Hyponatraemia : identification and evaluation in the marathon medical area.

Exercise-associated hyponatraemia (EAH) in marathon runners has been reported in the medical literature with incidence varying from 0-130 per 1000 finishers. EAH assessment is enhanced utilising a combination of race weight changes, screening questions, vital signs and clinical examination. Those who fail to lose 0.75kg are seven times more likely to be hyponatraemic than those who lose >0.75kg. Because EAH presentations vary, a three-level surveillance system may help identify mild to moderate cases of EAH that may progress and speed treatment for those in need. After the initial evaluation, the clinical response to treatment is very important to evaluating the severity of EAH. For mild symptomatic hyponatraemia, restrict hypotonic fluids until the runner is urinating and give oral hypertonic solutions if the runner can take oral fluids. For severely symptomatic EAH, intravenous 3% sodium chloride solution will speed recovery and improve outcomes. Pre-race education addressing early symptoms and expected weight changes as well as follow-up instructions detailing the appropriate post-race fluids should be available to all registered runners and specifically given to those runners monitored/treated in the medical area.

Ankle sprain discharge instructions from the emergency department.

OBJECTIVES: (1) To describe the incidence of inclusion of early mobilization components in emergency department (ED) discharge instructions; (2) to describe the prescribed follow-up appointments; and (3) to analyze the differences between the treatment of pediatric and adult patients. METHODS: A 1-year retrospective chart review of ED records of a large urban hospital was performed. Medical records of 374 (95%) of the 397 adult and pediatric patients with ICD-9 code for ankle sprains were reviewed (213 males and 171 females, mean age 28.4 +/- 14.5; 291 adults, 93 pediatric). RESULTS: Sixteen percent of records contained discharge instructions that included rest, ice, compression, elevation, and medications (RICEM). Twenty percent included RICE. Pediatricians (33.7%) were more likely than adult physicians (10.3%) to have given RICEM (P < 0.0001) and RICE (P = 0.05, pedi = 45.8%, adult = 13.1%). Follow-up referrals were recommended as needed 50% of the time. Follow-up referrals were made to community clinics (59%), orthopedic clinic (23%), the ED (14%), and others (4%). Pediatricians were more likely to recommend routine scheduled follow up (pedi = 62%, adult = 47%, P = 0.018), suggest follow-up in a community clinic or doctors office (pedi = 68.6%, adult = 51.2%, P < 0.0001), and to recommend earlier follow up (pedi = 1.6 weeks +/- 1.1, adult = 2.0 weeks +/- 1.1, P = 0.002) than adult physicians. CONCLUSIONS: Programs that train physicians who work in the ED need to include education on the proper treatment, rehabilitation, and follow up of patients with acute ankle sprains. Providing easy-to-complete discharge instruction templates can help providers give patients discharge instructions that may help patients minimize the risk of long-term sequelae.

The incidence, risk factors, and clinical manifestations of hyponatremia in marathon runners.

OBJECTIVE: To report on the incidence, identify the risk factors, and clarify the clinical manifestations of acute hyponatremia in marathon runners. DESIGN: An observational and retrospective case-controlled series. SETTING: The medical care area of the 2000 Houston Marathon. PATIENTS: Marathon finishers treated in medical area receiving intravenous fluids (N=55), including a more detailed analysis of 39 runners completing a retrospective questionnaire. MAIN OUTCOME MEASURES: Vital signs, serum electrolytes, and finish time were analyzed via ANOVA studies between all non-hyponatremic (NH: N=34)) and hyponatremic (H: N=21)) runners. Fluid intake, training variables, NSAID use, and Symptomatology were further analyzed to delineate all significant differences between groups. RESULTS: There were no significant differences in vital signs, training variables, or NSAID use between H and NH groups, although there was a trend towards the less experienced runners presenting with lower post-race sodium levels. H runners had lower potassium [K] (p=.04), chloride [Cl] (p<.001), and blood urea nitrogen [BUN] (p=.004) levels than NH runners. There was a significant inverse linear relationship between both finish time versus [Na] (r2 =.51) and total amount of fluid ingested versus [Na] (r2 =.39). The total cups of water (p=.004), electrolyte/carbohydrate solution (p=.005) and total amount of fluid ingested (p<.001) were significantly higher in H compared to NH runners and the degree of hyponatremia was related in a dose dependent manner. Vomiting was observed more frequently in H than NH runners (p=.03). CONCLUSION: 21 runners presented to the medical area of the Houston Marathon with hyponatremia (.31% of entrants). Excessive fluid consumption and longer finishing times were the primary risk factors for developing this condition. Vomiting was the only clinical sign differentiating hyponatremia from other conditions that induce exercise-associated collapse.

Two educational interventions to improve pediatricians' knowledge and skills in performing ankle and knee physical examinations.

BACKGROUND: Methods are needed to improve pediatricians' skills for physical examination of the ankle and knee. OBJECTIVE: To compare the effect of 2 methods of teaching the physical examination of the ankle and knee on the knowledge and skills of pediatricians. DESIGN: Prospective intervention trial with preintervention and postintervention tests. SETTING: Pediatricians' offices. PARTICIPANTS: Twenty-three practice groups of community pediatricians, including 75 pediatricians (74% of the eligible sample). INTERVENTIONS: Practice groups were assigned by clustered randomization to 1 of 2 teaching interventions: (1) a videotape showing correct performance of the ankle and knee physical examinations (videotape only; 15 groups) and (2) the same videotape plus a skills building session (18 groups). The randomization was stratified by practice size. MAIN OUTCOME MEASURES: Knowledge of ankle and knee examinations and ankle and knee physical examination skills, assessed by means of a Clinical Skills Assessment Examination (CSAE), at 18 weeks. RESULTS: The pediatricians' baseline mean ankle CSAE score was 26% correct in both groups. These scores improved to 44% and 59% correct in the videotape and videotape plus skills instruction groups, respectively, at 18 weeks (P<.001 for both). The baseline mean knee CSAE score was 25% in both groups and improved to 30% (P =.02, videotape group) and 41% (P<.001, videotape plus skills instruction group) at 18 weeks. The change in CSAE scores was greater in the videotape plus skills instruction group. Written test scores improved significantly in both groups. CONCLUSIONS: Pediatricians' skills were lacking at baseline. Both teaching interventions were associated with improved skills and knowledge.

Baseline injury risk factors for runners starting a marathon training program.

OBJECTIVE: To describe the baseline characteristics of participants starting a 25-week marathon training program, and their relationship to injury risk factors. DESIGN: Prospective survey. SETTING: Community-based marathon training program. PARTICIPANTS: 1,548 of 2,314 registrants for the Houston Fit Marathon Training Program (mean age 35.8 +/- 9.3 years, mean body mass index 24.3 +/- 3.9, 63% female). INTERVENTION: 4-page survey administered at registration. MAIN OUTCOME MEASURE: Running experience, training practices, demographics, chronic medical problems and previous injuries. RESULTS: Females were more likely to be classified as underweight and males as overweight or obese (p < 0.0001). The mean number of years of running experience was 6.2 +/- 6.2. Most (87.5%) planned to train at a 9-minute mile or slower pace. 52.3% of the participants had not previously trained for a marathon. In the 3 months prior to starting the program 16.1% had been sedentary. Those runners who had not previously completed a marathon and not previously trained with Houston Fit had a higher prevalence of baseline training techniques that could be risk factors for injury. During the previous 3 years, 38.1% reported having an injury, and 35% of all injuries were still symptomatic at the start of the program. CONCLUSIONS: Training programs for the marathon attract more female athletes and those with less running and marathon experience. The prevalence of being overweight or obese is 35.6%. 16.1% are sedentary during the 3 months before starting this program. Training programs must take measures to establish baseline fitness, to educate on injury prevention training techniques, and to set appropriate fitness goals. CLINICAL RELEVANCE: The research study shows that many patients wanting to start a marathon training program are relatively untrained and inexperienced with reference to endurance running. These patients will need special care and education so as to minimize injury and maximize the effect on their physical activity habits.