Pujalte, George

Background: The cumulative effect of repetitive subconcussive head impacts on neurocognitive function during youth contact sports remains largely unknown. There is a paucity of literature evaluating cumulative helmet forces over a season and their correlation with preseason and postseason cognitive performance tasks such as the King-Devick test (KDT). Hypothesis: Higher helmet forces recorded throughout a 10-week, 10-game youth football season would correlate with slower performance on postseason KDT. Study Design: Prospective cohort study. Level of Evidence: Level 3. Methods: A cohort of 58 youth football players (ages 9-13 years) underwent pre- and postseason KDT. Players wore SpeedFlex helmets (Riddell) fitted with InSite Impact Response System helmet accelerometers (Riddell) which recorded impacts of ≥15 g . Head impacts were tallied over a season and assigned a score of 1, 2, or 3 based on magnitude of g forces. Suspected concussions were correlated with KDT times and recorded instances of head impact. Pre- and postseason KDT scores were compared. Results: During the season, 2013 head impacts were recorded. Median (range) total cumulative force score was 24 (5-476); 6 players sustained head impacts concerning for concussion, and 4 were clinically diagnosed with concussions. Overall, postseason KDT times improved compared with preseason, with a median (range) change of −4.8 seconds (−7.6, −1.1). Analysis showed no correlation between changes in KDT time and total cumulative force score over the season. Conclusion: KDT times in youth football players did not change significantly based on head impact exposure over a single youth football season; most players’ KDT times improved from preseason to postseason. Clinical Relevance: Although our study did not show significant cognitive impact as measured by KDT over a single youth football season, the long-term effects of concussion on the immature brain and how it can impact cognitive development remains largely unknown and should be an area of ongoing study.

AbstractPrimary care physicians (PCPs) are commonly approached with concerns involving patient genetics. This is a challenge because most PCPs lack expertise in genetic testing compared to their genetic counselor counterparts. Currently, the recommended best practice is to refer patients for genetic testing based on cancer‐related family history questionnaires with a genetic counseling referral to discuss their results and any implications. However, the extent to which PCPs are using these questionnaires for this purpose remains poorly understood. In this cross‐sectional study, PCPs were presented with the American Cancer Society's seven recommended family history questions to determine the percentage who consider each to be an indicator for referral to a genetics specialist. Questionnaires were completed by 88 of 260 attending PCPs at a national primary care review conference. The main outcome was the percentage of PCPs who identified each question as a trigger for genetic testing. Secondary outcomes included correlations with years of practice, genetics training, and methods used to obtain patient family history. Only two of the seven questions were considered triggers by most PCPs (range, 76–83%). The remaining five had lower percentages (range, 22–55%). Years of practice did not influence the number of triggers identified (Spearman correlation coefficient test: r = 0.05, p = 0.68). Few PCPs (3.4%) felt they had good to excellent genetics training during residency. Only 44.3% had genetics specialists available for referral. Overall, low percentages of PCPs consider the American Cancer Society questions to be triggers for genetic testing referrals. Furthermore, many do not have a genetics specialist or counselor available for referral. Addressing these concerns may help PCPs understand the basics of genetic testing and use standardized questionnaires to make appropriate referrals to genetic specialists, thereby reducing inappropriate referrals and improving appointment access to this precious resource for those who truly need it.

AbstractSonography and specific shoulder positions allow for injections into both the long head of the biceps tendon sheath (LHBTS) and the subacromial space (SS) with one needlestick. We validated this technique using cadavers. An experienced proceduralist injected latex solution into 12 unembalmed cadaveric shoulders, aiming for the LHBTS and SS, using an ultrasound‐guided injection technique that employs a single‐needle entry point. An experienced surgeon dissected each specimen and graded latex location as: (1) completely accurate (in both the SS and LHBTS); (2) partially accurate (in either the SS or LHBTS); (3) accurate with overflow (in both locations, but also elsewhere); (4) partially accurate with overflow (in either location, but also somewhere else); or (5) completely inaccurate (no latex in either location). All 12 ultrasound‐guided injections using the technique accurately placed latex into both LHBTS and SS (100% accuracy). Latex was also found in adjacent regions after two (17%) injections: one within the shoulder joint and one within the deltoid musculature. This newly described technique allows highly accurate access to the LHBTS and SS with single‐needle entry. This technique could become a favored alternative to subjecting patients to two needlesticks and preparing separate injections to address often concomitant pathologies.

There is a movement in the United States to transform family medicine practices from single physician–based patient care to team-based care. These teams are usually composed of multiple disciplines, including social workers, pharmacists, registered nurses, physician assistants, nurse practitioners, and physicians. The teams support patients and their families, provide holistic care to patients of all ages, and allow their members to work to the highest level of their training in an integrated fashion. Grouping care team members together within visual and auditory distance of each other is likely to enhance communication and teamwork, resulting in more efficient care for patients. This grouping is termed colocation. The authors describe how the use of colocation can lead to clearer, faster communication between care team members. This practice style has the potential to be expanded into various clinical settings in any given health system and to almost all clinical specialties and practices.

Teaching primary care providers how to perform musculoskeletal procedures has become increasingly important as more and more patients with orthopedic conditions present in primary care clinics. This study aims to evaluate whether targeted simulation model training in residency can increase residents’ comfort level in performing intra-articular knee injections and decrease the pain of the procedure, as reported by patients injected. Residents were randomized into intervention and control groups. The comfort level of the residents as well as the pain levels from the procedures, as reported by patients, was recorded. The mean comfort level for the intervention group was 1.2, compared with that in the control group, which was 2.13; P value was .047. The mean pain level in the intervention group was 1.8, whereas in the control group was 3.63; P value was .156. Simulation training may boost residents’ comfort level, but not necessarily decrease patient discomfort during intra-articular knee injections.

An adolescent, right hand-dominant, baseball pitcher presented to sports medicine clinic with posterolateral right elbow pain over 4 months. He rated his pain as 8/10 with pitching, especially at the late cocking phase of throwing. Prior to consult, he had rested 3 months from pitching, progressing to strengthening exercises, with no pain relief. On physical examination, he had 120° of active external rotation, 80° of active internal rotation, mild tenderness to palpation over the capitellum and normal elbow radiography. Magnetic resonance arthrogram of the right elbow revealed subtle, posterolateral joint capsular tear and adjacent synovial hypertrophy. The patient was diagnosed with elbow synovial fold syndrome that was causing impingement at the radiocapitellar joint and was referred to an orthopaedic surgeon. Arthroscopy revealed redundant tissue; scar formation at the radiocapitellar joint was debrided. The patient participated in physical therapy for 2 months and was able to start throwing 3 months later.

Objectives: Uncover literature pertaining to: (1) attention deficit hyperactivity disorder (ADHD) and how it impacts athletes; (2) ADHD medication effects; (3) regulations regarding ADHD medications; (4) approaches to conditions similar to, and occurring with, ADHD; and (5) use of stimulants. Data Sources: MEDLINE, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Ovid interface. Main Results: ADHD can have many effects on athletes and sports participation. Exercise has positive benefits on ADHD behaviors and players' attitudes. Athletes with ADHD can have worsened ADHD symptoms after concussions. Attention deficit hyperactivity disorder is a modifier of return to play; baseline ADHD symptoms should be used to guide management. Management should include medications, behavioral/psychosocial therapy, and academic accommodations. Behavioral therapy combined with medication is superior to behavioral treatment alone. Sustained exercise as ADHD treatment should be considered mainstay in management. Sports can increase thermogenic effects of stimulants, heat injury, and cardiac arrhythmias. Increased aggressiveness, improved pain tolerance, and decreased sense of fatigue are some attributes of stimulants that are presumed to impart some advantage to athletes, but evidence is uncertain. Attention deficit hyperactivity disorder medications may lead to myocardial infarctions, cerebrovascular accidents, paranoid psychoses, seizures, insomnia, tremors, anxiety, hypertension, and death. Conclusions: Athletes' performance and quality of life can be negatively affected by ADHD. Risks exist for those who take ADHD medications. More research is needed on the implications ADHD may have in specific sports, and on possible advantages of medication use. Potential deleterious effects of these medications should be addressed.