Significantly lower physical activity participation in individuals with chronic pancreatitis compared to controls: An exploratory study of objectively assessed physical activity levels

Introduction The beneficial effects of exercise and physical activity (PA) have been demonstrated in many chronic inflammatory diseases. Knowledge on physical activity levels is unknown in the chronic pancreatitis population and there are currently no specific PA recommendations for this condition. Methods Physical activity was measured objectively over a 7- day period in 17 individuals with chronic pancreatitis using an accelerometer (Acti-graph) and in 15 controls, matched for age, sex, and body mass index. Results Participants with chronic pancreatitis spent a significantly lower amount of time in moderate, light, and moderate/vigorous activity compared to the healthy control group. Mean time in light activity in the chronic pancreatitis group 825.4 +- 972 (SD) compared to 1500 +- 958 (SD) in the healthy control group. Moderate activity mean mins was 61.6 +-85 in the chronic pancreatitis group compared to 161.4 +-131.2 in the healthy control group. Moderate /Vigorous mean minutes was 62.1+- 86 (SD) in the chronic pancreatitis group compared to 164.3 +-132 (SD) in the healthy control group. There was no significant difference found between the groups for either vigorous activity or time spent sedentary. Discussion/Conclusion This exploratory study offers early objective evidence that activity levels in the chronic pancreatic group are not meeting current international recommendations. Further investigation of this chronic illness population is strongly recommended.

212 FATIGUE EXPERIENCED BY ADULTS WITH LONG-COVID WAS NOT ASSOCIATED WITH AN EMG-DERIVED MUSCLE FATIGUE INDEX

Background

One of the most prominent challenges of the COVID-19 pandemic is the emergence of the post-COVID-19 syndrome or ‘long-COVID’ following the acute phase of the viral infection. With a plethora of debilitating symptoms across many physiological systems, the pathophysiology of long-COVID remains elusive and subject of intense research efforts. Adults with long COVID are often affected by prolonged fatigue, which could be linked to neuromuscular function impairment. We hypothesised that there might be a correlation between subjective fatigue and an Electromyograph(EMG)-derived muscle fatigue index in adults with long-COVID.

Methods

As part of a neuro-cardiovascular instability assessment protocol, participants were asked to squeeze the thigh muscles as hard as possible for ten seconds during both supine resting and after active and passive standing (head-up tilt) tests. Surface EMG was used to capture on each leg the physiological activity of the vastus lateralis and rectus femoris during the squeezes, from which the muscle fatigue index was computed based on both the mean and median frequencies of each 10-second maximum prompted muscle contraction. Using two-sided Spearman correlation coefficients, we examined the associations between the muscle fatigue indices and self-reported fatigue measured by the Chalder Fatigue Scale (CFQ).

Results

108 participants were included, 77 female and 31 male, with a mean age of 46 (range 25-78) years, 22% of whom were hospitalised in the acute phase of SARS-CoV-2 infection. Strong intercorrelations were found between the muscle fatigue indices derived from the mean and median frequencies of thigh muscle contractions. However, no significant correlations were detected between the muscle fatigue indices and CFQ scores.

Conclusion

Self-reported fatigue as measured by the CFQ was not associated with an EMG-derived muscle fatigue index in this long-COVID cohort.

A Review of Heart Rate and Blood Pressure Responses to Active Standing in Healthy Adults

OBJECTIVES

This review outlines the normal heart rate and blood pressure response to active standing, the physiological mechanisms governing these, and the effect of ageing on the responses.

METHODS

A literature search was conducted to identify articles investigating the normal heart rate and/or blood pressure response to standing.

RESULTS

Heart rate when standing increases and then decreases and recovers to baseline. Blood pressure responses are inverse. Skeletal muscle contraction and the baroreceptor reflex drive this. With ageing, heart rate response attenuates and the initial blood pressure response increases.

DISCUSSION

Normal heart rate and blood pressure responses are attributed to the baroreceptor reflex and skeletal muscle contraction. Decreased muscle strength and baroreceptor sensitivity are associated with ageing, suggesting a possible benefit in improving skeletal muscle strength to maintain an efficient response. Understanding these responses and their variation with ageing is clinically relevant and may be beneficial in improving rehabilitation outcomes.

Physical activity for chronic pancreatitis: a systematic review

BACKGROUND

Chronic pancreatitis (CP) is a progressive inflammatory disorder of the pancreas. Sarcopenia is a degenerative loss of skeletal muscle mass, quality, and strength and is commonly associated with chronic pancreatitis. Regular physical activity and adequate functional fitness have been found to ameliorate the risk and effects of sarcopenia in other chronic diseases. The objective of this systematic review was to collate all the published evidence which has examined any type of physical activity as an intervention in the chronic pancreatitis patient population.

METHODS

This systematic review was conducted in accordance with the PRISMA guidelines. The search strategy was designed by the medical librarian (DM) for Embase and then modified for the other search platforms. Two of the researchers (BM) and (AM) then performed the literature search using the databases Embase, Medline, CINAHL, and Web of Science.

RESULTS

An electronic identified a total of 571 references imported to Covidence as 420 when the duplicates (151) were removed. 420 titles were screened and 390 were removed as not relevant from their titles. 30 full text papers were selected and from these, only one full text paper was deemed suitable for inclusion.

CONCLUSIONS

There is currently insufficient evidence to advise physical activity in the chronic pancreatitis population. However, given the evidence to support physical activity in many other chronic diseases this review highlights the need for urgent investigation of physical activity as an intervention on this specific patient population.

Prevalence of frailty in patients with non-cirrhotic non-alcoholic fatty liver disease

OBJECTIVE

End-stage chronic liver disease is associated with accelerated ageing and increased frailty. Frailty measures have provided clinical utility in identifying patients at increased risk of poor health outcomes, including those awaiting liver transplantation. However, there is limited data on the prevalence and severity of frailty in patients with non-cirrhotic non-alcoholic fatty liver disease (NAFLD). The aim of this study was to evaluate the prevalence of frailty and prefrailty in patients with non-cirrhotic NAFLD and correlate with severity of liver disease.

DESIGN

A cross-sectional analysis of functional and laboratory frailty assessments, including the Fried frailty index (FFI), a self-reported frailty index (SRFI) and a lab-based frailty index (FI-LAB), was performed in a cohort of 109 patients with NAFLD, and results compared with fibrosis staging based on transient elastography.

RESULTS

Patients with NAFLD had a high prevalence of prefrailty and frailty, with a median SRFI score of 0.18 (IQR: 0.18), FFI of 1 (IQR: 1) and FI-LAB of 0.18 (IQR: 0.12). Using the SRFI, 45% of F0/F1 patients were classified as prefrail and 20% were classified as frail, while in F2/F3 patients this increased to 36% and 41%, respectively. SRFI, 30 s sit-to-stand and FI-LAB scores increased with increasing liver fibrosis stages (p=0.001, 0.006 and <0.001, respectively). On multivariate linear regression, female gender was identified as a significant predictor of elevated frailty scores.

CONCLUSION

This study identifies a high prevalence of frailty in individuals with non-cirrhotic NAFLD. Addressing frailty through early rehabilitation interventions may reduce overall morbidity and mortality in this population.

Predictors of Submaximal Exercise Test Attainment in Adults Reporting Long COVID Symptoms

Adults with long COVID often report intolerance to exercise. Cardiopulmonary exercise testing (CPET) has been used in many settings to measure exercise ability but has been conducted in a few long COVID cohorts. We conducted CPET in a sample of adults reporting long COVID symptoms using a submaximal cycle ergometer protocol. We studied pre-exercise predictors of achieving 85% of the age-predicted maximum heart rate (85%HRmax) using logistic regression. Eighty participants were included (mean age 46 years, range 25−78, 71% women). Forty participants (50%) did not reach 85%HRmax. On average, non-achievers reached 84% of their predicted 85%HRmax. No adverse events occurred. Participants who did not achieve 85%HRmax were older (p < 0.001), had more recent COVID-19 illness (p = 0.012) with higher frequency of hospitalization (p = 0.025), and had been more affected by dizziness (p = 0.041) and joint pain (p = 0.028). In the logistic regression model including age, body mass index, time since COVID-19, COVID-19-related hospitalization, dizziness, joint pain, pre-existing cardiopulmonary disease, and use of beta blockers, independent predictors of achieving 85%HRmax were younger age (p = 0.001) and longer time since COVID-19 (p = 0.008). Our cross-sectional findings suggest that exercise tolerance in adults with long COVID has potential to improve over time. Longitudinal research should assess the extent to which this may occur and its mechanisms. ClinicalTrials.gov identifier: NCT05027724 (TROPIC Study).

Orthostatic Intolerance in Adults Reporting Long COVID Symptoms Was Not Associated With Postural Orthostatic Tachycardia Syndrome

In this observational cross-sectional study, we investigated predictors of orthostatic intolerance (OI) in adults reporting long COVID symptoms. Participants underwent a 3-min active stand (AS) with Finapres^® NOVA, followed by a 10-min unmedicated 70° head-up tilt test. Eighty-five participants were included (mean age 46 years, range 25–78; 74% women), of which 56 (66%) reported OI during AS (OI_AS). OI_AS seemed associated with female sex, more fatigue and depressive symptoms, and greater inability to perform activities of daily living (ADL), as well as a higher heart rate (HR) at the lowest systolic blood pressure (SBP) point before the first minute post-stand (mean HR_nadir: 88 vs. 75 bpm, P = 0.004). In a regression model also including age, sex, fatigue, depression, ADL inability, and peak HR after the nadir SBP, HR_nadir was the only OI_AS predictor (OR = 1.09, 95% CI: 1.01–1.18, P = 0.027). Twenty-two (26%) participants had initial (iOH) and 5 (6%) classical (cOH_AS) orthostatic hypotension, but neither correlated with OI_AS. Seventy-one participants proceeded to tilt, of which 28 (39%) had OI during tilt (OI_tilt). Of the 53 who had a 10-min tilt, 7 (13%) had an HR increase >30 bpm without cOH_tilt (2 to HR > 120 bpm), but six did not report OI_tilt. In conclusion, OI_AS was associated with a higher initial HR on AS, which after 1 min equalised with the non-OI_AS group. Despite these initial orthostatic HR differences, POTS was infrequent (2%). ClinicalTrials.gov Identifier: NCT05027724 (retrospectively registered on August 30, 2021).

A Systematic Review of Persistent Symptoms and Residual Abnormal Functioning following Acute COVID-19: Ongoing Symptomatic Phase vs. Post-COVID-19 Syndrome

Objective: To compare the two phases of long COVID, namely ongoing symptomatic COVID-19 (OSC; signs and symptoms from 4 to 12 weeks from initial infection) and post-COVID-19 syndrome (PCS; signs and symptoms beyond 12 weeks) with respect to symptomatology, abnormal functioning, psychological burden, and quality of life. Design: Systematic review. Data Sources: Electronic search of EMBASE, MEDLINE, ProQuest Coronavirus Research Database, LitCOVID, and Google Scholar between January and April 2021, and manual search for relevant citations from review articles. Eligibility Criteria: Cross-sectional studies, cohort studies, randomised control trials, and case-control studies with participant data concerning long COVID symptomatology or abnormal functioning. Data Extraction: Studies were screened and assessed for risk of bias by two independent reviewers, with conflicts resolved with a third reviewer. The AXIS tool was utilised to appraise the quality of the evidence. Data were extracted and collated using a data extraction tool in Microsoft Excel. Results: Of the 1145 studies screened, 39 were included, all describing adult cohorts with long COVID and sample sizes ranging from 32 to 1733. Studies included data pertaining to symptomatology, pulmonary functioning, chest imaging, cognitive functioning, psychological disorder, and/or quality of life. Fatigue presented as the most prevalent symptom during both OSC and PCS at 43% and 44%, respectively. Sleep disorder (36%; 33%), dyspnoea (31%; 40%), and cough (26%; 22%) followed in prevalence. Abnormal spirometry (FEV₁ < 80% predicted) was observed in 15% and 11%, and abnormal chest imaging was observed in 34% and 28%, respectively. Cognitive impairments were also evident (20%; 15%), as well as anxiety (28%; 34%) and depression (25%; 32%). Decreased quality of life was reported by 40% in those with OSC and 57% with PCS. Conclusions: The prevalence of OSC and PCS were highly variable. Reported symptoms covered a wide range of body systems, with a general overlap in frequencies between the two phases. However, abnormalities in lung function and imaging seemed to be more common in OSC, whilst anxiety, depression, and poor quality of life seemed more frequent in PCS. In general, the quality of the evidence was moderate and further research is needed to understand longitudinal symptomatology trajectories in long COVID. Systematic Review Registration: Registered with PROSPERO with ID #CRD42021247846.

Exploring bi-directional temporal associations between timed-up-and-go and cognitive domains in the Irish longitudinal study on ageing (TILDA)

INTRODUCTION

The bi-directional longitudinal associations between mobility and cognition in older adults are poorly understood. Our objective was to study the temporal associations between timed-up-and-go (TUG) and five cognitive function domains: global cognition, processing speed, verbal fluency, executive function, and sustained attention.

METHODS

We designed two longitudinal samples: A (for cognition as predictor of mobility), and B (for mobility as predictor of cognition). To examine the associations between the five cognitive domains at wave 1 and change in TUG times up to wave 5 (eight years), five linear mixed-effect models were fitted. To examine the associations between TUG times at wave 1 and change in the five cognitive domains between waves 1 and 3 (four years), five linear-regression models were fitted.

RESULTS

After removing participants with missing data, sample A numbered 4913 participants (mean age 62), and sample B 3675 (mean age 61). Baseline cognitive domains were all significant predictors of future change in TUG times. Baseline TUG time was also a significant predictor of future change in all five cognitive domains. In both cases, poorer performance at baseline predicted greater future loss of function.

CONCLUSION

There was evidence of bi-directional temporal relationships between cognition and mobility. In both directions, the effect of the explanatory variable was small, though cognition as predictor of future mobility may have greater clinical relevance than vice versa. Our findings underscore the importance for clinicians of considering the bi-directional associations between cognition and mobility when observing subtle changes in either, especially as impairments emerge.

123 ACUTE-PHASE BED-REST DURATION WAS ASSOCIATED WITH LOWER GRIP STRENGTH IN A POST-COVID-19 COHORT

Background

Though age-related muscle loss is traditionally associated with older cohorts, strong evidence suggests a life-spanning precipitation of decreasing muscle mass and strength beginning as early as the fourth decade of life, with established deleterious consequences for later-life morbidity and mortality. Periods of low activity and bed rest (LA/BR) can further compound this depletion of muscle strength. Our aim was to examine such associations in a post-COVID-19 cohort.

Methods

Participants reporting ongoing symptomatology and fatigue post COVID-19 underwent assessments of grip strength via hand-held dynamometry (2 measures on each hand). Demographics of COVID-19 illness, including time since diagnosis, duration of LA/BR during acute illness, and levels of fatigue were captured via self-reported questionnaires. Independent predictors of mean grip strength were investigated using a linear regression model.

Results

Forty-nine participants underwent assessments (69% female, mean age 44(12) years). At the time of assessment, days post COVID-19 diagnosis ranged from 39–522 (mean 262(140)). The mean self-reported period of LA/BR during the acute illness was 15(18) days. In general, participants reported significant levels of fatigue (median Chalder Fatigue Scale score 22(8)). Mean grip strength was 41.3(6.3) Kg for men and 22.8(6.7) Kg for women. When predictors of grip strength were investigated, an increased duration of LA/BR was found to be associated with lower grip strength, independently of age, gender, time since COVID-19 diagnosis, and self-reported fatigue (Beta = −0.158, 95% Confidence Interval − 0.242 to −0.074, p = 0.001).

Conclusion

In this cohort, every day of LA/BR during acute COVID-19 illness was independently associated with subsequent lower grip strength of approximately 150 g. These results underscore the importance of early mobilization and discouraging bed rest in the acute phase of COVID-19. Patients who are isolating should be encouraged to maintain physical activity and muscle strength as part of a modified isolation-friendly rehabilitation programme.

Improvement in cognitive impairment following a 12-week aerobic exercise intervention in individuals with non-cirrhotic chronic hepatitis C

Cognitive impairment occurs in 30%-50% of patients with non-cirrhotic chronic hepatitis C virus (HCV) infection. Exercise is beneficial in preventing and treating cognitive impairment and cardiometabolic abnormalities in many chronic inflammatory diseases, but there are few studies investigating the impact of exercise in HCV infection. The study aimed to assess the effect of a 12-week aerobic exercise intervention on cognition and extrahepatic manifestations in individuals with HCV. In this nonrandomized controlled pilot study, individuals with HCV participated in a 12-week aerobic exercise intervention. Outcome measures included cognition (Montreal Cognitive Assessment [MOCA], Trail Making Test A & B [TMT-A; TMT-B], Digit Symbol Test [DST]), cardiorespiratory fitness (estimated V˙O2max ), physical activity (accelerometry), anthropometry, quality of life (depression; fatigue; sleep quality) and biochemical markers. Outcomes were assessed at baseline (T0), intervention completion (T1) and 12 weeks after intervention completion (T2). Thirty-one patients completed the study (exercise group n = 13, control group n = 18). In the exercise group, cognition improved at T1 in the TMT-A (31% mean improvement, p = 0.019), TMT-B (15% mean improvement, p = 0.012) time and MOCA (14% mean improvement, p ≤ 0.001). These improvements were not maintained at T2. Depression (p = 0.038), sleep quality (p = 0.002), fatigue (p = 0.037) and estimated V˙O2max (7.8 mL kg^-1  min^-1 [22%] mean increase, p = 0.004) also improved at T1. In conclusion, this study demonstrates the benefits of a 12-week aerobic exercise intervention in improving cognition, quality of life and cardiorespiratory fitness in individuals with HCV. Larger studies are needed to confirm these findings and strategies for continued exercise engagement in individuals with HCV are warranted for sustained benefits.

A systematic review of physical activity in people with haemophilia and its relationship with bleeding phenotype and treatment regimen

INTRODUCTION

Although the measurement of physical activity (PA) amongst people with haemophilia (PWH) has become increasingly widespread in recent years, the relationship between PA and bleeding phenotype remains poorly understood. In addition, the influence of various treatment regimens on this relationship has not been defined.

AIM

This review aimed to systematically assess the data that are available regarding PA levels amongst PWH, as well as the relationship between PA and bleeding.

METHODS

A systematic search of the online databases EMBASE, Cochrane, MEDLINE Ovid, CINAHL and Web of Science was conducted by two independent reviewers. Quality assessment was undertaken using the AXIS Critical Appraisal Tool for Cross-sectional Studies and the STROBE checklist.

RESULTS

Of 1902 sources identified overall, 36 articles were included. Low-to-moderate transparency of reporting and various sources of bias were identified. PA levels varied amongst heterogeneous samples of PWH. The relationship between PA and bleeds was inconclusive, although there was evidence that improvements in treatment over recent decades have appeared to enable PWH to become more physically active.

CONCLUSION

Based upon the limited available evidence, the relationship between PA and bleeding phenotype in PWH remains unclear. However, with the development of improved prophylaxis treatment regimens in recent years, there is evidence that PA levels have increased, especially amongst people with severe haemophilia. The use of validated outcome measures of PA and more robust reporting of bleeds and treatment regimen are warranted in future research, especially in a rapidly evolving era of new treatments for PWH.

Determinants of Physical Activity Engagement in Patients With Nonalcoholic Fatty Liver Disease: The Need for an Individualized Approach to Lifestyle Interventions

OBJECTIVES

Physical activity (PA) is an important non-pharmacological treatment for non-alcoholic fatty liver disease (NAFLD). This study investigated the determinants of PA engagement and awareness of the World Health Organization (WHO) PA guidelines in patients with NAFLD.

METHODS

Study participants were 101 patients with NAFLD (median age: 54 [IQR = 15] y; 53 men and 48 women) who completed 4 questionnaires: (1) a PA guideline awareness questionnaire; (2) a PA questionnaire assessing PA levels; and (3) 2 questionnaires assessing perceived barriers and motivators for engaging in PA. Binary logistic regression was performed to assess predictors of PA levels.

RESULTS

Twenty-four percent of participants correctly identified the recommended WHO weekly PA guidelines, and 39% adhered to the guidelines. Lack of willpower, time, and energy were the most frequently cited barrier domains. Scores for lack of willpower (odds ratio [OR] = 1.445, 95% CI = 1.088-1.919) and lack of resources (OR = 1.378, 95% CI = 1.003-1.893), and reporting 3 or more "significant" barrier domains (OR = 5.348, 95% CI = 1.792-15.873) were significant predictors of PA levels. Maintaining health and fitness was the most cited motivator domain and was a significant predictor (OR = 2.551, 95% CI = 1.253-5.208) of PA levels.

CONCLUSIONS

This study highlights the lack of awareness of the WHO PA guidelines and the key determinants of PA participation in patients with NAFLD. Determinants of PA should be identified at the individual level to create a personalized approach for PA maintenance for people with NAFLD to promote lifelong participation in PA.

IMPACT

This study closes a gap in the published data on the determinants of PA engagement in patients with NAFLD.

LAY SUMMARY

Physical inactivity is the fourth leading cause of global mortality and contributes to many chronic inflammatory diseases, including obesity, type 2 diabetes, cardiovascular disease, and nonalcoholic fatty liver disease (NAFLD). People with NAFLD engage in less physical activity compared with people who are healthy, and this study provides new information that clinicians can use to help these patients increase their physical activity participation.

Improvement in histological endpoints of MAFLD following a 12-week aerobic exercise intervention

BACKGROUND

Lifestyle interventions are the primary treatment for metabolic (dysfunction) associated fatty liver disease (MAFLD). However, the histological and cardiometabolic effects of aerobic exercise in MAFLD remain unclear.

AIMS

To assess the effects of a 12-week aerobic exercise intervention on histological and cardiometabolic endpoints in MAFLD.

METHODS

Patients with biopsy-confirmed MAFLD participated in a 12-week aerobic exercise intervention. Liver histology, cardiorespiratory fitness (estimated V̇O_2max ), physical activity, anthropometry and biochemical markers were assessed at baseline, intervention completion, and 12 and 52 weeks after intervention completion.

RESULTS

Twenty-four patients completed the exercise intervention (exercise group n = 16, control group n = 8). In the exercise group, 12 weeks of aerobic exercise reduced fibrosis and hepatocyte ballooning by one stage in 58% (P = 0.034) and 67% (P = 0.020) of patients, with no changes in steatosis (P = 1.000), lobular inflammation (P = 0.739) or NAFLD activity score (P = 0.172). Estimated V̇O_2max increased by 17% compared to the control group (P = 0.027) but this level of improvement was not maintained at 12 or 52 weeks after the intervention. Patients with fibrosis and ballooning improvement increased estimated V̇O_2max by 25% (P = 0.020) and 26% (P = 0.010), respectively. Anthropometric reductions including body mass (P = 0.038), waist circumference (P = 0.015) and fat mass (P = 0.007) were also observed, but no patient achieved 7%-10% weight loss.

CONCLUSION

This study highlights the potential benefits of a 12-week aerobic exercise intervention in improving histological endpoints of MAFLD. The development of strategies to ensure continued engagement in aerobic exercise in MAFLD are needed.

Meta-analysis of the influence of lifestyle changes for preoperative weight loss on surgical outcomes

Background

The aim was to investigate whether preoperative weight loss results in improved clinical outcomes in surgical patients with clinically significant obesity.

Methods

This was a systematic review and aggregate data meta-analysis of RCTs and cohort studies. PubMed, MEDLINE, Embase and CINAHL Plus databases were searched from inception to February 2018. Eligibility criteria were: studies assessing the effect of weight loss interventions (low-energy diets with or without an exercise component) on clinical outcomes in patients undergoing any surgical procedure. Data on 30-day or all-cause in-hospital mortality were extracted and synthesized in meta-analyses. Postoperative thromboembolic complications, duration of surgery, infection and duration of hospital stay were also assessed.

Results

A total of 6060 patients in four RCTs and 12 cohort studies, all from European and North American centres, were identified. Most were in the field of bariatric surgery and all had some methodological limitations. The pooled effect estimate suggested that preoperative weight loss programmes were effective, leading to significant weight reduction compared with controls: mean difference –7·42 (95 per cent c.i. –10·09 to –4·74) kg (P &lt; 0·001). Preoperative weight loss interventions were not associated with a reduction in perioperative mortality (odds ratio 1·41, 95 per cent c.i. 0·24 to 8·40; I2 = 0 per cent, P = 0·66) but the event rate was low. The weight loss groups had shorter hospital stay (by 27 per cent). No differences were found for morbidity.

Conclusion

This limited preoperative weight loss has advantages but may not alter the postoperative morbidity or mortality risk.

Behaviour change intervention increases physical activity, spinal mobility and quality of life in adults with ankylosing spondylitis: a randomised trial

QUESTIONS

Does a 3-month behaviour change intervention targeting physical activity (PA) increase habitual physical activity in adults with ankylosing spondylitis (AS)? Does the intervention improve health-related physical fitness, AS-related features, and attitude to exercise? Are any gains maintained over a 3-month follow-up?

DESIGN

Parallel-group, randomised, controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis.

PARTICIPANTS

Forty adults with a diagnosis of AS, on stable medication, and without PA-limiting comorbidities.

INTERVENTION

Over a 3-month period, the experimental group engaged in individually-tailored, semi-structured consultations aiming to motivate and support individuals in participating in PA. The control group continued with usual care.

OUTCOME MEASURES

The primary outcome was PA measured by accelerometry over 1 week. Secondary outcomes included clinical questionnaires and measures of health-related physical fitness. Measures were taken at baseline, post-intervention, and after a 3-month follow-up period.

RESULTS

Baseline characteristics were similar across groups, except age and body composition. There were statistically significant, moderate-to-large time-by-group effects in health-enhancing PA (mixed-design ANOVA for overall effect F(2, 76)=14.826, p<0.001), spinal mobility (F(2, 76)=5.691, p<0.005) and quality of life (χ²(2)=8.400, p<0.015) favouring the intervention group; post-intervention improvements were sustained 3 months later. No significant effects were seen in other physical fitness outcomes or on clinical questionnaires. No adverse effects were reported during the study.

CONCLUSION

Health-enhancing PA, spinal mobility and quality of life were significantly improved after the intervention, and improvements were maintained at 3-month follow-up.

TRIAL REGISTRATION

NCT02374502. [O'Dwyer T, Monaghan A, Moran J, O'Shea F, Wilson F (2016) Behaviour change intervention increases physical activity, spinal mobility and quality of life in adults with ankylosing spondylitis: a randomised trial.Journal of PhysiotherapyXX: XX-XX].

Venous malformations of the head and neck: current concepts in management

Low-flow venous malformations are congenital lesions and they are the third most common vascular anomaly in the head and neck. In this paper, the third in a series of three educational reviews, we discuss current trends in their management, and include a summary of common sclerosant agents used in their control.

The use of foam sclerotherapy to treat low-flow vascular malformations of the head and neck

Liquid sclerotherapy, laser and surgery have been used in the treatment of head and neck vascular anomalies with variable success for many years. A multidisciplinary team consisting of plastic surgery, maxillofacial surgery and interventional radiology currently treats such lesions by converting liquid sclerosant into foam. Foam sclerotherapy is currently used successfully to treat varicosities of the lower limbs and in this study, we present four cases in which 3% sodium tetradecyl sulfate has been used to treat low-flow vascular malformations in the head and neck.

The contemporary management of midface and craniofacial trauma

The successful management of midface and craniofacial trauma requires a thorough understanding of the anatomy and functional demands of this complex region. To achieve optimal outcomes, it is necessary that these injuries are accurately diagnosed and managed in a multi-disciplinary environment at the appropriate time. This review article discusses an overview of these injuries and highlights some of the key principles of management.

Carbon deposition and phase transformations in red mud on exposure to methane

A characterization study detailing the phase transformations and microstructural nature of the carbon deposited during methane decomposition over red mud has been undertaken. In situ XRD was carried out to study the phase transformation sequences of red mud during the reaction. Scanning electron microscopy, high resolution transmission electron microscopy, thermogravimetric analysis, BET surface area determination and CHN analysis were carried out to investigate the properties of the post-reaction samples. Exposure to methane with increasing temperature caused a stepwise reduction of iron oxides in red mud and promoted methane cracking leading to carbon deposition. The presence of carbon nanostructures was confirmed by HRTEM observations. The carbon formed was graphitic in nature and the spent red mud, rich in Fe and Fe(3)C formed as a result of the reduction of the iron oxide, was magnetic in nature. The surface area of the material was enhanced upon reaction. In addition, reactivity comparisons between goethite and red mud were carried out to study the formation of carbon oxides during reaction.

Use of a temporary cohort ward as part of an intervention to reduce the incidence of meticillin-resistant Staphylococcus aureus in a vascular surgery ward

This article describes the effect of introducing a cohort area into a vascular surgery ward where a sustained increase in new cases of meticillin-resistant Staphylococcus aureus (MRSA) made the implementation of standard MRSA infection control precautions untenable. A recent review of published reports concluded, 'that little evidence could be found to suggest that isolation measures recommended in the UK are effective'. The authors recommended a reporting format to enable the evidence for isolation to be gathered more systematically. This paper follows the recommended reporting format. The setting was a 30-bedded acute and subacute vascular surgery ward within a tertiary care hospital in Glasgow, UK. The data were analysed as an interrupted time series of 19 months pre-cohort, eight months with cohort and eight months post cohort. Following the instigation of the cohort area, there was a significant reduction in the number of nosocomial MRSA isolates from patients (P=0.0005). This reduction was sustained after the cohort area was discontinued. In conclusion, effective separation of MRSA-colonized/-infected patients from patients who are not colonized/infected with MRSA, using a cohort area, resulted in a significant reduction in MRSA cross-colonization and cross-infection. The resulting reduction in MRSA prevalence within the unit facilitated effective screening and isolation of subsequent patients once the cohort area had been discontinued.

Acute exacerbation of macroglossia

We report the case of a large venous malformation of the tongue, preventing the patient from being able to contain it within the oral cavity. The extent of the malformation precluded a complete surgical excision. The immediate problems were; impending airway compromise, inability to speak, eat or drink, severe discomfort due to exposure-induced dryness and an embarrassing spectacle. This case demonstrates that even malformations considered to be incurable may be managed appropriately.

Dysregulated expression of the major telomerase components in leukaemic stem cells

Telomere loss is rapid during the progression of chronic myeloid leukaemia (CML) and correlates with prognosis. We therefore sought to measure expression of the major telomerase components (hTR and hTERT) in CD34+ cells from CML patients and normal controls, to determine if their altered expression may contribute to telomere attrition in vivo. High-purity (median 94.1%) BCR-ABL+ CD34+ cells from CML (n=16) and non-CML (n=14) patients were used. CML samples had a small increase in telomerase activity (TA) compared to normal samples (approximately 1.5-fold, P=0.004), which was inversely correlated with the percentage of G0 cells (P=0.02) suggesting TA may not be elevated on a cell-to-cell basis in CML. Consistent with this, hTERT mRNA expression was not significantly elevated; however, altered mRNA splicing appeared to play a significant role in determining overall full length, functional hTERT levels. Interestingly, Q-RT-PCR for hTR demonstrated a mean five-fold reduction in levels in the chronic phase (CP) CML samples (P=0.002), raising the possibility that telomere homeostasis is disrupted in CML. In summary, the molecular events regulating telomerase gene expression and telomere maintenance during the CP of CML may influence the disease progression observed in these patients.

Cortical bone screw fixation in ionically modified apatite cements

Hydroxyapatite cements are used in reconstruction of the face; usually in well-defined cavities where the cement can be stabilized without the need for internal fixation. A hydroxyapatite cement that could enable screw fixation and some loading therefore has considerable potential in maxillofacial reconstruction. It has been demonstrated recently that water demand of calcium phosphate cements can be reduced by ionically modifying the liquid component. This study investigated the capacity of an ionically modified precompacted apatite cement to retain self-tapping cortical bone screws. Screw pullout forces were determined in the direction of the screw long axis and perpendicular to it, using cortical bone and polymethylmethacrylate cement as a control. In bending pullout tests, measured forces to remove screws from ionically modified precompacted cement were insignificantly different from cortical bone. However, pullout forces of bone screws from hydroxyapatite cement decreased with aging time in vitro.

Modified retractor for use in sectioning the inferior alveolar nerve

We designed a modified tonsillar blade to retract the tissues medial to the ramus of the mandible to gain access to the inferior alveolar nerve at the lingula.

Clinical leadership

FOR SOME TIME now we have been contemplating the meaning of leadership. We recognised the need to discover a new direction to refresh the environments in which we work and aid implementation of the emerging health- care agenda. Most of all, we wanted to develop a leadership style that would, by focusing on team and group working, have an impact on patient care.