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Purpose: To evaluate the effect of implementing a new pain assessment tool in a trauma/neurosurgical ICU. Outcome measures were patient and staff satisfaction, frequency of pain documentation, and amount of [...]

Abstract Background Homelessness and poverty are important social problems, and reducing the prevalence of homelessness and the incidence of injury and illness among people who are homeless would have significant financial, societal, and individual implications. Recent research has identified high rates of traumatic brain injury (TBI) among this population, but to date there has not been a review of the literature on this topic. The objective of this systematic review was to review the current state of the literature on TBI and homelessness in order to identify knowledge gaps and direct future research. Methods A systematic literature search was conducted in PsycINFO (1887–2012), Embase (1947–2012), and MEDLINE/Pubmed (1966–2012) to identify all published research studies on TBI and homelessness. Data on setting, sampling, outcome measures, and rate of TBI were extracted from these studies. Results Eight research studies were identified. The rate of TBI among samples of persons who were homeless varied across studies, ranging from 8%-53%. Across the studies there was generally little information to adequately describe the research setting, sample sizes were small and consisted mainly of adult males, demographic information was not well described, and validated screening tools were rarely used. The methodological quality of the studies included was generally moderate and there was little information to illustrate that the studies were adequately powered or that study samples were representative of the source population. There was also an absence of qualitative studies in the literature. Conclusions The rate of TBI is higher among persons who are homeless as compared to the general population. Both descriptive and interventional studies of individuals who are homeless should include a psychometrically sound measure of history of TBI and related disability. Education of caregivers of persons who are at risk of becoming, or are homeless, should involve training on TBI. Dissemination of knowledge to key stakeholders such as people who are homeless, their families, and public policy makers is also advocated.

Introduction: Workplace violence (WPV) is a significant concern in healthcare settings and indicates the need for accurate reporting to plan and implement effective interventions. This article presents the results of a quality improvement (QI) initiative implemented at a large academic health sciences center to improve the reporting of WPV events., Methods: The Plan-Do-Study-Act (PDSA) model was adopted to optimize the electronic reporting process, reduce inaccuracies of WPV reporting, and ensure appropriate follow-up from leadership and the Workplace Health, Safety, and Wellness (WHSW) team. Over two PDSA cycles, modifications of an electronic incident reporting form were made., Results: The proportion of inaccurate reporting was significantly lower (χ 2 (1, N = 1,219) = 111.86, p = .001), after the QI initiative. In addition, the revisions increased staff follow-up and support from WHSW., Conclusions: Our QI initiative demonstrated that simple adjustments to our WPV reporting, with the revision of an electronic reporting form, had a significant improvement on incident data accuracy and staff follow-up. These findings will contribute to our organization's staff and patient safety., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2025 National Association for Healthcare Quality.)

The clinical externship program for nursing students was developed and implemented during the COVID-19 pandemic at a multi-site healthcare organization. The program aimed to address the critical shortage of health human resources by hiring qualifying undergraduate nursing and diploma program practical nursing students as unregulated care providers to meet staffing needs. The program incorporated a structured orientation, providing a mix of e-learning modules, in-person learning and shifts with an assigned preceptor. The program also included guidelines to define roles and responsibilities, ensuring safe integration of externs into the healthcare setting. A qualitative study design was employed using semi-structured interviews to explore the perceptions and experiences of the clinical externs (CEs), the extern mentor coordinators and the unit managers involved in the program. Five major themes emerged from the study, including the importance of orientation and the need for increased role clarity. The findings underscore the value of this opportunity both for nursing students as CEs and the broader healthcare system. This study provides valuable insights for nurse leaders aiming to develop or expand clinical externship programs, highlighting their potential to address health human resource challenges and enhance the preparedness and integration of nursing students into the healthcare workforce., (Copyright © 2024 Longwoods Publishing.)

A research fellowship geared toward registered practical nurses was designed to support the nurse's knowledge development in practice-based research. In this paper, we describe a six-month fellowship experience, which comprised research education, application and mentorship. Through the implementation of the research fellowship, we identified six components necessary for success, which include program infrastructure, application of training and leadership development. The research fellowship framework can support nurse leaders in the professional development of their nursing staff through building research capacity. Our fellowship description can also help guide the implementation of similar initiatives at other acute care sites., (Copyright © 2024 Longwoods Publishing.)

Background: Warfarin dosing in cardiac surgery patients is complicated by a heightened sensitivity to the drug, predisposing patients to adverse events. Predictive algorithms are therefore needed to guide warfarin dosing in cardiac surgery patients., Objective: This study aimed to develop and validate an algorithm for predicting the warfarin dose needed to attain a therapeutic international normalized ratio (INR) at the time of discharge in cardiac surgery patients., Methods: We abstracted variables influencing warfarin dosage from the records of 1031 encounters initiating warfarin between April 1, 2011, and November 29, 2019, at St Michael's Hospital in Toronto, Ontario, Canada. We compared the performance of penalized linear regression, k-nearest neighbors, random forest regression, gradient boosting, multivariate adaptive regression splines, and an ensemble model combining the predictions of the 5 regression models. We developed and validated separate models for predicting the warfarin dose required for achieving a discharge INR of 2.0-3.0 in patients undergoing all forms of cardiac surgery except mechanical mitral valve replacement and a discharge INR of 2.5-3.5 in patients receiving a mechanical mitral valve replacement. For the former, we selected 80% of encounters (n=780) who had initiated warfarin during their hospital admission and had achieved a target INR of 2.0-3.0 at the time of discharge as the training cohort. Following 10-fold cross-validation, model accuracy was evaluated in a test cohort comprised solely of cardiac surgery patients. For patients requiring a target INR of 2.5-3.5 (n=165), we used leave-p-out cross-validation (p=3 observations) to estimate model performance. For each approach, we determined the mean absolute error (MAE) and the proportion of predictions within 20% of the true warfarin dose. We retrospectively evaluated the best-performing algorithm in clinical practice by comparing the proportion of cardiovascular surgery patients discharged with a therapeutic INR before (April 2011 and July 2019) and following (September 2021 and May 2, 2022) its implementation in routine care., Results: Random forest regression was the best-performing model for patients with a target INR of 2.0-3.0, an MAE of 1.13 mg, and 39.5% of predictions of falling within 20% of the actual therapeutic discharge dose. For patients with a target INR of 2.5-3.5, the ensemble model performed best, with an MAE of 1.11 mg and 43.6% of predictions being within 20% of the actual therapeutic discharge dose. The proportion of cardiovascular surgery patients discharged with a therapeutic INR before and following implementation of these algorithms in clinical practice was 47.5% (305/641) and 61.1% (11/18), respectively., Conclusions: Machine learning algorithms based on routinely available clinical data can help guide initial warfarin dosing in cardiac surgery patients and optimize the postsurgical anticoagulation of these patients., (©Lindsay Dryden, Jacquelin Song, Teresa J Valenzano, Zhen Yang, Meggie Debnath, Rebecca Lin, Jane Topolovec-Vranic, Muhammad Mamdani, Tony Antoniou. Originally published in JMIR Cardio (https://cardio.jmir.org), 06.12.2023.)

Structured morning rounds have been used to improve communication, provide learning opportunities, and support patient care in various healthcare settings. The leadership team in an inner-city Inpatient Mental Health Unit identified a gap in the structure of morning rounds; to remedy this, a standardized reporting tool and structured morning rounding process were implemented. This short communication reports on an evaluation of staff...s perceptions on the outcomes of using a standardized reporting tool and structured rounding process to improve efficiency and communication regarding patient care among an interprofessional team. Feedback was provided on logistics, attendance, supporting factors that ensured ease of use for the new structure, and benefits of the program. While this evaluation focuses on the opinions of nurses, it serves as an example for leadership in various healthcare units on the benefits of a structured rounding program, and key factors that contribute to making the process successful. This short communication also provides an example for an efficient communication tool that can be adapted to meet the needs of various groups of healthcare disciplines., (Copyright © 2022. Published by Elsevier Inc.)

Representatives from various practice-based research programs have come together to establish a Canadian Practice-Based Research Network (CP-BRN). CP-BRN is a collective of healthcare leaders focused on identifying approaches and leveraging resources to support clinician-led research to advance evidence-based practice. This paper presents an overview of the development of the CP-BRN, the proceedings from the inaugural meeting of CPBRN members, and recommendations for nursing and allied health profession leaders considering establishing their own practice-based research programs. Next steps for the network are to raise awareness of its mission, expand the network membership as to grow its influence among healthcare leaders and to further advance evidence-based practice across both healthcare and academic institutions., (Copyright © 2022. Published by Elsevier Inc.)

Background: Dissemination of practice-based research findings is critical to advancing evidence and improving practice. While frontline clinicians are well-positioned to identify gaps in practice-based evidence, many barriers exist that challenge their ability to write and submit manuscripts for publication., Purpose: Our study examined whether a manuscript writing workshop effectively increased nursing and health discipline clinicians' self-perceived confidence in manuscript writing., Method: Participants recruited from an ongoing manuscript writing workshop completed an assessment tool at the beginning and end of each session. Thirty-one assessment tools were completed., Results: Participants reported higher levels of confidence following participation in the manuscript writing sessions. They also noted high levels of satisfaction with the session., Conclusions: A manuscript writing workshop providing a supportive environment, mentorship, protected time, and quiet space is an effective way for leadership to increase confidence in manuscript writing amongst nursing and health disciplines clinicians., (Copyright © 2022. Published by Elsevier Inc.)

Background: Traumatic brain injury (TBI) has a higher prevalence in the homeless population. Caregivers to individuals who have TBIs may require better education surrounding screening, diagnosis and management of this disease to tailor interventions to their clients' needs., Objective: To assess the insight and educational needs of homeless care providers in recognizing and dealing with clients who had experienced a TBI., Methods: A survey assessing the point of views of homeless care providers across Canada regarding their level of confidence in identifying and managing symptoms of TBI., Results: Eight-eight completed surveys were included. Overall, frontline workers expressed a moderate level of confidence in identifying and managing TBI, stating that educational initiatives in this context would be of high value to themselves and their clients., Conclusions: Frontline workers to homeless clients rate their educational needs on the identification and management of TBI to be high such that educational initiatives for shelter workers across Canada may be beneficial to increase their knowledge in identifying and managing the TBI-related symptoms. Improved education would not only benefit frontline workers but may also have a positive effect on health outcomes for their clients.

Context: Many brain-injured patients are unable to self-report their pain during their hospitalization in the intensive care unit (ICU), and existing behavioral pain scales may not be well suited., Objectives: The objectives of this study were to describe and compare behaviors in brain-injured patients with different levels of consciousness during nociceptive and nonnociceptive care procedures in the ICU and to examine interrater agreement of individual behaviors as well as discriminative and criterion validation of putative pain behaviors., Methods: Brain-injured ICU patients were observed using a 40-item behavioral checklist before and during soft touch (i.e., nonnociceptive procedure), turning, and other care procedures (nociceptive) by pairs of trained raters. When possible, patients self-reported their pain on a 0-10 visual thermometer. Patients were classified into unconscious (Glasgow Coma Scale, 3

Objective: The goal of this research was to assess the effectiveness of available concussion educational resources in Canada, the means used to disseminate this knowledge and the impact of these educational resources on players' concussion prevention knowledge. Methods: We assessed concussion knowledge before and after exposure to one or more of 19 resources introduced through a national program aimed to increase awareness and knowledge of concussion. The effectiveness of the mode of delivery was measured by changes in concussion knowledge scores (CKS) between pre and pro scores. Measures: Concussion knowledge scores (CKS) were calculated for pre- and post- exposure to concussion educational resources and used as a measure of both, the effectiveness of each resource as well as the effectiveness of the delivery method. The effectiveness of each educational resource was also measured by the respondents' rating of each concussion educational resource. Results: Respondents in post-survey had higher CKS than those in pre-survey. Two out of the 19 newly developed concussion educational resources were effective in improving the resource users' CKS. Linear regression showed that using more resources further increased CKS. Four out of six modes of delivery enhanced respondents' concussion knowledge. Conclusion: Our findings demonstrate that the newly developed Canadian concussion educational resources were effective at improving users' concussion knowledge. Our data demonstrates that using three or more resources further enhanced the users' concussion knowledge. Future research, however, is critical to assess whether concussion prevention knowledge is sufficient to reduce injuries and factors influencing it.

Background: The evidence shows that brain-injured patients express behaviours that are related to their level of consciousness (LOC), and different from other patients in the intensive care unit (ICU). Therefore, existing behavioural scales should be revised to enhance their content and validity for use in these patients., Objectives: The aim was to evaluate the content relevance of behaviours and autonomic responses for pain assessment of brain-injured ICU patients from the perspective of critical care clinicians., Methods: A total of 77 clinicians from four adult neuroscience ICUs (three from Canada and one from the United States) participated in this descriptive study. A physician/nurse ratio of 21% (13/61) was reached in this quota sample, and three physiotherapists also participated. They completed a content validation questionnaire of 19 items rated on clarity and relevance based on the patient's LOC. Item Content Validity Index (I-CVI), and modified kappa (κ*) were calculated. Values higher than 0.78 and 0.75 respectively were considered excellent., Results: Regardless of the patient's LOC, brow lowering, grimacing, and trying to reach the pain site were rated as the most relevant behaviours by clinicians, with excellent values of I-CVI>0.78 and κ*>0.75. Eyes tightly closed, moaning and verbal complaints of pain also obtained excellent values in altered LOC and conscious patients. Eye weeping obtained excellent values only in conscious patients. Other items showed fair (0.40-0.59) to good (0.60-0.74) values, while blinking and coughing showed poor values (<0.40) at various LOC., Conclusions: Facial expressions, movements towards the pain site, and vocalisation of pain were the most relevant pain-related behaviours rated by critical care clinicians. The relevance of some behaviours (e.g., moaning and verbal complaints of pain) varied across LOCs, thereby calling forth adaptations of behavioural pain scales to allow for interpretation in the context of a patient's LOC and ability to express specific behaviours., (Copyright © 2017. Published by Elsevier Ltd.)

Objectives: Sport-related traumatic brain injuries are a significant public health burden, with hundreds of thousands sustained annually in North America. While sports offer numerous physical and social health benefits, traumatic brain injuries such as concussion can seriously impact a player's life, athletic career, and sport enjoyment. The culture in many sports encourages winning at all costs, placing athletes at risk for traumatic brain injuries. As social media has become a central part of everyday life, the content of users' messages often reflects the prevailing culture related to a particular event or health issue., Methods: We hypothesized that Twitter data might be useful for understanding public perceptions and misperceptions of sport-related traumatic brain injuries. We performed a content and sentiment analysis of 7483 Twitter ® tweets related to traumatic brain injuries in sports collected during June and July 2013., Results: We identified five major themes. Users tweeted about personal traumatic brain injuries experiences, reported traumatic brain injuries in professional athletes, shared research about sport-related concussions, and discussed policy and safety in injury prevention, such as helmet use. We identified mixed perceptions of and sentiment toward traumatic brain injuries in sports: both an understanding that brain injuries are serious and disregard for activities that might reduce the public burden of traumatic brain injuries were prevalent in our Twitter analysis., Conclusion: While the scientific and medical community considers a concussion a form of traumatic brain injuries, our study demonstrates a misunderstanding of this fact among the public. In our current digital age, social media can provide useful insight into the culture around a health issue, facilitating implementation of prevention and treatment strategies., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The present study is to identify factors contributing to underreporting of concussion in adolescent athletes., Design: Qualitative interviews., Setting: Participants were interviewed in an office environment., Participants: Interviews were conducted with 31 minor hockey players, 10 parents, 6 coaches, 4 trainers, 2 managers, and one game official. Players were 13 to 15 year old. With selective sampling, an inductive approach of analyzing the interviews was undertaken and themes were identified and analyzed., Assessment of Risk Factors: Underreporting is a complex phenomenon. A number of risk factors related to hockey culture, players, reference others, and rules of play were assessed., Main Outcome Measures: Reasons not reporting concussion is accepted in minor hockey., Results: Aspects of hockey culture such as an overemphasis on winning games and upheld misperceptions about the risks associated with concussion were identified as relevant to the underreporting of concussions. Various factors relevant to the underreporting of concussions include player's motivation to win, group membership dynamics such as a player's role as the team's "enforcer," coaches' own motivation to win to further their own opportunities in the sport, and parents' personal financial interest or alternative agenda in terms of time commitments and their child's future career prospects., Conclusions: Our findings indicate that underreporting of concussion among those players interviewed appears to be prevalent and associated with misconceptions about injury risk, and a culture that both reinforces and encourages underreporting with tacit or overt complicity of parents and coaches. Our findings support the need to alter the culture of violence and tough play in hockey by education, rule changes, economic measures, and changes in governance of the sport. Interviewing more stakeholders and policy makers would shed light on such potential interventions.

Neurofeedback therapy (NFT) has been used within a number of populations however it has not been applied or thoroughly examined as a form of cognitive rehabilitation within a stroke population. Objectives for this systematic review included: i) identifying how NFT is utilized to treat cognitive deficits following stroke, ii) examining the strength and quality of evidence to support the use of NFT as a form of cognitive rehabilitation therapy (CRT) and iii) providing recommendations for future investigations. Searches were conducted using OVID (Medline, Health Star, Embase + Embase Classic) and PubMed databases. Additional searches were completed using the Cochrane Reviews library database, Google Scholar, the University of Toronto online library catalogue, ClinicalTrials.gov website and select journals. Searches were completed Feb/March 2015 and updated in June/July/Aug 2015. Eight studies were eligible for inclusion in this review. Studies were eligible for inclusion if they: i) were specific to a stroke population, ii) delivered CRT via a NFT protocol, iii) included participants who were affected by a cognitive deficit(s) following stroke (i.e. memory loss, loss of executive function, speech impairment etc.). NFT protocols were highly specific and varied within each study. The majority of studies identified improvements in participant cognitive deficits following the initiation of therapy. Reviewers assessed study quality using the Downs and Black Checklist for Measuring Study Quality tool; limited study quality and strength of evidence restricted generalizability of conclusions regarding the use of this therapy to the greater stroke population. Progression in this field requires further inquiry to strengthen methodology quality and study design. Future investigations should aim to standardize NFT protocols in an effort to understand the dose-response relationship between NFT and improvements in functional outcome. Future investigations should also place a large emphasis on long-term participant follow-up.

Objective: characterize the prevalence of self-reported head injury with loss of consciousness (LOC) and associated demographic, clinical and service use factors in a sample of homeless adults with mental illness., Method: Participants in the At Home/Chez Soi study were interviewed at the time of study enrollment regarding their history of head injuries, mental and physical health diagnoses and justice system and healthcare interactions. Sociodemographic and clinical data were also collected., Results: Over half of the 2088 study respondents (52.6%, n = 1098) reported a history of head injury with a LOC, which was associated with several demographic, clinical and service use variables in this population. With respect to specific mental health conditions, a history of head injury with LOC was associated with higher odds of current depression (OR = 2.18, CI: 1.83-2.60), manic episode or hypomanic episode (OR = 1.91, CI: 1.45-2.50), PTSD (OR = 2.98, CI: 2.44-3.65), panic disorder (OR = 2.37, CI:1.91-2.93), mood disorder (OR = 1.78, CI: 1.40-2.26) and alcohol (OR = 2.09, CI: 1.75-2.49) and drug (OR = 1.73, CI: 1.46-2.06) misuse disorders, but reduced odds of having diagnosis of a psychotic disorder (OR = 0.63, CI: 0.53-0.76). A history of head injury with LOC was also associated with increased use of variety of services, including family medicine (OR = 1.33, CI: 1.12-1.59), criminal justice system (OR = 1.50, CI: 1.25-1.80) and the emergency department (OR = 1.03, CI: 1.01-1.05)., Conclusions: Amongst homeless adults with mental illness having a history of head injuries with LOC was independently associated with various adverse outcomes. These individuals constitute a high-risk group who may benefit from specialized services., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objectives: To determine the predictors of knowledge and awareness of concussion symptoms and outcomes through a survey of athletes, parents of players and coaches in sports settings in Canada., Methods: A cross-sectional survey of athletic communities in Canada was conducted. Respondents' concussion knowledge score consists of responses to questions about the symptoms, diagnosis, and treatment of a concussion and the timing of return-to-sport post-concussion. The percentage of correct responses was defined as the "identification rate." The extent to which participant factors affected the scores was examined by univariate and multivariate analyses., Results: Respondents were able to identify a mean of 80.6% of symptoms. Cognitive symptoms were most commonly known, and mental health symptoms associated with concussion were least known, and health professionals, coaches, and those with a personal history of concussion had the highest levels of overall knowledge. Language, age, educational level, annual household income, and traumatic brain injury history were good predictors of better concussion knowledge., Conclusion: Those designing and implementing interventions aimed at concussion management and prevention should ensure that younger, lower income, lower educational, non-English-speaking persons, and those without experience of traumatic brain injury or concussion be specifically accounted for in the design and implementation of interventions to prevent and treat concussion and mild traumatic brain injury., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Recruiting an adequate number of participants into medical research studies is challenging for many researchers. Over the past 10 years, the use of social media websites has increased in the general population. Consequently, social media websites are a new, powerful method for recruiting participants into such studies., Objective: The objective was to answer the following questions: (1) Is the use of social media more effective at research participant recruitment than traditional methods? (2) Does social media recruit a sample of research participants comparable to that recruited via other methods? (3) Is social media more cost-effective at research participant recruitment than traditional methods?, Methods: Using the MEDLINE, PsycINFO, and EMBASE databases, all medical research studies that used social media and at least one other method for recruitment were identified. These studies were then categorized as either interventional studies or observational studies. For each study, the effectiveness of recruitment, demographic characteristics of the participants, and cost-effectiveness of recruitment using social media were evaluated and compared with that of the other methods used. The social media sites used in recruitment were identified, and if a study stated that the target population was "difficult to reach" as identified by the authors of the study, this was noted., Results: Out of 30 studies, 12 found social media to be the most effective recruitment method, 15 did not, and 3 found social media to be equally effective as another recruitment method. Of the 12 studies that found social media to be the best recruitment method, 8 were observational studies while 4 were interventional studies. Of the 15 studies that did not find social media to be the best recruitment method, 7 were interventional studies while 8 were observational studies. In total, 8 studies stated that the target population was "hard-to-reach," and 6 of these studies found social media to be the most effective recruitment method. Out of 14 studies that reported demographic data for participants, 2 studies found that social media recruited a sample comparable to that recruited via traditional methods and 12 did not. Out of 13 studies that reported cost-effectiveness, 5 studies found social media to be the most cost-effective recruitment method, 7 did not, and 1 study found social media equally cost-effective as compared with other methods., Conclusions: Only 12 studies out of 30 found social media to be the most effective recruitment method. There is evidence that social media can be the best recruitment method for hard-to-reach populations and observational studies. With only 30 studies having compared recruitment through social media with other methods, more studies need to be done that report the effectiveness of recruitment for each strategy, demographics of participants recruited, and cost-effectiveness of each method., Competing Interests: Conflicts of Interest: None declared., (©Jane Topolovec-Vranic, Karthik Natarajan. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 07.11.2016.)

The Advanced Trauma Care for Nurses (ATCN) course was designed to help nurses increase their knowledge in management of the multiple trauma patient. To determine whether the trauma-related knowledge of ATCN course takers differed from nontakers, assess the factors associated with ATCN content knowledge among course takers, and explore the extent to which the ATCN content was used by course takers in their clinical practice. A cross-sectional online survey of 78 ATCN takers (nurses who had successfully completed the ATCN course within the previous 3 years) and 58 ATCN nontakers (a control group of nurses who had not taken the course but who worked in comparable clinical settings) was conducted. The survey consisted of demographic questions and a 15-item knowledge test spanning the ATCN course content. ATCN takers were also asked about the frequency with which a specific ATCN content had been used in their practice since taking the course. ATCN takers had a significantly higher (mean ± SD = 10.6 ± 2.2) total score on the study test than the ATCN nontakers (mean ± SD = 6.4 ± 2.6); t(134) = -10.0, p < .001. A shorter time since course completion was associated with higher knowledge scores. ATCN takers rated the clinical relevance and applicability of the course content as high. The findings suggest that completing the ATCN course increases knowledge levels of trauma patient management and that the ATCN course content is clinically relevant to the nurses. However, higher knowledge scores were observed for the most recent study participants, suggesting that booster sessions for ATCN course participants may be warranted.

Background: In North America, more than 800,000 youth are registered in organized ice hockey leagues. Despite the many benefits of involvement, young players are at significant risk for injury. Body-checking and aggressive play are associated with high frequency of game-related injury including concussion. We conducted a qualitative study to understand why youth ice hockey players engage in aggressive, injury-prone behaviours on the ice., Methods: Semi-structured interviews were conducted with 61 minor ice hockey participants, including male and female players, parents, coaches, trainers, managers and a game official. Players were aged 13-15 playing on competitive body checking teams or on non-body checking teams. Interviews were manually transcribed, coded and analyzed for themes relating to aggressive play in minor ice hockey., Results: Parents, coaches, teammates and the media exert a large influence on player behavior. Aggressive behavior is often reinforced by the player's social environment and justified by players to demonstrate loyalty to teammates and especially injured teammates by seeking revenge particularly in competitive, body-checking leagues. Among female and male players in non-body checking organizations, aggressive play is not reinforced by the social environment. These findings are discussed within the framework of social identity theory and social learning theory, in order to understand players' need to seek revenge and how the social environment reinforces aggressive behaviors., Conclusion: This study provides a better understanding of the players' motivations and environmental influences around aggressive and violent play which may be conducive to injury. The findings can be used to help design interventions aimed at reducing aggression and related injuries sustained during ice hockey and sports with similar cultures and rules.

Objective: The aim of this study was to determine the effectiveness of the canalith repositioning procedure (CRP) in the treatment of benign paroxysmal positional vertigo (BPPV) among patients after mild-to-moderate traumatic brain injury., Methods: An unblinded, nonrandomized, case comparison interventional study with repeated measures (1, 5, 9, and 12 weeks postenrollment) of three groups of patients with traumatic brain injury (BPPV, n = 21; nonspecific dizziness, n = 23; no dizziness, n = 12) was conducted. Patients in the BPPV group received the CRP at baseline and repeatedly until a negative Dix-Hallpike Maneuver was observed. Participants in the other two groups did not receive the CRP., Results: Symptom resolution at the 12-week follow-up was observed in 75% of patients in the BPPV group versus 8.3% in the nonspecific dizziness group (p = .0006). A significant Group × Time interaction was observed for the Dizziness Handicap Inventory (F = 4.2, p = .003) and 36-item Short Form Health Questionnaire physical component scores (F = 2.16, p = .035) with the BPPV group showing significantly improved scores by the 12-week follow-up. Although there were between-group differences on the 36-item Short Form Health Questionnaire mental health component scores (F = 4.06, p = .022), changes over time were not significant in the groups., Conclusions: Treatment with the CRP for posttraumatic BPPV resulted in significant symptom resolution and improvement in perceived physical health status.

Background: Traumatic brain injury (TBI) elicits intense sympathetic nervous system (SNS) activation with profuse catecholamine secretion. The resultant hyperadrenergic state is linked to immunomodulation both within the brain and systemically. Dysregulated inflammation post-TBI exacerbates secondary brain injury and contributes to unfavorable patient outcomes including death. The aim of this study was to characterize the early dynamic profile of circulating inflammatory cytokines/chemokines in patients admitted for moderate-to-severe TBI, to examine interrelationships between these mediators and catecholamines, as well as clinical indices of injury severity and neurological outcome., Methods: Blood was sampled from 166 isolated TBI patients (aged 45 ± 20.3 years; 74.7 % male) on admission, 6-, 12-, and 24-h post-injury and from healthy controls (N = 21). Plasma cytokine [interleukin (IL)-1β, -2, -4, -5, -10, -12p70, -13, tumor necrosis factor (TNF)-α, interferon (IFN)-γ] and chemokine [IL-8, eotaxin, eotaxin-3, IFN-γ-induced protein (IP)-10, monocyte chemoattractant protein (MCP)-1, -4, macrophage-derived chemokine (MDC), macrophage inflammatory protein (MIP)-1β, thymus activation regulated chemokine (TARC)] concentrations were analyzed using high-sensitivity electrochemiluminescence multiplex immunoassays. Plasma catecholamines [epinephrine (Epi), norepinephrine (NE)] were measured by immunoassay. Neurological outcome at 6 months was assessed using the extended Glasgow outcome scale (GOSE) dichotomized as good (>4) or poor (≤4) outcomes., Results: Patients showed altered levels of IL-10 and all chemokines assayed relative to controls. Significant differences in a number of markers were evident between moderate and severe TBI cohorts. Elevated IL-8, IL-10, and TNF-α, as well as alterations in 8 of 9 chemokines, were associated with poor outcome at 6 months. Notably, a positive association was found between Epi and IL-1β, IL-10, Eotaxin, IL-8, and MCP-1. NE was positively associated with IL-1β, IL-10, TNF-α, eotaxin, IL-8, IP-10, and MCP-1., Conclusions: Our results provide further evidence that exaggerated SNS activation acutely after isolated TBI in humans may contribute to harmful peripheral inflammatory cytokine/chemokine dysregulation. These findings are consistent with a potentially beneficial role for therapies aimed at modulating the inflammatory response and hyperadrenergic state acutely post-injury.

Antisaccades are thought to involve higher level inputs from neural centers involved in rapid eye movement inhibition and control. Previous work has demonstrated that performance on the antisaccade task can help in the assessment of injury in acute and/or chronic mild traumatic brain injury (mTBI). In this exploratory study, we performed cross-sectional and longitudinal comparisons of rapid eye movement, followed by correlations of antisaccade performance with assessments of symptom burden, diffusion tensor imaging, and a neuropsychological test of response inhibition. Significant deficits in antisaccade median latency, F(2, 31) = 3.65, p = 0.04 and prosaccade error mean duration, F(2, 31) = 3.63, p = 0.04 were found between patient groups and controls: the former was correlated with loss of white matter integrity in the splenium of the corpus callosum in acute mTBI, rho = 0.90, p = 0.0005. Furthermore, increased antisaccade median latency was also correlated with poor performance on an executive functioning task, r (2) = 0.439, p = 0.03, and greater symptom burden, r (2) = 0.480, p = 0.02 in the acute mTBI patients. Our preliminary research suggests that the antisaccade task could be useful as a neurological marker for mTBI and concussion, but more work is required.

Objective: To evaluate the awareness of concussion-related symptoms amongst members of the sports community in Canada., Methods: A cross-sectional national electronic survey was conducted. Youth athletes, parents, coaches and medical professionals across Canada were recruited through mailing lists from sports-related opt-in marketing databases. Participants were asked to identify, from a list of options, the symptoms of a concussion. The proportion of identified symptoms (categorized as physical, cognitive, mental health-related and overall) as well as participant factors associated with symptom recognition were analyzed., Results: The survey elicited 6,937 responses. Most of the respondents (92.1%) completed the English language survey, were male (57.7%), 35-54 years of age (61.7%), with post-secondary education (58.2%), or high reported yearly household income (>$80,000; 53.0%). There were respondents from all provinces and territories with the majority of respondents from Ontario (35.2%) or British Columbia (19.1%). While participants identified most of the physical (mean = 84.2% of symptoms) and cognitive (mean = 91.2% of symptoms), they on average only identified 53.5% of the mental health-related symptoms of concussions. Respondents who were older, with higher education and household income, or resided in the Northwest Territories or Alberta identified significantly more of the mental health-related symptoms listed., Interpretation: While Canadian youth athletes, parents, coaches and medical professionals are able to identify most of the physical and cognitive symptoms associated with concussion, identification of mental health-related symptoms of concussion is still lagging.

Background: Depression is a common comorbidity in individuals with cognitive impairment. Those with cognitive impairments face unique challenges in receiving the benefits of many conventional therapies for depression, and may have poorer outcomes in areas such as recovery and quality of life. However, the stigmatization of mental health disorders, cost barriers and physical disabilities may prevent these individuals from seeking mental health care. An online, self-help intervention specifically developed for adults with cognitive deficits and depression may be particularly beneficial to this population. We aim to inform the design of such an intervention through a systematic review by answering the following research question: among adults with cognitive impairment (including those with acquired brain injuries or neurodegenerative diseases), which technology-amenable interventions have been shown to effectively decrease symptoms of depression? Specifically, psychotherapeutic and/or behavioural interventions that could be delivered in a self-guided, online system will be included., Methods: Comprehensive electronic searches will be conducted in MEDLINE, EMBASE, PsycINFO and CINAHL. Additional studies will be obtained through manually searching the references of relevant systematic reviews, contacting primary authors of select articles and tracking conference proceedings and trial registries. Article titles and abstracts will be screened using predefined eligibility criteria, and then judged for their amenability to the proposed self-help, technology-based intervention. The full text of those articles with selected interventions will then be screened to determine final eligibility for inclusion. Included articles will be categorized by intervention type and assessed for risk of bias using the Cochrane Effective Practice and Organization of Care Risk of Bias tool for non-randomized trials, controlled before-after studies and interrupted time series. The primary outcome will be a change in score on a validated depression scale, and adverse events will be documented as a secondary outcome. After data extraction from selected articles, pooling of data and meta-analysis will be conducted if a sufficient pool of studies with comparable methodology and quality are identified. Alternatively, plain language summaries will be developed. The quality of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system., Systematic Review Registration: PROSPERO CRD42014014417.

Cognitive impairment may interfere with an individual's ability to function independently in the community and may increase the risk of becoming and remaining homeless. The purpose of this study was to systematically review the literature on memory deficits among people who are homeless in order to gain a better understanding of its nature, causes and prevalence. Studies that measured memory functioning as an outcome among a sample of homeless persons were included. Data on sampling, outcome measures, facet of memory explored and prevalence of memory impairment were extracted from all selected research studies. Included studies were evaluated using a critical appraisal process targetted for reviewing prevalence studies. Eleven studies were included in the review. Verbal memory was the most commonly studied facet of memory. Potential contributing factors to memory deficits among persons who are homeless were explored in seven studies. Memory deficits were common among the samples of homeless persons studied. However, there was a great deal of variation in the methodology and quality of the included studies. Conceptualisations of "homelessness" also differed across studies. There is a need for more controlled research using validated neuropsychological tools to evaluate memory impairment among people who are homeless.

Purpose: Pain behaviors such as grimacing and muscle rigidity are recommended for pain assessment in nonverbal populations. However, these behaviors may not be appropriate for critically ill patients with a traumatic brain injury (TBI) depending on their level of consciousness (LOC). This study aimed to validate the use of behaviors for assessing pain of critically ill TBI adults with different LOC., Methods: Using a repeated measure within subject design, participants (N=45) were observed for 1 minute before (baseline), during, and 15 minutes after 2 procedures: (1) noninvasive blood pressure: NIBP (non-nociceptive); and (2) turning (nociceptive). A behavioral checklist combining 50 items from existing pain assessment tools and video recording were used to describe participants' behaviors. Intrarater and interrater agreements of observed behaviors were also examined., Results: Overall, pain behaviors were observed more frequently during turning (median=4; T=-5.336; P≤0.001) than at baseline (median=1), or during noninvasive blood pressure (median=0). TBI patients' pain behaviors were mostly "atypical" and included uncommon responses such as flushing, sudden eye opening, eye weeping, and flexion of limbs. These behaviors were observed in ≥25.0% of TBI participants during turning independent of their LOC, and in 22.2% to 66.7% of conscious participants who reported the presence of pain. Agreements were >92% among and between the 2 raters., Conclusions: This study support previous findings that critically ill TBI patients could exhibit atypical behaviors when exposed to nociceptive procedures. As such, use of current recommended pain behaviors as part of standardized scales may not be optimal for assessing the analgesic needs of this vulnerable group.

Background: Although depression is known to affect millions of people worldwide, individuals seeking aid from qualified health care professionals are faced with a number of barriers to treatment including a lack of treatment resources, limited number of qualified service providers, stigma associated with diagnosis and treatment, prolonged wait times, cost, and barriers to accessibility such as transportation and clinic locations. The delivery of depression interventions through the Internet may provide a practical solution to addressing some of these barriers., Objective: The purpose of this scoping review was to answer the following questions: (1) What Web-delivered programs are currently available that offer an interactive treatment component for depression?, (2) What are the contents, accessibility, and usability of each identified program?, and (3) What tools, supports, and research evidence are available for each identified program?, Methods: Using the popular search engines Google, Yahoo, and Bing (Canadian platforms), two reviewers independently searched for interactive Web-based interventions targeting the treatment of depression. The Beacon website, an information portal for online health applications, was also consulted. For each identified program, accessibility, usability, tools, support, and research evidence were evaluated and programs were categorized as evidence-based versus non-evidence-based if they had been the subject of at least one randomized controlled trial. Programs were scored using a 28-point rating system, and evidence- versus non-evidence-based programs were compared and contrasted. Although this review included all programs meeting exclusion and inclusion criteria found using the described search method, only English language Web-delivered depression programs were awarded an evaluation score., Results: The review identified 32 programs meeting inclusion criteria. There was a great deal of variability among the programs captured in this evaluation. Many of the programs were developed for general adolescent or adult audiences, with few (n=2) focusing on special populations (eg, military personnel, older adults). Cognitive behavioral therapy was the most common therapeutic approach used in the programs described. Program interactive components included mood assessments and supplementary homework sheets such as activity planning and goal setting. Only 12 of the programs had published evidence in support of their efficacy and treatment of depressive symptoms., Conclusions: There are a number of interactive depression interventions available through the Internet. Recommendations for future programs, or the adaptation of existing programs include offering a greater selection of alternative languages, removing registration restrictions, free trial periods for programs requiring user fees, and amending programs to meet the needs of special populations (eg, those with cognitive and/or visual impairments). Furthermore, discussion of specific and relevant topics to the target audience while also enhancing overall user control would contribute to a more accessible intervention tool.

Introduction: Alterations from first-party and surrogate decision-maker consent can enhance the feasibility of research involving critically ill patients., Objective: To describe the use of a deferred-consent model to enable participation of critically ill patients in a minimal-risk biomarker study., Methods: A prospective observational study was conducted in which serum biomarker samples were collected three times daily over the first 14 days following aneurysmal subarachnoid hemorrhage. Sample collection was initiated on intensive care unit admission and consent was obtained when research personnel could approach the patient or the patient's surrogate decision maker., Results: Twenty-seven patients were eligible for the study, of whom only five were capable of providing informed consent. Full consent was obtained for 21 (78%) patients through self- (n=4) and surrogate (n=17) consent. Partial consent or refusal (only permitting the collection of blood samples as a part of routine care or use of data) occurred in three patients. Among the 22 consents sought from surrogates, three (11%) refused participation. The refusals included the sickest patients in the cohort. Once consent was provided, no patient or surrogate withdrew consent before study completion., Discussion: Use of a deferred consent model enabled participation of critically ill patients in a minimal-risk biomarker study with no withdrawals., Conclusions: Further research and enhanced awareness of the potential utility of hybrid models, including deferred consent in addition to patient or surrogate consent, in the conduct of low-risk and minimally interventional time-sensitive studies of critically ill patients are required.

Background: Every year, millions of people worldwide suffer traumatic brain injuries (TBIs). Aggressive behavior, a known psychological symptom following TBI, has been regarded as an obstacle toward rehabilitation. Having measures that accurately assess aggression during rehabilitation is critical toward proper evaluation., Objective: To undertake a systematic review of the validated scales used to assess aggression in the postacute stage (≥3 months) after sustaining a TBI in the adult population. A comprehensive search was performed and studies meeting the inclusion criteria were reviewed in full. Quality and validity of supporting articles were assessed via the Downs and Black and QUADAS checklists along with their supporting statistics., Results: A total of 1329 articles were reviewed from the literature. Thirty-two were reviewed in detail and 6 studies eventually passed the exclusion criteria. Of these, 6 neuropsychological scales were represented pertaining to the measurement of aggressive behavior; however, only 1 directly addressed the validity of their scale's aggression component., Conclusions: Further research is required to establish the validity of scales that specifically address aggression for use in the adult TBI population which could be used to support rehabilitation and social reintegration strategies.

Purpose: To examine cognitive performance among a sample of men in a residential unit of an urban homeless shelter and to compare cognitive performance between those with and without a history of traumatic brain injury (TBI)., Methods: An exploratory, quantitative study of participants recruited through convenience sampling. Participants were screened for TBI using the Brain Injury Screening Questionnaire, and cognitive function using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Data were analyzed to examine associations between TBI status and cognitive performance., Results: Thirty-four participants were recruited for the study: n = 12 with a positive and n = 22 with a negative screen for TBI. Both groups performed below norms in all cognitive domains measured by the RBANS. Those with a positive screen for TBI performed significantly worse on attention tasks than those with a negative screen for TBI (p = 0.026). RBANS scores were not associated with either mental health or substance abuse status., Conclusions: A history of TBI was associated with generally poorer cognitive performance in the study sample. An improved awareness of TBI and cognitive dysfunction among service providers and routine TBI screening could improve treatment and service delivery for this population.

Background. Many critically ill patients with a traumatic brain injury (TBI) are unable to communicate. While observation of behaviors is recommended for pain assessment in nonverbal populations, they are undetectable in TBI patients who are under the effects of neuroblocking agents. Aim. This study aimed to validate the use of vital signs for pain detection in critically ill TBI patients. Methods. Using a repeated measure within subject design, participants (N = 45) were observed for 1 minute before (baseline), during, and 15 minutes after two procedures: noninvasive blood pressure: NIBP (nonnociceptive) and turning (nociceptive). At each assessment, vital signs (e.g., systolic, diastolic, mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), capillary saturation (SpO2), end-tidal CO2, and intracranial pressure (ICP)) were recorded. Results. Significant fluctuations (P < 0.05) in diastolic (F = 6.087), HR (F = 3.566), SpO2 (F = 5.740), and ICP (F = 3.776) were found across assessments, but they were similar during both procedures. In contrast, RR was found to increase exclusively during turning (t = 3.933; P < 0.001) and was correlated to participants' self-report. Conclusions. Findings from this study support previous ones that vital signs are not specific for pain detection. While RR could be a potential pain indicator in critical care, further research is warranted to support its validity in TBI patients with different LOC.

Background: Studies have demonstrated that patients in the intensive care unit experience high levels of pain. While many of these patients are nonverbal at some point during their stay, there are few valid tools available to assess pain in this group., Objectives: To evaluate the validity and clinical utility of two pain assessment tools, the revised Adult Non-Verbal Pain Scale (NVPS-R) and the Critical Care Pain Observation Tool (CPOT), in a trauma and neurosurgical patient population., Methods: Patients were assessed using the NVPS-R and CPOT by trained intensive care unit nurses (n=23) and research assistants before, during and after two procedures: turning of the patient (nociceptive procedure) and noninvasive blood pressure cuff inflation (non-nociceptive procedure). Communicative patients were also asked to report their level of pain during each assessment., Results: A total of 66 patients (34 communicative, 32 noncommunicative) were included in the study. CPOT and NVPS-R scores increased significantly when participants were exposed to turning, but not during noninvasive blood pressure measurement (repeated measures ANOVA: CPOT, F=5.81, P=0.019; NVPS-R, F=5.32, P=0.025) supporting discriminant validity. CPOT and NVPS-R scores were significantly higher during the turning procedure for patients who had indicated that they were in pain versus those who were not, indicating criterion validity. Inter-rater reliability was generally higher for the CPOT than NVPS-R. Nurses rated the feasibility of the two tools as comparable but provided higher ratings of acceptability for the CPOT., Conclusions: While the present study supports the use of the CPOT and the NVPS-R with critically ill trauma and neurosurgical patients, further research should explore the role of vital signs in pain.

A systematic review of studies which evaluated depression and anxiety in parent versus spouse caregivers of adults with traumatic brain injury (TBI) was conducted. Demographic variables of the TBI patients and caregivers, study design, measurement tools used, and outcomes reported were collected. Twenty-four studies met the inclusion criteria and were evaluated for methodological quality. While the majority of studies revealed no significant differences between caregiver types on measures of depression and/or anxiety, there was a great deal of variation in methodology and quality between the studies. Overall, high levels of caregiver distress were exposed, regardless of caregiver type (parent versus spouse). There is a need for qualitative and quantitative research designs in order to elucidate the factors that put caregivers at risk for depression and anxiety.

Purpose: To disseminate the proceedings of a 1-day multidisciplinary stakeholder workshop aimed at examining the inter-relationship between traumatic brain injury (TBI) and homelessness., Methods: Thirty-seven stakeholders participated in the workshop, including frontline workers with individuals who are homeless, physicians, nurses and other healthcare workers, researchers, policy-makers, students and individuals with lived experience of homelessness. Didactic presentations, large group discussions and break-out sessions were used to disseminate knowledge, identify service and research gaps, develop a research agenda and facilitate networking., Results: The participants identified barriers to service provision for individuals who are homeless and have sustained TBI with a focus on age- and gender-related issues, co-morbid TBI and mental illness and jurisdictional differences. Challenges and strategies related to engaging stakeholders in research with this population, as well as disseminating knowledge were discussed and research questions were identified., Conclusion: There is very little empirical literature on the topic of TBI and homelessness. The workshop identified key issues for consideration, including gaps in knowledge related to this topic.

Background: To determine, using a civilian model of mild traumatic brain injury (TBI), the added value of biomarker sampling upon prognostication of outcome at 1 week and 6 weeks postinjury., Methods: The Galveston Orientation and Amnesia test was administered, and blood samples for serum protein S100B and neuron-specific enolase (NSE) were collected from 141 emergency department patients within 4 hours of a suspected mild TBI (mTBI). The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) was administered via telephone 3 days postinjury. Patients were assessed by a physician at 1 week (n = 113; 80%) and 6 weeks (n = 95; 67%) postinjury. Neurocognitive and postural stability measures were also administered at these follow-ups., Results: Levels of S100B and NSE were found to be abnormally elevated in 49% and 65% of patients with TBI, respectively. Sixty-eight percent and 38% of the patients were considered impaired at 1 week and 6 weeks postinjury, respectively. Stepwise logistic regression modeling identified admission Galveston Orientation and Amnesia test score, S100B level, and RPQ score at day 3 postinjury to be predictive of poor outcome at 1 week postinjury (c-statistic 0.877); female gender, loss of consciousness, NSE level, and RPQ score at day 3 postinjury were predictive of poor outcome at 6 weeks postinjury (c-statistic 0.895). The discriminative power of the biomarkers alone was limited., Conclusions: Biomarkers, in conjunction with other readily available determinants of outcome assessed in the acute period after injury, add value in the early prognostication of patients with mTBI. Our findings are consistent with the notion that S100B and NSE point to biological mechanisms underlying poor outcome after mTBI.

Primary Objective: The most frequently reported psychiatric symptom after traumatic brain injury (TBI) is depression. This study examined whether internet-delivered cognitive behaviour therapy (CBT) could be appropriate and effective for patients with mild or moderate TBI and depression., Methods and Procedures: Patients were recruited for an at-home, 6-week internet-based CBT program (MoodGYM). Participants were assessed during this period by weekly telephone calls and at 12 months post-enrolment. Intervention completion rates, predictors of adherence, user feedback and changes in scores on validated depression scales were assessed., Main Outcomes and Results: Twenty-one patients were recruited: 64% and 43% completed the 6-week intervention and the 12-month follow-up, respectively. Adherence rates were not predicted by demographic or injury characteristics in this small sample. Patients identified reading, memory and comprehension requirements as limitations of the program. Scores on the depression scales were significantly decreased upon completion of the intervention and at the 12-month follow-up., Conclusions: The MoodGYM program may be effective for treating symptoms of depression in patients with TBI. While adherence rates were not predicted by age, education level or injury severity, demands upon memory and concentration which may already be compromised in these patients need to be considered.