Aetiology and incidence of sudden cardiac arrest and death in young competitive athletes in the USA: a 4-year prospective study.

OBJECTIVE: To investigate the aetiology and incidence of sudden cardiac arrest and death (SCA/D) in US competitive athletes. METHODS: Prospective surveillance was conducted from 1 July 2014 to 30 June 2018 through the National Center for Catastrophic Sports Injury Research in collaboration with national sports organisations. Autopsy reports, death certificates, and medical records were reviewed by an expert panel to determine aetiology. Athlete participation statistics from the National Federation of State High School Associations and the National Collegiate Athletic Association (NCAA) were used to calculate incidence rates per athlete-years (AY). Comparisons of incidence rates were calculated using incidence rate ratios (IRR) with 95% CIs. RESULTS: 331 cases of confirmed SCA/D (158 survivors; 173 fatalities) were identified; 15.4% in middle school, 61.6% in high school and 16.6% in college and professional athletes. Average age was 16.7 (11-29) years, and the majority were in male (83.7%), basketball (28.7%) or American football (25.4%) athletes. Common causes included hypertrophic cardiomyopathy (20.6%), idiopathic left ventricular hypertrophy (13.4%), coronary artery anomalies (12.0%) and autopsy-negative sudden unexplained death (9.6%). Coronary anomalies were more common in middle school athletes (28%), while cardiomyopathies (hypertrophic, arrhythmogenic, dilated, non-compaction or restricted) accounted for 47% of cases in college and professional athletes. Incidence was higher in male versus female athletes at the high school (1:43 932 AY (95% CI 1:38 101 to 1:50 907) vs 1:203 786 AY (95% CI 1:145 251 to 1:293 794); IRR 4.6 (95% CI 3.1 to 7.2)) and NCAA (1:34 906 AY (95% CI 1:25 385 to 1:49 173) vs 1:123 278 AY (95% CI 1:66 078 to 1:249 853); IRR 3.5 (95% CI 1.5 to 9.5)) levels. African American male NCAA Division I basketball players had the highest annual incidence rate of SCA/D (1:2087 AY (95% CI 1:1073 to 1:4 450)). CONCLUSIONS: Cardiomyopathies account for nearly half of SCA/D cases in college and professional athletes, while coronary artery anomalies play a more prominent role than expected in middle school athletes. Over half of SCA cases in athletes result in sudden death, calling for improved prevention strategies.

Etiology of Sudden Cardiac Arrest and Death in US Competitive Athletes: A 2-Year Prospective Surveillance Study.

OBJECTIVE: To determine the etiology of sudden cardiac arrest and death (SCA/D) in competitive athletes through a prospective national surveillance program. DESIGN: Sudden cardiac arrest and death cases in middle school, high school, college, and professional athletes were identified from July 2014 to June 2016 through traditional and social media searches, reporting to the National Center for Catastrophic Sports Injury Research, communication with state and national high school associations, review of the Parent Heart Watch database, and search of student-athlete deaths on the NCAA Resolutions List. Autopsy reports and medical records were reviewed by a multidisciplinary panel to determine the underlying cause. SETTING AND PARTICIPANTS: US competitive athletes with SCA/D. MAIN OUTCOME MEASURES: Etiology of SCA/D. RESULTS: A total of 179 cases of SCA/D were identified (74 arrests with survival, 105 deaths): average age 16.6 years (range 11-29), 149 (83.2%) men, 94 (52.5%) whites, and 54 (30.2%) African American. One hundred seventeen (65.4%) had an adjudicated diagnosis, including 83 deaths and 34 survivors. The most common etiologies included hypertrophic cardiomyopathy (19, 16.2%), coronary artery anomalies (16, 13.7%), idiopathic left ventricular hypertrophy/possible cardiomyopathy (13, 11.1%), autopsy-negative sudden unexplained death (8, 6.8%), Wolff-Parkinson-White (8, 6.8%), and long QT syndrome (7, 6.0%). Hypertrophic cardiomyopathy was more common in male basketball (23.3%), football (25%), and African American athletes (30.3%). An estimated 56.4% of cases would likely demonstrate abnormalities on an electrocardiogram. CONCLUSIONS: The etiology of SCA/D in competitive athletes involves a wide range of clinical disorders. More robust reporting mechanisms, standardized autopsy protocols, and accurate etiology data are needed to better inform prevention strategies.

Survival After Exercise-Related Sudden Cardiac Arrest in Young Athletes: Can We Do Better?

BACKGROUND:: Sudden cardiac arrest (SCA) is the leading cause of death in young athletes during sports. HYPOTHESIS:: Survival after SCA in young athletes is variable. STUDY DESIGN:: Prospective, active surveillance study. LEVEL OF EVIDENCE:: Level 3. METHODS:: From July 1, 2014, to June 30, 2016, exercise-related SCA in competitive young athletes was identified through a systematic search of traditional and social media sources, direct reporting to the National Center for Catastrophic Sports Injury Research, searching of the National Collegiate Athletic Association Resolutions List, regular communication with national and state high school athletic associations, and review of cases in the Parent Heart Watch database. RESULTS:: A total of 132 cases were identified during the 2-year study period (mean patient age, 16 years; age range, 11-27 years; 84% male; 51% white non-Hispanic/Latino, 30% black/African American, and 11% white Hispanic/Latino). High school athletes accounted for 78 (59%) cases, with 28 (21%) in middle school and 15 (11%) in college athletes. Overall survival was 48% (95% CI, 40%-57%; 64 survivors, 68 deaths). Survival was similar in male versus female athletes but higher in white non-Hispanic/Latino (40/67; 60%) versus black/African American (13/39; 33%) athletes (difference, 27%; 95% CI, 7%-45%; P = 0.008) and white non-Hispanic/Latino versus all minority (18/59; 31%) athletes (difference, 29%; 95% CI, 13%-46%; P = 0.001). Basketball accounted for 30% of cases, followed by football (25%), track/cross-country (12%), and soccer (11%). The majority (93%) of cases were witnessed. If a certified athletic trainer was on-site and involved in the resuscitation, 83% of athletes survived. If an on-site automated external defibrillator was used in the resuscitation, 89% of athletes survived. CONCLUSION:: Exercise-related SCA in young, competitive athletes is typically witnessed, providing an opportunity for rapid resuscitation. Additional research is needed to identify factors that affect survival in different athlete populations. CLINICAL RELEVANCE:: Public access defibrillator programs should be universal in schools and youth sporting venues and have the potential to increase survival after SCA in young athletes.

The Second Annual Think Tank on Prevention of Sudden Cardiac Death in the Young: Developing a rational, reliable, and sustainable national health care resource. A report from the Cardiac Safety Research Consortium.

Sudden cardiac death in the young (SCDY) spans gender, race, ethnicity, and socioeconomic class. The loss of any pediatric patient is a matter of national and international public health concern, and focused efforts should be aimed at preventing these burdensome tragedies. Prepared by members of the Cardiac Safety Research Consortium, this White Paper summarizes and reports the dialogue at the second Think Tank related to the issues and the proposed solutions for the development of a national resource for screening and prevention of SCDY. This Think Tank, sponsored by the Cardiac Safety Research Consortium and the United States Food and Drug Administration, convened on February 18, 2016, in Miami, FL, to identify and resolve the barriers that prevent early identification of patients at risk for SCDY. All potential stakeholders including national and international experts from industry, medicine, academics, engineering, and community advocacy leaders had an opportunity to share ideas and collaborate.

A preliminary survey of Trichinella spp. in pigs raised under controlled housing conditions in Colombia: 2014-2016.

A preliminary survey of Trichinella spp. infection was conducted in Colombian swine herds between 2014 and 2016. A total of 1,773 pigs reared on farms under controlled housing conditions and processed in 34 slaughterhouses were tested either by the artificial digestion of pooled muscle samples (n = 1,173) or by serology (n = 600). In addition, 550 rats trapped on 29 swine farm premises were also tested by artificial digestion. No positive pig samples were detected. Similarly, no Trichinella spp. muscle larvae were detected in rats. These results are in agreement with the lack of historical Trichinella infection reports in domestic and wild animals and humans in Colombia. However, a more extensive epidemiological investigation and a continuous surveillance program are needed to continue declaring swine herds in Colombia free of Trichinella infection.

Prevention of sudden cardiac death in the young: Developing a rational, reliable, and sustainable national health care resource. A report from the Cardiac Safety Research Consortium.

This White Paper, prepared by members of the Cardiac Safety Research Consortium, discusses important issues regarding sudden cardiac death in the young (SCDY), a problem that does not discriminate by gender, race, ethnicity, education, socioeconomic level, or athletic status. The occurrence of SCDY has devastating impact on families and communities. Sudden cardiac death in the young is a matter of national and international public health, and its prevention has generated deep interest from multiple stakeholders, including families who have lost children, advocacy groups, academicians, regulators, and the medical industry. To promote scientific and clinical discussion of SCDY prevention and to germinate future initiatives to move this field forward, a Cardiac Safety Research Consortium-sponsored Think Tank was held on February 21, 2015 at the US Food and Drug Administration's White Oak facilities, Silver Spring, MD. The ultimate goal of the Think Tank was to spark initiatives that lead to the development of a rational, reliable, and sustainable national health care resource focused on SCDY prevention. This article provides a detailed summary of discussions at the Think Tank and descriptions of related multistakeholder initiatives now underway: it does not represent regulatory guidance.

Multi-drug resistant Haemonchus contortus in a sheep flock in Antioquia, Colombia.

A sheep farm experiencing high lamb mortality and poor body conditions of ewes due to haemonchosis was tested for the presence of anthelmintic-resistant nematodes in August 2014. A fecal egg count reduction test was performed in Colombia on this farm and a DrenchRite® Larval development Assay (LDA) was shipped to the University of Georgia in the United States for resistance testing. The fecal egg count reduction test (FECRT) was conducted on 70 out of 500 animals allocated into five groups of 14 animals each: untreated control, albendazole (ABZ; 3.5mg/kg sc), ivermectin (IVM; 0.2mg/kg sc), moxidectin (MOX; 0.2mg/kg sc) and levamisole (LEV; 5mg/kg sc) plus triclabendazol/ivermectin (TBZ; 10mg/kg and IVM; 0.2mg/kg po). Individual fecal egg counts (FEC) using the modified McMaster technique and pooled larval cultures were performed 10days after anthelmintic treatment. Following 10days the initial results from the ABZ and IVM groups, 24 animals were treated twice with trichlorfon (TCF; 50mg/kg po) on days 0 and 6, and then checked for FEC on day 10. Mean differences in FEC before and after treatment were negligible (3 to 8% change) for the control, ABZ, LEV-TBZ and IVM groups. The MOX treatment resulted a mean FEC reduction of 76.7%, which was not-significant by t-test (p=0.08). The TCF treatment showed a mean FEC reduction of 42.3%, which was also not-significant (p=0.1). The DrenchRite® LDA was used to evaluate the resistance status to benzimidazole, levamisole, ivermectin and moxidectin on this farm. Coprocultures indicated that the predominant worm species was Haemonchus contortus (Colombia 94-100%) (UGA 77% H. contortus and 23% Trichostrongylus colubriformis). Resistance was evaluated for both H. contortus and T. colubriformis. The LDA results indicated high resistance to all 4 anthelmintics for both parasite species. The current study, together with similar surveys in 4 other Antioquian goat and sheep farms, confirms the presence of multi-drug resistant H. contortus to all three classes of anthelmintics in this region of Colombia.

Cardiac Emergency Response Planning for Schools: A Policy Statement.

A sudden cardiac arrest in school or at a school event is potentially devastating to families and communities. An appropriate response to such an event-as promoted by developing, implementing, and practicing a cardiac emergency response plan (CERP)-can increase survival rates. Understanding that a trained lay-responder team within the school can make a difference in the crucial minutes between the time when the victim collapses and when emergency medical services arrive empowers school staff and can save lives. In 2015, the American Heart Association convened a group of stakeholders to develop tools to assist schools in developing CERPs. This article reviews the critical components of a CERP and a CERP team, the factors that should be taken into account when implementing the CERP, and recommendations for policy makers to support CERPs in schools.

Ivermectin resistance of three Rhipicephalus microplus populations using the larval immersion test / Resistencia de tres poblaciones de Rhipicephalus microplus a la ivermectina por el ensayo de inmersión de larvas / Resistência de três populações de Rhipicephalus microplus à ivermectina pelo teste de imersão de larvas

Background: in Colombia, the control of tick infestation in cattle is almost exclusively performed with chemical acaricides. It is important to determine the degree of resistance of Riphicephalus microplus field populations to ivermectins (IVM) as the first step to design strategies to increase the useful life of acaricides and decrease the reliance on chemical controls. Objective: to test the degree of resistance to IVM. Methods: three cattle farms in Antioquia (Colombia) where IVM had previously failed to control infestations of R. microplus ticks were studied. Ticks were collected several months apart in 2013, and the larval immersion test (LIT) was performed on the progeny of the adult females. Concentration-mortality data were subjected to probit analysis. Results: the three populations showed lethal concentrations (LC) 50 and 99 of ≥ 30 ppm and ≥ 400 ppm, respectively. There was no difference observed in the LC at different times of collection for each population studied. Such high values for LC, together with very low regression slopes (≤ 2), indicated a very heterogeneous response to increasing concentrations of IVM, which is common for resistant populations. At two farms, subcutaneous injection with a long-acting formulation of IVM at a dosage of 630 μg/Kg was ineffective at eliminating existing infestations and protecting against reinfestations, confirming farmer suspicions of lost efficacy. Conclusion: epidemiological studies are necessary to assess the current status of resistance to IVM in this region of Colombia, and it is likely that the intensive use of IVM will aggravate this situation in the future.

Antecedentes: en Colombia, el control de la infestación de garrapatas en el ganado se ha realizado casi exclusivamente con acaricidas químicos y es importante determinar el grado de resistencia de las poblaciones de campo de Riphicephalus microplus a ivermectinas (IVM) como el primer paso para diseñar tácticas que aumenten su vida útil y disminuyan la dependencia de los controles químicos. Objetivo: probar el grado de resistencia a IVM. Métodos: se evaluó la resistencia de R. microplus a IVM en tres fincas ganaderas en Antioquia (Colombia) donde se sospechaba que productos con IVM estaban fracasando para controlar infestaciones por garrapatas. Se recolectaron garrapatas con varios meses de diferencia durante el año 2013 y se empleó la prueba de inmersión de larvas (LIT) con la descendencia de las hembras adultas. Los datos de concentraciónmortalidad fueron sometidos a análisis probit. Resultados: los resultados para las tres poblaciones estudiadas mostraron concentraciones letales (LC) 50 y 99 de ≥ 30 ppm y ≥ 400 ppm, respectivamente. No se observó diferencia en las LC obtenidas en diferentes momentos de recogida para cada población estudiada. Los altos valores de LC, junto con pendientes muy bajas en las rectas de regresión (≤ 2), indicaron una respuesta muy heterogénea a concentraciones crecientes de IVM, propio de poblaciones resistentes. En dos de las granjas, la administración de inyecciones subcutáneas con una formulación de acción prolongada de la IVM a dosis de 630 μg/Kg fue incapaz de eliminar las infestaciones y proteger frente a reinfestaciones, confirmando las sospechas de los ganaderos de pérdida de eficacia. Conclusión: estudios epidemiológicos son necesarios para evaluar el estado actual de la resistencia a IVM en esta región de Colombia, y es probable que el uso intensivo de IVM agrave esta situación en el futuro.

Antecedentes: na Colômbia, o controle de infestação com carrapatos em bovinos tem sido realizado quase exclusivamente com acaricidas químicos pelo qual se faz importante para determinar o grau de resistência de populações de campo de Rhipicephalus microplus a uma das drogas antiparasitárias de maior uso no manejo de gado, a ivermectina (IVM), como o primeiro passo para projetar táticas para aumentar a sua vida útil e diminuir a dependência de controles químicos. Objetivo: testar o grau de resistência à ivermectina. Método: foi avaliada a resistência de R. microplus à ivermectina em três fazendas de gado leiteiro localizadas no departamento de Antioquia (Colômbia) com suspeita de que o controle dos carrapatos com a utilização deste produto não estava sendo efetivo. Coletaram-se carrapatos em diferentes meses durante o ano 2013, e foi utilizado o teste de imersão de larvas (LIT) na descendência das fêmeas adultas, como método para detecção da resistência. Os dados de concentração-mortalidade foram submetidos à análise Probit. Resultados: todas as três populações avaliadas mostraram concentrações letais (LC) 50 de ≥ 30 ppm, e LC 99 de ≥ 400 ppm. Não foram observadas diferenças na LC entre as coletas feitas nos diferentes meses, em cada população amostrada. Os altos valores de LC encontrados junto com uma baixa regressão linear (≤ 2), indicam uma resposta muito heterogênea as concentrações crescentes de ivermectina, próprio de populações resistentes. Em duas das fazendas, a administração de injeções subcutâneas de ivermectina com uma formulação de longa ação, em doses de 630 μg/Kg, não foram capazes de eliminar as infestações e proteger contra a reinfestação, confirmando as reclamações dos fazendeiros para a perda de eficácia da droga antiparasitária. Conclusões: os estudos epidemiológicos são necessários para avaliar o estado atual da resistência à ivermectina nesta região da Colômbia, e é provável que o uso intensivo da ivermectina agrave ainda mais esta situação no futuro.

Pathogeneses of sudden cardiac death in national collegiate athletic association athletes.

BACKGROUND: The pathogenesis of sudden cardiac death in college athletes has not been defined by systematic case identification. METHODS AND RESULTS: A total of 45 cases of sudden cardiac death were identified in National Collegiate Athletic Association (NCAA) athletes from 2004 to 2008 based on an internal reporting system and review of media reports. Autopsy reports were reviewed and adjudicated by a multidisciplinary panel. Cause of death could be reasonably determined in 36 cases; 3 athletes had no autopsy, 5 autopsy reports could not be obtained, and 1 autopsy had insufficient information to determine cause of death. The most common finding at death was a structurally normal heart or autopsy-negative sudden unexplained death (11, 31%), followed by coronary artery abnormalities (5, 14%), dilated cardiomyopathy (3, 8%), myocarditis related (3, 8%), aortic dissection (3, 8%), and idiopathic left ventricular hypertrophy/possible hypertrophic cardiomyopathy (HCM; 3, 8%). There was 1 case each (3%) of hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, commotio cordis, and Kawasaki disease. There was 1 case of death in a sickle cell positive athlete who also had left ventricular hypertrophy. The adjudicated diagnosis agreed with the official pathology report in only 59% of cases. CONCLUSIONS: Unexplained death with a structurally normal heart is the most common finding after suspected sudden cardiac death in NCAA athletes. Hypertrophic cardiomyopathy is infrequently seen, and conclusions in autopsy reports may not accurately reflect the pathological findings. Standardized protocols for cardiovascular autopsies in athletes are needed, including postmortem genetic testing, particularly in autopsy-negative cases.

Cutaneous leishmaniasis in the dorsal skin of hamsters: a useful model for the screening of antileishmanial drugs.

Traditionally, hamsters are experimentally inoculated in the snout or the footpad. However in these sites an ulcer not always occurs, measurement of lesion size is a hard procedure and animals show difficulty to eat, breathe and move because of the lesion. In order to optimize the hamster model for cutaneous leishmaniasis, young adult male and female golden hamsters (Mesocricetus auratus) were injected intradermally at the dorsal skin with 1 to 1.5 x l0(7) promastigotes of Leishmania species and progression of subsequent lesions were evaluated for up to 16 weeks post infection. The golden hamster was selected because it is considered the adequate bio-model to evaluate drugs against Leishmania as they are susceptible to infection by different species. Cutaneous infection of hamsters results in chronic but controlled lesions, and a clinical evolution with signs similar to those observed in humans. Therefore, the establishment of the extent of infection by measuring the size of the lesion according to the area of indurations and ulcers is feasible. This approach has proven its versatility and easy management during inoculation, follow up and characterization of typical lesions (ulcers), application of treatments through different ways and obtaining of clinical samples after different treatments. By using this method the quality of animal life regarding locomotion, search for food and water, play and social activities is also preserved.