101-120 of 350 results by Brian Corwell
Study Question: A recent study investigated whether a history of concussion caused greater disturbances in cerebral blood flow and cerebral white matter after subsequent concussions.
Background: Researchers used changes in blood flow in the cingulate cortex and white matter microstructure in the corpus callosum as evidence of underlying brain injury.
Population: 228 athletes with an average age of 20. Divided into 2 groups, recent and non-recent concussion.
61 athletes had a recent (uncomplicated) concussion and 167 did not. Within the first group, 36 had a history of concussion. Within the second group, 73 had a history of concussion.
Note: researchers used “self-reported” history of concussion in study.
Intervention: Researchers took up to 5 MRI scans of each recently concussed athlete. This encompassed the acute phase of injury (1 to 7 days post-injury), the subacute phase (8 to 14 days), medical clearance to return to sport, one month post return and one year post return.
The sport concussion assessment tool (SCAT) was also used to evaluate effects of history of concussion on symptoms, cognition and balance.
Results: One year after a recent concussion, those athletes with a history of concussion had sharper declines in blood flow within one area of the cingulate cortex compared to those without a history of prior concussions.
Athletes with a history of concussion had an average cerebral blood flow of 40 mL per minute, per 100 grams of brain tissue.
Athletes without a history of concussion had an average cerebral blood flow of 53 mL per minute, per 100g of brain tissue.
In the weeks following concussion, those athletes with a prior history of concussion had microstructural changes in the corpus callosum.
Effects were seen in the absence of differences in SCAT domains or time to return to sport.
Conclusion: Athletes with a history of concussion experience identifiable injury to their brains as evidenced by changes in blow flow and white matter microstructure. Athletes “cleared” for return to play following concussion may be at greater risk of subtle patterns of brain injury versus their peers.
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Chronic Exertional Compartment Syndrome (CECS)
Similar pathology to acute compartment syndrome except symptoms are related to activity (frequently running) and abate with rest.
95% involve lower extremity
Inappropriately elevated tissue pressure in one or more lower leg compartments associated with exercise
Anterior compartment most frequently involved
As tissue pressure increases, local perfusion is decreased. This leads to symptoms of pain, pressure, cramping and paresthesias.
Also commonly associated with team sports such as soccer, lacrosse and field hockey.
More likely in competitive athletes than recreational.
Patient will be symptom free at time of ED evaluation
Make diagnosis of CECS with history
- Pain must be induced with exercise
- Usually limited to a single compartment, frequently the anterior
- Pain occurs at predictable time in exercise and forces athlete to stop running
- Pain resolves with rest
- If witnessed, tenderness is present only in the involved compartment and not elsewhere
Diagnosis with compartment pressure measurements done in office with treadmill exercise.
Non operatively, gait retraining programs have been shown to help symptoms. Appropriate if symptoms are mild.
Surgical treatment involves a minimally invasive fasciotomy
Post surgery success rates are between 63-100% with recurrence rates up to 20%
Low dose ketamine was compared to morphine for the treatment of patients with long bone fractures
126 patients with upper and lower extremity long bone fractures were divided into two treatment groups
- IV morphine at a dose of 0.1 mg/kg
- IV ketamine at a dose of 0.5mg/kg
Pain scores were compared pre and at 10 minutes post treatment
Pain severity significantly decreased in both groups to a similar degree
Increase adverse effects (emergence phenomenon) noted in ketamine group but all effects resolved spontaneously without intervention.
Conclusion: Analgesic effect of ketamine is similar to morphine in patients with long bone fractures.
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NSAIDs for lower back pain (LBP)
NSAIDs are recommended for first line treatment of lower back pain.
Ibuprofen (600mg), ketorolac (10mg) and diclofenac (50mg) were compared.
3 arm, double-blinded study in an ED population with musculoskeletal LBP.
66 patients in each arm.
Outcomes via telephone interview 5 days later
Primary outcome was improvement in Roland-Morris Disability Questionnaire (RMDQ).
Lower scores indicate better LBP functional outcomes.
Secondary outcomes: Pain intensity and the presence of stomach irritation.
Baseline characteristics similar in 3 groups.
Results: No significant differences between 3 arms in primary outcome.
Ibuprofen 9.4, ketorolac 11.9, and diclofenac 10.9 (p = 0.34).
Ketorolac group reported less overall pain intensity at day 5.
Ketorolac group reported less stomach irritation that the other drugs ((p < 0.01).
While there was no differences in terms of functional outcomes, there may be a benefit of using ketorolac in terms of overall pain intensity and stomach irritation. This would benefit from further study in a larger population in order to draw definitive conclusions.
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You are covering a sporting event or working an ED shift when a young adolescent athlete without significant PMH presents with SOB and wheezing associated with exercise.
You immediately think exercise-induced asthma, prescribe a short-acting bronchodilator and pat yourself on the back.
While you may be right, there is increasing recognition of an alternative diagnosis
Exercise-induced laryngeal obstruction (EILO)
During high intensity exercise, the larynx can partially close, thereby causing a reduction in normal airflow. This results in the reported symptoms of SOB and wheezing.
This diagnosis has previously been called exercise induced vocal cord dysfunction. As the narrowing most frequently occurs ABOVE the level of the vocal cord, EILO is a more correct term.
While exercise induced bronchoconstriction has a prevalence of 5-20%, EILO is less common with a prevalence of 5-6%.
Patients are typically adolescents, with exercise associated wheezing and SOB, frequently during competitive or very strenuous events. Wheezing is inspiratory and high-pitched. Symptoms are unlikely to be present at time of medical contact unless you are at the event as resolution occurs within 5 minutes though associated cough or throat discomfort can persist after exercise cessation. EIB symptoms typically last up to 30 minutes following exercise.
Inhaler therapy is unlikely to help though some athletes report subjective partial relief. This may be explained as approximately 10% of individuals have both EIB and EILO.
In athletes with respiratory symptoms referred to asthma clinic, EILO was found in 35%.
Consider EILO in athletes with unexplained respiratory symptoms especially in those with ongoing symptoms despite appropriate therapy for EIB.
Hand elevation test
- Hand elevation has been known to reproduce the symptoms of carpal tunnel syndrome.
- This phenomenon prompted the idea of developing a simple hand elevation test to diagnose carpal tunnel syndrome.
- To perform: Ask the patient to elevate both arms in the air for one minute. Hands are raised actively and without strain, keeping the elbows and shoulders relatively loose.
- A positive test reproduces symptoms of carpal tunnel syndrome.
- The hand elevation test has a high sensitivity (75-86%) and specificity (89-98.5%) and may be comparable to or likely better than other provocative tests.
https://www.youtube.com/watch?v=IO2qC5qHVFE
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A recent article in Pediatrics attempted to estimate the association between fluoroquinolone use and tendon injury in an adolescent population.
Fluoroquinolones are thought to negatively impact tendons and cartilage in the load-bearing joints of the lower limbs through collagen degradation, necrosis, and disruption of the extracellular matrix.
Population: 4.4 million adolescents aged 12–18 years with filled outpatient fluoroquinolone prescription vs. an oral broad-spectrum antibiotic for comparison.
Fluoroquinolones included ciprofloxacin, levofloxacin, moxifloxacin, and gatifloxacin
Comparator antibiotics included amoxicillin-clavulanate, azithromycin, cefalexin, cefixime, cefdinir, nitrofurantoin, and bactrim.
Outcomes: Primary outcome was 90-day tendon rupture (Achilles, patellar, quadricep, patellar, tibial) identified by diagnosis and procedure codes. Secondary outcome was tendinitis.
Results: The weighted 90-day tendon rupture risk was 13.6 per 100 000 fluoroquinolone-treated adolescents and 11.6 per 100 000 comparator-treated adolescents.
Fluoroquinolone-associated excess risk: 1.9 per 100 000 adolescents; the corresponding number needed to treat to harm was 52 632.
The weighted 90-day tendinitis risk was 200.8 per 100 000 fluoroquinolone-treated adolescents and 178.1 per 100 000 comparator-treated adolescents
Fluoroquinolone-associated excess risk excess risk: 22.7 per 100 000 adolescents; the corresponding number needed to treat to harm was 4405.
Conclusion:
The excess risk of tendon rupture associated with fluoroquinolone treatment was extremely small, and these events were rare. On average, 50,000 adolescents would need to be treated with a fluoroquinolone for 1 additional tendon rupture to occur
The excess risk of tendinitis associated with fluoroquinolone treatment though larger was also small.
Besides tendon rupture, other more common potential adverse drug effects may be more important to consider for treatment decision-making, in adolescents without other risk factors for tendon injury.
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Both erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are highly sensitive (84-100%) for spinal infections and are observed in >80% with vertebral osteomyelitis and epidural abscesses.
ESR
Most sensitive and specific serum marker, usually elevated in both spinal epidural abscess (SEA) and vertebral osteomyelitis.
ESR was elevated in 94-100% of patients with SEA vs. only 33% of non-SEA patients
Mean ESR in patients with SEA was significantly elevated (51-77mm/hour)
CRP
Not highly specific
Less useful for acute diagnosis since CRP levels rise faster and return to baseline faster than ESR (elevated CRP seen in 87% of patients with SEA as well as in 50% of patients with spine pain not due to a SEA)
Better used as a marker of response to treatment.
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Erythrocyte sedimentation rate (ESR) for spinal infection
Sensitive for spinal infection but not specific
Elevated ESR is observed in greater than 80% of patients with vertebral osteomyelitis and epidural abscess
ESR is the most sensitive and specific serum marker for spinal infection
Usually elevated in acute presentations of SEA and vertebral osteomyelitis
ESR was elevated in 94-100% of patients with SEA vs. only 33% of non-SEA patients
Mean ESR in patients with SEA was significantly elevated (51-77mm/hour)
Infection is unlikely in patients with an ESR less than 20 mm/h.
Incorporating ESR into an ED decision guideline may improve diagnostic delays and help distinguish patients in whom MRI may be performed on a non-emergent basis
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Study Question: A recent study investigated whether adult patients presenting to the ED with a diagnosis of mTBI prescribed light exercise were less likely to develop persistent postconcussion symptoms.
Setting: Randomized controlled trial conducted in three Canadian EDs. Consecutive, adults (18–64 years) seen in ED with a mTBI sustained within the preceding 48 hours.
The intervention group received discharge instructions prescribing 30 minutes of daily light exercise.
The control group was given standard mTBI instructions advising gradual return to exercise following symptom resolution.
Outcome: The primary outcome was the proportion of patients with postconcussion symptoms at 30 days,
A total of 367 patients were enrolled. Median age was 32 years Male 43%/Female 57%.
Result: There was no difference in the proportion of patients with postconcussion symptoms at 30 days. There were no differences in median change of concussion testing scores, median number of return PCP visits, median number of missed school or work days, or unplanned return ED visits within 30 days. Participants in the control group reported fewer minutes of light exercise at 7 days (30 vs 35).
Conclusion
Prescribing light exercise for acute mTBI, demonstrated no differences in recovery or health care utilization outcomes.
Extrapolating from studies in the athletic population, there may be a patient benefit for light exercise prescription.
Make sure that the patient is only exercising to their symptomatic threshold as we recommend with concussed athletes. Previous studies have shown that athletes with the highest post injury activity levels had poorer visual memory and reaction time scores than those with moderate activity levels.
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Home management versus PCP follow-up of patients with distal radius buckle (torus) fractures
A recent study investigated outcomes of patients with distal radius buckle fractures who were randomized to
- Home removal of splint and physician follow-up as needed (home management)
Versus
- Prescribed PCP follow-up in 1-2 weeks
Noninferior study
Torus/buckle fractures of the distal radius are the most common fractures in childhood occurring on average in 1 in 25 children
This is a stable fracture typically treated with removable wrist splint and very rarely require orthopedic intervention
Outcome: functional recovery at 3 weeks
Randomized controlled trial at a tertiary care children’s hospital
All radiographs reviewed by pediatric radiologist with MSK specialization
149 patients. Mean age 9.5 years. 54.4% male
Telephone follow-up at 3 and 6 weeks following ED discharge by blinded interviewer
Primary outcome was comparison of Activities Scale for Kids-performance scores between groups at 3 weeks
Outcomes: Home management performance score was 95.4% and PCP follow-up group was 95.9%. Mean cost savings were $100.10.
Conclusion: Home management is at least as good as PCP follow-up with respect to functional recovery in ED patients with distal radius buckle fractures.
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What time of day is best for exercise to achieve weight loss goals?
Working out in the morning has traditionally held the edge, especially if done on an empty stomach.
Upon walking, elevated levels of cortisol and GH will aid in fat metabolism.
Switching to a morning workout may also decrease appetite throughout the day.
Morning exercise may also induce significant circadian phase?shifting effects. Patients report feeling more alert in the morning and get more tired at night. This may “force” people to get increased rest as poor sleep quality and duration has been associated with weight gain.
Moderate intensity aerobic exercise has been shown to cause immediate mood improvement and mental productivity. These effects can last up to 12 hours and may be a simple aid to combat job stress.
However, a recent small study looked at this question with a group of men at high risk for Type 2 diabetes.
Those that exercised in the morning had better blood sugar control and lost more abdominal fat than those who exercised in the morning.
Study: 32 adult males (58 ± 7 years) at risk for or diagnosed with type 2 diabetes performed 12 weeks of supervised exercise training either:
In the morning (8.00–10.00 a.m., N = 12) OR
In the afternoon (3.00–6.00 p.m., N = 20)
Test: Graded cycling test with ECG monitoring until exhaustion
Results: Compared to those who trained in the morning, participants who trained in the afternoon experienced superior beneficial effects of exercise training on peripheral insulin sensitivity, insulin?mediated suppression of adipose tissue lipolysis, fasting plasma glucose levels, exercise performance and fat mass.
Conclusion: Metabolically compromised patients may benefit from shifting their exercise routine to the afternoon from the morning. Ultimately, any exercise is great in this population, but this study may be worth sharing to your patients.
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Exercise and Covid-19
The majority of COVID-19 cases fall into the mild-to-moderate category, with symptoms lasting less than 6 weeks on average.
The disease presents a challenge for clinicians seeking to offer counsel for patients wishing to return to exercise.
A recent cohort study in Germany looked at 100 patients (avg. age 49, 53% male) who had recovered from Covid-19 infection.
Most had been healthy, with no pre-existing medical conditions, before becoming infected.
The group had cardiac MRI (CMR) performed.
Average time interval between Covid-19 diagnosis and CMR was 71 days.
Cardiac involvement was seen in 78% of patients and ongoing myocardial inflammation in 60%.
Evidence based return to activity guidelines being developed are more conservative than in the past with other viral infections
https://link.springer.com/article/10.1007/s11420-020-09777-1/tables/1
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A recent retrospective observational study looked at the association of oral antibiotics (primarily fluroquinolones) and tendon rupture.
Outcome data is very interesting for our practice, deviates from traditional teaching.
Population: 1 million Medicare fee for service beneficiaries from 2007-2016 (>65 years old)
Antibiotics queried: Seven total oral antibiotics of mixed class:
- Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin)
- Other: Amoxicillin, amoxicillin-clavulanate, azithromycin and cephalexin.
Outcome measures: all combined tendon ruptures and 3 by anatomic site (Achilles, rotator cuff {RC} and other)
Results: Of the 3 quinolones, only LEVOfloxacin showed a significant increase in risk of tendon rupture (16% for RC) and (120% for Achilles) in a 1 month window. The others did not show an increased risk
Among the other antibiotics, cephalexin showed an increase risk across all anatomic sites.
The authors note that the risk with levofloxacin never exceeded the risk of cephalexin in any comparison!
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Chief complaint: “My hip snaps when I exercise”
Both athletes and non-athletes may report a “snapping” sound with certain movements
This may affect up to 10% of the population
May be associated with activities than involve repetitive hip flexion
Symptoms may be due to an internal or an external cause
External causes are usually due to a tendon passing over a bony prominence
This can be felt as either an audible sensation and/or even a palpable snap
This may or may not involve pain or discomfort
This is most commonly due to a benign cause
During movements in flexion, extension or combined with internal rotation the iliotibial band may move over the greater trochanter.
Alternatively, the hamstring tendon may pass over the ischial tuberosity
There are several other causes with similar mechanisms
Symptoms are usually minimal and not serious
This can be reproduced on bedside clinical exam
Ask the patient to identify the area of snapping with one finger which will help with anatomic localization
First line therapy is physical therapy which focuses on:
Improving muscle length if muscle is too tight OR
Improving neuromuscular activation if problem is due to excessive muscle activation
The Romberg test is part of the standard neurologic examination. The patient is asked to stand with feet together, hand on hips/sides and the eyes are closed. Vestibular and proprioceptive input is being tested.
This test is not very sensitive overall, but especially in concussed athletes.
Many concussed athletes are able to stand relatively stable despite their neurologic injury.
In order to better identify postural instability in concussion, we perform 3 separate balance tests (modified balance error scoring system, mBESS).
A) Romberg
B) Single leg stance
- Standing on the non dominant foot, the hip is flexed to approximately 30° and the is knee flexed to approximately 45°.
- NonDominant Leg: The nondominant leg is defined as the opposite leg of the preferred kicking leg
C) Tandem Stance
Have patient stand quietly with hands on hips
Have patient close eyes and start 20 second trial
If error occurs tell patient to return to start as quickly as possible
Examples of errors: opening eyes, lifting hands, falling out of position
A 25 year old athlete presents to the ED with right anterior shoulder pain.
Pain radiates into proximal biceps.
It is worse with heavy lifting and especially “pulling” exercises at the gym.
How do we evaluate for biceps tendonitis?
- Tenderness to palpation in the bicipital groove
- Speed’s test
- Yergason’s test
Pathology is often the long head of the biceps
https://physioworks.com.au/wp-content/uploads/2019/12/biceps-tendonitis.jpg
Start by palpating this area and attempt to reproduce the discomfort
Speed’s test
- Arm is supinated and extended and elevated against examiner’s downward resistance
- https://youtu.be/N00gA4Pvsbw
Yergason’s test
- Arm is placed to patient’s side, in pronation and flexed to 90 degrees at elbow
- Patient attempts to supinate and externally rotate arm against resistance
- https://youtu.be/rQ2Mp6aSi88
Ulnar Collateral ligament injuries of the elbow
Overhead throwing athletes are at risk of insufficiency and rupture of the ulnar collateral ligament (UCL) of the elbow
This can lead to valgus instability similar to what can occur in the knee
Overhead throwing places a significant valgus stress on the elbow
Though classically seen in baseball pitchers, may also be seen in javelin throwers and other high velocity throwing sports
In the acute setting may be seen after an elbow dislocation
History includes a “pop” and medial elbow pain following throwing activities
In cases of overuse injury, athletes will report a progressive loss of velocity, accuracy, and/or endurance with throwing.
The ulnar collateral ligament is the primary restraint to valgus stress from 30 to 120 degrees of flexion
One classic test for UCL instability is the milking maneuver
Patient may be sitting or standing
Patient’s forearm is supinated and elbow flexed at 90 degrees
A valgus force is applied by pulling the patient’s thumb while the examiner’s other hand stabilizes the elbow and palpates the medial joint line.
Instability, pain or apprehension at the UCL is considered a positive test
https://www.youtube.com/watch?v=gbn24X_qqn0
Carpal Tunnel Syndrome (CTS)
The hallmark of classic CTS: pain or paresthesia (numbness and tingling) in a distribution that includes the median nerve territory, with involvement of the first three digits and the radial half of the fourth digit.
The symptoms of CTS are typically worse at night and often awaken patients from sleep.
Fixed sensory loss is usually a late finding
Involves the median-innervated fingers BUT spares the thenar eminence.
This pattern occurs because the palmar sensory cutaneous nerve arises proximal to the wrist and passes over, rather than through, the carpal tunnel.
Consider a more proximal lesion in cases involving sensory loss in the thenar eminence
Example: pronator syndrome
Physical injury patterns associated with physical elder abuse
Elder abuse is both common and underrecognized
Between 5 and 10% of US older adults are victims of elder abuse annually
For many older adults, contact with a health care provider may represent their only contact outside the home
Differentiating physical elder abuse from unintentional trauma can be very difficult
A recent study compared these two groups with a case-control design
Study cases: 100 successfully prosecuted physical elder abuse cases from a single urban ED
Physical abuse victims were more likely to have:
Bruising (78% vs. 54%)
Injuries to maxillofacial, dental or neck region (67% vs. 28%)
Particularly the LEFT side
Neck injuries 6x more common is assault
Ear injuries occurred in assault but not in falls
Absence of fracture (8% vs. 22%)
Less likely to have lower extremity injuries (9% vs. 41%)
22% of victims had no visible injuries
Most common mechanism assault with hands or fists and pushing or shoving causing a fall
Take home: Consider elder abuse especially in cases of the above red flags