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Yuka Tsukahara,1,2 Hiroshi Kamada,2,3 Suguru Torii,2,4 Hiroshi Yamamoto,5 Fumihiro Yamasawa2 1Department of Sports Medicine, Tokyo Women’s College of Physical Education, Kunitachi, Japan; 2Medical Committee, Japan Association of Athletics Federations (JAAF), Tokyo, Japan; 3Department of Orthopaedic Surgery, University of Tsukuba, Tsukuba, Japan; 4Faculty of Sport Sciences, Waseda University, Tokorozawa, Japan; 5School of Sports and Health, Hosei University, Tokyo, JapanCorrespondence: Yuka Tsukahara, Department of Sports Medicine, Tokyo Women’s College of Physical Education, 4-30-1 Fujimidai, Kunitachi, Japan, Email yuka.voila@gmail.comIntroduction: Little is known regarding medical knowledge pertaining to female athletes among track and field coaches and their interactions with female athletes regarding medical problems.Methods: Participants were track and field coaches (369 males and 43 females) with Japan Sport Association certification and they completed an anonymous survey on their knowledge of medical problems pertinent to female athletes including whether the coaches knew about the female athlete triad and relative energy deficiency in sports; their feelings about female athletes’ use of contraceptive pills; whether they speak about menses with the female athletes; and whether they have a gynecologist for consultation regarding their medical problems.Results: Females coaches were significantly more likely to be aware of the triad (odds ratio (OR), 3.44; p = 0.003); to have access to a physician able to address the gynecological problems of female athletes (OR, 9.22; p < 0.001); and to talk to their female athletes about menses (OR, 2.30; p = 0.015) than their male counterparts. Coaches with more experience tended to be aware of the triad and relative energy deficiency in sports compared with those with ≤ 5 years of experience.Conclusion: Females coaches are aware of the triad, talk about menses with their female athletes, and have access to a physician who can address gynecological problems with compared to male counterparts. Educating all coaches on these problems is essential to provide adequate support to female athletes.Keywords: track and field, relative energy deficiency in sports, female athlete triad syndrome

Doping control has been conducted since 1980 in athletic events in Japan. Twelve athletes had been found in violation of anti-doping rules by the end of 2008. Among them, five cases were disclosed to be administered or assisted by athlete support personnel. To provide athlete support personnel with updated and accurate information on anti-doping rules, the anti-doping handbook "To Be Clean Athletes" was published in 1997 and has been revised several times. The rate of positive tests in the past 11 years was 0.11%, which suggests the information and education program for doping-free athletics has been effective in the Japanese Athletics Federation. It should be stressed that sports doctors in national sports federations will work to provide up-dated anti-doping information to other athlete support personnel. [ABSTRACT FROM AUTHOR]

To provide healthcare and sports medicine services to all participants in Tokyo Marathon 2007, the Tokyo Marathon Medical Committee was established for the risk management of the athletes' health. This Committee, responsible for the biggest Marathon race in Japan, provided primary and emergency care from the start to the finish, including 16 medical stations, 43 of automated external defibrillators (AED) , roving medical bicycles with AED and doctors' runners among the participants. There were 1,192 visits to the medical stations and 2 cardiac arrests occurred. Both of the victims were rescued by by-stander CPR and AED and they were discharged from hospital without any complications. [ABSTRACT FROM AUTHOR]

There have been 13 sudden death cases reported in and during road races or marathons over the past 2 and half years in Japan. Of these, the typical case is that of 'a middle aged man dropping dead just before the finish line in a half marathon race due to an acute cardiovascular event'. The most probable cause of death was ventricular tachyeardia and ventricular fibrillation. The organizers of the road race events were advised to provide automatic external defibrillators and to introduce mobile medical teams at their races. The participants were also advised to have medical checkups, consultation with doctors if necessary, and self-checkup before participating in the races. It is particularly important to advise participants not to exert themselves excessively in their races. This advice and information is available on the website of the Japan Association of Athletics Federations. [ABSTRACT FROM AUTHOR]

Background: The patient population receiving long-term oxygen therapy has increased with the rising morbidity of COPD. Although high-dose oxygen induces pulmonary edema and interstitial fibrosis, potential lung injury caused by long-term exposure to low-dose oxygen has not been fully analyzed. This study was designed to clarify the effects of long-term low-dose oxygen inhalation on pulmonary epithelial function, edema formation, collagen metabolism, and alveolar fibrosis.Methods: Guinea pigs (n = 159) were exposed to either 21% or 40% oxygen for a maximum of 16 weeks, and to 90% oxygen for a maximum of 120 hours. Clearance of inhaled technetium-labeled diethylene triamine pentaacetate (Tc-DTPA) and bronchoalveolar lavage fluid-to-serum ratio (BAL/Serum) of albumin (ALB) were used as markers of epithelial permeability. Lung wet-to-dry weight ratio (W/D) was measured to evaluate pulmonary edema, and types I and III collagenolytic activities and hydroxyproline content in the lung were analyzed as indices of collagen metabolism. Pulmonary fibrotic state was evaluated by histological quantification of fibrous tissue area stained with aniline blue.Results: The clearance of Tc-DTPA was higher with 2 week exposure to 40% oxygen, while BAL/Serum Alb and W/D did not differ between the 40% and 21% groups. In the 40% oxygen group, type I collagenolytic activities at 2 and 4 weeks and type III collagenolytic activity at 2 weeks were increased. Hydroxyproline and fibrous tissue area were also increased at 2 weeks. No discernible injury was histologically observed in the 40% group, while progressive alveolar damage was observed in the 90% group.Conclusion: These results indicate that epithelial function is damaged, collagen metabolism is affected, and both breakdown of collagen fibrils and fibrogenesis are transiently induced even with low-dose 40% oxygen exposure. However, these changes are successfully compensated even with continuous exposure to low-dose oxygen. We conclude that long-term low-dose oxygen exposure does not significantly induce permanent lung injury in guinea pigs. [ABSTRACT FROM AUTHOR]

Doping is strongly prohibited in sports. Since the implementation of the World Anti-Doping Code, anti-doping movements have been harmonized across countries and sports. Substances and methods are listed in the Prohibited List International Standard. The Code permits athletes and their physicians to apply for Therapeutic Use Exemptions (TUE) to use substances or methods in the Prohibited List. Physicians as athlete support personnel should be well informed about the Code and International Standards and they should adequately prescribe medicine to athletes and submit TUE application forms when required. [ABSTRACT FROM AUTHOR]

Iron and vitamin D deficiencies can affect athletes' health and performance. However, the epidemiology and associated risk factors remain unclear. Forty-three elite female athletics athletes (20.2 ± 1.9 years) were included. A survey regarding the training schedule and Eating Attitudes Test-26, body composition, bone mineral density, and serum 25-hydroxyvitamin D (25(OH)D) and ferritin levels were assessed. Mean serum 25(OH)D and ferritin levels were 25.2 ± 5.5 ng/mL and 29.0 ± 13.2 ng/mL, respectively, and 83.7% and 41.9 % of athletes had vitamin D and ferritin insufficiency, respectively. Serum 25(OH)D level was negatively correlated with the number of rest days per week (Coefficient, -6.19; 95% confidence interval [CI], -9.82--2.57; p = 0.002), and serum ferritin level was negatively correlated with body mass index (Coefficient, -3.87; 95% CI, -7.57--0.16; p = 0.041). Performance levels were positively correlated with serum vitamin D levels (Coefficients, 7.25; 95% CI, 0.25-14.25; p = 0.043) and negatively correlated with EAT-26 scores (Coefficient, -7.30; 95% CI, -12.61--1.98; p = 0.009) and body fat percentage (Coefficient, -13.26; 95% CI, -24.66--1.86; p = 0.025). Vitamin D and ferritin insufficiencies are prevalent among Japanese female athletics athletes. Serum vitamin D level was related to performance level., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Jet lag and travel fatigue can occur after crossing multiple time zones in a short period of time, possibly affecting various aspects of an athlete's behavior. However, there are few studies regarding this issue, particularly considering junior athletes. This study aimed to investigate and quantify the symptoms of jet lag and travel fatigue and the factors impacting these conditions. A survey was completed by 41 Japanese junior athletes (21 men and 20 women), competing at an international game in Finland, to assess their performance, sleeping habits, digestion, fatigue, and jet lag on the first day of arrival and on the opening day of the competition. Although athletes awoke less often during sleep on the opening day of the competition compared with the first day, sleep time, ease of falling asleep, and sleep quality decreased significantly. Prior experience traveling abroad for international competitions was positively associated with improvements regarding ease of falling asleep (coefficient = 2.22, p = 0.01), quality of sleep (coefficient = 2.16, p = 0.02), and alertness after waking up (coefficient = 1.85, p = 0.05) by the opening day of the competition when compared with the results for athletes who had no such prior experiences. Junior athletes experience symptoms of jet lag and travel fatigue that may persist until the day of competition, and prior experience traveling abroad may help in alleviating their symptoms.

Background: The aim of this study was to analyze muscle injuries and their related risk factors during the Athletics events of the 2020 Tokyo Olympic Games including the differences in muscle injury rates between heats and finals., Methods: We included and analyzed in this study muscle injuries diagnosed by either magnetic resonance imaging, ultrasound, or physical examinations by at least two physicians, from Athletics athletes participating at the 2020 Tokyo Olympic Games. Data from electronic medical records, including sex, nationality, event, and the round (heat vs. final) during which the muscle injury occurred and the air temperature in the stadium, measured every five minutes during the competition were extracted., Results: Among the 1631 athletes who competed, a total of 36 athletes (20 males and 16 females) were diagnosed with a muscle injury during the 2020 Tokyo Olympic Games. Among them, 24 occurred during heats (1.47 per 100 athletes) and 12 during finals (2.20 per 100 athletes) (P=0.25). Logistic regression analysis revealed that the geographic region of athletes' origin was a factor associated with muscle injury, with the highest muscle injury rate being in athletes from Africa (odds ratio [OR]=4.74, 95% confidence interval [CI]) = 1.75 to 12.82) and North America (OR=3.02, 95%CI=1.27 to 7.20). For male athletes, competing in finals was a risk factor to sustain a muscle injury (OR=2.55, 95%CI=1.01 to 6.45)., Conclusions: During the 2020 Olympic Games, muscle injury rate was higher in finals than in heats, reaching statistical significance in male athletes.

Objectives: Anemia is a common condition in long-distance runners (LDRs). Recently, not only iron deficiency (ID) but also energy deficiency has been considered as a risk factor for anemia in athletes but no evidence has yet been established. The aim of this study was to investigate the prevalence of anemia and ID and the influence of body mass index (BMI) on anemia in high-school LDRs., Methods: The participants were 406 male and 235 female elite Japanese LDRs who competed in the All-Japan High-School Ekiden Championship 2019. They submitted their anthropometric data and results of a blood test within five days after the competition. The prevalence of anemia and ID and the influence of BMI on anemia were assessed retrospectively., Results: Mean hemoglobin concentrations (Hb) were 14.8 ± 0.9 g/dl in males and 13.2 ± 0.9 g/dl in females. The prevalence of anemia (Hb < 14 g/dl in males and < 12 g/dl in females) was significantly higher in males (16.3%) than females (6.4%), but males also showed higher prevalence of non-iron deficiency anemia (NIDA) than females (11.6% and 3.0%, respectively). No significant gender difference was found in the prevalence of iron deficiency anemia (IDA) (4.7% in males and 3.4% in females). ID (serum ferritin level < 25 ng/ml) was significantly more prevalent in females (37.4%) than males (18.5%). A binary logistic regression analysis revealed that low BMI was a contributor to anemia in females (odds ratios: 0.577 (95% CI: 0.369-0.901), p  = 0.012)., Conclusion: In Japanese high-school LDRs, one in six males was anemic, but most males did not have ID. Conversely, one-third of females were diagnosed with ID. Lower BMI was identified as a risk for anemia in females, suggesting that leanness may also lead to anemia in females.

Background: The effect of physician-patient sex concordance in medicine has been reported in many studies. Whether physicians believe that the sex concordance between physician and athlete influences treatment has not been investigated., Objective: To determine whether physicians believe that the sex concordance between physician and athlete influences treatment., Design: Cross-sectional study., Setting: Online survey., Participants: One thousand one hundred ninety-three sports medicine physicians in 51 countries. Participants were sports medicine physicians trained in orthopedics (n = 443 [37.1%]) and nonorthopedics (n = 750 [62.9%])., Interventions: Not applicable., Main Outcome Measures: Participants were asked to decide whether sex of the physician made them better suited to care for athletes of concordant or different sexes along with their personal background., Results: Orthopedic sports medicine physicians agreed less than nonorthopedic sports medicine physicians regarding the statement "MALE sports medicine physicians are better suited than their female counterparts to care for MALE athletes" (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.35-0.91, p = .02), and compared to sports medicine physicians based in Europe, those based in Asia agreed more to this statement (OR 7.91, 95% CI 4.60-13.60, p < .01). In addition, regarding the statement "FEMALE sports medicine physicians are better suited than their male counterparts to care for FEMALE athletes," compared to sports medicine physicians based in Europe, those based in Asia (OR 9.12, 95% CI 5.63-14.79, p < .01) and North America (OR 2.18, 95% CI 1.46-3.25, p < .01) agreed more and orthopedic sports medicine physicians agreed less than nonorthopedic sports medicine physicians (OR 0.61, 95% CI 0.39-0.93, p = .02) to this statement., Conclusions: Sports medicine physicians trained in orthopedics felt sex concordance was less important than physicians trained in other specialties. Asian sports medicine physicians believed sex concordance was more important compared to physicians in other regions., (© 2023 American Academy of Physical Medicine and Rehabilitation.)

Objectives: Supporting female sports medicine physicians to simultaneously be mothers and pursue professional careers is crucial to maintain gender diversity in sports medicine physicians. The purpose of this study is to understand the attitudes toward female sports medicine physicians during pregnancy and postpartum., Methods: An anonymous online survey was distributed to sports medicine physicians practicing in 51 different countries. They were asked how comfortable they felt with female sports medicine physicians working on the sidelines of sporting events during pregnancy, if the female sports medicine physicians were as productive as their male counterparts after giving birth, and how satisfied they were with the percentage of female sports medicine physicians in their country. Data were analyzed using the chi-square test, and multivariate logistic regression analysis was performed to identify independent variables., Results: In total, 1193 physicians (380 [31.9%] female) were included for analysis. Physicians in Asia were the least comfortable with pregnant sports medicine physicians working on the sidelines and those in North America were the most comfortable (odds ratio = 0.28 and 2.51, 95% confidence interval 0.18-0.44 and 1.55-4.06, respectively). More experienced sports medicine physicians (odds ratio = 1.01, 95% confidence interval 1.00-1.03; p < 0.05) and divorced physicians (odds ratio = 0.33, 95% confidence interval 0.12-0.91; p < 0.05) were less comfortable with pregnant female sports medicine physicians working on sidelines, and those trained in orthopedics were less likely to agree that female sports medicine physicians were equally as productive as male counterparts postpartum (odds ratio = 0.29, 95% confidence interval 0.10-0.88; p < 0.05). Female physicians were less satisfied with the percentage of female sports medicine physicians in their country (odds ratio = 0.41, 95% confidence interval 0.27-0.60; p < 0.01) than their male counterparts., Conclusions: Female sports medicine physicians may experience bias in their practice during pregnancy and postpartum.

Diagnosing overtraining syndrome is challenging and it is often correlated with other diseases, especially those related to low energy availability. Therefore, we investigated the prevalence of overtraining syndrome-like symptoms and correlative factors in 389 female and 572 male national-level high school track and field athletes. They were asked to complete a survey regarding their history of overtraining syndrome-like symptoms, injuries, and diseases. The survey results revealed that 13.4% (52/389) of female and 13.3% (76/572) of male athletes had a history of overtraining syndrome-like symptoms. Logistic regression analysis showed that training hours per day (odds ratio, 1.74; 95% confidence interval, 1.12-2.71) was an associated factor in female athletes, while rest days per week (odds ratio, 0.61; 95% confidence interval, 0.37-1.00), skipping meals (odds ratio, 3.73; 95% confidence interval, 1.50-9.29), and having snacks/light meals on a regular basis (odds ratio, 0.46; 95% confidence interval, 0.26-0.83) were the associated factors in male athletes. In conclusion, athletes with overtraining syndrome-like symptoms may be prone to injuries and diseases. Hence, although overtraining syndrome is difficult to diagnose, further attention should be paid to minimize overtraining syndrome-related risks., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Coaching athletes is a complex and lengthy process. Recently, attention has been given to coaches over-controlling behavior toward the athletes' personal lives and possible sex bias, but the impact of these behaviors on coaching success is unclear. An anonymous survey was answered by 412 track and field coaches (male: 369; female: 43), comprising questions regarding controlling behaviors, sex bias, and personal background. A Chi-square test and logistic regression were performed to determine the factors related to the coach's characteristics and their success in coaching athletes (to national vs. non-national level). The results showed that controlling behaviors and sex-bias-related beliefs were present. The coaches who coached national-level athletes were more likely to be older, more experienced, and were national level athletes themselves. More national-level coaches reported controlling behaviors but fewer held sex bias beliefs than the non-national level coaches. However, the strength of these beliefs (scores for controlling behavior and sex bias) was not related to the coaching success.

This document presents the recommendations developed by the IOC Medical and Scientific Commission and several international federations (IF) on the protection of athletes competing in the heat. It is based on a working group, meetings, field experience and a Delphi process. The first section presents recommendations for event organisers to monitor environmental conditions before and during an event; to provide sufficient ice, shading and cooling; and to work with the IF to remove regulatory and logistical limitations. The second section summarises recommendations that are directly associated with athletes' behaviours, which include the role and methods for heat acclimation; the management of hydration; and adaptation to the warm-up and clothing. The third section explains the specific medical management of exertional heat stroke (EHS) from the field of play triage to the prehospital management in a dedicated heat deck, complementing the usual medical services. The fourth section provides an example for developing an environmental heat risk analysis for sport competitions across all IFs. In summary, while EHS is one of the leading life-threatening conditions for athletes, it is preventable and treatable with the proper risk mitigation and medical response. The protection of athletes competing in the heat involves the close cooperation of the local organising committee, the national and international federations, the athletes and their entourages and the medical team., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To evaluate the difference between female and male sports medicine physicians regarding disrespectful attitudes and sexual harassment perceived from athletes, coaches, physicians, athletic trainers (ATs) and organisations/administrations., Methods and Study Design: anonymous survey was distributed to sports medicine physicians practicing in 51 countries. χ 2 analysis was used to detect differences between female and male sports medicine physicians and logistic regression analysis was used to determine the independent variables that affect disrespectful attitudes and sexual harassment from sports participants., Results: 1193 sports medicine physicians (31.9% female) participated from 51 countries. The survey revealed that female physicians, compared with male physicians, perceive significantly more disrespect or have their judgement questioned more by the following categories: male and female athletes, male and female coaches, female physicians with more years of experience, male physicians (regardless of years of experience), male and female ATs and organisation/administrations (all p<0.05). The only category where the frequency of disrespect was perceived equally by male and female physicians was during their interactions with female physicians who have the same or lesser years of experience. Female sports medicine physicians noted more sexual harassment than male physicians during interactions with male athletes, coaches, ATs and physicians (all p<0.001). In the logistic regression, gender was a related factor for perceiving disrespect, especially from male coaches (OR=2.01) and physicians with more years of experience (OR=2.18)., Conclusions: Female sports medicine physicians around the world experience disrespectful attitudes, questioning of their judgement and are sexually harassed significantly more often than male counterparts., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Epidemiological data from race walk and marathon events suggest that a high incidence rate of exertional heat illness is associated with high ambient temperature and relative humidity. The 2020 Summer Olympics in Tokyo was no exception, which led the organizing committee to relocate the race walk and marathon competitions to Sapporo, which was predicted to experience much milder heat. Nonetheless, during the Games, Sapporo recorded the highest daytime ambient temperature in the past 97 years, with consecutive days over 30°C from July 22nd to August 7th, 2021. Five events (men's and women's 20 km race walk, men's 50 km race walk, women's and men's marathon) were held in Sapporo from August 5th to August 8th, 2021. The percentage of athletes who did not finish (DNF) in each event was 8.8% in men's 20 km race walk, 20.3% in men's 50 km race walk, 8.6% in women's 20 km race walk, 17.1% in women's marathon and 28.3% in men's marathon. A total of fifty athletes were transferred to the athlete medical station: 28 athletes completed the race (i.e., collapsed after finish line), while 24 were DNF athletes transported from the course. Forty-eight (96%) of athletes who were admitted to the athlete medical station exhibited signs and symptoms of exertional heat illness. Two athletes diagnosed with exertional heat stroke and three athletes diagnosed with severe heat exhaustion (rectal body temperature >39.5°C with or without central nervous system disturbance) were cooled using whole-body cold water immersion at the heat deck located within the athlete medical station. All athletes who were cooled successfully recovered without any complications. These athletes required an average of 14 ± 9.4 min (range, 6-30 min) to cool their rectal temperature below 39°C. These results show the importance for event organizers to prepare strategies to keep athletes cool, such as an ample amount of ice and water to supply whole-body cold water immersion., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Sugawara, Manabe, Yamasawa and Hosokawa.)

Objectives: The minimum body mass index (BMI) required to menarche and the relationship between the training onset age of sports and menarche is not fully understood. The aim of this study is to elucidate the minimum BMI required to attain menarche in female adolescent athletes competing at a national level, and to determine how the occurrence of menarche is associated with training onset age in track-and-field athletes., Methods: Overall, 134 sprinters and 44 long-distance (LD) runners of ninth-grade females at a national level were enrolled and an anonymous questionnaire was administered., Results: As BMI increased, the proportion of athletes who had attained menarche increased. The BMI cutoff values for menarche were 17.3 and 17.1 kg/m 2 for sprinters and LD runners, respectively. Menarche had not occurred in almost 50% of the LD runners who began training at elementary school, and among LD runners, those who began training at elementary school had 18.4 higher odds of not attaining menarche until the age of 15 years as opposed to those who started training after elementary school., Conclusions: The BMI cutoff values could be an indicator for menarche in sprinters and LD runners. For LD runners, starting to compete at elementary school could be a risk factor for delayed menarche., (© 2021 Wiley Periodicals LLC.)

With intensive training, bone injuries are a major concern for athletes. To assess bone condition, we often measure bone turnover markers, bone mineral content and density; however, in junior athletes, it is not easy to distinguish changes caused by bone injuries from those caused by growth, because the metabolism is increased in both cases. Moreover, although some studies have examined female endurance athletes, knowledge regarding changes in static and dynamic bone conditions in late teen athletes is limited. In this study, we measured the bone mineral content and density, as well as bone turnover markers, in 40 elite female sprinters in their late teens. Whole body mode dual-energy X-ray absorptiometry was performed to measure bone mineral content and density. Blood samples were collected to determine bone resorption and formation markers at the end of track season in 2016 and during the same period of the following year. Body weight and bone mineral content significantly increased, and tartrate-resistant acid phosphatase type 5b, bone-type alkaline phosphatase, and osteocalcin significantly decreased after a year. Furthermore, the rate of change in bone mineral content was higher in younger athletes, indicating that bone growth approaches completion in the late teen years and that bone metabolism accordingly decreases., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Objectives: This document aimed to summarise the key components of exertional heat stroke (EHS) prehospital management., Methods: Members of the International Olympic Committee Adverse Weather Impact Expert Working Group for the Olympic Games Tokyo 2020 summarised the current best practice regarding the EHS prehospital management., Results: Sports competitions that are scheduled under high environmental heat stress or those that include events with high metabolic demands should implement and adopt policy and procedures for EHS prehospital management. The basic principles of EHS prehospital care are: early recognition, early diagnosis, rapid, on-site cooling and advanced clinical care. In order to achieve these principles, medical organisers must establish an area called the heat deck within or adjacent to the main medical tent that is optimised for EHS diagnosis, treatment and monitoring. Once admitted to the heat deck, the rectal temperature of the athlete with suspected EHS is assessed to confirm an elevated core body temperature. After EHS is diagnosed, the athlete must be cooled on-site until the rectal temperature is below 39°C. While cooling the athlete, medical providers are recommended to conduct a blood analysis to rule out exercise-associated hyponatraemia or hypoglycaemia, provided that this can be safely performed without interrupting cooling. The athlete is transported to advanced care for a full medical evaluation only after the treatment has been provided on-site., Conclusions: A coordination of care among all medical stakeholders at the sports venue, during transport, and at the hospital is warranted to ensure effective management is provided to the EHS athlete., Competing Interests: Competing interests: All authors are members of the International Olympic Committee Adverse Weather Impact expert working Group for the Olympic Games Tokyo 2020; not receiving honorarium., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Since the definition of secondary amenorrhea is cessation of regular menses for more than 3 months, it is likely that athletes with irregular menstrual cycles, including oligomenorrhea, do not consider the condition as serious. However, the consequences of untreated oligomenorrhea have not been investigated in elite track and field athletes., Materials and Methods: The cohort consisted of 91 elite-level track and field athletes. Body compositions, including bone parameters and bone turnover markers (BTMs), were measured., Results: Among the 91 participants, 52 were eumenorrheic and 33 were oligomenorrheic. The eumenorrheic athletes had significantly higher bone mineral density (BMD) and bone mineral content (BMC) of the lumbar spine, lower extremities, and whole body than had the oligomenorrheic athletes (p < 0.01). There were no significant differences in BTMs between the two groups, but oligomenorrheic athletes had significantly lower percent body fat., Conclusion: More than 40% of the elite-level female track and field athletes in this study reported menstrual disorders with oligomenorrhea as the most common. However, none sought medical attention. As compared to the eumenorrheic athletes, the oligomenorrheic athletes had lower BMC and BMD. Hence, if an athlete is oligomenorrheic, bone parameter measurements are considerably important., (© 2021. The Japanese Society Bone and Mineral Research.)

Rapid advances in wearable technologies and real-time monitoring have resulted in major inroads in the world of recreational and elite sport. One such innovation is the application of real-time monitoring, which comprises a smartwatch application and ecosystem, designed to collect, process and transmit a wide range of physiological, biomechanical, bioenergetic and environmental data using cloud-based services. We plan to assess the impact of this wireless technology during Tokyo 2020, where this technology could help characterize the physiological and thermal strain experienced by an athlete, as well as determine future management of athletes during a medical emergency as a result of a more timely and accurate diagnosis. Here we describe some of the innovative technologies developed for numerous sports at Tokyo 2020 ranging from race walking (20 km and 50 km events), marathon, triathlon, road cycling (including the time trial event), mountain biking, to potentially team sports played outdoors. A more symbiotic relationship between sport, health and technology needs to be encouraged that harnesses the unique demands of elite sport (e.g., the need for unobtrusive devices that provide real-time feedback) and serves as medical and preventive support for the athlete's care. The implementation of such applications would be particularly welcome in the field of medicine (i.e., telemedicine applications) and the workplace (with particular relevance to emergency services, the military and generally workers under extreme environmental conditions). Laboratory and field-based studies are required in simulated scenarios to validate such emerging technologies, with the field of sport serving as an excellent model to understand and impact disease.

The Tokyo 2020 Olympic Games is expected to be among the hottest Games in modern history, increasing the chances for exertional heat stroke (EHS) incidence, especially in non-acclimatised athletes/workers/spectators. The urgent need to recognise EHS symptoms to protect all attendees' health has considerably accelerated research examining the most effective cooling strategies and the development of wearable cooling technology and real-time temperature monitoring. While these technological advances will aid the early identification of EHS cases, there are several potential ethical considerations for governing bodies and sports organisers. For example, the impact of recently developed cooling wearables on health and performance is unknown. Concerning improving athletic performance in a hot environment, there is uncertainty about this technology's availability to all athletes. Furthermore, the real potential to obtain real-time core temperature data will oblige medical teams to make crucial decisions around their athletes continuing their competitions or withdraw. Therefore, the aim of this review is (1) to summarise the practical applications of the most novel cooling strategies/technologies for both safety (of athletes, spectators and workers) and performance purposes, and (2) to inform of the opportunities offered by recent technological developments for the early recognition and diagnosis of EHS. These opportunities are presented alongside several ethical dilemmas that require sports governing bodies to react by regulating the validity of recent technologies and their availability to all., Competing Interests: Competing interests: GIA is supported by a fellowship from the Office of Academic Affiliations at the US Veterans Health Administration., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Mass gatherings are events characterized by "the concentration of people at a specific location for a specific purpose over a set period of time that have the potential to strain the planning and response resources of the host country or community." Previous reports showed that, as a result of the concentration of people in the limited area, injury and illness occurred due to several factors. The response plan should aim to provide timely medical care to the patients and to reduce the burden on emergency hospitals, and to maintain a daily emergency medical services system for residents of the local area. Although a mass gathering event will place a significant burden on the local health-care system, it can provide the opportunity for long-term benefits of public health-care and improvement of daily medical service systems after the end of the event. The next Olympic and Paralympic Games will be held in Tokyo, during which mass gatherings will occur on a daily basis in the context of the coronavirus disease (COVID-19) epidemic. The Academic Consortium on Emergency Medical Services and Disaster Medical Response Plan during the Tokyo Olympic and Paralympic Games in 2020 (AC2020) was launched 2016, consisting of 28 academic societies in Japan, it has released statements based on assessments of medical risk and publishing guidelines and manuals on its website. This paper outlines the issues and countermeasures for emergency and disaster medical care related to the holding of this big event, focusing on the activities of the academic consortium., Competing Interests: Approval of the research protocol: N/A. Informed consent: N/A. Registry and the registration no. of the study/trial: N/A. Animal studies: N/A. Conflict of interest: None declared., (© 2021 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Competing Interests: Competing interests: WD reports grants from IOC Research Centers Grant, other from IPC Travel Support, grants from World Rugby, grants from AXA, grants from Ossur, outside the submitted work.

The Japanese Society of Travel and Health (JSTH) and the Japanese Society for Occupational Health (JSOH) have compiled "Novel Coronavirus Information" together as a joint document, which has been shared with the public on their respective websites since February 2020. In May 11, 2020, this document was to be published as "A Guide for Businesses and Employers Responding to Novel Coronavirus Disease (COVID-19)" (hereinafter referred to as "this Guide"). This Guide was prepared for persons in charge of COVID-19 control measures in their workplace. It should be used at the discretion of each business operator according to their workplace environment. The examples of infection control measures shown in this Guide are not guaranteed to work for all situations, and they do not limit or bind actual measures being put in place. When selecting actual measures, it is necessary to obtain new information and thoroughly understand individual cases and situations. This Guide was prepared based on findings and reports about the virus and response measures taken by the relevant ministries (Ministry of Health, Labour and Welfare, Ministry of Foreign Affairs, etc.) that could be confirmed as of December 15, 2020. Therefore, the contents of this Guide may need to be modified in the future, depending on changes in the situations mentioned above. In the preparation of this Guide, every effort has been made to ensure the accuracy of currently obtainable information. However, neither JSTH or JSOH shall be held liable for any unfavorable circumstance, such as loss and damage (including lost profits and various expenses), harmful rumors, etc. experienced by a business operator, his/her employees, and any other persons concerned as a result of various measures considered/implemented using this Guide by persons responsible for infection control in the workplace., (© 2021 The Authors. Journal of Occupational Health published by John Wiley & Sons Australia, Ltd on behalf of The Japan Society for Occupational Health.)

Many elite female athletes struggle to maintain performance while transitioning from high school to university-level (senior) sports. This study explores factors of body composition that influenced performance in elite junior female track and field athletes transitioning to the senior division. Forty-two elite female track and field athletes, ranked among the top 100 in Japan, were enrolled in this study. Whole-body mode dual-energy X-ray absorptiometry scans were performed during the post-season of 2016 and 2017. Athletes' performances were assessed using the International Association of Athletics Federation scoring system. Relationships between changes in performance and those in body composition were investigated. There were significant negative correlations between changes in performance and fat mass (FM), and percentage FM (FM%). This was seen in total body and lower extremities, and not in the trunk and upper extremities. In addition, there was a positive correlation between changes in performance and percentage lean mass (LM%). However, there were no correlations between changes in performance and LM and total mass. Elite female track and field athletes transitioning to senior division should decrease their FM and FM% and increase LM%, to sustain or improve performance. It is also more important to monitor changes in body composition than body mass.

Background: While scientific evidence supports the efficacy of only limited nutritional supplements (NS) on sports performance, the use of NS is widespread in athletes. Given the serious issues of health damage or unintended Anti-Doping Rule Violations due to ingestion of contaminated NS in sports, accurately understanding NS practices by athletes is crucial. This study therefore elucidated the use of NS by elite Japanese track and field (TF) athletes., Methods: The subjects were 574 Japanese TF athletes, including 275 junior athletes (under 20 years) and 299 senior athletes, who participated in international competitions from 2013 to 2018. Data on NS use were collected through pre-participation medical forms obtained from all entrants before their participation in competitions. NS users were requested to report the product names and primary components of all NS they were taking., Results: The overall prevalence of NS use was 63.9%. The mean number of NS products used per athlete was 1.4. The prevalence was significantly higher in women (69.2%) than in men (59.6%) (p = 0.018) and significantly higher in senior athletes (68.9%) than in junior athletes (58.9%) (p = 0.012). The prevalence of NS use was higher in long-distance runners (75.8%) and lower in jumpers (52.3%) and throwers (49.2%) than other disciplines (p < 0.001). The most prevalent components were amino acids (49.3%), followed by vitamins (48.3%), minerals (22.8%), and protein (17.8%)., Conclusions: Approximately two-thirds of elite Japanese TF athletes reported the use of NS, and NS practices varied by gender, age, and discipline.

Background: No reports have evaluated the long-term trends of the prevalence of anemia in Universiade athletes using preparticipation medical examinations (PPMEs). We aimed to investigate the prevalence of anemia among Japanese Universiade athletes, using longitudinal PPMEs., Methods: In this retrospective, observational study, athletes with published data from official reports of the Japanese delegation of the summer Universiade games between 1977 and 2011 were included, as were similar-aged nonathletes with published health data, extracted from official national reports from the Japanese Ministry of Health, Labour and Welfare. PPME data and national health survey data included blood tests for anemia and the age of each participant. We compared the anemia prevalence in both groups using an unpaired t test., Results: Anemia prevalence among Universiade athletes decreased by 11.6% over the study period (13.3% in 1977 to 1.7% in 2011). Moreover, anemia prevalence between 1991 and 2011 in the total Universiade athlete population was significantly lower than that in the nonathletic population (mean ± standard deviation: 5.2 ± 2.9% vs 9.8 ± 1.5%, respectively; P  = .025). In female Universiade athletes, anemia prevalence between 1977 and 1981 was higher than that in the nonathletic populations (48.1% vs 19.7%, respectively). However, in 2003, this value was lower than that in nonathletic female populations (8.5% vs 19.8%, respectively)., Conclusions: A decrease in anemia prevalence in Japanese Universiade athletes was revealed with longitudinal PPMEs. Hematological parameters should be evaluated longitudinally in athletes to provide continuous performance support throughout the athlete's career.

Objective: The present study investigated the risk for future diabetes among individuals with high-normal glycemia (fasting plasma glucose (FPG) of 100-109 mg/dL) in an early middle-aged population., Methods: We retrospectively observed a workplace cohort all aged 40 and followed the incidence of diabetes according to the FPG levels at baseline. A total of 901 non-diabetic males were included in the analysis. The 10-year cumulative incidence of diabetes was calculated. The hazard ratios of developing diabetes were calculated using a Cox proportional hazards regression., Results: The proportions of those with high-normal glycemia and impaired fasting glucose (IFG) (FPG of 110-125 mg/dL) at baseline were 21.5% and 4.7%. The 10-year cumulative incidence of diabetes was 14.7% and 48.9%, respectively, in these individuals. After adjustment for possible confounders, the hazard ratios of developing diabetes among individuals with high-normal glycemia and IFG were 5.2 (95% CI=2.4-11.2) and 21.3 (95% CI=9.2-49.5) relative to those with an FPG of <90 mg/dL., Conclusion: High-normal glycemia is a risk for future diabetes even in the relatively young and healthy workplace population. Although the relative risk is much higher in those with IFG, the absolute number of incident diabetes developing from those with high-normal glycemia seems to be considerable given the prevalence of this condition.

We investigated the association between the angiotensin I-converting enzyme (ACE) gene insertion (I)/deletion (D) polymorphism and endurance running performance in Japanese elite runners, including several Olympic athletes. The frequency of the I/I genotype was not significantly higher and the frequency of the D/D genotype was not significantly lower in elite runners compared with non-athletes. However, the frequency of the I/D genotype tended to be lower in elite runners than in non-athletes. The best performance was significantly higher for runners with the D/D genotype than for those with the I/I genotype, and the average running speed was significantly higher for those with the combined D/D + I/D genotypes than for those with the I/I genotype. There were no I/I genotypes among the five fastest marathon runners. These results suggest that the D allele of the ACE gene I/D polymorphism is associated with a high level of human endurance.

Tobacco smoke is believed to cause small airway disease and then chronic obstructive pulmonary disease (COPD), but the molecular mechanisms by which small airway obstruction occurs remain unknown. To study the gene expression levels of transforming growth factor (TGF)-beta1, a potent fibrogenic factor, in small airway epithelium from smokers and patients with COPD, we harvested highly pure samples of epithelial cells from small airways under direct vision by using an ultrathin bronchofiberscope BF-2.7T (outer diameter 2.7 mm with a biopsy channel of 0.8 mm in diameter). The expression levels of TGF-beta1 were evaluated by reverse transcription-polymerase chain reaction (RT-PCR). The mRNA levels of TGF-beta1 corrected by beta-actin transcripts were significantly higher in the smoking group and patients with COPD than those in nonsmokers (p < 0.01). Furthermore, among smokers and patients with COPD, TGF-beta1 mRNA levels correlated positively with the extent of smoking history (pack-years) and the degree of small airway obstruction as assessed by measurements of flow-volume curves. Immunocytochemistry of the cells demonstrated more intense stainings for TGF-beta1 in samples from smokers and patients with COPD than from nonsmokers. Spontaneously released immunoreactive TGF-beta1 levels from cultured epithelial cells were more elevated in subjects with a history of smoking and patients with COPD than in nonsmokers. Our study showed a close link between smoking and expression of TGF-beta1 in small airways. Our results also suggested that small airway epithelial cells might be involved in obstructive changes found in smokers and patients with COPD.

To study the inflammatory responses of small-airway epithelium in smokers, we harvested enough living epithelial cells (1.97 x 10(6) +/- 0.74 x 10(6)) with a new ultrathin fiberscope from the very peripheral airways of 22 current smokers and 17 subjects who never smoked after informed consent was obtained. The cells were keratin positive and composed mainly of nonciliated cells. The expression levels of inflammatory markers [interleukin (IL)-8 and intercellular adhesion molecule (ICAM)-1] were evaluated with RT-PCR. The magnitude of the mRNA levels corrected by beta-actin transcripts of IL-8 and ICAM-1 was significantly higher in the smokers than in the nonsmokers (P < 0.001). Furthermore, among current smokers, IL-8 mRNA levels correlated positively with the extent of smoking history [in pack. years (packs/day x no. of years of smoking); r = 0.754, P < 0.001]. Spontaneously released IL-8 and soluble ICAM-1 levels (n = 12) from cultured epithelial cells were elevated in subjects with a smoking history than in those without it (IL-8, 1,580 +/- 29.6 vs. 354 +/- 39.4 pg. 10(6) cells(-1). 24 h(-1); P < 0.001; soluble ICAM-1, 356.0 +/- 45.9 vs. 112.9 +/- 12.9 pg. 10(6) cells(-1). 24 h(-1); P < 0.01 by Student's t-test ). In contrast, the epithelial cells from the main bronchi did not show such differences between smokers and nonsmokers. Our study highlighted a close link between smoking and the expression of inflammatory mediators such as IL-8 and ICAM-1 in small airways. Our results also suggested that this new ultrathin bronchofiberscope promised a good approach for the evaluation of cellular changes in the small airways.

The 13C breath test is a method of clarifying the metabolism of loaded substances by administering 13C-labelled materials and calculating the 13CO2 and 12CO2 ratio (13C/12C isotope ratio) in the expired gas. The materials are metabolized and expelled in the expired gas. Because simultaneous continuous measurement of 13CO2 and 12CO2 in expired gas has been difficult up to the present, respective expired gases, including dead space before and after administration, have been sampled to separate sampling bags and 13C/12C has been measured in the bags and changed fraction of 13C/12C after administration (delta) has been used to judge the metabolic process. This method is affected by the contamination of the dead space gas. In the present study, in order to exclude the dead space effect, simultaneous continuous analysis of 12CO2 and 13CO2 of expired gas identifying alveolar gas was applied to the 13C-urea breath test in addition to the conventional sampling bag method. Both isotope detectors were attached to a mass spectrometer. Fifty-six cases receiving stomach health check-ups for Helicobacter pylori were examined. Delta was calculated in the bag or in phase III of continuous gas measurement. Because the bag contains dead space, delta was reduced and sensitivity and specificity with reference to gastric fluoroscopy or Helicobacter pylori IgG antibody were reduced. Decreasing the dead space contamination is important in reducing the measurement error in the 13C breath test and simultaneous continuous measurement is a good tool for this purpose.

A 75-year-old man was admitted to the hospital due to acute onset of a dry cough and dyspnea on exertion. Arterial blood gas analysis showed hypoxemia (PaO2 = 63 Torr) on room air. Chest radiography and computed tomography showed diffuse bilateral infiltrates. Adult respiratory distress syndrome was diagnosed from the findings described above and from the lack of evidence of left heart failure. Diffuse alveolar damage was confirmed at autopsy. During the course of his illness, the patient underwent bronchoalveolar lavage five times. The recovered fluid had high concentrations of interleukin-8 (IL-8), with a maximum of 6260 pg/ml and a minimum of 190 pg/ml, and these values correlated with the number of polymorphonuclear cells in the fluid. Levels of leukotriene B4, another chemotactic factor for PMN, in the lavage fluid were not high. We conclude that IL-8 was a major chemoattractant for PMN in the alveoli of this patient.

A 52-year-old man was admitted to Keio University Hospital for determination of the etiology of a bilateral pleural effusion associated with marked eosinophilia (10200 cells/mm3). He had been in Vietnam for three years and had returned to Japan in May 1993. He was suffering from tropical eosinophilia, as clearly indicated by eosinophilia, elevation of serum IgE level (708 IU/ml), the presence of anti-dirofilarial antibodies, and the absence of microfilaria in the blood. The pleural effusion was an exudate and 51% of the cells in the effusion were eosinophils. In the effusion, no parasites were detected but anti-dirofilarial antibodies were found (the titer was as high as that in the serum). Diethylcarbamazine was given, and a steroid had to be superimposed because of wheezing. These treatments successfully reduced the bronchoconstriction, eosinophilia and accumulation of pleural effusion. Tropical eosinophilia has generally been thought not to be associated with pleural effusion. This is only the third case report of tropical eosinophilia with authentic pleural effusion.

We describe the long-term course of a patient with bronchiectasis and bronchiolitis obliterans, both of which developed as late complications of a smoke inhalation injury. Sequential chest X-rays obtained during the observation period showed gradual progression of bronchiectasis from the saccular to the cystic type. Symptoms, spirometry and blood gas analysis, however, remained stable for 15 years. We believe that symptoms and physiological derangement were due mainly to bronchiolitis obliterans, and that once the pathophysiological condition had been established following the initial injury, it could be maintained by conservative medical management.

We developed a new type of bronchoscope (BF-2.7T) and cytology brush (BC-0.7T) that permit collection of pulmonary cells during direct observation of the small airways. This kind of cell collection has been previously impossible. With our cytology brush, 3.58 +/- 2.76 x 10(4) cells were collected from small airways. The rate of living cells was 33.13 +/- 3.61 percent from the small airways. Analysis of endoscopic findings and investigation of pulmonary cells are very important for elucidating the pathophysiologic state of the small airways. The use of the BF-2.7T allowed collection of cancer cells under direct endoscopic vision in all five patients with peripheral lung cancer. They also contribute to our understanding of the relationship between exogenous factors and cells that compose the lung, and will provide means for treatment and prevention of diseases.

To assess the significant role of diffusion impairment and its unequal distribution in acutely injured lungs with alveolar flooding, oleic acid was intravenously injected into twenty-five mongrel dogs. The animals were divided into two groups, A and B. 0.1% CO in air was delivered, as an inspired gas, to the animals of group A. Simultaneously, saline containing a trace amount of six foreign inert gases was infused through a peripheral vein. While allowing the animals in group B to breathe air, saline containing ethylene, acetylene and freon 22 was infused. After injection of oleic acid, group A revealed increase in intrapulmonary shunt accompanied by a marked broadening of ventilation-perfusion (VA/Q) and diffusing capacity-perfusion (G/Q) distributions. A considerable amount of total cardiac output was received by the lung areas with low G/Q ratios where significant diffusion limitation was predicted to occur. Group B showed that excretion of freon 22 (gas with lower diffusivity) in injured lungs was considerably distorted as compared to those of ethylene and acetylene (gases with higher diffusivities), again ascertaining the importance of diffusion limitation in lungs with exudate in alveolar regions.