Clinical characteristics of SARS-CoV-2-associated encephalopathy in children: Nationwide epidemiological study.

OBJECTIVE: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sometimes triggers acute encephalopathy as a serious neurological complication in children. We previously reported the clinico-radiological findings of SARS-CoV-2-associated encephalopathy. The advent of the SARS-CoV-2 omicron variant led to a marked increase in pediatric patients with coronavirus disease 2019 (COVID-19); however, epidemiological changes with acute encephalopathy according to the emergence of SARS-CoV-2 have not yet been documented. Therefore, the present study investigated epidemiological differences in SARS-CoV-2-associated encephalopathy during the BA.1/BA.2 and BA.5 predominant periods and also between SARS-CoV-2-associated and non-SARS-CoV-2-associated encephalopathy. METHODS: We conducted a nationwide survey of SARS-CoV-2-associated encephalopathy in Japanese children between June and November 2022. We compared the present results during the BA.5 predominant period and previous findings during the BA.1/BA.2 predominant period. We also compared the clinico-radiological syndromes of encephalopathy between SARS-CoV-2-associated and non-SARS-CoV-2-associated encephalopathy. RESULTS: Although many patients with SARS-CoV-2-associated encephalopathy in the BA.5 predominant period had seizures as their initial symptoms, no significant differences were observed in the clinical features. Patients with SARS-CoV-2-associated encephalopathy had worse outcomes than those with non-SARS-CoV-2-associated encephalopathy (p-value = 0.003). Among 103 patients with SARS-CoV-2-associated encephalopathy, 14 (13.6%) had severe types of acute encephalopathy, namely, encephalopathy with acute fulminant cerebral edema (AFCE) and hemorrhagic shock and encephalopathy syndrome (HSES). Also, 28 (27.2%) patients with SARS-CoV-2-associated encephalopathy had poor outcome: severe neurological sequelae or death. Ninety-five patients (92.2%) were not vaccinated against SARS-CoV-2. CONCLUSIONS: In SARS-CoV-2-associated encephalopathy, high percentages of AFCE and HSES can result in poor outcomes.

Factors influencing the development of infantile traumatic brain injury with a biphasic clinical course and late reduced diffusion.

BACKGROUND: Infantile traumatic brain injury (TBI) with a biphasic clinical course and late reduced diffusion (TBIRD) has been reported as a type of TBI. However, it remains uncertain which pediatric patients with TBI develop TBIRD. METHODS: Patients with TBI who were admitted to our hospital and underwent magnetic resonance imaging (MRI) between December 2006 and October 2022 were included in this study. A diagnosis of TBIRD was made in patients with or suspected TBI, with initial symptoms being convulsions or disturbance of consciousness and late-onset subcortical reduced diffusion, the so-called bright tree appearance. Clinical features, neuroimaging (computed tomography (CT) and MRI) findings, laboratory data, and Tada score were retrospectively compared between TBIRD and non-TBIRD patients. Neurological prognosis was assessed using the Pediatric Cerebral Performance Category scale. RESULTS: Of 21 patients who met the inclusion criteria, a diagnosis of TBIRD was made in 7 patients (median age: 8 months). The factors contributing to TBIRD development were seizures lasting over 30 min as the initial symptom (5/7 in TBIRD vs. 0/14 in non-TBIRD), tracheal intubation during initial treatment (5/7 vs. 0/14), and brain parenchymal lesions on CT (3/7 vs. 0/14), suggesting that severe TBI may progress to TBIRD. The Tada score was more positive in patients with TBIRD (6/7) than in those without (0/14). CONCLUSIONS: It is important to monitor infant patients with severe TBI for the development of TBIRD. The Tada score can be a useful tool for TBIRD prediction.

The association between subjective anti-doping knowledge and objective knowledge among Japanese university athletes: a cross-sectional study.

Introduction: This study aimed to assess the association between subjective anti-doping knowledge (subjective ADK) and objective anti-doping knowledge (objective ADK) among Japanese university athletes, framed within the context of the Theory of Planned Behavior (TPB). Methods: Eligible participants were 486 university athletes [320 men (65.8%), 166 women; mean age of 18.9 ± 1.0 years]. The participants categorized themselves in terms of the quality of their anti-doping knowledge. This assessment resulted in an independent variable coded as "(1) substantial lack of adequate knowledge," "(2) some lack of adequate knowledge," "(3) fair amount of knowledge" or "(4) good amount of knowledge." Objective ADK was assessed using the Athlete Learning Program about Health and Anti-Doping (ALPHA) test, a set of questions derived from the ALPHA-a former World Anti-Doping Agency e-learning program. The test comprises 12 questions (four choices each; passing index: ≧10 points or 80% correct answer rate). ANCOVA was conducted using subjective ADK as an independent variable and ALPHA scores as a dependent variable, adjusting for confounding factors (anti-doping experience). Results: The ALPHA corrected answer rate across subjective ADK levels for the group were 73.10% for "(1) substantial lack of adequate knowledge," 71.97% for "(2) some lack of adequate knowledge," 75.18% for "(3) fair amount of knowledge" and 72.86% for "(4) good amount of knowledge." Comparison between different levels of subjective ADK revealed no significant differences in ALPHA score considering the main effects or any of their interactions. Discussion: The present results revealed that Japanese university athletes' subjective ADK did not match their objective ADK. In the context of the TPB, there may be limitations in the perceived behavioral control in anti-doping knowledge. Even if athletes view doping as a wrongful act and have formed attitudes and subjective norms to comply with the rules, the results suggest that errors may occur in the composition of behavioral intentions due to a lack of knowledge. This could lead to the possibility of facing the risk of unintentional anti-doping rule violations. It highlights the need for targeted educational interventions to align subjective ADK of athletes with their objective ADK.

Multidimensional background examination of young underweight Japanese women: focusing on their dieting experiences.

Introduction: This study examines the background of underweight young women in Japan from multiple perspectives, focusing on whether they have ever dieted. Methods: A screening survey was administered to 5,905 underweight (BMI < 18.5 kg/m2) women aged 18-29 years, who could report their birth weight recorded in their mother-child handbook. Valid responses were obtained from 400 underweight and 189 normal-weight women. The survey collected data regarding height, weight (BMI), body image and perception of weight, dieting experience, exercise habits from elementary school age onwards, and current eating habits. Additionally, five standardized questionnaires were used (EAT-26, eHEALTH, SATAQ-3 JS, TIPI-J, and RSES). The primary analysis was a comparative analysis (t-test/χ2)-with the presence or absence of underweight and diet experience as independent variables, and each questionnaire as a dependent variable. Results: The screening survey revealed that approximately 24% of the total population was underweight, with a low mean BMI. Of the respondents, more than half reported their body image as skinny and a small percentage as obese. Compared with the non-diet-experienced group (NDG), the diet-experienced group (DG) had a significantly higher proportion of past to current exercise habits. There was a significantly higher percentage of disagreement responses from the DG for weight and food gain than for the NDG. The NDG weighed significantly less than the DG in terms of birth weight, and lost weight easier than the DG. Additionally, the NDG was significantly more likely to agree with increasing weight and food intake. The NDG's exercise habits were below 40% from elementary school age to the present, predominantly owing to a dislike for exercise and a lack of opportunity to implement it. In the standardized questionnaire, the DG was significantly higher for EAT-26, eHEALTH, SATAQ-3 JS, and Conscientiousness (TIPI-J), whereas the NDG was only significantly higher for Openness (TIPI-J). Discussion: The results suggest the need for different health education programs for underweight women who desire to lose weight and experience dieting and for those who do not. This study's results are reflected in the development of sports opportunities optimized for each individual, and in the development of measures to ensure adequate nutritional intake.

Severe pediatric acute encephalopathy syndromes related to SARS-CoV-2.

Background and objectives: To clarify whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection cause acute encephalopathy in children and which are the most common syndromes that cause them and what are the outcomes. Methods: A nationwide web-based survey among all members of the Japanese Society of Child Neurology to identify pediatric patients aged < 18 years who developed acute encephalopathy in Japan between 1 January 2020 and 31 May 2022 associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection confirmed by polymerase chain reaction or antigen tests using pharyngeal swabs. Acute encephalopathy was defined as acute onset of impaired consciousness lasting > 24 h or an altered mental state; neurological symptoms arising within 2 weeks of onset of COVID-19 or multisystem inflammatory syndrome in children (MIS-C)/pediatric inflammatory multisystem syndrome (PIMS); evidence of SARS-CoV-2 infection; and reasonable exclusion of other diseases. Patients were divided into the known clinico-radiological acute encephalopathy syndrome group and unexplained or unclassifiable acute encephalopathy group. Outcomes were assessed by pediatric cerebral performance category (PCPC) score at hospital discharge. Results: Of the 3,802 society members, 217 representing institutions responded, and 39 patients with suspected acute encephalopathy were reported, of which 31 met inclusion criteria. Of these patients, 14 were diagnosed with known clinico-radiological acute encephalopathy syndromes, with acute encephalopathy with biphasic seizures and late reduced diffusion (five patients) being the most common. Five developed acute encephalopathy associated with MIS-C/PIMS. Among 31 patients, 9 (29.0%) had severe sequelae or died (PCPC ≥ 4). Two of three patients with encephalopathy with acute fulminant cerebral edema and two with hemorrhagic shock and encephalopathy syndrome died. The PCPC scores were higher in the known clinico-radiological acute encephalopathy syndrome group than in the unexplained or unclassifiable acute encephalopathy group (P < 0.01). Discussion: Acute encephalopathy related to SARS-CoV-2 infection was demonstrated to be more severe than that caused by other viruses in Japan. Acute encephalopathy syndromes characterized by specific neuroradiological findings was associated with poor clinical outcomes.

Multimodal MR imaging in acute exacerbation of methylmalonic acidemia.

Methylmalonic acidemia (MMA) is a disorder of methylmalonic acid metabolism caused by impaired methylmalonyl CoA mutase. Neuroimaging shows symmetric hypodensity on CT, and T2 prolongation on MRI in the globus pallidus; however, there have been only a few reports on MR spectroscopy findings and no previous reports on arterial spin labeling (ASL), both of which could reflect neurochemical derangement in MMA. We herein report an 18-month-old Sri Lankan boy presented with severe acute exacerbation of MMA due to bacteremia of Salmonella sp. O7. MRI on the seventh day showed T1 and T2 prolongation with decreased diffusion in the bilateral globus pallidus. ASL revealed hyperperfusion in the bilateral globus pallidus. MR spectroscopy showed increased choline (Cho), myo-inositol (mIns), glutamine (Gln), and lactate (Lac) in the globus pallidus; and increased Gln and Lac in the white matter. The globus pallidus is the site of high energy demand around the age of 1 year. In severe acute exacerbation of MMA, increased anaerobic metabolism due to impaired mitochondrial function may lead to hyperperfusion in the globus pallidus to compensate for a disturbed energy supply. Increased Cho, mIns, and Lac in the globus pallidus may result from active demyelination, astrogliosis, and increased anaerobic metabolism. Increased Gln in the basal ganglia and white matter may reflect excitotoxicity.

Changes in the treatment of pediatric acute encephalopathy in Japan between 2015 and 2021: A national questionnaire-based survey.

BACKGROUND: Although acute encephalopathy (AE) is the most serious disorder associated with a viral infection in childhood and often causes death or neurological sequelae, standard treatments have not been established. In 2016, the Japanese Society of Child Neurology published the "Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood 2016" (AE GL 2016). We conducted a questionnaire survey to evaluate the status of the treatment of pediatric AE in 2021 and the changes in treatment before and after the publication of the AE GL 2016. METHODS: In October 2021, questionnaires were mailed via the web to members of two mailing lists who were involved in the practice of pediatric neurological disorders. RESULTS: Most Japanese physicians (98 %) engaged in the treatment of pediatric AE used the AE GL 2016 as a clinical reference. From 2015 to 2021, the number of institutions that implemented targeted temperature management (TTM), vitamin administration, and continuous electroencephalographic monitoring increased significantly. Regarding the targeted temperature for TTM, the proportion of patients who were treated with normothermia (36.0-37.0 °C) increased from 2015 (55 %) to 2021 (79 %). The use of corticosteroids in patients with AE caused by a cytokine storm, which is recommended in the AE GL 2016, had already been implemented in most institutions by 2015. CONCLUSION: The AE GL 2016 could be used to disseminate the knowledge accumulated to date. Evidence of the efficacy and proper indication criteria for the treatment of AE is insufficient and must be further accumulated.

The development and validation of an emotional vulnerability scale for university students.

This study developed an emotional vulnerability scale and examined its reliability and validity with a sample of university students. In health psychology, a measurement of emotional pain ("hurt feelings") can contribute to the prevention and improvement of physical and mental health problems in daily life. We collected data from 361 Japanese university students (186 men and 175 women; mean age = 19.6 ± 0.98 years). From preliminary interviews with 20 participants, 42 semantic units were extracted. For scale development, a questionnaire survey was conducted using the 42 extracted categories, and exploratory and confirmatory factor analyses were performed. Four factors (16 items) emerged, which were both reliable and valid: (1) "vulnerability toward criticism or denial," (2) "vulnerability toward worsening relationships," (3) "vulnerability toward interpersonal discord," and (4) "vulnerability toward procrastination and emotional avoidance." This scale can be useful to understand vulnerability in everyday situations and grasp the vulnerable conditions experienced by individuals. This can help prevent stress responses (such as depression and sadness) and mental health problems, which are valuable contributions to health psychology.

Relationship between the level of willingness to learn about anti-doping and objective knowledge among Japanese university athletes: A cross-sectional study.

Previous studies have indicated that athletes' anti-doping knowledge is inadequate. Athletes' willingness to learn about anti-doping (willingness to learn) may influence their anti-doping knowledge, but the actual situation is unclear. This study aimed to determine the relationship between athletes' willingness to learn about anti-doping and their objective measurement knowledge and explore directions for educational interventions. The eligible participants were 971 male and 802 female university athletes. We used the ALPHA test (12 questions/four choices; passing index: ≥10 points/80% correct answer rate) to assess objective anti-doping knowledge. The willingness to learn question was, "Would you like to learn more about anti-doping?" Responses were given on a 4-point scale ranging from 1: strongly disagree to 4: strongly agree. An ANCOVA was conducted with four levels of willingness to learn as the independent variable and ALPHA correct answer rate as the dependent variable, adjusting for confounding factors (years of athletic experience and anti-doping education experience). The percentage of athletes (%) and each ALPHA correct answer rate (%) by the level of willingness to learn was 1: strongly disagree, n = 1.64%, 61.78%; 2: somewhat disagree, n = 13.14%, 62.38%; 3: somewhat agree, n = 62.94%, 64.08%; 4: strongly agree, n = 22.28%, 67.11%. The ALPHA correct answer rates showed significant differences in the main effect by the level of willingness to learn [F (3, 1767) = 2.873, p < 0.05, η2 = 0.01], although the effect size was small, and multiple comparisons showed no significant differences between the levels. The results indicated that the ALPHA correct answer rate did not reach 80% even for the "strongly agree" level of willingness to learn, suggesting that information on anti-doping may be inadequate. The need to provide sufficient educational content to improve knowledge was evident.

The most severe form of LMNA-associated congenital muscular dystrophy.

Alterations in the LMNA gene cause a wide spectrum of diseases collectively called laminopathies. LMNA-associated congenital muscular dystrophy is a form of laminopathy, which usually causes infantile onset of muscle weakness, predominantly in the cervical-axial muscles, and motor developmental retardation. Cardiac symptoms during the first decade of life are rare. We report a case of LMNA-associated congenital muscular dystrophy in which the patient did not achieve head control and experienced facial muscle weakness. Cardiac dysrhythmias were observed at 5 years with development of dilated cardiomyopathy and ischemic strokes at 7 years. Despite intensive medical intervention, he died suddenly at 9 years. This report broadens the spectrum of phenotypes of this disorder with the most severe symptoms during the first decade of life. Our case underscores the need for early genetic testing for LMNA in patients with congenital muscular dystrophy to screen for cardiac manifestations and intervene as necessary.

Ketogenic Diet for KARS-Related Mitochondrial Dysfunction and Progressive Leukodystrophy.

KARS encodes lysyl-tRNA synthetase, which is essential for protein translation. KARS mutations sometimes cause impairment of cytoplasmic and mitochondrial protein synthesis, and sometimes lead to progressive leukodystrophies with mitochondrial signature and psychomotor regression, and follow a rapid regressive course to premature death. There has been no disease-modifying therapy beyond supportive treatment. We present a 5-year-old male patient with an asymmetrical leukodystrophy who showed overt evidence of mitochondrial dysfunction, including elevation of lactate on brain MR spectroscopy and low oxygen consumption rate in fibroblasts. We diagnosed this patient's condition as KARS-related leukodystrophy with cerebral calcification, congenital deafness, and evidence of mitochondrial dysfunction. We employed a ketogenic diet as well as multiple vitamin supplementation with the intention to alleviate mitochondrial dysfunction. The patient showed alleviation of his psychomotor regression and even partial restoration of his abilities within 4 months. This is an early report of a potential disease-modifying therapy for KARS-related progressive leukodystrophy without appreciable adverse effects.

Recurrent acute necrotizing encephalopathy in a boy with RANBP2 mutation and thermolabile CPT2 variant: The first case of ANE1 in Japan.

BACKGROUND: Acute necrotizing encephalopathy (ANE) is a severe encephalopathy associated with acute viral infection. While most ANE cases are sporadic, pathogenic variants in the gene RAN binding protein 2 (RANBP2) have been identified as a major cause of familial or recurrent ANE (ANE1). Although sporadic ANE predominantly affects Asian children, ANE1 is very rare in east Asia. CASE REPORT: A 1-year-7-month-old boy, born to unrelated Japanese parents, presented with a seizure and impaired consciousness after 3 days of fever. Brain magnetic resonance imaging (MRI) showed a characteristic involvement of the bilateral thalami, external capsules, insular cortices, and brainstem, suggesting ANE. He received intravenous steroids. Two months later, he had another episode of acute encephalopathy during respiratory syncytial virus infection, from which he recovered relatively well. The recurrent encephalopathic episodes and the characteristic MRI suggested ANE1. Genetic analyses revealed two variants: a rare heterozygous missense variant of RANBP2 [c.1754C>T; p.Thr585Met], and a thermolabile polymorphism in carnitine palmitoyltransferase 2 (CPT2) [c. 1055T>G; p.Phe352Cys]. CONCLUSION: This is the first case of recurrent ANE with an RANBP2 mutation in Japan. The patient also harbored a CPT2 polymorphism that is linked to acute encephalopathy in Japanese patients. Thus, he had a genetic background with two susceptibility variants for acute encephalopathy, RANBP2 (frequent in the Caucasians), and CPT2 (frequent in the Japanese). Further studies are needed to fully discover the genetic predisposition to familial or recurrent ANE in the Asian population.

Effects of Different Exercise Conditions on Antioxidant Potential and Mental Assessment.

Exercise increases oxidative stress, leading the body to strengthen its antioxidant defenses, thus reducing the incidence of major diseases. As these associations are relatively unclear for ordinary levels of exercise for reduced stress, this study evaluated the effects of different exercise conditions on diacron-reactive oxygen metabolites (d-ROMs), biological antioxidant potential (BAP), and subjective mood. Forty-nine students (22.4 ± 2.6 years) were assessed using the Profile of Mood States (POMS) before and after exercising for 60 min. Participants were divided into two groups: Group A engaged in compulsory sports and Group B in freely chosen sports. d-ROMs and BAP were measured, and their modified ratio was calculated as an index of antioxidant potential. Physiological evaluation showed significant improvements in BAP and the BAP/d-ROMs ratio, irrespective of exercise condition (p < 0.001, p < 0.01). Comparison between the exercise conditions revealed a significant difference in the modified ratio (p < 0.02). In mood assessment, scores on emotion-related scales without vigor improved significantly under both exercise conditions (p < 0.001). Mental changes were evident after exercise, and potential antioxidant capacity was higher in freely chosen sports (p < 0.03). Assessment of antioxidant status before and after exercise may provide an objective index of mental and physical conditioning.

Neurochemistry of hyponatremic encephalopathy evaluated by MR spectroscopy.

MR spectroscopy in a patient with hyponatremic encephalopathy due to the syndrome of inappropriate secretion of antidiuretic hormone revealed decreased N-acetyl-aspartate, creatine plus phosphocreatine, choline-containing compounds, and myo-inositol, with normal glutamate and increased glutamine, which normalized after Na normalization. The decreased concentrations of creatine plus phosphocreatine, choline-containing compounds and myo-inositol are explained by their release as osmolytes from brain cells to adapt to hypo-osmolality induced cerebral edema. Increased glutamine, which not only acts as an osmolyte but also protects neurons under excitotoxic conditions, may suggest that a disrupted glutamate-glutamine cycle may play an important role in the pathogenesis of hyponatremic encephalopathy.

Cerebral white matter lacerations in children caused by repetitive head trauma.

It has been known that infants less than 1 year develop cerebral white matter (WM) lacerations associated with head trauma, however, there has been no report of similar WM lesions over 1 year. We report three teenage boys (11, 12, and 18 years at final MRI studies) with acquired WM lacerations associated with recurrent head trauma who developed neurologic symptoms such as spastic paralysis, afebrile convulsions, and cognitive impairment. Two of them (patients 1 and 2) were given a diagnosis of autism spectrum disorder and had a history of repeated severe self-inflicted head trauma from preschool age. Patient 3, who practiced karate and boxing from preschool age, showed gradual declining intellectual ability. Brain MRI of the three patients revealed severe lacerations in the bilateral cerebral WM. Previous neuroimaging showed no WM lacerations at 4 and 5 years in patients 1 and 2, or mild WM lacerations at 17 years in patient 3, indicating the WM lacerations could have been acquired in childhood. It is suggested that repetition of head trauma in children can cause cerebral WM lacerations and brain dysfunction.

Prognostic value of MR spectroscopy in patients with acute excitotoxic encephalopathy.

PURPOSE: Acute excitotoxic encephalopathy is the most common encephalopathy syndrome in Japan, and consists of acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) and mild encephalopathy associated with excitotoxicity (MEEX). Neurological sequelae remain in approximately 70% of patients with AESD, however, it is difficult to predict the prognosis early in the course. We evaluated the brain metabolites observed on MRS as to whether they can predict the neurological outcome. METHODS: 16 previously healthy Japanese patients with excitotoxic encephalopathy (8 with AESD and 8 with MEEX) were included in this study. MR spectroscopy (MRS) was acquired from the fronto-parietal white matter (TR/TE = 5000/30 msec) with a 3.0 T scanner. Quantification of metabolites was performed using an LCModel. Neurological outcome was assessed with the Pediatric Cerebral Performance Category score, score 1 being classified as G1 (normal), scores 2 and 3 as G2 (mild to moderate), and scores 4-6 as G3 (severe). RESULTS: MRS data which predict a poor neurological outcome (G2 and 3) include the following: decreased N-acetyl aspartate (NAA) (sensitivity 88%, specificity 100%), decreased creatine (47%, 100%), increased lactate (47%, 100%), and decreased glutamate (sensitivity 35%, specificity 100%). Limited to the acute stage within seven days of onset, those for a poor prognosis are as follows, decreased NAA (88%, 100%), decreased creatine (38%, 100%), and increased lactate (38%, 100%). CONCLUSION: MRS is useful for prognosis prediction of acute excitotoxic encephalopathy. Decreased NAA will be the most effective metabolite for neurological prognosis prediction.

Impact of anti-doping education and doping control experience on anti-doping knowledge in Japanese university athletes: a cross-sectional study.

BACKGROUND: This study was conducted to elucidate the anti-doping (AD) education, doping control experience, and AD knowledge according to the World Anti-doping Code (Code) of Japanese university athletes. METHODS: We collected data from 514 male athletes (Mage = 19.53 years, SD = 1.13) and 629 female athletes (Mage = 20.99 years, SD = 1.07). We asked them about their experience undergoing doping control and the AD education they had received. Then, we assessed their AD knowledge using the World Anti-Doping Agency's Athlete Learning Program about Health and AD (ALPHA) test. RESULTS: The results showed that 2.54% of the participants had undergone doping control. Further, 30.10% received AD education at least once, and 20.82% received AD education more than once. When comparing the ALPHA scores of athletes with/without doping test experience, we observed no significant difference. However, the ALPHA scores of athletes with/without AD education were significantly different; specifically, athletes who received AD education more than once had significantly higher ALPHA scores than non-educated athletes. CONCLUSION: These results revealed that doping control experience was not related to AD knowledge and that AD education was associated with AD knowledge, suggesting that athletes who receive AD education more than once have more accurate AD knowledge than less educated athletes on this topic. The importance of AD education in promoting understanding of AD according to the Code in sports is highlighted in this study.