Evaluation of the Effect of Aneurysmal Clipping on Electrocardiography and Echocardiographic Changes in Patients With Subarachnoid Hemorrhage: A Prospective Observational Study.

Background: Electrocardiographic (ECG) and echocardiographic changes that are subsequent to aneurysmal subarachnoid hemorrhage (a-SAH) are commonly observed with a prevalence varying from 27% to 100% and 13% to 18%, respectively. There are sparse data in the literature about the pattern of ECG and echocardiographic changes in patients with SAH after clipping of the aneurysm. Hence, we observed the effect of aneurysmal clipping on ECG and echocardiographic changes during the first week after surgery, and the impact of these changes on outcome at the end of 1 year. Materials and Methods: This prospective, observational study was conducted in 100 consecutive patients with a-SAH undergoing clipping of ruptured aneurysm. ECG and echocardiographic changes were recorded preoperatively and every day after surgery until 7 days. Outcome was evaluated using the Glasgow outcome scale at the end of 1 year. Results: Of 100 patients, 75 had ECG changes and 17 had echocardiographic changes preoperatively. The ECG changes observed were QTc prolongation, conduction defects, ST-wave and T-wave abnormalities, tachyarrhythmias, and bradyarrhythmias. The echocardiography changes included global hypokinesia and regional wall motion abnormalities. Both echocardiographic and ECG changes showed significant recovery on the first postoperative day. Patients presenting with both echocardiographic and ECG changes were found to require higher ionotropic support to maintain the desired blood pressure, and were associated with poor outcome (Glasgow outcome scale, 1 to 2) at 1 year after surgery. There was no association of ECG and echocardiographic changes with mortality (both in-hospital or at 1 year). Conclusions: The ECG changes, such as QTc prolongation, bradycardia, conduction abnormality, and echocardiographic changes, recover on postoperative day-1, in most of the cases after clipping. Patients with combined ECG and echocardiographic changes tend to have poor neurological outcome at the end of 1 year. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved

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Cognitive Functioning After Surgery in Middle-aged and Elderly Danish Twins.

No abstract available

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Journal Club.

No abstract available

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Bowel Preparation in Awake Craniotomy: An Overlooked Entity.

No abstract available

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Effect of Acute Exercise on Fatigue in People with ME/CFS/SEID: A Meta-analysis.

Purpose: A prominent symptom of Myalgic Encephalomyelitis, Chronic Fatigue Syndrome, or Systemic Exertion Intolerance Disease (ME/CFS/SEID) is persistent fatigue that is worsened by physical exertion. Here the population effect of a single bout of exercise on fatigue symptoms in people with ME/CFS/SEID was estimated and effect moderators were identified. Methods: Google Scholar was systematically searched for peer-reviewed articles published between February 1991 and May 2015. Studies were included where people diagnosed with ME/CFS/SEID and matched control participants completed a single bout of exercise and fatigue self-reports were obtained before and after exercise. Fatigue means, standard deviations, and sample sizes were extracted to calculate effect sizes and the 95% CI. Effects were pooled using a random-effects model and corrected for small-sample bias to generate mean [INCREMENT]. Multi-level regression modeling adjusted for nesting of effects within studies. Moderators identified a priori were diagnostic criteria, fibromyalgia comorbidity, exercise factors (intensity, duration, type) and measurement factors. Results: Seven studies examining 159 people with ME/CFS/SEID met inclusion criteria, and 47 fatigue effects were derived. The mean fatigue effect was [INCREMENT] = 0.73 (95% CI = 0.24, 1.23). Fatigue increases were larger for people with ME/CFS/SEID when fatigue was measured four or more hours after exercise ended rather than during or immediately after exercise ceased. Conclusions: This preliminary evidence indicates that acute exercise increases fatigue in people with ME/CFS/SEID more than in control groups, but effects were heterogeneous between studies. Future studies with no-exercise control groups of people with ME/CFS/SEID are needed to obtain a more precise estimate of the effect of exercise on fatigue in this population. (C) 2016 American College of Sports Medicine

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Strategic Priorities for Physical Activity Surveillance in the United States.

Purpose: Develop strategic priorities to guide future physical activity surveillance in the United States. Methods: The Centers for Disease Control and Prevention and the American College of Sports Medicine convened a Scientific Roundtable of physical activity and measurement experts. Participants summarized the current state of aerobic physical activity surveillance for adults, focusing on practice and research needs in three areas: 1) behavior, 2) human movement, and 3) community supports. Needs and challenges for each area were identified. At the conclusion of the meeting, experts identified one overarching strategy and five strategic priorities to guide future surveillance. Results: The identified overarching strategy was to develop a national plan for physical activity surveillance similar to the U.S. National Physical Activity Plan for promotion. The purpose of the plan would be to enhance coordination and collaboration within and between sectors, such as transportation and public health, and to address specific strategic priorities identified at the Roundtable. These strategic priorities were: 1) identify and prioritize physical activity constructs, 2) assess the psychometric properties of instruments for physical activity surveillance, 3) provide training and technical assistance for those collecting, analyzing, or interpreting surveillance data, 4) explore accessing data from alternative sources, and 5) improve communication, translation, and dissemination about estimates of physical activity from surveillance systems. Conclusion: This Roundtable provided strategic priorities for physical activity surveillance in the United States. A first step is to develop a national plan for physical activity surveillance that would provide an operating framework from which to execute these priorities. (C) 2016 American College of Sports Medicine

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Increased Visual Utilization in Chronic Ankle Instability: A Meta-analysis.

Purpose: The underlying cause of balance impairments in chronic ankle instability (CAI) patients remains unknown but an altered utilization of sensory information has been hypothesized as a potential cause. The purpose of this systematic review with meta-analysis was to determine if CAI patients utilize somatosensory information to the same extent as uninjured controls during static single limb stance. Method: We searched PubMed, CINAHL, SPORTDiscus, and Scopus databases from origin to March 2016 using the combination of key words including: postural control, postural stability, single limb stance, single leg stance, single leg balance, single limb balance, time-to-boundary, or TTB. Eligible studies had to include instrumented single leg stance with both eyes open (EO) and closed (EC) in healthy, CAI, or both groups as well as report time-to-boundary (TTB) means and standard deviations (SD). Results: A total of 11 articles were identified. Effect sizes using EC to EO standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated for all studies that were included in this investigation. Similarly, pooled estimates for each TTB outcome were compared between the CAI and uninjured control groups. The 95% CI of the mediolateral (ML) TTB mean (Control: -1.50 (-1.71 to -1.29), CAI: -2.04 (-2.31 to -1.77)), anterioposterior (AP) mean (Control: -2.19 (-2.43 to -1.96), CAI: -2.82 (-3.13 to -2.52)), and AP SD (Control: -1.81 (-2.03 to -1.58), CAI: -2.50 (-2.79 to -2.22)) did not overlap, indicating significant differences between two groups. Conclusion: On the basis of our systematic review with meta-analysis, it appears that CAI patients do not utilize somatosensory information to the same extent as uninjured controls and instead upregulate the use of visual information during single limb stance. (C) 2016 American College of Sports Medicine

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Contralateral Repeated Bout Effect of Eccentric Exercise of the Elbow Flexors.

Purpose: This study compared the magnitude of the repeated bout effect for different time intervals between two bouts of eccentric exercise of the elbow flexors to better understand the contralateral repeated bout effect (CL-RBE). Methods: Untrained young men (22.0 +/- 1.8 y) were allocated to either a control or one of seven CL-RBE groups (n=13/group). The CL-RBE groups performed exercise consisting of 30 maximal isokinetic (30[degrees]/s) eccentric contractions of the elbow flexors (ECC1) with either dominant or non-dominant arm followed 0.5 (0.5h), 6 (6h), 12 (12h) and 24 hours (1d), 7 (1wk), 28 (4wk) or 56 days (8wk) by the same exercise (ECC2) using the opposite arm. The control group used the non-dominant arm for ECC1 and ECC2 separated by 2 weeks. Results: Maximal voluntary concentric contraction torque, peak torque angle, range of motion, upper arm circumference, muscle soreness, ultrasound echo-intensity, and plasma creatine kinase activity and myoglobin concentration changed (P8 weeks), and requires a day to be conferred. (C) 2016 American College of Sports Medicine

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High-Intensity Interval Training on Cognitive and Mental Health in Adolescents.

Purpose: Emerging literature suggests that physical activity and fitness may have a positive impact on cognitive and mental health for adolescents. The purpose of the current study was to evaluate the efficacy of two high intensity interval training (HIIT) protocols for improving cognitive and mental health outcomes (executive function, psychological wellbeing, psychological distress and physical self-concept) in adolescents. Methods: Participants (n=65; mean age=15.8+/-0.6) were randomized to three conditions: aerobic exercise program (AEP; n=21), resistance and aerobic exercise program (RAP; n=22) and control (n=22). HIIT sessions (8-10min/session) were delivered during physical education lessons or at lunchtime three times/week for 8-weeks. Assessments were conducted at baseline and immediate post-intervention to detect changes in executive function (Trail Making Test, TMT), psychological wellbeing, psychological distress and physical self-description, by researchers blinded to treatment allocation. Intervention effects were examined using linear mixed models. Cohen's d effect sizes and clinical inference were also calculated. Results: Small improvements in executive function (d=-0.32, 95%CI -9.12 to 9.77; p=0.386) and psychological wellbeing (d=0.34, 95%CI -1.73 to 2.37; p=0.252) were evident in the AEP group. Moderate improvements in executive function (d=-0.51, 95% CI -8.92 to 9.73; p=0.171), and small improvements in wellbeing (d=0.35, 95%CI -1.46 to 2.53; p=0.219) and perceived appearance (d=0.35, 95%CI -0.74 to 0.41; p=0.249), were observed for the RAP group. Mean feelings state scores improved from pre-workout to post-post workout in both HIIT conditions, with significant results for the AEP (p=0.001). Conclusions: This study highlights the potential of embedding HIIT within the school day for improving cognitive and mental health among adolescents. (C) 2016 American College of Sports Medicine

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A Cluster RCT to Reduce Office Workers' Sitting Time: Impact on Activity Outcomes.

Purpose: To evaluate, compared to usual practice, the initial and long-term effectiveness of a workplace intervention targeting reducing sitting on activity outcomes. Methods: Office worksites (>=1km apart) from a single organization in Victoria, Australia were cluster randomized to intervention (n=7) or control (n=7). Participants were 231 desk-based office workers (5 to 39 participants per worksite) working at least 0.6 full time equivalent. The workplace-delivered intervention addressed organizational, physical environment, and individual behavioural change to reduce sitting time. Assessments occurred at baseline, three-, and 12-months, with the primary outcome participants' objectively measured (activPAL3TM device) workplace sitting time (mins/8-h workday). Secondary activity outcomes were: workplace time spent standing, stepping (light, moderate-vigorous and total) and in prolonged (>=30min) sitting bouts (h/8-h workday); usual duration of workplace sitting bouts; and, overall sitting, standing and stepping time (mins/16-h day). Analysis was by linear mixed models, accounting for repeated measures and clustering and adjusting for baseline values and potential confounders. Results: At baseline, on average, participants (68% women; mean+/-SD age = 45.6+/-9.4 years) sat, stood and stepped for 78.8+/-9.5%, 14.3+/-8.2%, and 6.9+/-2.9% of work hours respectively. Workplace sitting time was significantly reduced in the intervention group compared to the controls at three months (-99.1 [95% CI -116.3 to -81.8] min/8-h workday) and 12 months (-45.4 [-64.6 to -26.2] min/8-h workday). Significant intervention effects (all favoring intervention) were observed for standing, prolonged sitting, and usual sitting bout duration at work, as well as overall sitting and standing time, with no significant nor meaningful effects observed for stepping. Conclusions: This workplace-delivered multicomponent intervention was successful at reducing workplace and overall daily sitting time in both the short- and long- term. (C) 2016 American College of Sports Medicine

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Neutrophil Depletion Attenuates Muscle Injury following Exhaustive Exercise.

PURPOSE: The infiltration of macrophages in skeletal muscle during exhaustive exercise promotes inflammation, myofiber lesion, and muscle injury. Although neutrophils upregulate macrophage infiltration in skeletal muscles during exercise, the role of neutrophils in promoting muscle injury following exhaustive exercise remains unclear. In this study, we investigated the effects of pre-exercise neutrophil depletion with anti-neutrophil antibody treatment on muscle injury, inflammation, and macrophage infiltration following exhaustive exercise. METHODS: Male C57BL/6J mice were randomly assigned to four groups, namely, Sedentary with control antibody (n = 10), Sedentary with anti-neutrophil antibody (n = 10), Exhaustive exercise with control antibody (n = 10), and Exhaustive exercise with anti-neutrophil antibody (n = 10). The mice were given intraperitoneal injection of the anti-neutrophil antibody (anti-Ly-6G, clone 1A8) or the control antibody (anti-Ly-6G, clone 2A3), and remained inactive or performed exhaustive exercise on a treadmill 48 h after the injection. Twenty-four hours after the exhaustive exercise, the gastrocnemius muscles were removed for histological and PCR analyses. Infiltration of neutrophils and macrophages was evaluated with Ly-6G and F4/80 immunohistochemistry staining procedures. Muscle fiber injury was detected based on the number of IgG staining fiber. The mRNA expression levels of proinflammatory cytokines and chemokines were evaluated with real time-RT-PCR. RESULTS: Exhaustive exercise increased neutrophil infiltration into the gastrocnemius muscle substantially by 3.1-fold and caused muscle injury, but these effects were markedly suppressed by pre-exercise treatment with anti-neutrophil antibody (neutrophil infiltration, 0.42-fold and muscle injury, 0.18-fold). Treatment with anti-neutrophil antibody also decreased macrophage infiltration (0.44-fold) and mRNA expression of TNF-[alpha] (0.55-fold) and IL-6 (0.51-fold) in the skeletal muscle after exhaustive exercise. CONCLUSION: These results suggest that neutrophils contribute to exacerbating muscle injury by regulating inflammation through the induction of macrophage infiltration. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. (C) 2016 American College of Sports Medicine

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Fitness during Breast Cancer Treatment and Recovery in an Athlete: A Case Study.

Purpose: This is a case study of an aerobically trained, multi-sport, female athlete (age = 39) diagnosed with stage IIIc human epidermal growth factor receptor 2 positive breast cancer. The focus of the study is on measures of cardiorespiratory fitness (VO2peak) through the course of cancer therapy. Methods: A symptom-limited cardiopulmonary exercise tolerance test was performed to determine VO2peak. The test were performed at 5 different time points; 1) at diagnosis of breast cancer and prior to initiating chemotherapy, 2) after completion of chemotherapy (5-months post diagnosis), 3) 2 1/2 months after bilateral mastectomy surgery (9-months post diagnosis), 4) immediately following radiation therapy (11-months post diagnosis), 5) recovery (32 months post diagnosis). Results: At diagnosis and prior to initiating chemotherapy VO2peak was 50.1 mLO2*min-1*kg-1. The most precipitous decline in fitness, approximately 14%, was observed during the period of time from initial diagnosis through the completion of chemotherapy. The subject regained 9% of her fitness after chemotherapy, despite an intervening mastectomy surgery. Radiation therapy was associated with an approximately 4% decline in fitness from her post-mastectomy surgery value. Ultimately, 32 months after diagnosis and 22 months following the completion of radiation therapy, the subject was able to regain pretreatment fitness levels. Conclusion: The results of the case study describe the effects of undergoing extensive breast cancer therapy on measures of VO2peak for a highly aerobically trained, multi-sport athlete. In this case, exercise training reversed the decrement in measured VO2peak that occurred during cancer therapy. (C) 2016 American College of Sports Medicine

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Intensity-dependent Contribution of Neuromuscular Fatigue after Constant-Load Cycling.

Purpose: We tested the hypothesis that central and peripheral fatigue after constant-load cycling exercise would vary with exercise intensity and duration. Methods: Twelve, well-trained male cyclists (V[Combining Dot Above]O2max, 4.49+/-0.35 L[middle dot]min-1) completed three constant-load cycling trials to the limit of tolerance in a randomized, crossover design. Exercise intensities were set according to the respiratory responses to a preliminary ramp test to elicit cardiorespiratory and metabolic responses consistent with exercise in the severe and heavy exercise domains; 1) at power at V[Combining Dot Above]O2max (S+, 379+/-31 W), 2) at 60% of the difference between gas exchange threshold and V[Combining Dot Above]O2max (S-, 305+/-23 W) and 3) at the respiratory compensation point (RCP, 254+/-26 W). Pre- and post-exercise twitch responses from the quadriceps to electrical stimulation of the femoral nerve and magnetic stimulation of the motor cortex were recorded to assess neuromuscular and corticospinal function, respectively. Results: Exercise time was 3.14+/-0.59 min, 11.11+/-1.86 min and 42.14+/-9.09 min for S+, S- and RCP respectively. All trials resulted in similar reductions in maximum voluntary force (P=0.61). However, the degree of peripheral fatigue varied in an intensity-dependent manner, with greater reductions in potentiated twitch force after S+ (-33+/-9%) compared to both S- (-16+/-9%, P

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Head Impact Biomechanics in Women's College Soccer.

INTRODUCTION: There are limited non-laboratory soccer head impact biomechanics data. This is surprising given soccer's global popularity. Epidemiological data suggest female college soccer players are at a greater concussion injury risk than their male counterparts. Therefore, the purpose of our study was to quantify head impact frequency and magnitude during NCAA women's soccer practices and games, and to characterize these data across event type, playing position, year on the team, and segment of game (first and second halves). METHODS: Head impact biomechanics were collected from female college soccer players (n=22; age=19.1+/-0.1 years; height=168.0+/-3.5 cm; mass=63.7+/-6.0 kg). We employed a helmetless head impact measurement device (X2 Biosystems xPatch) prior to each competition and practice across a single season. Peak linear and rotational accelerations were categorized based on impact magnitude, and subsequently analyzed using appropriate non-parametric analyses. RESULTS: Overall, women's college soccer players experience ~7 impacts per 90 minutes of game play. The overwhelming majority (~90%) of all head impacts were categorized into our mildest linear acceleration impact classification (10-20 g). Interestingly, a higher percentage of practice impacts in the 20-40 g range compared to games (11% versus 7%) was observed. CONCLUSION: Head impact biomechanics studies have provided valuable insights into understanding collision sports, and for informing evidence-based rule and policy changes. These have included changing the football kickoff, ice hockey body checking ages, and head-to-head hits in both sports. Given soccer's global popularity, and the growing public concern for the potential long-term neurological implications of collision and contact sports, studying soccer has the potential to impact many athletes and the sports medicine professionals caring for them. (C) 2016 American College of Sports Medicine

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Leisure-Time Physical Activity and the Risk of Suspected Bacterial Infections.

Introduction: The risk of upper-respiratory tract viral infections is reduced with increased physical activity, but little information is available regarding bacterial infections. We examined the relationship between leisure-time physical activity and suspected bacterial infections. Methods: Information on leisure-time physical activity was obtained from the 2007 and 2010 North Denmark Region Health Surveys of 18,874 Danes and linked to data from nationwide administrative registries. Suspected bacterial infections were determined based on filled prescriptions for antibiotics. Adjusted estimates were calculated using logistic regression models. Results: During a one-year follow-up, 5,368 participants filled at least one antibiotic prescription. There was a statistically significant difference between physical activity level and filling any antibiotic prescriptions among women (p=0.003) but not among men (p=0.191). Logistic regression analysis showed that compared with sedentary behaviour, all levels of leisure-time physical activities lowered the likelihood of filling an antibiotic prescription. However, after multivariable adjustments, only estimates of low physical activity were significant (OR 0.90; 95% CI 0.82; 0.99). Multivariable adjusted subgroup analyses of suspected cystitis showed a decreased likelihood of engaging in low (OR 0.79; 95% CI 0.65; 0.95) and moderate (OR 0.68; 95% CI 0.54; 0.87) physical activity. Conclusion: Low leisure-time physical activity is associated with a statistically significant 10% lower risk of suspected bacterial infections over a one-year follow-up compared with sedentary behaviour. Further, low and moderate physical activity was associated with statistical significant reduction of suspected cystitis. No reduction in suspected respiratory tract infections was statistical significant associated with physical activity compared to sedentary behaviour. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. (C) 2016 American College of Sports Medicine

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The Relation of Arm Exercise Peak Heart Rate to Stress Test Results and Outcome.

Purpose: Arm exercise is an alternative to pharmacologic stress testing for >50% of patients unable to perform treadmill exercise but no data exist regarding the effect of attained peak arm exercise heart rate on test sensitivity. Thus, the purpose of this investigation was to characterize the relationship of peak arm exercise heart rate responses to abnormal stress test findings, coronary revascularization, and mortality in patients unable to perform leg exercise. Methods: From 1997 until 2002 arm cycle ergometer stress tests were performed in 443 consecutive veterans aged 64.1(11.0) yrs. [mean(SD)], of whom 253 also underwent myocardial perfusion imaging(MPI). Patients were categorized by frequency distributions of quartiles of percentage age-predicted peak heart rate(APPHR), heart rate reserve(HRR), and peak heart rate-systolic blood pressure product(PRPP). Exercise-induced ST-segment depression, abnormal MPI findings, coronary revascularization, and 12.0(1.3) yr. Kaplan-Meier all-cause and cardiovascular mortality plots were then characterized by quartile of APPHR, HRR, and PRPP. Results: A reduced frequency of abnormal arm exercise electrocardiogram(ECG) results was associated only with the lowest quartile of APPHR(

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Ischemic Preconditioning and Repeated Sprint Swimming: A Placebo and Nocebo Study.

Purpose: Ischemic preconditioning (IPC) has been shown to improve performance of exercises lasting 10-90 s (anaerobic) and more than 90 s (aerobic). However, its effect on repeated sprint performance has been controversial, placebo effect has not been adequately controlled, and nocebo effect has not been avoided. Thus, the IPC effect on repeated sprint performance was investigated using a swimming task and controlling placebo/nocebo effects. Methods: Short-distance university swimmers were randomized to two groups. One group [n = 15, 24 +/- 1 years (mean +/- SEM)] was exposed to IPC (ischemia cycles lasted 5 min) and control (CT, no ischemia); another (n = 15, 24 +/- 1 years) to a placebo intervention (SHAM, ischemia cycles lasted 1 min) and CT. Seven subjects crossed over groups. Subjects were informed IPC and SHAM would improve performance compared to CT and would be harmless despite circulatory occlusion sensations. The swimming task consisted of six 50-m all-out efforts repeated every 3 min. Results: IPC, in contrast with SHAM, reduced worst sprint time (IPC: 35.21 +/- 0.73 vs. CT 36.53 +/- 0.72 s, P = 0.04) and total sprints time (IPC: 203.7 +/- 4.60 vs. CT 206.03 +/- 4.57 s, P = 0.02), moreover augmented swimming velocity (IPC: 1.45 +/- 0.03 vs. CT 1.44 +/- 0.03 m/s, P = 0.049). Six out of 7 subjects who crossed over groups reduced total sprints time with IPC versus SHAM (delta = -3.95 +/- 1.49 s, P = 0.09). Both IPC and SHAM did not change blood lactate concentration (P = 0.20) and perceived effort (P = 0.22). Conclusion: IPC enhanced repeated sprint swimming performance in university swimmers, whereas a placebo intervention did not. (C) 2016 American College of Sports Medicine

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A Randomized Trial on the Effect of Exercise Mode on Breast Cancer-related Lymphedema.

Purpose: Breast cancer-related lymphedema is a common and debilitating side effect of cancer treatment. This randomized trial compared the effect of progressive resistance- or aerobic-based exercise on breast cancer-related lymphedema extent and severity, as well as participants' muscular strength and endurance, aerobic fitness, body composition, upper-body function and quality of life. Methods: Women with a clinical diagnosis of stable unilateral, upper-limb lymphedema secondary to breast cancer were randomly allocated to a resistance- (n=21) or aerobic-based (n=20) exercise group (12-week intervention). Women were assessed pre-, post- and 12 weeks post-intervention, with generalised estimating equation models used to compare over time changes in each group's lymphedema (two-tailed p

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The predictive roles of neural oscillations in speech motor adaptability

The human speech system exhibits a remarkable flexibility by adapting to alterations in speaking environments. While it is believed that speech motor adaptation under altered sensory feedback involves rapid reorganization of speech motor networks, the mechanisms by which different brain regions communicate and coordinate their activity to mediate adaptation remain unknown, and explanations of outcome differences in adaption remain largely elusive. In this study, under the paradigm of altered auditory feedback with continuous EEG recordings, the differential roles of oscillatory neural processes in motor speech adaptability were investigated. The predictive capacities of different EEG frequency bands were assessed, and it was found that theta-, beta-, and gamma-band activities during speech planning and production contained significant and reliable information about motor speech adaptability. It was further observed that these bands do not work independently but interact with each other suggesting an underlying brain network operating across hierarchically organized frequency bands to support motor speech adaptation. These results provide novel insights into both learning and disorders of speech using time frequency analysis of neural oscillations.

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Incorporating spike-rate adaptation into a rate code in mathematical and biological neurons

For a slowly varying stimulus, the simplest relationship between a neuron's input and output is a rate code, in which the spike rate is a unique function of the stimulus at that instant. In the case of spike-rate adaptation, there is no unique relationship between input and output, because the spike rate at any time depends both on the instantaneous stimulus and on prior spiking (the "history"). To improve the decoding of spike trains produced by neurons that show spike-rate adaptation, we developed a simple scheme that incorporates "history" into a rate code. We utilized this rate-history code successfully to decode spike trains produced by 1) mathematical models of a neuron in which the mechanism for adaptation (I_AHP) is specified, and 2) the gastropyloric receptor (GPR2), a stretch-sensitive neuron in the stomatogastric nervous system of the crab Cancer borealis, that exhibits long-lasting adaptation of unknown origin. Moreover, when we modified the spike rate either mathematically in a model system or by applying neuromodulatory agents to the experimental system, we found that changes in the rate-history code could be related to the biophysical mechanisms responsible for altering the spiking.

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ON and OFF inhibition as mechanisms for forward masking in the inferior colliculus: a modeling study

Masking effects of a preceding stimulus on the detection or perception of a signal have been found in several sensory systems in mammals, including humans and rodents. In the auditory system, it has been hypothesized that a central "OFF-inhibitory" mechanism, which is generated by neurons that respond after a sound is terminated, may contribute to the observed psychophysics. The present study constructed a systems model for the inferior colliculus that includes major ascending monaural and binaural auditory pathways. The fundamental characteristics of several neuron types along the pathways were captured by Hodgkin-Huxley models with specific membrane and synaptic properties. OFF responses were reproduced with a model of the superior paraolivary nucleus containing a hyperpolarization-activated h current and a T-type calcium current. When the gap between the end of the masker and the onset of the signal was large, e.g., >5 ms, OFF inhibition generated strong suppressive effects on the signal response. For smaller gaps, an additional inhibitory source, which was modeled as ON inhibition from the contralateral dorsal nucleus of the lateral lemniscus, showed the potential of explaining the psychophysics. Meanwhile, the effect of a forward masker on the binaural sensitivity to a low-frequency signal was examined, which was consistent with previous psychophysical findings related to sound localization.

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A common control signal and a ballistic stage can explain the control of coordinated eye-hand movements

Voluntary control has been extensively studied in the context of eye and hand movements made in isolation, yet little is known about the nature of control during eye-hand coordination. We probed this with a redirect task. Here subjects had to make reaching/pointing movements accompanied by coordinated eye movements but had to change their plans when the target occasionally changed its position during some trials. Using a race model framework, we found that separate effector-specific mechanisms may be recruited to control eye and hand movements when executed in isolation but when the same effectors are coordinated a unitary mechanism to control coordinated eye-hand movements is employed. Specifically, we found that performance curves were distinct for the eye and hand when these movements were executed in isolation but were comparable when they were executed together. Second, the time to switch motor plans, called the target step reaction time, was different in the eye-alone and hand-alone conditions but was similar in the coordinated condition under assumption of a ballistic stage of ~40 ms, on average. Interestingly, the existence of this ballistic stage could predict the extent of eye-hand dissociations seen in individual subjects. Finally, when subjects were explicitly instructed to control specifically a single effector (eye or hand), redirecting one effector had a strong effect on the performance of the other effector. Taken together, these results suggest that a common control signal and a ballistic stage are recruited when coordinated eye-hand movement plans require alteration.

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Noradrenaline Reuptake Inhibition Impairs Cortical Output and Limits Endurance Time

Purpose: To assess the neural mechanisms that limit endurance time, we compared a fatiguing task performed under the influence of reboxetine (REB), a noradrenaline reuptake inhibitor, and placebo (PLA). Methods: Nine male subjects (age = 24 ± 2 yr) participated in this study. The fatiguing task involved repeated 3-s submaximal isometric contractions of the knee extensors (∼33% maximal voluntary contraction) with a 2-s rest between each contraction and performed until task failure. Before, during, and after exercise, changes in voluntary activation, corticospinal (motor-evoked potential) and spinal excitability (Hoffman reflex), and muscle contractile properties were tested using electrical and transcranial magnetic stimulations. A psychomotor vigilance task assessed reaction time before and after exercise. Results: Compared with PLA, REB reduced the endurance time by 15.6% (P = 0.04). The maximal voluntary contraction torque decreased to a similar extent at task failure in both conditions (P

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Diaphragm Recruitment Increases during a Bout of Targeted Inspiratory Muscle Training

Purpose: The extent to which the diaphragm is targeted during a bout of inspiratory muscle training (IMT) is unknown. The purpose of this study was to characterize the relative activation patterns of the diaphragm and extradiaphragmatic inspiratory muscles during a bout of IMT and to determine whether diaphragmatic recruitment can be increased by giving subjects specific diaphragmatic breathing instructions (IMTdi). Methods: Ten healthy men were instrumented with surface EMG electrodes on the sternocleidomastoid (EMGscm), scalenes (EMGsca), parasternal intercostals (EMGpic), and seventh intercostal space (EMG7ic). A multipair esophageal electrode catheter measured crural diaphragmatic EMG (EMGdi) and transdiaphragmatic pressure (Pdi). Trial 1 of IMT involved 25 dynamic inspiratory maneuvers at 40% of maximal inspiratory mouth pressure using a variable flow resistive loading device where subjects were free to choose their own inspiratory muscle recruitment strategy. Trial 2 involved the same procedures, but subjects were given specific instructions to actively recruit their diaphragm. Cervical magnetic stimulation of the phrenic nerves verified the absence of diaphragmatic fatigue before commencing the second trial. Results: Compared with IMT, IMTdi resulted in a significant increase in EMGdi (56 ± 12 vs 73 ± 10%max, P = 0.002) and Pdi swings (39 ± 14 vs 64 ± 17 cm H2O, P

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Central Regulation and Neuromuscular Fatigue during Exercise of Different Durations

Purpose: The aim of this study was to determine if exercise time trials (TT) of different durations would cause different levels of peripheral and central fatigue during exercise. Methods: Twelve trained subjects (11 men, one woman) performed TT lasting 3, 10, and 40 min with repetitive self-paced concentric right knee extension at 60°·s−1 on an isokinetic dynamometer. Neuromuscular function was assessed before, during, and immediately after the TT using voluntary and electrically evoked forces. Results: Maximal voluntary contraction force, evoked peak force for single stimulus, and rating of perceived exertion reached similar levels at termination of all TT. Evoked peak force for paired stimuli of 100 Hz decreased more for the 40-min TT compared with the 3-min TT (−42% ± 15% vs −37% ± 13%, P

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Quick Questions in Ankle Sprains: Expert Advice in Sports Medicine

No abstract available

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Functional and Neuromuscular Changes after Anterior Cruciate Ligament Rupture in Rats

Purpose: This study was designed to highlight the functional impairments and the neuromuscular adaptations following an anterior cruciate ligament (ACL) injury in rat. Methods: Animals were randomized into five groups: control (n = 8), SHAM-1wk (n = 6), SHAM-5wk (n = 8), ACL-1wk (n = 8), and ACL-5wk (n = 8). Rats performed three behavioral tests (the ladder-climbing test, the dynamic weight-bearing distribution, and the dynamic function assessment during locomotion) before the surgery (PRE) and at day (D) 1 (D1), D2, D3, D5, D7, D14, D21, D28, and D35 after ACL transection. Electrophysiological recordings, including responses of muscle metabosensitive afferents to a combination of specific chemical activators, namely, lactic acid and potassium chloride, and the quadriceps motor reflex activity, were performed at D7 (ACL-1wk) and at D35 (SHAM and ACL-5wk). Results: Behavioral results indicated an alteration of both weight-bearing distribution over the four paws and fine motor skills (ladder-climbing test) for the injured animals. Maximal motor reflex amplitude was higher after ACL injury compared with the other groups. Moreover, the regulation of motor reflex induced by metabosensitive afferents was perturbed from the first week after ACL transection, without affecting the response of these muscle afferents to their specific stimuli. Conclusions: This study brings some new evidence about the motor dysfunctions and spinal adaptations after ACL rupture in rats. Such information might be needed for assessing, in our animal model, the effectiveness of the diverse functional rehabilitation strategies used in human clinic after knee injuries.

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Correlation between Cardiorespiratory Fitness and Platelet Function in Healthy Women

Purpose: Low cardiorespiratory fitness (CRF) represents a major risk factor for atherosclerosis, and platelets play a key role in the development of this chronic inflammatory disease. Therefore, the purpose of this study was to assess the relationship between CRF and platelet function. Methods: CRF and different aspects of platelet function were assessed in healthy, young, nonsmoking women. Results were compared between groups of low (LF), medium (MF) and high CRF (HF). Measurements were repeated in group LF after a supervised endurance training program lasting two menstrual cycles and obtained results were compared with groups MF and HF. CRF was quantified by maximal oxygen consumption (V˙O2max) determined by an incremental treadmill exercise test. V˙O2max criteria for groups were (mL·min−1·kg−1 bodyweight): LF 55. Platelet activation state and platelet reactivity were assessed by basal and agonist-induced surface expression of CD62P and CD40L as well as the intraplatelet amount of reactive oxygen species. Results: In group LF, basal platelet activation as well as agonist-induced platelet reactivity were increased compared with groups MF and HF. Between groups MF and HF parameters of platelet function were roughly equal despite a pronounced difference regarding CRF. Exercise training improved CRF in group LF and aligned platelet function to levels observed in groups MF and HF, although CRF still markedly differed. Conclusions: Low levels of CRF favor a proinflammatory platelet phenotype. A relatively low dose of exercise is sufficient to normalize platelet function, whereas superior levels of physical activity and CRF do not provide any further substantial benefit, but also no appreciable adverse effects.

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Leisure Time Physical Activity and Gestational Diabetes Mellitus in the Omega Study

Purpose: Findings of studies investigating associations of leisure time physical activity (LTPA) with gestational diabetes mellitus (GDM) risk have been inconsistent. We investigated associations of LTPA with GDM and whether these associations differ by prepregnancy overweight/obese status or gestational weight gain category. Methods: Participants (N = 3209) of the Omega study, a pregnancy cohort study in Washington State (1996–2008), reported LTPA duration (h·wk−1) and energy expenditure (MET·h·wk−1) in the year before pregnancy and in early pregnancy. Diagnoses of GDM were abstracted from medical records. Poisson regression models were used to determine relative risks of GDM across tertiles of prepregnancy or early pregnancy LTPA duration and energy expenditure. Stratified analyses and interaction terms were used to assess effect modification by prepregnancy overweight/obese status (BMI ≥25 kg·m−2) or gestational weight gain category (adequate or excessive). Results: Each tertile increase in prepregnancy LTPA duration or energy expenditure was associated with 15% (95% CI = 0.72–1.00) and 19% (95% CI = 0.69–0.96) lower risk of GDM, respectively. Each tertile increase in early pregnancy LTPA duration or energy expenditure was associated with 16% (95% CI = 0.72–0.97) and 17% (95% CI = 0.72–0.95) lower risk of GDM, respectively. LTPA during both prepregnancy and early pregnancy was associated with a 46% reduced risk of GDM (95% CI = 0.32–0.89) compared with inactivity during both periods. LTPA–GDM associations were similar by prepregnancy BMI and gestational weight gain. Conclusion: Our results support a role for the promotion of physical activity before and during pregnancy in the prevention of GDM.

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Hypoventilation Training at Supramaximal Intensity Improves Swimming Performance

Purpose: This study aimed to determine whether hypoventilation training at supramaximal intensity could improve swimming performance more than the same training conducted under normal breathing conditions. Methods: For a 5-wk period, 16 triathletes (12 men and 4 women) were asked to include one supramaximal set of 12 to 20 × 25-m front crawl swimming twice a week into their usual swimming session, performed either with hypoventilation at low lung volume (VHL group) or with normal breathing (CONT group). Before (Pre) and after (Post) training, all triathletes performed all-out front crawl trials for 100, 200, and 400 m. Results: Time performance was significantly improved in VHL in all trials (100 m: −3.7 ± 3.7 s [−4.4% ± 4.0%]; 200 m: −6.9 ± 5.0 s [−3.6% ± 2.3%]; 400 m: −13.6 ± 6.1 s [−3.5% ± 1.5%]) but did not change in CONT. In VHL, the maximal lactate concentration (+2.35 ± 1.3 mmol·L−1 on average) and the rate of lactate accumulation in blood (+41.7% ± 39.4%) were higher at Post than at Pre in the three trials, whereas they remained unchanged in CONT. Arterial oxygen saturation, heart rate, breathing frequency, and stroke length were not altered in both groups at the end of the training period. On the other hand, stroke rate was higher at Post compared with Pre in VHL but not different in CONT. The measurements of gas exchange for the 400-m trial revealed no change in peak oxygen consumption as well as in any pulmonary variable in both groups. Conclusion: This study demonstrated that VHL training, when performed at supramaximal intensity, represents an effective method for improving swimming performance, partly through an increase in the anaerobic glycolysis activity.

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Association of Injury History and Incident Injury in Cadet Basic Military Training

Purpose: This study aimed to determine the association between injury history at enrollment and incident lower extremity (LE) injury during cadet basic training among first-year military cadets. Methods: Medically treated LE injuries during cadet basic training documented in the Defense Medical Surveillance System were ascertained in a prospective cohort study of three large US military academies from 2005 to 2008. Both acute injuries (International Classification of Disease, Ninth Revision, codes in the 800–900s, including fracture, dislocations, and sprains/strains) and injury-related musculoskeletal injuries (International Classification of Disease, Ninth Revision, codes in the 700s, including inflammation and pain, joint derangement, stress fracture, sprain/strain/rupture, and dislocation) were included. Risk ratio (RR) and 95% confidence interval (CI) were computed using multivariate log-binomial models stratified by gender. Results: During basic training, there were 1438 medically treated acute and 1719 musculoskeletal-related LE injuries in the 9811 cadets. The most frequent LE injuries were sprains/strains (73.6% of acute injuries) and inflammation and pain (89.6% of musculoskeletal-related injuries). The overall risk of incident LE injury was 23.2% (95% CI = 22.3%–24.0%). Cadets with a history of LE injury were at increased risk for incident LE injury. This association was identical in males (RR = 1.74, 95% CI = 1.55–1.94) and females (RR = 1.74, 95% CI = 1.52–1.99). In site-specific analyses, strong associations between injury history and incident injury were observed for hip, knee ligament, stress fracture, and ankle sprain. Injury risk was greater (P

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Motor Performance as Risk Factor for Lower Extremity Injuries in Children

Purpose: Physical activity–related injuries in children constitute a costly public health matter. The influence of motor performance on injury risk is unclear. The purpose of this study was to examine if motor performance was a risk factor of traumatic and overuse lower extremity injuries in a normal population of children. Methods: This study included 1244 participants from 8 to 14 yr old at baseline, all participating in the "Childhood Health, Activity and Motor Performance School Study Denmark." The follow-up period was up to 15 months. The motor performance tests were static balance, single leg hop for distance, core stability tests, vertical jump, shuttle run, and cardiorespiratory fitness test. Lower extremity injuries were registered by clinicians using weekly questionnaires and classified according to the International Classification of Diseases, 10th Revision, system. Results: Poor balance increased the risk for traumatic injury in the foot region (incidence rate ratio [IRR] = 1.09–1.15), and good performance in single leg hop for distance protected against traumatic knee injuries (IRR = 0.66–0.68). Good performance in core stability tests and vertical jump increased the risk for traumatic injuries in the foot region (IRR = 1.12–1.16). Poor balance increased the risk for overuse injuries in the foot region (IRR = 1.65), as did good performance in core stability tests and shuttle run, especially for knee injuries (IRR = 1.07–1.18). Conclusions: Poor balance (sway) performance was a consistent predictor of traumatic injuries, in particular, for traumatic ankle injuries. Good motor performance (core stability, vertical jump, and shuttle run) was positively associated with traumatic and overuse injuries and negatively (single leg hop) associated with traumatic injuries, indicating different influences on injury risk. Previous injury was a confounder affecting the effect size and the significance. More studies are needed to consolidate the findings, to clarify the influence of different performance tests on different types of injuries, and to examine the influence of behavior in relation to injury risk.

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A recessive syndrome of intellectual disability, moderate overgrowth, and renal dysplasia predisposing to Wilms tumor is caused by a mutation in FIBP gene

Clinical classification of overgrowth syndromes represents a challenge since a wide spectrum of disorders result in marked overgrowth. Therefore, there is a continuous effort to identify the genetic basis of these disorders that will eventually facilitate their molecular classification. Here, we have identified the genetic etiology and the pathogenetic mechanism underlying a rare autosomal recessive overgrowth syndrome in three affected siblings. The overgrowth phenotype in the patients was accompanied by developmental delay, learning disabilities, and variable congenital abnormalities. To elucidate the genetic etiology of the disorder, whole-genome genotyping and whole-exome sequencing were used. The disease was mapped to 3p21.1-p14.2 and 11q13.1-q13.4, where an in-frame insertion (c.175_176insTAA) in FIBP gene was revealed. The resulting indel (p.H59LN) was predicted to change the protein conformation with likely deleterious effect on its function as one of the fibroblast growth factor signaling mediators. In vitro cellular proliferation assay and in situ hypridization in vivo were then performed to understand the pathophysiology of the disease. The patients' skin fibroblasts showed an increased proliferation capacity compared to the controls' explaining the observed overgrowth phenotype. In addition, we detected Fibp expression most notably in the brains of mice embryos suggesting a possible effect on cognitive functions early in development. To date, only one patient has been reported with a homozygous nonsense mutation in FIBP exhibiting an overgrowth syndrome with multiple congenital abnormalities. Taken all together, these findings provide convincing evidence implicating FIBP aberrations in the newly recognized overgrowth syndrome and expand the associated phenotypes to include possible Wilms tumor predisposition. © 2016 Wiley Periodicals, Inc.

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The crucial role of FBXO28 in the pathogenesis of the 1q41q42 microdeletion syndrome

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Coming of age: ten years of next-generation sequencing technologies

Nature Reviews Genetics 17, 333 (2016). doi:10.1038/nrg.2016.49

Authors: Sara Goodwin, John D. McPherson & W. Richard McCombie

Since the completion of the human genome project in 2003, extraordinary progress has been made in genome sequencing technologies, which has led to a decreased cost per megabase and an increase in the number and diversity of sequenced genomes. An astonishing complexity of genome architecture

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Genetic variation: Genomic monomorphism off the scale

Nature Reviews Genetics 17, 316 (2016). doi:10.1038/nrg.2016.61

Author: Linda Koch

The generality of the small-population paradigm in conservation genetics is called into question by a recent report in Current Biology. It has long been thought that loss of genetic variation drives the extinction of isolated populations. However, an analysis of complete genome sequence data

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Bioinformatics: Benchmarking transcript expression quantification

Nature Reviews Genetics 17, 316 (2016). doi:10.1038/nrg.2016.62

Author: Linda Koch

A new study presents a set of assessment metrics and visualization techniques for the statistical evaluation of algorithms for quantifying RNA sequencing data. The benchmarks are available as a R/Bioconductor package (http://ift.tt/23QBzZd). The new set of interpretable assessment metrics relate to the quantification

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Human genetics: Splicing: linking genetic variation and disease

Nature Reviews Genetics 17, 317 (2016). doi:10.1038/nrg.2016.64

Author: Denise Waldron

It is well known that noncoding genetic variants contribute to complex traits and diseases, but the mechanisms through which they act are not fully understood. Now, a study published in Science reports that RNA splicing is a primary link between genetic variation and complex

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Genetic sources of population epigenomic variation

Nature Reviews Genetics 17, 319 (2016). doi:10.1038/nrg.2016.45

Authors: Aaron Taudt, Maria Colomé-Tatché & Frank Johannes

The field of epigenomics has rapidly progressed from the study of individual reference epigenomes to surveying epigenomic variation in populations. Recent studies in a number of species, from yeast to humans, have begun to dissect the cis- and trans-regulatory genetic mechanisms that shape

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Genetic Engineering: A CORRECT step forward in disease modelling

Nature Reviews Genetics 17, 316 (2016). doi:10.1038/nrg.2016.60

Author: Linda Koch

A CRISPR–Cas9-based strategy enables the targeted introduction of homozygous or heterozygous sequence changes by homology-directed repair. The CORRECT (consecutive re-guide or re-Cas steps to erase CRISPR–Cas-blocked targets) method allows for the introduction of targeted modifications together with silent CRISPR–Cas-blocking mutations aimed at preventing 're-editing' due

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Genetic variation: Linking TF binding to disease risk using pooled ChIP–seq

Nature Reviews Genetics 17, 317 (2016). doi:10.1038/nrg.2016.55

Author: Bryony Jones

A pooled ChIP–seq (chromatin immunoprecipitation followed by sequencing) approach for mapping quantitative trait loci (QTLs) can identify genetic variants that affect the binding of transcription factors (TFs), according to new research published in Cell. Ultimately, this approach reveals links between binding QTLs (bQTLs), chromatin

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RNA modifications: what have we learned and where are we headed?

Nature Reviews Genetics 17, 365 (2016). doi:10.1038/nrg.2016.47

Authors: Michaela Frye, Samie R. Jaffrey, Tao Pan, Gideon Rechavi & Tsutomu Suzuki

Proper control of the transcriptome is key for diverse aspects of gene expression, cellular functions and development, and its disruption can result in disease. A rapidly accumulating wealth of studies are identifying and functionally characterizing diverse types of RNA base modifications in protein-coding and non-coding

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Genetic screens: Finding the resilient few

Nature Reviews Genetics 17, 316 (2016). doi:10.1038/nrg.2016.54

Author: Denise Waldron

Researchers of a study published in Nature Biotechnology have identified 13 healthy individuals who harbour genetic variants associated with severe Mendelian diseases that were previously thought to be completely penetrant.Studies of disease genetics are generally focused on the identification of disease-causing variants in

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Gene regulation: Finding genetic target sites

Nature Reviews Genetics 17, 314 (2016). doi:10.1038/nrg.2016.53

Author: Darren J. Burgess

There is increasing realization that genetic variation in non-coding regulatory elements, such as enhancers, has a major role in evolution, complex traits and diseases. However, a key challenge is to identify the genes regulated by these elements in order to dissect the gene regulatory networks

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The statistical properties of gene-set analysis

Nature Reviews Genetics 17, 353 (2016). doi:10.1038/nrg.2016.29

Authors: Christiaan A. de Leeuw, Benjamin M. Neale, Tom Heskes & Danielle Posthuma

The rapid increase in loci discovered in genome-wide association studies has created a need to understand the biological implications of these results. Gene-set analysis provides a means of gaining such understanding, but the statistical properties of gene-set analysis are not well understood, which compromises our

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Genetic screens: Combination screens for combination therapies

Nature Reviews Genetics 17, 313 (2016). doi:10.1038/nrg.2016.52

Author: Darren J. Burgess

Resources for genome-scale loss-of-function screens in mammalian cells have progressed rapidly, particularly with RNA interference (RNAi)-based libraries and, more recently, with CRISPR–Cas9-based libraries. A new parallel screening study leverages the complementary strengths of each system to dissect antiviral drug mechanisms and to identify potential combination

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Does Preprocedural Ultrasound Increase the First-Pass Success Rate of Epidural Catheterization Before Cesarean Delivery? A Randomized Controlled Trial.

BACKGROUND: Preprocedural ultrasound may improve the efficacy and safety of epidural catheterization, especially in difficult cases. Most studies of ultrasound-assisted epidural catheterization in the obstetric population are dated and nonblinded with inconsistent designs. This double-blind, randomized controlled study aimed to compare the ultrasound-assisted with the conventional palpation techniques for epidural catheterization in parturients undergoing cesarean delivery. We hypothesized that the use of preprocedural ultrasound would increase the success rate of epidural catheterization at the first needle pass. METHODS: Eligible subjects were American Society of Anesthesiologists physical status II parturients with full-term singleton pregnancy undergoing elective cesarean delivery using double-interspace combined spinal-epidural anesthesia. Exclusion criteria were age 40 years, body mass index >=35 kg/m2, women presenting in labor or having any contraindication to neuraxial anesthesia, marked spinal deformity, previous spinal surgery, or impalpable anatomical landmarks. One hundred ten patients were randomly allocated into 2 equal groups (palpation and ultrasound groups). All procedures were performed by a single experienced anesthesiologist. Patients and investigators assessing the outcome data were blinded to group allocation. A systematic spinal ultrasound assessment and a sham procedure were performed in the ultrasound and palpation groups, respectively, before attempting epidural catheterization. The primary outcome was the rate of successful epidural catheterization at the first needle pass. Secondary outcomes were the rate of successful epidural catheterization at the first skin puncture, number of performed needle passes and skin punctures, duration of the epidural procedure, patient satisfaction from the procedure, and complications of the procedure (incidence of unintentional dural and vascular punctures, failed block, unilateral or patchy block, and backache). RESULTS: Data from 108 patients (55 patients in the palpation group and 53 patients in the ultrasound group) were analyzed. The rate of successful epidural catheterization at the first needle pass was 60% in the palpation group and 58.5% in the ultrasound group (95% confidence interval of the difference in proportions between groups is -18.5% to 21.6%; P > 0.99). There were no significant differences between the 2 groups in the success rate at the first skin puncture, the number of needle passes and skin punctures, or patient satisfaction. The median (range) duration of the epidural procedure was 185 (57-680) seconds in the ultrasound group and 215 (114-720) seconds in the palpation group (P = 0.036 with the Mann-Whitney U test and P = 0.083 with the Student t test with unequal variances). The overall rate of complications of the procedure was low in both groups. CONCLUSIONS: For experienced anesthesiologists, it remains unclear whether preprocedural ultrasound improves the epidural catheterization technique in parturients with palpable anatomical landmarks undergoing cesarean delivery. (C) 2016 International Anesthesia Research Society

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Continuing the Terra Firma and Establishing a New EQUATOR for Anesthesia & Analgesia.

No abstract available

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Advanced Uses of Pulse Oximetry for Monitoring Mechanically Ventilated Patients.

Pulse oximetry is an undisputable standard of care in clinical monitoring. It combines a spectrometer to detect hypoxemia with a plethysmograph for the diagnosis, monitoring, and follow-up of cardiovascular diseases. These pulse oximetry capabilities are extremely useful for assessing the respiratory and circulatory status and for monitoring of mechanically ventilated patients. On the one hand, the key spectrography-derived function of pulse oximetry is to evaluate a patient's gas exchange that results from a particular ventilatory treatment by continuously and noninvasively measuring arterial hemoglobin saturation (SpO2). This information helps to maintain patients above the hypoxemic levels, leading to appropriate ventilator settings and inspired oxygen fractions. However, whenever higher than normal oxygen fractions are used, SpO2 can mask existing oxygenation defects in ventilated patients. This limitation, resulting from the S shape of the oxyhemoglobin saturation curve, can be overcome by reducing the oxygen fraction delivered to the patient in a controlled and stepwise manner. This results in a SpO2/FIO2 diagram, which allows a rough characterization of a patient's gas exchange, shunt, and the amount of lung area with a low ventilation/perfusion ratio without the need of blood sampling. On the other hand, the photoplethysmography-derived oximeter function has barely been exploited for the purpose of monitoring hemodynamics in mechanically ventilated patients. The analysis of the photoplethysmography contour provides useful real-time and noninvasive information about the interaction of heart and lungs during positive pressure ventilation. These hemodynamic monitoring capabilities are related to both the assessment of preload dependency-mainly by analyzing the breath-by-breath variation of the photoplethysmographic signals-and the analysis of arterial impedance, which examines the changes in the plethysmographic amplitude, contour, and derived indexes. In this article, we present and describe these extended monitoring capabilities and propose a more holistic monitoring concept that takes advantage of these advanced uses of pulse oximetry in the monitoring of ventilated patients. Today's monitors need to be improved if such novel functionalities were to be offered for clinical use. Future developments and clinical evaluations are needed to establish the true potential of these advanced monitoring uses of pulse oximetry. (C) 2016 International Anesthesia Research Society

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Clostridium Difficile Infection in Children: a Review.

Clostridium difficile is a sporogenic, anaerobic, Gram-positive, emerging enteric pathogen. It represents the most common cause of healthcare-associated diarrhoea in the United States, with significantly associated morbidity, mortality and healthcare costs. Historically regarded as a little more than an innocent colonizer bystander of the gastrointestinal tract of children, Clostridium difficile has increasingly demonstrated its behavior as a true pathogen in the paediatric age groups. This organism may be responsible for a broad spectrum of diseases in children, ranging from self-limiting secretory diarrhoea to life-threatening conditions, such as pseudomembranous colitis, toxic megacolon, intestinal perforation and septic shock. However, the incidence and severity of Clostridium difficile infection are not completely understood in this population. In particular, while asymptomatic carriage remains high among infants, the clinical significance of detecting Clostridium difficile in children aged 1 to 3 years is not fully understood. Moreover, recent epidemiological surveillance has demonstrated a rise in the incidence of Clostridium difficile infection, particularly in the community and in low-risk settings. Interestingly, such cases may not show the disease pattern to be associated with typical risk factors, such as recent exposure to antimicrobial drugs or on-going contacts with the healthcare system. The purpose of this review is to present the features of Clostridium difficile infection that are unique to paediatric patients and to update paediatricians on information and recommendations regarding Clostridium difficile infection in children. (C) 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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