Concussion in National Football League Athletes Is Not Associated With Increased Risk of Acute, Noncontact Lower Extremity Musculoskeletal Injury

Background: Impaired neuromuscular function after concussion has recently been linked to increased risk of lower extremity injuries in athletes. Purpose: To determine if National Football League (NFL) athletes have an increased risk of sustaining an acute, noncontact lower extremity injury in the 90-day period after return to play (RTP) and whether on-field performance differs pre- and postconcussion. Study Design: Cohort study, Level of evidence, 3. Methods: NFL concussions in offensive players from the 2012-2013 to the 2016-2017 seasons were studied. Age, position, injury location/type, RTP, and athlete factors were noted. A 90-day RTP postconcussive period was analyzed for lower extremity injuries. Concussion and injury data were obtained from publicly available sources. Nonconcussed, offensive skill position NFL athletes from the same period were used as a control cohort, with the 2014 season as the reference season. Power rating performance metrics were calculated for ±1, ±2, and ±3 seasons pre- and postconcussion. Conditional logistic regression was used to determine associations between concussion and lower extremity injury as well as the relationship of concussions to on-field performance. Results: In total, 116 concussions were recorded in 108 NFL athletes during the study period. There was no statistically significant difference in the incidence of an acute, noncontact lower extremity injury between concussed and control athletes (8.5% vs 12.8%; Conclusion: Concussed, NFL offensive athletes did not demonstrate increased odds of acute, noncontact, lower extremity injury in a 90-day RTP period when compared with nonconcussed controls. Immediate on-field performance of skill position players did not appear to be affected by concussion

An analysis of inpatient pediatric sickle cell disease: Incidence, costs, and outcomes

ObjectiveTo identify characteristics of pediatric sickle cell disease (SCD) hospitalizations and to examine admission demographics and medical expenditures.MethodsAdmissions with SCD were identified from the 2009 and 2012 releases of the Healthcare and Cost Utilization Project’s Kids Inpatient Database. Diseaseâ specific secondary diagnoses including acute chest syndrome (ACS), vasoâ occlusive pain crisis (VOC), splenic sequestration, and stroke/transient ischemic attack were analyzed for patient and hospital demographics. Analytical endpoints included total healthcare expenditures and mortality.ResultsWe reviewed 75,234 inpatient hospitalizations with a diagnosis of SCD. Over $900,000,000 was spent annually in associated healthcare expenditure. The median length of hospitalization stay (LOS) for all admissions was 3 days (interquartile range [IQR] 2â 5 days). VOC was the most frequent secondary diagnosis, recording 48,698 total hospitalizations and a median LOS of 3 days (IQR 2â 6 days). Of the 8,490 hospitalizations with ACS, the infant population had a significantly higher mortality rate compared to other age groups (2$18,956), behind ACS ($22,631). A high proportion of Caucasian patients died during hospitalization for VOC (0.4% vs. 0.1%, P = 0.014) and ACS (4% vs. 0.2%, P < 0.001) when compared to nonâ Caucasians.ConclusionInpatient hospitalizations for secondary manifestations of pediatric SCD were associated with significant healthcare expenditures. Patients with an increased statistical risk for death during hospitalization included Caucasians with SCD complications of ACS and VOC, and patients <1â yearâ old with ACS. Further research is needed to substantiate the associated clinical significance of these findings.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140014/1/pbc26758.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/140014/2/pbc26758_am.pd

The Relationship Between Shoulder Range of Motion and Arm Stress in College Pitchers: A MOTUS Baseball Study

The Relationship Between Shoulder Range of Motion and Arm Stress in College Pitchers: A MOTUS Baseball Study Abstract Predictors of Elbow Torque Among College Baseball Pitchers Purpose: To investigate the relationship of shoulder range of motion (ROM) conditions, such as glenohumeral internal rotation deficiency (GIRD) and external rotation gain (ERG), to torque across the medial elbow in college pitchers. Methods: Pitchers were recruited from three local college baseball teams. Exclusion criteria included injury or restricted activity due to pain. They were evaluated within two weeks before their first game of the season. Pitchers completed an intake survey at the time of shoulder ROM and upper extremity length measurements. Pitchers were fitted with a MOTUS sensor baseball sleeve (Motus Global, Massapequa, NY). The sensor placed at the medial elbow reported elbow torque, arm speed, arm slot, and shoulder rotation for each pitch, while a radar gun measured peak ball velocity. After adequate warmup, pitchers threw 5 fastballs in a standardized manner off the mound at game-speed effort. The primary outcome was to evaluate the relationship between shoulder ROM and medial elbow torque. Additional outcomes evaluated pitcher characteristics, demographics, and outcome scores in the context of shoulder ROM. Outcomes were assessed via a multivariable model, which controlled for possible covariates. Results: Twenty-eight pitchers were included in the preseason analysis with an average (SD) age of 20.1 (1.3) years and playing experience of 15.3 (1.8) years, 2.5 (1.2) of those years at collegiate level. The dominant shoulder demonstrated decreased internal rotation (54.5+/-10.6 vs 65.8+/-9.1) and increased external rotation (ER, 94.1+/-10.4 vs 88.4+/-9.2) relative to the non-dominant side (p \u3c 0.001), while total rotational range of motion (TRROM) was significantly decreased in the dominant arm (148.6+/-12.4 vs 154.1+/-10.6, p \u3c 0.001). The average GIRD was 11.3 (9.87) and average ERG was 4.4 (8.87). External rotation was found to be a predictor of arm stress, with an increase in 0.35 Nm of elbow torque for every degree increase in ER (beta = 0.35+/-0.06, p = 0.003); there was moderate correlation between ER and arm stress (r = .45, P\u3c.001). Pitchers demonstrated significantly greater arm stress with the following shoulder ROM measurements: GIRD \u3c 20 as compared to greater than 20 degrees (46.6 +/- 0.5 versus 43.5 +/- 1.1, P=.011), ERG \u3e 5 as compared to \u3c 5 degrees (47.4 +/- 0.7 versus 45.1 +/- 0.6, P=.014), and loss of total rotational ROM \u3c 5 as compared to \u3e 5 degrees (46.6 +/- 0.5 versus 43.6 +/- 1.1, P=.013). Conclusions: College pitchers with external rotation gain produced greater medial elbow torque during the pitching movement. These findings indicate that pitchers with increased external rotation of their throwing arm may experience greater elbow stress while pitching, placing their medial elbow at risk of injury. Level of Evidence: Level II prospective observational study Key Words: UCL, Ulnar Collateral Ligament, Pitching, Tommy John, Laxity, Pain, Elbow, Injur

The evolving SARS-CoV-2 epidemic in Africa: Insights from rapidly expanding genomic surveillance

INTRODUCTION Investment in Africa over the past year with regard to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequencing has led to a massive increase in the number of sequences, which, to date, exceeds 100,000 sequences generated to track the pandemic on the continent. These sequences have profoundly affected how public health officials in Africa have navigated the COVID-19 pandemic. RATIONALE We demonstrate how the first 100,000 SARS-CoV-2 sequences from Africa have helped monitor the epidemic on the continent, how genomic surveillance expanded over the course of the pandemic, and how we adapted our sequencing methods to deal with an evolving virus. Finally, we also examine how viral lineages have spread across the continent in a phylogeographic framework to gain insights into the underlying temporal and spatial transmission dynamics for several variants of concern (VOCs). RESULTS Our results indicate that the number of countries in Africa that can sequence the virus within their own borders is growing and that this is coupled with a shorter turnaround time from the time of sampling to sequence submission. Ongoing evolution necessitated the continual updating of primer sets, and, as a result, eight primer sets were designed in tandem with viral evolution and used to ensure effective sequencing of the virus. The pandemic unfolded through multiple waves of infection that were each driven by distinct genetic lineages, with B.1-like ancestral strains associated with the first pandemic wave of infections in 2020. Successive waves on the continent were fueled by different VOCs, with Alpha and Beta cocirculating in distinct spatial patterns during the second wave and Delta and Omicron affecting the whole continent during the third and fourth waves, respectively. Phylogeographic reconstruction points toward distinct differences in viral importation and exportation patterns associated with the Alpha, Beta, Delta, and Omicron variants and subvariants, when considering both Africa versus the rest of the world and viral dissemination within the continent. Our epidemiological and phylogenetic inferences therefore underscore the heterogeneous nature of the pandemic on the continent and highlight key insights and challenges, for instance, recognizing the limitations of low testing proportions. We also highlight the early warning capacity that genomic surveillance in Africa has had for the rest of the world with the detection of new lineages and variants, the most recent being the characterization of various Omicron subvariants. CONCLUSION Sustained investment for diagnostics and genomic surveillance in Africa is needed as the virus continues to evolve. This is important not only to help combat SARS-CoV-2 on the continent but also because it can be used as a platform to help address the many emerging and reemerging infectious disease threats in Africa. In particular, capacity building for local sequencing within countries or within the continent should be prioritized because this is generally associated with shorter turnaround times, providing the most benefit to local public health authorities tasked with pandemic response and mitigation and allowing for the fastest reaction to localized outbreaks. These investments are crucial for pandemic preparedness and response and will serve the health of the continent well into the 21st century

Clinical Evaluation and Physical Exam Findings in Patients with Anterior Shoulder Instability.

PURPOSE OF REVIEW: The goal of this paper is to provide an overview in evaluating the patient with suspected or known anteroinferior glenohumeral instability. RECENT FINDINGS: There is a high rate of recurrent subluxations or dislocations in young patients with history of anterior shoulder dislocation, and recurrent instability will increase likelihood of further damage to the glenohumeral joint. Proper identification and treatment of anterior shoulder instability can dramatically reduce the rate of recurrent dislocation and prevent subsequent complications. Overall, the anterior release or surprise test demonstrates the best sensitivity and specificity for clinically diagnosing anterior shoulder instability, although other tests also have favorable sensitivities, specificities, positive likelihood ratios, negative likelihood ratios, and inter-rater reliabilities. Anterior shoulder instability is a relatively common injury in the young and athletic population. The combination of history and performing apprehension, relocation, release or surprise, anterior load, and anterior drawer exam maneuvers will optimize sensitivity and specificity for accurately diagnosing anterior shoulder instability in clinical practice

Using a Web-Based Data Collection Platform to Implement an Effective Electronic Patient-Reported Outcome Registry

Modern health care places significant emphasis on patient-centered care. As a result, many orthopaedic providers are incorporating routine patient-reported outcome measure (PROM) collection into their practice. However, routine PROM collection often disrupts clinical workflow and can place a burden on both the patient and the provider. Electronic PROM collection systems, if implemented deliberately to maximize convenience and efficiency, have the potential to mitigate these obstacles. This technique guide presents an overview of designing and implementing a PROM-based clinical registry for the ambulatory orthopaedic clinic using Research Electronic Data Capture (REDCap; Vanderbilt University, Nashville, TN). We outline the basic steps of creating a simple but effective patient registry using this accessible data collection platform

Technology assessment and cost-effectiveness in orthopedics: how to measure outcomes and deliver value in a constantly changing healthcare environment.

PURPOSE OF REVIEW: The purpose of this study is to review the basic concepts of healthcare value, patient outcome measurement, and cost-effectiveness analyses as they relate to the introduction of new surgical techniques and technologies in the field of orthopedic surgery. RECENT FINDINGS: An increased focus on financial stewardship in healthcare has resulted in a plethora of cost-effectiveness and patient outcome research. Recent research has made great progress in identifying orthopedic technologies that provide exceptional value and those that do not meet adequate standards for widespread adoption. As the pace of technological innovation advances in lockstep with an increased focus on value, orthopedic surgeons will need to have a working knowledge of value-based healthcare decision-making. Value-based healthcare and cost-effectiveness analyses can aid orthopedic surgeons in making ethical and fiscally responsible treatment choices for their patients

Predictors of Elbow Torque Among Youth and Adolescent Baseball Pitchers.

BACKGROUND: There has been an increasing incidence of overuse elbow injuries among youth and adolescent pitchers. Pitch type has been implicated as a risk factor for excess torque at the medial elbow; however, this has not been definitively demonstrated. PURPOSE: To assess predictors of torque across the medial elbow in youth and adolescent pitchers with a mobile sensor. In addition, the authors aimed to determine the differences in elbow torque produced according to pitch type (fastball, curveball, changeup) and pitcher demographics. STUDY DESIGN: Descriptive laboratory study. METHODS: Twenty youth and adolescent pitchers were instructed to throw 8 fastballs, 8 curveballs, and 8 changeups in a standardized but randomized sequence over a 25-minute period. Five pitchers were evaluated each day. A sensor placed at the medial elbow reported elbow torque, arm speed, arm slot, and shoulder rotation for each pitch, while a radar gun measured peak ball velocity. The primary outcome was a determination of thrower and pitch characteristics associated with elevated torque across the medial elbow. Secondary outcomes included the evaluation of differences in throwing biomechanics among different pitch types. Outcomes were assessed via a multivariable model, which controlled for possible covariates. RESULTS: In total, 20 youth baseball pitchers with a mean age of 14.1 years (range, 12-17 years) were included in the study. On average, fastballs caused the greatest torque across the medial elbow (least squares mean ± SE, 47.3 ± 0.5 N·m) as compared with changeups (44.2 ± 0.5 N·m; P \u3c .001) and curveballs (45.0 ± 0.5 N·m; P = .002). However, curveballs produced the greatest arm speed (917.8 rpm). Pitchers who started throwing curveballs at an older age experienced less elbow torque ( P \u3c .001). A multivariable model demonstrated that increased ball velocity and body mass index and decreased arm slot were independent predictors of increased elbow torque. Conversely, increasing age, longer arm length, and greater elbow circumference were independent protectors against elbow torque. CONCLUSION: This study found that among youth and adolescent pitchers, fastballs generate the highest elbow torque while curveballs generated the greatest arm speed. Increased ball velocity and body mass index and decreased arm slot were predictors of elbow torque; however, increasing age and size of a pitcher\u27s arm were protectors against elbow torque. These findings are important to better understand risk factors for overuse injury in this at-risk athletic population. CLINICAL RELEVANCE: These findings may inform future pitching recommendations with intentions of curtailing medial elbow injuries experienced by young pitchers, such as ulnar collateral ligament injuries

Assessment of Elbow Torque and Other Parameters During the Pitching Motion: Comparison of Fastball, Curveball, and Change-up.

PURPOSE: To assess the precision of a new wearable device in detecting medial elbow torque during the pitching motion in competitive baseball pitchers and to determine the differences in torque across pitch types and thrower demographic characteristics. METHODS: High school and collegiate baseball pitchers were recruited from August 1, 2016, to January 31, 2017, through direct request by athletic trainers and coaches. Body dimensions and throwing arm measurements of the participants were collected. The sensor was positioned directly over the medial elbow and pitchers were instructed to throw 8 fastballs, 8 curveballs, and 8 change-ups in a standard, randomized sequence. The sensor reported elbow torque, arm speed, arm slot, and shoulder rotation, whereas a radar gun measured peak ball velocity. Precision was calculated by measuring outlier rate, and mixed model regression analysis was performed to detect differences in throwing biomechanics among pitch types. RESULTS: In total, 37 competitive baseball pitchers were included in the study. The device had a precision of 96.9% for fastballs, 96.9% for curveballs, and 97.9% for change-ups. The device was sensitive enough to distinguish pitches according to elbow torque, arm speed, arm slot, and shoulder rotation. Fastballs caused the greatest relative torque across the medial elbow (average = 45.56 N m), compared with change-ups (43.77 N m; P = .006) and curveballs (43.83 N m; P = .01). Ball velocity contributed most to medial elbow torque (P = .003), followed by elbow circumference (P = .021), where smaller elbow circumference predicted greater medial elbow torque. CONCLUSIONS: The sensor is a precise and reproducible device for measuring torque across the medial elbow, as well as additional parameters of arm speed, arm slot, and shoulder rotation. Torque was significantly relatively higher in fastballs than curveballs and change-ups. LEVEL OF EVIDENCE: Level III, comparative study