A scoping review of guidelines and frameworks for advance care planning for adolescents and young adults with life-limiting or life-threatening conditions.

BACKGROUND: Advance care planning discussions are crucial in the management and support of individuals with life-limiting or life-threatening conditions. Few studies have examined best practices for advance care planning with adolescents and young adults. AIM: To identify core components of current guidelines, frameworks and tools for advance care planning discussions with adolescents and young adults with life-limiting or life-threatening conditions and their families. DESIGN: A scoping review of the literature was conducted followed by a thematic analysis of the included papers. The scoping review was reported according to the Joanna Briggs Institute approach to the conduct of scoping reviews. DATA SOURCES: Five databases [Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, PsycInfo, PubMed and Scopus] were searched for English-language papers published between inception until January 2023. RESULTS: The search yielded 2976 papers, of which 9 met the inclusion criteria. Five main themes were identified: (i) utilisation of standardised documents and protocols; (ii) shared decision-making between the adolescents and young adults, their families and the healthcare team; (iii) the importance of open and honest communication with adolescents and young adults during advance care planning discussions; (iv) individualisation and flexibility in the advance care planning process and (v) timing of advance care planning initiation. CONCLUSIONS: Results highlight the importance of engaging adolescents and young adults in advance care planning and considering their unique needs when initiating and framing these discussions. Our findings can be used by healthcare professionals to inform advance care planning in this group.

Trajectories of Daily Postconcussion Symptoms in Children.

OBJECTIVES: To identify trajectories of daily postconcussion symptoms (PCS) from the acute postinjury period to symptom resolution among concussed children and examine demographic factors and acute PCS associated with the identified symptom trajectories. SETTING AND PARTICIPANTS: Seventy-nine participants with a concussion were enrolled within 72 hours of injury and completed a daily survey that assessed PCS from enrollment until symptom resolution. DESIGN: This was a prospective cohort study among concussed children aged 11-17 years. MAIN MEASURES: Children rated their concussion symptoms daily using the Post-Concussion Symptom Scale. Symptom duration was assessed using participants' date of symptom resolution and coded as a dichotomous variable: (1) PCS duration 14 days or less or (2) PCS duration longer than 14 days. RESULTS: Of the 79 participants, most were male ( n = 53, 67%), injured during a sporting activity ( n = 67, 85%), or had PCS that persisted for more than 14 days post-injury ( n = 41, 52%). Group-based trajectory modeling yielded 4 trajectory groups: (1) low acute/resolved PCS ( n = 39, 49%), (2) moderate/persistent PCS ( n = 19, 24%), (3) high acute/persistent PCS ( n = 13, 16%), and (4) high acute/resolved PCS ( n = 8, 10%). No significant associations were found between demographic factors and the trajectory group. A higher symptom burden at injury was associated with an increased odds of being in the high acute/resolved or high acute/persistent recovery groups than being in the low acute/resolved group (odds ratio [OR] 1.39, 95% CI = 1.11-1.74; OR = 1.33, 95% CI = 1.11-1.60, respectively), as was a higher symptom severity at injury (OR = 1.09, 95% CI = 1.03-1.15; OR = 1.06, 95% CI = 1.02-1.11, respectively). CONCLUSION: Our findings may help clinicians identify concussed children on slower recovery trajectories, and implement early, individualized treatment plans that foster optimal recovery for concussed children.

A Virtual Reality App Intervention to Improve Concussion Recognition and Reporting in Athletes Aged 9 to 12 Years: Development and Pilot Testing.

BACKGROUND: Existing concussion education programs for preteen athletes typically do not result in sustained improvements in concussion symptom recognition or reporting behaviors. Virtual reality (VR) technology offers an innovative tool that may improve concussion symptom recognition and reporting behaviors among preteen athletes. OBJECTIVE: We aimed to describe the design and development of a VR concussion education app, Make Play Safe (MPS), and present findings on the usability and preliminary efficacy of MPS in improving concussion recognition and reporting intentions among soccer athletes aged 9-12 years. METHODS: A collaborative user-centered design process was implemented to develop and evaluate MPS, a semi-immersive VR concussion education app designed to address two behavioral outcomes in preteen athletes aged 9-12 years: (1) recognizing concussion and (2) reporting concussion. The development of MPS occurred in three phases: (1) design and development, (2) usability testing, and (3) preliminary efficacy testing. During phase 1, consultations were completed with 6 experts. Additionally, 5 interviews with children who had a history of concussion were conducted to collect feedback about the proof of concept of MPS. During phase 2, a participatory workshop with 11 preteen athletes and a small group discussion with 6 parents and 2 coaches were conducted to explore the usefulness and acceptability of MPS from the perspective of end users. Finally, phase 3 included preliminary efficacy testing with 33 soccer athletes aged 9-12 years to examine changes in concussion-related knowledge, attitudes, and reporting intentions from pre- to postintervention. The data generated from each phase of this study informed the development of the final version of the proof of concept of the VR concussion education app, MPS. RESULTS: Experts positively rated the features of MPS and noted that the design and content were innovative and age-appropriate. Preteens with a history of concussion indicated the scenarios and symptoms portrayed in the app represented well what they experienced while concussed. Further, they stated that the app would be an engaging way for children to learn about concussions. The 11 healthy children in the workshop perceived the app positively, noting that the scenarios were informative and engaging. Results from preliminary efficacy testing revealed increases in many athletes' knowledge and reporting intentions from pre- to postintervention. Others demonstrated no significant changes or a decrease in knowledge, attitudes, or reporting intentions from pre- to postintervention. Group-level changes in concussion knowledge and intention to report concussions were statistically significant (P<.05), while changes in attitudes toward reporting concussions were not (P=.08). CONCLUSIONS: Results suggest VR technology may be an effective and efficient tool to equip preteen athletes with the requisite knowledge and skills to recognize and report future concussions. Further research is recommended to examine the use of VR as an effective strategy to improve concussion-reporting behaviors in preteen athletes.

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.

Social Support and Post-Injury Depressive and Anxiety Symptoms among College-Student Athletes.

Social support can positively influence both physical and psychological recovery from sport-related injury. However, few studies have examined the influence of the quantity, quality, and timing of social support on athletes' psychological health following injury. This study examined the effects of changes in social support on post-injury depressive and anxiety symptoms among college-student athletes. We conducted a prospective cohort study among Division I college-student athletes. Participants completed surveys at baseline and at multiple time points post-injury until return to play (RTP). A total of 597 injuries sustained by 389 student athletes (n = 400 (67.0%) males; n = 238 (39.9%) football players; n = 281 (47.1%) freshman) were included. The overall amount of social support increased from baseline to 1-week post-injury (p < 0.05) and then remained unchanged until RTP. The overall satisfaction with the support received increased from baseline to 1-week post-injury (p < 0.05) but decreased (p < 0.05) from 1-week post-injury to RTP. Increases in satisfaction with the support received were associated with decreases in post-injury depressive (ß = −0.404), p < 0.0001) and anxiety symptoms (ß = −0.406), p < 0.0001). Interventions involving social support may help hasten college-student athletes' psychological recovery from injury.

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.

Implementation of Transgender/Gender Nonbinary Care in a Family Medicine Teaching Practice.

PURPOSE: Numerous studies have shown that transgender or gender nonbinary (TGNB) individuals encounter significantly more health care barriers, including overall lack of access to gender-affirming care providers. This study describes 2 assessments of transgender care services at a large family medicine teaching practice. METHODS: Staff and providers were invited to attend an optional, practice-wide, hourlong free training session on gender-affirming care offered on 3 different dates in 2019. A structured protocol was used to collect observational data from which key takeaways from the training sessions were developed. Separately, a retrospective chart review of patients with a gender dysphoria diagnosis was completed. Charts were reviewed for adherence to regional and international organization recommendations for comprehensive transgender care. RESULTS: Three main takeaways from the training sessions included lack of knowledge or familiarity with gender terminology and expression, fear of offending patients, and employee hesitation to change behaviors when interacting with patients. On chart review, the most common interventions identified were need to schedule a follow-up visit (61.5%), need for health maintenance screenings (osteoporosis screening, 50%; Papanicolaou smear, 56.3%; mammogram, 66.7%), need for mental health screening (41.5%), need for laboratory monitoring of testosterone therapy (20%), and corrected gender markers/names listed in the appropriate place in the patient chart (16.9%). CONCLUSIONS: This study highlighted hesitation to provide and lack of familiarity with transgender care among practice staff. Although some aspects of comprehensive transgender care are well implemented, maintaining follow-up, completing health maintenance and mental health screenings, and appropriate laboratory monitoring are areas for improvement.

Concussion Recovery in Children and Adolescents: A Qualitative Study of Parents' Experiences.

BACKGROUND: Although parents play an instrumental role in youth concussion management, few studies have qualitatively explored youth concussion recovery from the parents' perspective. This study explored parents' experiences with and perceptions of their child's recovery from concussion, particularly with regards to the return-to-school process. METHODS: We conducted 11 face-to-face semi-structured interviews with the parents of concussed youth aged 11 to 17 years between October 2018 and April 2019. We used the methods of open coding, axial coding, and selective coding to analyze the data. RESULTS: We identified 7 themes during data analysis, which we divided into 2 categories: at home (prior to school re-entry) and at school (during the school reintegration process). The at-home category included 4 themes: (1) physical and cognitive rest; (2) child-led decision-making; (3) the role of parent-child communication in recovery; and (4) feelings about returning to school following concussion. The at-school category included 3 themes: (1) availability and utilization of academic accommodations; (2) return-to-school policies and procedures; and (3) support from school officials and teachers. CONCLUSIONS: Parents' experiences of their child's return-to-school post-concussion underscore the need for evidence-based guidelines for cognitive rest post-concussion and a collaborative, team-based approach to concussion management.

Physical Activity among Adults Residing in 11 Countries during the COVID-19 Pandemic Lockdown.

During the novel coronavirus (COVID-19) pandemic, physical activity (PA) behaviors were altered worldwide due to public health measures such as "lockdown." This study described PA among adults residing in 11 countries during COVID-19 lockdown and examined factors associated with PA engagement. We conducted a cross-sectional anonymous survey among adults (≥18 years old) in 11 countries (Brazil, Bulgaria, China, India, Ireland, Malaysia, North Macedonia, Singapore, Spain, Turkey, United States). Of 11,775 participants, 63.7% were female and 52.8% were 18-34 years old. More than 40% of participants were insufficiently active (43.9%) and reported a decrease in their PA during lockdown (44.8%). Statistically significant differences were observed in (1) proportions of participants being insufficiently active, (2) level of PA, and (3) decrease in PA across the 11 countries. More stringent governmental policy responses were associated with greater likelihood of being insufficiently active during lockdown (adjusted odds ratio = 1.22, 95% confidence interval = 1.03, 1.45). Higher depression or anxiety scores were associated with greater likelihood of decreased level of PA during lockdown.We found substantial reductions in PA levels during COVID-19 lockdown across countries. Country-specific PA promotion interventions are needed during this and similar global emergencies.

Mental Health among Adults during the COVID-19 Pandemic Lockdown: A Cross-Sectional Multi-Country Comparison.

Despite the global impact of COVID-19, studies comparing the effects of COVID-19 on population mental health across countries are sparse. This study aimed to compare anxiety and depression symptoms during the COVID-19 lockdown among adults from 11 countries and to examine their associations with country-level COVID-19 factors and personal COVID-19 exposure. A cross-sectional survey was conducted among adults (≥18 years) in 11 countries (Brazil, Bulgaria, China, India, Ireland, North Macedonia, Malaysia, Singapore, Spain, Turkey, United States). Mental health (anxiety, depression, resilient coping, hope) and other study data were collected between June-August 2020. Of the 13,263 participants, 62.8% were female and 51.7% were 18-34 years old. Participants living in Brazil had the highest anxiety and depression symptoms while participants living in Singapore had the lowest. Greater personal COVID-19 exposure was associated with increased anxiety and depression symptoms, but country-level COVID-19 factors were not. Higher levels of hope were associated with reduced anxiety and depression; higher levels of resilient coping were associated with reduced anxiety but not depression. Substantial variations exist in anxiety and depression symptoms across countries during the COVID-19 lockdown, with personal COVID-19 exposure being a significant risk factor. Strategies that mitigate COVID-19 exposure and enhance hope and resilience may reduce anxiety and depression during global emergencies.

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.

Association Between Design Elements of Concussion Laws and Reporting of Sports-Related Concussions Among US High School Athletes, 2009-2017.

OBJECTIVES: Studies that evaluate the effectiveness of concussion laws often use only a single variable (ie, presence of the law), failing to account for law complexity. We examined the association between multiple design elements of state concussion laws and rates of sports-related concussion reporting among US high school athletes. METHODS: We derived 3 design elements of concussion laws from the 2009-2017 LawAtlas database: (1) strength of law, (2) number of law revisions, and (3) speed of law adoption. We examined the association between these design elements and rates of new and recurrent sports-related concussion reporting from the 2009-2010 through 2016-2017 academic years in a nationally representative sample of high school athletes participating in High School Report Information Online, an online data collection tool. RESULTS: A total of 7064 sports-related concussions (6332 [89.6%] new and 732 [10.4%] recurrent concussions) were reported during the study period, with an overall rate of 39.7 sports-related concussions per 100 000 athletic exposures (eg, game or practice). Rates of new concussion reporting were higher among high schools in states with medium- or high-strength concussion laws than in states with low-strength concussion laws and in states with at least 1 concussion law revision than in states with no concussion law revisions. Rates of recurrent concussion reporting were lower among high schools in states with ≥2 concussion law revisions than in states with <2 concussion law revisions. Early law adoption was associated with higher rates of new and recurrent concussion reporting, and late law adoption was associated with lower rates of new and recurrent concussion reporting. CONCLUSION: Our findings may help inform legislators of the public health effect of concussion laws.

The Effect of Helium Ion Radiation on the Material Properties of Bone.

Ionizing radiation, from both space and radiation therapy, is known to affect bone health. While there have been studies investigating changes in bone density and microstructure from radiation exposure, the effects of radiation on material properties are unknown. The current study addresses this gap by assessing bone material property changes in rats exposed to helium-4 radiation through spherical micro-indentation. Rats were exposed to a single dose of 0, 5, and 25 cGy whole body helium-4 radiation. Animals were euthanized at 7, 30, 90, or 180-days after exposure. Spherical micro-indentation was performed on axial cross sections of the femur cortical bone to determine instantaneous and relaxed shear moduli. At 90-days after exposure, the 25 cGy exposure caused a significant decline in shear modulus compared to control and 5 cGy groups. The instantaneous modulus decreased 33% and the relaxed modulus decreased 32% as compared to the sham group. This decline was followed by a recovery of both moduli, which was observed by 180-days after exposure; at 180 days, the moduli were no longer statistically different from those at 7 or 30 days. The observed decrease at 90 days, followed by recovery to baseline levels, can be attributed to the biological mechanisms involved in bone formation that were affected by radiation, bone turnover, and systemic changes in hormones due to radiation exposure. Continued assessment of the mechanisms that drive such a response in material properties may enable identification of pathways for therapeutic countermeasures against radiation exposure.

Ultra-Early Venous Thromboembolism (VTE) Prophylaxis in Spontaneous Intracerebral Hemorrhage (sICH).

OBJECTIVE: To determine if ultra-early (<24 h) venous thromboembolism (VTE) prophylaxis was associated with hematoma growth in spontaneous intracerebral hemorrhage (ICH). BACKGROUND: Patients with ICH have a high risk of VTE. Pharmacological prophylaxis such as unfractionated heparin (UFH) have been demonstrated to reduce VTE. However, published datasets exclude patients with recent ICH out of concern for hematoma enlargement. American Heart/Stroke Association guidelines recommend UFH 1-4 days after hematoma stabilization while the European Stroke Organization has no recommendations on when to begin UFH. Our institutional practice is to obtain stability CT scans at 6 to 24 h and to begin UFH following documented clinical and radiologic stability. We examined the impact of this practice on hematoma expansion. METHODS: We performed a retrospective cohort analysis of consecutive ICH patients treated at a single tertiary academic referral center in the US. Demographic and clinical characteristics were abstracted. ICH volume was measured via 3D volumetrics for a CT head done on admission, follow-up stability, and prior to discharge. The primary outcome was analyzed as ≥3 mL hematoma enlargement. Secondary outcomes include hematoma expansion of ≥6mL and ≥ 33%, length of stay (LOS), discharge disposition and mortality. RESULTS: A total of 163 ICH patients were analyzed. There were 58 (35.6%) patients in the ultra-early UFH group and UFH was initiated on average at 13.8 h from initial scan. There were 105 (64.6%) patients in the standard group who initiated UFH at an average of 46.6 h. The primary outcome of hematoma enlargement ≥3 mL was observed in 2/58(3.4%) patients with ultra-early initiation of UFH and in 7/105(6.7%) in the standard group (p=0.49). Secondary outcomes were not significant including hematoma expansion in the ultra-early group ≥ 6 mL 3/58 (5.2%) and ≥33% 7/58 (12.1%) (p=0.91, 0.61, respectively) as well as mortality or LOS. CONCLUSION: Venous thromboembolism prophylaxis started ultra-early (≤24 h) after ICH was not associated with hematoma expansion.

Concussion-Related Health Care Utilization Among Medicaid Insured Children in Ohio: Rural and Urban Differences.

PURPOSE: The current study examines rural-urban differences in trends in rates and type of concussion-related health care utilization over time from 2008 to 2016 among Medicaid insured children in Ohio. METHODS: We analyzed Medicaid claims for health care utilization for diagnosed concussions among children aged ≤18 years between April 1, 2008, and December 31, 2016. We compared the trends in rates of concussion-related health care utilization between children who lived in rural and urban areas using Poisson regressions. We examined trends in the type of concussion-related health care utilization by location of residence using linear regressions. FINDINGS: We found a significant increase in health care utilization for concussion over time, with rates of treated concussion consistently higher in rural children compared to urban children (P < .0001) throughout the study period. Although initial care at the Emergency Department (ED) remained the most common type of initial concussion-related health care utilization for rural children throughout the study period, the most common type of initial care sought by urban children shifted over time from the ED to primary care providers (PCPs). For both rural and urban children, PCPs remained the most common type of follow-up care sought throughout the study period, with no significant rural-urban differences in the trends of follow-up care sought through PCPs over time. CONCLUSIONS: We observed significant rural-urban differences in the trends in rates and types of concussion-related health care utilization over time from 2008 to 2016. Future studies are needed to further our understanding of the effect of these observed rural-urban differences on concussion recovery.

Sports and non-sports-related concussions among Medicaid-insured children: health care utilization before and after Ohio's concussion law.

OBJECTIVE: To evaluate patterns of health care utilization for sports-related concussions (SRCs) and non-sports-related concussions (NSRCs) among Medicaid-insured children before and after the enactment of Ohio's concussion law in April 2013. METHODS: We analyzed claim data from the Partners For Kids (PFK) Ohio Medicaid database. Concussion diagnoses were identified between April 1, 2008 and June 30, 2017. We compared frequency of concussions by age and sex across the law period. We evaluated type of health care utilization before and after law enactment using multinomial logistic regression. RESULTS: Over the 9 year study period, 6157 concussions were included, most of which (70.4%) were NSRCs. The proportion of SRCs increased with age. Among children younger than 5 years old, the majority (96.1%) of concussions were NSRCs. During the post-law period, greater odds of primary care visits than emergency department (ED) visits were observed for both SRCs (OR = 1.53; 95% CI 1.34, 1.75) and NSRCs (OR = 1.73; 95% CI 1.58, 1.90) compared to the pre-law period. CONCLUSIONS: We observed higher proportions of health care utilization for NSRCs than SRCs in Medicaid insured children and a shift in health care utilization from the ED to primary care in the post-law period. SRCs and NSRCs are likely to have different patterns of health care utilization before and after the enactment of Ohio's concussion law. Our results demonstrate that Ohio's youth concussion law had a quantifiable impact on health care utilization.

Analyzing the impact of a state concussion law using an autoregressive integrated moving average intervention analysis.

BACKGROUND: Existing studies analyzing the impact of state concussion laws have found an increase in concussion-related medical encounters post-law, in some instances, such increases were observed during the pre-law period due to a potential "spillover" effect. This study assessed the effects of Ohio's concussion law, while accounting for such a "spillover" effect, on the trends in monthly rates of concussion-related medical encounters in Medicaid insured children using autoregressive integrated moving average (ARIMA) analysis. METHODS: We analyzed claim data obtained from the Partners For Kids database, a pediatric accountable care organization in Ohio. Concussion-related medical encounters for Medicaid-insured children (ages 0-18 years) treated between April 1, 2008 to December 31, 2016 were selected and analyzed. We assessed pre- and post-law trends in concussion-related medical encounters using an ARIMA intervention model. We also used traditional regression methods to validate the study results. RESULTS: A total of 16,943 concussion-related medical encounters sustained by 15,545 unique patients were included. Monthly rates of concussion-related medical encounters significantly increased from 4.64 per 10,000 member months during the pre-law period to 6.69 per 10,000 member months in the post-law period (P < 0.0001). Three upward breaks in the monthly rates of concussion-related medical encounters were observed between 2009 and 2016, with two breaks observed during the pre-law period. Specifically, the increased breakpoint observed in July 2011 (P = 0.0186) was significantly associated with an estimated 7.3% increase (95% CI: 1.1-13.7) in the rate of concussion-related medical encounters. This finding was confirmed in the Poisson regression and curve fitting models. Furthermore, a seasonal trend in concussion-related medical encounters was observed with the highest rates in September and October of each year. CONCLUSIONS: Two of the three upward breaks identified in the monthly rate of concussion-related medical encounters occurred before the enactment of Ohio's concussion law, suggesting a potential "spillover" effect. Further research is needed to confirm such an effect in children with other types of medical insurance.

Is Pediatric Traumatic Brain Injury Associated with Adult Alcohol Misuse?

Evidence suggests that pediatric traumatic brain injury (TBI) may be causally related to alcohol misuse later in life; however, the nature and extent of the association has not been well described. This study examined the relationship between pediatric TBI and adult alcohol misuse in a population sample ≥20 years of age. We sought to determine (1) whether first self-reported incidence of TBI with loss of consciousness (LOC) before the age of 20 increased the risk for alcohol misuse later in life; and (2) whether sex, injury severity, and age at time of injury modified the association. We found a greater likelihood of binge but not heavy drinking for those whose first self-reported TBI with LOC occurred before the age of 20 when compared with those whose first self-reported TBI with LOC occurred later in life (28.5% vs. 20.4%, p = 0.003). When limited to those with only mild TBI, the relationship to binge drinking remained significant (31.9% vs. 19.3%, p < 0.001) and was evident for both males (38.4% vs. 25.6%, p = 0.016) and females (20.9% vs. 12.4%, p = 0.044). When controlling for sex, age, and race/ethnicity, reporting a first TBI with LOC before age 20 was associated with binge drinking only for those with mild TBI (adjusted odds ratio [AOR] = 1.32; 95% confidence interval [CI] = 1.00-1.74). Results also showed that those with first TBI with LOC occurring between the ages of 10 and 19 years were more likely to binge drink as adults than those first injured earlier in life, regardless of TBI severity. Further research is needed at both the epidemiological and pre-clinical levels to better understand this relationship.

Putting Policy Into Practice: School-Level Compliance With and Implementation of State Concussion Laws.

CONTEXT: Each year, approximately 2 million US children 18 years or younger sustain a concussion, a type of mild traumatic brain injury (TBI). Concussions can have detrimental effects on physical, cognitive, emotional, or sleep health. POLICY: Between 2009 and 2014, all 50 US states and Washington, District of Columbia, enacted state concussion laws aimed to increase awareness about concussion and reduce the prevalence and severity of this injury. Most state laws include the following core tenets: (1) immediate removal from play after an actual or suspected concussion; (2) medical clearance before an athlete can return to play (RTP); and (3) concussion education for athletes, parents, and coaches. IMPLEMENTATION: State concussion laws allow for substantial interpretation at the school level, resulting in considerable variation in the content of school written concussion policies and the level of implementation of state law requirements at the school level. EVALUATION: We assessed the degree of high school written concussion policy compliance with the respective state law and examined the relationship between concussion policy compliance and school-level implementation of concussion laws. Seventy-one school officials completed a semistructured telephone interview and submitted their school's written concussion policy. Of the 71 policies analyzed, most complied with the removal-from-play, RTP, and concussion education tenets (90.1%, 97.2%, and 76.1%, respectively). The majority of participants reported that their school implemented the removal-from-play (91.5%), RTP (93.0%), and concussion education (80.6%) tenets well or very well. No significant relationships were found between researcher-rated school policy compliance and school-reported implementation of state law requirements at the school level. DISCUSSION: Our findings suggest that most participating schools complied with their state concussion law and implemented law requirements well or very well. Future studies should identify facilitators and barriers to the implementation of state concussion laws at the school level.