All right. Thank you very much. Echo Tom's comments. Glad to be back this year to talk to you about topics that you may not encounter every day in your practice, depending on what you do. This talk, we're going to focus on infectious disease, dermatology, and ergogenic AIDS as it pertains to the sports medicine physician. I don't have anything to disclose for the talk, so here's kind of the outline. We'll talk briefly about immunology and infection and exercise. We'll talk about some common infections, and I'll try to really highlight for you the things that are important as you think about how you care for athletes with infectious disease. We'll spend some time talking about infectious mononucleosis because this comes up on every single sports medicine exam, and you need to know some things about it. Dr. Best mentioned some things about myocarditis that I will reemphasize, and we'll talk a little bit about blood-borne infections. I'll talk to you about some dermatologic conditions and especially highlight some of the treatment issues that you want to know about dermatologic conditions if you're a sports medicine physician, and then we'll spend some time on ergogenic AIDS, supplements, and performance-enhancing drugs. So let's start by talking about infectious disease. So as you know or may remember, if it goes all the way back to your medical school days, the immune system is made up of two systems. There's an innate and acquired system. The innate system are your natural killer cells, your phagocytes, your skin, mucous membranes, hair, and then you have your acquired T and B cells with your immunoglobulins, secretory IgA, and mucus. Things to think about for athletes with exercise. When you exercise, your nasal breathing transitions to mouth breathing, and that's important because it allows more foreign particles to be deposited in lower airways. So you want to think about that transition in breathing when you think about athletes. You also want to remember that in athletes, for intense and prolonged exercise, there can be a deleterious effect on the immune system. So there can be a decreased function of lymphocytes and decreased number of neutrophils, which can put you at risk for infection. So exercisers are mouth breathers, and if you have exercisers who are ultramarathoners, for example, or are under intense exercise, their immune function may be decreased somewhat, and that may put them at risk for illness or other infections. Other things we think about with infection and exercise that you need to pay attention to when you think about an athlete with an infection. Fever. Fever impairs coordination, concentration, muscle strength, and aerobic power, and it is a qualified no for exercise. So no exercise or sport with a fever, and that is traditionally described as a temperature of greater than 101 Fahrenheit. So any athlete with documented fever should not participate in exercise. Think about drugs used to treat infections. If you think about common antibiotics, they can cause diarrhea and oftentimes C. difficile, and so you want to think about that when you're prescribing antibiotics as one of the side effects, and you want to make certain you'll use them with proper indication, and we're going to discuss some of those indications here as we talk about some of these infections. As I think all of you are aware of, but likes to be asked on exams over and over again, is the risk of tendon rupture or tendon injury with quinolones. So quinolones get used very often. Levaquin is a common drug that's used for lots of upper respiratory infections, but puts you at risk for tendon rupture, and you'll see that reflected in some of the questions. And when you think about return to play for many common upper respiratory infections, you want to be aware of this neck check rule. Symptoms confined to upper respiratory region, that is anything that is above the neck, those folks can exercise at a lower intensity as long as their symptoms don't worsen. But if you have folks that are showing signs of lower respiratory disease or GI illness, those sorts of things, they cannot exercise. They should be held from sport, and that is commonly referred to as the neck check rule, and you're going to want to be aware of that as you look at questions that may come up on infection and exercise. So here's a couple examples of questions that could be asked when you think about these sorts of situations. So you have a collegiate women's basketball player presents to her athletic trainer with dysuria, hematuria, urinary urgency and frequency. She's referred to her team physician, and your analysis suggests diagnosis of a urinary tract infection. Which of the following antibiotics should the team physician avoid prescribing given concern regarding tendon injury or rupture? And we just talked about that, right, the quinolone class. So all of these medications you see here, trimethoprim, sulfa, nitrofurantoin, amoxicillin, Keflex, or cephalexin, and ciprofloxacin are very commonly used in this age group, and in fact cipro may be the most commonly used medication, but it will put you at risk potentially for tendon rupture. You're seeing an athlete with complaints of a common cold. Which of the following symptoms require you to withhold the athlete from exercise and sport? So you don't need to know much about upper respiratory illness to get back to this neck check rule. So rhinorrhea, sore throat, bronchiolar wheezing, sinus pressure, or post-nasal drainage. And the answer, as we mentioned here, is bronchiolar wheezing, because that involves the lower respiratory tract, and so folks with bronchiolar wheezing should not participate in sport as compared to those who can do low impact sport if they have upper respiratory illness. So those sorts of themes will help you as you see these sorts of questions that may come up when they pertain to infectious disease. Let's talk a little bit about some specific infectious disease, and I'll try to highlight some important things as they pertain to athletes. Upper respiratory infections, they are common and they are viral. So they do not need antibiotic treatment. 90% of upper respiratory tract infections are viral. They spread very easily in sports situations. You know about the clinical diagnosis, but low-grade fever still can allow you to participate. So remember that kind of idea about fever of a temperature of 101 Fahrenheit. Symptoms are usually self-limited. The treatment is symptomatic. Fluids, acetaminophen, rest, sometimes non-sedating antihistamines, but you want to be very cautious with ephedrine-containing products because that can cause a positive drug test. So just kind of highlight that for yourself that ephedrine is not necessarily good in athletes because of the issue of drug testing. Handwashing is always a positive. Any question they give you about preventing the spread of infectious disease amongst athletes, hygiene is very important. And so they'll ask you about those simple things, making certain that you understand that. And the influenza vaccine or the flu vaccine is probably the number one thing you can do to prevent upper respiratory illness in athletes. So vaccination and prevention is really important when you think about athletes. What about sinusitis? Very common in athletes. Again, it can be a complication of a URI, but they are viral. Again, most of them do not require antibiotic treatment. There are bacterial causes. You can see those listed here. You can see the symptoms for that, usually purulent discharge, sinus pain that worsens over 10 to 14 days. Treatment is antibiotics for those. And the most common antibiotics used are amoxicillin, amoxicillin clavulonate, or Augmentin, or trimethopen sulfa or Bactrim. Acute bronchitis, again, very common. Many athletes present cough, maybe some sputum production, three weeks with URI symptoms. Most causes of bronchitis are viral. Again, prescribing antibiotics is not usually the correct answer on these exams. So if you see questions about upper respiratory infections in athletes, giving an antibiotic is not the correct answer. And symptomatic treatment is usually, for acute bronchitis, is all that's required. Here's the one that you do want to know about, is pneumonia. This is a lower respiratory infection, obviously. There's many viral causes of pneumonia, but about 50% of the causes of pneumonia are bacterial, with the most common being strep pneumonia, even in younger folks. You obviously know about atypical pneumonias and mycoplasma, the so-called walking pneumonia, but most common still is strep pneumonia in athletes. You can see the symptoms. They include fever, productive cough, fatigue. The diagnostic test, as you may or may not remember, but CBC usually shows a large leukocytosis. Chest x-ray is the imaging study of choice, looking for infiltrates. Sputum cultures are not sensitive, so sputum cultures are not required most time for the diagnosis of pneumonia, but blood cultures are very sensitive. So given a choice, you would choose blood cultures for the diagnosis of pneumonia. The treatment for pneumonias is oftentimes antibiotics, and the most common first-line treatment is a macrolide antibiotic or azithromycin. These folks cannot return to sport after all symptoms have resolved. Pharyngitis, another very common infection that you'll see in athletes. Most common cause, again, is viral. I've only mentioned one infection so far where bacterial should be sticking out in your mind, and that's lobar pneumonia. Strep throat, group A beta-hemolytic strep, which is over-treated continuously for the general population and in athletes, is only about 5-15% of these infections. Things you need to think about, and you'll want to think about this as you contrast this with someone who has infectious mononucleosis when we get to that. Red swollen tonsils with a white exudate. Anterior cervical lymphadenopathy, so very classic anterior cervical lymph nodes. Fever, abdominal pain, and headaches are common, but people with strep throat do not have upper respiratory symptoms. So if they were to present you with a scenario where someone had rhinorrhea, cough, those sorts of symptoms, that is a viral infection. That is not consistent with strep throat. I'm not going to go into all the center criteria and all the things for strep throat, but upper respiratory symptoms are not common with strep throat. Rapid strep tests are very sensitive, but not very specific, and throat culture is still the gold standard. Don't forget about the complication of a peritonsillar abscess, and so that can occur if this is not left untreated, and if this is left untreated and the treatment is penicillin or amoxicillin for 10 days, second line treatment would be the macrolides or azithromycin. So let's try to put this in the context of some questions as you're sitting here thinking about how could this apply to athletes. So an athlete presents with upper respiratory symptoms including a productive cough, malaise, and fever. You remember that the most common upper and lower respiratory infections are caused by viruses. Which of the following is most likely to be associated with bacterial infection and require antibiotic treatment? And if you remember, I've only mentioned one infection that is more common for bacterial infection, acute bronchitis, low-bar pneumonia, acute pharyngitis, or acute sinusitis, and the answer would be low-bar pneumonia. Let's spend a little bit of time about talking about infectious mononucleosis because I would guess that if there'll be a number of questions on the exam, this is one area where they'll at least ask one question because it's considered very important for all sports medicine physicians. As you know, it's caused by the Epstein-Barr virus, which is a herpes virus. It's transmitted via oropharyngeal secretions, commonly caused a kissing disease given the incidence of ages between 15 and 25. It's very common amongst college students as you can see here and many of them are susceptible to infection. Even though many of them don't acquire the disease each year, very common amongst athletes. Significant clinical symptoms are obviously the older we get, the more significant the clinical symptoms. So if you contract Epstein-Barr when you're young, you tend to have just regular upper respiratory symptoms. When you get Epstein-Barr when you're over the age of 15, you tend to have more significant symptoms that we're going to talk about. So the clinical syndrome of infectious mononucleosis can occur several weeks after exposure. So it can be someone who presents with two, three, four weeks of symptoms. The prodromal symptoms of malaise, headache, myalgias are very nonspecific, but there's this classic glandular fever triad that is described for patients with mononucleosis, which is the combination of fever, this pharyngitis, and lymphadenopathy. And that lymphadenopathy different than strep throat is anterior and posterior cervical lymphadenopathy. So anyone with these symptoms that they would mention to you that has posterior cervical lymphadenopathy has a diagnosis of infectious mononucleosis. There are lots of other symptoms that can be seen in athletes with infectious mononucleosis. Fatigue is very common but nonspecific. There are some rashes, palatal petechiae. We're going to talk about organomegaly, splenomegaly, hepatomegaly, which are very important, and then vague abdominal pain. And most of these symptoms will resolve after about four to eight weeks. So how do we make the diagnosis of mononucleosis? It is not made by a throat culture. It's primarily based on clinical symptoms and then looking at the CBC with elevated white blood cell count, usually between 12 and 20,000. And remember that there is a lymphocytosis and specifically an atypical lymphocytosis. So a large increase in the number of atypical lymphocytes, usually greater than 10%. So any CBC that they would suggest to you in a student athlete that shows a high number of atypical lymphocytes, the diagnosis is going to be infectious mononucleosis or Epstein-Barr infection. EBV titers are commonly drawn in order to make the diagnosis of acute infection versus chronic carrier. And there is oftentimes elevated liver function test as well in infectious mononucleosis due to infectious hepatitis caused by the virus. One of the reasons we need to know about infectious mononucleosis is because in athletes and other patients there are a number of complications that are important. And you see the one highlighted at the bottom that we're going to spend some time on. But airway obstruction is not uncommon. Hemolytic uremic syndrome is not uncommon. There is an aplastic anemia that can occur with infectious mononucleosis. It is one of the most common causes in a young population of Guillain-Barre syndrome. There can be prolonged or chronic fatigue. So many of these patients can have greater than six months of fatigue. And then obviously in athletes the most important risk consideration is splenic rupture. It's a rare complication. It does not occur commonly. Although we make a big deal about it in infectious mononucleosis, it occurs in less than .3% of athletes that actually contract infectious mononucleosis. But it can be obviously catastrophic. One of the things you want to remember about splenic rupture in an athlete with infectious mononucleosis is that it is more common in athletes from a traumatic cause than traumatic. So we worry a lot about the football player that has infectious mononucleosis going back to contact sport and getting hit, right, and causing splenic rupture. But the cause of splenic rupture is much more commonly reported in athletes that just return to atraumatic exercise, running, swimming, weight lifting, those sorts of things. The data suggests that most splenic ruptures occur within 21 days of acute infection or the diagnosis and rarely after 28 days. Although there's case reports, usually after four weeks the risk of splenic rupture is significantly decreased. We know a few things about spleen. We know there's a large variation in splenic size and so that routine ultrasound is not helpful in evaluating for splenomegaly. There may be some benefit in very large athletes in referring to nomograms if you do get a splenic ultrasound because we don't have an idea about what their normal spleen size is. But in general, splenic ultrasounds are not helpful in preventing the risk or making the return to play decision for splenic rupture and infectious mononucleosis. And as I mentioned to you, the spleen returns to normal size usually after about four weeks following the diagnosis of infectious mono. So how do we make decisions on return to play? Because this is where you'll be asked. It all focuses around splenic rupture. So if you remember that time that we just talked about, you'll be very happy when you go to answer this question. We know that you cannot predict return to play based on physical exam. So palpation indicating splenomegaly may not be a good indicator and is not a good indicator of return to play. So you can't count on your physical exam to tell you that the spleen has returned to normal size. The recommendations by all consensus statement is that there should be no physical activity for the first three weeks after the diagnosis or symptom onset and very limited activity like cardio activity in week four if the patient has returned to feeling well. Return to sport is often at four weeks after the diagnosis or symptom resolution. So if they give you a time period, it is four weeks for infectious mononucleosis before you can actually return to sport. The other thing to know about infectious mononucleosis is that steroids do not improve return to play. They do not improve symptom resolution and do not help with infection. So they're only indicated with airway complication in infectious mononucleosis. So how could this show up on the exam? Let's take a look at a question here. So you have a swimmer that's diagnosed with mononucleosis. Which of the following is true regarding the care of the athlete with mononucleosis? Splenic rupture only occurs in athletes exposed to contact activity and this swimmer can return to sport without restriction. I've told you that the most common cause of splenic rupture is from atraumatic sport activity. So that's incorrect. Splenic palpation is an accurate way to determine normal spleen size and return to play and we just talked about the lack of efficacy for physical exam. If the athlete is asymptomatic and tolerates light exercise, she may return to swimming four weeks following symptom onset and diagnosis. And I just mentioned the importance of that four week mark and the actual return to play guideline. And then steroids are indicated for symptom resolution and faster return to play in an athlete with mononucleosis and we just mentioned you're only going to use those in airway compromise. So for the team physician, they need to know that if the athlete is asymptomatic and tolerates light exercise, after four weeks they can return to sport. Other things that very quickly for infectious disease, otitis media, again most commonly is viral. You'll see a red bulging tympanic membrane but antibiotics are rarely indicated. So again, I hope I'm driving home the point that if you see answers on your exam that include antibiotics, very often unless you see something to do with lobar pneumonia, that is not the correct answer for treatment for your athlete. Otitis externa is usually caused by bacterial and fungal infections. They have ear pain, they're pulling at their tragus, sometimes you'll notice a purulent discharge and those are topical eardrops that are most commonly needed. And then again, conjunctivitis is most commonly viral and treated symptomatically. If you have a purulent discharge, you can't have a bacterial cause and bacterial drops may be needed but you want to restrict activity is the most important thing. Remember amongst athletes, these infections spread very quickly and so making certain that their symptoms have resolved before they return to contact with other athletes is very important. Let's talk a little bit about meningitis because this will show up again very common in an athletic population, especially in a collegiate athletic population. The most common cause again is viral, right? Aseptic meningitis. People walk around with this, probably have a little bit of headache, stiff neck, mild fever. They never present to their clinician for evaluation but it's bacterial meningitis that we need to worry about and especially Neisseria meningitidis. High morbidity and mortality and very common. You'll read about cases of this every year in athletes at colleges who will come up with this infection. You need to remember the classic triad fever, stiff neck, and headache and then certainly neurocognitive dysfunction and deterioration is very common in these athletes. One of the big things that you need to remember if you see this is one of the responsibilities is a notification of close contacts for treatment in isolation. So you don't want these infections to spread. So if you have someone in a team sport who has been diagnosed, it's very important that their teammates are screened and treated for this infection. So if a question about that were to show up, that's important for the treatment. Dr. Best mentioned myocarditis. I'm going to mention it again because I think it's very likely that there will be a test question on myocarditis. Usually when this shows up in multiple areas, it's a ripe area for testing. Again, it's a complication following common viral infections. So virus is the cause of the most common cause. Men are most commonly affected at sport ages between 20 and 40. Dr. Best mentioned symptoms are sometimes nonspecific. Chest pain, fatigue, fever for unknown reason, maybe palpitations. Dr. Best mentioned that the diagnosis can be made by ECG. There's very nonspecific abnormal ST and T wave abnormalities that can suggest problems with the myocardium. The echocardiogram is often used. It shows global decreased ventricular function and more commonly today now cardiac MRI looking for areas of inflammation for myocarditis. It's typically self-limited, but while infected with damage to the myocardium, there is risk for arrhythmia as Dr. Best mentioned, ventricular tachycardia, ventricular fibrillation, and death. And again, you need to know no exercise or strenuous activities as was mentioned earlier for six months. So this is a question that I would not be surprised if it shows up on your examination, just understanding when an athlete can return to play following the diagnosis of myocarditis. Gastroenteritis is very common. Again, most of the common causes of gastroenteritis are viral. Good hygiene is the most important prevention key. So to prevent this from spreading. Dehydration is the most common complication and you can see here that it does occur. Most folks should be rehydrated with oral rehydration solutions and I doubt that they're going to ask you specifics about oral rehydration, but they're going to want you to plug people into IVs. They're going to want you to do all sorts of fantastic things to try to get these athletes back on the field. And by far and away, most athletes can be rehydrated with an oral rehydration solution and monitoring. So although in your training rooms and in your stadiums and other places, IVs may be very common. They are not necessary and not recommended for people that have mild dehydration. Most symptoms from gastroenteritis will resolve within about two to four days and they can return to play when they're rehydrated and their symptoms resolve. There are bacterial gastroenteritis causes. Again, most commonly campylobacter is the most common bacteria that you will see. So if bacterial campylobacter is most common, again, let these run their course. Campylobacter and E. coli do not require antibiotics for treatment. If you have someone, they give you some sort of wilderness athlete who develops diarrhea and you think that they may have contracted a parasite or Giardia that is treated with metronidazole. And so that was one case where you would need to know something specific about that. I did not mention it here, but I mentioned it earlier that antibiotics and one of the reasons we don't want to overprescribe puts people at risk for C. difficile. And so again, if you have someone who's been on antibiotics, C. difficile is a common cause of diarrhea, especially in athletes who are over-treated with antibiotics and they need to be treated as well with metronidazole or oral vancomycin. Travelers diarrhea. Lots of athletes travel and again, they're a short course of antibiotics and the number one choice is ciprofloxacin can prevent symptoms. But as I mentioned to you earlier, remember quinolones and their risk for tendon rupture. But this would be the best choice if you're going to give something short for travelers diarrhea. How about bloodborne infectious diseases? We need to know something about HIV. There are no documented cases of HIV transmission in sport. So if someone asked you if you could give them a question about risk, that there has been no documented cases of HIV transmission in sport. Exercise is beneficial for athletes with HIV. In general, exercise is good. So if you're given a patient with a chronic condition, exercise in general is a very good choice for treatment for them. There is not restriction for exercise in an HIV patient and it is not a reason for exclusion from athletics. Sexually transmitted diseases. These are very common in athletes. As you know, if you take a look at things that go on at the Olympic Games, one of the most common infections that's treated are STDs. Chlamydia is treated with oral azithromycin and Neisseria gonorrhea is treated with IM ceftriaxone. Those are CDC guidelines for the treatment of the two most common sexually transmitted diseases. But again, prevention is the best course and so barrier methods of contraception are the best preventative method for reduced spread of STDs if given choice in athletes. So which of the following is not a reason for exclusion from sport? So HIV, active gastroenteritis, fever, myocarditis and pneumonia. I put this here just again to drive home the point that HIV is not a reason for exclusion from sport. Active gastroenteritis, that athlete should be excluded at the risk of dehydration. We talked about the risk for fever. Myocarditis has been mentioned now a couple of times and the risk for sudden cardiac death with active participation in sport and we mentioned pneumonia and being a lower respiratory tract infection that requires treatment and no return until the athlete has recovered. That is in 27 minutes an update on infectious disease in athletes. So hopefully I've given you some pointers that will draw your attention to answers on your exam should you come up with questions that refer to infectious disease. Let's talk a little bit about dermatology. Dermatology is about pattern recognition, treatment and return to play in athletes. That's all that this is and so you just have to be familiar with some of these conditions and then really some of the things that allow the athlete then to return to play. So urticaria, also known as hives, very common. Many causes that can be difficult to identify. There is exercise-induced urticaria. It's a very common condition. It's a very common condition. It's exercise-induced urticarial disease so you need to be aware of that. Obviously you know that these are acute. They can resolve spontaneously, often very puritic, lots of ranges in size. The number one treatment is to eliminate any allergen. So if you're asked about urticarial disease or to modify activity or temperature, whatever it is that the athlete may be doing. If treated, non-sedating antihistamines can be used, rarely steroids, and then an EpiPen obviously should be available for anaphylactic shock. Blisters you know about. I'm not going to spend much time on these except they're one of the most common traumatic causes of skin disorder. You can drain them if they're full and tense and if they're open, put on a firm occlusive dressing. But again, I want to drive home the fact to you that prevention with proper fitting equipment and decreasing friction is more important than treatment. So as you move forward, prevention is really key for these traumatic types of skin issues in athletes. Talon nor is something you want to be aware of because it oftentimes can be misdiagnosed as melanoma. It's commonly referred to as black heel. It's due to the repeated rapid movement of the calcaneal area against an athletic shoe, rupture of superficial capillaries. So again, prevention is key for this condition. It doesn't need any treatment. I mentioned prevention with padding, but it can mimic malignant melanoma, so you want to be aware of it. And the diagnosis is made by paring away the surface of the skin and that pigment being removed. Obviously, we're going to talk about melanoma just in a minute. If you think something is melanoma, you should not be trying to remove it. But in this case, just removing that superficial layer of the skin can make the diagnosis for you. Auricular hematomas. Auricular hematomas are common in rugby players and wrestlers. It's caused by bleeding between the skin and the auricular cartilage. These things can sometimes be seen as this badge of honor amongst wrestlers or rugby players. You know, they walk around with the wrestler's ear or cauliflower ear, but this is a dermatologic emergency in athletes because left untreated, it can be disfiguring. These need to be IND'd and pressure dressings applied, and if infected, antibiotics applied. but it's important that you know that there's this chronic fibrous tissue and calcification of sequelae that once occurs cannot be treated, so this is a dermatologic emergency and needs to be treated appropriately. Dr. Best mentioned earlier environmental injuries, so I won't spend much time on cold injuries, except to know that if you have someone with frost nip, as he mentioned, you want to have rapid rewarming of that area. Frostbite is a completely different animal, and again the only time rewarming should occur is in a health facility, so that you know that there's no chance of refreezing and further damage to that tissue, so make the distinction between frost nip and frostbite in those areas where that can occur. I mentioned melanoma, you need to know about this because it's one of the most common cancers in athletes, secondary to sun exposure, so again prevention is very key, and the use of sunscreen in athletes is very important. SPF 30 or higher to prevent malignant melanoma, the skin changes to a mole, the classic ABCDs that you see here, asymmetry, border irregularity, color, and diameter, a again issue in athletes if they're not using prevention, but something that you should be able to recognize again by pattern if you see this on exam question. Let's talk about some of the infectious causes of skin diseases, because these will be important for you to be aware of and understand some of the treatments of. So impetigo is a honey-crested lesion on a weeping red base, as you can see here. It's caused most commonly by group A beta hemolytic strep or staph aureus. It's commonly treated by with a muperose and ointment, a cephalosporin or erythromycin, so it does require antibiotic treatment, and you need to be able to cover these lesions before someone can return to activity, except in wrestling, as we'll mention here, in wrestling these lesions, if they're active, you cannot return to wrestling with these lesions even if covered. Folliculitis is another very common bacterial infection we see in athletes, erythematous pustules and papules centered on a hair follicle. Again, staph and strep are the most common, but in our athletes who sit around in hot tubs, pseudomonas is very common for causing hot tub folliculitis. This can be confused with acne mechanica, so if there is trauma to the hair follicle itself from padding or from equipment, that can lead to an infection as well. You see the treatments here, again, the cephalosporin or erythromycin, but again, if you have an athlete with folliculitis who's been in a hot tub, the treatment, again, is a quinolone or ciprofloxacin. Let's talk a little bit about staph aureus, because something about MRSA could show up on your exam. As you know, staph aureus is a gram-positive cocci. It's a very common colonizer of the skin and nasal mucosa. Staph aureus can cause mild and severe infections, so mild skin or soft tissue infections that oftentimes are even left untreated, but can lead to sepsis and toxic shock syndrome, and as you're aware of, there is methicillin-sensitive and now methicillin-resistant staph aureus that is very common in athletes. Community-acquired MRSA is the type that we're concerned about in athletes. We are not worried about the type that occurs in the ICU or in the hospital. That's a much different animal than what we most commonly see in athletes. First recognized in the 1980s, it was first seen in prisoners, children, athletes, and military, and less multi-drug resistance than the type of MRSA that's seen in the hospital, but that resistance is increasing. What's the appearance of MRSA in the athlete? It's very classic, this pustule with an erythematous base, this leading erythematous base, so this thing that many people or athletes come in and say, look at this spider bite that I have, you know, I've got this central pustule with this big erythematous base, and oftentimes over 24 to 48 hours, these will progress to larger furuncles or abscesses with associated cellulitis, so they need to be recognized so that they can be treated appropriately when seen. These lesions occur in areas of skin trauma, so where there's micro abrasions, so if someone has an abrasion, for example, on their shin or on their knee, elbows, these are the areas where oftentimes we'll see MRSA infections in athletes. Community-acquired MRSA obviously is increasing in incidence, as I mentioned, and looking at risk factors is important, and we know that there are some factors that contribute to spread, so if you have an abrasion or laceration or an open area that needs to be cleaned, and that area then needs to be protected so that you don't put yourself at risk for contact with this organism and infection. Physical contact, so there's many studies or case clusters out there where you look where the spread of this MRSA is amongst athletes that are in frequent contact with each other, so amongst football teams where linemen are congregating and hitting each other, much more common than in other athletes where they're not coming into contact with each other, and then certainly the sharing of equipment, so sharing of equipment that carries this. Whirlpool use, all the clean cleansers that come out for the training room, you know, to clean down off your training room tables, mop the floors, sterilize the room, we don't really know if that's effective for reducing the spread of MRSA. We also don't know much about nasal colonization, so it used to be about ten twelve years ago that everybody needed, if they were nasal colonizers, needed to be treated. We don't really know the results of treating nasal colonizers. So what do we need to do if we're going to treat MRSA infections? What are the things that you need to be aware of if you get presented with this and it shows up in a question? Well, you need to be able to identify it and you need to know that it needs prompt treatment. It's not something you monitor for a week and kind of watch. These people can end up ill if that's the case. You need to have a culture of the wound and you need for antibiotic, for adequate antibiotic use, and there's lots of different antibiotics used depending on where you are, and I doubt you'd get asked a question about which antibiotic to use. But incision and drainage is first and foremost, so these lesions need to be IND, they need to be packed, and they need to be followed. Mupirocin for nasal colonizers. Again, I just mentioned to you we don't know the effectiveness of that, but in someone with recurrent community-acquired MRSA infections, that's recommended. Chlorhexidine soap for cleansing, and then close monitoring for systemic infections. So if given a question, what's the most important thing for treatment? It's incision and drainage. So what do we know about bacterial infections and return to play? And these are some things you just want to keep in mind. If you're going to return to athlete to play, they cannot have had a new lesion within 48 hours for bacterial infections. So that's a number that you want to just keep in mind. They can't have any moist or exudative lesions at the time of competition. You want to get a gram stain if possible, but bacterial lesions before return to play need to be treated with antibiotics for 72 hours. And you cannot cover active purulent lesions for participation, especially in wrestling, and this is where this comes up mostly. So the things you want to be aware of is no new active lesions for 48 hours, and they need to be treated with antibiotics for 72 hours. How about herpes infections? Most common viral infection in athletes, herpes simplex infections, herpes gladiatorum, or herpes zoster. As you know, clinically presents with burning, tingling, itching, with vesicles on an erythematous base. So you know, the person that comes in that says, hey, I had this burning, tingling sensation, and now I've developed this kind of, these blisters, and on this red skin, that is herpes infection. Lips and fingertips, oftentimes affected, it's highly infectious. So if somebody, a wrestler for example, in a room has active lesions and is wrestling, you can almost be guaranteed everybody they came into contact with is going to end up with a herpetic infection. You have to have to suggest contact precautions and use appropriate hygiene, and these infections need to be treated with antivirals, either acyclovir or valacyclovir most commonly. What do you need to know about viral infections? Really what you need to know is the return-to-play guidelines. So I mentioned to you no new lesions for bacterial infections for 48 hours and treatment for 72 hours. For return-to-play with a herpetic infection, you cannot have any constitutional symptoms obviously, but no new blisters for 72 hours, so a little bit longer time period than for bacterial infections. No moist lesions, they have to have a firm adhering crust, and you have to be on systemic antiviral treatment for five days. So four time periods to remember, the two for bacterial infection and now the two for viral infections. No new lesions for 72 hours, and you have to be on antiviral treatment to return to activity for five days. And again, you cannot cover these for participation most commonly in wrestling, which is where these lesions are seen. Molluscum contagiosum is a pox virus infection. It's a discrete skin colored papule with central umbilication, and I think you can make out probably one or two of those lesions and how they look different from what a herpetic lesion would look like. These can be treated locally by cryotherapy, curatage, electro desiccation, sometimes immunologic creams, but the most important thing to know about molluscum lesions is that if you can get a firm occlusive dressing over them, you can return to play with them. You have to come into contact with these for spread, but you can return if these lesions are covered, which is different than what I've mentioned to you so far. What about fungal infections, dermatologic fungal infections? Again, very common in athletes. Tinea corporis or gladiatorum, most commonly known as ringworm. Again, you can see here that erythematous plaque with scaling edge and central clearing, so clearly different from what we've seen with bacterial infections with no central clearing and that weeping honey-crusted appearance. And you can then again distinguish this from a herpes infection and also from a molluscum infection, so very classic appearance they would give you if they're going to show you a fungal infection in a wrestler or other athlete. Caused by dermatophytes, they need to be treated with topical or oral antifungals and you want to cover these lesions so that you don't have local spread or spread to other athletes. Again, return to play for fungal infections. They have to be on topical therapy for at least 72 hours. So again, you've got two treatment, three treatments, bacterial needs to be treated. You know that now fungal needs to be treated for 72 hours. You know viral needs to be treated for five days. If they were to present you, which I don't think they will, with tinea capitis, which is a separate fungal infection, they have to have two weeks of systemic therapy with griseofulvin, but that is not a likely infection that you would see on your exam. The difference here is is that if you have a solitary lesion, you can cover these lesions for active participation in wrestlers. So if they are treated with topical therapy for 72 hours and you can get a firm occlusive dressing on these lesions, they can return to play. Any other itchy rash in an athlete should be suspected to be scabies, unless you have something else there. Scabies is very common in athletes. This unexplained puritic papule and burrows, oftentimes in finger webs, in the wrist, the axillae, genitals. You know it's caused by the mite sarcoptes scabii. They need to be treated with Nixor Quell appropriately. This is extremely difficult to treat if you let it go and will last for a long, long time and can be spread amongst athletes. And they can only return following adequate treatment and negative scabies prep. So I put this in there because as a puritic erythematous rash, again, it's something that you want to distinguish from the other dermatologic conditions that that you've seen here today. So where would questions be focused on dermatologic lesions for you and your examination? Well, I think one of the areas where they would focus is on participation, right? What can you participate with? So which of the following dermatologic conditions can an athlete participate with if completely covered with no treatment? Scabies, herpes zoster, impetigo, tinea gladiatorum, or molluscum contagiosum. Well, I just told you that scabies needs to be treated with Nixor Quell and they have to have complete resolution before they return to play. You know now that with herpetic infections, they have to be on antivirals for five days and that you cannot return someone to play even if the lesions are covered. You know that with impetigo, they need to be treated with antibiotics with for at least 72 hours, no new lesions for 48 hours, and you know that they cannot be covered for return to play. I just told you about tinea gladiatorum or fungal infections. They have to be treated with topical antifungals for 72 hours before you can cover and return to play. So they have to have treatment before you can cover and return the athlete to competition. And then I just mentioned molluscum contagiosum, which is a different viral infection. Don't forget that central umbilication and that lesion, but those can be covered and the athlete can be returned to competition without any treatment. So molluscum contagiosum would be the correct answer. And how about a wrestler being seen for a skin rash that has the appearance of herpetic gladiatorum? And they might give you a picture, but they'll tell you that it has that appearance. You're asked about return to play requirements for this condition. Which of the following is required for return to play? Do you need a viral culture confirming the diagnosis? No new lesions for 48 hours? Cover the active lesions before return to play or systemic antiviral therapy for five days? Well nowhere here other than with MRSA have we mentioned that for a virus you need a culture. You can't have any new lesions for 72 hours. Remember 48 hours is for bacterial lesions. Remember the only lesions you can cover return to play with is the tinea lesions I just mentioned with treatment or the molluscum contagiosum lesions. And for viral infections, these herpetic infections, not only can you have no new lesions for 72 hours, but you have to treat for five days with systemic antivirals before the person can go back to competition. All right, that should cover about what you will see in dermatologic conditions in an athlete on your exam. Again, recognizing patterns, recognizing return to play conditions, and what an athlete can and cannot return with. So let's talk a little bit about ergogenic aids, i.e. what helps an athlete perform better. And we'll spend a little bit of time here in this area. Dietary supplements. There are lots of dietary supplements that are out there that athletes will use, but there is very little evidence that any dietary supplement is an ergogenic aid to actually help athletes. Lots and lots of theory, lots of stores, lots of millions and billions of dollars being made off of dietary supplements, but there is very little evidence for ergogenic effects. One of the biggest things you need to know about dietary supplements, as it affects the athlete, is your role as a team physician, is that oftentimes their production and content are not regulated. And maybe even greater than 20% or higher, upwards of 50%, can be contaminated with substances that could cause your athlete to have a positive drug screen on a drug test. So you need to be aware of that when you think about dietary supplements. Many athletes blame their failed drug test on supplement use, and so therefore there's got to be a lot of caution in recommending its use. And there's really not much evidence on side effects and long-term effects of use. So we don't know a lot about how long should you use this, what's the long-term effect, does it have deleterious effects. So ergogenic aids for dietary supplements, the recommendation is oftentimes not very effective, and we don't know a whole lot about these aids in general. Dr. Best mentioned some things, and I'll reiterate them here, because they're important and numbers that you need to know, so repetition is always good. Carbohydrate, as Dr. Best mentioned, over 65% of VO2 max or anaerobic activity is your primary energy source. It should be a large part of an athlete's diet. These protein numbers, again, I put them here because they're important and you need to recognize them in case they show up. For endurance athletes, and most of us, we only need 1.2 to 1.4 grams per kilogram per day of protein. For strength athletes, they may have a slightly higher requirement of 1.6 to 1.8 grams per kilogram per day, but anything really above 2 grams per kilogram per day is just wasted. So all these protein supplements and using all this protein is probably not effective for athletes. Protein can help with gaining strength during conditioning and aid in recovery, so it can be important ergogenically, but there's no evidence that taking in large amounts of protein improves performance in sport-related activities. Again, Dr. Best mentioned, and I will re-emphasize at this point, take a look at these numbers before you take the exam. They oftentimes show up the difference between endurance and strength athletes and the need for protein requirements. Very easy numbers to put in a multiple choice question that can show up on your exam. Let's spend a little bit of time talking about creatine, because it's very commonly used and oftentimes asked about. Creatine monohydrate, as you probably know, is needed for short-burst muscle contraction and acts to regenerate ATP. Its benefit depends on individuals' normal stores, so there's many of us that already saturate our stores of creatine, so if we use it, we don't get any benefit and it's hard to know which of those individuals are, so it's really a trial and error system. Creatine, if used appropriately, can enhance activity with short bursts of maximal activity, such as weightlifting, but there's no benefit for creatine in general for endurance activities. The dosing is commonly a loading dose of 20 to 30 grams per day for a week, followed by 2 to 5 grams a day for 3 to 6 weeks of a maintenance dose, so there's an initial loading dose of creatine and then a period of weeks with a maintenance dose. And creatine will cause weight gain, but most of that weight gain is due to water retention, so most of the effects of weight gain from creatine are lost once you stop using it. Excess creatine is eliminated through the kidneys, and this is important to understand because some of the side effects that you need to be aware of if your athletes are using creatine can be associated with that. Most commonly, dehydration is one of the side effects, especially in those athletes using creatine if they're in heat or participating in their sport. Oftentimes they'll complain of muscle cramps and dizziness, sometimes diarrhea, and there are suggested long-term renal issues with prolonged high-dose use and can put an athlete at risk for acute renal failure and other issues if used long-term, so you want to keep that in mind. Creatine in general is contraindicated in liver or renal disease, so if you've got problems with the liver or problems with the kidneys, you do not want to suggest that someone use creatine. It can lead to significant effects. Creatine is really the only well-studied and I think the only supplement that you would be asked about on your exam. There's tons of other dietary supplements that I mentioned have very limited evidence that are used by athletes but don't have evidence for ergogenic effects. Let's turn our attention for a minute here to anabolic steroids. I'm certain most of you, if you take care of athletes and have been involved in sports medicine, have come across anabolic steroid use in your practices or with your teams. You know that these can be natural or synthetic derivatives of testosterone, and these have true ergogenic effects. They absolutely work. They reduce recovery time. They increase lean body mass, both strength and weight. There's an increase in aggressive behavior, which can be beneficial. There can be enhanced sport performance. So think about these folks can run faster, jump higher, lift more weight, etc. And so many of us have lots and lots of examples of folks that have likely been using some of these anabolic agents, and you've seen them. And they can have heightened sexual arousal and function. They're used in many different ways. So some are taken orally, some are used IM by injection, and some can be used with a cream or transdermal, as many people follow the Barry Bonds and other things. You know that these can be delivered many different ways. They're often stacked with other aids, so they're oftentimes used in conjunction with other ergogenic or anabolic aids in order to produce effect, and often are cycled as well. So one to three cycles per year. Testing is most commonly urine testing, and I don't think they'll ask you about ratios, but you're looking for increased levels of testosterone, or an abnormal testosterone to epitestosterone ratio would be the testing that is used to detect anabolic steroids. One of the things you're going to pay attention to is side effects, because this gets asked a lot about anabolic steroids. How do you identify someone who's using them, and the way you identify them is to become familiar with these side effects. And so I'm not going to take a lot all this time to read this to you, except to say put a little star here. This is where questions will arise, being able to recognize side effects so you can recognize athletes that have used anabolic steroids. You might take a look at the generalized section, elevated blood pressure, increased cholesterol, decreased HDL, liver abnormalities, congestive heart failure, things that may not be readily evident to you just on inspection. There's increased risk of acute myocardial infarction and sudden cardiac death, an increased risk of liver, renal, and hepatic malignancy. So there is a risk of malignancy in anabolic steroid users. You're aware of the musculoskeletal problems that occur and the psych problems, but overall anabolic steroid users have a decreased lifespan. So there is an increased risk of mortality at a younger age in anabolic steroid users. Erythropoietin, or EPO, you need to know about as well. It's a commonly used ergogenic aid in endurance athletes and especially gets a lot of publicity in cyclists. It's produced by the kidneys, secondary to hypoxia, many times is given by a subcutaneous injection as a recombinant EPO. It acts by increasing red blood cell production and hemoglobin levels, increasing the oxygen carrying capacity of the blood, and it can act to increase VO2 max. So in endurance athletes you can see where this would be very beneficial. Again, you want to know about the adverse effects. There's an increased risk of because of the increased viscosity of blood and thrombosis and embolism, especially for CBA. There's acute increased risk of acute myocardial infarction and then liver or cardiac disease, secondary to iron overload. You can get similar effects to EPO if you see questions about high altitude training, blood doping, the hypoxic hypobaric sleeping chambers that are popular. This is a quicker, faster way to do this. Testing is often looking at hematocrits that are greater than 50% and decreased reticulocyte counts. I'm sorry, increased reticulocyte counts due to the EPO that's been injected. Stimulants are very common ergogenic aids. They're used commonly amongst athletes and especially collegiate athletes. As you know, amphetamines are used to treat ADD and ADHD disorders, and they're the most abused prescription drug amongst college athletes. They do have ergogenic effects, though, that are positive. They can increase energy and awareness, delay fatigue, enhance speed, power, endurance, and concentration, and so therefore are very oftentimes sought after by athletes. Ephedrine and ephedra I mentioned to you to be careful to use, especially in those with common cold, because they can cause a positive drug test. And you can see they're very common in energy drinks and dietary supplements. They oftentimes were used in combination with caffeine for increased energy and increased lean mass, but those were removed by the FDA secondary to catastrophic side effects, including CVA, sudden death associated with arrhythmia and seizure, which is what you need to think about with many of these stimulants or amphetamines. Caffeine is ergogenic, but you have to get to very, very high doses. So in the normal doses of your cups of coffee or your soda that you're drinking, caffeine is not ergogenic. But in super physiologic doses, caffeine can also have this effect, and it can also have the same side effects as other stimulants if you're using it for ergogenic aid. So remember, stimulants are very highly addictive, and they have lots of side effects. So again, I would draw your attention to the side effects of these anabolic ergogenic aids. Delirium is very common if abused, paranoia, aggression. Oftentimes, as you can imagine, problems with insomnia, agitation, restlessness. Palpitations are a very common complaint. So the people that are using a lot of stimulant will come in complaining of increased palpitations. And oftentimes, you'll catch them on your physical exam and vital signs with an elevated blood pressure in an athlete that otherwise should have normal blood pressure. The problem with stimulants is if you stop using them, you get all the deleterious effects of all the positives that they were causing for you. And many times, there's this rebound fatigue. So that's why athletes want to continue to use them and depressed mood or depression can occur after the use of stimulants. Human growth hormone. I think just to mention human growth hormone, as you probably know, the ergogenic effects are mediated through insulin-like growth factor, or IGF-1, which increases protein synthesis and fat breakdown, which is a good thing for most athletes. There's an increase in hepatic glucose production, and it stimulates the liver to make more IGF-1 to increase bone and muscle growth, which you'll see, again, causes some of the side effects of human growth hormone. It can work synergistically with testosterone. So many people believe that if you find an athlete who's using an anabolic steroid, even if you can't detect it, they are probably using human growth hormone along with it. It is available as a recombinant product. And the problem is, is that there's not great testing for it. It's removed quickly from the body, and in order to test for it, the products continue to change. So it's difficult for us to test for human growth hormone on a regular basis. Again, know about the side effects of human growth hormone. Many of these ergogenic aids, what they want you to know is how is this going to be harmful to your athlete. So the side effects, again, we mentioned thickened bone or acromegaly, fluid retention or edema, elevated blood pressure or hypertension. There's an increased risk of cardiovascular disease and CHF with the use of human growth hormone, and an increased risk of insulin resistance. Probably the most important thing for you to know for your patients is that there's no good evidence that human growth hormone provides benefit in performance. It can do all the things we just talked about, but we're not certain that it's truly ergogenic and improves performance. So some questions to finish up here in the last minute. Which of the following is true in the use of creatinine monohydrate? It is effective as an ergogenic aid in distance running. It commonly causes weight gain, secondary to increase in lean body mass. All athletes respond to creatinine in a similar fashion. There are no side effects with creatine use, and creatine use is contraindicated in renal liver disease. I mentioned it's an effective ergogenic aid, but it's in short maximal burst activities, such as weightlifting, not in distance running. It commonly causes weight gain, but that's secondary to fluid retention, and that's why that weight gain disappears when you stop using it. I told you most athletes won't respond the same because some are saturators already. There are many side effects, as I mentioned, with creatinine use, but you know now that it's contraindicated in renal or liver disease. You are seeing a bodybuilder with a ruptured biceps tendon. Based on your evaluation, you are concerned that he's using anabolic steroids. You counsel him regarding the risk of long-term anabolic steroid use. Which of the following is not associated with anabolic steroid use? Elevated blood pressure, testicular atrophy, hepatic cancer, decreased total cholesterol, or gynecomastia. And so you would know if you review those that there is actually increased total cholesterol along with increased LDL and decreased HDL in those that use anabolic steroids. Last question, which of the following has not been proven to have ergogenic properties for athletes? I mentioned to you that anabolic steroids, stimulants, creatinine, and EPO have all been shown to have ergogenic effects, but we don't know about the ergogenic effects of human growth hormone. 15 seconds over my time limit, so I'll stop there and I think we're scheduled for a break. Thanks for your attention and good luck on the exam.

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