A Narrative Review of Interhospital Transfers for Intracerebral Hemorrhage.

Of the 750,000 strokes in the United States every year, 15% patients suffer from hemorrhagic stroke. Intracerebral hemorrhage (ICH) is a subtype of hemorrhagic stroke. Despite advances in acute management, patients with hemorrhagic stroke continue to suffer from high mortality and survivors suffer from multidomain impairments in the physical, cognitive, and mental health domains which could last for months to years from their index stroke. Long-term prognosis after ICH is critically dependent on the quality and efficacy of care a patient receives during the acute phase of care. With ongoing care consolidation in stroke systems of care, the number of ICH patients who need to undergo interhospital transfers (IHTs) is increasing. However, the associations between IHT and ICH outcomes have not been well described in literature. In this review, we describe the epidemiology of IHT for ICH, the relationship between IHT and ICH patient outcomes, and proposed improvements to the IHT process to ensure better long-term patient outcomes. Our review indicates that evidence regarding the safety and benefit of IHT for ICH patients is conflicting, with some studies reporting poorer outcomes for transferred patients compared to direct admissions via emergency rooms and other studies showing no effect on outcomes. The American Heart Association guidelines for ICH provide recommendations for timely blood pressure control and anticoagulation reversal to improve patient outcomes. The American Heart Association stroke systems of care guidelines provide recommendations for transfer agreements and but do not provide details on how patients should be managed while undergoing IHT. Large, prospective, and multicenter studies comparing outcomes of IHT patients to direct admissions are necessary to provide more definitive guidance to optimize IHT protocols and aid clinical decision-making.

Intermittent hypoxic training - derived exosomes in stroke rehabilitation.

Ischemic stroke is the fourth leading cause of adult disability in the US, and it is a huge social burden all over the world. However, the efficient treatment of ischemic stroke is not available. An apparent reason for failing to find or develop an intervention for ischemic stroke is contributed to the tight blood-brain barrier (BBB). The unique characteristics of exosomes that can traverse BBB have been highlighted among researchers investigating interventions for ischemic stroke conditions. Additionally, intermittent hypoxic training has been considered a potential intervention in the treatment or rehabilitation process of ischemic stroke patients. In this mini-review, we are going to review the possibility of applying exosomes produced by a subject who does intermittent hypoxic conditioning in a treatment program for ischemic stroke.

Frailty predicts worse outcomes for spine surgery patients with interhospital transfer status: Analysis of 295,875 patients from the National Surgical Quality Improvement Program (NSQIP) 2015-2019.

STUDY DESIGN: Retrospective analysis of a prospectively maintained database. OBJECTIVES: To evaluate the effects of interhospital transfer (IHT) status, age, and frailty on postoperative outcomes in patients who underwent spine surgery. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent spine surgeries from 2015 to 2019 (N = 295,875). Univariate and multivariable analyses were utilized to analyze the effect of IHT on postoperative outcomes and the contribution of baseline frailty status (mFI-5 score stratified into "pre-frail", "frail", and "severely frail") on outcomes in IHT patients. Effect sizes were summarized by odds ratio (OR) with associated 95% confidence intervals (95% CI). RESULTS: Of 295,875 patients in the study, 3.3% (N = 9666) were IHT status. On multivariable analysis, controlling for covariates, IHT status was significantly associated with greater likelihood of 30-day mortality (odds ratio [OR] = 9.3), major complications (OR=5.0), Clavien-Dindo (CD) grade IV complications (OR=7.0), unplanned readmission (OR=2.1), unplanned reoperation (OR=2.6), eLOS (OR=16.1), and discharge to non-home destination (OR=12.7) (all P < 0.001). Increasing frailty was significantly associated with poor outcomes in spine surgery patients with IHT status compared to chronological age. CONCLUSIONS: This study provides evidence that IHT status is associated with poor outcomes in spine surgery patients. Furthermore, increasing frailty more than increasing age was a robust predictor of poor outcomes among IHT spine surgical patients. Baseline frailty status, as measured by the mFI-5, may be utilized for preoperative risk stratification of patients with IHT status with anticipated spine surgery.

Deep Neural Networks Predict the Need for CT in Pediatric Mild Traumatic Brain Injury: A Corroboration of the PECARN Rule.

PURPOSE: Only 10% of CT scans unveil positive findings in mild traumatic brain injury, raising concerns of its overuse in this population. A number of clinical rules have been developed to address this issue, but they still suffer limitations in their specificity. Machine learning models have been applied in limited studies to mimic clinical rules; however, further improvement in terms of balanced sensitivity and specificity is still needed. In this work, the authors applied a deep artificial neural networks (DANN) model and an instance hardness threshold algorithm to reproduce the Pediatric Emergency Care Applied Research Network (PECARN) clinical rule in a pediatric population collected as a part of the PECARN study between 2004 and 2006. METHODS: The DANN model was applied using 14,983 patients younger than 18 years with Glasgow Coma Scale scores ≥ 14 who had head CT reports. The clinical features of the PECARN rules, PECARN-A (group A, age < 2 years) and PECARN-B (group B, age ≤ 2 years), were used to directly evaluate the model. The average accuracy, sensitivity, precision, and specificity were calculated by comparing the model's prediction outcome to that reported by the PECARN investigators. The instance hardness threshold and DANN model were applied to predict the need for CT in pediatric patients using 5-fold cross-validation. RESULTS: In the first phase, the DANN model resulted in 98.6% sensitivity and 99.7% specificity for predicting the need for CT using the predictors of the two PECARN clinical rules combined to train the model. In the second phase, the DANN model was superior to both the PECARN-A and PECARN-B rules using the predictors for each age group separately to train the model. Compared with the clinical rule, for group A, the model achieved an average sensitivity (93.7% versus 100%) and specificity (97.5% versus 53.6%); for group B, the average sensitivity of the model was 99.2% versus 98.6%, and the specificity was 98.8% versus 58.2%. CONCLUSIONS: In this study, a DANN model achieved comparable sensitivity and outstanding specificity for replicating the PECARN clinical rule and predicting the need for CT in pediatric patients after mild traumatic brain injury compared with the original statistically derived clinical rule.

Worse cranial neurosurgical outcomes predicted by increasing frailty in patients with interhospital transfer status: Analysis of 47,736 patients from the National Surgical Quality Improvement Program (NSQIP) 2015-2019.

INTRODUCTION: With limited healthcare resources and risks associated with unwarranted interhospital transfers (IHT), it is important to select patients most likely to have improved outcomes with IHT. The present study analyzed the effect of IHT and frailty on postoperative outcomes in a large database of patients who underwent cranial neurosurgical operations. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent cranial neurosurgical procedures (2015-2019, N = 47,736). Baseline demographics, clinical characteristics, and outcome variables were compared between IHT and n-IHT patients. Univariate and multivariable analyses analyzed the effect of IHT status on postoperative outcomes and the utility of frailty (modified frailty index-5 [mFI-5] stratified into "pre-frail, "frail", and "severely frail") as a preoperative risk factor. Effect sizes from regression analyses were presented as odds ratio (OR) with associated 95% confidence intervals (95% CI). RESULTS: Of 47,736 patients with cranial neurosurgical operations, 9612 (20.1%) were IHT. Patients with IHT were older, frailer, with a higher rate of functional dependence. In multivariable analysis adjusted for baseline covariates, IHT status was independent associated with 30-day mortality (OR: 2.0, 95% CI: 1.2-3.6), major complication (OR: 1.5, 95% CI: 1.1-2.1), extended hospital length of stay (eLOS) (OR: 3.8, 95% CI: 3.6-4.1), and non-routine discharge disposition (OR: 2.4, 95% CI: 1.8-3.2) (all p < 0.05). Within the IHT cohort, increasing frailty ("pre-frail", "frail", "severely frail") was independently associated with increasing odds of 30-day mortality (OR: 1.4, 1.9, 3.9), major complication (OR: 1.4, 1.9, 3.3), unplanned readmission (OR: 1.1, 1.4, 2.1), reoperation (OR: 1.3, 1.5, 1.9), eLOS (OR: 1.2, 1.3, 1.5), and non-routine discharge (OR: 1.4, 1.9, 4.4) (all p < 0.05). All levels of frailty were more strongly associated with postoperative outcomes than chronological age. CONCLUSIONS: This novel analysis suggests that patients transferred for cranial neurosurgery operations are significantly more likely to have worse postoperative health outcomes. Furthermore, the analysis suggests that frailty (as measured by mFI-5) is a powerful independent predictor of outcomes in transferred cranial neurosurgery patients. The findings support the use of frailty scoring in the pre-transfer and preoperative setting for patient counseling and risk stratification.

The effects of intermittent hypoxic training on aerobic capacity and endurance performance in cyclists.

The aim of the present study was to evaluate the efficacy of intermittent hypoxic training (IHT) with 95 % of lactate threshold workload (WRLT) on aerobic capacity and endurance performance in well-trained cyclists. Twenty male elite cyclists, randomly divided into a hypoxia (H) group (n=10; age 22 ± 2.7years; VO2max 67.8 ± 2.5 ml·kg(-1)·min(-1); body height (BH) 1.78 ± 0.05 m; body mass (BM) 66.7 ± 5.4kg; fat free mass (FFM) 59.3 ± 5.1kg; fat content (FAT%) 11.3 ± 2.1%), and a control (C) group (n = 10; age 23.5 ± 3. 5years; VO2max 67.7 ± 2.0 ml·kg(-1)·min(-1); BH 1.79 ± 3.2 m; BM 69.2 ± 5.5 kg; FFM 63.6 ± 4.8 kg; FAT% 7.9 ± 1.94 %) took part in the research project. The training program used during the experiment was the same for the both groups. For three weeks, the subjects in H group performed 3 training sessions per week in normobaric hypoxia environment (IHT - O2 = 15. 2%). During the elemental core of the IHT session, the intensity was set at 95% WRLT for 30-min in 1(st) microcycle, 35-min in 2(nd) microcycle and 40-min in 3(rd) microcycle. The same training procedure was provided in C group, yet the intensity of the main sessions were set at 100% WRLT in the normoxia environment. The results indicate a significant (p < 0.05) increase in VO2max,VO2LT, WRmax, WRLT and change in lactate concentration (∆LA) during incremental test in H group. Also a significant (p < 0.05) decrease in time of the time trial was seen, associated with a significant increase (p < 0.05) in average generated power (Pavg) and average speed (Vavg) during the time trial. The intermittent hypoxic training (IHT) applied in this research did not significantly affect the hematological variables considered: number of erythrocytes (RBC), hemoglobin concentration (HGB) and haematocrit value (HCT). Significant blood value increases (p < 0.05) were only observed in MCV in H group. This data suggests that intermittent hypoxic training at lactate threshold intensity and medium duration (30-40min) is an effective training means for improving aerobic capacity and endurance performance at sea level. Key pointsThe efficacy of the intermittent hypoxic training is mostly dependent on volume and intensity of exercise in the hypoxic environment.The observed results suggests that intermittent hypoxic training at lactate threshold intensity and medium duration (30-40min) is an effective training means for improving aerobic capacity and endurance performance at sea level.

Perspectives on the Gamification of an Interactive Health Technology for Postoperative Rehabilitation of Pediatric Anterior Cruciate Ligament Reconstruction: User-Centered Design Approach.

BACKGROUND: Pediatric and adolescent athletes are a large demographic undergoing anterior cruciate ligament reconstruction (ACL-R). Postoperative rehabilitation is critical, requiring patients to complete home exercise programs (HEPs). To address obstacles to HEP adherence, we developed an interactive health technology, interACTION (iA), to monitor knee-specific rehabilitation. iA is a web-based platform that incorporates wearable motion sensors and a mobile app that provides feedback and allows remote monitoring. The Wheel of Sukr is a gamification mechanism that includes numerous behavioral elements. OBJECTIVE: This study aims to use a user-centered design process to incorporate behavioral change strategies derived from self-management theory into iA using the Wheel of Sukr, with the aim of influencing patient behavior. METHODS: In total, 10 athletes aged 10-18 years with a history of ACL-R were included in this study. Patients were between 4 weeks and 1 year post-ACL-R. Participants underwent a 60-minute triphasic interview. Phase 1 focused on elements of gaming that led to high participation and information regarding surgery and recovery. In phase 2, participants were asked to think aloud and rank cards representing the components of the Wheel of Sukr in order of interest. In phase 3, the patients reviewed the current version of iA. Interviews were recorded, transcribed, and checked for accuracy. Qualitative content analysis segmented the data and tagged meaningful codes until descriptive redundancy was achieved; next, 2 coders independently coded the data set. These elements were categorized according to the Wheel of Sukr framework. The mean age of participants was 12.8 (SD 1.32) years, and 70% (7/10) were female. Most participants (7/10, 70%) reported attending sessions twice weekly. All patients were prescribed home exercises. Self-reported HEP compliance was 75%-100% in 40% (4/10), 50%-75% in 40% (4/10), and 25%-50% of prescribed exercises in 20% (2/10) of the participants. RESULTS: The participants responded positively to an app that could track home exercises. Desirable features included exercise demonstrations, motivational components, and convenience. The participants listed sports specificity, competition, notifications, reminders, rewards, and social aspects of gameplay as features to incorporate. In the Wheel of Sukr card sort exercise, motivation was ranked first; self-management, second; and growth, esteem, and fun tied for the third position. The recommended gameplay components closely followed the themes from the Wheel of Sukr card sort activity. CONCLUSIONS: The participants believe iA is a helpful addition to recovery and want the app to include exercise movement tracking and encouragement. Despite the small number of participants, thematic saturation was reached, suggesting the sample was sufficient to obtain a representative range of perspectives. Future work will implement motivation; self-management; and growth, confidence, and fun in the iA user experience. Young athlete ACL-R patients will complete typical clinical scenarios using increasingly developed prototypes of the gamified iA in a controlled setting.

Effect of comorbidities on clinical outcome of patients with burn injury - An analysis of the German Burn Registry.

BACKGROUND: Severe burn injuries are associated with high morbidity and mortality. Well-implemented scoring systems for patients with major burns exist in the literature. A major disadvantage of these scores is the partial non-consideration of patient-related comorbidities. Published data on this matter is limited to small study cohorts and/or single center studies. Further, the effect of comorbidities on clinical outcome of patients with severe burn injuries has not yet been examined nationwide in a large cohort in Germany. Hence, the aim of this study was to examine the influence of comorbidities on clinical outcome of these patients based on data from the national registry. METHODS: Anonymized data from a total of 3455 patients with documented burns of 1% or more Total Burn Surface Area (TBSA) and over 16 years of age included in the German Burn Registry between 2017 and 2018 were analyzed retrospectively. Data included burn extent, body weight, age, burn depth, inhalation injury, comorbidities, mortality, number of operations and length of hospital stay (LOS). RESULTS: In the logistic regression analysis age (OR 1.07 [1.06-1.09], p < 0.001), TBSA (OR 1.09 [1.08-1.11], p < 0.001), IHT (OR 2.15 [1.44-3.20], p < 0001), third degree burn (OR 2.08 [1.39-3.11], p < 0.001), Chronic Obstructive Pulmonary Disease (COPD) (OR 2.45 [1.38-4.35], p = 0.002) and renal insufficiency (OR 2.02 [1.13-3.59], p = 0.017) influenced mortality significantly. If a patient had more than one comorbidity, mortality was higher and in-hospital length of stay (LOS) longer. Renal insufficiency was significantly (p < 0.001) associated with the most prolonged LOS by 11.44 days. TBSA (p < 0.001), Abbreviated Burn Severity Index (ABSI) > 3 (p < 0.001) and IHT (p = 0.001) correlated with the amount of required surgeries and significantly predicted the need for intubation. Patients with arrhythmia significantly required more surgeries (p = 0.041), whereas patients with COPD required significantly less surgical interventions (p = 0.013). CONCLUSION: Preexisting comorbidities have a significant impact on the clinical outcome of patients with severe burn injuries. Further investigation is warranted in order to supplement existing prognostic scores with new mortality-associated parameters.

Effects of Eight Interval Training Sessions in Hypoxia on Anaerobic, Aerobic, and High Intensity Work Capacity in Endurance Cyclists.

Aim: This study aimed to determine if eight sessions of supramaximal but steady-state, set duration interval training in hypoxia enhanced measured anaerobic capacity and work performed during high intensity exercise. High Alt Med Biol. 21:370-377, 2020. Materials and Methods: Eighteen cyclists (V̇O2peak: 57 ± 7 ml·kg-1·min-1) were pair-matched for anaerobic capacity determined by maximal accumulated oxygen deficit (MAOD) and allocated to a 4-week interval training in hypoxia (IHT; FiO2 = 14.7% ± 0.5%, n = 9) or interval training in normoxia (NORM; FiO2 = 20.6% ± 0.3%, n = 9). Cyclists completed twice weekly interval training (8 × 1 minutes: ∼120% V̇O2peak, 5 minutes recovery: ∼50% V̇O2peak) in addition to their habitual training. Before and after the intervention, a constant work rate supramaximal time to fatigue and a graded exercise test were used to determine changes in anaerobic capacity/supramaximal work performed and aerobic capacity/peak aerobic power output, respectively. Results: No interaction or main effects were observed. Using indirect calorimetry, anaerobic capacity was not significantly different in either group pre- to postintervention using MAOD (IHT: 4% ± 15%; NORM: -5% ± 12%) or gross efficiency methods (IHT: 7% ± 14%; NORM: -2% ± 9%), and VO2peak was unchanged (IHT: 1% ± 6%; NORM: 1% ± 4%). However, within-group analysis shows that supramaximal work performed improved with IHT (14% ± 13%; p = 0.02; d = 0.42) but not NORM (1% ± 22%), and peak aerobic power output increased with IHT (5% ± 7%; p = 0.04; d = 0.32) but not NORM (2% ± 4%). Conclusion: Steady-state, set duration supramaximal interval training in hypoxia appears to provide a small beneficial effect on work capacity during supramaximal and high intensity exercise.

ECG-derived respiration based on iterated Hilbert transform and Hilbert vibration decomposition.

Monitoring of the respiration using the electrocardiogram (ECG) is desirable for the simultaneous study of cardiac activities and the respiration in the aspects of comfort, mobility, and cost of the healthcare system. This paper proposes a new approach for deriving the respiration from single-lead ECG based on the iterated Hilbert transform (IHT) and the Hilbert vibration decomposition (HVD). The ECG signal is first decomposed into the multicomponent sinusoidal signals using the IHT technique. Afterward, the lower order amplitude components obtained from the IHT are filtered using the HVD to extract the respiration information. Experiments are performed on the Fantasia and Apnea-ECG datasets. The performance of the proposed ECG-derived respiration (EDR) approach is compared with the existing techniques including the principal component analysis (PCA), R-peak amplitudes (RPA), respiratory sinus arrhythmia (RSA), slopes of the QRS complex, and R-wave angle. The proposed technique showed the higher median values of correlation (first and third quartile) for both the Fantasia and Apnea-ECG datasets as 0.699 (0.55, 0.82) and 0.57 (0.40, 0.73), respectively. Also, the proposed algorithm provided the lowest values of the mean absolute error and the average percentage error computed from the EDR and reference (recorded) respiration signals for both the Fantasia and Apnea-ECG datasets as 1.27 and 9.3%, and 1.35 and 10.2%, respectively. In the experiments performed over different age group subjects of the Fantasia dataset, the proposed algorithm provided effective results in the younger population but outperformed the existing techniques in the case of elderly subjects. The proposed EDR technique has the advantages over existing techniques in terms of the better agreement in the respiratory rates and specifically, it reduces the need for an extra step required for the detection of fiducial points in the ECG for the estimation of respiration which makes the process effective and less-complex. The above performance results obtained from two different datasets validate that the proposed approach can be used for monitoring of the respiration using single-lead ECG.

Daily Intermittent Normobaric Hypoxia Over 2 Weeks Reduces BDNF Plasma Levels in Young Adults - A Randomized Controlled Feasibility Study.

Background: The results from animal and human research indicate that acute intermittent hypoxia can enhance brain-derived neurotrophic factor (BDNF) plasma levels and gene expression. As BDNF is known to promote the differentiation of new neurons and the formation of synapses, it has been proposed to mediate adult neuroplasticity. Thus, the present study aimed to analyze the long-term effects of daily intermittent exposure to normobaric hypoxia (simulating high altitude exposure at approximately 4000-5000 m) over 2 weeks on BDNF levels in young adults. Methods: Twenty-eight young adults (age: 19-33 years) were randomized into a hypoxic intervention group (N = 14) or the control group (N = 14). Participants in the intervention group breathed intermittent normobaric hypoxic air at resting conditions (5 min intervals, 80-85% SpO2 measured via a finger pulse oximeter, 12 sessions for 60 min/day for 2 weeks) via a hypoxic generator. BDNF plasma and serum levels were determined at baseline and at 2 weeks after intervention using sandwich ELISAs. Results: After 2 weeks of daily intermittent hypoxic treatment (IHT), we found a significant group x time interaction effect for BDNF plasma levels based on a significant decrease in BDNF levels in the hypoxia group. Conclusion: Our results demonstrate that daily intermittent administration of hypoxic air has a significant effect on BDNF regulation in healthy young adults. Contrary to other results reporting an increase in BDNF levels under hypoxic conditions, the present data suggest that hypoxic treatment using intensive IHT can reduce BDNF plasma levels for at least 2 weeks. This finding indicates that the daily application of hypoxic air is too frequent for the aimed physiological response, namely, an increase in BDNF levels.

Effects of distance and transport method on intervention and mortality in aneurysmal subarachnoid hemorrhage.

OBJECTIVE Most patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) initially present to a hospital that lacks a neurosurgical unit. These patients require interhospital transfer (IHT) to tertiary facilities capable of multidisciplinary neurosurgical intervention. Yet, little is known about the effects of IHT on the outcomes of patients suffering from aSAH. In this study, the authors examined the effects of IHT and transport method on the timing of treatment, rebleed rates, and overall outcomes of patients who have experienced aSAH. METHODS A retrospective review of medical records identified all consecutive patients who presented with aSAH at an outside hospital and subsequently underwent IHT to a tertiary aneurysm care center and patients who initially presented directly to a tertiary aneurysm care facility between 2008 and 2015. Demographic, operative, radiological, hospital of initial evaluation, transfer method, and outcome data were retrospectively collected. RESULTS The authors identified 763 consecutive patients who were evaluated for aSAH at a tertiary aneurysm care facility either directly or following IHT. For patients who underwent IHT and after accounting for these patients' clinical variability and dichotomizing the patients into groups transferred less than 20 miles and more than 20 miles, the authors noted a significant increase in mortality rates: 7% (< 20 miles) and 18.8% (> 20 miles) (p = 0.004). The increased mortality rate was partially explained by an increased rate of initial presentation to an accredited stroke center in patients undergoing IHT of less than 20 miles (p = 0.000). The method of transport (ground or air ambulance) was found to have significant effect on the patients' outcomes as measured by the Glasgow Outcome Scale score (p = 0.021); patients who underwent ground transport demonstrated a higher likelihood of discharge to home (p = 0.004). The increased severity of presentation in the patient cohort undergoing IHT by air as defined by the Glasgow Coma Scale score, a need for an external ventricular drain, Hunt and Hess grade, and intubation status at presentation did not result in increased mortality when compared with the ground cohort (p = 0.074). In addition, there was an 8-hour increase in duration of time from admission to treatment for the air cohort as compared with the ground cohort (p = 0.054), indicating a potential for further improvement in the overall outcome of this patient group. CONCLUSIONS Aneurysmal SAH remains a challenging neurosurgical disease process requiring highly coordinated care in tertiary referral centers. In this study, the overall distance traveled and the transport method affected patient outcomes. The time from admission to treatment should continue to improve. Further analysis of IHT with a focus on patient monitoring and treatment during transport is warranted.

The Effect of 4 Weeks Fixed and Mixed Intermittent Hypoxic Training (IHT) on Respiratory Metabolic and Acid-base Response of Capillary Blood During Submaximal Bicycle Exercise in Male Elite Taekwondo Players.

Purpose: The purpose of our study was to determine the effectiveness of 4 weeks fixed and mixed intermittent hypoxic training (IHT) and its difference from exercise training at sea-level on exercise load, respiratory metabolic and acid-base response of capillary blood during 80% maximal heart rate (HRmax) bicycle exercise in male elite Taekwondo players. Methods: Male elite Taekwondo players (n = 25 out of 33) were randomly assigned to training at sea-level (n = 8, control group), training at 16.5%O2 (2000 m) simulated hypoxic condition (n = 9, fixed IHT group), and training at 14.5%O2 (3000 m) up to 2 weeks and 16.5%O 2 (2000 m) simulated hypoxic condition (n = 8, mixed IHT group) for 3 weeks. We compared their average exercise load, respiratory metabolic, and acid-base response of the capillary blood during 80% HRmax submaximal bicycle exercise before and after 4 weeks training. Results: Fixed and mixed IHT groups showed positive improvement in respiratory metabolic and acid-base response of the capillary blood during 80% HRmax submaximal bicycle exercise after 4 weeks training. However, all dependent variables showed no significant difference between fixed IHT and mix IHT. Conclusion: Results suggested that mixed and fixed IHT is effective in improving respiratory metabolic and acid-base response of capillary blood in male elite Taekwondo players. Thus, IHT could be a novel and effective method for improving exercise performance through respiratory metabolic and acid-base response.

The effects of intermittent hypoxia training on hematological and aerobic performance in triathletes.

The aim of the present research was to analyze modifications on hematological and aerobic performance parameters after a 7-week intermittent hypoxia training (IHT) program. Eighteen male trained triathletes were divided in two groups: an intermittent hypoxia training group (IHTG: n: 9; 26.0 ± 6.7 years; 173.3 ± 5.9 cm; 66.4 ± 5.9 kg; VO2max: 59.5 ± 5.0 ml/kg/min) that conducted a normoxic training plus an IHT and a control group (CG: n: 9; 29.3 ± 6.8 years; 174.9 ± 4.6 cm; 59.7 ± 6.8 kg; VO2max: 58.9 ± 4.5 ml/kg/min) that performed only a normoxic training. Training process was standardized across the two groups. The IHT program consisted of two 60-min sessions per week at intensities over the anaerobic threshold and atmospheric conditions between 14.5 and 15% FiO2. Before and after the 7-week training, aerobic performance in an incremental running test and hematological parameters were analyzed. After this training program, the IHTG showed higher hemoglobin and erythrocytes (p < 0.05) values than in the CG. In terms of physiological and performance variables, between the two groups no changes were found. The addition of an IHT program to normoxic training caused an improvement in hematological parameters but aerobic performance and physiological variables compared to similar training under normoxic conditions did not increase.

Nurse knowledge of intrahospital transport.

Preventable adverse events and other medical errors occur to hundreds of thousands of Americans every year. The financial burden of these preventable events is estimated to be $29 billion. According to the World Health Organization, reducing medical errors has become an international concern. Protecting patients from harm is a primary responsibility of all nurses regardless of whether the nurse works in the intensive care unit or operating room. Adherence to policies to maintain patient safety can be discerned once the level of knowledge of these policies among nurses is determined.

Isolated Lymphangiomatous Polyp Nasopharynx in an Adult First Case Report in English Literature.

Lymphangiomas are rare benign, hamartomatous, congenital malformations of the lymphatic system involving the skin and subcutaneous tissues of head, neck and oral cavity. Occasional adult onset cases occur, this condition is thought to be a developmental malformation of lymph vessels which have poor communication with normal lymph system. Most of these malformations are present at birth or appear within two years of life. 75 % of cases occur in head and neck area, submandibular and parotid being the most affected parts. Lymphangioma arising in nasopharynx and in an adult has not been reported in english literature. This prompted us to report the very first case of Lymphangioma Nasopharynx.

Defining adrenal status with salivary cortisol by gold-standard insulin hypoglycemia.

BACKGROUND: Insulin-induced hypoglycemia (IHT) is considered the gold standard test for evaluating the HPA axis. Serum free cortisol or its surrogate, salivary cortisol as opposed to total cortisol concentrations, offers a better reflection of the activation of HPA axis. Our study aimed to derive reference ranges for the normal salivary cortisol levels in healthy patients and patients with adrenal insufficiency. DESIGN AND METHODS: Serum cortisol concentrations, using the gold standard of IHT, and salivary cortisol were obtained. 36 patients referred to our outpatient endocrine testing unit for evaluation of adrenal function were included in the study. Most subjects had a history of suspected hypothalamic/pituitary disease causing adrenal insufficiency. RESULTS: We found a strong linear correlation between the serum and salivary cortisol concentrations in simultaneously collected samples (r=0.81, 95% CI 0.74-0.86, p<0.0001). The corresponding salivary cortisol equivalent to a serum cortisol of 500 nmol/L, using a linear-regression equation, was 16.7 nmol/L (95% CI 13.3-20.1 nmol/L, p=0.0001). A salivary cortisol of 13.3 nmol/L has a specificity of 89.3% to detect abnormal HPA function. Using the upper 95% CI result of salivary cortisol 20.1 yields a sensitivity of 87.5%. CONCLUSION: With the present assay, adrenal insufficiency may be diagnosed with reasonable confidence if a random salivary cortisol is lower than 13.3 nmol/L and excluded if a random salivary cortisol is higher than 20.1 nmol/L. Future studies should correlate these thresholds with clinical outcomes.