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In this paper, I have discussed about fractals. The two key properties of fractals have been stated. A brief history about fractals is also mentioned. I have discussed about Mandelbrot fractal and have plotted it using python. A computer-generated fern is compared to a real fern to show how much fractals resemble the real-world objects. Various applications of fractal geometry have also been included.

Measuring adherence to the 2015 U.S. Preventive Services Task Force (USPSTF) diabetes prevention guidelines can inform implementation efforts to prevent or delay Type 2 diabetes. A retrospective cohort was used to study patients without a diagnosis of diabetes attributed to primary care clinics within two large healthcare systems in our state to study adherence to the following: (1) screening at-risk patients and (2) referring individuals with confirmed prediabetes to participate in an intensive behavioral counseling intervention, defined as a Center for Disease Control and Prevention (CDC)-recognized Diabetes Prevention Program (DPP). Among 461,866 adults attributed to 79 primary care clinics, 45.7% of patients were screened, yet variability at the level of the clinic ranged from 14.5% to 83.2%. Very few patients participated in a CDC-recognized DPP (0.52%; range 0%-3.53%). These findings support the importance of a systematic implementation strategy to specifically target barriers to diabetes prevention screening and referral to treatment.

There is overwhelming evidence in the scientific and medical literature that physical inactivity is a major public health problem with a wide array of harmful effects. Over 50% of health status can be attributed to unhealthy behaviors with smoking, diet, and physical inactivity as the main contributors. Exercise has been used in both the treatment and prevention of a variety of chronic conditions such as heart disease, pulmonary disease, diabetes, and obesity. While the negative effects of physical inactivity are widely known, there is a gap between what physicians tell their patients and exercise compliance. Exercise is Medicine was established in 2007 by the American College of Sports Medicine to inform and educate physicians and other health care providers about exercise as well as bridge the widening gap between health care and health fitness. Physicians have many competing demands at the point of care, which often translates into limited time spent counseling patients. The consistent message from all health care providers to their patients should be to start or to continue a regular exercise program. Exercise is Medicine is a solution that enables physicians to support their patients in implementing exercise as part of their disease prevention and treatment strategies.

Background:Few have examined predictive relationships between physical activity (PA) and health using electronic health records (EHRs) of patient-reported PA.Objective:Assess initial predictive validity of the Physical Activity “Vital Sign” (PAVS) recorded in EHRs with BMI and disease burden.Methods:EHRs were from November 2011 to November 2013 (n = 34,712). Differences in not meeting Physical Activity Guidelines (PAG) were tested using chi-square analysis between being normal weight versus overweight/obese, and scoring below versus above the 50th percentile of the Charlson Comorbidity Index (CCI). Repeated measures logistic regression was used to determine odds of BMI and CCI classifications according to responses to the PAVS as not meeting PAG.Results:Patients who did not meet PAG according to the PAVS were more likely than normal weight patients to have a higher BMI (BMI 25.0–29.9, OR = 1.19, P = .001; BMI 30.0–34.9, OR = 1.39, P < .0001; BMI 35.0–39.9, OR = 2.42, P < .0001; BMI ≥ 40, OR = 3.7, P < .0001) and also higher disease burden (above 50th percentile for CCI, OR = 1.8, P < .0001).Conclusions:The strong association of the PAVS found with patient BMI and moderately-strong association with disease burden supports initial predictive validity of the PAVS recorded in EHRs. PA recorded in EHRs may be vastly useful for assessing patient disease and cost burdens attributed independently to PA behavior.

Nearly 60% of U.S. children live in counties with particulate matter less than or equal to 2.5 μm in aerodynamic diameter (PMTo evaluate the association between ambient PMUsing an observational case-crossover design, subjects (n = 146,397) were studied if they had an ALRI diagnosis and resided on Utah's Wasatch Front. PMApproximately 77% (n = 112,467) of subjects were 0-2 years of age. The odds of ALRI encounter for these young children increased within 1 week of elevated PMIn this large sample of urban/suburban patients, short-term exposure to elevated PM

Physical inactivity is one of the most prevalent major health risk factors, with 8 in 10 US adults not meeting aerobic and muscle-strengthening guidelines, and is associated with a high burden of cardiovascular disease. Improving and maintaining recommended levels of physical activity leads to reductions in metabolic, hemodynamic, functional, body composition, and epigenetic risk factors for noncommunicable chronic diseases. Physical activity also has a significant role, in many cases comparable or superior to drug interventions, in the prevention and management of >40 conditions such as diabetes mellitus, cancer, cardiovascular disease, obesity, depression, Alzheimer disease, and arthritis. Whereas most of the modifiable cardiovascular disease risk factors included in the American Heart Association’s My Life Check - Life’s Simple 7 are evaluated routinely in clinical practice (glucose and lipid profiles, blood pressure, obesity, and smoking), physical activity is typically not assessed. The purpose of this statement is to provide a comprehensive review of the evidence on the feasibility, validity, and effectiveness of assessing and promoting physical activity in healthcare settings for adult patients. It also adds concrete recommendations for healthcare systems, clinical and community care providers, fitness professionals, the technology industry, and other stakeholders in order to catalyze increased adoption of physical activity assessment and promotion in healthcare settings and to contribute to meeting the American Heart Association’s 2020 Impact Goals.

Every year in the USA, 8 million athletes participate in high school sports and 460 000 participate in intercollegiate sports.1 Sport participation is an important vehicle for many adolescents and young adults to achieve recommended levels of physical activity. High school and college athletes are more likely to meet nationally recommended levels of physical activity in comparison to non-athlete peers,2 3 and sports participation confers many health benefits not discussed here. However, sports participation also can be a risk factor for unhealthy behaviours, high training loads and metabolic disturbances in a subset of vulnerable athletes. As the level of competition increases from high school to college, the duration and intensity of an athlete’s training typically increases. For running sports such as cross country and track and field, the transition from high school to collegiate training may result in a substantial increase in weekly running mileage. Along with this increase in training load, college athletes are exposed to changes in their dietary intake (eg, cooking for themselves or eating in a residence hall), sleep patterns (eg, staying up late …

Women are 3 times more likely to injure their anterior cruciate ligament (ACL) while playing soccer than men. ACL injury prevention programs (IPPs) involving stretching and strengthening drills can reduce the incidence of ACL injury when incorporated into routine training. The rate of implementation among coaches is largely unknown. The purpose of this study was to determine the rate of implementation of ACL IPP, to identify factors that influence implementation, and to acquire information to assist in design dissemination and implementation strategies. Study subjects were coaches of woman soccer players aged 11-22 years in Utah (n = 756). Data were gathered using a Web-based survey followed by a qualitative study in which "best practice coaches"-coaches who met criteria for successful implementation of ACL IPP-were interviewed via telephone. A minority of survey respondents, 19.8% (27/136), have implemented ACL IPP. Factors associated with successful implementation include length of coaching experience and presence of additional support staff such as a strength and conditioning coach or athletic trainer. Best practice coaches (14/136) unanimously agreed on the following: (a) there are performance-enhancing benefits of ACL IPP, (b) education on ACL injury prevention should be required for licensure, and (c) dissemination and implementation will require soccer associations to enact policies that require IPPs. In conclusion, a minority of girls soccer coaches have implemented ACL IPP and those that have do so because they believe that prevention improves performance and that soccer organizations should enact policies requiring ACL injury prevention education and implementation. Efforts to implement ACL IPP should be driven by soccer organizations, emphasize performance-enhancing benefits, and engage additional coaching staff.

The American Heart Association recognizes the importance of physically active lifestyles to the health and well-being of children and adults with congenital heart defects. Counseling of patients with congenital heart defects should emphasize the importance of daily physical activity and decreasing sedentary behavior as appropriate for the patient’s clinical status. The suggested practices are based on relevant research regarding the benefits of physical activity for healthy children and adults, because research on physical activity among patients with congenital heart defects is lacking. There is no evidence regarding whether or not there is a need to restrict recreational physical activity among patients with congenital heart defects, apart from those with rhythm disorders. It is important to recognize that most patients with congenital heart defects are relatively sedentary and that the physical and psychosocial health benefits of physical activity are important for this population, which is at risk for exercise intolerance, obesity, and psychosocial morbidities. Therefore, counseling to encourage daily participation in appropriate physical activity should be a core component of every patient encounter.

Physical inactivity's propensity to cause preventable morbidity and mortality grossly is under-recognized by both the public and by health care professionals. If health care professionals are serious about doing the best for every patient every patient visit, then we must be skilled in assessing physical activity levels as well as providing appropriate advice and must be able to guide patients through options and to activity. We have a professional duty and responsibility to know and deliver best treatments as well as keep ourselves up to date with and strive for the current best practice. Physical activity is central to health, and doing nothing is not a responsible option for our patients or health care professionals. More importantly, there is an urgent need for all health care professionals to embrace physical activity and strive for systems change, at governmental, organizational, educational, and medical leadership levels.

The importance of habitual physical activity (PA) on health starts even before a child is born as meeting recommended levels of PA during pregnancy is associated with lower rates of maternal conditions that adversely affect the developing fetus including excessive gestational weight gain, gestational diabetes and pregnancy-induced hypertension.1 Women who are physically active during pregnancy, are also more likely to continue activity postpartum2 and the children of active mothers are more likely to be active themselves;3 thereby elevating the importance of PA promotion during pregnancy and postpartum. Regular PA is important in each stage of a child's life. Infants and toddlers should be allowed and encouraged to engage in activities that develop essential motor skills.4 Preschool-aged children should participate in activities that begin the process of motor skill development such as kicking and throwing a ball. School-age children spend the majority of their waking hours in school and school-related activities. Active transportation to and from school, recess, quality physical education, sport and after school activities provide numerous opportunities for children and adolescents to achieve the recommended 60 min/day of moderate to vigorous PA.5 ,6 Despite these opportunities, only 27.1% of US high school students surveyed participate in at least 60 min/day of PA on 7 days of the week, and only 29% attend daily physical education.7 By age 15, only 17% of US girls, compared to 33% of boys, report at least 1 hour of moderate-to-vigorous PA daily.8 Multiple sectors of society (eg, school, public health, …

Multidisciplinary management of the female athlete triad (disordered eating, amenorrhea, and osteoporosis) is optimal, but what exactly does it entail? With the primary care physician as the point person, the healthcare team addresses the underlying causes of disordered eating through such measures as drawing up a contract for returning to play, resolving nutrition issues, exploring psychotherapy options, and, sometimes, prescribing antidepressants. Hormone replacement therapy and conservative or orthopedic intervention for stress fractures may also be required. Communication among the members of the treatment team is crucial, and athletic trainers especially can provide valuable input. Prevention strategies need to involve education of coaches, teachers, trainers, parents, and others who work closely with female athletes.

The female athlete triad of disordered eating, amenorrhea, and osteoporosis affects many active women and girls, especially those in sports that emphasize appearance or leanness. Because of the athlete's psychological defense mechanisms and the stigma surrounding disordered eating, physicians may need to ask targeted questions about nutrition habits when assessing a patient who has a stress fracture or amenorrhea, or during preparticipation exams. Carefully worded questions can help. Physical signs and symptoms include unexplained recurrent or stress fracture, dry hair, low body temperature, lanugo, and fatigue. Targeted lab tests to assess nutritional and hormonal status are essential in making a diagnosis that will steer treatment, as are optimal radiologic tests like dual-energy x-ray absorptiometry for assessing bone density.

To determine if participation in a learning collaborative (LC) would improve care processes for prevention, early recognition, and treatment of childhood obesity by primary care physicians (PCP), the authors conducted pre-post evaluations of the use of obesity related care processes by 18 primary care practices following participation in a 9-month LC based on the Model for Improvement. Prior to the LC, chart audits revealed that 55% of patients had a BMI recorded; this rose to 97% of patients at its conclusion. Following the LC, 11 practices had implemented systematic prevention advice to parents of infants compared with 3 prior to the LC. All practices developed plans for evaluation and management of children with an elevated BMI. Participation in an LC increased the number of primary care practices that provided anticipatory guidance regarding obesity prevention and that identified and treated overweight or obese children.

Background:Only 25% of US adults achieve adequate physical activity (PA). Obtaining a PA history is an appropriate first step when evaluating this behavior. The Physical Activity Vital Sign (PAVS) is a clinical tool designed to screen for PA in adults.Methods:To determine how responses to the PAVS questions associate with BMI, overweight, and obesity, we performed a cross-sectional study utilizing the PAVS, and measured height and weight. Data were collected from adults at 2 clinics within the Utah Health Research Network.Results:Adjusting for demographic factors, BMI decreased 0.91 units for every reported day of PA during a typical week (P < .001), and the odds of obesity was significantly decreased by 0.73 for every day of PA reported in a typical week, (P = .001).Conclusion:Response to the PAVS question of typical behavior is highly correlated with BMI. Although response to the PAVS question of behavior last week is not correlated, this question may prompt accurate recall to the typical week question and help guide patient counseling. Our results support the construct validity for the use of the PAVS as a clinical screening tool and suggest the need for additional research to characterize the properties of the PAVS.

Objectives An association between depression and coronary artery disease (CAD) is well established. Poor adherence to cardiac treatments may be one way depression could contribute to the increased risk of coronary events among depressed patients. We sought to evaluate whether adherence to antilipid medication, a therapy shown to be beneficial in secondary prevention of coronary events, differs among CAD patients with and without an ICD-9 depression diagnosis. Methods Patients were included if, at angiography, they were determined to have CAD (stenosis ≥70%), were discharged on an antilipid medication, and re-filled their prescriptions at a participating pharmacy. A patient was determined to have depression ( ICD-9 codes 296.2–296.36, 311) if the diagnosis occurred prior to angiography or within 6 months of the CAD diagnosis. Adherence and long-term outcomes were evaluated at 6 months, 1 year, 18 months and 2 years. Results A total of 585 patients were included, with 73 (12.5%) having a diagnosis of depression prior to or within 6 months of CAD diagnosis. At all time-points, those with depression had a lower mean adherence compared to those without depression. Differences in adherence rates after adjustment were 7% ( P =.001), 6% ( P =.02), 13% ( P P =.18) at 6 months, 1 year, 18 months, and 2 years, respectively. Though not statistically significant, there were clinically important associations between adherence and depression on the combined outcome of death, myocardial infarction, and revascularization. Conclusion Depression was the strongest predictor of antilipidemic medication adherence after 2 years of follow-up among CAD patients. Such results suggest that poor antilipid adherence may be one mechanism by which depression contributes to CAD events.

Objective To identify risk factors for volleyball-related shoulder pain and dysfunction. Design Cross-sectional, observational. Setting National championship sporting event. Participants Competitors at the 2006 National Intramural & Recreational Sports Association Collegiate Club Volleyball Championship competition were invited to volunteer for the study. A total of 422 athletes returned questionnaires, of whom 276 also underwent a structured physical examination. Assessment of Risk Factors Study participants provided information on any history of volleyball-related shoulder pain or dysfunction. The simple shoulder test (SST) and a visual analog scale permitted subjects to quantify the extent of their perceived functional limitation. Subjects also were invited to undergo a physical examination in which dynamic scapular positioning, glenohumeral range of motion, shoulder girdle strength, and core stability were assessed. Main Outcome Measurements Standard statistical methods of comparison and tests of association were used to identify risk factors for shoulder pain among participating volleyball athletes. Results Approximately 60% of participants reported a history of shoulder problems. Attackers and "jump" servers were more likely to have shoulder problems than setters, defensive specialists, and "float" servers. Nearly half of the athletes who reported shoulder problems perceived some associated functional limitation, with female athletes providing lower SST scores than male athletes (9.0 versus 10.1, P = .001). Athletes reporting shoulder pain and dysfunction were more likely to have SICK scapula scores of 3 or greater ( P = .010). Participants who demonstrated core instability also had greater SICK scapula scores (3.9 versus 2.9, P = .038), and were more likely to report a history of shoulder problems (χ 2 = 8.83, P = .032). Although the authors observed a significant mean left-right difference of 8.9° in available glenohumeral internal rotation among participating athletes, this deficit was not associated with shoulder problems. However, there was an association between asymmetric coracoid tightness /pectoral shortening and shoulder pain ( P = .030), as well as for restricted shoulder flexion in the sagittal plane and shoulder problems ( P = .015). Conclusions Although most risk factors for volleyball-related shoulder problems are similar to those identified for other overhead sports, there appear to be additional volleyball-specific risk factors that may reflect the biomechanical demands of the sport. An understanding of modifiable risk factors is critical to providing optimal care for overuse injuries and may facilitate future efforts to prevent shoulder problems among volleyball athletes.

The purpose of this study was to evaluate the influence of post-coronary artery disease (CAD) depression diagnosis on heart failure (HF) incidence.Depression has been shown to be a risk factor for poor outcomes among CAD patients. However, little is known about the influence of depression on HF development in CAD patients.Patients (n = 13,708) without a diagnosis of HF and depression (International Classification of Diseases-Ninth Revision [ICD-9] codes: 296.2 to 296.36 and 311) and who were not prescribed antidepressant medication (ADM) at the time of CAD diagnosis (or=70% stenosis) were studied. For those with available medication records (n = 7,719), patients subsequently diagnosed with depression were stratified by use of ADM. Patients were followed until HF diagnosis (physician-diagnosed or ICD-9 code: 428) or death. Results were analyzed by Cox proportional hazards regression models.A total of 1,377 patients (10.0%) had a post-CAD clinical depression diagnosis. The incidence of HF among those without a post-CAD depression diagnosis was 3.6 per 100 compared with 16.4 per 100 for those with a post-CAD depression diagnosis. Depression was associated with an increased risk for HF incidence (adjusted hazard ratio [HR]: 1.50, p0.0001). Results were similar among those with available follow-up medication information (vs. no depression: depression without ADM use [HR: 1.68, p0.0001]; depression with ADM use [HR: 2.00, p0.0001]). No difference was found between depressed patients with and without ADM treatment (HR: 0.84, p = 0.24).Depression diagnosis was shown to be associated with an increased incidence of HF after CAD diagnosis, regardless of ADM treatment. This finding suggests the need to further study the effect of depression on HF risk among CAD patients.

Child and adolescent obesity is increasing at a rapid pace. A significant contributing factor relates to the overall decline in physical activity for both children and adults. It will take efforts by many to reverse this trend. Primary care and sports medicine providers are poised optimally to counsel patients on the benefits of regular physical activity. However, only a minority of patients are counseled regarding physical activity at any given office visit. To improve upon this, providers need to understand current recommendations regarding physical activity, have available clinical tools that help in the diagnosis of physical inactivity, and develop office systems to ensure consistency in addressing physical activity at every office visit.

Context Single-sport specialization (SSS) is becoming more prevalent in youth athletes. Deficits in functional movement have been shown to predispose athletes to injury. It is unclear whether a link exists between SSS and the development of functional movement deficits that predispose SSS athletes to an increased risk of knee injury.Objective To determine whether functional movement deficits exist in SSS athletes compared with multi-sport (M-S) athletes.Design Cross-sectional study.Setting Soccer practice fields.Patients or Other Participants A total of 40 (21 SSS [age = 15.05 ± 1.2 years], 19 M-S [age = 15.32 ± 1.2 years]) female high school athlete volunteers were recruited through local soccer clubs. All SSS athletes played soccer.Intervention(s) Participants were grouped into 2 categories: SSS and M-S. All participants completed 3 trials of the standard Landing Error Scoring System (LESS) jump-landing task. They performed a double-legged jump from a 30-cm platform, landing on a rubber mat at a distance of half their body height. Upon landing, participants immediately performed a maximal vertical jump.Main Outcome Measure(s) Values were assigned to each trial using the LESS scoring criteria. We averaged the 3 scored trials and then used a Mann-Whitney U test to test for differences between groups. Participant scores from the jump-landing assessment for each group were also placed into the 4 defined LESS categories for group comparison using a Pearson χ2 test. The α level was set a priori at .05.Results Mean scores were 6.84 ± 1.81 for the SSS group and 6.07 ± 1.93 for the M-S group. We observed no differences between groups (z = −1.44, P = .15). A Pearson χ2 analysis revealed that the proportions of athletes classified as having excellent, good, moderate, or poor LESS scores were not different between the SSS and M-S groups ( = 1.999, P = .57).Conclusions Participation in soccer alone compared with multiple sports did not affect LESS scores in adolescent female soccer players. However, the LESS scores indicated that most female adolescent athletes may be at an increased risk for knee injury, regardless of the number of sports played.

Knowledge about proper coding in sports medicine will not benefit a physician or his or her practice if bills submitted to insurance companies are not regularly monitored and analyzed for trends. Physicians can help ensure successful collections by understanding the dynamics of reimbursement, enlisting the efforts of office colleagues, and facilitating patient involvement when appropriate. This is the third article in a three-part series about economics issues encountered in a sports medicine practice. The authors are not certified coding experts, and the articles are not meant to serve as a definitive guide to billing and coding in sports medicine, but rather to provide insight into this poorly understood and complex area of medicine that can make or break a practice. The first article, on coding basics, appeared in May, and the second, on advanced sports medicine coding, appeared in June.

Proper understanding of coding, billing, and other practice economics issues in sports medicine is vital for practice success. Lack of accuracy and understanding in these areas may lead to problems that range from lost income to practice audits and potentially steep fines. A basic understanding of current procedural terminology (CPT), awareness of international classification of diseases (ICD-9) and healthcare common procedure coding system (HCPCS) codes, and the knowledge of how to apply them benefit sports medicine physicians.

The multidisciplinary team approach to the patient with disordered eating is widely recognized as the best practice. Team members include a physician, a nutritionist, and a mental health professional. All should be experienced in the care of individuals with disordered eating. Each member of the treatment team has unique skills and responsibilities with respect to patient care. However, there is considerable overlap in what each member of the treatment team does to promote recovery from disordered eating. It is important to remember that eating problems exist on a spectrum from disordered eating behaviors that do not meet the Diagnostic and Statistical Manual of Mental Disorders criteria, to anorexia nervosa, and bulimia nervosa. Prognosis is directly related to duration of illness, so early intervention, even when symptoms may be minimal, is preferable. Despite multi- disciplinary treatment efforts, overall prognosis is poor, with only 40% to 50% of patients with anorexia nervosa and bulimia nervosa progressing to complete recovery. Continued efforts and early, comprehensive intervention must be undertaken by all practitioners.

Acute traumatic injuries are common in ballet dancers. A careful history, thorough examination, and appropriate imaging should allow for the diagnosis of most problems. The clinician must have a high index of suspicion for occult bony injuries, especially if the patient fails to recover as expected. Aggressive treatment of the sprained ankle is essential to maintain foot and ankle mobility and prevent prolonged disability and subsequent overuse injuries. Kinetic chain dysfunctions are common in ballet dancers with overuse injuries and commonly follow ankle sprains. They may represent a secondary phenomenon that developed in response to the compensatory movement changes caused by the initial injury. It is important to remember, however, that these dysfunctions may have been long standing and a causative factor in the injury. Regardless of the time of onset of the dysfunction, residual kinetic chain dysfunction associated with incomplete rehabilitation of an injury may predispose the dancer to further injuries. Untreated dysfunctions at one site in the kinetic chain may predispose to compensatory dysfunction at other sites in the chain. Accordingly, it is essential to thoroughly examine the entire chain for functional movements when dealing with an injury, because identification and treatment of the kinetic chain dysfunction is important in the rehabilitation of the dancing athlete. Kinetic chain dysfunctions are common in injured ballet dancers and may be a cause of repeated injury. Why then are these dysfunctions left untreated? Medical personnel caring for dancers are sometimes guilty of tunnel vision, and focus solely on the injured site without considering what is happening at other sites in the kinetic chain. This oversight is compounded when the physicians or therapists are satisfied with discovering simply what injury has occurred rather than asking why the injury has occurred. The significance of kinetic chain dysfunctions is only just beginning to be recognized, and many examiners are not aware of the relationship between abnormal motion and injury. Generally, people see only what they look for, and they look only for what they know. Kinetic chain dysfunctions can easily be detected with simple tests of functional movement if the examiners include these tests in their assessment of the injured dancer. As long as clinicians are either unaware of or unwilling to perform these tests, these dysfunctions will remain untreated and may put the dancer at risk of failed rehabilitation or predispose them to further injury.

In brief In most people, mitral valve prolapse, which affects women more than men, is a benign condition with few or no symptoms. But in some patients it poses a significant problem. Potential sequelae include endocarditis, serious arrhythmia, and sudden death. Although a midsystolic click followed by a late systolic murmur is characteristic, definitive diagnosis requires echocardiography. Treatment ranges from education and reassurance in those who have mild disease to valve replacement in severe cases. Most athletes who have mitral valve prolapse can safely participate in all activities. Those with evidence of significant valvular disease, serious arrhythmia, or a family history of sudden death due to mitral valve prolapse, however, should participate only in low-intensity competitive sports.

Objectives. Disease surveillance combines data collection and analysis with dissemination of findings to decision makers. The timeliness of these activities affects the ability to implement preventive measures. Influenza surveillance has traditionally been hampered by delays in both data collection and dissemination. Methods. We used statistical process control (SPC) to evaluate the daily percentage of outpatient visits with a positive point-of-care (POC) influenza test in the University of Utah Primary Care Research Network. Results. Retrospectively, POC testing generated an alert in each of 4 seasons (2004–2008, median 16 days before epidemic onset), suggesting that email notification of clinicians would be 9 days earlier than surveillance alerts posted to the Utah Department of Health website. In the 2008-09 season, the algorithm generated a real-time alert 19 days before epidemic onset. Clinicians in 4 intervention clinics received email notification of the alert within 4 days. Compared with clinicians in 6 control clinics, intervention clinicians were 40% more likely to perform rapid testing () and twice as likely to vaccinate for seasonal influenza () after notification. Conclusions. Email notification of SPC-generated alerts provided significantly earlier notification of the epidemic onset than traditional surveillance. Clinician preventive behavior was not significantly different in intervention clinics.

Physical activity (PA) is a key component of healthy lifestyle and disease prevention. In contrast, physical inactivity accounts for a significant proportion of premature deaths worldwide. Physicians are in a critical position to help patients develop healthy lifestyles by actively counseling on PA. Sports medicine physicians, with their focus on sports and exercise medicine are uniquely trained to provide such expertise to patients, learners and colleagues. To succeed, physicians need clinical tools and processes that support PA assessment and counseling. Linking patients to community resources, and specifically to health and fitness professionals is a key strategy. Efforts should be made to expand provider education during medical school, residency and fellowship training, and continuing medical education. Lastly, physically active physicians are more likely to counsel patients to be active. A key message for the sports medicine community is the importance of serving as a positive PA role model.

Background Skeletal muscle mass declines after the age of 50. Loss of skeletal muscle mass is associated with increased morbidity and mortality. Objective This study aims to identify predictors of low skeletal muscle mass in older adults toward development of a practical clinical assessment tool for use by clinicians to identify patients requiring dual-energy X-ray absorptiometry (DXA) screening for muscle mass. Methods Data were drawn from the National Health and Nutrition Examination Surveys (NHANES) from 1999 to 2004. Appendicular skeletal mass (ASM) was calculated based on DXA scans. Skeletal muscle mass index (SMI) was defined as the ratio of ASM divided by height in square centimeters. Elderly participants were classified as having low muscle mass if the SMI was 1 standard deviation (SD) below the mean SMI of young adults (20–40 years old). Logistic regression was conducted separately in males and females age ≥65 years of age to examine the relationship between patients identified as having low muscle mass and health behavior characteristics, adjusting for comorbid conditions. The model was validated on a separate sample of 200 patients. Results Among the NHANES study population, 551 (39.7 %) males and 374 (27.5 %) females had a SMI below the 1 SD cutoff point. NHANES study subjects with a low SMI were older (mean age, 76.2 vs. 72.7 for male; 76.0 vs. 73.7 for female; and both p

To assess the association of second-generation antipsychotics (SGAs) with changes in body mass index (BMI) among adolescents compared with a matched untreated comparison group.A retrospective cohort study was conducted using an electronic medical record database between January 2004 and July 2009. Adolescents (12-19 years old), newly initiated on SGAs formed the exposure group and untreated adolescents formed the comparison group matched (3:1) to the antipsychotic group based on age, gender, and month of index SGA. Both the exposure and comparison groups were followed for slightly more than a year (395 days). Baseline and follow-up BMI were evaluated for both groups and percentage change from baseline BMI to follow-up BMI was calculated. Multivariate linear regression was conducted to assess the impact of SGAs on percent change in follow-up BMI from baseline controlling for demographic characteristics, baseline medications, comorbidities, and other covariates.The mean percentage increase in follow-up BMI from baseline for antipsychotic group was significantly higher than the comparison group (p.01). After adjusting for covariates, adolescents on olanzapine had the highest percentage increase in follow-up BMI from baseline (5.84%, 95% confidence interval [CI], 4.07-7.61) followed by aripiprazole (4.36%; 95% CI, 3.08-5.64), risperidone (3.65%; 95% CI, 2.61-4.68), and quetiapine (1.53%; 95% CI, .53-2.52) compared with the comparison group.This study further validates a growing concern of increased BMI in adolescents on SGA therapy.

The scaphoid is the most frequently fractured carpal bone, with fractures of the middle third accounting for 80% of all scaphoid fractures (1-3). These fractures are commonly treated with a thumb spica, long arm cast that immobilizes both the wrist and the elbow. This type of cast is cumbersome and creates economic hardship for some patients.

Anterior dislocations of the shoulder are relatively common, and many techniques in the literature report achieving safe and satisfactory reductions. One such technique is called the Boss-Holzach-Matter method (1,2)-referred to in this article as the self-reduction technique. With physician guidance, this technique safely allows patients to assist and control relocation of the shoulder. It is atraumatic, simple, and quick; can be used by medical and nonmedical personnel; is possible without analgesics or general anesthesia; and can be done in any setting, including a medical facility. It is ideal for use outdoors or in the backcountry where transport to a medical facility would be time-consuming and difficult.

It's 8:00 pm on a Monday night. Just as you're getting ready to put your 5-year-old son to bed, he falls from a chair, landing on his wrist. It quickly swells, requiring a visit to a nearby urgent care clinic. At the clinic, a pleasant young resident takes a history, performs a physical exam, and orders an x-ray to evaluate the injury. You are told that nothing is broken, and a wrist splint is placed. The following day, however, you receive a phone call from the clinic informing you that upon further review of the radiographs, a fracture was detected, and your son will need a cast for definitive treatment.

Exercise is beneficial for women of all ages and is associated with long-term health benefits and enhanced well-being. Nevertheless, active women and girls are at risk for conditions resulting from sports and exercise participation. Because of their unique physiology, children are more susceptible to heat illness than adolescents and younger adults. Childhood sports injuries tend to involve the growth plate. Adolescents share some concerns with child athletes but have injuries more similar to those that occur in adults, especially ligament and tendon injuries. Adolescents and adult women are at risk for anterior cruciate ligament injuries, patellofemoral pain syndrome, and stress fractures. For athletes in these age groups, physicians should screen for pelvic floor dysfunction and the female athlete triad, especially in patients with a history of stress fractures. In adult women, exercise can contribute to disease prevention and management. Continuation of an appropriate exercise routine helps older women maintain independence and prevent falls.

Stress fractures are common among female athletes, especially runners. Although both intrinsic and extrinsic factors can contribute to stress injury etiology, the female athlete triad--negative energy balance leading to menstrual irregularity, and reduced bone mineral mass--is a significant contributor to the incidence of stress fractures in the female athlete. When combined with impact weight-bearing activity, this triad puts these women at increased risk for stress fractures. Treatment must focus on reversing identified risk factors, in addition to relative rest, and maintenance of fitness. Most stress fractures heal without complication. High-risk stress fractures should be evaluated and treated by a practitioner with expertise in the care of these injuries.

Proper understanding of coding, billing, and other practice economics issues in sports medicine is vital for practice success. Lack of accuracy and understanding in these areas may lead to problems that range from lost income to practice audits and potentially steep fines. A basic understanding of current procedural terminology (CPT), awareness of international classification of diseases (ICD-9) and healthcare common procedure coding system (HCPCS) codes, and the knowledge of how to apply them benefit sports medicine physicians.

Background: Today's collegiate student athlete is a highly diverse individual and as such is at higher risk for many health problems both on and off the field. Objective: To determine if a preparticipation evaluation (PPE) can be optimized to help the collegiate team physician and athletic trainer assess both current and past health issues of student athletes. Data Sources: Utilizing MEDLINE and other medical literature database search engines, the authors conducted detailed literature searches on this subject. Key words used in these searches included preparticipation physical evaluation, collegiate, athlete, cardiovascular, preventive healthcare, high risk, alcohol, tobacco, sexually transmitted disease, motor vehicle accident, adolescent, and female. Methods: Approximately 35 articles were selected for review for this report. Authors reviewed articles within their particular area of content responsibility. Personal communications with several sports medicine experts were also conducted. Results: Twenty-three articles were selected for inclusion, in addition to information obtained from the American College of Sports Medicine and National Collegiate Athletic Association (NCAA) Web sites. Utilizing these sources, as well as guidance and suggestions from other sports medicine physicians, the authors determined that the NCAA-mandated PPE should deliver an overview of the athlete's entire health status. Conclusions: As detailed in this report, it is recommended that the NCAA PPE serve as a tool in tracking and assessing both current and past health issues of student athletes. These health issues would include (1) on-field health concerns such as cardiac and musculoskeletal conditions, (2) off-field health concerns (that may adversely impact on-field performance) such as sexual activity and substance abuse, and (3) health issues unique to the female student athlete, such as eating habits, nutritional record, and menstrual history. Primary care physicians should be involved in all PPEs as they have the necessary expertise to recognize potential problems in these areas.

Attitudes toward exercise during pregnancy have changed dramatically over the past 20 years. Recent studies show that, in most cases, exercise is safe for both the mother and fetus during pregnancy, and support the recommendation to initiate or continue exercise in most pregnancies. This report discusses the rationale behind the changes, and offers educational tools that may be employed to initiate behavioral change. We also propose exercise prescriptions for pregnant women who are sedentary, physically active, and competitive athletes. Armed with this information, the practitioner will be better equipped to counsel patients and incorporate a discussion on physical activity into prenatal visits.