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Jain D, Graci V, Beam ME, Master CL, Prosser LA, McDonald CC, Arbogast KB. Impaired Neuromotor Control During Gait in Concussed Adolescents-A Frequency Analysis. J Appl Biomech 2024; 40:138-146. [PMID: 38154023 DOI: 10.1123/jab.2023-0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/27/2023] [Accepted: 11/06/2023] [Indexed: 12/30/2023]
Abstract
Disruptions in gait function are common after concussion in adolescents; however, the neuromotor control deficits driving these gait disruptions are not well known. Fifteen concussed (age mean [SD]): 17.4 [0.6], 13 females, days since injury: 26.3 [9.9]) and 17 uninjured (age: 18.0 [0.7], 10 females) adolescents completed 3 trials each of single-task gait and dual-task gait (DT). During DT, participants simultaneously walked while completing a serial subtraction task. Gait metrics and variability in instantaneous mean frequency in lower extremity muscles were captured by inertial sensors and surface electromyography, respectively. A 2-way analysis of covariance was used to compare gait metrics across groups and conditions. Functional principal components analysis was used to identify regions of variability in instantaneous mean frequency curves. Functional principal component scores were compared across groups using a Welch statistic. Both groups displayed worse performance on gait metrics during DT condition compared to single-task, with no differences between groups (P < .001). Concussed adolescents displayed significantly greater instantaneous mean frequency, indicated by functional principal component 1, in the tibialis anterior, biceps femoris, and semitendinosus (P < .05) during single-task and DT compared with uninjured adolescents. Our observations suggest that concussed adolescents display inefficient motor unit recruitment lasting longer than 2 weeks following injury, regardless of the addition of a secondary task.
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Affiliation(s)
- Divya Jain
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Valentina Graci
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA, USA
| | - Megan E Beam
- Department of Physical Therapy, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christina L Master
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Laura A Prosser
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Rehabilitation Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Catherine C McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristy B Arbogast
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Corwin DJ, Mandel F, McDonald CC, Barnett I, Arbogast KB, Master CL. Optimizing the Combination of Common Clinical Concussion Batteries to Predict Persistent Postconcussion Symptoms in a Prospective Cohort of Concussed Youth. Am J Sports Med 2024; 52:811-821. [PMID: 38305042 PMCID: PMC11033620 DOI: 10.1177/03635465231222936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
BACKGROUND Studies have evaluated individual factors associated with persistent postconcussion symptoms (PPCS) in youth concussion, but no study has combined individual elements of common concussion batteries with patient characteristics, comorbidities, and visio-vestibular deficits in assessing an optimal model to predict PPCS. PURPOSE To determine the combination of elements from 4 commonly used clinical concussion batteries and known patient characteristics and comorbid risk factors that maximize the ability to predict PPCS. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS We enrolled 198 concussed participants-87 developed PPCS and 111 did not-aged 8 to 19 years assessed within 14 days of injury from a suburban high school and the concussion program of a tertiary care academic medical center. We defined PPCS as a Post-Concussion Symptom Inventory (PCSI) score at 28 days from injury of ≥3 points compared with the preinjury PCSI score-scaled for younger children. Predictors included the individual elements of the visio-vestibular examination (VVE), Sport Concussion Assessment Tool, 5th Edition (SCAT-5), King-Devick test, and PCSI, in addition to age, sex, concussion history, and migraine headache history. The individual elements of these tests were grouped into interpretable factors using sparse principal component analysis. The 12 resultant factors were combined into a logistic regression and ranked by frequency of inclusion into the combined optimal model, whose predictive performance was compared with the VVE, initial PCSI, and the current existing predictive model (the Predicting and Prevention Postconcussive Problems in Pediatrics (5P) prediction rule) using the area under the receiver operating characteristic curve (AUC). RESULTS A cluster of 2 factors (SCAT-5/PCSI symptoms and VVE near point of convergence/accommodation) emerged. A model fit with these factors had an AUC of 0.805 (95% CI, 0.661-0.929). This was a higher AUC point estimate, with overlapping 95% CIs, compared with the PCSI (AUC, 0.773 [95% CI, 0.617-0.912]), VVE (AUC, 0.736 [95% CI, 0.569-0.878]), and 5P Prediction Rule (AUC, 0.728 [95% CI, 0.554-0.870]). CONCLUSION Among commonly used clinical assessments for youth concussion, a combination of symptom burden and the vision component of the VVE has the potential to augment predictive power for PPCS over either current risk models or individual batteries.
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Affiliation(s)
- Daniel J. Corwin
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Francesca Mandel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Catherine C. McDonald
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ian Barnett
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kristy B. Arbogast
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christina L. Master
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Sports Medicine and Performance Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Sartin EB, Webb MS, Labows CG, Myers RK, Yerys BE, McDonald CC, Curry AE. Caregivers' Perspectives on Use of and Need for Driving Resources for Their Autistic Adolescent. Autism Adulthood 2024; 6:86-94. [PMID: 38435323 PMCID: PMC10902266 DOI: 10.1089/aut.2022.0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Introduction Autistic individuals who independently travel-or commute without companionship or supervision-report feeling more connected to social, education, and employment opportunities. Despite the potential for independent transportation to improve quality of life, little is known about what transportation-related resources, specifically driving focused ones, exist for autistic individuals or how they and their families find and use them. The objectives of this study were to characterize: (1) where and how families in the United States find driving-related resources for their autistic adolescents; (2) families' perceived availability and utility of identified resources; and (3) resources families believe should be developed. Methods We conducted semi-structured interviews with 33 caregivers of autistic adolescents aged 16-24 years without an intellectual disability. We used a directed-content approach to develop and implement codes; three trained coders analyzed all transcripts (inter-rater reliability ≥0.8 for all codes). Members of the research team reviewed coded data and created code summaries, which were then developed and discussed by the larger research team to determine final consensus. Results Caregivers described a few existing resources that were helpful in guiding driving-related decisions. In addition, caregivers voiced that there were limited resources tailored to the unique needs that arise while teaching or learning how to drive, particularly ones that support their own and their adolescent's mental health. The limited resources and services identified as helpful-specifically support groups/perspectives of other families and specialized driving instructors-are seemingly difficult to find, costly, and/or perceived as having geographic- and time-related barriers. Conclusion There is a critical need and opportunity for stakeholders of the autism community to both expand access to existing and develop novel driving-related resources for families with autistic adolescents, with a particular focus of supporting caregiver and adolescent mental health.
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Affiliation(s)
- Emma B. Sartin
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Margaret S. Webb
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christina G. Labows
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rachel K. Myers
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Benjamin E. Yerys
- Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Catherine C. McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Allison E. Curry
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Corwin DJ, Metzger KB, McDonald CC, Pfeiffer MR, Arbogast KB, Master CL. The Variability of Recovery From Pediatric Concussion Using Multimodal Clinical Definitions. Sports Health 2024; 16:79-88. [PMID: 36896665 PMCID: PMC10732108 DOI: 10.1177/19417381231152448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND While concussions are common pediatric injuries, a lack of agreement on a standard definition of recovery creates multiple challenges for clinicians and researchers alike. HYPOTHESIS The percentage of concussed youth deemed recovered as part of a prospective cohort study will differ depending on the recovery definition. STUDY DESIGN Descriptive epidemiologic study of a prospectively enrolled observational cohort. LEVEL OF EVIDENCE Level 3. METHODS Participants aged 11 to 18 years were enrolled from the concussion program of a tertiary care academic center. Data were collected from initial and follow-up clinical visits ≤12 weeks from injury. A total of 10 recovery definitions were assessed: (1) cleared to full return to sports; (2) return to full school; (3) self-reported return to normal; (4) self-reported full return to school; (5) self-reported full return to exercise; (6) symptom return to preinjury state; (7) complete symptom resolution; (8) symptoms below standardized threshold; (9) no abnormal visio-vestibular examination (VVE) elements; and (10) ≤1 abnormal VVE assessments. RESULTS In total, 174 participants were enrolled. By week 4, 63.8% met at least 1 recovery definition versus 78.2% by week 8 versus 88.5% by week 12. For individual measures of recovery at week 4, percent recovered ranged from 5% by self-reported full return to exercise to 45% for ≤1 VVE abnormality (similar trends at 8 and 12 weeks). CONCLUSION There is wide variability in the proportion of youth considered recovered at various points following concussion depending on the definition of recovery, with higher proportions using physiologic examination-based measures and lower proportions using patient-reported measures. CLINICAL RELEVANCE These results further emphasize the need for a multimodal assessment of recovery by clinicians as a single and standardized definition of recovery that captures the broad impact of concussion on a given patient continues to be elusive.
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Affiliation(s)
- Daniel J. Corwin
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kristina B. Metzger
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Catherine C. McDonald
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa R. Pfeiffer
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kristy B. Arbogast
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christina L. Master
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Sports Medicine and Performance Center, and The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Corwin DJ, Mandel F, McDonald CC, Mohammed FN, Margulies S, Barnett I, Arbogast KB, Master CL. Maximizing the Accuracy of Adolescent Concussion Diagnosis Using Individual Elements of Common Standardized Clinical Assessment Tools. J Athl Train 2023; 58:962-973. [PMID: 36645832 PMCID: PMC10784885 DOI: 10.4085/1062-6050-0020.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
CONTEXT Multiple clinical evaluation tools exist for adolescent concussion with various degrees of correlation, presenting challenges for clinicians in identifying which elements of these tools provide the greatest diagnostic utility. OBJECTIVE To determine the combination of elements from 4 commonly used clinical concussion batteries that maximize discrimination of adolescents with concussion from those without concussion. DESIGN Cross-sectional study. SETTING Suburban school and concussion program of a tertiary care academic center. PATIENTS OR OTHER PARTICIPANTS A total of 231 participants with concussion (from a suburban school and a concussion program) and 166 participants without concussion (from a suburban school) between the ages of 13 and 19 years. MAIN OUTCOME MEASURE(S) Individual elements of the visio-vestibular examination (VVE), Sport Concussion Assessment Tool, fifth edition (SCAT5; including the modified Balance Error Scoring System), King-Devick test (K-D), and Postconcussion Symptom Inventory (PCSI) were evaluated. The 24 subcomponents of these tests were grouped into interpretable factors using sparse principal component analysis. The 13 resultant factors were combined with demographic and clinical covariates into a logistic regression model and ranked by frequency of inclusion into the ideal model, and the predictive performance of the ideal model was compared with each of the clinical batteries using the area under the receiver operating characteristic curve (AUC). RESULTS A cluster of 4 factors (factor 1 [VVE saccades and vestibulo-ocular reflex], factor 2 [modified Balance Error Scoring System double-legged stance], factor 3 [SCAT5/PCSI symptom scores], and factor 4 [K-D completion time]) emerged. A model fit with the top factors performed as well as each battery in predicting concussion status (AUC = 0.816 [95% CI = 0.731, 0.889]) compared with the SCAT5 (AUC = 0.784 [95% CI = 0.692, 0.866]), PCSI (AUC = 0.776 [95% CI = 0.674, 0.863]), VVE (AUC = 0.711 [95% CI = 0.602, 0.814]), and K-D (AUC = 0.708 [95% CI = 0.590, 0.819]). CONCLUSIONS A multifaceted assessment for adolescents with concussion, comprising symptoms, attention, balance, and the visio-vestibular system, is critical. Current diagnostic batteries likely measure overlapping domains, and the sparse principal component analysis demonstrated strategies for streamlining comprehensive concussion assessment across a variety of settings.
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Affiliation(s)
- Daniel J. Corwin
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, PA
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, PA
| | - Francesca Mandel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Catherine C. McDonald
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, PA
- School of Nursing, University of Pennsylvania, Philadelphia
| | - Fairuz N. Mohammed
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, PA
| | - Susan Margulies
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta
| | - Ian Barnett
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Kristy B. Arbogast
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, PA
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, PA
| | - Christina L. Master
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, PA
- Sports Medicine and Performance Center, Children’s Hospital of Philadelphia, PA
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Hafetz J, McDonald CC, Long DL, Ford CA, Mdluli T, Weiss A, Felkins J, Wilson N, MacDonald B. Promoting transportation safety in adolescence: the drivingly randomized controlled trial. BMC Public Health 2023; 23:2020. [PMID: 37848929 PMCID: PMC10580546 DOI: 10.1186/s12889-023-16801-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 09/20/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND The impact of young drivers' motor vehicle crashes (MVC) is substantial, with young drivers constituting only 14% of the US population, but contributing to 30% of all fatal and nonfatal injuries due to MVCs and 35% ($25 billion) of the all medical and lost productivity costs. The current best-practice policy approach, Graduated Driver Licensing (GDL) programs, are effective primarily by delaying licensure and restricting crash opportunity. There is a critical need for interventions that target families to complement GDL. Consequently, we will determine if a comprehensive parent-teen intervention, the Drivingly Program, reduces teens' risk for a police-reported MVC in the first 12 months of licensure. Drivingly is based on strong preliminary data and targets multiple risk and protective factors by delivering intervention content to teens, and their parents, at the learner and early independent licensing phases. METHODS Eligible participants are aged 16-17.33 years of age, have a learner's permit in Pennsylvania, have practiced no more than 10 h, and have at least one parent/caregiver supervising. Participants are recruited from the general community and through the Children's Hospital of Philadelphia's Recruitment Enhancement Core. Teen-parent dyads are randomized 1:1 to Drivingly or usual practice control group. Drivingly participants receive access to an online curriculum which has 16 lessons for parents and 13 for teens and an online logbook; website usage is tracked. Parents receive two, brief, psychoeducational sessions with a trained health coach and teens receive an on-road driving intervention and feedback session after 4.5 months in the study and access to DriverZed, the AAA Foundation's online hazard training program. Teens complete surveys at baseline, 3 months post-baseline, at licensure, 3months post-licensure, 6 months post-licensure, and 12 months post-licensure. Parents complete surveys at baseline, 3 months post-baseline, and at teen licensure. The primary end-point is police-reported MVCs within the first 12 months of licensure; crash data are provided by the Pennsylvania Department of Transportation. DISCUSSION Most evaluations of teen driver safety programs have significant methodological limitations including lack of random assignment, insufficient statistical power, and reliance on self-reported MVCs instead of police reports. Results will identify pragmatic and sustainable solutions for MVC prevention in adolescence. TRIAL REGISTRATION ClinicalTrials.gov # NCT03639753.
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Affiliation(s)
- Jessica Hafetz
- Department of Clinical and Health Psychology, Centre for Applied Developmental Psychology, The University of Edinburgh, Edinburgh, UK.
| | - Catherine C McDonald
- Penn Injury Science Center, University of Pennsylvania School of Nursing, Philadelphia, USA
| | - D Leann Long
- School of Public Health, Department of Biostatistics, University of Alabama at Birmingham, Birmingham, USA
| | - Carol A Ford
- The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, USA
| | - Thandwa Mdluli
- University of Pennsylvania School of Nursing, Philadelphia, USA
| | - Andrew Weiss
- University of Pennsylvania School of Nursing, Philadelphia, USA
| | - Jackson Felkins
- University of Pennsylvania School of Nursing, Philadelphia, USA
| | - Nicole Wilson
- School of Public Health, Department of Biostatistics, University of Alabama at Birmingham, Birmingham, USA
| | - Bradley MacDonald
- The University of Edinburgh, Department of Clinical and Health Psychology, Edinburgh, UK
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Jain D, Graci V, Beam ME, Ayaz H, Prosser LA, Master CL, McDonald CC, Arbogast KB. Neurophysiological and gait outcomes during a dual-task gait assessment in concussed adolescents. Clin Biomech (Bristol, Avon) 2023; 109:106090. [PMID: 37696165 PMCID: PMC10758982 DOI: 10.1016/j.clinbiomech.2023.106090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Gait deficits are common after concussion in adolescents. However, the neurophysiological underpinnings of these gait deficiencies are currently unknown. Thus, the goal of this study was to compare spatiotemporal gait metrics, prefrontal cortical activation, and neural efficiency between concussed adolescents several weeks from injury and uninjured adolescents during a dual-task gait assessment. METHODS Fifteen concussed (mean age[SD]: 17.4[0.6], 13 female, days since injury: 26.3[9.9]) and 17 uninjured adolescents (18.0[0.7], 10 female) completed a gait assessment with three conditions repeated thrice: single-task walking, single-task subtraction, and dual-task, which involved walking while completing a subtraction task simultaneously. Gait metrics were measured using an inertial sensor system. Prefrontal cortical activation was captured via functional near-infrared spectroscopy. Neural efficiency was calculated by relating gait metrics to prefrontal cortical activity. Differences between groups and conditions were examined, with corrections for multiple comparisons. FINDINGS There were no significant differences in gait metrics between groups. Compared to uninjured adolescents, concussed adolescents displayed significantly greater prefrontal cortical activation during the single-task subtraction (P = 0.01) and dual-task (P = 0.01) conditions with lower neural efficiency based on cadence (P = 0.02), gait cycle duration (P = 0.03), step duration (P = 0.03), and gait speed (P = 0.04) during the dual-task condition. INTERPRETATION Our findings suggest that several weeks after injury concussed adolescents demonstrate lower neural efficiency and display a cost to gait performance when cognitive demand is high, e.g., while multitasking, suggesting that the concussed adolescent brain is less able to compensate when attention is divided between two concurrent tasks.
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Affiliation(s)
- Divya Jain
- Department of Bioengineering, University of Pennsylvania, USA; Center for Injury Research and Prevention, Children's Hospital of Philadelphia, USA.
| | - Valentina Graci
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, USA; School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA, USA
| | - Megan E Beam
- Department of Physical Therapy, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hasan Ayaz
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, USA; School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA, USA; Department of Psychological and Brain Sciences, College of Arts and Sciences, Drexel University, Philadelphia, PA, USA; Drexel Solutions Institute, Drexel University, Philadelphia, PA, USA; School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Laura A Prosser
- Division of Rehabilitation Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christina L Master
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Catherine C McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, USA; School of Nursing, University of Pennsylvania, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristy B Arbogast
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Jain D, Huber CM, Patton DA, McDonald CC, Wang L, Ayaz H, Master CL, Arbogast KB. Use of functional near-infrared spectroscopy to quantify neurophysiological deficits after repetitive head impacts in adolescent athletes. Sports Biomech 2023:1-15. [PMID: 37430440 PMCID: PMC10776807 DOI: 10.1080/14763141.2023.2229790] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/21/2023] [Indexed: 07/12/2023]
Abstract
There is concern that repetitive head impact exposure (RHIE) may lead to neurophysiological deficits in adolescents. Twelve high school varsity soccer players (5 female) completed the King-Devick (K-D) and complex tandem gait (CTG) assessments pre- and post-season while wearing a functional near-infrared spectroscopy (fNIRS) sensor. The average head impact load (AHIL) for each athlete-season was determined via a standardised protocol of video-verification of headband-based head impact sensor data. Linear mixed effect models were used to determine the effects of AHIL and task condition (3 K-D cards or 4 CTG conditions) on the change in mean prefrontal cortical activation measured by fNIRS, and performance on K-D and CTG, from pre- to post-season. Although there was no difference in the pre- to post-season change in K-D or CTG performance, greater AHIL was associated with greater cortical activation at post-season in comparison to pre-season during the most challenging conditions of K-D (p = 0.003) and CTG (p = 0.02), suggesting that greater RHIE necessitates increased cortical activation to complete the more challenging aspects of these assessments at the same level of performance. These results describe the effect of RHIE on neurofunction and suggest the need for further study of the time course of these effects.
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Affiliation(s)
- Divya Jain
- Department of Bioengineering, University of Pennsylvania, PA, USA
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Colin M. Huber
- Department of Bioengineering, University of Pennsylvania, PA, USA
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Declan A. Patton
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Catherine C. McDonald
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lei Wang
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
- Data Science and Biostatistics Unit, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hasan Ayaz
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Data Science and Biostatistics Unit, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA, USA
- Department of Psychology, College of Arts and Sciences, Drexel University, Philadelphia, PA
| | - Christina L. Master
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Drexel Solutions Institute, Drexel University, Philadelphia, PA
| | - Kristy B. Arbogast
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Arbogast KB, McDonald CC. Sport Safety for Adolescents: Linking Biomechanics of Repetitive Head Impacts With Health and Wellbeing. J Adolesc Health 2023; 72:485-486. [PMID: 36933942 DOI: 10.1016/j.jadohealth.2022.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 03/20/2023]
Affiliation(s)
- Kristy B Arbogast
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Pittsburgh, Pennsylvania; Minds Matter Concussion Program, Children's Hospital of Philadelphia, Pittsburgh, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Pittsburgh, Pennsylvania
| | - Catherine C McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Pittsburgh, Pennsylvania; Minds Matter Concussion Program, Children's Hospital of Philadelphia, Pittsburgh, Pennsylvania; School of Nursing, University of Pennsylvania, Pittsburgh, Pennsylvania; Penn Injury Science Center, University of Pennsylvania, Pittsburgh, Pennsylvania
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10
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Fish AM, Vanni J, Mohammed FN, Fedonni D, Metzger KB, Shoop J, Master CL, Arbogast KB, McDonald CC. Comparison of Anxiety and Depression Symptoms in Concussed and Nonconcussed Adolescents. Sports Health 2023; 15:185-191. [PMID: 35919017 PMCID: PMC9950990 DOI: 10.1177/19417381221113840] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Few studies have examined psychiatric symptoms during the acute phase following a concussion in adolescents. Thus, this study compares anxiety and depression in acutely concussed and nonconcussed adolescents. HYPOTHESIS Acutely concussed adolescents will report greater anxiety and depressive symptoms compared with nonconcussed adolescents. STUDY DESIGN Prospective cohort study. LEVEL OF EVIDENCE Level 3. METHODS Data were collected from 282 adolescents (111 concussed within 28 days of injury, 171 nonconcussed), 13 to 18 years of age, who completed Patient-Reported Outcome Measurement Information System (PROMIS) Anxiety and Depressive Symptoms measures. We calculated average T-scores for anxiety and depression across both groups and compared the proportion of those who scored above normal limits. Finally, we calculated risk ratios for anxiety and depression scores above normal limits. RESULTS Average T-scores for anxiety did not differ in concussed versus nonconcussed adolescents (mean: 45.9 [SD 10.84] vs 45.2 [8.1], respectively, P = 0.54), whereas average T-scores for depression were significantly higher in concussed versus nonconcussed adolescents (46.0 [10.88] vs 42.8 [8.48], respectively, P < 0.01). The proportion of concussed adolescents above normal limits for depression was greater than nonconcussed adolescents (32.4% vs 20.5%, respectively, P = 0.02). Post hoc sensitivity analyses excluding those with a history of anxiety or depression demonstrated a 1.45 (95% CI, 0.97, 2.01) and 1.56 (95% CI, 0.95, 2.56) increased risk of an above-normal anxiety and depression score for concussed compared with nonconcussed adolescents, respectively, although both were nonsignificant. CONCLUSION Although we found few significant differences between the 2 groups, the results highlight that many concussed adolescents met the threshold for above-average symptoms on the depression and anxiety PROMIS measures. CLINICAL RELEVANCE In adolescents, there is increased risk for psychiatric sequalae in the acute period after a concussion. As such, we suggest that clinicians consider incorporating depression screening when caring for adolescents after a concussion.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Catherine C. McDonald
- Catherine C. McDonald, PhD,
RN, FAAN, University of Pennsylvania, School of Nursing, Claire Fagin Hall, Rm
414, 418 Curie Boulevard, Philadelphia, PA 19104 (
) (Twitter: @KateMcD_PhDRN)
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11
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Mohammed FN, Master CL, Arbogast KB, McDonald CC, Sharma S, Kang B, Corwin DJ. Disparities in Adherence to Concussion Clinical Care Recommendations in a Pediatric Population. J Head Trauma Rehabil 2023; 38:147-155. [PMID: 36731016 PMCID: PMC9998329 DOI: 10.1097/htr.0000000000000823] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To characterize the relationship of sociodemographic factors to adherence to provider recommendations for pediatric concussion. SETTING Primary care (PC) practices within the Children's Hospital of Philadelphia network. PARTICIPANTS Patients aged 5 to 18 years old who presented to any PC site for concussion from September 26, 2019, to December 31, 2019. DESIGN Retrospective medical record review. MAIN MEASURES The primary outcome was adherence to follow-up recommendations as defined by (1) continued follow-up until provider clearance to return to full activity; (2) no more than 2 no-show visits; and (3) for those referred to specialty care (SC), attending at least 1 visit. We compared adherence by race/ethnicity, insurance, age, sex, injury mechanism, and repeat head injury using bivariate and multivariate analyses. A secondary outcome of referral to SC was compared by sociodemographic factors. RESULTS A total of 755 patients were included. Overall, 80.5% of the patients met adherence criteria. Following adjustment, non-Hispanic Black patients and publicly insured/self-pay patients were less likely to adhere to recommendations than non-Hispanic White patients (adjusted odds ratio [AOR] = 0.60; 95% CI, 0.37-1.00) and privately insured patients (AOR = 0.48; 95% CI, 0.30-0.75), respectively. When assessing differences in referral to SC, non-Hispanic Black patients and publicly insured/self-pay patients were more likely to receive a referral than their non-Hispanic White peers (OR = 1.56; 95% CI, 1.00-2.45) and privately insured patients (OR = 1.56; 95% CI, 1.05-2.32), respectively. CONCLUSION This study highlights disparities in adherence to concussion care recommendations, with non-Hispanic Black and publicly insured/self-pay patients less likely to adhere to follow-up recommendations than non-Hispanic White and privately insured patients, respectively. These disparities may impact recovery trajectories. Future studies should aim to identify specific individual- and system-level barriers preventing adherence to care in order to ultimately inform targeted interventions to achieve equity in care delivery and outcomes.
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Affiliation(s)
- Fairuz N Mohammed
- Center for Injury Research and Prevention (Mrs Mohammed, Drs Master, Arbogast, McDonald, and Corwin, and Mss Sharma and Kang), Sports Medicine and Performance Center (Dr Master), and Division of Emergency Medicine (Drs Arbogast and Corwin), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Perelman School of Medicine (Drs Master, Arbogast, McDonald, and Corwin) and School of Nursing (Dr McDonald), University of Pennsylvania, Philadelphia
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12
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Bader CE, Flynn DM, Buckenmaier CC, McDonald CC, Meghani SH, Glaser D, Polomano RC. Patterns of Change in Pain-related Physical, Mental, and Social Health Outcomes in a Military Population. Pain Manag Nurs 2023; 24:265-272. [PMID: 36746698 DOI: 10.1016/j.pmn.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 12/08/2022] [Accepted: 01/05/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Military persons frequently experience pain conditions stemming from noncombat and combat injuries. This study assessed the patterns of change over time and the associations of pain intensity and interference with physical, mental, and social health domains in a military sample. METHODS A secondary analysis of Pain Assessment Screening Tool and Outcomes Registry (PASTOR) was conducted using data collected over 10 months. Participants selected for analysis completed ≥3 assessments with an interval of ≥14 days between assessments. The Defense and Veterans Pain Rating Scale (DVPRS) measured average and worst pain intensity, and Patient-Reported Outcomes Measurement Information System (PROMIS®) T-scores measured pain and health outcomes. RESULTS The sample (N = 190) majority reported being active duty (96%); serving in the U.S. Army (93%); and being enlisted (86%). The percent difference from assessment one to assessment three showed improvement for DVPRS average pain (-4.85%) and worst pain (-2.16%), and PROMIS Pain Interference T-score (-1.98%). Improvements were observed for all PROMIS outcomes except depression. The Defense and Veterans Pain Rating Scale average and worst pain intensity and PROMIS pain interference were strongly correlated with physical function. Multilevel models showed that an increase in average and worst pain, and pain interference were associated with a decrease in satisfaction with social roles. CONCLUSION Analysis identified patterns of change over time in physical, mental, and social health outcomes, as well as associations important to understanding the complexities of pain. This work has implications for pain management nursing in ambulatory settings where ongoing collection and analyses of multivariable outcomes data can inform clinical care.
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Affiliation(s)
- Christine E Bader
- Special Assistant to the Dean, Graduate School of Nursing, Uniformed Services University of the Health Sciences.
| | - Diane M Flynn
- Department of Rehabilitative Medicine, Madigan Army Medical Center, Tacoma, Washington
| | - Chester C Buckenmaier
- Professor Emeritus, Department of Anesthesiology, Uniformed Services University of the Health Sciences
| | - Catherine C McDonald
- Associate Professor, University of Pennsylvania, School of Nursing, Perelman School of Medicine at the University of Pennsylvania, Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Salimah H Meghani
- Professor & Craig M. Wasserman Term Chair of Palliative Care, Department of Biobehavioral Health Sciences, Associate Director, NewCourtland Center for Transitions and Health, Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Dale Glaser
- Principal, Glaser Consulting, Lecturer and Adjunct Faculty at San Diego State University/University of San Diego/University of California San Diego
| | - Rosemary C Polomano
- Associate Dean for Practice, Professor of Pain Practice, University of Pennsylvania, School of Nursing, Professor of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania
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13
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Roby PR, Metzger KB, McDonald CC, Corwin DJ, Huber CM, Patton DA, Margulies SS, Grady MF, Master CL, Arbogast KB. Pre- and post-season visio-vestibular function in healthy adolescent athletes. PHYSICIAN SPORTSMED 2022; 50:522-530. [PMID: 34521303 PMCID: PMC8934744 DOI: 10.1080/00913847.2021.1980744] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/10/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate pre - to post-season differences in individual subtests of the Visio-Vestibular Examination (VVE) in healthy middle and high school athletes. METHODS This prospective cohort study recruited participants from a private suburban United States secondary school. Participants completed a demographic questionnaire prior to the start of their season. A proxy for head impact exposure was estimated by incorporating previously published head impact frequencies by team and sport. The VVE was completed pre - and post-season and consisted of 9 subtests: smooth pursuit, horizontal/vertical saccades and gaze stability, binocular convergence, left/right monocular accommodation, and complex tandem gait. Generalized estimating equations were employed to assess the relative risk of an abnormal VVE outcome based on testing session (pre - vs. post-season). RESULTS Participants included middle and high school athletes (n = 115; female = 59 (51.3%); median age at first assessment = 14.9 years, [IQR = 13.6, 16.0]) during 2017/18 - 2019/20 school years. During pre-season testing, accommodation (10.0%) and complex tandem gait (9.2%) had the largest proportion of abnormal outcomes, while smooth pursuits (10.6%) and convergence (9.5%) had the largest proportion of abnormal outcomes post-season. When assessing the effect of testing session on the relative risk of any abnormal VVE subtest, there were no significant findings (P ≥ 0.25). Additionally, there were no significant effects of testing session when adjusting for estimated head impact exposure for any VVE subtest (P ≥ 0.25). CONCLUSIONS Visio-vestibular function as measured by the VVE does not change from pre - to post-season in otherwise healthy adolescent athletes. Our findings suggest that the VVE may be stable and robust to typical neurodevelopment occurring in this dynamic age group and help inform post-injury interpretation of visio-vestibular impairments.
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Affiliation(s)
- Patricia R Roby
- Center for Injury Research and Prevention, the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kristina B Metzger
- Center for Injury Research and Prevention, the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Catherine C McDonald
- Center for Injury Research and Prevention, the Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel J Corwin
- Center for Injury Research and Prevention, the Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Colin M Huber
- Center for Injury Research and Prevention, the Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Declan A Patton
- Center for Injury Research and Prevention, the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan S Margulies
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Matthew F Grady
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Sports Medicine Performance Center, the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christina L Master
- Center for Injury Research and Prevention, the Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Sports Medicine Performance Center, the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kristy B Arbogast
- Center for Injury Research and Prevention, the Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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14
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Arbogast KB, Ghosh RP, Corwin DJ, McDonald CC, Mohammed FN, Margulies SS, Barnett I, Master CL. Trajectories of Visual and Vestibular Markers of Youth Concussion. J Neurotrauma 2022; 39:1382-1390. [PMID: 35785959 PMCID: PMC9529314 DOI: 10.1089/neu.2022.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Visual and vestibular deficits, as measured by a visio-vestibular examination (VVE), are markers of concussion in youth. Little is known about VVE evolution post-injury, nor influence of age or sex on trajectory. The objective was to describe the time trend of abnormal VVE elements after concussion. Two cohorts, 11-18 years, were enrolled: healthy adolescents (n = 171) from a high school with VVE assessment before or immediately after their sport seasons and concussed participants (n = 255) from a specialty care concussion program, with initial assessment ≤28 days from injury and VVE repeated throughout recovery during clinical visits. The primary outcome, compared between groups, is the time course of recovery of the VVE examination, defined as the probability of an abnormal VVE (≥2/9 abnormal elements) and modeled as a cubic polynomial of days after injury. We explored whether probability trajectories differed by: age (<14 years vs. 14+ years), sex, concussion history (0 versus 1+), and days from injury to last assessment (≤28 days vs. 29+ days). Overall, abnormal VVE probability peaked at 0.57 at day 8 post-injury, compared with an underlying prevalence of 0.083 for uninjured adolescents. Abnormal VVE probability peaked higher for those 14+ years, female, with a concussion history and whose recovery course was longer than 28 days post-injury, compared with their appropriate strata subgroups. Females and those <14 years demonstrated slower resolution of VVE abnormalities. VVE deficits are common in adolescents after concussion, and the trajectory of resolution varies by age, sex, and concussion history. These data provide insight to clinicians managing concussions on the timing of deficit resolution after injury.
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Affiliation(s)
- Kristy B. Arbogast
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Riddhi P. Ghosh
- Department of Mathematics and Statistics, Bowling Green State University, Bowling Green, Ohio, USA
| | - Daniel J. Corwin
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Catherine C. McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fairuz N. Mohammed
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susan S. Margulies
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Ian Barnett
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christina L. Master
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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15
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Jain D, Arbogast KB, McDonald CC, Podolak OE, Margulies SS, Metzger KB, Howell DR, Scheiman MM, Master CL. Eye Tracking Metrics Differences among Uninjured Adolescents and Those with Acute or Persistent Post-Concussion Symptoms. Optom Vis Sci 2022; 99:616-625. [PMID: 35848958 PMCID: PMC9361745 DOI: 10.1097/opx.0000000000001921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SIGNIFICANCE Eye tracking assessments that include pupil metrics can supplement current clinical assessments of vision and autonomic dysfunction in concussed adolescents. PURPOSE This study aimed to explore the utility of a 220-second eye tracking assessment in distinguishing eye position, saccadic movement, and pupillary dynamics among uninjured adolescents, those with acute post-concussion symptoms (≤28 days since concussion), or those with persistent post-concussion symptoms (>28 days since concussion). METHODS Two hundred fifty-six eye tracking metrics across a prospective observational cohort of 180 uninjured adolescents recruited from a private suburban high school and 224 concussed adolescents, with acute or persistent symptoms, recruited from a tertiary care subspecialty concussion care program, 13 to 17 years old, from August 2017 to June 2021 were compared. Kruskal-Wallis tests were used, and Bonferroni corrections were applied to account for multiple comparisons and constructed receiver operating characteristic curves. Principal components analysis and regression models were applied to determine whether eye tracking metrics can augment clinical and demographic information in differentiating uninjured controls from concussed adolescents. RESULTS Two metrics of eye position were worse in those with concussion than uninjured adolescents, and only one metric was significantly different between acute cases and persistent cases. Concussed adolescents had larger left and right mean, median, minimum, and maximum pupil size than uninjured controls. Concussed adolescents had greater differences in mean, median, and variance of left and right pupil size. Twelve metrics distinguished female concussed participants from uninjured; only four were associated with concussion status in males. A logistic regression model including clinical and demographics data and transformed eye tracking metrics performed better in predicting concussion status than clinical and demographics data alone. CONCLUSIONS Objective eye tracking technology is capable of quickly identifying vision and pupillary disturbances after concussion, augmenting traditional clinical concussion assessments. These metrics may add to existing clinical practice for monitoring recovery in a heterogeneous adolescent concussion population.
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Affiliation(s)
| | | | | | - Olivia E Podolak
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan S Margulies
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | | | | | - Mitchell M Scheiman
- Pennsylvania College of Optometry, Salus University, Philadelphia, Pennsylvania
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16
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Corwin DJ, McDonald CC, Arbogast KB, Mohammed FN, Grady MF, Master CL. Visio-Vestibular Deficits in Healthy Child and Adolescent Athletes. Clin J Sport Med 2022; 32:376-384. [PMID: 34173781 PMCID: PMC8692490 DOI: 10.1097/jsm.0000000000000955] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 05/05/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the relationship between patient characteristics and performance on the visio-vestibular examination (VVE) in a cohort of healthy youth athletes and explore the potential association between the VVE and other standardized concussion batteries. DESIGN Cross-sectional. SETTING Suburban middle and high school. PATIENTS One hundred ninety subjects age 11 to 18 enrolled before their respective scholastic sport season between August 2017 and March 2020. ASSESSMENT OF INDEPENDENT VARIABLES Patient age, sex, concussion history, comorbidities, hours of weekly exercise, Sport Concussion Assessment Tool, 5th edition (SCAT-5), King-Devick (K-D), Postconcussion Symptom Inventory (PCSI). MAIN OUTCOME MEASURES Visio-vestibular examination abnormalities (smooth pursuit, horizontal and vertical saccades, horizontal and vertical gaze stability, convergence, right and left monocular accommodation, complex tandem gait). RESULTS Overall, 29.5% of subjects had at least one of 9 VVE elements abnormal, 7.9% at least 2, and 3.2% at least 3. None of 72 comparisons of the VVE elements, when stratified by age, sex, concussion history, history of headaches, attention deficit hyperactivity disorder, learning issues, psychiatric problems, motion sickness, or weekly hours of exercise, reached significance using the Benjamini-Hochberg procedure at a false discovery rate of 5%. There were no significant associations between VVE elements and the SCAT-5, K-D, or PCSI. CONCLUSIONS The VVE is robust across multiple patient characteristics. Although healthy subjects may have one abnormal element, multiple abnormal elements are a less common feature, making multiple abnormal elements more indicative of concussion, highlighting the use of this assessment in the setting of injury. The VVE tests unique domains when compared with the PCSI, SCAT-5, and K-D.
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Affiliation(s)
- Daniel J Corwin
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Catherine C McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Kristy B Arbogast
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fairuz N Mohammed
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew F Grady
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christina L Master
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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17
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Myers RK, Labows C, Yerys BE, McDonald CC, Sartin EB, Mollen CJ, Curry AE. Transition to Adulthood for Autistic Adolescents: Topics Discussed by Healthcare Providers With Autistic Patients and Families. J Adolesc Health 2022; 70:829-832. [PMID: 35165029 PMCID: PMC9038620 DOI: 10.1016/j.jadohealth.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/07/2021] [Accepted: 12/03/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE We surveyed healthcare providers to determine the extent to which they discuss transition-to-adulthood topics with autistic patients without intellectual disabilities. METHODS Seventy-four healthcare providers in the Philadelphia area reported on the patient age at which they begin transition conversations, topics covered, and provider comfort. We calculated the proportion of providers who endorsed each transition topic, overall and by clinical setting. RESULTS Providers initiated transition-related conversations at a median age of 16 years (IQR: 14, 18), with over half reporting they were "somewhat" or "a little" comfortable with discussions. Nearly all providers discussed at least one healthcare, well-being, and mental health topic, while basic need-related discussions were limited. DISCUSSION Results suggest providers may delay and feel poorly prepared to provide anticipatory guidance to autistic patients for transition to adulthood. Future efforts to enhance the available resources and preparation available to providers are essential to meet autistic patients' needs.
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Affiliation(s)
- Rachel K Myers
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Christina Labows
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Benjamin E Yerys
- Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Psychiatry, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Catherine C McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Pediatrics, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emma B Sartin
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia J Mollen
- Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Allison E Curry
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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18
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McDonald CC, Mirman JH. Achieving Transportation Equity: How Can We Support Young People's Autonomy and Health in a Rapidly Changing Society? J Adolesc Health 2022; 70:701-702. [PMID: 35461652 DOI: 10.1016/j.jadohealth.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/13/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Catherine C McDonald
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States; Penn Injury Science Center, University of Pennsylvania, Philadelphia, Pennsylvania, United States; Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Jessica Hafetz Mirman
- Centre for Applied Developmental Psychology (CADP), University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Neuroscience, University of Edinburgh, Edinburgh, United Kingdom; Department of Clinical and Health Psychology, School of Health in Social Science, University of Edinburgh, Edinburgh, United Kingdom
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19
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Lipsky RK, McDonald CC, Souders MC, Carpio CC, Teitelman AM. Adverse childhood experiences, the serotonergic system, and depressive and anxiety disorders in adulthood: A systematic literature review. Neurosci Biobehav Rev 2021; 134:104495. [PMID: 34919986 DOI: 10.1016/j.neubiorev.2021.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/26/2021] [Accepted: 12/09/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent studies have examined the role that the serotonergic system plays in moderating the association between adverse childhood experiences (ACEs) and depressive and anxiety disorders in adulthood. The aim of this literature review is to synthesize studies that examined serotonin's impact in relation to ACEs, and depressive and anxiety disorders in this population. METHODS Published studies from 2008 to 2018 were retrieved from PubMed, CINAHL, and PsychINFO databases, and were included if ACEs, the serotonergic system, and depressive and or anxiety disorders were assessed in those with a mean age between nineteen and forty. RESULTS Twenty-eight studies were included. Various genetic polymorphisms in the serotonergic signaling system moderated the association between ACEs and depression. Additionally, selective serotonin reuptake inhibitors with a high affinity for the serotonin transporter, resulted in poor treatment outcomes for those with history of ACEs. CONCLUSION Additional research is needed in order to further define the role that the serotonergic genes play in the association between ACEs and depressive and anxiety disorders in adulthood.
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Affiliation(s)
- R K Lipsky
- University of Pennsylvania, School of Nursing, Family and Community Health, 418 Curie Blvd., Philadelphia, PA, 19104, United States; National Clinician Scholars Program, Duke University, 40 Duke Medicine Circle, Durham, NC, 27705, United States.
| | - C C McDonald
- University of Pennsylvania, School of Nursing, Family and Community Health, 418 Curie Blvd., Philadelphia, PA, 19104, United States
| | - M C Souders
- University of Pennsylvania, School of Nursing, Family and Community Health, 418 Curie Blvd., Philadelphia, PA, 19104, United States
| | - C C Carpio
- University of Pennsylvania, School of Nursing, Family and Community Health, 418 Curie Blvd., Philadelphia, PA, 19104, United States; National Clinician Scholars Program, Duke University, 40 Duke Medicine Circle, Durham, NC, 27705, United States
| | - A M Teitelman
- University of Pennsylvania, School of Nursing, Family and Community Health, 418 Curie Blvd., Philadelphia, PA, 19104, United States
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20
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Sartin EB, Myers RK, Labows CG, Metzger KB, Carey ME, Yerys BE, McDonald CC, Mollen CJ, Curry AE. Brief Report: Healthcare Providers' Discussions Regarding Transportation and Driving with Autistic and Non-autistic Patients. J Autism Dev Disord 2021; 53:2535-2539. [PMID: 34853958 PMCID: PMC9156719 DOI: 10.1007/s10803-021-05372-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To characterize healthcare and behavioral service providers' transportation-related discussions with their autistic and non-autistic patients. METHOD 78 providers completed a cross-sectional survey assessing their transportation discussions with patients. We used Mann-Whitney U tests and chi-square tests to compare differences in provider reports by patient diagnosis. RESULTS Compared with one in two providers who reported they discuss transportation with non-autistic patients, only one in five have these conversations with their autistic patients. Few (8%) providers felt prepared to assess driving readiness in autistic patients, yet only a quarter refer patients elsewhere. CONCLUSION There is a critical need to develop resources for use in medical settings to effectively support autistic adolescents' independence and mobility as they transition into adulthood.
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Affiliation(s)
- Emma B Sartin
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA.
| | - Rachel K Myers
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA.,Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.,Center for Violence Prevention, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA
| | - Christina G Labows
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA
| | - Kristina B Metzger
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA
| | - Meghan E Carey
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA.,Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Benjamin E Yerys
- Center for Autism Research, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA.,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Catherine C McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA.,School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA, 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.,Penn Injury Science Center, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Cynthia J Mollen
- Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.,PolicyLab, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA
| | - Allison E Curry
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA.,Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
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21
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Cui N, Raine A, Connolly CA, Richmond TS, Hanlon AL, McDonald CC, Liu J. P300 Event-Related Potentials Mediate the Relationship Between Child Physical Abuse and Externalizing Behavior. Front Psychol 2021; 12:720094. [PMID: 34790145 PMCID: PMC8592122 DOI: 10.3389/fpsyg.2021.720094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 10/05/2021] [Indexed: 11/25/2022] Open
Abstract
The psychophysiological mechanism linking early childhood experiences to behavior problems remains unclear. This study aimed to examine the association of child physical abuse with P300 event-related potentials (ERP), and to test the mediating effect of P300 amplitude and latency in the relationship between child physical abuse and externalizing behaviors. Cross-sectional secondary data were obtained from 155 children (55.5% boys, mean age: 11.28 ± 0.57 years) who participated in the China Jintan Child Cohort Study. Children self-reported maternal and paternal physical abuse and externalizing behaviors, as well as P300 were obtained in 2013. Additionally, parents and teachers reported child externalizing behaviors in preschool in 2007. P300 were recorded during a standard novel auditory oddball task. Path analysis shows that after controlling for child sex, socioeconomic status, area of residence, IQ, and child externalizing behavior in preschool, children exposed to maternal physical abuse exhibited increased novelty P300 amplitude, which links to more externalizing behavior. Novelty P300 amplitude partially mediated the relationship between maternal physical abuse and externalizing behavior. These findings are the first to document the partial mediating effect of P300 amplitude on the abuse-externalizing relationship and are consistent with the view that physical abuse affects the attention bias to novel cues that likely places them at increased risk for the development and maintenance of externalizing behavior.
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Affiliation(s)
- Naixue Cui
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
| | - Adrian Raine
- Department of Criminology, Psychiatry and Psychology, School of Arts & Sciences, University of Pennsylvania, Philadelphia, PA, United States
| | - Cynthia A Connolly
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
| | - Therese S Richmond
- Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Catherine C McDonald
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
| | - Jianghong Liu
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
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22
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Roby PR, Metzger KB, McDonald CC, Corwin DJ, Huber CM, Patton DA, Grady MF, Master CL, Arbogast KB. Pre- And Post-season Visio-vestibular Function In Healthy Adolescent Athletes. Med Sci Sports Exerc 2021. [DOI: 10.1249/01.mss.0000763588.43774.2f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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23
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Master CL, Podolak OE, Ciuffreda KJ, Metzger KB, Joshi NR, McDonald CC, Margulies SS, Grady MF, Arbogast KB. Utility of Pupillary Light Reflex Metrics as a Physiologic Biomarker for Adolescent Sport-Related Concussion. JAMA Ophthalmol 2021; 138:1135-1141. [PMID: 32970102 DOI: 10.1001/jamaophthalmol.2020.3466] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Concussion diagnosis remains clinical, without objective diagnostic tests available for adolescents. Known deficits in visual accommodation and autonomic function after concussion make the pupillary light reflex (PLR) a promising target as an objective physiological biomarker for concussion. Objective To determine the potential utility of PLR metrics as physiological biomarkers for concussion. Design, Setting, and Participants Prospective cohort of adolescent athletes between ages 12 and 18 years recruited between August 1, 2017, and December 31, 2018. The study took place at a specialty concussion program and private suburban high school and included healthy control individuals (n = 134) and athletes with a diagnosis of sport-related concussion (SRC) (n = 98). Analysis was completed June 30, 2020. Exposures Sports-related concussion and pupillometry assessments. Main Outcomes and Measures Pupillary light reflex metrics (maximum and minimum pupillary diameter, peak and average constriction/dilation velocity, percentage constriction, and time to 75% pupillary redilation [T75]). Results Pupillary light reflex metrics of 134 healthy control individuals and 98 athletes with concussion were obtained a median of 12.0 days following injury (interquartile range [IQR], 5.0-18.0 days). Eight of 9 metrics were significantly greater among athletes with concussion after Bonferroni correction (maximum pupil diameter: 4.83 mm vs 4.01 mm; difference, 0.82; 99.44% CI, 0.53-1.11; minimum pupil diameter: 2.96 mm vs 2.63 mm; difference, 0.33; 99.4% CI, 0.18-0.48; percentage constriction: 38.23% vs 33.66%; difference, 4.57; 99.4% CI, 2.60-6.55; average constriction velocity: 3.08 mm/s vs 2.50 mm/s; difference, 0.58; 99.4% CI, 0.36-0.81; peak constriction velocity: 4.88 mm/s vs 3.91 mm/s; difference, 0.97; 99.4% CI, 0.63-1.31; average dilation velocity, 1.32 mm/s vs 1.22 mm/s; difference, 0.10; 99.4% CI, 0.00-0.20; peak dilation velocity: 1.83 mm/s vs 1.64 mm/s; difference, 0.19; 99.4% CI, 0.07-0.32; and T75: 1.81 seconds vs 1.51 seconds; difference, 0.30; 0.10-0.51). In exploratory analyses, sex-based differences were observed, with girls with concussion exhibiting longer T75 (1.96 seconds vs 1.63 seconds; difference, 0.33; 99.4% CI, 0.02-0.65). Among healthy control individuals, diminished PLR metrics (eg, smaller maximum pupil size 3.81 mm vs 4.22 mm; difference, -0.41; 99.4% CI, -0.77 to 0.05) were observed after exercise. Conclusions and Relevance These findings suggest that enhancement of PLR metrics characterize acute adolescent concussion, while exercise produced smaller pupil sizes and overall slowing of PLR metrics, presumably associated with fatigue. Quantifiable measures of the PLR may serve in the future as objective physiologic biomarkers for concussion in the adolescent athlete.
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Affiliation(s)
- Christina L Master
- Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Olivia E Podolak
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Kristina B Metzger
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nabin R Joshi
- College of Optometry, State University of New York, New York
| | - Catherine C McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia.,University of Pennsylvania School of Nursing, Philadelphia
| | - Susan S Margulies
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta
| | - Matthew F Grady
- Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kristy B Arbogast
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia
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24
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Huber CM, Patton DA, Jain D, Master CL, Margulies SS, McDonald CC, Arbogast KB. Variations in Head Impact Rates in Male and Female High School Soccer. Med Sci Sports Exerc 2021; 53:1245-1251. [PMID: 33986230 PMCID: PMC8122001 DOI: 10.1249/mss.0000000000002567] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Repetitive head impacts in soccer have been linked to short-term neurophysiological deficits, and female soccer players have higher concussion rates than males. These findings have inspired investigation into gender differences in head impact exposure and how head impact rate contributes to the cumulative effect of head impact exposure on neurological outcomes. Various periods of exposure have been used to calculate head impact rates, including head impacts per season, game, and player-hour. PURPOSE The aim of this study was to apply different methodological approaches to quantify and compare head impact rates by gender for two seasons of high school varsity soccer. METHODS Video review was used to confirm all events recorded by a headband-mounted impact sensor and calculate playing time for all players. Impact rates were calculated per athlete exposure (presence and participation) and per player-hour (scheduled game time, individual play time, and absolute time). RESULTS Impact rates per athlete exposure ranged from 2.5 to 3.2 for males and from 1.4 to 1.6 for females, and impact rates per player-hour ranged from 2.7 to 3.8 for males and from 1.0 to 1.6 for females. The exposure calculation method significantly affected head impact rates; however, regardless of approach, the head impact rate for males was higher, up to threefold, than for females. Individual head impact exposure varied substantially within a team with one in five players experiencing no impacts. CONCLUSIONS Overall, the gender differences found in this study indicate that males experience higher head impact exposure compared with females. Future studies are needed to understand potential clinical implications of variability in head impact exposure and reconcile higher female concussion rates with the reduced head impact rates presented herein.
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Affiliation(s)
- Colin M Huber
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA,Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Declan A. Patton
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Divya Jain
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA,Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Christina L. Master
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA,Sports Medicine and Performance Center, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Susan S. Margulies
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA
| | - Catherine C. McDonald
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA,School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Kristy B. Arbogast
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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25
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Sartin EB, Long DL, McDonald CC, Stavrinos D, Clay OJ, Mirman JH. Evaluating disparities in child occupant protection using a proportion-eliminated approach to mediation. Traffic Inj Prev 2021; 22:252-255. [PMID: 33688773 DOI: 10.1080/15389588.2021.1885652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 12/16/2020] [Accepted: 02/01/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE While there are clear racial/ethnic disparities in child restraint system (CRS) use, to date no studies have identified mediators that quantitatively explain the relationship between race and CRS use. Therefore, the objective of this study was to provide an example of how a proportion-eliminated approach to mediation may be particularly useful in understanding the complex relationship between race and CRS use. METHODS Sixty-two mothers with a child between 4-8 years old completed a survey and had their CRS use assessed by a Child Passenger Safety Technician using a structured assessment based on the 2018 American Academy of Pediatrics' Best Practice guidelines. Recruitment and data collection occurred in Birmingham, Alabama between June 2018 and January 2019. We used chi-squared tests, logistic regressions, and a proportion-eliminated approach to mediation to compare our variables of interest and to estimate the amount of the association between racial group membership and errors in restraint use that may be explained by sociodemographic, psychosocial, and parenting variables. RESULTS Before mediation, Nonwhite mothers in this sample had a 7.38 greater odds of having an error in CRS use than White mothers. Mediation analyses indicated that being married and self-reported seatbelt use explained 47% and 35% of the effect of race on CRS use errors, respectively. CONCLUSION A proportion-eliminated approach to mediation may be particularly useful in child passenger safety research aiming to inform the development of interventions tailored for racial minority populations.
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Affiliation(s)
- Emma B Sartin
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - D Leann Long
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Catherine C McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Despina Stavrinos
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Olivio J Clay
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jessica H Mirman
- Department of Clinical and Health Psychology, School of Health in Social Science, University of Edinburgh, Edinburgh, UK
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26
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Huber CM, Patton DA, McDonald CC, Jain D, Simms K, Lallo VA, Margulies SS, Master CL, Arbogast KB. Sport- and Gender-Based Differences in Head Impact Exposure and Mechanism in High School Sports. Orthop J Sports Med 2021; 9:2325967120984423. [PMID: 33738313 PMCID: PMC7933779 DOI: 10.1177/2325967120984423] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/27/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Repeated head impacts sustained by athletes have been linked to short-term neurophysiologic deficits; thus, there is growing concern about the number of head impacts sustained in sports. Accurate head impact exposure data obtained via head impact sensors may help identify appropriate strategies across sports and between genders to mitigate repetitive head impacts. Purpose: To quantify sport- and gender-based differences in head impact rate and mechanism for adolescents. Study Design: Cohort study; Level of evidence, 2. Methods: High school female and male varsity soccer, basketball, lacrosse, and field hockey (female only) teams were instrumented with headband-mounted impact sensors during games over 2 seasons of soccer and 1 season of basketball, lacrosse, and field hockey. Video review was used to remove false-positive sensor-recorded events, and the head impact rate per athlete-exposure (AE) was calculated. Impact mechanism was categorized as equipment to head, fall, player to head, or head to ball (soccer only). Results: Male players had significantly higher head impact rates as compared with female players in soccer (3.08 vs 1.41 impacts/AE; rate ratio, 2.2 [95% CI, 1.8-2.6]), basketball (0.90 vs 0.25; 3.6 [2.6-4.6]), and lacrosse (0.83 vs 0.06; 12.9 [10.1-15.8]). Impact mechanism distributions were similar within sports between boys and girls. In soccer, head to ball represented 78% of impacts, whereas at least 88% in basketball were player-to-player contact. Conclusion: Across sports for boys and girls, soccer had the highest impact rate. Male high school soccer, basketball, and lacrosse teams had significantly higher head impact rates than did female teams of the same sport. For girls, basketball had a higher head impact rate than did lacrosse and field hockey, and for boys, basketball had a similar impact rate to lacrosse, a collision sport. Sport differences in the distribution of impact mechanisms create sport-specific targets for reducing head impact exposure.
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Affiliation(s)
- Colin M Huber
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Declan A Patton
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Catherine C McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Divya Jain
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katherine Simms
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Valerie A Lallo
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Biomedical Engineering Department, Widener University, Chester, Pennsylvania, USA
| | - Susan S Margulies
- Walter H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
| | - Christina L Master
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kristy B Arbogast
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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27
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Jain D, Arbogast KB, Master CL, C McDonald C. An Integrative Review of Return to Driving After Concussion in Adolescents. J Sch Nurs 2020; 37:17-27. [PMID: 33043755 DOI: 10.1177/1059840520963625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Concussion is a common injury among adolescents. It is unknown how a concussion affects driving behavior and performance in adolescents. Although there are guidelines for return to learn, exercise, and sports that school nurses can help support in school, little is known about return to driving after concussion. The goal of this integrative review was to summarize the current literature on return to driving after concussion in adolescents. Six articles published between 2016 and 2020 were included in the review. Physicians and nurse practitioners find providing driving recommendations to adolescents to be appropriate; however, they are unclear what metrics to use to determine whether a patient is fit to drive. Future studies should explore clinical predictors of readiness to return to driving in adolescents. School nurses have an opportunity to support adolescents in their resumption of typical activities after concussion including school, sports, and, as more evidence becomes available, driving.
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Affiliation(s)
- Divya Jain
- Department of Bioengineering, 272124University of Pennsylvania, Philadelphia, PA, USA.,Center for Injury Research and Prevention, 6567The Children's Hospital of Philadelphia, PA, USA.,Penn Injury Science Center, 6572University of Pennsylvania, Philadelphia, PA, USA
| | - Kristy B Arbogast
- Center for Injury Research and Prevention, 6567The Children's Hospital of Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine at 6572the University of Pennsylvania, Philadelphia, PA, USA
| | - Christina L Master
- Center for Injury Research and Prevention, 6567The Children's Hospital of Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine at 6572the University of Pennsylvania, Philadelphia, PA, USA.,Division of Orthopedics, Sports Medicine and Performance Center, 6567The Children's Hospital of Philadelphia, PA, USA
| | - Catherine C McDonald
- Center for Injury Research and Prevention, 6567The Children's Hospital of Philadelphia, PA, USA.,Penn Injury Science Center, 6572University of Pennsylvania, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine at 6572the University of Pennsylvania, Philadelphia, PA, USA.,School of Nursing, 6572University of Pennsylvania, Philadelphia, PA, USA
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28
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Corwin DJ, McDonald CC, Arbogast KB, Mohammed FN, Metzger KB, Pfeiffer MR, Patton DA, Huber CM, Margulies SS, Grady MF, Master CL. Clinical and Device-based Metrics of Gait and Balance in Diagnosing Youth Concussion. Med Sci Sports Exerc 2020; 52:542-548. [PMID: 31524833 DOI: 10.1249/mss.0000000000002163] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Evaluate the discriminatory ability of two clinical measures and one device-based measure of gait and balance for concussed youth. METHODS We enrolled 81 cases and 90 controls age 14-18 yr old from August 2017 to June 2018. Controls were recruited from a suburban high school, and cases were recruited from the concussion program of an academic pediatric tertiary care center. Tests included two clinical measures: 1) complex tandem gait, scored as sway/errors walking forward and backward eyes open and closed; 2) Modified Balance Error Scoring System (mBESS), scored as total number of errors on three standing tasks; and one device-based measure; 3) Modified Clinical Test of Sensory Interaction and Balance (mCTSIB) using the Biodex Biosway Balance System, scored as a sway index. Sensitivity, specificity, ideal cutpoint, and area under the receiver operating characteristic curve (AUC) were calculated for all test components. RESULTS Ideal cutpoint for total number of sway/errors for tandem gait = 5, sensitivity 41%, specificity 90%. Ideal cutpoint for total mBESS errors = 4, sensitivity 55%, specificity 75%. Ideal cutpoint for mCTSIB = 1.37, sensitivity 37%, specificity 88%. Among each test, some individual components outperformed overall composites, in particular tandem gait (specificity forward eyes open = 99%, sensitivity backward eyes closed = 81%). Among the 40 cases and 65 controls with all three assessments, AUC (95% CI) for tandem gait = 0.63 (0.52,0.75), mBESS = 0.70 (0.60,0.81), and mCTSIB = 0.54 (0.42,0.66). CONCLUSIONS A device-based measure of balance did not produce better discriminatory ability than two clinical assessments. Complex tandem gait has the additional benefit of being an easy-to-perform and graded test with highly sensitive and specific individual components.
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Affiliation(s)
| | | | | | - Fairuz N Mohammed
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kristina B Metzger
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Melissa R Pfeiffer
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Declan A Patton
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Colin M Huber
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA
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29
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McDonald CC, Fargo JD, Swope J, Metzger KB, Sommers MS. Initial Testing of a Web-Based Intervention to Reduce Adolescent Driver Inattention: A Randomized Controlled Trial. J Emerg Nurs 2020; 47:88-100.e3. [PMID: 33023788 DOI: 10.1016/j.jen.2020.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Motor vehicle crashes are the leading cause of adolescent death. Inattention to the roadway contributes to crash risk. The objective of this study was to deploy an initial study of a web-based intervention (Let's Choose Ourselves) designed to improve adolescent driver attention to the roadway. METHODS We used a randomized controlled trial design in a sample of adolescent drivers to test if a web-based intervention decreased cell phone engagement in driving simulation at 3 months as compared with controls. As secondary hypotheses, we tested if the intervention increased the use of peer passengers to manage distractions and decreased eyes off the forward roadway in driving simulation and decreased self-reported risky driving behaviors. Adolescents, aged 16-17 years, licensed for ≤90 days were randomized to Let's Choose Ourselves with distractions in the simulator protocol at baseline, Let's Choose Ourselves with no distractions, an attention control intervention on healthy eating with distractions, or attention control with no distractions. We used Poisson regression modeling to test the primary and secondary hypotheses. RESULTS The trial included 60 adolescents (66.7% female, 78.3% non-Hispanic white subjects, mean age 16.8 years, licensed 50.8 days). In Poisson regression, controlling for sex, we found no significant effects of Let's Choose Ourselves on primary or secondary outcomes. However, there was a significant effect of visit on self-report outcomes, with self-reported distracted driving behaviors increasing over time. DISCUSSION Although there were no significant effects of Let's Choose Ourselves, self-reported risky driving behaviors increased over time. Further investigation of the relationship between driving experience and increasing inattention to the road in adolescents is warranted.
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30
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Sartin E, McDonald CC, Long DL, Stavrinos D, Mirman JH. Variations in booster seat use by child characteristics. J Safety Res 2020; 74:89-95. [PMID: 32951799 DOI: 10.1016/j.jsr.2020.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/23/2020] [Accepted: 04/16/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Child weight and height are the basis of manufacturer and best practice guidelines for child restraint system use. However, these guides do not address behavioral differences among children of similar age, weight, and height, which may result in child-induced restraint use errors. The objective of this study was to characterize child behaviors across age in relation to appropriate restraint system use during simulated drives. METHODS Fifty mother-child (4-8 years) dyads completed an installation into a driving simulator, followed by a simulated drive that was video-recorded and coded for child-induced errors. Time inappropriately restrained was measured as the total amount of the simulated drive spent in an improper or unsafe position for the restraint to be effective divided by the total drive time. Kruskal-Wallis tests were used to determine differences across age in the frequency of error events and overall time inappropriately restrained. RESULTS Children in harnessed seats had no observed errors during trips. Within children sitting in booster seats there were differences in time inappropriately restrained across age (p = 0.01), with 4 year-olds spending on average 67% (Median = 76%) of the drive inappropriately restrained, compared to the rest of the age categories spending less than 28% (Medians ranged from 3% to 23%). CONCLUSION Some children may be physically compatible with booster seats, but not behaviorally mature enough to safely use them. More research is needed that examines how child behavior influences child passenger safety. Practical Applications: Not all children physically big enough are behaviorally ready to use belt positioning booster seats. Primary sources of information should provide caregivers with individualized guidance about when it is appropriate to transition children out of harnessed seats. Additionally, best practice guidelines should be updated to reflect what behaviors are needed from children to safely use specific types of child restraint systems.
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Affiliation(s)
- Emma Sartin
- University of Alabama at Birmingham, Department of Psychology, Birmingham, AL, USA.
| | - Catherine C McDonald
- University of Pennsylvania, School of Nursing, Philadelphia, PA, USA; Children's Hospital of Philadelphia, Center for Injury Research and Prevention, Philadelphia, PA, USA.
| | - D Leann Long
- University of Alabama at Birmingham, Department of Biostatistics, Birmingham, AL, USA.
| | - Despina Stavrinos
- University of Alabama at Birmingham, Department of Psychology, Birmingham, AL, USA.
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Gance-Cleveland B, McDonald CC, Walker RK. Use of theory to guide development and application of sensor technologies in Nursing. Nurs Outlook 2020; 68:698-710. [PMID: 32620271 DOI: 10.1016/j.outlook.2020.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/01/2020] [Accepted: 04/25/2020] [Indexed: 11/28/2022]
Abstract
Sensor technologies for health care, research, and consumers have expanded and evolved rapidly. Many technologies developed in commercial or engineering spaces, lack theoretical grounding and scientific evidence to support their need, safety, and efficacy. Theory is a mechanism for synthesizing and guiding knowledge generation for the discipline of nursing, including the design, implementation, and evaluation of sensors and related technologies such as artificial intelligence and machine learning. In this paper, three nurse scientists summarize their presentations at the Council for the Advancement of Nursing Science 2019 Advanced Methods Conference on Expanding Science of Sensor Technology in Research discussing the theoretical underpinnings of sensor technologies development and use in nursing research and practice. Multiple theories with diverse epistemological roots guide decision-making about whether or not to apply sensors to a given use; development of, components of, and mechanisms by which sensor technologies are expected to work; and possible outcomes.
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Affiliation(s)
| | - Catherine C McDonald
- University of Pennsylvania School of Nursing, University of Pennsylvania Injury Science Center, Center for Injury Research Prevention at the Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rachel K Walker
- College of Nursing, IALS Center for Health & Human Performance, University of Massachusetts-Amherst, Amherst, MA
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Affiliation(s)
- Catherine C McDonald
- Assistant Professor, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.,Assistant Professor of Nursing in Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.,Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, USA.,Member, Journal of School Nursing Editorial Advisory Board
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McDonald CC, Delgado MK, Zonfrillo MR. Opportunities to Reduce Distracted Driving and Adolescent Driver Motor Vehicle Crashes. Pediatrics 2020; 145:peds.2020-0419. [PMID: 32414895 PMCID: PMC7263051 DOI: 10.1542/peds.2020-0419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Catherine C. McDonald
- Department of Family and Community Health, School of Nursing and,Departments of Pediatrics,,Penn Injury Science Center and,Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - M. Kit Delgado
- Biostatistics, Epidemiology, and Informatics, and,Emergency Medicine and Center for Emergency Care Policy and Research, Perelman School of Medicine and,Penn Injury Science Center and,Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania;,Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Mark R. Zonfrillo
- Departments of Emergency Medicine and,Pediatrics, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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McDonald CC, Pfeiffer MR, Robinson RL, Arbogast KB, Master CL. Telephone Triage in Pediatric Head Injury: Follow-up Patterns and Subsequent Diagnosis of Concussion. Clin Nurs Res 2020; 30:104-109. [PMID: 32441131 DOI: 10.1177/1054773820924572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Head injuries in childhood can result in concussion. Families of a child with a head injury often seek medical advice through telephone triage call systems. It is important to understand if patients follow telephone triage recommendations and what proportion of triage calls result in subsequent concussion diagnosis. We used a one-year retrospective cohort of triage calls screened with the Barton Schmitt Pediatric Head Injury Telephone Triage Protocol. The objectives were to estimate the proportion who followed up with urgent recommendations to see a provider and determine prevalence of diagnoses of concussion. Out of 2,454 calls with recommendations to be seen urgently, the estimated proportion of being seen in the medical home network or an outside health care facility was 84.1%. Estimated overall diagnoses of concussion among those who were seen was 39.5%. These data can be used to improve patient education and follow-up, as well as the utility of the telephone triage system.
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Affiliation(s)
- Catherine C McDonald
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.,Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Melissa R Pfeiffer
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Roni L Robinson
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kristy B Arbogast
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Christina L Master
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Abstract
BACKGROUND Recent advances in technology have enabled the development of head impact sensors, which provide a unique opportunity for sports medicine researchers to study head kinematics in contact sports. Studies have suggested that video or observer confirmation of head impact sensor data is required to remove false positives. In addition, manufacturer filtering algorithms may be ineffective in identifying true positives and removing true negatives. PURPOSE To (1) identify the percentage of video-confirmed events recorded by headband-mounted sensors in high school soccer through video analysis, overall and by sex; (2) compare video-confirmed events with the classification by the manufacturer filtering algorithms; and (3) quantify and compare the kinematics of true- and false-positive events. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Adolescent female and male soccer teams were instrumented with headband-mounted impact sensors (SIM-G; Triax Technologies) during games over 2 seasons of suburban high school competition. Sensor data were sequentially reduced to remove events recorded outside of game times, associated with players not on the pitch (ie, field) and players outside the field of view of the camera. With video analysis, the remaining sensor-recorded events were identified as an impact event, trivial event, or nonevent. The mechanisms of impact events were identified. The classifications of sensor-recorded events by the SIM-G algorithm were analyzed. RESULTS A total of 6796 sensor events were recorded during scheduled varsity game times, of which 1893 (20%) were sensor-recorded events associated with players on the pitch in the field of view of the camera during verified game times. Most video-confirmed events were impact events (n = 1316, 70%), followed by trivial events (n = 396, 21%) and nonevents (n = 181, 10%). Female athletes had a significantly higher percentage of trivial events and nonevents with a significantly lower percentage of impact events. Most impact events were head-to-ball impacts (n = 1032, 78%), followed by player contact (n = 144, 11%) and falls (n = 129, 10%) with no significant differences between male and female teams. The SIM-G algorithm correctly identified 70%, 52%, and 66% of video-confirmed impact events, trivial events, and nonevents, respectively. CONCLUSION Video confirmation is critical to the processing of head impact sensor data. Percentages of video-confirmed impact events, trivial events, and nonevents vary by sex in high school soccer. Current manufacturer filtering algorithms and magnitude thresholds are ineffective at correctly classifying sensor-recorded events and should be used with caution.
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Affiliation(s)
- Declan A. Patton
- Address correspondence to Declan A. Patton, PhD, Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, 734 Schuylkill Avenue, Philadelphia, PA 19104, USA ()
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McDonald CC, Pinto-Martin J, Compton P, Parikh M, Meisel ZF. School nurse reported supply and administration of naloxone in schools. Public Health Nurs 2020; 37:347-352. [PMID: 32090378 DOI: 10.1111/phn.12715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/31/2020] [Accepted: 02/04/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe school nurse reported naloxone supply and administration in Pennsylvania, as well as nurse and school-level characteristics associated with naloxone availability. METHODS Cross-sectional, online survey with school nurses in Pennsylvania. Data were collected (3/14/18-6/5/18) on school nurse demographic and professional characteristics, school characteristics, naloxone supply and administration, and when not available, reasons for not having a naloxone supply. RESULTS A total of 362 school nurses met inclusion criteria, representing schools in 56 of the 67 Pennsylvania counties. Over half of the school nurses reported a naloxone supply in their school building (53.6%, n = 194). Additionally, 5.2% of those who had a naloxone supply reported that it had been administered in their school or at a school sponsored activity. The most common reasons for not having naloxone available included lack of support and the belief that naloxone was not needed in their school. CONCLUSION Although many school nurses reported having a naloxone supply in their school, and a small percentage reported administration, particular barriers to access and use remain.
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Affiliation(s)
- Catherine C McDonald
- University of Pennsylvania, School of Nursing, Philadelphia, PA, USA.,Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer Pinto-Martin
- University of Pennsylvania, School of Nursing, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Peggy Compton
- University of Pennsylvania, School of Nursing, Philadelphia, PA, USA
| | - Madeleine Parikh
- University of Pennsylvania, School of Nursing, Philadelphia, PA, USA
| | - Zachary F Meisel
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, USA.,Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Glerum KM, Zonfrillo MR, Fleisher L, McDonald CC. Systematic review of child restraint system interventions (2007-2018). Traffic Inj Prev 2019; 20:866-872. [PMID: 31725324 DOI: 10.1080/15389588.2019.1666372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 07/22/2019] [Accepted: 09/07/2019] [Indexed: 06/10/2023]
Abstract
Objective: To systematically review and summarize articles evaluating the effectiveness of child restraint system (CRS) interventions targeting parents/caregivers' knowledge of, overall rates of and/or proper use of CRSs published in a recent time period.Methods: Using multiple databases, we identified peer-reviewed journal articles published between January 1, 2007 and December 31, 2018 using selected key search terms. Inclusion criteria were: (1) evaluation of an intervention/program for child passenger safety targeting a parent or caregiver of a child (2) quantitative data-based results (i.e., change in knowledge, behavior, or observed outcomes), (3) English-language, and (4) peer-reviewed journal publication. Through a systematic review process and peer consensus, n = 23 articles met inclusion criteria. References of these articles were reviewed for inclusion using the same process and n = 12 additional articles were identified.Results: A total of n = 35 articles met inclusion criteria. Of the n = 35 articles, n = 9 were randomized controlled trials (RCTs), n = 4 were cluster RCTs, n = 11 were nonrandomized trials, and n = 11 were pretest post-test studies. Types of interventions included face-to-face education (n = 26), web/video-based education (n = 8) or written educational materials (n = 1). Of the articles reviewed, n = 20 involved distribution of free or subsidized CRSs to some or all subjects. N = 20 articles involved trained CRS technicians and/or CRS installation check-points. In terms of outcomes measured, n = 3 articles assessed changes in knowledge of CRS use, n = 22 assessed changes in CRS behaviors (which includes self-report or observed behavior change), and n = 10 assessed changes in both CRS knowledge and behaviors. All articles (n = 3) that measured changes in knowledge as their only outcome demonstrated positive effects while articles measuring behavioral outcomes (self-report or observed) (n = 32) had mixed results.Conclusions: This review included a wide range of articles of heterogeneous methodologies, sample sizes, and outcomes measured. Although different approaches to CRS interventions were effective in increasing awareness and knowledge, the effects on CRS use behaviors - whether self-reported or observed - were mixed. Future research is needed to increase appropriate CRS use and reduce the burden of motor vehicle crash-related injuries among children.
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Affiliation(s)
- Kimberly M Glerum
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Mark R Zonfrillo
- Departments of Emergency Medicine and Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Linda Fleisher
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Catherine C McDonald
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
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Axson SA, Giordano NA, McDonald CC, Pinto-Martin JA. Opioid Prescribing to Adolescents upon Discharge from an Admission of 48 Hours or Less. Journal of Child & Adolescent Substance Abuse 2019. [DOI: 10.1080/1067828x.2019.1679688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Sydney A. Axson
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Catherine C. McDonald
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- The Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer A. Pinto-Martin
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Sartin E, Bell TR, McDonald CC, Mirman JH. Assessment of Caregiver-Targeted Interventions for Use of Motor Vehicle Passenger Safety Systems for Children: A Systematic Review and Meta-analysis. JAMA Netw Open 2019; 2:e1914180. [PMID: 31664445 PMCID: PMC6824219 DOI: 10.1001/jamanetworkopen.2019.14180] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Caregiver-targeted interventions to improve the use of child restraint systems (CRS) in motor vehicles are common and heterogeneous in their implementation. The effectiveness of these interventions is unknown. OBJECTIVES To quantify the effects of caregiver-targeted interventions using meta-analytic methods, assess the quality of published studies, and assess for publication bias. DATA SOURCES PubMed and PsychINFO (January 1, 2004, to April 1, 2019) were searched for English-language studies using a list of search terms. The search and screening process was completed between May 25, 2018, and April 1, 2019. STUDY SELECTION Studies met inclusion criteria if they included a caregiver-targeted intervention that focused on increasing CRS use for children (age, ≤9 years) and report the use of CRS before and after the intervention. DATA EXTRACTION AND SYNTHESES Cochrane and PRISMA guidelines were used for the meta-analysis and risk-of-bias review. Information was extracted on intervention type, setting, implementation, and attributes of the study independently between 2 coders. Data were pooled from independent samples, with 1 outcome measure from each intervention implementation or study. MAIN OUTCOMES AND MEASURES This study was an exploratory random-effects meta-analysis. Unadjusted odds ratios were calculated using the sample size and the observed number of children in incorrect or correct restraints in motor vehicles before and after the intervention to determine the odds of incorrect CRS use after completing an intervention. Setting, measurement method, randomization, use of vouchers, and types of restraint were tested as moderators. A funnel plot was used to assess for publication bias. RESULTS Of 1240 potential articles, 51 were deemed eligible for screening and 10 (8238 participants total) were included in the meta-analysis. Caregiver-targeted interventions were associated with a reduction in the number of children not riding in a CRS (odds ratio, 0.51; 95% CI, 0.36-0.71; P < .001). Variance in the averaged effect size was driven by self-report methods (when removed from analyses, I2 = 61.8%; R2 change = 26.3; P = .02) and hospital settings (when removed from analyses, I2 = 70.7%; R2 change = 17.4; P = .002). Risk of bias was high in most studies; however, there was low evidence for publication bias. CONCLUSIONS AND RELEVANCE In this meta-analysis, caregiver-targeted interventions were associated with a reduction in the number of children not riding in a CRS in motor vehicles; however, the methodological rigor of intervention studies should be enhanced.
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Affiliation(s)
- Emma Sartin
- Department of Psychology, University of Alabama at Birmingham
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tyler R. Bell
- College of Nursing, Pennsylvania State University, Philadelphia
| | - Catherine C. McDonald
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia
| | - Jessica Hafetz Mirman
- Department of Psychology, University of Alabama at Birmingham
- The School of Health in Social Science, University of Edinburgh, Edinburgh, Scotland
- The Scottish Collaboration for Health Research and Policy, University of Edinburgh, Edinburgh, Scotland
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McDonald CC, Ward K, Huang Y, Wiebe DJ, Delgado MK. Novel Smartphone-Based Measures of Cell Phone Use While Driving in a Sample of Newly Licensed Adolescent Drivers. Health Educ Behav 2019; 46:10-14. [PMID: 30041576 PMCID: PMC6345599 DOI: 10.1177/1090198118788612] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Motor vehicle crashes are the leading cause of adolescent death. Cell phone use while driving is a contributor to adolescent motor vehicle crash risk. Objective and directly observable measures of cell phone use while driving are needed to implement interventions aimed at reducing cell phone-related crash risk. AIMS To describe novel smartphone-based measures of cell phone use while driving in a sample of newly licensed male and female adolescent drivers. METHODS Newly licensed adolescents in Pennsylvania installed a windshield-mounted device that pairs with a smartphone application to collect data on cell phone use while driving over 2 weeks during June 2016-October 2016. Descriptive statistics, independent t tests, and Wilcoxin Mann-Whitney U test were used to characterize handheld cell phone use ("unlock") and call time while accounting for driving exposure. RESULTS Data from 16 adolescents (50% male) resulted in 5,624 miles in 705 trips, 964 cell phone unlocks, and 146.22 minutes of call time. Participants had a mean of 23.96 unlocks/100 miles ( SD = 22.97), 1.23 unlocks/trip ( SD = 0.96), and 4.87 unlocks/hour driven ( SD = 3.93). Males had significantly more unlocks/100 miles, unlocks at speed >25 mph/100 miles, unlocks/hour driven, and unlocks at speed > 25 mph/hour driven ( p < .05). CONCLUSIONS Smartphone-based applications are an innovative means by which to collect continuous data on cell phone use while driving that can be used to better understand and intervene on this frequent behavior in newly licensed adolescent drivers.
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Affiliation(s)
- Catherine C. McDonald
- Department of Family and Community Health, School of Nursing, University of Pennsylvania
- Department of Pediatrics, Perelman School of Medicine
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia
- Penn Injury Science Center, University of Pennsylvania
- Center for Public Health Initiatives, University of Pennsylvania
| | - Kristen Ward
- Center for Public Health Initiatives, University of Pennsylvania
| | - Yanlan Huang
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania
| | - Douglas J. Wiebe
- Penn Injury Science Center, University of Pennsylvania
- Center for Public Health Initiatives, University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania
| | - M. Kit Delgado
- Penn Injury Science Center, University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania
- Behavioral Science & Analytics For Injury Reduction (BeSAFIR) Lab, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania
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McDonald CC, Kennedy E, Fleisher L, Zonfrillo MR. Factors Associated with Cell Phone Use While Driving: A Survey of Parents and Caregivers of Children Ages 4-10 Years. J Pediatr 2018; 201:208-214. [PMID: 30017337 DOI: 10.1016/j.jpeds.2018.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 05/09/2018] [Accepted: 06/01/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To examine characteristics associated with cell phone use while driving by parents and caregivers of children ages 4-10 years. STUDY DESIGN National cross-sectional online survey with a convenience sample (March 2017-April 2017). INCLUSION CRITERIA Parent/caregiver of a child age 4-10 years in their home, age ≥18 years, read and spoke English, and drove child ≥6 times in previous 3 months. Adjusted logistic regression analyses were modeled for outcome measures of previous 3-month self-report cell phone use while driving with the child. RESULTS The analytic sample was n = 760. In the previous 3 months, 47% of parent/caregivers talked on a hand-held phone, 52.2% talked on a hands-free phone, 33.7% read texts, 26.7% sent texts, and 13.7% used social media while driving with their child in the vehicle. Compared with those who always used their typical child restraint system, participants who did not always use were more likely to talk on a hands-free phone (aOR 1.97, 95% CI 1.26-3.09), read a text (aOR 1.74, 95% CI 1.11-2.73), send a text (aOR 1.65, 95% CI 1.04-2.62), and use social media (aOR 2.92, 95% CI 1.73-4.94) while driving. Higher income, not wearing a seat belt (driver) on every trip, and driving under influence of alcohol also were associated with various types of cell phone use while driving. CONCLUSIONS Inconsistent child restraint system use, lack of seat belt use, and driving under the influence of alcohol are associated with parent/caregiver cell phone use while driving. Screening and education related to parental driving behaviors should include addressing multiple risk behaviors.
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Affiliation(s)
- Catherine C McDonald
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA; Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA.
| | - Erin Kennedy
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA; Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Linda Fleisher
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark R Zonfrillo
- Department of Emergency Medicine, Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, RI
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McDonald CC, Kennedy E, Fleisher L, Zonfrillo MR. Situational Use of Child Restraint Systems and Carpooling Behaviors in Parents and Caregivers. Int J Environ Res Public Health 2018; 15:ijerph15081788. [PMID: 30127291 PMCID: PMC6121359 DOI: 10.3390/ijerph15081788] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 11/16/2022]
Abstract
Suboptimal compliance with child restraint system (CRS) recommendations can increase risk for injury or death in a motor vehicle crash. The purpose of this study was to examine scenarios associated with incomplete CRS use and non-use in children ages 4⁻10 years. We used a cross-sectional online survey with a convenience sample of parent/caregivers from the United States, age ≥18 years, with a child age 4⁻10 years in their home, who could read and spoke English, and drove child ≥6 times in previous three months. We used descriptive statistics and Mann-Whitney U to describe and compare the distribution of responses to situational use of CRSs among car seat users and booster seat users. We also used descriptive statistics and the Mann-Whitney U to describe and compare the distribution of responses to carpooling items among booster seat users and non-booster seat users. There were significant differences among those who reported most often using booster seats (n = 282) and car seats (n = 127) in situations involving rental cars, driving just around the corner, car too crowded to fit the CRS, not enough CRSs in the vehicle, the CRS is missing from the car, or the child is in someone else's car without a CRS (p < 0.05). Among those who reported most often using booster seats and who carpooled other children (n = 159), 71.7% (n = 114) always used a booster seat for their own child. When carpooling other children, booster seat users were significantly more likely to use booster seats for other children ages 4⁻10 than the non-booster seat users (p < 0.01). Continued education and programs surrounding CRS use is critical, particularly for children who should be in booster seats.
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Affiliation(s)
- Catherine C McDonald
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA 19104, USA.
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Erin Kennedy
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA 19104, USA.
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Linda Fleisher
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Mark R Zonfrillo
- Department of Emergency Medicine, Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, RI 02903, USA.
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Cowell JM, McDonald CC. School Safety. J Sch Nurs 2018; 34:254. [DOI: 10.1177/1059840518782215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Catherine C. McDonald
- University of Pennsylvania, School of Nursing, Member of the Editorial Advisory Board, The Journal of School Nursing
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Bader CE, Giordano NA, McDonald CC, Meghani SH, Polomano RC. Musculoskeletal Pain and Headache in the Active Duty Military Population: An Integrative Review. Worldviews Evid Based Nurs 2018; 15:264-271. [PMID: 29957866 DOI: 10.1111/wvn.12301] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Since 2001, the U.S. Armed Forces' training and deployment have greatly increased, escalating the risk of injury and pain-related issues both at home station and deployment environments. AIMS This integrative review examines the incidence, prevalence, and risk factors for musculoskeletal pain (MSP) and headaches in active duty (AD) military populations. METHODS Peer-reviewed research published between 2001 and 2016 was identified relevant to MSP and headache in AD military personnel using MeSH terms in key biomedical databases. Inclusion criteria were: epidemiological studies examining MSP or headache as primary or secondary outcome; samples that included AD populations; and studies conducted in the theater of operations, at home station, and in military treatment or Veterans Health Administration facilities. RESULTS Twenty-six articles met inclusion criteria. Low back pain (LBP) was the most prevalent MSP diagnosis. The incidence of LBP was 40.5 per 1,000 person-years and was comparable to nonmilitary populations. Inflammation and pain from overuse comprised the largest proportion of injury mechanism, accounting for about 82% of all injuries among nondeployed military personnel. The risk of MSP was greater for AD, female, Army, enlisted personnel, and those with greater time in a motor vehicle. Evidence suggests posttraumatic headache, occurring in up to 92% of military personnel who have sustained a mild traumatic brain injury, is associated with chronic daily headaches. IMPLICATIONS Nurses must recognize the consequences military service can have on the development of pain. Nurses have an opportunity to positively impact the health and well-being of military and veteran populations through early recognition and treatment of pain. LINKING EVIDENCE TO ACTION The findings from this review underscore considerable magnitude of MSP in military personnel and expose modifiable risk factors and potential targets for designing nurse-led interventions to improve pain and symptoms in military subpopulations.
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Affiliation(s)
- Christine E Bader
- Former PhD Student, Robert Wood Johnson Foundation Future of Nursing Scholar (Independence Blue Cross Foundation), University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Nicholas A Giordano
- Former PhD Student, Hillman Scholar in Nursing Innovation, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Catherine C McDonald
- Assistant Professor, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Salimah H Meghani
- Associate Professor & Term Chair in Palliative Care, Chair, Graduate Group in Nursing, University of Pennsylvania School of Nursing, and Associate Director, NewCourtland Center for Transitions and Health Senior Fellow, Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
| | - Rosemary C Polomano
- Professor of Pain Practice, University of Pennsylvania School of Nursing, and Professor of Anesthesiology and Critical Care (Secondary), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Delgado MK, McDonald CC, Winston FK, Halpern SD, Buttenheim AM, Setubal C, Huang Y, Saulsgiver KA, Lee YC. Attitudes on technological, social, and behavioral economic strategies to reduce cellphone use among teens while driving. Traffic Inj Prev 2018; 19:569-576. [PMID: 29652523 PMCID: PMC6215497 DOI: 10.1080/15389588.2018.1458100] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 03/23/2018] [Indexed: 05/12/2023]
Abstract
OBJECTIVE The majority of U.S. teens admit to handheld cellphone use while driving, an increasingly common cause of crashes. Attitudes toward novel cellphone applications and settings that block use while driving are poorly understood, potentially limiting uptake. We examined teens' willingness to reduce cellphone use while driving and perceptions of potential strategies to limit this behavior. METHODS Teen drivers (n = 153) aged 16-17 who owned smartphones and admitted to texting while driving completed an online survey. Survey instruments measured willingness to give up cellphone use and perceptions of technological and behavioral economic strategies to reduce cellphone use while driving. We used chi-square tests to test the hypothesis that willingness to give up certain types of cellphone use while driving and the perceptions of strategies to reduce cellphone use while driving would differ by self-reported frequency of texting while driving in the past 30 days (low [1-5 days] vs. high [6 or more days]). RESULTS Most teens were willing or somewhat willing to give up reading texts (90%), sending texts (95%), and social media (99%) while driving. However, they were not willing to give up navigation (59%) and music applications (43%). Those who engaged in high-frequency texting while driving were more likely to say that they were not willing to give up navigation applications (73 vs. 44%, P <.001), music applications (54 vs. 32%, P <.001), and reading texts (15 vs. 4%, P =.029). Overall, the following strategies where rated as likely to be very effective for reducing texting while driving: gain-framed financial incentives (75%), loss-framed financial incentives (63%), group-based financial incentives (58%), insurance discounts (53%), automatic phone locking while driving (54%), e-mail notifications to parents (47%), automated responses to incoming texts (42%), peer concern (18%), and parental concern (15%). Those who engaged in high-frequency texting while driving were less likely to say that following strategies would be very effective: automated responses to incoming texts (33 vs. 53%, P =.016), peer concern (9 vs. 29%, P =.002), and parental concern (9 vs. 22%, P =.025). The strongest perceived benefit of cellphone blocking apps was decreasing distraction (86%). The predominant reason for not wanting to use this technology was not wanting parents to monitor their behavior (60%). CONCLUSIONS Promising strategies for increasing acceptance of cellphone blocking technology among teen drivers include automated screen locking and permitting hands-free navigation and music combined with behavioral economic incentives to sustain engagement.
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Affiliation(s)
- M Kit Delgado
- a Behavioral Science and Analytics for Injury Reduction (BeSAFIR) Lab, Department of Emergency Medicine, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
- b Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
- c Center for Health Incentives and Behavioral Economics , University of Pennsylvania , Philadelphia , Pennsylvania
- d Penn Injury Science Center, University of Pennsylvania , Philadelphia , Pennsylvania
- e Center for Injury Research and Prevention, The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania
| | - Catherine C McDonald
- d Penn Injury Science Center, University of Pennsylvania , Philadelphia , Pennsylvania
- e Center for Injury Research and Prevention, The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania
- f Department of Family and Community Health, School of Nursing , University of Pennsylvania , Philadelphia , Pennsylvania
- g Department of Pediatrics, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
| | - Flaura K Winston
- e Center for Injury Research and Prevention, The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania
- g Department of Pediatrics, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
| | - Scott D Halpern
- b Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
- c Center for Health Incentives and Behavioral Economics , University of Pennsylvania , Philadelphia , Pennsylvania
- h Department of Medicine, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
- i Department of Medical Ethics and Health Policy, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
| | - Alison M Buttenheim
- c Center for Health Incentives and Behavioral Economics , University of Pennsylvania , Philadelphia , Pennsylvania
- f Department of Family and Community Health, School of Nursing , University of Pennsylvania , Philadelphia , Pennsylvania
| | - Claudia Setubal
- a Behavioral Science and Analytics for Injury Reduction (BeSAFIR) Lab, Department of Emergency Medicine, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
- b Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
- d Penn Injury Science Center, University of Pennsylvania , Philadelphia , Pennsylvania
| | - Yanlan Huang
- a Behavioral Science and Analytics for Injury Reduction (BeSAFIR) Lab, Department of Emergency Medicine, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
- h Department of Medicine, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
| | - Kathryn A Saulsgiver
- a Behavioral Science and Analytics for Injury Reduction (BeSAFIR) Lab, Department of Emergency Medicine, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
- b Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
- c Center for Health Incentives and Behavioral Economics , University of Pennsylvania , Philadelphia , Pennsylvania
- h Department of Medicine, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
| | - Yi-Ching Lee
- j Department of Psychology , George Mason University , Fairfax , Virginia
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Abstract
School violence is a public health issue with direct and collateral consequences that has academic and social impacts for youth. School violence is often considered a uniquely urban problem, yet more research is needed to understand how violence in rural and suburban schools may be similar or different from urban counterparts. Using school violence data from a state with urban, suburban, and rural counties, we explored the landscape of school violence in Pennsylvania (PA) through mapping, descriptive statistics, and factor analysis. Results show school violence is not solely an urban problem. Schools in all county types and across grade levels deal with violence to varying degrees, and the majority of schools across county types experience low levels of violence. Types of violence experienced by PA schools loaded onto three factors, suggesting that targeted interventions may be better suited to addressing school violence.
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Affiliation(s)
- Kalen Flynn
- 1 School of Social Policy & Practice, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Bernadette A D'Alonzo
- 3 Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Vicky Tam
- 4 Cartographic Modeling Lab, University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas J Wiebe
- 3 Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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McDonald CC, Brawner BM, Fargo J, Swope J, Sommers MS. Development of a Theoretically Grounded, Web-Based Intervention to Reduce Adolescent Driver Inattention. J Sch Nurs 2017; 34:270-280. [PMID: 28553750 DOI: 10.1177/1059840517711157] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Motor vehicle crashes are the leading cause of adolescent death. Inattention to the roadway contributes to crash risk and often results from distractions, such as cell phone calls, texting, and peer passengers. We report on the development of a web-based intervention based on the Theory of Planned Behavior that aims to reduce adolescent driver inattention ( Let's Choose Ourselves). In Phase I, we collected qualitative and quantitative data on adolescents' attitudes, perceived behavioral control, and subjective norms about driver inattention through focus groups with newly licensed adolescent drivers. In Phase II, we developed the content in an e-learning delivery system, performed beta- and pilot testing, and made refinements. In Phase III, we conducted a randomized controlled trial to evaluate feasibility. The development of Let's Choose Ourselves provides information for school nurses regarding intervention development strategies as well as promotion of safe adolescent driving by reducing driver inattention.
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Affiliation(s)
- Catherine C McDonald
- 1 School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.,2 Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,3 Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Jamison Fargo
- 4 Department of Psychology, Utah State University, Logan, UT, USA
| | - Jennifer Swope
- 5 The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marilyn S Sommers
- 1 School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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McDonald CC, Sommers MS. "Good Passengers and Not Good Passengers:" Adolescent Drivers' Perceptions About Inattention and Peer Passengers. J Pediatr Nurs 2016; 31:e375-e382. [PMID: 27496828 PMCID: PMC5124382 DOI: 10.1016/j.pedn.2016.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/21/2016] [Accepted: 07/18/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this qualitative focus group elicitation research study was to explore teen driver perceptions of peer passengers and driver inattention. DESIGN & METHODS We utilized focus groups for data collection and content analysis to analyze the data, both of which were guided by the theory of planned behavior. We conducted 7 focus groups with 30 teens, ages 16-18, licensed for ≤1year to examine attitudes, perceived behavioral control, and norms related to driving inattention and peer passengers. RESULTS The sample was 50% male, mean age 17.39 (SD 0.52) with mean length of licensure 173.7days (SD 109.2). Three themes emerged: 1) "Good and not good" passengers; 2) Passengers and technology as harmful and helpful; and 3) The driver is in charge. CONCLUSIONS While passengers can be a source of distraction, our participants also identified passenger behaviors that reduced risk, such as assistance with technology and guidance for directions. PRACTICAL IMPLICATIONS An understanding of teens' perceptions of peer passengers can contribute to the development of effective interventions targeting teen driver inattention. Nurses are well-positioned to contribute to these teen crash prevention efforts.
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Affiliation(s)
- Catherine C McDonald
- University of Pennsylvania, School of Nursing, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Marilyn S Sommers
- Lillian S. Brunner Professor of Medical-Surgical Nursing, University of Pennsylvania, School of Nursing, Philadelphia, PA
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Affiliation(s)
- Catherine C McDonald
- Assistant Professor, University of Pennsylvania, School of Nursing, Claire Fagin Hall, 418 Curie Boulevard, 414, Philadelphia, PA 19104-4217, USA Department of Pediatrics, The Center for Injury Research and Prevention at the Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frederick Rivara
- Department of Pediatrics and Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
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McDonald CC, Kandadai V, Loeb H, Seacrist TS, Lee YC, Winston Z, Winston FK. Simulated Driving Assessment (SDA) for teen drivers: results from a validation study. Inj Prev 2015; 21:145-52. [PMID: 25740939 DOI: 10.1136/injuryprev-2014-041480] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 02/05/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Driver error and inadequate skill are common critical reasons for novice teen driver crashes, yet few validated, standardised assessments of teen driving skills exist. The purpose of this study is to evaluate the construct and criterion validity of a newly developed Simulated Driving Assessment (SDA) for novice teen drivers. METHODS The SDA's 35 min simulated drive incorporates 22 variations of the most common teen driver crash configurations. Driving performance was compared for 21 inexperienced teens (age 16-17 years, provisional license ≤90 days) and 17 experienced adults (age 25-50 years, license ≥5 years, drove ≥100 miles per week, no collisions or moving violations ≤3 years). SDA driving performance (Error Score) was based on driving safety measures derived from simulator and eye-tracking data. Negative driving outcomes included simulated collisions or run-off-the-road incidents. A professional driving evaluator/instructor (DEI Score) reviewed videos of SDA performance. RESULTS The SDA demonstrated construct validity: (1) teens had a higher Error Score than adults (30 vs. 13, p=0.02); (2) For each additional error committed, the RR of a participant's propensity for a simulated negative driving outcome increased by 8% (95% CI 1.05 to 1.10, p<0.01). The SDA-demonstrated criterion validity: Error Score was correlated with DEI Score (r=-0.66, p<0.001). CONCLUSIONS This study supports the concept of validated simulated driving tests like the SDA to assess novice driver skill in complex and hazardous driving scenarios. The SDA, as a standard protocol to evaluate teen driver performance, has the potential to facilitate screening and assessment of teen driving readiness and could be used to guide targeted skill training.
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Affiliation(s)
- Catherine C McDonald
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA The Center for Injury Research and Prevention at The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Venk Kandadai
- The Center for Injury Research and Prevention at The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Helen Loeb
- The Center for Injury Research and Prevention at The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Thomas S Seacrist
- The Center for Injury Research and Prevention at The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yi-Ching Lee
- The Center for Injury Research and Prevention at The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Zachary Winston
- The Center for Injury Research and Prevention at The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Flaura K Winston
- The Center for Injury Research and Prevention at The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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