COVID-19 Vaccination Reactions and Risk of Breakthrough Infections Among People With Diabetes: Cohort Study Derived From Community Reporters

BACKGROUND

This exploratory study compares self-reported COVID-19 vaccine side effects and breakthrough infections in people who described themselves as having diabetes with those who did not identify as having diabetes.

OBJECTIVE

The study uses person-reported data to evaluate differences in the perception of COVID-19 vaccine side effects between adults with diabetes and those who did not report having diabetes.

METHODS

This is a retrospective cohort study conducted using data provided online by adults aged 18 years and older residing in the United States. The participants who voluntarily self-enrolled between March 19, 2021, and July 16, 2022, in the IQVIA COVID-19 Active Research Experience project reported clinical and demographic information, COVID-19 vaccination, whether they had experienced any side effects, test-confirmed infections, and consented to linkage with prescription claims. No distinction was made for this study to differentiate prediabetes or type 1 and type 2 diabetes nor to verify reports of positive COVID-19 tests. Person-reported medication use was validated using pharmacy claims and a subset of the linked data was used for a sensitivity analysis of medication effects. Multivariate logistic regression was used to estimate the adjusted odds ratios of vaccine side effects or breakthrough infections by diabetic status, adjusting for age, gender, education, race, ethnicity (Hispanic or Latino), BMI, smoker, receipt of an influenza vaccine, vaccine manufacturer, and all medical conditions. Evaluations of diabetes medication-specific vaccine side effects are illustrated graphically to support the examination of the magnitude of side effect differences for various medications and combinations of medications used to manage diabetes.

RESULTS

People with diabetes (n=724) reported experiencing fewer side effects within 2 weeks of vaccination for COVID-19 than those without diabetes (n=6417; mean 2.7, SD 2.0 vs mean 3.1, SD 2.0). The adjusted risk of having a specific side effect or any side effect was lower among those with diabetes, with significant reductions in fatigue and headache but no differences in breakthrough infections over participants' maximum follow-up time. Diabetes medication use did not consistently affect the risk of specific side effects, either using self-reported medication use or using only diabetes medications that were confirmed by pharmacy health insurance claims for people who also reported having diabetes.

CONCLUSIONS

People with diabetes reported fewer vaccine side effects than participants not reporting having diabetes, with a similar risk of breakthrough infection.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04368065; https://clinicaltrials.gov/study/NCT04368065.

Data sources and applied methods for paclitaxel safety signal discernment

Background

Following the identification of a late mortality signal, the Food and Drug Administration (FDA) convened an advisory panel that concluded that additional clinical study data are needed to comprehensively evaluate the late mortality signal observed with the use of drug-coated balloons (DCB) and drug-eluting stent (DES). The objective of this review is to (1) identify and summarize the existing clinical and cohort studies assessing paclitaxel-coated DCBs and DESs, (2) describe and determine the quality of the available data sources for the evaluation of these devices, and (3) present methodologies that can be leveraged for proper signal discernment within available data sources.

Methods

Studies and data sources were identified through comprehensive searches. original research studies, clinical trials, comparative studies, multicenter studies, and observational cohort studies written in the English language and published from January 2007 to November 2021, with a follow-up longer than 36 months, were included in the review. Data quality of available data sources identified was assessed in three groupings. Moreover, accepted data-driven methodologies that may help circumvent the limitations of the extracted studies and data sources were extracted and described.

Results

There were 39 studies and data sources identified. This included 19 randomized clinical trials, nine single-arm studies, eight registries, three administrative claims, and electronic health records. Methodologies focusing on the use of existing premarket clinical data, the incorporation of all contributed patient time, the use of aggregated data, approaches for individual-level data, machine learning and artificial intelligence approaches, Bayesian approaches, and the combination of various datasets were summarized.

Conclusion

Despite the multitude of available studies over the course of eleven years following the first clinical trial, the FDA-convened advisory panel found them insufficient for comprehensively assessing the late-mortality signal. High-quality data sources with the capabilities of employing advanced statistical methodologies are needed to detect potential safety signals in a timely manner and allow regulatory bodies to act quickly when a safety signal is detected.

Epidemiology of Stingers in the National Football League, 2015-2019

BACKGROUND

Transient traumatic neuropraxia of either the brachial plexus or cervical nerve root(s) is commonly described as a "stinger" or "burner" by the athlete. Stingers in American Football commonly occur acutely as isolated injuries; however, concomitant injuries, including cervical spine pathologies, have also been reported.

HYPOTHESIS

Among National Football League (NFL) athletes, the incidence rate of stingers is higher during the regular season than during the preseason and among positions with high velocity impacts such as running backs, linebackers, defensive backs, and receivers.

STUDY DESIGN

Retrospective epidemiology study.

LEVEL OF EVIDENCE

Level 4.

METHODS

Aggregation of all in-game injuries with a clinical impression of "neck brachial plexus stretch" or "neck brachial plexus compression" entered into the NFL injury surveillance database through the centralized league-wide electronic medical record system over 5 years (2015-2019 seasons). Incidence rates per player-play were calculated and reported.

RESULTS

A total of 691 in-game stingers occurred during the study period, with a mean of 138.2 per year. Average single-season injury risk for incident stinger was 3.74% (95% CI, 3.46%-4.05%). The incidence rate was higher during regular season games than during preseason games (12.26 per 100,000 player-plays [11.30-13.31] vs 8.87 [7.31-10.76], P < 0.01, respectively). The highest reported stinger incidence rates were among running backs and linebackers (both >15 per 100,000 player-plays). Among stingers, 76.41% did not miss time. Of those that resulted in time lost from football activities, mean time missed due to injury was 4.79 days (range, 3.17-6.41 days). Concomitant injuries were relatively low (7.09%).

CONCLUSION

In-game stinger incidence was stable across the study period and occurred most frequently in running backs and linebackers. Stingers were more common during the regular season, and most players did not miss time. Concomitant injuries were relatively rare.

CLINICAL RELEVANCE

An improved understanding of the expected time loss due to stinger and concomitant injuries may provide insight for medical personnel in managing these injuries.

The "Bubble": What Can Be Learned from the National Basketball Association (NBA)'s 2019-20 Season Restart in Orlando during the COVID-19 Pandemic

BACKGROUND

The National Basketball Association (NBA) suspended operations in response to the COVID-19 pandemic in March 2020. To safely complete the 2019-20 season, the NBA created a closed campus in Orlando, Florida, known as the NBA "Bubble." More than 5000 individuals lived, worked, and played basketball at a time of high local prevalence of SARS-CoV-2.

METHODS

Stringent protocols governed campus life to protect NBA and support personnel from contracting COVID-19. Participants quarantined before departure and upon arrival. Medical and social protocols required that participants remain on campus, test regularly, physically distance, mask, use hand hygiene, and more. Cleaning, disinfection, and air filtration was enhanced. Campus residents were screened daily and confirmed cases of COVID-19 were investigated.

RESULTS

In the Bubble population, 148 043 COVID-19 reverse transcriptase PCR (RT-PCR) tests were performed across approximately 5000 individuals; Orlando had a 4% to 15% test positivity rate in this timeframe. There were 44 COVID-19 cases diagnosed either among persons during arrival quarantine or in non-team personnel while working on campus after testing but before receipt of a positive result. No cases of COVID-19 were identified among NBA players or NBA team staff living in the Bubble once cleared from quarantine.

CONCLUSIONS

Drivers of success included the requirement for players and team staff to reside and remain on campus, well-trained compliance monitors, unified communication, layers of protection between teams and the outside, activation of high-quality laboratory diagnostics, and available mental health services. An emphasis on data management, evidence-based decision-making, and the willingness to evolve protocols were instrumental to successful operations. These lessons hold broad applicability for future pandemic preparedness efforts.

Determining the True Incidence of Glenohumeral Instability Among Players in the National Football League: An Epidemiological Study of Non-Missed Time Shoulder Instability Injuries

Background

Shoulder instability encompasses a spectrum of glenohumeral pathology ranging from subluxation to dislocation. While dislocation frequently leads to removal from play, athletes are often able to play through subluxation. Previous research on glenohumeral instability among athletes has largely focused on missed-time injuries, which has likely disproportionately excluded subluxation injuries and underestimated the overall incidence of shoulder instability.

Purpose

To describe the epidemiology of shoulder instability injuries resulting in no missed time beyond the date of injury (non-missed time injuries) among athletes in the National Football League (NFL).

Study Design

Descriptive epidemiology study.

Methods

The NFL's electronic medical record was retrospectively reviewed to identify non-missed time shoulder instability injuries during the 2015 through 2019 seasons. For each injury, player age, player position, shoulder laterality, instability type, instability direction, injury timing, injury setting, and injury mechanism were recorded. For injuries that occurred during games, incidence rates were calculated based on time during the season as well as player position. The influence of player position on instability direction was also investigated.

Results

Of the 546 shoulder instability injuries documented during the study period, 162 were non-missed time injuries. The majority of non-missed time injuries were subluxations (97.4%), occurred during games (70.7%), and resulted from a contact mechanism (91.2%). The overall incidence rate of game-related instability was 1.6 injuries per 100,000 player-plays and was highest during the postseason (3.5 per 100,000 player-plays). The greatest proportion of non-missed time injuries occurred in defensive secondary players (28.4%) and offensive linemen (19.8%), while kickers/punters and defensive secondary players had the highest game incidence rates (5.5 and 2.1 per 100,000 player-plays, respectively). In terms of direction, 54.3% of instability events were posterior, 31.9% anterior, 8.5% multidirectional, and 5.3% inferior. Instability events were most often anterior among linebackers and wide receivers (50% and 100%, respectively), while posterior instability was most common in defensive linemen (66.7%), defensive secondary players (58.6%), quarterbacks (100.0%), running backs (55.6%), and tight ends (75.0%).

Conclusion

The majority of non-missed time shoulder instability injuries (97.4%) were subluxations, which were likely excluded from or underreported in previous shoulder instability studies due to the inherent difficulty of detecting and diagnosing shoulder subluxation.

Tactical Considerations for Designing Real-World Studies: Fit-for-Purpose Designs That Bridge Research and Practice

Real-world evidence (RWE) is being used to provide information on diverse groups of patients who may be highly impacted by disease but are not typically studied in traditional randomized clinical trials (RCT) and to obtain insights from everyday care settings and real-world adherence to inform clinical practice. RWE is derived from so-called real-world data (RWD), ie, information generated by clinicians in the course of everyday patient care, and is sometimes coupled with systematic input from patients in the form of patient-reported outcomes or from wearable biosensors. Studies using RWD are conducted to evaluate how well medical interventions, services, and diagnostics perform under conditions of real-world use, and may include long-term follow-up. Here, we describe the main types of studies used to generate RWE and offer pointers for clinicians interested in study design and execution. Our tactical guidance addresses (1) opportunistic study designs, (2) considerations about representativeness of study participants, (3) expectations for transparency about data provenance, handling and quality assessments, and (4) considerations for strengthening studies using record linkage and/or randomization in pragmatic clinical trials. We also discuss likely sources of bias and suggest mitigation strategies. We see a future where clinical records - patient-generated data and other RWD - are brought together and harnessed by robust study design with efficient data capture and strong data curation. Traditional RCT will remain the mainstay of drug development, but RWE will play a growing role in clinical, regulatory, and payer decision-making. The most meaningful RWE will come from collaboration with astute clinicians with deep practice experience and questioning minds working closely with patients and researchers experienced in the development of RWE.

The National Football League Concussion Protocol: A Review

Sport-related concussion remains an area of high concern for contact sport athletes and their families, as well as for the medical and scientific communities. The National Football League (NFL), along with the NFL Players Association and experts in the field, has developed protocols for the detection and management of sport-related concussions. This article reviews the NFL's most recent concussion protocol including preseason education and baseline testing for players, concussion surveillance by gameday medical teams and neurotrauma consultants and athletic trainers, gameday concussion protocol and procedures, and return to participation guidelines.

Factors associated with antibody titer levels among an occupational cohort of fully vaccinated individuals and subsequent risk of COVID-19 infection: A cohort study

This study (1) determined the association of time since initial vaccine regimen, booster dose receipt, and COVID-19 history with antibody titer, as well as change in titer levels over a defined period, and (2) determined risk of COVID-19 associated with low titer levels. This observational study used data from staff participating in the National Football League COVID-19 Monitoring Program. A cohort of staff consented to antibody-focused sub-study, during which detailed longitudinal data were collected. Among all staff in the program who received antibody testing, COVID-19 incidence following antibody testing was determined. Five hundred eighty-six sub-study participants completed initial antibody testing; 80% (469) completed follow-up testing 50-101 days later. Among 389 individuals who were not boosted at initial testing, the odds of titer < 1000 AU/mL (vs. ≥1000 AU/mL) increased 44% (odds ratio [OR] = 1.44, 95% confidence interval [CI]: 1.18-1.75) for every 30 days since final dose. Among 126 participants boosted before initial testing with no COVID-19 history, 125 (99%) had a value > 2500 AU/ml; 86 (96%) of 90 tested at follow-up and did not develop COVID-19 in the interim remained at that value. One thousand fifty-seven fully vaccinated (330 [29%] boosted at antibody test) individuals participating in the monitoring program were followed to determine COVID-19 status. Individuals with titer value < 1000 AU/mL had twice the risk of COVID-19 as those with >2500 AU/mL (HR = 2.02, 95% CI: 1.28-3.18). Antibody levels decrease postvaccination; boosting increases titer values. While antibody level is not a clear proxy for infection immunity, lower titer values are associated with higher COVID-19 incidence, suggesting increased protection from boosters.

Lower Extremity Strains in the US National Football League, 2015-2019

BACKGROUND

Lower extremity (LEX) strains, including hamstring, quadriceps, adductor, and calf strains, are among the most common injuries in sports. These injuries lead to high burden, resulting in significant missed participation time.

PURPOSE

To describe the incidence of LEX strains in professional American football.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

This study included all players who played in ≥1 National Football League (NFL) game or sustained a LEX strain during participation in the 2015-2019 seasons. LEX strain frequency was calculated by setting (game, practice, conditioning), timing in season (offseason, preseason, regular season, postseason), and roster position. Game incidence rates were calculated for season, roster position, and play type. LEX strains were identified in the standardized leaguewide electronic health record (n = 32 teams).

RESULTS

Across 5 years, 5780 LEX strains were reported among 2769 players (1-year risk, 26.7%; 95% CI, 26.0%-27.3%); 69% (n = 4015) resulted in time loss. Among all LEX strains, 54.7% were hamstring (n = 3163), 24.1% adductor (n = 1393), 12.6% calf (n = 728), 8.3% quadriceps (n = 477), and 0.3% multiple muscle groups (n = 19). Most were reported during preseason practices (n = 1076; 27%) and regular season games (n = 1060; 26%). The 2-week period of training camp practices comprised 19% of all time-loss strains. Among game injuries, preseason games had the highest rate of LEX strain (2.9/10,000 player-plays; 95% CI, 2.6-3.2). Defensive secondary players accounted for the highest proportion of time-loss LEX strains (27%; n = 1082). In games, punt plays had nearly twice the injury rate of kickoff plays (14.9/1000 plays [95% CI, 13.1-17.0] vs 7.5/1000 plays [95% CI, 6.2-8.9], respectively) and >3 times the rate of pass plays (4.3/1000 plays; 95% CI, 4.0-4.7) and run plays (2.6/1000 plays; 95% CI, 2.3-2.9). In aggregate, LEX strains led to an estimated 16,748 participation days missed each year and a median 12 days missed per injury.

CONCLUSION

LEX strains affected 1 in 4 NFL players each year, resulting in a high burden of injury in terms of time lost from practice and competition. Safe return to the NFL season during training camp and reduction of injuries during regular season games are key focuses for future injury reduction.

Cognitive and other neuropsychiatric symptoms in COVID-19: analysis of person-generated longitudinal health data from a community-based registry

OBJECTIVE

To describe cognitive symptoms in people not hospitalised at study enrolment for SARS-CoV-2 infection and associated demographics, medical history, other neuropsychiatric symptoms and SARS-CoV-2 vaccination.

DESIGN

Longitudinal observational study.

SETTING

Direct-to-participant registry with community-based recruitment via email and social media including Google, Facebook and Reddit, targeting adult US residents. Demographics, medical history, COVID-19-like symptoms, tests and vaccinations were collected through enrolment and follow-up surveys.

PARTICIPANTS

Participants who reported positive COVID-19 test results between 15 December 2020 and 13 December 2021. Those with cognitive symptoms were compared with those not reporting such symptoms.

MAIN OUTCOME MEASURE

Self-reported cognitive symptoms (defined as 'feeling disoriented or having trouble thinking' from listed options or related written-in symptoms) RESULTS: Of 3908 participants with a positive COVID-19 test result, 1014 (25.9%) reported cognitive symptoms at any time point during enrolment or follow-up, with approximately half reporting moderate/severe symptoms. Cognitive symptoms were associated with other neuropsychiatric symptoms, including dysgeusia, anosmia, trouble waking up, insomnia, headache, anxiety and depression. In multivariate analyses, female sex (OR, 95% CI): 1.7 (1.3 to 2.2), age (40-49 years (OR: 1.5 (1.2-1.9) compared with 18-29 years), history of autoimmune disease (OR: 1.5 (1.2-2.1)), lung disease (OR: 1.7 (1.3-2.2)) and depression (OR: 1.4 (1.1-1.7)) were associated with cognitive symptoms. Conversely, black race (OR: 0.6 (0.5-0.9)) and COVID-19 vaccination before infection (OR: 0.6 (0.4-0.7)) were associated with reduced occurrence of cognitive symptoms.

CONCLUSIONS

In this study, cognitive symptoms among COVID-19-positive participants were associated with female gender, age, autoimmune disorders, lung disease and depression. Vaccination and black race were associated with lower occurrence of cognitive symptoms. A constellation of neuropsychiatric and psychological symptoms occurred with cognitive symptoms. Our findings suggest COVID-19's full health and economic burden may be underestimated.

TRIAL REGISTRATION NUMBER

NCT04368065.

MRI Findings Associated With Anterior Cruciate Ligament Tears in National Football League Athletes

Background

Anterior cruciate ligament (ACL) tears are a high-frequency injury requiring a lengthy recovery in professional American football players. Concomitant pathology associated with ACL tears as identified on magnetic resonance imaging (MRI) is not well understood in these athletes.

Purpose

To describe the MRI findings of concomitant injuries associated with ACL tears among athletes in the National Football League (NFL).

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Of 314 ACL injuries in NFL athletes from 2015 through 2019, 191 complete MRI scans from the time of primary ACL injury were identified and reviewed by 2 fellowship-trained musculoskeletal radiologists. Data were collected on ACL tear type and location, as well as presence and location of bone bruises, meniscal tears, articular cartilage pathology, and concomitant ligament pathology. Mechanism data from video review were linked with imaging data to assess association between injury mechanism (contact vs noncontact) and presence of concomitant pathology.

Results

Bone bruises were evident in 94.8% of ACL tears in this cohort, most often in the lateral tibial plateau (81%). Meniscal, additional ligamentous, and/or cartilage injury was present in 89% of these knees. Meniscal tears were present in 70% of knees, lateral (59%) more than medial (41%). Additional ligamentous injury was present in 71% of all MRI scans, more often a grade 1/2 sprain (67%) rather than a grade 3 tear (33%), and most often involving the medial collateral ligament (MCL) (57%) and least often the posterior cruciate ligament (10%). Chondral damage was evident in 49% of all MRI scans, with ≥1 full-thickness defect in 25% of all MRI scans, most often lateral. Most (79%) ACL tears did not involve direct contact to the injured lower extremity. Direct contact injuries (21%) were more likely to have a concomitant MCL tear and/or medial patellofemoral ligament injury and less likely to have a medial meniscal tear.

Conclusion

ACL tears were rarely isolated injuries in this cohort of professional American football athletes. Bone bruises were almost always present, and additional meniscal, ligamentous, and chondral injuries were also common. MRI findings varied by injury mechanism.

Validity of Research Based on Public Data in Sports Medicine: A Quantitative Assessment of Anterior Cruciate Ligament Injuries in the National Football League

BACKGROUND

Numerous researchers have leveraged publicly available Internet sources to publish publicly obtained data (POD) studies concerning various orthopaedic injuries in National Football League (NFL) players.

PURPOSE

To provide a comprehensive systematic review of all POD studies regarding musculoskeletal injuries in NFL athletes and to use anterior cruciate ligament (ACL) injuries in NFL players to quantify the percentage of injuries identified by these studies.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was conducted to identify all published studies utilizing POD regarding ACL injury in NFL athletes from 2000 to 2019. Data regarding player demographics were extracted from each publication. These results were compared with prospectively collected data reported by the teams' medical staff to the NFL Injury Surveillance System database linked to the League's electronic health record. An ACL "capture rate" for each article was calculated by dividing the number of ACL injuries in the POD study by the total number of ACL injuries in the NFL injury database occurring in the study period of interest.

RESULTS

A total of 42 studies were extracted that met the definition of a POD study: 28 evaluated a variety of injuries and 14 dealt specifically with ACL injuries, with 35 (83%) of the 42 studies published during or since 2015. POD studies captured a mean of 66% (range, 31%-90%) of ACL injuries reported by the teams' medical staff. This inability to capture all injury rates varied by position, with 86% capture of ACL injuries in skill athletes, 72% in midskill athletes, and 61% in linemen. POD studies captured 35% of injuries occurring during special teams play.

CONCLUSION

The frequency of studies leveraging publicly obtained injury data in NFL players has rapidly increased since 2000. There is significant heterogeneity in the degree to which POD studies correctly identify ACL injuries from public reports. Sports medicine research relying solely on publicly obtained sources should be interpreted with an understanding of their inherent limitations and biases. These studies underreport the true incidence of injuries, with a bias toward capturing injuries in more popular players.

Metacarpal Fractures in the National Football League: Injury Characteristics, Management, and Return to Play

PURPOSE

This study investigated metacarpal fracture occurrences, characteristics, treatments, and return-to-play times for National Football League (NFL) athletes.

METHODS

NFL players who sustained metacarpal fractures during the 2012 to 2018 seasons were reviewed. All players on the 32 NFL team active rosters with metacarpal fractures recorded through the NFL Injury Database were included. Player age, time in the league, player position, injury setting, injury mechanism, fractured ray, management, and return-to-play were recorded.

RESULTS

There were 208 injury occurrences resulting in 1 or more metacarpal fractures, identified in 205 players. Of these, 81 (39%) injuries were operated. Return-to-play data were available for 173 (83%) injured players. The median return-to-play time for all athletes was 15 days (interquartile range, 1-55 days). Of the injured players, 130 (71%) missed time but returned the same season. Within this 130-player subset, 69 (53%) were treated nonsurgically and 61 (47%) operatively with median return-to-play times of 16 days (interquartile range, 6-30 days) and 20 days (interquartile range, 16-42 days) respectively. Eighteen individuals in this 130-player subgroup sustained a thumb metacarpal fracture. The return-to-play time was slower for patients sustaining thumb metacarpal fractures compared to other metacarpal fractures, and was significantly longer (median, 55 days) following nonsurgical treatment of thumb fractures compared with operative intervention (median, 24 days). A regression analysis revealed no trend or difference in return to football with respect to player age, time in the league, injury setting (practice vs game), injury mechanism, articular involvement, multiple concomitant injuries, or player position.

CONCLUSIONS

Most NFL players who sustain metacarpal fractures miss less than 3 weeks and return to play the same season. The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Effectiveness and Use of RT‐PCR Point of Care Testing in a Large‐Scale COVID ‐19 Surveillance System

Background

Rapid COVID‐19 testing platforms can identify infected individuals at the point of care (POC), allowing immediate isolation of infected individuals and reducing the risk of transmission. While lab‐based nucleic acid amplification testing (NAAT) is often considered the gold standard to detect SARS‐CoV‐2 in the community, results typically take 2–7 days to return, rendering POC testing a critical diagnostic tool for infection control. The National Football League (NFL) and NFL Players Association deployed a new POC testing strategy using a newly available reverse transcriptase polymerase chain reaction (RT‐PCR) rapid test during the 2020 season, and evaluated diagnostic effectiveness compared to other available devices using real‐world population surveillance data.

Methods

RT‐PCR POC test results were compared to NAAT results from same‐day samples by calculation of positive and negative concordance. Sensitivity analyses were performed for three subgroups: (1) individuals symptomatic at time of positive test; (2) individuals tested during the pilot phase of rollout; and (3) individuals tested daily.

Results

Among 4989 same‐day POC/NAAT pairs, 4957 (99.4%) were concordant, with 93.1% positive concordance and 99.6% negative concordance. Based on adjudicated case status, the false negative rate was 0.2% and false positive rate was 2.9%. In 43 instances, the immediate turnaround of results by POC allowed isolation of infected individuals 1 day sooner than lab‐based testing. Positive/negative concordance in sensitivity analyses were relatively stable.

Conclusion

RT‐PCR POC testing provided timely results that were highly concordant with lab‐based NAAT in population surveillance. Expanded use of effective RT‐PCR POC can enable rapid isolation of infected individuals and reduce COVID‐19 infection in the community.

Results from a Test-to-Release from Isolation Strategy Among Fully Vaccinated National Football League Players and Staff Members with COVID-19 - United States, December 14-19, 2021

During December 2021, the United States experienced a surge in COVID-19 cases, coinciding with predominance of the SARS-CoV-2 B.1.1.529 (Omicron) variant (1). During this surge, the National Football League (NFL) and NFL Players Association (NFLPA) adjusted their protocols for test-to-release from COVID-19 isolation on December 16, 2021, based on analytic assessments of their 2021 test-to-release data. Fully vaccinated* persons with COVID-19 were permitted to return to work once they were asymptomatic or fever-free and experiencing improving symptoms for ≥24 hours, and after two negative or high cycle-threshold (Ct) results (Ct≥35) from either of two reverse transcription-polymerase chain reaction (RT-PCR) tests^† (2). This report describes data from NFL's SARS-CoV-2 testing program (3) and time to first negative or Ct≥35 result based on serial COVID-19 patient testing during isolation. Among this occupational cohort of 173 fully vaccinated adults with confirmed COVID-19 during December 14-19, 2021, a period of Omicron variant predominance, 46% received negative test results or had a subsequent RT-PCR test result with a Ct≥35 by day 6 postdiagnosis (i.e., concluding 5 days of isolation) and 84% before day 10. The proportion of persons with positive test results decreased with time, with approximately one half receiving positive RT-PCR test results after postdiagnosis day 5. Although this test result does not necessarily mean these persons are infectious (RT-PCR tests might continue to return positive results long after an initial positive result) (4), these findings indicate that persons with COVID-19 should continue taking precautions, including correct and consistent mask use, for a full 10 days after symptom onset or initial positive test result if they are asymptomatic.

Anatomy of an American football game: Player-to-player contact before, during and after an NFL game in context of the 2020 COVID-19 pandemic

OBJECTIVES

To quantify levels of potential exposure to SARS-CoV-2 surrounding a typical professional American football game, with a focus on interactions on-field between teammates and opposing players before, during, and immediately after competition.

METHODS

We examined across-Club consecutive interactions ≥2 minutes within 6 feet [1.8 meters] between athletes on opposing Clubs for all 2020 NFL regular season games (n = 256). Cumulative interaction was measured for a representative subset (n = 119; 46%) of games. Wearable proximity tracking devices (Kinexon) were used to measure distance and duration of interactions; these data were combined with game schedule and Club rosters for analyses. Frequency and per-game mean, median, interquartile range for consecutive interactions ≥2/≥5 minutes and cumulative interactions ≥5/≥15 were described overall and stratified by pre-game, in-game, and post-game.

RESULTS

Of the 1964 distinct player-to-opponent contacts ≥2 minutes in NFL regular season games, the majority (n = 1,699; 87%) were fewer than 5 minutes in consecutive length. Among the mean 7.7 distinct contacts ≥2 minutes with opponents each game (median = 4; IQR = 2, 8), very few were ≥5 consecutive minutes at any point (mean = 1.0; median = 0; IQR = 0, 0). Most (n = 849; 43.2%) distinct contacts were pre-game, 546 (27.8%) were during competition, and 569 (29%) were post-game. In games where cumulative interactions were analyzed, there was an average of 17.1 player/opponent interactions with cumulative exposure ≥5 minutes (median = 12; IQR = 4, 30), almost all of which occurred during competition.

CONCLUSION

There is limited and short contact between and among competing players in professional American football. In the setting of infectious disease such as the COVID-19 pandemic, a robust prevention program integrating masking, distancing, hygiene, and ventilation when off-field can be created to minimize on- and off-field exposures, which effectively reduces transmission risk in outdoors and/or well-ventilated stadium settings.

Epidemiology of Traumatic Posterior Hip Instability in the National Football League

Background:

There is a paucity of literature regarding injury incidence, mechanism, and return to play in National Football League (NFL) players who have sustained traumatic posterior hip instability.

Purpose:

To describe the incidence of traumatic posterior hip instability and the rate of return to play in NFL players across 18 seasons.

Study Design:

Descriptive epidemiology study.

Methods:

We retrospectively assessed all traumatic posterior hip dislocations/subluxations that occurred during football-related activities in the NFL seasons from 2000 through 2017. Player demographics and injury data (injury mechanism, season of injury, treatment, days missed, and return to play time) were collected from all 32 NFL teams prospectively through a leaguewide electronic health record system. Descriptive statistics are presented.

Results:

Across the 18 NFL seasons, 16 posterior hip instability injuries in 14 players were reported, with a maximum incidence of 4 (25%) in 2013. Posterior hip instability was predominantly sustained by offensive players (64.3%), with tight ends being the most affected (31.3%). Half of the injuries occurred during the regular season, 43.8% in the preseason, and 6.2% in the offseason. Of all injuries, 37.5% were noncontact, while 56.3% involved contact (direct or indirect), and 6.2% were of unknown mechanism. Among noncontact injuries, 66.7% occurred during cutting and change of direction while sprinting. The time of return to full participation was documented for 11 of the 16 reported injuries (68.8%); among them, the mean time loss was 136.7 ± 83.8 days—143.3 ± 99.6 days if the player underwent surgery (n = 4) and 116.7 ± 76.2 days missed by players without surgery (n = 6)—the treatment modality was unknown in 1 player.

Conclusion:

Although the incidence of traumatic posterior hip instability during the study period was low, all injured athletes missed time from football activities and competitions. Injuries that required surgery led to more missed time than those that did not. Ongoing research to understand risk factors and mechanisms of this injury, in conjunction with improvements to prevention and rehabilitation protocols, is necessary to ensure the safety of professional American football players.

Epidemiology of Tibial Fractures in Professional American Football Athletes From 2013 to 2019

Background:

Lower extremity injuries occur with high frequency in National Football League (NFL) athletes and cause high burden to players and teams. Tibial fractures are among the most severe lower extremity injuries sustained in athletes and are associated with prolonged time loss from sport.

Purpose:

To determine the number of tibial fractures in NFL athletes from the 2013 to 2019 NFL seasons and describe athlete demographics, fracture characteristics, and details of injury onset.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective review of the NFL injury database was performed to identify all NFL athletes sustaining tibial fractures over the 2013 to 2019 NFL seasons. Athlete characteristics, injury characteristics, days missed, and treatment (operative vs nonoperative) were examined. Descriptive statistics were used to calculate means, standard deviations, ranges, and percentages.

Results:

A total of 64 tibial fractures were identified in 60 athletes, resulting in a median loss of 74 days. Defensive secondary athletes had the highest number of injuries (n = 10; 16%), followed by running backs (n = 9; 14%), while 61% of these injuries occurred during NFL regular-season games, primarily between weeks 13 and 17. The most commonly reported activity during injury was athletes being tackled, with a direct impact to the tibia being the most common mechanism of injury. Lateral tibial plateau fractures were the most frequently reported, while distal tibial fractures resulted in the greatest number of days lost. The median time lost for injuries requiring surgery was 232 days compared with 56 days for injuries treated using conservative management.

Conclusion:

The highest proportion of tibial fractures were injuries to defensive secondary athletes and athletes being tackled while sustaining a direct impact to the leg, primarily to the lateral tibial plateau. Tibial fracture injuries were commonly sustained during NFL regular-season games, primarily during the final 4 weeks of the NFL regular season. Further investigations examining performance and career longevity in athletes sustaining tibial fractures are warranted to help improve the health and safety of NFL athletes.

Factors Associated With the Mechanism of ACL Tears in the National Football League: A Video-Based Analysis

Background

The factors associated with anterior cruciate ligament (ACL) injury mechanism in professional American football players are not well-understood.

Hypothesis

It was hypothesized that football-related and player-specific factors, such as position and body mass index (BMI), are associated with ACL injury mechanism in these athletes.

Study Design

Descriptive epidemiology study.

Methods

Videos of ACL tears occurring in National Football League (NFL) games over 6 consecutive seasons from 2014 to 2019 were reviewed by 2 orthopaedic surgeons who specialize in sports medicine. For each injury, the role of contact (direct contact [contact to the injured knee/lower extremity], indirect contact [contact not involving the injured knee/lower extremity], or no contact) as well as playing situation and lower extremity position were recorded. Additional player characteristics, timing of injury, and surface information were obtained from NFL game-day and injury database statistics.

Results

Of the 140 ACL tears, a minority occurred via direct contact to the injured lower extremity (30%), although this varied by position. Just over two-thirds (70%) of ACL tears in offensive linemen occurred via direct contact to the injured lower extremity, while wide receivers had no direct contact ACL tears. Elevated BMI was associated with a greater likelihood of ACL tears occurring via direct contact (53% in players with BMI ≥35 kg/m² vs 24% in players with BMI <35 kg/m²; P = <.01). Rookies had the lowest percentage of direct contact ACL tears (18%; P = .22). ACL tears that occurred during the middle 8 weeks of the regular season resulted more often from direct contact (38%; P = .06). ACL tears that occurred in the third quarter were the most likely to occur via direct contact (44%), while those that occurred in the fourth quarter were the least likely to occur via direct contact (13%; P < .01).

Conclusion

Although most NFL players sustained ACL tears via a noncontact mechanism (ie, through indirect or no contact), players with an elevated BMI, especially on the offensive line, were more likely to injure their ACL through direct contact. Position-dependent variance in injury mechanism may help guide injury prevention efforts in these athletes.

SARS-CoV-2 Reinfection: A Case Series from a 12-Month Longitudinal Occupational Cohort

Seven cases of COVID-19 SARS-CoV-2 reinfection from the NBA 2020-2021 occupational testing cohort are described including clinical details, antibody test results, genomic sequencing, and longitudinal RT-PCR results. Reinfections were infrequent and varied in clinical presentation, viral dynamics, and immune response.

SARS-CoV-2 Transmission Risk Among National Basketball Association Players, Staff, and Vendors Exposed to Individuals With Positive Test Results After COVID-19 Recovery During the 2020 Regular and Postseason

IMPORTANCE

Clinical data are lacking regarding the risk of viral transmission from individuals who have positive reverse-transcription-polymerase chain reaction (RT-PCR) SARS-CoV-2 test results after recovery from COVID-19.

OBJECTIVE

To describe case characteristics, including viral dynamics and transmission of infection, for individuals who have clinically recovered from SARS-CoV-2 infection but continued to have positive test results following discontinuation of isolation precautions.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data collected from June 11, 2020, to October 19, 2020, as part of the National Basketball Association (NBA) closed campus occupational health program in Orlando, Florida, which required daily RT-PCR testing and ad hoc serological testing for SARS-CoV-2 IgG antibodies. Nearly 4000 NBA players, staff, and vendors participated in the NBA's regular and postseason occupational health program in Orlando. Persistent positive cases were those who recovered from a documented SARS-CoV-2 infection, satisfied US Centers for Disease Control and Prevention criteria for discontinuation of isolation precautions, and had at least 1 postinfection positive RT-PCR test(s) result.

EXPOSURES

Person-days of participation in indoor, unmasked activities that involved direct exposure between persistent positive cases and noninfected individuals.

MAIN OUTCOMES AND MEASURES

Transmission of SARS-CoV-2 following interaction with persistent positive individuals, as measured by the number of new COVID-19 cases in the Orlando campus program.

RESULTS

Among 3648 individuals who participated, 36 (1%) were persistent positive cases, most of whom were younger than 30 years (24 [67%]) and male (34 [94%]). Antibodies were detected in 33 individuals (91.7%); all remained asymptomatic following the index persistent positive RT-PCR result. Cycle threshold values for persistent positive RT-PCR test results were typically above the Roche cobas SARS-CoV-2 limit of detection. Cases were monitored for up to 100 days (mean [SD], 51 [23.9] days), during which there were at least 1480 person-days of direct exposure activities, with no transmission events or secondary infections of SARS-CoV-2 detected (0 new cases).

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study of the 2020 NBA closed campus occupational health program, recovered individuals who continued to test positive for SARS-CoV-2 following discontinuation of isolation were not infectious to others. These findings support time-based US Centers of Disease Control and Prevention recommendations for ending isolation.

Epidemiology of Anterior Cruciate Ligament Tears in the National Football League

BACKGROUND

Anterior cruciate ligament (ACL) tears are common in contact athletics and have a significant effect on the athletic performance and well-being of affected players. The prevalence, timing, and characteristics of ACL tears in National Football League (NFL) athletes are lacking.

PURPOSE

To define the epidemiology of ACL tears among NFL athletes.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

This retrospective study includes all ACL injuries entered into the NFL injury database through the centralized leaguewide electronic health record system for the 2015-2019 seasons.

RESULTS

A total of 314 ACL injuries occurred during the 5-year study period, with a mean of 62 per year. The overall 1-season injury risk of an NFL player sustaining an ACL injury was 1.9% (95% CI, 1.7%-2.1%). Most ACL injuries occurred during games (n = 199), with a higher rate observed in the preseason games as compared with the regular season games (6.1 vs 2.7 per 10,000 player-plays; P < .01). NFL players with ≤3 of experience had a higher preseason injury rate (9.57 ACL tears per 1000 player-seasons) than those with ≥4 years of experience (5.12 ACL tears per 1000 player-seasons; P < .01). NFL athletes playing on special teams had the highest rate of ACL injuries (7.6 per 10,000 player-plays) in comparison with all other player positions.

CONCLUSION

ACL injury incidence was fairly consistent across all years studied and occurred more frequently in players with ≤3 years of NFL experience. Tears were more common during games, special teams play, and the preseason.

Epidemiology of Shoulder Instability in the National Football League

Background

Shoulder instability is a common and potentially debilitating injury among collision sport athletes that can lead to long-term damage of the glenohumeral joint. Limited data exist regarding instability among elite athletes in the National Football League (NFL).

Purpose

To describe the epidemiology of shoulder instability in the NFL from 2012 through 2017.

Study Design

Descriptive epidemiology study.

Methods

The NFL's injury database was reviewed for shoulder instability injuries resulting in missed time during the study inclusion dates. Injuries were classified by type and direction, as well as timing, setting, and mechanism. Median missed time was determined for the different types and directions of instability. Incidence rates for game-related injuries were calculated based on timing during the season and player position. Finally, the relationship between player position and instability direction was assessed.

Results

During the 6-year study period, 355 players sustained 403 missed-time shoulder instability injuries. Most injuries occurred during games (65%) via a contact mechanism (85%). The overall incidence rate of game-related instability was 3.6 injuries per 100,000 player-plays and was highest during the preseason (4.9 per 100,000 player-plays). The defensive secondary position accounted for the most injuries, but quarterbacks had the highest incidence rate in games (5.5 per 100,000 player-plays). Excluding unspecified events (n = 128; 32%), 70% (n = 192) of injuries were subluxations and 30% (n = 83) were dislocations; 75% of dislocations were anterior, while subluxations were more evenly distributed between the anterior and posterior directions (45% vs 52%, respectively). Players missed substantially more time after dislocation compared with subluxation (median, 47 days vs 13 days, respectively). When instability direction was known, the majority of instability events among quarterbacks and offensive linemen were posterior (73% and 53%, respectively), while anterior instability was most common for all other positions.

Conclusion

Shoulder instability is a common injury in the NFL and can result in considerable missed time. Dislocations occur less frequently than subluxations but lead to greater time lost. While most dislocations are anterior, more than half of subluxations are posterior, which is likely the result of repetitive microtrauma to the posterior capsulolabral complex sustained during sport-specific motions such as blocking. The risk of instability varies by player position, and position may also influence instability direction.

Leveraging unstructured data to identify hereditary angioedema patients in electronic medical records

Background

The epidemiologic impact of hereditary angioedema (HAE) is difficult to quantify, due to misclassification in retrospective studies resulting from non-specific diagnostic coding. The aim of this study was to identify cohorts of patients with HAE-1/2 by evaluating structured and unstructured data in a US ambulatory electronic medical record (EMR) database.

Methods

A retrospective feasibility study was performed using the GE Centricity EMR Database (2006–2017). Patients with ≥ 1 diagnosis code for HAE-1/2 (International Classification of Diseases, Ninth Revision, Clinical Modification 277.6 or International Classification of Diseases, Tenth Revision, Clinical Modification D84.1) and/or ≥ 1 physician note regarding HAE-1/2 and ≥ 6 months’ data before and after the earliest code or note (index date) were included. Two mutually exclusive cohorts were created: probable HAE (≥ 2 codes or ≥ 2 notes on separate days) and suspected HAE (only 1 code or note). The impact of manually reviewing physician notes on cohort formation was assessed, and demographic and clinical characteristics of the 2 final cohorts were described.

Results

Initially, 1691 patients were identified: 190 and 1501 in the probable and suspected HAE cohorts, respectively. After physician note review, the confirmed HAE cohort comprised 254 patients and the suspected HAE cohort decreased to 1299 patients; 138 patients were determined not to have HAE and were excluded. The overall false-positive rate for the initial algorithms was 8.2%. Across final cohorts, the median age was 50 years and > 60% of patients were female. HAE-specific prescriptions were identified for 31% and 2% of the confirmed and suspected HAE cohorts, respectively.

Conclusions

Unstructured EMR data can provide valuable information for identifying patients with HAE-1/2. Further research is needed to develop algorithms for more representative HAE cohorts in retrospective studies.

Epidemiology of Concussion in the National Football League, 2015-2019

BACKGROUND

Concussion in American football, and specifically the National Football League (NFL) is a major area of interest and key focus for injury prevention. Complete and accurate characterization of when, how, and to whom these injuries occur can facilitate injury reduction efforts. Existing studies of concussion in the NFL use publicly available data, potentially limiting data quality and the inferences that can be made.

HYPOTHESIS

Concussion incidence in the NFL decreased across the 2015-2019 seasons.

STUDY DESIGN

Descriptive epidemiology study.

LEVEL OF EVIDENCE

Level 4.

METHODS

Concussion incidence, including counts, one-season risk, and rates per game and player-plays, among active NFL players from 2015 to 2019 is described by year, season, play type, and roster position.

RESULTS

A total 1302 concussions were identified from 2015 to 2019 among 1004 players. Of these, 80% occurred in NFL games. The average annual incidence of in-season game concussions changed over the study period, from 230.7 per season (2015-2017) to 177.0 per season (2018-2019); this represented a 23% decrease in game settings (P < 0.01). Practice concussions fluctuated across the years of the study from 38 to 67 per season (average = 50.8/season). There were 70.6 concussions per 100 preseason games, which was slightly higher than the regular season rate per game of 61.7. Overall, there were 790 regular season game concussions across 4,657,243 player-plays and 114,428 player-games during the 5-year study. In regular season games, the majority of concussions were sustained on running and passing plays (n = 119/season), and the highest average rate per play occurred on kickoffs (0.69/100 plays). Defensive secondary (cornerbacks, safeties, and generic defensive backs) and offensive line incurred the most concussions, and the highest rates of concussion were among tight ends and wide receivers.

CONCLUSION AND RELEVANCE

Concussions in the NFL are a key focus for player safety. Concussion reduction strategies were implemented before 2018, after which there was a sustained 2-year decrease in concussion incidence, providing a new benchmark from which to work toward further injury reduction.

Real-World Evidence: A Review of Real-World Data Sources Used in Orthopaedic Research

SUMMARY

Real-world data (RWD) play an increasingly important role in orthopaedics as demonstrated by the rapidly growing number of publications using registry, administrative, and other databases. Each type of RWD source has its strengths and weaknesses, as does each specific database. Linkages between real-world data sets provide even greater utility and value for research than single data sources. The unique qualities of an RWD data source and all data linkages should be considered before use. Close attention to data quality and use of appropriate analysis methods can help alleviate concerns about validity of orthopaedic studies using RWD. This article describes the main types of RWD used in orthopaedics and provides brief descriptions and a sample listing of publications from selected, key data sources.

Randomized Clinical Trial or Real-World Evidence: How Historical Events, Public Demand, and the Resulting Laws and Regulations Shaped the Body of Medical Evidence

SUMMARY

The signing of the 21st Centuries Cures Act in 2016 was a confirmational step in a long journey toward an understood use and need for real-world evidence (RWE), even though the Food and Drug Administration (FDA) had the legislative authority to accept RWE since 1962 to demonstrate efficacy. The 21st Century Cures Act, as well as the subsequent FDA guidance published in 2017 and other supporting guidance, documents that since are opening the doors for the clinical and research community. They specifically allow for labeling changes and indication expansion based on RWE. The legislative discussion of efficacy requirements started in the late 1950s, when evidence of effectiveness was not required in the United States before the marketing of a drug or medical device, and calls for the real-world comparative effectiveness research were being made by Senator Estes Kefauver. When the thalidomide tragedy stuck, Congress and the Kennedy Administration rushed to pass a new law to require that drugs be "effective in use." The regulations subsequently drafted by the FDA to enforce the law often required placebo-controlled, randomized clinical trials (RCTs). In the 1980s, some started to label the RCT as the gold standard for medical evidence. The use of real-world data for new indication approval was not specifically prohibited by the 1962 law, but the new 2016 law sent a clear mandate to FDA, requiring the agency to review new forms of evidence such as RWE.

Breaking Barriers: Studying Fracture Healing in the BONES Program

SUMMARY

The Bioventus Observational Noninterventional EXOGEN Studies (BONES) Program includes 3 concurrent studies designed to estimate the incidence of fracture nonunions in patients treated with the EXOGEN Ultrasound Bone Healing System compared with those receiving standard fracture care. This article outlines the design and methodology within the fifth metatarsal fracture study; similar approaches are taken in the second and third BONES Program studies, which examine nonunions of the tibia and scaphoid. The BONES Program is an external comparator design and incorporates several unique, fit-for-purpose components to strengthen the approach and allow it to be submitted to the US Food and Drug Administration (FDA) to be considered for a label expansion. BONES consisted of 2 cohorts: (1) EXOGEN-treated patients recruited into a patient registry and (2) comparator patients from a large administrative health claims database. The study used International Classification of Diseases, Tenth Revision, nonunion diagnosis codes reported by the treating clinician for the primary outcome measure. Many data sources (medical and billing records, patient-reported health data, usage data from the device itself, and commercial product complaint system) were used on the registry side, alongside insurance claims data to source the external comparator cohort, to achieve broader understanding of factors predisposing patients to the development of nonunions. In step with the FDA's increasing acceptance of real-world evidence for use in regulatory decision making and coupled with the infeasibility of a randomized clinical trial in this setting, the innovative study design of the BONES Program allowed for both an evaluation of the effect of EXOGEN in mitigating nonunions in a real-world setting and an assessment of the patient experience with EXOGEN treatment.

Real-World Evidence: A Primer

SUMMARY

The insights that real-world data (RWD) can provide, beyond what can be learned within the traditional clinical trial setting, have gained enormous traction in recent years. RWD, which are increasingly available and accessible, can further our understanding of disease, disease progression, and safety and effectiveness of treatments with the speed and accuracy required by the health care environment and patients today. Over the decades since RWD were first recognized, innovation has evolved to take real-world research beyond finding ways to identify, store, and analyze large volumes of data. The research community has developed strong methods to address challenges of using RWD and as a result has increased the acceptance of RWD in research, practice, and policy. Historic concerns about RWD relate to data quality, privacy, and transparency; however, new tools, methods, and approaches mitigate these challenges and expand the utility of RWD to new applications. Specific guidelines for RWD use have been developed and published by numerous groups, including regulatory authorities. These and other efforts have shown that the more RWD are used and understood and the more the tools for handling it are refined, the more useful it will be.

Leveraging Real-World Evidence: A Paradigm Shift in Regulation

SUMMARY

The study methodology and regulatory frameworks for real-world data collection is quickly evolving, opening new avenues to use valid and robust real-world evidence (RWE) to support regulatory decision making. Although the Food and Drug Administration has historically accepted specific applications of RWE to support regulatory determinations, significant progress has been made in recent years to examine conditions in which this information can be used to support specific types of premarket decisions. Of note, hybrid study designs that incorporate aspects of randomized clinical trials, including randomization and pragmatic outcomes, are expected to be a driving factor to accelerate the adoption of RWE in regulatory contexts. Generation of RWE to better understand effectiveness and safety of orthopaedic- and trauma-related devices requires careful planning, but it is achievable as demonstrated by the Bioventus Observational Non-Interventional EXOGEN Studies (BONES) clinical development program. This article examines the role of RWE in regulatory decision making and reviews key concepts in RWE study design methodology to facilitate creation of valid scientific evidence in support of marketing authorizations.

Sports Performance and Injury Research: Methodologic Limitations and Recommendations for Future Improvements

Evidence-based research has resulted in incredible advances in sports medicine and is an important component of minimizing injury risk. Such research is similarly important when applied to care delivery to athletes after injury. For research into injury reduction and treatment outcomes to be most impactful, however, the methods must be of sufficient rigor to generate high-quality evidence. Two recent trends in sports injury research have led to specific concerns about evidence quality: 1) use of athletic performance metrics as an injury or treatment outcome and 2) use of publicly available data for injury or treatment research.

Oral contraceptive use and anterior cruciate ligament injury: comparison of active comparator new user cohort and case-control study designs

BACKGROUND

This study further investigates a protective association between oral contraceptive (OC) use and anterior cruciate ligament (ACL) injury noted in prior case-control studies.

METHODS

Active comparator new user cohort analysis of women aged 13-45 years in the United States from the IBM MarketScan Commercial Claims and Encounters database who newly-initiated low-dose OCs (exposed) or underwent intrauterine device (IUD) insertion (comparison group) from 2000 to 2014. Women were followed for ACL injury starting 90 days after OC initiation or IUD insertion until OC or IUD discontinuation or end of continuous enrollment. Adjusted hazard ratios (adjHR) and 95% confidence intervals (CI) were estimated controlling for age. Secondary analysis replicated previously-published case-control studies assessing "ever" versus "never" OC use over 1- and 5-year periods among women who underwent ACL reconstruction compared to age-matched controls.

RESULTS

In the cohort analysis, 2,370,286 women initiated OCs and 621,798 underwent IUD insertion. There were 3571 (0.15%) ACL injuries during an average 370.6 days of continuous OC use and 1620 (0.26%) during an average 590.5 days of IUD use. No difference in risk of ACL injury was observed between OC initiators and IUD users (adjHR = 0.95; 95%CI 0.89, 1.01). The case-control analysis replicated the slight protective association observed in prior studies over a 5-year period (OR = 0.90; 95%CI 0.85, 0.94).

CONCLUSIONS

This cohort study suggests no association between OC use and ACL injury, while the case-control study suggested bias from uncontrolled confounding and selection factors may have influenced previous findings that suggested a protective association between OC use and ACL injury.

Comparison of Laboratory and On-Field Performance of American Football Helmets

The relationship between laboratory and on-field performance of football helmets was assessed for 31 football helmet models selected from those worn by players in the 2015-2019 National Football League (NFL) seasons. Linear impactor tests were conducted with helmets placed on an instrumented Hybrid III head and neck assembly mounted on a sliding table. Based on impacts to each helmet at six impact locations and three velocities, a helmet performance score (HPS) was calculated using a linear combination of the head injury criterion (HIC) and the diffuse axonal multi-axis general evaluation (DAMAGE). To determine the on-field performance of helmets, helmet model usage, player participation, and incident concussion data were collected from the five NFL seasons and used to calculate helmet model-specific concussion rates. Comparison of laboratory HPS to the helmet model-specific concussion rates on a per play basis showed a positive correlation (r² = 0.61, p < 0.001) between laboratory and on-field performance of helmet models, indicating that helmets which exhibited reduced impact severity in the laboratory tests were also generally associated with lower concussion rates on-field. Further analysis showed that NFL-prohibited helmet models exhibited a significantly higher odds of concussion (OR 1.24; 95% CI 1.04-1.47; p = 0.017) relative to other helmet models.

Incidence of Lower Extremity Injury in the National Football League: 2015 to 2018

BACKGROUND

Lower extremity injuries are the most common injuries in professional sports and carry a high burden to players and teams in the National Football League (NFL). Injury prevention strategies can be refined by a foundational understanding of the occurrence and effect of these injuries on NFL players.

PURPOSE

To determine the incidence of specific lower extremity injuries sustained by NFL players across 4 NFL seasons.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

This retrospective, observational study included all time-loss lower extremity injuries that occurred during football-related activities during the 2015 through 2018 seasons. Injury data were collected prospectively through a leaguewide electronic health record (EHR) system and linked with NFL game statistics and player participation to calculate injury incidence per season and per 10,000 player-plays for lower extremity injuries overall and for specific injuries. Days lost due to injury were estimated through 2018 for injuries occurring in the 2015 to 2017 seasons.

RESULTS

An average of 2006 time-loss lower extremity injuries were reported each season over this 4-year study, representing a 1-season risk of 41% for an NFL player. Incidence was stable from 2015 to 2018, with an estimated total missed time burden each NFL season of approximately 56,700 player-days lost. Most (58.7%) of these injuries occurred during games, with an overall higher rate of injuries observed in preseason compared with regular season (11.5 vs 9.4 injuries per 10,000 player-plays in games). The knee was the most commonly injured lower extremity region (29.3% of lower body injuries), followed by the ankle (22.4%), thigh (17.2%), and foot (9.1%). Hamstring strains were the most common lower extremity injury, followed by lateral ankle sprains, adductor strains, high ankle sprains, and medial collateral ligament tears.

CONCLUSION

Lower extremity injuries affect a high number of NFL players, and the incidence did not decrease over the 4 seasons studied. Prevention and rehabilitation protocols for these injuries should continue to be prioritized.

Pectoralis Major Injuries in the National Football League

BACKGROUND

Pectoralis major (PM) injuries are rare, primarily occurring in males during athletic activity. In the current literature, these injuries have not been well described in National Football League (NFL) athletes.

HYPOTHESIS

The incidence of PM injuries will be low in NFL athletes, with athletes missing significantly more time after injuries requiring operative management.

STUDY DESIGN

Cohort study.

LEVEL OF EVIDENCE

Level 4.

METHODS

All documented PM injuries were retrospectively analyzed using the NFL Injury Surveillance System over a 15-season period. The data were analyzed by season, session, position, activity, and contact type at the time of injury. Additionally, the incidence, treatment, and days missed as a result of injury were assessed.

RESULTS

Over 15 consecutive seasons, there were a total of 211 PM injuries. Of these injuries, 132 were classified as strains and 79 as ruptures. The incidence of strains was 0.41 per 10,000 athlete-exposures, compared with 0.25 per 10,0000 athlete-exposures for ruptures (P < 0.01). Players with PM ruptures treated operatively missed significantly more days than players treated nonoperatively (146.7 ± 55.0 vs 77.2 ± 72.9; P < 0.01).

CONCLUSION

NFL athletes miss significantly more time after operative compared with nonoperative management of PM ruptures.

CLINICAL RELEVANCE

PM injuries are rare, with the current literature lacking description of these injuries in NFL athletes. The paucity of data limits physicians from providing adequate counseling and expectations for athletes with this injury. This research represents the largest study assessing PM injuries in NFL athletes.

Lessons on Data Collection and Curation From the NFL Injury Surveillance Program

BACKGROUND

"Research-ready" evidence platforms that link sports data with anonymized electronic health records (EHRs) or other data are important tools for evaluating injury occurrence in response to changes in games, training, rules, and other factors. While there is agreement that high-quality data are essential, there is little evidence to guide data curation.

HYPOTHESIS

We hypothesized that an EHR used in the course of clinical care and curated for research readiness can provide a robust evidence platform. Our purpose was to describe the data curation used for active injury surveillance by the National Football League (NFL).

STUDY DESIGN

Dynamic cohort study.

LEVEL OF EVIDENCE

Level 2.

METHODS

Players provide informed consent for research activities through the collective bargaining process. A league-wide EHR is used to record injuries that come to the attention of the teams' athletic trainers and physicians, NFL medical spotters, or unaffiliated neurotrauma consultants. Information about football activities and injuries are linkable by player, setting, and event to other sports-related data, including game statistics and game-day stadium quality measures, using a unique player identification designed to protect player privacy. Ongoing data curation is used to review data completeness and accuracy and is adjusted over time in response to findings.

RESULTS

The core data curation activities include monthly injury summaries to team staff, queries to resolve incomplete reporting, and periodic external checks. Experiences derived from producing more than 100 reports per year on diverse topics are used to update coding training and related guidance documents in response to missing data or inconsistent coding that is observed. Roughly 20% more injuries were recorded for the same "reportable" injuries after switching from targeted reporting to an EHR.

CONCLUSION

Research-ready databases need systematic curation for quality and completeness, along with related action plans. More injuries were reported through EHR than through targeted reporting.

CLINICAL RELEVANCE

Evidence-driven decision-making thrives on reliable data fine-tuned through systematic use, review, and ongoing adjustments to the curation process.

The Establishment and Refinement of the National Basketball Association Player Injury and Illness Database

The National Basketball Association (NBA; also referred to as "the league") has established a centralized, audited electronic medical record system that has been linked with external sources to provide a platform for robust research and to allow the NBA to conduct player health and safety reviews. The system is customized and maintained by the NBA and individual teams as part of the employment records for each player and is deployed uniformly across all 30 teams in the league, thereby allowing for standardized data on injuries, illnesses, and player participation in NBA games and practices. The electronic medical record data are enriched by linkage with other league external data sources that provide additional information about injuries, players, game and practice participation, and movement. These data linkages allow for the assessment of potential injury trends, development of injury-prevention programs, and rule changes, with the ultimate goal of improving player health and wellness. The purpose of this article is to describe this NBA injury database, including the details of data collection, data linkages with external data sources, and activities related to reporter training and data quality improvement.

Higher Rates of Lower Extremity Injury on Synthetic Turf Compared With Natural Turf Among National Football League Athletes: Epidemiologic Confirmation of a Biomechanical Hypothesis

BACKGROUND

Biomechanical studies have shown that synthetic turf surfaces do not release cleats as readily as natural turf, and it has been hypothesized that concomitant increased loading on the foot contributes to the incidence of lower body injuries. This study evaluates this hypothesis from an epidemiologic perspective, examining whether the lower extremity injury rate in National Football League (NFL) games is greater on contemporary synthetic turfs as compared with natural surfaces.

HYPOTHESIS

Incidence of lower body injury is higher on synthetic turf than on natural turf among elite NFL athletes playing on modern-generation surfaces.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Lower extremity injuries reported during 2012-2016 regular season games were included, with all 32 NFL teams reporting injuries under mandated, consistent data collection guidelines. Poisson models were used to construct crude and adjusted incidence rate ratios (IRRs) to estimate the influence of surface type on lower body injury groupings (all lower extremity, knee, ankle/foot) for any injury reported as causing a player to miss football participation as well as injuries resulting in ≥8 days missed. A secondary analysis was performed on noncontact/surface contact injuries.

RESULTS

Play on synthetic turf resulted in a 16% increase in lower extremity injuries per play than that on natural turf (IRR, 1.16; 95% CI, 1.10-1.23). This association between synthetic turf and injury remained when injuries were restricted to those that resulted in ≥8 days missed, as well as when categorizations were narrowed to focus on distal injuries anatomically closer to the playing surface (knee, ankle/foot). The higher rate of injury on synthetic turf was notably stronger when injuries were restricted to noncontact/surface contact injuries (IRRs, 1.20-2.03; all statistically significant).

CONCLUSION

These results support the biomechanical mechanism hypothesized and add confidence to the conclusion that synthetic turf surfaces have a causal impact on lower extremity injury.

Trends in Incidence of ACL Reconstruction and Concomitant Procedures Among Commercially Insured Individuals in the United States, 2002-2014

Background:

Few population-based descriptive studies on the incidence of anterior cruciate ligament (ACL) reconstruction and concomitant pathology exist.

Hypothesis:

Incidence of ACL reconstruction has increased from 2002 to 2014.

Study Design:

Descriptive clinical epidemiology study.

Level of Evidence:

Level 3.

Methods:

The Truven Health Analytics MarketScan Commercial Claims and Encounters database, which contains insurance enrollment and health care utilization data for approximately 158 million privately insured individuals younger than 65 years, was used to obtain records of ACL reconstructions performed between 2002 and 2014 and any concomitant pathology using Current Procedures Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) codes. The denominator population was defined as the total number of person-years (PYs) for all individuals in the database. Annual rates were computed overall and stratified by age, sex, and concomitant procedure.

Results:

There were 283,810 ACL reconstructions and 385,384,623 PYs from 2002 to 2014. The overall rate of ACL reconstruction increased 22%, from 61.4 per 100,000 PYs in 2002 to 74.6 per 100,000 PYs in 2014. Rates of isolated ACL reconstruction were relatively stable over the study period. However, among children and adolescents, rates of both isolated ACL reconstruction and ACL reconstruction with concomitant meniscal surgery increased substantially. Adolescents aged 13 to 17 years had the highest absolute rates of ACL reconstruction, and their rates increased dramatically over the 13-year study period (isolated, +37%; ACL + meniscal repair, +107%; ACL + meniscectomy, +63%). Rates of isolated ACL reconstruction were similar for males and females (26.1 vs 25.6 per 100,000 PYs, respectively, in 2014), but males had higher rates of ACL reconstruction with concomitant meniscal surgery than females.

Conclusion:

Incidence rates of isolated ACL reconstruction and rates of concomitant meniscal surgery have increased, particularly among children and adolescents.

Clinical Relevance:

A renewed focus on adoption of injury prevention programs is needed to mitigate these trends. In addition, more research is needed on long-term patient outcomes and postoperative health care utilization after ACL reconstruction, with a focus on understanding the sex-based disparity in concomitant meniscal surgery.

Synthetic Turf: History, Design, Maintenance, and Athlete Safety

CONTEXT:

Synthetic turf has become an increasingly common playing surface for athletics and has changed dramatically since its introduction more than 50 years ago. Along with changes to surface design, maintenance needs and recommendations have become more standardized and attentive both to upkeep and player-level factors. In particular, synthetic turf maintenance as it relates to athlete health and safety is an important consideration at all levels of play.

EVIDENCE ACQUISITION:

A literature search of MEDLINE and PubMed for publications between the years 1990 and 2018 was conducted. Keywords included s ynthetic turf, artificial turf, field turf, and playing surface. Additionally, expert opinion through systematic interviews and practical implementation were obtained on synthetic turf design and maintenance practices in the National Football League.

STUDY DESIGN:

Clinical review.

LEVEL OF EVIDENCE:

Level 5.

RESULTS:

Synthetic turf has changed considerably since its inception. Playing surface is a critical component of the athletic environment, playing a role both in performance and in athlete safety. There are several important structural considerations of third-generation synthetic turf systems currently used in the United States that rely heavily on strong and consistent maintenance. A common misconception is that synthetic turf is maintenance free; in fact, however, these surfaces require routine maintenance. Whether athletes experience more injuries on synthetic over natural surfaces is also of interest among various levels and types of sport.

CONCLUSION:

Modern synthetic turf is far different than when originally introduced. It requires routine maintenance, even at the level of local athletics. It is important for sports medicine personnel to be familiar with playing surface issues as they are often treating athletes at the time of injury and should maintain a level of awareness of contemporary research and practices regarding the relationships between synthetic turf and injury.

Trends in Antibiotic Use by Birth Season and Birth Year

OBJECTIVES

We examined 2 birth cohort effects on antibiotic prescribing during the first year of life (henceforth, infancy) in Denmark: (1) the birth season effect on timing and overall occurrence of antibiotic prescribing, and (2) the birth year effect amid emerging nationwide pneumococcal vaccination programs and changing prescribing guidelines.

METHODS

We linked data for all live births in Denmark from 2004 to 2012 (N = 561 729) across the National Health Service Prescription Database, Medical Birth Registry, and Civil Registration System. Across birth season and birth year cohorts, we estimated 1-year risk, rate, and burden of redeemed antibiotic prescriptions during infancy. We used interrupted time series methods to assess prescribing trends across birth year cohorts. Graphical displays of all birth cohort effect data are included.

RESULTS

The 1-year risk of having at least 1 redeemed antibiotic prescription during infancy was 39.5% (99% confidence interval [CI]: 39.3% to 39.6%). The hazard of a first prescription increased with age throughout infancy and varied by season; subsequently, Kaplan-Meier-derived risk functions varied by birth season cohort. After rollout of a first vaccination program and new antibiotic prescribing guidelines, 1-year risk decreased by 4.4% over 14 months (99% CI: 3.4% to 5.5%); it decreased again after rollout of a second vaccination program by 6.9% over 3 years (99% CI: 4.4% to 9.3%).

CONCLUSIONS

In Denmark, birth season and birth year cohort effects influenced timing and risk of antibiotic prescribing during infancy. Future studies of antibiotic stewardship, effectiveness, and safety in children should consider these cohort effects, which may render some children inherently more susceptible than others to downstream antibiotic effects.

Incidence of Anterior Cruciate Ligament Reconstruction Among Adolescent Females in the United States, 2002 Through 2014

This study explores sex disparities among 13- to 17-year-olds who undergo anterior cruciate ligament reconstruction.

Superior Labrum Anterior-Posterior Tears in the National Football League

BACKGROUND

Shoulder disorders are common in football players, with up to 50% of National Football League (NFL) recruits reporting a history of shoulder injuries. Superior labrum anterior-posterior (SLAP) tears are an entity with well-described detrimental effects on return to play in overhead-throwing athletes but with minimal data in contact athletes.

PURPOSE

To identify the incidence, predisposing factors, and effect of SLAP tears in NFL athletes and prospects as well as the treatment patterns of NFL team physicians.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

This study was a comprehensive analysis of SLAP tears in elite football players using a dual approach: (1) SLAP injuries recorded in the NFL Injury Surveillance System from 2000 to 2014 were evaluated by player position, type of play, days/games lost, and surgical intervention; (2) NFL Scouting Combine athletes from 2003 to 2011 with prior SLAP repair were evaluated for draft success, and drafted athletes were compared with matched controls for career length and performance scores.

RESULTS

SLAP tears represented a small portion (3.1%) of shoulder injuries in NFL athletes from 2000 to 2014, occurring most commonly in offensive linemen (28%). Surgically treated SLAP tears (42%) resulted in more days missed than did nonoperatively managed tears (140.2 vs 21.5 days; P < .001) and more games missed (8.4 vs 2.6 games; P = .003). SLAP repairs were also rare in NFL Combine athletes (n = 25 of 2965 athletes), with most having been performed in offensive linemen (32%). As compared with control NFL Combine athletes without SLAP tears, those drafted into the NFL with prior SLAP repair played significantly fewer games (33.7 vs 48.3; P = .049) and had fewer game starts (19.6 vs 35.4; P = .036).

CONCLUSION

In this comprehensive analysis of SLAP tears in elite football players, it is clear that these injuries have the potential to cause significant detriment to an athlete's career.

Propensity score estimation to address calendar time-specific channeling in comparative effectiveness research of second generation antipsychotics

Background

Channeling occurs when a medication and its potential comparators are selectively prescribed based on differences in underlying patient characteristics. Drug safety advisories can provide new information regarding the relative safety or effectiveness of a drug product which might increase selective prescribing. In particular, when reported adverse effects vary among drugs within a therapeutic class, clinicians may channel patients toward or away from a drug based on the patient's underlying risk for an adverse outcome. If channeling is not identified and appropriately managed it might lead to confounding in observational comparative effectiveness studies.

Objective

To demonstrate channeling among new users of second generation antipsychotics following a Food and Drug Administration safety advisory and to evaluate the impact of channeling on cardiovascular risk estimates over time.

Data Source

Florida Medicaid data from 2001–2006.

Study Design

Retrospective cohort of adults initiating second generation antipsychotics. We used propensity scores to match olanzapine initiators with other second generation antipsychotic initiators. To evaluate channeling away from olanzapine following an FDA safety advisory, we estimated calendar time-specific propensity scores. We compare the performance of these calendar time-specific propensity scores with conventionally-estimated propensity scores on estimates of cardiovascular risk.

Principal Findings

Increased channeling away from olanzapine was evident for some, but not all, cardiovascular risk factors and corresponded with the timing of the FDA advisory. Covariate balance was optimized within period and across all periods when using the calendar time-specific propensity score. Hazard ratio estimates for cardiovascular outcomes did not differ across models (Conventional PS: 0.97, 95%CI: 0.81–3.18 versus calendar time-specific PS: 0.93, 95%CI: 0.77–3.04).

Conclusions

Changes in channeling over time was evident for several covariates but had limited impact on cardiovascular risk estimates, possibly due to unmeasured confounding. Although calendar time-specific propensity scores appear to improve covariate balance, the impact on comparative effectiveness results is limited in this setting.

Racial disparities in receipt and comparative effectiveness of oxaliplatin for stage III colon cancer in older adults

BACKGROUND

African Americans in the United States have higher rates of colon cancer mortality than other races. This study examines the use of oxaliplatin, a novel chemotherapeutic agent approved in 2004, among African American and Caucasian American patients with stage III colon cancer to determine whether differential receipt or differential effectiveness of the drug may explain the racial disparity in colon cancer mortality.

METHODS

The authors conducted a population-based retrospective cohort study of stage III colon cancer patients aged 65 years and older treated from 2004 through 2006 who initiated chemotherapy within 90 days of surgical resection (N = 1162) using Surveillance, Epidemiology and End Results-Medicare data. Patients receiving oxaliplatin (n = 477) were compared with those receiving 5-fluorouracil without oxaliplatin (n = 685). The authors estimated prevalence ratios and hazard ratios (HRs) using multivariate binomial regression and Cox models to evaluate racial differences in oxaliplatin receipt and survival.

RESULTS

African Americans were as likely as Caucasian Americans to receive oxaliplatin (40.5 vs 41.1%; prevalence ratio, 0.90; 95% confidence interval [CI], 0.71-1.13). Oxaliplatin was associated with lower mortality compared with 5-fluorouracil (HR, 0.76; 95% CI, 0.58-1.00). This benefit appeared stronger among African Americans (HR, 0.31; 95% CI, 0.09-1.05) than Caucasian Americans (HR, 0.80; 95% CI, 0.60-1.06).

CONCLUSIONS

In Medicare-insured patients receiving chemotherapy, the authors observed no meaningful racial disparities in receipt of oxaliplatin and, among those receiving it, potentially better survival among African Americans. Differential receipt and effectiveness of oxaliplatin-containing regimens does not appear to contribute to the previously documented racial disparities in colon cancer survival. Understanding reasons for potentially enhanced effectiveness among African Americans may inform efforts to resolve racial disparities in colon cancer outcomes.