Beta-Thalassemia in Adulthood Previously Suspected as Treatment-Resistant Iron Deficiency Anemia: A Case Report.

Beta-thalassemia (ß-thalassemia) is a hematologic genetic condition that causes microcytic anemia due to defective synthesis of the hemoglobin beta chain. As a hypochromic microcytic anemia that is commonly associated with symptoms such as fatigue and pallor when identified in adulthood, ß-thalassemia may be commonly underdiagnosed or misdiagnosed as iron deficiency anemia. This study presents a case of a patient with ß-thalassemia who was initially misdiagnosed with treatment-resistant iron deficiency anemia. Here, we present the case of a 66-year-old male of Mediterranean descent with a history of military service who presented with persistent fatigue. He had a past medical history of hypertension, diabetes mellitus type 2, sleep apnea, and iron deficiency anemia. Despite undergoing unnecessarily prolonged iron supplementation for suspected iron deficiency anemia, the patient's complete blood count and peripheral blood smear continued to identify hypochromic microcytic anemia. Ultimately, hemoglobin electrophoresis was performed, and mutations were identified in the hemoglobin beta chain consistent with ß-thalassemia minor. Due to its rarity and wide variation in presentation, ß-thalassemia may be frequently misdiagnosed. ß-thalassemia is a spectrum of disorders ranging from ß-thalassemia minor, which may be asymptomatic and incidentally discovered in adulthood, to ß-thalassemia major, which may include bone marrow deformities from extramedullary hematopoiesis and require frequent blood transfusions to sustain life. Therefore, patients who present with symptoms of ß-thalassemia minor may not be identified until later in life after undergoing decades of ineffective treatment. ß-thalassemia is a multifactorial disease with a variety of clinical presentations that can easily be misdiagnosed as other types of anemia. This case highlights the importance of performing thorough laboratory testing and casting a wide net of differential diagnoses when evaluating patients with treatment-resistant anemia. This case calls for further research on the genetic contributions to ß-thalassemia as well as improved ways to identify this disorder, particularly in patients who may not have a severe form that is easily diagnosed in early childhood.

Maternal Evaluation of a Team-Based Maternity Care Model for Women of Low Obstetric Risk.

In response to the need for affordable and comprehensive maternity care, a multidisciplinary team-based maternity care service led by general practitioners with obstetric training (GPOs) and midwives was established for women of low obstetric risk. We evaluated maternal satisfaction with this model of care. All women that attended the service and gave birth in 2020 were approached. Participants used an online survey to rate their satisfaction with aspects of their pregnancy, hospital stay and postpartum care and were invited to provide additional written feedback. Fifty percent (81/162) of women (33 ± 3.9 years) responded, with 59% primiparous. Proportions of participants that were very satisfied with their overall pregnancy, hospital stay, and postpartum care were 91%, <50%, and 85%, respectively. Both survey and qualitative data identified high satisfaction with emotional care and time afforded to discuss concerns during appointments. High levels of satisfaction can be achieved in women of low obstetric risk through the provision of GPO-midwife led multidisciplinary care throughout the maternity journey.

Evolution and extinction of the giant rhinoceros Elasmotherium sibiricum sheds light on late Quaternary megafaunal extinctions.

Understanding extinction events requires an unbiased record of the chronology and ecology of victims and survivors. The rhinoceros Elasmotherium sibiricum, known as the 'Siberian unicorn', was believed to have gone extinct around 200,000 years ago-well before the late Quaternary megafaunal extinction event. However, no absolute dating, genetic analysis or quantitative ecological assessment of this species has been undertaken. Here, we show, by accelerator mass spectrometry radiocarbon dating of 23 individuals, including cross-validation by compound-specific analysis, that E. sibiricum survived in Eastern Europe and Central Asia until at least 39,000 years ago, corroborating a wave of megafaunal turnover before the Last Glacial Maximum in Eurasia, in addition to the better-known late-glacial event. Stable isotope data indicate a dry steppe niche for E. sibiricum and, together with morphology, a highly specialized diet that probably contributed to its extinction. We further demonstrate, with DNA sequencing data, a very deep phylogenetic split between the subfamilies Elasmotheriinae and Rhinocerotinae that includes all the living rhinoceroses, settling a debate based on fossil evidence and confirming that the two lineages had diverged by the Eocene. As the last surviving member of the Elasmotheriinae, the demise of the 'Siberian unicorn' marked the extinction of this subfamily.

Effects of training and competition on the sleep of elite athletes: a systematic review and meta-analysis.

OBJECTIVES: To characterise the sleep of elite athletes and to identify factors associated with training and competition that negatively affect sleep. DESIGN: Prognosis systematic review. DATA SOURCES: Three databases (PubMed, SCOPUS and SPORTDiscus) were searched from inception to 26 February 2018. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Included studies objectively reported total sleep time (TST) and/or sleep efficiency (SE) in elite athletes. Studies were required to be observational or to include an observational trial. RESULTS: Fifty-four studies were included. During training, many studies reported athletes were unable to achieve TST (n=23/41) and/or SE (n=16/37) recommendations. On the night of competition, most studies reported athletes were unable to achieve TST (n=14/18) and/or SE (n=10/16) recommendations. TST was shorter (60 min) the night of competition compared with previous nights. SE was lower (1%) the night of competition compared with the previous night. TST was shorter the night of night competition (start ≥18:00; 80 min) and day competition (20 min) compared with the previous night. SE was lower (3%-4%) the night of night competition but unchanged the night of day competition compared with previous nights. Early morning training (start <07:00), increases in training load (>25%), late night/early morning travel departure times, eastward air travel and altitude ascent impaired sleep. CONCLUSION: Athletes were often unable to achieve sleep recommendations during training or competition periods. Sleep was impaired the night of competition compared with previous nights. Early morning training, increases in training load, travel departure times, jet lag and altitude can impair athletes' sleep. PROSPERO REGISTRATION NUMBER: CRD42017074367.

Blood flow restriction walking and physical function in older adults: A randomized control trial.

OBJECTIVES: The progressive age-related declines in muscle health and physical function in older adults are related to muscle size and strength. Walking with an applied blood flow restriction is an alternative to maintain muscle volume in older adults to increase the value for time spent walking. Therefore, the aim of this study was to examine the effect of adding blood flow restriction to low-intensity walking on clinical measures of physical function. DESIGN/METHODS: Sedentary older men and women were randomised to either a low-intensity blood flow restriction walking group (BFRW; n=10), or a non-blood flow restriction walking control group (CON; n=9). Participants were assessed at baseline, three-weeks and six-weeks for the 30second sit to stand, six-minute walk test, timed up and go, and a modified Queen's College step test. While a rating of perceived exertion (RPE) for training sessions at baseline, three-weeks and six-weeks. RESULTS: BFRW typically resulted in a 2.5-4.5 fold greater improvement in performance on all measures of physical function compared with CON among these older adults. However, RPE was greater for BFRW at all time points (for baseline, three-weeks, six-weeks: 14±0; 11±0; 11±0) compared with CON (8±0; 7±0; 8±0), despite declining across the study for BFRW. CONCLUSIONS: The greater improvement in physical function with blood flow restriction demonstrates how this addition can increase the quality of simple walking exercise for populations that may be contraindicated to heavy-load resistance training.

Corticomotor Excitability is Increased Following an Acute Bout of Blood Flow Restriction Resistance Exercise.

We used transcranial magnetic stimulation (TMS) to investigate whether an acute bout of resistance exercise with blood flow restriction (BFR) stimulated changes in corticomotor excitability (motor evoked potential, MEP) and short-interval intracortical inhibition (SICI), and compared the responses to two traditional resistance exercise methods. Ten males completed four unilateral elbow flexion exercise trials in a balanced, randomized crossover design: (1) heavy-load (HL: 80% one-repetition maximum [1-RM]); (2) light-load (LL; 20% 1-RM) and two other light-load trials with BFR applied; (3) continuously at 80% resting systolic blood pressure (BFR-C); or (4) intermittently at 130% resting systolic blood pressure (BFR-I). MEP amplitude and SICI were measured using TMS at baseline, and at four time-points over a 60 min post-exercise period. MEP amplitude increased rapidly (within 5 min post-exercise) for BFR-C and remained elevated for 60 min post-exercise compared with all other trials. MEP amplitudes increased for up to 20 and 40 min for LL and BFR-I, respectively. These findings provide evidence that BFR resistance exercise can modulate corticomotor excitability, possibly due to altered sensory feedback via group III and IV afferents. This response may be an acute indication of neuromuscular adaptations that underpin changes in muscle strength following a BFR resistance training programme.

Millennial climatic fluctuations are key to the structure of last glacial ecosystems.

Whereas fossil evidence indicates extensive treeless vegetation and diverse grazing megafauna in Europe and northern Asia during the last glacial, experiments combining vegetation models and climate models have to-date simulated widespread persistence of trees. Resolving this conflict is key to understanding both last glacial ecosystems and extinction of most of the mega-herbivores. Using a dynamic vegetation model (DVM) we explored the implications of the differing climatic conditions generated by a general circulation model (GCM) in "normal" and "hosing" experiments. Whilst the former approximate interstadial conditions, the latter, designed to mimic Heinrich Events, approximate stadial conditions. The "hosing" experiments gave simulated European vegetation much closer in composition to that inferred from fossil evidence than did the "normal" experiments. Given the short duration of interstadials, and the rate at which forest cover expanded during the late-glacial and early Holocene, our results demonstrate the importance of millennial variability in determining the character of last glacial ecosystems.

The earliest record of human activity in northern Europe.

The colonization of Eurasia by early humans is a key event after their spread out of Africa, but the nature, timing and ecological context of the earliest human occupation of northwest Europe is uncertain and has been the subject of intense debate. The southern Caucasus was occupied about 1.8 million years (Myr) ago, whereas human remains from Atapuerca-TD6, Spain (more than 780 kyr ago) and Ceprano, Italy (about 800 kyr ago) show that early Homo had dispersed to the Mediterranean hinterland before the Brunhes-Matuyama magnetic polarity reversal (780 kyr ago). Until now, the earliest uncontested artefacts from northern Europe were much younger, suggesting that humans were unable to colonize northern latitudes until about 500 kyr ago. Here we report flint artefacts from the Cromer Forest-bed Formation at Pakefield (52 degrees N), Suffolk, UK, from an interglacial sequence yielding a diverse range of plant and animal fossils. Event and lithostratigraphy, palaeomagnetism, amino acid geochronology and biostratigraphy indicate that the artefacts date to the early part of the Brunhes Chron (about 700 kyr ago) and thus represent the earliest unequivocal evidence for human presence north of the Alps.