Use of Emergency Rooms for Mental Health Reasons in Quebec: Barriers and Facilitators

Abstract

This study explored barriers and facilitators in mental health (MH) patient management in four Quebec (Canada) emergency rooms (ERs) that used different operational models. Forty-nine stakeholders (managers, physicians, ER and addiction liaison team members) completed semi-structured interviews. Barriers and facilitators affecting patient management emanated from health systems, patients, organizations, and from professionals themselves. Effective management of MH patients requires ER access to a rich network of outpatient, community-based MH services; integration of general and psychiatric ERs; on-site addiction liaison teams; round-the-clock ER staffing, including psychiatrists; ER staff training in MH; and adaptation to frequent and challenging ER users.

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Measurement Characteristics and Clinical Utility of the Short Physical Performance Battery Among Community-Dwelling Older Adults

Publication date: Available online 2 August 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Andrea W. Westman, Stephanie Combs-Miller, Jennifer Moore, Linda Ehrlich-Jones

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A Systematic In Silico Analysis of the Legionellaceae Family for Identification of Novel Drug Target Candidates

Microbial Drug Resistance, Ahead of Print.


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Molecular Analysis of PBP1A in Streptococcus pneumoniae Isolated from Clinical and Normal Flora Samples in Tehran, Iran: A Multicenter Study

Microbial Drug Resistance, Ahead of Print.


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Spinal epidural lipomatosis is a previously unrecognized manifestation of metabolic syndrome

Spinal epidural lipomatosis (SEL) is a condition in which excess lumbar epidural fat (EF) deposition often leads to compression of the cauda equina or nerve root. Although SEL is often observed in obese adults, no systematic research investigating the potential association between SEL and metabolic syndrome has been conducted.

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Dialysis is an independent risk factor for perioperative adverse events, readmission, reoperation and mortality for patients undergoing elective spine surgery

The prevalence of dialysis-dependent patients in the United States is growing. Prior studies evaluating the risk of perioperative adverse events for dialysis-dependent patients are either institutional cohort studies limited by patient numbers or administrative database studies limited to inpatient data.

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Elevated inflammatory cytokine expression in CSF from patients with symptomatic thoracic disc herniations correlates with increased pain scores

The pathophysiology of pain in symptomatic thoracic disc herniation (TDH) patients remains poorly understood. Mere mechanical compression of the spinal cord and/or the exiting nerve root by a prolapsed disc cannot explain the pathogenesis of pain in all cases. Previous studies report a direct correlation between the levels of proinflammatory cytokines in disc biopsies and the severity of leg pain in patients with lumbar disc herniations. A similar correlation in patients with TDHs has not been investigated.

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Decreasing subthalamic deep brain stimulation frequency reverses cognitive interference during gait initiation in Parkinson’s disease

Publication date: Available online 2 August 2018

Source: Clinical Neurophysiology

Author(s): Pasquale Varriale, Antoine Collomb-Clerc, Angele Van Hamme, Anaik Perrochon, Gilles Kemoun, Giuseppe Sorrentino, Nathalie George, Brian Lau, Carine Karachi, Marie-Laure Welter

Abstract

Objective

Freezing of gait (FOG) represents a major burden for Parkinson's disease (PD) patients. High-frequency (130-Hz) subthalamic deep-brain-stimulation (STN-DBS) has been reported to aggravate FOG whereas lowering the frequency to 60-80 Hz improves FOG. To further understand the effects of STN-DBS on FOG, we assessed the effects of 80-Hz and 130-Hz STN-DBS on gait initiation performance, in relation to motor and executive function processing.

Methods

Gait initiation was recorded in 19 PD patients and 20 controls, combined or not with a cognitive interference task with a modified Stroop paradigm. PD patients were recorded before surgery with and without dopaminergic treatment, and after surgery with 80-Hz and 130-Hz STN-DBS in a randomised double-blind crossover study.

Results

In the absence of cognitive interference, PD patients exhibited significant gait initiation improvement with dopaminergic treatment, 80-Hz and 130-Hz STN-DBS. Nine patients performed the cognitive interference task. With 130-Hz STN-DBS, all gait initiation parameters were significantly degraded, whereas the cognitive interference task induced no major changes before surgery and with 80-Hz STN-DBS, as in controls.

Conclusions

High-frequency STN-DBS leads to an inability to simultaneously process motor and cognitive information while this ability seems preserved with low-frequency STN-DBS.

Significance

This study supports the potential benefit of 80-Hz STN-DBS on FOG.

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Body balance function of cochlear implant patients with and without sound conditions

Publication date: Available online 2 August 2018

Source: Clinical Neurophysiology

Author(s): Kaori Oikawa, Yumiko Kobayashi, Harukazu Hiraumi, Kiyoshi Yonemoto, Hiroaki Sato

Abstract

Objective

The relation between well-controlled auditory stimulation through cochlear implant (CI) and the body balance has been sparsely investigated. The purpose of this study was to evaluate the body balance function of CI patients with- and without-sound in anechoic sound-shielded room.

Methods

We recorded 8 experienced CI recipients and 8 young normal-hearing volunteers. All subjects were assessed using posturography under 4 conditions: (1) eyes open with-sound, (2) eyes closed with-sound, (3) eyes open without-sound, and (4) eyes closed without-sound.

Results

The total path length and the total area were significantly larger in the eyes closed condition than in the eyes open condition. In normal hearing subjects, the average displacement of center of pressure (COP) in the mediolateral direction under with-sound condition was not different from that under without-sound condition. In CI recipients, the COP significantly displaced to the CI side after the deprivation of visual cues in without-sound condition. This shift was eliminated in with-sound condition (significant interaction among sound condition, eye condition, and between-group factor).

Conclusion

In CI subjects, sound stimulation improves the abnormal displacement of COP in the mediolateral direction.

Significance

A posturographic study under an anechoic condition proved that sound stimulation improves body balance function in CI subjects.

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Body balance function of cochlear implant patients with and without sound conditions

A cochlear implant (CI) is a standard treatment for profound sensorineural hearing loss patients where hearing aids are no longer sufficient. A CI is generally comprised of a speech processor, a receiver-stimulator, and an electrode array. The receiver-stimulator is surgically implanted subcutaneously behind the ear, while the electrode array is inserted into the cochlea. The sound is sensed and processed in the speech processor. The processed sound signal is transcutaneously transmitted to the receiver-stimulator which stimulates the intracochlear electrode according to the transmitted sound signal.

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Decreasing subthalamic deep brain stimulation frequency reverses cognitive interference during gait initiation in Parkinson’s disease

Parkinson's disease (PD) is a neurodegenerative disorder due to a loss of nigrostriatal dopaminergic neurons. From a clinical point of view, PD patients present both motor and cognitive deficits. The classical motor triad consists of akinesia, tremor and rigidity. With time, about 50-70% of patients will develop gait and balance disorders and show freezing of gait (FOG) which is characterised by brief episodes of inability to step and lift their feet from the ground or by extremely short steps (Bloem et al., 2004, Nutt et al., 2011).

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Foundation Ambulance welcomes Scott Frazier as production manager

Foundation Ambulance, the industry's newest expert in high-quality emergency vehicle remounting and Type II transits, announced today that EMS veteran Scott Frazier will be joining our team as Production Manager. Frazier brings his 30 years of experience in the field to Foundation, whose goal is to use its cutting-edge remounting facility to build better ambulances at a tremendous value. He...

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Using an upper extremity exoskeleton for semi-autonomous exercise during inpatient neurological rehabilitation- a pilot study

Motor deficits are the most common symptoms after stroke. There is some evidence that intensity and amount of exercises influence the degree of improvement of functions within the first 6 months after the injury.

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Workplace Accidents Among Nepali Male Workers in the Middle East and Malaysia: A Qualitative Study

Abstract

There are many Nepali men working in the Middle East and Malaysia and media reports and anecdotal evidence suggest a high risk of workplace-related accidents and injuries for male Nepali workers. Therefore, this study aims to explore the personal experiences of male Nepali migrants of unintentional injuries at their place of work. In-depth, face-to-face interviews (n = 20) were conducted with male Nepali migrant workers. Study participants were approached at Kathmandu International Airport, hotels and lodges around the airport. Interviews were transcribed and analysed using thematic analysis. Almost half of study participants experienced work-related accident abroad. The participants suggested that the reasons behind this are not only health and safety at work but also poor communication, taking risks by workers themselves, and perceived work pressure. Some participants experienced serious incidents causing life-long disability, extreme and harrowing accounts of injury but received no support from their employer or host countries. Nepali migrant workers would appear to be at a high risk of workplace unintentional injuries owing to a number of interrelated factors poor health and safety at work, pressure of work, risk taking practices, language barriers, and their general work environment. Both the Government of Nepal and host countries need to be better policing existing policies, introduce better legislation where necessary, ensure universal health (insurance) coverage for labour migrants, and improve preventive measures to minimize the number and severity of accidents and injuries among migrant workers.

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What does the 2018 EMS Trend Report tell us about the future of the industry?

Our co-hosts are joined by EMS1 Editor-in-Chief Greg Friese discuss the most EMS trend report and what it means for industry personnel

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Multiplexed assays of variant effects contribute to a growing genotype–phenotype atlas

Abstract

Given the constantly improving cost and speed of genome sequencing, it is reasonable to expect that personal genomes will soon be known for many millions of humans. This stands in stark contrast with our limited ability to interpret the sequence variants which we find. Although it is, perhaps, easiest to interpret variants in coding regions, knowledge of functional impact is unknown for the vast majority of missense variants. While many computational approaches can predict the impact of coding variants, they are given a little weight in the current guidelines for interpreting clinical variants. Laboratory assays produce comparatively more trustworthy results, but until recently did not scale to the space of all possible mutations. The development of deep mutational scanning and other multiplexed assays of variant effect has now brought feasibility of this endeavour within view. Here, we review progress in this field over the last decade, break down the different approaches into their components, and compare methodological differences.

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Asthma/COPD Disparities in Diagnosis and Basic Care Utilization Among Low-Income Primary Care Patients

Abstract

Obstructive pulmonary disease outcomes in the United States differ between Latinos and non-Hispanic whites. There is little objective data about diagnosis prevalence and primary care visit frequency in these disease processes. We used electronic health record data to perform a retrospective cohort analysis of 34,849 low-income patients seen at Oregon community health centers between 2009 and 2013 to assess joint racial/ethnic and insurance disparities in diagnosis and visit rates between Latino and non-Hispanic white patients. The overall study prevalence of obstructive lung disease was 18%. Latinos had lower odds of obstructive lung disease diagnosis (OR 0.37, 95% CI 0.30–0.44). Among those diagnosed prior to 2009, the uninsured (regardless of race/ethnicity) had lower visit rates during 2009–2013 than the insured. This study identified racial/ethnic disparities in the diagnosis of obstructive pulmonary disease between Latinos and non-Hispanic Whites, confirming trends observed in survey research but controlling for important confounders. Health insurance was associated with basic care utilization, suggesting that lack of health insurance could lessen the quality of care for obstructive pulmonary disease in Latino and non-Hispanic white patients.

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Modified PAGE-B score predicts the risk of hepatocellular carcinoma in Asians with chronic hepatitis B on antiviral therapy

Journal of Hepatology

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Endotoxinemia contributes to steatosis, insulin resistance and atherosclerosis in chronic hepatitis C: The role of pro-inflammatory cytokines and oxidative stress

Infection

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Glycemic control and microvascular complications in adults with type 1 diabetes and long-lasting treated celiac disease: A case-control study

Diabetes Research and Clinical Practice

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No gender differences in growth patterns in a cohort of children with cystic fibrosis born between 1986 and 1995

Clinical Nutrition

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The hedgehog pathway and ocular developmental anomalies

Abstract

Mutations in effectors of the hedgehog signaling pathway are responsible for a wide variety of ocular developmental anomalies. These range from massive malformations of the brain and ocular primordia, not always compatible with postnatal life, to subtle but damaging functional effects on specific eye components. This review will concentrate on the effects and effectors of the major vertebrate hedgehog ligand for eye and brain formation, Sonic hedgehog (SHH), in tissues that constitute the eye directly and also in those tissues that exert indirect influence on eye formation. After a brief overview of human eye development, the many roles of the SHH signaling pathway during both early and later morphogenetic processes in the brain and then eye and periocular primordia will be evoked. Some of the unique molecular biology of this pathway in vertebrates, particularly ciliary signal transduction, will also be broached within this developmental cellular context.

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Transcriptome profiling and identification of functional genes involved in H 2 S response in grapevine tissue cultured plantlets

Abstract

Hydrogen sulfide (H₂S), a small bioactive gas, has been proved functioning in plant growth and development as well as alleviation of abiotic stresses, which including promoting seed germination, accelerating embryonic root growth, regulating flower senescence, inducing stomatal closure, and defending drought, heat, heavy metals and osmotic stresses etc. However, the molecular functioning mechanism of H₂S was still unclear. The primary objective of this research was to analyze the transcriptional differences and functional genes involved in the H₂S responses. In details, 4-week-old plantlets in tissue culture of grapevine (Vitis vinifera L.) cultivar 'Zuoyouhong' were sprayed with 0.1 mM NaHS for 12 h, and then transcriptome sequencing and qRT-PCR analysis were used to study the transcriptional differences and functional genes involved in the H₂S responses. Our results indicated that 650 genes were differentially expressed after H₂S treatment, in which 224 genes were up-regulated and 426 genes were down-regulated. The GO enrichment analysis and KEGG enrichment analysis results indicated that the up-regulated genes after H₂S treatment focused on carbon metabolism, biosynthesis of amino acids, and glycolysis/gluconeogenesis, and the down-regulated genes were mainly in metabolic pathways, biosynthesis of secondary metabolites, and plant hormone signal transduction. Analyzing the transcription factor coding genes in details, it was indicated that 10 AP2/EREBPs, 5 NACs, 3 WRKYs, 3 MYBs, and 2 bHLHs etc. transcription factor coding genes were up-regulated, while 4 MYBs, 3 OFPs, 3 bHLHs, 2 AP2/EREBPs, 2 HBs etc. transcription factor coding genes were down-regulated. Taken together, H₂S increased the productions in secondary metabolites and a variety of defensive compounds to improve plant development and abiotic resistance, and extend fruits postharvest shelf life by regulating the expression of AP2/EREBPs, WRKYs, MYBs, CABs, GRIP22, FERRITINs, TPSs, UGTs, and GHs etc.

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The effects of proprioceptive neuromuscular facilitation lower-leg taping and treadmill training on mobility in patients with stroke

The elastic-taping method of the proprioceptive neuromuscular facilitation (PNF) concept is nonexistent. Therefore, our study aimed to investigate the effect of treadmill training (TT) using PNF lower-leg taping (PNFLT) on walking and balance ability in patients with stroke. There were a total of 27 patients: a stroke allocated control group (n=13) and an experimental group (n=14). The control group performed the TT and the experimental group performed the TT using PNF taping five times a week for 6 weeks. Walking and balance ability were measured using the 6-min walk test (6MWT), the 10-m walking test (10MWT), and the timed up and go test (TUG). Before and after the intervention, a paired t-test was performed to compare different within-group differences. Independent t-tests were performed to compare different between-group differences. All statistical significance levels were set at α of 0.05. After intervention, 6MWT, 10MWT and TUG improved significantly in PNFLT-TT and TT group (P

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Postoperative acute kidney injury: A never-ending challenge

No abstract available

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Cardiac arrest during spinal anaesthesia in a patient with undiagnosed Brugada syndrome

No abstract available

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Impact of intra-operative fluid and noradrenaline administration on early postoperative renal function after cystectomy and urinary diversion: A retrospective observational cohort study

BACKGROUND The use of noradrenaline to enable a restrictive approach to intra-operative fluid therapy to avoid salt and water overload has gained increasing acceptance. However, concerns have been raised about the impact of this approach on renal function. OBJECTIVES To identify risk factors for acute kidney injury (AKI) in patients undergoing cystectomy with urinary diversion and determine whether administration of noradrenaline and intra-operative hydration regimens affect early postoperative renal function. DESIGN Retrospective observational cohort study. SETTING University hospital, from 2007 to 2016. PATIENTS A total of 769 consecutive patients scheduled for cystectomy and urinary diversion. Those with incomplete data and having pre-operative haemodialysis were excluded. MAIN OUTCOME MEASURES AKI was defined as a serum creatinine increase of more than 50% over 72 postoperative hours. Multiple logistic regression analysis was performed to model the association between risk factors and AKI. RESULTS Postoperative AKI was diagnosed in 86/769 patients (11.1%). Independent predictors for AKI were the amount of crystalloid administered (odds ratio (OR) 0.79 [95% confidence interval (CI), 0.68 to 0.91], P = 0.002), antihypertensive medication (OR 2.07 [95% CI, 1.25 to 3.43], P = 0.005), pre-operative haemoglobin value (OR 1.02 [95% CI, 1.01 to 1.03], P = 0.010), duration of surgery (OR 1.01 [95% CI, 1.00 to 1.01], P = 0.002), age (OR 1.32 [95% CI, 1.44 to 1.79], P = 0.002) but not the administration of noradrenaline (OR 1.09 [95% CI, 0.94 to 1.21], P = 0.097). Postoperative AKI was associated with longer hospital stay (18 [15 to 22] vs. 16 [15 to 19] days; P = 0.035) and a higher 90-day major postoperative complication rate (41.9 vs. 27.5%; P = 0.002). CONCLUSION Noradrenaline administration did not increase the risk for AKI. A too restrictive approach to administration of crystalloids was associated with an increased risk for AKI, particularly in older patients, those receiving antihypertensive medication, and those whose surgery was prolonged. As AKI was associated with longer hospital stay and increased postoperative morbidity, these observations should be taken into account to improve outcome when addressing peri-operative fluid management. TRIAL REGISTRATION Not applicable.

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Association between pre-operative biological phenotypes and postoperative pulmonary complications: An unbiased cluster analysis

BACKGROUND Biological phenotypes have been identified within several heterogeneous pulmonary diseases, with potential therapeutic consequences. OBJECTIVE To assess whether distinct biological phenotypes exist within surgical patients, and whether development of postoperative pulmonary complications (PPCs) and subsequent dependence of intra-operative positive end-expiratory pressure (PEEP) differ between such phenotypes. SETTING Operating rooms of six hospitals in Europe and USA. DESIGN Secondary analysis of the 'PROtective Ventilation with HIgh or LOw PEEP' trial. PATIENTS Adult patients scheduled for abdominal surgery who are at risk of PPCs. INTERVENTIONS Measurement of pre-operative concentrations of seven plasma biomarkers associated with inflammation and lung injury. MAIN OUTCOME MEASURES We applied unbiased cluster analysis to identify biological phenotypes. We then compared the proportion of patients developing PPCs within each phenotype, and associations between intra-operative PEEP levels and development of PPCs among phenotypes. RESULTS In total, 242 patients were included. Unbiased cluster analysis clustered the patients within two biological phenotypes. Patients with phenotype 1 had lower plasma concentrations of TNF-α (3.8 [2.4 to 5.9] vs. 10.2 [8.0 to 12.1] pg ml−1; P 

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Implementation of closed-loop-assisted intra-operative goal-directed fluid therapy during major abdominal surgery: A case–control study with propensity matching

BACKGROUND Goal-directed fluid therapy (GDFT) has been associated with improved patient outcomes. However, implementation of GDFT protocols remains low despite growing published evidence and the recommendations of multiple regulatory bodies in Europe. We developed a closed-loop-assisted GDFT management system linked to a pulse contour monitor to assist anaesthesiologists in applying GDFT. OBJECTIVE To assess the impact of our closed-loop system in patients undergoing major abdominal surgery in an academic hospital without a GDFT programme. DESIGN A case–control study with propensity matching. SETTING Operating rooms, Erasme Hospital, Brussels. PATIENTS All patients who underwent elective open major abdominal surgery between January 2013 and December 2016. INTERVENTION Implementation of our closed-loop-assisted GDFT in April 2015. METHODS A total of 104 patients managed with closed-loop-assisted GDFT were paired with a historical cohort of 104 consecutive non-GDFT patients. The historical control group consisted of patients treated before the implementation of the closed-loop-system, and who did not receive GDFT. In the closed-loop group, the system delivered a baseline crystalloid infusion of 3 ml kg−1 h−1 and additional 100 ml fluid boluses of either a crystalloid or colloid for haemodynamic optimisation. MAIN OUTCOME MEASURES The primary outcome was intra-operative net fluid balance. Secondary outcomes were composite major postoperative complications, composite minor postoperative complications and hospital length of stay (LOS). RESULTS Baseline characteristics were similar in both groups. Patients in the closed-loop group had a lower net intra-operative fluid balance compared with the historical group (median interquartile range [IQR] 2.9 [1.6 to 4.4] vs. 6.2 [4.0 to 8.3] ml kg−1 h−1; P 

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Epidrum is an unreliable device for identifying the thoracic epidural space

No abstract available

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Safety of moderate-to-deep sedation performed by sedation practitioners: A national prospective observational study

BACKGROUND In the Netherlands, a significant proportion of moderate-to-deep sedation is performed by sedation practitioners under the indirect supervision of an anaesthesiologist but there are limited safety data available. OBJECTIVE To estimate the rate of sedation-related adverse events and patient relevant outcomes (PRO). DESIGN This was a prospective national observational study. Data were collected with a modified adverse event reporting tool from the International Sedation Task Force of the World Society of Intravenous Anaesthesia. SETTING A total of 24 hospitals in the Netherlands where moderate-to-deep sedation was performed by sedation practitioners from the 1 February 2015 to 1 March 2016. PATIENTS Consecutive adults undergoing moderate-to-deep sedation for gastrointestinal, pulmonary and cardiac procedures. INTERVENTION Observation: Analysis included descriptive statistics and a multivariate logistic regression model for an association between adverse events and PRO. MAIN OUTCOME MEASURES The primary outcome was the rate of unfavourable PRO (admission to ICU, permanent neurological deficit, pulmonary aspiration or death). Secondary outcome was the rate of moderate-to-good PRO (unplanned hospital admission or escalation of care). Composite outcome was the sum of all primary and secondary outcomes. RESULTS A total of 11 869 patients with a median age of 64 years [interquartile range 51 to 72] were included. ASA physical score distribution was: first, 19.1%; second, 57.6%; third, 21.6%; fourth, 1.2%. Minimal adverse events occurred in 1517 (12.8%), minor adverse events in 113 (1.0%) and major adverse events in 80 instances (0.7%). Primary outcome: Five (0.04%) unfavourable PRO were observed; four patients needing admission to the intensive care unit; and one died. Secondary outcome: 12 (0.1%) moderate-to-good PRO were observed. Moderate and major adverse events were associated with the composite outcome [3.7 (95% confidence interval 1.1 to 11.9) and 40.6 (95% confidence interval 11.0 to 150.4)], but not minimal or minor adverse events. CONCLUSION Moderate-to-deep sedation performed by trained sedation practitioners has a very low rate of unfavourable outcome.

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The LAS VEGAS risk score for prediction of postoperative pulmonary complications: An observational study

BACKGROUND Currently used pre-operative prediction scores for postoperative pulmonary complications (PPCs) use patient data and expected surgery characteristics exclusively. However, intra-operative events are also associated with the development of PPCs. OBJECTIVE We aimed to develop a new prediction score for PPCs that uses both pre-operative and intra-operative data. DESIGN This is a secondary analysis of the LAS VEGAS study, a large international, multicentre, prospective study. SETTINGS A total of 146 hospitals across 29 countries. PATIENTS Adult patients requiring intra-operative ventilation during general anaesthesia for surgery. INTERVENTIONS The cohort was randomly divided into a development subsample to construct a predictive model, and a subsample for validation. MAIN OUTCOME MEASURES Prediction performance of developed models for PPCs. RESULTS Of the 6063 patients analysed, 10.9% developed at least one PPC. Regression modelling identified 13 independent risk factors for PPCs: six patient characteristics [higher age, higher American Society of Anesthesiology (ASA) physical score, pre-operative anaemia, pre-operative lower SpO2 and a history of active cancer or obstructive sleep apnoea], two procedure-related features (urgent or emergency surgery and surgery lasting ≥ 1 h), and five intra-operative events [use of an airway other than a supraglottic device, the use of intravenous anaesthetic agents along with volatile agents (balanced anaesthesia), intra-operative desaturation, higher levels of positive end-expiratory pressures > 3 cmH2O and use of vasopressors]. The area under the receiver operating characteristic curve of the LAS VEGAS risk score for prediction of PPCs was 0.78 [95% confidence interval (95% CI), 0.76 to 0.80] for the development subsample and 0.72 (95% CI, 0.69 to 0.76) for the validation subsample. CONCLUSION The LAS VEGAS risk score including 13 peri-operative characteristics has a moderate discriminative ability for prediction of PPCs. External validation is needed before use in clinical practice. TRIAL REGISTRATION The study was registered at Clinicaltrials.gov, number NCT01601223.

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Placebo versus low-dose ketamine infusion in addition to remifentanil target-controlled infusion for conscious sedation during oocyte retrieval: A double-blinded, randomised controlled trial

BACKGROUND Currently, there is no gold standard for monitored anaesthesia care during oocyte retrieval. OBJECTIVE In our institution, the standard is a conscious sedation technique using a target-controlled infusion (TCI) of remifentanil, titrated to maintain a visual analogue pain score less than 30 mm. This protocol is well accepted by patients but is associated with frequent episodes of respiratory depression. The main objective of this study was to evaluate whether the addition of a continuous intravenous infusion of ketamine could reduce these episodes. DESIGN Controlled, randomised, prospective, double-blinded study. SETTING The current study was conducted in a tertiary-level hospital in Brussels (Belgium) from December 2013 to June 2014. PATIENTS Of the 132 women undergoing oocyte retrieval included, 121 completed the study. INTERVENTION After randomisation, patients received either a ketamine infusion (40 μg kg−1 min−1 over 5 min followed by 2.5 μg kg−1 min−1) or a 0.9% saline infusion in addition to the variable remifentanil TCI. MAIN OUTCOME MEASURES The primary outcome was the number of respiratory depression episodes. Effect site target remifentanil concentrations, side effects, pain score, patient satisfaction and incidence of pregnancy were also recorded. RESULTS No significant difference in the incidence of respiratory events was noted (pulse oximetry oxygen saturation 

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Sudden-onset trismus after respiratory arrest in a patient with an acute exacerbation of hereditary angioedema

No abstract available

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Does a hypnosis session reduce the required propofol dose during closed-loop anaesthesia induction?: A randomised controlled trial

BACKGROUND Hypnosis has a positive effect on peri-operative anxiety and pain. OBJECTIVE The objective of this study was to assess the impact of a formal deep hypnosis session on the consumption of propofol for anaesthetic induction using automated administration of propofol guided by the bispectral index (BIS) in a closed loop. DESIGN A 1 : 1 randomised, usual-care-controlled, single-centre trial. SETTING Tertiary care centre in France from April 2014 to December 2015. PATIENTS Female adult patients scheduled for outpatient gynaecological surgery under general anaesthesia. INTERVENTION Before surgery, patients were randomised to receive either a deep hypnosis session or routine care. Anaesthetic induction was performed automatically by propofol without opioids and was assisted by the BIS in a closed loop. MAIN OUTCOME MEASURES The primary endpoint was the propofol dose required for anaesthesia induction, defined as a BIS less than 60 for at least 30 s. RESULTS Data for 31 patients in the hypnosis group and 35 in the control group were analysed. There was no evidence of a difference in the mean required propofol dose for anaesthetic induction between the hypnosis and the control groups (2.06 mg kg−1 (95% confidence interval [1.68 to 2.43]) versus 1.79 mg kg−1 (95% CI [1.54 to 2.03]), P = 0.25, respectively). CONCLUSION The current study, which was designed to determine the effect of a deep hypnosis session on anaesthesia induction using an automated tool for propofol administration, failed to detect a difference in the required dose of propofol. TRIAL REGISTRATION ClinicalTrials.gov, NCT02249364.

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Comparative study of concordance between bispectral index recordings obtained from the standard frontal and infra-orbital sensor position

No abstract available

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Peri-operative copeptin concentrations and their association with myocardial injury after vascular surgery: A prospective observational cohort study

BACKGROUND Copeptin levels in conjunction with cardiac troponin may be used to rule out early myocardial infarction in patients presenting with chest pain. Raised pre-operative copeptin has been shown to be associated with postoperative cardiac events. However, very little is known about the peri-operative time course of copeptin or the feasibility of very early postoperative copeptin measurement to diagnose or rule-out myocardial injury. OBJECTIVES In this preparatory analysis for a larger trial, we sought to examine the time course of peri-operative copeptin and identify the time at which concentrations returned to pre-operative levels. Second, in an explorative analysis, we sought to examine the association of copeptin in general and at various time points with myocardial injury occurring within the first 48 h. DESIGN Preparatory analysis of a prospective, observational cohort study. SETTING Single university centre from February to July 2016. PATIENTS A total of 30 consecutive adults undergoing vascular surgery. INTERVENTION Serial peri-operative copeptin measurements. MAIN OUTCOME MEASURE We measured copeptin concentrations before and immediately after surgery (0 h), then at 2, 4, 6 and 8 h after surgery and on the first and second postoperative day. Postoperative concentrations were compared with pre-operative levels with a Wilcoxon signed-rank test. Second, we explored an association between postoperative copeptin concentrations and myocardial injury by the second postoperative day. Myocardial injury was defined as a 5 ng l−1 increase between pre-operative and postoperative high-sensitivity cardiac troponin T with an absolute peak of at least 20 ng l−1. RESULTS Immediate postoperative copeptin concentrations (median [interquartile range]) increased nearly eight-fold from pre-operative values (8.5 [3.6 to 13.8] to 64.75 pmol l−1 [29.6 to 258.7]; P 

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European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium: erratum

No abstract available

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Differences in vascular function between trained and untrained limbs assessed by near-infrared spectroscopy

Abstract

Purpose

The aim of this study was to examine whether differences in vascular responsiveness associated with training status would be more prominent in the trained limb (leg) than in the untrained limb (arm) microvasculature.

Methods

Thirteen untrained (26 ± 5 year) and twelve trained (29 ± 4 year) healthy men were submitted to a vascular occlusion test (VOT) (2 min baseline, 5 min occlusion, and 8 min re-oxygenation). The oxygen saturation signal (StO₂) was assessed using near-infrared spectroscopy (NIRS) throughout the VOT. Vascular responsiveness within the microvasculature was evaluated by the re-oxygenation Slope 2 (Slope 2 StO₂) and the area under the curve (StO_2AUC) of (StO₂) signal during re-oxygenation in the leg and arm.

Results

There was a significant interaction between training status and limb for the slope 2 StO₂ (P < 0.01). The leg of the trained group showed a steeper slope 2 StO₂ (1.35 ± 0.12% s⁻¹) when compared to the slope 2 StO₂ of the leg in their untrained counterparts (0.86 ± 0.09% s⁻¹) (P < 0.05). There was a medium effect size of 0.58 for slope 2 StO₂ on the arm and a large effect size of 1.21 for slope 2 StO₂ on the leg. In addition, there was a small effect size of 0.24 for StO_2AUC on the arm and a medium effect size of 0.64 for StO_2AUC on the leg.

Conclusion

The present study suggests that the vascular adaptations induced by lower limb endurance exercise training are more prominent in the trained limb than in the untrained limb microvasculature.

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Predatory Open-Access Medical Publishers: “Caveat Emptor”

No abstract available

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Longitudinal Growth Outcomes Following First Line Treatment For Pediatric Eosinophilic Esophagitis Patients

Objectives: No formal comparative effectiveness studies have been conducted to evaluate the effect of eosinophilic esophagitis (EoE) treatment choice on long-term growth in pediatric patients. However, long-term studies of inhaled corticoid steroids in asthma suggest possible effects on linear growth. The aim of this study was to compare longitudinal, anthropometric growth in children with EoE according to treatment approach. Methods: We conducted a retrospective, multicenter cohort study of anthropometric growth (height and BMI z-scores) in pediatric (

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Recent Prescription Patterns for Children with Acute Infectious Diarrhea

Background: This study investigated recent trends in antibiotic use and factors associated with antibiotic use among children with acute infectious diarrhea. We obtained records of outpatients aged under 18 years diagnosed with acute infectious diarrhea from the Japan Medical Data Center database during 2012–2015. Objective: We investigated prescription patterns of antibiotics at their initial visit and evaluated factors associated with antibiotic usage using multivariable log-binomial regression models. Results: Overall, we identified 4493 patients diagnosed with acute infectious diarrhea; 29.6% received antibiotics. The most commonly prescribed antibiotic is fosfomycin (20.3%). In multivariable log-binomial regression analysis, out-of-hour visits, clinical diagnoses of suspected bacterial enterocolitis, private outpatient clinics, and pediatric departments are significantly associated with higher prevalence of antibiotic use. Conclusion: Antibiotics are over-prescribed for children with acute infectious diarrhea. Our investigation provides important information to promote education of physicians and of health policy considerations for appropriate antibiotic prescription practices. Address correspondence and reprint requests to Yusuke Okubo, National Center for Child Health and Development, 2–10–1 Okura, Setagaya-ku, Tokyo, 1570074, Japan (e-mail: sunning_dale@yahoo.co.jp). Received 11 April, 2018 Accepted 12 July, 2018 Financial Disclosure: The authors have no financial relationships relevant to this article to disclose. Funding source: This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan; Ministry of Education, Culture, Sports, Science and technology, Japan; and the Japan Agency for Medical Research and Development. Potential Conflict of Interest: The authors have no conflict of interest relevant to this article to disclose. Authorship statement Drs. Okubo and Michihata designed the data collection instruments, coordinated data, drafted the initial manuscript, performed the initial analyses. Drs. Kinoshita, Morisaki, Miyairi, Urayama, and Prof. Yasunaga supervised data collection, revised the manuscript, and approved the final manuscript as submitted. Each author listed on the manuscript has seen and approved the submission of this version of the manuscript and takes full responsibility for its contents. Supplemental Table 1, Supplemental Digital Content, https://ift.tt/2ODE5x5 Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.jpgn.org). © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Argon Plasma Coagulation as a Treatment of Multiple Esophageal Papillomata in a Girl with Goltz Syndrome

No abstract available

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Is the Scout Out? The Utility of Scout Radiographs in the Pediatric Upper Gastrointestinal Exam

Objective: To demonstrate the scout radiograph does not change patient management, alter planning, or contribute to interpretation of the outpatient pediatric upper gastrointestinal fluoroscopic examination (UGI). Materials and Methods: We retrospectively reviewed 197 outpatient pediatric UGIs performed over a two year period. We performed a chart review on all patients to evaluate for potentially clinically significant findings on the scout radiograph. Scout findings were categorized into 4 groups: no new clinically significant findings (group 1), potentially clinically significant findings that were not directly addressed in the electronic medical record (group 2), incidental non-GI findings that necessitated further workup; however were later deemed insignificant (group 3), and clinically significant findings that changed patient GI management, altered the planning of the procedure, or contributed to the interpretation of the fluoroscopic study (group 4). Results: 197 UGIs were analyzed. A significant majority of cases (97.0%) were classified into group 1. Three cases (1.5%) were classified into group 2 with findings not addressed in the medical record. Two cases (1.0%) were classified into group 3, which, after further work-up, were deemed not clinically significant. One case (0.5%) was classified into group 4 which resulted in a change in patient GI management. Conclusion: In our review, there was only 1 case in which the scout radiograph changed patient GI management, with moderate stool burden leading to a miralax cleanout, although there were no cases which altered the planning of the procedure or contributed to the interpretation of the study. The scout radiograph can be omitted and/or substituted with the last image hold function in order to decrease radiation exposure. Address correspondence and reprint requests to Selwan Abdullah, University of Maryland Medical Center, 22 S. Greene Street Department of Diagnostic Radiology & Nuclear Medicine Baltimore, MD 21201 (e-mail: salbabdullah@gmail.com). Received 13 September, 2017 Accepted 13 July, 2018 Conflicts of interest: None Funding Sources: None Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.jpgn.org). © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Anti-Cytomegalovirus Activity in Human Milk and Colostrum from Mothers of Preterm Infants

Objectives: This study aimed to investigate the anti-CMV activity of milk from seropositive and seronegative mothers of preterm infants and to analyze its changes throughout the different stages of lactation and after Holder pasteurization, a procedure adopted by donor human milk banks. Methods: Eighteen mothers of preterm infants were enrolled in the study. Colostrum, transitional milk and mature milk samples were collected and tested for anti-CMV activity. Depletion of IgA from milk samples was carried out by jacalin resin. Pools of milk samples were pasteurized according to Holder technique. Results: All samples were endowed with anti-CMV activity, although to a different extent. In CMV IgG-positive mothers, colostra were significantly more active than the transitional milk and mature milk samples. Moreover, they were more potent than colostra from seronegative-mothers. IgA depletion in colostra from IgG-positive mothers resulted in a partial loss of anti-CMV activity. Holder pasteurization significantly reduced the antiviral activity. Conclusions: Human milk is endowed with anti-CMV activity and its potency may vary depending on the stage of lactation and the serological status of the mother. This biological property could partially neutralize CMV particles excreted in the milk of CMV IgG-positive mothers thus reducing the risk of transmitting infectious viruses to the infant. Address correspondence and reprint requests to Prof. David Lembo, Department of Clinical and Biological Sciences, University of Torino, S. Luigi Gonzaga Hospital, Regione Gonzole, 10, 10043, Orbassano, Torino, Italy (e-mail: david.lembo@unito.it). Received 9 February, 2018 Accepted 13 June, 2018 Declaration of Funding Source: This work was supported by a donation from Italian Association of Human Milk Banks (AIBLUD) Conflicts of interest: There is no conflict of interest associated with the authors of this paper. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.jpgn.org). © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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A Dynamic Assessment of Children’s Physical Competence: The Dragon Challenge

Purpose The first aim was to develop a dynamic measure of physical competence that requires a participant to demonstrate fundamental, combined and complex movement skills, and for assessors to score both processes and products (Dragon Challenge; DC). The second aim was to assess the psychometric properties of the DC in 10–14 year old children. Methods The first phase involved the development of the DC, including the review process that established face and content validity. The second phase used DC surveillance data (n=4,355; 10–12 years) to investigate construct validity. In the final phase, a convenience sample (n=50; 10–14 years) performed the DC twice (one-week interval), the Test of Gross Motor Development-2 (TGMD-2), and the Stability Skills Assessment (SSA). This data was used to investigate concurrent validity, and test-retest, inter-rater and intra-rater reliability. Results In support of construct validity, boys (P .85). Conclusion The DC is a valid and reliable tool to measure elements of physical competence physical competence in children aged 10–14 years. Corresponding author: Richard Tyler; Applied Sports Technology Exercise and Medicine (A-STEM) Research Centre, College of Engineering, Swansea University; Bay Campus, Fabian Way, Swansea, SA1 8EN, UK; (+44)07983629791; R.P.O.Tyler.837039@swansea.ac.uk. This work was supported by a grant from Sport Wales, and postgraduate support from the Swansea University Scholarship Fund. The authors declare there are no known conflicts of interest in the present study. The results of the study do not constitute endorsement by ACSM, and are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. Accepted for Publication: 19 July 2018 © 2018 American College of Sports Medicine

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Biceps Femoris Long-Head Architecture Assessed Using Different Sonographic Techniques

Purpose To assess the repeatability of, and measurement agreement between, four sonographic techniques used to quantify biceps femoris long head (BFlh) architecture: i) static-image with linear extrapolation technique; ii) extended field-of-view (EFOV) with linear ultrasound probe path (linear-EFOV) using either a straight or segmented analyses; and iii) EFOV with nonlinear probe path and segmented analysis (nonlinear-EFOV) to follow the complex fascicle trajectories. Methods Twenty individuals (24.4±5.7 years; 175±0.8 cm; 73±9.0 kg) without history of hamstring strain injury were tested in two sessions separated by 1-hour. An ultrasound scanner coupled with 6-cm linear probe was used to assess BFlh architecture in B-mode. Results The ultrasound probe was positioned at 52.0±5.0% of femur length and 57.0±6.0% of BFlh length. We found an acceptable repeatability when assessing BFlh fascicle length (ICC3,k = 0.86-0.95; SEM = 1.9-3.2 mm) and angle (ICC3,k = 0.86-0.97; SEM = 0.8-1.1o) using all sonographic techniques. However, the nonlinear-EFOV technique showed the highest repeatability (fascicle length ICC3,k = 0.95; fascicle angle, ICC3,k = 0.97). The static-image technique, which estimated 35.4±7.0% of the fascicle length, overestimated fascicle length (8-11%) and underestimated fascicle angle (8-9%) compared to EFOV techniques. Also, the rank order of individuals varied by ~15% between static-image and nonlinear-EFOV (segmented) when assessing the fascicle length. Conclusions Although all techniques showed good repeatability, absolute errors were observed using static-image (7.9±6.1 mm for fascicle length) and linear-EFOV (between 3.7±3.0 and 4.2±3.7 mm), probably because the complex fascicle trajectories were not followed. The rank order of individuals for fascicle length and angle were also different between static-image and nonlinear-EFOV, so different muscle function and injury risk estimates could likely be made when using this technique. Corresponding author: Sandro R. Freitas, Faculdade de Motricidade Humana, Universidade de Lisboa, Estrada da Costa, 1499-002, Cruz Quebrada, Dafundo, Portugal, sfreitas@fmh.ulisboa.pt. +351 91 785 99 38 The authors have declared no conflict of interests and that the study was not funded. Authors thank the study participants for their participation. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation, and statement that results of the present study do not constitute endorsement by ACSM. Accepted for Publication: 16 July 2018. © 2018 American College of Sports Medicine

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School Physical Activity Intervention Effect on Adolescents' Performance in Maths

Purpose The primary aim of this study was to test the effect of a school-based physical activity intervention on adolescents' performance in mathematics. A secondary aim was to explore potential mechanisms that might explain the intervention effect. Methods The Activity and Motivation in Physical EDucation (AMPED) intervention was evaluated using a two-arm cluster randomized controlled trial in 14 secondary schools located in low socioeconomic areas of Western Sydney, Australia. Study participants (n=1,173) were Grade 8 students (mean age = 12.94 years, SD = .54). The multi-component intervention was designed to help teachers maximize students' opportunities for moderate-to-vigorous physical activity (MVPA) during physical education (PE) and enhance students' motivation towards PE. Mathematics performance was assessed as part of national testing in Grade 7, which was the year before the trial began and then again in Grade 9. Potential mediators were: (i) proportion of PE lesson time that students spent in MVPA and leisure-time MVPA (%), measured using Actigraph GT3X+ accelerometers, and (ii) students' self-reported engagement (behavioral, emotional, and cognitive) during mathematics lessons. Mediators were assessed at baseline (Grade 8) and follow-up (Grade 9, 14-15 months after baseline). Results The effect of the intervention on mathematics performance was small-to-medium (β = .16, p

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Neuromuscular Fatigue and Recovery after Heavy Resistance, Jump, and Sprint Training

Purpose Training methods that require maximal intensity efforts against light- and heavy-resistance are commonly used for athletic development. Typically these sessions are separated by at least 48 hours recovery on the assumption that such efforts elicit marked fatigue of the central nervous system (CNS), but this posit has not been well-studied. The aim of the study was to assess the aetiology and recovery of fatigue after heavy-resistance (strength), jump, and sprint training methods. Methods Ten male athletes completed three training sessions requiring maximal efforts that varied in their loading characteristics; i) heavy resistance exercise (10 × 5 back squats at 80% 1RM) (STR); ii) jumping exercise (10 × 5 jump squats) (JUMP); iii) maximal sprinting (15 × 30 m) (SPR). Pre-, post- and at 24, 48 and 72 h post- participants completed a battery of tests to measure neuromuscular function using electrical stimulation of the femoral nerve, and single- and paired-pulse magnetic stimulation of the motor cortex, with evoked responses recorded from the knee extensors. Fatigue was self-reported at each time point using a visual analogue scale. Results Each intervention elicited fatigue that resolved by 48 (JUMP) and 72 h (STR & SPR). Decrements in muscle function (reductions in the potentiated quadriceps twitch force) persisted for 48 h after all exercise. Reductions in voluntary activation were present for 24 h after JUMP and SPRINT, and 48 h after STR. No other differences in CNS function were observed as a consequence of training. Conclusion Strength, jump, and sprint training requiring repeated maximum efforts elicits fatigue that requires up to 72 h to fully resolve, but this fatigue is not primarily underpinned by decrements in CNS function. Address for correspondence: Glyn Howatson, Faculty of Health and Life Science, Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle-upon-Tyne, NE1 8ST, UK. Tel: +44 191 227 4863, Fax: +44 191 227 4713. Email: glyn.howatson@northumbria.ac.uk Support for the study was provided by the United Kingdom Strength & Conditioning Association research grants programme. The authors have no conflict of interest to declare. The results of the study do not constitute endorsement by ACSM. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. Accepted for Publication: 14 July 2018 © 2018 American College of Sports Medicine

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A 9-Month Jumping Intervention to Improve Bone Geometry in Adolescent Male Athletes

Purpose Sports have different effects on bone development and effective interventions to improve bone health of adolescent athletes are needed. The purpose of the study was to investigate the effect of a 9-month jumping intervention on bone geometry and metabolism in adolescent male athletes Methods Ninety-three adolescent (14.1 years old) male swimmers (SWI), footballers (FOO) and cyclists (CYC) were randomized to an intervention and sport (INT-SWI=19, INT-FOO=15, INT-CYC=14) or sport only (CON-SWI =18, CON-FOO =15, CON-CYC =12) groups. Cross-sectional area (CSA), cross-sectional moment of inertia (CSMI) and section modulus (Z) at the femoral neck were assessed using hip structural analysis, and trabecular texture of the lumbar spine using trabecular bone score (TBS). Bone mineral content (BMC) at femoral neck and lumbar spine was assessed using dual-energy x-ray absorptiometry. Serum N-terminal propeptide of procollagen type I (PINP), isomer of the Carboxi-terminal telopeptide of type 1 collagen (CTX-I), total serum calcium and 25 hydroxyvitamin D [25(OH)D] were analysed. Results INT-CYC acquired significantly higher lumbar spine BMC (4.6 %) and femoral neck BMC (9.8 %) than CON-CYC. INT-CYC acquired significantly higher CSA (11.0 %), CSMI (10.1 %) and TBS (4.4 %) than CON-CYC. INT-SWI acquired significantly higher femoral neck BMC (6.0 %) and CSMI (10.9 %) than CON-SWI. There were no significant differences between INT-FOO and CON-FOO in any bone outcomes. PINP significantly decreased in CON-SWI, INT-FOO, CON-FOO and CON-CYC. CTX-I significantly decreased in CON-SWI and CON-CYC. 25(OH)D significantly increased in INT-CYC, CON-CYC, INT-FOO and CON-FOO. Conclusions A 9-month jumping intervention improved bone outcomes in adolescent swimmers and cyclists, but not in footballers. This intervention might be used by sports clubs to improve bone health of adolescent athletes. Corresponding Author: Dr. Dimitris Vlachopoulos, Children's Health and Exercise Research Centre, Sport and Health Sciences, College of Life and Environmental Sciences, University of Exeter, St. Luke's Campus, Exeter, EX1 2LU, United Kingdom. Tel: +44 (0)1392 724721, Fax: +44 (0)1392 724726. Email: D.Vlachopoulos@exeter.ac.uk Trial registration number: ISRCTN17982776https://ift.tt/2n2S2rN The research leading to these results has received funding from the European Union Seventh Framework Programme ([FP7/2007-2013] under grant agreement n°. PCIG13-GA-2013-618496. The authors declare that they have no competing interests. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation, and the present study do not constitute endorsement by ACSM. Accepted for Publication: 28 June 2018 © 2018 American College of Sports Medicine

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Wrist-worn Accelerometry for Runners: Objective Quantification of Training Load

Purpose This study aimed to apply open-source analysis code to raw habitual physical activity data from wrist-worn monitors to: 1) objectively, unobtrusively and accurately discriminate between 'running' and 'non-running' days; and 2) develop and compare simple accelerometer-derived metrics of external training load with existing self-report measures. Methods Seven-day wrist-worn accelerometer (GENEActiv, Activinsights Ltd, Kimbolton, UK) data obtained from 35 experienced runners (age, 41.9±11.4 years; height 1.72±0.08 m; mass 68.5±9.7 kg; Body Mass Index, 23.2±2.2 kg.m2; 19 [54%] women) every other week over 9-18 weeks were date-matched with self-reported training log data. Receiver-Operating-Characteristic analyses were applied to accelerometer metrics ('Average Acceleration', 'Most Active-30mins', 'Mins≥400mg') to discriminate between 'running' and 'non-running' days and cross-validated (leave one out cross-validation; LOOCV). Variance explained in training log criterion metrics (Miles, Duration, Training Load) by accelerometer metrics ('Mins≥400mg', 'WL(workload)400-4000mg') was examined using linear regression with LOOCV. Results 'Most Active-30mins' and 'Mins≥400mg' had >94% accuracy for correctly classifying 'running' and 'non-running' days, with validation indicating robustness. Variance explained in Miles, Duration and Training Load by 'Mins≥400mg' (67-76%) and 'WL400-4000mg' (55-69%) was high, with validation indicating robustness. Conclusion Wrist-worn accelerometer metrics can be used to objectively, unobtrusively and accurately identify running training days in runners, reducing the need for training logs or user input in future prospective research or commercial activity tracking. The high percentage of variance explained in existing self-reported measures of training load by simple, accelerometer-derived metrics of external training load supports the future use of accelerometry for prospective, preventative and prescriptive monitoring purposes in runners. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Corresponding author contact details: Corresponding author, Dr Victoria Stiles, Sport and Health Sciences, College of Life and Environmental Sciences, University of Exeter, Exeter, UK; Tel: +44(0)1392 722885; Fax: +44(0)1392 724726; email: v.h.stiles@exeter.ac.uk This project was supported by Medical Research Council Proximity to Discover funding (Reference: MC_PC_14127) in collaboration with Activinsights Ltd, UK. AR is with the National Institute for Health Research (NIHR) Biomedical Research Centre based at University Hospitals of Leicester and Loughborough University, the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care – East Midlands (NIHR CLAHRC – EM) and the Leicester Clinical Trials Unit. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Conflicts of Interest As a collaborative study with industry supported by MRC Proximity to Discover funding, the industry partner may potentially benefit from the outcomes from the research. However, the open-source analysis procedures employed in the current study impose no restriction for other members of the activity monitoring industry to also benefit. There are no other competing interests. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation and do not constitute endorsement by ACSM. Accepted for Publication: 15 June 2018 © 2018 American College of Sports Medicine

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Exercise Timing in Type 2 Diabetes Mellitus: A Systematic Review

Purpose The timing of exercise relative to meal consumption has recently been identified as potentially moderating the effectiveness of exercise on glycemic responses in type 2 diabetes mellitus (T2DM). The aim of this study was to systematically review the literature related to exercise timing, relative to meal consumption, and glycemic control in individuals with T2DM. Methods Systematic searches in PubMed, EMBASE, CINAHL, Cochrane Library and ClinicalTrials.gov Registry databases were performed to identify articles published in English from inception to October 2017. Two authors independently extracted data and evaluated the quality of studies using the Cochrane Collaboration Data Collection Form and Cochrane Collaboration Risk of Bias Assessment Tool respectively. A qualitative synthesis was performed on the included studies, and results summarized in tables. Results 19 randomized controlled trials (RCTs) with a total of 346 participants were included. Improvements in glycemia (glucose concentrations and glucose-AUC) and insulin-AUC appeared more consistent when exercise was performed during the post-meal period as compared to the pre-meal period, however, this observation was largely based on indirect comparisons between studies. Conclusions There is some evidence from RCTs that exercise performed 30 min after meal consumption may convey greater improvements in glycemic control for individuals with T2DM. However, there are only two studies which have directly assessed the role of exercise timing on glycemic management and adopted methodologies are heterogeneous. Future low risk trials in this field are warranted. Corresponding Author: Timothy J. Fairchild, School of Psychology and Exercise Science, Murdoch University, 90 South Street, Murdoch WA 6150, +61 (08) 9360 2959. t.fairchild@murdoch.edu.au ST is supported by an Australian Government Research Training Program (RTP) Scholarship. No additional sources of funding were declared by the remaining authors. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. The results of the present study do not constitute endorsement by ACSM. Accepted for Publication: 4 July 2018 © 2018 American College of Sports Medicine

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