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Background: Youth sports coaches play a critical role in proper concussion recognition and management, reinforcing the need for coach concussion education. As of 2021, most states have statutory and policy measures mandating concussion education for coaches. In practice, these mandates have been enacted through state legislatures and their respective youth sport governing bodies. Prior studies have found significant variations in the contents of state-level concussion risk reduction policies and have raised questions about their specificity., Objective: To expand on previous analyses to provide an overview of youth sports coach concussion education, highlighting variations in state policies and discrepancies between state mandates and youth sport governing bodies., Methods: This report utilized qualitative content analysis to characterize and compare U.S. state and governing body concussion education requirements for youth sport coaches. State concussion statutes were identified via the National Conference of State Legislatures and Open States databases, and governing body handbooks/bylaws were obtained via their websites. Two researchers independently coded the policies, and discrepancies were resolved through consensus meetings with additional youth traumatic brain injury experts., Results: We found significant variability in educational requirements and their implementation. A majority (68%; n = 34) of states require the completion of concussion education training for coaches. Notably, many states designate responsibility for enforcement and implementation of provisions to another party but just four state statutes delineate explicit consequences for noncompliance. Additionally, only 12 state statutes extend mandates to noninterscholastic sports, limiting their reach. In most cases, independent sanctioning authorities implement more stringent policies than the minimum acceptable standard established by state law., Conclusion: Our findings provide a coded data set of youth coach concussion laws and independent sanctioning authority guidelines that can be used in future research efforts. Further research investigating a relationship between the strength of coach concussion education policies and relevant youth and adolescent concussion-related metrics is required., (© 2024 American Academy of Physical Medicine and Rehabilitation.)

Objectives: Evaluate professional rugby players' self-reported perceived understanding of the head injury assessment (HIA) and return to play (RTP) processes and determine factors related to understanding and trust pertaining to these processes., Methods: An electronic survey measured concepts of interest. A thematic analysis of player understanding was performed, and player statements were coded., Results: 207 U.S. Major League Rugby (MLR) players participated (26.7 ± 3.4 years). HIA and RTP protocol understanding was not correlated with concussion history ( p  = 0.41). International rugby experience and trust regarding MLR support of the following protocols and opposing team medical staff practices varied in their relationship to HIA understanding. Trust that all MLR teams follow the same protocols was positively correlated with all HIA questions (ps < 0.03). No HIA questions were correlated with trust in their own team's medical staff. All trust questions were significantly correlated with RTP process understanding. Qualitative analysis identified four HIA- and RTP-related themes: education needs, staffing needs, HIA criticisms, and importance of player safety., Conclusion: International playing experience and greater trust in the MLR and league stakeholders were associated with greater player understanding of the HIA and RTP protocols. These results provide insight into the importance of educating players on league-specific concussion protocols.

Objective: To investigate dizziness, vestibular/oculomotor symptoms, and cervical spine proprioception among adults with/without a concussion history., Methods: Adults ages 18-40 years with/without a concussion history completed: dizziness handicap inventory (DHI), visio-vestibular exam (VVE), and head repositioning accuracy (HRA, assesses cervical spine proprioception). Linear regression models were used to assess relationships between (1) concussion/no concussion history group and VVE, HRA, and DHI, and (2) DHI with HRA and VVE for the concussion history group., Results: We enrolled 42 participants with concussion history (age = 26.5 ± 4.5 years, 79% female, mean = 1.4± 0.8 years post-concussion) and 46 without (age = 27.0± 3.8 years, 74% female). Concussion history was associated with worse HRA (β = 1.23, 95% confidence interval [CI]: 0.77, 1.68; p < 0.001), more positive VVE subtests (β = 3.01, 95%CI: 2.32, 3.70; p < 0.001), and higher DHI scores (β = 9.79, 95%CI: 6.27, 13.32; p < 0.001) after covariate adjustment. For the concussion history group, number of positive VVE subtests was significantly associated with DHI score (β = 3.78, 95%CI: 2.30, 5.26; p < 0.001) after covariate adjustment, while HRA error was not (β = 1.10, 95%CI: -2.32, 4.51; p = 0.52)., Conclusions: Vestibular/oculomotor symptom provocation and cervical spine proprioception impairments may persist chronically (i.e., 3 years) after concussion. Assessing dizziness, vestibular/oculomotor and cervical spine function after concussion may inform patient-specific treatments to address ongoing dysfunction., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Research reported in this work was supported by the Children's Hospital Colorado Research Institute, the Eunice Kennedy Shriver National Institute of Child Health & Human Development (R01HD108133), and the National Institute of Health (T32AR080630). Unrelated to this study, Dr. Howell has received research support from the Eunice Kennedy Shriver National Institute of Child Health & Human Development (R03HD094560), the National Institute of Neurological Disorders And Stroke (R01NS100952, R43NS108823), the National Institute of Arthritis and Musculoskeletal and Skin Diseases (1R13AR080451), the Denver Broncos Foundation, and the Colorado Clinical and Translational Sciences Institute (UL1 TR002535‐05)., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Concussions are mild traumatic brain injuries that are often undiagnosed due to difficulties in identifying symptoms. To minimize the negative sequelae associated with undiagnosed concussion, efforts have targeted improving concussion reporting. However, knowing more about concussions does not indicate how likely an athlete is to report their concussion. Alternatively, the attitudes and beliefs of athletes and surrounding stakeholders have shown to be a better indication of whether an athlete intends to report their concussion. Prior research has shown that athletes report concussions less often when the injury is described using language that minimizes their severity, such as when it is referred to as a "ding." This study evaluated whether describing concussions using the word "brain" was associated with individuals' underlying attitudes and beliefs about the injury's severity., Objective: To measure the relationship between perceived concussion severity and the language used to describe concussions, specifically whether participants used the word "brain" in describing the injury., Methods: One-on-one semi-structured telephone interviews were conducted, and a cross sectional secondary qualitative analysis was performed to assess participants' perceived concussion severity and their use of the word "brain" to describe concussions., Design: Cross-sectional secondary qualitative analysis., Setting: One-on-one semistructured telephone interviews., Participants: In 2017, 94 individuals involved in high school sports, including athletes, coaches, educators, parents of athletes, and athletic directors were recruited via convenience sampling., Main Outcome Measures: Respondents' perceived severity of concussions., Results: Individuals who used a brain phrase to describe concussion also perceived concussions as more severe (p < .001). Specifically, those who described concussions with maximum severity had higher odds of using brain phrases than those who described concussions as having minimum (odds ratio [OR] = 0.05, 95% confidence interval [CI] = 0.002-0.299, p < .001) or moderate severity (OR = 0.24, 95% CI = 0.086-0.647, p = .003), with the most significant relationship found among coaches., Conclusions: These findings demonstrate the relationship between medical terminology and perceived severity of concussions. This relationship may play a role in concussion reporting behavior for coaches, athletes, and parents. Education programs using similar medical terminology may promote concussion reporting behaviors., (© 2024 American Academy of Physical Medicine and Rehabilitation.)

Importance: Sponsorship of promotional events for health professionals is a key facet of marketing campaigns for pharmaceuticals and medical devices; however, there appears to be limited transparency regarding the scope and scale of this spending., Objective: To develop a novel method for describing the scope and quantifying the spending by US pharmaceutical and medical companies on industry-sponsored promotional events for particular products., Design and Setting: This was a cross-sectional study using records from the Centers for Medicare & Medicaid's Open Payments database on payments made to prescribing clinicians from January 1 to December 21, 2022., Main Outcomes and Measures: An event-centric approach was used to define sponsored events as groupings of payment records with matching variables. Events were characterized by value (coffee, lunch, dinner, or banquet) and number of attendees (small vs large). To test the method, the number of and total spending for each type of event across professional groups were calculated and used to identify the top 10 products related to dinner events. To validate the method, we extracted all event details advertised on the websites of 4 state-level nurse practitioner associations that regularly hosted industry-sponsored dinner events during 2022 and compared these with events identified in the Open Payments database., Results: A total of 1 154 806 events sponsored by pharmaceutical and medical device companies were identified for 2022. Of these, 1 151 351 (99.7%) had fewer than 20 attendees, and 922 214 (80.0%) were considered to be a lunch ($10-$30 per person). Seven companies sponsored 16 031 dinners for the top 10 products. Of the 227 sponsored in-person dinner events hosted by the 4 state-level nurse practitioner associations, 168 (74.0%) matched events constructed from the Open Payments dataset., Conclusions and Relevance: These findings indicate that an event-centric analysis of Open Payments data is a valid method to understand the scope and quantify spending by pharmaceutical and medical device companies on industry-sponsored promotional events attended by prescribers. Expanding and enforcing the reporting requirements to cover all payments to all registered health professionals would improve the accuracy of estimates of the true extent of all sponsored events and their impact on clinical practice.

Background: Approximately 20% of the United States' population lives in a state or jurisdiction where medical aid in dying (MAiD) is legal. It is unknown how physicians' own barriers are associated with their provision of the spectrum of MAiD services., Objective: To measure physicians' religious and/or ethical barriers to providing MAiD services and how such barriers relate to physicians' intentions and behaviors., Design: Three-wave cross-sectional survey fielded in Colorado in 2020-2021., Participants: Physicians providing care to patients likely clinically eligible for MAiD according to probabilistic sampling., Main Measures: Physicians self-reported barriers to their own participation in MAiD. We considered large ethical and/or religious barriers to be conscience-based barriers. We measured physicians' self-reported intention to participate and self-reported prior participation in MAiD since it was legalized in Colorado in 2017. We estimated differences in intention and behavior outcomes according to presence of conscience-based barriers, adjusting for physician gender, race/ethnicity, time in practice, and specialty., Key Results: Among 300 respondents, 26% reported "large" ethical and/or religious barriers to their involvement in MAiD. Physicians with longer time in practice and those identifying as non-White were more likely to report conscience-based barriers to MAiD. Comparing physicians with and without conscience-based barriers to MAiD, we found no difference in ancillary participation (discussing, referring) but significant differences in direct participation (serving as consultant [5% vs. 31%] or attending [0% vs. 22%])., Conclusions: Approximately one-quarter of physicians likely to care for MAiD-eligible patients in Colorado reported religious and/or ethical barriers to MAiD. Despite religious and/or ethical barriers, the vast majority of physicians were willing to discuss MAiD and/or refer patients seeking MAiD services. These data provide important empirical foundation for policy from hospitals and health systems as well as medical specialty groups with official positions on MAiD., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: The pharmaceutical industry promotes prescribing through the cultivation of key opinion leaders. Advanced practice nurses (APNs) are a growing and influential group of prescribers across generalist and specialty practice. Public reporting of industry payments to APNs allows for exploration of their influence within practice settings., Objective: To understand the characteristics of APNs with top industry payments including their positions of influence and other payment recipients at the same address., Design and Setting: Cross-sectional study of US national Open Payments reports of industry payments made between January 1, 2021, and December 31, 2021., Participants: APNs who received > $50,000 USD in industry payments for speaking, consulting, and honoraria ("personal fees")., Measures: Description of top APN recipients' practice setting type, clinical specialty, presence of other payment recipients, value of payments attributed to the same address, and top manufacturers and therapeutic categories associated with payments to top APN recipients. Structured content analysis of public-facing websites for evidence of APNs' clinical, research, and teaching leadership., Results: A total of 99 APNs received > $50,000 USD in aggregate personal fees and a median $74,080 USD (IQR $57,303-101,702) in aggregate payments. They shared a practice setting with a median of 1 (IQR 0-5) physician and 0 (IQR 0-3) other APN payment recipients and were often the only (39%, 42/109) or the dominant (45%, 30/67) payment recipient in their practice setting. In total, 36% held clinical leadership positions, 25% led scientific research, and 18% had university appointments. Forty-two percent (37/88) owned a clinical practice, including cosmetic clinics (51%, 19/37) and mental/behavioral health clinics (24%, 9/37)., Conclusions: Top APN payment recipients attracted high-value payments in practice settings and specialities associated with high-cost drug development; however, there may be little oversight of APNs' industry relationships. Policy development related to industry relationships must be inclusive of and responsive to the activities of interprofessional providers., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: There is limited data regarding how clinicians operationalize shared decision-making (SDM) with athletes with cardiovascular diagnoses. This study was designed to explore sports cardiologists' conceptions of SDM and approaches to sports eligibility decisions., Methods: 20 sports cardiologists were interviewed by telephone or video conference from October 2022 to May 2023. Qualitative descriptive analysis was conducted with the transcripts., Results: All participants endorsed SDM for eligibility decisions, however, SDM was defined and operationalized heterogeneously. Only 6 participants specifically referenced eliciting patient preferences during SDM. Participants described variable roles for the physician in SDM and variable views on athletes' understanding, perception, and tolerance of risk. Participants thresholds for prohibitive annual risk of sudden cardiac death ranged from <1 % to >10 %., Conclusions: These findings reinforce the general acceptance of SDM for sports eligibility decisions and highlight the need to better understand this process and identify the most effective approach for operationalization., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Dickert reports consulting and research funding from Abiomed, Inc. and research funding from NIH and AHRQ. Dr. Baggish receives compensation for his role as consultant / team cardiologist from the US Olympic Committee / US Olympic Training Centers, International Olympic Committee, National Football League Players Association, US Soccer, and US Rowing. Dr. Campbell has served as a paid expert witness on law cases related to financial conflicts of interest in medicine. The other authors report no conflicts., (© 2024 The Authors.)

Context: The abrupt cessation of school and sport participation during the COVID-19 pandemic may have negative implications for adolescent mental health., Objectives: To (1) compare mental, physical, and social health and behaviors during pandemic-related stay-at-home mandates with the same measures collected 1 to 2 years earlier and (2) evaluate the relationships between physical activity and sleep during the pandemic and changes in anxiety, fatigue, and peer relationships between assessment times., Design: Cohort study., Setting: Pediatric sports medicine center., Patients or Other Participants: A total of 39 high school athletes (25 adolescent girls, 14 adolescent boys; age = 16.2 ± 0.9 years)., Main Outcome Measure(s): Patient-Reported Outcome Measurement System anxiety, fatigue, and peer relationships short forms and the Pittsburgh Sleep Quality Index were completed twice (initial assessment in May 2018 or 2019, follow-up assessment in May or June 2020). Frequency and duration of physical activity and frequency of interaction with other individuals (family, peers, sport coaches, etc) were self-reported at follow-up assessment for the 2 weeks before school or sport closure and the 2 weeks before questionnaire completion., Results: Higher levels of anxiety (5.5 ± 4.0 versus 3.6 ± 3.4 points; P = .003) and fatigue (5.4 ± 3.7 versus 2.3 ± 2.5 points; P < .001) and worse sleep quality (6.6 ± 2.9 versus 4.3 ± 2.3 points; P < .001) were observed during the pandemic compared with previous assessments. Reductions in physical activity were noted between assessments (exercise duration: 86.4 ± 41.0 versus 53.8 ± 30.0 minutes; P < .001). Sleep quality but not physical activity during the pandemic predicted changes in fatigue (P = .03, β = 0.44 [95% CI = 0.06, 0.83]) and peer relationships (P = .01, β = -0.65 [95% CI = -1.16, -0.15]) from initial to follow-up assessment., Conclusions: Mental and physical health declined during stay-at-home mandates compared with assessments 1 to 2 years earlier. Physical activity behaviors and sources of social interaction underwent changes after school and sport cessation. Sleep quality may have provided some protection against declining adolescent mental health during the pandemic, although this relationship requires further investigation., (© by the National Athletic Trainers’ Association, Inc.)

Enabling athletes to achieve peak performances while also maintaining high levels of health is contextually complex. We aim to describe what a 'health system' is and apply the essential functions of stewardship, financing, provision of services and resource generation to an Australian high-performance sport context. We introduce a fifth function that health systems should not detract from athletes' ability to achieve their sports goals. We describe how these functions aim to achieve four overall outcomes of safeguarding the health of the athletes, responding to expectations, providing financial and social protection against the costs of ill health, and efficient use of resources. Lastly, we conclude with key challenges and potential solutions for developing an integrated health system within the overall performance system in high-performance sport., (© 2023. Crown.)

Chronic traumatic encephalopathy (CTE) is a neurodegenerative tauopathy associated with repetitive head impacts (RHI), but the components of RHI exposure underlying this relationship are unclear. We create a position exposure matrix (PEM), composed of American football helmet sensor data, summarized from literature review by player position and level of play. Using this PEM, we estimate measures of lifetime RHI exposure for a separate cohort of 631 football playing brain donors. Separate models examine the relationship between CTE pathology and players' concussion count, athletic positions, years of football, and PEM-derived measures, including estimated cumulative head impacts, linear accelerations, and rotational accelerations. Only duration of play and PEM-derived measures are significantly associated with CTE pathology. Models incorporating cumulative linear or rotational acceleration have better model fit and are better predictors of CTE pathology than duration of play or cumulative head impacts alone. These findings implicate cumulative head impact intensity in CTE pathogenesis., (© 2023. The Author(s).)

This manuscript uses competitive college football as a lens into the complexities of decision-making amid the Covid-19 pandemic. Pulling together what is known about the decision-makers, the decision-making processes, the social and political context, the risks and benefits, and the underlying obligations of institutions to these athletes, we conduct an ethical analysis of the decisions surrounding the 2020 fall football season. Based on this ethical analysis, we provide key recommendations to improve similar decision processes moving forward.

Background: While healthcare and health outcome disparities have been studied across a variety of different injuries, their relation to concussion incidence and management are relatively understudied., Aim: The aim of this study was to evaluate the association between history of concussion or musculoskeletal injury, and family affluence and/or school-level measures of socioeconomic status., Methods: We conducted a cross-sectional study of adolescent athletes in a local school district. Adolescent athletes ( n = 192; mean age = 15.3, SD = 1.6 years; 49% female), who presented for a pre-participation physical evaluation reported concussion and injury history, and family affluence scale (FAS) scores. We also examined the percent of students on free/reduced lunch at each school compared to state averages. Independent variables, individual FAS score and school-based marker of socioeconomic status, were compared between those with and without a history of concussion and time-loss musculoskeletal injury., Results: Of the participants, 40 (21%) reported a history of concussion. Athletes with a concussion history had significantly lower FAS scores than athletes without a history of concussion (mean difference = 0.7, 95%CI = 0.1, 1.4; P = 0.027). There was no significant difference in FAS scores between those with and without a history of time-loss musculoskeletal injury (mean difference = 0.0, 95% CI = -0.5, 0.5; P = 0.97). Athletes with a history of concussion had a higher proportion of a prior time-loss musculoskeletal injury (68% vs. 32%; P < 0.001). After adjusting for age, school free-reduced lunch rate, and history of musculoskeletal injury, a lower FAS score was associated with concussion history (adjusted odds ratio = 0.79; 95% CI = 0.64, 0.96; P = 0.019). Concussion and musculoskeletal injury were not associated with school-level markers of socioeconomic status., Conclusion: Lower individual measures, but not school-level measures, of socioeconomic status were associated with a history of concussion in our sample of adolescent athletes., Relevance for Patients: Enhance providers' understanding of how socioeconomic factors may impact concussion history and empower providers to adequately screen for and provide concussion education to mitigate disparities., Competing Interests: The authors have no conflicts of interest relevant to this article to disclose., (Copyright: © 2022 Author(s).)

Background: Concussion underreporting is endemic, and social norms are an established predictor of concussion reporting behavior. However, pluralistic ignorance-a situation in which most individuals in a group hold the belief that their peers' views differ from their own, despite views actually being similar-has not been studied in this context., Aim: To assess whether pluralistic ignorance contributes to concussion underreporting., Method: We surveyed 2,504 military service academy cadets. Each cadet was presented with a survey asking about their willingness to self-report a concussion, their perception of other cadets' willingness to report a concussion, and personal and demographic factors., Results: Most cadets viewed themselves as more willing to report a concussion than others (mean difference = 1.12, 95% CI [1.02, 1.21]), a belief consistent with pluralistic ignorance. Demographic characteristics were associated with holding this belief. For example, female cadets and upper-class cadets were more likely to show this disparity than male or under-class cadets, respectively. Collegiate athletes not only showed similar willingness to report concussion as nonathletes but also perceived other cadets as less likely to report concussions. Meanwhile, future pilots showed less self-report willingness and perceived that others were similarly unwilling to report concussions., Discussion: A majority of this economically and geographically diverse population displays characteristics of pluralistic ignorance: They largely share proconcussion reporting sentiments but incorrectly perceive that others do not. This belief is not held uniformly in all subpopulations, which may inform how these beliefs are developed and maintained., Conclusions: Pluralistic ignorance is an important consideration in concussion education efforts.

Undiagnosed concussions increase the risk of additional concussion and persistent symptoms from concussion. Because there are no reliable objective markers of concussion, self-reporting of subjective and non-visible symptoms are critical to ensuring proper concussion management. For this reason, educational interventions target concussion reporting, but the majority of studies have examined the efficacy of single educational interventions or compared interventions to one another. This randomized crossover study sought to identify whether there was benefit to administering multiple concussion education programs in tandem, back to back. The study randomized 313 male high school football players to first receive CrashCourse concussion education (CC) or Centers for Disease Control and Prevention video concussion education (CDC) followed by crossover with the other education. Athlete concussion-reporting intention, attitudes, subjective norms, perceived behavioral control, and enjoyment of education were assessed at baseline and after each intervention. There were statistically significant improvements across all measures, both after single intervention and crossover (all p  < 0.001). Secondary analyses examining differences between education found that athletes reported higher enjoyment of concussion education immediately after participating in CC, as compared to CDC ( p  < 0.001). These findings demonstrate an additive benefit to implementing CC and CDC education in tandem, without decrement in enjoyment of concussion education after experiencing dual educations; in fact, enjoyment of concussion education improved after receiving education programs back to back. These educational programs appear to complement one another, and the results support the use of multi-modal concussion education to differentially target and maximize concussion reporting., Competing Interests: P.S. is founder and CEO for the non-profit, TeachAids, where she receives a salary of $1 per year. The following authors have a non-reimbursed relationship as medical advisors for CrashCourse: D.H.D., M.Y., R.D.P., S.G., G.A.G., J.G., and L.M.S. C.M.B. previously received funding from the NCAA as a graduate student research grant recipient, the Datalys Center for Sports Injury Research and Prevention as a graduate student research grant recipient, and through the Football Players' Health Study at Harvard, which is funded by the NFL Players' Association. R.C. is a paid consultant to the NFL Head Neck and Spine Committee, NOCSAE, Concussion Legacy Foundation, royalties from book publications, and compensation from expert legal opinion. He is a member of the Mackey-White Committee of the NFL Players Association. R.Z. serves on scientific advisory boards for Oxeia BioPharma, ElMIndA, and MYOMO; serves on the editorial board of Journal of Neurotrauma; receives publishing royalties for Brain Injury Medicine: Principles and Practice (Demos, 2013) and Physical Medicine and Rehabilitation—A Comprehensive Review (Oakstone); and receives research support from the NIH, NIDILRR, USARMC, and the Football Players Health Study at Harvard funded, in part, by the NFL Players' Association., (© Daniel H. Daneshvar et al., 2021; Published by Mary Ann Liebert, Inc.)

Importance: Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease; understanding ALS risk factors is a critical public health issue., Objectives: To evaluate the incidence of and mortality from ALS in National Football League (NFL) athletes and to describe characteristics associated with ALS within this cohort., Design, Setting, and Participants: This population-based cohort study included all 19 423 NFL athletes who debuted between 1960 and 2019 and played 1 or more professional game. It was conducted between October 3, 2020, and July 19, 2021., Exposure: Participation in the NFL, including playing 1 or more professional games., Main Outcomes and Measures: Cases of ALS and death information were identified based on public records from NFL statistics aggregators, news reports, obituaries, and National Death Index results. The standardized incidence ratio and the standardized mortality ratio were calculated based on data acquired from surveillance studies of ALS accounting for age, sex, and race. Secondary analyses examined the association of body mass index, NFL career duration, race, birth location, and markers of fame, using a nested case-control design, matching athletes with ALS to athletes without ALS, by NFL debut year., Results: A total of 19 423 male former and current NFL players (age range, 23-78 years) were included in this cohort study and were followed up for a cumulative 493 168 years (mean [SD] follow-up, 30.6 [13.7] years). Thirty-eight players received a diagnosis of ALS, and 28 died during the study time frame, representing a significantly higher incidence of ALS diagnosis (standardized incidence ratio, 3.59; 95% CI, 2.58-4.93) and mortality (standardized mortality ratio, 3.94; 95% CI, 2.62-5.69) among NFL players compared with the US male population, adjusting for age and race. Among NFL athletes, nested-case-control analyses found that those who received a diagnosis of ALS had significantly longer careers (mean [SD] duration, 7.0 [3.9] years) than athletes without ALS (mean [SD] duration, 4.5 [3.6] years; odds ratio, 1.2; 95% CI, 1.1-1.3). There were no differences in ALS status based on proxies of NFL fame, body mass index, position played, birth location, or race., Conclusions and Relevance: The age-, sex-, and race-adjusted incidence of and mortality from ALS among all NFL players who debuted between 1960 and 2019 were nearly 4 times as high as those of the general population. Athletes with a diagnosis of ALS had longer NFL careers than those without ALS, suggesting an association between NFL duration of play and ALS. The identification of these risk factors for ALS helps to inform the study of pathophysiological mechanisms responsible for this fatal neurodegenerative disease.

Objective: This report estimates the percent of medically eligible adolescents who are referred for metabolic and bariatric surgery (MBS) evaluation or factors associated with referral., Methods: This cross-sectional retrospective review evaluated patients aged 13 to 18 years seen between 2017 and 2019 for demographics, insurance status, body mass index (BMI), obesity-related comorbidities, and compared these data to patients whom had been referred and received MBS., Results: Half of the patients (86 411/163137, 53%) between ages of 13 and 18 years identified had BMI documented, of which, 1974 (2.3%) were medically eligible for MBS, 238 (12%) were referred for MBS and 52 (22%) underwent MBS. Females had similar odds of being eligible for MBS [odds ratio (OR) = 1.01, 95% confidence interval (CI) 0.92-1.11, P = .9], but greater odds of referral (OR = 1.58, 95% CI 1.13-2.23, P = .009). Independently, miniorities and patients with public insurance had higher odds of being eligible for MBS, but similar odds of being referred as non-Hispanic white patients. Black patients with public insurance had greater odds of being referred for MBS (OR = 12.22, 95% CI 2.08-235.15, P = .022). Patients' multiple comorbidities had greater odds of being referred for MBS (OR = 2.16, 95% CI 1.29-3.68, P = .004)., Conclusions: Referral is barrier for patients medically eligible for MBS; however, this barrier is not uniformly faced by all patients., (© 2021 World Obesity Federation.)

Context: Concussion underreporting leads to delays in diagnosis and treatment, prolonging recovery time. Athletes' self-reporting of concussion symptoms, therefore, reduces risk., Objective: To evaluate the effectiveness of 3 concussion-education programs in improving concussion-reporting intention., Design: Randomized controlled clinical trial., Setting: Three high schools in California., Patients or Other Participants: A total of 118 male football players (age = 14.88 ± 1.19 years)., Intervention(s): Participants were randomly assigned to receive concussion education via CrashCourse (CC), Centers for Disease Control and Prevention (CDC) video education materials (CDC-Vi), or CDC written education materials (CDC-Wr)., Main Outcome Measure(s): The primary outcome was concussion-reporting intention, which was assessed at baseline, immediately after education, and at 1-month follow-up. Secondary outcomes were concussion knowledge, concussion-reporting attitudes, perceived concussion-reporting norms, and perceived behavioral control., Results: Across all education formats, a total sample of athletes improved in concussion-reporting intention at immediate and 1-month follow-ups (mean improvements = 6.8% and 11.4%, respectively; F4,224 = 11.1, P < .001). Similar findings were observed across all education formats in secondary analyses examining knowledge, attitudes, and perceived behavioral control. However, we noted differences in concussion-reporting intention by education format and time (F4,224 = 2.8, P = .03). Post hoc analysis showed that athletes who received CC had increased concussion-reporting intentions at immediate and 1-month follow-ups (baseline = 4.7, immediate follow-up = 6.1, 1-month follow-up = 6.0; F16,61.1 = 6.1, P = .007) compared with increases only at 1-month follow-up for CDC-Vi (baseline = 4.3, immediate follow-up = 5.2, 1-month follow-up = 5.8; F1.6,61.6 = 8.4, P = .001) and no improvement for CDC-Wr (P = .10). Secondary analyses indicated differences between CC and both CDC interventions in concussion knowledge and attitudes at immediate and 1-month follow-ups. We identified no differences in perceived behavioral control among interventions (F4,216 = 0.2, P = .93) or perceived concussion-reporting norms across (F4,224 = 0.3, P = .73) or among (F4,224 = 1.7, P = .15) interventions., Conclusions: All athletes exhibited an improved intent to report concussions, increased concussion knowledge, better concussion attitudes, and more perceived behavioral control at both immediate and 1-month follow-ups. However, athletes randomized to receive CC reported a greater intent to report concussion, more knowledge, and improved concussion-reporting attitudes when compared with those who received CDC-Vi and CDC-Wr., (© by the National Athletic Trainers' Association, Inc.)