Welcome to the National Fellow Online Lecture Series. Today's topic is high-yield medical topics in the training room. My name is Melody Rubisch, that's how you pronounce my last name, and I have the honor of moderating for the amazing Siobhan, that's how you pronounce her first name, Statuta, and she has a huge jam-packed lecture for us. And I personally requested her to do this because this is something that when I was a fellow, I needed somebody to tell me what to do, and I didn't know who to ask. So if I had been able to walk up to her and say her last name correctly, I would have so asked her. Okay, so the next lecture is the Upper Extremity Dislocations and Management. So that's gonna be Dr. Jack Spitler. This is an incredible talk. He's kind of gonna give us his greatest hits from a couple AMSSM lectures. That's gonna be on September 21st. This should serve as an adjunct to your individual program's educational programming. It should provide our fellows with direct access to educational experiences with experienced AMSSM members, and at times invited guest experts in a variety of formats. It should assist in the CAQ exam preparation. Please mute your device microphone and turn off your video. Submit any questions through the chat function. If you'd like to include your name and program, that's great. Please tell me how to pronounce it if it's complicated. I will ask the questions during the Q&A based on the questions you submit. And after the program, please complete the evaluation, which will be sent at the end of the lecture. So Siobhan has already said, if we don't get to all of the questions during the hour format, then she's happy to stay on longer. We wanna make sure everybody gets their questions asked. This is a safe space to do so. I would love to brag about Dr. Siobhan Statuta. So at education, she did medical school at George Washington University. Her residency was in family medicine and her fellowship were at the University of Virginia, and it's no surprise they kept her and begged her to stay. So she's a team physician at UVA Athletics. She's an associate professor in the departments of family medicine and physical medicine and rehabilitation. She's the director of the Primary Care Sports Medicine Fellowship. For fun, I do know that she's currently moving into a new home and she's in transition. So this is very exciting. We'll all have to go have a housewarming when it's done. She keeps up with her husband, two middle school children and a two-year-old golden. And she's part of the coverage team for US National Women's Soccer U20s National Team. Siobhan, it's your turn to take it away. Weeks. Now I'm gonna try to share. And a week. I think this is the one I'm sharing. Does this look right? That looks perfect. All right, you guys. Well, thank you for having me here tonight. I'm really honored, first of all, to be here. And I'm really excited to talk to you guys about this topic, high-yield medical topics for the training world. All right, talk about an open book, you guys. This one was a tough one to decide what to talk about. So what did I do? I picked up the phone and I called my previous fellows and I said, guys, you need to tell me what did you guys learn that was really high-yield that you think would be helpful to talk about in this type of setting or this format? And so we picked three of them and I'll lead into that. I have nothing to disclose, but I do want to thank the potential that I have some material here. Acknowledge my partners for possible sharing of pictures and material. I have over the years pulled different slides from different talks, so I did want to thank them. The objectives are what we discussed at the beginning. We want you guys to have a solid standing off of which you can build your knowledge and be able to continue your fellowship, which is already two years into it. You're two months already into it, so that's crazy. Before we get into it too far, I do want to talk about our tactic tonight. We're going to start out on the outside of the body and we're going to address some skin stuff. Then we're going to start moving inside outside and address some respiratory illnesses. And then we're going to move inside to what makes up the human person mental health. Before we go too much further, Andy, would you mind queuing up the CAQ questions? I have a couple of questions here, guys, for you to get to start getting you thinking about topics that we're going to discuss. So Andy, do I need to stop my share? No, you're good. Okay. All right, so question one. Oh, there are no pictures included. Okay, this might be a little tricky for you then. After inspection, you find a taut bola on the posterior heel of a runner that's consistent with a blister. So you advise, number one, continue activities as usual. Two, decompress and protect with bandages. C, de-roof the blisters and provide topical antibiotics. Or D, start a third short burst of PO, start a three-week burst of PO antibiotics as feet are a high-risk area for infection. So you guys go ahead and pick one that you think might be the correct answer. We'll give you a few seconds. This is a cross-country runner that you see right in their season. And how do I advance from here? Okay. All right, so we've got a smattering of answers. Continue activities as usual. Decompress and protect with bandages or de-roof the blisters. So we'll be talking about that a little bit. So I want you guys to pay attention. And then we're gonna move on to question number two and then get into the talk. So question number two. There is a gentleman who, again, you'll be seeing pictures later on. He has a little raised area on his neck, a little bit of a rash, but he says, this is a wrestler, he's absolutely sure it's from shaving, but he has a tournament coming up. So number one, you allow him to wrestle. This is definitely razor burn. You allow him to wrestle, start him on PO medications and it will have been enough time to safely participate. Don't allow him to wrestle. You need to IND this and consider IV antibiotics or don't allow him to wrestle, start him on PO antibiotics. But unfortunately the timing does not permit for safe participation. Now, without looking at it, it's gonna be impossible for you to answer this question. So let's just get on with the talk. And then at the very end, you'll be able to see the pictures that these questions are linked with. So we're gonna move on. And again, don't allow him to wrestle, start him on PO meds. All right, very good. So moving on with the talk, we're gonna start out with skin. Now, skin, why are we talking about skin? Well, because you see a lot of it in your daily activities in a training room. It's the largest organ of the body. And did you know that the average adult has eight pounds of skin? And if we stretched it all out, it would be 22 square feet. So we have a lot of it. And it's on the outside of the body. So people are aware of what's going on. But before we get into that, we can't move on without reviewing some of the jargon. So there's a lot going on with skin. We've got papules, ulcers, fissures, so many things that can be used to describe the skin. So let's review some of this. Beginning with the macule, this is a circumscribed flat discoloration. And it's small, it's less than a centimeter. Then we have papules, which are elevated, but still small. And you can see the cartoon drawings with actual pictures next to it. Then we have a plaque, which is circumscribed yet elevated and flat. This is, again, still small. Moving on to wheels. Another word for a wheel is a hive. And these are firm edematous plaques, but they're transient. So they come and go, they change in size. They can convalesce and then they can combine and then separate and then go away, but they're transient. Vesicles are a collection of fluid. These are small. Embola or bole are larger forms of that. So you can see some pictures right there. Now with these definitions, a lot of it has to do with the size. So the column to the left, you'll see macule, papule, vesicle. Those are all the smaller things. Greater than a centimeter, we're talking patches, plaques, embolas, and that's getting larger. And I know for the sake of this talk, I'm moving quite quickly, but you guys, if you Google skin findings and definitions, you'll find many of these similar cartoon drawings that you can refer to, but it helps you be able to communicate with other providers and document in your notes with accuracy. All right, so moving on, some additional ones. Here's a scale. A scale's excess epidermal cells, abnormal keratization. You can pick it right off. Then you have a crust, which is a collection of dried fluid and cellular debris. It forms a scab of sorts. And then you've got some breakdown. So we're talking an erosion, which is a partial thickness loss. It goes through the epidermis, but it's not going to penetrate into the dermis, which means that when it's allowed to heal, it's going to heal without scarring. So you can see in the cartoon, it's not getting into the lighter pink. It's just staying superficial. So it's going to heal beautifully. An ulcer though, on the other hand, is an erosion into the dermis. And this is going to require some scarring to heal. Fissures are linear, sharply defined vertical cuts into the wall of the epidermis and dermis, really typically found on the heels of individuals. And then we've got atrophy, which is a skin thinning or depression of the skin of the epidermis or the dermis. This can be as a side effect of medications like topical steroids for long periods of time, or just simple aging. You can see the thinness on this individual's hands. So now that we're speaking intelligently, we're going to move into some skin findings that are resultant of mechanical changes. So let's start out with the bread and butter of derm, acne. So acne mechanica results from constant friction and pressure against the skin. And what happens is it begins to obstruct the pores and the pores can't get out their material. It's going to start forming pustules. And this is commonly found underneath protective equipment or chin straps where people will sweat. It's dark, it's moist, it's warm. And a lot of bacteria are going to like to grow there. Since COVID, a lot of people started to get this underneath their face masks. And so the treatment, education about the cause and discussing methods of sweat-wicking clothing in areas that are susceptible to that. You want to regularly clean the equipment and you want to use keratolytics and astringents. And in severe cases, consider antibiotics. All right, talon noir, otherwise known as black heel. These are these irregular spots. Sometimes they're groups, sometimes they're punctate findings. Typically linear along the striations of the skin and typically on the heel of a foot. Common in sports because people are pounding their feet. So this is from traumatic shearing forces that result in micro hemorrhages. So you're going to find these common sports, basketball players, tennis, football, even people in the marching band are going to be developing these things and even runners. So endurance runners are going to have this. What do we do about this? Well, nothing. You can reassure the individual or you can consider pairing this down with a scalpel. So you take a 15 blade and you want to just kind of cut off the stratum corneum, which is the outer layer. And you'll see that these hemorrhages will remove themselves. Now, the other thing to keep in the back of your mind is could this be melanoma? Melanoma will not be removed with a scalpel, but if there's any question at all in mind, you want to get these individuals to a professional dermatologist. Now, there's a palm version of this, palmar petechiae or tachynoir, which is in the palm. Now think about this. This is going to be rowers. This is going to be rock climbers, people that use their hands a lot. It's going to be in gymnasts and it's going to be in golfers, weightlifters, things like that. Again, findings on the palms of the hand. All right, joggers nipples. There's no sports medicine germ talk that can happen without this topic. It is frictional irritation and chafing, especially in long distance runners. They're painful, fissured, eroded nipples. How do we treat this? Well, we educate. We teach them about friction. We tell them never use a brand new shirt when you're running your first race. Using soft fiber shirts can be protective. For women, properly fitted bras. And you can use adhesive bandages. So athletic tape can be used to cover the nipples, but if you can use a gauze to add even one more layer of protection underneath it, that's great. What you don't want individuals to use is just regular scotch tape. The adhesive is going to promote fissuring and it's just not going to be great. Consider petroleum jelly, lubricants. And if you guys don't have anything else, just use a good old bandaid to cover the nipple area. If you stop irritating it, it will heal on its own. Blisters. These result from excessive friction. And I know you guys are fellows and you might be wondering, why am I talking about blisters? You guys know what we're talking about right now. But if a foot is moist in a sock that is sweaty, or somebody is participating in a sport where it's raining outside, they're going to be predisposed. So poorly fitting shoes, moist skin, they're going to form vesicles and blood. Treatment, prevention, drainage. So what you can do is you want to leave, if the blister is large enough, you can decompress it by sticking a needle and removing the fluid, but you want to leave the roof of the blister because that protects the underlying skin from secondary infection. You can also cut out a tiny little window to prevent the reaccumulation of that blister. And also consider a hydrocolloid dressing that adds a little bit additional cushioning and can help the individual. You can see in the bottom right-hand corner, there's a donut pad of sorts that offloads the pressure and can help prevent worsening of a non-symptomatic blister. So not all of them have to be drained, but these are some tactics for it. So this might sound familiar with one of the questions at the beginning. So you want to leave the roof of the blister if at all possible. Subungual hematomas, black toenails, joggers' toes, skier's toes, tennis toes. This is from trauma or pressure or poor fitting shoes. You can see an accumulation of blood underneath the fingernail. Treatment, you can consider treformation, which is a release of the material underneath. So mild cases, you don't need to even do anything at all, but larger cases or cases that are uncomfortable, you can use a cautery right here, or you can use a needle that is disinfected and then heated and you can burn a tiny little hole into that fingernail at the base. What you do is you apply some pressure and you just feel an instant pop as you break through the nail, but you want to retreat really quickly because you don't want to do damage to the nail bed underneath. And if done correctly, people get instantaneous relief and it's a very satisfying thing to do, but you can also prevent these from happening. So like me, I went four years skiing in ski boots that did not fit. I would get these, just get proper fitting shoes. It will totally help. For runners, consider a metatarsal pad that will prevent flattening of the front arch of the foot, which keeps the toes in a more protected alignment from the edges of the shoe. So considering metatarsal pads can be helpful in runners. Okay, ingrown toenails. These result from pressures forcing the nail edge. Usually nail edges start to crack and the nail edge cuts into the side of the toe, into the soft tissue. Again, improper fitting footwear or trimming. Things that you can do, Epsom salts, soaks, antibiotics if it's infected. You can elevate the nail by taking a little bit of a wisp of cotton, rolling it and tucking it under the edge of the nail. You can tape to pull that excess skin around. And sometimes you can remove a portion of the nail to get rid of the aggravating portion of the nail that is cutting into the skin. All right, now throughout the talk, you guys, I have thrown in some articles that I absolutely love. These are well worth your time to look up, print, actually keep a hard copy so that you can refer back to. I've marked these as having a heart in the corner. And this one is Ingro Antonio Management from the American Family Physician from 2019 by these authors listed. And I have the resource here at the bottom. What I love about this is it does a really good explanation as to improper cuts versus the proper cut. And it also goes through sort criteria and it really explains step-by-step how to manage these cases. So definitely a really good article to consider. All right, moving on, pysogenic papules. These are focal herniations of subcutaneous fat, typically in weight-bearing areas. So around the foot, around the heel, even in just the lower extremities, present with weight bearing. And it's not associated with obesity. So lean runners will have these. These are typically asymptomatic and they just look like little bumps, typically painless. But on a rare occasion, they can be painful if they herniate along with a nerve fiber that travels with the fat. How do we deal with this? Just talk about padding, compression stockings or socks, taping for support, heel cups. And so you're just educating the individual about softening their surface. And what you're doing is preventing further exacerbation of these. Here's an ultrasound image of fat herniating through. Again, nothing to worry about with these cases. Corns and calluses. Yes, we keep on talking about the feet. The feet are susceptible to a lot of findings. This is a hyperkeratosis due to repeated friction or too much pressure on one area. And this does not always have to do with poor fitting shoes, but it can deal with the alignment of your toes. So if somebody has claw toes, for example, they're gonna be more susceptible to getting corns and calluses. These have hard or soft conical lesions with a translucent center that you can see here in this picture off to the right. So very common. But what I'd like to point out is you can see that the dermatoglyphics, the lines are continuing as normal. Now, this is a clue to point out a corn and a callus as opposed to a plantar wart, which we'll talk about in a few minutes. Treatment. What do we wanna do? Well, if it's due to too much pressure, we wanna offload the pressure. So we wanna redistribute the forces. So consider changing footwear. Think about orthotics and paddings. Topical salicylic acid can help remove this. And you can soak the foot and then gently shave off little by little, and it will start peeling off some of this added keratinization. Excuse me. All right, rower's rump. What on earth is this? Well, it's in rowers, and it has to deal with the rump. It develops in the gluteal cleft, and it's because these individuals are sitting on really hard skull seats, and they're moving forward and back. So that friction is developing a lichen simplex chronicus. So like a thicker leathery style skin, and you can see exaggerated skin markings in that top picture. Well, this type of skin is itchy. And so that individual may start scratching, which perpetuates the process. Scratching is going to cause added skin to be deposited there. So it's this cycle that this individual will get into. So how do we treat this? Padding the rowing seat, getting padded shorts on, and educating the individual to really try not to scratch the area and consider some topical steroids to calm down that inflammation and break that cycle. All right. Environmental injuries. I have pared this down quite a bit, but miliaria rubra, this is known as prickly heat or sweat rash. And I think this is an important topic to discuss because we see it quite a bit in the training room. This is from heat, this is from sweating, and it's when the sweat ducts become occluded. And so that sweat seeps into the epidermis and it creates an inflammatory reaction. So you start getting two to four millimeter little pustules on an erythematous base, and it can be prickly. It can cause a pins and needles sensation. There's nothing to worry about. What we want to do as sports medicine doctors is again, educate. We want to prevent this from happening in the first place. So dry wicking, hygiene, rinsing off after a workout, trying to work out in air conditioning and really hot, muggy, humid conditions. And then things on the skin that can calm down inflammation, lanolin, which can prevent blockages, calamine lotion, and even topical steroids. Now going from heat to the cold, we have frostbite, one step before frostbite is frostnip. This is where it's getting so cold that the fluids are actually crystallizing within the body and it's disrupting cell membranes. So the tissue appears cold and white and without pain until it thaws. If an individual has frostbite, what you want to do is get them into a warm, safe place first, then remove any cold and wet clothing. If they have frostbite on their feet, try to prevent them from walking, transport them into a warm place first. You want rapid rewarming and circulating water. You want to be careful. If there's a heater or a stove, really avoid them getting really close to it because much of these tissues are insensate. They're not going to be able to realize that their skin is getting too hot. So you want to be really careful about that. Get analgesics on board immediately for rewarming. It is really, really painful. Oftentimes the emergency departments will use narcotics even for this one case. And then you want to get surgery involved at some point once everything has been stabilized because you want to assess for dry gangrene, which is when the tissues have lost their vasculature and we don't want dry rot to present. So really making sure that they still have remaining healthy skin. Infectious causes of skin. Let's start out with bacterial stuff. Impetigo, this is a superficial skin infection. When I hear impetigo, I think honey-crusted lesions. So yellow crusts on an erythematous base. Treatment, mupiricin or Bactroban, very simple. Oral antibiotics, if it's in a larger area, you can use larger guns, so oral antibiotics. And then the NCAA has its own section on bacterial infections. They say no new lesions for over 48 hours, no moist or purulent lesions at the meat and active lesions cannot be covered just to allow participation, which brings us on a very lovely tangent. So what about this NCAA? What do we do about the NCAA? Well, the NCAA has this form out there. This form, notice there's a heart in the corner, guys, well worth you looking at this and really focusing on the bottom half of this form. This right here on your screen will answer three to five board questions, promise you. It talks about bacterial infections, herpetic lesions, molluscum, when to allow a wrestler back into competition. So there will be a lot of management. It is at your fingertips. I have included, if you just type in NCAA wrestling skin form it is right here. For a wrestler to be allowed to participate in an NCAA tournament and they have something on their skin, you as the doctor need to fill out the top portion of this listing. What have you diagnosed them with? What is the treatment they're under? When did you begin treatment? That way you're abiding by the NCAA regulations. So guys look this up. And I've circled impetigo there just to prove it to you. Erythrasma, this is caused by a corn bacterium. Sharply demarcated patches initially pink that later term brown and scaly. These are in intertergenous regions. So we're talking inframammary underneath the breasts where it's dark, moist. In your axilla, in the groin region. If you have access to a Woods Lamp, bring this baby out and light it up because this will light up as this coral luminescence. And there you have your diagnosis. Other tinea's will light up yellowish and whitish but this is really pathogenic for erythrasma. How do we treat it? Oral or topical clindamycin or erythromycin but really get that Woods Lamp out. And then NCAA follow their guidelines. It's on that form. Okay, furuncles. I really was trying to figure out how to avoid talking about this because it's just not a fun topic to talk about. But these are a must because you have to be able to identify these. These are well circumscribed, really painful separative nodules that involve a hair follicle. So this is part of a continuum. It begins with folliculitis. If not treated or getting worse, it's gonna turn into a furuncle. So now well circumscribed usually arises from like a staph infection and it's highly contagious. Erythematous around the edge. You wanna use warm compresses, bring that out. Antibiotics times 10 days and consider incision and drainage. If it's going in the wrong direction, it's gonna morph into its big cousin, the carbuncle. Yes, that is not lovely to look at. It's way more expensive than the furuncle. Again, staph treatment, same thing, IND. Now we're kicking it up oral or IV antibiotics. You need to take these things seriously. And if you don't treat this, this can turn into a big abscess. You wanna be really careful about these guys. While you're choosing an antibiotic, you want to consider MRSA. MRSA is always something that should be kept in the back of your minds. With the NCAA, there's no participation of infected athletes until completely cured. You wanna protect exposed skin if in a high-risk sport. You wanna properly clean and protect the injured skin and you wanna use proper general hygiene. But MRSA infections, you wanna treat with antibiotics that are gonna help with methicillin-resistant staph aureus. So you're talking about the back drems, you're talking about clindamycin, and there will be, locally where you practice, there'll be higher susceptibilities to one than the other. So know your local susceptibility patterns before treating your athletes. So that's bacterial. Let's move on the viral topics. Verrucae or warts. These are caused by HPV. These are unsightly and painful. And these, although this finger looks pretty much like warts, others are single and may look much like a corn, even calluses. But you can see the dermatoglyphics are lost and these have black dots with shaved downs. So those represent thrombus capillaries. We can treat these similarly, salicylic acid patches. You can use liquid nitrogen cryotherapy and just apply 10 seconds at a time, three or four times, and then have them come back for repeat treatments. Or you can even use duct tape, all right? So duct tape, really cool way to do it. You can't use the modern, very cool, stylish duct tape. You have to go back to the silver, old school duct tape. Cut off a little square, put it over this little wart and leave it there for about three days. You peel it off, leave it exposed to the air for about six to 12 hours, and then reapply a new patch. There's something about that adhesive in the duct tape that will help soften the top layer of the wart and peel off a few layers at a time while it's protecting it from spread. These things can spread. So duct tape is a simple, cheap, and really interesting method that your athletes and your patient population will be super impressed with. So something that you can treat with. NCAA, you want to cover prior to competition. Molluscum, these are not uncommon. You will see them. These are wrestler's warts caused by apoxvirus. These are firm, skin-colored, kind of pearly pink is the description with an umbilicated center or a little dip in the center. These, if left alone, will eventually spontaneously resolve, but they can sometimes take months to years. What we can do is use topicals, benzoyl peroxide, and or cryotherapy. You can also curetage these, but that can lead to scarring. NCAA, you want to cure it and remove these lesions before the meet and cover with a gas-permeable membrane and tape. Herpes gladiatorum, these are wrestler's herpes. Matpox, scrumpox, these are caused by HSV-1 in contact sports, typically clustered. They're vesicles, they're painful, and they're transmitted directly by skin-to-skin. Treatment, your antiviral of choice, acyclovir or Valtrex. And then if somebody gets recurrent cases or a wrestler is in their season, they might want to use suppression, which is acyclovir 400 milligrams daily. Again, NCAA, no systemic symptoms allowed, no new lesions greater than 72 hours, and all must have a firm crust. And they want proof that there's been antiviral therapy for at least 120 hours. Guys, that is five days of treatment for those who are not math savvy. So five days of treatment for herpes. Fungal infections, tinea infections. We've got tinea pedis, corporis, incurus. These are dermatophyte infections. They're on, excuse me, an erythematous base with an advancing border. It's itchy. Topical antifungals can be really helpful. And then no skin lesions. You want 72 hours of topical treatment. Tinea capitis though, before we move on, that's of the scalp. That's gonna require oral treatment and sometimes weeks and weeks up to, usually you start out six to eight weeks, sometimes even 12, because that infection is in the follicle of the hairs. So it takes a lot longer, much more serious to treat. Tinea versicolor. This is pitoriasis versicolor. This is chronic and it's asymptomatic. It's usually in summertime when people notice that they have something going on because they are out in the sun and their skin tans, but they have these hypo or hyperpigmented spots. You treat this easy way to do it is sell some blue selenium sulfide shampoo, apply it, leave it on for a couple of minutes in the shower, then rinse it off. You can also use azoles or zinc to help with treatment with this. Onychomycosis, fungal infections of the nail, discoloration, scaling, thickening, painful, they start cracking. Really common because you can transmit them through showers and mats and so really in our sports arenas. Topical treatment can be considered if less than 50% of the nail is affected, but I will be honest, it is not gonna do the job easily because it's not gonna percolate into the nail. So considering a systemic treatment as well or a combination of the two is gonna get you the best results. Now, the oral medications require two to four months of medications. These are hepatotoxic in some cases, they get broken down by the liver. So you really wanna counsel about alcohol consumption, being very careful and considering monitoring LFTs because this can cause an asymptomatic jump in your transaminases. So just be really careful with these medications. They're not light medications to treat with. Here's another heart slide. We need you guys to really pay attention to this. Anybody who's gonna be dealing with wrestlers, guys, this is an amazing article. I have a copy in my office. I pull it out probably twice a week. What I love about it is it talks about all the conditions the wrestlers are gonna have. And it talks about NCAA considerations and then high school considerations. Now it's an older article from 2013. So there may be updates, but the treatments are right here. Whether you're talking about primary versus recurrent infections versus prophylaxis, really great article to have on hand. And then finally, miscellaneous conditions, scabies. Those of us who treat college athletes, it's gonna see you. This is caused by a mite. It's exquisitely pruritic, and it tends to go between your fingers, between your toes, around your belt region. Very itchy and excoriations. Topical, you can do a topical promethrin, or you might need to rely on an oral treatment. Lindane, if the patient can't tolerate. And the NCAA wants verification of treatments and negative scrapings before somebody is allowed to participate. Genital herpes. This is HSV2 and 1. These are small grouped vesicles, similar to herpes glad, but in different areas of the body. Painful, burning, pruritic, sometimes transmitted by contact. Be mindful of that. You can never get rid of this, but you can treat the flares with acyclovir or thalacyclovir. Contact dermatitis. This is a direct chemical irritant or allergic delayed reaction. It's going to be itchy. It's going to have patches of vesicles. If it's, for example, from poison ivy or poison oak, this right here is a local infection caused by presumably zinc or copper in this metal belt. So be on the lookout for that. We want to avoid that irritant. Use calamine lotion and other things that will calm down topical inflammation. All right. So we've done the outside of the body. That's only touching upon derm stuff, guys. There's way more, and there will be further talks this year on skin findings. But now we're going to switch over to respiratory illnesses because tis the season. I want to draw your attention to this picture. I find this picture to be highly disturbing, but it just goes to show what we're dealing with when we're talking about respiratory illnesses. I don't know how this gentleman is sneezing, but boy, that is impressive. We're going to start out with acute rhinosinusitis, ARS. This is the common cold. It's an acute URI. They're going to have nasal congestion, sore throat, cough, malaise, low-grade fever. Symptoms are typically self-limited, five to 10 days, usually caused by the rhinovirus. And guys, this is common. Every person is, the incidence is about two to five episodes per person, per year. But the deal is we normally get over it quite quickly. It's not that big of a deal. So when somebody comes in with day one of a sore throat, add some education to this. Talk to them about supportive treatments, analgesics, decongestants, antihistamines, will work when combined with analgesics and decongestants, zinc, lozenges, probiotics. Consider these things that will help the body feel better. Good hand hygiene is the most effective way to prevent URIs. There's no better protective feature to antibacterial soap than just regular soap. So good old fashioned hand washing is going to do the trick. Here are your sinuses. Know which ones you're talking about. So frontal, sphenoid, ethmoid, septal, and then maxillary sinuses. Be specific when you're documenting. And once we start getting a sinusitis picture, we're getting mucus collection in there. It's dripping down the throat. It's causing throat pain. Here's another one of these amazing articles, Treatment of the Common Cold by Kate DeGeorge. What I love about this article is not only does it go through best practices of infectious diseases, talking about how antibiotics should not be used for these, but it also talks about effective treatments for cold symptoms in adults. It talks about teslam pearls and acetaminophen and the pros and cons of these. But what I really like about this is this portion that talks about managing discussions with patients. Patients are going to come in to you. They want their antibiotics. They want to feel better. And this helps educate you on how to address this. Once those five days are over, now we're entering a post-viral acute rhinosinusitis. That's when symptoms are now lasting a little bit longer than 10 days, or there's sudden worsening after five days. You want to consider, could this be bacterial rhinosinusitis? So that's beginning to enter the back of your head. But notice purulence of nasal discharge is not listed. So it's flipping over into bacterial if you have at least three of the following, fever over 38 degrees, double sickening, meaning that you were sick, the person got better, then they got worse again. Unilateral disease, one side is affected. They get severe pain, they get dental pain, or they have raised ESR or CRP, which is really interesting. Let's dig into that a little bit in the next few slides. Bacterial causes are going to happen. It's about 0.5 to 2% of all viral infections. It's going to flip over into a bacterial cause. Classic imaging is not recommended because mucus is mucus, and it's going to look the same on a lot of these imaging techniques. So people are considering looking into biomarkers, which is where the CRP ESR component comes in. If somebody gets tested and the values are low, the chances of having a bacterial infection are also very low. When they're normal to high, it's not going to tell you much besides somebody is ill, or maybe that it's normal. They're also looking into leukestrase. Yes, leukestrase, think urinary tract infection, leukestrase of nasal discharge to see if it's elevated. Could that indicate that there's bacterial sources of this? So stay tuned for that. Treatment, amoxicillin or apenicillin or Augmentin will treat this, make sure the individual takes the entire course. Also, this is the time to educate patients. And I love this article because of this portion of the article. It says the overuse of antibiotics has also been associated with an increment of antibiotic resistance, which is directly related to increased morbidity and mortality due to resistant bacterial infections. So once again, in spite of the clinical suspicion of acute bacterial rhinosinusitis, the decision to treat a patient with antibiotics should be made on an individual basis. So in order to help decrease the inappropriate use of antibiotics, published studies emphasize the importance of physician communication skills on the use of antibiotics. Going on, going on. So this loops back with this AFP article, guys. Again, it's nothing groundbreaking, but it just has really good, simple ways to address with your patients why they don't need antibiotics. Now, those of you out there who practice in a training room, who have athletic trainers, use that to your advantage. These athletic trainers are gonna be your eyes and ears, keeping an eye on your athletes. If this athlete is going in the wrong direction, get them back into the training room, and then you can reassess whether they do need any antibiotics at that point. Use your circumstances to your benefit. Okay, acute bronchitis. again, caused by a rhinovirus. This is a clinical diagnosis. This is, coughing is now the big thing. It's due to acute tracheal or large airway inflammation, but there's no pneumonia going on. There's increased sputum production, dyspnea, nasal congestion. These can last two to three weeks, but there's really no role for antibiotics in this unless you're talking about pertussis. Now, for pertussis to occur, you need to have paroxysms of cough. You need to have an inspiratory whoop, post-tussive emesis, and apnea or cyanosis. That puts you into the category of pertussis. Usually people will treat right away because if you can get antibiotics, the macrolides on board, the person will be transmitting the infection less. So it's important to get antibiotics on board sooner than later. But you can go ahead and diagnose with PCR testing. But if you are suspecting pertussis, it sounds like somebody is really having these like fits of cough, go ahead and treat with a macrolide. And this talk would not be complete without me dedicating a slide or two to strep. This is strep throat, streptococcus pharyngitis. It is a red, beefy oropharynx. These are exudates. You want to treat this and you want to try to avoid steroids unless there's airway complication or the person is extremely uncomfortable and cannot swallow. Use your analgesics, they're your friends, but you want to avoid steroids because strep is something that should be treated and has complications that are really long, like a long list of them. You can have otitis media or peritonsillar abscesses. You can get sinusitis, meningitis. You can get necrotizing fasciitis. You can also get the cardiac manifestation of rheumatic fever. You can get post-strep glomerular nephritis. You can get reactive arthritis, so many things. So it's thought that when somebody is put on steroids, it increases the risk of that. So to diagnose, it goes back to centaur criteria. These are four conditions that if they have, they get a point each, the individual does. So if there's tonsillar exudate, that's one point. If they have anterior cervical lymphadenopathy, and some people say it's got to be painful, there they get a second one. No cough. If that person has cough, they don't get the point. And then fever greater than 100.4. So if they score, it depends on which way you're going to go down the pathway. If you have access to rapid testing, you want to go down the right side of the pathway. If they have zero to one, no antibiotics. If they score two or three, rapid tests, because you're on the line. You're not quite sure whether they need antibiotics or not. And if they score all four, go ahead and treat. They likely have strep. All right, guys. I know I've been talking for a while, but I cannot finish this high-yield talk without addressing mental health. Now, mental health is a topic that is becoming more and more imperative these days. This is a word cloud that you can see is from the IOC. And this was created by a cohort of elite athletes and their entourage of like support staff and coaches and families. And you can see that this is a real thing and it needs to be addressed. Okay. Here in the corner is Michael Phelps. And this is the Weight of Gold. This was a documentary on HBO. The heart is associated with this. You guys need to watch this. It is impressive. It's an hour long. It is very powerful. And it talks about the importance of mental health in elite athletes, but in all athletes. A lot of the message can be related to athletes of all levels. So really important for you guys to watch this. So why am I including this topic in this talk? We all have seen it. We're living through this. The strain of mental health and behavioral disorders accounts for more years of lived disability with a chronic illness than any other illness in society today. Then you tack on COVID and cancellation of the Olympics and what the college students are going through and what us physicians are going through. It is really having its toll. So we're seeing an increased prevalence of mental health illness and health concerns. And anecdotally, we've all seen it. People are having more and more flares and they're more serious. So we have to do our part in this. So words matter. So this is work done by COIL that came out in 2017 and in which there were interviews with elite athletes. And it talked about what is mental health? That was the question. And here's some of the replies. If that it prevents them from competing, it's seen through the lens of an illness. Overall, it's negative and it's bad. And there's a lack of trust and confidentiality that they were afraid to talk to people because they'd be afraid of losing their sponsorship or being cut from a team. And it led to a lot of fear and anger. This is regarding the words mental health. But if you look at definitions, mental health is the state of wellbeing in which every individual, you and I, realize his or her own potential, can cope with the normal stresses of life and can work productively and fruitfully. So it's part of health. There's physical health, there's mental health. It combined is your health. However, mental health symptoms and disorders are changes in thinking, emotional, and or behavior that occurs over time resulting in distress or problems functioning. So there's a clear difference in mental health and mental health symptoms and disorders. So mental health, similar to physical health, and it's a resource for us. It's like working out and having a healthy body. A good mental health allows people to function and deal with stress and perform meaningful work and contribute to the broader good. Mental health promotion strategies have now come about and we're trying to educate more and more individuals about it. The way we're doing that is by trying to increase mental health literacy. This is the strategy that promotes knowledge and belief about mental disorders, which aid in their recognition, management, or prevention. So there are public stigmas, what everybody else thinks about mental health. And there's self stigma, what you think about it. And combined, it plays a role in the conversations that are being had. Public beliefs can affect yours and ultimately influence whether an individual seeks support for a disorder or symptom or not. And so approaches can be taken to improve mental health literacy. I wrote down coaches here in parentheses. So mental health literacy, it's a strategy that's promoting this knowledge, really educating. So we want to improve knowledge, improve attitudes, and increase intentions and knowledge of how to seek and guide people to help. So what about in sport? I wrote down coaches. Coaches we know have a tremendous impact on athletes. They need to improve their own mental health literacy. They need to increase their knowledge, de-stigmatize the environment, and create an intolerance of observed negative stigma. So here's a picture of one of our coaches and it's foundational to improving the health and the wellbeing of athletes all around. But this is where I challenge you guys. Look at this slide. And if we change just a few words, it's going to impact you. What about in sports medicine? The medical entourage, you guys, the fellows, all of us as attendings, we need to do our role in improving our own mental health literacy. We need to improve our knowledge and all in all, it's going to improve the health environment. So it's going to allow our athletes to feel comfortable, to approach a really difficult topic with you because they trust you. They see you. They see you on the sidelines. You're waving. You're approachable. Guys, do the work because these individuals need your help. So sometimes it's going to be obvious. This is one of our athletes. That's a pretty obvious finding, but I would argue Michael Phelps didn't look like he was suffering too much, right? But if you watch that documentary, you really hear it from his mouth and he's gone very public about his struggles with mental health. What we have to do is learn to ask the question. We need to delve into these conversations. So the AMSSM came out with this position statement. This is one of the hearted topics. This is a really great paper in which a group of experts went through tons and tons of articles out there and they made it, they broke it down into simple digestible topics. There are key findings where sports medicine physicians should be familiar with psychological, cultural and environmental factors that influence mental health in athletes, as well as common mental health disorders affecting the athlete population. So it helps me, like I always think about Pink Floyd and Dark Side of the Moon, where it looks, if you look at the prism in one way, everything looks fine. But if you just look a little bit harder or from a different angle, it's gonna break out so much more. So all of these things are addressed in that AMSSM position paper. It's really worth looking through. I picked one topic, which is pretty seemingly innocuous, sleep. And what do I mean about it? How can we help with sleep? Well, sleep is something that our athletes are struggling with all the time. Let's go back to the basic science. We have light sleep, stages one and two. Light, easy sleep. This is real sleep. And then you get into the deeper sleep, which is stage N3. And this is where the muscles are relaxed. And this is where most of the recovery and repair occurs. This is where growth hormone gets released. And then we have our REM sleep. This is the light. Brain is very active. Memories, emotions, dreams are occurring here. Look at, this is a timeline of a night of sleep. The first three, four hours, you're going into deep sleep. So a lot of muscle recovery, a lot of repair, a lot of growth hormone. This right here is where the sleep myth stating, oh, I got my core four hours of sleep and I'm good to go came from because it helped with muscle recovery. But what people are realizing is that this lighter sleep, the REM sleep is imperative for memories, emotions, mental health. People need seven, eight hours of sleep a night. So what can we do? Well, there are things that we know. Athletes wished that they had more data on sleep provided to them. 60% reported excessive tiredness more than three days out of the week. That's more than three days out of the week, excessive tiredness. And a nearly 30% report extreme difficulty falling asleep or with early morning awakenings. Think about early morning practices. Nearly 80% of student athletes did not get seven hours of sleep a night. Sleep is a risk factor for mental health symptoms in athletes. It impairs athletic performance. It affects GPAs. People need sleep. So we need to be able to counsel individuals on how to do this. CBT, sleep hygiene, light therapy, melatonin. There are things out there. And here are two articles that really give great information, explicit recommendations on what to do to help guide these individuals. So you can screen, educate. There are nutritional strategies you can approach and even talk about a sleep toolbox. What's the sleep toolbox? Provide education, screen, encourage napping. So getting even less than a 30 minute nap between the hours of 1 p.m. and 4 p.m. when your circadian rhythm is down a little bit, that will be beneficial for you. Also educate that you can bank sleep. So if somebody has a big competition coming up that weekend or that Friday night, and they know that they're gonna be nervous the night before and they're not gonna sleep well, well, knowing this, heading into that week ahead, they can start sleeping, really focusing on getting the same quality sleep, going to bed at the same time, and they can bank up sleep. So that one night of poor sleep is not gonna affect them as much. They're also gonna know that they're doing their role ahead of time. It's gonna decrease anxiety and it's gonna help them out. So these are examples of ways that we can help our athletes with this. Now, taking a step back, you guys, there are these amazing tools out there. There will be more talks on this throughout the year. The IOC has come out with these tools, the SMAT and the SMIRT. Margot Patoukian has spoken on these in the past, giving great lectures on these. The SMAT is what we're looking at. This is the Sport Mental Health Assessment Tool. It's helpful for sports medicine physicians, other licensed professionals. But if somebody is going to manage information based off of these assessment tools, the action and the guidance has to come from the sports medicine physician. Essentially, it's a questionnaire that will lead to a type of score. If they score a certain number or above, they have to answer more questions, which helps delineate and tease out whether somebody is at high risk. So the bottom line is, guys, we have to ask the question. I don't know who of you out there was at, were at AMSSM last year where there was, his name escapes my brain right now, but he was a professional athlete struggling with mental health. And he just kept on saying, I saw doctor after doctor after doctor and nobody would ask me the question. So it's up to us and it's up to you guys. Get comfortable with these topics. Ask the questions. Don't shy away. Don't lower your voice. Don't be like, how you doing? You've been depressed lately. Just work on it. It takes time. It takes a skill level. And learn, read, practice. Here are two courses, Mental Health First Aid with links associated. It's a great one that all our athletic trainers at the University of Virginia have taken. There's also the IOC Diploma in Mental Health and Elite Sport. I did this program last year. It is a phenomenal course. So I encourage you guys to look into this and work on your own skillset. Really improve. So wrapping up, here are the questions. Guys, here are the pictures. This is the individual who came in with a blister on the posterior aspect of the heel. You advise, and the correct answer is, you want to decompress it and protect with bandages. You want to maybe consider sticking a needle into the side, draining it, leaving that roof to protect the underlying skin. Here is the image that that wrestler came in. He couldn't quite see it because he was shaving. This is Herpes Glad. He came in on a Thursday. His competition was Saturday. There was no way he was going to get five days of treatment in. So the correct answer for this is, do not allow him to wrestle. Start him on PO meds, and he'll be ready to go for the next tournament. All right, and with that, I'm going to open up the floor for questions. Thank you, Dr. Statuta, for such an amazingly thorough and really helpful talk. That was Dr. Statuta from the University of Virginia, UVA. And so that was actually Sam Acho who spoke at MSSM. It was great. And I know we're going to be able to have some good speakers in Phoenix for the spring. So hopefully people can make that one. I do have to say I was a little itchy for the first part. Those were very helpful pictures, and I really appreciated some of those pearls that you gave us. Those were really helpful tips too. There are some questions that came in. Do you have a good, quick resource for antibiotic selection and dosing timing for basic skin or respiratory infections? Skin infections. It is that wrestler's form. It is in the talk, guys. It is also, hold on. I'm going to move up one slide. Can I move? Oh, there we go. Let me see. It is the skin infection. Infectious disease, oh, no, hold on. It is one of the hearted ones, guys. I put a heart in the corner. Kevin DeWeber was the second author on it. Oh, it's in yellow. It's that important I put it in yellow. So there's a chart right there. Respiratory infections, not really. I mean, strep, you always want to start out with a penicillin if there's allergies. That's when you want to reconsider, but there's not a really quick, easy reference to those, not off the top of my head. So that also, this is such a great lecture that I think people will want to be able to refer back to. Somebody asked if there would be a consolidated document with the recommended articles and videos or a way they could. I would love to just review this before my board's next. Yes, I'm happy to do that. And yeah, these articles, I wonder if we could even add the links to the articles. We will work on that. Maybe we could link this to the talk. So we'll see what we can do behind the scenes. You guys, my email is my first name, Siobhan at Virginia.edu. You can email me and I'd be happy to send you the list of references as well. And you spell your first name, S-I-O-B-H-A-N. Correct, at Virginia, spelled out, .edu. And Andy said he'll put the links. He can share the links in the YouTube comment section. So somebody had asked early on during the DERM part, will you, oh, don't forget you guys, if you guys are starting to go back to your evenings, fill out the form, if you can, for the review and any comments. That's really helpful for Dr. Statuta and also us as we're trying to make sure we're creating and curating good content for you guys. The question was, will you still trephinate subungual hematomas if you have an associated tuft fracture? No, and that is a great topic. You guys, I tried to cram in so much that I neglected to bring that up. So thank you so much, great question. No, if I suspect that there's a displaced fracture, if there's an intra-articular fracture, if there's an extensive nail bed injury or there's any type of infection, I'm not gonna mess with that. I'm gonna send them to the hand specialists and have them handle it. They may consider, remember, once you remove that nail, it becomes an open fracture, increases the chance of infection. So get that out to the proper individuals to handle. Okay, there is time to ask more questions if anybody's interested. I certainly, one thing, Siobhan, I thought was really great was how you talked about not starting antibiotics right away. I think that's something that patients are often asking for and they don't wanna have to come back and especially athletes when they're on their way to, like on a road trip, they're always kind of wanting to have everything they need. So I think it's really helpful how you said, utilize your team, you have athletic trainers, you're their doc. So if you're doing training room stuff, they have access to you. It's not like they don't have to, they have to wait until you're back in a month. So just make sure they realize there's a low threshold. Exactly, exactly. And, you know, if you paint the picture, I mean, take each case individually. So if you are entering a bowl game and it is somebody who is really sick and it's, you know, every case needs to be considered differently, just like your grandmother who's about to get on a plane to go visit her grandchild overseas. Like every case needs to be individualized. But just in general, handing out antibiotics, you're really doing a disservice. So having that conversation is super important and use what we have to our benefit, which is eyes and ears on the ground. Well, with that said, I think that we have used our time wisely and this was just an incredible, incredible intro, but also a great reference for people. So Dr. Statuta, thank you for putting this together and thank you for taking this time. And I know I'll look forward to watching this again. Thank you. Thanks for having me guys. Take care.

3rd Edition, CASE 27

3rd Edition

Infectious Disease

sports medicine

skin conditions

respiratory illnesses

mental health

athlete's foot

antibiotic resistance

psychological well-being

healthcare providers

athletic settings

education strategies