Return to Sports Following Sports-Related Concussion in Collision Sports: An Expert Consensus Statement Using the Modified Delphi Technique

PURPOSE

To perform a Delphi consensus for return to sports (RTS) following sports-related concussion (SRC).

METHODS

Open-ended questions in rounds 1 and 2 were answered. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤80% for an item, if panel members were outside consensus or there were >30% neither agree/disagree responses, the results were carried forward into round 4. The level of agreement and consensus was defined as 90%.

RESULTS

Individualized graduated RTS protocols should be used. A normal clinical, ocular and balance examination with no more headaches, and asymptomatic exertional test allows RTS. Earlier RTS can be considered if athletes are symptom free. The Sports Concussion Assessment Tool 5 and vestibular and ocular motor screening are recognized as useful tools to assist in decision-making. Ultimately RTS is a clinical decision. Baseline assessments should be performed at both collegiate and professional level and a combination of neurocognitive and clinical tests should be used. A specific number of recurrent concussions for season-or career-ending decisions could not be determined but will affect decision making for RTS.

CONCLUSIONS

Consensus was achieved for 10 of the 25 RTS criteria: early RTS can be considered earlier than 48 to 72 hours if athletes are completely symptom-free with no headaches, a normal clinical, ocular and balance examination. A graduated RTS should be used but should be individualized. Only 2 of the 9 assessment tools were considered to be useful: Sports Concussion Assessment Tool 5 and vestibular and ocular motor screening. RTS is mainly a clinical decision. Only 31% of the baseline assessment items achieved consensus: baseline assessments should be performed at collegiate and professional levels using a combination of neurocognitive and clinical tests. The panel disagreed on the number of recurrent concussions that should be season- or career-ending.

LEVEL OF EVIDENCE

Level V, expert Opinion.

On-Field and Pitch-Side (Sideline) Assessment of Sports Concussion in Collision Sports: An Expert Consensus Statement Using the Modified Delphi Technique

PURPOSE

To perform a Delphi consensus for on-field and pitch-side assessment of sports-related concussion (SRC).

METHODS

Open-ended questions in rounds 1 and 2 were answered. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤80% for an item, if panel members were outside consensus, or there were >30% neither agree/disagree responses, the results were carried forward into round 4. The level of agreement and consensus was defined as 90%.

RESULTS

Loss of consciousness (LOC) or suspected LOC, motor incoordination/ataxia, balance disturbance, confusion/disorientation, memory disturbance/amnesia, blurred vision/light sensitivity, irritability, slurred speech, slow reaction time, lying motionless, dizziness, headaches/pressure in the head, falling to the ground with no protective action, slow to get up after a hit, dazed look, and posturing/seizures were clinical signs of SRC and indicate removal from play. Video assessment is helpful but should not replace clinical judgment. LOC/unresponsiveness, signs of cervical spine injury, suspicion of other fractures (skull/maxillo-facial), seizures, Glasgow Coma Scale score <14 and abnormal neurologic examination findings are indications for hospitalization. Return to play should only be considered when no clinical signs of SRC are present. Every suspected concussion should be referred to an experienced physician.

CONCLUSIONS

Consensus was achieved for 85% of the clinical signs indicating concussion. On-field and pitch-side assessment should include the observation of the mechanism, a clinical examination, and cervical spine assessment. Of the 19 signs and red flags requiring removal from play, consensus was reached for 74%. Normal clinical examination and HIA with no signs of concussion allow return to play. Video assessment should be mandatory for professional games but should not replace clinical decision-making. Sports Concussion Assessment Tool, Glasgow Coma Scale, vestibular/ocular motor screening, Head Injury Assessment Criteria 1, and Maddocks questions are useful tools. Guidelines are helpful for non-health professionals.

LEVEL OF EVIDENCE

Level V, expert opinion.

Differential expression of immunity-related genes in larval Manduca sexta tissues in response to gut and systemic infection

Introduction

The midgut epithelium functions as tissue for nutrient uptake as well as physical barrier against pathogens. Additionally, it responds to pathogen contact by production and release of various factors including antimicrobial peptides, similar to the systemic innate immune response. However, if such a response is restricted to a local stimulus or if it appears in response to a systemic infection, too is a rather underexplored topic in insect immunity. We addressed the role of the midgut and the role of systemic immune tissues in the defense against gut-borne and systemic infections, respectively.

Methods

Manduca sexta larvae were challenged with DAP-type peptidoglycan bacteria - Bacillus thuringiensis for local gut infection and Escherichia coli for systemic stimulation. We compared the immune response to both infection models by measuring mRNA levels of four selected immunity-related genes in midgut, fat body, hematopoietic organs (HOs), and hemocytes, and determined hemolymph antimicrobial activity. Hemocytes and HOs were tested for presence and distribution of lysozyme mRNA and protein.

Results

The midgut and circulating hemocytes exhibited a significantly increased level of lysozyme mRNA in response to gut infection but did not significantly alter expression in response to a systemic infection. Conversely, fat body and HOs responded to both infection models by altered mRNA levels of at least one gene monitored. Most, but not all hemocytes and HO cells contain lysozyme mRNA and protein.

Discussion

These data suggest that the gut recruits immune-related tissues in response to gut infection whereas systemic infections do not induce a response in the midgut. The experimental approach implies a skewed cross-talk: An intestinal infection triggers immune activity in systemic immune organs, while a systemic infection does not elicit any or only a restricted immune response in the midgut. The HOs, which form and release hemocytes in larval M. sexta, i) synthesize lysozyme, and ii) respond to immune challenges by increased immune gene expression. These findings strongly suggest that they not only provide phagocytes for the cellular immune response but also synthesize humoral immune components.

Amsterdam 2022 process: A summary of the methodology for the Amsterdam International Consensus on Concussion in Sport

The purpose of this paper is to summarise the consensus methodology that was used to inform the International Consensus Statement on Concussion in Sport (Amsterdam 2022). Building on a Delphi process to inform the questions and outcomes from the 5th International Conference on Concussion in Sport, the Scientific Committee identified key questions, the answers to which would help encapsulate the current science in sport-related concussion and help guide clinical practice. Over 3½ years, delayed by 2 years due to the pandemic, author groups conducted systematic reviews on each selected topic. The 6th International Conference on Concussion in Sport was held in Amsterdam (27-30 October 2022) and consisted of 2 days of systematic review presentations, panel discussions, question and answer engagement with the 600 attendees, and abstract presentations. This was followed by a closed third day of consensus deliberations by an expert panel of 29 with observers in attendance. The fourth day, also closed, was dedicated to a workshop to discuss and refine the sports concussion tools (Concussion Recognition Tool 6 (CRT6), Sport Concussion Assessment Tool 6 (SCAT6), Child SCAT6, Sport Concussion Office Assessment Tool 6 (SCOAT6) and Child SCOAT6). We include a summary of recommendations for methodological improvements for future research that grew out of the systematic reviews.

Examining later-in-life health risks associated with sport-related concussion and repetitive head impacts: a systematic review of case-control and cohort studies

OBJECTIVE

Concern exists about possible problems with later-in-life brain health, such as cognitive impairment, mental health problems and neurological diseases, in former athletes. We examined the future risk for adverse health effects associated with sport-related concussion, or exposure to repetitive head impacts, in former athletes.

DESIGN

Systematic review.

DATA SOURCES

Search of MEDLINE, Embase, Cochrane, CINAHL Plus and SPORTDiscus in October 2019 and updated in March 2022.

ELIGIBILITY CRITERIA

Studies measuring future risk (cohort studies) or approximating that risk (case-control studies).

RESULTS

Ten studies of former amateur athletes and 18 studies of former professional athletes were included. No postmortem neuropathology studies or neuroimaging studies met criteria for inclusion. Depression was examined in five studies in former amateur athletes, none identifying an increased risk. Nine studies examined suicidality or suicide as a manner of death, and none found an association with increased risk. Some studies comparing professional athletes with the general population reported associations between sports participation and dementia or amyotrophic lateral sclerosis (ALS) as a cause of death. Most did not control for potential confounding factors (eg, genetic, demographic, health-related or environmental), were ecological in design and had high risk of bias.

CONCLUSION

Evidence does not support an increased risk of mental health or neurological diseases in former amateur athletes with exposure to repetitive head impacts. Some studies in former professional athletes suggest an increased risk of neurological disorders such as ALS and dementia; these findings need to be confirmed in higher quality studies with better control of confounding factors.

PROSPERO REGISTRATION NUMBER

CRD42022159486.

Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022

For over two decades, the Concussion in Sport Group has held meetings and developed five international statements on concussion in sport. This 6th statement summarises the processes and outcomes of the 6th International Conference on Concussion in Sport held in Amsterdam on 27-30 October 2022 and should be read in conjunction with the (1) methodology paper that outlines the consensus process in detail and (2) 10 systematic reviews that informed the conference outcomes. Over 3½ years, author groups conducted systematic reviews of predetermined priority topics relevant to concussion in sport. The format of the conference, expert panel meetings and workshops to revise or develop new clinical assessment tools, as described in the methodology paper, evolved from previous consensus meetings with several new components. Apart from this consensus statement, the conference process yielded revised tools including the Concussion Recognition Tool-6 (CRT6) and Sport Concussion Assessment Tool-6 (SCAT6, Child SCAT6), as well as a new tool, the Sport Concussion Office Assessment Tool-6 (SCOAT6, Child SCOAT6). This consensus process also integrated new features including a focus on the para athlete, the athlete's perspective, concussion-specific medical ethics and matters related to both athlete retirement and the potential long-term effects of SRC, including neurodegenerative disease. This statement summarises evidence-informed principles of concussion prevention, assessment and management, and emphasises those areas requiring more research.

The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury

OBJECTIVE

To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings.

DESIGN

Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus.

PARTICIPANTS

The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations.

RESULTS

The first two Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that 'the diagnostic label 'concussion' may be used interchangeably with 'mild TBI' when neuroimaging is normal or not clinically indicated.'

CONCLUSIONS

New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care.

Cross-sectional study of characteristics and prevalence of musculoskeletal complaints in 1170 male golfers

Objectives

The primary aim was to describe the characteristics and prevalence of musculoskeletal complaints of a large group of non-professional golfers. Secondary aims were to compare golfers different in (A) skill-level, (B) presence of low back pain (LBP) and (C) performance of prevention exercises.

Methods

A sample of 1170 male golfers (mean age 54.98, SD=13.3) were surveyed online on personal and golf-specific characteristics, medical history and complaints in the preceding 7 days. Subgroups (A) with different golfing handicap (0 to 5, >5 to 10, >10), (B) with and without LBP and (C) who performed versus did not perform injury prevention exercises were compared using analysis of variance and χ2test.

Results

The prevalence and severity of musculoskeletal complaints was similar in everyday life and when playing golf. More than one-third of the golfers (n=436; 37.3%) reported LBP in the preceding 7 days, while other frequently affected body parts were the shoulder and knee. Golfers with different skill level differed in age and most golf-related characteristics but not in prevalence and severity of musculoskeletal complaints. Golfers with and without LBP were similar in almost all variables. Golfers who performed prevention exercises (n=371; 27.1%) were older and had a higher prevalence of complaints.

Conclusion

The prevalence and severity of musculoskeletal complaints in golfers were similar to the wider population. It seems that injury prevention exercises were implemented after injury, rather than as primary prevention. Prospective studies looking at the epidemiology of injury, risk factors and interventions are required.

Association between sonographic sling location and success of surgery for stress urinary incontinence

OBJECTIVE

To determine the relationship between the clinical outcome of suburethral sling surgery for stress urinary incontinence and sling location on ultrasound examination.

METHODS

This was a retrospective study of patients diagnosed with stress urinary incontinence who were treated with a suburethral sling by a single surgeon between January 2009 and October 2016. Four-dimensional volumes acquired on transperineal ultrasound at least 3 months postoperatively were analyzed and the gap between the sling and symphysis pubis (sling-pubis gap (SPG)) on Valsalva maneuver was measured. Continence was assessed on a cough stress test at follow-up.

RESULTS

A total of 378 patients were included, with a mean follow-up of 14.3 months. The success rate of sling surgery was 89.4%. The mean ± SD SPG on Valsalva maneuver was 12.0 ± 2.5 mm in women who were clinically continent at follow-up and 14.1 ± 2.8 mm in those with failed surgery (P < 0.001).

CONCLUSION

A shorter SPG on transperineal ultrasound imaging after suburethral sling surgery is associated with cure of stress urinary incontinence. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Effects of silver sulfide nanoparticles on the earthworm Eisenia andrei

The massive production and use of silver nanoparticles (Ag NPs) have led to their increasing release into the environment. Even though the antimicrobial and cytotoxic effects of native nanoparticles have been well studied, the environmental impacts of transformation products such as silver sulfide nanoparticles (Ag₂S NPs) have not been elucidated. In the present study, we assessed the toxicity of Ag₂S NPs and silver nitrate (AgNO₃), as a source of Ag, to the earthworm Eisenia andrei using a nominal concentration of 5 mg Ag kg^-1 soil. We used the OECD guidelines to assess effects on weight loss and mortality for 14 days. After exposure, we also extracted the immune effector cells (coelomocytes) and conducted a battery of biomarker tests. To ensure the quality of the toxicological results, the structural changes of NPs during the experiment and the uptake of silver by the earthworms were monitored. During the experiment, mortality effects were not detected, but a weight loss was observed in the earthworms exposed to Ag₂S NPs. Altough Ag₂S NPs were engulfed by E. andrei cells, neither phenoloxidase activity nor lipid peroxidation differed from the untreated control group. Cells from earthworms treated with Ag₂S NPs exerted very broad value range of nitric oxide (NO) generation, suggesting an imbalance in the NO metabolism. Overall, this study suggests minimal risks associated with Ag₂S NPs exposure to earthworms. However, further studies are needed to assure no immunotoxicological or chronic effects on a wider range of terrestrial organisms.

Influence of Cryo-Processing and Post-SPD Annealing on Creep Behavior of CP Titanium

The commercial purity of VT1-0 titanium was processed by the rolling process and executed at elevated, room, and cryo-temperatures. These processings led to the formation of an ultrafine-grained microstructure, with the mean grain size at a nanometer level. Some of these materials were statically annealed at a temperature of 823 K for 1 h, which led to significant subgrains and grain coarsening. The constant load creep tests in tension were carried out in argon on all states of materials, at temperatures of 648–723 K and different ranges of applied stresses. From the value of the steady-state creep rate, the control creep mechanisms were determined. The microstructure analyses were carried out via SEM and TEM. It was found that titanium prepared at elevated and room temperatures have a higher creep strength than titanium prepared at cryo-temperatures. Furthermore, the post-SPD —annealing led to a significant decrease in the creep properties. The influence of the preparation temperature on the difference of the creep behavior were discussed and explained using the microstructure analyses of the tests’ samples.

The intestinal microbiota and metabolites in patients with anorexia nervosa

Brain-gut microbiota interactions are intensively studied in connection with various neurological and psychiatric diseases. While anorexia nervosa (AN) pathophysiology is not entirely clear, it is presumably linked to microbiome dysbiosis. We aimed to elucidate the gut microbiota contribution in AN disease pathophysiology. We analyzed the composition and diversity of the gut microbiome of patients with AN (bacteriome and mycobiome) from stool samples before and after renourishment, and compared them to healthy controls. Further, levels of assorted neurotransmitters and short-chain fatty acids (SCFA) were analyzed in stool samples by MS and NMR, respectively. Biochemical, anthropometric, and psychometric profiles were assessed. The bacterial alpha-diversity parameter analyses revealed only increased Chao 1 index in patients with AN before the realimentation, reflecting their interindividual variation. Subsequently, core microbiota depletion signs were observed in patients with AN. Overrepresented OTUs (operation taxonomic units) in patients with AN taxonomically belonged to Alistipes, Clostridiales, Christensenellaceae, and Ruminococcaceae. Underrepresented OTUs in patients with AN were Faecalibacterium, Agathobacter, Bacteroides, Blautia, and Lachnospira. Patients exhibited greater interindividual variation in the gut bacteriome, as well as in metagenome content compared to controls, suggesting altered bacteriome functions. Patients had decreased levels of serotonin, GABA, dopamine, butyrate, and acetate in their stool samples compared to controls. Mycobiome analysis did not reveal significant differences in alpha diversity and fungal profile composition between patients with AN and healthy controls, nor any correlation of the fungal composition with the bacterial profile. Our results show the changed profile of the gut microbiome and its metabolites in patients with severe AN. Although therapeutic partial renourishment led to increased body mass index and improved psychometric parameters, SCFA, and neurotransmitter profiles, as well as microbial community compositions, did not change substantially during the hospitalization period, which can be potentially caused by only partial weight recovery.

Altered Serum Immunological and Biochemical Parameters and Microbiota Composition in Patients With AN During Realimentation

Anorexia nervosa (AN) is a life-threatening psychiatric disorder with not well-described pathogenesis. Besides the genetic and sociological factors, autoimmunity is also considered to take part in AN pathogenesis. We evaluated general serological factors showing the physiological state of 59 patients with AN at hospital admission and their discharge. We detected the altered levels of some general biochemical and immunological parameters. We also detected decreased levels of appetite-regulating alpha-melanocyte stimulating hormone (α-MSH) in patients at hospital admission. Moreover, elevated anti-α-MSH IgM levels and decreased anti-α-MSH IgA levels were observed in patients with AN. Therefore, we analyzed the gut microbiota composition with special focus on α-MSH antigen-mimetic containing microbes from the Enterobacteriaceae family. We correlated gut bacterial composition with anti-α-MSH Ig levels and detected decreasing IgG levels with increasing alpha diversity. The upregulation of pro-inflammatory cytokines IL-6, IL-17, and TNF-α were detected in patients with AN both prior and after hospitalization. We also evaluated the treatment outcome and improvement was observed in the majority of patients with AN. We provide new data about various serum biochemical parameters and their changes during the patients' hospitalization, with emphasis on the immune system, and its possible participation in AN pathogenesis.

An 11-week school-based 'health education through football programme' improves health knowledge related to hygiene, nutrition, physical activity and well-being-and it's fun! A scaled-up, cluster-RCT with over 3000 Danish school children aged 10-12 years old

ObjectivesOur large-scale cluster randomised controlled trial aimed to investigate the effects on health knowledge and enjoyment of an 11 week 'health education through football' programme for children aged 10-12 years old. Methods 3127 Danish school children (49% girls) aged 10-12 years from a total of 154 schools located in 63% of the Danish municipalities (69 of 98) took part in the analysis. A 5:1 cluster randomisation was performed at school level for the intervention group (IG) or the control group (CG). The twice-weekly 45 min intervention was the '11 for Health in Denmark' programme, which includes health education, football drills and small-sided games. The health education element focused on hygiene, nutrition, physical activity and well-being. Outcomes: The participants completed a 34-item multiple-choice computer-based health knowledge questionnaire preintervention and postintervention. IG also evaluated whether the programme was enjoyable. Results Between-group differences (p<0.05) were observed in overall health knowledge in favour of IG (+7.2% points, 95% CI 6.1% to 8.4%, effect size, ES:0.59), with similar effects for girls (+7.4% points, 95% CI 5.9% to 9.0%, ES:0.57) and for boys (+7.0% points, 95% CI 5.3% to 8.7%, p<0.05, ES:0.51). Marked between-group differences were observed in favour of IG, for health knowledge related to hygiene (IG vs CG:+13.9% points, 95% CI 11.1% to 16.7%, ES:0.53), nutrition (+10.3% points, 95% CI 8.5% to 12.1%, ES:0.53), physical activity (+5.9% points, 95% CI 4.1% to 7.7%, ES:0.36) and well-being (+4.4% points, 95% CI 2.7% to 6.1%, ES:0.28). Both girls and boys gave the programme moderate to high scores for enjoyment (3.6±1.0 and 3.7±1.1, respectively). Conclusion Health education through sport, using the '11 for Health' model, was enjoyable for girls and boys aged 10-12 years old, and improved health knowledge related to hygiene, nutrition, physical activity and well-being.

In Vitro Interactions of TiO2 Nanoparticles with Earthworm Coelomocytes: Immunotoxicity Assessment

Titanium dioxide nanoparticles (TiO₂ NPs) are manufactured worldwide. Once they arrive in the soil environment, they can endanger living organisms. Hence, monitoring and assessing the effects of these nanoparticles is required. We focus on the Eisenia andrei earthworm immune cells exposed to sublethal concentrations of TiO₂ NPs (1, 10, and 100 µg/mL) for 2, 6, and 24 h. TiO₂ NPs at all concentrations did not affect cell viability. Further, TiO₂ NPs did not cause changes in reactive oxygen species (ROS) production, malondialdehyde (MDA) production, and phagocytic activity. Similarly, they did not elicit DNA damage. Overall, we did not detect any toxic effects of TiO₂ NPs at the cellular level. At the gene expression level, slight changes were detected. Metallothionein, fetidin/lysenin, lumbricin and MEK kinase I were upregulated in coelomocytes after exposure to 10 µg/mL TiO₂ NPs for 6 h. Antioxidant enzyme expression was similar in exposed and control cells. TiO₂ NPs were detected on coelomocyte membranes. However, our results do not show any strong effects of these nanoparticles on coelomocytes at both the cellular and molecular levels.

Current Aspects of the Role of Autoantibodies Directed Against Appetite-Regulating Hormones and the Gut Microbiome in Eating Disorders

The equilibrium and reciprocal actions among appetite-stimulating (orexigenic) and appetite-suppressing (anorexigenic) signals synthesized in the gut, brain, microbiome and adipose tissue (AT), seems to play a pivotal role in the regulation of food intake and feeding behavior, anxiety, and depression. A dysregulation of mechanisms controlling the energy balance may result in eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN). AN is a psychiatric disease defined by chronic self-induced extreme dietary restriction leading to an extremely low body weight and adiposity. BN is defined as out-of-control binge eating, which is compensated by self-induced vomiting, fasting, or excessive exercise. Certain gut microbiota-related compounds, like bacterial chaperone protein Escherichia coli caseinolytic protease B (ClpB) and food-derived antigens were recently described to trigger the production of autoantibodies cross-reacting with appetite-regulating hormones and neurotransmitters. Gut microbiome may be a potential manipulator for AT and energy homeostasis. Thus, the regulation of appetite, emotion, mood, and nutritional status is also under the control of neuroimmunoendocrine mechanisms by secretion of autoantibodies directed against neuropeptides, neuroactive metabolites, and peptides. In AN and BN, altered cholinergic, dopaminergic, adrenergic, and serotonergic relays may lead to abnormal AT, gut, and brain hormone secretion. The present review summarizes updated knowledge regarding the gut dysbiosis, gut-barrier permeability, short-chain fatty acids (SCFA), fecal microbial transplantation (FMT), blood-brain barrier permeability, and autoantibodies within the ghrelin and melanocortin systems in eating disorders. We expect that the new knowledge may be used for the development of a novel preventive and therapeutic approach for treatment of AN and BN.

Secretory IgA N-glycans contribute to the protection against E. coli O55 infection of germ-free piglets

Mucosal surfaces are colonized by highly diverse commensal microbiota. Coating with secretory IgA (SIgA) promotes the survival of commensal bacteria while it inhibits the invasion by pathogens. Bacterial coating could be mediated by antigen-specific SIgA recognition, polyreactivity, and/or by the SIgA-associated glycans. In contrast to many in vitro studies, only a few reported the effect of SIgA glycans in vivo. Here, we used a germ-free antibody-free newborn piglets model to compare the protective effect of SIgA, SIgA with enzymatically removed N-glycans, Fab, and Fc containing the secretory component (Fc-SC) during oral necrotoxigenic E. coli O55 challenge. SIgA, Fab, and Fc-SC were protective, whereas removal of N-glycans from SIgA reduced SIgA-mediated protection as demonstrated by piglets' intestinal histology, clinical status, and survival. In vitro analyses indicated that deglycosylation of SIgA did not reduce agglutination of E. coli O55. These findings highlight the role of SIgA-associated N-glycans in protection. Further structural studies of SIgA-associated glycans would lead to the identification of those involved in the species-specific inhibition of attachment to corresponding epithelial cells.

International consensus statement: methods for recording and reporting of epidemiological data on injuries and illnesses in golf

Epidemiological studies of injury in elite and recreational golfers have lacked consistency in methods and definitions employed and this limits comparison of results across studies. In their sports-generic statement, the Consensus Group recruited by the IOC (2020) called for sport-specific consensus statements. On invitation by International Golf Federation, a group of international experts in sport and exercise medicine, golf research and sports injury/illness epidemiology was selected to prepare a golf-specific consensus statement. Methodological stages included literature review and initial drafting, online feedback from the consensus group, revision and second draft, virtual consensus meetings and completion of final version. This consensus statement provides golf-specific recommendations for data collection and research reporting including: (i) injury and illness definitions, and characteristics with golf-specific examples, (ii) definitions of golf-specific exposure measurements and recommendations for the calculation of prevalence and incidence, (iii) injury, illness and exposure report forms for medical staff and for golfers, and (iv) a baseline questionnaire. Implementation of the consensus methodology will enable comparison among golf studies and with other sports. It facilitates analysis of causative factors for injuries and illness in golf, and can also be used to evaluate the effects of prevention programmes to support the health of golfers.

The Effects of In Vivo Exposure to Copper Oxide Nanoparticles on the Gut Microbiome, Host Immunity, and Susceptibility to a Bacterial Infection in Earthworms

Nanomaterials (NMs) can interact with the innate immunity of organisms. It remains, however, unclear whether these interactions can compromise the immune functioning of the host when faced with a disease threat. Co-exposure with pathogens is thus a powerful approach to assess the immuno-safety of NMs. In this paper, we studied the impacts of in vivo exposure to a biocidal NM on the gut microbiome, host immune responses, and susceptibility of the host to a bacterial challenge in an earthworm. Eisenia fetida were exposed to CuO-nanoparticles in soil for 28 days, after which the earthworms were challenged with the soil bacterium Bacillus subtilis. Immune responses were monitored by measuring mRNA levels of known earthworm immune genes. Effects of treatments on the gut microbiome were also assessed to link microbiome changes to immune responses. Treatments caused a shift in the earthworm gut microbiome. Despite these effects, no impacts of treatment on the expression of earthworm immune markers were recorded. The methodological approach applied in this paper provides a useful framework for improved assessment of immuno-safety of NMs. In addition, we highlight the need to investigate time as a factor in earthworm immune responses to NM exposure.

International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS))

Injury and illness surveillance, and epidemiological studies, are fundamental elements of concerted efforts to protect the health of the athlete. To encourage consistency in the definitions and methodology used, and to enable data across studies to be compared, research groups have published 11 sport-specific or setting-specific consensus statements on sports injury (and, eventually, illness) epidemiology to date. Our objective was to further strengthen consistency in data collection, injury definitions and research reporting through an updated set of recommendations for sports injury and illness studies, including a new Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist extension. The IOC invited a working group of international experts to review relevant literature and provide recommendations. The procedure included an open online survey, several stages of text drafting and consultation by working groups and a 3-day consensus meeting in October 2019. This statement includes recommendations for data collection and research reporting covering key components: defining and classifying health problems; severity of health problems; capturing and reporting athlete exposure; expressing risk; burden of health problems; study population characteristics and data collection methods. Based on these, we also developed a new reporting guideline as a STROBE Extension-the STROBE Sports Injury and Illness Surveillance (STROBE-SIIS). The IOC encourages ongoing in- and out-of-competition surveillance programmes and studies to describe injury and illness trends and patterns, understand their causes and develop measures to protect the health of the athlete. Implementation of the methods outlined in this statement will advance consistency in data collection and research reporting.

International Olympic Committee Consensus Statement: Methods for Recording and Reporting of Epidemiological Data on Injury and Illness in Sports 2020 (Including the STROBE Extension for Sports Injury and Illness Surveillance (STROBE-SIIS))

BACKGROUND

Injury and illness surveillance, and epidemiological studies, are fundamental elements of concerted efforts to protect the health of the athlete. To encourage consistency in the definitions and methodology used, and to enable data across studies to be compared, research groups have published 11 sport- or setting-specific consensus statements on sports injury (and, eventually, illnesses) epidemiology to date.

OBJECTIVE

To further strengthen consistency in data collection, injury definitions, and research reporting through an updated set of recommendations for sports injury and illness studies, including a new Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist extension.

STUDY DESIGN

Consensus statement of the International Olympic Committee (IOC).

METHODS

The IOC invited a working group of international experts to review relevant literature and provide recommendations. The procedure included an open online survey, several stages of text drafting and consultation by working groups, and a 3-day consensus meeting in October 2019.

RESULTS

This statement includes recommendations for data collection and research reporting covering key components: defining and classifying health problems, severity of health problems, capturing and reporting athlete exposure, expressing risk, burden of health problems, study population characteristics, and data collection methods. Based on these, we also developed a new reporting guideline as a STROBE extension-the STROBE Sports Injury and Illness Surveillance (STROBE-SIIS).

CONCLUSION

The IOC encourages ongoing in- and out-of-competition surveillance programs and studies to describe injury and illness trends and patterns, understand their causes, and develop measures to protect the health of the athlete. The implementation of the methods outlined in this statement will advance consistency in data collection and research reporting.

Pattern recognition receptors in annelids

The existence of pattern recognition receptors (PRRs) on immune cells was discussed in 1989 by Charles Janeway, Jr., who proposed a general concept of the ability of PRRs to recognize and bind conserved molecular structures of microorganisms known as pathogen-associated molecular patterns (PAMPs). Upon PAMP engagement, PRRs trigger intracellular signaling cascades resulting in the expression of various proinflammatory molecules. These recognition molecules represent an important and efficient innate immunity tool of all organisms. As invertebrates lack the instruments of the adaptive immune system, based on "true" lymphocytes and functional antibodies, the importance of PRRs are even more fundamental. In the present review, the structure, specificity, and expression profiles of PRRs characterized in annelids are discussed, and their role in innate defense is suggested.

Whole-body MRI: a powerful alternative to bone scan for bone marrow staging without radiation and gadolinium enhancer

PURPOSE

Whole-body magnetic resonance imaging (WB-MRI) is a radiation-free alternative to the ^99mTc-HDP bone scan (BS) for the detection of bone metastasis. The major drawback is the long examination time and application of gadolinium enhancer. The aim of this study is to analyze (i) the performance of WB-MRI versus the BS and (ii) the diagnostic benefit of gadolinium (WB-MRI + Gd) compared to a non-enhanced protocol (NE WB-MRI).

METHODS AND MATERIALS

1256 eligible WB-MRI scans were analyzed retrospectively with a single inclusion criterion, a clinical 12-month follow-up or a biopsy as ground truth. N = 285 patients received both a WB-MRI and a BS within 12 months. All the patients were imaged with a coronal T1w and a STIR, and n = 528 (42%) received an additional T1w-mDixon with gadoteridol (0.1 mmol Gd-DTPA/kg).

RESULTS

From 1256 eligible patients, n = 884 (70%) had breast cancer as a primary disease, n = 101(8%) prostate cancer, and n = 77(6%) lung cancer. The sensitivity (Se) and negative predictive value (NPV) of the WB-MRI was 98/99%, significantly higher compared to BS with 82/89%, P < 0.001 Mc Nemar's test. The specificity (Spe) and positive predictive value (PPV) of the WB-MRI and BS was 85/82% and 91/86%, respectively. The interobserver agreement between WB-MRI and BS was 71%, Cohen's kappa 0.42. Analysis of the added diagnostic value of gadolinium revealed Se/Spe/PPV/NPV of 98/93/92/98% for the NE WB-MRI and 99/93/85/100% for the WM-MRI + Gd, P > 0.05 binary logistic regression with Fischer's exact test.

CONCLUSION

WB-MRI exceeds the sensitivity of BS without compromising the specificity, even after omitting the gadolinium enhancer.

Imaging biomarkers of adiposity and sarcopenia as potential predictors for overall survival among patients with endometrial cancer treated with bevacizumab

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Elevated visceral fat area may be a negative prognostic marker in women undergoing treatment for endometrial cancer.

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Treatment with bevacizumab in this cohort of women did not impact overall or progressive free survival.

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When evaluated based on treatment with or without bevacizumab, no marker of adiposity was prognostic of outcomes.

Objective

To examine associations of body mass index (BMI), subcutaneous fat area (SFA) and density (SFD), visceral fat area (VFA) and density (VFD) and total psoas area (TPA) to outcomes among patients receiving chemotherapy with or without bevacizumab for advanced or recurrent endometrial cancer (EC).

Methods

This was a multi-institutional, retrospective study of patients with EC treated with and without bevacizumab as part of front-line, platinum based chemotherapy. Demographics and clinical characteristics were collected. SFA, VFA, SFD, VFD, and TPA were determined from pre-treatment CT scans using a deep learning algorithm. Data was compared with overall survival (OS) and progression free survival (PFS).

Results

Seventy-eight patients were analyzed. The majority were Caucasian (87.2%) with a mean BMI of 34.7 kg/m². PFS and OS did not differ between patients with BMI, SFA, VFA, SFD, VFD, or TPA ≥ the 50th percentile compared to <50th percentile (p = 0.91, 0.45, 0.71, 0.74, 0.60, and 0.74 respectively) and (p = 0.99, 0.59, 0.14, 0.77, and 0.85 respectively). When adjusting for prognostic factors, elevated VFA trended towards shorter OS (25.1 vs 59.5 months, HR = 1.68 [0.92–3.05]).

Patients receiving bevacizumab had similar OS compared to those who did not (37.6 vs 44.5 months, p = 0.409). When stratified by adiposity markers, no subset demonstrated benefit from bevacizumab.

Conclusion

Obesity has been associated with increased levels of vascular endothelial growth factor (VEGF), the main target for bevacizumab therapy. Imaging measurements of VFA may provide prognostic information for patients with EC but no adiposity marker was predictive of improved response to bevacizumab.

Developmental and Immune Role of a Novel Multiple Cysteine Cluster TLR From Eisenia andrei Earthworms

Earthworms are not endowed with adaptive immunity and they are rely on the tools of innate immunity. Cells of the innate immune system utilize pattern recognition receptors, such as Toll-like receptors, to detect the pathogen-associated molecular patterns (PAMPs). The first earthworm TLR was isolated from Eisenia andrei earthworms (EaTLR), which belongs to the single cysteine cluster TLR (sccTLR). Here, we identified a new multiple cysteine cluster TLR (mccTLR) in E. andrei earthworms. Phylogenetic DNA analysis revealed that it has no variability within one earthworm as well as in the population. By screening of the tissue expression profile, the TLR was expressed primarily in earthworm seminal vesicles and receptacles suggesting a connection to sperm cells. Seminal vesicles are often heavily infected by gregarine parasites. As a sign of immune response, a strong melanization reaction is visible around parasites. Stimulation experiments with profilin from related parasite Toxoplasma gondii, led to the upregulation of mccEaTLR in the earthworm seminal vesicles. Also, profilin activated prophenoloxidase cascade, the efficient mechanism of innate immunity. However, its involvement in the NF-κB signaling was not proven. Further, we provide evidence that the antibiotics metronidazole and griseofulvin destroyed the developing spermatocytes. The observed decrease in the mccEaTLR mRNA levels after the antibiotic treatment of parasites is caused by the decline of sperm cells numbers rather than by diminution of the parasites. Since earthworms with extensively reduced parasite load had a similar amount of mccEaTLR mRNA, presumably, earthworm sperm cells have a certain level of mccEaTLR expressed as a standard, which can be augmented by particular antigenic stimulation. Also, mccEaTLR was expressed mainly in the early stages of earthworm development and presumably is primarily involved in early embryonic development. Expression of mccEaTLR in seminal vesicles correlates with the expression of endothelial monocyte-activation polypeptide II. High-throughput sequencing of gregarine DNA from seminal vesicles of individual earthworms resulted in great diversity of the observed genotypes. Phylogenetically, all observed OTUs belong to the clade of earthworm gregarines suggesting host specificity. Overall, mccEaTLR is supposed to play a function role in early embryonic development and potentially it participates in immune response against parasites.

Crucial Role of Microbiota in Experimental Psoriasis Revealed by a Gnotobiotic Mouse Model

Psoriatic patients have altered microbiota, both in the intestine and on the skin. It is not clear, however, whether this is a cause or consequence of the disease. In this study, using an experimental mouse model of psoriasis induced by imiquimod (IMQ), we show that oral treatment with a broad spectrum of antibiotics (MIX) or metronidazole (MET) alone mitigates the severity of skin inflammation through downregulation of Th17 immune response in conventional mice. Since some antibiotics, including MET, can influence immune system reactivity, we also evaluated the effect of MIX in the same model under germ-free (GF) conditions. GF mice treated with MET did not show milder signs of imiquimod-induced skin inflammation (IISI) which supports the conclusion that the therapeutic effect is mediated by changes in microbiota composition. Moreover, compared to controls, mice treated with MIX had a significantly higher abundance of the genus Lactobacillus in the intestine and on the skin. Mice treated with MET had a significantly higher abundance of the genera Bifidobacterium and Enterococcus both on the skin and in the intestine and of Parabacteroides distasonis in the intestine. Additionally, GF mice and mice monocolonized with either Lactobacillus plantarum or segmented filamentous bacteria (SFB) were more resistant to IISI than conventional mice. Interestingly, compared to GF mice, IMQ induced a higher degree of systemic Th17 activation in mice monocolonized with SFB but not with L. plantarum. The present findings provide evidence that intestinal and skin microbiota directly regulates IISI and emphasizes the importance of microbiota in the pathogenesis of psoriasis.

Head Injury in Soccer: From Science to the Field; summary of the head injury summit held in April 2017 in New York City, New York

There has been an increased focus and awareness of head injury and sport-related concussion (SRC) across all sports from the medical and scientific communities, sports organisations, legislators, the media and the general population. Soccer, in particular, has been a focus of attention due to the popularity of the game, the frequency of SRC and the hypothesised effects of repetitive heading of the ball. Major League Soccer, US Soccer and the National Women’s Soccer League jointly hosted a conference entitled, ‘Head Injury in Soccer: From Science to the Field’, on 21–22 April 2017 in New York City, New York. The mission of this conference was to identify, discuss and disseminate evidence-based science related to the findings and conclusions of the fifth International Conference on Concussion in Sport held by the Concussion in Sport Group and apply them to the sport of soccer. In addition, we reviewed information regarding the epidemiology and mechanism of head injuries in soccer at all levels of play, data regarding the biomechanics and effects of repetitive head impacts and other soccer-specific considerations. We discussed how to release the information raised during the summit to key stakeholders including athletes, parents, coaches and healthcare providers. We identified future areas for research and collaboration to enhance the health and safety of soccer (football) players.

Grating metrology for X-ray and V-UV synchrotron beamlines at SOLEIL

Diffraction gratings are key elements of soft X-ray synchrotron beamlines. Besides wavelength dispersion, specific parameters can be tailored to adjust the energy dependent efficiency and focusing, and to correct wavefront aberrations. As key elements of a beamline, any departure from the design values can severely reduce the overall performance. On the other hand, known non-conformities can often be corrected by slight adjustment of the alignment parameters. A careful and accurate metrology is therefore required before installation on the beamline. After presenting what variable line spacing gratings, variable groove depth gratings, and alternate multilayer gratings are, the use of the SOLEIL long trace profiler for the measurement of groove density variation along the surface and of the atomic force microscope for the groove geometry and roughness characterizations will be discussed. A few examples of grating metrology will be presented and analyzed with the help of optical simulations.

NF-κB/p65 expression before and after treatment in rectal cancer patients undergoing neoadjuvant (chemo)radiotherapy and surgery: prognostic marker for disease progression and survival

Nuclear factor-kappaB (NF-κB), especially p65 subunit, has been associated with origin and progression of cancer as well as with the resistance to radiotherapy and chemotherapy in experimental models. The aim of the present study was to determine expression of NF-κB/p65 in tumor specimens before and after treatment of rectal cancer patients and to evaluate possible relationship between expression of NF-κB/p65 before and after (chemo)radiotherapy, other tumor characteristics and the clinical outcome. Furthermore, NF-κB/p65 was studied in relationship to pathologic response to preoperative (chemo)radiotherapy. Fifty patients with rectal cancer undergoing neoadjuvant (chemo)radiotherapy and surgery were included in the study. Pre-treatment rectal cancer specimens were obtained from diagnostic colonoscopy. Post-treatment rectal cancer specimens were obtained from surgically removed part of the rectum with the tumor. NF-κB/p65 expression was determined by immunohistochemistry and analysis was performed both in biopsies and in post-treatment tumor samples. Cytoplasmic positivity in tumor cells and nuclear positivity in lymphocytes were detected. High NF-κB/p65 positivity in pre-treatment tumor samples was significantly associated with shortened overall survival (OS). Disease-free survival (DFS) tends to be shortened as well. In post-treatment tumor samples, high NF-κB/p65 positivity was neither associated with shortened OS nor with shortened DFS. In post-treatment samples residual tumor cells deeply infiltrating the wall of the rectum with high NF-κB/p65 expression were found. The cells were linked to significantly worse clinical outcome in terms of shortened OS and DFS. NF-κB/p65 positivity did not correlate with pathologic response to preoperative (chemo)radiotherapy. In conclusion, our data suggest that high level of NF-κB/p65 subunit may be associated with more aggressive features of the tumor, higher metastatic potential, and shortened overall survival, but it does not correlate with resistance to (chemo)radiotherapy. Consequently, the level of NF-κB/p65 may help to select those patients who have poor prognosis and are candidates for more intensive anticancer therapy. For these purposes both pre-treatment and post-treatment tumor samples may be used.

The impact and value of uni- and multimodal intraoperative neurophysiological monitoring (IONM) on neurological complications during spine surgery: a prospective study of 2728 patients

PURPOSE

We compared the value of different uni- and multimodal intraoperative neurophysiological monitoring (IONM) methods on the detection of neurological complications during spine surgery.

METHODS

IONM data derived from sensory spinal and cortical evoked potentials combined with continuous electromyography monitoring, motor evoked potentials and spinal recording were evaluated in relation to subsequent post-operative neurological changes. Patients were categorised based on their true-positive or true-negative post-operative neurological status.

RESULTS

In 2728 consecutive patients we had 909 (33.3%) IONM alerts. We had 8 false negatives (0.3%) with post-operative radicular deficit that completely recovered within 3 months, except for one. There was no false negative for spinal cord injury. 107 were true positives, and 23 were false positives. Multimodal IONM sensitivity and specificity were 93.0% and 99.1%, respectively. The frequency of neurological complications including minor deficits was 4.2% (n = 115), of which 0.37% (n = 10) were permanent. Analysis of the single IONM modalities varied between 13 and 81% to detect neurological complications compared with 93% when using all modalities.

CONCLUSION

Multimodal IONM is more effective and accurate in assessing spinal cord and nerve root function during spine surgeries to reduce both neurological complications and false-negative findings compared to unimodal monitoring. We recommend multimodal IONM in all complex spine surgeries. These slides can be retrieved from Electronic Supplementary Material.

A Multinational Cluster Randomised Controlled Trial to Assess the Efficacy of '11+ Kids': A Warm-Up Programme to Prevent Injuries in Children's Football

Objective

The objective of this study was to assess the efficacy of a newly developed warm-up programme (‘11+ Kids’) regarding its potential to reduce injuries in children’s football.

Methods

Children’s football teams (under 9 years, under 11 years, and under 13 years age groups) from Switzerland, Germany, the Czech Republic and the Netherlands were invited. Clubs were randomised to an intervention group and a control group, and followed for one season. The intervention group replaced their usual warm-up by ‘11+ Kids’, while the control group warmed up as usual. The primary outcome was the overall risk of football-related injuries. Secondary outcomes were the risks of severe and lower extremity injuries. We calculated hazard ratios using extended Cox models, and performed a compliance analysis.

Results

In total, 292,749 h of football exposure of 3895 players were recorded. The mean age of players was 10.8 (standard deviation 1.4) years. During the study period, 374 (intervention group = 139; control group = 235) injuries occurred. The overall injury rate in the intervention group was reduced by 48% compared with the control group (hazard ratio 0.52; 95% confidence interval 0.32–0.86). Severe (74% reduction, hazard ratio 0.26; 95% confidence interval 0.10–0.64) and lower extremity injuries (55% reduction, hazard ratio 0.45; 95% confidence interval 0.24–0.84) were also reduced. Injury incidence decreased with increasing compliance.

Conclusion

‘11+ Kids’ is efficacious in reducing injuries in children’s football. We observed considerable effects for overall, severe and lower extremity injuries. The programme should be performed at least once per week to profit from an injury preventive effect. However, two sessions per week can be recommended to further increase the protective benefit.

Trial Registration

ClinicalTrials.gov identifier: NCT02222025.

Electronic supplementary material

The online version of this article (10.1007/s40279-017-0834-8) contains supplementary material, which is available to authorized users.

Effects of the '11+ Kids' injury prevention programme on severe injuries in children's football: a secondary analysis of data from a multicentre cluster-randomised controlled trial

BACKGROUND

To assess the effects of the injury prevention programme '11+ Kids' on reducing severe injuries in 7 to 13 year old football (soccer) players.

METHODS

Football clubs (under-9, under-11 and under-13 age groups) from the Czech Republic, Germany, the Netherlands and Switzerland were cluster-randomised (clubs) into an intervention (INT) and a control group (CON). INT replaced their usual warm-up by '11+ Kids' two times a week. CON followed their regular training regime. Match and training exposure and injury characteristics were recorded and injury incidence rates (IRs) and 95% CIs calculated. For the present analysis, only severe injuries (absence from training/match ≥28 days) were considered. Hazard ratios (HR) were calculated using extended Cox models.

RESULTS

The overall IR of severe injuries per 1000 football hours was 0.33 (95% CI 0.25 to 0.43) in CON and 0.15 (95% CI 0.10 to 0.23) in INT. There was a reduction of severe overall (HR 0.42, 95% CI 0.24 to 0.72), match (0.41, 0.17 to 0.95) and training injuries (0.42, 0.21 to 0.86) in INT. The injury types that were prevented the most were: other bone injuries 66%, fractures 49% and sprains and ligament injuries 37%. Severe injuries located at the knee (82%), hip/groin (81%), the foot/toe (80%) and the ankle (65%) were reduced tremendously.

CONCLUSIONS

'11+ Kids' has a large preventive effect on severe injuries by investing only 15 to 20 min per training session. The present results should motivate coaches to implement effective injury prevention programmes such as the '11+ Kids' in children's football.

TRIAL REGISTRATION NUMBER

NCT02222025.

Comparison of the '11+ Kids' injury prevention programme and a regular warmup in children's football (soccer): a cost effectiveness analysis

OBJECTIVE

To evaluate a potential reduction in injury related healthcare costs when using the '11+ Kids' injury prevention programme compared with a usual warmup in children's football.

METHODS

This cost effectiveness analysis was based on data collected in a cluster randomised controlled trial over one season from football teams (under-9 to under-13 age groups) in Switzerland. The intervention group (INT) replaced their usual warmup with '11+ Kids', while the control group (CON) warmed up as usual. Injuries, healthcare resource use and football exposure (in hours) were collected prospectively. We calculated the mean injury related costs in Swiss Francs (CHF) per 1000 hours of football. We calculated the cost effectiveness (the direct net healthcare costs divided by the net health effects of the '11+ Kids' intervention) based on the actual data in our study (trial based) and for a countrywide implementation scenario (model based).

RESULTS

Costs per 1000 hours of exposure were CHF228.34 (95% CI 137.45, 335.77) in the INT group and CHF469.00 (95% CI 273.30, 691.11) in the CON group. The cost difference per 1000 hours of exposure was CHF-240.66 (95%CI -406.89, -74.32). A countrywide implementation would reduce healthcare costs in Switzerland by CHF1.48 million per year. 1002 players with a mean age of 10.9 (SD 1.2) years participated. During 76 373 hours of football, 99 injuries occurred.

CONCLUSION

The '11+ Kids' programme reduced the healthcare costs by 51% and was dominant (ie, the INT group had lower costs and a lower injury risk) compared with a usual warmup. This provides a compelling case for widespread implementation.

"FIFA 11 for Health" for Europe in the Faroe Islands: Effects on health markers and physical fitness in 10- to 12-year-old schoolchildren

We evaluated effects of the school-based intervention "FIFA 11 for Health" for Europe on health and fitness profile in 10- to 12-year-old Faroese schoolchildren. 392 fifth-grade children were randomized into a control group (CG: n = 100, 11.1 ± 0.3 years, 149.0 ± 6.7 cm, 42.4 ± 10.2 kg) and an intervention group (IG: n = 292, 11.1 ± 0.3 years, 150.6 ± 6.9 cm, 44.2 ± 9.4 kg). IG underwent an 11-week intervention in which 2 weekly sessions of 45 minutes were included in the school curriculum focusing on health aspects, football skills, and 3v3 small-sided games. CG continued with their regular activities. Body composition, blood pressure, and resting heart rate, as well as Yo-Yo intermittent recovery children's test (YYIR1C) performance, horizontal jumping ability and postural balance were assessed pre and post intervention. Systolic blood pressure decreased more (-2.8 ± 9.9 vs 2.9 ± 8.4 mm Hg, P < .05) in IG than in CG. Lean body mass (1.0 ± 1.7 vs 0.7 ± 1.6 kg), postural balance (0.3 ± 3.9 vs -1.2 ± 5.9 seconds) and horizontal jump performance (5 ± 9 vs -5 ± 10 cm) increased more (P < .05) in IG than in CG. YYIR1C performance improved in CG (17%, 625 ± 423 to 730 ± 565 m) and IG (18%, 689 ± 412 vs 813 ± 391 m), but without between-group differences. A within-group decrease from 23.1 ± 8.4 to 22.5 ± 8.3% (P < .05) was observed in body fat percentage in IG only. In conclusion, the "FIFA 11 for Health" for Europe program had beneficial effects on SBP, body composition, jump performance and postural balance in 10- to 12-year-old Faroese schoolchildren, supporting the notion that school-based football interventions can facilitate health of children in a small-scale society and serve as an early step in the prevention of non-communicable diseases.

The Effect of Ultrafine-Grained Microstructure on Creep Behaviour of 9% Cr Steel

The effect of ultrafine-grained size on creep behaviour was investigated in P92 steel. Ultrafine-grained steel was prepared by one revolution of high-pressure torsion at room temperature. Creep tensile tests were performed at 873 K under the initially-applied stress range between 50 and 160 MPa. The microstructure was investigated using transmission electron microscopy and scanning electron microscopy equipped with an electron-back scatter detector. It was found that ultrafine-grained steel exhibits significantly faster minimum creep rates, and there was a decrease in the value of the stress exponent in comparison with coarse-grained P92 steel. Creep results also showed an abrupt decrease in the creep rate over time during the primary stage. The abrupt deceleration of the creep rate during the primary stage was shifted, with decreasing applied stress with longer creep times. The change in the decline of the creep rate during the primary stage was probably related to the enhanced precipitation of the Laves phase in the ultrafine-grained microstructure.