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Context State laws provide general guidelines for sport-related concussion (SRC) management but do not comprehensively address the multiple layers of management for this complex injury. Although high schools are encouraged to develop SRC protocols that include both state law tenets and additional management practices, the execution of these protocols warrants examination. Objective To investigate state law compliance and practice components included in high school SRC protocols and determine whether the degree of sports medicine coverage influenced protocol quality. Design Qualitative document analysis. Setting High school athletics. Patients or Other Participants In total, 184 Pennsylvania high schools (24.3% of schools statewide; full-time athletic trainers [ATs] = 149, part-time ATs = 13, missing = 22) voluntarily provided copies of their protocols from the 2018–2019 academic year. Main Outcome Measure(s) Four ATs conducted document analyses using a 67-item component analysis guide. Frequencies were computed for included protocol components related to the state law, preparticipation and prevention, recognition and assessment, and management. The difference in the total number of included components (maximum = 60) by sports medicine coverage was assessed using a Mann-Whitney U test. Results Heterogeneity existed in the components included in the submitted protocols. Only 23.4% included all mandatory state law tenets. Immediate removal from play was noted in 67.4% of protocols, whereas only 1.6% contained prevention strategies. Return to play was addressed more frequently than return to learn (74.5% versus 32.6%). The sample had a mean of 15.5 ± 9.7 total components per protocol. Schools with full-time sports medicine coverage had more protocol components than those with part-time ATs (15 [interquartile range = 8.5–22.5] versus 6 [3–10.5] median components; U = 377.5, P < .001). Conclusions School-level written SRC protocols were often missing components of the state law and additional best-practice recommendations. Full-time sports medicine coverage in high schools is recommended to increase SRC protocol and health care quality.

Objective To evaluate a novel technique designed to reduce the negative impact of motion artifacts in infant dual-energy X-ray absorptiometry (DXA) scans. Study design Using cross-sectional data from a large multicenter study, we developed and tested advanced methods for infant scan analysis. Newborns (n = 750) received spine and whole-body DXA scans with up to 3 attempts to acquire a motion free scan. Precision of infant DXA was estimated from visits with multiple valid scans. Accuracy of regional reflection, fusion, and omission techniques was estimated by comparing modified scans to unmodified valid scans. The effectiveness of the acquisition and analysis protocol was represented by the reduction in rate of failure to acquire valid results from infant visits. Results For infant whole-body DXA, arm reflection and all fusion techniques caused no significant changes to bone mineral content, bone mineral density, bone area, total mass, fat mass, lean mass, and percentage fat. Leg reflection and arm/leg dual-reflection caused significant changes to total mass, but the percentage change remained small. For infant spine DXA, fusion and omission caused no significant changes. Advanced analysis techniques reduced the failure rate of whole-body scanning from 20.8% to 9.3% and the failure rate of spine scanning from 8.9% to 2.4%. Conclusions Advanced analysis techniques significantly reduced the impact of motion artifacts on infant DXA scans. We suggest this protocol be used in future infant DXA research and clinical practice.

Background: Total body volume (TBV), with the exclusion of internal air voids, is necessary to quantify body composition in Lohman's 4-compartment (4C) model. Objective: This investigation sought to derive a novel, TBV measure with the use of only dual-energy X-ray absorptiometry (DXA) attenuation values for use in Lohman's 4C body composition model. Design: Pixel-specific masses and volumes were calculated from low- and high-energy attenuation values with the use of first principle conversions of mass attenuation coefficients. Pixel masses and volumes were summed to derive body mass and total body volume. As proof of concept, 11 participants were recruited to have 4C measures taken: DXA, air-displacement plethysmography (ADP), and total body water (TBW). TBV measures with the use of only DXA (DXA-volume) and ADP-volume measures were compared for each participant. To see how body composition estimates were affected by these 2 methods, we used Lohman's 4C model to quantify percentage fat measures for each participant and compared them with conventional DXA measures. Results: DXA-volume and ADP-volume measures were highly correlated (R2 = 0.99) and showed no statistically significant bias. Percentage fat by DXA volume was highly correlated with ADP-volume percentage fat measures and DXA software-reported percentage fat measures (R2 = 0.96 and R2 = 0.98, respectively) but were slightly biased. Conclusions: A novel method to calculate TBV with the use of a clinical DXA system was developed, compared against ADP as proof of principle, and used in Lohman's 4C body composition model. The DXA-volume approach eliminates many of the inherent inaccuracies associated with displacement measures for volume and, if validated in larger groups of participants, would simplify the acquisition of 4C body composition to a single DXA scan and TBW measure.

Few studies have described the long-term repeatability of dual-energy X-ray absorptiometry scans. Even fewer studies have been performed with enough participants to identify possible precision covariates such as sex, age, and body mass index (BMI). Our objective was to investigate the long-term repeatability of both total and subregional body composition measurements and their associations with covariates in a large sample. Two valid whole-body dual-energy X-ray absorptiometry scans were available for 609 participants in the National Health and Nutrition Examination Survey 2000–2002. Participants with scan-quality issues were excluded. Participants varied in race and ethnicity, sex, age (mean 38.8 ± 17.5; range 16–69 yr), and BMI (mean, 26.9 ± 5.2; range 14.1–43.5 kg/m 2 ). The length of time between scans ranged from 3 to 51 days (mean, 18.7 ± 8.4). Precision error estimates for total body measures (bone mineral density, bone mineral content, lean mass, total mass, fat mass, and percent body fat) were calculated as root mean square percent coefficients of variation and standard deviations. The average root mean square percent coefficients of variation and root mean square standard deviations of the precision error for total body variables were 1.12 and 0.01 g/cm 2 for bone mineral density, 1.14 and 27.3 g for bone mineral content, 1.97 and 505 g for fat mass, 1.46 and 760 g for lean mass, 1.10 and 858 g for total mass, and 1.80 and 0.59 for percent body fat. In general, only fat and lean masses were impacted by participant and scan qualities (obesity category, sex, the magnitude of the body composition variables, and time between scans). We conclude that long-term precision error values are impacted by BMI, and sex. Our long-term precision error estimates may be more suitable than short-term precision for calculating least significant change and monitoring time intervals.

Aims: Increased visceral adipose tissue (VAT) volume is strongly associated with several serious metabolic diseases including heart disease and diabetes, and also to fracture risk. Accurate measure of this soft tissue compartment is imperative if it is to be included in clinical risk models. Hologic software, version Apex 4.0, now includes a VAT estimate from whole body scans. Although the analysis is automated, the region is visible and allows for manual adjustment if necessary. The aim of our study was to evaluate how often the VAT region needed adjustment and what would be the error if no manual adjustment is made. Methods: We reanalyzed a subset of the NHANES study whole body scans (20112012) to include VAT volume to the study results. These NHANES participants are considered a representative sample of the US population from ages 18 years to 59 years old. All scans were analyzed using Hologic version Apex 4.0 auto-analysis mode and manually reviewed for proper VAT region placement. VAT regions needing correction were manually adjusted. Paired T-tests were used to determine the difference in error between the auto and manual analyses for VAT and subcutaneous adipose tissue volume (SAT). Results: A total 3283 adult whole body scans were reviewed. VAT boundary marker adjustment was required on 247, or approximately 8% of the scans. The average difference between manual and auto analysis for both VAT and SAT were significantly different (p!0.0001) with VAT being -17.9 34.8 cm and SAT higher +18.0 35.5 cm. Absolute differences ranged from -213.7 to 145.8 cm and -145.8 to 213.7 cm for VAT and SAT, respectively. Conclusion: Our results confirm that for VAT and SAT regions, it is imperative to visualize the and check the region demarcations to assure high accuracy. Failure to do this necessary quality control review could lead to clinically inaccurate results in 1 out of 12 patients. Disclosure of Interest: None Declared