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Introduction: This study analyzed the content of intermediate licensing restrictions of all 50 US states and examined the variation in strictness and language of four restriction categories: minimum age, nighttime driving restrictions, passenger restrictions, and traffic violation penalties. Methods: We analyzed state intermediate licensing restrictions using data from four online sources (AAA Guide to Teen Driver Safety, National Conference of State Legislatures, Teen Driving Laws, and Insurance Institute for Highway Safety). Two trained coders independently coded the content of the restrictions, identified four restricted categories and subthemes for each category, and scored each subtheme from 0 to 2, with a higher score indicating a stricter restriction. Direct quotes from state laws were identified to support each subtheme. Results: All 50 states included a minimum age for obtaining an intermediate license. Of 50 states, 49 (98.0%) contained nighttime driving restrictions, 46 (92.0%) contained passenger restrictions, and 43 (86.0%) included traffic violation penalties. Variations existed in the minimum age for an intermediate license and length required in the learner permit phase, the starting time and length of the nighttime driving restrictions, the number and age of passengers in passenger restrictions, the minimum time the driver needs to be violation-free before obtaining a full license, and the type and severity of traffic violation penalties. Conclusions: Although all states have intermediate licensing restrictions, variations exist in the strictness and language of these restrictions. Future research should assess how these variations impact driving safety among teens when they first start driving unsupervised.

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

To determine if a resilience training program improved knowledge of and intention to use adaptive coping strategies among college student-athletes; and explore college student-athletes' experiences and satisfaction with program components.

Objective To examine the association of objectively measured, self-paced physical and cognitive activities across the first week postconcussion with symptom resolution in youth. Setting Emergency department or concussion clinics. Participants Youth aged 11 to 17 years with physician-confirmed concussion. Design Prospective cohort with repeated measures. Main measures Days from injury to symptom resolution, based on daily ratings by youth on the Post-Concussive Symptom Scale. Physical and cognitive activities were assessed using an ActiGraph and a Narrative Clip, respectively. Results A total of 83 youth participants were included (n = 54 [65%] males; mean age = 14.2 years, SD = 1.9). While self-paced daily physical and cognitive activities increased across the first week postinjury, daily postconcussion symptoms decreased. Increased daily step count was associated with an increased likelihood of early symptom resolution (hazard ratio [HR] = 1.17; 95% confidence interval [CI], 1.02-1.34). However, this association was not statistically significant after adjusting for acute postconcussion symptoms and other covariates. Greater school attendance time was associated with earlier symptom resolution (adjusted HR = 1.14; 95% CI, 1.02-1.27). Conclusion Self-paced physical and cognitive activities across the first week postinjury alone neither hastened nor prolonged concussion recovery. Youth with concussion may have some latitude to determine their activity levels.

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

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

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

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

Evidence suggests that pediatric traumatic brain injury (TBI) may be causally related to alcohol misuse later in life; however, the nature and extent of the association has not been well described. This study examined the relationship between pediatric TBI and adult alcohol misuse in a population sample ≥20 years of age. We sought to determine (1) whether first self-reported incidence of TBI with loss of consciousness (LOC) before the age of 20 increased the risk for alcohol misuse later in life; and (2) whether sex, injury severity, and age at time of injury modified the association. We found a greater likelihood of binge but not heavy drinking for those whose first self-reported TBI with LOC occurred before the age of 20 when compared with those whose first self-reported TBI with LOC occurred later in life (28.5% vs. 20.4%

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

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

Background The aim of this study was to investigate the epidemiological characteristics of pediatric traumatic brain injury (TBI) requiring hospitalization in Chinese children ≤17 years of age according to sex and age group. Methods This study retrospectively analyzed pediatric TBI inpatient data obtained via electronic health records from one children's hospital in China. Patients aged ≤17 years admitted to the hospital due to TBI between 1 January 2013 and 31 December 2015 were identified using International Classification of Diseases (ICD) -9 and ICD-10 codes. The demographic, injury, and hospitalization characteristics were analyzed by sex and age groups. Results The subject consisted of 1,087 pediatric TBI patients admitted to the hospital (61.5% boys). The highest proportion of hospitalization was observed in the 1-3 years age group. For both boys and girls, the most common diagnosis was "traumatic epidural hematoma" and the leading mechanism of TBI was "fall". The median length of hospital stay was 8.5 days and the median hospitalization cost was 7,977.4 Chinese yuan (approximately $US 1,140). Conclusions Boys and children aged 1-3 years incurred more pediatric TBI requiring hospitalization than their counterparts. Prevention of falls, the most common injury mechanism in both boys and girls, is an important strategy to reduce pediatric TBI and related hospitalizations.

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

Statement of purpose We investigated the longitudinal and bidirectional association between daily physical activity and postconcussion symptoms (PCS) among concussed youth aged 11–17 years. Methods/Approach We prospectively enrolled youth aged 11–17 years with a physician-confirmed concussion within 72 hours of injury. We measured daily physical activity using an ActiGraph and daily PCS using the Postconcussion Symptom Scale from day 1 to day 7 postinjury. We grouped daily step count and PCS into three waves: days 1–3 (Wave 1), days 4–5 (Wave 2), and days 6–7 (Wave 3) postinjury. We examined the bidirectional associations between daily step counts and PCS in the 3-wave, longitudinal design using both a traditional cross-lagged panel model (CLPM) and a random-intercept cross-lagged panel model (RI-CLPM). Results Participants included 83 concussed youth (54 boys [65%]; mean age 14.2 years; 59 White participants [72%]; and 70 sports-related concussions [84%]). The mean daily step counts were 9,167 at Wave 1, 10,143 at Wave 2, and 10,786 at Wave 3, while the mean daily PCS scores were 27.7, 21.0, and 15.9. In the CLPM, daily step counts and PCS scores showed significant positive autoregressive associations across all waves. In contrast, in the RI-CLPM, the only significant autoregressive association was the path for PCS scores from Wave 1 to Wave 2 (p=.002). In the CLPM, only one cross-lagged path was significant, with higher PCS scores at Wave 1 being associated with lower daily step counts at Wave 2 (p=.047). No cross-lagged paths were significant in the RI- CLPM. Conclusion While youth who engaged in more physical activity reported fewer PCS, only one cross- lagged association was significant. Future randomized controlled trials are needed to better understand the effects of physical activity on PCS. Significance This study is the first to assess the bidirectional association between physical activity and PCS using cross-lagged panel analyses.

Background Sport-related concussion is a significant public health issue, especially among children and adolescents. A growing body of evidence suggests that athletes who do not immediately report concussion and continue to play while concussed take longer to recover than their counterparts. Yet, many child and adolescent athletes do not immediately report concussion symptoms to a responsible adult. Aim This study examined the utility of the Theory of Planned Behavior (TPB) in predicting concussion reporting intentions and in-season reporting behaviors among high school, Gaelic Athletic Association (GAA) athletes in the Republic of Ireland. Methods High school GAA athletes aged 12-18 years completed surveys at baseline and at three-month follow-up. Concussion-related perceived behavioral control (PBC), attitudes, subjective norms, and reporting intentions were assessed at baseline. In-season concussion reporting behaviors were assessed at three-month follow-up. Hierarchical linear regression models were used to examine the relationship between the constructs of the TPB and baseline reporting intentions. Logistic regression models were used to examine the relationship between the constructs of the TPB and in-season reporting behaviors. All data were collected during the 2016–2017 academic year. Results A total of 153 adolescent athletes were included (n = 102 [66.7%] females; Mage = 14.4 years, [SD = 1.6]). Consistent with the TPB, results revealed that PBC and reporting intentions contributed to the prediction of in-season reporting behaviors. Reporting intentions, in turn, were strongly influenced by PBC, attitudes, and subjective norms. PBC was the strongest predictor of concussion reporting intentions and in-season reporting behaviors; the stronger the athletes’ PBC, the stronger their reporting intentions and the more likely they were to have reported concussion symptoms during the current season. Conclusion Although the findings from the current study must be interpreted cautiously given the small sample size, the findings suggest that the TPB has some utility in the prediction of concussion reporting intentions and reporting behaviors. However, our findings suggest that the TPB should not be used in isolation; other models that incorporate personal factors and environmental constraints may be needed to better our understanding of concussion reporting intentions and behaviors among high school athletes. Concussion education programs that include strategies to enhance PBC over concussion reporting may help improve concussion reporting behaviors among high school athletes.

Purpose To examine the effects of different sources of social support (team vs. family/friends) during recovery from injury on post-injury depression and anxiety symptoms among college student-athletes. Methods College student-athletes from two Big 10 universities were prospectively enrolled at the beginning of the 2007–2008 through 2011–2012 sport seasons and followed for injury. Depression and anxiety scores were assessed at baseline and at multiple time points post-injury until return-to-play. Linear mixed models were used to examine the effects of social support from family/friends or from the team (coaches, athletic trainers, and teammates) during recovery, along with satisfaction with the support received, on changes in post-injury depression and anxiety scores. Results A total of 597 injuries (sustained by 397 athletes) were included in the analysis. Of these injuries, 67% occurred in males, 39.9% occurred during football, and 11.9% were concussions. Average depression and anxiety scores at baseline were 10.7 and 41.3, respectively. Results showed that the quantity of social support received from family/friends during recovery significantly influenced post-injury depression scores (β=0.60, p=0.028). No such relationship was found between social support received from the team and depression scores. Furthermore, overall satisfaction with social support received during recovery, regardless of the source of social support, was negatively associated with post-injury scores in depression (p Conclusion College student-athletes’ satisfaction with the social support received from both family/friends and one’s team post-injury was negatively associated with post-injury depression and anxiety scores. Although family/friends are often a major source of social support post-injury, future efforts are needed to increase social support from one’s team, which in turn may help mitigate the risk of depression and anxiety post-injury. Significance Social support from family/friends or one’s team post-injury may help college student-athletes cope with the psychological impact of injury, reducing post-injury depression and anxiety symptoms.

Purpose Up to one-third of children with concussion develop persistent post-concussion symptoms (PPCS), which can give rise to subsequent problems for years post-injury. This pilot study aimed to (1) monitor gene expression of a panel of salivary miRNAs over time post-concussion and (2) identify biomarkers that differentiate concussed children who develop PPCS from those who do not. Methods Saliva samples were collected from concussed children ages 11–17 at ≤1 week, 2-weeks, and 4-weeks post-injury. Post-concussion symptoms were also monitored daily throughout enrollment. PPCS was defined as a symptom score of 5 or higher than pre-injury level beyond 28 days post-injury. Changes in salivary miRNA expression over time post-injury were analyzed using the NanoString nCounter® human v3 miRNA panel to compare children with and without PPCS. Results Of the 23 children studied (64 saliva samples provided), the average age was 14.4 years, 52.2% were male, and 34.7% (n=8) experienced PPCS. Of the 798 different human miRNAs analyzed, 46 (5.8%) had gene expression levels above threshold in at least 75% of the saliva samples analyzed. Six miRNAs that were differentially expressed in the PPCS group were significantly under expressed within one week of injury (p Conclusion Additional studies are needed to verify our findings and to examine the biological regulatory or inflammatory mechanisms of the differently expressed miRNAs. Significance The identification of clinically-relevant biomarker miRNAs could inform the development of individually-tailored treatment plans for children at risk for PPCS.

Statement of Purpose Current clinical guidelines call for a brief period of rest post-concussion, followed by a gradual return to activities. However, studies to date have relied primarily on self-reported measures to identify levels of rest needed to promote concussion recovery.This study assessed the relationship between objectively measured and self-reported physical and cognitive activities (the inverse of rest) in concussed youth for a period of 7 days post-injury. Methods Youth ages 11 to 17 were enrolled within 72 hours following a physician-diagnosed concussion. We monitored participants’ physical and cognitive activities, including activity duration and intensity, for a 7-day period using an Actigraph (to measure physical activity) and a Narrative Clip (to measure cognitive activity). Participants also completed a daily survey that captured data on their physicial and cognitive activities as well as their post-concussive symptoms from enrollment until symptom resolution. Results A total of 83 concussed youth (Mean age=14.2 years ± 1.9 years) were included, with most being males (65.1%), white (72.3%), and injured in a sporting activity (84.3%). The average symptom score at injury was 39.5. Over half (54.2%) of youth experienced symptoms for >2 weeks. We found no significant correlations between objectively measured and self-reported level of physical activity (duration X intensity). There were only weak correlations between objectively measured and self-reported cognitive activities by level of activity (low: r=0.16, p=0.0022; medium: r=0.16, p=0.0111; high: r=0.31, Conclusions Our findings suggest that Actigraphy is a better tool for measuring physical activity post-concussion than self-reported measures. Additional research is needed to validate tools that measure physical and cognitive activity post-concussion. Significance and Contributions This study furthers our knowledge of objective tools for monitoring physical and cognitive activity post-concussion. Findings of this study provide insight on how best to measure physical and cognitive activity post-concussion.

Statement of Purpose All 50 US States enacted Graduated Driver Licensing (GDL) laws to protect and prevent teens from injuries and death while learning to drive. However, GDL laws differ across states as there are no federally required provisions. This study describes the distribution of the content of state GDL laws in relation to five key law elements: (1) curfew restrictions, (2) passenger restrictions, (3) drug/alcohol use, (4) traffic violations, and (5) cell phone usage. Methods A content analysis was conducted on all 50 US state GDL laws. State GDL laws were independently reviewed and analyzed by two coders. For each GDL law, the written language corresponding to each of the five key elements were coded based on the presence of the element in the state law: 1= present in state law or 0= absent in state law. Variation in the specific language used for the five key law elements across states were identified and described. Results Most state GDL laws included specific language in relation to curfew restrictions (98%), passenger restrictions (94%), and traffic violations (86%). Fewer state laws included specific language on drug/alcohol violations (52%) and cell phone usage (76%). We found great variation in the language used in relation to the five key law elements across states, with curfew times and penalties for traffic violations varying widely across states. Conclusion While all states have GDL laws, variations exist in the law elements included in state laws and the language used in these laws. Future research should examine how these variations in GDL laws may impact crash rates among young drivers. Significance and Contributions This study furthers our knowledge of the content and language used in GDL laws across states as well variations in these laws from state to state.

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

The relationship between cyberbullying and friendship dynamics on adolescent body dissatisfaction was examined. Data from the Irish contribution to the international cross-sectional 2013/2014 Health Behaviour in School-aged Children study were used. Results showed that girls were three times more likely than boys to report that their body is too fat, and adolescents who were cyberbullied were almost twice as likely as adolescents who were not cyberbullied to consider themselves too fat. Stronger friendship dynamics were associated with decreased levels of body dissatisfaction, and friendship dynamics were found to partially mediate the relationship between cyberbullying and body dissatisfaction.

Introduction Despite inherit dangers of horseback riding (HBR), research on HBR-related injuries is sparse. This study used both quantitative and qualitative methods to (1) examine HBR-related injuries treated in emergency departments (EDs) and associated risk factors and (2) explore HBR-related injury experiences and recommendations for prevention strategies from the perspective of riders. Method: We retrospectively analyzed data from the Nationwide Emergency Department Sample (NEDS), identifying HBR-related ED visits between 2010 and 2014. Additionally, we conducted 10 phone interviews with active horseback riders to understand their experiences and perspectives regarding HBR-related injuries and recommendations for prevention measures. Results: A total of 21,899 ED visits for HBR-related injuries were identified. When weighted, these represented 100,964 ED visits in the United States. Females had a consistently higher proportion of ED visits compared to males across the study period, with the proportion of ED visits being highest in females aged 15–19. Most injuries (85.9%) were treated and released from the ED. Three primary themes were identified as key to the prevention of HBR-related injuries: (1) rider safety (e.g., use of protective equipment), (2) external factors (e.g., awareness of environment), and (3) rider and horse interactions (e.g., matching skill level of the rider to the horse). Conclusions: Results indicate that HBR-related injuries treated in EDs are prevalent, with female riders aged 15–19 years having the highest proportion of injuries treated in EDs. Practical Applications: There is a critical need for injury prevention programs that not only promote the use of protective equipment, but that also educate horseback riders on horse behavior, the proper handling of horses, and safe riding practices.

IntroductionAlthough current guidelines for the early clinical management of sports-related concussion (SRC) call for a gradual return-to-activity, the optimal level of rest needed to promote recovery remains unknown. This paper describes the protocol of the Rest Evaluation for Active Concussion Treatment (ReAct) study which objectively measures physical and cognitive rest following SRC and its relation to recovery among youth athletes.Methods and analysisYouth athletes aged 11–17 years are recruited preinjury and enrolled within 72 hours following a physician-diagnosed concussion. Injury information and acute clinical presentation are assessed at the time of injury. Youth participants are prospectively followed to objectively monitor daily physical and cognitive rest using two electronic devices: ActiGraph (to measure physical rest and sleep) and Narrative Clip (to measure cognitive rest), along with self-reported postconcussive symptoms using daily surveys. Other concussion outcomes, including functional outcomes, are assessed by surveying youth and their parents at three time points: (1) within 72 hours of injury, (2) at day 7 postenrolment and (3) at symptom resolution (or a maximum of 45 days postconcussion).Ethics and disseminationThis study has received ethical approval from the Institutional Review Board (IRB) at the participating institution (IRB at Nationwide Children’s Hospital, IRB16-00613). The results of the study will be presented at national and international scientific conferences and published in peer-reviewed journals.

This cohort study investigates whether a bidirectional association exists between daily physical activity and postconcussion symptoms among youths with physician-confirmed concussion.

Although symptom burden and symptom profile severity are independent predictors of post-concussion symptom duration, few studies have examined their effects on prolonged recovery simultaneously. This study examined differences in symptom burden and symptom profile scores between concussed children with prolonged recovery and those with typical recovery. We conducted a retrospective case-control study of concussed children aged 10&ndash, 18 years. Prolonged recovery was defined as symptom duration beyond 28 days post-injury. Symptom burden was measured as total symptom score (TSS) at injury. Symptom profiles included: (1) vestibular, (2) ocular, (3) cognitive/fatigue, (4) migraine, and (5) anxiety. A total of 4380 unique concussions sustained by 3777 patients were included, 80.3% white, 60.0% male, and 44.0% aged 13&ndash, 15 years. The prolonged recovery group had a significantly higher TSS and greater number of symptoms than the typical recovery group (p &lt, 0.001 and p &lt, 0.001, respectively). The prolonged recovery group had significantly higher scores on all five symptom profiles, including vestibular (p &lt, 0.001), ocular (p &lt, 0.001), cognitive/fatigue (p &lt, 0.001), migraine (p &lt, 0.001) and anxiety (p &lt, 0.001), than the typical recovery group, even after adjusting for number of symptoms and other covariates. Further studies using prospective cohort designs are needed to better understand the influence of symptom burden and profiles on pediatric concussion recovery.

Background/aim Sport-related concussion is associated with various short- and long-term health consequences, especially among adolescent athletes. Yet, many concussions go unreported and/or unrecognised. The purpose of this study was to assess high school athletes’ concussion-related knowledge, attitudes, intentions and reporting behaviours, and to explore whether gender differences are evident. Methods A total of 435 high school athletes (52.2% female; mean age, 14.55 ± 1.67 years) participated in the survey. Questions assessed athletes’ knowledge, attitudes, reporting intention and reporting behaviours, in respect to sports-related concussion. Comparisons between male and female athletes were explored using Mann-Whitney tests and chi-squared (χ2) tests as appropriate. Results We found that 60% of the participants stated that they have played in practice or during a game (this season) with concussion symptoms. Males expressed more negative outcomes of concussion reporting and lower concussion reporting intention, compared to females. We found no significant gender differences in concussion-reporting behaviours. Conclusion Our findings suggest that knowledge, favourable attitudes towards reporting and reporting intention alone are not enough to create an environment that encourages the disclosure of concussion symptoms. Health promotion communication campaigns, coupled with concussion education and awareness programmes, should be utilised to further highlight the importance of timely concussion management, and to create a culture in which the reporting of concussion is considered normative.

Concussion education is an important aspect of concussion prevention. The purpose of this study was to investigate the effect of a novel, theory of planned behavior (TPB)-driven concussion education program on secondary school athletes' concussion-reporting relevant cognitions immediately post-intervention and at 3 months follow-up. Data were collected from 428 secondary school athletes during the 2016-2017 academic year: 229 were assigned to an intervention group of which 59 (25.76%) completed assessments at all timepoints; 199 were assigned to a control group of which 153 (76.88%) completed assessments at all timepoints. Using repeated measures ANOVAs, we examined differences in athletes' concussion-reporting cognitions, by group and gender. The program had a significant positive effect on athletes' knowledge (P < 0.01), perceived behavioral control over concussion recognition and reporting (P < 0.01), and reporting intention (P < 0.01). These results were maintained at 3 months follow-up, with the exception of perceived behavioral control. The program did not have a significant effect on athletes' attitudes toward concussion reporting and subjective reporting norms. Results suggest that the TPB may be a useful framework to inform the development of more effective educational programs. There is a need for multi-layered interventions that aim to create sporting environments that encourage positive concussion care seeking behaviors.

Background/Aim: Sports-related concussions are now recognized as a major public health concern. However, despite the association of concussion with short- and long-term health consequences, many young athletes still lack basic knowledge about concussion and seem to believe that concussions may be “toughed out” and do not require medical attention. This study assessed self-reported practice of playing in training or a match while concussed among Gaelic Athletic Association (GAA) athletes in Ireland aged 13–25 years old (M=19.19, SD=3.54). This study also assessed knowledge about and attitudes towards sports-related concussion in GAA players in Ireland. Methods: Using a self-report questionnaire, data were captured electronically on GAA athletes aged 13–25 years old (n=80) regarding knowledge about the detection, assessment and management of sports-related concussion, as well as participant’s attitudes towards concussion and self-reported practice of playing in training or a match while concussed. Data were collected from June to August 2013. Results: This study revealed that approximately one in four athletes reported having played while concussed in practice or during a match. Males were significantly more likely to play while concussed than females (40.9% and 17.2%, respectively). Results from this study indicated participants lack a complete understanding of concussion, as common misconceptions about concussion prevailed. Analyses revealed that participants generally have safe attitudes towards concussion and concussion management. Conclusion: Generating awareness of the potential short- and long-term health consequences of concussion, coupled with the promotion of safer attitudes towards this injury, could minimize the number of players who return-to-play pre-maturely and promote a more safety-conscious sports culture in Ireland.

During the fast switching in Ge2Sb2Te5 phase change memory devices, both the amorphous and fcc crystalline phases remain metastable beyond the fcc and hexagonal transition temperatures respectively. In this work, the metastable electrical properties together with crystallization times and resistance drift behaviour of GST are studied using a high-speed, device-level characterization technique in the temperature range of 300 K to 675 K.

Phase-change memory (PCM) devices are enabled by amorphization- and crystallization-induced changes in the devices' electrical resistances. Amorphization is achieved by melting and quenching the active volume using short duration electrical pulses (similar to ns). The crystallization (set) pulse duration, however, is much longer and depends on the cell temperature reached during the pulse. Hence, the temperature-dependent crystallization process of the phase-change materials at the device level has to be well characterized to achieve fast PCM operations. A main challenge is determining the cell temperature during crystallization. Here, we report extraction of the temperature distribution on a lateral PCM cell during a set pulse using measured voltage-current characteristics and thermal modelling. The effect of the thermal properties of materials on the extracted cell temperature is also studied, and a better cell design is proposed for more accurate temperature extraction. The demonstrated study provides promising results for characterization of the temperature-dependent crystallization process within a cell. Published by AIP Publishing.

Background Sports-related concussion among youth has been identified as a public health problem. As a result, an abundance of concussion education programmes for youth athletes have been developed. Although some of these programmes have resulted in an increase in concussion knowledge, these programmes have failed to increase athletes’ concussion reporting behaviours. Accordingly, research suggests a need for theory-driven concussion interventions that go beyond those that aim at increasing concussion knowledge alone. This study will apply the theory of planned behaviour (TPB) to the development and evaluation of a targeted concussion education programme for athletes aged 13 to 18 years old. The primary aim of this study is to assess the immediate and short-term impact of the programme on intention to report concussion and concussion reporting behaviours; and to explore, the process of implementation and the relationship between this process and the programme’s outcomes. Methods This study will employ a cluster randomised control trial, with data collection at baseline (T0), immediately post-intervention (T1), and three-months after programme implementation (T2). The sample will be comprised of county-level Gaelic Athletic Association (GAA) clubs throughout the Republic of Ireland and will include teams with athletes aged 13 to 18 years old. Using a range of structured questionnaires and qualitative measures, data will be captured on athletes’ (i) attitudes towards concussion and concussion reporting, (ii) subjective norms, (iii) perceived behavioural control, (iv) intention to report concussion, (v) concussion reporting behaviour and (vi) programme fidelity. Results Preliminary results from the evaluation and issues with programme implementation will be presented. Quantitative data will be analysed with SPSS Version 22. Thematic analysis will be used to analyse qualitative data. Conclusions Findings from this evaluation will be used to assess the efficacy of the TPB in programme development and evaluation and will support the knowledge and practice of primary and secondary concussion prevention. Results from the process evaluation will assist in helping understand the context within which the programme was implemented and how these characteristics may affect the quality of implementation.

Background Annually, it is estimated that 3.8 million sports- and recreation-related concussions are sustained in the USA alone, with a particularly high incidence among adolescents. At youth sporting events, however, medical professionals are rarely present. Accordingly, coaches play a crucial role in recognising the signs and symptoms of concussion, and ensuring that players with a suspected concussion are managed correctly. Coaches have also been found to play a central role in reinforcing or undermining a sport culture in which athletes report injuries, including concussion. The aim of this study was to assess perceived ability to assess and manage concussion; and to explore, coaches’ communication practices about concussion safety with their players. Methods Using a self-report questionnaire data were captured on coaches’ communication practices about concussion safety and perceived ability to assess and manage concussion among their athletes. Data was collected electronically from June-September 2015. Results were analysed using SPSS Version 22. Results The final sample consisted of 106 coaches (59 male, 37 female) from the island of Ireland. Results showed that a majority of coaches did not feel equipped to promote concussion education among their athletes (76.5%), determine if a player has sustained a concussion (69.7%) or to help an athlete who obtained a suspected concussion during training or a match (62.6%). Additionally, before the season, a majority of coaches did not talk to their athletes about concussion safety and the importance of concussion reporting. Conclusions Findings from this study suggest that interventions should encourage communication about concussion safety with athletes and should provide coaches with communication skills and strategies about how to do this. Additionally, coach targeted interventions should focus on instructing coaches on how to recognise and manage a suspected concussion in one of their athletes.