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Chromogranin A (CgA) is a well-known biomarker for neuroendocrine tumors (NETs). However, due to its non-specificity, a proper assessment of CgA test results requires a detailed knowledge of the factors, conditions, and medications influencing its serum concentration. We describe a case of a 61-year-old patient presenting with a mass suspicious of a gastrointestinal NET and an exceedingly high level of serum CgA persistent after mass resection. Following a thorough review of patient's medical history and clinical presentation, along with radiographic and pathological findings, no evidence of a NET was detected. A trial of proton-pump inhibitor (PPI) withdrawal led to a dramatic normalization of CgA level, marking it as the culprit causing this tumor marker elevation. This case highlights the significant impact of PPI use on CgA level, and should incentivize clinicians to provide proper education to patients prior to testing., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Alkhayat et al.)

Abstract: Bentley, I, Sinclair, JK, Atkins, SJ, Metcalfe, J, and Edmundson, CJ. Effect of velocity-based loading on acceleration kinetics and kinematics during sled towing. J Strength Cond Res 35(4): 1030-1038, 2021-Sled towing (ST) provides an external load in the form of a sled towed using a shoulder or waist harness and cord behind the athlete. Loading strategies have varied greatly between studies, and despite many investigations, there is little agreement on the optimum sled loading to develop the acceleration phase. The aim of this study was to investigate the kinetics and kinematics of velocity-based ST during the acceleration phase of sprinting. Twelve academy rugby league players performed a series of 6-m sprints in different conditions; uninhibited, 10, 15, and 20% velocity decrement (VDec). Sagittal plane kinematics and kinetic measures were examined using 1-way repeated-measures analysis of variance. Results indicated that ST affected trunk, knee, and ankle joint kinematics (p < 0.05). Peak knee flexion increased as sled loads increased (p < 0.05), which may enable athletes to lower their center of mass and increase their horizontal force application. Net horizontal and propulsive impulse measures were greater in all sled conditions (p < 0.05), which increased significantly because sled loadings were heavier. In conclusion, this study highlights the effects of differential loads to help coaches understand acute kinetics and kinematic changes to improve the planning of sprint training., (Copyright © 2018 National Strength and Conditioning Association.)

IL-23 and IL-12, two structurally related heterodimeric cytokines sharing a common subunit, divergently promote Th cell development and expansion. Both cytokines have been implicated in the pathogenesis of thyroid-associated ophthalmopathy (TAO), an autoimmune component of Graves disease. In TAO, CD34 + fibrocytes, putatively derived from bone marrow, can be identified in the orbit. There they masquerade as CD34 + orbital fibroblasts (OF) (CD34 + OF) and cohabitate with CD34 - OF in a mixed fibroblast population (GD-OF). Slit2, a neural axon repellent, is expressed and released by CD34 - OF and dampens the inflammatory phenotype of fibrocytes and CD34 + OF. In this study we report that thyrotropin (TSH) and the pathogenic, GD-specific monoclonal autoantibody, M22, robustly induce IL-23 in human fibrocytes; however, IL-12 expression is essentially undetectable in these cells under basal conditions or following TSH-stimulation. In contrast, IL-12 is considerably more inducible in GD-OF, cells failing to express IL-23. This divergent expression and induction of cytokines appears to result from cell type-specific regulation of both gene transcription and mRNA stabilities. It appears that the JNK pathway activity divergently attenuates IL-23p19 expression while enhancing that of IL-12p35. The shift from IL-23p19 expression in fibrocytes to that of IL-12p35 in their derivative CD34 + OF results from the actions of Slit2. Thus, Slit2 might represent a molecular determinant of balance between IL-23 and IL-12 expression, potentially governing immune responses in TAO., (Copyright © 2020 by The American Association of Immunologists, Inc.)

Purpose: Orbital fibroblasts from patients with Graves' disease (GD-OF) express many different cytokines when treated with bovine thyrotropin (bTSH). The present study aimed to determine why TNF-α cannot be induced by bTSH in GD-OF., Methods: Fibrocytes and GD-OFs were cultivated from donors who were patients in a busy academic medical center practice. Real-time PCR, Western blot analysis, reporter gene assays, cell transfections, mRNA stability assays, ELISA, and flow cytometry were performed., Results: We found that bTSH induces TNF-α dramatically in fibrocytes but is undetectable in GD-OF. The induction in fibrocytes is a consequence of increased TNF-α gene promoter activity and is independent of ongoing protein synthesis. It could be attenuated by dexamethasone and the IGF-1 receptor inhibiting antibody, teprotumumab. When separated into pure CD34+ OF and CD34- OF subsets, TNF-α mRNA became highly inducible by bTSH in CD34+ OF but remained undetectable in CD34- OF. Conditioned medium from CD34- OF inhibited induction of TNF-α in fibrocytes., Conclusions: Our data indicate that CD34- OF appear to release a soluble(s) factor that downregulates expression and induction by bTSH of TNF-α in fibrocytes and their derivative CD34+ OF. We proffer that CD34- OF produce an unidentified modulatory factor that attenuates TNF-α expression in GD-OF and may do so in the TAO orbit.

In this work, the thermal stability of the room temperature ionic liquid (RTIL) 1-ethyl-3-methylimidazolium ethylsulfate ([EMIM][EtSO 4 ]) is investigated using infrared (IR) spectroscopy. Quantitative IR absorption spectral data are measured for heated [EMIM][EtSO 4 ]. Spectra have been collected between 25 ℃ and 100 ℃ using a heated optical cell. Multiple samples and cell pathlengths are used to determine quantitative values for the molar absorptivity of [EMIM][EtSO 4 ]. These results are compared to previous computational models of the ion pair. These quantitative spectra are used to measure the rate of thermal decomposition of [EMIM][EtSO 4 ] at elevated temperatures. The spectroscopic measurements of the rate of decomposition show that thermogravimetric methods overestimate the thermal stability of [EMIM][EtSO 4 ].

Fibrocytes are monocyte progenitor cells that have been implicated in normal and pathological tissue remodeling. Among the prominent chemokine receptors expressed by these cells is CXC motif receptor 4 (CXCR4), which, with its cognate ligand CXCL motif ligand 12 (CXCL-12), directs fibrocytes to sites of fibrosis. Fibrocytes have been implicated in the pathogenesis of thyroid-associated ophthalmopathy, the ocular manifestation of Graves' disease (GD), by virtue of their unique accumulation as CD34 + orbital fibroblasts (OFs). Fibrocytes also express high levels of functional TSH receptor (TSHR). Here, we determined CXCL-12 and CXCR4 expression in fibrocytes and GD-OF and whether that pathway interacts with TSHR. CXCL-12 is highly expressed in GD-OF, whereas CXCR4 levels are dramatically higher in fibrocytes. Levels of these proteins are differentially regulated by TSH in a cell type-specific manner. Further, CXCL-12 enhances the induction by TSH of IL-6 in fibrocytes but attenuates this induction in GD-OF. In contrast, in pure CD34 + OF, the interplay between TSH and CXCL-12 reverts to that observed in fibrocytes. Our results indicate that CXCL-12 enhances TSH actions in fibrocytes but inhibits them in GD-OF, a dichotomy imposed by factors emanating from CD34 - OF. They also suggest a potentially important modulatory role for CD34 - OF in determining the factors that influence pathological TSHR signaling in the TAO orbit.

The aim of this study was to examine bilateral differences in ground reaction forces (GRF), measured during a deep squat (DS) exercise, in a population of elite youth soccer players. Bilateral muscle balance is a key component in promoting musculoskeletal health of performers, yet there is a limited evidence base investigating such imbalances in youth. Seventy-four subjects were assigned to performance groups according to chronological age (younger than 13, 14, 15, 16, 17 years). Analysis of physical maturity status revealed that very few players were classified as "early" or "late" maturers. Players completed an overhead DS exercise, as part of preseason functional movement screening. Peak GRF were assessed using a twin force plate system. Significant differences (p ≤ 0.05) were identified between right and left side peak GRF for all groups except the youngest (U13) and oldest (U17). Nondominant "sides" showed the highest levels of PGRF across all groups. The magnitude of PGRF was not significantly different both within and between groups, except for the left side in the U13 to U15 groups (p = 0.04). Results from this study show that performance asymmetry is marked in adolescence. There seems a "trigger point" during the early stage of adolescence, when bilateral imbalances become marked. These differences do seem to reduce during the later stages of adolescence. Correct attention to focussed training, designed to remediate any imbalance, is warranted in adolescent groups. This is important with respect of the key associations between bilateral asymmetry and risk of injury.

Resisted sprint training is performed in a horizontal direction and involves similar muscles, velocities, and ranges of motion (ROM) to those of normal sprinting. Generally, sleds are attached to the athletes through a lead (3 m) and harness; the most common attachment points are the shoulder or waist. At present, it is not known how the different harness point's impact on the kinematics and kinetics associated with sled towing (ST). The aim of the current investigation was to examine the kinetics and kinematics of shoulder and waist harness attachment points in relation to the acceleration phase of ST. Fourteen trained men completed normal and ST trials, loaded at 10% reduction of sprint velocity. Sagittal plane kinematics from the trunk, hip, knee, and ankle were measured, together with stance phase kinetics (third footstrike). Kinetic and kinematic parameters were compared between harness attachments using one-way repeated-measures analysis of variance. The results indicated that various kinetic differences were present between the normal and ST conditions. Significantly greater net horizontal mean force, net horizontal impulses, propulsive mean force, and propulsive impulses were measured (p < 0.05). Interestingly, the waist harness also led to greater net horizontal impulse when compared with the shoulder attachment (p < 0.001). In kinematic terms, ST conditions significantly increased peak flexion in hip, knee, and ankle joints compared with the normal trials (p < 0.05). Results highlighted that the shoulder harness had a greater impact on trunk and knee joint kinematics when compared with the waist harness (p < 0.05). In summary, waist harnesses seem to be the most suitable attachment point for the acceleration phase of sprinting. Sled towing with these attachments resulted in fewer kinematic alterations and greater net horizontal impulse when compared with the shoulder harness. Future research is necessary in order to explore the long-term adaptations of these acute changes.

A relationship between the actions of TSH and IGF-1 was first recognized several decades ago. The close physical and functional associations between their respective receptors (TSHR and IGF-1R) has been described more recently in thyroid epithelium and human orbital fibroblasts as has the noncanonical behavior of IGF-1R. Here we report studies conducted in lung fibroblasts from female wild-type C57/B6 (TSHR(+/+)) mice and their littermates in which TSHR has been knocked out (TSHR(-/-)). Flow cytometric analysis revealed that cell surface IGF-1R levels are substantially lower in TSHR(-/-) fibroblasts compared with TSHR(+/+) fibroblasts. Confocal immunofluorescence microscopy revealed similar divergence with regard to both cytoplasmic and nuclear IGF-1R. Western blot analysis demonstrated both intact IGF-1R and receptor fragments in both cellular compartments. In contrast, IGF-1R mRNA levels were similar in fibroblasts from mice without and with intact TSHR expression. IGF-1 treatment of TSHR(+/+) fibroblasts resulted in reduced nuclear and cytoplasmic staining for IGF-1Rα, whereas it enhanced the nuclear signal in TSHR(-/-) cells. In contrast, IGF-1 enhanced cytoplasmic IGF-1Rβ in TSHR(-/-) fibroblasts while increasing the nuclear signal in TSHR(+/+) cells. These findings indicate the intimate relationship between TSHR and IGF-1R found earlier in human orbital fibroblasts also exists in mouse lung fibroblasts. Furthermore, the presence of TSHR in these fibroblasts influenced not only the levels of IGF-1R protein but also its subcellular distribution and response to IGF-1. They suggest that the mouse might serve as a suitable model for delineating the molecular mechanisms overarching these two receptors.

CD34(+) fibrocytes are bone marrow-derived monocyte progenitor cells that traffic to sites of tissue injury and repair. They putatively infiltrate the orbit in thyroid-associated ophthalmopathy where they appear to transition into CD34(+) orbital fibroblasts (OFs) that interact with residential CD34(-) fibroblasts. A unique phenotypic attribute of fibrocytes and CD34(+) OFs is their expression of the functional thyrotropin receptor (TSHR) and other "thyroid-specific" proteins. When activated through TSHR, fibrocytes express a number of cytokines and other inflammatory genes. Here we sought to determine whether pentraxin-3 (PTX-3), an acute-phase protein involved in inflammation and autoimmunity, might be induced by TSH in fibrocytes and OFs. These cells were collected from patients with Graves disease and healthy individuals. PTX-3 mRNA levels were determined by real-time PCR, protein was determined by ELISA and Western blot, and PTX-3 gene promoter activity was assessed with reporter assays. PTX-3 expression was induced by TSH in both cell types, regardless of the health status of the donor and was a consequence of increased steady-state PTX-3 mRNA levels. M22, a TSHR-activating monoclonal antibody, also induced PTX-3. The induction could be attenuated by dexamethasone and by IGF-I receptor-blocking antibodies, teprotumumab and 1H7. TSH effects were mediated through phosphatidylinositol 3-kinase/AKT, mammalian target of rapamycin/p70(s6k), Janus tyrosine kinase 2 pathways, and enhanced PTX-3 mRNA stability. These findings indicate that PTX-3 is a TSH target gene, the expression of which can be induced in fibrocytes and OFs. They suggest that PTX-3 might represent a previously unidentified nexus between the thyroid axis and the mechanisms involved in tissue remodeling.

Core stability training traditionally uses stable-base techniques. Less is known as to the use of unstable-base techniques, such as suspension training, to activate core musculature. This study sought to assess the neuromuscular activation of global core stabilizers when using suspension training techniques, compared with more traditional forms of isometric exercise. Eighteen elite level, male youth swimmers (age, 15.5 ± 2.3 years; stature, 163.3 ± 12.7 cm; body mass, 62.2 ± 11.9 kg) participated in this study. Surface electromyography (sEMG) was used to determine the rate of muscle contraction in postural musculature, associated with core stability and torso bracing (rectus abdominus [RA], external obliques [EO], erector spinae [ES]). A maximal voluntary contraction test was used to determine peak amplitude for all muscles. Static bracing of the core was achieved using a modified "plank" position, with and without a Swiss ball, and held for 30 seconds. A mechanically similar "plank" was then held using suspension straps. Analysis of sEMG revealed that suspension produced higher peak amplitude in the RA than using a prone or Swiss ball "plank" (p = 0.04). This difference was not replicated in either the EO or ES musculature. We conclude that suspension training noticeably improves engagement of anterior core musculature when compared with both lateral and posterior muscles. Further research is required to determine how best to activate both posterior and lateral musculature when using all forms of core stability training.

Context: CD34(+) fibrocytes, bone marrow-derived progenitor cells, infiltrate orbital connective tissue in thyroid-associated ophthalmopathy, a manifestation of Graves' disease. In the orbit, they become CD34(+) fibroblasts and coexist with native CD34(-) fibroblasts. Fibrocytes have been shown to express TSH receptor and thyroglobulin., Objective: The objective of the study was to determine whether a broader repertoire of thyroid protein expression can be detected in fibrocytes and whether a common factor is responsible., Design/setting/participants: Fibrocytes and fibroblasts were collected and analyzed from healthy individuals and those with Graves' disease in an academic clinical practice., Main Outcome Measures: Real-time PCR, Western blot analysis, gene promoter analysis, cell transfections, and flow cytometric cell sorting were performed., Results: We detect two additional thyroid proteins expressed by fibrocytes, namely sodium-iodide symporter and thyroperoxidase. The autoimmune regulator (AIRE) protein appears necessary for this expression. AIRE expression in fibrocytes results from an active AIRE gene promoter and stable AIRE mRNA. Knocking down AIRE with a targeting small interfering RNA reduces the expression of these thyroid proteins in fibrocytes as well as the transcription factors paired box-8 and thyroid transcription factor-1. When compared with an unaffected first-degree relative, levels of these proteins are substantially reduced in fibrocytes from an individual with an inactivating AIRE mutation. Levels of AIRE and the thyroid proteins are lower in orbital fibroblasts from patients with thyroid-associated ophthalmopathy than in fibrocytes. However, when mixed fibroblast populations are sorted into pure CD34(+) and CD34(-) subsets, the levels of these proteins are dramatically increased selectively in CD34(+) fibroblasts., Conclusions: Fibrocytes express four proteins, the aggregate expression of which was previously thought to be restricted to thyroid epithelium. These proteins represent the necessary molecular biosynthetic machinery necessary for thyroid hormone production. Our findings implicate AIRE in the promiscuous expression of thyroid proteins in fibrocytes.

Context: Rituximab depletes CD20(+) B cells and has shown potential benefit in thyroid-associated ophthalmopathy (TAO). The impact of rituximab on T cell phenotype in TAO is unexplored., Objective: The objective of the study was to quantify the abundance of IGF-I receptor-positive (IGF-1R(+)) CD4 and CD8 T cells in active TAO before and after treatment with rituximab., Design: This was a retrospective case series assessing IGF-1R(+) T cells before and after treatment with rituximab with an 18-month follow-up., Setting: The study was conducted at a tertiary care medical center., Patients: Study participants included eight patients with severe TAO., Interventions: Two infusions of rituximab (1 g or 500 mg each) were administered 2 weeks apart., Main Outcome Measures: Quantification of IGF-1R(+) T cells using flow cytometry was measured., Results: Eight patients with moderate to severe TAO [mean pretreatment clinical activity score (CAS) 5.1 ± 0.2 (SEM)] were treated. Four to 6 weeks after treatment, CAS improved to 1.5 ± 0.3, whereas the proportion of IGF-1R(+) CD3(+) T cells declined from 41.9% to 28.3% (P = .004). The proportion of IGF-1R(+) CD4(+) and IGF-1R(+) CD8(+) T cells declined 4-6 weeks after treatment (from 45.6% to 21.5% and from 32.0% to 15.8%, P = .003 and P = .001, respectively). In two patients, IGF-1R(+) CD4(+) and IGF-1R(+) CD8(+) subsets approximated pretreatment levels after 16 weeks., Conclusions: Frequency of IGF-1R(+) T cells in patients with TAO declines within 4-6 weeks after rituximab treatment. This phenotypic shift coincides with clinical improvement. Thus, assessment of the abundance of IGF-1R(+) T cells in response to rituximab may provide a biomarker of clinical response. Our current findings further implicate the IGF-1R pathway in the pathogenesis of TAO.

Context: Factors common to multiple autoimmune diseases have been sought vigorously. Graves' disease (GD) and type 1 diabetes mellitus (T1DM) involve end-organ remodeling. Fibrocytes participate in inflammatory diseases and were recently shown to express thyroid-specific proteins such as the thyrotropin receptor and thyroglobulin., Objective: The objective of the study was to determine whether a broader repertoire of autoantigen expression, such as proteins associated with T1DM, can be ascribed to fibrocytes., Design, Setting, and Participants: Fibrocytes and fibroblasts were collected and analyzed from healthy individuals and those with autoimmune diseases in an academic clinical practice., Main Outcome Measures: Real-time PCR, Western blot analysis, gene promoter analysis, cell transfections, and flow cytometric cell sorting were performed., Results: Islet cell antigen ICA512 (IA-2) and islet cell autoantigen of 69 kDa (ICA69), two islet-specific proteins implicated in T1DM, are expressed by fibrocytes from healthy donors and those with T1DM, GD, and multiple sclerosis. Both transcripts are detected by PCR, the proteins are resolved on Western blots, and both gene promoters are active in fibrocytes. Levels of ICA69 are substantially higher than those of IA-2 in fibrocytes. ICA69 localizes to CD34(+) GD orbital fibroblasts putatively derived from fibrocytes, whereas higher levels of IA-2 are found in CD34(-) fibroblasts., Conclusions: In addition to autoantigens implicated in thyroid autoimmunity, fibrocytes and derivative fibroblasts express multiple autoantigens associated with T1DM. This expression results from active gene promoters and abundant steady-state mRNA encoding ICA69 and IA-2. These latest findings demonstrate that fibrocytes express antigens relevant to multiple forms of endocrine autoimmunity. They suggest the potential for these cells playing a direct role in immune reactivity directed at the thyroid and pancreatic islets.

Purpose: CD40-CD40 ligand (CD40L) interactions appear to play pathogenic roles in autoimmune disease. Here we quantify CD40 expression on fibrocytes, circulating, and bone marrow-derived progenitor cells. The functional consequences of CD40 ligation are determined since these may promote tissue remodeling linked with thyroid-associated ophthalmopathy (TAO)., Methods: CD40 levels on cultivated fibrocytes and orbital fibroblasts (GOFB) from patients with Graves' disease (GD), as well as fibrocyte abundance, were determined by flow cytometry. CD40 mRNA expression was evaluated by real-time PCR, whereas response to CD40 ligation was measured by Luminex and RT-PCR. Protein kinase B (Akt) and nuclear factor (NF)-kappa B (NF-κB) signaling were determined by Western blot and immunofluorescence., Results: Basal CD40 expression on fibrocytes is greater than that on GOFB. IFN-γ upregulates CD40 in both cell types and its actions are mediated at the pretranslational level. Fibrocytes produce high levels of cytokines, including interleukin-6 (IL-6), TNF-α, IL-8, MCP-1, and RANTES (Regulated on Activation, Normal T Cell Expressed and Secreted) in response to CD40L. IL-6 induction results from an increase in steady state IL-6 mRNA, and is mediated through Akt and NF-κB activation. Circulating CD40(+)CD45(+)Col1(+) fibrocytes are far more frequent in vivo in donors with TAO compared with healthy subjects., Conclusions: Particularly high levels of functional CD40 are displayed by fibrocytes. CD40L-provoked signaling results in the production of several cytokines. Among these, IL-6 expression is mediated through Akt and NF-κB pathways. The frequency of circulating CD40(+) fibrocytes is markedly increased in patients with TAO, suggesting that this receptor might represent a therapeutic target for TAO.

Defects in biogenesis or function(s) of primary cilia are associated with numerous inherited disorders (called ciliopathies) that may include retinal degeneration phenotype. The cilia-expressed gene RPGR (retinitis pigmentosa GTPase regulator) is mutated in patients with X-linked retinitis pigmentosa (XLRP) and encodes multiple protein isoforms with a common N-terminal domain homologous to regulator of chromosome condensation 1 (RCC1), a guanine nucleotide exchange factor (GEF) for Ran GTPase. RPGR interacts with several ciliopathy proteins, such as RPGRIP1L and CEP290; however, its physiological role in cilia-associated functions has not been delineated. Here, we report that RPGR interacts with the small GTPase RAB8A, which participates in cilia biogenesis and maintenance. We show that RPGR primarily associates with the GDP-bound form of RAB8A and stimulates GDP/GTP nucleotide exchange. Disease-causing mutations in RPGR diminish its interaction with RAB8A and reduce the GEF activity. Depletion of RPGR in hTERT-RPE1 cells interferes with ciliary localization of RAB8A and results in shorter primary cilia. Our data suggest that RPGR modulates intracellular localization and function of RAB8A. We propose that perturbation of RPGR-RAB8A interaction, at least in part, underlies the pathogenesis of photoreceptor degeneration in XLRP caused by RPGR mutations.

The purpose of this study was to assess the performance of elite rugby league players by using the Yo-Yo Intermittent Recovery Test. Fifty players were recruited to the study during preseason and were classified as professional (P) or semiprofessional (SP). All performed the level 1 Yo-Yo Intermittent Recovery Test. Total distance achieved was taken as the performance index. Physiological (heart rate and blood lactate) correlates of performance were also assessed. Results showed that P players achieved a greater total distance than did SP players (p > 0.05). End heart rates did not differ significantly (p < 0.05). Semiprofessional players had significantly lower end blood lactate values than did P players (p < 0.05). Relationships between test performance and physiological variables were not significant (p > 0.05). These findings showed that P and SP players performed the test at a comparable level. Physiological indices indicated that performance was near maximal. The test is considered a useful measure of intermittent high-intensity performance for rugby league players.

Physical strength has often been expressed per kilogram of body mass. Research suggests that strength increases in proportion to a body mass raised to a power between 0.6 and 0.7 rather than the ratio held exponent of 1. The current study was designed to identify differences in the strength of elite-level rugby league players and to identify whether ratio (per kg(-1)) expressions would penalize heavier subjects. Fifty-four elite rugby league players were recruited to the study during the preseason. Subjects were classified according to their highest playing level. Players performed 3 maximal lifts, using a dynamometer, to determine leg strength. Body mass and muscle mass estimations were also recorded. Results showed that absolute expressions of strength revealed differences by playing level (p < 0.05). These differences were removed when a ratio scaling technique was applied (p > 0.05). Mass and muscle mass exponents of 0.62 and 0.63 were derived and applied to the strength data. Differences in strength by playing level were reestablished following this adjustment (p < 0.05). These findings emphasize that ratio (per kg(-1)) expressions, despite being commonly used, can penalize heavier athletes and mask differences in performance. Coaches and sports scientists should reconsider using the ratio expression due to its potential for error when describing physical strength.