Sudden cardiac death has always been at the apex of ’serious’ sports medicine conditions. We all agree that one death is one too many. Sports physicians with expertise in cardiac issues — Jon Drezner and Babette Pluim — will guest edit a 2009 Themed Issue that will include, but not be limited to, original data and commentary on the use of automated external defibrillators (AEDs) in the athletic setting, emergency preparedness for sudden cardiac arrest, and the secondary prevention of sudden cardiac death in young athletes.

We look forward to the opportunity to work with authors, groups convening to provide consensus statements, and partner journals to contribute to minimizing sudden cardiac death in the sporting setting.

This special issue will form the June 2009 Issue of BJSM. More details will follow and the deadline for submissions is 11:00 pm, Dec 31. 2008.

This is your chance for fame in one of the world’s leading general medical journals.

The BMJ is planning a theme issue on sport and exercise medicine in July 2008. Send high quality original research to the BMJ online editorial office at http://submit.bmj.com by Tuesday 8 April 2008.

The BMJ is particularly interested in clinical research and will give priority to reports of randomised controlled trials or other original quantitative research that will help doctors and patients to make better decisions. The BMJ also loves translational research that is relevant to clinical decision making. Resources for authors are on bmj.com and an editorial provide answers to common questions about submitting research to the BMJ.

All submissions should follow the standard requirements for BMJ articles and are subject to standard editorial and peer review processes. For additional advice on possible submissions for this theme issue, please email Domhnall MacAuley.

I connected with ACSM president Bob Sallis today - he is heading up the ‘Exercise Is Medicine’ initiative through ACSM.

Bob, a family doctor in California, shared his frustration with mainstream medicine overlooking physical activity as the most powerful therapy available to physicians. The Exercise is Medicine initiative aims to have every family doctor assessing current level of physical activity by a simple questionnaire at every consultation. This question would be asked by the office assistant so that the doctor, of course 100% reliable, would not need to take up time to do that.

Patients who are doing less than 150 minutes of physical activity per week could then be readily flagged for interventions. And that is a whole new ball of wax as they say! But there is hope - more and more interventions are proving successful so combining the best of research from psychology, exercise physiology, engineering and electronics should allow us to make a difference. As Bob says, ‘we can convince patients to have their stomach stapled and take medications that sometimes make them feel awful, so promoting physical activity shouldn’t be that difficult!’.

The Exercise is Medicine initiative aims to have every family doctor assessing current level of physical activity by a simple questionnaire at every consultation. This question would be asked by the office assistant so that the doctor, of course 100% reliable, would not need to take up time to do that.

Do you have a successful way of promoting physical activity in the office? And please remember the BJSM special issue for 2009 - Integrating Physical Activity into Clinical Practice.

The April issue of BJSM has 4 papers related to physical activity and health:
check them out online first!

An active school model to promote physical activity in elementary schools: Action Schools! BC
Patti-Jean Naylor, Heather M Macdonald, Darren E. R. Warburton, Katherine E Reed, and Heather A McKay

Walking or vitamin B for cognition in older adults with mild cognitive impairment? A randomized controlled trial
Jannique G.Z. van Uffelen, Marijke J.M. Chinapaw, Willem van Mechelen, and Marijke Hopman-Rock

Effect of commercial airline travel on oxygen saturation in athletes
Celeste Geertsema, Anthony B Williams, Peter Dzendrowskyj, and Chris Hanna

Best The Practice of Primary Care Sports Medicine in the United States
Jason J Diehl, Jason J Pirozzolo, and Thomas M

Submitted by editorial board member Dr Gavin Davis

As clinicians, we often wish we had expert guidance at hand. There are some list-serves that provide this function and we hope that this blog might do the same thing. Feel free to submit difficult cases, and invite submissions from the readership to assist with patient management.

As a starter example, consider the case of a patient presenting to a sports medicine office with a past history of craniotomy for tumour, and insertion ventriculo-peritoneal shunt. She wants medical clearance to be able to play women’s rugby.

What are your thoughts on this case?

In this March issue of BJSM, Wilson and colleagues investigate sudden cardiac death:

[Abstract]
[Full Text]
[PDF]

This emotional and very important area of sports medicine always raises the issue of how many children how have cardiac abnormalities may need to be disqualified from sport to save one life.

Editorial Board member Jon Drezner posted the following comments relating to this paper (originally posted to the AMSSM listserve):

The studies on ECG screening are mounting fast with improved and more specific ECG criteria that lower the total positive (and thus false positive) rate. Pelliccia et al (Euro Heart J 2007) recently described their experience reviewing 32,652 screening ECGs primarily in young amateur athletes (median age 17). Distinct ECG abnormalities suggesting cardiac disease were present in only 4.8%. This lower total positive rate was after acknowledging that a prolonged PR, incomplete RBBB, and early repolarization patterns are essentially normal/common findings in athletes and not indicative of cardiac disease. Other refinements to the definition of “abnormal” for a screening ECG are also being recognized. A recent study presented at the 2007 AHA Scientific Sessions by Melacini et al (Marginal overlap between ECG abnormalities in patients with HCM and trained athletes: implications for preparticipation screening) found that voltage criteria alone for LVH (without ST depression, T wave inversion, or pathologic Q waves) is a common finding in trained athletes and unlikely to be indicative of cardiac disease.

Two recent studies have used modifications of the Corrado criteria and found a substantially lower (about 2%) total positive rate. In a recent study by Wilson et al. (BJSM 2007) out of the U.K., 2,720 national/international athletes and physically active school children (mean age 16) were screened using personal & family history, exam, and ECG. They found a total ECG positive rate of only 1.5%. Nine athletes (0.3%) were identified with cardiac disease known to cause SCD (WPW, LQT1, ARVC, RVOT), and none of these 9 cases were symptomatic or would have been identified by personal or famhx. (see abstract below). I found it interesting that the true positive rate found was consistent with the AHA estimate regarding the prevalence of cardiac disease known to cause SCD in young athletes ( 0.3% or 3 in 1,000).

Also recently, Joseph Marek from the Midwest Heart Foundation presented at the 2007 AHA Scientific Sessions their findings of screening over 12,500 high school aged individuals with ECG. They also used modified Corrado criteria for defining abnormal ECGs. Their total positive rate was only 2%. This is the largest study in the U.S. and the first I am aware of to apply the Italian criteria to a U.S. population.

Another way to look at the numbers is to model a screening program for 50,000 high school freshman athletes: (1) Incidence of SCD is approx 1:50,000 (based on current data from the U.S. Sudden Death in Young Athletes Registry by Barry Maron); (2) Prevalence for any cardiac disease known to cause SCD in young athletes is estimated to be 0.3% or 3 in 1,000 (from the 2007 AHA Scientific Statement on preparticipation screening); (3) A screening ECG will suggest about 60% of silent CV dz known to cause SCD.

Assume 2-5% total positive rate (based on studies above using updated ECG criteria) = 1,000 to 2,500 total positives. 150 potential true positives (prevalence 0.3%), but only 100 (about 60%) true positives with CV dz suggested by ECG (0.2%). That leaves 900 to 2,400 false positives (1.8% to 4.8%).

In other words, we would need to temporarily disqualify/work-up 9 to 24 kids with false positives to identify 1 kid at risk for SCA, or we would need to disqualify 99 kids with CV diagnosis to potentially prevent 1 death (in the first year of screening). However, each year it is possible that an additional SCD event will be prevented through disqualification (this is shown in Corrado’s study from Italy). Assuming high school participation for 4 years (200,000 person years of athletic participation in this model), we might expect 4 cases of SCD (incidence 1:50,000 per year). Since ECG did not capture all of the silent CV dz (only about 60%), then screening 50,000 high school freshmen with ECG would likely prevent 2-3 deaths (of the predicted 4) through disqualification of 100 kids with identified cardiac dz. In other words, we would need to disqualify 30-50 kids with identified CV dz from high school athletics to prevent 1 death.

I recognize these calculations are rough, but I’m trying to pull from the most recent studies and apply to our setting.

Anyway, new studies, more accurate and rigorous ECG criteria, and lower total positive rates. Over time with confirmatory studies and a better understanding of disease prevalence, this will change our calculations on false positives, disqualifications, cost, and lives saved, and quite possibly compel us to revisit our recommendations on the role of ECG in the screening process.

One of the questions that is always asked of sports medicine clinicians is how much training kids should be doing. At a time where physical inactivity is the major childhood disease, we also have the paradox of parents encouraging 3-yr old golfers and 4 yr-old tennis players. After all, the earning potential of those children exceeds the annual salary of all but the most successful CEOs.

Until now, there has been very little to guide training the elite athlete. The IOC Medical Commissionhas a goal of protecting the health of the athlete and to this end, it convened a group to develop a Consensus Statement on the training of the elite child athlete. The paper provides a holistic approach to training the elite child athlete, including exercise prescription, psychological training, nutritional guidelines and special considerations.

It is now available in the March issue of BJSM (Br J Sports Med 2008;42:163–164). The expert committee members were: M Mountjoy, N Armstrong, L Bizzini, C Blimkie, J Evans, D Gerrard, J Hangen, K Knoll, L Micheli, P Sangenis, W Van Mechelen.

What are your thoughts? Is this helpful? How could it be improved? What is your experience with the elite child athlete. Please leave any feedback in the comment section below.

Article by Dr Claire Roche, Clinical Fellow in Emergency Medicine, Countess of Chester Hospital.

The setting for this year’s polar medicine course was Alta, a small settlement, 72 degrees north and well within the Arctic Circle. A place with a deserted high street where you would be lucky to see one other passer by every 15 minutes, easily explained by a temperature at least ten degrees below freezing and a good foot of snow on the ground.

Base camp was a 40 km drive along icy roads to a picturesque mountain lodge by the name of Ongajoksetra. At the higher altitude the temperature was that much lower and if a wind was blowing, temperatures as low as minus fifty could be achieved. We were introduced to the Scandinavian team who would teach us methods of navigation across such tough terrain in harsh conditions and also to the Expedition Medicine team who would teach us polar medicine in a series of lectures and practical sessions both in the classroom and in the field. One more group I must not forget to mention is the team of fifty sled dogs who would provide another mode of transport across the snow.

My first day involved skidooing up a mountain demonstrating the importance of protective clothing, navigation aids and preparation for travel in severe blizzards with visibility of approximately two metres, sudden drops in temperature and rapid weather changes. I realised that without our trustworthy guide, Espen Ottem, we could become hopelessly lost in such conditions where you would be unable to survive more than a couple of hours at most. Our dog sledding guide, Pre-Thore was the perfect example of this as he told us of the time where inadequate preparation resulted in frostbite, blackening of his fingertips but fortunately no amputation. This story made me somewhat paranoid about the daily pain and numbness in my hands and feet when outside in the cold for prolonged periods. A “buddy system” was paramount to preventing frostnip. Simply by having that small exposed area of skin, pointed out to you to cover up.

Dr Leslie Thomson, a consultant anaesthetist who had first - hand experience of polar medicine after spending several years in Antarctica taking part in the British Antarctic Survey gave an excellent lecture on hypothermia, bringing home how hypothermia is not just a condition seen near the poles but also in the Saturday night party goer who collapses under the stars, the homeless and the elderly. We were taught how to treat by various re-warming methods and when to commence C.P.R in the hypothermic patient sending home the message of not pronouncing death until warm and dead in certain individuals. This information was demonstrated by the story of Dr Anna Bagenholm , a 29 year old doctor who fell into icy water whilst skiing in Northern Sweden, immersed for approximately an hour, her body temperature was 13.7 degrees centigrade. C.P.R continued for three and a half hours alongside re-warming techniques such as bypass, bladder / stomach / peritoneal lavage and warm intravenous fluids. She survived to become the person with the lowest body temperature ever to survive.

Expedition Medicine obviously feel that first- hand experience is the best way of teaching and as a result each member of the group had to undergo cold water immersion. Prior to undertaking this challenge we were kindly taught about the cardiac arrhythmias that can be induced by the shock of entering the water, the short term cold water gasp reflex increasing the chance of aspiration and swimmers failure! One by one we stepped up to an ice hole in our thermal underwear and in the more daring members of the group a little less! to swim across icy water. I can confidently say that was the coldest I had ever been. As if several knives had been plunged into my body, breath taking and inducing chest pain, I swam across water of ridiculously low temperature to attempt getting out of the hole using my ski poles.

Of our nights spent in the field we were taught how to construct snow holes. Five hours later our own little home with two double beds, stove, cupboards and shelves for our candles was constructed. It was as comfortable as it could be on a mountain side with winds blowing outside dropping the temperature to twenty below. I was amazed that the snow hole was so warm at five degrees compared to the outside however a slight air of nervousness was in the back of my mind as my avalanche detector slowly flashed in the corner and a rope attached to a spade inside connected our holes to other holes in case of us having to be dug out. The course perfectly demonstrated how to survive in such conditions.

In summary the course prepared 25 everyday doctors to be able to traverse the polar landscape, recognise and competently treat local cold injury and hypothermia as well as to be safe expedition medics capable of caring for their groups and evacuating when required. To spend a week in such a location gave me the upmost respect for those who live in these regions and cross the landscape as part of everyday life, as well as a great respect for the land. In a day and age of global warming and melting of the polar ice caps it becomes paramount to look after our environment, to take only photographs and to leave only footprints.

The next expedition medicine course will be in Desert Medicine which will be held in Namibia, August 17th – 23rd 2008. For more details go to: www.expeditionmedicine.co.uk.

Click here to see a great slideshow video from the last Polar Expedition Medical Course.

A Reader of the BJSM Blog Asks:

Nitro Patches for Tendinopathy?

I am quite intrigued by this, not only as a physician but more so as a patient with some current injuries. Would you be so kind as to reply with a source that might describe the mechanis(s) of action as well as a link or two to get more detail.

Answer:

Although the precise mechanism is not known, cell culture studies suggest that Nitric Oxide (NO) has a direct stimulating effect on collagen synthesis. For a background to the discussion and direction to the clinical papers on the effectiveness of nitro patches, please see Dr Murrell’s summary in the BJSM Tendinopathy Issue (April 2007).