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Blood flow restriction (BFR) training is commonly used to induce muscle hypertrophy and strength and is gaining popularity as a modality for treatment of musculoskeletal conditions and postoperative rehabilitation. This article reviews the current literature on BFR as a rehabilitative tool, identifies gaps in the literature, and reports the authors experience using BFR in the postoperative environment.

Background Thoracic aortic aneurysms (TAAs) occur because of abnormal remodeling of aortic extracellular matrix and are accompanied by the emergence of proteolytically active myofibroblasts. The microRNA miR‐133a regulates cellular phenotypes and is reduced in clinical TAA specimens. This study tested the hypothesis that miR‐133a modulates aortic fibroblast phenotype, and overexpression by lentivirus attenuates the development of TAA in a murine model. Methods and Results TAA was induced in mice. Copy number of miR‐133a was reduced in TAA tissue and linear regression analysis confirmed an inverse correlation between aortic diameter and miR‐133a. Analyses of phenotypic markers revealed an mRNA expression profile consistent with myofibroblasts in TAA tissue. Fibroblasts were isolated from the thoracic aortae of mice with/without TAA. When compared with controls, miR‐133a was reduced, migration was increased, adhesion was reduced, and the ability to contract a collagen disk was increased. Overexpression/knockdown of miR‐133a controlled these phenotypes. After TAA induction in mice, a single tail‐vein injection of either miR‐133a overexpression or scrambled sequence (control) lentivirus was performed. Overexpression of miR‐133a attenuated TAA development. The pro‐protein convertase furin was confirmed to be a target of miR‐133a by luciferase reporter assay. Furin was elevated in this murine model of TAA and repressed by miR‐133a replacement in vivo resulting in reduced proteolytic activation. Conclusions miR‐133a regulates aortic fibroblast phenotype and over‐expression prevented the development of TAA in a murine model. These findings suggest that stable alterations in aortic fibroblasts are associated with development of TAA and regulation by miR‐133a may lead to a novel therapeutic strategy.

Resistance training is becoming more important as an integral part of comprehensive sport training regimens, school physical education classes, and after-school fitness programs. The increasing number of youth who are involved in sport activities, coupled with the health problems of inactivity and being overweight, have resulted in increased interest in resistance training. Secular declines in measures of muscular fitness in modern-day youth highlight the need for participation in youth resistance training for nonathletes as well as athletes. Parents often ask pediatricians to offer advice regarding the safety, benefits, and implementation of an effective resistance-training program. This report is a revision of the 2008 American Academy of Pediatrics policy statement and reviews current information and research on the benefits and risks of resistance training for children and adolescents.

Context:Infections are common in contact sports. This review aims to describe the epidemiology, presenting signs and symptoms, treatment guidelines, and regulations for several common infections seen in contact sport athletes. The conditions discussed include bacterial skin infections, herpes simplex virus, molluscum contagiosum, common warts, tinea, scabies, head lice, conjunctivitis, human immunodeficiency virus, hepatitis C virus, and vaccine-preventable illnesses.Evidence Acquisition:Searches were performed across PubMed and MEDLINE research databases. In addition, general internet search engine results and reviews of reference lists of relevant papers were used to identify additional sources of evidence.Study Design:Clinical review.Level of Evidence:Level 4.Results:The most common infections seen in contact sport athletes include bacterial skin infections, herpes simplex virus, molluscum contagiosum, common warts, tinea, scabies, head lice, conjunctivitis, and vaccine-preventable illnesses. Other infections, including human immunodeficiency virus and hepatitis C, are uncommon but potentially life threatening.Conclusion:Infections are common in contact sport athletes. The provider who cares for these athletes should be aware of the most common infections and their appropriate management. Early diagnosis and appropriate clinical management are important for treating the infected athlete, minimizing risk of transmission, minimizing time lost from competition, and preventing large outbreaks.

1. Shane M. Miller, MD, FAAP* 2. Andrew R. Peterson, MD, MSPH, FAAP† 1. *Departments of Orthopaedics and Pediatrics, UT Southwestern, and Texas Scottish Rite Hospital for Children Sports Medicine Center, Dallas, TX 2. †Departments of Pediatrics and Orthopaedics/Rehabilitation, University of Iowa, Iowa City, IA * Abbreviations: AAP: : American Academy of Pediatrics AAS: : anabolic-androgenic steroid AHA: : American Heart Association BP: : blood pressure CDC: : Centers for Disease Control and Prevention DM: : diabetes mellitus ECG: : electrocardiography FDA: : Food and Drug Administration LVH: : left ventricular hypertrophy PES: : performance-enhancing substance PPE: : preparticipation physical evaluation SCAT5: : Sports Concussion Assessment Tool, Version 5 SCD: : sickle cell disease SCT: : sickle cell trait Lack of familiarity with current recommendations diminishes the confidence to perform a preparticipation physical evaluation (PPE). In a 2014 survey, Madsen et al (1) reported, “Only 37% of physicians reported an awareness of the PPE Monograph.” (2) Clinicians should be aware of current guidelines for performing a PPE and identify children who may be at increased risk from sport participation. After completing this article, readers should be able to: 1. Perform a preparticipation history and physical examination and identify children and adolescents who may be at increased risk for morbidity or mortality from sport participation. 2. Recognize that the mandatory preparticipation physical evaluation serves as an opportunity to address medical and psychosocial issues not necessarily associated with sport participation and as an entry point for healthy adolescents into the health-care system. 3. Recognize the cardiac risks associated with sport participation and when additional cardiac evaluation is required. 4. Understand the importance of assessing and documenting neurocognitive function before sport participation. 5. Identify which sports are appropriate for athletes with some common medical conditions. 6. Recognize the effect of a febrile illness on sport participation. In the United States, sport participation is increasing, with more than 60 million children and adolescents competing in organized sports every year. The number of high school athletes has increased from 7.2 million to 7.9 million during the past 10 years. (3) The physical and psychosocial benefits of sport participation are well-documented, and pediatricians serve a vital role …

Adam J Kruse,1 Andrew S Nugent,2 Andrew R Peterson3 1Carver College of Medicine, The University of Iowa, Iowa City, IA, USA; 2Department of Emergency Medicine, The University of Iowa, Iowa City, IA, USA; 3Department of Pediatrics, The University of Iowa, Iowa City, IA, USA Purpose: Traumatic brain injury (TBI) is a significant cause of death and disability in the United States. Many patients with TBI are initially treated in the emergency department (ED), but there is no evidence-based method of detecting or grading TBI in patients who have normal structural neuroimaging. This study aims to evaluate the validity of two common sideline concussion tests. The Concussion Symptom Severity Score (CSSS) and modified Balance Error Scoring System (mBESS) tests are well-validated sideline tests for concussion, but have not been validated in the setting of non-sport-related concussion, in settings other than the sideline or athletic training room or in moderate or severe TBI. Patients and methods: One hundred forty-eight subjects who had sustained a TBI within the previous 72 hours and 53 healthy control subjects were enrolled. CSSS and mBESS were administered. Clinical outcomes were followed up prospectively. Results: The CSSS was collected in 147 TBI subjects but only 51 TBI subjects were able to complete the mBESS. The CSSS was collected for all 53 control subjects, and the mBESS was completed for 51 control subjects. The mean CSSS for TBI and control subjects was 32.25 and 2.70, respectively (P < 0.001). The average mBESS for TBI and control subjects was 7.43 and 7.20, respectively (P = 0.82). CSSS greater than 5.17 was 93.43% sensitive and 69.84% specific for TBI. Conclusion: The mBESS is poorly tolerated and, among those who can complete the test, not sensitive to TBI in the ED. The CSSS is both sensitive to TBI and well tolerated. Keywords: traumatic brain injury, balance, emergency room, Sport Concussion Assessment Tool, concussion symptom severity score, modified balance error scoring system

OBJECTIVE:: To determine the amount of within-day variation of Concussion Symptom Severity Scores (CSSSs) in athletes with a clinically diagnosed concussion. DESIGN:: This prospective cohort study used a text-messaging robot to survey concussed athletes using the CSSS 5-times daily while they remained symptomatic. SETTING:: Academic sports concussion clinic at a large tertiary care medical center. PARTICIPANTS:: Fourteen 14- to 22-year-old athletes with clinically diagnosed concussions were enrolled. All were injured in sport, still in season, English speaking, and used a cellular telephone to text message on a regular basis. ASSESSMENT OF RISK FACTORS:: This study did not collect any demographic or other information about the subjects. The only data collected were the individual responses to the questions in the Post Concussion Symptom Score (PCSS). The only aim of this study was to evaluate the variability in responses to the CSSS, which is calculated from the PCSS. MAIN OUTCOME MEASUREMENTS:: The primary outcome measure was a repeatability coefficient from a random-effects model. Concussion Symptom Severity Score, mean daily CSSS, and standard deviation of CSSS differences from the mean were also calculated. RESULTS:: Mean follow-up was 23.9 days. A total of 24 180 text messages were received from subjects. Eight hundred four complete surveys were analyzed. Repeatability coefficient was ±23.1. CONCLUSIONS:: When surveyed frequently by a text-messaging robot, concussed athletes report poorly repeatable Sport Concussion Assessment Tool 2 (SCAT2) Symptom Severity Scores. CLINICAL RELEVANCE:: The SCAT2 Symptom Severity Score may be an invalid method of tracking concussion severity and resolution over time. Language: en

The Balance Error Scoring System (BESS) is a commonly used concussion assessment tool. Recent studies have questioned the stability and reliability of baseline BESS scores. The purpose of this longitudinal prospective cohort study is to examine differences in yearly baseline BESS scores in athletes participating on an NCAA Division-I football team. NCAA Division-I freshman football athletes were videotaped performing the BESS test at matriculation and after 1 year of participation in the football program. Twenty-three athletes were enrolled in year 1 of the study, and 25 athletes were enrolled in year 2. Those athletes enrolled in year 1 were again videotaped after year 2 of the study. The paired t-test was used to assess for change in score over time for the firm surface, foam surface, and the cumulative BESS score. Additionally, inter- and intrarater reliability values were calculated. Cumulative errors on the BESS significantly decreased from a mean of 20.3 at baseline to 16.8 after 1 year of participation. The mean number of errors following the second year of participation was 15.0. Inter-rater reliability for the cumulative score ranged from 0.65 to 0.75. Intrarater reliability was 0.81. After 1 year of participation, there is a statistically and clinically significant improvement in BESS scores in an NCAA Division-I football program. Although additional improvement in BESS scores was noted after a second year of participation, it did not reach statistical significance. Football athletes should undergo baseline BESS testing at least yearly if the BESS is to be optimally useful as a diagnostic test for concussion.

Objective: Hyperhidrosis can cause dehydration and exercise intolerance. There are several case reports of extremely high sweat rates in athletes. We present as case report of a 17-year-old male with the highest sweat rate recorded in the literature (5.8 L/h). Our goal was to determine if glycopyrrolate, an anticholinergic medication with primarily anti-muscarinic effects that is known to decrease sweat production, would reduce the sweat rate of our subject in a controlled exercise setting. Methods: Our patient and a control subject were subjected to an exercise protocol consisting of running on a treadmill (5.4–6.7 mile/h at 1° of incline) in a warm climate-controlled chamber after receiving 0, 2, or 4 mg of glycopyrrolate. Core temperature, heart rate, rater of perceived exertion, and sweat rate were monitored in both subjects. Results: Glycopyrrolate dose was not significantly correlated with decreased sweat rate and maximal core temperature. However, the clinical effect of reducing the sweat rate was very strong. The improvement of the subject’s sweat rate allowed him to successfully return to sport. Conclusion: Our findings suggest that low-dose glycopyrrolate may be a safe and effective method of controlling exertional hyperhidrosis.

Background: There are approximately 2.8 million youth football players between the ages of 7 and 14 years in the United States. Rates of injury in this population are poorly described. Recent studies have reported injury rates between 2.3% and 30.4% per season and between 8.5 and 43 per 1000 exposures. Hypothesis: Youth flag football has a lower injury rate than youth tackle football. The concussion rates in flag football are lower than in tackle football. Study Design: Cohort study; Level of evidence, 3. Methods: Three large youth (grades 2-7) football leagues with a total of 3794 players were enrolled. Research personnel partnered with the leagues to provide electronic attendance and injury reporting systems. Researchers had access to deidentified player data and injury information. Injury rates for both the tackle and flag leagues were calculated and compared using Poisson regression with a log link. The probability an injury was severe and an injury resulted in a concussion were modeled using logistic regression. For these 2 responses, best subset model selection was performed, and the model with the minimum Akaike information criterion value was chosen as best. Kaplan-Meier curves were examined to compare time loss due to injury for various subgroups of the population. Finally, time loss was modeled using Cox proportional hazards regression models. Results: A total of 46,416 exposures and 128 injuries were reported. The mean age at injury was 10.64 years. The hazard ratio for tackle football (compared with flag football) was 0.45 (95% CI, 0.25-0.80; P = .0065). The rate of severe injuries per exposure for tackle football was 1.1 (95% CI, 0.33-3.4; P = .93) times that of the flag league. The rate for concussions in tackle football per exposure was 0.51 (95% CI, 0.16-1.7; P = .27) times that of the flag league. Conclusion: Injury is more likely to occur in youth flag football than in youth tackle football. Severe injuries and concussions were not significantly different between leagues. Concussion was more likely to occur during games than during practice. Players in the sixth or seventh grade were more likely to suffer a concussion than were younger players.

Summary Astrocytes from familial amyotrophic lateral sclerosis (ALS) patients or transgenic mice are toxic specifically to motor neurons (MNs). It is not known if astrocytes from sporadic ALS (sALS) patients cause MN degeneration in vivo and whether the effect is specific to MNs. By transplanting spinal neural progenitors, derived from sALS and healthy induced pluripotent stem cells (iPSCs), into the cervical spinal cord of adult SCID mice for 9 months, we found that differentiated human astrocytes were present in large areas of the spinal cord, replaced endogenous astrocytes, and contacted neurons to a similar extent. Mice with sALS but not non-ALS cells showed reduced non-MNs numbers followed by MNs in the host spinal cord. The surviving MNs showed reduced inputs from inhibitory neurons and exhibited disorganized neurofilaments and aggregated ubiquitin. Correspondingly, mice with sALS but not non-ALS cells showed declined movement deficits. Thus, sALS iPSC-derived astrocytes cause ALS-like degeneration in both MNs and non-MNs., Highlights • sALS iPSC-derived astrocytes integrate into the adult spinal cord extensively • ALS iPSC-derived astrocytes cause degeneration of non-MNs earlier than MNs • Degenerating neurons exhibit disorganized neurofilaments and aggregated ubiquitin • Animals grafted with sALS cells exhibit motor behavioral deficits, In this article, Zhang, Chen, and colleagues show that in the chimeric model created by transplanting human iPSC-derived neural progenitors into the adult mouse spinal cord, sALS astrocytes induced ALS-like degeneration in non-MNs followed by MNs. The results demonstrate the causal role of sALS astrocytes in vivo and suggest the role of non-MNs in mediating MN degeneration.

Headache, a nearly universal experience, remains costly, disabling, and often suboptimally managed. The most common presentations in the United States are migraine, tension-type headache (TTH) and “sinus” headache, but their extensive symptomatic overlap suggests that these conditions can be approached as variations in the same underlying pathology and managed accordingly. We use case studies of patients with varying prior diagnoses (none, migraine, TTH, and sinus headache), as well as a 4-question diagnostic screening tool, to illustrate how pharmacists can use this conceptual framework to simplify identification, management, and referral of patients with primary headache conditions of uncertain etiology.

Helping a wrestler manage body weight can be a daunting process for a pediatric health care provider. Each high school wrestling program has been mandated by the National Federation of State High School Associations to determine an appropriate weight classification for each individual wrestler. This article discusses how an appropriate weight class is determined, the methods for ascertaining a person's hydration status and body density, and the importance of a fully hydrated and normally nourished state that will allow for optimal athletic performance for a wrestler. [ Pediatr Ann . 2016;45(3):e87–e90.]

Lactic acid has played an important role in the traditional theory of muscle fatigue and limitation of endurance exercise performance. It has been called a waste product of anaerobic metabolism and has been believed to be responsible for the uncomfortable "burn" of intense exercise and directly responsible for the metabolic acidosis of exercise, leading to decreased muscle contractility and ultimately cessation of exercise. Although this premise has been commonly taught, it is not supported by the scientific literature and has led to a great deal of confusion among the sports medicine and exercise science communities. This review will provide the sports medicine clinician with an understanding of contemporary lactate theories, including lactate's role in energy production, its contributions to metabolic acidosis, and its function as an energy substrate for a variety of tissues. Lactate threshold concepts will also be discussed, including a practical approach to understanding prediction of performance and monitoring of training progress based on these parameters.

This review summarizes the evidence base for using compression, massage, caloric replacement, cold, and heat as exercise recovery aids in sport.

The number of head injuries from skiing and snowboarding accidents is increasing among adolescents. Ski helmets reduce the risk of head injury. This study explored adolescent attitudes regarding helmet use.This pilot study included 11 high school students participating in a 1-hour focus group.There was agreement that head injury is unlikely compared to other injuries, and use of helmets is determined by level of difficulty of the activity. Peer use makes personal use more acceptable and likely. Helmet cost is a minor barrier. Personal experience with a head injury increases use. Mandatory helmet use was viewed positively by most of the subjects.This pilot study suggests that, similar to bicycle helmet promotion programs, ski and snowboard helmet campaigns should focus on delivering a positive image of helmet use and peer acceptance.

Objectives To compare the cost of diagnosing cystic fibrosis (CF) through a newborn screening program with the traditional method and to estimate the cost of CF diagnosis if a national newborn screening program is implemented. Study design Surveys were conducted to determine the annual number of sweat tests in 1991 and in 2000 after implementation of statewide screening. A national survey of sweat test costs was used to estimate the annual expense for diagnosing CF in the United States through newborn screening. Results Since the introduction of newborn screening for CF, the numbers of sweat tests ordered annually have decreased from 1670 to 804 (including 134 follow-up tests from screening). The current estimated annual cost of Wisconsin CF newborn screening and diagnosis is $4.58 per newborn infant. The estimated annual cost per newly diagnosed CF infant using the traditional method is $4.97 per newborn infant. If no additional sweat tests were ordered outside of the newborn screening program, the estimated annual cost of a Wisconsin CF newborn screening and diagnosis is $2.66 per newborn and $2.47 per newborn for a national CF newborn screening program. Conclusions A CF newborn screening program provides a potentially cost-saving alternative to the traditional method of diagnosis of CF. (J Pediatr 2003;142:617-23)

Objective To evaluate the effectiveness of neuromuscular training in reducing the rate of acute knee injury in adolescent female football players. Design Stratified cluster randomised controlled trial with clubs as the unit of randomisation. Setting 230 Swedish football clubs (121 in the intervention group, 109 in the control group) were followed for one season (2009, seven months). Participants 4564 players aged 12-17 years (2479 in the intervention group, 2085 in the control group) completed the study. Intervention 15 minute neuromuscular warm-up programme (targeting core stability, balance, and proper knee alignment) to be carried out twice a week throughout the season. Main outcome measures The primary outcome was rate of anterior cruciate ligament injury; secondary outcomes were rates of severe knee injury (>4 weeks’ absence) and any acute knee injury. Results Seven players (0.28%) in the intervention group, and 14 (0.67%) in the control group had an anterior cruciate ligament injury. By Cox regression analysis according to intention to treat, a 64% reduction in the rate of anterior cruciate ligament injury was seen in the intervention group (rate ratio 0.36, 95% confidence interval 0.15 to 0.85). The absolute rate difference was −0.07 (95% confidence interval −0.13 to 0.001) per 1000 playing hours in favour of the intervention group. No significant rate reductions were seen for secondary outcomes. Conclusions A neuromuscular warm-up programme significantly reduced the rate of anterior cruciate ligament injury in adolescent female football players. However, the absolute rate difference did not reach statistical significance, possibly owing to the small number of events. Trial registration Clinical trials NCT00894595.

Existing methods for measuring vapor pressure are too expensive or not quantitative enough for chemistry classes in secondary schools. Our method measures the vapor pressure inside a bubble trapped in a graduated microtube made from a disposable 1-mL glass pipet. Vapor pressures of water, methanol, and ethanol are measured over temperature ranges of 4-90 °C. The enthalpy and entropy of vaporization and boiling points, calculated using the Clausius-Clapeyron equation, agree well with published values. The vapor pressures of aqueous solutions of ethanol and methanol plotted against mole fractions of water give positive deviations from Raoult's law, but concentrations were identified from which molecular weights of the alcohols could be calculated. These molecular weights are not significantly different from published values. Sources of error in the method are analyzed. A procedure for use in secondary schools is outlined.