Search

ObjectiveAn e-learning resource (MEdic GAming, MEGA) was developed based on the contents of the Faculty of Sports and Exercise Medicine exercise prescription booklet. This study aimed to (i) explore medical students’ perspectives of physical activity promotion and e-learning and (ii) investigate medical students’ response to the design, content and usability of the MEGA e-learning resource.DesignQualitative think-aloud interview study.SettingA London medical school.Participants19 undergraduate medical students were interviewed using the think-aloud method while using the e-learning resource concurrently.ResultsIn general, medical students felt current education on physical activity is inadequate and held a strong desire for more teaching on exercise medicine. Students believed the MEGA e-learning resource addressed a gap in their knowledge on physical activity but noted e-learning should not replace face-to-face teaching and suggested physical activity education would be best delivered through a blended learning approach. Students felt such an approach would allow better opportunity to practice physical activity counselling skills with patients while on clinical placement. Students’ motivation to engage with the MEGA e-learning resource was positively impacted by aesthetically appealing design and interactive gamification elements such as self-assessment quizzes and visual progress tracking.ConclusionMedical students value the role of physical activity in health but are disappointed by the lack of teaching within the current medical curriculum. E-learning resources, such as MEGA, which contain interactive features are a viable means to integrate physical activity into the undergraduate curriculum but should be supplemented by the opportunity to practice physical activity counselling in-person.

Curriculum design in higher education environments, namely the consideration of aims, learning outcomes, syllabus, pedagogy and assessment, can often be ad hoc and driven by informal cultural habits. Academics with disciplinary expertise may be resistant to (or ignorant of) pedagogical approaches beyond existing practice. In an environment where there is a need to develop online activities for students, one way to counter this friction is through a team-based approach underpinned by design-thinking. A design-thinking team brings together content, pedagogical and technical expertise to examine and resolve curriculum design issues. This paper explores a number of case studies in which such teams developed units of study and programmes for online delivery. The paper looks at the possibilities that the team approach can be a vehicle to instigate cultural change within and beyond the team; that is, from an individualist to a collective approach and ownership of the curriculum and its design, maintenance and co...

Background In September 2015, the United Kingdom became the first country to introduce the multicomponent group B meningococcal vaccine (4CMenB) into a national infant immunisation programme. In early clinical trials 51–61% of infants developed a fever when 4CMenB was administered with other routine vaccines. Whilst administration of prophylactic paracetamol is advised, up to 3% of parents may seek medical advice for fever following vaccination. We used research-level general practitioner consultations to identify any increase in attendances for all-cause fever in vaccine-eligible infants following 4CMenB introduction in England. Methods Consultations for infant all-cause fever in the year following the vaccine introduction were identified from The Phoenix Partnership (TPP) ResearchOne general practice database using Read (CTV3) codes. Average daily consultation rates and incidence rate ratios (IRRs) were calculated for vaccine-eligible age groups and compared to the two years preceding vaccine introduction. The difference between pre- and post-vaccine all-cause fever consultations was estimated. Results All-cause fever consultations in vaccine-eligible 7–10 week olds were 1.6-fold higher (IRR, 1.58; 95% CI, 1.22–2.05) compared to the two previous years and 1.5-fold higher (IRR 1.47; 95% CI, 1.17–1.86) in 15–18 week-olds. There were no significant differences in 0–6 or 11–14 week-olds. Applying the difference between pre- and post-vaccine consultation rates to the 4CMenB vaccine-eligible age groups across England estimated 1825 additional fever consultations in the year following 4CMenB introduction. Conclusions We found a small but significant difference in all-cause fever consultation rates in vaccine-eligible infants who would have received 4CMenB with other vaccines.

Objective To use syndromic surveillance data to assess whether there has been an increase in GP fever consultations since the inclusion of the meningococcal B (MenB) vaccine in the UK vaccination schedule. Introduction From 1 September 2015, babies in the United Kingdom (UK) born on/after 1 July 2015 became eligible to receive the MenB vaccine, given at 2 and 4 months of age, with a booster at 12 months. 1 Early trials found a high prevalence of fever (over 38°C) in babies given the vaccine with other routine vaccines at 2 and 4 months. We used syndromic surveillance 2 data to assess whether there had been increased family doctor (general practitioner (GP)) consultations for fever in young infants following the introduction of the vaccine. Methods GP consultations for fever in infants aged under 1 year were extracted from The Phoenix Partnership (TPP) ResearchOne database (400 GP surgeries in England). 3 Data were stratified by week of age over the period 1 September 2015 to 30 November 2015 and 1 December 2015 to 29 February 2016. Fever consultation rates (per 100,000 registered practice population in the database) were compared to the same 3 month periods of the previous 5 years (2010-14) using incident rate ratios (IRR). Pre- and post-vaccination consultation rates were applied to the England 0-26 week population to estimate excess fever consultations. Results Between 1 September and 30 November 2015 the average daily fever consultation rate for infants aged 0-26 weeks was 4.72/100,000; the incident rate ratio was 1.46 (95% CI, 1.09-1.92). In the 7-10 week age group the average daily fever consultation rate was 7.79/100,000. The incidence rate was 2.68 times higher than in previous years (95% CI, 1.42-4.94). Between 1 December 2015 and 29 February 2016 the average daily consultation rate for infants aged 0-26 weeks was 6.19/100,000. The incidence rate was 1.49 times higher than in the same 3 month period of previous years (95% CI, 1.16-1.90). In infants aged 7-10 weeks the average daily consultation rate was 8.44/100,000 and the incidence rate was 1.83 times higher than previous years (95% CI 1.03-3.16). Between 1 September 2015 and 29 February 2016 there were an estimated additional 959 fever consultations for infants aged 0-26 weeks to English family doctors. Conclusions We have demonstrated an innovative use of syndromic surveillance to quickly and easily assess the impact on healthcare seeking behaviour for infants with fever following the introduction of a new vaccination into the routine vaccination programme in England. Our study provides reassurance that in infants aged 0-26 weeks there was no marked increase in consultations following the introduction of the new MenB vaccination. However, in some age groups below 0-26 weeks there was an increase in healthcare seeking behaviour for fever, in particular, the 7-10 week age group which includes infants aged 8 weeks receiving their first vaccination. Other age groups also demonstrated increased fever consultations during these two periods, albeit at less significant levels. We will analyse data for the full year from 1 September 2015 to further explore these findings, investigate potential confounders and assess trends since vaccine introduction.

Background We assessed the applicability, acceptability and cost implications of introducing the manual vacuum aspiration (MVA) technique with local anaesthesia for fully conscious first-trimester termination of pregnancy within our service and for our population. Setting The outpatient setting of a Pregnancy Advisory Service within a NHS Sexual Health Service. Methods Self-administered misoprostol and diclofenac, extra-amniotic local anaesthetic gel and paracervical mepivicaine prior to MVA. Routinely collected data were used to provide information on uptake, demographic details, timing, pain score, complications, contraceptive uptake, and economic implications for our service. Results MVA was chosen by 305/1681 potentially eligible women. Forty percent had the procedure on the day they attended for assessment. Seventy-nine percent gave a pain score of 3 or less out of 10. Complications occurred in six cases (2%); these included cervical rigidity, a false passage, retained products of conception, bleeding (more than 200 ml) and one allergic reaction. Eighty percent of women chose to commence a long-acting reversible contraception (LARC) method at the time of MVA. Operating theatre utilisation was reduced by one termination list per week and cost savings of around £60 000 per annum were realised. Conclusions The technique for fully conscious MVA was very suitable for our outpatient setting. It was associated with very low levels of pain and bleeding. The uptake of LARC was high, and particularly the ability to provide intrauterine contraception at MVA was associated with a very high uptake.

Summary Introduction This aim of the present study was to compare metabolic rates at critical running speed vs. critical power in cycling. Summary of facts Eight participants (33.6 ± 12.1 years) performed a series of constant-intensity exhaustive trials to model the speed–time -1 (treadmill; 1% gradient) and power time -1 relationship (cycle ergometry) for intercept of the two relationships to be determined (Critical Speed [CS], Critical Power [CP]). A time to exhaustion (tlim) at CS and CP then followed. tlim did not differ between conditions (CS: 30.2 ± 4.7 min, CP: 26.8 ± 1.4 min, p = 0.58). The mean VO 2 values at minute 3 of the tlim were not significantly different with a strong relationship between the two sets of data ( r = 0.87, p 2 max (CP) at end exercise, with no difference between the two sets of data ( p Conclusion There is a metabolic, critical intensity (i.e. CS and CP) that induces similar metabolic stress, thus independent of the muscular contraction regimens.

Summary Introduction This study investigated the effect of a change in muscle contraction regimen via the manipulation of treadmill gradient on critical running speed. Summary of facts Ten participants performed a series of constant-speed exhaustive trials to model the speed–time −1 relationship using a 2-parameter equation (intercept: critical speed, CS). The treadmill gradient was either 0% (CS 0% ) or 10% (CS 10% ). A time to exhaustion ( t lim ) at both CS then followed in a randomised order. CS 10% was lower by ∼35% (2.57 ± 0.10 vs. 3.95 ± 0.15 m.s −1 ) yet the mean VO 2 values at minute 3 of t lim did not differ significantly. There was no difference in the t lim at CS 0% and CS 10% (∼30 minutes). However, there were some differences in the physiological responses between minute 3 and end exercise, and consequently the pattern between the two time points. Conclusion CS is affected by a change in treadmill gradient while its associated metabolic rate isn’t. But when exercising at CS, differences in the metabolic stress over time suggests for the development of fatigue, and therefore the sustainability of CS, to be dependent on the muscular contraction regimens.

This article examines the importance of clinical reviews for people receiving care in custodial settings. A case study is used to illustrate the need for accurate record-keeping, particularly following death. Healthcare professionals have a duty to ensure that prisoners have the same rights as members of the general public in relation to access to health care and opportunities to improve their health.

Chronic deep brain stimulation (DBS) of the periventricular gray (PVG) has been used for the treatment of chronic central pain for decades. In recent years motor cortex stimulation (MCS) has largely supplanted DBS in the surgical management of intractable neuropathic pain of central origin. However, MCS provides satisfactory pain relief in about 50-75% of cases, a range comparable to that reported for DBS (none of the reports are in placebo-controlled studies and hence the further need for caution in evaluating and comparing these results). Our experience also suggests that there is still a role for DBS in the control of central pain. Here we present a series of eight consecutive cases of intractable chronic pain of central origin treated with PVG DBS with an average follow-up of 9 months. In each case, two electrodes were implanted in the PVG and the ventroposterolateral thalamic nucleus, respectively, under guidance of corneal topography/magnetic resonance imaging image fusion. The PVG was stimulated in the frequency range of 2-100 Hz in alert patients while pain was assessed using the McGill-Melzack visual analogue scale. In addition, local field potentials (FPs) were recorded from the sensory thalamus during PVG stimulation. Maximum pain relief was obtained with 5-35 Hz stimulation while 50-100 Hz made the pain worse. This suggests that pain suppression was frequency dependent. Interestingly, we detected low frequency thalamic FPs at 0.2-0.4 Hz closely associated with the pain. During 5-35 Hz PVG stimulation the amplitude of this potential was significantly reduced and this was associated with marked pain relief. At the higher frequencies (50-100 Hz), however, there was no reduction in the FPs and no pain suppression. We have found an interesting and consistent correlation between thalamic electrical activity and chronic pain. This low frequency potential may provide an objective index for quantifying chronic pain, and may hold further clues to the mechanism of action of PVG stimulation. It may be possible to use the presence of these slow FPs and the effect of trial PVG DBS on both the clinical status and the FPs to predict the probable success of future pain control in individual patients.

Nurses lead many projects to manage change aimed at improving patient safety and care. This two-part series offers practical guidance on how to bring about an evidence-based change in practice, and how to demonstrate the success, or otherwise, of that change. Part 2 is concerned with discovering why the practice is falling short, how to implement improvements and measure the effect of the changes. It also highlights ways in which nurses can use their work as part of the revalidation process.

In order to ensure the service they offer is of an appropriate standard, nurses need to know how to assess its quality, identify the need for change, and implement and evaluate that change. This two-part series offers practical guidance on how to bring about an evidence-based change in practice, and how to demonstrate the success, or otherwise, of that change. It uses the example of an initiative undertaken to improve medicines management in a hospice to illustrate the process. The article also illustrates how work undertaken in changing practice can form part of the evidence submitted in the nurse revalidation process. Part 1 considers how to determine when a change in practice is needed, how to assess and measure current practice, and identify gaps or weaknesses. Part 2 will discuss how to find out why the current practice is falling short of the desired level, and how to go about implementing improvements and measuring the effect of changes.

The Wingate cycle test (WAnT) is a 30-s test commonly used to estimate anaerobic work capacity (AWC). However, the test may be too short to fully deplete anaerobic energy reserves. We hypothesized that a 90-s all-out isokinetic test (ISO_90) would be valid to assess both aerobic and anaerobic capacities in young females. Eight girls (11.9 ± 0.5 y) performed an exhaustive incremental test, a WAnT and an ISO_90. Peak VO2 attained during the ISO_90 was significantly greater than VO2peak. Mean power, end power, fatigue index, total work done and AWC were not significantly different between the WAnT and after 30 s of the 90-s test (i.e., ISO_30). However, 95% limits of agreement showed large variations between the two tests when comparing all anaerobic parameters. It is concluded that an ISO-90 may be a useful test to assess aerobic capacity in young girls. However, since the anaerobic parameters derived from the ISO_30 did not agree with those derived from a traditional WAnT, the validity of using an ISO_90 to assess anaerobic performance and capacity within this population group remains unconfirmed.

This study aimed to examine if the faster pulmonary oxygen uptake (VO2p) phase 2 in children could be explained by increased O2 availability or extraction at the muscle level. For that purpose, O2 availability and extraction were assessed using deoxyhemoglobin (HHb) estimated by near-infrared spectroscopy during moderate-intensity constant load cycling exercise in children and young adults. Eleven prepubertal boys and 12 men volunteered to participate in the study. They performed one maximal graded exercise to determine the power associated with the gas exchange threshold (GET) and four constant load exercises at 90% of GET. VO2p and HHb were continuously monitored. VO2p , HHb, and estimated capillary blood flow (Qcap) kinetics were modelled after a time delay and characterized by the time to achieve 63% of the amplitude (τ) and by mean response time (MRT: time delay + τ), respectively. Mean values of τ for VO2p (P < 0.001), of MRT for HHb (P < 0.01) and of MRT for Qcap (P < 0.001) were significantly shorter in children. Faster VO2p kinetics have been shown in children; these appear due to both faster O2 extraction and delivery kinetics as indicated by faster HHb and Qcap kinetics, respectively.

A 3D cycling model is presented that combines bicycle dynamics, a tyre model, rider biomechanics and environmental factors into a single dynamic system. The system is constructed using Matlab toolboxes (SimMechanics/Simulink) with the aim of identifying mechanical mechanisms that can influence performance in a road cycling time trial. Initial conditions are specified and a variable step ODE solver numerically integrates solutions to the equations of motion. Initial validation compared rider-less self-stability presented in a published “benchmark” with model simulation and found an error of

Background: Interval training is recommended for chronic heart failure patients (CHF), but specific guidelines on setting appropriate workloads have not been fully established. The aim of this study was to compare a traditional method of interval training prescription with a protocol specifically designed for CHF. Methods: Ten CHF and 7 healthy controls performed 2 maximal incremental cycle tests to determine interval training workload; a standard test (10 W min −1 ) and a steep test (25 W.10 −s ). Peak work rate and oxygen uptake (VO2peak) were determined. Training workloads were defined as 100% standard test and 50% steep test peak work rate. Results: Training workload determined from the standard test was higher than from the steep test in healthy controls (151±17 W vs 118± 13 W; Pb0.01), whereas in CHF there was no significant difference between methods (88±10 W vs 96±9 W; PN0.05). Steep test VO2peak reached 91±5% of standard test VO2peak in controls, and 99±4% in CHF, with no significant differences between tests in either group. Conclusion: Prescribing interval training from a standard test results in higher workloads than from a steep test in healthy individuals, but in CHF both methods prescribe similar workloads. However it should not be assumed that the two tests can be used interchangeably for CHF. This small-sized study raises issues about interval training prescription that may be hypothesis-generating for future larger-scale studies.

The aim of this study was to examine differences in cycling efficiency between competitive male and female cyclists. Thirteen trained male (mean ± SD: 34 ± 8 yr, 74.1 ± 6.0 kg, Maximum Aerobic Power (MAP) 414 ± 40 W, VO2max 61.3 ± 5.4 ml·kg-1·min-1) and 13 trained female (34 ± 9 yr, 60.1 ± 5.2 kg, MAP 293 ± 22 W, VO2max 48.9 ± 6.1 ml·kg-1·min-1) competitive cyclists completed a cycling test to ascertain their gross efficiency (GE). Leg and lean leg volume of all cyclists was also measured. Calculated GE was significantly higher in female cyclists at 150W (22.5 ± 2.1 vs 19.9 ± 1. 8%; p < 0.01) and 180W (22.3 ± 1.8 vs 20.4 ± 1.5%; p = 0.01). Cadence was not significantly different between the groups (88 ± 6 vs 91 ± 5 rev·min-1). Lean leg volume was significantly lower for female cyclists (4.04 ± 0.5 vs 5.51 ± 0.8 dm3; p < 0.01) and was inversely related to GE in both groups at 150 and 180W (r = -0.59 and -0.58; p < 0.05). Lean leg volume was shown to account for the differences in GE between the males and females. During an "unloaded" pedalling condition, male cyclists had a significantly higher O2 cost than female cyclists (1.0 ± 0.1 vs 0.7 ± 0.1 L·min-1; p < 0.01), indicative of a greater non-propulsive cost of cycling. These results suggest that differences in efficiency between trained male and female cyclists can be partly accounted for by sex-specific variation in lean leg volume

There has been much debate in the recent scientific literature regarding the possible ability to increase gross efficiency in cycling via training. Using cross-sectional study designs, researchers have demonstrated no significant differences in gross efficiency between trained and untrained cyclists. Reviewing this literature provides evidence to suggest that methodological inadequacies may have played a crucial role in the conclusions drawn from the majority of these studies. We present an overview of these studies and their relative shortcomings and conclude that in well-controlled and rigorously designed studies, training has a positive influence upon gross efficiency. Putative mechanisms for the increase in gross efficiency as a result of training include, muscle fibre type transformation, changes to muscle fibre shortening velocities and changes within the mitochondria. However, the specific mechanisms by which training improves gross efficiency and their impact on cycling performance remain to be determined.

PURPOSE: This prospective study was designed to assess the efficacy and safety of a novel technique in treating outlet obstruction syndrome using a transanal double-stapling procedure. METHODS: Two hundred thirty patients (187 female) with obstructed defecation underwent stapled transanal rectal resection over a six-year period with follow-up at 2 6, and 12 months, then yearly; median follow-up was 24 (range, 12-68) months. All failed conservative measures. Patients with slow transit constipation and puborectalis dyssynergia were excluded. RESULTS: Operating time was short (median, 35 (range, 20-95) minutes), with 159 (69%) performed as day cases (outpatient). Major complications were seen in 16 (7%); there were no deaths. Twelve (5%) patients reported severe postoperative pain. Immediate postoperative fecal urgency was reported by 107 (46%) patients, but persisted at six months in only 26 (11%). Three (1%) developed recurrent rectal prolapse. Nearly all incontinent patients (98%) reported an improvement, with a median Wexner score reduction of 5 points (P < 0.0001). Constipation improved in 77% of patients. Seventy-seven percent of patients were "very glad" they had the operation, and 86% "recommended" stapled transanal rectal resection to a friend. CONCLUSION: Stapled transanal rectal resection can be performed on a day-case basis with high levels of patient satisfaction. Incontinence and constipation are improved. However, significant morbidity occurs in 7% of patients, and urgency of defecation persists beyond six months in 11%.

To examine the impact of low-intensity and a mixture of low- and high-intensity training on physiological and performance responses in rowing.Eighteen experienced rowers undertook a 12-wk program of 100%or = lactate threshold (LT) training (LOW) or 70% training ator = LT and 30% at halfway (50%Delta) between the V O2 at LT and V O2peak (MIX). Responses were assessed before and after training by a progressive exercise test to exhaustion; multiple "square-wave" rest-to-exercise transitions of 6-min duration at 50%Delta; and a maximal 2000-m ergometer time trial.Improvements (P0.001) in 2000-m ergometer performance and V O2peak occurred independently of groups (P = 0.8 and 0.42, respectively). LOW improved the power at LT (23.5 +/- 12.2 vs 5.1 +/- 5.0 W, P = 0.013) and power at a [blood lactate] of 4 mM (32.3 +/- 6.9 vs 13.1 +/- 3.7 W, P = 0.03) compared with MIX. The time constant and gain of the primary component were unchanged with training, whereas the gain of the V O2 slow component was reduced with training, but independently of group.Both LOW and MIX training programs improved performance and V O2peak by the same magnitude, whereas LOW attenuated the blood lactate response to a given exercise intensity more so than MIX.

The aim of this study was to compare .VO2 kinetics of highly- versus recreationally-trained subjects during a constant velocity test of supramaximal intensity. Eighteen trained male subjects were recruited to one of two groups: highly trained (HT, n = 8, .VO(2max) = 70.1 +/- 6.5 ml . min (-1) . kg (-1)) and recreationally trained (RT, n = 10, .VO(2max) = 63.2 +/- 6.4 ml . min (-1) . kg (-1)). All subjects performed an incremental test to exhaustion for the determination of .VO(2max) and peak treadmill velocity (PTV), two constant velocity tests at 110 % of PTV to determine .VO2 kinetics and oxygen deficit (O(2)def), and a 800-m time trial to determine running performance (mean velocity over the distance, V (800 m)). We found significant differences between HT and RT for the on-transient of the .VO2 response (tau, 24.7 +/- 3.3 and 30.9 +/- 7.0 s, respectively), the amplitude of the .VO2 response (60.0 +/- 5.0 and 53.5 +/- 5.7 ml . min (-1) . kg (-1), respectively) and V (800 m) (6.27 +/- 2.1 and 5.45 +/- 0.38 m . s (-1), respectively). O(2)def (24.6 +/- 2.7 and 27.7 +/- 7.8 ml . kg (-1), respectively) and the gain of the .VO2 response (193 +/- 14 and 194 +/- 13 ml . kg (-1) . m (-1), respectively) were similar between groups. tau was associated with O(2)def (r = 0.90, p0.05), but not with V (800 m) (r = 0.30, p0.05). It was concluded that HT subjects exhibited faster on-kinetics and higher amplitude than their RT counterparts. The higher amplitude was not thought to reflect any difference in underlying physiological mechanisms. The faster tau, whose exact mechanisms remain to be elucidated, may have practical implications for coaches.

Purpose: To test the hypothesis that elite rowers would possess a faster, more economic oxygen uptake response than club standard rowers. Methods: Eight Olympic champion (ELITE) rowers were compared with a cohort of eight club standard (CLUB) rowers. Participants completed a progressive exercise test to exhaustion, repeated 6-min moderate and heavy square-wave transitions, and a maximal 2000-m ergometer time trial. Results: The time constant (t) of the primary component (PC) was faster for the ELITE group compared with CLUB for moderate-intensity (13.9 vs 19.4 s, P = 0.02) and heavy-intensity (18.7 vs 22.4 s, P = 0.005) exercise. ELITE rowers consumed less oxygen for moderate (14.2 vs 15.6 mL·min-1·W-1; P = 0.009) and heavy (12.1 vs 13.7 mL·min-1·W-1; P = 0.01) exercise. A greater absolute slow component was observed in the ELITE group (P = 0.009), but no differences were noted when the slow component was expressed relative to work rate performed (P = 0.14). Intergroup correlation with time trial performance speed was significant for tPC during heavy-intensity exercise (r = -0.59, P = 0.02). Conclusions: Compared with CLUB rowers, the shorter time constant response and greater economy observed in ELITE rowers may suggest advantageous adjustment of oxidative processes from rest to work. Training status or performance level do not seem to be associated with a smaller slow component when comparing CLUB and ELITE oarsmen.

The purpose of this study was to establish the validity of a 90-s all-out test for the estimation of maximal oxygen uptake (V.O (2max)) and submaximal aerobic ability as represented by critical power. We hypothesized that the fall in power output by the end of the 90-s all-out test (end power) would represent the exhaustion of anaerobic work capability, and as such, would correspond with the critical power. Sixteen active individuals (mean +/- SD: 30 +/- 6 years; 69.6 +/- 9.9 kg) carried out a series of tests: (i) an incremental ramp test to determine V.O (2max), (ii) three fixed-work rate trials to exhaustion to determine critical power, and (iii) two 90-s all-out tests to measure end power and peak V.O (2). End power (292 +/- 65 W) was related to (r=0.89) but was significantly higher (p

We analyse the evolution of the slope (critical speed) and the y-intercept (anaerobic distance capacity) of the linear distance-time relationship over a century of Olympic running performances. The distance-time relationship of each Olympic Games (1920-2004) was plotted using the performances in the 800-, 1500- and 5000-m track events. Values for critical speed and anaerobic distance capacity were determined by linear modelling. Mean performances for the 800, 1500 and 5000 m were 104.9 +/- 1.5 s (1.4%), 217.2 +/- 2.8 s (1.3%) and 808.9 +/- 18.4 s (2.3%), respectively. Critical speed improved during the first three-quarters of the twentieth century to reach a plateau in 1984. This is in accordance with the literature (Peronnet & Thibault, 1989) and suggests that "human aerobic endurance" has improved within the century (+13.4%) and tends to stabilize. Anaerobic distance capacity was highly variable over the century (coefficient of variation = 9.4%) and did not show a linear improvement over the years as has previously been suggested (Peronnet & Thibault, 1989). This could be due to an artefact in the application of the two-parameter model to only three Olympic performances. A limitation to the use of this linear mathematical model to fit physiological data may have been demonstrated.

Accurate classification of VO2 kinetics is essential to correctly interpret its control mechanisms. The purpose of this study was to examine VO2 kinetics in severe and supra-maximal intensity running exercise using two modelling techniques. Nine subjects (mean +/- S.D: age, 27 +/- 7 years; mass, 69.8 +/- 9.0 kg; VO2max, 59.1 +/- 1.8 mL x kg x min(-1)) performed a series of "square-wave" exercise transitions to exhaustion at running speeds equivalent to 80% of the difference between the VO2 at LT and VO2max (delta), and at 100%, 110% and 120% VO2max. The VO2 response was modelled with an exponential model and with a semi-logarithmic transformation, the latter assuming a certain steady state VO2. With the exponential model there was a significant reduction in the "gain" of the primary component in supra-maximal exercise (167 +/- 5 mL x kg(-1) x km(-1) at 80% delta to 142 +/- 5 mL x kg(-1) x km(-1) at 120% VO2max, p = 0.005). The time constant of the primary component also reduced significantly with increasing intensity (17.8 +/- 1.1 s at 80% delta to 12.5 +/- 1.2 s at 120% VO2max, p < 0.05). However, in contrast, using the semi-log model, the time constant significantly increased with intensity (30.9 +/- 13.5 s at 80% delta to 72.2 +/- 23.9 s at 120% VO2max, p < 0.05). Not withstanding the need for careful interpretation of mathematically modelled data, these results demonstrate that neither the gain nor the time constant of the VO2 primary component during treadmill running are invariant across the severe and supra-maximal exercise intensity domains when fit with an exponential model. This suggests the need for a reappraisal of the VO2/work rate relationship in running exercise.

The curvature of the power-time (P-t) relationship (W') has been suggested to be constant when exercising above critical power (CP) and to represent the anaerobic work capacity (AWC). The aim of this study was to compare W' to (1) the total amount of work performed above CP (W (90s)') and (2) the AWC, both determined from a 90s all-out fixed cadence test. Fourteen participants (age 30.5 +/- 6.5 years; body mass 67.8 +/- 10.3 kg), following an incremental VO(2max) ramp protocol, performed three constant load exhaustion tests set at 103 +/- 3, 97 +/- 3 and 90 +/- 2% P-VO(2max) to calculate W' from the P-t relationship. Two 90s all-out efforts were also undertaken to determine W (90s)' (power output-time integral above CP) and AWC (power output-time integral above the power output expected from the measured VO(2)). W' (13.6 +/- 1.3 kJ) and W (90s)' (13.9 +/- 1.1 kJ; P = 0.96) were not significantly different but were lower than AWC (15.9 +/- 1.2 kJ) by 24% (P = 0.03) and 17%, respectively (P = 0.04). All these variables were correlated (P < 0.001) but great extents of disagreement were reported (0.2 +/- 6.4 kJ between W' and W (90s)', 2.3 +/- 7.2 kJ between W' and AWC, and 2.1 +/- 4.3 kJ between W (90s)' and AWC). The underestimation of AWC from both W' and W (90s)' can be explained by the aerobic inertia not taking into consideration when determining the two latter variables. The low extents of agreement between W', W (90s)' and AWC mean the terms should not be used interchangeably.

The aim of the present study was to ascertain whether the intensity of prior exercise altered the time to exhaustion at critical power (CP).Eleven participants volunteered to take part in the study (mean +/- SD: VO2max 4.1 +/- 0.5 L x min(-1); age 30.1 +/- 7.2 yr; body mass 74.6 +/- 9.1 kg) and completed three trials to exhaustion at their CP under differing prior exercise conditions: 1) a control trial (CON); 2) a trial preceded by three 60-s efforts at 110% CP (severe); and 3) a trial preceded by three 73-s efforts at 90% CP (heavy). All trials followed a 5-min baseline at 50 W.Time to exhaustion was significantly lengthened after prior heavy exercise (1071 +/- 18 s) when compared with CON (973 +/- 16 s, F = 9.53, P = 0.006). However, there was no effect on TTE after prior severe exercise (967 +/- 16 s). Oxygen deficit was significantly reduced from that in CON (3.8 +/- 0.2 L) after prior heavy (3.2 +/- 0.3 L) and prior severe exercise (3.1 +/- 0.3 L, F = 10.95, P = 0.001). Concurrently, there was a significant reduction in the magnitude of the VO2 slow component (SC) in the trials with prior exercise (197 +/- 34 and 126 +/- 19 mL x min(-1) after heavy and severe exercise, respectively) when compared with CON (223 +/- 31 mL x min(-1), F = 9.62, P = 0.006).Prior heavy exercise does appear to improve the time to exhaustion at CP by approximately 10% and is associated with a reduction in the VO2 SC. However, the reduction in the SC, with no change in performance after prior severe exercise, suggests that a reduced SC may not necessarily lead to improved TTE.

The performance of prior high intensity constant work rate (CWR) exercise significantly influences the gain of the fundamental oxygen uptake (VO2) response during subsequent high intensity CWR exercise. The purpose of the present study was to investigate whether equivalent effects could be elicited in the second of two bouts of exhaustive ramp exercise. We therefore hypothesised that a prior bout of exhaustive ramp exercise would increase the VO2-work rate (DeltaVO2/DeltaWR) slope during subsequent ramp exercise. Nine healthy males performed two ramp exercise tests to exhaustion on an electrically braked cycle ergometer separated by a 10-min period of cycling at 20 W. Pulmonary VO2 was measured breath-by-breath throughout both tests, and the mean response time (MRT) and the DeltaVO2/DeltaWR slope for exercise below the gas exchange threshold (GET) (S1), above the GET (S2), and over the S1 + S2 region (ST) were determined. Paired t-tests were used to analyse the data with significance accepted at p < 0.05. Blood [lactate] was higher at the onset of the second ramp test compared to the first (mean +/- SEM 1.2 +/- 0.1 vs. 6.2 +/- 0.7 mM; p < 0.01), but baseline VO2 was not significantly different between tests (0.93 +/- 0.05 vs. 0.99 +/- 0.06 L. min (-1)). The MRT (42 +/- 4 vs. 40 +/- 5 s) did not differ between tests, but the DeltaVO2/DeltaWR slope was steeper in the second ramp test for S2 (9.1 +/- 0.4 vs. 9.8 +/- 0.5 ml. min (-1). W (-1); p < 0.01) and ST (9.0 +/- 0.4 vs. 9.6 +/- 0.5 ml. min (-1). W (-1); p < 0.05). The demonstration that prior ramp exercise increases the DeltaVO2/DeltaWR slope during subsequent ramp exercise is consistent with the results of previous CWR studies and indicates that exercise economy is sensitive to the prior activity of the engaged muscles.

This article describes a working partnership between the Cairns Clinical Librarian Service, Health Care Libraries, University of Oxford and the Emergency Department (ED) at the John Radcliffe Hospital, Oxford. This collaboration resulted in the establishment of a guideline development group in June 2002. The aim of the group is to produce a set of easily accessible, user-orientated, evidence-based guidelines for the use of clinicians in the Emergency Department, within a realistic timescale. The Cairns Clinical Librarian Project was built on previous models of clinical librarianship and incorporated an evaluation of previous programmes. The objective was to provide information to clinicians at the time and point of need. Consultation with the ED from the outset determined the approach adopted by the Cairns team. Clinical guidelines have been shown to improve clinical practice. Pending the introduction of nationally available protocols, we have begun to establish a collection of evidence-based guidelines using web-based architecture in conjunction with the Oxford Radcliffe Hospitals NHS Trust's IT department. A piece of diagnostic analysis was undertaken to ensure a coherent strategy was developed for the guideline project. An ‘intermediate approach’ was adopted, where existing valid guidelines were modified to fit local circumstances. We strove to be transparent at all times about all aspects of the guideline development process. Formative evaluation has shown how the application of evidence-based health care needs adequate resources and requires people with appropriate knowledge and skills. This article charts the progress of the project and highlights how the partnership between the clinical team and the Clinical Librarian has been deemed to be essential to the success of the project.

While data exist on the prevalence and causes of anemia in defined groups of the elderly, information on palliative care patients is limited. Compared to actively treated oncology patients, for whom anemia treatment has demonstrated improved quality of life and symptom alleviation, studies of treatment outcomes in palliative care patients are limited. Knowledge of the extent and causes of anemia in palliative care patients is needed, as correction of anemia in these patients could potentially improve their physical, emotional, and cognitive functioning. In the present study, clinical data and blood test results of 105 patients meeting specific eligibility criteria were examined to estimate the prevalence of anemia and investigate its causes. Ninety-five (90.5%) patients had advanced cancer. Based on World Health Organization criteria, anemia was found in 77% of men (Hb

The purpose of the present study was to test the hypothesis that muscle fibre type influences the oxygen uptake (.VO(2)) on-kinetic response (primary time constant; primary and slow component amplitudes) during moderate, heavy and severe intensity sub-maximal cycle exercise. Fourteen subjects [10 males, mean (SD) age 25 (4) years; mass 72.6 (3.9) kg; .VO(2peak) 47.9 (2.3) ml kg(-1) min(-1)] volunteered to participate in this study. The subjects underwent a muscle biopsy of the vastus lateralis for histochemical determination of muscle fibre type, and completed repeat "square-wave" transitions from unloaded cycling to power outputs corresponding to 80% of the ventilatory threshold (VT; moderate exercise), 50% (heavy exercise) and 70% (severe exercise) of the difference between the VT and .VO(2peak). Pulmonary .VO(2) was measured breath-by-breath. The percentage of type I fibres was significantly correlated with the time constant of the primary .VO(2) response for heavy exercise (r=-0.68). Furthermore, the percentage of type I muscle fibres was significantly correlated with the gain of the .VO(2) primary component for moderate (r=0.65), heavy (r=0.57) and severe (r=0.57) exercise, and with the relative amplitude of the .VO(2) slow component for heavy (r=-0.74) and severe (r=-0.64) exercise. The influence of muscle fibre type on the .VO(2) on-kinetic response persisted when differences in aerobic fitness and muscle capillarity were accounted for. This study demonstrates that muscle fibre type is significantly related to both the speed and the amplitudes of the .VO(2) response at the onset of constant-load sub-maximal exercise. Differences in contraction efficiency and oxidative enzyme activity between type I and type II muscle fibres may be responsible for the differences observed.

We hypothesized that a higher pedal rate (assumed to result in a greater proportional contribution of type II motor units) would be associated with an increased amplitude of the O2 uptake (V˙o 2) slow component during heavy-cycle exercise. Ten subjects (mean ± SD, age 26 ± 4 yr, body mass 71.5 ± 7.9 kg) completed a series of square-wave transitions to heavy exercise at pedal rates of 35, 75, and 115 rpm. The exercise power output was set at 50% of the difference between the pedal rate-specific ventilatory threshold and peakV˙o 2, and the baseline power output was adjusted to account for differences in the O2 cost of unloaded pedaling. The gain of the V˙o 2primary component was significantly higher at 35 rpm compared with 75 and 115 rpm (mean ± SE, 10.6 ± 0.3, 9.5 ± 0.2, and 8.9 ± 0.4 ml · min−1 · W−1, respectively; P < 0.05). The amplitude of theV˙o 2 slow component was significantly greater at 115 rpm (328 ± 29 ml/min) compared with 35 rpm (109 ± 30 ml/min) and 75 rpm (202 ± 38 ml/min) ( P < 0.05). There were no significant differences in the time constants or time delays associated with the primary and slow components across the pedal rates. The change in blood lactate concentration was significantly greater at 115 rpm (3.7 ± 0.2 mM) and 75 rpm (2.8 ± 0.3 mM) compared with 35 rpm (1.7 ± 0.4 mM) ( P < 0.05). These data indicate that pedal rate influences V˙o 2 kinetics during heavy exercise at the same relative intensity, presumably by altering motor unit recruitment patterns.

The first New Zealand hospital palliative care support service was established in 1985. Different service models have now been adopted by various major hospitals. In 1998, a palliative care service, funded by Mary Potter Hospice, was piloted at Wellington Public Hospital. Twelve months post-implementation, the hospital staff's views of the service were evaluated. It was found that referrals to palliative care from hospital specialities outside the Cancer Centre increased. While most doctors, nurses and social workers strongly agreed or agreed that the service positively influenced patients’ care and effectively addressed their symptom management needs, spiritual needs were less often met. Over 90 percent of each discipline strongly agreed or agreed that the service had assisted them in caring for patients, but, only about a half agreed that useful discharge planning advice and staff support was provided. Significant differences in responses were found between different disciplines and specialities. One fifth of the staff identified palliative care education needs. Recommendations are made concerning the development of a future hospital palliative care service.

OBJECTIVES To set up and evaluate a multidisciplinary suicide assessment training course for "front-line" clinical staff. METHODS We looked at the impact of two types of training courses: full day Workshops with actors role-playing patients; and a half-day Lecture. Outcome measures included the Suicide Intervention Response Inventory Form 2, a reliable and valid measure of the ability to intervene with suicidal clients, and confidence in clinical management scales. RESULTS One hundred and seven trainees from different disciplines attended the courses. Both types of course led to improvements in the skills and confidence of the trainees which were sustained at the two month follow up. CONCLUSION Although using actors to role play was more expensive, trainees commented positively on their use. The better attendance and feedback at the sessions with actors suggest the extra expense involved in using them is worthwhile. We have shown it is feasible to run a reasonably inexpensive educational course in a Mental Health facility that provides effective training in suicide prevention to a large number of trainees.

Hospital referrals to Mary Potter Hospice were reviewed prior to the implementation of a new hospital palliative care support service. The hospital palliative care service aims to improve the communication between health professionals in the acute hospital and hospice, and to advise the hospital staff on its management of terminally ill patients. The purpose of this review was to provide baseline information that would assist the hospice with the planning and future evaluation of the new service. Information included the timing of the referrals, the type of referral information provided by hospital doctors, and their expectations of hospice care. One fifth of patients were referred near to death. While medical information was nearly always provided on referral, information on the psychological, spiritual and social dimensions of care was often absent. A third of hospital doctors expressed their expectation of the hospice as “to take over” the patient's care. This suggests the hospital palliative care support service should encourage health professionals to take a more active role in caring for dying patients. The findings are discussed in relation to the goals of the new hospital palliative care support service.

Voluntary organizations such as hospices are increasingly being called upon to substitute for state health and social welfare delivery at a time when volunteer contributions are threatened because of organizational and demographic changes. These changes include: the adoption by the nonprofit sector of market strategies in response to health and social welfare reforms, increases in the size and complexity of hospices, increasing professionalization of staff, and the move of women away from voluntary work in the health and welfare services to paid employment. With these changes, hospices must be knowledgeable about their volunteer workforce and resourceful if they are to continue to attract and retain volunteers. A survey of volunteers conducted at the Mary Potter Hospice, Wellington, New Zealand, examined differences in volunteers’ characteristics, motivations for joining hospice, and factors affecting work satisfaction according to age, gender, and the length of time volunteers had worked. Those findings of particular relevance to program development were: (1) the tendency for the recently recruited volunteers to be in paid employment; (2) the mixed motivations of the younger volunteers, reflecting both altruistic and personal gain needs; and (3) the rewards commonly identified by volunteers, such as feeling their work is of value, being accepted by hospice staff, and feeling like important team members. Practical outcomes of the study are described.

Purpose: The purpose of this study was to assess the relationship between pulmonary O2 and running speed over a range of exercise intensities. During constant-load cycle exercise above the lactate threshold (Tlac), it has been shown that O2 does not attain a steady state within 3 min but continues to rise until either a delayed but elevated steady-state O2 is attained or exhaustion occurs. Since this greater oxygen cost of exercise ( O2 slow component) has only been demonstrated at discrete exercise intensities above Tlac, it was hypothesised that the onset of the O2 slow component would coincide with Tlac during an incremental test if the stage durations were of sufficient length. Methods: Five male subjects (mean +/- SD age 31 +/- 2 yr; O2peak 60.1 +/- 5.8 mL[middle dot]kg-1[middle dot]min-1) performed four identical treadmill tests within an 8-d period. The tests involved the completion of six stages of 7-min duration. Running speed was increased by 0.5 km[middle dot]h-1 between stages. In the first test, fingertip capillary blood was sampled at the end of each stage for determination of Tlac. For all tests expired air was collected into Douglas bags from 3.0 to 3.75 min and from 6.0 to 6.75 min of each stage to determine any increase in O2 (ΔO2) over the duration of the stage. Results: The mean Δ O2 for each stage over the four tests was determined for each subject. Repeated measures ANOVA with post-hoc Tukey tests revealed a significant increase in Δ O2 at running speeds above, but not below, Tlac. Conclusions: The results of this study confirm the close association between the O2 slow component and the onset of lactic acidosis and demonstrate alinearity in the O2-exercise intensity relationship above Tlac for incremental treadmill exercise.

PURPOSE The purpose of this study was to investigate the effect of altering the initial running speed (RS) in the incremental portion of the lactate minimum test on the lactate minimum speed (LMS). METHODS Eight well-trained endurance runners (mean +/- SD age 29.0 +/- 5.4 yr, body mass 72.0 +/- 5.6 kg, VO2max 63.1 +/- 3.8 mL x kg(-1) min(-1)) completed a standard incremental treadmill test for the assessment of the lactate threshold (LT) and VO2max, and eight lactate minimum tests. Following a period of supramaximal exercise, subjects were allowed 8 min of recovery to allow blood [lactate] to peak. Subjects then undertook eight randomly-assigned incremental treadmill tests from different initial running speeds (3.0, 2.5, 2.0, 1.5, 1.0, and 0.5 km x h(-1) below the predetermined RS-LT, at the RS-LT, and at 1.0 km x h(-1) above the RS-LT) with RS increased by 1.0 km x h(-1) every 5 min until volitional fatigue. Blood samples for the determination of blood [lactate] were taken at the end of each stage and the LMS was determined by fitting a spline function to the data. RESULTS No LMS could be determined for the two highest initial RS conditions. For the other conditions, the LMS was significantly affected by the initial RS used in the incremental test and varied from 13.8 +/- 0.7 km x h(-1) with an initial RS of 3.0 km x h(-1) below the RS-LT, to 15.8 +/- 0.8 km x h(-1) with an initial RS of 0.5 km x h(-1) below the RS-LT. The LMS was significantly different from the RS-LT (15.4 +/- 0.8 km x h(-1)) (P < 0.05), except when the incremental test started at 1.0 or 1.5 km x h(-1) below the RS-LT. CONCLUSIONS These results suggest that the LMS test is not a valid method for estimation of the LT since it is profoundly influenced by the starting speed selected for the incremental portion of the test.