Preventing Exertional Heat Stroke in Football: Time for a Paradigm Shift.

CONTEXT: Among American sports, football has the highest incidence of exertional heat stroke (EHS), despite decades of prevention strategies. Based on recent reports, 100% of high school and college EHS football fatalities occur during conditioning sessions. Linemen are the at-risk population, constituting 97% of football EHS deaths. Linemen heat up faster and cool down slower than other players. EVIDENCE ACQUISITION: Case series were identified from organized, supervised football at the youth, high school, and collegiate levels and compiled in the National Registry of Catastrophic Sports Injuries. Sources for event occurrence were media reports and newspaper clippings, autopsy reports, certificates of death, school-sponsored investigations, and published medical literature. Articles were identified through PubMed with search terms "football," "exertional heat stroke," and "prevention." STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: Football EHS is tied to (1) high-intensity drills and conditioning that is not specific to individual player positions, (2) physical exertion as punishment; (3) failure to modify physical activity for high heat and humidity, (4) failure to recognize early signs and symptoms of EHS, and (5) death when cooling is delayed. CONCLUSION: To prevent football EHS, (1) all training and conditioning should be position specific; (2) physical activity should be modified per the heat load; (3) understand that some players have a "do-or-die" mentality that supersedes their personal safety; (4) never use physical exertion as punishment; (5) eliminate conditioning tests, serial sprints, and any reckless drills that are inappropriate for linemen; and (6) consider air-conditioned venues for linemen during hot practices. To prevent EHS, train linemen based on game demands. STRENGTH-OF-RECOMMENDATION TAXONOMY: n/a.

Evidence-based medicine applied to sentinel lymph node biopsy in patients with breast cancer.

Sentinel lymph node biopsy (SLNB) has not been examined using the principles of evidence-based medicine (EBM). Specifically, likelihood ratios have not been used to assess the validity of SLNB. The Surveillance, Epidemiology, and End Results (SEER) public database of the National Cancer Institute was used to establish the baseline or pretest probability of finding a positive lymph axillary node for each stage of breast cancer. Rates of false negative results of SLNB for all breast cancer stages were determined from the surgical literature. Positive and negative likelihood ratios (LR) were calculated. For each stage of breast cancer, the Bayesian nomogram was used to find the post-test probability of missing a metastatic axillary node when the SLN was negative. The SEER database of 213,292 female patients with breast cancer yielded the following rates of positivity of axillary lymph nodes for each breast tumor size: T1a, 7.8 per cent; T1b, 13.3 per cent; T1c, 28.5 per cent; T2, 50.2 per cent; T3, 70.1 per cent. The combined data from 13 published studies of SLNB (6444 successful SLNBs) demonstrated a false negative rate of 8.5 per cent. The LR of a negative test is 0.086. According to the nomogram, the chances of missing a positive node for stage of cancer are as follows: T1a, 0.7 per cent; T1b, 1.5 per cent; T1c, 3.0 per cent; T2, 7 per cent; T3, 18 per cent. The risk of missing a positive axillary node can accurately be estimated for each stage of breast cancer using the LR, which is much more useful than the simple false negative rate. Surgeons should use this information when deciding whether to perform SLNB and in their informed consent discussions.

Exertional compartment syndrome in an equestrian does inadequate staffing compromise healthcare?

When evaluating lower-leg pain, the clinician must consider compartment syndrome resulting from exercise, even in the absence of trauma or if the exercise is seemingly benign. Equestrian sports would seem an unlikely source of acute compartment syndrome, but the examiner should consider unusual mechanisms of injury in any case. Although intracompartment tissue pressure measurements can help make the diagnosis, excessive pain is a more reliable early warning sign of acute compartment syndrome. A timely diagnosis and immediate surgical treatment may prevent serious long-term sequelae.

Requirement for hourly Glasgow Coma Scores in the emergency department: process or outcome based?

BACKGROUND: The lack of hourly Glasgow Coma Score (GCS) documentation in trauma patients while in the emergency department (ED) is frequently cited by American College of Surgeons (ACS) Trauma Center Verification Review Committee site visitors. The basis for this requirement is unclear. We suspected that hourly recording of GCS has no impact on patient outcome. METHODS: The trauma registry of a 300-bed ACS-verified, state-designated Level II trauma center was reviewed retrospectively for head trauma patients over 16 years of age. Demographic data, field and ED GCS, presence or absence of hourly GCS in the ED, objective injury scores, complications, discharge status, and hospital length of stay were determined. RESULTS: A total of 463 patients were identified. Hourly GCS was recorded in the ED in 244 (53%) patients. No significant difference was found in the Trauma and Injury Severity Score or the Abbreviated Injury Score of the head between those who had hourly GCS recorded and those who did not. Patients who had hourly GCS recorded were significantly younger, 42.3 +/- 19.7 years vs 53.9 +/- 24.9 years for those who did not have hourly GCS recorded (P < 0.001). Seventy percent (126/179) of patients involved in a motorcycle or motor vehicle crash had hourly GCS recorded while only 39% (69/175) of patients admitted for falls had hourly GCS (P < 0.001). There were no differences in mortality or complication rates between the groups. CONCLUSION: The recording of hourly GCS on head injured patients is reflective of the initial presentation of the patient and not an objective evaluation of the patient. The presence or absence of hourly GCS in the ED was not associated with any increase in complications or mortality. The ACS should reevaluate the requirement for hourly recording of GCS in trauma patients.

The Leapfrog Initiative: a potential threat to surgical education.

PURPOSE: The Leapfrog Initiative was established in January 2000 by the Business Roundtable (BRT) in response to the Institute of Medicine report on quality and safety of medical care. The BRT is composed of chief executive officers of U.S. corporations representing more than 28 million employees. Leapfrog has proposed 3 hospital safety measures-computerized physician order entry, intensive care unit physician staffing standards and evidence-based hospital referral, which states that hospitals must meet certain volume/year criteria. Three of these criteria are pertinent to general surgery. They are abdominal aortic aneurysm (AAA) repair greater than or equal to 30/year, carotid endarterectomy (CE) greater than or equal to 100/year, and esophageal cancer surgery (ECS) greater than or equal to 7/year. Hospitals failing to meet these requirements would not be eligible to treat patients employed by BRT corporations. METHODS: Data were obtained from the Residency Review Committee (RRC) for Surgery Resident Statistics Summary for 1999 to 2001. Comparisons were made between the numbers of the Leapfrog index cases required and the actual number of cases performed by each graduating chief resident. Data from the Connecticut Hospital Association (CHA) for fiscal year 2000 were also analyzed. Outcomes for procedures at The Stamford Hospital were reviewed. RESULTS: Data obtained from the RRC reveal that the mode numbers for each of the 3 evidence-based standards for each graduating chief resident in 2000 and 2001 are 5 and 3 for AAA, 15 and 17 for CE, and 0 in both years for ECS. Extrapolation using the mode for each procedure reveals that hospitals with 5 or 6 graduating chief residents may be ineligible to treat patients for AAA and CE. Hospitals with less than or equal to 5 chief residents would be excluded from performing CE. Very few institutions are performing adequate numbers of ECS. Only 4 of 31 CT hospitals would be allowed to perform AAA, and only 3 of 31 could perform CE. Only 1 Connecticut hospital performed more than 7 ECS cases in FY 2000. It is apparent that Leapfrog standards will have serious economic impact on many hospitals, as well as displacing patients to other cities for care. CONCLUSIONS: Surgical chairs and program directors should be aware of the Leapfrog standards and assess their own programs and institutions for compliance. Performance improvement and outcomes data for all evidence-based standards should be reviewed.