All right, guys, we'll try to rouse everyone back in from the break and have Dr. Borchers give his second presentation. All right. Thank you. All right. So we'll cover the second half of medicine here in the next hour. This second talk, we're going to focus on infectious disease, dermatology, and then some common ergogenic aids and some highlights of those areas. So again, here's the outline for the talk, and I'll talk about immunology and infection and exercise, some common infections, spend a little time talking about infectious mononucleosis because there's some pearls there that you want to know about, especially for sports medicine. I'll briefly talk about myocarditis. I know Dr. Best, in his talk this afternoon in the cardiovascular portion, will talk about myocarditis as well. We'll talk a little bit about blood-borne infections, and then we'll talk about dermatology and some key things about some mechanical and environmental dermatologic conditions, and then all the viral, bacterial, and fungal conditions, and then we'll talk about ergogenic aids, supplements, and PEDs. So a few things to know when we think about infectious disease and in the immune system. It's important to think about the innate immune system, which are our cells, phagocytes, skin, mucus, membranes, and hair, and then our acquired immune system, which, as you know, is the T and B cells with immunoglobulins. Think about secretory IgA and mucus, those sorts of things. Couple key pearls when we think about exercise. In exercise, nasal breathing transitions to mouth breathing, which allows for more foreign particles to be deposited in the lower airways. So if you think about infection, one of the reasons that happens is that we go from nasal breathing to mouth breathing. And it's important to know that with intense and prolonged exercise, you can have a deleterious effect on the immune system, and a couple things you need to know is that people that do intense and prolonged exercise have decreased function of lymphocytes and decreased numbers of neutrophils, which can put them at risk for infection. So just a couple of things to think about when we think about the immune system in general. Couple other things that you just want to think about and know about infection in exercise. We want to know that fever is a real problem for exercise. So fever is something you should just think of as a qualified no when it's participation in exercise. So athlete fever equals no participation. Fever impairs coordination, concentration, muscle strength, and aerobic power. And think about fever, and I'm just putting this number out there for you as a temperature greater than 101. So oftentimes they're going to present an athlete to you with a 102, 103. They're going to make it clear that they have a fever. What they're not going to do is tell you that their temperature is 99.8 and expect you to like distinguish is that a fever or not. Think about drugs used to treat infections, and especially antibiotics, and someone had mentioned prophylactic antibiotics. There's no need for prophylactic antibiotics, shouldn't use them ever, and in fact they cause problems. So oftentimes the GI tract can cause diarrhea. So you want to make certain we're using antibiotics only with proper indication, and you'll see that's important when I talk about infections here coming up. You're probably all familiar with this, but the quinolone antibiotics equal tendon rupture. So oftentimes in sports medicine we think about Cipro or levofloxacin or one of those antibiotics just recognize the risk of tendon rupture and even tendinopathy, tendon issues with that. And then when we think about return to play, think about this neck check, and I think this is a good rule of thumb for folks to think about. Symptoms that are confined to the upper respiratory region, you can exercise with those at lower intensity as long as they don't worsen. So sinus pressure, rhinorrhea, you know, those sorts of symptoms you can exercise with. But if you have symptoms that are lower, if you have significant cough, if you're producing sputum, if you're wheezing, if you're short of breath, you shouldn't be exercising with those symptoms until they're evaluated and treated appropriately. So let's take a look at a couple questions how this might be presented to you. So a collegiate women's basketball player presents to her athletic trainer with dysuria, hematuria, urinary urgency, and frequency. She is referred to her team physician and urinalysis 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 so I've mentioned this already, but all of these antibiotics listed here, trimethopen sulfa, nitrofurantoin, amoxicillin, ciprofloxacin, or cefalexin, can all be used to treat urinary tract infections. But you're going to want to think about cipro in an athlete being one you don't want to use because of that risk of tendon injury or rupture. And then question number two, you're seeing an athlete with complaints of a common cold. Which of the following symptoms require you to withhold the athlete from exercise in sport? So rhinorrhea, sore throat, bronchiole or wheezing, sinus pressure, or postnasal drainage. And we just mentioned, think about that neck check rule. So athletes that present with things that are coming from lower than the neck, bronchiole or wheezing, for example, you want to have them evaluated before you let them continue. All right, let's talk about some infectious disease as it pertains to the athlete. Upper respiratory infections are common and they're often viral. Like 90% are viral. So again, don't use antibiotics. They spread easily in sports situations. So this can be kind of rapid spread and you can see this, kind of that herd mentality. These infections can spread quickly. Clinical diagnosis you see there, pretty straightforward. Nasal congestion, rhinorrhea, cough, mild fatigue, and low-grade fever. Symptoms are usually self-limited. Treatment is symptomatic fluids, acetaminophen, rest, antihistamines. You want to be very cautious with any ephedrine products because that can cause a positive drug test. So be very careful with anything that has ephedrine. A couple things that you want to know about common upper respiratory tract infections. Good hygiene is preventative. So hand washing and promoting good hygiene is important. But most importantly is the influenza vaccination. So it's recommended that for all athletes that compete at the collegiate level or lower that they have an annual influenza vaccination. So most important preventative vaccination for athletes. Sinusitis, a complication of a URI and is viral in most common cases. It's different than what most people think. But most sinus infections are viral. They don't need treated with antibiotics. There are other rare cases of bacterial sinus infections. You can see the most common organisms there. And when it's bacterial, it's usually fever, purulent discharge, and sinus pain that worsens and it's been around for 10 to 14 days. You can see the most common antibiotics there to treat amoxicillin or amoxicillin and clobionate augmentin or trimethoprim sulfa. But remember that sinusitis is most commonly viral. So supportive treatment. Acute bronchitis. This is another one. Cough for three weeks with URI symptoms. 90% of bronchitis is viral. So there's Z-packs that are handed out all over the place and it doesn't, that's not what makes bronchitis better. It's just the time. So what makes them better is you telling them azithromycin lasts for 10 days after they've already had five days of symptoms. So then you get the next 10 days and they get better and they think it's a Z-pack. So then they keep asking you for the Z-pack. It's not the Z-pack. It's that they had a viral infection. So symptomatic treatment for acute bronchitis. So on the test, these are viral infections. Except for this one. Okay. Pneumonia is the one that you need to be thinking about for bacterial. So 50% of all pneumonias are bacterial. And pneumonia is obviously fever, productive cough, fatigue, anorexia, and myalgias. Obviously the diagnostic testing. So if you see a leukocytosis, obviously they'll present with an infiltrate oftentimes on chest X-ray. Sputum culture and blood, I'm sorry, sputum culture is not sensitive. Blood cultures are much more sensitive. So blood culture is the culture of choice in pneumonia. The initial treatment for most community-acquired pneumonias is macrolides. So that's where the Z-pack is probably a good choice. Although it's probably prescribed like 95% more often for other things that are viral. You return to sport from pneumonia once all symptoms have resolved. Okay. Pharyngitis. Common theme. Most sore throats are not strep throat. Most are viral. But you can have strep throat. Group A beta hemolytic strep 5 to 15% of the time. I think you're all familiar with strep throat. Red swollen tonsils with white exudate. And again, we'll contrast this with infectious mononucleosis here in a minute. Think about for strep throat, anterior cervical lymphadenopathy. Not anterior and posterior, which is EBV virus, but just anterior cervical lymphadenopathy. Fever, abdominal pain, and headaches are common. URI symptoms are uncommon in strep throat. So if they have runny nose, rhinorrhea, mild cough, and sore throat, viral infection. If they are nauseated, headache, fever, sore throat, may be more likely to be strep throat. Rapid strep cysts are fairly sensitive, but throat cultures are gold standards. The most common complication from strep throat is a peritonsillar abscess. So difficulty breathing, someone who's getting more sick, has fullness in that peritonsillar region. Be thinking about a peritonsillar abscess. The initial treatment is penicillin or amoxicillin for 10 days. And azithromycin is second line. Okay, a couple questions here. An athlete presents with upper respiratory symptoms, including productive cough, malaise, and fever. You remember that the most common upper and lower respiratory infections are caused by viruses. Which of the following are most likely to be associated with a bacterial infection and require antibiotic treatment? Acute bronchitis, low-bar pneumonia, acute pharyngitis, or acute sinusitis. So of all the upper respiratory infections we talked about, the only one that is likely to be bacterial more likely than viral is low-bar pneumonia. So any pneumonias need to be treated. All right, let's talk about infectious mononucleosis. This comes up a lot with athletes, common infection in adolescent and young adult athletes. It's caused, as you know, I mentioned the Epstein-Barr virus, so know that. It's a herpes virus that's transmitted via oropharyngeal secretion. So common in adolescents and college age is a kissing disease, you know, transmitted between significant others who are exchanging saliva. The peak incidence is 15 to 25 years of age. And it's a wide range of college students that can be susceptible to acute infection. There are significant clinical symptoms in adolescents and young adults. But remember, it's more common, fortunately, most of us get this when we're children. And when we're children and we get the EBV virus, it's not a very significant, looks like nothing more than the common cold. Okay, which is why testing is important. So the older you are when you get EBV infection, the more significant the clinical symptoms, which is why kids that are, you know, in high school or college that get EBV have more significant symptoms than like an eight or nine year old that gets EBV. Infectious mononucleosis is a clinical syndrome that can occur several weeks after exposure. You need to understand what the symptoms are. The prodromal symptoms of malaise, headache, and myalgias oftentimes looks like a viral, any common viral infection. But think about this glandular fever triad that's oftentimes described. Fever, pharyngitis, and lymphadenopathy. And this is where I just mentioned if you get a clinical scenario with somebody with anterior and posterior cervical lymphadenopathy, that's classic for EBV infection. They can have all sorts of additional symptoms, fatigue, rash, palatal petechiae, splenomegaly or epatomegaly on exam, vague abdominal pain. And it's important to know that with infectious mononucleosis, symptoms most often resolve in about four to eight weeks. The diagnosis is primarily based on clinical symptoms, but just realize that with infectious mononucleosis, there's usually an elevated white count with this atypical lymphocytosis. So that's the classic thing. If you, if they mention an atypical lymphocytosis in a clinical exam or give you this long clinical vignette and they show you the CBC and you've got atypical lymphocytes over 10%, be thinking about EBV. It can be diagnosed with a monospot test, which looks at the heterophile antibodies or EBV titers, which look at viral capsule antigens, IgG and IgM. Just as of note, EBV nuclear antigen antibodies, if they're present, suggest prior infection and not an acute infection. So if those are positive, likely not to be EBV. And then oftentimes elevated LFTs, because EBV oftentimes causes an infectious hepatitis as part of the syndrome. Lots of complications from EBV, airway obstruction, hemolytic uremic syndrome, aplastic anemia. It's the most common cause in young adults of Guillain-Barre syndrome, chronic fatigue syndrome or prolonged fatigue. But the one we think about in athletics the most is splenic rupture, even though it's extremely rare. So I just want to emphasize that. This is not common. Okay. It's not a common thing with someone with EBV. There's probably a lot of people that have EBV or infectious mono that go on and participate and never get diagnosed and never have a splenic rupture. But it's the thing that we need to be worried about in athletes and gets asked most about. So it's the, the other thing you need to know about splenic rupture that I mentioned here in the first bullet point is that splenic rupture in athletes following mononucleosis is usually atraumatic. It's not traumatic. It's not because we put somebody back to football and they get drilled in the side or fall. It's usually atraumatic. In fact, there's just as many splenic ruptures in swimmers and runners from EBV as there are in contact athletes. Data suggests that most splenic ruptures occur within 21 days of acute infection or diagnosis and rarely after 28 days. So that's the magic number here is kind of 28 days or four weeks. It's important to know that there's a really large variation in normal spleen sizes and splenic ultrasound is not routinely recommended to make the diagnosis of or to evaluate for the resolution of enlarged spleen in light of infectious mononucleosis. In some studies, the spleen, you know, looks as though it returns to normal size again after four weeks. So that four week time period after diagnosis or acute onset of infection is the time period you want to know about. When we think about return to play for infectious mononucleosis from the latest consensus statement is based on physical exam. So again, your physical exam is placed on the risk of splenic rupture. So that four week period is really important. So no physical activity for the first three weeks after diagnosis or symptom onset. Very limited activity in four weeks and then a return to sport four weeks after diagnosis or symptom onset. But four weeks is the number that you want to think about for infectious mononucleosis and return to sport. The other thing I just want to mention here is steroids are not indicated in the treatment of infectious mononucleosis. The only time they're indicated is when there's compromise of the airway. But they do not hasten recovery from infectious mononucleosis and they do not allow a quicker return to play or decrease spleen size or anything else quicker. So lots of people like to put people with infectious mononucleosis on steroids, but it does not decrease morbidity or improve return to play. Okay, so a question that might highlight some of these issues. 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. And I just mentioned to you that the most common splenic ruptures are due to atraumatic causes in athletes. Splenic palpation is an accurate way to determine normal spleen size and return to play. I've already mentioned to you that there's variation and that splenic palpation is not an accurate way to determine spleen size. If the athlete is asymptomatic and tolerates light exercise, she may return to swimming four weeks following symptom onset and diagnosis. And there's that magic number you need to be looking for in four weeks. And then steroids are indicated for symptom resolution and faster return to play in an athlete with mononucleosis. And I just mentioned to you that steroids don't have any indication in the treatment unless there's airway compromise. So the correct answer would be C. All right, other infectious diseases, very quickly that you want to make certain you know about. Otitis media or middle ear infections. Again, most common cause is viral. So you love the answer of supportive care on this test for most infections unless it's lobar pneumonia. Otitis externa, swimmer's ear is bacterial or fungal. Ear pain and cleansing and topical eardrops can be helpful for this. And then again, conjunctivitis, another common infection that's seen in athletes is most commonly viral. If you have a purulent discharge, it can suggest a bacterial cause, but most commonly viral. But oftentimes just treated with symptomatic care, antibiotic eyedrops only if you suspect a bacterial cause. All right, meningitis, we need to spend just a couple minutes talking about meningitis because it is common amongst especially collegiate athletes. Aseptic meningitis fortunately is the most common cause. And that's viral most commonly due to Coxsackie virus. So we see probably a lot of athletes with aseptic or viral meningitis that present with just viral syndromes and we probably don't make the diagnosis of viral meningitis. But it's the septic or bacterial meningitis or the Neisseria meningitis that we need to worry about because that can be fatal. There's a high morbidity even with treatment and the key to this is immunization. Okay, so it's treatment of close contacts and then immunization. So influenza immunization, Neisseria meningitis immunization, want to think about. If they present with fever, stiff neck, and headache, you need to be thinking about aseptic meningitis until proven otherwise. And obviously I mentioned notification of close contacts for treatment and isolation. So they may ask you as a, you know, sports clinician or sports physician, what's your next step of action and it would be to notify close contacts, isolate, immunize, and treat close contacts. Myocarditis, I know Dr. Best this afternoon will talk a little bit more about myocarditis, especially in the context of some of the cardiovascular emergencies that occur in athletes and cardiovascular conditions that occur in athletes. But myocarditis is a complication that follows viral infections. Men ages 20 to 40 are most commonly affected. Think about this when you think about chest pain, fatigue, fever, and palpitations or arrhythmias. Okay, so think about that with myocarditis. Unfortunately, many people with myocarditis don't have symptoms and there is sudden death from myocarditis. The diagnosis made with ECG, so ST and T wave abnormalities that are very nonspecific echocardiogram can oftentimes show global decreased ventricular function and I, although I doubt they'll ask on your test, cardiac MRI is now considering, is now being considered gold standard for these athletes to have initial evaluation of myocarditis. Fortunately, myocarditis is usually self-limited. But while they're infected, they're at risk for arrhythmia and death. And so the most important thing you need to know is that an athlete who's made it, had a diagnosis of myocarditis is not allowed to have any strenuous activity or exercise for six months. All right, gastroenteritis, we're moving our way down. Again, most common causes are viral and even in athletes are viral. So there is very limited, if ever, need for use of antibiotics with an athlete with gastroenteritis. Again, good hygiene here is the most important thing. So preventing spread is really important. Dehydration can occur. It's really important to know that rehydrating athletes is most appropriate unless they are not hemodynamically stable using oral rehydration solutions. So IV fluids is not the correct answer on the test. It's oral rehydration. Symptoms are often resolved in two to four days. They can return to play when they're rehydrated and their symptoms have resolved. Bacterial gastroenteritis is more rare. Campylobacter is the most common cause of bacterial gastroenteritis, but doesn't need to be treated with antibiotics. Just let it run its course. If someone, if they present you with a wilderness athlete or somebody who's been out in the woods and may have gotten Giardia with a parasite, obviously that needs to be treated with metronidazole. And then they could ask about traveler's diarrhea and that does oftentimes warrant a short course treatment of antibiotics. Some people travel when they travel with ciprofloxacin, but remember about the risk of cipro in athletes. And again, I would encourage you not to be writing prescriptions for antibiotics for athletes when they're traveling. So again, prophylactic use of antibiotics is, in general, in this test, not a good answer. Talk about some of the blood-borne infections, and most importantly, HIV. You need to be aware that there are no documented cases of HIV as of today in transmission in sport, okay? Exercise is beneficial for athletes with HIV. If they ask you about a patient with HIV and about exercise, all exercise is good for patients with HIV. And HIV is not a reason for exclusion from athletics. Sexually transmitted diseases, I just put these up here because these are common amongst athletes. I think in the last Olympics, STDs were the number one infectious disease that were seen amongst athletes, and they had significant problems with chlamydia and gonorrhea in Olympic Village. You need to know that the CDC has some recently updated guidelines that chlamydia needs to be treated with azithromycin and that Neisseria gonorrhea needs to be treated with IM-Ceftriaxone. So if you're treating for both, you need IM-Ceftriaxone and then azithromycin. But also, again, prevention, burial methods of contraception are best for reduced spread of STDs. So again, which of the following is not a reason for exclusion from sport, okay? Active gastroenteritis, fever, myocarditis, and pneumonia are, HIV is not. Okay, so there are athletes with HIV that are participating in sport and should not be excluded from sport. The others are qualified no's. Infectious disease in 25 minutes. Let's go on to dermatology or dermatologic disorders and some pattern recognition, okay? So urticaria, really common in sports, common hives due to histamine release. Many different causes, really difficult to identify, normally acute and resolved spontaneously, often puritic. The treatment is to eliminate the allergen, non-sedating antihistamines. Rarely do you need steroids or EpiPens needed for anaphylactic shock. But just know that exercise can cause urticarial reactions in some people. So there is a condition, exercise-induced urticaria, okay, and it can be very difficult to treat that because oftentimes these athletes don't wanna eliminate the causative agent, which is exercise. So you need to be able to think about how you're gonna treat that athlete, and those athletes should travel with an EpiPen. So some things to think about if somebody's presenting with exercise-induced urticaria. Blisters, I'm not gonna spend time here, but just know that prevention or altering equipment is probably the best way to prevent blisters, okay? So just think about the preventative issues for blisters, and especially with proper fitting equipment, decreasing friction, petroleum jelly, you know, those sorts of things. In general, if blisters aren't really full and tense, and this is in general for most dermatologic conditions that don't involve acute infection, don't be sticking things into them. You're just probably gonna cause infection, so needles and you know, those sorts of things. Talon nor, I bring this up because it can oftentimes be mistaken for melanoma. It's commonly referred to as black heel. It's due to friction in the calcaneal area against an athletic shoe and the rupture of superficial capillaries, oftentimes seen in tennis players. No treatment is needed. Again, reassurance, this is pattern recognition, understanding where this is. And you can take a scalpel and just kind of remove this superficial pigmentation from the skin and it comes away. Don't do that if you think that this might be a melanoma. If you're not sure. But it's oftentimes mistaken for melanoma. Dermat, this is the first dermatologic emergency or urgency that I'm presenting, and it's auricular hematoma. Okay, this is I know oftentimes in rugby players and wrestlers kind of a badge of honor and courage and you know. But this is truly considered for us as an emerg, sports medicine emergency. It's caused by bleeding between the skin and the auricular cartilage in the ear. These need to be incised and drained and have a pressure dressing applied for four to seven days so that that doesn't recur. I will almost guarantee in real life, right, wrestlers and rugby players rip that off or rip it out and they go back to doing what they're doing. But they need to be educated on the risk of having permanent disfigurement from this. Because if this is left under pressure there's chronic fibrous tissue and calcification that occurs and this is what ends up being that wrestler's ear or cauliflower ear. But the treatment of choice is urgent IND and an application of a pressure dressing for four to seven days. Cold injuries, I know Dr. Best will talk about environmental injuries but I want to bring them up here because of the dermatologic issues. Frost nip is a cold painful and periodic right on white patchy exposed skin. So think about this like on the ears, tips of the nose, things like that, the chin and these areas need to be rapidly rewarmed. Okay please contrast that with frostbite. Okay so frostbite is frozen tissue. It's firm, it can appear gangrenous and that crystallization of the tissue leads to damage. You don't want to rewarm this tissue if there's any chance of that tissue refreezing. So if they talk to you about an altitude athlete or a mountain climber or something like that, it's better not to rewarm that especially unless you think you're going to be able to continue that process. So for frost nip, if somebody has that on their nose or what you want to try to rewarm that skin. Frostbite, not as quickly especially if there's a chance of refreezing. I mentioned melanoma because you need to just be able to distinguish melanoma. It's malignant change in a skin mole and again I bring this up because of prevention. So the best that you should be recommending is prevention to athletes. Sunscreen use of an SPF 30 or higher. Obviously think about the ABCDs here of melanoma, asymmetry, border irregularity, color and diameter. But melanoma is actually increasing in frequency in athletes and so there is a big push for prevention and the use of appropriate sunscreen in athletes. Let's move on to some of the other skin infections here. This is impetigo. It's a honey-crusted lesion on a weeping red base. You can see a depiction of it here. It's caused most often by group A beta hemolytic strep or staph aureus. Oftentimes seen on the face, around the corners of the mouth, or around the nose. It's treated with mupirose and ointment or systemically with cephalosporin or erythromycin. You have to be able to cover these lesions before someone can return to play and I'll talk a little bit about the return to play for bacterial skin infections here in a second. Folliculitis is another common bacterial skin infection seen in athletes. You can see the erythromycus pustules and papules centered on hair follicle. Staph and strep are most common but in athletes they can develop a hot tub folliculitis which is caused by pseudomonas. So that's the one you want to be aware of because lots of athletes in hot tubs and pseudomonas is treated differently. It's treated by that lovely antibiotic ciprofloxacin which will cause them to rupture their tendons but that's the appropriate treatment for pseudomonas. So for most folliculitis you treat with a cephalosporin. If they're allergic erythromycin but if you get that athlete who's been in a hot tub and develops a folliculitis it's caused by pseudomonas and you treat with a quinolone. Staph aureus. I'm going to spend just a couple minutes here talking about staph aureus infections because they're important and prevalent in sports. You know they're gram-positive cocci and a common colonizer of the skin and nasal mucosa. Staph aureus causes all sorts of mild and then severe infections. Okay and we know that it causes a lot of mild skin and soft tissue infections. I just mentioned a couple there folliculitis and impetigo but it can lead to sepsis or toxic shock syndrome as well and there's methicillin sensitive and methicillin resistant staph aureus and you can see where this is going with the risk of MRSA infections in athletes. So we know that a community-acquired MRSA was recognized in the 1980s and with increasing occurrence in children in prisons and athletes especially and in the military and there was less multi-drug resistance. It's important to recognize what multi what MRSA methicillin resistant staph aureus looks like. It oftentimes looks like this kind of classic spider bite. It has a big erythematous base with a pustule. It can progress to a fur uncle or abscess with associated cellulitis. It occurs in areas of skin trauma so micro abrasions or around the elbows or knees so athletes that wear equipment that have trauma you'll see MRSA infections as well. Trying to look at risk factors abrasions and lacerations physical contact there's some nice studies out there you may have seen that look at football players and athletes who have transmitted MRSA when they're in close physical contact to each other and the sharing of equipment. It's unknown if whirlpool use or nasal colonization have risk of spread for MRSA. For treatment of MRSA and this is probably the most important thing you have to be able to identify it and treat it appropriately. It's really important to culture for adequate antibiotic use if possible in an athlete because there's more antibiotic resistance but in general sulfa trimethoprim is first-line and revampin is first-line treatment. But most importantly for these fur uncles or abscesses that develop they need to be IND so they need to be opened up and drained and packed and allowed to heal. It is recommended that if you have a nasal colonizer with recurrent MRSA infection that they're treated with muproresin ointment for the nasal mucosa and obviously that they were washed with chlorhexidine soap for cleansing and you need to monitor closely for systemic and other more serious infections with MRSA. So here's some pearls for bacterial infections dermatologic bacterial infections in general that you need to think about. Athletes can participate when they have no new lesions for 48 hours so that number is important that no new lesions for 48 hours and they can't have any moist or exudative lesions at the time of competition. You need to even cover non-purulent lesions for competition but they need to be on antibiotics for 72 hours that's probably the most important thing that you need to know is that if an athlete that has a skin bacterial infection it comes up in wrestling rugby these MMA sports they need to be on appropriate antibiotic treatment for 72 hours even if they don't have active lesions and you cannot cover active purulent lesions for participation. Let's talk about some of the viral infections that we see in athletes that come up commonly herpes simplex infections in wrestlers herpes gladiatorum or herpes zoster you know caused by herpes virus classic burning tingling itching with vesicles on an erythematous base lips fingertips it's really infectious I mean this stuff spreads like wildfire through a wrestling room so you have to be certain that it's treated appropriately you have to have appropriate hygiene and contact precautions and it needs to be treated with appropriate antivirals most commonly acyclovir or valcyclovir. This is what you need to know about herpetic infections for return to play they can't have any constitutional symptoms they can't have any new blisters or signs of herpetic lesions for 72 hours so remember for bacterial infections no new lesions for 48 hours viral or herpetic infections 72 hours they can't be moist they have to have firm adhering crust but they got to be on systemic antiviral treatment for five days prior to return to participation so bacterial 48 hours no new lesions treatment for 72 hours for viral no new lesions for 72 hours treatment for five days and you cannot cover active lesions for participation. Molluscum contagiosum very common in athletes distinct their discreet skin colored papules with central umbilication they're highly contagious it's they're caused by a pox virus they're treated with local treatment so it's either cryotherapy either freeze these things curatagem you can use electro desiccation if you can cover these appropriately an athlete can return with these so they if they're appropriately covered they can return with molluscum and there's no systemic treatment for molluscum no sakes okay so just contrast that with the bacterial infections we talked about and then those herpes infections that we talked about tinea lesions or tinea corporis or gladiatorum oftentimes seen in wrestlers and other athletes are commonly referred to as ringworm an erythematous plaque with scaling edge and central clearing okay not that they're going to present you with psoriasis on the exam but it's the central clearing in ringworm that gives it away from the other plaque like lesions you can see in dermatologic conditions caused by dermatophytes you need topical or oral fungals and you want to always try to cover these if possible because they can spread here's the return to play stuff you need to know about fungal infections so topical therapy for 72 hours okay so you've got to treat bacterial and fungal infections for 72 hours viral herpes infections for five days unless you have a fungal infection in the scalp and I doubt they would ask you that but that needs to be treated with griseo fulvin for two weeks before return so sometimes wrestlers get that okay and you can cover those active lesions for participation once they've been treated for 72 hours so just distinguish those return to play for bacterial viral fungal lesions and I threw molluscum in there because that's a little bit different one they oftentimes will get asked on exams I threw scabies in here very pruritic papules and burrows this occurs in athletes a lot kind of the old axiom is if you have a really itchy rash that you can't identify it's scabies until proven otherwise okay especially if they have involvement of the webs of the feet or the of the hands it's caused by sarcoptae scabii it needs to be treated completely with nix or quell and you can only return following adequate treatment in a negative scabies prep so you got to have proof of treatment for scabies in order to return alright couple questions here about some of these issues which of the following dermatologic conditions can an athlete participate with if completely covered in no treatment and so I only mentioned one to you is it scabies herpes zoster impetigo tinea gladiatorium and molluscum contagiosum and so for scabies again just by way of review we just mentioned that needs to be treated appropriately and we need to have test of cure for herpes we know we can't have any new lesions for 72 hours and we need to treat for five days before they can return for impetigo no new lesions for 48 hours and we need to treat for 72 hours before they can return tinea gladiatorium we can cover active lesions and they can return but only after they've been treated appropriately for 72 hours and then molluscum we know that if it can be covered appropriately it doesn't require any systemic treatment so we can allow an athlete to return with molluscum contagiosum if covered completely another question here wrestlers being seen for a skin rash that has the appearance of herpetic gladiatorium you're asked about return to play requirements for this condition which of the following is required for return to play and I just told you this but do you need a viral culture confirming the diagnosis we don't need any culture no new lesions for 48 hours we know it's 72 hours cover active lesions before return to play we know that they cannot have active lesions before they return but we do know that they need systemic antiviral therapy for five days dermatology for the sports medicine physician completed all right go on here to ergogenic aids and talk a little bit about some of the ergogenic aids and some of the highlights and maybe some things that you're aware of or not aware of and try to highlight some things that might be important for you for your exam dietary supplements in general for purposes of the exam there's really little evidence for you for their benefit of use okay the right answer is appropriate diet and nutrition not dietary aids okay so a good nutritional diet and meeting with a dietitian and eating the right foods does more for you than taking supplements so living on pills or dietary supplements not a good thing it's really important to know that supplement production and content are not regulated and it's estimated that up to 20% can be contaminated and so probably the most important thing to know is that many athletes blame a failed drug test on a dietary supplement so it's important as a sports medicine clinician you may be asked a question to make a recommendation that you cannot guarantee that a dietary supplement does not have a banned substance and could cause a positive drug test there's really little evidence on side effects and long-term effects of use as far as nutritional supplements carbohydrate we know that that's the primary energy source for anaerobic activity and should make up 55 to 70% of most athletes diet I think protein is an area where you want to be aware that in an endurance athlete they need about 1.2 to 1.4 grams per kilogram per day and in a strength athlete they need 1.6 to 1.8 grams per kilogram per day these numbers I know we're on the non-operative sports boards last year I don't know if they would ever show up on your boards but might be a quick number just to look at 10 minutes before you go in if you want a quick number for protein we know that protein helps with gaining strength during conditioning and aid in recovery but there's no evidence that increased use of protein improves sport performance spent a few minutes here talking about creatine because it's very commonly used and commonly asked about we know that creatine monohydrate is needed for short burst muscle contraction and acts to regenerate ATP its benefit depends on individuals normal stores right so some of us are always fully saturated with creatine and if we take exogenous creatine it's going to do nothing for us we're going to do nothing but urinate it out so it really depends on the individual some individuals that don't have their stores completely saturated will get some benefit from using creatine but some will not we know that creatine enhances activity when short bursts of maximal activity are needed like in weightlifting but there's no benefit in endurance activity okay so you're trying to lift weights get stronger there may be some benefit but if you're saying I just want to run some more miles or I'm gonna keep running at the same pace there's no benefit for creatine use for those activities common dosing for creatine there's a loading dose of 20 to 30 grams per day for one week and then followed usually by a maintenance dose for about three to six weeks and then there's usually a break from its use and creatine does cause weight gain so lots of you know athletes out there want to gain weight but almost all the weight gain is due to water retention okay so doesn't really effectively cause weight gain in the short term with lean muscle mass or other weight gain we know that excess creatine is eliminated through the kidneys and so there are side effects with creatine use that have been described dehydration can occur muscle cramping dizziness diarrhea and there is questionable long-term renal issues with prolonged high-dose use so the creatine is contraindicated in anyone who has any sort of liver or renal disease so anybody who's hypertensive that has elevated creatine anything like that no creatine use many other dietary supplements used by athletes but there's no evidence for ergogenic effects lots of things that are sold lots of you know people that make claims about lots of agents but not things out there that have good evidence for ergogenic effects talk about anabolic steroids here we mentioned corticosteroid injections in the last lecture you know that anabolic steroids are natural or synthetic derivatives of testosterone these are quickly the engineering of these quickly outpaces our ability to identify them and their use and so you know that athletes almost every year pop for something that is in some product that is being banned they have true ergogenic effects there is no doubt that if you use a natural synthetic derivative of testosterone you will have ergogenic effects it reduces recovery time in for muscle increase in lean body mass and both strength and weight there's an increase in aggressive behavior there's enhanced sport performance you can run faster jump higher and lift more weight etc if you use anabolics and there's a heightened sexual arousal and function they're most often used orally intramuscularly or as a cream they're often stacked with other aids so somebody's using anabolics you can almost be certain that they're using something else as well usually they're cycled so think about one to three cycles per year and although I doubt that they would ask you about testing because it's always it's gotten much more sophisticated traditionally you look at testosterone to epitestosterone ratios but I doubt that they would ask you that now because testing has gotten so much more sophisticated for looking at anabolics what you need to know about anabolic steroids is probably the side effects of anabolics and how to identify them and then the risk associated with them so you can see there are significant side effects obviously with using anabolic steroids so in males breast enlargement testicular atrophy and decreased sperm count for women you see male pattern baldness voice deepening and large clitoris increased facial hair and irregular menses in general you'll see increased act acne and it's important to know some of these systemic things that they cause because they like to ask this so you'll see elevated blood pressure increased LDL and total cholesterol and decreased HDL so the exact opposite of what you want most lipid panels to look like increased risk of myocardial infarction and sudden cardiac death increased risk of liver renal and hepatic malignancy in those folks that use anabolics you've heard about the musculoskeletal effects we know about the psychologic effects mood disorders or what's been termed roid rage overall you need to know that those athletes that use anabolics have a decreased lifespan compared to age matched controls that do not erythropoietin or EPO is produced by the kidneys secondary to hypoxia recombinant EPO is given by a subcutaneous injection and it increases the red blood cell production and hemoglobin levels classically used in endurance athletes and most commonly by endurance cyclists so tour de France Lance Armstrong you know all those folks EPO is very commonly been used on the there is a true ergogenic effect and we know that with the use of EPO and by increasing hemoglobin levels you can increase an individual's vo2 max there's a lot of adverse effects with the use of EPO though because you can get elevated you can get increased risk of thrombosis or embolism cardiovascular accidents or stroke there's an increased risk of acute myocardial infarction liver or cardiac disease secondary to iron overload for chronic users you can get similar effects from high altitude training blood doping so just by infusing red blood cells and then some folks and you know many professional and other collegiate athletes use hypoxic hyperbaric sleeping chambers to try to generate the same effect the testing is looking especially at hematocrit greater than fifty percent you should be worried about some sort of problem in an athlete and looking at their reticulocyte count stimulants or amphetamines used to treat ADHD disorders are probably most one of the most commonly used and abused ergogenic aids out there there are the most abused prescription drug among college students and the most abused prescription drug among amongst college athletes and includes opioids ergogenic effects include increased energy awareness and delayed fatigue they have been shown with use to enhance speed power endurance and concentration ephedrine or ephedra which I mentioned to you earlier does the same thing and was common are commonly used in energy drinks and dietary supplements for a long time there were energy drinks and supplements that combine this with caffeine for increased energy and lean mass those were removed by the market from the FDA secondary to catastrophic side effects including CBA sudden death associated with arrhythmia and seizure so the bottom line is stimulants are dangerous for athletes and lots of athletes that are taking you know ADHD meds and then they're using five-hour energy and then they're drinking a monster energy drink and then they're drinking coffee and they're doing it that's dangerous for an athlete and there can be significant issues with it so you need to understand that caffeine is ergogenic at very high doses but not with regular normal dose use so you gotta drink a lot of caffeine to get ergogenic effects but just know that caffeine in general is an ergogenic aid but you gotta you gotta drink a lot of caffeine to get their stimulants are highly addictive and they have a quite a number of side effects that you want to be aware of delirium paranoia aggression insomnia so athletes don't sleep well palpitations and elevated blood pressure and they when you come off of them they can give you a significant rebound fatigue and depression which is why a lot of athletes have a hard time coming off of them once they start using them because they get really sluggish really fast human growth hormone there are two ergogenic effects mediated through insulin like growth factor increases protein synthesis and fat breakdown increases hepatic glucose production stimulates liver insulin micro factor one to increase bone and muscle growth work synergistically with testosterone so you can almost bet that if somebody is using an anabolic testosterone agent they're likely stacking with some sort of human growth hormone derivative it's available as a recombinant product and obviously blood testing is available but not very widely used lots of side effects and this is what you need to be aware of and you probably are aware of the side effects here of human growth hormone thickened bone or acromegaly fluid retention but probably most importantly the systemic effects of significant elevation and blood pressure and hypertension there's a significant increased risk of cardiovascular disease and congestive heart failure and those folks that use exogenous human growth hormone and a significant increased risk of insulin resistance there is no evidence despite all the ergogenic effects no one has ever been able to state that using human growth hormone provides benefit in actual performance like do people actually run fat I mean there's all these other effects but so we obviously think there is but human growth hormone has a lot of bad side effects but is being commonly used alright a few questions here to kind of finish up so which of the following is true regarding the use of creatinine monohydrate it is effective as an ergogenic aid in distance running and I told you before it's effective in short burst maximal activities but not endurance activities so it's not a effective ergogenic aid in distance running it commonly causes weight gain secondary to increase in lean body mass and I mentioned to you it does cause weight gain but it's due to fluid retention or water retention all athletes respond to creatine I'm sorry in a similar fashion I mentioned to you that they do not many of us have already saturated our creatine stores and won't have any response will pass it right through our kidneys and excrete the creatine in our urine there are no side effects with creatine use I mentioned either a number of side effects of creatine use and creatine use is contraindicated in renal or liver disease and I mentioned to you that there is a questionable risk of long-term renal damage with creatine use and so it's contraindicated in renal or liver disease question nine you're seeing a bodybuilder with a ruptured biceps tendon dr. Gill talked about this earlier based on your evaluation you're concerned that he's using anabolic steroids you counsel him regarding the long-term risk of anabolic steroid use which of the following is not associated with anabolic steroid use a elevated blood pressure be testicular hypertrophy see hepatic cancer D decreased total cholesterol or e gynecomastia so I mentioned to you that elevated blood pressure is common in males that take anabolic steroids or testosterone derivatives they get testicular atrophy they're at risk for hepatic cancer and gynecomastia but remember that not only with elevated pressure and increased risk of acute mi and congestive heart failure and cardiovascular death but remember that with the use of anabolics they have increased total cholesterol and LDL and decreased HDL it's the exact opposite of what we want for good cardiovascular health with the exogenous use of anabolics and question number 10 which of the following has not been proven to have ergogenic properties for athletes anabolic steroids stimulants protein creatine or erythropoietin and I told you that anabolic steroids we know have ergogenic effects we know that stimulants have ergogenic effects creatine can have ergogenic effects and we know that EPO does for endurance athletes but I mentioned to you that although protein values differ a little bit between an endurance athlete of 1.2 to 1.4 to a strength athlete of 1.6 to 1.8 grams per kilogram per day that exogenous protein use is not an ergogenic agent so although there may be a slight difference in requirement protein in and of itself is not ergogenic again some references and thanks for your attention good luck on your exam

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