Courtney Kipps

Hydration Strategies of Runners in the London Marathon

Objective To explore the hydration strategies of marathon runners, their sources of information and knowledge about fluid intake in the marathon, and their understanding of exercise-associated hyponatremia (EAH). Design Anonymized questionnaire. Setting London Marathon. Participants Marathon race participants. Main Outcome Measures Responses regarding planned fluid consumption, volume to be consumed, volume of water and sports drink bottles, and the number of stations from which planning to take a drink. In addition, sources of information about appropriate drinking and understanding of hyponatremia. Results In total, 93.1% of the runners had read or been told about drinking fluids on marathon day and 95.8% of competitors had a plan regarding fluid intake. However, 12% planned to drink a volume large enough to put them at higher risk of EAH. Only 21.7% knew the volumes of water and sports drink bottles available on the course; 20.7% were planning to take a drink from all 24 water stations. Only 25.3% planned to drink according to thirst. Although 68.0% of the runners had heard of hyponatremia or low sodium levels, only 35.5% had a basic understanding of its cause and effects. Conclusions Marathon runners lack knowledge about appropriate fluid intake to prevent hyponatremia on race day. Twelve percent reported drinking strategies that put them at risk of EAH. Effective educational interventions are still necessary to prevent overdrinking during marathons.

AN ANONYMOUS ONLINE SURVEY OF THE VIEWS AND ATTITUDES OF MEDICAL STUDENTS AND JUNIOR DOCTORS TOWARDS PHYSICAL ACTIVITY (PA) TEACHING AND PROMOTION

Background Physical inactivity is the fourth leading cause of mortality globally according to the WHO. Several recent studies have highlighted that physical activity (PA) is inadequately covered during UK medical school training. This study aims to investigate the frequency of PA questions and advice during routine consultations by medical students and junior doctors. Methods A link to an anonymous online survey was sent to 195 medical students and 68 junior doctors based at a hospital near London. Thirty-four of the fifty responders were medical students. Results Less than a quarter of respondents routinely asked about PA levels in the medical history. In contrast, more than 90 percent always asked about tobacco and alcohol. Fear of offending or alienating patients, lack of knowledge and lack of time were the three most common themes identified by responders when asked about the perceived barriers to giving PA advice. Almost half reported having no teaching on PA guidelines. None of the medical students or junior doctors were able to correctly identify the WHO top 4 global mortality risk factors. Discussion/Conclusions This study found that clinical medical students and recent graduates rarely include questions or advice about PA in routine medical consultations. Responders tended to under prioritise physical inactivity as a mortality risk factor, and this may reflect a lack of adequate teaching and emphasis on physical inactivity within medical schools. Fear of offending of alienating patients was the most frequently cited barrier to giving PA advice. This may be due to the inexperience of juniors, or view that labelling someone as physically inactive is stigmatising. This study reaffirms previous findings of low levels of teaching about PA in medical schools and identifies lack of knowledge as one of the prime reasons why PA is neglected in routine medical history taking. This calls for urgent action to include PA teaching as a priority in UK medical school teaching.

Attention problems as a risk factor for concussion in youth ice-hockey players

Objective To examine attention problems in youth ice-hockey players as a risk factor for concussion. Design Secondary analysis of two prospective cohort studies. Setting Ice-rinks and Sport Medicine Centres in two Canadian cities over three ice-hockey seasons (2011/12, 2012/13, 2014/15). Assessment of risk factors Self-report of formal diagnosis of attention or learning disorders were collected on previously validated preseason baseline questionnaires by all participating players. Parents and players completed the Behaviour Assessment System for Children (BASC-2), which includes inattention and hyperactivity scales. Participants 2,364 Canadian ice-hockey players (11–17 years old, 87% male). Outcome measures A previously validated prospective injury surveillance system was used. All suspected concussions were referred to the study physician for confirmation of diagnosis. Concussion risk ratios (RR) were estimated, including stratification by known risk factors. Results One-hundred ninety-two of 2,215 players (9%) self-reported attention and/or learning disorders at baseline. Overall, 256 players (11%) sustained one or more concussions during a season. Players identified as “at-risk” for attention-deficit hyperactivity disorder (ADHD), based on BASC-2 T-scores (inattention and/or hyperactivity scale) greater than 60, had a greater risk of concussion during the season based on child report [RR=1.51 (95% CI 1.13–2.04)] and parent report [2.97 (95% CI 1.65–5.34)]. In players with no history of previous concussion, the RR based on child report was 1.88 (95% CI 1.22–2.90) and based on parent report was 5.03 (95% CI 2.45–10.29). Conclusions Ice-hockey players identified as “at-risk” for ADHD on the basis of baseline BASC-2 scores are at a greater risk of concussion. Competing interests None.

Swimming-induced pulmonary edema: current perspectives

With the growing popularity of water-based sports, cases of swimming-induced pulmonary edema (SIPE) are becoming increasingly recognized. SIPE, a potentially life-threatening condition, is an acute cause of breathlessness in athletes. It has been described frequently in scuba divers, swimmers, and triathletes and is characterized by symptoms and signs of pulmonary edema following water immersion. It is important to recognize that athletes’ symptoms can present with a spectrum of severity from mild breathlessness to severe dyspnea, hemoptysis, and hypoxia. In most cases, there is rapid resolution of symptoms within 48 hours of exiting the water. Recent advances in the understanding of the pathophysiology of SIPE, particularly regarding exaggerated pulmonary vascular pressures, have begun to explain this elusive condition more clearly and to distinguish its predisposing factors. It is essential that event organizers and athletes are aware of SIPE. Prompt recognition is required not only to prevent drowning, but also to implement appropriate medical management and subsequent advice regarding return to swimming and the risk of recurrence. This manuscript provides a current perspective on SIPE regarding the incidence rate, the current understanding of the pathophysiology, clinical presentation, medical management, recurrence rates, and advice on return to sport.

Knowledge and practice habits of hospital doctors who manage sports-related concussion in sri lanka

Objective To investigate the knowledge and practice habits of hospital doctors who evaluate and treat concussions in Sri Lanka. Design email questionnaire survey Setting Emergency departments and surgical wards in hospitals in Sri Lanka Participants The survey was distributed via email to 400 ED and surgical doctors working in hospital practice in Sri Lanka. Only doctors who routinely deal with sport-related concussion were included. Doctors who did not manage concussion were excluded. Outcome measures Survey analysis of concussion knowledge and management habits. Main results 88 surveys from doctors who met the inclusion criteria were returned completed. Respondents answered a mean 72.9% of the concussion signs and symptoms knowledge questions correctly. However only 21 (23%) of doctors surveyed were aware of any concussion management guidelines and 41 (47%) believed that players could resume normal training once they were symptom-free. 71 (80.7%) respondents believed that wearing headgear could help prevent concussion. There was no significant difference in concussion knowledge between consultants and non-consultant grades (p=0.5). 23/88 respondents said they have been pressurised (by the injured player (n=14), coach or manager (13), other players (5), parents (4), other administrators (8)) to return to play early. Conclusions ED and surgical doctors in Sri Lanka have a moderate level of knowledge of sports-related concussion, however few are aware of concussion management guidelines and many continue to adhere to outdated advice. This is the first such survey in Sri Lanka and demonstrates a need for additional sports concussion education. Competing interests None.

Clinician knowledge and practice habits when evaluating sports related concussion in the emergency department

Objective To investigate emergency department (ED) clinicians’ knowledge and practice habits when evaluating and treating concussions in the Republic of Ireland (ROI) Design An 84-item anonymous questionnaire Setting Emergency Departments and Minor Injury Units in the ROI Participants The survey was distributed by email to the national cohort of Registered Advanced Nurse Practitioners (RANP; n-84), and Emergency Medicine Consultants (n=86), working in EDs in the ROI Main results 101 Surveys were completed (43 RANP, 43 NCHD, 15 EM Consultants). 60% of all respondents rated themselves as very confident in identifying the signs and symptoms of concussion. Only 40% had heard of or were mildly familiar with the SCAT3 concussion assessment tool. 15% believed MRI and/or CT would demonstrate damage following a concussion. 60% felt that they were very confident giving discharge advice and return to play (RTP) instructions following concussion although half of all respondents advise waking the patient up several times over the first 24hours. Only 37% believe that adolescent players (<18 yrs) take longer to recover from concussion than adults. 70% of all respondents believe appropriate headgear can help prevent concussion. Conclusions Current guidelines regarding assessment tools have not reached the majority of ED clinicians. Additionally, knowledge gaps exist regarding concussion symptom identification and management, and further education is warranted. Competing interests None.

55 the recognition of paediatric sports related concussion (5–16 year olds), initial management and advice among london based emergency medicine trainees

Objective This study aimed to investigate knowledge of paediatric concussion amongst emergency medicine trainees, testing the hypothesis that emergency medicine trainees lack sufficient knowledge to competently assess, diagnose and manage sports-related paediatric concussion. Design cross-sectional questionnaire survey. Setting Secondary care emergency medicine departments. Participants All emergency medicine trainees in one geographical training region in the UK were invited to participate. Outcome measures occupational grade, years of experience, history of specific concussion training, awareness of head injury guidelines, perceived knowledge and confidence in concussion diagnosis and management. Main results Sixty questionnaires were returned. Across all training grades, the mean correct response score on questions of diagnosis, assessment and management of concussion was 73.4%. Nearly 70% of trainees were not aware of any concussion guidelines, and only 10% had attended a course or received training regarding concussion. There was a negative correlation between awareness of guidelines and perceived confidence (r=−0.50 p<0.001), and knowledge in diagnosis and management of concussion (r=−0.51, p<0.001). The majority (91.7%) of the participants would like further education on concussion management, with an online learning module being the preferred format (71.7%). Conclusions The study revealed insufficient level of knowledge and confidence in the assessment, diagnosis and management of paediatric concussion among emergency medicine trainees. None of the variables studied statistically predicted knowledge score. Additional concussion-specific education would be beneficial to optimise trainees’ knowledge of paediatric concussion. Competing interests None.

EXERCISE ASSOCIATED HYPONATREMIA (EAH) AND FLUID INTAKE DURING THE 2016 LONDON MARATHON

Background Exercise-Associated Hyponatremia (EAH) is a potentially fatal condition during endurance exercise (Petzold et al, 2007). Excessive fluid intake over and above normal fluid losses is the most common risk factor in the development of EAH. A “drink to thirst” fluid regime is considered best practice (Hew-Butler et al, 2015). Objective To investigate fluid intake and changes in serum sodium concentrations ([Na]+) in runners during a marathon Design Prospective observational study. Setting 2016 London Marathon. Participants 28 amateur athletes were recruited at the marathon registration. Independent Variables Online and printed medical advice was available to all participants. A drink to thirst fluid regime was recommended to all athletes by the event organisers. Main Outcome Measures Serum sodium samples were collected and body mass measured at the marathon start and finish lines. Questionnaires regarding estimated fluid intake data were collected at the finish. Results The average volume of fluid intake during the marathon was 1.4 litres (range 0–5.5 litres). Change in serum sodium concentration was inversely correlated with change in body mass (r=−0.383, p=0.044) and with estimated fluid intake (r=−0.406, p=0.032). A significant correlation between fluid intake and weight change was not found. The average pre-race and post-race [Na]+ were 141.7 mmol/L and 141.5 mmol/L, respectively (p=0.8673). One runner (1/28, 3.6%) was found to have asymptomatic hyponatraemia ([Na]++=130 mmol/L). This runner had consumed an estimated 5l of fluid over the course of the marathon. A trend in correlation was seen between fluid intake and race time (r=0.349, p=0.069). Conclusions Runners consumed potentially dangerous volumes of fluid during a marathon despite the written guidance recommending against such practices. The consequence of this behaviour is overhydration and an increased risk of developing potentially fatal EAH. The optimal medium for runner education on safe drinking practices is yet to be determined.

Does concussion education have an impact in behaviours amongst school-age rugby players?

Background Concussion is a common injury in school-boy rugby, if managed incorrectly it can have serious consequences such as further injury, prolonged symptoms, and second impact syndrome. Adolescent players show poor knowledge levels and symptoms-reporting behaviour. Objective Investigate the effects of an educational presentation on the knowledge and behaviour of school age rugby players regarding concussion. Design Questionnaire based study. Setting 120 male rugby players, aged 16–18. Participants Three large rugby union playing schools in England. Interventions Independent Variable – Educational presentation aimed at school-age rugby players to improve their education and behaviours related to the condition. Players completed a questionnaire testing for likely behavioural responses from a selection of common concussion scenarios. Additional questions assessed knowledge of concussion symptoms, diagnosis and management. The questionnaires were completed pre-season and repeated 2–3 months after the presentation. Outcome Dependent variable: Questionnaire scores. Results The students had significantly improved their responses giving 53.9% appropriate responses after the presentation (Md=55, n=34) compared to 46.1% before (Md=33.5, n=34) (U=400, Z=-2.18, p=0.029) with a moderate effect size (r?=?0.37). The knowledge of students increased from 37.85% correct responses before (Md=28, n=35) and 44.07% on follow up?(Md=28, n=35) but with no significant difference (U?=?575.5, Z?=?-?0.88, p=0.378 with a small effect size (r?=?0.15)). Completed surveys showed increased awareness of guidelines from 19.4% to 73.2% (p=0.00 McNemars Test). Conclusions The students had showed improved concussion behaviour in response to concussion scenarios at 2–3 month follow up in contrast to previous studies on educational interventions. There was no increase in players knowledge of concussion. The literature shows increases in short-term knowledge with other forms of concussion education but this effect is often lost at long term follow up. There was increased awareness of guidelines. Future concussion education should be modeled on the educational presentation to improve behavioural outcomes.

P-41 ACTN3 R577x genotype is not associated with elite european caucasian marathon performance

Objectives A common nonsense polymorphism (R577X) in the ACTN3 (α-actinin-3 protein) has been associated with elite athlete status previously. Specifically, the X allele has been positively associated with elite endurance status, however, this remains inconclusive due to contradictory reports within the literature. Thus, the current study aimed to compare ACTN3 R577X genotype and allele frequency distributions in ‘elite’ and ‘sub-elite’ marathon runners with those of a non-athletic, control population and to determine whether marathon personal best time was associated with ACTN3 R577X genotype. Method Four hundred and eighty four elite and sub-elite European Caucasian marathon runners and 554 ethnically matched controls provided a DNA sample from which the ACTN3 R577X polymorphism was genotyped using real-time PCR. Personal best (PB) times were used to determine elite (men < 2 h 30 min, n = 111; women < 3 h 00 min, n = 105) or sub-elite (men 2 h 30 min – 2 h 45 min, n = 189; women 3 h 00 min – 3 h 15 min, n = 79) status. Genotype and allele frequencies were compared between athletes and controls using Chi-square analyses. One-way ANOVAs were implemented to identify any genotype-dependent differences in PB times for men and women, which were subject to correction for multiple comparisons. Results The X allele was ∼3% more frequent in the marathon runners than in non-athlete controls (see Table 1 and Figure 1), although this small difference did not approach statistical significance. There were no significant differences in genotype (χ2 = 3.40; P = 0.182) or allele (χ2 = 2.31; P = 0.128) frequency distributions between athletes (RR = 29.1%, RX = 50.6% XX = 20.2%; R = 54.4%, X = 45.6%) and controls. There were also no differences between elite and sub-elite genotype (P = 0.968, χ2 = 0.66) and allele frequencies (P = 0.916, χ2 = 0.11). Similarly, no differences in genotype or allele frequencies were found between either elite (P = 0.439, χ2 = 1.65; P = 0.265, χ2 = 1.24) or sub-elite (P = 0.254, χ2 = 2.74; P = 0.183, χ2 = 1.77) runners and the control group. Neither were PB times genotype-dependent for either men (P = 0.864) or women (P = 0.966). Abstract P-41 Table 1 ACTN3 R577X polymorphism count, genotype and allele frequencies in elite, sub-elite and control groups. Genotype count (%) Allele count (%) RR RX XX R X Elite (n = 216) 64 (29.6) 108 (50.0) 44 (20.4) 236 (54.6) 196 (45.4) Sub-elite (n = 268) 77 (28.7) 137 (51.1) 54 (20.1) 291 (54.3) 245 (45.7) Controls (n = 554) 191 (34.5) 258 (46.6) 105 (19.0) 640 (57.8) 468 (42.2) Abstract P-41 Figure 1 Genotype and allele frequencies of the ACTN3 R577X polymorphism in elite endurance athletes (n = 484) and controls (n = 554) Conclusion No differences in genotype and allele frequencies were observed between athletes and controls, elite vs sub-elite, nor elite and sub-elite comparisons with the control group. Additionally, there was no genotype-dependent influence on PB time, which further emphasises that the ACTN3 R577X polymorphism does not influence elite endurance athlete status or determine marathon performance in European Caucasian runners. This is congruent with some previous findings and suggests other genetic variants or environmental factors may play a more prominent role in achieving elite endurance athlete status.