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John W Orchard,1 Markus Waldén,2 Martin Hägglund,3 Jessica J Orchard,1 Ian Chivers,4 Hugh Seward,5 Jan Ekstrand21School of Public Health, University of Sydney, Sydney, NSW, Australia; 2Department of Medical and Health Sciences, Division of Community Medicine, Linköping University, Linköping, Sweden; 3Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden; 4Native Seeds, Cheltenham, VIC, Australia; 5Australian Football League Medical Officers Association, Melbourne, VIC, AustraliaAbstract: Australian Football League (AFL) teams in northern (warmer) areas generally have higher rates of injury than those in southern (cooler) areas. Conversely, in soccer (football) in Europe, teams in northern (cooler) areas have higher rates of injury than those in southern (warmer) areas, with an exception being knee anterior cruciate ligament (ACL) injuries, which are more common in the southern (warmer) parts of Europe. This study examined relative injury incidence in the AFL comparing 9,477 injuries over 229,827 player-weeks from 1999–2012. There was a slightly higher injury incidence for teams from warmer parts of Australia (relative risk [RR] 1.05, 95% confidence interval [CI] 1.01–1.10) with quadriceps strains (RR 1.32, 95% CI 1.10–1.58), knee cartilage injuries (RR 1.42, 95% CI 1.16–1.74), and ankle sprains (RR 1.17, 95% CI 1.00–1.37) all being more likely in warmer region teams. Achilles injuries followed a reverse pattern, tending to be more common in cooler region teams (RR 0.70, 95% CI 0.47–1.03). In conclusion, common findings from the AFL and European soccer are that ankle sprains and ACL injuries are generally more likely in teams playing in warmer climate zones, whereas Achilles tendinopathy may be more likely in teams playing in cooler zones. These injuries may have climate or surface risk factors (possibly related to types and structure of grass and shoe-surface traction) that are universal across different football codes.Keywords: climate, grass, shoe-surface traction, Australian football, soccer

Background and Aim: SARS-CoV-2 infection is associated with increased cardiovascular (CV) morbidity and mortality, manifesting as increased adverse outcomes in the first 30 days, extending to 12 months. This study aimed to investigate trends in sudden unexpected deaths between 2018 and 2022, with a focus on CV deaths., Method: A retrospective analysis was performed on autopsy reports (n=9,330) obtained from New South Wales Coroners Court, Australia, specifically targeting cases of unexplained deaths that occurred between 2018 and 2022. Statistical analysis was conducted using chi-square tests and a post hoc analysis with Bonferroni correction, as well as analysis of variance with multiple comparisons., Results: There were 349 (18.3%) CV deaths in 2018, 346 (18.0%) in 2019, 338 (17.5%) in 2020, 395 (21.9%) in 2021, and (23.4%) 413 in 2022 (p=0.0002). Among CV deaths, the number of deaths from sudden arrhythmic death syndrome were 25 (7.2%) in 2018, 26 (7.5%) in 2019, 18 (5.3%) in 2020, 52 (13.2%) in 2021, and 80 (19.4%) in 2022 (p=0.0001). Atherosclerosis was the most common cause of death among all CV categories; there were 196 (56.2%) atherosclerosis deaths in 2018, 207 (59.8%) in 2019, 192 (56.8%) in 2020, 221 (56.0%) in 2021, and 197 (47.7%) in 2022 (p=0.43). The average age of death from sudden arrhythmic death syndrome (42.8±19.1 years) across 2018-2022 was younger than atherosclerosis (56.2±12.4 years) and total groups (53.1±15.1 years) (p<0.001). Males comprised 76% of all CV deaths from 2018 to 2022 (p<0.0001)., Conclusions: Compared with pre-pandemic data, a noteworthy increase in CV deaths was observed in occurrence with the escalation in COVID-19 cases in Australia. This may be attributed to direct or indirect factors, such as lifestyle modifications, disrupted access to routine cardiac care, or COVID-19 infection-triggered CV deaths., Competing Interests: Conflicts of Interest There are no conflicts of interest to disclose., (Copyright © 2024 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Cardiac screening of elite athletes is widely recommended by Australasian sporting federations, but data are not structured to be shared. Data are lacking from underrepresented groups to inform ECG interpretation guidelines. The ARENA (Australasian Registry of Screening ECGs in National Athletes) project is a retrospective and prospective, multicenter, longitudinal, observational registry of athlete cardiac screening results and outcomes. The aim is to create a repository to improve our understanding of the diagnoses and outcomes of screening., Methods: Participating sports that conduct cardiac screening of athletes will contribute data. This includes an initial collection (retrospective data, waiver of consent) and future prospective data (opt-out consent). Data include sex, age, sport/event, screening date, ECG findings, cardiac test results, follow-up details, sport participation status, cardiac diagnoses, and major cardiovascular outcomes defined as sudden cardiac arrest/death, cardiac syncope or implanted cardioverter defibrillator shock, cardiac hospitalization, and arrhythmias requiring intervention. Comparisons will be made between diagnoses, outcomes, and ECG features and analyzed by sport and sex. The ARENA project was developed in collaboration with sporting bodies, team physicians, and players association representatives and endorsed by the Australasian College of Sport & Exercise Physicians and Sports Medicine Australia., Conclusions: The ARENA project will provide a long-term international data repository to improve our understanding of ECG interpretation, cardiac screening and diagnoses, and the prevalence of cardiovascular outcomes in screened athletes. A unique aim is to address evidence gaps in underrepresented athlete groups, specifically female athletes and Indigenous populations. Results will inform screening policies and guidelines.

Background: Sports medicine (injury and illnesses) requires distinct coding systems because the International Classification of Diseases is insufficient for sports medicine coding. The Orchard Sports Injury and Illness Classification System (OSIICS) is one of two sports medicine coding systems recommended by the International Olympic Committee. Regular updates of coding systems are required., Methods: For Version 15, updates for mental health conditions in athletes, sports cardiology, concussion sub-types, infectious diseases, and skin and eye conditions were considered particularly important., Results: Recommended codes were added from a recent International Olympic Committee consensus statement on mental health conditions in athletes. Two landmark sports cardiology papers were used to update a more comprehensive list of sports cardiology codes. Rugby union protocols on head injury assessment were used to create additional concussion codes., Conclusion: It is planned that OSIICS Version 15 will be translated into multiple new languages in a timely fashion to facilitate international accessibility. The large number of recently published sport-specific and discipline-specific consensus statements on athlete surveillance warrant regular updating of OSIICS., (Copyright © 2024. Production and hosting by Elsevier B.V.)

Competing Interests: Conflict of interest: J.J.O., K.G., N.L., and B.F. report investigator-initiated grants to their institution from Pfizer/BMS. B.F. also reports prior fees and advisory board honoraria from Bayer Pharma AG, Daiichi-Sankyo, Omron, and Pfizer/BMS. L.N. reports speaker fees from Daiichi-Sankyo and grants and honoraria from Pfizer/BMS, Bayer, and Boehringer Ingelheim. J.W.O. and A.L.G. have no disclosures to make. C.H. reports independent research grants from Amgen and Sanofi and honoraria for education/advisory boards from AstraZeneca, Boehringer Ingelheim, and Pfizer.

Objectives: To report findings from the High Performance Sport New Zealand cardiac screening programme, including comparisons between sexes and ethnicities., Design: Retrospective cohort study., Methods: Elite Olympic-sport athletes were screened (2012-2022) with personal/family history, physical examination, resting 12-lead ECG and followed from the date of first screening until July 2022. An audit reviewed screening records, including demographic data, ECGs, follow-up and diagnoses. Flagged/equivocal ECGs were re-reviewed (International Criteria)., Results: 2075 ECGs from 1189 athletes (53 % female, mean age 21 years; 83 % European, 9 % Māori, 5 % Pacific Islander, 3 % other) were included. No athletes retired for cardiac reasons; there were no cardiac deaths or major cardiac incidents (mean follow-up from first screening: 6.1 years (range: 0.6-10.9 years)). Diagnoses included Wolff-Parkinson-White (WPW) syndrome (0.7 %) and cardiomyopathies (0.3 %). Overall, 3.5 % of ECGs were abnormal, with ECGs of females more commonly abnormal (4.4 % vs 2.5 %, p = 0.02) and with a higher proportion of ECGs with abnormal T-wave inversion (TWI) (3.1 % vs 0.9 %, p < 0.001) compared to males. Of the abnormal TWI in females (all aged ≥16 years), 47 % was limited to V1-V3 with no other abnormalities. Abnormality rates were similar between Māori, Pacific Islander and European athlete ECGs., Conclusions: WPW was the most frequent diagnosis, with very little cardiomyopathy found. The proportion of abnormal ECGs was low overall, but higher in females. This was driven by anterior TWI in V1-V3 which was not associated with diagnoses of conditions associated with sudden cardiac death (SCD). There was no difference in the proportion of abnormal ECGs of Māori or Pacific Island athletes compared to European athletes., Competing Interests: Declaration of interest statement RND holds the Heart Foundation Chair of Heart Health at the University of Auckland and undertook the ECG interpretation as a consultant to HPSNZ facilitated by The Heart Group. BH is an employee of HPSNZ., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background/objectives: Previous studies have shown a trend that elite athletes tend to live longer than the general population, which has been attributed to the "healthy worker hire effect" and the health benefits of exercise. There have not been any previous studies looking at survival of elite cricketers with the general population as a reference cohort. This study aimed to compare the annual mortality rates of current and retired elite male Australian cricket players to that of the age-matched general Australian male population., Methods: Analysis of publicly accessible dates of birth, death, and cricket debut data for male Australian Sheffield Shield cricket players who played before 2022 and had not died before 1971. Included persons were Sheffield Shield players who lived primarily in Australia during and after their cricket careers. Death rates from 1971 to 2021 (inclusive) were compared to the general Australian male population., Results: 1824 Sheffield Shield players had not died prior to 1971 (798 had played before the 1971 season, 1026 debuting subsequently). There were 586 deaths in the 51 years of observations, compared to 825 expected deaths, giving a Standardized Mortality Ratio of 0.71 (95% CI 0.63-0.80)., Conclusion: Elite Australian male Sheffield Shield cricket players outlive the general male population with lower death rates. This is probably due to a combination of the healthy worker hire effect and the health benefits of exercise. This study provides evidence that in terms of longevity, it is safe to play elite-level cricket in Australia., Competing Interests: Conflict of interestNathan Luies is a team doctor for Cricket Australia. John W Orchard is the Chief Medical Officer of Cricket Australia. Jessica J Orchard is a consultant for Cricket Australia. Tim Driscoll, Saaz Kaur Sahdra, Johnathan Cheng, and Angus J Davis declare that they have no conflicts of interest., (© The Author(s) 2023.)

Screening elite athletes for conditions associated with sudden cardiac death is recommended by numerous international guidelines. Current athlete electrocardiogram interpretation criteria recommend the Bazett formula (QTcB) for correcting QT interval. However, other formulae may perform better at lower and higher heart rates (HR). This review aimed to examine the literature on various QT correction methods in athletes and young people aged 14-35 years and determine the most accurate method of calculating QTc in this population. A systematic review of MEDLINE, EMBASE, Scopus, and SportDiscus was performed. Papers comparing at least two different methods of QT interval correction in athletes or young people were included. Quality and risk of bias were assessed using a standardized tool. The search strategy identified 545 papers, of which 10 met the criteria and were included. Nine of these studies concluded that QTcB was least reliable for removing the effect of HR and was inaccurate at both high (>90 beats per min [BPM]) and low (<60 BPM) HRs. No studies supported the use of QTcB in athletes and young people. Alternative QT correction algorithms such as Fridericia (QTcF) produce more accurate correction of QT interval at HRs seen in athletes and young people. QTcB is less accurate at lower and higher HRs. QTcF has been shown to be more accurate in these HR ranges and may be preferred to QTcB for QTc calculation in athletes and young people. However, accurate QTc reference values for discrete HRs using alternative algorithms are not well established and require further research., (© 2023 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Background: Cardiac screening of elite athletes including a 12‑lead electrocardiogram (ECG) is recommended by numerous international bodies. Current athlete ECG interpretation guidelines recommend the Bazett method to correct the QT interval (QTc)., Objective: This study sought to investigate normative QTc changes by age using athlete screening ECGs and different QT correction methods in a population of elite cricketers., Methods: Initial cardiac screening ECGs from an existing database of elite Australian cricketers aged 14-35 years were examined. Average QT interval, QTcB (corrected QT-Bazett), QTcF (Fridericia), QTcH (Hodges), and heart rate (HR) were analyzed by age and sex., Results: A total of 1310 athletes (66% male, 34% female) were included with mean age 19.1 years and mean heart rate 66.9 bpm (range 38-121 bpm). With increasing age, HR decreased and absolute QT increased. The pattern of QTc change with age differed depending on the method of correction: Bazett correction (QTcB) demonstrated a "dish-shaped" or broad U-shaped appearance; while Fridericia and Hodges corrections showed a linear increase in QTc from young to older age. The Bazett method had a stronger correlation of HR with QTc (R 2  = 0.32) than either Fridericia (R 2  = 0.0007) or Hodges (R 2  = 0.009) methods., Conclusions: The Bazett method is not the most accurate QT correction in athletes, especially during adolescence. In elite cricketers, QTcB revealed a drop in QTc from adolescence to early adulthood due to mis-correction of the QT interval. The Fridericia method has the smoothest correction of HR and least QT variation by age and may be preferred for athlete screening., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To determine age-matched death rates of current and retired elite male Australian football players (Australian and/or Victorian Football League) with the general population., Design: Analysis of publicly-available birth, debut and death data for all Australian Victorian Football/Victorian Football League players who debuted prior to (and were still alive at) the start of 1971 or debuted 1971-2020., Methods: Wikipedia was used to source the dates of death (or record that the player was alive in 2021) for the cohort. New players became part of the cohort for analysis on debut and existing cohort members left it at death. Actual death rates (per year and per decade) were then compared to expected deaths, based on age-specific population death rates., Results: There were 5400 players and ex-players in the cohort at the start of 1971 (average age 47.3) and a further 4532 players debuted between 1971 and 2020 inclusive (a total of 9932 players). The expected deaths for the cohort in this 50-year period were 4955, but only 3914 deaths occurred (Standardized Mortality Ratio 0.79, 95 %CI 0.76-0.82). For younger members of the cohort (age <50) the discrepancy between expected (222) and actual (98) deaths was also significant (Standardized Mortality Ratio 0.44, 95 %CI 0.35-0.56)., Conclusions: We conclude that the death rates of elite male Australian footballers are lower than the reference general population, similar to other studies of elite athletes. Some of this may be explained by "healthy cohort" selection bias, a limitation which affects almost all studies in this genre., (Copyright © 2022 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Athlete ECG interpretation criteria have been developed and refined from research in athlete populations; however, current guidelines are based on available data primarily from Caucasian and Black athletes. This study aimed to assess the impact of ethnicity on ECG interpretation in athletes. A systematic review was conducted of the MEDLINE, EMBASE, Scopus, SPORTDiscus, and Web of Science databases, for papers that assessed athlete screening ECGs and compared findings on the basis of ethnicity. Fifty-one papers which compared ECGs from various ethnicities were included. Most studies assessed Black athletes against Caucasian athletes and found a greater prevalence of T-wave inversion (TWI) (2.6-22.8% vs. 0-5.0%) and anterior TWI (3.7-14.3% vs. 0.6-2.0%). Black athlete subgroups in Africa had TWI (20-40%) and anterior TWI (4.3-18.7%) at a higher prevalence than other Black athletes. Athletes who were defined as mixed-race, Asian, and Pacific Islander are potentially more like Black athletes than Caucasian athletes. Black ethnicity is known to have an impact on the accurate interpretation of athlete ECGs; however, there is nuance related to origin of both parents. Asian and Pacific Islander origin also may impact athlete ECG interpretation. Further research is required to assist in distinguishing abnormal and normal athlete ECGs in different ethnic populations.

Objective: To provide a review and discussion of a range of legal and ethical issues commonly faced by team physicians, with reference to high-profile international integrity crises in sport that have involved doctors. The article also presents some recommendations and guidance for team doctors and sporting organizations., Data Sources: Media reports, legal cases, and journal articles describing recent sporting integrity crises that have involved medical issues and governance reforms which are emerging in response., Main Results: Many of the modern "integrity crises" in sport have a medical aspect (eg, doping cases, catastrophic injuries and illnesses, "Bloodgate" and other "medical cheating," sexual contact between doctors and athletes, harassment/bullying of doctors, concussion mismanagement, and management of the coronavirus pandemic in sport). A key issue is that while doctors bear ultimate responsibility for any perceived medical negligence, they do not always have ultimate power in decision-making. This is common in the traditional governance structure where the coach/manager "outranks" the doctor and can overrule medical decisions. There can be a blurring of the traditional doctor-patient relationship, especially on tour, and conflicts of interests occur when the needs of the employer/sporting organization differ from the player (patient). Further issues can arise in treating other staff members and players' family members., Conclusions: Doctors must be aware of range of important legal and ethical issues that arise in the team setting. Medical integrity crises have inspired governance reforms, such as policy development, appointment of chief medical officers, medical staff reporting to integrity departments, and sanctions of teams that breach medical integrity requirements. Sporting organizations must continue to implement and strengthen frameworks reinforcing doctors' seniority in the medical area., Competing Interests: J. J. Orchard is a cardiac research fellow for Cricket Australia and was supported by a postdoctoral fellowship (award reference No. 104809) from the National Heart Foundation of Australia. D. Maddocks is a coinvestigator in research on long-term follow-up of neuropsychological function in former Australian rules footballers, funded through the Florey Institute of Neuroscience and Mental Health. He has a legal practice in medical law and has provided legal advice to professional sporting clubs and the Australian Football League (AFL). He is a member of the AFL Grievance Tribunal and the AFL Concussion Working Group. J. W. Orchard is the Chief Medical Officer for Cricket Australia. The remaining author reports no conflicts of interest. Many of the modern “integrity crises” in sport have a medical aspect (eg, doping cases, catastrophic injuries and illnesses, “Bloodgate” and other “medical cheating,” sexual contact between doctors and athletes, harassment/bullying of doctors, concussion mismanagement, and management of the coronavirus pandemic in sport). A key issue is that while doctors bear ultimate responsibility for any perceived medical negligence, they do not always have ultimate power in decision-making. This is common in the traditional governance structure where the coach/manager “outranks” the doctor and can overrule medical decisions. There can be a blurring of the traditional doctor–patient relationship, especially on tour, and conflicts of interests occur when the needs of the employer/sporting organization differ from the player (patient). Further issues can arise in treating other staff members and players' family members., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Exercise is a critical protective factor for most chronic medical conditions and is strongly recommended during pregnancy and the postpartum period. The preventive health effect of exercise status (versus non-exercise) is similar to the effect of being a non-smoker (versus smoker). This makes lifelong exercise habits for the population critical for public health. Childbirth is a traumatic process (whether vaginal or by Caesarean section) that temporarily prevents usual exercise postpartum., Objective: The aim of this article is to describe the return to normal exercise in the months postpartum, including the additional challenge of commencing good exercise habits for those new mothers who were not regular exercisers before childbirth., Discussion: Pelvic issues, regardless of mode of delivery, affect return to exercise postpartum. Development of musculoskeletal injuries is also a significant risk, for example De Quervain's tenosynovitis from new activities such as changing, bathing and nursing. Hormonal and postural changes, extra body weight and support networks all affect successful return to exercise.

The coronavirus pandemic has given everyone in society an education on the harms of spread of respiratory illness. Young healthy athletes are far less likely to suffer severe adverse consequences of viral illnesses than the elderly and frail, but they are not completely immune. Chronic fatigue (overtraining) is an uncommon outcome and myocarditis a rare one, but they both warrant due consideration. It is, therefore, a sensible individual strategy to 'stay home when sick' if only for these risks. Traditionally though, athletes have tended to push through (train and play when ill) because of competing concerns, such as key events/matches and 'not wanting to let teammates down'. Data from both low COVID-19 and high COVID-19 countries show that the number of cardiovascular deaths in a society correlates with the number of respiratory deaths at the same time, further linking respiratory viruses to cardiovascular deaths. We are now more aware of public health obligations to prevent the spread of respiratory illnesses, in particular to protect the more vulnerable members the community. This hopefully will correspond with a change in the culture of sport to one where it is considered 'the right thing to do', to 'stay home when sick'., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To compare cardiovascular screening policies of Australian elite sporting organizations., Design: Online survey., Setting: Elite/professional sports in Australia., Participants: Chief medical officers (CMOs) of elite/professional sports in Australia, including rugby union and league, cricket, tennis, Australian football, and cycling., Assessment of Variables: Survey questions about each sport's cardiac screening policy: which screening components were included [eg, history and physical (H&P), resting 12-lead electrocardiogram (ECG)], whether screening was mandatory, whether the policy applied to elite junior and/or adult players, and which criteria were used to interpret ECGs., Main Outcome Measures: Which sports had a formal cardiac screening policy, which athletes the policy applied to, components of screening, ECG interpretation criteria used., Results: Chief medical officers for 22/31 (71%) sports responded, representing >5000 athletes. Of these, 19/22 (86%) perform regular screening (100% H&P; 89% included ECG) with international cyclists also having routine echocardiograms and stress testing. Thirty-three percent of CMOs used the 2017 International Criteria for athlete ECG interpretation. Screening was mandatory with enforcement (26%), mandatory without enforcement (48%), and opt-out (26%). All screened adult elite athletes, and 68% screened junior elite athletes. Forty-two percent indicated athletes were required to pay for screening tests, and 63% required athletes to pay for follow-up tests. Almost all (94%) sports with a sports physician as the CMO screened athletes., Conclusions: Most sports have a screening policy, with reasonable uniformity of components. All included H&P, and almost all included ECG. Only one sport included an echocardiogram and stress test as a standard (international players only). Promoting the latest ECG interpretation criteria may reduce false-positives and cost. Future work should explore cardiac emergency plans, screening infrastructure, cost, and long-term follow-up., Competing Interests: J. J. Orchard is supported by an Australian Government Research Training Program scholarship. C. Semsarian is supported by an NHMRC Australia Practitioner Fellowship (#1154992). J. W. Orchard is the chief medical officer of Cricket Australia. D. Hughes is the chief medical officer at the Australian Institute of Sport. The remaining authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Athletes sometimes experience transient arrhythmias during intense exercise, which may be difficult to capture with traditional Holter monitors. New and highly portable technology, such as smartphone electrocardiogram (ECG) devices, may be useful in documenting and contribute to diagnosis of exercise-induced arrhythmias. There are little data available regarding the new Kardia 6 lead device (6L) and no data regarding its use in athletic populations. In this short communication, we present pilot data from 30 healthy athletes who underwent a 12‑lead ECG and subsequent 6L reading. Our pilot data show relatively high levels of agreement for QTc and PR interval and QRS duration, with the 6L readings slightly but significantly shorter on average., Competing Interests: Declaration of Competing Interest No competing interests to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To determine the rates of muscle strain injury recurrence over time after return to play in Australian football and to quantify risk factors., Methods: We analysed Australian Football League player data from 1992 to 2014 for rates of the four major muscle strain injury types (hamstring, quadriceps, calf and groin) diagnosed by team health professionals. Covariates for analysis were: recent history (≤8 weeks) of each of the four muscle strains; non-recent history (>8 weeks) of each; history of hip, knee anterior cruciate ligament, knee cartilage, ankle sprain, concussion or lumbar injury; age; indigenous race; match level and whether a substitute rule was in place., Results: 3647 (1932 hamstring, 418 quadriceps, 458 calf and 839 groin) muscle strain injuries occurred in 272 759 player matches. For all muscle strains combined, the risk of injury recurrence gradually reduced, with recurrence risks of 9% (hamstring), 5% (quadriceps), 2% (calf) and 6% (groin) in the first match back and remaining elevated for 15 weeks after return to play. The strongest risk factor for each muscle injury type was a recent history of the same injury (hamstring: adjusted OR 13.1, 95% CI 11.5 to 14.9; calf OR 13.3, 95% CI 9.6 to 18.4; quadriceps: OR 25.2, 95% CI 18.8 to 33.8; groin OR 20.6, 95% CI 17.0 to 25.0), followed by non-recent history of the same injury (hamstring: adjusted OR 3.5, 95% CI 3.2 to 3.9; calf OR 4.4, 95% CI 3.6 to 5.4; quadriceps OR 5.2, 95% CI 4.2 to 6.4; groin OR 3.5, 95% CI 3.0 to 4.0). Age was an independent risk factor for calf muscle strains (adjusted OR 1.6, 95% CI 1.3 to 2.0). Recent hamstring injury increased the risk of subsequent quadriceps (adjusted OR 1.8, 95% CI 1.2 to 2.7) and calf strains (OR 1.8, 95% CI 1.2 to 2.6). During the 'substitute rule' era (2011-2014), hamstring (adjusted OR 0.76, 95% CI 0.67 to 0.86), groin (OR 0.78, 95% CI 0.65 to 0.93) and quadriceps (OR 0.70, 95% CI 0.53 to 0.92) strains were less likely than outside of that era but calf (OR 1.6, 95% CI 1.3 to 1.9) strains were more likely than before the substitute rule era., Conclusion: Recent injury is the greatest risk factor for the four major muscle strains, with increased risk persisting for 15 weeks after return to play., Competing Interests: Competing interests: JWO was the AFL injury surveillance coordinator between 1992 and 2014. KR was the GWS Giants AFL team medical officer in the 2018 season., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To report the compliance and results of an electrocardiogram (ECG) cardiac screening program in male and female elite Australian cricketers., Design: cross-sectional study., Methods: Elite cricketers were offered screening in accordance with Cricket Australia policy. Players who consented provided a personal and family history, physical examination and resting 12-lead ECG. An audit (1 February 2019) examined all cardiac screening records for male and female players in all Australian Cricket state squads from 16 years upwards. Data extracted from the Cricket Australia database included the number of players who underwent screening; signed waivers opting out; and had follow-up tests. ECGs were re-reviewed according to the International Criteria., Results: 710 players were included in the cohort (mean age 20.4±4.9 years, 62% male). 692 (97.5%) players underwent recommended cardiac screening or signed a waiver opting out (1.1%). 173 (24.4%) players were screened (or signed a waiver) more than once. Follow-up testing was conducted for 59 (6.9%) cases. No players were excluded from sport due to a cardiac problem and no major cardiac incidents occurred to any player in the audit cohort. Review of 830 ECGs showed benign athlete heart changes, including sinus bradycardia (33.5%), left ventricular hypertrophy (16.3%), and incomplete/partial right bundle branch block (8.4%), were common but abnormal screening ECGs were uncommon (2.0%)., Conclusions: An audit of a cardiac screening program in elite Australian cricketers found excellent compliance. A small proportion required follow-up testing and no player was excluded from sport due to a cardiac problem. ECG analysis suggested cricket is a sport of moderate cardiac demands, with benign athlete heart changes common., (Copyright © 2019 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: Competing interests: JWO is a consultant of Cricket Australia. CS is the recipient of an NHMRC Practitioner Fellowship (1059156). JJO is supported by an Australian Government Research Training Program (RTP) Scholarship.

Screening asymptomatic people with a resting electrocardiogram (ECG) has been theorized to detect latent cardiovascular disease. However, resting ECG screening is not recommended for numerous populations, such as asymptomatic middle-aged (sedentary) people, as it is not sufficiently sensitive to detect coronary artery disease. While the issues raised in this article are largely common to all screening programs, this review focuses on 2 distinct programs: (1) screening elite athletes for conditions associated with sudden cardiac death (SCD); and (2) screening people aged ≥65 years for atrial fibrillation (AF). These 2 settings have recently gained attention for their promise and concerns regarding prevention of SCD and stroke, respectively. If screening is to be done, it must be done well. Organizations conducting screening must consider a range of legal, ethical, and logistical responsibilities that arise from the beginning to the end of the process. This includes consideration of who to screen, timing of screening, whether screening is mandatory, consent issues, and auditing systems to ensure quality control. Good infrastructure for interpretation of ECG results according to expert guidelines and follow-up testing for abnormal screening results, including a pathway to treatment, are essential. Finally, there may be significant implications for those diagnosed with cardiac disease, including insurance, employment, the ability to play sport, and mental health issues. There are several legal risks, and the best protective measures are good communication systems, thorough clinical record-keeping, careful handling of eligibility questions for those diagnosed, and reference to expert guidelines as the standard of care., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: The precise age distribution and calculated stroke risk of screen-detected atrial fibrillation (AF) is not known. Therefore, it is not possible to determine the number needed to screen (NNS) to identify one treatable new AF case (NNS-Rx) (i.e., Class-1 oral anticoagulation [OAC] treatment recommendation) in each age stratum. If the NNS-Rx is known for each age stratum, precise cost-effectiveness and sensitivity simulations can be performed based on the age distribution of the population/region to be screened. Such calculations are required by national authorities and organisations responsible for health system budgets to determine the best age cutoffs for screening programs and decide whether programs of screening should be funded. Therefore, we aimed to determine the exact yield and calculated stroke-risk profile of screen-detected AF and NNS-Rx in 5-year age strata., Methods and Findings: A systematic review of Medline, Pubmed, and Embase was performed (January 2007 to February 2018), and AF-SCREEN international collaboration members were contacted to identify additional studies. Twenty-four eligible studies were identified that performed a single time point screen for AF in a general ambulant population, including people ≥65 years. Authors from eligible studies were invited to collaborate and share patient-level data. Statistical analysis was performed using random effects logistic regression for AF detection rate, and Poisson regression modelling for CHA2DS2-VASc scores. Nineteen studies (14 countries from a mix of low- to middle- and high-income countries) collaborated, with 141,220 participants screened and 1,539 new AF cases. Pooled yield of screening was greater in males across all age strata. The age/sex-adjusted detection rate for screen-detected AF in ≥65-year-olds was 1.44% (95% CI, 1.13%-1.82%) and 0.41% (95% CI, 0.31%-0.53%) for <65-year-olds. New AF detection rate increased progressively with age from 0.34% (<60 years) to 2.73% (≥85 years). Neither the choice of screening methodology or device, the geographical region, nor the screening setting influenced the detection rate of AF. Mean CHA2DS2-VASc scores (n = 1,369) increased with age from 1.1 (<60 years) to 3.9 (≥85 years); 72% of ≥65 years had ≥1 additional stroke risk factor other than age/sex. All new AF ≥75 years and 66% between 65 and 74 years had a Class-1 OAC recommendation. The NNS-Rx is 83 for ≥65 years, 926 for 60-64 years; and 1,089 for <60 years. The main limitation of this study is there are insufficient data on sociodemographic variables of the populations and possible ascertainment biases to explain the variance in the samples., Conclusions: People with screen-detected AF are at elevated calculated stroke risk: above age 65, the majority have a Class-1 OAC recommendation for stroke prevention, and >70% have ≥1 additional stroke risk factor other than age/sex. Our data, based on the largest number of screen-detected AF collected to date, show the precise relationship between yield and estimated stroke risk profile with age, and strong dependence for NNS-RX on the age distribution of the population to be screened: essential information for precise cost-effectiveness calculations., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: GYHL reports consultancy and speaker fees from Bayer, Bayer/Janssen, BMS/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Microlife, Roche, and Daiichi-Sankyo outside the submitted work. No fees were received personally. YC reports grants from Bayer during the conduct of the study. DDM reports grants from National Institutes of Health, grants and other research support from Bristol Myers Squibb, Pfizer, Boehringer Ingelheim, grants, personal fees and other from Bristol Myers Squibb and Pfizer, other research support from Apple, Samsung Electronics, grants from National Science Foundation during the conduct of the study; other from Mobile Sense Technologies and grants from Philips outside the submitted work. MP reports consultancy activity for Boehringer Ingelheim. JJO reports grants from Pfizer, nonfinancial support from Alivecor, outside the submitted work. JW reports grants from Bayer during the conduct of the study. GHM reports grants from Belgian Heart Rhythm Association during the conduct of the study; personal fees from Boehringer Ingelheim, Bayer, Daiichi Sankyo, BMS/Pfizer, St Jude Medical outside the submitted work. RBS reports personal fees from Bristol-Myers Squibb/Pfizer Pharma outside the submitted work. JSH reports grants from Medtronic, grants from Bristol-Meyers-Squibb/Pfizer outside the submitted work. FDRH reports personal fees from BMS/Pfizer, BI, and Bayer outside the submitted work. FRQ reports personal fees from Bayer, personal fees from Servier, grants from Bayer, grants from Boehringer Ingelheim, personal fees from BMS outside the submitted work. BF reports grants, personal fees and nonfinancial support from Bayer, grants, personal fees and nonfinancial support from BMS-Pfizer, personal fees and non-financial support from Daiichi-Sankyo outside the submitted work. PSW reports grants and personal fees from Boehringer Ingelheim, grants from Philips Medical Systems, grants and personal fees from Sanofi-Aventis, grants and personal fees from Bayer Vital, grants from Daiichi Sankyo Europe, personal fees from Bayer HealthCare, personal fees from Astra Zeneca, personal fees and nonfinancial support from DiaSorin, nonfinancial support from I.E.M., grants from Evonik, outside the submitted work. FK reports grants from Boehringer Ingelheim outside the submitted work. RT reports grants and personal fees from Boehringer Ingelheim during the conduct of the study. In addition, RT has a patent as a co-inventor of the MyDiagnostick with royalties paid. The following authors have declared that no competing interests exist: VWL, AD, JH, NL, JO, LAPDT, AKR, RKS, SAC, TFC, JN, EMR, WK, JM, JM, LN, JWM, BPY, TM, JJGD, AS, BS, JSL, and DAF.

Introduction: Screening for atrial fibrillation (AF) in people ≥65 years is now recommended by guidelines and expert consensus. While AF is often asymptomatic, it is the most common heart arrhythmia and is associated with increased risk of stroke. Early identification and treatment with oral anticoagulants can substantially reduce stroke risk. The general practice setting is ideal for opportunistic screening and provides a natural pathway for treatment for those identified.This study aims to investigate the feasibility of implementing screening for AF in rural general practice using novel electronic tools. It will assess whether screening will fit within an existing workflow to quickly and accurately identify AF, and will potentially inform a generalisable, scalable approach., Methods and Analysis: Screening with a smartphone ECG will be conducted by general practitioners and practice nurses in rural general practices in New South Wales, Australia for 3-4 months during 2018-2019. Up to 10 practices will be recruited, and we aim to screen 2000 patients aged ≥65 years. Practices will be given an electronic screening prompt and electronic decision support to guide evidence-based treatment for those with AF. De-identified data will be collected using a clinical audit tool and qualitative interviews will be conducted with selected practice staff. A process evaluation and cost-effectiveness analysis will also be undertaken. Outcomes include implementation success (proportion of eligible patients screened, fidelity to protocol), proportion of people screened identified with new AF and rates of treatment with anticoagulants and antiplatelets at baseline and completion. Results will be compared against an earlier metropolitan study and a 'control' dataset of practices., Ethics and Dissemination: Ethics approval was received from the University of Sydney Human Research Ethics Committee on 27 February 2018 (Project no.: 2017/1017). Results will be disseminated through various forums, including peer-reviewed publication and conference presentations., Trial Registration Number: ACTRN12618000004268; Pre-results., Competing Interests: Competing interests: NL and BF report grants from BMS/Pfizer during the conduct of the study. RW and AP report other financial interests from George Health, outside the submitted work. CF reports personal fees from Pfizer outside the submitted work. LN reports grants from Pfizer/BMS and Boehringer Ingelheim outside the submitted work. BF reports prior fees and advisory board honoraria from Bayer Pharma AG, Boehringer Ingelheim, and BMS/Pfizer but for the past year has removed himself from pharmaceutical advisory boards and receives speaker fees only for accredited educational meetings., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To establish whether the use of ultrasound to direct shock waves to the area of greater calcification in calcaneal enthesopathies was more effective than the common procedure of directing shock waves to the point where the patient has the most tenderness., Design: Two-armed nonblinded randomized control trial with allocation concealment., Setting: The Sports Clinic at Sydney University., Patients: Participants 18 years or older with symptomatic plantar fasciitis (PF) (with heel spur) or calcific Achilles tendinopathy (CAT). Seventy-four of 82 cases completed treatment protocol and 6-month follow-up., Interventions: Patients were randomized to receive either ultrasound-guided (UG) or patient-guided (PG) shock wave at weekly intervals over 3 to 5 weeks., Main Outcome Measures: Reduced pain on visual analog scale (VAS) and improved functional score on Maryland Foot Score (MFS) (for PF) or Victorian Institute of Sport Assessment-Achilles (VISA-A) (for CAT). Follow-up was at 6 weeks and 3 and 6 months., Results: Comparative 6-month improvements in MFS for the 47 PF cases were PG +20/100 and UG +14/100 (P = 0.20). Comparative 6-month improvement in VISA-A score for the 27 CAT cases were PG +35/100 and UG +27/100 (P = 0.37). Comparative (combined PF and CAT) 6-month improvement in VAS pain scores for all 38 PG cases were +38/100 with +37/100 for all 36 UG shock wave cases., Conclusions: Although both treatment groups had good clinical outcomes in this study, results for the 2 study groups were almost identical., Clinical Relevance: This study shows that there is no major advantage in the addition of ultrasound for guiding shock waves when treating calcaneal enthesopathies (PF and CAT).

Objective: To assess workload-related risk factors for injuries to particular tissue types in cricket fast bowlers., Design: 235 fast bowlers who bowled in 14600 player innings over a period of 15 years were followed in a prospective cohort risk factor study to compare overs bowled in each match (including preceding workload patterns) and injury risk in the 3-4 weeks subsequent to the match. Injuries were categorised according to the affected tissue type as either: bone stress, tendon injuries, muscle strain or joint injuries. Workload risk factors were examined using binomial logistic regression multivariate analysis, with a forward stepwise procedure requiring a significance of <0.05., Results: High acute match workload and high previous season workload were risk factors for tendon injuries, but high medium term (3-month workload) was protective. For bone stress injuries, high medium term workload and low career workload were risk factors. For joint injuries, high previous season and career workload were risk factors. There was little relationship between muscle injury and workload although high previous season workload was slightly protective., Conclusions: The level of injury risk for some tissue types varies in response to preceding fast bowling workload, with tendon injuries most affected by workload patterns. Workload planning may need to be individualised, depending on individual susceptibility to various injury types. This study supports the theory that tendons are at lowest risk with consistent workloads and susceptible to injury with sudden upgrades in workload. Gradual upgrades are recommended, particularly at the start of a bowler's career to reduce the risk of bone stress injury., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: This study examined whether high match fast bowling workloads in the short to medium term were associated with increased bowling injury rates., Design: Prospective cohort study., Methods: Over a 15 year period, workload patterns for 235 individual fast bowlers during time periods from 5 to 26 days were examined to consider whether there was an increased injury rate during the month (28 days) subsequent to the workload., Results: Fast bowlers who bowled more than 50 match overs in a 5 day period had a significant increase in injury over the next month compared to bowlers who bowled 50 overs or less RR 1.54 (95% CI 1.04-2.29). For periods ranging from 12 to 26 days, there was no statistically-significant increase in injury over the next month from exceeding thresholds of certain amounts of overs, although bowlers who bowled more than 100 overs in 17 days had a non-significant increase in injury over the next month RR 1.78 (95% CI 0.90-3.50)., Conclusion: There were no statistically-significant increases in subsequent injury risk for high workloads for periods of 12-26 days, although exceeding 100 overs in 17 days (or less) was associated with higher injury rates. Compression of cricket fixtures is likely to have only a minimal contribution to increased fast bowling injury rates being seen in the T20 era (along with sudden workload increases due to transferring between forms of the game, which has been previously established as a major contributor)., (Copyright © 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Background: Injuries are common in all professional football codes (including soccer, rugby league and union, American football, Gaelic football, and Australian football)., Purpose: To report the epidemiology of injuries in the Australian Football League (AFL) from 1992-2012 and to identify changes in injury patterns during that period., Study Design: Descriptive epidemiology study., Methods: The AFL commenced surveying injuries in 1992, with all teams and players included since 1996. An injury was defined as "any physical or medical condition that causes a player to miss a match in the regular season or finals (playoffs)." Administrative records of injury payments (which are compulsory as part of salary cap compliance) to players who do not play matches determined the occurrence of an injury. The seasonal incidence was measured in units of new injuries per club (of 40 players) per season (of 22 matches)., Results: There were 4492 players listed over the 21-year period who suffered 13,606 new injuries/illnesses and 1965 recurrent injuries/illnesses, which caused 51,919 matches to be missed. The lowest seasonal incidence was 30.3 new injuries per club per season recorded in 1993, and the highest was 40.3 recorded in 1998. The injury prevalence (missed matches through injury per club per season) varied from a low of 116.3 in 1994 to a high of 157.1 in 2011. The recurrence rate of injuries was highest at 25% in 1992 and lowest at 9% in 2012 and has steadily fallen across the 21 years (P < .01). The most frequent and prevalent injury was hamstring strain (average of 6 injuries per club per season, resulting in 20 missed matches per club per season; recurrence rate, 26%), although the rate of hamstring injuries has fallen in the past 2 seasons after a change to the structure of the interchange bench (P < .05). The rate of knee posterior cruciate ligament injuries fell in the years after a rule change to prevent knee-to-knee collisions in ruckmen (P < .01)., Conclusion: Annual public reporting (by way of media release and reports available freely online) of injury rates, using units easily understood by laypeople, has been well received. It has also paved the way for rule changes with the primary goal of improving player safety.

Objectives: To study risk factors for hamstring injury in the Australian Football League (AFL), in particular the effect of recent changes in match participation (increased use of the interchange bench) on hamstring injury., Design: Analysis of hamstring match injury statistics extracted from an injury database combined with match participation statistics extracted from a player statistics database., Methods: 56,320 player matches in the AFL over the period 2003-2010 were analyzed, in which 416 hamstring injuries occurred., Results: In a Generalized Estimating Equation (GEE) analysis accounting for clustering of different teams, significant predictors of hamstring injuries were recent hamstring injury (RR 4.16, 95% CI 3.19-5.43), past history of ACL reconstruction (RR 1.69, 95% CI 1.09-2.60), past history of calf injury (RR 1.58, 95% CI 1.37-1.82), opposition team making 60 or more interchanges during the game (RR 1.38, 95% CI 1.12-1.68) and player having made 7 or more interchanges off the field in the last 3 weeks (protective RR 0.74, 95% CI 0.59-0.93)., Conclusions: These findings suggest that regular interchanges protect individual players against hamstring injuries, but increase the risk of hamstring injury for opposition players. These findings can be explained by a model in which both fatigue and average match running speed are risk factors for hamstring injury. A player who returns to the ground after a rest on the interchange bench may himself have some short-term protection against hamstring injury because of the reduced fatigue, but his rested state may contribute to increased average running speed for his direct opponent, increasing the risk of injury for players on the opposition team., (Copyright © 2011 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Objective: To ascertain whether it is possible to assess countries bidding for international sporting events based on public health and sports medicine criteria. In particular, the authors undertook this exercise for countries bidding for the 2018 Fédération Internationale de Football Association (FIFA) Football World Cup (2018 World Cup)., Design: A scorecard framework approach to pose and answer nine relevant questions. Questions were answered using Medline-listed references (where possible) and internet research., Results: England scored the highest overall, largely due to its sports medicine training programme and recognition, and funding of treatment for sports injuries. The Netherlands/Belgium scored highly in the questions relating to public health expenditure, Australia was very strong in sports medicine research, and Japan was the best of the bidding countries in terms of having a lower prevalence of overweight and obese people., Conclusions: It is possible to assess countries bidding for international sporting events based on their performance with respect to sports medicine, physical activity and health promotion criteria. Bodies organising major sporting events such as FIFA and the International Olympic Committee may wish to consider making public health measures part of the bidding criteria for hosting these events.