Infographic: 10 apps every paramedic should have

Stay up to speed on the latest mobile technology to help you do your job

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New Face of Hepatitis C

Abstract

Chronic hepatitis C viral (HCV) infection continues to carry a high burden of disease despite recent and emerging advancements in treatment. The persistently high prevalence of HCV is attributed to the rising opioid epidemic, with a history of injection drug use as the primary risk factor for infection. As a result, the epidemiology of HCV-infected individuals is changing. Previously a disease of "Baby Boomers," males, and non-Hispanic blacks, the new generation of patients with HCV includes younger adults from 20 to 39 years of age, both men and women similarly represented, and non-Hispanic whites. Shifting trends in these demographics may be attributed to the use of injection drugs, which also has suggested impact on fibrosis progression in infected individuals. Awareness of the changing face of HCV is necessary to expand and revise recommendations regarding screening, outreach, and care engagement of infected individuals, in order to best identify patients at-risk for infection.

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Paramedic - King County Medic One

King County Medic One plans on hiring up to 6 in 2019! All testing, Firefighter & EMT written exams, must be completed through Public Safety Testing by March 31, 2019. Please make sure to have your personal history statement (PHS) completed and uploaded into your account by the March 31, 2019 deadline! To learn more about the requirements for this position and to sign up to take the exams, please visit: ...

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Comprehensive analysis of genetic aberrations linked to tumorigenesis in regenerative nodules of liver cirrhosis

Abstract

Background

Hepatocellular carcinoma (HCC) recurrently develops in cirrhotic liver containing a number of regenerative nodules (RNs). However, the biological tumorigenic potential of RNs is still unclear. To uncover the molecular bases of tumorigenesis in liver cirrhosis, we investigated the genetic aberrations in RNs of cirrhotic tissues using next-generation sequencing.

Methods

We isolated 205 RNs and 7 HCC tissues from the whole explanted livers of 10 randomly selected patients who had undergone living-donor liver transplantation. Whole-exome sequencing and additional targeted deep sequencing on 30 selected HCC-related genes were conducted to reveal the mutational landscape of RNs and HCCs.

Results

Whole-exome sequencing demonstrated that RNs frequently harbored relatively high-abundance genetic alterations, suggesting a clonal structure of each RN in cirrhotic liver. The mutation signature observed in RNs was similar to those determined in HCC, characterized by a predominance of C>T transitions, followed by T>C and C>A mutations. Targeted deep sequencing analyses of RNs identified nonsynonymous low-abundance mutations in various tumor-related genes, including TP53 and ARID1A. In contrast, TERT promoter mutations were not detected in any of the RNs examined. Consistently, TERT expression levels in RNs were comparable to those in normal livers, whereas every HCC tissue demonstrated an elevated level of TERT expression.

Conclusion

Analyses of RNs constructing cirrhotic liver indicated that a variety of genetic aberrations accumulate in the cirrhotic liver before the development of clinically and histologically overt HCC. These aberrations in RNs could provide the basis of tumorigenesis in patients with liver cirrhosis.

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Multistage neurorehabilitation of an adolescent with severe anti-N-methyl-D-aspartate receptor encephalitis: a case report

We report on a 15-year-old girl with severe anti-N-methyl-D-aspartate receptor encephalitis who had initial poor prognostic factors. We delineate the unique challenges faced in the rehabilitation of our patient including sleep disruption and food aversion. After 20 months of hospitalization and intensive rehabilitation, there was a significant improvement in functional abilities and self-care skills. However, she had residual neurocognitive deficits, visual perceptual, and motor coordination difficulties that continued to improve after discharge, attesting to the need for long-term rehabilitation. The case showed the need for a coordinated multidisciplinary approach, with both targeted therapies and neuropharmacology, tailored to facilitate the different stages of recovery unique to anti-N-methyl-D-aspartate receptor encephalitis patients.

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Postural control skills, proprioception, and risk of fall in long-term survivor patients treated with knee rotationplasty

Knee A1 rotationplasty is a particular type of limb salvage surgery alternative to hip disarticulation and high transfemoral amputation for skeletally immature children with bone cancers in the distal femur. Notwithstanding optimal functional outcomes, long-term survivor patients often report frequent falls, and a sense of instability during gait, particularly on uneven terrain. This study aimed to assess the postural control, the proprioception, and the risk of fall in these patients, which have not been explored before. Eighteen long-term survivor patients participated in the study. The mean follow-up from surgery was 23 years, mean age 32 years. Patients were assessed using a specific instrumental device (Delos Postural Proprioceptive System) both for the static double-stance and the single-stance test in the open eyes and closed eyes conditions. The double-stance test showed postural instability values within the normal range for healthy individuals, whereas in the single-stance test stability index, when assessed in the average of both lower limbs, values were lower than the literature findings for older individuals. However, when separating the operated from the nonoperated limb performance, standing on the operated limb was very unstable, with a low stability index and a low degree of autonomy, indicating a certain risk of falling, whereas standing on the nonoperated limb had a performance close to normal or even superior. In conclusion, knee rotationplasty patients had very good postural control when standing on both limbs, whereas single stance on the operated limb was compromised, with particular involvement of the proprioceptive component. This may determine a higher risk of falling than their normal-age counterparts and rehabilitation intervention for prevention is indicated.

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Smartphone applications validated for joint angle measurement: a systematic review

Mobile health apps are growing constantly in number and popularity. Some mobile apps are used for clinical assessment, and consequently need to be verified and validated appropriately, along with the mobile platform, to ensure their safe and effective operation. We review the current literature on available smartphone goniometric apps validated for joint angle measurement and their main psychometric characteristics. A literature search of Medline and Scopus databases was performed to select papers on smartphone commercial apps validated for joint angle measurement and relevant to Physical Medicine and Rehabilitation. A platform search verified whether the selected apps were still available for download. The literature search identified 126 papers in Medline and 113 in Scopus, 49 of which were selected. They dealt with the validation of 23 apps, eight of which were no longer available and therefore excluded from the review. Psychometric characteristics of the selected apps were robust, but heterogeneity of the studies did not enable comparisons between apps to identify the most valid one. The increase in the number of apps and validation studies highlights the growing interest in this new approach for measuring body angles. Given the precarious commercial availability of some apps, when research is the goal, it is advisable to select apps with the longest durability. A need continues to exist for validation studies on available apps focused on goniometric measurement in gait or during performance of therapeutic exercises in neurological and orthopedic disorders.

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Cost-effectiveness of a high-intensity rapid access outpatient stroke rehabilitation program

A common strategy to improve cost-effectiveness in healthcare is to offer outpatient care instead of in-hospital care. Toronto Rehabilitation Institute developed an outpatient high-intensity fast-track (FT) stroke rehabilitation program aimed at discharging inpatient stroke rehabilitation patients earlier or bypassing inpatient rehabilitation altogether. This cost-effectiveness analysis compares FT rehabilitation within 1 week of discharge with no FT in a single healthcare payer system. Patient costs and outcomes over a 12-week time horizon were included. Using individual-level FT data from April 2015 to March 2016, incremental cost-effectiveness ratios (ICERs) (with 95% confidence interval) were estimated using regression. Subgroup analysis was completed for patients entering FT directly from inpatient rehabilitation and acute stroke care. Uncertainty was assessed using a cost-effectiveness acceptability curve with a range of willingness-to-pay values ($0–1000 per inpatient day saved). ICER (95% confidence interval) estimate for patients entering FT from inpatient rehabilitation was $404 ($270–620) per inpatient day saved. ICER estimate for direct from acute care admissions was $37 ($20–55) per day saved. At willingness-to-pay of $698 (cost of one alternate level of care day in acute care awaiting rehabilitation), the probability of FT being cost-effective was 99.2 and 100% for patients from inpatient rehabilitation and acute stroke care, respectively. From a single healthcare payer perspective, FT is a cost-effective method of providing appropriate rehabilitation intensity for stroke patients early on, and likely to provide savings to the healthcare system upstream through fewer days awaiting rehabilitation admission.

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Turkish adaptation of Parkinson fatigue scale and investigating its psychometric properties

Parkinson's disease (PD) is one of the most common chronic degenerative diseases of the nervous system. In PD, nonmotor symptoms are seen as frequently as motor symptoms. Fatigue can occur in all stages of PD and leads to significant disabilities. The aim of this study was to investigate the psychometric properties of the Turkish version of Parkinson fatigue scale (PFS). Ninety-six patients with idiopathic PD were included in this study with a cross-sectional and test–retest design. Structural validity, internal consistency and test–retest reliability of PFS were analyzed. For convergent validity, fatigue severity scale and modified fatigue impact scale were used. Internal consistency was determined by the Cronbach's α coefficient. For test–retest reliability, PFS was repeated after a 7–14-day period. Significant strong correlations were found between the PFS and the fatigue severity scale (rs=0.844) and the modified fatigue impact scale (rs=0.764), which indicate a high convergent validity. The Cronbach's α coefficient, which indicates the internal consistency of the scale, was calculated as 0.947. The test–retest reliability was found to be high (intraclass correlation coefficient=0.928). This study suggests that the Turkish version of PFS is valid and reliable. PFS is suitable for use by researchers and healthcare professionals to assess fatigue in Turkish-speaking patients with PD.

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Stroke survivor activity during subacute inpatient rehabilitation: how active are patients?

Being active following stroke is recommended, but inactivity is common. The current study aimed to observe stroke survivors physical, social and cognitive activities in a large regional inpatient rehabilitation centre. Patients were observed over 8 separate days at 10-min intervals between 8 a.m. and 8 p.m. Patients were engaged in any form of activity 59.9% of the time and in therapy 4.6% of the time. Patients were inactive and alone 34.3% of the time. Activity levels were weakly associated with patients' functional abilities (Spearman's ρ≤0.39). Independent walkers spent a higher proportion of the day physically active (37.5%) compared with nonindependent walkers (30.6%) (P=0.019). Days since stroke was not correlated with patient activity levels. Initiatives to increase activity during inpatient rehabilitation appear to be warranted.

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Manual function of the unaffected upper extremity can affect functional outcome after stroke

Traditionally, motor deficits of ipsilesional side, generally considered as the unaffected side, have been investigated less and the influence of the impairment is unknown. To evaluate the association between the manual function test (MFT) of nonparetic limb and poststroke functional outcome. We conducted a retrospective analysis of 71 hemiplegic patients with stroke. MFT on both sides was routinely measured at admission and 1 month later after admission by an experienced occupational therapist. The parameters of functional outcome after stroke were measured with the total score of functional independence measure (FIM) and the self-care subscore of FIM. Age, initial cognitive function, and MFT of the affected hand and unaffected hand were each significant factors for independently predicting short-term functional outcome after stroke. Linear regression analysis showed that initial MFT score of unaffected side is a significant predictor for 1 month follow-up subscore FIM (P

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Noninvasive neuromodulation techniques for the management of phantom limb pain: a systematic review of randomized controlled trials

Neuromodulation techniques work by modulating pain perception by inducing changes in polarity of the neuronal membrane and thereby cortical excitability. The aim of this review is to evaluate the efficiency and safety of noninvasive neuromodulation techniques for phantom limb pain (PLP). A systematic literature search in the PubMed, Scopus, Web of Science, and Cochrane Library databases was performed to identify studies investigating the effects of noninvasive neuromodulation for PLP. The included journal articles were assessed with Furlan et al.'s method for examining the risk of bias to assess methodologic quality, and evidence was graded using the GRADE approach. The literature search identified 239 studies. Of these 239, four studies fulfilled the inclusion criteria and were included for data extraction. Two of the studies focused on repetitive transcranial magnetic stimulation (rTMS) whereas two other concentrated on transcranial direct current stimulation (tDCS). The present review showed that there is conflicting evidence to support the use of tDCS in short term and moderate evidence to support the use of rTMS in immediate and short term. It is important to recognize that this evidence comes from a very small sample size. No serious adverse effects were reported. Further information from randomized controlled trials with larger sample size investigating immediate and short-term and long-term effects are needed to clarify the best effective stimulation parameters and number of sessions of tDCS and rTMS for PLP.

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Clinical study of combined mirror and extracorporeal shock wave therapy on upper limb spasticity in poststroke patients

Mirror therapy is a simple, inexpensive, and patient-oriented method that has been shown to reduce phantom sensations and pain caused by amputation and improve range of motion, speed, and accuracy of arm movement and function. Extracorporeal shock wave therapy (ESWT) is a new, reversible, and noninvasive method for the treatment of spasticity after stroke. To investigate the therapeutic effect of the combination of mirror and extracorporeal shock wave therapy on upper limb spasticity in poststroke patients. We randomly assigned 120 patients into four groups: A, B, C, and D. All groups received conventional rehabilitation training for 30 min per day, five times a week, for 4 weeks. Moreover, participants in groups A, B, and C also added mirror therapy, ESWT, and a combination of mirror and ESWT, respectively, for 20 min per day. Motor recovery and spasticity were measured using Fugl–Meyer assessment and modified Ashworth scale. The differences in the Fugl–Meyer assessment and modified Ashworth scale scores in group C were significantly greater than those of group D at all observed time points after treatment and were significantly greater than those of groups A and B (P

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Development of a simplified Cold Intolerance Symptom Severity questionnaire in patients with peripheral nerve injury

The aim of this study was to analyse the Cold Intolerance Symptom Severity (CISS) questionnaire in its Italian validated version, using Rasch analysis, to gain insights for a possible refinement of the questionnaire. The CISS was administered to a convenience sample of 96 consecutively recruited outpatients with upper limb peripheral nerve injury. Data were analysed using Rasch analysis. According to rating scale diagnostics, response options of items 3 and 5 did not comply with the pre-set criteria for an optimal category functioning. After collapsing the malfunctioning categories, all items fitted the measured construct. Principal component analysis of standardized residuals showed local dependence between two items (one of them was considered redundant and deleted); after this deletion, unidimensionality of the 12-item questionnaire (CISS-12) was achieved. The reliability indices of CISS-12 were high (>0.85). Some clearer item wording was introduced in response to comments from an expert panel and patient feedback. Overall, Rasch analysis provided the rationale for improving the measurement qualities of the questionnaire, refining its rating scales, identifying those items most useful for measuring the intended construct and confirming the high reliability of its person-ability and item-difficulty estimates. In conclusion, the new simplified CISS-12 presents robust psychometric properties for measuring cold intolerance in patients with upper limb peripheral nerve injury and represents a solid basis for clinical studies aimed at a precise (interval level) measurement of cold-induced symptoms in these patients.

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Effects of functional electrical stimulation-cycling on shoulder pain and subluxation in patients with acute–subacute stroke: a pilot study

Functional electrical stimulation (FES)-cycling is a technique used to provide voluntary muscle contraction during a functional task. The aims were primarily to determine the effects of FES-cycling on shoulder pain and subluxation, and secondarily to evaluate the improvement of upper extremity motor function in patients with acute–subacute stroke patient. In this prospective trial, 21 patients with acute–subacute stroke, randomly assigned into the FES-cycling group or the standard rehabilitation program (control group). Analyses of shoulder subluxation were carried out by radiography. The numeric rating scale was used to evaluate the intensity of pain, Fugl-Meyer and Frenchay arm tests for motor function, and functional independence measure for functional status. The outcome data were evaluated at baseline and at the end of 4-week treatment. Intragroup comparisons showed improvement of acromiohumeral distance, Fugl-Meyer assessment, and functional independence measure in both groups after treatment. In intergroup comparison, FES-cycling group exerted better outcomes in shoulder pain compared with the control group (P=0.015). Correlation analyses demonstrated only positive correlation between shoulder subluxation and pain (P=0.022). FES-cycling was superior to standard rehabilitation therapy for shoulder pain relief in patients with acute–subacute stroke. Therefore, combining FES-cycling with a standard rehabilitation program alleviates shoulder pain and may prevent development of shoulder subluxation over time.

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The effect of task-oriented electromyography-triggered electrical stimulation of the paretic wrist extensors on upper limb motor function early after stroke: a pilot randomized controlled trial

The combined effect of task-oriented motor training and electromyography (EMG)-triggered electrical stimulation (ES) has been examined in chronic stroke, but there are no published reports in patients with early stroke. Therefore, the purpose of this study was to determine the short-term and long-term effects of task-oriented EMG-triggered ES on upper limb motor function in acute/subacute stroke. Twenty-seven patients with stroke within the first 3 months after stroke onset were randomly allocated to an experimental group and a control group. Twenty-three patients (12 patients in the experimental group and 11 patients in the control group) completed the study. The control group received a conventional physical therapy for 20 sessions, and the experimental group received task-oriented EMG-triggered ES therapy for the wrist/finger extensors in addition to conventional physical therapy for 5 sessions a week for 4 weeks. Primary outcome measures were the Action Research Arm Test, the Brunnstrom stages of the hand/upper extremity, and the motor Functional Independence Measure. All patients were evaluated before the treatment, after the treatment, and at 3 months. The parametric and nonparametric statistics at the 5% level of significance (α=0.05) was used for testing the differences between the two groups at each main end point. At the end of the treatment, the experimental group showed significantly greater improvements in Brunnstrom stages and ARAT grasp/grip/pinch scores, but not motor Functional Independence Measure scores, when compared with the control group. The differences between the 3-months and postintervention evaluations were not significant between the two groups suggesting retention of the postintervention gains. Our results indicate that task-oriented EMG-triggered ES training may result in improvements in the paretic upper limb function in patients with acute/subacute stroke that are superior to the conventional treatment.

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Combining Russian stimulation with isometric exercise improves strength, balance, and mobility in older people with falls syndrome

One of the main causes of falls in older people is muscle strength loss associated with aging. Russian stimulation can improve muscle strength in healthy individuals, but the effect has never been tested in older individuals with falls syndrome. The aim of this study was to evaluate the usefulness of Russian stimulation plus isometric exercise to improve muscular strength, balance, and mobility in older people with falls syndrome. The recruited participants (older than 60 years, at least one fall in the past year) were evaluated by a physiatrist, who collected clinical data and performed baseline and final evaluations (muscle strength, Berg balance scale, Tinetti mobility test, get up and go test, and 6-min walk test). A physical therapist applied the 10/50/10 protocol for Russian stimulation, stimulating the quadriceps and tibialis anterior muscles separately; simultaneously, the participants performed isometric exercise at a frequency of three sessions per week for 12 weeks. Descriptive statistics, the paired-sample t-test, and the χ2-test were performed. The study included 25 participants (96% women, mean age 65.2±5.5 years). After the intervention, there was a significant improvement in the strength of the quadriceps (~30%) and tibialis anterior (~40%) muscles as well as the results of the balance (Tinetti 22%, Berg 10%) and mobility (get up and go 25%, 6-min distance 20%) tests. On the basis of the improvements in the Tinetti and Berg scores, significantly fewer participants were classified as being at increased risk for falls. The muscle strength correlated with several clinical evaluation results, but not with the Tinetti test score. Russian stimulation plus isometric exercise improves strength, balance, and mobility, which may decrease the fall risk.

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Relationship between body image and physical functioning following rehabilitation for lower-limb amputation

The aim of the present study was to evaluate change in body image and the association between body image at discharge and mobility 4 months after rehabilitation. A prospective cohort comprising adults older than or equal to 50 years of age undergoing rehabilitation for first major lower-limb amputation at an inpatient prosthetic rehabilitation program were assessed at discharge and 4 months after rehabilitation. Paired t-tests compared total Amputee Body Image Scale (ABIS), gait velocity, and L-test scores between discharge (T1) and 4 months (T2). Multivariable linear regression assessed relationship between ABIS scores and mobility. Nineteen participants completed assessments (mean±SD age=60.86±6.85 years; 63.20% male patients). Body image changed from T1 (43.58±7.83) to T2 (48.26±12.21), but was not statistically significant (P=0.063). Mobility significantly improved at T2. ABIS scores at T1 were not associated with mobility at T2. Mobility improved after discharge but was not related to body image at T1. Additional research on the impact of body image perception on patient outcomes after rehabilitation is needed.

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Rhythmic robotic training enhances motor skills of both rhythmic and discrete upper-limb movements after stroke: a longitudinal pilot study

Discrete and rhythmic movements are two fundamental motor primitives being, at least partially, controlled by separate neural circuitries. After a stroke, both primitives may be impaired in the upper limb. Currently, intensive functional movement therapy is recommended after stroke, but it is mainly composed of discrete movements. No recommendation is made for the specific training of rhythmic movements. However, if they form two different primitives, both should receive a specific training to recover the complete motor repertoire, as many daily live movements integrate both of them. This paper reports the effects of a pure unilateral rhythmic movement therapy on motor performance, after stroke. Thirteen patients with chronic stroke participated in this longitudinal pilot study. They were assessed twice before the therapy to validate their chronic state, and twice after the last session to establish the short-term and long-term effects of the therapy. The therapy itself was composed of 12 sessions spread over 1 month. The exercises consisted in performing straight or circular rhythmic movements, while receiving assistance as need through a robotic device. Short-term and long-term improvements were observed in rhythmic movements regarding smoothness, velocity, and harmonicity. More surprisingly, some transfer occurred to the untrained discrete movements. This finding disputes previous studies that reported no transfer from rhythmic to discrete movements with healthy participants.

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Phonemic fluency improved after inhibitory transcranial magnetic stimulation in a case of chronic aphasia

Twenty-six months after a left hemispheric ischemic stroke an aphasic patient showed a significant improvement in verbal fluency following ten daily sessions of inhibitory 1 Hz repetitive transcranial magnetic stimulation over the right cortex homologous to the Broca's area. No improvement was observed for other linguistic functions or for executive ones. Results confirm the segregation of neural circuitries subtending phonemic and semantic fluency and suggest a selective usefulness of the repetitive transcranial magnetic stimulation treatment.

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Transjugular aspiration liver biopsy performed by hepatologists trained in HVPG measurements is safe and provides important diagnostic information

Transjugular liver biopsy (TJLB) represents an alternative to percutaneous liver biopsy especially in patients with impaired coagulation and ascites.

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Short-Homology-Mediated CRISPR/Cas9-Based Method for Genome Editing in Fission Yeast

The CRISPR/Cas9 system enables the editing of genomes of numerous organisms through the induction of the double-strand breaks (DSB) at specific chromosomal targets. We improved the CRISPR/Cas9 system to ease the direct introduction of a point mutation or a tagging sequence into the chromosome by combining it with the noncanonical homology-directed DNA repair (HDR) based genome editing in fission yeast. We constructed convenient cloning vectors, which possessed a guide RNA (gRNA) expression module, or the humanized Streptococcus pyogenes Cas9 gene that is expressed under the control of an inducible promoter to avoid the needless expression, or both a gRNA and Cas9 gene. Using this system, we attempted the short-homology-mediated genome editing and found that the HDR pathway provides high-frequency genome editing at target loci without the need of a long donor DNA. Using short oligonucleotides, we successfully introduced point mutations into two target genes at high frequency. We also precisely integrated the sequences for epitope and GFP tagging using donor DNA possessing short homology into the target loci, which enabled us to obtain cells expressing N-terminally tagged fusion proteins. This system could expedite genome editing in fission yeast, and could be applicable to other organisms.

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QTL Underlying Circadian Clock Parameters Under Seasonally Variable Field Settings in Arabidopsis thaliana

The circadian clock facilitates coordination of the internal rhythms of an organism to daily environmental conditions, such as the light-dark cycle of one day. Circadian period length (the duration of one endogenous cycle) and phase (the timing of peak activity) exhibit quantitative variation in natural populations. Here, we measured circadian period and phase in June, July and September in three Arabidopsis thaliana recombinant inbred line populations. Circadian period and phase were estimated from bioluminescence of a genetic construct between a native circadian clock gene (COLD CIRCADIAN RHYTHM RNA BINDING 2) and the reporter gene (LUCIFERASE) after lines were entrained under field settings. Using a Bayesian mapping approach, we estimated the median number and effect size of genomic regions (Quantitative Trait Loci, QTL) underlying circadian parameters and the degree to which these regions overlap across months of the growing season. We also tested for QTL associations between the circadian clock and plant morphology. The genetic architecture of circadian phase was largely independent across months, as evidenced by the fact that QTL determining phase values in one month of the growing season were different from those determining phase in a second month. QTL for circadian parameters were shared with both cauline and rosette branching in at least one mapping population. The results provide the first insights into the QTL architecture of the clock under field settings, and suggest that the circadian clock is highly responsive to changing environments and that selection can act on clock phase in a nuanced manner.

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Do not open Pandora's box!

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How to achieve operational uniformity with consolidated communication centers

Striking the balance between agency independence and operational synergy through conflict resolution, funding and governance

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Adult Spinal Deformity and Its Relationship with Hip Range of Motion: A Cohort Study of Community-Dwelling Females

Adult spinal deformity affects lower extremity alignment with compensation in joint range of motion (ROM) and alignment of the hip.

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HLA-DQ Genotyping, Duodenal Histology, and Response to Exclusion Diet in Autistic Children With Gastrointestinal Symptoms

Objectives: A correlation between autism spectrum disorders (ASDs) and gastrointestinal (GI) problems, and a possible link between gluten consumption and ASD have been increasingly reported. Gluten/casein-free diet (GCFD) is often undertaken, with conflicting results. This study aimed at evaluating the distribution of human leukocyte antigen (HLA)-DQ2/DQ8 typing among patients with ASD with GI symptoms, together with its correlation with duodenal histology and response to GCFD. Methods: Between 2002 and 2015 all patients with ASD with GI symptoms referred to our outpatient clinic, displaying clinical, laboratory, or ultrasound findings suggestive of organic disease, underwent endoscopy, celiac disease (CD) serum antibodies testing and HLA-DQ2/DQ8 genotyping. Patients were prescribed a 6-month GCFD, and then clinically reassessed. Results: Among 151 enrolled patients, 134 (89%) were negative for CD-specific antibodies; 72 (48%) were positive for HLA-DQ2/DQ8; and 56 (37%) showed duodenal microscopic inflammation. Clinical improvement was observed in non-CD patients irrespective of the rigorous or partial adherence to the diet, being the difference nonstatistically significant. Response to diet was related to the presence of histological duodenal alterations at baseline (odds ratio 11.323, 95% confidence interval 1.386–92.549 for Marsh 2 pattern), but not to HLA-DQ2/DQ8 positivity (odds ratio 1.120, 95% confidence interval 0.462–2.716). Conclusions: Our data suggest that children with ASD with GI symptoms have a high prevalence of duodenal intraepithelial lymphocytic infiltration, which seems to be linked to a mechanism other than autoimmune response to gluten consumption. Alteration of duodenal histology, but not the HLA-DQ2/DQ8 status, was associated with clinical response to the diet. Address correspondence and reprint requests to Carlo Alessandria, MD, Division of Gastroenterology and Hepatology, Città Della Salute e Della Scienza di Torino Hospital, University of Turin, C.so Bramante 88, 10126 Turin, Italy (e-mail: carloalessandria@libero.it). Received 22 June, 2018 Accepted 22 January, 2019 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). The authors report no conflicts of interest. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Risk-factors Associated with Poor Outcomes in VEO-IBD Secondary to XIAP Deficiency: A Case Report and Literature Review

Very early onset inflammatory bowel disease (VEO-IBD) represents a diagnostic and treatment challenge. Here we present a case of VEO-IBD secondary to a mutation in BIRC4 gene, which encodes X-linked inhibitor of apoptosis protein (XIAP), in a 17 month-old male with severe failure to thrive, intractable diarrhea and hepatosplenomegaly. Endoscopy and histology identified only mild duodenitis and ileitis, but severe pancolitis with crypt abscesses and epithelium apoptosis. Minimal improvement in symptoms was achieved with total parenteral nutrition (TPN), intravenous (IV) corticosteroids and tacrolimus, whereas induction and maintenance therapy with adalimumab led to complete remission. After 6 months, the patient developed hemophagocytic lymphohistiocytosis (HLH) and eventually died due to multi-system organ failure. A review of the literature revealed that some patients with VEO-IBD secondary to XIAP deficiency develop symptoms that are refractory to medical and surgical management, while initial reports suggest that allogeneic hematopoietic stem cell transplantation (HSCT), with reduced intensity conditioning, can successfully induce long lasting remission and may even be curative. We propose that in patients with XIAP deficiency a constellation of symptoms including colitis at an early age, severe failure to thrive and splenomegaly/hepatosplenomegaly can identify a subgroup of patients at high-risk of experiencing medically-refractory IBD phenotype and increased mortality. Hematopoietic stem cell transplant should be considered early in these high-risk patients, as it may resolve both their intestinal inflammation and a risk of developing life threatening HLH. Address correspondence and reprint requests to Samir Softic, MD, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02215 (e-mail: samir.softic@childrens.harvard.edu). Received 3 October, 2018 Accepted 30 December, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). The authors report no conflicts of interest. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Mean Corpuscular Volume to White Blood Cell Ratio for Thiopurine Monitoring in Pediatric Inflammatory Bowel Disease

Objectives: Thiopurines, commonly used to treat inflammatory bowel disease (IBD), cause lymphopenia and red blood cell macrocytosis, requiring therapeutic monitoring. Mean corpuscular volume/white blood cell (MCV/WBC) ratio has been proposed as a surrogate for therapeutic monitoring. Our aim was to investigate MCV/WBC ratio for assessing clinical response to thiopurines among pediatric IBD patients. Methods: We performed a retrospective cross-sectional study at a tertiary care center using laboratory results and standardized physician global assessments (PGA) among pediatric patients taking thiopurines. Erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), fecal calprotectin, and 6-thioguanine nucleotides were assessed when available. The primary outcome was association between MCV/WBC ratio and clinical remission assessed by ESR, CRP, calprotectin, or PGA. We also used a composite outcome requiring all available data to be normal. Analyses were limited to one occurrence per patient, >60 days after starting thiopurine, and comparators were required to be within 14 days of one another. Results: 471 patients met inclusion criteria. MCV/WBC ratio poorly predicted quiescent disease as defined by PGA (area under receiver operating characteristic curve [AuROC] 0.55, 95% confidence interval [CI] 0.43–0.66). MCV/WBC ratio better predicted quiescent disease defined as normal CRP (AuROC 0.64, 95% CI 0.58–0.70) or normal ESR (AuROC 0.59, 95% CI 0.52–0.66). When the composite outcome measure was used, MCV/WBC ratio had an AuROC of 0.65 (95% CI 0.59- 0.70), indicating it is reasonably accurate in discriminating between clinical remission and active disease. Conclusions: MCV/WBC ratio is a non-inferior, easy, and low-cost alternative to thiopurine metabolite monitoring. Address correspondence and reprint requests to Jeremy Adler, 300 North Ingalls 6D18 Ann Arbor, MI 48109-5456 (e-mail: jeradler@umich.edu) Received 23 August, 2018 Accepted 28 December, 2018 Sources of support: We wish to thank Hannah K. Jary, MPH for her assistance in data management. No financial or material support was received. Conflicts of Interest and Source of Funding: All authors have no disclosures or conflicts of interest. No funding was received for this study. Authorship Statement: Jeremy Adler is the guarantor of this article. Prashanthi Kandavel and Jeremy Adler were involved in study concept and design, data collection, data analyses, drafting of the manuscript, critical revision of the manuscript for important intellectual content, and study supervision. Sally J. Eder collected the data and critically reviewed the manuscript. Akbar K. Waljee was involved in analysis and critical revision of the manuscript. Noah E. Newman assisted in data analysis and critical revision of the manuscript. Emily P. Whitfield participated in study design and critically reviewed the manuscript. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Young Age Predicts Acute Pancreatitis Severity in Children

Objectives: The course and evolution of pediatric acute pancreatitis (AP) is poorly understood. Prognostication models in children perform poorly and lack consensus. We aimed to identify predictors of AP severity, and the risk for AP recurrence. Methods: We retrospectively studied all patients hospitalized with AP at a single tertiary center, between January 1995 and June 2016. Patient demographics and admission laboratory data were assessed for severity and recurrence prediction. Results: A total of 68 patients accounting for a total of 117 (15 moderate-severe) AP episodes were reviewed. Patients with moderate-severe disease were significantly younger (median [interquartile range (IQR)] of 8.3 [4.0–14.4] vs 13.8 [8.1–16.0] years, P = 0.02). Young age at presentation was associated with odds ratio of 3.8 (confidence interval [CI] 1.2–12.1) for children younger than 12 years and 5.8 (CI 1.6–21.4) for children younger than 6 years for developing moderate-severe disease. Further subanalysis of the 59 patients with first-time AP episodes, demonstrated younger age (median [IQR] of 5.3 [2.9–10.4] vs 12.0 [6.3–15.8] years, P = 0.03) and elevated white blood cell count (median [IQR] of 22.8 [11.8–31.3] vs 11.0 [8.1–14.6] 109/L, P 15 × 109/L, respectively. Fourteen (23.7%) of 59 patients with first-time episodes had recurrent AP. Analysis of the data at the primary episode failed to identify predictors to indicate future recurrence. Conclusions: In our cohort, only young age (

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A Novel VPS33B Mutation Causing a Mild Phenotype of ARC Syndrome

No abstract available

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Editorial: Treating Biliary Atresia: The Challenge Continues

No abstract available

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“Y” in the Gall Bladder Fossa: Think of Duplicated Gall Bladder

No abstract available

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Magnetically Controlled Capsule Endoscopy in Children: A Single Center, Retrospective Cohort Study

Objective: Capsule endoscopy (CE) is a noninvasive diagnostic tool for the digestive tract. We aim to investigate the feasibility and safety of newly-developed magnetically controlled capsule endoscopy (MCE) in children. Methods: A total of 129 children who underwent MCE in Shanghai Children's Hospital were retrospectively recruited between March 2016 and August 2018. The feasibility, positive findings, and safety of MCE were evaluated and systematically analyzed. Results: Of all those children, 68 were boys, and 61 were girls with a mean age of 9.8 ± 1.9 years (6–14 years). The MCE procedure was feasible in all children. The mean esophageal transit time was 6.0 ± 4.6 seconds. The mean gastric examination time was 14.4 ± 3.9 minutes, and the average gastric transit time was 83.9 ± 59.1 minutes. Positive findings were detected in 82 children (82/129, 63.6%), 1 had esophageal lesions, 30 had superficial gastritis, 14 had superficial gastritis with bile reflux, 18 had nodular gastritis, 1 had ulcers and 2 had heterotopic pancreas. There were 5 patients who had duodenal bulbar ulcers. One had lymphatic follicle, 1 had celiac disease, 1 had blue rubber bleb nevus syndrome, and 2 polyps were detected in 16 patients who were examined the small bowel. No serious adverse event was reported during the MCE examination and follow-up, and all subjects excreted the capsules spontaneously within 2 weeks. Conclusions: We showed that MCE is feasible and safe in children above 6 years. More studies are needed to further investigate the efficacy of MCE in children. Address correspondence and reprint requests to Haifeng Liu, MD, PhD, Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, Shanghai Jiao Tong University, 355 Luding Road, Shanghai 200062, China (e-mail: haifengliush@aliyun.com). Received 12 November, 2018 Accepted 21 January, 2019 Funding: This work was supported by the grants from the National Natural Science Foundation of China (to Y. Wang, 81500449), and Shanghai Appropriate Health Technology Project of Municipal Hospitals (to H. Liu, SHDC12014224). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Conflicts of Interest: All authors disclosed no conflicts of interest for this article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Z.G. and Y.W. Both authors contributed equally to this study. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Efficacy of a new strength training design: the 3/7 method

Abstract

Aim

This study investigated the efficacy of a new strength training method on strength gain, hypertrophy, and neuromuscular fatigability.

Methods

The training exercise consisted of elbow flexion against a load of ~ 70% of one repetition maximal (1RM). A new method (3/7 method) consisting of five sets of an increasing number of repetitions (3 to 7) during successive sets and brief inter-set intervals (15 s) was repeated two times after 150 s of recovery and compared to a method consisting of eight sets of six repetitions with an inter-set interval of 150 s (8 × 6 method). Subjects trained two times per week during 12 weeks. Strength gain [1RM load and maximal isometric voluntary contraction (MVC)], EMG activity of biceps brachii and brachioradialis, as well as biceps' brachii thickness were measured. Change in neuromuscular fatigability was assessed as the maximal number of repetitions performed at 70% of 1RM before and after training.

Results

Both 3/7 and 8 × 6 methods increased 1RM load (22.2 ± 7.4 and 12.1 ± 6.6%, respectively; p < 0.05) and MVC force (15.7 ± 8.2 and 9.5 ± 9.5%; p < 0.05) with a greater 1RM gain (p < 0.05) for the 3/7 method. Normalized (%M_max) EMG activity of elbow flexors increased (p < 0.05) similarly (14.5 ± 23.2 vs. 8.1 ± 20.5%; p > 0.05) after both methods but biceps' brachii thickness increased to a greater extent (9.6 ± 3.6 vs. 5.5 ± 3.7%; p < 0.05) for the 3/7 method. Despite subjects performing more repetitions with the same absolute load after training, neuromuscular fatigability increased (p < 0.05) after the two training methods.

Conclusion

The 3/7 method provides a better stimulus for strength gain and muscle hypertrophy than the 8 × 6 method.

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Clinical outcomes of endoscopic resection for non-ampullary duodenal laterally spreading tumors

Abstract

Background and aims

Non-ampullary duodenal laterally spreading tumors (NAD-LSTs) mimic the morphological features and natural history of colorectal LSTs, even achieving a large size but lacking invasive behavior; thus, they are suited for endoscopic resection (ER). At present, the endoscopic therapeutic approach in NAD-LSTs has not been clearly established. The aim of this study was to evaluate the efficacy and safety of ER for NAD-LSTs and to evaluate the risk factors for delayed perforation after ER of NAD-LSTs.

Patients and methods

A total of 54 patients with 54 NAD-LSTs treated with ER at the Chinese PLA General Hospital between January 2007 and January 2018 were retrospectively analyzed. Data on patient demographic, clinicopathological characteristics of the lesions, outcomes of ER, and results of follow-up endoscopies were collected.

Results

The mean (SD) lesion size was 26.9 mm (8.5). Endoscopic mucosal resection (EMR) was performed in 21 lesions, and endoscopic submucosal dissection (ESD) was performed in 33 lesions. R0 resection was achieved in 93.9% of the ESD group and 38.1% of the EMR group (p = 0.000). Delayed bleeding was noted in two patients. Delayed perforation was identified in four patients. The incidence of delayed perforation showed a significant association with post-ampullary tumor location (p = 0.030). Follow-up endoscopy was performed in all cases with a mean (SD) period of 22.1 months (8.2), and local recurrence was identified in four cases after piecemeal EMR.

Conclusions

ER of NAD-LSTs is a feasible and less invasive treatment. However, ER of NAD-LSTs is associated with serious adverse events such as delayed perforation, especially in patients with lesions located distal to Vater's ampulla.

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Piloting a Telephone Based Health Coaching Program for Pregnant Women: A Mixed Methods Study

Abstract

Objectives Get Healthy in Pregnancy (GHiP) is a telephone based lifestyle coaching service for pregnant women, in New South Wales, Australia. GHiP had two service options; a telephone-based health coaching program consisting of up to 10 calls and information only (including one call). This study sought to compare the outcomes of the two GHiP options, to determine the characteristics of women likely to use the service and to explore the feedback from women and health professionals. Methods A pragmatic stratified clustered randomised controlled trial was conducted. Two metro and three rural hospitals were randomised into health coaching or information only arms. Self-reported measures of height and weight and health behaviours (dietary and physical activity) were collected at baseline and 36 weeks gestation. Process evaluation included descriptive analysis of routine program data, and semi-structured interviews with participants and health professionals. Results Of 3736 women screened, 1589 (42.5%) were eligible to participate, and of those eligible, 923 (58.1%) were recruited. More women in the health coaching arm gained weight within the target range for their BMI at 36 weeks gestation (42.9%) compared with information only (31.9%). Women found GHiP to be useful and supportive and midwives and doctors said that it facilitated conversations about weight with pregnant women. Conclusions for Practice Telephone-based lifestyle programs integrated with routine clinical care show promise in helping pregnant women achieve healthy gestational weight gain, but in this case was not significantly different from one information telephone call. Strong positive feedback suggests that scaled-up service delivery would be well received.

Trial Registration

ACTRN12615000397516 (retrospectively registered).

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Criteria-Based Return to Sport Decision-Making Following Lateral Ankle Sprain Injury: a Systematic Review and Narrative Synthesis

Abstract

Objective

The aim of this systematic review was to identify prospective studies that used a criteria-based return to sport (RTS) decision-making process for patients with lateral ankle sprain (LAS) injury.

Design

Systematic review and narrative synthesis.

Data sources

The PubMed (MEDLINE), Web of Science, PEDro, Cochrane Library, SPORTDiscus (EBSCO), ScienceDirect, and Scopus databases were searched to 23 November 2018.

Eligibility criteria for selecting studies

Studies were included if they prospectively applied a criteria-based RTS decision-making process for patients with LAS injury, but were excluded if they merely gathered outcome measures at the RTS time point. Studies were also excluded if patients were recovering from ankle fracture, high ankle sprain, medial ankle sprain, chronic ankle instability or complex ankle injury.

Results

No studies were identified that used a criteria-based RTS decision-making process for patients with LAS injury. We were unable to conduct a quantitative synthesis or meta-analysis, therefore we provide a narrative synthesis of relevant questionnaires, as well as clinical and functional assessments commonly used in studies retrieved in the search.

Conclusion

There are currently no published evidence-based criteria to inform RTS decisions for patients with an LAS injury. Based on our narrative synthesis, we propose a number of variables that could be used to develop a criteria-based RTS decision paradigm. Future research should aim to reach consensus on these variables and apply them to actual RTS decisions within prospective study designs. Furthermore, we suggest that complex systems theory and the RTS continuum could be used to inform the development of an RTS decision-making paradigm for athletes with LAS injury.

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The Differential Role of Vitamin D in Type 2 Diabetes Management and Control in Minority Populations

Abstract

Vitamin D deficiency is associated with incidence of type 2 diabetes (T2DM) as well as poor glycemic control among T2DM patients, yet comparative studies of its association among ethnic minority populations are scarce. Using baseline data from a behavioral intervention study of Korean Americans (KAs) with T2DM (N = 250 KAs) and the NHANES data set, we explored differential roles of vitamin D on HbA1_C level or T2DM control in several racial groups. Significantly more KAs (55.2%) were vitamin D-deficient (U.S. average, 37.8%). Both common and unique correlates of vitamin D deficiency in minority populations were identified, including significant associations between Vitamin D and HbA1_C in both non-diabetic and diabetic populations. Future studies are warranted to explain the causal mechanism of the effect of vitamin D and glycemic control as well as to examine contextual factors associated with vitamin D deficiency in certain minority groups.

Clinical Trials Registry: Identifier NCT01264796

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Coagulation and deep vein flow changes following laparoscopic total extraperitoneal inguinal hernia repair: a single-center, prospective cohort study

Abstract

Background and purpose

Venous thromboembolism (VTE) is a serious complication encountered in surgical practice. The purpose of this study was to identify changes in coagulation status and deep vein flow parameters, within 24 h postoperatively, for patients undergoing laparoscopic total extraperitoneal inguinal hernia repair (TEP).

Methods

For 144 patients undergoing TEP, coagulation markers including prothrombin time (PT), partial thromboplastin time, thrombin time, D-dimer, fibrinogen, fibrin degradation products (FDP), and international normalized ratio (INR) were monitored preoperatively and in the first morning postoperatively. Echo-Doppler recordings preoperatively and again within 24 h postoperatively were completed for 23 patients to monitor lower extremity deep vein flow parameters including speed of flow (cm/s), diameter (cm), and cross-sectional area (cm²). Clinically significant VTE and other complications were recorded.

Results

No significant VTE were diagnosed. Significant increases were seen in the first morning postoperatively for PT, D-dimer, FDP, and INR (P < 0.05). Stratified by age, except for those < 50 years, the ratio of value-outside-the-normal-range (VONR) for D-dimer and FDP increased significantly postoperatively for all age groups. Stratified by operation duration, a significant difference in the ratio of VONR in D-dimer was identified postoperatively between those with an operation duration < 60 min and ≥ 60 min. There were significant decreases in the iliac and common femoral vein flow velocity of the ipsilateral extremity postoperatively (P < 0.05).

Conclusions

Activated hypercoagulability and hampered lower extremity deep vein flow were observed immediately after TEP. DVT formation was more pronounced in older patients and for those with operation duration ≥ 60 min. Proper VTE risk stratification for laparoscopic inguinal hernia repair (LIHR) and prophylaxis early after LIHR should be important clinical considerations.

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Endoscopic vacuum assisted wound closure (EVAC) device to treat esophageal and gastric leaks: assessing time to proficiency and cost

Abstract

Background

Endoluminal vacuum therapy (EVAC) is an emerging procedure used to treat anastomotic leaks and/or perforations that would otherwise require surgery. The aim of this study was to determine time to proficiency in EVAC and the cost effectiveness of the procedure.

Methods

We retrospectively reviewed a prospectively maintained IRB approved database for all patients undergoing EVAC after esophageal and gastric complications between October 2013 and December 2017. Proficiency was determined by obtaining predicted estimates and analyzing the point at which average procedure time plateaued based on case volume. Total cost was calculated based on supplies and location where the procedure was performed.

Results

There were 50 patients (17 males, 33 female), with a mean age of 52.1 years. EVAC was placed in 23 (46%) patients with esophageal injuries and 28 (56%) with gastric injuries. Two advanced endoscopists performed all EVAC procedures in this study (1 surgeon, 1 gastroenterologist). The average procedure time for all patients was 43.5 min and the average wheel in/wheel out time for all patients was 75.6 min. Analysis of the trend based on average procedure times for EVAC revealed that proficiency was obtained after 10 cases. Total cost of the procedure is significantly lower in the GI lab compared to the operating room ($4528 vs. $11889). The majority of EVAC were performed in the GI lab (62%) compared to the operating room (38%).

Conclusion

Successful outcomes in managing anastomotic leaks or intestinal perforations non-operatively has led to an increased interest in EVAC. For advanced endoscopists, time to proficiency is approximately 10 cases. Performing the procedure in the GI lab has a 2.5 reduction in total cost compared to the operating room.

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Development of a novel tool to assess skills in laparoscopic gastrectomy using the Delphi method: the Japanese operative rating scale for laparoscopic distal gastrectomy (JORS-LDG)

Abstract

Background

Assessment of the performance of laparoscopic gastrectomy is yet unreported, likely because of the complexity of the procedure. We aimed to develop a tool to assess the skills required for laparoscopic distal gastrectomy (LDG) through cognitive task analysis (CTA) and expert consensus using the Delphi method.

Methods

CTA involved the listing of the knowledge and criteria required for completing each step of LDG as subtasks based on interviews by experts and novices and text book, instructional video, and procedural review. The Delphi evaluation method involved anonymous online surveys, conducted to merge the opinions of experts in laparoscopic gastrectomy. The experts were asked to rate (from 1 to 5) the importance of subtasks for skill evaluation and training for LDG using a Likert scale. Consensus among expert viewpoints was determined by the internal consistency of each item using Cronbach's approach.

Results

Essential subtasks drafted for the assessment of LDG performance were determined based on the CTA. Thirty-one LDG experts participated in the online-survey with a response rate over 90%. A consensus was achieved after 2 rounds of surveys with a Cronbach alpha of 0.86, and 34 subtasks of LDG were selected. We finally created the Japanese Operative Rating Scale for Laparoscopic Distal Gastrectomy (JORS-LDG) based on the 34 subtasks.

Conclusions

We developed the JORS-LDG using CTA and the Delphi method.

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Dose–response relationship of intermittent normobaric hypoxia to stimulate erythropoietin in the context of health promotion in young and old people

Abstract

Purpose

Erythropoietin (EPO) has multifactorial positive effects on health and can be increased by intermittent normobaric hypoxia (IH). Recommendations about the intensity and duration of IH to increase EPO exist, but only for young people. Therefore, the aim of the study was to investigate the dose–response relationship regarding the duration of hypoxia until an EPO expression and the amount of EPO expression in old vs. young cohorts.

Methods

56 young and 67 old people were assigned to two separate investigations with identical study designs (3-h hypoxic exposure) but with different approaches to adjust the intensity of hypoxia: (i) the fraction of inspired oxygen (FiO₂) was 13.5%; (ii) the FiO₂ was individually adjusted to an oxygen saturation of the blood of 80%. Age groups were randomly assigned to a hypoxia or control group (normoxic exposure). EPO was assessed before, during (90 and 180 min), and 30 min after the hypoxia.

Results

EPO increased significantly after 180 min in both cohorts and in both investigations [old: (i) + 16%, p = 0.007 and (ii) + 14%, p < 0.001; young: (i) + 27%, p < 0.001 and (ii) + 45%, p = 0.007]. In investigation (i), EPO expression was significantly higher in young than in old people after 180 min of hypoxic exposure (p = 0.024) and 30 min afterwards (p = 0.001).

Conclusion

The results indicate that after a normobaric hypoxia of 180 min, EPO increases significantly in both age cohorts. The amount of EPO expression is significantly higher in young people during the same internal intensity of hypoxia than in old people.

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Physical Literacy, Physical Activity and Health: Toward an Evidence-Informed Conceptual Model

Abstract

Physical literacy (PL) provides a powerful lens for examining movement in relation to physical activity (PA) and motor skill outcomes, environmental context, and broader social and affective learning processes. To date, limited consideration has been given to the role PL plays in promoting positive health behaviours. There is no clear conceptual framework based on existing empirical evidence that links PL to health, nor has an evidence-informed case been made for such a position. The purpose of this paper is to (1) present a conceptual model positioning PL as a health determinant, and (2) present evidence in support of PL as a health determinant, drawing on research largely from outside physical education. Viewing PL from the perspective of a multidimensional, experiential convergence process enables it to be differentiated from other models. However, parallels between our model and existing models that focus on movement competence are also drawn. Arguing from a pragmatic perspective on PL, we present evidence for positioning PL as a determinant of health from two literature sources: research on motor coordination disorders in children, and associations between motor competence, PA and health in typically developing children. Statistical modelling approaches consistent with the concept of PL are discussed. Results from these approaches—confirmatory factor analysis and cluster analysis—support the idea that measures related to motor competence, motivation and positive affect work in an integrative manner to produce differences in PA and subsequent health outcomes in children. There is increasing interest in PL, particularly in the field of public health. Presenting a model that explicitly links PL to health can lead to the generation of new research questions and the possibility of broadening impact beyond the context of physical education alone. To date, there has been little conceptual attention to what positioning PL as a determinant of health means. By providing an evidence-based model of PL as a determinant of health, we hope to further the discussion and stimulate increased empirical research in the field.

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The Relationship Between Motor Competence and Physical Fitness from Early Childhood to Early Adulthood: A Meta-Analysis

Abstract

Background

Motor competence and physical fitness are important factors for promoting positive trajectories of health over time. In 2008, Stodden and colleagues developed a model that discussed the role of both factors in physical activity. Furthermore, the authors hypothesized that the relationship between motor competence and physical fitness is reciprocal and changes over time.

Objective

The aim of the present meta-analysis was to synthesize the evidence on the relationship between motor competence and components of physical fitness from early childhood to early adulthood and the potential influence of age.

Methods

Scientific databases Web of Science and PubMed were used for the literature search. German- as well as English-language studies were included that assessed typically developing children. In accordance with the PRISMA guidelines, 93 studies between 2005 and June 2018 were screened in full. Nineteen studies comprising of 32 samples, 87 single data points from 15,984 participants aged 4.5–20.4 years (M_age = 11.44, SD = 4.77) were included in the analysis.

Results

A random effects model was conducted for the meta-regression with age as moderator variable. The relationship between motor competence and physical fitness was moderate to large (r = 0.43, p < 0.001) after controlling for multiple effects, including dependent samples and small sample sizes in the quantitative synthesis. Additionally, age was a small significant positive moderator of the effect size.

Conclusions and Implications

The findings provide support for a moderate to large positive relationship between motor competence and physical fitness that strengthens with increasing age. However, the results also indicate that there may be an overlap in content between motor competence and physical fitness assessments, which warrants further investigation. More research is also needed to assess similarities and differences in terms of the construct structures.

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Is Heat Intolerance State or Trait?

Abstract

The existing literature suggests two standpoints in defining heat intolerance, which are heat tolerance as state or trait. The former bases its case in the plasticity of human physiology, where one may gain or lose the adaptations associated with heat acclimatization and the ability to tolerate heat is considered transient. This phenomenon is exemplified in the recovery process of exertional heat stroke (EHS) patients in that victims of EHS are able to eventually regain heat tolerance and return to activity without recurrent episodes of EHS. On the other hand, an increasing number of reports imply that genetic predisposition may be associated with one's vulnerability to heat stress. Individuals who seem to exhibit lower than expected exercise tolerance in moderate heat and those who never regain heat tolerance post EHS fall into this category. However, there is a large area of uncertainty in this debate because a true prospective investigation of factors associated with heat intolerance is methodologically difficult. We conclude from the current literature that both mechanisms of heat intolerance (state and trait) should be considered in interpreting the mechanism and cause of heat intolerance.

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Estimated Age of First Exposure to American Football and Neurocognitive Performance Amongst NCAA Male Student-Athletes: A Cohort Study

Abstract

Background

Repetitive head impacts in young athletes are potentially detrimental to later life (e.g., age 50 + years) neurological function; however, it is unknown what the short-term effects (e.g., age 20 years) are in collegiate student-athletes.

Objective

The purpose of this study was to determine the effect of the estimated age of first exposure to American tackle football participation on neurocognitive performance and symptom severity scores in collegiate student-athletes.

Methods

We used a cohort study in which neurocognitive performance was assessed using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) test in 4376 male athletes (age 19.3 ± 1.5 years, mass 96.3 ± 20.3 kg, height 185.0 ± 7.4 cm). Athletes were grouped by sport participation [American football (n = 3462) or non-contact (n = 914)] and estimated age of first exposure [< 12 years (n = 3022) or ≥ 12 years (n = 1354)]. The outcome measures were the four primary cognitive scores and the symptom severity score from ImPACT. We assessed primary outcomes across groups, controlling for age, learning accommodations, and concussion history.

Results

Neurocognitive performance was not associated with the estimated age of first exposure-by-group interaction.

Conclusion

Our findings indicate that participation in American tackle football before age 12 years does not result in neurocognitive deficits in college. Therefore, we suggest the following: the consequences of early exposure to repetitive head impacts do not manifest by college, the ImPACT test was not sensitive enough to identify the effects of an earlier estimated age of first exposure, or there is no association between an earlier estimated age of first exposure and neurocognitive functioning. Future longitudinal studies are warranted.

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Regulatory effect of host miR-101b-3p on parasitism of nematode Angiostrongylus cantonensis via superoxide dismutase 3

Publication date: Available online 11 February 2019

Source: Biochimica et Biophysica Acta (BBA) - Gene Regulatory Mechanisms

Author(s): Dongjuan Yuan, Shiqi Luo, Lian Xu, Xingda Zeng, Zhongdao Wu

Abstract

MicroRNA plays a vital role in the regulation of host-parasite interaction. In recent years, genomic and transcriptomic resources have become increasingly available for many helminths, but only a limited number of reports in this area are on the regulatory effects of host microRNAs on parasitic nematodes. In this work, we screened increased expression of host microRNAs after nematode infection from miRNA-seq data and predicted target genes by combined bioinformatics analysis and transcriptional profiling. We elucidated regulatory effects of one host miRNA on nematode infection using miRNA inhibitor and adeno-associated virus (AAV)-based TuD miRNA inhibitor. Using AAV-based TuD miRNA inhibitor, we showed that stable blockade of mmu-miR-101b-3p could alleviate the pathological damages of Angiostrongylus cantonensis, a parasitic nematode. Data from a luciferase report assay showed that mmu-miR-101b-3p targeted the extracellular superoxide dismutase 3 (Acsod3). Increased Acsod3 expression in larvae and alleviated oxidative damages were seen in the groups receiving mmu-miR-101b-3p inhibitor treatment in vitro and AAV-based TuD miRNA inhibitor injection in vivo. Results of this study demonstrate that murine miR-101b-3p inhibits the expression of antioxidant enzyme in A. cantonensis to strengthen host oxidative responses to nematodes. This work expands our knowledge of interspecies regulation of nematode gene expression by of host miRNAs.

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The radiation exposure of fish in the period of the Techa river peak contamination

Publication date: May 2019

Source: Journal of Environmental Radioactivity, Volume 201

Author(s): E.A. Shishkina, E.A. Pryakhin, P.A. Sharagin, D.I. Osipov, G.A. Tryapitsina, N.I. Atamanyuk, E.A. Egoreichenkov, A.V. Trapeznikov, G. Rudolfsen, H.C. Teien, M.K. Sneve

Abstract

Waterborne radioactive releases into the Techa River from the Mayak Production Association in Russia during 1949–1956 resulted in downstream contamination of the river ecosystem. The discharged liquid waste contained both short-lived isotopes (⁹⁵Zr, ⁹⁵Nb, ^103,106Ru, ^141,144Ce, ⁹¹Y, ⁸⁹Sr and ¹⁴⁰Ba with half-life from 3 days to 1.02 years) and the long-lived ⁹⁰Sr and ¹³⁷Cs (half-life - 28.79 y and 30.07 y, respectively). Even now, when two half-lives of ⁹⁰Sr and ¹³⁷Cs have passed, the contamination in the upper river region (about 70 km from the source of releases) is still relatively high. Current anthropogenic dose rates calculated for the fish of the Techa River depend on the distance along the stream and decrease from 150 to 3 μGy day⁻¹. Radiation exposure of fish is expected to have been much higher at the time of the releases. The aim of the study was to evaluate the dose rates for the most common fish species of the river, viz., roach (Rutilus rutilus), perch (Perca fluviatilis) and pike (Esox lucius), in the period of peak contamination of the upper reaches of the Techa River from 1950 to 1951. To achieve this objective, calculation of both internal and external dose rates was performed. For dose rate calculation, the contamination of the river compartments was modeled, body-size dependent dose coefficients were evaluated, morphometric data were analyzed. Maximum dose rates were obtained for roach; minimum – for pike, it depends on fish lifestyle (time spent at the bottom). In the period before September 1950, fish of the upper reaches are assessed to have been exposed to dose rates exceeding the screening level equal to 240 μGy day⁻¹. From September 1950 up to the end of 1952 the fish dose rates along the Techa River were found to be close to the UNSCEAR threshold equal to 9.6 × 10³ μGy day⁻¹ or even much more higher (up to 1.9 × 10⁵ μGy day⁻¹). Extremely high historical dose rates did not lead to the difference in fish size and fish growth rate currently observed in the Techa River and in the comparison waterbody (the Miass River). Discussion includes the description of radiation effects observed currently in the river fish. Today the effects observed in hematopoietic system may be the consequence of radiation exposure of fish over several generations. For example, long term dwelling of fish in the radioactively contaminated environment leads to their adaptation to chronic radiation exposure. At the same time, an increase their sensitivity and decrease their adaptive capacity to respond to other stress factors can be observed.

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Depleted uranium assessment and natural radioactivity monitoring in North West of Iraq over a decade since the last Gulf War

Publication date: May 2019

Source: Journal of Environmental Radioactivity, Volume 201

Author(s): E. Salama, S.U. El-kameesy, Rawaa Elrawi

Abstract

For the sake of completeness of the surveillance process concerning the spread of depleted uranium (DU) in the Arabian Gulf region, we have applied a simple gamma spectroscopy technique to evaluate its content in Al Jolan, Nazzal and Askari districts in Al Fallujah area, Iraq for the first time and after more than one decade. The measurements were carried out along the lines of the wars that have been witnessed in Iraq last period and expected to be the region of impact of residuals of a large quantity of DU. The observed radionuclides are ⁴ K and other naturally occurring radioactive members of uranium and thorium series. The obtained results show that, the average specific activity concentrations of ²²⁶Ra, ²³²Th, ⁴ K, ²¹⁰Pb ²³⁸U and ²³⁵U in different soil samples collected from Al Fallujah area, Iraq in range of 20.09 ± 4.0 to 21.94 ± 2.4, 11.51 ± 2.3 to 11.75 ± 3.2, 96.53 ± 8.0 to 112.13 ± 49.8, 19.98 ± 4.6 to 20.76 ± 4.8, 25.4 ± 3.9 to 26.1 ± 6.0 and 1.28 ± 0.18 to 1.34 ± 0.21 respectively. The obtained values of Ra_eq for all the investigated samples are less than the recommended limit of 370 Bq kg⁻¹ and those for H_ex are less than one. These results have been compared with the previous works and the world mean values specified by the UNSCEAR reports. The mean ratio of ²³⁸U/²³⁵U activity in all cases is about the natural value (21.73) which is less than its value in case of DU (76.92). The present obtained results of DU levels show that although a large amount of DU was released in Iraq during the Gulf wars, the tested samples are DU free. This may be attributed to the reduction of DU from the soil surface by wind or sandstorms and the downward leaching process.

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Direct analysis of 210Pb in drinking water by liquid scintillation counting after sulfate precipitation

Publication date: May 2019

Source: Journal of Environmental Radioactivity, Volume 201

Author(s): Yadong Wang, Yan Ma, Xiongxin Dai

Abstract

Lead-210 in drinking water can be rapidly determined by liquid scintillation counting (LSC) using a new sulfate precipitation method. In this method, ²¹⁰Pb was first preconcentrated from water using iron hydroxide co-precipitation followed by sulfate precipitation to decontaminate most of non-alkaline earth elements. The Pb in the sulfate precipitate was then dissolved in strong alkaline solution, while alkaline earth elements (Sr, Ba, Ra) were separated as the sulfate/carbonate precipitate. To optimize the method, the influences of different acids and sulfate concentration on sulfate precipitation as well as the effects of pH, the added SO₄²⁻/CO₃²⁻ concentrations and the Sr/Ba contents in the sulfate precipitate on the dissolution of PbSO₄ were studied. In addition, X-ray fluorescence (XRF) analysis was applied for rapid determination of the chemical recovery and triple-to-double coincidence ratio (TDCR) quench correction curve for counting of ²¹⁰Pb by LSC was established. The method was validated using 5 L of tap water samples and minimum detectable activity concentration (MDC) of ∼0.016 Bq·L⁻¹ was achieved, which is sufficiently sensitive to meet the guidance level of 0.1 Bq·L⁻¹ for ²¹⁰Pb in drinking water as recommended by the World Health Organization (WHO).

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Natural radioactivity of thermal springs and related precipitates in Gellért Hill area, Buda Thermal Karst, Hungary

Publication date: May 2019

Source: Journal of Environmental Radioactivity, Volume 201

Author(s): Petra Kovács-Bodor, Katalin Csondor, Anita Erőss, Dénes Szieberth, Ágnes Freiler-Nagy, Ákos Horváth, Árpád Bihari, Judit Mádl-Szőnyi

Abstract

The elevated radioactivity of the thermal waters of Buda Thermal Karst (BTK), Hungary is known and studied since the beginning of the 20th century. In the recent studies, the anomalous ²²²Rn/²²⁶Ra ratios have drawn the attention to the existence of local ²²²Rn source. Biogeochemical precipitates (i.e. biofilms) in spring caves were found to have high adsorption capacity, accumulating e.g. ²²⁶Ra. Biogeochemical precipitates are ubiquitous in the thermal springs of BTK, occurring in different amount and colours (dark grey, brown, red, white), and have different microbial communities and elemental composition. The detailed investigation of the radioactivity of spring waters highlighted the different ²²⁶Ra and ²²²Rn activity concentrations. The present study aimed to survey the radioactivity of the thermal springs of Gellért Hill area, together with the biogeochemical precipitates and air above the water level, and to assess the evolution of the radioactivity of known-aged precipitates, formed during in situ experiments. We found that the basic physicochemical parameters of the spring waters (field parameters, major ions) do not affect the adsorption capacity of biogeochemical precipitates. It was revealed by the conducted in situ experiments, that the flow conditions influence the evolution rate of precipitates, so their adsorption capacity. The ²²²Rn activity concentrations of spring waters are dependent on the area of the water surface, volume of air space above the water level, ventilation of the caves/channels and presence of calcite layer on the water surface. The latter has a blocking effect on degassing.

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Skeletal morphology of the early Paleocene plesiadapiform Torrejonia wilsoni (Euarchonta, Palaechthonidae)

Publication date: March 2019

Source: Journal of Human Evolution, Volume 128

Author(s): Stephen G.B. Chester, Thomas E. Williamson, Mary T. Silcox, Jonathan I. Bloch, Eric J. Sargis

Abstract

Plesiadapiforms, like other Paleogene mammals, are known mostly from fossil teeth and jaw fragments. The several families of plesiadapiforms known from partial skeletons have all been reconstructed as arborealists, but differences in postcranial morphology among these taxa indicate a diversity of positional behaviors. Here we provide the first detailed descriptions and comparisons of a dentally associated partial skeleton (NMMNH P-54500) and of the most complete dentary with anterior teeth (NMMNH P-71598) pertaining to Torrejonia wilsoni, from the early Paleocene (late Torrejonian To3 interval zone) of the Nacimiento Formation, San Juan Basin, New Mexico, USA. NMMNH P-54500 is the oldest known partial skeleton of a plesiadapiform and the only known postcrania for the Palaechthonidae. This skeleton includes craniodental fragments with all permanent teeth fully erupted, and partial forelimbs and hind limbs with some epiphyses unfused, indicating that this individual was a nearly fully-grown subadult. Analysis of the forelimb suggests mobile shoulder and elbow joints, a habitually flexed forearm, and capacity for manual grasping. The hip joint allowed abduction and lateral rotation of the thigh and provides evidence for frequent orthograde postures on large diameter supports. Other aspects of the hind limb suggest a habitually flexed thigh and knee with no evidence for specialized leaping, and mobile ankle joints capable of high degrees of inversion and eversion. Although it is likely that some variability exists within the group, analysis of this skeleton suggests that palaechthonids are most like paromomyids among plesiadapiforms, but retain more plesiomorphic postcranial features than has been documented for the Paromomyidae. These observations are congruent with craniodental evidence supporting palaechthonids and paromomyids as closely related within the Paromomyoidea. The skeleton of T. wilsoni also demonstrates that many regions of the postcranium were already well adapted for arboreality within the first few million years of the diversification of placental mammals following the Cretaceous-Paleogene extinction event.

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Effects of chronic beetroot juice supplementation on maximum oxygen uptake, velocity associated with maximum oxygen uptake, and peak velocity in recreational runners: a double-blinded, randomized and crossover study

Abstract

Purpose

This study investigated the effects of chronic 3-day beetroot juice (BRJ) supplementation on maximum oxygen uptake (VO_2max), velocity associated with VO_2max(vVO_2max), and peak velocity (V_peak) in recreational runners.

Methods

Thirteen male recreational runners (age 28.2 ± 3.0 years, height 176.8 ± 0.1 cm, body mass 74.4 ± 9.5 kg) performed four tests on a treadmill in a randomized, double-blind, crossover design: two maximum incremental tests to determine VO_2max and vVO_2max, and two tests to determine V_peak. Trials were performed following 3 days of supplementation of NO₃⁻-rich BRJ in natura (8.4 mmol NO₃⁻ day^− 1) or BRJ NO₃⁻-depleted placebo (0.01 mmol NO₃⁻ day^− 1), with the last dose being ingested 2 h before each test. During the tests, maximum heart rate (HR_max), maximal rating of perceived exertion (RPE_max), pre- and post-test glucose concentrations (Gluc_pre, Gluc_post), and peak blood lactate concentration were determined.

Results

VO_2max was higher following BRJ vs PLA (46.6 ± 6.4 vs 45.1 ± 5.8 mL kg^− 1 min^− 1; P = 0.022), as well as vVO_2max (14.5 ± 0.8 vs 13.9 ± 1.0 km h^− 1P = 0.024) and V_peak (15.5 ± 1.1 vs 15.2 ± 1.2 km h^− 1P = 0.038), with no differences in the other variables.

Conclusion

Consumption of NO₃⁻-rich BRJ in natura (8.4 mmol NO₃⁻ day^− 1) once per day for 3 days improved VO_2max, vVO_2max and V_peak in recreational runners without changing the other analyzed variables.

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Effects of the trunk position on muscle stiffness that reflects elongation of the lumbar erector spinae and multifidus muscles: an ultrasonic shear wave elastography study

Abstract

Purpose

The present study aimed to clarify the effects of the trunk position on muscle stiffness that reflects elongation of the lumbar erector spinae and lumbar multifidus muscles using ultrasonic shear wave elastography (SWE).

Methods

The study included ten healthy men. The shear elastic modulus of the left lumbar erector spinae and lumbar multifidus muscles were evaluated using ultrasonic SWE. Measurement postures for the left lumbar erector spinae muscle were (1) prone position (Rest), (2) sitting position with the trunk flexed (Flexion), (3) the Flexion position adding right trunk lateral flexion (Flexion-Lateral Flexion), and (4) the Flexion position adding right trunk rotation (Flexion-Rotation 1). The left lumbar multifidus muscle were measured in positions (1)–(3), and (5) the Flexion position adding left trunk rotation (Flexion-Rotation 2).

Results

The shear elastic modulus of the lumbar erector spinae muscle in the Flexion-Lateral Flexion position was significantly higher than that in the Rest, Flexion, or Flexion-Rotation 1 positions. Shear elastic modulus of the lumbar multifidus muscle was similar in the Flexion, Flexion-Lateral Flexion, and Flexion-Rotation 2 positions, but significantly lower in the Rest position.

Conclusions

The results of the present study suggest that the lumbar erector spinae muscle is stretched effectively in the position adding trunk contralateral lateral flexion to flexion. The results also indicate that the lumbar multifidus muscle, which does not appear to be affected by adding trunk contralateral lateral flexion or ipsilateral rotation to flexion, is stretched effectively in the trunk flexion position.

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Low-dose spinal anesthesia for cesarean section to prevent spinal-induced hypotension

Purpose of review Low-dose combined spinal epidural (CSE) anesthesia is a common technique to anesthetize women for cesarean section. It is used to reduce the incidence of hypotension while providing excellent anesthetic conditions. Recent findings Low spinal doses produce effective anesthesia but of limited duration. Therefore, an epidural catheter (and thus CSE) is required to guarantee pain-free surgery. Recent work confirmed that lower spinal doses can reduce significantly hypotension. Summary Low-dose CSE is a valuable strategy to anesthetize pregnant women for cesarean section but requires attention and training. Correspondence to Marc Van de Velde, MD, PhD, EDRA, Professor, Department of Cardiovascular Sciences, Chair, Department of Anaesthesiology, Herestraat 49, B - 3000 Leuven, Belgium. E-mail: marc.vandevelde@uzleuven.be Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Time-efficient, goal-directed, and evidence-based teaching in the ICU

Purpose of review Teaching in the stressful, high-acuity environment of the ICU is challenging. The intensivist-educator must use teaching strategies that are both effective and time-efficient, as well as evidence-based approaches to the ICU curriculum. This review provides an overview of pertinent educational theories and their implications on educational practices, a selection of effective teaching techniques, and a review on feedback. Recent findings Evidence supports the role of conceptual frameworks in providing the educator with a key perspective to obtain a deeper understanding of the factors contributing to an effective and goal-directed education in the ICU. The role of simulation training for technical and nontechnical skills acquisition is growing. Feedback is difficult to provide, but critical to facilitate learner success; frameworks, and approaches are becoming more standardized. Summary Direct teaching should be goal-oriented, sequential, and adjusted to the level of the learner. The ICU curriculum should optimize cognitive load, reduce stress that is unrelated to the activity, include resilience training, and help trainees deal with stressful clinical situations better. Simulation is a powerful tool to promote technical and nontechnical skills. Providing feedback is essential and a skill that can be taught and enhanced with structure, prompts, and tools. Correspondence to Marek Brzezinski, MD, PhD, VA Medical Center, Anesthesiology Service (129), 4150 Clement Street, San Francisco, CA 94121, USA. Tel: +1 415 750 2069; e-mail: marek.brzezinski@ucsf.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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