Comparative before-after study of fever prevention versus targeted temperature management following out-of-hospital cardiac arrest

Background

International guidelines for neuroprotection following out-of-hospital cardiac arrest (OHCA) recommend fever prevention ahead of routine temperature management. This study aimed to identify any effect of changing from targeted temperature management to fever prevention on neurological outcome following OHCA.

Methods

A retrospective observational cohort study was conducted of consecutive admissions to an ICU at a tertiary OHCA centre. Comparison was made between a period of protocolised targeted temperature management (TTM) to 36 °C and a period of fever prevention.

Results

Data were available for 183 patients. Active temperature management was administered in 86/118 (72%) of the TTM cohort and 20/65 (31%) of the fever prevention group. The median highest temperature prior to the start of temperature management was significantly lower in the TTM group at 35.6 (IQR 34.9-36.2) compared to 37.9 °C (IQR 37.7-38.2) in the fever prevention group (adjusted p < 0.001).There was no difference in the proportion of patients discharged with Cerebral Performance Category 1 or 2 between the groups (42% vs. 40%, p = 0.88). Patients in the fever prevention group required a reduced duration of noradrenaline (36 vs. 46 h, p = 0.03) and a trend towards a reduced duration of propofol (37 vs. 56 h, p = 0.06).In unadjusted analysis, use of active temperature management (irrespective of group) appeared to be associated with decreased risk of poor outcome (OR = 0.43, 95% CI 0.23-0.78) but after adjustment for patient age, presenting rhythm, witnessed arrest and duration of CPR, this was no longer significant (OR = 0.93, 95% CI 0.37-2.31, p = 0.88).

Conclusion

Switching from TTM to fever prevention following OHCA was associated with similar rates of neurological outcomes, with a possible decrease in sedation and vasopressor requirements.

The implementation of a public health alcohol policy in Ireland

In 2012, the Irish Department of Health published a strategy in relation to alcohol and flagged that a Public Health (Alcohol) Act would be pursued through the Houses of the Oireachtas. This Public Health (Alcohol) Act was intended to reduce alcohol consumption and the harms caused by the misuse of alcohol. The act includes various means for this purpose, including introducing statutory minimum prices on alcohol, restricting alcohol advertising, addition of warning labels to alcohol products, and reducing the visibility of alcohol products in retail outlets. This perspective piece aims to provide an account of how this public health alcohol policy has been implemented in Ireland. The strategy relied in a major way on the World Health Organisation framework for alcohol policy. It took 3 years from the launch of that strategy to get the Public Health (Alcohol) Bill published, in December 2015. It took almost another 3 years to get the Public Health (Alcohol) Act passed by the Houses of the Oireachtas, in October 2018. The Act was signed into law by the President of Ireland in November 2018, and it's implementation has commenced in the last few years. This perspective piece highlights the complexities and challenges of implementing legislation related to public health policy, but also demonstrates that real action can occur with advocacy from public health clinicians and key stakeholders.

Detailed analysis of in-hospital transmission of SARS-CoV-2 using whole genome sequencing

BACKGROUND

Hospital transmission of SARS-CoV-2 has proved difficult to control, with healthcare-associated infections troublesome throughout.

AIM

To understand factors contributing to hospital transmission of infections, which is necessary for containing spread.

METHODS

An outbreak of 56 staff and patient cases of COVID-19 over a 31-day period in a tertiary referral unit is presented, with at least a further 29 cases identified outside of the unit and the hospital by whole genome sequencing (WGS).

FINDINGS

Transmission is documented from staff to staff, staff to patients, and patients to staff, showing disruption of a tertiary referral service, despite implementation of nationally recommended control measures, superior ventilation, and use of personal protective equipment. There was extensive spread from the index case, despite this patient spending only 10 h bed bound on the ward in strict cubicle isolation and with an initial single target low level (C_T = 32) polymerase chain reaction test.

CONCLUSION

This investigation highlights how effectively and rapidly SARS-CoV-2 can spread in certain circumstances. It raises questions about infection control measures in place at the time and calls into question the premise that transmissibility can be reliably detected by using lower sensitivity rapid antigen lateral flow tests. We also highlight the value of early intervention in reducing impact as well as the value of WGS in understanding outbreaks.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Safety of the use of Gold Nanoparticles conjugated with proinsulin peptide and administered by hollow microneedles as an immunotherapy in Type 1 diabetes

Antigen-specific immunotherapy is an immunomodulatory strategy for autoimmune diseases, such as type 1 diabetes, in which patients are treated with autoantigens to promote immune tolerance, stop autoimmune β-cell destruction and prevent permanent dependence on exogenous insulin. In this study, human proinsulin peptide C19-A3 (known for its positive safety profile) was conjugated to ultrasmall gold nanoparticles (GNPs), an attractive drug delivery platform due to the potential anti-inflammatory properties of gold. We hypothesised that microneedle intradermal delivery of C19-A3 GNP may improve peptide pharmacokinetics and induce tolerogenic immunomodulation and proceeded to evaluate its safety and feasibility in a first-in-human trial. Allowing for the limitation of the small number of participants, intradermal administration of C19-A3 GNP appears safe and well tolerated in participants with type 1 diabetes. The associated prolonged skin retention of C19-A3 GNP after intradermal administration offers a number of possibilities to enhance its tolerogenic potential, which should be explored in future studies

Effect of feeding single-dam or pooled colostrum on maternally derived immunity in dairy calves

The role of colostrum management in providing adequate immunological protection to neonatal calves has been widely investigated, and thresholds for colostrum quality, as well as optimum volume and timing for colostrum feeding have been established. However, limited information is available on the effect of colostrum source (single dam or pooled) on passive immunity, as well as subsequent antibody survival in the calf. This study aimed to assess the effect of feeding single-dam colostrum (own and other dam) or pooled colostrum on transfer of passive immunity, and also investigate the rate of depletion of disease-specific antibodies among dairy calves. In total, 320 cows and 119 dairy heifer calves were enrolled in the study. Calves were blood-sampled immediately after birth and received either own-dam, other-dam, or pooled colostrum. Calves were blood-sampled at 24 h to assess serum IgG concentrations and at monthly intervals thereafter to document disease-specific antibody survival. Mean colostrum IgG concentration was higher for other-dam treatment group, whereas own-dam and pooled treatments were similar. For all treatment groups, the mean IgG concentration was >80 mg/mL, exceeding the quality threshold of 50 mg/mL. Mean calf serum IgG concentration was lower for calves fed pooled colostrum compared with those that received colostrum from a single cow. There was a negative association with 24-h serum IgG and calf birth bodyweight; calves <30 kg at birth had the highest 24-h serum IgG concentration. Survival of antibodies to bovine viral diarrhea, Salmonella infection, leptospirosis, bovine parainfluenza 3 virus, bovine respiratory syncytical virus, rotavirus, and coronavirus was not associated with colostrum source; however, antibodies to infectious bovine rhinotracheitis had a greater period of survival among calves fed own-dam colostrum. We found that feeding single-dam colostrum can thus improve calf immunity through increased serum IgG levels and antibody survival rates. Furthermore, we hypothesize that immune exclusion may occur with pooled colostrum; therefore, providing pooled colostrum may still be a good practice as long as it can be ensured that enough antibodies are absorbed into the blood stream to deal with pathogens calves may encounter because different dams may have antibodies against different strains of viruses and bacteria, yielding cross protection.

The politics of COVID-19 on the island of Ireland

Background

Political systems are the means through which the science of public health achieves its objectives. This is a qualitative study of public health policies for COVID-19 in Northern Ireland and the Republic of Ireland that seeks to establish if inter-jurisdictional commitments have led to co-ordination and co-operation on the island of Ireland.

Methods

10 indicators from the OxCGRT codebook directed data collection with directed qualitative content analysis supporting comprehensive reading of policy documents. Cross-case and within-case analysis of policy alignment and divergence across ten OxCGRT indicators was undertaken.

Results

Closing Schools Republic of Ireland: 12th March 2020 Northern Ireland: 23rd March 2020; Workplace Closing - Republic of Ireland: 12th and 15th March and 24th March 2020. Northern Ireland: 20th March 2020 followed by mandatory closure on 28th March 2020. Cancelling events and mass gatherings (St Patrick's Day, 17th March)-Republic of Ireland: 9th March 2020-Northern Ireland: 9th March 2020;Lockdown/Shelter-in-place policies. Republic of Ireland: 27th March 2020- Northern Ireland: 28th March 2020; Restrictions on Internal Movement Republic of Ireland: 27th March 2020 Northern Ireland: 28th March 2020. Physical Distancing Measures -Republic of Ireland: 2-metres 24th March 2020 Northern Ireland: 2 metres 23rd March 2020. Mandatory Face Masks in Enclosed Spaces-Republic of Ireland: 10th August 2020 -Northern Ireland: 10th August 2020.

Conclusions

The historical and constitutional politics of the island of Ireland is the obstacle to an all-island response to COVID-19 and this has almost certainly been compounded by Brexit. Defying the odds, however, this study has demonstrated substantial public health policy alignment brought about through ongoing dialogue and co-operation between the health administrations in each jurisdiction.

Key messages

Historical and constitutional politics of the island of Ireland is the obstacle to an all-island response to COVID-19. Even pandemics cannot overcome realpolitik.

Cardiorespiratory fitness and accelerometer-determined physical activity following one year of free-living high-intensity interval training and moderate-intensity continuous training: a randomized trial

Background

Free-living adherence to high-intensity interval training (HIIT) has not been adequately tested. This randomized trial examined changes in cardiorespiratory fitness (CRF) and accelerometer-measured purposeful physical activity over 12 months of free-living HIIT versus moderate-intensity continuous training (MICT).

Methods

Ninety-nine previously low-active participants with overweight/obesity were randomly assigned to HIIT (n = 47) or MICT (n = 52). Both interventions were combined with evidence-based behaviour change counselling consisting of 7 sessions over 2 weeks. Individuals in HIIT were prescribed 10 X 1-min interval-based exercise 3 times per week (totalling 75 min) whereas individuals in MICT were prescribed 150 min of steady-state exercise per week (50 mins 3 times per week). Using a maximal cycling test to exhaustion with expired gas analyses, CRF was assessed at baseline and after 6 and 12 months of free-living exercise. Moderate-to-vigorous physical activity of 10+ minutes (MVPA10+) was assessed by 7-day accelerometry at baseline, 3, 6, 9, and 12 months. Intention to treat analyses were conducted using linear mixed models.

Results

CRF was improved over the 12 months relative to baseline in both HIIT (+ 0.15 l/min, 95% CI 0.08 to 0.23) and MICT (+ 0.11 l/min, 95% CI 0.05 to 0.18). Both groups improved 12-month MVPA10+ above baseline (HIIT: + 36 min/week, 95% CI 17 to 54; MICT: + 69 min/week, 95% CI 49 to 89) with the increase being greater (by 33 min, 95% CI 6 to 60) in MICT (between group difference, P = 0.018).

Conclusion

Despite being prescribed twice as many minutes of exercise and accumulating significantly more purposeful exercise, CRF improvements were similar across 12 months of free-living HIIT and MICT in previously low-active individuals with overweight/obesity.

Development of a welfare assessment protocol for dairy calves from birth through to weaning

The aim of this study was to develop a welfare assessment protocol using different indicators, for pre-weaned dairy calves, that is feasible and time efficient. To this end, the protocol had to combine animal-based indicators (measurements on physiology, general appearance and behaviour) providing the basis for welfare assessment, with resource-based indicators (measurements on management and the environment) providing the basis for identifying risk factors. Indicators, both animal- and resource-based, were selected by a review of existing literature and a process of expert consultation. Following the formulation phase, the protocol was then applied on five Irish dairy farms to develop further for completeness and on-farm feasibility. After each on-farm application, the protocol was critically evaluated, and modifications were made accordingly. Upon completion of the on-farm application phase, a feasible, reliable and time-efficient protocol was produced.

Brief Exercise Counseling and High-Intensity Interval Training on Physical Activity Adherence and Cardiometabolic Health in Individuals at Risk of Type 2 Diabetes: Protocol for a Randomized Controlled Trial

Background

Worldwide incidence of type 2 diabetes (T2D) is rapidly increasing. Given the numerous negative health consequences associated with T2D, prevention of this disease has become a priority. Lifestyle changes, including regular exercise, can reduce the onset of T2D in those at elevated risk. However, long-term adherence to exercise is often poor in this population. Existing lifestyle interventions targeting exercise are labor intensive and costly for staff and participants. Evidence-informed counseling delivered in a manner that reduces dependence on staff and facilitates self-regulatory skills could alleviate time and financial barriers while promoting independent exercise.

Objective

This protocol outlines the design, recruitment, and proposed analysis of a brief, 2-week evidence-informed exercise counseling intervention combined with either high-intensity interval training (HIIT) or traditional moderate-intensity continuous training (MICT).

Methods

Small Steps for Big Changes is a 2-arm randomized controlled trial that will examine the effectiveness of combining brief exercise counseling with HIIT or MICT on adherence to moderate and vigorous exercise over 1 year. Cardiorespiratory fitness will be assessed at baseline, post intervention (2 weeks), and at 6- and 12-month follow-up. Physical activity behavior will be examined at baseline, post intervention, and 3-, 6-, 9-, and 12-month follow-up. The impact of the intervention on psychosocial outcomes pertinent to exercise adherence will be examined.

Results

Data collection was complete in March 2017. Data analysis is currently underway, and the first results are expected to be submitted for publication in 2019.

Conclusions

The results of this brief intervention have the potential to inform future public health efforts designed to increase exercise in individuals at risk of T2D.

Trial Registration

ClinicalTrials.gov NCT02164474; https://clinicaltrials.gov/ct2/show/NCT02164474 (Archived by WebCite at http://www.webcitation.org/74Hx1ipj6)

International Registered Report Identifier (IRRID)

DERR1-10.2196/11226

Public cost of privately inserted laparoscopic adjustable gastric bands

Background

Laparoscopic adjustable gastric banding (LAGB) remains a commonly performed procedure for morbid obesity. Concerns regarding its long‐term consequences include high rates of band removal from complications and failure to lose weight. Many private practices continue to perform LAGB but, owing to short follow‐up periods, the burden of surgical complications falls upon National Health Service (NHS) bariatric units. This study aimed to review the NHS treatment of patients for complications related to privately performed LAGB.

Methods

All surgical complications following bariatric surgery referred to the Welsh Institute of Metabolic and Obesity Surgery (WIMOS) between September 2010 and September 2014 were reviewed. Type of complication, procedures performed, and number of outpatient attendances and inpatient stays were recorded. Costs of treatment were estimated using standard tariffs.

Results

A total of 78 patients presented with complications after privately performed bariatric surgery. Sixty had undergone LAGB; the remainder had had other bariatric procedures. Median age was 45 (range 22–78) years, and 65 (83 per cent) were women. Urgent band deflation was undertaken in 53 patients. Band removal surgery was required in 32 patients; one patient needed a subtotal gastrectomy. There was a total of 123 outpatient/ward attendances and 340 days of inpatient care, including 10 days of intensive care. The estimated total cost to the NHS of managing these patients was €337 400 (€84 350 per annum).

Conclusion

The cost burden to the NHS of managing the complications of bariatric surgery performed in the private sector is considerable. Although it is imperative that such complications be managed in well equipped specialist units, private surgery providers should have better follow‐up plans and/or contractual agreements with the NHS.

Short-term exercise training reduces glycaemic variability and lowers circulating endothelial microparticles in overweight and obese women at elevated risk of type 2 diabetes

Exercise is recognized as a frontline therapy for the prevention and treatment of type 2 diabetes (T2D) but the optimal type of exercise is not yet determined. We compared the effects of high-intensity interval training (HIIT) with moderate-intensity continuous training (MICT) for improvement of continuous glucose monitoring (CGM)-derived markers of glycaemic variability, and biomarkers of endothelial cell damage (CD31+ and CD62+ endothelial microparticles (EMPs)) within a population at elevated risk of developing T2D. Fifteen inactive overweight or obese women were randomized to 2 weeks (10-sessions) of progressive HIIT (n = 8, 4-10X 1-min @ ∼90% peak heart rate, 1-min rest periods) or MICT (n = 7, 20-50 min of continuous activity at ∼65% peak heart rate). Prior and three days post-training, fasting blood samples were collected. Both HIIT and MICT improved glycaemic variability as measured by CGM standard deviation (HIIT: 0.82 ± 0.39 vs. 0.72 ± 0.33 mmol/L; MICT: 0.82 ± 0.19 vs. 0.62 ± 0.16 mmol/L, pre vs. post) and mean amplitude of glycaemic excursions (MAGE; HIIT: 1.98 ± 0.81 vs. 1.41 ± 0.90; MICT; 1.98 ± 0.43 vs. 1.65 ± 0.48, pre vs. post) with no difference between groups. CD62+ EMPs were lower following HIIT (187.7 ± 65 vs. 174.9 ± 55, pre vs. post) and MICT (170 ± 60 vs. 160.3 ± 59, pre vs. post) with no difference between groups. There was no change in 24-h mean glucose or CD31+ EMPs. Two weeks of both HIIT or MICT similarly decreased glycaemic variability and CD62+ EMPs in overweight/obese women at elevated risk of T2D.

Acyl-ghrelin mediated lipid retention and inflammation in obesity-related Type 2 diabetes

Acyl-ghrelin has various peripheral effects including the potential role in mediating cellular lipid removal and macrophage polarization. Previous reports are contradictory as to how glycaemia and acyl-ghrelin mediates lipid retention and inflammation within individuals with Type 2 diabetes (T2D). Our aim was to explore acyl-ghrelin levels and ghrelin expression in relation to lipid and inflammatory markers within an ex vivo human model, biopsied visceral adipose tissue. Results indicated that acyl-ghrelin was associated with a decline in key lipid homeostasis genes ABCG1 and LXRβ expression. Within T2D there was also a down regulation of these genes which was independent of acyl-ghrelin levels. Circulatory pro-inflammatory markers (IL-6 and TNFα) had no association with ghrelin expression nor circulating acyl-ghrelin levels. Anti-inflammatory marker (IL-10) and total antioxidant status (TAOS%) were positively associated with ghrelin expression across samples from all groups combined (total sample cohort) and specifically within the obesity sample cohorts. Data supported the hypothesis that hyperglycaemia and acyl-ghrelin have a regulatory role in lipid retention. Furthermore, that both acyl- and desacyl-ghrelin is responsible for a protective inflammatory response; however this response is diminished in T2D.

Pre-pregnancy weight loss in women with obesity requesting removal of their intra-uterine contraceptive device in order to conceive: a pilot study of full meal replacement

Obesity during pregnancy is associated with increased risks of thromboembolism, gestational diabetes, pre-eclampsia, miscarriage, congenital anomaly, macrosomia and stillbirth. The current practice, directed at reducing gestational weight gain, is largely ineffective. The present pilot study was designed to assess the acceptability of a 24-week intensive weight management programme (IWMP; full meal replacement followed by partial meal replacement and weight stabilization) to achieve weight loss for women with obesity requesting removal of their intra-uterine contraceptive device in order to conceive. Twenty six (65%) of eligible participants consented to the IWMP; three received this as routine National Health Service care in the University College Hospital clinic and 14 participated in the study. The commonest reasons for not participating were dislike of milk, anxiety and lack of support from family and friends. Omitting one woman who dropped out because of problems unrelated to the intervention, the completion rate was 46.2%. Including all women who started the programme, mean body mass index decreased significantly (P = 0.005) from 37.8 to 35.3 kg/m² . The median percentage decrease was significantly (P = 0.007) greater for women who completed the study (14.2) compared to those who dropped out (1.2). These results suggest an impressive level of weight loss in about one third of all women offered the IWMP who had to defer what they were seeking (pregnancy) while following a challenging programme that they were not seeking. However, studies of other interventions, such as partial meal replacement or commercial products, which may have higher rates of completion are still required.

Below the surface: Twenty-five years of seafloor litter monitoring in coastal seas of North West Europe (1992-2017)

Marine litter presents a global problem, with increasing quantities documented in recent decades. The distribution and abundance of marine litter on the seafloor off the United Kingdom's (UK) coasts were quantified during 39 independent scientific surveys conducted between 1992 and 2017. Widespread distribution of litter items, especially plastics, were found on the seabed of the North Sea, English Channel, Celtic Sea and Irish Sea. High variation in abundance of litter items, ranging from 0 to 1835 pieces km^-2 of seafloor, was observed. Plastic tems such as bags, bottles and fishing related debris were commonly observed across all areas. Over the entire 25-year period (1992-2017), 63% of the 2461 trawls contained at least one plastic litter item. There was no significant temporal trend in the percentage of trawls containing any or total plastic litter items across the long-term datasets. Statistically significant trends, however, were observed in specific plastic litter categories only. These trends were all positive except for a negative trend in plastic bags in the Greater North Sea - suggesting that behavioural and legislative changes could reduce the problem of marine litter within decades.

Impact of a single bout of high-intensity interval exercise and short-term interval training on interleukin-6, FNDC5, and METRNL mRNA expression in human skeletal muscle

BACKGROUND

Exercise promotes numerous phenotypic adaptations in skeletal muscle that contribute to improved function and metabolic capacity. An emerging body of evidence suggests that skeletal muscle also releases a myriad of factors during exercise, termed "myokines". The purpose of this study was to examine the effects of high-intensity interval training (HIIT) on the acute regulation of the mRNA expression of several myokines, including the prototypical myokine interleukin-6 (IL-6), and recently identified myokines fibronectin type III domain-containing protein 5 (FNDC5) (irisin) and meteorin-like protein (METRNL).

METHODS

Both before and after a 20-day period of twice-daily high-volume HIIT, 9 healthy males (20.5 ± 1.5 years performed a standardized bout of high-intensity interval exercise (HIIE; 5 × 4 min at ~80% pretraining peak power output) with skeletal muscle biopsy samples (vastus lateralis) obtained at rest, immediately following exercise, and at 3 h recovery.

RESULTS

Before training, a single bout of HIIE increased IL-6 (p < 0.05) and METRNL (p < 0.05) mRNA expression measured at 3 h recovery when compared to rest. Following 20 days of HIIT, IL-6 and FNDC5 mRNA were increased at 3 h recovery from the standardized HIIE bout when compared to rest (both p < 0.05). Resting METRNL and FNDC5 mRNA expression were higher following training (p < 0.05), and there was an overall increase in FNDC5 mRNA post-training (main effect of training, p < 0.05).

CONCLUSION

In human skeletal muscle (1) an acute bout of HIIE can induce upregulation of skeletal muscle IL-6 mRNA both before and after a period of intensified HIIT; (2) Resting and overall FNDC5 mRNA expression is increased by 20 days of HIIT; and (3) METRNL mRNA expression is responsive to both acute HIIE and short-term intense HIIT. Future studies are needed to confirm these findings at the protein and secretion level in humans.

A Longitudinal Qualitative Analysis of the Lived Experience of the Recovery Process in Opioid-Dependent Patients Post-Detoxification

The aim of the study was to gain an in-depth understanding of opioid-dependent patients' lived experiences post-detoxification.

METHOD

The study employed a naturalistic, observational longitudinal design, involving baseline screening and tracking of patients post-detoxification, with follow-up interviews at three, six, and nine months to observe specific processes of interest. This in-depth investigation of patients at four points was new within an Irish context and novel throughout the literature.

FINDINGS

Recovery was seen as a process that was not always linear, and lapse and relapse were viewed as part of this process. Patients had great insight into "risk factors for relapse," information and knowledge gained over several years and many treatment episodes. Furthermore, the findings illustrate the role insight plays in any learning and growth experience and the emphasis that is placed upon it within the treatment journey; insight is a fundamental underpinning to any real growth and development. The current article argues that insight merits a more explicit role in the model of recovery capital.

A big data approach to macrofaunal baseline assessment, monitoring and sustainable exploitation of the seabed

In this study we produce a standardised dataset for benthic macrofauna and sediments through integration of data (33,198 samples) from 777 grab surveys. The resulting dataset is used to identify spatial and temporal patterns in faunal distribution around the UK, and the role of sediment composition and other explanatory variables in determining such patterns. We show how insight into natural variability afforded by the dataset can be used to improve the sustainability of activities which affect sediment composition, by identifying conditions which should remain favourable for faunal recolonisation. Other big data applications and uses of the dataset are discussed.

The effect of foraging and ontogeny on the prevalence and intensity of the invasive parasite Anguillicola crassus in the European eel Anguilla anguilla

Infection patterns of the invasive Anguillicola crassus nematode were investigated in a population of the European eel Anguilla anguilla where parasite invasion is very recent, Loch Lomond, Scotland. Intensity levels of the parasite were associated with differences in fish ontogeny and trophic ecology. Although eels foraged on both fish and invertebrates, individuals which were smaller and fed on invertebrates (>70% contribution to diet) were found to contain a greater number of swim bladder parasites compared to larger eel with a predominance of fish (>60% contribution) in their diet. Within affected fish, a significant negative relationship was found between fish length and parasite intensity, with smaller individuals having higher parasite intensity than larger individuals. This study indicates that food intake and infection risk are linked in this recently infected host-parasite system. From a management perspective increasing our understanding of how infection intensity and repeated exposure is linked to resource use in an ecosystem is important for the future management of this endangered species in Europe.

Spatial and temporal analysis of the risks posed by total petroleum hydrocarbon and trace element contaminants in coastal waters of Kuwait

Nine trace elements including As, Cd, Cu, Fe, Hg, Ni, Pb, V and Zn, and total petroleum hydrocarbons were analysed from water samples collected from 23 stations since 1984 from Kuwaiti coastal waters. Here it was investigated whether concentrations of these determinants are at levels above Kuwaiti and internationally established assessment criteria (AC). The results indicate that Cu and Cd had the most Kuwaiti AC breaches over time. Comparing the data of the last sampled year to the least stringent international AC, then Cu and Cd showed breaches at all stations. The trends for trace metals are significantly downwards, especially for Cd and Hg. No determinant measured showed a significant upward trend, indicating that water pollution for these contaminants is not a worsening situation. However, further sampling should be carried out to confirm these findings, especially at shoreline locations, where routine monitoring ceased in 2011 to investigate any recent changes.

Resuscitation practices for infants in the NICU, PICU and CICU: results of a national survey

OBJECTIVE

Infants requiring resuscitation at birth are resuscitated using neonatal resuscitation guidelines. Sometime after birth, resuscitation practice must transition to pediatric guidelines. There is no evidence on when this transition should occur. The objective of this study was to describe infant resuscitation practices in Neonatal Intensive Care Units (NICUs), Pediatric Intensive Care Units (PICUs) and Cardiac Intensive Care Units (CICUs).

STUDY DESIGN

An electronic survey was sent to medical directors of NICUs, PICUs and CICUs in the U.S. The survey examined resuscitation practices, and preference for use of neonatal or pediatric guidelines, for different postnatal ages, clinical scenarios and etiologies of arrest.

RESULTS

A total of 152 responses were received, including 118 NICUs, 19 PICUs and 15 CICUs. The majority of NICU responders used greater than 28 days as the time to change from neonatal to pediatric guidelines. The majority of PICU and CICU transitioned to pediatric guidelines immediately after birth. Pediatric guidelines were preferred in the PICU and CICU regardless of the arrest etiology. NICU responders favored pediatric guidelines only if the arrest was cardiac.

CONCLUSIONS

Our results suggest that infants are resuscitated using neonatal guidelines in the NICU and pediatric guidelines in the PICU and CICU, even if they are the same age and have the same etiology of arrest. There is no agreement on the time to change from neonatal to pediatric guidelines. Further research comparing the outcomes of infants resuscitated in these different units could inform future guideline refinement.

Does size matter? A test of size-specific mortality in Atlantic salmon Salmo salar smolts tagged with acoustic transmitters

Mortality rates of wild Atlantic salmon Salmo salar smolts implanted with acoustic transmitters were assessed to determine if mortality was size dependent. The routinely accepted, but widely debated, '2% transmitter mass: body mass' rule in biotelemetry was tested by extending the transmitter burden up to 12·7% of body mass in small [mean fork length (LF ) 138·3 mm, range 115-168 mm] downstream migrating S. salar smolts. Over the short timescale of emigration (range 11·9-44·5 days) through the lower river and estuary, mortality was not related to S. salar size, nor was a relationship found between mortality probability and transmitter mass: body mass or transmitter length: LF ratios. This study provides further evidence that smolt migration studies can deviate from the '2% rule' of thumb, to more appropriate study-specific measures, which enables the use of fishes representative of the body size in natural populations without undue effects.

Freshwater and coastal migration patterns in the silver-stage eel Anguilla anguilla

The unimpeded downstream movement patterns and migration success of small female and male Anguilla anguilla through a catchment in north-west Europe were studied using an acoustic hydrophone array along the River Finn and into the Foyle Estuary in Ireland. Twenty silver-stage A. anguilla (total length, LT , range: 332-520 mm) were trapped 152 km upstream from a coastal marine sea-lough outlet and internally tagged with acoustic transmitters of which 19 initiated downstream migration. Migration speed was highly influenced by river flow within the freshwater (FW) compartment. Anguilla anguilla activity patterns were correlated with environmental influences; light, tidal direction and lunar phase all influenced the initiation of migration of tagged individuals. Migration speed varied significantly between upstream and lower river compartments. Individuals migrated at a slower speed in transitional water and sea-lough compartments compared with the FW compartment. While 88·5% survival was recorded during migration through the upper 121 km of the river and estuary, only 26% of A. anguilla which initiated downstream migration were detected at the outermost end of the acoustic array. Telemetry equipment functioned efficiently, including in the sea-lough, so this suggests high levels of mortality during sea-lough migration, or less likely, long-term sea-lough residence by silver A. anguilla emigrants. This has important implications for eel management plans.

Neck length and mean arterial pressure in the sauropod dinosaurs

How blood was able to reach the heads of the long-necked sauropod dinosaurs has long been a matter of debate and several hypotheses have been presented. For example, it has been proposed that sauropods either had exceptionally large hearts, multiple ‘normal’ sized hearts spaced at regular intervals up the neck, held their necks horizontal, or the siphon effect was in operation. By means of an experimental model, we demonstrate that the siphon principle is able to explain how blood was able to adequately perfuse the sauropod brain. The return venous circulation may have been protected from complete collapse by a structure akin to the vertebral venous plexus. We derive an equation relating neck height and mean arterial pressure, which indicates that with a mean arterial pressure similar to the giraffe, the maximum safe vertical distance between heart and head would have been about 12 m. A hypothesis is presented that the maximum neck length in the fossil record is due to the siphon height limit. The equation indicates that to migrate over high ground, sauropods would either have had to significantly increase their mean arterial pressure or keep their necks below a certain height dependent on altitude.

Changes in the water quality conditions of Kuwait's marine waters: Long term impacts of nutrient enrichment

This work analyses a 30 year water quality data set collated from chemical analyses of Kuwait's marine waters. Spatial patterns across six sites in Kuwait Bay and seven sites located in the Arabian Gulf are explored and discussed in terms of the changing influences associated with point and diffuse sources. Statistical modelling demonstrated significant increases for dissolved nutrients over the time period. Kuwait marine waters have been subject to inputs from urban development, untreated sewage discharges and decreasing river flow from the Shatt al-Arab River. Chlorophyll biomass showed a small but significant reduction; the high sewage content of the coastal waters from sewage discharges likely favouring the presence of smaller phytoplankton taxa. This detailed assessment of temporal data of the impacts of sewage inputs into Kuwait's coastal waters establishes an important baseline permitting future assessments to be made as sewage is upgraded, and the river continues to be extracted upstream.

Local scale, coastal currents influence recruitment to freshwater populations in the European eel Anguilla anguilla: a case study from the Isle of Man

This study examines juvenile Anguilla anguilla (<30 cm) abundance in five study catchments on the Isle of Man. Preliminary results suggest that juvenile abundance is negatively correlated with increasing coastal current speed at river mouth entry (P < 0·05). These findings indicate that at least under some circumstances, tidally driven coastal currents may influence recruitment to freshwater habitats; therefore, it is presumed that high coastal current speed at the entry to river mouths may reduce the likelihood of freshwater entry.

Treatment outcome for adolescents abusing alcohol and cannabis: how many 'reliably improve'?

Alcohol and cannabis are the primary substances contributing to referrals of adolescents to substance abuse treatment services. Their outcome has not been examined in Ireland. A three month follow-up was conducted in an outpatient adolescent treatment program. We followed up 35 high risk users of alcohol and 55 high risk users of cannabis. Although the high risk drinkers achieved a significant reduction in median number of days drinking (p = 0.004), only four (11 %) were abstinent at follow up. A further five (14%) achieved a reliable reduction in days of drinking. The high risk cannabis users demonstrated a significant drop in median days of use (p < 0.001), although only six (11%) were abstinent at follow up. A further 20 (36%) achieved a reliable reduction in days of use. Calculation of reliable change allows examination of outcomes which fall short of the elusive goal of abstinence.

Towards a framework for implementing evidence based alcohol interventions

Alcohol is ranked as the eighth leading cause of death globally and is a causal factor in more than sixty major types of diseases and injuries and results in approximately 2.5 million deaths a year. This study tested the feasibility of screening and brief intervention (SBI) within four emergency departments. A total of 944 patients were screened for hazardous and harmful alcohol use. The results showed that there was good co-operation from the public with 888 (94%) people agreeing to be screened. The screening tool detected that 460 (49%) of those needed no intervention, 345 (36%) needed brief advice and 83 (9%) required referral to specialist services. This showed the value of the screening but also helped to reassure staff that people were happy to take part.

Metal-on-metal hip resurfacing compared with 28-mm diameter metal-on-metal total hip replacement: a randomised study with six to nine years' follow-up

A total of 219 hips in 192 patients aged between 18 and 65 years were randomised to 28-mm metal-on-metal uncemented total hip replacements (THRs, 107 hips) or hybrid hip resurfacing (HR, 112 hips). At a mean follow-up of eight years (6.6 to 9.3) there was no significant difference between the THR and HR groups regarding rate of revision (4.0% (4 of 99) vs 5.8% (6 of 104), p = 0.569) or re-operation rates without revision (5.1% (5 of 99) vs 2.9% (3 of 104), p = 0.428). In the THR group one recurrent dislocation, two late deep infections and one peri-prosthetic fracture required revision, whereas in the HR group five patients underwent revision for femoral head loosening and one for adverse reaction to metal debris. The mean University of California, Los Angeles activity scores were significantly higher in HR (7.5 (sd 1.7) vs 6.9 (sd 1.7), p = 0.035), but similar mean Western Ontario and McMaster Universities Osteoarthritis Index scores were obtained (5.8 (sd 9.5) in HR vs 5.1 (sd 8.9) in THR, p = 0.615) at the last follow-up. Osteolysis was found in 30 of 81 THR patients (37.4%), mostly in the proximal femur, compared with two of 83 HR patients (2.4%) (p < 0.001). At five years the mean metal ion levels were < 2.5 μg/l for cobalt and chromium in both groups; only titanium was significantly higher in the HR group (p = 0.001). Although revision rates and functional scores were similar in both groups at mid-term, long-term survival analysis is necessary to determine whether one procedure is more advantageous than the other.

Alcohol consumption in pregnancy: results from the general practice setting

BACKGROUND

There is no established safe level of alcohol consumption in pregnancy. Studies from Ireland have consistently shown lower abstention and higher binge drinking rates in pregnancy than other countries, indicating a high potential for foetal alcohol-related disorders. There has been little research on alcohol in pregnancy in primary care.

AIMS

To determine the prevalence of alcohol consumption amongst pregnant women attending their GP for antenatal care, and to compare this to use in the year prior to conception.

METHODS

Prospective cross-sectional study was carried out in fifteen teaching practices in the greater Dublin area. Women were recruited at their antenatal visits. Data were gathered by self-completed questionnaire in the practice, or researcher-administered telephone questionnaire. The questionnaire was based on the AUDIT, a WHO-validated data collection instrument designed for use in primary care.

RESULTS

Two hundred and forty valid questionnaires were returned (80 % recruitment rate). Alcohol intake and binge drinking levels were much lower during pregnancy compared to the year prior to pregnancy (p < 0.001). There was a marked reduction in the prevalence of alcohol use in pregnancy compared to previous research. Over 97 % drink no more than once a week, including almost two-thirds of women who abstain totally from alcohol in pregnancy. Non-pregnant Irish women drink alcohol more frequently, and with higher rates of binge drinking, than women of other nationalities.

CONCLUSIONS

Primary care is a suitable setting to research alcohol use in pregnancy. Alcohol use in pregnancy in Ireland has decreased markedly compared to previous research from this jurisdiction.