Avenues for prevention using the epidemiology of sport-related concussion from a large high school surveillance study.

OBJECTIVE: Epidemiology provides fundamental opportunities to protect student-athlete health. The goal of this study was to describe the epidemiology of sport-related concussion (SRC) across 8 years (2015/2016-2022/2023) and compare boys' and girls' sports for SRC incidence and SRC mechanisms. METHODS: This was a retrospective cohort study performed using a statewide high school head injury surveillance system of high school student-athletes (n = 2,182,128; boys, n = 1,267,389; girls, n = 914,739). Exposures of interest included study year and boys and girls in comparable sports. Clinical incidence was calculated by dividing SRC counts in each sport by the number of participants per 100 player-seasons and presented with 95% CIs. The 2019/2020 and 2020/2021 data were included in the analysis, however caution is warranted due to the COVID-19 pandemic. Clinical incidence ratios (CIRs) were estimated for sex-comparable sports, and significance was determined if 95% CIs excluded 1.00. The authors compared mechanism of injury in boys' and girls' comparable sports with chi-square analyses (p < 0.05). RESULTS: Among 25,482 total SRCs, the overall clinical incidence of SRC for all boys and girls was 1.17 (95% CI 1.15-1.18) per 100 player-seasons across all years. Across all years, the overall clinical incidence in boys' sports was 1.34 (95% CI 1.32-1.36) per 100 player-seasons, and 0.93 (95% CI 0.91-0.95) per 100 player-seasons in girls' sports. Boys' sports with the highest clinical incidence included football, ice hockey, and wrestling. Girls' sports with the highest clinical incidence included basketball, soccer, lacrosse, competitive cheer, and gymnastics. Girls consistently had higher SRC rates relative to boys for baseball/softball, basketball, and soccer (CIR range 1.65 [95% CI 1.41-1.93] to 3.32 [95% CI 2.67-4.16]). Girls had lower SRC in lacrosse in 2015/2016 (CIR 0.63, 95% CI 0.40-0.97); no difference in 2016/2017-2020/2021, but had higher clinical incidence in 2021/2022 (CIR 1.69, 95% CI 1.18-2.44) relative to boys. In boys the most common mechanism of SRC occurred from person-to-person contact (n = 8752, 62.8%), whereas girls commonly sustained SRC from person-to-object contact (n = 2369, 33.4%) and from person-to-person contact (n = 2368, 33.4%). There were significant associations between boys' versus girls' sports and mechanism of injury within baseball/softball (χ2 = 12.71, p = 0.005); basketball (χ2 = 36.47, p < 0.001); lacrosse (χ2 = 185.15, p < 0.001); and soccer (χ2 = 122.70, p < 0.001). CONCLUSIONS: These findings can help understand the potential impact of interventions aimed at preventing or reducing SRC. Including girls' sports within this study extends research for a largely underrepresented group.

Feedback and Financial Incentives for Reducing Cell Phone Use While Driving: A Randomized Clinical Trial.

Importance: Handheld phone use while driving is a major factor in vehicle crashes. Scalable interventions are needed to encourage drivers not to use their phones. Objective: To test whether interventions involving social comparison feedback and/or financial incentives can reduce drivers' handheld phone use. Design, Setting, and Participants: In a randomized clinical trial, interventions were administered nationwide in the US via a mobile application in the context of a usage-based insurance program (Snapshot Mobile application). Customers were eligible to be invited to participate in the study if enrolled in the usage-based insurance program for 30 to 70 days. The study was conducted from May 13 to June 30, 2019. Analysis was completed December 22, 2023. Interventions: Participants were randomly assigned to 1 of 6 trial arms for a 7-week intervention period: (1) control; (2) feedback, with weekly push notification about their handheld phone use compared with that of similar others; (3) standard incentive, with a maximum $50 award at the end of the intervention based on how their handheld phone use compared with similar others; (4) standard incentive plus feedback, combining interventions of arms 2 and 3; (5) reframed incentive plus feedback, with a maximum $7.15 award each week, framed as participant's to lose; and (6) doubled reframed incentive plus feedback, a maximum $14.29 weekly loss-framed award. Main Outcome and Measure: Proportion of drive time engaged in handheld phone use in seconds per hour (s/h) of driving. Analyses were conducted with the intention-to-treat approach. Results: Of 17 663 customers invited by email to participate, 2109 opted in and were randomized. A total of 2020 drivers finished the intervention period (68.0% female; median age, 30 [IQR, 25-39] years). Median baseline handheld phone use was 216 (IQR, 72-480) s/h. Relative to control, feedback and standard incentive participants did not reduce their handheld phone use. Standard incentive plus feedback participants reduced their use by -38 (95% CI, -69 to -8) s/h (P = .045); reframed incentive plus feedback participants reduced their use by -56 (95% CI, -87 to -26) s/h (P < .001); and doubled reframed incentive plus feedback participants reduced their use by -42 s/h (95% CI, -72 to -13 s/h; P = .007). The 5 active treatment arms did not differ significantly from each other. Conclusions and Relevance: In this randomized clinical trial, providing social comparison feedback plus incentives reduced handheld phone use while individuals were driving. Trial Registration: ClinicalTrials.gov Identifier: NCT03833219.

Using mobile health to expedite access to specialty care for youth presenting to the emergency department with concussion at highest risk of developing persisting symptoms: a protocol paper for a non-randomised hybrid implementation-effectiveness trial.

INTRODUCTION: Paediatric concussion is a common injury. Approximately 30% of youth with concussion will experience persisting postconcussion symptoms (PPCS) extending at least 1 month following injury. Recently, studies have shown the benefit of early, active, targeted therapeutic strategies. However, these are primarily prescribed from the specialty setting. Early access to concussion specialty care has been shown to improve recovery times for those at risk for persisting symptoms, but there are disparities in which youth are able to access such care. Mobile health (mHealth) technology has the potential to improve access to concussion specialists. This trial will evaluate the feasibility of a mHealth remote patient monitoring (RPM)-based care handoff model to facilitate access to specialty care, and the effectiveness of the handoff model in reducing the incidence of PPCS. METHODS AND ANALYSIS: This study is a non-randomised type I, hybrid implementation-effectiveness trial. Youth with concussion ages 13-18 will be enrolled from the emergency department of a large paediatric healthcare network. Patients deemed a moderate-to-high risk for PPCS using the predicting and preventing postconcussive problems in paediatrics (5P) stratification tool will be registered for a web-based chat platform that uses RPM to collect information on symptoms and activity. Those patients with escalating or plateauing symptoms will be contacted for a specialty visit using data collected from RPM to guide management. The primary effectiveness outcome will be the incidence of PPCS, defined as at least three concussion-related symptoms above baseline at 28 days following injury. Secondary effectiveness outcomes will include the number of days until return to preinjury symptom score, clearance for full activity and return to school without accommodations. The primary implementation outcome will be fidelity, defined as the per cent of patients meeting specialty care referral criteria who are ultimately seen in concussion specialty care. Secondary implementation outcomes will include patient-defined and clinician-defined appropriateness and acceptability. ETHICS AND DISSEMINATION: This study was approved by the Institutional Review Board of the Children's Hospital of Philadelphia (IRB 22-019755). Study findings will be published in peer-reviewed journals and disseminated at national and international meetings. TRIAL REGISTRATION NUMBER: NCT05741411.

Response Rate Patterns in Adolescents With Concussion Using Mobile Health and Remote Patient Monitoring: Observational Study.

Background: A concussion is a common adolescent injury that can result in a constellation of symptoms, negatively affecting academic performance, neurobiological development, and quality of life. Mobile health (mHealth) technologies, such as apps for patients to report symptoms or wearables to measure physiological metrics like heart rate, have been shown to be promising in health maintenance. However, there is limited evidence about mHealth engagement in adolescents with a concussion during their recovery course. Objective: This study aims to determine the response rate and response rate patterns in concussed adolescents reporting their daily symptoms through mHealth technology. It will also examine the effect of time-, demographic-, and injury-related characteristics on response rate patterns. Methods: Participants aged between 11-18 years (median days since injury at enrollment: 11 days) were recruited from the concussion program of a tertiary care academic medical center and a suburban school's athletic teams. They were asked to report their daily symptoms using a mobile app. Participants were prompted to complete the Post-Concussion Symptom Inventory (PCSI) 3 times (ie, morning, afternoon, and evening) per day for 4 weeks following enrollment. The primary outcome was the response rate pattern over time (by day since initial app use and the day since injury). Time-, demographic-, and injury-related differences in reporting behaviors were compared using Mann Whitney U tests. Results: A total of 56 participants were enrolled (mean age 15.3, SD 1.9 years; n=32, 57% female). The median response rate across all days of app use in the evening was 37.0% (IQR 27.2%-46.4%), which was significantly higher than the morning (21.2%, IQR 15.6%-30.5%) or afternoon (26.4%, IQR 21.1%-31.5%; P<.001). The median daily response was significantly different by sex (female: 53.8%, IQR 46.2%-64.2% vs male: 42.0%, IQR 28.6%-51.1%; P=.003), days since injury to app use (participants starting to use the app >7 days since injury: 54.1%, IQR 47.4%-62.2% vs starting to use the app ≤7 days since injury: 38.0%, IQR 26.0%-53.3%; P=.002), and concussion history (participants with a history of at least one prior concussion: 57.4%, IQR 44.5%-70.5% vs participants without concussion history: 42.3%, IQR 36.8%-53.5%; P=.03). There were no significant differences by age. Differences by injury mechanism (sports- and recreation-related injury: 39.6%, IQR 36.1%-50.4% vs non-sports- or recreation-related injury: 30.6%, IQR 20.0%-42.9%; P=.04) and initial symptom burden (PCSI scores greater than the median score of 47: 40.9%, IQR 35.2%-53.8% vs PCSI scores less than or equal to the median score: 31.9%, IQR 24.6%-40.6%; P=.04) were evident in the evening response rates; however, daily rates were not statistically different. Conclusions: Evening may be the optimal time to prompt for daily concussion symptom assessment among concussed adolescents compared with morning or afternoon. Multiple demographic- and injury-related characteristics were associated with higher daily response rates, including for female participants, those with more than 1 week from injury to beginning mHealth monitoring, and those with a history of at least one previous concussion. Future studies may consider incentive strategies or adaptive digital concussion assessments to increase response rates in populations with low engagement.

Comparison of different definitions of traumatic brain injury: implications for cohort characteristics and survival in women, Philadelphia, USA.

BACKGROUND: Traumatic brain injury (TBI) is an acute injury that is understudied in civilian cohorts, especially among women, as TBI has historically been considered to be largely a condition of athletes and military service people. Both the Centres for Disease Control and Prevention (CDC) and Department of Defense (DOD)/Veterans Affairs (VA) have developed case definitions to identify patients with TBI from medical records; however, their definitions differ. We sought to re-examine these definitions to construct an expansive and more inclusive definition among a cohort of women with TBI. METHODS: In this study, we use electronic health records (EHR) from a single healthcare system to study the impact of using different case definitions to identify patients with TBI. Specifically, we identified adult female patients with TBI using the CDC definition, DOD/VA definition and a combined and expanded definition herein called the Penn definition. RESULTS: We identified 4446 adult-female TBI patients meeting the CDC definition, 3619 meeting the DOD/VA definition, and together, 6432 meeting our expanded Penn definition that includes the CDC ad DOD/VA definitions. CONCLUSIONS: Using the expanded definition identified almost two times as many patients, enabling investigations to more fully characterise these patients and related outcomes. Our expanded TBI case definition is available to other researchers interested in employing EHRs to investigate TBI.

Survival analysis under imperfect record linkage using historic census data.

BACKGROUND: Advancements in linking publicly available census records with vital and administrative records have enabled novel investigations in epidemiology and social history. However, in the absence of unique identifiers, the linkage of the records may be uncertain or only be successful for a subset of the census cohort, resulting in missing data. For survival analysis, differential ascertainment of event times can impact inference on risk associations and median survival. METHODS: We modify some existing approaches that are commonly used to handle missing survival times to accommodate this imperfect linkage situation including complete case analysis, censoring, weighting, and several multiple imputation methods. We then conduct simulation studies to compare the performance of the proposed approaches in estimating the associations of a risk factor or exposure in terms of hazard ratio (HR) and median survival times in the presence of missing survival times. The effects of different missing data mechanisms and exposure-survival associations on their performance are also explored. The approaches are applied to a historic cohort of residents in Ambler, PA, established using the 1930 US census, from which only 2,440 out of 4,514 individuals (54%) had death records retrievable from publicly available data sources and death certificates. Using this cohort, we examine the effects of occupational and paraoccupational asbestos exposure on survival and disparities in mortality by race and gender. RESULTS: We show that imputation based on conditional survival results in less bias and greater efficiency relative to a complete case analysis when estimating log-hazard ratios and median survival times. When the approaches are applied to the Ambler cohort, we find a significant association between occupational exposure and mortality, particularly among black individuals and males, but not between paraoccupational exposure and mortality. DISCUSSION: This investigation illustrates the strengths and weaknesses of different imputation methods for missing survival times due to imperfect linkage of the administrative or registry data. The performance of the methods may depend on the missingness process as well as the parameter being estimated and models of interest, and such factors should be considered when choosing the methods to address the missing event times.

Symptom characteristics, perceived causal attributions, and contextual factors influencing self-care behaviors: An ecological daily assessment study of adults with chronic illness.

OBJECTIVE: Insights into how symptoms influence self-care can guide patient education and improve symptom control. This study examined symptom characteristics, causal attributions, and contextual factors influencing self-care of adults with arthritis, asthma, chronic obstructive pulmonary disease, diabetes, or heart failure. METHODS: Adults (n = 81) with a symptomatic chronic illness participated in a longitudinal observational study. Using Ecological Daily Assessment, participants described one symptom twice daily for two weeks, rating its frequency, severity, bothersomeness, duration, causes, and self-care. RESULTS: The most frequent symptoms were fatigue and shortness of breath. Pain, fatigue, and joint stiffness were the most severe and bothersome. Most participants engaged in active self-care, but those with fatigue and pain engaged in passive self-care (i.e., rest or do nothing), especially when symptoms were infrequent, mild, somewhat bothersome, and fleeting. In people using passive self-care, thoughts, feelings, and the desire to conceal symptoms from others interfered with self-care. CONCLUSION: Most adults with a chronic illness take an active role in managing their symptoms but some conceal or ignore symptoms until the frequency, severity, bothersomeness, or duration increases. PRACTICE IMPLICATIONS: When patients report symptoms, asking about self-care behaviors may reveal inaction or ineffective approaches. A discussion of active self-care options may improve symptom control.

Firearm manufacturing and imports in the USA and their association to firearm homicides in Central America and the Caribbean, 1991-2019.

BACKGROUND: Firearm manufacturing and imports grew in the US during the mid-2000s. We hypothesise those increases corresponded to increased international firearms trafficking and in turn were associated with increases in firearm homicides abroad. METHODS: We used the Global Burden of Disease database to quantify annual firearm and non-firearm homicide rates in Central American and Caribbean countries, 1991-2019. We obtained US firearm manufacturing and import data from the Bureau of Alcohol, Tobacco, Firearms and Explosives. We used two-way fixed effects regressions to estimate within-country associations between homicide rates (firearm and non-firearm) and US firearm manufacturing and imports. FINDINGS: Firearm homicide rates in Central American and Caribbean countries increased from 8.38/100K population in 2004 to 17.55/100 K in 2012 and remained steady thereafter. Those surges coincided with increases in US firearm manufacturing/imports (from 4.99 million in 2004 to 13.12 million in 2012). Non-firearm homicides remained roughly constant from 1991 to 2019. Adjusted analysis showed that an annual increase of one million firearms manufactured/imported in the US corresponded to an annual increase of 1.42 (95% CI 0.62 to 2.21) firearm homicides per 100 K in Central American and Caribbean countries. The corresponding change for non-firearm homicides was -0.18 (95% CI -1.46 to 1.11). We found country-to-country variability in these effects. INTERPRETATION: Increases in US firearm manufacturing/imports were associated with increases in firearm homicide rates in Central American and Caribbean countries but not associated with non-firearm homicides. The specificity to firearm homicides suggests possible international repercussions of increased firearm manufacturing and imports in the US implications are discussed.

Acute Sport-Related Concussion Management and Return to Sport Time in High School Athletes.

BACKGROUND: The current evidence for acute management practices of sport-related concussion (SRC) is often limited to in-clinic visits, with limited studies identifying professionals in early SRC care and the association with prolonged recovery outcomes. PURPOSE: To describe acute SRC management practices (ie, the personnel in the initial evaluations, removal from activity) and test the association with prolonged return to sport (RTS) time. STUDY DESIGN: Descriptive epidemiology study. METHODS: We conducted a retrospective cohort study of 17,081 high school SRCs accrued between the 2015-2016 and 2020-2021 academic years. We reported acute management practices and RTS time as frequencies stratified by sex, sport, and event type and compared athletic trainer (AT) access in initial evaluation with chi-square tests (P < .05). Separate logistic regressions estimated odds ratios (ORs) and 95% CIs for removal from activity and prolonged RTS >21 days by acute management practices. RESULTS: Most SRCs (n = 12,311 [72.1%]) had complete initial evaluation by an AT. Boys had an AT evaluation in 75.5% (n = 2860/3787) of practice-related and 74.8% (n = 5551/7423) of competition-related events. Girls had an AT evaluation in 61.3% (n = 1294/2110) of practice-related and 69.3% (n = 2606/3761) of competition-related events. In sex-comparable sports (n = 6501), there was no difference between boys (n = 1654/2455 [67.4%]) and girls (n = 2779/4046 [68.7%]) having an AT involved in the first evaluation (χ2 = 1.21; P = .27). Notably, 25.3% of girls' SRCs were evaluated by a coach alone, and we observed differences in personnel in initial evaluations by sport. The odds of immediate removal were higher when an AT made the initial evaluation (OR, 2.8 [95% CI, 2.54-3.08]). The odds of prolonged RTS >21 days was lower for those with an AT in the initial evaluation (OR, 0.74 [95% CI, 0.65-0.84]) adjusting for significant factors from univariate analyses, boys relative to girls (OR, 0.85 [95% CI, 0.76-0.96]), specialty care relative to PCP (OR, 2.16 [95% CI, 1.90-2.46]), specialty care relative to urgent or ready care (OR, 0.99 [95% CI, 0.82-1.22]) concussion history (OR, 1.41 [95% CI, 1.22-1.63]), and removal from activity (OR, 0.90 [95% CI, 0.78-1.05]). CONCLUSION: This study found variability in personnel involved in initial SRC evaluations, with higher percentages of athletes with SRCs having ATs make the initial evaluation during competitive events. There was no association between sex and AT involvement in comparable sports. There was an association between prolonged RTS and AT involvement, sex, concussion history, and location of follow-up care.

Parent and Youth Athlete Perceptions of Concussion Injury: Establishing a Factor Structure.

OBJECTIVE: The first objective was to establish the respective factor structures of a concussion perceptions inventory that was adapted for youth athletes (ages 8-14 years) and their parents from the Perceptions of Concussion Inventory for Athletes. The second objective was to understand the associations between the concussion perceptions of youth athlete-parent dyads. METHOD: In this cross-sectional study, 329 parent-youth athlete dyads completed a respective concussion perception inventory. Mean age of youth respondents was 10.9 ± 1.8 years (70.1% male) and mean age of parent respondents was 40.5 ± 13.6 years (60.9% female). RESULTS: Exploratory factor analyses revealed unique 7-factor structures for both the youth athlete and parent inventories (youth athlete: anxiety, clarity, treatment, permanent injury, symptom variability, long-term outcomes, and personal control; parent: anxiety, clarity, treatment, permanent injury, symptom variability, and long-term outcomes, and affect others). Weak associations were found between dyads on the 5 factors that were composed of identical items (anxiety, clarity, treatment, permanent injury, and symptom variability). CONCLUSIONS: Findings suggest that this adapted inventory has adequate psychometric properties to be used in the study of the concussion perceptions of youth athletes and their parents. Weak correlations across the concussion perceptions in the dyads suggest that parents and children hold different concussion perceptions and this should be considered in instrument selection of future studies.

Publicly available data sources in sport-related concussion research: a caution for missing data.

BACKGROUND: Researchers often use publicly available data sources to describe injuries occurring in professional athletes, developing and testing hypotheses regarding athletic-related injury. It is reasonable to question whether publicly available data sources accurately indicate athletic-related injuries resulting from professional sport participation. We compared sport-related concussion (SRC) clinical incidence using data from publicly available sources to a recent publication reporting SRC using electronic health records (EHR) from the National Football League (NFL). We hypothesize publicly available data sources will underrepresent SRC in the NFL. We obtained SRCs reported from two publicly available data sources (NFL.com, pro-football-reference.com) and data reported from the NFL's published EHR. We computed SRC per 100 unique player signings from 2015-2019 and compared the clinical incidence from publicly available data sources to EHR rates using clinical incidence ratios (CIR) and 95% confidence intervals (CI). FINDINGS: From 2015-2019, SRC counts from published EHR record data ranged from 135-192 during the regular season, whereas SRC counts ranged from 102-194 and 69-202 depending on the publicly available data source. In NFL.com the SRC clinical incidence was significantly and progressively lower in 2017 (CIR: 0.73, 95% CI: 0.58-0.91), 2018 (CIR: 0.66, 95% CI: 0.50-0.87), and 2019 (CIR: 0.48, 95% CI: 0.35-0.64) relative to the gold-standard EHR. In the pro-football-reference.com data, the documented SRCs in publicly available data sources for other years were ~ 20-30% lower than the gold-standard EHR numbers (CIRs 0.70-0.81). CONCLUSIONS: Publicly available data for SRCs per 100 unique player signings did not match published data from the NFL's EHR and in several years were significantly lower. Researchers should use caution before using publicly available data sources for injury research.

Colleges and Crime-Comparing Homicide and Suicide Rates Among College Towns and Their Counterparts.

INTRODUCTION: To investigate differences in homicide and suicide rates across college town status and determine whether college towns were predisposed to changes in rates over time. METHODS: We analyzed county-level homicide and suicide rates (total and by firearm) across college town status using 2015-2019 CDC death certificate data and data from the American Communities Project. RESULTS: Population-level homicide rates were similar across college town status, but younger age groups were at increased risk for firearm homicide and total homicide in college towns. College town status was associated with lower population-level firearm suicide rates, but individuals aged less than 18 y were at increased risk for total and firearm suicide. Finally, college towns were not classified as outliers for changes in either firearm homicide or suicide rates over time. CONCLUSIONS: College towns had similar homicide rates and significantly lower firearm suicide rates than other counties; however, individuals aged less than 18 y were at increased risk for both outcomes. The distinctive demographic, social, economic, and cultural features of college towns may contribute to differing risk profiles among certain age groups, thus may also be amenable to focused prevention efforts.

Relationship between anxiety and concussion symptoms among adolescents enrolled in a randomized controlled trial of aerobic exercise.

BACKGROUND: Affective symptoms, specifically, anxiety, are often overlooked after sport-related concussion (SRC), and may contribute to prolonged recovery. OBJECTIVE: To examine the impact of anxiety during clinical recovery among adolescents (13-18y) enrolled in a randomized trial of aerobic exercise for SRC. METHODS: Patients at three sites were randomized into aerobic exercise or stretching arms, and enrolled in the 4-week intervention. The relationship between PROMIS Anxiety score at initial visit and time to symptom resolution was evaluated with survival analysis. The relationship between weekly PROMIS Anxiety score and Post-concussion Symptom Inventory (PCSI) score was evaluated with Linear Mixed Models. Analyses adjusted for study arm and baseline covariates. RESULTS: Among 54 adolescents (median age = 15.8y, initial visit PCSI score = 32, pre-injury PROMIS Anxiety score = 2), median time to symptom resolution was 10 days (25th-75th percentiles: 6-24) in the Low-PROMIS Anxiety group and 12 days (25th-75th percentiles: 5-21) in the High-PROMIS Anxiety group (p = 0.62). Each additional unit of PROMIS Anxiety score corresponded to a 1.52-unit higher PCSI total score (p <  0.01). Neither effect varied by aerobic exercise/stretching group. CONCLUSION: Higher initial PROMIS Anxiety score was not significantly associated with delayed symptom resolution. However, over time, PROMIS Anxiety score was significantly associated with elevated PCSI score, regardless of exercise/stretching group.

Using medicare claims to estimate risk-adjusted performance of Pennsylvania trauma centers.

Trauma centers use registry data to benchmark performance using a standardized risk adjustment model. Our objective was to utilize national claims to develop a risk adjustment model applicable across all hospitals, regardless of designation or registry participation. Patients from 2013-14 Pennsylvania Trauma Outcomes Study (PTOS) registry data were probabilistically matched to Medicare claims using demographic and injury characteristics. Pairwise comparisons established facility linkages and matching was then repeated within facilities to link records. Registry models were estimated using GLM and compared with five claims-based LASSO models: demographics, clinical characteristics, diagnosis codes, procedures codes, and combined demographics/clinical characteristics. Area under the curve and correlation with registry model probability of death were calculated for each linked and out-of-sample cohort. From 29 facilities, a cohort comprising 16,418 patients were linked between datasets. Patients were similarly distributed: median age 82 (PTOS IQR: 74-87 vs. Medicare IQR: 75-88); non-white 6.2% (PTOS) vs. 5.8% (Medicare). The registry model AUC was 0.86 (0.84-0.87). Diagnosis and procedure codes models performed poorest. The demographics/clinical characteristics model achieved an AUC = 0.84 (0.83-0.86) and Spearman = 0.62 with registry data. Claims data can be leveraged to create models that accurately measure the performance of hospitals that treat trauma patients.

Adolescents With More Oculomotor and Vestibular Signs of Sport-Related Concussion Benefit from Aerobic Exercise: An Exploratory Analysis.

Abstract Early targeted heart rate (HR) aerobic exercise has been shown to reduce the duration of recovery from sport-related concussion (SRC) as well as the incidence of persistent post-concussive symptoms (PPCS). It is not known, however, if more severe oculomotor and vestibular presentations of SRC benefit from a prescription of aerobic exercise. The current study is an exploratory analysis of two published randomized controlled trials that compared aerobic exercise within 10 days of injury with a placebo-like stretching intervention. Combining the two studies yielded a larger sample size to stratify severity of concussion based on the number of abnormal physical examination signs present at the initial office evaluation, which were confirmed with self-reported symptoms and recovery outcomes. The most discriminant cut-off was between those who had ≤3 oculomotor and vestibular signs and those who had >3 signs. Aerobic exercise (hazard ratio = 0.621 [0.412, 0.936], p = 0.023) reduced recovery times even when controlling for site (hazard ratio = 0.461 [0.303, 0.701], p < 0.001), severity (hazard ratio = 0.528 [0.325, 0.858], p = 0.010) and the interaction term of intervention and severity (hazard ratio = 0.972 [0.495, 1.909], p = 0.935). Adolescents who presented with >3 signs and were assigned to the placebo-like stretching group had a PPCS incidence of 38%, which was the highest of all subgroups (aerobic exercise and ≤3 findings: 8%; stretching and ≤3 findings: 11%; aerobic exercise and >3 findings: 21%). This exploratory study provides pilot evidence that prescribed sub-symptom threshold aerobic exercise treatment early after SRC may be effective for adolescents with more oculomotor and vestibular physical examination signs and should be validated in future adequately powered trials.

Optimizing sobriety checkpoints to maximize public health benefits and minimize operational costs.

BACKGROUND: Sobriety checkpoints are a highly effective strategy to reduce alcohol-impaired driving, but they are used infrequently in the USA. Recent evidence from observational studies suggests that using optimized sobriety checkpoints-operating for shorter duration with fewer officers-can minimize operational costs without reducing public health benefits. The aim of this research was to conduct a pilot study to test whether police can feasibly implement optimized sobriety checkpoints and whether researchers can examine optimized sobriety checkpoints compared to usual practice within a non-randomized controlled trial study design. METHODS: The study site was the Town of Apex, NC. We worked with Apex Police Department to develop a schedule of sobriety checkpoints during calendar year 2021 that comprised 2 control checkpoints (conducted according to routine practice) and 4 optimized checkpoints staffed by fewer officers. Our primary operations aim was to test whether police can feasibly implement optimized sobriety checkpoints. Our primary research aim was to identify barriers and facilitators for conducting an intervention study of optimized sobriety checkpoints compared to usual practice. A secondary aim was to assess motorist support for sobriety checkpoints and momentary stress while passing through checkpoints. RESULTS: Apex PD conducted 5 of the 6 checkpoints and reported similar operational capabilities and results during the optimized checkpoints compared to control checkpoints. For example, a mean of 4 drivers were investigated for possibly driving while impaired at the optimized checkpoints, compared to 2 drivers at control checkpoints. The field team conducted intercept surveys among 112 motorists at 4 of the 6 checkpoints in the trial schedule. The survey response rate was 11% from among 1,045 motorists who passed through these checkpoints. Over 90% of respondents supported sobriety checkpoints, and momentary stress during checkpoints was greater for motorists who reported consuming any alcohol in the last 90 days compared to nondrinkers (OR = 6.7, 95%CI: 1.6, 27.1). CONCLUSIONS: Results of this study indicate the sobriety checkpoints can feasibly be optimized by municipal police departments, but it will be very difficult to assess the impacts of optimized checkpoints compared to usual practice using an experimental study design.

How have firearm laws changed in states with unexpected decreases or increases in firearm homicide, 1990-2019?

Background: Firearm violence is one of the leading preventable causes of death and injury in the United States and is on the rise. While policies regulating access to firearms offer opportunities to prevent firearm-related deaths, an understanding of the holistic impact of changing state firearm policies on firearm homicide rates over the last 30 years is limited. Objectives: To identify US states that showed unexpected decreases and increases in firearm homicide rates and summarise their firearm policy changes in the last three decades. Methods: We analysed changes in firearm homicide rates by US state and county from 1990 to 2019. We triangulated across three estimation approaches to derive state rankings and identify the top and bottom three states which consistently showed unexpected decreases (low outliers) and increases (high outliers) in firearm homicide rates. We summarised firearm policy changes in state outliers using the RAND State Firearm Law Database. Results: We identified New York, District of Columbia, and Hawaii as low state outliers and Delaware, New Jersey, and Missouri as high state outliers. Low state outliers made more restrictive firearm policy changes than high state outliers, which covered a wider range of policy types. Restrictive changes in high state outliers primarily targeted high-risk populations (e.g., prohibited possessors, safe storage). Specific legislative details, such as the age threshold (18 vs 21 years old) for firearm minimum age requirements, also emerged as important for differentiating low from high state outliers. Conclusions: While no firearm law change emerged as necessary or sufficient, an accumulation of diverse restrictive firearm policies may be key to alleviating the death toll from firearm homicide.

A Randomized Trial of Incentivization to Maximize Retention for Real-Time Symptom and Activity Monitoring Using Ecological Momentary Assessment in Pediatric Concussion.

OBJECTIVE: The aims of this study were to determine the incentivization strategy that maximizes patient adherence to report symptoms and activity via ecological momentary assessment (EMA) after pediatric concussion, and assess the feasibility of tracking concussed youth using EMA from the emergency department (ED) setting. METHODS: This study was a randomized controlled trial of participants ages 13 to 18 years with concussion presenting to an urban, academic pediatric ED within 5 days of injury. Participants were randomized to 1 of 4 incentive arms: 2 dynamic (loss-based and streak) and 2 control flat-rate (monetary and electronic device). Participants reported symptoms 3 times per day and cognitive activity once each evening for 3 weeks. Physical activity (step count) and sleep were monitored using a Fitbit (kept by participants in the device flat-rate arm). The primary outcome was proportion of prompts to which participants responded. Secondary outcomes included differential response rates by demographics, and comparison of outcome determination between EMA and subsequent clinical visits. RESULTS: Thirty participants were enrolled, with a median age of 15.5 years and 60% female. Median cumulative proportion of prompts responded to was 68.3% (interquartile range, 47.6%-82.5%) in the dynamic arms versus 54.0% (interquartile range. 20.6%-68.3%) in the flat-rate arms, P = 0.065. There were nonsignificant differences in median response by sex (65.9% for female vs 40.0% for male, P = 0.072), race/ethnicity (61.9% for non-Hispanic White vs 43.7% for non-Hispanic Black participants, P = 0.097), and insurance (61.9% for private insurance vs 47.6% for public insurance, P = 0.305). Recovery at 3 weeks was discernible for all but 2 participants (93.3%) using EMA data, compared with only 9 participants (30.0%) ( P < 0.001) from clinical visits. CONCLUSIONS: Dynamic incentivization showed higher rates of response to tridaily symptom prompts compared with flat-rate incentivization. These data show tracking concussed youth using EMA from the ED is feasible using a dynamic incentivization strategy, with improved ability to discern outcomes compared with prospective monitoring using follow-up clinical visits.

Unintended reductions in assaults near sobriety checkpoints: A longitudinal spatial analysis.

BACKGROUND: Sobriety checkpoints are a form of proactive policing in which law enforcement officers concentrate at a point on the roadway to systematically perform sobriety tests for all passing drivers. We investigated whether sobriety checkpoints unintentionally reduce assaults in surrounding areas. METHODS: Exposures of interest were sobriety checkpoints conducted by the Los Angeles Police Department between 2012 and 2017. Comparison units were matched 1:2 to sobriety checkpoints, selected as the same point location temporally lagged by exactly ±168 hours. The outcome was the density of police-reported assaults around the checkpoint location. RESULTS: In mixed effects regression analyses, assault incidence was lower when sobriety checkpoints were in operation compared to the same location ±168 hours [b= -0.0108, 95% CI: (-0.0203, -0.0012)]. CONCLUSIONS: Sobriety checkpoints were associated with decreased assault incidence, but estimated effect sizes were small and effects did not endure long after checkpoints ended.