Eye-Tracking and Adolescent Interest in Alcohol Responsibility Messages: The Message Matters.

OBJECTIVE: Through the use of eye-tracking technology, this study explores the efficacy of current alcohol responsibility messages viewed by adolescents and proposes the development of new alcohol warning message design. METHOD: An adolescent sample (N = 121; 72 males) was shown 14 advertisements (4 alcohol, 10 non-alcohol) in randomized order featuring messages modified by type size, type contrast, and message content (a 2 × 2 × 2 factorial design). RESULTS: Results suggested that modifying message content to include direct language and a consequence enhances recall and attention to alcohol responsibility messages among adolescents. No significant differences in attentional outcomes were observed for messages that included variances in type size or type contrast. CONCLUSIONS: Overall, to increase attention to and recall of alcohol responsibility messages, the greatest efficacy lies in varying the message itself, irrespective of size or contrast.

Institutionally Based ImPACT Test® Normative Values May Differ from Manufacturer-Provided Normative Values.

OBJECTIVE: The necessity for pre-injury baseline computerized neurocognitive assessments versus comparing post-concussion outcomes to manufacturer-provided normative data is unclear. Manufacturer-provided norms may not be equivalent to institution-specific norms, which poses risks for misclassifying the presence of impairment when comparing individual post-concussion performance to manufacturer-provided norms. The objective of this cohort study was to compare institutionally derived normative data to manufacturer-provided normative values provided by ImPACT® Applications, Incorporated. METHOD: National Collegiate Athletic Association Division 1 university student athletes (n = 952; aged 19.2 ± 1.4 years, 42.5% female) from one university participated in this study by completing pre-injury baseline Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) assessments. Participants were separated into 4 groups based on ImPACT's age and gender norms: males <18 years old (n = 186), females <18 years old (n = 165), males >19 years old (n = 361) or females >19 years old (n = 240). Comparisons were made between manufacturer-provided norms and institutionally derived normative data for each of ImPACT's clinical composite scores: Verbal (VEM) and Visual (VIM) Memory, Visual Motor Speed (VMS), and Reaction Time (RT). Outcome scores were compared for all groups using a Chi-squared goodness of fit analysis. RESULTS: Institutionally derived normative data indicated above average performance for VEM, VIM, and VMS, and slightly below average performance for RT compared to the manufacturer-provided data (χ2 ≥ 20.867; p < 0.001). CONCLUSIONS: Differences between manufacturer- and institution-based normative value distributions were observed. This has implications for an increased risk of misclassifying impairment following a concussion in lieu of comparison to baseline assessment and therefore supports the need to utilize baseline testing when feasible, or otherwise compare to institutionally derived norms rather than manufacturer-provided norms.

Valid but Invalid: Suboptimal ImPACT Baseline Performance in University Athletes.

PURPOSE: This study aimed to investigate the frequency of valid yet suboptimal Immediate Postconcussion Assessment and Cognitive Test (ImPACT) performance in university athletes and to explore the benefit of subsequent ImPACT administrations. METHODS: This descriptive laboratory study involved baseline administration of ImPACT to 769 university athletes per the institution's concussion management protocol. Testing was proctored in groups of ≤2 participants. Participants who scored below the 16th percentile according to ImPACT normative data were readministered the ImPACT test up to two additional times because these scores were thought to be potentially indicative of suboptimal effort or poor understanding of instructions. Descriptive analyses were used to examine validity indicators and individual Verbal and Visual Memory, Visual Motor Speed, and Reaction Time ImPACT composite scores in initial and subsequent administrations. RESULTS: On the basis of ImPACT's validity criteria, 1% (9/769) of administrations were invalid and 14.6% (112/769) had one or more composite score of <16th percentile but were considered valid. After one readministration, 71.4% (80/112) achieved scores of ≥16th percentile and an additional 18 of 32 scored ≥16th percentile after a third administration. Verbal Memory was most commonly <16th percentile on the first administration (43%), Verbal Memory and Visual Motor Speed on the second administration (44% each), and Visual Motor Speed alone on the third administration (50%). CONCLUSIONS: Approximately 16% of ImPACT records were flagged as invalid or had one or more composite scores of <16th percentile, potentially indicative of suboptimal performance. Upon readministration, 88% of those participants scored >16th percentile. Clinicians must be aware of suboptimal ImPACT performance as it limits the clinical utility of the baseline assessment. Further research is needed to address factors leading to "valid" but invalid baseline performance.

A review of post-concussion syndrome and psychological factors associated with concussion.

OBJECTIVE: This study reviewed several topics related to post-concussion syndrome and psychological factors associated with concussion. Topics include neurobiological perspectives, psychological predictors of post-concussion syndrome including pre-morbid anxiety, anxiety sensitivity and cognitive biases and misattribution. In addition, the iatrogenic effects of excessive rest are reviewed and treatment options are discussed briefly. MAIN RESULTS: Animal models of concussion and mild traumatic brain injury suggest that a concussion can result in anxiety and fear reactions. The pathophysiology of depression following a concussion appears to be consistent with the cortico-limbic model of depression. Additionally, some individuals may be at risk for neurobiological depression and/or anxiety following a concussion. The literature also demonstrates that pre-morbid and concurrent anxiety increases the risk for prolonged concussion recovery. Cognitive biases and misattribution of symptoms contribute to lengthy recovery from concussion. In addition, medically prescribed excessive cognitive and physical rest may contribute to a protracted concussion recovery. Supervised and graduated physical activity, the introduction of anxiety reduction techniques and cognitive-behavioural therapy of cognitive biases and misattribution are effective means of shortening the length of post-concussion syndrome. CONCLUSIONS: Understanding, assessing and treating the psychological factors associated with concussion are effective means of preventing or shortening the length of post-concussion syndrome.

Psychiatric and neuropsychological issues in sports medicine.

This article reviews psychiatric/psychological issues in the athletic training room, including recognition of these issues and a framework for management. Because the majority of research has been conducted in college settings, most of the issues discussed are presented in the context of college sports, although the results generalize to other athletic arenas. Greater awareness of psychological issues, empirical research, and education about mental health issues in the sports medicine community are clearly needed.

The relationship between psychological distress and baseline sports-related concussion testing.

OBJECTIVE: This study examined the effect of psychological distress on neurocognitive performance measured during baseline concussion testing. DESIGN: Archival data were utilized to examine correlations between personality testing and computerized baseline concussion testing. Significantly correlated personality measures were entered into linear regression analyses, predicting baseline concussion testing performance. Suicidal ideation was examined categorically. SETTING: Athletes underwent testing and screening at a university athletic training facility. PARTICIPANTS: Participants included 47 collegiate football players 17 to 19 years old, the majority of whom were in their first year of college. INTERVENTIONS: Participants were administered the Concussion Resolution Index (CRI), an internet-based neurocognitive test designed to monitor and manage both at-risk and concussed athletes. Participants took the Personality Assessment Inventory (PAI), a self-administered inventory designed to measure clinical syndromes, treatment considerations, and interpersonal style. MAIN OUTCOME MEASURES: Scales and subscales from the PAI were utilized to determine the influence psychological distress had on the CRI indices: simple reaction time, complex reaction time, and processing speed. RESULTS: Analyses revealed several significant correlations among aspects of somatic concern, depression, anxiety, substance abuse, and suicidal ideation and CRI performance, each with at least a moderate effect. When entered into a linear regression, the block of combined psychological symptoms accounted for a significant amount of baseline CRI performance, with moderate to large effects (r = 0.23-0.30). When examined categorically, participants with suicidal ideation showed significantly slower simple reaction time and complex reaction time, with a similar trend on processing speed. CONCLUSIONS: Given the possibility of obscured concussion deficits after injury, implications for premature return to play, and the need to target psychological distress outright, these findings heighten the clinical importance of screening for psychological distress during baseline and post-injury concussion evaluations.

A multidisciplinary program to educate and advocate for living donors.

Education is critical in decision making and the informed consent process in prospective living donors. Little has been written about how and what living donors should be taught. This article describes a multidisciplinary program for living donor education at the University of Virginia. The goals of the program are to impart information needed for prospective donors to make an informed decision and to independently evaluate donors' medical and psychosocial suitability. A partnership between the transplant department and an independent donor advocacy team establishes an environment conducive to education. By embracing independence, transparency, partnership, and advocacy, our program permits bidirectional education. This partnership facilitates unbiased understanding and appreciation of this education and considers each individual's unique circumstances when making informed decisions. Likewise, prospective donors educate the team about their circumstances, which helps the team safeguard the prospective donor and may enhance the safety of prospective donors and the perceived integrity of living organ donation.

Psychiatric and neuropsychological issues in sport medicine.

This article reviews what is known about training room psychiatric/psychological issues and how to recognize them, and provides an initial framework for how to manage them. There is some focus on psychiatric issues involved in collegiate sports medicine environments, because the majority of research on this topic has been done with this population, but it is believed that this information generalizes to other athletic settings. Greater awareness of these problems, empirical research, and education about mental health issues in the sports medicine community is clearly needed.

Sex differences in outcome following sports-related concussion.

OBJECT: Females comprise an increasing percentage of the athlete population across all age groups, and analysis of recent literature reveals that they sustain more concussions in collegiate sports. Results of human and animal studies indicate that females may have poorer outcomes after traumatic brain injury; however, no return-to-play guideline takes sex or other individual differences into account. In the present study the authors evaluated the influence of patient sex on objective neurocognitive performance and subjective reporting of symptoms following sports-related concussion. METHODS: According to preseason baseline neurocognitive computerized testing in 2340 male and female high school and collegiate athletes, individuals who sustained sports-related concussions (155 persons) were reevaluated using an alternate form of the cognitive test. Sex differences in the magnitude of cognitive change from baseline levels and the subjective experience of symptoms were analyzed. To account for the possible protective effects of helmets, comparisons were performed among females, males with helmets, and males without helmets; none of the female athletes wore helmets. Female athletes had significantly greater declines in simple and complex reaction times relative to preseason baseline levels, and they reported more postconcussion symptoms compared with males. As a group, females were cognitively impaired approximately 1.7 times more frequently than males following concussions. Furthermore, females experienced more objective and subjective adverse effects from concussion even after adjusting for the use of helmets by some groups of male athletes (for example, in football). CONCLUSIONS: Return-to-play decisions and concussion management must be objective and made on an individual basis, including consideration of factors such as patient sex rather than relying on a one-size-fits-all guideline.

Symptom-based assessment of the severity of a concussion.

OBJECT: Current grading systems of concussion and return-to-play guidelines have little empirical support. The authors therefore examined the relationships of the characteristics and symptoms of concussion and the history of concussion to three indicators of concussion severity-number of immediate symptoms, number of symptoms at the initial follow-up examination, and duration of symptoms--to establish an empirical basis for grading concussions. METHODS: Forty-seven athletes who sustained concussions were administered alternate forms of an Internet-based neurocognitive test until their performances were within normal limits relative to baseline levels. Assessments of observer-reported and self-reported symptoms at the sideline of the playing field on the day of injury, and at follow-up examinations were also obtained as part of a comprehensive concussion management protocol. Although loss of consciousness (LOC) was a useful indicator of the initial severity of the injury, it did not correlate with other indices of concussion severity, including duration of symptoms. Athletes reporting memory problems at follow-up examinations had significantly more symptoms in general, longer durations of those symptoms, and significant decreases in scores on neurocognitive tests administered approximately 48 hours postinjury. This decline of scores on neurocognitive testing was significantly associated with an increased duration of symptoms. A history of concussion was unrelated to the number and duration of symptoms. CONCLUSIONS: This paper represents the first documentation of empirically derived indicators of the clinical course of postconcussion symptom resolution. Self-reported memory problems apparent 24 hours postconcussion were robust indicators of the severity of sports-related concussion and should be a primary consideration in determining an athlete's readiness to return to competition. A decline on neurocognitive testing was the only objective measure significantly related to the duration of symptoms. Neither a brief LOC nor a history of concussion was a useful predictor of the duration of postconcussion symptoms.

Assessing cognitive dysfunction in breast cancer: what are the tools?

The goal of adjuvant chemotherapy in the treatment of breast cancer is to reduce recurrence and mortality. With respect to quality of life and morbidity, however, such treatments come at a cost. Decreased cognitive functioning, development of fatigue, and mood alterations are common during chemotherapy and persist after its conclusion as evidenced by subjective self-reports and objective neurocognitive performance records. Few efforts, however, have used standardized neuropsychological measures, and no study has empirically selected those measures that best distinguish women in active chemotherapy from those who have previously completed it. Perhaps the most glaring deficit in the literature is that no study has used baseline data to track individual neurocognitive changes across treatment phases and after completion. This article provides an overview of the field of neuropsychology and the cognitive domains theorized to be affected by chemotherapy and the measures typically used, including validated computerized tests, which are tools for future studies; briefly summarizes existing research on the cognitive effects that chemotherapy has on breast cancer patients; compares data resulting from an ongoing pilot study of the cognitive performance of women actively undergoing anthracycline-containing chemotherapy with that of women 6-12 months post chemotherapy completion; and provides a preliminary analysis of the relationship between cognitive and emotional functioning. Future uses of these data to refine the ideal tools that efficiently, accurately, and validly detect short-term and persistent chemotherapy effects are proposed.

Acceleration-Deceleration Sport-Related Concussion: The Gravity of It All.

OBJECTIVE: To discuss a newtonian physics model for understanding and calculating acceleration-deceleration forces found in sport-related cerebral concussions and to describe potential applications of this formula, including (1) an attempt to measure the forces applied to the brain during acceleration-deceleration injuries, (2) a method of accruing objective data regarding these forces, and (3) use of these data to predict functional outcome, such as neurocognitive status, recovery curves, and return to play. BACKGROUND: Mild concussion in sports has gained considerable attention in the last decade. Athletic trainers and team physicians have attempted to limit negative outcomes by gaining a better understanding of the mechanisms and severity of mild head injuries and by developing meaningful return-to-play criteria. Mild head injury in sports has become an even greater area of focus and concern, given the negative neurobehavioral outcomes experienced by several recent high-profile professional athletes who sustained repeated concussions. Applying the principles of physics to characterize injury types, injury severity, and outcomes may further our development of better concussion management techniques and prevention strategies. DESCRIPTION: We describe the search for models to explain neuronal injury secondary to concussion and provide an exploratory method for quantifying acceleration-deceleration forces and their relationship to severity of mild head injury. Implications for injury prevention and reduction of morbidity are also considered.