Adverse Effects of Anabolic-Androgenic Steroids: A Literature Review

The Spectrum of Minimal Change Disease/Focal Segmental Glomerulosclerosis: From Pathogenesis to Proteomic Biomarker Research

Podocyte injury plays a central role in both focal segmental glomerulosclerosis (FSGS) and minimal change disease (MCD). Pathogenic mechanisms are diverse and incompletely understood, partially overlap between FSGS and MCD, and are not reflected by kidney biopsy. In order to optimize the current variable response to treatment, personalized management should rely on pathogenesis. One promising approach involves identifying biomarkers associated with specific pathogenic pathways. With the advancement of technology, proteomic studies could be a valuable tool to improve knowledge in this area and define valid biomarkers, as they have in other areas of glomerular disease. This work attempts to cover and discuss the main mechanisms of podocyte injury, followed by a review of the recent literature on proteomic biomarker studies in podocytopathies. Most of these studies have been conducted on biofluids, while tissue proteomic studies applied to podocytopathies remain limited. While we recognize the importance of non-invasive biofluid biomarkers, we propose a sequential approach for their development: tissue proteomics could first identify proteins with increased expression that may reflect underlying disease mechanisms; subsequently, the validation of these proteins in urine or plasma could pave the way to a diagnostic and prognostic biomarker-based approach.

Unraveling binding interactions between methasterone and bovine serum albumin (BSA): A spectroscopic and computational study

In this study, binding interactions between methasterone and bovine serum albumin (BSA) were analyzed using spectroscopic techniques and molecular docking. UV absorption spectroscopy showed the formation of a ground-state complex between methasterone and bovine serum albumin (BSA). Thermodynamic parameters from fluorometric analysis indicated that the hydrogen bonding and van der Waal forces were the main interacting forces between the complex and the reaction was found to be spontaneous. Molecular docking further validated it. Nano differential scanning fluorimetry showed the protein was found to be more thermally stable in the presence of methasterone. Circular dichroism spectroscopy revealed slight reduction in the helicity after binding with methasterone suggesting conformational changes to promote binding. As no prior information exists on the binding interactions between methasterone and BSA, this study provides insights into methasterone-BSA interactions, which can serve as a foundation for future investigations into its pharmacological properties.

Adverse Effects of Anabolic Androgenic Steroid Abuse in Athletes and Physically Active Individuals: A Systematic Review and Meta-Analysis

BACKGROUND

Anabolic-androgenic steroids (AAS) are synthetic derivatives of testosterone, primarily used for their anabolic effects in increasing muscle mass. However, AAS have been increasingly abused, posing significant health risks due to their severe effects.

OBJECTIVES

This study aimed to quantify the adverse effects of AAS abuse across a diverse population of various ages. The effects were categorized across cardiovascular, hepatic, endocrine, musculoskeletal, and psychiatric domains.

METHODS

A comprehensive search was conducted across multiple databases following PRISMA guidelines. Study quality was assessed using a modified QUADAS-2 tool, and meta-analyses were performed.

RESULTS

Meta-analysis revealed significant adverse outcomes. AAS use was linked to an increase in systolic blood pressure (BP) by a pooled mean difference (MD) of 12.43 mmHg (95% CI: 9.59 to 15.26) and diastolic BP by 8.09 mmHg (95% CI: 5.62 to 10.57). There was also a significant rise in LDL-C levels, with an MD of 9.12 mg/dL (95% CI: 6.75 to 11.49), indicating heightened cardiovascular risk. Hepatic effects were marked by elevated levels of AST and ALT, with MD of 14.47 U/L (95% CI: 12.41 to 16.52) and 12.16 U/L (95% CI: 3.28 to 21.04), respectively, suggesting significant liver stress or damage. Endocrine disruptions were profound, with a substantial reduction in testosterone levels observed, showing an MD of -141.57 ng/dL (95% CI: -160.42 to -122.72).

CONCLUSIONS

Raising awareness among athletes and physically active people using AAS is crucial. Future research should focus on elucidating the long-term effects of AAS and developing strategies to mitigate the associated risks.

Multiplex Nontargeted Framework Enables Tracking Metabolic Profile of Oxymetholone and Methasterone In Vivo at Nanogram Level by GC-Orbitrap-HRMS for Antidoping Purpose

Oxymetholone and methasterone are anabolic androgenic steroids prohibited by the World Anti-Doping Agency (WADA) for both in-competition and out-of-competition use. Detecting metabolites of exogenous steroids is crucial for establishing doping violations, making the study of these metabolites essential in antidoping efforts. This study investigated the urinary metabolic profiles of oxymetholone and methasterone using gas chromatography-orbitrap high-resolution mass spectrometry (GC-Orbitrap-HRMS) in nanogram level by utilizing a novel multiplex nontargeted framework protocol. Healthy volunteers each ingested one tablet of the drug, and urine samples were collected over 50 days in postadministration phase. The complete detection of the three fractions (free fraction, glucuronide fraction, and sulfate fraction) of the metabolites was carried out. The GC-Orbitrap-HRMS full-scan mode was employed to detect postadministration urine samples, comparing these with preadministration baseline urine samples to identify newly formed substances. Electron ionization (EI) mass spectra were used to infer possible metabolite structures, leading to the discovery of three novel metabolites of oxymetholone and two novel metabolites of methasterone. Notably, the newly identified oxymetholone metabolite, 2-methylene-17α-methyl-androstane-16ξ,17β-diol-3-one (O-M6), was detectable as a glucuronide conjugate up to 4 days after administration. The methasterone metabolite, 18-nor-17β-hydroxymethyl-2α,17α-dimethyl-5α-androst-13-en-3-one (M-M4), exhibited prolonged detectability as a glucuronide conjugate, being present in urine samples from both volunteers up to 50 days after administration. These findings have significant implications for antidoping purpose, providing extended detection windows for these anabolic steroids.

Feasibility of implementing current best clinical practice for people who are using anabolic androgenic steroids within a Swiss primary care practice: a quality assurance study

BACKGROUND

The non-medical use of anabolic androgenic steroids for the improvement of aesthetic and sports performance purposes has become a global substance use disorder, particularly among men in recreational sports. Health outcomes among people who are using anabolic androgenic steroids may be detrimental, yet healthcare services for these users are scarce. Therefore, the aim of this project was to conduct a quality assurance study to evaluate the feasibility of providing current best clinical practice for anabolic androgenic steroids users based on the published literature within a primary care practice in Zurich (Switzerland).

METHODS

A primary healthcare practice for current or past anabolic androgenic steroids use was established at the Arud Centre for Addiction Medicine in Zurich providing specialised medical care for this population. The reporting and methodology to evaluate feasibility of this quality assurance study follow a checklist for pilot studies. The primary feasibility outcomes for this study were satisfaction with the services received (customer satisfaction score), as well as loyalty towards the services (net promoter score). These customer metrics have been used successfully in the medical field to measure patient experiences, as well as infer future word-of-mouth advertisement (i.e. return and refer). Furthermore, the objective was to describe patient characteristics and substance use behaviours in a Swiss context. Patients could access these services in Zurich from 1 June 2023 onwards. The recruitment strategy was word-of-mouth advertising among anabolic androgenic steroids users and paper advertisement (i.e. flyers) about the healthcare service. Eligibility criteria were based on legal restrictions regarding doping laws and professional ethical principles of medicine. In an initial visit at the practice, a focused patient history was assessed, and patients received a physical, psychometric, instrumental as well as laboratory examination. Datasets are summarised using descriptive statistics.

RESULTS

Overall, 34 eligible patients were seen over the period from June until December 2023. Excellent results regarding loyalty towards the service (net promoter score: 100; integer) as well as patient satisfaction with the received services (customer satisfaction score: 100%) were achieved. Patients were commonly young professional males (mean: 38.5 years, standard deviation: 8 years), with educational level beyond compulsory schooling. The main motivation for using anabolic androgenic steroids was aesthetic purposes. Acquisition of these substances occurred mostly through non-medical sources. Patterns of anabolic androgenic steroids use were complex with extensive polypharmacy and concomitant illicit substance use. Most patients suffered from side effects with multiple physical as well as mental health complications. Many abnormal findings were found regarding the physical as well as laboratory and instrumental examination, although mostly mild and transient, some possibly severe regarding health outcomes.

CONCLUSION

With this first quality assurance study, we demonstrate that integration of current best clinical practice for anabolic androgenic steroids users in recreational sports appears to be feasible with high acceptance in a Swiss primary care practice. Furthermore, those patients may engage in high-risk behaviours and a high prevalence of comorbid medical conditions was demonstrated. Anabolic androgenic steroids users likely benefit from integrated medical care provided and coordinated in a primary health care setting. On the basis of the initial study results, these services were continued at a larger scale to further assess as well as mitigate health risks among this user population. Importantly, current doping legislation was demonstrated to be a major limitation to provision of adequate medical care for this user population, thus changes in legislation are crucial to avert this growing public health threat.

Possible consequences of the abuse of anabolic steroids on different organs of athletes

Objective: Androgenic steroids abuse among young athletes has long-term health consequences, causing profound damage to vital organs such as the heart, blood vessels, brain, liver, gonads, kidneys, and skin.

Results: In the vessels, steroids cause plaque formation, vascular calcification, thrombosis, and coronary artery disease, and in the heart, they lead to pathological fibrosis, dilated cardiomyopathy, heart failure, fatal ventricular arrhythmias, acute myocardial infarction, and reduced ejection fraction. The brain also suffers from cognitive decline, memory impairment, and a constellation of neurotransmitter abnormalities that lead to depression. In the liver, the consequences are severe and manifest as increased oxidative stress, liver dysfunction, hepatotoxicity, cholestatic jaundice, liver tumours, cell death, and elevations in liver enzymes, bilirubin, and cholesterol. Male athletes experience testicular atrophy, temporary suppression of spermatogenesis, hypogonadism, reduced fertility, infertility, and hormonal imbalance. In contrast, women experience ovarian dysfunction and menstrual irregularities. In the kidney, steroids lead to increased inflammatory cytokines, fibrosis, renal tubular hypertrophy, glomerular changes, and structural damage, and show higher levels of serum creatinine, urinary protein, and cystatin C. In athletes, steroids can lead to various skin problems such as acne, gynecomastia, prostatitis, and alopecia.

Anabolic-androgen steroids: A possible independent risk factor to Cardiovascular, Kidney and Metabolic Syndrome

Millions of individuals make illicit use of anabolic-androgenic steroids (AAS), remaining a public health issue. It often leads to detrimental effects, including cardiovascular and renal diseases, besides hormonal and metabolic imbalances. The objective of this review is to emphasize the contribution of oxidative stress and inflammation to these effects and connect the findings of experimental animal studies with the alterations found in clinical contexts, in AAS users. The study's results showed that AAS promotes a redox disruption and a pro-inflammatory state on organs that are involved in important physiologic processes. These drugs increase inflammatory high-sensitivity C-reactive protein (hs-CRP) and cytokines that contribute to the progression of atherosclerosis, cardiovascular disease risk or endpoints, including stroke, myocardial infarction and death. In the kidney, the AAS increase proteinuria and structural damage. Studies have linked AAS abuse with high BP, low HDL-C levels, high triglyceride levels and impaired fasting blood glucose that characterize Metabolic syndrome. Overall, the studies indicate that oxidative stress, apoptosis, and AAS-mediated inflammation play a significant role in tissue damage, regardless of the dose and duration of exposure, and we point it as a putative independent risk factor to Cardiovascular, Kidney and Metabolic syndrome.

Excessive androgen exposure and risk of malignancies: A cohort study

BACKGROUND

A link between androgen use and the risk of cancers, especially prostate and breast cancer, has been suggested. The knowledge about a possible association is limited.

OBJECTIVE

The study aimed to investigate cancer incidence rates, particularly those related to prostate and breast cancer, in male androgen users and compare them to a control group.

METHODS

We included male androgen users identified through a nationwide anti-doping testing program in Danish fitness centers from 2006 to 2018. We paired each case with 50 male controls of the same age, selected randomly. The cohort was followed from baseline and until 2023. The outcome was the incidence of prostate cancer, breast cancer, or any cancer excluding non-melanoma skin cancer.

RESULTS

The study included 1,189 androgen users and 59,450 controls, with a mean age of 27 years at enrolment. During the follow-up period with a mean length of 11 years, 13 androgen users, and 612 controls were diagnosed with cancer. This resulted in an incidence rate ratio of 1.05 (95% CI: 0.55-1.81). None of the androgen users were diagnosed with prostate or breast cancer.

DISCUSSION AND CONCLUSION

Male androgen users did not face an increased short-term risk of cancer, neither overall nor related to prostate or breast cancer. Our study indicates that the absolute risk of malignancies in androgen users is comparable to that in the background population. However, we cannot exclude androgens as a cancer risk factor due to the limited sample size, relatively short follow-up period, and subject age.

Clinician's guide to the management of azoospermia induced by exogenous testosterone or anabolic-androgenic steroids

ABSTRACT

Azoospermia, defined as the absence of sperm in the ejaculate, is a well-documented consequence of exogenous testosterone (ET) and anabolic-androgenic steroid (AAS) use. These agents suppress the hypothalamic-pituitary-gonadal (HPG) axis, leading to reduced intratesticular testosterone levels and impaired spermatogenesis. This review examines the pathophysiological mechanisms underlying azoospermia and outlines therapeutic strategies for recovery. Azoospermia is categorized into pretesticular, testicular, and post-testicular types, with a focus on personalized treatment approaches based on the degree of HPG axis suppression and baseline testicular function. Key strategies include discontinuing ET and monitoring for spontaneous recovery, particularly in patients with shorter durations of ET use. For cases of persistent azoospermia, gonadotropins (human chorionic gonadotropin [hCG] and follicle-stimulating hormone [FSH]) and selective estrogen receptor modulators (SERMs), such as clomiphene citrate, are recommended, either alone or in combination. The global increase in exogenous testosterone use, including testosterone replacement therapy and AAS, underscores the need for improved management of associated azoospermia, which can be temporary or permanent depending on individual factors and the type of testosterone used. Additionally, the manuscript discusses preventive strategies, such as transitioning to short-acting testosterone formulations or incorporating low-dose hCG to preserve fertility during ET therapy. While guidelines for managing testosterone-related azoospermia remain limited, emerging research indicates the potential efficacy of hormonal stimulation therapies. However, there is a notable lack of well-structured, controlled, and long-term studies addressing the management of azoospermia related to exogenous testosterone use, highlighting the need for such studies to inform evidence-based recommendations.

Androgen Signaling in Prostate Cancer: When a Friend Turns Foe

Androgen (AR) signaling is the main signaling for the development of the prostate and its normal functioning. AR is highly specific for testosterone and dihydrotestosterone, significantly contributing to prostate development, physiology, and cancer. All these receptors have emerged as crucial therapeutic targets for PCa. In the year 1966, the Noble prize was awarded to Huggins and Hodge for their groundbreaking discovery of AR. As it is a pioneer transcription factor, it belongs to the steroid hormone receptor family and consists of domains, including DNA binding domain (DBD), hormone response elements (HRE), C-terminal ligand binding domain (LBD), and N-terminal regulatory domains. Structural variations in AR, such as AR gene amplification, LBD mutations, alternative splicing of exons, hypermethylation of AR, and co- regulators, are major contributors to PCa. It's signaling is crucial for the development and functioning of the prostate gland, with the AR being the key player. The specificity of AR for testosterone and dihydrotestosterone is important in prostate physiology. However, when it is dysregulated, AR contributes significantly to PCa. However, the structural variations in AR, such as gene amplification, mutations, alternative splicing, and epigenetic modifications, drive the PCa progression. Therefore, understanding AR function and dysregulation is essential for developing effective therapeutic strategies. Thus, the aim of this review was to examine how AR was initially pivotal for prostate development and how it turned out to show both positive and detrimental implications for the prostate.

Anabolic-androgenic steroids are linked to depression and anxiety in male bodybuilders: the hidden psychogenic side of anabolic androgenic steroids

BACKGROUND

The prevalence of anabolic-androgenic steroids (AAS) use is on the rise among athletes and bodybuilders worldwide. In addition to the well-documented adverse effects on hepatic, renal, and reproductive functions, there is an increasing recognition of psychiatric complications associated with AAS use. This study aimed to investigate psychiatric morbidity among male bodybuilders who are AAS users.

METHODS

In this cross-sectional study, 25 male bodybuilders using AAS (mean age 31.2 ± 8.9 years) were compared with a control group of 25 healthy male bodybuilders matched in age (31.3 ± 5.5 years). The demographic, hormonal, and biochemical parameters of the participants were recorded. The impact of AAS use on psychiatric morbidity was assessed using the Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) in both groups.

RESULTS

The BDI and BAI scores were significantly higher in male bodybuilders using anabolic-androgenic steroids (p < 0.0001). While the control group showed no instances of anxiety, seven individuals in the AAS user group reported mild anxiety. No participants in the control group exhibited depression, whereas seven AAS users displayed depressive symptoms (4 mild, 3 moderate). Correlations were observed between lactate dehydrogenase (LDH) levels and BAI scores, creatinine levels and both BAI and BDI scores, as well as between estradiol levels and BDI.

CONCLUSION

The study concluded that AAS use among male bodybuilders is associated with elevated levels of depression and anxiety. Our findings suggest a potential correlation between anxiety and depression levels and the levels of creatinine, LDH, and estradiol in AAS users.

Impacts of Anabolic-androgenic steroid supplementation on female health and offspring: Mechanisms, side effects, and medical perspectives

The increasing prevalence of Anabolic-androgenic steroids (AAS) among women, driven by the pursuit of improved body aesthetics, characterized by higher lean mass and reduced adipose tissue, raises significant health concerns, particularly due to the limited knowledge regarding their effects on the female organism. Prolonged use and/or high doses of AAS are linked to various harmful side effects, including mood changes, psychiatric disorders, voice deepening, clitoromegaly, menstrual irregularities, and cardiovascular complications, prompting medical societies to discourage their widespread use due to insufficient evidence supporting their safety and efficacy. Studies in female rodents have shown that AAS can lead to increased aggression, inflammation, reduced neuronal density, and negative impacts on the myocardium and blood vessels. Additionally, maternal administration of androgens during pregnancy can adversely affect offspring's reproductive, neuronal, and metabolic health, resulting in long-term impairments. The complexity of the mechanisms underlying AAS effects, and their potential genotoxicity remains poorly understood. This review aims to elucidate the various ways in which AAS can impact female physiology and that of their offspring, highlight commonly used anabolic substances, and discuss the positions of medical societies regarding AAS use.

Drug Repositioning for Scorpion Envenomation Treatment Through Dual Inhibition of Chlorotoxin and Leiurotoxin

Scorpion envenomation, a grave public health concern, is primarily driven by the potent neurotoxins chlorotoxin and leiurotoxin present in Leiurus species venom. Developing effective treatments is crucial to mitigate its impact. Utilizing a drug-repositioning bioinformatics-based approach, potential inhibitors of these neurotoxins were identified from Food and Drug Administration (FDA)-approved drugs. Through virtual screening and subsequent molecular dynamics simulations, their ability to stabilize the peptides over time was evaluated. Among the compounds scrutinized, bolazine emerged as a promising candidate, demonstrating significant affinity for both neurotoxins, indicating potential dual inhibitory activity. Molecular dynamics simulations further corroborated the enhanced stability of bolazine complexes compared to neurotoxins alone. These findings suggest the feasibility of repurposing existing drugs to develop new therapeutic strategies to treat scorpion envenomation. Such interventions hold promise in alleviating the severe health repercussions of scorpion stings and meeting the urgent demand for effective remedies in affected communities.

Nandrolone decanoate-induced hypogonadism in male rats: Dose- and time-dependent effects on pituitary and testicular hormonal functions

Anabolic-androgenic steroids (AASs) impairment of reproduction has been reported. We investigated dose- and time-dependent effects of Nandrolone decanoate (ND) on reproductive system in comparison with Testosterone enanthate (TE). Male Wistar rats were administrated with 1, 3, and 9 mg/kg/weeks ND or 1 and 3 mg/kg/weeks TE for 8 weeks, and testicular phenotype and reproductive hormones were assessed at 4 and 8 weeks post-treatments. AASs × treatment period interaction was significant for gonadosomatic index (GSI), testosterone (T), 17β-estradiol (E2), and luteinizing hormone (LH). At 4 weeks post-treatment, GSI was decreased in rats treated with 3 mg/kg/weeks ND and T was decreased in all ND-treated groups, while no significant changes in LH levels were observed. At 8 weeks post-treatment, GSI was decreased in rats treated with 1 and 3 mg/kg/weeks ND and with 3 mg/kg/weeks TE, T was decreased in all groups, and E2 and LH were increased and decreased, respectively, in rats treated with 9 mg/kg/weeks ND and with 3 mg/kg/weeks TE. The testes showed histopathological defects in both ND- and TE-treated rats suggesting a delay in seminiferous cycle. This study shows AASs-induced hypogonadism at low-dose that coincided with inhibition of T biosynthesis and disruption of T feedback on pituitary.

The Impact of Vitamin D on Androgens and Anabolic Steroids among Adult Males: A Meta-Analytic Review

BACKGROUND

Recent studies indicate that vitamin D impacts male reproductive function, with deficiency linked to infertility. This review evaluates the effect of vitamin D supplementation on male fertility, focusing on total testosterone, free testosterone, the free androgen index (FAI), follicle-stimulating hormone (FSH), luteinizing hormone (LH), sex-hormone-binding globulin (SHBG), and estradiol.

METHODS

We systematically searched Medline, Web of Science, Cochrane Library, and Scopus from their inception until July 2024 for randomized controlled trials (RCTs) involving adult males. The primary focus of these studies was on reproductive hormone parameters, analyzed using a random-effects meta-analysis and weighted mean difference (WMD). Evidence quality was assessed using ROB2 and GRADE. Meta-regression and dose-response analyses were performed.

RESULTS

Seventeen studies met the criteria for quantitative analysis. Vitamin D supplementation significantly increased total testosterone levels (WMD 0.38, 95% CI 0.06-0.70, n = 15, I2 = 67.03). However, it had no significant effect on other hormone parameters: free testosterone (WMD 0.00, 95% CI -0.02-0.03, n = 9, I2 = 48.12), FSH (WMD -0.02, 95% CI -0.57-0.53, n = 7, I2 = 48.72), LH (WMD -0.09, 95% CI -0.30-0.12, n = 8, I2 = 0.00), SHBG (WMD 0.73, 95% CI -1.14-2.61, n = 10, I2 = 69.05), FAI (WMD -0.92, 95% CI -2.12-0.27, n = 6, I2 = 0.00), and estradiol (WMD -0.02, 95% CI -2.95-2.92, n = 5, I2 = 20.63).

CONCLUSION

This meta-analysis shows that vitamin D supplementation may increase total testosterone levels in men. However, further well-designed RCTs are needed to determine vitamin D's effects on other reproductive hormone parameters.

A hormonal side effect of anabolic steroids among a sample of Baghdad male bodybuilders

Anabolic-androgenic steroids (AAS) are used widely, but in illegal ways mostly by young men as performance-enhancing and image-enhancing drugs (IPED). long-term usage of AAS, usually in conjunction with other illegal substances, can have extremely detrimental impacts on the reproductive system. The primary goal of this study was to examine any possible detrimental effects of AAS on sex hormone levels, a liver and kidney function in individuals who frequent fitness centers in Iraq-Baghdad. In this research, there are 60 participants (20-37 years old); 30 athletes who visited the different gyms in Baghdad/ Iraq and used AAS such as testosterone, Boldenone, Cybontae, Deca Durabellin; and 30 athletes who did not take any synthetics hormones and serve as control. All participants answered the questionnaire form which included their age, the type of used AAS, when they started to take it, and the total usage number per week. The blood (5 ml) was drawn from every participant to separate the serum. The serum was used to measure some hormones (Testosterone, FSH, LH, prolactin and Estrodiol) and liver and kidney function parameters. The results showed a significantly lower level of testosterone and FSH in the AAS-users' bodybuilding group compared to the control group. In comparison with the control group, there was a notable rise in the PRL level in the serum of AA users. However, when comparing the serum levels of LH and Estrodiol in the AAS-user group to those in the control group, no discernible variations were seen. AAS users had a significantly higher level of ALT and lower ALP than controls, although there is no difference in AST levels between the two groups. The creatine level was significantly higher in the AAS-user compared to the control group, but not urea. In conclusion, the effects of AAS and other supplements on sex hormones and kidney, liver function, and vary depending on how long they are used, with the effects of AAS being more pronounced. Therefore, there is a need for culturally sensitive measures to prevent steroid abuse among youth.

The association of caffeine and nandrolone decanoate modulates aversive memory and nociception in rats

Caffeine and anabolic-androgenic steroids (AAS) are commonly used to improve muscle mass and athletic performance. Nandrolone Decanoate (ND) is one of the most abused AAS worldwide, leading to behavioral changes in both humans and rodents. Caffeine, the most widely consumed psychostimulant globally, is present in various thermogenic and gym supplements. Low and moderate doses of caffeine antagonize adenosine receptors and have been linked to improved memory and pain relief. We have previously demonstrated that consuming caffeine prevents the risk-taking behavior triggered by nandrolone. In this study, we aimed to investigate the long-term effects of ND and caffeine, either alone or in combination, on passive avoidance memory and nociception. We used the step-down and hot-plate tasks in male and female Lister Hooded rats. Our results confirmed the antinociceptive effect of caffeine and indicated that chronic administration of the ND-caffeine association promotes the evocation of aversive memory in female rats.

Non-ischemia Cardiomyopathy and Polycythemia Secondary to Anabolic-Androgenic Steroid Use

Athletes and bodybuilders use anabolic-androgenic steroids (AAS) to increase muscle mass and enhance performance. Its use is widespread among competitive athletes in order to enhance athletic performances. However, the use of AAS has been linked to many deleterious adverse effects, including cardiomyopathy and polycythemia. We present the case of a young man in his late 20s who presented with uncontrolled hypertension and elevated hemoglobin. He was found to have a reduced left ventricular ejection fraction of 20-25%. Further workup showed dilated cardiomyopathy and low normal erythropoietin (EPO) levels. Evaluation for polycythemia vera was negative, and there was no evidence of ischemic cardiomyopathy. The patient later admitted to using injected AAS for professional bodybuilding. The coexistence of both these conditions can be challenging to diagnose and treat. While primary and secondary polycythemia can lead to hyperviscosity and result in ischemic cardiomyopathy from coronary occlusion, anabolic steroids can directly result in cardiomyopathy and polycythemia. This case points to the importance of identifying cardiomyopathy and polycythemia from illicit drug use, which can often be missed, and the workups needed to identify the etiology.

Nandrolone decanoate impairs gastrointestinal motility and duodenal morphometry in moderately exercised rats

The misuse of anabolic androgenic steroid associated or not with physical workouts disrupts gastrointestinal (GI) function homeostasis. Our goal was to investigate the effects of nandrolone decanoate (ND) and moderate swimming on the GI transit of solid meals, GI motor contractility, and intestinal histology in rats. Male Wistar rats were allocated to four groups that received intramuscular injections of ND (5.0 mg/kg) or vehicle (60.0 µL) and were submitted or not to swimming sessions (60 min, 5% body weight overload) for 4 weeks. Gastric emptying, intestinal transit, in vitro GI contractility, intestinal morphometry, and duodenal mucosal mast cells were evaluated in all experimental groups. ND treatment accelerated gastric emptying, slowed small intestine transit time, enhanced gastric carbachol-mediated reactivity, decreased crypt depth and villus height, reduced mucosal thickness, and increased the circular and longitudinal muscle layer thickness of the duodenum in sedentary rats. Moderate exercise accelerated intestinal transit time and reduced submucosa thickness. In vehicle-treated animals, a strong negative correlation was found between intestinal transit and mucosal mast cells, which was reversed by ND treatment. Combining ND treatment and swimming accelerated gastric emptying, increased duodenal cholinergic reactivity, inhibited the sodium nitroprusside relaxing response, increased the number of duodenal mast cells, decreased villus height, and increased the thickness of all muscle layers. ND changed the morphological and functional properties of the GI tract over time, with intense dysmotility, especially in sedentary animals, but moderate exercise seemed to have played a compensatory role in these harmful effects in the gut.

Contaminants in Dietary Supplements: Toxicity, Doping Risk, and Current Regulation

Athletes, both amateur and professional, often resort to the consumption of nutritional supplements without professional supervision and without being aware of the risks they may entail. We conducted an exhaustive literature search to determine the most common substances found as contaminants in dietary supplements. For each substance, we analyzed its mechanism of action, clinical indication, health risk, and putative use as doping agent. In addition, we evaluated the current regulation of these supplements. Contamination of nutritional supplements (accidental or intentional), especially with steroids and stimulants, is a hazardous situation. The prolonged consumption of these products without being aware of their composition can cause serious health risks and, in the case of professional athletes, a possible sanction for doping.

Muscle dysmorphia: an under-recognised aspect of body dissatisfaction in men

Although men and women both experience eating disorders such as anorexia nervosa and bulimia nervosa, there are differences in the way their eating disorder may present. Body dissatisfaction or body dysmorphia in men may be more related to a drive for muscularity as opposed to thinness. Muscle dysmorphic disorder (also known as muscle dysmorphia) is a form or subtype of body dysmorphia that is characterised by an extreme desire for muscularity and a preoccupation with the idea that one's physique is too small or not sufficiently muscular. It is more common in men than women and is associated with body image distortion, excessive exercise routines, muscularity-orientated disordered eating and the use of appearance- and performance-enhancing drugs such as anabolic androgenic steroids. Risk factors for muscle dysmorphic disorder include social pressure (including to conform to gender stereotypes) and low self-esteem. The condition has negative psychological, physical, relational and financial effects. Nurses can play a role in health promotion as well as in the assessment, care and referral of men with muscle dysmorphic disorder.

The Use of Anabolic Steroids by Bodybuilders in the State of Sergipe, Brazil

Bodybuilding, as a high-performance sport, requires regular strength and resistance exercises with the principal objective of increasing muscle hypertrophy. However, many bodybuilders resort to the use of anabolic-androgenic steroids (AASs) to improve their performance in a short period of time. This study employs a survey-type, cross-sectional, descriptive-analytical method to evaluate the profile of bodybuilding athletes in the State of Sergipe, Brazil, and verify the level of knowledge/awareness about the health risks and impacts resulting from the use of such substances. Finite- and convenience-type populations are assessed, including individuals of both sexes, aged older than 18 years, self-declared bodybuilding athletes residing in the State of Sergipe, Brazil, and participating in regional and/or state competitions. As a result, no significant relationships were determined between sex (p = 0.492), age (p = 0.460), family income (p = 0.141), and medical follow-up sessions. For the variables level of education and medical follow-up vs. no follow-up sessions, a significant result was achieved (p = 0.01), with 74.3% of individuals reporting having follow-up treatment and 25.7% responding that they had no follow-up treatment, a percentage representing the group that completed their higher education. The substances most used by the athletes were Sustanon 250 or Durateston, Nandrolone Decanoate (Deca or Deca-Durabolin), and Testosterone. The most-reported acute side effects were acne at 33.8% (n = 20), irritability at 32.1% (n = 19), alopecia (hair loss), and nervousness at 23.7% (n = 14). The most-reported chronic side effects were arterial hypertension at 36.0% (n = 9), liver disease at 28.0% (n = 7), and cancer (non-specific) at 8.0% (n = 2). We concluded that, regardless of the athletes' socioeconomic profiles, the use of AASs was high, with two or more substances being used in combination and for a prolonged period. Thus, it is necessary to promote awareness campaigns regarding the use of AASs and their effects on high-performance and recreational athletes.

Impact of androgenic anabolic steroid use on cardiovascular and mental health in Danish recreational athletes: protocol for a nationwide cross-sectional cohort study as a part of the Fitness Doping in Denmark (FIDO-DK) study

INTRODUCTION

The use of androgenic anabolic steroids (AASs) among recreational athletes is steadily increasing. However, knowledge regarding the potentially harmful effects of AAS primarily originates from case reports and small observational studies. This large-scale study aims to investigate the impact of AAS use on vascular plaque formation, preclinical coronary disease, cardiac function, circulating cardiovascular risk markers, quality of life (QoL) and mental health in a broad population of illicit AAS users.

METHODS AND ANALYSES

A nationwide cross-sectional cohort study including a diverse population of men and women aged ≥18 years, with current or previous illicit AAS use for at least 3 months. Conducted at Odense University Hospital, Denmark, the study comprises two parts. In part A (the pilot study), 120 recreational athletes with an AAS history will be compared with a sex-matched and age-matched control population of 60 recreational athletes with no previous AAS use. Cardiovascular outcomes include examination of non-calcified coronary plaque volume and calcium score using coronary CT angiography, myocardial structure and function via echocardiography, and assessing carotid and femoral artery plaques using ultrasonography. Retinal microvascular status is evaluated through fundus photography. Cardiovascular risk markers are measured in blood. Mental health outcomes include health-related QoL, interpersonal difficulties, body image concerns, aggression dimensions, anxiety symptoms, depressive severity and cognitive function assessed through validated questionnaires. The findings of our comprehensive study will be used to compose a less intensive investigatory cohort study of cardiovascular and mental health (part B) involving a larger group of recreational athletes with a history of illicit AAS use.

ETHICS AND DISSEMINATION

The study received approval from the Regional Committee on Health Research Ethics for Southern Denmark (S-20210078) and the Danish Data Protection Agency (21/28259). All participants will provide signed informed consent. Research outcomes will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

NCT05178537.

The decanoate esters of nandrolone, testosterone, and trenbolone induce steroid specific memory impairment and somatic effects in the male rat

Long-term use of anabolic androgenic steroids (AAS) in supratherapeutic doses is associated with severe adverse effects, including physical, mental, and behavioral alterations. When used for recreational purposes several AAS are often combined, and in scientific studies of the physiological impact of AAS either a single compound or a cocktail of several steroids is often used. Because of this, steroid-specific effects have been difficult to define and are not fully elucidated. The present study used male Wistar rats to evaluate potential somatic and behavioral effects of three different AAS; the decanoate esters of nandrolone, testosterone, and trenbolone. The rats were exposed to 15 mg/kg of nandrolone decanoate, testosterone decanoate, or trenbolone decanoate every third day for 24 days. Body weight gain and organ weights (thymus, liver, kidney, testis, and heart) were measured together with the corticosterone plasma levels. Behavioral effects were studied in the novel object recognition-test (NOR-test) and the multivariate concentric square field-test (MCSF-test). The results conclude that nandrolone decanoate, but neither testosterone decanoate nor trenbolone decanoate, caused impaired recognition memory in the NOR-test, indicating an altered cognitive function. The behavioral profile and stress hormone level of the rats were not affected by the AAS treatments. Furthermore, the study revealed diverse AAS-induced somatic effects i.e., reduced body weight development and changes in organ weights. Of the three AAS included in the study, nandrolone decanoate was identified to cause the most prominent impact on the male rat, as it affected body weight development, the weights of multiple organs, and caused an impaired memory function.

Anabolic steroids induced changes at the level of protein expression: Effects of prolonged administration of testosterone and nandrolone to pigs

Synthetic derivatives of steroid hormones, specifically anabolic-androgenic steroids (AAS), have gained prominence due to their observed benefits in enhancing meat quality. The study replicated the administration of banned AAS and investigated their impacts on pigs to contribute to the understanding of animal biochemistry and to explore the feasibility of detecting AAS administration by employing a non-targeted analysis. The effects were corroborated by evaluating changes in the expression of selected proteins, as well as examining haematological and biochemical profiles and histological alterations. Exposure to AAS influenced the expression of proteins related to drug-metabolizing enzymes, muscle and lipid metabolism, kidney function, reproductive processes, immune system functions, and carcinogenic changes. The effects of AAS appear intricate and contingent on factors such as the specific drug used, dosage, and duration of administration. The results underscore that protein expression analysis holds promise as a valuable tool for detecting illicit AAS use in the fattening process.

The dichotomy between health and drug abuse in bodybuilding

Aim: The aim of the present study was to investigate the expansion and prevalence of anabolic steroid use by examining the divergent effects between health and drug abuse and to create more awareness around the harmful consequences of these drugs when administered at abusive levels. Methods: A focused and concise literature search was conducted, and 101 high-quality articles were included in the review. Results: The findings underscore the adverse health risks of steroid abuse, emphasizing the stark contrast between health and drug abuse. Conclusions: While steroids and other performance-enhancing drugs can yield muscle growth, strength and even fat loss, abusing these substances can lead to adverse health outcomes. Furthermore, within the fitness subculture, particularly in the realm of bodybuilding, steroid abuse fosters an atmosphere of cheating and deception, frequently downplaying or ignoring the negative and sometimes deadly consequences it brings.

Carotid intima media thickness as a marker of increased cardiovascular risk due to androgenic anabolic steroids in male bodybuilders: a cross-sectional study

BACKGROUND

The usage of androgenic-anabolic steroids (AAS) leads to severe side effects. The aim of our study was to investigate the effects of AAS on the increase in the carotid intima-media thickness which is regarded as predictor of cardiovascular disorders and determine the association of ASS usage to urinary, hepatic, and hematological systems as well as lipid disorders.

METHODS

A total of 60 male bodybuilders (30 AAS users with a mean age of 31.2±8.9 years and 30 AAS nonusers with a mean age of 31.2±8.9 years) were assessed in this cross-sectional study. The patients' demographic, radiologic, hormonal, and biochemical parameters were recorded. The carotid intima-media thickness (CIMT) was measured using B-mode ultrasound in both groups. Abdominal ultrasonography was used to assess for the presence of fatty liver.

RESULTS

CIMT was significantly increased in AAS (0.72±0.13 mm) users than in the controls (0.47±0.07 mm) (P<0.001). The mean duration of AAS usage was 2.70±2.13 years. There was a statistically significant positive correlation between the duration of AAS usage and CIMT (r=0.710; P<0.001). A statistically significant negative correlation among HDL, LH, and CIMT was found in the correlation analysis between biochemical parameters and CIMT among AAS users (respectively, r and P values were: r=0.399; P=0.029; r=-0.366; P=0.047; r=-0.287; P=0.035). Likewise, a negative correlation (r=-0.425; P=0.019) was found between FSH and CIMT.

CONCLUSIONS

We found that the usage of AAS among male bodybuilders has led to an increase in CIMT, which is associated with poor cardiovascular health. The results of our study highlight the vital importance of educating male bodybuilders who use these chemicals about the side effects.

Osteonecrosis of the Knee: The Unintended Consequence of Steroid Abuse

The anti-inflammatory and immunosuppressive properties of steroids allow their use in a wide variety of rheumatological diseases, asthma, inflammatory bowel disease, cancer therapy, and severe viral infections. Though life-saving or organ-saving, long-term clinical use leads to a vast array of complications. Osteoporosis is the most common orthopedic side effect of steroid abuse, while osteonecrosis is a rare occurrence. The risk of osteonecrosis appears to be dose and duration dependent, but several patient factors also play a major role and usually affect the femoral head followed by the knee joint. The long-term effects of steroids must be explained to all patients on therapy, but this risk is missed in individuals who abuse steroids for recreational or performance-enhancing purposes. We describe a male, aged 29 years, who presented with dull aching bilateral knee pain of 2-years' duration after a long-term steroid abuse for weight and muscle mass gain. Radiological and magnetic resonance imaging studies confirmed osteonecrosis of femoral and tibial condyles and secondary degenerative arthritis of the knee joint. Prompt suspicion, early diagnosis, and intervention in osteonecrosis of knee joints, and termination of steroids may reverse the pathology and prevent progression of disease.

Prolonged testosterone 17β-cyclopentylpropionate exposition induces behavioral, ovarian, oviductal, uterine and reproductive disturbances in female mice

Anabolic-androgenic steroids (AAS) abuse is often associated with metabolic disorders and infertility. However, the current evidence on AAS-induced reproductive toxicity is mainly based on male studies. Thus, AAS repercussions on female reproductive capacity remain poorly understood, despite scarce evidence that fertility determinants may be more severely impaired in females than males exposed to these drugs. Accordingly, this study used an integrated framework to investigate the impact of different testosterone 17β-cyclopentylpropionate (TC) doses on pain sensitivity, aggressiveness, anxiety, sexual behavior, ovarian, oviductal, uterine and reproductive morphofunctional and molecular outcomes. These parameters were used to explore the reproductive capacity in female mice exposed to this synthetic testosterone ester. The animals were untreated or intraperitoneally treated with 5, 10 and 20 mg/kg TC every 48 h for 12 weeks. Our findings indicated that testosterone was upregulated while the hormones luteinizing, follicle-stimulating, estrogen and progesterone were down-regulated by TC. This AAS also exerted deleterious effects on anxiety, aggressivity, nociception, exploratory and sexual behavior in female mice. Concurrently, TC attenuated ovarian follicle maturation, interrupted the estrous cycle, induced oviductal and uterine hypotrophy. Estrous cyclicity was reestablished 60 days after AAS treatment. However, TC-treated mice still exhibited impaired reproductive capacity, a disturbance potentially related to deficiency in folliculogenesis, sex hormones production, and endometrial receptivity mediate by ER-α, PR, HOXA-10 and LIF down-regulation. Taken together, our findings indicated that in addition to female behavior, reproductive organs microstructure and function are markedly impaired by TC in a dose-dependent manner, whose time-dependent reversibility remains to be clarified.

Osteoporosis therapy using nanoparticles: a review

Osteoporosis, characterized by low bone density and increased risk of fractures, represents a major healthcare challenge. Anti-resorptive and anabolic medications are now used to treat osteoporosis in an effort to reduce bone loss and increase bone mass. Innovative methods are required since current therapies have drawbacks. Promising options for improving bone health and medicine delivery are provided by nanotechnology. Bisphosphonates with tetracyclines and oligopeptides, among other compounds that target the bone, make it easier to provide a particular medication to bone tissue. Additionally, nanocarriers are essential for the administration of both organic and inorganic nanoparticles in the treatment of osteoporosis. Drug encapsulation and controlled release may be done in a variety of ways using organic nanoparticles. Inorganic nanoparticles have special qualities that help in medication transport and bone repair. This review explores the potential of nanoparticle-based strategies in the treatment of osteoporosis.

Association between steroid use and concussions among high school athletes: a cross-sectional analysis of the Youth Risk Behavior Surveillance System

CONTEXT

In 2017, there were almost 2.5 million high school students who experienced a concussion while playing a sport, raising concern for the neurologic problems that they could face. Some of these athletes may seek to gain a competitive advantage in their sport by utilizing substances like steroids. However, steroid use can cause increased aggression and body mass index (BMI), which might lead to heightened risk for concussions. Despite extensive research, we found no previous evidence linking these two factors.

OBJECTIVES

This analysis aims to investigate steroid use trends in high school athletes and to determine whether there is an association between steroid use and concussions in these athletes.

METHODS

We conducted a cross-sectional analysis of the cumulative Youth Risk Behavior Surveillance System (YRBSS). Respondents were added if they participated in sports and answered the steroid and concussion prompts. Demographic variables were assessed including age, grade, BMI, gender, and race/ethnicity.

RESULTS

We found that 3.7 % (n=2991) of high school athletes reported previous steroid use and that 20.7 % (n=2273) reported having sustained a concussion. There was a statistically significant difference in steroid use by race/ethnicity (p<0.001), with the highest rate of use (7.2 %) among American Indian/Alaska Natives (AI/AN). A significantly higher prevalence of steroid use occurred in athletes who were males (4.7 %) than females (2.5 %) and in athletes with a BMI>95 % (5.2 %) compared with those with a BMI between 85 and 95 % (3.9 %) and <85 % (3.5 %) (χ2=135.1, p<0.001 and χ2=16.3, p<0.001, respectively). Further, our results showed that the prevalence of steroid use among high school athletes decreased from 3.4 % in 1999 to 1.9 % in 2019, with the most drastic drop occurring between 2015 and 2019-declining 1.9 %. Whereas 19.6 % of athletes reported a concussion without steroid use, 54.6 % of steroid-utilizing athletes reported having experienced a concussion-a statistically significant finding (adjusted odds ratio [AOR]=4.3; 95 % CI: 3.2-5.9). Finally, compared with White athletes, we found that AI/AN athletes were significantly more likely to have sustained a concussion (AOR=2.3; 95 % CI=1.2-4.3).

CONCLUSIONS

Although our study found decreasing rates of steroid use among high school athletes from 1999 through 2019, our results also show that steroid use is significantly associated with sustaining a concussion. Additionally, the data from YRBSS also demonstrates that AI/AN high school athletes are more likely to utilize steroids and sustain a concussion. Given the long-term consequences of traumatic brain injuries, we recommend that coaches should be aware of potential steroid use among players, and that coaches, athletic trainers, and physicians should all be aware of concussion protocols and remove players from games for evaluation when a concussion is suspected.

Online information and availability of three doping substances (anabolic agents) in sports: role of pharmacies

Background: The Internet has become an important source for easy access to doping substances, where people and athletes may acquire, outside pharmacies and without a (medical) prescription. These online websites do not always offer quality-assured products, and are outside the regular distribution channels of medicines. The aim of this study was to estimate the availability and accessible information on the Internet about the sale of three doping substances (oxandrolone, DHEA, androstenedione). Methods: Cross-sectional exploratory study, being an observation at a point in time of the online availability of these three doping substances (WADA S1 category: anabolic agents), purchased from Spain, Puerto Rico, Canada, United States, Ukraine and Russia. The characteristics of the websites, the countries the webs sold to, the pharmaceutical forms offered and the recommendations for its use were analyzed by using a computer tool designed ad hoc. Results: There were significant differences between countries in the number of webpages that sold the products (Chi-square test, p < 0.05). Oxandrolone was available for purchase mainly when buying from Spain (27.12%) and Ukraine (26.58%), in websites dedicated to sports (77.26%). For DHEA, most of the pages offered it if the search was done from Canada (23.34%) and Russia (21.44%). Products containing androstenedione or DHEA are claimed to enhance sports performance or for sports use without providing details. Compared to the total number of websites checked, the proportion of pharmacies offering these products was low, ranging from 4.86% for DHEA to 15.79% for androstenedione. Conclusion: The three substances selected are easily available without control through the Internet. Only a small number of websites offering them were online pharmacies, and requested a prescription. Most of the doping substances are purchased from the country where they are requested. Product information described benefits for sports performance, but did not do the same with their side effects. It would be advisable for these products to be sold through pharmacies, to guarantee their quality and provide evidence-based information on their safe use, benefits and risks, and only with a prescription. Athletes should be encouraged to consult health professionals about those supplements suitable for their type of training and sports objectives.

Fertility outcomes in men with prior history of anabolic steroid use

OBJECTIVE

To study sperm parameters recovery and fertility outcomes in men with azoospermia or severe oligospermia caused by anabolic steroid use who underwent a standardized treatment regimen for spermatogenesis recovery.

DESIGN AND SUBJECTS

A retrospective analysis of a cohort of men with a prior history of anabolic steroid use and infertility complaints (between 2018 and 2022) was conducted.

EXPOSURE

The standardized treatment approach involved discontinuing testosterone replacement therapy and administering a combination regimen of clomiphene citrate and human chorionic gonadotropin for a minimum of 3 to 6 months.

MAIN OUTCOME MEASURES

The main outcome measures included changes in sperm parameters, predominantly sperm concentration, and subsequent pregnancy outcomes.

RESULTS

A total of 45 men (median age 37 years, IQR 32-45) met the inclusion criteria for this analysis. Median duration of prior T use was 4 years (IQR 1.3-10), with the 2 most common modalities consisting of injection therapy (43.5%) and oral therapy (34.8%). The median initial sperm concentration was 0 million/cc (IQR 0-1.15), and 23 (51.1%) men initially presented with azoospermia. The median duration of combination human chorionic gonadotropin/clomid therapy was 5 months (IQR 3-12). In initially azoospermic men (N: 23), 5 were lost to follow-up, 6 (33.3%) progressed to severe oligospermia (<5 million/cc), 6 (33.3%) to oligospermia (<15 million/cc), 1 (5.6%) to normozoospermia (>15 million/cc), and 5 (27.8%) remained azoospermic after medical treatment for 6 months. Among the 24 couples who responded to the follow-up call, a total of 9 (37.5%) achieved a successful subsequent pregnancy. Of these, 33.3% (3 couples) used assisted reproductive technology, whereas 66.7% (6 couples) conceived naturally. On logistic regression analysis, no significant predictors for improved sperm parameters or successful pregnancy were identified.

CONCLUSION

Despite appropriate treatment regimens, a significant proportion of men with a prior history of anabolic steroid use continue to exhibit severe oligospermia, with more than half showing limited improvement in semen parameters after 6 months of treatment. Only a fraction of men achieves normozoospermia after treatment. Further research is needed to explore predictors for improved sperm parameters and successful pregnancy outcomes in men with a history of anabolic steroid use.

Prevalence and correlates of androgen dependence: a meta-analysis, meta-regression analysis and qualitative synthesis

PURPOSE OF REVIEW

To investigate the prevalence and correlates of androgen dependence among users. A meta-analysis, meta-regression analysis, and qualitative synthesis were conducted based on a systematic literature search in Google Scholar, ISO Web of Science, PsycNET, and PubMed.

RECENT FINDINGS

Twenty-six studies were included in the review and 18 studies ( N  = 1782) in the statistical analysis. The overall lifetime androgen dependence prevalence was 34.4% [95% confidence interval (CI): 27.8-41.7, Q  = 113.1, I2  = 85.0, P  < 0.001]. Although males (36.1%, P  < 0.001) and females (37.0%, P  = 0.188) did not differ ( Q  = 0.0, P  = 0.930) in dependence prevalence, controlling for other study characteristics, higher study male sample proportion was related to higher dependence prevalence. Combined interview and questionnaire assessments showed higher prevalence compared to interviews only. Publications from 1990-1999 generated higher prevalence compared to 2000-2009 and 2010-2023 publications. Dependents were associated with a wide array of demographic inequalities, and biophysical, cognitive, emotional, and psychosocial problems.

SUMMARY

One of three persons who initiate androgen use experiences dependence along with various serious disorders. Androgen use and dependence should be considered an important public health issue requiring targeted health interventions.

The awareness and experience of healthcare providers with the use of anabolic androgenic steroids by gym users

OBJECTIVES

This study aims to evaluate healthcare providers' awareness and experience with anabolic androgenic steroid (AAS) use among gym users in Jordan and their role in mitigating AAS misuse.

METHODS

A cross-sectional study was conducted between November 2022 and Feb 2023. During the study period, 158 physicians involved in prescribing AAS or treating adverse effects associated with these agents were invited to participate. A questionnaire was created and uploaded on Google Forms and distributed through social media platforms to reach physicians from different medical subspecialties.

RESULTS

Of the 158 physicians surveyed, 30.4% were general practitioners, and 63.3% reported having formal education about the risks of bodybuilding with AAS. Among the participants, 48.7% had encountered gym users who were using AAS, with the main reason for referral being the management of side effects associated with AAS use. The median knowledge score regarding AAS and their complications was 10.0 out of 14 (IQR = 7.0), indicating adequate knowledge about most AAS side effects. Around 46% of the physicians (n = 73, 46.2%) believed that gym users might struggle to disclose AAS because they lack trust in them. Finally, the most common advice to gym users was informing them about the health-associated consequences of AAS use, with 92.2% of physicians providing this advice.

CONCLUSION

Although healthcare professionals in Jordan had adequate knowledge about AAS, they needed more to make them confident in dealing with AAS use. This highlights the necessity for specialized teaching and training programs to enhance their knowledge and skills in providing accurate information to AAS users.

Police officers' perspective on doping and prevention among recreational athletes: a cross-sectional study

Introduction

The use of anabolic androgenic steroids among recreational athletes has received growing attention in recent decades. Several countries have implemented bans on doping; however, recreational athletes and other subpopulations continue to use doping substances. Recognizing that the police play a crucial role in preventing the use and dealing of doping substances in Sweden, efforts have been made to intensify police interventions and enhance collaboration with other key actors. This study examined police officers' perceptions of doping as defined in Swedish law, related problems, and suggestions for effective prevention of doping in the society.

Methods

A cross-sectional survey study was conducted using a web survey of police officers (N = 597). Data were analyzed using descriptive statistics and free-form text responses were analyzed using content analysis.

Results

Participant responses to the survey (73.7% response rate) indicated that approximately 62.6% thought that doping is a societal problem, and approximately 26% perceived that the availability of doping substances has increased over the past three years. A total of 95.6% of respondents believed that doping occurred in connection with other crimes such as intimate partner violence (88.2%) and drug-related crimes (88.0%). Further, 96.3% of respondents perceived that it was their duty to prevent doping, but 63.8% indicated that doping-related work was not prioritized within their local police district.

Discussion

Police officers perceived doping as a societal problem and expressed motivation to counteract it, highlighting increased knowledge, legislative changes, intensified doping prevention in gyms, and commitment from other societal actors to increase the effectiveness of doping prevention. Suggestions for increasing the efficiency of doping prevention included education and increased knowledge at all levels in the police organization, intensified prevention efforts at gyms, legislative changes to permit simplified doping test procedures, and breach of secrecy for postal items. There was also a suggestion for further engagement from other actors, such as healthcare workers, school officials, and non-governmental organizations.

Innovative Reports on the Effects of Anabolic Androgenic Steroid Abuse-How to Lose Your Mind for the Love of Sport

Anabolic-androgenic steroids (anabolic-androgenic steroids, AAS) are testosterone-derived compounds whose popularity and use are constantly growing. Chronic use of AAS leads to many hormonal and metabolic disorders in the human body, which often lead to permanent health damage. Changes affect the following systems: cardiovascular, musculoskeletal, reproductive, digestive, and nervous. We decided to collect the existing knowledge in the literature and enrich it with the latest research reports in the field of degenerative effects of AAS on the nervous system. The work aimed to increase public awareness of the dangers and consequences of AAS use and improve it with the latest research on the neurodegenerative effects of AAS. We hope that our work will contribute to raising public awareness and reducing the use of AAS.

Ergogenic Aids and Testing in Pediatric Athletes

In the quest for winning the game, some athletes take various chemicals (ie, drugs, herbs, or supplements) in attempts to develop greater strength, endurance, or other elements that bring a competitive advantage. There are more than 30,000 chemicals sold throughout the world with unrestrained and unproven claims; however, some athletes consume them with hopes of increasing their athletic abilities, often without knowledge of the potential adverse effects and with limited evidence of efficacy. Complicating this picture is that research on ergogenic chemicals is typically conducted with elite adult male athletes and not with athletes who are in high school. A few of these ergogenic aids include creatine, anabolic androgenic steroids, selective androgen receptor modulators, clenbuterol, androstenedione, dehydroepiandrosterone, human growth hormone, ephedrine, gamma hydroxybutyrate, caffeine, stimulants (amphetamines or methylphenidate), and blood doping. In this article, we describe the purpose of ergogenic aids as well as the potential side effects. [Pediatr Ann. 2023;52(6):e207-e212.].

Chronic anabolic androgenic steroid administration reduces global longitudinal strain among off-cycle bodybuilders

BACKGROUND

Supra-physiologic doses of anabolic androgenic steroids (AAS) lead to multiple cardiovascular complications. The long-term clinical effect of AAS overuse on cardiac structure and function, which persists during off-cycle periods, remains unclear.

METHODS

A total of 15 sedentary subjects and 79 bodybuilders (26 AAS non-users and 53 AAS-users), matched for age and male gender, were assessed in a cross-sectional design for echocardiography measures. AAS-users were included during an off-cycle phase, abstained from AAS for at least 1 month. 2D standard M-mode and speckle tracking echocardiography were used to measure cardiac dimensions and functions.

RESULTS

Inter-ventricular septum and posterior wall thickness were significantly higher among chronic off-cycle AAS-users compared to AAS non-users and sedentary group. Off-cycle AAS-users showed lower E/A ratio of the diastolic function. Left ventricular systolic function was not affected in terms of ejection fraction, but significant subclinical systolic dysfunction, assessed by GLS, was observed for chronic off-cycle AAS-users compared to AAS non-users (GLS = -16.8% vs. -18.5%, respectively; p = 0.001). Diameter of left atrium and right ventricle were significantly enlarged among off-cycle AAS-user bodybuilders (p = 0.002 and 0.040). TAPSE and RV S', and cardiac vasculature of aorta were comparable in all groups.

CONCLUSIONS

This study demonstrates that during off-cycle phase, AAS-users show long-term impaired GLS, even after considerable AAS abstain, despite normal LVEF. It highlights the importance of following GLS to predict hypertrophy and heart failure events, and not relying on LVEF alone. In addition, the hypertrophic effect of chronic AAS consumption is transitional during AAS washout periods.

The Cell Transformation Assay: A Historical Assessment of Current Knowledge of Applications in an Integrated Approach to Testing and Assessment for Non-Genotoxic Carcinogens

The history of the development of the cell transformation assays (CTAs) is described, providing an overview of in vitro cell transformation from its origin to the new transcriptomic-based CTAs. Application of this knowledge is utilized to address how the different types of CTAs, variously addressing initiation and promotion, can be included on a mechanistic basis within the integrated approach to testing and assessment (IATA) for non-genotoxic carcinogens. Building upon assay assessments targeting the key events in the IATA, we identify how the different CTA models can appropriately fit, following preceding steps in the IATA. The preceding steps are the prescreening transcriptomic approaches, and assessment within the earlier key events of inflammation, immune disruption, mitotic signaling and cell injury. The CTA models address the later key events of (sustained) proliferation and change in morphology leading to tumor formation. The complementary key biomarkers with respect to the precursor key events and respective CTAs are mapped, providing a structured mechanistic approach to represent the complexity of the (non-genotoxic) carcinogenesis process, and specifically their capacity to identify non-genotoxic carcinogenic chemicals in a human relevant IATA.

The toxic effects of anabolic steroids "nandrolone decanoate" on cardiac and skeletal muscles with the potential ameliorative effects of silymarin and fenugreek seeds extract in adult male albino rats

BACKGROUND

Anabolic steroids (AS) are commonly abused by body builders and athletes aiming to increase their strength and muscle mass but unfortunately, the long-term use of AS may lead to serious side effects. Nandrolone Decanoate is one of the Class II anabolic androgenic steroids which quickly spread globally and used clinically and illicitly. Our research was directed to assess the toxic effects of anabolic steroids on cardiac and skeletal muscles in male albino rats and to evaluate the potential ameliorative effects of fenugreek seeds extract and silymarin.

METHODS

Our research was done on 120 male albino rats that were allocated into 6 groups; group I: Served as a control group, group II: Received the anabolic steroid Nandrolone Decanoate, group III: Received silymarin orally, group IV: Received fenugreek seeds extract orally, group (V): Received the anabolic steroid Nandrolone Decanoate and silymarin and group (VI): Received the anabolic steroid Nandrolone Decanoate and fenugreek seeds extract. By the end of the study, rats were sacrificed, and blood samples were collected for biochemical analysis and autopsy samples for histopathological examination.

RESULTS

The anabolic steroids toxic effects on rats showed a significant decrease in serum High Density Lipoprotein (HDL) level and increase in cholesterol, triglycerides, and Low-Density Lipoprotein (LDL) levels. There was a significant elevation in cardiac troponin I level. As regards to histopathological examination of the cardiac and skeletal muscles, the study showed marked degenerative changes and necrosis. Both silymarin and fenugreek seeds extract provided a protective effect on the biochemical and histopathological changes. The antioxidant effects of silymarin and fenugreek seeds extract were evaluated on the heart, skeletal muscles and showed that, the tissue levels of Superoxide dismutase (SOD), Catalase and reduced glutathione (GSH) decreased in AS treated rats compared to the control group. On the other hand, the tissue Malondialdehyde (MDA) levels were elevated.

CONCLUSIONS

Anabolic steroids have a toxic effect on the cardiac and skeletal muscles of albino rats with improvement by treatment with fenugreek seeds extract and silymarin.

Misadventures in Toxicology: Concentration Matters for Testosterone-Induced Neurotoxicity

Testosterone is the predominant androgen in men and has important physiological functions. Due to declining testosterone levels from a variety of causes, testosterone replacement therapy (TRT) is increasingly utilized, while testosterone is also abused for aesthetic and performance-enhancing purposes. It has been increasingly speculated that aside from more well-established side effects, testosterone may cause neurological damage. However, the in vitro data utilized to support such claims is limited due to the high concentrations used, lack of consideration of tissue distribution, and species differences in sensitivity to testosterone. In most cases, the concentrations studied in vitro are unlikely to be reached in the human brain. Observational data in humans concerning the potential for deleterious changes in brain structure and function are limited by their inherent design as well as significant potential confounders. More research is needed as the currently available data are limited; however, what is available provides rather weak evidence to suggest that testosterone use or abuse has neurotoxic potential in humans.

Impact of anabolic androgenic steroids on male sexual and reproductive function: a systematic review

INTRODUCTION

Anabolic-androgenic steroids (AASs) are a complex cluster of synthetic derivatives of testosterone. AAS abuse is considered a major public health issue since it has increased among young/adolescent males. The use of steroids has a prevalence rate of 14% in young athletes and 30-75% in professional athletes or bodybuilders. AASs simulate the testosterone mechanism, binding the intracellular androgen receptor, and dysregulating the normal hypothalamic-pituitary-gonadal axis in the same way as exogenous testosterone. Abuse can produce several side effects on organs, such as the genital system. The physio-pathological mechanisms that cause AAS abuse-related, genital system disorders in humans are still not completely known.

EVIDENCE ACQUISITION

This study focuses on the effect of AASs on the male reproductive organs in humans and animals.

EVIDENCE SYNTHESIS

A systematic review was performed using SCOPUS, PubMed, Google Scholar, and Web of Sciences database up to 31 December 2021 using the keywords: "anabolic-androgenic steroids," "erectile dysfunction," "spermatogenesis" and "infertility;" (anabolic agents) "erectile dysfunction," "spermatogenesis" and "infertility." The review of the literature identified 66 articles published until 2021. Sixty-two articles were included. The use of AASs induces testicular atrophy and azoospermia known as "anabolic steroid-induced hypogonadism." Anabolic steroid induced infertility is characterized by oligo or azoospermia and abnormalities in sperm motility and morphology. Although sperm quality recovers in most cases within 4 months of stopping anabolic steroid abuse, the negative consequences on spermatogenesis can take up to 3 years to disappear. Human studies reported a positive correlation between AAS abuse in athletes and an increase in morphologically abnormal spermatozoa. Animal studies showed the destruction of Leydig cells and testicular atrophy in animals treated with cycles of AASs.

CONCLUSIONS

The present review of the literature highlights how little is known about the action of AASs on the male genital system. However, although their use is prohibited in many countries, the black market for these substances is still very frequent. The scientific landscape still has a lot to invest in the research of AAS on the male genital system to make young people even more aware of the negative aspects of these substances, contributing to the reduction of these products in an inappropriate way.

Repurposing existing products to accelerate injury recovery (REPAIR) of military relevant musculoskeletal conditions

Musculoskeletal injuries (MSKIs) are a great hindrance to the readiness of the United States Armed Forces through lost duty time and reduced operational capabilities. While most musculoskeletal injuries result in return-to-duty/activity with no (functional) limitations, the healing process is often long. Long healing times coupled with the high frequency of musculoskeletal injuries make them a primary cause of lost/limited duty days. Thus, there exists an urgent, clinically unmet need for interventions to expedite tissue healing kinetics following musculoskeletal injuries to lessen their impact on military readiness and society as a whole. There exist several treatments with regulatory approval for other indications that have pro-regenerative/healing properties, but few have an approved indication for treating musculoskeletal injuries. With the immediate need for treatment options for musculoskeletal injuries, we propose a paradigm of Repurposing Existing Products to Accelerate Injury Recovery (REPAIR). Developing treatments via repurposing existing therapeutics for other indications has shown monumental advantages in both cost effectiveness and reduced time to bring to market compared to novel candidates. Thus, undertaking the needed research efforts to evaluate the effectiveness of promising REPAIR-themed candidates has the potential to enable near-term solutions for optimizing musculoskeletal injuries recovery, thereby addressing a top priority within the United States. Armed Forces. Herein, the REPAIR paradigm is presented, including example targets of opportunity as well as practical considerations for potential technical solutions for the translation of existing therapeutics into clinical practice for musculoskeletal injuries.

Serum testosterone level correlates with left ventricular hypertrophy in older women

Introduction

Sex hormones may play an important role in age-related cardiac remodeling. However, their impact on cardiac structure and function in females of advanced age still remains unclear. The aim of this study is to evaluate the relationship between sex hormones level and echocardiographic parameters in older women with concomitant cardiovascular diseases.

Materials and Methods

The study group included 52 community-dwelling women with mean age 79.5 ± 2.8 years, consecutive patients of an outpatient geriatric clinic. In all the subjects, a transthoracic echocardiogram was performed and serum testosterone, estradiol, follicle-stimulating hormone, luteinising hormone, dehydroepiandrosterone sulphate, and cortisol levels were determined.

Results

Testosterone level correlated positively with interventricular septum diastolic dimension (IVSd) (rS=0.293, p<0.05), left ventricular mass index (rS=0.285, p<0.05), E/E' ratio (rS=0.301, p<0.05), and negatively with E' (rS=-0.301, p<0.05). Estradiol level showed a positive correlation with the posterior wall dimension (rS=0.28, p<0.05). Besides, no significant correlations between clinical or echocardiographic parameters and other hormones were observed. Female subjects with diagnosed left ventricular hypertrophy (LVH) (n=34) were characterized by a significantly higher rate of hypertension (p=0.011), higher waist-to-height ratio (p=0.009), higher testosterone level (0.82 vs. 0.48 nmol/L, p=0.024), higher testosterone/estradiol ratio (16.4 vs. 9.9, p=0.021), and received more anti-hypertensive drugs (p=0.030). In a multiple stepwise logistic regression, the best determinants of LVH were the presence of hypertension (OR=6.51; 95% CI 1.62-26.1), and testosterone level (OR= 6.6; 95% CI 1.19-36.6).

Conclusions

Higher serum testosterone levels may contribute to pathological cardiac remodeling, especially in hypertensive women. Estradiol, gonadotropins, DHEAS, and cortisol were not related to echocardiographic parameters.

A study to demonstrate the potential of Anabolic Androgen Steroid to activate oxidative tissue damage, nephrotoxicity and decline endogenous antioxidant system in renal tissue of Adult Wistar Rats

Anabolic Androgenic steroids (AAS) are abused and reports have been made on their deleterious effects on various organs. It is imperative to report the mechanism of inducing oxidative tissue damage even in the presence of an intracellular antioxidant system by the interaction between lipid peroxidation and the antioxidant system in the kidney. Twenty (20) adult male Wistar rats used were grouped into: A- Control, BOlive oil vehicle, C- 120 mg/kg of AAS orally for three weeks, and D- 7 days withdrawal group following 120 mg/kg/ 21days of AAS intake. Serum was assayed for lipid peroxidation marker Malondialdehyde (MDA) and antioxidant enzyme -superoxide Dismutase (SOD). Sectioned of kidneys were stained to see the renal tissue, mucin granules, and basement membrane. AAS-induced oxidative tissue damage, in the presence of an endogenous antioxidant, is characterized by increased lipid peroxidation and decreased SOD level which resulted in the loss of renal tissue cells membrane integrity which is a characteristic of the pathophysiology of nephron toxicity induced by a toxic compound. However, this was progressively reversed by a period of discontinuation of AAS drug exposure.

LGD-4033 and MK-677 use impacts body composition, circulating biomarkers, and skeletal muscle androgenic hormone and receptor content: A case report

NEW FINDINGS

What is the main observation in this case? Co-administration of LGD-4033 and MK-677 increased body mass, lean mass and fat mass, while negatively impacting bone, serum lipids, liver enzymes, testosterone (total and free) and, probably, follicle-stimulating hormone. What insights does it reveal? Our cross-sectional data imply that these compounds might alter intramuscular androgenic hormone and receptor concentrations along with promoting muscular strength, when compared with previously published data from trained males.

ABSTRACT

LGD-4033, a selective androgen receptor modulator, and MK-677, a growth hormone secretagogue, are being used increasingly amongst recreationally active demographics. However, limited data exist describing their effects on health- and androgen-related biomarkers. The purpose of this case study was to determine changes in body composition and biomarkers during and after continued co-administration of LGD-4033 and MK-677. We also aimed to examine muscular strength and intramuscular androgen-associated biomarkers relative to non-users. A 25-year-old male ingested LGD-4033 (10 mg) and MK-677 (15 mg) daily for 5 weeks. Blood and body composition metrics were obtained pre-, on- and post-cycle. One-repetition maximum leg and bench press, in addition to intramuscular androgens and androgen receptor content, were analysed on-cycle. We observed pre- to on-cycle changes in body composition (body mass, +6.0%; total lean body mass, +3.1%; trunk lean body mass, +6.6%; appendicular lean body mass, +4.3%; total fat mass, +15.4%; trunk fat mass, +2.8%; and appendicular fat mass, +14.8%), bone (bone mineral content, -3.60%; area, -1.1%; and bone mineral density, -2.1%), serum lipid-associated biomarkers (cholesterol, +14.8%; triglycerides, +39.2%; low-density lipoprotein-cholesterol, +40.0%; and high-density lipoprotein-cholesterol, -36.4%), liver-associated biomarkers (aspartate aminotransferase, +95.8%; and alanine aminotransferase, +205.0%) and androgen-associated biomarkers (free testosterone, -85.7%; total testosterone, -62.3%; and sex hormone-binding globulin, -79.6%); however, all variables returned to pre-cycle values post-cycle, apart from total fat mass, appendicular fat mass, bone area, total cholesterol and low-density lipoprotein-cholesterol. Follicle-stimulating hormone was below clinical reference values on- (1.2 IU/L) and post-cycle (1.3 IU/L). Intramuscular androgen receptor (-44.6%), testosterone (+47.8%) and dihydrotestosterone (+34.4%), in addition to one-repetition maximum leg press and bench press (+39.2 and +32.0%, respectively), were different in the case subject compared with non-users. These data demonstrate that LGD-4033 and MK-677 increase several body composition parameters, whilst negatively impacting bone and several serum biomarkers. Given the sparsity of data in recreationally using demographics, further research is warranted to elucidate the acute and chronic physiological effects of these anabolic agents.

Facilitators and barriers in preventing doping among recreational athletes: A qualitative interview study among police officers

Background

Doping is a societal problem associated with health problems, violence, and other crimes, especially when combined with alcohol and drugs. Elite, as well as recreational athletes who exercise in gyms may use doping to enhance their performance and/or improve their appearance. According to Swedish law, manufacturing, selling, supplying, possessing, and using anabolic androgenic steroids and growth hormones is forbidden. Exceptions apply if these substances are used for medical purposes and prescribed by doctors. As doping is illegal, the police authority is vital in counteracting doping.

Aim

We aimed to identify facilitators and barriers to effective doping prevention at gyms by examining police officers' views on doping as a societal problem, their experiences of doping prevention efforts, and their perceptions on what enables or hinders doping prevention.

Methods

Interviews with police officers (n = 15) were conducted from December 2021 to May 2022. The interviews were recorded and transcribed verbatim. A targeted content analysis of the material was performed.

Results

Facilitators for effective doping prevention involving the police included the recognition of doping as a societal problem; mobilization of key actors; motivated police management and officers; adequate resource allocation; collaboration between the police, gyms, and other relevant authorities; and skills development for police and other professions. Barriers to effective doping prevention included a lack of knowledge about doping, time-consuming processes around the detection and collection of evidence in doping offenses, and competing tasks for police officers.

Conclusion

Doping prevention should become more efficient by taking advantage of existing facilitators and removing remaining barriers. This study could guide recommendations linked to the police organization and the surrounding society regarding doping prevention.

Fatal Form of COVID-19 in a Young Male Bodybuilder Anabolic Steroid Using: The First Autopsied Case

We report the case of a 34-year-old male patient, a bodybuilding trainer and user of anabolic androgenic steroids (AASs) for 16 years. He was found in cardio-respiratory arrest in his home. By performing a medico-legal autopsy, a severe form of COVID-19, aortic atherosclerotic plaques, and an old myocardial infarction was found. The SARS-CoV-2 RT-PCR test on necroptic lung fragments was positive, with a B.1.258 genetic line. The histopathological examinations showed microthrombi with endothelitis in the cerebral tissue, massive pulmonary edema, diffuse alveolar damage grade 1, pulmonary thromboembolism, hepatic peliosis, and severe nesidioblastosis. The immunohistochemical examinations showed SARS-CoV-2 positive in the myocardium, lung, kidneys, and pancreas. ACE-2 receptor was positive in the same organs, but also in the spleen and liver. HLA alleles A*03, A*25, B*18, B*35, C*04, C*12, DRB1*04, DRB1*15, DQB1*03, DQB1*06 were also identified. In conclusion, death was due to a genetic predisposition, a long-term abuse of AASs that favored the development of a pluriorganic pathological tissue terrain, and recent consumption of AASs, which influenced the immune system at the time of infection.

Psychosocial aspects of sports medicine in pediatric athletes: Current concepts in the 21st century

Behavioral aspects of organized sports activity for pediatric athletes are considered in a world consumed with winning at all costs. In the first part of this treatise, we deal with a number of themes faced by our children in their sports play. These concepts include the lure of sports, sports attrition, the mental health of pediatric athletes (i.e., effects of stress, anxiety, depression, suicide in athletes, ADHD and stimulants, coping with injuries, drug use, and eating disorders), violence in sports (i.e., concepts of the abused athlete including sexual abuse), dealing with supervisors (i.e., coaches, parents), peers, the talented athlete, early sports specialization and sports clubs. In the second part of this discussion, we cover ergolytic agents consumed by young athletes in attempts to win at all costs. Sports doping agents covered include anabolic steroids (anabolic-androgenic steroids or AAS), androstenedione, dehydroepiandrostenedione (DHEA), human growth hormone (hGH; also its human recombinant homologue: rhGH), clenbuterol, creatine, gamma hydroxybutyrate (GHB), amphetamines, caffeine and ephedrine. Also considered are blood doping that includes erythropoietin (EPO) and concepts of gene doping. In the last section of this discussion, we look at disabled pediatric athletes that include such concepts as athletes with spinal cord injuries (SCIs), myelomeningocele, cerebral palsy, wheelchair athletes, and amputee athletes; also covered are pediatric athletes with visual impairment, deafness, and those with intellectual disability including Down syndrome. In addition, concepts of autonomic dysreflexia, boosting and atlantoaxial instability are emphasized. We conclude that clinicians and society should protect our precious pediatric athletes who face many challenges in their involvement with organized sports in a world obsessed with winning. There is much we can do to help our young athletes find benefit from sports play while avoiding or blunting negative consequences of organized sport activities.