Embedding Child Rights Principles and Practises in Mega Sport Event Planning.

Recently, there has been growing concern about the lack of intentionality of mega sport event (MSE) organisers in ensuring that child rights are adequately respected, protected and promoted before, during, and after the events take place. In the context of the summer Olympic Games, reported child rights infringements have been on the rise, both in relation to abuse in sport itself and the negative consequences associated with planning and delivering the Games. In response to reports of child rights infringements, a coalition of actors, including non-governmental and civil society organisations have sought to pressure event owners and organisers to strengthen protections in the planning and delivery of their events. To date, however, child rights commitments have not been fully embedded in policies and principles guiding the planning and delivery of the Olympic Games. In this article, we explore the field of child rights in the context of the Olympic Games, focusing on a case study of the Tokyo 2020 edition. Drawing on documentary analysis and semi-structured interviews with Tokyo 2020 stakeholders and affiliates, detailed appraisal of the planning process was undertaken. Findings show that while the Japanese authorities have signed up to international child rights conventions and embedded some child participation strategies in Games-related activity, there was little evidence that Tokyo 2020 organisers had developed or implemented robust policies, principles or practises to respect, protect and promote child rights in Games planning. This absence, we argue, is because there was no requirement to embed child rights commitments during the bidding or planning phases, as the IOC had yet to enshrine human rights in its host city contract when the Games were first awarded to Tokyo. In conclusion, we argue that it is imperative the IOC embeds child rights principles and protocols in the bidding and planning processes to ensure that the risks to children are foregrounded and acted upon by host cities and their partners, elevating human rights to a position equal to other Games requirements. This study is of international significance as the evidence will aid future host city bidders to ensure children's rights are embedded in MSE policies for each nation.

Developing Evidence for Football (Soccer) Reminiscence Interventions Within Long-term Care: A Co-operative Approach Applied in Scotland and Spain.

Loneliness is a common experience within long-term care and, to promote well-being and quality of life among people with dementia, it is important to draw upon a repertoire of strategies that provide social stimulation, companionship, and enjoyment. This paper describes and reflects on a program of co-operative social participatory research that sought to introduce football-focused (ie, soccer-based) reminiscence based in 4 community settings within Spain and Scotland. Findings are reported and inform an original conceptual model that supports the introduction of sustainable approaches to the development of football-focused reminiscence with and for people with dementia.

Expectant parents' understanding of the implications and management of fever in the neonate.

OBJECTIVE: We estimated the extent to which Canadian expectant parents would seek medical care in a febrile neonate (age 30 days or less). We also evaluated expectant parents' knowledge of signs and symptoms of fever in a neonate, and explored the actions Canadian expectant parents would take to optimize the health of their child. METHODS: We conducted a cross-sectional survey of a sample of expectant parents from a large urban center in Canada. We recruited participants from waiting rooms in an obstetrical ultrasound clinic located in an urban tertiary care hospital in Montreal, Canada. We asked participants nine questions about fever in neonates including if, and how, they would seek care for their neonate if they suspected he/she were febrile. RESULTS: Among the 355 respondents, (response rate 87%) we found that 75% of parents reported that they would take their febrile neonate for immediate medical assessment, with nearly one fifth of the sample reporting that they would not seek medical care. We found no significant associations between the choice to seek medical care and expectant parents socio-demographic characteristics. CONCLUSIONS: Despite universal access to high quality health care in Canada, our study highlights concerning gaps in the knowledge of the care of the febrile infant in one fifth of expectant parents. Physicians and health providers should strive to provide early education to expectant parents about how to recognize signs of fever in the neonate and how best to seek medical care. This may improve neonatal health outcomes in Canada.

Quality assurance evaluation of a simple linear protocol for the treatment of impending status epilepticus in a pediatric emergency department 2 years postimplementation.

OBJECTIVE: To evaluate the efficacy and safety of a simple linear midazolam-based protocol for the management of impending status epilepticus in children up to 18 years of age. METHODS: This is a descriptive, quality assessment, retrospective chart review of children presenting with the chief complaint of seizure disorder in the emergency department (ED) of a tertiary care pediatric hospital and a triage category of resuscitation or urgent from April 1, 2009, to August 31, 2011. In children with at least one seizure episode in the ED treated according to the linear protocol, three main outcomes were assessed: compliance, effectiveness, and complications. RESULTS: Of the 128 children meeting the above study criteria, 68 had at least one seizure episode in the ED, and treatment was required to terminate at least one seizure episode in 46 of 68 patients (67.6%). Fifty-five seizure episodes were treated in the 46 patients: 51 of 55 seizure episodes were treated with midazolam (92.7%) and 4 of 55 with lorazepam or diazepam (7.3%). Of those treated with midazolam, 86.3% (44 of 51) were successfully treated with one or two doses of midazolam. The median seizure duration for all treated patients was 6 minutes. Of the 42 patients treated with midazolam, 7 required either continuous positive airway pressure or intubation, and two patients were treated for hypotension. One patient died of pneumococcal meningitis. CONCLUSION: This simple linear protocol is an effective and safe regimen for the treatment of impending status epilepticus in children.

Visibility of the urethral meatus and risk of urinary tract infections in uncircumcised boys.

BACKGROUND: Uncircumcised boys are at higher risk for urinary tract infections than circumcised boys. Whether this risk varies with the visibility of the urethral meatus is not known. Our aim was to determine whether there is a hierarchy of risk among uncircumcised boys whose urethral meatuses are visible to differing degrees. METHODS: We conducted a prospective cross-sectional study in one pediatric emergency department. We screened 440 circumcised and uncircumcised boys. Of these, 393 boys who were not toilet trained and for whom the treating physician had requested a catheter urine culture were included in our analysis. At the time of catheter insertion, a nurse characterized the visibility of the urethral meatus (phimosis) using a 3-point scale (completely visible, partially visible or nonvisible). Our primary outcome was urinary tract infection, and our primary exposure variable was the degree of phimosis: completely visible versus partially or nonvisible urethral meatus. RESULTS: Cultures grew from urine samples from 30.0% of uncircumcised boys with a completely visible meatus, and from 23.8% of those with a partially or nonvisible meatus (p = 0.4). The unadjusted odds ratio (OR) for culture growth was 0.73 (95% confidence interval [CI] 0.35-1.52), and the adjusted OR was 0.41 (95% CI 0.17-0.95). Of the boys who were circumcised, 4.8% had urinary tract infections, which was significantly lower than the rate among uncircumcised boys with a completely visible urethral meatus (unadjusted OR 0.12 [95% CI 0.04-0.39], adjusted OR 0.07 [95% CI 0.02-0.26]). INTERPRETATION: We did not see variation in the risk of urinary tract infection with the visibility of the urethral meatus among uncircumcised boys. Compared with circumcised boys, we saw a higher risk of urinary tract infection in uncircumcised boys, irrespective of urethral visibility.

Effects of temperature on power output and contraction kinetics in the locomotor muscle of the regionally endothermic common thresher shark (Alopias vulpinus).

The common thresher shark (Alopias vulpinus) is a pelagic species with medially positioned red aerobic swimming musculature (RM) and regional RM endothermy. This study tested whether the contractile characteristics of the RM are functionally similar along the length of the body and assessed how the contractile properties of the common thresher shark compare with those of other sharks. Contractile properties of the RM were examined at 8, 16 and 24 °C from anterior and posterior axial positions (0.4 and 0.6 fork length, respectively) using the work loop technique. Experiments were performed to determine whether the contractile properties of the RM are similar along the body of the common thresher shark and to document the effects of temperature on muscle power. Axial differences in contractile properties of RM were found to be small or absent. Isometric twitch kinetics of RM were ~fivefold slower than those of white muscle, with RM twitch durations of about 1 s at 24 °C and exceeding 5 s at 8 °C, a Q(10) of nearly 2.5. Power increased approximately tenfold with the 16 °C increase in temperature, while the cycle frequency for maximal power only increased from about 0.5-1.0 Hz over this temperature range. These data support the hypothesis that the RM is functionally similar along the body of the common thresher shark and corroborate previous findings from shark species both with and without medial RM. While twitch kinetics suggest the endothermic RM is not unusually temperature sensitive, measures of power suggest that the RM is not well suited to function at cool temperatures. The cycle frequency at which power is maximized appeared relatively insensitive to temperature in RM, which may reflect the relatively cooler temperature of the thresher RM compared to that observed in lamnid sharks as well as the relatively slow RM phenotype in these large fish.

Early administration of systemic corticosteroids reduces hospital admission rates for children with moderate and severe asthma exacerbation.

STUDY OBJECTIVE: The variable effectiveness of clinical asthma pathways to reduce hospital admissions may be explained in part by the timing of systemic corticosteroid administration. We examine the effect of early (within 60 minutes [SD 15 minutes] of triage) versus delayed (>75 minutes) administration of systemic corticosteroids on health outcomes. METHODS: We conducted a prospective observational cohort of children aged 2 to 17 years presenting to the emergency department with moderate or severe asthma, defined as a Pediatric Respiratory Assessment Measure (PRAM) score of 5 to 12. The outcomes were hospital admission, relapse, and length of active treatment; they were analyzed with multivariate logistic and linear regressions adjusted for covariates and potential confounders. RESULTS: Among the 406 eligible children, 88% had moderate asthma; 22%, severe asthma. The median age was 4 years (interquartile range 3 to 8 years); 64% were male patients. Fifty percent of patients received systemic corticosteroids early; in 33%, it was delayed; 17% of children failed to receive any. Overall, 36% of patients were admitted to the hospital. Compared with delayed administration, early administration reduced the odds of admission by 0.4 (95% confidence interval 0.2 to 0.7) and the length of active treatment by 0.7 hours (95% confidence interval -1.3 to -0.8 hours), with no significant effect on relapse. Delayed administration was positively associated with triage priority and negatively with PRAM score. CONCLUSION: In this study of children with moderate or severe asthma, administration of systemic corticosteroids within 75 minutes of triage decreased hospital admission rate and length of active treatment, suggesting that early administration of systemic corticosteroids may allow for optimal effectiveness.

Is a lumbar puncture necessary when evaluating febrile infants (30 to 90 days of age) with an abnormal urinalysis?

OBJECTIVES: Guidelines for the management of febrile infants aged 30 to 90 days presenting to the emergency department (ED) suggest that a lumbar puncture (LP) should be performed routinely if a positive urinalysis is found during initial investigations. The aim of our study was to assess the necessity of routine LPs in infants aged 30 to 90 days presenting to the ED for a fever without source but are found to have a positive urine analysis. METHODS: We retrospectively reviewed the records of all infants aged 30 to 90 days, presenting to the Montreal Children's Hospital ED from October 2001 to August 2005 who underwent an LP for bacterial culture, in addition to urinalysis and blood and urine cultures. Descriptive statistics and their corresponding confidence intervals were used. RESULTS: Overall, 392 infants were identified using the microbiology laboratory database. Fifty-seven patients had an abnormal urinalysis. Of these, 1 infant (71 days old) had an Escherichia coli urinary tract infection, bacteremia, and meningitis. This patient, however, was not well on history, and the peripheral white blood cell count was low at 2.9 × 109/L. Thus, the negative predictive value of an abnormal urinalysis for meningitis was 98.2%. CONCLUSIONS: Routine LPs are not required in infants (30-90 days) presenting to the ED with a fever and a positive urinalysis if they are considered at low risk for serious bacterial infection based on clinical and laboratory criteria. However, we recommend that judicious clinical judgment be used; in doubt, an LP should be performed before empiric antibiotic therapy is begun.

Written action plan in pediatric emergency room improves asthma prescribing, adherence, and control.

RATIONALE: An acute-care visit for asthma often signals a management failure. Although a written action plan is effective when combined with self-management education and regular medical review, its independent value remains controversial. OBJECTIVES: We examined the efficacy of providing a written action plan coupled with a prescription (WAP-P) to improve adherence to medications and other recommendations in a busy emergency department. METHODS: We randomized 219 children aged 1-17 years to receive WAP-P (n = 109) or unformatted prescription (UP) (n = 110). All received fluticasone and albuterol inhalers, fitted with dose counters, to use at the discretion of the emergency physician. The main outcome was adherence to fluticasone (use/prescribed × 100%) over 28 days. Secondary outcomes included pharmacy dispensation of oral corticosteroids, ß(2)-agonist use, medical follow-up, asthma education, acute-care visits, and control. MEASUREMENTS AND MAIN RESULTS: Although both groups showed a similar drop in adherence in the initial 14 days, adherence to fluticasone was significantly higher over Days 15-28 in children receiving WAP-P (mean group difference, 16.13% [2.09, 29.91]). More WAP-P than UP patients filled their oral corticosteroid prescription (relative risk, 1.31 [1.07, 1.60]) and were well-controlled at 28 days (1.39 [1.04, 1.86]). Compared with UP, use of WAP-P increased physicians' prescription of maintenance fluticasone (2.47 [1.53, 3.99]) and recommendation for medical follow-up (1.87 [1.48, 2.35]), without group differences in other outcomes. CONCLUSIONS: Provision of a written action plan significantly increased patient adherence to inhaled and oral corticosteroids and asthma control and physicians' recommendation for maintenance fluticasone and medical follow-up, supporting its independent value in the acute-care setting. Clinical trial registered with www.clinicaltrials.gov (NCT 00381355).

Focusing the focus group: impact of the awareness of major factors contributing to non-adherence to acute paediatric asthma guidelines.

RATIONALE: The administration of oral corticosteroids within the first hour in the emergency department is associated with reduced hospitalization rates in children with moderate and severe asthma, yet less than half of patients benefit from this recommendation. To ensure patients receive recommended treatment, a clear understanding of what is causing suboptimal care management is needed. The assessment of barriers and solutions to optimal care is often done without a thorough examination of the factors associated with non-adherence. OBJECTIVE: To evaluate whether knowledge of factors associated with delayed administration of systemic corticosteroids modifies the focus and prioritization of barriers and solutions identified by focus groups. METHODS: We conducted two parallel focus groups of emergency health care professionals - one group informed and the other non-informed of key factors. Both groups received a presentation on the acute asthma guidelines, the evidence supporting its recommendations, and current practice. In addition, the informed group was provided with the factors associated and not associated with delayed administration. The groups were given 20 minutes to discuss barriers and solutions, with 5 minutes each for voting for the main barriers and solutions. Group difference in the misdirection of discussion was measured as time spent discussing barriers that were shown not to be associated with systemic corticosteroids. Prioritization of barriers and solutions was based on group endorsement. RESULTS: The non-informed group spent more time discussing barriers not associated with delayed administration (15 vs. 2 minutes, P = 0.05). Although the non-informed group proposed more solutions, most were to overcome barriers not associated with delayed administration. Of the main barriers and solutions identified by each group, only one barrier and solution were similar between the two groups: emergency department overcrowding and administrating corticosteroids at triage. CONCLUSION: The awareness of objective factors of non-adherence enabled a more directed discussion on relevant barriers and solutions, affecting prioritization of each. The administration of oral corticosteroids at triage appears to be the best solution to overcome delayed administration.

Adherence to pediatric asthma guidelines in the emergency department: a survey of knowledge, attitudes and behaviour among health care professionals.

BACKGROUND: Despite strong evidence for using clinical care pathways to manage acute pediatric asthma, adherence remains suboptimal. OBJECTIVES: To elicit information from health care professionals regarding their knowledge, attitudes and use of a care pathway for acute childhood asthma. METHODS: A cross-sectional, self-administered survey of physicians, nurses and respiratory therapists who worked in the emergency department at the Montreal Children's Hospital (Montreal, Quebec) from August to December 2007 was conducted. The survey assessed knowledge, attitude toward and agreement with the care pathway, as well as its use four years after its implementation. RESULTS: Of the 128 health care professionals surveyed, 72 (56%) responded. Of these, 99% reported being familiar with the pathway, more than 90% agreed with its use for mild and moderate asthma, while 79% agreed with its use for severe asthma. For 99% of health care professionals, the advantages of using the pathway outweighed the disadvantages; however, 64% admitted to making variations to the pathway. Although 92% of respondents reported that they were quite comfortable with using the asthma severity Pediatric Respiratory Assessment Measure, only 53% and 36% correctly identified the severity score cut-offs for moderate and severe asthma, respectively. Seventeen per cent of respondents underestimated the delay of onset of action of oral corticosteroids, while 36% of physicians incorrectly believed that a higher than necessary dose was recommended for ipratropium bromide. CONCLUSIONS: Results of the survey confirmed that the health care professionals queried had a positive attitude toward the pediatric asthma care pathway. Knowledge gaps and the balance between standardization versus individualization of care may be key elements to explain suboptimal adherence to the pathway.

Markers of overcrowding in a pediatric emergency department.

OBJECTIVES: The objective of this study was to identify markers of overcrowding in pediatric emergency departments (PEDs) according to expert opinion and then to use statistical methods to further explore the underlying construct of overcrowding. METHODS: A cross-sectional survey of all PED directors (n = 12) and pediatric emergency medicine fellowship program directors (n = 10) across Canada was conducted to elicit expert opinion on relevant markers of emergency department (ED) crowding. The list of markers was reduced to those specific to the ED for which data could be extracted from one tertiary care PED from an existing computerized patient tracking system. Data representing 2,190 consecutive shifts and 138,361 patient visits were collected between April 2005 and March 2007. Common factor analysis (CFA) was used to determine the underlying factors that best represented overcrowding as determined by markers identified by experts in pediatric emergency medicine RESULTS: The main markers of overcrowding identified by the survey included measures of patient volume (25%), ED operational processes (55%), and delays in transferring patients to inpatient beds (13%). Data collected on 41 markers were retained for the CFA. The results of the CFA indicated that the largest portion of variation in the data (48%) was accounted for by markers describing patient volumes and flow through the ED. Measures of admission delays accounted for a smaller proportion of variability (9%). CONCLUSIONS: The results suggest that for this tertiary PED, markers of ED operational processes and patient volume may be more relevant for determination of overcrowding than markers reflecting delays in transferring patients to inpatient beds. This study provides a foundation for further research on markers of overcrowding specific to the pediatric setting.

A simple case of a small elbow effusion.

An 11-month-old child presented with what initially appeared to be 2 simple problems, a small elbow effusion followed 1 week later by croup. This case history is presented to remind emergency medicine physicians of the importance of index of suspicion and recognition of the difference between common events occurring in a normal host versus common events occurring in an abnormal host.

Function of the medial red muscle during sustained swimming in common thresher sharks: contrast and convergence with thunniform swimmers.

Through convergent evolution tunas and lamnid sharks share thunniform swimming and a medial position of the red, aerobic swimming musculature. During continuous cruise swimming these muscles move uniformly out of phase with local body curvature and the surrounding white muscle tissue. This design results in thrust production primarily from the caudal fin rather than causing whole-body undulations. The common thresher shark (Family Alopiidae) is the only other fish known to share the same medial red muscle anatomy as the thunniform swimmers. However, the overall body shape and extremely heterocercal caudal fin of the common thresher is not shared with the thunniform swimmers, which have both fusiform bodies and high aspect-ratio, lunate caudal fins. Our study used sonomicrometry to measure the dynamics of red and white muscle movement in common thresher sharks swimming in the ocean to test whether the medial position of red muscle is associated with uncoupling of muscle shortening and local body bending as characteristic of thunniform swimmers. Common threshers ( approximately 60-100kg) instrumented with sonomicrometric and electromyographic (EMG) leads swam alongside of the vessel with a tail-beat frequency of approximately 0.5Hz. EMG signals confirmed that only the red muscle was active during sustained swimming. Despite the more medial position of the red muscle relative to the white muscle, its strain was approximately 1.5-times greater than that of the overlying white muscle, and there was a notable phase shift between strain trajectories in the red muscle and adjacent white muscle. These results suggest an uncoupling (shearing) of the red muscle from the adjacent white muscle. Although the magnitude of the phase shift between red and white muscle strain was relatively constant within individuals, it varied among sharks, ranging from near zero (red and white in phase) to almost 180 degrees out of phase. This extent in variability has not been documented previously for thunniform swimmers with a medial red muscle position and may be a characteristic of the thresher's unique body and caudal fin morphology. Nonetheless, the uncoupling of red and white muscle strain remains a consistent character associated with fishes having a medially positioned red muscle.

Duration of fever affects the likelihood of a positive bag urinalysis or catheter culture in young children.

OBJECTIVE: To test the hypothesis that there will be a clinically significant rise in the proportion of positive bag urinalyses and catheter cultures in young children with increasing duration of fever. STUDY DESIGN: This was a prospective cohort study of 818 infants and children age 3-36 months presenting to a tertiary care emergency department with documented fever without source. Following the documentation of fever from < 1 to > or = 5 days, bag specimens were collected for urinalysis. The primary outcome was the yield of positive bag dipsticks by day, defined as positive for nitrates or more than trace leukocyte esterase. The secondary outcome was positive catheter cultures on each day of fever. RESULTS: Positive bag urinalyses increased with duration of fever: 14.8% (35/237) on day 1 versus 26.4% (43/163) on day 3 (relative risk [RR] = 1.8; 95% confidence interval [CI] = 1.2-2.7; P = .004). Positive catheter cultures increased in the same fashion: 4.8% (11/229) on day 1 versus 12.6% (20/159) on day 3 (RR = 2.6; 95% CI = 1.3-5.3; P = .005). CONCLUSIONS: The yield of positive bag urinalyses and catheter cultures increased significantly in children with fever of 3 days or longer duration.

Locomotor trade-offs in mice selectively bred for high voluntary wheel running.

We investigated sprint performance and running economy of a unique ;mini-muscle' phenotype that evolved in response to selection for high voluntary wheel running in laboratory mice (Mus domesticus). Mice from four replicate selected (S) lines run nearly three times as far per day as four control lines. The mini-muscle phenotype, resulting from an initially rare autosomal recessive allele, has been favoured by the selection protocol, becoming fixed in one of the two S lines in which it occurred. In homozygotes, hindlimb muscle mass is halved, mass-specific muscle oxidative capacity is doubled, and the medial gastrocnemius exhibits about half the mass-specific isotonic power, less than half the mass-specific cyclic work and power, but doubled fatigue resistance. We hypothesized that mini-muscle mice would have a lower whole-animal energy cost of transport (COT), resulting from lower costs of cycling their lighter limbs, and reduced sprint speed, from reduced maximal force production. We measured sprint speed on a racetrack and slopes (incremental COT, or iCOT) and intercepts of the metabolic rate versus speed relationship during voluntary wheel running in 10 mini-muscle and 20 normal S-line females. Mini-muscle mice ran faster and farther on wheels, but for less time per day. Mini-muscle mice had significantly lower sprint speeds, indicating a functional trade-off. However, contrary to predictions, mini-muscle mice had higher COT, mainly because of higher zero-speed intercepts and postural costs (intercept-resting metabolic rate). Thus, mice with altered limb morphology after intense selection for running long distances do not necessarily run more economically.

Prospective validation of the pediatric appendicitis score in a Canadian pediatric emergency department.

OBJECTIVES: Clinical scoring systems attempt to improve the diagnostic accuracy of pediatric appendicitis. The Pediatric Appendicitis Score (PAS) was the first score created specifically for children and showed excellent performance in the derivation study when administered by pediatric surgeons. The objective was to validate the score in a nonreferred population by emergency physicians (EPs). METHODS: A convenience sample of children, 4-18 years old presenting to a pediatric emergency department (ED) with abdominal pain of less than 3 days' duration and in whom the treating physician suspected appendicitis, was prospectively evaluated. Children who were nonverbal, had a previous appendectomy, or had chronic abdominal pathology were excluded. Score components (right lower quadrant and hop tenderness, anorexia, pyrexia, emesis, pain migration, leukocytosis, and neutrophilia) were collected on standardized forms by EPs who were blinded to the scoring system. Interobserver assessments were completed when possible. Appendicitis was defined as appendectomy with positive histology. Outcomes were ascertained by review of the pathology reports from the surgery specimens for children undergoing surgery and by telephone follow-up for children who were discharged home. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated. The overall performance of the score was assessed by a receiver operator characteristic (ROC) curve. RESULTS: Of the enrolled children who met inclusion criteria (n = 246), 83 (34%) had pathology-proven appendicitis. Using the single cut-point suggested in the derivation study (PAS 5) resulted in an unacceptably high number of false positives (37.6%). The score's performance improved when two cut-points were used. When children with a PAS of or=8 determined the need for appendectomy, the score's specificity was 95.1% with a PPV of 85.2%. Using this strategy, the negative appendectomy rate would have been 8.8%, the missed appendicitis rate would have been 2.4%, and 41% of imaging investigations would have been avoided. CONCLUSIONS: The PAS is a useful tool in the evaluation of children with possible appendicitis. Scores of or=8 help predict appendicitis. Patients with a PAS of 5-7 may need further radiologic evaluation.

Changes in efficiency and myosin expression in the small-muscle phenotype of mice selectively bred for high voluntary running activity.

Mice from lines selectively bred for high levels of voluntary wheel running express a high incidence of a small muscle phenotype ('mini-muscles') that may confer an adaptive advantage with respect to endurance-running capacity. Plantar flexors in the mini-muscle phenotype exhibit a high capacity for aerobic activity, including altered enzyme activities, loss of expression of type IIb myosin heavy chain (MHC), increased expression of type I, IIx and IIa MHC, and mechanical performance consistent with slower, more fatigue-resistant muscles. We hypothesized that these changes may accompany enhanced efficiency of contraction, perhaps in support of the enhanced capacity for endurance running. To assess efficiency, we measured work and associated oxygen consumption from isolated soleus and medial gastrocnemius muscles from mice with mini-muscle and normal phenotypes. We also measured the MHC expression of the plantar flexor muscles to better understand the physiological basis of any differences in efficiency. The proportion of the various MHC isoforms in the soleus was shifted toward a slightly faster phenotype in the mini-muscle mice, whereas in the gastrocnemius and plantaris it was shifted toward a markedly slower phenotype, with large reductions in type IIb MHC and large increases in type I, IIa, and IIx MHC. Soleus muscles from normal and mini-muscle mice showed no statistical differences in efficiency, but medial gastrocnemius from mini-muscle mice were significantly less efficient than those from normal mice, despite the distinctly slower MHC phenotype in mini-muscle mice. Thus, based on measures of efficiency from isolated muscles under conditions near optimal for power output, the shift toward a slower phenotype in 'mini' gastrocnemius muscles does not appear to confer advantages directly through increased efficiency. Rather, the slower phenotype may reduce energy used by the muscles and be permissive to enhanced running ability, perhaps by reducing reliance on anaerobic metabolism.

Two for one: a self-management plan coupled with a prescription sheet for children with asthma.

BACKGROUND: Despite strong recommendations in the asthma guidelines, the use of written self-management plans remains low among asthmatic patients. OBJECTIVES: To develop a written self-management plan, based on scientific evidence and expert opinions, in a format intended to facilitate its dispensing by health care professionals, and to test the perception of its relevance and clarity by asthmatic children, adolescents and adults. METHODS: Inspired by previously tested self-management plans, surveys of asthma educators, expert opinions and the 2004 Canadian Asthma Guidelines, the authors simultaneously developed French and English versions of a written self-management plan that coupled with a prescription. The self-management plan was tested in parents and their asthmatic children (aged one to 17 years), and it was revised until 85% clarity and perceived relevance was achieved. RESULTS: Ninety-seven children and their parents were interviewed. Twenty per cent had a self-management plan. On the final revision, nearly all items were clear and perceived relevant by 85% or more of the interviewees. Two self-management plans were designed for clinics and acute care settings, respectively. The plans are divided into three control zones identified by symptoms with optional peak flow values and symbolized by traffic light colours. They are designed in triplicate format with a prescription slip, a medical chart copy and a patient copy. CONCLUSION: The written self-management plans, based on available scientific evidence and expert opinions, are clear and perceived to be relevant by children, adolescents and their parents. By incorporating the prescription and chart copies, they were designed to facilitate dispensing by physicians in both clinics and acute care settings.