omen use more health care services during pregnancy than at other times. An unforeseen or new-onset health condition -whether in pregnancy or soon after birth -may necessitate an unplanned health care visit(s), including to an emergency department. 1 A limited number of studies have suggested that emergency department use in pregnancy is often associated with suboptimal antenatal care, psychosocial instability, and worse maternal and infant outcomes. 2,3 Those studies also documented a higher rate of emergency department use among pregnant women with preexisting comorbidities than among pregnant women without preexisting comorbidities. [2][3][4] In the United States, emergency department use during pregnancy has been reported to vary between 21% and 58%, with a higher frequency of repeat emergency department visits than seen among nonpregnant women. 2-5 A major limitation of those studies is that the study populations consisted of commercially insured or low-income patients in the US, who likely differ considerably from women who receive care within health care systems such as that in Canada, where there is universal access to physician and hospital care.
Objectives: It is estimated that 15%-25% of patients with a mild traumatic brain injury (MTBI) diagnosed in the emergency department (ED) will develop postconcussive syndrome. The objective of this study was to determine if patients randomized to graduated return to usual activity discharge instructions had a decrease in their PostConcussion Symptom Score (PCSS) 2 weeks after MTBI compared to patients who received usual care MTBI discharge instructions.Methods: This was a pragmatic, randomized trial of adult (18-64 years) patients of an academic ED (annual census 60,000) diagnosed with MTBI occurring within 24 hours of ED visit. The intervention group received cognitive rest and graduated return to usual activity discharge instructions, and the control group received usual care discharge instructions that did not instruct cognitive rest or graduated return. Patients were contacted by text message or phone 2 and 4 weeks post-ED discharge and asked to complete the PCSS, a validated, 22-item questionnaire, to determine if there was a change in their symptoms. Secondary outcomes included change in PCSS at 4 weeks, number follow-up physician visits, and time off work/school.Results: A total of 118 patients were enrolled in the study (58 in the control group and 60 in the intervention). The mean (AESD) age was 35.2 (AE13.7) years and 43 (36.4%) were male. There was no difference with respect to change in PCSS at 2 weeks (10.5 vs. 12.8; Δ2.3, 95% confidence interval [CI] = 7.0 to 11.7) and 4 weeks post-ED discharge (21.1 vs 18.3; Δ2.8, 95% CI = 6.9 to 12.7) for the intervention and control groups, respectively. The number of followup physician visits and time off work/school were similar when the groups were compared. Thirty-eight (42.2%) and 23 (30.3%) of patients in this cohort had ongoing MTBI symptoms (PCSS > 20) at 2 and 4 weeks, respectively. Conclusions:Results from this study suggest graduated return to usual activity discharge instructions do not impact rate of resolution of MTBI symptoms 2 weeks after ED discharge. Given that patients continue to experience symptoms 2 and 4 weeks after MTBI, more investigation is needed to determine how best to counsel and treat patients with postconcussive symptoms.
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