T oday’s young athlete is faced with many challenges in sports participation. There are demanding practice and travel schedules that need to fit within the rigors of academics. Pressure to perform can come from parents and caregivers alike, as well as coaches. Some sports are so exclusive that young athletes will need to compete for a position on a team to advance. But there is one challenge all young athletes go through that they will need to overcome and is often overlooked the pubertal growth spurt. As a nonsurgical pediatric sports medicine physician, I care for many young athletes for acute and chronic musculoskeletal injuries. After almost 10 years of practice, anecdotally, I would estimate that the most common age-group of young athletes I see is between 10 and 14 years. There is no coincidence that this age also closely corresponds to the pubertal growth spurt. I often think about how we can prevent common injuries I see in my clinic, several of which can be linked to the consequences of pubertal growth. When I speak to many young athletes, parents, and caregivers, there is often a request to order an expensive magnetic resonance imaging (MRI) scan for a “diagnosis,” even when it is not necessary. A fraction of the cost of the MRI could have gone to a good integrative neuromuscular training (INT) program, focused on core strength, flexibility, and proprioception, that could have prevented injury. However, there is more emphasis by parents and coaches on skill development and early sports specialization in young athletes than on preventative conditioning and INT programs, especially during the pubertal growth spurt. This tends to remind us all that youth sports are a $19.2 billion industry that is recession proof. Puberty is the physiologic process during which adolescents undergo dramatic changes in physical growth and sexual maturation. There are changes in body size, shape, and composition. It is sexually dimorphic. The onset of puberty has been linked to timing from parental history, obesity, ethnicity, socioeconomic status, nutrition, and stress. In girls, puberty begins around age 11 years (range, 9-14 years), and is seen earlier in Black girls than White girls. In boys, pubertal onset is around age 13 years (range, 10-14 years). Peak height velocity occurs at Tanner stage 2 to 3 in girls and Tanner stage 4 in boys. Girls can gain 9 cm/year during their growth spurt, which ends at age 15 years, whereas boys can gain 10.3 cm/year and their growth spurt ends at age 17 years. Flexibility tends to decrease in boys leading up to 14 to 16 years. In girls, flexibility tends to increase in girls between 10 and 13 years and plateaus by 14 to 15 years. Skeletal growth typically occurs before musculotendinous growth, especially in boys. Lastly, predicted adult height, also known as midparental height, for a young athlete can be calculated within 2 standard deviations. For girls, this is the sum of the father’s and mother’s height minus 13 (in centimeters) divided by 2. For boys, this is the sum of the father’s and mother’s height plus 13 (in centimeters) divided by 2. While there are many advantages the young athlete has from pubertal growth, such as increases in height and strength, as seen in boys more dramatically than girls, there are a few disadvantages. As with dramatic increases in linear bone growth during the pubertal growth spurt, muscle inflexibility ensues, especially in the posterior chain muscles, predominantly in boys. I cannot recall one 13-year-old boy whom I have seen recently who did not have hamstring tightness. Hamstring inflexibility has been linked to low back pain, hamstring injuries, and anterior knee pain. For girls, the pelvis widens during pubertal growth more dramatically than with boys, increasing the Q-angle and resulting in knee valgus. The increased risk for patellofemoral disorders and ACL injuries associated with increased dynamic valgus knee motion in young female adolescent athletes is well known. A 14-year-old adolescent girl does not run or jump with the same biomechanics as when she was 9. So where do we go from here? As a multidisciplinary group of sports medicine providers, we can encourage athletes as young as 7 years to participate in conditioning and INT programs to help prevent injuries, especially during their pubertal growth spurt. This age recommendation comes from the work by Dr. Avery Faigenbaum and colleagues from his paper, “How Young is ‘Too Young’ to Start Training?” He suggests that offering INT programs early in childhood sets the stage for instilling good exercise habits and greater physical gains during postpubertal growth. He adds that, although there is no evidence to suggest an age to start INT programs, it is generally accepted that young athletes must be able to follow coaching instructions and handle attention demands, which typically occurs around 7 to 1187909 SPHXXX10.1177/19417381231187909RiedererSPORTS HEALTH editorial2023

Background: The Pediatric Research in Sports Medicine (PRiSM) society is a multi-disciplinary group of healthcare providers who provide clinical care to young athletes with a variety of conditions, including isthmic spondylolysis. It is thought that significant practice differences exist in the way providers diagnose, image, and treat this condition. Hypothesis/Purpose: The purpose of this study is to survey the members of PRiSM on clinical practice patterns in the diagnosis, imaging, and management of isthmic spondylolysis in young athletes. Methods: An electronic, thirty-three question REDCaps survey was distributed to the PRISM membership via email during the 2021 virtual annual meeting and one reminder was sent after the meeting. Responses were collected during a 6-week period. The survey collected information based upon the following: demographics, diagnosis, imaging, and management. Results: Ninety-eight surveys were completed. Most of the respondents were divided between orthopaedic surgeons, non-operative sports medicine physicians and physical therapists, approximately half of which are fellowship trained. Approximately 42% of respondents make the diagnosis based upon MRI results in addition to history, physical examination, and plain radiographs. Approximately 24% obtain oblique radiographs as part of their assessment. MRI is the most frequently used advanced imaging modality with nearly 90% of respondents using this. The use of rigid bracing varies widely among respondents, with 20.6% bracing regularly, 35.3% sometimes bracing, and 44.1% not using rigid braces at all. The use of non-rigid bracing is similarly varied with 17.6% prescribing this regularly, 44.1% sometimes, and 38.2% not using non-rigid bracing at all. There is variance as well with regards to initiation of physical therapy (PT): prescribing immediately (42.6%) versus prescribing a period to rest prior to PT (57.4%). When young athletes are returned to sport, 52.9% of respondents indicated that they would impose restrictions to activity and 47.1% would not. Conclusion: Although there are similarities in how the diagnosis of isthmic spondylolysis in young athletes is made by PRISM members, there is variability in management, especially the use of bracing, the timing of physical therapy, and return to sport restrictions. MRI is the most common advanced imaging modality being used to help with the diagnosis.

Background: Juvenile osteochondritis dissecans (OCD) of the knee is a defect of subchondral bone seen primarily in active children and adolescents. Studies have evaluated the incidence of surgery in knee OCD, but the incidence of subsequent surgery in patients with stable, healing lesions cleared to return to activities is unknown. This study sought to determine the incidence of surgery in participants with knee OCD lesions cleared to return to activities and evaluate predictors of subsequent surgery. Methods: A single center, retrospective review was performed of participants aged 7 to 18 with knee OCD. Inclusion criteria were stable lesion, skeletal immaturity, no history of previous knee surgery, release to activity without surgery, and at least 12 months of follow-up. Documentation of subsequent surgery was queried in the electronic health record. Participants with no recorded surgery were contacted through phone. Analysis included bivariate and logistic regression. Results: Twenty-five individuals were included in this study, with 7 undergoing surgery after returning to activity. Medial femoral condyle lesions were less likely to undergo surgery ( B =−2.6, P =0.038). Average lesion size for the Surgery and No Surgery groups was 1.76±0.65 and 1.32±0.81 cm 2 , respectively, though not significantly different ( P =0.21). The Surgery group returned to activity sooner (3.7 mo, range 1.1 to 6.4) than the No Surgery group (8.1 mo, range 1.8 to 35.4), though not significantly different ( P =0.18). Mean follow-up time for the study was 42.7 (range 12.6 to 77.6) months. No participants contacted by phone progressed to surgery or reported symptoms that limited their activities. Conclusions: While the majority of participants with stable, healing, and asymptomatic knee OCD lesions have favorable outcomes with nonoperative management, some lesions may progress to surgery. Lesions on the medial femoral condyle may be predictive of lower likelihood of progression to surgery. Our study provides insight on the outcomes of nonoperative management of OCD lesions. Level of Evidence: Level IV—prognostic study.

Abstract Isthmic spondylolysis is a common cause of back pain in young athletes. The condition presents to numerous medical providers who employ a variety of different practices in diagnosis and management. The purpose of this study was twofold: to review the literature of diagnosis and management of the young athlete with isthmic spondylolysis and to survey Pediatric Research in Sports Medicine (PRiSM) members during the 2021 PRiSM Annual Meeting on practice patterns of diagnosis and management of the young athlete with isthmic spondylolysis. The response rate was 27%. Per respondents: 24% obtain oblique radiographs; 90% use magnetic resonance imaging as the advanced imaging modality; 60% treat with bracing; 57% recommend rest prior to physical therapy (PT); 53% prescribe return to sport activity restrictions. Although there are similarities in the diagnosis of isthmic spondylolysis in young athletes, this survey confirmed variability in management, especially bracing, timing of PT and return to sport activity restrictions.

► Limited movement in both arms ► Diffuse pain in elbows, forearms, and upper arms ► Pronated hands.

Sleep is an important aspect in the recovery and performance in athletes. Recently, there has been increasing interest in exploring the various affects that sleep has on performance in athletes. Youth athletes represent a unique population in that not only do they have demands in training schedules and training load, but they also have demands in academics. There is a growing body of evidence to suggest that youth athletes do not get the recommended required amount of sleep and that this has negatively affected performance and well-being. The focus of this article is to review the most recent literature over the past year that investigates the impact of sleep on youth performance.

HISTORY: A 14-year-old adolescent volleyball, baseball, and soccer athlete presents for evaluation of a two month history of left mid-thigh tightness, discomfort and bulge. Upon multiple attempts to elicit an injury mechanism, there was no single, discrete injury that he can recall. He experiences some tightness when running. He denies feeling weak in the hip or knee. He denies any bruising. He can feel a hard mass in the location of his symptoms. PHYSICAL EXAMINATION: He has a normal gait without limp. There is no visible swelling, bruising or deformities of the left thigh. Approximately over the mid to superior quadriceps there is an area of approximately 4 cm x 3 cm that is slightly indurated, non-tender but the patient reports it is uncomfortable to palpate. There is no fluctuance. There is no limitation or pain with active and passive range of motion at the knee or hip. Hip flexion and knee extension strength are a 4/5 without pain with resistance. The remainder of the physical examination is non-contributory. DIFFERENTIAL DIAGNOSIS: 1. Quadriceps strain 2. Myositis ossificans 3. Quadriceps hematoma 4. Lipoma 5. Occult tumor TEST AND RESULTS: Initial imaging included plain radiographs, which did not show any acute or chronic osseous abnormalities. The soft tissues appear normal. Musculoskeletal ultrasound demonstrated a large hypoechoic defect within the rectus femoris muscle. An MRI showed a full-thickness tear of the indirect muscle of the rectus femoris, with a 1.5 cm craniocaudad gap/retraction of the indirect muscle at the myotendinous unit. FINAL/WORKING DIAGNOSIS: Full-thickness tear of the indirect head of the left rectus femoris tendon with retraction of the myotendinous unit TREATMENT AND OUTCOMES: Due to the fact that the patient was not very symptomatic, we recommended a trial of non-operative management. This included rest from sports and physical therapy to work on strengthening. Displeased with this plan, the family sought a second opinion from the team physician for a local Division I college volleyball team. In a telephone follow up conversation with the patient’s mother, the team physician also recommended non-operative management.

Extra-articular hip impingement from prior traumatic injury to the anterior inferior iliac spine (AIIS) is an uncommon cause of groin pain in young athletes. Currently, the most common treatment for this injury is arthroscopic decompression. However, hip arthroscopy is not universally available and requires advanced skills. We report 2 cases of the development of extra-articular hip impingement from unusual bony exostoses off the AIIS after traumatic injury in 2 young athletes who underwent open surgical resection. The multidisciplinary sports medicine team should be aware of the development of extra-articular impingement from traumatic injury to the AIIS and that open surgical resection is a viable alternative to arthroscopic decompression.

Swimming is one of the most popular sports worldwide. Competitive swimming is one of the most watched sports during the Olympic Games. Swimming has unique medical challenges as a result of a variety of environmental and chemical exposures. Musculoskeletal overuse injuries, overtraining, respiratory problems, and dermatologic conditions are among the most common problems swimmers encounter. Although not unique to swimming, overtraining is a serious condition which can have significant negative impact on swimmers' health and performance. This review article is an attempt to discuss various issues that a medical team should consider when caring for swimmers.

In 2011, the Centers for Disease Control and Prevention reported approximately 25.8 million children and adults in the United States were affected by diabetes mellitus, making diabetes one of the most prevalent chronic diseases in our population.1Centers for Disease Control and PreventionNational Diabetes Fact Sheet: National Estimates and General Information on Diabetes and Prediabetes in the United States, 2011. US Department of Health and Human Services, Atlanta, GA2011Google Scholar Although people with type 1 diabetes mellitus (DM1) constitute a small percentage of this population, the majority of them are involved in various levels of athletic activities, including endurance sports.2Chansky M.E. Corbett J.G. Cohen E. Hyperglycemic emergencies in athletes.Clin Sports Med. 2009; 28: 469-478Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The American Diabetes Association published a position statement in 2004 reinforcing the fact that persons with DM1 can participate in all levels of activity granted that they have no complications of their diabetes and are in good glycemic control.3American Diabetes AssociationPhysical activity/exercise and diabetes.Diabetes Care. 2004; 27: 58-62PubMed Google Scholar Subsequent to this position statement, there have been a few articles discussing the recommended management of glycemic control in diabetic patients participating in endurance sports.2Chansky M.E. Corbett J.G. Cohen E. Hyperglycemic emergencies in athletes.Clin Sports Med. 2009; 28: 469-478Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 3American Diabetes AssociationPhysical activity/exercise and diabetes.Diabetes Care. 2004; 27: 58-62PubMed Google Scholar, 4Devadoss M. Kennedy L. Herbold N. Endurance athletes and type 1 diabetes.Diabetes Educ. 2011; 37: 193-207Crossref PubMed Scopus (17) Google Scholar However, only a few papers have reported case series of athletes with DM1 in endurance and ultraendurance sports.4Devadoss M. Kennedy L. Herbold N. Endurance athletes and type 1 diabetes.Diabetes Educ. 2011; 37: 193-207Crossref PubMed Scopus (17) Google Scholar, 5Boehncke S. Poettgen K. Maser-Gluth C. Reusch J. Boehncke W.H. Badenhoop K. Endurance capabilities of triathlon competitors with type 1 diabetes mellitus [in German]..Dtsch Med Wochenschr. 2009; 134: 677-682Crossref PubMed Scopus (25) Google Scholar, 6Vlahek P. Car S. Ostroski I. Sweet 452 km—a report on the first type 1 diabetes patient to finish Double Ironman, a 30-hour endurance triathlon race.Croat Med J. 2013; 54: 306-307Crossref PubMed Scopus (15) Google Scholar The purpose of the present study was to report the number and performance of athletes with DM1 who participated in the Leadville 100 races. The Leadville 100 consists of a 161-km mountain bike race and a 161-km ultramarathon in Leadville, Colorado, in August of each year. The courses range in altitude from 2800 m to 3840 m, and the majority are on forest trails with some mountain roads.7Khodaee M. Myers R. Spittler J. Lee J.A. Hill J.C. Yeakel D. Risk factors for injuries in a high-altitude ultramarathon.Br J Sports Med. 2011; 45: 355-356Crossref Google Scholar The Leadville 100 mountain bike race starts at 6:30 am on the second Saturday of each August. Participants should finish the race within 12 hours to be able to successfully complete the race. The Leadville 100 ultramarathon starts at 4:00 am of the third Saturday of each August. Runners should finish the race within 30 hours to be able to successfully complete the race. All Leadville 100 race participants have to report their medical history and medication use through an electronic medical check-in before the race. A medical team reviews the responses for any potential risks for participation before the race. At-risk athletes are counseled during the medical check-in before the race. After reviewing our database, we included all self-described athletes with DM1 who reported being on insulin from 2011 to 2013 in the study. We excluded athletes with type 2 diabetes who reported being on insulin. We performed a descriptive analysis of demographics and unpaired t test to compare our study population to all other athletes of these two races. The Colorado Multiple Institutional Review Board and the Leadville 100 race approved this study. From 2011 to 2013, a total of 7215 athletes competed in the Leadville 100 races. Of these, 5194 athletes (4851 mountain bikers and 2364 runners) were able to successfully complete the races (72%). Nineteen athletes reported having DM1. Only 2 runners with DM1 started the race more than once (2011 and 2012, and 2012 and 2013). Both runners who were not able to finish the race on their first attempt were able to successfully complete the race the next year. The other 15 athletes with DM1 only participated once during the 2011–2013 period. The Figure illustrates the comparison of athletes with DM1 to all other athletes. The majority of the participants with DM1 were male, with average age of 39 years (range 22 to 61 years). The majority (68.4%) of athletes with DM1 were able to successfully complete the race. The average finish time for mountain bike and run for DM1 athletes, respectively, was 10 hours, 36 minutes (range 8 hours, 44 minutes, to 11 hours, 45 minutes), and 27 hours, 54 minutes (range 24 hours, 45 minutes, to 29 hours, 52 minutes). Because of the small number of athletes with DM1, including or excluding them from the entire population did not change any statistics (eg, completion rate). There was no statistically significant difference for successfully completing the races between athletes with DM1 and all other athletes (odds ratio 0.84; 95% confidence interval, 0.32 to 2.22). Ultraendurance events are growing in popularity. It is inevitable that athletes with chronic diseases, including DM1, who desire to push their limits will be encountered. In the retrospective, self-reported enrollment data from an ongoing longitudinal observational study, 0.7% of ultramarathon runners reported having diabetes (type of diabetes was not reported).8Hoffman M.D. Krishnan E. Health and exercise-related medical issues among 1,212 ultramarathon runners: baseline findings from the Ultrarunners Longitudinal Tracking (ULTRA) study.PLoS One. 2014; 9: e83867Crossref PubMed Scopus (79) Google Scholar There have been only a handful of reported cases of athletes with DM1 who completed endurance races.5Boehncke S. Poettgen K. Maser-Gluth C. Reusch J. Boehncke W.H. Badenhoop K. Endurance capabilities of triathlon competitors with type 1 diabetes mellitus [in German]..Dtsch Med Wochenschr. 2009; 134: 677-682Crossref PubMed Scopus (25) Google Scholar, 6Vlahek P. Car S. Ostroski I. Sweet 452 km—a report on the first type 1 diabetes patient to finish Double Ironman, a 30-hour endurance triathlon race.Croat Med J. 2013; 54: 306-307Crossref PubMed Scopus (15) Google Scholar, 9Graveling A.J. Frier B.M. Risks of marathon running and hypoglycaemia in type 1 diabetes.Diabet Med. 2010; 27: 585-588Crossref PubMed Scopus (29) Google Scholar, 10Grimm J.J. Muchnick S. Type I diabetes and marathon running.Diabetes Care. 1993; 16: 1624Crossref PubMed Scopus (10) Google Scholar This number is much smaller for ultraendurance races.5Boehncke S. Poettgen K. Maser-Gluth C. Reusch J. Boehncke W.H. Badenhoop K. Endurance capabilities of triathlon competitors with type 1 diabetes mellitus [in German]..Dtsch Med Wochenschr. 2009; 134: 677-682Crossref PubMed Scopus (25) Google Scholar, 6Vlahek P. Car S. Ostroski I. Sweet 452 km—a report on the first type 1 diabetes patient to finish Double Ironman, a 30-hour endurance triathlon race.Croat Med J. 2013; 54: 306-307Crossref PubMed Scopus (15) Google Scholar To our knowledge, this is the largest number of reported athletes with DM1 who participated in 161-km mountain bike and run races. It appears that athletes with DM1 are able to compete in ultraendurance events. Owing to its retrospective nature, our report has limitations connected to this type of study. When planning medical coverage for these ultraendurance events—which frequently have remote, difficult-to-access courses over a single track, mountain passes, and densely wooded areas—medical teams should be prepared to manage unusual, but serious circumstances such as hypoglycemia.11Khodaee M. Ansari M. Common ultramarathon injuries and illnesses: race day management.Curr Sports Med Rep. 2012; 11: 290-297Crossref PubMed Scopus (36) Google Scholar Many athletes with DM1 use insulin pumps and frequent or continuous glucose monitoring to stay on top of their insulin and caloric needs, and they can complete these ultraevents with few issues. However, that should not be assumed, because often athletes with DM1 are not aware of guidelines on how to manage glycemic fluctuations during long exercises and can run into serious problems with glycemic control.4Devadoss M. Kennedy L. Herbold N. Endurance athletes and type 1 diabetes.Diabetes Educ. 2011; 37: 193-207Crossref PubMed Scopus (17) Google Scholar Close glycemic and dietary monitoring before and during the race is the key to avoid complications.12Marcason W. Is there a recommended target range for blood glucose for the type 1 diabetic endurance athlete?.J Acad Nutr Diet. 2012; 112: 2092Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Further prospective studies focusing on metabolic and physiologic changes as a result of these extreme exercises among athletes with DM1 are required. We would like to thank Mr Joshua Colley and Lifetime Fitness for allowing us to conduct this study, and we also thank our study participants.

OBJECTIVE: To determine the variability between hospitals in diagnostic testing and management interventions for children with bronchiolitis admitted to inpatient wards and identify its association with patient characteristics.METHODS: A prospective, multicenter (16 hospitals), multi-year (2007-2010) observational study of children (age <2 years) hospitalized with bronchiolitis. Outcomes included variability in diagnostic testing (complete blood count, chest radiographs) and medications or interventions (bronchodilator, systemic corticosteroid, antibiotic, IV placement) by hospital. A modified Respiratory Distress Severity Score was utilized to assess severity of illness. For all outcomes, intraclass correlation coefficient (ICC) was calculated from a model to estimate the random effects of hospital without added covariates and compared to ICCs from a second model that adjusted for demographic and clinical patient characteristics. A second unadjusted and adjusted model was created for age >= 2 months.RESULTS: Of 2207 subjects, 1715 were identified as admitted to inpatient wards. We observed wide variations in the proportion of patients who received diagnostic testing (complete blood count 21-75%, chest radiograph 36-85%) and medications/interventions (bronchodilators 19-91%, systemic corticosteroids 8-44%, antibiotics 17-43%, IV placement 38-93%). Adjusting for demographic and clinical patient characteristics did not materially affect the proportion of variability attributable to hospitals (differences in ICCs with and without model adjustment <4%).CONCLUSIONS: Wide variations in diagnostic test utilization and management interventions seen among children with bronchiolitis treated on the inpatient wards at 16 US hospitals were not attributable to demographic or clinical patient characteristics. These results further support efforts to standardize care for bronchiolitis through active quality improvement strategies.

The letter by Khodaee et al1Khodaee M. Riederer M. VanBaak K. Hill J.C. Ultraendurance athletes with type 1 diabetes: Leadville 100 experience.Wilderness Environ Med. 2015; 26: 273-275Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar nicely describes the performance of 19 athletes with type 1 diabetes (DM1) out of 7215 total athletes competing in the 2011–2013 Leadville 100, a 161-km mountain bike race and 161-km ultramarathon run. There was no statistical difference between the 68.4% completion rate of the DM1 athletes and the other endurance athletes. However, concern was expressed in this letter about awareness of, or adherence to, diabetes management guidelines. Education for DM1 patients on multiple daily injections or pumps usually (or should) include exercise instructions for reduced insulin basal needs, carbohydrate boluses, and correction boluses as well as increased use of glucose monitoring, target ranges of glucose to avoid hypoglycemia, and calorie intake. All of this is labor-intensive. Insulin adjustments are highly individualized and involve some trial and error, but are helped especially by the ever-increasing sophistication of insulin pumps, pump trainer/educators, and pump users. Guidelines by the American Diabetes Association2American Diabetes AssociationStandards of medical care in diabetes—2014.Diabetes Care. 2014; 37: S14-S80Crossref PubMed Scopus (3680) Google Scholar are expectedly generalized. More specifics are available, for example, from other sources about endurance athletes with DM1.3Devadoss M. Kennedy L. Herbold N. Endurance athletes and type 1 diabetes.Diabetes Educ. 2011; 37: 193-207Crossref PubMed Scopus (17) Google Scholar In the arduous Leadville 100, perhaps the patient-provider(s) relationship, the Internet, social media, and personal experience offered detailed advice for individual insulin management. Or perhaps information was available from Team Novo Nordisk, a global all-diabetes sports team of cyclists, triathletes, and runners, spearheaded by the world’s first all-diabetes professional cycling team and sponsored by the Danish insulin manufacturer Novo Nordisk.4Team Novo Nordisk. Racing with diabetes. Available at: http://www.teamnovonordisk.com/. Accessed July 13, 2015.Google Scholar I agree with the authors that further studies are needed, but they are hard to come by in such a setting. Until that day arrives, are there any practical tips that can be gleaned from their review? For example, was there any prerace diabetes planning vs actual implementation to change doses of insulin before, during, and after the event when hypoglycemia can still strike? As most were probably pump users, were pump basal infusions reduced and by how much, or temporarily suspended? Were carb boluses cut, say, in half? Were square-wave profiles used rather than simple boluses? Were insertion site set failures common? Were continuous glucose-monitoring systems that measure interstitial glucose levels accurate or useful in this dynamic setting? This was a retrospective study with limitations, and such information may not be available from the entire group, but even individual or anecdotal information would be helpful for both providers and athletes with DM1. Thank you.

We read with enthusiasm the letter from Dr Lankford1Lankford HV. In response to Ultraendurance athletes with type 1 diabetes: Leadville 100 experience, by Khodaee et al. Wilderness Environ Med. 2015;26:588Google Scholar in response to our recently published letter to the editor “Ultraendurance athletes with type 1 diabetes: Leadville 100 experience.”2Khodaee M. Riederer M. VanBaak K. Hill J.C. Ultraendurance athletes with type 1 diabetes: Leadville 100 experience.Wilderness Environ Med. 2015; 26: 273-275Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar We are pleased that our findings have started to generate discussion among clinicians and researchers. As Dr Lankford mentioned in his letter, there is a lack of specific guidelines for endurance athletes with type 1 diabetes mellitus (DM1).1Lankford HV. In response to Ultraendurance athletes with type 1 diabetes: Leadville 100 experience, by Khodaee et al. Wilderness Environ Med. 2015;26:588Google Scholar Anecdotally, most of our athletes with DM1 did not use insulin pumps. Although we had glucose monitoring capabilities at our medical aid stations, most of our athletes with DM1 used their own glucose monitors. Unfortunately, we are unable to answer any other specific questions raised by Dr Lankford owing to the retrospective nature of our study. We hope this reply has made it clear that until we have large-scale prospective studies, an individualized and well-thought-out plan designed and reviewed by the athletes with DM1, the athletes’ physicians, and the race medical team should be used to achieve optimal glycemic control during these long races. In addition to the standard medical alert bracelets, we recommend using medical wristbands for each athlete highlighting the information about pertinent medical conditions, medications, and allergies.3Hoffman M.D. Pasternak A. Rogers I. et al.Medical services at ultra-endurance foot races in remote environments: medical issues and consensus guidelines.Sports Med. 2014; 44: 1055-1069Crossref PubMed Scopus (80) Google Scholar

OBJECTIVE:To evaluate the effect of the Centers for Disease Control and Prevention (CDC) Heads-Up concussion campaign on appropriateness of discharge instructions for youth sports-related concussion (SRC) patients presenting to a pediatric emergency department (ED).DESIGN:Retrospective cohort study.SETTING:Pediatric ED.PATIENTS:Children up to 18 years.ASSESSMENT OF RISK FACTORS:A retrospective chart review was conducted on patients evaluated from 2004 to 2012. Patients were selected by ICD-9 code for having a concussion during a sporting activity.MAIN OUTCOME MEASURES:Discharge instructions were reviewed for recommendations for cognitive rest, physical rest, primary care physician follow-up, and referral to a concussion specialist or center.RESULTS:There were 497 youth SRCs from 392 908 total ED visits. Overall, only 66% had appropriate discharge recommendations. This improved to 75% after 2010, which was not statistically significant (odds ratio = 1.02, P = 0.179). Only 4% of patients received a recommendation of cognitive rest, which only increased to 12% of the patients seen after 2010. Finally, referrals to a sports concussion specialist or center dramatically increased from an average of 8% to 43% after 2010.CONCLUSIONS:Even with the CDC Heads-Up campaign on concussion education, there is still need to improve appropriateness of discharge instructions for youth SRCs. There have been dramatic increases in referrals to sports concussion specialists and centers after 2010.