Nutritional support for a person with type 1 diabetes undertaking endurance swimming

Long distance and open water swimming have increased in popularity over recent years. Swimming a long distance in lakes, rivers and the sea present numerous challenges, including cold water exposure and maintaining adequate nutritional intake to fuel exercising muscles. Guidelines exist outlining issues to consider and potential solutions to overcome the difficulties in feeding athletes. Exercising with type 1 diabetes adds further complexity, mostly around matching insulin to the recommended high carbohydrate intake, but also because of the way in which higher circulating insulin levels affect glucose utilisation and fat oxidation. This paper describes the nutritional considerations for people with type 1 diabetes intending to undertake long distance open water events, and insulin management suggestions to trial alongside. In addition, we include personal testimony from a swimmer with type 1 diabetes describing the challenges and considerations he faced when undertaking marathon swimming

Biophysical aspects of handcycling performance in rehabilitation, daily life and recreational sports; a narrative review

Aim In this narrative review the potential and importance of handcycling are evaluated. Four conceptual models form the framework for this review; (1) the International Classification of Functioning, Disability and Health; (2) the Stress-Strain-Capacity model; (3) the Human-Activity-Assistive Technology model; and (4) the power balance model for cyclic exercise. Methods Based on international handcycle experience in (scientific) research and practice, evidence-based benefits of handcycling and optimization of handcycle settings are presented and discussed for rehabilitation, daily life and recreational sports. Results As the load can be distributed over the full 360° cycle in handcycling, peak stresses in the shoulder joint and upper body muscles reduce. Moreover, by handcycling regularly, the physical capacity can be improved. The potential of handcycling as an exercise mode for a healthy lifestyle should be recognized and advocated much more widely in rehabilitation and adapted sports practice. The interface between handcycle and its user should be optimized by choosing a suitable person-specific handcycle, but mainly by optimizing the handcycle dimensions to one’s needs and desires. These dimensions can influence efficient handcycle use and potentially improve both endurance and speed of handcycling. Conclusion To optimize performance in rehabilitation, daily life and recreational sports, continued and more systematic research is required. Implications for rehabilitation Handcycling allows users to travel farther distances at higher speeds and to train outdoors. It should be recognized as an alternative exercise modality for daily outdoor use, also already in early rehabilitation, while it contributes to a healthy lifestyle. To individualize handcycle performance, the user-handcycle (assistive device) interface as well as the vehicle mechanics should be optimized to minimize external power and reduce friction, so that the upper body capacity can be efficiently used. To optimize handcycling individual performance, both the physiological and biomechanical aspects of handcycling should be considered when monitoring or testing handcycle exercise

Effects of Topically Administered Neuroprotective Drugs in Early Stages of Diabetic Retinopathy:Results of the EUROCONDOR Clinical Trial

The primary objective of this study was to assess whether the topical administration of two neuroprotective drugs (brimonidine and somatostatin) could prevent or arrest retinal neurodysfunction in patients with type 2 diabetes. For this purpose, adults aged between 45 and 75 years with a diabetes duration ≥5 years and an Early Treatment of Diabetic Retinopathy Study (ETDRS) level of ≤35 were randomly assigned to one of three arms: placebo, somatostatin, or brimonidine. The primary outcome was the change in implicit time (IT) assessed by multifocal electroretinography between baseline and at the end of follow-up (96 weeks). There were 449 eligible patients allocated to brimonidine (n = 152), somatostatin (n = 145), or placebo (n = 152). When the primary end point was evaluated in the whole population, we did not find any neuroprotective effect of brimonidine or somatostatin. However, in the subset of patients (34.7%) with preexisting retinal neurodysfunction, IT worsened in the placebo group (P < 0.001) but remained unchanged in the brimonidine and somatostatin groups. In conclusion, the topical administration of the selected neuroprotective agents appears useful in preventing the worsening of preexisting retinal neurodysfunction. This finding points to screening retinal neurodysfunction as a critical issue to identify a subset of patients in whom neuroprotective treatment might be of benefit

Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

Background Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects. Methods FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762. Findings Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839–1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26–6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38–2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months. Interpretation Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function. Funding UK Stroke Association and NIHR Health Technology Assessment Programme

Effects of dynamic upper body exercise on lower limb isometric endurance.

Following preliminary indications that in some individuals arm exercise enhanced rather than reduced simultaneous leg endurance, ten young men and women performed three forms of intermittent work to volitional exhaustion, under duty cycles of 45 s work, 15 s rest. The protocols were as follows: (A) knee extensions at 30% maximum voluntary contraction (MVC); (B) 30% MVC knee extensions combined with arm cranking at 130% of their own lactate threshold; (C) combined 30% MVC knee extensions and arm cranking at 20% of their own lactate threshold. Heart rate, oxygen uptake ( _V O2), and blood lactate concentration were among the variables recorded throughout. All physiological indicators of demand were substantially higher in protocol B than in protocols A or C [heart rate: (A) 154 beats � min71, (B) 171 beats � min71, (C) 150 beats � min71; _V O2: (A) 11.9 ml � kg71 � min71, (B) 21.7 ml � kg71 � min71, (C) 14.2 ml � kg71 � min71; blood lactate concentration: (A) 3.3 mmol � l71, (B) 5.1 mmol � l71, (C) 2.8 mmol � l71], yet there were no significant differences (P40.05) in the endurance times between the three conditions [(A) 11.43 min, (B) 11.1 min, (C) 10.57 min] and seven participants endured longest in protocol B. Results from protocol (C) cast doubt on explanations in terms of psychological distraction. We suggest that lactic acid produced by the arms is shuttled to the legs and acts there either as a supplementary fuel source or as an antagonist to the depressing effects of increased potassium concentration

Hiking physiology and the "quasi-isometric" concept

The literature indicates that the heart rate of a planing-dinghy sailor, in winds of 4 – 5 m · s−1, is in the range seen in aerobic athletes, yet oxygen consumption ([Vdot]O2) is roughly half that of the same individual cycling at that heart rate. Thus, although upper-body dynamic activity is a contributing factor, the dominant physiological demand must be the “quasi-isometric” stress on the lower-body anterior muscles – especially the quadriceps, which appears to impose 40 – 50% of the total oxygen demand in a typical hiking posture. Therefore, a non-trivial part of the sailor's fitness training should involve sustained quadriceps stress. Estimates of this stress on water vary widely in the literature, but about 25 – 30% maximal voluntary contraction (MVC) tallies with endurance times recorded both in the literature and in an outline of new work reported here. Muscle blood flow is restricted under such a load, but not occluded. Laser Doppler measurements of femoral blood flow on a leg-extension ergometer found similar values during 10 – 30% MVC, much less at 40%, and marked hyperaemia on relaxation from 20% MVC or more – implying metabolic debt. Adding low-amplitude alternating leg movements while holding the same overall load stationary, and therefore increasing only internal not external work, further elevates blood flow and [Vdot]O2 both during and after exercise. Femoral-vein lactate concentration is also higher after these movements. Speculations that unusually dynamic lower-body movements by elite sailors might assist hiking endurance are not supported by these findings. Nevertheless, afloat or ashore, capillary lactate concentrations hardly ever exceed 5 mmol · l−1, even during the post-exercise surge – challenging assumptions that the quadriceps had been profoundly anaerobic while under load. On the contrary, it appears that aerobic metabolism contributes substantially, if not completely, to energy supply. A preliminary comparison of elite sailors with aerobic athletes suggests that isometric endurance at a given percentage MVC does not differ between the two groups, but the sailors have higher MVCs. In individuals not highly strength-trained, greater electromyogram activity immediately before capitulation than in an MVC performed while fresh indicates that physiological (not just volitional) limits have been reached. It is concluded that the literature and the outline of my recent work with colleagues support the view that the predominant physiological load during single-handed dinghy sailing is quasi-isometric in form and accounts for roughly half of the metabolic demand. Any more complete account of the physiology of hiking will require simultaneous on-water measurement of electromyographic, cardiovascular, and metabolic indicators in sailors extending from club to Gold Medal standard