Brett G. Toresdahl

Outcomes from sudden cardiac arrest in US high schools: a 2-year prospective study from the National Registry for AED Use in Sports

Background Sudden cardiac arrest (SCA) is the leading cause of death in athletes during exercise. The effectiveness of school-based automated external defibrillator (AED) programmes has not been established through a prospective study. Methods A total of 2149 high schools participated in a prospective observational study beginning 1 August 2009, through 31 July 2011. Schools were contacted quarterly and reported all cases of SCA. Of these 95% of schools confirmed their participation for the entire 2-year study period. Cases of SCA were reviewed to confirm the details of the resuscitation. The primary outcome was survival to hospital discharge. Results School-based AED programmes were present in 87% of participating schools and in all but one of the schools reporting a case of SCA. Fifty nine cases of SCA were confirmed during the study period including 26 (44%) cases in students and 33 (56%) in adults; 39 (66%) cases occurred at an athletic facility during training or competition; 55 (93%) cases were witnessed and 54 (92%) received prompt cardiopulmonary resuscitation. A defibrillator was applied in 50 (85%) cases and a shock delivered onsite in 39 (66%). Overall, 42 of 59 (71%) SCA victims survived to hospital discharge, including 22 of 26 (85%) students and 20 of 33 (61%) adults. Of 18 student-athletes 16 (89%) and 8 of 9 (89%) adults who arrested during physical activity survived to hospital discharge. Conclusions High school AED programmes demonstrate a high survival rate for students and adults who suffer SCA on school campus. School-based AED programmes are strongly encouraged.

Incidence of sudden cardiac arrest in high school student athletes on school campus

BACKGROUND An accurate estimate of the incidence of sudden cardiac arrest (SCA) in high school student athletes is needed to guide prevention strategies. OBJECTIVE To prospectively investigate SCA rates in high school student athletes vs student nonathletes. METHODS A prospective observational study of 2149 US high schools participating in the National Registry for AED Use in Sports was conducted from August 2009 to July 2011. Schools were contacted quarterly to collect and review SCA cases occurring on school campus. Ninety-five percent (2045) of the schools confirmed participation for the entire 2-year period. RESULTS The average numbers of total students and student athletes per school were 963 and 367, respectively, providing more than 4.1 million total student-years and more than 1.5 million student athlete-years of surveillance. Twenty-six cases of SCA occurred in students, including 18 cases in student athletes-all during exercise. The incidence of SCA in all students was 0.63 per 100,000; in student athletes, 1.14 per 100,000; and in student nonathletes, 0.31 per 100,000. The relative risk of SCA in student athletes vs nonathletes was 3.65 (95% confidence interval 1.6-8.4; P < .01). Sixteen of 18 (89%) student athletes with SCA were boys, resulting in an incidence of 1.73 per 100,000 in boys and 0.31 per 100,000 in girls and a relative risk in male compared with female student athletes of 5.65 (95% confidence interval 1.3-24.6; P < .01). CONCLUSION The incidence of SCA in high school student athletes is higher than previous estimates and may justify more advanced cardiac screening and improved emergency planning in schools.

Cardiovascular screening in adolescents and young adults: a prospective study comparing the Pre-participation Physical Evaluation Monograph 4th Edition and ECG

Background This study compares the accuracy of cardiovascular screening in active adolescents and young adults using a standardised history, physical examination and resting 12-lead ECG. Methods Participants were prospectively screened using a standardised questionnaire based on the Pre-participation Physical Evaluation Monograph 4th Edition (PPE-4), physical examination and ECG interpreted using modern standards. Participants with abnormal findings had focused echocardiography and further evaluation. Primary outcomes included disorders associated with sudden cardiac arrest (SCA). Results From September 2010 to July 2011, 1339 participants underwent screening: age 13–24 (mean 16) years, 49% male, 68% Caucasian, 17% African-American and 1071 (80%) participating in organised sports. Abnormal history responses were reported on 916 (68%) questionnaires. After physician review, 495/916 (54%) participants with positive questionnaires were thought to have non-cardiac symptoms and/or a benign family history and did not warrant additional evaluation. Physical examination was abnormal in 124 (9.3%) participants, and 72 (5.4%) had ECG abnormalities. Echocardiograms were performed in 586 (44%) participants for abnormal history (31%), physical examination (8%) or ECG (5%). Five participants (0.4%) were identified with a disorder associated with SCA, all with ECG-detected Wolff-Parkinson-White. The false-positive rates for history, physical examination and ECG were 31.3%, 9.3% and 5%, respectively. Conclusions A standardised history and physical examination using the PPE-4 yields a high false-positive rate in a young active population with limited sensitivity to identify those at risk for SCA. ECG screening has a low false-positive rate using modern interpretation standards and improves detection of primary electrical disease at risk of SCA.

Emergency cardiac care in the athletic setting: from schools to the Olympics

Medical providers at sporting events must be well-trained in the care of cardiac emergencies. Optimal outcomes are most likely achieved through comprehensive emergency planning that ensures prompt and appropriate care. The diversity of athletic venues, as well as the age and competition level of different athlete populations, present challenges to the provision of appropriate emergency care in sport. An efficient and coordinated medical response to cardiac emergencies requires an established emergency action plan, training of potential first responders in cardiopulmonary resuscitation and use of an automated external defibrillator, coordinating communication and transportation systems, and ensuring access to appropriate medical equipment and supplies. Prompt recognition and early defibrillation are critical in the management of athletes suffering sudden cardiac arrest. This article reviews emergency planning and cardiac care in athletics, with special considerations presented for the school, large arena, mass event and Olympic settings.

High School Automated External Defibrillator Programs as Markers of Emergency Preparedness for Sudden Cardiac Arrest

CONTEXT School-based automated external defibrillator (AED) programs have demonstrated a high survival rate for individuals suffering sudden cardiac arrest (SCA) in US high schools. OBJECTIVE To examine the relationship between high schools having an AED on campus and other measures of emergency preparedness for SCA. DESIGN Cross-sectional study. SETTING United States high schools, December 2006 to September 2009. PATIENTS OR OTHER PARTICIPANTS Principals, athletic directors, school nurses, and certified athletic trainers represented 3371 high schools. MAIN OUTCOME MEASURE(S) Comprehensive surveys on emergency planning for SCA submitted by high school representatives to the National Registry for AED Use in Sports from December 2006 to September 2009. Schools with and without AEDs were compared to assess other elements of emergency preparedness for SCA. RESULTS A total of 2784 schools (82.6%) reported having 1 or more AEDs on campus, with an average of 2.8 AEDs per school; 587 schools (17.4%) had no AEDs. Schools with an enrollment of more than 500 students were more likely to have an AED (relative risk [RR] = 1.12, 95% confidence interval [CI] = 1.08, 1.16, P < .01). Suburban schools were more likely to have an AED than were rural (RR = 1.08, 95% CI = 1.04, 1.11, P < .01), urban (RR = 1.13, 95% CI = 1.04, 1.16, P < .01), or inner-city schools (RR = 1.10, 95% CI = 1.04, 1.23, P < .01). Schools with 1 or more AEDs were more likely to ensure access to early defibrillation (RR = 3.45, 95% CI = 2.97, 3.99, P < .01), establish an emergency action plan for SCA (RR = 1.83, 95% CI = 1.67, 2.00, P < .01), review the emergency action plan at least annually (RR = 1.99, 95% CI = 1.58, 2.50, P < .01), consult emergency medical services to develop the emergency action plan (RR = 1.18, 95% CI = 1.05, 1.32, P < .01), and establish a communication system to activate emergency responders (RR = 1.06, 95% CI = 1.01, 1.08, P < .01). CONCLUSIONS High schools with AED programs were more likely to establish a comprehensive emergency response plan for SCA. Implementing school-based AED programs is a key step associated with emergency planning for young athletes with SCA.

Suicide in National Collegiate Athletic Association (NCAA) Athletes: A 9-Year Analysis of the NCAA Resolutions Database

Background: The National Collegiate Athletic Association (NCAA) has recently highlighted mental health concerns in student athletes, though the incidence of suicide among NCAA athletes is unclear. The purpose of this study was to determine the rate of suicide among NCAA athletes. Hypothesis: The incidence of suicide in NCAA athletes differs by sex, race, sport, and division. Study Design: Retrospective cohort study. Level of Evidence: Level 3. Methods: NCAA Memorial Resolutions list and published NCAA demographic data were used to identify student-athlete deaths and total participant seasons from 2003-2004 through 2011-2012. Deaths were analyzed by age, sex, race, division, and sport. Results: Over the 9-year study period, 35 cases of suicide were identified from a review of 477 student-athlete deaths during 3,773,309 individual participant seasons. The overall suicide rate was 0.93/100,000 per year. Suicide represented 7.3% (35/477) of all-cause mortality among NCAA student athletes. The annual incidence of suicide in male athletes was 1.35/100,000 and in female athletes was 0.37/100,000 (relative risk [RR], 3.7; P < 0.01). The incidence in African American athletes was 1.22/100,000 and in white athletes was 0.87/100,000 (RR, 1.4; P = 0.45). The highest rate of suicide occurred in men’s football (2.25/100,000), and football athletes had a relative risk of 2.2 (P = 0.03) of committing suicide compared with other male, nonfootball athletes. Conclusion: The suicide rate in NCAA athletes appears to be lower than that of the general and collegiate population of similar age. NCAA male athletes have a significantly higher rate of suicide compared with female athletes, and football athletes appear to be at greatest risk. Clinical Relevance: Suicide represents a preventable cause of death, and development of effective prevention programs is recommended.

Falsely Negative F-18 FDG PET of Osteosarcoma Arising In Paget Disease.

We present the case of a large, painful pelvic bone tumor in a 53-year-old woman with severe Paget disease. Her presentation was complicated with bilateral total hip arthroplasty, history of spinal stenosis, and multiple lucent lesions in the spine and pelvis in severely affected pagetoid bone. This case features the rare but dreaded complication of osteosarcomatous transformation in Paget disease. A variety of imaging modalities including PET/CT were utilized in the evaluation of these lesions. The PET/CT findings were counter-intuitive with regard to the intense uptake of the underlying chronic disease process and the near-absence of uptake in the tumors. The histology of the pelvic mass is also intriguing, as it demonstrated a sarcoma with giant cell features. Conservative, non-operative management was chosen, due to the patient’s poor medical condition, so we may never know the nature of the spinal lesion in this case, but will discuss the differential diagnosis for a lytic spinal lesion in a patient with severe Paget disease complicated by osteosarcoma with giant cell features.

Update on Zika Virus Considerations for the Traveling Athlete

As public health experts work to contain the outbreak of Zika virus in South America and minimize the devastating prenatal complications, the international sports community prepares for the 2016 Summer Olympic and Paralympic Games in Rio de Janeiro, Brazil. Athletes have publicly expressed concern regarding the health risks of competition in Zika-endemic areas.33 Ensuring the safety of the athletes during training and competition is the primary role of the team physician. Special consideration is needed for sports teams preparing for travel to areas affected by Zika virus.

Reply to the editor--Incidence of sudden cardiac death in high school athletes: implications for cardiovascular screening.

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The evidenced-based shoulder evaluation.

The physical examination of the shoulder has been studied extensively, but the quality and statistical power of the published research often is lacking. The initial reports of new shoulder examination techniques commonly describe impressive performance. However recent meta-analyses have found that when the majority of these tests are used in isolation, they lack the ability to rule in or rule out the pathology in question, with few exceptions. The diagnostic accuracy of the physical examination improves when the shoulder tests are evaluated in combination, such as positive passive distraction and active compression identifying a superior labral anterior to posterior (SLAP) lesion. The accuracy also can be improved when the shoulder tests are evaluated in conjunction with specific historical findings, such as age greater than 39 years, history of popping or clicking, and a positive painful arc (pain experienced between 60° and 120° of abduction) identifying rotator cuff tendinopathy. The literature on shoulder imaging demonstrates that rotator cuff tears can be ruled in or ruled out by both ultrasound and magnetic resonance imaging. For SLAP lesions, magnetic resonance arthrography can be used to rule out a tear but may not be as accurate as combined physical examinations to rule in a tear.