Structural Competency in the U.S. Healthcare Crisis: Putting Social and Policy Interventions Into Clinical Practice.

This symposium of the Journal of Bioethical Inquiry illustrates structural competency: how clinical practitioners can intervene on social and institutional determinants of health. It will require training clinicians to see and act on structural barriers to health, to adapt imaginative structural approaches from fields outside of medicine, and to collaborate with disciplines and institutions outside of medicine. Case studies of effective work on all of these levels are presented in this volume. The contributors exemplify structural competency from many angles, from the implications of epigenetics for environmental intervention in personalized medicine to the ways clinicians can act on fundamental causes of disease, address abuses of power in clinical training, racially desegregate cities to reduce health disparities, address the systemic causes of torture by police, and implement harm-reduction programs for addiction in the face of punitive drug laws. Together, these contributors demonstrate the unique roles that clinicians can play in breaking systemic barriers to health and the benefit to the U.S. healthcare system of adopting innovations from outside of the United States and outside of clinical medicine.

Considering intersections of race and gender in interventions that address US men's health disparities.

Although gender, racial and ethnic differences in health in the USA are well documented, it is less clear how race and gender intersect to produce large and consistently poor health outcomes for men of colour, particularly Black American men. This paper will illustrate how race and gender intersect at multiple levels to shape men's health and health behaviours, and function as fundamental social determinants of health. The paper will conclude by discussing the need to attend to the role of male gender in pathways and processes underlying racial health disparities, and the challenges of developing health promotion interventions for Black American men.

Creatine use among young athletes.

OBJECTIVE: Creatine is a nutritional supplement that is purported to be a safe ergogenic aid in adults. Although as many as 28% of collegiate athletes admit taking creatine, there is little information about creatine use or potential health risk in children and adolescents. Although the use of creatine is not recommended in people less than 18 years of age, numerous anecdotal reports indicate widespread use in young athletes. The purpose of this study was to determine the frequency, risk factors, and demographics of creatine use among middle and high school student athletes. METHODS: Before their annual sports preparticipation physical examinations, middle and high school athletes aged 10 to 18 in Westchester County, a suburb north of New York City, were surveyed in a confidential manner. Information was collected regarding school grade, gender, specific sport participation, and creatine use. RESULTS: Overall, 62 of 1103 participants (5.6%) admitted taking creatine. Creatine use was reported in every grade, from 6 to 12. Forty-four percent of grade 12 athletes surveyed reported using creatine. Creatine use was significantly more common (P <.001) among boys (53/604, 8.8%) than girls (9/492, 1.8%). Although creatine was taken by participants in every sport, use was significantly more common among football players, wrestlers, hockey players, gymnasts, and lacrosse players (P <.001 for all). The most common reasons cited for taking creatine were enhanced performance (74.2% of users) and improved appearance (61.3%), and the most common reason cited for not taking creatine was safety (45.7% of nonusers). CONCLUSIONS: Despite current recommendations against use in adolescents less than 18 years old, creatine is being used by middle and high school athletes at all grade levels. The prevalence in grades 11 and 12 approaches levels reported among collegiate athletes. Until the safety of creatine can be established in adolescents, the use of this product should be discouraged.

Pediatric sports emergencies.

This article reviewed the major categories of sports-related medical emergencies in young athletes. Sports participation is a healthy and generally safe activity for child and adolescent athletes, and should be encouraged by health care providers. Thankfully, medical emergencies are rare events during youth [figure: see text] sports participation. When these events occur, however, prompt recognition and appropriate treatment are of tremendous importance.

The adolescent preparticipation physical examination. Is it helpful?

The preparticipation examination (PPE) is a widely practiced method of screening athletes for medical limitations before sports participation. Although the PPE is widely implemented, there is little consistency regarding content or method in providing this important service. This lack of uniformity undermines the overall effectiveness of the PPE. The history, efficiency, and nature of athletic screening in adolescents are discussed in this article, and specific suggestions are offered on how the examination might be improved in the future. As sports participation among teens continues to change--in number of participants and in athlete-demographics--and as the field of sports medicine expands equally rapidly, the adolescent PPE, the commonest interaction between adolescent patients and the medical system, should be updated.

Sports-specific concerns in the young athlete: baseball.

The sport of baseball is played by millions of children across America and around the world. Although generally considered a safe activity, it is estimated that there are over 100,000 acute baseball injuries yearly in the 5- to 14-year age range in the United States, many of which present to the emergency department. Acute injuries often involve ball impact to the face and hands; baseball is the leading cause of sport-related eye injury. Ball impact particularly to the chest results in a small but steady number of fatalities each year, many of which are widely publicized events. In addition to acute injury, many young baseball players are affected by chronic and acute conditions of the elbow. In this article, we review the history, epidemiology, and common injury patterns that are specific to baseball. Case reports are included, as well as a section on the physical examination of the elbow.

Sports-specific concerns in the young athlete: basketball.

Basketball is played by millions of athletes throughout the world and is the most popular team sport in American high schools. Basketball is the leading cause of sports-related injury in the United States. Acute basketball injuries most often involve the extremities, especially the hands, wrists, ankles, and knees. This article reviews the history, epidemiology, and common injury patterns that occur in this sport. We include several case reports to emphasize diagnostic dilemmas frequently encountered by emergency physicians.

Sports-specific concerns in the young athlete: football.

There are over 1.5 million males playing American football at all levels in the United States. American football is the most common participant sport among high-school-aged males. Owing to its high rate of injury per exposure hour, American football injuries are commonly treated in the emergency department during the autumn sports season. This article will review the history, epidemiology, and specific injury patterns seen in American football, with a focus on head and shoulder injuries.

Anterior cruciate ligament reconstructive surgery in adolescent soccer and basketball players.

OBJECTIVE: To evaluate trends in the frequency of anterior cruciate ligament (ACL) tears among adolescent soccer and basketball players resulting in reconstructive surgery, and to assess differences between female and male adolescent athletes. DESIGN: A retrospective review of ACL reconstructive surgeries performed from 1992 through 1997 and annual statewide participation rates obtained from the National Federation of State High School Associations. SETTING: Children's Hospital, Boston, Massachusetts, U.S.A. PATIENTS: Adolescent athletes 13 to 19 years of age (78 girls, 31 boys) admitted for ACL reconstruction due to soccer or basketball injuries. MAIN OUTCOME MEASURES: Number of ACL reconstructive surgeries and number of Massachusetts participants in high school soccer and basketball. RESULTS: A total of 69 soccer (49 girls, 20 males) and 40 basketball (29 girls, 11 males) players underwent ACL reconstruction. A greater proportion of girls underwent ACL surgery in both sports. The frequency increased over time for both sexes in both sports. Soccer-related surgeries increased at a faster rate among girls than boys. Basketball-related surgeries increased at a similar rate for both sexes, although in any given year more surgeries were performed on girls. CONCLUSION: The frequency of ACL surgery at our institution has increased among high school soccer and basketball players in a manner consistent with trends in sports participation. In our study, ACL surgery was more common among girls than boys.

Strength training and nutritional supplement use in adolescents.

The "win at all costs" mentality is becoming increasingly common in youth sports, and young athletes are often looking for methods to improve sports performance and avoid injury. As organized sports participation continues to increase among American adolescents, questions related to sports medicine are more frequently encountered in the pediatric and adolescent office setting. Concerned with the improvement of athletic performance and the prevention of injury, adolescents are turning to strength training to help improve bone density and muscle strength. These efforts should be encouraged if the strength program is properly designed and supervised. Another topic of concern to many adolescents is nutritional supplement use. Products known as ergogenic aids are designed to chemically improve sports performance and are currently being used by many adolescent athletes. Of these products, nutritional supplements are presented as a natural and safe method of improving athletic ability. None of these products has been tested in or approved for use in pediatric or adolescent subjects. Recommendations regarding the use of these products should be approached with a significant amount of trepidation in the pediatric and adolescent health communities.

An interesting case of infant sudden death: severe hypertrophic cardiomyopathy in Pompe's disease.

Glycogen storage disease type II (Pompe's disease) is a rare inherited metabolic disorder, which often leads to infantile death from severe cardiomyopathy. This case of sudden death illustrates the features of the cardiac findings in the disorder, resulting from massive lysosomal accumulation of glycogen in the heart and other tissues. Pompe's disease should be considered in cases of unexplained infantile cardiomyopathy.

Sports-specific concerns in the young athlete: soccer.

This article on soccer marks the first of a biannual series on sports-specific injury. Sports-related injury in the young athlete has become an issue of increasing importance to both emergency physicians and the pediatric community at large. Across America, increasing numbers of children and adolescents are participating in youth sports, a trend that translates into increasing numbers of injured young athletes interfacing with the medical system. This series of reviews is designed to provide a better understanding of sports-specific patterns, with the hope of assisting the emergency physician in the diagnosis and treatment of sports-related injury. From an epidemiologic perspective, sports-related trauma is an area of tremendous research potential. For reasons that are not entirely clear, there is a paucity of research on sports injury being undertaken within emergency departments. Since the majority of patients with sports injuries of a serious nature initially seek care in the emergency department, an opportunity exists for significant intervention and epidemiologic study within this setting. Therefore, these sports-specific reviews are intended not only to educate readers about the specific injury data and injury patterns found in certain sports, but also to stimulate further research on this topic. Finally, from an educational perspective, these sports-specific reviews are designed to further facilitate the incorporation of Sports Medicine teaching into the pediatric curriculum. Unfortunately, the teaching of proper musculoskeletal evaluation and treatment has received little emphasis in the traditional pediatric residency program. We believe that the evolving demographics of childhood morbidity, as witnessed by the increasing frequency of sports-related trauma in young athletes, should prompt the pediatric community to put greater emphasis on including instruction in musculoskeletal medicine in pediatric training programs. Therefore, we hope that this series of articles will hasten the introduction of a formal Sports Medicine curriculum into residency training. We hope that you enjoy this initial submission on soccer. Please let us know your thoughts on this article so that we may continue to revise the format to make these reviews as useful as possible.

Psycotherapy, managed care, and the economy of interaction.

This paper examines the disclosure over the value of long-term psychotherapy in a managed-care system. Many managed-care companies define extended psychotherapy as superfluous. Those who defend psychotherapy respond that the restrictions imposed by managed care are misguided and potentially harmful. After briefly discussing the relevant literature, the points of contention between psychotherapy and managed care are examined from the perspective of narrative literary theory. The analysis highlights the contrasting narrative assumptions implied about the importance of the clinical interaction. Pointing out each side's use of point-of-view, narrative structure, and informational exchange, it is posited that beneath arguments that often focus on the commodities of time and money lie larger, conceptual differences. These stealthily serve to undermine the possibility of a rational debate. The paper concludes by asserting that psychotherapy and managed care assume incommensurate narratives of interaction when discussing the value of therapy. The terms of discourse must be expanded in order to account for the philosophical differences described. Several ways this might be accomplished are proposed.

Youth soccer: an epidemiologic perspective.

The youth soccer movement in the United States is developing at a tremendous rate. This article explores the epidemiology of youth soccer including trends in participation, injury data, and injury categories that are of specific concern to the young athlete. Finally, recommendations are made regarding possible future areas of study and research on youth soccer.