Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: known knowns and known unknowns.

The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD) updates the KDIGO 2012 guideline and has been developed with patient partners, clinicians, and researchers around the world, using robust methodology. This update, based on a substantially broader base of evidence than has previously been available, reflects an exciting time in nephrology. New therapies and strategies have been tested in large and diverse populations that help to inform care; however, this guideline is not intended for people receiving dialysis nor those who have a kidney transplant. The document is sensitive to international considerations, CKD across the lifespan, and discusses special considerations in implementation. The scope includes chapters dedicated to the evaluation and risk assessment of people with CKD, management to delay CKD progression and its complications, medication management and drug stewardship in CKD, and optimal models of CKD care. Treatment approaches and actionable guideline recommendations are based on systematic reviews of relevant studies and appraisal of the quality of the evidence and the strength of recommendations which followed the "Grading of Recommendations Assessment, Development, and Evaluation" (GRADE) approach. The limitations of the evidence are discussed. The guideline also provides practice points, which serve to direct clinical care or activities for which a systematic review was not conducted, and it includes useful infographics and describes an important research agenda for the future. It targets a broad audience of people with CKD and their healthcare, while being mindful of implications for policy and payment.

Standardization and other approaches to meta-analyze differences in means.

Meta-analysts often use standardized mean differences (SMD) to combine mean effects from studies in which the dependent variable has been measured with different instruments or scales. In this tutorial we show how the SMD is properly calculated as the difference in means divided by a between-subject reference-group, control-group, or pooled pre-intervention SD, usually free of measurement error. When combining mean effects from controlled trials and crossovers, most meta-analysts have divided by either the pooled SD of change scores, the pooled SD of post-intervention scores, or the pooled SD of pre- and post-intervention scores, resulting in SMDs that are biased and difficult to interpret. The frequent use of such inappropriate standardizing SDs by meta-analysts in three medical journals we surveyed is due to misleading advice in peer-reviewed publications and meta-analysis packages. Even with an appropriate standardizing SD, meta-analysis of SMDs increases heterogeneity artifactually via differences in the standardizing SD between settings. Furthermore, the usual magnitude thresholds for standardized mean effects are not thresholds for clinically important differences. We therefore explain how to use other approaches to combining mean effects of disparate measures: log transformation of factor effects (response ratios) and of percent effects converted to factors; rescaling of psychometrics to percent of maximum range; and rescaling with minimum clinically important differences. In the absence of clinically important differences, we explain how standardization after meta-analysis with appropriately transformed or rescaled pre-intervention SDs can be used to assess magnitudes of a meta-analyzed mean effect in different settings.

Accuracy of flight time and countermovement-jump height estimated from videos at different frame rates with MyJump.

Recent improvements in smartphone video technology may provide sufficient accuracy for estimation of jump height via flight time determined from video recordings of vertical-jump tests. The aim of this study is to evaluate the accuracy of jump height estimated from videos at different frame rates. High-definition videos of 10 young adults (6 males, 4 females) performing 5 countermovement jumps were recorded at a frame rate of 1000 Hz and transcoded to frame rates of 120, 240, and 480 Hz. Flight time in the videos was assessed independently by three observers at each of the four frame rates with MyJump. Flight time and jump height were analyzed with mixed models for estimation of means and of standard deviations representing technical error of measurement (free of within-subject jump-to-jump variability) at each frame rate. The four frame rates and three observers produced practically identical estimates of mean jump height. The technical errors at 120, 240, 480 and 1000 Hz were respectively 3.4, 1.8, 1.2 and 0.8 ms for flight time, and 1.4%, 0.7%, 0.5% and 0.3% for jump height. Assessed relative to either differences in jump height between elite football players (standard deviation of ~12%) or the smallest expected test-retest variability (typical error of ~3%), the technical error was substantial at 120 Hz but negligible at 240 Hz or higher. In conclusion, use of frame rates above 240 Hz to estimate jump height with MyJump will not improve accuracy substantially.

The Effectiveness of Psychological Workshops for Coaches on Well-Being and Psychomotor Performance of Children Practicing Football and Gymnastics.

Coach workshops based on seven principles (inspiration, explanation, expectation, support, reward, appreciation, growth and winning) enhance the sport experience of adult athletes. Therefore, we have investigated the effects of such workshops with coaches of child athletes. Study participants were coaches of 57 9- to 12-year old girls (practicing gymnastics) and boys (practicing football). Three coaches of 28 children attended three workshops over 12 weeks, while a control group of 5 coaches of 29 children attended no workshops. Measures of well-being and psychomotor performance were taken on the children before and after the intervention; differences in mean changes between intervention and control groups were adjusted for baseline, standardized, and assessed with a conservative magnitude-based decision method. There were clear substantial effects of the workshop on motivation averaged across several dimensions (girls, large, most likely beneficial), on a decision test (boys, small-moderate, very likely beneficial), on state anxiety self-reflection (girls, moderate, likely harmful), and on reaction time (boys, small, possibly harmful). The beneficial effects of the workshop in this pilot study are encouraging, but the unclear and potentially harmful effects and the roles of presenter- and coach-specific effects need to be investigated further with a representative sample of coaches and more children before the workshop is recommended for implementation.

Pacing Profiles and Competitive Performance of Elite Female 400-m Freestyle Swimmers.

Lipinska, P, and Hopkins, WG. Pacing profiles and competitive performance of elite female 400-m freestyle swimmers. J Strength Cond Res 34(1): 218-224, 2020-Pacing can impact competitive endurance performance. The objective of this study was to determine relationships between pacing parameters and competitive performance of elite female 400-m freestyle swimmers. Publicly available websites provided 50-m split and final times for 381 swims of 20 elite female swimmers in over 150 national and international competitions between 2004 and 2016. Most pacing profiles displayed negative quadratic curvature, with the fifth of the 8 laps being the median slowest. The mean times for the first and last laps were faster than predicted by the quadratic by 5.6 and 1.9%, respectively, and lap-to-lap variability was 0.65%. Scatter plots of each swimmer's final time often showed no obvious relationships with their pacing parameters, suggesting that swimmers compensated for changes in one parameter with changes in another. However, some plots showed a U shape or linear trend that allowed tentative identification of optimum values of the pacing parameters. In these plots, it was apparent that about half the swimmers might make small to moderate improvements (up to ∼1%) by changing the slope or curvature of their pacing profile or by changing time in the first or last laps. This approach for characterizing pacing profiles to identify possible improvements might be appropriate to assess pacing in other sports with multiple laps, frequent competitions, and relatively constant environmental conditions.

Maximal Upper-Body Strength and Oxygen Uptake Are Associated With Performance in High-Level 200-m Sprint Kayakers.

Pickett, CW, Nosaka, K, Zois, J, Hopkins, WG, and Blazevich, AJ. Maximal upper-body strength and oxygen uptake are associated with performance in high-level 200-m sprint kayakers. J Strength Cond Res 32(11): 3186-3192, 2018-Current training and monitoring methods in sprint kayaking are based on the premise that upper-body muscular strength and aerobic power are both important for performance, but limited evidence exists to support this premise in high-level athletes. Relationships between measures of strength, maximal oxygen uptake (V[Combining Dot Above]O2max), and 200-m race times in kayakers competing at national-to-international levels were examined. Data collected from Australian Canoeing training camps and competitions for 7 elite, 7 national, and 8 club-level male sprint kayakers were analyzed for relationships between maximal isoinertial strength (3 repetition maximum bench press, bench row, chin-up, and deadlift), V[Combining Dot Above]O2max on a kayak ergometer, and 200-m race time. Correlations between race time and bench press, bench row, chin-up, and V[Combining Dot Above]O2max were -0.80, -0.76, -0.73, -0.02, and 0.71, respectively (90% confidence limits ∼±0.17). The multiple correlation coefficient for 200-m race time with bench press and V[Combining Dot Above]O2max was 0.84. Errors in prediction of 200-m race time in regression analyses were extremely large (∼4%) in relation to the smallest important change of 0.3%. However, from the slopes of the regressions, the smallest important change could be achieved with a 1.4% (±0.5%) change in bench-press strength and a 0.9% (±0.5%) change in V[Combining Dot Above]O2max. Substantial relationships were found between upper-body strength or aerobic power and 200-m performances. These measures may not accurately predict individual performance times, but would be practicable for talent identification purposes. Training aimed at improving upper-body strength or aerobic power in lower performing athletes could also enhance the performance in 200-m kayak sprints.

Importance of Standardized DXA Protocol for Assessing Physique Changes in Athletes.

PURPOSE: The implications of undertaking DXA scans using best practice protocols (subjects fasted and rested) or a less precise but more practical protocol in assessing chronic changes in body composition following training and a specialized recovery technique were investigated. METHODS: Twenty-one male cyclists completed an overload training program, in which they were randomized to four sessions per week of either cold water immersion therapy or control groups. Whole-body DXA scans were undertaken with best practice protocol (Best) or random activity protocol (Random) at baseline, after 3 weeks of overload training, and after a 2-week taper. Magnitudes of changes in total, lean and fat mass from baseline-overload, overload-taper and baseline-taper were assessed by standardization (Δmean/SD). RESULTS: The standard deviations of change scores for total and fat-free soft tissue mass (FFST) from Random scans (2-3%) were approximately double those observed in the Best (1-2%), owing to extra random errors associated with Random scans at baseline. There was little difference in change scores for fat mass. The effect of cold water immersion therapy on baseline-taper changes in FFST was possibly harmful (-0.7%; 90% confidence limits ±1.2%) with Best scans but unclear with Random scans (0.9%; ±2.0%). Both protocols gave similar possibly harmful effects of cold water immersion therapy on changes in fat mass (6.9%; ±13.5% and 5.5%; ±14.3%, respectively). CONCLUSIONS: An interesting effect of cold water immersion therapy on training-induced changes in body composition might have been missed with a less precise scanning protocol. DXA scans should be undertaken with Best.

Comparison of Activity Profiles and Physiological Demands Between International Rugby Sevens Matches and Training.

The specificity of contemporary training practices of international rugby sevens players is unknown. We quantified the positional group-specific activity profiles and physiological demands of on-field training activities and compared these with match demands. Twenty-two international matches and 63 rugby-specific training drills were monitored in 25 backs and 17 forwards from a national squad of male rugby sevens players over a 21-month period. Drills were classified into 3 categories: low-intensity skill refining (n = 23 drills, 560 observations), moderate- to high-intensity skill refining (n = 28 drills, 600 observations), and game simulation (n = 12 drills, 365 observations). Movement patterns (via Global Positioning System devices) and physiological load (via heart rate monitors) were recorded for all activities, and the differences between training and matches were quantified using magnitude-based inferential statistics. Distance covered in total and at ≥3.5 m·s, maximal velocity, and frequency of accelerations and decelerations were lower for forwards during competition compared with those for backs by a small but practically important magnitude. No clear positional group differences were observed for physiological load during matches. Training demands exceeded match demands only for frequency of decelerations of forwards during moderate- to high-intensity skill-refining drills and only by a small amount. Accelerations and distance covered at ≥6 m·s were closer to match values for forwards than for backs during all training activities, but training drills consistently fell below the demands of international competition. Coaches could therefore improve physical and physiological specificity by increasing the movement demands and intensity of training drills.

Multi-omic integrated networks connect DNA methylation and miRNA with skeletal muscle plasticity to chronic exercise in Type 2 diabetic obesity.

Epigenomic regulation of the transcriptome by DNA methylation and posttranscriptional gene silencing by miRNAs are potential environmental modulators of skeletal muscle plasticity to chronic exercise in healthy and diseased populations. We utilized transcriptome networks to connect exercise-induced differential methylation and miRNA with functional skeletal muscle plasticity. Biopsies of the vastus lateralis were collected from middle-aged Polynesian men and women with morbid obesity (44 kg/m(2) ± 10) and Type 2 diabetes before and following 16 wk of resistance (n = 9) or endurance training (n = 8). Longitudinal transcriptome, methylome, and microRNA (miRNA) responses were obtained via microarray, filtered by novel effect-size based false discovery rate probe selection preceding bioinformatic interrogation. Metabolic and microvascular transcriptome topology dominated the network landscape following endurance exercise. Lipid and glucose metabolism modules were connected to: microRNA (miR)-29a; promoter region hypomethylation of nuclear receptor factor (NRF1) and fatty acid transporter (SLC27A4), and hypermethylation of fatty acid synthase, and to exon hypomethylation of 6-phosphofructo-2-kinase and Ser/Thr protein kinase. Directional change in the endurance networks was validated by lower intramyocellular lipid, increased capillarity, GLUT4, hexokinase, and mitochondrial enzyme activity and proteome. Resistance training also lowered lipid and increased enzyme activity and caused GLUT4 promoter hypomethylation; however, training was inconsequential to GLUT4, capillarity, and metabolic transcriptome. miR-195 connected to negative regulation of vascular development. To conclude, integrated molecular network modelling revealed differential DNA methylation and miRNA expression changes occur in skeletal muscle in response to chronic exercise training that are most pronounced with endurance training and topographically associated with functional metabolic and microvascular plasticity relevant to diabetes rehabilitation.

Adjustment of measures of strength and power in youth male athletes differing in body mass and maturation.

Adjustment for body mass and maturation of strength, power, and velocity measures of young athletes is important for talent development. Seventy-four youth male athletes performed a ballistic leg press test at five loads relative to body mass. The data were analyzed in maturity groups based on years from peak height velocity: -2.5 to -0.9 y (n = 29); -1.0 to 0.4 y (n = 28); and 0.5 to 2.0 y (n = 16). Allometric scaling factors representing percent difference in performance per percent difference in body mass were derived by linear regression of log-transformed variables, which also permitted adjustment of performance for body mass. Standardized differences between groups were assessed via magnitude-based inference. Strength and power measures showed a greater dependency on body mass than velocity-related variables (scaling factors of 0.56-0.85 vs. 0.42-0.14%/%), but even after adjustment for body mass most differences in strength and power were substantial (7-44%). In conclusion, increases in strength and power with maturation are due only partly to increases in body mass. Such increases, along with appropriate adjustment for body mass, need to be taken into account when comparing performance of maturing athletes.

A 1-year follow-up of effects of exercise programs on well-being in older adults.

PURPOSE: The purpose of this study was to investigate the long-term effects of three types of training on wellbeing and frequency of physical activity and to determine whether preintervention motivation moderates the effects. METHODS: Sixty-two older adults (M = 75 years old, SD = 5; 61% women) completed 4-mo programs of endurance, functional or strength training, with reassessment of well-being (life satisfaction, positive affect, negative affect, vitality) and physical activity 12 mo later. RESULTS: All groups showed small improvements in most measures of well-being at 4 mo. At follow-up, endurance training still had small beneficial effects, while changes with functional and strength training were generally trivial or harmful. Analysis for moderators indicated that autonomously motivated individuals better maintained gains in well-being and had higher frequencies of physical activity at follow-up compared with controlled individuals. CONCLUSION: Endurance training is recommended for older adults, but the long-term outcomes depend on the individual's motivational regulation at commencement.

Assessing the variation in the load that produces maximal upper-body power.

Substantial variation in the load that produces maximal power has been reported. It has been suggested that the variation observed may be due to differences in subjects' physical characteristics. Therefore, the aim of this study was to determine the extent in which anthropometric measures correlate with the load that produces maximal power. Anthropometric measures (upper-arm length, forearm length, total arm length, and upper-arm girth) and bench press strength were assessed in 26 professional rugby union players. Peak power was then determined in the bench press throw exercise using loads of 20-60% of one repetition maximum (1RM) in the bench press exercise. Maximal power occurred at 30 ± 14% 1RM (mean ± SD). Upper-arm length had the highest correlation with the load maximizing power: -0.61 (90% confidence limits -0.35 to -0.78), implying loads of 22 vs. 38% 1RM maximize power for players with typically long vs. short upper-arm length. Correlations for forearm length, total arm length, and upper-arm girth to the load that maximized power were -0.29 (0.04 to -0.57), -0.56 (-0.28 to -0.75), and -0.29 (0.04 to -0.57), respectively. The relationship between 1RM and the load that produced maximal power was r = -0.23 (0.10 to -0.52). The between-subject variation in the load that maximized power observed (SD = ±14% of 1RM) may have been due to differences in anthropometric characteristics, and absolute strength and power outputs. Indeed, athletes with longer limbs and larger girths and greater maximal strength and power outputs used a lower percentage of 1RM loads to achieve maximum power. Therefore, we recommend individual assessment of the load that maximizes power output.

From model to molecules: the development and experimental manipulation of an in vivo contaminated extremity war wound.

Wound infection is a key determinant of outcome in survivors of armed conflict. One factor having potential for promoting healing, decreasing bacterial burden and influencing prognosis is the dressing that covers the ballistic-injured extremity. Although antiseptic and silver dressings are applied to acute wounds, evidence to support their use is scarce with no controlled studies reported of antimicrobial wound dressings in extremity trauma. Given the recent burden of ballistic extremity injury, the requirement to investigate the role of antimicrobial dressings in contaminated wounds is transparent. This paper details a programme of work undertaken at the Defence Science and Technology Laboratory of developing and trialling a recovery model to investigate the early management of contaminated war wounds. A New Zealand White rabbit flexor carpi ulnaris muscle belly, isolated and then injured by a drop rig mechanism, was contaminated with Staphylococcus aureus to provide a reproducible contaminated muscle wound. This model was developed to support a series of randomised controlled trials to determine the impact of antimicrobial dressings on decreasing the bacterial burden of combat related extremity wounds. The results of the initial trial indicated that over a 48-h period, dressings augmented with antiseptic or silver offer no advantage over saline-soaked gauze in reducing the bacterial burden of a contaminated soft tissue injury. The model has subsequently been used to investigate the efficacy of dressings over a 7-day study period and impact of antibiotics and to evaluate biofilm formation and wound cytokines.

Performance indicators related to points scoring and winning in international rugby sevens.

Identification of performance indicators related to scoring points and winning is needed to inform tactical approaches to international rugby sevens competition. The aim of this study was to characterize team performance indicators in international rugby sevens and quantify their relationship with a team's points scored and probability of winning. Performance indicators of each team during 196 matches of the 2011/2012 International Rugby Board Sevens World Series were modeled for their linear relationships with points scored and likelihood of winning within (changes in team values from match to match) and between (differences between team values averaged over all matches) teams. Relationships were evaluated as the change and difference in points and probability of winning associated with a two within- and between-team standard deviations increase in performance indicator values. Inferences about relationships were assessed using a smallest meaningful difference of one point and a 10% probability of a team changing the outcome of a close match. All indicators exhibited high within-team match-to-match variability (intraclass correlation coefficients ranged from 0.00 to 0.23). Excluding indicators representing points-scoring actions or events occurring on average less than once per match, 13 of 17 indicators had substantial clear within-team relationships with points scored and/or likelihood of victory. Relationships between teams were generally similar in magnitude but unclear. Tactics that increase points scoring and likelihood of winning should be based on greater ball possession, fewer rucks, mauls, turnovers, penalties and free kicks, and limited passing. Key pointsSuccessful international rugby sevens teams tend to maintain ball possession; more frequently avoid taking the ball into contact; concede fewer turnovers, penalties and free kicks; retain possession in scrums, rucks and mauls; and limit passing the ball.Selected performance indicators may be used to evaluate team performances and plan more effective tactical approaches to competition.There is greater match-to-match variability in performance indicator values within than between international rugby sevens teams.The priorities for a rugby sevens team's technical and tactical preparation should reflect the magnitudes of the relationships between performance indicators, points scoring and the likelihood of winning.

Quantifying Offense and Defense Workloads in Professional Rugby Union.

PURPOSE: Rugby union is a contact team sport demanding high levels of physical capacity, and understanding the match workloads can be useful to inform training. In this study, the factors influencing locomotion and contact workloads for offensive and defensive ball-in-play periods are quantified. METHODS: Locomotion and contact metrics were collected from global positioning system units and videos for 31 professional players of a Super Rugby team across 14 games in the 2021 season. Data were analyzed with a generalized mixed-model procedure that included effects for type of play, playing position, match outcome, and ball-in-play time. Magnitudes were assessed with standardization, and evidence for substantial magnitudes was derived from sampling uncertainty. RESULTS: When offense was compared to defense, most metrics showed decisively substantial increases (small to moderate) for forwards and backs. There was decisive evidence that locomotion metrics were substantially lower (large differences) and contact metrics were higher (very large differences) when comparing forwards to backs on offense and defense. When winning was compared to losing, there was good evidence that forwards experienced small increases in overall workload on defense, and backs experienced a small increase in high-speed running and a moderate decrease in contacts on offense. Match-to-match changes associated with ball-in-play time, attributed to fatigue, were decisive (moderate to very large) across most metrics for forwards and backs in offense and defense. CONCLUSIONS: The increased locomotion and contact workloads in offensive periods and the differing physical requirements between positions and match outcomes for both types of play are novel findings that should aid practitioners in designing effective training.

Exploration of collective tactical variables in elite netball: An analysis of team and sub-group positioning behaviours.

Collective tactical behaviours are aspects of player interactions that are particularly important in netball, due to its unique restrictions on player movement (players unable to move when in possession of the ball and positional spatial restrictions). The aim of this study was to explore variables representing collective tactical behaviours in netball. A local positioning system provided player positions of one team throughout seven elite-level netball matches. The positions were analysed to provide mean, variability (standard deviation) and irregularity (normalised approximate entropy) for each attack and defence possession (470 and 423, respectively) for the team and positional subgroups (forwards, midcourts and defenders) for 10 position-related variables. Correlational analyses showed collective tactical variables could be grouped as lateral and longitudinal dispersion variables. The variables were each analysed after log transformation with a linear mixed model to compare attack and defence and to estimate standardised effects on attack and defence of possession outcome, possession duration, score difference, match time, opposition strength and season time. During attack, the team and all sub-groups adopted greater lateral dispersion between players, while on defence there was generally greater longitudinal dispersion. The team also showed increased longitudinal dispersion when home and opposition possessions ended in a score. Additionally, greater irregularity was observed in active sub-groups (forwards on attack, defenders on defence). Score difference and opposition strength had trivial-small but generally unclear effects. In conclusion, these effects show that analysis of player positions on attack and defence is a promising avenue for coaches and analysts to modify collective tactical behaviours in netball.

Differences and changes in the physical characteristics of professional and amateur rugby union players.

Numerous studies have highlighted differences between playing levels and positions in rugby union; however, few studies have investigated longitudinal progressions of body composition and physical performance. Between-player differences and within-player changes in body composition, strength, power, speed, and repeated sprint ability, from 1,161 New Zealand rugby union players from 2004 to 2007, were estimated using a mixed modeling procedure. Props had the highest mass, percent body fat, strength, and slowest speed times compared with the other positions, whereas outside backs had the fastest speed time and lowest percent body fat. For most measures, there were small-to-moderate differences (range, 1.1-14%) between players selected and not selected for provincial teams and small-to-large differences (range, 1.8-15%) between provincial and Super Rugby (professional) players. The faster 20-m sprint times in international compared with Super Rugby players was small in magnitude for both the forwards (1.9%) and backs (2.2%). The average annual improvements were small to moderate for strength (range, 2.1-15%) and small for repeated sprint ability within the lower playing levels (~1.5%). Small increases occurred in lower body strength (~7.0%) as players moved from Super Rugby to provincial competition. Small decreases in sprint time (~1.6%) and small increases in strength (~6.3%) occurred as players moved from Super Rugby to midyear international competition. The differences between levels in performance provide level-specific characteristics from Super Rugby and below, but international players may be selected because of greater skill and experience. Changes in physical performance between competitions may be a result of reduced training loads because of regular high-intensity matches and greater travel involved in the Super Rugby competition.

Monitoring Changes in Lower-Limb Strength and Power in Elite Athletes With the Countermovement-Jump and Keiser Leg-Press Tests.

PURPOSE: To determine the utility of countermovement-jump and Keiser leg-press tests for tracking changes in elite athletes of different sports. METHODS: Elite athletes of the Norwegian Olympic Federation (126 individuals from 18 sports) performed countermovement-jump and Keiser tests on 2 to 11 occasions between 2014 and 2021. Separate analyses were performed for male and female alpine skiing, male and female handball, male ice hockey, and males and females of other sports. Means and standard deviations of consecutive change scores were combined with short-term error of measurement (3.7%-7.0%) and smallest important changes (2.0%-3.6%, defined by standardization) to determine the proportions of athletes who experienced decisive changes in 2 senses: first, the athlete did not get substantially worse or better (>90% chance of either), and second, the athlete did get substantially worse or better (>90% chance of either). RESULTS: Averaged over sports, Keiser peak power and relative peak power had the highest proportions of decisive changes in the first (60% and 55%) and second senses (25% and 28%). The velocity intercept of the force-velocity relationship had the lowest proportions in the first and second senses (29% and 11%), while jump height, Keiser mean power, relative mean power, the force intercept, and the slope of the force-velocity relationship had similar proportions (40%-53% and 15%-21%). CONCLUSIONS: With the possible exception of the Keiser test velocity intercept, the proportions of observed decisive changes in elite athletes using Keiser measures and countermovement-jump height between tests appear adequate for the measures to be useful for routine monitoring.

Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic: a systematic review and meta-analysis.

BACKGROUND: There is a lack of consensus about the effect of the COVID-19 pandemic on the mental health of children and adolescents. We aimed to compare rates of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation during the pandemic with those before the pandemic. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO for studies published between Jan 1, 2020, and Dec 19, 2022. Studies published in English with data on paediatric (ie, those aged <19 years) emergency department visits before and during the COVID-19 pandemic were included. Case studies and qualitative analyses were excluded. Changes in attempted suicide, self-harm, suicidal ideation, and other mental-illness indicators (eg, anxiety, depression, and psychosis) were expressed as ratios of the rates of emergency department visits during the pandemic compared with those before the pandemic, and we analysed these with a random-effects meta-analysis. This study was registered with PROSPERO, CRD42022341897. FINDINGS: 10 360 non-duplicate records were retrieved, which yielded 42 relevant studies (with 130 sample-estimates) representing 11·1 million emergency department visits for all indications of children and adolescents across 18 countries. The mean age of the samples of children and adolescents across studies was 11·7 years (SD 3·1, range 5·5-16·3), and there were on average 57·6% girls and 43·4% boys as a proportion of emergency department visits for any health reasons (ie, physical and mental). Only one study had data related to race or ethnicity. There was good evidence of an increase in emergency department visits for attempted suicide during the pandemic (rate ratio 1·22, 90% CI 1·08-1·37), modest evidence of an increase in emergency department visits for suicidal ideation (1·08, 0·93-1·25), and good evidence for only a slight change in self-harm (0·96, 0·89-1·04). Rates of emergency department visits for other mental-illness indications showed very good evidence of a decline (0·81, 0·74-0·89), and paediatric visits for all health indications showed strong evidence of a reduction (0·68, 0·62-0·75). When rates for attempted suicide and suicidal ideation were combined as a single measure, there was good evidence of an increase in emergency department visits among girls (1·39, 1·04-1·88) and only modest evidence of an increase among boys (1·06, 0·92-1·24). Self-harm among older children (mean age 16·3 years, range 13·0-16·3) showed good evidence of an increase (1·18, 1·00-1·39), but among younger children (mean age 9·0 years, range 5·5-12·0) there was modest evidence of a decrease (0·85, 0·70-1·05). INTERPRETATION: The integration of mental health support within community health and the education system-including promotion, prevention, early intervention, and treatment-is urgently needed to increase the reach of mental health support that can mitigate child and adolescent mental distress. In future pandemics, increased resourcing in some emergency department settings would help to address their expected increase in visits for acute mental distress among children and adolescents. FUNDING: None.