51 results found
Parsons IT, Stacey MJ, Faconti L, et al., 2021, Histamine, mast cell tryptase and post-exercise hypotension in healthy and collapsed marathon runners (vol 121, pg 1451, 2021), EUROPEAN JOURNAL OF APPLIED PHYSIOLOGY, ISSN: 1439-6319
Avari P, Unsworth R, Rilstone S, et al., 2021, Improved glycaemia during the Covid-19 pandemic lockdown is sustained post-lockdown and during the "Eat Out to Help Out" Government Scheme, in adults with Type 1 diabetes in the United Kingdom, PLOS ONE, Vol: 16, ISSN: 1932-6203
Parsons IT, Stacey MJ, Faconti L, et al., 2021, Histamine, mast cell tryptase and post-exercise hypotension in healthy and collapsed marathon runners, EUROPEAN JOURNAL OF APPLIED PHYSIOLOGY, Vol: 121, Pages: 1451-1459, ISSN: 1439-6319
Walter E, Gibson OR, Stacey M, et al., 2021, Changes in gastrointestinal cell integrity after marathon running and exercise-associated collapse, EUROPEAN JOURNAL OF APPLIED PHYSIOLOGY, Vol: 121, Pages: 1179-1187, ISSN: 1439-6319
Izzi-Engbeaya C, Distaso W, Amin A, et al., 2021, Adverse outcomes in COVID-19 and diabetes – a retrospective cohort study from three London Teaching hospitals, BMJ Open Diabetes Research and Care, Vol: 9, Pages: 1-10, ISSN: 2052-4897
INTRODUCTION: Patients with diabetes mellitus admitted to hospital with COVID-19 have poorer outcomes. However, the drivers for this are not fully elucidated. We performed detailed characterisation of COVID-19 patients to determine clinical and biochemical factors that may be the drivers of poorer outcomes. RESEARCH DESIGN AND METHODS: Retrospective cohort study of 889 consecutive inpatients diagnosed with COVID-19 between 9th March 2020 and 22nd April 2020 in a large London NHS Trust. Unbiased multivariate logistic regression analysis was performed to determine variables that were independently and significantly associated with increased risk of death and/or ICU admission within 30 days of COVID-19 diagnosis. RESULTS: 62% of patients in our cohort were of non-White ethnic backgrounds and the diabetes prevalence was 38%. 323 (36%) patients met the primary outcome of death/admission to the intensive care unit (ICU) within 30 days of COVID-19 diagnosis. Male gender, lower platelet count, advancing age and higher Clinical Frailty Scale (CFS) score (but not diabetes) independently predicted poor outcomes on multivariate analysis. Antiplatelet medication was associated with a lower risk of death/ICU admission. Factors that were significantly and independently associated with poorer outcomes in patients with diabetes were co-existing ischaemic heart disease, increasing age and lower platelet count. CONCLUSIONS: In this large study of a diverse patient population, comorbidity (i.e. diabetes with ischaemic heart disease; increasing CFS score in older patients) were major determinants of poor outcomes with COVID-19. Antiplatelet medication should be evaluated in randomised clinical trials amongst high-risk patient groups.
Fitzpatrick D, Walter E, Leckie T, et al., 2021, Association between collapse and serum creatinine and electrolyte concentrations in marathon runners: a 9-year retrospective study., European Journal of Emergency Medicine, Vol: 28, Pages: 34-42, ISSN: 0969-9546
OBJECTIVE: Abnormal biochemical measurements have previously been described in runners following marathons. The incidence of plasma sodium levels outside the normal range has been reported as 31%, and the incidence of raised creatinine at 30%. This study describes the changes seen in electrolytes and creatinine in collapsed (2010-2019 events) and noncollapsed (during the 2019 event) runners during a UK marathon. METHODS: Point-of-care sodium, potassium, urea and creatinine estimates were obtained from any collapsed runner treated by the medical team during the Brighton Marathons, as part of their clinical care, and laboratory measurements from control subjects. RESULTS: Results from 224 collapsed runners were available. Serum creatinine was greater than the normal range in 68.9%. About 6% of sodium results were below, and 3% above the normal range, with the lowest 132 mmol/l. Seventeen percent of potassium readings were above the normal range; the maximum result was 8.4 mmol/l, but 97% were below 6.0 mmol/l. In the control group, mean creatinine was significantly raised in both the collapse and control groups, with 55.4% meeting the criteria for acute kidney injury, but had resolved to baseline after 24 h. Sodium concentration but not the potassium was significantly raised after the race compared with baseline, but only 15% were outside the normal range. CONCLUSION: In this study, incidence of a raised creatinine was higher than previously reported. However, the significance of such a rise remains unclear with a similar rise seen in collapsed and noncollapsed runners, and resolution noted within 24 h. Abnormal sodium concentrations were observed infrequently, and severely abnormal results were not seen, potentially reflecting current advice to drink enough fluid to quench thirst.
Hill NE, Oliver NS, 2020, DISTINGUISHING BETWEEN TYPE 1 AND TYPE 2 DIABETES Evolving type 1 diabetes in distinguishing between type 1 and type 2 diabetes, BMJ-BRITISH MEDICAL JOURNAL, Vol: 370, ISSN: 1756-1833
Ji H, Godsland I, Oliver NS, et al., 2020, Loss of association between HbA1c and vascular disease in older adults with type 1 diabetes, PLOS ONE, Vol: 15, ISSN: 1932-6203
Faconti L, Parsons I, Farukh B, et al., 2020, Post-exertional increase in first-phase ejection fraction in recreational marathon runners, JRSM Cardiovascular Disease, Vol: 9, Pages: 1-7, ISSN: 2048-0040
ObjectivesRunning a marathon has been equivocally associated with acute changes in cardiac performance. First-phase ejection fraction is a novel integrated echocardiographic measure of left ventricular contractility and systo-diastolic coupling which has never been studied in the context of physical activity. The aim of this study was to assess first-phase ejection fraction following recreational marathon running along with standard echocardiographic indices of systolic and diastolic function.Design and participants: Runners (n = 25, 17 males), age (mean ± standard deviation) 39 ± 9 years, were assessed before and immediately after a marathon race which was completed in 4 h, 10 min ± 47 min.Main outcome measuresCentral hemodynamics were estimated with applanation tonometry; cardiac performance was assessed using standard M-mode two-dimensional Doppler, tissue-doppler imaging and speckle-tracking echocardiography. First-phase ejection fraction was calculated as the percentage change in left ventricular volume from end-diastole to the time of peak aortic blood flow.ResultsConventional indices of systolic function and cardiac performance were similar pre- and post-race while aortic systolic blood pressure decreased by 9 ± 8 mmHg (P < 0.001) and first-phase ejection fraction increased by approximately 48% from 16.3 ± 3.9% to 22.9 ± 2.5% (P < 0.001). The ratio of left ventricular transmitral Doppler early velocity (E) to tissue-doppler imaging early annular velocity (e′) increased from 5.1 ± 1.8 to 6.2 ± 1.3 (P < 0.01).ConclusionIn recreational marathon runners, there is a marked increase in first-phase ejection fraction after the race despite no other significant change in cardiac performance or conve
Hill N, Michell DL, Ramirez-Solano M, et al., 2020, Glomerular endothelial derived vesicles mediate podocyte dysfunction: A potential role for miRNA, PLoS One, Vol: 15, ISSN: 1932-6203
MicroRNAs (miRNA) are shown to be involved in the progression of several types of kidney diseases. Podocytes maintain the integrity of the glomerular basement membrane. Extracellular vesicles (EV) are important in cell-to-cell communication as they can transfer cellular content between cells, including miRNA. However, little is known about how extracellular signals from the glomerular microenvironment regulate podocyte activity. Using a non-contact transwell system, communication between glomerular endothelial cells (GEnC) and podocytes was characterised in-vitro. Identification of transferred EV-miRNAs from GEnC to podocytes was performed using fluorescence cell tracking and miRNA mimetics. To represent kidney disease, podocyte molecular profiling and functions were analysed after EV treatments derived from steady state or activated GEnC. Our data shows activation of GEnC alters EV-miRNA loading, but activation was not found to alter EV secretion. EV delivery of miRNA to recipient podocytes altered cellular miRNA abundance and effector functions in podocytes, including decreased secretion of VEGF and increased mitochondrial stress which lead to altered cellular metabolism and cytoskeletal rearrangement. Finally, results support our hypothesis that miRNA-200c-3p is transfered by EVs from GEnC to podocytes in response to activation, ultimately leading to podocyte dysfunction.
Johnson A, Hill NE, Godsland I, et al., 2020, Glycemic Tracking Before and After Insulin Pump Initiation., J Diabetes Sci Technol, Pages: 1932296820910506-1932296820910506
Foster MA, Taylor AE, Hill NE, et al., 2020, Mapping the steroid response to major trauma from injury to recovery: a prospective cohort study, Journal of Clinical Endocrinology and Metabolism, Vol: 105, Pages: 925-937, ISSN: 0021-972X
CONTEXT: Survival rates after severe injury are improving, but complication rates and outcomes are variable. OBJECTIVE: This cohort study addressed the lack of longitudinal data on the steroid response to major trauma and during recovery. DESIGN: We undertook a prospective, observational cohort study from time of injury to 6 months postinjury at a major UK trauma centre and a military rehabilitation unit, studying patients within 24 hours of major trauma (estimated New Injury Severity Score (NISS) > 15). MAIN OUTCOME MEASURES: We measured adrenal and gonadal steroids in serum and 24-hour urine by mass spectrometry, assessed muscle loss by ultrasound and nitrogen excretion, and recorded clinical outcomes (ventilator days, length of hospital stay, opioid use, incidence of organ dysfunction, and sepsis); results were analyzed by generalized mixed-effect linear models. FINDINGS: We screened 996 multiple injured adults, approached 106, and recruited 95 eligible patients; 87 survived. We analyzed all male survivors <50 years not treated with steroids (N = 60; median age 27 [interquartile range 24-31] years; median NISS 34 [29-44]). Urinary nitrogen excretion and muscle loss peaked after 1 and 6 weeks, respectively. Serum testosterone, dehydroepiandrosterone, and dehydroepiandrosterone sulfate decreased immediately after trauma and took 2, 4, and more than 6 months, respectively, to recover; opioid treatment delayed dehydroepiandrosterone recovery in a dose-dependent fashion. Androgens and precursors correlated with SOFA score and probability of sepsis. CONCLUSION: The catabolic response to severe injury was accompanied by acute and sustained androgen suppression. Whether androgen supplementation improves health outcomes after major trauma requires further investigation.
Biswas JS, Lentaigne J, Burns DS, et al., 2020, Undifferentiated febrile illnesses in South Sudan: a case series from Operation TRENTON from June to August 2017, BMJ Military Health, ISSN: 2633-3767
<jats:p>Undifferentiated febrile illnesses present diagnostic and treatment challenges in the Firm Base, let alone in the deployed austere environment. We report a series of 14 cases from Operation TRENTON in South Sudan in 2017 that coincided with the rainy season, increased insect numbers and a Relief in Place. The majority of patients had headaches, myalgia, arthralgia and back pain, as well as leucopenia and thrombocytopenia. No diagnoses could be made in theatre, despite a sophisticated deployed laboratory being available, and further testing in the UK, including next-generation sequencing, was unable to establish an aetiology. Such illnesses are very likely to present in tropical environments, where increasing numbers of military personnel are being deployed, and clinicians must be aware of the non-specific presentation and treatment, as well as the availability of Military Infection Reachback services to assist in the management of these cases.</jats:p>
Foster MA, Taylor AE, Hill NE, et al., 2020, Mapping the Steroid Response to Major Trauma from Injury to Recovery: A Prospective Cohort Study, SSRN Electronic Journal
Lim SY, Bodagh N, Scott G, et al., 2019, Hyponatraemia: the importance of obtaining a detailed history and corroborating point-of-care analysis with laboratory testing, BMJ Case Reports, Vol: 12, ISSN: 1757-790X
We describe a 67-year-old man admitted from a mental health unit with an incidental finding of hyponatraemia on routine blood tests. Laboratory investigations were in keeping with syndrome of inappropriate antidiuretic hormone secretion (SIADH). He had been recently commenced on mirtazapine. During his inpatient stay, he became increasingly confused. Review of a previous admission with hyponatraemia raised the possibility of voltage-gated potassium channel antibody-associated limbic encephalitis, although subsequent investigations deemed this unlikely as a cause of hyponatraemia. Although his sodium levels improved with fluid restriction, serial point-of-care testing proved misleading in monitoring the efficacy of treatment as inconsistencies were seen in comparison with laboratory testing. The cause of hyponatraemia may have been medication-induced SIADH and/or polydipsia. This case highlights the importance of collating detailed histories and laboratory blood testing to guide management in cases of hyponatraemia of unknown aetiology.
Omassoli J, Hill NE, Woods DR, et al., 2019, Variation in renal responses to exercise in the heat with progressive acclimatisation, Journal of Science and Medicine in Sport, Vol: 22, Pages: 1004-1009, ISSN: 1440-2440
ObjectivesTo investigate changes in renal status from exercise in the heat with acclimatisation and to evaluate surrogates markers of Acute Kidney Injury.DesignProspective observational cohort study.Methods20 male volunteers performed 60 min standardised exercise in the heat, at baseline and on four subsequent occasions during a 23-day acclimatisation regimen. Blood was sampled before and after exercise for serum creatinine, copeptin, interleukin-6, normetanephrine and cortisol. Fractional excretion of sodium was calculated for corresponding urine samples. Ratings of Perceived Exertion were reported every 5 min during exercise. Acute Kidney Injury was defined as serum creatinine rise ≥26.5 μmol L−1 or fall in estimated glomerular filtration rate >25%. Predictive values of each candidate marker for developing Acute Kidney Injury were determined by ROC analysis.ResultsFrom baseline to Day 23, serum creatinine did not vary at rest, but showed a significant (P < 0.05) reduction post-exercise (120 [102, 139] versus 102 [91, 112] μmol L−1). Acute Kidney Injury was common (26/100 exposures) and occurred most frequently in the unacclimatised state. Log-normalised fractional excretion of sodium showed a significant interaction (exercise by acclimatization day), with post-exercise values tending to rise with acclimatisation. Ratings of Perceived Exertion predicted AKI (AUC 0.76, 95% confidence interval 0.65–0.88), performing at least as well as biochemical markers.ConclusionsHeat acclimatization is associated with reduced markers of renal stress and AKI incidence, perhaps due to improved regional perfusion. Acclimatisation and monitoring Ratings of Perceived Exertion are practical, non-invasive measures that could help to reduce renal injury from exercise in the heat.
Preau S, Ambler M, Sigurta A, et al., 2019, Protein recycling and limb muscle recovery after critical illness in slow- and fast-twitch limb muscle, American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, Vol: 316, Pages: R584-R593, ISSN: 0363-6119
<jats:p> An impaired capacity of muscle to regenerate after critical illness results in long-term functional disability. We previously described in a long-term rat peritonitis model that gastrocnemius displays near-normal histology whereas soleus demonstrates a necrotizing phenotype. We thus investigated the link between the necrotizing phenotype of critical illness myopathy and proteasome activity in these two limb muscles. We studied male Wistar rats that underwent an intraperitoneal injection of the fungal cell wall constituent zymosan or n-saline as a sham-treated control. Rats ( n = 74) were killed at 2, 7, and 14 days postintervention with gastrocnemius and soleus muscle removed and studied ex vivo. Zymosan-treated animals displayed an initial reduction of body weight but a persistent decrease in mass of both lower hindlimb muscles. Zymosan increased chymotrypsin- and trypsin-like proteasome activities in gastrocnemius at days 2 and 7 but in soleus at day 2 only. Activated caspases-3 and -9, polyubiquitin proteins, and 14-kDa fragments of myofibrillar actin (proteasome substrates) remained persistently increased from day 2 to day 14 in soleus but not in gastrocnemius. These results suggest that a relative proteasome deficiency in soleus is associated with a necrotizing phenotype during long-term critical illness. Rescuing proteasome clearance may offer a potential therapeutic option to prevent long-term functional disability in critically ill patients. </jats:p>
Joint problems commonly occur in people with diabetes. Cheiroarthropathy affects the hands and results in painless limited finger joint extension, appearing to be associated with longer diabetes duration and the presence of microvascular complications. The prevalence of cheiroarthropathy seems to be falling, perhaps as a result of improvements in glycaemic management. Non‐enzymatic glycation of collagen results in abnormally crosslinked protein resistant to degradation with subsequent increased build‐up of collagen in joints. The management of cheiroarthropathy is predominantly conservative, with occupational and hand therapy at the forefront. Tendinopathy is more common in people with diabetes than those without, and is associated with obesity and insulin resistance. As with cheiroarthropathy, the exact causative mechanism of tendinopathy in diabetes is not known, but may be linked to inflammation, apoptosis and increased vascularity of affected tendons, driven by hyperinsulinaemia. Local fat pads have also been suggested to play a role in the pathogenesis of tendinopathy.
Bailey MS, Gurney I, Lentaigne J, et al., 2019, Clinical activity at the UK military level 2 hospital in Bentiu, South Sudan during Op TRENTON from June to September 2017, Journal of the Royal Army Medical Corps, ISSN: 0035-8665
<jats:sec><jats:title>Introduction</jats:title><jats:p>Diseases and non-battle injuries (DNBIs) are common on UK military deployments, but the collection and analysis of clinically useful data on these remain a challenge. Standard medical returns do not provide adequate clinical information, and clinician-led approaches have been laudable, but not integrated nor standardised nor used long-term. Op TRENTON is a novel UK military humanitarian operation in support of the United Nations Mission in South Sudan, which included the deployment of UK military level 1 and level 2 medical treatment facilities at Bentiu to provide healthcare for UK and United Nations (UN) personnel.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>A service evaluation of patient consultations and admissions at the UK military level 2 hospital was performed using two data sets collected by the emergency department (ED) and medicine (MED) teams.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Over a three-month (13-week) period, 286 cases were seen, of which 51% were UK troops, 29% were UN civilians and 20% were UN troops. The ED team saw 175 cases (61%) and provided definitive care for 113 (40%), whereas the MED team saw and provided definitive care for 128 cases (45%). Overall, there were 75% with diseases and 25% with non-battle injuries. The most common diagnoses seen by the ED team were musculoskeletal injuries (17%), unidentified non-malarial undifferentiated febrile illness (UNMUFI) (17%), malaria (13%), chemical pneumonitis (13%) and wounds (8%). The most common diagnoses seen by the MED team were acute gastroenteritis (AGE) (56%), UNMUFI (12%) and malaria (9%). AGE was due to viruses (31%), diarrhoeagenic <jats:italic>Escherichia coli</jats:italic> (32%), other bacteria (6%) and protozoa (12%).</jats:p></jats:sec><jats:sec>
Biswas JS, Lentaigne J, Hill NE, et al., 2019, Epidemiology and etiology of diarrhea in UK military personnel serving on the United Nations Mission in South Sudan in 2017: A prospective cohort study, Travel Medicine and Infectious Disease, Vol: 28, Pages: 34-40, ISSN: 1477-8939
Background.Diarrhea is a well-established problem in travellers, with military personnel at especially high risk. This study aimed to characterise the spectrum of pathogens causing diarrhea in UK military personnel in South Sudan, and assess the utility of culture-independent testing for etiology and antimicrobial resistance in a logistically challenging and austere environment.Methods.All military personnel presenting with diarrhea were admitted to the UK Level 2 Medical Treatment Facility in Bentiu, South Sudan. Samples were tested for etiology utilising multiplex PCR-based diagnostics (BioFire FilmArray). In addition, the presence of carbapenemase resistance genes was determined using the geneXpert Carba-R platform.Results.Over 5 months, 127 samples were tested. The vast majority of pathogens detected were diarrheagenic Escherichia coli. The presence of either enterotoxigenic (ETEC) or enteropathogenic (EPEC) E. coli was a significant predictor of the other being present. In this study patients presenting with vomiting were 32 times more likely to have norovirus than not (p < 0.001). No carbapenem resistance was detected.Conclusions.Diarrhea in UK military personnel in South Sudan was determined to be predominantly bacterial, with norovirus presenting a distinct clinical and epidemiological pattern. Multiplex PCR and molecular resistance point of care testing were robust and effective in this environment.
Fallowfield JL, Delves SK, Hill NE, et al., 2019, Serum 25-hydroxyvitamin D fluctuations in military personnel during 6-month summer operational deployments in Afghanistan, British Journal of Nutrition, Vol: 121, Pages: 384-392, ISSN: 0007-1145
<jats:title>Abstract</jats:title><jats:p>Soldier operational performance is determined by their fitness, nutritional status, quality of rest/recovery, and remaining injury/illness free. Understanding large fluctuations in nutritional status during operations is critical to safeguarding health and well-being. There are limited data world-wide describing the effect of extreme climate change on nutrient profiles. This study investigated the effect of hot-dry deployments on vitamin D status (assessed from 25-hydroxyvitamin D (25(OH)D) concentration) of young, male, military volunteers. Two data sets are presented (pilot study, <jats:italic>n</jats:italic> 37; main study, <jats:italic>n</jats:italic> 98), examining serum 25(OH)D concentrations before and during 6-month summer operational deployments to Afghanistan (March to October/November). Body mass, percentage of body fat, dietary intake and serum 25(OH)D concentrations were measured. In addition, parathyroid hormone (PTH), adjusted Ca and albumin concentrations were measured in the main study to better understand 25(OH)D fluctuations. Body mass and fat mass (FM) losses were greater for early (pre- to mid-) deployment compared with late (mid- to post<jats:italic>-</jats:italic>) deployment (<jats:italic>P</jats:italic><0·05). Dietary intake was well-maintained despite high rates of energy expenditure. A pronounced increase in 25(OH)D was observed between pre- (March) and mid-deployment (June) (pilot study: 51 (<jats:sc>sd</jats:sc> 20) <jats:italic>v.</jats:italic> 212 (<jats:sc>sd</jats:sc> 85) nmol/l, <jats:italic>P</jats:italic><0·05; main study: 55 (<jats:sc>sd</jats:sc> 22) <jats:italic>v.</jats:italic> 167 (<jats:sc>sd</jats:sc> 71) nmol/l, <jats:italic>P</jats:italic><0·05) and remained elevated post-deploymen
Hill NE, Rilstone S, Stacey M, et al., 2018, Changes in northern hemisphere male international rugby union players body mass and height between 1955 and 2015, BMJ Open Sport and Exercise Medicine, Vol: 4, ISSN: 2055-7647
Objectives We sought to establish the effects of professionalism, which officially began in 1995, on the body mass and height of northern hemisphere male international rugby union (RU) players. We hypothesised that mass would significantly increase following professionalism. We also investigated the changes in size of players according to their playing position, and we compared changes to rugby league (RL) players and the public.Methods The body mass and height of players representing their international team for that country’s first game of the Five Nations in 1955, 1965, 1975, 1985 and 1995 and, for 2005 and 2015, the Six Nations, were collected from matchday programmes. RL players’ data were collected from the Challenge Cup final games played in the same years.Results International RU player body mass has significantly increased since 1995. In 1955 mean (±SD) player body mass was 84.8 kg (±8.2); in 2015, it was 105.4 kg (±12.1), an increase of 24.3%. Between 1955 and 2015, the body mass of forwards increased steadily, whereas that of backs has mostly gone up since 1995. RU player body mass gain has exceeded that of RL, but the age-matched difference between RU players and the public has remained relatively constant.Conclusions The factors influencing the gain in body mass of rugby players are legion; however, we believe that the interpretation of the law relating to the scrum put-in and changes allowing substitutions have, at least in part, contributed to the observed changes. Injury severity is increasing, and this may be linked to greater forces (caused by greater body mass) occurring in contact. RU law makers should adjust the rules to encourage speed and skill at the expense of mass.
Hill NE, Deighton K, Matu J, et al., 2018, Continuous Glucose Monitoring at High Altitude-Effects on Glucose Homeostasis., Med Sci Sports Exerc, Vol: 50, Pages: 1679-1686
PURPOSE: Exposure to high altitude has been shown to enhance both glucose and lipid utilization depending on experimental protocol. In addition, high and low blood glucose levels have been reported at high altitude. We hypothesized that gradual ascent to high altitude results in changes in glucose levels in healthy young adults. METHODS: Twenty-five adult volunteers, split into two teams, took part in the British Services Dhaulagiri Medical Research Expedition completing 14 d of trekking around the Dhaulagiri circuit in Nepal reaching a peak altitude of 5300 m on day 11 of the trek. Participants wore blinded continuous glucose monitors (CGM) throughout. Blood samples for C-peptide, proinsulin, and triacylglycerides were taken at sea level (United Kingdom) and in acclimatization camps at 3600, 4650, and 5120 m. Energy intake was determined from food diaries. RESULTS: There was no difference in time spent in hypoglycemia stratified by altitude. Nocturnal CGM readings (2200-0600 h) were chosen to reduce the short-term effect of physical activity and food intake and showed a significant (P < 0.0001) increase at 3600 m (5.53 ± 0.22 mmol·L), 4650 m (4.77 ± 0.30 mmol·L), and 5120 m (4.78 ± 0.24 mmol·L) compared with baseline altitude 1100 m (vs 4.61 ± 0.25 mmol·L). Energy intake did not differ by altitude. Insulin resistance and beta-cell function, calculated by homeostatic model assessment, were reduced at 3600 m compared with sea level. CONCLUSIONS: We observed a significant increase in nocturnal CGM glucose at 3600 m and greater despite gradual ascent from 1100 m. Taken with the changes in insulin resistance and beta-cell function, it is possible that the stress response to high altitude dominates exercise-enhanced insulin sensitivity, resulting in relative hyperglycemia.
Hill NE, 2018, Response to Howard et al (Howard M, Bakker-Dyos J, Gallagher L, et al Power supplies and equipment for military field research: lessons from the British Service Dhaulagiri Research Expedition 2016 Journal of the Royal Army Medical Corps 2018;164:41-45), Journal of the Royal Army Medical Corps
Hill NE, Rilstone S, Jairam C, et al., 2018, Establishing the multidisciplinary Imperial Physical Activity and Diabetes clinic, Practical Diabetes, Vol: 35, Pages: 11-15, ISSN: 2047-2897
Increasing numbers of people with diabetes are adopting exercise programmes. Fear of hypoglycaemia, and hypoglycaemia itself, are major issues for many people with diabetes undertaking physical activity. The risk of hypoglycaemia is exacerbated by endurance exercise. In addition, soft tissue injuries are more common in people with diabetes. We have established a multidisciplinary physical activity and diabetes clinic with the aim of empowering, educating and enabling people with diabetes to enjoy sport and exercise without fear of hypoglycaemia or frustration at glycaemic variability or soft tissue injuries. The multidisciplinary team (MDT) includes a diabetologist, sports and exercise physician, radiologist, dietitian, diabetes specialist nurse, and psychologist. Between October 2015 and September 2017, we undertook 19 clinics and saw 66 patients (48 new and 18 follow-up). Of the 48 new referrals (median age 35; range 20–72) 47 had type 1 diabetes and 27 (56%) used an insulin pump. Attendees had a median 18 years of diabetes (range 1–50). Diabetes distress was variable (median PAID score 18; range 0–64). Twenty-five patients attended for glycaemic management, 15 for musculoskeletal issues and eight for both. Sixteen (33%) required physiotherapy and nine (19%) were referred for joint imaging. It is possible to establish a new service to support physical activity in diabetes. To meet demand and enhance the MDT, physiotherapy will be added. A means of assessing the effects of diabetes on physical activity and outcome measures that matter to people with diabetes must be developed. Copyright © 2018 John Wiley & Sons.
Mellor A, Bakker-Dyos J, Howard M, et al., 2017, The British Services Dhaulagiri Medical Research Expedition 2016: a unique military and civilian research collaboration, Journal of the Royal Army Medical Corps, Vol: 163, Pages: 371-375, ISSN: 0035-8665
Stacey M, Hill NE, woods D, 2017, Physiological monitoring for healthy military personnel, Journal of the Royal Army Medical Corps, Pages: 290-292
Khoo B, Boshier PR, Freethy A, et al., 2017, Redefining the stress cortisol response to surgery., Clin Endocrinol (Oxf), Vol: 87, Pages: 451-458
BACKGROUND: Cortisol levels rise with the physiological stress of surgery. Previous studies have used older, less-specific assays, have not differentiated by severity or only studied procedures of a defined type. The aim of this study was to examine this phenomenon in surgeries of varying severity using a widely used cortisol immunoassay. METHODS: Euadrenal patients undergoing elective surgery were enrolled prospectively. Serum samples were taken at 8 am on surgical day, induction and 1 hour, 2 hour, 4 hour and 8 hour after. Subsequent samples were taken daily at 8 am until postoperative day 5 or hospital discharge. Total cortisol was measured using an Abbott Architect immunoassay, and cortisol-binding globulin (CBG) using a radioimmunoassay. Surgical severity was classified by POSSUM operative severity score. RESULTS: Ninety-three patients underwent surgery: Major/Major+ (n = 37), Moderate (n = 33) and Minor (n = 23). Peak cortisol positively correlated to severity: Major/Major+ median 680 [range 375-1452], Moderate 581 [270-1009] and Minor 574 [272-1066] nmol/L (Kruskal-Wallis test, P = .0031). CBG fell by 23%; the magnitude of the drop positively correlated to severity. CONCLUSIONS: The range in baseline and peak cortisol response to surgery is wide, and peak cortisol levels are lower than previously appreciated. Improvements in surgery, anaesthetic techniques and cortisol assays might explain our observed lower peak cortisols. The criteria for the dynamic testing of cortisol response may need to be reduced to take account of these factors. Our data also support a lower-dose, stratified approach to dosing of steroid replacement in hypoadrenal patients, to minimize the deleterious effects of over-replacement.
Matu J, O'Hara J, Hill N, et al., 2017, Changes in appetite, energy intake, body composition, and circulating ghrelin constituents during an incremental trekking ascent to high altitude., Eur J Appl Physiol, Vol: 117, Pages: 1917-1928
PURPOSE: Circulating acylated ghrelin concentrations are associated with altitude-induced anorexia in laboratory environments, but have never been measured at terrestrial altitude. This study examined time course changes in appetite, energy intake, body composition, and ghrelin constituents during a high-altitude trek. METHODS: Twelve participants [age: 28(4) years, BMI 23.0(2.1) kg m-2] completed a 14-day trek in the Himalayas. Energy intake, appetite perceptions, body composition, and circulating acylated, des-acylated, and total ghrelin concentrations were assessed at baseline (113 m, 12 days prior to departure) and at three fixed research camps during the trek (3619 m, day 7; 4600 m, day 10; 5140 m, day 12). RESULTS: Relative to baseline, energy intake was lower at 3619 m (P = 0.038) and 5140 m (P = 0.016) and tended to be lower at 4600 m (P = 0.056). Appetite perceptions were lower at 5140 m (P = 0.027) compared with baseline. Acylated ghrelin concentrations were lower at 3619 m (P = 0.046) and 4600 m (P = 0.038), and tended to be lower at 5140 m (P = 0.070), compared with baseline. Des-acylated ghrelin concentrations did not significantly change during the trek (P = 0.177). Total ghrelin concentrations decreased from baseline to 4600 m (P = 0.045). Skinfold thickness was lower at all points during the trek compared with baseline (P ≤ 0.001) and calf girth decreased incrementally during the trek (P = 0.010). CONCLUSIONS: Changes in plasma acylated and total ghrelin concentrations may contribute to the suppression of appetite and energy intake at altitude, but differences in the time course of these responses suggest that additional factors are also involved. Interventions are required to maintain appetite and energy balance during trekking at terrestrial altitudes.
Malcolm G, Rilstone S, Sivasubramaniyam S, et al., 2017, Managing diabetes at high altitude: Personal experience with support from a Multidisciplinary Physical Activity and Diabetes Clinic, BMJ Open Sport and Exercise Medicine, Vol: 3, ISSN: 2055-7647
Objective Physical activity is important for well-being but can be challenging for people with diabetes. Data informing support of specialist activities such as climbing and high-altitude trekking are limited. A 42-year-old man with type 1 diabetes (duration 30 years) attended a Multidisciplinary Physical Activity and Diabetes Clinic planning to climb Mont Blanc during the summer and trek to Everest Base Camp in the autumn. His aims were to complete these adventures without his diabetes impacting on their success. Methods We report the information provided that enabled him to safely facilitate his objectives, in particular, the requirement for frequent checking of blood glucose levels, the effects of altitude on insulin dose requirements, and recognition that acute mountain sickness may mimic the symptoms of hypoglycaemia and vice versa. Real-time continuous glucose monitoring was made available for his treks. Results The effects of high altitude on blood glucose results and glycaemic variability while treated on multiple daily injections of insulin are reported. In addition, we present a first-person account of his experience and lessons learnt from managing diabetes at high altitude. Conclusions A dedicated Multidisciplinary Physical Activity and Diabetes Clinic delivering individualised, evidence-based, patient-focused advice on the effects of altitude on blood glucose levels, and provision of real-time continuous glucose monitoring enabled uneventful completion of a trek to Everest Base Camp in a person with type 1 diabetes.
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