Asthma is more prevalent in elite swimming adolescents despite better mental and physical health

Inorganic chloramines: a critical review of the toxicological and epidemiological evidence as a basis for occupational exposure limit setting

Inorganic chloramines are not commercially available, but monochloramine is produced in situ for disinfection or for use in chemical synthesis. Inorganic chloramines are also formed when free chlorine reacts with nitrogen containing substances, e.g. ammonia and urea, present in chlorinated water sources. Occupational exposure may, therefore, occur in e.g. swimming pool facilities and the food processing industry. Monochloramine is soluble and stable in water and the dominating inorganic chloramine in chlorinated water sources. No clinical effects were seen in healthy volunteers given monochloramine in drinking water during 4 or 12 weeks in doses of 0.043 or 0.034 mg/kg bw/day, respectively. Limited data indicate that monochloramine is weakly mutagenic in vitro but not genotoxic in vivo. One drinking water study indicated equivocal evidence of carcinogenicity in female rats but not in male rats and mice. No reproductive or developmental effects were shown in rodents in the few studies located. Dichloramine is soluble but unstable in water. In the only study located, mild histological effects in kidneys, thyroid and gastric cardia were observed in rats administered dichloramine in drinking water for 13 weeks. Trichloramine is immiscible with water and evaporates easily from water into air. Therefore, the primary exposure route of concern in the occupational setting is inhalation. Occupational exposure to trichloramine has been demonstrated in indoor swimming pool facilities and in the food processing industry where chlorinated water is used for disinfection. Exposure-response relationships between airborne levels and self-reported ocular and upper airway irritation have been shown in several studies. Exposure to trichloramine may aggravate asthma symptoms in individuals with existing asthma. The risk of developing asthma following long-term exposure to trichloramine cannot be evaluated at present. No data on genotoxic, carcinogenic, reproductive or developmental effects were located. The toxicological data for mono- and dichloramine are insufficient to recommend health-based occupational exposure limits (OELs).As regard trichloramine, the critical effect is judged to be irritation observed in several studies on pool workers, starting at approximately 0.4 mg/m³ (stationary sampling). Based on these data, a health-based OEL of 0.1 mg/m³ (8-h time-weighted average) is recommended. This corresponds to 0.2 mg/m³ for stationary measurements in swimming pool facilities. No short-term exposure limit (STEL) is recommended.

Cough in exercise and athletes

In the general population, particularly in individuals with asthma, cough is a common symptom, often reported after exertion, although regular exercise may be associated with a reduction in the prevalence of cough. In athletes, exercise-induced cough is also a particularly frequent symptom. The main etiologies of cough in athletes are somewhat similar to non-athletes, including asthma/airway hyperresponsiveness, upper airways disorders such as allergic or non-allergic rhinitis, and exercise-induced laryngeal obstruction, although these conditions are more frequently observed in athletes. In these last, this symptom can also be related to the high ventilation and heat exchange experienced during exercise, particularly during exposure to cold/dry air or pollutants. However, gastroesophageal reflux, a common cause of cough in the general population, despite being highly prevalent in athletes, has not been reported as a main cause of cough in athletes. Cough may impair quality of life, sleep and exercise performance in the general population and probably also in athletes, although there are few data on this. The causes of cough should be documented through a systematic evaluation, the treatment adapted according to identified or most probable cough etiology and pattern of presentation, while respecting sports anti-doping regulations. More research is needed on exercise-induced persistent cough in the athlete to determine its pathophysiology, optimal management and consequences.

Do we know how best to disinfect child care sites in the United States? A review of available disinfectant efficacy data and health risks of the major disinfectant classes

BACKGROUND

Children in child care settings have a high infectious burden. They are frequently exposed to sanitizing and disinfecting agents, whose toxicities have not been studied in these settings. Current guidance on the preferred disinfection agents for child care is vague.

METHODS

This article combines 2 different sources of information: the Environmental Protection Agency registration data on the efficacy of hospital-grade disinfectants and a review of the research on the toxicities of the most common of these disinfectants to summarize information that could be used for more evidence-based early care and education disinfection regulations and guidelines.

RESULTS

Coverage of these organisms varied both between disinfectant classes (defined by active ingredient), as well as within classes. The 3 most common active ingredients in the database-quaternary ammonias, bleaches, and hydrogen peroxides-had 251, 63, and 31 products, respectively. Quaternary ammonias and bleaches are both known asthmagens, with the potential for toxic gas release when mixed. Quaternary ammonias may also cause reproductive toxicity. Disinfectant-grade peroxides have relatively low inhalational toxicity.

CONCLUSIONS

A clear rationale is needed to establish policies for determining preferable disinfection products for use in child care settings, based on efficacy against relevant pathogens, toxicity, ease of use, and cost. When other factors are equal, the use of peroxide-based disinfectant products is recommended to minimize inhalational toxicity.

Asthma symptoms, mannitol reactivity and exercise-induced bronchoconstriction in adolescent swimmers versus tennis players

Background

Strenuous physical activity at an elite level is associated with an increased risk for asthma and, in some sports, also prevalence of allergies. The aim of this study was to investigate the prevalence of asthma and allergy among elite swimmers and tennis players and compare airway hyperreactivity to mannitol and exercise.

Materials and methods

One hundred and one adolescent swimmers and 86 tennis players answered a questionnaire about respiratory symptoms and allergy and performed mannitol challenge and sport-specific exercise challenge. Atopy was assessed and fractional exhaled nitric oxide was measured. Mannitol positivity was defined as drop in FEV₁ ≥15% (ordinary criteria) and/or β₂-reversibility (≥15%) after provocation (extended criteria). A positive exercise test was defined as a drop in FEV₁ ≥10% (ordinary criteria) and/or β₂-reversibility (≥15%) after provocation (extended criteria). Club cell protein (CC16) was measured in urine before and after the challenges.

Results

Asthma symptoms were common in both groups. More swimmers had exercise-induced symptoms (77% versus 50%) and current asthma symptoms (56% versus 38%), compared to the tennis players. More swimmers also had a positive mannitol challenge test both using ordinary (26% versus 6%) and extended criteria (43% versus 17%), while the number of positive exercise tests did not differ. After exercise (but not mannitol) challenge, CC16 level was increased in both groups, but to a higher extent in tennis players. There were no differences in atopy, rhinitis or fractional exhaled nitric oxide.

Conclusion

We found a high prevalence of asthma among elite swimmers and tennis players and a higher frequency of current asthma and positive mannitol challenge tests among the swimmers. This indicates an unfavorable exercise environment.

Cough in the Athlete: CHEST Guideline and Expert Panel Report

BACKGROUND

Cough is a common symptom experienced by athletes, particularly after exercise. We performed a systematic review to assess the following in this population: (1) the main causes of acute and recurrent cough, either exercise-induced or not, (2) how cough is assessed, and (3) how cough is treated in this population. From the systematic review, suggestions for management were developed.

METHODS

This review was performed according to the CHEST methodological guidelines and Grading of Recommendations Assessment, Development and Evaluation framework until April 2015. To be included, studies had to meet the following criteria: participants had to be athletes and adults and adolescents aged ≥ 12 years and had to complain of cough, regardless of its duration or relationship to exercise. The Expert Cough Panel based their suggestions on the data extracted from the review and final grading by consensus according to a Delphi process.

RESULTS

Only 60 reports fulfilled the inclusion criteria, and the results of our analysis revealed only low-quality evidence on the causes of cough and how to assess and treat cough specifically in athletes. Although there was no formal evaluation of causes of cough in the athletic population, the most common causes reported were asthma, exercise-induced bronchoconstriction, respiratory tract infection (RTI), upper airway cough syndrome (UACS) (mostly from rhinitis), and environmental exposures. Cough was also reported to be related to exercise-induced vocal cord dysfunction among a variety of less common causes. Although gastroesophageal reflux disease (GERD) is frequent in athletes, we found no publication on cough and GERD in this population. Assessment of the causes of cough was performed mainly with bronchoprovocation tests and suspected disease-specific investigations. The evidence to guide treatment of cough in the athlete was weak or nonexistent, depending on the cause. As data on cough in athletes were hidden in a set of other data (respiratory symptoms), evidence tables were difficult to produce and were done only for cough treatment in athletes.

CONCLUSIONS

The causes of cough in the athlete appear to differ slightly from those in the general population. It is often associated with environmental exposures related to the sport training environment and occurs predominantly following intense exercise. Clinical history and specific investigations should allow identification of the cause of cough as well as targeting of the treatment. Until management studies have been performed in the athlete, current guidelines that exist for the general population should be applied for the evaluation and treatment of cough in the athlete, taking into account specific training context and anti-doping regulations.

Sex differences in asthma in swimmers and tennis players

BACKGROUND

Elite athletes, independent of sport, have increased risk of developing asthma, but little is known about sex difference among adolescent athletes.

OBJECTIVE

To investigate and compare sex-related differences according to symptoms and treatment of asthma, allergy, and health among elite athletes and a reference group.

METHODS

Adolescent elite swimmers (n = 101), tennis players (n = 86), and a reference group (n = 1,628) responded to a questionnaire about respiratory symptoms, allergy, health behavior, psychosomatic symptoms, self- esteem, and well-being. The athletes performed a mannitol provocation and a sport-specific exercise provocation. Atopy was assessed by skin prick tests, and fractional exhaled nitric oxide was measured.

RESULTS

The females reported more asthma symptoms than the males in both the reference group (29.1% vs 22.3%) and the athlete group (56.4% vs 40.2%). However, no significant differences were found in physician-diagnosed asthma or treatment with inhaled corticosteroids. More female athletes had a positive mannitol provocation result (48.7% vs 35.8% in male athletes), and more female swimmers had a positive exercise provocation result (15.1% vs 7.7% in male swimmers). The females in all groups had more psychosomatic symptoms compared with the respective males, and the males in the reference group reported higher self-esteem and felt more well-being compared with the reference group females.

CONCLUSION

Overall, we found a higher prevalence of asthma symptoms in the females. However, the frequency of physician-diagnosed asthma and the prescription of inhaled corticosteroids were the same in both sexes. This finding demonstrates an insufficient diagnosis of asthma in females.

Aquaticity: A discussion of the term and of how it applies to humans

The relationship between humans and water and the effects on aspects related to human performance has never been studied scientifically. The aim of the current systematic review is to attempt to define the term "aquaticity", present the factors that describe it and reveal the form in which it presents itself in today's society, in order to become a distinct scientific field of study. A systematic review of the literature has been conducted using anecdotal reports from the internet and forums as well as scientific articles and books from databases on issues related to aquatic sports. To the best of our knowledge there are no scientific articles dealing with human's aquaticity. In the current systematic review, four factors have been recognized that are closely related to human aquaticity. Those are related to physical condition in the water, to apnea and ability to immerse, to mental health and to parameters related to body composition. According to our findings, "Aquaticity is the capacity of a terrestrial mammalian organism to function and habitualise in the aquatic environment. The level of aquaticity depends on mental and physical characteristics and can be improved by frequent exposure to the water element". The ideal state of aquaticity is achieved through the activation of the diving reflex, when the human body is totally immersed in water. The development of knowledge regarding the aquatic environment leads humans to an improved state of aquaticity.

Prevalence and characteristics of asthma in the aquatic disciplines

BACKGROUND

Despite the health benefits of swimming as a form of exercise, evidence exists that both the swimming pool environment and endurance exercise are etiologic factors in the development of asthma. The prevalence of asthma in swimmers is high compared with that in participants in other Olympic sport disciplines. There are no publications comparing the prevalence of asthma in the 5 aquatic disciplines.

OBJECTIVE

The purpose of this study is to examine and compare the prevalence of asthma in the aquatic disciplines and in contrast with other Olympic sports.

METHODS

Therapeutic Use Exemptions containing objective evidence of athlete asthma/airway hyperresponsiveness (AHR) were collected for all aquatic athletes participating in swimming, diving, synchronized swimming, water polo, and open water swimming for major events during the time period from 2004-2009. The prevalence of asthma/AHR in the aquatic disciplines was analyzed for statistical significance (with 95% CIs) and also compared with that in other Olympic sports.

RESULTS

Swimming had the highest prevalence of asthma/AHR in comparison with the other aquatic disciplines. The endurance aquatic disciplines have a higher prevalence of asthma/AHR than the aquatic nonendurance disciplines. Asthma/AHR is more common in Oceania, Europe, and North America than in Asia, Africa, and South America. In comparison with other Olympic sports, swimming, synchronized swimming, and open water swimming were among the top 5 sports for asthma/AHR prevalence.

CONCLUSION

Asthma/AHR in the endurance aquatic disciplines is common at the elite level and has a varied geographic distribution. Findings from this study demonstrate the need for development of aquatic discipline-specific prevention, screening, and treatment regimens.