Nominal Differences in Acute Symptom Presentation and Recovery Duration of Sport-Related Concussion Between Male and Female Collegiate Athletes in the PAC-12.

BACKGROUND: Sport-related concussion (SRC) is a heterogenous injury that often presents with varied symptoms and impairment. Recently, research has focused on identifying subtypes, or clinical profiles of concussion to be used in assessing and treating athletes with SRC. The purpose of this study was to investigate sex differences in clinical profiles, recovery duration, and initial symptom severity after SRC in a cohort of collegiate athletes in the Pacific-12 Conference (Pac-12). METHODS: This prospective cohort study examined post-SRC symptoms, recovery, and return-to-play times using data from the Pac-12 CARE Affiliated Program and Pac-12 Health Analytics Program. Clinical profiles reported by student-athletes were defined by the number (> 50%) of specific symptoms frequently reported for each profile. Generalized linear mixed models were used to examine associations among sex, clinical profiles, time-to-recovery, and return-to-play times. RESULTS: 479 concussion incidents met inclusion criteria. The probabilities of initial presentation of each clinical profile, initial injury severity scores, and recovery times within a profile did not differ between sexes (p = 0.33-0.98). However, both males and females had > 0.75 probabilities of exhibiting cognitive and ocular profiles. Initial injury severity score was a strong nonlinear predictor of initial number of clinical profiles (p < 0.0001), which did not differ between sexes. The number of clinical profiles was also a nonlinear predictor of time-to-recovery (p = 0.03) and return-to-play times (p < 0.0001). CONCLUSIONS: Initial symptom severity was strongly predictive of the number of acute clinical profiles experienced post-SRC. As the number of clinical profiles increased, time-to-recovery and time to return-to-play also increased. Factors other than sex may be better associated with acute symptom presentation post-concussion as no sex differences were found in reported clinical profiles or recovery. Understanding the number and type of clinical profiles experienced post-SRC may help inform concussion diagnostics and management.

Recovery duration and concussion severity in sport- and non-sport-related concussion among Pac-12 collegiate athletes: a retrospective cohort study.

OBJECTIVES: To examine non-sport- and sport-related concussion severity, clinical care frequency and delayed reporting in relation to recovery duration among collegiate athletes. DESIGN: Retrospective cohort study. SETTING: Pac-12 varsity collegiate athletes. PARTICIPANTS: 461 collegiate male and female athletes PRIMARY AND SECONDARY OUTCOME MEASURES: The incidence of sport-related concussion (SRC) and non-sport-related concussion (NRC) were collected as well as times to recovery and return-to-play (RTP), symptom score and symptom severity and reported a loss of consciousness (LOC), retrograde amnesia (RGA) and post-traumatic amnesia (PTA) following concussion incidence. RESULTS: Among 461 concussions, 388 (84%) occurred within sport and 73 (16%) occurred outside of sport. NRC, on average, required 3.5 more days to become asymptomatic (HR: 0.73, 95%confidence interval: 0.56 to 0.96, p=0.02) and 7 more days to RTP (HR: 0.64, 95% confidence interval: 0.49 to 0.85, p<0.01) compared with SRC. NRC were associated with an increase of 1.83 (p=0.07) symptoms reported at the time of diagnosis, an increase of 6.95 (p=0.06) in symptom severity and a higher prevalence of reported LOC (22% NRC vs. 3% SRC, p<0.001), PTA (15% NRC vs. 5% SRC, p<0.01) and RGA (10% NRC vs. 4% SRC, p=0.06), compared with SRC. There was no significant difference in clinical care (p=0.28) or immediate reporting (p=0.35) between NRC and SRC. CONCLUSION: NRC were associated with greater severity and longer recovery duration when compared with SRC in a cohort of collegiate athletes.

Suicide in National Collegiate Athletic Association athletes: a 20-year analysis.

OBJECTIVES: To determine the incidence rate of suicide from 2002 to 2022 among athletes from the National Collegiate Athletic Association (NCAA) and assess for potential differences by, sex, race, division and sport. METHODS: NCAA athlete deaths over a 20-year period from 2002 to 2022 were identified. Poisson regression models were built to assess changes in incidence rates over time. Linear and quadratic fits between year and suicide incidence for males and females were evaluated. RESULTS: Of 1102 total deaths, 128 (11.6%) deaths by suicide were reported (male n=98, female n=30). The overall incidence was 1:71 145 athlete-years (AYs). Over the last decade, suicide was the second most common cause of death after accidents. The proportion of deaths by suicide doubled from the first 10 years (7.6%) to the second 10 years (15.3%). The suicide incidence rate for males increased linearly (5-year incidence rate ratio 1.32 (95% CI 1.14 to 1.53)), whereas a quadratic association was identified among female athletes (p=0.002), with the incidence rate reaching its lowest point in females in 2010-2011 and increasing thereafter. Male cross-country athletes had the highest suicide incidence rate (1:29 815 AYs) and Division I and II athletes had a higher suicide incidence rate than Division III athletes. No significant differences in suicide incidence rates by sex, race or sport were identified. CONCLUSION: Deaths by suicide among NCAA athletes increased in both males and females throughout the 20-year study period, and suicide is now the second most common cause of death in this population. Greater suicide prevention efforts geared towards NCAA athletes are warranted.

Effect of the 2018 NCAA Kickoff Rule Change on Concussion Rates in Collegiate Football: Results From a Division 1 Conference.

Background: Kickoff plays in American football are associated with an increased risk of concussion compared with other play types. In 2018, the National Collegiate Athletic Association (NCAA) Football Rules Committee altered the kickoff rules so a fair catch inside the 25-yard line results in a touchback, with the ensuing drive starting on the 25-yard line. The intention was to decrease the number of kickoff returns with a corresponding decrease in the rate of concussions on kickoff plays. Purpose: To determine whether the 2018 rule changes had the intended effects in an NCAA Division 1 Conference. Study Design: Cohort study; Level of evidence, 3. Methods: The study population included football athletes in the NCAA Pacific-12 (Pac-12) Conference. Data on the total number of plays, punts, kickoffs, touchbacks, and fair catches were obtained for all in-conference games from the 2016 to 2021 seasons. The number of game concussions and the play type were provided by each conference institution. Incidence of concussions occurring during kickoff plays before (2016-2017) and after (2018-2021) the rule change were compared with a difference-in-difference analysis using Poisson general linear models. Results: There were 242 concussions in 108,774 total plays in the study period, with an overall concussion rate of 2.2 per 1000 plays. The percentage of touchbacks increased significantly from 45% to 51% (P < .001) and the percentage of fair catches increased from 1% to 7% (P < .001) from before to after the rule change. Kickoffs accounted for 6% of plays both before and after the rule change and 11% of concussions before and 14% after the change. The mean annual concussion rate (per 1000 plays) on kickoffs was 3.42 before and 5.31 after the rule change (rate difference: 1.89; 95% confidence interval, -1.22 to 5.01). Conclusion: Touchbacks and fair catches increased after the kickoff rule change, but there was not a corresponding decrease in concussions during kickoff plays as anticipated. Concussions occurring during other football plays remained stable.

King-Devick testing and concussion recovery time in collegiate athletes.

OBJECTIVES: To assess whether the King-Devick (KD) test is useful as a prognostic test for prolonged concussion symptoms by examining the relationship between a) change in performance on KD test from baseline to within two days post-injury and b) the absolute KD time at post-concussion testing, with an outcome of time to return to play (RTP). DESIGN: Prospective Cohort Study. METHODS: Collegiate varsity athletes in the Concussion Assessment, Research, and Education (CARE) Consortium completed baseline and post-injury King-Devick tests from 2014 to 2018. Two exposures were evaluated: 1) change in KD score from baseline to within two days post-injury and 2) absolute KD score within two days post-injury, adjusted for baseline KD. We used Cox proportional hazards models to analyze the relationships between these exposures and time to RTP post-concussion. RESULTS: A total of 309 concussion injuries were included. Median baseline KD score was 40.0 s (IQR: 35.8, 45.2). Median post-injury KD score was 45.8 s (IQR: 39.8, 57.1). Median number of days until RTP in this cohort was 11 (IQR: 8, 17). Post-injury KD score adjusted for baseline KD had a stronger association with time to RTP duration (HR: 0.99 (0.98, 1.00), p = 0.03) than the difference in KD score from baseline to post-injury (HR: 0.99 (0.99, 1.00), p = 0.07). CONCLUSIONS: Higher post-injury KD scores are associated with longer RTP. The association between KD post-concussion test and longer RTP warrants further investigation to assess the utility of the KD for prognostication in a clinical setting.

Diagnostic accuracy and reliability of sideline concussion evaluation: a prospective, case-controlled study in college athletes comparing newer tools and established tests.

OBJECTIVE: To assess diagnostic accuracy and reliability of sideline concussion tests in college athletes. METHODS: Athletes completed baseline concussion tests including Post-Concussion Symptom Scale, Standardised Assessment of Concussion (SAC), modified Balance Error Scoring System (m-BESS), King-Devick test and EYE-SYNC Smooth Pursuits. Testing was repeated in athletes diagnosed acutely with concussion and compared to a matched teammate without concussion. RESULTS: Data were collected on 41 concussed athletes and 41 matched controls. Test-retest reliability for symptom score and symptom severity assessed using control athletes was 0.09 (-0.70 to 0.88) and 0.08 (-1.00 to 1.00) (unweighted kappa). Intraclass correlations were SAC 0.33 (-0.02 to 0.61), m-BESS 0.33 (-0.2 to 0.60), EYE-SYNC Smooth Pursuit tangential variability 0.70 (0.50 to 0.83), radial variability 0.47 (0.19 to 0.69) and King-Devick test 0.71 (0.49 to 0.84). The maximum identified sensitivity/specificity of each test for predicting clinical concussion diagnosis was: symptom score 81%/94% (3-point increase), symptom severity score 91%/81% (3-point increase), SAC 44%/72% (2-point decline), m-BESS 40%/92% (5-point increase), King-Devick 85%/76% (any increase in time) and EYE-SYNC Smooth Pursuit tangential variability 48%/58% and radial variability 52%/61% (any increase). Adjusted area under the curve was: symptom score 0.95 (0.89, 0.99), symptom severity 0.95 (95% CI 0.88 to 0.99), SAC 0.66 (95% CI 0.54 to 0.79), m-BESS 0.71 (0.60, 0.83), King-Devick 0.78 (0.69, 0.87), radial variability 0.47 (0.34, 0.59), tangential variability 0.41 (0.30, 0.54) CONCLUSION: Test-retest reliability of most sideline concussion tests was poor in uninjured athletes, raising concern about the accuracy of these tests to detect new concussion. Symptom score/severity had the greatest sensitivity and specificity, and of the objective tests, the King-Devick test performed best.

Prevalence and risk factors for depression, anxiety and suicidal ideation in youth with persistent post-concussive symptoms (PPCS).

Objectives: To assess the prevalence and risk factors for emotional distress in youth with persistent post-concussive symptoms (PPCS) greater than one month.Methods: We used baseline data from an intervention study for youth with PPCS, utilizing Poisson regression to examine factors associated with exceeding clinical cut-points on measures of depression, anxiety, self-harm and suicidal ideation. Predictors included: age, sex, socioeconomic status, mental health history, duration of concussion symptoms, history of prior concussion, trauma history and sleep quality.Results: The sample included 200 youth with PPCS, (mean 14.7 SD 1.7 years, 82% white, 62% female). Forty percent reported clinically significant depressive symptoms, 25% anxiety, 14% thoughts of self-harm and 8% thoughts of suicide. History of depression was associated with 3-fold higher risk for thoughts of self-harm (95% CI:1.82-6.99) and 6-fold higher risk for suicidal ideation (95% CI:1.74-24.46). Better sleep quality was associated with lower risk for all outcomes. History of prior concussion and duration of PPCS were not significantly associated with any outcomes.Conclusions: Suicidal thoughts are common post-concussion, and history of depression is a strong risk factor. Tailored interventions may be needed to address mental health in this population.

Predictors of Failure to Reach Viral Suppression Within 1 Year After Human Immunodeficiency Virus Diagnosis: A Surveillance-Based Analysis.

BACKGROUND: Identifying factors associated with poor human immunodeficiency virus (HIV) care continuum outcomes in the first year after HIV diagnosis could guide care engagement efforts at the time of diagnosis. METHODS: We analyzed data from newly diagnosed persons living with HIV (PLWH) who received a partner services (PS) interview in King County, WA from January 1, 2013, to June 30, 2016. The outcome measure was failure to reach viral suppression, defined as the lack of an HIV RNA result <200 copies/mL reported to surveillance within one year after diagnosis. We constructed Kaplan-Meier curves of time to viral suppression and examined associations between viral suppression and demographic characteristics, substance use, housing status, and plan for HIV care. RESULTS: Among 549 individuals, 69 (13%) did not achieve viral suppression within 1 year. Failure to reach suppression was associated with having no plan for HIV care at the time of PS interview (n = 72; 13% of the total population; RR, 1.19; 95% CI, 1.04-1.36] and unstable housing (n = 81; 15% of the total population; [RR, 1.19; 95% CI, 1.05-1.35). Among persons with one of these two risk factors, 76% achieved viral suppression, compared with 91% of those with stable housing and a plan for care. Overall, 80% of persons who ultimately reached suppression did so by 7.3 months. CONCLUSIONS: Providing early support services to PLWH who have unstable housing or no plan for care at the time of HIV partner services interview and to those who do not reach viral suppression shortly after diagnosis could improve the HIV care continuum.