Enhancing patient safety: detection of in-hospital hazards and effect of training on detection (by training in a low-fidelity simulation Room of Improvement based on hospital-specific CIRS cases).

IMPORTANCE: Adequate situational awareness in patient care increases patient safety and quality of care. To improve situational awareness, an innovative, low-fidelity simulation method referred to as Room of Improvement, has proven effective in various clinical settings. OBJECTIVE: To investigate the impact after 3 months of Room of Improvement training on the ability to detect patient safety hazards during an intensive care unit shift handover, based on critical incident reporting system (CIRS) cases reported in the same hospital. METHODS: In this educational intervention, 130 healthcare professionals observed safety hazards in a Room of Improvement in a 2 (time 1 vs time 2)×2 (alone vs in a team) factorial design. The hazards were divided into immediately critical and non-critical. RESULTS: The results of 130 participants were included in the analysis. At time 1, no statistically significant differences were found between individuals and teams, either overall or for non-critical errors. At time 2, there was an increase in the detection rate of all implemented errors for teams compared with time 1, but not for individuals. The detection rate for critical errors was higher than for non-critical errors at both time points, with individual and group results at time 2 not significantly different from those at time 1. An increase in the perception of safety culture was found in the pre-post test for the questions whether the handling of errors is open and professional and whether errors are discussed in the team. DISCUSSION: Our results indicate a sustained learning effect after 12 weeks, with collaboration in teams leading to a significantly better outcome. The training improved the actual error detection rates, and participants reported improved handling and discussion of errors in their daily work. This indicates a subjectively improved safety culture among healthcare workers as a result of the situational awareness training in the Room of Improvement. As this method promotes a culture of safety, it is a promising tool for a well-functioning CIRS that closes the loop.

Oral transmucosal fentanyl citrate analgesia in prehospital trauma care: an observational cohort study.

BACKGROUND: Pain is one of the major prehospital symptoms in trauma patients and requires prompt management. Recent studies have reported insufficient analgesia after prehospital treatment in up to 43% of trauma patients, leaving significant room for improvement. Good evidence exists for prehospital use of oral transmucosal fentanyl citrate (OTFC) in the military setting. We hypothesized that the use of OTFC for trauma patients in remote and challenging environment is feasible, efficient, safe, and might be an alternative to nasal and intravenous applications. METHODS: This observational cohort study examined 177 patients who were treated with oral transmucosal fentanyl citrate by EMS providers in three ski and bike resorts in Switzerland. All EMS providers had previously been trained in administration of the drug and handling of potential adverse events. RESULTS: OTFC caused a statistically significant and clinically relevant decrease in the level of pain by a median of 3 (IQR 2 to 4) in NRS units (P < 0.0001). Multiple linear regression analysis showed a significant absolute reduction in pain, with no differences in all age groups and between genders. No major adverse events were observed. CONCLUSIONS: Prehospital administration of OTFC is safe, easy, and efficient for extrication and transport across all age groups, gender, and types of injuries in alpine environments. Side effects were few and mild. This could provide a valuable alternative in trauma patients with severe pain, without the delay of inserting an intravenous line, especially in remote areas, where fast action and easy administration are important.

Risk-Adjusted Mortality Rates as a Quality Proxy Outperform Volume in Surgical Oncology-A New Perspective on Hospital Centralization Using National Population-Based Data.

PURPOSE: Despite a long-known association between annual hospital volume and outcome, little progress has been made in shifting high-risk surgery to safer hospitals. This study investigates whether the risk-standardized mortality rate (RSMR) could serve as a stronger proxy for surgical quality than volume. METHODS: We included all patients who underwent complex oncologic surgeries in Germany between 2010 and 2018 for any of five major cancer types, splitting the data into training (2010-2015) and validation sets (2016-2018). For each surgical group, we calculated annual volume and RSMR quintiles in the training set and applied these thresholds to the validation set. We studied the overlap between the two systems, modeled a market exit of low-performing hospitals, and compared effectiveness and efficiency of volume- and RSMR-based rankings. We compared travel distance or time that would be required to reallocate patients to the nearest hospital with low-mortality ranking for the specific procedure. RESULTS: Between 2016 and 2018, 158,079 patients were treated in 974 hospitals. At least 50% of high-volume hospitals were not ranked in the low-mortality group according to RSMR grouping. In an RSMR centralization model, an average of 32 patients undergoing complex oncologic surgery would need to relocate to a low-mortality hospital to save one life, whereas 47 would need to relocate to a high-volume hospital. Mean difference in travel times between the nearest hospital to the hospital that performed surgery ranged from 10 minutes for colorectal cancer to 24 minutes for pancreatic cancer. Centralization on the basis of RSMR compared with volume would ensure lower median travel times for all cancer types, and these times would be lower than those observed. CONCLUSION: RSMR is a promising proxy for measuring surgical quality. It outperforms volume in effectiveness, efficiency, and hospital availability for patients.

Ketamine vs. haloperidol for prevention of cognitive dysfunction and postoperative delirium: A phase IV multicentre randomised placebo-controlled double-blind clinical trial.

STUDY OBJECTIVE: Delirium is frequently observed in the postoperative and intensive care unit (ICU) population. Due to the multifactorial origin of delirium and according to international guidelines (e.g., American Geriatrics Society; Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) guideline), there are several but no incontestable options for prevention and symptomatic treatment. The purpose of the Baden PRIDe (Prevention and Reduction of Incidence of postoperative Delirium) trial was to determine whether postoperative cognitive dysfunction and delirium could be prevented by the combination of possible preventive agents such as haloperidol and ketamine. In addition, pre- and postoperative levels of the biomarkers cortisol, neuron specific enolase (NSE) and S100ß were measured to investigate their dynamics in delirious and non-delirious patients after surgery. DESIGN: The Baden PRIDe Trial was an investigator-initiated, phase IV, two-centre, randomised, placebo-controlled, double-blind clinical trial. SETTING: Perioperative care. PATIENTS: 182 adult patients that underwent elective or emergency surgery under general or combined (i.e., general and regional) anaesthesia. INTERVENTIONS: Pre-anaesthetic, pharmacologic prevention of postoperative brain dysfunction with haloperidol, ketamine, and the combination of both vs. placebo. MEASUREMENTS: Assessment of cognitive performance pre- and postoperatively with the MMSE, the DOS, the Nursing Delirium Screening Scale (Nu-DESC) or the Intensive Care Delirium Screening Checklist (ICDSC) during ICU stay. MAIN RESULTS: None of the three study arms - haloperidol, ketamine, or both drugs combined - was significantly superior to placebo for prevention of postoperative brain dysfunction and delirium (P = 0.39). Measured levels of postoperative cortisol were significantly higher in delirious patients. S-100ß levels were significantly higher in all postoperative outcome groups (cognitive impairment, delirium, no cognitive decline), whereas postoperative NSE levels declined in all groups. CONCLUSIONS: The study results offer no possibility for a novel recommendation for prevention of postoperative cognitive decline including delirium. Perioperative S-100ß trajectories in patients with cognitive deterioration suggest affection of glial cells in particular. TRIAL REGISTRATION: ClinicalTrials.govNCT02433041; registered on April 7, 2015.

Performance Differences Between the Sexes in the Boston Marathon From 1972 to 2017.

Knechtle, B, Di Gangi, S, Rüst, CA, and Nikolaidis, PT. Performance differences between the sexes in the Boston Marathon from 1972 to 2017. J Strength Cond Res 34(2): 566-576, 2020-The differences between the sexes in marathon running have been investigated for athletes competing in world class-level races. However, no information exists about changes in these differences since the first women officially began participating in marathons. We examined trends in participation and performance in the Boston Marathon from 1972 to 2017. A total of 371,250 different finishers (64% men) and 553,890 observations-with 187,998 (34%) being of women and 365,892 (66%) of men-were analyzed using Generalized Additive Mixed Models. The number of finishers increased over the years. Female participation started at 2.81% in 1972 and reached 45.68% in 2016. Considering all finishers, men (03:38:42 ± 00:41:43 h:min:s) were overall faster than women (04:03:28 ± 00:38:32 h:min:s) by 10.7%. Average performance worsened over the years, but the differences between the sexes decreased. For the annual 10 fastest runners, performance improved with a decrease in speed difference (18.3% overall, men: 02:13:30 ± 00:04:08 h:min:s vs. women: 02:37:42 ± 00:17:58 h:min:s). For the annual winners, performance improved with a decrease in speed difference (15.5% overall, men: 02:10:24 ± 00:03:05 h:min:s vs. women: 02:30:43 ± 00:11:05 h:min:s). For the near-elite finishers from the 21st to the 100th place and from the 101st to the 200th place, women's performance improved with a decrease in the difference to men. In summary, the trend in performance over the years depended on the methodological approach (i.e., all vs. annual 10 fastest finishers vs. annual winners), but the difference between the sexes decreased in all instances. Although men were 10.7% faster than women, the fastest men (i.e., top 10 and winners) increased the gap between men and women by an average of 18.3% for the annual 10 fastest and 15.5% for the annual winners.

A preoperative single dose of methadone for moderate-to-severely painful surgery reduces postoperative morphine consumption.

BACKGROUND: Data from patient questionnaires reveal that the intensity of postoperative pain is widely underestimated. Insufficient pain control may contribute to impaired short- and long-term outcome. Preoperative administration of methadone might potentially improve postoperative pain control due to its long pharmacological half-life. METHODS: The aim of this study was to evaluate the effect of a single dose of methadone administered at anesthesia induction on postoperative analgesic requirements in ASA I-III patients after moderate-to-severely painful surgery scheduled for ≥90 minutes. Patients were randomized to receive either a single dose of methadone (0.2 mg/kg) or fentanyl (standard, 0.003 mg/kg) intravenously (IV) at anesthesia induction. For postoperative pain control, all study patients were accommodated with morphine on the basis of patient-controlled analgesia (PCA). RESULTS: Per-protocol analysis revealed that the median cumulative morphine consumption was significantly lower in patients receiving a single dose of methadone, in the Postanesthesia Care Unit (0 mg vs. 7 mg of morphine, P<0.01) and during the first 72 hours after surgery (19 mg vs. 35 mg of morphine, P<0.05 for all days). Fentanyl consumption during surgery (0.25 mg [0.1-0.425 mg] in the study group vs. 0.3 mg [0.15-0.45 mg] in the control group, P=0.4499) was comparable among groups. Median pain scores at rest and in motion, and patient satisfaction were also similar in both groups (95.7% vs. 89.3% of patients were satisfied in the study and control group, respectively) during follow-up on postoperative days 1-3. CONCLUSIONS: A single dose of methadone administered at anesthesia induction prior to moderate-to-severely painful surgery is a possible strategy to reduce postoperative morphine consumption.

The role of weather conditions on running performance in the Boston Marathon from 1972 to 2018.

This study examined the relationship of weather conditions, together with sex and country of origin, with running performance in the Boston Marathon from 1972 to 2018. A total of 580,990 observations from 382,209 different finishers were analyzed using Generalized Additive Mixed Models. Different groups and subgroups were considered such as all runners, near elite 101:200 finishers, near elite 21:100, annual top ten finishers and annual winners. Weather conditions, over the hours of the event, were average air temperature (°C), total precipitations (mm), wet-bulb globe temperature (WBGT) (°C), wind speed (km/h), wind direction (head wind, side wind, tail wind) and barometric pressure (hPa). These effects were examined in a multi-variable model, together with: sex, country of origin, calendar year, an interaction term country:sex and a spline smooth term in function of calendar year and sex. The average temperature, when increasing by 1°C, was related to worsened performance (by 00:01:47 h:min:sec for all finishers and by 00:00:20 h:min:sec for annual winners). Also, the pressure and wet-bulb globe temperature, when increasing, were related to worsened performances. Tail wind improved performances of all groups. Increasing precipitation was significantly (p<0.05) related to worsened performances in all groups except annual winners. Increasing wind speed was also related to worsened performances in all finishers and near elite groups. Kenyans and Ethiopians were the fastest nationalities. The sex differences (men faster than women in all groups) were the largest in near elite groups. Our findings contributed to the knowledge of the performance in Boston Marathon across calendar years, considering as main effects weather conditions, country of origin and sex.

The Role of Environmental Conditions on Marathon Running Performance in Men Competing in Boston Marathon from 1897 to 2018.

This study investigated the effects of weather conditions on male performance during the Boston Marathon from 1897 to 2018. A total of 383,982 observations from 244,642 different finishers were analysed using Generalized Additive Mixed Models. All runners, annual top 100 finishers and annual top ten finishers were considered. Weather conditions, on race day, were: average air temperature (°C), precipitations (mm), wet-bulb globe temperature (WBGT) (°C), wind speed (km/h), wind direction (N, S, W, E) and pressure (hPa). These effects were examined in multi-variable models with spline smooth terms in function of calendar year. Temperature, when increasing by 1 °C, was related to worsened performance for all groups (i.e., by 00:01:53 h:min:sec for all finishers, p < 0.001). Wind coming from the West, compared to wind coming from other directions, was the most favourable for performance of all groups of finishers. Increasing precipitations worsened performances of top 100 (estimate 00:00:04 h:min:sec, p < 0.001) and top 10 finishers (estimate 00:00:05 h:min:sec, p < 0.001). Wind speed, when increasing by 1 km/h, was related to worsened performance for all finishers (estimate 00:00:19 h:min:sec, p < 0.001), but not for top 100 group, where performances were 00:00:09 h:min:sec faster, p < 0.001. Pressure and WBGT were examined in uni-variable models: overall, performances worsened as pressure and WBGT increased. Our findings contributed to the knowledge about the effect of weather conditions on performance level in male marathon runners.

Men's Participation and Performance in the Boston Marathon from 1897 to 2017.

This study examined men's participation and performance in the Boston Marathon. Data from all 368,940 official male finishers in the Boston Marathon from 1897 through 2017 were analyzed using different analyses and regression models for all runners, annual top hundred finishers, annual top ten finishers and annual winners. Effect of calendar year on race time was examined alone, in a uni-variable model, and together with country of origin and weather conditions (average air temperature and precipitation) in a multi-variable model. The mean race time of all finishers increased across calendar years, in line with the participation, but it decreased when we considered the annual winners, 10 and 100 fastest. Kenyans and Ethiopians were the fastest nationalities (p<0.001) when we considered all finishers and the annual top 100 fastest but not when the annual 10 fastest were considered. Air temperature≤8 °C improved (p<0.001) race times compared to air temperature>8°C. Precipitation (>0 mm) improved performance for the annual 100 fastest and annual 10 fastest (p=0.013-0.031) but not for all finishers. Our findings improved the knowledge about the evolution of male marathoners across calendar years, considering as main effects country of origin and particular weather conditions.

Influence of skin disinfection prior removal of perineural catheter on bacterial colonization, contamination and local inflammation: a prospective randomized study.

BACKGROUND: There is a wide variation of perineural catheter (PNC) colonization rates in the literature. The impact of skin disinfection on PNC colonization and inflammation is not clear. The objective of this prospective, randomized clinical study was to investigate the influence of alcoholic skin disinfection before PNC removal on the detection of bacteria on PNC. METHODS: Two hundred patients receiving a PNC for orthopedic surgery were randomized to receive (with-group) or not (without-group) a skin disinfection with a sprayed alcoholic solution before removal of the PNC. Bacterial colonization and contamination of the PNC and clinical signs of inflammation and infection of the PNC insertion site were evaluated. Skin disinfection with a sprayed alcoholic solution and sterile removal of the distal and subcutaneous part of the PNC was performed after 72 hours or earlier if signs of infection occurred with semiquantitative culture and enrichment culture of both parts. RESULTS: Alcoholic skin disinfection before PNC removal significantly reduced bacterial colonization with a reduction from 28% to 14% and from 32% to 17% for the tip and the subcutaneous part of the PNC, respectively (P<0.05). Clinical signs of inflammation at the PNC insertion site were similar (73%) in the two groups. The detection of colonization in 54 (27%) out of 200 PNC did not correlate with clinical signs of inflammation independently of the number of bacteria isolated. Redness was noted in 71% and 68% of patients in the without- and with-alcoholic skin disinfection-group respectively. Local pain on pressure was present in 28% and 19% in the without- and with-group respectively. CONCLUSIONS: Alcoholic skin disinfection before PNC removal reduced the detection of PNC colonisation by 50%. There was no correlation between clinical signs of inflammation and PNC colonization.

The Age-Related Performance Decline in Ironman Triathlon Starts Earlier in Swimming Than in Cycling and Running.

Käch, I, Rüst, CA, Nikolaidis, PT, Rosemann, T, and Knechtle, B. The age-related performance decline in Ironman triathlon starts earlier in swimming than in cycling and running. J Strength Cond Res 32(2): 379-395, 2018-In Ironman triathlon, the number of overall male and female finishers increased in the past 30 years, while an improvement in performance has been reported. Studies concluding these numbers only analyzed the top 10 athletes per age group instead of all finishers; therefore, a selection bias might have occurred. The aim of this study was to investigate participation, performance, and the age-related performance decline of all pro- and age-group triathletes ranked in all Ironman triathlons held worldwide between 2002 and 2015. Split and overall race times of 329,066 (80%) male and 81,815 (20%) female athletes competing in 253 different Ironman triathlon races were analyzed. The number of finishers increased in all age groups with the exception of women in age group 75-79 years. In pro athletes, performance improved in all disciplines. In age-group athletes, performance improved in younger age groups for running (from 18-24 to 40-44 years) and older age groups for swimming (from 50-54 to 65-69 years) and cycling (from 35-39 to 55-59 years), whereas it impaired in younger age groups for swimming (from 18-24 to 45-49 years) and cycling (from 18-24 to 30-34 years), and older age groups in running (from 45-49 to 70-74 years). The age-related performance decline started in women in age group 25-29 years in swimming and in age group 30-34 years in cycling, running, and overall race time, whereas it started in men in age group 25-29 years in swimming and in age group 35-39 years in cycling, running, and overall race time. For athletes and coaches, performance improved in younger age groups for running and older age groups for swimming and cycling, and the age-related decline in performance started earlier in swimming than in cycling and running. In summary, women should start competing in Ironman triathlon before the age of 30 years and men before the age of 35 years to achieve their personal best Ironman race time.

Performance Trends in Master Butterfly Swimmers Competing in the FINA World Championships.

Performance trends in elite butterfly swimmers are well known, but less information is available regarding master butterfly swimmers. We investigated trends in participation, performance and sex differences in 9,606 female and 13,250 male butterfly race times classified into five-year master groups, from 25-29 to 90-94 years, competing in the FINA World Masters Championships between 1986 and 2014. Trends in participation were analyzed using linear regression analysis. Trends in performance changes were investigated using mixed-effects regression analyses with sex, distance and a calendar year as fixed variables. We also considered interaction effects between sex and distance. Participation increased in master swimmers older than ~30-40 years. The men-to-women ratio remained unchanged across calendar years and master groups, but was lower in 200 m compared to 50 m and 100 m. Men were faster than women from 25-29 to 85-89 years (p < 0.05), although not for 90-94 years. Sex and distance showed a significant interaction in all master groups from 25-29 to 90-94 years for 200m (p < 0.05). For 50 m and 100 m, a significant sex × distance interaction was observed from 25-29 to 75-79 years (p < 0.05), but not in the older groups. In 50 m, women reduced the sex difference in master groups 30-34 to 60-64 years (p < 0.05). In 100 m, women decreased the gap to men in master groups 35-39 to 55-59 years (p < 0.05). In 200 m, the sex difference was reduced in master groups 30-34 to 40-44 years (p < 0.05). In summary, women and men improved performance at all distances, women were not slower compared to men in the master group 90-94 years; moreover, women reduced the gap to men between ~30 and ~60 years, although not in younger or older master groups.

Performance Trends in Age Group Triathletes in the Olympic Distance Triathlon at the World Championships 2009-2014.

Performance trends in elite triathletes competing in age group classes have been investigated for Ironman triathlon in 'Ironman Hawaii' but not for short distance triathletes competing at international level in events such as the Olympic distance triathlon at the World Championships. The aim of the present study was to evaluate participation and performance trends of age group triathletes competing in the Olympic distance triathlon at the International Triathlon Union (ITU) World Championships 2009-2014. During this period, the number of participants remained constant. Swimming performance improved in athletes in age groups 25-29 years to 55-59 years, but not in younger (18-24 years) and older (> 60-64 years) age groups. Cycling performance improved in athletes in age groups 18-24 years to 70-74 years, but not in age group 75-79 years. In running, athletes in age groups 18-24 years, 30-34 years, 35-39 years and 65-69 years improved, but not in the other age groups. Overall race time was improved by athletes in age groups 18-24 to 65-69 years, but not in age groups 70-74 years and 75-79 years. Transition times were improved by all age group athletes. Women were slower than men in swimming, cycling, running and overall race time in age groups 18-24 years to 70-74 years, but not in the age group 75-79 years. For transition times, women were slower than men in age groups 18-24 years to 65-69 years, but not in age groups 70-74 years to 75-79 years. In summary, women and men improved performance in most age groups across all years, men were faster than women except in the age group 75-79 years and the sex difference between women and men remained constant. This knowledge should be considered when future age group triathletes train for and compete in Olympic distance triathlons at international level.

Differences in age of peak marathon performance between mountain and city marathon running - The 'Jungfrau Marathon' in Switzerland.

The age of the best marathon performance has been well investigated for flat city marathon running, but not for mountain marathon running. The aim of this study was to determine the age of the best mountain marathon performance and to compare to results of a flat city marathon. Race times and ages of finishers of a mountain marathon with 1,830 m of altitude change (Jungfrau Marathon, Switzerland) and two flat city marathons (Lausanne Marathon and Zurich Marathon, Switzerland) were analysed using linear, non-linear and mixed-effects regression analyses. Race times were slower in the mountain compared to the city marathon. In both the mountain marathon and the city marathons, women and men improved performance and men were faster than women when the fastest per year and all per year were considered. When the fastest runners in 1-year age intervals were considered in the mountain marathon, the fastest man (3:01 h:min) was ~35.6 years and the fastest women (3:28 h:min) ~34.5 years old. When all finishers were considered in 1-year age intervals, the fastest men (4:59 h:min) were ~29.1 years old and the fastest women (5:16 h:min) were ~25.6 years old. In the city marathons in 1-year age intervals, the fastest man (2:10 h:min) was ~23.7 years old and the fastest woman (2:36 h:min) ~32.2 years old. When all finishers were considered in 1-year age intervals, the fastest men (3:41 h:min) were ~35.0 years old and the fastest women (4:00 h:min) ~33.8 years old. In summary, the age of the fastest women and men was higher in the mountain marathon compared to the city marathons when the fastest runners were considered. However, when all finishers were considered the age of the fastest women and men was lower in the mountain marathon compared to the city marathons.

Performance and age of African and non-African runners in World Marathon Majors races 2000-2014.

The age for the fastest marathoners is well investigated, but not the age and nationality of the fastest. We investigated the age of peak marathon performance for the annual top 100 women and men competing in four races of the "World Marathon Majors" (Boston, Berlin, Chicago and New York) and the "Stockholm Marathon" between 2000 and 2014 using mixed-effects regression analyses and one-way ANOVA. Race times of Ethiopian men decreased to 2:14 h:min, but remained unchanged for Kenyan (2:14 h:min), Moroccan (2:15 h:min) and South African (2:18 h:min) men. Race times in Ethiopian (2:34 h:min), Kenyan (2:29 h:min) and South African (2:49 h:min) women showed no changes. Age increased in Ethiopian and South African men to 29.0 ± 5.0 and 32.0 ± 1.0 years, respectively. Age for Kenyan (29.9 ± 2.0 years) and Moroccan (34.9 ± 3.9 years) men remained unchanged. Age remained unchanged for Ethiopian (26.5 ± 2.0 years), Kenyan (30.0 ± 0.8 years) and South African (36.3 ± 7.0 years) women. In summary, Ethiopian men improved marathon race times, but not Ethiopian women. Age increased in Ethiopian men, but not in Ethiopian women. For practical applications, female and male marathoners from Ethiopia were the youngest and the fastest.

Performance trends in 3000 m open-water age group swimmers from 25 to 89 years competing in the FINA World Championships from 1992 to 2014.

We investigated trends in participation, performance and sex difference in performance in 3000 m freestyle in age groups swimmers (25-29 to 85-89 years) competing in the Fédération Internationale de Natation World Masters Championships between 1992 and 2014. During this period, participation increased in women and men. Women and men improved race times across years in all age groups. Women were slower in age groups 25-29 to 70-74 years. In age groups 75-79 and 85-89 years, however, race times were similar for both women and men. Sex difference in performance remained unchanged across years. In summary, performance improved across years in all age groups, men were faster than women up to the age group 70-74 years and women were not able to reduce the sex difference in performance to men across years. For athletes and coaches, an increase in participation and a continuous improvement in performance can be expected in these age group athletes.

Positive pacing in elite IRONMAN triathletes.

Pacing is known to influence athletic performance. For the Ironman triathlon program, a positive pacing strategy, i.e., the continuous decrease of speed over time was recommended. By analyzing split times, we assessed the pacing strategies of the top 100 finishers of the cycling part of 13 Ironman races and of the running part of 11 Ironman races taking place in 2014. Furthermore, sex-associated differences in performance and pacing strategies were calculated. We analyzed 7,687 cycling and 11,894 running split times of 1,392 triathletes (1,263 men, 129 women). Changes in speed were assessed using mixed-effects regression analyses. A continuous decrease in speed was observed during cycling in 10/13 races, and during running in 11/11 races. In 6/13 races, women decreased their speed during cycling significantly more than men. The running part showed no significant difference of changes in speed between the sexes. In summary, in the Ironman races evaluated, a positive pacing strategy was adopted in most races. Women were slower than men in 6/13 cycling races, but there was no difference between men and women in the run splits. Women used the same pacing strategy as men.

Performance trends in age group breaststroke swimmers in the FINA World Championships 1986-2014.

Performance trends in breaststroke swimmers competing at world class level in pool competitions are well investigated for elite swimmers, but not for age group swimmers. This study investigated trends in participation, performance and sex difference in performance in a total of 35,143 (16,160 women and 18,983 men) age group breaststroke swimmers aged 25-29 to 95-99 years competing in the Fédération Internationale de Natation (FINA) World Masters Championships between 1986 and 2014. Trends in participation were analysed using linear regression analyses and trends in performance were investigated using mixed-effects regression analyses with sex, distance and calendar year as fixed variables. Women and men improved performance in all age groups. For age groups 25-29 to 85-89 years, men were faster than women. For age groups 90-94 to 95-99 years, men were not faster than women. Sex and distance showed a significant interaction for all distances in age groups 25-29 to 80-84 years. In 50 m, women reduced the gap to men in age groups 40-44 to 70-74 years and in 100 m and 200 m, women reduced the gap in age groups 50-54 to 60-64 years. In summary, (i) women and men improved performance in all race distances and in all age groups, (ii) men were faster than women from 25 to 89 years, but not from 90 to 99 years, and (iii), women reduced the gap to men between ~40 and ~75 years, but not in younger (<40 years) or older (>75 years) age groups. Based on these findings for a time period of nearly 30 years, we may assume a further increase in participation and a further improvement in performance in the near future in age group breaststroke swimmers competing at world class level.

Performance and sex differences in 'Isklar Norseman Xtreme Triathlon'.

The performance and sex differences of long-distance triathletes competing in 'Ironman Hawaii' are well investigated. However, less information is available with regards to triathlon races of the Ironman distance held under extreme environmental conditions (e.g. extreme cold) such as the 'Isklar Norseman Xtreme Triathlon' which started in 2003. In 'Isklar Norseman Xtreme Triathlon', athletes swim at a water temperature of ~13-15°C, cycle at temperatures of ~5-20°C and run at temperatures of ~12-28°C in the valley and of ~2-12°C at Mt. Gaustatoppen. This study analysed the performance trends and sex differences in 'Isklar Norseman Xtreme Triathlon' held from 2003 to 2015 using mixed-effects regression analyses. During this period, a total of 175 women (10.6%) and 1,852 men (89.4%) successfully finished the race. The number of female (r² = 0.53, P = 0.0049) and male (r² = 0.37, P = 0.0271) finishers increased and the men-to-women ratio decreased (r² = 0.86, P < 0.0001). Men were faster than women in cycling (25.41 ± 2.84 km/h versus 24.25 ± 2.17 km/h) (P < 0.001), but not in swimming (3.06 ± 0.62 km/h vs. 2.94 ± 0.57 km/h), running (7.43 ± 1.13 km/h vs. 7.31 ± 0.93 km/h) and overall race time (874.57 ± 100.62 min vs. 899.95 ± 90.90 min) (P > 0.05). Across years, women improved in swimming and both women and men improved in cycling and in overall race time (P < 0.001). In running, however, neither women nor men improved (P > 0.05). In summary, in 'Isklar Norseman Xtreme Triathlon' from 2003 to 2015, the number of successful women increased across years, women achieved a similar performance to men in swimming, cycling and overall race time, and women improved across years in swimming, cycling and overall race time.