 Up next is Dr. Doug Wieb, who's a professor of epidemiology, it's like having to do that to church service where you have to read from the book of Ecclesiastes. But a professor of epidemiology in the School of Medicine at the University of Pennsylvania, also the director of the Penn Injury Science Center, one of nine injury research centers funded by the CDC. And growing up in Canada, his primary sport was volleyball. He was a member. I think he's proud about this. He was as he should be. He was a member of the University of Calgary Dinosaurs team, Go Dinos, that won the national championship in 1989. So Dr. Wieb, please bring some dino magic to your presentation. Thanks to Lauren Peerpoint and to the organizers for the chance to be here. I'm here representing the Ivy League Big Ten Epidemiology of Concussion Study, and that study is operated by the TBI Collaboration. The TBI Collaboration is hosted by the Big Ten Academic Alliance, and that was created in 2012, and participating institutions are all of those in the two conferences, Ivy League and Big Ten. And the goal is to increase collaborative research on sport-related concussion and to collect data that can inform practice. The epidemiology study was initiated in 2011. Data collection began in 2013. Schools in the Big Ten started to join in 2014, and in 2017 the Data Coordinating Center was moved from the Ivy League office to our offices at the University of Pennsylvania and the Pen Injury Science Center. Participating sites in this study at present are the eight schools in the Ivy League and 12 of the campuses in the Big Ten. And high-level overview of this study. It's a prospective, obviously multi-site observational study. It's a surveillance system and a prospective cohort study. It was started using informed consent of student athletes across all participating sites, and participation is estimated at over 90% of athletes who sustain a sport-related concussion. The data that are collected include demographics, circumstances of the injury and mechanism of injury, and information on the impact of the concussion, and return to academics and to athletics. Also, athletic exposure information is collected to enable calculation of rates. The study is in its eighth year of operation. We have an asterisk on the current year for ending early, and at present, total number of cases in the database is 3,006. You can see the, of course, the majority are sport-related concussions, but the database also includes non-sport-related concussions that are captured across all sites. And 27 sports are represented in this study. It was just last year that we published the first report, high-level overview of findings from the study, and detailed information on the history of the study, and on the methods that are used. That study reported on concussion rates by competition and practice and overall for sports. It reported high-level information on the symptom, the prevalence of symptoms. Symptoms are collected using the SCAT, and we reported on time to a number of outcomes. Here is time to symptom resolution for four different sports, time to return to academics and to exertion and to competition by sex. These are crude Kaplan-Meier curves, and there is much more to be studied with these data. From an epidemiologic standpoint, and also from a policy standpoint, another report that we put out in the last two years was conducting an evaluation of the experimental kickoff rule that was introduced in the Ivy League in 2016. We did that rule using a difference in differences analysis, comparing changes in rates of concussion during kickoff returns in competition to changes in rates in sport-related concussion during all other types of plays. We found that there was a large excess reduction in sport-related concussion rates during kickoffs over this time period that we attributed to that experimental kickoff rule. That was a nice start and a very good example of how this study, because data are being collected across conferences and over a considerable period of time, are in a position to really inform policy decisions and practice decisions, and try to find ways to make participation in varsity athletics. Now there are many opportunities for learning about risks for concussion and risks for prolonged recovery following concussion, and also for the prevention of concussion. And analyses are planned for a number of these items, and in the long run much more can be explored and data collection is continuing. Sex differences is something that will be exploring important issue of club sports compared to varsity sports, and perhaps different risks of concussion or different types of management for sport-related concussion, because typically the lack of athletic trainers assigned to sports, club sports across campuses, exploring different helmet types and risk of concussion, exploring the tackling robot, for example, that was introduced at Dartmouth, and more. Zooming in on a couple of them, one example of work that can be done next is looking at mechanism of concussion, and here we've taken a first pass at looking at that in four different sports. Basketball, lacrosse, soccer, and water polo, where we have both women's and men's teams. And quick snapshot of findings here from a descriptive perspective are that in basketball there were differences in mechanism of injury by gender. We also saw that in the cross, for example, where the most common mechanism was contact from a ball or from a person, but more men sustained sport-related concussion from a person or person during a ground ball compared to women, and more women had contact with a sticker ball compared to men. For soccer there were also sex differences in the mechanism of injury, but we didn't see sex differences in water polo, perhaps because being immersed in the water largely leveled the playing field. So opportunities to look even closer to think about how the games are played and whether there are opportunities to make these sports safer and identify what is it specifically, what's happening on the field when concussions are sustained in these sports in women and men. Abby Bretzen is a postdoctoral fellow with us and a certified athletic trainer who completed her PhD at Michigan State. And this is a poster that she presented in February this year at Big Sky. And she was exploring the non-sport-related concussion data. In the top right you can see that there were 415 non-sport-related concussion cases captured in the database so far. Mechanisms of injury included moped and scooter from a fight, some were alcohol involved, some were car crashes, some were falls, and in considerable time out of sport resulted due to these non-sport-related concussions. So more to be explored and for example we can look across campuses and see if any of these mechanisms are disproportionately happening on different campuses maybe due to different ways campuses or laws are enacted there and chances or opportunities for prevention. At Rutgers they have introduced use of the guardian cap in practices in football and what catches our eye is that a handful of scarlet knights have been assigned the guardian caps to see if those might reduce the risk of concussion in practice. This is such a tightly knit group of campuses that are participating. I think that we're actually in a position to do even more and rather than look retrospectively and treat some of some changes in practice like this as a natural experiment. We could even consider introducing countermeasures like this with randomized designs and if there is an interest in having all athletes receive an intervention and not have it held back from any of them even using for example a step wedge design over time to introduce a countermeasure in a systematic way and have a really robust test of whether that might reduce the risk of concussion. So there's potential for this kind of countermeasure to be evaluated with rigorous methods beyond observational studies. So many people to thank for the collection of data and the creativity that goes into ways to to make that happen and have the data be valid. In particular I want to thank Bernadette DeLonzo who is the lead research coordinator on this study sitting there in the front row on my left. She will be starting the PhD program in epidemiology at Penn this fall and also thank you to Abby Bretzen back row on the left who's with us and who's been working very very closely with me and Bernadette for the past eight months. And thank you to the athletic trainers and team physicians and researchers across the collaboration who continue to collect these data and put so much hard work and creativity into it and we look forward to further participation and research collectively as a group to keep on trying to find ways to make participation and athletics safer. Thanks again for the chance to be here.