Publications by authors named "Stephen W Marshall"

286 Publications

Association Between Automated Landing Error Scoring System Performance and Bone Stress Injury Risk in Military Trainees.

J Athl Train 2021 Aug 17. Epub 2021 Aug 17.

John A. Feagin Jr. Orthopaedic Sports Medicine Fellowship.

Context: Lower extremity bone stress injuries (BSI) place a significant burden on the health and readiness of the US Armed Forces.

Objective: To determine if pre-injury baseline performance on an expanded and automated 22-item version of the Landing Error Scoring System (LESS-22) is associated with the incidence of BSI in a military training population.

Design: Prospective cohort study.

Setting: US Military Academy at West Point Participants: 2,235 (510 females, 22.8%) incoming cadets Main outcome measures: Multivariable Poisson regression models were used to produce adjusted incidence rate ratios (IRR) to quantify the association between pre-injury LESS scores and BSI incidence rate during follow-up, adjusted for pertinent risk factors. Risk factors were included as covariates in the final model if the 95% confidence interval (95% CI) for the crude IRR did not contain 1.00.

Results: A total of 54 BSI occurred during the study period, resulting in an overall incidence rate of 0.07 BSI per 1,000 person-days (95% CI: 0.05, 0.09). The mean number of exposure days was 345.4 (SD 61.12, range 3-368). The final model was adjusted for sex and BMI and yielded an adjusted IRR for LESS-22 score of 1.06 (95% CI: 1.002, 1.13; p=0.04), indicating that each additional LESS error documented at baseline was associated with a 6.0% increase in the incidence rate of BSI during the follow-up period. In addition, six individual LESS-22 items, including two newly added items, were significantly associated with BSI incidence.

Conclusions: This study provides evidence that performance on the expanded and automated version of the LESS is associated with BSI incidence in a military training population. These results suggest that the automated LESS-22 may be a scalable solution for screening military training populations for BSI risk.
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http://dx.doi.org/10.4085/1062-6050-0263.21DOI Listing
August 2021

The impact of the COVID-19 pandemic on the utilization of emergency department services for the treatment of injuries.

Am J Emerg Med 2021 Sep 20;47:187-191. Epub 2021 Apr 20.

Injury Prevention Research Center, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., Chapel Hill, NC 27599-7505, USA; Carolina Center for Health Informatics, Department of Emergency Medicine, University of North Carolina at Chapel Hill, 100 Market Street, Suite 1, Chapel Hill, NC 27516, USA. Electronic address:

Context: The global COVID-19 pandemic has had a major impact on the utilization of healthcare services; however, the impact on population-level emergency department (ED) utilization patterns for the treatment of acute injuries has not been fully characterized.

Objective: This study examined the frequency of North Carolina (NC) EDs visits for selected injury mechanisms during the first eleven months of the COVID-19 pandemic.

Methods: Data were obtained from the NC Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT), NC's legislatively mandated statewide syndromic surveillance system for the years 2019 and 2020. Frequencies of January - November 2020 NC ED visits were compared to frequencies of 2019 visits for selected injury mechanisms, classified according to International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) injury diagnosis and mechanism codes.

Results: In 2020, the total number of injury-related visits declined by 19.5% (N = 651,158) as compared to 2019 (N = 809,095). Visits related to motor vehicle traffic crashes declined by a greater percentage (29%) and falls (19%) declined by a comparable percentage to total injury-related visits. Visits related to assault (15%) and self-harm (10%) declined by smaller percentages. Medication/drug overdose visits increased (10%), the only injury mechanism studied to increase during this period.

Conclusion: Both ED avoidance and decreased exposures may have contributed to these declines, creating implications for injury morbidity and mortality. Injury outcomes exacerbated by the pandemic should be addressed by timely public health responses.
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http://dx.doi.org/10.1016/j.ajem.2021.04.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8056481PMC
September 2021

Differences in Lower Extremity Movement Quality by Level of Sport Specialization in Cadets Entering a United States Service Academy.

Sports Health 2021 Feb 22:1941738121994097. Epub 2021 Feb 22.

John A. Feagin Jr Sports Medicine Fellowship, Keller Army Hospital, United States Military Academy, West Point, New York.

Background: Sport specialization in youth athletes is associated with increased risk for musculoskeletal injury; however, little is known about whether sport specialization is associated with lower extremity movement quality. The purpose of this study was to examine differences in lower extremity movement quality by level of sport specialization in US Service Academy cadets.

Hypothesis: Cadets who report an increased level of sport specialization would have a lower level of movement quality than those who are less specialized.

Study Design: Cross-sectional analysis from an ongoing prospective cohort study.

Level Of Evidence: Level 3.

Methods: Cadets completed the Landing Error Scoring System (LESS) and a baseline questionnaire evaluating level of sport specialization during high school. Data were analyzed using separate 1-way analysis of variance models.

Results: Among all participants (n = 1950), 1045 (53.6%) reported low sport specialization, 600 (30.8%) reported moderate sport specialization, and 305 (15.6%) reported high sport specialization at the time of data collection during the first week. Ages ranged from 17 to 23 years. Men (1491) and women (459) reported comparable specialization levels ( = 0.45). There were no statistically significant differences in lower extremity movement quality by level of specialization for all subjects combined ( = 0.15) or when only men were included in the analyses ( = 0.69). However, there were statistically significant differences in movement quality by level of specialization in women ( = 0.02). Moderately specialized women had the best movement quality (mean, 4.63; SD, 2.21) followed by those with high specialization (mean, 4.90; SD, 2.08) and those with low levels of specialization (mean, 5.23; SD, 2.07).

Conclusion: Women reporting moderate sport specialization had improved movement quality and significantly better LESS scores compared to those with high/low specialization.

Clinical Relevance: Athletes, especially women, should be encouraged to avoid early sport specialization to optimize movement quality, which may affect injury risk.
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http://dx.doi.org/10.1177/1941738121994097DOI Listing
February 2021

Association Between Previous Concussion Education and Concussion Care-Seeking Outcomes Among National Collegiate Athletic Association Division I Student-Athletes.

J Athl Train 2021 Feb 22. Epub 2021 Feb 22.

Keller Army Community Hospital, West Point, NY.

Context: Limited data exist concerning differences in concussion-education exposure and how education exposures relate to care seeking and symptom disclosure, specifically by National Collegiate Athletic Association Division I student-athletes.

Objective: To investigate demographic characteristics associated with concussion-education exposure and examine whether overall education exposure (yes versus no) and education-source exposure number (multiple sources versus a single source) affect concussion care-seeking and disclosure factors in Division I student-athletes.

Design: Cross-sectional study.

Setting: Classroom or online survey.

Patients Or Other Participants: Division I student-athletes (n = 341).

Main Outcome Measure(s): Frequencies and proportions were computed for sex, race, school year, sport, and concussion history across concussion-education groups. Prevalence ratios (PRs) and 95% CIs were calculated to quantify the associations between student-athlete characteristics and (1) overall concussion-education exposure and (2) source-exposure number. Separate multivariable linear regression models estimated adjusted mean differences (MDs) and 95% CIs, which allowed us to assess differences in concussion knowledge, attitudes, and perceived social norms relative to concussion-education exposure and exposure to multiple sources. Separate multivariable binomial regression models were performed to estimate adjusted PRs and 95% CIs in order to evaluate associations of intention, perceived control, and care-seeking or disclosure behaviors and overall concussion-education exposure and exposure to multiple sources. All models controlled for sex, sport, and concussion history.

Results: Overall, 276 (80.9%) participants reported previous concussion education, with 179 (64.9%) being exposed to multiple sources. Student-athletes who participated in a contact sport (adjusted PR = 1.24; 95% CI = 1.06, 1.44) and those who had a concussion history (adjusted PR = 1.19; 95% CI = 1.09, 1.31) had higher prevalences of concussion-education exposure. Females had a lower prevalence of reporting multiple sources (adjusted PR = 0.82; 95% CI = 0.68, 0.99). Overall concussion-education exposure was significantly associated with more favorable perceived social norms surrounding concussion care seeking (adjusted MD = 1.37; 95% CI = 0.13, 2.61).

Conclusions: These findings highlighted the potential differences in overall concussion-education exposure and provide clinicians with information on groups who may benefit from additional targeted education.
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http://dx.doi.org/10.4085/1062-6050-0211.20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8010936PMC
February 2021

Defining a Research Agenda for Youth Sport Specialization in the United States: The AMSSM Youth Early Sport Specialization Summit.

Clin J Sport Med 2021 Mar;31(2):103-112

Musculoskeletal Clinical Program, Intermountain Healthcare, Salt Lake City, Utah; and.

Abstract: Sport specialization is becoming increasingly common among youth and adolescent athletes in the United States and many have raised concern about this trend. Although research on sport specialization has grown significantly, numerous pressing questions remain pertaining to short- and long-term effects of specialization on the health and well-being of youth, including the increased risk of overuse injury and burnout. Many current elite athletes did not specialize at an early age. Methodological and study design limitations impact the quality of current literature, and researchers need to prioritize pressing research questions to promote safe and healthy youth sport participation. The American Medical Society for Sports Medicine hosted a Youth Early Sport Specialization Summit in April 2019 with the goal of synthesizing and reviewing current scientific knowledge and developing a research agenda to guide future research in the field based on the identified gaps in knowledge. This statement provides a broad summary of the existing literature, gaps and limitations in current evidence, and identifies key research priorities to help guide researchers conducting research on youth sport specialization. Our goals are to help improve the quality and relevance of research on youth sport specialization and to ultimately assure that opportunities for healthy and safe sport participation continue for all youth.
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http://dx.doi.org/10.1097/JSM.0000000000000900DOI Listing
March 2021

Musculoskeletal Injury History Is Associated With Lower Physical and Mental Health in a Historical Cohort of Former National Football League Players.

J Sport Rehabil 2021 Jan 25;30(5):760-767. Epub 2021 Jan 25.

Context: Little research has examined health-related quality of life in former National Football League (NFL) players.

Objective: Examine the association of musculoskeletal injury history and current self-reported physical and mental health in former NFL players.

Setting: Cross-sectional questionnaire.

Patients Or Other Participants: Historical cohort of 2,103 former NFL players that played at least one season between 1940 and 2001.

Intervention: Players were grouped by self-reported professional career musculoskeletal injury history and whether injuries affected current health: (1) no musculoskeletal injury history; (2) musculoskeletal injury history, currently affected by injuries; and (3) musculoskeletal injury history, not currently affected by injuries.

Main Outcome Measure: The Short Form 36 Measurement Model for Functional Assessment of Health and Well-Being (SF-36) yielded physical and mental health composite scores (PCS and MCS, respectively); higher scores indicated better health. Multivariable linear regression computed mean differences (MD) among injury groups. Covariates included demographics, playing history characteristics, surgical intervention for musculoskeletal injuries, and whether injury resulted in premature end to career. MD with 95% CI excluding 0.00 were deemed significant.

Results: Overall, 90.3% reported at least one musculoskeletal injury during their professional football careers, of which 74.8% reported being affected by their injuries at time of survey completion. Adjusting for covariates, mean PCS in the "injury and affected" group was lower than the "no injury" (MD = -3.2; 95% CI: -4.8, -1.7) and "injury and not affected" groups (MD = -4.3; 95% CI: -5.4, -3.3); mean MCS did not differ.

Conclusion: Many players reported musculoskeletal injuries, highlighting the need for developing and evaluating injury management interventions.
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http://dx.doi.org/10.1123/jsr.2020-0231DOI Listing
January 2021

Validation of a Commercially Available Markerless Motion-Capture System for Trunk and Lower Extremity Kinematics During a Jump-Landing Assessment.

J Athl Train 2021 Jan 22. Epub 2021 Jan 22.

Department of Exercise and Sport Science, Gillings School of Global Public Health, University of North Carolina at Chapel Hill.

Context: Field-based, portable motion-capture systems can be used to help identify individuals at greater risk of lower extremity injury. Microsoft Kinect-based markerless motion-capture systems meet these requirements; however, until recently, these systems were generally not automated, required substantial data postprocessing, and were not commercially available.

Objective: To validate the kinematic measures of a commercially available markerless motion-capture system.

Design: Descriptive laboratory study.

Setting: Laboratory.

Patients Or Other Participants: A total of 20 healthy, physically active university students (10 males, 10 females; age = 20.50 ± 2.78 years, height = 170.36 ± 9.82 cm, mass = 68.38 ± 10.07 kg, body mass index = 23.50 ± 2.40 kg/m2).

Intervention(s): Participants completed 5 jump-landing trials. Kinematic data were simultaneously recorded using Kinect-based markerless and stereophotogrammetric motion-capture systems.

Main Outcome Measure(s): Sagittal- and frontal-plane trunk, hip-joint, and knee-joint angles were identified at initial ground contact of the jump landing (IC), for the maximum joint angle during the landing phase of the initial landing (MAX), and for the joint-angle displacement from IC to MAX (DSP). Outliers were removed, and data were averaged across trials. We used intraclass correlation coefficients (ICCs [2,1]) to assess intersystem reliability and the paired-samples t test to examine mean differences (α ≤ .05).

Results: Agreement existed between the systems (ICC range = -1.52 to 0.96; ICC average = 0.58), with 75.00% (n = 24/32) of the measures being validated (P ≤ .05). Agreement was better for sagittal- (ICC average = 0.84) than frontal-plane (ICC average = 0.35) measures. Agreement was best for MAX (ICC average = 0.77) compared with IC (ICC average = 0.56) and DSP (ICC average = 0.41) measures. Pairwise comparisons identified differences for 18.75% (6/32) of the measures. Fewer differences were observed for sagittal- (0.00%; 0/15) than for frontal-plane (35.29%; 6/17) measures. Between-systems differences were equivalent for MAX (18.18%; 2/11), DSP (18.18%; 2/11), and IC measures (20.00%; 2/10). The markerless system underestimated sagittal-plane measures (86.67%; 13/15) and overestimated frontal-plane measures (76.47%; 13/17). No trends were observed for overestimating or underestimating IC, MAX, or DSP measures.

Conclusions: Moderate agreement existed between markerless and stereophotogrammetric motion-capture systems. Better agreement existed for larger (eg, sagittal plane, MAX) than for smaller (eg, frontal plane, IC) joint angles. The DSP angles had the worst agreement. Markerless motion-capture systems may help clinicians identify individuals at greater risk of lower extremity injury.
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http://dx.doi.org/10.4085/1062-6050-0023.20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901583PMC
January 2021

Defining a research agenda for youth sport specialisation in the USA: the AMSSM Youth Early Sport Specialization Summit.

Br J Sports Med 2021 Feb;55(3):135-143

Musculoskeletal Clinical Program, Intermountain Health Care Inc, Salt Lake City, Utah, USA.

Sport specialisation is becoming increasingly common among youth and adolescent athletes in the USA and many have raised concern about this trend. Although research on sport specialisation has grown significantly, numerous pressing questions remain pertaining to short-term and long-term effects of specialisation on the health and well-being of youth, including the increased risk of overuse injury and burnout. Many current elite athletes did not specialise at an early age. Methodological and study design limitations impact the quality of current literature, and researchers need to prioritise pressing research questions to promote safe and healthy youth sport participation. The American Medical Society for Sports Medicine hosted a Youth Early Sport Specialization Summit in April 2019 with the goal of synthesising and reviewing current scientific knowledge and developing a research agenda to guide future research in the field based on the identified gaps in knowledge. This statement provides a broad summary of the existing literature, gaps and limitations in current evidence and identifies key research priorities to help guide researchers conducting research on youth sport specialisation. Our goals are to help improve the quality and relevance of research on youth sport specialisation and to ultimately assure that opportunities for healthy and safe sport participation continue for all youth.
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http://dx.doi.org/10.1136/bjsports-2020-102699DOI Listing
February 2021

Trends in unintentional polysubstance overdose deaths and individual and community correlates of polysubstance overdose, North Carolina, 2009-2018.

Drug Alcohol Depend 2021 02 2;219:108504. Epub 2021 Jan 2.

Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, United States; Injury Prevention Research Center, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr Blvd, Chapel Hill, NC, 27514, United States. Electronic address:

Background: Polysubstance involvement is increasing among fatal drug overdoses. However, little is known about the epidemiology of polysubstance drug overdoses. This paper describes emerging trends in unintentional polysubstance overdose deaths in North Carolina (NC) and examines associations with individual and community factors.

Methods: Using 2009-2018 NC death certificate data, we identified unintentional drug overdose deaths and commonly involved substances (opioids, stimulants, benzodiazepines, alcohol, and antiepileptics). We examined polysubstance combinations, comparing opioid and non-opioid involved deaths. We examined individual level correlates from death certificate data and community level correlates from the American Community Survey and Robert Wood Johnson Foundation County Health Rankings to quantify associations.

Results: From 2009-2018, 53 % of opioid and 19 % of non-opioid overdose deaths involved multiple substances. During this period, polysubstance overdose death increased dramatically, from 2.9 to 12.1 per 100,000 persons, with the greatest increases among drug combinations involving stimulants. The most common polysubstance combinations were: opioids and stimulants (12.1 % of overdose deaths); opioids and benzodiazepines (9.0 %); opioids and alcohol (5.1 %); opioids, stimulants, and benzodiazepines (3.1 %); and opioids, benzodiazepines, and antiepileptics (2.2 %). Compared to overdoses involving opioids alone, overdoses involving combinations of opioids, stimulants, and benzodiazepines involved younger individuals (53.7 % in 15-34 years of age vs. 40.7 %). Men comprised two-thirds of overdoses involving opioids alone, however, overdoses involving opioids, benzodiazepines, and antiepileptics were predominantly among women (60.6 %).

Conclusions: Polysubstance involvement has increased among overdose deaths in NC. These findings can be used to inform public health interventions addressing polysubstance deaths and associated individual and community level factors.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108504DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8126267PMC
February 2021

Trends in movement quality in US Military Academy cadets 2005-17: A JUMP-ACL study.

Phys Ther Sport 2021 Mar 28;48:109-115. Epub 2020 Dec 28.

Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Objectives: This study sought to determine if there were significant trends in lower extremity movement quality, as assessed by the Landing Error Scoring System (LESS) scores and plane-specific LESS subscales, across in 12 recent cohorts of incoming USMA cadets.

Design: prospective cohort study.

Setting: United States Military Academy.

Participants: 7,591.

Main Outcome Measures: Landing Error Scoring System (LESS) scores, adjusted for sex and ACL injury history.

Results: Statistically significant inverse trends were found between total LESS score and year (p < 0.01) and sagittal plane subscale and year (p < 0.01). A statistically significant direct trend was found for the frontal/transverse plane subscale and year (p < 0.01). However, each of these trends had a small associated effect size, and none were considered clinically meaningful.

Conclusions: There were no meaningful changes in lower extremity movement quality in incoming US Military Academy cadets between 2005 and 2017.
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http://dx.doi.org/10.1016/j.ptsp.2020.12.020DOI Listing
March 2021

State Medical Board Policy and Opioid Prescribing: A Controlled Interrupted Time Series.

Am J Prev Med 2021 03 10;60(3):343-351. Epub 2020 Dec 10.

Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina; Injury Prevention Research Center, University of North Carolina, Chapel Hill, North Carolina.

Introduction: In March 2016, the Centers for Disease Control and Prevention issued opioid prescribing guidelines for chronic noncancer pain. In response, in April 2016, the North Carolina Medical Board launched the Safe Opioid Prescribing Initiative, an investigative program intended to limit the overprescribing of opioids. This study focuses on the association of the Safe Opioid Prescribing Initiative with immediate and sustained changes in opioid prescribing among all patients who received opioid and opioid discontinuation and tapering among patients who received high-dose (>90 milligrams of morphine equivalents), long-term (>90 days) opioid therapy.

Methods: Controlled and single interrupted time series analysis of opioid prescribing outcomes before and after the implementation of Safe Opioid Prescribing Initiative was conducted using deidentified data from the North Carolina Controlled Substances Reporting System from January 2010 through March 2017. Analysis was conducted in 2019-2020.

Results: In an average study month, 513,717 patients, including patients who received 47,842 high-dose, long-term opioid therapy, received 660,912 opioid prescriptions at 1.3 prescriptions per patient. There was a 0.52% absolute decline (95% CI= -0.87, -0.19) in patients receiving opioid prescriptions in the month after Safe Opioid Prescribing Initiative implementation. Abrupt discontinuation, rapid tapering, and gradual tapering of opioids among patients who received high-dose, long-term opioid therapy increased by 1% (95% CI= -0.22, 2.23), 2.2% (95% CI=0.91, 3.47), and 1.3% (95% CI=0.96, 1.57), respectively, in the month after Safe Opioid Prescribing Initiative implementation.

Conclusions: Although Safe Opioid Prescribing Initiative implementation was associated with an immediate decline in overall opioid prescribing, it was also associated with an unintended immediate increase in discontinuations and rapid tapering among patients who received high-dose, long-term opioid therapy. Better policy communication and prescriber education regarding opioid tapering best practices may help mitigate unintended consequences of statewide policies.
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http://dx.doi.org/10.1016/j.amepre.2020.09.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7902466PMC
March 2021

Association Between Previous Concussion Education and Concussion Care-Seeking Outcomes among NCAA Division I Student-Athletes.

J Athl Train 2020 Nov 5. Epub 2020 Nov 5.

1. Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Context: There are limited data concerning differences in concussion education exposure and how education exposures relates to care-seeking and symptom disclosure, specifically in Division I student-athletes.

Objective: Investigate demographic characteristics associated with concussion education exposure and examine whether overall education exposure (yes vs. no) and education source exposure number (multiple sources vs. single source) affects concussion care-seeking and disclosure factors in Division I student-athletes.

Design: Cross-sectional survey.

Setting: Classroom or online.

Participants: NCAA Division I student-athletes (n=341).

Main Outcome Measure(s): Frequencies and proportions were computed for sex, race, school year, sport, and concussion history across concussion education groups. Prevalence ratios (PR) and 95% confidence intervals (CI) quantified the association between student-athlete characteristics and 1) overall concussion education exposure and 2) source exposure number. Separate multivariable linear regression models estimated adjusted mean differences (MD) and 95%CI to assess differences in concussion knowledge, attitudes, and perceived social norms relative to concussion education exposure and exposure to multiple sources. Separate multivariable binomial regression models estimated adjusted PRs and 95%CI to assess associations of intention, perceived control, and care-seeking/disclosure behaviors and overall concussion education exposure and exposure to multiple sources. All models controlled for sex, sport, and concussion history.

Results: Overall, n=276 (80.9%) reported previous concussion education, with 179 (64.9%) exposed to multiple sources. Student-athletes that participated in a contact sport (adjusted PR=1.24, 95%CI=1.06,1.44) and those who had a concussion history (adjusted PR=1.19, 95%CI=1.09,1.31) had higher prevalence of previous concussion education exposure. Females had a lower prevalence of reporting multiple sources (adjusted PR=0.82, 95%CI=0.68, 0.99). Overall concussion education exposure was significantly associated with more favorable perceived social norms surrounding concussion care-seeking (adjusted MD=1.37, 95%CI=0.13,2.61).

Conclusions: Findings highlight potential differences in overall concussion education exposure and provide clinicians with information on groups who may benefit from targeted additional education.
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http://dx.doi.org/10.4085/211-20DOI Listing
November 2020

Validity of Urine NGALds Dipstick for Acute Kidney Injury in a Malawian Trauma Cohort.

Kidney Int Rep 2020 Oct 25;5(10):1791-1798. Epub 2020 Jul 25.

Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Public Health, Chapel Hill, North Carolina, USA.

Introduction: Acute kidney injury (AKI) is a major cause of mortality worldwide, particularly in low-resource settings with limited diagnostic testing. Neutrophil gelatinase-associated lipocalin (NGAL) has shown promise in predicting AKI. Nested within a larger, prospective cohort study evaluating AKI incidence in admitted trauma patients, our objective was to evaluate a novel dipstick, NGALds, for the prediction of AKI in Malawi, Africa.

Methods: Participants were >6 months of age. Spearman rank correlation coefficients () assessed NGAL categories (negative [≤50 ng/ml], low risk [51-149 ng/ml], moderate risk [150-299 ng/ml], and high risk [≥300 ng/ml]) for the urine NGALds dipstick and laboratory-based NGAL Test.

Results: We enrolled 285 participants (one-third children). Thirteen percent developed AKI. The dipstick captured 45 of 52 participants (86.5%) with moderate- or high-risk NGAL values on laboratory-based testing ( = 0.74). The dipstick had sensitivity of 44.4%, specificity of 73.5%, positive predictive value of 19.5%, and negative predictive value of 90.2% for predicting AKI. Acute kidney injury was associated with an increased risk of mortality (relative risk [RR] = 3.9, 95% confidence interval [CI] = 1.9-8.2), but mortality risk greatly increased among children who first had a positive (≥150 ng/ml) NGALds result (RR = 12.0, 95% CI = 1.8-78.4).

Conclusions: The NGALds dipstick performed similarly to the NGAL Test in this low-resource setting and may be a useful tool to rule out AKI. It may be even more important in predicting high mortality risk among children.
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http://dx.doi.org/10.1016/j.ekir.2020.07.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7569698PMC
October 2020

Potential injuries and costs averted by increased use of evidence-based behavioral road safety policies in North Carolina.

Traffic Inj Prev 2020 23;21(8):545-551. Epub 2020 Oct 23.

Department of Epidemiology and Injury Prevention Research Center, University of North Carolina at Chapel Hill, Carrboro, North Carolina.

Objective: The purpose of this study was to estimate the potential injuries and costs that could be averted by implementing evidence-based road safety policies and interventions not currently utilized in one U.S. state, North Carolina (NC). NC consistently has annual motor vehicle-related death rates above the national average.

Methods: We used the Centers for Disease Control and Prevention's Motor Vehicle Prioritizing Interventions and Cost Calculator for States (MV PICCS) tool as a foundation for examining the potential injuries and costs that could be averted from underutilized evidence-based policies, assuming a $1.5 million implementation budget and that income generated from policy-related fines and fees would help offset costs. We further examined costs by payer source.

Results: Model results indicated that seven interventions should be prioritized for implementation in NC: increased alcohol ignition interlock use, increased seat belt fines, in-person license renewal for ages 70 and older, license plate impoundment, seat belt enforcement campaigns, saturation patrols, and speed cameras. Increasing the seat belt fine had the potential to avert the greatest number of fatal ( = 70) and non-fatal ( = 6,597) injuries annually, along with being the most cost-effective of the recommended interventions. Collectively, the seven recommended evidence-based policies/interventions have the potential to avert 302 fatal injuries, 16,607 non-fatal injuries, and $839 million annually in NC with the greatest costs averted for insurers.

Conclusions: This study demonstrates the utility of the MV PICCS tool as a foundation for exploring state-specific impacts that could be realized through increased evidence-based road safety policy and intervention implementation. For NC, we found that increasing the seat belt fine would avert the most injuries, and had the greatest financial benefits for the state, and the lowest implementation costs. Incorporating fines and fees into policy implementation can create important financial feedbacks that allow for implementation of additional evidence-based and cost-effective policies/interventions. Given the recent uptick in U.S. motor vehicle-related deaths, analyses informed by the MV PICCS tool can help researchers and policy makers initiate discussions about successful state-specific strategies for reducing the burden of crashes.
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http://dx.doi.org/10.1080/15389588.2020.1824066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8126265PMC
April 2021

Oral contraceptive use and anterior cruciate ligament injury: comparison of active comparator new user cohort and case-control study designs.

Inj Epidemiol 2020 Oct 19;7(1):53. Epub 2020 Oct 19.

Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, McGavran Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA.

Background: This study further investigates a protective association between oral contraceptive (OC) use and anterior cruciate ligament (ACL) injury noted in prior case-control studies.

Methods: Active comparator new user cohort analysis of women aged 13-45 years in the United States from the IBM MarketScan Commercial Claims and Encounters database who newly-initiated low-dose OCs (exposed) or underwent intrauterine device (IUD) insertion (comparison group) from 2000 to 2014. Women were followed for ACL injury starting 90 days after OC initiation or IUD insertion until OC or IUD discontinuation or end of continuous enrollment. Adjusted hazard ratios (adjHR) and 95% confidence intervals (CI) were estimated controlling for age. Secondary analysis replicated previously-published case-control studies assessing "ever" versus "never" OC use over 1- and 5-year periods among women who underwent ACL reconstruction compared to age-matched controls.

Results: In the cohort analysis, 2,370,286 women initiated OCs and 621,798 underwent IUD insertion. There were 3571 (0.15%) ACL injuries during an average 370.6 days of continuous OC use and 1620 (0.26%) during an average 590.5 days of IUD use. No difference in risk of ACL injury was observed between OC initiators and IUD users (adjHR = 0.95; 95%CI 0.89, 1.01). The case-control analysis replicated the slight protective association observed in prior studies over a 5-year period (OR = 0.90; 95%CI 0.85, 0.94).

Conclusions: This cohort study suggests no association between OC use and ACL injury, while the case-control study suggested bias from uncontrolled confounding and selection factors may have influenced previous findings that suggested a protective association between OC use and ACL injury.
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http://dx.doi.org/10.1186/s40621-020-00282-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7570098PMC
October 2020

Oral contraceptive use and anterior cruciate ligament injury: comparison of active comparator new user cohort and case-control study designs.

Inj Epidemiol 2020 Oct 19;7(1):53. Epub 2020 Oct 19.

Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, McGavran Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA.

Background: This study further investigates a protective association between oral contraceptive (OC) use and anterior cruciate ligament (ACL) injury noted in prior case-control studies.

Methods: Active comparator new user cohort analysis of women aged 13-45 years in the United States from the IBM MarketScan Commercial Claims and Encounters database who newly-initiated low-dose OCs (exposed) or underwent intrauterine device (IUD) insertion (comparison group) from 2000 to 2014. Women were followed for ACL injury starting 90 days after OC initiation or IUD insertion until OC or IUD discontinuation or end of continuous enrollment. Adjusted hazard ratios (adjHR) and 95% confidence intervals (CI) were estimated controlling for age. Secondary analysis replicated previously-published case-control studies assessing "ever" versus "never" OC use over 1- and 5-year periods among women who underwent ACL reconstruction compared to age-matched controls.

Results: In the cohort analysis, 2,370,286 women initiated OCs and 621,798 underwent IUD insertion. There were 3571 (0.15%) ACL injuries during an average 370.6 days of continuous OC use and 1620 (0.26%) during an average 590.5 days of IUD use. No difference in risk of ACL injury was observed between OC initiators and IUD users (adjHR = 0.95; 95%CI 0.89, 1.01). The case-control analysis replicated the slight protective association observed in prior studies over a 5-year period (OR = 0.90; 95%CI 0.85, 0.94).

Conclusions: This cohort study suggests no association between OC use and ACL injury, while the case-control study suggested bias from uncontrolled confounding and selection factors may have influenced previous findings that suggested a protective association between OC use and ACL injury.
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http://dx.doi.org/10.1186/s40621-020-00282-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7570098PMC
October 2020

Head Impact Telemetry System's Video-based Impact Detection and Location Accuracy.

Med Sci Sports Exerc 2020 10;52(10):2198-2206

Department of Exercise and Sport Science, Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC.

Purpose: This study aimed to quantify the Head Impact Telemetry (HIT) System's impact detection and location measurement accuracy using an impact biomechanics data set paired with video of high school football special teams plays.

Methods: The head impact biomechanics data set and video were collected from 22 high school football players, wearing HIT System instrumented helmets, competing in 218 special teams plays over a single high school football season. We used two separate video analysis approaches. To quantify the impact detection accuracy, we evaluated the video for head impacts independently of the impact data collection triggers collected by the HIT System. Video-observed impacts matched to valid and invalid head impacts by the HIT System algorithm were categorized as true positives, false positives, false negatives, and true negatives. To quantify impact location accuracy, we analyzed video-synchronized head impacts for impact location independent of the HIT System's impact location measurement and quantified the estimated percent agreement of impact location between the HIT System recorded impact location and the impact location observed on video.

Results: The HIT System's impact-filtering algorithm had 69% sensitivity, 72% specificity, and 70% accuracy in categorizing true and non-head impact data collection triggers. The HIT System agreed with video-observed impact locations on 64% of the 129 impacts we analyzed (unweighted k = 0.43, 95% confidence interval = 0.31-0.54).

Conclusion: This work provides data on the HIT System's impact detection and location accuracy during high school football special teams plays using game video analysis that has not been previously published. Based on our data, we believe that the HIT System is useful for estimating population-based impact location distributions for special teams plays.
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http://dx.doi.org/10.1249/MSS.0000000000002371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7503201PMC
October 2020

Trunk and Lower Extremity Movement Patterns, Stress Fracture Risk Factors, and Biomarkers of Bone Turnover in Military Trainees.

J Athl Train 2020 Jul;55(7):724-732

Department of Exercise and Sport Science, University of North Carolina at Chapel Hill.

Context: Military service members commonly sustain lower extremity stress fractures (SFx). How SFx risk factors influence bone metabolism is unknown. Understanding how SFx risk factors influence bone metabolism may help to optimize risk-mitigation strategies.

Objective: To determine how SFx risk factors influence bone metabolism.

Design: Cross-sectional study.

Setting: Military service academy.

Patients Or Other Participants: Forty-five men (agepre = 18.56 ± 1.39 years, heightpre = 176.95 ± 7.29 cm, masspre = 77.20 ± 9.40 kg; body mass indexpre = 24.68 ± 2.87) who completed Cadet Basic Training (CBT). Individuals with neurologic or metabolic disorders were excluded.

Intervention(s): We assessed SFx risk factors (independent variables) with (1) the Landing Error Scoring System (LESS), (2) self-reported injury and physical activity questionnaires, and (3) physical fitness tests. We assessed bone biomarkers (dependent variables; procollagen type I amino-terminal propeptide [PINP] and cross-linked collagen telopeptide [CTx-1]) via serum.

Main Outcome Measure(s): A markerless motion-capture system was used to analyze trunk and lower extremity biomechanics via the LESS. Serum samples were collected post-CBT; enzyme-linked immunosorbent assays determined PINP and CTx-1 concentrations, and PINP : CTx-1 ratios were calculated. Linear regression models demonstrated associations between SFx risk factors and PINP and CTx-1 concentrations and PINP : CTx-1 ratio. Biomarker concentration mean differences with 95% confidence intervals were calculated. Significance was set a priori using α ≤ .10 for simple and α ≤ .05 for multiple regression analyses.

Results: The multiple regression models incorporating LESS and SFx risk factor data predicted the PINP concentration (R2 = 0.47, P = .02) and PINP : CTx-1 ratio (R2 = 0.66, P = .01). The PINP concentration was increased by foot internal rotation, trunk flexion, CBT injury, sit-up score, and pre- to post-CBT mass changes. The CTx-1 concentration was increased by heel-to-toe landing and post-CBT mass. The PINP : CTx-1 ratio was increased by foot internal rotation, lower extremity sagittal-plane displacement (inversely), CBT injury, sit-up score, and pre- to post-CBT mass changes.

Conclusions: Stress fracture risk factors accounted for 66% of the PINP : CTx-1 ratio variability, a potential surrogate for bone health. Our findings provide insight into how SFx risk factors influence bone health. This information can help guide SFx risk-mitigation strategies.
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http://dx.doi.org/10.4085/1062-6050-134-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384468PMC
July 2020

Cancer and noncancer mortality among aluminum smelting workers in Badin, North Carolina.

Am J Ind Med 2020 09 10;63(9):755-765. Epub 2020 Jul 10.

Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Badin, North Carolina, hosted an aluminum smelting plant from 1917 to 2007. The Concerned Citizens of West Badin reported suspected excess cancer mortality among former employees. This study aimed to investigate these concerns.

Methods: The study cohort was enumerated from United Steel Workers' records of workers employed from 1980 to 2007. Cause-specific mortality rates in the cohort were compared with North Carolina population mortality rates using standardized mortality ratios (SMRs), standardized by age, sex, race, and calendar period. We estimated cause-specific adjusted standardized mortality ratios (aSMRs) using negative controls to mitigate healthy worker survivor bias (HWSB). Standardized rate ratios (SRRs) were calculated to compare mortality rates between workers ever employed vs never employed in the pot room.

Results: All-cause mortality among Badin workers was lower than in the general population (SMR: 0.81, 95% confidence interval [CI]: 0.71-0.92). After adjusting for HWSB, excesses for all cancers (aSMR: 1.55, 95% CI: 1.10-2.21), bladder cancer (3.47, 95% CI: 1.25-9.62), mesothelioma (17.33, 95% CI: 5.40-55.59), and respiratory cancer (1.24, 95% CI: 0.77-1.99) were observed. Black males worked the highest proportion of their employed years in the pot room. Potroom workers experienced higher respiratory cancer (SRR: 2.99, 95% CI: 1.23-7.26), bladder cancer (SRR: 1.58, 95% CI: 0.15-15.28), and mesothelioma (SRR: 3.36, 95% CI: 0.21-53.78) mortality rates than never workers in the pot room.

Conclusions: This study responds to concerns of a group of former aluminum workers. The results, while imprecise, suggest excess respiratory and bladder cancers among pot room workers in a contemporary cohort of union employees at a US smelter.
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http://dx.doi.org/10.1002/ajim.23150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7890681PMC
September 2020

Incidence and epidemiology of acute kidney injury in a pediatric Malawian trauma cohort: a prospective observational study.

BMC Nephrol 2020 03 14;21(1):98. Epub 2020 Mar 14.

Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Public Health, Chapel Hill, NC, USA.

Background: Acute kidney injury (AKI) is highly associated with mortality risk in children worldwide. Trauma can lead to AKI and is a leading cause of pediatric death in Africa. However, there is no information regarding the epidemiology of pediatric, trauma-associated AKI in Africa.

Methods: Prospective cohort study of pediatric trauma patients admitted to a tertiary referral hospital in Malawi. Participants enrolled at admission were followed prospectively throughout their hospitalization. AKI was defined by creatinine-only Kidney Disease Improving Global Outcomes criteria. We calculated descriptive statistics and univariate relative risks (RR) for hypothesis-generation of potential risk factors associated with AKI.

Results: We analyzed data from 114 participants. Depending on baseline creatinine definition, AKI incidence ranged from 4 to 10%. The new Schwartz equation estimated baseline creatinine values best and yielded an AKI incidence of 9.7%. Almost one in ten children died during hospitalization, but those with AKI (n = 4) were at significantly higher risk of death compared to those without AKI (40.0% vs 6.2%; RR 6.5, 95% CI 2.2-19.1). Burn injuries were most commonly associated with AKI (63.6%). Other potential AKI risk factors included multiple injuries, trunk or facial injuries, and recent consumption of herbal remedies.

Conclusions: AKI occurs in up to 10% of admitted pediatric trauma patients in Malawi and increases the risk of death 7-fold compared to those without AKI. This large unrecognized burden in trauma requires further investment by researchers, clinicians and policymakers to develop evidenced-based triage, recognition, and management approaches to prevent the associated sequelae and potential mortality from AKI.
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http://dx.doi.org/10.1186/s12882-020-01755-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071651PMC
March 2020

International Olympic Committee Consensus Statement: Methods for Recording and Reporting of Epidemiological Data on Injury and Illness in Sports 2020 (Including the STROBE Extension for Sports Injury and Illness Surveillance (STROBE-SIIS)).

Orthop J Sports Med 2020 Feb 18;8(2):2325967120902908. Epub 2020 Feb 18.

Background: Injury and illness surveillance, and epidemiological studies, are fundamental elements of concerted efforts to protect the health of the athlete. To encourage consistency in the definitions and methodology used, and to enable data across studies to be compared, research groups have published 11 sport- or setting-specific consensus statements on sports injury (and, eventually, illnesses) epidemiology to date.

Objective: To further strengthen consistency in data collection, injury definitions, and research reporting through an updated set of recommendations for sports injury and illness studies, including a new Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist extension.

Study Design: Consensus statement of the International Olympic Committee (IOC).

Methods: The IOC invited a working group of international experts to review relevant literature and provide recommendations. The procedure included an open online survey, several stages of text drafting and consultation by working groups, and a 3-day consensus meeting in October 2019.

Results: This statement includes recommendations for data collection and research reporting covering key components: defining and classifying health problems, severity of health problems, capturing and reporting athlete exposure, expressing risk, burden of health problems, study population characteristics, and data collection methods. Based on these, we also developed a new reporting guideline as a STROBE extension-the STROBE Sports Injury and Illness Surveillance (STROBE-SIIS).

Conclusion: The IOC encourages ongoing in- and out-of-competition surveillance programs and studies to describe injury and illness trends and patterns, understand their causes, and develop measures to protect the health of the athlete. The implementation of the methods outlined in this statement will advance consistency in data collection and research reporting.
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http://dx.doi.org/10.1177/2325967120902908DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7029549PMC
February 2020

International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS)).

Br J Sports Med 2020 Apr 18;54(7):372-389. Epub 2020 Feb 18.

Aspetar Sports Medicine and Orthopedic Hospital, Doha, Qatar.

Injury and illness surveillance, and epidemiological studies, are fundamental elements of concerted efforts to protect the health of the athlete. To encourage consistency in the definitions and methodology used, and to enable data across studies to be compared, research groups have published 11 sport-specific or setting-specific consensus statements on sports injury (and, eventually, illness) epidemiology to date. Our objective was to further strengthen consistency in data collection, injury definitions and research reporting through an updated set of recommendations for sports injury and illness studies, including a new Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist extension. The IOC invited a working group of international experts to review relevant literature and provide recommendations. The procedure included an open online survey, several stages of text drafting and consultation by working groups and a 3-day consensus meeting in October 2019. This statement includes recommendations for data collection and research reporting covering key components: defining and classifying health problems; severity of health problems; capturing and reporting athlete exposure; expressing risk; burden of health problems; study population characteristics and data collection methods. Based on these, we also developed a new reporting guideline as a STROBE Extension-the STROBE Sports Injury and Illness Surveillance (STROBE-SIIS). The IOC encourages ongoing in- and out-of-competition surveillance programmes and studies to describe injury and illness trends and patterns, understand their causes and develop measures to protect the health of the athlete. Implementation of the methods outlined in this statement will advance consistency in data collection and research reporting.
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http://dx.doi.org/10.1136/bjsports-2019-101969DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146946PMC
April 2020

Racial and health insurance disparities in pediatric acute kidney injury in the USA.

Pediatr Nephrol 2020 06 29;35(6):1085-1096. Epub 2020 Jan 29.

Department of Epidemiology, University of North Carolina Gillings School of Public Health, Chapel Hill, NC, USA.

Background: Acute kidney injury (AKI) significantly increases morbidity and mortality for hospitalized children, yet sociodemographic risk factors for pediatric AKI are poorly described. We examined sociodemographic differences in pediatric AKI amongst a national cohort of hospitalized children.

Methods: Secondary analysis of the most recent (2012) Kids' Inpatient Database (KID) from the Agency for Healthcare Research and Quality. Study sample weights were used to obtain national estimates of AKI (defined by administrative data). KID is a nationally representative sample of pediatric discharges throughout the USA. Linear risk regression models were used to assess the relationship between our primary exposures (race/ethnicity, health insurance, household urbanization, gender, and age) and the diagnosis of AKI, adjusting for comorbidities.

Results: A total of 1,699,841 hospitalizations met our study criteria. In 2012, AKI occurred in approximately 12.3/1000 pediatric hospitalizations, which translates to almost 30,000 children nationally. Asian/Pacific Islander, African-American, and Hispanic children were at slightly increased risk for AKI compared to Caucasian children (adjusted risk difference (RD) 4.5 per 1000 hospitalizations, 95% confidence interval (CI) 2.9-6.0; 2.5/1000 hospitalizations, 95% CI 1.7-3.3; and 1.7/1000 hospitalizations, 95% CI 0.9-2.5, respectively). Uninsured children were more likely to suffer AKI compared to children with any health insurance (e.g., no insurance versus Medicaid: adjusted RD 14.4/1000 hospitalizations, 95% CI 12.7-16.2). Based on these national estimates, one episode of AKI might be prevented if 70 (95% CI 62-79) hospitalized children without insurance were provided with Medicaid.

Conclusions: Pediatric AKI occurs more frequently in racial minority and uninsured children, factors linked to lower socioeconomic status.
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http://dx.doi.org/10.1007/s00467-020-04470-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188561PMC
June 2020

Perceived social norms and concussion-disclosure behaviours among first-year NCAA student-athletes: implications for concussion prevention and education.

Res Sports Med 2021 Jan-Feb;29(1):1-11. Epub 2020 Jan 25.

John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Hospital , West Point, NY, USA.

Timely disclosure and identification of concussion symptoms are essential to proper care. Perceived social norms are a potential driving factor in many health-related decisions. The study purpose was to describe concussion disclosure behaviours and identify the association between perceived social norms and these disclosure behaviours. First-year student-athletes (n = 391) at two NCAA institutions completed a cross-sectional survey about concussion disclosure and disclosure determinants. Log-binomial regression models identified factors associated with concussion disclosure behaviour prevalence for: higher intention to disclose symptoms, disclosed all at time of injury, eventually disclosed all, and never participated with concussion symptoms. More favourable perceived social norms were associated with higher prevalence of intention to disclose (PR = 1.34; 95%CI: 1.18, 1.53) and higher prevalence of never participating in sports with concussion symptoms (PR = 1.50; 95%CI: 1.07, 2.10). Clinicians, coaches, sports administrators, and healthcare practitioners should be mindful of the need to create supportive social environments to improve concussion symptom disclosure.
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http://dx.doi.org/10.1080/15438627.2020.1719493DOI Listing
March 2021

Patterns of Risk and Protective Factors Among Alaska Children: Association With Maternal and Child Well-Being.

Child Dev 2020 09 22;91(5):1650-1662. Epub 2020 Jan 22.

University of North Carolina at Chapel Hill.

This study used population-representative data to examine associations of risk and protective factor patterns among Alaska Native/American Indian (AN/AI; N = 592) and non-Native (N = 1,018) children with maternal and child outcomes at age 3 years. Among AN/AI children, a high risk/moderate protection class was associated with child developmental risk and mothers being less likely to feel comfortable asking for help or knowing where to go for parenting information compared to a low socioeconomic status/high protection class. Among non-Native children, a moderate risk/high protection class was associated with child developmental risk and mothers being less likely to feel comfortable asking for help compared to a low risk/high protection class. Results provide insight on the intersection of risk and protective factors among Alaska families.
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http://dx.doi.org/10.1111/cdev.13356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375914PMC
September 2020

Association between opioid analgesic therapy and initiation of buprenorphine management: An analysis of prescription drug monitoring program data.

PLoS One 2020 10;15(1):e0227350. Epub 2020 Jan 10.

Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.

Background: In the US, medication assisted treatment, particularly with office-based buprenorphine, has been an important component of opioid dependence treatment among patients with iatrogenic addiction to opioid analgesics. The predictors of initiating buprenorphine for addiction among opioid analgesic patients have not been well-described.

Methods: We conducted a time-to-event analysis using data from the North Carolina (NC) Prescription Drug Monitoring Program (PDMP). Our outcome of interest was time-to-initiation of sublingual buprenorphine. Our study population was a prospective cohort of all state residents receiving a full-agonist opioid analgesic between 2011 and 2015. Predictors of initiation of sublingual buprenorphine examined included: age, gender, cumulative pharmacies and prescribers utilized, cumulative opioid intensity (defined as cumulative opioid exposure divided by duration of opioid exposure), and benzodiazepine dispensing.

Findings: Of 4.3 million patients receiving opioid analgesics in NC between 2011 and 2015 (accumulated 8.30 million person-years of follow-up), and a total of 28,904 patients initiated buprenorphine formulations intended for addiction treatment (overall rate 3.48 per 1,000 person-years). In adjusted multivariate models, the utilization of 3 or more pharmacies (HR: 2.93; 95% CI: 2.82, 3.05) or 6 or more controlled substance prescribers (HR: 12.09; 95% CI: 10.76, 13.57) was associated with buprenorphine initiation. A dose-response relationship was observed for cumulative opioid intensity (HR in highest decile relative to lowest decile: 5.05; 95% CI: 4.70, 5.42). Benzodiazepine dispensing was negatively associated with buprenorphine initiation (HR: 0.63; 95% CI: 0.61, 0.65).

Conclusions: Opioid analgesic patients utilizing multiple prescribers or pharmacies are more likely to initiate sublingual buprenorphine. This finding suggests that patients with multiple healthcare interactions are more likely to be treated for high-risk opioid use, or may be more likely to be identified and treated for addiction. Future research should utilize prescription monitoring program data linked to electronic health records to include diagnosis information in analytic models.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0227350PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6953786PMC
April 2020

Connections Between Opioids and Road Injury: Linkage of Prescription Monitoring and Crash Databases.

Am J Prev Med 2020 03 19;58(3):461-466. Epub 2019 Dec 19.

Department of Civil and Environmental Engineering, University of Tennessee, Knoxville, Tennessee.

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http://dx.doi.org/10.1016/j.amepre.2019.10.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8126264PMC
March 2020

Integrating complex systems science into road safety research and practice, Part 2: applying systems tools to the problem of increasing pedestrian death rates.

Inj Prev 2020 10 17;26(5):424-431. Epub 2019 Dec 17.

Health Policy and Management Department, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.

Objectives: To provide a specific example of how systems dynamics tools can increase understanding of stakeholder 'mental models' and generate robust systems-based hypotheses about the escalating problem of rising pedestrian death rates in the USA.

Methods: We designed and facilitated two group model building (GMB) workshops. Participants generated causal loop diagrams (CLDs) individually and in small groups to explore hypotheses concerning time-dynamic interacting factors underlying the increasing rates of pedestrian deaths. Using a grounded theory approach, research team members synthesised the structures and hypotheses into a single CLD.

Results: CLDs from the 41 participants indicated four core factors hypothesised to have a direct impact on pedestrian fatalities: pedestrian-vehicle crashes, vehicle speed at the time of the crash, vehicle size/dimensions and emergency response time. Participants diagrammed how actions and reactions impacted these proximal factors over time and led to ripple effects throughout a larger system to generate an increase in pedestrian deaths. Hypothesised contributing mechanisms fell within the following broad categories: community responses; research, policy and industry influence; potential unintended consequences of responses to pedestrian deaths; and the role of sprawl.

Conclusions: This application of systems science tools suggested several strategies for advancing injury prevention research and practice. The project generated robust hypotheses and advanced stakeholder communication and depth of understanding and engagement in this key issue. The CLD and GMB process detailed in this study provides a concrete example of how systems tools can be adopted and applied to a transportation safety topic.
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http://dx.doi.org/10.1136/injuryprev-2019-043316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8126266PMC
October 2020

Influence of Concussion Education Exposure on Concussion-Related Educational Targets and Self-Reported Concussion Disclosure among First-Year Service Academy Cadets.

Mil Med 2020 03;185(3-4):e403-e409

John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Hospital, United States Military Academy, 990 Washington Road, West Point, NY, 10996.

Introduction: Concussion disclosure is often essential for military personnel to receive appropriate care following concussive injury. Concussion-related education and training may play a role in improving disclosure and recognition among peers, allowing for more timely concussion identification and treatment. The objectives of this study were to: (1) describe concussion education exposure among first-year service academy cadets and (2) examine the association between exposure to concussion education sources (multiple vs. only one) and concussion-related knowledge, attitudes, perceived social norms, intention to disclose symptoms, and disclosure behaviors.

Materials And Methods: First-year service academy cadets completed a cross-sectional survey to assess perceptions of concussion disclosure during preseason concussion baseline testing sessions. Associations between key cadet characteristics and exposure to multiple concussion education sources were examined using odds ratios and 95% confidence intervals. Linear regression was used to model the continuous measures of concussion-related knowledge, attitudes, and perceived social norms. Log-binomial regression was used to model the categorical outcomes of high perceived control over concussion disclosure (higher vs. lower), intention to disclose (higher vs. lower), and disclosure of all possible concussive events at the time of injury (yes vs. no). The primary predictor for all models was exposure to multiple sources of concussion education (video, coach, medical professional, or other) vs. exposure to only one educational source. All models were adjusted for gender, high school contact sport participation, and previous concussion history.

Results: Of the 972 first-year cadets (85% response; age = 18.4 ± 0.9 years; 21.7% female, 29.0% NCAA student-athlete), 695 (71.5%) reported receiving some type of previous concussion education and 229 (23.6%) reported a previous concussion history (206/229 reported the actual number they experienced). Of those reporting previous concussion-related education (n = 695), 542 (78.0%) watched a video, 514 (74.0%) talked with a coach about concussion, 433 (62.3%) talked with a medical professional, and 61 (8.8%) reported other sources of education ranging from anatomy teachers to brochures. Overall, 527 (75.8%) reported receiving more than one source of concussion education. Having played a contact sport in high school and having a history of concussion were associated with having multiple concussion education exposures. Being female was associated with lower odds of multiple exposures. Exposure to multiple sources of concussion education was not associated with knowledge, attitudes, perceived norms, or higher intention to disclose concussion symptoms. However, among those with a concussion history, exposure to multiple sources of concussion education was associated with a nearly 40% higher prevalence of disclosing all concussions at the time of injury compared to only one source of educational exposure (67.1% vs. 48.3%; prevalence ratio = 1.4; 95% confidence interval: 0.9, 2.1). Thus, although multiple sources of education may not influence intermediate variables of knowledge, attitudes, perceived norms and intentions, exposure to multiple sources of concussion education may influence actual decision-making around concussion disclosure among first-year service academy cadets.

Conclusion: These data suggest disparities in concussion education exposure that can be addressed in first-year cadets. Additionally, findings support the importance and use of multiple sources of concussion education in improving cadet's concussion-related decision-making.
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http://dx.doi.org/10.1093/milmed/usz414DOI Listing
March 2020

Methodology and Implementation of a Randomized Controlled Trial (RCT) for Early Post-concussion Rehabilitation: The Active Rehab Study.

Front Neurol 2019 8;10:1176. Epub 2019 Nov 8.

Department of Neurosurgery, Center for Neurotrauma Research, Medical College of Wisconsin, Milwaukee, WI, United States.

Sports-related concussion (SRC) is a complex injury with heterogeneous presentation and management. There are few studies that provide guidance on the most effective and feasible strategies for recovery and return to sports participation. Furthermore, there have been no randomized studies of the feasibility, safety, and efficacy of early rehabilitation strategies across multiple sports and age groups. This international cluster-randomized pragmatic trial evaluates the effectiveness of early multi-dimensional rehabilitation integrated with the current return to sport strategy vs. the current return to sport strategy alone. The study is a cluster-randomized pragmatic trial enrolling male and female athletes from 28 sites. The sites span three countries, and include multiple sports, levels of play (high school, college, and professional), and levels of contact. The two study arms are Enhanced Graded Exertion (EGE) and Multidimensional Rehabilitation (MDR). The EGE arm follows the current return to sport strategy and the MDR arm integrates early, MDR strategies in the context of the current return to sport strategy. Each arm employs a post-injury protocol that applies to all athletes from that site in the event they sustain a concussion during their study enrollment. Participants are enrolled at pre-season baseline. Assessment timepoints include pre-season baseline, time of injury (concussion), 24-48 h post-injury, asymptomatic, and 1-month post-injury. Symptoms and activity levels are tracked post injury through the return to play process and beyond. Injury and recovery characteristics are obtained for all participants. Primary endpoints include time to medical clearance for full return to sport and time to become asymptomatic. Secondary endpoints include symptom, neurocognitive, mental status, balance, convergence insufficiency, psychological distress, and quality of life trajectories post-injury. Outputs from the trial are expected to inform both research and clinical practice in post-concussion rehabilitation across all levels of sport and extend beyond civilian medicine to care for military personnel. The study is approved by the data coordinating center Institutional Review Board and registered at clinicaltrials.gov. Dissemination will include peer-reviewed publications, presentation to patients and public groups, as well as dissemination in other healthcare and public venues of interest. www.ClinicalTrials.gov, identifier: NCT02988596 National Football League.
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http://dx.doi.org/10.3389/fneur.2019.01176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6856221PMC
November 2019
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