The Influence of High-Intensity Work on the Record Power Profile of Under-23, Pro Team, and World Tour Cyclists

BACKGROUND

Durability (ie, the ability to attenuate the decline in performance after accumulated work) has been identified as a performance determinant in elite cyclists. The aim of the present study was to compare durability in elite cyclists of various performance levels, particularly after high-intensity work, referred to as "high-intensity durability."

METHODS

Forty-nine (N = 49) male road cyclists were categorized as either under 23 years of age (U23) (N = 11), Pro Team (N = 13), or World Tour (N = 24). The participants' critical power (CP) was assessed during the preseason. Thereafter, the participants' maximum mean power (MMP) values were determined for efforts of different durations (from 5 s to 30 min) after different levels of accumulated work above CP (from 0 to 7.5 kJ·kg-1).

RESULTS

U23 cyclists showed a significant reduction of all relative MMP values for durations ≥1 minute after ≥5 kJ·kg-1 above CP compared with the "fresh" state (0 kJ·kg-1), whereas in Pro Team and World Tour cyclists, a significant reduction was not observed until 7.5 kJ·kg-1 above CP. In the "fresh" state, both Pro Team and particularly World Tour cyclists attained higher MMP values for efforts ≥10 minutes than U23 riders. However, more differences emerged with greater previous work levels, and indeed after 7.5 kJ·kg-1 above CP World Tour cyclists attained higher MMP values than both U23 and Pro Team cyclists for most efforts (≥30 s).

CONCLUSION

Pro Team and particularly World Tour cyclists tolerate greater levels of accumulated work at high intensity, which might support the importance of high-intensity durability for performance.

Is all work the same? Performance after accumulated work of differing intensities in male professional cyclists

OBJECTIVES

Although the ability to attenuate power output (PO) declines after accumulated work (i.e., 'durability') is increasingly recognized as a major determinant of cycling performance, the potential role of the intensity of the previous work is unclear. We assessed the effect of work-matched levels of accumulated work at different intensities on performance in male professional cyclists.

DESIGN

Observational field-based study.

METHODS

PO data was registered in 17 cyclists during a competition season, and the critical power (CP) was repeatedly determined every 4 weeks from training sessions and competitions. Participants' maximum mean power (MMP) for different durations (5 s, 5 min, 10 min, and 20 min) and the CP were determined under 'fresh' conditions (0 kJ·kg-1) and after varying levels of accumulated work (2.5, 5.0 and 7.5 kJ·kg-1) at intensities below and above the CP.

RESULTS

A significant decline was found for all MMP values following all levels of accumulated work above the CP (-4.0 %, -1.7 %, -1.8 %, and -3.2 % for 30s, 5 min, 10 min and 20 min-MMP, respectively; all p < 0.001), versus no change after any level of accumulated work below the CP (all p > 0.05). Similar results were observed for the CP, which decreased after all levels of accumulated work above (-2.2 %, -6.1 %, and -16.2 %, after 2.5, 5.0 and 7.5 kJ·kg-1, p < 0.001) but not below this indicator (p > 0.05).

CONCLUSIONS

In male professional cyclists, accumulated work above the CP impairs performance compared with work-matched, albeit less intense efforts. This raises concerns on the use of mechanical work per se as a single fatigue/stress indicator in these athletes.

An improved methodology for estimating critical power from mean maximal power output data

The aim of this study was to determine if Critical Power (CP) and W' can be estimated from mean maximal power output (MMP) data collected in cycling races. Data were collected from 13 under 23 professional cyclists (mean ± SD; age, 19.5 ± 1.1 y; body mass, 66.3 ± 5.0 kg; height, 180.0 ± 5.0 cm; CP, 5.7 ± 0.3 W · kg-1). Participants conducted a CP test in the field to determine CPTest and W'Test. MMP data were then collected in races for the subsequent 90 days. CP and W' were estimated from MMP values in two ways, using fixed MMP durations, 2, 5 and 12 min (CPFixed and W'Fixed), and via a novel filtering of second-by-second MMP data (CPFiltered and W'Filtered). CPFixed and CPFiltered were not significantly different from CPTest (Mean Difference (MD) 5 W and 7 W, respectively, p > 0.05). W'Fixed and W'Filtered were not significantly different from W'Test (MD 2.68 kJ and 0.89 kJ, respectively, p > 0.05). CPFixed and CPFiltered correlated significantly with CPTest (r = 0.872 and 0.922, respectively, p < 0.0001 for both). Neither W'Fixed nor W'Filtered correlated significantly with W'Test (p > 0.05). Both CPFixed and CPFiltered provide valid estimates of CPTest.; however, CPFiltered provides a better estimate.

Physiological Characteristics of Competitive Male Junior Cyclists Transitioning to the Under-23 Level: A Retrospective Comparative Study

PURPOSE

The purpose of the current investigation was to retrospectively assess possible differences in physiological performance characteristics between junior cyclists signing a contract with an under-23 (U23) development team versus those failing to sign such a contract.

METHODS

Twenty-five male junior cyclists (age: 18.1 [0.7] y, stature: 181.9 [6.0] cm, body mass: 69.1 [7.9] kg, peak oxygen uptake: 71.3 [6.2] mL·min-1·kg-1) were assigned to this investigation. Between September and October of the last year in the junior category, each cyclist performed a ramp incremental exercise test to determine certain physiological performance characteristics. Subsequently, participants were divided in 2 groups: (1) those signing a contract with a U23 development team (JUNIORU23) and (2) those failing to sign such a contract (JUNIORNON-U23). Unpaired t tests were used to assess possible between-groups differences in physiological performance characteristics. The level of statistical significance was set at P < .05 two tailed.

RESULTS

No significant between-groups differences in submaximal (ie, gas exchange threshold, respiratory compensation point) and maximal physiological performance characteristics (ie, peak work rate, peak oxygen uptake) expressed in absolute values (ie, L·min-1, W) were observed (P > .05). However, significant between-groups differences were observed when physiological performance characteristics were expressed relative to the cyclists' body weights (P < .05).

CONCLUSIONS

The current investigation showed that junior cyclists stepping up to a U23 development team might be retrospectively differentiated from junior cyclists not stepping up based on certain physiological performance characteristics, which might inform practitioners and/or federations working with young cyclists during the long-term athletic development process.

Alterations in aerobic fitness and muscle deoxygenation during ramp incremental exercise in trained youth cyclists: a ~3-year longitudinal study

Alterations of aerobic fitness and muscle deoxygenation during a ramp incremental exercise test (GXT) were assessed on two occasions within a time-frame of 2.9 ± 0.1y in competitive youth cyclists. Nine cyclists (age, 14.5 ± 1.1y; peak oxygen uptake (V˙O_2peak), 62.6 ± 4.2 mL.min^-1.kg^-1) participated in this investigation. V˙O_2peak, the gas exchange threshold (GET) and the respiratory compensation point (RCP), as well as the muscle deoxygenation response pattern were determined during a GXT using open circuit spirometry and near-infrared spectroscopy, respectively. T-tests and Pearson's correlations were used to assess effects of time on the dependent variables and relationships between changes of parameter estimates of aerobic fitness and the muscle deoxygenation response, respectively. Workrate and metabolic rate at GET (33 ± 20 and 42 ± 23%) and RCP (36 ± 20 and 40 ± 22%), and V˙O_2peak (30 ± 18%) significantly increased throughout the study (P < 0.05). The muscle deoxygenation response showed a significant rightward shift from occasion one to two (P < 0.05). Alterations in the workrate/metabolic rate at RCP, and V˙O_2peak, were correlated with alterations of the muscle deoxygenation response (R = 0.71-0.89, P < 0.05). Together, this is thought to indicate a superior muscle perfusion within the tissue of interrogation at the same metabolic rate on occasion two vs. one, which partially contributed to the improved aerobic fitness in the cyclists herein.

The Relationship between Physiological Characteristics and Durability in Male Professional Cyclists

PURPOSE

This study aimed to determine if durability can be predicted from laboratory measures in a professional cycling population.

METHODS

Data were collected from 10 professional cyclists (age = 19.2 ± 0.8 yr, body mass = 70.4 ± 5.5 kg, height = 182.9 ± 4.0 cm, body mass index = 21.0 ± 1.3 kg·m -2 , V̇O 2max = 74.4 ± 4.8 mL·kg -1 ·min -1 , critical power [CP] = 5.6 ± 0.6 W·kg -1 , W' = 23.7 ± 5.4 kJ). Participants completed a laboratory test and a CP test on two occasions. The second occasion was preceded by a novel fatiguing protocol, which consisted of five bouts of 8-min of exercise at 105%-110% of CP. CP in a fatigued state was expressed as a percentage of the fresh CP and coined delta CP (∆CP). The Pearson product correlation analysis was conducted to determine the relationship between laboratory-based measures and ∆CP.

RESULTS

Significant positive relationships were found between ∆CP and relative peak power output ( r = 0.891, P < 0.001), relative maximum oxygen uptake ( r = 0.835, P = 0.003), relative power output at the second ventilatory threshold ( r = 0.738, P = 0.015), power output at the first ventilatory threshold ( r = 0.748, P = 0.013) and relative power output at the first ventilatory threshold ( r = 0.826, P = 0.003), gross efficiency at 300 W ( r = 0.869, P = 0.001), and at 200 W ( r = 0.792, P = 0.006). Significant negative relationships were found between ∆CP and carbohydrate oxidation at 200 W ( r = -0.702, P = 0.024). A multiple linear regression demonstrated that ∆CP can be predicted from laboratory measures ( R2 = 0.96-0.98, P < 0.001).

CONCLUSIONS

These findings demonstrate the physiological determinants of durability in a professional cycling population.

Predictors of cycling performance success: Traditional approaches and a novel method to assess performance capacity in U23 road cyclists

OBJECTIVES

This study aimed to investigate predictors of cycling performance in U23 cyclists by comparing traditional approaches to a novel method - the compound score. Thirty male U23 cyclists (N = 30, age 20.1 ± 1.1 yrs, body mass 69.0 ± 6.9 kg, height 182.6 ± 6.2 cm, V̇O_2max 73.8 ± 2.5 mL·kg^-1·min^-1) participated in this study.

DESIGN

Power output information was derived from laboratory and field-testing during pre-season and mean maximal power outputs (MMP) from racing season. Absolute and relative 5-min MMP, 5-min MMP after 2000 kJ (MMP_{2000 kJ}), allometric scaling and the compound score were compared to the race score and podium (top 3) performance during a competitive season.

METHODS

Positive and negative predictive values were calculated for all significant performance variables for the likelihood of a podium performance.

RESULTS

The absolute 5-min MMP of the field test revealed the highest negative predictive capacity (82.4%, p = 0.012) for a podium performance. The compound score of the 5-min MMP_{2000 kJ} demonstrated the highest positive and average predictive capacity (83.3%, 78.0%, p = 0.007 - respectively). The multi-linear regression analysis revealed a significant predictive capacity between performance variables and the race score (R² = 0.55, p = 0.015).

CONCLUSIONS

Collectively the results of the present study reveal that the compound score, alongside absolute power, was able to predict the highest positive and average likelihood for a podium performance. These findings can help to better understand performance capacity from field data to predict future cycling success.

Elite versus non-elite cyclist - Stepping up to the international/elite ranks from U23 cycling

This study investigated the physiological, performance and training characteristics of U23 cyclists and assessed the requirements of stepping up to the elite/international ranks. Twenty highly trained U23 cyclists (age, 22.1 ± 0.8 years; body mass, 69.1 ± 6.8 kg; VO_2max, 76.1 ± 3.9 ml·kg^-1·min^-1) participated in this study. The cyclists were a posteriori divided into two groups based on whether or not they stepped up to elite/international level cycling (U23_ELITE vs. U23_NON-ELITE). Physiological, performance and training and racing characteristics were determined and compared between groups. U23_ELITE demonstrated higher absolute peak power output (p = .016), 2 min (p = .026) 5 min (p = .042) and 12 min (p ≤ .001) power output as well as higher absolute critical power (p = .002). Further, U23_ELITE recorded more accumulated hours (p ≤ .001), covered distance (p ≤ .001), climbing metres (p ≤ .001), total sessions (p ≤ .001), total work (p ≤ .001) and scored more UCI points (p ≤ .001). These findings indicate that U23_ELITE substantially differed from U23_NON-ELITE regarding physiological, performance and training and racing characteristics derived from laboratory and field. These variables should be considered by practitioners supporting young cyclists throughout their development towards the elite/international ranks.

Stable and Discriminatory Radiomic Features from the Tumor and Its Habitat Associated with Progression-Free Survival in Glioblastoma: A Multi-Institutional Study

BACKGROUND AND PURPOSE

Glioblastoma is an aggressive brain tumor, with no validated prognostic biomarkers for survival before surgical resection. Although recent approaches have demonstrated the prognostic ability of tumor habitat (constituting necrotic core, enhancing lesion, T2/FLAIR hyperintensity subcompartments) derived radiomic features for glioblastoma survival on treatment-naive MR imaging scans, radiomic features are known to be sensitive to MR imaging acquisitions across sites and scanners. In this study, we sought to identify the radiomic features that are both stable across sites and discriminatory of poor and improved progression-free survival in glioblastoma tumors.

MATERIALS AND METHODS

We used 150 treatment-naive glioblastoma MR imaging scans (Gadolinium-T1w, T2w, FLAIR) obtained from 5 sites. For every tumor subcompartment (enhancing tumor, peritumoral FLAIR-hyperintensities, necrosis), a total of 316 three-dimensional radiomic features were extracted. The training cohort constituted studies from 4 sites (n = 93) to select the most stable and discriminatory radiomic features for every tumor subcompartment. These features were used on a hold-out cohort (n = 57) to evaluate their ability to discriminate patients with poor survival from those with improved survival.

RESULTS

Incorporating the most stable and discriminatory features within a linear discriminant analysis classifier yielded areas under the curve of 0.71, 0.73, and 0.76 on the test set for distinguishing poor and improved survival compared with discriminatory features alone (areas under the curve of 0.65, 0.54, 0.62) from the necrotic core, enhancing tumor, and peritumoral T2/FLAIR hyperintensity, respectively.

CONCLUSIONS

Incorporating stable and discriminatory radiomic features extracted from tumors and associated habitats across multisite MR imaging sequences may yield robust prognostic classifiers of patient survival in glioblastoma tumors.

Effects of Flat and Uphill Cycling on the Power-duration Relationship

The purpose of this study was to investigate the effects of flat and uphill cycling on critical power and the work available above critical power. Thirteen well-trained endurance athletes performed three prediction trials of 10-, 4- and 1-min in both flat (0.6%) and uphill (9.8%) cycling conditions on two separate days. Critical power and the work available above critical power were estimated using various mathematical models. The best individual fit was used for further statistical analyses. Paired t-tests and Bland-Altman plots with 95% limits of agreement were applied to compare power output and parameter estimates between cycling conditions. Power output during the 10- and 4-min prediction trial and power output at critical power were not significantly affected by test conditions (all at p>0.05), but the limits of agreement between flat and uphill cycling power output and critical power estimates are too large to consider both conditions as equivalent. However, power output during the 1-min prediction trial and the work available above critical power were significantly higher during uphill compared to flat cycling (p<0.05). The results of this investigation indicate that gradient affects cycling time-trial performance, power output at critical power, and the amount of work available above critical power.

Differences in training characteristics between junior, under 23 and professional cyclists

The aim was to compare the training characteristics of junior, under 23 and professional road cyclists. Training data collected during the 2019 competitive season of thirty male cyclists, divided into three age-related categories (JUN; U23; PRO), were retrospectively analyzed for training characteristics, external and internal training load. Higher duration per training session were observed in PRO (2.6 ± 0.3 h) compared to both U23 (2.2 ± 0.3 h; P < 0.001) and JUN (2.0 ± 0.2 h; P < 0.001). Elevation gain per distance was higher in PRO (13.8 ± 1.9 m⋅km-1) compared to U23 (10.6 ± 0.9 m⋅km-1; P = 0.001) and JUN (6.7 ± 0.3 m⋅km-1; P < 0.001), and in U23 compared to JUN (P < 0.001). Annual total work was lower in JUN (3694 ± 467 kJ⋅kg-1) compared to U23 (5268 ± 746 kJ⋅kg-1; P = 0.001) and PRO (5759 ± 1103 kJ⋅kg-1; P < 0.001). eTRIMP per hour was higher in JUN (151 ± 40) compared to both U23 (115 ± 23; P = 0.003) and PRO (112 ± 22; P = 0.013). JUN spent more training time at medium and high heart rate intensity zones compared to U23 and PRO (P < 0.05).

The relationship between training characteristics and durability in professional cyclists across a competitive season

RESULTS

Absolute 5MMP_fatigue, 12MMP_fatigue and relative 12MMP_fatigue were significantly lower in late-season compared with early- and mid-season (p < 0.05). The difference in absolute 12MMP_fresh and 12MMP_fatigue was significantly greater in late than in early- and mid-season.A significant relationship was found between training time below the first ventilatory threshold (Time < VT1) and improvements in absolute and relative 2MMP_fatigue (r = 0.43 p = 0.018 and r = 0.376 p = 0.04 respectively); and between a shift towards a polarised training intensity distribution and improvements in absolute and relative 12MMP_fatigue (r = 0.414p = 0.023 for both) between subsequent periods.

CONCLUSION

There is greater variability in the fatigue power profile across a competitive season than the fresh power profile.

Power profiling and the power-duration relationship in cycling: a narrative review

Emerging trends in technological innovations, data analysis and practical applications have facilitated the measurement of cycling power output in the field, leading to improvements in training prescription, performance testing and race analysis. This review aimed to critically reflect on power profiling strategies in association with the power-duration relationship in cycling, to provide an updated view for applied researchers and practitioners. The authors elaborate on measuring power output followed by an outline of the methodological approaches to power profiling. Moreover, the deriving a power-duration relationship section presents existing concepts of power-duration models alongside exercise intensity domains. Combining laboratory and field testing discusses how traditional laboratory and field testing can be combined to inform and individualize the power profiling approach. Deriving the parameters of power-duration modelling suggests how these measures can be obtained from laboratory and field testing, including criteria for ensuring a high ecological validity (e.g. rider specialization, race demands). It is recommended that field testing should always be conducted in accordance with pre-established guidelines from the existing literature (e.g. set number of prediction trials, inter-trial recovery, road gradient and data analysis). It is also recommended to avoid single effort prediction trials, such as functional threshold power. Power-duration parameter estimates can be derived from the 2 parameter linear or non-linear critical power model: P(t) = W′/t + CP (W′—work capacity above CP; t—time). Structured field testing should be included to obtain an accurate fingerprint of a cyclist’s power profile.

Climbing Performance in U23 and Professional Cyclists during a Multi-stage Race

The aim of this study was to analyze climbing performance across two editions of a professional multistage race, and assess the influence of climb category, prior workload, and intensity measures on climbing performance in U23 and professional cyclists. Nine U23 cyclists (age 20.8±0.9 years) and 8 professional cyclists (28.1±3.2 years) participated in this study. Data were divided into four types: overall race performance, climb category, climbing performance metrics (power output, ascent velocity, speed), and workload and intensity measures. Differences in performance metrics and workload and intensity measures between groups were investigated. Power output, ascent velocity, speed were higher in professionals than U23 cyclists for Cat 1 and Cat 2 (p≤0.001-0.016). Workload and intensity measures (Work_total, Work_total∙km^-1, Elevation_gain, eTRIMP and eTRIMP∙km^-1) were higher in U23 compared to professionals (p=0.002-0.014). Climbing performance metrics were significantly predicted by prior workload and intensity measures for Cat 1 and 2 (R²=0.27-0.89, p≤0.001-0.030) but not Cat 3. These findings reveal that climbing performance in professional road cycling is influenced by climb categorization as well as prior workload and intensity measures. Combined, these findings suggest that Cat 1 and 2 climbing performance could be predicted from workload and intensity measures.

Postoperative Myocardial Injury in Patients Classified as Low Risk Preoperatively Is Associated With a Particularly Increased Risk of Long-Term Mortality After Noncardiac Surgery

Background

Prior studies have shown an association between myocardial injury after noncardiac surgery (MINS) and all‐cause mortality in patients following noncardiac surgery. However, the association between preoperative risk assessments, Revised Cardiac Risk Index and American College of Surgeons National Surgical Quality Improvement Program, and postoperative troponin elevations and long‐term mortality is unknown.

Methods and Results

A retrospective chart review identified 548 patients who had a troponin I level drawn within 14 days of noncardiac surgery that required an overnight hospital stay. Patients aged 40 to 80 years with at least 2 cardiovascular risk factors were included, while those with trauma, pulmonary embolism, and neurosurgery were excluded. Kaplan–Meier survival and odds ratio (OR) with sensitivity/specificity analysis were performed to assess the association between preoperative risk and postoperative troponin elevation and all‐cause mortality at 1 year. Overall, 69%/31% were classified as low‐risk/high‐risk per the Revised Cardiac Risk Index and 66%/34% per American College of Surgeons National Surgical Quality Improvement Program. Comparing the low‐risk versus high‐risk groups, preoperative risk assessment was not associated with either postoperative troponin elevation or 1‐year mortality. MINS portended a 1‐year mortality of OR, 3.9 (95% CI, 2.44–6.33) in the total population. Patients classified as low risk preoperatively with MINS had the highest risk of 1‐year mortality (OR, 9.6; 95% CI, 4.27–24.38), with a low prevalence of statin use.

Conclusions

Current preoperative risk stratification tools do not prognosticate the risk of postoperative troponin elevation and all‐cause mortality at 1 year. Interestingly, patients classified as low risk preoperatively with MINS had a markedly higher 1‐year mortality risk compared with the general population, and most of them are not taking a statin. Our results suggest that evaluating preoperatively low‐risk patients for MINS presents an opportunity for prognostication, risk reclassification, and initiating therapies such as statins to mitigate long‐term risk.

Training Characteristics and Power Profile of Professional U23 Cyclists throughout a Competitive Season

BACKGROUND

The purpose of this study was to investigate differences in the power profile derived from training and racing, the training characteristics across a competitive season and the relationships between training and power profile in U23 professional cyclists.

METHODS

Thirty male U23 professional cyclists (age, 20.0 ± 1.0 years; weight, 68.9 ± 6.9 kg; V˙O2max, 73.7 ± 2.5 mL·kg-1·min-1) participated in this study. The cycling season was split into pre-, early-, mid- and late-season periods. Power data 2, 5, 12 min mean maximum power (MMP), critical power (CP) and training characteristics (Hours, Total Work, eTRIMP, Work·h-1, eTRIMP·h-1, TimeVT2) were recorded for each period. Power profiles derived exclusively from either training or racing data and training characteristics were compared between periods. The relationships between the changes in training characteristics and changes in the power profile were also investigated.

RESULTS

The absolute and relative power profiles were higher during racing than training at all periods (p ≤ 0.001-0.020). Training characteristics were significantly different between periods, with the lowest values in pre-season followed by late-season (p ≤ 0.001-0.040). Changes in the power profile between early- and mid-season significantly correlated with the changes in training characteristics (p < 0.05, r = -0.59 to 0.45).

CONCLUSION

These findings reveal that a higher power profile was recorded during racing than training. In addition, training characteristics were lowest in pre-season followed by late-season. Changes in training characteristics correlated with changes in the power profile in early- and mid-season, but not in late-season. Practitioners should consider the influence of racing on the derived power profile and adequately balance training programs throughout a competitive season.

AB0015 IDENTIFICATION OF KEY GENES TO SUPPORT SYSTEMIC LUPUS ERYTHEMATOSUS, RHEUMATOID ARTHRITIS AND ANKYLOSING SPONDYLITIS DIAGNOSIS BY TRANSCRIPTOMIC APPROACH

Background:

Early diagnosis of inflammatory rheumatic diseases (IRD), as Systemic Lupus Erythematosus (SLE), Rheumatoid Arthritis (RA) and axial Spondyloarthritis (axSpA) represents in our days a major clinical challenge. Increasing evidence has determined that early diagnosis, prompt treatment initiation and early achievement of remission are the best predictors of long-term clinical, functional and radiographic outcomes. Therefore, identification of sensitive biomarkers to support an early diagnosis to enable early therapy is of utmost importance [1,2].

Objectives:

This study aims to identify novel genes that may improve the current clinical diagnosis approach for early SLE, RA and axSpA.

Methods:

A cross-sectional study was conducted on 44 participants, 12 with axSpA (according to ASAS criteria), 11 with RA (according to ACR/EULAR criteria for RA), 10 with SLE (according to ACR classification criteria for SLE) and 11 Healthy Controls (HC), gender and age matched. Patients with co-occurrence of other IRD or having received biological therapies were excluded. Peripheral blood samples were collected into PAXgene tubes and stored in -80°C. mRNA profiling by RNA-seq was performed. Unpaired t-tests with multivariate permutation correction were applied to identify differentially expressed genes (DEGs) between patients and HC for each disease and within diseases. Enrichment analysis, Gene ontology (GO) and Kyoto Enrichment of Genes and Genomes (KEGG) analysis were also performed. DEGs that allow to distinguish each disease from HC and between diseases. The top DEGs (axSpA n=2, RA n=2, SLE n=3) identified were confirmed by quantitative RT-PCR.

Results:

For axSpA, genes involved in negative regulation of cytokines by JAK/STAT pathway and in osteoblast differentiation through STAT3 pathway, were confirmed. In SLE, genes involved in trap for immune complexes in peripheral blood and involved in nucleosome regulation, were also confirmed. Regarding RA, no genes were confirmed.

Conclusion:

Our work provides new insights into IRD pathogenesis, and discloses new biomarkers, which may be useful as either predictive biomarkers for diagnosis or therapeutic targets to improve IRD approach.Further validation are needed in different cohorts.

References:

[1]Monti, S. et al. (2015) ‘Rheumatoid arthritis treatment: The earlier the better to prevent joint damage’, RMD Open, 1(Suppl 1), pp. 1–5. doi: 10.1136/rmdopen-2015-000057.

[2]Oglesby, A. et al. (2014) ‘Impact of early versus late systemic lupus erythematosus diagnosis on clinical and economic outcomes.’, Applied health economics and health policy, 12(2), pp. 179–90. doi: 10.1007/s40258-014-0085-x.

Acknowledgments:

To all patients and healthy controls who participated in the study

Disclosure of Interests:

Atlas Mashayekhi Sardoo: None declared, Paul Leo: None declared, Mariana Santos: None declared, Tiago Costa: None declared, Sergio Fernandes Almeida: None declared, Sara Maia: None declared, Vladimir Benes: None declared, Mattew Brown Speakers bureau: MSD, Pfizer, Novartis, Jaime Branco Speakers bureau: Vitoria, Fernando Pimentel dos Santos Speakers bureau: Novartis, Pfizer, Biogen, Vitoria,

Gastroenterology in Italian clinical practice. The RING Study: six years' data from gastroenterology departments

AIM

Computer systems in hospitals provide information on the work of each single operative unit and the complexity of its caselist. However, in Italy, there is no official data-base for Gastroenterology Departments, to summarize their work.

METHODS

The RING (Ricerca-INformatizzata-in-Gastroenterologia) study has collected, through a software made on purpose, 113 237 hospital discharge files (HDF) from 55 Italian hospital Gastroenterology Units, since 2001. This caselist provides a picture of the patients and is useful for clinical/management evaluation.

RESULTS

Between January 2001 and December 2006, 55 Gastroenterology Units gathered 88240 HDF referring to ''ordinary admissions''. The male:female rate was 1:1, mean age was 61.3+/-18.5 years. Mean hospital stay was around eight days. Over the years there was a significant drop in DRG183 (miscellaneous digestive disorders-without complications) from 11.5% to 7.4% (P<0.0001), with no similar increase in DRG182 (with complications) which rose from 3.1% to 4.0%. Principal discharge diagnoses are post-hepatic and alcohol-related cirrhosis, hepatocarcinoma, acute pancreatitis, duodenal/gastric ulcer.

CONCLUSIONS

The RING data show that the gastroenterologist has been working increasingly with patients whose pathologies would have been ''inappropriately'' treated surgically (DRGs 204 and 174). Inappropriate gastroenterological treatment seems to have decreased as well as the DRG183 with no apparent ''opportunistic'' compensatory increase in DRGs with complications, such as 182.

Management and outcomes of hepatic cirrhosis: Findings from the RING study

BACKGROUND/AIM

Hepatic cirrhosis is a frequent reason for ordinary hospital admission (OA). The RING study collected hospital discharge files (HDF) from Italian hospital gastroenterology units (IGU). This caselist provides a broad picture of the patients admitted for this pathology.

MATERIAL/METHODS

More than 50,000 HDF for OA were collected between 2001 and 2004 from 26 IGU.

RESULTS

Eight thousand four hundred and eighty-seven HDF (16%) had a diagnosis of hepatic cirrhosis; Child-Pugh classes were 20.2% A, 34.8% B and 45.0% C. Patients' mean age was 63.7+/-12.1 years and 62.5% were male. A 61.1% of the cirrhosis cases had ascites, 29.9% portal-systemic encephalopathy, 29.2% hepatocellular carcinoma (HCC), 10% bleeding varices, 3.0% hepatorenal syndrome (HRS). Mortality for OA for cirrhosis was 5.7% versus 2.6% for other diagnoses. The proportion varied with the severity of the cirrhosis: 0% for Child A, 1.1% B, 10.5% C. Mortality was significantly associated with: Child-Pugh at admission (odds ratio: OR 9.2), HRS (OR 11.7), bleeding varices (OR 2.2), HCC (OR 1.8).

CONCLUSIONS

Hepatic cirrhosis was found in 16% of the OA to IGU and mortality was double the rate for all the other pathologies in the same wards. Child-Pugh is a useful prognostic tool, higher classes implying a greater risk of death. HRS and bleeding varices were the complications with most influence on in-hospital mortality.

Seasonal patterns of hospital treatment for inflammatory bowel disease in Italy

AIM

It is still debated whether clinical flare-ups of chronic inflammatory bowel disease follow a seasonal pattern, and the various reports are based on general practitioners' records or hospital discharge charts. There are, however, no specific figures for treatment in hospital gastroenterology units, which serve as a reference point for these disorders. This study was therefore designed to investigate whether there is a seasonal pattern in admissions for inflammatory intestinal disease in Italy, differing from what is generally known about gastrointestinal pathologies, since there are no nation-wide figures on the subject.

METHODS

The RING (Ricerca Informatizzata in Gastroenterologia) project is an observational study collecting hospital discharge forms from 22 centers in Italy.

RESULTS

From winter 2000 to autumn 2003, the 22 gastroenterology units participating in the RING project discharged 32,357 patients following ordinary hospital admissions. Of these, 2,856 (8.8%) had a main diagnosis of inflammatory bowel disease: 1,541 Crohn's disease, and 1,315 ulcerative colitis. No seasonal patterns were detected for either category, or when the analysis was done by age, sex and site of disease.

CONCLUSIONS

The most serious flare-ups of inflammatory bowel disease, i.e. those requiring routine hospital treatment, do not appear to follow any seasonal pattern, regardless of the site of the disease or the patient's age or sex.

A painless treatment for patients undergoing Milligan-Morgan haemorrhoidectomy

BACKGROUND

Postoperative pain associated with Milligan Morgan haemorrhoidectomy (MMH) remains problematic. Most patients complaint a severe pain on defecation and in the 1st postoperative week because of secondary infection and sphincter spasm. We studied the effect of metronidazole, lactulose and glyceryl-trinitrate on pain after MMH.

METHOD

Thirty patients were randomly assigned to two groups. The 1st received a treatment with oral laxative (lactulose 66.7%) metronidazole and a topical glyceryl-trinitrate ointment at 0.2% both pre and postoperative; the 2nd received a placebo at the same dosage. The amount of pain in the 1st week and at the time of two defecation, postoperative analgesic requirement and time to return to normal activities were documented.

RESULTS

A significant differences in the score pain on 2nd and 3rd day and on the 1st two defecation were observed among group. Analgesic consumption was highest in the placebo group.

CONCLUSION

The treatment with lactulose, metronidazole and topic glyceryl-trinitrate in patients undergoing MMH, seems to reduce secondary pain and increase patients satisfaction and earlier return to work with improvement of cost and benefit.

[Free perforation in Crohn's disease]

Free perforation in abdominal cavity in patients with Crohn's disease is a rare entity as attested from the data reported in the literature. It is a very dangerous event and requires a surgical urgency management. The Authors reported two cases of free perforation, in patients with Crohn' disease, undergoing surgical operation in urgency. Analyzing pathogenesis, difficulty in diagnosis making and therapeutic choices, they underline that CT is very useful in the diagnosis, while resection of the perforated intestinal tract represent the best surgical treatment.

[Jejunal cystic lymphangioma in adult with rapid growth]

Abdominal cystic lymphangiomas are a rare pathology that are related to abnormal development of the lymphatic system. They predominate in a children and are very uncommon in adults. Here the authors report a case of a cystic intra-abdominal lymphangioma in a 64-years old woman in which the cyst was situated in the mesentery of the jejuneum, with rapid growth. Ultrasonography, computed tomography and magnetic resonance imaging led us to evaluate a cystic characterizations and his site. Surgical excision remain the treatment of choice because we can establish an histologic diagnosis. Complete surgical excision of cyst, although it can be difficult, consent a definitive healing.

Paraduodenal hernia: an uncommon cause of recurrent abdominal pain

Internal abdominal hernias are a rare entity and may cause unexplained abdominal pain. This report concerns a 46 year old male patient, with a four year history of episodic colicky peristaltic abdominal pains, in whom a left paraduodenal hernia was found at surgical exploration after a negative diagnostic screening by ultrasound, CT and small bowel enema. Upon laparotomy the Authors found a left-sided paraduodenal hernia with an empty herniated sack. Repair of the hernial defect resulted in the complete and stable resolution of abdominal symptoms. The importance of considering paraduodenal hernias in the differential diagnosis of unexplained intermittent abdominal pain is discussed.

[Advantages in the ultrasound guided central venous catherization (new notes of technique)]

The authors analyzed the results of 175 central venous catheterization CVC of internal jugular vein performed with the ultrasound guide (US) from January 1998 to October 2002. The average performing time was 4.5 minutes, 98.2% of success and 4% of complications (one vagal hypotension, one artery puncture, four catheter dislocation, one haematoma). The US guide CVC is a safe procedure with short performing time, low rate of failures and complications and high rate of success; it is helpful in all patients with vascular anatomical variations, with not visualized or palpable landmarks and with coagulation disorders.

Unreported concussion in high school football players: implications for prevention

OBJECTIVE

To investigate the frequency of unreported concussion and estimate more accurately the overall rate of concussion in high school football players.

DESIGN

Retrospective, confidential survey completed by all subjects at the end of the football season.

SETTING AND PARTICIPANTS

A total of 1,532 varsity football players from 20 high schools in the Milwaukee, Wisconsin, area were surveyed.

MAIN OUTCOME MEASUREMENTS

The structured survey assessed (1) number of concussions before the current season, (2) number of concussions sustained during the current season, (3) whether concussion during the current season was reported, (4) to whom concussion was reported, and (5) reasons for not reporting concussion.

RESULTS

Of respondents, 29.9% reported a previous history of concussion, and 15.3% reported sustaining a concussion during the current football season; of those, 47.3% reported their injury. Concussions were reported most frequently to a certified athletic trainer (76.7% of reported injuries). The most common reasons for concussion not being reported included a player not thinking the injury was serious enough to warrant medical attention (66.4% of unreported injuries), motivation not to be withheld from competition (41.0%), and lack of awareness of probable concussion (36.1%).

CONCLUSIONS

These findings reflect a higher prevalence of concussion in high school football players than previously reported in the literature. The ultimate concern associated with unreported concussion is an athlete's increased risk of cumulative or catastrophic effects from recurrent injury. Future prevention initiatives should focus on education to improve athlete awareness of the signs of concussion and potential risks of unreported injury.

Inflammatory bowel disease and hospital treatment in Italy: the RING multi-centre study

AIM

To explore the management of chronic inflammatory bowel disease, specifically Crohn's disease and ulcerative colitis, in Italian gastroenterology units.

METHODS

The RING (Ricerca Informatizzata in Gastroenterologia) project is an observational study collecting hospital discharge forms from 56 centres. Factors associated with the length of hospital stay were studied using multivariate logistic regression.

RESULTS

In 24 months starting from August 2000, out of 29,376 hospital discharge forms, 2131 (7.3%) were collected for inflammatory bowel disease (1163 for Crohn's disease and 968 for ulcerative colitis). The Crohn's disease and ulcerative colitis groups were compared according to demographic characteristics, diagnoses, procedures and hospital stay. In Crohn's disease, computed tomography/magnetic resonance imaging, x-rays/barium enema, number of procedures and number of diagnoses were significantly associated with a hospital stay longer than 10 days. In ulcerative colitis, this association was found for parenteral nutrition, malnutrition, computed tomography/magnetic resonance imaging and number of procedures.

CONCLUSIONS

Crohn's disease was confirmed as a disabling disorder requiring more frequent hospital treatment than ulcerative colitis. For the latter, parenteral nutrition and malnutrition were related to a longer hospital stay. The number of procedures, especially abdominal computed tomography/magnetic resonance imaging, was a major item for both pathologies.

[Integration of operative endoscopy and laparoscopic surgery in the treatment of cholecysto-choledocholithiasis]

Laparoscopic cholecystectomy has become first choice for symptomatic gallstones, but there are not agreement about therapy of supposed synchronous choledocholithiasis. We report our experience about the sequential treatment (endoscopic-laparoscopic) of the gallstone and the associated common bile duct stones.

METHODS

During the period Jan. 1992 Dec. 1997 we have evaluated 128 patients that were submitted to ERCP for suspicion CBDS and gallstone. All patients undertook a systematic assessment: Patient age, sex, history of jaundice, history of pancreatitis, levels of serum alanine aminotransferase, alkaline phosphatase, amylase, total and direct bilirubin and CBD diameter on ultrasonography.

RESULTS

In the 96 (75%) cases of choledocholithiasis endoscopic sphincterotomy has been performed and combined with laparoscopic cholecystectomy. Thirty-two patients (25%) submitted to ERCP have been negative for stones. Only 4 patients have needed surgery because of big stones inside the CBD after ESWL failure. The incidence of complications of ERCP-ES has been, in our experience, 7.1% and mortality 0.8%. All the complications have been treated conservatively and did not need surgery.

CONCLUSIONS

The sequential treatment (endoscopic-laparoscopic) of synchronous CBDS and gallstone, in hands of expertise, is efficient with high rate of success and low rate of complications in order to morbidity and mortality. Finally we believe that it is very important to discover CBDS preoperatively with the non invasive methods as the MRI-Colangiography and to assay the liver tests in order to avoid negative ERCP for choledocholithiasis.

Inflammatory response in open and laparoscopic cholecystectomy

The modifications of IL-6. CRP, ceruloplasmin, alpha 1 antitrypsin, fibrinogen, transferrin, albumin and leukocytes counts have been evaluated after traditional open cholecystectomy (OC) or laparoscopic cholecystectomy (LC). Forty-two patients were included in this study, 20 underwent to OC and 22 underwent to LC. Serum samples were performed before surgery and at distance of 6, 24, 48 and 168 hours. The results show a more significant increase in acute phase inflammatory response after OC compared with LC as attested by highest values of leukocytosis, IL-6, CRP, fibrinogen and alpha 1 antitrypsin and lower levels of albumin. In conclusion, after LC, the phase acute response is attenuate and it can explain the reduced period of convalescence of patients treated with LC.

Resolution of Ménétrier's disease after Helicobacter pylori eradicating therapy

Some cases of Ménétrier's disease associated with Helicobacter pylori (HP) have recently been reported in the literature. We report here the case of a 51-year-old man with a diagnosis of Ménétrier's disease who had previously been unsuccessfully treated with H(2) antagonists. A subsequent demonstration of HP infection led us to treat the patient with an eradicating therapy which prompted complete regression of clinical symptoms, resolution of the gastric endoscopic picture, and absence of HP on gastric histology. This result, in accordance with others in the literature, indicates an eventual association of HP infection with Ménétrier's disease and that consequent therapy is mandatory.

Th1-like and Th2-like cytokines in patients undergoing open versus laparascopic cholecystectomy

The advantages of laparoscopic (LC versus, open cholecystectomy (OC) seems to be related to minimal invasive procedure and to the moderate inflammatory response. The aim of this study is to define the involvement of Th1 (IFN-gamma) and Th2 (IL-4, IL-6, IL-10, IL-13) cytokines production in vivo and in vitro in patients undergoing OC or LC. In 42 patients undergoing LC (n = 22) and OC (n = 20) Th1-like and Th2-like was evaluated before operation and at 6, 24 and 48 hours after operation for white blood cell counting and cytokines (IL-4, IL-6, IL-10, IL-13, IFN-gamma, TNF-alpha) in the sera and in the supernatants from circulating mononuclear cells stimulated with phytohemagglutinin or lipopolysaccharide. The acute phase response cytokine, IL-6, appeared significantly increased following OC than after LC. All other cytokines did not very significantly. In vitro data shows a reduction of IFN-gamma and increase in Th2-like cytokines in OC patients compared with the basal value. In LC subjects we observed an high production of IFN-gamma associated to an increase of Th2-like cytokines, like IL-10 and IL-13, even though IL-4 and IL-6 were unmodified. In contrast to OC, LC did not significantly affect immunocompetence, maintaining a moderate inflammatory response and an adequate balance between Th1 and Th2 cytokine. Furthermore, the strong activation of cells producing Th1-like cytokines in LC patients following mitogen activation indicated a consistent anti-microbial activity, that was not detectable in OC patients, that showed after activation only a Th2 response.

Concomitant inflammatory pseudotumor of the liver and spleen

We report the case of a 53-year-old man with inflammatory pseudotumor (IPT) of the liver and spleen. This concomitant association has rarely been reported. The patient presented with a hypoechoic mass in the liver and a clinical picture of recurrent sepsis; hematochemical exams and imaging data were nonspecific. Antibiotic therapy improved the clinical course, but did not resolve it definitively. After 50 days of therapy, as the hepatic mass decreased a similar lesion appeared in the spleen. The final diagnosis was made on splenectomy and an intra-operative biopsy of the residual liver lesion. The diagnostic problems encountered in this very rare association of IPT of the liver and spleen were similar to those for isolated IPT in the respective single organ sites. After 15 months of follow-up, the patient is in good health and no recurrence of symptoms or masses has been observed.

Cytokine modifications after tension-free hernioplasty or open conventional inguinal hernia repair

BACKGROUND

The purpose of this study was to evaluate the involvement of proinflammatory cytokines (interferon-gamma [INF-gamma], interleukin [IL]-6) and anti-inflammatory cytokines (IL-4, IL-l0, IL-13) in patients undergoing Lichtenstein tension-free hernioplasty (LH) using polypropylene prosthetic materials or conventional Bassini hernia (BH) repair.

METHODS

Thirty-five male patients (age range 25 to 60 years) with unilateral inguinal hernia without complications or recurrence were included in this study. Randomly, patients underwent conventional operation and had their inguinal hernia repair performed with polypropylene mesh. Peripheral venous blood samples were collected 24 hours prior to surgery and then 6, 24, 48, and 168 hours postoperatively. Fifteen healthy controls were included.

RESULTS

We present evidence that LH patients showed both an increased serum level of Thelper 1 (Th1)-like cytokines (IFN-gamma) and an increase in Thelper 2 (Th2)-like cytokines (IL-6 and IL-l0), associated with a slight reduction of peripheral blood mononuclear cells (PBMC) producing IL-6 and a normal level of PBMC producing IFN-gamma, IL-l0, IL-13, and IL-4. Whereas BH patients showed in part an amplification of Th2-like cells, characterized by the sustained serum production of IL-6 and IL-l0, associated with an increase in IL-l0 secreted by in vitro stimulated PMBC.

CONCLUSIONS

Our data show that LH is associated with a higher production of inflammatory cytokines (IFN-gamma and IL-6) compared with BH, likely induced by the presence of the polypropylene prostheses.

Tension-free hernia repair is associated with an increase in inflammatory response markers against the mesh

BACKGROUND

The purpose of this study was to evaluate the involvement of inflammatory mediators in patients undergoing Lichtenstein tension-free hernioplasty (LH) using polypropylene prosthetic materials or conventional Bassini hernia repair (BH).

METHODS

Thirty patients male with unilateral inguinal hernia without complications or recurrence were included in this study. Randomly, patients underwent LH or BH. Peripheral venous bloods samples were collected 24 hours prior to surgery and then 6, 24, 48 and 168 hours postoperatively.

RESULTS

We present evidences that LH patients showed a higher increased serum level of fibrinogen, C-reactive protein, alpha-1-antitrypsin, and interleukin-6 than BH patients. Postoperative visual analogue scales for pain were reduced on mobilization for patients undergoing LH compared with BH. Neutrophils were significantly increased only in LH compared with baseline. Ceruloplasmin, transferrin, and albumin levels were unmodified after BH or LH.

CONCLUSIONS

In conclusion our data show that although LH induces less pain and more rapid postoperative recovery, it is associated with an higher inflammatory response compared with BH, likely due to polypropylene mesh.

[Fibrinolytic system after laparoscopic cholecystectomy]

BACKGROUND

Deep-vein thrombosis (DVT) and pulmonary embolism (PE) are the most important causes of morbility and mortality in patients submitted to surgical intervention: some peculiar factors of laparoscopic surgery can modify their risk. The aim of this study is to evaluate possible variations of the fibrinolytic system after cholecystectomy.

METHODS

Eighteen patients affected by symptomatic and non-complicated gallstones have been included in this study. They were divided into two groups of nine patients each: the first group was submitted to laparoscopic cholecystectomy (LC) and the second to open cholecystectomy (OC). Antitrombin III (ATIII), fibrinogen degradation products (FDP), tissue plasminogen activator (tPA), and plasminogen activator inhibitor (PAI) have been evaluated preoperatively and 6, 12, 24 and 48 hours after the operation.

RESULTS

The levels of ATIII did not present significantly variations. The FDP in both groups were significantly increased 48 hours after open cholecystectomy. Levels of PAI instead were increased in comparison to the basal values at 6, 12, 24, 48 hours with p < 0.05; p < 0.01 and p < 0.05 respectively in patients submitted to OC, in the LC group no variations were observed; a comparison between the groups showed a significant modification (p < 0.05) only at the 12th hour.

CONCLUSIONS

The early mobilization of patients in the postoperative course and the lower invasion of LC can oppose the prothrombotic effect in the lower limbs.

[Cell-mediated immunity after laparoscopic cholecystectomy]

Cell-mediated immunity (CMI) is temporarily decreased after major surgical procedures in relation to type of anaesthesia, length and severity of an intervention. In this study it has been evaluated CMI response in vivo, after laparoscopic (LC) and open cholecystectomy (OC). 5 healthy persons and 16 patients with symptomatic and uncomplicated gallstones were studied. They were subdivided in two groups: 8 were treated by OC, 8 by LC. A skin test system (Multitest, IMC-Institute Merieux, Lyon, France) consisting of a plastic disposable multiple-puncture device capable of simultaneous application of seven delayed-type hypersensitivity antigens and a glycerin and saline diluent (negative control) was used. The test was performed 48 hours before and 24 hours after the surgical procedure. A diameter of 2 mm or more of the induration was considered as a positive response. A score expressed, as the sum in millimeters of all the mean diameters (DM) of positive reactions and as numbers of antigens (NA) positive was calculated. Statistics was assessed by Student's t test for comparison of averages. There was no difference of age, sex, anesthesiologic risk, length of the operation between the two groups. We observed a significative reduction of DM (P < 0.05) and of NA (P < 0.05) in patients in which OC was performed while there were no significant in the group treated by LC. Results show a significant suppression of the CMI after OC, no particular changes after LC according to other studies in vitro.