EDITORIALS

March 2015 sampling durations, investigations that incorporate either natural or controlled community disturbances of interest, such as antibiotic exposure,15 are apt to be particularly enlightening. The types of investigative and analytic approaches brought to bear should include multi-‘omics’ methods to interrogate genomic, transcriptomic, proteomic, and metabolomic features and interactions. New insights from these types of investigations hold promise for informing clinical treatment decisions as well as rationally designing potential new interventions for modulating the host microbiota in specific ways to promote better health at various life stages. n Daniel B. DiGiulio, MD Division of Infectious Diseases Department of Medicine Stanford University School of Medicine Veterans Affairs Palo Alto Health Care System Palo Alto, California Reprint requests: Daniel B. DiGiulio, MD, Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Mail Code 5107, Stanford, CA 94305-5107. E-mail: [email protected]

References 1. Lawn JE, Cousens S, Zupan J, Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? Lancet 2005;365:891-900. 2. Turnbaugh PJ, Ley RE, Hamady M, Fraser-Liggett CM, Knight R, Gordon JI. The human microbiome project. Nature 2007;449:804-10.

3. DiGiulio DB. Diversity of microbes in amniotic fluid. Semin Fetal Neonatal Med 2012;17:2-11. 4. Palmer C, Bik EM, DiGiulio DB, Relman DA, Brown PO. Development of the human infant intestinal microbiota. PLoS Biol 2007;5:e177. 5. Dominguez-Bello MG, Costello EK, Contreras M, Magris M, Hidalgo G, Fierer N, et al. Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proc Natl Acad Sci U S A 2010;107:11971-5. 6. Koenig JE, Spor A, Scalfone N, Fricker AD, Stombaugh J, Knight R, et al. Succession of microbial consortia in the developing infant gut microbiome. Proc Natl Acad Sci U S A 2011;108(Suppl 1):4578-85. 7. Costello EK, Stagaman K, Dethlefsen L, Bohannan BJ, Relman DA. The application of ecological theory toward an understanding of the human microbiome. Science 2012;336:1255-62. 8. Arboleya S, Sanchez B, Milani C, Duranti S, Solıs G, Fernandez N, et al. Intestinal microbiota development in preterm neonates and effect of perinatal antibiotics. J Pediatr 2015;166:538-44. 9. Bedford Russell AR, Murch SH. Could peripartum antibiotics have delayed health consequences for the infant? BJOG 2006;113:758-65. 10. Hubbell SP. The Unified Neutral Theory of Biodiversity and Biogeography. Princeton, NJ: Princeton University Press; 2001. 11. Lindstr€ om ES, Langenheder S. Local and regional factors influencing bacterial community assembly. Environ Microbiol Rep 2012;4:1-9. 12. Levy R, Borenstein E. Metabolic modeling of species interaction in the human microbiome elucidates community-level assembly rules. Proc Natl Acad Sci U S A 2013;110:12804-9. 13. Sommer F, B€ackhed F. The gut microbiota—masters of host development and physiology. Nat Rev Microbiol 2013;11:227-38. 14. Langley-Evans SC. Developmental programming of health and disease. Proc Nutr Soc 2006;65:97-105. 15. Dethlefsen L, Relman DA. Incomplete recovery and individualized responses of the human distal gut microbiota to repeated antibiotic perturbation. Proc Natl Acad Sci U S A 2011;108(Suppl 1): 4554-61.

Overuse and Underutilization in Youth Sports: Time to Seek Equipoise

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n the world of pediatric sports medicine, arguably the two ment to halt too much of the same type of sport motion, hottest topics are the growth of youth sports—with the too soon. This can be a hard concept for parents to accept, resultant myriad of injuries—and concussion. Commuas we seem to have adopted the “more is better” culture nity sports for children and adolescents have long been popwhen it comes to sports. The lure of potential elite, college, ular, but over the last decade the ascent of the “select” or and professional sport involvement is strong, but deceptive. “travel” team has guided many young athFor example, less than 3 out of every 50 See related articles, p 594 letes to earlier sport specialization and high school senior boys’ soccer athletes will and p 600 more of the same sport, with more injury play college soccer; about 2 of 2000 will exposure. Young athletes who once played multiple sports ever be drafted by a Major League Soccer team.2 throughout high school and then specialized in college are In this issue of The Journal, Schroeder et al3 present findnow focusing as early as age 10 or younger, in sports such ings on overuse injuries from a 5-year period recorded in the as soccer, swimming, or gymnastics. With this hyperfocus high school Reporting Information Online study. Their comes stressors for which the immature skeleton is not prestudy, “Epidemiology of overuse injuries among highpared. school athletes in the United States,” comes from a rich Accordingly, overuse injuries are a common reason to visit data set that has information on many different sports, fueled pediatricians and sports medicine specialists. In a recent 10by detailed injury reports from high school athletic trainers year study of athletes ages 5 to 17 years seen in a busy acaacross all areas of the country. In the US, almost 8 million demic sports clinic, overuse injuries accounted for 53% of the patient visits.1 Sports medicine has tended to emphasize treating acute injuries and returning patched-up studentThe author declares no conflicts of interest. athletes to play, but now sports medicine specialists are 0022-3476//$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. learning to shift toward education, prevention, and treathttp://dx.doi.org/10.1016/j.jpeds.2014.11.024

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students participated in high school sports during the 20132014 seasons.4 By almost 2-fold, football is the boys’ sport with the highest number of participants; the most popular girls’ program, by a much narrower margin, is track and field. In the Schroeder report, overuse accounted for 5.5% of boys’ and 13.3% of girls’ injuries, with girls’ track and field having the highest rate. Injuries reported had to have been termed “overuse” or “chronic” and had to have resulted in “medical attention by an athletic trainer or physician” and “resulted in restriction of the student-athlete’s participation for at least 1 day beyond the day of injury.” The sheer number of athletes participating in these sports results in an incredible amount of time lost from both sports and school because of overuse injuries. Their study also reports that 26% of injured athletes were evaluated by a primary care physician. Pediatricians are the front line for evaluating these injuries. We cannot miss them! Overuse injuries usually have their basis in training errors or underlying mechanical problems, in addition to the simple repetitive stress that predisposes young athletes in the first place. Pediatricians must seek to correct these problems and encourage appropriate physical activity. Primary providers might even be able to help their patients stay in their sport(s) longer, with fewer injuries.5 Concussion is another injury flooding sports medicine and pediatric clinics. Better recognition over the past few years is responsible for this, as is state legislation (all 50 states have concussion-related legislation, as of February 2014) mandating evaluation and clearance of youth and school athletes before returning to play following a concussion. Progress in education about the dangers of playing contact sports while concussed has been fair to good. Many physicians, lay people, and schools now recognize that there needs to be a return to play progression and have put programs in place to address this, while supervising the student-athlete returning to sports. Medical providers are evaluating athletes prior to return to sport. In a recent survey of high school athletes in Nebraska who had been concussed, almost 95% of them received clearance from a medical professional prior to sport return. This is good. However, we are not doing as good a job regarding return of these youths to the classroom. In that same Nebraska survey, almost 60% of the respondents indicated that they did not have extra assistance in the classroom.6 As a sports medicine physician who sees patient volume balloon every autumn from concussions, I am also seeing student-athletes struggle more with academic issues and school-related stress than sport limitations. We address cognitive rest, limiting mental stress to promote cognitive recovery, in all areas of the patient’s academic environment. Getting this information to the patient, then to the right person at the school, who can then disseminate it to the relevant stakeholders for the student, is difficult. There are so many ways communication can go wrong. The school’s concussion knowledge and ability to make academic adjustments quickly for the student can create an environment that supports healing, or it can result in additional stress for the student, potentially prolonging the injury. Little research on how to refocus education following concussion has been done. 518

Vol. 166, No. 3 Heyer et al, also in this issue of The Journal, report their findings on “High school principals’ resources, knowledge, and practices regarding the returning student with concussion.”7 This survey of public high school principals in Ohio asked about a variety of topics, from whether school nurses and athletic trainers are present at the school, to whether they have access to concussion training and have academic accommodations available for their concussed students. Over one-third of principals had participated in some form of concussion training within the past year, which is still lower than expected because in 2013 Ohio passed concussion legislation that includes required online education; this study was done in 2013-2014. Only one-third of schools had written concussion plans for their students, with only onequarter of schools addressing academic adjustments for the student during recovery. The spectrum of school concussion care differed with school size and availability of athletic trainers. Results of this study tell us we have a long way to go with education regarding cognitive rest and academic recovery in concussion. We must talk to our patients with concussion about “return to learn” just as we do “return to play.” Physician communication with the school is imperative, whether by note or phone call (and sometimes both).8 Engaging with your local schools in a return to learning program serves as advocacy for patients with concussion and likely quicker recovery. Both the Schroeder et al and Heyer et al studies involve counseling and common sense for our patients, their parents, and their school personnel. A philosophy of rational engagement in youth sports without overuse but with close attention to the school needs of the student athlete when injured or concussed is sorely needed. A balance must be struck. Careful, kind conversation about the motivation behind sport is important, whether addressing overuse injuries or returning the concussed patient to school. Your patients will thank you for it. n Kelsey Logan, MD, MPH, FAAP, FACP Division of Sports Medicine Cincinnati Children’s Hospital Medical Center Department of Pediatrics University of Cincinnati College of Medicine Cincinnati, Ohio Reprint requests: Kelsey Logan, MD, MPH, FAAP, FACP, Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 10001, Cincinnati, OH 45229. E-mail: [email protected]

References 1. Stracciolini A, Casciano R, Friedman HL, Stein CJ, Meehan WP, Micheli L. Pediatric sports injuries: a comparison of males vs females. Am J Sports Med 2014;42:965-72. 2. NCAA. Estimated Probability of Competing in Athletics Beyond the High School Interscholastic Level [Internet]. 2013 [cited 2014 Oct 19]. https:// www.ncaa.org/sites/default/files/Probability-of-going-pro-methodology_ Update2013.pdf. Acessed October 20, 2014.

EDITORIALS

March 2015 3. Schroeder AN, Comstock RD, Collins CL, Everhart J, Flanigan D, Best TM. Epidemiology of overuse injuries among high-school athletes in the United States. J Pediatr 2015;166:600-6. 4. 2013-14 High school athletics participation survey [Internet]. 2014 [cited 2014 Oct 20]. https://www.library.uq.edu.au/training/citation/vancouv. pdf. Accessed October 20, 2014. 5. Brenner JS, the Council on Sports Medicine and Fitness. Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics 2007;119:1242-5.

6. 2013 Nebraska Sports Concussion Survey Results: Youth Survey [Internet]. http://dhhs.ne.gov/publichealth/concussion/Documents/ 2013%20Nebraska%20Sports%20Concussion%20Youth%20Survey%20 Results.pdf. Accessed October 20, 2014. 7. Heyer GL, Weber KD, Rose SC, Perkins SQ, Schmittauer CE. High school principals’ resources, knowledge, and practices regarding the returning student with concussion. J Pediatr 2015;166:594-9. 8. Halstead ME, McAvoy K, Devore CD, Carl R, Lee M, Logan K. Returning to learning following a concussion. Pediatrics 2013;132:948-57.

Preventing Pediatric Readmissions: Which Ones and How?

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ospital readmission rates constitute an established, if In this issue of The Journal, two groups report their obserdisputed, quality metric in adult healthcare.1,2 High vations on hospital readmissions and contribute to our readmission rates can adversely affect hospital reveknowledge of the accuracy and actionability of readmission nue and prestige. The Centers for Medicare and Medicaid rates as a quality metric.8,9 Gay et al report “potentially” preServices levies financial penalties for “excessive” readmisventable readmissions (PPR) from a large sample of patients sions after an initial admission for selected from children’s hospitals using the 3M PPR See related articles, p 607 conditions, such as acute myocardial software (3M, St Paul, Minnesota),8 and Edand p 613 infarction, heart failure, and pneumonia. monson et al report readmissions and reCenters for Medicare and Medicaid Services is expanding visits after tonsillectomy in a statewide database.9 The two the number of initial diagnoses covered and the penalties groups took divergent approaches but converge on similar reach 3% of all Medicare reimbursements in 2015 for hospiconclusions. Pediatric readmissions occur commonly, and tals with excessive readmissions. Additionally, the Hospital seem like they should be preventable, at least in some inCompare website3 displays hospital readmission rates and alstances. Both studies also suggest that one of the first targets for reducing readmissions should be those that occur after lows comparisons among hospitals in the same geographic procedures, especially elective procedures. area. Edmonson et al examined hospital, emergency departThis focus on readmission rates has also arisen in pediatric ment, and clinic revisits in pediatric and young adult patients health care. Readmission rates have been examined and reafter tonsillectomy.9 They found an 8.6% to 24.5% revisit ported,4-6 and “excessive” rates lead in some states to finan7 cial penalties by Medicaid. Pediatric readmissions impart rate that increased with age. Pain, nausea/vomiting, and dehydration prompted 68% of these revisits. By choosing a medical risks to the patient, create inconvenience for patients single, elective procedure, the authors provide a reproducible and families, and may reflect suboptimal inpatient care or readmissions metric, which should be applicable to most care transitions to community clinicians. These factors, hospitals. Their observations are actionable in that they idencoupled with the putative cost savings associated with tify a high-risk population, adolescents, and their data sugreducing readmissions (27.3% of $1.7 billion in children’s gest that better patient preparation prior to discharge and hospitals, according to Gay et al8 in this issue of The Journal), outpatient management after discharge could prevent many ensure that readmissions will endure as a quality metric. revisits. However, pediatric readmissions have not been a straightGay et al used the proprietary, 3M PPR software to forward quality measure.9 Unlike medication errors or distinguish “potentially” preventable from all-cause readwrong-site surgeries, which should always be preventable, missions.8 This comprehensive, electronic approach posreadmissions do not necessarily reflect suboptimal care 6,8 and most are not preventable. In our experience, most resesses many appealing features for payers and regulators, but holds less appeal for clinicians. The software uses admissions within 7 days of discharge are planned. Furtheradministrative data, so there is no need to acquire addimore, sociodemographic and other factors adversely affect tional data or perform case review. The software identifies readmission rates to an extent that likely varies by center.1 only PPR and does so in aggregate, thus preventing a cliniAlthough clinicians and health systems can prevent some recian’s challenge that a specific patient’s readmission was not admissions, the question is which readmissions could be preventable. The software starts by examining all discharges prevented and by whom. The evidence base supporting using combinations of All Patient Refined Diagnosis effective practices to prevent pediatric readmissions is thin. Related Groups at discharge and readmission and other Quality metrics should be accurate and actionable. By those criteria, pediatric readmission rate, as a quality metric, needs refinement. The authors declare no conflicts of interest.

PPR

“Potentially” preventable readmissions

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Overuse and underutilization in youth sports: time to seek equipoise.

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