Medicalization of Sport? A Mixed-Method Study on the Use of Medications in Elite Ice Hockey

Ice hockey is a high-risk sport known for its dominant macho culture. The purpose of this study was to examine experiences surrounding medication use among male, elite ice hockey players in Norway. A mixed-method design was employed, which first examined medications registered on doping control forms (DCFs) (n = 177) and then involved semi-structured focus group interviews (n = 5) with elite athletes (n = 25). Overall, 68% of the DCFs contained information about ≥1 medication. Among the most registered medications were NSAIDs and hypnotics (20% and 19% of all DCFs, respectively). During the interviews, numerous athletes reported using analgesics to manage injuries and pain caused by the sport, often being motivated by sacrificing themselves for the team during important matches and playoffs. Hypnotics were used due to high cumulative stress due to heavy training and competition load, late-night matches, and playing in a semi-professional league. Athlete support personnel (ASP), including physicians and trainers, were the athletes' main sources of information. The athletes often displayed a profound and non-critical trust in the advice and products provided to them by their team physician. The findings indicate that male, elite ice hockey players, through their excessive and somewhat ignorant use of medications, expose themselves to health risks and inadvertent doping.

Use of pharmaceuticals amongst athletes tested by Anti-Doping Norway in a five-year period

Introduction

The aim of the study was to map the use of pharmaceuticals by Norwegian athletes registered on doping control forms (DCFs) in a five-year period to examine general and some class specific use of pharmaceuticals across sports and athlete levels.

Method

Anonymous data from DCFs collected in 2015-2019 were manually entered into a database using the Anatomical Therapeutic Chemical (ATC) system for classification of the pharmaceuticals. Variables entered were year of control, gender, age group, athlete level, sport, test type, nationality, and pharmaceuticals (and dietary supplements) used.

Results

Pain killers in the ATC groups M01 A (Nonsteroidal anti-inflammatory drugs - NSAIDs) and N02 B (other analgesics), and anti-asthmatics in ATC groups R03 A and R03 B were the most frequently used pharmaceuticals. National level athletes reported more use of pharmaceuticals (1.4 ± 1.7 pharmaceuticals per form) than recreational level athletes (0.9 ± 1.2). The highest proportion of DCFs containing information about at least one pharmaceutical were found in speed skating (79.1%), alpine skiing (74.0%), rowing (72.4%) and cross-country skiing (71.7%). Painkillers were most frequently used in muscular endurance sports (30.4% and 21.2 % for M01A and N02 B, respectively) and ball and team sports (17.9% and 17.0%). Use of hypnotics was reported from ice-hockey players and alpine skiers in around 8% of the cases.

Coclusion

Use of anti-asthmatics was most often reported amongst athletes specially exposed to cold, chemicals and heavy endurance training. Athletes in specialized sports requiring high levels of strength and/or endurance reported a higher use of pharmaceuticals out-of-competition compared to in-competition, while there was no such difference in complex sports, such as team, gymnastic, aiming and combat sports.

Liquid-phase microextraction of aromatic amines: hollow fiber-liquid-phase microextraction and parallel artificial liquid membrane extraction comparison

Aromatic amines (AA) are carcinogenic compounds that can enter the human body through many sources, one of the most important being tobacco smoke. They are excreted with the urine, from which they can be extracted and measured. To that end, hollow fiber-liquid-phase microextraction (HF-LPME) and parallel artificial liquid membrane extraction (PALME) were optimized for the analysis of representative aromatic amines, as alternatives to liquid-liquid extraction (LLE). Relevant extraction parameters, namely organic solvent, extraction time, agitation speed, and acceptor solution pH, were studied, and the two optimized techniques-HF-LPME: dihexyl ether, 45 min, 250 rpm, and pH 1; PALME: undecane, 20 min, 250 rpm and pH 1-were compared. Comparison of the optimized methods showed that significantly higher recoveries could be obtained with PALME than with HF-LPME. Therefore, PALME was further validated. The results were successful for nine different AA, with regression coefficients (R²) of at least 0.991, limits of detection (LOD) of 45-75 ng/L, and repeatability and peak area relative standard deviations (RSD) below 20%. Furthermore, two urine samples from smokers were measured as proof of concept, and 2-methylaniline was successfully quantified in one of them. These results show that PALME is a great green alternative to LLE. Not only does it use much smaller volumes of toxic organic solvents, and sample-enabling the study of samples with limited available volumes-but it is also less time consuming and labor intensive, and it can be automated.

Trends in dietary supplement use among athletes selected for doping controls

Background

Dietary supplements (DS) may be beneficial for athletes in certain situations, whereas incorrect or excessive use may impair performance, pose a risk to the athlete's health and cause positive doping tests by containing prohibited substances. To provide athletes with relevant and tailored information on safe supplement use, a better knowledge about DS trends over time and between sport disciplines are needed.

Methods

This study examines the use of DS among athletes who have participated in doping controls by extracting information derived from 10,418 doping control forms (DCF) collected by Anti-Doping Norway from 2015 to 2019.

Results

Overall, 51% of the DCFs contained information about at least one DS. National level athletes (NLA) more often reported using DS than recreational athletes (RA) (53 vs. 47%, p < 0.001). Athletes in strength and power (71%), VO2max endurance (56%) and muscular endurance sports (55%) had the highest proportion of DCFs with information about DS. Medical supplements were the most used supplement category for both genders and across all sports. Dietary supplements with a high risk of containing doping substances were most common among male, RA in strength and power sports. There were small and non-significant year-to-year variations in the prevalence of athletes using DS, while the number of products used concomitantly peaked in 2017 before declining in 2019 (2.30 vs. 2.08, p < 0.01). The use of medical supplements and ergogenic substances increased slightly for both NLA and RA from 2015 to 2019, while the use of all other supplement categories declined.

Conclusion

Half of the 10,418 DCFs contained information about DS, with variations within the athlete population. DS with high risk of containing prohibited substances were mostly seen in sport disciplines requiring a high degree of specialization in strength/power, including powerlifting and weightlifting, as well as in some team sports, such as cheerleading and american football.

Ten years of collecting hematological athlete biological passport samples—perspectives from a National Anti-doping Organization

The hematological module of the Athlete Biological Passport (ABP) aims to reveal blood doping indirectly by looking at selected biomarkers of doping over time. For Anti-Doping Organizations (ADOs), the ABP is a vital tool in the fight against doping in sports through improved target testing and analysis, investigations, deterrence, and as indirect evidence for use of prohibited methods or substances. The physiological characteristics of sport disciplines is an important risk factor in the overall risk assessment and when implementing the hematological module. Sharing of experiences with implementing the hematological ABP between ADOs is key to further strengthen and extend its use. In this study, we present 10 years of experience with the hematological ABP program from the perspectives of a National ADO with special attention to sport disciplines' physiological characteristics as a potential risk factor for blood doping. Not surprisingly, most samples were collected in sport disciplines where the aerobic capacity is vital for performance. The study highlights strengths in Anti-Doping Norway's testing program but also areas that could be improved. For example, it was shown that samples were collected both in and out of season in a subset of the data material that included three popular sports in Norway (Cross-Country Skiing, Nordic Combined, and Biathlon), however, from the total data material it was clear that athletes were more likely to be tested out of competition and on certain days of the week and times of the day. The use of doping control officers with a flexible time schedule and testing outside an athlete's 60 min time-slot could help with a more even distribution during the week and day, and thus reduce the predictability of testing. In addition to promoting a discussion on testing strategies, the study can be used as a starting point for other ADOs on how to examine their own testing program.

Rapid determination of designer benzodiazepines, benzodiazepines, and Z-hypnotics in whole blood using parallel artificial liquid membrane extraction and UHPLC-MS/MS

Benzodiazepines (BZD) and Z-hypnotics are frequently analyzed in forensic laboratories, and in 2012, the designer benzodiazepines (DBZD) emerged on the illegal drug scene. DBZD represent a particular challenge demanding new analytical methods. In this work, parallel artificial liquid membrane extraction (PALME) is used for sample preparation of DBZD, BZD, and Z-hypnotics in whole blood prior to UHPLC-MS/MS analysis. PALME of BZD, DBZD, and Z-hypnotics was performed from whole blood samples, and the analytes were extracted across a supported liquid membrane (SLM) and into an acceptor solution of dimethyl sulfoxide and 200 mM formic acid (75:25, v/v). The method was validated according to EMA guidelines. The method was linear throughout the calibration range (R² > 0.99). Intra- and inter-day accuracy and precision, as well as matrix effects, were within the guideline limit of ± 15%. LOD and LLOQ ranged from 0.10 to 5.0 ng mL^-1 and 3.2 to 160 ng mL^-1, respectively. Extraction recoveries were reproducible and above 52%. The method was specific, and the analytes were stable in the PALME extracts for 4 and 10 days at 10 and - 20 °C. No carry-over was observed within the calibration range. PALME and UHPLC-MS/MS for the determination of DBZD, BZD, and Z-hypnotics in whole blood are a green and low-cost alternative that provides high sample throughput (96-well format), extensive sample clean-up, good sensitivity, and high reproducibility. The presented method is also the first method incorporating analysis of DBZD, BZD, and Z-hypnotics in whole blood in one efficient analysis. Graphical abstract.

Electromembrane extraction-Recent trends and where to go

Electromembrane extraction (EME) is an analytical microextraction technique, where charged analytes (such as drug substances) are extracted from an aqueous sample (such as a biological fluid), through a supported liquid membrane (SLM) comprising a water immiscible organic solvent, and into an aqueous acceptor solution. The driving force for the extraction is an electrical potential (dc) applied across the SLM. In this paper, EME is reviewed. First, the principle for EME is explained with focus on extraction of cationic and anionic analytes, and typical performance data are presented. Second, papers published in 2016 are reviewed and discussed with focus on (a) new SLMs, (b) new support materials for the SLM, (c) new sample additives improving extraction, (d) new technical configurations, (e) improved theoretical understanding, and (f) pharmaceutical new applications. Finally, important future research objectives and directions are defined for further development of EME, with the aim of establishing EME in the toolbox of future analytical laboratories.

Expanding the knowledge on dried blood spots and LC-MS-based protein analysis: two different sampling materials and six protein targets

The combination of dried blood spots (DBS) and bottom-up LC-MS-based protein analysis was investigated in the present paper using six model proteins (1 mg/mL of each protein) with different physicochemical properties. Two different materials for DBS were examined: a water-soluble DBS material (carboxymethyl cellulose, (CMC)) and a commercially available (non-soluble) material (DMPK-C). The sample preparation was optimised regarding the water-soluble material and achieving acceptable repeatability of the signal was emphasised. Five microlitres of whole blood were deposited and dried on either CMC or DMPK-C. The samples were dissolved (CMC) or extracted (DMPK-C) prior to tryptic digest and matrix precipitation. The optimization of the sample preparation showed that an increased buffer concentration (100 mM ammonium bicarbonate) for dissolving the DBS samples gave better repeatability combined with a decrease in analyte signal. CMC seemed to add extra variability (RSD 8-60%) into the analysis compared to sample prepared without CMC (RSD 6-36%), although equal performance compared to DMPK-C material (RSD 13-60%) was demonstrated. The stability of the analytes was examined for different storage periods (1 and 4 weeks) and different storage temperatures (-25, 25, and 40 °C). The stability on both CMC (> 70% compared to reference) and DMPK-C (> 50% compared to reference) was acceptable for most of the peptides. This paper shows that both DBS materials can be used in targeted LC-MS-based protein analysis of proteins with different physicochemical properties. Graphical Abstract Overview of the experimental set-up for expanding the knowledge of dried blood spots in LC-MS-based protein anaysis.

Parallel artificial liquid membrane extraction of new psychoactive substances in plasma and whole blood

Parallel artificial liquid membrane extraction (PALME) was combined with ultra-high performance liquid chromatography-mass spectrometry (UHPLC-MS) and the potential for screening of new psychoactive substances (NPS) was investigated for the first time. PALME was performed in 96-well format comprising a donor plate, a supported liquid membrane (SLM), and an acceptor plate. Uncharged NPS were extracted from plasma or whole blood, across an organic SLM, and into an aqueous acceptor solution, facilitated by a pH gradient. MDAI (5,6-methylenedioxy-2-aminoindane), methylone, PFA (para-fluoroamphetamine), mCPP (meta-chlorophenylpiperazine), pentedrone, methoxetamine, MDPV (methylenedioxypyrovalerone), ethylphenidate, 2C-E (2,5-dimethoxy-4-ethylphenethylamine), bromo-dragonfly, and AH-7921 (3,4-dichloro-N-{[1-(dimethylamino)cyclohexyl]methyl}benzamide) were selected as representative NPS. Optimization of operational parameters was necessary as the NPS were novel to PALME, and because PALME was performed from whole blood for the very first time. In the PALME method developed for plasma, NPS were extracted from a 250μL alkalized donor solution consisting of 125μL plasma sample, 115μL 40mM NaOH, and 10μL internal standard. In the PALME method from whole blood, the 250μL alkalized donor solution consisted of 100μL whole blood, 50μL deionized water, 75μL 80mM NaOH, and 25μL internal standard. In both methods, extraction was accomplished across an SLM of 5μL dodecyl acetate with 1% trioctylamine (w/w), and further into an acidic acceptor solution of 50μL 20mM formic acid. The extraction was promoted by agitation at 900rpm and was carried out for 120min. Method validation was performed and the following parameters were considered: linearity, limits of quantification (LOQ), intra- and inter-day precision, accuracy, extraction recoveries, carry-over, and matrix effects. The validation results were in accordance with FDA guidelines.

Electromembrane extraction--three-phase electrophoresis for future preparative applications

The purpose of this article is to discuss the principle and the future potential for electromembrane extraction (EME). EME was presented in 2006 as a totally new sample preparation technique for ionized target analytes, based on electrokinetic migration across a supported liquid membrane under the influence of an external electrical field. The principle of EME is presented, and typical performance data for EME are discussed. Most work with EME up to date has been performed with low-molecular weight pharmaceutical substances as model analytes, but the principles of EME should be developed in other directions in the future to fully explore the potential. Recent research in new directions is critically reviewed, with focus on extraction of different types of chemical and biochemical substances, new separation possibilities, new approaches, and challenges related to mass transfer and background current. The intention of this critical review is to give a flavor of EME and to stimulate into more research in the area of EME. Unlike other review articles, the current one is less comprehensive, but put more emphasis on new directions for EME.

Simulation of flux during electro-membrane extraction based on the Nernst–Planck equation

The present work has for the first time described and verified a theoretical model of the analytical extraction process electro-membrane extraction (EME), where target analytes are extracted from an aqueous sample, through a thin layer of 2-nitrophenyl octylether immobilized as a supported liquid membrane (SLM) in the pores in the wall of a porous hollow fibre, and into an acceptor solution present inside the lumen of the hollow fibre by the application of an electrical potential difference. The mathematical model was based on the Nernst-Planck equation, and described the flux over the SLM. The model demonstrated that the magnitude of the electrical potential difference, the ion balance of the system, and the absolute temperature influenced the flux of analyte across the SLM. These conclusions were verified by experimental data with five basic drugs. The flux was strongly dependent of the potential difference over the SLM, and increased potential difference resulted in an increase in the flux. The ion balance, defined as the sum of ions in the donor solution divided by the sum of ions in the acceptor solution, was shown to influence the flux, and high ionic concentration in the acceptor solution relative to the sample solution was advantageous for high flux. Different temperatures also led to changes in the flux in the EME system.

Microextraction across supported liquid membranes forced by pH gradients and electrical fields

The present work has for the first time compared extraction of basic analytes across a supported liquid membrane (SLM) based on (1) passive diffusion in a pH gradient sustained over the SLM and (2) electrokinetic migration in an electrical field sustained over the SLM. For the passive diffusion experiments, performed as liquid-phase microextraction (LPME), five basic drugs were extracted under strong agitation from alkaline samples (10mM NaOH), through 2-nitrophenyl octylether immobilized in the pores of a porous hollow fibre of polypropylene (SLM), and into 25 microl of 10mM HCl as the acceptor solution. The experiments based on electrokinetic migration, performed as electro membrane isolation (EMI), were conducted under strong agitation from acidic samples (10mM HCl), through the same SLM as in LPME, and into 25 microl of 10mM HCl as the acceptor solution. Whereas LPME relied on diffusion and to some extent also convection as the principal mechanisms of mass transfer, mass transfer in EMI also included a strong contribution from electrokinetic migration. Thus, extraction kinetics was improved by a factor between 6 and 17 utilizing EMI instead of LPME. This major difference in terms of speed was especially pronounced from small sample volumes (150 microl), and suggest that EMI may be a very interesting future concept for miniaturized sample preparation. In addition to improved extraction kinetics, extraction rates were strongly compound dependent in EMI, opening the possibility to control the extraction selectivity by the extraction time.

Electrokinetic migration of acidic drugs across a supported liquid membrane

Electrokinetic cross membrane extraction of acidic drugs was demonstrated for the first time. The acidic drugs were extracted from an alkaline aqueous donor solution (300 microl), through a thin supported liquid membrane of 1-heptanol sustained in the pores of the wall of a porous hollow fiber, and into an aqueous alkaline acceptor solution (30 microl) present inside the lumen of the hollow fiber by the application of a d.c. electrical potential. The negative electrode was placed in the donor solution, and the positive electrode was placed in the acceptor solution. Optimal extractions were accomplished with 1-heptanol as the supported liquid membrane, with 50 V as the driving force, and with pH 12.0 in both the donor and acceptor solutions, respectively (NaOH). Equilibrium extraction conditions were obtained after 5 min of operation with the whole assembly agitated at 1200 rpm. Eleven different acidic drugs were extracted with recovery values between 8 and 100%, and initial data supported that electrokinetic cross membrane extraction provided repeatable data and linear response between original donor concentration and final acceptor concentration of the acidic model compounds.

Electrokinetic migration across artificial liquid membranes

Twenty different basic drugs were electrokinetically extracted across a thin artificial organic liquid membrane with a 300 V d.c. electrical potential difference as the driving force. From a 300 microl aqueous sample (acidified corresponding to 10mM HCl), the drugs were extracted for 5 min through a 200 microm artificial liquid membrane of a water immiscible organic solvent immobilized in the pores of a polypropylene hollow fiber, and into a 30 microl aqueous acceptor solution of 10mM HCl inside the lumen of the hollow fiber. Hydrophobic basic drugs (logP>1.7) were effectively isolated utilizing 2-nitrophenyl octyl ether (NPOE) as the artificial liquid membrane, with recoveries up to 83%. For more hydrophilic basic drugs (logP<1.0), a mixture of NPOE and 25% (w/w) di-(2-ethylhexyl) phosphate (DEHP) was required to ensure efficient extraction, resulting in recoveries up to 75%. DEHP was expected to act as an ion-pair reagent ion-pairing the protonated hydrophilic drugs at the interface between the sample and the membrane, resulting in permeation of the interface.

Ion-pair mediated transport of angiotensin, neurotensin, and their metabolites in liquid phase microextraction under acidic conditions

This paper discusses the behaviour of angiotensin 1 and neurotensin together with their metabolites in a three-phase liquid phase microextraction under acidic conditions. Variations in donor phase, organic phase, and acceptor phase are studied with extraction recovery as response variable. It is proved that for all peptides the transport across the organic phase is mediated by heptane-1-sulphonic acid. n-Octanol gave overall best results as organic phase. A donor phase volume of 1.0 mL was chosen as a compromise between optimal recovery and robustness of the LPME device. The optimal pH of the donor phase (using acceptor phase of pH 2) was found to be different for the peptides, which opens opportunities for selective sample preparation. Decreasing the acceptor phase pH to 1.0 resulted in increased extraction recoveries. On using 1.0 mL of donor phase containing 50 mM heptane-1-sulphonic acid pH 3, n-octanol as organic phase immobilized in the pores of the fibre, and 20 microL of acceptor phase containing 0.1 mol/L HCl, extraction recoveries up to 82% (enrichment factor = 41) were achieved. To our knowledge this is the first report on liquid phase microextraction of angiotensins and neurotensins.