Gary W. Dorshimer

Progressive multifocal leukoencephalopathy after rituximab therapy in HIV-negative patients: a report of 57 cases from the Research on Adverse Drug Events and Reports project

Rituximab improves outcomes for persons with lymphoproliferative disorders and is increasingly used to treat immune-mediated illnesses. Recent reports describe 2 patients with systemic lupus erythematosus and 1 with rheumatoid arthritis who developed progressive multifocal leukoencephalopathy (PML) after rituximab treatment. We reviewed PML case descriptions among patients treated with rituximab from the Food and Drug Administration, the manufacturer, physicians, and a literature review from 1997 to 2008. Overall, 52 patients with lymphoproliferative disorders, 2 patients with systemic lupus erythematosus, 1 patient with rheumatoid arthritis, 1 patient with an idiopathic autoimmune pancytopenia, and 1 patient with immune thrombocytopenia developed PML after treatment with rituximab and other agents. Other treatments included hematopoietic stem cell transplantation (7 patients), purine analogs (26 patients), or alkylating agents (39 patients). One patient with an autoimmune hemolytic anemia developed PML after treatment with corticosteroids and rituximab, and 1 patient with an autoimmune pancytopenia developed PML after treatment with corticosteroids, azathioprine, and rituximab. Median time from last rituximab dose to PML diagnosis was 5.5 months. Median time to death after PML diagnosis was 2.0 months. The case-fatality rate was 90%. Awareness is needed of the potential for PML among rituximab-treated persons.

Saccades and memory: Baseline associations of the King–Devick and SCAT2 SAC tests in professional ice hockey players

OBJECTIVE The Sports Concussion Assessment Tool 2 (SCAT2) and King-Devick (K-D) tests have both been proposed as sideline tools to detect sports-related concussion. We performed an exploratory analysis to determine the relation of SCAT2 components, particularly the Standardized Assessment of Concussion (SAC), to K-D test scores in a professional ice hockey team cohort during pre-season baseline testing. We also examined changes in scores for two athletes who developed concussion and had rinkside testing. METHODS A modified SCAT2 (no balance testing) and the K-D test, a brief measure of rapid number naming, were administered to 27 members of a professional ice hockey team during the 2011-2012 pre-season. Athletes with concussion also underwent rinkside testing. RESULTS Lower (worse) scores for the SCAT2 SAC Immediate Memory Score and the overall SAC score were associated with greater (worse) times required to complete the K-D test at baseline. On average, for every 1-point reduction in SAC Immediate Memory Score, we found a corresponding increase (worsening) of K-D time score of 7.3s (95% CI 4.9, 9.7, p<0.001, R(2)=0.62, linear regression, accounting for age). For the overall SAC score, 1-point reductions were associated with K-D score worsening of 2.2s (95% CI 0.6, 3.8, p=0.01, R(2)=0.25, linear regression). In two players tested rinkside immediately following concussion, K-D test scores worsened from baseline by 4.2 and 6.4s. These athletes had no differences found for SCAT2 SAC components, but reported symptoms of concussion. CONCLUSION In this study of professional athletes, scores for the K-D test, a measure for which saccadic (fast) eye movements are required for the task of rapid number naming, were associated with reductions in Immediate Memory at a pre-season baseline. Both working memory and saccadic eye movements share closely related anatomical structures, including the dorsolateral prefrontal cortex (DLPFC). A composite of brief rapid sideline tests, including SAC and K-D (and balance testing for non-ice hockey sports), is likely to provide an effective clinical tool to assess the athlete with suspected concussion.

Sweat Rates, Sweat Sodium Concentrations, and Sodium Losses in 3 Groups of Professional Football Players

CONTEXT Sweat sodium losses have never been reported in a large cohort of American football players. OBJECTIVE To compare sweat rates (SwtRs), sweat sodium concentrations (SwtNa(+)), and sodium losses in 3 groups of players (backs and receivers [BK], linebackers and quarterbacks [LB/QB], and linemen [LM]) to determine if positional differences and, therefore, size differences exist. DESIGN Observational study. SETTING Data were collected during practices in the second week of 2 consecutive training camps. The wet bulb globe temperature was 78.5 degrees F +/- 3.5 degrees F (25.9 degrees C +/- 1.9 degrees C). PATIENTS OR OTHER PARTICIPANTS Eighteen BK, 12 LB/QB, and 14 LM volunteered. INTERVENTION(S) Sterile sweat patches were applied to the right forearm after the skin was appropriately cleaned. The patches were removed during practice, placed in sterile tubes, centrifuged, frozen, and later analyzed by flame photometry. MAIN OUTCOME MEASURE(S) Sweat rate, SwtNa(+), and sodium loss. We calculated SwtR by change in mass adjusted for urine produced and fluids consumed divided by practice time in hours. RESULTS Other than age, physical characteristics were different among groups (P < .001). The SwtR was different among groups (F(2,41) = 7.3, P = .002). It was lower in BK (1.42 +/- 0.45 L/h) than in LB/QB (1.98 +/- 0.49 L/h) (P < .05) and LM (2.16 +/- 0.75 L/h) (P < .01), but we found no differences between SwtRs for LB/QB and LM. The SwtNa(+) was not different among groups (BK = 50 +/- 16 mEq/L, LB/QB = 48.2 +/- 23 mEq/L, and LM = 52.8 +/- 25 mEq/L) and ranged from 15 to 99 mEq/L. Sweat sodium losses ranged from 642 mg/h to 6.7 g/h, and findings for group comparisons approached significance (P = .06). On days when players practiced 4.5 hours, calculated sodium losses ranged from 2.3 to 30 g/d. CONCLUSIONS The BK sweated at lower rates than did the midsized LB/QB and large LM, but LB/QB sweated similarly to LM. Sweat sodium concentration and daily sodium losses ranged considerably. Heavy, salty sweaters require increased dietary consumption of sodium during preseason.

Pneumomediastinum from sports-related trauma: key findings and recommendations.

Pneumomediastinum can result from blunt chest trauma in sports. Diagnosis is made using chest radiography. The natural history of isolated pneumomediastinum is benign; however, it can be associated with more serious injuries, such as disruption of the tracheobronchial tree or a perforated digestive viscus. Patients with isolated pneumomediastinum should be monitored with serial chest radiographs. Patients may return to full activity once their chest radiographs have returned to normal, they exhibit no symptoms, and they have regained their stamina.

Isolated jejunal rupture after blunt trauma.

Jejunal ruptures and other hollow viscus injuries are relatively uncommon manifestations of blunt abdominal injury that can often be masked by more serious injuries, such as solid-organ ruptures. Also, symptoms can be quite subtle and slow to appear. When the injury is suspected, the results of serial exams can be used to determine the need for laparotomy to establish the diagnosis. This report of an isolated jejunal rupture in a professional hockey player, in which the initial work-up was negative for any serious pathology, illustrates the need for continued vigilance in cases of blunt abdominal trauma.

Case Report: Peptic Ulcer Disease in a Professional Athlete

Abstract Peptic ulcer disease (PUD) is a common problem that affects 4 million people in the United States. Although its prevalence has not been studied in the athletic population, one would suspect PUD would affect athletes at a similar rate or higher based on the predispositions to certain risk factors of this disease. This case report addresses the particular predispositions for PUD in a professional football athlete.