A systematic review of non-pharmacologic interventions to reduce anxiety in adults in advance of diagnostic imaging procedures.

OBJECTIVES: Anticipation of a diagnostic imaging (DI) procedure, particularly one involving advanced technology, can provoke feelings of anxiety in patients. Anxiolytics (anxiety reducing drugs) can be used to reduce pre-procedural anxiety in patients, however there are several known disadvantages to this approach. The aim of this systematic review was to identify and evaluate any preparatory non-pharmacological interventions used to reduce patient anxiety in advance of DI procedures. KEY FINDINGS: Database searches revealed twelve studies met the eligibility criteria and were included in the review. A narrative synthesis identified three intervention categories: patient information/education, cognitive strategies (i.e. guided imagery, breathing techniques, imaginative visualisation) and music therapy. CONCLUSION: The current review demonstrates that despite the existence of a number of studies providing some evidence for the effectiveness of a range of anxiety reducing interventions for patients prior to DI, the small number and overall low quality of studies identified makes it difficult to draw firm conclusions regarding the application of a specific intervention in clinical practice. IMPLICATIONS FOR PRACTICE: The majority of interventions included in this review were shown to be practical for inclusion in the clinical setting and did have some positive effect on patient anxiety levels. As a result those professionals working with adults undergoing advanced technology DI procedures may consider implementing some of the strategies that have been discussed within their practice.

The effects of bovine colostrum supplementation on in vivo immunity following prolonged exercise: a randomised controlled trial.

BACKGROUND: Bovine colostrum (COL) has been advocated as a nutritional countermeasure to exercise-induced immune dysfunction, but there is a lack of research with clinically relevant in vivo measures. AIM: To investigate the effects of COL supplementation on in vivo immunity following prolonged exercise using experimental contact hypersensitivity (CHS) with the novel antigen diphenylcyclopropenone (DPCP). METHODS: In a double-blind design, 31 men were randomly assigned to COL (20 g/day) or placebo (PLA) for 58 days. Participants ran for 2 h at 60% maximal aerobic capacity on day 28 and received a primary DPCP exposure (sensitisation) 20 min after. On day 56, participants received a low-dose-series DPCP challenge to elicit recall of in vivo immune-specific memory (quantified by skinfold thickness 24 and 48 h later). Analysis of the dose-response curves allowed determination of the minimum dose required to elicit a positive response (i.e., sensitivity). RESULTS: There was no difference in summed skinfold thickness responses between COL and PLA at 24 h (p = 0.124) and 48 h (p = 0.405). However, sensitivity of in vivo immune responsiveness was greater with COL at 24 h (p < 0.001) and 48 h (p = 0.023) with doses ~ twofold greater required to elicit a positive response in PLA. CONCLUSIONS: COL blunts the prolonged exercise-induced decrease in clinically relevant in vivo immune responsiveness to a novel antigen, which may be a mechanism for reduced illness reports observed in the previous studies. These findings also suggest that CHS sensitivity is highly relevant to host defence.

Assessment of the comparability of CLSI, EUCAST and Stokes antimicrobial susceptibility profiles for Escherichia coli uropathogenic isolates.

BACKGROUND: As many clinical laboratories convert between Stokes, Clinical and Laboratory Standards Institute (CLSI) and European Committee for Antimicrobial Susceptibility Testing (EUCAST) methods, the problem of comparing differently derived sets of antimicrobial susceptibility testing (AST) data with each other arises, owing to a scarcity of knowledge of inter-method comparability. The purpose of the current study was to determine the comparability of CLSI, EUCAST and Stokes AST methods for determining susceptibility of uropathogenic Escherichia coli to ampicillin, amoxicillin-clavulanate, trimethoprim, cephradine/cephalexin, ciprofloxacin and nitrofurantoin. METHODS: A total of 100 E. coli isolates were obtained from boric acid urine samples from patients attending GP surgeries. For EUCAST and CLSI, the Kirby-Bauer disc diffusion method was used and results interpreted using the respective breakpoint guidelines. For the Stokes method, direct susceptibility testing was performed on the urine samples. RESULTS: The lowest levels of agreement were for amoxicillin-clavulanate (60%) and ciprofloxacin (89%) between the three AST methods, when using 2017 interpretive guidelines for CLSI and EUCAST. A comparison of EUCAST and CLSI without Stokes showed 82% agreement for amoxicillin-clavulanate and 94% agreement for ciprofloxacin. Discrepancies were compounded by varying breakpoint susceptibility guidelines issued during the period 2011-2017, and through the inclusion of a definition of intermediate susceptibility in some cases. CONCLUSIONS: Our data indicate that the discrepancies generated through using different AST methods and different interpretive guidelines may result in confusion and inaccuracy when prescribing treatment for urinary tract infection.

Post-exercise hot water immersion induces heat acclimation and improves endurance exercise performance in the heat.

We examined whether daily hot water immersion (HWI) after exercise in temperate conditions induces heat acclimation and improves endurance performance in temperate and hot conditions. Seventeen non-heat-acclimatized males performed a 6-day intervention involving a daily treadmill run for 40 min at 65% V̇O2max in temperate conditions (18 °C) followed immediately by either HWI (N = 10; 40 °C) or thermoneutral (CON, N = 7; 34 °C) immersion for 40 min. Before and after the 6-day intervention, participants performed a treadmill run for 40 min at 65% V̇O2max followed by a 5-km treadmill time trial (TT) in temperate (18 °C, 40% humidity) and hot (33 °C, 40% humidity) conditions. HWI induced heat acclimation demonstrated by lower resting rectal temperature (Tre , mean, -0.27 °C, P < 0.01), and final Tre during submaximal exercise in 18 °C (-0.28 °C, P < 0.01) and 33 °C (-0.36 °C, P < 0.01). Skin temperature, Tre at sweating onset and RPE were lower during submaximal exercise in 18 °C and 33 °C after 6 days in HWI (P < 0.05). Physiological strain and thermal sensation were also lower during submaximal exercise in 33 °C after 6 days in HWI (P < 0.05). HWI improved TT performance in 33 °C (4.9%, P < 0.01) but not in 18 °C. Thermoregulatory measures and performance did not change in CON. Hot water immersion after exercise on 6 days presents a simple, practical, and effective heat acclimation strategy to improve endurance performance in the heat.

The impact of cortical remapping interventions on pain and disability in chronic low back pain: a systematic review.

BACKGROUND: Cortical change, in the manner of cortical remapping is a common feature of and potential driver for chronic low back pain (CLBP). Novel interventions such as graded motor imagery (GMI) and mirror visual feedback (MVF) have been shown to facilitate correction of cortical changes and improve symptoms in other chronic pain states. However, little is known regarding the effectiveness of these treatment approaches in CLBP. OBJECTIVE: To identify and assess the current evidence regarding the effectiveness of interventions which target cortical remapping in the management of CLBP. DATA SOURCES: The electronic databases Medline, Embase, CINAHL, AMED, OVID, PEDro, BNI, PsycINFO, HMIC, and Cochrane library were systematically searched. STUDY SELECTION: Of 11 potential citations identified, 5 articles were identified for inclusion and critiqued. These comprised 3 randomised controlled trials (RCTs), 1 randomised cross-over study, and 1 multiple case study design. RESULTS: Visualisation of lumbar movement may significantly improve movement-related pain severity and duration. A combined sensorimotor retraining approach has been shown to produce short-term improvements in both pain and disability outcomes in CLBP. The relative effectiveness of individual interventions and their long-term efficacy have yet to be established. CONCLUSIONS: There is a paucity of robust literature which has examined the application and efficacy of these novel treatments in the management of CLBP. Results from the few CLBP studies which are available are encouraging. Further, robust research is needed to optimise treatment protocols and establish their long-term effectiveness in CLBP.

From parallel policies to integrated practice: PMS and PCG/Ts.

This paper describes findings from an exploratory study of attempts by primary care clinicians and managers to utilize two distinct Government policy initiatives (the establishment of Primary Care Groups [PCGs] and Trusts [PCTs] and the establishment of Primary Medical Services [PMS] pilots) to promote innovation in primary care. The study purposively selected three whole PCG-PMS sites and one PCT-PMS site. A range of different qualitative methods were used to collect data. Although the data suggest that attempts to integrate the two policies produced impressive corporate innovation by practices working together to benefit patients in whole localities, the four sites shared features that would not necessarily be present in all PCG/Ts. These include a strong history of inter-practice working, mutually supportive relationships between clinicians and managers, and a carefully designed, managed and inclusive change process led by credible clinicians. The study has implications for the continuing implementation of both policies, especially in view of the increasing size of PCTs.

Effect of oral glutamine supplementation on human neutrophil lipopolysaccharide-stimulated degranulation following prolonged exercise.

Recent studies have shown that neutrophils can utilize glutamine and that glutamine supplementation can improve neutrophil function in postoperative and burn patients. The present study investigated the influence of oral glutamine supplementation on stimulated neutrophil degranulation and oxidative burst activity following prolonged exercise. Subjects, 7 well-trained men, reported to the laboratory following an overnight fast and cycled for 2 hrs at 60% VO2max on two occasions a week apart. They were randomly assigned to either a glutamine or placebo treatment. For both trials, subjects consumed a sugar-free lemon drink at 15-min intervals until 90 minutes, then a lemon flavored glutamine drink (GLN) or sugar-free lemon drink (PLA) was consumed at 15-min intervals for the remaining exercise and the 2-hr recovery period. Venous blood samples were taken pre-, during, and postexercise. Glutamine supplementation had no effect on the magnitude of postexercise leukocytosis, the plasma elastase concentration following exercise (which increased in both trials), or the plasma elastase release in response to bacterial stimulation (which fell in both trials). Neutrophil function assessed by oxidative burst activity of isolated cells did not change following exercise in either trial. These findings therefore suggest that the fall in plasma glutamine concentration does not account for the decrease in neutrophil function (degranulation response) following prolonged exercise.

The effects of carbohydrate supplementation on immune responses to a soccer-specific exercise protocol.

The aim of this study was to determine the effect of carbohydrate (CHO) versus placebo (PLA) beverage consumption on the immune and plasma cortisol responses to a soccer-specific exercise protocol in 8 university team soccer players. In a randomized, counterbalanced design, the players received carbohydrate or placebo beverages before, during and after two 90 min soccer-specific exercise bouts (3 days apart) designed to mimic the activities performed and the distance covered in a typical soccer match. Blood and saliva samples were collected before, during and after the exercise protocol. Plasma lactate concentration increased to approximately 4 mmol x l(-1) at 45 and 90 min of exercise in both treatments (P<0.01). Plasma glucose concentration was significantly lower after 90 min of exercise with ingestion of the placebo than the carbohydrate (PLA: 4.57+/-0.12 mmol x l(-1); CHO: 5.49+/-0.11 mmol x l(-1); P<0.01). The pattern of change in plasma cortisol, circulating lymphocyte count and saliva immunoglobulin A secretion did not differ between the carbohydrate and placebo trials. Blood neutrophil counts were 14% higher 1 h after the placebo trial than the carbohydrate trial (PLA: 4.8+/-0.5x10(9) cells x l(-1); CHO: 4.2+/-0.5x10(9) cells x l(-1); P = 0.06), but the treatment had no effect on the degranulation response of blood neutrophils stimulated by bacterial lipopolysaccharide. We conclude that, although previous studies have shown that carbohydrate feeding is effective in attenuating immune responses to prolonged continuous strenuous exercise, the same cannot be said for a soccer-specific intermittent exercise protocol. When overall exercise intensity is moderate, and changes in plasma glucose, cortisol and immune variables are relatively small, it would appear that carbohydrate ingestion has only a minimal influence on the immune response to exercise.

Nutritional aspects of immunosuppression in athletes.

The literature suggests that a heavy schedule of training and competition leads to immunosuppression in athletes, placing them at a greater risk of opportunistic infection. There are many factors which influence exercise-induced immunosuppression, and nutrition undoubtedly plays a critical role. Misinterpretation of published data and misleading media reports have lead many athletes to adopt an unbalanced dietary regimen in the belief that it holds the key to improved performance. Some sports have strict weight categories, whilst in others low body fat levels are considered to be necessary for optimal performance or seen as an aesthetic advantage. This leads some athletes to consume a diet extremely low in carbohydrate content which, whilst causing rapid weight loss, may have undesirable results which include placing the athlete at risk from several nutrient deficiencies. Complete avoidance of foods high in animal fat reduces the intake of protein and several fat-soluble vitamins. On the other hand, diets with a very high carbohydrate content are usually achieved at the expense of protein. In addition, anecdotal and media reports have often promoted the supposed performance benefits of certain vitamins and minerals, yet most athletes do not realise that micronutrient supplementation is only beneficial when correcting a deficiency, and to date there is little scientific evidence to substantiate claims that micronutrients act as an ergogenic aid. Moreover, excessive intakes of micronutrients can be toxic. Deficiencies or excesses of various dietary components can have a substantial impact on immune function and may further exacerbate the immunosuppression associated with heavy training loads. This review examines the role of nutrition in exercise-induced immunosuppression and the effect of both excessive and insufficient nutrient intake on immunocompetence. As much of the present literature concerning nutrition and immune function is based on studies with sedentary participants, the need for future research which directly investigates the relationship between exercise, training, immunity and nutrition is highlighted.

Glutamine, exercise and immune function. Links and possible mechanisms.

Glutamine is the most abundant free amino acid in human muscle and plasma and is utilised at high rates by rapidly dividing cells, including leucocytes, to provide energy and optimal conditions for nucleotide biosynthesis. As such, it is considered to be essential for proper immune function. During various catabolic states including surgical trauma, infection, starvation and prolonged exercise, glutamine homeostasis is placed under stress. Falls in the plasma glutamine level (normal range 500 to 750 mumol/L after an overnight fast) have been reported following endurance events and prolonged exercise. These levels remain unchanged or temporarily elevated after short term, high intensity exercise. Plasma glutamine has also been reported to fall in patients with untreated diabetes mellitus, in diet-induced metabolic acidosis and in the recovery period following high intensity intermittent exercise. Common factors among all these stress states are rises in the plasma concentrations of cortisol and glucagon and an increased tissue requirement for glutamine for gluconeogenesis. It is suggested that increased gluconeogenesis and associated increases in hepatic, gut and renal glutamine uptake account for the depletion of plasma glutamine in catabolic stress states, including prolonged exercise. The short term effects of exercise on the plasma glutamine level may be cumulative, since heavy training has been shown to result in low plasma glutamine levels (< 500 mumol/L) requiring long periods of recovery. Furthermore, athletes experiencing discomfort from the overtraining syndrome exhibit lower resting levels of plasma glutamine than active healthy controls. Therefore, physical activity directly affects the availability of glutamine to the leucocytes and thus may influence immune function. The utility of plasma glutamine level as a marker of overtraining has recently been highlighted, but a consensus has not yet been reached concerning the best method of determining the level. Since injury, infection, nutritional status and acute exercise can all influence plasma glutamine level, these factors must be controlled and/or taken into consideration if plasma glutamine is to prove a useful marker of impending overtraining.

A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain.

A number of treatments are widely prescribed for chronic back pain, but few have been rigorously evaluated. We examined the effectiveness of transcutaneous electrical nerve stimulation (TENS), a program of stretching exercises, or a combination of both for low back pain. Patients with chronic low back pain (median duration, 4.1 years) were randomly assigned to receive daily treatment with TENS (n = 36), sham TENS (n = 36), TENS plus a program of exercises (n = 37), or sham TENS plus exercises (n = 36). After one month no clinically or statistically significant treatment effect of TENS was found on any of 11 indicators of outcome measuring pain, function, and back flexion; there was no interactive effect of TENS with exercise. Overall improvement in pain indicators was 47 percent with TENS and 42 percent with sham TENS (P not significant). The 95 percent confidence intervals for group differences excluded a major clinical benefit of TENS for most outcomes. By contrast, after one month patients in the exercise groups had significant improvement in self-rated pain scores, reduction in the frequency of pain, and greater levels of activity as compared with patients in the groups that did not exercise. The mean reported improvement in pain scores was 52 percent in the exercise groups and 37 percent in the nonexercise groups (P = 0.02). Two months after the active intervention, however, most patients had discontinued the exercises, and the initial improvements were gone. We conclude that for patients with chronic low back pain, treatment with TENS is no more effective than treatment with a placebo, and TENS adds no apparent benefit to that of exercise alone.

Can trials of physical treatments be blinded? The example of transcutaneous electrical nerve stimulation for chronic pain.

Therapeutic trials often attempt to "blind" patient and investigator to the true nature of treatments received, reducing the influences of conscious or subconscious prejudices. In drug trials, this is accomplished with placebo tablets, but blinding in trials of physical treatments is more problematic. This issue arose in a clinical trial of transcutaneous electrical nerve stimulation (TENS) for patients with chronic low back pain. Several study design features were incorporated to promote blinding: use of sham TENS units visually identical with real units, exclusion of potential subjects with previous TENS experience, avoidance of a crossover design and use of identical visit frequency, instructions and modifications in electrode placement. Subjects were asked not to discuss treatments with the clinicians who performed outcome assessments. Both patients and clinicians were asked to guess actual treatment assignments at the trial's end. Every patient in the true TENS group believed the unit was functioning properly, but the degree of certainty varied. In the sham TENS group, 84% also believed they had functioning units, but their certainty was significantly less than in the active treatment group. Differences in patient perceptions did not affect compliance, as the two groups had similar dropout rates, appointment compliance, days of TENS use and daily duration of TENS use. Clinicians guessed treatments correctly 61% of the time (as opposed to 50% expected by chance), again suggesting partial success in blinding. These efforts at blinding may partly explain the negative trial results for TENS efficacy. We conclude that complete blinding is difficult to achieve because of sensory difference in treatment and unintended communication between patient and examiner.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic variability among chronic pain patients: implications for study design, interpretation, and reporting.

Chronic pain patients share many characteristics, but there is important prognostic variability among them. By selecting for certain characteristics, different recruitment methods and entry criteria for clinical or research programs may influence the likelihood of success regardless of treatment efficacy. This was demonstrated when subjects (n = 55) were recruited through lay publicity for a clinical trial of therapy for chronic back pain. In comparison to routine pain clinic patients (n=61), subjects in the clinical trial were better educated, were more often employed, had more favorable personality profiles, and were less likely to have had surgery or narcotic use (all p less than 0.004). Pain relief was significantly better for clinical trial subjects, apparently due to baseline prognostic differences rather than uniquely efficacious therapy. We conclude that chronic pain patients vary in prognostically important ways; that recruitment methods and criteria strongly influence these characteristics; and that greater attention to these details is needed when interpreting and reporting clinical research.