All right, I've been put back on the clock, and so if you're making your way back into the room, we'll go ahead and get started with this second talk here today on medical issues. Again, I will try to highlight important features of these areas for you that are testable or on an exam that would relate to sports medicine or to an athlete. This talk will focus on infectious disease, dermatology, and then ergogenic AIDS, so some high-yield areas in sports medicine that you may or may not deal with on a frequent basis. Again, I don't have anything to disclose for this talk. Infectious disease, I'll talk a little bit about what you need to know about immunology and infection and exercise. I'll talk about some common infections. I'll spend a bit of time talking about infectious mononucleosis, which I would be shocked if that's not one of the questions you get on your exam. I'll briefly mention myocarditis, which I know Dr. Best will talk more about in his talk that includes cardiology. I'll talk a little bit about other blood-borne infections that you need to be aware of. In dermatology, I'll talk about some of the mechanical and environmental dermatologic conditions that occur in athletes, and then I'll spend some time talking about the viral bacterial and fungal issues that occur in athletes, and some of the things you need to know about treatment, duration of treatment, and ability to return to play with these infections. And then I'll talk some about high-yield issues with ergogenic AIDS, supplements, and performance-enhancing drugs. So let's start by talking about infectious disease. The immune system, as you're aware, or maybe you're remembering now as you go back to medical school, has an innate and acquired system. The innate system is made up of natural killer cells, phagocytes, skin, mucus membranes, and hair, and your acquired system is the T and B cells with immunoglobulins and secretory IgA and mucus. In exercise, it's important for you to know that nasal breathing that we normally do when we're just sitting here in this room transitions to mouth breathing, which allows more foreign particles to be deposited in lower airways. So it's important to know that there's a transition that occurs between nasal breathing and mouth breathing that can lead to foreign particles being deposited in those lower airways. And that intense and prolonged exercise can have a deleterious effect on the immune system, which is a decreased function of lymphocytes and decreased number of neutrophils. So if you have an athlete who's an extreme athlete, maybe involved in Ironman triathletes or one of these people that does 24-hour runs or something like that, they may be at risk for infection because of these effects on the immune system. Infection in exercise, we know that fever impairs coordination, concentration, muscle strength, and aerobic power, and it also inhibits our ability to deal with heat. So it is a best practice that no exercise or sport should occur with fever, and that is routinely defined as a temperature at or greater than 101 degrees Fahrenheit. We need to know that drugs used to treat infections, antibiotics, can cause diarrhea and need to be used with proper indication, and that could lead to dehydration. And of course, I think most of you are probably aware you need to make special note of the fact that quinolones have been associated with a risk of tendon rupture. So the use of quinolone antibiotics for the treatment of infection could put your athlete at risk for tendon rupture. It's also important to know that with infection in general, we think about return to play, and you need to be aware of this concept of the neck check. The neck check refers to symptoms confined to upper respiratory region. Most athletes can exercise at lower intensity as long as their symptoms don't worsen. So if all I have is nasal congestion, a mild sore throat, those sorts of things, it's reasonable for someone to exercise at a low intensity if they're considered to be afebrile. But below the neck and systemic symptoms, so if I have a bronchitis, if I have a pneumonia, if I have a gastrointestinal illness, something like that, they should discontinue exercise until their symptoms have resolved. And so be aware of that neck check idea when you think about symptoms for infectious disease. So let's go through a couple questions here, as we have previously, that may highlight how this could be asked. A collegiate women's basketball player presents to her athletic trainer with dysuria, hematuria, urinary urgency, and frequency. These are all very common signs and symptoms of a urinary tract infection or cystitis. She's referred to her team physician and urinalysis suggests diagnosis of urinary tract infection. Which of the following antibiotics should the team physician avoid prescribing given concern regarding tendon injury or rupture? And all of the antibiotics I've listed here would be reasonable for the treatment of urinary tract infections in most situations. I just mentioned to you that the quinolones are the ones that have an associated risk of tendon rupture. Question two, you're seeing an athlete with complaints of a common cold. Which of the following symptoms will require you to withhold the athlete from exercise and sport? So rhinorrhea, a sore throat, bronchiolar wheezing, sinus pressure, or post-nasal drainage? And I just mentioned to you this idea in sport and exercise about a neck check, which means that any symptoms that occur below the neck in the lower respiratory system or GI system are reasoned to withhold someone from sport. And so bronchiolar wheezing does not pass the neck check rule and would be a reason to withhold an athlete from sport. Let's talk about some common infectious diseases that you may see in athletes and give you some information about them. Upper respiratory infections are common and they're most often viral. Pay attention to the causative reasons for these infections. They're spread very easily in sports situations. The clinical diagnosis is very common nasal congestion or rhinorrhea, cough, mild fatigue, and a low-grade fever. Symptoms are usually self-limited and the treatment is often symptomatic. Fluids, acetaminophen, rest, potentially some non-sedating antihistamines. But you want to have caution with ephedrine-based medications because they can cause a positive drug test. Hygiene is really important. So if you get a question about what to do to prevent the spread of common infectious disease, think about common things being common hygiene, you know, hand-washing, promoting good personal hygiene. It minimizes transmission. The other thing you need to know in athletes that the influenza vaccine is effective in 70 to 90% of cases most of the time and is recommended for all athletes because of the risk of spread for influenza. So vaccinations are good. They're good in most folks and they're good in athletes. Sinusitis is common. It's a common complication of URI, but it is most commonly viral. Bacterial sinusitis caused by Haemophilus influenzae, strep pneumonia, or M. catarrhalis can present with fever, purulent discharge, sinus pain that worsens after URI symptoms for seven days, or for several days, I'm sorry. And usually that's after a period of greater than 10 to 14 days. The treatment for bacterial sinusitis is antibiotics for 10 to 14 days, amoxicillin, amoxicillin clavionate, or Augmentin, or trimethopim, sulfa, or Bactrim. But remember that the most common cause of sinusitis is still viral. So the treatment is still supportive. Acute bronchitis, a cough for three weeks with URI symptoms, 90% of the time is viral, does not require antibiotics and they're rarely needed. So symptomatic treatment. So I've yet to really mention an infection other than an acute bacterial sinusitis where you need to use antibiotics. And so there is a thought, obviously, with overprescribing of antibiotics, and certainly with athletes, most sports physicians are very quick to prescribe antibiotics, the idea that symptomatic treatment is most effective. Pneumonia is different. In pneumonia, about 30 to 50% of the time it's viral, but 50% of the time it's bacterial. And even in most athletic populations, it's due to strep pneumoniae. So this is the one infection now that I've mentioned to you that is more commonly bacterial rather than viral. Symptoms include fever, a productive cough, fatigue, anorexia, and myalgias. There are diagnostic tests here that you can see. CBC, obviously, showing a leukocytosis. A chest X-ray is recommended to evaluate for infiltrates. Remember that sputum cultures for pneumonia are not sensitive. Blood cultures are. So if given a choice, you want to get two blood cultures from separate sites. The treatment for pneumonia is most often antibiotics, and our first choice are macrolides such as azithromycin for a community-acquired pneumonia. You cannot return to sport until all symptoms have resolved. Pharyngitis. Most common cause is viral. Probably the number one reason in most adolescent and collegiate younger athletes for overprescription of antibiotics is pharyngitis because very infrequently is it due to a bacterial cause. But when it is, it's usually due to strep throat or group B beta hemolytic strep. There'll be red swollen tonsils with a whitis exudate, and we're going to contrast that with infectious mononucleosis here in a minute. Oftentimes in group A beta hemolytic strep infections, they will have anterior cervical lymphadenopathy, fever, abdominal pain and headache are common, but URI symptoms are uncommon. So strep throat very rarely presents with cough, rhinorrhea, post-nasal drainage, any of those sorts of things. These common things that I've mentioned to you are included in what's called the CENTOR, C-E-N-T-O-R criteria, and as you have more of those symptoms, the likelihood of you having strep throat increases. Rapid strep tests are 80 to 90% sensitive, but throat culture is the gold standard. You need to be aware that in strep throat, the most common complication is a peritonsillar abscess. Peritonsillar abscesses are most often treated with antibiotics and IND. The treatment for group A beta hemolytic strep is penicillin or amoxicillin for 10 days, and azithromycin is considered second line from either cephalosporins or penicillins for those that have an allergy. So how about a couple questions here in this area? When an athlete presents with upper respiratory symptoms, including productive cough, malaise, and fever, you remember that most common upper and lower respiratory infections are caused by viruses. Which of the following is most likely to be associated with a bacterial infection and require antibiotic treatment? An acute bronchitis, a low bar pneumonia, an acute pharyngitis, or an acute sinusitis? And to this point, I've only mentioned to you that one of these is caused by bacterial infections over 50% of the time, and those are pneumonias. So a low bar pneumonia has at least a 50% bacterial infection rate. Let's talk about infectious mononucleosis. Infectious mononucleosis is an infection that all sports medicine physicians need to be aware of. It's caused by the Epstein-Barr virus, which is a herpes virus. It's transmitted via oropharyngeal secretions, and that's why it's referred to as, quote unquote, the kissing disease. Very common in adolescents and collegiate college students, young adults under the age of 22 or 23. You can see the peak incidence there for infectious mononucleosis is ages 15 to 25. Remember that many of us are exposed to Epstein-Barr virus when we're young children, and it causes a much less significant infection than when we're older. So 30% to 70% of collegiate students are susceptible to acute infection, and 1% to 3% acquire the disease each year. And there are significant clinical symptoms in adolescents and young adults. But as I mentioned to you, in pediatric patients, they deal with this much more like just a common upper respiratory infection. In infectious mononucleosis, it's important to know that the clinical syndrome can occur several weeks after the exposure to the virus. There is common prodromal symptoms of fatigue or malaise, headaches, and common myalgias that may be very nonspecific and consistent with other infections. But you need to at least be aware of this classic glandular fever triad for infectious mononucleosis, which is the combination of fever, significant pharyngitis, and cervical lymphadenopathy, both anterior and posterior cervical lymph nodes. So to contrast this with strep throat, commonly in strep throat, you only see anterior cervical lymphadenopathy. If they give you a clinical vignette or scenario where you have an athlete that has a fever, pharyngitis, and both anterior and posterior cervical lymphadenopathy, be thinking about infectious mononucleosis. There's lots of additional symptoms in infectious mononucleosis as well. Fever, fatigue, rash, palatal petechiae are very common in infectious mononucleosis. Splenomegaly and hepatomegaly, which we're going to talk about in a minute as a feared risk factor, are not common but can occur. And then vague abdominal pain or GI upset. Fortunately, in most patients with infectious mononucleosis, symptoms resolve after four to eight weeks. The diagnosis of infectious mononucleosis is made primarily based on clinical symptoms. So you'll oftentimes, if you're given a vignette or something that suggests infectious mononucleosis, it will be based on clinical symptoms. There is an elevated white blood count, and you need to know that there is an atypical lymphocytosis, which is very common and considered to be pathognomonic in this situation of greater than 10% for infectious mononucleosis. The monospot test or the heterophile antibodies can be used, but it's not as sensitive and specific as looking at EBV titers or the viral capsule antigens, IgG and IgM, for making the definitive diagnosis of infectious mononucleosis. If EBV nuclear antigen antibodies are present, there was a prior infection, and they are not acutely infected with the Epstein-Barr virus. Oftentimes also, because of the hepatitis that occurs with infectious mononucleosis, we'll see elevated LFTs or liver function tests in those affected with infectious mononucleosis. Infectious mononucleosis has a number of complications. Airway obstruction can occur because of local inflammation and pharyngeal swelling. There's a hemolytic uremic syndrome that can occur. Aplastic anemia can occur. EBV infections in a younger population are probably as highly associated with Guillain-Barre syndrome as any other viral infection. Early chronic fatigue syndrome or prolonged fatigue is something that's associated with infectious mononucleosis. And then splenic rupture in sport. And it's splenic rupture you need to think about. I mentioned the spleen in my last talk. But this is where, in athletics, obviously, we have many thoughts and some guidelines around the ability to return to sport. So in infectious mononucleosis, splenic rupture is a rare but feared complication of the disease itself or the infection itself, especially in the return to play. Atraumatic splenic rupture, atraumatic, is much more common than traumatic splenic rupture. So this can occur in any athlete that returns to sport. So there is a misnomer out there that it's only contact athletes that need to be restricted from sport if they have infectious mononucleosis. But the risk of splenic rupture is much higher and has a much higher incidence in atraumatic situations. So you don't need to have trauma in order to have splenic rupture. The data suggests that most splenic ruptures occur within about 21 days of acute infection or diagnosis and rarely after 28 days, although there are case reports of that occurring. Usually once you get about four weeks out from the infection, the risk of splenic rupture is significantly low and less than 1%. There's a very large variation in normal spleen sizes and there may be benefit if you're getting measurements of spleens and referring to nomograms when evaluating the spleen of a tall athlete if you're going to do splenic ultrasounds. But it is not recommended as standard of care or best practice to do repeated splenic ultrasounds in the evaluation of patients with infectious mononucleosis. I mentioned to you that the spleen returns to normal size on average about a month after the diagnosis of infectious mononucleosis. So return to play guidelines for those athletes with infectious mononucleosis. There's very limited prediction of safe return to play based on physical exam, i.e. your inability to detect splenomegaly does not improve the athlete's ability to return to play. So if you have an athlete who's two weeks out from a diagnosis or symptoms of infectious mononucleosis and you do a physical exam and you do not detect splenomegaly on your physical exam, it does not mean that they are at a decreased risk of splenic rupture. The recommendations for infectious mononucleosis is that there should be no physical activity for an athlete for the first three weeks after the diagnosis or symptom onset of infectious mononucleosis. If the athlete has recovered all their other symptoms, they may be allowed to have limited activity four weeks after, which would include low fitness activities such as getting on an exercise bike or doing some prolonged walking. At four weeks after the diagnosis or symptom onset, if they're doing well, they may begin to return to sports. So that's the number you need to be aware of is four weeks after the diagnosis or symptom onset. The other thing you need to know about infectious mononucleosis is that steroids do not decrease the risk of splenic rupture in athletes with infectious mononucleosis, and they are only indicated if there is airway complication, but they do not decrease other morbidity or enhance return to play in athletes with infectious mononucleosis. So they're oftentimes prescribed, but their benefit is really only in those that have airway complications. So how might you see this in a question? A swimmer is diagnosed with mononucleosis. Which of the following is true regarding the care of an athlete with mononucleosis? Splenic rupture only occurs in athletes exposed to contact activity, and this swimmer can return to sport without restriction. Splenic palpation is an accurate way to determine normal spleen size and return to play. If the athlete is asymptomatic and tolerates light exercise, she may return to swimming four weeks following symptom onset or diagnosis. Steroids are indicated for symptom resolution and faster return to play in an athlete with mononucleosis. So I mentioned to you that splenic rupture is more commonly atraumatic and can occur in athletes that do not involve contact in their sport. I just mentioned that splenic palpation is not an accurate way to determine splenic size and does not accurately predict return to sport or decreased risk of splenic rupture. We talked about that four-week period, and so it is accepted in best practice that C is the correct answer. And I just mentioned to you that steroids do not decrease morbidity or enhance return to sport following infectious mononucleosis. Other infectious diseases that you just need to kind of be aware of, otitis media, again, the most common cause is viral, significant overprescribing of antibiotics, a reg-bulging tympanic membrane, but you rarely need antibiotics. Otitis externa or swimmer's ear is more commonly due to bacterial and fungal infections. So otitis media is viral, otitis externa, bacterial and fungal. Oftentimes there's ear pain if there's pulling at the tragus, and oftentimes a purulent discharge from the external auditory canal. The treatment is cleaning and then topical antibiotic or antifungal eardrops. Conjunctivitis, again, most commonly is viral. A purulent discharge can suggest a bacterial cause. Treatment is antibiotic eyedrops, if indicated, and transmission control. So again, don't forget about hygiene in these viral infections. They'll sneak up and, you know, the simple answers are oftentimes right, you know, hand washing, for example. The other thing about conjunctivitis, as we mentioned with other ocular issues, is obviously it needs to be resolved before you would use contact lenses. So it needs to be completely resolved before an athlete would return to contact lenses. Meningitis, you need to be aware of this, especially in adolescent and college age athletes. The most common meningitis, fortunately, is aseptic meningitis or viral meningitis, and the most common virus that causes that is the Coxsackie virus. Aseptic meningitis is oftentimes not even diagnosed. There can be a malaise, low-grade fever, myalgias, maybe a mild stiff neck. Contrast that with septic or bacterial meningitis, which is a type that you need to be able to identify. Bacterial meningitis has high morbidity and mortality, even with treatment, so it needs to be diagnosed and treated quickly. The key here is immunization, right? So those people that are in the age group of 17 to 22 that are going off to college or into the armed forces or whatever is immunization. The classic triad that you'll see for meningitis is fever, stiff neck, and significant headache. These patients that have bacterial meningitis obviously decompensate very quickly. Immunization of septic meningitis requires notification of close contacts and treatment and isolation. So these patients, if you think you have a vignette where you have someone with septic meningitis, they need to be removed from their team, they need to be isolated, and the team that they are in contact with or the other players need to be offered treatment. And then certainly immunization is important. Myocarditis, like I said, I'll mention a few things here, and you'll get some more information on myocarditis I know from Dr. Best's talk here later this morning. Myocarditis is a complication following common viral infections. So common upper respiratory infections, or as I just mentioned, a septic meningitis, so Coxsackievirus, is commonly seen as a cause of myocarditis. Men are more commonly affected between the ages of 20 and 40. Symptoms can include chest pain, fatigue, fever, and palpitations, and I know Dr. Best will distinguish this from pericarditis in his talk. Diagnosis, nonspecific ST and T wave abnormalities are noted on the ECG, and an echocardiogram will oftentimes show global decreased ventricular function, oftentimes to get a true diagnosis cardiac biopsy is needed. Typically myocarditis is self-limited, but while the infection is there, and potentially even afterwards, there is an increased risk for arrhythmia and death. And so the Bethesda guidelines and the number you need to pay attention to is that you're not allowed to exercise or have strenuous activity for six months following the diagnosis of myocarditis. So it's that six-month number that you want to pay attention to. Gastroenteritis, the most common causes are viral, again. Very rare that we see bacterial gastroenteritis in athletes. Again, I'm mentioning hygiene. Just for this infectious disease, oftentimes they just want you to know simple things, but think about good hygiene is prevention. Certainly with gastroenteritis, one of the feared complications is dehydration. Remember that almost everyone can be rehydrated with proper oral rehydration solutions. So IV fluids are almost never indicated unless someone's orthostatic or showing significant signs of hypovolemia. Symptoms are often resolved in short term, in about two to four days. The athletes are allowed to go back to their sport when they're rehydrated, and their symptoms have completely resolved. Viral gastroenteritis, just to mention, is uncommon, but campylobacter is the most common. Infections with campylobacter and E. coli do not require antibiotics. Those are self-limited and just require supportive care. If you have somebody, if they give you, you know, a wilderness athlete who's been out and that may have contracted a parasitic infection such as Giardia, the treatment is with metronidazole. And traveler's diarrhea may require a short course of antibiotics. Ciprofloxacin, I mentioned here, can prevent symptoms, but you're going to remember that the quinolones can cause tendon issues. So if we're treating someone for traveler's diarrhea, we need to be careful to make certain that we remind them of that. Let me talk a little bit about some of the other blood-borne infections, HIV. We need to know that there are no documented cases of HIV transmission in sport. Exercise is beneficial for athletes with HIV. So if they give you an athlete that is HIV positive, there is nothing bad about exercise for someone with HIV. I did not mention an athlete with AIDS. AIDS is a different clinical syndrome, but any individual with HIV infection benefits from exercise. HIV in and of itself is not a reason for exclusion from athletics. So HIV is not a qualifier for disqualification from athletics. Sexually transmitted diseases, obviously in athletic populations, you need to be aware of this. I know that this was the number one thing that was treated in the 2012 London Summer Olympics were sexually transmitted diseases. Chlamydia is treated with azithromycin. Gonorrhea is treated with ceftriaxone IM. Those are CDC recommendations. Just remember those antibiotics. But that, again, prevention is key and barrier methods of contraception are the best preventative method to reduce the spread of sexually transmitted diseases. So questions. Question five. Which of the following is not a reason for exclusion from sport? HIV, active gastroenteritis, fever, myocarditis, and pneumonia. I just mentioned to you that HIV is not a disqualifier from sport. But active gastroenteritis, obviously with the risk of dehydration. We've already talked about the reason why you would not want someone to be active in sport with fever. We've talked about the risk of myocarditis. And we've talked about the risk of pneumonia. I'm going to move on to some dermatological conditions that are common in athletes and hopefully give you some high yield pointers here. For many of you, this may take you back to medical school or maybe a residency day where you saw some of these conditions. Urticaria is also known as hives due to histamine release. Many causes, oftentimes difficult to identify. Normally they're acute and they resolve spontaneously. They can range in size. Often a lot of puritus associated with it. The treatment is to eliminate allergens, non-sedating antihistamine, rarely steroid or EpiPen is needed only for anaphylactic shock. You need to be aware of this because there is a condition called exercise-induced urticaria. So athletes can get urticarial reactions from exercise themselves and you need to understand the treatment of urticaria and then the potential workup or treatment with identifying factors that could lead to that. Blisters are very common. I won't spend much time here except that you need to know how to treat them appropriately. You know that they're vesicular or bolus lesions found in superficial areas of the hands and feet exposed to friction. If they're very full and tense, you can drain them with a sterile needle and dress with antibiotic ointment and gauze. If they're open, you provide a firm occlusive dressing. Obviously, prevention is key for blisters to avoid infection. But if you have a small blister, the treatment is to treat locally and leave it alone. Talon nor, I put this picture up here just to contrast this. This is commonly in athletes referred to as black heel. They'll come in oftentimes with a discoloration on their heel and be worried that they have some sort of lesion. This is due to repeated rapid movement of the calcaneal area against an athletic shoe with this rupture of superficial capillaries. This needs to be contrasted against melanoma or other skin lesions that could occur. They don't need any treatment for this. You just need, again, to provide proper footwear for them. And the diagnosis is made by paring away the surface of the skin, finding the pigment removed. Auricular hematomas. I'm certain many of you in sports have seen auricular hematomas, especially if you care for wrestlers or rugby athletes. This is a complication that's caused with trauma to the auricular oracle and with bleeding between the skin and the auricular cartilage. These need to be treated, and this is considered an otologic emergency. They need to be IND'd and apply a pressure dressing to prevent the reaccumulation of blood in this area. If this does not occur frequently or if there is a reaccumulation, you end up with a chronic fibrous tissue and calcification is sequelae. And many people know this as wrestler's ear or cauliflower ear. And so this is a cosmetic deformity that once it occurs cannot be treated. Cold injuries. I believe Dr. Best will also mention these, but I'll mention them here. Frost nip is cold, painful, periodic, white, patchy, exposed skin. Usually on the nose, cheek, chin, or ear, common superficial areas that are exposed to very cold temperatures. If you have frost nip, the underlying tissue has not been frozen, and these can be treated reasonably well with rapid rewarming. If you have frostbite, frozen tissue, that's different, right firm tissue can lead to gangrene. And you only rewarm these folks if there's no risk of refreezing. So if they give you a mountaineer that's up on a side of a mountain and it has frostbite, you don't want to rapidly rewarm frostbite. If they have a risk of refreezing, you could cause further damage. I mentioned melanoma here just because it's the most common form of skin cancer in young athletes still. Just to be aware of the classic ABCDs and to be able to distinguish it if it occurs. Prevention is key. This is the question that I'll get asked, is that you need to use SPF 30 or higher to prevent melanoma. So prevention and sunscreen is important for the prevention of melanoma in athletes. Let's move on to some of the infectious diseases that cause skin lesions. Impetigo is common. You identify impetigo by looking at the lesion and you'll see a honey-crusted lesion on a red base with some weeping around it. Common on the face. It's most commonly caused by group A beta hemolytic strep or staph aureus. It's treated with muperosin ointment or Bactroban and either oral antibiotics, cephalosporins or erythromycin. These lesions have to be covered before you can return to play. We'll talk more about bacterial lesions and return to play in a minute. Folliculitis is common. You've probably all seen folliculitis, erythematous pustules and papules centered on a hair follicle. Staph and strep are the most common except in athletes. The hot tub variety of folliculitis is caused by pseudomonas. So be aware that there's a different cause of hot tub folliculitis, especially in athletes. Quinolone or erythromycin is used to treat common folliculitis and ciprofloxacin again for hot tub folliculitis and you know now about the side effects of quinolones. I want to spend just a couple minutes here talking about staph aureus. As you all know, staph aureus is a gram-positive cocci. It's a common colonizer of skin and nasal mucosa. It causes mild and severe infections. Skin and soft tissue infections are mild caused by staph aureus, but staph aureus, as you know, can cause sepsis and toxic shock syndrome. And certainly, methicillin-sensitive and methicillin-resistant staph aureus exist in sport. We need to be aware of community-acquired MRSA. Community-acquired MRSA infections in athletes was first recognized in the 1980s. It is still increasing in occurrence. It was identified initially in children, prisons, and in athletes, fencing athletes, football athletes, wrestlers, and in military recruits. And there is less multidrug resistance in this MRSA as opposed to iatrogenic MRSA. Here is the classic clinical appearance if they show you this. It's a significant pustule or furuncle on an erythematous base. There can be progression to an abscess with associated cellulitis. Oftentimes, in athletes, it occurs in areas of skin trauma, so microabrasions in the elbows or in the knees. There is an increasing reports of incidents and attempts to kind of classify the risk factors. But factors that contribute to spread of MRSA in athletes include sports that have frequent abrasions and lacerations, sports that involve physical contact. So, you know, some of the studies that were done on NFL athletes and athletes that were in close proximity to each other and practicing with each other or in close proximity in the locker room or certainly with sharing of equipment. Whirlpool use and nasal colonization have unknown risks for spread. And so all the people that come around to the training rooms, it might be really good to clean your training room, but we don't know if that decreases the spread of MRSA. The CDC has put out guidelines about community-acquired MRSA and the treatment of MRSA in athletes. You should be aware that you need to be able to identify it and treat it promptly to avoid spread, that you need culture for adequate antibiotic use, and oftentimes Bactrim or Revampin or Doxycycline, depending on your local sensitivities, is used. If you have a significant lesion, the treatment is still incision and drainage, and so those need to be open and drained. Muperosin is recommended for nasal colonizers, even though we do not understand if that is a significant risk factor for these furuncles or skin lesions that occur. It is recommended that you use chlorhexidine soap for cleaning so that athletes have good hygiene and are cleaning themselves appropriately. And then you certainly need to have close monitoring for systemic infections. Bacterial infections, you need to know about return-to-play guidelines. So return-to-play guidelines for bacterial infections, you need to know that there are no new lesions for 48 hours. So they can't have any new lesions for 48 hours, no moist or exudative lesions at the time of competition. And they need to have antibiotic treatment for 72 hours prior to return. You cannot cover active purulent lesions for participation. So those lesions that are weeping, but dried, crusted lesions can be covered if they've been treated with antibiotic for 72 hours with return to play. But probably the most important two things you need to know here, no new lesions for 48 hours and antibiotic treatment for 72 hours for return to play for those with bacterial skin infections. Viral skin infections, herpes simplex, herpes gladiatorum, herpes zoster, herpetic infections of the skin, burning, tingling, itching with vesicles on an erythematous base. They can occur on the lips and fingertips. They're highly infectious, lots of transmission. You need appropriate hygiene and contact precautions. And you treat them with antivirals, acyclovir or valcyclovir. They're usually, obviously, in some of these infections like zoster and dermatomal patterns, so it can be classic for a herpetic infection. Here's what you need to know about viral herpetic infections as it relates to return to play. They should not have any constitutional symptoms, so we've kind of made that a standard for infectious disease, right? You can't have fever. You need to be healthy. You should not have any new blisters for 72 hours. So I mentioned to you bacterial infections, no new lesions for 48 hours. Recommendation for viral infections such as herpes is no new blisters for 72 hours. No moist lesions, firm adhering crust, and they have to have systemic antiviral treatment for five days. So we mentioned 72 hours for bacterial lesions, five days for herpetic lesions. And you cannot cover active lesions for participation. I want to mention molluscum contagiosum because molluscum contagiosum is a pox virus infection. You can see here you get these discreet skin-colored papules with a central umbilication. They're very highly contagious, especially in water sports. They're treated locally, usually with cryotherapy, curatage, or electrodesiccation. But you can return to sport if you can cover the lesions effectively. So if it's diffuse, obviously you can't cover them. But if you can get the area where the molluscum is covered, they can return to sport. Tinea corporis, or gladiatorum, or fungal infections, or ringworm, very common amongst contact athletes, wrestlers especially. You'll see here they're identified by having an erythematous plaque with a scaling edge with central clearing. Psoriasis looks different than this. It doesn't have central clearing. I doubt that they would give you a question on the exam of a psoriatic athlete, unless it may be related to psoriatic arthritis. The central clearing here should identify this as ringworm for you. It's caused by dermatophytes, treated with topical or oral antifungals, and you'd want to try to cover these lesions, if possible, to prevent spread. Again, what you need to know about return to play for fungal infections is that they need topical therapy for 72 hours. So for bacterial and fungal infections, they need treatment for 72 hours before they can return to play. For viral infections, herpetic infections, they need five days of treatment before they can return to play. It's a little different for scalp lesions. I doubt that they'll give you any questions, but they need to be treated with systemic therapy with griseofulvin for two weeks. If you have a localized tinea infection, it can be covered and they can return to participation if the lesion is covered, provided that they've been treated with an antifungal for 72 hours. Scabies, any rash that's puritic and causes significant itching, and you can't identify the cause as scabies until proven otherwise. It usually occurs in the finger webs, wrists, axilla, and genitals of athletes. It's caused by the mite Sarcopte scabii. It's treated with Nix or Quell shampoos, and you can return following adequate treatment and a negative scabies prep. So let's take a look at a couple questions here that may refer to this section. Which of the following dermatologic conditions can an athlete participate with if completely covered and no treatment? Scabies. Well, I just mentioned to you that they have to have a negative scabies prep and they need to be treated with either Nix or Quell's. Herpes zoster. I mentioned to you there that active viral lesions can never be covered for return to play and that active viral lesions or herpetic lesions need to be treated with antivirals for five days prior to return to sport. Impetigo need to be treated for 72 hours prior to return and cannot have active lesions, so firm adherent crust with no weeping or purulent drainage. Tinea gladiatorum. We just mentioned that tinea gladiatorum needs to be treated for 72 hours with topical therapy and then an active lesion can be covered. And then molluscum contagiosum can be covered and requires no treatment prior to return to sport. So molluscum contagiosum would be the correct answer. A wrestler is being seen for a skin rash and has the appearance of herpetic gladiatorum. You are asked about return to play requirements for this condition. Which of the following is required for return to play? A viral culture requiring for diagnosis, confirming the diagnosis. We can make the diagnosis by clinical exam. No new lesions for 48 hours. Cover active lesions before return to play or systemic antiviral therapy for five days. I mentioned to you no new lesions for 72 hours and they need systemic antiviral treatment for five days. Let's spend a little bit of time here talking about ergogenic AIDS and I'll talk a little bit about these dietary supplements. There's very little evidence to support their use for benefit as an ergogenic aid for sport. Supplement production and content are not regulated and it's estimated that at least up to 20% could be contaminated. Many athletes blame failed drug tests on these so you need to have a lot of caution in recommending them. So they have to be aware of what they're taking and what they're putting into their body. And there's little evidence on side effects and long-term effects of many of these dietary supplements. Carbohydrates, primary energy source for anaerobic activity, 50 to 70% often of an athlete's diet. Protein requirements for athletes. Just mark down and maybe take a look at these numbers 30 seconds before you take your test. Endurance athletes require 1.2 to 1.4 grams per kilogram per day. Strength athletes require 1.6 to 1.8 grams per kilogram per day. Protein helps with gaining strength during conditioning and AIDS and recoveries but there's no evidence that using super physiologic amounts of protein improves performance for athletes. Spend a little bit of time talking about creatine or creatine monohydrate. Creatine is needed for short burst muscle contraction and acts to regenerate ATP. The benefit of creatine use as an ergogenic aid depends on an individual's normal stores. So many of you sitting here saturate your normal stores without using any supplement and if that's the case using additional creatine would not be helpful for you. If you do not have your stores saturated then using creatine can give you benefits in activities where short bursts of maximal activity are needed such as weight lifting. There's no benefit of using creatine for endurance athletic performance i.e. I can run a longer distance in a shorter amount of time. The dosing for creatine is often a loading dose 20 to 30 grams per day for about a week followed by 2 to 5 grams a day for 3 to 6 weeks and using creatine will cause weight gain but most of that is due to water retention. It's not due to lean muscle mass. Excess creatine is eliminated through the kidneys and what you need to know is there are side effects with creatine use. Dehydration and muscle cramps can occur and so it's not recommended that these are used in athletes that are training in hot environments. Sometimes dizziness, sometimes there can be GI upset and there is a question about long term renal issues with prolonged high dose use. It is not recommended that if someone has renal or liver disease that they use creatine. There's lots of other dietary supplements as I mentioned that are used by athletes but there's very little to no evidence for ergogenic effects. Lots of theory but not evidence. Let's spend a couple seconds here talking about anabolic steroids. Anabolic steroids are any natural or synthetic derivatives of testosterone. So there are a ton of these out there. They do have true ergogenic effects. There's no doubt that they work. They reduce recovery time. They increase lean body mass, strength and weight. They increase aggressive behavior if that's beneficial for your sport. They increase sport performance. They help you run faster, jump higher, lift more weight, etc. So they work. They also cause a heightened sexual arousal and function. They're used orally, intramuscularly or as a cream. So there's lots of different ways that anabolic steroids can be used. They're oftentimes quote unquote stacked with other aids. So they're oftentimes used with other anabolic or exercise performing aids. Cycling usually is used. So most people that use anabolic steroids will cycle one to three times a year with periodization where they have periods of use and then periods where they don't use. And urine testing when done is looking at testosterone to epitestosterone ratios to see if those are suggestive of the use of anabolic steroids beyond what would be considered normal. What you need to be aware of are the side effects of anabolic steroids. In males, they cause breast enlargement, testicular atrophy, and decreased sperm count. In females, they can lead to male pattern baldness, voice deepening, enlarged clitoris, increased facial hair, and irregular menses. Generalized, and these are important to highlight, increased acne. They cause hypertension or elevated blood pressure. They change cholesterol profiles by increasing LDL and total cholesterol, and they decrease HDL, which obviously is not good when we think about cholesterol. They can lead to liver abnormalities, hemangiomas, elevated liver function tests. They can cause congestive heart failure, increased risk of MI and sudden cardiac death in those that use. And there's an increased risk of liver, renal, and hepatic malignancy in those folks that use anabolic steroids. You know from musculoskeletal causes, they can cause early epiphyseal closure in young athletes, decreased tendon strength, and risk of rupture. There are psychiatric disorders associated with anabolic steroids, mood disorders, depression, increased rates of suicide, and what is referred to as roid rage. And overall, anabolic steroid users have a decreased expected lifespan when compared to their age-matched controls that did not use anabolic steroids. EPO, or erythropoietin, you need to be aware of. EPO is produced by kidneys, secondary hypoxia, recombinant EPO is given by a subcutaneous injection. EPO increases RBC production and hemoglobin levels. Ergogenic effects include increased VO2 max, so obviously the classic here is cyclists that are using EPO for these prolonged rides. Adverse effects, they can lead to hypercoagulability, thrombosis, and embolism, cerebrovascular accidents, acute MI, liver or cardiac disease, secondary to iron overload. You can get similar effects from high altitude training, but maybe not as quickly. Certainly blood doping, where we're taking blood and providing transfusion when not needed. Hypoxic, hypobaric sleeping chambers, etc. Testing, we look at hematocrits, certainly that are greater than 50%, and looking at reticulocyte counts as well. Stimulants, you need to be aware, I mentioned earlier, ephedrine, but amphetamines, especially those that are used to treat an ADHD diagnosis. Amphetamines are the most abused prescription drug amongst college students and college athletes. They do have ergogenic effects, they do work, they can increase energy and awareness and delayed fatigue. They can enhance speed and power and endurance and concentration. So oftentimes, athletes want to use these medications for ergogenic effects. Ephedrine and ephedra were common in energy drinks and dietary supplements. Used in combination with caffeine for increased energy and increased lean mass. Removed by the market from the FDA, secondary to catastrophic side effects including CVA, sudden death associated with arrhythmia and seizure. You're probably all aware of individual case reports, especially of young high school athletes drinking a number of these energy drinks that had ephedra-like compounds associated with caffeine that led to arrhythmia and death. Caffeine itself is ergogenic at very high doses, but not with regular use. So it can be ergogenic and is a banned substance at very high doses. But just drinking coffee or regular soda or Mountain Dew or whatever does not cause, is not ergogenic. You need to know that stimulants are highly addictive. You also need to know their side effects. They can cause delirium, paranoia, aggression, insomnia, agitation and restlessness, palpitations and elevated blood pressure, rebound fatigue and depression. So in athletes with palpitations, usually the medication that causes those is either excessive caffeine use or a stimulant. Human growth hormone. Human growth hormone is reported to have theoretical ergogenic effects mediated through insulin-like growth factor one or IGF-1. Human growth factor can increase protein synthesis and fat breakdown. It does increase hepatic glucose production and stimulates the liver, IGF-1 to increase bone and muscle growth. It can work synergistically with testosterone. So when stacked or cycled with testosterone can be an effective ergogenic aid. It's available as a recombinant product but certainly blood testing is not widely available or used with athletes. Side effects. These are the things you need to know about human growth hormone. Obviously thickened bone or acromegaly. It can cause fluid retention or significant edema, elevated blood pressure and hypertension. There's an increased risk of cardiovascular disease and CHF with those that use exogenous human growth hormone repeatedly. And it can cause insulin resistance. It's important that you know that there is no evidence that human growth hormone provides benefit in performance. Actual measured athletic performance. It's used a lot, but there are no good studies to suggest that it is truly ergogenic. Okay, some questions. Which of the following is true regarding the use of creatinine monohydrate? It is effective as an ergogenic aid in distance running. It's commonly causes weight gain secondary to increase in lean body mass. All athletes respond to creatine in a similar fashion. There are no side effects with creatine use and creatine is contraindicated in renal or liver disease. I mentioned to you that endurance athletes do not get any ergogenic effect that the use of creatine is only helpful for short maximal activities, short burst activities. It causes weight gain, but it's secondary to fluid retention, not increase in lean body mass. All athletes don't respond to creatine similarly. If you have your stores already maximally saturated, you will not get benefit from creatine. There are lots of side effects that we mentioned from creatine use. And creatine use is contraindicated in liver and renal disease. Okay, question nine. You're seeing a body builder with a ruptured biceps tendon. Based on your evaluation, you are concerned that he is 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. I mentioned to you that anabolic steroids can cause not only elevated blood pressure, but risk of acute myocardial infarction, sudden cardiac death, and congestive heart failure. We know that in males, the use of anabolic steroids causes testicular atrophy. We know that there's a risk of a number of malignancies, including hepatic cancer. We know that gynecomastia occurs in male athletes. And we know that anabolic steroids changes lipid profiles, but it causes an increase in total cholesterol and LDL, and a decrease in HDL. And then question ten. Which of the following has been proven, I'm sorry, has not been proven to have aerogenic properties for athletes? We know that anabolic steroids, stimulants, creatine, and EPO have. Human growth hormone is used, but there is not good evidence that it improves performance. So the answer here would be human growth hormone. Here are some references. And I did even better this time. We've got one minute and 50 seconds until the end of this session. So I think there's a break coming up. Thank you very much. Thank you.

sports medicine

infectious diseases

dermatology

ergogenic aids

return to play guidelines

supplements

performance-enhancing drugs

proper hygiene

side effects