Toward the unity of pathological and exertional fatigue: A predictive processing model.

Fatigue is a common experience in both health and disease. Yet, pathological (i.e., prolonged or chronic) and transient (i.e., exertional) fatigue symptoms are traditionally considered distinct, compounding a separation between interested research fields within the study of fatigue. Within the clinical neurosciences, nascent frameworks position pathological fatigue as a product of inference derived through hierarchical predictive processing. The metacognitive theory of dyshomeostasis (Stephan et al., 2016) states that pathological fatigue emerges from the metacognitive mechanism in which the detection of persistent mismatches between prior interoceptive predictions and ascending sensory evidence (i.e., prediction error) signals low evidence for internal generative models, which undermine an agent's feeling of mastery over the body and is thus experienced phenomenologically as fatigue. Although acute, transient subjective symptoms of exertional fatigue have also been associated with increasing interoceptive prediction error, the dynamic computations that underlie its development have not been clearly defined. Here, drawing on the metacognitive theory of dyshomeostasis, we extend this account to offer an explicit description of the development of fatigue during extended periods of (physical) exertion. Accordingly, it is proposed that a loss of certainty or confidence in control predictions in response to persistent detection of prediction error features as a common foundation for the conscious experience of both pathological and nonpathological fatigue.

Methodological issues with the assessment of voluntary activation using transcranial magnetic stimulation in the knee extensors.

PURPOSE: The assessment of voluntary activation of the knee extensors using transcranial magnetic stimulation (VATMS) is routinely performed to assess the supraspinal function. Yet methodological scrutiny of the technique is scarce. The aim of the present study was to examine face validity and reliability of VATMS and its two main determinants (superimposed twitch during a maximal voluntary contraction [SIT100%] and estimated resting twitch [ERT]). METHODS: SIT100%, ERT, and VATMS were measured on ten healthy males (age 24 ± 5 years) before and following intermittent isometric fatiguing exercise on two separate occasions. RESULTS: The findings indicated issues regarding the accuracy of ERT and suggested a three-point relationship should not be used to determine ERT. Reliabilities for VATMS, SIT100%, and ERT were acceptable pre- but much weaker post-exercise (especially for SIT100%). Despite statistically significant changes in main neuromuscular variables following the intermittent isometric fatiguing exercise (P < 0.05), when post-exercise reliability was considered, the exercise effect on VATMS was smaller than the smallest detectable change in 18 of the 20 individual tests performed, and for the whole sample for one of two visits. Finally, maximal voluntary contraction was reduced significantly following the neuromuscular assessment (NMA) pre-exercise but recovered during the NMA post-exercise. CONCLUSION: This is the first study to demonstrate a lack of sensitivity of key neuromuscular measurements to exercise and to evidence both presence of neuromuscular fatigue following the NMA in itself, and recovery of the neuromuscular function during the NMA post-exercise. These results challenge the face validity of this routinely used protocol.

Intermittent sprint performance in the heat is not altered by augmenting thermal perception via L-menthol or capsaicin mouth rinses.

PURPOSE: Cooling sensations elicited by mouth rinsing with L-menthol have been reported as ergogenic. Presently, responses to L-menthol mouth rinsing during intermittent sprint performance (ISP) in the heat are unknown and the impact of increased thermal perception on ISP via capsaicin has also not been quantified. This experiment aimed to identify whether eliciting cooling/warming sensations via L-menthol/capsaicin would alter ISP in the heat. METHOD: Fourteen participants (mass = 72 ± 9 kg, [Formula: see text] = 3.30 ± 0.90 L min-1), undertook four experimental trials, involving 40 min of ISP in hot conditions (40.2 ± 0.6 °C, 42 ± 2% R.H.) with mouth rinsing (25 mL, 6 s) at the protocol onset, and every 10 min thereafter. Cooling (0.01% L-menthol; MEN), warming (0.2% capsaicin; CAP), placebo (0.3 sham-CHO; PLA), and control (water; CON) mouth rinses were utilized. Performance was quantified via power (PP) and work done (WD) during sprints. Heart rate (HR), core (Trec) and skin (Tskin) temperature, perceived exertion (RPE), thermal sensation (Tsens), and comfort (Tcom) were measured at 10 min intervals. Sweat rate (whole-body sweat rate) was calculated from ∆mass. RESULT: PP reduced over time (P < 0.05); however, no change was observed between trials for PP or WD (P > 0.05). Tcom increased over time and was lower in MEN (2.7 ± 1.1; P < 0.05) with no difference between CAP (3.1 ± 1.2), PLA (3.2 ± 1.3) and CON (3.1 ± 1.3). RPE, Tsens HR, Trec, and Tskin increased over time (P < 0.05) with no between trial differences (P > 0.05). CONCLUSION: Despite improved thermal comfort via L-menthol, ISP did not improve. Capsaicin did not alter thermal perception or ISP. The reduction in ISP over time in hot conditions is not influenced by thermal perception.

Summary of the British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults.

Flexible bronchoscopy is an essential, established and expanding tool in respiratory medicine. Its practice, however, needs to be safe, effective and for the right indications to maximise clinical utility. This guideline is based on the best available evidence and is a revised update of the British Thoracic Society guideline on diagnostic flexible bronchoscopy.

Interactions between perceptions of fatigue, effort, and affect decrease knee extensor endurance performance following upper body motor activity, independent of changes in neuromuscular function.

Prior exercise has previously been shown to impair subsequent endurance performance in non-activated muscles. Declines in the neuromuscular function and altered perceptual/affective responses offer possible mechanisms through which endurance performance may be limited in these remote muscle groups. We thus conducted two experiments to better understand these performance-limiting mechanisms. In the first experiment, we examined the effect of prior handgrip exercise on the behavioral, perceptual, and affective responses to a sustained, sub-maximal contraction of the knee extensors. In the second experiment, transcranial magnetic stimulation was used to assess the neuromuscular function of the knee extensors before and after the handgrip exercise. The results of the first experiment demonstrated prior handgrip exercise increased the perceptions of effort and reduced affective valence during the subsequent knee extensor endurance exercise. Both effort and affect were associated with endurance performance. Subjective ratings of fatigue were also increased by the preceding handgrip exercise but were not directly related to knee extensor endurance performance. However, perceptions of fatigue were correlated with heightened effort perception and reduced affect during the knee extensor contraction. In the second experiment, prior handgrip exercise did not significantly alter the neuromuscular function of the knee extensors. The findings of the present study indicate that motor performance in the lower limbs following demanding exercise in the upper body appears to be regulated by complex, cognitive-emotional interactions, which may emerge independent of altered neuromuscular function. Subjective fatigue states are implicated in the control of perceptual and affective processes responsible for the regulation of endurance performance.

Walking modality, but not task difficulty, influences the control of dual-task walking.

During dual-task gait, changes in the stride-to-stride variability of stride time (STV) are suggested to represent the allocation of cognitive control to walking [1]. However, contrasting effects have been reported for overground and treadmill walking, which may be due to differences in the relative difficulty of the dual task. Here we compared the effect of overground and treadmill dual-task walking on STV in 18 healthy adults. Participants walked overground and on a treadmill for 120s during single-task (walking only) and dual-task (walking whilst performing serial subtractions in sevens) conditions. Dual-task effects on STV, cognitive task (serial subtraction) performance and perceived task difficulty were compared between walking modalities. STV was increased during overground dual-task walking, but was unchanged during treadmill dual-task walking. There were no differences in cognitive task performance or perceived task difficulty. These results show that gait is controlled differently during overground and treadmill dual-task walking. However, these differences are not solely due to differences in task difficulty, and may instead represent modality dependent control strategies.

State-of-the-art: Radiological investigation of pleural disease.

Pleural disease is common. Radiological investigation of pleural effusion, thickening, masses, and pneumothorax is key in diagnosing and determining management. Conventional chest radiograph (CXR) remains as the initial investigation of choice for patients with suspected pleural disease. When abnormalities are detected, thoracic ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) can each play important roles in further investigation, but appropriate modality selection is critical. US adds significant value in the identification of pleural fluid and pleural nodularity, guiding pleural procedures and, increasingly, as "point of care" assessment for pneumothorax, but is highly operator dependent. CT scan is the modality of choice for further assessment of pleural disease: Characterising pleural thickening, some pleural effusions and demonstration of homogeneity of pleural masses and areas of fatty attenuation or calcification. MRI has specific utility for soft tissue abnormalities and may have a role for younger patients requiring follow-up serial imaging. MRI and PET/CT may provide additional information in malignant pleural disease regarding prognosis and response to therapy. This article summarises existing techniques, highlighting the benefits and applications of these different imaging modalities and provides an up to date review of the evidence.

Conditions under which chlordiazepoxide influences gustatory contrast.

Rats shifted from 32% sucrose to 4% sucrose consumed less 4% than animals without prior experience with 32% sucrose. The influence of chlordiazepoxide (CDP) on this successive negative contrast obtained in sucrose ingestion was investigated in four experiments. The results indicated that (1) rats injected with CDP during both preshift experience with 32% sucrose and post-shift experience with 4% sucrose showed an essentially unchanged contrast effect compared with saline-injected rats, (2) CDP injection for the first time on post-shift day 2 eliminated contrast but post-shift day 1 injections had little effect, (3) animals injected with CDP throughout preshift and switched to saline coincident with the sucrose shift showed a contrast effect at least as great as control animals, and (4) injections of CDP tended to elevate lick rate regardless of other conditions. These results indicate a disinhibitory effect of CDP and possible neophobia operating on the first post-shift day.

The value of Modified Early Warning Score (MEWS) in surgical in-patients: a prospective observational study.

INTRODUCTION: The Modified Early Warning Score (MEWS) is a simple, physiological score that may allow improvement in the quality and safety of management provided to surgical ward patients. The primary purpose is to prevent delay in intervention or transfer of critically ill patients. PATIENTS AND METHODS: A total of 334 consecutive ward patients were prospectively studied. MEWS were recorded on all patients and the primary end-point was transfer to ITU or HDU. RESULTS: Fifty-seven (17%) ward patients triggered the call-out algorithm by scoring four or more on MEWS. Emergency patients were more likely to trigger the system than elective patients. Sixteen (5% of the total) patients were admitted to the ITU or HDU. MEWS with a threshold of four or more was 75% sensitive and 83% specific for patients who required transfer to ITU or HDU. CONCLUSIONS: The MEWS in association with a call-out algorithm is a useful and appropriate risk-management tool that should be implemented for all surgical in-patients.

Illusory continuity of tonal and infratonal periodic sounds.

Temporal induction can restore masked or obliterated portions of signals so that tones may seem continuous when alternated with sounds having appropriate spectral composition and intensity. The upper intensity limits for the induction of tones (pulsation thresholds) are related to masking functions and have been used to define the characteristics of frequency domain (place) analysis of tones. The present study has found that induction also occurs for infratonal periodic sounds that require a time domain analysis for perception of acoustic repetition. Limits for temporal induction were determined for iterated frozen noise segments from 10-2000 Hz alternated with a louder on-line noise. Masked thresholds were also obtained for the pulsed signals presented along with continuous noise, and it was found that the relation between induction limits and masking changed with frequency. The results obtained for induction and masking are discussed in terms of general principles governing restoration of obliterated sounds.