Sickle cell trait and safe athletic participation: the way forward.

Sickle cell trait (SCT) has garnered much attention for its association with extremely rare exertion-related events in athletes and soldiers. Recent Current Sports Medicine Reports Pearls and Pitfalls columns by Dr. E. Randy Eichner criticized the Army and the American Society of Hematology (ASH) for their approach to SCT testing and athletics (1,2). Contrary to his assertions, we actually agree that overexertion and ‘‘heroic intensity’’ can be problematic, especially in preseason sports training and new onset military training. Weagree that heat anddehydration can contribute to, but are not necessarily required for, an exercise-associated collapse. We additionally agree that when precautions are not properly implemented, a catastrophic collapse may ensue. Finally we agree that knowing how and when to intervene saves lives. However we believe that best practices need to be applied to all student athletes, whereas Dr. Eichner argues that they are uniquely relevant to, and/or should be applied selectively to, athletes with SCT. What specifically is ASH doing to move the field forward? ASH has participated in roundtable discussions organized by the Consortium for Health and Military Performance and the American College of Sports Medicine on ways to prevent, diagnose, and care for athletes with exertional collapse (6). These productive interactions resulted in a proposal for common terminology of events and a description of optimal interventions. ASH is exploring opportunities with leadership at the National Institutes of Health for research on SCT and adverse health consequences (3). ASH also has partnered with the U.S. Centers for Disease Control and Prevention to create or update educational materials for both athletes and the general public on SCT inheritance, possible complications, and how to mitigate risk (4). Screening for sickle cell disease (SCD) for all newborns was adopted as a public health imperative in the United States because of the strong scientific evidence that detection of SCD in young children and early intervention, such as penicillin to prevent infection, reduce morbidity and mortality. The same cannot be said of SCT screening for athletic participation (7). The National Collegiate Athletic Association (NCAA) testing requirement is presenting hundreds of thousands of young people with difficult ethical and practical choices. These student athletes need access to sound information and advice on which to base their decisions V decisions that could be life changing. Mechanisms for how SCT might contribute to exertional rhabdomyolysis have been proposed but remained untested, so prospective, hypothesis-driven studies are needed (5,7). In the meantime, guidelines that represent best practices can ensure that all student athletes participate safely. Defining and implementing best practices is how physicians generally approach decision making in complex situations. The Army has adopted this approach to ensure the safety of soldiers, as well as their readiness for combat; strategies to mitigate risk of exertion-related events and sudden deaths are regularly reviewed and revised as evidence-based data emerge (6). There are tremendous opportunities for experts across a broad scientific, medical, and ethical spectrum to partner on a best practice plan and a comprehensive research agenda. Many in the sports medicine community have been receptive to this approach, which would be greatly enhanced by constructive, respectful discourse. When risk is mitigated for all, mass screening for SCT, as currently employed by the NCAA, is unnecessary. Janis L. Abkowitz, MD Clement A. Finch Professor of Medicine Head, Division of Hematology University of Washington ASH President 2012, Seattle, WA