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Edward C Jauch,1 David Y Huang,2 Allison J Gardner,3 Julie L Blum3 1Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC, USA; 2Department of Neurology, Division of Stroke and Vascular Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA; 3QI Institute, Med-IQ, Baltimore, MD, USA Background: The timely evaluation and initiation of treatment for acute ischemic stroke (AIS) is critical to optimal patient outcomes. However, clinical practice often falls short of guideline-established goals. Hospitals in rural regions of the USA, and notably those in the Stroke Belt, are particularly challenged to meet timing goals since the vast majority of primary stroke centers (PSCs) are concentrated in urban academic institutions. Methods: Between May 2015 and May 2017, emergency department (ED) teams from 5 non-PSC hospitals in the Stroke Belt participated in a quality improvement (QI) initiative. The intervention included a baseline practice assessment survey, repeat audit-and-feedback cycles with patient data on AIS treatment timing, personalized Continuing Medical Education/Continuing Education-certified grand rounds sessions at each participating site with expert study faculty, targeted reinforcement of best practices, and follow-up to evaluate the benefits and limitations of the intervention. Results: At the start of the initiative, clinical staff from participating EDs overestimated the proportion of patients with AIS who received alteplase within the guideline-recommended 60-minute door-to-needle window at their facility. At the end of the 6-month intervention period, significantly more patients were treated with alteplase within 60 minutes of ED arrival compared to baseline across the entire sample (1.9% of patients at baseline vs. 5.2% at 6 months; P < 0.01). Similarly, there was a trend toward a decrease in the percentage of patients whose alteplase treatment was initiated more than 60 minutes after their arrival at the ED (67.3% at baseline vs. 22.2% at 6 months). Conclusion: Structured QI interventions that engage ED care teams to reflect on processes related to AIS diagnosis and treatment and deploy repeat audit-and-feedback cycles with real-time patient data have the potential to support an increase in the number of patients who receive alteplase within the guideline-recommended timeframe of 60 minutes from hospital arrival. Keywords: AIS, neurology, CME, quality improvement, alteplase

Allison J Gardner,1 Alice L Gray,2 Staci Self,3 Jeffrey S Wagener4 1Med-IQ, LLC, Baltimore, MD, 2Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, 3Division of Pediatric Pulmonology, University of Alabama at Birmingham, Birmingham, AL, 4Department of Pediatrics, University of Colorado Medical School, Aurora, CO, USA Background: Treatment regimens for patients with cystic fibrosis (CF) are complex, time consuming, and burdensome, and adherence to CF treatment is suboptimal. CF care teams play a critical role in supporting patients’ chronic self-management skills, but there is no uniform method for assessing patients’ adherence to treatment or standard interventions to help patients improve when necessary.Methods: Between May 2015 and March 2016, care team members from 10 CF centers in the USA participated in a practice assessment and quality improvement (QI) initiative. The intervention included a baseline practice assessment survey, personalized continuing medical education (CME)-certified Webconferences with expert study faculty, targeted reinforcement of key practice points, and follow-up online survey and telephone interviews to evaluate the benefits and limitations of the intervention.Results: Responses to the baseline practice assessment survey were received from 50 multidisciplinary care team members representing 10 CF centers. Primary barriers to adherence-related aspects of care in their clinics were motivating patients and caregivers to improve adherence and obtaining accurate information about adherence from patients. At the conclusion of the initiative, participants reported improvements in communication within their care team, implementation of new approaches to asking about adherence, and a renewed commitment to asking patients and caregivers about adherence at each clinic visit.Conclusion: Structured QI interventions that bring multidisciplinary care teams together to reflect on clinic processes and elicit objective insights from outside faculty have the potential to improve practice patterns related to the assessment and improvement of patient adherence in CF. Keywords: nonadherence, treatment burden, communication, team-based care

Concussions in contact sports are challenging for athletes, health professionals and sporting bodies to prevent, detect and manage. Design of interventions for primary prevention, early recognition of concussion and continuing to improve postconcussion management are essential for protecting athletes and promoting brain health. Over the last decade, there have been advancements in video technology for analysing head impact events and improvements in the clinical management of concussions. This study protocol describes how researchers, clinicians and staff from the Australasian National Rugby League (NRL) have brought these advancements together and developed a database of videos with head impact events and clinical outcomes. The intended outputs from this work will enhance the understanding of head impact events in NRL, from biomechanical and gameplay factors to concussion and return to play outcomes. Publishing this protocol increases the transparency of this large-scale effort to better identify head impacts and their relationship to concussions and player movement behaviour to contextualise these variables to generate new knowledge and support the reproducibility of these emerging findings. Between 2017 and 2023, over 5250 head contact cases were recorded in the database, from which >1700 head injury assessments were performed, and >600 concussions were diagnosed. Future studies using these data are planned to inform both primary and secondary injury prevention initiatives, such as risk analysis and prediction of game scenarios that result in concussion, as well as investigation of features and factors that help to inform the duration of recovery and return to play., Competing Interests: AG has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion (including current and former athletes). He has been a contracted concussion consultant to Rugby Australia. He is a member of the World Rugby Concussion Working Group, and a member of the Australian Football League Concussion Scientific Advisory Committee. He has received travel funding or been reimbursed by professional sporting bodies, and commercial organisations for discussing or presenting sport-related concussion research at meetings, scientific conferences, workshops and symposiums. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation (Australia), an Australian-American Fulbright Commission Postdoctoral Award, a Hunter New England Local Health District, Research, Innovation and Partnerships Health Research & Translation Centre and Clinical Research Fellowship Scheme and the Hunter Medical Research Institute (HMRI), supported by Jennie Thomas, and the HMRI, supported by Anne Greaves. He is supported by a National Health and Medical Research Council (NHMRC) Investigator Grant. He acknowledges unrestricted philanthropic support from the Tooth Foundation, and the National Rugby League (NRL) for research in retired professional rugby league players. GI has been reimbursed by the government, professional scientific bodies and commercial organisations for discussing or presenting research related to mild traumatic brain injury and sport-related concussion at meetings, scientific conferences and symposiums. He has a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild TBIs (including athletes). He has received research funding from several test publishing companies, including ImPACT Applications, CNS Vital Signs and Psychological Assessment Resources (PAR). He has received research funding from the National Football League. He has also received research funding from the Harvard Integrated Programme to Protect and Improve the Health of National Football League Players Association Members. He acknowledges unrestricted philanthropic support from ImPACT Applications, the Mooney-Reed Charitable Foundation, NRL, Boston Bolts, Heinz Family Foundation and Schoen Adams Research Institute at Spaulding Rehabilitation. PB was the past NRL chief medical officer (2015–2021) and initiated and developed the NRL injury surveillance bunker and NRL concussion rules. He is a past club medical officer (2000–2013) and current club medical officer with the Manly Sea Eagles NRL club. He also provides medical consultancy support to the Rugby League Players Association. SF is the NRL chief medical officer. JB has received research funding from World Rugby, the international governing body of rugby union. In addition, JB has received salary contributions and the coverage of travel costs from World Rugby. SE is an accredited sport scientist (ASpS2) and leads a tackle re-education programme that is partially funded by a NHMRC Ideas 2021 grant (202718). GF has previously received funding from World Rugby to attend research meetings and was a previous member of the Concussion in Sport expert panel. MG has received a Sports and Wellbeing Analytics/Cellbond Impact Solutions/Royal Academy of Engineering Senior Research Fellowship. PJ has no disclosures/conflicts of interest. BJ has secured research funding from World Rugby, Rugby Football Union, Scottish Rugby, Premiership Rugby, Rugby Football League, Catapult Sports, Prevent Biometrics, HitIQ, Leeds Rhinos Rugby League, Yorkshire Carnegie Rugby Union, Bath Rugby, Wasps Rugby. BJ is employed in a consultancy capacity by the Rugby Football League, and Premiership Rugby as their research lead. CRL serves as an honorary consultant neurologist to the NRL, providing a pro bono second opinion to current players regarding concussion assessment and management for the player’s club doctor. WMcD is Rugby Australia’s chief medical officer. SMcL has no disclosures/conflicts of interest. CO has a research fellowship that is part-funded by the Rugby Football League. GP has no disclosures/conflicts of interest. KLQ has been employed by New Zealand Rugby since 2000 and currently occupies the role of Chief Scientist, New Zealand Rugby. He was a member of World Rugby’s Scientific Committee from 2013 to 2024 and has contributed to various World Rugby working groups focussed on player welfare issues from 2011 to the time of publication. He has received funding for travel and accommodation to attend World Rugby’s medical meetings. OS and PS have no disclosures/conflicts of interest. DT has a PhD research programme that is part-funded by Leeds Rhinos rugby club. He also works as a medical doctor for multiple sports teams in the UK. TT is employed as the Senior Manager for Indigenous elite pathways at the NRL. He is also employed as a researcher by the University of Sydney through a 2021 NHMRC Ideas grant. DPT serves as a scientific advisor for HitIQ. He previously consulted for REACT Neuro. He has a consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild TBIs (including former athletes). He receives funding from Amgen and Football Research. CT has no disclosures/conflicts of interest. RT is a consultant to World Rugby. World Rugby is the governing body for the sport of Rugby Union and responsible for law changes in the sport. LVF is supported through research grant funding at Edith Cowan University. She has previously received project funding from several sports, health and government agencies including: Australian Football League; Australian Institute of Health and Welfare; Australian Institute of Sport; Combat Sport Commission Western Australia; Cricket Australia; Defence Science WA; Exercise & Sports Science Australia; Injury Matters; IOC; KidSafe WA; Rugby Australia; State Government of Victoria; VicSport., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Determining whether repetitive head impacts (RHI) cause the development of chronic traumatic encephalopathy (CTE)-neuropathological change (NC) and whether pathological changes cause clinical syndromes are topics of considerable interest to the global sports medicine community. In 2022, an article was published that used the Bradford Hill criteria to evaluate the claim that RHI cause CTE. The publication garnered international media attention and has since been promoted as definitive proof that causality has been established. Our counterpoint presents an appraisal of the published article in terms of the claims made and the scientific literature used in developing those claims. We conclude that the evidence provided does not justify the causal claims. We discuss how causes are conceptualised in modern epidemiology and highlight shortcomings in the current definitions and measurement of exposures (RHI) and outcomes (CTE). We address the Bradford Hill arguments that are used as evidence in the original review and conclude that assertions of causality having been established are premature. Members of the scientific community must be cautious of making causal claims until the proposed exposures and outcomes are well defined and consistently measured, and findings from appropriately designed studies have been published. Evaluating and reflecting on the quality of research is a crucial step in providing accurate evidence-based information to the public., (© 2024. The Author(s).)

Background: Athlete exposure to contact could be a risk factor for injury. Governing bodies should provide guidelines preventing overexposure to contact., Objectives: Describe the current contact load practices and perceptions of contact load requirements within men's and women's rugby league to allow the Rugby Football League (RFL) to develop contact load guidelines., Methods: Participants (n=450 players, n=46 coaching staff, n=32 performance staff, n=23 medical staff) completed an online survey of 27 items, assessing the current contact load practices and perceptions within four categories: "current contact load practices" (n=12 items), "perceptions of required contact load" (n = 6 items), "monitoring of contact load" (n=3 items), and "the relationship between contact load and recovery" (n=6 items)., Results: During men's Super League pre-season, full contact and controlled contact training was typically undertaken for 15-30 minutes per week, and wrestling training for 15-45 minutes per week. During the in-season, these three training types were all typically undertaken for 15-30 mins per week. In women's Super League, all training modalities were undertaken for up to 30 minutes per week in the pre- and in-season periods. Both men's and women's Super League players and staff perceived 15-30 minutes of full contact training per week was enough to prepare players for the physical demands of rugby league, but a higher duration may be required to prepare for the technical contact demands., Conclusion: Men's and women's Super League clubs currently undertake more contact training during pre-season than in-season, which was planned by coaches and is deemed adequate to prepare players for the demands of rugby league. This study provides data to develop contact load guidelines to improve player welfare whilst not impacting performance., Competing Interests: Conflict of interest and source of funding: The authors declare no conflict of interest and no source of funding.

Recognising and removing players with suspected sport-related concussions is crucial for community sports., Objectives: Quantify rates and factors associated with non-reporting of concussion symptoms in community rugby league., Methods: Overall, 484 community rugby league players aged ≥18 years and 965 parents of rugby league players aged <18 years completed an online survey, regarding concussion history, knowledge, prevalence and reasons for non-reporting of concussion, long-term implications and perceptions of concussion., Results: Thirty-five percent of players aged ≥18 years and 22% of parents of players aged <18 years reported at least one concussion in the last two seasons. Forty-three percent of players aged ≥18 years and 5% of parents of players aged<18 years surveyed stated they did not report concussion-related symptoms sustained during 2020 and 2021 seasons. The two most common reasons for non-reporting of concussion symptoms were 'didn't want to be ruled out of a match' and 'didn't want to let down the team' . Players aged ≥18 years who received external coaching pressures around concussion were more likely to not report concussion symptoms. Over 40% of parents and players were concerned about the potential long-term implications. Ten percent of players aged ≥18 years and 7% of parents of players aged <18 years would encourage their family members/children to not play rugby league., Conclusions: Non-reporting rates of suspected concussion symptoms in adult community players were twice as high as in professional rugby league, with similar reasons (wanting to play and not letting the team down). Engaging coaches to prioritise brain health and providing broader and appropriate education on concussion should be focused on, given the concerns reported by community players and parents., Competing Interests: Competing interests: Daniel Tadmor’s PhD is part-funded by Leeds Rhinos rugby club and works as a medical doctor for multiple sports teams. Kevin Till is employed by Leeds Rhinos in a consultancy capacity. Gemma Phillips is employed in a consultancy capacity by the Rugby Football League and Hull Kingston Rovers. Laura Fairbank is employed by the Rugby Football League. James Brown has received research funding from World Rugby. Matt Cross is employed by Premiership Rugby and has recieved funding for travel from World Rugby. He has previously been employed by the Rugby Football Union. Andrew J Gardner has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion (SRC) (including current and former athletes). He has been a contracted concussion consultant to Rugby Australia. He has received travel funding or been reimbursed by professional sporting bodies, and commercial organisations for discussing or presenting SRC research at meetings, scientific conferences, workshops and symposiums. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation (Australia), an Australian–American Fulbright Commission Postdoctoral Award, a Hunter New England Local Health District, Research, Innovation and Partnerships Health Research & Translation Centre and Clinical Research Fellowship Scheme, and the Hunter Medical Research Institute (HMRI), supported by Jennie Thomas, and the HMRI, supported by Anne Greaves. He has current philanthropic support from the Nick Tooth Foundation. He acknowledges unrestricted philanthropic support from the National Rugby League (NRL), Cameron Owen’s research fellowship is part-funded by the Rugby Football League, and he has consulted for World Rugby. Keith Stokes is employed by the Rugby Football Union. Ben Jones is employed in a consultancy capacity by Premiership Rugby and the Rugby Football League., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Over the last decade, the strain on the English National Health Service (NHS) has increased. This has been especially felt by acute hospital trusts where the volume of admissions has steadily increased. Patient outcomes, including inpatient mortality, vary between trusts. The extent to which these differences are explained by systems-based factors, and whether they are avoidable, is unclear. Few studies have investigated these relationships. A systems-based methodology recognises the complexity of influences on healthcare outcomes. Rather than clinical interventions alone, the resources supporting a patient's treatment journey have near-equal importance. This paper first identifies suitable metrics of resource and demand within healthcare delivery from routinely collected, publicly available, hospital-level data. Then it proceeds to use univariate and multivariable linear regression to associate such systems-based factors with standardised mortality. Three sequential cross-sectional analyses were performed, spanning the last decade. The results of the univariate regression analyses show clear relationships between five out of the six selected predictor variables and standardised mortality. When these five predicators are included within a multivariable regression analysis, they reliably explain approximately 36% of the variation in standardised mortality between hospital trusts. Three factors are consistently statistically significant: the number of doctors per hospital bed, bed occupancy, and the percentage of patients who are placed in a bed within four hours after a decision to admit them. Of these, the number of doctors per bed had the strongest effect. Linear regression assumption testing and a robustness analysis indicate the observations have internal validity. However, our empirical strategy cannot determine causality and our findings should not be interpreted as established causal relationships. This study provides hypothesis-generating evidence of significant relationships between systems-based factors of healthcare delivery and standardised mortality. These have relevance to clinicians and policymakers alike. While identifying causal relationships between the predictors is left to the future, it establishes an important paradigm for further research., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Gardner, Kristensen. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: To ascertain how the three-dimensional shoulder kinematics of tacklers alter when performing four legal types of front-on, one-on-one, rugby-style torso tackles., Design: Controlled laboratory study., Methods: Three-dimensional motion capture measured 15 male amateur-level rugby code players (24.3 ± 6.1 years) who were instructed by an expert coach to perform four sets of 10 front-on, one-on-one tackles. Four sets comprised two smother and two dominant tackles: two based on the Australian National Rugby League coaching manual (Dominant NRL, Smother NRL); and two modifications via increasing the contact height from the lower- to mid-torso (Dominant, Torso Stick) or from the upper- to mid-upper torso with a vertical 'pop action' that changes the way the tackler contacted the ball carrier's upper torso (Smother, Pop, Lock). Mixed general linear models were applied., Results: Greater shoulder abduction, flexion and internal rotation were displayed by the DNRL tackle technique than in any other technique (p < 0.001). At contact, the Smother and Dominant NRL (p < 0.03) showed greater head-uptrunk contralateral rotation away from the tackle than the Smother, Pop, Lock., Conclusions: Tacklers modified the way they positioned their shoulder joint when engaging in legal front-on, one-on-one tackles with different tackle instructions. More prominent positions of shoulder abduction and flexion, and head-uptrunk contralateral rotation were observed when executing the traditional tackle techniques (Smother NRL, Dominant NRL) as opposed to two variants of these (Smother, Pop, Lock, Dominant, Torso Stick). Inclusion of tackle specific coaching instructions provides emerging scientific evidence to support revised coaching tackling technique interventions that might enhance player safety., Competing Interests: Declaration of interest statement Suzi Edwards declares that she has no conflict of interest. Andrew Gardner, Ph.D. serves as a scientific advisor for hitIQ, Ltd. He has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion (including current and former athletes). He has been a contracted concussion consultant to Rugby Australia (2016–2020). He has received travel funding or been reimbursed by professional sporting bodies, and commercial organisations for discussing or presenting sport-related concussion research at meetings, scientific conferences, workshops, and symposiums. He has received research funding from the National Rugby League (NRL) for the Retired Players Brain Health research programme. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation (Australia), an Australian–American Fulbright Commission Postdoctoral Award, a Hunter New England Local Health District, Research, Innovation and Partnerships Health Research & Translation Centre and Clinical Research Fellowship Scheme, and the Hunter Medical Research Institute (HMRI), supported by Jennie Thomas, and the HMRI, supported by Anne Greaves. Ross Tucker is a research consultant to World Rugby (Pty) Ltd, the governing body for Rugby Union globally. Ken Quarrie is employed as the senior sport scientist for New Zealand Rugby., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: The rugby league tackle has been identified as the game event with the greatest propensity for a clinically diagnosed concussion. This study aims to replicate the work conducted in professional rugby league and rugby union by examining Head Injury Assessment (HIA) events to determine the associated tackle characteristics that increase concussion risk in sub-elite rugby league players. This comparison between competition levels is important due to the less developed physiological and tackle proficiency characteristics of sub-elite rugby league players and the fewer resources available for an on-field diagnosis, compared to the elite level of the sport., Results: Tackles resulting in Head Injury Assessments (HIAs, n = 131) and 2,088 tackles that did not result in a head injury were identified and coded from one season of the 2019 Queensland Cup. The body position of both ball carrier and tackler, tackle height, and body contact areas were evaluated. The propensity for tacklers to undergo a head injury assessment was 1.49 HIAs per 1,000 tackles, equating to a 2.5-fold higher risk than that of the ball carrier (0.59 HIAs per 1,000 tackles). The risk for an HIA was 2.75-fold greater when the tackler was upright (2.89 HIAs per 1,000 tackles) compared to a bent-at-the-waist tackler (1.05 HIAs per 1,000 tackles). The greatest risk for the tackler and ball carrier sustaining an HIA occurred when the tackle height was high, with head-to-head contact having the greatest propensity for an HIA (44.37 HIAs per 1,000 tackles). HIA risk was also greater for both players when the ball carrier did not employ an evasion strategy (3.73 HIAs per 1,000 tackles)., Conclusions: The study replicates results from research in elite rugby league and rugby union. A combination of higher head contact/proximity and upright body position significantly increase an HIA risk. Tackler head position and ball carrier evasion behaviours also affect risk, suggesting that injury prevention strategies designed to reduce tackle height and improve tackle technique by focusing on head position, body position, and in a novel finding, ball carrier evasion, may reduce head injury risk in sub-elite rugby league players., (© 2024. The Author(s).)

There are no validated diagnostic criteria for traumatic encephalopathy syndrome (TES). During the early and middle 20th century, TES was described as a clinical condition that was experienced by some high-exposure boxers-and it was believed to reflect chronic traumatic brain injury. Consensus criteria for the diagnosis of TES were published in 2021. We applied the consensus criteria for TES retrospectively to cases of chronic brain damage in boxers described in articles published in the 20th century that were obtained from narrative and systematic reviews. The sample included 157 boxers identified in 21 articles published between 1929 and 1999. Two authors reviewed each case description and coded the criteria for TES. For the core clinical features, cognitive impairment was noted in 63.1%, and in 28.7% of cases the person's cognitive functioning appeared to be broadly normal. Neurobehavioral dysregulation was present in 25.5%. One third (34.4%) were identified as progressive, 30.6% were not progressive, and the course could not be clearly determined in 35.0%. In total, 29.9% met the TES consensus criteria, 28.0% did not, and 42.0% had insufficient information to make a diagnostic determination. TES, in the 20th century, was described as a neurological condition, not a psychiatric disorder-and this supports the decision of the 2021 consensus group to remove primary and secondary psychiatric diagnoses from being a core diagnostic feature. Future research is needed to determine whether, or the extent to which, cognitive impairment or neurobehavioral dysregulation described as characterizing TES are associated with chronic traumatic encephalopathy neuropathological change., Competing Interests: Grant Iverson, PhD, serves as a scientific advisor for NanoDX®, Sway Operations, LLC, and Highmark, Inc. He has a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving persons who have sustained mild TBIs (including former athletes), and on the topic of suicide. He has received past research support or funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs, and Psychological Assessment Resources (PAR, Inc.). He receives royalties from the sales of one neuropsychological test (WCST-64). He has received travel support and honoraria for presentations at conferences and meetings. He has received research funding as a principal investigator from the National Football League and subcontract grant funding as a collaborator from the Harvard Integrated Program to Protect and Improve the Health of National Football League Players Association Members. Rudolph J. Castellani, MD, is a collaborator on a grant funded by the National Football League to study the spectrum of concussion, including possible long-term effects. He has a consulting practice in forensic neuropathology, including expert testimony, which has involved former athletes at amateur and professional levels, and sport organizations. Andrew J. Gardner, PhD, serves as a scientific advisor for hitIQ, Ltd. He has a clinical practice in neuropsychology involving persons who have sustained sport-related concussion (including current and former athletes). He has been a contracted concussion consultant to Rugby Australia since July 2016. He has received travel funding or been reimbursed by professional sporting bodies and commercial organizations for discussing or presenting sport-related concussion research at meetings, scientific conferences, workshops, and symposia. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation (Australia), an Australian-American Fulbright Commission Postdoctoral Award, a Hunter New England Local Health District, Research, Innovation and Partnerships Health Research & Translation Centre and Clinical Research Fellowship Scheme, and the Hunter Medical Research Institute (HMRI), supported by Jennie Thomas, and the HMRI, supported by Anne Greaves. A.J.G. is supported by a National Health and Medical Research Council (NHMRC) Investigator Grant. He acknowledges unrestricted philanthropic support from the National Rugby League for research in former professional rugby league players., (© Grant L. Iverson et al., 2024; Published by Mary Ann Liebert, Inc.)

Aims: We applied the 2021 consensus criteria for both chronic traumatic encephalopathy neuropathological change and traumatic encephalopathy syndrome in a small case series of six former elite-level Australian rugby code players., Methods: Neuropathological assessment of these cases was carried out at the Sydney and Victorian Brain Banks. Clinical data were collected via clinical interviews and health questionnaires completed by the participants and/or their next of kin, and neuropsychological testing was conducted with participants who were capable of completing this testing., Results: All cases exhibited progressive cognitive impairment during life. Chronic traumatic encephalopathy neuropathological change was identified in four out of the six cases. However, coexisting neuropathologies were common, with limbic-predominant age-related TDP-43 encephalopathy and ageing-related tau astrogliopathy seen in all cases, intermediate or high Alzheimer's disease neuropathological change seen in four cases and hippocampal sclerosis seen in two of the six cases., Conclusion: The presence of multiple neuropathologies in these cases complicates clinical diagnostic efforts for traumatic encephalopathy syndrome. It will be important for further clinicopathological studies on larger groups to report all neuropathological comorbidities found in cases diagnosed with either chronic traumatic encephalopathy neuropathological change and/or traumatic encephalopathy syndrome., (© 2024 The Authors. Neuropathology and Applied Neurobiology published by John Wiley & Sons Ltd on behalf of British Neuropathological Society.)

The placenta is a mixture of cell types, which may regulate maternal-fetal transfer of exogenous chemicals or become altered in response to exposures. We leveraged placental DNA methylation to characterize major constituent cell types and applied compositional data analysis to test associations with non-essential metal(loid)s measured in paired umbilical cord tissue (N = 158). Higher proportions of syncytiotrophoblasts were associated with lower arsenic, whereas higher proportions of Hofbauer cells were associated with higher cadmium concentrations in umbilical cords. These findings suggest that placental cellular composition influences amounts of metal(loid)s transferred to the fetus or that prenatal exposures alter the placental cellular makeup., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal realationship that could have appeared to influence the work reported in this article., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

This research aimed to inform the development of a health communication campaign to increase the uptake of COVID-19 prevention behaviors among university students. Twenty-eight students attending a mid-sized public university in the southeastern United States and 84 parents or guardians of university students were recruited. The study included an online survey assessing COVID-19 prevention behaviors, perceived susceptibility to COVID-19, perceived severity of COVID-19, and semi-structured interviews to elicit beliefs on COVID-19 prevention behaviors. Students and parents/guardians reported that getting COVID-19 was possible but not necessarily likely. COVID-19 was seen as serious and at least somewhat severe. Dominant interview themes for benefits, barriers, response efficacy, and self-efficacy related to prevention behaviors are reported. Overall, perceptions of behavioral benefits, barriers, and response efficacy were often shared by parents and students but varied across behaviors. These data provide insights for future campaign development for the control of infectious diseases among college students.

Background: To better understand the biomechanical profile of direct head impacts and the game scenarios in which they occur in Rugby Union, there is a need for an on-field validation of a new instrumented mouthguard (IMG) against the reference standard. This study considers the potential of a combined biomechanical (IMG) and video analysis approach to direct head impact recognition, both of which in isolation have limitations. The aim of this study is to assess the relationship between an instrumented mouthguard and video analysis in detection of direct head impacts in rugby union., Design: Pilot Study - Observational Cohort design., Methods: The instrumented mouthguard was worn by ten (3 backs, 7 forwards) professional Rugby Union players during the 2020-21 Gallagher Premiership (UK) season. Game-day video was synchronized with timestamped head acceleration events captured from the instrumented mouthguard. Direct Head Impacts were recorded in a 2 × 2 contingency table to determine sensitivity. Impact characteristics were also collected for all verified head impacts to further the understanding of head biomechanics during the game., Results: There were 2018 contact events that were reviewed using video analysis. Of those 655 were categorized as direct head impacts which also correlated with a head acceleration event captured by the IMG. Sensitivity analysis showed an overall sensitivity of 93.6% and a positive predictive value (PPV of 92.4%). When false positives were excluded due to ball out of play, mouthguard removal or handling after a scoring situation or stoppage, PPV was improved (98.3%). Most verified head impacts occurred in and around the ruck contest (31.2%) followed by impacts to the primary tackler (28.4%)., Conclusion: This pilot validation study demonstrates that this IMG provides a highly accurate measurement device that could be used to complement video verification in the recognition of on-field direct head impacts. The frequency and magnitude of direct head impacts derived from specific game scenarios has been described and allows for greater recognition of high-risk situations. Further studies with larger sample sizes and in different populations of Rugby Union players are required to develop our understanding of head impact and enable strategies for injury mitigation., Competing Interests: AG serves as a scientific advisor for hitIQ, Ltd. He has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion (including current and former athletes). He has been a contracted concussion consultant to Rugby Australia since July 2016. He has received travel funding or been reimbursed by professional sporting bodies, and commercial organisations for discussing or presenting sport-related concussion research at meetings, scientific conferences, workshops, and symposiums. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation (Australia), an Australian-American Fulbright Commission Postdoctoral Award, a Hunter New England Local Health District, Research, Innovation and Partnerships Health Research & Translation Centre and Clinical Research Fellowship Scheme, and the Hunter Medical Research Institute (HMRI), supported by Jennie Thomas, and the HMRI, supported by Anne Greaves. He has current philanthropic support from the Nick Tooth Foundation. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Field, Waddington, McKune, Goecke and Gardner.)

Video surveillance has almost universally been employed by professional sports to identify signs of concussion during competition. This study examined associations between video-identified possible loss of consciousness (LOC), acute concussion evaluation findings, and recovery time in concussed professional rugby league players. Medical personnel and sideline video operators identified head impact events sustained during three seasons of National Rugby League (NRL) matches to determine the need for further medical evaluation. If a concussion was suspected, players were removed from play and underwent a Head Injury Assessment, including the Sports Concussion Assessment Tool, Fifth Edition (SCAT5). Video footage was later examined to identify signs of possible LOC (i.e., observed LOC, no protective action in the fall, and unresponsiveness or lying motionless). Possible LOC was identified in 99 of the 1706 head impact events (5.8%). The median duration of apparent unresponsiveness was 4.2 sec (M = 7.4, standard deviation [SD] = 12.8, interquartile range [IQR] = 2.5-6.6). In the 661 athletes for whom SCAT5 data were available, those with possible LOC endorsed more SCAT5 symptoms and performed worse on Maddocks questions, Standardized Assessment of Concussion (SAC) total scores, orientation, immediate recall, concentration, and delayed recall. For the 255 players with medically diagnosed concussions, SCAT5 data were available for 245. Concussed players with possible LOC performed significantly worse on Maddocks questions. However, there were no group differences in SCAT5 symptom endorsement, SAC total scores, orientation, immediate recall, concentration, delayed recall, or the modified version of the Balance Error Scoring System (mBESS) total errors. Further, the presence or absence of possible LOC was not associated with number of games missed or time to medical clearance for match play. The duration of possible LOC was not associated with the number of games missed or time to medical clearance for match play. According to video review in NRL players, brief LOC might be more common than previously thought. The present study reveals possible LOC is not predictive of missed games or time to recover following concussion.

Objectives: To quantify the incidence of concussion and compare between playing levels in male rugby league., Design: Retrospective cohort., Methods: Between 2016 and 2022, medically diagnosed concussions in Super League, Championship, and Academy competitions were reported to the Rugby Football League via club medical staff. Anonymised data were analysed using generalised linear mixed-effects models by season, month, and between competitions., Results: Overall, 1403 concussions were identified from 104,209 player-match hours. Concussion incidence for Super League, Championship, and Academy was 15.5, 10.5, and 14.3 per 1000 player-match hours, respectively. Championship concussion incidence was significantly lower than the Super League (p < 0.001) and Academy (p < 0.001). No significant differences were identified between years for Super League (range: 13.3 to 18.8 per 1000 player-match hours) and Championship (range: 8.4 to 12.1 per 1000 player-match hours). In Academy (range: 9.6 to 20.5 per 1000 player-match hours), concussion incidence was significantly greater in 2021 compared to earlier years (2016, p = 0.01 and 2017, p = 0.03). No significant differences were identified between months for any competition., Conclusions: The incidence of concussion is greater in Super League and Academy compared to the Championship. Academy concussion incidence has increased over time. Different factors between and within competitions, such as changes to medical standards and knowledge, could have influenced the identification and diagnosis of concussion., Competing Interests: Declaration of interest statement David Eastwood was employed in a consultancy capacity by Wakefield Trinity at the time of study conceptualisation, investigation and writing of the original draft. His MSc was partly funded by BASEM (British Association of Sport and Exercise Medicine). Cameron Owen's research fellowship is funded by the Rugby Football League. Gemma Phillips is employed in a consultancy capacity by the Rugby Football League and Hull Kingston Rovers. James Brown has received research funding from World Rugby. Andrew Gardner serves as a scientific advisor for HitIQ, Ltd. He has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion (including current and former athletes). He has been a contracted concussion consultant to Rugby Australia. He has received travel funding or been reimbursed by professional sporting bodies, and commercial organisations for discussing or presenting sport-related concussion research at meetings, scientific conferences, workshops, and symposiums. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation (Australia), an Australian–American Fulbright Commission Postdoctoral Award, a Hunter New England Local Health District, Research, Innovation and Partnerships Health Research & Translation Centre and Clinical Research Fellowship Scheme, and the Hunter Medical Research Institute (HMRI), supported by Jennie Thomas, and the HMRI, supported by Anne Greaves. He has current philanthropic support from the Nick Tooth Foundation. He acknowledges unrestricted philanthropic support from the National Rugby League (NRL). Keith Stokes is employed by the Rugby Football Union. Daniel Tadmor's PhD is funded by Leeds Rhinos. Kevin Till is employed in a consultancy capacity by Leeds Rhinos. Ben Jones is employed in a consultancy capacity by Premiership Rugby, and the @23benjones Rugby Football League., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Sleep dysfunction is frequently experienced by people with Parkinson's disease (PD) and negatively influences quality of life. Although subthalamic nucleus (STN) deep brain stimulation (DBS) can improve sleep in PD, sleep microstructural features such as sleep spindles provide additional insights about healthy sleep. For example, sleep spindles are important for better cognitive performance and for sleep consolidation in healthy adults. We hypothesized that conventional STN DBS settings would yield a greater enhancement in spindle density compared to OFF and low frequency DBS., Methods: In a previous within-subject, cross-sectional study, we evaluated effects of low (60 Hz) and conventional high (≥130 Hz) frequency STN DBS settings on sleep macroarchitectural features in individuals with PD. In this post hoc , exploratory analysis, we conducted polysomnography (PSG)-derived quantitative electroencephalography (qEEG) assessments in a cohort of 15 individuals with PD who had undergone STN DBS treatment a median 13.5 months prior to study participation. Fourteen participants had unilateral DBS and 1 had bilateral DBS. During three nonconsecutive nights of PSG, the participants were assessed under three different DBS conditions: DBS OFF, DBS LOW frequency (60 Hz), and DBS HIGH frequency (≥130 Hz). The primary objective of this study was to investigate the changes in sleep spindle density across the three DBS conditions using repeated-measures analysis of variance. Additionally, we examined various secondary outcomes related to sleep qEEG features. For all participants, PSG-derived EEG data underwent meticulous manual inspection, with the exclusion of any segments affected by movement artifact. Following artifact rejection, sleep qEEG analysis was conducted on frontal and central leads. The measures included slow wave (SW) and spindle density and morphological characteristics, SW-spindle phase-amplitude coupling, and spectral power analysis during non-rapid eye movement (NREM) sleep., Results: The analysis revealed that spindle density was significantly higher in the DBS HIGH condition compared to the DBS LOW condition. Surprisingly, we found that SW amplitude during NREM was significantly higher in the DBS LOW condition compared to DBS OFF and DBS HIGH conditions. However, no significant differences were observed in the other sleep qEEG features during sleep at different DBS conditions., Conclusion: This study presents preliminary evidence suggesting that conventional HIGH frequency DBS settings enhance sleep spindle density in PD. Conversely, LOW frequency settings may have beneficial effects on increasing slow wave amplitude during sleep. These findings may inform mechanisms underlying subjective improvements in sleep quality reported in association with DBS. Moreover, this work supports the need for additional research on the influence of surgical interventions on sleep disorders, which are prevalent and debilitating non-motor symptoms in PD., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Memon, Edney, Baumgartner, Gardner, Catiul, Irwin, Joop, Miocinovic and Amara.)

Introduction: Some ultra-high exposure boxers from the 20th century suffered from neurological problems characterized by slurred speech, personality changes (e.g., childishness or aggressiveness), and frank gait and coordination problems, with some noted to have progressive Parkinsonian-like signs. Varying degrees of cognitive impairment were also described, with some experiencing moderate to severe dementia. The onset of the neurological problems often began while they were young men and still actively fighting. More recently, traumatic encephalopathy syndrome (TES) has been proposed to be present in athletes who have a history of contact (e.g., soccer) and collision sport participation (e.g., American-style football). The characterization of TES has incorporated a much broader description than the neurological problems described in boxers from the 20th century. Some have considered TES to include depression, suicidality, anxiety, and substance abuse., Purpose: We carefully re-examined the published clinical literature of boxing cases from the 20th century to determine whether there is evidence to support conceptualizing psychiatric problems as being diagnostic clinical features of TES., Methods: We reviewed clinical descriptions from 155 current and former boxers described in 21 articles published between 1928 and 1999., Results: More than one third of cases (34.8%) had a psychiatric, neuropsychiatric, or neurobehavioral problem described in their case histories. However, only 6.5% of the cases were described as primarily psychiatric or neuropsychiatric in nature. The percentages documented as having specific psychiatric problems were as follows: depression = 11.0%, suicidality = 0.6%, anxiety = 3.9%, anger control problems = 20.0%, paranoia/suspiciousness = 11.6%, and personality change = 25.2%., Discussion: We conclude that depression, suicidality (i.e., suicidal ideation, intent, or planning), and anxiety were not considered to be clinical features of TES during the 20th century. The present review supports the decision of the consensus group to remove mood and anxiety disorders, and suicidality, from the new 2021 consensus core diagnostic criteria for TES. More research is needed to determine if anger dyscontrol is a core feature of TES with a clear clinicopathological association. The present findings, combined with a recently published large clinicopathological association study, suggest that mood and anxiety disorders are not characteristic of TES and they are not associated with chronic traumatic encephalopathy neuropathologic change., Competing Interests: GI serves as a scientific advisor for NanoDX®, Sway Operations, LLC, and Highmark, Inc. He has a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild TBIs (including former athletes), and on the topic of suicide. He has received past research support or funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs, and Psychological Assessment Resources (PAR, Inc.). He receives royalties from the sales of one neuropsychological test (WCST-64). He has received travel support and honorariums for presentations at conferences and meetings. He has received research funding as a principal investigator from the National Football League, and subcontract grant funding as a collaborator from the Harvard Integrated Program to Protect and Improve the Health of National Football League Players Association Members. RC is a collaborator on a grant funded by the National Football League to study the spectrum of concussion, including possible long-term effects. He has a consulting practice in forensic neuropathology, including expert testimony, which has involved former athletes at amateur and professional levels, and sport organizations. AG serves as a scientific advisor for hitIQ, Ltd. He has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion (including current and former athletes). He has been a contracted concussion consultant to Rugby Australia since July 2016. He has received travel funding or been reimbursed by professional sporting bodies, and commercial organizations for discussing or presenting sport-related concussion research at meetings, scientific conferences, workshops, and symposiums. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation (Australia), an Australian-American Fulbright Commission Postdoctoral Award, a Hunter New England Local Health District, Research, Innovation and Partnerships Health Research & Translation Centre and Clinical Research Fellowship Scheme, and the Hunter Medical Research Institute (HMRI), supported by Jennie Thomas, and the HMRI, supported by Anne Greaves. AG is supported by a National Health and Medical Research Council (NHMRC) Investigator Grant. He acknowledges unrestricted philanthropic support from the National Rugby League for research in former professional rugby league players. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Iverson, Kissinger-Knox, Huebschmann, Castellani and Gardner.)

Objective: The tackle is the most injurious event in rugby league and carries the greatest risk of concussion. This study aims to replicate previous research conducted in professional men's rugby league by examining the association between selected tackle characteristics and head impact events (HIEs) in women's professional rugby league., Methods: We reviewed and coded 83 tackles resulting in an HIE and every tackle (6,318 tackles) that did not result in an HIE for three seasons (2018-2020) of the National Rugby League Women's (NRLW) competition. Tackle height, body position of the tackler and ball carrier, as well as the location of head contact with the other player's body were evaluated. Propensity of each situation that caused an HIE was calculated as HIEs per 1,000 tackles., Results: The propensity for tacklers to sustain an HIE was 6.60 per 1,000 tackles (95% CI: 4.87-8.92), similar to that of the ball carrier (6.13 per 1,000 tackles, 95% CI: 4.48-8.38). The greatest risk of an HIE to either the tackler or ball carrier occurred when head proximity was above the sternum (21.66 per 1,000 tackles, 95% CI: 16.55-28.35). HIEs were most common following impacts between two heads (287.23 HIEs per 1,000 tackles, 95% CI: 196.98-418.84). The lowest propensity for both tackler (2.65 per 1,000 tackles, 95% CI: 0.85-8.20) and ball carrier HIEs (1.77 per 1,000 tackles, 95% CI: 0.44-7.06) occurred when the head was in proximity to the opponent's shoulder and arm. No body position (upright, bent or unbalanced/off feet) was associated with an increased propensity of HIE to either tackler or ball carrier., Conclusions: In the NRLW competition, tacklers and ball carriers have a similar risk of sustaining an HIE during a tackle, differing from men's NRL players, where tacklers have a higher risk of HIEs. Further studies involving larger samples need to validate these findings. However, our results indicate that injury prevention initiatives in women's rugby league should focus on how the ball carrier engages in contact during the tackle as well as how the tackler executes the tackle., Competing Interests: MS is part-funded by Leeds Rhinos rugby league club. RT is a consultant to World Rugby Pty. World Rugby is the governing body for the sport of Rugby Union and responsible for law changes in the sport. BJ is employed by Leeds Rhinos, Rugby Football League and Premiership Rugby in a consultancy capacity. GLI serves as a scientific advisor for NanoDX® Sway Operations, LLC, and Highmark, Inc. He has a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild TBIs (including former athletes). He has received research funding as a principal investigator from the National Football League, and subcontract grant funding as a collaborator from the Harvard Integrated Program to Protect and Improve the Health of National Football League Players Association Members. He acknowledges unrestricted philanthropic support from ImPACT Applications, Inc., the Mooney-Reed Charitable Foundation, Boston Bolts, the National Rugby League, and the Schoen Adams Research Institute at Spaulding Rehabilitation. None of the above entities were involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication. AJG serves as a scientific advisor for HitIQ, Ltd. He has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion (including current and former athletes). He has been a contracted concussion consultant to Rugby Australia since July 2016. He has received travel funding or been reimbursed by professional sporting bodies, and commercial organisations for discussing or presenting sport-related concussion research at meetings, scientific conferences, workshops, and symposiums. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation (Australia), an Australian-American Fulbright Commission Postdoctoral Award, a Hunter New England Local Health District, Research, Innovation and Partnerships Health Research & Translation Centre and Clinical Research Fellowship Scheme, and the Hunter Medical Research Institute (HMRI), supported by Jennie Thomas, and the HMRI, supported by Anne Greaves. He has current philanthropic support from the Nick Tooth Foundation. He acknowledges unrestricted philanthropic support from the National Rugby League (NRL). The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 McLeod, Tucker, Edwards, Jones, Page, Spiegelhalter, West, Iverson and Gardner.)

Purpose: We sought to understand concerns fundamental to planning medical education specific to rural southern African Americans who are virtually nonexistent in American medical schools., Methods: A diverse multidisciplinary research team conducted this qualitative study with 3 focus groups, including 17 rural medical educators recruited nationwide, 10 African American alumni of a rural medical education pipeline in Alabama, and 5 community and institutional associates of this pipeline. Analysis of recorded transcripts generated themes fitting an ecological model suggesting concerns and intervention foci at individual, community, and institutional levels., Findings: Three major themes operating at all ecological levels were: (1) How "rural minority student" is defined, with "rural" often supplanting race to indicate minority status; (2) Multiple factors relate to rural racial minority student recruitment and success, including personal relationships with peers, mentors, and role models and supportive institutional policies and culturally competent faculty; and (3) Challenges to recruitment and retention of rural minority students, especially financial concerns and preparation for medical education., Conclusions: Our findings suggest that individuals, communities, and institutions provide intervention points for planning medical education specific to southern rural African Americans. These spheres of influence project a need for partnership among communities and rural medical educators to affect broad programmatic and policy changes that address the dire shortage of rural African American health professionals to help ameliorate health inequities experienced in their home communities. It is likely that linear thinking and programming will be replaced by integrated, intertwined conceptualizations to reach this goal., (© 2022 The Authors. The Journal of Rural Health published by Wiley Periodicals LLC on behalf of National Rural Health Association.)

Context: Concern is growing among soccer players, coaches, and parents regarding head and neck injuries, including concussion, particularly from heading a ball. Thus, we need to explore soccer-specific head injury risk-reduction initiatives. One such initiative is to condition the neck musculature of young players by adding neuromuscular neck exercises to existing injury-reduction exercise programs., Objective: To investigate the effect of neuromuscular neck exercises completed as part of an injury risk-reduction exercise program on the incidence of soccer-related head and neck injuries in adolescent soccer players., Design: Prospective cohort study., Setting: Two sports high schools and 6 soccer clubs during the 2021 soccer season., Patients or Other Participants: A total of 364 male and female soccer players, aged 12 to 18 years., Intervention(s): Members of 1 sports high school and 2 soccer clubs performed neuromuscular neck exercises as part of an injury-reduction program during training (neck training group). Members of another sports high school and 4 soccer clubs performed an injury-reduction program but without neck exercises (comparison group)., Main Outcome Measure(s): Self-reported injury data were collected from each player at the end of the season and used to calculate incidence rate ratios (IRRs) with 95% CIs., Results: In total, 364 players completed the study, including 146 players in the neck training group and 218 players in the comparison group. Despite players in the neck training group being less likely to self-report a concussion (IRR = 0.23; 95% CI = 0.03, 1.04) and pain on heading a ball (IRR = 0.62; 95% CI = 0.34, 1.07), only a lower incidence of possible concussive events (IRR = 0.38; 95% CI = 0.14, 0.90; P < .05) was significant., Conclusions: Integrating neuromuscular neck exercises into injury-reduction exercise programs has the potential to reduce the risk of adolescent soccer players sustaining a possible concussive event, concussion, or pain on heading a ball., (© by the National Athletic Trainers’ Association, Inc.)

Objectives: Identify the frequency, propensity, and factors related to tackle events which result in contact with the head in elite-level women's rugby league., Design: Prospective video analysis study., Methods: Video footage from 59 Women's Super League matches were analysed (n = 14,378 tackle events). All tackle events were coded as no head contact or head contact. Other independent variables included: area contacting head, impacted player, concussion outcome, penalty outcome, round of competition, time in match and team standard., Results: There were 83.0 ± 20.0 (propensity 304.0/1000 tackle events) head contacts per match. The propensity of head contact was significantly greater for the tackler than ball-carrier (178.5 vs. 125.7/1000 tackle events; incident rate ratio 1.42, 95 % confidence interval 1.34 to 1.50). Head contacts occurring from an arm, shoulder, and head occurred significantly more than any other contact type. The propensity of concussions was 2.7/1000 head contacts. There was no significant influence of team standard or time in match on the propensity of head contacts., Conclusions: The observed head contacts can inform interventions, primarily focusing on the tackler not contacting the ball-carrier's head. The tackler's head should also be appropriately positioned to avoid contact with the ball-carrier's knee (highest propensity for concussion). The findings are consistent with other research in men's rugby. Law modifications and/or enforcement (reducing the number of un-penalised head contacts), concurrent with coaching interventions (optimising head placement or reducing the head being contacted) may help minimise head contact risk factors for women's rugby league., Competing Interests: Declaration of interest statement MS PhD and OH's research fellowship is part-funded by Leeds Rhinos. BJ is employed by Leeds Rhinos and Premiership Rugby in a consultancy capacity. GP and BJ are employed in a consultancy capacity by the Rugby Football League. SS and CO's research fellowship is part-funded by the Rugby Football League. OH's research fellowship is part-funded by the Rugby Football Union. GP is a contracted Doctor by a SL club. CC received support in the form of research funding from the National Rugby League. AJG serves as a scientific advisor for hitIQ, Ltd. He has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion including current and former athletes. He has been a contracted concussion consultant to Rugby Australia. He is a member of the World Rugby concussion working group. He is a member of the Australian Football League concussion scientific advisory committee. SM declares no competing interests., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Prenatal exposure to toxic metals is linked to numerous adverse birth and later-in-life outcomes. These outcomes are tied to disrupted biological processes in fetal-derived tissues including the placenta and umbilical cord yet the precise pathways are understudied in these target tissues. We set out to examine the relationship between metal concentrations in umbilical cord and altered gene expression networks in placental tissue. These novel relationships were investigated in a subset of the Extremely Low Gestational Age Newborn (ELGAN) cohort (n = 226). Prenatal exposure to 11 metals/metalloids was measured using inductively coupled plasma tandem-mass spectrometry (ICP-MS/MS) in cord tissue, ensuring passage through the placental barrier. RNA-sequencing was used to quantify >37,000 mRNA transcripts. Differentially expressed genes (DEGs) were identified with respect to each metal. Weighted gene co-expression analysis identified gene networks modulated by metals. Two innovative mixtures modeling techniques, namely principal components analysis and quantile-based g-computation, were employed to identify genes/gene networks associated with multi-metal exposure. Individually, lead was associated with the strongest genomic response of 191 DEGs. Joint lead and cadmium exposure was related to 657 DEGs, including DNA Methyl Transferase 1 (DNMT1). These genes were enriched for the Eukaryotic Initiation Factor 2 (EIF2) pathway. Four gene networks, each containing genes within a Nuclear Factor kappa-light-chain-enhancer of Activated B Cells (NF-kB)-mediated network, were significantly increased in average expression level in relation to increases in all metal concentrations. All four of these metal mixture-associated gene networks were negatively correlated with important predictors of neonatal health including birth weight, placenta weight, and fetal growth. Bringing together novel methodologies from epidemiological mixtures analyses and toxicogenomics, applied to a unique cohort of extremely preterm children, the present study highlighted critical genes and pathways in the placenta dysregulated by prenatal metal mixtures. These represent potential mechanisms underlying the developmental origins of metal-induced disease., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: To examine the rates of concussion and recovery time over the course of 2 seasons of the National Rugby League (NRL)., Design: Descriptive cohort study., Setting: The NRL match play concussion injury surveillance system., Participants: All NRL players who participated in the 2017 and 2018 season., Main Outcome Measures: The (1) frequency of sideline injury surveillance identified head impact events in real-time during the games, (2) frequency of head injury assessments conducted by the medical staff, (3) frequency of medically diagnosed concussions, (4) number of days to medical clearance to return-to-play, and (5) number of games missed after concussion., Main Results: There were 472 head injury assessments conducted during the games and 149 medically diagnosed concussions over the course of 2 NRL seasons (1 concussion every 2.70 games). The median number of days until medical clearance was 6 (M = 6.85, SD = 8.03, interquartile range = 4-7; range = 0-79 days). There was a statistically significant difference in the number of days to be medically cleared to return to full contact or match play between seasons (U = 3517.00, P = 0.001), and the percentage of players medically cleared to return-to-play at 5 days after injury was 60.6% in 2017 and 27.6% in 2018. Most players (87.9%) did not miss a game after injury., Conclusions: There is approximately one concussion sustained for every 3 games in the NRL. Most players are medically cleared to return-to-play in 4 to 7 days., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: This study aimed to investigate how four types of successfully executed, legal front-on, one-on-one torso tackles influence the tacklers' and ball carriers' inertial head kinematics., Methods: A total of 455 successful front-on, one-on-one torso tackle trials completed by 15 rugby code players using three-dimensional motion capture were recorded. Tackles differed with respects to the height of the contact point on the ball carrier's torso. A series of mixed general linear models were conducted., Results: The tackler sustained the highest peak resultant linear ( P < 0.001) and angular ( P < 0.01) head accelerations when contacting the lower torso to execute a "dominant" tackle compared with mid or upper torso, although these latter tackle types had the lowest ball carrier inertial head kinematics. When executing a "smother" tackle technique, a significant decrease in peak resultant linear head acceleration was observed with a vertical "pop" then lock action used, compared with the traditional upper torso tackling technique ( P < 0.001)., Conclusions: Modifying the tackler's engagement with a ball carrier's torso, with respect to height and technical execution, alters the inertial head kinematics of the tackler and the ball carrier. The traditional thinking about optimal tackle technique, as instructed, may need to be reevaluated, with the midtorso being a potential alternative target contact height, whereas changes in tackle execution may be relatively protective for tacklers when executing either a dominant or smother tackle. This study provides critical scientific evidence to underpin revised coaching tackling technique interventions that might enhance player safety. Tackles in which the tackler contacts the ball carrier around the midtorso region, rather than lower torso, produce the lowest acceleration and thus may contribute to reducing head injury risk for the tackler., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Sports Medicine.)

Food insecurity has emerged as a leading health care problem in the United States, impacting college students' health, well-being, and academic performance. The aims of this study were: (1) to assess the prevalence of food insecurity, (2) to identify college students' perceptions about food access resources, and (3) to explore students' expressed needs from the university in improving food security status. A mixed-methods approach was used to assess the quantitative and qualitative aspects of the study aims. An online survey to gather demographic information and assess food security status using the 6-item version of the US Household Food Security Scale Module (HFSSM) was administered. Next, qualitative focus groups with subsets of participants was conducted to gain further insight into the perceptions, coping mechanisms, and resource utilization issues related to food insecurity. This study found 34.1% of undergraduate college students to be food insecure and demonstrates that students with a meal plan are less likely to be food insecure ( p = 0.012; OR = 0.68; 95% CI = 0.489, 0.918). Qualitative data identified key influencers of food insecurity: (1) personal beliefs, (2) life skills, and (3) the university. The results of this study contribute to the literature focused on food insecurity prevalence in college students and presents insight from the college student perspective. Findings may support the development of relevant interventions that are congruent with students' needs, enhancing resource utilization to increase food security status among college students.

Chronic traumatic encephalopathy neuropathologic change can only be definitively diagnosed post-mortem. It has been associated with repetitive mild neurotrauma sustained in amateur and professional contact, collision and combat sports, although it has also been documented in people with a single severe traumatic brain injury and in some people with no known history of brain injury. The characteristic neuropathology is an accumulation of perivascular neuronal and astrocytic phosphorylated tau in the depths of the cortical sulci. The tau-immunopositive neurons and astrocytes that are considered pathognomonic for chronic traumatic encephalopathy are morphologically indistinguishable from Alzheimer-related neurofibrillary tangles and ageing-related tau astrogliopathy, respectively, although they are found in different spatial distributions throughout the cortex. The Sydney Brain Bank collection consists of neurodegenerative diseases and neurologically normal controls. We screened 636 of these cases for chronic traumatic encephalopathy neuropathologic change. A subset of 109 cases had a known history of traumatic brain injury. Three cortical regions were screened for the presence of neuronal and astrocytic phosphorylated tau according to the current 2021 National Institute on Neurological Disorders and Stroke/National Institute of Biomedical Imaging and Bioengineering consensus criteria for chronic traumatic encephalopathy. Five cases (0.79%) showed pathological evidence of chronic traumatic encephalopathy and three of these had a history of traumatic brain injury. Three cases had coexisting Alzheimer's and/or Lewy body disease pathology meeting criteria for neurodegenerative disease. Another eight cases almost met criteria for chronic traumatic encephalopathy neuropathological change except for an absence of neuronal tau or a strict perivascular arrangement. Ageing-related tau astrogliopathy was found in all eight cases as a coexisting neuropathology. Traumatic brain injury was associated with increased odds ratio [1.79, confidence interval 1.18-2.72] of having a higher neurofibrillary tangle stage and phosphorylated TAR DNA binding protein 43 (OR 2.48, confidence interval 1.35-4.54). Our study shows a very low rate of chronic traumatic encephalopathy neuropathological change in brains with or without neurodegenerative disease from the Sydney Brain Bank. Our evidence suggests that isolated traumatic brain injury in the general population is unlikely to cause chronic traumatic encephalopathy neuropathologic change but may be associated with increased brain ageing., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Guarantors of Brain.)

Objective: A cavum septum pellucidum (CSP) has been reported as a visible brain anomaly in normal individuals as well in some former combat and collision sport athletes. The appearance of CSP with fenestrations and ventricular enlargement are considered associated features of the neuropathological diagnosis of chronic traumatic encephalopathy. The current study examined CSP anatomic features and lateral ventricle size in retired elite rugby league players and controls., Methods: Forty-one retired rugby league players and 41 healthy community controls, similar in age and education, underwent structural MRI scans. CSP grade, CSP length, corpus callosum septal length, and Evans' ratio (for lateral ventricle size) were rated by two of the current study authors. All participants also self-reported concussion exposure histories, depressive symptoms, daytime sleepiness, and impulsivity. They completed a neuropsychological test battery assessing premorbid intellectual functioning, attention, processing speed, language, visuospatial skills, memory, and aspects of executive functioning., Results: The two raters had high agreement for CSP grade (Cohen's κ = 0.80), CSP length [intraclass correlation (ICC) = 0.99], corpus callosum septal length (ICC = 0.73), the CSP/septal ratio (ICC = 0.99), and the Evans' ratio (ICC = 0.75). Twenty-five retired players (61.0%) had an abnormal CSP compared to 17 controls [41.5%; χ ( 1 ,   82 ) 2 = 3.12, p = 0.08, odds ratio = 2.21]. The CSP/septal ratio was larger for retired players than for the controls. The Evans' ratio did not differ between the two groups. In the retired rugby league players ( n = 41), those with normal ( n = 16) and abnormal ( n = 25) CSP grades did not differ across age, age of first exposure to collision sport, years of sport exposure, concussion history, or 23 clinical and cognitive variables., Conclusion: This study revealed a difference in the size of the CSP between retired professional rugby league players and controls. There was no significant difference in the size of the ventricles between the two groups. There were no significant differences between those with vs. without an abnormal CSP on age of first exposure to rugby league, years of exposure to repetitive neurotrauma, number of lifetime concussions, depression, impulsivity, perceived cognitive decline, or on any neuropsychological test., Competing Interests: PS has received previous grant funding from the NSW Sporting Injuries Committee, the Brain Foundation (Australia), and the Australian-American Fulbright Commission. GI serves as a scientific advisor for NanoDx™, Sway Operations, LLC, and Highmark, Inc. He has a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild TBIs (including athletes). He has received research funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs, and Psychological Assessment Resources (PAR, Inc.). He has received research funding as a principal investigator from the National Football League, and salary support as a collaborator from the Harvard Integrated Program to Protect and Improve the Health of National Football League Players Association Members. RC has received research funding as principal investigator from the Chuck Knoll Foundation. He has provided expert testimony involving deceased individuals who have sustained traumatic brain injury and deceased former athletes. PM is a co-investigator on competitive grants relating to mild TBI funded by several governmental and other organizations. He is funded under a Fellowship awarded by the National Health & Medical Research Council of Australia and the Medical Research Future Foundation of Australia. He is employed at the Florey Institute of Neuroscience and Mental Health. He has a clinical consulting practice in neurology, including medico-legal work. He has been reimbursed by the government, professional scientific bodies, and commercial organizations for discussing or presenting research relating to MTBI and sport-related concussion at meetings, scientific conferences, and symposiums. He does not hold any individual shares in or receive monies from any company related to concussion or brain injury assessment or technology. He acknowledges unrestricted philanthropic support from CogState Inc. (2001-16). He is the chair of the scientific committees of the International Concussion and Head Injury Research Foundation in London and the Sports Surgery Clinic in Dublin. AG serves as a scientific advisor for HitIQ, Ltd. He has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion (including current and former athletes). He has been a contracted concussion consultant to Rugby Australia. He is a member of the World Rugby concussion working group. He has received travel funding or been reimbursed by professional sporting bodies, and commercial organizations for discussing or presenting sport-related concussion research at meetings, scientific conferences, workshops, and symposiums. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation (Australia), an Australian-American Fulbright Commission Postdoctoral Award, an NHMRC Early Career Fellowship, a Hunter New England Local Health District, Research, Innovation and Partnerships Health Research & Translation Centre and Clinical Research Fellowship Scheme, and the Hunter Medical Research Institute (HMRI), supported by Jennie Thomas, and the HMRI, supported by Anne Greaves. He is currently funded through the University of Newcastle's Priority Research Centre for Stroke and Brain Injury. He has received research funding from the National Rugby League (NRL) and the Australian Institute of Sport (AIS) for the Retired Players Brain Health research program. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Stanwell, Iverson, Van Patten, Castellani, McCrory and Gardner.)

African American men are at a greater risk for contracting HIV infection, and geography may play an important role in the spread of the virus. This study aimed to quantitatively assess the readiness of rural African American men to participate in a barbershop-based HIV prevention program. A paper-and-pencil survey was administered to rural African American male barbershop attendees to assess their readiness for barbershop-based HIV prevention programs. The results suggested that participants were amenable to this form of programming in the barbershop setting. There was no significance detected by demographic variables in readiness for barbershop-based HIV prevention programs. The results of the study give health education specialists and other public health practitioners insight into ways to effectively research, communicate to, and develop culturally appropriate programming for this priority population in a setting in which they are more likely to frequent., Competing Interests: The authors declare that there are no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Prenatal exposures to metallic and metalloid trace elements have been linked to altered immune function in animal studies, but few epidemiologic studies have investigated immunological effects in humans. We evaluated the risk of bacterial sepsis (an extreme immune response to bacterial infection) in relation to prenatal metal/metalloid exposures, individually and jointly, within a US-based cohort of infants born extremely preterm., Methods: We analyzed data from 269 participants in the US-based ELGAN cohort, which enrolled infants delivered at <28 weeks' gestation (2002-2004). Concentrations of 8 trace elements-including 4 non-essential and 4 essential-were measured using inductively coupled plasma tandem mass spectrometry in umbilical cord tissue, reflecting in utero fetal exposures. The infants were followed from birth to postnatal day 28 with bacterial blood culture results reported weekly to detect sepsis. Discrete-time hazard and quantile g-computation models were fit to estimate associations for individual trace elements and their mixtures with sepsis incidence., Results: Approximately 30% of the extremely preterm infants developed sepsis during the follow-up period (median follow-up: 2 weeks). After adjustment for potential confounders, no trace element was individually associated with sepsis risk. However, there was some evidence of a non-monotonic relationship for cadmium, with hazard ratios (HRs) for the second, third, and fourth (highest) quartiles being 1.13 (95% CI: 0.51-2.54), 1.94 (95% CI: 0.87-4.32), and 1.88 (95% CI: 0.90-3.93), respectively. The HRs for a quartile increase in concentrations of all 8 elements, all 4 non-essential elements, and all 4 essential elements were 0.92 (95% CI: 0.68-1.25), 1.19 (95% CI: 0.92-1.55), and 0.77 (95% CI: 0.57-1.06). Cadmium had the greatest positive contribution whereas arsenic, copper, and selenium had the greatest negative contributions to the mixture associations., Conclusions: We found some evidence that greater prenatal exposure to cadmium was associated with an increased the risk of bacterial sepsis in extremely preterm infants. However, this risk was counteracted by a combination of arsenic, copper, and selenium. Future studies are needed to confirm these findings and to evaluate the potential for nutritional interventions to prevent sepsis in high-risk infants., Competing Interests: Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Background: Exposure to thousands of head and body impacts during a career in contact and collision sports may contribute to current or later life issues related to brain health. Wearable technology enables the measurement of impact exposure. The validation of impact detection is required for accurate exposure monitoring. In this study, we present a method of automatic identification (classification) of head and body impacts using an instrumented mouthguard, video-verified impacts, and machine-learning algorithms. Methods: Time series data were collected via the Nexus A9 mouthguard from 60 elite level men (mean age = 26.33; SD = 3.79) and four women (mean age = 25.50; SD = 5.91) from the Australian Rules Football players from eight clubs, participating in 119 games during the 2020 season. Ground truth data labeling on the captures used in this machine learning study was performed through the analysis of game footage by two expert video reviewers using SportCode and Catapult Vision. The visual labeling process occurred independently of the mouthguard time series data. True positive captures (captures where the reviewer directly observed contact between the mouthguard wearer and another player, the ball, or the ground) were defined as hits. Spectral and convolutional kernel based features were extracted from time series data. Performances of untuned classification algorithms from scikit-learn in addition to XGBoost were assessed to select the best performing baseline method for tuning. Results: Based on performance, XGBoost was selected as the classifier algorithm for tuning. A total of 13,712 video verified captures were collected and used to train and validate the classifier. True positive detection ranged from 94.67% in the Test set to 100% in the hold out set. True negatives ranged from 95.65 to 96.83% in the test and rest sets, respectively. Discussion and conclusion: This study suggests the potential for high performing impact classification models to be used for Australian Rules Football and highlights the importance of frequencies <150 Hz for the identification of these impacts., Competing Interests: HitIQ Ltd. is a company with commercial and proprietary interest in the mouthguard and classifier used in this study. PG, ND, BN, and SA are employed by HitIQ Ltd. AG serves as a scientific advisor for HitIQ Ltd. BN and SA are former employees of HitIQ Ltd. AG has a clinical practice. He has been a consultant to Rugby Australia ltd. He has received travel funding from professional sporting bodies and commercial organizations meetings, scientific conferences, workshops, and symposiums. He has received research funding from the National Rugby League (NRL) for the Retired Players Brain Health research program. Grant Iverson serves as a scientific advisor for NanoDxTM (formerly BioDirection, Inc.), Sway Operations, LLC, and Highmark, Inc. He has a clinical and consulting practice. He has received research funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs, and Psychological Assessment Resources (PAR, Inc.). He has received research funding as a principal investigator from the National Football League. He acknowledges unrestricted philanthropic support from ImPACT Applications, Inc. and the National Rugby League. These entities were not involved in the study design, collection, analysis, interpretation of data, the writing of this article, or the decision to submit it for publication. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Goodin, Gardner, Dokani, Nizette, Ahmadizadeh, Edwards and Iverson.)

Background: The tackle is the in-game activity carrying the greatest risk for concussion in rugby. A recent evaluation of tackle characteristics in rugby union precipitated a rule modification to reduce head impact risk during tackles. This study aims to replicate the work conducted in rugby union by examining the association between tackle characteristics and head injury events in professional rugby league., Methods: There were 446 tackles resulting in a head injury assessment (HIA) and 5,694 tackles that did not result in a head injury from two National Rugby League (NRL) seasons that were reviewed and coded. Tackle height, body position of players, and contact area on an opponent's body were evaluated, with the propensity of each situation to cause an HIA calculated as HIAs per 1000 events., Results: The propensity for tacklers to sustain a head injury was 0.99 HIAs per 1000 tackles, 1.74-fold greater than for the ball carrier (0.57 HIAs per 1000 tackles). There was a 3.2-fold higher risk for an HIA when the tackler was upright compared to bent-at-the-waist. The greatest risk of a tackler HIA occurred when head contact was very low (knee, boot) or high (head and elbow). HIAs were most common following head-to-head impacts. The lowest propensity for tackler HIA was found when the tackler's head was in proximity with the ball carrier's torso., Conclusions: The result of this study replicated the findings in professional rugby union. This has implications for the injury prevention initiatives implemented to reduce HIA risk because the majority of injuries are sustained by the tackler., (© 2021. The Author(s).)

Black/African American populations in the United States are disproportionately affected by the COVID-19 pandemic, and there is evidence suggesting that vaccine hesitancy is a concern among this group. As an alternative to the primary prevention method of vaccination, the tertiary method of disclosing one's COVID-19 status after contracting the virus is of utmost importance in reducing the spread of the virus. Recommendations to inform disclosure decisions based on an HIV disclosure model can be applied to COVID-19-positive Black populations in clinical and community settings to reduce the spread of the virus among this population.

Objective: Rugby league is an international full-contact sport, with frequent concussive injuries. Participation in other full-contact sports such as American football has been considered to be a risk factor for neuropsychiatric sequelae later-in-life, but little research has addressed the mental and cognitive health of retired professional rugby league players. We examined predictors and correlates of perceived (self-reported) cognitive decline in retired National Rugby League (NRL) players. Methods: Participants were 133 retired male elite level rugby league players in Australia. Participants completed clinical interviews, neuropsychological testing, and self-report measures. The Informant Questionnaire on Cognitive Decline in the Elderly, self-report (IQCODE-Self), measured perceived cognitive decline. Results: The median age of the sample was 55.0 (M = 53.1, SD = 13.9, range = 30-89) and the median years of education completed was 12.0 (M = 11.9, SD = 2.6, range = 7-18). The retired players reported a median of 15.0 total lifetime concussions (M = 28.0, SD = 36.6, range = 0-200). The mean IQCODE-Self score was 3.2 (SD = 0.5; Range = 1.3-5.0); 10/133 (7.5%) and 38/133 (28.6%) scored above conservative and liberal cutoffs for cognitive decline on the IQCODE-Self, respectively. Perceived cognitive decline was positively correlated with current depressive symptoms, negatively correlated with years of professional sport exposure and resilience, and unrelated to objective cognition and number of self-reported concussions. A multiple regression model with perceived cognitive decline regressed on age, concussion history, professional rugby league exposure, depression, resilience, objective cognitive functioning, daytime sleepiness, and pain severity showed depression as the only significant predictor. Conclusion: This is the first large study examining subjectively experienced cognitive decline in retired professional rugby league players. Similar to studies from the general population and specialty clinics, no relationship was found between objective cognitive test performance and perceived cognitive decline. Depressive symptoms emerged as the strongest predictor of perceived cognitive decline, suggesting that subjective reports of worsening cognition in retired elite rugby league players might reflect psychological distress rather than current cognitive impairment., Competing Interests: GI serves as a scientific advisor for NanoDx™, Sway Operations, LLC, and Highmark, Inc. He has a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild TBIs including athletes. He has received research funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs, and Psychological Assessment Resources PAR, Inc. He has received research funding as a principal investigator from the National Football League, and salary support as a collaborator from the Harvard Integrated Program to Protect and Improve the Health of National Football League Players Association Members. DT serves as a consultant for REACT Neuro, Inc. Christopher Levi, MBBS, serves as an honorary consultant neurologist to the National Rugby League NRL providing a pro bono second opinion to current players regarding concussion assessment and management for the player's club doctor. AG serves as a scientific advisor for hitIQ, Ltd. He has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion including current and former athletes. He has been a contracted concussion consultant to Rugby Australia since July 2016. He has received travel funding or been reimbursed by professional sporting bodies, and commercial organizations for discussing or presenting sport-related concussion research at meetings, scientific conferences, workshops, and symposiums. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation Australia, an Australian-American Fulbright Commission Postdoctoral Award, a Hunter New England Local Health District, Research, Innovation and Partnerships Health Research & Translation Centre and Clinical Research Fellowship Scheme, and the Hunter Medical Research Institute HMRI, supported by Jennie Thomas, and the HMRI, supported by Anne Greaves. He is currently funded through an NHMRC Early Career Fellowship, and the University of Newcastle's Priority Research Centre for Stroke and Brain Injury. He has received research funding from the National Rugby League NRL for the Retired Players Brain Health research program. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Van Patten, Iverson, Terry, Levi and Gardner.)

Background: Rugby league is a high-intensity collision sport that carries a risk of concussion. Youth athletes are considered to be more vulnerable and take longer to recover from concussion than adult athletes., Purpose: To review head impact events in elite-level junior representative rugby league and to verify and describe characteristics of X-patch TM -recorded impacts via video analysis., Study Design: Observational case series., Methods: The X-patch TM was used on twenty-one adolescent players (thirteen forwards and eight backs) during a 2017 junior representative rugby league competition. Game-day footage, recorded by a trained videographer from a single camera, was synchronised with X-patch TM -recorded timestamped events. Impacts were double verified by video review. Impact rates, playing characteristics, and gameplay situations were described., Results: The X-patch TM -recorded 624 impacts ≥ 20g between game start and finish, of which 564 (90.4%) were verified on video. Upon video review, 413 (73.2%) of all verified impacts ≥ 20g where determined to be direct head impacts. Direct head impacts ≥ 20g occurred at a rate of 5.2 impacts per game hour; 7.6 for forwards and 3.0 for backs (range = 0-18.2). A defender's arm directly impacting the head of the ball carrier was the most common event, accounting for 21.3% (n = 120) of all impacts, and 46.7% of all "hit-up" impacts. There were no medically diagnosed concussions during the competition., Conclusion: The majority (90.4%) of head impacts ≥ 20g recorded by the X-patch TM sensor were verified by video. Double verification of direct head impacts in addition to cross-verification of sensor-recorded impacts using a secondary source such as synchronised video review can be used to ensure accuracy and validation of data., (© 2021. The Author(s).)

Objective: To establish normative reference values for the Sport Concussion Assessment Tool-5th Edition (SCAT5) for the new National Rugby League Women's Premiership. Methods: Preseason SCAT5 baseline testing was administered individually to all National Rugby League Women's Premiership players ( N = 117). Testing was completed by the medical staff. Normative reference values were calculated for the components of the SCAT5, including the Standardized Assessment of Concussion, modified Balance Error Scoring System, and the Symptom Scale. A small case series of players who sustained concussions were included to illustrate the use of the new normative data. Results: The median Standardized Assessment of Concussion total score was 27.0 (M = 26.9, SD = 2.1). The median modified Balance Error Scoring System score was 2.0 (M = 2.4, SD = 2.2). The median number of symptoms score was 1.0 (M = 3.2, SD = 4.7) and the median symptom severity score was 2.0 (M = 5.4, SD = 8.2). The most common baseline symptom was fatigue or low energy (33%), followed by trouble sleeping (24%), headache (23%), neck pain (22%), and difficulty remembering (21%). In the total sample, 41% reported no symptoms. The clinical interpretation of these new normative data to a case series of women with concussions is provided. Conclusions: Normative reference values are provided for the SCAT5 for women who are professional rugby league players. Using these normative data will improve clinical interpretation of SCAT5 scores following a concussion., Competing Interests: GI serves as a scientific advisor for NanoDX® (formerly BioDirection, Inc.), Sway Operations, LLC, and Highmark, Inc. He has a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild TBIs (including athletes). He has received research funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs, and Psychological Assessment Resources (PAR, Inc.). He has received research funding from the National Football League. He has also received research funding from the Harvard Integrated Program to Protect and Improve the Health of National Football League Players Association Members. PB is the Chief Medical Officer of the National Rugby League. AG serves as a scientific advisor for hitIQ, Ltd. He has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion (including current and former athletes). He has been a contracted concussion consultant to Rugby Australia since July 2016. He has received travel funding or been reimbursed by professional sporting bodies, and commercial organizations for discussing or presenting sport-related concussion research at meetings, scientific conferences, workshops, and symposiums. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation (Australia), an Australian-American Fulbright Commission Postdoctoral Award, a Hunter New England Local Health District, Research, Innovation and Partnerships Health Research & Translation Centre and Clinical Research Fellowship Scheme, and the Hunter Medical Research Institute (HMRI), supported by Jennie Thomas, and the HMRI, supported by Anne Greaves. He has also received research funding from the National Rugby League (NRL) to conduct research into the health of retired professional rugby league players. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Iverson, Howell, Van Patten, Bloomfield and Gardner.)

The topic of potential long-term neurological consequences from having multiple concussions during a career in collision sports is controversial. We sought to investigate white matter microstructure using diffusion tensor imaging (DTI) in retired professional Australian National Rugby League (NRL) players ( n  = 11) with a history of multiple self-reported concussions compared with age- and education-matched controls ( n  = 13) who have had no history of brain trauma. Diffusion-weighted images were acquired with a Siemens 3T scanner. All participants completed a clinical interview. There were no significant differences between groups on measures of depression, anxiety, stress, or post-concussion symptoms; however, NRL players scored significantly higher on the alcohol use disorder identification test (AUDIT). Voxelwise analyses of DTI measures were performed using tract-based spatial statistics (TBSS) with age and AUDIT scores included as covariates. TBSS revealed significantly reduced fractional anisotropy (FA), and increased radial diffusivity (RD), axial diffusivity (AD), and trace (TR) in white matter regions of recently retired NRL players compared with controls. FA was significantly reduced in the right superior longitudinal fasciculus and right corticospinal tract while TR, RD, and AD were increased in these regions, as well as the corpus callosum, forceps major, right uncinate fasciculus, and left corticospinal tract. In summary, DTI in a small cohort of recently retired professional NRL players with a history of multiple concussions showed differences in white matter microstructure compared with age- and education-matched controls with no history of brain trauma.