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The prevention of infections is essential to athletes health and performance. Even mild infections can severely affect athletic performance and the eligibility to train and compete. One of the most effective means of avoiding severe infections are vaccinations. However, like the general population, athletes frequently do not receive the recommended vaccinations. This shortcoming is largely based on fear of adverse vaccine reactions, concerns about the efficacy, misinterpretations, negligence, and poor communication. As sports medicine physicians are involved in the regular screening of adolescent, adult, and senior athletes, they are in a unique position to advise on an individual basis about the risks and benefits of an athlete-specific vaccination schedule. Thus, every preparticipation physical examination should be used to check the vaccination status and, if needed, optimize and update the athletes vaccination profile. In this clinical review, recommendations for standard, travel, and specific-indication vaccinations in athletes will be given and their efficacy, timing, and administration in the sports context will be discussed. The review will be completed by recommended literature and useful apps for the sports medicine physician involved in the preparticipation physical examination of athletes.Key Words: Standard Vaccinations, Travel Vaccinations, Indication Vaccinations, Tetanus, Diphtheria, Pertussis, Measles, Mumps, Rubella, Hepatitis A/B, SARS-CoV-2, Influenza, Tick-Borne-Encephalitis, Sports

Manpreet Randhawa,1 Thomas Meyer,2 Mukta Sachdev,3 Ratan K Chaudhuri1 1Sytheon Ltd, Boonton, NJ, USA; 2Meyer Sun & Skin Care Consulting, LLC, Memphis, TN, USA; 3MSCR Pvt Ltd, Bengaluru, IndiaCorrespondence: Manpreet RandhawaSytheon Ltd, 315 Wootton Street, Boonton, NJ, USATel +1 973 947 1109Email manpreet@sytheonltd.comBackground: Identification of long-lasting natural antioxidants to protect against and repair skin damage induced by exposure to environmental pollution is in high demand.Objective: To investigate a standardized Terminalia chebula (TC) fruit extract for its long-lasting antioxidant and anti-inflammatory properties and its ability to reverse the visible signs of pollution-induced skin damage in an 8-week clinical study.Material and Methods: Chemical and cell-based in vitro studies were performed to characterize long-lasting antioxidant and anti-inflammatory properties; a clinical study with subjects with normal to dry skin living in a high-pollution city for the previous 5 years was conducted to assess if a formulation containing 1% standardized TC fruit extract affected significant improvements in skin’s visible condition and appearance compared with its placebo.Results: The standardized TC fruit extract provided longer-lasting and more efficient neutralization of reactive oxygen species (ROS) than tocopherol; treatment of keratinocytes with the fruit extract prior to being stressed with urban dust safeguarded against increases in intracellular ROS, inhibited release of inflammatory cytokines IL-6 and IL-8 and protected membrane lipids against peroxidation. A clinical study yielded statistically significant improvements in dermatologist scores and subject self-assessments for skin texture, hydration, tone, firmness and radiance as compared to its placebo.Conclusion: These studies validate the use of this standardized TC fruit extract not only as a restorative to diminish visible signs of existing damage but also as a preventative to help defend skin against damages caused by chronic exposure to environmental pollution.Keywords: long-lasting antioxidant, pollution, skin hydration, skin radiance, Terminalia chebula

Introduction: An infection with SARS-CoV-2 is relevant especially in high-performance sport due to possible organ damage and reduced performance which occurs in individual cases. Various recommendations are found in the literature concerning when safe return to sports is possible and what examinations are suitable to support this decision. The dominance of other virus variants than those at the start of the pandemic makes revision of earlier recommendations necessary. Methods and Analysis: The recommended actions are based on the currently-available scientific knowledge of the pathogenicity of the virus and on clinical experiences in general and elite athletes. Twenty-one recommended actions were proposed by the Scientific Council of the DGSP, discussed and agreed on in consensus with experts from German-language sports-medical facilities and evaluated by an independent co-author. The resultant position paper was subsequently released by mutual agreement. Results: The recommendations are oriented to the severity of the course and the symptoms. The required medical diagnostic is deduced therefrom. During persistent symptoms, sports should be paused and training only begun again at low intensity after a three-day symptom-free period. If COVID-19-associated complaints recur, physical exertion should be stopped and a doctor consulted. After moderate and serious course, medical diagnostics are required prior to the start of training. Summary: To prevent a health risk due to sports and thereby resultant organ damage after a SARS-CoV-2 infection, a procedure adapted to the symptoms and course before return to training and finally to competitive sports is recommended.

After prioritization of populations with risk factors for severe courses of Covid-19 (Corona) and occupational groups with a high number of close contacts with patients and other human beings, from now onward (performance-oriented) athletes will be considered for vaccination. Recommendations for vaccinations in this target group can be different from the ones for the general population in some aspects. However, there are only very few scientifically valid findings that may guide vaccinating medical doctors. This article summarizes available evidence and formulates recommendations for vaccinations in (high-performance) athletes.Key Words: Corona-Pandemics, COVID-19, Risk Factors, Priorization, General Population

Johannes Sperzel,1 Ingo Staudacher,2 Olaf Goeing,3 Martin Stockburger,4 Thorsten Meyer,5 Ana Sofia Oliveira Gonçalves,6 Hanna Sydow,6 Tonio Schoenfelder,6 Volker Eric Amelung6 1Department of Cardiology, Hospital Kerckhoff Klinik GmbH, Bad Nauheim, Germany; 2Department of Cardiology, Medical University Hospital Heidelberg, Heidelberg, Germany; 3Department of Cardiology, Sana-Hospital Lichtenberg, Berlin, Germany; 4Medical Department I, Havelland Kliniken GmbH, Nauen, Germany; 5Department of Public Health, Universität Bielefeld, Bielefeld, Germany; 6Institute for Applied Health Services Research, inav – privates Institut für angewandte Versorgungsforschung GmbH, Berlin, GermanyWe read with great interest the article “Wearable cardioverter defibrillators for the prevention of sudden cardiac arrest: a health technology assessment and patient focus group study” by Ettinger et al. The authors conclude that wearable cardioverter defibrillators (WCDs) seem to be fairly safe in the short-to-medium term, but the quality of the available evidence is low. They also state that – according to their study inclusion criteria – they were not able to identify studies to assess the clinical effectiveness of the WCD. Given the importance of WCD for its target population and considering our clinical expertise, we see a particular need to clarify some points of this article.Author's ReplySabine Ettinger,1 Michal Stanak,1 Piotr Szymański,2 Claudia Wild,1 Romana Tandara Haček,3 Darija Erčević,3 Renata Grenković,3 Mirjana Huić31Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria; 2Institute of Cardiology, Warsaw, Poland; 3Department for Development, Research and Health Technology Assessment, Agency for Quality and Accreditation in Health Care and Social Welfare, Zagreb, CroatiaWe read the letter to the editor with regard to our published paper on “Wearable cardioverter defibrillators for the prevention of sudden cardiac arrest: a health technology assessment and patient focus group study” and gladly take the opportunity to appropriately address and clarify the issues that were raised. View the original paper by Ettinger and colleagues.

As one of the most common Titanium alloys, Ti-6Al-4V faces new challenges concerning the ecological footprint. Due to the current processes, a high metal chip pollution leads to a Buy-to-Fly of 25:1. In this study the parameter / microstructure relationship of Ti-64 on the mechanical properties are discussed. Wire Arc Additive Manufacturing (WAAM) was applied to build samples for microstructural analyses and compression tests. A stress relief (SR) and a solution treatment and annealing (STA) was performed. It was found that SR had no influence on multi-layered samples due to intrinsic heat-treatment. A STA heat-treatment led to a reduction in the mechanical strength. Helium as process gas resulted in an increased mechanical strength due to higher heat capacity compared to argon.

Optimizing precision and efficacy of measures on the individual level beyond what is achievable based on group means is the characterizing aim of personalized medicine. Sports medicine is a promising field of application for this concept and some aspects of individualization are already integral part of standard care e.g. relative exercise intensities based on reference values measured in the respective individual. To provide the evidence base for further advancement, the gap between medical practice focused on the individual and experimental research focused on the (true/mean) effect of an independent variable has to be bridged. To this end, methodological specifics of analyses on the individual level need to be taken into account. The resulting toolbox contains two main aspects: intraindividual repetition of measurements including the systematic combination of group-based and individual information and the joint consideration of multiple explanatory variables. These two features individualization and the consideration of multiple, possibly interacting determinants set personalized sports medicine apart from standard care. While these fundamental considerations are deducibly based on statistical principles, their full implementation is beset with many practical difficulties. Therefore, from the applied perspective, the ways of implementing personalized sports medicine will differ considerably depending on the specific task and the framework conditions in the field of application (e.g. preventive or elite sports). KEY WORDS: Individualization, Precision Medicine, Study Design, Variance Components, Variability

Intraoperative Optical Imaging (IOI) is a neuro-imaging technique that allows the visualization of changes in optical properties of the brain cortex. Recent developments enhanced the method regarding the robustness under intraoperative conditions. However, the necessity of additional hardware still limits the use in the operating room (OR). Since modern surgical microscopes are potentially equipped with all required hardware for imaging, we investigated the possible use of such standard RGB camera for IOI. Measurements were performed on eight patients. Changes in optical properties of the cortical surface were acquired with a monochrome CCD camera (AxioCam MRm) and simultaneously with a standard RGB camera (Trio 610). Maps of cortical activity were calculated from the image data and the quality of these maps was assessed with a spatial signal-to-noise ratio. Activity maps calculated from AxioCam MRm data showed highest SNR in six out of eight patients. In two patients the activity map calculated from Trio 610 red channel performed best overall. The Trio 610 maps calculated from red channel data performed best in three out of eight cases like the activity maps calculated from green channel data, whereas the activity map calculated from blue channel data performed best in only two cases. If the color channel with the highest SNR is chosen in each patient for comparison to AxioCam MRm, the median of the SNR (SNRAxioCam/SNRBestColorChannel) is 84 % (Quartile 1 (Q1): 78 %, Quartile 3 (Q3): 99%). Results reveal that the integration of the Intraoperative Optical Imaging method into the OR and surgical workflow can be further improved by using RGB camera equipment. A robust identification of somato-sensory areas seems possible. Due to the gain of information from different wavelength bands the need for intelligent evaluation algorithms is increased and should therefore be topic of future research.

Serge Brand,1,2 Roumen Kirov,3 Nadeem Kalak,1 Markus Gerber,2 Uwe Pühse,2 Sakari Lemola,4 Christoph U Correll,5 Samuele Cortese,6–8 Till Meyer,1 Edith Holsboer-Trachsler1 1Psychiatric Clinics of the University of Basel, Center for Affective, Stress and Sleep Disorders (ZASS), Basel, Switzerland; 2Department of Sport, Exercise and Health, Division of Sport Science, University of Basel, Basel, Switzerland; 3Institute of Neurobiology, Bulgarian Academy of Sciences, Sofia, Bulgaria; 4Faculty of Psychology, University of Basel, Basel, Switzerland; 5Division of Psychiatric Research, North Shore – Long Island Jewish Health System, Zucker Hillside Hospital, NY, USA; 6School of Medicine, University of Nottingham UK; 7Centre for ADHD and Neuro-developmental Disorders Across Lifespan, Institute of Mental Health, University of Nottingham UK; 8New York University Child Study Centre, New York, NY, USA Background: Perfectionism is understood as a set of personality traits such as unrealistically high and rigid standards for performance, fear of failure, and excessive self-criticism. Previous studies showed a direct association between increased perfectionism and poor sleep, though without taking into account possible mediating factors. Here, we tested the hypothesis that perfectionism was directly associated with poor sleep, and that this association collapsed, if mediating factors such as stress and poor emotion regulation were taken into account. Methods: Three hundred and forty six young adult students (M=23.87 years) completed questionnaires relating to perfectionism traits, sleep, and psychological functioning such as stress perception, coping with stress, emotion regulation, and mental toughness. Results: Perfectionism was directly associated with poor sleep and poor psychological functioning. When stress, poor coping, and poor emotion regulation were entered in the equation, perfectionism traits no longer contributed substantively to the explanation of poor sleep. Conclusion: Though perfectionism traits seem associated with poor sleep, the direct role of such traits seemed small, when mediating factors such as stress perception and emotion regulation were taken into account. Keywords: perfectionism, perceived stress, emotion regulation, young adults, sleep quality

Upper respiratory tract infections (URTIs) represent ahazard with highrelevance for elite athletes of all disciplines. They can lead to a reduction in performance and/or the necessity of a training/competition break. On average, each athlete experiences 3 URTIs per year with symptoms lasting for a mean of five days. Therefore, the intention of this review is to summarize the risk factors for URTIs, deduce preventive measures and give recommendations for return to sports to reduce re-infections and to avoid serious complications.The influence of training and competitive load on the risk of illness has been discussed controversially. There are indications that the frequency of infections seems to be increased shortly after a competition (open window-theory). URTIs occur more frequently in the winter months like in the general population. International air travelling was identified as the single biggest circumstantial risk factor for infections.An instrumental task of sports medicine is education of athletes about measures for infection prophylaxis and supervision of their implementation. A significant infection reduction is reached through compliance to general hygiene recommendations and a minimization of the contact with people outside the team in the hours after competition. Moreover, URTIs are prevented by an optimized planning of exercise load and travel as well as through vaccinations.Return to sports should not be allowed before a medical examination indicates the absence of generalized symptoms. This should typically include a determination of laboratory parameters and other organ-specific parameters (e.g. resting ECG). KEY WORDS: URTI, Physical Activity, Influential Factors, Illness Precautions, Infection Management

Johannes Sperzel,1 Ingo Staudacher,2 Olaf Goeing,3 Martin Stockburger,4 Thorsten Meyer,5 Ana Sofia Oliveira Gonçalves,6 Hanna Sydow,6 Tonio Schoenfelder,6 Volker Amelung6 1Department of Cardiology, Hospital Kerckhoff Klinik GmbH, Bad Nauheim, Germany; 2Department of Cardiology, Medical University Hospital Heidelberg, Heidelberg, Germany; 3Department of Cardiology, Sana-Hospital Lichtenberg, Berlin, Germany; 4Medical Department I, Havelland Kliniken GmbH, Nauen, Germany; 5Department of Public Health, Universität Bielefeld, Bielefeld, Germany; 6inav – privates Institut für angewandte Versorgungsforschung GmbH, Berlin, GermanySince the authors’ reply to our critical appraisal did not properly address the points we raised, we still see need for further clarification. The wearable cardioverter defibrillator (WCD) is not an adequate substitute for an implantable cardioverter defibrillator (ICD). The authors state that both can be compared immediately post-myocardial infarction (MI). According to the current guidelines, primary prevention of sudden cardiac death with the ICD within 40 days after MI is generally not indicated.1 Therefore, we disagree with the authors’ proposal of conducting such a trial. In this context, the authors mentioned the VEST trial, which compares a WCD population and one receiving medical treatment. There is explicitly no comparison to an ICD population.View the original paper by Sperzel and colleagues.

This review articleaims to summarise general aspects regarding sleep and sports. It is generally assumed that sleep is a basic requirement for physiological and psychological recovery, whereas it appears that sleep of elite athletes is highly influenced by training stimuli and external as well as internal factors. Studies about sleep deprivationand restricted sleep indicate the importance forcognitive functions as well as mood and behavioural aspects. Effects on performance parameters are not reported asconsistently. In contrast to sleep restriction, extending sleep for several nights might lead to improvements in performance, mood, and alertness. In terms ofintercontinental travel, jet-lag might be an issue for elite athletes. Although afewstudies indicate that effects on athletic performance might not be present, sleep, mood and some physiological measures are affected due to shift in time zones.Simple strategiescan be applied to enhance adaptation to the destination and diminish jet-lag symptoms.KEY WORDS: Recovery, Sleep Loss, Jet-Lag, Performance

In the context of her check up for sports eligibility, an 11-year-old professional female gymnast reported a retrosternal pain during high intensity parts of the fitness training. The physical examination revealed a 2/6 systolic murmur in the second left intercostal space without radiation and a fixed splitting of the second heart sound. Resting ECG showed right heart overload with right axis deviation, incomplete right bundle branch block as well as terminal negative T-waves in V1-V3. Transthoracic echocardiography revealed a relevant atrial septal defect (ASD) of secundum type with a left to right shunt and consecutive right heart overload. This finding could be confirmed both angiographically and by means of transoesophageal echocardiography. Due to the size of the defect and the lack of sufficient caudal septal rim, transcatheter closure with implantation of an Amplatzer Septal Occluder could not be successfully performed. Thus, the indication was given for a surgical repair of the ASD which was performed with direct suture closure (primary closure). The postoperative course was uneventful. No signs of chest pain were noticedafterresumption of her usual training in the same intensity. Isolated chest pain during exercise is an unusual leading symptom in ASD patients and should always be clarified with cardiac imaging. Based on this case report, the important role of the resting ECG and echocardiography in the setting of preparticipation screening can be emphasized.KEY WORDS:Thoracic Pain, ASD, Echocardiography, Sports Eligibility