Association Between Symptoms of Anxiety and Depression, Hip Pathology, and Patient-Reported Outcomes After Hip Arthroscopy for Femoroacetabular Impingement

BACKGROUND

In patients with femoroacetabular impingement (FAI), mental health has been implicated in both symptom severity and postoperative outcomes. However, there are limited data regarding the independent influences of baseline mental health and hip pathology on patient-reported outcomes over time after hip arthroscopy.

PURPOSE

To evaluate the association between mental health and structural hip pathology with pain, hip function, and quality of life (QOL).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patient records from a single surgeon's hip outcomes registry were retrospectively reviewed. Mental health was evaluated using the Patient-Reported Outcomes Measurement Information System Anxiety and Depression scores. Pain was evaluated with the Single Assessment Numeric Evaluation score for Activities of Daily Living (SANE-ADL), while hip-related QOL was evaluated with the 12-item International Hip Outcome Tool (iHOT-12). Hip function was assessed with the Hip Outcome Score (HOS) Sport-Specific (SS) and ADL subscales. Separate mixed models were used to predict pain, QOL, and hip function, including hip pathology measures (size of labral tear, grade of chondral damage, preoperative alpha angle), anxiety, depression, and time as fixed effects and individuals as a random effect.

RESULTS

A total of 312 patients were included in this study. The preoperative alpha angle, degree of intraoperative cartilage damage, and size of the labral tear were not associated with pain or QOL (P > .05 for all). However, higher levels of anxiety and depression were significantly associated with lower SANE-ADL scores (estimate ± SE) (anxiety: -0.59 ± 0.07, P < .0001; depression: -0.64 ± 0.08, P < .0001), iHOT-12 scores (anxiety: -0.72 ± 0.07, P < .0001; depression: -0.72 ± 0.08, P < .0001), HOS-SS scores (anxiety: -0.68 ± 0.09, P < .0001; depression: -0.57 ± 0.10, P < .0001), and HOS-ADL scores (anxiety: -0.43 ± 0.05, P < .0001; depression: -0.43 ± 0.06, P < .0001).

CONCLUSION

Patients had similar improvements in pain scores, QOL, and hip function after hip arthroscopy for FAI irrespective of their degree of hip pathology. Additionally, preoperative symptoms of anxiety and depression symptoms were associated with greater pain, decreased QOL, and worse hip function both pre- and postoperatively, independent of the degree of hip pathology. This suggests that efforts to directly address symptoms of anxiety and depression may improve outcomes after hip arthroscopy.

The Associations Between Wellbeing and Injury Differ by Time Loss in Collegiate Athletes

BACKGROUND

Self-reported wellbeing measures such as mood and soreness have been identified as predictors of injury risk. However, most research has focused on investigating time-loss injuries even though nontime-loss injuries are more prevalent.

HYPOTHESIS

Impairments in sleep and subjective wellbeing would be associated with increased injury for both time-loss and nontime-loss injuries.

STUDY DESIGN

Prospective longitudinal study.

LEVEL OF EVIDENCE

Level 3.

METHODS

During 2022, 127 athletes completed a daily survey that inquired about training load and sleep from the previous day along with mood, stress, and soreness on the current day. Incidence of injury was also monitored using documentation provided by athletes' respective athletic trainers. Mixed effect models were used to analyze the relationship between wellbeing and sleep measures with injury.

RESULTS

Self-reported wellbeing, based most closely on soreness the day of injury, by National Collegiate Athletic Association Division 1 collegiate athletes was predictive of time-loss injuries, whereas no significant relationship was identified for nontime-loss injuries. Specifically, 1 unit increase in soreness was associated with a 39% increase in odds of sustaining a time-loss injury.

CONCLUSION

This study found that subjective wellbeing and sleep have a different relationship with injury dependent upon whether the resulting injury leads to time loss.

CLINICAL RELEVANCE

Self-reported wellbeing appears to be a relevant predictor of injury among collegiate athletes for time-loss injuries.

The Influence of Race, Socioeconomic Status, and Physical Activity on the Mental Health Benefits of Sport Participation During COVID-19

BACKGROUND

The purpose of this study was to compare the benefits of sport participation with no sport participation during the COVID-19 pandemic and determine the moderating effects of race and ethnicity, socioeconomic status (SES), and physical activity (PA) on mental health in adolescent athletes.

HYPOTHESIS

Sport participation would be associated with greater improvements in mental health for athletes from racial and ethnic minority and lower SES groups compared with White and high SES groups. PA would mediate <30% of the mental health benefits of sport participation.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

In May 2021, adolescent athletes completed an online survey (demographics, sport participation, measures of anxiety and depression, PA). Participants were classified as those who played sports (PLY) and those who did not (DNP). Mental health symptoms for the PLY and DNP groups were compared via analysis of variance models that controlled for demographic variables. Moderating analyses assessed the interaction of sport participation status by (1) race and ethnicity (White/non-White) and (2) SES (high/low) with mental health. Mediation analyses assessed the degree that PA scores explained the differences in anxiety and depression between the 2 groups.

RESULTS

Participants included 4874 adolescent athletes (52% female; age, 16.1 ± 1.3 years; PLY, 91%). Athletes who returned to sport from racial minority groups and low SES had greater decreases in anxiety (race and ethnicity: interaction estimate (b) = -1.18 ± 0.6, P = 0.04; SES, b = -1.23 ± 0.5, P = 0.02), and depression (race and ethnicity: b = -1.19 ± 0.6, P = 0.05; SES, b = -1.21 ± 0.6, P = 0.03) compared with White and high SES athletes, respectively. PA explained 24% of anxiety (P < 0.01) and 20% of depression scores (P < 0.01).

CONCLUSION

Athletes who identify as a racial or ethnic minority and from areas of lower household income experienced disproportionately greater negative mental health impacts from sport restrictions during COVID-19.

CLINICAL RELEVANCE

Improving access to sports in traditionally underserved areas may have significant mental health impact for adolescents.

Does Increased Physical Activity Explain the Psychosocial Benefits of Sport Participation During COVID-19?

CONTEXT

Although the return to sports during COVID-19 has been associated with improvements in mental health and quality of life (QOL), whether these benefits are primarily due to increases in physical activity (PA) is unknown.

OBJECTIVE

To determine whether PA increases were responsible for the improvements in mental health and QOL among adolescents who returned to sport during the COVID-19 pandemic.

DESIGN

Cross-sectional study.

SETTING

Wisconsin secondary schools.

PATIENTS OR OTHER PARTICIPANTS

A total of 559 adolescent athletes (age = 15.7 + 1.2 years, females = 43.6%) from 44 schools completed a survey in October 2020.

MAIN OUTCOME MEASURE(S)

Demographic information, whether they had returned to sport participation, school instruction type, anxiety (Generalized Anxiety Disorder-7), depression (Patient Health Questionnaire-9), QOL (Pediatric Quality of Life Inventory 4.0), and PA (Hospital for Special Surgery Pediatric Functional Activity Brief Scale). Mediation analysis was used to assess whether the relationships between sport status and anxiety, depression, and QOL were mediated by PA.

RESULTS

At the time of the study, 171 (31%) had returned to play and 388 (69%) had not. Athletes who had returned to play had less anxiety (3.6 ± 0.4 versus 8.2 ± 0.6, P < .001) and depression (4.2 ± 0.4 versus 7.3 ± 0.6, P < .001) and higher QOL (88.1 ± 1.0 versus 80.2 ± 1.4, P < .001) and more PA (24.0 ± 0.5 versus 16.3 ± 0.7, P < .001). Physical activity explained a significant, but small, proportion of the difference in depression (22.1%, P = .02) and QOL (16.0%, P = .048) but not anxiety (6.6%, P = .20) between athletes who had and those who had not returned to play.

CONCLUSIONS

Increased PA was responsible for only a small portion of the improvements in depression and QOL among athletes who returned to sports. This suggests that most of the mental health benefits of sport participation for adolescents during the COVID-19 pandemic were independent of the benefits of increased PA.

Anxiety and Depression Prevalence in Incoming Division I Collegiate Athletes From 2017 to 2021

BACKGROUND

Young adults report increased rates of anxiety and depression than other age groups. Furthermore, young adult athletes experience additional stressors that may negatively impact their mental health. The aim of this study was to investigate the prevalence of anxiety and depression symptoms among Division I collegiate athletes and the influences of sex, sport type, and distance from home.

HYPOTHESIS

It was hypothesized that self-reported levels of anxiety and depression would increase among this population during this timeframe.

STUDY DESIGN

Cross-sectional.

LEVEL OF EVIDENCE

Level 3.

METHODS

Participants included 792 incoming Division I collegiate athletes. The Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) scores were completed by all incoming student athletes at a single institution as part of their preparticipation examination over 5 years. Both survey scores were categorized into different levels of severity and separately compared with chi-square tests. Continuous scores were modeled separately using negative binomial regression models including year, sex, sport type, and home location as covariates.

RESULTS

Results showed consistent levels of anxiety and depression over time. Female athletes reported higher levels of both anxiety and depression than male athletes, and individual sport athletes reported higher levels of depression than team sport athletes. Distance from home was not associated with anxiety or depression levels.

CONCLUSION

Overall, levels of anxiety and depression did not change in this population over this time period. However, differences in anxiety and depression were seen between sexes and depression between sport types.

CLINICAL RELEVANCE

Understanding anxiety and depression risk factors among collegiate athletes can enhance early identification and intervention to improve mental health and allow for better allocation of resources to at-risk groups among Division I collegiate athletes.

COVID-19 Planning in United States Adolescent Sports: A Survey of 1880 Organizations Representing More Than 500 000 Youth Athletes

CONTEXT

High schools and youth sport organizations that restarted participation in the fall of 2020 during the COVID-19 pandemic relied on information sources to develop risk-mitigation procedures.

OBJECTIVE

To compare the risk-mitigation procedures and information sources used by high school athletic departments and youth sport organizations.

DESIGN

Cross-sectional study.

SETTING

Surveys of high school and youth sport organization programs from across the United States.

PATIENTS OR OTHER PARTICIPANTS

A total of 1296 high schools and 584 youth sport organizations, representing 519 241 adolescent athletes, responded to the surveys.

MAIN OUTCOME MEASURE(S)

Surveys regarding restarting sport, COVID-19 cases, risk-reduction procedures, and the information sources used to develop risk-reduction plans in the fall of 2020 were distributed to high school athletic directors and youth sport directors throughout the United States. The proportions of high schools and youth sport organizations using different risk-reduction procedures and information sources were compared using the χ2 test.

RESULTS

High schools used more risk-reduction procedures than did youth sport organizations (high schools = 7.1 ± 2.1 versus youth sport organizations = 6.3 ± 2.4; P < .001) and were more likely than youth sport organizations to use symptom monitoring (high schools = 93% versus youth sport organizations = 85%, χ2 = 26.3; P < .001), temperature checks on site (66% versus 49%, χ2 = 53.4; P < .001), face masks for athletes during play (37% versus 23%, χ2 = 38.1; P < .001) and when off the field (81% versus 71%, χ2 = 26.1; P < .001), social distancing for staff (81% versus 68%, χ2 = 43.3; P < .001) and athletes off the field (83% versus 68%, χ2 = 57.6; P < .001), and increased facility disinfection (92% versus 70%, χ2 = 165.0; P < .001). Youth sport organizations relied more on information from sport national governing bodies than did high schools (youth sport organizations = 52% versus high schools = 10%, χ2 = 411.0; P < .001), whereas high schools were more likely to use information from sources such as the National Athletic Trainers' Association (high schools = 20% versus youth sport organizations = 6%, χ2 = 55.20; P < .001) and the National Federation of State High School Associations (high schools = 72% versus youth sport organizations = 15%, χ2 = 553.00; P < .001) for determining risk-reduction strategies.

CONCLUSIONS

High schools and youth sport organizations reported using a broad range of risk-reduction procedures, but the average number was higher among high schools than youth sport organizations. Use of information from the Centers for Disease Control and Prevention and local health authorities was high overall, but use of information from professional health care organizations was low. Professional health care organizations should consider using additional measures to improve information uptake among stakeholders in youth sports.

A Multiyear Assessment of the Effect of Sport Participation on the Health of Adolescent Athletes During the COVID-19 Pandemic

CONTEXT

Sport cancellations early in the COVID-19 pandemic had a significant negative effect on the health of US adolescents. The effect of restarting sports during the pandemic has not been described.

OBJECTIVE

To identify the effect of sport participation on the health of adolescents before and during the COVID-19 pandemic.

DESIGN

Cross-sectional study.

SETTING

Sample recruited via social media.

PATIENTS OR OTHER PARTICIPANTS

Wisconsin adolescent athletes.

MAIN OUTCOME MEASURE(S)

Participants provided information regarding their age, sex, and sport(s) involvement and completed the Patient Health Questionnaire-9 Item to assess depression symptoms, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale to measure physical activity, and the Pediatric Quality of Life Inventory 4.0 to measure quality of life (QoL). Data were collected in spring 2021 (Spring21; n = 1906, age = 16.0 ± 1.2 years, females = 48.8%), when interscholastic sports had fully resumed, and were compared with similar cohorts of adolescent athletes at 2 time points: (1) spring 2020 (Spring20; n = 3243, age = 16.2 ± 1.2 years, females = 57.9%) when sports were cancelled and (2) 2016-2018 (PreCOVID-19) before the pandemic (n = 5231, age = 15.7 ± 1.1 years, females = 65.0%). Comparisons were conducted via analysis-of-variance models and ordinal regressions with age and sex as covariates.

RESULTS

The prevalence of moderate to severe depression was lower in Spring21 than in Spring20 but higher than in PreCOVID-19 (PreCOVID-19 = 5.3%, Spring20 = 37.8%, Spring21 = 22.8%; P < .001). Physical activity scores (mean [95% CI]) were higher in Spring21 than in Spring20 but lower than in PreCOVID-19 (PreCOVID-19 = 23.1 [22.7, 23.5], Spring20 = 13.5 [13.3, 13.7], Spring21 = 21.9 [21.6, 22.2]). Similarly, QoL scores were higher in Spring21 than in Spring20 but lower than in PreCOVID-19 (PreCOVID-19 = 92.8 [92.5, 93.1], Spring20 = 80.7 [80.3, 81.1], Spring21 = 84.3 [83.8, 84.8]).

CONCLUSIONS

Although sports have restarted, clinicians should be aware that physical activity, mental health, and QoL are still significantly affected in adolescent athletes by the ongoing pandemic.

Reported COVID-19 Incidence in Indoor Winter Sports Among US High-School Athletes

OBJECTIVE

To evaluate the association between COVID-19 incidence among high-school athletes participating in different indoor winter sports and attending schools with in-person versus virtual instructional delivery.

DESIGN

Cross-sectional survey.

SETTING

US high schools.

PARTICIPANTS

High-school athletic directors.

INDEPENDENT VARIABLES

Indoor winter sports, school instructional delivery method, and state COVID-19 incidence.

MAIN OUTCOME MEASURES

Surveys were distributed to high-school athletic directors throughout the United States regarding sport reinitiation and COVID-19 cases in winter 2020 to 2021. Separate mixed effects Poisson regression models were developed to evaluate the associations between reported COVID-19 incidence and (1) different sports and (2) school instructional delivery method, while adjusting for the background, state COVID-19 incidence.

RESULTS

Four hundred thirty schools had restarted fall sports, representing 31 274 athletes on 1404 teams from 14 states. One thousand four hundred sixty cases of COVID-19 were reported, representing a case rate of 4668 cases per 100 000 athletes and an incidence rate of 58.7 cases per 100 000 player-days. Reported COVID-19 incidence was greatest among girls' hockey (82.1 cases per 100 000 player-days (95% CI, 56.8-115) and boys' hockey [76.7 (61.8-94.2)] and lowest among swimming [39.0 (31.1-48.2)] and gymnastics [28.5 (13.1-54.2)]. No difference in reported COVID-19 incidence was identified among athletes attending schools with virtual versus in-person instruction [incidence rate ratio = 0.86 (0.52-1.4)].

CONCLUSIONS

In this nationwide survey of US high-school athletic directors regarding indoor winter sports, reported COVID-19 incidence was lower in noncontact sports but unrelated to school instructional delivery method. This information may help guide decision-making regarding high-school sport participation during the COVID-19 pandemic.

The Psychosocial Benefits of Sport Participation During COVID-19 Are Only Partially Explained by Increased Physical Activity

The purpose of this study was to determine whether physical activity (PA) increases were responsible for the improvements in mental health and quality of life (QOL) seen among adolescents who returned to sport during the COVID-19 pandemic.Adolescent athletes were asked to complete a survey in October 2020 regarding demographic information, whether they had returned to sport participation (no [DNP], yes [PLY]), school instruction type (virtual, in-person, hybrid), anxiety, depression, QOL, and PA. Anxiety, depression, QOL and PA were compared between PLY and DNP using least squares means from linear models adjusted for age, gender, and instruction type. Mediation analysis assessed whether the relationship between sport status and anxiety, depression, and QOL was mediated by PA. 171 athletes had returned to play, while 388 had not. PLY athletes had significantly lower anxiety (3.6±0.4 v 8.2±0.6, p<0.001) and depression (4.2±0.4 v 7.3±0.6, p<0.001), and significantly higher QOL (88.1±1.0 v 80.2±1.4, p<0.001) and PA (24.0±0.5 v 16.3±0.7, p<0.001). PA explained a significant, but relatively small portion of the difference in depression (22.1%, p=0.02) and QOL (16.0%, p=0.048) between PLY and DNP athletes, but did not explain the difference in anxiety (6.6%, p=0.20). Increased PA is only responsible for a small portion of the improvements in depression and QOL among athletes who returned to sports and unrelated to improvements in anxiety. This suggests that the majority of the mental health benefits of sport participation for adolescents during the COVID-19 pandemic are independent of, and in addition to, the benefits of increased PA.

Reported COVID-19 Incidence in Wisconsin High School Athletes in Fall 2020

OBJECTIVE

To describe the incidence of COVID-19 in Wisconsin high school athletes and investigate the relationship of COVID-19 incidence with sport and face mask use.

DESIGN

Retrospective survey.

SETTING

High schools across Wisconsin during September 2020.

PATIENTS OR OTHER PARTICIPANTS

Athletic directors representing 30 074 high school athletes with or without SARS-CoV-2.

MAIN OUTCOME MEASUREMENT(S)

The COVID-19 rates among athletes, counties, states, as well as school instruction type (virtual versus in person), sport type, and face mask use were assessed. Reported athlete case rates were compared with the county's general population and associations between COVID-19 incidence and sport type and face mask use, adjusting for each school's county incidence using multivariable negative binomial regression models.

RESULTS

The COVID-19 incidence rates for 207 of 244 responding schools were 32.6 cases per 100 000 player-days. Reported case rates for athletes in each county were positively correlated with the county's general population case rates (β = 1.14 ± 0.20, r = 0.60, P < .001). One case (0.5%) was attributed to sport contact by the reporting schools. No difference was identified between team and individual sports (incidence rate ratio [IRR] = 1.03 [95% CI = 0.49, 2.2], P = .93) or between noncontact and contact sports (IRR = 0.53 [0.23, 1.3], P = .14). Outdoor sports had a lower incidence rate than indoor sports, although this finding did not reach statistical significance (IRR = 0.52 [0.26, 1.1], P = .07). No significant associations were found between COVID-19 incidence and face mask use during play for those sports with greater than 50 schools reporting on face mask use (P values > .05).

CONCLUSIONS

The incidence of reported COVID-19 among high school athletes was related to the county incidence, and most cases were attributed to nonsport contact. A lower COVID-19 incidence in outdoor sports approached statistical significance. The lack of a significant benefit demonstrated for face mask use may be due to relatively low rates of COVID-19 in Wisconsin during September 2020. Further research is needed to better define COVID-19 transmission risk factors during adolescent sport participation.

High School Sports During the COVID-19 Pandemic: The Effect of Sport Participation on the Health of Adolescents

CONTEXT

During the fall of 2020, some high schools across the United States allowed their students to participate in interscholastic sports while others cancelled or postponed their sport programs due to concerns regarding COVID-19 transmission. What effect this has had on the physical and mental health of adolescents is unknown.

OBJECTIVE

To identify the effect of playing a sport during the COVID-19 pandemic on the health of student-athletes.

DESIGN

Cross-sectional study.

SETTING

Sample recruited via email.

PATIENTS OR OTHER PARTICIPANTS

A total of 559 Wisconsin high school athletes (age = 15.7 ± 1.2 years, female = 43.6%, male = 56.4%) from 44 high schools completed an online survey in October 2020. A total of 171 (30.6%) athletes played (PLY) a fall sport, while 388 (69.4%) did not play (DNP).

MAIN OUTCOME MEASURE(S)

Demographic data included sex, grade, and sport(s) played. Assessments were the General Anxiety Disorder-7 Item for anxiety, Patient Health Questionnaire-9 Item for depression, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale for physical activity, and the Pediatric Quality of Life Inventory 4.0 for quality of life. Univariable comparisons between the 2 groups were made via t tests or χ2 tests. Means for each continuous outcome measure were compared between groups using analysis-of-variance models that controlled for age, sex, teaching method (virtual, hybrid, or in person), and the percentage of students eligible for free or reduced-price lunch.

RESULTS

The PLY group participants were less likely to report moderate to severe symptoms of anxiety (PLY = 6.6%, DNP = 44.1%, P < .001) and depression (PLY = 18.2%, DNP = 40.4%, P < .001). They also demonstrated higher (better) Pediatric Functional Activity Brief Scale scores (PLY = 23.2 [95% CI = 22.0, 24.5], DNP = 16.4 [95% CI = 15.0, 17.8], P < .001) and higher (better) Pediatric Quality of Life Inventory total scores (PLY = 88.4 [95% CI = 85.9, 90.9], DNP = 79.6 [95% CI = 76.8, 82.4], P < .001).

CONCLUSIONS

Adolescents who played a sport during the COVID-19 pandemic described fewer symptoms of anxiety and depression and had better physical activity and quality-of-life scores compared with adolescent athletes who did not play a sport.

The Association of COVID-19 Incidence with Sport and Face Mask Use in United States High School Athletes

CONTEXT

The relationships between different sports, face mask use and COVID-19 risk among high school athletes remains unknown.

OBJECTIVE

The purpose of this study was to evaluate the influence of sport characteristics and face mask use on COVID-19 incidence among high school athletes.

DESIGN

Descriptive Epidemiology Study Setting: United States High School Athletic Departments Participants: Athletic Directors Interventions: None Main Outcome Measures: Surveys were completed regarding sport re-initiation, COVID-19 cases, and risk reduction procedures in fall 2020. Separate mixed effects Poisson regression models were developed to evaluate the associations between reported COVID-19 incidence and 1) sport characteristics (contact/non-contact, individual/team, indoor/outdoor) and 2) face mask use while playing (yes/no).

RESULTS

991 schools had restarted fall sports, representing 152,484 athletes on 5,854 teams. 2,565 cases of COVID-19 were reported, representing a case rate of 1,682 cases per 100,000 athletes and an incidence rate of 24.6 cases per 100,000 player-days. COVID-19 incidence was lower among outdoor versus indoor sports (incidence rate ratio [IRR]=0.54, 95% CI=0.49-0.60, p<0.001) and non-contact versus contact sports (IRR=0.78 [0.70-0.87], p<0.001), but not team versus individual sports (IRR=0.96 [0.84-1.1], p=0.49). Face mask use was associated with a decreased incidence in girls' volleyball (IRR=0.53 [0.37-0.73], p<0.001), boys' basketball (IRR=0.53 [0.33-0.83], p=0.008) and girls' basketball (IRR=0.36 [0.19-0.63], p<0.001), and approached statistical significance in football (IRR=0.79 [0.59-1.04], p=0.10) and cheer/dance (IRR=0.75 [0.53-1.03], p=0.081).

CONCLUSIONS

In this nationwide survey of high school athletes, lower COVID-19 incidence was independently associated with participation in outdoor versus indoor and non-contact versus contact sports, but not team versus individual sports. Face mask use was associated with decreased COVID-19 incidence among indoor sports, and may be protective among outdoor sports with prolonged close contact between participants.

Decreased Sleep and Subjective Well-Being as Independent Predictors of Injury in Female Collegiate Volleyball Players

Background:

The relationship among sleep duration, subjective well-being, and injury risk in athletes is poorly defined.

Purpose:

To evaluate the independent effects of sleep duration, sleep quality, and subjective well-being on in-season injuries in collegiate female volleyball athletes.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

During a 9-month competitive season, 17 female National Collegiate Athletic Association (NCAA) Division I volleyball players reported mood, fatigue, stress, soreness, sleep duration (hours), and sleep quality every morning. Well-being measures were recorded from 0 (worst) to 5 (best), and all time-loss injuries were recorded by the team athletic trainer. Separate mixed-effects logistic regression models were used to evaluate the effects of sleep and subjective well-being on in-season injury. Each well-being variable was also included in a separate mixed-effects logistic regression model with sleep duration as a covariate.

Results:

A total of 54 injuries were recorded during the study period. Compared with days without an injury, mood, fatigue, stress, soreness, sleep quality, and sleep duration were significantly worse the day before an injury occurred. In the separate prediction models, in-season injury was significantly predicted by fatigue (odds ratio [OR], 0.56 [95% CI, 0.36-0.86]; P = .008), mood (OR, 0.52 [95% CI, 0.35-0.78]; P = .002), stress (OR, 0.63 [95% CI, 0.42-0.94]; P = .023), soreness (OR, 0.54 [95% CI, 0.38-0.79]; P = .001), sleep quality (OR, 0.49 [95% CI, 0.34-0.7]; P < .001), and sleep duration (OR, 0.69 [95% CI, 0.55-0.87]; P = .001). In the multivariable models, sleep duration remained a significant independent predictor in each of the subsequent multivariable models (OR, 0.72-0.74; P < .05 for all), as did mood (OR, 0.55 [95% CI, 0.36-0.83); P = .005) and soreness (OR, 0.57 [95% CI, 0.39-0.83]; P = .003), while fatigue (OR, 0.65 [95% CI, 0.42-1]; P = .054) and stress (OR, 0.68 [95% CI, 0.45-1]; P = .061) no longer reached statistical significance.

Conclusion:

Increased sleep duration, mood, and decreased soreness were independently associated with a reduced risk of in-season injury in this cohort of female NCAA volleyball players.

Decreased ventricular size and mass mediate the reduced exercise capacity in adolescents and adults born premature

BACKGROUND

Premature birth is associated with lower levels of cardiorespiratory fitness (CRF) but the underlying mechanisms responsible remain unclear. This study assessed whether differences in cardiac morphology or function mediate differences in CRF among adolescents and young adults born preterm.

METHODS

Adolescents and young adults born moderately to extremely premature (gestational age ≤ 32 weeks or birth weight < 1500 g) and age-matched term born participants underwent resting cardiac MRI and maximal exercise testing. Mediation analysis assessed whether individual cardiovascular variables accounted for a significant proportion of the difference in maximal aerobic capacity between groups.

RESULTS

Individuals born preterm had lower VO2max than those born term (41.7 ± 8.6 v 47.5 ± 8.7, p < 0.01). Several variables differed between term and preterm born subjects, including systolic and diastolic blood pressure, mean pulmonary artery pressure, indexed left ventricular end-diastolic volume (LVEDVi), right ventricular end-diastolic volume (RVEDVi), LV mass (LVMi), LV stroke volume index (LVSVi), and LV strain (p < 0.05 for all). Of these variables, LVEDVi, RVEDVi, LVSVi, LVMi, and LV longitudinal strain were significantly related to VO2max (p < 0.05 for all). Significant portions of the difference in VO2max between term and preterm born subjects were mediated by LVEDVi (74.3%, p = 0.010), RVEDVi (50.6%, p = 0.016), and LVMi (43.0%, p = 0.036).

CONCLUSIONS

Lower levels of CRF in adolescents and young adults born preterm are mediated by differences in LVEDVi, RVEDVi, and LVMi. This may represent greater risk for long-term cardiac morbidity and mortality in preterm born individuals.

COVID-19 in US Youth Soccer Athletes During Summer 2020

CONTEXT

As sports are reinitiated around the United States, the incidence of COVID-19 among youth soccer athletes remains unknown.

OBJECTIVE

To determine the incidence of COVID-19 among youth soccer athletes and the risk-mitigation practices used by youth soccer organizations.

DESIGN

Cohort study.

SETTING

Survey distributed to Elite Clubs National League member clubs.

PATIENTS OR OTHER PARTICIPANTS

Youth soccer club directors throughout the United States.

MAIN OUTCOME MEASURE(S)

Surveys were completed in late August 2020 regarding the club's current phase of return to soccer (individual only, group noncontact, group contact), date of reinitiation, number of players, cases of COVID-19, and risk-reduction procedures being implemented. Case and incidence rates were compared with national pediatric data and county data from the prior 10 weeks. A negative binomial regression model was developed to predict club COVID-19 cases using the local incidence rate and phase of return as covariates and the log of club player-days as an offset.

RESULTS

A total of 124 respondents had reinitiated soccer, representing 91 007 players with a median duration of 73 days (interquartile range = 53-83 days) since restarting. Of the 119 clubs that had progressed to group activities, 218 cases of COVID-19 were reported among 85 861 players. Youth soccer players had a lower case rate and incidence rate than children in the United States (254 versus 477 cases per 100 000; incidence rate ratio = 0.511, 95% CI = 0.40, 0.57; P < .001) and the general population in the counties where data were available (268 versus 864 cases per 100 000; incidence rate ratio = 0.202, 95% CI = 0.19, 0.21; P < .001). After adjusting for the local COVID-19 incidence, we found no relationship between the club COVID-19 incidence and the phase of return (noncontact: b = 0.35 ± 0.67, P = .61; contact: b = 0.18 ± 0.67, P = .79). Soccer clubs reported using a median of 8 (interquartile range = 6-10) risk-reduction procedures.

CONCLUSIONS

The incidence of COVID-19 among youth soccer athletes was relatively low when compared with the background incidence among children in the United States during the summer of 2020. No relationship was identified between the club COVID-19 incidence and the phase of return to soccer.

COVID-19 Risk in Youth Club Sports: A nationwide sample representing over 200,000 Athletes

CONTEXT

The COVID-19 pandemic has affected almost every aspect of life including youth sports. Little data exists on COVID-19 incidences and risk mitigation strategies in youth club sports.

OBJECTIVE

To determine the reported incidence of COVID-19 cases among youth club sport athletes and the information sources used to develop COVID-19 risk mitigation procedures.

DESIGN

Cross-sectional study.

SETTING

Online surveys.

PATIENTS

Soccer and volleyball youth club directors.

INTERVENTION

A survey was completed by directors of youth volleyball and soccer clubs across the country in October 2020. Surveys included self-reported date of re-initiation, number of players, player COVID-19 cases, sources of infection, COVID-19 mitigation strategies, and information sources for the development of COVID-19 mitigation strategies.

MAIN OUTCOME MEASURES

Total number of cases reported, number of players, and days since club re-initiation were used to calculate an incidence rate of cases per 100,000 player-days. To compare reported incidence rates between soccer and volleyball, a negative binomial model was developed to predict player cases with sport and state incidence as covariates and log(player-days) as an offset. Estimates were exponentiated to yield a reported incidence rate ratio (IRR) with Wald confidence intervals.

RESULTS

A total of 205,136 athletes (soccer=165,580; volleyball=39,556) were represented by 437 clubs (soccer=159; volleyball=278). Club organizers reported 673 COVID-19 cases (soccer=322; volleyball=351), for a reported incidence rate of 2.8 cases per 100,000 player-days (soccer=1.7, volleyball=7.9). Volleyball had a significantly higher reported COVID-19 incidence rate compared to soccer (reported IRR = 3.06 [2.0-4.6], p<0.001). Out of 11 possible mitigation strategies, the median number of strategies used by all clubs was 7 with an interquartile range of 2.

CONCLUSIONS

The incidence of self-reported cases of COVID-19 was lower in soccer clubs than volleyball clubs. Most clubs report using many COVID-19 mitigation strategies to reduce the risk of COVID-19.

Defining a research agenda for youth sport specialisation in the USA: the AMSSM Youth Early Sport Specialization Summit

Sport specialisation is becoming increasingly common among youth and adolescent athletes in the USA and many have raised concern about this trend. Although research on sport specialisation has grown significantly, numerous pressing questions remain pertaining to short-term and long-term effects of specialisation on the health and well-being of youth, including the increased risk of overuse injury and burnout. Many current elite athletes did not specialise at an early age. Methodological and study design limitations impact the quality of current literature, and researchers need to prioritise pressing research questions to promote safe and healthy youth sport participation. The American Medical Society for Sports Medicine hosted a Youth Early Sport Specialization Summit in April 2019 with the goal of synthesising and reviewing current scientific knowledge and developing a research agenda to guide future research in the field based on the identified gaps in knowledge. This statement provides a broad summary of the existing literature, gaps and limitations in current evidence and identifies key research priorities to help guide researchers conducting research on youth sport specialisation. Our goals are to help improve the quality and relevance of research on youth sport specialisation and to ultimately assure that opportunities for healthy and safe sport participation continue for all youth.

Musculoskeletal Injuries and Their Association With Previous Concussion History: A Prospective Study of High School Volleyball and Soccer Players

BACKGROUND

Sports-related concussions may have a neurobiological recovery period that exceeds the period of clinical recovery, and one consequence of an extended neurobiological recovery may be the risk of subsequent musculoskeletal injuries. Most literature citing an increased risk of musculoskeletal injury after a sports-related concussion has been reported in populations other than adolescent athletes.

PURPOSE/HYPOTHESIS

The purpose was to prospectively determine if incidence rates of musculoskeletal injury differ between adolescent athletes with and without a previous sports-related concussion, while controlling for sex, sport, and age. A secondary aim was to determine if this relationship differs between male and female athletes of the same sport. Our hypotheses were that acute-noncontact injury rates would be higher in athletes with a previous sports-related concussion when compared with athletes without a previous sports-related concussion, and that this relationship would exist only in female athletes and not male athletes.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

High school soccer and volleyball players were recruited in 2 prospective cohort studies that observed 4837 athletes during their sporting season (females, 80%; soccer, 57%; mean [SD] age, 15.6 [1.1] years). At preseason, all participants self-reported demographics and previous sports-related concussion within the past 12 months. During the sport season, team athletic trainers electronically recorded athlete exposures and injury data, including injury characteristics. Injury rates per 1000 athlete exposures and injury rate ratios (IRRs) with 95% confidence intervals were calculated. All injury rates and IRRs were adjusted for sex, age, and sport.

RESULTS

The rate of acute-noncontact lower extremity injury was 87% greater (IRR, 1.87; 95% CI, 1.29-2.74) in participants with a previous sports-related concussion versus those without one. The acute-noncontact lower extremity injury rates (IRRs) for females and males with a previous sports-related concussion were 1.76 (95% CI, 1.19-2.59) and 2.83 (95% CI, 0.85-9.50), respectively. No difference was detected in acute-contact (IRR, 0.98; 95% CI, 0.56-1.73) or overuse (IRR, 1.09; 95% CI, 0.51-2.37) lower extremity injury rates by previous sports-related concussion.

CONCLUSION

Female adolescent athletes who reported a sports-related concussion within the past 12 months were more likely to sustain an acute-noncontact lower extremity injury during their high school sports season when compared with female athletes without a previous sport-related concussion.

Changes in the Health of Adolescent Athletes: A Comparison of Health Measures Collected Before and During the CoVID-19 Pandemic

CONTEXT

In the spring of 2020, schools closed to in-person teaching and sports were cancelled to control the transmission of CoVID-19. The changes that took place to the physical and mental health among young athletes during this time remain unknown, however.

OBJECTIVE

Identify changes in the health (mental health, physical activity and quality of life) of athletes that occurred during the CoVID-19 pandemic.

DESIGN

Cross-sectional study.

SETTING

Sample recruited via social media.

PATIENTS OR OTHER PARTICIPANTS

3243 Wisconsin adolescent athletes (age=16.2±1.2 yrs., female=58% female) completed an online survey in May 2020 (DuringCoVID-19). Health measures for this cohort were compared with previously reported data for Wisconsin adolescent athletes (n=5231, age=15.7±1.2, 47% female) collected in 2016-2018 (PreCoVID-19).

MAIN OUTCOME MEASURE(S)

Demographic information included: sex, grade and sports played. Health assessments included the Patient Health Questionnaire-9 Item (PHQ-9) to identify depression symptoms, the Pediatric Functional Activity Brief Scale (PFABS) for physical activity, and the Pediatric Quality of Life Inventory 4.0 (PedsQL) for health related quality of life (HRQoL). Univariable comparisons of these variables between groups were made via t-tests or chi-square tests. Means and 95% confidence intervals (CI) for each group were estimated by survey weighted ANOVA models.

RESULTS

Compared to PreCoVID-19, a larger proportion of the During-CoVID-19 participants reported rates of moderate to severe levels of depression (9.7% vs 32.9%, p<0.001). During-CoVID-19 participants reported 50% lower (worse) PFABS scores (mean:12.2 [95%CI: 11.9, 12.5] vs 24.7 [24.5, 24.9] p<0.001) and lower (worse) PedsQL total scores compared to the PreCoVID-19 participants (78.4 [78.0, 78.8] vs. 90.9 [90.5, 91.3] p<0.001).

CONCLUSIONS

During the CoVID-19 pandemic, adolescent athletes reported increased symptoms of depression, decreased physical activity and decreased quality of life compared to adolescent athletes in previous years.

Defining a Research Agenda for Youth Sport Specialization in the United States: The AMSSM Youth Early Sport Specialization Summit

ABSTRACT

Sport specialization is becoming increasingly common among youth and adolescent athletes in the United States and many have raised concern about this trend. Although research on sport specialization has grown significantly, numerous pressing questions remain pertaining to short- and long-term effects of specialization on the health and well-being of youth, including the increased risk of overuse injury and burnout. Many current elite athletes did not specialize at an early age. Methodological and study design limitations impact the quality of current literature, and researchers need to prioritize pressing research questions to promote safe and healthy youth sport participation. The American Medical Society for Sports Medicine hosted a Youth Early Sport Specialization Summit in April 2019 with the goal of synthesizing and reviewing current scientific knowledge and developing a research agenda to guide future research in the field based on the identified gaps in knowledge. This statement provides a broad summary of the existing literature, gaps and limitations in current evidence, and identifies key research priorities to help guide researchers conducting research on youth sport specialization. Our goals are to help improve the quality and relevance of research on youth sport specialization and to ultimately assure that opportunities for healthy and safe sport participation continue for all youth.

Psychosocial Impacts of Sports-related Injuries in Adolescent Athletes

ABSTRACT

Adolescence represents a time of tremendous physical, social, and emotional growth, and sport participation can provide significant mental health benefits for young athletes. Injuries are unfortunately common in sports and represent a threat to the short- and long-term health of athletes. While injury management has typically revolved around the minimization of pain and the restoration of physical function, emerging evidence suggests that the psychological consequences of injury may be significant, potentially jeopardizing return to play, increasing subsequent reinjury risk, and even leading to the development of mental health disorders. The majority of this research has been conducted in adult athletes and less is known about outcomes in youth athletes following injury. This review examines what is known about the psychosocial impact of sports injuries in youth athletes to identify areas of future research and to aid clinicians in the management of this population.

Mental Health, Physical Activity, and Quality of Life of US Adolescent Athletes During COVID-19-Related School Closures and Sport Cancellations: A Study of 13 000 Athletes

CONTEXT

In the spring of 2020, US schools closed to in-person teaching and sports were cancelled to control the transmission of coronavirus disease 2019 (COVID-19). It is critical to understand the mental and physical health of adolescent athletes during this time.

OBJECTIVE

To describe the health of athletes during COVID-19-related school closures and sport cancellations.

DESIGN

Cross-sectional study.

SETTING

A national sample recruited via social media.

PATIENTS OR OTHER PARTICIPANTS

A total of 13 002 US adolescent athletes (age = 16.3 ± 1.2 years, females = 52.9%, males = 47.0%) completed an anonymous online survey.

MAIN OUTCOME MEASURE(S)

Demographic information collected was sex, grade, sport(s) played, and zip code. Assessments used were the General Anxiety Disorder 7-Item for anxiety, Patient Health Questionnaire 9-Item for depression, the Pediatric Functional Activity Brief Scale for physical activity, and the Pediatric Quality of Life Inventory 4.0 for quality of life. Mental health, physical activity, and health-related quality-of-life variables were compared among sex, grade, sport(s) played, and poverty level using means and 95% confidence intervals (CIs) from the survey-weighted analysis of variance.

RESULTS

Females reported a higher prevalence of moderate to severe anxiety symptoms (females = 43.7% versus males = 28.2%). The Pediatric Functional Activity Brief Scale score was highest (best) for grade 9 (mean = 14.5, 95% CI = 14.0, 15.0) and lowest for grade 11 (mean = 10.9, 95% CI = 10.5, 11.3). The prevalence of depression symptoms was highest in team sport (74.1%) and lowest in individual sport (64.9%) participants. The total Pediatric Quality of Life Inventory score was lowest (worst) for athletes from counties with the highest poverty levels (high: mean = 74.5, 95% CI = 73.7, 75.3; middle: mean = 78.9, 95% CI = 78.0, 79.8; and low: mean = 78.3, 95% CI = 77.4, 79.1).

CONCLUSIONS

The health of US adolescents during the COVID-19-related school closures and sport cancellations varied to differing degrees depending on sex, grade level, type of sport participation, and level of poverty. Health policy experts should consider these findings in the future when creating and implementing policies to improve the health of adolescents in the United States.

The Health Of Us Adolescent Athletes During Covid-19 Related School Closures And Sport Cancellations

CONTEXT

In the spring of 2020, US schools closed to in-person teaching and sports were cancelled to control the transmission of COVID-19. It is critical to understand the mental and physical health of adolescent athletes during this time.

OBJECTIVE

Describe the health of athletes during COVID-19 related school closures and sport cancellations.

DESIGN

Cross sectional.

SETTING

A national sample recruited via social media.

PATIENTS OR OTHER PARTICIPANTS

13,002 US adolescent athletes (age=16.3+1.2 yrs., female=53.1%) completed an anonymous online survey.

MAIN OUTCOME MEASURE(S)

Demographic information included: sex, grade, sports played and zip code. Assessments included the: General Anxiety Disorder-7 Item (GAD-7) for anxiety, Patient Health Questionnaire-9 Item (PHQ-9) for depression, the Pediatric Functional Activity Brief Scale (PFABS) for physical activity, and the Pediatric Quality of Life Inventory 4.0 (PedsQL) for quality of life. Mental health, physical activity and quality of life variables were compared between sex, grade, sports played and poverty level using means and 95%CI from the survey weighted ANOVA.

RESULTS

Females reported a higher prevalence of moderate to severe anxiety symptoms (females=43.7% vs. males=28.2%). The PFABS score (mean [95%CI] was highest (best) for grade 9 (14.5 [14.0,15.0]) and lowest for grade 11 (10.9 [10.5,11.3]. The prevalence of depression symptoms was highest in team sport (74.1%) and lowest for individual sport participants (64.9%). The total PedsQL score was lowest (worst) for athletes from counties with the highest poverty levels (high=74.5[73.7,75.3], middle=78.9[78.0,79.8], low=78.3 [77.4,79.1]).

CONCLUSIONS

The health of US adolescents during the COVID-19 related school closures and sport cancellations varied to differing degrees depending on sex, grade level, type of sport participation and level of poverty. Health policy experts should consider these findings when creating and implementing policies to improve the health of adolescents in the US in the future.

Training Load and Injury Among Middle School-Aged Athletes

CONTEXT

Young athletes are encouraged to participate in high-intensity sport programs. However, most research on the association between training volume (TV) and injury has been performed on adult or professional athletes.

OBJECTIVE

To evaluate the association between acute and chronic TV (hours/week) and reported injury (yes/no) and evaluate the relationship between acute : chronic TV and injury while controlling for sex, age, and prior injury in young athletes.

DESIGN

Cohort study.

SETTING

Online surveys.

PATIENTS OR OTHER PARTICIPANTS

Middle school-aged adolescents.

MAIN OUTCOME MEASURE(S)

We conducted a baseline survey at the start of the 2017-2018 academic year. The baseline survey solicited information regarding demographics, injury history, and primary sport. Subsequent surveys were delivered electronically at the start of each week. Information obtained with the weekly survey included weekly TV and injuries sustained the previous week. Injuries were reported and classified (eg, acute or gradual onset) by the participants. Weekly TV was aggregated as rolling averages over the prior 2, 3, and 4 weeks. Acute:chronic TV was calculated for each participant for every week as the prior week TV divided by the TV during the prior 2 (1 : 2), 3 (1 : 3), and 4 (1 : 4) weeks of the study period.

RESULTS

A total of 244 recruits participated. Higher average TV over the prior 4 weeks (odds ratio [OR] = 0.97; 95% confidence interval [CI] = 0.93, 1.00; P = .05) was associated with fewer reported injuries. Additionally, higher average TV over the prior 2 (OR = 0.96; 95% CI = 0.93, 0.99; P = .04), 3 (OR = 0.95; 95% CI = 0.91, 0.99; P = .02), and 4 (OR = 0.95; 95% CI = 0.91, 0.99; P = .05) weeks was associated with fewer reported acute injuries the following week. Acute:chronic TV and any injury type were not related.

CONCLUSIONS

Consistent, higher levels of physical activity may offer protection against acute injury in young athletes.

Association Between Preterm Birth and Arrested Cardiac Growth in Adolescents and Young Adults

Importance

Premature birth is associated with substantially higher lifetime risk for cardiovascular disease, including arrhythmia, ischemic disease, and heart failure, although the underlying mechanisms are poorly understood.

Objective

To characterize cardiac structure and function in adolescents and young adults born preterm using cardiac magnetic resonance imaging (MRI).

Design, Setting, and Participants

This cross-sectional cohort study at an academic medical center included adolescents and young adults born moderately to extremely premature (20 in the adolescent cohort born from 2003 to 2004 and 38 in the young adult cohort born in the 1980s and 1990s) and 52 age-matched participants who were born at term and underwent cardiac MRI. The dates of analysis were February 2016 to October 2019.

Exposures

Premature birth (gestational age ≤32 weeks) or birth weight less than 1500 g.

Main Outcomes and Measures

Main study outcomes included MRI measures of biventricular volume, mass, and strain.

Results

Of 40 adolescents (24 [60%] girls), the mean (SD) age of participants in the term and preterm groups was 13.3 (0.7) years and 13.0 (0.7) years, respectively. Of 70 adults (43 [61%] women), the mean (SD) age of participants in the term and preterm groups was 25.4 (2.9) years and 26.5 (3.5) years, respectively. Participants from both age cohorts who were born prematurely had statistically significantly smaller biventricular cardiac chamber size compared with participants in the term group: the mean (SD) left ventricular end-diastolic volume index was 72 (7) vs 80 (9) and 80 (10) vs 92 (15) mL/m2 for adolescents and adults in the preterm group compared with age-matched participants in the term group, respectively (P < .001), and the mean (SD) left ventricular end-systolic volume index was 30 (4) vs 34 (6) and 32 (7) vs 38 (8) mL/m2, respectively (P < .001). Stroke volume index was also reduced in adolescent vs adult participants in the preterm group vs age-matched participants in the term group, with a mean (SD) of 42 (7) vs 46 (7) and 48 (7) vs 54 (9) mL/m2, respectively (P < .001), although biventricular ejection fractions were preserved. Biventricular mass was statistically significantly lower in adolescents and adults born preterm: the mean (SD) left ventricular mass index was 39.6 (5.9) vs 44.4 (7.5) and 40.7 (7.3) vs 49.8 (14.0), respectively (P < .001). Cardiac strain analyses demonstrated a hypercontractile heart, primarily in the right ventricle, in adults born prematurely.

Conclusions and Relevance

In this cross-sectional study, adolescents and young adults born prematurely had statistically significantly smaller biventricular cardiac chamber size and decreased cardiac mass. Although function was preserved in both age groups, these morphologic differences may be associated with elevated lifetime cardiovascular disease risk after premature birth.

Sport specialization and sport participation opportunities and their association with injury history in female high school volleyball athletes

OBJECTIVE

Determine the association of sport specialization in female volleyball athletes with previous injury history and determine the association of sport specialization with volleyball participation opportunities.

DESIGN

Cross-sectional.

SETTING

Recruitment occurred from 83 Wisconsin high schools during the 2018 volleyball season.

PARTICIPANTS

Female volleyball athletes (N = 1,588, grades 9-12, age = 15.6 ± 1.1 years).

MAIN OUTCOMES

Participants completed a pre-season questionnaire soliciting information regarding 1) demographics, 2) sport specialization, 3) sport participation, and 4) sport-related injuries in the previous 12 months. Univariable logistic regression models were used to identify associations with previous injury. Chi-square analyses were used to investigate associations between sport specialization classification and other sport participation opportunities.

RESULTS

Both moderately and highly specialized athletes were more likely to report a previous injury compared to low specialized athletes (moderate OR: 1.84 [1.29-2.62]; p < 0.001 and high OR: 2.30 [1.64-3.24]; p < 0.001). Highly specialized athletes were more likely to report participating in club volleyball, summer tournaments, and training camps in the past 12 months. Participants who reported participating in club volleyball, summer competitions, and training camps last year were more likely to report an injury.

CONCLUSIONS

Specialization was associated with injury history and year-round volleyball opportunities among female adolescent volleyball athletes.

Early Pulmonary Vascular Disease in Young Adults Born Preterm

Rationale: Premature birth affects 10% of live births in the United States and is associated with alveolar simplification and altered pulmonary microvascular development. However, little is known about the long-term impact prematurity has on the pulmonary vasculature.Objectives: Determine the long-term effects of prematurity on right ventricular and pulmonary vascular hemodynamics.Methods: Preterm subjects (n = 11) were recruited from the Newborn Lung Project, a prospectively followed cohort at the University of Wisconsin-Madison, born preterm with very low birth weight (≤1,500 g; average gestational age, 28 wk) between 1988 and 1991. Control subjects (n = 10) from the same birth years were recruited from the general population. All subjects had no known adult cardiopulmonary disease. Right heart catheterization was performed to assess right ventricular and pulmonary vascular hemodynamics at rest and during hypoxic and exercise stress.Measurements and Main Results: Preterm subjects had higher mean pulmonary arterial pressures (mPAPs), with 27% (3 of 11) meeting criteria for borderline pulmonary hypertension (mPAP, 19-24 mm Hg) and 18% (2 of 11) meeting criteria for overt pulmonary hypertension (mPAP ≥ 25 mm Hg). Pulmonary vascular resistance and elastance were higher at rest and during exercise, suggesting a stiffer vascular bed. Preterm subjects were significantly less able to augment cardiac index or right ventricular stroke work during exercise. Among neonatal characteristics, total ventilatory support days was the strongest predictor of adult pulmonary pressure.Conclusions: Young adults born preterm demonstrate early pulmonary vascular disease, characterized by elevated pulmonary pressures, a stiffer pulmonary vascular bed, and right ventricular dysfunction, consistent with an increased risk of developing pulmonary hypertension.

A Comparison of Emergency Preparedness Between High School Coaches and Club Sport Coaches

CONTEXT

Recent studies suggested that a large population of high school-aged athletes participate on club sport teams. Despite attempts to document emergency preparedness in high school athletics, the adherence to emergency and medical coverage standards among club sport teams is unknown.

OBJECTIVE

To determine if differences in emergency preparedness and training existed between coaches of high school teams and coaches of high school-aged club teams.

DESIGN

Cross-sectional survey.

SETTING

Online questionnaire.

PATIENTS OR OTHER PARTICIPANTS

A total of 769 coaches (females = 266, 34.6%) completed an anonymous online questionnaire regarding their emergency preparedness and training.

MAIN OUTCOME MEASURE(S)

The questionnaire consisted of (1) demographics and team information, (2) emergency preparedness factors (automated external defibrillator [AED] availability, emergency action plan [EAP] awareness, medical coverage), and (3) emergency training requirements (cardiopulmonary resuscitation/AED, first aid).

RESULTS

High school coaches were more likely than club sport coaches to be aware of the EAP for their practice venue (83.9% versus 54.4%, P < .001), but most coaches in both categories had not practiced their EAP in the past 12 months (70.0% versus 68.9%, P = .54). High school coaches were more likely to be made aware of the EAP during competitions (47.5% versus 37.1%, P = .02), but the majority of coaches in both categories indicated that they were never made aware of EAPs. High school coaches were more likely than club coaches to (1) have an AED available at practice (87.9% versus 58.8%, P < .001), (2) report that athletic trainers were responsible for medical care at practices (31.2% versus 8.8%, P < .001) and competitions (57.9% versus 31.2%, P < .001), and (3) be required to have cardiopulmonary resuscitation, AED, or first-aid training (P < .001).

CONCLUSIONS

High school coaches displayed much greater levels of emergency preparedness and training than coaches of high school-aged club teams. Significant attention and effort may be needed to address the lack of emergency preparedness and training observed in club coaches.

Sport-Specific Associations of Specialization and Sex With Overuse Injury in Youth Athletes

BACKGROUND

Significant evidence has emerged that sport specialization is associated with an increased risk of overuse injury in youth athletes. Several recommendations exist to reduce the risk of overuse injury in youth sports, but the risk of overuse injuries may be dependent on specific movements required by a given sport.

HYPOTHESES

Associations between specialized sport participation and overuse injury will exist in volleyball athletes but not soccer or basketball athletes. Female athletes will be more likely to report an overuse injury in the previous year, regardless of sport.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Youth athletes between the ages of 12 and 18 years were recruited in-person at club team tournaments, competitions, and events around the state of Wisconsin during the 2016-2017 school year. Participants were asked to complete an anonymous questionnaire that consisted of (1) participant demographics, (2) sport specialization status, (3) monthly and weekly sport volume, and (4) sport-related injury history in the previous year.

RESULTS

A total of 716 youth athletes completed the questionnaire (70.8% female; mean age, 14.21 ± 1.50 years; 43.2% basketball, 19.4% soccer, 37.4% volleyball; 41.8% highly specialized; 32.3% reported overuse injury in the previous year). Sex was associated with overuse injury among basketball athletes, with female basketball athletes nearly 4 times more likely to report an overuse injury compared with male basketball athletes (odds ratio, [OR], 3.7; 95% CI, 2.1-6.6; P < 0.001). High specialization (OR, 2.3; 95% CI, 1.1-4.9; P = 0.02) and participating in a single sport for more than 8 months per year (OR, 2.0; 95% CI, 1.1-3.5; P < 0.05) were associated with overuse injury only among volleyball athletes.

CONCLUSION

Specialization and exceeding 8 months per year in a single sport was associated with overuse injury in volleyball, which is one of the most popular youth sports for female athletes. Specialization was not associated with overuse injury in basketball or soccer athletes. Female basketball athletes were nearly 4 times more likely to report a history of overuse injury compared with male basketball athletes. The sex of a youth athlete and the sport that he or she plays may influence the risk of overuse injury associated with sport specialization.

CLINICAL RELEVANCE

Youth athletes, parents, and clinicians should be aware that the potential risks of specialization might vary based on the athlete's sport and sex.

A Comparison of Team Sport Volume Surveyed Between High School and Club Sport Coaches

BACKGROUND

Club sport participation is increasingly common among high school athletes. Sport participation characteristics may vary widely between the high school and club sport settings. However, there have been no large-scale comparisons of sport participation volume between high school and club teams from similar sports.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare the sport participation characteristics of high school and high school-aged club teams. We hypothesized that club team athletes would participate in more months per year and hours per week and would take more overnight trips than high school athletes and that club team coaches would be less likely to track their athletes' sport volume than high school coaches.

STUDY DESIGN

Cross-sectional study.

METHODS

A total of 769 coaches (266 female; 34.6%) from 3 sports (basketball, volleyball, soccer) completed an anonymous online questionnaire regarding their team's sport volume and their knowledge, attitudes, and beliefs regarding sport specialization. Coaches were eligible to participate if they had served as the head or assistant coach of a high school sport team or high school-aged club sport team in the past 12 months.

RESULTS

Overall, 64.6% (n = 497) were coaches of a high school team, and 35.4% (n = 272) were coaches of a club team with high school-aged athletes. Club coaches' teams played more months out of the year and took more overnight trips for competitions than high school coaches' teams but participated in fewer hours per week of practices or competitions during their season. There were no differences between club and high school coaches in tracking their athletes' sport volume, with most coaches in both settings reporting that they do not track the amount of time that their athletes participate in other sports.

CONCLUSION

Significant differences in sport participation volume exist between the teams of high school and club coaches.

Knowledge, Attitudes, and Beliefs of Youth Club Athletes Toward Sport Specialization and Sport Participation

Background:

There are a variety of proposed motivations for sport specialization, such as improving sport skills to an elite level, making all-star or travel teams, or receiving a scholarship or professional contract. However, there has not been a quantitative examination of the attitudes and beliefs that may be contributing to the trend of sport specialization and year-round sport participation.

Purpose:

The primary aim was to describe the attitudes and beliefs of youth club sport athletes regarding sport specialization and sport participation. A secondary objective was to investigate whether an association exists between the level of sport specialization and the belief in receiving a college scholarship.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 974 youth athletes (578 female; mean age, 14.2 ± 1.6 years) completed an anonymous questionnaire that focused on attitudes and beliefs toward sport specialization and sport participation. Questions were developed utilizing the feedback of a panel of content area experts and the University of Wisconsin Survey Center. Data were summarized using frequencies, proportions (%), and means ± SDs.

Results:

Fewer than half of all athletes (45.8%) believed that specialization increased their chances of getting injured either “quite a bit” or “a great deal.” However, 91% of athletes believed that specialization increased their chances of getting better at their sport either “quite a bit” or “a great deal.” Similarly, the majority of athletes believed that specialization increased their chances of making their high school team (80.9%) or a college team (66.9%) either “quite a bit” or “a great deal.” Overall, 15.7% of athletes believed that they were either “very” or “extremely” likely to receive a college scholarship based on athletic performance. Highly specialized athletes were nearly twice as likely to have a high belief in receiving a college scholarship compared with low-specialization athletes (20.2% vs 10.2%, respectively; χ² = 18.8; P = .001).

Conclusion:

Most youth athletes in this study believe that specialization increases their sport performance and ability to make not only a college team but also their high school team. Highly specialized athletes were more likely to believe that they will receive a college scholarship.

Sleep and Athletic Performance

Sleep is an essential component of health and well-being, with significant impacts on physical development, emotional regulation, cognitive performance, and quality of life. Along with being an integral part of the recovery and adaptive process between bouts of exercise, accumulating evidence suggests that increased sleep duration and improved sleep quality in athletes are associated with improved performance and competitive success. In addition, better sleep may reduce the risk of both injury and illness in athletes, not only optimizing health but also potentially enhancing performance through increased participation in training. Despite this, most studies have found that athletes fail to obtain the recommended amount of sleep, threatening both performance and health. Athletes face a number of obstacles that can reduce the likelihood of obtaining proper sleep, such as training and competition schedules, travel, stress, academic demands, and overtraining. In addition, athletes have been found to demonstrate poor self-assessment of their sleep duration and quality. In light of this, athletes may require more careful monitoring and intervention to identify individuals at risk and promote proper sleep to improve both performance and overall health. This review attempts to highlight the recent literature regarding sleep issues in athletes, the effects of sleep on athletic performance, and interventions to enhance proper sleep in athletes.

Impaired autonomic function in adolescents born preterm

Preterm birth temporarily disrupts autonomic nervous system (ANS) development, and the long-term impacts of disrupted fetal development are unclear in children. Abnormal cardiac ANS function is associated with worse health outcomes, and has been identified as a risk factor for cardiovascular disease. We used heart rate variability (HRV) in the time domain (standard deviation of RR intervals, SDRR; and root means squared of successive differences, RMSSD) and frequency domain (high frequency, HF; and low frequency, LF) at rest, as well as heart rate recovery (HRR) following maximal exercise, to assess autonomic function in adolescent children born preterm. Adolescents born preterm (less than 36 weeks gestation at birth) in 2003 and 2004 and healthy age-matched full-term controls participated. Wilcoxon Rank Sum tests were used to compare variables between control and preterm groups. Twenty-one adolescents born preterm and 20 term-born controls enrolled in the study. Preterm-born subjects had lower time-domain HRV, including SDRR (69.1 ± 33.8 vs. 110.1 ± 33.0 msec, respectively, P = 0.008) and RMSSD (58.8 ± 38.2 vs. 101.5 ± 36.2 msec, respectively, P = 0.012), with higher LF variability in preterm subjects. HRR after maximal exercise was slower in preterm-born subjects at 1 min (30 ± 12 vs. 39 ± 9 bpm, respectively, P = 0.013) and 2 min (52 ± 10 vs. 60 ± 10 bpm, respectively, P = 0.016). This study is the first report of autonomic dysfunction in adolescents born premature. Given prior association of impaired HRV with adult cardiovascular disease, additional investigations into the mechanisms of autonomic dysfunction in this population are warranted.

In-season changes in ventricular morphology and systolic function in adolescent female athletes

PURPOSE

To evaluate the influence of physical maturity on the changes in ventricular morphology and function with sport training in female youth athletes.

METHODS

Thirty-two female athletes (age 13-18 years) underwent height and weight measurement and 2-D echocardiographic evaluation immediately prior to, and following, a 20-week soccer season. Pre- and post-season left ventricular end-diastolic diameter (LVEDD), end-diastolic volume (LVEDV), ejection fraction (LVEF), stroke volume (LVSV), mass (LVM), and posterior wall thickness (LVPWT), right ventricular end-diastolic diameter (RVEDD), end-diastolic area (RVEDA), and fractional area change (RVFAC), and interventricular septal thickness (IVST) were compared. In-season change in each variable was compared across pre-season hours of vigorous physical activity (0-1, 2-3, >3 hours).

RESULTS

Significant increases were identified in LVEDV (51.3 ± 10.4 v 56.4 ± 9.6 ml/m², p = 0.001) and RVEDA (10.5 ± 1.9 v 11.3 ± 2.5 cm²/m², p = 0.040), but not LVEDD, LVM, LVPWT, LVSV, RVEDD, RVEDA, RVFAC, or IVST (p > 0.05 for all). In-season changes in echocardiographic variables did not differ across hours of pre-season vigorous physical activity (p > 0.05 for all).

CONCLUSION

Among female adolescent soccer players, in-season training elicits changes in resting ventricular volume, but not wall thickness or systolic function. These adaptations do not appear to be influenced by pre-season physical activity level.

Sport Specialization Characteristics Between Rural and Suburban High School Athletes

Background:

Sport specialization has been associated with overuse injuries and is more common in larger high schools, which are often located in more urban/suburban settings. However, sport participation characteristics have not been compared between suburban and rural high schools.

Purpose/Hypothesis:

The purpose of this study was to examine the differences in sport participation characteristics between athletes at suburban and rural high schools. It was hypothesized that suburban high school students would be more likely to be highly specialized, participate in more athletic competitions per year, and play in a league outside of school. We also hypothesized that suburban high school students would start playing their primary sport at a younger age, would have participated in their primary sport for longer, and would play more months per year and hours per week.

Study Design:

Cross-sectional study.

Methods:

High school athletes from 4 high schools (2 suburban and 2 rural) participated in this study (N = 354 [222 females]; mean age, 15.7 ± 1.2 years). Athletes were on a school-sponsored athletic team in 1 of 4 sports (volleyball, tennis, basketball, soccer). The suburban schools (study enrollment, n = 226) had total school enrollments of 2271 and 622 students, while the rural schools (study enrollment, n = 128) had total school enrollments of 443 and 297. Participants completed a questionnaire prior to the start of their high school sport season. The questionnaire consisted of demographic information, a sport specialization scale, and sport participation information. Primary sport competition volume in the previous 12 months was classified as high (>60 primary sport competitions), moderate (30-60), or low (<30). Sport specialization status was classified via a 3-point scale as low, moderate, or high.

Results:

As compared with athletes at rural schools, athletes at suburban schools started playing their primary sport at a younger age (suburban, 7.8 ± 2.9 years; rural, 9.7 ± 3.2 years; P < .001) and participated for more years (suburban, 7.9 ± 3.1 years; rural, 6.1 ± 3.3 years; P < .001), more months per year (suburban, 7.6 ± 3.6 months; rural, 5.6 ± 2.8 months; P < .001), and more hours per week (suburban, 15.2 ± 5.1 hours; rural, 12.9 ± 3.3 hours; P < .001). Athletes at suburban schools were more likely than rural athletes to be classified as highly specialized (χ² = 52.5, P < .001), participate in more competitions (χ² = 16.5, P < .001), play in a league outside of school (χ² = 18.4, P < .001), and train in their primary sport for >8 months per year (χ² = 27.8, P < .001) and >16 hours per week (χ² = 15.0, P < .001).

Conclusion:

High school athletes at suburban schools are more likely to exhibit sport participation patterns that are associated with increased risk of overuse injury. These include being classified as highly specialized, playing their primary sport >8 months per year and >16 hours per week, engaging in a high competition volume, and participating in a sport league (eg, club) outside of school. Efforts aimed at safe sport participation should target these groups, as they seem more likely to violate safe sport recommendations.

Short-Term Heart Rate Recovery is Related to Aerobic Fitness in Elite Intermittent Sport Athletes

Watson, AM, Brickson, SL, Prawda, ER, and Sanfilippo, JL. Short-term heart rate recovery is related to aerobic fitness in elite intermittent sport athletes. J Strength Cond Res 31(4): 1055-1061, 2017-Although heart rate recovery (HRR) has been suggested as a measure of fitness, minimal data exist among athletes. The purpose of this study was to determine if HRR is related to aerobic fitness in elite athletes and whether this relationship is influenced by sex or body composition. Eighty-four collegiate athletes (45 male athletes) underwent body fat percentage (BF%) determination by dual-energy x-ray absorptiometry and maximal treadmill testing followed by 5 minutes of recovery. V[Combining Dot Above]O2max and heart rate (HRmax) were determined, and HRR was calculated as a percentage of HRmax at 10 seconds, 30 seconds, and 1, 2, 3, 4, and 5 minutes after test completion. After stratifying by sex, participants were grouped as high fit or low fit based on V[Combining Dot Above]O2max median split. Heart rate recovery was compared between sexes and fitness level at each time point. Multivariable regression analysis was used to identify independent predictors of HRR using V[Combining Dot Above]O2max, BF%, and sex as covariates. Heart rate recovery did not differ significantly between sexes and was faster among high-fit participants at 10 and 30 seconds, but at no other time. V[Combining Dot Above]O2max was significantly correlated with HRR at 10 and 30 seconds (r = -0.34, p < 0.001 and r = -0.28, p = 0.008) only. After controlling for BF% and sex, V[Combining Dot Above]O2max remained significantly associated with HRR at 10 seconds (p = 0.007) but not at 30 seconds (p = 0.067) or any time thereafter. Aerobic capacity is related to faster HRR during the first 30 seconds only, suggesting that only very short term HRR should be used as a measure of aerobic fitness in intermittent sport athletes.

Pharmacologically-induced mitotic synchrony in airway epithelial cells as a mechanism of action of anti-inflammatory drugs

BACKGROUND

Mitotic synchrony is the synchronous progression of a population of cells through the cell cycle and is characteristic of non-diseased airway epithelial cells. However, we previously showed that asthmatic airway epithelial cells are characterized by mitotic asynchrony and are pro-inflammatory as a result. Glucocorticoids can induce mitotic synchrony that in turn suppresses the pro-inflammatory state of diseased cells, suggesting a novel anti-inflammatory mechanism of action. Herein, we benchmarked traditional glucocorticoids against the ability of a new clinical-stage dissociative steroidal drug, VBP15, for mitotic resynchronization and associated anti-inflammatory activity in asthmatic airway epithelial cells.

METHODS

Primary airway epithelial cells differentiated at air-liquid interface were exposed to VBP15, dexamethasone or vehicle following in vitro mechanical injury. Basolateral cytokine secretions (TGF-β1, IL-6, IL-10, IL-13, and IL-1β) were analyzed at different time points using cytometric bead assays and mitosis was examined by flow cytometry.

RESULTS

VBP15 improved mitotic synchrony of proliferating asthmatic cells in air-liquid interface cultures compared to vehicle-exposed cultures. VBP15 also significantly reduced the basolateral secretion of pro-inflammatory (i.e. IL-1β) and pro-fibrogenic cytokines (i.e. TGF-β1) in air-liquid interface-differentiated asthmatic epithelial cultures following mechanical injury.

CONCLUSION

VBP15 improves mitotic asynchrony and injury-induced pro-inflammatory and fibrogenic responses in asthmatic airway epithelial cultures with efficacy comparable to traditional glucocorticoids. As it is predicted to show superior side effect profiles compared to traditional glucocorticoids, VBP15 holds potential for treatment of asthma and other respiratory conditions.

Emergency response planning and sudden cardiac arrests in high schools after automated external defibrillator legislation

OBJECTIVE

To compare medical emergency response plan (MERP) and automated external defibrillator (AED) prevalence and define the incidence and outcomes of sudden cardiac arrest (SCA) in high schools before and after AED legislation.

STUDY DESIGN

In 2011, Tennessee Secondary School Athletic Association member schools were surveyed regarding AED placement, MERPs, and on-campus SCAs within the last 5 years. Results were compared with a similar study conducted in 2006, prior to legislation requiring AEDs in schools.

RESULTS

Of the schools solicited, 214 (54%, total enrollment 182 289 students) completed the survey. Compared with 2006, schools in the 2011 survey had a significantly higher prevalence of MERPs (84% vs 71%, P < .001), annual practice (56% vs 36%, P < .001), medical emergency communication systems (80% vs 62%, P < .001), and defibrillators (90% vs 47%, P < .001). No differences were noted in the prevalence of cardiopulmonary resuscitation training (20% vs 17%, P = .58) or full compliance with American Heart Association guidelines (11% vs 7%, P = .16). Twenty-two SCA victims were identified, yielding a 5-year incidence of 1 in 10 schools.

CONCLUSIONS

After state legislation, schools demonstrated a significant increase in MERPs and on-campus defibrillators but rates of cardiopulmonary resuscitation training and overall compliance with guidelines remained low.

Relationships between disease control, green leaf duration, grain quality and the production of alcohol from winter wheat

BACKGROUND

Since demand for distilling wheat is expected to increase rapidly as a result of the development of the bioethanol industry, efficient production will become of increasing importance. Achieving this will require an understanding of the agronomic factors that influence both grain yield and alcohol yield. Therefore five field experiments using the winter distilling wheat variety Glasgow were conducted over three seasons (2006-2007, 2007-2008 and 2008-2009) to study the relationships between foliar disease and alcohol yield.

RESULTS

There was a significant relationship between alcohol yield and the severity of the disease septoria leaf blotch (Septoria tritici), which was present in the experiments from natural infection. Retention of green flag leaf area as affected by disease control following fungicide application was also shown to be important for achieving high alcohol yields. Measurements of grain quality showed that high thousand-grain weight and low grain protein concentration were significantly related to increased alcohol yield.

CONCLUSION

The experiments showed the importance of disease management to protect alcohol yields in the distilling wheat crop. Fungicides that provide greater disease control and improved green leaf retention are likely to be beneficial to alcohol yield.

Cell division autoantigen 1 plays a profibrotic role by modulating downstream signalling of TGF-beta in a murine diabetic model of atherosclerosis

AIMS/HYPOTHESIS

Excess accumulation of vascular extracellular matrix (ECM) is an important pathological process in cardiovascular diseases including diabetes-associated atherosclerosis. We explored how a recently identified molecule, cell division autoantigen 1 (CDA1), influences the profibrotic TGF-beta pathway leading to vascular ECM accumulation.

METHODS

Expression levels of genes encoding for CDA1, TGF-beta and connective tissue growth factor (CTGF) were examined in aorta from Apoe(-/-) mice with or without diabetes. We used retroviral and adenoviral constructs to knockdown or overexpress Tspyl2, the gene encoding CDA1, in mouse vascular smooth muscle cells (VSMCs) with or without TGF-beta treatment in order to demonstrate the role of CDA1 in TGF-beta signalling.

RESULTS

In vivo studies indicated that the mRNA levels of CDA1-encoding gene Tspyl2 and protein levels of CDA1 were elevated in the aorta of diabetic Apoe(-/-) mice, accompanied by increased levels of Tgf-beta (also known as Tgfb1), Ctgf and ECM accumulation. In vitro studies in vascular cells showed that TGF-beta treatment rapidly increased CDA1 protein levels, which then amplified TGF-beta signalling leading to upregulation of ECM genes. Knockdown of CDA1-encoding gene Tspyl2 to reduce cellular CDA1 level markedly attenuated TGF-beta-stimulated MAD homologue 3 (drosophila; SMAD3) phosphorylation and transcriptional activities. CDA1 overproduction increased and Tspyl2 knockdown decreased expression of TGF-beta receptor type I, TbetarI (also known as Tgfbr1), but not TGF-beta receptor type II, TbetarII (also known as Tgfbr2), providing a mechanism for CDA1's action in modulating TGF-beta signalling. Knockdown of CDA1-encoding gene Tspyl2 also blocked the profibrotic effect of TGF-beta in VSMCs.

CONCLUSIONS/INTERPRETATION

CDA1 plays an important role in vascular ECM accumulation by amplifying TGF-beta signalling. This is critical for the profibrotic effect of TGF-beta in the vasculature. CDA1 is therefore a potential target for attenuating vascular ECM accumulation caused by enhanced TGF-beta action, as seen in diabetic atherosclerosis.