Within the past few decades brain injury, or traumatic brain injury (TBI), has gained widespread attention. Early focus was on more severe forms of TBI; severity typically measured using the Glasgow Coma Scale. In more recent years, however, mild traumatic brain injury (mTBI), most notably concussions, has gained increasing interest due to the high frequency of concussions suffered in athletes of all levels and, recently, in military personnel due to blast injuries. Studies being performed have focused not only on ways to help minimize the incidence of concussion as well as treating concussive symptoms, but also on detecting concussions. Many concussions go unreported due to inadequate knowledge of concussive symptoms amongst the general population. Because many concussions go unnoticed and hence unreported the individual who has sustained a concussion is at risk for a more serious injury in the future. One such injury is Second Impact Syndrome (SIS). Second Impact Syndrome is essentially a synergistic event where the sum of two seemingly mild concussions combine to create an event that is potentially fatal. The findings during the autopsy are that there is insignificant damage to the brain to cause death. The damage that occurs, however, is on a molecular level causing a strain on the metabolic processes of the brain called dysautoregulation. Without an understanding of the changes that have occurred on a molecular level in SIS the assignment of cause and manner of death is difficult for the medical examiner. Currently, in order to diagnose SIS, a thorough scene investigation, along with the documentation of a previous head injury is needed. Without a full understanding of SIS and the pathophysiology changes that take place a medical examiner (ME) could misclassify the cause and manner of death in a death due to SIS. In the future, eliminating the prerequisite of identification and documentation of previous head injuries in order to diagnose SIS is needed. This paper evaluates the literature on the current knowledge of TBI and concussions in an attempt to create a protocol on how a medical examiner should approach a case where autopsy findings are unremarkable.

Children and youth who suffer a mild traumatic brain injury or concussion are at risk for a number of negative outcomes. The symptoms of concussion and the management of these symptoms can be disruptive to the child’s everyday activities, especially if they are prolonged. Depression can result and may complicate the course of recovery. Depression has overlapping symptoms with concussion and is thought to lengthen the recovery period. There has been much research done in populations of mixed severities of brain injury but very little addresses children with concussion. Knowledge in this area is crucial due to depression’s impact on all aspects of functioning as well as the potential alteration of the child’s developmental trajectory. The purpose of this research was to examine the risks and predictors of depression following concussion in youth and to explore the experiences of a subsample of youth and their families with prolonged recovery from concussion, complicated by depression. Chapter One provides a review of the current literature setting the context for the research within what is known about concussion in youth, what is known about depression in youth and because of the early stages of this type of research, what is known about depression as an outcome of concussion in all age groups. Chapter Two presents a study highlighting the tangible risk for depression in a sample of children being followed in a tertiary care clinic (N=92). Significant predictors of depressive symptomatology were found to be the need for hospital admission and high symptom scores in the first few days and weeks after injury, which may be valuable information for prevention, early identification and treatment of youth at risk for depression after concussion. Chapter Three provides an in-depth exploration of the experiences of youth and families who have gone through prolonged recovery from concussion with significant depressive symptomatology. A phenomenological approach was used with six participants and their families who were interviewed and their responses analyzed. A trajectory of recovery was identified; common themes within each of four key stages of the trajectory were discussed and illustrated using direct quotes from the participants. Chapter Four outlines the important implications of these two studies for health care professionals; particularly in raising awareness of the mental health outcomes of concussion. Knowledge of the impact of debilitating symptoms, activity restrictions and depression can inform discussions early after a concussion to prepare and possibly prevent some of the losses experienced by youth that can lead to depression. / Thesis / Master of Science Rehabilitation Science (MSc)

No description available.

Objectives: After mild traumatic brain injury (mTBI), psychological factors can contribute to persisting post-concussion symptoms (PCS). Consistent with constructive theories of memory, negative expectations for increased symptoms after mTBI may contribute to misattributing symptoms to the mTBI and underestimating pre-injury symptoms, called the “good old days’ bias” (Gunstad & Suhr, 2001). The good old days’ bias is not thought to be a general retrospective recall bias but studies to date have largely not controlled for normative memory processes including those that lead to a biased, more positive recall of the past. Therefore, the current study examines whether there is a good old days’ bias after mTBI above and beyond normal memory biases. This study also examines how soon after mTBI the good old days’ bias affects recall of pre-injury symptoms in the first month after mTBI in adolescents as well as whether the good old days’ bias causes pre-injury symptom severity to be underestimated or if symptoms are entirely forgotten. Finally, the clinical significance of symptom recall biases is investigated. Method: The sample is 42 adolescents who sustained an mTBI (ages 13-18 years; 24 males) and 42 uninjured adolescents (ages 13-18 years; 24 males, ). The mTBI group rated current and retrospective post-concussion symptom ratings within one week and again, at one month, post-injury. The control group rated current and retrospective post-concussion symptoms at baseline and one month later. Cross-sectional and longitudinal comparisons using non-parametric statistical tests were used. Results: Wilcoxon signed-rank tests showed that, by one month post-mTBI, adolescents report fewer total, physical, and emotional pre-injury symptoms than they had reported within one week of their concussion. The control group did not demonstrate this good old days’ bias. There were no between-group differences in retrospective PCS ratings at either time point. Chi-square analyses found that the mTBI group was as likely as the control group to recall “no” pre-injury/past symptoms one month post-injury after having initially reported some pre-injury symptoms. Only four more adolescents were classified as “recovered” if their one-month PCS ratings were compared with pre-injury PCS ratings made within 1-week post-concussion rather than pre-injury ratings from 1-month post-injury. Discussion: There was mixed evidence for a good old days’ bias by one month post-concussion. This bias was not demonstrated in healthy adolescents, suggesting that the good old days’ bias is found specifically after concussion. During the acute post-injury period, the good old days’ bias may only be apparent by studying changes in concussed individuals’ own PCS ratings. The good old days’ bias leads to underestimating the severity of pre-injury symptoms rather than forgetting them entirely. The good old days’ bias does not greatly affect symptom recovery tracking by one month post-concussion. Future studies should directly examine expectations about concussion and their effect on current and retrospective symptom reporting. / Graduate / 2019-07-10

No description available.

Le syndrome post-commotionnel (SPC) a été proposé comme un ensemble de symptômes qui peuvent apparaître après un traumatisme crânien léger (TCL) et perdurer des semaines, des mois, parfois jusqu’à un an, engendrant des conséquences importantes sur la vie quotidienne. Des débats entourent la définition et même l’existence du SPC. Ils portent notamment sur la spécificité des symptômes (qui peuvent apparaître dans d’autres conditions, ou chez des personnes non traumatisées), et sur la validité des outils diagnostiques qui restent très hétérogènes. La relation entre le SPC et le stress post-traumatique (SSPT) est également au cœur de ces questionnements. La cohorte PERICLES permet d’apporter un éclairage sur ces questions. Elle porte sur un groupe de patients TCL ainsi qu’un groupe de patients avec un traumatisme léger dont le siège n’est pas la tête. Dans un premier temps, nous avons étudié la spécificité des symptômes en comparant leur prévalence et évolution entre ces deux groupes de patients. Nous avons ensuite tenté de définir un critère diagnostique à partir des symptômes spécifiques à l’aide de tests de corrélations et analyse factorielle. Les facteurs prédictifs du SPC ont été évalués à partir de ce critère, à l’aide d’une régression logistique. Dans un deuxième temps, les facteurs prédictifs des SPC et SSPT ont été évalués et comparés, tout comme la proximité des symptômes des deux syndromes, à l’aide d’une analyse des correspondances multiples. Huit symptômes ont été sélectionnés comme spécifiques au TCL. Un critère diagnostique a pu être défini à partir de ces huit symptômes. Le TCL a été observé facteur prédictif du SSPT (OR = 4,47 [2,38 - 8,40]) mais pas du SPC. Enfin, les symptômes du SPC présentaient une forte proximité avec les variables de la dimension « hypervigilance » du SSPT. Ainsi, le SSPT apparaît être plus spécifique du TCL que le SPC. Les variables du SPC semblent être proches de celles du SSPT. Il semblerait que le stress lié au traumatisme joue un rôle plus important dans la persistance de symptômes à long terme que le mécanisme subi par le cerveau. / Postconcussion syndrome (PCS) has been proposed as a set of symptoms that may occur after mild traumatic brain injury (MTBI) and continue for weeks, months, sometimes up to a year, causing a significant impact on daily life. Debates surround the definition and even the existence of the PCS. They relate in particular to the specific symptoms (which may occur in other conditions or in people not traumatized), and the validity of diagnostical tools that are very heterogeneous. The relationship between the SPCS and post-traumatic stress disorder (PTSD) is also at the heart of these questions. The Pericles cohort can shed light on these issues. It focuses on a group of MTBI patients and a group of patients with mild trauma not related to the head (controls). At first we studied the specificity of symptoms by comparing their prevalence and evolution between these two groups of patients. We then attempted to define a diagnostical test based on specific symptoms using test correlations and factor analysis. Predictors of PCS were evaluated from this test, using logistic regression. In a second step, predictors of PCS and PTSD were assessed and compared, as well as the proximity between symptoms of both syndromes using a multiple correspondence analysis.Eight symptoms were selected as specific to MTBI. A diagnostic criterion has been defined from the eight symptoms. TCL was observed as a predictor of PTSD (OR = 4.47 [2.38 to 8.40]) but not of PCS. Finally PCS symptoms showed strong proximity with variables from "hypervigilance" PTSD dimension. Thus, PTSD appears to be more specific to MTBI than PCS. PCS variables appear to be similar to those of PTSD. It seems that the stress linked to the trauma plays a more important role in the persistence of long-term symptoms than the mechanism of the brain.

Objective: The long-term cognitive effects of mild traumatic brain injury (MTBI) and sport-related concussion (SRC) are not always clear. Higher-level longer-term cognitive difficulties can indicate enduring neurological damage, as part of a post-concussion syndrome (PCS). This study aimed to investigate whether cognitive performance and self-reported PCS symptoms of athletes (rugby players) relate to SRC and whether gender moderates these effects. Method: Eighty-six participants completed a questionnaire detailing SRC history (frequency and severity) and rated long-term symptoms using the Sport Concussion Assessment Tool 3 (SCAT3) symptom evaluation scales, before completing the CogState Brief Battery and STOP-IT (stop-signal response inhibition task). Results: No significant relationships between SRC dosage (frequency/severity), self-reported PCS symptoms, and cognitive test performance were identified. A greater proportion of males reported SRC compared to females, but no effect of gender was found on any of the cognitive outcome measures or self-reports of PCS symptoms. Conclusions: The results show that SRC has no observable long-term effects on cognitive test performance or PCS symptom self-reports. The analysis may have lacked power to detect effects. Analysis of individual performance over time against baseline scores may be more relevant for accurate diagnosis than relying on normative test scores. Recommendations for future research were made.

Mild traumatic brain injury (MTBI) has gained increasing attention over recent years with much research directed at the nature of persisting symptoms experienced by individuals with MTBI. Owing to the subtle nature of cognitive-communicative difficulties after MTBI, as well as the lack of sensitivity of traditional assessment tools in identifying these difficulties, individuals with MTBI are seldom referred for speech-language therapy services. The need has therefore arisen for the communicative abilities of individuals with MTBI to be assessed in ways other than through the implementation of traditional assessment tools. This preliminary study, for which a qualitative approach with a multiple case study design was adopted, aimed to investigate communication following MTBI from the perspective of a spouse. The spouses of three individuals with MTBI were selected to participate in this study. Semi-structured interviews consisting of two open-ended questions were held with each spouse. The content obtained from the interviews was subjected to a discourse analysis (DA) and the themes that were identified were interpreted within the Model of Social Communication (Hartley, 1995). The results of this study revealed that each of the participants perceived changes in the communication of their spouses since the MTBI. When interpreted within the Model of Social Communication (Hartley, 1995), these communication difficulties were considered to be either the result of impaired internal processes (including impairments in executive control, stored knowledge, subcortical and limbic input or cognition) or the interaction between these impaired internal processes and the environment. The implications of these results regarding the role of the speech-language therapist in MTBI are highlighted. The potential value of the spouse, and the use of DA as both a methodological and clinical tool in the field of speech-language therapy are discussed. Recommendations for future research are made. / Dissertation (M (Communication Pathology))--University of Pretoria, 2007. / Speech-Language Pathology and Audiology / M (Communication Pathology) / unrestricted

<p>Uvod: Traumatsko o&scaron;tećenje mozga (TOM) nastaje usled dejstva spolja&scaron;nje mehničke sile na kranijum i endokranijalni sadržaj, koje se karakteri&scaron;e privremenim ili trajnim neurolo&scaron;kim o&scaron;tećenjem, funkcionalnom onesposobljeno&scaron;ću ili psihosocijalnom neprilagođeno&scaron;ću. Blago TOM je najče&scaron;će i čini između 70% i 90% svih povređenih sa TOM. Postoji veliki broj definicija ovog kliničkog entiteta, ali gotovo sve sadrže Glazgov koma skor 13-15, poremećaj stanja svesti u različitom trajanju, te posttraumatsku amneziju kao odrednice koje defini&scaron;u blago TOM. Najveći broj povređenih sa blagim TOM ima dobru prognozu i potpunu rezoluciju tegoba u kratkom vremenskom periodu nakon povređivanja, bez medicinski relevantnih posledica. Međutim, jedna grupa povređenih koja navodi nagla&scaron;enije i dugotrajnije tegobe koje mogu imati uticaja na ukupno zdravstveno stanje i kvalitet života. U savremenom naučnoistraživačkom radu aktuelni su poku&scaron;aji da se primenom novih dijagnostičkih metoda, detaljnim praćenjem povređenih i primenom neuropsiholo&scaron;kih testova objektivizuju ove tvrdnje, kako bi se pacijenti sa povi&scaron;enim rizikom od nastanka dugotrajnih tegoba pravovremeno identifikovali i kako bi se mogao sprovesti adekvatan tretman. Cilj: Cilj ove studije je da se utvrditi da li postoji korelacija između kliničkih i radiolo&scaron;kih simptoma i znakova i rezultata neuropsiholo&scaron;kog testiranja kod povređenih sa blagim traumatskim o&scaron;tećenjem mozga, kao i da se utvrdi da li neki od od kliničkih simptoma i znakova mogu biti pouzdan prediktor pojave perzistentnih neuropsiholo&scaron;kih posledica, i koja je priroda moždanih o&scaron;tećenja koja mogu biti u njihovoj osnovi. Materijal i metode: Sprovedeno istraživanje je u celosti bilo kliničko, prospektivno, i obuhvatilo je 64 povređena sa blagim TOM koji su u periodu od 2012. do 2015. godine hospitalizovani na Klinici za neurohirurgiju Kliničkog centra Vojvodine u Novom Sadu. Pre prijema je svim ispitanicima načinjen pregled endokranijuma kompjuterizovanom tomografijom (CT) koji nije prikazivao znakove traumatskih o&scaron;tećenja kranijuma niti endokranijalnog sadržaja. U toku hospitalizacije kod povređenih su praćeni i beleženi relevantni klinički parametri. U prvih 72 sata od povređivanja je kod 37 ispitanika načinjen pregled endokranijuma magnetnom rezonancom (MRI). Kod 25 ispitanika je načinjeno neuropsiholo&scaron;ko ispitivanje baterijom neuropsiholo&scaron;kih testova mesec dana nakon povređivanja i 6-9 meseci nakon povređivanja. Rezultati su uno&scaron;eni u bazu podataka i nakon toga statistički analizirani. Rezultati: U analiziranoj grupi od 64 povređena sa blagim TOM kod 37 ispitanika (58%) je načinjen MRI pregled endokranijuma, a pozitivan nalaz u smislu postojanja traumom izazvanih o&scaron;tećenja moždanog parenhima pronađen je kod 17 ispitanika (46%). Najsenzitivnije MRI sekvence su SWI i T2* kojima se otkrivaju veoma diskretni depoziti razgradnih produkata krvi. Povređeni sa pozitivnim MRI nalazom imaju lo&scaron;ije postignuće na rekogniciji liste B Rejovog testa verbalnog učenja u odnosu na povređene iz grupe bez intrakranijalne traumatske lezije. Rezultati neuropsiholo&scaron;kih testova ukazuju na pobolj&scaron;anje rezultata između prvog i drugog testiranja u pogledu egzekutivnih i govornih funkcija u ispitivanoj grupi. U ostalim ispitivanim kognitivnim aspektima nije pronađena značajna razlika među navedenim grupama Zaključak: TOM predstavlja jedan od najvećih savremenih medicinskih izazova koji se nameće zbog svoje visoke incidence, dijagnostičkih i terapijskih problema, ali i potencijalno lo&scaron;eg ishoda i visokih tro&scaron;kova rehabilitacije i resocijalizacije povređenih. Rezultati studije se mogu iskoristiti za bolje razumevanje blagog TOM u smislu lak&scaron;eg re&scaron;avanja dijagnostičkih dilema, kreiranje efikasnijih dijagnostičkih protokola i preciznije procene ishoda nakon povređivanja ove vrste.</p> / <p>Introduction: Traumatic brain injury (TBI) is a result of the influence of external mechanical forces on scull and endocranial structures which can produce temporarily or permanent neurological impairment, functional disability or psychosocial unconformity. Mild TBI is the most frequent form of TBI and represent between 70% and 90% of all TBI cases. There are several different definitions of mild TBI, but almost all of them contain Glasgow Coma Scale score 13-15, altered state of consciousness and different forms of amnesia as criteria for mild TBI diagnosis. Largest number of patients suffered mild TBI have good prognosis and complete resolution of symptoms in short period of time after injury, with out of any kind of sequeles. However, small group of patients report various symptoms and complaints which can last longer than is usual and seriously affect quality of life of this patients. Numerous researches has been conducted applying novel imaging technologies, long follow-up periods and neuropsychological testing in order to make these non-specific self-reported complaints as much objective as possible. The other reason is necessity of timely identification of patients in risk of developing long term complaints so they can be treated in a proper manner. Objective: The aim of this study was to determine is there correlation between clinical and radiological signs and symptoms and results of neuropsychological testing in patients with mild TBI. The aim also was to determine are there some clinical signs which can be reliable predictor of appearance of neuropsychological consequences and what is the nature of cerebral lesion suspected to be a cause of this consequences. Materials and methods: The research was clinical, completely prospective and included total of 64 patients with mild TBI who were hospitalized between 2012 and 2015 at Clinic for neurosurgery, Clinical Centre of Vojvodina in Novi Sad. All patients had computed tomography scan (CT) at the admission which failed to show any signs of trauma of cranial bones or endocranial content. During the first 72 hours after injury the magnetic resonance imaging (MRI) has been performed in 37 patients. 25 patients had neuropsychological testing one month and 6-9 months after injury. We entered results in database and after completion we performed statistical analysis. Results: In 37 of 64 patients (58%) MRI examination has been performed and in 46% of patients we found trauma induced small haemorrhagic and oedematous brain lesions. The most sensitive sequences in our protocol were SWI and T2* confirmed superb sensitivity in detection of small foci of blood. Patients with detected MRI abnormalities showed poorer accomplishment at recognition of list B of Ray Auditory Verbal Learning Test in comparison with group with no intracranial lesions. The results of neuropsychological testing showed significant improvement of executive and speech functions between two periods in time when tests have been administered. We found no other significant differences between analysed cognitive functions in this period in our group of patients. Conclusion: TBI is one of the most important contemporary medical problems due to his high incidence, diagnostics and therapy related issues, but also potentially poor outcome and high costs of rehabilitation. Results of this study can be used for better understanding of mild TBI in order to solve some diagnostic dilemma, create more efficient diagnostic protocols and facilitate more precise outcome assessment after mild TBI.</p>

Trauma de crânio leve (TCE leve) é definido como um déficit neurológico transitório que ocorre após um trauma incluindo história de náuseas, vômitos, cefaléia ou tontura acompanhada de alteração ou perda da consciência com duração inferior a 15 minutos, amnésia pós traumática e Escala de Coma de Glasgow entre 13 e 15. Apesar da alta taxa de sobrevida, pode cursar com alguma morbidade, principalmente nos três primeiros meses posteriores ao trauma e cerca de 18 % dos pacientes desenvolvem pelo menos uma síndrome psiquiátrica no primeiro ano após o acidente. O diagnóstico ainda é um desafio no sentido de minimizar-se gastos desnecessários com exames subsidiários entretanto, intervenções precoces podem evitar seqüelas. Nosso objetivo foi verificar o impacto do TCE leve na qualidade de vida de suas vítimas e diagnosticar as várias alterações neuropsicológicas que podem advir deste trauma. Esses alterações podem ser verificadas através de instrumentos de pesquisa. Inicialmente, foram avaliadas cinqüenta vítimas com TCE leve, atendidas no Hospital João XXIII, em Belo Horizonte - MG, as quais foram submetidas a dosagem de proteína S100B e tomografia de crânio (TCC) na admissão. Nessa fase, verificou-se que a proteína S100B tem valor preditivo negativo de 100%. Dezoito meses após o trauma, esses pacientes foram procurados em suas residências, quando foi lhes solicitado para que respondessem a quatro instrumentos de pesquisa [dois para diagnóstico de qualidade de vida (World Health Organization WHOQOL-100), e o Short Form-36 (SF-36), um para análise da presença de ansiedade e depressão (Escala Hospitalar de Ansiedade e Depressão (EHAD) e o Questionário de Sinais e Sintomas (QSS), baseado no Post Concussion Questionnaire] com o objetivo de pesquisar a presença de sinais e sintomas da síndrome pós-concussão. Também foram pesquisados aspectos sociodemográficos, como idade, escolaridade, estado civil, renda pessoal e origem desta renda. Os mesmos questionários foram preenchidos por um grupo de controle composto, necessariamente, por coabitantes dos pacientes, sem história de trauma craniano de qualquer gravidade e com idade a mais próxima possível da do paciente. Na avaliação pelo WHOQOL-100, pacientes apresentaram qualidade de vida inferior nos domínios nível de independência, ambiente e no total de domínios (p< 0,05). Na avaliação do SF-36, pacientes revelaram qualidade de vida inferior nos domínios capacidade funcional, vitalidade, saúde mental (p<0,001), dor, estado geral de saúde e aspectos mentais (p<0,05). Pacientes apresentaram mais ansiedade e estavam uma classe acima de seus controles pela EHAD. Pacientes referem ainda número maior de sinais e sintomas da síndrome pós-concussão do que seus respectivos controles. Não verificamos correlação entre a qualidade de vida, classificação na EHAD ou número de sinais e sintomas da SPC com as dosagens de proteína S100B ou com a presença de lesão na TCC realizadas na admissão / Mild head trauma (MHT) is defined as a transitory neurological deficit that happens after the trauma and includes a history of nausea, vomiting, headache or dizziness and loss or alteration of consciousness (less than 15 minutes), post-trauma amnesia, and Glasgow Coma Scale (GCS) at admission between 13 and 15. Despite the high survival rates, some morbidity has been observed in the three month period after this trauma. Approximately 18% of head trauma patients develop at least one psychiatric syndrome in the first year after the accident. The diagnostics difficulty and the risks of complications after the MHT continue to be a relevant problem at the emergency departments around the world. Limitations of active participation in daily life are alterations that influence life quality. Several of these alterations may be diagnosed through Interview Instruments. Our study was divided in two phases. In the first phase, 50 MHT patients admitted at Hospital João XXIII, Belo Horizonte-MG, Brazil, had protein S100B dosing and head CT taken at admission. Concentration values of S100B lower than 0.01 g/l were considered negative once this was the lowest value found in patients who did not show brain injuty signs in the CT scan. In that study it was found that protein S100B has 100% negative predictive value. In this second phase of the study, 18 months after the trauma, these patients were contacted at their homes and asked to answer four self- assessment questionnaires: two for quality of life diagnostic - World Health Organizations WHOQOL-100 and the Short Form-36 (SF36); one for the analysis of anxiety and depression - Hospital anxiety and depression scale-HADS; and one instrument developed by the author based on the Rivermead Post Concussion Questionnaire to evaluate the presence of post-concussion syndrome signs and symptoms. Several socio-demographic aspects were also analyzed, including income, source of income, means of transportation used, etc. The same questionnaires were filled by a control group formed necessarily by patients co-inhabitants, with no history of head trauma of any severity, and with closest age as possible to the patients. In the WHOQOL assessment patients showed a lower quality of life in the independence, environment, as well as in the total domains (p< 0,05). In the SF 36 assessment patients showed a lower quality of life in the functional capacity, vitality, and mental health domains (p<0,001); and also in pain, general health situation, and mental aspects (p<0,05). Patients showed more anxiety and, in the HADS Scale, showed at least a level higher, on average, than their controls. Patients also showed a higher number of post-concussion signs and symptoms than their respective controls. We did not find correlation between the later quality of life and protein S100B dosing at admission. We were not able to find correlation between the protein concentrations with the presence of brain lesions in the CCT scans taken at patients admission in the emergency department