Preparticipation Screening Of Athletes Research Articles

583 ELEVATED BLOOD PRESSURE IN YOUNG ATHLETES IS ASSOCIATED WITH INCREASED LEFT VENTRICLE MASS AND REDUCED ARTERIAL COMPLIANCE

Objectives: Scarce data exists on elevated blood pressure (BP) and secondary effects in young athletes. Hence we wanted to study prevalence of hypertension (≥ 140/90 mmHg) (HT) and the association to arterial compliance (AC), left ventricle (LV) mass and left atrium endsystolic volume (LA ESV). Design and Methods: A Norwegian preparticipation cardiac screening of male professional football players in 2008 enrolled 493 white European players and 47 matched controls. ECG was recorded in the supine position ≥1 hour after exercise and BP was recorded seated as a mean of two measurements less than 30 minutes before echocardiography. Sokolow-Lyon (Sv1 + Rv5/Rv6) was computed from the ECG software. Height and weight were self-reported, body surface area (BSA) was calculated. LV mass, LA ESV and stroke volume (SV) were measured by echocardiography and indexed to BSA. Arterial compliance was calculated as SVBSA/PP. Results: The players mean age was 25 years (18-38) and BP 122/69 ± 11/8 mmHg. LV massBSA, LA ESVBSA and SVBSA were significantly higher in players versus controls, but there was no significant difference in prevalence of HT between them, 32 (7%) and 4 (9%) respectively. For the players there was a significant positive linear relationship between BP and Sokolow-Lyon, LV massBSA, LA ESVBSA and SVBSA, and negative to AC.Conclusions: The prevalence of HT was low. Still, this novel association to reduced arterial compliance, increased LV mass and LA size even in young athletes with elevated BP emphasizes the need for closer focus on BP measurements and standardized follow-up after preparticipation screening of athletes.

Significance of False Negative Electrocardiograms in Preparticipation Screening of Athletes for Hypertrophic Cardiomyopathy

Preparticipation screening of athletes with 12-lead electrocardiography has been promoted for the detection of asymptomatic cardiovascular disease, particularly hypertrophic cardiomyopathy (HC). Although false-positive electrocardiographic (ECG) results for HC are well recognized in athlete screening, expected false-negative rates are unknown. The aim of this study was to characterize the rate of false-negative ECG findings in a cohort of young asymptomatic patients with phenotypically expressed HC, defined by cardiovascular magnetic resonance, using the 2010 European Society of Cardiology recommended ECG criteria for the identification of suspected heart disease in trained athletes. Cardiac magnetic resonance studies and 12-lead electrocardiography were performed in 114 consecutive asymptomatic patients with HC aged ≤35 years (mean age 22 ± 8 years; 77% male patients). Electrocardiograms were analyzed to distinguish pathologic ECG patterns from alterations considered nonpathologic and physiologic consequences of athletic training. Among the 114 patients with HC, 103 (90%) demonstrated ≥1 pathologic ECG abnormality, while the remaining 11 patients (10%) had normal or nonpathologic ECG patterns and therefore defined a subgroup in whom ECG screening would not be expected to raise suspicion of heart disease (i.e., false-negative results). In this false-negative ECG results group, maximal left ventricular wall thickness was 17 ± 2 mm (range 15 to 21), compared to patients with pathologic ECG patterns, in whom maximal left ventricular wall thickness was 22 ± 5 mm (p = 0.003). In conclusion, a substantial minority of young asymptomatic patients with HC with phenotypically expressed left ventricular hypertrophy have nonpathologic ECG findings on the basis of the 2010 European Society of Cardiology guidelines. In principle, this high false-negative rate of 10% represents an important limitation in applying 12-lead electrocardiography to large, apparently healthy athletic populations for the detection of HC.

Accuracy of ECG-inclusive preparticipation screening in athletes: more work to be done

Accuracy of ECG-inclusive preparticipation screening in athletes: more work to be done

Pre Participation Screening in Athletes

Pre Participation Screening in Athletes

Trends in e-Health Monitoring Implementation in Sports

E-Health focusing on mobile telemonitoring, detection and management of unrecognized health abnormalities and disorders in physically active people is a major field of interest. Telemedicine services are most frequently requested in the area of: (a) pre-participation screening of athletes; (b) athletes monitoring mainly during extreme sports; and (c) home-exercise training telecare, especially for patients with chronic diseases who participate in rehabilitation programs.

Cardiovascular Risk and Clinical Factors in Athletes

Preparticipation screening in athletes is a very current but controversial theme. Part of this controversy is due to the cost benefit, especially when the screening is merely used as a prevention of sudden cardiac death caused by rare and hereditary diseases. The purpose of this study was to describe the prevalence of preexisting diseases, cardiovascular risk factor for cardiovascular diseases development, and hematological profile in a population of amateur and professional athletes. Data of 623 athletes (529 men and 94 women), aged 13-77 yr, were analyzed to detect preexisting diseases. The variables total cholesterol, LDL, HDL, triglycerides, fasting glucose, body mass index, hemoglobin, hematocrit, and ferritin were analyzed in two groups according to age, that is, younger and older 35 yr old, and their prevalence (%) and distribution in quartiles were presented. χ test and Pearson product-moment correlation coefficients between variables were applied, and P < 0.05 was adopted for significance. Hypertension was the most prevalent preexisting diseases, although the data showed low prevalence of cardiomyopathy. Cardiovascular risk factors were prevalent in both genders. There were positive correlations between cardiovascular risk factors and age and between body mass index and lipid levels in male athletes. Also, there was a high prevalence of low ferritin levels for women, with positive correlation between the levels of hemoglobin and ferritin. In the present study, hypertension was the most prevalent diagnosed disease, and cardiovascular risk factors showed important prevalence, especially in athletes older than 35 yr. Although physical training represents a cardioprotective factor to the onset of cardiovascular disease, it does not exclude the prevalence of risk factors and diseases in athletes.

Value Of Routine X-rays Of The Lumbar Spine In Orthopedic Preparticipation Screening

BACKGROUND: Considering orthopedic preparticipation screening in athletes of disciplines with high lumbar spine loads, it is unclear whether routinely performed x-rays of the lumbar spine are of additional value in detecting pathologies. Furthermore, it has to be discussed if findings lead to a limitation of eligibility for competitive sports or if medical follow-up examinations and specific training are required. PURPOSE: To analyze radiographic findings of either routinely performed or indicated x-rays of the lumbar spine during preparticipation examinations in young athletes with sport specific loads of the lumbar spine. METHODS: Radiographic findings of the lumbar spine in 325 children (12.2 ± 0.6 years; 173 boys, 152 girls) of an elite sport school were analyzed. Findings were categorized into: 0 = inconspicuous; 1 = findings without clinical relevance (e.g. side deviation, spina bifida occulta); 2 = findings requiring follow-up examinations, physical therapy or specific training (e.g. scoliosis, unilateral spondylolysis); and 3 = findings limiting sports eligibility (spondylolisthesis, spinal instability). Data were analyzed using the Chi Square test and the Fisher Exact test. RESULTS: X-rays were performed in 325 cases. In 21 athletes lumbar pain in history or clinical findings in examination led to additional radiographs. Radiographs were inconspicuous in 285 (88 %), without clinical relevance in 13 (4 %), needed to be controlled in 11 (3 %) and led to a limited sports eligibility in 16 (5 %) children. Findings in 9 of 21 (43 %) indicated and in 18 of 304 (6 %) routinely performed radiographs were classified into grades 2 and 3 (p<0.01). Spondylolisthesis or spinal instability were found in 2 indicated (11 %) and 14 routine x-rays (5 %; p>0.05). CONCLUSION: X-rays of the lumbar spine without any clinical indication have to be questioned in preparticipation screening of young athletes.

Mandatory Electrocardiographic Screening of Athletes to Reduce Their Risk for Sudden Death: Proven Fact or Wishful Thinking?

The purpose of this study was to determine if pre-participation screening of athletes with a strategy including resting and exercise electrocardiography (ECG) reduces their risk for sudden death. An increasing number of countries mandate pre-participation ECG screening of athletes for the prevention of sudden death. However, the evidence showing that such a strategy actually reduces the risk of sudden death in athletes is limited. We therefore analyzed the impact of the National Sport Law enacted in Israel in 1997-which mandates screening of all athletes with resting ECG and exercise testing-on the incidence of sudden death among competitive athletes. We conducted a systematic search of the 2 main newspapers in Israel to determine the yearly number of cardiac arrest events among competitive athletes. The size of the population at risk was retrieved from the Israel Sport Authority and was extrapolated to the changes in population size over time. There were 24 documented events of sudden death or cardiac arrest events among competitive athletes during the years 1985 through 2009. Eleven occurred before the 1997 legislation and 13 occurred after it. The average yearly incidence of sudden death or cardiac arrest events was 2.6 events per 100,000 athlete-years. The respective averaged yearly incidence during the decade before and the decade after the 1997 legislation was 2.54 and 2.66 events per 100,000 person years, respectively (p = 0.88). The incidence of sudden death of athletes in our study is within the range reported by others. However, mandatory ECG screening of athletes had no apparent effect on their risk for cardiac arrest.

Is There Evidence for Mandating Electrocardiogram as Part of the Pre-Participation Examination?

The risk of sudden cardiac death may be increased up to 2.8 times in competitive athletes compared with nonathletes. The majority of sudden cardiac death cases are caused by an underlying abnormality that potentially may be identified on cardiovascular screening, depending on the specific abnormality and the content of the cardiovascular screening applied. Indeed, today, cardiac screening is universally recommended by the cardiac societies [European Society of Cardiology (ESC) and American Heart Association (AHA)] and required by the sporting bodies [Fédération Internationale de Football Association (FIFA) and Union of European Football Associations (UEFA)]. Pre-participation examination is by consensus understood to include personal history and physical examination; controversy exists regarding the usefulness and appropriateness of screening using resting 12-lead electrocardiogram (ECG), with an apparent transatlantic difference. The ESC recommends screening consisting of personal history, physical examination, and 12-lead resting ECG, whereas recommendations from the AHA includes only personal history and physical examination. There is firm scientific ground to state that the sensitivity of screening with ECG is vastly superior to, and the cost-effectiveness significantly better than, screening without ECG. Cardiac screening of elite athletes with personal history, physical examination, and ECG is cost-effective also in comparison with other well-accepted procedures of modern health care, such as dialysis and implantable cardiac defibrillators. Newly published recommendations for the interpretation of the ECG in athletes (ESC) and future studies on ECGs in athletes of different ethnicity, gender, and age may further increase the specificity of ECG in cardiac screening, refining the screening procedure and lowering the costs for additional follow-up testing. Cardiac screening without ECG is not cost-effective and may be only marginally better than no screening at all and at a considerable higher cost. The difficulties in feasibility and liability issues for recommending ECGs in some countries need to be acknowledged but must be dealt with within those countries/systems. On ethical grounds, the reasons (logistical, legal, economic) for not screening individual athletes should be clearly stated. Alas, the current evidence, as presented here, suggests that the ECG should be mandatory in pre-participation screening of athletes.

Incidence and etiology of sports-related sudden cardiac death in Denmark—Implications for preparticipation screening

Studies on incidences of sports-related sudden cardiac death (SrSCD) are few and data are needed for the discussion of preparticipation screening for cardiac disease. We sought to chart the incidence and etiology of SrSCD in the young in Denmark (population 5.4 million) and to compare this to the incidence of sudden cardiac death (SCD) in the background population. All 5,662 death certificates for decedents in the period 2000 to 2006 in the age group 12 to 35 years in Denmark were read independently by 2 physicians to identify cases of SCD. Information from autopsy reports, selected hospital records, and multiple registries was used to identify cases of SCD and SrSCD. SrSCD was defined as SCD occurring during or within 1 hour after exercise in a competitive athlete. The size of the athlete population was estimated from national survey data. Fifteen (range 0 to 5 per year) cases of SrSCD were found, 8 of which had antecedent symptoms. The incidence rate was 1.21 (95% confidence interval [CI]: 0.68 to 2.00) per 100,000 athlete person-years. The most common autopsy findings were arrhythmogenic right ventricular cardiomyopathy (n = 4), sudden unexplained death (n = 4), and coronary artery disease (n = 2). The incidence of SCD in the general population age 12 to 35 was 3.76 (95% CI: 3.42 to 4.14) per 100,000 person-years. In Denmark, SrSCD is a rare occurrence and the incidence rate is lower than that of SCD in the general population. This may imply a low value of preparticipation screening of athletes in Denmark.

Subclinical hyperthyroidism and sport eligibility: An exploratory study on cardiovascular pre-participation screening in subjects treated with levothyroxine for multinodular goiter

Subclinical hyperthyroidism (sHT) affects cardiovascular (CV) morphology and function; whether such changes can impact on sport eligibility is unclear. This exploratory study evaluated the CV system and sport eligibility in athletes with levothyroxine-induced sHT, in the setting of mandatory pre-participation screening. A full, non-invasive CV screening (history and physical examination, 12-lead ECG, echocardiography, 24-hour Holter ECG, exercise stress test) was performed in two groups of untrained female athletes affected by non-toxic multinodular goiter. One group was taking levothyroxine at mildly suppressive doses (TG) whereas the other was untreated (UG). There was also a group of healthy controls (HC). In TG the following characteristics were observed: a) a higher resting heart rate (HR; p<0.01 and p<0.05, vs HC and UG respectively), b) a thicker left ventricular posterior wall (p<0.05 vs HC, and p<0.05 vs HC and UG, respectively), c) a higher mean HR during the 24-hour Holter ECG (p<0.01 and p<0.05, vs HC and UG respectively), and d) a lower achieved maximum work load (p<0.05, vs HC). No differences in the prevalence of cardiac arrhythmias among groups were observed. Sport eligibility was granted to all except one subject in the TG. Although some alterations were found in athletes with levothyroxine-induced mild sHT, these are probably of limited clinical relevance and they did not contraindicate sport participation in the majority of cases. Future research to address both health risks and the need for specific evaluations (e.g. free thyroxine, TSH, echocardiography) during the preparticipation screening of athletes with sHT is warranted.

Hypertrophic cardiomyopathy as a cause of sudden death

Hypertrophic cardiomyopathy (HCM) is the main cause of sudden unexpected death in the young and especially in young athletes with an incidence up to 2.3 per 100,000 athletes and year. Risk stratification models including patient history (syncope, familial risk of sudden death) and findings in noninvasive tests (nonsustained ventricular tachycardia, abnormal blood pressure response during exercise, maximum left ventricular wall thickness > or = 30 mm) have been developed in order to estimate the risk of individual patients. Echocardiographic parameters are helpful in distinguishing HCM from athlete's heart. Definitive diagnosis of HCM implicates disqualification from competitive sports resulting in a significant reduction of sudden cardiac death due to HCM during sports competition. This positive development should lead to a widespread preparticipation screening of athletes including historical, clinical, and electrocardiographic examination. At least in borderline findings and symptomatic athletes, an additional echocardiogram should be performed in order to minimize or better exclude the risk of sudden cardiac death.

Preparticipation Screening of Competitive Athletes

Sports used to be simple. The major decision my friends and I faced as youngsters was who would get to be Y.A. Tittle of the New York Giants in our Sunday afternoon football pickup games. The preparticipation screening of athletes also used to be simple and generally consisted of a medical form completed by a parent and a cursory physical examination performed in the gym by a general physician. Now, recreation for many young Americans requires formal play dates, and there are T-ball leagues for those too young to hit an unsupported baseball. The preparticipation screening of athletes also has become more formalized and is, in some countries, a legally regulated activity.1 The goal of both increased athletic supervision and formalized preparticipation screening is to protect young athletes from the risks inherent in athletic participation, but how best to accomplish this goal is now in hot debate. Article p 1085 Screening athletes has received increased attention because the issue of sudden cardiac death (SCD) in athletes and during exercise has become a prominent health issue. Public interest in these events probably arises from both the importance of sport in many societies and the paradox that physical activity can have both a positive and negative impact on an individual’s health.2 It is clear that vigorous exertion transiently increases the risk of SCD in individuals with established cardiovascular disease.2 Atherosclerotic coronary artery disease is the primary pathological finding in individuals >40 years of age who die during physical activity, whereas inherited cardiovascular conditions are primarily responsible for such events in younger athletes.2 Hypertrophic cardiomyopathy (HCM), an entity described shortly before Tittle played for the Giants,3 accounts for most (36% to 44%) of these deaths in American athletes, with other abnormalities, including anomalous coronary arteries (17%), myocarditis (6%), …

Sarcomere Mutations in Cardiomyopathy, Noncompaction, and the Developing Heart

In this issue of Circulation , Klaassen and colleagues1 describe mutations in the genes encoding myosin heavy chain (MHC), cardiac actin, and troponin T in patients with left ventricular noncompaction (LVNC). LVNC, defined as excessive and unusual trabeculation of the mature left ventricle, is thought to reflect a developmental failure of the heart to form fully the compact myocardium during the later stages of cardiac development. Previously, mutations in sarcomeric genes have been linked extensively to the development of hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM). The finding of similar, but not identical, mutations in patients with LVNC suggests a continuum of cardiomyopathy that includes LVNC and further supports the essential role for normal sarcomere function during cardiac development. Article p 2893 Noncompaction of the ventricular myocardium is characterized by a spongy morphological appearance of the myocardium occurring primarily in the left ventricle and most evident in the apical portion.2 Noncompaction often is visualized as deep recesses within the thickened apex, and these sinusoids communicate with the ventricular cavity. During heart development, the myocardium is initially trabeculated during a period before coronary artery development and is thought to be an adaptation to provide blood flow to the developing myocardium. The development of the coronary vasculature is associated temporally with the loss of trabeculae and the full maturation of the compact myocardium. Between embryonic weeks 5 and 8, the trabeculae regress as the compact myocardium develops from base to apex. Isolated LVNC is defined as occurring in the absence of other cardiac structural malformation. Nonsyndromic LVNC refers to the absence of other extracardiac developmental disorders. In 2006, the American Heart Association scientific statement on classification of cardiomyopathies reclassified LVNC as its own disease entity.3 Klaassen et al now link genetic sarcomere defects to both familial and sporadic isolated, …

Electrocardiograms Should Be Included in Preparticipation Screening of Athletes

Among the adolescent and young adult population, the absolute risk of sudden cardiac arrest (SCA) is low, whereas the benefits of identifying predisposing conditions and preventing SCA are disproportionately large.1,2 Competitive athletes included within this population subgroup are at higher risk of SCA than expected for the general population in this age category.3–5 Recently, there has been considerable debate in the United States about the appropriate strategies, effectiveness, and logistics of various preparticipation screening techniques for identifying individuals at risk. Despite the recommendations of the European Society of Cardiology (ESC)6 and the International Olympic Committee (IOC)7 that an ECG be added to the preparticipation screening process, the American Heart Association (AHA) has recently reaffirmed its long-held position on preparticipation screening for cardiovascular abnormalities in competitive athletes.8 The AHA suggests that ECG screening is not warranted as a component of preparticipation evaluations unless specific observations in the history or physical examination exist that trigger a more extensive cardiovascular evaluation.8 This position is retained despite various sources of data supporting an incremental benefit attributable to routine ECG screening.9 General agreement exists on preparticipation screening guidelines that include an appropriate personal medical and family history and physical examination, but the inclusion of additional elements such as an ECG is in dispute. The purpose of this article is to respond to the AHA recommendation and to provide a reasoned alternative approach. Response by Chaitman p 2626 SCA leads to unexpected death and affects all segments of society. It is a large public health problem, accounting for at least 50% of all cardiovascular deaths and a higher proportion in selected segments of society . 10 From the perspectives of clinical and epidemiological impact, SCA did not receive the attention it deserved until recent years, with recognition notably absent …

Transtelephonic Electrocardiographic Transmission in the Preparticipation Screening of Athletes

Transtelephonic electrocardiographic transmission (TET) is the most widespread form of telecardiology since it enables clinicians to assess patients at a distance. The purpose of this study was to assess the efficacy and effectiveness of TET either by fixed telephone line (POTS) or by mobile phone in the preparticipation screening of young athletes. A total of 506 players, aged 20.5 ± 6.2 years, from 23 soccer clubs in the prefecture of Thessaloniki, Greece, were physically examined in their playfields by a general practitioner (GP) and had their ECG recorded. In 142 cases, and on the judgment of the GP, the ECG was transmitted via POTS and/or global system for mobile communications (GSM) to a specialised medical centre where it was evaluated by a cardiologist. The mean total time for recording, storing, and transmitting the ECG was four minutes per subject. It was found that the success rate for transmission at first attempt was similar for both fixed and mobile networks, that is, 93% and 91%, respectively. The failure rate in the GSM network was correlated to the reception level at the site of transmission. Only in about half (n = 74) of the transmitted ECGs did the cardiologist confirm “abnormal” findings, although in 16, they were considered to be clinically insignificant. Consequently, 58 athletes were referred for further medical examination. Our results indicate that TET (either by fixed telephone line or by mobile phone) can ensure valid, reliable, and objective measurements, and significantly contribute to the application of medical screening in a great number of athletes. Therefore, it is recommended as an alternative diagnostic tool for the preparticipation screening of athletes living in remote areas.

Gray zone problem in athletes

Sudden death is the most unpleasant complication of hypertrophic cardiomyopathy (HCM), which is the leading cause of cardiac death in athletes. The accurate diagnosis of HCM is a more important problem than its risk stratification profile.1,2 An early and correct diagnosis of HCM, particularly in asymptomatic subjects, is crucial during pre-participation screening in athletes. However, detection of an increased risk group remains to be a major problem with many aspects, including medical, social, ethical, financial, and legal.3 The law allows the medical profession to establish the appropriate nature and scope of pre-participation screening of athletes, based on its collective …

Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athletes: 2007 Update

Sudden deaths of young competitive athletes are tragic events that continue to have a considerable impact on the lay and medical communities.1–17 These deaths are usually due to a variety of unsuspected cardiovascular diseases and have been reported with increasing frequency in both the United States and Europe.1,5 Such deaths often assume a high public profile because of the youth of the victims and the generally held perception that trained athletes constitute the healthiest segment of society, with the deaths of well-known elite athletes often exaggerating this visibility. These counterintuitive events strike to the core of our sensibilities, periodically galvanizing discussion and action, and in the process raise practical and ethical issues related to detection of the responsible cardiovascular conditions. Preparticipation cardiovascular screening is the systematic practice of medically evaluating large, general populations of athletes before participation in sports for the purpose of identifying (or raising suspicion of) abnormalities that could provoke disease progression or sudden death.13,16 Indeed, identification of the relevant diseases may well prevent some instances of sudden death after temporary or permanent withdrawal from sports or targeted treatment interventions.15,17–21 In addition, the increasing awareness that automated external defibrillators (AEDs) may not always prove successful in the secondary prevention of sudden death for athletes with cardiovascular disease22 underscores the importance of preparticipation screening for the prospective identification of at-risk athletes and the prophylactic prevention of cardiac events during sports by selective disqualification. Although some critics have questioned the effectiveness of cardiovascular screening,23,24 overwhelming support for the principle of this public health initiative exists in both the medical and lay communities.13–16,25 The efficacy of the various athlete screening strategies is not easily resolved in the context of evidence-based investigative medicine. Recently, recommendations of the European Society of Cardiology (ESC)16 and International …

A preparticipation screening program can decrease the incidence of sudden cardiac death among young athletes

A preparticipation screening program can decrease the incidence of sudden cardiac death among young athletes

Changing for the Better

One of my uncles maintained a perpetual pot of soup to which he would add some new foods each day, constantly creating a fresh taste from the same batch of soup. Although the analogy cannot be stretched too far, in a sense Pediatrics in Review (PIR) is like that marvelous soup in that the journal, while maintaining its basic character, evolves over time to meet the needs of our readers and our ultimate consumers, children around the world.The basic “stock” in our soup pot is the body of content specifications of the American Board of Pediatrics (ABP), which provides a core of knowledge objectives encompassing the fundamentals of today’s pediatric medicine. Using this material to guide us, and teaming with the PREP Self-Assessment, we are able to meet our major objectives of keeping readers current in pediatric knowledge and preparing them for the cognitive portion of the ABP’s Maintenance of Certification program. The PREP Curriculum is a learning system that covers the spectrum of pediatric medicine every 5 years.The meat and potatoes are the review articles and shorter “In Brief” pieces, augmented by the different flavors of “Index of Suspicion,” “Back to Basics,” “Visual Diagnosis,” and other special sections.Some newer ingredients have been added. In 2006, we expanded our capability by offering some articles in an online-only format. This additional publishing space has allowed presentation of important and interesting topics outside of the core content, such as assessing the potential for violence in adolescents, a practical approach to quality improvement in the office, and telemedicine. The telemedicine article also demonstrated the capability of online articles for providing striking audiovisual enhancement of the text.Another new flavor in 2006 was a section that informs readers of therapies outside of the mainstream that may be affecting their patients. Our colleagues at the University of Alberta have created this series in conjunction with the Provisional Section on Complementary, Holistic, and Integrative Medicine of the American Academy of Pediatrics (AAP). Topics already covered include probiotics, Echinacea, peppermint oil, and garlic.Beginning with this issue, we highlight successful programs for children resulting from outreach of pediatric residents into the community. In collaboration with the Community Pediatric Training Initiative of the AAP and with support from the Anne E. Dyson Foundation, this series may inspire others to further the cause of community pediatrics. Our first report features a unique program that uses bicycles to make children more active physically while teaching them skills and self-reliance.PIR’s link with residents continues, as they write the “Focus on Diagnosis” articles and submit many of our “Index of Suspicion” cases, including the case that results from their annual case-writing contest. A grant from Ross allows distribution of PIR to all residents in the United States.Our international perspective is maintained by contributions from authors in many countries and through our international editions. We published a commentary by an Italian pediatrician on Italy’s intensive program of preparticipation screening of athletes (November 2006), and we are exploring other such observations by our colleagues worldwide.I would like to extend my thanks to the many individuals who have made this PIR soup so nourishing and tasty, including our Associate Editors Drs Tina Cheng and Joseph Zenel; section editors Drs Henry Adam, Janet Serwint, and Laura Ibsen; editorial board members; editorial assistant Sydney Sutherland; Luann Zanzola and Kerry O’Rourke at the AAP; Medical Copy Editor Deborah Kuhlman; the people at Cadmus and Highwire publishers; and our Consulting and Founding Editor Robert J. Haggerty.