Increased maternal abdominal subcutaneous fat thickness and body mass index are associated with increased cesarean delivery: A prospective cohort study.

INTRODUCTION: Early pregnancy body mass index (BMI) is known to predict adverse pregnancy outcomes but does not account for body fat distribution. This study aimed to determine prospectively whether maternal abdominal subcutaneous fat thickness (SCFT) measured by ultrasound at the fetal morphology scan is a better predictor than BMI of mode of delivery and other pregnancy outcomes. MATERIAL AND METHODS: This was a prospective cohort study of women delivering singleton neonates at a tertiary public hospital. Women were included if they had appropriate images at the routine fetal anomaly ultrasound scan and delivered in the facility. The primary outcome was mode of delivery categorized as cesarean section or vaginal delivery. The relation between maternal SCFT and BMI was described using the Pearson correlation coefficient. The association of maternal abdominal SCFT BMI at booking-in was compared with pregnancy outcomes using univariate linear and logistic regression. RESULTS: SCFT and BMI were obtained for 997 women. The median (interquartile range) SCFT was 15.3 mm (12.8-19.6) and median (interquartile range) BMI 24.3 kg/m2 (21.7-28.3). Maternal abdominal SCFT and BMI were highly correlated (R2  = 0.55). Both were significantly associated with cesarean delivery: SCFT per 5 mm (odds ratio [OR] 1.32, 95% confidence interval (CI) 1.18-1.48; BMI per 5 kg/m2 OR 1.29, 95% CI 1.15-1.44. CONCLUSIONS: Maternal abdominal SCFT and BMI were both significantly associated with cesarean delivery and other outcomes. More research is needed to define the strengths of maternal SCFT in predicting pregnancy outcomes.

A systems-based investigation into vitamin D and skeletal muscle repair, regeneration, and hypertrophy.

Skeletal muscle is a direct target for vitamin D. Observational studies suggest that low 25[OH]D correlates with functional recovery of skeletal muscle following eccentric contractions in humans and crush injury in rats. However, a definitive association is yet to be established. To address this gap in knowledge in relation to damage repair, a randomised, placebo-controlled trial was performed in 20 males with insufficient concentrations of serum 25(OH)D (45 ± 25 nmol/l). Prior to and following 6 wk of supplemental vitamin D3 (4,000 IU/day) or placebo (50 mg of cellulose), participants performed 20 × 10 damaging eccentric contractions of the knee extensors, with peak torque measured over the following 7 days of recovery. Parallel experimentation using isolated human skeletal muscle-derived myoblast cells from biopsies of 14 males with low serum 25(OH)D (37 ± 11 nmol/l) were subjected to mechanical wound injury, which enabled corresponding in vitro studies of muscle repair, regeneration, and hypertrophy in the presence and absence of 10 or 100 nmol 1α,25(OH)2D3. Supplemental vitamin D3 increased serum 25(OH)D and improved recovery of peak torque at 48 h and 7 days postexercise. In vitro, 10 nmol 1α,25(OH)2D3 improved muscle cell migration dynamics and resulted in improved myotube fusion/differentiation at the biochemical, morphological, and molecular level together with increased myotube hypertrophy at 7 and 10 days postdamage. Together, these preliminary data are the first to characterize a role for vitamin D in human skeletal muscle regeneration and suggest that maintaining serum 25(OH)D may be beneficial for enhancing reparative processes and potentially for facilitating subsequent hypertrophy.

Quantification of training load, energy intake, and physiological adaptations during a rugby preseason: a case study from an elite European rugby union squad.

Rugby Union (RU) is a high-speed collision sport consisting of an intermittent activity profile. Given the extreme physical demands of the sport, significant emphasis is placed on players possessing high lean body mass while minimizing body fat. Anecdotally, the most significant changes in body composition are observed during the preseason; however, there are no objective data on the physiological demands and energy intake during this time. We therefore monitored 45 elite European RU players over the 10-week preseason period by assessing training load using Global Positioning System and session rate of perceived exertion (sRPE) while also assessing changes in anthropometry and physical performance. For forwards and backs, respectively, mean weekly distance covered was 9,774 m (1,404) and 11,585 m (1,810) with a total mean weekly sRPE of 3,398 (335) arbitrary units and 2,944 (410) arbitrary units. Mean daily energy intake was 14.8 MJ (1.9) and 13.3 MJ (1.9), carbohydrate (CHO) intake was 3.3 (0.7) and 4.14 (0.4) g·kg body mass, protein intake was 2.52 (0.3) and 2.59 (0.6) g·kg body mass, and fat intake was 1.0 (0.3) and 0.95 (0.3) g·kg body mass for forwards and backs, respectively. Markers of physical performance (1 repetition maximum strength, speed, and repeated sprint tests) and anthropometry (body fat and estimated lean mass) improved in all players. Interestingly, all players self-selected a "low" CHO "high" protein diet. Based on physiological improvements the training load and energy intake seems appropriate, although further research is required to evaluate if such energy intakes would also be suitable for match day performance.

Vitamin D supplementation does not improve human skeletal muscle contractile properties in insufficient young males.

PURPOSE: Vitamin D may be a regulator of skeletal muscle function, although human trials investigating this hypothesis are limited to predominantly elderly populations. We aimed to assess the effect of oral vitamin D3 in healthy young males upon skeletal muscle function. METHODS: Participants (n = 29) received an oral dose of 10,000 IU day(-1) vitamin D3 (VITD) or a visually identical placebo (PLB) for 3 months. Serum 25[OH]D and intact parathyroid hormone (iPTH) were measured at baseline and at week 4, 8 and 12. Muscle function was assessed in n = 22 participants by isokinetic dynamometry and percutaneous isometric electromyostimulation at baseline and at week 6 and 12. RESULTS: Baseline mean total serum 25[OH]D was 40 ± 17 and 41 ± 20 nmol L(-1) for PLB and VITD, respectively. VITD showed a significant improvement in total 25[OH]D at week 4 (150 ± 31 nmol L(-1)) that remained elevated throughout the trial (P < 0.005). Contrastingly, PLB showed a significant decrease in 25[OH]D at week 12 (25 ± 15 nmol L(-1)) compared with baseline. Despite marked increases in total serum 25[OH]D in VITD and a decrease in PLB, there were no significant changes in any of the muscle function outcome measures at week 6 or 12 for either group (P > 0.05). CONCLUSIONS: Elevating total serum 25[OH]D to concentrations > 120 nmol L(-1) has no effect on skeletal muscle function. We postulate that skeletal muscle function is only perturbed in conditions of severe deficiency (<12.5 nmol L(-1)).

Effects of an Acute Dose of Zinc Monomethionine Asparate and Magnesium Asparate (ZMA) on Subsequent Sleep and Next-Day Morning Performance (Countermovement Jumps, Repeated Sprints and Stroop Test).

The goal of the present study was to determine whether an acute dose of a zinc-containing nutritional supplement (ZMA) has any effects on sleep and morning performance in recreationally trained males. Nineteen males participated in a repeated-measures within-subjects study to assess objective and subjective measures of sleep, completed counter-movement jumps (CMJ) and repeated sprint morning performance (RSP). Three days of baseline food intake showed no major deficiencies of zinc, magnesium or vitamin B6 for all participants (11.9 ± 3.4, 395 ± 103 and 2.7 ± 0.9 mg.day-1, respectively). Sleep (22:30-06:30 h) was assessed via actimetry, and either a control (no tablets, NoPill), dextrose placebo (PLAC) or ZMA was ingested 30-60 min before retiring to bed for two nights. The participants undertook the three conditions (NoPill, PLAC or ZMA) administered in a counterbalanced order. The data were analyzed using general linear models with repeated measures. In healthy active males who consume diets of adequate micronutrients, sleep normally and maintain good sleep hygiene (time to bed and wake times), ZMA supplementation had no beneficial effect on RSP or performance in the Stroop test (p > 0.05) but did improve CMJ height (p < 0.001) compared to that of PLAC but not NoPill (p > 0.05). Supplementation of ZMA for two nights had no effect on sleep, RSP or cognitive function. The NoPill condition elucidated the effects of the intervention under investigation.

Medications for increasing milk supply in mothers expressing breastmilk for their preterm hospitalised infants.

BACKGROUND: Breastmilk remains the optimal form of enteral nutrition for term and preterm infants until up to six months postnatal age. Mothers of preterm infants who have not established suck feeds must express their breastmilk and often have difficulty in maintaining sufficient volume for their infants' needs (Donath 2008). In preterm infants, donor breastmilk reduced the occurrence of necrotising enterocolitis, when compared with formula feeds (McGuire 2003). Also, case-control studies have suggested that breastmilk is associated with an improvement in feeding tolerance, a reduction in significant gastrointestinal infective events (Beeby 1992) and a reduction in late-onset sepsis (Schanler 1999) when compared with formula feeds in preterm hospitalised infants. OBJECTIVES: To assess the effect of medication given for at least seven days to mothers of preterm infants whose breastmilk is insufficient for their infants' needs on the outcomes of expressed milk volume and duration of breastfeeding. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2011). SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of breastmilk-augmenting medications (compared with placebo or with other augmenting medications) in mothers with preterm hospitalised infants whose breastmilk volumes failed to meet their infants' requirements. We did not include trials with a cluster-randomised or cross-over design. DATA COLLECTION AND ANALYSIS: Both review authors independently assessed studies for inclusion, assessed risk of bias, and extracted data. Any differences were resolved by consensus. Data were checked for accuracy. MAIN RESULTS: Two trials (involving 59 mothers) that examined the use of domperidone in a total of 59 mother-infant pairs met the inclusion criteria. Meta-analysis of these trials showed a modest increase in expressed breastmilk (EBM) of 99.49 mL/day (95% confidence intervals -1.94 to 200.92; random-effects, T² 3511.62, I² 63%) in mothers given domperidone. Both trials gave the same dose of domperidone (10 mg three times per day) with a duration of seven days in the smaller trial and 14 days in the larger.Neither trial showed significant improvements in longer-term outcomes of breastfeeding in a preterm population and no adverse effects were reported. AUTHORS' CONCLUSIONS: Two studies with a total of 59 mothers suggest modest improvements in short-term EBM volumes when a medication is used after insufficient EBM occurs in mothers following preterm delivery. In both studies, the medication was commenced ≧14 days post delivery and following insufficient EBM supply with other lactation supports.Currently, no studies support prophylactic use of a galactagogue medication at any gestation. Use of any galactagogue medication has only been examined at more than 14 days post delivery and after full lactation support has been given. Further trials should examine larger groups of preterm mothers and consider breastfeeding outcomes over a longer period.

Energy Expenditure of a Male and Female Tennis Player during Association of Tennis Professionals/Women's Tennis Association and Grand Slam Events Measured by Doubly Labeled Water.

METHODS: Doubly labeled water assessed TEE during a 17-d period analyzed by days 1 to 7 (P1) and 7-17 (P2) which included a Women's Tennis Association/Association of Tennis Professionals tournament and culminated at the Wimbledon Championships. Daily training and match loads were assessed using a 10-point Borg scale multiplied by time. Match data were provided by video analysis and player tracking technology. RESULTS: The TEE during P1 for the female player was 3383 kcal·d-1 (63.5 kcal·kg-1) fat-free mass (FFM) with 362 points played over 241 min in three matches covering a distance of 2569 m, with an additional 875 min training. During P2, TEE was 3824 kcal·d-1 (71.7 kcal·kg-1) FFM with 706 points played over 519 min during five matches, covering a distance of 7357 m with an additional 795 min training. The TEE during P1 for the male player was 3712 kcal·d-1 (56.3 kcal·kg-1) FFM with 133 points played over 88 min during one match covering 1125 m, with an additional 795 min training. During P2, TEE was 5520 kcal·d-1 (83.7 kcal·kg-1) FFM with 891 points played over 734 min during five matches, covering 10,043 m, with an additional 350 min training. CONCLUSIONS: This novel data positions elite tennis, played at the highest level, as a highly energetic demanding sport, highlighting that nutritional strategies should ensure sufficient energy availability during competition schedules.

Current management of transitional feeding issues in preterm neonates born in Queensland, Australia.

BACKGROUND: Many preterm neonates display difficulty establishing suck-feeding competence in the weeks following birth. Ineffective management of transitional feeding issues may cause patient complications, and can contribute to increased length of stay. AIMS: Given that many neonatal nurseries appear to vary in their neonatal feeding management practices, the aim of this study was to investigate and document the routine level of support and intervention currently provided for preterm neonates with transitional feeding issues across the various level II (special care) nurseries (SCNs) in Queensland, Australia. METHODS: A questionnaire was mailed to all Queensland SCNs in 2005 (n=36). The questionnaire contained a series of closed-choice and short-answer questions designed to obtain information from each SCN regarding their current practices for managing transitional feeding issues in preterm neonates. Results were confirmed during a follow-up phone call. RESULTS: Responses were obtained from 29 SCNs (80.6%). None of these nurseries reported having any formal, written policies regarding the management of transitional feeding issues in preterm neonates. Wide variations were reported in relation to the suck-feeding assessments and interventions used by staff within the various SCNs. Of the 29 nurseries, 4 (13.8%) reported using checklists or assessments to judge readiness for suck-feeds, and 5 (17.2%) reported using pulse oximetry to judge tolerance of suck-feeding attempts. Eighteen SCNs (62.1%) reported offering some form of active intervention to assist neonates with transitional feeding issues, with the most common intervention techniques reported being non-nutritive sucking during tube feeds, pre-feeding oral stimulation, and actively pacing suck-feeds. Twenty-two SCNs (75.4%) reported having access to a lactation consultant to assist mothers with breastfeeding issues. CONCLUSIONS: Differences were reported in the routine management of transitional feeding issues in preterm neonates across the various SCNs in Queensland. It is suggested that evidence based guidelines need to be developed, and that, in order to do this, further research studies are required to determine current best practice, as well as to answer remaining questions.

Comprehensive Health Care Economics Curriculum and Training in Radiology Residency.

PURPOSE: To investigate the ability to successfully develop and institute a comprehensive health care economics skills curriculum in radiology residency training utilizing didactic lectures, case scenario exercises, and residency miniretreats. METHODS: A comprehensive health care economics skills curriculum was developed to significantly expand upon the basic ACGME radiology residency milestone System-Based Practice, SBP2: Health Care Economics requirements and include additional education in business and contract negotiation, radiology sales and marketing, and governmental and private payers' influence in the practice of radiology. RESULTS: A health care economics curriculum for radiology residents incorporating three phases of education was developed and implemented. Phase 1 of the curriculum constituted basic education through didactic lectures covering System-Based Practice, SBP2: Health Care Economics requirements. Phase 2 constituted further, more advanced didactic lectures on radiology sales and marketing techniques as well as government and private insurers' role in the business of radiology. Phase 3 applied knowledge attained from the initial two phases to real-life case scenario exercises and radiology department business miniretreats with the remainder of the radiology department. CONCLUSION: A health care economics skills curriculum in radiology residency is attainable and essential in the education of future radiology residents in the ever-changing climate of health care economics. Institution of more comprehensive programs will likely maximize the long-term success of radiology as a specialty by identifying and educating future leaders in the field of radiology.

Review: Is rapid fat accumulation in early life associated with adverse later health outcomes?

This review discusses ways in which the maternal environment and placental function affect the birth weight and adult health outcomes of offspring. These maternal and placental factors have varying and sometimes opposing effects on birth weight, resulting in infants that are born small for gestational age (SGA), large for gestational age (LGA) or preterm. However, all these alterations in weight have similar effects on adult health, increasing the risk of obesity and its associated cardiovascular and metabolic disorders. While birth weight has been used as a marker for risk of adverse adult health, we propose that a common feature of all these scenarios - early accumulation of excess body fat - may be a better marker than birth weight alone. Furthermore, altered neonatal fat accumulation may be more closely related to the mechanism by which maternal environment and placental adaptation mediate effects on adult health. We suggest that more research should be focussed on early fat accretion, factors that promote fat accretion and if it can be avoided, and whether it would be beneficial to try to reduce fat accumulation in early life.

Muscle glycogen utilisation during Rugby match play: Effects of pre-game carbohydrate.

OBJECTIVES: Although the physical demands of Rugby League (RL) match-play are well-known, the fuel sources supporting energy-production are poorly understood. We therefore assessed muscle glycogen utilisation and plasma metabolite responses to RL match-play after a relatively high (HCHO) or relatively low CHO (LCHO) diet. DESIGN: Sixteen (mean±SD age; 18±1 years, body-mass; 88±12kg, height 180±8cm) professional players completed a RL match after 36-h consuming a non-isocaloric high carbohydrate (n=8; 6gkgday-1) or low carbohydrate (n=8; 3gkgday-1) diet. METHODS: Muscle biopsies and blood samples were obtained pre- and post-match, alongside external and internal loads quantified using Global Positioning System technology and heart rate, respectively. Data were analysed using effects sizes ±90% CI and magnitude-based inferences. RESULTS: Differences in pre-match muscle glycogen between high and low carbohydrate conditions (449±51 and 444±81mmolkg-1d.w.) were unclear. High (243±43mmolkg-1d.w.) and low carbohydrate groups (298±130mmolkg-1d.w.) were most and very likely reduced post-match, respectively. For both groups, differences in pre-match NEFA and glycerol were unclear, with a most likely increase in NEFA and glycerol post-match. NEFA was likely lower in the high compared with low carbohydrate group post-match (0.95±0.39mmoll-1 and 1.45±0.51mmoll-1, respectively), whereas differences between the 2 groups for glycerol were unclear (98.1±33.6mmoll-1 and 123.1±39.6mmoll-1) in the high and low carbohydrate groups, respectively. CONCLUSIONS: Professional RL players can utilise ∼40% of their muscle glycogen during a competitive match regardless of their carbohydrate consumption in the preceding 36-h.

Energy intake and expenditure assessed 'in-season' in an elite European rugby union squad.

Rugby union (RU) is a complex high-intensity intermittent collision sport with emphasis placed on players possessing high lean body mass and low body fat. After an 8 to 12-week pre-season focused on physiological adaptations, emphasis shifts towards competitive performance. However, there are no objective data on the physiological demands or energy intake (EI) and energy expenditure (EE) for elite players during this period. Accordingly, in-season training load using global positioning system and session rating of perceived exertion (sRPE), alongside six-day assessments of EE and EI were measured in 44 elite RU players. Mean weekly distance covered was 7827 ± 954 m and 9572 ± 1233 m with a total mean weekly sRPE of 1776 ± 355 and 1523 ± 434 AU for forwards and backs, respectively. Mean weekly EI was 16.6 ± 1.5 and 14.2 ± 1.2 megajoules (MJ) and EE was 15.9 ± 0.5 and 14 ± 0.5 MJ. Mean carbohydrate (CHO) intake was 3.5 ± 0.8 and 3.4 ± 0.7 g.kg(-1) body mass, protein intake was 2.7 ± 0.3 and 2.7 ± 0.5 g.kg(-1) body mass, and fat intake was 1.4 ± 0.2 and 1.4 ± 0.3 g.kg(-1) body mass. All players who completed the food diary self-selected a 'low' CHO 'high' protein diet during the early part of the week, with CHO intake increasing in the days leading up to a match, resulting in the mean EI matching EE. Based on EE and training load data, the EI and composition seems appropriate, although further research is required to evaluate if this diet is optimal for match day performance.

Regional brain activations predicting subsequent memory success: an event-related fMRI study of the influence of encoding tasks.

We determined the brain regions that were differentially sensitive to two, randomly inter-mixed tasks: Deep Encoding, in which subjects processed items according to their meaning (is the word pleasant or unpleasant?) and Shallow Encoding, in which items were processed according to two underlined letters in the word (are the letters in alphabetical order?). The former task was associated with activations in a set of brain regions including left lateral prefrontal cortex (PFC) and left medial temporal cortex. The latter showed relatively greater activation in right PFC. Both findings are consistent with predictions made on the basis of previous functional neuroimaging work. Following scanning, each subject underwent a recognition memory task. The results of these provided the basis for a further sub-division of encoding events, according to whether they were predictive of subsequent recognition success or not. Unsurprisingly, recognition performance was greater for words that had been deeply encoded. For both encoding conditions, words that were subsequently recognised were associated with greater activation in a sub-set of regions identified by the deep versus shallow contrast. These included left PFC and medial temporal regions. In left PFC this performance-predicting activation was significantly greater for the deep encoding condition. Our results support previous studies suggesting a role for left PFC and medial temporal cortex in episodic memory encoding. They provide more evidence, too, for a less consistent finding: the interaction between the encoding task and the success of subsequent recognition.

Orogastric and intravenous indomethacin administration to very premature neonates with patent ductus arteriosus: population pharmacokinetics, absolute bioavailability, and treatment outcome.

A population pharmacokinetic model was developed after administration of orogastric and/or intravenous indomethacin for the treatment of patent ductus arteriosus in preterm infants. Plasma indomethacin concentrations (n=227) were obtained from 90 preterm infants of median gestational age 27 weeks, mean postnatal age of 12 days, and a mean current weight (WT) of 1010 g. Infants received one to three courses of indomethacin (0.1 mg/kg per day for 6 days). A one-compartment model was fitted to the data to obtain estimates of clearance (CL), volume of distribution (V), absorption rate constant (Ka) and orogastric bioavailability (F), using NONMEM. Model robustness was assessed by bootstrapping with replacement (500 samples). The structural model was: CL (L/h)=0.0166 (WT / 0.936)1.54; V (L)=0.484 (WT / 0.936)1.41; F=0.986; Ka (h(-1))=0.786. The interindividual variability for CL and V was 57.7% and 45.6%, respectively. There remained considerable residual unexplained variability (45.4%). Mean (range) conditional estimates from individual infants for CL, V, and elimination half-life were 18.9 (4.7-45.5) mL/h/kg, 509 (191-1120) mL/kg, and 20.0 (12.0-37.3) hours, respectively. Complete ductus closure occurred in 67% of patients. Infants of lower gestational age or birth weight had less chance of successful ductal closure. There was no obvious dose-response relationship between systemic exposure to varying plasma indomethacin concentrations and ductus closure, which does not support individualized indomethacin dosing based on monitoring to a target plasma concentration.

Errors in the MRI evaluation of musculoskeletal tumors and tumorlike lesions.

Interpretation of an MRI of a suspected musculoskeletal neoplasm can be extremely difficult. Fifty-six MRIs originally evaluated by outside radiologists were independently evaluated by an expert panel consisting of three specialized musculoskeletal radiologists. The outside reports were then graded based upon accuracy and completeness of the differential diagnosis. We compared the expert opinions with those of the outside radiologists. According to the expert panel, only 30 of the 56 (54%) outside reports listed the most likely diagnosis as such and only 35 (63%) listed it at all. A complete appropriate differential diagnosis was listed in only 22 (39%) of the outside reports. Furthermore, 18 (32%) of the outside reports listed diagnoses judged to be extremely unlikely by the experts. In a subset of 15 patients with images that the expert panel had judged diagnostic of specific entities, only nine of the outside reports listed the correct diagnosis as such and only 10 listed it at all. Furthermore, 11 (73%) of the outside reports listed extremely unlikely possibilities for these diagnostic images. We found a substantial difference between the expert and the outside opinions.

Application of routine monitoring data for determination of the population pharmacokinetics and enteral bioavailability of phenytoin in neonates and infants with seizures.

This study investigated the population pharmacokinetics and the enteral bioavailability of phenytoin (PTN) in neonates and infants with seizures. Data from 83 patients were obtained retrospectively from medical records. A 1-compartment model was fitted to the log-transformed concentration data using NONMEM. Between-subject variability and interoccasion variability were modelled exponentially together with a log transform, both-sides exponential residual unexplained variance model. Covariates in nested models were screened for significance. Model robustness was assessed by bootstrapping with replacement (n = 500) from the study data. The parameters of the final pharmacokinetic model were clearance (L/h) = 0.826.[weight (WT, kg) / 70].[1 + 0.0692.(postnatal age (d) - 11)]; volume of distribution (L) = 74.2.[WT (kg) / 70]; absolute enteral bioavailability = 0.76; absorption rate constant (h) = 0.167. The between-subject variability for clearance and volume of distribution was 74.2% and 65.6%, respectively. The interoccasion variability for clearance was 54.4%. The unexplained variability was 51.1%. Final model parameter values deviated from median bootstrap estimates by less than 9%. Phenytoin disposition in neonates and infants can be described satisfactorily by linear pharmacokinetics. The values of allometrically scaled clearance and volume were similar to adult values, suggesting no major kinetic differences between adults and infants on the basis of size alone. Postnatal age independently influenced clearance. Switching from enteral to intravenous routes may require a dosage adjustment. The results of this study provide a basis for more rational prescribing of phenytoin in infants and neonates.