Why glucocorticosteroids should remain in the list of prohibited substances: a sports medicine viewpoint.

In addition to their therapeutic applications, glucocorticosteroids have been widely used and abused in the belief that these substances may enhance athletic performance. Analysis of athlete urine samples by antidoping laboratories around the world support this conclusion. It is commonly accepted in medical practice to use local glucocorticosteroid injections in the treatment of non-infectious local musculotendinous inflammatory conditions conveying symptom relief and often a speedier return to sporting activity. This practice is not to be considered illicit, but sports physicians must accept that such an intervention is not in itself an immediate cure and that an athlete will still require a period of recuperation before continuing sporting activity. How long such a period of recuperation should last is a matter of conjecture and there is little concrete data to support what is, or what is not, an acceptable period of inactivity. In the interest of athlete safety, we would propose to maintain systemic glucocorticosteroids on the World Anti-Doping Agency's (WADA) list of prohibited substances, both in and out-of-competition as well as a mandatory period of 48 hours of rest from play after receiving a local glucocorticosteroid injection.

Treatment of exercise-induced asthma, respiratory and allergic disorders in sports and the relationship to doping: Part II of the report from the Joint Task Force of European Respiratory Society (ERS) and European Academy of Allergy and Clinical Immunology (EAACI) in cooperation with GA(2)LEN.

AIM: The aims of part II is to review the current recommended treatment of exercise-induced asthma (EIA), respiratory and allergic disorders in sports, to review the evidence on possible improvement of performance in sports by asthma drugs and to make recommendations for their treatment. METHODS: The literature cited with respect to the treatment of exercise induced asthma in athletes (and in asthma patients) is mainly based upon the systematic review given by Larsson et al. (Larsson K, Carlsen KH, Bonini S. Anti-asthmatic drugs: treatment of athletes and exercise-induced bronchoconstriction. In: Carlsen KH, Delgado L, Del Giacco S, editors. Diagnosis, prevention and treatment of exercise-related asthma, respiratory and allergic disorders in sports. Sheffield, UK: European Respiratory Journals Ltd, 2005:73-88) during the work of the Task Force. To assess the evidence of the literature regarding use of beta(2)-agonists related to athletic performance, the Task Force searched Medline for relevant papers up to November 2006 using the present search words: asthma, bronchial responsiveness, exercise-induced bronchoconstriction, athletes, sports, performance and beta(2)-agonists. Evidence level and grades of recommendation were assessed according to Sign criteria. RESULTS: Treatment recommendations for EIA and bronchial hyper-responsiveness in athletes are set forth with special reference to controller and reliever medications. Evidence for lack of improvement of exercise performance by inhaled beta(2)-agonists in healthy athletes serves as a basis for permitting their use. There is a lack of evidence of treatment effects of asthma drugs on EIA and bronchial hyper-responsiveness in athletes whereas extensive documentation exists in treatment of EIA in patients with asthma. The documentation on lack of improvement on performance by common asthma drugs as inhaled beta(2)-agonists with relationship to sports in healthy individuals is of high evidence, level (1+). CONCLUSIONS: Exercise induced asthma should be treated in athletes along same principles as in ordinary asthma patients with relevance to controller and reliever treatment after careful diagnosis. There is very high level of evidence for the lack of improvement in athletic performance by inhaled beta2-agonists.

Exercise-induced asthma, respiratory and allergic disorders in elite athletes: epidemiology, mechanisms and diagnosis: part I of the report from the Joint Task Force of the European Respiratory Society (ERS) and the European Academy of Allergy and Clinical Immunology (EAACI) in cooperation with GA2LEN.

AIMS: To analyze the changes in the prevalence of asthma, bronchial hyperresponsiveness (BHR) and allergies in elite athletes over the past years, to review the specific pathogenetic features of these conditions and to make recommendations for their diagnosis. METHODS: The Task Force reviewed present literature by searching Medline up to November 2006 for relevant papers by the search words: asthma, bronchial responsiveness, EIB, athletes and sports. Sign criteria were used to assess level of evidence and grades of recommendation. RESULTS: The problems of sports-related asthma and allergy are outlined. Epidemiological evidence for an increased prevalence of asthma and BHR among competitive athletes, especially in endurance sports, is provided. The mechanisms for development of asthma and bronchial hyperresponsiveness in athletes are outlined. Criteria are given for the diagnosis of asthma and exercise induced asthma in the athlete. CONCLUSIONS: The prevalence of asthma and bronchial hyperresponsiveness is markedly increased in athletes, especially within endurance sports. Environmental factors often contribute. Recommendations for the diagnosis of asthma in athletes are outlined.

Report of a serious reportable communicable disease at a major sporting event.

A European Youth Olympic Sports Festival (EYOF), in Jaca, Northern Aragon, Spain, involving 1500 athletes, from 43 countries was held in January for 7 days. The event was marred by a case of type B Neisseria meningitidis. The usual care of the patient was performed in a local hospital. He eventually made a full recovery. The case was reported to the Local Health Authority and the National Public Health authority of the patient's country. Their advice was to treat the core case, give prophylactic therapy to the inner circle (28 athletes and officials) and surveillance of the other close contacts (84 total) with temperature and symptom review daily. They advised against further information being given to the rest of the athletes and officials, in case it might give rise to a panic situation. The dilemma of the responsible physicians was that 1500 athletes were traveling back to 43 countries within the incubation period of the bacterial meningitis. It was decided that informing each country was appropriate. This was done at the event by informing the Chef of the Missions and writing to the Secretary Generals of each National Olympic Committee attending. This was the first serious contagious disease at a major sporting event. The way in which the wider dispersing attendees were informed at the event should form the basis of management at sporting events in the likelihood of a serious communicable disease.

Obstructive sleep apnea syndrome and tracheostomy. Long-term follow-up experience.

Obstructive sleep apnea syndrome (OSAS), a disabling disorder that leads to life-threatening cardiorespiratory events during sleep, has been treated by tracheostomy. This article reports long-term follow-up data of 50 patients who have undergone this procedure, and the indications for surgery are summarized. Surgery may result in secondary local and general acute and subacute complications, but, on a long-term basis, patients were completely relieved of clinical symptoms, returned to full activity, and adapted normally to social and familial life. Temporary closure of the tracheostomy during sleep led to recurrence of obstructive sleep apnea.

Automatic respiratory failure: sleep studies and Leigh's disease (case report).

A 34-year-old woman with a history of chronic nephropathy, kidney transplant rejections, and repeated hemodialysis developed symptoms of automatic respiratory failure during all states of sleep. The neuropathologic examination revealed symmetric brainstem lesions, explaining the sleep-related respiratory failure. Histology affirmed the diagnosis of Leigh's disease.

Comparison of the anticholinergic bronchodilator ipratropium bromide with metaproterenol in chronic obstructive pulmonary disease. A 90-day multi-center study.

The short- and long-term efficacy and safety of an inhaled quaternary ammonium anticholinergic agent, ipratropium bromide, and a beta agonist aerosol, metaproterenol, were compared in 261 nonatopic patients with chronic obstructive pulmonary disease (COPD). The study was a randomized, double-blind, 90-day, parallel-group trial. On three test days-one, 45, and 90-mean peak responses for forced expiratory volume in one second and forced vital capacity and mean area under the time-response curve were higher for ipratropium than for metaproterenol. Clinical improvement was noted in both treatment groups, especially during the first treatment month, with persistence of improvement throughout the remainder of the study. Side effects were relatively infrequent and generally mild; tremor, a complication of beta agonists, was not reported by any subject receiving ipratropium. These results support the effectiveness and safety of long-term treatment with inhaled ipratropium in COPD.

Respiratory and hemodynamic study during wakefulness and sleep in myotonic dystrophy.

Six young male patients with grade I (mild) myotonic dystrophy and a complaint of excessive daytime sleepiness were studied during wakefulness and sleep. Pulmonary function tests during wakefulness showed evidence of mild abnormality related to respiratory muscle weakness. During sleep, some patients developed a sleep apnea syndrome with high sleep Apnea Indices. There was no relation between hypoxic and hypercapnic ventilatory responses during wakefulness and sleep Apnea Indices. But hypoxemia and hypercapnia worsened considerably during REM sleep. Myotonic dystrophy patients with sleep apnea presented increased pulmonary and systemic arterial pressures during sleep. It was also during sleep that arrhythmias were observed.

The effects of flurazepam on sleep studies in patients with chronic obstructive pulmonary disease.

We studied five male nonobese patients (mean age, 61 years) who had moderate chronic obstructive pulmonary disease (COPD). Each patient underwent three successive nights of systematic monitoring of sleep variables. On nights 2 and 3, patients received placebo and flurazepam (30 mg). Patients were also given flurazepam (15 mg) for seven consecutive nights and underwent sleep monitoring on nights 1 and 7. Two patients exhibited oxygen desaturation during rapid-eye-movement (REM) sleep, both spontaneously and after administration of flurazepam. The three other patients had no nocturnal oxygen desaturation, either spontaneously or after ingestion of flurazepam. We concluded that sleep-induced respiratory abnormalities are not systematically worsened by flurazepam. Flurazepam (15 mg) had no effect on the sleep disturbances of our patients with COPD after seven nights of administration.

Sarcoidosis in Europe: a cooperative study.

The data on the epidemiologic situation of sarcoidosis from 24 countries of Europe have been reviewed. The new facts seem to demonstrate that the differences between the frequency of this disease in the north and south are not real. The actual situation is dependent on the general knowledge of this disease and on the extent and intensity of the active detection of its asymptomatic stage. A new prospective cooperative study of the yearly incidence of all forms of sarcoidosis in the total population of at least some European countries would be desirable.

Alcohol and the respiratory tract.

Possible mechanisms by which alcohol may adversely affect the respiratory system are considered. Alcohol ingestion impairs glottic reflexes, and alcoholics are predisposed to pneumonias and lung abscesses from aspiration of oropharyngeal bacteria. Alcohol intoxication also increases the frequency of sleep apnea and may result in respiratory failure from oversedation.

Exercise-induced asthma: an overview.

Asthmatic attack in exercise-induced asthma is brought about by hyperventilation (not necessarily to exercise), cold air, and low humidity of the air breathed. The effects are an increase in airway resistance, damage to bronchial mucosa, and an increase in bronchovascular permeability. The mechanism of these changes is the release of mediators such as histamine, leukotrienes, nitric oxide, sensory neuropeptides, the inhibition of neuronal activity, and bronchovascular permeability. The cause of asthma and exercise-induced asthma is unknown. It is probably an abnormality of vascular control in the peribronchium and/or an alteration in local adrenergic function. The importance of exercise-induced asthma definition and the use of stimulants in sport and antidoping in sport are discussed.

Computerized rapid analysis of pulmonary function test: use of a least mean squares correlation for interpretation of data.

Although systems for automated calculation and interpretation of screening pulmonary function tests (PFT) have been discussed by previous investigators, these systems are often unavailable to other users, require large or hybrid computers, or are difficult to modify. The use of a branching decision tree for PFT interpretation may also limit the number of correlations possible and make revision of the program difficult because changes in the proximal branches of the tree require a rewriting of the entire distal program. We have developed a system based on a minicomputer which uses a least mean squares analysis for rapidly analyzing the patient's PFT data. This program considers the following types of PFT data singly and in combination: percentage predicted total lung capacity and/or alveolar volume, forced expiratory volume in one second to forced vital capacity ratio (before and after bronchodilator or 80% helium challenge), and percentage predicted single breath diffusing capacity for carbon monoxide. The interpretation program (IP) then selects the 'best interpretation' for the patient by computing the variance between the patient's data and data from a menu of over 120 interpretation statements. During the past two years we have used this system for screening over 3000 patients. In about 90% of patients the computer selected interpretation statements which were acceptable to a sub-specialty pulmonary physician. The use of this IP for screening purposes has facilitated the efficient use of laboratory personnel and equipment.

Medical care of athletes in the era of performance enhancing drugs of sport (PEDOS) syndrome.

We have arrived at a watershed in the fight against drugs in sport. This must not be looked upon as a war. War eventually has winners and losers. In the fight against drugs in sport we have a major ethical, educational, financial, health and management problem. The solution to the problem will be complex. At this moment in time there is a suggestion that we move away from sports administering the problem, to governments doing the job of controlling drugs in sport. We must remind ourselves that there is no track record for governments doing the job. Perhaps representatives from the two groups, to include athletes, sports administrators, politicians, doctors with an interest in pharmacology, endocrinology, respiratory medicine, sport, and rehabilitation, pharmacists, lawyers, medical and political administrators and laboratory personnel, under the chairmanship of a compassionate person working together may be the answer.