The testing of relational indexing procedures by diagnostic computer programs

Information retrieval in a relational indexing system has been tested by means of a suite of computer programs which will carry out searches in a variety of ways, with, on demand, detailed diagnostic feedback at any stage. The performance of the system can thus be evaluated as a 'system' separately from user judgments of the output. Details of the programming are described. Some initial results are discussed with respect to strengths and possible weaknesses of the system.

Assessment in Response to Individual Referrals

This paper provides a summary of the deliberations of a working party on assessment set up by the tutors to the 14 educational psychology training courses in England, Wales and Northern Ireland. As such it reflects the thoughts of all 14 tutors who subsequently discussed the document and agreed to use it as the basis for their taught courses on assessment in the professional training of educational psychologists.

The Utility of Point-of-Care Ultrasound in Detecting Distal Forearm Buckle Fractures in Paediatric Patients

BACKGROUND: Distal forearm fractures are common paediatric injuries. The use of plain radiographs is almost universal for diagnosis but this technology can be painful and time consuming. It is well known that children’s pain in the emergency department (ED) is both under-recognized and suboptimally managed. Point-of-care ultrasound (POCUS) has demonstrated good accuracy in detecting cortical disruption in adults but test characteristics in the most common paediatric fracture type (buckle or torus fractures) have not been explored. POCUS may also lead to quicker assessment and be associated with less pain and improved caregiver satisfaction compared to plain radiographs. Our results may provide support an alternative diagnostic strategy for centres where plain radiographs are not readily accessible and where severe pain is an issue.

OBJECTIVES: The objectives of this study were to: (i) evaluate the diagnostic accuracy POCUS in detecting suspected non-angulated distal forearm fractures in children presenting to the ED compared to AP and lateral plain film x-rays of the forearm, (ii) determine the length of time required to complete a POCUS evaluation for a suspected distal forearm non-angulated fracture in children in the ED, (iii) explore the differences in caregiver satisfaction with POCUS evaluation compared to plain radiography, and (iv) explore differences in associated pain between POCUS and plain radiography.

DESIGN/METHODS: This was a prospective cohort study designed to test the hypothesis that POCUS provides comparable sensitivity and specificity to plain radiography and is associated with less pain and greater caregiver satisfaction. We included children aged 4-17 years who presented to the paediatric ED with a suspected non-angulated distal forearm fracture based on a typical mechanism of injury. The patient underwent an x-ray and a POCUS evaluation of the affected region by a Canadian Emergency Ultrasound (CEUS)-trained physician who was blinded to the x-ray results. Caregivers were asked to complete a satisfaction questionnaire using a five-point Likert scale and children were asked to complete the Faces Pain Scale – Revised (FPS-R) reflecting discomfort associated with the diagnostic modality. The primary POCUS diagnosis made by the physician was compared to the x-ray diagnosis made by the staff paediatric radiologist. All POCUS images were independently interpreted by a second expert POCUS sonographer blinded to the original POCUS interpretation, x-ray, and final diagnosis. The primary outcomes were sensitivity of POCUS and pain score using the FPS-R.

RESULTS: Eighty-five participants were enrolled, of whom 33 (39%) sustained a buckle fracture. The mean (SD) age of the participants was 11 (3.4) years and 52 (61%) were male. Sensitivity and sensitivity of POCUS for detecting any cortical disruption was 97% [95% CI: 84.2, 99.9] and 96% [95% CI: 86.8, 99.5], respectively. Agreement (kappa) between sonographers was 0.74 [95% CI: 0.64, 0.87] representing substantial agreement. POCUS was associated with significantly lower mean (SD) pain scores compared to plain radiography [2.3 (2.5) vs 3.6 (3.0), p < 0.01]. The median (IQR) time to perform POCUS was significantly lower that plain radiography [68 (42) vs 1200 (1440) seconds, p < 0.01]. POCUS was associated with comparable mean caregiver satisfaction compared to plain radiography [4.7 (0.7) vs 4.4 (1.0), p = 0.15].

CONCLUSION: This prospective study of POCUS for non-angulated distal forearm injuries in children suggests that POCUS is associated with excellent sensitivity and specificity for the detection of cortical disruption. Furthermore, POCUS is associated with significantly less pain and procedure time compared to plain radiography. The results suggest that POCUS could be a useful diagnostic strategy in resource-limited settings for children with suspected forearm injuries and has the added benefit of lower associated pain.

What do patients really know? An evaluation of patients' physical activity guideline knowledge within general practice

Background

Physical inactivity is well recognised as one of the leading causes of preventable death. However, little is known about the general public’s knowledge surrounding national physical activity guidelines, particularly within general practice (GP).

Setting

Two GPs (York and Maidenhead, UK).

Question

Are GP patients aware of the national physical guidelines? Also, are health care professionals routinely raising the issue of physical inactivity and would patients welcome support from health care professionals regarding inactivity?

Methodology

A questionnaire was distributed in two GPs over a one-week period to evaluate patients knowledge of the national physical activity guidelines.

Results

Ninety-four participants completed the questionnaire over one week (60 female; 34 male), with an average age of 54.2 (standard deviation: 19.9 years). 14% (95% Confidence Interval (CI): 8–22%) of the total participants correctly knew the recommended national guidelines for physical activity. 52% (95% CI: 42–63%) recalled being asked by a health care professional about their activity levels. 46% (95% CI: 35–56%) would welcome support from a health care professional around improving their activity levels.

Discussion/Conclusion

Only 14% of responders correctly knew the current national minimum activity guidelines. Encouragingly 46% of participants in our study were interested in physical activity advice from a health care professional. Health care professionals need to be aware that many patients do not know the current physical activity guidelines and recognise that primary care may be an underutilised opportunity to educate and promote physical activity.

Supraesophageal Reflux: Validation of a Symptom Questionnaire

OBJECTIVES: To develop and validate a questionnaire for supraesophageal manifestations of reflux (SER) that will facilitate its study in clinical and research settings.

STUDY DESIGN: The Supraesophageal Reflux Questionnaire (SERQ) and previously validated Reflux Symptom Index (RSI) were subjected to multiple types of validity testing, including content validity, concurrent validity, reproducibility, and predictive validity.

RESULTS: The concurrent validity and reproducibility of both instruments was good to excellent for most items tested. The predictive validity of the SERQ was superior to the RSI when it included the covariates of history of sinusitis, use of over-the-counter antacid medications, age, gender, and body mass index.

CONCLUSIONS: The SERQ will serve as both a useful clinical and research tool by offering not only SER symptom information, like the RSI, but also information about the patient's medical history and medication usage that will facilitate use of the SERQ in research protocols.

EBM rating: B-2b

A case-control study of risk factors for death from 2009 pandemic influenza A(H1N1): is American Indian racial status an independent risk factor?

Historically, American Indian/Alaska Native (AI/AN) populations have suffered excess morbidity and mortality from influenza. We investigated the risk factors for death from 2009 pandemic influenza A(H1N1) in persons residing in five states with substantial AI/AN populations. We conducted a case-control investigation using pandemic influenza fatalities from 2009 in Alaska, Arizona, New Mexico, Oklahoma and Wyoming. Controls were outpatients with influenza. We reviewed medical records and interviewed case proxies and controls. We used multiple imputation to predict missing data and multivariable conditional logistic regression to determine risk factors. We included 145 fatal cases and 236 controls; 22% of cases were AI/AN. Risk factors (P 45 years vs. <18 years], pre-existing medical conditions (mOR 7·1), smoking (mOR 3·0), delayed receipt of antivirals (mOR 6·5), and barriers to healthcare access (mOR 5·3). AI/AN race was not significantly associated with death. The increased influenza mortality in AI/AN individuals was due to factors other than racial status. Prevention of influenza deaths should focus on modifiable factors (smoking, early antiviral use, access to care) and identifying high-risk persons for immunization and prompt medical attention.

Effect of extended morning fasting upon ad libitum lunch intake and associated metabolic and hormonal responses in obese adults

Background/Objectives:

Breakfast omission is positively associated with obesity and increased risk of disease. However, little is known about the acute effects of extended morning fasting upon subsequent energy intake and associated metabolic/regulatory factors in obese adults.

Subjects/Methods:

In a randomised cross-over design, 24 obese men (n=8) and women (n=16) extended their overnight fast by omitting breakfast consumption or ingesting a typical carbohydrate-rich breakfast of 2183±393 kJ (521±94 kcal), before an ad libitum pasta lunch 3 h later. Blood samples were obtained throughout the day until 3 h post lunch and analysed for hormones implicated in appetite regulation, along with metabolic outcomes and subjective appetite measures.

Results:

Lunch intake was unaffected by extended morning fasting (difference=218 kJ, 95% confidence interval −54 kJ, 490 kJ; P=0.1) resulting in lower total intake in the fasting trial (difference=−1964 kJ, 95% confidence interval −1645 kJ, −2281 kJ; P<0.01). Systemic concentrations of peptide tyrosine–tyrosine and leptin were lower during the afternoon following morning fasting (P⩽0.06). Plasma-acylated ghrelin concentrations were also lower following the ad libitum lunch in the fasting trial (P<0.05) but this effect was not apparent for total ghrelin (P⩾0.1). Serum insulin concentrations were greater throughout the afternoon in the fasting trial (P=0.05), with plasma glucose also greater 1 h after lunch (P<0.01). Extended morning fasting did not result in greater appetite ratings after lunch, with some tendency for lower appetite 3 h post lunch (P=0.09).

Conclusions:

We demonstrate for the first time that, in obese adults, extended morning fasting does not cause compensatory intake during an ad libitum lunch nor does it increase appetite during the afternoon. Morning fasting reduced satiety hormone responses to a subsequent lunch meal but counterintuitively also reduced concentrations of the appetite-stimulating hormone-acylated ghrelin during the afternoon relative to lunch consumed after breakfast.

Predicting physical activity energy expenditure in wheelchair users with a multisensor device

Aim

To assess the error in predicting physical activity energy expenditure (PAEE), using a multisensor device in wheelchair users, and to examine the efficacy of using an individual heart rate calibration (IC) method.

Methods

15 manual wheelchair users (36±10 years, 72±11 kg) completed 10 activities: resting, folding clothes, wheelchair propulsion on a 1% gradient (3456 and 7 km/h) and propulsion at 4 km/h (with an additional 8% of body mass, 2% and 3% gradient) on a motorised wheelchair treadmill. Criterion PAEE was measured using a computerised indirect calorimetry system. Participants wore a combined accelerometer and heart rate monitor (Actiheart). They also performed an incremental arm crank ergometry test to exhaustion which permitted retrospective individual calibration of the Actiheart for the activity protocol. Linear regression analysis was conducted between criterion (indirect calorimetry) and estimated PAEE from the Actiheart using the manufacturer's proprietary algorithms (group calibration, GC) or IC. Bland-Altman plots were used and mean absolute error was calculated to assess the agreement between criterion values and estimated PAEE.

Results

Predicted PAEE was significantly (p<0.01) correlated with criterion PAEE (GC, r=0.76 and IC, r=0.95). The absolute bias ±95% limits of agreement were 0.51±3.75 and −0.22±0.96 kcal/min for GC and IC, respectively. Mean absolute errors across the activity protocol were 51.4±38.9% using GC and 16.8±15.8% using IC.

Summary

PAEE can be accurately and precisely estimated using a combined accelerometer and heart rate monitor device, with integration of an IC. Interindividual variance in cardiovascular function and response to exercise is high in this population. Therefore, in manual wheelchair users, we advocate the use of an IC when using the Actiheart to predict PAEE.

Physiological and molecular responses to an acute bout of reduced-exertion high-intensity interval training (REHIT)

PURPOSE

We have previously shown that 6 weeks of reduced-exertion high-intensity interval training (REHIT) improves VO2max in sedentary men and women and insulin sensitivity in men. Here, we present two studies examining the acute physiological and molecular responses to REHIT.

METHODS

In Study 1, five men and six women (age: 26 ± 7 year, BMI: 23 ± 3 kg m(-2), VO2max: 51 ± 11 ml kg(-1) min(-1)) performed a single 10-min REHIT cycling session (60 W and two 20-s 'all-out' sprints), with vastus lateralis biopsies taken before and 0, 30, and 180 min post-exercise for analysis of glycogen content, phosphorylation of AMPK, p38 MAPK and ACC, and gene expression of PGC1α and GLUT4. In Study 2, eight men (21 ± 2 year; 25 ± 4 kg·m(-2); 39 ± 10 ml kg(-1) min(-1)) performed three trials (REHIT, 30-min cycling at 50 % of VO2max, and a resting control condition) in a randomised cross-over design. Expired air, venous blood samples, and subjective measures of appetite and fatigue were collected before and 0, 15, 30, and 90 min post-exercise.

RESULTS

Acutely, REHIT was associated with a decrease in muscle glycogen, increased ACC phosphorylation, and activation of PGC1α. When compared to aerobic exercise, changes in VO2, RER, plasma volume, and plasma lactate and ghrelin were significantly more pronounced with REHIT, whereas plasma glucose, NEFAs, PYY, and measures of appetite were unaffected.

CONCLUSIONS

Collectively, these data demonstrate that REHIT is associated with a pronounced disturbance of physiological homeostasis and associated activation of signalling pathways, which together may help explain previously observed adaptations once considered exclusive to aerobic exercise.