Athletes with valvular heart disease and competitive sports: a position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology

This article provides an overview of the recommendations from the Sports Cardiology section of the European Association of Preventive Cardiology on sports participation in individuals with valvular heart disease (VHD). The aim of these recommendations is to encourage regular physical activity including sports participation, with reasonable precaution to ensure a high level of safety for all affected individuals. Valvular heart disease is usually an age-related degenerative process, predominantly affecting individuals in their fifth decade and onwards. However, there is an increasing group of younger individuals with valvular defects. The diagnosis of cardiac disorders during routine cardiac examination often raises questions about on-going participation in competitive sport with a high dynamic or static component and the level of permissible physical effort during recreational exercise. Although the natural history of several valvular diseases has been reported in the general population, little is known about the potential influence of chronic intensive physical activity on valve function, left ventricular remodelling pulmonary artery pressure, and risk of arrhythmia. Due to the sparsity of data on the effects of exercise on VHD, the present document is largely based on clinical experience and expert opinion.

Development of a global health curriculum for family medicine based on ACGME competencies

BACKGROUND

With the popularity of global health among medical students and residents, family medicine (FM) residencies are developing pathways in global health. Curriculum based on Accreditation Council for Graduate Medical Education (ACGME) competencies adds rigor to the efforts.

DESCRIPTION

We describe the adaptation of a comprehensive pediatric global health curriculum based on ACGME competencies for family medicine. The curriculum maps out goals, objectives, curricular elements, and evaluation modalities for each of the six competencies (medical knowledge, patient care, practice-based learning, professionalism, communication, and systems-based practice). A literature review, followed by an iterative process, guided the expansion of the pediatric curriculum and the prioritization of domains for FM. Input was sought from FM global health faculty at our 8 residencies, affiliated community faculty, and international health experts from across the United States who attended our workshop at a national FM global health meeting. The final product includes comprehensive competency-based curriculum, open-source resources, and evaluation modalities. The goals and objectives pertinent to all FM residents, and those specific to global health pathway residents and fellows, are outlined.

EVALUATION

The limiting and enabling factors of the curriculum implementation are presented.

CONCLUSIONS

This global family medicine curriculum has added structure and rigor to our international electives in the department at the University of Minnesota. The competency-based curriculum is in the early stages of implementation and evaluation. It has already strengthened components of the residency learning experience for all residents. A robust evaluation is needed and requires monitoring pathway graduates and their career choices into the future. The curriculum is available for adoption by other FM residencies.

Recommendations for interpretation of 12-lead electrocardiogram in the athlete

Cardiovascular remodelling in the conditioned athlete is frequently associated with physiological ECG changes. Abnormalities, however, may be detected which represent expression of an underlying heart disease that puts the athlete at risk of arrhythmic cardiac arrest during sports. It is mandatory that ECG changes resulting from intensive physical training are distinguished from abnormalities which reflect a potential cardiac pathology. The present article represents the consensus statement of an international panel of cardiologists and sports medical physicians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and management of young competitive athletes. The document provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease. When the ECG of an athlete is examined, the main objective is to distinguish between physiological patterns that should cause no alarm and those that require action and/or additional testing to exclude (or confirm) the suspicion of an underlying cardiovascular condition carrying the risk of sudden death during sports. The aim of the present position paper is to provide a framework for this distinction. For every ECG abnormality, the document focuses on the ensuing clinical work-up required for differential diagnosis and clinical assessment. When appropriate the referral options for risk stratification and cardiovascular management of the athlete are briefly addressed.

Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology

The 1996 American Heart Association consensus panel recommendations stated that pre-participation cardiovascular screening for young competitive athletes is justifiable and compelling on ethical, legal, and medical grounds. The present article represents the consensus statement of the Study Group on Sports Cardiology of the Working Group on Cardiac Rehabilitation and Exercise Physiology and the Working Group on Myocardial and Pericardial diseases of the European Society of Cardiology, which comprises cardiovascular specialists and other physicians from different European countries with extensive clinical experience with young competitive athletes, as well as with pathological substrates of sudden death. The document takes note of the 25-year Italian experience on systematic pre-participation screening of competitive athletes and focuses on relevant issues, mostly regarding the relative risk, causes, and prevalence of sudden death in athletes; the efficacy, feasibility, and cost-effectiveness of population-based pre-participation cardiovascular screening; the key role of 12-lead ECG for identification of cardiovascular diseases such as cardiomyopathies and channelopathies at risk of sudden death during sports; and the potential of preventing fatal events. The main purpose of the consensus document is to reinforce the principle of the need for pre-participation medical clearance of all young athletes involved in organized sports programmes, on the basis of (i) the proven efficacy of systematic screening by 12-lead ECG (in addition to history and physical examination) to identify hypertrophic cardiomyopathy-the leading cause of sports-related sudden death-and to prevent athletic field fatalities; (ii) the potential screening ability in detecting other lethal cardiovascular diseases presenting with ECG abnormalities. The consensus document recommends the implementation of a common European screening protocol essentially based on 12-lead ECG.

Faith among patients with advanced cancer. A pilot study on patients offered "no more than" palliation

Spiritual wellbeing is an important topic in cancer care. Being religious is reported by patients facing dilemmas concerning the quality and meaning of life to be potentially helpful. However, the fear of death may be close to the surface and easily stimulated. The aim of this study was to clarify patients' attitudes to faith. Between February 1998 and February 1999, 20 patients aged 37-74 years and suffering from ten different incurable cancers were enrolled in the study. An interview technique focusing on the topic by way of an open question about faith was employed. The topic was only continued if the patient signalled a clear wish for this. Half the patients had a close relative present during the conversation, and an oncology nurse was present in all cases. Most patients (18, or 90%) intimated that the topic was of interest: 85% responded by saying they believed in God, and 75% reported that they prayed. A quarter (25%) mentioned that they had visited their local Lutheran pastor before their admission to hospital. One patient reported being a Jehovah's Witness and one, a member of the Norwegian Humanistically Ethical Association (HEA). Following the conversation, 4 patients requested a visit from the hospital chaplain, 1 asked for contact with the Salvation Army to be arranged, and 1 wanted to talk to the local leader of HEA. Following the conversation all patients were observed by a nurse, and no raised level of anxiety was reported. Sixteen of the patients died within a median of 18 (1-180) days after the conversation. In conclusion, most patients responded positively to a question about faith. The topic should be addressed in the treatment of patients with advanced disease. However, care must be taken to avoid frightening the patients. Patients' attitudes with regard to what death brings deserve respect.

Colonization of the rat liver by syngeneic tumor cells. An experimental approach by in vivo and in situ studies

Syngeneic colon carcinoma cells and glioma cells were injected into the portal vein of BD IX rats. After various time periods the animals were sacrificed and the livers and lungs were fixed and prepared for histology. Atypical cells were observed in the liver 4 and 7 days after the injection of tumor cells, whereas distinct colonies of both colon carcinoma and glioma cells were demonstrated after 14 days. Lung metastases of both tumor cell types were seen after 14 and 30 days. Furthermore, injection of glioma and carcinoma cells into the tail vein gave detectable lung metastases after 7 and 4 days respectively. Intraperitoneal injection of tumor cells resulted in the accumulation of large tumor masses, particularly in the mesentery. By in situ perfusions of the liver with tumor cells included in the perfusion medium it was possible to establish that all the tumor cells were arrested in the course of 4 min. In contrast, normal rat leukocytes were not trapped in the liver, whereas trypsin-treated leukocytes were, suggesting the importance of trypsin-sensitive structures for binding to hepatic tissue. The binding of both glioma and carcinoma cells to the liver and the ensuing growth of tumor nodules in this organ indicate a lack of specificity on part of the malignant cell types for metastasis to the liver in the rat. Both tumor cell types colonized the first organ encountered after injection.