Concussion Evaluation Patterns Among US Adults.

OBJECTIVE: The objective of this study was to compare individuals who were not evaluated by a doctor or nurse for a self-reported concussion versus individuals who were evaluated for a concussion by demographic variables, concussion history, and concussion circumstances. SETTINGS AND PARTICIPANTS: Data were collected from 2018 SpringStyles, a web-based panel survey of US adults 18 years or older ( n = 6427), fielded in March-April. DESIGN: Cross-sectional. MAIN MEASURES: Respondents were asked whether they believed they had sustained a concussion in their lifetime and details about their most recent concussion, including whether they were evaluated by a doctor or nurse. RESULTS: Twenty-seven percent of adults in the survey reported a lifetime concussion ( n = 1835). Among those individuals, 50.4% were not evaluated by a healthcare provider for their most recent concussion. Not being evaluated was higher among individuals whose concussion was caused by a slip, trip, or fall (adjusted prevalence ratio [APR] = 2.22; 95% CI, 1.65-2.99), riding a bicycle (APR = 2.28; 95% CI, 1.58-3.27), being struck by or against something by accident (APR = 2.50; 95% CI, 1.88-3.34), or being struck by or against something during a fight or argument (APR = 2.89; 95% CI, 2.11-3.97), compared with individuals whose concussion was caused by a motor vehicle crash. No evaluation was also higher among individuals whose concussion occurred while engaging in a sports or recreational activity (APR = 1.39; 95% CI, 1.07-1.82) or engaging in regular activities around the house (APR = 1.65; 95% CI, 1.27-2.14), compared with individuals whose concussion occurred while working for pay. CONCLUSION: More than a quarter of adults reported a lifetime concussion; however, half of them were not evaluated for their last concussion by a healthcare provider. Examination by a healthcare professional for a suspected concussion may prevent or mitigate potential long-term sequelae. Furthermore, current US surveillance methods may underestimate the burden of TBI because many individuals do not seek evaluation.

Substance Use and Sports- or Physical Activity-Related Concussions Among High School Students.

History of concussion is associated with substance use. Data from the 2017 National Youth Risk Behavior Survey (N = 14,765) were used in this study to examine associations between sports- or physical activity-related concussions and current cigarette, alcohol, and marijuana use among high school students, and whether other factors moderate those associations. In addition to having played on a sports team, potential moderators examined included persistent feelings of sadness or hopelessness, hours of sleep, and serious difficulty concentrating, remembering, or making decisions. The association between sports- or physical activity-related concussions and current cigarette, alcohol, and marijuana use was significant when controlling for sex, grade, and race/ethnicity and the potential moderators with the exception of cigarette smoking while controlling for hours of sleep. Those involved in the care of high school students after a concussion may consider assessing current cigarette, alcohol, and marijuana use.

Understanding Traumatic Brain Injury in Females: A State-of-the-Art Summary and Future Directions.

In this report, we identify existing issues and challenges related to research on traumatic brain injury (TBI) in females and provide future directions for research. In 2017, the National Institutes of Health, in partnership with the Center for Neuroscience and Regenerative Medicine and the Defense and Veterans Brain Injury Center, hosted a workshop that focused on the unique challenges facing researchers, clinicians, patients, and other stakeholders regarding TBI in women. The goal of this "Understanding TBI in Women" workshop was to bring together researchers and clinicians to identify knowledge gaps, best practices, and target populations in research on females and/or sex differences within the field of TBI. The workshop, and the current literature, clearly highlighted that females have been underrepresented in TBI studies and clinical trials and have often been excluded (or ovariectomized) in preclinical studies. Such an absence in research on females has led to an incomplete, and perhaps inaccurate, understanding of TBI in females. The presentations and discussions centered on the existing knowledge regarding sex differences in TBI research and how these differences could be incorporated in preclinical and clinical efforts going forward. Now, a little over 2 years later, we summarize the issues and state of the science that emerged from the "Understanding TBI in Women" workshop while incorporating updates where they exist. Overall, despite some progress, there remains an abundance of research focused on males and relatively little explicitly on females.

Characteristics of Diagnosed Concussions in Children Aged 0 to 4 Years Presenting to a Large Pediatric Healthcare Network.

OBJECTIVE: The aim of the study was to comprehensively describe the natural history of concussion in early childhood between 0 and 4 years. METHODS: Retrospective cohort study of 329 patients aged 0 to 4 years, with an International Classification of Diseases, Ninth Revision, concussion diagnosis in the Children's Hospital of Philadelphia healthcare network from October 1, 2013, to September 30, 2015. Clinical data were abstracted from the Children's Hospital of Philadelphia electronic health record, which captured all clinical care visits and injury characteristics. RESULTS: Nearly 9 (86.6%) of 10 patients sought care in the emergency department or urgent care setting, most commonly on the day of injury (56.2%) and as a result of a fall (64.4%). More than two-thirds (64.4%) of patients or their parent/caregiver reported somatic symptoms (ie, vomiting or headache), whereas close to half (49.2%) reported sleep issues. One of 5 patients identified emotional symptoms (21.9%) or visio-vestibular dysfunction (20.4%). Many patients also experienced symptoms not included in standard assessment tools including personality changes (34.0%) and change in appetite (12.8%). CONCLUSIONS: These results provide insight into the clinical characteristics of concussion in early childhood up to 4 years of age. Because assessment in this group relies heavily on parent/caregiver symptom reporting, rather than patient self-report, these results will aid clinicians with the challenge of diagnosing concussions in this population. These findings highlight the need to develop additional tools to adequately and systematically assess common signs and symptoms of concussion in early childhood that may not be included in standard assessment scales routinely used in older adolescents and adults.

Characteristics of Concussion in Elementary School-Aged Children: Implications for Clinical Management.

OBJECTIVE: To comprehensively characterize the clinical presentation and course of care for concussion among 5- to 11-year-old children, identifying preinjury and injury factors potentially influencing clinical outcomes. STUDY DESIGN: A single-institution retrospective cohort study using electronic health record data from children ages 5- to 11 years with a concussion from July 1, 2014, through June 30, 2015. Electronic health record data were abstracted for a 20% random sample of 292 patients. RESULTS: Three-fourths of patients (74.3%) presenting for concussion care had a standardized visiovestibular assessment performed. Almost all of those who eventually sought specialty care (92.9%) also had such an assessment, and only 42.9% patients initially seen in the emergency department or urgent care were examined in this manner. Of those assessed, 62.7% (n = 136) demonstrated deficits, with children ages 9-11 years more frequently exhibiting deficits than their younger counterparts (67.9% vs 53.2%; P = .03). Almost all patients (95.9%) reported at least 1 somatic symptom (eg, headache, dizziness), and one-half to two-thirds reported problems with sleep (54.1%) and visiovestibular symptoms (66.1%). Only 11.6% of children were referred for rehabilitation therapies and less than one-half of concussed patients (43.8%) were provided with a letter recommending school accommodations. CONCLUSIONS: Somatic symptoms, sleep problems, and visiovestibular deficits are common in elementary school-aged children with concussion, but specific visiovestibular clinical assessments are often not performed, particularly in the emergency department setting. Recommendations for school accommodations are often not provided at the time of concussion diagnosis. Incorporating a standardized visiovestibular assessment into practice could facilitate early targeted school accommodations and thereby improve return to learning for elementary school-aged children with concussion.

Self-Reported Lifetime Concussion Among Adults: Comparison of 3 Different Survey Questions.

OBJECTIVE: Because of limitations in current national data sets, respondent self-report may be critical to obtaining concussion prevalence estimates. We examined whether self-report of lifetime concussion among adults varies with the provision of a concussion definition and by the content of that definition. SETTING AND PARTICIPANTS: A convenience sample of 6427 American adults who participated in the 2018 Porter Novelli SpringStyles survey. DESIGN: Cross-sectional. MAIN MEASURES: Frequency of self-reported concussion by variation in concussion definition. RESULTS: A quarter of respondents (28.9%) reported experiencing a concussion in their lifetime. While concussion prevalence varied by demographic characteristics, it did not vary significantly by concussion definition. Variation in concussion definition did not result in differences related to recency of last concussion, mechanism of injury, or respondent activity engaged in during which they sustained their most recent concussion. CONCLUSION: The current study suggested that in this sample of adults, the percentage reporting a concussion did not significantly vary by whether a concussion definition was provided or by the content of the definition. However, research suggests that prompting about mechanism of injury, listing symptoms individually, and considering only athletic populations may affect estimates and these factors should be included in future question comparisons.

Examination of sports and recreation-related concussion among youth ages 12-17: results from the 2018 YouthStyles survey.

Background: This paper sought to examine the frequency of self-reported sports- and recreation-related (SRR) concussion, as well as care-seeking behaviors and potential activity restrictions after concussions, in a sample of youth.Methods: A sample of 845 youth ages 12-17 years responded to the web-based YouthStyles survey in 2018. The survey measured the frequency of self-reported lifetime SRR concussion, the setting of their most recent SRR concussion, whether a doctor or nurse evaluated them, and the types of activity restrictions they experienced.Results: Forty-three percent of youth surveyed sustained their most recent concussion while playing on a sports team, 21.1% while playing on a community-based team, and 36.0% while engaged in a sport or recreational activity. Nearly half (45.3%) reported having to miss playing sports or participating in physical activity for at least one day; about two in ten (19.7%) reported having to miss time on their phone or computer for at least one day.Conclusion: Despite wide-spread efforts to promote protocols for SRR concussion among youth, a third of participants in this study did not seek medical care and more than half did not miss at least one day of sports or physical activity participation following a concussion.

Risk of Repeat Concussion Among Patients Diagnosed at a Pediatric Care Network.

OBJECTIVE: To quantify the risk of repeat concussions for children and identify demographic and clinical aspects of the index concussion associated with repeat injury. STUDY DESIGN: For this retrospective cohort study, we queried the Children's Hospital of Philadelphia healthcare network's unified electronic health record to identify all 5- to 15-year-old patients who had their first clinical visit for an index concussion at a Children's Hospital of Philadelphia location from July 2012 through June 2013. A 25% random sample (n = 536) were selected. Clinical data were abstracted for their index concussion and all concussion-related visits for 2 years following the index concussion. RESULTS: Overall, 16.2% (n = 87) of patients experienced at least 1 repeat concussion within 2 years of their index concussion. The risk of repeat concussion increased with patient age (9.5% for ages 5-8 years; 10.7% for ages 9-11 years; and 19.8% for ages 12-15 years). After we adjusted for other factors, risk was particularly heightened among patients whose index concussion had a longer clinical course (>30 vs 0-7 days, adjusted risk ratio 1.65 [1.01-2.69]) and greater symptom burden (>11 vs 0-2 symptoms, adjusted risk ratio 2.12 [1.12-3.72]). CONCLUSIONS: We estimate that 1 in 6 youth diagnosed with a concussion are diagnosed with a subsequent concussion within 2 years and that several clinical characteristics of the index concussion increase this risk. Identifying factors associated with a repeat injury is essential to inform the clinical management of concussion and direct injury prevention efforts.

Emergency Department Visits for Sports- and Recreation-Related Traumatic Brain Injuries Among Children - United States, 2010-2016.

Traumatic brain injuries (TBIs), including concussions, are at the forefront of public concern about athletic injuries sustained by children. Caused by an impact to the head or body, a TBI can lead to emotional, physiologic, and cognitive sequelae in children (1). Physiologic factors (such as a child's developing nervous system and thinner cranial bones) might place children at increased risk for TBI (2,3). A previous study demonstrated that 70% of emergency department (ED) visits for sports- and recreation-related TBIs (SRR-TBIs) were among children (4). Because surveillance data can help develop prevention efforts, CDC analyzed data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP)* by examining SRR-TBI ED visits during 2010-2016. An average of 283,000 children aged <18 years sought care in EDs each year for SRR-TBIs, with overall rates leveling off in recent years. The highest rates were among males and children aged 10-14 and 15-17 years. TBIs sustained in contact sports accounted for approximately 45% of all SRR-TBI ED visits. Activities associated with the highest number of ED visits were football, bicycling, basketball, playground activities, and soccer. Limiting player-to-player contact and rule changes that reduce risk for collisions are critical to preventing TBI in contact and limited-contact sports. If a TBI does occur, effective diagnosis and management can promote positive health outcomes among children.

Strengthening the Evidence Base: Recommendations for Future Research Identified Through the Development of CDC's Pediatric Mild TBI Guideline.

OBJECTIVE: The recently published Centers for Disease Control and Prevention evidence-based guideline on pediatric mild traumatic brain injury (mTBI) was developed following an extensive review of the scientific literature. Through this review, experts identified limitations in existing pediatric mTBI research related to study setting and generalizability, mechanism of injury and age of cohorts studied, choice of control groups, confounding, measurement issues, reporting of results, and specific study design considerations. This report summarizes those limitations and provides a framework for optimizing the future quality of research conduct and reporting. RESULTS: Specific recommendations are provided related to diagnostic accuracy, population screening, prognostic accuracy, and therapeutic interventions. CONCLUSION: Incorporation of the recommended approaches will increase the yield of eligible research for inclusion in future systematic reviews and guidelines for pediatric mTBI.

Self-Reported Concussions from Playing a Sport or Being Physically Active Among High School Students - United States, 2017.

Increased susceptibility to concussions and longer recovery times among high school athletes compared with older athletes (1) make concussions among youths playing a sport or being physically active an area of concern. Short-term and long-term sequelae of concussions can include cognitive, affective, and behavioral changes (1). Surveillance methods used to monitor concussions among youths likely underestimate the prevalence. Estimates assessed from emergency departments miss concussions treated outside hospitals, those generated using high school athletic trainer reports miss concussions sustained outside of school-based sports (2), and both sources miss medically untreated concussions. To estimate the prevalence of concussions among U.S. high school students related to playing a sport or being physically active, CDC analyzed data from the 2017 national Youth Risk Behavior Survey (YRBS). Overall, 15.1% of students (approximately 2.5 million*) reported having at least one of these concussions during the 12 months before the survey, and 6.0% reported two or more concussions. Concussion prevalence was significantly higher among male students than among female students and among students who played on a sports team than among students who did not. Among all sex, grade, and racial/ethnic subgroups, the odds of reporting a concussion increased significantly with the number of sports teams on which students played. These findings underscore the need to 1) foster a culture of safety in which concussion prevention and management is explicitly addressed; 2) expand efforts to educate students, parents, coaches, and health care providers regarding the risk for concussion; and 3) identify programs, policies, and practices that prevent concussions.

Disability and Risk of Recent Sexual Violence in the United States.

OBJECTIVES: To examine the relative prevalence of recent (past 12 months) penetrative and nonpenetrative sexual violence comparing men and women with and without a disability. METHODS: Data are from the 2010 National Intimate Partner and Sexual Violence Survey, a national telephone survey of US adults, and includes an expansive measure of sexual violence victimization. A total of 9086 women and 7421 men completed the telephone survey in 2010. RESULTS: Compared with persons without a disability, persons with a disability were at increased risk for recent rape for women (adjusted odds ratio = 3.3; 95% confidence interval = 1.6, 6.7), and being made to penetrate a perpetrator for men (adjusted odds ratio = 4.2; 95% confidence interval = 1.6, 10.8). An estimated 39% of women raped in the 12 months preceding the survey had a disability at the time of the rape. For women and men, having a disability was associated with an increased risk of sexual coercion and noncontact unwanted sexual experiences. CONCLUSIONS: In this nationally representative sample, men and women with a disability were at increased risk for recent sexual violence, compared to those without a disability.

Beyond correlates: a review of risk and protective factors for adolescent dating violence perpetration.

Dating violence is a serious public health problem. In recent years, the U.S. Centers for Disease Control and Prevention and other entities have made funding available to community based agencies for dating violence prevention. Practitioners who are tasked with developing dating violence prevention strategies should pay particular attention to risk and protective factors for dating violence perpetration that have been established in longitudinal studies. This has been challenging to date because the scientific literature on the etiology of dating violence is somewhat limited, and because there have been no comprehensive reviews of the literature that clearly distinguish correlates of dating violence perpetration from risk or protective factors that have been established through longitudinal research. This is problematic because prevention programs may then target factors that are merely correlated with dating violence perpetration, and have no causal influence, which could potentially limit the effectiveness of the programs. In this article, we review the literature on risk and protective factors for adolescent dating violence perpetration and highlight those factors for which temporal precedence has been established by one or more studies. This review is intended as a guide for researchers and practitioners as they formulate prevention programs. We reviewed articles published between 2000 and 2010 that reported on adolescent dating violence perpetration using samples from the United States or Canada. In total, 53 risk factors and six protective factors were identified from 20 studies. Next steps for etiological research in adolescent dating violence are discussed, as well as future directions for prevention program developers.

Risk factors associated with sexual violence towards girls in Swaziland.

OBJECTIVE: To explore risk factors for sexual violence in childhood in a nationally representative sample of females aged 13 to 24 years in Swaziland. METHODS: During a household survey respondents were asked to report any experiences of sexual violence before the age of 18 years. The association between childhood sexual violence and several potential demographic and social risk factors was explored through bivariate and multivariate logistic regression. FINDINGS: Participants totalled 1244. Compared with respondents who had been close to their biological mothers as children, those who had not been close to her had higher odds of having experienced sexual violence (crude odds ratio, COR: 1.89; 95% CI: 1.14-3.14), as did those who had had no relationship with her at all (COR: 1.93; 95% CI: 1.34-2.80). In addition, greater odds of childhood sexual violence were noted among respondents who were not attending school at the time of the survey (COR: 2.26; 95% CI: 1.70-3.01); who were emotionally abused as children (COR: 2.04; 95% CI: 1.50-2.79); and who knew of another child who had been sexually assaulted (COR: 1.77; 95% CI: 1.31-2.40) or was having sex with a teacher (COR: 2.07; 95% CI: 1.59-2.69). Childhood sexual violence was positively associated with the number of people the respondent had lived with at any one time (COR: 1.03; 95% CI: 1.01-1.06). CONCLUSION: Inadequate supervision or guidance and an unstable environment put girls at risk of sexual violence. Greater educational opportunities and an improved mother-daughter relationship could help prevent it.

The relationship between intimate partner violence and children's asthma in 10 US states/territories.

Intimate partner violence (IPV) has been shown to negatively impact the health of both the adults who experience IPV and the children who are exposed to IPV. Although IPV experienced by women has been linked to children's asthma, this study is the first to examine this question among both women and men, and the first study in the United States to examine this question as part of a population-based data set. In 2005, ten US states/territories administered an IPV module and a children's asthma module within the Behavioral Risk Factor Surveillance System (BRFSS). Lifetime IPV was assessed by four questions that asked about threatened, attempted, or completed physical violence, as well as unwanted sex, by a current or former intimate partner. The children's asthma module asked respondents to report whether a randomly selected child in their household had ever been diagnosed with asthma and whether the same child currently had asthma. Women who experienced lifetime IPV, in contrast to women who never experienced IPV, were significantly more likely to report that their children had ever had asthma and currently have asthma. Among men, significant differences were not found when comparing men who reported lifetime IPV to those that did not report lifetime IPV. The results highlight the importance of primary prevention of IPV, as reducing the occurrence of IPV could improve not only the long-term health of those who experience IPV but also the health of their children.

Sports- and Physical Activity-Related Concussion and Risk for Youth Violence.

INTRODUCTION: Sports and physical activities are an important cause of traumatic brain injury among adolescents. Childhood traumatic brain injury has been associated with cognitive impairment, emotional problems, and impaired behavior control, and these neuropsychological changes may place these youth at increased risk for engagement in violence-related behaviors. METHODS: Data from the 2017 National Youth Risk Behavior Survey (N=14,765), a nationally representative survey of U.S. high school students, were analyzed in 2019 to examine the associations between sports- and physical activity-related concussion and violence-related behaviors occurring in the community and at school. Multivariable logistic regression models were used to calculate sex-stratified, adjusted (for race/ethnicity, grade, athlete status, impaired cognitive functioning, feeling sad/hopeless, and current substance use) prevalence ratios. Prevalence ratios were considered statistically significant if p<0.05. RESULTS: Male students (17.1%) were more likely than female students (13.0%) to experience a sports- and physical activity-related concussion during the 12 months preceding the survey. Compared with students who did not have a concussion, those who experienced ≥1 sports- and physical activity-related concussion were more likely to be in a physical fight (male students, adjusted prevalence ratio=1.45; female students, adjusted prevalence ratio=1.55), carry a weapon (male students, adjusted prevalence ratio=1.24; female students, adjusted prevalence ratio=1.79), and fight at school (male students, adjusted prevalence ratio=1.40; female students, adjusted prevalence ratio=1.77). In addition, male students were more likely to carry a gun (adjusted prevalence ratio=1.62) and carry a weapon at school (adjusted prevalence ratio=1.73). CONCLUSIONS: Although the direction of these associations is unknown, return-to-school programs may benefit from inclusion of assessment and counseling around issues of psychological and social functioning, conflict resolution, and coordination with violence prevention programs.

The Association Between Sports- or Physical Activity-Related Concussions and Suicidality Among US High School Students, 2017.

BACKGROUND: This study examined the association between sports- or physical activity-related concussions and having seriously considered attempting suicide, made a suicide plan, or attempted suicide (ie, suicidality), and tested potential moderators of the association. HYPOTHESIS: Risk factors such as persistent feelings of sadness or hopelessness, low academic grades, few hours of sleep, and current alcohol or marijuana use will increase the odds of suicidality among those who self-reported sports- or physical activity-related concussions, while protective factors such as physical activity and having played on a sports team will decrease the odds. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 4. METHODS: This study used data from the 2017 Youth Risk Behavior Survey, a biennial, school-based, nationally representative survey of US students in grade levels 9 to 12 (N = 14,765). Logistic regression models examined associations between self-reported sports- or physical activity-related concussions and suicidality among the students, and whether physical activity, having played on a sports team, persistent feelings of sadness or hopelessness, academic grades, hours of sleep, or current alcohol or marijuana use moderated those associations. RESULTS: Sports- or physical activity-related concussions were found to be associated with suicidality. The associations remained significant in models that adjusted for demographic characteristics, and they did not appear to be moderated by physical activity, having played on sports team, academic grades, or sleep. CONCLUSIONS: Given the findings of this study and others, health care providers are advised to ask students who have experienced a concussion about their emotional well-being as part of their symptom-based assessment, using validated, age- appropriate concussion symptom scales. Comprehensively assessing students who have experienced a sports- or physical activity-related concussion for persistent feelings of sadness or hopelessness may alert providers to thoughts of suicidal ideation and will allow for earlier intervention. CLINICAL RELEVANCE: If thoughts of suicide are discovered among adolescents with a concussion, or if other risk factors are observed, referrals to medical and mental health providers for a more comprehensive assessment may be warranted.

Differences in Head Impact Exposures Between Youth Tackle and Flag Football Games and Practices: Potential Implications for Prevention Strategies.

BACKGROUND: Interventions designed to reduce the risk for head impacts and concussion in youth football have increased over the past decade; however, understanding of the role of regular game play on head impact exposure among youth tackle and flag football athletes is currently limited. PURPOSE: To explore head impact exposure among youth tackle and flag football athletes (age range, 6-14 years) during both practices and games. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Using the Vector MouthGuard sensor, the authors collected head impact data from 524 tackle and flag youth football athletes over the course of a football season. Quantities of interest were estimated from regression models using Bayesian methods. RESULTS: For impacts ≥10g, a tackle football athlete had an estimated 17.55 (95% CI, 10.78-28.96) times more head impacts per practice compared with a flag football athlete (6.85 [95% CI, 6.05-7.76] and 0.39 [95% CI, 0.24-0.62] head impacts, respectively). Additionally, a tackle football athlete had an estimated 19.48 (95% CI, 12.74-29.98) times more head impacts per game compared with a flag football athlete (13.59 [95% CI, 11.97-15.41] and 0.70 [95% CI, 0.46-1.05] head impacts, respectively). Among tackle football athletes, the estimated average impact rate was 6.51 (95% CI, 5.75-7.37) head impacts during a practice and 12.97 (95% CI, 11.36-14.73) impacts during a game, resulting in 2.00 (95% CI, 1.74-2.29) times more ≥10g head impacts in games versus practices. Tackle football athletes had 2.06 (95% CI, 1.80-2.34) times more high-magnitude head impacts (≥40g) during a game than during a practice. On average, flag football athletes experienced an estimated 0.37 (95% CI, 0.20-0.60) head impacts during a practice and 0.77 (95% CI, 0.53-1.06) impacts during a game, resulting in 2.06 (95% CI, 1.29-3.58) times more ≥10g head impacts in games versus practices. Because of model instability caused by a large number of zero impacts for flag football athletes, a comparison of high-magnitude head impacts is not reported for practices or games. CONCLUSION: This study provides a characterization of the head impact exposure of practices and games among a large population of youth tackle and flag football athletes aged 6 to 14 years. These findings suggest that a greater focus on game-based interventions, such as fair play interventions and strict officiating, may be beneficial to reduce head impact exposures for youth football athletes.

Head Impact Exposures Among Youth Tackle and Flag American Football Athletes.

BACKGROUND: Promoted as a safer alternative to tackle football, there has been an increase in flag football participation in recent years. However, examinations of head impact exposure in flag football as compared with tackle football are currently limited. HYPOTHESIS: Tackle football athletes will have a greater number and magnitude of head impacts compared with flag football athletes. STUDY DESIGN: Cohort study. LEVEL OF EVIDENCE: Level 4. METHODS: Using mouthguard sensors, this observational, prospective cohort study captured data on the number and magnitude of head impacts among 524 male tackle and flag football athletes (6-14 years old) over the course of a single football season. Estimates of interest based on regression models used Bayesian methods to estimate differences between tackle and flag athletes. RESULTS: There were 186,239 head impacts recorded during the study. Tackle football athletes sustained 14.67 (95% CI 9.75-21.95) times more head impacts during an athletic exposure (game or practice) compared with flag football athletes. Magnitude of impact for the 50th and 95th percentile was 18.15g (17.95-18.34) and 52.55g (51.06-54.09) for a tackle football athlete and 16.84g (15.57-18.21) and 33.51g (28.23-39.08) for a flag football athlete, respectively. A tackle football athlete sustained 23.00 (13.59-39.55) times more high-magnitude impacts (≥40g) per athletic exposure compared with a flag football athlete. CONCLUSION: This study demonstrates that youth athletes who play tackle football are more likely to experience a greater number of head impacts and are at a markedly increased risk for high-magnitude impacts compared with flag football athletes. CLINICAL RELEVANCE: These results suggest that flag football has fewer head impact exposures, which potentially minimizes concussion risk, making it a safer alternative for 6- to 14-year-old youth football athletes.

Sexual violence and its health consequences for female children in Swaziland: a cluster survey study.

BACKGROUND: Despite concern, few studies have been done about sexual violence against girls younger than 18 years of age in sub-Saharan Africa. We report the prevalence and circumstances of sexual violence in girls in Swaziland, and assess the negative health consequences. METHODS: We obtained data from a nationally representative sample of girls and women aged 13-24 years from selected households in Swaziland between May 15, 2007, and June 16, 2007, with a two-stage cluster design. The questionnaire examined demographics, type of sexual violence that took place before the respondent was 18 years of age, circumstances of the incident, and health-related conditions. Information was gathered from 1244 women and girls (response rate 96.3%), of whom 1242 provided retrospective responses to questions about sexual violence. We used regression models adjusted for relevant demographics to estimate the odds ratios for the associations between sexual violence and health-related conditions. FINDINGS: 33.2% (95% CI 29.9-36.7) of respondents reported an incident of sexual violence before they reached 18 years of age. The most common perpetrators of the first incident were men or boys from the respondent's neighbourhood (32.3% [28.8-36.1]) and boyfriends or husbands (26.2% [22.2-30.7]). The first incident most often took place in the respondent's own home (26.1% [21.6-31.2]). Sexual violence was associated with reported lifetime experience of sexually transmitted diseases (adjusted OR 3.69 [95% CI 1.78-7.66]), pregnancy complications or miscarriages (3.54 [1.47-8.55]), unwanted pregnancy (2.92 [1.87-4.55]), and self-report of feeling depressed (2.30 [1.70-3.11]). INTERPRETATION: Knowledge of the high prevalence of sexual violence against girls in Swaziland and its associated serious health-related conditions and behaviours should be used to develop effective prevention strategies. FUNDING: UNICEF.