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ObjectiveTo quantify variability in pediatric concussion recovery across multiple outcomes of interest.BackgroundPediatric concussion studies are hindered by a common significant limitation: lack of agreement on a standard definition of “recovery.” A variety of clinical outcomes of interest utilized across studies, including symptom self-report, neurocognitive testing results, self-reported return to activity, and physician clearance for activity, leads to challenges for both research, as well as clinical concussion management.Design/MethodsWe enrolled concussed youth, ages 11–18 years, from a specialty sports medicine clinic = 28 days of injury. Patients were followed as part of clinical care for concussion for up to 13 weeks. At each visit, participants completed questionnaires and a battery of clinical measures. From these data, we constructed 10 potential definitions of recovery: 3 based on self-reported symptoms (change from pre-injury, no symptoms, below pre-determined thresholds), 2 based on visio-vestibular examination (VVE) deficits (none, = 1), 2 based on physician clearance (for return to school/sport), and 3 based on self-assessment (“back to normal”, return to school/exercise).ResultsOne hundred seventy-four concussed youth were enrolled (median age: 15 years, 54.6% female) with a median time from injury to initial visit of 12 days (IQR: 7, 20). Median number of visits was 2 (range: 1, 5). We observed a wide variation in the proportion of participants recovered across the 10 definitions. Depending on definition, between 4% and 45% were considered recovered within 4 weeks, and between 10% and 80% were considered recovered at the end of follow-up. The VVE-based definition (=1 deficit) consistently had the highest proportion recovered at all time points, while self-reported return to exercise had the lowest proportion.ConclusionsRecovery from concussion is not a single unitary point in time. These results will provide valuable guidance to clinicians in managing concussion and researchers in designing future observational and interventional trials of pediatric concussion.

ObjectiveTo explore the utility of an eye-tracking assessment in distinguishing binocular alignment, saccadic movement, and pupillary dynamics among uninjured adolescents, acute cases (= 28 days since concussion), and persistent cases (>28 days since concussion).BackgroundVisual and autonomic system disturbances are common sequelae of concussion. Quantification of visual and autonomic dysfunction via an eye tracking device could provide an objective method of acute diagnosis and subacute identification of ongoing injury.Design/MethodsWe compared 347 eye tracking metrics, derived from a 220 seconds eye-tracking assessment, among 132 uninjured adolescents (mean age: 15.3, 56.2% female), 110 acute cases (mean days since injury: 12.5, mean age: 15.4, 46.4% female), and 95 persistent cases (mean days since injury: 53.6, mean age: 15.4, 70.2% female) using Kruskal-Wallis tests with Bonferroni corrections to account for multiple comparisons.ResultsNine eye-tracking metrics were significantly associated with injury status. One measure of binocular alignment (acute v. control: p = 0.003, persistent v. control: p = 0.001) and one measure of saccadic movement (acute v. persistent: p = 0.03, acute v. control: p = 0.03, persistent v. control: p < 0.001) were worse in cases. Cases had larger left and right mean and median pupil size than uninjured adolescents (acute v. control, p < 0.001; persistent v. control, p < 0.001). Cases had greater differences in mean (acute v. control: p < 0.001, persistent v. control: p < 0.001), median (acute v. control, p < 0.001, persistent v. control, p = 0.003), and variance of (acute v. control: p < 0.001, persistent v. control: p < 0.001) left and right pupil size. Eight of these metrics distinguished female cases from uninjured adolescents, but similar differences were not observed in male participants.ConclusionsObjective eye tracking technology can identify vision and pupillary disturbances after concussion. These metrics could be integrated into clinical practice to monitor recovery in a heterogeneous adolescent concussion population and may identify sex-specific differences in autonomic dysfunction.

Background The adoption of tobacco-free policies in behavioral health settings is an important step in reducing staff tobacco use as well as the high rates of tobacco use among people with mental illness and behavioral disorders. Studies have demonstrated the importance of staff support when implementing tobacco-free workplace policies, but there is limited research examining tobacco use prevalence among staff and staff attitude before and after policy adoption. Community context Integral Care, a local authority for behavioral health and developmental disabilities in Austin, Texas, and Austin Public Health embarked on a comprehensive planning process before implementing a 100% tobacco-free campus policy. The objectives were 1) assess staff tobacco use and attitudes toward a tobacco-free policy, 2) communicate policy to staff, 3) provide staff education and training, and 4) provide cessation resources. Methods Integral Care and Austin Public Health conducted a web-based employee survey 6 months before and 6 and 12 months after implementation of the policy to measure tobacco use prevalence and attitudes among employees. Outcome Employees had significant improvements in tobacco use prevalence and attitudes toward the tobacco-free policy from pre-implementation to post-implementation. Tobacco use prevalence among staff decreased from 27.6% to 13.8%, and support for the policy increased from 60.6% to 80.3% at 12 months post-implementation. Interpretation Adoption of 100% tobacco-free campus policies in behavioral health settings can result in significant reductions in staff tobacco use. Leadership should provide staff with education, training, and cessation support before adoption of tobacco-free work site policies to ensure success.

ObjectiveOn April 17, 2013, a fire and subsequent explosion occurred at the West Fertilizer Company plant in West, Texas, and caused extensive damage to the adjacent neighborhood. This investigation described the fatal and nonfatal injuries caused by the explosion.MethodsPersons injured by the fertilizer plant explosion were identified through death certificates, medical examination reports, medical records, and survivor interviews. Data on patient characteristics, type of injury, and location of injury were collected.ResultsMedical record review indicated that 252 individuals sought medical care for nonfatal injuries directly related to the explosion immediately after the explosion. Fifteen patients died of injuries sustained by the blast. Almost one-quarter of patients were admitted for treatment of injuries. Injuries sustained in the explosion included abrasions/contusions, lacerations/penetrating trauma, traumatic brain injuries/concussions, tinnitus/hearing problems, eye injuries, and inhalational injuries. Patients located closer to the explosion were more likely to be admitted to the hospital for treatment of injuries than were those who were located further away.ConclusionExplosions of this magnitude are rare, but can inflict severe damage to a community and its residents. This investigation could be a useful planning resource for other communities, public health agencies, first responders, and medical facilities. (Disaster Med Public Health Preparedness. 2016;10:583–590)

Objectives: Child Restraint System (CRS) misuse is common. We characterized caregivers’ use of child passenger safety informational and instructional resources and determined whether there were differences in the quality of CRS installations associated with prior exposure to specific resources as evaluated in a standardized CRS installation environment. Methods: Caregivers completed self-report surveys and installed a forward-facing CRS in a controlled environment. Installations were evaluated for security (tightness) and accuracy (no errors) by a child passenger safety technician (CPST). Results: CRS manuals were the most common way caregivers learned to install a CRS. Primary care providers (PCP)s were the most frequently endorsed source of CRS safety information. There was no strong pattern of associations between prior exposure to resources and installation quality (security or accuracy), although some evidence supports protective effects of learning from CPSTs; 13% (19 out of 151) installations were secure and 57% (86 out of 151) installations were accurate. Conclusions: A focus on developing effective and lasting behavioral interventions is needed.