ZOom Delivered Intervention Against Cognitive decline (ZODIAC) COVID-19 pandemic adaptations to the Post-Ischaemic Stroke Cardiovascular Exercise Study (PISCES): protocol for a randomised controlled trial of remotely delivered fitness training for brain health.

BACKGROUND: Stroke increases subsequent dementia risk yet there are no specific post-stroke therapies to protect cognition. Cardiorespiratory exercise is recommended for secondary prevention of stroke and may be neuroprotective. The Post Ischaemic Stroke Cardiovascular Exercise Study (PISCES) aims to reduce post-stroke secondary neurodegeneration and cognitive decline. During the pandemic, we pivoted to a ZOom Delivered Intervention Against Cognitive decline (ZODIAC) protocol, reducing pandemic-amplified barriers to exercise. METHODS: We present pandemic adaptions for a multicentre phase IIb assessor-blinded randomised controlled trial of ischaemic stroke survivors testing the efficacy and feasibility of an 8-week home-based exercise intervention delivered at 2 months post-stroke. We compare cardiorespiratory exercise (intervention arm) versus balance and stretching (active control arm). Participants are assessed with magnetic resonance imaging (MRI), fitness, blood, microbiome, and neuropsychological tests at three study visits: before and after the exercise intervention and at 12 months. Modifications to the original protocol include pre-exercise safety home visits, commercial delivery of exercise equipment to facilitate assessor blinding, and reconsideration of statistical plan to allow pooling of the studies. We have reduced in-person study visits from 27 to 3. Primary outcome remains between-group (intervention versus control) difference in brain volume change; secondary outcome is between-group difference in global cognitive ability to allow remote administration of a validated cognitive scale. DISCUSSION: Remotely delivered exercise interventions reduce participant burden and may reduce barriers to recruitment. A decrease in the number of in-person study visits can be supported by greater information capture via self-reported questionnaires and phone surveys. TRIAL REGISTRATION: Prospectively ACTRN12616000942459. Registered on July 2016.

Risk Factor Analysis for Growth Arrest in Paediatric Physeal Fractures-A Prospective Study.

Background: Fractures through the physis account for 18-30% of all paediatric fractures, leading to growth arrest in up to 5.5% of cases. We have limited knowledge to predict which physeal fractures result in growth arrest and subsequent deformity or limb length discrepancy. The purpose of this study is to identify factors associated with physeal growth arrest to improve patient outcomes. Methods: This prospective cohort study was designed to develop a clinical prediction model for growth arrest after physeal injury. Patients ≤ 18 years old presenting within four weeks of injury were enrolled if they had open physes and sustained a physeal fracture of the humerus, radius, ulna, femur, tibia or fibula. Patients with prior history of same-site fracture or a condition known to alter bone growth or healing were excluded. Demographic data, potential prognostic indicators, and radiographic data were collected at baseline, during healing, and at one- and two-years post-injury. Results: A total of 332 patients had at least six months of follow-up or a diagnosis of growth arrest within six months of injury. In a comparison analysis, patients who developed growth arrest were more likely to be older (12.8 years vs. 9.4 years) and injured on the right side (53.0% vs. 45.7%). Initial displacement and angulation rates were higher in the growth arrest group (59.0% vs. 47.8% and 47.0% vs. 38.8%, respectively), but the amount of angulation was similar (27.0° vs. 28.4°). Rates of growth arrest were highest in distal femoral fractures (86%). Conclusions: The incidence of growth arrest in this patient population appears higher than the past literature reports at 30.1%. However, there may be variances in diagnostic criteria for growth arrest, and the true incidence may be lower. A number of patients were approaching skeletal maturity, and any growth arrest is likely to have less clinical significance in these cases. Further prospective long-term follow-up is required to determine risk factors, incidence, and true clinical impact of growth arrest when it does occur.

A structural vulnerability approach to older adult suicides: Trends and potential impacts of the COVID-19 pandemic in Clark County, NV (2017-2021).

The ongoing SARS-CoV-2 (COVID-19) pandemic has affected all aspects of life in the United States and around the world. This is particularly true for marginalized and vulnerable groups who face disproportionate levels of violence and premature death within their communities. While general impacts of the pandemic have been well-studied overall, little has been done to examine the correlation between COVID-19 and the risk of suicide among older adults. Older adults are particularly at risk because they face challenges including ageism, inadequate support systems, unreliable transportation, and frequent social isolation. Medicolegal casework offers a unique vantage of these issues, as it aims to identify manner of death which may be influenced by underlying structural vulnerabilities. The current research draws upon data collected from the Clark County Office of the Coroner/Medical Examiner. A sample of 871 older adults (aged 50+), whose manner of death was deemed a suicide between the years 2017-2021, were included in this analysis. Statistical analyses investigated differences between adults aged 50-64, 65-84, and 85+ years. Results suggest statistically significant changes in mechanism of death between pre-pandemic and pandemic periods, indicating a shift in risk factors related to social isolation and the home environment. Understanding such changes in trends directly affects the interpretation of skeletal data in forensic anthropology and thus, should be taken into consideration when developing structural vulnerability profiles. Furthermore, the inclusion of a structural vulnerability approach in forensic case reports has the potential to provide additional context for deaths by suicide and may help develop policies and procedures for mitigating future risk.

Comparisons between group- and individual-based interventions to support recovery from stroke and ischaemic heart disease in the community: a scoping review.

PURPOSE: To map and summarise available literature on the effectiveness or other benefits of group- and individual-based interventions provided for adults living with stroke or ischaemic heart disease (IHD) in the community. MATERIAL AND METHODS: The review was conducted based on JBI methodology and reported using Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Articles were retrieved from: Medline, PsychInfo, Embase, Scopus, and CINAHL from 2002-2022. Extracted data from eligible studies included type of health outcomes (e.g., impairments), retention and adherence, social connectedness, and the costs associated with group- and individual-based interventions. RESULTS: After screening, five articles (representing 4 unique studies) comparing a group- and individual-based intervention were included (total sample size n = 87). Three types of interventions were assessed: exercise (3/5), communication (1/5), and occupational therapy (1/5). Effectiveness of group- and individual-based interventions at improving health outcomes (i.e. physical ability, communication, motivation, and quality of life) is unclear. Currently there is insufficient evidence to guide clinical practice. CONCLUSIONS: There is limited evidence comparing interventions delivered in a group and individual modality for adults living with stroke or IHD. Adequately powered studies are needed to determine if mode of delivery is equivalent or more cost effective.

Rehabilitation interventions can be offered individually or in group settings with clinicians choosing the most appropriate modality.Both group- and individual-based interventions have advantages and disadvantages, with clinical, practical, and economic factors as important considerations when deciding between the two modalities.Based on this scoping review, the authors conclude that there is currently insufficient evidence to guide clinical practice in deciding which mode of delivery (group or individual) is optimal.There is insufficient research evidence to guide clinicians in their choice between offering rehabilitation interventions for stroke or IHD in groups or individually.

Is early initiated cardiorespiratory fitness training within a model of stroke-integrated cardiac rehabilitation safe and feasible?

OBJECTIVE: To investigate the safety and feasibility of an early initiated stroke-integrated Cardiac Rehabilitation program. METHODS: People with acute first or recurrent ischaemic stroke, admitted to Epworth HealthCare were screened for eligibility and invited to participate. In addition to usual care neurorehabilitation, participants performed 1) cardiorespiratory fitness training 3-days/week during inpatient rehabilitation (Phase 1), and/or 2) 2-days/week centre-based cardiorespiratory fitness training plus education and 1-day/week home-based cardiorespiratory fitness training for 6-weeks during outpatient rehabilitation (Phase 2). Safety was determined by the number of adverse and serious adverse events. Feasibility was determined by participant recruitment, retention, and attendance rates, adherence to exercise recommendations, and participant satisfaction. RESULTS: There were no study-related adverse or serious adverse events. Of 117 eligible stroke admissions, 62 (53%) were recruited, while 10 (16.1%) participants withdrew. Participants attended 189 of 201 (94%) scheduled cardiorespiratory fitness training sessions in Phase 1 and 341/381 (89.5%) scheduled sessions in Phase 2. Only 220/381 (58%) scheduled education sessions were attended. The minimum recommended cardiorespiratory fitness training intensity (40% heart rate reserve) and duration (20 minutes) was achieved by 57% and 55% of participants respectively during Phase 1, and 60% and 92% respectively during Phase 2. All respondents strongly agreed (69%) or agreed (31%) they would recommend the stroke-integrated Cardiac Rehabilitation program to other people with stroke. CONCLUSION: Cardiorespiratory fitness training in line with multiple clinical practice guidelines included within a model of stroke-integrated Cardiac Rehabilitation appears to be safe and feasible in the early subacute phase post-stroke.

Effect of Crystallite Size on the Flexibility and Negative Compressibility of Hydrophobic Metal-Organic Frameworks.

Flexible nanoporous materials are of great interest for applications in many fields such as sensors, catalysis, material separation, and energy storage. Of these, metal-organic frameworks (MOFs) are the most explored thus far. However, tuning their flexibility for a particular application remains challenging. In this work, we explore the effect of the exogenous property of crystallite size on the flexibility of the ZIF-8 MOF. By subjecting hydrophobic ZIF-8 to hydrostatic compression with water, the flexibility of its empty framework and the giant negative compressibility it experiences during water intrusion were recorded via in operando synchrotron irradiation. It was observed that as the crystallite size is reduced to the nanoscale, both flexibility and the negative compressibility of the framework are reduced by ∼25% and ∼15%, respectively. These results pave the way for exogenous tuning of flexibility in MOFs without altering their chemistries.

A novel method to quantify perivascular space enlargement near the syrinx in a rodent model of post-traumatic syringomyelia.

Posttraumatic syringomyelia (PTS) is an enigmatic condition characterized by the development of fluid-filled cysts (syrinxes) within the spinal cord. Perivascular spaces (PVS) are a critical component of fluid transport within the central nervous system (CNS), with dilated PVSs variably implicated in the pathogenesis of syringomyelia. The extent and spatial distribution of dilated PVSs in syringomyelia, however, remains unclear. This study aims to develop a method to assess PVS dimensions across multiple spinal cord segments in rats with PTS. Syrinxes were induced in two Sprague-Dawley rats at C6/7 with computer-controlled motorized spinal cord impaction; two control rats underwent sham laminectomies. Spinal cord segments were obtained at C4, C6 and C8, cleared via tissue clearing protocols, stained with immunofluorescent antibodies and imaged under confocal microscopy. Qualitative and quantitative analyses of PVS size were performed. Arteriolar PVSs were enlarged in the perisyringeal region of the spinal cord, compared to the control cord. No PVS enlargement was observed above or below the syrinx. These results confirm previous incidental findings of enlarged PVSs in the perisyringeal region, providing new insights into PVS dimensions across multiple spinal segments, and providing a novel method for quantifying spinal cord perivascular space size distributions.

Leg-Length and Alignment Changes in Children and Adolescents After Transphyseal Anterior Cruciate Ligament Reconstruction With Soft Tissue Graft: Results at 1-Year Follow-up.

Background: Growth disturbance to leg length or coronal plane alignment are important considerations in pediatric anterior cruciate ligament (ACL) reconstruction (ACLR). Purpose/Hypothesis: The purpose of this study was to investigate the lower limb alignment and leg length of pediatric patients preoperatively and at approximately 1 year after transphyseal ACLR. Our hypothesis was that there would be no significant change in leg-length discrepancy (LLD) or operated-side alignment at follow-up. Study Design: Case series; Level of evidence, 4. Methods: Data were extracted from the prospective Queensland Children's Hospital Pediatric ACL Injury Registry. Long-leg alignment radiographs were captured preoperatively and at an approximately 12-month postoperative follow-up. Radiographic measures included leg length, LLD (injured minus uninjured leg length), mechanical axis deviation (MAD), mechanical and anatomical lateral distal femoral angle (mLDFA and aLDFA, respectively), and medial proximal tibial angle. We evaluated the effect of time (annual vs baseline) on imaging measurements with analysis of covariance, using the covariates of age, sex, and body mass index. Results: Data were available for 104 patients, of whom 34 (33%) had >12 months of skeletal growth remaining based on skeletal age. At an average follow-up time of 14.5 months after ACLR, there were no significant differences in mean lower limb alignment or longitudinal growth compared with baseline. However, seven patients demonstrated clinically significant changes to their mechanical axis or LLD (>10 mm change). A subgroup analysis of patients with >12 months of growth remaining (n = 34) demonstrated no statistically significant changes in mean alignment or LLD. Before surgery, LLD was -1.39 mm and the injured limb was in significantly more valgus compared with the uninjured lower limb (mean difference: MAD, 4.79 mm [95% CI, 2.64 to 6.94 mm]; mLDFA, -0.93° [95% CI, -1.29° to -0.57°], and aLDFA, -0.91° [95% CI, -1.31° to -0.50°]). Conclusion: After ACLR, there were no statistically significant changes in mean alignment or longitudinal growth; however, 7 out of 104 patients (6.7%) demonstrated clinically significant changes in alignment or LLD. Preoperatively, the injured limb was statistically significantly in more valgus compared with the uninjured limb with lateralized MAD.

Optimization of the wetting-drying characteristics of hydrophobic metal organic frameworks via crystallite size: The role of hydrogen bonding between intruded and bulk liquid.

HYPOTHESIS: The behavior of Heterogeneous Lyophobic Systems (HLSs) comprised of a lyophobic porous material and a corresponding non-wetting liquid is affected by a variety of different structural parameters of the porous material. Dependence on exogenic properties such as crystallite size is desirable for system tuning as they are much more facilely modified. We explore the dependence of intrusion pressure and intruded volume on crystallite size, testing the hypothesis that the connection between internal cavities and bulk water facilitates intrusion via hydrogen bonding, a phenomenon that is magnified in smaller crystallites with a larger surface/volume ratio. EXPERIMENTS: Water intrusion/extrusion pressures and intrusion volume were experimentally measured for ZIF-8 samples of various crystallite sizes and compared to previously reported values. Alongside the practical research, molecular dynamics simulations and stochastic modeling were performed to illustrate the effect of crystallite size on the properties of the HLSs and uncover the important role of hydrogen bonding within this phenomenon. FINDINGS: A reduction in crystallite size led to a significant decrease of intrusion and extrusion pressures below 100 nm. Simulations indicate that this behavior is due to a greater number of cages being in proximity to bulk water for smaller crystallites, allowing cross-cage hydrogen bonds to stabilize the intruded state and lower the threshold pressure of intrusion and extrusion. This is accompanied by a reduction in the overall intruded volume. Simulations demonstrate that this phenomenon is linked to ZIF-8 surface half-cages exposed to water being occupied by water due to non-trivial termination of the crystallites, even at atmospheric pressure.

Physical Activity Preferences of People Living with Brain Injury: Formative Qualitative Research to Develop a Discrete Choice Experiment.

BACKGROUND AND OBJECTIVE: The World Health Organization physical activity guidelines for people living with disability do not consider the needs of people living with moderate-to-severe traumatic brain injury. This paper describes the qualitative co-development of a discrete choice experiment survey to inform the adaption of these guidelines by identifying the physical activity preferences of people living with moderate-to-severe traumatic brain injury in Australia. METHODS: The research team comprised researchers, people with lived experience of traumatic brain injury and health professionals with expertise in traumatic brain injury. We followed a four-stage process: (1) identification of key constructs and initial expression of attributes, (2) critique and refinement of attributes, (3) prioritisation of attributes and refinement of levels and (4) testing and refining language, format and comprehensibility. Data collection included deliberative dialogue, focus groups and think-aloud interviews with 22 purposively sampled people living with moderate-to-severe traumatic brain injury. Strategies were used to support inclusive participation. Analysis employed qualitative description and framework methods. RESULTS: This formative process resulted in discarding, merging, renaming and reconceptualising attributes and levels. Attributes were reduced from an initial list of 17 to six: (1) Type of activity, (2) Out-of-pocket cost, (3) Travel time, (4) Who with, (5) Facilitated by and (6) Accessibility of setting. Confusing terminology and cumbersome features of the survey instrument were also revised. Challenges included purposive recruitment, reducing diverse stakeholder views to a few attributes, finding the right language and navigating the complexity of discrete choice experiment scenarios. CONCLUSIONS: This formative co-development process significantly improved the relevance and comprehensibility of the discrete choice experiment survey tool. This process may be applicable in other discrete choice experiment studies.

The effect of physical activity on health outcomes in people with moderate-to-severe traumatic brain injury: a rapid systematic review with meta-analysis.

BACKGROUND: In 2020, the World Health Organization (WHO) released the first global physical activity and sedentary behaviour guidelines for children and adults living with disability. The evidence informing the guidelines though is not specific to people living with traumatic brain injury (TBI), but rather comes from other disabling conditions such as Parkinson's disease, and stroke. There remains a clear lack of direct evidence of the effects of physical activity for people living with TBI. The objective of this rapid review was to identify direct evidence of the effect of physical activity on health outcomes in people with moderate-to-severe TBI to inform adaptation of the WHO physical activity guidelines into clinical practice guidelines. METHODS: We conducted a rapid systematic review with meta-analysis of randomised controlled trials, including people of any age with moderate-to-severe TBI, investigating physical activity interventions compared to either usual care, a physical activity intervention with different parameters, or a non-physical activity intervention. Four databases (CENTRAL, SPORTDiscus, PEDro, Ovid MEDLINE) were searched from inception to October 8, 2021. The primary outcomes were physical function, cognition, and quality of life. RESULTS: Twenty-three studies were included incorporating 812 participants (36% females, majority working-age adults, time post-TBI in studies ranged from 56 days (median) to 16.6 years (mean)). A range of physical activity interventions were evaluated in rehabilitation (n = 12 studies), community (n = 8) and home (n = 3) settings. We pooled data from the end of the intervention for eight outcomes. Participation in a virtual reality physical activity intervention improved mobility, assessed by the Community Balance and Mobility Scale (range 0 to 96; higher score indicates better mobility) more than standard balance training (two studies, 80 participants, Mean Difference = 2.78, 95% CI 1.40 to 4.16; low certainty evidence). There was uncertainty of effect for the remaining outcomes, limited by small sample sizes, diverse comparators and a wide range of outcome measures. CONCLUSION: This review consolidates the current evidence base for the prescription of physical activity for people with moderate-to-severe TBI. There remains a pressing need for further rigorous research in order to develop practice guidelines to support clinical decision-making when prescribing physical activity in this population.

The safety and feasibility of early cardiorespiratory fitness testing after stroke.

BACKGROUND: Cardiorespiratory fitness testing is recommended as part of a pre-exercise evaluation to aid the programming of safe, tailored cardiorespiratory fitness training after stroke. But there is limited evidence for its safety and feasibility in people with stroke with varying impairment levels in the early subacute phase of stroke recovery. OBJECTIVE: To assess the safety and feasibility of cardiorespiratory fitness testing in the early subacute phase after stroke. DESIGN: A sub-study of a larger single service, multi-site, prospective cohort feasibility study (Cardiac Rehabilitation in Stroke Survivors to Improve Survivorship [CRiSSIS]). SETTING: Private subacute inpatient rehabilitation facilities. PARTICIPANTS: Consecutive admissions of people with ischemic stroke admitted to subacute rehabilitation facilities. INTERVENTION: Not applicable. MAIN OUTCOME(S): Safety was determined by the occurrence of adverse or serious adverse events. Feasibility was determined by assessing the (1) number of participants recruited and (2) number of participants able to complete the fitness test. RESULTS: Between April 2018 and December 2019, a total of 165 people with stroke were screened to participate; 109 were eligible and 65 were recruited. Of the 62 who completed testing, 41 participants were able to complete a submaximal fitness test at a median of 12 days post-stroke. One minor adverse event was recorded. Of the 21 participants unable to complete the fitness test; 4 declined to complete the test, 9 were unable to commence the test, and 8 were unable to complete the first stage of the protocol due to stroke-related impairments. Participants with mild stroke, greater motor and cognitive function, and fewer depressive symptoms were more likely to be able to complete the cardiorespiratory fitness test. CONCLUSION: Cardiorespiratory fitness testing was safe for most people with mild-to-moderately severe ischemic stroke and transient ischemic attack in the early subacute phase, but only two-thirds of the participants could complete the test.

Effect of Exercise on Brain-Derived Neurotrophic Factor in Stroke Survivors: A Systematic Review and Meta-Analysis.

BACKGROUND: BDNF (brain-derived neurotrophic factor) is a biomarker of neuroplasticity linked with better functional outcomes after stroke. Early evidence suggests that increased concentrations after exercise may be possible for people with stroke, however it is unclear how exercise parameters influence BDNF concentration. METHODS: This systematic review and meta-analysis searched 7 electronic databases. Experimental or observational studies measuring changes in BDNF concentration after exercise in people poststroke were included. Data were extracted including characteristics of the study, participants, interventions, and outcomes. Several fixed and random effects meta-analyses were completed. RESULTS: Seventeen studies including a total of 687 participants met the eligibility criteria (6 randomized trials). Significant improvements were observed in BDNF concentration following a single session (mean difference, 2.49 ng/mL; [95% CI, 1.10-3.88]) and program of high intensity aerobic exercise (mean difference, 3.42 ng/mL; [95% CI, 1.92-4.92]). CONCLUSIONS: High intensity aerobic exercise can increase circulating BDNF concentrations, which may contribute to increased neuroplasticity. REGISTRATION: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021251083.

Single versus double hamstring tendon graft in anterior cruciate ligament reconstruction in the paediatric patient: a single-blind randomised controlled trial study protocol.

INTRODUCTION: There is currently no clear indication in the literature regarding a single or double hamstring tendon (single bundle) autograft for anterior cruciate ligament (ACL) reconstruction in the paediatric patient. The primary aim of this single blind randomised controlled trial is to determine whether a single or double hamstring tendon graft ACLR leads to superior clinical outcomes postsurgery in paediatric patients with ACL injury. METHODS AND ANALYSIS: Single site, prospective, single blind, randomised controlled trial with two parallel treatment arms. 100 patients aged 10-18 years who present with an isolated ACL tear±meniscal injury, verified on MRI, will be randomly allocated to one of the two surgical groups. The primary outcomes will be side-to-side difference in anterior tibial translation and graft failure incidence 12 months postsurgery. Primary and secondary outcomes will also be assessed at 2-year and 5-year postsurgery. ETHICS AND DISSEMINATION: Results will be presented in peer-reviewed journals and at international conferences and disseminated to participants and healthcare professionals via newsletters and hospital presentations. This study is approved by the Children's Health Queensland Hospital and Health Service Human Research Ethics committee. TRIAL REGISTRATION NUMBER: ACTRN12620001170910p; Australian New Zealand Clinical Trials Registry.

Kinematic differences in the presentation of recurrent congenital talipes equinovarus (clubfoot).

BACKGROUND: The tibialis anterior tendon transfer (TATT) is the suggested surgical intervention in the Ponseti method for treatment of dynamic recurrent congenital talipes equinovarus (clubfoot) presenting as hindfoot varus and forefoot supination during the swing phase of gait. The indication for surgery, however, is typically based on visual assessment, which does not sufficiently examine the variability of foot motion in this cohort. RESEARCH QUESTION: The aim of this research was to determine whether subgroups, based on foot model kinematics, existed within a clubfoot cohort being considered for TATT surgery. METHODS: Sixteen children with recurrent clubfoot that had been previously treated with the Ponseti method and were being considered for tendon transfer surgery were prospectively recruited for this study and were required to attend a pre-surgery data collection session at the Queensland Children's Motion Analysis Service (QCMAS). Data collected included standard Plug-in-Gait (PiG) kinematics and kinetics, Oxford Foot Model (OFM) foot kinematics, and regional plantar loads based on anatomical masking using the integrated kinematic-pressure method. RESULTS: Results of this study identified two clear subgroups within the cohort. One group presented with increased hindfoot inversion across 91 % of the gait cycle. The second group presented with increased hindfoot adduction across 100 % of the gait cycle. Hindfoot adduction was statistically significantly different between the two groups. SIGNIFICANCE: The identification of these two groups propose a need for further classification of deformity within this cohort and query the appropriateness of this surgical intervention for both presentations.

A physiotherapy led Soft Tissue Injury Clinic is an efficient and cost effective model of care. A paediatric specific interrupted time series study.

OBJECTIVES: To evaluate the effect of introducing a physiotherapist-led paediatric Soft Tissue Injury Clinic model as an alternative to a medically led Fracture Clinic model for conservative hospital management of soft-tissue injuries on: patient wait times; healthcare resource use; and cost-effectiveness. DESIGN: Interrupted time-series analysis (including consecutive eligible-cases). SETTING: Children's hospital, Australia. PARTICIPANTS: The study included 245 cases (117 Soft Tissue Injury Clinic model sample, 128 Fracture Clinic model sample) of patients (<18 years) who presented to a specialist children's hospital emergency department and diagnosed with a soft tissue injury requiring non-surgical outpatient management. INTERVENTIONS: Patients were referred from the emergency department to either an orthopaedic-led fracture clinic (Fracture Clinic model) or physiotherapist-led clinic (Soft Tissue Injury Clinic model) for follow-up and further management as clinically indicated. MAIN OUTCOME MEASURES: Time from emergency department discharge to commencement of definitive outpatient management (primary); healthcare resource use and costs from hospital funder perspective (secondary) and cost-per-day less waiting (cost-effectiveness). RESULTS: The Soft Tissue Injury Clinic was associated with (mean per-person difference (95%CI), P-value) fewer wait days (-8 (-11, -5) days, P<0.001), fewer orthopaedic costs P<0.001, >99% probability of fewer days waiting, 81% probability of less total cost and 81% probability of dominance (cheaper and fewer days to access definitive care). There were no adverse events in either model. CONCLUSIONS: The physiotherapist-led Soft Tissue Injury Clinic represented a safe and efficient alternative referral pathway for patients presenting to the emergency department with soft tissue injuries requiring conservative management.

Genome Sequences of 22 T1-like Bacteriophages That Infect Enterobacteriales.

Here, the full genome sequences of 22 T1-like bacteriophages isolated from wastewater are reported. Eight (BlueShadow, Brooksby, Devorator, ElisaCorrea, Reinasaurus, SorkZaugg, Supreme284, ZeroToHero) were isolated on Citrobacter, six on Klebsiella (Chell, FairDinkum, HazelMika, Opt-817, P528, PeteCarol), and eight on Escherichia (Fulano1, Mishu, Opt-719, PhleaSolo, Punny, Poky, Phunderstruck, Sadiya).

Genome Sequences of 14 Siphophages That Infect Serratia marcescens.

We announce the complete genome sequences of 14 Serratia bacteriophages isolated from wastewater treatment plants. These phages define two previously undescribed types which we call the Carrot-like phage cluster (phages Carrot, BigDog, LittleDog, Niamh, Opt-148, Opt-169, PhooPhighters, Rovert, Serratianator, Stoker, Swain, and Ulliraptor) and Tlacuache-like phage cluster (Tlacuache and Opt-155).

Maintenance of Cardiorespiratory Fitness in People With Stroke: A Systematic Review and Meta-analysis.

OBJECTIVE: To determine if improvements in cardiorespiratory fitness are maintained in the short-, medium- and long-term after a cardiorespiratory fitness intervention in people with stroke. DATA SOURCES: MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, (CENTRAL) Cochrane, Web of Science, Sports Discus, and Physiotherapy Evidence Database were searched from inception. STUDY SELECTION: Randomized controlled trials and cohort studies including (1) people with stroke; (2) cardiorespiratory fitness interventions; (3) a direct measure of cardiorespiratory fitness; and (4) short- (0 to <3 months), medium- (3-6 months), or long-term (>6 months) follow-up data. DATA EXTRACTION: Two reviewers independently screened full texts and extracted data, including study methods, participant demographic information, stroke type and severity, outcome measures, intervention information, follow-up time points, and results, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A lower limit of -1.0 mL•kg-1•min-1 was used to determine maintenance (ie, no change) of cardiorespiratory fitness. DATA SYNTHESIS: Fourteen studies (N=324 participants) were included. Participants completed cardiorespiratory fitness training 2-5 days per week over 4-13 weeks at moderate to high intensity (40%-70% heart rate reserve [HRR]; n=4 studies), high intensity (60% to <90% HRR; n=7 studies), and intervals of high intensity (85%-95% peak heart rate or maximal heart rate; n=3 studies). Most people with stroke did maintain cardiorespiratory fitness in the short- (-0.19 mL•kg-1•min-1 [95% CI, -1.66 to 1.28]), medium- (-0.61 mL•kg-1•min-1 [95% CI, -3.95 to 2.74]), and long-term (0.00 mL•kg-1•min-1 [95% CI, -2.23 to 2.23]) after completion of cardiorespiratory fitness interventions. CONCLUSIONS: People with stroke maintain cardiorespiratory fitness after a cardiorespiratory fitness intervention in the short-, medium-, and longer-term. However, little is known about the impact of participant and intervention characteristics on the long-term maintenance of cardiorespiratory fitness.