An Evaluation of Post-Concussion Return to School Guidelines: A Survey of Massachusetts School Nurses.

Although all states have legislation pertaining to youth sports concussion, most of these laws focus on return-to-play procedures; only a few address return-to-learn (RTL) accommodations for students who have experienced a concussion. To address this gap in the legislation, some states and nongovernmental organizations have developed RTL guidelines to advise school personnel, parents, and health care providers on best practices for accommodating students' postconcussion reintegration into academic activity. In 2018, the Massachusetts Department of Public Health (MDPH) developed RTL guidelines which were disseminated to school nurses (SNs) at all public and nonpublic middle and high schools in the state. In 2020, the MDPH engaged the Injury Prevention Center at Boston Medical Center to survey Massachusetts SNs to assess the usefulness of the guidelines. The response rate was 63%; 92% found the booklet extremely useful or moderately useful; and 70% endorsed that the booklet fostered collaboration among stakeholders.

Implementation of Concussion Management Policies in High Schools: The Critical Role of School Nurses.

Evidence-based practices in concussion management (CM) have been codified into legislation. However, legislation is varied, and implementation is narrowly evaluated. School nurses hold a unique position to assess the implementation of health policies. The implementation of concussion management policies across Massachusetts high schools was evaluated by the school nurse. A cross-sectional survey was sent to school nurses (N = 304), and responses (n = 201; 68.1% response rate) were tallied whereby higher scores indicated more practices being implemented. One open-text question was included to encourage nurses to provide context regarding implementation in their school. Descriptive statistics and thematic analysis were used to assess current implementation and nursing perspectives. Findings indicate that the degree of implementation varies, and some nurses reported difficulty with mobilizing clinical uptake of concussion management practices in their schools. Further implementation research is needed, and school nurses are an important stakeholder to include when assessing the clinical uptake of concussion management policies in schools.

Application of Components of the Massachusetts' Sports Concussion Regulations to All Students With Concussion: A Survey of School Nurses.

Appropriate management by schools of all students with a concussion, regardless of the cause, has not received the same attention as sports-related concussions. Focus groups conducted with Massachusetts School Nurses in 2015 found that some had applied protocols required in the state's sports concussion regulations to all students with concussion, not just student athletes. We surveyed high school nurses in Massachusetts to examine (1) the extent of this practice and (2) the extent to which protocols for all students with concussion are included in school policies. Of 168 (74%) responding, 94% applied the return-to-learn and play, and medical clearance requirements to all students with concussion, regardless of how or where the concussion occurred and 77% reported their school's policy required these protocols for all students with concussion. A significant association (odds ratio: 13.3, 95% confidence interval [2.4, 72.8], p <.01) existed between the two measures. These findings have important clinical and academic implications.

Evaluation of a Safer Opioid Prescribing Protocol (SOPP) for Patients Being Discharged From a Trauma Service.

The aims of this study were to evaluate the effects on opioid medication prescribing, patient opioid safety education, and prescribing of naloxone following implementation of a Safer Opioid Prescribing Protocol (SOPP) as part of the electronic health record (EHR) system at a Level I trauma center. This was a prospective observational study of the EHR of trauma patients pre- (n = 191) and post-(n = 316) SOPP implementation between 2014 and 2016. At a comparison Level I trauma site not implementing SOPP, EHRs for the same time period were assessed for any historical trends in opioid and naloxone prescribing. After SOPP implementation, the implementation site increased the use of nonnarcotic pain medication, decreased dispensing high opioid dose (≥100 MME [milligram morphine equivalent]), significantly increased the delivery of opioid safety education to patients, and initiated prescribing naloxone. These changes were not found in the comparison site. Opioid prescribing for acute pain can be effectively reduced in a busy trauma setting with a guideline intervention incorporated into an EHR. Guidelines can increase the use of nonnarcotic medications for the treatment of acute pain and increase naloxone coprescription for patients with a higher risk of overdose.

Evaluation of Implementation of Massachusetts Sports Concussion Regulations: Results of Focus Groups With School Nurses and Athletic Trainers.

In 2015, the Massachusetts Department of Public Health conducted focus groups with school nurses (SNs) and athletic trainers (ATs) from Massachusetts middle and high schools to assess implementation of legislated regulations relative to the management of students' head injuries incurred during extracurricular sports. Four tape-recorded focus groups were conducted by experienced facilitators. Lists of themes were synthesized by investigators for each focus group. Participating SNs and ATs supported the sports concussion legislation, felt that implementation had gone well, indicated that the law empowered them in managing return-to-school/play for students with concussion, and experienced support from their school administrators. Some SNs reported that they had applied relevant procedures to all students with head injuries, regardless of how or where the injury occurred. Challenges identified included protocols for away games, inconsistent concussion care by physicians, and a need for teacher education. Further research is required to quantify these findings.

A systematic review of emergency department interventions for college drinkers.

BACKGROUND: Alcohol use in college-age individuals is associated with increased injury risk. Many college drinkers end up in the emergency department (ED) as a result of their drinking, providing a unique opportunity to intervene. OBJECTIVE: This systematic review evaluates the existing evidence for the use of brief ED interventions for alcohol use in the college-age population. METHODS: A systematic search of on-line databases was conducted. Articles were limited to those in English published since 1990. Studies were included if they specifically studied 18- to 20-year-old alcohol users, if they were performed in an ED or acute care setting, and if an intervention regarding alcohol use was attempted. RESULTS: There were 400 studies identified; 60 abstracts were reviewed, 18 full-text articles were evaluated, and 7 met the inclusion criteria for review. Eligible studies focused on alcohol use only, except for one study that addressed alcohol and other drug use. All examined changes in alcohol intake patterns as a primary outcome, and most also looked for reductions in alcohol-related harm. Each found reductions in alcohol intake patterns or reductions in alcohol-related harm in the intervention group, although some between-group differences were not statistically significant reductions. CONCLUSION: Seven studies were identified that measured the outcomes of ED interventions for alcohol use in the college-age population. The studied interventions showed promise but had variable success. More research is needed to establish short- and long-term efficacy, specifically in high-risk underage college students.

Reducing fall injuries with better data.

BACKGROUND: Fall deaths in the USA almost tripled in the twenty-first century. While various interventions have been effective in reducing fall deaths, they have failed to make a substantial impact at a population level. MAIN BODY: An overarching factor that has been relatively neglected in fall injury prevention is the need for more and better data. We need better data on the causes and circumstances of older adult fall deaths. While there are excellent national surveillance systems on the circumstances of other injury deaths (e.g., motor vehicle crashes, suicides, and homicides), such a system is lacking for fall deaths. These other data systems have been instrumental in indicating and evaluating policies that will reduce injury. It is also important to provide consumers with better information concerning the many products that affect the likelihood of fall injury (e.g., flooring, hip protectors, footwear). Automotive buyers are provided with relevant up-to-date make-model safety information from crash tests and real-world performance. Such information not only helps protect buyers from purchasing dangerous products, but it provides producers with the incentive to make ever safer products over time. CONCLUSION: We believe that creation of a national surveillance system on the circumstances of fall deaths, and increased testing/certifying of fall-related products, are two steps that would help create the conditions for continuous reductions in fall fatalities. Fall prevention should apply some of the same basic strategies that have proved effective in addressing other injuries.

Knowledge, Perceived Competence, and Behaviors Relative to Traumatic Brain Injury Among a Sample of Domestic Violence Emergency Shelter Advocates in a New England State.

This cross-sectional study describes knowledge, perceived competence, and behaviors relative to intimate partner violence (IPV)-related brain injury (BI) among staff in residential domestic violence shelter programs across a New England state. A 23-item questionnaire was administered to registrants of an online IPV-related BI training series. Within this sample, knowledge about IPV-related BI was high, but relative to providing screening, accommodations, and specialized referrals to survivors with BI, perceived competence was low, and behaviors were infrequent. IPV shelter agencies should facilitate IPV-related BI training programs for staff and prioritize developing and implementing BI screening, accommodation, and referral policies and procedures.

Sleep following alcohol intoxication in healthy, young adults: effects of sex and family history of alcoholism.

BACKGROUND: This study evaluated sex and family history of alcoholism as moderators of subjective ratings of sleepiness/sleep quality and polysomnography (PSG) following alcohol intoxication in healthy, young adults. METHODS: Ninety-three healthy adults [mean age 24.4 ± 2.7 years, 59 women, 29 subjects with a positive family history of alcoholism (FH+)] were recruited. After screening PSG, participants consumed alcohol (sex/weight adjusted dosing) to intoxication [peak breath alcohol concentration (BrAC) of 0.11 ± 0.01 g% for men and women] or matching placebo between 20:30 and 22:00 hours. Sleep was monitored using PSG between 23:00 and 07:00 hours. Participants completed the Stanford Sleepiness Scale and Karolinska Sleepiness Scale at bedtime and on awakening and a validated post-sleep questionnaire. RESULTS: Following alcohol, total sleep time, sleep efficiency, nighttime awakenings, and wake after sleep onset were more disrupted in women than men, with no differences by family history status. Alcohol reduced sleep onset latency, sleep efficiency, and rapid eye movement sleep while increasing wakefulness and slow wave sleep across the entire night compared with placebo. Alcohol also generally increased sleep consolidation in the first half of the night, but decreased it during the second half. Sleepiness ratings were higher following alcohol, particularly in women at bedtime. Morning sleep quality ratings were lower following alcohol than placebo. CONCLUSIONS: Alcohol intoxication increases subjective sleepiness and disrupts sleep objectively more in healthy women than in men, with no differences evident by family history of alcoholism status. Evaluating moderators of alcohol effects on sleep may provide insight into the role of sleep in problem drinking.

It is time to rewrite state youth sports concussion laws.

Between 2009 and 2014, all 50 states and the District of Columbia passed legislation to improve the recognition and management of youth concussed in sports. These laws can include requirements for concussion training for school athletic personnel, concussion education for children and their parents, return-to-play (RTP) procedures, and medical clearance to for RTP. Concussion can impact academic learning and performance in children and adolescents. Postconcussion academic accommodations during recovery can be an important component of secondary prevention for mitigating the sequalae of head injury. Few state youth concussion laws, however, include provision of postconcussion return-to-learn (RTL) accommodations and most of those that do address RTL apply to student athletes only. Concussions may occur in youth who are not participating in organised sports (eg, falls, traffic crashes) and thus may not be subjected to RTL accommodations, even if the state mandates such procedures for athletes. Low income and students of colour may be more likely to have non-sports concussions than their more affluent and white peers, thus potentially creating demographic disparities in the benefits of RTL procedures. State youth sports concussion laws should be revised so that they include RTL provisions that apply to all students, athletes and non-athletes alike.

A hybrid underwater robot for multidisciplinary investigation of the ocean twilight zone.

Mesobot, an autonomous underwater vehicle, addresses specific unmet needs for observing and sampling a variety of phenomena in the ocean's midwaters. The midwater hosts a vast biomass, has a role in regulating climate, and may soon be exploited commercially, yet our scientific understanding of it is incomplete. Mesobot has the ability to survey and track slow-moving animals and to correlate the animals' movements with critical environmental measurements. Mesobot will complement existing oceanographic assets such as towed, remotely operated, and autonomous vehicles; shipboard acoustic sensors; and net tows. Its potential to perform behavioral studies unobtrusively over long periods with substantial autonomy provides a capability that is not presently available to midwater researchers. The 250-kilogram marine robot can be teleoperated through a lightweight fiber optic tether and can also operate untethered with full autonomy while minimizing environmental disturbance. We present recent results illustrating the vehicle's ability to automatically track free-swimming hydromedusae (Solmissus sp.) and larvaceans (Bathochordaeus stygius) at depths of 200 meters in Monterey Bay, USA. In addition to these tracking missions, the vehicle can execute preprogrammed missions collecting image and sensor data while also carrying substantial auxiliary payloads such as cameras, sonars, and samplers.

Intoxication with bourbon versus vodka: effects on hangover, sleep, and next-day neurocognitive performance in young adults.

BACKGROUND: This study assessed the effects of heavy drinking with high or low congener beverages on next-day neurocognitive performance, and the extent to which these effects were mediated by alcohol-related sleep disturbance or alcoholic beverage congeners, and correlated with the intensity of hangover. METHODS: Healthy heavy drinkers age 21 to 33 (n = 95) participated in 2 drinking nights after an acclimatization night. They drank to a mean of 0.11 g% breath alcohol concentration on vodka or bourbon one night with matched placebo the other night, randomized for type and order. Polysomnography recordings were made overnight; self-report and neurocognitive measures were assessed the next morning. RESULTS: After alcohol, people had more hangover and more decrements in tests requiring both sustained attention and speed. Hangover correlated with poorer performance on these measures. Alcohol decreased sleep efficiency and rapid eye movement sleep, and increased wake time and next-day sleepiness. Alcohol effects on sleep correlated with hangover but did not mediate the effects on performance. No effect of beverage congeners was found except on hangover severity, with people feeling worse after bourbon. Virtually no sex differences appeared. CONCLUSIONS: As drinking to this level affects complex cognitive abilities, safety could be affected, with implications for driving and for safety-sensitive occupations. Congener content affects only how people feel the next day so does not increase risk. The sleep disrupting effects of alcohol did not account for the impaired performance so other mechanisms of effect need to be sought. As hangover symptoms correlate with impaired performance, these might be contributing to the impairment.

Evaluation of Implementation of Massachusetts Sports Concussion Regulations: Results of Focus Groups with Athletic Directors.

In 2018, the Massachusetts Department of Public Health (MDPH) conducted focus groups with athletic directors (ADs) from Massachusetts middle and high schools to assess the implementation of legislated regulations relative to the management of concussion (mild traumatic brain injuries; mTBI) among students engaged in extracurricular sports. Two tape-recorded focus groups were conducted with a facilitator. Lists of themes were synthesized by investigators. Overall, participating ADs expressed that the law and accompanying regulations were necessary and important for protecting student athletes, despite some burdensome aspects of implementation. Emerging themes included support for the law, some implementation problems, impact on workload, and recommendations for improving mandated procedures. ADs assume an important role in the management of middle and high school students' mTBI when given the authority to do so through legislation and regulation. Nonetheless, challenges to the daily application of legislated protocols exist and should continue to be evaluated.

Perceptions of implementation of Massachusetts sports concussion regulations: results of a survey of athletic directors.

BACKGROUND: In 2011 the Massachusetts Department of Public Health issued regulations pursuant to 2010 Massachusetts youth sports concussion legislation that provided policies and procedures for persons engaged in the prevention, training, management, and return-to-activity for students who sustain head injury during interscholastic athletics, including Athletic Directors (ADs). METHODS: A survey instrument was developed with participation from injury prevention experts at the Boston University School of Medicine, the Massachusetts Department of Public Health, and ADs. An electronic survey was sent to all AD members of the Massachusetts Interscholastic Athletic Association to assess their perceptions of implementation of the sports concussion law. RESULTS: Response rate was 75% (260/346). The mean rating on a 0-10 scale (10 being "very important") on importance of the law for student safety was 9.24, and the mean rating of the law's impact on workload was 5.54. Perceived impact on workload varied as a function of whether or not the school also employed an athletic trainer (t = 2.24, p = 0.03). Most respondents (88%) reported that their school had a concussion management team, and 74% reported that they were informed "always" (31%) or "often" (43%) when a student-athlete experienced a head injury in a venue other than extracurricular sports. Most respondents (95%) endorsed that "all" or "most" school nurses were "very knowledgeable" about the law and regulations. Approximately half of all respondents endorsed that "all" or "most" teachers and guidance counselors were "very knowledgeable" about the law and regulations; 76% endorsed that "all" or "most" of students' physicians were "very knowledgeable" about the law and regulations; 59% endorsed that "all" or "most" parents were "very knowledgeable" about the law and regulations. Sixty-six percent endorsed that student-athletes with concussion "often" (10%) or "sometimes" (56%) misrepresent their symptoms to accelerate return-to-play; and, 70% perceived that student-athletes with concussion "often" (15%) or "sometimes" (55%) misrepresent their symptoms to avoid academics. CONCLUSIONS: ADs perceive the sports concussion legislation as very important to student safety and positively assess implementation of the law and associated regulations. More effort is needed to increase understanding of the law among stakeholders including teachers, parents, and physicians.

Disparities in baseline neurocognitive testing for student concussion management in Massachusetts high schools.

PURPOSE: There is evidence of socioeconomic disparities with respect to the implementation of student-sports concussion laws nationally. The purpose of this study was to examine school sociodemographic characteristics associated with the provision of computerised baseline neurocognitive testing (BNT) in Massachusetts (MA) high schools, and to assess whether the scope of testing is associated with the economic status of student populations in MA. METHODS: A cross-sectional secondary analysis of surveys conducted with MA athletic directors (n=270) was employed to investigate school characteristics associated with the provision of BNT. Correlation and regression analyses were used to assess whether the scope of testing is associated with the economic status of student populations in MA. RESULTS: The scope of BNT was independently associated with the economic disadvantage rate (EDR) of the student population (ß=-0.02, p=0.01); whether or not the school employs an athletic trainer (AT) (ß=0.43, p=0.03); and school size (ß=-0.54, p=0.03). In a multivariable regression model, EDR was significantly associated with the scope of baseline testing, while controlling for AT and size (ß=-0.01, p=0.03, adj-R2=0.1135). CONCLUSION: Among public high schools in MA, disparities in the provision of BNT for students are associated with the economic characteristics of the student body. Schools that have a greater proportion of low-income students are less likely to provide comprehensive BNT. The clinical implications of not receiving BNT prior to concussion may include diminished quality of postconcussive care, which can have short-term and long-term social, health-related and educational impacts.

Pre-fracture medication use as a predictor of 30-day mortality in hip fracture patients: an analysis of 141,201 patients.

PURPOSE: To evaluate the predictive value of pre-fracture medication usage on 30-day mortality following a hip fracture. METHODS: Information on age, sex, fracture type, time of death and Charlson co-morbidity index (CCI) was collected from the Danish National Patient Registry on all patients above 60 years, sustaining a hip fracture during the period January 1995 to December 2013. Information on drug usage was obtained from the Danish National Prescription Database. Hazard ratios were calculated with 30-day mortality as the outcome. A univariate and 3 multivariate analyses were conducted with increasing adjustments, starting with age, sex and fracture type, adding co-morbidity and dose in the latter. RESULTS: 141,201 patients were included and a total of 12 drugs/drug groups were identified for analysis. Increased mortality was evident in all analyses for antiarrhythmics, beta blockers, proton pump inhibitors, loop diuretics, opioids, acetaminophen and for psycholeptics. For ACE-inhibitors, increased mortality was found in all analyses, except after adjustment for co-morbidity and dose. For thiazide diuretics, a significantly reduced mortality was evident in all but the univariate analyses while NSAIDs and statins were associated with a significantly reduced mortality in all analyses. For calcium channel blockers, an insignificant decrease was found after adjustment for dose. Further analysis showed a dose-response relationship for all drugs except ACE-inhibitors and calcium channel blockers. CONCLUSION: The study shows a correlation between pre-fracture usage of certain drugs and 30 day mortality after a hip fracture.

The incidence and severity of hangover the morning after moderate alcohol intoxication.

AIMS: To determine the incidence and covariates of hangover following a night of moderate alcohol consumption at a targeted breath alcohol level. DESIGN: Data were combined from three randomized cross-over trials investigating the effects of heavy drinking on next-day performance. A total of 172 participants received either alcoholic beverage (mean=0.115 g% breath alcohol concentration) or placebo on one night and the other beverage a week later. The next day, participants completed a hangover scale. PARTICIPANTS: Participants were 54 professional merchant mariners attending a recertification course at Kalmar Maritime Academy (Kalmar, Sweden) and 118 university students or recent graduates recruited from greater Boston. SETTING: One trial was conducted at Kalmar Maritime Academy (Sweden); the other two were conducted at the General Clinical Research Center at Boston Medical Center. MEASUREMENTS: A nine-item scale assessed hangover. FINDINGS: Hangover was reported by 76% of participants. Neither alcoholic beverage type nor participant characteristics was associated with incidence of hangover. CONCLUSIONS: Our findings on the propensity of hangover suggest that 25-30% of drinkers may be resistant to hangover.

The effects of transdermal scopolamine on simulated ship navigation and attention/reaction time.

Transdermal scopolamine is commonly used by mariners to prevent or treat seasickness. Most studies indicate that scopolamine administered transdermally via an adhesive patch does not impair performance of skills required to navigate a vessel, but trials have not been conducted testing navigation and ship handling under realistic conditions. The aim of this study was to test the effects of transdermal scopolamine on performance using training simulators to assess complex vessel navigation and rough-weather ship handling abilities. A randomized double-blind crossover study assessed 32 Swedish maritime cadets under transdermal scopolamine and placebo conditions on simulated navigation and ship handling performance, sleepiness, and subjective measures of fitness and performance. There were no significant differences on occupational outcomes by medication condition, but sustained reaction time was significantly increased under transdermal scopolamine, relative to placebo. We conclude that the transdermal scopolamine patch does not impair simulated ship handling.