Risk factors for prolonged recovery from concussion in young patients.

OBJECTIVES: For young patients sustaining concussion, assessing recovery is vital in determining safe return to play. Identifying risk factors may aid clinicians in recognising patients at risk for prolonged recovery. The study objective is to identify risk factors for prolonged (>28 days) and extended (>90 days) recovery (defined as symptom duration) and analyse how these risk factors differ between the two groups. METHODS: We retrospectively analysed electronic health record data (n=4937) among patients aged 10-18 years collected at Nationwide Children's Hospital Sports Medicine concussion clinics between 1 July 2012 and 30 June 2019. Data collected included patient demographics, comorbidities (eg, prior psychiatric diagnoses, prior concussions) and injury characteristics (eg, loss of consciousness, injury setting). We examined patient risk factors for prolonged (>28 days) and/or extended (>90 days) recovery using modified Poisson regression models. RESULTS: Factors associated with increased risk of prolonged recovery from concussion included prior concussions (adjusted risk ratio (ARR) 1.19, 95% CI 1.02 to 1.38) for two concussions (ARR 1.36, 95% CI 1.14 to 1.61), for >3, and higher initial symptom score (ARR 2.57, 95% CI 2.34 to 2.83) for postconcussion symptom (PCS) scores 21-60 (ARR 2.89, 95% CI 2.54 to 3.29), for PCS>60. Risk factors for extended recovery included history of concussion (ARR 1.50, 95% CI 1.09 to 2.06) for two concussions (ARR 1.75, 95% CI 1.17 to 2.62), for >3 and older age (15-18 years, ARR 1.11, 95% CI 1.05 to 1.18). Additionally, comorbid attention deficit hyperactivity disorder increased risk of prolonged recovery (ARR 1.14, 95% CI 1.01 to 1.29) while anxiety increased risk for extended recovery (ARR 1.47, 95% CI 1.10 to 1.95). CONCLUSION: Overall, risk factors for prolonged recovery differ somewhat from risk factors for extended recovery. For patients who present to clinic with concussion, mental health is an important consideration which may impact the timeline for symptom recovery.

Association of Self-Paced Physical and Cognitive Activities Across the First Week Postconcussion With Symptom Resolution in Youth.

OBJECTIVE: To examine the association of objectively measured, self-paced physical and cognitive activities across the first week postconcussion with symptom resolution in youth. SETTING: Emergency department or concussion clinics. PARTICIPANTS: Youth aged 11 to 17 years with physician-confirmed concussion. DESIGN: Prospective cohort with repeated measures. MAIN MEASURES: Days from injury to symptom resolution, based on daily ratings by youth on the Post-Concussive Symptom Scale. Physical and cognitive activities were assessed using an ActiGraph and a Narrative Clip, respectively. RESULTS: A total of 83 youth participants were included (n = 54 [65%] males; mean age = 14.2 years, SD = 1.9). While self-paced daily physical and cognitive activities increased across the first week postinjury, daily postconcussion symptoms decreased. Increased daily step count was associated with an increased likelihood of early symptom resolution (hazard ratio [HR] = 1.17; 95% confidence interval [CI], 1.02-1.34). However, this association was not statistically significant after adjusting for acute postconcussion symptoms and other covariates. Greater school attendance time was associated with earlier symptom resolution (adjusted HR = 1.14; 95% CI, 1.02-1.27). CONCLUSION: Self-paced physical and cognitive activities across the first week postinjury alone neither hastened nor prolonged concussion recovery. Youth with concussion may have some latitude to determine their activity levels.

Influence of insurance type on rate and type of initial concussion-related medical visits among youth.

BACKGROUND: A growing number of studies report increased concussion-related health care utilization in recent years, but factors impacting care-seeking behaviors among youth following a concussion are not well described. This study aimed to evaluate the influence of insurance type on the rate and type of initial concussion visits and the time from injury to the initial visit in youth. METHODS: We extracted and analyzed initial concussion-related medical visits for youth ages 10 to 17 from electronic health records. Patients must have visited Nationwide Children's Hospital's (NCH) concussion clinic at least once between 7/1/2012 and 12/31/2017. We evaluated the trends and patterns of initial concussion visits across the study period using regression analyses. RESULTS: Of 4955 unique concussion visits included, 60.1% were males, 80.5% were white, and 69.5% were paid by private insurance. Patients' average age was 13.9 years (SD = 3.7). The rate of the initial concussion visits per 10,000 NCH visits was consistently higher in privately insured than publicly insured youth throughout the study period (P < .0001). Privately insured youth had greater odds of initial concussion visits to sports medicine clinics (AOR = 1.45, 95% CI = 1.20, 1.76) but lower odds of initial concussion visits to the ED/urgent care (AOR = 0.74, 95% CI = 0.60, 0.90) than publicly insured youth. Days from injury to initial concussion visit significantly decreased among both insurance types throughout the study (P < .0001), with a greater decrease observed in publicly insured than privately insured youth (P = .011). CONCLUSIONS: Results on the differences in the rate, type, and time of initial concussion-related visits may help inform more efficient care of concussion among youth with different types of insurance.

Evaluation of a resilience training program for college student-athletes: A pilot study.

Objective: To determine if a resilience training program improved knowledge of and intention to use adaptive coping strategies among college student-athletes; and explore college student-athletes' experiences and satisfaction with program components. Participants: Division I college student-athletes. Methods: Pretest-posttest design with surveys completed at baseline and immediately post-program. Results: A total of 79 participants were included (n = 43 [54.4%] females; n = 36 [45.6%] males; Mage = 20.94, [SD = 1.05]). Overall intention to use adaptive coping strategies significantly increased from baseline (M = 29.05, SD = 4.50) to post-program (M = 32.38, SD = 5.62) (p = 0.0004), as did intentions to use the coping strategies seeking social support (p = 0.0037) and self-controlling (p = 0.0007). We found no statistically significant differences in knowledge scores from baseline to post-program. Conclusions: Resilience training may increase college student-athletes' likelihood of using adaptive coping strategies to manage academic and sport-related stressors.

Salivary miRNA Expression in Children With Persistent Post-concussive Symptoms.

Background: Up to one-third of concussed children develop persistent post-concussive symptoms (PPCS). The identification of biomarkers such as salivary miRNAs that detect concussed children at increased risk of PPCS has received growing attention in recent years. However, whether and how salivary miRNA expression levels differ over time between concussed children with and without PPCS is unknown. Aim: To identify salivary MicroRNAs (miRNAs) whose expression levels differ over time post-concussion in children with vs. without PPCS. Methods: We conducted a prospective cohort study with saliva collection at up to three timepoints: (1) within one week of injury; (2) one to two weeks post-injury; and (3) 4-weeks post-injury. Participants were children (ages 11 to 17 years) with a physician-diagnosed concussion from a single hospital center. We collected participants' daily post-concussion symptom ratings throughout their enrollment using the Post-concussion Symptom Scale, and defined PPCS as a total symptom score of ≥ 5 at 28 days post-concussion. We extracted salivary RNA from the saliva samples and measured expression levels of 827 salivary miRNAs. We then compared the longitudinal expression levels of salivary miRNAs in children with vs. without PPCS using linear models with repeated measures. Results: A total of 135 saliva samples were collected from 60 children. Of the 827 miRNAs analyzed, 91 had expression levels above the calculated background threshold and were included in the differential gene expression analyses. Of these 91 miRNAs, 13 had expression levels that differed significantly across the three timepoints post-concussion between children with and without PPCS (i.e., hsa-miR-95-3p, hsa-miR-301a-5p, hsa-miR-626, hsa-miR-548y, hsa-miR-203a-5p, hsa-miR-548e-5p, hsa-miR-585-3p, hsa-miR-378h, hsa-miR-1323, hsa-miR-183-5p, hsa-miR-200a-3p, hsa-miR-888-5p, hsa-miR-199a-3p+hsa-miR-199b-3p). Among these 13 miRNAs, one (i.e., hsa-miR-203a-5p) was also identified in a prior study, with significantly different expression levels between children with and without PPCS. Conclusion: Our results from the longitudinal assessment of miRNAs indicate that the expression levels of 13 salivary miRNAs differ over time post-injury in concussed children with vs. without PPCS. Salivary miRNAs may be a promising biomarker for PPCS in children, although replication studies are needed.

Balancing safety on the road with risk from COVID-19: A content analysis of policy adaptations by Divisions of Motor Vehicles.

PURPOSE: The COVID-19 pandemic significantly altered people's daily lives, including driving. However, how state Divisions of Motor Vehicles (DMV) adapted their operation policies in response to COVID-19 remains unknown. This study analyzed adaptations to the content of state DMV operation policies during the COVID-19 pandemic across 50 US states and assessed the relationships between these policy adoptions and their state-level COVID-19 restriction orders. METHODS: We merged data on policy adaptations due to COVID-19 obtained from DMV websites for all 50 states with data on state-level restrictions obtained from the National Academy for State Health Policy (NASHP). We created a codebook and analyzed the DMV policy adaptations in the following three areas: (1) road testing, (2) licensure extension and renewals, and (3) facility reopening. Two trained coders independently reviewed and coded the adaptations of policy content related to precaution to spread of COVID-19 and ease of obtaining licensure. We calculated summary scores for policy adaptations and ease of licensure and compared these scores across three categories of state-level COVID-19 restrictions using ANOVA. RESULTS: DMVs in all 50 states adapted their policies to slow the spread of COVID-19. The ease of licensure summary scores increased in some states but decreased in others. Extensions for licensure renewals was the most common change. Adoption of COVID-19 precautions during the road test was the most common road test adaptation, while road test waivers were the most controversial. Requiring appointments, social distancing, and/or face coverings/personal protective equipment [PPE] were common adaptations during facility reopening. However, variations in level of policy adaptations and ease of licensure were not associated with the state's COVID-19 restrictions. CONCLUSIONS: Our findings provide insight into policy adaptations made by state DMVs to reduce the spread of COVID-19 and may inform future policy adaptations in DMVs and other government agencies during public health emergencies.