'Blood doping' from Armstrong to prehabilitation: manipulation of blood to improve performance in athletes and physiological reserve in patients

Athlete biological passport: longitudinal biomarkers and statistics in the fight against doping

As novel substances, short time windows, and limits of detection increasingly challenge direct methods of doping detection in sports, indirect tools inevitably take a greater role in the fight against it. One such tool is the athlete biological passport (ABP) - a longitudinal profiling of the measured haematological and biochemical biomarkers, combined with calculated scores, against the background of epidemiological data crucial for doping detection. In both of its modules, haematological and steroidal, ABP parameters are analysed with the Bayesian adaptive model, which individualises reference and cut-off values to improve its sensitivity. It takes into account the confounding factors with proven and potential influence on the biomarkers, such as race and altitude exposure. The ABP has already changed the fight against doping, but its importance will further grow with the new modules (e.g., endocrinological), parameters (e.g., plasma volume-independent parameters), and complementing indirect methods (e.g., transcriptomic).

Potential for using simulated altitude as a means of prehabilitation: a physiology study

The current pandemic of surgical complications necessitates urgent and pragmatic innovation to reduce postoperative morbidity and mortality, which are associated with poor pre-operative fitness and anaemia. Exercise prehabilitation is a compelling strategy, but it has proven difficult to establish that it improves outcomes either in isolation or as part of a multimodal approach. Simulated altitude exposure improves performance in athletes and offers a novel potential means of improving cardiorespiratory and metabolic fitness and alleviating anaemia within the prehabilitation window. We aimed to provide an initial physiological foundation for 'altitude prehabilitation' by determining the physiological effects of one week of simulated altitude (FI O2 15%, equivalent to approximately 2438 m (8000 ft)) in older sedentary volunteers. The study used a randomised, double-blind, sham-controlled crossover design. Eight participants spent counterbalanced normoxic and hypoxic weeks in a residential hypoxia facility and underwent repeated cardiopulmonary exercise tests. Mean (SD) age of participants was 64 (7) y and they were unfit, with mean (SD) baseline anaerobic threshold 12 (2) ml.kg-1 .min-1 and mean (SD) peak V̇O2 15 (3) ml.kg-1 .min-1 . Hypoxia was mild (mean (SD) Sp O2 93 (2) %, p < 0.001) and well-tolerated. Despite some indication of greater peak exercise capacity following hypoxia, overall there was no effect of simulated altitude on anaerobic threshold or peak V̇O2 . However, hypoxia induced a substantial increase in mean (SD) haemoglobin of 1.5 (2.7) g.dl-1 (13% increase, p = 0.028). This study has established the concept and feasibility of 'altitude prehabilitation' and demonstrated specific potential for improving haematological fitness. Physiologically, there is value in exploring a possible role for simulated altitude in pre-operative optimisation.

Cardiopulmonary exercise testing before and after intravenous iron in preoperative patients: a prospective clinical study

BACKGROUND

Anemia is associated with impaired physical performance and adverse perioperative outcomes. Iron-deficiency anemia is increasingly treated with intravenous iron before elective surgery. We explored the relationship between exercise capacity, anemia, and total hemoglobin mass (tHb-mass) and the response to intravenous iron in anemic patients prior to surgery.

METHODS

A prospective clinical study was undertaken in patients having routine cardiopulmonary exercise testing (CPET) with a hemoglobin concentration ([Hb]) < 130 g^.l^-1 and iron deficiency/depletion. Patients underwent CPET and tHb-mass measurements before and a minimum of 14 days after receiving intravenous (i.v.) Ferric derisomaltose (Monofer®) at the baseline visit. Comparative analysis of hematological and CPET variables was performed pre and post-iron treatment.

RESULTS

Twenty-six subjects were recruited, of whom 6 withdrew prior to study completion. The remaining 20 (9 [45%] male; mean ± SD age 68 ± 10 years) were assessed 25 ± 7 days between baseline and the final visit. Following i.v. iron, increases were seen in [Hb] (mean ± SD) from 109 ± 14 to 116 ± 12 g l^-1 (mean rise 6.4% or 7.3 g l^-1, p =  < 0.0001, 95% CI 4.5-10.1); tHb-mass from 497 ± 134 to 546 ± 139 g (mean rise 9.3% or 49 g, p =  < 0.0001, 95% CI 29.4-69.2). Oxygen consumption at anerobic threshold ([Formula: see text] O_{2 AT}) did not change (9.1 ± 1.7 to 9.8 ± 2.5 ml kg^-1 min^-1, p = 0.09, 95% CI - 0.13 - 1.3). Peak oxygen consumption ([Formula: see text] O_{2 peak}) increased from 15.2 ± 4.1 to 16 ± 4.4 ml^.kg^.-1 min^-1, p = 0.02, 95% CI 0.2-1.8) and peak work rate increased from 93 [67-112] watts to 96 [68-122] watts (p = 0.02, 95% CI 1.3-10.8).

CONCLUSION

Preoperative administration of intravenous iron to iron-deficient/deplete anemic patients is associated with increases in [Hb], tHb-mass, peak oxygen consumption, and peak work rate. Further appropriately powered prospective studies are required to ascertain whether improvements in tHb-mass and performance in turn lead to reductions in perioperative morbidity.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT 033 46213.

Doping and sports endocrinology: growth hormone, IGF-1, insulin, and erythropoietin

Among the substances prohibited by the World Anti-Doping Agency, "peptide hormones, growth factors, related substances, and mimetics" are classified as prohibited both in- and out-of-competition in section S2. This work reviews growth hormone and its releasing peptides, insulin-like growth factor 1 as the main growth factor, insulin, and erythropoietin and other agents that affect erythropoiesis. This review analyzes the prevalence of use among professional athletes and gym clients, the forms of use, dosing, ergogenic effects and effects on physical performance, as well as side effects and anti-doping detection methods.

Anaesthesia for elite athletes

BACKGROUND

Sports participation has been growing rapidly since the 1960s. Anaesthesiologists are increasingly confronted with athletes in a peri-operative setting. The right choice of type of anaesthesia technique, pain management of injuries, specific physiologic adaptations of the athlete and knowledge of prohibited substances are eminent for a correct approach of this subpopulation.

PURPOSE

This review aims to give an overview of athletes' specific anaesthetic management in peri-operative and postoperative settings and to guide the nonspecialised anaesthetist.

METHODS

We comprehensively reviewed the literature, gathered all the information available on, and synthesised it in a narrative way, regarding preoperative evaluation, intraoperative implications and postoperative pain management of the elite athlete undergoing a surgical procedure.

RESULTS

An anaesthesiologist should recognise the most common benign ECG findings in athletes like bradycardia, isolated left ventricle hypertrophy on voltage criteria and early repolarisation as normal features in the athlete's heart. Isotonic physiology typically produces four-chamber dilation. In contrast, isometric stress creates high intravascular pressure leading to left ventricular hypertrophy. Pre-operative evaluation should also identify possible consumers of performance-enhancing drugs. Intraoperative points of interest for the anaesthesiologist is mainly avoiding drugs on the prohibited list of the World Anti-Doping Agency (WADA). Postoperative and chronic pain management are still developing fields in this population. The International Olympic Committee (IOC) proposed treating acute pain with a combination of paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), topical analgesics, injectable NSAIDs and local anaesthetics. It may be suggested that chronic pain management in elite athletes could benefit from treatment in specialised multidisciplinary pain clinics.

CONCLUSION

This literature review aims to serve as a guide for the anaesthesiologist taking care of the elite athlete.

Athlete’s physiological parameter monitoring system based on K-means and MTLS-SVM algorithm

In the non-medical model physiological parameter monitoring system, learning the monitoring parameters can improve the diagnostic and prediction accuracy. Aiming at the problems of insufficient information mining and low prediction accuracy in multi-task time series, the supervised and semi-supervised learning methods in machine learning are combined to predict the physiological status of remote health monitoring objects. This method uses the K-means algorithm to cluster the same type of data and use the Multitasking Least Squares Support Vector Machine (MTLS-SVM) to train historical data for trend prediction. In order to evaluate the effectiveness of the method, the MTLS-SVM method is compared with the K-means and MTLS-SVM methods. It can be seen from the experimental results that the body temperature data measured by the GY-MCU90615 is close to that of the digital thermometer. Moreover, the body temperature speed collected by the GY-MCU90615 can reach the millisecond level, which can well meet the needs of the system. The research shows that the method has higher prediction accuracy and has a breakthrough significance for the monitoring of athletes’ physiological parameters.

Calculating the optimal hematocrit under the constraint of constant cardiac power

In humans and higher animals, a trade-off between sufficiently high erythrocyte concentrations to bind oxygen and sufficiently low blood viscosity to allow rapid blood flow has been achieved during evolution. Optimal hematocrit theory has been successful in predicting hematocrit (HCT) values of about 0.3-0.5, in very good agreement with the normal values observed for humans and many animal species. However, according to those calculations, the optimal value should be independent of the mechanical load of the body. This is in contradiction to the exertional increase in HCT observed in some animals called natural blood dopers and to the illegal practice of blood boosting in high-performance sports. Here, we present a novel calculation to predict the optimal HCT value under the constraint of constant cardiac power and compare it to the optimal value obtained for constant driving pressure. We show that the optimal HCT under constant power ranges from 0.5 to 0.7, in agreement with observed values in natural blood dopers at exertion. We use this result to explain the tendency to better exertional performance at an increased HCT.

A carbon monoxide 'single breath' method to measure total haemoglobin mass: a feasibility study

NEW FINDINGS

What is the central question of this study? Is it possible to modify the CO-rebreathing method to acquire reliable measurements of haemoglobin mass in ventilated patients? What is the main finding and its importance? A 'single breath' of CO with a subsequent 30 s breath hold provides almost as exact a measure of haemoglobin mass as the established optimized CO-rebreathing method when applied to healthy subjects. The modified method has now to be checked in ventilated patients before it can be used to quantify the contributions of blood loss and of dilution to the severity of anaemia.

ABSTRACT

Anaemia is defined by the concentration of haemoglobin (Hb). However, this value is dependent upon both the total circulating haemoglobin mass (tHb-mass) and the plasma volume (PV) - neither of which is routinely measured. Carbon monoxide (CO)-rebreathing methods have been successfully used to determine both PV and tHb-mass in various populations. However, these methods are not yet suitable for ventilated patients. This study aimed to modify the CO-rebreathing procedure such that a single inhalation of a CO bolus would enable its use in ventilated patients. Eleven healthy volunteers performed four CO-rebreathing tests in a randomized order, inhaling an identical CO volume. In two tests, CO was rebreathed for 2 min (optimized CO rebreathing; oCOR), and in the other two tests, a single inhalation of a CO bolus was conducted with a subsequent breath hold of 15 s (Proc_new 15s) or 30 s (Proc_new 30s). Subsequently, the CO volume in the exhaled air was continuously determined for 20 min. The amount of CO exhaled after 7 and 20 min was respectively 3.1 ± 0.3 and 5.9 ± 1.1 ml for oCOR, 8.7 ± 3.6 and 12.0 ± 4.4 ml for Proc_new 15s and 5.1 ± 2.0 and 8.4 ±2.6 ml for Proc_new 30s. tHb-mass was 843 ± 293 g determined by oCOR, 821 ± 288 g determined by Proc_new 15s (difference: P < 0.05) and 849 ± 311 g determined by Proc_new 30s. Bland-Altman plots demonstrated slightly lower tHb-mass values for Proc_new 15s compared with oCOR (-21.8 ± 15.3 g) and similar values for Proc_new 30s. In healthy volunteers, a single inhalation of a CO bolus, preferably followed by a 30 s breath hold, can be used to determine tHb-mass. These results must now be validated for ventilated patients.

Replicating measurements of total hemoglobin mass (tHb-mass) within a single day: precision of measurement; feasibility and safety of using oxygen to expedite carbon monoxide clearance

Hemoglobin concentration ([Hb]) is a function of total hemoglobin mass (tHb-mass) and plasma volume. [Hb] may fall by dilution due to plasma volume expansion and changes in the perioperative period may therefore correlate poorly with blood loss. A simple, reliable, repeatable way to measure plasma volume and tHb-mass would have substantial clinical utility. The "optimized carbon monoxide re-breathing method" (oCOR) meets these criteria. However, it is recommended that a minimum of 12 h (when breathing room air) is left between repeat measurements. Twenty-four subjects underwent 3 days of testing. Two oCOR tests were performed (T1 and T2), 3 h apart, with a different CO clearance method employed between tests aiming to keep the carboxyhemoglobin level below 10%. The primary aim was to ascertain whether tHb-mass testing could be safely repeated within 3 h if carboxyhemoglobin levels were actively reduced by breathing supplemental oxygen (PROCA ). Secondary aims were to compare two other clearance methods; moderate exercise (PROCB ), or a combination of the two (PROCC ). Finally, the reliability of the oCOR method was assessed. Mean (SD) tHb-mass was 807.9 ± (189.7 g) (for T1 on day 1). PROCA lowered the carboxyhemoglobin level from the end of T1 (mean 6.64%) to the start of T2 (mean 2.95%) by a mean absolute value of 3.69%. For PROCB and PROCC the mean absolute decreases in carboxyhemoglobin were 4.00% and 4.31%, respectively. The fall in carboxyhemoglobin between T1 and T2 was greatest in PROCC ; this was statistically significantly lower than that of PROCA (P = 0.0039) and PROCB (P = 0.0289). The test-retest reliability for the measurement of total hemoglobin mass was good with a mean typical error (TE) of 2.0%. The oCOR method is safe and can be repeated within 3 h when carbon monoxide is suitably cleared between tests. Using oxygen therapy alone adequately achieves this.

The athlete's hematological response to hypoxia: A meta-analysis on the influence of altitude exposure on key biomarkers of erythropoiesis

Altitude training is associated with changes in blood markers, which can confound results of the Athlete?s Biological Passport (ABP). This meta-analysis aims to describe the fluctuations during- and post-altitude in key ABP variables; hemoglobin concentration ([Hb]), square-root transformed reticulocyte percentage (sqrt(retic%)) and the OFF-score. Individual de-identified raw data were provided from 17 studies. Separate linear mixed effects analyses were performed for delta values from baseline for [Hb], sqrt(retic%) and OFF-score, by altitude phase (during and post). Mixed models were fitted with the hierarchical structure: study and subject within study as random effects. Delta values as response variables and altitude dose (in kilometer hours; km.hr = altitude (m) / 1000 x hours), sex, age, protocol and baseline values as fixed effects. Allowances were made for potential autocorrelation. Within two days at natural altitude [Hb] rapidly increased. Subsequent delta [Hb] values increased with altitude dose, reaching a plateau of 0.94 g/dL [95%CI (0.69, 1.20)] at ~1000 km.hr. Delta sqrt(retic%) and OFF-score were the first to identify an erythrocyte response, with respective increases and decreases observed within 100 to 200 km.hr. Post-altitude, [Hb] remained elevated for two weeks. Delta sqrt(retic%) declined below baseline, the magnitude of change was dependent on altitude dose. Baseline values were a significant covariate (p<0.05). The response to altitude is complex resulting in a wide range of individual responses, influenced primarily by altitude dose and baseline values. Improved knowledge of the plausible hematological variations during- and post-altitude provides fundamental information for both the ABP expert and sports physician.

Considerations on the Assessment and Use of Cycling Performance Metrics and their Integration in the Athlete's Biological Passport

Over the past few decades the possibility to capture real-time data from road cyclists has drastically improved. Given the increasing pressure for improved transparency and openness, there has been an increase in publication of cyclists' physiological and performance data. Recently, it has been suggested that the use of such performance biometrics may be used to strengthen the sensitivity and applicability of the Athlete Biological Passport (ABP) and aid in the fight against doping. This is an interesting concept which has merit, although there are several important factors that need to be considered. These factors include accuracy of the data collected and validity (and reliability) of the subsequent performance modeling. In order to guarantee high quality standards, the implementation of well-structured Quality-Systems within sporting organizations should be considered, and external certifications may be required. Various modeling techniques have been developed, many of which are based on fundamental intensity/time relationships. These models have increased our understanding of performance but are currently limited in their application, for example due to the largely unaccounted effects of environmental factors such as, heat and altitude. In conclusion, in order to use power data as a performance biometric to be integrated in the biological passport, a number of actions must be taken to ensure accuracy of the data and better understand road cycling performance in the field. This article aims to outline considerations in the quantification of cycling performance, also presenting an alternative method (i.e., monitoring race results) to allow for determination of unusual performance improvements.

The use of biomarkers to describe plasma-, red cell-, and blood volume from a simple blood test

Plasma volume and red cell mass are key health markers used to monitor numerous disease states, such as heart failure, kidney disease, or sepsis. Nevertheless, there is currently no practically applicable method to easily measure absolute plasma or red cell volumes in a clinical setting. Here, a novel marker for plasma volume and red cell mass was developed through analysis of the observed variability caused by plasma volume shifts in common biochemical measures, selected based on their propensity to present with low variations over time. Once a month for 6 months, serum and whole blood samples were collected from 33 active males. Concurrently, the CO-rebreathing method was applied to determine target levels of hemoglobin mass (HbM) and blood volumes. The variability of 18 common chemistry markers and 27 Full Blood Count variables was investigated and matched to the observed plasma volume variation. After the removal of between-subject variations using a Bayesian model, multivariate analysis identified two sets of 8 and 15 biomarkers explaining 68% and 69% of plasma volume variance, respectively. The final multiparametric model contains a weighting function to allow for isolated abnormalities in single biomarkers. This proof-of-concept investigation describes a novel approach to estimate absolute vascular volumes, with a simple blood test. Despite the physiological instability of critically ill patients, it is hypothesized the model, with its multiparametric approach and weighting function, maintains the capacity to describe vascular volumes. This model has potential to transform volume management in clinical settings. Am. J. Hematol. 92:62-67, 2017. © 2016 Wiley Periodicals, Inc.