Jim Peter's Collapse in the 1954 Vancouver Empire Games marathon

On 7 August 1954 the world 42km marathon record holder, Jim Peters, collapsed repeatedly during the final 385 metres of the British Empire and Commonwealth Games marathon held in Vancouver, Canada. It has been assumed that Peters’s collapsed from heatstroke because he ran too fast and did not drink during the race held in windless, cloudless conditions with a dry bulb temperature of 28°C. Review of his hospital records recently made available to the authors indicates that Peters may not have suffered from exertional heatstroke, which classically produces a rectal temperature of > 42°C, cerebral effects and a usually fatal outcome without vigorous active cooling. Thermal balance calculations also suggest that the environmental conditions were probably not sufficiently severe to induce heatstroke even at the high rate of energy expenditure sustained by Peters for 2 hours and 22 minutes. Although Peters was unconscious on admission to hospital approximately 60 minutes after he was removed from the race, his rectal temperature was 39.4°C and he recovered fully even though he was managed conservatively and was not actively cooled. We propose that Peters collapse was more likely due to the combination of hyperthermia-induced fatigue which caused him to stop running; the onset of exercise-associated postural hypotension as a result of a low peripheral vascular resistance immediately he stopped running; the combined cerebral effects of hyperthermia, hypertonic hypernatraemia associated with dehydration and perhaps an undiagnosed hypoglycaemia. But none of these conditions should have caused a prolonged period of unconsciousness, raising the possibility that Peters may have been suffering from a transient encephalopathy, the exact nature of which is not currently recognized

Circulation Study From Birth to 22 Years of Age Fetal, Infant, and Childhood Growth and Adult Blood Pressure: A Longitudinal Fetal, Infant, and Childhood Growth and Adult Blood Pressure A Longitudinal Study From Birth to 22 Years of Age

Background-People who are small at birth tend to have higher blood pressure in later life. However, it is not clear whether it is fetal growth restriction or the accelerated postnatal growth that often follows it that leads to higher blood pressure. Methods and Results-We studied blood pressure in 346 British men and women aged 22 years whose size had been measured at birth and for the first 10 years of life. Their childhood growth was characterized using a conditional method that, free from the effect of regression to the mean, estimated catch-up growth. People who had been small at birth but who gained weight rapidly during early childhood (1 to 5 years) had the highest adult blood pressures. Systolic pressure increased by 1.3 mm Hg (95% CI, 0.3 to 2.3) for every standard deviation score decrease in birth weight and, independently, increased by 1.6 mm Hg (95% CI, 0.6 to 2.7) for every standard deviation score increase in early childhood weight gain. Adjustment for adult body mass index attenuated the effect of early childhood weight gain but not of birth weight. Relationships were smaller for diastolic pressure. Weight gain in the first year of life did not influence adult blood pressure. Conclusions-Part of the risk of adult hypertension is set in fetal life. Accelerated weight gain in early childhood adds to this risk, which is partly mediated through the prediction of adult fatness. The primary prevention of hypertension may depend on strategies that promote fetal growth and reduce childhood obesity

Long-term radiological and histological outcomes following selective internal radiation therapy to liver metastases from breast cancer

Liver metastasis from breast cancer is associated with poor prognosis and is a major cause of early morbidity and mortality. When liver resection is not feasible, minimally invasive directed therapies are considered to attempt to prolong survival. Selective internal radiation therapy (SIRT) with yttrium-90 microspheres is a liver-directed therapy that can improve local control of liver metastases from colorectal cancer. We present a case of a patient with a ductal breast adenocarcinoma, who developed liver and bone metastasis despite extensive treatment with systemic chemotherapies. Following SIRT to the liver, after an initial response, the patient ultimately progressed in the liver after 7 months. Liver tumor histology obtained 20 months after the SIRT intervention demonstrated the presence of the resin microspheres in situ. This case report demonstrates the long-term control that may be achieved with SIRT to treat liver metastases from breast cancer that is refractory to previous chemotherapies, and the presence of microspheres in situ long-term. Keywords: Selective internal radiation therapy, SIRT, Transarterial radioembolization, Liver-directed therap

Cost Analysis and Outcomes of Endoscopic, Minimal Access and Open Pancreatic Necrosectomy

Objectives:. To assess both individual patient and institutional costs as well as outcomes in patients with pancreatic necrosis who underwent either endoscopic, minimal access or open pancreatic necrosectomy. These data can be used to evaluate clinical effectiveness with a view to informing local healthcare providers. Background:. Intervention for infected pancreatic necrosis is associated with a high morbidity, mortality, and long hospital stays. Minimal access surgical step-up approaches have been the gold standard of care; however, endoscopic approaches are now offered preferentially. Methods:. All patients undergoing endoscopic (EN), minimal access retroperitoneal (MARPN), and open (OPN) necrosectomy at a single institution from April 2015 to March 2017 were included. Patients were selected for intervention based on morphology and position of the necrosis and on clinical factors. Patient-level costing systems were used to determine inpatient and outpatient costs. Results:. Eighty-six patients were included: 38 underwent EN, 35 MARPN, and 13 OPN. Preoperative APACHEII was 6 versus 9 versus 9 (P = 0.017) and CRP 107 versus 204 versus 278 (P = 0.012), respectively. Postoperative stay was 19 days for EN versus 41 for MARPN versus 42 for OPN (P = 0.007). Complications occurred in 68.4%, 68.6%, and 46.2% (P = 0.298), whereas mortality was 10.5%, 22.9%, and 15.4% (P = 0.379), respectively. Mean total cost was £31,364 for EN, £52,770 for MARPN (P = 0.008), and £60,346 for OPN. Ward and critical care costs for EN were lower than for MARPN (ward: £9430 vs £14,033, P = 0.024; critical care: £5317 vs £16,648, P = 0.056). Conclusions:. EN was at least as safe and effective as MARPN and OPN and was associated with markedly reduced hospital stay and cost, although some markers of disease severity were higher in patients undergoing MARPN and OPN. These results support EN as the preferred approach to necrosectomy, but hybrid utilization of all available techniques remains integral to optimal outcomes

Organizational risk profiling and education associated with reduction in professional pitching arm injuries: a natural experiment

Background: Risk profiling and education are strategies implemented to help reduce injury risk; however, currently. there is little evidence on the effect of these interventions on injury incidence. The purpose of this study was to evaluate the influence of risk profiling and education on upper extremity injury incidence in minor league (MiLB) pitchers and to stratify by injury severity. Methods: A prospective natural experiment study was conducted from 2013 to 2019 on MiLB pitchers. Beginning in the 2015 season, pitchers were examined and risk profiled for upper extremity injury. Shoulder external, internal, total range of motion, horizontal adduction, and humeral torsion were measured. Organizational risk profiling and education was implemented starting in 2015, based on preseason assessments. Chi-squared test was performed to investigate potential differences between shoulder range of motion risk categories between 2013-2014 (pre) and 2015-2019 (post) seasons. Interrupted time series analyses were performed to assess the association between organizational risk profiling and education on arm injury in MiLB pitchers and were repeated for 7-27 and 28+ day injury severity. Results: 297 pitchers were included (pre: 119, post: 178). Upper extremity injury incidence was 1.5 injuries per 1000 athletic exposures. Pitchers in the 2015-2019 seasons demonstrated increased preseason shoulder injury risk for internal (P = .003) and external (P = .007), while the 2013-2014 seasons demonstrated greater horizontal adduction risk (P = .04). There were no differences between seasons for total range of motion risk (P =.76). Risk profiling and education resulted in an adjusted time loss upper extremity injury reduction for the 2015-2019 seasons (0.68 (95% CI: 0.47, 0.99)), which impacted 7-27 days (0.62 (95% CI: 0.42, 0.93)) but not for 28+ days (0.71 (95% CI: 0.47, 1.06)) time loss. There was no reduction in combined trunk and lower extremity injuries for the 2015-2019 seasons (1.55 (95% CI: 0.79, 3.01)). Conclusions: Organizational risk profiling and education appear to reduce professional pitching overall and 7-27-day upper extremity injury risk by 33%-38%. There was no difference in trunk and lower extremity injuries over the period, strengthening the reduction in upper extremity injury risk results. This suggests that while injury risk increased over time, organizational risk profiling mitigated the expected increase in upper extremity injury rates. Risk profiling and education can be used as a clinical screening and intervention tool to help decrease upper extremity injuries in professional baseball populations

Assistant Editors

should be addressed t

Assistant Editors

Don’t just do it, do it right: evidence for better health in low and middle income countries Evidence for better health outcomes involves a two-step process: getting the right sort of evidence and getting this evidence used [1]

London, UK

Continued overleaf Systemic lupus erythematosus and pregnancy – a challenge to the clinicia

Assistant Editors

Continued overleaf Management of pain in chronic pancreatitis. New solutions to an old problem Management of pain in chronic pancreatitis is a challenging clinical problem. Lack of proper understanding of the mechanisms responsible for pain, high morbidity and mortality rates historically associated with pancreatic surgery, and the long held view that pain will eventually subside when the pancreas "burns itself out " as a result of progressive fibrosis have all contributed to a non-surgical therapeutic approach for decades [1]. Many recent studies have challenged this view, and at present there is a shift from the "wait and see " approach to a more pro-active type of therapeutic approach in the management of pancreatic pain [2]. It is accepted that, at least in a majority of cases, the pain results from pressure increase within the pancreatic duct system from obstruction to the main pancreatic duct by stones or from post-inflammatory strictures [3]