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Patient-centered care is widely advocated in rheumatology. This involves collaboration among patients, caregivers, and health professionals and is particularly important in chronic rheumatic conditions because the disease and treatment can impair patients’ health and well-being. Qualitative research can systematically generate insights about people’s experiences, beliefs, and attitudes, which patients may not always express in clinical settings. These insights can address complex and challenging areas in rheumatology, such as treatment adherence and transition to adult healthcare services. Despite this, qualitative research comprises 1% of studies published in top-tier rheumatology journals. A better understanding about the effect and role, methods, and rigor of qualitative research is needed. This overview highlights the recent contributions of qualitative research in rheumatology, summarizes the common approaches and methods used, and outlines the key principles to guide appraisal of qualitative studies.

Study design Multiround wiki-based Delphi expert panel survey. Objective To provide proof of concept for an alternative method for creating sets of nationally-agreed point-of-care clinical indicators, and obtain consensus among end-user groups on "appropriate care" for the assessment, diagnosis, acute, and ongoing care of people with low back pain (LBP). Summary of background data The provision of inappropriate and low value care for LBP is a significant healthcare and societal burden. Vague clinical practice guideline (CPG) recommendations can be difficult to apply and measure in real world clinical practice, and a likely barrier to "appropriate care." Methods Draft "appropriate care" clinical indicators for LBP were derived from CPG recommendations published between 2011 and 2017. Included CPGs were independently appraised by two reviewers using the Appraisal of Guidelines for Research and Evaluation instrument. Headed by a Clinical Champion, a 20-member Expert Panel reviewed and commented on the draft indicators over a three-round modified e-Delphi process using a collaborative online wiki. At the conclusion of each review round, the research team and the Clinical Champion synthesized and responded to experts' comments and incorporated feedback into the next iteration of the draft indicators. Results From seven CPGs and six qualitative meta-syntheses, 299 recommendations and themes were used to draft 42 "appropriateness" indicators. In total, 17 experts reviewed these indicators over 18 months. A final set of 27 indicators comprising screening and diagnostic processes (n = 8), assessment (n = 3), acute (n = 5), and ongoing care (n = 9), and two which crossed the acute-ongoing care continuum. Most indicators were geared toward recommended care (n = 21, 78%), with the remainder focused on care to be avoided. Conclusion These 27 LBP clinical indicators can be used by healthcare consumers, clinicians, researchers, policy makers/funders, and insurers to guide and monitor the provision of "appropriate care" for LBP.Level of Evidence: 4.

Objectives To examine the epidemiology of bone stress injuries in an elite sports institute. Design Retrospective cohort study at the Australian Institute of Sport. Methods A retrospective analysis of the clinical records contained within the Australian Institute of Sport Athlete Management System electronic database was performed. Records with Orchard Sports Injury Classification System codes relating to bone stress injuries and stress fractures were reviewed and descriptive statistics relating to sport, site of injury, athlete age, sex and activity were analysed. Results In the three-year period January 2014–2017, 11,942 injuries were recorded across 48 sports. 181 bone stress injuries (0.15% of all injuries) were recorded across 16 sports. BSIs in the foot and lumbar spine were the most common accounting for 30% and 23% of all the reported BSIs respectively. Gymnasts had a high frequency of lumbar spine stress injuries (n = 24, 51%) and rowers had a high frequency of rib stress injuries (n = 22, 88%). The most common location for stress injuries, equally distributed across a variety of sports, were in the foot (n = 54, 30%). Female athletes recorded more BSIs than males. Conclusion Across a three-year period, 0.15% of injuries were related to bone stress injuries. Almost double the cases were recorded in female athletes. Sport specific injury sites were observed in the dataset.

Background Exercise was once viewed as having a deleterious effect on joint pain and function in those with rheumatic diseases. Positive evidence, both related to exercises at specific joints and for exercise in the management of comorbidities and for general illness prevention, is now well established. Objective The aim of this article is to provide an update on the role of therapeutic exercise at individual joints and the utility of general exercise programs in the management of comorbidities and prevention of chronic disease in those with rheumatic disease. Discussion Major international rheumatology bodies now recommend multiple forms of exercise as part of the non-pharmacological management of both osteoarthritis and the more classically inflammatory rheumatic disorders.

The COVID-19 pandemic has restricted the physical activity of the population, but maintaining exercise could reduce the risk of contracting the infection itself and mitigate the effects of quarantine.

Background Most general practices will have patients who have more than a passing interest in fitness and exercise. These range from the elite athlete to the recreational enthusiast. These patients are highly motivated, but treating them can be challenging. Objective The aims of this article are to increase awareness of the management of a number of overuse injuries frequently seen in athletes, to assist in understanding the mindset of the athlete in relation to his or her injuries and to indicate the importance of a confident approach to these problems and a multidisciplinary management plan in facilitating a successful outcome. Discussion Athletes generally have dynamic personalities and high standards for themselves and others. Complete rest can be anathema to them. Fortunately, in cases of tendinopathy, a structured exercise program is an important component of management. A proactive approach, often with the assistance of a physiotherapist, is likely to improve outcomes.

ObjectiveTo provide deeper insight into why patients are admitted to hospital with gout and discover potential targets for better disease control.DesignData from semi-structured interviews were analysed using a thematic analysis approach.Participants and settingEleven inpatients from a tertiary institution in the Australian Capital Territory of Australia and their respective general practitioners (GPs) were invited to participate in the semi-structured interviews.ResultsDespite significant pain and disability that accompanied acute flares, patients continue to experience shame in seeking treatment and regarded gout as being not particularly important. Other barriers included patients’ poor continuity of care with and lack of confidence in GPs, suboptimal management in outpatient and inpatient settings, poor understanding of disease and treatment, and misconceptions held by both patients and physicians leading to uncontrolled disease activity.ConclusionsBarriers to optimal gout management including patient and health practitioner factors have produced a complex effect which has led to a cycle of treatment avoidance behaviours and recurrent hospitalisations for severe acute gout flares. These barriers could be addressed using a multipronged approach guided by the chronic care model which has been applied in a variety of other chronic diseases with improved patient and professional-level outcomes. Managing gout according to best practice for chronic disease is more likely to prevent recurrent hospitalisations and improve health outcomes in patients with gout.

Background Acute lateral ankle ligament sprains (LALS) are a common injury seen by many different clinicians. Knowledge translation advocates that clinicians use Clinical Practice Guidelines (CPGs) to aid clinical decision making and apply evidence-based treatment. The quality and consistency of recommendations from these CPGs are currently unknown. The aims of this systematic review are to find and critically appraise CPGs for the acute treatment of LALS in adults. Methods Several medical databases were searched. Two authors independently applied inclusion and exclusion criteria. The content of each CPG was critically appraised independently, by three authors, using the Appraisal of Guidelines for REsearch and Evaluation (AGREE II) instrument online version called My AGREE PLUS. Data related to recommendations for the treatment of acute LALS were abstracted independently by two reviewers. Results This study found CPGs for physicians and physical therapists (Netherlands), physical therapists, athletic trainers, physicians, and nurses (USA) and nurses (Canada and Australia). Seven CPGs underwent a full AGREE II critical appraisal. None of the CPGs scored highly in all domains. The lowest domain score was for domain 5, applicability (discussion of facilitators and barriers to application, provides advice for practical use, consideration of resource implications, and monitoring/auditing criteria) achieving an exceptionally low joint total score of 9% for all CPGs. The five most recent CPGs scored a zero for applicability. Other areas of weakness were in rigour of development and editorial independence. Conclusions The overall quality of the existing LALS CPGs is poor and majority are out of date. The interpretation of the evidence between the CPG development groups is clearly not consistent. Lack of consistent methodology of CPGs is a barrier to implementation. Systematic review Systematic review registered with PROSPERO (CRD42015025478). Electronic supplementary material The online version of this article (10.1186/s12891-019-2750-6) contains supplementary material, which is available to authorized users.

SummaryBackground Muscle wasting or sarcopenia arising from chronic inflammation is found in 60% of patients with Crohn's disease. Transcriptional protein NF-κB reduces muscle formation through MyoD transcription and increases muscle breakdown by proteolysis. Aim As TNF is a potent activator of NF-κB, and anti-TNF agent infliximab (IFX) prevents NF-κB activation, to determine whether or not Crohn's patients treated with IFX gain muscle volume and strength. Methods We performed a prospective, repeated-measures cohort study in adult Crohn's disease patients with an acute disease flare. Patients were instructed not to vary diet or activity. Concomitant medications were kept stable. At week 1 (pre-treatment), week 16 (post-IFX induction) and week 25 (post-first IFX maintenance dose), we assessed (i) MRI volume of quadriceps femoris at anatomical mid-thigh; (ii) maximal concentric quadriceps contractions strength at three specific speeds of contraction; (iii) physical activity by validated instrument (IPAQ); (iv) Three-day food record of intake and composition (food-weighing method); (v) Serum levels of IL6. Results Nineteen patients (58% female; mean age 33.2 ± 10.7 years) were recruited. IFX increased muscle volume in both legs from baseline (right, 1505 cm3) to week 25 (right, 1569 cm3; P = 0.010). IFX also increased muscle strength in both legs from baseline (right 30°/s, 184.8 Nm) to week 25 (right 30°/s, 213.6 Nm; P = 0.002). Muscle volume gain correlated with male gender (P = 0.003). Significant gains in muscle volume and strength were unrelated to prednisolone use. Serum IL6 levels decreased by week 25 (P = 0.037). Conclusion The anti-TNF agent infliximab reverses inflammatory sarcopenia in patients with Crohn's disease.

Most data assessing the accuracy of electrocardiographic (ECG) screening in identifying cardiac pathology in athletes are derived from relatively unselected cohorts of subjects involved in competitive sports. We hypothesized that the prevalence of ECG abnormalities may be greater in athletes performing the greatest combination of exercise intensity and duration, namely professional endurance athletes. A total of 1,007 male and 254 female elite adult athletes underwent cardiovascular screening inclusive of an electrocardiogram, interpreted using the 2010 European Society of Cardiology guidelines. Training-related ECG changes (group 1) were more common in endurance athletes (EAs) than nonendurance athletes (NEAs; 90.8% vs 86.0%, p = 0.04), as were multiple (≥2) training-related changes (78.9% vs 53.5%, p

Alexander Matthews1, David Pyne1,2, Philo Saunders2, Kieran Fallon1,2, Peter Fricker1,21Medical School, Australian National University, Canberra, ACT, Australia; 2Australian Institute of Sport, Canberra, ACT, AustraliaPurpose: To develop and evaluate a questionnaire that quantifies the self-reported frequency, duration and severity of illness symptoms in highly-trained athletes. We examined whether runners had more symptoms than recreationally-active individuals, and whether runners more prone to illness were undertaking more strenuous training programs.Methods: A daily illness questionnaire was administered for three months during the summer to quantify the type, frequency, duration, and severity of illness symptoms as well as the functional impact on the ability to undertake exercise performance. A total of 35 participants (12 highly-trained runners living in a community setting and 23 recreationally-active medical students) completed the questionnaire.Results: Runners had a similar frequency of illness (2.1 ± 1.2 vs. 1.8 ± 2.3 episodes, mean ± SD, P = 0.58), but substantially longer duration (5.5 ± 9.9 vs 2.8 ± 3.1 days, P < 0.01) and illness load (7.7 ± 16.2 vs 4.5 ± 4.8 units, P = 0.001) than age- and sex-matched recreationally-active individuals respectively. Runners more prone to illness symptoms had marginally higher training loads.Conclusions: The athlete illness questionnaire is useful for quantifying the pattern of self-reported symptoms of illness in field settings. Highly-trained runners experience longer episodes of illness with a greater impact on daily activity than recreationally-active individuals.Keywords: athlete, self-reported illness, questionnaire, exercise performance

OBJECTIVE To characterize differences in the perception and understanding of the placebo effect between sports physicians, coaches, athletes, and sports science personnel. DESIGN A short 11-item questionnaire was administered addressing demographic details, understanding of the placebo effect, and willingness to use the effect in an elite sport setting. SETTING All participants were involved in national level sporting programs. PARTICIPANTS A total of 187 individuals (17 sports physicians, 44 sports scientists, 30 national-level coaches, and 96 national-level athletes) completed the questionnaire. All participants were contacted and invited to participate voluntarily. INTERVENTIONS/ASSESSMENT OF RISK FACTORS: Not applicable. MAIN OUTCOME MEASUREMENTS Self-reported responses on understanding and use of placebo effect in sport. RESULTS A total of 94% of physicians and 98% of scientists, but only 44% of athletes, indicated a good understanding of the placebo effect. A majority of scientists (63%) and physicians (59%) administered placebo at least once a year. Most of scientists (95%) and a majority of physicians (71%) either mildly or strongly encouraged use of the placebo in their clinical practice. About 60% of athletes indicated they would not care if they were unknowingly administered a placebo: however, 30% of them would not appreciate being misled. CONCLUSIONS There is a substantial difference in the level of understanding of the placebo effect between physicians and athletes in elite sport. Although athletes are willing to use the placebo effect, physicians need to be mindful of the manner of its implementation.

Objective: To determine, in a population of elite athletes at their initial presentation with tiredness or fatigue, whether a set of haematological and biochemical investigations enhances the diagnostic process over and above the information gained from clinical history and examination. Methods: A sequential series of 50 elite athletes were studied at the initial consultation for a primary complaint of fatigue, tiredness, or a synonym thereof. A standardised clinical history, physical examination, and series of haematological and biochemical test were performed. The effects of the results of the blood tests on the diagnosis made after the clinical history and examination were examined. Results: In only one case did the test results lead to an alteration in diagnosis. Physical examination did not provide any findings that would not have been suspected from the history, except for a number of incidental findings not relevant to the presenting symptom. Discussion: In cases of short term fatigue in elite athletes, a thorough clinical history is mandatory. Physical examination is unlikely to reveal any findings not suspected from the history. Routine ordering of a panel of blood tests at the initial consultation should be discouraged. Unless specifically indicated by the history and examination, investigations are not required at the initial consultation.

Objectives: To investigate issues of curriculum in the context of a postgraduate sports medicine training programme, specifically in the field of clinical biochemistry and haematology. Methods: Following the Delphi methodology, a series of sequential questionnaires was administered to curriculum developers, clinical teachers, examiners, and registrars. Results: Agreement on a core syllabus for this subject with an indication of the core aims and objectives of teaching and learning in this field and the associated required skills and competencies. An indication of current and ideal teaching and learning methods and reasons for these preferences. A consensus of key features of a teaching module for this field and of appropriate methods of examination. Conclusions: The data derived from this study, as well as the experience of engaging in it, will better inform curriculum developers, teachers, and students of one another’s perceptions as to what is important in and appropriate to teaching and learning in this field of sports medicine. Engagement in the exercise and broader consideration of the outcomes by those who develop the curriculum, teach, and formulate the examination process will facilitate attainment of the ideal of well aligned teaching, learning, and examination in this specific field.

To determine the clinical and performance related utility of hematological and iron-related screening in elite athletes.Prospective cohort study.The Department of Sports Medicine at the Australian Institute of Sport.Male and female elite athletes undergoing routine medical screening over a period of 2 to 3 years.Blood testing for hematological and iron-related biochemical variables.White blood cell count, red blood cell count, hemoglobin, hematocrit, mean cell volume, mean cell hemoglobin concentration, platelet count, percent hypochromic red cells, serum iron, ferritin, transferrin, and percent transferrin saturation.Eight female athletes (4.6%) had clinically relevant abnormal results, 6 with an obvious explanation on clinical history and examination and 1 who was diagnosed with hemochromatosis following genetic testing. Eighty-nine (51.1%) female athletes had abnormal results that were not associated with obvious clinical signs or symptoms. Twenty-seven female athletes had a serum ferritin less than 30 ng/mL and were placed on iron supplementation. In male athletes, 5 cases had screening abnormalities that were associated with illness or other factors identified during the clinical consultations. Nonclinically significant abnormalities in males were generally minor reductions in hemoglobin and/or hematocrit or minor alterations in red cell parameters. Five male athletes had a serum ferritin less than 30 ng/mL and were placed on iron supplementation.Screening for hematological and iron-related abnormalities in male athletes has a very low yield. Due to the critical nature of the effects of anemia and low serum ferritin on some aspects of performance, it is reasonable to perform a full blood count and a serum ferritin on male athletes entering an elite training program. Further testing should be performed on clinical grounds. In females, the yield is greater. Again, it is reasonable to perform a full blood count and a serum ferritin on female athletes entering an elite training program. In view of their greater risk of iron depletion and to assess the effect of increased training inherent in elite programs, this could be repeated at 6-month intervals, or an isolated measurement of serum ferritin could be performed. Further testing should be performed on clinical grounds.

It is the position of Sports Dietitians Australia (SDA) that adolescent athletes have unique nutritional requirements as a consequence of undertaking daily training and competition in addition to the demands of growth and development. As such, SDA established an expert multidisciplinary panel to undertake an independent review of the relevant scientific evidence and consulted with its professional members to develop sports nutrition recommendations for active and competitive adolescent athletes. The position of SDA is that dietary education and recommendations for these adolescent athletes should reinforce eating for long term health. More specifically, the adolescent athlete should be encouraged to moderate eating patterns to reflect daily exercise demands and provide a regular spread of high quality carbohydrate and protein sources over the day, especially in the period immediately after training. SDA recommends that consideration also be given to the dietary calcium, Vitamin D and iron intake of adolescent athletes due to the elevated risk of deficiency of these nutrients. To maintain optimal hydration, adolescent athletes should have access to fluids that are clean, cool and supplied in sufficient quantities before, during and after participation in sport. Finally, it is the position of SDA that nutrient needs should be met by core foods rather than supplements, as the recommendation of dietary supplements to developing athletes over-emphasizes their ability to manipulate performance in comparison with other training and dietary strategies.

To document injuries during a 6-day track race (in which direction was reversed every 2 hours) and compare these injuries with those incurred during other ultra-marathon track and road races, and to investigate a characteristic ultra-marathon injury, tendonitis of the ankle dorsiflexors.A prospective, cohort study of competitors during a 6-day race.400-m grass track in Colac, Victoria.All 17 competitors (16 men and 1 woman).Total numbers and percentages of specific musculoskeletal injuries.A total of 36 injuries were recorded in 11 competitors. The ankle (36%) and the knee (22%) were the regions most frequently injured. The four most common diagnoses were: Achilles tendonitis (19%); extensor digitorum longus tendonitis (14%); retropatellar pain syndrome (14%); and anterior compartment pain (11%).Achilles tendonitis, patellofemoral pain, and tendonitis of the foot dorsiflexors are the three most common injuries in ultra-marathons of 6 days or more. Ankle injuries predominate in track races, whereas knee injuries are more common in road races. Road races are associated with higher frequency of injury to the leg on the downside of the camber. Track races have an even distribution of injury. Confirmation is presented that the characteristic ultra-marathon injury is tendonitis of the foot dorsiflexors.

OBJECTIVE: To investigate haematological variations and iron related changes in the serum of participants in a 1600 kilometre ultramarathon run. PARTICIPANTS: Seven male and two female participants in a 1600 km foot race. METHODS: Blood samples were obtained from the participants before, after four and 11 days of running, and at the end of the event. Samples were analysed by standard methods for haemoglobin, packed cell volume, total red cell count, mean red cell volume, mean red cell haemoglobin, total white cell count and differential, platelets, reticulocytes, iron, ferritin, total iron binding capacity, percentage transferrin saturation, haptoglobin, and bilirubin and corrected for changes in plasma volume. RESULTS: The following variables decreased during the event (p < 0.05): haemoglobin, packed cell volume, mean red cell volume, percentage lymphocytes, percentage monocytes, serum iron, total iron binding capacity, and percentage transferrin saturation. Increases (p < 0.05) were found in plasma volume, total red cell count (day 4 only), total white cell count, percentage and absolute numbers of neutrophils and reticulocytes, absolute numbers of lymphocytes and monocytes (day 4 only), absolute numbers of eosinophils (day 11 and race end), absolute numbers of basophils (race end only), platelets, ferritin, haptoglobin, and bilirubin (day 4 only). CONCLUSION: Ultramarathon running is associated with a wide range of changes in haematological parameters, many of which are related to the normal acute phase response to injury. These should not be confused with indicators of disease.

The fluid and food intakes of 7 male participants in a 100-km ultramarathon were recorded. The mean exercise time was 10 hr 29 min. Nutrient analysis revealed a mean inlrarace energy intake of 4.233 kJ. with 88.6% derived from carbohydrate. 6.7% from fat, and 4.7% from protein. Fluid intake varied widely. 3.3–1 1.1 L, with a mean of 5.7 L. The mean decrease in plasma volume at 100 km was 7.3%, accompanied by an estimated mean sweat rale of 0.86 L ⋅ hr−1. Blood glucose concentrations remained normal during the event, and free fatty acids and glycerol were elevated both during and at the conclusion of the event. No significant correlations were found between absolute amounts and rates of ingestion of carbohydrate and/or fluid and race performance.

Purpose: Iron deficiency is prevalent in distance runners and may impair endurance performance. The current practice of oral supplementation is slow and often not well tolerated. The aim of this study was to assess the efficacy of intravenous (IV) iron supplementation (ferric carboxymaltose) compared with oral supplementation (ferrous sulfate) on iron status, hemoglobin mass (Hbmass), and physiological indices of running performance in distance runners. Methods: Twenty-seven highly trained distance runners with low (LOW) (ferritin < 35 [mu]g[middle dot]L-1 and transferrin saturation < 20%, or ferritin < 15 [mu]g[middle dot]L-1) or suboptimal (SUB) iron status (ferritin < 65 [mu]g[middle dot]L-1) were supplemented with either IV iron (Ferinject(R)) or oral (ORAL) supplements (Ferrogradumet) for 6 wk. Iron status and Hbmass were assessed before supplementation and at 1, 2, 4, 6, and 8 wk in the four groups (IV LOW, IV SUB, ORAL LOW, and ORAL SUB). In addition, athletes completed a treadmill running test for running economy, lactate threshold, and V[spacing dot above]O2max before and after supplementation. Results: Both forms of supplementation substantially increased ferritin levels in all four groups. IV supplementation resulted in higher ferritin in both IV groups compared with both ORAL groups from week 1 onward. Hemoglobin concentration did not change substantially in any group. Hbmass increased in IV LOW (mean = +4.9%, 90% confidence interval [CI] = 1.1%-8.9%) and was accompanied by an increase in V[spacing dot above]O2max (mean = +3.3%, 90% CI = 0.4%-6.3%) and run time to exhaustion (mean = +9.3%, 90% CI = 0.9%-18.3%. Conclusions: IV supplementation can effectively increase iron stores in iron-deficient runners within 6 wk and, if Hbmass is compromised, may enhance endurance capacity by facilitating erythropoiesis. Hbmass appears a more sensitive tool for measuring changes in whole body hemoglobin than hemoglobin concentration and may be useful in the diagnosis and follow-up for iron deficiency.

OBJECTIVE: To document the injuries sustained by participants in a 1005 km ultramarathon. METHODS: Clinical notes were reviewed on entrants in the 1005 km Sydney to Melbourne ultramarathon. An injury was recorded following self referral by a participant or if the history obtained from the runner or his support crew indicated the likelihood of a significant injury which could have an impact upon performance. RESULTS: 64 injuries were found in 32 runners. The knee (31.3%) and ankle (28.1%) regions were most commonly injured. The most common single diagnosis was retropatellar pain syndrome, and Achilles tendinitis and medial tibial stress syndrome were the next most common injuries. Peritendinitis/tendinitis of the tendons passing under the extensor retinaculum at the ankle, an injury infrequently reported in other sports, was common (19% of all injuries). CONCLUSIONS: The injuries were typically associated with running but 12 (19% of the total) involved the tendons of the muscles of the anterior compartment of the lower leg, and in almost every case the major site of inflammation was at the extensor retinaculum at the anterior aspect of the ankle. This injury appears to be relatively specific to the ultramarathon-"ultramarathoner's ankle".

Haemoglobin mass in a female endurance athlete was measured via carbon monoxide rebreathing upon diagnosis of iron-deficiency anemia (haemoglobin concentration = 8.8 g/dL, ferritin = 9.9 ng/mL) and regularly during treatment thereafter. Haemoglobin mass increased by 49% in the 2 wk following an intramuscular iron injection and continued to increase with oral iron supplementation for 15 wk. The presented case illustrates that haemoglobin mass is readily responsive to iron supplementation in a severely iron-defcient anemic athlete and that changes can be tracked efficiently using the CO-rebreathing method.

Summary Objectives The aim of the study was to determine if Lyprinol ® is effective in reducing pain, indicators of inflammation and muscle damage, and in turn improving performance in well trained athletes suffering from delayed onset muscle soreness (DOMS). Design A double blind randomised placebo controlled trial. Setting Twenty well trained male volunteers, matched by VO 2max were randomly assigned to consume 200mg of Lyprinol ® or an indistinguishable placebo daily for 8 weeks prior to a downhill treadmill running episode designed to induce DOMS. Main outcome measures Performance measures (Kin-Com, counter movement and squat jump), pain assessments (visual analogue scale, algometer) and blood analyses (Interleukin-1, Interleukin-6, Interleukin-10, tumour necrosis factor-α, C-reactive protein, myoglobin, creatine kinase) were assessed at 7 time points over 5 days (pre, post, 4, 24, 48, 72 and 96h after the downhill run). Results No statistically significant differences were identified in any parameters between the active and placebo groups at any time point. Conclusion After 2 months ingestion of Lyprinol ® at the currently recommended dosage (200mg/day) and a demanding eccentric exercise intervention, Lyprinol ® did not convincingly affect DOMS and indicators of muscle damage.

The deletion (D) allele of the gene for angiotensin-converting enzyme (ACE) is associated with higher plasma and tissue levels of the enzyme and has also been related to a variety of cardiovascular complications, particularly myocardial infarction. On the basis of indirect evidence, we hypothesized that inheritance of the D allele would contribute to elite athletic ability. Over a period of 4 yr, 120 Caucasian athletes who were national (Australian) representatives in sports demanding a high level of aerobic fitness were recruited. Their ACE genotypes were compared with those of a community control group recruited randomly from the electoral roll. There was no difference in ACE genotype frequencies between the two groups. The DD genotype frequency was 30% in athletes and 29% in the control group, and the II genotype frequency was 22.5 and 22%, respectively. The results do not exclude the possibility that ACE genotype could be related to some attribute relating to a specific type of elite athletic ability or that there may be a difference between genders. Larger studies are desirable.

Objective: To determine the clinical utility of screening for biochemical parameters in elite athletes. Design: A prospective sequential case series. Setting: The Department of Sports Medicine at the Australian Institute of Sport. Participants: 100 elite athletes from 11 sports (56 male and 44 female athletes, mean age 19 years, range 16–27), undergoing routine medical screening. Intervention: Initial and follow-up assessment of the following biochemical parameters in association with clinical assessment; serum iron, ferritin, transferrin, percent transferrin saturation, sodium, potassium, chloride, calcium, magnesium, phosphate, urate, urea and creatinine, total protein, albumin, creatine kinase (CK), lactate dehydrogenase, aspartate aminotransaminase (AST), alanine aminotransferase, alkaline phosphatase, gamma-glutamyl transpeptidase, total bilirubin, cholesterol and triglycerides (non-fasting), and random glucose. Results: 18 athletes showed no abnormalities on biochemical screening. 194 abnormal results were found in 82 athletes. 115 abnormalities were noted in 46 male and 79 in 36 female athletes. In 43 individual tests, the results did not return to normal on repeat testing. The most common abnormalities were increases in AST (27%), phosphate (13%), CK (13%), urea (12%) and bilirubin (12%). Three cases of hypercholesterolaemia and one case of haemochromatosis were identified, and one athlete, who was asymptomatic, was diagnosed with Epstein–Barr virus infection, which was suspected because of an abnormal liver function test. The other abnormalities found appeared not to be of clinical significance. Conclusion: Most abnormalities found on routine biochemical screening in elite athletes are of no clinical significance, therefore such testing should, if used only for clinical purposes, be abandoned. When athletes are tested for iron status it would be prudent to include assessment of serum cholesterol in those with a family history of hyperlipidaemia.

The use of supplements and alternative medicines iscommon in elite athletes. Many of these products havemultiple components, and because they are marketed asnatural, it may be presumed by the consumer that side effectsare infrequent. In this case report, we describe an elitetriathlete who presented with a sensation of diffuse mildswelling and weight increase that resolved after discontinu-ation of a herbal supplement that had been marketed assupportive of adrenal function. The supplement containedlicorice, which is well known to induce a state of hyper-mineralocorticoidism, which is associated with sodium andwater retention, hypertension, hypokalemia, and suppressionof the renin–angiotensin system.

Summary The aim of this prospective, cohort study was to determine the clinical and performance related utility of haematological and iron-related screening in elite athletes. Three hundred and three male and 273 female elite athletes underwent routine medical screening over a three-year period. In association with a standard medical consultation, a full blood count and iron-related variables were measured. Ten male athletes had a serum ferritin less than 30 ng/mL and satisfied AIS criteria for iron supplementation. In only one case was a disorder identified which was not expected following the clinical history and examination. Fifty-two female athletes had a serum ferritin less than 30 ng/mL and satisfied AIS criteria for iron supplementation. In the females, there were no instances in which a medical condition was identified which was not expected following the clinical history and examination. In both groups, clinically non-significant abnormalities were generally minor or isolated reductions in haemoglobin and/or haematocrit, and alterations in red cell parameters or single measures of iron status. Conclusion : Screening for haematological and iron-related abnormalities in athletes has a low yield. Due to the critical nature of the effects of anaemia and low serum ferritin on some aspects of performance it is reasonable to perform a haemoglobin and a serum ferritin on male and female athletes entering an elite training program. Isolated abnormalities which are close to the limits of their normal ranges and not accompanied by symptoms or signs of illness can almost certainly be ignored.

Earthing (or grounding) is an essential part of any electrical installation. Within industrial and pharmaceutical plants with potentially explosive atmospheres earthing plays an essential role in maintaining the electrical and instrumentation systems in safe condition. The earthing system, although a single physical system, it carries out many different functions including automatic detection and clearance of electrical faults, prevention of dangerous potential differences which could cause injury, prevention and dissipation of static charges, screening and reduction of interference in instrumentation system and provision of a reference point for intrinsically safe Zener barriers systems

OBJECTIVES To assess the effect of short-term iron supplementation on soluble transferrin receptor (sTfR) and the soluble transferrin receptor/log ferritin ratio in a group of elite, iron-depleted, nonanemic female athletes and to assess the relationship between soluble transferrin receptor and serum ferritin in a group of elite, iron-depleted female athletes. DESIGN A prospective, interventional study and an observation at 1 point in time. The primary inclusion criteria for each component of the study was serum ferritin less than 30 ng/mL and hemoglobin greater than 12 g/dL. The exclusion criteria were use of iron supplementation within 1 month of the initial assessment, acute or chronic infectious or inflammatory disease, hematological disorders, and recent musculoskeletal injury. SETTING The Department of Sports Medicine at the Australian Institute of Sport. SUBJECTS For the prospective study, 51, and for the observational study, 85 elite, iron-depleted (serum ferritin

Objective To investigate the possibility of early changes in erythropoiesis during prolonged exercise being reflected in reticulocyte parameters. Design This was a case-control field study of hematological variables in a group of ultramarathon runners competing in a 6-day track race. Setting A 6-day ultramarathon in Colac, Australia. Participants 7 male and 1 female experienced ultramarathon runners. Intervention A track race of 6 days' duration. Main outcome measures A wide range of red cell and reticulocyte parameters. Results Resting red cell parameters were within normal clinical limits. However, except for the expected findings typical of hemodilution, red cell parameters were relatively unchanged during and after the event, with the exception of small but statistically significant changes in number and percentage of macrocytic, microcytic, hypochromic, and hyperchromic red cells. No reticulocytosis was found in an event that would have been expected to be associated with significant foot-strike hemolysis; however, an increase in the percentage of reticulocytes with high RNA content late in the event indicates early release from the marrow. Reduction in reticulocyte mean cell volume, which is consistent with functional iron deficiency, was demonstrated during the event. This finding is consistent with changes in some of the iron-related parameters associated with the acute phase response, but the dissociation in time between these changes makes a causal relationship unlikely. Other changes such as those in reticulocyte hemoglobin distribution width, reticulocyte distribution width, cell hemoglobin concentration mean, and lack of change in corpuscular hemoglobin are not typical of true iron deficiency, and the mechanism of these changes is currently unknown. Conclusion The hematopoietic system demonstrates remarkable stability in the face of very significant exercise stress. No reticulocyte response was demonstrated in this study, but reticulocyte changes both consistent with and contrary to early release from the marrow were demonstrated after several days of strenuous running. The significance of several newly developed ratios of red cell and reticulocyte parameters in conditions of exercise stress requires further investigation.

Stress fractures of the clavicle are rare. This is the report of one such fracture in a 10 year old female gymnast, who presented with a six week history of medial clavicular pain. Radiographs and a computed tomography scan showed an undisplaced fracture through the medial third of the clavicle extending inferiorly to the rhomboid fossa in the inferior aspect of the clavicle. Pathological fracture was excluded by magnetic resonance imaging. The patient was treated conservatively and was able to return to full training eight weeks later.

Objective —To determine the presence or absence of an acute phase response after training for court and field sports. Participants —All members of the Australian women9s soccer team (n = 18) and all members of the Australian Institute of Sport netball team (n = 14). Methods —Twelve acute phase reactants (white blood cell count, neutrophil count, platelet count, serum iron, ferritin, and transferrin, percentage transferrin saturation, α 1 antitrypsin, caeruloplasmin, α 2 acid glycoprotein, C reactive protein, and erythrocyte sedimentation rate) were measured during a rest period and after moderate and heavy training weeks in members of elite netball and women9s soccer teams. Results —Responses consistent with an acute phase response were found in five of 24 tests in the soccer players, and in three of 24 tests in the netball players. Responses in the opposite direction were found in seven of 24 tests in the soccer players and two of 24 tests in the netballers. The most sensitive reactant measured, C reactive protein, did not respond in a manner typical of an acute phase response. Conclusion —An acute phase response does not seem to occur as a consequence of the levels of training typical of elite female netball and soccer teams. This has implications for the interpretation of biochemical variables in these groups.

The purpose of this study was to determine the effect of altering substrate availability on metabolism and performance during intense cycling. Seven highly trained men ingested a random order of three isoenergetic meals 90 min before cycling at 80 % maximal oxygen uptake (VO2max) for 20 min (about 310 W), followed by a 600 kJ time trial lasting about 30 min. Meals consisted of either 1·2 g saturated fat/kg body mass (BM) with 3500 U heparin intravenously (HIFAT) to elevate circulating plasma free fatty acid (FA) concentration, 2·5 g carbohydrate/kg BM (CHO) to elevate plasma glucose and insulin concentrations or 2·5 g carbohydrate+20 mg nicotinic acid/kg BM (NA) to suppress lipolysis and reduce free FA concentration. HIFAT elevated free FA concentration (HIFAT 1·3 (SEM 0·2), CHO 0·2 (sem 0·1), NA 0·1 (sem 0·1) mm; P2max) exercise is dominated by carbohydrate oxidation.

Objective Controversy exists in relation to the nature of the acute phase response, which is known to occur following endurance exercise. This study was conducted to demonstrate the similarities between this response and the response consequent to general medical and surgical conditions. Design This is a case series field study of serum levels of acute phase reactants in a group of ultramarathon runners competing in a 6-day track race. Participants Seven male and one female experienced ultramarathon runners. Intervention A track race of 6 days duration. Main outcome measures Serum iron, ferritin, transferrin, albumin, haptoglobin, alpha-1 antitrypsin, complement components 3 and 4, C-reactive protein, and erythrocyte sedimentation rate, total iron binding capacity, and transferrin saturation. Results Of the 11 acute phase reactants measured, 6 (serum iron, ferritin, percent transferrin saturation, C-reactive protein, erythrocyte sedimentation rate, and haptoglobin) responded as if an acute phase response was present; 5 (tranferrin, albumin, alpha-1 antitrypsin, and complement components 3 and 4) did not respond in such a fashion. Conclusion This study provides further evidence that the acute phase response consequent to exercise is analogous to that which occurs in general medical and surgical conditions. The previous demonstration of the presence of the appropriate cytokines following exercise, the findings of others in relation to acute phase reactants not the subjects of this study, the possibility that a training effect leading to attenuation of the response and the realization that the acute phase response is not identical across a range of medical conditions lends weight to the above conclusion.

Eight competitive cyclists [mean peak oxygen consumption, (VO2(peak)) = 65 ml x min(-1) x kg(-1)] undertook two 60-min cycle ergometer time trials at 32 degrees C and 60% relative humidity. The time trials were split into two 30-min phases: a fixed-workload phase and a variable-workload phase. Each trial was preceded by ingestion of either a glycerol solution [1 g x kg(-1) body mass (BM) in a diluted carbohydrate (CHO)-electrolyte drink] or a placebo of equal volume (the diluted CHO-electrolyte drink). The total fluid intake in each trial was 22 ml x kg(-1) BM. A repeated-measures, double blind, cross over design with respect to glycerol was employed. Glycerol ingestion expanded body water by approximately 600 ml over the placebo treatment. Glycerol treatment significantly increased performance by 5% compared with the placebo group, as assessed by total work in the variable-workload phase (P0.04). There were no significant differences in rectal temperature, sweat rate or cardiac frequency between trials. Data indicate that the glycerol-induced performance increase did not result from plasma volume expansion and subsequently lower core temperature or lower cardiac frequencies at a given power output as previously proposed. However, during the glycerol trial, subjects maintained a higher power output without increased perception of effort or thermal strain.

OBJECTIVE: To investigate biochemical changes related to muscle breakdown, hepatic damage, hyponatraemia, and a number of other variables in the serum of participants in a 1600 km ultramarathon run. METHODS: Blood samples were obtained from nine participants (seven men, two women) in a 1600 km foot race before, after 4 and 11 days of running, and at the conclusion of the event. Samples were analysed by standard methods and results corrected, where appropriate, for changes in plasma volume. RESULTS: Significant (p < 0.05) increases in the following variables were found during or at the conclusion of the event: plasma volume, sodium, chloride, urea, alkaline phosphatase, gamma-glutamyltransferase, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, creatine kinase, bilirubin, total protein, albumin, glucose, calcium, and phosphate. Significant (p < 0.05) decreases in the following variables were found during or at the conclusion of the event: globulin, uric acid, and cholesterol. No change occurred in serum potassium, bicarbonate, creatinine, and triglycerides. CONCLUSION: A wide range of biochemical perturbations occur during ultramarathon running but a number of variables remain within normal limits despite severe physical stress. Large increases in plasma volume occur, and hyponatraemia is rare in events of this duration. The time course of increases in enzymic indicators of muscle damage indicates that duration of running is not the sole determinant of such increases. This study provides indirect evidence of possible hepatic damage during prolonged exercise and an increase in serum calcium both of which warrant further investigation.

Pneumomediastinum is an uncommon complication of sporting activity. The case of a young asthmatic surf lifesaver is reported in which several factors are thought to have been involved in the aetiology of his condition. Treatment was expectant and a full recovery was made over a short period. This is the first reported case of pneumomediastinum occurring following training for a surf belt race.