Successful endoscopic clipping management of a left atrioesophageal fistula after atrial fibrillation catheter ablation: A case report of a young male patient.

Atrioesophageal fistula (AEF) is a rare and serious complication of atrial fibrillation (AF) ablation, forming a connection between the atrium and esophagus. A systematic treatment approach for AEF has not been established to date. Herein, we report the case of a young male patient with left AEF after AF catheter ablation, which was successfully treated with the Over-the-Scope Clip (Ovesco Endoscopy AG, Tübingen, Germany) and conservative management. Despite having a double-orifice mitral valve and tricuspid valve, the patient had no symptoms or valve disease. The patient was readmitted three weeks after the procedure owing to fever, hematemesis, consciousness disturbance, hemiplegia, and systemic convulsions. Indigenous bacteria in the oral cavity were detected in blood culture. Magnetic resonance imaging of the brain showed multiple cerebral infarctions. Chest computed tomography showed mediastinal air, suggesting an AEF diagnosis. Subsequently, an endoscopic closure using the Over-the-Scope Clip was performed, leading to a successful recovery and patient discharge on day 87 after admission. This is the first case report of a successful management of AEF after radiofrequency ablation using the Over-the-Scope Clip system. Although surgery is the main treatment for AEFs, we performed nonsurgical management using the clip, demonstrating a potential treatment option for AEF. Learning objective: Surgical intervention is usually superior to endoscopic intervention and conservative management for treatment of atrioesophageal fistula. To the best of our knowledge, this is the first case to be successfully managed by endoscopic clipping and conservative management.

Impact of telephone support programme using telemonitoring on stage of change towards healthy eating and active exercise in people with prediabetes.

INTRODUCTION: This study evaluated the impact of a telephone support programme with telemonitoring on changes in healthy eating and active exercise in adults with prediabetes using the stage of change framework. METHODS: We performed a post hoc analysis using data from the Japan Diabetes Outcome Trial-1. A total of 2607 participants aged 20-65 years with impaired fasting glucose were recruited from the workplace/community in Japan and randomized to a one year telephone support programme intervention arm (n = 1240) or self-directed control arm (n = 1367). Participants in both arms received monthly data feedback from a weight scale and pedometer. The main outcome measure was the stages of change toward healthy eating and active exercise. The secondary outcome was fasting plasma glucose (FPG). RESULTS: After the one year intervention, the adjusted odds ratio of progressing to the action/maintenance stage in the intervention vs. control arm for healthy eating was 1.31 (95% confidence interval (CI) 1.21-1.43; p < 0.001), but that for active exercise was 1.07 (95% CI 0.99-1.15; p = 0.062). The intervention decreased FPG levels in participants in the contemplation stage, but not in the precontemplation, preparation and action/maintenance stages. DISCUSSION: These findings suggest that the telephone support programme by healthcare providers advanced the stage of changes toward healthy eating in people with prediabetes. In particular, it decreased FPG levels in the contemplation stage.

Self-weighing frequency and the incidence of type 2 diabetes: post hoc analysis of a cluster-randomized controlled trial.

OBJECTIVES: Frequent self-weighing is associated with weight loss and maintenance, but the relationship between frequent self-weighing and the incidence of type 2 diabetes (T2D) remains unclear. The study aim was to examine the association between self-weighing frequency and the incidence of T2D in people with impaired fasting glucose (IFG). RESULTS: We tested the hypothesis that self-weighing frequency and the incidence of T2D are associated in 2607 people with IFG (1240 in the intervention arm; 1367 in the self-directed control arm). Both arms received a weighing scale with storage function. Healthcare providers offered a one-year goal-focused lifestyle intervention via phone. Participants were divided into 4 categories based on self-weighing frequency (No data sent [reference group], low: < 2 times/week, middle: 3-4 times/week, and high: 5-7 times/week). The adjusted hazard ratio (AHR) and 95% confidence interval (CI) were calculated. In the intervention arm, middle- and high-frequency self-weighing were associated with a decreased incidence of T2D relative to the reference group (AHR = 0.56, 95% CI [0.32, 0.98] and AHR = 0.43, 95% CI [0.25, 0.74], respectively). In the control arm, high-frequency self-weighing was also associated with a decreased incidence of T2D relative to the reference group (AHR = 0.54, 95% CI [0.35, 0.83]). Trial registration This trial has been registered with the University Hospital Medical Information Network (UMIN000000662).

Validity of estimating physical activity intensity using a triaxial accelerometer in healthy adults and older adults.

BACKGROUND: A triaxial accelerometer with an algorithm that could discriminate locomotive and non-locomotive activities in adults has been developed. However, in the elderly, this accelerometer has not yet been validated. The aim were to examine the validity of this accelerometer in the healthy elderly, and to compare the results with those derived in a healthy younger sample. METHODS: Twenty-nine healthy elderly subjects aged 60-80 years (Elderly), and 42 adults aged 20-59 years (Younger) participated. All subjects performed 11 activities, including locomotive and non-locomotive activities with a Douglas bag while wearing the accelerometer (Active style Pro HJA-750C). Physical activity intensities were expressed as metabolic equivalents (METs). The relationship between the METs measured using the Douglas bag and METs predicted using the accelerometer was evaluated. RESULTS: A significant correlation between actual and predicted METs was observed in both Elderly (r=0.85, p<0.001) and Younger (r=0.88, p<0.001). Predicted METs significantly underestimated compared with actual METs in both groups (p<0.001). The mean of the errors was -0.6±0.6 METs in Elderly and -0.1±0.5 METs in Younger. The degree of underestimation increased with increasing METs in Elderly (p<0.001). A stepwise multiple regression analysis revealed that predicted METs, age, and weight were related to actual METs in both groups. CONCLUSION: The degree of correlation between predicted and actual METs was comparable in elderly and younger participants, but the prediction errors were greater in elderly participants, particular at higher-intensity activities, which suggests that different predicting equations may be needed for the elderly.

Prediction of Physical Activity Intensity with Accelerometry in Young Children.

Background: An algorithm for the classification of ambulatory and non-ambulatory activities using the ratio of unfiltered to filtered synthetic acceleration measured with a triaxial accelerometer and predictive models for physical activity intensity (METs) in adults and in elementary school children has been developed. The purpose of the present study was to derive predictive equations for METs with a similar algorithm in young children. Methods: Thirty-seven healthy Japanese children (four- to six-years old) participated in this study. The five non-ambulatory activities including low-intensity activities, and five ambulatory activities were selected. The raw accelerations using a triaxial accelerometer and energy expenditure by indirect calorimetry using the Douglas bag method during each activity were collected. Results: For non-ambulatory activities, especially light-intensity non-ambulatory activities, linear regression equations with a predetermined intercept (0.9) or quadratic equations were a better fit than the linear regression. The equations were different from those for adults and elementary school children. On the other hand, the ratios of unfiltered to filtered synthetic acceleration in non-ambulatory activities were different from those in ambulatory activities, as in adults and elementary school children. Conclusions: Our calibration model for young children could accurately predict intensity of physical activity including low-intensity non-ambulatory activities.

Non-locomotive physical activity intervention using a tri-axial accelerometer reduces sedentary time in type 2 diabetes.

OBJECTIVES: The purpose of this study is to examine whether the use of a tri-axial accelerometer can reduce sedentary time and increase non-locomotive physical activity (N-LPA), and to investigate the effect of this intervention on parameters of glucose and fat metabolism in patients with type 2 diabetes. METHODS: Thirty-eight patients with type 2 diabetes (Age: 61.8 ± 1.4 years, BMI: 24.8 ± 0.6, HbA1c: 6.6 ± 0.1 %) participated in this 12-week randomized controlled study, and 31 patients were included in the final analyses. Patients were randomly assigned to one of three groups: control, N-LPA or locomotive physical activity (LPA). Patients in the N-LPA and LPA groups were asked to increase their N-LPA and LPA, respectively, using tri-axial accelerometer feedback. Glucose and fat metabolic parameters were evaluated before and after 12-week intervention. RESULTS: Only the N-LPA intervention significantly reduced sedentary time (p < 0.05) and increased N-LPA (p < 0.05). However, these changes were insufficient to improve parameters associated with glucose and fat metabolism (p > 0.05), despite a significant positive correlation between the change in sedentary time and HbA1c levels (p < 0.05). CONCLUSION: Our results showed that the N-LPA intervention using a tri-axial accelerometer successfully reduced sedentary time in patients with type 2 diabetes, however that induced no significant improvement of glucose and fat metabolism. Further research is required to determine the degree of reduction in sedentary time and increase in N-LPA needed to improve glucose and fat metabolism.

Optimal Conditions for Obtaining Valid Step Count Measurements in Hospitalized Patients with Abnormal Gait.

OBJECTIVE: This study investigated the optimum conditions for obtaining valid step-count measurements for patients with abnormal gait. METHODS: Subjects comprised 61 hospitalized patients with abnormal gait. Four different devices were tested: Active Style Pro (AS), Walking Style (WS), Lifecorder PLUS, and Steps. The same device type was attached to the waist on both the affected and the unaffected side. Patients then walked 25 m at a comfortable speed. This test was repeated four times, once for each device. The measurement error (ME) and walking parameters (gait velocity, step length, and cadence) were calculated from the test data. ME scores smaller than 3% and 10% were classified as valid: scores above these standards were classified as invalid. Walking parameter values that identified the invalid group with a specificity of 0.95 were set as the cut-off velocity (COV), the cut-off step length (COS), and the cut-off cadence. Sensitivity values >0.40 and positive predictive values >80% were then set as necessary conditions. RESULTS: COV values were 0.90 m/s (AS on the unaffected side at 3% ME and AS on the affected side or the unaffected side at 10% ME), 0.92 m/s (WS on the unaffected side at 10% ME), and 0.98 m/s (WS on the affected side at 3% ME). COS values were 0.50 m (AS on the affected side at 10% ME) and 0.52 m (AS on the unaffected side at 3% ME). CONCLUSION: The most accurate measurements were obtained using AS attached to the unaffected side with a gait velocity of >0.90 m/s.

Effects of non-exercise activity and daily exercise activity upon glucose and fat metabolism in type 2 diabetes.

BACKGROUND: The purpose of this study was to disclose the relationship between objectively measured non-exercise activity (NEA) and moderate to vigorous physical activity (MVPA) using triaxial accelerometer and the effect of each activity on glucose and fat metabolism in active type 2 diabetes. Elucidating this relationship and effect would lead to support educational programs for the management of type 2 diabetes. METHODS: Seventy-seven patients with type 2 diabetes who had performed daily programmed walking exercise participated in this cross-sectional study. Physical activity including NEA and MVPA was measured by triaxial accelerometer for 10 consecutive days and the measurements of body composition and glucose and lipid profile were performed. RESULTS: There was no significant correlation between NEA and MVPA in active type 2 diabetes. NEA had a significant inverse correlation with body fat (P<0.05) and higher MVPA manifested a positive influence upon glucose and/or fat metabolism (P<0.05). CONCLUSIONS: This study suggested even patients who performed a routine programmed MVPA remained sedentary other than MVPA, thus, clinicians should counsel patients to not only promote MVPA but to increase NEA by quantification of NEA. The results of this study should be taken into consideration for the development of educational programs and management of type 2 diabetes.

Effects of telephone-delivered lifestyle support on the development of diabetes in participants at high risk of type 2 diabetes: J-DOIT1, a pragmatic cluster randomised trial.

OBJECTIVES: To examine the effects of telephone-delivered lifestyle coaching on preventing the development of type 2 diabetes mellitus (T2DM) in participants with impaired fasting glucose (IFG). DESIGN: Cluster randomised trial. SETTING: 40 groups from 17 healthcare divisions in Japan: companies (31), communities (6) and mixed settings (3). PARTICIPANTS: Participants aged 20-65 years with fasting plasma glucose (FPG) of 5.6-6.9 mmol/L were invited from the 17 healthcare divisions. RANDOMISATION: The groups were then randomly assigned to an intervention or a control arm by independent statisticians according to a computer-generated list. INTERVENTION: The intervention arm received a 1-year telephone-delivered intervention provided by three private lifestyle support centres (at different frequencies: low-frequency (3 times), middle-frequency (6 times) and high-frequency (10 times) support calls). The intervention and control arms both received self-help devices such as a weight scale and pedometer. OUTCOMES: Participants were followed up using data from annual health check-ups and a questionnaire regarding lifestyle. The primary outcome was the development of T2DM defined as FPG ≥ 7.0 mmol/L, the diagnosis of diabetes, or use of an antidiabetic drug, confirmed by referring to medical cards. RESULTS: Of 14,473 screened individuals, participants were enrolled in either the intervention (n = 1240) arm or control (n = 1367) arm. Overall, the HR for the development of T2DM in the intervention arm during 5.5 years was 1.00 (95% CI 0.74 to 1.34). In the subanalysis, the HR was 0.59 (95% CI 0.42 to 0.83) in the subgroup that received phone calls the most frequently, compared with the control arm. A limitation of the study includes a lack of blinding. CONCLUSIONS: High-frequency telephone-delivered lifestyle support could effectively prevent T2DM in participants with IFG in a primary healthcare setting, although low-frequency and middle-frequency phone calls did not. TRIAL REGISTRATION NUMBER: This trial has been registered with the University Hospital Medical Information Network (UMIN000000662).

Validity and reproducibility of a novel method for time-course evaluation of diet-induced thermogenesis in a respiratory chamber.

We developed a novel method for computing diet-induced thermogenesis (DIT) in a respiratory chamber and evaluated the validity and reproducibility of the method. We hypothesized that DIT may be calculated as the difference between postprandial energy expenditure (EE) and estimated EE (sum of basal metabolic rate and physical activity (PA)-related EE). The estimated EE was derived from the regression equation between EE from respiration and PA intensity in the fasting state. It may be possible to evaluate the time course of DIT using this novel technique. In a validity study, we examined whether DIT became zero (theoretical value) for 6 h of fasting in 11 subjects. The mean value of DIT calculated by the novel and traditional methods was 22.4 ± 13.4 and 3.4 ± 31.8 kcal/6 h, respectively. In the reproducibility study, 15 adult subjects lived in the respiratory chamber for over 24 h on two occasions. The DIT over 15 h of postprandial wake time was calculated. There were no significant differences in the mean values of DIT between the two test days. The within-subject day-to-day coefficient of variation for calculated DIT with the novel and traditional methods was approximately 35% and 25%, respectively. The novel method did not have superior reproducibility compared with that of the traditional method. However when comparing the smaller variation in the fasting state than the theoretical value (zero), the novel method may be better for evaluating interindividual differences in DIT than the traditional method and also has the ability to evaluate the time-course.

Prediction models discriminating between nonlocomotive and locomotive activities in children using a triaxial accelerometer with a gravity-removal physical activity classification algorithm.

The aims of our study were to examine whether a gravity-removal physical activity classification algorithm (GRPACA) is applicable for discrimination between nonlocomotive and locomotive activities for various physical activities (PAs) of children and to prove that this approach improves the estimation accuracy of a prediction model for children using an accelerometer. Japanese children (42 boys and 26 girls) attending primary school were invited to participate in this study. We used a triaxial accelerometer with a sampling interval of 32 Hz and within a measurement range of ±6 G. Participants were asked to perform 6 nonlocomotive and 5 locomotive activities. We measured raw synthetic acceleration with the triaxial accelerometer and monitored oxygen consumption and carbon dioxide production during each activity with the Douglas bag method. In addition, the resting metabolic rate (RMR) was measured with the subject sitting on a chair to calculate metabolic equivalents (METs). When the ratio of unfiltered synthetic acceleration (USA) and filtered synthetic acceleration (FSA) was 1.12, the rate of correct discrimination between nonlocomotive and locomotive activities was excellent, at 99.1% on average. As a result, a strong linear relationship was found for both nonlocomotive (METs = 0.013×synthetic acceleration +1.220, R2 = 0.772) and locomotive (METs = 0.005×synthetic acceleration +0.944, R2 = 0.880) activities, except for climbing down and up. The mean differences between the values predicted by our model and measured METs were -0.50 to 0.23 for moderate to vigorous intensity (>3.5 METs) PAs like running, ball throwing and washing the floor, which were regarded as unpredictable PAs. In addition, the difference was within 0.25 METs for sedentary to mild moderate PAs (<3.5 METs). Our specific calibration model that discriminates between nonlocomotive and locomotive activities for children can be useful to evaluate the sedentary to vigorous PAs intensity of both nonlocomotive and locomotive activities.

Effect of weight-loss program using self-weighing twice a day and feedback in overweight and obese subject: a randomized controlled trial.

OBJECTIVE: To investigate the effectiveness of self-weighing twice a day with a supportive program installed on a body composition monitor in overweight adults. SUBJECTS: Sixty adults with BMI > 24 kg/m(2) were randomly assigned to either a group that weighed themselves once per day (group 1, n = 30) or a group that weighed themselves twice per day (group 2, n = 30). INTERVENTION: Group 1 was instructed to self-weigh at the same time once per day and group 2 was instructed to self-weigh immediately after waking up in the morning and immediately before going to bed every day for twelve weeks. In addition, participants in group 2 was received the daily target setting during morning weighing and the difference between the measured weight and the target weight during bedtime weighing. RESULTS: Average weight reduction in group 1 was significantly lower than that in group 2 (1.0 ± 1.4 kg vs. 2.7 ± 2.1 kg, p < 0.05). The proportion of participants who lost ≥ 5% of their pre-program weight in group 2 was significantly higher than that in group 1 (28.6% vs. 3.6%, p < 0.05). CONCLUSION: A self-weighing twice per day plus daily target setting and feedback is more effective in promoting weight loss than once-daily self-measurement.

Real-time estimation of daily physical activity intensity by a triaxial accelerometer and a gravity-removal classification algorithm.

We have recently developed a simple algorithm for the classification of household and locomotive activities using the ratio of unfiltered to filtered synthetic acceleration (gravity-removal physical activity classification algorithm, GRPACA) measured by a triaxial accelerometer. The purpose of the present study was to develop a new model for the immediate estimation of daily physical activity intensities using a triaxial accelerometer. A total of sixty-six subjects were randomly assigned into validation (n 44) and cross-validation (n 22) groups. All subjects performed fourteen activities while wearing a triaxial accelerometer in a controlled laboratory setting. During each activity, energy expenditure was measured by indirect calorimetry, and physical activity intensities were expressed as metabolic equivalents (MET). The validation group displayed strong relationships between measured MET and filtered synthetic accelerations for household (r 0·907, P < 0·001) and locomotive (r 0·961, P < 0·001) activities. In the cross-validation group, two GRPACA-based linear regression models provided highly accurate MET estimation for household and locomotive activities. Results were similar when equations were developed by non-linear regression or sex-specific linear or non-linear regressions. Sedentary activities were also accurately estimated by the specific linear regression classified from other activity counts. Therefore, the use of a triaxial accelerometer in combination with a GRPACA permits more accurate and immediate estimation of daily physical activity intensities, compared with previously reported cut-off classification models. This method may be useful for field investigations as well as for self-monitoring by general users.

Classifying household and locomotive activities using a triaxial accelerometer.

The purpose of this study was to develop a new algorithm for classifying physical activity into either locomotive or household activities using a triaxial accelerometer. Sixty-six volunteers (31 men and 35 women) participated in this study and were separated randomly into validation and cross-validation groups. All subjects performed 12 physical activities (personal computer work, laundry, dishwashing, moving a small load, vacuuming, slow walking, normal walking, brisk walking, normal walking while carrying a bag, jogging, ascending stairs and descending stairs) while wearing a triaxial accelerometer in a controlled laboratory setting. Each of the three signals from the triaxial accelerometer was passed through a second-order Butterworth high-pass filter to remove the gravitational acceleration component from the signal. The cut-off frequency was set at 0.7 Hz based on frequency analysis of the movements conducted. The ratios of unfiltered to filtered total acceleration (TAU/TAF) and filtered vertical to horizontal acceleration (VAF/HAF) were calculated to determine the cut-off value for classification of household and locomotive activities. When the TAU/TAF discrimination cut-off value derived from the validation group was applied to the cross-validation group, the average percentage of correct discrimination was 98.7%. When the VAF/HAF value similarly derived was applied to the cross-validation group, there was relatively high accuracy but the lowest percentage of correct discrimination was 63.6% (moving a small load). These findings suggest that our new algorithm using the TAU/TAF cut-off value can accurately classify household and locomotive activities.

Accuracy of spring-levered and piezo-electric pedometers in primary school Japanese children.

Pedometers are used in many studies because physical activities can be simply assessed using them. In addition to the spring-levered type, piezo-electric pedometers have recently been used. However, their accuracy in children has not been investigated in previous studies. In this study, we investigated the accuracy of spring-levered pedometer and piezo-electric pedometer step counts in comparison with hand-tallied step counts with children during self-paced walking. First to 6th-grade primary school children (394 subjects; 201 boys and 193 girls) walked with pedometers on an outdoor 50-m course, and the measured values were compared with actual steps at 3 speeds: normal, slow, and fast paces. The counts obtained by the spring-levered pedometer were significantly lower than the actual steps in most grades at all walking paces. In the normal- and fast-pace walking, the counts by spring-levered pedometer were significantly lower than the actual steps in all grades excluding the 5th grade. Moreover, the spring-levered pedometer underestimated by 25% or more in all grades at slow pace. In contrast, the percent error of the counts by the piezo-electric pedometers at normal pace were mostly within +/-3%, confirming their high accuracy. Based on these findings, spring-levered pedometers are not appropriate for children, whereas piezo-electric pedometers are useful for investigation of the physical activity of children.

The heart rate increase at the onset of high-work intensity exercise is accelerated by central blood volume loading.

Using a water immersion (WI) method, the combined effect of central blood volume (CBV) loading and work intensity on the time course of heart rate (HR) at the onset of upright dynamic exercise was investigated. Seven males cranked a cycle ergometer for 12 min using their un-immersed arms at low-, moderate- and high-work intensities, followed by a 12-min rest. For WI, the pre-exercise resting cardiac output increased by 36%, while HR decreased by 22% [from 76.8 (10.4) to 59.6 (9.8) beats/min]. WI also increased the high-frequency (HF, 0.15-0.40 Hz) component of the HR variability, suggesting an increased vagal activity. During the initial 2 min of the exercise period at low-work intensity, HR increased by 34.9 and 25.8% in the WI and control conditions, respectively. These were 117 and 73% at high-work intensity, indicating more accelerated HR with WI than the control. The plasma norepinephrine concentration increased less during high-work intensity exercise during WI, as compared to exercise during control conditions. In conclusion, the HR increase at the onset of high-work intensity exercise is accelerated by CBV loading but not at low intensity, possibly reflecting vago-sympathetic interaction and reduced baroreflex sensitivity.

Effects of electrical stimulation and voluntary exercise on muscle oxygenation assessed by NIRS.

In this study, we investigated the effect of low-frequency ES (electric stimulation) to muscle oxygenation level by NIRS (near infrared spectroscopy) from comparing with V-Ex (voluntary exercise). Ten subjects performed ES and V-Ex test in supine position on a bed with 90 degrees flexion of the right knee joint and fixation of the right ankle to the end of the bed with a strap. NIRS probe was placed on middle point of the vastus lateralis, and four electrodes were placed across the motor point of the rectus femoris and vastus lateralis. Stimulation voltage was started at 20 V (20 Hz, pulse duration: 200 micros, duty-cycle: 1s-1s), and then was increased at a rate of 3 V/30 s until maximal tolerance level. V-Ex (isometric knee extension) was performed with same posture as in ES, and exercise pattern was set at a 1-s contraction and 1-s relaxation cycle. Exercise intensity was started at 5% MVC (maximal voluntary contraction) and was increased at a rate of 5% MVC/30 sec until exhaustion. In ES and V-Ex, tissue oxygenation index was decreased with decrease in O2Hb (oxy-hemoglobin) and increase in HHb (deoxyhemoglobin), and muscle oxygenation levels at the end of test were very alike. Oxygen consumption, heart rate, systolic and diastolic blood pressure in ES and V-Ex increased significantly, however, the degree of change in ES was significantly lower than V-Ex. Blood lactate was significantly increased in both tests. Adrenaline and noradrenaline were significantly increased in V-Ex, even though they showed no change in ES. These results lead us to believe that ES is an effective technique activated muscle hypoxia and glycolytic pathway metabolism with low stress on respiratory, circulatory and sympathetic nervous systems.