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Stefania Di Gangi,1 Christophe Bagnoud,2 Giuseppe Pichierri,1 Thomas Rosemann,1 Andreas Plate1 1Institute of Primary Care, University and University Hospital Zurich, Zürich, Switzerland; 2Groupe Mutuel, Martigny, SwitzerlandCorrespondence: Stefania Di GangiInstitute of Primary Care, University and University Hospital Zurich, Pestalozzistrasse 24, Zürich, CH-8091, SwitzerlandTel +41 44 255 75 02Fax +41 44 255 90 97Email Stefania.DiGangi@usz.chPurpose: Low back pain (LBP) is one of the most frequent reasons for medical consultations. Literature suggests a large evidence-performance gap, especially regarding pain management. Therefore, the monitoring of treatment patterns is important to ensure high quality of treatment. This study aimed to describe treatment patterns specific to patients with diagnostic imaging of the spine for LBP.Patients and Methods: The study was retrospective observational and based on health claims data from 2015 to 2019 provided by a Swiss health insurance company covering around 12% of the population. Patients, ≥ 18 years of age, with diagnostic imaging of the spine were included and observed 12 months before and after imaging. Patients with back surgery or comorbidities associated with the use of pain medications were excluded.Results: In total, 60,822 patients (mean age: 53.5 y, 56.1% female) were included and 85% received at least one pain medication. Of these, non-steroidal anti-inflammatory drugs, paracetamol, or opioids were prescribed in 88.6%, 70.7%, and 40.3% of patients, respectively. Strong opioids were used in 17% of patients given opioids. Patients with combinations of diagnostic imaging methods had the highest odds of receiving pain medication prescriptions (1.81, 95% CI: 1.66, 1.96, P < 0.001). Prescribed defined daily doses corresponded to short-term therapies.Conclusion: Although the majority of patients received non-opioid short-term therapies, we found a substantial use of opioids, and in particular, a relative high usage of strong opioids. Our results highlighted the importance of both patient and healthcare provider awareness regarding the prudent treatment of LBP.Keywords: low back pain medication, radiology, diagnostic imaging, NSAIDs, opioids, non-pharmacologic therapies

Salome Landolt,1 Thomas Rosemann,1 Eva Blozik,1,2 Beat Brüngger,2 Carola A Huber1,2 1Institute of Primary Care, University of Zürich, University Hospital Zürich, Zürich, Switzerland; 2Department of Health Sciences, Helsana Insurance Group, Zürich, SwitzerlandCorrespondence: Carola A HuberHelsana Insurance Group, P.O. 8081, Zürich, SwitzerlandTel + 41 43 340 6341Fax +41 43 340 0434Email carola.huber@helsana.chPurpose: This study aimed to give a nationwide comprehensive picture of the prevalence and prescription patterns of benzodiazepines (BZ) and Z-drugs (ZD) in Switzerland and to analyze the association with adverse health care outcomes.Patients and Methods: A population-based, cross-sectional study was conducted, using a large health insurance database in Switzerland. Records from all adult patients with ≥ 1 prescription for a benzodiazepine and/or a Z-drug in 2018 were included. We calculated the prevalence of BZ and ZD user (extrapolated to the Swiss general population), the number of prescriptions and the type of provider (among each BZ and ZD only user). Multivariate logistic regression models were performed to estimate the association between drug prescription and the risk of hospitalization in different healthcare settings.Results: Of a total of 844ʹ692 patients, 95ʹ179 had ≥ 1 BZ and/or ZD prescription in 2018. The extrapolated one-year prevalence for the general Swiss population was 8.1% for a BZ prescription, 3.5% for a ZD prescription, and 10.5% for a BZ and/or ZD prescription, and continuously increased with age. The majority of the elderly (over 65 years) had ≥ 1 prescription (BZ: 51.9%; ZD: 56.9%; BZ and/or ZD: 53.5). The proportion of patients with ≥ 6 prescriptions per year was 23.1% for BZ only user and 35.2% for ZD only user. Most patients had ≥ 1 prescription from a general practitioner. Regression models showed a higher likelihood to be admitted to acute care, psychiatry, rehabilitation, or nursing home with ≥ 1 prescription for a benzodiazepine and/or a Z-drug.Conclusion: This study is the first to give a nationwide overview of the current use of benzodiazepines and Z-drugs in Switzerland based on health insurance claims data. The results revealed a remarkably high prevalence among the general Swiss population, especially in older generations. The negative consequences of heavy BZ and ZD use are a crucial public health problem, that should be addressed.Keywords: anxiolytics, sedatives, pharmacoepidemiology, health insurance claims data

Carola A Huber,1,2 Michael Nagler,3 Thomas Rosemann,2 Eva Blozik,1,2 Markus Näpflin,1 Stefan Markun2 1Department of Health Sciences, Helsana Insurance Group, Zürich, Switzerland; 2Institute of Primary Care, University of Zürich, University Hospital Zürich, Zürich, Switzerland; 3University Institute of Clinical Chemistry, Inselspital Bern University Hospital, University of Bern, Bern, SwitzerlandCorrespondence: Carola A HuberDepartment of Health Sciences, Helsana Insurance Group, P.O. Box, 8081, Zürich, SwitzerlandTel +41 43 340 6341Fax +41 43 340 0434Email carola.huber@helsana.chBackground: Micronutrient laboratory tests (MLT) are increasing in many healthcare systems. This study assessed time trends of annual MLT incidence in the Swiss population and examined the frequency of specific MLT, defined as the number of yearly tests performed in individual persons.Methods: For annual time trends, we used a longitudinal design with a seven-year observation period (2012– 2018) and for yearly testing frequency we used a cross-sectional design (2018 only). The database consisted of nationwide insurance claims from adult persons.Results: Persons with MLT compared to persons without were older (mean age 57.1 years vs 48.6 years) and to a higher proportion female (65.1% vs 45.5%). Between 2012 and 2018, we included 6.7 million person years and found an increase in the proportion of persons receiving any MLT from 24.5% to 35.0%. Tests with strongest absolute increase during the observation period were vitamin D (from 7.4% of persons to 20.4%), vitamin B12 (from 9.0% to 17.6%) and ferritin (from 17.4% to 26.6%). In 2018, vitamin D and vitamin B12 tests were performed more than once in 4.5% and 3.3% of the population, respectively.Conclusion: We found that the Swiss population undergoes MLT with high and increasing frequency. Testing for vitamin D, vitamin B12 and ferritin is very common and of questionable appropriateness.Keywords: laboratory testing, micronutrient, claims data, trend

Stefania Di Gangi, Stefan Markun, Thomas Rosemann, Andreas Plate Institute of Primary Care, University and University Hospital of Zürich, Zürich, SwitzerlandCorrespondence: Stefania Di GangiInstitute of Primary Care, University of Zurich, Pestalozzistrasse 24, Zürich 8091, SwitzerlandTel +41 44 255 75 02Fax +41 44 255 90 97Email stefania.digangi@usz.chPurpose: Sleeping disturbances are highly prevalent in the general population, and pharmacological drug treatment harbours the risk of serious side effects. Many affected persons use dietary supplements for self-treating their symptoms, but little is known about the specific characteristics and preferences of these patients. Even less evidence exists about the consequences of a specific dietary supplement usage on health care utilization. The aim of this study was to explore characteristics, preferences and the impact on health care utilization in patients using a specific over-the-counter dietary supplement, which is promoted for improving sleeping disturbances.Patients and Methods: We conducted a structured survey and invited a sample of 297 customers of a specific dietary supplement to participate. The survey was open between June and September 2020. Participants were invited by email. All participants accepted an informed consent.Results: A total of 127 customers participated in the survey (participation rate: 42.8%). Of them, 87.7% were female and the mean age 50.5 years. Participants reported an overall good improvement of symptoms (7.66 on a ten-point Likert-scale) and showed a strong belief in the effectiveness of supplements in general; 67% of participants reported that the intake led to fever physician encounters, and 48.3% reported that they could stop the intake of other pharmaceutical sleeping drugs.Conclusion: A significant proportion of participants reported a substantial reduction in pharmaceutical drug use and health care utilization. While these self-reports lack an adequate control, they are still real consumer experiences, and the large beneficial effects – whether placebo or not – explain the popularity of such supplements and their therapeutic potential in sleeping disorders.Keywords: supplement use, sleeping disorders, usage patterns, drugs, health care utilization

Nahara Anani Martínez-González, Andreas Plate, Stefan Markun, Oliver Senn, Thomas Rosemann, Stefan Neuner-JehleInstitute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich CH-8091, SwitzerlandAims: To synthesize the empirical evidence on the effectiveness of shared decision making (SDM) compared to usual care for prostate cancer (PC) treatment.Methods and results: A systematic review of academic (MEDLINE, EMBASE, Cochrane Library, CINHAL, PsychINFO, and Scopus) and grey (clinicaltrials.gov, WHO trial search, meta-Register ISRCTN, Google Scholar, opengrey, and ohri.ca) literature, also identified from contacting authors and hand-searching bibliographies. We included randomized controlled trials (RCTs): 1) comparing SDM to usual care for decisions about PC treatment, 2) conducted in primary or specialized care, 3) fulfilling the key SDM features, and 4) reporting quantitative outcome data. Four RCTs from Canada (n=3) and the USA were included and comprised 1,065 randomized men, most (89.8%) of whom were in PC stage T1-T2. The studies reported 24 outcome measures. In 62.5% study estimates, SDM was similar to usual care at improving patient satisfaction and mood, and at reducing decisional conflict and decisional regret. In 37.5% study estimates, SDM significantly improved knowledge, perception of being informed and patient-perceived quality of life (QoL) at four weeks. There was a dearth of outcome data, particularly on the adherence to treatment and on patient-important and clinically relevant health outcomes such as symptoms and mortality.Conclusion: SDM may positively influence men’s knowledge and may have a positive but short-term effect on patient-perceived QoL. The (long-term) effects of SDM on patient-related outcomes for decisions about PC treatment are unclear. Future research needs consensus about the interventions and outcomes needed to evaluate SDM and should address the absence of evidence on health outcomes.Keywords: systematic review, shared decision making, prostate cancer, treatment, controlled clinical trials, urology

Zbigniew Waśkiewicz,1,2 Pantelis T Nikolaidis,3,4 Aïna Chalabaev,5 Thomas Rosemann,6 Beat Knechtle6,7 1Department of Team Sports, Jerzy Kukuczka Academy of Physical Education, Katowice, Poland; 2Department of Sports Medicine and Medical Rehabilitation, Sechenov University, Moscow, Russia; 3Exercise Testing Laboratory, Hellenic Air Force Academy, Acharnes, Greece; 4Exercise Physiology Laboratory, Nikaia, Greece; 5UFR APS, Université Grenoble Alpes, Grenoble, France; 6Medbase St. Gallen Am Vadianplatz, St. Gallen, Switzerland; 7Institute of Primary Care, University of Zurich, Zurich, Switzerland Background: In ultra-marathon running the proper motivation of the athlete is one of the milestones, not only during the races, but also during the practice sessions, which are long and very exhausting. Purpose: The aim of this study was to examine the relationship of sport experience (expressed as number of finishes in ultra-marathons) with motivation characteristics of ultra-marathon runners. Subjects and methods: The Motivation of Marathoners Scale examined the motivation of ultra-marathon runners compared to endurance runners of shorter distances (control group). Participants were 1,539 Polish runners, 382 women (24.7%) and 1,157 men (75.3%). Ultra-marathoners (N=425; 26.7%) finished at least one ultra-marathon, whereas the control group consisted of runners of shorter distances (N=1,114, 72.3%). Results: Ultra-marathoners had higher scores in affiliation (3.55±1.60 vs 3.34±1.62, P

Rodrigo L Vancini,1 Claudio AB de Lira,2 Sarah A Anceschi,1 André V Rosa,1 Ana P Lima-Leopoldo,1 André S Leopoldo,1 Weverton Rufo-Tavares,1 Marilia S Andrade,3 Pantelis T Nikolaidis,4 Thomas Rosemann,5 Beat Knechtle5 1Departamento de Desportos, Centro de Educação Física e Desportos, Universidade Federal do Espírito Santo, Vitória, Brazil; 2Setor de Fisiologia Humana e do Exercício, Faculdade de Educação Física e Dança, Universidade Federal de Goiás, Goiânia, Goiás, Brazil; 3Departamento de Fisiologia, Universidade Federal de São Paulo, São Paulo, Brazil; 4Exercise Physiology Laboratory, Nikaia, Greece; 5Institute of Primary Care, University of Zurich, Zurich, Switzerland Background: Police officers are subjected to high work-related stress. This scenario of irregular and insalubrious working conditions may be related to an increase in psychiatric disorders and overweight. In particular, low levels of physical activity and high work stress levels may predispose police officers to obesity, poor lifestyles, and, consequently, major risk of psychological disorders. Thus, our aim was to profile the anxiety/depression symptoms and habitual physical activity (HPA) levels of Brazilian elite police officers classified by body mass index (BMI). Patients and methods: Eighty-seven male police officers classified as normal-weight (NG, BMI =18.5–24.9 kg/m2, n=34) and excess-weight (EG, BMI ≥25 kg/m2, n=53) completed (before work routine time) the questionnaires: Baecke (HPA levels), State-Trait Anxiety Inventory (anxiety), and Beck Depression Inventory (depression). Results: There was a slight trend (despite did not reach statistical significance) of the EG group (which have a significantly [P=0.0369] higher mean [8.8±7.6] of military service time [in years] when compared to NG group [5.8±6.0]) presenting higher values of anxiety-trait (+5.0%) and depression (+16.0%) and lower levels of leisure time HPA (–3.7%) than NG group. Conclusion: Although our hypothesis was not ratified, our findings have clinical relevance because we profiled the anxiety and depression symptoms and HPA levels of elite police officers. Moreover, it is possible to suppose that the military service time (years) is a relevant factor, that it needs to be studied in depth, and that it may impact the predisposition for mood disorders and low levels of physical activity of police officers. Keywords: depression, mood state, physical activity, physical exercise, physical fitness, police officers

George Georgoudis,1,2 Bledjana Felah,2 Pantelis T Nikolaidis,3 Maria Papandreou,1 Evanthia Mitsiokappa,4 Andreas F Mavrogenis,4 Thomas Rosemann,5 Beat Knechtle5,6 1Musculoskeletal and Respiratory Research Lab, Department of Physiotherapy, University of West Attica, Athens, Greece; 2PhysioPain Group, Pain Specialist & Rehabilitation Centers, Athens, Greece; 3Exercise Physiology Laboratory, Nikaia, Greece; 4First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece; 5Institute of Primary Care, University of Zurich, Zurich, Switzerland; 6Medbase St. Gallen Am Vadianplatz, St. Gallen, Switzerland Introduction: Nonpharmacological therapies have been widely used to treat tension-type headache (TTH); however, limited evidence exists with regards to their effectiveness. Therefore, the aim of the present study was to examine the combined effect of acupuncture, stretching, and physiotherapy (myofascial release techniques and microwave diathermy) on psychocognitive, somatic, quality of life, and disability characteristics in such patients. Subjects and methods: Patients with TTH (n=44) performed either acupuncture or stretching (control group, n=20) or acupuncture, stretching, and physiotherapy (experimental group, n=24) during a 4-week intervention period including 10 treatment sessions. They were tested for the Greek version of the Short-Form McGill Pain Questionnaire, the Greek version of the Migraine Disability Assessment Questionnaire, the Greek version of the Hospital Anxiety and Depression Scale, Short Form Health Survey 12 9 (SF-12), and Pain Catastrophizing Scale at baseline after the fifth and tenth sessions. Results: All measures were improved throughout the first to tenth session (P0.05). Conclusion: In summary, a significant beneficial role of acupuncture, stretching, and physiotherapy on cognitive, psychosomatic pain measures, disability index, quality of life, and catastrophizing in patients with TTH was observed. Keywords: tension-type headache, acupuncture, physiotherapy, stretching, psychocognitive characteristics, myofascial release

Caio Victor Sousa,1 Marcelo Magalhães Sales,2 Pantelis Theodoros Nikolaidis,3 Thomas Rosemann,4 Beat Knechtle4,5 1Graduate Program in Physical Education, Universidade Católica de Brasília, Brasília, Brazil; 2Physical Education Department, Universidade Estadual de Goiás, Quirinópolis, Goiás, Brazil; 3Exercise Physiology Laboratory, Nikaia, Greece; 4Institute of Primary Care, University of Zurich, Zurich, Switzerland; 5Medbase St. Gallen Am Vadianplatz, St. Gallen, Switzerland Abstract: The sub-2-hour marathon is a new barrier in endurance running performance, and it has been widely debated in the scientific community. In this review we present a mathematical model to estimate the possible year when a male could break through the sub-2-hour barrier, and also an estimation of when a female could break Paula Radcliffe’s marathon running record. Further, we present several aspects (ie, physiology, nationality, age, biomechanics, pacing, and drafting) that are associated with marathon running performance in elite runners and, finally, the possible characteristics of the male to break the sub-2-hour barrier. In summary, with the results of the developed equations, it is possible that a male athlete can break through the sub-2-hour barrier in the next decade (with Nike® Breaking2 performance 1920–2018 [NBP]: y =0.0417x2–14.18x +3,128; year of 2026; without NBP 1920–2018: y =0.045x2–15.12x +3,194; year of 2027). This marathoner will possibly have a maximal oxygen uptake >85 mL∙kg–1∙min–1 and should perform the race at a pacing higher than 85% of maximal oxygen uptake. In addition, this runner should pay more attention to strength training, endurance strength, speed training, and focus on running training at an intensity above the anaerobic threshold. Most likely, this runner originates from East Africa (especially from Ethiopia) and will have an age of ~27 years. For the females, there is poor evidence regarding the physiological profile of the female marathoner who will break Radcliffe’s record, but the available literature suggests that it will not happen any time soon. Keywords: endurance, running, performance, pacing, drafting

Pantelis T Nikolaidis,1,2 Elias Villiger,3 Luca P Ardigò,4 Zbigniew Waśkiewicz,5 Thomas Rosemann,3 Beat Knechtle3,6 1Exercise Physiology Laboratory, Nikaia, Greece; 2Exercise Testing Laboratory, Hellenic Air Force Academy, Acharnes, Greece; 3Institute of Primary Care, University of Zurich, Zurich, Switzerland; 4Department of Neurosciences, Biomedicine and Movement Sciences, School of Exercise and Sport Science, University of Verona, Verona, Italy; 5Department of Team Sports, Academy of Physical Education, Katowice, Poland; 6Medbase St. Gallen Am Vadianplatz, St. Gallen, Switzerland Purpose: The age of peak performance (APP) has been studied extensively in various endurance and ultra-endurance sports; however, less information exists in regard to duathlon (ie, Run1, Bike, and Run2). The aim of the present study was to assess the APP of duathletes competing either in a short (ie, 10 km Run1, 50 km Bike, and 5 km Run2) or a long distance (ie, 10 km Run1, 150 km Bike, and 30 km Run2) race. Participants and methods: We analyzed 6,671 participants (women, n=1,037, age 36.6±9.1 years; men, n=5,634, 40.0±10.0 years) in “Powerman Zofingen” from 2003 to 2017. Results: Considering the finishers in 5-year age groups, in the short distance, a small main effect of sex on race time was observed (p

Stefan Markun,1,* Daniel P Franzen,2,* Kaba Dalla Lana,1 Swantje Beyer,3 Stephan Wieser,4 Thomas Hess,3 Malcolm Kohler,2 Thomas Rosemann,1 Oliver Senn,1 Claudia Steurer-Stey1,5 1Institute of Primary Care, 2Department of Pneumology, University Hospital Zurich, University of Zurich, Zurich, 3Department of Pneumology, Cantonal Hospital of Winterthur, Winterthur, 4Department of Pneumology, City Hospital Waid, 5MediX Group Practice Ltd, Zurich, Switzerland *These authors contributed equally to this work Introduction: Hospitalizations because of acute exacerbated COPD (AECOPD) are a major burden to patients and the health care system. Interventions during acute and post-acute hospital care exist not only to improve short-term outcomes but also to prevent future exacerbations and disease progression. We aimed at measuring the implementation rates of acute and post-acute hospital care interventions for AECOPD.Methods: We performed 24 months (January 1, 2012, to December 31, 2013) retrospective medical chart review of consecutive cases hospitalized to one of three public hospitals in the canton of Zurich due to AECOPD. Implementation rates of five acute care and seven post-acute care interventions were assessed.Results: Data from 263 hospitalizations (61% male, mean age 68.5 years, 47% active smokers) were analyzed. The median length of stay was 9 days (interquartile range [IQR] 6–12 days). In all, 32% of hospitalizations were caused by individuals with previous hospitalizations because of AECOPD. Implementation rates of four acute care interventions were >75% (lowest was appropriate antibiotic therapy with 56%). Compared to this, implementation rates of five post-acute care interventions were

Stefan Neuner-Jehle, Stefan Zechmann, Daniela Grundmann Maissen, Thomas Rosemann, Oliver Senn Institute of Primary Care, University of Zurich, Zurich, Switzerland Background: Multiple chronic health conditions are leading to multiple treatment procedures and polypharmacy. Prioritizing treatment according to patients’ needs and preferences may be helpful for deprescribing. Thus, for improving health care, it is crucial for general practitioners (GPs) to perceive the chief complaints (CCs) of patients. The primary aim of this study was to investigate the patient–provider concordance of CCs and the secondary aim was to investigate the concordance between CCs and diagnosis, in a sample of Swiss multimorbid patients. Materials and methods: A cross-sectional analysis based on a cluster randomized controlled trial (RCT) among 46 GPs, recruited between March 2015 to July 2016, and 334 multimorbid patients (≥60 years taking ≥5 drugs for at least 6 months) in Northern Switzerland was performed. CCs listed by GPs and by patients (n=128) were classified according to the International Classification of Primary Care, version 2 (ICPC-2) coding system on chapter and component level and defined as concordant if ICPC-2 codes of patients and GPs were identical. Concordance was classified into full, moderate or low, depending on the ranking of patients’ CCs on GPs’ list. As secondary outcome, we compared patients’ CCs to GPs’ diagnosis. Statistics included descriptive measures and a multivariate regression analysis of factors that are modifying concordance. Results: The mean age of patients was 76.9 (SD 8.1) years, where 38% were male, taking 7.9 (SD 2.6) drugs on the long term. The most frequent complaint was pain. Concordance of the CC was given in 101/128 (78.9%) on the ICPC-2 chapter level, whereby 86/128 (67.2%) showed full, 8/128 (6.3%) moderate and 7/128 (5.5%) low concordance; 27/128 (21.1%) were discordant. Concordance between CCs and diagnosis was 53.6%. Concordance increased with the intensity of the CC rated by patients (OR 1.48, CI 1.13–1.94, P

Sima Djalali, Ryan Tandjung, Thomas Rosemann, Stefan Markun Institute of Primary Care, University of Zurich, University Hospital Zurich, Zurich, Switzerland Background: Facing the upcoming shortage of primary care physicians (PCPs), medical and governmental organizations have recently made major investments to foster vocational training programs in Switzerland, designed to provide context-specific training for trainees in primary care practices. Less is known about the impact of these programs on the skills and specific knowledge of trainees. We aimed to evaluate the Cantonal program for vocational primary care training in the Canton of Zurich, Switzerland’s largest Canton.Methods: We undertook a pretest–posttest study and surveyed physicians before and after participating in the Cantonal program for vocational primary care training in the Swiss Canton of Zurich. All trainees who participated in the program from 2013 until the end of 2015 were eligible. Primary outcome was the proportion of trainees being confident about their professional, organizational, examination and management skills before and after completing vocational training. Secondary outcomes were the proportion of trainees stating knowledge gain in entrepreneurship and the proportion of trainees being motivated to pursue a career as PCP.Results: Data of 47 trainees participating in the vocational training between 2013 and 2015 were eligible. In total, 35 (74.5%) participated in the T1 survey and 34 (72.3%) in the T2 survey. At T2, significantly more trainees (T1: 11%−89%, T2: 79%−100%) stated to be at least “slightly confident” about their skills (p

Carola A Huber,1 Michael Brändle,2 Roland Rapold,1 Oliver Reich,1 Thomas Rosemann3 1Department of Health Sciences, Helsana Group, Zürich, 2Division of Endocrinology and Diabetes, Department of Internal Medicine, Kantonsspital St Gallen, St Gallen, 3Institute of Primary Care, University of Zürich, University Hospital Zürich, Zürich, Switzerland Background: The link between guideline adherence and outcomes is a highly demanded issue in diabetes care. We aimed to assess the adherence to guidelines and its impact on hospitalization using a simple set of performance measures among patients with diabetes. Methods: We performed a retrospective cohort study, using health care claims data for adult patients with treated diabetes (2011–2013). Patients were categorized into three drug treatment groups (with oral antidiabetic agents [OAs] only, in combination with insulin, and insulin only). Performance measures were based on international established guidelines for diabetes care. Multivariate logistic regression models predicted the probability of hospitalization (2013) by adherence level (2011) among all treatment groups. Results: A total of 40,285 patients with diabetes were enrolled in 2011. Guideline adherence was quite low: about 70% of all patients received a biannual hemoglobin A1c measurement and 19.8% had undergone an annual low-density lipoprotein cholesterol test. Only 4.8% were exposed to full adherence including all performance measures (OAs: 3.7%; insulin: 7.7%; and in combination: 7.2%). Increased guideline adherence was associated with decreased probability of hospitalization. This effect was strongest in patients using OAs and insulin in combination. Conclusion: Our study showed that measures to reflect physicians’ guideline adherence in diabetes care can easily be calculated based on already available datasets. Furthermore, these measures are clearly linked with the probability of hospitalization suggesting that a better guideline adherence by physicians could help to prevent a large number of hospitalizations. Keywords: diabetes, adherence, guidelines, hospitalization, antidiabetic agents, insulin

Beat Knechtle,1 Matthias Alexander Zingg,2 Patrizia Knechtle,1 Thomas Rosemann,2 Christoph Alexander Rüst2 1Gesundheitszentrum St Gallen, St Gallen, 2Institute of Primary Care, University of Zurich, Zurich, Switzerland Abstract: Recent studies investigating ultraendurance athletes showed an association between excessive fluid intake and swelling of the lower limbs such as the feet. To date, this association has been investigated in single-stage ultraendurance races, but not in multistage ultraendurance races. In this case study, we investigated a potential association between fluid intake and feet swelling in a multistage ultraendurance race such as a Deca Iron ultratriathlon with ten Ironman triathlons within 10 consecutive days. A 49-year-old well-experienced ultratriathlete competed in autumn 2013 in the Deca Iron ultratriathlon held in Lonata del Garda, Italy, and finished the race as winner within 129:33 hours:minutes. Changes in body mass (including body fat and lean body mass), foot volume, total body water, and laboratory measurements were assessed. Food and fluid intake during rest and competing were recorded, and energy and fluid turnovers were estimated. During the ten stages, the volume of the feet increased, percentage body fat decreased, creatinine and urea levels increased, hematocrit and hemoglobin values decreased, and plasma [Na+] remained unchanged. The increase in foot volume was significantly and positively related to fluid intake during the stages. The poststage volume of the foot was related to poststage total body water, poststage creatinine, and poststage urea. This case report shows that the volume of the foot increased during the ten stages, and the increase in volume was significantly and positively related to fluid intake during the stages. Furthermore, the poststage volume of the foot was related to poststage total body water, poststage creatinine, and poststage urea. The continuous feet swelling during the race was most probably due to a combination of a high fluid intake and a progressive decline in renal function (ie, continuous increase in creatinine and urea), leading to body fluid retention (ie, increase in total body water). Keywords: swimming, cycling, running, fluid

Beat Knechtle,1,2 Raphael Knechtle,2 Michael Stiefel,2 Matthias Alexander Zingg,2 Thomas Rosemann,2 Christoph Alexander Rüst21Gesundheitszentrum St Gallen, St Gallen, 2Institute of Primary Care, University of Zurich, Zurich, SwitzerlandObjective: This narrative review summarizes findings for Ironman triathlon performance and intends to determine potential predictor variables for Ironman race performance in female and male triathletes.Methods: A literature search was performed in PubMed using the terms “Ironman”, “triathlon”, and “performance”. All resulting articles were searched for related citations.Results: Age, previous experience, sex, training, origin, anthropometric and physiological characteristics, pacing, and performance in split disciplines were predictive. Differences exist between the sexes for anthropometric characteristics. The most important predictive variables for a fast Ironman race time were age of 30–35 years (women and men), a fast personal best time in Olympic distance triathlon (women and men), a fast personal best time in marathon (women and men), high volume and high speed in training where high volume was more important than high speed (women and men), low body fat, low skin-fold thicknesses and low circumference of upper arm (only men), and origin from the United States of America (women and men).Conclusion: These findings may help athletes and coaches to plan an Ironman triathlon career. Age and previous experience are important to find the right point in the life of a triathlete to switch from the shorter triathlon distances to the Ironman distance. Future studies need to correlate physiological characteristics such as maximum oxygen uptake with Ironman race time to investigate their potential predictive value and to investigate socio-economic aspects in Ironman triathlon.Keywords: swimming, cycling, running, age, body fat, sex

Beat Knechtle,1,2 Matthias Alexander Zingg,1 Thomas Rosemann,1 Michael Stiefel,1 Christoph Alexander Rüst11Institute of Primary Care, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland Objective: This narrative review summarizes recent intentions to find potential predictor variables for ultra-triathlon race performance (ie, triathlon races longer than the Ironman distance covering 3.8 km swimming, 180 km cycling, and 42.195 km running). Results from studies on ultra-triathletes were compared to results on studies on Ironman triathletes. Methods: A literature search was performed in PubMed using the terms “ultra”, “triathlon”, and “performance” for the aspects of “ultra-triathlon”, and “Ironman”, “triathlon”, and “performance” for the aspects of “Ironman triathlon”. All resulting papers were searched for related citations. Results for ultra-triathlons were compared to results for Ironman-distance triathlons to find potential differences. Results: Athletes competing in Ironman and ultra-triathlon differed in anthropometric and training characteristics, where both Ironmen and ultra-triathletes profited from low body fat, but ultra-triathletes relied more on training volume, whereas speed during training was related to Ironman race time. The most important predictive variables for a fast race time in an ultra-triathlon from Double Iron (ie, 7.6 km swimming, 360 km cycling, and 84.4 km running) and longer were male sex, low body fat, age of 35–40 years, extensive previous experience, a fast time in cycling and running but not in swimming, and origins in Central Europe. Conclusion: Any athlete intending to compete in an ultra-triathlon should be aware that low body fat and high training volumes are highly predictive for overall race time. Little is known about the physiological characteristics of these athletes and about female ultra-triathletes. Future studies need to investigate anthropometric and training characteristics of female ultra-triathletes and what motivates women to compete in these races. Future studies need to correlate physiological characteristics such as maximum oxygen uptake (VO2max) with ultra-triathlon race performance in order to investigate whether these characteristics are also predictive for ultra-triathlon race performance. Keywords: swimming, cycling, running, age, experience, ultra-endurance

Beat Knechtle,1,2 Thomas Rosemann,1 Matthias A Zingg,1 Michael Stiefel,1 Christoph A Rüst11Institute of Primary Care, University of Zurich, Zurich, 2Gesundheitszentrum St Gallen, St Gallen, SwitzerlandAbstract: Pacing strategy has been investigated in elite 100 km and elite 161 km (100 mile) ultra-marathoners, but not in age group ultra-marathoners. This study investigated changes in running speed over segments in male elite and age group 100 km ultra-marathoners with the assumption that running speed would decrease over segments with increasing age of the athlete. Running speed during segments in male elite and age group finishers for 5-year age groups (ie, 18–24 to 65–69 years) in the 100 km Lauf Biel in Switzerland was investigated during the 2000–2009 period. Average running speed over segment time station (TS) TS1–TS2 (56.1 km) was compared with running speed Start–TS1 (38 km) and Start–TS3 (76.7 km) and running speed TS2–TS3 was compared with running speed Start–Finish. For the top ten athletes in each edition, running speed decreased from 2000 to 2009 for TS1–TS2 and TS2–TS3 (P0.05). During TS1–TS2, athletes were running at 98.0%±2.1% of the running speed of Start–TS1. In TS2–TS3, they were running at 94.6%±3.4% of the running speed of TS1–TS2. In TS3–Finish, they were running at 95.5%±3.8% of running speed in TS2–TS3. For age group athletes, running speed decreased in TS1–TS2 and TS2–TS3. In TS3–Finish, running speed remained unchanged with the exception of the age group 40–44 years for which running speed increased. Running speed showed the largest decrease in the age group 18–24 years. To summarize, the top ten athletes in each edition maintained their running speed in the last segment (TS3–Finish) although running speed decreased over the first two segments (TS1–TS2 and TS2–TS3). The best pacers were athletes in the age group 40–44 years, who were able to achieve negative pacing in the last segment (TS3–Finish) of the race. The negative pacing in the last segment (TS3–Finish) was likely due to environmental conditions, such as early dawn and the flat circuit in segment TS3–Finish of the race.Keywords: running, men, long distance, master athlete

Matthias A Zingg,1 Beat Knechtle,1,2 Thomas Rosemann,1 Christoph A Rüst1 1Institute of Primary Care, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland Abstract: Anecdotal reports have assumed that women would be able to outrun men in long-distance running. The aim of this study was to test this assumption by investigating the changes in performance difference between sexes in the best ultramarathoners in 50-mile, 100-mile, 200-mile, 1,000-mile, and 3,100-mile events held worldwide between 1971 and 2012. The sex differences in running speed for the fastest runners ever were analyzed using one-way analysis of variance with subsequent Tukey–Kramer posthoc analysis. Changes in sex difference in running speed of the annual fastest were analyzed using linear and nonlinear regression analyses, correlation analyses, and mixed-effects regression analyses. The fastest men ever were faster than the fastest women ever in 50-mile (17.5%), 100-mile (17.4%), 200-mile (9.7%), 1,000-mile (20.2%), and 3,100-mile (18.6%) events. For the ten fastest finishers ever, men were faster than women in 50-mile (17.1%±1.9%), 100-mile (19.2%±1.5%), and 1,000-mile (16.7%±1.6%) events. No correlation existed between sex difference and running speed for the fastest ever (r2=0.0039, P=0.91) and the ten fastest ever (r2=0.15, P=0.74) for all distances. For the annual fastest, the sex difference in running speed decreased linearly in 50-mile events from 14.6% to 8.9%, remained unchanged in 100-mile (18.0%±8.4%) and 1,000-mile (13.7%±9.1%) events, and increased in 3,100-mile events from 12.5% to 16.9%. For the annual ten fastest runners, the performance difference between sexes decreased linearly in 50-mile events from 31.6%±3.6% to 8.9%±1.8% and in 100-mile events from 26.0%±4.4% to 24.7%±0.9%. To summarize, the fastest men were ~17%–20% faster than the fastest women for all distances from 50 miles to 3,100 miles. The linear decrease in sex difference for 50-mile and 100-mile events may suggest that women are reducing the sex gap for these distances. Keywords: running, sex difference, running speed, ultraendurance

Corinne Chmiel, Oliver Senn, Thomas Rosemann, Valerio Del Prete, Claudia Steurer-Stey Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland Background: Inadequate blood pressure (BP) control is a frequent challenge in general practice. The objective of this study was to determine whether a color-coded BP booklet using a traffic light scheme (red, >180 mmHg systolic BP and/or >110 mmHg diastolic BP; yellow, >140–180 mmHg systolic BP or >90–110 mmHg diastolic BP; green, ≤140 mmHg systolic BP and ≤90 mmHg diastolic BP) improves BP control and adherence with home BP measurement.Methods: In this two-group, randomized controlled trial, general practitioners recruited adult patients with a BP >140 mmHg systolic and/or >90 mmHg diastolic. Patients in the control group received a standard BP booklet and the intervention group used a color-coded booklet for daily home BP measurement. The main outcomes were changes in BP, BP control (treatment goal

Beat Knechtle,1 Matthias A Zingg,2 Thomas Rosemann,2 Christoph A Rüst21Gesundheitszentrum St Gallen, St Gallen, Switzerland; 2Institute of General Practice and Health Services Research, University of Zurich, Zurich, SwitzerlandAbstract: This study investigated changes in performance and sex difference in top performers for ultra-triathlon races held between 1978 and 2013 from Ironman (3.8 km swim, 180 km cycle, and 42 km run) to double deca iron ultra-triathlon distance (76 km swim, 3,600 km cycle, and 844 km run). The fastest men ever were faster than the fastest women ever for split and overall race times, with the exception of the swimming split in the quintuple iron ultra-triathlon (19 km swim, 900 km cycle, and 210.1 km run). Correlation analyses showed an increase in sex difference with increasing length of race distance for swimming (r2=0.67, P=0.023), running (r2=0.77, P=0.009), and overall race time (r2=0.77, P=0.0087), but not for cycling (r2=0.26, P=0.23). For the annual top performers, split and overall race times decreased across years nonlinearly in female and male Ironman triathletes. For longer distances, cycling split times decreased linearly in male triple iron ultra-triathletes, and running split times decreased linearly in male double iron ultra-triathletes but increased linearly in female triple and quintuple iron ultra-triathletes. Overall race times increased nonlinearly in female triple and male quintuple iron ultra-triathletes. The sex difference decreased nonlinearly in swimming, running, and overall race time in Ironman triathletes but increased linearly in cycling and running and nonlinearly in overall race time in triple iron ultra-triathletes. These findings suggest that women reduced the sex difference nonlinearly in shorter ultra-triathlon distances (ie, Ironman), but for longer distances than the Ironman, the sex difference increased or remained unchanged across years. It seems very unlikely that female top performers will ever outrun male top performers in ultra-triathlons. The nonlinear change in speed and sex difference in Ironman triathlon suggests that female and male Ironman triathletes have reached their limits in performance.Keywords: triathlon, swimming, cycling, running, ultra-endurance

Corinne Chmiel, Thomas Rosemann, Oliver SennInstitute of General Practice and Health Services Research, University of Zurich, Raemistrasse, Zurich, SwitzerlandBackground: To investigate characteristics of and satisfaction with psychiatric 24-hour emergency primary care performed by mandatory rotation of licensed psychiatrists as a viable baseline for possible reorganizational measures.Methods: This was a questionnaire-based cross-sectional study (November 2010–April 2011). The number of patient–psychiatrist encounters, modes of contact, and patient and psychiatrist characteristics were assessed. Diagnoses were coded with ICD-10 (International Classification of Diseases, version 10).Results: From 167 duty episodes, 74 (44%) were recorded. Of the psychiatrists (n44), 52% were female, and mean age (standard deviation) was 49.9 (5.2) years. The median number of encounters per episode was 4 (interquartile range 0–8), mainly in the evenings. Demand for “face-to-face” (direct) patient visits was significantly more common (64.0%) than practice (1.3%) or telephone consultations (34.7%). In 83.8%, psychiatrists judged the encounter as adequate at the patient’s location. A total of 43 different diagnoses were recorded: mainly schizophrenic disorders (23.9%), suicidal behavior (15.2%), and acute stress reactions (10.3%). Psychiatrists felt burdened by services (62.5%): in 39.2%, they felt threatened; and in 6.8%, violence occurred. In 32.4%, bills were not paid for. If services were optional, 45.2% would participate.Conclusion: Our findings indicate justified demand for direct mobile patient visits, suggesting that emergency care should be multifaceted, and sole provision of psychiatric care at stationed emergency facilities may not always be appropriate. Reorganization of 24-hour emergency services should carefully evaluate patient and provider’s needs before changing established structures.Keywords: primary health care, after-hours care, emergencies, satisfaction, psychiatry

Christoph Alexander Rüst,1 Beat Knechtle,1,2 Evelyn Eichenberger,1 Thomas Rosemann,1 Romuald Lepers31Institute of General Practice and for Health Services Research, University of Zurich, Zurich, 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3French Institute of Health and Medical Research, Faculty of Sport Sciences, University of Burgundy, Dijon, FranceBackground: This study examined changes according to age group in the number of finishers and running times for athletes in female and male mountain ultramarathoners competing in the 78 km Swiss Alpine Marathon, the largest mountain ultramarathon in Europe and held in high alpine terrain.Methods: The association between age and performance was investigated using analysis of variance and both single and multilevel regression analyses.Results: Between 1998 and 2011, a total of 1,781 women and 12,198 men finished the Swiss Alpine Marathon. The number of female finishers increased (r2 = 0.64, P = 0.001), whereas the number of male finishers (r2 = 0.18, P = 0.15) showed no change. The annual top ten men became older and slower, whereas the annual top ten women became older but not slower. Regarding the number of finishers in the age groups, the number of female finishers decreased in the age group 18–24 years, whereas the number of finishers increased in the age groups 30–34, 40–44, 45–49, 50–54, 55–59, 60–64, and 70–74 years. In the age groups 25–29 and 35–39 years, the number of finishers showed no changes across the years. In the age group 70–74 years, the increase in number of finishers was linear. For all other age groups, the increase was exponential. For men, the number of finishers decreased in the age groups 18–24, 25–29, 30–34, and 35–39 years. In the age groups 40–44, 45–49, 50–54, 55–59, 60–64, 70–74, and 75–79 years, the number of finishers increased. In the age group 40–44 years, the increase was linear. For all other age groups, the increase was exponential. Female finishers in the age group 40–44 years became faster over time. For men, finishers in the age groups 18–24, 25–29, 30–34, 40–44, and 45–49 years became slower.Conclusion: The number of women older than 30 years and men older than 40 years increased in the Swiss Alpine Marathon. Performance improved in women aged 40–44 years but decreased in male runners aged 18–49 years.Keywords: ultraendurance, female, male, age group

André Aschmann,1 Beat Knechtle,2 Marco Cribari,1 Christoph Alexander Rüst,1 Vincent Onywera,3 Thomas Rosemann,1 Romuald Lepers4 1Institute of General Practice and for Health Services Research, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3Department of Recreation Management and Exercise Science, Kenyatta University, Kenya; 4Institut National de la Santé et de la Recherche Médicale, Faculty of Sport Sciences, University of Burgundy, Dijon, France Background: Endurance running performance of African (AF) and non-African (NAF) athletes is investigated, with better performances seen for Africans. To date, no study has compared the age of peak performance between AF and NAF runners. The present research is an analysis of the age and running performance of top AF and NAF athletes, using the hypothesis that AF athletes were younger and faster than NAF athletes. Methods: Age and performance of male and female AF and NAF athletes in half-marathons and marathons held in Switzerland in 2000–2010 were investigated using single and multilevel hierarchical regression analyses. Results: For half-marathons, male NAF runners were older than male AF runners (P = 0.02; NAF, 31.1 years ± 6.4 years versus AF, 26.2 years ± 4.9 years), and their running time was longer (P = 0.02; NAF, 65.3 minutes ± 1.7 minutes versus AF, 64.1 minutes ± 0.9 minutes). In marathons, differences between NAF and AF male runners in age (NAF, 33.0 years ± 4.8 years versus AF, 28.6 years ± 3.8 years; P < 0.01) and running time (NAF, 139.5 minutes ± 5.6 minutes versus AF, 133.3 minutes ± 2.7 minutes; P < 0.01) were more pronounced. There was no difference in age (NAF, 31.0 years ± 7.0 years versus AF, 26.7 years ± 6.0 years; P > 0.05) or running time (NAF, 75.0 minutes ± 3.7 minutes versus AF, 75.6 minutes ± 5.3 minutes; P > 0.05) between NAF and AF female half-marathoners. For marathoners, NAF women were older than AF female runners (P = 0.03; NAF, 31.6 years ± 4.8 years versus AF, 27.8 years ± 5.3 years), but their running times were similar (NAF, 162.4 minutes ± 7.2 minutes versus AF, 163.0 minutes ± 7.0 minutes; P > 0.05). Conclusion: In Switzerland, the best AF male half-marathoners and marathoners were younger and faster than the NAF counterpart runners. In contrast to the results seen in men, AF and NAF female runners had similar performances. Future studies need to investigate performance and age of AF and NAF marathoners in the World Marathon Majors Series. Keywords: endurance, running, ethnicity, road race, gender difference

Saskia Carolin Jampen,1 Beat Knechtle,1,2 Christoph Alexander Rüst,1 Romuald Lepers,3 Thomas Rosemann11Institute of General Practice and for Health Services Research, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3INSERM U1093, Faculty of Sport Sciences, University of Burgundy, Dijon, FranceAim: The aim of the study was to examine finisher and performance trends of ultrarunners in the Marathon des Sables, the world's largest multistage ultramarathon.Methods: The age and running speed was analyzed for 6945 finishes of 909 women and 6036 men between 2003 and 2012 at the Marathon des Sables covering about 240 km in the Moroccan desert.Results: The number of finishes increased significantly for both women and men from 2003–2012. The annual number of finishes increased in age groups: 30–34 years (r2 = 0.50; P = 0.021), 45–49 years (r2 = 0.81; P = 0.0004), and 50–54 years (r2 = 0.46; P = 0.029) for women and in all age groups older than 35 years for men (35–39 years: r2 = 0.64, P = 0.0054; 40–44 years: r2 = 0.67, P = 0.0036; 45–49 years: r2 = 0.77, P = 0.0007; 50–54 years: r2 = 0.72, P = 0.0018; 55–59 years: r2 = 0.42, P = 0.041; and 60–64 years: r2 = 0.67, P = 0.0038). The fastest running speed was achieved by runners in the age group of 35–39 years for both sexes. The mean age of overall finishers was 41.0 ± 9.1 years for women and 41.3 ± 9.5 years for men. For men, running speed improved for athletes in the age group of 35–39 years (r2 = 0.44; P = 0.036) and of 40–44 years (r2 = 0.51; P = 0.019), while it decreased for athletes in the age group of 30–34 years (r2 = 0.66, P = 0.0039). For women, running speed remained stable during the study period for athletes in all age groups.Conclusion: These data suggest that the number of finishers of masters runners older than 40 years increased for both sexes at the Marathon des Sables, as has been previously observed for single-stage ultramarathons. In contrast to women, men aged 35 to 44 years improved running speed during the study period. Future studies are needed to investigate the reasons for the growing numbers of masters athletes in endurance sports and their improvement in performance.Keywords: age group, athlete, ultraendurance, running speed

Christoph Alexander Rüst,1 Beat Knechtle,1,2 Thomas Rosemann11Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, SwitzerlandAbstract: The cases of two brothers training and competing as master cyclists and both preparing for a cycling tour are presented. The older brother aged 66 years went first to the primary care physician and presented with an asymptomatic depression in the exercise stress test of the ST segment in V5 and V6 during recovery after complete exhaustion. Coronary angiography revealed a multi vessel coronary artery disease and he underwent bypass surgery. One year later, he successfully completed his planned cycling tour of ~600 km in seven stages and covering ~12,000 m of total ascent. The younger brother aged 59 years went a few months later to the primary care physician and also performed asymptomatic exercise stress testing without changes in the ST segments. Unfortunately, 2 months later he suffered a cardiac arrest during his cycling tour and survived following immediate successful cardiopulmonary resuscitation on the road by his cycling colleagues. Immediate invasive coronary arteriography showed a complete stenosis of the trunk of arteria coronaria sinistra (left coronary artery), a 40%–50% stenosis of ramus circumflexus, and a 20% stenosis of arteria coronaria dextra (right coronary artery). The left coronary artery was dilated and he continued cycling 2 months later. In both brothers, familial hypercholesterolemia was the main cardiovascular risk factor for the multi vessel coronary artery disease. A negative exercise electrocardiogram in siblings with an increased risk for coronary artery disease seemed not to exclude an advanced multi vessel coronary artery disease. In master athletes with asymptomatic exercise electrocardiogram but a positive family history, further examinations should be performed in order to detect relevant stenosis in coronary arteries.Keywords: cyclist, exercise stress test, electrocardiogram, coronary artery, hypercholesterolemia

Uwe Teutsch,1 Beat Knechtle,1,2 Christoph Alexander Rüst,1 Thomas Rosemann,1 Romuald Lepers31Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3INSERM U1093, Faculty of Sport Sciences, University of Burgundy, Dijon, FranceBackground: Participation and performance trends in age group athletes have been investigated in endurance and ultraendurance races in swimming, cycling, running, and triathlon, but not in long-distance inline skating. The aim of this study was to investigate trends in participation, age, and performance in the longest inline race in Europe, the Inline One-Eleven over 111 km, held between 1998 and 2009.Methods: The total number, age distribution, age at the time of the competition, and race times of male and female finishers at the Inline One-Eleven were analyzed.Results: Overall participation increased until 2003 but decreased thereafter. During the 12-year period, the relative participation in skaters younger than 40 years old decreased while relative participation increased for skaters older than 40 years. The mean top ten skating time was 199 ± 9 minutes (range: 189–220 minutes) for men and 234 ± 17 minutes (range: 211–271 minutes) for women, respectively. The gender difference in performance remained stable at 17% ± 5% across years.Conclusion: To summarize, although the participation of master long-distance inline skaters increased, the overall participation decreased across years in the Inline One-Eleven. The race times of the best female and male skaters stabilized across years with a gender difference in performance of 17% ± 5%. Further studies should focus on the participation in the international World Inline Cup races.Keywords: endurance, men, women, gender

Matthias Zingg,1 Beat Knechtle,1,2 Christoph A Rüst,1 Thomas Rosemann,1 Romuald Lepers3 1Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3INSERM U1093, Faculty of Sport Sciences, University of Burgundy, Dijon, France Background: Participation and performance trends for athletes by age group have been investigated for marathoners and ultramarathoners competing in races up to 161 km, but not for longer distances of more than 200 km. Methods: Participation and performance trends in athletes by age group in the Badwater (217 km) and Spartathlon (246 km) races were compared from 2000 to 2012. Results: The number of female and male finishers increased in both races across years (P < 0.05). The age of the annual five fastest men decreased in Badwater from 42.4 ± 4.2 years to 39.8 ± 5.7 years (r2 = 0.33, P = 0.04). For women, the age remained unchanged at 42.3 ± 3.8 years in Badwater (P > 0.05). In Spartathlon, the age of the annual five fastest finishers was unchanged at 39.7 ± 2.4 years for men and 44.6 ± 3.2 years for women (P > 0.05). In Badwater, running speed increased in men from 7.9 ± 0.7 km/hour to 8.7 ± 0.6 km/hour (r2 = 0.51, P < 0.01) and in women from 5.4 ± 1.1 km/hour to 6.6 ± 0.5 km/hour (r2 = 0.61, P < 0.01). In Spartathlon, running speed remained unchanged at 10.8 ± 0.7 km/hour in men and 8.7 ± 0.5 km/hour in women (P > 0.05). In Badwater, the number of men in age groups 30–34 years (r2 = 0.37, P = 0.03) and 40–44 years (r2 = 0.75, P < 0.01) increased. In Spartathlon, the number of men increased in the age group 40–44 years (r2 = 0.33, P = 0.04). Men in age groups 30–34 (r2 = 0.64, P < 0.01), 35–39 (r2 = 0.33, P = 0.04), 40–44 (r2 = 0.34, P = 0.04), and 55–59 years (r2 = 0.40, P = 0.02) improved running speed in Badwater. In Spartathlon, no change in running speed was observed. Conclusion: The fastest finishers in ultramarathons more than 200 km in distance were 40–45 years old and have to be classified as “master runners” by definition. In contrast to reports of marathoners and ultramarathoners competing in races of 161 km in distance, the increase in participation and the improvement in performance by age group were less pronounced in ultramarathoners competing in races of more than 200 km. Keywords: ultra-endurance, master runner, running speed, sex difference

Matthias A Zingg,1 Beat Knechtle,1,2 Christoph Alexander Rüst,1 Thomas Rosemann,1 Romuald Lepers3 1Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3INSERM U1093, Faculty of Sport Sciences, University of Burgundy, Dijon, France Background: The performance in master marathoners has been investigated in flat city marathons but not in mountain marathons. This study examined changes in the sex differences in performance across time in female and male master runners competing in a mountain marathon compared to a flat city marathon. Methods: The association between age and performance of finishers in the Jungfrau Marathon, Switzerland, with 1830 meter changes in altitude and a flat city marathon (Lausanne Marathon), Switzerland, were analyzed from 2000 to 2011. Results: In both events, athletes in the 35–44 years age group showed the highest number of finishers. In the mountain marathon, the number of female master runners aged > 35 years increased in contrast to female finishers aged < 35 years, while the number of male finishers was unchanged in all age groups. In the city marathon, the number of female finishers was unchanged while the number of male finishers in the age groups for 25–34-year-olds and 35–44-year-olds decreased. In female marathoners, performance improved in athletes aged 35–44 and 55–64 years in the city marathon. Male marathoners improved race time in age group 45–54 years in both the city marathon and the mountain marathon. Female master runners reduced the sex difference in performance in the 45–54-year age group in both competitions and in the 35–44-year age group in the mountain marathon. The sex difference in performance decreased in the 35–44-year age group from 19.1% ± 4.7% to 16.6% ± 1.9% in the mountain marathon (r2 = 0.39, P = 0.03). In age groups 45–54 years, the sex difference decreased from 23.4% ± 1.9% to 15.9% ± 6.1% in the mountain marathon (r2 = 0.39, P < 0.01) and from 34.7% ± 4.6% to 11.8% ± 6.2% in the city marathon (r2 = 0.39, P < 0.01). Conclusion: These findings suggest that female master runners aged 35–54 years reduced sex differences in their performance in both mountain and city marathon running. Keywords: endurance, age, female, male

Klaus Karner-Rezek,1 Beat Knechtle,2,3 Matthias Fenzl,4 Christian Schlegel,4 Manuela Konrad,5 Thomas Rosemann2 1Private University of the Principality of Liechtenstein, Triesen, Principality of Liechtenstein, 2Institute of General Practice and for Health Services Research, University of Zurich, Zurich, Switzerland; 3Gesundheitszentrum St Gallen, St Gallen, Switzerland; 4Swiss Olympic Medical Center, Medizinisches Zentrum Bad Ragaz, Switzerland; 5University of Applied Sciences JOANNEUM, Bad Gleichenberg, Austria Background: High intensity exercise is considered as an effective means for reducing body fat. The aims of the present study were to investigate (1) whether body mass would be lost and body composition would change and (2) whether variables of anaerobic fitness prior to the intervention period would be related to loss of body mass and changes in body composition in overweight and obese children and adolescents. Methods: A total of 28 children and adolescents (19 boys, 9 girls) attended an 8-week multicomponent inpatient program. Caloric intake was based on the subject's weight and a daily energy deficit of ~500 kcal was targeted. At the beginning and at the end of the program, variables of anaerobic fitness were assessed using Wingate tests. Body composition was measured before and after the program using dual-energy X-ray absorptiometry. Results: Body mass decreased by 11.4% ± 1.6% in boys and by 11.0% ± 2.8% in girls (P < 0.001). Fat mass decreased by 23.8% ± 6.1% in boys and by 21.5% ± 5.2% in girls (P < 0.001). The decrease in fat mass was associated with the decrease in body mass in boys (r = 0.54, P = 0.017) but not in girls (P > 0.05). The decrease in body mass and the decrease in fat mass were neither associated with overall energy expenditure nor with the energy deficit in both genders (P > 0.05). Mean power in W/kg increased in the Wingate tests by 95.4% ± 109.1% in boys and by 100.0% ± 119.9% in girls (P < 0.001). Conclusions: Adjustments of the chronically positive imbalance of energy intake and energy expenditure of obese children and adolescents living in obesogenic environments should be addressed in a multisectoral approach. Future research in multicomponent childhood and adolescent weight loss programs should be directed towards a better understanding of the underlying complex dynamics in energy homeostasis which promote weight loss and changes in body composition due to high intensity exercise interventions. Keywords: obesity, dual-energy X-ray absorptiometry, Wingate test, training, diet

Christof Buhl,1 Beat Knechtle,1,2 Christoph Alexander Rüst,1 Thomas Rosemann,1 Romuald Lepers31Institute of General Practice and for Health Services Research, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3Faculty of Sport Sciences, University of Burgundy, Dijon, FranceAbstract: The change in swim performance over time has been investigated for freestyle, but not for other strokes, such as in the medley. The aim of the study was to examine changes in 200 m and 400 m swim performances in medley swimmers at national (Switzerland) and international level (world championship finals) from 1994 to 2011. The 200 m and 400 m freestyle performances were also analyzed for comparison. Swim performances were analyzed using linear regression and one-way analysis of variance. Male Swiss swimmers improved swim speed by 5.4% in the 200 m medley, 5.3% in the 200 m freestyle, 5.1% in the 400 m medley, and 5.7% in the 400 m freestyle (P < 0.01). Female Swiss swimmers improved swim speed by 4.4% in the 200 m medley, 3.3% in the 200 m freestyle, 3.9% in the 400 m medley, and 3.4% in the 400 m freestyle (P < 0.05). Male swimmers at international level improved swim speed by 4.5% in the 200 m medley, 4.6% in the 200 m freestyle, 2.6% in the 400 m medley, and 2.7% in the 400 m freestyle (P < 0.01). Female swimmers improved swim speed by 4.3% in the 200 m medley, 3.5% in the 400 m medley, and 3.1% in the 400 m freestyle (P ≤ 0.02), but 200 m freestyle performance remained unchanged (P > 0.05). The sex difference in national swim performance remained unchanged at 10.2% ± 0.6% for the 200 m medley (P > 0.05) and increased from 8.8% to 9.8% for the 400 m medley (P < 0.05). In freestyle, it increased from 8.8% to 10.7% in the 200 m, and from 7.8% to 9.4% in the 400 m (P < 0.01). The sex difference in international athletes remained unchanged at 11.1% ± 0.9% in the 200 m medley, 10.1% ± 0.8% in the 400 m medley, 10.0% ± 1.3% in the 200 m, and 9.2% ± 0.6% in the 400 m freestyle (P > 0.05). For the 400 m medley, the sex difference was lower compared to the 200 m medley for national (9.3% ± 0.8% vs 10.2% ± 0.6%, P = 0.01) and for international (10.1% ± 0.8% vs 11.1% ± 0.9%) athletes. For the 400 m freestyle, the sex difference was lower compared to the 200 m freestyle for national (7.9% ± 0.9% vs 9.3% ± 0.8%) and international (9.2% ± 0.6% vs 10.0% ± 1.3%) athletes (P < 0.01), and lower in the freestyle than the medley for the same distances (P < 0.01). Future studies should investigate the reasons for the greater sex difference in the medley than the freestyle.Keywords: men, women, athlete, swimming

Michael Stiefel,1 Christoph Alexander Rüst,1 Thomas Rosemann,1 Beat Knechtle2 1Institute of General Practice and for Health Services Research, University of Zurich, Zurich, 2Gesundheitszentrum St Gallen, St Gallen, Switzerland Background: Athletes intending to compete in Ironman Hawaii need to qualify in an age-group based qualification system. We compared participation and top ten performances of athletes in various age groups between Ironman Hawaii and its qualifier races.Methods: Finishes in Ironman Hawaii and in its qualifier races in 2010 were analyzed in terms of performance, age, and sex. Athletes were categorized into age groups from 18–24 to 75–79 years and split and race times were determined for the top ten athletes in each age group.Results: A higher proportion of athletes aged 25–49 years finished in the qualifier races than in Ironman Hawaii. In athletes aged 18–24 and 50–79 years, the percentage of finishes was higher in Ironman Hawaii than in the qualifier races. For women, the fastest race times were slower in Ironman Hawaii than in the qualifier races for those aged 18–24 (P < 0.001), 25–29 (P < 0.05), and 60–64 (P < 0.05) years. Swim split times were slower in Ironman Hawaii than in the qualifier races for all age groups (P < 0.05). Cycling times were slower in Ironman Hawaii for 18–24, 25–29, 40–44, 50–54, and 60–64 years (P < 0.05) in age groups. For men, finishers aged 18–24 (P < 0.001), 40–44 (P < 0.001), 50–54 (P < 0.01), 55–59 (P < 0.001), 60–64 (P < 0.01), and 65–69 (P < 0.001) years were slower in Ironman Hawaii than in the qualifier races. Swim split times were slower in Ironman Hawaii than in the qualifier races for all age groups (P < 0.05). Cycling times were slower in Ironman Hawaii for those aged 18–24 and those aged 40 years and older (P < 0.05).Conclusion: There are differences in terms of participation and performance for athletes in different age groups between Ironman Hawaii and its qualifier races. Triathletes aged 25–49 years and men generally were underrepresented in Ironman Hawaii compared with in its Ironman qualifier races. These athletes may have had less chance to qualify for Ironman Hawaii than female athletes or younger (50 years) athletes. Keywords: triathlon, ultra-endurance, swimming, cycling, running

Mohannad Abou Shoak,1 Beat Knechtle,1,2 Patrizia Knechtle,2 Christoph Alexander Rüst,1 Thomas Rosemann,1 Romuald Lepers31Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3INSERM U1093, Faculty of Sport Sciences, University of Burgundy, Dijon, FranceBackground: Participation and performance trends have been investigated in ultramarathons and ultratriathlons but not in ultracycling. The aim of the present study was to investigate (1) participation and performance trends in ultraendurance cyclists, (2) changes in cycling speed over the years, and (3) the age of the fastest male and female ultraendurance cyclists.Methods: Participation and performance trends in the 5000 km Race Across America (RAAM) and in two RAAM-qualifier races – the 818 km Furnace Creek 508 in the United States and the 715 km Swiss Cycling Marathon in Europe – were investigated using linear regression analyses and analyses of variance.Results: On average, ~41% of participants did not finish either the RAAM or the Furnace Creek 508, whereas ~26% did not finish the Swiss Cycling Marathon. Female finishers accounted for ~11% in both the RAAM and the Furnace Creek 508 but only ~3% in the Swiss Cycling Marathon. The mean cycling speed of all finishers remained unchanged during the studied periods. The winner’s average speed was faster for men than for women in the RAAM (22.6 ± 1.1 km · h-1 versus 18.4 ± 1.7 km · h-1, respectively; average speed difference between male and female winners, 25.0% ± 11.9%), the Swiss Cycling Marathon (30.8 ± 0.8 km · h-1 versus 24.4 ± 1.9 km · h-1, respectively; average speed difference between male and female winners, 27.8% ± 9.4%), and the Furnace Creek 508 (27.4 ± 1.6 km · h-1 versus 23.4 ± 3.0 km · h-1, respectively; average speed difference between male and female winners, 18.4% ± 13.9%). In both the Furnace Creek 508 and the Swiss Cycling Marathon, ~46% of the finishers were aged between 35 and 49 years. The mean age of winners, both male and female, across the years in the Furnace Creek 508 and in the Swiss Cycling Marathon was 37 ± 10 years.Conclusion: These findings in ultracycling races showed that (1) ~26%–40% of starters were unable to finish, (2) the percentage of female finishers was ~3%–11%, (3) the gender difference in performance was ~18%–28%, and (4) ~46% of the successful finishers were master athletes. Future studies need to investigate the reasons for the low female participation and focus on the age-related performance decline in other ultraendurance events in order to confirm that master athletes are predisposed to ultraendurance performances.Keywords: ultraendurance, finisher, speed, gender difference, master athlete, cycling

Mohannad Abou Shoak,1 Beat Knechtle,1,2 Christoph Alexander Rüst,1 Romuald Lepers,3 Thomas Rosemann11Institute of General Practice and for Health Services Research, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3INSERM U1093, Faculty of Sport Sciences, University of Burgundy, Dijon, FranceBackground: Participation and performance trends regarding the nationality of ultraendurance athletes have been investigated in the triathlon, but not in running. The present study aimed to identify the countries in which multistage ultramarathons were held around the world and the nationalities of successful finishers.Methods: Finisher rates and performance trends of finishers in multistage ultramarathons held worldwide between 1992 and 2010 were investigated.Results: Between 1992 and 2010, the bulk of multistage ultramarathons were held in Germany and France, with more than 30 races organized in each country. Completion rates for men and women increased exponentially, with women representing on average 16.4% of the total field. Since 1992, 6480 athletes have competed in Morocco, 2538 in Germany, and 1842 in France. A total of 81.9% of athletes originated from Europe, and more specifically from France (22.9%), Great Britain (18.0%), and Germany (13.4%).Conclusion: European ultramarathoners dominated the athletes who completed multistage ultramarathons worldwide, with specific dominance of French, British, and German athletes. Future studies should investigate social aspects, such as sport tourism, among European athletes to understand why European athletes are so interested in participating in multistage ultramarathons.Keywords: ultraendurance, run, nationality, distance, stage

Christoph Alexander Rüst,1 Beat Knechtle,1,2 Thomas Rosemann11Institute of General Practice and for Health Services Research, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, SwitzerlandBackground: The age of peak swim performance has been investigated for freestyle swimmers for distances ranging from 50 m to 1500 m among swimmers aged 19 to 99 years. However, studies have yet to investigate the 10 to 19 year-old age group. The aims of the present study were (1) to investigate the age range of peak freestyle swim speed, and (2) to find differences in age range and peak freestyle swim speed between male and female freestyle swimmers from 50 m to 1500 m at a national level.Methods: The changes in age range and peak freestyle swim speed among Swiss elite freestyle swimmers aged 0–9 years and 70–79 years who were ranked on the Swiss high score list between 2006 and 2010 were analyzed using linear regression analyses and analysis of variance.Results: Men were fastest at ages 22–23 years for 100 m and 200 m; at ages 24–25 years for 400 m and 800 m; and at 26–27 years for 50 m and 1500 m. Women achieved peak freestyle swim speed at ages 20–21 years for all distances with the exception of 800 m. In the 800 m, women were fastest at ages 26–27 years. The difference in peak freestyle swim speed decreased with increasing swim distance from 50 m to 800 m (ie, 13.1% ± 1.3% in 50 m; 13.2% ± 0.9% in 100 m; 10.8% ± 0.9% in 200 m; 7.9% ± 1.3% in 400 m; and 4.2% ± 2.0% in 800 m). For 1500 m, however, the gender difference increased to 6.4% ± 2.3%.Conclusion: These findings suggest that peak freestyle swim speed is achieved at lower age ranges in women when compared to men at 50 m to 1500 m, but not at 800 m. The gender difference in peak freestyle swim speed decreased with increasing swim distance from 50 m to 800 m, but not for 1500 m. These data should be confirmed with swimmers at an international level.Keywords: gender, performance, endurance, athlete

Nina Badertscher, Seraina Morell, Thomas Rosemann, Ryan TandjungInstitute of General Practice and Health Services Research, University of Zurich, Zurich, SwitzerlandIntroduction: Diseases caused by Streptococcus pneumoniae generate substantial morbidity and mortality. Despite official recommendations to vaccinate everyone over the age of 64, the estimated vaccination rate for this target population is around 2%. In Switzerland, pneumococcal vaccinations are for the most part provided by general practitioners (GPs); in addition, a small number of patients get vaccinated during a hospital stay. We wanted to investigate GPs' attitudes and opinions about the pneumococcal vaccination in primary care and why it is so rarely provided.Methods: For this qualitative study, we conducted semistructured interviews with 20 GPs. Transcriptions of all interviews were analyzed following the technique of qualitative content analysis, supported by the ATLAS.ti© software.Results: Most GPs reported that they know pneumococcal vaccination is recommended for several risk groups and elderly patients. As to reasons for the low vaccination rate, GPs mentioned the pneumococcal vaccination had little priority in daily practice, especially in comparison with the importance of other vaccinations, namely influenza. This low level of priority was supported by the fact that the GPs rarely ever experienced a case of a severe pneumococcal disease in their daily work. Furthermore, perceived insufficient evidence resulting from existing epidemiologic data and clinical trials enhanced the little attention given to the pneumococcal vaccination.Conclusion: We found the generally low level of priority given within a consultation, the missing awareness of this subject in daily practice, and the perception of epidemiologic and scientific data as insufficient, as the reasons for the low rate in pneumococcal vaccinations. Efforts to increase the epidemiologic data on the pneumococcal vaccination should be taken. To increase the vaccination rate, it would be necessary to raise the awareness and priority of the pneumococcal vaccination; a feasible way could be the combination of the seasonal flu vaccination campaign with a campaign for pneumococcal vaccination.Keywords: prevention, Swiss primary care, barriers and facilitators, Streptococcus pneumoniae

Christoph Alexander Rüst,1 Beat Knechtle,1,2 Patrizia Knechtle,2 Thomas Rosemann,1 Romuald Lepers31Institute of General Practice and for Health Services Research, University of Zurich, 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3INSERM U1093, Faculty of Sport Sciences, University of Burgundy, Dijon, FranceBackground: The age of peak performance in elite endurance athletes has been investigated for elite marathoners, but not for elite Ironman triathletes. The aim of this study was to analyze the age of peak performance in swimming (3.8 km), cycling (180 km), running (42 km), and overall race time for elite female and male Ironman triathletes competing in Ironman Switzerland, a qualifier for the Ironman world championship, known as the Ironman Hawaii.Methods: The age of the annual top ten overall swimmers, cyclists, runners, and annual overall finishers for both male and female elite triathletes and their corresponding split and overall race times at the Ironman Switzerland were analyzed between 1995 and 2011.Results: The mean age of the elite Ironman triathletes was 33 ± 3 years for men and 34 ± 4 years for women. For women, the age of peak performance was not significantly different between the three disciplines (P > 0.05), while for men, the best swimmers (29 ± 3 years) were significantly (P < 0.05) younger than the best runners (35 ± 5 years). During the study period, the age of peak performance remained unchanged for men at 31 ± 3 years (P > 0.05), but increased for women from 30 ± 4 years in 1995 to 36 ± 5 years in 2011 (P < 0.01).Conclusion: Although both women and men improved their overall race times during the 1995–2011 period, the age of peak performance was similar between women and men in the three disciplines and in overall race time. Future studies need to examine the change in age of peak performance across years in the Ironman Hawaii world championship event.Keywords: gender difference, swimming, cycling, running, ultraendurance

Christoph Alexander Rüst,1 Beat Knechtle,1,2 Patrizia Knechtle,2 Thomas Rosemann11Institute of General Practice and for Health Services Research, University of Zurich, Zurich, 2Gesundheitszentrum St Gallen, St Gallen, SwitzerlandBackground: Of the anthropometry and training variables used to predict race performance in a 24-hour ultrarun, the personal best marathon time is the strongest predictor in recreational male 24-hour ultramarathoners. This finding raises the question of whether similarities exist between male recreational 24-hour ultramarathoners and male recreational marathoners.Methods: The association between age, anthropometric variables (ie, body mass, body height, body mass index, percent body fat, skeletal muscle mass, limb circumference, and skinfold thickness at the pectoral, mid axillary, triceps, subscapular, abdominal, suprailiac, front thigh, and medial calf sites), previous experience and training characteristics (ie, volume, speed, and personal best time), and race time for 79 male recreational 24-hour ultramarathoners and 126 male recreational marathoners was investigated using bivariate and multivariate analysis.Results: The 24-hour ultramarathoners were older (P < 0.05), had a lower circumference at both the upper arm (P < 0.05) and thigh (P < 0.01), and a lower skinfold thickness at the pectoral, axillary, and suprailiac sites (P < 0.05) compared with the marathoners. During training, the 24-hour ultramarathoners were running for more hours per week (P < 0.001) and completed more kilometers (P < 0.001), but were running slower (P < 0.01) compared with the marathoners. In the 24-hour ultramarathoners, neither anthropometric nor training variables were associated with kilometers completed in the race (P > 0.05). In the marathoners, percent body fat (P < 0.001) and running speed during training (P < 0.0001) were related to marathon race times.Conclusion: In summary, differences in anthropometric and training predictor variables do exist between male recreational 24-hour ultramarathoners and male recreational marathoners for race performance.Keywords: endurance, performance, athlete, body fat, skinfold thickness

Katrin Sigg,1 Beat Knechtle,1,2 Christoph Alexander Rüst,1 Patrizia Knechtle,2 Romuald Lepers,3 Thomas Rosemann11Institute of General Practice and Health Services Research, University of Zurich, Zurich; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3INSERM U1093, Faculty of Sport Sciences, University of Burgundy, Dijon, FranceBackground: A recent study showed that European triathletes performed faster in Double Iron ultratriathlons than North American athletes. The present study analyzed triathletes participating in Double Iron ultratriathlons to determine the origin of the fastest Double Iron ultratriathletes, focusing on European countries.Methods: Participation and performance trends of finishers in Double Iron ultratriathlons from 1985–2011 of the different countries were investigated. Additionally, the performance trends of the top three women and men overall from 2001–2011 were analyzed.Results: A total of 1490 finishers originated from 24 different European countries and the United States. The number of European triathletes increased for both women (r2 = 0.56; P < 0.01) and men (r2 = 0.63; P < 0.01). The number of the North American triathletes increased for women (r2 = 0.25; P < 0.01), but not for men (r2 = 0.02; P > 0.05). Hungarian triathletes showed a significant improvement in both overall race times and in cycling split times, Swiss triathletes improved both their swim and run times, and French triathletes improved their swim times.Conclusion: Men and women triathletes from Central European countries such as France, Germany, Switzerland, and Hungary improved Double Iron ultratriathlon overall race times and split times during the 26-year period. The reasons might be the social and economic factors required to be able to participate in such an expensive and lavish race. Also, a favorable climate may provide the ideal conditions for successful training. Future studies need to investigate the motivational aspects of European ultraendurance athletes.Keywords: triathlon, ultraendurance, swimming, cycling, running

Beat Knechtle,1,2 Sabrina Baumgartner,1 Patrizia Knechtle,2 Christoph Alexander Rüst,1 Thomas Rosemann,1 Raúl Bescós31Institute of General Practice and Health Services Research, University of Zurich, Zurich; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3National Institute of Physical Education, Barcelona, SpainBackground: Changes in single skinfold thickness and body fat have been investigated in ultraswimmers and ultracyclists, but not in ultrarunners. The present study investigated the changes in single skinfold thickness during a 100 km ultramarathon.Methods: Firstly, we investigated associations between prerace preparation and prerace body composition and, secondly, changes in single skinfold thickness during a 100 km ultramarathon in 219 male ultramarathoners. Changes in fat mass and skeletal muscle were estimated using anthropometric methods.Results: Kilometers run weekly prerace and running speed during training were negatively associated with all skinfold thicknesses (P < 0.05) except for the front thigh skinfold. During the race, skinfold thickness at the pectoral (−0.1%), suprailiac (−1.8%), and calf (−0.8%) sites decreased (P < 0.05). The subjects lost 1.9 ± 1.4 kg of body mass (P < 0.001), 0.7 ± 1.0 kg of estimated skeletal muscle mass (P < 0.001), and 0.2 ± 1.3 kg of estimated fat mass (P < 0.05). The decrease in body mass was positively related to the decrease in both estimated skeletal muscle mass (r = 0.21, P = 0.0017) and estimated fat mass (r = 0.41, P < 0.0001).Conclusion: Firstly, prerace fat mass and prerace skinfold thickness were associated with both volume and speed in running training. Secondly, during the ultramarathon, skinfold thickness decreased at the pectoral, suprailiac, and calf sites, but not at the thigh site. Percent decreases in skinfold thickness for ultrarunners was lower than the percent decreases in skinfold thickness reported for ultraswimmers and ultracyclists.Keywords: endurance, athlete, fat mass, muscle mass, adipose subcutaneous tissue

Kaspar Kälin,1 Beat Knechtle,1,2 Christoph Alexander Rüst,1 Karsten Mydlak,3 Thomas Rosemann11Institute of General Practice and Health Services Research, University of Zurich, Zurich; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3Gemeinschaftslabor Cottbus, Medizinisches Versorgungszentrum für Labormedizin, Mikrobiologie und Infektionsepidemiologie, Cottbus, GermanyBackground: We describe a runner who completed a self-paced marathon (42.195 km) in a climate chamber with a temperature difference of 100°C, starting at an ambient temperature (Tambient) of −45°C and finishing at an Tambient of +55°C.Methods: Tambient was set at −45°C at the start, and was steadily increased at a rate of 1°C at 4.5-minute intervals to +55°C. Before the start, after every 10.5 km, and at the end of the marathon, body mass, urine, and sweat production were measured and samples of venous blood and urine were collected. The runner’s temperature was recorded every 10 seconds at four sites, ie, the rectum for body core temperature (Tcore), and at the forehead, right wrist, and right ankle for surface temperatures (Tskin).Results: The subject took 6.5 hours to complete the marathon, during which Tcore varied by 0.9°C (start 37.5°C, peak 38.4°C). The largest difference (Δ) of Tskin was recorded at the ankle (Δ16°C). The calculated amount of sweat produced increased by 888% from baseline. In the blood samples, myoglobin (+250%) showed the highest change. Of the pituitary hormones, somatotropic hormone (+391%) and prolactin (+221%) increased the most. Regarding fluid regulation hormones, renin (+1145%) and aldosterone (+313%) showed the greatest increase.Conclusion: These results show that running a marathon in a climate chamber with a total ΔTambient of 100°C is possible, and that the Tambient to Tcore relationship is maintained. These results may offer insight into regulatory mechanisms to avoid hypothermia and hyperthermia. The same study is to be performed using more subjects with the same characteristics to validate the present findings.Keywords: endocrine regulation, thermoregulation, skin temperature, ambient temperature, sweat production

Christoph Alexander Rüst,1 Beat Knechtle,1,2 Thomas Rosemann,1 Felix Wermelinger31Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland; 2St Gallen Health Center, St Gallen, Switzerland; 3Department of Rheumatology, University Hospital, University of Bern, SwitzerlandAbstract: The case of a married couple developing polymyalgia rheumatica (PMR) consecutively is presented. The 55-year-old wife complained in June 2010 about pain in her neck. Case history, physical examination, and erythrocyte sedimentation rate (ESR) of 80 mm/hour led to the diagnosis of PMR. In May 2011, her 66-year old husband complained about pain in his neck, shoulders, buttocks, and thighs. Considering anamnesis, physical examination, and ESR of 56 mm/hour, the diagnosis of PMR was made. Both wife and husband responded to steroid treatment. When the steroid dose was gradually reduced, both patients relapsed. In order to lower the cumulative dose of glucocorticoid therapy, 10 mg methotrexate per week was added. In the literature, six cases of polymyalgia rheumatica in married couples have been described to date. In four cases, polymyalgia rheumatica occurred first in the wife. The interval of the diagnosis between the spouses ranged from 0 to 89 months. Although in most of the previous case reports a genetic disposition and an infectious agent have been discussed, this hypothesis must be questioned.Keywords: husband, wife, erythrocyte sedimentation rate, C-reactive protein, polymyalgia rheumatica

Evelyn Eichenberger,1 Beat Knechtle,1,2 Christoph Alexander Rüst,1 Thomas Rosemann,1 Romuald Lepers31Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3INSERM U1093, Faculty of Sport Sciences, University of Burgundy, Dijon, FranceBackground: The aims of the study were to examine the (a) participation, (b) difference in running times between the sexes, and (c) age-related decline in the running times of ultramarathoner women and men competing in the Swiss Alpine Marathon from 1998 to 2011.Methods: The ultramarathoners competing in the Swiss Alpine Marathon were analyzed in terms of participation, difference in running times between the sexes, age of the fastest runners, and age-related decline in the fastest running times. The race covers a distance of 78 km, with a total altitude change of approximately 2260 m. A total of 12,194 men and 1781 women finished the race between 1998 and 2011.Results: Women's participation increased from approximately 10% in 1998 to approximately 16% in 2011 (r2 = 0.57; P = 0.001), but participation remained unchanged in men (r2 = 0.17; P > 0.05). Over the years, the top ten women showed no change in running times (r2 = 0.02; P > 0.05), whereas the top ten men's running times increased (r2 = 0.46; P < 0.01). The age for peak running times increased over time both for the top ten women (r2 = 0.58; P < 0.01) and for the top ten men (r2 = 0.40; P = 0.01).Conclusion: Among the top women, participation increased, the age for peak running times increased, and the running times remained unchanged. Among the men, however, the participation remained steady, and both the peak running-time age and the running times increased.Keywords: ultra-endurance, aging, sex difference, running

Background: Recent studies have shown that personal best marathon time is a strong predictor of race time in male ultramarathoners. We aimed to determine variables predictive of marathon race time in recreational male marathoners by using the same characteristics of anthropometry and training as used for ultramarathoners.Methods: Anthropometric and training characteristics of 126 recreational male marathoners were bivariately and multivariately related to marathon race times.Results: After multivariate regression, running speed of the training units (β=-0.52, P

Beat Knechtle,1,2 Christoph Alexander Rüst,2 Thomas Rosemann,2 Romuald Lepers31Gesundheitszentrum St Gallen, St Gallen, Switzerland; 2Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland; 3INSERM U1093, Faculty of Sport Sciences, University of Burgundy, Dijon, FranceBackground: To date, the age-related decline and gender differences in performance have been investigated for both Olympic and Ironman distance triathlons, but not for the intermediate distance (ie, the half-Ironman distance triathlon covering 1.9 km swimming, 90 km cycling and 21.1 km running, Ironman 70.3®). We determined the age-related differences in performance and the gender differences for female and male half-Ironman triathletes of 6303 finishers (1115 women and 5188 men) at the Ironman 70.3 Switzerland in Rapperswil, Switzerland, from 2007 to 2010.Methods: Analyses of variance were used to examine performance trends and differences between the genders.Results: Gender differences in total event time were affected by age (F = 4.2; P < 0.001). Women achieved their best performance between 25 and 39 years whereas men attained their fastest race times between 18 and 39 years. The gender difference for ages 18–24 years was significantly (P < 0.01) greater compared to older age groups (25–29 years and 40–44 years), and the gender difference for age groups 45–49 years and 50–54 years was significantly (P < 0.01) greater than for those between the ages of 35–39 years.Conclusion: The present data suggest that the fastest race time in a half-Ironman triathlon was achieved between the age of 25 and 39 years for women and between 18 and 39 years for men. Further studies considering the influences on endurance performance are required to better understand the age and gender interactions in half-Ironman triathlon performances, and these studies may provide valuable information to delineate the difference in performance between female and male half-Ironman triathletes.Keywords: cycling, endurance, female, male, running, swimming

David Eisner, Marco Zoller, Thomas Rosemann, Carola A Huber, Nina Badertscher, Ryan TandjungInstitute for General Practice and Health Services Research, University of Zurich, Zurich, SwitzerlandBackground and objectives: Prevention is a challenging area of primary care. In Switzerland, little is known about attitudes to and performance of screening and prevention services in general practice. To implement prevention services in primary care it is important to know about not only potential facilitators but also barriers. Primary care encompasses the activities of general practitioners, including those with particular interest and/or specializations (eg, pediatrics, gynecology). The aim of this study was to review all studies with a focus on prevention services which have been conducted in Switzerland and to reveal barriers and facilitators for physicians to participate in any preventive measures.Methods: The Cochrane Library, PubMed, EMBASE and BIOSIS were searched from January 1990 through December 2010. Studies focussing on preventive activities in primary care settings were selected and reviewed. The methodological quality of the identified studies was classified according to the guidelines in the Consolidated Standards of Reporting Trials (CONSORT) statement.Results: We identified 49 studies including 45 descriptive studies and four randomised controlled trials (RCTs). Twelve studies addressed the prevention of epidemics, eleven out of them vaccinations. Further studies focused on lifestyle changes, physical activity counselling, smoking cessation, cardiovascular prevention and cancer screening. Perceived lack of knowledge/training and lack of time were the most commonly stated barriers. Motivation, feasibility and efficiency were the most frequently reported supporting factors for preventive activities. The methodological quality was weak, only one out of four RCTs met the applied quality criteria.Conclusion: Most studies focussing on screening and prevention activities in primary care addressed vaccination, lifestyle modification or cardiovascular disease prevention. Identified barriers and facilitators indicate a need for primary-care-adapted education and training which are easy to handle, time-saving and reflect the specific needs of general practitioners. If new prevention programs are to be implemented in general practices, RCTs of high methodological quality are needed to assess their impact.Keywords: disease prevention, primary care, Switzerland, epidemic, screening, education, descriptive study

Ryan Tandjung, Thomas Rosemann, Nina BadertscherInstitute of General Practice and Health Services Research, University of Zurich, SwitzerlandIntroduction: Discontinuity of care at the interface between inpatient and outpatient management can lead to increased morbidity and mortality. Appropriate communication and flow of information is indispensable to ensure continuity of care. Consequently, the aim of this study was to assess general practitioners’ (GPs) experiences of cooperation with a university hospital, as well as their needs and obvious barriers regarding an optimized information flow.Methods: A qualitative study was performed. In March 2011, 300 GPs from the Zurich Canton were invited to participate in two focus group meetings. Based on a review of the literature, an interview guide was created addressing two main issues. In the first part, experiences and barriers regarding cooperation with the university were explored. In the second part, needs and suggestions to improve cooperation were addressed.Results: Fifteen GPs participated in two focus groups. GPs complained that they have often not been adequately informed about ongoing treatments or appointments for their patients. GPs feel responsible for the continuity of care and wish to be more involved, especially in long-term treatment decisions or at the end of life. By not involving them, they stated, important information concerning patients’ medical history and social setting was not taken into account. Improvements are also required at discharge: GPs often do not receive important information about treatments in the hospital and further requirements within a reasonable time.Conclusion: Exchange of information between the hospital and the GP at admission and discharge is essential. However, at present, involvement during hospitalization of the patient is lacking. This includes the exchange of information after an unexpected clinical procedure and input from GPs when difficult clinical decisions are made, such as at the beginning or termination of long-term therapies.Keywords: referral, general practitioners, hospital, cooperation, handover, communication

Christoph Alexander Rüst1, Beat Knechtle1,2, Patrizia Knechtle2, Ursula Barandun1, Romuald Lepers3, Thomas Rosemann11Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3INSERM U887, University of Burgundy, Faculty of Sport Sciences, Dijon, FranceAbstract: The aim of this study was to investigate predictor variables of anthropometry, training, and previous experience in order to predict a half marathon race time for future novice recreational male half marathoners. Eighty-four male finishers in the ‘Half Marathon Basel’ completed the race distance within (mean and standard deviation, SD) 103.9 (16.5) min, running at a speed of 12.7 (1.9) km/h. After multivariate analysis of the anthropometric characteristics, body mass index (r = 0.56), suprailiacal (r = 0.36) and medial calf skin fold (r = 0.53) were related to race time. For the variables of training and previous experience, speed in running of the training sessions (r = –0.54) were associated with race time. After multivariate analysis of both the significant anthropometric and training variables, body mass index (P = 0.0150) and speed in running during training (P = 0.0045) were related to race time. Race time in a half marathon might be partially predicted by the following equation (r2 = 0.44): Race time (min) = 72.91 + 3.045 * (body mass index, kg/m2) –3.884 * (speed in running during training, km/h) for recreational male runners. To conclude, variables of both anthropometry and training were related to half marathon race time in recreational male half marathoners and cannot be reduced to one single predictor variable.Keywords: anthropometry, body fat, skin-folds, training, endurance

Romuald Lepers1, Beat Knechtle2,3, Patrizia Knechtle2, Thomas Rosemann2 1INSERM U887, Faculty of Sport Sciences, University of Burgundy, Dijon, France; 2Institute of General Practice and Health Services Research, University of Zurich, Switzerland; 3Gesundheitszentrum St Gallen, St Gallen, Switzerland Abstract: Despite increased interest in ultra-endurance events, little research has examined ultra-triathlon performance. The aims of this study were: (i) to compare swimming, cycling, running, and overall performances in three ultra-distance triathlons, double Ironman distance triathlon (2IMT) (7.6 km swimming, 360 km cycling, and 84.4 km running), triple Ironman distance triathlon (3IMT) (11.4 km, 540 km, and 126.6 km), and deca Ironman distance triathlon (10IMT) (38 km, 1800 km, and 420 km) and (ii) to examine the relationships between the 2IMT, 3IMT, and 10IMT performances to create predicted equations of the 10IMT performances. Race results from 1985 through 2009 were examined to identify triathletes who performed the three considered ultra-distances. In total, 73 triathletes (68 men and 5 women) were identified. The contribution of swimming to overall ultra-triathlon performance was lower than for cycling and running. Running performance was more important to overall performance for 2IMT and 3IMT compared with 10IMT. The 2IMT and 3IMT performances were significantly correlated with 10IMT performances for swimming and cycling, but not for running. 10IMT total time performance might be predicted by the following equation: 10IMT race time (minutes) = 5885 + 3.69 × 3IMT race time (minutes). This analysis of human performance during ultra-distance triathlons represents a unique data set in the field of ultra-endurance events. Additional studies are required to determine the physiological and psychological factors associated with ultra-triathlon performance. Keywords: triathlon, swimming, cycling, running, ultra-endurance

Christoph Alexander Rüst1, Beat Knechtle1,2, Patrizia Knechtle2, Thomas Rosemann1, Romuald Lepers31Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland; 2Gesundheitszentrum St Gallen, St Gallen, Switzerland; 3INSERM U887, University of Burgundy, Faculty of Sport Sciences, Dijon, FranceBackground: The purpose of this study was to define predictor variables for recreational male Ironman triathletes, using age and basic measurements of anthropometry, training, and previous performance to establish an equation for the prediction of an Ironman race time for future recreational male Ironman triathletes.Methods: Age and anthropometry, training, and previous experience variables were related to Ironman race time using bivariate and multivariate analysis.Results: A total of 184 recreational male triathletes, of mean age 40.9 ± 8.4 years, height 1.80 ± 0.06 m, and weight 76.3 ± 8.4 kg completed the Ironman within 691 ± 83 minutes. They spent 13.9 ± 5.0 hours per week in training, covering 6.3 ± 3.1 km of swimming, 194.4 ± 76.6 km of cycling, and 45.0 ± 15.9 km of running. In total, 149 triathletes had completed at least one marathon, and 150 athletes had finished at least one Olympic distance triathlon. They had a personal best time of 130.4 ± 44.2 minutes in an Olympic distance triathlon and of 193.9 ± 31.9 minutes in marathon running. In total, 126 finishers had completed both an Olympic distance triathlon and a marathon. After multivariate analysis, both a personal best time in a marathon (P < 0.0001) and in an Olympic distance triathlon (P < 0.0001) were the best variables related to Ironman race time. Ironman race time (minutes) might be partially predicted by the following equation: (r2 = 0.65, standard error of estimate = 56.8) = 152.1 + 1.332 × (personal best time in a marathon, minutes) + 1.964 × (personal best time in an Olympic distance triathlon, minutes).Conclusion: These results suggest that, in contrast with anthropometric and training characteristics, both the personal best time in an Olympic distance triathlon and in a marathon predict Ironman race time in recreational male Ironman triathletes.Keywords: body fat, swimming, cycling, running, triathlon