Background: There is concern about whether cardiac damage occurs as a result of prolonged strenuous exercise. Objective: To investigate whether competing in a triathlon is associated with cardiac damage based on a sustained increase in cardiac troponin T (cTnT), and whether such an increase correlates with echocardiographic changes Methods: cTnT and echocardiographic measurements were made in 38 participants in the 2001 Australian ironman triathlon. cTnT was measured the day before, immediately after, and the day following the race. Echocardiography was done the day before, immediately after, and two to six weeks later for measurement of ejection fraction, stroke volume, cardiac output, wall motion analysis, and global left ventricular function (LVF). Results: No subject had detectable cTnT in the pre-race sample. Following the race, 32 subjects (86.5%) had detectable levels of cTnT (.0.01 ng/ml), with six (16.2%) having .0.10 ng/ml. The day after the race, nine subjects (23.7%) still had detectable cTnT, with two recording a level .0.10 ng/ml. Previously described echocardiographic changes of ''cardiac fatigue'' were observed in the whole cohort. There was a modest but significant correlation between change in ejection fraction and peak cTnT level (p = 0.02, r = 0.39). Athletes with a post-race cTnT .0.10 ng/ml had a greater decrease in global LVF (p = 0.02) and a trend toward a greater fall in ejection fraction and stroke volume than athletes with cTnT levels ,0.10 ng/ml. Cardiac output fell in the group with cTnT .0.10 ng/ml (p.0.05). Conclusions: Participation in ironman triathlon often resulted in persistently raised cTnT levels, and the troponin rise was associated with echocardiographic evidence of abnormal left ventricular function. The clinical significance and long term sequelae of such damage remains to be determined.

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The number of food systems education programs and curricula in the U.S. has increased in response to the growing interest in where food comes from and how it is grown. While these educational efforts aim to increase learners' connection to food and the land, they do not always focus explicitly on the structural inequities that shape food systems and the experiences of food workers. There is, however, a small but growing number of food systems education programs that seek to shed light on and challenge these inequities. We build on these existing critical approaches to food systems education by introducing the notion of critical food literacy-or the ability to examine one's assumptions, grapple with multiple perspectives and values that underlie the food system, understand the larger sociopolitical contexts that shape the food system, and take action toward creating just, sustainable food systems. In particular, we discuss and highlight the potential of multicultural texts to make visible food workers, especially those who tend to be less visible, and identify pedagogical strategies for cultivating critical food literacy by drawing on empirical research on response to multicultural literature and using a multicultural text produced by the Food Chain Workers Alliance as an illustrative example. Ultimately, we argue that citizens who develop and demonstrate critical food literacy can participate in public, democratic discourse about food systems and help create food systems that are just and sustainable for all.

Training in the medical specialty of sport and exercise medicine (SEM) is available in many, but not all countries. In 2015, an independent Delphi group, the International Syllabus in Sport and Exercise Medicine Group (ISSEMG), was formed to create a basic syllabus for this medical specialty. The group provided the first part of this syllabus, by identifying 11 domains and a total of 80 general learning areas for the specialty, in December 2017. The next step in this process, and the aim of this paper was to determine the specific learning areas for each of the 80 general learning areas. A group of 26 physicians with a range of primary medical specialty qualifications including, Sport and Exercise Medicine, Family Medicine, Internal Medicine, Cardiology, Rheumatology and Anaesthetics were invited to participate in a multiple round online Delphi study to develop specific learning areas for each of the previously published general learning areas. All invitees have extensive clinical experience in the broader sports medicine field, and in one or more components of sports medicine governance at national and/or international level. SEM, Family Medicine, Internal Medicine, Cardiology, Rheumatology and Anaesthetics were invited to participate in a multiple round online Delphi study to develop specific learning areas for each of the previously published general learning areas. All invitees have extensive clinical experience in the broader sports medicine field, and in one or more components of sports medicine governance at national and/or international level. The hierarchical syllabus developed by the ISSEMG provides a useful resource in the planning, development and delivery of specialist training programmes in the medical specialty of SEM.

Stress fractures are a well-recognized hazard for athletes who undergo intensive training; they occur predominantly in the lower limb and are associated with high-mileage running. Stress fractures of the upper limb do occur, however, and have been reported in association with a number of sports as diverse as gymnastics' and body building.' Isolated stress fractures have previously been reported in tennis players,2,4 particularly in the dominant arm, but no stress fracture associated with a specific technique has emerged. We report two cases of a stress fracture at the same site in the nondominant arms of professional tennis players. The fractures were associated with the same technique, the double-handed backhand stroke. CASE REPORTSCase 1 A 17-year-old, right-handed, female professional tennis player came to our Institute complaining of pain in the left forearm. She had been participating in a state competition and had played several matches over a weekend. On that Sunday she had noticed gradually increasing pain when using the double-handed backhand stroke. The pain became steadily worse, causing her to become unable to use this stroke the following week, at which time she came to our Institute.At presentation the only physical findings were tenderness over the middle third of the ulna and pain on resisted pronation. Radiographs were unremarkable, but a technetium bone scan showed markedly increased uptake over the site of tenderness (Fig. 1). Routine blood tests excluded any metabolic bone disease. Figure 1. Bone scan showing stress fracture of the ulna shaft.LT, local tenderness. Case 2A 21-year-old, right-handed, male professional tennis player came to our Institute complaining of pain in the left forearm. He had been undertaking intensive backhand training over the prevous few weeks and had developed increasing pain over the anteromedial aspect of the forearm on ball contact when using the double-handed backhand stroke. The pain progressed until it was present after matches. On examination, the only physical finding was tenderness of the anteromedial aspect of the ulna at the junction of the proximal and middle thirds. Radiographs were normal; the bone