244Word Count: 4664 ABSTRACT Aim: To describe the electrocardiographic (ECG) and echocardiographic manifestations of the paediatric athlete's heart, and examine the impact of age, race and sex upon cardiac remodelling responses to competitive sport. Design: Systematic review and meta-analysisData sources: Six electronic databases were searched to May 2016: MEDLINE, PubMed, EMBASE, Web of Science, CINAHL and SPORTDiscus.Inclusion criteria: 1) Male and/or female competitive athletes, 2) participants aged 6-18 years, 3) original research article published in English language.Results: Data from 14,278 athletes and 1,668 non-athletes were included for qualitative (43 articles) and quantitative synthesis (40 articles). Paediatric athletes demonstrated a greater prevalence of training-related and training-unrelated ECG changes than non-athletes. Athletes ≥14 years were 15.8 times more likely to have inferolateral T-wave inversion than athletes <14 years. Paediatric black athletes had significantly more training-related and training-unrelated ECG changes than Caucasian athletes. Age was a positive predictor of left ventricular (LV) internal diameter during diastole, interventricular septum thickness during diastole, relative wall thickness and LV mass. When age was accounted for, these parameters remained significantly larger in athletes than non-athletes. Paediatric black athletes presented larger posterior wall thickness during diastole (PWTd) than Caucasian athletes. Paediatric male athletes also presented with larger PWTd than females. Conclusions:The paediatric athlete's heart undergoes significant remodelling both before and during 'maturational years'. Paediatric athletes have a greater prevalence of training related and training-unrelated ECG changes than non-athletes, with age, race and sex mediating factors on cardiac electrical and LV structural remodelling. Word count: 244 What is already known? Chronic training loads are associated with a number of electrophysiological, structural and functional cardiac adaptations in adult athletes.  Race and sex significantly impact upon the cardiac remodelling of the adult athlete's heart.  Paediatric athletes undergo significant growth and maturational changes; but unlike known musculoskeletal changes, there is limited information regarding how the heart may adapt to training before, during and after puberty. What are the new findings? Paediatric athletes were up to 13 times more likely to have deep T-wave inversion (TWI) (≥2mm) than age-matched non-athletes  Paediatric athletes ≥14 years of age were up to 16 times more likely to have inferolateral TWI (warranting further investigation) than athletes <14 years  Paediatric black athletes were up to 36 times more likely to have extended anterior TWI (leads V1-V4) than Caucasians.  Even after accounting for age, left ventricular structural parameters were larger among paediatric athletes than paediatric non-athletes

groups IA and IIIA (50 ± 6 and 54 ± 8 ml/(m 2 ) 1.5 versus 42 ± 7 and 43 ± 2 ml/(m 2 ) 1.5 respectively). Group IIIC also had significantly larger mean wall thickness (MWT) compared to all groups. Athletes from group IIIC required greater longitudinal strain for any given % volume which correlated to MWT (r = 0.4, p < 0.0001). Findings were similar in the RV with the exception that group IIIC athletes required lower strain for any given % area. There are physiological differences between athletes with the largest LV and RV in athletes from group IIIC. These athletes also have greater resting longitudinal contribution to volume change in the LV which, in part, is related to an increased wall thickness. A lower longitudinal contribution to area change in the RV is also apparent in these athletes.

Bi-atrial hypertrophy is demonstrated in HDHS athletes and not in LDHS athletes, suggesting that the dynamic component to training is the primary driver for both LA and RA adaptation. Although functional data derived from volume shifts suggest augmented function in HDHS athletes, MST imaging demonstrated no difference in intrinsic atrial ε in any of the groups.

The collective term 'black' should not imply that the hearts of all black athletes are universally comparable. There is considerable variability in the cardiac electrical and structural remodelling response to exercise that appears to be dependent on geographic origin.

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Background: International electrocardiographic (ECG) recommendations regard anterior Twave-inversion (ATWI) in athletes <16 years to be normal. Design: Identify the prevalence, distribution, and determinants of TWI by ethnicity, chronological and biological age within paediatric athletes. Secondly, establish diagnostic accuracy of international ECG recommendations against refinement within athletes who present ECG variants isolated to ATWI (V1-V4) using receiver operator curve (ROC) analysis. Clinical context was calculated using Bayesian analysis. Methods: 418 Arab and 314 black male athletes (11-18 years) were evaluated by ECG, echocardiogram and biological age (via radiological x-ray) assessment. Results: 116 (15.8%) athletes presented ATWI (V1-V4), of which 96 (82.8%) were ECG variants isolated to ATWI. 91 (12.4%) athletes presented ATWI confined to V1-V3, with prevalence predicted by black ethnicity (odds ratio (OR) 2.2; 95% CI 1.3-3.5) and biological age <16 years (OR 2.0; 95% CI 1.2-3.3). Of the 96 with ATWI (V1-V4) observed in the absence of other ECG findings considered to be abnormal as per international recommendations for ECG interpretation in athletes, diagnostic accuracy was 'fail' (0.47 95% CI 0.00-1.00) for international recommendations and 'excellent' (0.97 95% CI 0.92-1.00), when governed by biological age <16 years, providing a positive (+LR) and negative (-LR) likelihood ratio of 15.8 (95% CI 1.8-28.1) and 0.0 (95% CI 0.0-0.8), respectively. Conclusion: Interpretation of ECG variants isolated to ATWI (V1-V4) using international recommendations (chronological age <16 years), warrants caution, but governance by biological age yielded an 'excellent' diagnostic accuracy. In clinical context, the 'chance' of detecting cardiac pathology within a paediatric male athlete presenting ATWI in the absence of other ECG findings considered to be abnormal as per international recommendations for ECG interpretation in athletes (+LR=15.8), was 14.4%, whereas a negative ECG (-LR=0.0) was 0%.

We have investigated prospectively the diagnostic accuracy, specialist satisfaction and patient-specialist rapport of a low-cost audio-visual link between a junior doctor with a patient and a consultant rheumatologist. Using a telephone link and subsequently a video-phone link, 20 patients, with various rheumatological problems, were presented by a junior doctor to the consultant rheumatologist for provisional diagnosis. All patients were then seen face to face by the consultant, when a final diagnosis was made. An independent consultant rheumatologist made a 'gold standard' diagnosis. Thirty-five per cent of diagnoses were made correctly over the telephone and 40% over the video-phone--there was no significant difference in the diagnostic accuracy between these two methods of communication. Rapport over the video-phone was universally poor. Where it was important, clinical signs could not be visualized over the video-phone and in more than 85% of cases small joint swellings could not be seen clearly.

In Arab and black male paediatric athletes, new international recommendations outperform both the Seattle criteria and 2010 ESC recommendations, reducing false positive rates, while yielding a 'fair' diagnostic accuracy for cardiac pathology that may predispose to SCA/D. In clinical context, the 'chance' of detecting cardiac pathology within a paediatric male athlete with a positive ECG (+LR=9.0) was 8.3%, whereas a negative ECG (-LR=0.4) was 0.4%.