title: Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED.
abstract: OBJECTIVE
  Approximately one-third of children experiencing acute concussion experience ongoing somatic, cognitive, and psychological or behavioral symptoms, referred to as persistent postconcussion symptoms (PPCS). However, validated and pragmatic tools enabling clinicians to identify patients at risk for PPCS do not exist.
  
  
  OBJECTIVE
  To derive and validate a clinical risk score for PPCS among children presenting to the emergency department.
  
  
  METHODS
  Prospective, multicenter cohort study (Predicting and Preventing Postconcussive Problems in Pediatrics [5P]) enrolled young patients (aged 5-<18 years) who presented within 48 hours of an acute head injury at 1 of 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network from August 2013 through September 2014 (derivation cohort) and from October 2014 through June 2015 (validation cohort). Participants completed follow-up 28 days after the injury.
  
  
  METHODS
  All eligible patients had concussions consistent with the Zurich consensus diagnostic criteria.
  
  
  METHODS
  The primary outcome was PPCS risk score at 28 days, which was defined as 3 or more new or worsening symptoms using the patient-reported Postconcussion Symptom Inventory compared with recalled state of being prior to the injury.
  
  
  RESULTS
  In total, 3063 patients (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 1205 [39.3%] girls) were enrolled (n = 2006 in the derivation cohort; n = 1057 in the validation cohort) and 2584 of whom (n = 1701 [85%] in the derivation cohort; n = 883 [84%] in the validation cohort) completed follow-up at 28 days after the injury. Persistent postconcussion symptoms were present in 801 patients (31.0%) (n = 510 [30.0%] in the derivation cohort and n = 291 [33.0%] in the validation cohort). The 12-point PPCS risk score model for the derivation cohort included the variables of female sex, age of 13 years or older, physician-diagnosed migraine history, prior concussion with symptoms lasting longer than 1 week, headache, sensitivity to noise, fatigue, answering questions slowly, and 4 or more errors on the Balance Error Scoring System tandem stance. The area under the curve was 0.71 (95% CI, 0.69-0.74) for the derivation cohort and 0.68 (95% CI, 0.65-0.72) for the validation cohort.
  
  
  CONCLUSIONS
  A clinical risk score developed among children presenting to the emergency department with concussion and head injury within the previous 48 hours had modest discrimination to stratify PPCS risk at 28 days. Before this score is adopted in clinical practice, further research is needed for external validation, assessment of accuracy in an office setting, and determination of clinical utility.
authors.affiliation: Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada.
authors.forename: Roger
authors.initials: R
authors.lastname: Zemek
authors.affiliation: Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.
authors.forename: Nick
authors.initials: N
authors.lastname: Barrowman
authors.affiliation: Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada.
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Freedman
authors.affiliation: Department of Pediatrics, Hospital Ste Justine, University of Montreal, Montreal, Quebec, Canada.
authors.forename: Jocelyn
authors.initials: J
authors.lastname: Gravel
authors.affiliation: Department of Pediatrics, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Gagnon
authors.affiliation: Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.
authors.forename: Candice
authors.initials: C
authors.lastname: McGahern
authors.affiliation: Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.
authors.forename: Mary
authors.initials: M
authors.lastname: Aglipay
authors.affiliation: Department of Pediatrics, Children's Hospital of Western Ontario, Western University, London, Canada.
authors.forename: Gurinder
authors.initials: G
authors.lastname: Sangha
authors.affiliation: Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Kathy
authors.initials: K
authors.lastname: Boutis
authors.affiliation: Department of Pediatrics, Manitoba Children's Hospital, Winnipeg, Canada.
authors.forename: Darcy
authors.initials: D
authors.lastname: Beer
authors.affiliation: Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada.
authors.forename: William
authors.initials: W
authors.lastname: Craig
authors.affiliation: Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada.
authors.forename: Emma
authors.initials: E
authors.lastname: Burns
authors.affiliation: Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada.
authors.forename: Ken J
authors.initials: KJ
authors.lastname: Farion
authors.affiliation: Department of Pediatrics, Alberta Children's Hospital, Calgary, Canada.
authors.forename: Angelo
authors.initials: A
authors.lastname: Mikrogianakis
authors.affiliation: Department of Pediatrics and Clinical Neurosciences, Alberta's Children's Hospital, University of Calgary, Calgary, Canada.
authors.forename: Karen
authors.initials: K
authors.lastname: Barlow
authors.affiliation: Department of Pediatrics, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada.
authors.forename: Alexander S
authors.initials: AS
authors.lastname: Dubrovsky
authors.affiliation: Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Willem
authors.initials: W
authors.lastname: Meeuwisse
authors.affiliation: Department of Neuropsychology, Children's National Health System, George Washington University School of Medicine, Rockville, Maryland.
authors.forename: Gerard
authors.initials: G
authors.lastname: Gioia
authors.affiliation: Sports Concussion Clinic, Boston Children's Hospital, Boston, Massachusetts.
authors.forename: William P
authors.initials: WP
authors.lastname: Meehan
authors.affiliation: Ste Justine Research Center, University of Montreal, Montreal, Quebec, Canada.
authors.forename: Miriam H
authors.initials: MH
authors.lastname: Beauchamp
authors.affiliation: Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.
authors.forename: Yael
authors.initials: Y
authors.lastname: Kamil
authors.affiliation: Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.
authors.forename: Anne M
authors.initials: AM
authors.lastname: Grool
authors.affiliation: Department of Kinesiology, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Blaine
authors.initials: B
authors.lastname: Hoshizaki
authors.affiliation: Department of Psychology, Children's Hospital of Eastern Ontario, Ottawa, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Anderson
authors.affiliation: Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada.
authors.forename: Brian L
authors.initials: BL
authors.lastname: Brooks
authors.affiliation: Department of Psychology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada.
authors.forename: Keith Owen
authors.initials: KO
authors.lastname: Yeates
authors.affiliation: Department of Neurosurgery, Children's Hospital of Eastern Ontario, Ottawa, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Vassilyadi
authors.affiliation: Department of Pediatrics, Manitoba Children's Hospital, Winnipeg, Canada.
authors.forename: Terry
authors.initials: T
authors.lastname: Klassen
authors.affiliation: Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada.
authors.forename: Michelle
authors.initials: M
authors.lastname: Keightley
authors.affiliation: Department of Neurology, Stollery Children's Hospital, Edmonton, Alberta, Canada.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Richer
authors.affiliation: School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Carol
authors.initials: C
authors.lastname: DeMatteo
authors.affiliation: Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada.
authors.forename: Martin H
authors.initials: MH
authors.lastname: Osmond
mesh_terms: D000063:Accidents, Traffic / Q000706:statistics & numerical data; D000293:Adolescent; D000367:Age Factors; D019540:Area Under Curve; D001265:Athletic Injuries / Q000150:complications; D001924:Brain Concussion / Q000175:diagnosis / Q000209:etiology; D002648:Child; D002675:Child, Preschool; D004636:Emergency Service, Hospital; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008487:Medical History Taking; D015999:Multivariate Analysis; D015588:Observer Variation; D017063:Outcome Assessment, Health Care; D038223:Post-Concussion Syndrome / Q000175:diagnosis* / Q000209:etiology; D011446:Prospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012737:Sex Factors; D013997:Time Factors