Return to play after acute infectious disease in football players

Cardiopulmonary function in paediatric post-COVID-19: a controlled clinical trial

Recently, the importance of post-COVID-19 in children has been recognized in surveys and retrospective chart analysis. However, objective data in the form of cardiopulmonary exercise test as performed in adults suffering from this condition are still lacking. This study aimed to investigate the cardiopulmonary effects of post-COVID-19 on children and adolescents. In this cross-sectional study (the FASCINATE study), children fulfilling the criteria of post-COVID-19 and an age- and sex-matched control group underwent cardiopulmonary exercise testing on a treadmill and completed a questionnaire with regard to physical activity before, during and after the infection with SARS-CoV-2. We were able to recruit 20 children suffering from post-COVID-19 (mean age 12.8 ± 2.4 years, 60% females) and 28 control children (mean age 11.7 ± 3.5 years, 50% females). All participants completed a maximal treadmill test with a significantly lowerV ˙ O 2 peak in the post-COVID-19 group (37.4 ± 8.8 ml/kg/min vs. 43.0 ± 6.7 ml/kg/min. p = 0.019). This significance did not persist when comparing the achieved percentage of predictedV ˙ O 2 peak . There were no significant differences for oxygen pulse, heart rate, minute ventilation or breathing frequency.   Conclusion: This is the first study to investigate post-COVID-19 in children using the cardiopulmonary exercise test. Although there was a significantly reducedV ˙ O 2 peak in the post-COVID-19 group, this was not true for the percent of predicted values. No pathological findings with respect to cardiac or pulmonary functions could be discerned. Deconditioning was the most plausible cause for the experienced symptoms.    Trial registration: clinicaltrials.gov, NCT054445531, Low-field Magnetic Resonance Imaging in Pediatric Post Covid-19-Full Text View-ClinicalTrials.gov. What is Known: • The persistence of symptoms after an infection with SARS-CoV 2, so-called post-COVID-19 exists also in children. • So far little research has been conducted to analyze this entity in the pediatric population. What is New: • This is the first study proving a significantly lower cardiopulmonary function in pediatric patients suffering from post-COVID-19 symptoms. • The cardiac and pulmonary function appear similar between children suffering from post-COVID-19 and those who don't, but the peripheral muscles seem affected.

Myocarditis and sports in the young: data from a nationwide registry on myocarditis-"MYKKE-Sport"

Background

Myocarditis represents one of the most common causes of Sudden Cardiac Death in children. Myocardial involvement during a viral infection is believed to be higher as a consequence of intensive exertion. Recommendations for return to sports are based on cohort and case studies only. This study aims to investigate the relationship between physical activity and myocarditis in the young.

Patient

Every patient in the MYKKE registry fulfilling criteria for suspicion of myocarditis was sent a questionnaire regarding the physical activity before, during and after the onset of myocarditis.

Method

This study is a subproject within the MYKKE registry, a multicenter registry for children and adolescents with suspected myocarditis. The observation period for this analysis was 93 months (September 2013-June 2021). Anamnestic, cardiac magnetic resonance images, echocardiography, biopsy and laboratory records from every patient were retrieved from the MYKKE registry database.

Results

58 patients (mean age 14.6 years) were enrolled from 10 centers. Most patients participated in curricular physical activity and 36% in competitive sports before the onset of myocarditis. There was no significant difference of heart function at admission between the physically active and inactive subjects (ejection fraction of 51.8 ± 8.6% for the active group vs. 54.4 ± 7.7% for the inactive group). The recommendations regarding the return to sports varied widely and followed current guidelines in 45%. Most patients did not receive an exercise test before returning to sports.

Conclusion

Sports before the onset of myocarditis was not associated with a more severe outcome. There is still a discrepancy between current literature and actual recommendations given by health care providers. The fact that most participants did not receive an exercise test before being cleared for sports represents a serious omission.

International Olympic Committee (IOC) consensus statement on acute respiratory illness in athletes part 1: acute respiratory infections

Acute illnesses affecting the respiratory tract are common and form a significant component of the work of Sport and Exercise Medicine (SEM) clinicians. Acute respiratory illness (ARill) can broadly be classified as non-infective ARill and acute respiratory infections (ARinf). The aim of this consensus is to provide the SEM clinician with an overview and practical clinical approach to ARinf in athletes. The International Olympic Committee (IOC) Medical and Scientific Commission appointed an international consensus group to review ARill (non-infective ARill and ARinf) in athletes. Six subgroups of the IOC Consensus group were initially established to review the following key areas of ARill in athletes: (1) epidemiology/risk factors for ARill, (2) ARinf, (3) non-infective ARill including ARill due to environmental exposure, (4) acute asthma and related conditions, (5) effects of ARill on exercise/sports performance, medical complications/return-to-sport and (6) acute nasal/vocal cord dysfunction presenting as ARill. Several systematic and narrative reviews were conducted by IOC consensus subgroups, and these then formed the basis of sections in the consensus documents. Drafting and internal review of sections were allocated to 'core' members of the consensus group, and an advanced draft of the consensus document was discussed during a meeting of the main consensus core group in Lausanne, Switzerland on 11 to 12 October 2021. Final edits were completed after the meeting. This consensus document (part 1) focusses on ARinf, which accounts for the majority of ARill in athletes. The first section of this consensus proposes a set of definitions and classifications of ARinf in athletes to standardise future data collection and reporting. The remainder of the consensus paper examines a wide range of clinical considerations related to ARinf in athletes: epidemiology, risk factors, pathology/pathophysiology, clinical presentation and diagnosis, management, prevention, medical considerations, risks of infection during exercise, effects of infection on exercise/sports performance and return-to-sport guidelines.

Acute respiratory illness and return to sport: a systematic review and meta-analysis by a subgroup of the IOC consensus on 'acute respiratory illness in the athlete'

OBJECTIVE

To determine the days until return to sport (RTS) after acute respiratory illness (ARill), frequency of time loss after ARill resulting in >1 day lost from training/competition, and symptom duration (days) of ARill in athletes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, EBSCOhost, Web of Science, January 1990-July 2020.

ELIGIBILITY CRITERIA

Original research articles published in English on athletes/military recruits (15-65 years) with symptoms/diagnosis of an ARill and reporting any of the following: days until RTS after ARill, frequency (%) of time loss >1 day after ARill or symptom duration (days) of ARill.

RESULTS

767 articles were identified; 54 were included (n=31 065 athletes). 4 studies reported days until RTS (range: 0-8.5 days). Frequency (%) of time loss >1 day after ARill was 20.4% (95% CI 15.3% to 25.4%). The mean symptom duration for all ARill was 7.1 days (95% CI 6.2 to 8.0). Results were similar between subgroups: pathological classification (acute respiratory infection (ARinf) vs undiagnosed ARill), anatomical classification (upper vs general ARill) or diagnostic method of ARinf (symptoms, physical examination, special investigations identifying pathogens).

CONCLUSIONS

In 80% of ARill in athletes, no days were lost from training/competition. The mean duration of ARill symptoms in athletes was 7 days. Outcomes were not influenced by pathological or anatomical classification of ARill, or in ARinf diagnosed by various methods. Current data are limited, and future studies with standardised approaches to definitions, diagnostic methods and classifications of ARill are needed to obtain detailed clinical, laboratory and specific pathogen data to inform RTS.

PROSPERO REGISTRATION NUMBER

CRD42020160479.

Symptom cluster is associated with prolonged return-to-play in symptomatic athletes with acute respiratory illness (including COVID-19): a cross-sectional study-AWARE study I

BACKGROUND

There are no data relating symptoms of an acute respiratory illness (ARI) in general, and COVID-19 specifically, to return to play (RTP).

OBJECTIVE

To determine if ARI symptoms are associated with more prolonged RTP, and if days to RTP and symptoms (number, type, duration and severity) differ in athletes with COVID-19 versus athletes with other ARI.

DESIGN

Cross-sectional descriptive study.

SETTING

Online survey.

PARTICIPANTS

Athletes with confirmed/suspected COVID-19 (ARICOV) (n=45) and athletes with other ARI (ARIOTH) (n=39).

METHODS

Participants recorded days to RTP and completed an online survey detailing ARI symptoms (number, type, severity and duration) in three categories: 'nose and throat', 'chest and neck' and 'whole body'. We report the association between symptoms and RTP (% chance over 40 days) and compare the days to RTP and symptoms (number, type, duration and severity) in ARICOV versus ARIOTH subgroups.

RESULTS

The symptom cluster associated with more prolonged RTP (lower chance over 40 days; %) (univariate analysis) was 'excessive fatigue' (75%; p<0.0001), 'chills' (65%; p=0.004), 'fever' (64%; p=0.004), 'headache' (56%; p=0.006), 'altered/loss sense of smell' (51%; p=0.009), 'Chest pain/pressure' (48%; p=0.033), 'difficulty in breathing' (48%; p=0.022) and 'loss of appetite' (47%; p=0.022). 'Excessive fatigue' remained associated with prolonged RTP (p=0.0002) in a multiple model. Compared with ARIOTH, the ARICOV subgroup had more severe disease (greater number, more severe symptoms) and more days to RTP (p=0.0043).

CONCLUSION

Symptom clusters may be used by sport and exercise physicians to assist decision making for RTP in athletes with ARI (including COVID-19).

The adolescent athlete's heart; A miniature adult or grown-up child?

The systematic development of early age talent in sports academies has led to the professionalization of pediatric sport and the sports physician need to be aware of pediatric cardiological problems. Research into the medical cardiac care and assessment of the pediatric athlete are accumulating, but specific pediatric international guidelines are not available yet and reference data for ECG and echocardiography are incomplete, in particular for the age group <12 years of age. This article is an introduction to the physiological and diagnostics specifics of the pediatric athlete. The focus lies in the differences in presentation and diagnosis between pediatric and adult athletes for the most common pathologies. Reference data for electrical and structural adaptations to intensive exercise are sparse particularly in athletes aged below 12 years old. Training related changes include decrease of resting heart rate, increase of cardiac output, ventricular cavity size, and wall thickness. Cardiac hypertrophy is less pronounced in pediatric athletes, as HR mediated cardiac output increase to endurance exercise is the dominant mechanism in peripubertal children. As in adults, the most pronounced cardiovascular adaptations appear in classical endurance sports like rowing, triathlon, and swimming, but the specifics of pediatric ECG and echocardiographic changes need to be considered.

The Assessment of the Paediatric Athlete

The success of systematic early age talent development has led to the professionalisation of youth sports academies used by clubs and governing bodies alike, and sports physicians are nowadays commonly confronted with paediatric cardiological problems. Medical cardiac care of the paediatric athlete is however in its infancy, and the international guidelines that are present for adult athletes, are not yet available. Similarly, reference data for ECG and echocardiography are incomplete. The aim of this article is to provide and introduction to the cardiac care of the paediatric athlete to facilitate healthy and above all, safe talent development, but also provide guidance on how to distinguish adaptive, beneficial cardiovascular remodelling from underlying pathology of congenital or inherited cardiovascular disease. Differences in presentation, diagnosis and treatment between childhood and adult athletes are highlighted and can educate the reader in the emerging field of paediatric sports cardiology.

Myocarditis in athletes: A clinical perspective

Myocarditis is an important cause of arrhythmias and sudden cardiac death (SCD) in both physically active individuals and athletes. Elite athletes seem to have an increased risk for viral infection and subsequent myocarditis due to increased exposure to pathogens (worldwide traveling/international competition) or impaired immune system (continuing training during infections/resuming training early thereafter, strenuous exercise training or competition, and exercising in extreme weather conditions). Initial clinical presentation is variable, but athletes characteristically express non-specific symptoms of fatigue, muscle soreness, increased heart rate at rest, as well as during exercise and reduced overall exercise capacity. Beyond resting electrocardiogram (ECG), cardiac biomarkers, echocardiography, and 24-hour Holter ECG, diagnostic work-up should include cardiac magnetic resonance imaging (CMR) assessing inflammation, oedema, and fibrosis by late gadolinium enhancement (LGE), respectively, as these measures are crucial for prognosis and sports eligibility. For patients with insufficient cardiac recovery, endomyocardial biopsy is recommended to clarify differential diagnoses and initiate specific treatment options. In uncomplicated cases with normal left ventricular function during acute phase and absent LGE, eligibility for sports can be attested to three months after clinical recovery. In those with persistent pathological findings, even after six months, the risk for SCD remains increased and resuming exercise beyond recreational activities can only be recommended individually based on course of disease, left ventricular function, arrhythmias, pattern of LGE in CMR, as well as intensity and volume of exercise performed during training and competition. For all athletes, follow-up examination should be performed yearly.

Sports and Infections

Acute infectious diseases are frequent among athletes and can result in training and competition absence. Since athletes are expected to return to training as soon as possible, the knowledge of these diseases, their clinical presentation, possible complications, transmission mechanisms, and prevention should be among the main concerns of sports medicine. Infectious diseases can be prolonged or aggravated by continuing physical activity and athletes also risk having other acute or chronic organ manifestations such as bronchitis or pneumonia, myocarditis, pericarditis, and other secondary complications, for this reason exercise should not be allowed during convalescence and recovery. In the case of elite athletes, the return-to-play decision is particularly important and consensus between scientific evidence and clinical experience is necessary. Although infectious diseases are highly prevalent in athletes, there is a scarcity of literature focused on evidence and guidelines for sports physicians regarding RTP decision. Each case should be individualized according to subjective and objective symptoms together with the patient’s progress in every particular case.

Bewegung und Erkrankungen des Immunsystems

Die Effektivität von körperlicher Aktivität in der Primär- als auch Sekundär- und Tertiärprävention ist hinlänglich bekannt. Das Immunsystem spielt eine entscheidende Rolle bei einer Vielzahl von Erkrankungen, da es durch seine Botenfunktion (z. B. durch Zytokine) in einer Vielzahl der Regulationsprozesse mit involviert ist. So kommt es durch moderat-intensive körperliche Aktivität zu einer Stärkung des Immunsystems mit konsekutiv verminderter Infektanfälligkeit sowie eher anti-inflammatorischen Effekten, wohingegen langandauernde und höher intensive Belastungen zu einer Schwächung der Abwehrfunktion sowie einem pro-inflammatorischen Effekt führen. Somit stellt eine adäquat dosierte körperliche Aktivität eine erfolgversprechende Therapieoption bei Erkrankungen des infektiologischen Formenkreises sowie des Immunsystems dar.

Upper Respiratory Tract Diseases in Athletes in Different Sports Disciplines

Upper respiratory tract diseases in athletes are a very common medical problem. Training conditions in different sports disciplines increase the risk of upper respiratory disease. Epidemiological evidence suggests that heavy acute or chronic exercise is related to an increased incidence of upper respiratory tract infections in athletes. Regular physical exercise at high intensity may lead to transient immunosuppression due to high prevalence of allergic diseases in athletes. Regardless of the cause they can exclude athletes from the training program and significantly impair their performance. In the present work, the most common upper respiratory tract diseases in athletes taking into account the disciplines in which they most often occur were presented. The focus was laid on symptoms, diagnostic methods and pharmacotherapy. Moreover, preventive procedures which can help reduce the occurrence of upper respiratory tract disease in athletes were presented. Management according to anti-doping rules, criteria for return to training and competition as an important issues of athlete’s health were discussed.

Mucosal immunity and upper respiratory tract infections during a 24-week competitive season in young ice hockey players

The aim of this study was to examine upper respiratory tract infections (URTI) and their associations with resting saliva and blood immune and endocrine parameters in ice hockey players. Twenty-seven participants (age 16.5 ± 0.5 years) completed the 24-week study period. The counts/concentrations of immune and endocrine markers were compared between healthy-prone athletes (≤2 episodes of URTI during the study period) and illness-prone athletes (≥3 episodes of URTI) and between the URTI state (when athletes had infections) and the healthy state (the time without URTI). There were no differences in concentration/counts of saliva and blood immune and endocrine parameters between the illness-prone and illness-free athletes. Athletes had significantly lower sIgA, sIgA1 and sIgA2 concentrations (sIgA: 119.88 ± 66.88, 144.10 ± 75.0 µg/ml; sIgA1: 90.2 ± 40.64, 108.44 ± 29.8 U; sIgA2: 67.58 ± 30.1, 80.3 ± 25.61 U, respectively) and significantly higher WBC, neutrophil, monocyte and eosinophil count values and IL-1ra concentration at the time when they had symptoms of URTI than in the period without symptoms of infections. There were no differences in salivary cortisol concentration between the period of URTI symptoms and the period without URTI symptoms. In conclusion, we observed lower concentrations of salivary immunoglobulins and higher levels of blood immune parameters during URTI in athletes, which may confirm the suppression of mucosal immunity and initiation responses to pathogenic infections by innate immunity.

Data from a nationwide registry on sports-related sudden cardiac deaths in Germany

Background

Prospective national registries examining the incidence and aetiology of sports-related sudden cardiac death (SrSCD) not only in competitive athletes but also in recreational sports participants are uncommon. In May 2012, a prospective registry on SrSCD was installed to examine the incidence and particularly the aetiology of such events in the general population in Germany.

Methods

The registry consists of a web-based platform to record SrSCD cases. Media-monitoring and cooperation with 15 institutes of forensic medicine complemented the search. SrSCD was defined as death occurring during sports activity or up to 1 hour after its cessation, regardless of successful resuscitation. We included subjects at all levels of competition as well as recreational athletes.

Results

After 30 months of observation, 144 SrSCDs were recorded (mean age 46.8 ± 16.2 years). The overall incidence was 1.2–1.5/million/year, with 97% being male. Most of the cases occurred in the context of non-elite competitive or recreational sports. Football and running were the most common disciplines. In subjects ≤35 years, myocarditis prevailed, whereas in athletes ≥35 years, CAD predominated by far. Few cardiomyopathies were observed.

Conclusions

In Germany, the largest proportion of SrSCDs occurs in middle-aged men during recreational sports or non-elite competitive sports. The distribution of cardiac diseases responsible for SrSCD seems to vary among European countries. Our findings may indicate the need for a larger focus on myocarditis prevention in the young as well as widening the screening scope to younger athletes below the ‘elite’ level and to senior athletes.