Background: Infectious mononucleosis is typically a self-limited disease commonly affecting young adults. Splenic rupture is a rare but serious complication affecting 0.1% to 0.5% of patients with mononucleosis. Current guidelines (based on published case reports) recommend complete activity restriction for 3 weeks after onset of mononucleosis symptoms to reduce rupture risk. We examined actual timing of mononucleosis-associated splenic injury using a large repository of unpublished patient data. Hypothesis: The risk of splenic injury after infectious mononucleosis will remain elevated longer than previously estimated. Study Design: Retrospective case series. Level of Evidence: Level 4. Methods: The Military Health System Management Analysis and Reporting Tool (M2) was used to conduct a retrospective chart review. Coding records of TRICARE beneficiaries aged 5 to 65 years between 2006 and 2016 were screened. Patients diagnosed with both splenic injury and mononucleosis-like symptoms were identified, and their medical records were reviewed for laboratory confirmation of infection and radiographically evident splenic injury. Results: A total of 826 records of splenic injury were found in M2. Of these, 42 cases met the study criteria. Mean time to splenic injury was 15.4 (±13.5) days. Only 73.8% (n = 31) of injuries occurred within 21 days, and 90.5% (n = 38) of splenic injuries occurred within 31 days of symptom onset. Conclusion: A substantial number of splenic injuries occur between 21 and 31 days after symptom onset. While most splenic injuries were atraumatic, consideration should be given to extending return-to-play guidelines to 31 days after symptom onset to minimize risk. Risk of chronic pain after splenic injury may be higher than previously believed. Clinical Relevance: The risk for postmononucleosis splenic injuries remains elevated longer than current guidelines suggest. Restricting activity for 31 days after mononucleosis symptom onset may reduce the risk of splenic injury.
Patients often seek care from a family physician when they have a musculoskeletal injury or sport-related ailment. Family physicians must be adequately trained to provide this care. While general guidance is provided by the Accreditation Counsel for Graduate Medical Education (ACGME) it is left up to the individual programs to develop, implement, and execute their orthopedic and sports medicine curriculums. The American Academy of Family Physicians' (AAFP) Recommended Curriculum Guideline for Family Medicine Residents — Musculoskeletal and Sports Medicine provides a basic outline format for curriculum content and reference resources. The aim of this article is to elaborate on those training requirements and help programs to develop a curriculum implementation plan that will deliver a baseline level of competence for family medicine trainees.
Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiovascular disease and the leading cause of sudden death in athletes. An autosomal dominant disorder affecting approximately 1 in 500 individuals, HCM has been linked to multiple mutations and exhibits variable phenotypic expression. The utility of cardiovascular screening in diagnosing risk factors for sudden cardiac death continues to be debated intensely. Genetic testing has been employed increasingly in diagnosing HCM, resulting in a subset of patients with genotype positive-phenotype negative disease; these patients carry the mutation for HCM but lack pathologic evidence of disease. These individuals pose a dilemma in the clinical management of HCM: should treatment guidelines for phenotypically normal HCM patients be the same as that of symptomatic patients? Governing bodies continue to disagree, providing conflicting guidelines for sports participation. This review examines the current fund of knowledge regarding HCM and the debate regarding screening.
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