Asymptomatic sonographic abnormalities of the hindfoot region in Division I collegiate gymnasts.

BACKGROUND: The hindfoot region is commonly injured in gymnasts, and musculoskeletal ultrasound can be used to identify structural abnormalities in this region. Although prior studies have shown that sonographic abnormalities may not correlate with symptomatic pathology, the presence of asymptomatic sonographic abnormalities of the hindfoot in Division I collegiate gymnasts has not been evaluated. OBJECTIVE: To identify and describe commonly seen asymptomatic sonographic abnormalities of the hindfoot region in Division I collegiate gymnasts. DESIGN: Cross-sectional study. SETTING: Tertiary care academic medical center. PARTICIPANTS: 39 Division I NCAA men's and women's collegiate gymnasts without current hindfoot pain or history of hindfoot injury. INTERVENTIONS: Diagnostic musculoskeletal ultrasound of the hindfoot region. MAIN OUTCOME MEASURES: Sonographic appearance of the hindfoot region, specifically the plantar fascia, plantar fad pad, and Achilles tendon. RESULTS: A total of 37 of 39 gymnasts included in the study were found to have at least one asymptomatic sonographic abnormality of the hindfoot region. A total of 28.2% of athletes were found to have sonographic abnormalities within the Achilles tendon, with Doppler flow being the most common finding, and 35.8% of athletes were found to have a Haglund's deformity. However, only 7% of athletes with a Haglund's deformity demonstrated abnormal sonographic findings within the tendon. Sonographic abnormalities of the plantar fascia and plantar fat pad were seen in 30.7% and 69.2% of athletes, respectively. CONCLUSIONS: Asymptomatic sonographic abnormalities of the hindfoot region are common in collegiate gymnasts. Clinicians should use clinical judgment when interpreting these findings as they may not represent symptomatic pathology.

Chest and Thorax Injuries in Athletes.

Injuries to the chest and thorax are rare, but when they occur, they can be life-threatening. It is important to have a high index of suspicion to be able to make these diagnoses when evaluating a patient with a chest injury. Often, sideline management is limited and immediate transport to a hospital is indicated.

The Impact of Alcohol Sales in A College Football Stadium on Healthcare Utilization.

INTRODUCTION: In 2021, a large Midwestern university began selling alcohol to spectators within the football stadium for the first time. The stadium routinely hosts >65,000 spectators, and drinking alcohol is highly prevalent at pre-game tailgating events. Our goal in this study was to determine the impact of in-stadium alcohol sales on the incidence of alcohol-related emergency department (ED) visits and local emergency medical services (EMS) calls. We hypothesized that the availability of alcohol throughout the stadium would lead to an increase in alcohol-related patient presentations. METHODS: This was a retrospective study including patients who used local EMS and presented to the ED on football Saturdays in the 2019 and 2021 seasons. There were 11 Saturday games with seven home games each year. The 2020 season was excluded due to the impact of COVID-19- related restrictions on attendance. Trained extractors using predefined criteria reviewed records for each patient to determine whether the visit was alcohol related. Using logistic regression analysis we examined the odds of an EMS call and ED visit being alcohol-related before and after the start of stadium alcohol sales. We compared characteristics of visits before and after the onset of stadium alcohol sales using Student's t-test for continuous variables and chi-square test for categorical variables. RESULTS: In 2021, after the onset of in-stadium alcohol sales, there were a total of 505 emergency calls to local EMS on football Saturdays (home and away), and 29% of them were for alcohol-related incidents down from 36% of 456 calls in 2019. After adjustment for covariates, the odds of a call being alcohol-related were lower in 2021 than 2019, but this difference was not significant (adjusted odds ratio [aOR] 0.83, 95% CI 0.48-1.42). Looking specifically at the seven home games each season, the difference was more pronounced (31% of calls in 2021 compared to 40% in 2019) but not statistically significant after adjustment for covariates (aOR 0.54, 95% CI 0.15-2.03). In the ED, 1,414 patients were evaluated on game days in 2021 and 8% of them for alcohol-related reasons. This is similar to 2019, when 9% of the 1,538 patients presented due to alcohol-related complaints. After adjustment for covariates, the odds of an ED visit being alcohol-related were similar in 2021 and 2019 (aOR 0.98, 95% CI 0.70-1.38). CONCLUSION: There was a decrease in alcohol-related EMS calls on home game days in 2021, although the result was not statistically significant. In-stadium alcohol sales had no significant impact on the frequency or proportion of alcohol-related ED visits. The reason for this outcome is unclear, but it is possible that fans drank less at tailgate parties knowing they could consume more once the game started. Long lines and a two-beverage limit at stadium concessions may have kept patrons from consuming excessively. The results of this study may inform similar institutions regarding the safe implementation of alcohol sales during mass-gathering events.

Training and Practice Settings of Physicians Dual-Certified in Emergency and Sports Medicine.

ABSTRACT: Survey study of training and practice paradigms and job satisfaction of dual-boarded emergency medicine (EM) and sports medicine (SM) physicians. The REDCap survey was sent to 193 American Board of EM members who hold a Certificate of Added Qualification in SM. A total of 124 EM/SM physicians responded (67.5% male). More than 70% completed three-year residencies while only 28.5% had an EM/SM residency faculty. One-quarter delayed fellowship after residency 6.45 years on average. Regarding their first job after fellowship, 27.6% practiced only EM, 54.5% practiced both EM and SM, and 12.2% practiced only SM. Regarding their current job, 29.1% practice only EM. 47.3% practice both EM and SM, and 20.9% practice only SM. Only 13.9% and 9.9% indicated they are unhappy with their first job and current job, respectively. There is significant variability in practice settings for EM/SM physicians with the overwhelming majority being happy with their career choices.

A Case Series and Literature Review: Isolated Traumatic First Rib Fracture in Athletes.

OBJECTIVE: To present a case series of 14 isolated traumatic first rib fractures sustained in sport and review the literature on clinical presentation, mechanism of injury, diagnosis, and management of sport-related traumatic first rib fractures. DESIGN: We compiled a series of isolated traumatic first rib fractures seen in 2 Division 1-associated sports medicine clinics. We also performed a literature search for additional publications of isolated traumatic first rib fractures in sport. SETTING: Patients in our case series were all evaluated and treated at 2 tertiary care center sports medicine clinics. PATIENTS: Patients were those who sustained isolated traumatic first rib fracture during sport. INTERVENTIONS: None. MAIN OUTCOME MEASURES: None. RESULTS: None. CONCLUSIONS: Traumatic fracture of the first rib in sport is certainly not a common diagnosis, but it is likely more widespread than sports medicine providers realize. Considering the diagnosis of first rib fracture for athletes with shoulder pain after trauma is essential for identifying this injury. Although more study is likely needed to make definitive recommendations on treatment and return to play protocols, the case series and literature review presented suggests that rehabilitation and return to play when the patient is asymptomatic may be appropriate care.

Concurrent Proximal Fractures Are Rare in Distal Forearm Fractures: A National Cross-sectional Study.

INTRODUCTION: Distal forearm fractures (DFF) account for 1.5% of emergency department (ED) visits in the United States. Clinicians frequently obtain imaging above/below the location of injury to rule out additional injuries. We sought to determine the incidence of associated proximal fractures (APF) in the setting of DFF and to evaluate the imaging practices in a nationally representative sample of EDs. METHODS: We queried the 2013 National Emergency Department Sample using International Classification of Diseases, 9th edition, diagnostic codes for DFF and APF. Current Procedural Technology codes identified associated imaging studies. We calculated national estimates using a weighted analysis of patient and hospital-level characteristics associated with APF and imaging practices. An analysis of costs estimated the financial impact of additional imaging in patients with DFF using Medicare reimbursement to approximate costs according to the 2018 Medicare Physician Fee Schedule. RESULTS: In 2013, an estimated 297,755 ED visits (weighted) were associated with a DFF, of which 1.6% (4836 cases) had an APF. The incidence of APF was lower among females (odds ratio [OR] (0.76); 95% confidence interval [CI], 0.64-0.91) but higher in metropolitan teaching hospitals compared to metropolitan non-teaching hospitals (OR [2.39]; 95% CI, 1.43-3.99) and Level 1 trauma centers (OR [3.9]; 95%, 1.91-7.96) compared to non-trauma centers. Approximately 40% (n = 117,948) of those with only DFF received non-wrist radiographs and 19% (n = 55,236) underwent non-wrist/non-forearm imaging. Factors independently associated with additional imaging included gender, payer, patient and hospital rurality, hospital region, teaching status, ownership, and trauma center level. Nearly $3.6 million (2018 U.S. dollars) was spent on the aforementioned additional imaging. CONCLUSION: Despite the frequency of proximal imaging in patients with DFF, the incidence of APF was low. Further study to identify risk factors for APF based on mechanism and physical examination factors may result in reduced imaging and decreased avoidable healthcare spending.

Emergency Medicine Residency Selection Criteria: An Update and Comparison.

OBJECTIVE: The primary objective was to describe emergency medicine (EM) residency selection criteria. METHODS: A survey was sent to the Council of Emergency Medicine Residency Directors listserv. Respondents were asked to rank order the various components of the application on a Likert scale from 1 (minimally important) to 10 (highly important). The mean ranking and standard deviation for each of the components were calculated. The survey sought to determine characteristics associated with offering an applicant an invitation to interview and subsequent ranking. Percentages with defined minimum requirements were calculated. Comparisons across residency length and location were completed with a Pearson chi-square test for categorical variables and Student's t-test for continuous variables. RESULTS: A total of 120 surveys were completed. The highest ranked components included away/visiting institution departmental standardized letter of evaluation (SLOE) (mean ± SD = 8.80 ± 1.25), residency interview (mean ± SD = 8.74 ± 1.28), home institution departmental SLOE (mean ± SD = 8.61 ± 1.18), away/visiting institution EM rotation grade (mean ± SD = 8.29 ± 1.43), and home institution EM rotation grade (mean ± SD = 8.07 ± 1.42). The most consistently ranked items included home institution departmental SLOE (SD = 1.18), away/visiting institution departmental SLOE (1.25), and residency interview (1.28). Characteristics associated with offering an interview to an applicant included only 10% of responses indicating a United States Medical Licensing Examination Step 1 score of 220 was needed. At least one SLOE was required in 80% of responses. Program location was related to the number of SLOEs required (p = 0.03). Length of residency and program location differed significantly in how a residency ranked components when considering an applicant (p < 0.05). CONCLUSION: Emergency medicine programs put high value in departmental SLOEs, the interview, and EM rotation grades when selecting potential residents. Higher value is placed on SLOEs and grades from away/visiting institutions compared with students' home institutions.

A case report: Glycopyrrolate for treatment of exercise-induced hyperhidrosis.

OBJECTIVE: Hyperhidrosis can cause dehydration and exercise intolerance. There are several case reports of extremely high sweat rates in athletes. We present as case report of a 17-year-old male with the highest sweat rate recorded in the literature (5.8 L/h). Our goal was to determine if glycopyrrolate, an anticholinergic medication with primarily anti-muscarinic effects that is known to decrease sweat production, would reduce the sweat rate of our subject in a controlled exercise setting. METHODS: Our patient and a control subject were subjected to an exercise protocol consisting of running on a treadmill (5.4-6.7 mile/h at 1° of incline) in a warm climate-controlled chamber after receiving 0, 2, or 4 mg of glycopyrrolate. Core temperature, heart rate, rater of perceived exertion, and sweat rate were monitored in both subjects. RESULTS: Glycopyrrolate dose was not significantly correlated with decreased sweat rate and maximal core temperature. However, the clinical effect of reducing the sweat rate was very strong. The improvement of the subject's sweat rate allowed him to successfully return to sport. CONCLUSION: Our findings suggest that low-dose glycopyrrolate may be a safe and effective method of controlling exertional hyperhidrosis.