Παρασκευή, 16 Φεβρουαρίου 2018

Menstrual phase and the vascular response to acute resistance exercise

Abstract

Introduction

Aerobic exercise has a favorable effect on systemic vascular function, reducing both central (large elastic artery) and peripheral (smaller muscular artery) stiffness. The effects of resistance exercise (RE) on arterial stiffness are more complex. Acute RE increases central artery stiffness while decreasing peripheral stiffness. To date, the majority of studies have been performed in predominantly male participants.

Purpose

To examine the effect of acute RE on central and peripheral arterial stiffnesses in women, a secondary purpose was to explore the influence of cyclic changes in estrogen status across the menstrual cycle on the arterial response to acute RE.

Methods

18 healthy women [28 ± 7 years, body mass index (BMI) 22.6 ± 2.9 kg/m2] completed an acute RE bout during the early follicular and the early luteal phase of their menstrual cycle. Salivary 17β-Estradiol concentration was measured during each phase, using a passive drool technique. Pulse-wave velocity (PWV) was obtained from the carotid–femoral and carotid–radial pulse sites to measure central and peripheral stiffness, respectively, using applanation tonometry. PWV was measured at rest, immediately, 10, 20, and 30 min post-RE.

Results

17β-Estradiol concentration was significantly lower in the early follicular vs. the early luteal phase of the menstrual cycle (1.78 ± 0.51 vs. 2.40 ± 0.26 pg/ml, p = 0.01). Central PWV significantly increased (p < 0.05) and peripheral PWV significantly decreased (p < 0.05) post-RE in both the early follicular and early luteal phases. No phase-by-time interaction was detected for either vascular segment (p > 0.05).

Conclusion

Women experience increases in central arterial stiffness and reductions in peripheral arterial stiffness following acute RE. Menstrual cycle phase may not influence changes in arterial stiffness in response to acute RE.



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Post-Cardiac Arrest Management: Time to Cool It on Cooling?

imageNo abstract available

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Targeted Temperature Management After Cardiac Arrest: Systematic Review and Meta-analyses

imageBACKGROUND: Targeted temperature management (TTM) with therapeutic hypothermia is an integral component of postarrest care for survivors. However, recent randomized controlled trials (RCTs) have failed to demonstrate the benefit of TTM on clinical outcomes. We sought to determine if the pooled data from available RCTs support the use of prehospital and/or in-hospital TTM after cardiac arrest. METHODS: A comprehensive search of SCOPUS, Elsevier's abstract and citation database of peer-reviewed literature, from 1966 to November 2016 was performed using predefined criteria. Therapeutic hypothermia was defined as any strategy that aimed to cool post–cardiac arrest survivors to a temperature ≤34°C. Normothermia was temperature of ≥36°C. We compared mortality and neurologic outcomes in patients by categorizing the studies into 2 groups: (1) hypothermia versus normothermia and (2) prehospital hypothermia versus in-hospital hypothermia using standard meta-analytic methods. A random effects modeling was utilized to estimate comparative risk ratios (RR) and 95% confidence intervals (CIs). RESULTS: The hypothermia and normothermia strategies were compared in 5 RCTs with 1389 patients, whereas prehospital hypothermia and in-hospital hypothermia were compared in 6 RCTs with 3393 patients. We observed no difference in mortality (RR, 0.88; 95% CI, 0.73–1.05) or neurologic outcomes (RR, 1.26; 95% CI, 0.92–1.72) between the hypothermia and normothermia strategies. Similarly, no difference was observed in mortality (RR, 1.00; 95% CI, 0.97–1.03) or neurologic outcome (RR, 0.96; 95% CI, 0.85–1.08) between the prehospital hypothermia versus in-hospital hypothermia strategies. CONCLUSIONS: Our results suggest that TTM with therapeutic hypothermia may not improve mortality or neurologic outcomes in postarrest survivors. Using therapeutic hypothermia as a standard of care strategy of postarrest care in survivors may need to be reevaluated.

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Perioperative Cardiac Arrest: Focus on Malignant Hyperthermia (MH)

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Perioperative Cardiac Arrest: Focus on Local Anesthetic Systemic Toxicity (LAST)

imageNo abstract available

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Perioperative Cardiac Arrest: Focus on Anaphylaxis

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Cardiac Arrest in the Operating Room: Part 2—Special Situations in the Perioperative Period

imageAs noted in part 1 of this series, periprocedural cardiac arrest (PPCA) can differ greatly in etiology and treatment from what is described by the American Heart Association advanced cardiac life support algorithms, which were largely developed for use in out-of-hospital cardiac arrest and in-hospital cardiac arrest outside of the perioperative space. Specifically, there are several life-threatening causes of PPCA of which the management should be within the skill set of all anesthesiologists. However, previous research has demonstrated that continued review and training in the management of these scenarios is greatly needed and is also associated with improved delivery of care and outcomes during PPCA. There is a growing body of literature describing the incidence, causes, treatment, and outcomes of common causes of PPCA (eg, malignant hyperthermia, massive trauma, and local anesthetic systemic toxicity) and the need for a better awareness of these topics within the anesthesiology community at large. As noted in part 1 of this series, these events are always witnessed by a member of the perioperative team, frequently anticipated, and involve rescuer–providers with knowledge of the patient and the procedure they are undergoing or have had. Formulation of an appropriate differential diagnosis and rapid application of targeted interventions are critical for good patient outcome. Resuscitation algorithms that include the evaluation and management of common causes leading to cardiac in the perioperative setting are presented. Practicing anesthesiologists need a working knowledge of these algorithms to maximize good outcomes.

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Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist Part 1

imageCardiac arrest in the operating room and procedural areas has a different spectrum of causes (ie, hypovolemia, gas embolism, and hyperkalemia), and rapid and appropriate evaluation and management of these causes require modification of traditional cardiac arrest algorithms. There is a small but growing body of literature describing the incidence, causes, treatments, and outcomes of circulatory crisis and perioperative cardiac arrest. These events are almost always witnessed, frequently known, and involve rescuer providers with knowledge of the patient and their procedure. In this setting, there can be formulation of a differential diagnosis and a directed intervention that treats the likely underlying cause(s) of the crisis while concurrently managing the crisis itself. Management of cardiac arrest of the perioperative patient is predicated on expert opinion, physiologic rationale, and an understanding of the context in which these events occur. Resuscitation algorithms should consider the evaluation and management of these causes of crisis in the perioperative setting.

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Extended-Spectrum β-Lactamase, AmpC, and MBL-Producing Gram-Negative Bacteria on Fresh Vegetables and Ready-to-Eat Salads Sold in Local Markets

Microbial Drug Resistance , Vol. 0, No. 0.


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In Response

No abstract available

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Perioperative Inflammation and Its Modulation by Anesthetics

imageSurgery and other invasive procedures, which are routinely performed during general anesthesia, may induce an inflammatory response in the patient. This inflammatory response is an inherent answer of the body to the intervention and can be both beneficial and potentially harmful. The immune system represents a unique evolutionary achievement equipping higher organisms with an effective defense mechanism against exogenous pathogens. However, not only bacteria might evoke an immune response but also other noninfectious stimuli like the surgical trauma or mechanical ventilation may induce an inflammatory response of varying degree. In these cases, the immune system activation is not always beneficial for the patients and might carry the risk of concomitant, harmful effects on host cells, tissues, or even whole organ systems. Research over the past decades has contributed substantial information in which ways surgical patients may be affected by inflammatory reactions. Modulations of the patient's immune system may be evoked by the use of anesthetic agents, the nature of surgical trauma and the use of any supportive therapy during the perioperative period. The effects on the patient may be manifold, including various proinflammatory effects. This review focuses on the causes and effects of inflammation in the perioperative period. In addition, we also highlight possible approaches by which inflammation in the perioperative may be modulated in the future.

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Perioperative Cardiac Arrest: Focus on Local Anesthetic Systemic Toxicity (LAST)

imageNo abstract available

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Macintosh Blade Videolaryngoscopy Combined With Rigid Bonfils Intubation Endoscope Offers a Suitable Alternative for Patients With Difficult Airways

imageBACKGROUND: In the armamentarium of an anesthesiologist, videolaryngoscopy is a valuable addition to secure the airway. However, when the videolaryngoscope (VLS) offers no solution, few options remain. Earlier, we presented an intubation technique combining Macintosh blade VLS and Bonfils intubation endoscope (BIE) for a patient with a history of very difficult intubation. In the present study, we evaluated this technique to establish whether it is a valuable alternative. METHODS: In this single-blinded nonrandomized study, 38 patients with a history of difficult intubation or 1 or more predictors of difficult intubation, scoring a Cormack & Lehane (C&L) grade III or IV using Macintosh blade VLS, were included. Patients were intubated combining the VLS with the BIE. The C&L grade was scored 3 times during (1) direct laryngoscopy; (2) indirect videolaryngoscopy; and (3) using the combined technique (VLS + BIE). Afterward, 2 blinded anesthesiologists assessed the C&L grade using the pictures taken during the procedure. RESULTS: Data of 38 patients were analyzed. An improvement of the C&L grade with the combined technique occurred in 33 of 38 patients (86.8%; 95% confidence interval, 71.9%–95.6%). Reviewer 1 reported an improvement of the C&L grade with the combined technique in 37 of 38 patients. Reviewer 2 reported improvement in 33 and deterioration in 2 of the patients. No complications occurred. CONCLUSIONS: The combined use of a VLS with Macintosh blade and BIE gives the anesthesiologist a valuable alternative intubation option in patients with extremely difficult airways.

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Perioperative Cardiac Arrest: Focus on Malignant Hyperthermia (MH)

imageNo abstract available

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In Response

No abstract available

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Post-Cardiac Arrest Management: Time to Cool It on Cooling?

imageNo abstract available

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Efficacy Outcome Measures for Pediatric Procedural Sedation Clinical Trials: An ACTTION Systematic Review

imageObjective evaluations comparing different techniques and approaches to pediatric procedural sedation studies have been limited by a lack of consistency among the outcome measures used in assessment. This study reviewed those existing measures, which have undergone psychometric analysis in a pediatric procedural sedation setting, to determine to what extent and in what circumstances their use is justified across the spectrum of procedures, age groups, and techniques. The results of our study suggest that a wide range of measures has been used to assess the efficacy and effectiveness of pediatric procedural sedation. Most lack the evidence of validity and reliability that is necessary to facilitate rigorous clinical trial design, as well as the evaluation of new drugs and devices. A set of core pediatric sedation outcome domains and outcome measures can be developed on the basis of our findings. We believe that consensus among all stakeholders regarding appropriate domains and measures to evaluate pediatric procedural sedation is possible and that widespread implementation of such recommendations should be pursued.

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Meta-analysis, Medical Reversal, and Settled Science

No abstract available

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The Effect of Adductor Canal Block on Knee Extensor Muscle Strength 6 Weeks After Total Knee Arthroplasty: A Randomized, Controlled Trial

imageBACKGROUND: Total knee arthroplasty (TKA) reduces knee extensor muscle strength (KES) in the operated limb for several months after the surgery. Immediately after TKA, compared to either inguinal femoral nerve block or placebo, adductor canal block (ACB) better preserves KES. Whether this short-term increase in KES is maintained several weeks after surgery remains unknown. We hypothesized that 48 hours of continuous ACB immediately after TKA would improve KES 6 weeks after TKA, compared to placebo. METHODS: Patients scheduled for primary unilateral TKA were randomized to receive either a continuous ACB (group ACB) or a sham block (group SHAM) for 48 hours after surgery. Primary outcome was the difference in maximal KES 6 weeks postoperatively, measured with a dynamometer during maximum voluntary isometric contraction. Secondary outcomes included postoperative day 1 (POD1) and day 2 (POD2) KES, pain scores at rest and peak effort, and opioid consumption; variation at 6 weeks of Knee Osteoarthritis Outcome Score, patient satisfaction, and length of hospital stay. RESULTS: Sixty-three subjects were randomized and 58 completed the study. Patients in group ACB had less pain at rest during POD1 and during peak effort on POD1 and POD2, consumed less opioids on POD1 and POD2, and had higher median KES on POD1. There was no significant difference between groups for median KES on POD2, variation of Knee Osteoarthritis Outcome Score, patient satisfaction, and length of stay. There was no difference between groups in median KES 6 weeks after surgery (52 Nm [31–89 Nm] for group ACB vs 47 Nm [30–78 Nm] for group SHAM, P= .147). CONCLUSIONS: Continuous ACB provides better analgesia and KES for 24–48 hours after surgery, but does not affect KES 6 weeks after TKA. Further research could evaluate whether standardized and optimized rehabilitation over the long term would allow early KES improvements with ACB to be maintained over a period of weeks or months.

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Motor Evoked Potential Monitoring During Thoracoabdominal Aortic Surgery: Useful or Not?

No abstract available

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You’re Wrong, I’m Right: Dueling Authors Reexamine Classic Teachings in Anesthesia

No abstract available

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The Night Shift Nightmare

No abstract available

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In Response

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Anesthesia Advanced Cardiac Life Support: A Guideline Validated?

No abstract available

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Perioperative Cardiac Arrest: Focus on Anaphylaxis

imageNo abstract available

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Hyperglycemia and Elevated Lactate in Trauma: Where Do We Go From Here?

No abstract available

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A Retrospective Analysis of Clinical Research Misconduct Using FDA-Issued Warning Letters and Clinical Investigator Inspection List From 2010 to 2014

imageBACKGROUND: The US Food and Drug Administration (FDA) conducts inspections of clinical investigation sites as a component of clinical trial regulation. The FDA describes the results of these inspections in the Clinical Investigator Inspection List (CLIIL). More serious violations are followed up in FDA warning letters issued to investigators. The primary objective of the current study is to qualitatively and quantitatively describe the CLIIL data and contents of FDA-issued warning letters from 2010 to 2014. METHODS: We retrospectively analyzed the CLIIL and FDA warning letters. For the CLIIL, we quantified the frequency of each violation among other data points. We compared recent data (2010–2014) to the previous 5 years (2005–2009). To analyze FDA warning letters, we developed a coding system to quantify the frequency of violations found. RESULTS: We analyzed 3637 inspections in the CLIIL database and 60 warning letters. Overall, there was a decrease or no change in all violations in the CLIIL database. The largest violation code reported was "failure to follow investigational plan" in both the 2005–2009 and 2010–2014 timeframes. Coding of FDA warning letters shows that the most common violations reported were failing to maintain accurate case histories (10.82%), enrolling ineligible subjects (8.85%), and failing to perform required tests (8.52%). CONCLUSIONS: The overall decrease in violations is encouraging. But, the high proportion of violations related to failure to follow the investigational plan is concerning as the complexity of trials increases. We conclude that more detailed information is necessary to accurately evaluate these violations. The current study provides a model for creating more granular data of violations to better inform clinical investigators and improve clinical trials.

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Between a ROCK and an IR Place

No abstract available

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Chinese Anesthesiologists Have High Burnout and Low Job Satisfaction: A Cross-Sectional Survey

imageBACKGROUND: The Chinese health care system must meet the needs of 19% of the world's population. Despite recent economic growth, health care resources are unevenly distributed. This creates the potential for job stress and burnout. We therefore conducted a survey among anesthesiologists in the Beijing–Tianjin–Hebei region focusing on job satisfaction and burnout to determine the incidence and associated factors. METHODS: A large cross-sectional study was performed in the Beijing–Tianjin–Hebei region of China. The anonymous questionnaire was designed to collect and analyze the following information: (1) demographic characteristics and employer information; (2) job satisfaction assessed by Minnesota Satisfaction Questionnaire; (3) burnout assessed by Maslach Burnout Inventory-Human Service Survey; and (4) sleep pattern and physician–patient communication. RESULTS: Surveys were completed and returned from 211 hospitals (response rate 74%) and 2873 anesthesiologists (response rate 70%) during the period of June to August 2015. The overall job satisfaction score of Minnesota Satisfaction Questionnaire was 65.3 ± 11.5. Among the participants, 69% (95% confidence interval [CI], 67%–71%) met the criteria for burnout. The prevalence of high emotional exhaustion, high depersonalization, and low personal accomplishment was 57% (95% CI, 55%–59%), 49% (95% CI, 47%–51%), and 57% (95% CI, 55%–58%), respectively. Using multivariable logistic regression analysis, we found that age, hospital category, working hours per week, caseload per day, frequency of perceived challenging cases, income, and sleep quality were independent variables associated with burnout. Anesthesiologists with a high level of depersonalization tended to engage in shorter preoperative conversations with patients, provide less information about pain or the procedure, and to have less empathy with them. CONCLUSIONS: The anesthesiologists in the Beijing–Tianjin–Hebei region of China expressed a below-average level of job satisfaction, and suffered a significant degree of burnout. Improvement in job satisfaction and burnout might create a positive work climate that could benefit both the quality of patient care and the profession of anesthesiology in China.

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SideKick Disinfecting Wipes

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Sidekick Disinfecting Wipes are convenient and effective at disinfecting healthcare surfaces with a two-minute wet contact time. Its broad-spectrum efficacy is tuberculocidal, bactericidal, fungicidal and virucidal. Visit Stryker at EMS Today Booth #1205

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Significant reduction in indoor radon in newly built houses

Publication date: Available online 16 February 2018
Source:Journal of Environmental Radioactivity
Author(s): Ingvild E. Finne, Trine Kolstad, Maria Larsson, Bård Olsen, Josephine Prendergast, Anne Liv Rudjord
Results from two national surveys of radon in newly built homes in Norway, performed in 2008 and 2016, were used in this study to investigate the effect of the 2010 building regulations introducing limit values on radon and requirements for radon prevention measures upon construction of new buildings.In both surveys, homes were randomly selected from the National Building Registry. The overall result was a considerable reduction of radon concentrations after the implementation of new regulations, but the results varied between the different dwelling categories. A statistically significant reduction was found for detached houses where the average radon concentration was almost halved from 76 to 40 Bq/m3. The fraction of detached houses which had at least one frequently occupied room with a radon concentration above the Action Level (100 Bq/m3) fell from 23.9% to 6.4%, while the fraction above the Upper Limit Value (200 Bq/m3) was reduced from 7.6% to 2.5%. In 2008 the average radon concentration measured in terraced and semi-detached houses was 44 and in 2016 it was 29 Bq/m3, but the reduction was not statistically significant. For multifamily houses, it was not possible to draw a conclusion due to insufficient number of measurements.



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Novel spectrometers for environmental dose rate monitoring

Publication date: Available online 16 February 2018
Source:Journal of Environmental Radioactivity
Author(s): P. Kessler, B. Behnke, R. Dabrowski, H. Dombrowski, A. Röttger, S. Neumaier
A new generation of dosemeters, based on the scintillators LaBr3, CeBr3 and SrI2, read out with conventional photomultipliers, to be used in the field of environmental gamma-radiation monitoring, was investigated. The main features of these new instruments and especially their outdoor performance, studied by long-term investigations under real weather conditions, are presented. The systems were tested at the reference sites for environmental radiation of the Physikalisch-Technische Bundesanstalt. The measurements are compared with that of well characterized classical dose rate reference instruments to demonstrate the suitability of new spectrometers for environmental dose rate monitoring even in adverse weather conditions. Their potential to replace the (mainly Geiger Müller based) dose rate meters operated in about 5000 European early waning network stations as well as in environmental radiation monitoring in general is shown.



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A brief overview of decommissioning and environmental remediation over the last 20 years

Publication date: Available online 16 February 2018
Source:Journal of Environmental Radioactivity
Author(s): Monken-Fernandes Horst, Michal Vladimir




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Moderate financial incentive does not appear to influence the P300 Concealed Information Test (CIT) effect in the Complex Trial Protocol (CTP) version of the CIT in a forensic scenario, while affecting P300 peak latencies and behavior

Publication date: Available online 15 February 2018
Source:International Journal of Psychophysiology
Author(s): J. Peter Rosenfeld, Evan Sitar, Joshua Wasserman, Anne Ward
Previous research indicated that the skin conductance response (SCR) of the Autonomic Nervous System (ANS) in the Concealed Information Test (CIT) is typically increased in subjects who are financially and otherwise incentivized to defeat the CIT (the paradoxical "motivational impairment" effect). This is not the case for RT-based CITs, nor for P300 tests based on the 3-stimulus protocol or Complex Trial Protocol for detection of cognitive malingering (although these are not the same as forensic CITs). The present report extends earlier studies of malingerers by running five groups of subjects (15–16 per group yielding 78 total) in a mock crime (forensic) scenario: paid (to beat the test) and unpaid, instructed and uninstructed, and simply guilty. There was no evidence that the "CIT effect" (probe-minus-irrelevant P300 differences) differed among groups, although behavioral differences among groups were seen.



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Beyond the FRN: Broadening the time-course of EEG and ERP components implicated in reward processing

Publication date: Available online 15 February 2018
Source:International Journal of Psychophysiology
Author(s): James E. Glazer, Nicholas J. Kelley, Narun Pornpattananangkul, Vijay A. Mittal, Robin Nusslock
Most reward-related electroencephalogram (EEG) studies focus exclusively on the feedback-related negativity (FRN, also known as feedback negativity or FN, medial-frontal negativity or MFN, feedback error-related negativity or fERN, and reward positivity or RewP). This component is usually measured approximately 200–300 ms post-feedback at a single electrode in the frontal-central area (e.g., Fz or FCz). The present review argues that this singular focus on the FRN fails to leverage EEG's greatest strength, its temporal resolution, by underutilizing the rich variety of event-related potential (ERP) and EEG time-frequency components encompassing the wider temporal heterogeneity of reward processing. The primary objective of this review is to provide a comprehensive understanding of often overlooked ERP and EEG correlates beyond the FRN in the context of reward processing with the secondary goal of guiding future research toward multistage experimental designs and multicomponent analyses that leverage the temporal power of EEG. We comprehensively review reward-related ERPs (including the FRN, readiness potential or RP, stimulus-preceding negativity or SPN, contingent-negative variation or CNV, cue-related N2 and P3, Feedback-P3, and late-positive potential or LPP/slow-wave), and reward-related EEG time-frequency components (changes in power at alpha, beta, theta, and delta bands). These electrophysiological signatures display distinct time-courses, scalp topographies, and reflect independent psychological processes during anticipatory and/or outcome stages of reward processing. Special consideration is given to the time-course of each component and factors that significantly contribute to component variation. Concluding remarks identify current limitations along with recommendations for potential important future directions.



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The Accuracy of Perioperative Noninvasive Blood Pressure Monitoring in Obese Patients

No abstract available

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In Response

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Bivalirudin for Pediatric Procedural Anticoagulation: A Narrative Review

Bivalirudin (Angiomax; The Medicines Company, Parsippany, NJ), a direct thrombin inhibitor, has found increasing utilization as a heparin alternative in the pediatric population, most commonly for the treatment of thrombosis secondary to heparin-induced thrombocytopenia. Due to the relative rarity of heparin-induced thrombocytopenia as well as the lack of Food and Drug Administration–approved indications in this age group, much of what is known regarding the pharmacokinetics and pharmacodynamics of bivalirudin in this population has been extrapolated from adult data. This narrative review will present recommendations regarding the use of bivalirudin for procedural anticoagulation in the pediatric population based on the published literature. Accepted for publication December 19, 2017. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Katherine L. Zaleski, MD, Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115. Address e-mail to Katherine.Zaleski@childrens.harvard.edu. © 2018 International Anesthesia Research Society

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Combined Colloid Preload and Crystalloid Coload Versus Crystalloid Coload During Spinal Anesthesia for Cesarean Delivery: A Randomized Controlled Trial

BACKGROUND: The optimal strategy of fluid administration during spinal anesthesia for cesarean delivery is still unclear. Ultrasonography of the inferior vena cava (IVC) has been recently used to assess the volume status and predict fluid responsiveness. In this double-blind, randomized controlled study, we compared maternal hemodynamics using a combination of 500-mL colloid preload and 500-mL crystalloid coload versus 1000-mL crystalloid coload. We assessed the IVC at baseline and at subsequent time points after spinal anesthesia. METHODS: Two hundred American Society of Anesthesiologists physical status II parturients with full-term singleton pregnancies scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated to receive either 500-mL colloid preload followed by 500-mL crystalloid coload (combination group) or 1000-mL crystalloid coload (crystalloid coload group) administered using a pressurizer. Ephedrine 3, 5, and 10 mg boluses were administered when the systolic blood pressure decreased below 90%, 80% (hypotension), and 70% (severe hypotension) of the baseline value, respectively. The IVC was assessed using the subcostal long-axis view at baseline, at 1 and 5 minutes after intrathecal injection, and immediately after delivery; the maximum and minimum IVC diameters were measured, and the IVC collapsibility index (CI) was calculated using the formula: IVC-CI = (maximum IVC diameter – minimum IVC diameter)/maximum IVC diameter. The primary outcome was the total ephedrine dose. RESULTS: Data from 198 patients (99 patients in each group) were analyzed. The median (range) of the total ephedrine dose was 11 (0–60) mg in the combination group and 13 (0–61) mg in the crystalloid coload group; the median of the difference (95% nonparametric confidence interval) was −2 (−5 to 0.00005) mg, P = .22. There were no significant differences between the 2 groups in the number of patients requiring ephedrine, the incidence of hypotension and severe hypotension, the time to the first ephedrine dose, and neonatal Apgar scores at 1 and 5 minutes. The maximum and minimum IVC diameters in each group increased after spinal anesthesia and after delivery, and they were larger in the combination group. The IVC-CI after delivery was higher in the crystalloid coload group. CONCLUSIONS: The combination of 500-mL colloid preload and 500-mL crystalloid coload did not reduce the total ephedrine dose or improve other maternal outcomes compared with 1000-mL crystalloid coload. The IVC was reliably viewed before and during cesarean delivery, and its diameters significantly changed over time and differed between the 2 groups. Accepted for publication December 29, 2017. Funding: This work was supported by the Department of Anesthesia and Surgical Intensive Care at the Mansoura University Hospital, Mansoura, Egypt. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Clinical trial registration: NCT02961842 (ClinicalTrials.gov). The institutional review board approved the study protocol before starting the study; Mansoura Faculty of Medicine Institutional Review Board, http://ift.tt/2Eu0StM, Ahmed Shokeir, MD (Chairman), Professor of Urology, Faculty of Medicine, Mansoura University, Mansoura, Egypt. E-mail: irb.mfm@hotmail.com. Reprints will not be available from the authors. Address correspondence to Mohamed Mohamed Tawfik, MD, Department of Anesthesia and Surgical Intensive Care, Mansoura University Hospital, 26 Elgomhoria St, Mansoura, Dakahlia, Egypt. Address e-mail to m2tawfik@mans.edu.eg. © 2018 International Anesthesia Research Society

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Neuraxial Anesthesia in Children With Ventriculoperitoneal Shunts

Neuraxial anesthesia has been demonstrated to be safe and effective for children undergoing subumbilical surgery. There is limited evidence regarding the safety of neuraxial anesthesia in pediatric patients with a ventriculoperitoneal shunt. We evaluated a series of 25 patients with indwelling ventriculoperitoneal shunts for complications within 30 days of any procedure performed with a neuraxial technique. One patient required a ventriculoperitoneal shunt revision 5 days after a lumbar catheter placement. The neurosurgeon determined the revision to be likely unrelated to the patient's lumbar catheter. Concerns about the use of neuraxial anesthesia in patients with an indwelling ventriculoperitoneal shunt may be overstated. Accepted for publication December 19, 2018. Funding: None. The authors declare no conflicts of interest. A.B.L. and E.C.C. contributed equally to this work. Reprints will not be available from the authors. Address correspondence to Anthony B. Longhini, MD, Department of Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611. Address e-mail to alonghini@luriechildrens.org. © 2018 International Anesthesia Research Society

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Painless Evidence-Based Medicine, 2nd ed

No abstract available

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Approaches to Patient Counseling Regarding Effectiveness of Oral Contraceptives

No abstract available

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The role of feedback in ameliorating burnout

Purpose of review Assessment of the current literature surrounding interventions directed toward the prevention of burnout in the field of medicine and particularly in anesthesiology. Recent findings Recently, burnout has been noted to lead to medication errors and subsequently increased harm to our patients. On a personal level, burnout can lead to depression and even suicide amongst physicians. Strategies to prevent burnout amongst anesthesiologists that have been studied in the literature include multisource feedback, mentorship and early recognition. Summary There remains no clear or definitive intervention to prevent burnout for physicians. However, changing our environment to embrace mentorship, the continual exchange of feedback and the fostering self-care could startlingly improve our work environment. Correspondence to Emily K. Gordon, MD, MSEd, Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, 3400 Spruce Street, 6 Dulles Building, Philadelphia, PA 19104, USA. Tel: +1 267 977 7203; e-mail: emily.gordon@uphs.upenn.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Exercise Preserves Physical Function in Prostate Cancer Patients with Bone Metastases

imageABSTRACTPurposeThe presence of bone metastases has excluded participation of cancer patients in exercise interventions and is a relative contraindication to supervised exercise in the community setting because of concerns of fragility fracture. We examined the efficacy and safety of a modular multimodal exercise program in prostate cancer patients with bone metastases.MethodsBetween 2012 and 2015, 57 prostate cancer patients (70.0 ± 8.4 yr; body mass index, 28.7 ± 4.0 kg·m−2) with bone metastases (pelvis, 75.4%; femur, 40.4%; rib/thoracic spine, 66.7%; lumbar spine, 43.9%; humerus, 24.6%; other sites, 70.2%) were randomized to multimodal supervised aerobic, resistance, and flexibility exercises undertaken thrice weekly (EX; n = 28) or usual care (CON; n = 29) for 3 months. Physical function subscale of the Medical Outcomes Study Short-Form 36 was the primary end point as an indicator of patient-rated physical functioning. Secondary end points included objective measures of physical function, lower body muscle strength, body composition, and fatigue. Safety was assessed by recording the incidence and severity of any adverse events, skeletal complications, and bone pain throughout the intervention.ResultsThere was a significant difference between groups for self-reported physical functioning (3.2 points; 95% confidence interval, 0.4–6.0 points; P = 0.028) and lower body muscle strength (6.6 kg; 95% confidence interval, 0.6–12.7; P = 0.033) at 3 months favoring EX. However, there was no difference between groups for lean mass (P = 0.584), fat mass (P = 0.598), or fatigue (P = 0.964). There were no exercise-related adverse events or skeletal fractures and no differences in bone pain between EX and CON (P = 0.507).ConclusionsMultimodal modular exercise in prostate cancer patients with bone metastases led to self-reported improvements in physical function and objectively measured lower body muscle strength with no skeletal complications or increased bone pain.Trial Registration: ACTRN12611001158954. Purpose The presence of bone metastases has excluded participation of cancer patients in exercise interventions and is a relative contraindication to supervised exercise in the community setting because of concerns of fragility fracture. We examined the efficacy and safety of a modular multimodal exercise program in prostate cancer patients with bone metastases. Methods Between 2012 and 2015, 57 prostate cancer patients (70.0 ± 8.4 yr; body mass index, 28.7 ± 4.0 kg·m−2) with bone metastases (pelvis, 75.4%; femur, 40.4%; rib/thoracic spine, 66.7%; lumbar spine, 43.9%; humerus, 24.6%; other sites, 70.2%) were randomized to multimodal supervised aerobic, resistance, and flexibility exercises undertaken thrice weekly (EX; n = 28) or usual care (CON; n = 29) for 3 months. Physical function subscale of the Medical Outcomes Study Short-Form 36 was the primary end point as an indicator of patient-rated physical functioning. Secondary end points included objective measures of physical function, lower body muscle strength, body composition, and fatigue. Safety was assessed by recording the incidence and severity of any adverse events, skeletal complications, and bone pain throughout the intervention. Results There was a significant difference between groups for self-reported physical functioning (3.2 points; 95% confidence interval, 0.4–6.0 points; P = 0.028) and lower body muscle strength (6.6 kg; 95% confidence interval, 0.6–12.7; P = 0.033) at 3 months favoring EX. However, there was no difference between groups for lean mass (P = 0.584), fat mass (P = 0.598), or fatigue (P = 0.964). There were no exercise-related adverse events or skeletal fractures and no differences in bone pain between EX and CON (P = 0.507). Conclusions Multimodal modular exercise in prostate cancer patients with bone metastases led to self-reported improvements in physical function and objectively measured lower body muscle strength with no skeletal complications or increased bone pain. Trial Registration: ACTRN12611001158954.

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FES-assisted Cycling Improves Aerobic Capacity and Locomotor Function Postcerebrovascular Accident

imageABSTRACTPurposeAfter a cerebrovascular accident (CVA) aerobic deconditioning contributes to diminished physical function. Functional electrical stimulation (FES)–assisted cycling is a promising exercise paradigm designed to target both aerobic capacity and locomotor function. This pilot study aimed to evaluate the effects of an FES–assisted cycling intervention on aerobic capacity and locomotor function in individuals post-CVA.MethodsEleven individuals with chronic (>6 months) post-CVA hemiparesis completed an 8-wk (three times per week; 24 sessions) progressive FES-assisted cycling intervention. V˙O2peak, self-selected, and fastest comfortable walking speeds, gait, and pedaling symmetry, 6-min walk test (6MWT), balance, dynamic gait movements, and health status were measured at baseline and posttraining.ResultsFunctional electrical stimulation-assisted cycling significantly improved V˙O2peak (12%, P = 0.006), self-selected walking speed (SSWS, 0.05 ± 0.1 m·s−1, P = 0.04), Activities-specific Balance Confidence scale score (12.75 ± 17.4, P = 0.04), Berg Balance Scale score (3.91 ± 4.2, P = 0.016), Dynamic Gait Index score (1.64 ± 1.4, P = 0.016), and Stroke Impact Scale participation/role domain score (12.74 ± 16.7, P = 0.027). Additionally, pedal symmetry, represented by the paretic limb contribution to pedaling (paretic pedaling ratio [PPR]) significantly improved (10.09% ± 9.0%, P = 0.016). Although step length symmetry (paretic step ratio [PSR]) did improve, these changes were not statistically significant (−0.05% ± 0.1%, P = 0.09). Exploratory correlations showed moderate association between change in SSWS and 6-min walk test (r = 0.74), and moderate/strong negative association between change in PPR and PSR.ConclusionsThese results support FES-assisted cycling as a means to improve both aerobic capacity and locomotor function. Improvements in SSWS, balance, dynamic walking movements, and participation in familial and societal roles are important targets for rehabilitation of individuals after CVA. Interestingly, the correlation between PSR and PPR suggests that improvements in pedaling symmetry may translate to a more symmetric gait pattern. Purpose After a cerebrovascular accident (CVA) aerobic deconditioning contributes to diminished physical function. Functional electrical stimulation (FES)–assisted cycling is a promising exercise paradigm designed to target both aerobic capacity and locomotor function. This pilot study aimed to evaluate the effects of an FES–assisted cycling intervention on aerobic capacity and locomotor function in individuals post-CVA. Methods Eleven individuals with chronic (>6 months) post-CVA hemiparesis completed an 8-wk (three times per week; 24 sessions) progressive FES-assisted cycling intervention. V˙O2peak, self-selected, and fastest comfortable walking speeds, gait, and pedaling symmetry, 6-min walk test (6MWT), balance, dynamic gait movements, and health status were measured at baseline and posttraining. Results Functional electrical stimulation-assisted cycling significantly improved V˙O2peak (12%, P = 0.006), self-selected walking speed (SSWS, 0.05 ± 0.1 m·s−1, P = 0.04), Activities-specific Balance Confidence scale score (12.75 ± 17.4, P = 0.04), Berg Balance Scale score (3.91 ± 4.2, P = 0.016), Dynamic Gait Index score (1.64 ± 1.4, P = 0.016), and Stroke Impact Scale participation/role domain score (12.74 ± 16.7, P = 0.027). Additionally, pedal symmetry, represented by the paretic limb contribution to pedaling (paretic pedaling ratio [PPR]) significantly improved (10.09% ± 9.0%, P = 0.016). Although step length symmetry (paretic step ratio [PSR]) did improve, these changes were not statistically significant (−0.05% ± 0.1%, P = 0.09). Exploratory correlations showed moderate association between change in SSWS and 6-min walk test (r = 0.74), and moderate/strong negative association between change in PPR and PSR. Conclusions These results support FES-assisted cycling as a means to improve both aerobic capacity and locomotor function. Improvements in SSWS, balance, dynamic walking movements, and participation in familial and societal roles are important targets for rehabilitation of individuals after CVA. Interestingly, the correlation between PSR and PPR suggests that improvements in pedaling symmetry may translate to a more symmetric gait pattern.

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Neurovascular Response during Exercise and Mental Stress in Anabolic Steroid Users

imageABSTRACTPurposeIncreased resting muscle sympathetic nerve activity (MSNA) and lower forearm blood flow (FBF) were observed in young men who use anabolic androgenic steroids (AAS). However, the response of MSNA and FBF in AAS users triggered by muscle mechanoreflex and central command has never been tested. In addition, we evaluated the blood pressure (BP) and heart rate (HR) responses during these maneuvers.MethodsNineteen AAS users (AASU) 31 ± 6 yr of age and 18 AAS nonusers (AASNU) 29 ± 4 yr of age were recruited. All participants were involved in strength training. AAS use was determined using a urine test (liquid chromatography with tandem mass spectrometry). MSNA was measured using the microneurography technique. FBF was measured by using venous occlusion plethysmography. BP was measured using an automatic oscillometric device. HR was recorded continuously through ECG. Isometric handgrip exercise was performed at 30% of the maximal voluntary contraction for 3 min, and mental stress was elicited by the Stroop color–word test for 4 min.ResultsThe MSNA and FBF responses during exercise were similar between AASU and AASNU, with a trend toward higher MSNA (bursts per minute; P = 0.084) and lower forearm vascular conductance (FVC; units; P = 0.084) in AASU than in AASNU. During mental stress, AASU showed a significantly higher MSNA (P

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Neuromuscular Electrical Stimulation Superimposed on Movement Early after ACL Surgery

imageABSTRACTPurposeQuadriceps weakness and asymmetrical loading of lower limbs are two major issues after anterior cruciate ligament reconstruction (ACLR). The aim of this study was to evaluate the effectiveness of a 6-wk training protocol involving neuromuscular electrical stimulations (NMES) of the quadriceps muscle superimposed on repeated sit-to-stand-to-sit exercises (STSTS), as an additional treatment to standard rehabilitation, from the 15th to the 60th day after ACLR.MethodsSixty-three ACLR patients were randomly allocated to one of the three treatment groups: NMES superimposed on STSTS (NMES + STSTS), STSTS only, or no additional treatment (NAT) to standard rehabilitation. Maximal isometric strength of the knee extensor and flexor muscles was measured 60 and 180 d after surgery. Asymmetry in lower extremity loading was measured during a sit-to-stand movement at 15, 30, 60, and 180 d after surgery and during a countermovement jump 180 d after surgery by means of two adjacent force platforms placed under each foot.ResultsThe NMES + STSTS participants showed higher muscle strength of the knee extensors, which was accompanied by lower perception of pain and higher symmetry in lower extremity loading compared with STSTS-only and NAT participants after both 60 and 180 d from surgery. Participants in the STSTS-only treatment group showed higher symmetry in lower extremity loading compared with those in the NAT group 60 d after surgery.ConclusionsThese results suggest that an early intervention based on NMES superimposed to repeated STSTS exercises is effective for recovering quadriceps strength and symmetry in lower extremity loading by the time of return to sport. Purpose Quadriceps weakness and asymmetrical loading of lower limbs are two major issues after anterior cruciate ligament reconstruction (ACLR). The aim of this study was to evaluate the effectiveness of a 6-wk training protocol involving neuromuscular electrical stimulations (NMES) of the quadriceps muscle superimposed on repeated sit-to-stand-to-sit exercises (STSTS), as an additional treatment to standard rehabilitation, from the 15th to the 60th day after ACLR. Methods Sixty-three ACLR patients were randomly allocated to one of the three treatment groups: NMES superimposed on STSTS (NMES + STSTS), STSTS only, or no additional treatment (NAT) to standard rehabilitation. Maximal isometric strength of the knee extensor and flexor muscles was measured 60 and 180 d after surgery. Asymmetry in lower extremity loading was measured during a sit-to-stand movement at 15, 30, 60, and 180 d after surgery and during a countermovement jump 180 d after surgery by means of two adjacent force platforms placed under each foot. Results The NMES + STSTS participants showed higher muscle strength of the knee extensors, which was accompanied by lower perception of pain and higher symmetry in lower extremity loading compared with STSTS-only and NAT participants after both 60 and 180 d from surgery. Participants in the STSTS-only treatment group showed higher symmetry in lower extremity loading compared with those in the NAT group 60 d after surgery. Conclusions These results suggest that an early intervention based on NMES superimposed to repeated STSTS exercises is effective for recovering quadriceps strength and symmetry in lower extremity loading by the time of return to sport.

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No Effect of β-alanine on Muscle Function and Kayak Performance

imageABSTRACTPurposeIf β-alanine supplementation counteracts muscular fatigue development or improves athletic performance was investigated.MethodsElite kayak rowers (10 men and 7 women) were supplemented with either 80 mg·kg−1 body mass·d−1 of β-alanine or placebo for 8 wk. Muscular fatigue development was investigated by applying a 2-min elbow flexor maximal voluntary contraction (MVC). EMG was recorded continuously, and voluntary activation was determined 30, 60, 90, and 115 s into the 2-min MVC. In addition, performance was evaluated as 1000-m and 5 × 250-m kayak ergometer rowing.ResultsForce reduction during the 2-min MVC was similar before and after supplementation with β-alanine (30.9% ± 10.3% vs 36.0% ± 14.1%) and placebo (35.5% ± 7.7% vs 35.1% ± 8.0%). No time effect was apparent in voluntary activation during the 2-min MVC. In addition, there was no detectable effect of β-alanine supplementation on 1000-m kayak ergometer performance (β-alanine: 0.26% ± 0.02% vs placebo: −0.18% ± 0.02%) or accumulated 5 × 250-m time (β-alanine: −1.0% ± 0.3% vs placebo: −1.0% ± 0.2%). In 5 × 250 m, mean power output was reduced to a similar extent from first to fifth interval before and after supplementation with β-alanine (23% ± 11% vs 22% ± 10%) and placebo (26% ± 13% vs 20% ± 5%).ConclusionsTwo-minute MVC characteristics are unaffected by β-alanine supplementation in elite kayakers, and likewise, both a 1000-m kayak ergometer time trial lasting 4–5 min and a 5 × 250-m repeated sprint ability were unaltered by supplementation. Purpose If β-alanine supplementation counteracts muscular fatigue development or improves athletic performance was investigated. Methods Elite kayak rowers (10 men and 7 women) were supplemented with either 80 mg·kg−1 body mass·d−1 of β-alanine or placebo for 8 wk. Muscular fatigue development was investigated by applying a 2-min elbow flexor maximal voluntary contraction (MVC). EMG was recorded continuously, and voluntary activation was determined 30, 60, 90, and 115 s into the 2-min MVC. In addition, performance was evaluated as 1000-m and 5 × 250-m kayak ergometer rowing. Results Force reduction during the 2-min MVC was similar before and after supplementation with β-alanine (30.9% ± 10.3% vs 36.0% ± 14.1%) and placebo (35.5% ± 7.7% vs 35.1% ± 8.0%). No time effect was apparent in voluntary activation during the 2-min MVC. In addition, there was no detectable effect of β-alanine supplementation on 1000-m kayak ergometer performance (β-alanine: 0.26% ± 0.02% vs placebo: −0.18% ± 0.02%) or accumulated 5 × 250-m time (β-alanine: −1.0% ± 0.3% vs placebo: −1.0% ± 0.2%). In 5 × 250 m, mean power output was reduced to a similar extent from first to fifth interval before and after supplementation with β-alanine (23% ± 11% vs 22% ± 10%) and placebo (26% ± 13% vs 20% ± 5%). Conclusions Two-minute MVC characteristics are unaffected by β-alanine supplementation in elite kayakers, and likewise, both a 1000-m kayak ergometer time trial lasting 4–5 min and a 5 × 250-m repeated sprint ability were unaltered by supplementation.

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Thermoeffector Responses at a Fixed Rate of Heat Production in Heart Failure Patients

imageABSTRACTPurposeHeart failure (HF) patients seem to exhibit altered thermoregulatory responses during exercise in the heat. However, the extent to which these responses are altered due to physiological impairments independently of biophysical factors associated with differences in metabolic heat production (Hprod), evaporative heat balance requirements (Ereq), and/or body size is presently unclear. Therefore, we examined thermoregulatory responses in 10 HF patients and 10 age-matched controls (CON) similar in body size during exercise at a fixed rate of Hprod and therefore Ereq in a 30°C environment.MethodsRectal temperature, local sweat rate, and cutaneous vascular conductance were measured throughout 60 min of cycle ergometry. Whole-body sweat rate was estimated from pre–post nude body weight corrected for fluid intake.ResultsDespite exercising at the same rate of Hprod (HF, 338 ± 43 W; CON, 323 ± 31 W; P = 0.25), the rise in rectal temperature was greater (P

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Validity of Wearable Activity Monitors during Cycling and Resistance Exercise

imageABSTRACTIntroductionThe use of wearable activity monitors has seen rapid growth; however, the mode and intensity of exercise could affect the validity of heart rate (HR) and caloric (energy) expenditure (EE) readings. There is a lack of data regarding the validity of wearable activity monitors during graded cycling regimen and a standard resistance exercise. The present study determined the validity of eight monitors for HR compared with an ECG and seven monitors for EE compared with a metabolic analyzer during graded cycling and resistance exercise.MethodsFifty subjects (28 women, 22 men) completed separate trials of graded cycling and three sets of four resistance exercises at a 10-repetition-maximum load. Monitors included the following: Apple Watch Series 2, Fitbit Blaze, Fitbit Charge 2, Polar H7, Polar A360, Garmin Vivosmart HR, TomTom Touch, and Bose SoundSport Pulse (BSP) headphones. HR was recorded after each cycling intensity and after each resistance exercise set. EE was recorded after both protocols. Validity was established as having a mean absolute percent error (MAPE) value of ≤10%.ResultsThe Polar H7 and BSP were valid during both exercise modes (cycling: MAPE = 6.87%, R = 0.79; resistance exercise: MAPE = 6.31%, R = 0.83). During cycling, the Apple Watch Series 2 revealed the greatest HR validity (MAPE = 4.14%, R = 0.80). The BSP revealed the greatest HR accuracy during resistance exercise (MAPE = 6.24%, R = 0.86). Across all devices, as exercise intensity increased, there was greater underestimation of HR. No device was valid for EE during cycling or resistance exercise.ConclusionsHR from wearable devices differed at different exercise intensities; EE estimates from wearable devices were inaccurate. Wearable devices are not medical devices, and users should be cautious when using these devices for monitoring physiological responses to exercise. Introduction The use of wearable activity monitors has seen rapid growth; however, the mode and intensity of exercise could affect the validity of heart rate (HR) and caloric (energy) expenditure (EE) readings. There is a lack of data regarding the validity of wearable activity monitors during graded cycling regimen and a standard resistance exercise. The present study determined the validity of eight monitors for HR compared with an ECG and seven monitors for EE compared with a metabolic analyzer during graded cycling and resistance exercise. Methods Fifty subjects (28 women, 22 men) completed separate trials of graded cycling and three sets of four resistance exercises at a 10-repetition-maximum load. Monitors included the following: Apple Watch Series 2, Fitbit Blaze, Fitbit Charge 2, Polar H7, Polar A360, Garmin Vivosmart HR, TomTom Touch, and Bose SoundSport Pulse (BSP) headphones. HR was recorded after each cycling intensity and after each resistance exercise set. EE was recorded after both protocols. Validity was established as having a mean absolute percent error (MAPE) value of ≤10%. Results The Polar H7 and BSP were valid during both exercise modes (cycling: MAPE = 6.87%, R = 0.79; resistance exercise: MAPE = 6.31%, R = 0.83). During cycling, the Apple Watch Series 2 revealed the greatest HR validity (MAPE = 4.14%, R = 0.80). The BSP revealed the greatest HR accuracy during resistance exercise (MAPE = 6.24%, R = 0.86). Across all devices, as exercise intensity increased, there was greater underestimation of HR. No device was valid for EE during cycling or resistance exercise. Conclusions HR from wearable devices differed at different exercise intensities; EE estimates from wearable devices were inaccurate. Wearable devices are not medical devices, and users should be cautious when using these devices for monitoring physiological responses to exercise.

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Propranolol and Oxandrolone Therapy Accelerated Muscle Recovery in Burned Children

imageABSTRACTIntroductionSevere burns result in prolonged hypermetabolism and skeletal muscle catabolism. Rehabilitative exercise training (RET) programs improved muscle mass and strength in severely burned children. The combination of RET with β-blockade or testosterone analogs showed improved exercise-induced benefits on body composition and muscle function. However, the effect of RET combined with multiple drug therapy on muscle mass, strength, cardiorespiratory fitness, and protein turnover are unknown. In this placebo-controlled randomized trial, we hypothesize that RET combined with oxandrolone and propranolol (Oxprop) will improve muscle mass and function and protein turnover in severely burned children compared with burned children undergoing the same RET with a placebo.MethodsWe studied 42 severely burned children (7–17 yr) with severe burns over 30% of the total body surface area. Patients were randomized to placebo (22 control) or to Oxprop (20) and began drug administration within 96 h of admission. All patients began RET at hospital discharge as part of their standardized care. Muscle strength (N·m), power (W), V˙O2peak, body composition, and protein fractional synthetic rate and fractional breakdown rate were measured pre-RET (PRE) and post-RET (POST).ResultsMuscle strength and power, lean body mass, and V˙O2peak increased with RET in both groups (P

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Contralateral Repeated Bout Effect of the Knee Flexors

imageABSTRACTPurposeEccentric exercise of the elbow flexors (EF) confers protective effect against muscle damage of the same exercise performed by the opposite arm at 1, 7, or 28 d later. This is known as the contralateral repeated bout effect (CL-RBE), but it is not known whether CL-RBE is evident for the knee flexors (KF). The present study tested the hypothesis that KF CL-RBE would be observed at 1, 7, and 28 d after the initial bout.MethodsYoung untrained men were assigned to a control or one of three experimental groups (n = 13 per group). The experimental groups performed 60 maximal KF eccentric contractions (60MaxEC) using one leg followed by the same exercise using the opposite leg at 1, 7, or 28 d later. The control group used the nondominant leg to repeat 60MaxEC separated by 14 d. Changes in several indirect muscle damage markers after 60MaxEC were compared between bouts and among the groups by using a mixed-design, two-way ANOVA.ResultsChanges in maximal voluntary isokinetic concentric contraction torque, range of motion, muscle soreness, and plasma creatine kinase activity after the first 60MaxEC were similar among the groups. These changes were smaller after the second than the first 60MaxEC for the control, 1-d, and 7-d groups, and the changes after the second 60MaxEC were smaller for the control than for both the 1- and 7-d groups (P

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Impact of Blood Flow Restriction Exercise on Muscle Fatigue Development and Recovery

imageABSTRACTPurposeThe present study was designed to provide mechanistic insight into the time course and etiology of muscle fatigue development and recovery during and after low-intensity exercise when it is combined with blood flow restriction (BFR).MethodsSeventeen resistance-trained males completed four sets of low-intensity isotonic resistance exercise under two experimental conditions: knee extension exercise (i) with BFR and (ii) without BFR (CON). Neuromuscular tests were performed before, during (immediately after each set of knee extension exercise), and 1, 2, 4, and 8 min after each experimental condition. Maximal voluntary torque, quadriceps twitch torque in response to paired electrical stimuli at 10 Hz (PS10) and 100 Hz (PS100), PS10·PS100−1 ratio as an index of low-frequency fatigue, and voluntary activation were measured under isometric conditions. Perceptual and EMG data were recorded during each exercise condition.ResultsAfter the first set of exercise, BFR induced significantly greater reductions in maximal voluntary torque, PS100, and PS10·PS100−1 ratio compared with CON. These parameters progressively declined throughout the BFR protocol but recovered substantially within 2 min postexercise when blood flow was restored. Neither a progressive decline in the course of the exercise protocol nor a substantial recovery of these parameters occurred during and after CON. Only at exercise termination, voluntary activation differed significantly between BFR and CON with greater reductions during BFR.ConclusionAt the early stage of exercise, BFR exacerbated the development of muscle fatigue mainly due to a pronounced impairment in contractile function. Despite the high level of muscle fatigue during BFR exercise, the effect of BFR on muscle fatigue was diminished after 2 min of reperfusion, suggesting that BFR has a strong but short-lasting effect on neuromuscular function. Purpose The present study was designed to provide mechanistic insight into the time course and etiology of muscle fatigue development and recovery during and after low-intensity exercise when it is combined with blood flow restriction (BFR). Methods Seventeen resistance-trained males completed four sets of low-intensity isotonic resistance exercise under two experimental conditions: knee extension exercise (i) with BFR and (ii) without BFR (CON). Neuromuscular tests were performed before, during (immediately after each set of knee extension exercise), and 1, 2, 4, and 8 min after each experimental condition. Maximal voluntary torque, quadriceps twitch torque in response to paired electrical stimuli at 10 Hz (PS10) and 100 Hz (PS100), PS10·PS100−1 ratio as an index of low-frequency fatigue, and voluntary activation were measured under isometric conditions. Perceptual and EMG data were recorded during each exercise condition. Results After the first set of exercise, BFR induced significantly greater reductions in maximal voluntary torque, PS100, and PS10·PS100−1 ratio compared with CON. These parameters progressively declined throughout the BFR protocol but recovered substantially within 2 min postexercise when blood flow was restored. Neither a progressive decline in the course of the exercise protocol nor a substantial recovery of these parameters occurred during and after CON. Only at exercise termination, voluntary activation differed significantly between BFR and CON with greater reductions during BFR. Conclusion At the early stage of exercise, BFR exacerbated the development of muscle fatigue mainly due to a pronounced impairment in contractile function. Despite the high level of muscle fatigue during BFR exercise, the effect of BFR on muscle fatigue was diminished after 2 min of reperfusion, suggesting that BFR has a strong but short-lasting effect on neuromuscular function.

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Short Trail Running Race: Beyond the Classic Model for Endurance Running Performance

imageABSTRACTPurposeThis study aimed to examine the extent to which the classical physiological variables of endurance running performance (maximal oxygen uptake (V˙O2max), %V˙O2max at ventilatory threshold (VT), and running economy (RE)) but also muscle strength factors contribute to short trail running (TR) performance.MethodsA homogeneous group of nine highly trained trail runners performed an official TR race (27 km) and laboratory-based sessions to determine V˙O2max, %V˙O2max at VT, level RE (RE0%) and RE on a +10% slope, maximal voluntary concentric and eccentric knee extension torques, local endurance assessed by a fatigue index (FI), and a time to exhaustion at 87.5% of the velocity associated with V˙O2max. A simple regression method and commonality analysis identifying unique and common coefficients of each independent variable were used to determine the best predictors for the TR race time (dependent variable).ResultsPearson correlations showed that FI and V˙O2max had the highest correlations (r = 0.91 and r = −0.76, respectively) with TR performance. The other selected variables were not significantly correlated with TR performance. The analysis of unique and common coefficients of relative V˙O2max, %V˙O2max at VT, and RE0% provides a low prediction of TR performance (R2 = 0.48). However, adding FI and RE on a +10% slope (instead of RE0%) markedly improved the predictive power of the model (R2 = 0.98). FI and V˙O2max showed the highest unique (49.8% and 20.4% of total effect, respectively) and common (26.9% of total effect) contributions to the regression equation.ConclusionsThe classic endurance running model does not allow for meaningful prediction of short TR performance. Incorporating more specific factors into TR such as local endurance and gradient-specific RE testing procedures should be considered to better characterize short TR performance. Purpose This study aimed to examine the extent to which the classical physiological variables of endurance running performance (maximal oxygen uptake (V˙O2max), %V˙O2max at ventilatory threshold (VT), and running economy (RE)) but also muscle strength factors contribute to short trail running (TR) performance. Methods A homogeneous group of nine highly trained trail runners performed an official TR race (27 km) and laboratory-based sessions to determine V˙O2max, %V˙O2max at VT, level RE (RE0%) and RE on a +10% slope, maximal voluntary concentric and eccentric knee extension torques, local endurance assessed by a fatigue index (FI), and a time to exhaustion at 87.5% of the velocity associated with V˙O2max. A simple regression method and commonality analysis identifying unique and common coefficients of each independent variable were used to determine the best predictors for the TR race time (dependent variable). Results Pearson correlations showed that FI and V˙O2max had the highest correlations (r = 0.91 and r = −0.76, respectively) with TR performance. The other selected variables were not significantly correlated with TR performance. The analysis of unique and common coefficients of relative V˙O2max, %V˙O2max at VT, and RE0% provides a low prediction of TR performance (R2 = 0.48). However, adding FI and RE on a +10% slope (instead of RE0%) markedly improved the predictive power of the model (R2 = 0.98). FI and V˙O2max showed the highest unique (49.8% and 20.4% of total effect, respectively) and common (26.9% of total effect) contributions to the regression equation. Conclusions The classic endurance running model does not allow for meaningful prediction of short TR performance. Incorporating more specific factors into TR such as local endurance and gradient-specific RE testing procedures should be considered to better characterize short TR performance.

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Exercise-induced Protein Arginine Methyltransferase Expression in Skeletal Muscle

imageABSTRACTPurposeThis study aimed to determine protein arginine methyltransferase 1 (PRMT1), -4 (also known as coactivator-associated arginine methyltransferase 1 [CARM1]), and -5 expression and function during acute, exercise-induced skeletal muscle remodeling in vivo.MethodsC57BL/6 mice were assigned to one of three experimental groups: sedentary, acute bout of exercise, or acute exercise followed by 3 h of recovery. Mice in the exercise groups performed a single bout of treadmill running at 15 m·min−1 for 90 min. Hindlimb muscles were collected, and quantitative real-time polymerase chain reaction and Western blotting were used to examine exercise-induced gene expression.ResultsThe PRMT gene expression and global enzyme activity were muscle-specific, generally being higher (P

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Wrist Acceleration Cut Points for Moderate-to-Vigorous Physical Activity in Youth

imageABSTRACTPurposeThis study aimed to examine the validity of wrist acceleration cut points for classifying moderate (MPA), vigorous (VPA), and moderate-to-vigorous (MVPA) physical activity.MethodsFifty-seven children (5–12 yr) completed 15 semistructured activities. Three sets of wrist cut points (>192 mg, >250 mg, and >314 mg), previously developed using Euclidian norm minus one (ENMO192+), GENEActiv software (GENEA250+), and band-pass filter followed by Euclidian norm (BFEN314+), were evaluated against indirect calorimetry. Analyses included classification accuracy, equivalence testing, and Bland–Altman procedures.ResultsAll cut points classified MPA, VPA, and MVPA with substantial accuracy (ENMO192+: κ = 0.72 [95% confidence interval = 0.72–0.73], MVPA: area under the receiver operating characteristic curve (ROC-AUC) = 0.85 [0.85–0.86]; GENEA250+: κ = 0.75 [0.74–0.76], MVPA: ROC-AUC = 0.85 [0.85–0.86]; BFEN314+: κ = 0.73 [0.72–0.74], MVPA: ROC-AUC = 0.86 [0.86–0.87]). BFEN314+ misclassified 19.7% non-MVPA epochs as MPA, whereas ENMO192+ and GENEA250+ misclassified 32.6% and 26.5% of MPA epochs as non-MVPA, respectively. Group estimates of MPA time were equivalent (P 192 mg, >250 mg, and >314 mg), previously developed using Euclidian norm minus one (ENMO192+), GENEActiv software (GENEA250+), and band-pass filter followed by Euclidian norm (BFEN314+), were evaluated against indirect calorimetry. Analyses included classification accuracy, equivalence testing, and Bland–Altman procedures. Results All cut points classified MPA, VPA, and MVPA with substantial accuracy (ENMO192+: κ = 0.72 [95% confidence interval = 0.72–0.73], MVPA: area under the receiver operating characteristic curve (ROC-AUC) = 0.85 [0.85–0.86]; GENEA250+: κ = 0.75 [0.74–0.76], MVPA: ROC-AUC = 0.85 [0.85–0.86]; BFEN314+: κ = 0.73 [0.72–0.74], MVPA: ROC-AUC = 0.86 [0.86–0.87]). BFEN314+ misclassified 19.7% non-MVPA epochs as MPA, whereas ENMO192+ and GENEA250+ misclassified 32.6% and 26.5% of MPA epochs as non-MVPA, respectively. Group estimates of MPA time were equivalent (P

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Associations of Muscle Mass and Strength with All-Cause Mortality among US Older Adults

imageABSTRACTIntroductionRecent studies suggested that muscle mass and muscle strength may independently or synergistically affect aging-related health outcomes in older adults; however, prospective data on mortality in the general population are sparse.MethodsWe aimed to prospectively examine individual and joint associations of low muscle mass and low muscle strength with all-cause mortality in a nationally representative sample. This study included 4449 participants age 50 yr and older from the National Health and Nutrition Examination Survey 1999 to 2002 with public use 2011 linked mortality files. Weighted multivariable logistic regression models were adjusted for age, sex, race, body mass index (BMI), smoking, alcohol use, education, leisure time physical activity, sedentary time, and comorbid diseases.ResultsOverall, the prevalence of low muscle mass was 23.1% defined by appendicular lean mass (ALM) and 17.0% defined by ALM/BMI, and the prevalence of low muscle strength was 19.4%. In the joint analyses, all-cause mortality was significantly higher among individuals with low muscle strength, whether they had low muscle mass (odds ratio [OR], 2.03; 95% confidence interval [CI], 1.27–3.24 for ALM; OR, 2.53; 95% CI, 1.64–3.88 for ALM/BMI) or not (OR, 2.66; 95% CI, 1.53–4.62 for ALM; OR, 2.17; 95% CI, 1.29–3.64 for ALM/BMI). In addition, the significant associations between low muscle strength and all-cause mortality persisted across different levels of metabolic syndrome, sedentary time, and LTPA.ConclusionsLow muscle strength was independently associated with elevated risk of all-cause mortality, regardless of muscle mass, metabolic syndrome, sedentary time, or LTPA among US older adults, indicating the importance of muscle strength in predicting aging-related health outcomes in older adults. Introduction Recent studies suggested that muscle mass and muscle strength may independently or synergistically affect aging-related health outcomes in older adults; however, prospective data on mortality in the general population are sparse. Methods We aimed to prospectively examine individual and joint associations of low muscle mass and low muscle strength with all-cause mortality in a nationally representative sample. This study included 4449 participants age 50 yr and older from the National Health and Nutrition Examination Survey 1999 to 2002 with public use 2011 linked mortality files. Weighted multivariable logistic regression models were adjusted for age, sex, race, body mass index (BMI), smoking, alcohol use, education, leisure time physical activity, sedentary time, and comorbid diseases. Results Overall, the prevalence of low muscle mass was 23.1% defined by appendicular lean mass (ALM) and 17.0% defined by ALM/BMI, and the prevalence of low muscle strength was 19.4%. In the joint analyses, all-cause mortality was significantly higher among individuals with low muscle strength, whether they had low muscle mass (odds ratio [OR], 2.03; 95% confidence interval [CI], 1.27–3.24 for ALM; OR, 2.53; 95% CI, 1.64–3.88 for ALM/BMI) or not (OR, 2.66; 95% CI, 1.53–4.62 for ALM; OR, 2.17; 95% CI, 1.29–3.64 for ALM/BMI). In addition, the significant associations between low muscle strength and all-cause mortality persisted across different levels of metabolic syndrome, sedentary time, and LTPA. Conclusions Low muscle strength was independently associated with elevated risk of all-cause mortality, regardless of muscle mass, metabolic syndrome, sedentary time, or LTPA among US older adults, indicating the importance of muscle strength in predicting aging-related health outcomes in older adults.

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Sports Medicine for the Emergency Physician: A Practical Handbook

No abstract available

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Increased Walking’s Additive and No Substitution Effect on Total Physical Activity

imageABSTRACTPurposeWe assessed the associations between a change in time spent walking and a change in total physical activity (PA) time within an urban living adult sample to test for additive or substitution effects.MethodsParticipants living in the greater Seattle area were assessed in 2008–2009 and again 1–2 yr later (2010–2011). At each time point, they wore accelerometers and GPS units and recorded trips and locations in a travel diary for seven consecutive days. These data streams were combined to derive a more objective estimate of walking and total PA. Participants also completed the International Physical Activity Questionnaire to provide self-reported estimates of walking and total PA. Regression analyses assessed the associations between within-participant changes in objective and self-reported walking and total PA.ResultsData came from 437 participants. On average, a 1-min increase in total walking was associated with an increase in total PA of 1 min, measured by objective data, and 1.2-min, measured by self-reported data. A similar additive effect was consistently found with utilitarian, transportation, or job-related walking, measured by both objective and self-reported data. For recreational walking, the effect of change was mixed between objective and self-reported results.ConclusionBoth objective and self-reported data confirmed an additive effect of utilitarian and total walking on PA. Purpose We assessed the associations between a change in time spent walking and a change in total physical activity (PA) time within an urban living adult sample to test for additive or substitution effects. Methods Participants living in the greater Seattle area were assessed in 2008–2009 and again 1–2 yr later (2010–2011). At each time point, they wore accelerometers and GPS units and recorded trips and locations in a travel diary for seven consecutive days. These data streams were combined to derive a more objective estimate of walking and total PA. Participants also completed the International Physical Activity Questionnaire to provide self-reported estimates of walking and total PA. Regression analyses assessed the associations between within-participant changes in objective and self-reported walking and total PA. Results Data came from 437 participants. On average, a 1-min increase in total walking was associated with an increase in total PA of 1 min, measured by objective data, and 1.2-min, measured by self-reported data. A similar additive effect was consistently found with utilitarian, transportation, or job-related walking, measured by both objective and self-reported data. For recreational walking, the effect of change was mixed between objective and self-reported results. Conclusion Both objective and self-reported data confirmed an additive effect of utilitarian and total walking on PA.

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Ischemic Preconditioning Improves Time Trial Performance at Moderate Altitude

imageABSTRACTPurposeEndurance athletes often compete and train at altitude where exercise capacity is reduced. Investigating acclimation strategies is therefore critical. Ischemic preconditioning (IPC) can improve endurance performance at sea level through improved O2 delivery and utilization, which could also prove beneficial at altitude. However, data are scarce, and there is no study at altitudes commonly visited by endurance athletes.MethodsIn a randomized, crossover study, we investigated performance and physiological responses in 13 male endurance cyclists during four 5-km cycling time trials (TT), preceded by either IPC (3 × 5 min ischemia/5-min reperfusion cycles at 220 mm Hg) or SHAM (20 mm Hg) administered to both thighs, at simulated low (FIO2 0.180, ~1200 m) and moderate (FIO2 0.154, ~2400 m) altitudes. Time to completion, power output, cardiac output (Q˙), arterial O2 saturation (SpO2), quadriceps tissue saturation index (TSI) and RPE were recorded throughout the TT. Differences between IPC and SHAM were analyzed at every altitude using Cohen effect size (ES) and compared with the smallest worthwhile change.ResultsAt low altitude, IPC possibly improved time to complete the TT (−5.2 s, −1.1%; Cohen ES ± 90% confidence limits −0.22, −0.44; 0.01), power output (2.7%; ES 0.21, 0.08; 0.51), and Q˙ (5.0%; ES 0.27, 0.00; 0.54), but did not alter SpO2, muscle TSI, and RPE. At moderate altitude, IPC likely enhanced completion time (−7.3 s; −1.5%; ES −0.38, −0.55; −0.20), and power output in the second half of the TT (4.6%; ES 0.28, −0.15; 0.72), increased SpO2 (1.0%; ES 0.38, −0.05; 0.81), and decreased TSI (−6.5%; ES −0.27, −0.73; 0.20) and RPE (−5.4%, ES −0.27, −0.48; −0.06).ConclusionsIschemic preconditioning may provide an immediate and effective strategy to defend SpO2 and enhance high-intensity endurance performance at moderate altitude. Purpose Endurance athletes often compete and train at altitude where exercise capacity is reduced. Investigating acclimation strategies is therefore critical. Ischemic preconditioning (IPC) can improve endurance performance at sea level through improved O2 delivery and utilization, which could also prove beneficial at altitude. However, data are scarce, and there is no study at altitudes commonly visited by endurance athletes. Methods In a randomized, crossover study, we investigated performance and physiological responses in 13 male endurance cyclists during four 5-km cycling time trials (TT), preceded by either IPC (3 × 5 min ischemia/5-min reperfusion cycles at 220 mm Hg) or SHAM (20 mm Hg) administered to both thighs, at simulated low (FIO2 0.180, ~1200 m) and moderate (FIO2 0.154, ~2400 m) altitudes. Time to completion, power output, cardiac output (Q˙), arterial O2 saturation (SpO2), quadriceps tissue saturation index (TSI) and RPE were recorded throughout the TT. Differences between IPC and SHAM were analyzed at every altitude using Cohen effect size (ES) and compared with the smallest worthwhile change. Results At low altitude, IPC possibly improved time to complete the TT (−5.2 s, −1.1%; Cohen ES ± 90% confidence limits −0.22, −0.44; 0.01), power output (2.7%; ES 0.21, 0.08; 0.51), and Q˙ (5.0%; ES 0.27, 0.00; 0.54), but did not alter SpO2, muscle TSI, and RPE. At moderate altitude, IPC likely enhanced completion time (−7.3 s; −1.5%; ES −0.38, −0.55; −0.20), and power output in the second half of the TT (4.6%; ES 0.28, −0.15; 0.72), increased SpO2 (1.0%; ES 0.38, −0.05; 0.81), and decreased TSI (−6.5%; ES −0.27, −0.73; 0.20) and RPE (−5.4%, ES −0.27, −0.48; −0.06). Conclusions Ischemic preconditioning may provide an immediate and effective strategy to defend SpO2 and enhance high-intensity endurance performance at moderate altitude.

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Effect of Early- and Adult-Life Socioeconomic Circumstances on Physical Inactivity

imageABSTRACTPurposeThis study aimed to investigate the associations between early- and adult-life socioeconomic circumstances and physical inactivity (level and evolution) in aging using large-scale longitudinal data.MethodsThis study used the Survey of Health Ageing and Retirement in Europe, a 10-yr population-based cohort study with repeated measurements in five waves, every 2 yr between 2004 and 2013. Self-reported physical inactivity (waves 1, 2, 4, and 5), household income (waves 1, 2, 4, and 5), educational attainment (wave of the first measurement occasion), and early-life socioeconomic circumstance (wave 3) were collected in 22,846 individuals 50 to 95 yr of age.ResultsRisk of physical inactivity was increased for women with the most disadvantaged early-life socioeconomic circumstances (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.20–1.86). With aging, the risk of physical inactivity increased for both sexes and was strongest for those with the most disadvantaged early-life socioeconomic circumstances (OR, 1.04 (95% CI, 1.02–1.06) for women; OR, 1.02 (95% CI, 1.00–1.05) for men), with the former effect being more robust than the latter one. The association between early-life socioeconomic circumstances and physical inactivity was mediated by adult-life socioeconomic circumstances, with education being the strongest mediator.ConclusionsEarly-life socioeconomic circumstances predicted high levels of physical inactivity at older ages, but this effect was mediated by socioeconomic indicators in adult life. This finding has implications for public health policies, which should continue to promote education to reduce physical inactivity in people at older ages and to ensure optimal healthy aging trajectories, especially among women with disadvantaged early-life socioeconomic circumstances. Purpose This study aimed to investigate the associations between early- and adult-life socioeconomic circumstances and physical inactivity (level and evolution) in aging using large-scale longitudinal data. Methods This study used the Survey of Health Ageing and Retirement in Europe, a 10-yr population-based cohort study with repeated measurements in five waves, every 2 yr between 2004 and 2013. Self-reported physical inactivity (waves 1, 2, 4, and 5), household income (waves 1, 2, 4, and 5), educational attainment (wave of the first measurement occasion), and early-life socioeconomic circumstance (wave 3) were collected in 22,846 individuals 50 to 95 yr of age. Results Risk of physical inactivity was increased for women with the most disadvantaged early-life socioeconomic circumstances (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.20–1.86). With aging, the risk of physical inactivity increased for both sexes and was strongest for those with the most disadvantaged early-life socioeconomic circumstances (OR, 1.04 (95% CI, 1.02–1.06) for women; OR, 1.02 (95% CI, 1.00–1.05) for men), with the former effect being more robust than the latter one. The association between early-life socioeconomic circumstances and physical inactivity was mediated by adult-life socioeconomic circumstances, with education being the strongest mediator. Conclusions Early-life socioeconomic circumstances predicted high levels of physical inactivity at older ages, but this effect was mediated by socioeconomic indicators in adult life. This finding has implications for public health policies, which should continue to promote education to reduce physical inactivity in people at older ages and to ensure optimal healthy aging trajectories, especially among women with disadvantaged early-life socioeconomic circumstances.

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Menstrual Disruption with Exercise Is Not Linked to an Energy Availability Threshold

imageABSTRACTIntroductionChronic reductions in energy availability (EA) suppress reproductive function. A particular calculation of EA quantifies the dietary energy remaining after exercise for all physiological functions. Reductions in luteinizing hormone pulse frequency have been demonstrated when EA using this calculation is

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