Doping yesterday, today, tomorrow: A challenge for the clinical laboratory.

This work highlights the role of the clinical laboratory, in the early detection of the use of substances prohibited for doping. This is because most people who practice sports today are non-professional athletes and amateurs, in particular young kids. These persons are not subjected to anti-doping controls but are at risk for their health. Endocrinologists and laboratory tests, by detecting evidence of such usage can help protect their health. Anti-doping testing require specific instruments for qualitative and quantitative chemistry, to meet regulations of official competitions but are impossible to be used in every person because of high cost. A particular role the clinical laboratory can acquire in the future is through its molecular biology sections, when genetic doping will probably be a reality and quantitative chemistry will be unable to detect it. A brief history of doping is provided to understand the reasons of its spread. Although doping has great resonance nowadays, it is not a recent problem. It was common among ancient Greek wrestlers and Romans, who used mixtures of herbs and stimulants. Ancient Greece started the Olympic Games and winners assumed great esteem, akin to demi-god status. Therefore, any attempt to improve athletic performance was a norm, also because the damage caused by the substances used was not known at that time. The use became so widespread that soldiers also used drugs to better combat during recent wars, and doping was practiced by athletes, actors and musicians in attempts to obtain better performance results. Today, doping has been refined so as not to be discovered and there is a continuous race between those who promote new substances and those who, like the World Anti-Doping Agency (WADA), were created to defend the health of athletes and comply with regulations of competitions. The clinical laboratory plays a fundamental role in identifying the use of prohibited substances, especially in competitions not classified as official, which are the majority and involve thousands of amateurs. In this paper a series of laboratory tests are proposed in this perspective, at low cost without the need of qualitative/quantitative chemical analyses required by the sport jurisdictions. Finally, a glance into genetic doping illustrates a likely future and imminent practice.

A Retrospective Analysis of Major League Baseball Hit-by-Pitch Rates before and after the Crackdown on Foreign Substance Use.

OBJECTIVE: Determine whether there was an increased incidence of hit-by-pitch events in Major League Baseball (MLB) following the decision to enforce the foreign substance ban for pitchers during the 2021 season. DESIGN: Descriptive Epidemiological Study. SETTING: Major League Baseball hit-by-pitch data from publicly available Web sites ( mlb.com and fangraphs.com ). PARTICIPANTS: Major League Baseball players during the 2017, 2018, 2019, 2021, and 2022 seasons. INDEPENDENT VARIABLES: Hit-by-pitch exposure data by season and individual pitch type. MAIN OUTCOME MEASURES: Hit-by-pitch incidence rates from the 2017 to 2019 seasons (preenforcement) and the 2021 to 2022 seasons (postenforcement). Rates were compared with incidence rate ratios (IRRs). RESULTS: Hit-by-pitch incidence rate increased from 2.66 to 3.06 per 1000 total pitches (IRR, 1.15 [95% CI, 1.08-1.23]; P < 0.0001) following the enforcement. Incidence rates for 2017, 2018, and 2019 did not differ from each other individually, but incidence rate of all 3 seasons individually were significantly lower than that for the 2021 season ( P < 0.005). Sliders were 29% more likely to hit batters following the enforcement ( P = 0.0015). CONCLUSIONS: Major League Baseball batters were hit by pitches at a significantly higher rate following the league's crackdown on foreign substance use for the 2021 seasons compared with the same time of year during the 2017 to 2019 seasons. This was followed by a slight regression toward preenforcement levels during the 2022 season.

Anabolic-Androgenic Steroid Use in Sports, Health, and Society.

This consensus statement is an update of the 1987 American College of Sports Medicine (ACSM) position stand on the use of anabolic-androgenic steroids (AAS). Substantial data have been collected since the previous position stand, and AAS use patterns have changed significantly. The ACSM acknowledges that lawful and ethical therapeutic use of AAS is now an accepted mainstream treatment for several clinical disorders; however, there is increased recognition that AAS are commonly used illicitly to enhance performance and appearance in several segments of the population, including competitive athletes. The illicit use of AAS by competitive athletes is contrary to the rules and ethics of many sport governing bodies. Thus, the ACSM deplores the illicit use of AAS for athletic and recreational purposes. This consensus statement provides a brief history of AAS use, an update on the science of how we now understand AAS to be working metabolically/biochemically, potential side effects, the prevalence of use among athletes, and the use of AAS in clinical scenarios.

Olympic competition climbing: the beginning of a new era-a narrative review.

Climbing as a competition sport has become increasingly popular in recent years, particularly the sub-discipline of bouldering. The sport will debut in the Tokyo Summer Olympic Games. National and international competitions have three disciplines: lead (climbing with rope protection), bouldering (climbing at lower heights with mattress floor protection) and speed (maximum speed climbing on a standardised route in 1-on-1 mode). There is also a 'combined mode' of all three disciplines (combined) which forms the Olympic competition format; all competition formats are held on artificial walls. Existing literature describes a predominantly low injury frequency and severity in elite climbing. In comparison to climbing on real rock, artificial climbing walls have recently been associated with higher injury rates. Finger injuries such as tenosynovitis, pulley lesions and growth plate injuries are the most common injuries. As finger injuries are sport-specific, medical supervision of climbing athletes requires specific medical knowledge for diagnosis and treatment. There is so far little evidence on effective injury prevention measures in top athletes, and antidoping measures, in general, requiring further work in this field. An improved data situation regarding high-performance climbing athletes is crucial to ensure that the sport continues to be largely safe and injury-free and to prevent doping cases as extensively as possible.

Prevalence of therapeutic use exemptions at the Olympic Games and association with medals: an analysis of data from 2010 to 2018.

OBJECTIVES: The percentage of athletes with Therapeutic Use Exemptions (TUEs) competing in elite sport and the association with winning medals has been a matter of speculation in the absence of validated competitor numbers. We used International Olympic Committee (IOC) and World Anti-Doping Agency (WADA) data to identify athletes competing with TUEs at five Olympic Games (Games) and a possible association between having a TUE and winning an Olympic medal. METHODS: We used the IOC's competition results and WADA's TUE database to identify the number of TUEs for athlete competitions (ACs, defined as one athlete competing in one event) and any associations with medals among athletes competing in individual competitions. We calculated risk ratios (RR) for the probability of winning a medal among athletes with a TUE compared with that of athletes without a TUE. We also reported adjusted RR (RRadj) controlling for country resources, which is a potential confounder. RESULTS: During the Games from 2010 to 2018, there were 20 139 ACs and 2062 medals awarded. Athletes competed with a TUE in 0.9% (181/20 139) of ACs. There were 21/2062 medals won by athletes with a TUE. The RR for winning a medal with a TUE was 1.13 (95% CI: 0.73 to 1.65; p=0.54), and the RRadj was 1.07 (95% CI: 0.69 to 1.56; p=0.73). CONCLUSION: The number of athletes competing with valid TUEs at Games is <1%. Our results suggested that there is no meaningful association between being granted a TUE and the likelihood of winning a medal.

Anti-doping research and the Helsinki Declaration: (mis)match?

The fight against doping in sport is internationally coordinated by the World Anti-Doping Agency (WADA). Through its World Anti-Doping Code, WADA aims to harmonize anti-doping policies, rules and regulations. One key reference document bound to the Code is the International Standard for Laboratories (ISL), which mainly specifies the criteria that must be met for laboratory accreditation, as well as standards to adopt for the production of valid test results and evidentiary data. Within the ISL, the Code of Ethics refers to the Helsinki Declaration as a guiding framework for anti-doping research. However, inasmuch as anti-doping research structurally differs from human subject research as considered by the Helsinki Declaration, the applicability of the latter to anti-doping research can be called into question. In this work, we discuss how key principles of the Helsinki Declaration apply to anti-doping research and highlight frictions, incompatibilities and misalignments. Furthermore, we indicate possible solutions for operationalizing the Helsinki principles within the context of anti-doping research.

Sports Supplements: Pearls and Pitfalls.

Sports supplements can be generally divided into 3 categories: sports foods (foods/drinks containing macronutrients), medical supplements (vitamins/minerals used to treat deficiencies), and ergogenic supplements (used to benefit performance). Supplements are not regulated by the US Food and Drug Administration. They may get to the market and be contaminated with substances banned in sport or dangerous to health; and the contents may not contain what is listed on the label. When choosing to use a supplement, the safest practice is to choose a certified brand, which tests and authenticates label verification, quality, and lack of contaminants and banned substances for sport.

Glucocorticoids in elite sport: current status, controversies and innovative management strategies-a narrative review.

The use of systemic glucocorticoids (GCs), as well as local injections, continues to be a controversial issue in the sport/anti-doping community. There is widespread and legitimate use of GCs for numerous health conditions, yet there are concerns about side effects and the possibility of enhanced athletic performance in limited settings. This is compounded by the uncertainty regarding the prevalence of GC use, mechanisms underlying physiological effects and complex pharmacokinetics of different formulations. While WADA continues to promote research in this complex area, some international sporting federations, major event organisers and professional sports leagues have introduced innovative rules such as needle policies, mandatory rest periods and precompetition guidelines to promote judicious use of GCs, focusing on athlete health and supervision of medical personnel. These complementary sport-specific rules are helping to ensure the appropriate use of GCs in athletes where overuse is a particular concern. Where systemic GCs are medically necessary, Therapeutic Use Exemptions (TUEs) may be granted after careful evaluation by TUE Committees based on specific and strict criteria. Continued vigilance and cooperation between physicians, scientists and anti-doping organisations is essential to ensure that GC use in sport respects not only principles of fairness and adherence to the rules but also promotes athlete health and well-being. The purpose of this narrative review is to summarise the use and management of GCs in sport illustrating several innovative programmes by sport leagues and federations.

Gene doping: Present and future.

Being an elite athlete is an extremely coveted position, which can lead an individual to use doping. As knowledge is extended, doping techniques have become increasingly sophisticated, and the newest method of doping is gene doping. This article aims to present an updated bibliographic survey that addresses gene doping between 1983 and 2018. Anti-doping agencies have not yet approved any detection technique for this type of doping. The possibility of eradicating such doping is almost zero mainly because gene therapy advances rapidly. In this scenario, the future of gene doping must be discussed and decided before irreversible limits are exceeded.

Education to legality and doping.

When planning actions to prevent doping in the general population, public health operators may collide against the interests of criminal organizations involved in illicit trafficking of drugs. In addition to technical and professional expertise, or clinical and pharmacological skills, also a deep knowledge of legal and social issues is strongly required to face the problem and assure the effectiveness of the preventive actions. Sports competitions, athletes training or adapted physical activity may all represent conditions and environments at risk for misusing or abusing drugs and dietary supplements. A correct approach to sport and physical activity implies respect of competition rules, attention to own body limits and knowledge of risk factors. Health education campaigns and preventive actions should also consider education to legality in the different settings. The comprehension of the complex net that is available to access doping, locally or globally through online Internet sites, is essential as well as the awareness of the huge economic burden of crime interests behind the illicit trafficking of drugs. A modern whole rounded approach needs to consider doping not only as a violation of sport rules but also of the own body health, representing almost a form of addiction involving individuals and communities, and being supported by crime. Within this frame, doping is considered not just as a sport violation or a risk factor for individual's health, but as a disease of the society, in the society, against the society. A peculiar equilibrium seems to prevail between crime external pressures and resigned internal acceptance, according to the 'mafia hypothesis' model, where hosts accept parasitism to avoid retaliation. Here, main contributes and topics from the Erice 53rd Course are summarized and reviewed, providing links and references for further studies in the field. Health education and education to legality represent two sides of a same question, concerning both the general population and the health authorities. In conclusion, education to legality is a key component for prevention of doping and a priority for public health operators involved in protecting population health.

Changing attitudes and intentions related to doping: An analysis of individual differences in need for cognition.

Research has shown that athletes' attitudes towards the use of banned performance-enhancing substances are reliable predictors of their intentions to use these substances, which in turn can be relevant predictors of their actual doping behaviours. Despite the important role played by attitudes and intentions in doping, research analysing how to change those attitudes and intentions is relatively scarce. The present study examined how individual differences in Need for Cognition (NC, Cacioppo & Petty, 1982) influenced doping-related attitude change and subsequent behavioural intentions. Participants were randomly assigned to read a persuasive message either against or in favour of legalising the use of several banned substances, including anabolic androgenic steroids (AAS) and Erythropoietin (EPO). In addition, participants completed the NC scale, and finally reported their attitudes and behavioural intentions regarding the legalisation proposal. As hypothesised, results showed that participants who received an anti-legalisation message had significantly more unfavourable attitudes towards the proposal than participants who received a pro-legalisation message, regardless of NC. However, as predicted, NC moderated the relationship between individuals' attitudes and their intentions. That is, high-NC participants showed greater attitude-intention correspondence than low-NC participants.

The Landscape of the "Spirit of Sport" : A Systematic Review.

The World Anti-Doping Agency (WADA) sets out a detailed description of what its own conception of the "spirit of sport" as employed in the World Anti-Doping Code (WADC) entails. However, controversies as to the significance and meaning to be ascribed to the term abound in the literature. In order to unravel the core of the debates and to move discussions forward, the authors aimed at reviewing understandings of the spirit of sport in the conceptual literature. The main databases were searched using relevant keywords. After the inclusion and exclusion criteria were applied, eighteen publications were included in the review. The most striking result to emerge from the data is the multivalence of the concept of spirit of sport. Our thematic analysis generated the contestability of the spirit of sport as the predominant theme in the conceptual literature. There is a need for empirical research to generate data about perspectives on the spirit of sport from other stakeholders especially those of the athletes themselves.

Systematic analysis to assess the scientific validity of the international residue limits for caffeine and theophylline in horse-racing.

Based on their performance-enhancing potential, caffeine and theophylline are prohibited substances in equine sports. Residues in horses can be caused by wilful application or by unintended uptake of contaminated feed. The International Federation of Horseracing Authorities recently introduced international residue limits (IRLs) to facilitate the discrimination between pharmacological relevant and irrelevant concentrations in doping samples. The objective of this study was to investigate the scientific validity of these IRLs. A systematic analysis was performed to assess the IRLs by different statistical approaches using published pharmacokinetic data. 31 out of 218 potentially relevant publications met the inclusion criteria. Thereby, both IRLs were found to be appropriate for the exclusion of the presence of a relevant pharmacological effect after a wilful application. The IRL of theophylline was also determined to be suitable for the prevention of positive doping tests caused by the ingestion of contaminated feed. In contrast, the IRL of caffeine is not suitable to prevent positive doping test caused by the ingestion of more than 10 mg caffeine per day per horse with contaminated feed. The lack of corresponding regulation for paraxanthine, a major active metabolite of caffeine and theophylline, was recognised as a substantial shortcoming of the current system, rendering both IRLs incomplete.

Improving scientific practice in sports-associated drug testing.

Antidoping work is heavily based on scientific analyses of biological material, such as urine and blood. Because of the high stakes both for sports and for the athletes involved it is important that analyses are performed and interpreted in agreement with established scientific standards and professional norms. This is not always the case, as we document here. It is our experience that the antidoping movement does not appear willing to consider that errors can occur and should be corrected. The consequences of the lack of transparency and responsibility are carried by unlucky athletes. Scientific, ethical and legal considerations urge the antidoping movement to reform some of their rules and regulations and to include the possibility that the World Anti-Doping Agency position could, in some cases, be incorrect.

Essential Features of Third-Party Certification Programs for Dietary Supplements: A Consensus Statement.

The presence of performance-enhancing drugs in dietary supplements poses serious anti-doping and health risks to athletes and military service members. A positive drug test, suboptimal health, or adverse event can ruin a career in either setting. These populations need to be certain in advance that a product is of high quality and free from performance-enhancing drugs and other banned substances. However, no regulatory authority conducts or mandates a quality review before dietary supplements are sold. Under the Food Drug and Cosmetic Act, the Food and Drug Administration does not have a role in the premarket safety review of dietary supplements. Due to the increasing demand for high-quality, properly labeled dietary supplements, multiple companies have stepped into this void by offering testing and quality review programs for dietary supplements. Each of these third-party programs has its own quality assurance program with varying testing components. It is difficult for consumers in the sport and military settings to assess whether a particular certification program reduces the risks enough so that they can use a product with confidence. This article puts forward the consensus of the authors on current best practices for third-party certification programs for dietary supplements consumed by athletes and military service members. Also discussed are important ways that third-party programs can develop in the future to improve access to safe, high-quality dietary supplements for these populations.