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Ruptured sinus of Valsalva (RSOV) upon physical exertion is rare but should be considered in differential in young adults. Symptoms of acute heart failure, hemodynamic instability, and continuous heart murmur raises suspicion for RSOV and requires emergent surgical repair of right ventricular outflow tract.

Axillary web syndrome (AWS) is characterized by the formation of cords in the axilla. Classically, it develops after surgical biopsy or removal of axillary lymph nodes for breast cancer. It can cause a limited range of motion and may contribute to abnormal shoulder movements or patterns that can cause pain. In this report, an atypical case of AWS presented in a 38-year-old male after physical activity but with no surgical history or breast cancer. This case report highlights that AWS can appear in healthy individuals with no history of breast cancer and/or surgical intervention. It also emphasizes the need to consider AWS in clinical practice as a differential diagnosis of painful shoulder movement and restricted range of motion.

Editor\'s note: This is the next installment in a series on electrocardiogram (ECG) interpretation. Nurses in all settings should know the basics, as medications and physiological changes can cause cardiac arrhythmias. Each article will start with a brief case scenario and an ECG strip and then take you step by step through analyzing the heart rhythm.

OBJECTIVE: Effects of intense and/or prolonged exercise have been studied extensively in male athletes. Nevertheless, data are scare on the effect of long duration events on cardiac function in female athletes. Our aim was to investigate the effect of a long-lasting moderate-intensity stage cycling event on cardiac function of young female athletes.
METHODS: Seven well-trained female cyclists were included. They completed a cycling event of 3529 km on 23 days. All underwent an echocardiography on 6 time-points (baseline and at the arrival of day (D) 3, 7, 12, 13 and 23). Cardiac function was assessed by conventional echocardiography, tissue Doppler imaging and speckle tracking techniques. Daily exercise load was determined by heart rate (HR), power output and rate of perceived exertion data (RPE, Borg scale).
RESULTS: All stages were mainly done at moderate intensity (average HR: 65% of maximal, average aerobic power output: 36% of maximal, average RPE: 4). Resting HR measured at the time of echocardiography did not vary during the event. Resting cardiac dimensions did not significantly change during the 23 days of cycling. No significant modification of cardiac function, whatever the studied cavity, were observed all along the event.
CONCLUSIONS: The results suggest that, in the context of our case study, the long-lasting moderate-intensity stage cycling event was not associated with cardiac function alteration. Nevertheless, we must be careful in interpreting them due to the limits of an underpowered study.

The aim of this study was two-fold: (i) analyze the weekly variations of well-being and training/match intensity measures in youth soccer players, and (ii) test relations between well-being and training intensity outcomes. The study followed a descriptive case study design. Twenty-seven under-17 male soccer players were monitored for well-being and training intensity parameters over seventeen consecutive weeks. An adjusted version of the Hooper questionnaire was used to monitor the perceptive sleep quality, readiness, fatigue, and delayed onset muscle soreness (DOMS) early in the morning. The CR-10 Borg’s scale was also used for monitoring the rate of perceived exertion (RPE) of players after training sessions. Repeated-measures analysis of variance was executed to test the between-week variations of both well-being and training intensity outcomes. Moreover, Pearson product moment correlation was used to test the relations between well-being and training intensity outcomes. Repeated measures ANOVA revealed significant differences between weeks in the sleep quality (F = 0.422; p < 0.001; ηp2 = 0.140), readiness (F = 0.8.734; p < 0.001; ηp2 = 0.251), fatigue (F = 4.484; p < 0.001; ηp2 = 0.147), DOMS (F = 3.775; p = 0.001; ηp2 = 0.127), RPE (F = 7.301; p < 0.001; ηp2 = 0.219), and session-RPE (F = 17.708; p < 0.001; ηp2 = 0.405). Correlations between well-being and training intensity outcomes in the same week revealed moderate correlations between fatigue and session-RPE (r = 0.325). As conclusions, it was found that well-being and training intensity fluctuates over the season, while well-being outcomes seems to be related with training intensity, although with a small magnitude.

OBJECTIVE: To evaluate how an exertional field-test impacts the Sport Concussion Assessment Tool 5 (SCAT5) subcomponents in uninjured athletes.
METHODS: Prospective case-series.
METHODS: Sports medicine setting.
METHODS: A total of 37 rugby and wrestling athletes (76% female) with a median age of 19 years (range: 18-23). Twenty-one (57%) had a history of concussion.
METHODS: The SCAT5 was administered prior-to and following a volitionally fatiguing, field-based 30-15 Intermittent Fitness Test. The primary outcome measures included: total symptom scores and severity, standardized assessment of concussion, neurological screening, and balance errors during the modified balance error scoring system. Wilcoxon signed-rank tests examined differences in ordinal data between pre- and post-exertion with Bonferroni corrections (alpha = 0.006). Data were also stratified into time to SCAT5 administration post-exertion and compared via Cliff\'s Delta (d).
RESULTS: The SCAT5 was administered a median of 20-min (interquartile range: 14-26-min) following exertion. No differences were found pre- and post-exertion across all SCAT5 metrics (p > 0.048). Within the post-exertion 0-10-min stratification, total symptoms and severity scores appeared to be elevated with a large effect size (d ≥ 0.64).
CONCLUSIONS: While SCAT5 metrics were not statistically altered when quantified a median of 20-min following high-intensity exertion; greater symptom reporting may occur 10-min following exertion.

UNASSIGNED: Athletes with sickle cell trait (SCT) have up to a 37-fold increased risk of exercise-related death. Exertional collapse associated with sickle cell trait (ECAST) is uncommon but can lead to exercise-related death due to exertional sickling. We present a case series of fatal ECAST in high school athletes aged 14 to 16 years. All 3 athletes experienced collapse during practice sessions with muscle pain or weakness. Upon evaluation at the hospital, the athletes had a significant metabolic acidosis that did not respond as expected to fluid resuscitation. Admitting diagnoses for the athletes included exertional heat stroke or dehydration. All 3 athletes had profound rhabdomyolysis leading to acute renal failure, worsening metabolic acidosis, and hyperkalemia. They rapidly progressed to disseminated intravascular coagulation, multiorgan system failure, and death. The autopsies of all 3 athletes showed extensive sickle cell vaso-occlusion involving the spleen liver, and muscles. Final clinical and pathologic diagnosis supported ECAST with fatal exertional rhabdomyolysis. Exertional collapse associated with sickle cell trait is an uncommon but potentially deadly condition that is often underrecognized or misdiagnosed as exertional heat stroke. The development of ECAST is thought to be multifactorial with exercise intensity, recent illness, and exercising conditions (ie, heat and altitude). Prevention should be the primary goal for athletes with SCT through exercise modification, education of precipitation factors, and cessation of exercise with recent illness. Athletes with suspected ECAST should undergo aggressive resuscitation with a low threshold for early transfer to a tertiary care facility for further management and potential hemodialysis.

Sudden death due to anomalous aortic origin of a coronary artery is far less common among young children in the absence of exercise stress. This report describes the case of a 2-year-old boy with a lower respiratory tract infection who suffered sudden cardiac arrest in his bed at home. The autopsy revealed that the left coronary artery (LCA) originated from the right sinus of Valsalva with an acute angle takeoff and traveled between the aorta and the pulmonary trunk (an interarterial course). Upon histological examination, the LCA, before reaching its major branches, was located adjacent to the outside of the aortic wall without an intramural passage, and the arterial wall was composed almost exclusively of elastic fibers without media containing smooth muscle cells throughout the entire length of the abnormal running. Screening tests for respiratory virus infection detected enterovirus in the lung tissue. In association with an acute angle takeoff and interarterial course, the wall structure with highly abundant elastic fibers that are more flexible tissues among blood vessel components might suggest their vulnerability to compression during the great vessels\' systolic expansion in the sympathetic activation induced by the viral infection, leading to fatal myocardial ischemia without physical exertion.

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