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Importance: Racial disparities in cardiovascular health, including sudden cardiac death (SCD), exist among both the general and athlete populations. Among competitive athletes, disparities in health outcomes potentially influenced by social determinants of health (SDOH) and structural racism remain inadequately understood. This narrative review centers on race in sports cardiology, addressing racial disparities in SCD risk, false-positive cardiac screening rates among athletes, and the prevalence of left ventricular hypertrophy, and encourages a reexamination of race-based practices in sports cardiology, such as the interpretation of screening 12-lead electrocardiogram findings., Observations: Drawing from an array of sources, including epidemiological data and broader medical literature, this narrative review discusses racial disparities in sports cardiology and calls for a paradigm shift in approach that encompasses 3 key principles: race-conscious awareness, clinical inclusivity, and research-driven refinement of clinical practice. These proposed principles call for a shift away from race-based assumptions towards individualized, health-focused care in sports cardiology. This shift would include fostering awareness of sociopolitical constructs, diversifying the medical team workforce, and conducting diverse, evidence-based research to better understand disparities and address inequities in sports cardiology care., Conclusions and Relevance: In sports cardiology, inadequate consideration of the impact of structural racism and SDOH on racial disparities in health outcomes among athletes has resulted in potential biases in current normative standards and in the clinical approach to the cardiovascular care of athletes. An evidence-based approach to successfully address disparities requires pivoting from outdated race-based practices to a race-conscious framework to better understand and improve health care outcomes for diverse athletic populations.

Background: People diagnosed with genetic heart diseases (GHDs) associated with sudden cardiac death (SCD) have historically been restricted from competitive sports. Recent data documenting return-to-play (RTP) experiences following shared decision making (SDM) suggest that cardiac event rates for athletes with a GHD are lower than previously described, thereby suggesting an opportunity to reconsider this paradigm., Objectives: The purpose of this study was to evaluate clinical outcomes among National Collegiate Athletic Association Division I university and professional athletes diagnosed with a GHD., Methods: A multicenter retrospective analysis was performed to examine demographics, clinical characteristics, RTP outcomes, and cardiac events among elite athletes with a GHD., Results: A total of 76 elite (66%, Division I, 34% professional) athletes (age 19.9 ± 5 years, 28% women) diagnosed with a GHD (hypertrophic cardiomyopathy [53%], long QT syndrome, long QT syndrome [26%]) comprise this cohort. Most athletes were asymptomatic (48 of 76, 63%) before diagnosis and had their GHD detected during routine preparticipation cardiovascular screening. Most athletes (55 of 76, 72%) were initially disqualified from their sport but subsequently opted for unrestricted RTP after comprehensive clinical evaluation and SDM. To date, (mean follow-up 7 ± 6 years), only 1 exercise-related (1.3%) and 2 nonexercise-related GHD-associated adverse cardiac events occurred. There have been no fatalities during follow-up., Conclusions: This is the first study describing the experience of athletes with a known SCD-predisposing GHD who are competing at the elite level. After careful evaluation, risk stratification, and tailoring of their GHD therapy, RTP following SDM appears associated with low, nonfatal events rates at elite levels of sport., Competing Interests: Funding Support and Author Disclosures This work was supported by the Mayo Clinic Windland Smith Rice Comprehensive Sudden Cardiac Death Program (to Dr Ackerman) and Mayo Clinic Center for Clinical and Translational Science through grant number UL1TR002377 from the National Center for Advancing Translational Sciences, a component of the National Institutes of Health. Dr Ackerman is a consultant for Abbott, Boston Scientific, Bristol Myers Squibb, Daiichi-Sankyo, Invitae, Medtronic, Tenaya Therapeutics, Thryv Therapeutics, and UpToDate. Dr Ackerman and Mayo Clinic are involved in an equity/royalty relationship with AliveCor, Anumana, ARMGO Pharma, and Pfizer; however, none of these entities were involved in this study. Dr Martinez is a consultant for Bristol Myers Squibb and Cytokinetics. Dr Phelan is a consultant for Bristol Myers Squibb, Pfizer, and Caption Health. Dr Baggish has received funding from the National Institute of Health/National Heart, Lung, and Blood Institute, the National Football Players Association, the American Heart Association, and the American Society for Sports Medicine to study cardiovascular outcomes among elite athletes; and receives compensation for his role as team cardiologist from the U.S. Olympic Committee/U.S. Olympic Training Centers, U.S. Soccer, and U.S. Rowing. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The coronavirus disease 2019 (COVID-19) pandemic has enabled the adoption of digital health platforms for self-monitoring and diagnosis. Notably, the pandemic has had profound effects on athletes and their ability to train and compete. Sporting organizations worldwide have reported a significant increase in injuries manifesting from changes in training regimens and match schedules resulting from extended quarantines. While current literature focuses on the use of wearable technology to monitor athlete workloads to guide training, there is a lack of literature suggesting how such technology can mediate the return to sport processes of athletes infected with COVID-19. This paper bridges this gap by providing recommendations to guide team physicians and athletic trainers on the utility of wearable technology for improving the well-being of athletes who may be asymptomatic, symptomatic, or tested negative but have had to quarantine due to a close exposure. We start by describing the physiologic changes that occur in athletes infected with COVID-19 with extended deconditioning from a musculoskeletal, psychological, cardiopulmonary, and thermoregulatory standpoint and review the evidence on how these athletes may safely return to play. We highlight opportunities for wearable technology to aid in the return-to-play process by offering a list of key parameters pertinent to the athlete affected by COVID-19. This paper provides the athletic community with a greater understanding of how wearable technology can be implemented in the rehabilitation process of these athletes and spurs opportunities for further innovations in wearables, digital health, and sports medicine to reduce injury burden in athletes of all ages., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: JEV serves as an education consultant for Arthrex. TJG works as a consultant to several high-performance organizations, including sporting teams, industry, military, and higher education institutions., (© The Author(s) 2023.)

Objective: To evaluate the psychological implications of cardiovascular preparticipation screening (PPS) in athletes., Design: Systematic review., Data Sources: MEDLINE, EMBASE, PubMed, CINAHL, SPORTDiscus, APA PsycInfo, Cochrane Library and grey literature sources., Study Eligibility Criteria: Observational and experimental studies assessing a population of athletes who participated in a cardiovascular PPS protocol, where psychological outcomes before, during and/or after PPS were reported., Methods: Results of included studies were synthesised by consolidating similar study-reported measures for key psychological outcomes before, during and/or after screening. Summary measures (medians, ranges) were computed across studies for each psychological outcome., Results: A total of eight studies were included in this review (median sample size: 479). Study cohorts consisted of high school, collegiate, professional and recreational athletes (medians: 59% male, 20.5 years). Most athletes reported positive reactions to screening and would recommend it to others (range 88%-100%, five studies). Increased psychological distress was mainly reported among athletes detected with pathological cardiac conditions and true-positive screening results. In comparison, athletes with false-positive screening results still reported an increased feeling of safety while participating in sport and were satisfied with PPS. A universal conclusion across all studies was that most athletes did not experience psychological distress before, during or after PPS, regardless of the screening modality used or accuracy of results., Conclusion: Psychological distress associated with PPS in athletes is rare and limited to athletes with true-positive findings. To mitigate downstream consequences in athletes who experience psychological distress, appropriate interventions and resources should be accessible prior to the screening procedure., Prospero Registration Number: CRD42021272887., Competing Interests: Competing interests: All authors report no competing financial interests. JAD is Editor-in-Chief of the British Journal of Sports Medicine, although was fully recused from the editorial and review process., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Heat-related illnesses, which range from heat exhaustion to heatstroke, affect thousands of individuals worldwide every year and are characterized by extreme hyperthermia with the core body temperature (CBT) usually > 40 °C, decline in physical and athletic performance, CNS dysfunction, and, eventually, multiorgan failure. The measurement of CBT has been shown to predict heat-related illness and its severity, but the current measurement methods are not practical for use in high acuity and high motion settings due to their invasive and obstructive nature or excessive costs. Noninvasive predictions of CBT using wearable technology and predictive algorithms offer the potential for continuous CBT monitoring and early intervention to prevent HRI in athletic, military, and intense work environments. Thus far, there has been a lack of peer-reviewed literature assessing the efficacy of wearable devices and predictive analytics to predict CBT to mitigate heat-related illness. This systematic review identified 20 studies representing a total of 25 distinct algorithms to predict the core body temperature using wearable technology. While a high accuracy in prediction was noted, with 17 out of 18 algorithms meeting the clinical validity standards. few algorithms incorporated individual and environmental data into their core body temperature prediction algorithms, despite the known impact of individual health and situational and environmental factors on CBT. Robust machine learning methods offer the ability to develop more accurate, reliable, and personalized CBT prediction algorithms using wearable devices by including additional data on user characteristics, workout intensity, and the surrounding environment. The integration and interoperability of CBT prediction algorithms with existing heat-related illness prevention and treatment tools, including heat indices such as the WBGT, athlete management systems, and electronic medical records, will further prevent HRI and increase the availability and speed of data access during critical heat events, improving the clinical decision-making process for athletic trainers and physicians, sports scientists, employers, and military officers.

Myocarditis is a leading cause of sudden death in athletes. Early data demonstrating increased prevalence of cardiac injury in hospitalized patients with COVID-19 raised concerns for athletes recovered from COVID-19 and the possibility of underlying myocarditis. However, subsequent large registries have provided reassuring data affirming low prevalence of myocarditis in athletes convalesced from COVID-19. Although the clinical significance of subclinical myocarditis detected by cardiac MRI remains uncertain, clinical outcomes have not demonstrated an increase in acute cardiac events in athletes throughout the pandemic. Future directions include defining mechanisms underlying "long-haul" COVID-19 and the potential impact of new viral variants., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Abstract: We developed a video-enhanced preparticipation evaluation symptom questionnaire (the V-PPE), intended to help screen athletes for heart disease. We now report results of a pilot quality improvement study evaluating V-PPE's performance. In a prospective before-and-after study, approximately 5700 high-school athletes were prompted to voluntarily fill out the V-PPE questionnaire. We compared symptom frequencies on standard PPE to those on V-PPE. Of 5700 athletes, 46 (0.8%), 117 (2.0%), 33 (0.6%), and 101 (1.8%) reported syncope, angina, palpitations, and dyspnea, respectively on routine screening. Four hundred and ninety-two (8.6%) voluntarily filled out the V-PPE. Athletes were more likely to report palpitations on V-PPE than PPE, but not angina, dyspnea, syncope, or at least one symptom. Symptom frequencies on electronic PPE questionnaires are lower than recent reports suggest. Embedded videos can alter screening yield. More research is necessary to evaluate the predictive value of the V-PPE for clinically relevant cardiac pathology., (Copyright © 2021 by the American College of Sports Medicine.)

Objective: To report the Mayo Clinic experience with coronavirus disease 2019 (COVID-19) related to patient outcomes., Methods: We conducted a retrospective chart review of patients with COVID-19 diagnosed between March 1, 2020, and July 31, 2020, at any of the Mayo Clinic sites. We abstracted pertinent comorbid conditions such as age, sex, body mass index, Charlson Comorbidity Index variables, and treatments received. Factors associated with hospitalization and mortality were assessed in univariate and multivariate models., Results: A total of 7891 patients with confirmed COVID-19 infection with research authorization on file received care across the Mayo Clinic sites during the study period. Of these, 7217 patients were adults 18 years or older who were analyzed further. A total of 897 (11.4%) patients required hospitalization, and 354 (4.9%) received care in the intensive care unit (ICU). All hospitalized patients were reviewed by a COVID-19 Treatment Review Panel, and 77.5% (695 of 897) of inpatients received a COVID-19-directed therapy. Overall mortality was 1.2% (94 of 7891), with 7.1% (64 of 897) mortality in hospitalized patients and 11.3% (40 of 354) in patients requiring ICU care., Conclusion: Mayo Clinic outcomes of patients with COVID-19 infection in the ICU, hospital, and community compare favorably with those reported nationally. This likely reflects the impact of interprofessional multidisciplinary team evaluation, effective leveraging of clinical trials and available treatments, deployment of remote monitoring tools, and maintenance of adequate operating capacity to not require surge adjustments. These best practices can help guide other health care systems with the continuing response to the COVID-19 pandemic., (Copyright © 2020 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Wearable sensors enable the real-time and non-invasive monitoring of biomechanical, physiological, or biochemical parameters pertinent to the performance of athletes. Sports medicine researchers compile datasets involving a multitude of parameters that can often be time consuming to analyze in order to create value in an expeditious and accurate manner. Machine learning and artificial intelligence models may aid in the clinical decision-making process for sports scientists, team physicians, and athletic trainers in translating the data acquired from wearable sensors to accurately and efficiently make decisions regarding the health, safety, and performance of athletes. This narrative review discusses the application of commercial sensors utilized by sports teams today and the emergence of descriptive analytics to monitor the internal and external workload, hydration status, sleep, cardiovascular health, and return-to-sport status of athletes. This review is written for those who are interested in the application of wearable sensor data and data science to enhance performance and reduce injury burden in athletes of all ages., Competing Interests: JV serves as an educational consultant for Arthrex. TG works as a consultant to several high-performance organizations, including sporting teams, industry, military, and higher education institutions. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Seshadri, Thom, Harlow, Gabbett, Geletka, Hsu, Drummond, Phelan and Voos.)

Purpose of Review: This review will summarize the distinction between hypertrophic cardiomyopathy (HCM) and exercise-induced cardiac remodeling (EICR), describe treatments of particular relevance to athletes with HCM, and highlight the evolution of recommendations for exercise and competitive sport participation relevant to individuals with HCM., Recent Findings: Whereas prior guidelines have excluded individuals with HCM from more than mild-intensity exercise, recent data show that moderate-intensity exercise improves functional capacity and indices of cardiac function and continuation of competitive sports may not be associated with worse outcomes. Moreover, recent studies of athletes with implantable cardioverter defibrillators (ICDs) demonstrated a safer profile than previously understood. In this context, the updated American Heart Association/American College of Cardiology (AHA/ACC) and European Society of Cardiology (ESC) HCM guidelines have increased focus on shared decision-making and liberalized restrictions on exercise and sport participation among individuals with HCM., Summary: New data demonstrating the safety of exercise in individuals with HCM and in athletes with ICDs, in addition to a focus on shared decision-making, have led to the most updated guidelines easing restrictions on exercise and competitive athletics in this population. Further athlete-specific studies of HCM, especially in the context of emerging therapies such as mavacamten, are important to inform accurate risk stratification and eligibility recommendations., Competing Interests: Conflict of InterestBradley S. Lander, Dermot M. Phelan, Matthew W. Martinez and Elizabeth H. Dineen declare that they have no conflict of interest., (© The Author(s) 2021.)

Objectives: The aims of this study were to assess outcomes of pulmonary vein isolation (PVI) performed on athletes at a tertiary care center and to characterize its efficacy and physiological effects., Background: The incidence of atrial fibrillation (AF) is increased in highly trained athletes and poses unique management challenges., Methods: Athletes were identified through a database of patients undergoing PVI from January 2000 through October 2015. Outcomes of AF ablation were defined in accordance with published guidelines. Available electrocardiographic, echocardiographic, and exercise treadmill testing data were also analyzed., Results: The study population included 144 athletes (93% men; mean age 50.4 ± 8.6 years; 97 paroxysmal, 38 persistent, and 9 long-standing persistent) with median follow-up of 3 years. Single-procedure freedom from arrhythmia was 75%, 68%, and 33% at 1 year for paroxysmal, persistent, and long-standing persistent AF, respectively. Multiple-procedure freedom from arrhythmia off antiarrhythmic drugs was 86%, 76%, and 56% in respective groups at the end of follow-up (mean 1.4 ± 0.7 ablations per athlete). Compared with a matched cohort of nonathletes who underwent PVI, there was no difference in arrhythmia recurrence (log-rank p = 0.23). Excluding long-standing persistent AF, longer diagnosis-to-ablation time was the only variable in Cox proportional hazards analyses associated with arrhythmia recurrence (adjusted heart rate per log increase: 1.92; 95% confidence interval: 1.40 to 2.73; p < 0.0001), and PVI within 2 years of diagnosis was notably associated with successful outcomes (log-rank p = 0.002). Sinus rate increased following the index ablation (mean 54 beats/min vs. 64 beats/min at >1 year; p < 0.0001), but maximum metabolic equivalents on exercise treadmill testing were unchanged (13.1 ± 1.2 vs. 12.7 ± 1.4; p = 0.44)., Conclusions: PVI is an effective therapy in athletes with paroxysmal and persistent AF, and arrhythmia recurrence was no different from that among matched nonathletes. Early ablation was associated with improved success rates. Sustained cardioautonomic effects were observed following ablation, but exercise capacity was preserved., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Cardiac amyloidosis results in an infiltrative restrictive cardiomyopathy, with a number of characteristic features: biventricular hypertrophy, abnormal myocardial global longitudinal strain with relative apical sparing, biatrial dilation, and small pericardial effusion along with conduction abnormalities. Amyloid deposits leading to hemodynamically significant valvular heart disease are very rare. We describe a rare case of concomitant moderately severe tricuspid and mitral valve stenosis because of ongoing amyloid deposition in a patient with progressive multiple myeloma and fat pad biopsy-proven light chain amyloidosis. Worsening infiltrative cardiomyopathy and valvulopathy despite evidence-based chemotherapy and heart failure pharmacotherapy led to end-stage disease and death. Valvular involvement in cardiac amyloidosis requires early recognition of the underlying disease condition to guide directed medical therapy and prevent its progression. In this instance, valvuloplasty or valve replacement is not a viable option., (© 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

During herpes simplex virus (HSV) latency, most viral genes are silenced, with the exception of one region of the genome encoding the latency-associated transcript (LAT). This long noncoding RNA was originally described as having a role in enhancing HSV-1 reactivation. However, subsequent evidence showing that the LAT blocked apoptosis and promoted efficient establishment of latency suggested that its effects on reactivation were secondary to establishment. Here, we utilized an adeno-associated virus (AAV) vector to deliver a LAT-targeting hammerhead ribozyme to HSV-1-infected neurons of rabbits after the establishment of HSV-1 latency. The rabbits were then induced to reactivate latent HSV-1. Using this model, we show that decreasing LAT levels in neurons following the establishment of latency reduced the ability of the virus to reactivate. This demonstrates that the HSV-1 LAT RNA has a role in reactivation that is independent of its function in establishment of latency. In addition, these results suggest the potential of AAV vectors expressing LAT-targeting ribozymes as a potential therapy for recurrent HSV disease such as herpes stromal keratitis, a leading cause of infectious blindness. IMPORTANCE Herpes simplex virus (HSV) establishes a lifelong infection and remains dormant (latent) in our nerve cells. Occasionally HSV reactivates to cause disease, with HSV-1 typically causing cold sores whereas HSV-2 is the most common cause of genital herpes. The details of how HSV reactivates are largely unknown. Most of HSV's genes are silent during latency, with the exception of RNAs made from the latency-associated transcript (LAT) region. While viruses that make less LAT do not reactivate efficiently, these viruses also do not establish latency as efficiently. Here we deliver a ribozyme that can degrade the LAT to the nerve cells of latently infected rabbits using a gene therapy vector. We show that this treatment blocks reactivation in the majority of the rabbits. This work shows that the LAT RNA is important for reactivation and suggests the potential of this treatment as a therapy for treating HSV infections., (Copyright © 2018 American Society for Microbiology.)

Background: Ascending aortic dimensions are slightly larger in young competitive athletes compared with sedentary controls, but rarely >40 mm. Whether this finding translates to aortic enlargement in older, former athletes is unknown., Methods and Results: This cross-sectional study involved a sample of 206 former National Football League (NFL) athletes compared with 759 male subjects from the DHS-2 (Dallas Heart Study-2; mean age of 57.1 and 53.6 years, respectively, P <0.0001; body surface area of 2.4 and 2.1 m 2 , respectively, P <0.0001). Midascending aortic dimensions were obtained from computed tomographic scans performed as part of a NFL screening protocol or as part of the DHS. Compared with a population-based control group, former NFL athletes had significantly larger ascending aortic diameters (38±5 versus 34±4 mm; P <0.0001). A significantly higher proportion of former NFL athletes had an aorta of >40 mm (29.6% versus 8.6%; P <0.0001). After adjusting for age, race, body surface area, systolic blood pressure, history of hypertension, current smoking, diabetes mellitus, and lipid profile, the former NFL athletes still had significantly larger ascending aortas ( P <0.0001). Former NFL athletes were twice as likely to have an aorta >40 mm after adjusting for the same parameters., Conclusions: Ascending aortic dimensions were significantly larger in a sample of former NFL athletes after adjusting for their size, age, race, and cardiac risk factors. Whether this translates to an increased risk is unknown and requires further evaluation., (© 2017 American Heart Association, Inc.)

Complex Citrus tristeza virus (CTV) populations composed of mixtures of different strains of the virus are commonly found in citrus trees in the field. At present, little is known about how these populations are formed, maintained, and how they are structured within a host. Here we used a novel in situ hybridization approach allowing simultaneous visualization of two different RNA targets with high sensitivity and specificity to examine the distribution of two isolates, T36 and T68-1, representing phylogenetically distinct strains of CTV, in a citrus host in single and mixed infections. Remarkably, in doubly inoculated plants the two virus variants appeared to be well mixed within the infected tissue and showed no spatial segregation. In addition, both CTV variants were often found occupying the same cells. Possible mechanisms involved in shaping CTV populations and the biological significance of the observed lack of structural separation of the individual components are discussed., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Humoral and cell-mediated immune responses are important in protection against measles. Non-response to vaccination has been associated with specific HLA-DR and HLA-DQ alleles; however, little is known about the relative importance of these alleles in the cellular immune response induced by measles virus vaccine. To investigate the role of HLA-DR/DQ class II restriction, a small pilot study was conducted. Lymphoproliferation assays using class II DR and DQ-specific monoclonal antibodies (MoAb) were performed at one week and two weeks post immunization with MMRII vaccine. The mean stimulation index (SI) was 4.4 and 5.3 at one and two weeks with reductions in SI of 47.6% and 70.2%, respectively, following the addition of DR-specific MoAb (p<0.001). These results clearly show that a significant proportion of the cell-mediated immune response to measles virus vaccine, as measured by SI, is HLA-DR restricted., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objectives: This study was designed to evaluate the impact of eplerenone on collagen turnover in preserved systolic function heart failure (HFPSF)., Background: Despite growing interest in abnormal collagen metabolism as a feature of HFPSF with diastolic dysfunction, the natural history of markers of collagen turnover and the impact of selective aldosterone antagonism on this natural history remains unknown., Methods: We evaluated 44 patients with HFPSF, randomly assigned to control (n = 20) or eplerenone 25 mg daily (n = 24) for 6 months, increased to 50 mg daily from 6 to 12 months. Serum markers of collagen turnover and inflammation were analyzed at baseline and at 6 and 12 months and included pro-collagen type-I and -III aminoterminal peptides, matrix metalloproteinase type-2, interleukin-6 and -8, and tumor necrosis factor-alpha. Doppler-echocardiographic assessment of diastolic filling indexes and tissue Doppler analyses were also obtained., Results: The mean age of the patients was 80 +/- 7.8 years; 46% were male; 64% were receiving an angiotensin-converting enzyme inhibitor, 34% an angiotensin-II receptor blocker, and 68% were receiving beta-blocker therapy. Pro-collagen type-III and -I aminoterminal peptides, matrix metalloproteinase type-2, interleukin-6 and -8, and tumor necrosis factor-alpha increased with time in the control group. Eplerenone treatment had no significant impact on any biomarker at 6 months but attenuated the increase in pro-collagen type-III aminoterminal peptide at 12 months (p = 0.006). Eplerenone therapy was associated with modest effects on diastolic function without any impact on clinical variables or brain natriuretic peptide., Conclusions: This study demonstrates progressive increases in markers of collagen turnover and inflammation in HFPSF with diastolic dysfunction. Despite high background utilization of renin-angiotensin-aldosterone modulators, eplerenone therapy prevents a progressive increase in pro-collagen type-III aminoterminal peptide and may have a role in management of this disease. (The Effect of Eplerenone and Atorvastatin on Markers of Collagen Turnover in Diastolic Heart Failure; NCT00505336).

Fungal prosthetic joint infection (PJI) is rare, with Candida species being the most frequently reported pathogen in the medical literature. The risk of relapse following delayed reimplantation arthroplasty for candidal PJI is unknown. We describe 4 new cases and summarize 6 previously reported cases of candidal PJI treated with delayed reimplantation arthroplasty. Ninety percent of the patients received antifungal therapy. Eight patients received amphotericin B either alone or in combination with other antifungals. One patient received fluconazole alone. The median duration of time from resection arthroplasty to reimplantation for total hip and total knee arthroplasties was 8.6 and 2.3 months, respectively. Eight patients did not have relapse of candidal PJI following delayed reimplantation arthroplasty after a median duration of follow-up of 50.7 months (range, 2--73 months). Candidal PJI can be successfully treated with delayed reimplantation arthroplasty after receipt appropriate antifungal therapy.

The Ah receptor (AhR) is a soluble ligand-dependent DNA regulatory protein that mediates many of the biological responses to 2,3,7, 8-tetrachlorodibenzo-p-dioxin (TCDD, dioxin) and related chemicals. In the absence of ligand, the cytosolic form of the AhR is found complexed with at least two molecules of hsp90, a heat shock protein of 90 kDa. In addition to its role in AhR protein folding and ability to repress the inherent nuclear localization, dimerization, and DNA binding activity of the AhR, it has been reported that hsp90 is absolutely required for maintaining the AhR in its high-affinity ligand binding conformation. The ability of high salt conditions (0. 4 M KCl) to dissociate the multimeric AhR complex into its monomeric form provides us with an avenue to examine the role of hsp90 in AhR ligand binding activity. In contrast to previous reports, we demonstrate that salt-dissociated "hsp90-free" AhR from several species still retains the ability to specifically bind ligand ([3H]TCDD). Although partial inactivation of ligand binding of salt-dissociated rat hepatic AhR was observed (to a maximum of 50% of total AhR binding), the presence of bound ligand protected against this inactivation. Little or no inactivation of the ligand binding ability of salt-dissociated guinea pig or rabbit AhR occurred. Our results not only indicate a significant species-difference in AhR ligand binding stability and/or activity, but also demonstrate that AhR ligand binding activity does not absolutely require the presence of receptor-bound hsp90., (Copyright 1998 Academic Press.)

When indicated, artificial feeding in critically ill patients should be instituted as early and as simply as possible. If feasible, enteral feeding is preferable but a period of intravenous nutrition is usually necessary in the critically ill. A compounded feed, administered via a sterile single lumen subclavian catheter is recommended. The volume and electrolyte composition are centrally important. High nitrogen and relatively low caloric intake are more likely requirements in stressed patients. The most important supplements are water soluble vitamins (including folate) and the trace element zinc. Safe practice requires a system of monitoring and awareness of potential complications.

Oral rehydration therapy (ORT)--World Health Organisation formula--has reduced the mortality of severe diarrhoea tenfold but its use in Intensive Care has not been reported. ORT was administered via a nasogastric tube to 3 adult intensive care patients who developed severe diarrhoea and post-operative acute renal impairment. The median intake of ORT was 2.21/day (range 1.5-3.0) and the mean duration of therapy was 7 days (range 6-10). Renal function improved (creatinine fell from 389 to 165 mmol/l) and both haemodynamic and metabolic stability (Na, K, Mg, PO4 and urea) were maintained. While it may not reduce the volume of diarrhoea, ORT provides a cheap, effective and physiological solution to severe gastrointestinal losses in intensive care and may have wider application in both adult and paediatric practice.

A 55-year-old woman with renal tubular acidosis and urinary potassium wasting became comatose and subsequently fitted when her plasma potassium level fell to 0.9 mmol/l. Her neurological state resolved with potassium therapy. She had no other recognised cause for her coma. It appears that coma represents the extreme of the spectrum of neurological change that may occur in association with hypokalaemia.

The comparative efficacy of two solutions of bupivacaine, 0.5% plain (isobaric-specific gravity 1.010), and 0.4% bupivacaine (hyperbaric-specific gravity 1.027) in 4% dextrose, for spinal anaesthesia was studied in 67 patients. Both solutions were clinically satisfactory (94% completely successful neural blockade). Hyperbaric bupivacaine blocks a greater number of spinal segments (p less than 0.01), causes a more rapid fall in blood pressure (p less than 0.05), and is more predictable in effect with regard to the number of segments blocked and to the lateralisation of the block. The duration of perioperative analgesia with the hyperbaric preparation is, however, shorter-3.8 hours as opposed to 5.8 hours (p less than 0.01)--but this was likely to be due to the smaller total dosage of bupivacaine used in the hyperbaric group. It is concluded that either solution may be used satisfactorily in clinical practice. The isobaric solution, however, despite its ready availability, is less satisfactory than the hyperbaric because its effect with regard to the extent of blockade is less predictable.

A 19-year-old woman who sustained multiple trauma, but no head injury, developed the fat embolism syndrome. Her severe, fulminant and reversible neurological deterioration was associated with cerebral oedema. We suggest that cerebral oedema may contribute to the neurological deterioration in the fat embolism syndrome.

Two patients suffered perforation of the oesophagus during attempted placement of a cricothyroid minitracheostomy. We discuss the probable mechanisms and means of preventing such a recurrence.

The "cherry red" laryngoscopic appearance of adult epiglottitis, as visualized through a fiberscope, is reproduced. The possible role of the fiberoptic bronchoscope, both as a diagnostic aid and as a means of facilitating endotracheal intubation, in this condition, is discussed.