Modeling Risk for Lower Extremity Musculoskeletal Injury in U.S. Military Academy Cadet Basic Training.

INTRODUCTION: Sport and tactical populations are often impacted by musculoskeletal injury. Many publications have highlighted that risk is correlated with multiple variables. There do not appear to be existing studies that have evaluated a predetermined combination of risk factors that provide a pragmatic model for application in tactical and/or sports settings. PURPOSE: To develop and test the predictive capability of multivariable risk models of lower extremity musculoskeletal injury during cadet basic training at the U.S.Military Academy. MATERIALS AND METHODS: Cadets from the class of 2022 served as the study population. Sex and injury history were collected by questionnaire. Body Mass Index (BMI) and aerobic fitness were calculated during testing in the first week of training. Movement screening was performed using the Landing Error Scoring System during week 1 and cadence was collected using an accelerometer worn throughout initial training. Kaplan-Meier survival curves estimated group differences in time to the first musculoskeletal injury during training. Cox regression was used to estimate hazard ratios (HRs) and Akaike Information Criterion (AIC) was used to compare model fit. RESULTS: Cox modeling using HRs indicated that the following variables were associated with injury risk : Sex, history of injury, Landing Error Scoring System Score Category, and Physical Fitness Test (PT) Run Score. When controlling for sex and history of injury, amodel including aerobic fitness and BMI outperformed the model including movement screening risk and cadence (AIC: 1068.56 vs. 1074.11) and a model containing all variables that were significant in the univariable analysis was the most precise (AIC: 1063.68). CONCLUSIONS: In addition to variables typically collected in this tactical setting (Injury History, BMI, and aerobic fitness), the inclusion of kinematic testing appears to enhance the precision of the risk identification model and will likely continue to be included in screening cadets at greater risk.

Twenty-five year occupational homicide mortality trends in North Carolina: 1992-2017.

INTRODUCTION: Determining industry of decedents and victim-perpetrator relationships is crucial to inform and evaluate occupational homicide prevention strategies. In this study, we examine occupational homicide rates in North Carolina (NC) by victim characteristics, industry and victim-perpetrator relationship from 1992 to 2017. METHODS: Occupational homicides were identified from records of the NC Office of the Chief Medical Examiner system and the NC death certificates. Sex, age, race, ethnicity, class of worker, manner of death, victim-perpetrator relationship and industry were abstracted. Crude and age-standardised homicide rates were calculated as the number of homicides that occurred at work divided by an estimate of worker-years (w-y). Rate ratios and 95% CIs were calculated, and trends over calendar time in occupational homicide rates were examined overall and by industry. RESULTS: 456 homicides over 111 573 049 w-y were observed. Occupational homicide rates decreased from 0.82 per 100 000 w-y for the period 1992-1995 to 0.21 per 100 000 w-y for the period 2011-2015, but increased to 0.32 per 100 000 w-y in the period 2016-2017. Fifty-five per cent (252) of homicides were perpetrated by strangers. Taxi drivers experienced an occupational homicide rate that was 110 times (95% CI 76.52 to 160.19) the overall occupational homicide rate in NC; however, this rate declined by 76.5% between 1992 and 2017. Disparities were observed among workers 65+ years old, racially and ethnically minoritised workers and self-employed workers. CONCLUSION: Our findings identify industries and worker demographics that experienced high occupational homicide fatality rates. Targeted and tailored mitigation strategies among vulnerable industries and workers are recommended.

25-Year fatal workplace suicide trends in North Carolina: 1992-2017.

BACKGROUND: Suicide is a serious public health problem in the United States, but limited evidence is available investigating fatal suicides at work. There is a substantial need to characterize workplace suicides to inform suicide prevention interventions and target high-risk settings. This study aims to examine workplace suicide rates in North Carolina (NC) by worker characteristics, means of suicide used, and industry between 1992 and 2017. METHODS: Fatal workplace suicides were identified from records of the NC Office of the Chief Medical Examiner system and the NC death certificate. Sex, age, race, ethnicity, class of worker, manner of death, and industry were abstracted. Crude and age-standardized homicide rates were calculated as the number of suicides that occurred at work divided by an estimate of worker-years (w-y). Rate ratios and 95% confidence intervals (CIs) were calculated, and trends over calendar time for fatal workplace suicides were examined overall and by industry. RESULTS: 81 suicides over 109,464,430 w-y were observed. Increased rates were observed in workers who were male, self-employed, and 65+ years old. Firearms were the most common means of death (63%) followed by hanging (16%). Gas service station workers experienced the highest fatal occupational suicide rate, 11.5 times (95% CI: 3.62-36.33) the overall fatal workplace suicide rate, followed by Justice, Public Order, and Safety workers at 3.23 times the overall rate (95% CI: 1.31-7.97). CONCLUSION: Our findings identify industries and worker demographics that were vulnerable to workplace suicides. Targeted and tailored mitigation strategies for vulnerable industries and workers are recommended.

Impact of alcohol driving-while-impaired license suspension duration on future alcohol-related license events and motor vehicle crash involvement in North Carolina, 2007 to 2016.

BACKGROUND/PURPOSE: License suspensions are a strategy to address alcohol-impaired driving behavior and recidivism following an alcohol driving while impaired (alcohol-DWI) conviction. Little is known about the specific impacts of conviction-related suspensions on safety outcomes and given recent fluctuations in alcohol-impaired driving behavior, crashes, and suspension trends, updated and focused assessments of this intervention are necessary. This study aimed to 1) examine the association between type of recent alcohol-DWI suspension and having a secondary alcohol-related license outcome and/or future crash event in North Carolina (NC) between 2007 and 2016; and 2) assess potential modification of these associations by race/ethnicity. METHODS: We used linked NC licensing data, NC crash data, and county-level contextual data from a variety of data sources. We compared individuals ages 21 to 64 who sustained initial (1-year) versus repeat (4-year) suspensions for alcohol-related license and crash involvement outcomes. We estimated unadjusted and adjusted hazard ratios (aHRs) using Cox proportional hazards models and produced Kaplan-Meier (KM) survival curves using a three-year follow-up period. After observing statistically significant modification by race/ethnicity, we calculated stratified aHRs for each outcome (Black and White subgroups only, as other subgroups had low numbers of outcomes). RESULTS: 122,002 individuals sustained at least one alcohol-DWI conviction suspension (117,244 initial, 4,758 repeat). Adjusted KM survival curves indicated that within three years of the index suspension, the predicted risks of having a license outcome and crash outcome were about 8 % and 15 %, respectively, among individuals with an initial suspension and 5 % and 10 %, respectively, among individuals with a repeat suspension. After adjusting for potential confounding, we found that compared to those with an initial suspension, those with repeat suspensions had a lower incidence of future license (aHR: 0.49; 95 % CI: 0.42, 0.57) and crash outcomes (aHR: 0.67; 95 % CI: 0.60, 0.75). Among Black individuals, license outcome incidence was 162 % lower among repeat versus initial index suspension groups (aHR: 0.38; 95 % CI: 0.26, 0.55), while for White individuals, the incidence was 87 % lower (aHR: 0.54; 95 % CI: 0.45, 0.64). Similarly, crash incidence for repeat versus initial suspensions among Black individuals was 56 % lower (aHR: 0.64; 95 % CI: 0.50, 0.83), while only 39 % lower among White individuals (aHR: 0.72; 95 % CI: 0.63, 0.81). CONCLUSIONS: Decreased incidence of both license and crash outcomes were observed among repeat versus initial index suspensions. The magnitude of these differences varied by race/ethnicity, with larger decreases in incidence among Black compared to White individuals. Future research should examine the underlying mechanisms leading to alcohol-impaired driving behavior, convictions, recidivism, and crashes from a holistic social-ecological perspective so that interventions are designed to both improve road safety and maximize other critical public health outcomes, such as access to essential needs and services (e.g., healthcare and employment).

Medications for Opioid Use Disorder and Mortality and Hospitalization Among People With Opioid Use-related Infections.

BACKGROUND: Severe skin and soft tissue infections related to injection drug use have increased in concordance with a shift to heroin and illicitly manufactured fentanyl. Opioid agonist therapy medications (methadone and buprenorphine) may improve long-term outcomes by reducing injection drug use. We aimed to examine the association of medication use with mortality among people with opioid use-related skin or soft tissue infections. METHODS: An observational cohort study of Medicaid enrollees aged 18 years or older following their first documented medical encounters for opioid use-related skin or soft tissue infections during 2007-2018 in North Carolina. The exposure was documented medication use (methadone or buprenorphine claim) in the first 30 days following initial infection compared with no medication claim. Using Kaplan-Meier estimators, we examined the difference in 3-year incidence of mortality by medication use, weighted for year, age, comorbidities, and length of hospital stay. RESULTS: In this sample, there were 13,286 people with opioid use-related skin or soft tissue infections. The median age was 37 years, 68% were women, and 78% were white. In Kaplan-Meier curves for the total study population, 12 of every 100 patients died during the first 3 years. In weighted models, for every 100 people who used medications, there were four fewer deaths over 3 years (95% confidence interval = 2, 6). CONCLUSION: In this study, people with opioid use-related skin and soft tissue infections had a high risk of mortality following their initial healthcare visit for infections. Methadone or buprenorphine use was associated with reductions in mortality.

Fatal occupational injuries in North Carolina, 1992-2017.

OBJECTIVES: After declining for several decades, fatal occupational injury rates have stagnated in the USA since 2009. To revive advancements in workplace safety, interventions targeting at-risk worker groups must be implemented. Our study aims to identify these at-risk populations by evaluating disparities in unintentional occupational fatalities occurring in North Carolina (NC) from 1992 to 2017. METHODS: Our retrospective cohort study drew on both the NC Office of the Chief Medical Examiner system and the NC death certificate data system to identify unintentional fatal occupational injuries occurring from 1992 to 2017. Unintentional fatal occupational injury rates were reported across industries, occupations and demographic groups, and rate ratios were calculated to assess disparities. RESULTS: Among those aged 18 and older, 2645 unintentional fatal occupational injuries were identified. Fatal occupational injury rates declined by 0.82 injuries/100 000 person-years over this period, falling consistently from 2004 to 2009 and increasing from 2009 to 2017. Fatal injury rates were highest among Hispanic workers, who experienced 2.75 times the fatal injury rate of non-Hispanic White workers (95% CI 2.42 to 3.11) and self-employed workers, who experienced 1.44 times the fatal injury rate of private workers (95% CI 1.29 to 1.60). We also observed that fatal injury rates increased with age group and were higher among male relative to female workers even after adjustment for differential distributions across occupations. CONCLUSIONS: The decline in unintentional fatal occupational injury rates over this period is encouraging, but the increase in injury rate after 2009 and the large disparities between occupations, industries and demographic groups highlight the need for additional targeted safety interventions.

Efficacy of a Novel Telehealth Application in Health Behavior Modification and Symptomology in Military Service Members at Risk for Post-traumatic Osteoarthritis.

INTRODUCTION: Mobile applications (apps) may be beneficial to promote self-management strategies to mitigate the risk of developing post-traumatic osteoarthritis in military members following a traumatic knee injury. This study investigated the efficacy of a mobile app in facilitating behavior modification to improve function and symptomology among military members. MATERIALS AND METHODS: This is a preliminary pre and post hoc analysis of a randomized control trial. The MARX scale, Intermittent and Constant Osteoarthritis Pain (ICOAP) questionnaire, and the Knee Injury and Osteoarthritic Outcome Score Readiness to Manage Osteoarthritis Questionnaire were completed at baseline, 6-week, 6-month, and 12-month follow-up. Participants in the treatment arm completed the System Usability Scale. Data were analyzed using descriptive statistics, the Wilcoxon sum of ranks test, the Wilcoxon signed-rank test, and Cohen's d effect size. RESULTS: A total of 28 participants were included. Between-group differences for baseline and 6-week follow-up were significantly improved in the injured knee ICOAP constant pain score for the treatment group (treatment: -4.2 ± 12, 95% CI: -11.5, 3.1; control: 5.5 ± 9.9, 95% CI: 0.9, 10.1; P = .035, effect size = 0.905). Within-group differences for baseline and 6-week follow-up demonstrated a significant decline in the injured knee ICOAP constant pain score among the control group (signed-rank: 16.0, P = .031, Cohen's d = 0.339). No other significant differences were observed. A good System Usability Scale score for usability was found (76.6 ± 8.8). CONCLUSIONS: These results indicate that the mobile app is easy to use and may contribute to improved constant pain symptomology for patients at risk for post-traumatic osteoarthritis.

Mortality associated with bacterial and fungal infections and overdose among people with drug use diagnoses.

PURPOSE: Hospital visits for drug use-related bacterial and fungal infections have increased alongside overdose deaths. The incidence of mortality from these infections and the comparison to overdose mortality is not established. METHODS: This cohort study examined mortality outcomes among adults with drug use diagnoses who were insured by public and private plans during 2007 through 2018 in North Carolina. We examined bacterial- and fungal infection-related mortality and overdose mortality using cumulative incidence functions. RESULTS: Among 131,522 people with drug use diagnoses, the median age was 45 years (interquartile range: 31-57), 58% were women and 65% had an opioid use disorder diagnosis. The 1-year incidence of bacterial and fungal infection-associated mortality was progressively higher as age increased (35-49 years: 9 per 10,000 people, 50-64 years: 23 per 10,000, 65+ years: 50 per 10,000 people). Conversely, the 1-year incidence of overdose mortality was markedly lower among older adults compared to those under the age of 65 (18-34 years: 34 deaths per 10,000 people; 35-49 years: 47 per 10,000; 50-64 years: 41 per 10,000; 65+ years: 9 per 10,000). CONCLUSIONS: Bacterial and fungal infections and overdose were notable causes of death among adults with drug use diagnoses, and varied by age group.

Age, period and cohort-related trends in prescription opioid use in the USA, 1999-2018.

BACKGROUND: To provide insight into the longitudinal dynamics of opioid use throughout the overdose crisis, this study estimated the separate influences of age, period and cohort on prescription opioid use during 1999-2018 in the USA. METHODS: Data from 10 cycles of the cross-sectional National Health and Nutrition Examination Survey were used to conduct an age-period-cohort analysis of the prevalence of prescription opioid use (n=63 500 across 1999-2018). Temporal trends were graphically visualised. The median polish approach was used to estimate age, period and cohort-related effects on prescription opioid use. RESULTS: Prescription opioid use broadly increased across the lifespan, with steeper prevalence increases observed from young adulthood to mid-adulthood. Period-related variation was consistent with recognised nationwide declines in opioid prescribing. While there was no evidence of systematic cohort effects, compared with individuals born in 1951-1954, those born during 1963-1966 had greater prescription opioid use (prevalence ratio (PR)=1.23, 95% CI: 1.05 to 1.43), whereas the 1991-1994 and 1999-2002 cohorts had lower prescription opioid use (PR91-94=0.70, 95% CI: 0.50 to 0.98; PR99-02=0.72, 95% CI: 0.63 to 0.81). CONCLUSION: In the USA, longitudinal trends in prescription opioid use during 1999-2018 were predominantly driven by age and period influences. The cohort of youngest baby boomers experienced greater prescription opioid use, whereas recent-born cohorts have had lower use. As the overdose crisis continues evolving, such population-level characterisations of age, period and cohort dynamics are instrumental in understanding opioid use and can inform prevention and intervention approaches by identifying population groups more likely to use opioids who, thus, may also experience related outcomes.

Association of Dynamic Knee Valgus and Bone Stress Injury in US Military Academy Cadets.

CONTEXT: Early identification of incoming military personnel at elevated odds for bone stress injury (BSI) is important for the health and readiness of the US military. DESIGN: Prospective cohort study. METHODS: Knee kinematic data of the incoming US Military Academy cadets were collected while performing a jump-landing task (The Landing Error Scoring System) using a markerless motion capture system and depth camera. Data on incidence of lower-extremity injury, including BSI, were collected throughout the study period. RESULTS: A total of 1905 participants (452 females, 23.7%) were examined for knee valgus and BSI status. A total of 50 BSI occurred during the study period (incidence proportion = 2.6%). The unadjusted odds ratio for BSI at initial contact was 1.03 (95% confidence interval [CI], 0.94-1.14; P = .49). Adjusted for sex, the odds ratio for BSI at initial contact was 0.97 (95% CI, 0.87-1.06; P = .47). At the instant of maximum knee-flexion angle, the unadjusted odds ratio was 1.06 (95% CI, 1.02-1.10; P = .01), and the odds ratio was 1.02 (95% CI, 0.98-1.07; P = .29) after adjusting for sex. This suggests that there was not a significant enough association for an increase in the odds of BSI based on either degree of knee valgus. CONCLUSIONS: Our results did not demonstrate an association between knee valgus angle data during a jump-landing task and future increased odds of BSI in a military training population. Further analysis is warranted, but the results suggests the association between kinematics and BSI cannot be effectively screened by knee valgus angle data in isolation.

Disparities in Fatal Occupational Injury Rates in North Carolina, 1978-2017: Comparing Nonmanagerial Employees to Managers.

BACKGROUND: We examined fatal occupational injuries among private-sector workers in North Carolina during the 40-year period 1978-2017, comparing the occurrence of fatal injuries among nonmanagerial employees to that experienced by managers. METHODS: We estimated a standardized fatal occupational injury ratio by inverse probability of exposure weighting, taking nonmanagerial workers as the target population. When this ratio measure takes a value greater than unity it signals settings in which nonmanagerial employees are not provided as safe a work environment as that provided for managers. RESULTS: Across all industries, nonmanagerial workers in North Carolina experienced fatal occupational injury rates 8.2 (95% CI = 7.0, 10.0) times the rate experienced by managers. Disparities in fatal injury rates between managers and the employees they supervise were greatest in forestry, rubber and metal manufacturing, wholesale trade, fishing and extractive industries, and construction. CONCLUSIONS: The results may help focus discussion about workplace safety between labor and management upon equity, with a goal of providing a work environment for nonmanagerial employees as safe as the one provided for managers.

School-level determinants of incidence of sports-related concussion: Findings from the CARE Consortium.

OBJECTIVE: Epidemiologic research on sports-related concussion (SRC) has focused on individual risk factors, with limited research on institutional risk factors and variability in concussion rates. METHODS: This study used data from 53,822 athletes-seasons collected at 30 United States sites (26 civilian institutions and 4 military service academies), from 2014/15 to 2018/19 academic years, by the Concussion Assessment, Research, and Education Consortium. School-level risk factors included competitive division (DI, DII, DIII), school type (military/civilian) and a Sport Risk Index (SRI; Low, Medium, High). For comparability between civilian institutions and military academies, only NCAA athletes and concussions in sports games and practices were included. Random intercepts log-binomial regression was used to estimate Risk Ratios (RRs) and model variability in SRC risk. RESULTS: A total of 2,503 SRCs were observed during the study period, including 829 competition SRCs (33%) and 1,674 practice SRCs (67%). Most variability in SRC risk was at the level of athlete or team (within-school), rather than at the school-level. Specifically, across the three SRC outcomes (all [competition and practice combined], competition-only, and practice-only), within-school variability was 5 to 7 times greater than between-school variability. Three school-level risk factors (Division, School Type, and SRI) accounted for over one-third (36%) of between-school variability. SRI was the strongest school-level predictor of SRC risk (RR = 5.7; 95%CI: 4.2, 7.6 for High vs. Low). SRC risk was higher for Division I compared to Divisions II/III (RR = 1.6; 95%CI: 0.9, 2.9 for DI vs. DIII), and military academies had a moderately elevated risk of SRC (RR = 1.4; 95%CI: 0.7, 2.7). CONCLUSION: A large portion of the apparent variability between schools was attributable to structural factors (sport risk and competitive level), suggesting that there were minimal systemic differences in concussion identification between schools. While most variability is within-school, understanding school-level determinants of concussion risk may still be important in providing the implementation science context for individual-level interventions.

Disparities in job characteristics by race and sex in a Southern aluminum smelting facility.

BACKGROUND: Former workers at a Southern aluminum smelting facility raised concerns that the most hazardous jobs were assigned to Black workers, but the role of workplace segregation had not been quantified or examined in the company town. Prior studies discuss race and gender disparities in working conditions, but few have documented them in the aluminum industry. METHODS: We obtained workers' company records for 1985-2007 and characterized four job metrics: prestige (sociologic rankings), worker-defined danger (worker assessments), annual wage (1985 dollars), and estimated total particulate matter (TPM) exposure (job exposure matrix). Characteristics of job at hire and trajectories were compared by race and sex using linear binomial models. RESULTS: Non-White males had the highest percentage of workers in low prestige and high danger jobs at hire and up to 20 years after. After 20 years tenure, 100% of White workers were in higher prestige and lower danger jobs. Most female workers, regardless of race, entered and remained in low-wage jobs, while 50% of all male workers maintained their initial higher-wage jobs. Non-White females had the highest prevalence of workers in low-wage jobs at hire and after 20 years-increasing from 63% (95% CI: 59-67) to 100% (95% CI: 78-100). All female workers were less likely to be in high TPM exposure jobs. Non-White males were most likely to be hired into high TPM exposure jobs, and this exposure prevalence increased as time accrued, while staying constant for other race-sex groups. CONCLUSIONS: There is evidence of job segregation by race and sex in this cohort of aluminum smelting workers. Documentation of disparities in occupational hazards is important for informing health interventions and research.

Association of Traumatic Knee Injury With Radiographic Evidence of Knee Osteoarthritis in Military Officers.

OBJECTIVE: The association between knee injury and knee osteoarthritis (OA) is understudied relative to its importance, particularly in younger populations. This study was undertaken to examine the association of knee injury with radiographic features of knee OA in military officers, who have a physically demanding profession and high rates of knee injury. METHODS: Participants were recruited in 2015-2017 from an existing program that enrolled 6,452 military officers during 2004-2009. Officers with a history of knee ligament or meniscal injuries (n = 117 via medical record review) were compared to officers with no history of knee injury (n = 143). Bilateral posteroanterior knee radiographs were obtained using a standardized fixed-flexion positioning frame. All images were read for Kellgren/Lawrence (K/L) grade, osteophyte (OST), and joint space narrowing (JSN) scores. Data were analyzed using linear-risk regression models with generalized estimating equations. RESULTS: Injured and noninjured participants were similar (mean age 28 years, mean body mass index 25 kg/m2 , ~40% female). The mean time from first knee injury to imaging among injured participants was 9.2 years. Compared with noninjured knees, greater prevalence of radiographic OA (K/L grade ≥ 2), OST (grade ≥ 1), and JSN (grade ≥ 1) was observed among injured knees, with prevalence differences of +16% (95% confidence interval [95% CI] 10%, 22%), +29% (95% CI 20%, 38%), and + 17% (95% CI 10%, 24%), respectively. Approximately 1 in 6 officers with prior knee injury progressed to radiographic OA by age 30 years. CONCLUSION: At the midpoint of a projected 20-year military career, officers with a history of traumatic knee injury have a markedly increased prevalence of knee radiographic OA compared to officers without injury.

Development and validation of an electronic health records-based opioid use disorder algorithm by expert clinical adjudication among patients with prescribed opioids.

BACKGROUND: In the US, over 200 lives are lost from opioid overdoses each day. Accurate and prompt diagnosis of opioid use disorders (OUD) may help prevent overdose deaths. However, international classification of disease (ICD) codes for OUD are known to underestimate prevalence, and their specificity and sensitivity are unknown. We developed and validated algorithms to identify OUD in electronic health records (EHR) and examined the validity of OUD ICD codes. METHODS: Through four iterations, we developed EHR-based OUD identification algorithms among patients who were prescribed opioids from 2014 to 2017. The algorithms and OUD ICD codes were validated against 169 independent "gold standard" EHR chart reviews conducted by an expert adjudication panel across four healthcare systems. After using 2014-2020 EHR for validating iteration 1, the experts were advised to use 2014-2017 EHR thereafter. RESULTS: Of the 169 EHR charts, 81 (48%) were reviewed by more than one expert and exhibited 85% expert agreement. The experts identified 54 OUD cases. The experts endorsed all 11 OUD criteria from the Diagnostic and Statistical Manual of Mental Disorders-5, including craving (72%), tolerance (65%), withdrawal (56%), and recurrent use in physically hazardous conditions (50%). The OUD ICD codes had 10% sensitivity and 99% specificity, underscoring large underestimation. In comparison our algorithm identified OUD with 23% sensitivity and 98% specificity. CONCLUSIONS AND RELEVANCE: This is the first study to estimate the validity of OUD ICD codes and develop validated EHR-based OUD identification algorithms. This work will inform future research on early intervention and prevention of OUD.

Factors and expectations influencing concussion disclosure within NCAA Division I athletes: A mixed methodological approach.

BACKGROUND: Participation in sports is associated with many benefits to all aspects of health; however, it also comes with the risk of injury, particularly concussions. Self-disclosure and care seeking following a concussion are especially important because of the lack of outwardly visible signs and/or symptoms. Although recent research has explored factors affecting concussion disclosure, use of isolated methodologies limits the ability to contextualize how disclosure or nondisclosure occurs. Therefore, the purpose of this study was to describe the factors and expectations of National Collegiate Athletic Association (NCAA) athletes that may influence concussion disclosure. METHODS: This mixed-methods convergent parallel research study included 25 NCAA Division I athletes representing 13 sports, all of whom completed a concussion-education session with pre-/post-test surveys and a semistructured interview. Eligible athletes were at least 18 years old and on an NCAA roster. The surveys focused on previous concussion-related disclosure behaviors, knowledge, attitudes, beliefs, norms, and intentions about disclosing concussion. Interviews focused on the athletes' experiences related to concussion disclosure. Survey data were analyzed using descriptive statistics and Mann-Whitney U tests. Interviews were analyzed using a Consensual Qualitative Research tradition. RESULTS: Participants had good concussion knowledge (median = 46.0), positive attitudes (median = 38.0), strong beliefs (median = 13.0), and strong intentions to disclose concussion symptoms (median = 7.0). None of the constructs differed by participants' gender. Although quantitative findings were mostly positive, interview data highlighted factors that may explain why some participants are successful in disclosing concussions and why others may find disclosure difficult. Educational efforts, sport culture, and medical professional presence were the primary facilitators discussed by participants. Stigma, pressure, and a lack of team support were perceived as disclosure barriers. CONCLUSION: The context in which concussion disclosure occurs or does not occur is vital to the success of educational interventions. Interventions must prioritize stakeholder- and team-based perspectives on concussion to establish a network supportive to disclosure.

Sustained impacts of North Carolina prison therapeutic diversion units on behavioral outcomes, mental health, self-injury, and restrictive housing readmission.

Therapeutic Diversion Units (TDUs) in North Carolina prisons are intended to reduce cycling of individuals with mental health conditions through restrictive housing (i.e., solitary confinement). This paper investigates if previously identified benefits of TDU are sustained when individuals return to the general prison population. Using administrative data on 3170 people, we compare individuals placed in TDUs to TDU-eligible individuals (i.e., individuals with mental health needs) placed in restrictive housing. We use survival analysis methods to estimate hazard ratios (HRs) with confidence intervals (CIs), controlling for confounders. Compared to restrictive housing placement, TDU placement reduced the hazard of infractions (HR: 0.66; 95% CI: 0.52, 0.84) and subsequent restrictive housing placement (HR: 0.64; 95% CI: 0.55, 0.73) but increased the hazard of self-harm (HR: 2.67; 95% CI: 1.66, 4.29) upon program release to the general prison population. These findings suggest a need for additional investments and research on restrictive housing diversion programming, including post-diversion program supports.