Epidemiology of Hamstring Tears in National Collegiate Athletic Association Athletes: Findings From the National Collegiate Athletic Association Injury Surveillance Program Between 2014/2015 and 2018/2019.

OBJECTIVE: To describe the epidemiology of hamstring tears in National Collegiate Athletic Association (NCAA) sports. DESIGN: Descriptive epidemiology study. Athletic trainers from NCAA schools reported injuries to the NCAA Injury Surveillance Program. SETTING: A convenience sample of NCAA hamstring tear injuries during the 2014/2015 through 2018/2019 academic years. PATIENTS OR PARTICIPANTS: NCAA student-athletes. INDEPENDENT VARIABLES: Sport, sex, event type, season segment, injury history, and activity at the time of injury. MAIN OUTCOME MEASURES: Injury counts, rates, and proportions were used. RESULTS: Two thousand ninety-six hamstring tears from 8 474 400 athlete-exposures (AEs) were reported (2.47 per 10 000 AEs). Rates were highest in Men's Soccer (5.97 per 10 000 AEs) and Women's Soccer (3.13 per 10 000 AEs), among all Men's and Women's sports, respectively. Competition-related rates in Men's and Women's sports were highest in 2015 to 2016 then followed a decreasing pattern across the remainder of the study period. Among sex-comparable sports, rates were higher in men's (compared with women's) Baseball/Softball, Soccer, and Track and Field. The prevalence of recurrent injuries was comparable among men's (14.8%) and women's (11.5%) sports. Time loss hamstring tears were more prevalent in Men's sports than Women's sports [injury proportion ratio = 1.33; 95% confidence interval, (1.21, 1.47)]. CONCLUSIONS: Overall, hamstring tear rates were higher across all Men's sports compared with Women's sports. Rates across event type were comparable in several sports; and so, adjustments to practice are needed considering that practice environments are more modifiable than competitions. Indeed, improving hamstring tear prevention programs to reduce the burden of this injury in NCAA athletes remains critical.

A dominance analysis of subjective cognitive complaint comorbidities in former professional football players with and without mild cognitive impairment.

OBJECTIVES: Subjective cognitive difficulties (SCDs) are associated with factors commonly reported in older adults and former contact sport athletes, regardless of objective cognitive decline. We investigated the relative contribution of these factors to SCD in former National Football League (NFL)-players with and without a diagnosis of mild cognitive impairment (MCI). METHODS: Former NFL players (n = 907) aged ≥ 50 years (mean = 64.7 ± 8.9), with (n = 165) and without (n = 742) a diagnosis of MCI completed health questionnaires. Multivariable regression and dominance analyses determined the relative importance of SCD factors on SCD: 1) depression, 2) anxiety, 3) sleep disturbance, 4) pain interference, 5) ability to participate in social roles and activities, 6) stress-related events, 7) fatigue, 8) concussion history, and 9) education. SCD outcomes included Neuro-QoL Emotional-Behavioral Dyscontrol and the PROMIS Cognitive Function. Fisher's z-transformation compared comorbid contributing factors to SCD across MCI and non-MCI groups. RESULTS: Complete dominance of anxiety was established over most comorbid factors across the MCI and non-MCI groups. Fatigue also exhibited complete dominance over most comorbid factors, though its influence in the MCI group was less robust (general dominance). Average contributions to variance accounted for by comorbid factors to ratings of SCD across MCI and non-MCI groups did not statistically differ (Z-statistics <1.96, ps>.05). CONCLUSIONS: Anxiety and fatigue are the most robust factors associated with SCD in former professional football players across various combinations of clinical presentations (different combinations of comorbid factors), regardless of documented cognitive impairment. Self-reported deficits may be less reliable in detecting objective impairment in the presence of these factors, with multidimensional assessment being ideal.

Clinical recovery from concussion-return to school and sport: a systematic review and meta-analysis.

OBJECTIVE: To define the time frames, measures used and modifying factors influencing recovery, return to school/learn (RTL) and return to sport (RTS) after sport-related concussion (SRC). DESIGN: Systematic review and meta-analysis. DATA SOURCES: 8 databases searched through 22 March 2022. ELIGIBILITY CRITERIA: Studies with diagnosed/suspected SRC and interventions facilitating RTL/RTS or investigating the time and modifying factors for clinical recovery. Outcomes included days until symptom free, days until RTL and days until RTS. We documented study design, population, methodology and results. Risk of bias was evaluated using a modified Scottish Intercollegiate Guidelines Network tool. RESULTS: 278 studies were included (80.6% cohort studies and 92.8% from North America). 7.9% were considered high-quality studies, while 23.0% were considered high risk of bias and inadmissible. The mean days until symptom free was 14.0 days (95% CI: 12.7, 15.4; I2=98.0%). The mean days until RTL was 8.3 (95% CI: 5.6, 11.1; I2=99.3%), with 93% of athletes having a full RTL by 10 days without new academic support. The mean days until RTS was 19.8 days (95% CI: 18.8, 20.7; I2=99.3%), with high heterogeneity between studies. Several measures define and track recovery, with initial symptom burden remaining the strongest predictor of longer days until RTS. Continuing to play and delayed access to healthcare providers were associated with longer recovery. Premorbid and postmorbid factors (eg, depression/anxiety, migraine history) may modify recovery time frames. Though point estimates suggest that female sex or younger age cohorts take longer to recover, the heterogeneity of study designs, outcomes and overlap in CIs with male sex or older age cohorts suggests that all have similar recovery patterns. CONCLUSION: Most athletes have full RTL by 10 days but take twice as long for an RTS. PROSPERO REGISTRATION NUMBER: CRD42020159928.

Incorporation of concussion history as part of the LIfestyle for BRAin Health (LIBRA) modifiable factors risk score and associations with cognition in older former National Football League players.

OBJECTIVE: Investigate associations between the LIfestyle for BRAin Health (LIBRA) risk score with odds of mild cognitive impairment (MCI) diagnosis and cognitive function, incorporating concussion history. METHODS: Former National Football League (NFL) players (N = 1050; mean age = 64.8 ± 9.0-years) completed initial testing for integration of concussion history into LIBRA scores (i.e., modified-LIBRA) and completed the Brief Test of Adult Cognition by Telephone (BTACT). Modified-LIBRA score (including concussion history) associations with odds of MCI and cognitive dysfunction were assessed via logistic and linear regression. RESULTS: The highest quartile LIBRA scores were six times more likely to have a diagnosis of MCI compared to the lowest quartile (OR = 6.27[3.61, 10.91], p < 0.001). Modified-LIBRA scores significantly improved model fit for odds of MCI above original LIBRA scores (χ2 (1) = 7.76, p = 0.005) and accounted for a greater fraction of variance in executive function (ΔR2  = 0.02, p = 0.003) and episodic memory (ΔR2  = 0.02, p = 0.002). CONCLUSIONS: Modified-LIBRA score, incorporating concussion history, may help monitoring risk status in former contact sport athletes, by targeting modifiable, lifestyle-related risk factors.

Cumulative Concussion and Odds of Stroke in Former National Football League Players.

BACKGROUND AND PURPOSE: Postmortem and experimental studies indicate a potential association between repeated concussions and stroke risk in older contact sport athletes. We examined the relationship between concussion and stroke history in former National Football League players aged ≥50 years. METHODS: Former professional football players aged ≥50 years who played ≥1 year in the National Football League were enrolled in the cross-sectional study. Indirect standardization was used to calculate overall and decade-specific standardized prevalence ratios. Logistic regression using Firth's bias reduction method examined the association between lifetime concussion history 0 (n=119; 12.2%), 1 to 2 (n=152; 15.5%), 3 to 5 (n=242; 24.7%), 6 to 9 (201; 20.5%), and 10+(n=265; 27.1%) and stroke. Adjusted odds ratios for stroke were calculated for concussion history groups, age, and coronary artery disease and/or myocardial infarction. RESULTS: The 979 participants who met inclusion criteria had a mean age of 65.0±9.0 years (range, 50-99). The prevalence of stroke was 3.4% (n=33), significantly lower than expected based on rates of stroke in US men aged 50 and over (standardized prevalence ratio=0.56, Z= -4.56, P<0.001). Greater odds of stroke history were associated with concussion history (10+ versus 0, adjusted odds ratio [95% CI]=5.51 [1.61-28.95]), cardiovascular disease (adjusted odds ratio [95% CI]=2.24 [1.01-4.77]), and age (1-year-increase adjusted odds ratio [95% CI]=1.07 [1.02-1.11]). CONCLUSIONS: The prevalence of stroke among former National Football League players aged ≥50 years was lower than the general population, with significantly increased risk among those with 10 or more prior concussions. Findings add to the evidence suggesting that traumatic brain injuries are associated with increased risk of stroke. Clinically, management of cardio- and cerebrovascular health may be pertinent to those with a history of multiple prior concussions.

Longitudinal trajectory of depression symptom severity and the influence of concussion history and physical function over a 19-year period among former National Football League (NFL) players: an NFL-LONG Study.

OBJECTIVE: This study investigated the longitudinal course of depressive symptom severity over 19 years in former American football players and the influence of concussion history, contact sport participation and physical function on observed trajectories. METHODS: Former American football players completed a general health questionnaire involving demographic information, medical/psychiatric history, concussion/football history and validated measures of depression and physical function at three time points (2001, 2010 and 2019). Parallel process latent growth curve modelling tested associations between concussion history, years of football participation, and overall and change in physical function on the overall level and trajectory of depressive symptoms. RESULTS: Among the 333 participants (mean(SD) age, 48.95 (9.37) at enrolment), there was a statistically significant, but small increase in depressive symptom severity from 2001 (48.34 (7.75)) to 2019 (49.77 (9.52)), slope=0.079 (SE=0.11), p=0.007. Those with greater concussion history endorsed greater overall depressive symptom severity, B=1.38 (SE=0.33), p<0.001. Concussion history, B<0.001 (SE=0.02), p=0.997 and years of participation, B<0.001 (SE=0.01), p=0.980, were not associated with rate of change (slope factor) over 19 years. Greater decline in physical function, B=-0.71 (SE=0.16), p<0.001, was predictive of a faster growth rate (ie, steeper increase) of depression symptom endorsement over time. CONCLUSIONS: Concussion history, not years of participation, was associated with greater depressive symptom severity. Neither factor was predictive of changes over a 19-year period. Decline in physical function was a significant predictor of a steeper trajectory of increased depressive symptoms, independent of concussion effects. This represents one viable target for preventative intervention to mitigate long-term neuropsychiatric difficulties associated with concussion across subsequent decades of life.

Disparate Associations of Years of Football Participation and a Metric of Head Impact Exposure with Neurobehavioral Outcomes in Former Collegiate Football Players.

OBJECTIVES: Years of sport participation (YoP) is conventionally used to estimate cumulative repetitive head impacts (RHI) experienced by contact sport athletes. The relationship of this measure to other estimates of head impact exposure and the potential associations of these measures with neurobehavioral functioning are unknown. We investigated the association between YoP and the Head Impact Exposure Estimate (HIEE), and whether associations between the two estimates of exposure and neurobehavioral functioning varied. METHODS: Former American football players (N = 58; age = 37.9 ± 1.5 years) completed in-person evaluations approximately 15 years following sport discontinuation. Assessments consisted of neuropsychological assessment and structured interviews of head impact history (i.e., HIEE). General linear models were fit to test the association between YoP and the HIEE, and their associations with neurobehavioral outcomes. RESULTS: YoP was weakly correlated with the HIEE, p = .005, R2 = .13. Higher YoP was associated with worse performance on the Symbol Digit Modalities Test, p = .004, R2 = .14, and Trail Making Test-B, p = .001, R2 = .18. The HIEE was associated with worse performance on the Delayed Recall trial of the Hopkins Verbal Learning Test-Revised, p = .020, R2 = .09, self-reported cognitive difficulties (Neuro-QoL Cognitive Function), p = .011, R2 = .10, psychological distress (Brief Symptom Inventory-18), p = .018, R2 = .10, and behavioral regulation (Behavior Rating Inventory of Executive Function for Adults), p = .017, R2 = .10. CONCLUSIONS: YoP was marginally associated with the HIEE, a comprehensive estimate of head impacts sustained over a career. Associations between each exposure estimate and neurobehavioral functioning outcomes differed. Findings have meaningful implications for efforts to accurately quantify the risk of adverse long-term neurobehavioral outcomes potentially associated with RHI.

The stability of self-reported professional football concussion history among former players: A longitudinal NFL-LONG study.

OBJECTIVES: To examine the stability of former National Football League (NFL) players' recall of professional football concussion. METHODS: Two-hundred-and-nine former NFL players (ceasing football participation before/in 2001) completed surveys in 2001, 2010, and 2019 and reported the number of concussions sustained during their professional careers (0, 1 … 10, >10). Participants were categorized into four 'recall stability' groups, based upon concussion recall [e.g., 'Same' (same number recalled), 'Increased' (more recalled than in prior time point)]. In 2019, participants completed measures of functioning (e.g., PROMIS Cognitive Function, Anxiety, Depression). Fleiss Kappa and generalized linear mixed models (GLMM)-based ordinal measures Kappa assessed stability across time points. 'Recall stability group' functioning scores were compared. RESULTS: Overall, 45.9% recalled more concussions over time; 14.8% reported the same number. Fleiss Kappa and GLMM-based ordinal measures Kappa suggested fair (0.22, 95% CI: 0.26, 0.38) and moderate stability (0.41, 95% CI: 0.35, 0.46), respectively. Higher cognitive functioning (P = 0.002), lower anxiety (P = 0.003), and lower depression (P = 0.007) were observed in the 'Same' vs 'Increased' groups. CONCLUSIONS: Despite subtle time-based variations in reporting, professional football concussion history recall was relatively stable. Better cognitive and psychological functioning was associated with greater stability in concussion recall.

Transition-Related Psychosocial Factors and Mental Health Outcomes in Former National Football League Players: An NFL-LONG Study.

Transition from professional sport to nonsport endeavors has implications for postcareer health and well-being of athletes. The purpose of the current study was to examine associations among transition-related psychosocial factors and current mental health outcomes in former National Football League (NFL) players. Participants were former NFL players (n = 1,784; mean age = 52.3 ± 16.3 years) who responded to a questionnaire assessing the nature of their discontinuation from professional football (i.e., any degree of voluntary choice vs. forced discontinuation), prediscontinuation transition planning (yes vs. no), and current symptoms of depression and anxiety. After adjusting for relevant covariates, having an involuntary discontinuation and no transition plan prior to discontinuation were associated with greater depressive and anxiety symptom severity. Autonomy in discontinuation and pretransition planning are important to former NFL football players' mental health. Increasing autonomy in the discontinuation decision and pretransition planning represent psychoeducational intervention targets for this population.

Non-Time-Loss and Time-Loss Injuries in Secondary School Girls' Volleyball Athletes: A Report From the National Athletic Treatment, Injury, and Outcomes Network Surveillance Program.

CONTEXT: Volleyball is a popular sport with a risk of injury to the entire body. Insight into non-time-loss (NTL) and time-loss (TL) injuries is needed to inform seasonal injury trends that may lead to appropriate prevention and management strategies. This study provides a descriptive analysis of volleyball injuries among secondary school athletes. STUDY DESIGN: Descriptive epidemiology study. METHODS: Data were collected from 72 secondary schools, representing 135 team seasons of data from the National Athletic Treatment, Injury, and Outcomes Network Surveillance Program (2014-2015 to 2018-2019 academic years). Injury counts, injury rates (IR) per 1000 athlete exposures (AEs), and incidence rate ratios (IRR) were reported with 95% confidence intervals (CIs). RESULTS: In total, 529 injuries over 193,858 AEs for girls' volleyball were captured, producing an IR of 2.73/1000AEs (95% CI = 2.50-2.96). The overall IR was highest during the preseason compared with regular season (IRR = 1.31, 95% CI = 1.09-1.59). Overall IRs were higher in competition (IR: 3.56, 95% CI = 3.07-4.05) compared with practice (IR: 2.38, 95% CI = 2.12-2.64; IRR = 1.49, 95% CI = 1.25-1.79). Common body locations injured were ankle (n = 141, 26.7%; NTL: n = 56, 21.7%; TL: n = 85, 31.7%), knee (n = 61, 11.5%; NTL: n = 33, 12.8%, TL: n = 28, 10.5%), hand/wrist (n = 59, 11.2%; NTL: n = 32, 12.4%, TL: n = 27, 10.1%), and head/face (n = 62, 11.7%; NTL: n = 14, 5.4%; TL: n = 47, 17.5%). CONCLUSIONS: Volleyball IRs were highest in preseason and during competition. Most injuries affected the lower-extremity which is notable considering the high upper-extremity load in volleyball. Consideration of strategies to reduce injuries prior to the start of the formal sports season may be needed to help reduce the incidence of preseason injuries.

Determinants of lower-extremity injury severity and recovery in U.S. High School Soccer Players.

Lower-extremity injuries are common among soccer players, yet few studies have attempted to identify determinants of lower-extremity injury severity and recovery within this group. We aim to identify determinants of lower-extremity injury severity and recovery among high school (HS) soccer players in the US. We used soccer-related injury observations recorded within the NATION-SP during 2011/12-2013/14. Odds of a season-ending game-related injury were higher than a season-ending practice-related injury (Adj. OR = 2.64, 95% CI = [1.39, 5.01]). Gender, setting, and playing surface emerged as significant determinants of any time loss following lower-extremity injuries in multivariable logistic regression models, and multivariable random effects Poisson regression models also revealed significant differences in recovery durations across levels of these variables for "similarly severe" injuries. Findings suggest that gender, injury setting, playing surface contribute to injury corollaries differently. Similar multi-method approaches are needed to identify determinants of injury severity and recovery in this group.

Patterns and predictors of concussion symptom presentations in NCAA athletes.

Sport-related concussion (SRC) is a complex injury, and SRCs are notably prevalent among National Collegiate Athletic Association (NCAA) athletes. We analysed SRCs and associated exposure data collected within the NCAA Injury Surveillance Program during 2014-2019. A total of 1,709 SRCs were reported with complete symptom profiles during the study period (Women's sports n = 499; Men's sports n = 1,210). Event type and academic class year most commonly predicted specific symptom presentations among athletes in men's sports, while symptom presentation among athletes in women's sports was most commonly predicted by class year and sport classification. We observed 78 and 69 significant pairwise symptom dependencies in men's and women's sports athletes, respectively; odds of longer symptom resolution time were higher with greater counts of symptoms with strongest cross-domain associations. Our findings highlight several contextual predictors of specific symptom presentations and identify parsimonious symptom subsets that may indicate protracted recovery among men's and women's sports athletes.

Distinct latent profiles based on neurobehavioural, physical and psychosocial functioning of former National Football League (NFL) players: an NFL-LONG Study.

OBJECTIVE: To identify subgroups of former National Football League (NFL) players using latent profile analysis (LPA) and examine their associations with total years of participation (TYP) and self-reported lifetime sport-related concussion history (SR-CHx). METHODS: Former NFL players (N=686) aged 50-70 years, with an average 18.0 TYP (±4.5) completed a questionnaire. SR-CHx distributions included: low (0-3; n=221); intermediate (4-8; n=209) and high (9+; n=256). LPA measures included: Quality of Life in Neurological Disorders Emotional-Behavioral Dyscontrol, Patient Reported Outcomes Measurement Information System Cognitive Function, Emotional Support, Self-Efficacy, Meaning and Purpose, Physical Function, Pain Interference, Participation in Social Roles and Activities, Anxiety, Depression, Fatigue, and Sleep Disturbance. Demographic, medical/psychiatric history, current psychosocial stressors, TYP and SR-CHx were compared across latent profiles (LPs). RESULTS: A five profile solution emerged: (LP1) global higher functioning (GHF; 26.5%); (LP2) average functioning (10.2%); (LP3) mild somatic (pain and physical functioning) concerns (22.0%); (LP4) somatic and cognitive difficulties with mild anxiety (SCA; 27.5%); LP5) global impaired functioning (GIF; 13.8%). The GIF and SCA groups reported the largest number ofe- medical/psychiatric conditions and higher psychosocial stressor levels. SR-CHx was associated with profile group (χ2(8)=100.38, p<0.001); with a higher proportion of GIF (72.6%) and SCA (43.1%) groups reporting being in the high SR-CHx category, compared with GHF (23.1%), average (31.4%) and somatic (27.8%) groups. TYP was not significantly associated with group (p=0.06), with greater TYP reported by the GHF group. CONCLUSIONS: Five distinct profiles of self-reported functioning were identified among former NFL players. Several comorbid factors (ie, medical/psychiatric diagnoses and psychosocial stressors) and SR-CHx were associated with greater neurobehavioural and psychosocial dysfunction.

Health-promoting behaviours and concussion history are associated with cognitive function, mood-related symptoms and emotional-behavioural dyscontrol in former NFL players: an NFL-LONG Study.

OBJECTIVES: To examine the relationships among self-reported sport-related concussion (SRC) history and current health-promoting behaviours (exercise frequency, diet quality and sleep duration) with self-reported measures of brain health (cognitive function, symptoms of depression and anxiety and emotional-behavioural dyscontrol) in former NFL players. METHODS: In this cross-sectional study, a questionnaire was sent to former NFL players. Respondents reported SRC history (categorical: 0; 1-2; 3-5; 6-9; 10+ concussions), number of moderate-to-vigorous aerobic and resistance exercise sessions per week, diet quality (Rapid Eating Assessment for Participants-Shortened) and average nightly sleep duration. Outcomes were Patient-Reported Outcomes Measurement Information System Cognitive Function, Depression, and Anxiety, and Neuro-QoL Emotional-Behavioral Dyscontrol domain T-scores. Multivariable linear regression models were fit for each outcome with SRC history, exercise frequency, diet quality and sleep duration as explanatory variables alongside select covariates. RESULTS: Multivariable regression models (n=1784) explained approximately 33%-38% of the variance in each outcome. For all outcomes, SRC history (0.144≤|ß|≤0.217) was associated with poorer functioning, while exercise frequency (0.064≤|ß|≤0.088) and diet quality (0.057≤|ß|≤0.086) were associated with better functioning. Sleeping under 6 hours per night (0.061≤|ß|≤0.093) was associated with worse depressive symptoms, anxiety and emotional-behavioural dyscontrol. CONCLUSION: Several variables appear to be associated with mood and perceived cognitive function in former NFL players. SRC history is non-modifiable in former athletes; however, the effects of increasing postplaying career exercise frequency, making dietary improvements, and obtaining adequate sleep represent important potential opportunities for preventative and therapeutic interventions.

Neuroinflammatory Biomarkers Associated With Mild Traumatic Brain Injury History in Special Operations Forces Combat Soldiers.

BACKGROUND: Special Operations Forces (SOF) combat soldiers are frequently exposed to blast and blunt neurotrauma, most often classified as mild traumatic brain injury (mTBI). Repetitive mTBI may increase the risk of developing long-term neurological sequelae. Identifying changes in neuroinflammatory biomarkers before chronic conditions emerge could serve as preliminary evidence of developing neuropathology. OBJECTIVE: To determine the effects of mTBI history, lifetime mTBI incidence, and recency on blood biomarker concentrations of axonal protein neurofilament light (NfL), glycolytic enzyme neuron-specific enolase (NSE), astrocyte-expressed S100 calcium-binding protein B (S100B), and neurotrophic cytokine interleukin-6 (IL-6) in healthy, active duty SOF combat soldiers. METHODS: Self-reported mTBI history/recency and fasted blood samples were collected in this cross-sectional study of 104 asymptomatic SOF combat soldiers. Biomarker concentrations were quantified using commercial enzyme-linked immunosorbent assays. Mann-Whitney U and Kruskal-Wallis tests were used to compare groups. Post hoc tests with appropriate corrections were conducted as warranted. RESULTS: Soldiers with mTBI history had higher NSE concentrations than those without (z = -2.60, P = .01). We also observed significant main effects of lifetime mTBI incidence on NSE (χ(3) = 9.52, P = .02) and S100B (χ(3) = 8.21, P = .04) concentrations and a significant main effect of mTBI recency on NfL concentration (χ(2) = 6.02, P = .049). CONCLUSION: The SOF combat soldiers with mTBI history had increased NSE. Longitudinal studies in this population are needed due to between-subject heterogeneity in biomarker concentrations. The NfL concentrations in our SOF combat soldiers-regardless of mTBI history or recency-were similar to values previously reported in civilian acute TBI patients.

Sports Medicine Fellowship Training Improves Sport-related Concussion Evaluation.

Evaluating acute sport-related concussion (SRC) differs among providers, who apply international consensus and national guidelines variably. Retrospective medical record review was completed for 889 outpatients aged 7 to 18 years, diagnosed with SRC from 2014 to 2017. Associations between board-certified sports medicine fellowship (SMF) training status and assessment of concussion-specific history and physical examination items were tested using nonparametric χ tests. Differential odds (by fellowship training status) of using history and physical examination items were assessed using multivariable logistic regression modeling. Each SRC history and physical examination items were assessed in higher proportions by SMFs, as compared with non-SMFs, statistically significant for all tested items with the exception of headache history. SMFs demonstrated higher odds of detailed neurologic examinations and clinical cognitive testing compared with non-SMFs, after adjusting for patient and physician characteristics. Physicians caring for concussed patients should seek continuing education opportunities aligning them with training provided to sports medicine fellows.

Determinants of concussion diagnosis, symptomology, and resolution time in U.S. high school soccer players.

Determinants of concussion diagnosis, symptomology, and other sequelae have not been examined in high school soccer players. Using a sample of soccer-related head/neck injuries from the NATION Surveillance Program, we evaluated potential determinants (sex, injury history, injury mechanism, setting) of concussion characteristics. A total of 378 head/neck injuries were recorded, and 189 (50.0%) injuries from this sample, resulted in a concussion diagnosis. Odds of concussion diagnosis were 84% higher among female players compared with their male counterparts, and over two-fold higher in game settings compared with practice settings. We also observed several significant symptom dependencies, such as higher odds of difficulty concentrating (OR = 5.84, 95% CI = [2.99, 11.42]) given concurrent light sensitivity. Furthermore, we identified injury mechanism as a determinant of concussion symptom resolution time. Our results suggest that determinants of soccer-related concussions and their sequelae are multifactorial, and extend the existing literature with the potential to inform clinical practice.

Impact of the Community Eligibility Provision on meal counts and participation in Pennsylvania and Maryland National School Lunch Programs.

OBJECTIVE: To determine whether school-level participation in the federal Community Eligibility Provision (CEP), which provides free school lunch to all students, is associated with school meal participation rates. Participation in school meals is important for decreasing food insecurity and improving child health and well-being. DESIGN: Quasi-experimental evaluation using negative binomial regression to predict meal count rates per student-year overall and by reimbursement level adjusted for proportion eligible for free and reduced-price lunch (FR eligibility) and operating days. SETTING: Schools (grades kindergarten to 12th) participating in the National School Lunch Program (NSLP) in Maryland and Pennsylvania, USA, from the 2013-2015 (n 1762) and 2016-2017 (n 2379) school years. PARTICIPANTS: Administrative, school-level data on school lunch counts and student enrolment. RESULTS: CEP was associated with a non-significant 6 % higher total NSLP meal count adjusting for FR eligibility, enrolment and operating days (rate ratio = 1·06, 95 % CI 0·98, 1·14). After controlling for participation rates in the year prior to CEP implementation, the programme was associated with a significant 8 % increase in meal counts (rate ratio = 1·08, 95 % CI 1·03, 1·12). In both analyses, CEP was associated with lower FR meal participation and substantial increases in paid meal participation. CONCLUSIONS: School-level implementation of CEP is associated with increases in total school meal participation. Current funding structures may prevent broader adoption of the programme by schools with fewer students eligible for FR meals.

Association between relative age effect and organisational practices of American youth football.

The popular method of organising youth sport participants into age divisions, based solely on their birthdate, can result in an imbalance of the distribution of players. This is known as relative age effect (RAE), which inadvertently creates bias and is associated with deleterious short and long-term consequences. The overall purpose of this study was to examine how the potential for RAE is mitigated when simultaneously accounting for additional player criterion, supplementary to age. A mid-Atlantic American youth football registration database was acquired, including chronological (age), anthropometric (weight), and competency (skill) factors. Player (n = 1,265) data were classified into quartiles and multiple chi-square goodness of fit tests were conducted using proportions of live births as expected theoretical distribution values. When data were categorised by a single developmental criterion (e.g. age), results indicated significant departures (p ≤ 0.002) from expected proportions. However, when categorised using multiple criteria (i.e. age, weight, and skill), equitable birthdate distributions were observed. Findings from this study indicate using only one developmental criterion for organising players is associated with RAE, whereas approaches accounting for multiple variables are not associated with RAE. This study provides youth football programs with early evidence for considering alternative methods of organising players.