Summit on Exercise Collapse Associated with Sickle Cell Trait: Finding the "Way Ahead"

Universal Training Precautions: A Review of Evidence and Recommendations for Prevention of Exercise-Related Injury, Illness, and Death in Warfighters and Athletes

Facing pressure to train for victory, warfighters and athletes encounter numerous health risks that are directly related to their regular physical training. The concept of universal training precautions (UTPs) signifies universal processes designed to prevent unnecessary bodily harm, including injury, illness, and death, during physical training programs. Although no formal guidelines exist for collectively implementing a defined set of UTPs to address a broad scope of exercise-related health risks, recommendations and guidelines have been published relating to preventing sudden death during high school sports and collegiate conditioning sessions. A long list of critical topics must be considered as UTPs, including physical fitness factors, transition-period accommodation, hydration, environmental factors and acclimatization, appropriate recovery, use of medications and dietary supplements, and importantly, leadership. In this article, we outline in detail, with corresponding Strength of Recommendation Taxonomy ratings, what should be considered universal recommendations to minimize the risk of warfighters and athletes coming to harm when participating in group physical activities.

Association of Sickle Cell Trait on Career and Operational Outcomes in the United States Air Force

INTRODUCTION

Sickle cell trait (SCT) is a heterozygotic state defined by having one normal hemoglobin gene and one sickle hemoglobin gene. Individuals with SCT are at increased risk for negative health outcomes during intense physical exertion, especially in hot climates and high-elevation locations, or when dehydrated. The U.S. Air Force mitigates this risk through universal screening after accession followed by education of SCT-positive airmen. Airmen who are SCT positive but remain asymptomatic are not restricted in occupation choice or deployment/duty locations based on their SCT status. Previous studies have analyzed the relationship between SCT and health and fitness outcomes. The objective of this study was to analyze the relationship between SCT and career and operational outcomes in a large cohort of airmen and secondarily to analyze the relationship between hemoglobin S (HgbS) percentage and these outcomes.

METHODS

This is a retrospective cohort study of all recruits who entered U.S. Air Force (USAF) Basic Military Training (BMT) between January 2009 and December 2013. The SCT status was assessed through a sickle solubility test. Hemoglobin electrophoresis permitted subgroup analysis of SCT-positive individuals by HgbS percentage. The following career and operational outcomes were assessed: BMT graduation; retention at 4 and 6 years; promotion to the rank of staff sergeant by 4 and 6 years; overseas deployment and number of deployments within 6 years; and high-elevation assignment and cumulative months at a high-elevation assignment within 6 years. Multivariable logistic regression was used to assess all binary outcomes, controlling for age, sex, and race, to produce adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Multivariable Poisson regression was used to assess cumulative count outcomes and to produce adjusted incidence rate ratios (aIRRs) with 95% CIs. Attrition from BMT by SCT status was also assessed as a hazards function using the Kaplan-Meier approach with Cox proportional hazards.

RESULTS

A total of 180,355 civilians entered USAF BMT during the 5-year surveillance period, of whom 169,837 graduated and had data available for analysis. Compared to their SCT-negative peers, SCT-positive airmen (n = 1,697) had 26% lower adjusted odds of promotion to staff sergeant within 4 years of BMT graduation (aOR = 0.74; 95% CI: 0.59-0.92) and served less time at a high-elevation assignment during their first 6 years (aIRR = 0.88; 95% CI: 0.85-0.91). The SCT status was not associated with statistically significant differences in BMT graduation, retention at 4 and 6 years, promotion to staff sergeant by 6 years, likelihood or number of overseas deployments, and likelihood of ever working at a high-elevation assignment. Retention at 4 and 6 years was inversely associated with HgbS percentage.

CONCLUSIONS

SCT-positive and SCT-negative airmen had similar career and operational outcomes, with two exceptions: SCT-positive airmen were less likely to be promoted to staff sergeant within 4 years, and they spent less time at a high-elevation location during their first 6 years of service. The underlying explanation of these findings should be explored with an aim to support SCT-positive airmen and to reduce potentially unwarranted discrepancies. Efforts should continue to reduce the stigma associated with SCT.

Athlete Preparticipation Physical Evaluation

Preparticipation evaluations (PPE) are both a traditional and legal requirement by many governing bodies for sport. The ideal goal of the PPE is safe participation in sport for athletes. This article provides an overview of common PPE elements and current best practice recommendations. Descriptions of every possible examination are published elsewhere and are beyond the intent of this article. Additional considerations for transgender, masters athletes, and Special Olympians are also outside the scope of this review, but are well covered in The Preparticipation Physical Evaluation, fifth edition monograph.