Hypothalamic-Pituitary-Adrenal (HPA) Axis Functioning in Overtraining Syndrome: Findings from Endocrine and Metabolic Responses on Overtraining Syndrome (EROS)-EROS-HPA Axis

Assessment of salivary cortisol dynamics in an infantry training exercise: a pilot study

INTRODUCTION

Measuring cortisol during military training offers insights into physiological responses to stress. We attempted precisely timed, cortisol awakening response (CAR) and pre-sleep cortisol (PSC), and diurnal slope (peak morning minus evening cortisol), during a British Army exercise. We aimed to understand cortisol dynamics and evaluate the feasibility of CAR and PSC in this environment.

METHOD

Setting: high-intensity, 10-day infantry exercise. Participants: regular infantry soldiers exercising (EX, n=25) or headquarters-based (HQ, n=6). Participants undertook PSC and WAKE and WAKE+30 min samples after 1-2 days, 5-6 days and 9-10 days. Wrist-worn GENEActiv accelerometers were used to assess sleep duration in EX only. Samples taken ±15 min from prespecified time points were deemed adherent. Validated questionnaires were used to measure resilience and perceived stress. Cortisol and cortisone were measured simultaneously by liquid chromatography tandem mass spectrometry.

RESULTS

From adherent participants' samples, CAR was positive and tended to decrease as the exercise progressed. From all available data, HQ demonstrated greater diurnal slope than EX (F=7.68, p=0.02), reflecting higher morning cortisol (F=4.72, p=0.038) and lower PSC (p=0.04). No differences were seen in cortisol:cortisone ratio. 26.1% of CAR samples were adherent, with moderately strong associations between adherence and stress (r=0.41, p=0.009) but no association between adherence and day of exercise (χ2=0.27, p=0.8), sleep duration (r=-0.112, p=0.43) or resilience (r=-0.79, p=0.75). Test-retest reliability ratings for CAR were Cronbach's α of 0.48, -11.7 and 0.34 for the beginning, middle and end of the exercise, respectively.

CONCLUSIONS

We observed a reduction in morning cortisol and decreased diurnal slope during a high-intensity military exercise, compared with the HQ comparator cohort in whom diurnal slope was preserved. A carefully timed CAR was not feasible in this setting.

A Narrative Review on Adipose Tissue and Overtraining: Shedding Light on the Interplay among Adipokines, Exercise and Overtraining

Lifestyle factors, particularly physical inactivity, are closely linked to the onset of numerous metabolic diseases. Adipose tissue (AT) has been extensively studied for various metabolic diseases such as obesity, type 2 diabetes, and immune system dysregulation due to its role in energy metabolism and regulation of inflammation. Physical activity is increasingly recognized as a powerful non-pharmacological tool for the treatment of various disorders, as it helps to improve metabolic, immune, and inflammatory functions. However, chronic excessive training has been associated with increased inflammatory markers and oxidative stress, so much so that excessive training overload, combined with inadequate recovery, can lead to the development of overtraining syndrome (OTS). OTS negatively impacts an athlete's performance capabilities and significantly affects both physical health and mental well-being. However, diagnosing OTS remains challenging as the contributing factors, signs/symptoms, and underlying maladaptive mechanisms are individualized, sport-specific, and unclear. Therefore, identifying potential biomarkers that could assist in preventing and/or diagnosing OTS is an important objective. In this review, we focus on the possibility that the endocrine functions of AT may have significant implications in the etiopathogenesis of OTS. During physical exercise, AT responds dynamically, undergoing remodeling of endocrine functions that influence the production of adipokines involved in regulating major energy and inflammatory processes. In this scenario, we will discuss exercise about its effects on AT activity and metabolism and its relevance to the prevention and/or development of OTS. Furthermore, we will highlight adipokines as potential markers for diagnosing OTS.

Development and Validation of Sensitive, Fast and Simple LC-MS/MS Method to Investigate the Association between Adrenocortical Steroidogenesis and the High Intensity Exercise in Elite Athletes

The very high intensity of exercise accompanied by mental stress triggers adaptive mechanisms associated with adrenocortical steroidogenesis. However, the association between adrenocortical steroidogenesis and the high intensity of exercise in elite athletes is poorly studied. A significant obstacle to solving this complex task is the wide range (4-5 orders) of steroid concentrations in serum and limitations related to the amount of biological samples taken from professional athletes. To solve this task, we have developed and validated a non-trivial approach for targeted serum metabolic profiling based on the use of LC-MS/MS with dual-polarity electrospray ionization. The developed method based on the proposed approach allows for the quantitative determination of 14 stress resistance biomarkers in elite athletes using a small amount of specimen within 8.5 min.

IL-6 signaling in acute exercise and chronic training: Potential consequences for health and athletic performance

The cytokine interleukin-6 (IL-6) is involved in a diverse set of physiological processes. Traditionally, IL-6 has been thought of in terms of its inflammatory actions during the acute phase response and in chronic conditions such as rheumatoid arthritis and obesity. However, IL-6 is also an important signaling molecule during exercise, being acutely released from working muscle fibers with increased exercise duration, intensity, and muscle glycogen depletion. In this context, IL-6 enables muscle-organ crosstalk, facilitating a coordinated response to help maintain muscle energy homeostasis, while also having anti-inflammatory actions. The range of actions of IL-6 can be explained by its dichotomous signaling pathways. Classical signaling involves IL-6 binding to a cell-surface receptor (mbIL-6R; present on only a small number of cell types) and is the predominant signaling mechanism during exercise. Trans-signaling involves IL-6 binding to a soluble version of its receptor (sIL-6R), with the resulting complex having a much greater half-life and the ability to signal in all cell types. Trans-signaling drives the inflammatory actions of IL-6 and is the predominant pathway in disease. A single nucleotide polymorphism (rs2228145) on the IL-6R gene can modify the classical/trans-signaling balance through increasing the levels of sIL-6R. This SNP has clinical significance, having been linked to inflammatory conditions such as rheumatoid arthritis and type 1 diabetes, as well as to the severity of symptoms experienced with COVID-19. This review will describe how acute exercise, chronic training and the rs2228145 SNP can modify the IL-6 signaling pathway and the consequent implications for health and athletic performance.

A one-health approach to identifying and mitigating the impact of endocrine disorders on human and equine athletes

Endocrinopathies affect multiple species in ever-increasing percentages of their populations, creating an opportunity to apply one-health approaches to determining creative preventative measures and therapies in athletes. Obesity and alterations in insulin and glucose dynamics are medical concerns that play a role in whole-body health and homeostasis in both horses and humans. The role and impact of endocrine disorders on the musculoskeletal, cardiovascular, and reproductive systems are of particular interest to the athlete. Elucidation of both physiologic and pathophysiologic mechanisms involved in disease processes, starting in utero, is important for development of prevention and treatment strategies for the health and well-being of all species. This review focuses on the unrecognized effects of endocrine disorders associated with the origins of metabolic disease; inflammation at the intersection of endocrine disease and related diseases in the musculoskeletal, cardiovascular, and reproductive systems; novel interventions; and diagnostics that are informed via multiomic and one-health approaches. Readers interested in further details on specific equine performance conditions associated with endocrine disease are invited to read the companion Currents in One Health by Manfredi et al, JAVMA, February 2023.

The Athlete’s Paradox: Adaptable Depression

We proposed that an athlete’s depressive symptoms may be different from the general population in etiology if considered from the context of a depressive disorder. By shifting focus from a limited notion of symptoms onto a comprehensive model of depression, the full scope of the phenomenon becomes clearer. This paper investigated the relationship between neurotransmitters and allostatic load to explain the incidence of depression among elite athletes. This literature review extensively analyzed exercise-induced neurohormonal imbalance resulting in depressive states among athletes. The research revealed that 5-HTTLPR polymorphism, brain-derived neurotrophic factor (BDNF), extensive psychological demands, social stigma, and overtraining syndrome (OTS) may all contribute to a unique version of depression. The research revealed that the biological standards of athletes differ from those of non-athletes, to the point that the new model may be useful, thereby introducing the new term “Adaptable Depression (AD)” to the literature. This framework suggests a new direction for future research to precisely measure the neurotransmitter-related brain changes that result in “Adaptable Depression” in athletes and to establish a better understanding of the depressive tipping point.

Overtraining Syndrome Symptoms and Diagnosis in Athletes: Where Is the Research? A Systematic Review

CONTEXT

To understand overtraining syndrome (OTS), it is important to detail the physiological and psychological changes that occur in athletes.

OBJECTIVES

To systematically establish and detail the physiological and psychological changes that occur as a result of OTS in athletes.

METHODS

Databases were searched for studies that were (1) original investigations; (2) English, full-text articles; (3) published in peer-reviewed journals; (4) investigations into adult humans and provided (5) objective evidence that detailed changes in performance from prior to the onset of OTS diagnosis and that performance was suppressed for more than 4 weeks and (6) objective evidence of psychological symptoms.

RESULTS

Zero studies provided objective evidence of detailed changes in performance from prior to the onset of OTS diagnosis and demonstrated suppressed performance for more than 4 weeks accompanied by changes in psychological symptoms.

CONCLUSIONS

All studies failed to provide evidence of changes in performance and mood from "healthy" to an overtrained state with evidence of prolonged suppression of performance. While OTS may be observed in the field, little data is available describing how physiological and psychological symptoms manifest. This stems from vague terminology, difficulties in monitoring for prolonged periods of time, and the need for prospective testing. Real-world settings may facilitate the collection of such data, but the ideal testing battery that can easily be conducted on a regular basis does not yet exist. Consequently, it must be concluded that an evidence base of sufficient scientific quality for understanding OTS in athletes is lacking.

Selected Immunoendocrine Measures for Monitoring Responses to Training and Match Load in Professional Association Football: A Review of the Evidence

Biomarkers relating to player “stress balance,” immunological (ie, immunoglobulin-A), and hormonal (ie, testosterone and cortisol [T:C]) status are now commonly used in football. This article is our critical review of the scientific literature relating to the response of these measures to player load and their relationships with player health. The commonly reported relationship between immunoglobulin-A and training or match load highlights its sensitivity to changes in psychophysiological stress and the increased risk of compromised mucosal immunity. This is supported by its close relationship with symptoms of upper respiratory tract infection and its association with perceived fatigue in football players. Testosterone and cortisol concentrations and the testosterone–cortisol ratio are sensitive to changes in player load, but the direction of their response is often inconsistent and is likely influenced by player training status and non-sport-related stressors. Some evidence indicates that sustained periods of high training volume can increase resting testosterone and that sustained periods of low and high training intensity can increase resting cortisol, compromising the testosterone–cortisol ratio. These findings are noteworthy, as recent findings indicate interrelationships between testosterone, cortisol, and testosterone:cortisol and perceived measures of fatigue, sleep quality, and muscle soreness in football players. Variability in individual responses suggests the need for a multivariate and individualized approach to player monitoring. Overall, we consider that there is sufficient evidence to support the use of salivary immunoglobulin-A, testosterone, cortisol, and testosterone:cortisol measures as part of a multivariate, individualized player monitoring system in professional football.

Chronic Aerobic Training at Different Volumes in the Modulation of Macrophage Function and in vivo Infection of BALB/c Mice by Leishmania major

Physical inactivity is one of the main causes of chronic diseases; however, strenuous exercise can induce immunosuppression. Several studies suggest that moderate amounts of exercise lead to a Th1 response, favoring the resolution of infections caused by intracellular microorganisms, while high volumes of exercise tend to direct the response to Th2, favoring infection by them. Leishmaniasis is a parasitic disease promoted by parasites of the Leishmania genus, with clinical manifestations that vary according to the species of the parasite and the immune response of the host. The experimental Leishmania major–BALB/C mouse model provides a good model for the resistance (Th1 response) or susceptibility (Th2 response) that determines the progression of this infection. The aim of this study was to evaluate the effect of aerobic training at different volumes on modulation of in vitro macrophage infection by L. major, as well as to assess the effect of high volume (HV) aerobic training on the development of L. major in vivo in BALB/c mice. Uninfected animals were submitted to various exercise volumes: none (SED), light (LV), moderate (MV), high (HV), very high (VHV), and tapering (TAP). The macrophages of these animals were infected by L. major and the LV and MV groups showed a decrease in the infection factor, while the VHV showed an increase in the infection factor, when treated with LPS. The cytokine concentration pattern measured in the supernatants of these macrophages suggested a predominant Th1 response profile in the LV and MV groups, while the Th2 profile predominated in the VHV and TAP groups. Groups of BALB/C mice infected with L. major were subjected to high volume (iHV) or non-periodized high volume (iNPHV) exercise or kept sedentary (iSED). The exercised animals suffered a significant increase in injuries caused by the parasites. The animals in the group submitted to high volume exercise (iHV) showed visceralization of the infection. These data strongly suggest that a very high volume of aerobic training increased the susceptibility of BALB/C mice to L. major infection, while moderate distribution of training loads promoted immunological balance, better controlling the infection by this parasite.

Diagnosing Overtraining Syndrome: A Scoping Review

Context:

Overtraining syndrome (OTS) is a condition characterized by a long-term performance decrement, which occurs after a persisting imbalance between training-related and nontraining-related load and recovery. Because of the lack of a gold standard diagnostic test, OTS remains a diagnosis of exclusion.

Objective:

To systematically review and map biomarkers and tools reported in the literature as potentially diagnostic for OTS.

Data Sources:

PubMed, Web of Science, and SPORTDiscus were searched from database inception to February 4, 2021, and results screened for eligibility. Backward and forward citation tracking on eligible records were used to complement results of database searching.

Study Selection:

Studies including athletes with a likely OTS diagnosis, as defined by the European College of Sport Science and the American College of Sports Medicine, and reporting at least 1 biomarker or tool potentially diagnostic for OTS were deemed eligible.

Study Design:

Scoping review following the guidelines of the Joanna Briggs Institute and PRISMA Extension for Scoping Reviews (PRISMA-ScR).

Level of Evidence:

Level 4.

Data Extraction:

Athletes’ population, criteria used to diagnose OTS, potentially diagnostic biomarkers and tools, as well as miscellaneous study characteristics were extracted.

Results:

The search yielded 5561 results, of which 39 met the eligibility criteria. Three diagnostic scores, namely the EROS-CLINICAL, EROS-SIMPLIFIED, and EROS-COMPLETE scores (EROS = Endocrine and Metabolic Responses on Overtraining Syndrome study), were identified. Additionally, basal hormone, neurotransmitter and other metabolite levels, hormonal responses to stimuli, psychological questionnaires, exercise tests, heart rate variability, electroencephalography, immunological and redox parameters, muscle structure, and body composition were reported as potentially diagnostic for OTS.

Conclusion:

Specific hormones, neurotransmitters, and metabolites, as well as psychological, electrocardiographic, electroencephalographic, and immunological patterns were identified as potentially diagnostic for OTS, reflecting its multisystemic nature. As exemplified by the EROS scores, combinations of these variables may be required to diagnose OTS. These scores must now be validated in larger samples and within female athletes.

Overtraining Syndrome (OTS) and Relative Energy Deficiency in Sport (RED-S): Shared Pathways, Symptoms and Complexities

The symptom similarities between training-overload (with or without an Overtraining Syndrome (OTS) diagnosis) and Relative Energy Deficiency in Sport (RED-S) are significant, with both initiating from a hypothalamic-pituitary origin, that can be influenced by low carbohydrate (CHO) and energy availability (EA). In this narrative review we wish to showcase that many of the negative outcomes of training-overload (with, or without an OTS diagnosis) may be primarily due to misdiagnosed under-fueling, or RED-S, via low EA and/or low CHO availability. Accordingly, we undertook an analysis of training-overload/OTS type studies that have also collected and analyzed for energy intake (EI), CHO, exercise energy expenditure (EEE) and/or EA. Eighteen of the 21 studies (86%) that met our criteria showed indications of an EA decrease or difference between two cohorts within a given study (n = 14 studies) or CHO availability decrease (n = 4 studies) during the training-overload/OTS period, resulting in both training-overload/OTS and RED-S symptom outcomes compared to control conditions. Furthermore, we demonstrate significantly similar symptom overlaps across much of the OTS (n = 57 studies) and RED-S/Female Athlete Triad (n = 88 studies) literature. It is important to note that the prevention of under-recovery is multi-factorial, but many aspects are based around EA and CHO availability. Herein we have demonstrated that OTS and RED-S have many shared pathways, symptoms, and diagnostic complexities. Substantial attention is required to increase the knowledge and awareness of RED-S, and to enhance the diagnostic accuracy of both OTS and RED-S, to allow clinicians to more accurately exclude LEA/RED-S from OTS diagnoses.

Investigation of the Hypothalamo-pituitary-adrenal (HPA) axis: a contemporary synthesis

The hypothalamo-pituitary-adrenal (HPA) axis is one of the main components of the stress system. Maintenance of normal physiological events, which include stress responses to internal or external stimuli in the body, depends on appropriate HPA axis function. In the case of severe cortisol deficiency, especially when there is a triggering factor, the patient may develop a life-threatening adrenal crisis which may result in death unless early diagnosis and adequate treatment are carried out. The maintenance of normal physiology and survival depend upon a sufficient level of cortisol in the circulation. Life-long glucocorticoid replacement therapy, in most cases meeting but not exceeding the need of the patient, is essential for normal life expectancy and maintenance of the quality of life. To enable this, the initial step should be the correct diagnosis of adrenal insufficiency (AI) which requires careful evaluation of the HPA axis, a highly dynamic endocrine system. The diagnosis of AI in patients with frank manifestations is not challenging. These patients do not need dynamic tests, and basal cortisol is usually enough to give a correct diagnosis. However, most cases of secondary adrenal insufficiency (SAI) take place in a gray zone when clinical manifestations are mild. In this situation, more complicated methods that can simulate the response of the HPA axis to a major stress are required. Numerous studies in the assessment of HPA axis have been published in the world literature. In this review, the tests used in the diagnosis of secondary AI or in the investigation of suspected HPA axis insufficiency are discussed in detail, and in the light of this, various recommendations are made.

Quantification of training load distribution in mixed martial arts athletes: A lack of periodisation and load management

The aim of this study was to quantify typical training load and periodisation practices of MMA athletes. MMA competitors (n = 14; age = 22.4 ± 4.4 years; body mass = 71.3 ± 7.7 kg; stature = 171 ±9.9 cm) were observed during training for 8 consecutive weeks without intervention. Seven athletes were training for competitive bouts whilst the remaining 7 were not. Daily training duration, intensity (RPE), load (sRPE and segRPE), fatigue (short questionnaire of fatigue) and body region soreness (CR10 scale) were recorded. Using Bayesian analyses (BF₁₀≥3), data demonstrate that training duration (weekly mean range = 3.9–5.3 hours), sRPE (weekly mean range = 1,287–1,791 AU), strain (weekly mean range = 1,143–1,819 AU), monotony (weekly mean range = 0.63–0.83 AU), fatigue (weekly mean range = 16–20 AU) and soreness did not change within or between weeks. Between weeks monotony (2.3 ± 0.7 AU) supported little variance in weekly training load. There were no differences in any variable between participants who competed and those who did not with the except of the final week before the bout, where an abrupt step taper occurred leading to no between group differences in fatigue. Training intensity distribution corresponding to high, moderate and low was 20, 33 and 47%, respectively. Striking drills accounted for the largest portion of weekly training time (20–32%), with MMA sparring the least (2–7%). Only striking sparring and wrestling sparring displayed statistical weekly differences in duration or load. Athletes reported MMA sparring and wrestling sparring as high intensity (RPE≥7), BJJ sparring, striking sparring and wrestling drills as moderate intensity (RPE 5–6), and striking drills and BJJ drills as low intensity (RPE≤4). We conclude that periodisation of training load was largely absent in this cohort of MMA athletes, as is the case within and between weekly microcycles.

Salivary Immunoendocrine and Self-report Monitoring Profiles across an Elite-Level Professional Football Season

PURPOSE

This investigation examined the longitudinal changes and interrelationships of salivary and self-report monitoring measures across a professional football season.

METHODS

Measures were collected biweekly from 18 senior professional male players across a 6-wk preseason and eight 5-wk in-season mesocycles and analyzed using a linear mixed-effects model.

RESULTS

Analysis identified a small (P = 0.003) cross-season suppression of salivary immunoglobulin A, small reductions to salivary α-amylase (P = 0.047) and salivary cortisol (P = 0.007), and trivial changes to salivary testosterone (P > 0.05). The testosterone/cortisol ratio typically responded inversely to changes in player workload. Self-report measures of fatigue (P = 0.030), sleep quality (P = 0.003), and muscle soreness (P = 0.005) improved (ES = small) across the first half of the season. Fatigue and sleep measures were most consistently related to hormonal measures (R2 = 0.43-0.45). For these relationships, increases in cortisol were associated with compromised self-report responses, whereas increases in testosterone/cortisol were associated with improved responses. Nonlinear relationships were identified for fatigue with immunoglobulin A (P = 0.017; ES = trivial) and testosterone (P = 0.012; ES = trivial), for sleep quality with testosterone (P < 0.001; ES = trivial), for muscle soreness with testosterone (P = 0.012; ES = trivial), and for the self-report inventory sum with testosterone (P = 0.027; ES = trivial). For these relationships, self-report responses were optimal at mean immunoglobulin A and testosterone levels, and very low levels (-2 SD) exerted the most compromising effects.

CONCLUSIONS

Players can experience a chronic cross-season suppression of mucosal immunity. Salivary immunoglobulin A, testosterone, cortisol, and testosterone/cortisol measures relate to self-report measures of fatigue, sleep quality, and muscle soreness. In-season reductions in testosterone, cortisol, and testosterone/cortisol or increases in cortisol among elite football players could be used to indicate the need for reduced workload, which might lead to improved well-being.

Effects of Overtraining Status on the Cortisol Awakening Response-Endocrine and Metabolic Responses on Overtraining Syndrome (EROS-CAR)

The cortisol awakening response (CAR) is a distinct component of the circadian cortisol profile and has promise as a biomarker for the monitoring of athlete readiness and training status. Although some studies have suggested the CAR may be affected by the development of overtraining syndrome (OTS), this has yet to be systematically investigated.

PURPOSE

To compare the CAR and diurnal cortisol slope between athletes diagnosed with OTS, healthy athletes, and sedentary controls.

METHODS

This study was a secondary analysis of data from the Endocrine and Metabolic Responses on Overtraining study. Male participants were recruited to either OTS, healthy athlete, or sedentary control groups. The participants produced saliva samples immediately after waking (S1), 30 minutes after waking (S2), at 16:00 hours, and at 23:00 hours. Salivary cortisol concentration was determined by an electrochemiluminescence assay. Mixed-effects models were used to assess the conditional effect of group (sedentary controls, OTS, and healthy athletes) on the change in cortisol over time. Separate models were fit for the awakening samples (S1 and S2) and for the diurnal slope (linear change across S1, 16:00 h, and 23:00 h).

RESULTS

The models demonstrated significant time-by-group interaction for OTS for the 2 cortisol concentrations collected during the awakening period (β = -9.33, P < .001), but not for the diurnal cortisol slope (β = 0.02, P = .80).

CONCLUSIONS

These results suggest the CAR may be associated with OTS and should be considered within a panel of biomarkers. Further research is necessary to determine whether alterations in the CAR may precede the diagnosis of OTS.

Novel Markers of Recovery From Overtraining Syndrome: The EROS-LONGITUDINAL Study

PURPOSES

Overtraining syndrome (OTS) is an unexplained underperformance syndrome triggered by excessive training, insufficient caloric intake, inadequate sleep, and excessive cognitive and social demands. Investigation of the recovery process from OTS has not been reported to date. The objective was to unveil novel markers and biochemical and clinical behaviors during the restoration process of OTS.

METHODS

This was a 12-week interventional protocol in 12 athletes affected by OTS, including increase of caloric intake, transitory interruption of training, improvement of sleep quality, and management of stress, followed by the assessment of 50 parameters including basal and hormonal responses to an insulin tolerance test and nonhormonal biochemical markers, and body metabolism and composition.

RESULTS

Early cortisol (P = .023), late ACTH (adrenocorticotrophic hormone) (P = .024), and early and late growth hormone (P = .005 and P = .038, respectively) responses, basal testosterone (P = .038), testosterone:estradiol ratio (P = .0005), insulinlike growth factor 1 (P = .004), cortisol awakening response (P = .001), and free thyronine (P = .069) increased, while basal estradiol (P = .033), nocturnal urinary catecholamines (P = .038), and creatine kinase (P = .071) reduced. Conversely, markers of body metabolism and composition had slight nonsignificant improvements.

CONCLUSION

After a 12-week intervention, athletes affected by actual OTS disclosed a mix of non-, partial, and full recovery processes, demonstrating that remission of OTS is as complex as its occurrence.

Possible adaptogenic effects of Momordica charantia on high-intensity training-induced alteration in the hypothalamic-pituitary-adrenal axis

This study investigated the effects of a drink supplement containing Momordica charantia extract from bitter melon on physical fitness and levels of stress hormones during a four-week exercise training program in a hot environment. Ten male tennis players were orally administrated in a four-week (100 ml, 6 times a day), and the pre- and post-supplementation levels of different physical fitness variables and cortisol, and adrenocorticotropic hormone in plasma were measured at four time-points—before (baseline), during, and after the exercise, and on the next day of the supplementation. The findings showed that the supplementation has significant positive effects on enhancement of physical fitness parameters especially balance (d = 22.10, p = 0.013), flexibility (d = 4.83, p = 0.015), and cardiorespiratory fitness (d = 10.00, p = 0.030). Moreover, the adrenocorticotropic hormone levels were reduced during the exercise, and the cortisol levels showed the decreasing trend during and after the exercise, which was correlated with the change of cardiorespiratory fitness (r = 0.65, p<0.05). These results indicated the possible adaptogenic effects of Momordica charantia extract intake. Based on the findings, we suggest that Momordica charantia could be used as a source of adaptogenic supplement to alleviate the exercise- and environment-induced stress.

Laboratory medicine: health evaluation in elite athletes

The need to evaluate the health status of an athlete represents a crucial aim in preventive and protective sports science in order to identify the best diagnostic strategy to improve performance and reduce risks related to physical exercise. In the present review we aim to define the main biochemical and haematological markers that vary significantly during and after sports training to identify risk factors, at competitive and professional levels and to highlight the set up of a specific parameter's panel for elite athletes. Moreover, we also intend to consider additional biomarkers, still under investigation, which could further contribute to laboratory sports medicine and provide reliable data that can be used by athlete's competent staff in order to establish personal attitudes and prevent sports injuries.

Assessment of exercise-induced stress by automated measurement of salivary cortisol concentrations within the circadian rhythm in Japanese female long-distance runners

Background

Overtraining syndrome, caused by prolonged excessive stress, results in reduced performance and cortisol responsiveness in athletes. It is necessary to collect saliva samples sequentially within circadian rhythm for assessing exercise stress by measuring cortisol concentrations, and automated cortisol measurements using electrochemiluminescence immunoassay (ECLIA) may be useful for measuring a large number of saliva samples. In this study, we evaluated the appropriate use of cortisol-based exercise stress assessment within the circadian rhythm, which may diagnose and prevent overtraining syndrome in athletes.

Methods

We collected saliva and sera from 54 healthy participants and analyzed the correlation between salivary cortisol concentrations measured by ECLIA and enzyme-linked immunosorbent assay (ELISA) or serum cortisol analysis. We also collected saliva continuously from 12 female long-distance runners on 2 consecutive days involving different intensities and types of exercise early in the morning and in the afternoon and measured salivary cortisol concentrations using ECLIA. Each exercise intensity of runners was measured by running velocities, Borg Scale score, and rate of change in the pulse rate by exercise.

Results

ECLIA-based salivary cortisol concentrations correlated positively with those detected by ELISA (ρ = 0.924, p < 0.001) and serum cortisol (ρ = 0.591, p = 0.001). In long-distance runners, circadian rhythm of salivary cortisol, including the peak after waking and the decrease promptly thereafter, were detected on both days by continuous saliva sampling. The rates of change in salivary cortisol concentrations were significantly lower after an early morning exercise than after an afternoon exercise on both days (day 1, p = 0.002, and day 2, p = 0.003). In the early morning exercise, the rate of change in salivary cortisol concentration was significantly higher on day 1 than on day 2 (p = 0.034), similar to a significant difference in running velocities (p = 0.001).

Conclusions

Our results suggest that automated ECLIA-based salivary cortisol measurements are able to detect the athletes’ circadian rhythm and compare the exercise stress intensities at the same times on different days, even in the early morning, possibly leading to the prevention of overtraining syndrome.

Improving the Diagnosis of Nonfunctional Overreaching and Overtraining Syndrome

INTRODUCTION

This study aimed to simplify and optimize the distinction between nonfunctional overreaching (NFO) and overtraining syndrome (OTS) by developing a multivariate approach (discriminant analysis [DA]) including hormonal and psychological changes measured during the Training Optimization (TOP) test.

METHODS

Sensitivity of previously defined cutoff values for hypothalamic-pituitary-adrenal axis hormonal changes were recalculated on a larger database (n = 100). Discriminant analysis including hormonal and psychological variables measured during the TOP test was used to discriminate between NFO and OTS and predict the diagnosis of new cases.

RESULTS

Adrenocorticotrophic hormone (ACTH) and prolactin (PRL) responses to the second exercise test were most sensitive to NFO and OTS. Cutoff values for ACTH and PRL response to the second test (NFO > cutoff value (200%) > OTS), showed a sensitivity of 67% for ACTH and 93% for PRL in case of OTS and 74% for both ACTH and PRL in case of NFO. A DA including hormonal and psychological changes measured during the TOP test, resulted in the accurate diagnosis of NFO and OTS with 98% sensitivity. The ACTH and PRL responses to the first and second exercise tests and feeling of fatigue were the most discriminating variables.

CONCLUSIONS

The ACTH and PRL responses during the TOP test are the most sensitive markers to discriminate between NFO and OTS. Discriminant analysis including hormonal and psychological responses during the TOP test, can be used to optimize the diagnosis of NFO and OTS.

Is vitamin D status reflected by testosterone concentration in elite athletes?

Vitamin D is a nutrient whose active form affects tissues as a hormone and possibly enhances performance. One plausible mechanism is by increasing testosterone concentration, which is established as an important factor for athletic performance. Therefore the aim of the study was to examine the relationship between plasma concentration of 25(OH)D and testosterone in Polish elite track and field athletes depending on vitamin D status, season, training period, body composition, sex, type of training, sun exposure and vitamin D supplementation. Plasma concentrations of 25(OH)D and testosterone were measured in all seasons within two years in athletes (70 females, 79 males) who represent strength (n = 103) and endurance (n = 46) kinds of sports, in the preparatorycompetitive season and transition period. There were no differences in 25(OH)D concentration between male and female athletes, insufficiency [25(OH)D < 30 ng/ml] was observed in 32.9%, whereas deficiency [25(OH)D < 20 ng/ ml] in 3.2%. Circannual rhythm was noted for vitamin D but not for testosterone concentration; no correlations between them were found either in strength or endurance athletes or between 25(OH)D and body composition. Testosterone concentration was higher in the transition period than in the preparatory-competition period only in male athletes. Higher 25(OH)D was observed in athletes who trained during winter in Africa (higher sun exposure) or used oral supplementation, whereas the respective testosterone levels were unchanged. In athletes, testosterone concentration did not reflect vitamin D status. The widespread of inadequate vitamin D status among athletes, makes it vital to recommend them the regular monitoring of 25(OH)D concentration and use of reasonable supplementation.

Diagnosis of Overtraining Syndrome: Results of the Endocrine and Metabolic Responses on Overtraining Syndrome Study: EROS-DIAGNOSIS

Objectives

Overtraining syndrome (OTS), a common dysfunction among elite athletes, causes decreased performance and fatigue and has no standardized diagnostic criteria. The Endocrine and Metabolic Responses on Overtraining Syndrome (EROS) study identified more than 45 potential biomarkers of OTS. In the present study, we hypothesized that combinations of these biomarkers could be an accurate diagnostic tool for OTS.

Methods

We selected parameters with largest difference and fewest overlapping results compared to healthy athletes and highest feasibility and reproducibility. Among the multiple combinations attempted, we chose those that did not show overlapping results, according to the objective.

Results

We included 11 clinical parameters, 4 basal hormones, and 5 hormonal responses in Insulin Tolerance Test (ITT). The three selected diagnostic tools were the (i) EROS-CLINICAL, with only clinical parameters, which was suitable as an initial assessment for athletes suspected of OTS; (ii) EROS-SIMPLIFIED, with clinical parameters and basal hormones, when the EROS-CLINICAL was inconclusive; and (iii) EROS-COMPLETE, with basal and hormonal responses to stimulation tests, which was valuable for population-based screening, research purposes, and unusual presentations of OTS.

Conclusion

We identified innovative tools with 100% accuracy for the diagnosis of OTS, without the need to exclude confounding disorders.

Eating, Sleep, and Social Patterns as Independent Predictors of Clinical, Metabolic, and Biochemical Behaviors Among Elite Male Athletes: The EROS-PREDICTORS Study

Objectives: Physiological hormonal adaptions in athletes and pathological changes that occur in overtraining syndrome among athletes are unclear. The Endocrine and Metabolic Responses on Overtraining Syndrome (EROS) study evaluated 117 markers and unveiled novel hormonal and metabolic beneficial adaptive processes in athletes. The objective of the present study was to uncover which modifiable factors predict the behaviors of clinical and biochemical parameters and to understand their mechanisms and outcomes using the parameters evaluated in the EROS study. Methods: We used multivariate linear regression with 39 participants to analyze five independent variables-the modifiable parameters (caloric, carbohydrate, and protein intake, and sleep quality and duration of concurrent cognitive activity) on 37 dependent variables-that were elected among the parameters evaluated in the EROS study. Results: Carbohydrate intake predicted quick hormonal responses to stress and improved explosive responses during exercise. Protein intake predicted improved body composition and metabolism and caloric intake, regardless of the proportion of macronutrients, predicted muscle recovery, and alertness in the morning. Sleep quality predicted improved mood and excessive concurrent cognitive effort in athletes under intense training predicted impaired metabolism and libido. Conclusions: The results support the premise that eating, sleep, and social patterns modulate metabolic and hormonal function, clinical behaviors, and performance status of male athletes, and should be monitored continuously and actively to avoid dysfunctions.

Enhancement of hypothalamic-pituitary activity in male athletes: evidence of a novel hormonal mechanism of physical conditioning

BACKGROUND

Exercise is known to induce multiple beneficial conditioning processes. Conversely, although exercise may generate several hormonal effects, an intrinsic hormonal conditioning process has not been reported. In the Endocrine and Metabolic Responses on Overtraining Syndrome (EROS) study, we observed inherent and independent conditioning processes of the hypothalamic-pituitary axes in athletes. Our objective is to describe the theory of the novel hormonal conditioning mechanism using the findings from the EROS study.

METHODS

In this cross-sectional study, we selected 25 healthy athletes (ATL) and 12 non-physically active healthy controls (NPAC), 18-50 years old, males, with BMI 20-30 kg/m², with similar baseline characteristics, who underwent gold-standard exercise-independent tests: cosyntropin stimulation test (CST) and insulin tolerance test (ITT), to evaluate cortisol response to CST, and ACTH, cortisol, GH, and prolactin responses to an ITT.

RESULTS

Responses to ITT were significantly earlier and higher in ATL than NPAC for cortisol [Mean ± SD: 21.7 ± 3.1 vs 16.9 ± 4.1 μg/dL; p < 0.001], GH [Median (95% CI): 12.73 (1.1-38.1) vs 4.80 (0.33-27.36) μg/L; p = 0.015], and prolactin [24.3 (10.5-67.45) vs 10.50 (6.21-43.44) ng/mL; p = 0.002]. Cortisol response to CST was similar between ATL and NPAC. During ITT, cortisol, GH, and ACTH mean increase in ATL were 52.2, 265.2, and 18.6% higher than NPAC, respectively. Prolactin response was absent in NPAC, while present in ATL.

CONCLUSIONS

We found sufficient evidence to propose the existence of a diffuse enhancement of the hypothalamic-pituitary activity in athletes, not restricted to any axis, showing an intrinsic and independent process of "hormonal conditioning" in athletes, similar to those observed in the cardiovascular and neuromuscular systems. This novel conditioning process may be the missing link for understanding the improved responses observed in athletes to harmful situations, traumas, infections, inflammations, and psychiatric conditions.

Novel causes and consequences of overtraining syndrome: the EROS-DISRUPTORS study

Background

Hormonal physiology in athletes, dysfunctional paths leading to overtraining syndrome (OTS), and clinical and biochemical behaviors that are independently modified by the presence of OTS remain unclear. Although multiple markers of OTS have recently been identified, the independent influence of OTS on hormones and metabolism have not been assessed. Hence, the objective of the present study was to uncover the previously unrecognized independent predictors of OTS and understand how OTS independently modifies the behaviors of clinical and biochemical parameters.

Methods

In a total of 39 athletes (OTS-affected athletes (OTS) = 14 and healthy athletes (ATL) = 25), we performed two clusters of statistical analyses using the full data of the Endocrine and Metabolic Responses on Overtraining Syndrome (EROS) study, in a total of 117 markers. We first used logistic regression to analyze five modifiable parameters (carbohydrate, protein, and overall caloric intake, sleep quality, and concurrent cognitive effort) as potential additional independent risk factors for OTS, and OTS as the outcome. We then used multivariate linear regression to analyze OTS as the independent variable and 38 dependent variables. Training patterns were found to be similar between OTS and ATL, and therefore excessive training was not a risk, and consequently not a predictor, for OTS.

Results

Each of the three dietary patterns (daily carbohydrate, daily protein, and daily overall calorie intake) were found to be the independent triggers of OTS, while sleeping, social, and training characteristics depended on other factors to induce OTS. Once triggered, OTS independently induced multiple changes, including reductions of cortisol, late growth hormone and adrenocorticotropic hormone responses to stimulations, testosterone-to-estradiol ratio, neutrophils, neutrophil-to-lymphocyte ratio, vigor levels, hydration status, and muscle mass, while increase of tension levels and visceral fat.

Conclusions

OTS can be independently triggered by eating patterns, regardless of training patterns, while the occurrence of OTS reduced late hormonal responses and the testosterone-to-estradiol ratio, worsened mood, and affected the immunology panel. These novel findings may explain underperformance, which is the key characteristic of OTS.

The Effects of Preoperative Steroid Therapy on Perioperative Morbidity and Mortality After Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVES

To identify the effects of preoperative steroid therapy on 30-day perioperative complications after adult spinal deformity (ASD) surgery.

SUMMARY OF BACKGROUND DATA

Chronic steroid therapy has demonstrated therapeutic effects in the treatment of various medical conditions but is also known to be associated with surgical complications. There remains a gap in the literature regarding the impact of chronic steroid therapy in predisposing patients to perioperative complications after elective surgery for ASD.

METHODS

We performed a retrospective analysis of data from the 2008-2015 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were divided into two groups based on preoperative steroid therapy. Differences in baseline patient characteristics, comorbidities, and operative variables were assessed. Univariate analysis was performed to compare the incidence of perioperative complications. Multivariate stepwise logistic regression models were then used to adjust for baseline patient and operative variables in order to identify perioperative complications that were associated with preoperative steroid therapy.

RESULTS

We identified 7,936 patients who underwent surgery for ASD, of which 418 (5.3%) were on preoperative steroid therapy. Preoperative steroid therapy was an independent risk factor for four perioperative complications, including mortality (odds ratio [OR] 2.42, 95% confidence interval [CI] 1.30, 4.51; p = .005), wound dehiscence (OR 3.12, 95% CI 1.45, 6.70; p = .004), deep vein thrombosis (DVT) (OR 2.10, 95% CI 1.24, 3.55; p = .006), and blood transfusion (OR 1.34, 95% CI 1.08, 1.66; p < .007).

CONCLUSIONS

Patients on preoperative steroid therapy are at increased risk of 30-day mortality, wound dehiscence, DVT, and blood transfusion after surgery for ASD. An interdisciplinary approach to the perioperative management of steroid regimens is critical.

LEVEL OF EVIDENCE

Level III.

Basal Hormones and Biochemical Markers as Predictors of Overtraining Syndrome in Male Athletes: The EROS-BASAL Study

CONTEXT

Overtraining syndrome (OTS) and related conditions cause decreased training performance and fatigue through an imbalance among training volume, nutrition, and recovery time. No definitive biochemical markers of OTS currently exist.

OBJECTIVE

To compare muscular, hormonal, and inflammatory parameters among OTS-affected athletes, healthy athletes, and sedentary controls.

DESIGN

Cross-sectional study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Fifty-one men aged 18 to 50 years (14 OTS-affected athletes [OTS group], 25 healthy athletes [ATL group], and 12 healthy sedentary participants [NCS group]), with a body mass index of 20 to 30.0 kg/m² (sedentary) or 20 to 33.0 kg/m² (athletes), recruited through social media. All 39 athletes performed both endurance and resistance sports.

MAIN OUTCOME MEASURE(S)

We measured total testosterone, estradiol, insulin-like growth factor 1, thyroid-stimulating hormone, free thyronine, total and fractioned catecholamines and metanephrines, lactate, ferritin, creatinine, creatine kinase, erythrocyte sedimentation rate, C-reactive protein, lipid profile, hemogram, and testosterone : estradiol, testosterone : cortisol, neutrophil : lymphocyte, platelet: lymphocyte, and catecholamine : metanephrine ratios. Each parameter was statistically analyzed through 3-group comparisons, and whenever P < .05, pairwise comparisons were performed (OTS × ATL, OTS × NCS, and ATL × NCS).

RESULTS

Neutrophils and testosterone were lower in the OTS group than in the ATL group but similar between the OTS and NCS groups. Creatine kinase, lactate, estradiol, total catecholamines, and dopamine were higher in the OTS group than in the ATL and NCS groups, whereas the testosterone : estradiol ratio was lower, even after adjusting for all variables. Lymphocytes were lower in the ATL group than in the OTS and NCS groups. The ATL and OTS groups trained with the same intensity, frequency, and types of exercise.

CONCLUSIONS

At least in males, OTS was typified by increased estradiol, decreased testosterone, overreaction of muscle tissue to physical exertion, and immune system changes, with deconditioning effects of the adaptive changes observed in healthy athletes.

Impact of Menstrual Function on Hormonal Response to Repeated Bouts of Intense Exercise

Background

Strenous exercise stimulates the hypothalamic-pituitary (HP) axis in order to ensure homeostasis and promote anabolism. Furthermore, exercise stimulates a transient increase in the neurotrophin brain-derived neurotrophic factor (BDNF) suggested to mediate the anxiolytic effects of exercise. Athletes with secondary functional hypothalamic amenorrhea (FHA) have been reported to have lower BDNF, and a blunted HP axis response to exercise as athletes with overtraining syndrome.

Aim

The aim of the study was to investigate the hormonal and BDNF responses to a two-bout maximal exercise protocol with four hours of recovery in between in FHA and eumenorrheic (EUM) athletes.

Methods

Eumenorrheic (n = 16) and FHA (n = 14) endurance athletes were recruited from national teams and competitive clubs. Protocols included gynecological examination; body composition (DXA); 7-day assessment of energy availability; blood sampling pre and post the two exercises tests.

Results

There were no differences between groups in hormonal responses to the first exercise bout. After the second exercise bout IGFBP-3 increased more in FHA compared with EUM athletes (2.1 ± 0.5 vs. 0.6 ± 0.6 μg/L, p = 0.048). There were non-significant trends toward higher increase in IGF-1 (39.3 ± 4.3 vs. 28.0 ± 4.6 μg/L, p = 0.074), BDNF (96.5 ± 22.9 vs. 34.4 ± 23.5 μg/L, p = 0.058), GH to cortisol ratio (0.329 ± 0.010 vs. 0.058 ± 0.010, p = 0.082), and decrease in IGF-1 to IGFBP-3 ratio (−2.04 ± 1.2 vs. 0.92 ± 1.22, p = 0.081) in athletes with FHA compared with EUM athletes. Furthermore, there was a non-significant trend toward a higher increase in prolactin to cortisol ratio in EUM athletes compared with athletes with FHA (0.60 ± 0.15 vs. 0.23 ± 0.15, p = 0.071). No differences in the hormonal or BDNF responses between the two exercise bouts as a result of menstrual function were found.

Conclusion

No major differences in the hormonal or BDNF responses between the two exercise bouts as a result of menstrual function could be detected.

Competition Stress Leads to a Blunting of the Cortisol Awakening Response in Elite Rowers

Background: Anticipation of forthcoming demands is often met with biological up-regulation, for example, levels of the stress hormone cortisol are typically elevated immediately prior to an anticipated event. Similarly, the cortisol awakening response (CAR), a surge in cortisol in the period following waking, is elevated on days of anticipated demand and this is viewed as an adaptive response in the preparation for challenge. This study assessed the effects of competition as an anticipated challenge in elite rowers. Methods: Elite rowers (N = 8) were assessed during two training and two competition weekends. Each assessment involved the measurement of self-reported competitive (cognitive and somatic) anxiety and salivary diurnal cortisol across 2 days representing a preparation day prior to either a training or competition day. Competitive anxiety was measured each morning and saliva samples were provided immediately upon waking and 30 min post waking (CAR) and before bed. Results: Self-reported cognitive and somatic anxiety levels were significantly greater during the competition phase compared with training. Additionally, levels of cognitive anxiety were greater on the day of competition compared with the preparation day. CAR magnitude was significantly reduced during the competition phase compared with training; however, there were no differences between preparation and event days. Conclusions: Reduced or blunted CARs are typically observed in chronically stressed populations and are characteristic of burnout and fatigue. While an increased CAR during competition may represent an adaptive response to challenge, blunted CARs and the concomitant increases in competitive anxiety observed here indicate maladaptive responding during a period where maximized functioning is critical.

Novel insights of overtraining syndrome discovered from the EROS study

BACKGROUND

Excessive training and inadequate recovery could cause 'overtraining syndrome' (OTS), which is characterised by underperformance and fatigue. The pathophysiology of OTS is unclear. We aimed to describe novel mechanisms and risk factors associated with OTS, and thereby facilitate its early identification and prevention, from a comprehensive joint qualitative analysis of the findings from all the four arms of the Endocrine and Metabolic Responses on Overtraining Syndrome (EROS) study.

METHODS

We compared the types and proportions of behavioural patterns of 67 evaluated parameters of OTS from 51 participants-athletes with OTS (OTS, n=14), healthy athletes (n=25) and healthy non-physically active controls (n=12). We performed overall and pairwise comparisons for statistically significant differences between the three groups (p<0.05).

RESULTS

A total of 44 (65.7%) markers exhibited significant differences between the three groups: 32 (72.7%) showed a loss of the conditioning effect of exercise ('deconditioning'), 7 (15.9%) showed changes exclusive to OTS, 3 (6.8%) maintained the exercise-induced conditioning effects and 2 (4.5%) revealed an exacerbation of the adaptive changes to exercises.

CONCLUSION

Our findings suggest that OTS is likely triggered by multiple factors, not restricted to excessive training, resulted from a chronic energy deprivation, leading to multiple losses in the conditioning processes typically observed in healthy athletes, as a combination of 'paradoxical deconditioning' processes, which explains the gradual and marked loss of physical conditioning found in OTS. We, therefore, suggest that the term 'paradoxical deconditioning syndrome' better represents the features of this syndrome.

Inter-correlations Among Clinical, Metabolic, and Biochemical Parameters and Their Predictive Value in Healthy and Overtrained Male Athletes: The EROS-CORRELATIONS Study

Objectives: The Endocrine and Metabolic Responses on Overtraining Syndrome (EROS) study identified multiple hormonal and metabolic conditioning processes in athletes, and underlying mechanisms and biomarkers of overtraining syndrome (OTS). The present study's objective was to reveal independent predictors and linear correlations among the parameters evaluated in the EROS study to predict clinical, metabolic, and biochemical behaviors in healthy and OTS-affected male athletes. Methods: We used multivariate linear regression and linear correlation to analyze possible combinations of the 38 parameters evaluated in the EROS study that revealed significant differences between healthy and OTS-affected athletes. Results: The testosterone-to-estradiol (T:E) ratio predicted the measured-to-predicted basal metabolic rate (BMR) ratio; the T:E ratio and total testosterone level were inversely predicted by fat mass and estradiol was not predicted by any of the non-modifiable parameters. Early and late growth hormone, cortisol, and prolactin responses to an insulin tolerance test (ITT) were strongly correlated. Hormonal responses to the ITT were positively correlated with fat oxidation, predicted-to-measured BMR ratio, muscle mass, and vigor, and inversely correlated with fat mass and fatigue. Salivary cortisol 30 min after awakening and the T:E ratio were inversely correlated with fatigue. Tension was inversely correlated with libido and directly correlated with body fat. The predicted-to-measured BMR ratio was correlated with muscle mass and body water, while fat oxidation was directly correlated with muscle mass and inversely correlated with fat mass. Muscle mass was directly correlated with body water, and extracellular water was directly correlated with body fat and inversely correlated with body water and muscle mass. Conclusions: Hypothalamic-pituitary responses to stimulation were diffuse and indistinguishable between the different axes. A late hormonal response to stimulation, increased cortisol after awakening, and the T:E ratio were correlated with vigor and fatigue. The T:E ratio was also correlated with body metabolism and composition, testosterone was predicted by fat mass, and estradiol predicted anger. Hydration status was inversely correlated with edema, and inter-correlations were found among fat oxidation, hydration, and body fat.

The Effects of Chronic Preoperative Steroid Therapy on Perioperative Complications Following Elective Posterior Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Chronic steroid therapy is used in the treatment of various inflammatory and autoimmune conditions, but it is known to be associated with adverse effects. There remains a gap in the literature regarding the role of chronic steroid therapy in predisposing patients to perioperative complications following elective posterior lumbar fusion (PLF). We aimed to identify the effects of chronic preoperative steroid therapy on 30-day perioperative complications in patients undergoing PLF.

METHODS

A retrospective analysis was performed using the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. We identified 22 903 patients who underwent elective PLF. There were 849 patients (3.7%) who received chronic preoperative steroid therapy. Univariate and multivariate analyses were performed to examine steroid therapy as an independent risk factor for 30-day perioperative complications. A subgroup analysis of patients on chronic steroid therapy was then performed to identify additional patient characteristics that further increased the risk for perioperative complications.

RESULTS

Chronic preoperative steroid therapy was an independent risk factor for 7 perioperative complications, including superficial surgical site infection (SSI), deep SSI, wound dehiscence, urinary tract infection, pulmonary embolism, nonhome discharge, and readmission. Subgroup analysis demonstrated that morbid obesity further predisposed patients on chronic steroid therapy to an increased risk of superficial SSI and wound dehiscence.

CONCLUSIONS

Patients on chronic preoperative steroid therapy are at increased risk of multiple perioperative complications following elective PLF, particularly surgical site complications and venous thromboembolic events. This risk is further elevated in patients who are morbidly obese.