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ObjectiveWe present evidence that a neurovisual oriented training program is associated with decreased concussion incidence and faster return to play (RTP) post injury in this observational cohort study.BackgroundSports concussion has been in the public eye and has been associated with heightened fear concerning playing football and other collision based sports. Protecting from concussion and rehabilitating the brain after a concussion is a high priority for many sports medical practitioners as well as for athletes wanting to play. For these reasons researchers associated with the American Athletic Conference (AAC) have been monitoring concussion incidence in football.Design/MethodsThe 12 schools of the AAC were surveyed for 2014, 2015, and 2016 concerning football induced concussions.ResultsThe average seasonal concussion rate was 10.4 ± 1.02 concussions per year and average RTP time was 13.2 ± 1.21 days. In the one team where there was an aggressive neuro visual conditioning and rehabilitation post-concussion program employed the concussion rate was 3.0 ± 1.0 concussions per year and the RTP time was 6.5 ± 0.5 days. Both numbers are significantly lower than in the other AAC teams.ConclusionsThe current paper reports that there may be mitigation strategies that can be employed to decrease concussion incidence as well as aid in faster RTP times. Such attempts to make football safer are needed as brain injury has been associated with long term consequences. Improving safety and brain health through mitigation strategies along with rehabilitation methods may aid in keeping athletes safer during play and throughout the lifespan.

Dr. Kuller makes an excellent point in response to our article.1 Though it is plausible to hypothesize that our finding of sex differences in stroke incidence over time is driven by stroke in older women, after looking at data in age-stratified groups, we found that the sex differences in stroke incidence over time were driven by the middle age groups (ages 45–74), not the oldest age groups. These findings do not change the overall message in the article1—that the rate of stroke is going down more in men than women. We plan to publish data on sex differences in stroke incidence through 2015 and will include age-stratified analyses.

Patients with stroke may have cognitive deficits that impact their capacity to provide informed consent for research. Some institutional review boards restrict surrogate consent to persons who have specific legal authority to provide it. We examined the importance of surrogate consent in the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Trial, the study that led to the only US Food and Drug Administration-approved treatment for acute ischemic stroke.The NINDS rt-PA Stroke Trial randomized subjects with ischemic stroke to treatment with recombinant tissue plasminogen activator (rt-PA) or placebo. We compared the baseline characteristics and clinical outcomes of subjects enrolled by self-consent with those of subjects enrolled by surrogate consent.Surrogate consent was used to enroll 439 of 624 (70%) subjects. Subjects enrolled by surrogate consent were older (68.5 vs 63.4 years, p0.001), had more severe strokes (median NIH Stroke Scale score 17 vs 9, p0.001), and were less likely to make a good recovery (p0.001 for all measures) than patients who provided their own consent. There was no interaction between method of consent and response to rt-PA. If the trial had used the same sample size and recruited at the same rate but excluded patients who could not provide their own consent, it would have taken 12.5 years to complete.The National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator (rt-PA) Stroke Trial would not have been completed in a timely fashion without subjects enrolled by surrogate consent. Furthermore, exclusion of subjects who could not provide their own consent would have severely limited the generalizability and value of trial results.

Objective: Smoking and family history of aneurysmal subarachnoid hemorrhage (aSAH) are independent risk factors for aSAH. Using a population-based case-control study of hemorrhagic stroke, we hypothesized that having both a first-degree relative with a brain aneurysm or SAH (+FH) and current smoking interact to increase the risk of aSAH. Methods: Cases of aneurysmal SAH were prospectively recruited from all 17 hospitals in the five-county region around the University of Cincinnati. Controls were identified by random digit dialing. Controls were matched to cases of aSAH by age (±5 years), race, and sex. Conditional multiple logistic regression was used to identify independent risk factors. For deviation from the additive model, the interaction constant ratio test was used. Results: A total of 339 cases of aSAH were matched to 1,016 controls. Compared to current nonsmokers with no first-degree relatives with aSAH (−FH), the odds ratio (OR) for aSAH for current nonsmokers with +FH was 2.5 (95% confidence interval [CI] 0.9–6.9); for current smokers with −FH, OR = 3.1 (95% CI 2.2–4.4); and for current smokers with +FH, OR = 6.4 (95% CI 3.1–13. 2). The interaction constant ratio, which measured the deviation from the additive model, was significant: 2.19 (95% CI 0.80–5.99). The lower bound of the 95% CI >0.5 signifies a departure from the additive model. Conclusion: Evidence of a gene–environment interaction with smoking exists for aneurysmal subarachnoid hemorrhage. This finding is important to counseling family members and for screening of intracranial aneurysm (IA) as well as the design and interpretation of genetic epidemiology of IA studies.