Quantification of warm-up patterns in elite showjumping horses over three consecutive days: a descriptive study

There is very little reported information on warm-up practices in showjumping horses. The objective was to quantify warm-up jumping patterns/duration in a competition (field) environment in showjumping horses. Ten mixed-breed elite showjumping horses were assessed at a three-day training session. Riders warmed-up as they would normally for an elite competition and jumped at least one round of a 15-fence (135-145 cm) course on each day. Fence type/height, number of jumping efforts and lead take-off/landing limbs during warm-up were recorded. Rider global-positioning-system and inertial-motion-sensors recorded speed, time spent in each pace/rein plus stride length and stride duration during warm-up and course. Heart rate (HR) was recorded when the horse was resting in its stable and for the duration of the ridden exercise. Appropriate paired statistical tests were used to compare variables between days, and between warm-up and the round(s). Mean warm-up duration, time in each pace and on each rein did not differ within rider between days, however, there were inter-rider differences (mean warm-up duration = 18 min; range = 12-27 min). Number of jumping efforts and fence type/height did not differ between days. During warm-up, there was no preference in canter lead when approaching fences. However, on departure there was a preferred canter lead, plus jump landing and leaving lead limb asymmetry (left canter lead predominating in all cases). Horses cantered slower, with a shorter stride length and a longer stride duration during warm-up compared to when jumping the round (speed – warm-up: 4.21±0.09 m/s; round: 5.53±0.15 m/s; stride length – warm-up: 2.59±0.06 m; round: 3.16±0.08 m; stride duration – warm-up: 0.62±0.02 s; round: 0.58±0.03 s). Mean resting HR significantly decreased on consecutive study days. Mean, peak and final HR during warm-up did not significantly change between days. Results provide novel information on warm-up patterns in a competition (field) environment for elite horses, and suggest that showjumping horses may be warmed-up asymmetrically.

Impact of baseline covariates on the immunogenicity of the 9-valent HPV vaccine - A combined analysis of five phase III clinical trials

BACKGROUND

The immunogenicity profile of the 9-valent HPV (9vHPV) vaccine was evaluated across five phase III clinical studies conducted in girls and boys 9-15 years of age and young women 16-26 years of age. The effect of baseline characteristics of subjects on vaccine-induced HPV antibody responses was assessed.

METHODS

Immunogenicity data from 11,304 subjects who received ≥1 dose of 9vHPV vaccine in five Phase III studies were analyzed. Vaccine was administered as a 3-dose regimen. HPV antibody titers were assessed 1 month after dose 3 using a competitive Luminex immunoassay and summarized as geometric mean titers (GMTs). Covariates examined were age, gender, race, region of residence, and HPV serostatus and PCR status at day 1.

RESULTS

GMTs to all 9 vaccine HPV types decreased with age at vaccination initiation, and were otherwise generally similar among the demographic subgroups defined by gender, race and region of residence. For all subgroups defined by race or region of residence, GMTs were higher in girls and boys than in young women. Vaccination of subjects who were seropositive at day 1 to a vaccine HPV type resulted in higher GMTs to that type, compared with those in subjects who were seronegative for that type at day 1.

CONCLUSIONS

9vHPV vaccine immunogenicity was robust among subjects with differing baseline characteristics. It was generally comparable across subjects of different races and from different regions. Greater immunogenicity in girls and boys versus young women (the population used to establish 9vHPV vaccine efficacy in clinical studies) indicates that the anti-HPV responses generated by the vaccine in adolescents from all races or regions were sufficient to induce high-level protective efficacy. This immunogenicity profile supports a widespread 9vHPV vaccination program and early vaccination.

A cluster randomized trial of strategies to increase uptake amongst young women invited for their first cervical screen: The STRATEGIC trial

Objectives

To measure the feasibility and effectiveness of interventions to increase cervical screening uptake amongst young women.

Methods

A two-phase cluster randomized trial conducted in general practices in the NHS Cervical Screening Programme. In Phase 1, women in practices randomized to intervention due for their first invitation to cervical screening received a pre-invitation leaflet and, separately, access to online booking. In Phase 2, non-attenders at six months were randomized to one of: vaginal self-sample kits sent unrequested or offered; timed appointments; nurse navigator; or the choice between nurse navigator or self-sample kits. Primary outcome was uplift in intervention vs. control practices, at 3 and 12 months post invitation.

Results

Phase 1 randomized 20,879 women. Neither pre-invitation leaflet nor online booking increased screening uptake by three months (18.8% pre-invitation leaflet vs. 19.2% control and 17.8% online booking vs. 17.2% control). Uptake was higher amongst human papillomavirus vaccinees at three months (OR 2.07, 95% CI 1.69–2.53, p < 0.001). Phase 2 randomized 10,126 non-attenders, with 32–34 clusters for each intervention and 100 clusters as controls. Sending self-sample kits increased uptake at 12 months (OR 1.51, 95% CI 1.20–1.91, p = 0.001), as did timed appointments (OR 1.41, 95% CI 1.14–1.74, p = 0.001). The offer of a nurse navigator, a self-sample kits on request, and choice between timed appointments and nurse navigator were ineffective.

Conclusions

Amongst non-attenders, self-sample kits sent and timed appointments achieved an uplift in screening over the short term; longer term impact is less certain. Prior human papillomavirus vaccination was associated with increased screening uptake.

Born a bit too early: A study of early planned birth and child development at school age

ABSTRACT ObjectivesFetal growth and development is a continuum with the optimal time of birth at 39-40 weeks gestation. Internationally, significant changes in clinical practice have seen planned birth (labour induction or pre­labour caesarean section) before 40 completed weeks gestation increase. Fetal brain development accelerates rapidly in the later stages of pregnancy from 32 weeks gestation, making it vulnerable to disruption from even slightly shortened gestation. This study aimed to investigate the association of gestational age and mode of birth with early childhood development. ApproachThis study utilised a population-based record-linkage of administrative birth, hospital and development data to obtain a cohort of 153,730 live born infants in New South Wales, Australia. These infants were born between 2002 and 2007, with a gestational age of at least 32 weeks and had an early development assessment in their first year of school in 2009 or 2012. Childhood development was assessed in five main domains (physical health and wellbeing, language and cognitive skills, social competence, emotional maturity, and communication skills and general knowledge) with each comprised of a number of sub-domains. Children with a score below the 10th percentile nationally are considered developmentally vulnerable (DV) in that domain. Children who were DV for two or more of the five main domains are classified as developmentally high risk (DHR) and this was the primary study outcome. Robust multivariable Poisson models were used to obtain individual and combined relative risks for gestational age and mode of birth with DHR, adjusted for maternal demographic, socio-economic, perinatal, and child characteristics. ResultsOverall, 9.6% of children were DHR. The adjusted relative risk (aRR) (95% confidence interval) of being DHR decreased with increasing gestational age (referent: 40 weeks); 32-33 weeks 1.25 (1.08-1.44), 34­-36 weeks 1.26 (1.18-1.34), 37 weeks 1.17 (1.10-1.25), 38 weeks 1.06 (1.01-­1.10), 39 weeks 0.98 (0.94-1.02), 41+ weeks 0.99 (0.94-­1.03) and for planned birth (referent: vaginal birth following spontaneous labour), 1.07 (1.04­-1.11). The aRR for planned birth at 37 weeks was 1.26 (1.18-­1.34) and at 38 weeks 1.13 (1.08-­1.19). ConclusionEarly (<39 weeks gestation) planned birth is associated with an increased risk of poor development in children starting school. Given the timing of planned birth is modifiable, delaying birth for an additional week or more may improve child development. Strategies and interventions to inform more judicious decision making, weighing all the risks and benefits for early planned birth are required to ensure optimal child health and development.

Record linkage improves assessment of interpregnancy interval (IPI)

ABSTRACTObjectiveTo examine the impact on interpregnancy interval, of linking miscarriage and termination records to birth records.ApproachInterpregnancy interval (IPI) is the time between the end of one pregnancy and conception in a subsequent pregnancy. IPI is one of the few modifiable risk factors for adverse birth outcomes. Information about the effect of IPI is particularly important to women who have suffered a pregnancy loss (miscarriage, termination or perinatal death) and want to conceive again. Accurate measurement of the IPI is important for research into its effect. However, most population-based studies have been limited to the use of birth data, which typically only records births of ≥20 weeks gestation. Record linkage offers the opportunity to identify pregnancies ending <20 weeks. Our study population was all pregnancies ≥20 weeks in New South Wales, Australia in 2012. The birth records were longitudinally linked to all prior birth records and, to all hospitalisations for pregnancy losses <20 weeks gestation. We compared the IPI using birth records alone to the IPI when fetal loss data were included. We also determined the impact on the proportion of women identified with a prior pregnancy loss.ResultsOf 97,991 maternities in 2012 and using birth data alone, 49,650 (50.7%) women had a record of a previous birth with a mean IPI of 2.6 years (standard deviation +/-2.3; median 1.9 years). Linkage to hospital data identified 9,430 (9.6%) women with an early pregnancy loss in the preceding pregnancy, reducing the mean IPI to 2.3+/-2.2 years (median 1.7 years).Incorporating hospital records increased the number of women whose previous pregnancy had resulted in a loss. Using only the birth records, 616 (0.6%) pregnancies had been preceded by a loss. With the expanded records of loss, there were 10,046 (10.3%) women whose pregnancy was preceded by a loss. This subgroup of women had a shorter mean IPI 1.7+/-2.0 years (median 0.8 years). The impact was greater among nulliparous women.ConclusionsInclusion of records of pregnancy loss is important not just for accurate calculation of the IPI, but also for identification of women who have had a prior pregnancy; nulliparous women may have a preceding loss which goes unrecognised. Further, ascertainment of pregnancy losses can make a big difference in the calculated IPI for women whose preceding birth was a loss. This subgroup is one that can potentially benefit the most from accurate research on the effect of IPI.

Autonomic cardiac regulation, blood pressure and cardiorespiratory fitness responses to different training doses over a 12 week group program in the elderly

AIM

The study assessed the effects of different weekly training frequencies performed over a 12 week exercise programme (strength, endurance, balance) on autonomic cardiac activity, blood pressure and cardiorespiratory fitness (CRF) in elderly individuals.

METHODS

Fifty-eight individuals participated in the study: 2TG (N=24, 71.1±6.4 yrs; 19 females, 5 males) performing two, 60min sessions/week; and 3TG (N=34, 72.3±7.9 yrs; 25 females, 9 males) performing three, 60min sessions/week. Time domain and spectral analysis of heart rate variability (HRV) quantified autonomic cardiac regulation.

RESULTS

Natural logarithm (Ln) transformation was applied to all HRV parameters. There were significant reductions in total power (Ln TP) (p=0.006), low frequency (Ln LF) (p=0.013), high frequency (Ln HF) (p=0.013) and root mean square of successive differences (Ln rMSSD) (p=0.014) post training in 3TG after intervention. Diastolic BP (DBP) decreased significantly in both groups (2TG: P<0.001; 3TG: P<0.001). Both groups showed significant improvements in six-minute walk distance (2TG: P=0.003, 3TG: P=0.001). However, there were significant HRV differences between 2TG and 3TG for Ln TP (P=0.018), Ln LF (P=0.049), Ln HF (P=0.039) and Ln rMSSD (P=0.049).

CONCLUSIONS

A combined exercise programme resulted in improved DBP and CRF irrespective of training two or three 60min sessions/week. However, training three, sessions/week induced negative health-related changes in autonomic cardiac activity through reducing HRV parasympathetic function, while HRV was maintained in the group training twice a week.

Fat mass and obesity associated (FTO) gene influences skeletal muscle phenotypes in non-resistance trained males and elite rugby playing position

Background

FTO gene variants have been associated with obesity phenotypes in sedentary and obese populations, but rarely with skeletal muscle and elite athlete phenotypes.

Methods

In 1089 participants, comprising 530 elite rugby athletes and 559 non-athletes, DNA was collected and genotyped for the FTO rs9939609 variant using real-time PCR. In a subgroup of non-resistance trained individuals (NT; n = 120), we also assessed structural and functional skeletal muscle phenotypes using dual energy x-ray absorptiometry, ultrasound and isokinetic dynamometry. In a subgroup of rugby athletes (n = 77), we assessed muscle power during a countermovement jump.

Results

In NT, TT genotype and T allele carriers had greater total body (4.8% and 4.1%) and total appendicular lean mass (LM; 3.0% and 2.1%) compared to AA genotype, with greater arm LM (0.8%) in T allele carriers and leg LM (2.1%) for TT, compared to AA genotype. Furthermore, the T allele was more common (94%) in selected elite rugby union athletes (back three and centre players) who are most reliant on LM rather than total body mass for success, compared to other rugby athletes (82%; P = 0.01, OR = 3.34) and controls (84%; P = 0.03, OR = 2.88). Accordingly, these athletes had greater peak power relative to body mass than other rugby athletes (14%; P = 2 x 10^-6).

Conclusion

Collectively, these results suggest that the T allele is associated with increased LM and elite athletic success. This has implications for athletic populations, as well as conditions characterised by low LM such as sarcopenia and cachexia.

Reduced perfusion in systemic sclerosis digital ulcers (both fingertip and extensor) can be increased by topical application of glyceryl trinitrate

Objectives

In patients with systemic sclerosis (SSc), fingertip digital ulcers (DUs) are believed to be ischaemic, and extensor surface DUs a result of mechanical factors/microtrauma. Our aim was to assess blood flow response to topical glyceryl trinitrate (GTN) compared to placebo in SSc DUs, looking for differences in pathophysiology between fingertip and extensor lesions.

Method

This was a double-blind, randomised, crossover, placebo-controlled study. Sixteen (6 fingertip, 10 extensor) DUs were each studied twice (one day apart): once with GTN and once with placebo ointment. Perfusion at the DU centre (‘DUCore’) and periphery (‘DUPeriphery’), as measured by laser Doppler imaging was performed before and immediately after ointment application, then every 10 min, up to 90 min post-application. We calculated the area under the response curve (AUC) and the ratio of peak perfusion to baseline, then compared these between GTN and placebo.

Results

Perfusion was lower in the DUCore compared to the DUPeriphery (ratio of 0.52). The microvessels of the DUCore were responsive to GTN, with an increase in perfusion, with a similar effect in both fingertip and extensor DUs. The AUC and peak/baseline perfusion difference in means (ratio, 95% confidence interval) between GTN and placebo at the DUCore were 1.2 (1.0–1.6) and 1.2 (1.0–1.5) respectively, and at the DUPeriphery were 1.1 (0.8–1.6) and 1.0 (0.9–1.2) respectively.

Conclusion

DUs (both fingertip and extensor) were responsive to topical GTN, with an increase in perfusion to the ischaemic DU centre. If both fingertip and extensor DUs have a (potentially reversible) ischaemic aetiology, this has important treatment implications.

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SSc fingertip DUs are believed to be ischaemic, whereas, extensor surface DUs are a result of mechanical factors/microtrauma.

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DUs (both fingertip and extensor) were responsive to topical GTN, in particular the ischaemic centre.

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If both fingertip and extensor DUs have a ischaemic aetiology, this has important treatment implications.

Managing complex respiratory patients in the community: an evaluation of a pilot integrated respiratory care service

Introduction

In the UK, there is significant variation in respiratory care and outcomes. An integrated approach to the management of high-risk respiratory patients, incorporating specialist and primary care teams' expertise, is the basis for new integrated respiratory services designed to reduce this variation; however, this model needs evaluating.

Methods

To evaluate an integrated service managing high-risk respiratory patients, electronic searches for patients with asthma and chronic obstructive pulmonary disease at risk of poor outcomes were performed in two general practitioner (GP) practices in a local service-development initiative. Patients were reviewed at joint clinics by primary and secondary care professionals. GPs also nominated patients for inclusion. Reviews were delivered to best standards of care including assessments of diagnosis, control, spirometry, self-management, education, medication, inhaler technique and smoking cessation support. Follow-up of routine clinical data collected at 9-months postclinic were compared with seasonally matched 9-months prior to integrated review.

Results

82 patients were identified, 55 attended. 13 (23.6%) had their primary diagnosis changed. In comparison with the seasonally adjusted baseline period, in the 9-month follow-up there was an increase in inhaled corticosteroid prescriptions of 23.3%, a reduction in short-acting β₂-agonist prescription of 33.3%, a reduction in acute respiratory exacerbations of 67.6%, in unscheduled GP surgery visits of 53.3% and acute respiratory hospital admissions reduced from 3 to 0. Only 4 patients (7.3%) required referral to secondary care. Health economic evaluation showed respiratory-related costs per patient reduced by £231.86.

Conclusions

Patients with respiratory disease in this region at risk of suboptimal outcomes identified proactively and managed by an integrated team improved outcomes without the need for hospital referral.

Patient and provider perspectives on home telecare: Preliminary results from a randomized controlled trial

A randomized controlled trial of home telecare for the management of acute exacerbations of chronic obstructive pulmonary disease has been undertaken in the north-west of England. A videophone was used that communicates via the ordinary telephone network. The intervention period for each participant was two weeks. Participants in the telecare arm of the trial were asked to complete logbooks to record their experiences of each telecare encounter. A simple, self-completed, 10–item questionnaire was used that consisted of a Likert scale, ranging from 1 (totally disagree) to 5 (totally agree). Fourteen nurses completed 150 logbooks and 22 patients completed 145 logbooks. These results demonstrate significant differences in perception between patients and their health-care providers with regard to telecare encounters across all the domains addressed. Participating patients consistently demonstrated more positive views of the telecare encounters than their health-care providers.

Recruitment difficulties in a home telecare trial

We analysed the difficulties encountered in recruiting predominantly older patients, suffering from an acute exacerbation of a chronic illness, to a randomized controlled trial of home telecare. Of 653 patients approached for study participation, after full assessment, 80% (519) met the trial eligibility criteria. Of these, 104 (20%) consented to study participation and 415 (80%) refused. A logistic regression model was constructed to examine independent effects of patient factors on probability of trial participation. Only two independent variables were associated with decreased likelihood of consent: increasing age (1 year older: odds ratio [OR] = 0.96); and being on inhaled steroid medication (OR = 0.60). The most common reason for refusal to participate, accounting for almost one-third of respondents, was a stated preference for a face-to-face nurse visiting service rather than a telecare service. Perhaps home telecare services should continue to be targeted at the more stable chronically ill population and not at those suffering from acute illness.

How much information about antibiotics do people recall after consulting in primary care?

BACKGROUND

Sharing information with patients within a consultation about their infection and value of antibiotics can help reduce antibiotic prescriptions for respiratory tract infections. However, we do not know how often information is given about antibiotics or infections, and if this is related to knowledge and attitudes.

OBJECTIVES

To determine the public's reported use of antibiotics, receipt of information from health professionals about antibiotics and resistance, trust in health professionals and knowledge levels about antibiotics and resistance.

METHODS

Face-to-face computer-assisted survey with 1625 adults over 15 years in randomly selected households using multistage sampling. Rim weighting was used to correct for any selection biases.

RESULTS

About 88% trusted their GP to determine the need for antibiotics. Of those who took antibiotics in the past year, 62% were for a throat infection, 60% for sinus infection and 42% for a cough. Although 67% who had been prescribed an antibiotic recalled being given advice about their infection or antibiotics, only 8% recalled information about antibiotic resistance. Those in lower social grades were less likely to recall advice. About 44% correctly indicated that antibiotics effectively treat bacterial rather than viral infections. Only 45% agreed that 'healthy people can carry antibiotic resistant bacteria'.

CONCLUSION

GPs and health carers are trusted decision-makers, but could share more information with patients about the need or not for antibiotics, self-care and antibiotic resistance, especially with younger patients and those of lower social grade. Better ways are needed for effective sharing of information about antibiotic resistance.

Does the Clinical Context Improve the Reliability of Rheumatologists Grading Digital Ulcers in Systemic Sclerosis?

OBJECTIVE

Digital ulcers (DUs) are often a primary end point in systemic sclerosis (SSc; scleroderma) clinical trials, although the reliability of rheumatologists grading DUs is poor to moderate at best. DU assessment in recent trials has been based upon visual inspection alone, which potentially misses "real-world" clinical contextual information. Our aim was to investigate whether this clinical information improves the reliability of rheumatologists grading DUs. A secondary aim was to assess agreement between patients and rheumatologists.

METHODS

Eighty images of a range of digital lesions were collected from patients with SSc with the clinical context: pain (severity and temporal relationship), lesion duration, and discharge (patient reported and clinician observed). Raters received all images either with or without the clinical context, and graded these images (using a custom-built interface) on an ordinal scale of severity: no ulcer, inactive ulcer, or active ulcer. Patients also graded their lesion(s) on the same scale.

RESULTS

Fifty-one rheumatologists from 15 countries completed the study (26 without and 25 with context): 4,590 (including 510 repeated) image gradings were obtained. Context did not significantly increase (without and with context) either intra- (0.64, 0.71) or interrater (0.32, 0.36) reliability. Pain (visual analog scale and temporal relationship) and discharge (patient reported and clinician observed) were associated with increased lesion severity, and duration with reduced severity. Agreement between individual patients and rheumatologists was poor without and with context (0.19, 0.28).

CONCLUSION

The overall intra- and interrater reliability of DU grading did not significantly improve with the clinical context. Agreement between patients and rheumatologists was poor.

Quality assurance in primary care with information management and technology

The Information Management and Technology (IM&T) Strategy for the UK National Health Service (NHS) is one of systems integration with an emphasis on improved communications and data accessibility using a common operational system. This strategy is examined within the framework of strategic analysis. The suitability of the IM&T strategy, as applied to quality assurance in primary care, is discussed in terms of strategic logic, research evidence and cultural fit. Emerging technologies such as expert systems and the Internet, require further research evidence before considering their suitability for inclusion in an NHS wide strategy.

Expression of the Protein Tyrosine Phosphatase-like Protein IA-2 During Pancreatic Islet Development

A tyrosine phosphatase-like protein, IA-2, is a major autoantigen in Type 1 diabetes but its role in islet function is unclear. Tyrosine phosphorylation mediates regulation of cellular processes such as exocytosis, cell growth, and cell differentiation. To investigate the potential involvement of IA-2 in islet differentiation and insulin secretion, we analyzed by immunohistochemistry expression of IA-2 during islet development in fetal rats and during the maturation of insulin secretory responses after birth. In the fetus, IA-2 immunoreactivity was detected in primitive islets positive for insulin and glucagon at 12 days' gestation. Subsequently, IA-2 was only weakly detectable in the fetal pancreas. In neonatal rat, a progressive increase in IA-2 immunoreactivity was observed in islets from very low levels at 1 day of age to moderate labeling at 10 days. In the adult, relatively high levels of IA-2 were detected in islets, with heterogeneous expression in individual cells within each islet. IA-2 marks a population of endocrine cells that transiently appear early in pancreatic ontogeny. Islet IA-2 expression reappears after birth concomitant with the development of mature insulin secretory responses, consistent with a role for this protein in regulated hormone secretion.

Do stronger school smoking policies make a difference? Analysis of the health behaviour in school-aged children survey

Background: Associations of the strength of school smoking policies with cigarette, e-cigarette and cannabis use in Wales were examined. Methods: Nationally representative cross-sectional survey of pupils aged 11–16 years (N=7376) in Wales. Senior management team members from 67 schools completed questionnaires about school smoking policies, substance use education and tobacco cessation initiatives. Multi-level, logistic regression analyses investigated self-reported cigarette, e-cigarette and cannabis use, for all students and those aged 15–16 years. Results: Prevalence of current smoking, e-cigarette use and cannabis use in the past month were 5.3%, 11.5% and 2.9%, respectively. Of schools that provided details about smoking policies (66/67), 39.4% were strong (written policy applied to everyone in all locations), 43.9% were moderate (written policy not applied to everyone in all locations) and 16.7% had no written policy. There was no evidence of an association of school smoking policies with pupils’ tobacco or e-cigarette use. However, students from schools with a moderate policy [OR = 0.47; 95% (confidence interval) CI: 0.26–0.84] were less likely to have used cannabis in the past month compared to schools with no written policy. This trend was stronger for students aged 15–16 years (moderate policy: OR = 0.42; 95% CI: 0.22–0.80; strong policy: OR = 0.45; 95% CI: 0.23–0.87). Conclusions: School smoking policies may exert less influence on young people’s smoking behaviours than they did during times of higher adolescent smoking prevalence. Longitudinal studies are needed to examine the potential influence of school smoking policies on cannabis use and mechanisms explaining this association.