The effect of age and sex on peak oxygen uptake during upper and lower body exercise: A systematic review

BACKGROUND

Large scale population norms for peak oxygen uptake (VO2peak) during cycle ergometry (CE) have been published for men and women across a wide range of ages. Although upper body functional capacity has an important role in activities of daily living far less is known regarding the effect of age and sex on upper body functional capacity (i.e. arm crank ergometry; ACE). The aim of this review was to determine the effect of age and sex on VO2peak obtained during ACE and CE in the same participants.

METHOD

The review was pre-registered with PROSEPERO (Ref: CRD42022349566). A database search using Academic Search Complete including CINAHL complete, CINHAL Ultimate, Medline, PubMed, SPORTDiscus was undertaken.

RESULTS

The initial search yielded 460 articles which was reduced to 243 articles following removal of duplicates. Twenty-five articles were subsequently excluded based on title resulting in 218 articles considered for retrieval. Following review of the abstracts, 78 further articles were excluded leaving 140 to be assessed for eligibility. Eighty-five articles were subsequently excluded, resulting in 55 articles being included. The decrease in VO2peak with age during CE was consistent with previous studies. Decreases in VO2peak during ACE with age, although paralleling those of CE, appeared to be of greater functional importance. When changes in VO2peak were considered below the age of 50 years little change was observed for absolute VO2peak during ACE and CE. In contrast, relative VO2peak demonstrated decreases in VO2peak for both ACE and CE likely reflecting increases in body mass and body fat percentage with age. After 50 years of age absolute and relative VO2peak demonstrated more similar and subtle responses. Heterogeneity across studies for both absolute and relative VO2peak between ACE and CE was large. Although strict inclusion criteria were applied, the inter-individual variation in sample populations was likely the main source of heterogeneity. There was a considerable lack data sets available for ages above 40 years of age.

CONCLUSIONS

These responses suggest that upper body VO2peak decreases in line with that of the lower body but, due to the lower peak values achieved during ACE, decreases in VO2peak may have more profound functional impact compared to that for the lower body. Using absolute and relative measures of VO2peak results in different age-related profiles when considered below 50 years of age. To further our understanding of whole body ageing more data is required for participants in mid and later life. The association between VO2peak and underlying physiological factors with age needs to be studied further, particularly in conjunction with activities of daily living and independent living.

Association of maternal lipid levels with birth weight and cord blood insulin: a Bayesian network analysis

OBJECTIVE

To assess the independent association of maternal lipid levels with birth weight and cord blood insulin (CBI) level.

SETTING

The Born in Guangzhou Cohort Study, Guangzhou, China.

PARTICIPANTS

Women who delivered between January 2015 and June 2016 and with umbilical cord blood retained were eligible for this study. Those with prepregnancy health conditions, without an available fasting blood sample in the second trimester, or without demographic and glycaemic information were excluded. After random selection, data from 1522 mother-child pairs were used in this study.

EXPOSURES AND OUTCOME MEASURES

Additive Bayesian network analysis was used to investigate the interdependency of lipid profiles with other metabolic risk factors (prepregnancy body mass index (BMI), fasting glucose and early gestational weight gain) in association with birth weight and CBI, along with multivariable linear regression models.

RESULTS

In multivariable linear regressions, maternal triglyceride was associated with increased birth weight (adjusted β=67.46, 95% CI 41.85 to 93.06 g per mmol/L) and CBI (adjusted β=0.89, 95% CI 0.06 to 1.72 μU/mL per mmol/L increase), while high-density lipoprotein cholesterol was associated with decreased birth weight (adjusted β=-45.29, 95% CI -85.49 to -5.09 g per mmol/L). After considering the interdependency of maternal metabolic risk factors in the Network analysis, none of the maternal lipid profiles was independently associated with birth weight and CBI. Instead, prepregnancy BMI was the global strongest factor for birth weight and CBI directly and indirectly.

CONCLUSIONS

Gestational dyslipidaemia appears to be secondary to metabolic dysfunction with no clear association with metabolic adverse outcomes in neonates. Maternal prepregnancy overweight/obesity appears the most influential upstream metabolic risk factor for both maternal and neonatal metabolic health; these data imply weight management may need to be addressed from the preconception period and during early pregnancy.

Machine learning of COVID-19 clinical data identifies population structures with therapeutic potential

Clinical outcomes for patients with COVID-19 are heterogeneous and there is interest in defining subgroups for prognostic modeling and development of treatment algorithms. We obtained 28 demographic and laboratory variables in patients admitted to hospital with COVID-19. These comprised a training cohort (n = 6099) and two validation cohorts during the first and second waves of the pandemic (n = 996; n = 1011). Uniform manifold approximation and projection (UMAP) dimension reduction and Gaussian mixture model (GMM) analysis was used to define patient clusters. 29 clusters were defined in the training cohort and associated with markedly different mortality rates, which were predictive within confirmation datasets. Deconvolution of clinical features within clusters identified unexpected relationships between variables. Integration of large datasets using UMAP-assisted clustering can therefore identify patient subgroups with prognostic information and uncovers unexpected interactions between clinical variables. This application of machine learning represents a powerful approach for delineating disease pathogenesis and potential therapeutic interventions.

Chromosomal polymorphisms in assisted reproduction: an analysis of 942 cycles

The use of intracytoplasmic sperm injection (ICSI) has recently increased worldwide. The live birth rate per ICSI cycle is low, and over half of infertile couples remain childless. Chromosomal polymorphisms are up to five times more common in couples with infertility compared to the general population. We aimed to investigate the association between chromosomal polymorphisms and reproductive outcomes in couples undergoing ICSI treatment. We analysed 942 ICSI fresh and frozen embryo transfer cycles in 697 women who underwent karyotyping analysis using Giemsa-Trypsin-Leishman banding prior to assisted conception at the Fertility Centre of Lanka Hospitals, Sri Lanka, between 2016 and 2018. The primary outcomes were pregnancy, miscarriage, and live birth rates. We compared outcomes according to the presence or absence of chromosomal polymorphism in females, males and couples. There were 294 pregnancies (31.2%) recorded in the study; 130 suffered a miscarriage (13.8%), 13 were ectopic pregnancies (1.3%) and 151 resulted in a live birth (16.0%). The evidence from univariable and multivariable analyses (adjusted for age, BMI, ovarian reserve and treatment type) did not confidently identify a difference in pregnancy, miscarriage or live birth rates between couples with no chromosomal polymorphisms compared to couples where the female, male or both partners were carriers of a chromosomal polymorphism. Further, we did not identify a clear association between the presence of chromosomal polymorphisms and reproductive outcomes compared to participants without chromosomal polymorphisms. Wide CIs precluded the identification of clinically meaningful associations.

O-009 Controlled ovarian stimulation (COS) protocols for assisted reproduction: a Cochrane systematic review and network meta-analysis

Study question

What is the relative effectiveness and safety of existing COS protocols for women undergoing assisted reproductive technology (ART) treatment?

Summary answer

There was no difference in live birth between all protocols, but short antagonist protocols may reduce ovarian hyperstimulation syndrome in women with predicted normal/high response.

What is known already

Controlled ovarian stimulation is an essential step in most ART cycles. It involves the administration of exogenous gonadotrophins to induce multifollicular growth, usually in addition to drugs that prevent untimely ovulation by suppressing the pituitary gland. Different treatment combinations may be used in COS. These vary according to the type of drugs administered for pituitary suppression (e.g., gonadotrophin-releasing hormone [GnRH] agonists, antagonists) and ovarian stimulation (e.g., urinary or recombinant gonadotrophins). Drug dosages, timing and routes of administration also vary between different regimens. However, there is no consensus on how the existing COS protocols rank according to their effectiveness and safety.

Study design, size, duration

We searched the following databases to November 2021: MEDLINE, EMBASE, CINAHL, CENTRAL and ClinicalTrials.gov. We included randomised controlled trials (RCTs) comparing at least two COS protocols using GnRH agonists or antagonists for pituitary suppression; and human menopausal gonadotrophin (hMG), urinary or recombinant follicle-stimulating hormone (u/rFSH), with or without luteinising hormone (LH) for ovarian stimulation. The primary outcomes were the rates of live birth (LBR) and ovarian hyperstimulation syndrome (OHSS) per participant after one stimulation cycle.

Participants/materials, setting, methods

Two reviewers independently selected studies and extracted data. We conducted pairwise and network meta-analyses (NMA) according to participants’ predicted response to COS (normal, high and low). Using the Cochrane-RoB-1 tool, we restricted our primary analyses to RCTs at low risk of selection and other biases. We presented effect estimates as risk ratio (RR) with 95% confidence interval (CI) and considered I2>50% as representing substantial heterogeneity. For each outcome, we generated ranking plots comparing different interventions.

Main results and the role of chance

In total, our searches identified 9464 studies. The primary analysis included 68 RCTs assessing 17861 women and 34 different COS protocols. The evidence showed that in women with predicted normal or high response, the use of short GnRH antagonist protocols may result in little to no difference in LBR (RR 0.98, 95% CI 0.85 to 1.13; 6 studies; 2063 women; I2 = 0%; low-certainty evidence) and a reduction in OHSS (RR 0.88, 95% CI 0.78 to 0.99; 7 studies; 2246 women; I2 = 0%; low-certainty evidence) compared with long GnRH agonist protocols. The rankogram comparing different COS protocols showed a probability of 98% that short GnRH antagonist regimens are the best treatment to prevent OHSS. Sensitivity analyses including all studies showed that in women with predicted normal response undergoing long GnRH agonist cycles for pituitary suppression, the use of rFSH for ovarian stimulation may result in decreased fresh-cycle LBR compared to hMG (RR 0.80, 95% CI 0.68 to 0.95; 7 studies; 1575 women; I2 = 1%; low-certainty evidence). For the remaining interventions (e.g., agonist flare or progestogens for pituitary suppression, in combination with various gonadotrophin regimens) the evidence was uncertain of an effect or insufficient for quantitative synthesis.

Limitations, reasons for caution

The high number of interventions resulted in disconnected networks, limiting our ability to perform NMA for some comparisons. The certainty of the evidence was limited by serious risk of bias. Finally, the lack of data on cumulative LBR and differences in oocyte yield made comparisons between FSH preparations potentially unbalanced.

Wider implications of the findings

Our findings suggest that the use of short GnRH antagonist protocols may result in reduced OHSS rates in women with predicted normal or high ovarian response without compromising live birth rates. There is a paucity of high-quality RCTs comparing different gonadotrophin preparations (e.g., hMG versus rFSH) for COS.

Trial registration number

N/A

Development and external validation of prognostic models for COVID-19 to support risk stratification in secondary care

OBJECTIVES

Existing UK prognostic models for patients admitted to the hospital with COVID-19 are limited by reliance on comorbidities, which are under-recorded in secondary care, and lack of imaging data among the candidate predictors. Our aims were to develop and externally validate novel prognostic models for adverse outcomes (death and intensive therapy unit (ITU) admission) in UK secondary care and externally validate the existing 4C score.

DESIGN

Candidate predictors included demographic variables, symptoms, physiological measures, imaging and laboratory tests. Final models used logistic regression with stepwise selection.

SETTING

Model development was performed in data from University Hospitals Birmingham (UHB). External validation was performed in the CovidCollab dataset.

PARTICIPANTS

Patients with COVID-19 admitted to UHB January-August 2020 were included.

MAIN OUTCOME MEASURES

Death and ITU admission within 28 days of admission.

RESULTS

1040 patients with COVID-19 were included in the derivation cohort; 288 (28%) died and 183 (18%) were admitted to ITU within 28 days of admission. Area under the receiver operating characteristic curve (AUROC) for mortality was 0.791 (95% CI 0.761 to 0.822) in UHB and 0.767 (95% CI 0.754 to 0.780) in CovidCollab; AUROC for ITU admission was 0.906 (95% CI 0.883 to 0.929) in UHB and 0.811 (95% CI 0.795 to 0.828) in CovidCollab. Models showed good calibration. Addition of comorbidities to candidate predictors did not improve model performance. AUROC for the International Severe Acute Respiratory and Emerging Infection Consortium 4C score in the UHB dataset was 0.753 (95% CI 0.720 to 0.785).

CONCLUSIONS

The novel prognostic models showed good discrimination and calibration in derivation and external validation datasets, and performed at least as well as the existing 4C score using only routinely collected patient information. The models can be integrated into electronic medical records systems to calculate each individual patient's probability of death or ITU admission at the time of hospital admission. Implementation of the models and clinical utility should be evaluated.

Disease burden of diabetes, diabetic retinopathy and their future projections in the UK: cross-sectional analyses of a primary care database

OBJECTIVES

To estimate the current disease burden, trends and future projections for diabetes mellitus (DM) and diabetic retinopathy (DR) in the IQVIA Medical Research Data (IMRD).

PARTICIPANTS/DESIGN/SETTING

We performed a cross-sectional study of patients aged 12 and above to determine the prevalence of DM and DR from the IMRD database (primary care database) in January 2017, involving a total population of 1 80 824 patients with DM. We also carried out a series of cross-sectional studies to investigate prevalence trends, and then applied a double exponential smoothing model to forecast the future burden of DM and DR in the UK.

RESULTS

The crude DM prevalence in 2017 was 5.2%. The DR, sight-threatening retinopathy (STR) and diabetic maculopathy prevalence figures in 2017 were 33.78%, 12.28% and 7.86%, respectively, in our IMRD cross-sectional study. There were upward trends in the prevalence of DM, DR and STR, most marked and accelerating in STR in type 1 DM but slowing in type 2 DM, and in the overall prevalence of DR.

CONCLUSION

Our results suggest differential rising trends in the prevalence of DM and DR. Preventive strategies, as well as treatment services planning, can be based on these projected prevalence estimates. Improvements that are necessary for the optimisation of care pathways, and preparations to meet demand and capacity challenges, can also be based on this information. The limitations of the study can be overcome by a future collaborative study linking DR screening and hospital eye services data.

Information given by websites selling home self-sampling COVID-19 tests: an analysis of accuracy and completeness

OBJECTIVES

To assess the accuracy and completeness of information provided by websites selling home self-sampling and testing kits for COVID-19.

DESIGN

Cross-sectional observational study.

SETTING

All websites (n=27) selling direct to user home self-sampling and testing kits for COVID-19 (41 tests) in the UK (39 tests) and USA (two tests) identified by a website search on 23 May 2020.

MAIN OUTCOME MEASURES

Thirteen predefined basic information items to communicate to a user, including who should be tested, when and how testing should be done, test accuracy, and interpretation of results.

RESULTS

Many websites did not provide the name or manufacturer of the test (32/41; 78%), when to use the test (10/41; 24%), test accuracy (12/41; 29%), and how to interpret results (21/41; 51%). Sensitivity and specificity were the most commonly reported test accuracy measures (either reported for 27/41 [66%] tests): we could only link these figures to manufacturers' documents or publications for four (10%) tests. Predictive values, most relevant to users, were rarely reported (five [12%] tests reported positive predictive values). For molecular virus tests, 9/23 (39%) websites explained that test positives should self-isolate, and 8/23 (35%) explained that test negatives may still have the disease. For antibody tests, 12/18 (67%) websites explained that testing positive does not necessarily infer immunity from future infection. Seven (39%) websites selling antibody tests claimed the test had a CE mark, when they were for a different intended use (venous blood rather than finger-prick samples).

CONCLUSIONS

At the point of online purchase of home self-sampling COVID-19 tests, users in the UK are provided with incomplete, and, in some cases, misleading information on test accuracy, intended use, and test interpretation. Best practice guidance for communication about tests to the public should be developed and enforced for online sales of COVID-19 tests.

Predictors for diabetic retinopathy progression-findings from nominal group technique and Evidence review

Objectives

Risk stratification is needed for patients referred to hospital eye services by Diabetic Eye Screening Programme UK. This requires a set of candidate predictors. The literature contains a large number of predictors. The objective of this research was to arrive at a small set of clinically important predictors for the outcome of the progression of diabetic retinopathy (DR). They need to be evidence based and readily available during the clinical consultation.

Methods and analysis

Initial list of predictors was obtained from a systematic review of prediction models. We sought the clinical expert opinion using a formal qualitative study design. A series of nominal group technique meetings to shorten the list and to rank the predictors for importance by voting were held with National Health Service hospital-based clinicians involved in caring for patients with DR in the UK. We then evaluated the evidence base for the selected predictors by critically appraising the evidence.

Results

The source list was presented at nominal group meetings (n=4), attended by 44 clinicians. Twenty-five predictors from the original list were ranked as important predictors and eight new predictors were proposed. Two additional predictors were retained after evidence check. Of these 35, 21 had robust supporting evidence in the literature condensed into a set of 19 predictors by categorising DR.

Conclusion

We identified a set of 19 clinically meaningful predictors of DR progression that can help stratify higher-risk patients referred to hospital eye services and should be considered in the development of an individual risk stratification model.

Study design

A qualitative study and evidence review.

Setting

Secondary eye care centres in North East, Midlands and South of England.

Effect of age on the relative efficacy of clozapine in schizophrenia

OBJECTIVE

Early treatment of schizophrenia improves outcomes. Clozapine appears to have unique benefit when other antipsychotic medication has failed. This systematic review and meta-analysis aims to assess clozapine's superiority over alternative antipsychotic medication and examine whether earlier use is associated with additional benefit.

METHOD

Systematic retrieval of blinded, randomized controlled trials comparing clozapine with alternative antipsychotics in adults with schizophrenia. The effect of mean age on relative clozapine response was examined using random effects meta-regression, and multiple linear regression on available patient data.

RESULTS

A total of 276 studies were retrieved. Thirty-four studies were included in the meta-analysis. Clozapine was significantly more effective than alternative antipsychotics in reducing psychotic symptoms and increasing response. However, meta-regression failed to show a more significant effect in younger patients (age on effect size (total psychotic symptoms) 0.00, P = 0.79 CI -0.03 to 0.03). Individual patient data were available for two studies, the larger of which showed a significant interaction between younger age and superiority of clozapine.

CONCLUSION

The results support clozapine's superiority over other antipsychotics. A convincing effect of age on this effect was not demonstrated, although this was suggested in one study. In view of the age of many of the included studies, and changes in reporting practice over time, new clozapine RCTs, which include age of illness onset as well as age at trial time, would be welcome in order to provide meta-analysable data for future use.

Glucose, Insulin, and Lipids in Cord Blood of Neonates and Their Association with Birthweight: Differential Metabolic Risk of Large for Gestational Age and Small for Gestational Age Babies

OBJECTIVES

To investigate the association of birthweight percentile with cord blood glucose, lipids, and insulin levels.

STUDY DESIGN

Data obtained from 1522 newborns were included in the Born in Guangzhou Cohort study. The generalized additive model and multivariable linear regression model were used to explore the nonlinear and linear relationships between birthweight and cord blood metabolic measures, and to evaluate the differences of metabolic measures Z-scores among small for gestational age, appropriate for gestational age, and large for gestational age babies.

RESULTS

Birthweight Z-score was linearly associated with increased cord blood insulin Z-score (adjusted β = 0.30; 95% CI, 0.22-0.37). Compared with appropriate for gestational age babies, neonates born small for gestational age had significantly higher cord blood triglycerides Z-score (adjusted mean difference [MD_adj], 0.60; 95% CI, 0.40-0.79) and lower cord blood insulin (MD_adj, -0.37; 95% CI, -0.57 to -0.16), high-density lipoprotein cholesterol (MD_adj, -0.34; 95% CI, -0.55 to -0.13), total cholesterol (MD_adj, -0.26; 95% CI, -0.47 to -0.05), and low-density lipoprotein (MD_adj, -0.23; 95% CI, -0.43 to -0.02) Z-scores, and neonates born large for gestational age had higher cord blood insulin Z-score (MD_adj, 0.31; 95% CI, 0.09 to 0.52).

CONCLUSIONS

Our findings support the hypothesis that babies born small for gestational age and large for gestational age are exposed to different intrauterine environments, which may contribute to altered fat accumulation patterns with implications for the risk of metabolic dysfunction later in life. There is a need to consider the development of tailored intervention strategies to prevent metabolic dysfunction in adult life for these babies.

How do pharmacy students select their pre-registration training providers? A mixed methods evaluation of the national recruitment scheme in England and Wales

Objectives

A national pre-registration pharmacist recruitment scheme, which replaces the local recruitment models, was introduced in England and Wales in 2017. This study aimed to explore pharmacy students' behaviour and associated factors in their selection of pre-registration training programmes.

Methods

A mixed-method study using (a) analysis of data from all applicants (n = 2694) of the national recruitment scheme, (b) an online survey and (c) a virtual focus group was undertaken. Survey and focus group questions were developed based on the Theoretical Domains Framework (TDF). Descriptive and inferential analysis of quantitative data was undertaken using Stata software. Qualitative data from focus groups and responses from the open-ended questions were analysed using framework technique.

Key findings

A vast majority of applicants (n = 2182, 83.9%) selected a hospital training programme as their first ranked preference, with the rest opting for community pharmacy. Urban areas, particularly London, were most popular geographically. A total of 307 survey responses were returned. Long-term career aspirations, followed by geographical factors, were rated most highly in applicants' decision-making. Qualitative data from survey and focus group demonstrated information about programmes/employers, perceived opportunity for skills development and aspiration towards a career path as key contributory factors in their decision-making.

Conclusions

Secondary care was the most desirable destination for pharmacy students to undertake early career training. The clinical roles and career opportunities in community pharmacy needs to be promoted as there is a risk that community pharmacy training programme places may be seen as a ‘left over’ opportunity for less competitive candidates to uptake.

National recruitment scheme for pre-registration pharmacist training in England and Wales: a mixed method evaluation of experiences of applicant pharmacy students

BACKGROUND

A national pre-registration pharmacist training recruitment scheme, which replaces local recruitment models, was introduced in England and Wales in 2017. The national recruitment system allows pharmacy students to apply for the 52 weeks training programmes (mandatory requirement for registration as a pharmacist), through a single application system prior to undertaking a nationally administered assessment. This study aimed to explore experiences of pharmacy students on the national recruitment scheme, particularly their views on the selection methodology, application process, and offer outcomes.

METHODS

This mixed method study involved a) an online survey of all (approximate n = 2800) year 4 (final year of MPharm degree) pharmacy students in England and Wales and b) a qualitative focus group with four students. The study population was eligible to participate in the 2017/18 national recruitment scheme. Survey respondents were invited to participate in a focus group. Quantitative data were analysed using descriptive and inferential analysis. Qualitative data were analysed using the framework technique. Participation was voluntary. Ethical approval from University of Birmingham was obtained.

RESULTS

A total of 307 completed surveys were returned (approximate response rate 11%). Respondents were generally satisfied with the application process and commended the fairness of the selection methodology and convenience in allowing them to apply to multiple training providers. Most survey respondents (n = 181, 72.9%) were either satisfied or highly satisfied with the training programme they were offered based on their assessment performances. Three themes and eight sub-themes obtained from the analysis of over 200 open comments data from the survey and transcript of a focus group with four participants. Results suggested the need to widen the timeframe available for applicants to shortlist their preferred employers, improve the method of programme listing in the application system, and consideration of prior achievements including academic performances and placement experiences to be included in the selection methodology.

CONCLUSIONS

Experiences of pharmacy students on the national recruitment scheme suggest that respondents considered the selection methodology to be fair. Student engagement and satisfaction with the recruitment system can be maximised through improved listing of employers and widening the timescales for students to shortlist their preferred employers during application process. Inclusion of University achievements in the selection methodology will require consideration of evidence based approaches. Low response rate limits generalisation of findings.

Impact of glycaemic control on fracture risk in 5368 people with newly diagnosed Type 1 diabetes: a time-dependent analysis

AIMS

To assess whether glycaemic control is associated with a lifelong increased risk of fracture in people with newly diagnosed Type 1 diabetes.

METHODS

People with newly diagnosed Type 1 diabetes between 1 January 1995 and 10 May 2016 were identified in The Health Improvement Network database. Longitudinal HbA_1c measurements from diagnosis to fracture or study end or loss to follow-up were collected. A Cox proportional hazards model with HbA_1c included as a time-dependent variable was fitted to these data.

RESULTS

Some 5368 people with newly diagnosed Type 1 diabetes were included. The estimated adjusted hazard ratio (aHR) for HbA_1c was statistically significant [aHR 1.007; 95% confidence interval (CI) 1.002-1.011 (mmol/mol) and aHR 1.07; 95% CI 1.03-1.12 (%)]. An incremental higher risk of fracture was observed with increasing levels of HbA_1c .

CONCLUSIONS

In people with newly diagnosed Type 1 diabetes, higher HbA_1c is associated with an increased risk for fractures.

Prevalence of hyperplasia and cancer in endometrial polyps in women with postmenopausal bleeding: A systematic review and meta-analysis

There is wide variation in reporting the prevalence of hyperplasia and cancer in endometrial polyps in women with postmenopausal bleeding. Most studies reported heterogenous populations of pre- and postmenopausal women both symptomatic and asymptomatic, making data interpretation difficult. The aim of this work is to quantify the prevalence of hyperplasia and cancer in polyps in women with postmenopausal bleeding aiming to produce data that help inform clinical practice as whether it is safer to remove all polyps, or some women could be offered expectant management. The search terms used were Medical Subject Headings terms, text words, truncations and word variations of the words or phrases ‘endometrial polyp’ or ‘uterine polyp’ or ‘womb polyp’ and ‘postmenopause’ or ‘menopause’. Search was limited to human studies and English language articles. Studies reporting separate analysis for women with postmenopausal bleeding were included. The included articles were assessed for risk of bias using the ‘Quality in Prognosis Studies’ tool. The prevalence was estimated with a random effect model using ‘DerSimonian and Laird’ method. The pooled estimate of prevalence of hyperplasia and cancer was 9% (95% confidence interval: 6.5%–11.5%). An I2 statistic of 77.2% suggests likely substantial heterogeneity. However, adjustment for small study effects had no influence on the pooled prevalence estimate suggesting no evidence for publication bias. Sensitivity analyses showed that no study exerted a big influence on the pooled estimate. The prevalence of hyperplasia and cancer in endometrial polyps in women with postmenopausal bleeding is high enough to warrant removal for accurate histopathological diagnosis.

Prognostic prediction models for diabetic retinopathy progression: a systematic review

With the increasing incidence of diabetic retinopathy and its improved detection, there is increased demand for diabetic retinopathy treatment services. Prognostic prediction models have been used to optimise services but these were intended for early detection of sight-threatening retinopathy and are mostly used in diabetic retinopathy screening services. We wanted to look into the predictive ability and applicability of the existing models for the higher-risk patients referred into hospitals. We searched MEDLINE, EMBASE, COCHRANE CENTRAL, conference abstracts and reference lists of included publications for studies of any design using search terms related to diabetes, diabetic retinopathy and prognostic models. Search results were screened for relevance to the review question. Included studies had data extracted on model characteristics, predictive ability and validation. They were assessed for quality using criteria specified by PROBAST and CHARMS checklists, independently by two reviewers. Twenty-two articles reporting on 14 prognostic models (including four updates) met the selection criteria. Eleven models had internal validation, eight had external validation and one had neither. Discriminative ability with c-statistics ranged from 0.57 to 0.91. Studies ranged from low to high risk of bias, mostly due to the need for external validation or missing data. Participants, outcomes, predictors handling and modelling methods varied. Most models focussed on lower-risk patients, the majority had high risk of bias and doubtful applicability, but three models had some applicability for higher-risk patients. However, these models will also need updating and external validation in multiple hospital settings before being implemented into clinical practice.

Gestational dyslipidaemia and adverse birthweight outcomes: a systematic review and meta-analysis

BACKGROUND

Low and high birthweight is known to increase the risk of acute and longer-term adverse outcomes, such as stillbirth, infant mortality, obesity, type 2 diabetes and cardiovascular diseases. Gestational dyslipidaemia is associated with a numbers of adverse birth outcomes, but evidence regarding birthweight is still inconsistent to reliably inform clinical practice and treatment recommendations.

OBJECTIVE

The aim of this study was to explore the relationship between maternal gestational dyslipidaemia and neonatal health outcomes, namely, birthweight, metabolic factors and inflammatory parameters.

METHODS

We searched systematically Embase, MEDLINE, PubMed, CINAHL Plus and Cochrane Library up to 1 August 2016 (with an updated search in MEDLINE at the end of July 2017) for longitudinal studies that assessed the association of maternal lipid levels during pregnancy with neonatal birthweight, or metabolic and inflammatory parameters up to 3 years old.

RESULTS

Data from 46 publications including 31,402 pregnancies suggest that maternal high triglycerides and low high-density-lipoprotein cholesterol levels throughout pregnancy are associated with increased birthweight, higher risk of large for gestational age and macrosomia and lower risk of small-for-gestational age. The findings were consistent across the studied populations, but stronger associations were observed in women who were overweight or obese prior to pregnancy.

CONCLUSIONS

This meta-analysis suggested that the potential under-recognized adverse effects of intrauterine exposure to maternal dyslipidaemia may warrant further investigation into the relationship between maternal dyslipidaemia and birthweight in large prospective cohorts or in randomized trials.

A systematic review of epigenetic biomarkers in progression from non-dysplastic Barrett's oesophagus to oesophageal adenocarcinoma

OBJECTIVES

The objective of this systematic review is to identify and summarise studies which examine epigenetic biomarkers in patients with Barrett's oesophagus (BO) and their association with progression to oesophageal adenocarcinoma (OADC). BO is a precursor lesion for OADC. There is no clinical test to predict patients who are likely to progress to OADC. An epigenetic biomarker could predict patients who are at high risk of progression from BO to OADC which could facilitate earlier diagnosis and spare those unlikely to develop cancer from regular invasive surveillance endoscopy.

SETTING

A systematic search was conducted of the following databases: MEDLINE, MEDLINE in Process, EMBASE, Cochrane Central, ISI Conference Proceedings Citation Index and the British Library's ZETOC. Studies were conducted in secondary and tertiary care settings.

PARTICIPANTS

All studies measuring epigenetic change in patients over 18 years old who progressed from non-dysplastic BO to OADC were included. Genetic, in vitro and studies which did not measure progression in the same patient cohort were excluded. Study inclusion and risk of bias of individual eligible studies were assessed in duplicate by two reviewers using a modified Quality in Prognostic Studies tool.

RESULTS

14 studies met the inclusion criteria. 42 epigenetic markers were identified, and 5 studies developed models aiming to predict progression to OADC.

CONCLUSIONS

The evidence from this systematic review is suggestive of a role for p16 as an epigenetic biomarker for the progression of BO to OADC.

PROSPERO NUMBER

CRD42016038654.

Effects of external loads on postural sway during quiet stance in adults aged 20-80 years

The purpose of this study was to investigate the effects of holding external loads on postural sway during upright stance across age decades. Sixty-five healthy adults (females, n = 35), aged 18-80 years were assessed in four conditions; (1) standing without holding a load, holding a load corresponding to 5% body mass in the (2) left hand, (3) right hand and (4) both hands. The centre of pressure (COP) path length and anteroposterior and mediolateral COP displacement were used to indirectly assess postural sway. External loading elicited reductions in COP measures of postural sway in older age groups only (P < 0.05). No changes were observed in younger or intermediate aged adults (P > 0.05). Holding external loads during standing is relevant to many activities of daily living (i.e. holding groceries). The reduction in postural sway may suggest this type of loading has a stabilising effect during quiet standing among older adults.

Proportion of Tubal Factor Infertility due to Chlamydia: Finite Mixture Modeling of Serum Antibody Titers

In this study, we examined whether the proportion of tubal factor infertility (TFI) that is attributable to Chlamydia trachomatis, the population excess fraction (PEF), can be estimated from serological data using finite mixture modeling. Whole-cell inclusion immunofluorescence serum antibody titers were recorded among infertile women seen at St. Michael's Hospital in Bristol, United Kingdom, during the period 1985-1995. Women were classified as TFI cases or controls based on laparoscopic examination. Finite mixture models were used to identify the number of component titer distributions and the proportion of serum samples in each, from which estimates of PEF were derived. Four titer distributions were identified. The component at the highest titer was found only in samples from women with TFI, but there was also an excess of the second-highest titer component in TFI cases. Minimum and maximum estimates of the PEF were 28.0% (95% credible interval: 6.9, 50.0) and 46.8% (95% credible interval: 23.2, 64.1). Equivalent estimates based on the standard PEF formula from case-control studies were 0% and over 65%. Finite mixture modeling can be applied to serological data to obtain estimates of the proportion of reproductive damage attributable to C. trachomatis Further studies using modern assays in contemporary, representative populations should be undertaken.

The effects of arm crank ergometry, cycle ergometry and treadmill walking on postural sway in healthy older females

Older adults are increasingly being encouraged to exercise but this may lead to muscle fatigue, which can adversely affect postural stability. Few studies have investigated the effects of upper body exercise on postural sway in groups at risk of falling, such as the elderly. The purpose of this study was to compare the effects arm crank ergometry (ACE), cycle ergometry (CE) and treadmill walking (TM) on postural sway in healthy older females. In addition, this study sought to determine the time necessary to recover postural control after exercise. A total of nine healthy older females participated in this study. Participants stood on a force platform to assess postural sway which was measured by displacement of the centre of pressure before and after six separate exercise trials. Each participant completed three incremental exercise tests to 85% of individual's theoretical maximal heart rate (HRMAX) for ACE, CE and TM. Subsequent tests involved 20-min of ACE, CE and TM exercise at a relative workload corresponding to 50% of each individual's predetermined heart rate reserve (HRE). Post fatigue effects and postural control recovery were measured at different times after exercise (1, 3, 5, 10, 15 and 30-min). None of the participants exhibited impaired postural stability after ACE. In contrast, CE and TM elicited significant post exercise balance impairments, which lasted for ∼ 10 min post exercise. We provide evidence of an exercise mode which does not elicit post exercise balance impairments. Older adults should exercise caution immediately following exercise engaging the lower limbs to avoid fall risk.

Multivariate meta-analysis using individual participant data

When combining results across related studies, a multivariate meta-analysis allows the joint synthesis of correlated effect estimates from multiple outcomes. Joint synthesis can improve efficiency over separate univariate syntheses, may reduce selective outcome reporting biases, and enables joint inferences across the outcomes. A common issue is that within-study correlations needed to fit the multivariate model are unknown from published reports. However, provision of individual participant data (IPD) allows them to be calculated directly. Here, we illustrate how to use IPD to estimate within-study correlations, using a joint linear regression for multiple continuous outcomes and bootstrapping methods for binary, survival and mixed outcomes. In a meta-analysis of 10 hypertension trials, we then show how these methods enable multivariate meta-analysis to address novel clinical questions about continuous, survival and binary outcomes; treatment–covariate interactions; adjusted risk/prognostic factor effects; longitudinal data; prognostic and multiparameter models; and multiple treatment comparisons. Both frequentist and Bayesian approaches are applied, with example software code provided to derive within-study correlations and to fit the models.

Familiarisation to and reproducibility of cycling at 110% peak power output

AIM

This study investigated the familiarisation to and test re-test reproducibility of constant load cycling at 110% peak power output (WPEAK).

METHODS

Eleven healthy, but not cycle trained, males performed a graded incremental exercise test to ascertain WPEAK followed by three trials (T1, T2 and T3) at 110% WPEAK to exhaustion. Trials were separated by ~7 days.

RESULTS

Although there was no difference in time to exhaustion (TLIM) between T1 and T2 (P=0.100) and T2 and T3 (P=0.095) respectively, a difference was observed between T1 and T3 (P=0.046). Correlation coefficients, coefficients of determination, limits of agreement (LoA) and within-subject coefficient of variation (CV) improved across trials demonstrating T2 and T3 had the strongest relationship (T1 vs. T3: r=0.73; r2=0.53; Bias=40 s; CV=14%; T1 vs. T2: r=0.66; r2=0.43; Bias=24 s; CV=10%; T2 vs. T3: r=0.97; r2=0.95; Bias=16 s; CV=7%). There was no difference across trials for HR (P=0.12), BLa (P=0.76), RER (P=0.52), VE, (P=0.32), VO2, (P=0.33), local RPE (RPEL; P=1) and overall RPE (RPEO; P=0.91) at exhaustion or BLa (P=0.76) and pH (P=0.47) 5-minutes post-exercise.

CONCLUSION

Constant load cycling at 110% WPEAK is a reliable protocol when assessing supramaximal exercise performance after completion of two familiarisation trials.

Detecting a thienopyridine effect by platelet reactivity assessment and its implications for risk stratification

BACKGROUND

On-treatment platelet reactivity (OTR) is a predictor of clinical outcomes in patients receiving thienopyridine therapy.

OBJECTIVE

To assess whether point-of-care platelet reactivity testing can discriminate between patients who have and have not received a thienopyridine.

PATIENTS/METHODS

This was an analysis of a randomized, multicenter, pharmacodynamic trial. Subjects with coronary artery disease treated with aspirin were randomly assigned to clopidogrel 75 mg daily or prasugrel 10 mg daily for 7 days. Platelet reactivity assessment with the VerifyNow P2Y12 test was performed before study drug admistration and 24 h after the final dose. Optimal cut-offs for a detectable drug effect were identified by the use of receiver operating characteristic curve analysis.

RESULTS

A total of 54 subjects were enrolled and completed the study. The c-statistic for the identification of a thienopyridine effect was highly significant (0.93, P < 0.001), including for the clopidogrel and prasugrel groups considered separately (P < 0.001 for both). The optimal cut-off was < 213 P2Y12 reaction units (PRU), which provided a sensitivity of 80% and a specificity of 98%. This cut-off provided a sensitivity of 58% and a specificity of 100% for a clopidogrel effect, and a sensitivity of 100% and specificity of 96% for a prasugrel effect.

CONCLUSIONS

OTR of < 213 PRU is highly specific for exposure to either clopidogrel or prasugrel. This may be useful in the management of thienoypridine-treated patients who require surgery. Furthermore, this diagnostic cut-off is similar to levels of OTR that have been associated with ischemic events in thienopyridine-treated patients, supporting the contention that a lack of drug effect is the mechanistic basis for the prognostic relationship between OTR and clinical outcomes.

Evaluating the clinical usefulness of platelet function testing: considerations for the proper application and interpretation of performance measures

Various diagnostic and prognostic performance measures have been used to describe the clinical usefulness of platelet function testing in the evaluation and management of patients taking P2Y12 inhibitors, which reduce the risk for thrombosis due to their action on the platelet P2Y12 receptor. Platelet function tests are used to confirm the presence of an antiplatelet effect of a P2Y12 inhibitor, and confirmation that the pharmacodynamic effect is associated with a reduction in the rate of thrombosis. Despite this clear association, enthusiasm for the clinical usefulness of platelet function testing has been tempered based on observed sensitivity, specificity, and positive predictive value for the detection of future thrombotic events. However, evaluating the prognostic utility of a test based on diagnostic performance indicators is not appropriate because prognostic tests are not used to diagnose which patients will have events; instead, they are used to assist in risk stratification. Therefore, when evaluating the usefulness of platelet function testing, diagnostic performance measures such as sensitivity, specificity, and predictive values should focus on diagnostic performance in identifying a pharmacodynamic effect, and prognostic performance should be evaluated using prognostic performance measures such as hazard ratios and net reclassification improvement, which are comparable to other well-established risk factors for cardiovascular events.

The effects of elevated levels of sodium bicarbonate (NaHCO₃) on the acute power output and time to fatigue of maximally stimulated mouse soleus and EDL muscles

This study examined the effects of elevated buffer capacity [~32 mM HCO₃(-)] through administration of sodium bicarbonate (NaHCO₃) on maximally stimulated isolated mouse soleus (SOL) and extensor digitorum longus (EDL) muscles undergoing cyclical length changes at 37 °C. The elevated buffering capacity was of an equivalent level to that achieved in humans with acute oral supplementation. We evaluated the acute effects of elevated [HCO₃(-)] on (1) maximal acute power output (PO) and (2) time to fatigue to 60 % of maximum control PO (TLIM60), the level of decline in muscle PO observed in humans undertaking similar exercise, using the work loop technique. Acute PO was on average 7.0 ± 4.8 % greater for NaHCO₃-treated EDL muscles (P < 0.001; ES = 2.0) and 3.6 ± 1.8 % greater for NaHCO₃-treated SOL muscles (P < 0.001; ES = 2.3) compared to CON. Increases in PO were likely due to greater force production throughout shortening. The acute effects of NaHCO₃ on EDL were significantly greater (P < 0.001; ES = 0.9) than on SOL. Treatment of EDL (P = 0.22; ES = 0.6) and SOL (P = 0.19; ES = 0.9) with NaHCO₃ did not alter the pattern of fatigue. Although significant differences were not observed in whole group data, the fatigability of muscle performance was variable, suggesting that there might be inter-individual differences in response to NaHCO₃ supplementation. These results present the best indication to date that NaHCO₃ has direct peripheral effects on mammalian skeletal muscle resulting in increased acute power output.

Measurement of the ZZ production cross section and limits on anomalous neutral triple gauge couplings in proton-proton collisions at sqrt[s] = 7 TeV with the ATLAS detector

A measurement of the ZZ production cross section in proton-proton collisions at sqrt[s] = 7 TeV using data corresponding to an integrated luminosity of 1.02 fb(-1) recorded by the ATLAS experiment at the LHC is presented. Twelve events containing two Z boson candidates decaying to electrons and/or muons are observed, with an expected background of 0.3 ± 0.3(stat)(-0.3)(+0.4)(syst) events. The cross section measured in a phase-space region with good detector acceptance and for dilepton masses within the range 66 to 116 GeV is σ(ZZ → ℓ+ ℓ- ℓ+ ℓ-)(fid) = 19.4(-5.2)(+6.3)(stat)(-0.7)(+0.9)(syst) ± 0.7(lumi) fb. The resulting total cross section for on-shell ZZ production, σ(ZZ)(tot) = 8.5(-2.3)(+2.7)(stat)(-0.3)(+0.4)(syst) ± 0.3(lumi) pb, is consistent with the standard model expectation of 6.5(-0.2)(+0.3) pb calculated at the next-to-leading order in QCD. Limits on anomalous neutral triple gauge boson couplings are derived.

Single-arc volumetric-modulated arc therapy can provide dose distributions equivalent to fixed-beam intensity-modulated radiation therapy for prostatic irradiation with seminal vesicle and/or lymph node involvement

OBJECTIVES

Volumetric-modulated arc therapy (VMAT) is becoming an increasingly utilised modality for treating a variety of anatomical sites. However, the efficacy of single-arc VMAT to treat prostate cancer suspicious for extraprostatic extension was heretofore unknown. In this work, we report our institutional experience with single-arc VMAT and fixed-beam intensity-modulated radiation therapy (IMRT) for prostate cancer patients treated for seminal vesicle and/or lymph node involvement.

METHODS

Single-arc VMAT and 7- or 9-field IMRT treatment plans were compared for 10 prostate cancer patients treated for seminal vesicle involvement and/or lymph node involvement. All treatment plans were constructed using the Philips Pinnacle treatment planning system (v.9.0, Fitchburg, WI) and delivered on an Elekta Infinity radiotherapy accelerator (Crawley, UK). Resulting plans were compared using metrics that characterised dosimetry and delivery efficiency.

RESULTS

No statistically significant differences in target coverage, target homogeneity or normal tissue doses were noted between the plans (p>0.05). For prostate patients treated for seminal vesicle involvement, VMAT plans were delivered in 1.4±0.1 min (vs 9.5±2.4 min for fixed-beam IMRT) (p<0.01) and required approximately 20% fewer monitor units (p=0.01). For prostate patients treated for lymph node involvement, VMAT plans were delivered in 1.4±0.1 min (vs 11.7±1.3 min for fixed-beam IMRT) (p<0.01) and required approximately 45% fewer monitor units (p<0.01).

CONCLUSION

Single-arc VMAT plans were dosimetrically equivalent to fixed-beam IMRT plans with significantly improved delivery efficiency.

Evaluation of clopidogrel responsiveness after drug-eluting stent implantation

Clopidogrel is a cornerstone of medical therapy in patients with cardiovascular disease, reducing the rate of ischemic events in patients with acute coronary syndrome, ST elevation myocardial infarction, and those undergoing percutaneous coronary intervention (PCI). Prolonged dual antiplatelet therapy with aspirin and a thienopyridine is mandated after drug-eluting stent implantation. However, there is substantial variability in the pharmacokinetics and pharmacodynamics of clopidogrel among individuals, and a lack of effect has been associated with adverse outcome after PCI, including drug-eluting stent thrombosis. The development of platelet function assays that can be performed in the clinical laboratory or at the point-of-care has made it possible to integrate the evaluation of clopidogrel response into clinical practice. Clinical utilization of platelet function testing requires an understanding of the types of methodologies that are available, the interpretation of the results that are provided, and the different potential treatment options in patients who are identified to be at risk. Several ongoing randomized clinical trials are testing the safety and efficacy of individualized antiplatelet therapy based on platelet function testing to reduce ischemic events after PCI with drug-eluting stents.

Cooling strategies improve intermittent sprint performance in the heat of athletes with tetraplegia

BACKGROUND

Precooling has been shown to enhance performance in repeated sprint exercise in able-bodied subjects in a hot environment. Spinal cord injury causes thermoregulatory impairment with a detrimental effect on performance. This study assessed whether cooling strategies before and during exercise in the heat enhances sprint performance in athletes with tetraplegia.

METHODS

Eight male athletes with tetraplegia performed intermittent arm crank exercise in the heat (32.0 degrees C (0.1 degrees C); humidity, 50% (0.1%)) for a maximum of 60 min or until exhaustion. Trials involved a no-cooling control (CON), precooling (PRE) or cooling during exercise (DUR). Each intermittent sprint protocol consisted of varied periods of passive rest, maximal sprinting and active recovery.

RESULTS

Both PRE and DUR cooling strategies improved the ability of the athletes to repeatedly perform high-intensity sprints, with times to exhaustion (TTE), whereas during the CON trial, athletes demonstrated a reduction in the total number of sprints and TTE (47.2 (10.8), 52.8 (5.8) and 36.2 (9.6) min for CON, PRE and DUR, respectively). Core temperature was significantly higher for CON (37.3 degrees C (0.3 degrees C)) when compared with both PRE and DUR (36.5 degrees C (0.6 degrees C) and 37.0 degrees C (0.5 degrees C), respectively, p<0.01). Ratings of perceived exertion and thermal sensation upon exhaustion or completion were not different.

CONCLUSIONS

Athletes with tetraplegia should use a precooling or during-exercise cooling strategy specific to the characteristics of their sport when exercising in hot conditions.

The influence of ramp rate on VO2peak and "excess" VO2 during arm crank ergometry

The principal aim of this study was to examine how different ramp rates influenced the attainment of peak physiological responses during incremental arm crank ergometry (ACE). Additionally, the study examined whether there was any evidence for the development of an "excess" VO (2) during ACE due to upward curvi-linearity in the VO (2)-work rate relationship, and whether this was influenced by the ramp rate. Sixteen physically active, though non-specifically trained, men (mean +/- S age 30 +/- 8 years; height 1.79 +/- 0.07 m; body mass 84.7 +/- 13.2 kg) volunteered to participate. Having completed a familiarisation test, all subjects returned to the laboratory to complete two ramp tests on an electrically-braked ergometer in a counter-balanced order. Both ramp tests started at 60 W with work rate subsequently incremented by either 6 or 12 W . min (-1). Pulmonary gas exchange was measured breath-by-breath throughout the tests. Subjects achieved a greater final work rate during the 12 W . min (-1) test compared to the 6 W . min (-1) test (168 +/- 28 vs. 149 +/- 26 W; p < 0.001). The VO (2peak) (3.06 +/- 0.65 vs. 2.96 +/- 0.48 L . min (-1); p = 0.27), HR (peak) (179 +/- 15 vs. 177 +/- 16 b . min (-1); p = 0.17) and V.E (peak) (112 +/- 22 vs. 105 +/- 16 L . min (-1); p = 0.09) were not different between the tests, but VCO (2peak) (3.54 +/- 0.64 vs. 3.27 +/- 0.46 L . min (-1); p = 0.01) RER (peak) (1.17 +/- 0.07 vs. 1.11 +/- 0.06; p < 0.001), and end-exercise blood (lactate) (11.9 +/- 2.1 vs. 10.8 +/- 2.6 mmol . L (-1); p = 0.005) were all higher in the 12 W . min (-1) test. An "excess" VO (2) was observed in 13 out of 16 tests at 12 W . min (-1) and in 15 out of 16 tests at 6 W . min (-1). Neither the magnitude of the "excess" VO (2) (0.42 +/- 0.41 vs. 0.37 +/- 0.18 L . min (-1); p = 0.66) nor the VO (2) at which the V.O (2)-work rate relationship departed from linearity (2.17 +/- 0.34 vs. 2.18 +/- 0.32 L . min (-1); p = 0.94) were significantly different between the two ramp tests. These data indicate that differences in ramp rate within the range of 6 - 12 W . min (-1) influence the peak values of work rate, VCO (2) and RER, but do not influence peak values of VO (2) or HR during ACE. The development of an "excess" VO (2) appears to be a common feature of ramp exercise in ACE, although the mechanistic basis for this effect is presently unclear.

The effect of crank rate on physiological responses and exercise efficiency using a range of submaximal workloads during arm crank ergometry

This study examined the effects of variations in crank rate on physiological responses during submaximal arm ergometry. Fifteen non-specifically trained male subjects volunteered to participate in this study. Each subject undertook a discontinuous arm crank ergometry test (30, 50, 70, 90 W) on three separate occasions using crank rates of 50, 70, and 90 rev.min(-1). Respiratory parameters and heart rate were continuously monitored. An 80-microL capillary blood sample was obtained immediately following each exercise bout for the determination of whole blood lactate. Measures of efficiency were calculated using specific caloric equivalents of oxygen consumption (V(O2)). Heart rate was lowest (p < 0.05) at 30, 50, and 70 W using 50 rev.min(-1). Values of gross and net efficiency tended to be higher (p < 0.05) using 50 rev.min (-1) at the lower absolute workloads, but no differences (p > 0.05) were observed between the three crank rates at 90 W. No differences (p > 0.05) were observed between crank rates for delta efficiency. This study confirms that variations in crank rate can influence gross and net values of V(O2) and exercise efficiency at low absolute workloads, but crank rate ceases to be an influential factor at moderate workloads. Further research is required to identify the specific mechanisms underpinning the observations reported in the present study relating to the interaction between crank rate, workload, and exercise efficiency during arm crank ergometry.

The expected burden of mesothelioma mortality in Great Britain from 2002 to 2050

The British mesothelioma register contains all deaths from 1968 to 2001 where mesothelioma was mentioned on the death certificate. These data were used to predict the future burden of mesothelioma mortality in Great Britain. Poisson regression analysis was used to model male mesothelioma deaths from 1968 to 2001 as a function of the rise and fall of asbestos exposure during the 20th century, and hence to predict numbers of male deaths in the years 2002–2050. The annual number of mesothelioma deaths in Great Britain has risen increasingly rapidly from 153 deaths in 1968 to 1848 in 2001 and, using our preferred model, is predicted to peak at around 1950 to 2450 deaths per year between 2011 and 2015. Following this peak, the number of deaths is expected to decline rapidly. The eventual death rate will depend on the background level and any residual asbestos exposure. Between 1968 and 2050, there will have been approximately 90 000 deaths from mesothelioma in Great Britain, 65 000 of which will occur after 2001.

The influence of step and ramp type protocols on the attainment of peak physiological responses during arm crank ergometry

The present study examined the impact of two exercise protocols on the attainment of peak physiological responses during arm crank ergometry (ACE). Fourteen physically active, although non-specifically trained male subjects completed two V.O (2) peak tests using an electrically braked arm ergometer (Lode Angio, Groningen, Netherlands). The tests consisted of a stepwise or rampwise increase in external workload. The order of tests was randomised and each test was separated by at least two days. Respiratory data were collected continuously using an on-line gas analysis system with sample time set at 30 s. Fingertip capillary blood samples ( approximately 20 microL) were collected at volitional exhaustion and at minute intervals for 7 min of passive recovery for the determination of peak whole blood lactate concentration. Time on the test (T (lim); s), peak minute power (PMP; W), and total work done (TWD; kJ) were also recorded. In addition to determining systematic bias using separate independent t-tests, the level of agreement was also examined by way of calculating the 95 % limits of agreement. Sub-maximal values of V.O (2), V.E, and HR were similar (p > 0.05) between test when the amount of external work completed was taken into consideration. There was no systematic bias (p > 0.05) for mean (+/- s) peak values of V.O (2) (3.12 [0.37] vs. 3.04 [0.38] L . min (-1)) or any other parameter between the step and ramp tests, respectively. Mean values of T (lim), PMP, and TWD were also similar (p > 0.05) between tests. However, the level of agreement for peak values of all test parameters was low. It is therefore concluded that while either test can be considered as being suitable for the purpose of eliciting V.O (2) peak and other physiological responses using ACE, they should not be used interchangeably for the purpose of assessing parameters linked to the aerobic capacity of the upper-body.

Effects of two cooling strategies on thermoregulatory responses of tetraplegic athletes during repeated intermittent exercise in the heat

Athletes with spinal cord injury (SCI), and in particular tetraplegia, have an increased risk of heat strain and consequently heat illness relative to able-bodied individuals. Strategies that reduce the heat strain during exercise in a hot environment may reduce the risk of heat illness. To test the hypotheses that precooling or cooling during intermittent sprint exercise in a heated environment would attenuate the rise in core temperature in tetraplegic athletes, eight male subjects with SCI (lesions C(5)-C(7); 2 incomplete lesions) undertook four heat stress trials (32.0 +/- 0.1 degrees C, 50 +/- 0.1% relative humidity). After assessment of baseline thermoregulatory responses at rest for 80 min, subjects performed three intermittent sprint protocols for 28 min. All trials were undertaken on an arm crank ergometer and involved a no-cooling control (Con), 20 min of precooling (Pre), or cooling during exercise (Dur). Trials were administered in a randomized order. After the intermittent sprint protocols, mean core temperature was higher during Con (37.3 +/- 0.3 degrees C) compared with Pre and Dur (36.5 +/- 0.6 degrees C and 37.0 +/- 0.5 degrees C, respectively; P < 0.01). Moreover, perceived exertion was lower during Pre (13 +/- 2; P < 0.01) and Dur (12 +/- 1; P < 0.01) compared with Con (14 +/- 2). These results suggest that both precooling and cooling during intermittent sprint exercise in the heat reduces thermal strain in tetraplegic athletes. The cooling strategies also appear to show reduced perceived exertion at equivalent time points, which may translate into improved functional capacity.

Cost-effectiveness of fluticasone propionate in the treatment of chronic obstructive pulmonary disease: a double-blind randomized, placebo-controlled trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a debilitating disease and places a large financial burden on health-care systems and society. We prospectively evaluated the cost-effectiveness offluticasone propionate (FP) treatment in patients with moderate-to-severe COPD, who were symptomatic on regular bronchodilator therapy.

METHODS

An economic analysis was performed in a 6-month, randomized, double-blind clinical trial comparing FP 1,000 microg/day with placebo in 281 patients aged 45-79 years with symptomatic moderate-to-severe COPD. Data on clinical efficacy, health-care resource use and productivity loss associated with the management of COPD were prospectively collected. The main outcome measures were the incremental cost-effectiveness of achieving a > or = 10% improvement in FEV1 and of remaining exacerbation-free throughout the study. The economic evaluation was costed from the perspective of the NHS (direct costs) and of society (direct and indirect costs).

RESULTS

FP was significantly more effective than placebo in terms of the proportions of patients demonstrating a > or = 10% improvement in FEV1 (32 vs. 19%; P = 0.02) and remaining free of moderate/severe exacerbations (75 vs. 63%; P = 0.02). The difference between the groups in total costs was not significantly different. Incremental cost-effectiveness analyses showed that the additional clinical benefits of FP relativeto placebo, in terms of a > or = 10% improvement in FEV1 or an increased number of patients free of moderate/severe exacerbations, were achieved at minimal additional costs from an NHS perspective (additional 0.25 pounds per day for bath) or at a net saving from a societal perspective. Sensitivity analysis showed that these results were robust to changes in the underlying assumptions.

CONCLUSIONS

Treatment with FP was associated with statistically significant clinical benefits in patients with moderate-to-severe COPD currently symptomatic on regular bronchodilator therapy. As the differences in direct and total costs compared with placebo were small and non-significant, this treatment can be considered cost-effective in this patient population.

Thermoregulatory responses during prolonged upper-body exercise in cool and warm conditions

The thermoregulatory responses of upper-body trained athletes were examined at rest, during prolonged arm crank exercise and recovery in cool (21.5 +/- 0.9 degrees C, 43.9 +/- 10.1% relative humidity; mean +/- s) and warm (31.5 +/- 0.6 degrees C, 48.9 +/- 8.4% relative humidity) conditions. Aural temperature increased from rest by 0.7 +/- 0.7 degrees C (P< 0.05) during exercise in cool conditions and by 1.6 +/- 0.7 degrees C during exercise in warm conditions (P< 0.05). During exercise in cool conditions, calf skin temperature decreased (1.5 +/- 1.3 degrees C), whereas an increase was observed during exercise in warm conditions (3.0 +/- 1.7 degrees C). Lower-body skin temperatures tended to increase by greater amounts than upper-body skin temperatures during exercise in warm conditions. No differences were observed in blood lactate, heart rate or respiratory exchange ratio responses between conditions. Perceived exertion at 45 min of exercise was greater than that reported at 5 min of exercise during the cool trial (P< 0.05), whereas during exercise in the warm trial the rating of perceived exertion increased from initial values by 30 min (P < 0.05). Heat storage, body mass losses and fluid consumption were greater during exercise in warm conditions (7.06 +/- 2.25 J x g(-1) x degrees C(-1), 1.3 +/- 0.5 kg and 1,038 +/- 356 ml, respectively) than in cool conditions (1.35 +/- 0.23 J x g(-1) x degrees C(-1), 0.8 +/- 0.2 kg and 530 +/- 284 ml, respectively; P < 0.05). The results of this study indicate that the increasing thermal strain with constant thermal stress in warm conditions is due to heat storage within the lower body. These results may aid in understanding thermoregulatory control mechanisms of populations with a thermoregulatory dysfunction, such as those with spinal cord injuries.

Cost-effectiveness of fluticasone propionate administered via metered-dose inhaler plus babyhaler spacer in the treatment of asthma in preschool-aged children

STUDY OBJECTIVES

To evaluate the cost-effectiveness of inhaled fluticasone propionate (FP) in children aged 12 to 47 months with asthma symptoms.

DESIGN

A retrospective economic analysis conducted from the perspective of the Danish health-care system, based on clinical data from a 12-week study.

SETTING

Thirty-three outpatient centers in nine countries.

PATIENTS

Two hundred thirty-seven children aged 12 to 47 months with documented history of recurrent wheeze or asthma symptoms.

INTERVENTIONS

Two dosages of FP, 100 microg/d and 200 microg/d, and placebo administered in two divided doses via a metered-dose inhaler and a Babyhaler (Glaxo Wellcome; Middlesex, UK) spacer device.

MEASUREMENTS

Effectiveness in terms of asthma exacerbations, control of cough and wheeze symptoms, symptom-free days, overall direct costs of asthma management in Danish kroner at 1999 prices, and mean and incremental cost-effectiveness ratios.

RESULTS

FP, 200 microg/d, was significantly more effective than placebo treatment in terms of the proportion of exacerbation-free patients (73.7% vs 59.8%; p = 0.025) and patients experiencing a > or = 25% improvement in cough symptoms (57.9% vs 39.0%; p = 0.018). The costs per exacerbation-free patient, per patient with a > or = 25% improvement in cough and wheeze symptoms from baseline, and per symptom-free day were lower in the FP groups than in the placebo group. The incremental cost-effectiveness ratios for these end points indicated that the additional benefits of FP, 200 microg/d, were achieved at a lower overall cost compared with placebo treatment.

CONCLUSIONS

From the perspective of the Danish health-care system, FP, 100 microg bid, administered via the Babyhaler inhalation device was cost-effective relative to standard therapy with bronchodilators alone.

The influence of crank rate on peak oxygen consumption during arm crank ergometry

The aim of this study was to assess the influence of three imposed crank rates on the attainment of peak oxygen consumption (VO2peak) and other physiological responses during incremental arm crank ergometry. Twenty physically active, although non-specifically trained, males volunteered for the study. They completed an exercise protocol using an electrically braked arm ergometer (Lode Angio, Groningen, Netherlands) at crank rates of 60, 70 and 80 rev x min(-1). The order of tests was randomized and they were separated by at least 2 days. Peak VO2 was significantly higher (P < 0.05) at 70 and 80 rev x min(-1) than at 60 rev x min(-1). Peak ventilation volume increased as a function of crank rate and was higher (P < 0.05) at 80 than at 60 rev x min(-1). Peak heart rate was higher (P < 0.05) at 70 and 80 rev x min(-1) than at 60 rev x min(-1). Furthermore, 70 and 80 rev x min(-1) resulted in an extended test time compared with 60 rev x min(-1). The greater physiological responses observed during the tests at the two faster crank rates might have been the result of a postponement of acute localized neuromuscular fatigue, allowing for more work to be completed. We recommend, therefore, that an imposed crank rate between 70 and 80 rev x min(-1) should be used to elicit VO2peak and other physiological responses in arm crank ergometry.

Comparison of once daily fluticasone propionate aqueous nasal spray with once daily budesonide reservoir powder device in patients with perennial rhinitis

BACKGROUND

Previous studies comparing the corticosteroids fluticasone propionate (FP) and budesonide (BUD) in both perennial and seasonal rhinitis have shown no consistent difference between treatments. However, the therapeutic outcomes may have been influenced by study design.

OBJECTIVE

To compare the effect of FP aqueous nasal spray (ANS; 200 microg/day) with BUD reservoir powder device (RPD; 200 microg/day) on rhinitis symptoms, productivity loss and device preference in patients with perennial rhinitis.

METHODS

After a 2-week run-in period, 440 patients were randomized to receive either FPANS, BUD RPD or matched placebo (ANS or RPD) for 8 weeks, followed by an open-label 4-week follow-up treatment with FPANS. Patients completed diary card visual analogue scores for nasal symptoms, and questionnaires on satisfaction with the treatment and preferred choice of device.

RESULTS

During weeks 1-4, the visual analogue total nasal symptom scores (VATNS) in the FPANS group were significantly lower than scores in the BUD RPD group (mean difference = -17.8; 95% CI = -34.4, -1.3; P = 0.036). FPANS also significantly reduced the VATNS compared with the ANS placebo at all time-points assessed (P < or = 0.005). BUD RPD did not significantly differ from the RPD placebo at weeks 5-8 (P = 0.167), or the ANS placebo at any time-point (P < or = 0.151). Over the 8-week treatment period FPANS was significantly more effective than BUD RPD at reducing sneezing (mean difference = -4.4; 95% CI = -8.6, -0.3; P = 0.036) and nasal itching (mean difference = -5.3; 95% CI = -9.9, -0.8; P = 0.022), and was significantly superior to the ANS placebo for all symptoms assessed at weeks 1-4 and 1-8 (P < 0.016). At the same time-points BUD RPD was no better at alleviating nasal itching than the RPD placebo (P < or = 0.306), and compared with the ANS placebo, significantly reduced only one symptom; nasal blockage (P < or = 0.016). After 8 weeks of treatment, patients preferred the ANS device to the RPD (P < 0.001), and at 12 weeks a significantly greater number of patients were satisfied with FPANS treatment compared with BUD RPD (P = 0.0019) or the respective placebos (P = 0.0001).

CONCLUSION

FPANS and BUD RPD are effective therapies with a good safety profile for the treatment of perennial rhinitis but, in this direct placebo-controlled comparison, FPANS was more efficacious than BUD RPD, and the patients preferred the ANS device to the RPD.

Cost-efficacy comparison of inhaled fluticasone propionate and budesonide in the treatment of asthma

BACKGROUND

The results of a recent meta-analysis comparing 2 inhaled corticosteroids, fluticasone propionate (FP) and budesonide, demonstrated that FP had an improved efficacy-to-safety ratio compared with budesonide. However, limited data are available on the relative economic benefits of these 2 regimens.

OBJECTIVE

This pharmacoeconomic analysis used individual patient data from studies in the meta-analysis to compare the relative cost-efficacy of 2 asthma regimens from the perspective of a US third-party payer.

METHODS

This analysis included all 7 studies in the meta-analysis that compared budesonide with FP dosed at approximately half the dose of budesonide and that included measurement of daily morning peak expiratory flow (PEF).

RESULTS

The total daily per-person cost of asthma management was higher for patients treated with budesonide than with FP ($3.00 vs $2.25, respectively). Treatment with FP had greater cost-efficacy than treatment with budesonide, based on a range of outcome measures that included improvement in morning PEF, symptom-free days, and episode-free days. The daily cost per effectively treated patient (an increase in PEF of > or = 10%) was $5.62 with FP and $10.05 with budesonide. The cost per symptom-free day was $4.36 with FP, compared with $6.67 with budesonide. The cost per episode-free day was $5.60 with FP and $9.42 with budesonide. The pharmacoeconomic difference continued to favor FP as the criteria for success were made more stringent and the cost of budesonide was lowered.

CONCLUSION

Based on data from the 7 randomized, controlled trials, treatment of asthma with FP was more effective and less expensive, using US health care assumptions and costs, than treatment with budesonide.

Patient and physician perspectives on the impact and management of perennial and seasonal allergic rhinitis

Patient and physician perspectives on the impact and management of perennial (PAR) and seasonal allergic rhinitis (SAR) were studied. In all, 2139 subjects were questioned about their medical conditions, severity and frequency of symptoms and satisfaction with treatment. A group of general practitioners (GPs) were also invited to discuss their experiences in the management of rhinitis. In this UK survey, allergic rhinitis was more common than asthma, hypertension, skin rashes, eczema and diabetes. The prevalence of SAR and PAR was 15% and 2%, respectively. Sneezing and runny nose were the most common symptoms and GPs were the main contact for advice and treatment (54% of patients). Symptoms were well-controlled in 32% of patients. Allergic rhinitis affected work, home and social life in 29%, 34% and 30% of patients, respectively. The GPs considered PAR to be more difficult to treat than SAR, and GP and patient level of satisfaction in the treatment of PAR was low. This suggests that education of patients and physicians on the benefits of allergen avoidance, and the selective use of the highly effective therapies available on prescription could improve the level of satisfaction with therapy. Adherence to current guidelines on the management of rhinitis could lead to an effective, structured treatment plan for patients.

Cost-effectiveness of salmeterol/fluticasone propionate combination product 50/250 microg twice daily and budesonide 800 microg twice daily in the treatment of adults and adolescents with asthma. International Study Group

Despite a good understanding of the disease and its treatments, asthma continues to place a large economic burden on healthcare systems. As such, it is important to consider the economic impact of alternative therapeutic options for the treatment of this condition to ensure that scarce resources are used in the most efficient manner possible. Thus, the aim of asthma management from an economic perspective is to reduce the burden of this disease through maximizing health gain with available resources. A prospective economic analysis was conducted as part of a multicentre, randomized, double-blind, comparative trial of salmeterol/fluticasone propionate combination product (SFC) 50/250 microg twice daily vs. budesonide (800 microg twice daily) in adults and adolescents with asthma who were symptomatic despite treatment with inhaled corticosteroids at doses of 800-1200 microg day(-1). Treatment effectiveness was measured in terms of successfully-treated weeks, defined as a > or =5% improvement in morning peak expiratory flow, episode-free days (a day without the need for rescue medication, no nocturnal awakening or adverse events) and symptom-free days. Cost-effectiveness analyses were performed using direct healthcare and drug costs, from the perspective of the Swedish healthcare system (1998 prices), with appropriate sensitivity analyses to test the robustness of the findings. Overall, SFC produced significantly higher (P<0.001) proportions of successfully-treated weeks, episode-free days and symptom-free days. Direct asthma management costs were similar between the two groups [SEK19.6 ($US2.4) for SFC vs. SEK18.5 (SUS2.2) for budesonide]. The cost per successfully-treated week was lower for SFC than for budesonide [SEK204 ($US24.8) vs. SEK300 ($US36.4) per week], as were the costs per episode-free day [SEK51.1 ($US6.2) vs. SEK75.1 ($US9.1) per day] and symptom-free day [SEK42.2 ($US5.1) vs. SEK53.0 ($US6.4) per day]. Incremental cost-effectiveness ratios showed that the additional costs to achieve additional benefits with SFC were minimal. Costs per additional successfully-treated week, symptom-free day and episode-free day with SFC were SEK31.6 ($US3.9), SEK9.2 ($US1.1) and SEK7.7 ($US0.9), respectively, relative to budesonide. Sensitivity analysis showed that the results were stable over a wide range of assumptions. The results suggest that SFC is a more cost-effective treatment than budesonide in the management of moderate to severe asthma.

Impact of suppressive antiviral therapy on the health related quality of life of patients with recurrent genital herpes infection

OBJECTIVE

To investigate whether suppressive antiviral therapy improves health related quality of life in patients with recurrent genital herpes.

METHODS

Health related quality of life was measured using the disease specific recurrent genital herpes quality of life questionnaire (RGHQoL) as part of a randomized, double blind, 52 week, placebo controlled, dose ranging study of once and twice daily valaciclovir or aciclovir for the suppression of recurrent genital herpes in patients with six or more recurrences per year.

RESULTS

Of 1479 participants, 1349 patients completed the baseline questionnaire. There were no significant baseline differences in RGHQoL score between any of the treatment groups. After 3 months there were significantly greater improvements in mean RGHQoL scores for all active treatment groups compared with placebo (p < 0.05). Mean RGHQoL score improvements from baseline remained significantly higher in the active treatment groups than in the placebo group after 6 and 12 months, indicating that the improved health related quality of life in patients receiving suppressive antiviral therapy was sustained over a prolonged period of time.

CONCLUSION

Suppressive antiviral therapy is an effective strategy for improving the quality of life of patients with recurrent genital herpes. These improvements in quality of life are sustained over time, thus enhancing the clinical benefit in the long term management of this condition.

Thermoregulatory responses of spinal cord injured and able-bodied athletes to prolonged upper body exercise and recovery

STUDY DESIGN

Single trial, two factor repeated measures design.

SETTING

England, Cheshire.

OBJECTIVES

To examine the thermoregulatory responses of able-bodied (AB) athletes, paraplegic (PA) athletes and a tetraplegic (TP) athlete at rest, during prolonged upper body exercise and recovery.

METHODS

Exercise was performed on a Monark cycle ergometer (Ergomedic 814E) adapted for arm exercise at 60% VO2 peak for 60 min in cool conditions ('normal' laboratory temperature; 21.5+/-1.7 degrees C and 47+/-7.8% relative humidity). Aural and skin temperatures were continually monitored.

RESULTS

Mean (+/-S.D.) peak oxygen uptake values were greater (P<0. 05) for the AB when compared to the PA (3.45+/-0.45 l min-1 and 2. 00+/-0.46 l min-1, respectively). Peak oxygen uptake for the TP was 0.91 l min-1. At rest, aural temperature was similar between groups (36.2+/-0.3 degrees C, 36.3+/-0.3 degrees C and 36.3 degrees C for AB, PA and TP athletes, respectively). During exercise, aural temperature demonstrated relatively steady state values increasing by 0.6+/-0.4 degrees C and 0.6+/-0.3 degrees C for the AB and PA athletes, respectively. The TP athlete demonstrated a gradual rise in aural temperature throughout the exercise period of 0.9 degrees C. Thigh skin temperature increased by 1.3+/-2.5 degrees C for the AB athletes (P<0.05) whereas the PA athletes demonstrated little change in temperature (0.1+/-3.4 degrees C and -0.7 degrees C respectively). Calf temperature increased for the PA athletes by 1.0+/-3.6 degrees C (P<0.05), whereas a decrease was observed for the AB athletes of -1.0+/-2.0 degrees C (P<0.05) during the exercise period. During 30 min of passive recovery, the AB athletes demonstrated greater decreases in aural temperatures than those for the PA athletes (P<0. 05). Aural temperature for the TP increased peaking at 5 min of recovery remaining elevated until the end of the recovery period. Fluid consumption and weight losses were similar for the AB and PA athletes (598+/-433 ml and 403+/-368 ml; 0.38+/-0.39 kg and 0.38+/-0. 31 kg, respectively), whereas changes in plasma volume were greater for the AB athletes (-9.8+/-5.8% and 4.36+/-4.9%, respectively; P<0. 05).

CONCLUSION

The results of this study suggest that under the experimental conditions PA athletes are at no greater thermal risk than AB athletes. A relationship between the available muscle mass for heat production and sweating capacity appears evident for the maintenance of thermal balance. During recovery from exercise, decreases in aural temperature, skin temperature and heat storage were greatest for the AB athletes with the greatest capacity for heat loss and lowest for the TP athlete with the smallest capacity for heat loss. Initial observations on one TP athlete suggest substantial thermoregulatory differences when compared to AB and PA athletes.

Thermoregulatory and physiological responses of wheelchair athletes to prolonged arm crank and wheelchair exercise

Seven wheelchair athletes participated in this study. On separate occasions all athletes performed 60 min of arm crank ergometry and wheelchair ergometry at 60% of the ergometer specific VO2peak in cool conditions (21.5+/-1.3 degrees C; 54.2+/-6.3% relative humidity, 21.2+/-1.9 degrees C; 55.5+/-11.9% relative humidity, respectively). The order of testing was randomised. Aural and skin temperatures were continually measured throughout the 60 min test. Expired air was collected at 5, 15, 30, 45, and 60 min during the exercise period. Oxygen consumption was similar for both trials (1.09+/-0.21 and 1.16+/-0.331 x min-(-1), for the ACE and WCE trials, respectively). Heat storage was calculated at these time-points. Aural temperature was elevated from rest between 25 to 45 min of wheelchair ergometry (0.5+/-0.3 degrees C; P < 0.05) when compared to between 20 min of exercise and 5 min of recovery (0.6+/-0.3 degrees C; P<0.05) during the arm crank ergometry trial. On the cessation of arm crank ergometry, heat storage was elevated above values observed at 5 min of exercise (P < 0.05). On the cessation of wheelchair ergometry, heat storage was not elevated above values at 5 minutes of exercise. Upper arm skin temperature was cooler during wheelchair ergometry when compared to arm crank ergometry (P<0.05). All other skin temperature responses were similar during both exercise modes. The efficiency of arm crank ergometry was greater than wheelchair ergometry throughout the exercise period (18.5+/-3.5 % and 8.9+/-3.7% at 60 minutes of exercise, respectively; P < 0.05). The results of this study suggest that although ACE demonstrates greater efficiency than WCE prolonged arm crank ergometry elicited greater thermal and physiological strain when compared with prolonged wheelchair ergometry. The lower thermal strain during WCE was suggested to be related to the propulsion biomechanics which may result in some degree of local cooling, and consequently heat dissipation, when compared to ACE. Due to the greater thermal strain during arm crank ergometry, it is recommended that for studies examining the exercise responses of wheelchair users wheel-chair ergometry should be employed.