No acetyl group deficit is evident at the onset of exercise at 90% of maximal oxygen uptake in humans.

The existence of an acetyl group deficit at or above 90% of maximal oxygen uptake (VO(2max)) has proved controversial, with contradictory results likely relating to limitations in previous research. The purpose of the present study was to determine whether the "acetyl group deficit" occurs at the start of exercise at 90%VO(2max) in a well-controlled study. Eight male participants (age: 33.6 +/- 2.0 years; VO(2max): 3.60 +/- 0.21 litres . min(-1)) completed two exercise bouts at 90%VO(2max) for 3 min following either 30 min of saline (control) or dichloroacetate (50 mg . kg(-1) body mass) infusion, ending 15 min before exercise. Muscle biopsies were obtained immediately before and after exercise while continuous non-invasive measures of pulmonary oxygen uptake and muscle deoxygenation were made. Muscle pyruvate dehydrogenase activity was significantly higher before exercise following dichloroacetate infusion (control: 2.67 +/- 0.98 vs. dichloroacetate: 17.9 +/- 1.1 mmol acetyl-CoA . min(-1) . mg(-1) protein, P = 0.01) and resulted in higher pre- and post-exercise muscle acetylcarnitine (pre-exercise control: 3.3 +/- 0.95 vs. pre-exercise dichloroacetate: 8.0 +/- 0.88 vs. post-exercise control: 11.9 +/- 1.1 vs. post-exercise dichloroacetate: 17.2 +/- 1.1 mmol . kg(-1) dry muscle, P < 0.05). However, substrate-level phosphorylation (control: 125 +/- 20 vs. dichloroacetate: 113 +/- 13 mmol adenosine triphosphate . kg(-1) dry muscle) and VO(2) kinetics (control: 19.2 +/- 2.2 vs. dichloroacetate: 22.8 +/- 2.5 s), were unaltered. Furthermore, dichloroacetate infusion blunted the slow component of VO(2) and muscle deoxygenation and slowed muscle deoxygenation kinetics, possibly by enhancing oxygen delivery during exercise. These data support the hypothesis that the "acetyl group deficit" does not occur at or above 90%VO(2max).

Acute appendicitis presenting as small bowel obstruction: two case reports.

Acute appendicitis is a common surgical problem however the diagnosis is often overlooked when it presents as a small bowel obstruction. In this report we present two cases of elderly patients who presented with small bowel obstruction and raised inflammatory markers. Both patients were successfully treated with a laparotomy, adhesiolysis and appendicectomy and went on to make a good recovery.

Towards a Formative Assessment of Classroom Competencies (FACCs) for postgraduate medical trainees.

BACKGROUND: An assumption of clinical competency is no longer acceptable or feasible in routine clinical practice. We sought to determine the feasibility, practicability and efficacy of undertaking a formal assessment of clinical competency for all postgraduate medical trainees in a large NHS foundation trust. METHODS: FY1 doctors were asked to complete a questionnaire to determine prior experience and self reported confidence in performing the GMC core competencies. From this a consensus panel of key partners considered and developed an 8 station Objective Structured Clinical Examination (OSCE) circuit to assess clinical competencies in all training grade medical staff... The OSCE was then administered to all training grade doctors as part of their NHS trust induction process. RESULTS: 106 (87.6% of all trainees) participated in the assessment during the first 14 days of appointment. Candidates achieved high median raw percentage scores for the majority of stations however analysis of pre defined critical errors and omissions identified important areas for concern. Performance of newly qualified FY1 doctor was significantly better than other grades for the arterial blood gas estimation and nasogastric tube insertion stations. DISCUSSION: Delivering a formal classroom assessment of clinical competencies to all trainees as part of the induction process was both feasible and useful. The assessment identified areas of concern for future training and also served to reassure as to the proficiency of trainees in undertaking the majority of core competencies.

Carbohydrate availability and muscle energy metabolism during intermittent running.

PURPOSE: To examine the influence of ingesting a carbohydrate-electrolyte (CHO-E) solution on muscle glycogen use and intermittent running capacity after consumption of a carbohydrate (CHO)-rich diet. METHODS: Six male volunteers (mean +/- SD: age 22.7 +/- 3.4 yr; body mass (BM) 75.0 +/- 4.3 kg; V O2 max 60.2 +/- 1.6 mL x kg(-1) x min(-1)) performed two trials separated by 14 d in a randomized, crossover design. Subjects consumed either a 6.4% CHO-E solution or a placebo (PLA) in a double-blind fashion immediately before each trial (8 mL x kg(-1) BM) and at 15-min intervals (3 mL x kg(-1) BM) during intermittent high-intensity running to fatigue performed after CHO loading for 2 d. Muscle biopsy samples were obtained before exercise, after 90 min of exercise, and at fatigue. RESULTS: Subjects ran longer in the CHO-E trial (158.0 +/- 28.4 min) compared with the PLA trial (131.0 +/- 19.7 min; P < 0.05). There were no differences in muscle glycogen use for the first 90 min of exercise (approximately 2 mmol of glucosyl units per kilogram of dry matter (DM) per minute). However, there was a trend for a greater use in the PLA trial after 90 min (4.2 +/- 2.8 mmol x kg(-1) DM x min(-1)) compared with the CHO-E trial (2.5 +/- 0.7 mmol x kg(-1) DM x min(-1); P = 0.10). Plasma glucose concentrations were higher at fatigue in the CHO-E than in the PLA trial (P < 0.001). CONCLUSIONS: These results suggest that CHO-E ingestion improves endurance capacity during intermittent high-intensity running in subjects with high preexercise muscle glycogen concentrations. The greater endurance capacity cannot be explained solely by differences in muscle glycogen, and it may actually be a consequence of the higher plasma glucose concentration towards the end of exercise that provided a sustained source of CHO for muscle metabolism and for the central nervous system.

Colonic gallstones: a case report.

BACKGROUND: Colonic gallstone is an uncommon entity with high morbidity and mortality due to various reasons. It remains a diagnostic challenge because of delayed and non-specific presentations, especially in the elderly population, often with multiple co-morbidities. METHOD: We present a case of 81-year-old woman who had a large bowel obstruction due to colonic gallstone. RESULTS: Immediately after a cholecysto-colonic fistula was found by laporotomy, she underwent a single stage enterolithotomy, cholecystectomy and fistula closure. CONCLUSIONS: A single stage enterolithotomy, cholecystectomy and fistula closure is ideal for this condition. Various other surgical options in the literature are discussed.

Ingestion of a high-glycemic index meal increases muscle glycogen storage at rest but augments its utilization during subsequent exercise.

The aim of this study was to compare the effect of preexercise breakfast containing high- and low-glycemic index (GI) carbohydrate (CHO) (2.5g CHO/kg body mass) on muscle glycogen metabolism. On two occasions, 14 days apart, seven trained men ran at 71% maximal oxygen uptake for 30 min on a treadmill. Three hours before exercise, in a randomized order, subjects consumed either isoenergetic high- (HGI) or low-GI (LGI) CHO breakfasts that provided (per 70 kg body mass) 3.43 MJ energy, 175 g CHO, 21 g protein, and 4 g fat. The incremental areas under the 3-h plasma glucose and serum insulin response curves after the HGI meal were 3.9- (P < 0.05) and 1.4-fold greater (P < 0.001), respectively, than those after the LGI meal. During the 3-h postprandial period, muscle glycogen concentration increased by 15% (P < 0.05) after the HGI meal but remained unchanged after the LGI meal. Muscle glycogen utilization during exercise was greater in the HGI (129.1 +/- 16.1 mmol/kg dry mass) compared with the LGI (87.9 +/- 15.1 mmol/kg dry mass; P < 0.01) trial. Although the LGI meal contributed less CHO to muscle glycogen synthesis in the 3-h postprandial period compared with the HGI meal, a sparing of muscle glycogen utilization during subsequent exercise was observed in the LGI trial, most likely as a result of better maintained fat oxidation.