Rationale for the Development of a Traumatic Brain Injury Case Definition for the Pilot National Concussion Surveillance System

BACKGROUND

Current methods of traumatic brain injury (TBI) morbidity surveillance in the United States have primarily relied on hospital-based data sets. However, these methods undercount TBIs as they do not include TBIs seen in outpatient settings and those that are untreated and undiagnosed. A 2014 National Academy of Science Engineering and Medicine report recommended that the Centers for Disease Control and Prevention (CDC) establish and manage a national surveillance system to better describe the burden of sports- and recreation-related TBI, including concussion, among youth. Given the limitations of TBI surveillance in general, CDC took this recommendation as a call to action to formulate and implement a robust pilot National Concussion Surveillance System that could estimate the public health burden of concussion and TBI among Americans from all causes of brain injury. Because of the constraints of identifying TBI in clinical settings, an alternative surveillance approach is to collect TBI data via a self-report survey. Before such a survey was piloted, it was necessary for CDC to develop a case definition for self-reported TBI.

OBJECTIVE

This article outlines the rationale and process the CDC used to develop a tiered case definition for self-reported TBI to be used for surveillance purposes.

CONCLUSION

A tiered TBI case definition is proposed with tiers based on the type of sign/symptom(s) reported the number of symptoms reported, and the timing of symptom onset.

Refinement of a Preliminary Case Definition for Use in Traumatic Brain Injury Surveillance

OBJECTIVE

Current methods used to measure incidence of traumatic brain injury (TBI) underestimate its true public health burden. The use of self-report surveys may be an approach to improve these estimates. An important step in public health surveillance is to define a public health problem using a case definition. The purpose of this article is to outline the process that the Centers for Disease Control and Prevention undertook to refine a TBI case definition to be used in surveillance using a self-report survey.

SETTING

Survey.

PARTICIPANTS

A total of 10 030 adults participated via a random digit-dial telephone survey from September 2018 to September 2019.

MAIN MEASURES

Respondents were asked whether they had sustained a hit to the head in the preceding 12 months and whether they experienced a series of 12 signs and symptoms as a result of this injury.

DESIGN

Head injuries with 1 or more signs/symptoms reported were initially categorized into a 3-tiered TBI case definition (probable TBI, possible TBI, and delayed possible TBI), corresponding to the level of certainty that a TBI occurred. Placement in a tier was compared with a range of severity measures (whether medical evaluation was sought, time to symptom resolution, self-rated social and work functioning); case definition tiers were then modified in a stepwise fashion to maximize differences in severity between tiers.

RESULTS

There were statistically significant differences in the severity measure between cases in the probable and possible TBI tiers but not between other tiers. Timing of symptom onset did not meaningfully differentiate between cases on severity measures; therefore, the delayed possible tier was eliminated, resulting in 2 tiers: probable and possible TBI.

CONCLUSION

The 2-tiered TBI case definition that was derived from this analysis can be used in future surveillance efforts to differentiate cases by certainty and from noncases for the purpose of reporting TBI prevalence and incidence estimates. The refined case definition can help researchers increase the confidence they have in reporting survey respondents' self-reported TBIs as well as provide them with the flexibility to report an expansive (probable + possible TBI) or more conservative (probable TBI only) estimate of TBI prevalence.

The Role of Level of Play in Concussions in High School Athletes

OBJECTIVES

To examine level of play (LOP) as a risk factor for concussion severity and recovery-related outcomes among high school athletes, stratified by sex, and among boys, by sport (football, non-football male sports).

DESIGN/SETTING

Secondary analysis of data collected through the High School Reporting Information Online surveillance system for academic years 2007-2008 through 2018-2019.

PARTICIPANTS

A total of 9916 concussions were reported between the academic years 2007-2008 and 2018-2019 from 9 sports (5189 from football; 2096 from non-football male sports; 2631 from female sports).

MAIN OUTCOME MEASURE

Examined the association between LOP (Freshman, Junior Varsity [JV], and Varsity teams) and concussion outcomes (number of concussion symptoms, symptom resolution time [SRT], and time to return to play [RTP]).

RESULTS

Compared with Varsity football athletes, concussed JV football athletes had on average 0.19 fewer concussion symptoms, longer SRT (>1 week vs <1 week: odds ratio [OR] = 1.3; 95% confidence interval [CI], 1.1-1.5), and longer RTP (1-3 weeks vs <1 week: OR = 1.5; 95% CI, 1.2-1.9; >3 weeks vs <1 week: OR = 1.6; 95% CI, 1.1-2.3). Compared with Varsity football athletes, Freshman football athletes had on average 0.48 fewer concussion symptoms, longer SRT (OR = 1.3; 95% CI, 1.1-1.5), and longer RTP (1-3 weeks vs <1 week: OR = 1.5; 95% CI, 1.1-2.0; >3 weeks vs <1 week: OR = 2.0; 95% CI, 1.3-3.0). Similarly, compared with female athletes on Varsity teams, concussed JV female athletes had longer RTP (1-3 weeks vs <1 week: OR = 1.8; 95% CI, 1.2-2.7). Trend analyses revealed an increase in the number of concussion symptoms between 2015-2016 and 2018-2019, a decrease between 2009-2010 and 2018-2019 for SRT of less than 1 week, and an increase between 2014-2015 and 2018-2019 for RTP of less than 1 week among Varsity football athletes. Among Varsity female athletes, there was a linear decrease during the study period for RTP of less than 1 week.

CONCLUSIONS

Despite a higher number of symptoms overall and in recent years, Varsity football players had shorter RTP than Freshman and JV athletes.

Using Transformer-Based Topic Modeling to Examine Discussions of Delta-8 Tetrahydrocannabinol: Content Analysis

BACKGROUND

Delta-8 tetrahydrocannabinol (THC) is a psychoactive cannabinoid found in small amounts naturally in the cannabis plant; it can also be synthetically produced in larger quantities from hemp-derived cannabidiol. Most states permit the sale of hemp and hemp-derived cannabidiol products; thus, hemp-derived delta-8 THC products have become widely available in many state hemp marketplaces, even where delta-9 THC, the most prominently occurring THC isomer in cannabis, is not currently legal. Health concerns related to the processing of delta-8 THC products and their psychoactive effects remain understudied.

OBJECTIVE

The goal of this study is to implement a novel topic modeling approach based on transformers, a state-of-the-art natural language processing architecture, to identify and describe emerging trends and topics of discussion about delta-8 THC from social media discourse, including potential symptoms and adverse health outcomes experienced by people using delta-8 THC products.

METHODS

Posts from January 2008 to December 2021 discussing delta-8 THC were isolated from cannabis-related drug forums on Reddit (Reddit Inc), a social media platform that hosts the largest web-based drug forums worldwide. Unsupervised topic modeling with state-of-the-art transformer-based models was used to cluster posts into topics and assign labels describing the kinds of issues being discussed with respect to delta-8 THC. Results were then validated by human subject matter experts.

RESULTS

There were 41,191 delta-8 THC posts identified and 81 topics isolated, the most prevalent being (1) discussion of specific brands or products, (2) comparison of delta-8 THC to other hemp-derived cannabinoids, and (3) safety warnings. About 5% (n=1220) of posts from the resulting topics included content discussing health-related symptoms such as anxiety, sleep disturbance, and breathing problems. Until 2020, Reddit posts contained fewer than 10 mentions of delta-8-THC for every 100,000 cannabis posts annually. However, in 2020, these rates increased by 13 times the 2019 rate (to 99.2 mentions per 100,000 cannabis posts) and continued to increase into 2021 (349.5 mentions per 100,000 cannabis posts).

CONCLUSIONS

Our study provides insights into emerging public health concerns around delta-8 THC, a novel substance about which little is known. Furthermore, we demonstrate the use of transformer-based unsupervised learning approaches to derive intelligible topics from highly unstructured discussions of delta-8 THC, which may help improve the timeliness of identification of emerging health concerns related to new substances.

Randomized Evaluation of Centers for Disease Control and Prevention HEADS UP Concussion Education Materials for Youth Sport Coaches

The Centers for Disease Control and Prevention (CDC) HEADS UP youth sports coach materials are the most widely adopted form of concussion education for coaches across the United States-reaching millions of youth sports coaches over the last decade. These materials focus on concussion symptom identification, response, and management (e.g., return to school and sports), while also addressing the importance of communicating to athletes and their families about concussion safety. The purpose of this study was to assess the effectiveness of CDC HEADS UP materials on coach knowledge and communication with youth athletes about concussion safety. This is the first randomized control study of the CDC HEADS UP materials in real world youth sport conditions. Participants were 764 coaches at 15 YMCA associations. Cluster randomization was used to assign branches within associations to intervention (CDC HEADS UP) and control (treatment as usual) conditions. Coaches completed surveys prior to and at the end of the competitive season. Communication with athletes about concussion increased among coaches in the intervention group (adjusted risk ratio [aRR] = 1.24, 95% confidence interval [CI] = 1.14, 1.36) but not the control group (aRR = 1.09, 95% CI = 0.90, 1.31), in multi-variate analyses controlling for coach demographic characteristics and baseline communication practices. Concussion symptom knowledge and communication intentions also significantly increased in the intervention group but not in the control group. This study provides evidence that CDC HEADS UP materials increase the likelihood that youth sport coaches communicate with their athletes about concussion safety. As youth sports organizations increasingly mandate concussion education for coaches, CDC HEADS UP materials may be considered a leading resource for adoption and setting-relevant implementation.

Substance Use and Sports- or Physical Activity-Related Concussions Among High School Students

History of concussion is associated with substance use. Data from the 2017 National Youth Risk Behavior Survey (N = 14,765) were used in this study to examine associations between sports- or physical activity-related concussions and current cigarette, alcohol, and marijuana use among high school students, and whether other factors moderate those associations. In addition to having played on a sports team, potential moderators examined included persistent feelings of sadness or hopelessness, hours of sleep, and serious difficulty concentrating, remembering, or making decisions. The association between sports- or physical activity-related concussions and current cigarette, alcohol, and marijuana use was significant when controlling for sex, grade, and race/ethnicity and the potential moderators with the exception of cigarette smoking while controlling for hours of sleep. Those involved in the care of high school students after a concussion may consider assessing current cigarette, alcohol, and marijuana use.

Injury Prevention Activities in US Schools, School Health Policies and Practices Survey 2014

BACKGROUND

Exposure to injury and violence early in life increases the risk of experiencing injury and violence later in life. In 2019, the top 3 leading causes of death among 15- to 18-year-olds in the United States were unintentional injury, suicide, and homicide. This study examines the extent to which schools promote injury and violence prevention.

METHODS

This study examined injury- and violence-related school policies and practices using nationally representative data from the 2014 School Health Policies and Practices Study. The social ecological model served as the theoretical framework to identify level of impact.

RESULTS

For many injury-related topics, more than 75% of schools nationwide had relevant policies and practices to address those topics. However, this study showed differences in schools' injury-related policies and practices by urbanicity.

CONCLUSIONS

Understanding and identifying gaps in school policies and practices is essential for reducing and preventing the injury and violence children experience. Collecting data on school policies and practices allows for better monitoring and evaluation to determine which are efficacious and aligned with the best available evidence.

Parent-Child communication about concussion: what role can the Centers for Disease Control and Prevention's HEADS UP concussion in youth sports handouts play?

BACKGROUND

Concussion education for parents/guardians (hereafter referred to as parents) has the potential to play an important role in youth athlete concussion safety. The goal of this study was to evaluate the impact of the Centers for Disease Control and Prevention's (CDC) HEADS UP handout on parent-child communication about concussion.

METHODS

YMCA branches from 15 associations from across the United States were randomized to CDC HEADS UP intervention condition or education as usual control condition using a cluster randomization strategy. In the intervention condition, coaches shared parent- and athlete-specific handouts with parents and asked parents to share and discuss the athlete-specific handouts with their child. Generalized estimating equations, with repeated measures to account for the correlation among matched participants and YMCA associations, were employed.

RESULTS

Multivariable analyses exploring the relationship between time (pre- and post-intervention) and communication showed that the percent of parents who talked to their child about concussion increased in the intervention group (aRR=1.33, 95% CI=1.22, 1.44), but not in the control group.

CONCLUSION

CDC HEADS UP handouts help families talk about concussion safety. Sports organizations seeking to educate parents of athletes about concussion should consider using CDC HEADS UP handouts and following a similar dissemination strategy.

Adverse Childhood Experiences and Overdose: Lessons From Overdose Data to Action

INTRODUCTION

Adverse childhood experiences and overdose are linked in a cycle that affects individuals and communities across generations. The Centers for Disease Control and Prevention's Overdose Data to Action cooperative agreement supports a comprehensive public health approach to overdose prevention and response activities across the U.S. Exposure to traumatic events during childhood can increase the risk for myriad health outcomes, including overdose; therefore, many Overdose Data to Action recipients leveraged funds to address adverse childhood experiences.

METHODS

In 2021, an inventory of Overdose Data to Action‒funded activities implemented in 2019 and 2020 showed that 34 of the 66 recipients proposed overdose prevention activities that support people who have experienced adverse childhood experiences or that focus on preventing the intergenerational transmission of adverse childhood experiences. Activities were coded by adverse childhood experience prevention strategy, level of the social ecology, and whether they focused on neonatal abstinence syndrome.

RESULTS

Most activities among Overdose Data to Action recipients occurred at the community level of the social‒ecologic model and under the intervene to lessen harms adverse childhood experience prevention strategy. Of the 84 adverse childhood experience‒related activities taking place across 34 jurisdictions, 44 are focused on neonatal abstinence syndrome.

CONCLUSIONS

Study results highlight the opportunities to expand the breadth of adverse childhood experience prevention strategies across the social ecology. Implementing cross-cutting overdose and adverse childhood experience‒related activities that span the social‒ecologic model are critical for population-level change and have the potential for the broadest impact. Focusing on neonatal abstinence syndrome also offers a unique intervention opportunity for both adverse childhood experience and overdose prevention.

The evolution of the overdose epidemic and CDC's research response: a commentary

The United States drug overdose epidemic has reached an all-time high, with 2020 provisional mortality data indicating that over 90,000 lives were lost to drug overdose in the 12-months ending in December 2020. The overdose epidemic has evolved over time with respect to the substances involved in overdose deaths and also with respect to the geographic distribution and epidemiology of deaths involving specific substances. Thus, a nimble approach to addressing the epidemic and preventing future overdoses is needed. CDC's response to the overdose epidemic supports implementation efforts at the state and local levels, where partners can better detect and respond to the evolving drug overdose landscape and implement prevention measures that meet their needs. CDC's framework for responding to the overdose epidemic focuses on five areas: (1) conducting surveillance and research; (2) building state, local and tribal capacity; (3) supporting providers, health systems and payers; (4) partnering with public safety; and (5) empowering consumers to make safe choices. Central to informing the implementation of evidence-based strategies to prevent drug overdose is rigorous research that undergirds the evidence. This Commentary describes recent investments in overdose prevention research and outlines opportunities for ensuring that future research efforts allow for the flexibility necessary to effectively respond to the continually evolving epidemic.

Differences in Head Impact Exposures Between Youth Tackle and Flag Football Games and Practices: Potential Implications for Prevention Strategies

BACKGROUND

Interventions designed to reduce the risk for head impacts and concussion in youth football have increased over the past decade; however, understanding of the role of regular game play on head impact exposure among youth tackle and flag football athletes is currently limited.

PURPOSE

To explore head impact exposure among youth tackle and flag football athletes (age range, 6-14 years) during both practices and games.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Using the Vector MouthGuard sensor, the authors collected head impact data from 524 tackle and flag youth football athletes over the course of a football season. Quantities of interest were estimated from regression models using Bayesian methods.

RESULTS

For impacts ≥10g, a tackle football athlete had an estimated 17.55 (95% CI, 10.78-28.96) times more head impacts per practice compared with a flag football athlete (6.85 [95% CI, 6.05-7.76] and 0.39 [95% CI, 0.24-0.62] head impacts, respectively). Additionally, a tackle football athlete had an estimated 19.48 (95% CI, 12.74-29.98) times more head impacts per game compared with a flag football athlete (13.59 [95% CI, 11.97-15.41] and 0.70 [95% CI, 0.46-1.05] head impacts, respectively). Among tackle football athletes, the estimated average impact rate was 6.51 (95% CI, 5.75-7.37) head impacts during a practice and 12.97 (95% CI, 11.36-14.73) impacts during a game, resulting in 2.00 (95% CI, 1.74-2.29) times more ≥10g head impacts in games versus practices. Tackle football athletes had 2.06 (95% CI, 1.80-2.34) times more high-magnitude head impacts (≥40g) during a game than during a practice. On average, flag football athletes experienced an estimated 0.37 (95% CI, 0.20-0.60) head impacts during a practice and 0.77 (95% CI, 0.53-1.06) impacts during a game, resulting in 2.06 (95% CI, 1.29-3.58) times more ≥10g head impacts in games versus practices. Because of model instability caused by a large number of zero impacts for flag football athletes, a comparison of high-magnitude head impacts is not reported for practices or games.

CONCLUSION

This study provides a characterization of the head impact exposure of practices and games among a large population of youth tackle and flag football athletes aged 6 to 14 years. These findings suggest that a greater focus on game-based interventions, such as fair play interventions and strict officiating, may be beneficial to reduce head impact exposures for youth football athletes.

Mental Health Among Parents of Children Aged <18 Years and Unpaid Caregivers of Adults During the COVID-19 Pandemic - United States, December 2020 and February-⁠March 2021

Early during the COVID-19 pandemic, nearly two thirds of unpaid caregivers of adults reported adverse mental or behavioral health symptoms, compared with approximately one third of noncaregivers^† (1). In addition, 27% of parents of children aged <18 years reported that their mental health had worsened during the pandemic (2). To examine mental health during the COVID-19 pandemic among U.S. adults on the basis of their classification as having a parenting role (i.e., unpaid persons caring for children and adolescents aged <18 years, referred to as children in this report) or being an unpaid caregiver of adults (i.e., persons caring for adults aged ≥18 years),^§ CDC analyzed data from cross-sectional surveys that were administered during December 2020 and February-March 2021 for The COVID-19 Outbreak Public Evaluation (COPE) Initiative.^¶ Respondents were categorized as parents only, caregivers of adults only, parents-caregivers (persons in both roles), or nonparents/noncaregivers (persons in neither role). Adjusted odds ratios (aORs) for any adverse mental health symptoms, particularly suicidal ideation, were higher among all respondents who were parents, caregivers of adults, or both compared with respondents who were nonparents/noncaregivers and were highest among persons in both roles (parents-caregivers) (any adverse mental health symptoms: aOR = 5.1, 95% confidence interval [CI] = 4.1-6.2; serious suicidal ideation: aOR = 8.2, 95% CI = 6.5-10.4). These findings highlight that parents and caregivers, especially those balancing roles both as parents and caregivers, experienced higher levels of adverse mental health symptoms during the COVID-19 pandemic than adults without these responsibilities. Caregivers who had someone to rely on for support had lower odds of experiencing any adverse mental health symptoms. Additional measures are needed to improve mental health among parents, caregivers, and parents-caregivers.

Costs of Nonfatal Traumatic Brain Injury in the United States, 2016

BACKGROUND

Traumatic brain injury (TBI) is a serious public health problem in the United States. Each year, TBIs substantially contribute to health care costs, which vary by severity. This is important to consider given the variability in recovery time by severity.

RESEARCH DESIGN

This study quantifies the annual incremental health care costs of nonfatal TBI in 2016 for the US population covered by a private health insurance, Medicaid, or Medicare health plan. This study uses MarketScan and defines severity with the abbreviated injury scale for the head and neck region. Nonfatal health care costs were compared by severity.

RESULTS

The estimated 2016 overall health care cost attributable to nonfatal TBI among MarketScan enrollees was $40.6 billion. Total estimated annual health care cost attributable to TBI for low severity TBIs during the first year postinjury were substantially higher than costs for middle and high severity TBIs among those with private health insurance and Medicaid.

CONCLUSIONS

This study presents economic burden estimates for TBI that underscore the importance of developing strategies to prevent TBIs, regardless of severity. Although middle and high severity TBIs were more costly at the individual level, low severity TBIs, and head injuries diagnosed as "head injury unspecified" resulted in higher total estimated annual health care costs attributable to TBI.

Head Impact Exposures Among Youth Tackle and Flag American Football Athletes

Background:

Promoted as a safer alternative to tackle football, there has been an increase in flag football participation in recent years. However, examinations of head impact exposure in flag football as compared with tackle football are currently limited.

Hypothesis:

Tackle football athletes will have a greater number and magnitude of head impacts compared with flag football athletes.

Study Design:

Cohort study.

Level of Evidence:

Level 4.

Methods:

Using mouthguard sensors, this observational, prospective cohort study captured data on the number and magnitude of head impacts among 524 male tackle and flag football athletes (6-14 years old) over the course of a single football season. Estimates of interest based on regression models used Bayesian methods to estimate differences between tackle and flag athletes.

Results:

There were 186,239 head impacts recorded during the study. Tackle football athletes sustained 14.67 (95% CI 9.75-21.95) times more head impacts during an athletic exposure (game or practice) compared with flag football athletes. Magnitude of impact for the 50th and 95th percentile was 18.15g (17.95-18.34) and 52.55g (51.06-54.09) for a tackle football athlete and 16.84g (15.57-18.21) and 33.51g (28.23-39.08) for a flag football athlete, respectively. A tackle football athlete sustained 23.00 (13.59-39.55) times more high-magnitude impacts (≥40g) per athletic exposure compared with a flag football athlete.

Conclusion:

This study demonstrates that youth athletes who play tackle football are more likely to experience a greater number of head impacts and are at a markedly increased risk for high-magnitude impacts compared with flag football athletes.

Clinical Relevance:

These results suggest that flag football has fewer head impact exposures, which potentially minimizes concussion risk, making it a safer alternative for 6- to 14-year-old youth football athletes.

Assessment of HEADS UP online training as an educational intervention for sports officials/athletic trainers

BACKGROUND

Sports- and recreation-related concussions are a common injury among children. Sports officials (SOs) and athletic trainers (ATs) are integral to setting the stage for safe play and managing concussions when they occur, and significant numbers of both groups have completed the Centers for Disease Control and Prevention's HEADS UP online concussion training course. However, the utility of the course for these audiences has not been assessed. We hypothesized that sports officials' and athletic trainers' concussion-related knowledge, attitudes, and behavioral intentions will improve from pre- and post-test after completing CDC's HEADS UP online concussion training course.

METHOD

Respondents' concussion-related knowledge, attitudes, and behavioral intentions were assessed both before and after taking the training course. Differences between pre- and post-test scores were calculated based on the Wilcoxon Signed Rank Test Z-score or McNemar's test. Effect sizes were interpreted.

RESULTS

The SOs and ATs who participated in the HEADS UP online training had a high level of concussion knowledge before taking the course: 90% or more of respondents could identify the correct response for at least seven of the 13 knowledge questions in the pre-test. Still, the course was effective at improving the respondents' knowledge about return-to-play protocols and concussion reporting. Further, SOs and ATs demonstrated improvement in their concussion-related attitudes and behavioral intentions between the pre- and post-test.

CONCLUSION

SOs' and ATs' concussion knowledge, attitudes, and behavioral intentions improved immediately following completion of the CDC HEADS UP online training. Future research could also focus on the long-term retention of this type of training. Practical Applications: This study provides insight into how to better focus concussion-related educational programs to fit SOs' and ATs' needs.

The Association Between Sports- or Physical Activity-Related Concussions and Suicidality Among US High School Students, 2017

BACKGROUND

This study examined the association between sports- or physical activity-related concussions and having seriously considered attempting suicide, made a suicide plan, or attempted suicide (ie, suicidality), and tested potential moderators of the association.

HYPOTHESIS

Risk factors such as persistent feelings of sadness or hopelessness, low academic grades, few hours of sleep, and current alcohol or marijuana use will increase the odds of suicidality among those who self-reported sports- or physical activity-related concussions, while protective factors such as physical activity and having played on a sports team will decrease the odds.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

This study used data from the 2017 Youth Risk Behavior Survey, a biennial, school-based, nationally representative survey of US students in grade levels 9 to 12 (N = 14,765). Logistic regression models examined associations between self-reported sports- or physical activity-related concussions and suicidality among the students, and whether physical activity, having played on a sports team, persistent feelings of sadness or hopelessness, academic grades, hours of sleep, or current alcohol or marijuana use moderated those associations.

RESULTS

Sports- or physical activity-related concussions were found to be associated with suicidality. The associations remained significant in models that adjusted for demographic characteristics, and they did not appear to be moderated by physical activity, having played on sports team, academic grades, or sleep.

CONCLUSIONS

Given the findings of this study and others, health care providers are advised to ask students who have experienced a concussion about their emotional well-being as part of their symptom-based assessment, using validated, age- appropriate concussion symptom scales. Comprehensively assessing students who have experienced a sports- or physical activity-related concussion for persistent feelings of sadness or hopelessness may alert providers to thoughts of suicidal ideation and will allow for earlier intervention.

CLINICAL RELEVANCE

If thoughts of suicide are discovered among adolescents with a concussion, or if other risk factors are observed, referrals to medical and mental health providers for a more comprehensive assessment may be warranted.

Examination of sports and recreation-related concussion among youth ages 12-17: results from the 2018 YouthStyles survey

Background: This paper sought to examine the frequency of self-reported sports- and recreation-related (SRR) concussion, as well as care-seeking behaviors and potential activity restrictions after concussions, in a sample of youth.Methods: A sample of 845 youth ages 12-17 years responded to the web-based YouthStyles survey in 2018. The survey measured the frequency of self-reported lifetime SRR concussion, the setting of their most recent SRR concussion, whether a doctor or nurse evaluated them, and the types of activity restrictions they experienced.Results: Forty-three percent of youth surveyed sustained their most recent concussion while playing on a sports team, 21.1% while playing on a community-based team, and 36.0% while engaged in a sport or recreational activity. Nearly half (45.3%) reported having to miss playing sports or participating in physical activity for at least one day; about two in ten (19.7%) reported having to miss time on their phone or computer for at least one day.Conclusion: Despite wide-spread efforts to promote protocols for SRR concussion among youth, a third of participants in this study did not seek medical care and more than half did not miss at least one day of sports or physical activity participation following a concussion.

Effectiveness of the US Centers for Disease Control and Prevention HEADS UP coaches' online training as an educational intervention

BACKGROUND

Concussions are common among youth athletes. Responsibility for the recognition and management of concussion is often put on coaches. To equip coaches with appropriate knowledge and skills, the US Centers for Disease Control and Prevention (CDC) launched the HEADS UP: Concussion in Youth Sports online training.

OBJECTIVES

To determine whether HEADS UP coaches' training improves knowledge, attitudes and behavioural intentions.

METHODS

Knowledge questions were grouped into scales by level of difficulty. Differences between pre-and post-test scores were calculated based on the Wilcoxon Signed Rank Test Z-score and effect sizes were interpreted.

RESULTS

Coaches displayed a high level of knowledge in the pre-test. While lower difficulty questions did not show improvement from pre- to post-test, moderate and high difficulty questions did. Use of the training was associated with improved knowledge about symptom resolution, return-to-play recommendations and under-reporting of incidents of concussion. Coaches demonstrated improvement in five of the seven concussion-related attitude and behavioural intention items post training.

CONCLUSION

HEADS UP training improved coaches' knowledge on select topics and helped them feel more comfortable about responding to concussion among their athletes. This study provides insight into how to better focus future HEADS UP concussion health education efforts to fit coaches' informational needs.

Risk of Repeat Concussion Among Patients Diagnosed at a Pediatric Care Network

OBJECTIVE

To quantify the risk of repeat concussions for children and identify demographic and clinical aspects of the index concussion associated with repeat injury.

STUDY DESIGN

For this retrospective cohort study, we queried the Children's Hospital of Philadelphia healthcare network's unified electronic health record to identify all 5- to 15-year-old patients who had their first clinical visit for an index concussion at a Children's Hospital of Philadelphia location from July 2012 through June 2013. A 25% random sample (n = 536) were selected. Clinical data were abstracted for their index concussion and all concussion-related visits for 2 years following the index concussion.

RESULTS

Overall, 16.2% (n = 87) of patients experienced at least 1 repeat concussion within 2 years of their index concussion. The risk of repeat concussion increased with patient age (9.5% for ages 5-8 years; 10.7% for ages 9-11 years; and 19.8% for ages 12-15 years). After we adjusted for other factors, risk was particularly heightened among patients whose index concussion had a longer clinical course (>30 vs 0-7 days, adjusted risk ratio 1.65 [1.01-2.69]) and greater symptom burden (>11 vs 0-2 symptoms, adjusted risk ratio 2.12 [1.12-3.72]).

CONCLUSIONS

We estimate that 1 in 6 youth diagnosed with a concussion are diagnosed with a subsequent concussion within 2 years and that several clinical characteristics of the index concussion increase this risk. Identifying factors associated with a repeat injury is essential to inform the clinical management of concussion and direct injury prevention efforts.

Youth and high school sports coaches' experience with and attitudes about concussion and access to athletic trainers by sport type and age of athlete coached

INTRODUCTION

Concussions are a commonly reported injury in youth and high school sports and much of the responsibility related to concussion identification and response for young athletes is allocated to sports coaches. This paper presents findings on concussion-related education, access to resources, experiences, and attitudes among a large number of youth and high school sports coaches across a variety of sports nationwide.

METHODOLOGY

Data were collected among coaches who completed the Centers for Disease Control and Prevention's (CDC) HEADS UP online concussion training pre-test between November 2016 and November 2017. Coaches' concussion-related education, access to resources, experiences, and attitudes were compared by age of athlete coached and level of contact of sport. Medium and large effect sizes were considered of practical significance for interpretation.

RESULTS

During the study period, 187,801 youth sports or high school sports coaches completed the CDC HEADS UP online training and corresponding pre-test. Access to previous concussion training significantly varied among respondents by age of athlete coached. For example, 27.4% of coaches of athletes aged 5 and younger had taken previous training compared to 72.9% of coaches of athletes aged 14-18. About one-quarter (27.4%) of all coaches reported ever having had to pull an athlete out of a game because of a possible concussion and 19.5% reported access to an athletic trainer at all games and practices. These variables differed significantly among coaches by age of athletes coached; coaches of older athletes were more likely to report access to an athletic trainer and having had to pull an athlete out of a game compared to coaches of younger athletes. No statistical differences by level of contact were considered to be of practical significance based on effect size.

CONCLUSION

Most coaches in this study report having access to education and hold attitudes consistent with best practices about concussion safety; however, overall access to concussion-related resources is limited. While differences in access to concussion-related education, experience, resources, and attitudes among coaches of varying levels of contact were small, medium to large variations were identified by age of athlete coached. Practical applications: Coaches bear an important part of the responsibility to prevent, identify, and manage concussions in young athletes. Tailored educational efforts may assist coaches of young athletes with recognition of concussion signs and symptoms and with feeling comfortable deciding whether an athlete needs to be evaluated for a possible concussion.

CDC's efforts to improve traumatic brain injury surveillance

INTRODUCTION

Youth sports concussion has become a prominent public health issue due to growing concern about the risk of long-term health effects.

METHOD

A broad spectrum of stakeholders has convened to propose solutions, including a committee of the National Academy of Sciences (NAS) who systematically examined the issue and, in a 2014 report, made a series of recommendations to better address this public health problem.

RESULTS

Among these recommendations, the NAS committee called for CDC to develop a plan for a comprehensive surveillance system to better quantify the incidence and outcomes of youth sports concussion among children 5 to 21years of age. Since the release of the NAS report, CDC has taken action to address this recommendation and, in the process, develop strategies to improve traumatic brain injury (TBI) surveillance more broadly. The challenges outlined by the NAS committee with respect to producing comprehensive incidence estimates of youth sports concussion are not exclusive to youth sports concussion, but also apply to TBI surveillance overall. In this commentary, we will discuss these challenges, the process CDC has undertaken to address them and describe our plan for improving TBI and youth sports concussion surveillance.

Sex Partner Type, Drug Use and Condom Use Self-Efficacy Among African Americans from Disadvantaged Neighborhoods: Are Associations with Consistent Condom Use Moderated by Gender?

Gender inequalities in sexual behavior are explored from the perspective of the theory of gender and power. This study focused on the effect of sex partner type (steady versus casual), drug use, and condom use self-efficacy regarding consistent condom use (CCU) among a community-based sample of adults. The sample included 1,357 African American men and women (M age 37.0, SD 13.1 years; 44% women, 66% men) from 61 disadvantaged census block groups in Atlanta, GA as part of a study of individual and neighborhood characteristics and HIV risk-taking. Having a steady partner decreased the odds of CCU, while higher condom use self-efficacy increased the odds of CCU. Among non-drug users, having a drug-using partner was associated with decreased odds of condom use for women only. Women with drug-using partners, especially a steady partner, were least likely to report CCU. Therefore, interventions intended to empower CCU among women need to expand beyond acknowledging the reduced control that women who use drugs demonstrate to also consider those who have drug-using sexual partners.

Excessive drinking among African American men: individual and contextual correlates

In this article, the authors explored associations of multiple domains with regular drinking and getting drunk among adult African American men. Questionnaire-based, computer-assisted interviews were conducted with 484 men in Atlanta, Georgia. Data analysis involved multivariate logistic regression analyses. Findings show that being older increased the odds of both drinking behaviors. Sensation seeking increased the odds of regular drinking, and having experienced childhood sexual and physical abuse increased the odds of getting drunk. Having health insurance reduced the odds of both outcomes. Insurance coverage and the heterogeneity among adult African American men must be considered in risk reduction efforts.

The assessment of complementary and alternative medicine use among individuals with HIV: a systematic review and recommendations for future research

OBJECTIVES

The use of complementary and alternative medicine (CAM), a group of health care practices and products that are not considered part of conventional medicine, has increased in recent years, particularly among individuals with human immune deficiency virus (HIV). Assessing the prevalence and predictors of CAM use among HIV-positive populations is important because some CAM therapies may adversely affect the efficacy of conventional HIV medications. Unfortunately, CAM use is not comprehensively or systematically assessed among HIV-positive populations. Therefore, the aim of the present study was to evaluate the quality of the instruments employed in observational studies assessing CAM use among HIV-positive populations by examining the degree to which these studies (1) evaluated the psychometric properties of their CAM instruments and (2) assessed the multidimensional nature of CAM use.

DESIGN

A systematic review of studies was undertaken and specific review criteria were used to guide the inclusion of studies. Specifically, articles were included that were published in English and in a peer-reviewed journal between 1997 and 2007, recruited HIV-positive study participants, and assessed CAM use. Thirty-two (32) studies met these inclusion criteria.

RESULTS

Results suggest that CAM assessment among HIV-positive populations continues to be problematic. For example, approximately 20% of the studies assessed the reliability and 3% assessed the validity of the CAM instrument employed.

CONCLUSIONS

CAM assessment--regardless of the specific study population--is a complex and challenging task. However, CAM instruments will not become more refined over time in the absence of rigorous psychometric evaluation. Future research must assess reliability and validity and report these data in a clear and nuanced manner.

Condom use among young women: modeling the theory of gender and power

OBJECTIVE

This study sought to articulate pathways between constructs from the theory of gender and power and their associations with sexual behavior.

DESIGN

The data were collected preintervention during a randomized controlled HIV prevention trial. Participants were 701 sexually active, unmarried African American females, aged 14-20, who were not pregnant, and were recruited from three health clinics in a southeastern US city. Structural equation modeling was used for the analyses.

MAIN OUTCOME MEASURE

Self-reported condom use.

RESULTS

Theoretical associations yielded a well-fitting structural model across initial and cross-validation samples. A significant amount of variance was explained for the variables of condom use (R2 = .31, .18), partner communication (R2 = .30, .26), substance use during sex (R2 = .32, .51), and negative personal affect (R2 = .36, .48). Partner communication (.35, .38) was the strongest predictor of condom use, negative personal affect (-.41, -.37) was the strongest predictor of partner communication, and physical risk (.54, .54) was the strongest predictor of negative personal affect.

CONCLUSION

This model provides evidence to support both direct and indirect associations between social and behavioral risk factors and condom use. Associations between theory of gender and power constructs and condom use can facilitate future development and analyses of interventions based on this theory.

Psychosocial predictors of lifestyle management in adults with epilepsy

The purposes of the work described in this article were to (1) describe a model of predictive relationships among psychosocial variables and lifestyle management, and (2) test the model among people with epilepsy. The variables selected for the model were based on social cognitive theory and the results of previous studies examining psychosocial predictors of self-management among people with chronic physical health conditions. Variables included in the model were self-efficacy, outcome expectancies, depressive symptoms, and social support. Participants for the study were recruited from epilepsy treatment facilities in Boston, MA, and Atlanta, GA, USA. Half of the participants were female, 81% were white, and their mean age was 43.1 years. As predicted by social cognitive theory, self-efficacy was related to lifestyle management and explained 23% of its variation. Depressive symptoms were related to both self-efficacy and social support. Social support was related to self-efficacy. These findings suggest that lifestyle management is influenced by a number of relationships between psychosocial variables, particularly by self-efficacy.