Reginald E. Dunn

Prevalence of Cardiovascular Disease Risk Factors Among National Football League Players

CONTEXT Concern exists about the cardiovascular health implications of large size among professional football players and those players who aspire to professional status. OBJECTIVES To assess cardiovascular disease (CVD) risk factors in active National Football League (NFL) players and to compare these findings with data from the Coronary Artery Risk Development in Young Adults (CARDIA) study. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study of 504 active, veteran football players from a convenience sample of 12 NFL teams at professional athletic training facilities between April and July 2007. Data were compared with men of the same age in the general US population (CARDIA study, a population-based observational study of 1959 participants aged 23 to 35 years recruited in 1985-1986). MAIN OUTCOME MEASURES Prevalence of CVD risk factors (hypertension, dyslipidemia, glucose intolerance, and smoking). RESULTS The NFL players were less likely to smoke when compared with the CARDIA group (0.1% [n = 1]; 95% confidence interval [CI], 0%-1.4%; vs 30.5% [n = 597]; 95% CI, 28.5%-32.5%; P < .001). Despite being taller and heavier, NFL players had significantly lower prevalence of impaired fasting glucose (6.7% [n = 24]; 95% CI, 4.6%-8.7%; vs 15.5% [n = 267]; 95% CI, 13.8%-17.3%; P < .001). The groups did not differ in prevalence of high total cholesterol and low-density lipoprotein cholesterol (LDL-C), low high-density lipoprotein cholesterol (HDL-C), or high triglycerides. Hypertension (13.8% [n = 67]; 95% CI, 11.0%-16.7%; vs 5.5% [n = 108]; 95% CI, 4.6%-6.6%) and prehypertension (64.5% [n = 310]; 95% CI, 58.3%-70.7%; vs 24.2% [n = 473]; 95% CI, 22.3%-26.1%) were significantly more common in NFL players than in the CARDIA group (both P < .001). Large size measured by body mass index (BMI) was associated with increased blood pressure, LDL-C, triglycerides, and fasting glucose, and decreased HDL-C. CONCLUSIONS Compared with a sample of healthy young-adult men, a sample of substantially larger NFL players had a lower prevalence of impaired fasting glucose, less reported smoking, a similar prevalence of dyslipidemia, and a higher prevalence of hypertension. Increased size measured by BMI was associated with increased CVD risk factors in this combined population.

Video Incident Analysis of Head Injuries in High School Girls’ Lacrosse:

Background: Knowledge of injury mechanisms and game situations associated with head injuries in girls’ high school lacrosse is necessary to target prevention efforts. Purpose: To use video analysis and injury data to provide an objective and comprehensive visual record to identify mechanisms of injury, game characteristics, and penalties associated with head injury in girls’ high school lacrosse. Study Design: Descriptive epidemiology study. Methods: In the 25 public high schools of 1 school system, 529 varsity and junior varsity girls’ lacrosse games were videotaped by trained videographers during the 2008 and 2009 seasons. Video of head injury incidents was examined to identify associated mechanisms and game characteristics using a lacrosse-specific coding instrument. Results: Of the 25 head injuries (21 concussions and 4 contusions) recorded as game-related incidents by athletic trainers during the 2 seasons, 20 head injuries were captured on video, and 14 incidents had sufficient image quality for analysis. All 14 incidents of head injury (11 concussions, 3 contusions) involved varsity-level athletes. Most head injuries resulted from stick-to-head contact (n = 8), followed by body-to-head contact (n = 4). The most frequent player activities were defending a shot (n = 4) and competing for a loose ball (n = 4). Ten of the 14 head injuries occurred inside the 12-m arc and in front of the goal, and no penalty was called in 12 injury incidents. All injuries involved 2 players, and most resulted from unintentional actions. Turf versus grass did not appear to influence number of head injuries. Conclusion: Comprehensive video analysis suggests that play near the goal at the varsity high school level is associated with head injuries. Absence of penalty calls on most of these plays suggests an area for exploration, such as the extent to which current rules are enforced and the effectiveness of existing rules for the prevention of head injury.

Effectiveness of the Women’s Lacrosse Protective Eyewear Mandate in the Reduction of Eye Injuries

Background: In an effort to minimize the risk of catastrophic eye injury, US Lacrosse initiated mandatory use of protective eyewear in women’s lacrosse in the 2004-2005 season. Purpose: The authors compared eye injury rates in girls’ scholastic lacrosse before and after implementation of protective eyewear. They also compared head/face injury rates, concussion rates, and overall injury rates before and after the rule change to assess possible unintended consequences of the change. Study Design: Cohort study; Level of evidence, 3. Methods: The study group included female scholastic lacrosse players in the 25 public high schools in Fairfax County, Virginia, during the 2004-2009 spring seasons. Injury rates were compared with those from the same data source for the 2000-2003 seasons. Premandate versus postmandate injury rates were adjusted for athlete exposures, or total opportunities for injury throughout the season. Results: The rate of eye injuries was reduced from 0.10 injuries per 1000 athlete exposures (AEs) in 2000 through 2003 before the use of protective eyewear to 0.016 injuries per 1000 AEs in 2004 through 2009 (incident rate ratio [IRR], 0.16; 95% confidence interval [CI], 0.06-0.42). The rate ratio of head/face injuries excluding concussion also decreased (IRR, 0.44; 95% CI, 0.26-0.76). There was no change in the rate ratio of total injuries involving all body parts (IRR, 0.93; 95% CI, 0.82-1.1) after introduction of protective eyewear. However, the rate ratio of concussion increased (IRR, 1.6; 95% CI, 1.1-2.3). Conclusion: The use of protective eyewear in women’s lacrosse was associated with a reduction in the number of eye injuries. The number of head/face injuries decreased in this study group after introduction of protective eyewear, and there was no change in overall injury rates. The reason for the increase in concussion rate cannot be determined conclusively based on this study, but the authors speculate that this increase resulted largely from increased recognition and diagnosis because overall injury rates do not indicate rougher play with introduction of protective equipment.

Association between traditional cholesterol parameters, lipoprotein particle concentration, novel biomarkers and carotid plaques in retired National Football League players

OBJECTIVES We assessed whether low-density lipoprotein particle concentration (LDL-P) and high-sensitivity C-reactive protein [hs-CRP] can identify subclinical atherosclerosis better than traditional cholesterol parameters in retired National Football League (NFL) players. BACKGROUND It is not known whether LDL-P and the biomarker hs-CRP can identify subclinical atherosclerosis better than low-density lipoprotein cholesterol (LDL-C) or non-high-density-lipoprotein cholesterol (non-HDL-C) in retired NFL players, given high prevalence of metabolic syndrome in these players. METHODS Carotid artery plaque screening was performed with traditional lipids, LDL-P, and hs-CRP in 996 retired players. Logistic regression analyses comparing highest with the lowest quartile were performed. RESULTS Carotid artery plaques were seen in 41%. LDL-C (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.06-2.59), non-HDL-C (OR 1.67, 95% CI 1.04-2.67), and LDL-P (OR 2.21, 95% CI 1.35-3.62) were associated with plaques in adjusted models. Among 187 retired players with metabolic syndrome, LDL-C (OR 1.40, 95% CI 0.53-3.72) was not associated with carotid plaques, whereas LDL-P (OR 3.71, 95% CI 1.16-11.84) and non-HDL-C (OR 2.63, 95% CI 0.91-7.63, p=0.07; borderline significant) were associated with carotid plaques. hs-CRP (OR 1.13, 95% CI 0.71-1.79) was not associated with carotid plaques. CONCLUSION Carotid artery plaques were common in retired NFL players and were strongly associated with LDL-P, especially among those with metabolic syndrome. hs-CRP was not associated with carotid plaques in this cohort.

Rate of injury among youth lacrosse players.

Objective:This study describes the rate of injury and the types and mechanisms of injuries incurred by girls and boys during youth recreational lacrosse. Design:Prospective cohort study. Setting:Games were played at a large turf community athletic complex. Participants:Participants included male and female lacrosse players aged 9-15 years. A total of 143 games were played, resulting in 4603 athlete-exposures (AEs). Assessment of Risk Factors:Youth players were grouped based on sex and 3 age categories: under 11 (U11; 9-10 years), under 13 (U13; 11-12 years), and under 15 (U15; 13-14 years). Main Outcome Measures:Certified athletic trainers collected data on type of injury and injury mechanism. Results:There were 6.3 injuries per 1000 AEs for boys and girls combined. Girls had 7 injuries (3.4 per 1000 AEs) and boys had 22 injuries (8.7 per 1000 AEs). Contusions and lacerations were the most frequent injury (n = 13), and body-to-body contact (n = 10) was the most common injury mechanism. There were 4 concussions among boys (U13 and U15) and none among girls. Conclusions:Most injuries evaluated in youth lacrosse were contusions/lacerations; however, serious injuries were observed, including concussions in boys in the age group where body contact is allowed.

Prevention of Anastomotic Thrombosis by Botulinum Toxin B After Acute Injury in a Rat Model

PURPOSE Revascularized or replanted digits may fail because of vessel thrombosis. Off-label use of botulinum toxin type A injected subcutaneously has been used successfully in limited case series to treat vasospastic disorders. Botulinum toxin type B (BTX-B) is thought to have an earlier onset of action than type A in certain settings. We used a rat model to determine the ability of BTX-B to decrease vasospasm and prevent thrombosis after acute vessel division and anastomotic repair. METHODS We transected and immediately repaired the bilateral femoral arteries and veins of 25 rats via microscopic technique. We measured each vessels diameter before transection. Each rat had 1 leg randomly assigned to receive BTX-B; the contralateral side received normal saline. We separated the animals into 5 groups. Each group underwent vasospastic stress at a different time point (12, 24, 48, 72, and 120 h) after the anastomoses and treatment with BTX-B or saline. Vasospastic stress included a lower extremity cold temperature challenge and systemic treatment with phenylephrine. After vasospastic stress, we reopened the wounds and recorded vessel thrombosis and diameter. RESULTS Vessel thrombosis rate was lower in the BTX-B-treated group of vessels compared with those receiving placebo. Thrombosis rate was 8% for BTX-B-treated arteries versus 68% for saline-treated arteries. Thrombosis rate was 20% for BTX-B-treated veins versus 76% for saline-treated veins. Overall vessel thrombosis rate was significantly lower for BTX-B at all time points except at 120 hours when no thrombotic events occurred for either group. Average increase in diameter for BTX-B-treated vessels was significantly greater than that for the controls regardless of patency. CONCLUSIONS BTX-B prevented or reduced the incidence of thrombosis after acute vessel anastomosis in this rat model at all time points less than 120 hours compared with placebo. The average final vessel diameter throughout the series of BTX-B-treated vessels was significantly larger than in the control group. CLINICAL RELEVANCE The use of BTX-B may improve the success rate of microvascular anastomoses by being protective against vasospastic stress and subsequent thrombosis.

Ascending Aortic Dimensions in Former National Football League AthletesCLINICAL PERSPECTIVE

Background— Ascending aortic dimensions are slightly larger in young competitive athletes compared with sedentary controls, but rarely >40 mm. Whether this finding translates to aortic enlargement in older, former athletes is unknown. Methods and Results— This cross-sectional study involved a sample of 206 former National Football League (NFL) athletes compared with 759 male subjects from the DHS-2 (Dallas Heart Study-2; mean age of 57.1 and 53.6 years, respectively, P<0.0001; body surface area of 2.4 and 2.1 m2, respectively, P<0.0001). Midascending aortic dimensions were obtained from computed tomographic scans performed as part of a NFL screening protocol or as part of the DHS. Compared with a population-based control group, former NFL athletes had significantly larger ascending aortic diameters (38±5 versus 34±4 mm; P<0.0001). A significantly higher proportion of former NFL athletes had an aorta of >40 mm (29.6% versus 8.6%; P<0.0001). After adjusting for age, race, body surface area, systolic blood pressure, history of hypertension, current smoking, diabetes mellitus, and lipid profile, the former NFL athletes still had significantly larger ascending aortas (P<0.0001). Former NFL athletes were twice as likely to have an aorta >40 mm after adjusting for the same parameters. Conclusions— Ascending aortic dimensions were significantly larger in a sample of former NFL athletes after adjusting for their size, age, race, and cardiac risk factors. Whether this translates to an increased risk is unknown and requires further evaluation.

Trends In Concussion Incidence In High School Sports, 2008-09 To 2015-16: 88 Board #2 May 30 9

87 Board #1 May 30 9:30 AM 11:30 AM Risk Of Concussion By Sex And Activity In U.S. Service Academy Cadets Kenneth L. Cameron, Megan N. Houston, Kathryn L. O’Connor, Karen Y. Peck, Steven J. Svoboda, Tim Kelly, C. Dain Allred, Darren E. Campbell, Christopher J. D’Lauro, Jonathan C. Jackson, Brian R. Johnson, Gerald T. McGinty, Patrick G. O’Donnell, Paul Pasquina, Thomas McAllister, Michael McCrea, Steven P. Broglio, FACSM. United States Military Academy, West Point, NY. University of Michigan, Ann Arbor, MI. United States Air Force Academy, Colorado Springs, CO. United States Coast Guard Academy, New London, CT. Uniformed Services University of the Health Sciences, Bethesda, MD. Indiana University, Indianapolis, IN. Medical College of Wisconsin, Milwaukee, WI. (Sponsor: Steven P Broglio, FACSM) (No relevant relationships reported)

Sleep-apnea risk and subclinical atherosclerosis in early-middle-aged retired National Football League players

Purpose Limited data from former National Football League (NFL) players suggest that obstructive sleep apnea (OSA) may be highly prevalent after retirement. It remains unclear whether the high prevalence of OSA in retired players is comparable to nonathletes. This retrospective analysis compared sleep apnea (SA) risk in retired NFL players to a community cohort (CARDIA Sleep study), and examined associations between SA risk and cardiovascular risk factors, including subclinical atherosclerosis. Materials and methods Retired NFL players (n=122) were matched to CARDIA Sleep participants by age ±2 years (range 37–55 years), body mass index ±2 kg/m2, race, and male sex. Participants underwent electron-beam computed tomography to measure coronary artery calcium (CAC) and completed the Berlin Questionnaire to determine SA risk. The presence of CAC was defined as an Agatston score >0. Results Retired NFL players had a greater prevalence of high SA risk than the matched CARDIA Sleep participants (27% vs 11.5%, P=0.002). Compared to the CARDIA Sleep participants, retired players were less likely to smoke, and had higher blood pressure, lower fasting glucose levels, and higher cholesterol levels. However, there was no difference in the prevalence of detectable CAC (30% vs 30%, P=1). In both players and the community cohort, SA risk was not significantly associated with CAC after controlling for age, race, and body mass index. Conclusion Retired NFL players have a greater prevalence of high SA risk but similar prevalence of CAC compared with a well-matched community cohort.

Carotid Intima-Medial Thickness in National Football League Players as an Index of Cardiovascular Disease Risk

To the Editor: The cardiovascular disease risk of professional football players has been questioned with regard to their increasing size, which reflects trends in the general population. Although a study of retired players by the National Institute of Occupational Safety and Health found that their