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Home , Alexander Fleming, Howard Florey, Peter Medawar, Robin Warren

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world to making a unique discovery. 43(3), Spring 2000, pp. 406-448. Which diseases in sports Secondly, even if your abstract is might be caused by ? It is worth noting that the “New Germ rejected from your society’s annual The number one candidate, in my Will a Nobel ever be awarded to Theory” does not pose a threat to the conference (as it was – see the MJA view, would have to be “chondral importance of public health, because article for evidence), it doesn’t mean degeneration” in the knee joint, of the ability for microorganisms you won’t end up winning a Nobel in particular. How many times do someone in sports medicine or to evolve rapidly. For example, Prize for the research. Thirdly, you you see a patient go in for a knee the HIV virus is an infection which can be a touch on the eccentric (mad) arthroscope for a meniscal tear, and is known to mutate according to side, as Robin Marshall obviously in which the surgeon also finds grade its environment. In Africa, where science? By Dr J was when he drank a helicobacter 1-2 chondral degeneration in the joint, unfortunately sexual practices are solution to give himself gastritis, and followed by a rapid deterioration after not generally very safe, HIV is far it may actually help you be a great the arthroscopy? A year later another more virulent, as it is usually given It is a time for great celebration that breakthrough in the field of ) just won the FE Johnson Memorial scientist. Fourthly, you might do well arthroscopy is performed and this ample opportunity to spread from we have just had two Australian would rank as highly as any of the Fellowship of the NSW Sporting to think that infection could have time the patient has grade 4 chondral victim to victim, even if the victims medical doctors awarded the Nobel Nobel prizes awarded for medicine. Injuries Committee for 2005, whereas an undiscovered role in a common damage (that is, frank osteoarthritis) die relatively quickly of the disease. Prize for medicine and is credited with Justin Paoloni has already won the condition where the ruling view is and a disability that will last a lifetime. The strains of HIV which are seen in ( and ). discovering that the mould David Garlick Memorial Scholarship that is has no role. Of course, the ruling dogma is that Western countries have, by contrast, Their discovery was that the could inhibit the growth of , but for this work. the “early” chondral damage seen One of my all-time favourite articles become far milder, presumably due bacterium Helicobacter pylori is in the Australian Sir (who in the first arthroscopy constituted There was an IOC Olympic Prize I have ever read was called “A New to the widespread institution of safe fact the major cause of stomach has an institute named after him in a joint “weakness” that after further in sports science and medicine Germ Theory” written by Judith sex practices. Because there is less ulcers which can now be successfully Melbourne) is considered to have been “mechanical loading” deteriorated which was awarded every two years Hooper and published in The Atlantic opportunity for the virus to spread treated with antibiotics. Those of us most responsible for introducing the to frank arthritis. Yes, I believe that between 1996 and 2002, but not Monthly in February 1999. This from patient to patient, it ‘evolves’ in sports medicine should greet this to clinical practice. early wear of the knee joint can later awarded in 2004 because of the article focused on the theories of to become more benign, as it would award with a similar level of elation become advanced wear, but in the Warren and Marshall deserve the withdrawal of sponsorship from the Greg Cochran and Paul Ewald, who be disadvantageous to kill its hosts that we felt, for example, when Cathy average patient this normally takes highest of our praises for making a Pfizer company. This award, if it is believe (via Darwinian theory) that before there was a chance to spread. Freeman won the 400 m at the Sydney 20-30 years. How come it can happen discovery which vastly improves a resurrected, may possibly be seen any common medical condition which Olympics. Admittedly the Freeman If, for example, the proponents of to some poor victims in under 12 common disease in clinical medicine, as the “Nobel” equivalent in sports has been around for generations gold might have warranted more the “New Germ Theory” are right months when they don’t run a single for being prepared to challenge science and medicine. Yet it would but which substantially reduces instantaneous joy in that the ‘event’ about Type-II diabetes, that it might step due to the fact that they have existing dogma about the causation only be an equivalent for as long as human fitness should be considered lasted less than a minute but there are involve an infectious agent, then it a knee effusion for the entire year? of peptic ulcer and, locally, for it was considered impossible for a an infectious disease until proven more than one hundred Australian would still be important to push the In my mind, the likely culprit is an conducting all of their work within sports medicine researcher actually to otherwise. For example, not only Olympic gold medallists yet only a public health message about exercise infectious agent and, sadly, the likely (in the city of ). You win a real . do they believe that peptic ulcer is dozen Australian Nobel Prize winners. and good nutrition. In a society source of entry to the joint is the should take any chance you get to caused by an infectious agent, they Those small-minded folk who think where there is a high population of initial knee arthroscopy itself. The only Australian Nobel Prize winners read about the story of Warren and assert that cardiovascular disease that I have tenuous grip on reality overweight and obese people, if an in medicine and physiology are: Marshall, including the free text in the must be too, along with diabetes, OK, some of you sceptics out there would probably suggest to me that infectious agent can cause diabetes Christmas edition of the Med J Aust at rheumatoid arthritis, Alzheimer’s who may actually be medicos who • Warren and Marshall in 2005 for sports medicine experts should stick in these people, from an evolutionary disease and many cancers, etc. have treated patients with chronic their discovery of Helicobacter http://www.mja.com.au/public/ to the task of proving to the Australian perspective it can afford to be a far effusion post-arthroscopy may be able pylori, issues/183_11_051205/van11000_ Government that we actually exist as a If you consider this concept to nastier agent, as the potential pool of fm.html distinct area of medicine before anyone to tell me that: • Peter Doherty (along with Rolf be preposterous, remember that victims is huge (and from the agent’s starts worrying about winning the Zinkernagel, a Swiss working With respect to the field of sports mainstream gastroenterologists have viewpoint it will not affect its spread 1. Whenever you have sent a knee Nobel prize for a sports medicine study. in Australia) in 1996 for their medicine, a recent Nobel award only accepted in the last decade that if a few victims die of the disease). In effusion in this scenario off for a Even though we tend to equate sports discoveries in , has major relevance ( Helicobacter pylori causes peptic a society (which unfortunately is now culture it has always come back medicine with sports injuries, if we start and in 2003 for the ulcers. There is some evidence that a hypothetical one) where everyone negative AND • John Eccles (along with Hodgkin to think along the sports and exercise various chlamydia organisms are exercised regularly and ate moderate discovery of magnetic resonance 2. If you have ever happened to treat and Huxley of the UK) in 1963 for medicine paradigm, perhaps it won’t associated with cardiovascular disease, amounts of food, if you were a imaging). In 1998 three Americans a patient in this scenario with a his discoveries regarding nerve be long before we see an exercise although this has not yet been proven diabetes-causing virus you would (Furchgott, Ignaro and Murad) shared standard antibiotic (eg, Amoxil) cells, medicine Nobel laureate. Researchers to nearly the same degree as the quickly mutate to a more benign the Nobel Prize for medicine for their it hasn’t helped with the knee such as Jeremy Morris, Ralph helicobacter/peptic ulcer connection. form. It would be very costly to kill • Frank Macfarlane Burnett (along discoveries with respect to the role effusion. Paffenbarger and Stephen Blair must with ) in 1960 for his of nitric oxide in the cardiovascular For a summary of of the Atlantic your victims due to the difficulty in surely be close to that elusive Nobel http://www. This is where a read of the story of discoveries in immunology, and system. Their work has probably article, please refer to: finding replacement victims (given for their work proving that exercise can injuryupdate.com.au/forum/ Marshall and Warren is extremely inspired that of George Murrell and that the virus might need a high-fat • Howard Florey (along with Fleming prevent heart disease and cancer. showthread.php?p=1066#post1066. valuable. They only managed to Justin Paoloni who have discovered host environment in which to live). and Chain of the UK) in 1945 for culture Helicobacter pylori when that nitrates can improve the clinical If we switch back to Marshall and And for a more formal reference, try Therefore, even if there are infectious the discovery of penicillin. one of their plates was accidentally outcome of tendinopathy, which Warren, there are lessons for us to Cochran GM, Ewald P and Cochran agents that cause diabetes that we left in a laboratory over the Easter In terms of the impact on improving may one day be worthy of a major learn. Firstly, that you can be an K (“Infectious Causation of Disease: are yet to discover, we can limit their break. Normally in if a the human condition, the discovery of international award in the field Australian and living and working in An Evolutionary Perspective) in spread by increasing rates of exercise culture is not positive after 48 hours, penicillin (which was the biggest ever sports medicine. George Murrell has Australia and still beat the rest of the Perspectives in and Medicine and improving nutrition.

 Sport Health VOLUME 23 – ISSUE 4 • SUMMER 2005-06  D R J A nti -D oping A uthority

the plates will be discarded and a by Vincent J, Podewell C, Franklin Achilles tendinopathy patients have negative result recorded. Helicobacter GW and Korn JH. This short cracked heels, presumably due to pylori managed to evade detection for PubMed abstract states that Kingella low-grade skin fungal infection The new Australian Sports many years because it takes longer (Moraxella) kingii, a gram-negative (see figure). A lot of the general than 48 hours to multiple on an agar bacillus, was isolated as the cause population also has low-grade fungal plate. When you think about it, based of septic knee arthritis in an adult. infection of the heel, but is it more on Darwinian theory, if you are an Three previous cases (one adult and common in Achilles tendinopathy Anti-Doping Authority infectious agent in modern times two children) of septic arthritis due to patients? I don’t know, but perhaps Adam Firth (such as a bacterium, virus or fungus) Moraxella species have been reported. one day in the future I will do a case- what would be the most important All cases have been characterised by control study to test this hypothesis, The year 2004-05 has been a landmark in Australia’s anti-doping effort, Chairperson Brian Sando says in the latest -– and characteristic you could evolve to difficulty in identifying the organism, and on another occasion I might treat probably the last -- annual report of ASDA before the Government turns it into ASADA, the Australian Sports Anti-Doping ensure your survival? The mainstream indolent clinical course and slow some of my non-response Achilles Authority. thinking is that “antibiotic resistance” response to antibiotic treatment. tendinopathy patients with Lamisil to Acting Chief Executive Kim Terrell points out in the report that the establishment of ASADA, implementing one of the biggest (or anti-viral resistance) is the major see how they go. Does this (underlined section) sound testing programs ever undertaken in Australia and the work on the 2006 Commonwealth Games will be high priorities for 2005- evolutionary defence mechanism that 06. For example, the Agency will conduct more than 7,000 drug tests in 2005-06 -- on average, that’s at least 19 athletes tested to you like the standard progress microorganisms have. What about every day of the year. of a post-arthroscopy patient with a inability to grow on an in chronic effusion? What if there are Sport Health here publishes extracts from the report on issues of special interest to its readers, such as no advance notice a pathology lab? Wouldn’t that be testing, trends in notifiable events and the prospects for an online athlete whereabouts system. actually dozens of organisms out a far more valuable characteristic there like Kingella kingii, which can to develop compared to antibiotic chew through knee articular cartilage resistance? If you are resistant to an but are difficult to identify and antibiotic, the humans will just hit you don’t respond to standard antibiotic On 23 June 2005 the Australian governing bodies in Australia sign on or other law enforcement agencies with a different antibiotic until they treatment? Apparently Kingella kingii Government announced its intention to use ASADA for such purposes. where relevant to a possible anti- nail you. However, if you refuse to to establish the Australian Sports doping policy breach; does not grow well in the laboratory It will be a condition of government conform to their belief that they must Anti-Doping Authority (ASADA), within 48 hours and if not transported funding and other support that • power to present the prosecution be able to see you grow within 48 which from early this year will take in blood culture bottles so, from sports submit all their anti-doping case before a tribunal (whether or hours on an agar plate in a pathology over from the Australian Sports a routine tap of the knee joint, a operations to ASADA, and ensure that not ASADA investigated the case). laboratory, they probably won’t even Drug Agency (ASDA) as Australia’s Kingella kingii infection will generally their members and staff cooperate This may include prosecuting know that you exist and therefore NADO under the World Anti-Doping return a negative result (just like fully with ASADA in the performance adverse analytical findings in won’t be throwing any antibiotics in Code (WADC), but with significant Helicobacter pylori used to do with of its functions. It will also be a respect of a sample tested by your direction in the first place. additional functions to ASDA in the peptic biopsies). For more info, read requirement that the sport accepts ASADA; and fight against doping in Australian If the bacteria (or other non-bacterial http://www.medterms.com/script/ any adverse finding of ASADA against sport. • the ability to publish results of any microorganisms) which are most likely main/art.asp?articlekey=33658. any of its athletes (or other persons to infect a knee after an arthroscopy The great thing about being involved hearing where it is in the public One of my personal areas of clinical No doubt ASADA is motivated at within the sport’s jurisdiction), happen to be resistant to amoxicillin in science is the thrill of watching interest. expertise is the treatment of Achilles least in part by the Australian cycling ensures that infraction notices are and don’t grow on agar plates, then our knowledge base evolve. Fifteen tendinopathy, and I occasionally think controversies of the past two years served on such persons and enforces The effect will be to have a common they can continue on their merry way years ago the internet didn’t exist and, about whether an infectious agent and the experiences in the United penalties imposed in accordance with procedure and consistent practices eating through the layers of articular 25 years ago, no one suspected that might be responsible for the failure States with the BALCO scandals. Its the sport’s anti-doping rules. The throughout Australian sport in hyaline cartilage whilst the doctors Helicobacter pylori was a common of Achilles tendinopathy patients enabling rules and regulations are Government has used purse string pursuing anti-doping rule violations who are supposed to be treating the cause of peptic ulcer. If you are to repair their degenerative lesions. not yet finalised and accordingly control to good effect in forcing all and enforcing anti-doping policies. patient nod their heads about the working in sports and exercise We know that tendon degeneration this article can only make comment Australian sports to sign on to the Consistency between and within inevitability of cartilage breakdown. I medicine, you are working in an area is very common (eg, the Jill Cook on some features that have been WADC and it can be expected that it sports can only be a positive thing in can remember a case from my intern which, despite its snubbing by the studies on patella tendons) yet we announced and in relation to such a will pursue use of ASADA with the reducing uncertainties that have in the year of a woman who had a persistent mainstream medical profession, is one know that many people with tendon body generally. same intent. past been seen in anti-doping matters effusion after a knee arthroscopy and which is critical to the advancement degeneration don’t get pain and in Australia and around the world. was stuck on my orthopaedic ward of human health. Maybe we won’t More specifically, in addition to many cure their own radiological for weeks due to severe knee pain. see a Nobel Prize-winning discovery ASADA’s powers ASDA’s existing powers, ASADA will The most significant new features tendinopathy spontaneously. Eventually the pathologists isolated in sports medicine in our lifetime, but have: of ASADA are its investigative Could it be that those who don’t Kingella kingii bacterium from maybe we will. What is assured is It has been confirmed that ASADA and prosecutorial functions. An spontaneously cure possibly have an • power to conduct investigations on her knee, but it was thought to be that there will be new and successful will replace ASDA in handling the independent, government-funded infectious agent responsible for the the basis of information acquired possibly a benign pathogen. ways to prevent and manage major responsibilities of sample collection body fulfilling such a role has been ongoing degeneration? I’m not saying from its drug testing and other sports injuries that are discovered in and testing, and education and sought by many sports organisations There is a case report which suggests that this is necessarily the case, but activities, or where it has received our lifetime, and that some of them advocacy. It will also play a role in in this country for some time as this may be a cause of septic I can hypothesise that it wouldn’t information from any other person, will be discovered in this wonderful policy development relevant to sports the burden of anti-doping policy arthritis in J Rheumatol (1981 May- be an in-your-face bacterium like or on its own initiative; country of ours. doping, and most significantly will enforcement distracts time and Jun;8(3):501-3): “Septic arthritis due aureus, or someone act as the investigator and prosector • power to receive, use and disclose resources from developing their to Kingella (Moraxella) kingii: case would have already cultured it. of all allegations of anti-doping rule (where appropriate) information sport, their competitions and their report and review of the literature”, I regularly notice that many of my violations relating to sports whose from Australian Customs Service athletes. This is particularly the case

 Sport Health VOLUME 23 – ISSUE 4 • SUMMER 2005-06