The Burden of Hepatitis A Outbreaks in the United States: Health Outcomes, Economic Costs, and Management Strategies.

BACKGROUND: Hepatitis A (HepA) vaccines are recommended for US adults at risk of HepA. Ongoing United States (US) HepA outbreaks since 2016 have primarily spread person-to-person, especially among at-risk groups. We investigated the health outcomes, economic burden, and outbreak management considerations associated with HepA outbreaks from 2016 onwards. METHODS: A systematic literature review was conducted to assess HepA outbreak-associated health outcomes, health care resource utilization (HCRU), and economic burden. A targeted literature review evaluated HepA outbreak management considerations. RESULTS: Across 33 studies reporting on HepA outbreak-associated health outcomes/HCRU, frequently reported HepA-related morbidities included acute liver failure/injury (n = 6 studies of 33 studies) and liver transplantation (n = 5 of 33); reported case fatality rates ranged from 0% to 10.8%. Hospitalization rates reported in studies investigating person-to-person outbreaks ranged from 41.6% to 84.8%. Ten studies reported on outbreak-associated economic burden, with a national study reporting an average cost of over $16 000 per hospitalization. Thirty-four studies reported on outbreak management; challenges included difficulty reaching at-risk groups and vaccination distrust. Successes included targeted interventions and increasing public awareness. CONCLUSIONS: This review indicates a considerable clinical and economic burden of ongoing US HepA outbreaks. Targeted prevention strategies and increased public awareness and vaccination coverage are needed to reduce HepA burden and prevent future outbreaks.

The Burden of Hepatitis A Outbreaks in the United States: Health Outcomes, Economic Costs, and Management Strategies.

BACKGROUND: Hepatitis A (HepA) vaccines are recommended for United States (US) adults at risk of HepA. Ongoing US HepA outbreaks since 2016 have primarily spread person-to-person, especially among at-risk groups. We investigated the health outcomes, economic burden, and outbreak management considerations associated with HepA outbreaks from 2016 onwards. METHODS: A systematic literature review was conducted to assess HepA outbreak-associated health outcomes, healthcare resource utilization (HCRU), and economic burden. A targeted literature review evaluated HepA outbreak management considerations. RESULTS: Across 33 studies reporting on HepA outbreak-associated health outcomes/HCRU, frequently reported HepA-related morbidities included acute liver failure/injury (n=6 studies/33 studies) and liver transplantation (n=5/33); reported case fatality rates ranged from 0-10.8%. Hospitalization rates reported in studies investigating person-to-person outbreaks ranged from 41.6-84.8%. Ten studies reported on outbreak-associated economic burden, with a national study reporting an average cost of over $16,000 per hospitalization. Thirty-four studies reported on outbreak management; challenges included difficulty reaching at-risk groups and vaccination distrust. Successes included targeted interventions and increasing public awareness. CONCLUSIONS: This review indicates a considerable clinical and economic burden of ongoing US HepA outbreaks. Targeted prevention strategies and increased public awareness and vaccination coverage are needed to reduce HepA burden and prevent future outbreaks.

Early targeted heart rate exercise is safe and May hasten return-to-duty in service members with acute concussion, a preliminary study.

OBJECTIVE: To evaluate the feasibility of an exercise tolerance assessment and intervention added to the Progressive Return to Activity Clinical Recommendations (PRA-CR) in acutely concussed service members (SMs). METHODS: This non-randomized, pilot trial was performed at one center. SMs in the experimental group (ERG) performed the Buffalo Concussion March-in-place Test (BCMT) at every clinic visit and were prescribed at least 20 minutes/day of targeted exercise in addition to PRA-CR. Data for the control group (SCG) were extracted from the same clinic immediately prior to ERG. SMs in both groups were assessed by the same clinician to determine return-to-duty. RESULTS: BCMT identified concussion-related exercise intolerance in 100% (n = 14) at screening visit (mean 3.4 days after injury) and in 0% (n = 7) who had recovered. No adverse effects were associated with BCMT. The estimated recovery time for ERG who performed the exercise intervention (n = 12) was 17.0 (12.8, 21.2) days and for SCG (n = 15) was 23.7 (19.9, 27.5) days (p = 0.039). CONCLUSION: Assessment of exercise tolerance was feasible and could be incorporated into the PRA-CR. Future definitive, randomized controlled trials should be performed to assess the effectiveness of exercise reset program for SMs after concussion.

Historical Population-Level Impact of Infant 13-Valent Pneumococcal Conjugate Vaccine (PCV13) National Immunization Programs on Invasive Pneumococcal Disease in Australia, Canada, England and Wales, Israel, and the United States.

INTRODUCTION: This study estimates the annual population-level impact of 13-valent pneumococcal conjugate vaccine (PCV13) infant national immunization programs (NIPs) on vaccine-type and non-vaccine type invasive pneumococcal disease (IPD) incidence across all ages using national surveillance data. METHODS: We identified countries (Australia, Canada, England and Wales, Israel, and the US) with national IPD active surveillance data that introduced the seven-valent PCV (PCV7) followed by PCV13, which also reported annual serotype- and age group-specific incidence. We extracted IPD incidence by serotype groupings [PCV13 minus PCV7 (PCV13-7) serotypes; PCV13-7 serotypes excluding serotype 3; non-PCV13 serotypes; and the 20-valent (PCV20) minus PCV13 (PCV20-13) serotypes] and by age groups (< 2 years, 2-4 years, 5-17 years, 18-34 years, 35-49 years, 50-64 years, and ≥ 65 years). For each country, we calculated the annual relative change in IPD incidence (percent change), and the corresponding incidence rate ratio (IRR), for 7 years post introduction compared to the year prior to PCV13 program initiation. RESULTS: PCV13-7 vaccine-type IPD incidence consistently decreased over time following introduction of PCV13 across countries, reaching an approximate steady state after 3-4 years in ages < 5 years, with roughly 60-90% decrease (IRRs = 0.1-0.4) and after 4-5 years in ages ≥ 65 years with approximately 60-80% decrease (IRRs = 0.2-0.4). Incidence declines were more substantial for the PCV13-7 grouping when excluding serotype 3. Non-PCV13 serotype incidence was variable by country and age group, ranging from virtually no serotype replacement compared to the PCV7 period across ages in the US to increases for other countries ranging from 10 to 204% (IRRs = 1.10-3.04) in children < 5 years and 41% to 123% (IRRs = 1.41-2.23) in ages ≥ 65 years. CONCLUSIONS: Countries with longstanding PCV13 infant NIPs have observed substantial direct and indirect benefits, which are demonstrated in this study by the reduction in PCV13-7 IPD incidence compared to PCV7 period in all age groups. Over time, non-PCV13 serotypes have emerged in response to the reduction of incidence of PCV13-unique serotypes. Higher-valent PCVs are needed to address this emerging pneumococcal disease burden as well as the direct vaccination of both pediatric and adult populations against the most prevalent circulating serotypes.

Pneumococcal Vaccination in Children: A Systematic Review and Meta-Analysis of Cost-Effectiveness Studies.

OBJECTIVES: Pneumococcal conjugate vaccines (PCVs) have significantly reduced disease burden caused by Streptococcus pneumoniae, a leading cause of childhood morbidity and mortality globally. This systematic review and meta-analysis aimed to assess the incremental net benefit (INB) of the 13-valent PCV (PCV13) and 10-valent PCV (PCV10) in children. METHODS: We performed a comprehensive search in several databases published before May 2022. Studies were included if they were cost-effectiveness or cost-utility analyses of PCV13 or PCV10 compared with no vaccination or with each other in children. Various monetary units were converted to purchasing power parity, adjusted to 2021 US dollars. The INBs were calculated and then pooled across studies stratified by country income level, perspective, and consideration of herd effects, using a random-effect model. RESULTS: Seventy studies were included. When herd effects were considered, PCV13 was cost-effective compared with PCV10 from the payer perspective in both high-income countries (HICs) (INB, $103.94; 95% confidence interval, $75.28-$132.60) and low- and middle-income countries (LMICs) (INB, $53.49; 95% confidence interval, $30.42-$76.55) with statistical significance. These findings were robust across a series of sensitivity analyses. PCV13 was cost-effective compared with no vaccination across perspectives and consideration of herd effects in both HICs and LMICs, whereas findings were less consistent for PCV10. CONCLUSION: PCVs were generally cost-effective compared with no vaccination in HICs and LMICs. Our study found that PCV13 was cost-effective compared with PCV10 when herd effects were considered from the payer perspective in both HICs and LMICs. The results are sensitive to the consideration of herd effects.

Association of Concussion History and Prolonged Recovery in Youth.

OBJECTIVE: To determine the number of prior concussions associated with increased incidence of persistent postconcussive symptoms (PPCS) in a cohort of acutely concussed pediatric patients. DESIGN: Prospective observational cohort study. SETTING: Three university-affiliated concussion clinics. PARTICIPANTS: Two hundred seventy participants (14.9 ± 1.9 years, 62% male, 54% with prior concussion) were assessed within 14 days of concussion and followed to clinical recovery. Participants with a second head injury before clinical recovery were excluded. MEASURES AND MAIN OUTCOME: Concussion history, current injury characteristics, recovery time, and risk for prolonged recovery from current concussion. RESULTS: There was no statistically significant change in PPCS risk for participants with 0, 1 or 2 prior concussions; however, participants with 3 or more prior concussions had a significantly greater risk of PPCS. Twelve participants sustained a subsequent concussion after clinical recovery from their first injury and were treated as a separate cohort. Our secondary analysis found that these participants took longer to recover and had a greater incidence of PPCS during recovery from their latest concussion. CONCLUSION: Pediatric patients with a history of 3 or more concussions are at greater risk of PPCS than those with fewer than 3 prior concussions.

Utilization of an implementation framework to obtain provider perspectives of pharmacist-led clinical services.

BACKGROUND: Pharmacist integration into health care teams has been shown to improve patients' clinical outcomes and satisfaction with care. Medication therapy management (MTM) has been implemented in a variety of pharmacy practice settings. Pharmacist-provided medication reviews, a core element of MTM, have been shown to optimize therapeutic outcomes for patients and identify medication-related problems in a patient's current regimen. Patients receiving care at Federally Qualified Health Centers (FQHCs) often face a number of challenges, such as multiple health conditions, transportation, and medication costs. Pharmacist-provided services can play an important role in providing patient-centered care in FQHCs. Seeking stakeholder input can be valuable to ensure services will benefit both patients and providers. OBJECTIVE: The objective of this study was to obtain provider perspectives of psychological, socioeconomic, and practice-based factors to consider before implementing a pharmacist-led medication review services in an FQHC in north central Indiana. METHODS: Five nurse practitioners employed by an FQHC in north central Indiana were interviewed. Thirty-four questions within 5 general domains were developed using the Consolidated Framework for Implementation Research. Responses were manually transcribed, coded by 3 reviewers, and then summarized using thematic analysis. RESULTS: Within the 5 interviews, a total of 97 codes were identified. The 251 mentions of the 97 codes were then thematically analyzed into 16 different themes. The 5 most referenced themes were feelings (N = 36), roles (N = 28), logistics (N = 26), benefits (N = 25), and communication (N = 21). Study participants noted that team roles, communication of information about the service, team or stakeholder concerns, and logistics should all be kept in mind when designing a new service. CONCLUSION: Semistructured interviews with providers at an FQHC in north central Indiana revealed multiple factors to consider before implementing a new pharmacist-led service in the clinic. Using a systematic approach to seek provider input can be beneficial in the design and implementation of pharmacist-led services.

A Response to: Letter to the Editor Regarding "Cost-Effectiveness of the 13-Valent Pneumococcal Conjugate Vaccine (PCV13) Versus Lower-Valent Alternatives in Filipino Infants".

This communication seeks to address the questions of Dhere and colleagues in their letter on our study "Cost-effectiveness of the 13-valent pneumococcal conjugate vaccine (PCV13) versus lower-valent alternatives in Filipino infants." We hope to provide clarity on each of the three potential misunderstandings of our cost-effectiveness analysis that were raised by Dhere and colleagues.

The broader impacts of otitis media and sequelae for informing economic evaluations of pneumococcal conjugate vaccines.

INTRODUCTION: Otitis media (OM) is a common childhood infection. Pneumococcal conjugate vaccines (PCVs) prevent OM episodes, thereby reducing short- and long-term clinical, economic, humanistic, and societal consequences. Most economic evaluations of PCVs focus on direct health gains and cost savings from prevented acute episodes but do not fully account for the broader societal impacts of OM prevention. AREAS COVERED: This review explores the broader burden of OM on children, caregivers, and society to better inform future economic evaluations of PCVs. EXPERT OPINION: OM causes a substantial burden to society through long-term sequelae, productivity losses, reduced quality of life for children and caregivers, and contribution to antimicrobial resistance from inappropriate antibiotic use. The effect of PCVs on acute OM has been recognized globally, yet the broader impact has not been consistently quantified, studied, or communicated. Economic evaluations of PCVs must evolve to include broader effects for patients, caregivers, and society from OM prevention. Future PCVs with broader coverage may further reduce OM incidence and antimicrobial resistance, but optimal uptake will depend on increasing the recognition and use of novel frameworks that include broader benefits. Communicating the full value of PCVs to decision makers may result in wider access and positive societal returns.

Clinical and Economic Burden of Pneumococcal Disease Due to Serotypes Contained in Current and Investigational Pneumococcal Conjugate Vaccines in Children Under Five Years of Age.

INTRODUCTION: The widespread implementation of pneumococcal conjugate vaccines (PCVs) has significantly reduced the burden of pneumococcal disease around the world. Although licensed 10-valent (PCV10) and 13-valent (PCV13) vaccines have considerably reduced mortality and morbidity, a sizeable disease burden attributable to serotypes not contained in these PCVs remains. This study aimed to estimate the annual clinical and economic burden of pneumococcal disease attributable to licensed (PCV10 and PCV13) and investigational PCVs, notably 15-valent (PCV15) and 20-valent (PCV20) vaccines, in 13 countries in children under 5 years of age. METHODS: A decision-analytic model was created to aggregate total cases [inclusive of invasive pneumococcal disease (IPD), pneumonia, and otitis media (OM)], deaths, and direct costs in each country of interest [stratified by PCV10/PCV13 countries, depending on national immunization programs (NIPs)] over 1 year, using up to the three most recent years of available serotype coverage data. Data inputs were sourced from local databases, surveillance reports, and published literature. RESULTS: In 5 PCV10 NIPs (Austria, Finland, Netherlands, New Zealand, Sweden), most remaining PCV20-type disease was due to PCV13-unique serotypes (30-85%), followed by PCV20-unique (9-50%), PCV15-unique (4-15%), and PCV10-unique (2-14%) serotypes. In 8 PCV13 NIPs (Australia, Canada, France, Germany, Italy, South Korea, Spain, United Kingdom), most remaining PCV20-type disease was caused by PCV20-unique serotypes (16-69%), followed by PCV13-unique (11-54%), PCV15-unique (2-33%), and PCV10-unique serotypes (3-19%). Across all countries, PCV20 serotypes caused 3000 to 345,000 cases of disease and cost between $1.3 and $44.9 million USD annually with variability driven by population size, NIP status, and epidemiologic inputs. In aggregate, PCV20 serotypes caused 1,234,000 cases and $213.5 million in annual direct medical costs in children under 5 years of age. CONCLUSION: Despite the success of PCV10 and PCV13 in reducing pneumococcal disease, a substantial clinical and economic burden remains due to serotypes contained in investigational vaccines.

Cost-Effectiveness of the 13-Valent Pneumococcal Conjugate Vaccine (PCV13) Versus Lower-Valent Alternatives in Filipino Infants.

INTRODUCTION: The Philippines pediatric national immunization program (NIP) included the 13-valent pneumococcal conjugate vaccine manufactured by Pfizer (PCV13-PFE) since 2015. Uptake has been slow in particular regions, with coverage only reaching all regions in 2019. Given affordability challenges in the context of higher coverage, this study seeks to determine whether universal coverage across all regions of the Philippines with PCV13-PFE will provide good value for money compared with 10-valent PCV alternatives manufactured by GlaxoSmithKline (PCV10-GSK) or Serum Institute of India (PCV10-SII). METHODS: A decision analytic model is adapted for this cost-effectiveness analysis in the Philippines. Clinical and economic input parameters are taken from published sources. Future disease is predicted using age-stratified and population-level observed serotype dynamics. Total cases of pneumococcal disease, deaths, direct and indirect healthcare costs, and quality-adjusted life years (QALYs) gained are discounted 7% annually and modeled for each PCV. Given clinical uncertainty, PCV10-SII outcomes are reported as ranges. Incremental cost-effectiveness ratios (ICERs) are calculated for PCV13-PFE versus lower-valent PCVs (PCV10-GSK or PCV10-SII) from a societal perspective over 10 years. RESULTS: Nationwide PCV13-PFE use over 10 years is estimated to avert 375,831 more cases, save 53,189 additional lives, and gain 153,349 QALYs compared with PCV10-GSK. This equates to cost-savings of PHP 12.27 billion after vaccine costs are accounted for. Similarly, PCV13-PFE is more effective and cost-saving compared with PCV10-SII. Switching programs to PCV10-SII would result in more cases of disease (313,797 - 666,889), more deaths (22,759 - 72,435), and lost QALYs (108,061 - 266,108), equating to a net economic loss (PHP 359.82 million - 14.41 billion). PCV13-PFE remains cost-effective in the presence of parameter uncertainty. CONCLUSION: PCV13-PFE would prevent exceedingly more cases and deaths compared with lower-valent PCVs. Additionally, the PCV13-PFE program is estimated to continue providing cost-savings, offering the best value for money to achieve universal PCV coverage in the Philippines.

Public health impact of pneumococcal conjugate vaccination: a review of measurement challenges.

INTRODUCTION: Modeling analyses have attempted to quantify the global impact of pneumococcal conjugate vaccines (PCVs) on pneumococcal disease (PD), however these pediatric models face several challenges in obtaining comprehensive impact measurements. AREAS COVERED: We present several measurement challenges and discuss examples from recently published pediatric modeling evaluations. Challenges include estimating the number of infants fully or partially vaccinated with PCVs, inclusion of indirect effects of vaccination, accounting for various dosing schedules, capturing effect of PCVs on nonspecific, noninvasive PD, and inclusion of adult PCV use. EXPERT OPINION: The true impact of PCVs has been consistently underestimated in published analyses due to multiple measurement challenges. Nearly 100 million adults are estimated to have received PCV13 over the last decade globally, potentially preventing up to 662 thousand cases of PD. Approximately 4.1 million cases of invasive PD alone may have been averted through indirect protection. Estimates of PCV impact on noninvasive PD remain a challenge due to altered epidemiology. Program switches, incomplete vaccination, and private market uptake among children also confound PD impact estimates. Taken together, the number of averted PD cases from PCV use in the last ten years may be up to three times higher than estimated in previous studies.

Estimating the Public Health and Economic Impact of Introducing the 13-Valent Pneumococcal Conjugate Vaccine or 10-Valent Pneumococcal Conjugate Vaccines into State Immunization Programs in India.

INTRODUCTION: Although the pneumococcal conjugate vaccine (PCV) has been introduced into select state immunization programs (SIPs) in India, many children remain unvaccinated. Recently, India's Advisory Committee on Vaccines & Immunization Practices recommended PCV on the pediatric immunization schedule nationally. This study estimates the public health and economic impact of introducing either Pfizer's 13-valent PCV (PCV13-PFE), GlaxoSmithKline's 10-valent PCV (PCV10-GSK), or Serum Institute of India's 10-valent PCV (PCV10-SII) into every pediatric SIP. METHODS: A model was developed to predict the disease cases, deaths, and costs associated with implementing PCV13-PFE, PCV10-GSK, or PCV10-SII in SIPs compared to no vaccination program across a 5-year period (2021-2025). State and national-level uptake rate and clinical and economic input parameters were collected from published literature. Disease outcomes included invasive pneumococcal disease, inpatient and outpatient pneumonia, and otitis media. Costs were estimated as vaccine-related costs and direct medical costs incurred to the healthcare system. Results were reported by individual state and aggregated nationally. RESULTS: Estimated over 5 years, implementing PCV13-PFE in SIPs could avert 12.1 million cases and save 626,512 lives among children under 5 years old compared to no vaccination. This corresponds to net national cost savings of over $1.0 billion. Both lower-valent PCVs are estimated to provide less economic savings than PCV13-PFE inclusive of vaccine-related costs. Compared with PCV13-PFE, implementing PCV10-GSK or PCV10-SII nationally is estimated to have a smaller public health impact, with PCV10-GSK averting 8.4 million cases (436,577 deaths) and PCV10-SII preventing 10.3 million cases (531,545 deaths) in India compared to no vaccination, respectively. CONCLUSION: Implementation of PCV13-PFE throughout India is estimated to provide greater public health and economic benefits than PCV10-GSK or PCV10-SII SIPs. Our analysis highlights the substantial disease cases, deaths, and health system cost savings that may be realized from implementing PCV programs throughout India.

Sex differences in the Buffalo Concussion Treadmill Test in adolescents with acute sport-related concussion.

OBJECTIVES: The Buffalo Concussion Treadmill Test (BCTT) is a safe and validated tool to assess exercise tolerance after sport-related concussion (SRC). Sex differences may affect the interpretation of this systematic exertion test in the concussed population, which is important for clinicians. The purpose of this study was to examine sex differences in BCTT performance in adolescents with acute SRC. DESIGN: Prospective cohort. METHODS: Male (n = 103, 15.3 ±â€¯2 years) and female (n = 87, 15.1 ±â€¯2 years) adolescents with SRC performed the BCTT within 10 days of injury. Heart rate (HR), HR threshold (HRt), Delta HR (difference between resting HR and HRt), symptom severity on Visual Analog Scale (VAS) and symptoms exacerbated on the BCTT were collected and compared. RESULTS: Males had lower resting HR (M: 70.9 ±â€¯12 vs F: 75.7 ±â€¯13 bpm, p < 0.01) and reached a lower HRt than females (M: 134.7 ±â€¯23 vs F: 141.5 ±â€¯25 bpm, p = 0.05). Sexes did not differ on Delta HR (M: 63.8 ±â€¯26 vs F: 65.9 ±â€¯24 bpm, p = 0.57), total treadmill time (M: 9.3 ±â€¯5 vs F: 8.4 ±â€¯4 min, p = 0.20), maximum VAS (M: 5.0 ±â€¯2 vs F: 5.4 ±â€¯2, p = 0.18) or incidence of a change in VAS (M: 91% vs F: 94%, p = 0.43) on the BCTT. CONCLUSIONS: Although males may reach symptom exacerbation at a slightly lower mean HRt than females on the BCTT within 10 days of SRC, the BCTT provides comparable information and both sexes reach symptom exacerbation at similar Delta HR.

Exercise for Sport-Related Concussion and Persistent Postconcussive Symptoms.

CONTEXT: Emerging research supports the use of mild to moderate aerobic exercise for treating sport-related concussion (SRC) and persistent postconcussive symptoms (PPCS), yet the current standard of care remains to be strict rest. The purpose of this review is to summarize the existing literature on physical activity and prescribed exercise for SRC and PPCS. EVIDENCE ACQUISITION: PubMed and Embase were searched in April of 2019 for studies assessing rest or prescribed exercise for SRC and PPCS. No specific search syntax was used. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: A majority of studies show that spontaneous physical activity is safe after SRC and that subsymptom threshold aerobic exercise safely speeds up recovery after SRC and reduces symptoms in those with PPCS. Exercise tolerance can safely be assessed using graded exertion test protocols within days of injury, and the degree of early exercise tolerance has diagnostic and prognostic value. CONCLUSION: Subsymptom threshold aerobic exercise is safe and effective for the treatment of SRC as well as in athletes with PPCS. Further research is warranted to establish the most effective method and dose of aerobic exercise for the active treatment of SRC and whether early exercise treatment can prevent PPCS in athletes. STRENGTH OF RECOMMENDATION TAXONOMY: 2.

Blunted Cardiac Parasympathetic Activation in Student Athletes With a Remote History of Concussion: A Pilot Study.

Introduction: Blunted cardiac autonomic nervous system (ANS) responses, quantified using heart rate variability (HRV), have been reported after sport-related concussion (SRC). Research suggests this persists beyond clinical recovery. This study compared cardiac parasympathetic responses in student athletes with a remote history of SRC (> 1-year ago, Concussion History: CH) with those who reported no lifetime history of SRC (Concussion Naïve: CN). Design: Retrospective nested case-control. Setting: University laboratory. Patients or Other Participants: CH (n = 9, 18.3 ± 2 years, 44% male, median 2 years since injury) were student athletes with a remote history of concussion(s) from more than 1 year ago. CN (n = 21, 16.7 ± 3 years, 67% male) were student athletes with no lifetime history of concussion. Exclusion criteria included taking medications that could affect ANS function, history of concussion within the past year, persistent concussion symptoms, lifetime history of moderate to severe brain injury, and lifetime history of more than 3 concussions. Material and Methods: Participants performed the Face Cooling (FC) test for 3-min after 10-min of supine rest while wearing a 3-lead electrocardiogram in a controlled environment. Outcome Measures: Heart rate (HR), R-R interval (RRI), root mean square of the successive differences (RMSSD) of RRI, high frequency (HF) and low frequency to HF (LF:HF) ratios. Results: At baseline, CH had a lower resting HR than CN (62.3 ± 11 bpm vs. 72.9 ± 12, p = 0.034). CH had a different HR response to FC than CN (+8.9% change from baseline in CH vs. -7.5% in CN, p = 0.010). CH also had a smaller RMSSD increase to FC than CN (+31.8% change from baseline in CH vs. +121.8% in CN, p = 0.048). There were no significant group differences over time in RRI (p = 0.106), HF (p = 0.550) or LF:HF ratio (p = 0.053). Conclusion: Asymptomatic student athletes with a remote history of concussion had a blunted cardiac parasympathetic response to FC when compared with athletes with no lifetime history of concussion. These data suggest that an impaired autonomic response to a physiological stressor persists after clinical recovery from SRC for longer than previously reported.

Effects of Adolescent Childbearing on Latino Siblings: Changes in Family Dynamics and Feelings Toward the Teen Mother.

Latinos have had the highest teenage birthrate of any racial or ethnic group in the United States for the past 15 years, yet little is known about how Latino families are affected by a teenage daughter's childbearing. In-depth interviews were conducted with 32 Mexican American younger siblings of parenting teens to discern how their sister's childbearing had affected them and their families. The most commonly reported negative effects were increased family stress and conflict, more arguments with the parenting older sister, and less time spent with family members. Regarding benefits, all youth described a loving bond with their sister's baby, two thirds described their family becoming closer, and 81% felt closer to their older sister. The implications of these effects for Mexican American families are discussed.

How an adolescent's childbearing affects siblings' pregnancy risk: a qualitative study of Mexican American youths.

CONTEXT: The siblings of teenage parents are known to be at very high risk of teenage pregnancy, but little is known about how an older sister's childbearing affects a younger sibling's risk. Understanding these influences could help address the very high rates of pregnancy and childbearing among Latino adolescents. METHODS: From 2005 through 2007, a sample of 41 Mexican American 12-18-year-olds from southern California completed in-depth interviews about how an older sister's teenage childbearing had affected them. Themes that emerged were categorized as risk factors (circumstances that increased youths' likelihood of becoming involved in a teenage pregnancy) or protective factors (conditions that reduced this likelihood) on the basis of well-established findings in the literature. RESULTS: Interview data reflected six risk factors and 11 protective factors. The most commonly reported risk factors (discussed by more than a quarter of participants) were that youths did not perceive early parenting as a hardship, had increased difficulties in school and wanted to have a baby too. The most commonly cited protective factors (mentioned by more than half) were an increased motivation to avoid early parenting, an increased appreciation of the difficulties of parenting, mothers' explicitly discouraging early parenting and youths' feeling of greater closeness with their mother. CONCLUSIONS: Interventions that build on the protective factors that result when a youth's older sibling has a teenage birth, while reducing the risk factors, might help families prevent younger children from becoming involved in a teenage pregnancy.