Temporal Considerations in Brain Metastases Radiation Therapy: The Intersection of Chronobiology and Patient Profiles.

The circadian system, a vital temporal regulator influencing physiological processes, has implications for cancer development and treatment response. Our study assessed circadian timing's impact on whole-brain radiotherapy outcomes in brain metastases for personalized cancer therapy insights. The aim of the study was to evaluate circadian influence on radiation treatment timing and its correlation with clinical outcomes and to identify patient populations benefiting from interventions synchronizing circadian rhythms, considering subgroup differences and potential disparities. An IRB-approved retrospective analysis of 237 patients undergoing whole-brain radiotherapy for brain metastases (2017-2021), receiving over 80% of treatments in the morning or afternoon, was performed. Survival analyses utilized Kaplan-Meier curves. This was a single-institution study involving patients receiving whole-brain radiotherapy. Demographic, disease, and socioeconomic parameters from electronic medical records were collected. Morning treatment (n = 158) showed a trend toward improved overall survival vs. afternoon (n = 79); the median survival was 158 vs. 79 days (p = 0.20, HR = 0.84, CI95% 0.84-0.91). Subgroup benefits for morning treatment in females (p = 0.04) and trends in controlled primary disease (p = 0.11) and breast cancer metastases (p = 0.08) were observed. Black patients exhibited diminished circadian influence. The present study emphasized chronobiological factors' relevance in brain metastases radiation therapy. Morning treatment correlated with improved survival, particularly in specific subgroups. Potential circadian influence disparities were identified, laying a foundation for personalized cancer therapy and interventions synchronizing circadian rhythms for enhanced treatment efficacy.

Cost-effectiveness analysis of 3 radiation treatment strategies for patients with multiple brain metastases.

Background: Patients diagnosed with multiple brain metastases often survive for less than 2 years, and clinicians must carefully evaluate the impact of interventions on quality of life. Three types of radiation treatment are widely accepted for patients with multiple brain metastases: Whole brain radiation therapy (WBRT), hippocampal avoidance whole-brain radiation therapy (HA-WBRT), and stereotactic radiosurgery (SRS). WBRT, the standard option, is less costly than its newer alternatives but causes more severe adverse effects such as memory loss. To determine whether the cost-effectiveness ratio of HA-WBRT and SRS are superior to WBRT, we used published data to simulate cases of multiple brain metastases. Methods: We designed a Markov model using data from previously published studies to simulate the disease course of patients with 5 to 15 brain metastases and determine the cost-effectiveness of HA-WBRT and SRS relative to WBRT. Incremental cost-effectiveness ratios (ICERs) were calculated and compared against a willingness-to-pay threshold of $100 000 per quality-adjusted life year. Results: SRS met the threshold for cost-effectiveness, with ICERs ranging $41 198-$54 852 for patients with 5 to 15 brain metastases; however, HA-WBRT was not cost-effective, with an ICER of $163 915 for all simulated patients. Model results were robust to sensitivity analyses. Conclusions: We propose that SRS, but not HA-WBRT, should be offered to patients with multiple brain metastases as a treatment alternative to standard WBRT. Incorporating these findings into clinical practice will help promote patient-centered care and decrease national healthcare expenditures, thereby addressing issues around health equity and access to care.

Generative Adversarial Networks in Medicine: Important Considerations for this Emerging Innovation in Artificial Intelligence.

The advent of artificial intelligence (AI) and machine learning (ML) has revolutionized the field of medicine. Although highly effective, the rapid expansion of this technology has created some anticipated and unanticipated bioethical considerations. With these powerful applications, there is a necessity for framework regulations to ensure equitable and safe deployment of technology. Generative Adversarial Networks (GANs) are emerging ML techniques that have immense applications in medical imaging due to their ability to produce synthetic medical images and aid in medical AI training. Producing accurate synthetic images with GANs can address current limitations in AI development for medical imaging and overcome current dataset type and size constraints. Offsetting these constraints can dramatically improve the development and implementation of AI medical imaging and restructure the practice of medicine. As observed with its other AI predecessors, considerations must be taken into place to help regulate its development for clinical use. In this paper, we discuss the legal, ethical, and technical challenges for future safe integration of this technology in the healthcare sector.

Physician Perceptions on Cancer Screening for LGBTQ+ Patients.

The LGBTQ+ community experiences cancer disparities due to increased risk factors and lower screening rates, attributable to health literacy gaps and systemic barriers. We sought to understand the experiences, perceptions, and knowledge base of healthcare providers regarding cancer screening for LGBTQ+ patients. A 20-item IRB-approved survey was distributed to physicians through professional organizations. The survey assessed experiences and education regarding the LGBTQ+ community and perceptions of patient concerns with different cancer screenings on a 5-point Likert scale. Complete responses were collected from 355 providers. Only 100 (28%) reported past LGBTQ+-related training and were more likely to be female (p = 0.020), have under ten years of practice (p = 0.014), or practice family/internal medicine (p < 0.001). Most (85%) recognized that LGBTQ+ subpopulations experience nuanced health issues, but only 46% confidently understood them, and 71% agreed their clinics would benefit from training. Family/internal medicine practitioners affirmed the clinical relevance of patients' sexual orientation (94%; 62% for medical/radiation oncology). Prior training affected belief in the importance of sexual orientation (p < 0.001), confidence in understanding LGBTQ+ health concerns (p < 0.001), and willingness to be listed as "LGBTQ+-friendly" (p = 0.005). Our study suggests that despite a paucity of formal training, most providers acknowledge that LGBTQ+ patients have unique health needs. Respondents had a lack of consensus regarding cancer screenings for lesbian and transgender patients, indicating the need for clearer screening standards for LGBTQ+ subpopulations and educational programs for providers.

Overcoming the cardiac toxicities of cancer therapy immune checkpoint inhibitors.

Immune checkpoint inhibitors (ICIs) have led recent advances in the field of cancer immunotherapy improving overall survival in multiple malignancies with abysmal prognoses prior to their introduction. The remarkable efficacy of ICIs is however limited by their potential for systemic and organ specific immune-related adverse events (irAEs), most of which present with mild to moderate symptoms that can resolve spontaneously, with discontinuation of therapy or glucocorticoid therapy. Cardiac irAEs however are potentially fatal. The understanding of autoimmune cardiotoxicity remains limited due to its rareness. In this paper, we provide an updated review of the literature on the pathologic mechanisms, diagnosis, and management of autoimmune cardiotoxicity resulting from ICIs and their combinations and provide perspective on potential strategies and ongoing research developments to prevent and mitigate their occurrence.

The use of telemedicine in pre-surgical evaluation: a retrospective cohort study of a neurosurgical oncology practice.

PURPOSE: To determine if there was a discrepancy between telemedicine versus in-person New Patient Visits (NPVs) regarding the conversion rate to operative and radiosurgery cases at a tertiary surgical neuro-oncology practice. METHODS: A retrospective analysis was performed of patients who had an outpatient encounter with a neurosurgeon from the Tumor Division at our institution's Department of Neurosurgery between February 1, 2021 and April 30, 2021. NPVs during this period were registered as either telemedicine or in-person appointments. The primary endpoint of the study was to compare the rate at which telemedicine NPVs and in-person NPVs underwent surgery or radiosurgery, reported as the surgical conversion rate. RESULTS: A total of 206 patients were included in this study. Of them, 119 (57.8%) were seen using telemedicine and 87 (42.2%) were seen in clinic via an in-person visit. A total of 70 (34%) of all patients underwent surgery or radiosurgery. Of the 119 patients seen via telemedicine, 40 (33.6%) underwent surgery or radiosurgery; during the same period, 87 NPVs were conducted in person and 30 (34.5%, p = 1.0) received an intervention. Further stratification revealed no differences between the two groups across measured criteria including diagnosis, number of pre-operative visits, elapsed time from appointment to surgery, follow-up visits, and distance from home address to neurosurgical clinic. CONCLUSION: Telemedicine NPVs did not differ significantly from in-person NPVs when evaluating the likelihood of a new patient committing to surgical treatment. This study provides quantifiable evidence that telemedicine is an effective means of meeting new patients and planning complex neurosurgical interventions.

Telemedicine in Neurosurgery During the COVID-19 Outbreak: Where We Are 1 Year Later.

BACKGROUND: Telemedicine use skyrocketed in March 2020 on implementation of shelter-in-place measures owing to the coronavirus disease 2019 (COVID-19) pandemic. Within the past year, shelter-in-place measures were lifted and the COVID-19 vaccine was released, resulting in many neurosurgeons returning to in-person outpatient clinics. This study aimed to determine the extent of usage of telemedicine in neurosurgery 1 year into the COVID-19 pandemic. METHODS: A retrospective cohort study of patients who received neurosurgical care at a single institution from February 1 to April 18 of the years 2020 and 2021 was performed. The inclusion criteria were met by 11,592 patients. During the 2 study periods, 1465 patients underwent surgery, 7083 were seen in clinic via an in-person meeting, and 3044 were assessed via telemedicine. RESULTS: At 1 year after the COVID-19 outbreak, telemedicine usage was at 81.3% of the initial volume on implementation of shelter-in-place measures. In-person outpatient visits increased 40.2% from the early pandemic volume. Among the 4 neurosurgery divisions, telemedicine usage remained high in tumor and functional neurosurgery, significantly increased in vascular neurosurgery, and decreased in spine neurosurgery. CONCLUSIONS: Telemedicine use in neurosurgery clinics continues 1 year after the COVID-19 outbreak. Even after the lifting of shelter-in-place measures, many neurosurgeons still use telemedicine, while the operative volume remains stable. Owing to the limited physical examination that can be performed via current telemedicine platforms, telemedicine use in spine neurosurgery is lower than peak use during the early pandemic, while use has remained high among tumor, vascular, and functional neurosurgery.

Chronoradiobiology of Breast Cancer: The Time Is Now to Link Circadian Rhythm and Radiation Biology.

Circadian disruption has been linked to cancer development, progression, and radiation response. Clinical evidence to date shows that circadian genetic variation and time of treatment affect radiation response and toxicity for women with breast cancer. At the molecular level, there is interplay between circadian clock regulators such as PER1, which mediates ATM and p53-mediated cell cycle gating and apoptosis. These molecular alterations may govern aggressive cancer phenotypes, outcomes, and radiation response. Exploiting the various circadian clock mechanisms may enhance the therapeutic index of radiation by decreasing toxicity, increasing disease control, and improving outcomes. We will review the body's natural circadian rhythms and clock gene-regulation while exploring preclinical and clinical evidence that implicates chronobiological disruptions in the etiology of breast cancer. We will discuss radiobiological principles and the circadian regulation of DNA damage responses. Lastly, we will present potential rational therapeutic approaches that target circadian pathways to improve outcomes in breast cancer. Understanding the implications of optimal timing in cancer treatment and exploring ways to entrain circadian biology with light, diet, and chronobiological agents like melatonin may provide an avenue for enhancing the therapeutic index of radiotherapy.

Perceptions of and barriers to cancer screening by the sexual and gender minority community: a glimpse into the health care disparity.

PURPOSE: A disparity exists in cancer screening rates for the Sexual and Gender Minority (SGM) community. We sought to understand the perceptions and baseline knowledge of cancer screening among SGM community members. METHODS: Survey administered via social media from June 2018 to October 2018. We asked 31 questions focused on cancer screening, human papillomavirus, emotional distress, and experience with the health care system. Those included were 18 years or older. Cancer screening attitudes and knowledge, as well as perceptions of the health care system were investigated. RESULTS: There were 422 respondents analyzed: 24.6% identified as female, 25.5% as male, 40.1% transgender, and 9.6% as other. 65.4% of the SGM community is not certain what cancer screening to do for themselves. Only 27.3% and 55.7% knew that HPV was a risk factor associated with head and neck cancer and anal cancer, respectively. Half stated their emotional distress prevents them from getting cancer screening. It was identified that process changes in making appointments, comforts during the visit, and formal training for physicians and nurses could increase cancer screening compliance for this community. The transgender population had a trend in more gaps in knowledge of appropriate cancer screening and significant excess emotional distress. CONCLUSION: Gaps in cancer screening knowledge and emotional and financial distress may be responsible for the disparity of lower cancer screening rates for the SGM population and the transgender population may be most at risk. Appreciating the cancer screening concerns of the SGM population can help shape future clinical and institutional approaches to improve health care delivery.

Bellagio II Report: Terrestrial Applications of Space Medicine Research.

AbstractINTRODUCTION: For over 50 yr, investigators have studied the physiological adaptations of the human system during short- and long-duration spaceflight exposures. Much of the knowledge gained in developing health countermeasures for astronauts onboard the International Space Station demonstrate terrestrial applications. To date, a systematic process for translating these space applications to terrestrial human health has yet to be defined.METHODS: In the summer of 2017, a team of 38 international scientists launched the Bellagio ll Summit Initiative. The goals of the Summit were: 1) To identify space medicine findings and countermeasures with highest probability for future terrestrial applications; and 2) To develop a roadmap for translation of these countermeasures to future terrestrial application. The team reviewed public domain literature, NASA databases, and evidence books within the framework of the five-stage National Institutes of Health (NIH) translation science model, and the NASA two-stage translation model. Teams then analyzed and discussed interdisciplinary findings to determine the most significant evidence-based countermeasures sufficiently developed for terrestrial application.RESULTS: Teams identified published human spaceflight research and applied translational science models to define mature products for terrestrial clinical practice.CONCLUSIONS: The Bellagio ll Summit identified a snapshot of space medicine research and mature science with the highest probability of translation and developed a Roadmap of terrestrial application from space medicine-derived countermeasures. These evidence-based findings can provide guidance regarding the terrestrial applications of best practices, countermeasures, and clinical protocols currently used in spaceflight.Sides MB, Johnston SL III, Sirek A, Lee PH, Blue RS, Antonsen EL, Basner M, Douglas GL, Epstein A, Flynn-Evans EE, Gallagher MB, Hayes J, Lee SMC, Lockley SW, Monseur B, Nelson NG, Sargsyan A, Smith SM, Stenger MB, Stepanek J, Zwart SR; Bellagio II Team. Bellagio II report: terrestrial applications of space medicine research. Aerosp Med Hum Perform. 2021; 92(8):650669.

Community-Based Production of Quality Face Masks for Personal Protection During the COVID-19 Pandemic.

The authors developed a process to produce a reliably fitting face mask from materials that were immediately available to health care workers, to reduce the risk of infection. Multiple materials and designs were developed to produce face masks that focused on ease of production, the ability to generate a reliable facial seal, and the ability to tailor the mask for those who did not fit commercially available N95 masks. Two final designs were selected. Mask components were assembled into kits and distributed to community sewists. Plan-Do-Study-Act cycles were developed for quality improvement. A process was successfully developed to produce 5000 face masks in a period of 3 weeks that fit almost all (95%) health care workers who did not fit in a commercially available mask. The process was able to produce quality face masks with specific attention paid to developing masks that would pass qualitative fit testing.

Implementing Culinary Medicine Training: Collaboratively Learning the Way Forward.

There is a documented substantial gap between the level of nutrition education for medical trainees and the need to provide nutrition counseling. Culinary medicine offers a solution, but there are multiple barriers and no guides to implementation. This article identifies core components and strategies to overcome barriers on the basis of experiences of multiple institutions. The outline forms a foundation to be built upon by future collaborators to empower more widespread implementation of culinary medicine education and improve medical nutrition education and ultimately, patient outcomes.

Neuroanesthesiologists as interoperative neurophysiologists: a collaborative cognitive apprenticeship model of training in a community of clinical practice.

Directing intraoperative neurophysiologic monitoring (IONM) is a patient care activity for which no formal training programs exist, even though the need for well-trained practitioners is readily evident while caring for patients with diseases of the brain, spinal cord, spinal column, or nervous system. Here, we present the theoretical basis and institutional experience for a successful model of learning a new and complex set of skills: the medical direction of IONM. In a major academic institution, a clinical community of practice absorbed new members with professional backgrounds ranging from a recent neuroanesthesia fellowship to several decades of neuroanesthesia practice and trained them in a collaborative cognitive apprenticeship model to medically direct IONM. Our community of practice comprises experienced technicians, a diplomate of the American Board of Neurophysiologic Monitoring (DABNM), and six neuroanesthesiologists. This group forms the base of the scaffolding or structure where the apprenticeship and learning take place. The clinical community of practice has trained eight new members in the medical direction of IONM. The group has also trained four outside anesthesiologists-one of whom went on to become certified as a DABNM-who went on to develop the IONM program at a major children's hospital. This collaborative cognitive apprenticeship in anesthesiology to learn the medical direction of IONM is quite innovative as it integrates new members and expands the range of existing ones. In our model, the entire community is elevated by the reciprocal interactions of master clinicians, novice apprentices, and the community of practice.

Epidemiology of skateboarding-related injuries sustained by children and adolescents 5-19 years of age and treated in US emergency departments: 1990 through 2008.

BACKGROUND: The goal was to examine the patterns and trends of skateboarding-related injuries sustained by children and adolescents in the United States. METHODS: A retrospective analysis was conducted using data from the National Electronic Injury Surveillance System for children and adolescents 5-19 years of age treated in emergency departments for injuries associated with skateboards from 1990 through 2008. RESULTS: An estimated 1 226 868 children/adolescents (95 % CI: 948 733-1 505 003) were treated in emergency departments for skateboarding-related injuries from 1990 through 2008, an average of 64,572 cases per year. From 1990 through 1994, the annual rate of injuries per 10,000 children/adolescents significantly decreased overall and for males (overall: 72.9 %, P = 0.014; males: 73.9 %, P = 0.011; females: 63.6 %, P = 0.062). From 1994 to 2008, annual rates of injuries per 10,000 children/adolescents significantly increased overall and for both males and females (overall: 378.9 %, P < 0.001; males: 393.4 %, P < 0.001; females: 283.3 % P < 0.001). From 1990 to 1994 the annual rate of injuries per 10,000 children/adolescents significantly decreased for all age groups (5-10 years: 69.9 %, P = 0.043; 11-14 years: 80.6 %, P = 0.017; 15-19 years: 64.2 %, P = 0.024), and then significantly increased from 1994 to 2008 (5-10 years: 164.5 %, P < 0.001; 11-14 years: 587.0 %, P < 0.001; 15-19 years: 407.9 %, P < 0.001). Most patients were male (89.0 %), injured at home (37.3 %) or in the street and/or highway (29.3 %), and were not hospitalized (96.9 %). Patients 11-14 years of age constituted 44.9 % of cases. The most commonly injured body regions were the upper (44.1 %) and lower (31.7 %) extremities. Fractures and dislocations were the most common diagnoses (32.1 %). Children/adolescents 11-14 years of age were hospitalized more often than younger or older children/adolescents. Lower extremity injuries increased with age, while face and head or neck injuries decreased with age. CONCLUSIONS: Skateboarding continues to be an important source of injury for children and adolescents. Further research, using more rigorous study designs, is required develop a broad perspective of the incidence and determinants of injury, and to further identify risk factors and viable injury countermeasures while simultaneously promoting participation in skateboarding.

Dance-related injuries in children and adolescents treated in US emergency departments in 1991-2007.

BACKGROUND: Dancing is one of the most physically strenuous activities on the musculoskeletal system. As other literature has previously described, the types, sites, and rates of dance-related injuries are similar to those suffered by athletes in traditional sports. METHODS: A retrospective analysis was conducted with data from the National Electronic Injury Surveillance System from 1991-2007. Sample weights were used to calculate national estimates of dance-related injuries. Trend significance of the numbers and age-adjusted rates of dance-related injuries over time was analyzed using linear regression. RESULTS: An estimated 113,084 children and adolescents 3-19 years of age were treated in US emergency departments for dance-related injuries. Classical dance (ballet, jazz, tap, modern) accounted for 55.0% of dance-related injuries. Adolescents 15-19 years of age constituted 40.4% of the dance-related injury cases. The majority of injuries (58.1%) occurred to the lower extremities. Sprains or strains were the most common injury (52.4%) and falls were the most common mechanism of injury (44.8%). CONCLUSIONS: Dance-related injuries have distinct injury patterns and mechanisms of injury. Injury patterns differ by types of dance and by age. Further research is needed to identify injury prevention strategies specific to these age groups.

Water tubing-related injuries treated in US emergency departments, 1991-2009.

BACKGROUND: The objective was to describe the patterns and mechanisms of water tubing-related injuries treated in U.S. emergency departments. METHODS: The National Electronic Injury Surveillance System was used to examine cases of water tubing-related injuries. Sample weights were used to calculate national estimates of water tubing-related injuries. Analyses were conducted in 2010. RESULTS: From 1991-2009 an estimated 69,471 injuries were treated in US emergency departments for water tubing-related injuries. The annual number of cases increased 250% over the 19-year study period (P < .001). Sprains and strains accounted for the largest portion of injuries (27.2%). The head was the most frequently injured body part (27.5%). Children and adolescents ≤ 19 years were more likely to be injured by contact with another person (OR: 2.47; 95% CI = 1.61-3.80) and were more likely to sustain injuries to the head (OR: 2.61; 95% CI = 2.01-3.38) compared with adults. Adults ≥ 20 years, were more likely than individuals ≤ 19 years to sustain sprains and strains (OR: 2.11; 95% CI = 1.64-2.71) and were most commonly injured by impact with the water (54.6%). CONCLUSIONS: Patterns of water tubing-related injuries differ for children and adults. Research is needed to determine how best to reduce these injuries.

Track-related injuries in children and adolescents treated in US emergency departments from 1991 through 2008.

BACKGROUND: Track is a popular sport among children and adolescents. Track participants have a high rate of injury, often from overuse. PURPOSE: To determine national patterns of track-related injuries among children and adolescents aged 10 to 18 years treated in US emergency departments. STUDY DESIGN: Descriptive epidemiologic study. METHODS: A retrospective analysis was conducted using data from the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission for patients aged 10 to 18 years from 1991 through 2008. Sample weights were used to calculate national estimates of track-related injuries based on 4496 actual cases. Bivariate comparisons between categorical variables were assessed with odds ratios and 95% CIs. Trend significance of the numbers and rates of track-related injuries over time was analyzed using linear regression. RESULTS: From 1991 through 2008, an estimated 159 663 patients aged 10 to 18 years were treated for track-related injuries in US emergency departments, with an average of 8870 cases per year. The overall number of cases increased 36.3%, from 7702 injuries in 1991 to 10 496 injuries in 2008 (P = 0.039). Boys were more likely to sustain pelvic injuries and girls were more likely to sustain ankle injuries. Body parts injured varied by the specific track activity or event performed; hurdling was more likely to result in an injury to the upper extremities and to the head, whereas sprinting was more likely to result in an injury to the pelvis or upper leg. CONCLUSION: There are several age-, sex-, and activity-specific patterns of track-related injuries. Given the increased participation and corresponding increase in track-related injuries, more research is needed to determine how best to prevent these injuries.

Running-related injuries in school-age children and adolescents treated in emergency departments from 1994 through 2007.

Running for exercise is a popular way to motivate children to be physically active. Running-related injuries are well studied in adults but little information exists for children and adolescents. Through use of the National Electronic Injury Surveillance System database, cases of running-related injuries were selected by using activity codes for exercise (which included running and jogging). Sample weights were used to calculate national estimates. An estimated 225 344 children and adolescents 6 to 18 years old were treated in US emergency departments for running-related injuries. The annual number of cases increased by 34.0% over the study period. One third of the injuries involved a running-related fall and more than one half of the injuries occurred at school. The majority of injuries occurred to the lower extremities and resulted in a sprain or strain. These findings emphasize the need for scientific evidence-based guidelines for pediatric running. The high proportion of running-related falls warrants further research.

Exertional heat-related injuries treated in emergency departments in the U.S., 1997-2006.

BACKGROUND: Exertional heat-related injuries are a risk to all physically active individuals in warm or hot environments. Unlike classic heat-related injury, exertional heat-related injuries do not require extreme ambient temperatures to cause injury. Still, exertional heat-related injuries, including heat cramps, heat syncope, heat exhaustion, heat stress, and heat stroke, can result in injuries causing a range of outcomes from minimal discomfort to death. PURPOSE: The purpose of this paper was to describe the epidemiology of exertional heat-related injuries treated in U.S. emergency departments. METHODS: A retrospective analysis was conducted using data from the National Electronic Injury Surveillance System of the U.S. Consumer Product Safety Commission for all ages from 1997 through 2006. Data provided by the National Electronic Injury Surveillance System were used to calculate national estimates of exertional heat-related injuries. Trends of exertional heat-related injuries over time were analyzed using linear regression. RESULTS: Nationally, an estimated 54,983 (95% CI=39995, 69970) patients were treated in U.S. emergency departments for exertional heat-related injuries from 1997 to 2006. The number of exertional heat-related injuries increased significantly from 3192 in 1997 to 7452 in 2006 (p=0.002), representing a 133.5% increase. The overall exertional heat-related injury rate per 100,000 U.S. population more than doubled from 1.2 in 1997 to 2.5 in 2006 (p=0.005). Patients aged ≤19 years accounted for the largest proportion of exertional heat-related injuries (47.6%). The majority of exertional heat-related injuries were associated with performing a sport or exercising (75.5%) and yard work (11.0%). The majority of patients (90.4%) were treated and released from the emergency department. Patients aged ≤19 years sustained a larger proportion of sports and recreation exertional heat-related injuries, whereas patients aged 40-59 years and ≥60 years sustained a larger proportion of exertional heat-related injuries from yard work. CONCLUSIONS: This study confirms that although there is a risk of exertional heat-related injury among all physically active individuals, sports pose a specific risk for people of all ages especially among children and adolescents playing football. Many "everyday" activities such as yard work and home maintenance also pose risks of exertional heat-related injury, particularly to those aged ≥40 years. Further research on risk factors of exertional heat-related injuries during home maintenance and yard work as well as appropriate prevention practices is needed.