurostimulation may enhance motor function, but the individual factors associated with responsiveness are undetermined. We explored the clinical and neurophysiological factors associated with responsiveness to CIMT and/or brain stimulation within a clinical trial. PLASTIC CHAMPS was a randomized, blinded, sham-controlled trial (n = 45) of CIMT and neurostimulation paired with intensive, goal-directed therapy. Primary outcome was the Assisting Hand Assessment (AHA). Classification trees created through recursive partitioning suggested clinical and neurophysiological profiles associated with improvement at 6-months. Both clinical (stroke side (left) and age >14 years) and neurophysiological (intracortical inhibition/facilitation and motor threshold) were associated with responsiveness across treatment groups with positive predictive values (PPV) approaching 80%. This preliminary analysis suggested sets of variables that may be associated with response to intensive therapies in HCP. Further modeling in larger trials is required. [ABSTRACT FROM AUTHOR]

In Tanzania, maternal and newborn deaths can be prevented via quality facility-based antenatal care (ANC), delivery, and postnatal care (PNC). Scalable, integrated, and comprehensive interventions addressing demand and service-side care-seeking barriers are needed. Assess coverage survey indicators before and after a comprehensive maternal newborn health (MNH) intervention in Misungwi District, Tanzania. A prospective, single-arm, pre- (2016) and post-(2019) coverage survey (ClinicalTrials.gov #NCT02506413) was used to assess key maternal and newborn health (MNH) outcomes. The Mama na Mtoto intervention included district activities (planning, leadership training, supportive supervision), health facility activities (training, equipment, infrastructure upgrades), and plus community health worker mobilization. Implementation change strategies, a process model, and a motivational framework incorporated best practices from a similar Ugandan intervention. Cluster sampling randomized hamlets then used 'wedge sampling' protocol as an alternative to full household enumeration. Key outcomes included: four or more ANC visits (ANC4+); skilled birth attendant (SBA); PNC for mother within 48 hours (PNC-woman); health facility delivery (HFD); and PNC for newborn within 48 hours (PNC-baby). Trained interviewers administered the 'Real Accountability: Data Analysis for Results Coverage Survey to women 15–49 years old. Descriptive statistics incorporated design effect; the Lives Saved Tool estimated deaths averted based on ANC4+/HFD. Between baseline (n = 2,431) and endline (n = 2,070), surveys revealed significant absolute percentage increases for ANC4+ (+11.6, 95% CI [5.4, 17.7], p < 0.001), SBA (+16.6, 95% CI [11.1, 22.0], p < 0.001), PNC-woman (+9.2, 95% CI [3.2, 15.2], p = 0.002), and HFD (+17.2%, 95% CI [11.3, 23.1], p < 0.001). A PNC-baby increase (+6.1%, 95% CI [−0.5, 12.8], p = 0.07) was not statistically significant. An estimated 121 neonatal and 20 maternal lives were saved between 2016 and 2019. Full-district scale-up of a comprehensive MNH package embedded government health system was successfully implemented over a short time and associated with significant maternal care-seeking improvements and potential for lives saved. [ABSTRACT FROM AUTHOR]

Background: Prenatal medical risk describes physical health issues or biological factors that predate or arise during pregnancy which heighten the risk of adverse outcomes, and often warrant specialized obstetric care. The influence of the nature and magnitude of prenatal risk on breastfeeding outcomes remains poorly understood. The objective of this study was to determine the association between prenatal medical risk and breastfeeding initiation and duration up to 1 year postpartum. Methods: We analysed a subset of data from the All Our Families longitudinal cohort (n = 2706) of women in Calgary, Canada who delivered a liveborn infant between 2008 and 2010. Data were collected from self-report questionnaires and medical records. Women with complete data on prenatal medical risk factors and breastfeeding outcomes were included in this analysis. Prenatal medical risk was operationalized as one integer score of risk severity and four binary risk types capturing pre-pregnancy characteristics, past obstetric problems, current obstetric problems, and substance use. Outcomes were breastfeeding initiation defined as the infant ever receiving breast milk, and duration operationalized as still breastfeeding at 4 months, at 12 months, and time to breastfeeding cessation in weeks. We used logistic regression and Cox regression with right censoring at 52 weeks or attrition to calculate odds ratios (OR) and hazard ratios (HR), respectively, adjusting for sociodemographic vulnerability, parity, mode of delivery, and gestational age. Results: Prenatal medical risk severity and type were not significantly associated with breastfeeding initiation, with the exception of pre-pregnancy risk type (OR 0.45; 95% CI 0.26, 0.77). Risk severity was associated with lower odds of breastfeeding to 4 months (OR 0.94; 95% CI 0.90, 0.99), 12 months (OR 0.93; 95% CI 0.87, 0.98), and earlier breastfeeding cessation (HR 1.05; 95% CI 1.02, 1.08). Associations with shorter breastfeeding length across the first postpartum year were observed for pre-pregnancy, current obstetric, and substance use risk types, but not past obstetric problems. Conclusion: Prenatal medical risk is associated with shortened duration of breastfeeding. Women with prenatal medical risk may benefit from the proactive arrangement of lactation support before and following delivery to promote continued breastfeeding. [ABSTRACT FROM AUTHOR]

Background The ability to identify bacterial pathogens that necessitate specific clinical management or public health action in children with acute gastroenteritis is crucial to patient care and public health. However, existing stool-testing guidelines offer inconsistent recommendations, and their performance characteristics are unknown. We evaluated 6 leading gastroenteritis guidelines (eg, those of the Centers for Disease Control and Prevention and Infectious Disease Society of America) that recommend when to test children's stool for bacterial enteropathogens. Methods Via 2 emergency departments in Alberta, Canada, we enrolled 2447 children <18 years old who presented with ≥3 episodes of diarrhea and/or vomiting in a 24-hour period. All participants were tested for 9 bacterial enteropathogens: Aeromonas, Campylobacter, Escherichia coli O157, other Shiga toxin–producing E. coli , enterotoxigenic E. coli , Salmonella, Shigella, Vibrio, and Yersinia. Patient data gathered at the index visit were used to determine whether guidelines would recommend testing. Sensitivity and specificity to recommend testing for children with bacterial enteropathogens were calculated for each guideline. Results Outcome data were available for 2391 (97.7%) participants, and 6% (144/2391) of participants tested positive for a bacterial enteropathogen. Guideline sensitivity ranged from 25.8% (95% confidence interval [CI] 18.7–33.0%) to 66.9% (95% CI 59.3–74.6%), and varied for individual pathogens. Guideline specificity for all bacterial enteropathogens ranged from 63.6% (95% CI 61.6–65.6%) to 96.5% (95% CI 95.7–97.2%). Conclusions No guideline provided optimally balanced performance. The most sensitive guidelines missed one-third of cases and would drastically increase testing volumes. The most specific guidelines missed almost 75% of cases. [ABSTRACT FROM AUTHOR]

* STUDY DESIGN: Historical cohort study. * BACKGROUND: History of a knee joint injury and increased fat mass are risk factors for joint disease. * OBJECTIVE: The objective of this study was to examine differences in adiposity, physical activity, and cardiorespiratory fitness between youths with a 3- to 10-year history of sport-related intra-articular knee injury and uninjured controls. *METHODS: Ore hundred young adults (aged 15-26 years; 55% female) with a sport-related intra-articular knee injury sustained 3 to 10 years previously and 100 controls matched for age, sex, and sport, who had no history of intra-articular knee injury, were recruited. Fat mass index (FMI) and abdominal fat (fat mass at the L1 to L4 vertebral levels) we re derived using dual-energy X-ray absorptiometry. Physical activity and cardiorespiratory fitness were measured using the Godin Leisure-Time Exercise Questionnaire and the multistage 20-meter shuttle run test for aerobic fitness, respectively. * RESULTS: Previously injured participants demonstrated higher FMI (within-pair difference, 1.05 kg/m²; 95% confidence interval [Cl]: 0.53, 1.57) and abdominal fat (461 g; 95% Cl: 228, 694) than uninjured controls. In multivariable linear regression analysis, previous injury was significantly associated with increased FMI. This increase was attenuated in those who participated in higher levels of physical activity or had higher estimated maximum volume of oxygen. * CONCLUSION: As a risk factor for osteoarthritis in an already susceptible group, excess adiposity is an undesirable trait in the potential pathway to joint disease. Increasing physical activity in this population may be a potential intervention to reduce adiposity thus impede disease initiation and/or progression. [ABSTRACT FROM AUTHOR]

Objectives The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments ( EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies. Methods Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression. Results Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014). Conclusions Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes. [ABSTRACT FROM AUTHOR]

Background Environmental audit tools must be reliable in order to accurately estimate the association between built environmental characteristics and bicycling injury risk. Objective To examine the inter-rater agreement of a built environment audit tool within a case-control study on the environmental determinants of bicycling injuries. Methods Auditor pairs visited locations where bicycling injuries occurred and independently recorded location characteristics using the Systematic Pedestrian and Cyclist Environmental Scan (SPACES). Two case groups were defined: (1) where a bicyclist was struck by a motor-vehicle (MV) and (2) where the bicyclist's injuries required hospitalisation. The two corresponding control groups were (1) where non-MV bicycle-related injuries occurred and (2) where minor bicycle-related injuries occurred. Inter-rater reliability of each item on the tool was assessed using observed agreement and κ with 95% CI. Results Ninety-seven locations were audited. Interobserver agreement was generally high (≥95%); most items had a 1-2% difference in responses. Items with ≥5% differences between raters included path condition, slope and obstructions. For land use, path and roadway characteristics,κ ranged from 0.3 for presence of offices and cleanliness to 0.9 for schools and number of lanes; overall, 78% of items had at least substantial agreement (κ≥0.61). For bicyclists struck by a MV the proportion of items with substantial agreement was 60%, compared with 73% for non-MV related injuries. For hospitalisations and minor bicycle-related injuries, 76% of items had substantial agreement. Conclusions Agreement was substantial for most, but not all SPACES items. The SPACES provides reliable quantitative descriptions of built environmental characteristics at bicycling injury locations. [ABSTRACT FROM AUTHOR]

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Background: Young children with end-stage renal disease (ESRD) requiring renal replacement therapy (RRT) have traditionally experienced high rates of morbidity and mortality; however, detailed long-term follow-up data is limited. Methods: Using a population-based retrospective cohort with data from a national organ failure registry and administrative data from Canada's universal health care system, we analysed the outcomes of 87 children starting RRT (before age 2 years) and followed them until death or date of last contact [median follow-up 4.7 years, interquartile range (IQR) 1.4-9.8). We assessed secular trends in survival and the influence of: (1) age at start of RRT and (2) etiology of ESRD with survival and time to transplantation. Results: Patients were mostly male (69.0 %) with ESRD predominantly due to renal malformations (54.0 %). Peritoneal dialysis was the most common initial RRT (83.9 %). Fifty-seven (65.5 %) children received a renal transplant (median age at first transplant: 2.7 years, IQR 2.0-3.3). During 490 patient-years of follow-up, there were 23 (26.4 %) deaths, of which 22 occurred in patients who had not received a transplant. Mortality was greater for patients commencing dialysis between 1992 and 1999 and among the youngest children starting RRT (0-3 months). Children with ESRD secondary to renal malformations had better survival than those with ESRD due to other causes. Among the transplanted patients, all but one survived to the end of the observation period. Conclusion: Children who start RRT before 3 months of age have a high risk of mortality. Among our paediatric patient cohort, mortality rates were much lower among children who had received a renal transplant. [ABSTRACT FROM AUTHOR]

Background. Adolescent friendships have been linked to physical activity levels; however, network characteristics have not been broadly examined. Method. In a cross-sectional analysis of 1061 adolescents (11-15 years), achieving 60 minutes/day of moderateto- vigorous physical activity (MVPA) and participating in over 2 hours/day of sedentary behaviour were determined based on friendship network characteristics (density; proportion of active/sedentary friends; betweenness centrality; popularity; clique membership) and perceived social support. Results. Adolescents with no friendship nominations participated in less MVPA. For boys and girls, a ten percent point increase in active friends was positively associated with achievement of 60 minutes/day of MVPA (OR 1.11; 95% CI 1.02-1.21, OR 1.14; 95% CI 1.02-1.27, resp.). For boys, higher social support from friends was negatively associated with achieving 60 minutes/day ofMVPA(OR 0.63; 95%CI 0.42-0.96). Compared with lowdensity networks, boys in higher density networks were more likely to participate in over 2 hours/day of sedentary behaviour (OR 2.93; 95% CI 1.32-6.49). Social support fromfriends alsomodified associations between network characteristics andMVPAand sedentary behaviour. Conclusion. Different network characteristics appeared to have different consequences.The proportion of active close friends was associated withMVPA, while network density was associated with sedentary behaviour.This poses challenges for intervention design. [ABSTRACT FROM AUTHOR]

Objective: To determine injured body regions and injury type resulting from snowboarding on aerial and nonaerial terrain park features and the accuracy of ski patrol assessments compared with physician diagnoses. Design: Case series study. Setting: An Alberta terrain park during the 2008-2009 and 2009-2010 seasons. Patients: There were 333 snowboarders injured on features (379 injuries). Assessment of Risk Factors: Aerial or nonaerial terrain park feature used at injury, injured body region, injury type, and additional risk factors were recorded from ski patrol Accident Report Forms, emergency department medical records, and telephone interviews. Measures: Odds of injury to body regions and injury types on aerial versus nonaerial features were calculated using multinomial logistic regression. Accuracy of ski patrol injury assessments was examined through sensitivity, specificity, and kappa (κ) statistics. Results: The wrist was the most commonly injured body region (20%), and fracture was the most common injury type (36%). Compared with the upper extremity, the odds of head/neck [odds ratio (OR), 2.58; 95% confidence interval (CI), 1.37-4.85] and trunk (OR, 3.65; 95% CI, 1.68-7.95) injuries were significantly greater on aerial features. There was no significant association between aerial versus nonaerial feature and injury type. The accuracy of ski patrol injury assessment was higher for injured body region (K = 0.65; 95% CI, 0.54-0.75) than for injury type (k = 0.29; 95% CI, 0.22-0.37). Conclusions: Snowboarders were significantly more likely to sustain head/neck or trunk injuries than upper extremity injuries on aerial features. Investigators should acknowledge potential misclassification when using ski patrol injury assessments. [ABSTRACT FROM AUTHOR]

BACKGROUND: Approximately 25% of children with concussion have persistent postconcussive symptoms (PPCS) with resultant significant impacts on quality of life. Melatonin has significant neuroprotective properties, and promising preclinical data suggest its potential to improve outcomes after traumatic brain injury. We hypothesized that treatment with melatonin would result in a greater decrease in PPCS symptoms when compared with a placebo. METHODS: We conducted a randomized, double-blind trial of 3 or 10 mg of melatonin compared with a placebo (NCT01874847). We included youth (ages 8-18 years) with PPCS at 4 to 6 weeks after mild traumatic brain injury. Those with significant medical or psychiatric histories or a previous concussion within the last 3 months were excluded. The primary outcome was change in the total youth self-reported Post-Concussion Symptom Inventory score measured after 28 days of treatment. Secondary outcomes included change in health- related quality of life, cognition, and sleep. RESULTS: Ninety-nine children (mean age: 13.8 years; SD = 2.6 years; 58% girls) were randomly assigned. Symptoms improved over time with a median Post-Concussion Symptom Inventory change score of -21 (95% confidence interval [CI]: -16 to -27). There was no significant effect of melatonin when compared with a placebo in the intention-to-treat analysis (3 mg melatonin, -2 [95% CI: -13 to 6]; 10 mg melatonin, 4 [95% CI: -7 to 14]). No significant group differences in secondary outcomes were observed. Side effects were mild and similar to the placebo. CONCLUSIONS: Children with PPCS had significant impairment in their quality of life. Seventy-eight percent demonstrated significant recovery between 1 and 3 months postinjury. This clinical trial does not support the use of melatonin for the treatment of pediatric PPCS. [ABSTRACT FROM AUTHOR]

Purpose: Active youth are vulnerable to knee injury and subsequent osteoarthritis. Improved understanding of the association between health-related outcomes and history of joint injury could inform osteoarthritis prevention strategies. The purpose of this historical cohort study is to examine the association between youth sport–related knee injury and various clinical, physiological, behavioral, and functional health-related outcomes, 3–10 yr postinjury. Methods: Participants included 100 individuals who experienced a youth sport–related knee injury 3–10 yr earlier and 100 age-, sex-, and sport-matched uninjured controls. Outcomes include the following: Knee Injury and Osteoarthritis Outcome Score (KOOS), Intermittent and Constant Osteoarthritis Pain Score, body mass index (BMI), fat mass index (FMI), weekly physical activity, estimated aerobic capacity, hip and knee muscle strength, and dynamic balance. Baseline characteristics were described. Multivariable regression models (95% confidence interval [CI]) were used to evaluate the association between injury history and each outcome, considering the influence of sex and time since injury. Results: Participant median age was 22 yr (range, 15–26 yr), and 55% were female. The injured group demonstrated poorer KOOS subscale scores, more total and intermittent pain, higher BMI (1.8 kg·m−2; 95% CI = 0.9–2.6), higher FMI (1.1 kg·m−2; 95% CI = 0.5–1.6), weaker knee extensor (−0.18 N·m·kg−1; 95% CI = −0.33 to −0.02) and flexor (−0.21 N·m·kg−1; 95% CI = −0.30 to −0.11) muscles, and poorer balance than controls. In the previously injured group, female sex was associated with poorer KOOS quality-of-life scores, knee flexor strength, and greater FMI, whereas longer time since injury was associated with poorer KOOS symptoms scores, knee extensor strength, and balance outcomes. Conclusion: Youth that suffer a sport-related knee injury demonstrate on average more negative health-related outcomes consistent with future osteoarthritis compared with uninjured matched controls 3–10 yr after injury. These negative outcomes differ by sex and time since injury. [ABSTRACT FROM AUTHOR]

Objective: To examine a school-based high-intensity neuromuscular training (NMT) program in reducing sport injury risk and improving fitness in youth. Participants: Students (ages 11-15) (n = 725) in physical education (PE) classes were randomized by school to intervention or control groups. Intervention: A 12-week high-intensity NMT program (including aerobic, strength, balance, and agility components) was designed to reduce sport injury risk and improve measures of fitness. The control program was a standard of practice warm-up (including running and stretching). Results: A Poisson regression model using an intent-to-treat analysis demonstrated a reduced risk of sport injury: incidence rate ratio (IRR)all injury = 0.30 (95% CI, 0.19-0.49), IRRlower extremity injury = 0.31 (95% CI, 0.19-0.51), IRRankle sprain injury = 0.27 (95% CI, 0.15-0.50), and IRRknee sprain injury = 0.36 (95% CI, 0.13-0.98). A change in waist circumference: 20.99 centimeters (95% CI, 21.84 to 20.14) and an increase in indirect measures of aerobic fitness: 1.28 mL⋅kg-1 ⋅min-1 (95% CI, 0.66-1.90) in the intervention school compared with the control school also occurred. Conclusions: A NMT program in junior high school PE class was efficacious in reducing sport-related injury and improving measures of adiposity and fitness in the intervention group. [ABSTRACT FROM AUTHOR]

Background Individuals with post-traumatic osteoarthritis demonstrate increased sway during quiet stance. The prospective association between balance and disease onset is unknown. Improved understanding of balance in the period between joint injury and disease onset could inform secondary prevention strategies to prevent or delay the disease. This study examines the association between youth sport-related knee injury and balance, 3–10 years post-injury. Methods Participants included 50 individuals (ages 15–26 years) with a sport-related intra-articular knee injury sustained 3–10 years previously and 50 uninjured age-, sex- and sport-matched controls. Force-plate measures during single-limb stance (center-of-pressure 95% ellipse-area, path length, excursion, entropic half-life) and field-based balance scores (triple single-leg hop, star-excursion, unipedal dynamic balance) were collected. Descriptive statistics (mean within-pair difference; 95% confidence intervals) were used to compare groups. Linear regression (adjusted for injury history) was used to assess the relationship between ellipse-area and field-based scores. Findings Injured participants on average demonstrated greater medio-lateral excursion [mean within-pair difference (95% confidence interval); 2.8 mm (1.0, 4.5)], more regular medio-lateral position [10 ms (2, 18)], and shorter triple single-leg hop distances [− 30.9% (− 8.1, − 53.7)] than controls, while no between group differences existed for the remaining outcomes. After taking into consideration injury history, triple single leg hop scores demonstrated a linear association with ellipse area (β = 0.52, 95% confidence interval 0.01, 1.01). Interpretation On average the injured participants adjusted their position less frequently and demonstrated a larger magnitude of movement during single-limb stance compared to controls. These findings support the evaluation of balance outcomes in the period between knee injury and post-traumatic osteoarthritis onset. [ABSTRACT FROM AUTHOR]