Placing the keystone: the LIMBIC Military and Tactical Athlete Research Study

OBJECTIVE

The LIMBIC Military and Tactical Athletic Research Study (MATARS) framework was established to confirm and extend understanding of concussion with initial studies driven by clinical data collected between 2015 and 2020 in a collegiate sports setting. The LIMBIC MATARS framework will be leveraged to apply gold-standard and innovative research designs to advance the science of concussion. This manuscript provides the background, methodology, and initial demographic data associated with the LIMBIC MATARS.

METHODS

Consensus-based common data elements were used to conduct a retrospective chart review, specific to collegiate athletes diagnosed with concussions between 2015 and 2020 at 11 universities.

RESULTS

A final sample of 1,311 (47.8% female) concussions were diagnosed during the five-year study period from athletes participating in a variety of National Collegiate Athlete Association (NCAA) sports. The LIMBIC MATARS demographic data, align with the NCAA and other pioneering multi-site concussion-related studies in terms of biological sex, race and ethnicity, and sport participation.

CONCLUSION

This pragmatic, methodological approach was used to address several a priori hypotheses related to concussion, align with other multi-site studies of concussion, and establish a consortium for future investigations.

Cutaneous manifestations of PIMS-TS: a single centre experience

Paediatric inflammatory multisystem syndrome associated with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection (PIMS-TS) is defined as 'a child presenting with persistent fever, inflammation and evidence of single or multi-organ dysfunction with additional features which include a rash'.¹ The World Health Organisation's (WHO) definition further includes a 'rash or bilateral non-purulent conjunctivitis or muco-cutaneous inflammation signs'.² Previously reported mucocutaneous manifestations (MCM) in PIMS-TS have been vague. This study aimed to delineate the MCM of children presenting with PIMS-TS in more detail.

The systemic autoinflammatory disorders for dermatologists. Part 1: overview

The systemic autoinflammatory disorders (SAIDs) or periodic fever syndromes are disorders of innate immunity, which can be inherited or acquired. They are almost all very rare and easily overlooked; typically, patients will have seen multiple specialities prior to diagnosis, so a high level of clinical suspicion is key. It is important to note that these are 'high-value' diagnoses as the majority of these syndromes can be very effectively controlled, dramatically improving quality of life and providing protection against the development of irreversible complications such as AA amyloidosis. In this article, we take an overview of SAIDs and look at the common features; in Part 2, we take a more in-depth look at the better recognized or more dermatologically relevant conditions.

The systemic autoinflammatory disorders for dermatologists. Part 2: disease examples

The systemic autoinflammatory disorders (SAIDS) or periodic fever syndromes are disorders of innate immunity, which can be inherited or acquired. They are almost all very rare and easily overlooked; typically, patients will have seen multiple specialities prior to diagnosis, so a high level of clinical suspicion is key. It is important to note that these are 'high-value' diagnoses as the majority of these syndromes can be very effectively controlled, dramatically improving quality of life and providing protection against the development of irreversible complications such as AA amyloidosis. In Part 1 of this review, we took an overview of SAIDS and described the common features; in this article, we take a more in-depth look at the better recognized or more dermatologically relevant conditions.

Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

Cyclicity, estrus expression and pregnancy rates in beef heifers with different reproductive tract scores following progesterone supplementation

Two experiments were conducted to determine effects of progesterone (P4) on cyclicity, estrus expression rate (EER) and artificial insemination pregnancy rate (AIPR) in beef heifers with various reproductive tract scores (RTS; 1 to 5; 1, immature, acyclic; 5, mature, cyclic). In Experiment 1, Angus-cross heifers (n = 100, 20 per RTS category; mean (±SEM) age, 15 ± 0.8 mo) were randomly assigned to receive a CIDR (Days -17 to -10) or no CIDR (untreated control), with weekly blood samples and ultrasonography (Days 0-85). Among heifers with RTS 2 to 4, median interval to cyclicity were shorter (P < 0.05) for heifers in CIDR versus control. In Experiment 2, Angus-cross heifers (n = 11,098) were assigned RTS, body condition score (BCS; 1 to 9; 1, emaciated; 9, obese) and temperament score (calm versus excitable). Heifers with RTS 2-5 (n = 10,569) were allocated to CO-Synch (n = 5099) or CO-Synch + CIDR (n = 5470). Estrus was detected until AI (72 h after PGF2α), with pregnancy diagnosis ∼70 d later. Controlling for RTS (P < 0.0001), BCS (P < 0.0001), temperament (P < 0.0001), age (P < 0.0001), treatment by RTS (P < 0.01), treatment by BCS (P < 0.01), and treatment by age, EER differed between CO-Synch and CO-Synch + CIDR (71.0 vs 75.9%, respectively, P < 0.0001). Accounting for RTS (P < 0.0001), BCS (P < 0.0001), temperament (P < 0.0001), age (P < 0.0001), heifers detected in estrus (P < 0.0001), RTS by treatment (P < 0.01), BCS by treatment (P < 0.01), and age by treatment, AIPR differed between CO-Synch versus CO-Synch + CIDR (55.3 vs 61.0%, P < 0.0001). In conclusion, exogenous P4 hastened cyclicity in pre- and peri-pubertal beef heifers. Further, it increased EER and AIPR. However, RTS, BCS and age influenced EER and AIPR. Among RTS 4 and 5, EER was greater for CO-Synch + CIDR vs CO-Synch. Among RTS 3 to 5, AIPR was greater for CO-Synch + CIDR versus CO-Synch. Progesterone status or supplementation at onset of synchronization protocols was critical to pregnancy outcomes, emphasizing heifer development for early puberty or progesterone supplementation.

Neural Efficiency in Expert Cognitive-Motor Performers During Affective Challenge

Skilled individuals demonstrate a spatially localized or relatively lower response in brain activity characterized as neural efficiency when performing within their domain of expertise. Elite athletes are experts in their chosen sport and thus must be not only adept in the motor domain but must be resilient to performing under the stress of high-level competition. Such stability of performance suggests this population processes emotion and mental stress in an adaptive and efficient manner. This study sought to determine if athletes with a history of successful performance under circumstances of mental stress demonstrate neural efficiency during affective challenges compared to age-matched controls. Using functional magnetic resonance imaging, the blood-oxygen level-dependent response was recorded during emotional challenge induced by sport-specific and general unpleasant images. The athletes demonstrated neural efficiency in brain regions critical to emotion regulation (prefrontal cortex) and affect (insula) independently of their domain of expertise, suggesting adaptive processing of negative events and less emotional reactivity to unpleasant stimuli.

Neoadjuvant Chemotherapy for Newly Diagnosed, Advanced Ovarian Cancer: Society of Gynecologic Oncology and American Society of Clinical Oncology Clinical Practice Guideline

PURPOSE

To provide guidance to clinicians regarding the use of neoadjuvant chemotherapy and interval cytoreduction among women with stage IIIC or IV epithelial ovarian cancer.

METHODS

The Society of Gynecologic Oncology and the American Society of Clinical Oncology convened an Expert Panel and conducted a systematic review of the literature.

RESULTS

Four phase III clinical trials form the primary evidence base for the recommendations. The published studies suggest that for selected women with stage IIIC or IV epithelial ovarian cancer, neoadjuvant chemotherapy and interval cytoreduction are noninferior to primary cytoreduction and adjuvant chemotherapy with respect to overall and progression-free survival and are associated with less perioperative morbidity and mortality.

RECOMMENDATIONS

All women with suspected stage IIIC or IV invasive epithelial ovarian cancer should be evaluated by a gynecologic oncologist prior to initiation of therapy. The primary clinical evaluation should include a CT of the abdomen and pelvis, and chest imaging (CT preferred). Women with a high perioperative risk profile or a low likelihood of achieving cytoreduction to < 1 cm of residual disease (ideally to no visible disease) should receive neoadjuvant chemotherapy. Women who are fit for primary cytoreductive surgery, and with potentially resectable disease, may receive either neoadjuvant chemotherapy or primary cytoreductive surgery. However, primary cytoreductive surgery is preferred if there is a high likelihood of achieving cytoreduction to < 1 cm (ideally to no visible disease) with acceptable morbidity. Before neoadjuvant chemotherapy is delivered, all patients should have confirmation of an invasive ovarian, fallopian tube, or peritoneal cancer. Additional information is available at www.asco.org/NACT-ovarian-guideline and www.asco.org/guidelineswiki.

Bone marrow lesions in knee osteoarthritis change in 6-12 weeks

OBJECTIVES

Knee osteoarthritis (OA) is thought to be a slowly evolving disease with glacial changes in cartilage morphology necessitating trials of potential treatments lasting 1-2 years with evidence that over 6 months change in cartilage is not detectable. In contrast to cartilage, bone has the capacity to adapt rapidly, such as after fracture. We tested whether bone marrow lesions (BMLs) change in volume in 6 and 12 weeks, suggesting they may provide evidence of short term fluctuations of joint damage.

METHODS

In 62 patients with patellofemoral knee OA (mean age 55.7 years, 59.7% women, mean BMI 31.0), we obtained baseline, 6 and 12 week knee MRIs with contrast enhancement. Of those with BMLs at baseline, we assessed BML volume on the axial proton density fat saturated (FS) images and postcontrast sagittal T1 weighted FS images. We manually segmented BML volumes, testing repeatability of BML volumes in knees remeasured. Using the standard deviation of the difference between repeated measurements to calculate Bland-Altman Limits of Agreement, we determined how much BML volume change represented a change greater than due to chance.

RESULTS

Fifty-two patients had BMLs at baseline. Test-retest reliability for BML volume was high (ICC 0.89, 95% CI 0.80-0.97). All knees showed at least some change in BML volume by 6 and 12 weeks. On the axial view at 6 weeks, 20/49 (40.8%) knees showed BML volume changes greater than the limits of agreement with similar results at 12 weeks. BML changes were evenly divided among knees with enlarging and shrinking BMLs. 63.3% of the knees had more than 50% change in BML volume at either 6 or 12 weeks on the axial view and 48.7% on the sagittal view.

CONCLUSIONS

Knee BML volumes change in several weeks in many persons with knee OA. To the extent that they could be regarded as treatment targets, trials testing BML effects could avoid the usual prolonged structure modification trials.

Improving cancer patients' pain: the impact of the hospital specialist palliative care team

Pain is reported to occur in the majority of patients with advanced cancer and is one of the main reasons for referral to a hospital specialist palliative care team. Yet despite this, there is a paucity of research into the impact the hospital specialist palliative care team has on pain control in patients. A non-equivalent control group design using a quota sample investigated 100 cancer patients who had been admitted to hospital for symptom control. Fifty patients received specialist hospital palliative care team intervention compared with 50 patients receiving traditional care. Outcome was assessed using the Palliative Care Assessment (PACA) tool on three occasions. There was no difference between the groups on the initial assessment and the results indicated that all cancer patients admitted to hospital had a significant improvement in their pain control. However, the patients who had the additional input of the palliative care team demonstrated a statistically significant greater improvement than the control group (P<0.001). Potential explanations are made for the results including the enhanced knowledge and skills of the hospital specialist palliative care team.

Cervical spine ROM measurements: optimizing the testing protocol by using a 3D ultrasound-based motion analysis system

The aim of this study was to evaluate the intra- and inter-examiner reliability and validity of neck range of motion (ROM) measurements. Thirty-five healthy subjects were assessed in all neck movements from two initial positions, sitting and standing, actively (open and closed eyes) and passively by using a 3D ultrasound-based motion analysis device (Zebris). Three tests were employed to assess intra-examiner reliability and two examiners used for the inter-examiner reliability. X-rays in neck flexion and extension were used to validate the Zebris system. The standing position yielded higher intraclass correlation coefficient (ICC) values (>0.86) with less error [smallest detectable difference (SDD)<13.8%] than sitting (ICC>0.79, SDD<14%). Passive assessment of neck ROM presented better reproducibility than active assessment with open or closed eyes in both positions. The inter-examiner reliability was moderate (ICC=0.43-0.68). The correlation between the Zebris system and X-rays was high in both flexion and extension movements. The results showed that the most reliable protocol for assessment of neck ROM is a passive measurement in the standing position. The measurements were well validiated against X-rays and the experience of the investigators must be considered before any comparison among studies is employed.

Intra-rater and inter-rater reliability of gait measurements with CODA mpx30 motion analysis system

Variations between measurements of clinical outcomes sometimes result from observer errors and are not due to the therapeutic intervention. For the correct interpretation of clinical data it is, therefore, important to ascertain the reliability of the measurement methods used. In the present study we evaluated the test-retest and between observer reliability of gait measurements with the Cartesian Optoelectronic Dynamic Anthropometer (CODA mpx30) motion analysis system. Our findings suggest a better intra-rater and inter-rater reliability of kinetic than kinematic data. Disagreements between the investigators were most marked for the kinematic data, especially the hip angle, and disagreements were least for the spatio-temporal gait parameters. The poor reproducibility of kinematic variables may be due to problems with the accurate placement of markers on the surface anatomical landmarks.

Poor prognosis of patients presenting with symptomatic myocardial infarction but without chest pain

OBJECTIVE

To describe the clinical features, prognosis, and treatment of patients presenting with atypical forms of acute myocardial infarction.

DESIGN

Consecutive cases of possible acute myocardial infarction were sought from coronary care registers, biochemistry records, and hospital management systems. Case notes were reviewed and predefined epidemiological and clinical variables were abstracted.

SETTING

20 adjacent hospitals in the former Yorkshire region.

PATIENTS

3684 consecutive cases of possible acute myocardial infarction admitted in a three month period were identified, of whom 2096 had a first episode of confirmed acute myocardial infarction.

RESULTS

20.2% of all patients admitted with an eventual diagnosis of acute myocardial infarction presented with symptoms other than chest pain. Compared with the group presenting with chest pain, these patients were older (76.6 v 69.1 years, p < 0.001), were more often women (54.6% v 35.3%, p < 0.001), and were more likely to have a history of heart failure (18.6% v 6.9%, p < 0.001). They had a higher 30 and 365 day mortality (49.2% and 61.0%, respectively) compared with patients presenting with chest pain (17.9% and 26.2%). In a Cox regression analysis the hazard ratio for presentation without chest pain was 1.60 (95% confidence interval 1.30 to 1.97) (p < 0.001) adjusted for age, heart rate, blood pressure, left ventricular impairment, and infarction with ST segment elevation as covariates. Importantly, they were also less likely to receive treatments with a proven ability to improve prognosis.

CONCLUSIONS

Atypical presentation of myocardial infarction without chest pain is common and associated with increased mortality. This may result in part from a failure to use beneficial treatment strategies.

A simple benchmark for evaluating quality of care of patients following acute myocardial infarction

OBJECTIVE

To develop a simple risk model as a basis for evaluating care of patients admitted with acute myocardial infarction.

METHODS

From coronary care registers, biochemistry records and hospital management systems, 2153 consecutive patients with confirmed acute myocardial infarction were identified. With 30 day all cause mortality as the end point, a multivariable logistic regression model of risk was constructed and validated in independent patient cohorts. The areas under receiver operating characteristic curves were calculated as an assessment of sensitivity and specificity. The model was reapplied to a number of commonly studied subgroups for further assessment of robustness.

RESULTS

A three variable model was developed based on age, heart rate, and systolic blood pressure on admission. This produced an individual probability of death by 30 days (P(30)) where P(30) = 1/(1 + exp(-L(30))) and L(30) = -5.624 + (0.085 x age) + (0.014 x heart rate) - (0.022 x systolic blood pressure). The areas under the receiver operating characteristic curves for the reference and test cohorts were 0.79 (95% CI 0.76 to 0.82) and 0.76 (95% CI 0.72 to 0.79), respectively. To aid application of the model to routine clinical audit, a normogram relating observed mortality and sample size to the likelihood of a significant deviation from the expected 30 day mortality rate was constructed.

CONCLUSIONS

This risk model is simple, reproducible, and permits quality of care of acute myocardial infarction patients to be reliably evaluated both within and between centres.

Myostatin regulation during skeletal muscle regeneration

Myostatin, a member of the TGF-beta superfamily, is a key negative regulator of skeletal muscle growth. The role of myostatin during skeletal muscle regeneration has not previously been reported. In the present studies, normal Sprague-Dawley and growth hormone (GH)-deficient (dw/dw) rats were administered the myotoxin, notexin, in the right M. biceps femoris on day 0. The dw/dw rats then received either saline or human-N-methionyl GH (200microg/100g body weight/day) during the ensuing regeneration. Normal and dw/dw M. biceps femoris were dissected on days 1, 2, 3, 5, 9 and 13, formalin-fixed, then immunostained for myostatin protein. Immunostaining for myostatin revealed high levels of protein within necrotic fibres and connective tissue of normal and dw/dw damaged muscles. Regenerating myotubes contained no myostatin at the time of fusion (peak fusion on day 5), and only low levels of myostatin were observed during subsequent myotube enlargement. Fibres which survived assault by notexin (survivor fibres) contained moderate to high myostatin immunostaining initially. The levels in both normal and dw/dw rat survivor fibres decreased on days 2-3, then increased on days 9-13. In dw/dw rats, there was no observed effect of GH administration on the levels of myostatin protein in damaged muscle. The low level of myostatin observed in regenerating myotubes in these studies suggests a negative regulatory role for myostatin in muscle regeneration.

Rethinking incentives

Financial incentives focused on individuals represent a naive understanding of the complexity of human motivation. This article recommends rethinking monetary incentives and moving toward the creation of workplaces that enable and allow the natural excellence that most individuals desire to achieve. Despite their wide use and superficial logic, monetary incentives have features that are toxic to systemic improvement and high performance. They often erode opportunities for true improvement, breed an atmosphere of expectation, decrease innovation, injure intrinsic motivation, and damage teamwork. When monetary "incentives" are used, we suggest directing them to a whole group or team of individuals to inspire teamwork, learning, and greater productivity.

Who are your patients? Patient information in practice planning and performance improvement

Knowledge of patients above the individual level is important for any quality improvement effort in the office practice, and for informing decisions for the organization's strategic direction on service delivery. Pivotal in this knowledge is the development of a registry of patients for an office, and understanding of how that is linked to improvement methods. This article describes a method of how this development and understanding may be achieved, giving practical detail and examples.

Growth factors controlling muscle development

The enlarged muscles of certain breeds of cattle, such as the Belgian Blue, have been shown to result from a marked increase in the number of normal sized muscle fibers. Originally insulin-like growth factors (IGFs) were implicated in this myofiber hyperplasia, as IGFs have been shown to stimulate myoblast proliferation as well as maintain fiber differentiation. Recently it has been reported that mice lacking a myostatin gene, a member of the TGFbeta superfamily, have enhanced skeletal mass resulting from increased muscle fiber number and size. Mutations in this gene have been found in double-muscled cattle, indicating that myostatin is an inhibitor of muscle growth. Myostatin is expressed early in gestation and then maintained to adulthood in certain muscles. Myostatin expression in bovine muscle is highest during gestation when muscle fibers are forming and some of the myogenic regulatory factors have elevated expression over the same period as myostatin. Molecular expression of the IGF axis does not differ between Belgian Blue and normal muscled cattle, and IGF-II mRNA is increased throughout formation of secondary fibers in both breeds. However, myostatin and MyoD expression in muscle differ between normal and hypertrophied muscle cattle breeds. This evidence strongly suggests that lack of myostatin is associated with an increase in fiber number which then results in a marked increase in potential muscle mass in double-muscled cattle.

The Internet and randomised controlled trials

Several factors constrain the implementation of Randomised Controlled Trials (RCTs). To obtain large sample sizes a multicentred multinational trial may be necessary or a long sampling period. The larger the trial the larger is the unit cost. To allow larger sample sizes, shorter sampling periods and lower unit costs, new methods are needed. The Internet and in particular the WWW provides such an opportunity. The WWW can provide global access, fast interaction and automation. A prototype Internet Trials Service (ITS) is currently being tested with a real international clinical trial (the Growth Restriction Intervention Trial--GRIT). The ITS is hosted on a Web server. It provides a series of HTML documents that describe the GRIT protocol. Registered centres may enter patients into the GRIT trial via ITS. Java applets are used to collect trial data before returning the study number and randomisation. ITS assumes all trial data will be intercepted by a sniffer. Therefore no information is sent that could specifically identify a patient, this must be sent later by more secure means. ITS assumes that trial centres can be spoofed. To authenticate the patients entered into the trial and the trial data sent, a regular audit report is sent to each centre by secure means for confirmation. By using Java, a full functional data entry system can be developed that runs locally within any Java enabled browser. It can perform data validation locally and also provide a sophisticated user interface.

The recruitment of ovarian follicles is enhanced by increased dietary intake in heifers

The objective of this study was to determine whether dietary-induced changes in growth hormone (GH), insulin, and IGF-I alter the pattern of ovarian follicular development in heifers. Twenty-eight 2- to 3-yr-old Hereford-Friesian heifers were equally allocated (n = 7) to one of four dietary treatments: 1) Control (C) fed a maintenance diet as two meals per day; 2) twice maintenance (2M2) given as two meals per day; 3) twice maintenance (2M6) given as six meals per day; 4) feed-deprived (F) fed maintenance requirements as for C, changed to straw ad libitum for 3 d from a synchronized estrus. On d 4 (estrus = d 0) heifers were transferred to grass silage (ad libitum access) until the end of the experiment. Blood samples were collected hourly for 10 h on d 1 and 3 and daily for an additional 14 d. Follicular development was monitored daily by ultrasonography until d 14. The number of small follicles (< 4 mm) was increased (P < .05) by 37% on d 1 and 2 in 2M2 and 2M6 heifers, with no carryover effect of nutrition to the second follicular wave. Number of medium-sized (4 to 8 mm) and large (> 8 mm) follicles did not vary (P > .05) among treatments. The FSH concentrations were not different (P > .05) among treatments. Insulin concentrations were higher (P < .05) in 2M2 and 2M6 heifers than in C or F heifers, with no carryover after the diet was changed. Increase in number of small follicles was independent of changes in FSH and IGF-I, negatively associated with GH, but positively associated with circulating insulin. These results indicate that a short-term increase in nutritional plane can affect follicular recruitment in cycling heifers.

Offering patients entry in clinical trials: preliminary study of the views of prospective participants

OBJECTIVE

To ascertain attitudes to different methods of obtaining informed consent for randomised clinical trials (RCTs).

DESIGN

Structured interviews with members of the public, medical secretaries and medical students.

SETTING

The public were approached in a variety of public places. Medical secretaries and students were approached in their place of work.

SUBJECTS

Fifty members of the public, 25 secretaries and 25 students.

MAIN OUTCOME MEASURES

Views on RCTs were elicited, with particular emphasis on how subjects thought the concept of randomisation should be explained. Each participant was presented with descriptions of proposed clinical trials and asked to select his or her preference from a range of options.

RESULTS

Written information was preferred over verbal information in 91% of replies. Most respondents (86%) would prefer to sign a consent form. Of the seven statements explaining randomisation, a significant difference was found in favour of explanations that were less explicit about the play of chance (ANOVA; p = 0.0004). Eighty-three per cent of participants thought that randomised trials were morally acceptable when there was no prior medical preference between treatments. However, over half (55%) thought they would find it upsetting to be offered entry in such a trial and a quarter thought the outcome of treatment might be adversely affected.

CONCLUSIONS

Our results offer some support for the idea that "economy with truth" is less unsettling than a frank description of the stark reality of what randomisation means. It is a matter of debate as to whether, if we are correct, autonomy should have precedence over beneficence. The offer of entry in a clinical trial is likely to affect the experience of care for many people, especially if the process of randomisation is described explicitly. Potential participants should be given a detailed written explanation of the rationale for the trial and be asked to sign a consent form if they agree to take part.

Antepartum and postpartum complications of twin-twin transfusion

Twin-twin transfusion is a condition that was previously associated with close to a 100% perinatal mortality. Recent reports suggest that a survival rate of about 60% can be achieved with serial amniocentesis and modern neonatal care. However, it is now apparent that the survivors of this condition have multisystem complications that can result in neonatal mortality and long-term morbidity. Fourteen cases of twin-twin transfusion were examined to determine the antenatal findings that may predict the postnatal outcomes of these infants. The overall survival was 61% (17 of 28). The mean gestation at diagnosis was 23.0 weeks (range 18-34 weeks) and the mean gestation at delivery was 29.0 weeks (range 23-37 weeks). The mean number of amniocenteses was 2.9 and the average total volume of amniotic fluid removed was 6,114 mL. Different patterns of complications were seen in the donor and recipient twins. Hypertrophic cardiomyopathy affected 9 of the recipient twins. Anuria/oliguria was found in 4 of the donor twins and none of the recipients. Periventricular leukomalacia was found in 8 twins and 7 also had mild ventriculomegaly; of the surviving 17 twins, 5 had either periventricular leukomalacia, mild ventriculomegaly or both. Amniotic fluid leakage and perforation of the intervening membrane subsequent to serial amniocentesis were seen in 5 cases. Severe intrauterine growth retardation and abnormal cardiotocographs were a common feature. These complications directly resulted in neonatal mortality and long-term morbidity in the survivors. Not all complications were detected antenatally and the severity was not able to be anticipated.

Measuring muscle tone and movement

Abnormal or altered muscle tone in the neurologically damaged patient presents major problems for restoring motor function. Many nursing interventions, such as passive limb exercises and correct limb positioning, attempt to normalise muscle tone. The effect of abnormal tone on movement can be clearly seen, therefore it may be more appropriate to measure the 'quality' of movement. This article describes various methods of measuring muscle tone, such as video analysis, and examines the reliability of these techniques.

Functional tests in elderly osteoarthritic subjects: variability of performance

The purpose of this study was to evaluate the variability of performance of timed walking and sit-to-stand tests in elderly osteoarthritic subjects. Thirteen elderly subjects were asked to walk, as quickly as possible, along a flat corridor a distance of ten metres. The time and number of strides taken were recorded. Fourteen subjects were asked to perform a series of five sit-to-stand movements as quickly as possible from a plinth 48 cm high. Subjects performed three repeats of each test procedure with a two-minute rest period between each. This was undertaken on three separate occasions within a one-week period. A significant difference (p < 0.05) was observed for the time taken to complete the ten metres over the nine tests, but no significant difference was observed in the number of strides taken. The mean coefficient of variation for time taken was 7.3 per cent, which compares favourably with normal biological systems (1). No significant difference was observed for the time taken during the sit-to-stand test over the nine tests. These simple tests of functional ability may be confidently applied as sequential measures in the clinical setting.

Statistical tests (Part 3): Non-parametric tests

The previous two articles in this series (1,2) have considered in some detail the descriptive and parametric approaches to statistical analysis. This final article now considers principally the non-parametric approach to statistical analysis and, briefly, looks at the concepts of dimension reduction, factor analysis and confidence limits.

Statistical tests (Part 1): Descriptive statistics

This series of three articles has been designed to facilitate an understanding of some commonly used statistical terms encountered when reading research articles. In addition, it is hoped that the nurse researcher who has access to a personal computer containing basic statistical software will gain some insight into which statistical tests to use and in what circumstances. The articles do not attempt to provide any understanding of the mathematics of the statistical tests employed.

The degree of day-to-day variation in food intake in diabetic patients

A prospective study of food intake using 7 day food diaries was undertaken in 92 diabetic men and women aged 17-81 years. The median individual day-to-day coefficients of variation for energy intake were: in insulin treated patients 12.0%, in non-insulin treated patients 13.7%; for carbohydrate intake 14.5% and 13.8% and for fat 20.7% and 20.8%, respectively. The median individual differences between the minimum and maximum daily intake of energy in insulin treated patients was 787 kcal, in non-insulin treated patients 649 kcal, for carbohydrate intake 89g and 77g and fat 50g and 43g, respectively. Only 39% patients ate within 20% of their prescribed carbohydrate diet. In non-insulin treated patients on prescribed calorie controlled diets, calorie consumption was on average 46% in excess of that prescribed. Although the variation in dietary intake in diabetic patients is large, it is smaller than that reported in non-diabetic subjects in the UK. This variation is likely to make the manipulation of other antidiabetic therapy both difficult and somewhat arbitrary.

Rehabilitation of muscle function. Part 2

This article describes the utilisation of a physiologically based research technique developed to facilitate the nursing care of patients with skeletal muscle wasting. The technique, which involved electrotherapeutic stimulation to the first dorsal interosseous muscle of a group of arthritic patients, demonstrates that patterned neuromuscular stimulation of skeletal muscle can have enormously beneficial effects in preserving and regenerating skeletal muscle. The reasons for the muscle wasting, and the subsequent vicious spiral of immobility, were reviewed in Part 1 (1), and both articles build on the concepts described in a previous paper published in Nursing Standard (2).

Rehabilitation of muscle function. Part 1

This article, which develops the concepts introduced in the authors' paper in last week's edition (1), is the first of two which review and summarise recent studies describing techniques to test the hypothesis that uniform frequency stimulation of skeletal muscle deprives the muscle of the type of signals that are necessary for rapid, appropriate and effective adaptation. Next week, clinical trials which have tested this hypothesis will be described, and the implications of the results for nurses involved in rehabilitation work discussed; Part 1 sets out the methodology of extracting the firing patterns of single motor units from a fatiguing muscle.

Rehabilitation: objective assessment of muscle function

The lack of an appropriate and objective measuring scale or tool has ensured that rehabilitation nurses' assessments of patients' muscle function have tended to be subjective and, arguably, inconsistent. Such inexact methods are no longer acceptable to the increasingly audit-conscious health service and research-oriented nursing profession. The authors introduce a means of completing an objective assessment of patients' muscle function which, they claim, will enable nurses to evaluate the efficacy of current and potential treatment options. In follow-up articles appearing in the next two editions of Nursing Standard, they discuss electrotherapeutic rehabilitation of skeletal muscle function.

Diabetic diets and nutritional recommendations: what happens in real life?

Prospective 7-day estimated weight food records were computer analysed in 92 diabetic patients, 45 men and 47 women, 25 with Type 1 and 67 Type 2 diabetes, attending a hospital-based diabetic clinic. The nutrient intakes were compared with a national survey in non-diabetic British adults (OPCS) and the current EASD recommendations for the diabetic diet. Only three diabetic patients achieved the recommended 50-60% energy intake as carbohydrate, four achieved less than 30% energy as fat, one patient less than 10% saturated fat and 20 ate greater than 30 g fibre per day. The overall nutrient intakes of these diabetic patients reflected those of non-diabetic subjects except for a greater intake of protein and smaller intakes of sugar and alcohol. These findings reinforce the problems currently faced in achieving the present recommendations for the diabetic diet.

Clinical education. Relating practical experiments to theory

Integrating theory into practice is not without its difficulties. Often concepts derived from the physical and behavioural sciences appear to be unrelated to nursing practice and although noted laboriously by student nurses no active learning occurs. As nurse education changes not only in curriculum content and teaching methodology but in who will do the teaching and in what venue, then the importance of ensuring the relevance of theoretical concepts to nursing practice will increase. This paper illustrates how physiological theory can be integrated into nursing practice by the use of ward-based practical experiments. Currently four such experiments have been introduced and are being evaluated. There is scope for developing further experiments and it is contended that this approach will enhance learning.