Trends in Sudden Unexpected Deaths in an Australian Population: Impact of the COVID-19 Pandemic.

BACKGROUND AND AIM: SARS-CoV-2 infection is associated with increased cardiovascular (CV) morbidity and mortality, manifesting as increased adverse outcomes in the first 30 days, extending to 12 months. This study aimed to investigate trends in sudden unexpected deaths between 2018 and 2022, with a focus on CV deaths. METHOD: A retrospective analysis was performed on autopsy reports (n=9,330) obtained from New South Wales Coroners Court, Australia, specifically targeting cases of unexplained deaths that occurred between 2018 and 2022. Statistical analysis was conducted using chi-square tests and a post hoc analysis with Bonferroni correction, as well as analysis of variance with multiple comparisons. RESULTS: There were 349 (18.3%) CV deaths in 2018, 346 (18.0%) in 2019, 338 (17.5%) in 2020, 395 (21.9%) in 2021, and (23.4%) 413 in 2022 (p=0.0002). Among CV deaths, the number of deaths from sudden arrhythmic death syndrome were 25 (7.2%) in 2018, 26 (7.5%) in 2019, 18 (5.3%) in 2020, 52 (13.2%) in 2021, and 80 (19.4%) in 2022 (p=0.0001). Atherosclerosis was the most common cause of death among all CV categories; there were 196 (56.2%) atherosclerosis deaths in 2018, 207 (59.8%) in 2019, 192 (56.8%) in 2020, 221 (56.0%) in 2021, and 197 (47.7%) in 2022 (p=0.43). The average age of death from sudden arrhythmic death syndrome (42.8±19.1 years) across 2018-2022 was younger than atherosclerosis (56.2±12.4 years) and total groups (53.1±15.1 years) (p<0.001). Males comprised 76% of all CV deaths from 2018 to 2022 (p<0.0001). CONCLUSIONS: Compared with pre-pandemic data, a noteworthy increase in CV deaths was observed in occurrence with the escalation in COVID-19 cases in Australia. This may be attributed to direct or indirect factors, such as lifestyle modifications, disrupted access to routine cardiac care, or COVID-19 infection-triggered CV deaths.

Analysis of athlete QT intervals by age: Fridericia and Hodges heart rate corrections outperform Bazett for athlete ECG screening.

BACKGROUND: Cardiac screening of elite athletes including a 12­lead electrocardiogram (ECG) is recommended by numerous international bodies. Current athlete ECG interpretation guidelines recommend the Bazett method to correct the QT interval (QTc). OBJECTIVE: This study sought to investigate normative QTc changes by age using athlete screening ECGs and different QT correction methods in a population of elite cricketers. METHODS: Initial cardiac screening ECGs from an existing database of elite Australian cricketers aged 14-35 years were examined. Average QT interval, QTcB (corrected QT-Bazett), QTcF (Fridericia), QTcH (Hodges), and heart rate (HR) were analyzed by age and sex. RESULTS: A total of 1310 athletes (66% male, 34% female) were included with mean age 19.1 years and mean heart rate 66.9 bpm (range 38-121 bpm). With increasing age, HR decreased and absolute QT increased. The pattern of QTc change with age differed depending on the method of correction: Bazett correction (QTcB) demonstrated a "dish-shaped" or broad U-shaped appearance; while Fridericia and Hodges corrections showed a linear increase in QTc from young to older age. The Bazett method had a stronger correlation of HR with QTc (R2 = 0.32) than either Fridericia (R2 = 0.0007) or Hodges (R2 = 0.009) methods. CONCLUSIONS: The Bazett method is not the most accurate QT correction in athletes, especially during adolescence. In elite cricketers, QTcB revealed a drop in QTc from adolescence to early adulthood due to mis-correction of the QT interval. The Fridericia method has the smoothest correction of HR and least QT variation by age and may be preferred for athlete screening.

A Review of Legal, Ethical, and Governance Issues for Team Doctors.

OBJECTIVE: To provide a review and discussion of a range of legal and ethical issues commonly faced by team physicians, with reference to high-profile international integrity crises in sport that have involved doctors. The article also presents some recommendations and guidance for team doctors and sporting organizations. DATA SOURCES: Media reports, legal cases, and journal articles describing recent sporting integrity crises that have involved medical issues and governance reforms which are emerging in response. MAIN RESULTS: Many of the modern "integrity crises" in sport have a medical aspect (eg, doping cases, catastrophic injuries and illnesses, "Bloodgate" and other "medical cheating," sexual contact between doctors and athletes, harassment/bullying of doctors, concussion mismanagement, and management of the coronavirus pandemic in sport). A key issue is that while doctors bear ultimate responsibility for any perceived medical negligence, they do not always have ultimate power in decision-making. This is common in the traditional governance structure where the coach/manager "outranks" the doctor and can overrule medical decisions. There can be a blurring of the traditional doctor-patient relationship, especially on tour, and conflicts of interests occur when the needs of the employer/sporting organization differ from the player (patient). Further issues can arise in treating other staff members and players' family members. CONCLUSIONS: Doctors must be aware of range of important legal and ethical issues that arise in the team setting. Medical integrity crises have inspired governance reforms, such as policy development, appointment of chief medical officers, medical staff reporting to integrity departments, and sanctions of teams that breach medical integrity requirements. Sporting organizations must continue to implement and strengthen frameworks reinforcing doctors' seniority in the medical area.

Comparison between a 6­lead smartphone ECG and 12­lead ECG in athletes.

Athletes sometimes experience transient arrhythmias during intense exercise, which may be difficult to capture with traditional Holter monitors. New and highly portable technology, such as smartphone electrocardiogram (ECG) devices, may be useful in documenting and contribute to diagnosis of exercise-induced arrhythmias. There are little data available regarding the new Kardia 6 lead device (6L) and no data regarding its use in athletic populations. In this short communication, we present pilot data from 30 healthy athletes who underwent a 12­lead ECG and subsequent 6L reading. Our pilot data show relatively high levels of agreement for QTc and PR interval and QRS duration, with the 6L readings slightly but significantly shorter on average.

Use and Outcome of Local Anesthetic Painkilling Injections in Athletes: A Systematic Review.

BACKGROUND: The use of local anesthetic painkilling injections to improve player availability is common practice in elite-level sport. OBJECTIVE: To document the published use of local anesthetic injections in sport, according to number of injections, sites of injections, and complications reported. DATA SOURCES: A systematic search of MEDLINE, Embase, CINAHL, AMED, Cochrane Database of Systematic reviews, SportDiscus, EBSCO Host, and Google Scholar. RESULTS: One thousand nine hundred seventy local anesthetic injections reported on 540 athletes in 10 studies (from rugby league, American football, Australian football, and soccer) were reviewed. The most common areas of injection were as follows: the acromioclavicular (AC) joint; hand (including fingers); sternoclavicular joint (including sternum); rib injuries; and iliac crest contusions. DISCUSSION: This review found some evidence of long-term safety for a limited number of injection sites (eg, AC joint) and some evidence of immediate complications and harmful long-term consequences for other sites. The quality of evidence is not high, with little long-term data and a lack of independent verification of the effects of the injections. Ideally, long-term follow-up should be conducted to determine whether these injections are safe, with follow-up undertaken independently of the treating physician and team. CONCLUSIONS: Based on limited publications, there is some evidence of long-term safety; however, there is a lack of clear proof of either absolute safety or long-term harm for many of these procedures. Physicians and players in professional sport should proceed with caution in using local anesthetic injections.

Cardiovascular Screening of Elite Athletes by Sporting Organizations in Australia: A Survey of Chief Medical Officers.

OBJECTIVE: To compare cardiovascular screening policies of Australian elite sporting organizations. DESIGN: Online survey. SETTING: Elite/professional sports in Australia. PARTICIPANTS: Chief medical officers (CMOs) of elite/professional sports in Australia, including rugby union and league, cricket, tennis, Australian football, and cycling. ASSESSMENT OF VARIABLES: Survey questions about each sport's cardiac screening policy: which screening components were included [eg, history and physical (H&P), resting 12-lead electrocardiogram (ECG)], whether screening was mandatory, whether the policy applied to elite junior and/or adult players, and which criteria were used to interpret ECGs. MAIN OUTCOME MEASURES: Which sports had a formal cardiac screening policy, which athletes the policy applied to, components of screening, ECG interpretation criteria used. RESULTS: Chief medical officers for 22/31 (71%) sports responded, representing >5000 athletes. Of these, 19/22 (86%) perform regular screening (100% H&P; 89% included ECG) with international cyclists also having routine echocardiograms and stress testing. Thirty-three percent of CMOs used the 2017 International Criteria for athlete ECG interpretation. Screening was mandatory with enforcement (26%), mandatory without enforcement (48%), and opt-out (26%). All screened adult elite athletes, and 68% screened junior elite athletes. Forty-two percent indicated athletes were required to pay for screening tests, and 63% required athletes to pay for follow-up tests. Almost all (94%) sports with a sports physician as the CMO screened athletes. CONCLUSIONS: Most sports have a screening policy, with reasonable uniformity of components. All included H&P, and almost all included ECG. Only one sport included an echocardiogram and stress test as a standard (international players only). Promoting the latest ECG interpretation criteria may reduce false-positives and cost. Future work should explore cardiac emergency plans, screening infrastructure, cost, and long-term follow-up.

Sport Medicine Diagnostic Coding System (SMDCS) and the Orchard Sports Injury and Illness Classification System (OSIICS): revised 2020 consensus versions.

Coding in sports medicine generally uses sports-specific coding systems rather than the International Classification of Diseases (ICD), because of superior applicability to the profile of injury and illness presentations in sport. New categories for coding were agreed on in the 'International Olympic Committee (IOC) consensus statement: Methods for recording and reporting of epidemiological data on injury and illness in sports 2020.' We explain the process for determining the new categories and update both the Sport Medicine Diagnostic Coding System (SMDCS) and the Orchard Sports Injury and Illness Classification System (OSIICS) with new versions that operationalise the new consensus categories. The author group included members from an expert group attending the IOC consensus conference. The primary authors of the SMDCS (WM) and OSIICS (JO) produced new versions that were then agreed on by the remaining authors using expert consensus methodology. The SMDCS and OSIICS systems have been adjusted and confirmed through a consensus process to align with the IOC consensus statement to facilitate translation between the two systems. Problematic areas for defining body part categories included the groin and ankle regions. For illness codes, in contrast to the ICD, we elected to have a taxonomy of 'organ system/region' (eg, cardiovascular and respiratory), followed by an 'aetiology/pathology' (eg, environmental, infectious disease and allergy). Companion data files have been produced that provide translations between the coding systems. The similar structure of coding underpinning the OSIICS and SMDCS systems aligns the new versions of these systems with the IOC consensus statement and also facilitates easier translation between the two systems. These coding systems are freely available to the sport and exercise research community.

Fifteen-week window for recurrent muscle strains in football: a prospective cohort of 3600 muscle strains over 23 years in professional Australian rules football.

OBJECTIVES: To determine the rates of muscle strain injury recurrence over time after return to play in Australian football and to quantify risk factors. METHODS: We analysed Australian Football League player data from 1992 to 2014 for rates of the four major muscle strain injury types (hamstring, quadriceps, calf and groin) diagnosed by team health professionals. Covariates for analysis were: recent history (≤8 weeks) of each of the four muscle strains; non-recent history (>8 weeks) of each; history of hip, knee anterior cruciate ligament, knee cartilage, ankle sprain, concussion or lumbar injury; age; indigenous race; match level and whether a substitute rule was in place. RESULTS: 3647 (1932 hamstring, 418 quadriceps, 458 calf and 839 groin) muscle strain injuries occurred in 272 759 player matches. For all muscle strains combined, the risk of injury recurrence gradually reduced, with recurrence risks of 9% (hamstring), 5% (quadriceps), 2% (calf) and 6% (groin) in the first match back and remaining elevated for 15 weeks after return to play. The strongest risk factor for each muscle injury type was a recent history of the same injury (hamstring: adjusted OR 13.1, 95% CI 11.5 to 14.9; calf OR 13.3, 95% CI 9.6 to 18.4; quadriceps: OR 25.2, 95% CI 18.8 to 33.8; groin OR 20.6, 95% CI 17.0 to 25.0), followed by non-recent history of the same injury (hamstring: adjusted OR 3.5, 95% CI 3.2 to 3.9; calf OR 4.4, 95% CI 3.6 to 5.4; quadriceps OR 5.2, 95% CI 4.2 to 6.4; groin OR 3.5, 95% CI 3.0 to 4.0). Age was an independent risk factor for calf muscle strains (adjusted OR 1.6, 95% CI 1.3 to 2.0). Recent hamstring injury increased the risk of subsequent quadriceps (adjusted OR 1.8, 95% CI 1.2 to 2.7) and calf strains (OR 1.8, 95% CI 1.2 to 2.6). During the 'substitute rule' era (2011-2014), hamstring (adjusted OR 0.76, 95% CI 0.67 to 0.86), groin (OR 0.78, 95% CI 0.65 to 0.93) and quadriceps (OR 0.70, 95% CI 0.53 to 0.92) strains were less likely than outside of that era but calf (OR 1.6, 95% CI 1.3 to 1.9) strains were more likely than before the substitute rule era. CONCLUSION: Recent injury is the greatest risk factor for the four major muscle strains, with increased risk persisting for 15 weeks after return to play.

International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS)).

Injury and illness surveillance, and epidemiological studies, are fundamental elements of concerted efforts to protect the health of the athlete. To encourage consistency in the definitions and methodology used, and to enable data across studies to be compared, research groups have published 11 sport-specific or setting-specific consensus statements on sports injury (and, eventually, illness) epidemiology to date. Our objective was to further strengthen consistency in data collection, injury definitions and research reporting through an updated set of recommendations for sports injury and illness studies, including a new Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist extension. The IOC invited a working group of international experts to review relevant literature and provide recommendations. The procedure included an open online survey, several stages of text drafting and consultation by working groups and a 3-day consensus meeting in October 2019. This statement includes recommendations for data collection and research reporting covering key components: defining and classifying health problems; severity of health problems; capturing and reporting athlete exposure; expressing risk; burden of health problems; study population characteristics and data collection methods. Based on these, we also developed a new reporting guideline as a STROBE Extension-the STROBE Sports Injury and Illness Surveillance (STROBE-SIIS). The IOC encourages ongoing in- and out-of-competition surveillance programmes and studies to describe injury and illness trends and patterns, understand their causes and develop measures to protect the health of the athlete. Implementation of the methods outlined in this statement will advance consistency in data collection and research reporting.

International study of video review of concussion in professional sports.

BACKGROUND: Video review has become an important tool in professional sporting codes to help sideline identification and management of players with a potential concussion. AIM: To assess current practices related to video review of concussion in professional sports internationally, and compare protocols and diagnostic criteria used to identify and manage potential concussions. METHODS: Current concussion management guidelines from professional national and international sporting codes were reviewed. Specific criteria and definitions of video signs associated with concussion were compared between codes. Rules and regulations adopted across the codes for processes around video review were also assessed. RESULTS: Six sports with specific diagnostic criteria and definitions for signs of concussion identified on video review participated in this study (Australian football, American football, world rugby, cricket, rugby league and ice hockey). Video signs common to all sports include lying motionless/loss of responsiveness and motor incoordination. The video signs considered by the majority of sports as most predictive of a diagnosis of concussion include motor incoordination, impact seizure, tonic posturing and lying motionless. Regulatory requirements, sideline availability of video, medical expertise of video reviewers and use of spotters differ across sports and geographical boundaries. By and large, these differences reflect a pragmatic approach from each sport, with limited underlying research and development of the video review process in some instances. CONCLUSIONS: The use of video analysis in assisting medical staff with the diagnosis or identification of potential concussion is well established across different sports internationally. The diagnostic criteria used and the expertise of the video review personnel are not clearly established, and research efforts would benefit from a collaborative harmonisation across sporting codes.

Injectable Corticosteroids in Sport.

OBJECTIVE: To review the literature guiding all aspects of the use of injectable corticosteroids for painful musculoskeletal conditions, with a focus on the treatment of athletes. DATA SOURCES: An extensive search of the literature was completed including search terms of corticosteroid, steroid, athlete, and injection, among others. Additional articles were used after being identified from previously reviewed articles. MAIN RESULTS: Injections of corticosteroids for a variety of painful conditions of the extremities and the axial spine have been described. Numerous minor and major complications have been reported, including those with a high degree of morbidity. There is a dearth of published research on the use of corticosteroid injections in athletes, with most of the research on this topic focused on older, nonathlete populations. Generally, these injections are well tolerated and can provide short-term pain improvement with little or no long-term benefits. CONCLUSIONS: Corticosteroid injections should be used cautiously in athletes and only after a full consideration of the pharmacology, pathogenesis of disease, potential benefits, complications, factors specific to the athlete, and rules of athletic governing bodies. Corticosteroid injections are just one component of a comprehensive rehabilitation plan available to the physician providing care to athletes.

Long-Term Safety of Using Local Anesthetic Injections in Professional Rugby League for Modified Indications.

OBJECTIVE: To assess and evaluate the long-term safety of local anesthetic injections before or during games in professional rugby league players. DESIGN: Retrospective case series. SETTING: Professional rugby league team. PARTICIPANTS: Sydney Roosters players over a 6-year period (2008-2013), who had been administered a local anesthetic injection for an injury before or during a match to aid return to play. INTERVENTIONS: Follow-up survey (no active intervention). MAIN OUTCOME MEASURES: Player self-reported satisfaction. Survey results were compared with a previous cohort who had received local anesthetic injection from 1998 to 2007. RESULTS: Thirty-two players who had been injected with local anesthetic on 249 occasions for 81 injuries completed the current survey at an average of 5.64 years postinjection. In the cohort of 2008 to 2013, fewer injections were performed to areas deemed higher risk compared with the 1998 to 2007 cohort (P < 0.00002). The vast majority of players (80/81 cases) would repeat the injection in the same circumstances and reported that ongoing side effects were uncommon. There were 6 cases (8%) in which players reported significant ongoing pain in the area of injection at long-term follow-up. CONCLUSIONS: This study affirmed the long-term safety of injections in most cases. LEVEL OF EVIDENCE: IV.

Ultrasound Guidance Does Not Improve the Results of Shock Wave for Plantar Fasciitis or Calcific Achilles Tendinopathy: A Randomized Control Trial.

OBJECTIVE: To establish whether the use of ultrasound to direct shock waves to the area of greater calcification in calcaneal enthesopathies was more effective than the common procedure of directing shock waves to the point where the patient has the most tenderness. DESIGN: Two-armed nonblinded randomized control trial with allocation concealment. SETTING: The Sports Clinic at Sydney University. PATIENTS: Participants 18 years or older with symptomatic plantar fasciitis (PF) (with heel spur) or calcific Achilles tendinopathy (CAT). Seventy-four of 82 cases completed treatment protocol and 6-month follow-up. INTERVENTIONS: Patients were randomized to receive either ultrasound-guided (UG) or patient-guided (PG) shock wave at weekly intervals over 3 to 5 weeks. MAIN OUTCOME MEASURES: Reduced pain on visual analog scale (VAS) and improved functional score on Maryland Foot Score (MFS) (for PF) or Victorian Institute of Sport Assessment-Achilles (VISA-A) (for CAT). Follow-up was at 6 weeks and 3 and 6 months. RESULTS: Comparative 6-month improvements in MFS for the 47 PF cases were PG +20/100 and UG +14/100 (P = 0.20). Comparative 6-month improvement in VISA-A score for the 27 CAT cases were PG +35/100 and UG +27/100 (P = 0.37). Comparative (combined PF and CAT) 6-month improvement in VAS pain scores for all 38 PG cases were +38/100 with +37/100 for all 36 UG shock wave cases. CONCLUSIONS: Although both treatment groups had good clinical outcomes in this study, results for the 2 study groups were almost identical. CLINICAL RELEVANCE: This study shows that there is no major advantage in the addition of ultrasound for guiding shock waves when treating calcaneal enthesopathies (PF and CAT).

How much is too much? (Part 2) International Olympic Committee consensus statement on load in sport and risk of illness.

The modern-day athlete participating in elite sports is exposed to high training loads and increasingly saturated competition calendar. Emerging evidence indicates that inappropriate load management is a significant risk factor for acute illness and the overtraining syndrome. The IOC convened an expert group to review the scientific evidence for the relationship of load-including rapid changes in training and competition load, competition calendar congestion, psychological load and travel-and health outcomes in sport. This paper summarises the results linking load to risk of illness and overtraining in athletes, and provides athletes, coaches and support staff with practical guidelines for appropriate load management to reduce the risk of illness and overtraining in sport. These include guidelines for prescription of training and competition load, as well as for monitoring of training, competition and psychological load, athlete well-being and illness. In the process, urgent research priorities were identified.

How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury.

Athletes participating in elite sports are exposed to high training loads and increasingly saturated competition calendars. Emerging evidence indicates that poor load management is a major risk factor for injury. The International Olympic Committee convened an expert group to review the scientific evidence for the relationship of load (defined broadly to include rapid changes in training and competition load, competition calendar congestion, psychological load and travel) and health outcomes in sport. We summarise the results linking load to risk of injury in athletes, and provide athletes, coaches and support staff with practical guidelines to manage load in sport. This consensus statement includes guidelines for (1) prescription of training and competition load, as well as for (2) monitoring of training, competition and psychological load, athlete well-being and injury. In the process, we identified research priorities.

International consensus statement on injury surveillance in cricket: a 2016 update.

Cricket was the first sport to publish recommended methods for injury surveillance in 2005. Since then, there have been changes to the nature of both cricket and injury surveillance. Researchers representing the major cricket playing nations met to propose changes to the previous recommendations, with an agreed voting block of 14. It was decided that 10 of 14 votes (70%) were required to add a new definition element and 11 of 14 (80%) were required to amend a previous definition. In addition to the previously agreed 'Match time-loss' injury, definitions of 'General time-loss', 'Medical presentation', 'Player-reported' and 'Imaging-abnormality' injuries are now provided. Further, new injury incidence units of match injuries per 1000 player days, and annual injuries per 100 players per year are recommended. There was a shift towards recommending a greater number of possible definitions, due to differing contexts and foci of cricket research (eg, professional vs amateur; injury surveillance systems vs specific injury category studies). It is recommended that researchers use and report as many of the definitions as possible to assist both comparisons between studies within cricket and with those from other sports.