Standardization and other approaches to meta-analyze differences in means.

Meta-analysts often use standardized mean differences (SMD) to combine mean effects from studies in which the dependent variable has been measured with different instruments or scales. In this tutorial we show how the SMD is properly calculated as the difference in means divided by a between-subject reference-group, control-group, or pooled pre-intervention SD, usually free of measurement error. When combining mean effects from controlled trials and crossovers, most meta-analysts have divided by either the pooled SD of change scores, the pooled SD of post-intervention scores, or the pooled SD of pre- and post-intervention scores, resulting in SMDs that are biased and difficult to interpret. The frequent use of such inappropriate standardizing SDs by meta-analysts in three medical journals we surveyed is due to misleading advice in peer-reviewed publications and meta-analysis packages. Even with an appropriate standardizing SD, meta-analysis of SMDs increases heterogeneity artifactually via differences in the standardizing SD between settings. Furthermore, the usual magnitude thresholds for standardized mean effects are not thresholds for clinically important differences. We therefore explain how to use other approaches to combining mean effects of disparate measures: log transformation of factor effects (response ratios) and of percent effects converted to factors; rescaling of psychometrics to percent of maximum range; and rescaling with minimum clinically important differences. In the absence of clinically important differences, we explain how standardization after meta-analysis with appropriately transformed or rescaled pre-intervention SDs can be used to assess magnitudes of a meta-analyzed mean effect in different settings.

Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: known knowns and known unknowns.

The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD) updates the KDIGO 2012 guideline and has been developed with patient partners, clinicians, and researchers around the world, using robust methodology. This update, based on a substantially broader base of evidence than has previously been available, reflects an exciting time in nephrology. New therapies and strategies have been tested in large and diverse populations that help to inform care; however, this guideline is not intended for people receiving dialysis nor those who have a kidney transplant. The document is sensitive to international considerations, CKD across the lifespan, and discusses special considerations in implementation. The scope includes chapters dedicated to the evaluation and risk assessment of people with CKD, management to delay CKD progression and its complications, medication management and drug stewardship in CKD, and optimal models of CKD care. Treatment approaches and actionable guideline recommendations are based on systematic reviews of relevant studies and appraisal of the quality of the evidence and the strength of recommendations which followed the "Grading of Recommendations Assessment, Development, and Evaluation" (GRADE) approach. The limitations of the evidence are discussed. The guideline also provides practice points, which serve to direct clinical care or activities for which a systematic review was not conducted, and it includes useful infographics and describes an important research agenda for the future. It targets a broad audience of people with CKD and their healthcare, while being mindful of implications for policy and payment.

Exploration of collective tactical variables in elite netball: An analysis of team and sub-group positioning behaviours.

Collective tactical behaviours are aspects of player interactions that are particularly important in netball, due to its unique restrictions on player movement (players unable to move when in possession of the ball and positional spatial restrictions). The aim of this study was to explore variables representing collective tactical behaviours in netball. A local positioning system provided player positions of one team throughout seven elite-level netball matches. The positions were analysed to provide mean, variability (standard deviation) and irregularity (normalised approximate entropy) for each attack and defence possession (470 and 423, respectively) for the team and positional subgroups (forwards, midcourts and defenders) for 10 position-related variables. Correlational analyses showed collective tactical variables could be grouped as lateral and longitudinal dispersion variables. The variables were each analysed after log transformation with a linear mixed model to compare attack and defence and to estimate standardised effects on attack and defence of possession outcome, possession duration, score difference, match time, opposition strength and season time. During attack, the team and all sub-groups adopted greater lateral dispersion between players, while on defence there was generally greater longitudinal dispersion. The team also showed increased longitudinal dispersion when home and opposition possessions ended in a score. Additionally, greater irregularity was observed in active sub-groups (forwards on attack, defenders on defence). Score difference and opposition strength had trivial-small but generally unclear effects. In conclusion, these effects show that analysis of player positions on attack and defence is a promising avenue for coaches and analysts to modify collective tactical behaviours in netball.

Quantifying Offense and Defense Workloads in Professional Rugby Union.

PURPOSE: Rugby union is a contact team sport demanding high levels of physical capacity, and understanding the match workloads can be useful to inform training. In this study, the factors influencing locomotion and contact workloads for offensive and defensive ball-in-play periods are quantified. METHODS: Locomotion and contact metrics were collected from global positioning system units and videos for 31 professional players of a Super Rugby team across 14 games in the 2021 season. Data were analyzed with a generalized mixed-model procedure that included effects for type of play, playing position, match outcome, and ball-in-play time. Magnitudes were assessed with standardization, and evidence for substantial magnitudes was derived from sampling uncertainty. RESULTS: When offense was compared to defense, most metrics showed decisively substantial increases (small to moderate) for forwards and backs. There was decisive evidence that locomotion metrics were substantially lower (large differences) and contact metrics were higher (very large differences) when comparing forwards to backs on offense and defense. When winning was compared to losing, there was good evidence that forwards experienced small increases in overall workload on defense, and backs experienced a small increase in high-speed running and a moderate decrease in contacts on offense. Match-to-match changes associated with ball-in-play time, attributed to fatigue, were decisive (moderate to very large) across most metrics for forwards and backs in offense and defense. CONCLUSIONS: The increased locomotion and contact workloads in offensive periods and the differing physical requirements between positions and match outcomes for both types of play are novel findings that should aid practitioners in designing effective training.

Monitoring Changes in Lower-Limb Strength and Power in Elite Athletes With the Countermovement-Jump and Keiser Leg-Press Tests.

PURPOSE: To determine the utility of countermovement-jump and Keiser leg-press tests for tracking changes in elite athletes of different sports. METHODS: Elite athletes of the Norwegian Olympic Federation (126 individuals from 18 sports) performed countermovement-jump and Keiser tests on 2 to 11 occasions between 2014 and 2021. Separate analyses were performed for male and female alpine skiing, male and female handball, male ice hockey, and males and females of other sports. Means and standard deviations of consecutive change scores were combined with short-term error of measurement (3.7%-7.0%) and smallest important changes (2.0%-3.6%, defined by standardization) to determine the proportions of athletes who experienced decisive changes in 2 senses: first, the athlete did not get substantially worse or better (>90% chance of either), and second, the athlete did get substantially worse or better (>90% chance of either). RESULTS: Averaged over sports, Keiser peak power and relative peak power had the highest proportions of decisive changes in the first (60% and 55%) and second senses (25% and 28%). The velocity intercept of the force-velocity relationship had the lowest proportions in the first and second senses (29% and 11%), while jump height, Keiser mean power, relative mean power, the force intercept, and the slope of the force-velocity relationship had similar proportions (40%-53% and 15%-21%). CONCLUSIONS: With the possible exception of the Keiser test velocity intercept, the proportions of observed decisive changes in elite athletes using Keiser measures and countermovement-jump height between tests appear adequate for the measures to be useful for routine monitoring.

Accuracy of flight time and countermovement-jump height estimated from videos at different frame rates with MyJump.

Recent improvements in smartphone video technology may provide sufficient accuracy for estimation of jump height via flight time determined from video recordings of vertical-jump tests. The aim of this study is to evaluate the accuracy of jump height estimated from videos at different frame rates. High-definition videos of 10 young adults (6 males, 4 females) performing 5 countermovement jumps were recorded at a frame rate of 1000 Hz and transcoded to frame rates of 120, 240, and 480 Hz. Flight time in the videos was assessed independently by three observers at each of the four frame rates with MyJump. Flight time and jump height were analyzed with mixed models for estimation of means and of standard deviations representing technical error of measurement (free of within-subject jump-to-jump variability) at each frame rate. The four frame rates and three observers produced practically identical estimates of mean jump height. The technical errors at 120, 240, 480 and 1000 Hz were respectively 3.4, 1.8, 1.2 and 0.8 ms for flight time, and 1.4%, 0.7%, 0.5% and 0.3% for jump height. Assessed relative to either differences in jump height between elite football players (standard deviation of ~12%) or the smallest expected test-retest variability (typical error of ~3%), the technical error was substantial at 120 Hz but negligible at 240 Hz or higher. In conclusion, use of frame rates above 240 Hz to estimate jump height with MyJump will not improve accuracy substantially.

Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic: a systematic review and meta-analysis.

BACKGROUND: There is a lack of consensus about the effect of the COVID-19 pandemic on the mental health of children and adolescents. We aimed to compare rates of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation during the pandemic with those before the pandemic. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO for studies published between Jan 1, 2020, and Dec 19, 2022. Studies published in English with data on paediatric (ie, those aged <19 years) emergency department visits before and during the COVID-19 pandemic were included. Case studies and qualitative analyses were excluded. Changes in attempted suicide, self-harm, suicidal ideation, and other mental-illness indicators (eg, anxiety, depression, and psychosis) were expressed as ratios of the rates of emergency department visits during the pandemic compared with those before the pandemic, and we analysed these with a random-effects meta-analysis. This study was registered with PROSPERO, CRD42022341897. FINDINGS: 10 360 non-duplicate records were retrieved, which yielded 42 relevant studies (with 130 sample-estimates) representing 11·1 million emergency department visits for all indications of children and adolescents across 18 countries. The mean age of the samples of children and adolescents across studies was 11·7 years (SD 3·1, range 5·5-16·3), and there were on average 57·6% girls and 43·4% boys as a proportion of emergency department visits for any health reasons (ie, physical and mental). Only one study had data related to race or ethnicity. There was good evidence of an increase in emergency department visits for attempted suicide during the pandemic (rate ratio 1·22, 90% CI 1·08-1·37), modest evidence of an increase in emergency department visits for suicidal ideation (1·08, 0·93-1·25), and good evidence for only a slight change in self-harm (0·96, 0·89-1·04). Rates of emergency department visits for other mental-illness indications showed very good evidence of a decline (0·81, 0·74-0·89), and paediatric visits for all health indications showed strong evidence of a reduction (0·68, 0·62-0·75). When rates for attempted suicide and suicidal ideation were combined as a single measure, there was good evidence of an increase in emergency department visits among girls (1·39, 1·04-1·88) and only modest evidence of an increase among boys (1·06, 0·92-1·24). Self-harm among older children (mean age 16·3 years, range 13·0-16·3) showed good evidence of an increase (1·18, 1·00-1·39), but among younger children (mean age 9·0 years, range 5·5-12·0) there was modest evidence of a decrease (0·85, 0·70-1·05). INTERPRETATION: The integration of mental health support within community health and the education system-including promotion, prevention, early intervention, and treatment-is urgently needed to increase the reach of mental health support that can mitigate child and adolescent mental distress. In future pandemics, increased resourcing in some emergency department settings would help to address their expected increase in visits for acute mental distress among children and adolescents. FUNDING: None.

Replacing statistical significance and non-significance with better approaches to sampling uncertainty.

A sample provides only an approximate estimate of the magnitude of an effect, owing to sampling uncertainty. The following methods address the issue of sampling uncertainty when researchers make a claim about effect magnitude: informal assessment of the range of magnitudes represented by the confidence interval; testing of hypotheses of substantial (meaningful) and non-substantial magnitudes; assessment of the probabilities of substantial and trivial (inconsequential) magnitudes with Bayesian methods based on non-informative or informative priors; and testing of the nil or zero hypothesis. Assessment of the confidence interval, testing of substantial and non-substantial hypotheses, and assessment of Bayesian probabilities with a non-informative prior are subject to differing interpretations but are all effectively equivalent and can reasonably define and provide necessary and sufficient evidence for substantial and trivial effects. Informative priors in Bayesian assessments are problematic, because they are hard to quantify and can bias the outcome. Rejection of the nil hypothesis (presented as statistical significance), and failure to reject the nil hypothesis (presented as statistical non-significance), provide neither necessary nor sufficient evidence for substantial and trivial effects. To properly account for sampling uncertainty in effect magnitudes, researchers should therefore replace rather than supplement the nil-hypothesis test with one or more of the other three equivalent methods. Surprisal values, second-generation p values, and the hypothesis comparisons of evidential statistics are three other recent approaches to sampling uncertainty that are not recommended. Important issues beyond sampling uncertainty include representativeness of sampling, accuracy of the statistical model, individual differences, individual responses, and rewards of benefit and costs of harm of clinically or practically important interventions and side effects.

Population, economic and geographic predictors of nations' medal tallies at the Pyeongchang and Tokyo Olympics and Paralympics.

Purpose: Ranking of nations by medal tally is a popular feature of the Olympics, but such ranking is a poor measure of sporting prowess or engagement until the tallies are adjusted for major factors beyond the control of individual nations. Here we estimate and adjust for effects of total population, economy expressed as gross domestic product per capita, absolute latitude and Muslim population proportion on total medal counts in female, male, mixed and all events at the Pyeongchang winter and Tokyo summer Olympics and Paralympics. Methods: The statistical model was multiple linear over-dispersed Poisson regression. Population and economy were log-transformed; their linear effects were expressed in percent per percent units and evaluated in magnitude as the factor effects of two between-nation standard deviations (SD). The linear effect of absolute latitude was expressed and evaluated as the factor effect of 30° (approximately 2 SD). The linear effect of Muslim proportion was expressed as the factor effect of 100% vs. 0% Muslim. Nations were ranked on the basis of actual vs. predicted all-events medal counts. Results: At the Pyeongchang Olympics, effects of population and economy were 0.7-0.8 %/% and 1.1-1.7 %/% (welldefined extremely large increases for 2 SD), factor effects of 30° of latitude were 11-17 (welldefined extremely large increases), and factor effects of 100% Muslim population were 0.08-0.69 (extremely large to moderate reductions, albeit indecisive). Effects at the Tokyo Olympics were similar in magnitude, including those of latitude, which were surprisingly still positive although diminished (large to very large increases). Effects at the Pyeongchang and Tokyo Paralympics were generally similar to those at the Olympics, but the effects of economy were diminished (large to very large increases). After adjustment of medal tallies for these effects, nations that reached the top-10 medalists in both winter games were Austria, Belarus, Kazakhstan, Slovakia and Ukraine, but only Azerbaijan reached the top-10 in both summer games. Conclusion: Adjusting medal counts for demographic and geographic factors provides a comparison of nations' sporting prowess or engagement that is more in keeping with the Olympic ideal of fair play and more useful for nations' Olympic-funding decisions.

Global Changes in Child and Adolescent Physical Activity During the COVID-19 Pandemic: A Systematic Review and Meta-analysis.

Importance: Numerous physical distancing measures were implemented to mitigate the spread of the COVID-19 virus, which could have negatively affected child and adolescent physical activity levels. Objectives: To conduct a systematic review and meta-analysis of the literature that used validated measures to document changes in child and adolescent physical activity during the COVID-19 pandemic and to estimate whether changes in physical activity differed between participant-level, contextual, and methodological moderators. Data Sources: PubMed, PsycInfo, SPORTDiscus, Web of Science, Scopus, CINAHL, and MEDLINE were searched (from January 1, 2020, to January 1, 2022). A total of 1085 nonduplicate records were retrieved. Study Selection: Studies were included if they reported (1) changes in the duration of physical activity at any intensity for children or adolescents (age ≤18 years) comparing before and during the COVID-19 pandemic using validated physical activity measurement tools and were (2) from general population samples, (3) peer-reviewed, and (4) published in English. Data Extraction and Synthesis: A total of 126 articles underwent full-text review. Data were analyzed using a random-effects meta-analysis, which was conducted in January 2022. Main Outcomes and Measures: Change in the duration of engagement in physical activity at any intensity comparing before and during COVID-19. Results: Twenty-two studies including 46 independent samples and 79 effect sizes from 14 216 participants (median age, 10.5 years; range, 3-18 years) were included. The percentage change in the duration of engagement in total daily physical activity from before to during COVID-19 was -20% (90% CI, -34% to -4%). Moderation analyses revealed that changes were larger for higher-intensity activities (-32%; 90% CI, -44% to -16%), corresponding to a 17-minute reduction in children's daily moderate-to-vigorous physical activity levels. The reduction in physical activity was also larger for samples located at higher latitudes (37%; 90% CI, -1% to 89%) and for studies with a longer duration between physical activity assessments (25%; 90% CI, -0.5% to 58%). Conclusions and Relevance: Children and adolescents have experienced measurable reductions in physical activity during the COVID-19 pandemic. Findings underscore the need to provide bolstered access to support and resources related to physical activity to ensure good health and social functioning among children and adolescents during pandemic recovery efforts.

Rule Changes to Increase Shared Medal Winning at the Olympics.

One of the most inspirational moments of the Tokyo Olympics was the sharing of the gold medal in the men's high jump. Rule changes that allow more medal sharing when athletes and teams are effectively equal in ability would improve the entertainment value of the Olympics, reward more athletes for their years of dedication to sport, and augment the Olympic ideal of fair play. Medals in all events are decided by a time, distance or points score in a final. When scores differ by ~0.1 or less of the variability in the score between competitions, the athlete or team with the better score would obtain a better score on average in only 52% of subsequent competitions, representing medals determined effectively by a coin toss. We have therefore quantified the medal sharing at the Tokyo Olympics that would have occurred if medals had been shared with such score differences (converted to rounded times or distances separating athletes in a final) in events with known variability between competitions (canoeing, kayaking, rowing, swimming, track and field events). In these events, 10%, 14% and 14% respectively of gold, silver and bronze medals would have been shared. The men's high jump would have produced three golds. Most of the sharing (68%) would have occurred with male athletes, presumably because greater depth of competition with males results in smaller differences between athletes at the highest level. The variability of performance scores in other events between competitions would need researching to establish maximum score differences for medal sharing in these events. For all events, the rule changes should exclude counting back, penalty shoot-outs, tie-breakers and any other methods for avoiding ties in the final. The acceptability of these rule changes to athletes, coaches and spectators (for example, in terms of separation of the athletes at the finishing line) would also need to be investigated.

Stable Isotope Tracing and Metabolomics to Study In Vivo Brown Adipose Tissue Metabolic Fluxes.

Brown adipose tissue (BAT) demonstrates extraordinary metabolic capacity. Previous research using conventional radio tracers reveals that BAT can act as a sink for a diverse menu of nutrients; still, the question of how BAT utilizes these nutrients remains unclear. Recent advances in mass spectrometry (MS) coupled to stable isotope tracing methods have greatly improved our understanding of metabolism in biology. Here, we have developed a BAT-tailored metabolomics and stable isotope tracing protocol using, as an example, the universally labeled 13C-glucose, a key nutrient heavily utilized by BAT. This method enables metabolic roadmaps to be drawn and pathway fluxes to be inferred for each nutrient tracer within BAT and its application could uncover new metabolic pathways not previously appreciated for BAT physiology.

Efficacy of percutaneous image-guided biopsy for diagnosis of intrahepatic cholangiocarcinoma.

PURPOSE: To evaluate the efficacy of percutaneous biopsy for diagnosing intrahepatic cholangiocarcinoma (IHCCA). METHODS: Retrospective review of biopsy and pathology databases from 2006 to 2019 yielded 112 patients (54F/58 M; mean age, 62.9 years; 27 cirrhotic) with IHCCA who underwent percutaneous biopsy. Data regarding the lesion, biopsy procedure technique, and diagnostic yield were collected. If biopsy was non-diagnostic or discordant with imaging, details of repeat biopsy or resection/explant were gathered. A control group of 100 consecutive patients (56F/44 M; mean age, 63 years, 5 cirrhotic) with focal liver lesions > 1 cm was similarly assessed. RESULTS: Mean IHCCA lesion size was 6.1 ± 3.6 cm, with dominant lesion sampled in 78% (vs. satellite in 22%). 95% (n = 106) were US guided and 96% were core biopsies (n = 108), typically 18G (n = 102, 91%), median 2 passes. 18 patients (16%) had discordant/ambiguous pathology results requiring repeat biopsy, with two patients requiring 3-4 total attempts. A 4.4% minor complication rate was seen. Mean time from initial biopsy to final diagnosis was 60 ± 120 days. Control group had mean lesion size of 2.9 ± 2.5 cm and showed a non-diagnostic rate of 3.3%, both significantly lower than that seen with CCA, with average time to diagnosis of 21 ± 28.8 days (p = 0.002, p = 0.001). CONCLUSION: IHCCA is associated with lower diagnostic yield at initial percutaneous biopsy, despite larger target lesion size. If a suspicious lesion yields a biopsy result discordant with imaging, the radiologist should recommend prompt repeat biopsy to prevent delay in diagnosis.

Understanding the Predictors of Missing Location Data to Inform Smartphone Study Design: Observational Study.

BACKGROUND: Smartphone location data can be used for observational health studies (to determine participant exposure or behavior) or to deliver a location-based health intervention. However, missing location data are more common when using smartphones compared to when using research-grade location trackers. Missing location data can affect study validity and intervention safety. OBJECTIVE: The objective of this study was to investigate the distribution of missing location data and its predictors to inform design, analysis, and interpretation of future smartphone (observational and interventional) studies. METHODS: We analyzed hourly smartphone location data collected from 9665 research participants on 488,400 participant days in a national smartphone study investigating the association between weather conditions and chronic pain in the United Kingdom. We used a generalized mixed-effects linear model with logistic regression to identify whether a successfully recorded geolocation was associated with the time of day, participants' time in study, operating system, time since previous survey completion, participant age, sex, and weather sensitivity. RESULTS: For most participants, the app collected a median of 2 out of a maximum of 24 locations (1760/9665, 18.2% of participants), no location data (1664/9665, 17.2%), or complete location data (1575/9665, 16.3%). The median locations per day differed by the operating system: participants with an Android phone most often had complete data (a median of 24/24 locations) whereas iPhone users most often had a median of 2 out of 24 locations. The odds of a successfully recorded location for Android phones were 22.91 times higher than those for iPhones (95% CI 19.53-26.87). The odds of a successfully recorded location were lower during weekends (odds ratio [OR] 0.94, 95% CI 0.94-0.95) and nights (OR 0.37, 95% CI 0.37-0.38), if time in study was longer (OR 0.99 per additional day in study, 95% CI 0.99-1.00), and if a participant had not used the app recently (OR 0.96 per additional day since last survey entry, 95% CI 0.96-0.96). Participant age and sex did not predict missing location data. CONCLUSIONS: The predictors of missing location data reported in our study could inform app settings and user instructions for future smartphone (observational and interventional) studies. These predictors have implications for analysis methods to deal with missing location data, such as imputation of missing values or case-only analysis. Health studies using smartphones for data collection should assess context-specific consequences of high missing data, especially among iPhone users, during the night and for disengaged participants.

In vivo isotope tracing reveals the versatility of glucose as a brown adipose tissue substrate.

Active brown adipose tissue (BAT) consumes copious amounts of glucose, yet how glucose metabolism supports thermogenesis is unclear. By combining transcriptomics, metabolomics, and stable isotope tracing in vivo, we systematically analyze BAT glucose utilization in mice during acute and chronic cold exposure. Metabolite profiling reveals extensive temperature-dependent changes in the BAT metabolome and transcriptome upon cold adaptation, discovering unexpected metabolite markers of thermogenesis, including increased N-acetyl-amino acid production. Time-course stable isotope tracing further reveals rapid incorporation of glucose carbons into glycolysis and TCA cycle, as well as several auxiliary pathways, including NADPH, nucleotide, and phospholipid synthesis pathways. Gene expression differences inconsistently predict glucose fluxes, indicating that posttranscriptional mechanisms also govern glucose utilization. Surprisingly, BAT swiftly generates fatty acids and acyl-carnitines from glucose, suggesting that lipids are rapidly synthesized and immediately oxidized. These data reveal versatility in BAT glucose utilization, highlighting the value of an integrative-omics approach to understanding organ metabolism.

Kinetics, Moderators and Reference Limits of Exercise-Induced Elevation of Cardiac Troponin T in Athletes: A Systematic Review and Meta-Analysis.

Background: Kinetics, moderators and reference limits for exercise-induced cardiac troponin T (cTnT) elevations are still unclear. Methods: A systematic review of published literature was conducted adhering to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Studies reporting high-sensitivity cardiac troponin T (hs-cTnT) concentrations before and after a bout of exercise in athletes were included and analyzed. The final dataset consisted of 62 estimates from 16 bouts in 13 studies of 5-1,002 athletes (1,421 in total). Meta-analysis was performed using general linear mixed modeling and Bayesian inferences about effect magnitudes. Modifying fixed-effect moderators of gender, age, baseline level, exercise duration, intensity and modalities were investigated. Simulation was used to derive 99th percentile with 95% limits of upper reference ranges for hs-cTnT of athletic populations. Results: The mean and upper reference limits of hs-cTnT before exercise were 4.4 and 19 ng.L-1. Clear increases in hs-cTnT ranging from large to very large (factor changes of 2.1-7.5, 90% compatibility limits, ×/÷1.3) were evident from 0.7 through 25 h, peaking at 2.9 h after the midpoint of a 2.5-h bout of running, when the mean and upper reference limit for hs-cTnT were 33 and 390 ng L-1. A four-fold increase in exercise duration produced a large clear increase (2.4, ×/÷1.7) in post-exercise hs-cTnT. Rowing exercise demonstrated an extremely large clear reduction (0.1 ×/÷2.4). Conclusions: The kinetics of cTnT elevation following exercise, the positive effect of exercise duration, the impact of exercise modality and 99th upper reference limits for athletic populations were reasonably well defined by this meta-analysis.

Convergent Validity of CR100-Based Session Ratings of Perceived Exertion in Elite Youth Football Players of Different Ages.

PURPOSE: To assess the convergent validity of internal load measured with the CR100 scale in youth football players of 3 age groups. METHODS: A total of 59 players, age 12-17 years, from the youth academy of a professional football club were involved in this study. Convergent validity was examined by calculating the correlation between session ratings of perceived exertion (sRPE) and Edwards load, a commonly used load index derived from the heart rate, with the data originating from 1 competitive season. The magnitude of the relationship between sRPE and Edwards load was obtained with weighted mean correlations and by assessing the effect of the change of the Edwards load on sRPE. Differences between the individuals' intercepts and slopes were assessed by interpreting the SD representing the random effects (player identity and the interaction of player identity and scaled Edwards load). Probabilistic decisions about true (infinite sample) magnitudes accounting for sampling uncertainty were based on 1-sided hypothesis tests of substantial magnitudes, followed by reference Bayesian analysis. RESULTS: Very high relationships exist between the sRPE and Edwards load across all age groups, with no meaningful differences in the magnitudes of the relationships between groups. Moderate to large differences between training sessions and games were found in the slopes of the relationships between the sRPE and Edwards load in all age groups. Finally, mostly small to moderate differences were observed between individuals for the intercepts and slopes of the relationships between the sRPE and Edwards load. CONCLUSION: Practitioners working in youth team sports can safely use the CR100 scale to track internal load.

Slow-Growing Pituitary Metastasis from Renal Cell Carcinoma: Literature Review.

BACKGROUND: Tumor metastasis to the pituitary is rare, most commonly reported with either breast or lung cancer metastasizing to the neurohypophysis. Pituitary metastases of renal cell carcinoma (RCC) are by contrast infrequently described even within this scarce literature. We present an illustrative case of RCC pituitary metastasis 15 years after radical nephrectomy for primary disease and a review of the published literature. CASE DESCRIPTION: A 69-year-old female was diagnosed with a large sellar mass with suprasellar extension. The initial radiologic diagnosis was most in keeping with pituitary macroadenoma, although prominent vascular flow voids were noted. Endoscopic endonasal transsphenoidal adenectomy was challenging on account of significant intraoperative hemorrhage from an unusually vascular tumor. Pathologic examination supported a diagnosis of metastatic clear cell renal carcinoma. Literature review identified 41 cases of RCC pituitary metastasis since 1984. The mean age at time of diagnosis with pituitary metastasis was 59.5 years (range 35-81 years, 73% male). Pituitary metastasis was the initial presentation of RCC in 10 patients. The median time from RCC diagnosis to pituitary metastasis was 1 year (range 0-27 years). Surgical resection was performed for 30 patients, of which 47% reported a highly vascular tumor. CONCLUSIONS: We highlight the potential for delayed metastasis to the pituitary to masquerade as a macroadenoma. Imaging consistent with rich vascularity should bring the diagnosis of RCC metastasis into the differential and is important to note when planning surgical resection in such cases.

The Effectiveness of Psychological Workshops for Coaches on Well-Being and Psychomotor Performance of Children Practicing Football and Gymnastics.

Coach workshops based on seven principles (inspiration, explanation, expectation, support, reward, appreciation, growth and winning) enhance the sport experience of adult athletes. Therefore, we have investigated the effects of such workshops with coaches of child athletes. Study participants were coaches of 57 9- to 12-year old girls (practicing gymnastics) and boys (practicing football). Three coaches of 28 children attended three workshops over 12 weeks, while a control group of 5 coaches of 29 children attended no workshops. Measures of well-being and psychomotor performance were taken on the children before and after the intervention; differences in mean changes between intervention and control groups were adjusted for baseline, standardized, and assessed with a conservative magnitude-based decision method. There were clear substantial effects of the workshop on motivation averaged across several dimensions (girls, large, most likely beneficial), on a decision test (boys, small-moderate, very likely beneficial), on state anxiety self-reflection (girls, moderate, likely harmful), and on reaction time (boys, small, possibly harmful). The beneficial effects of the workshop in this pilot study are encouraging, but the unclear and potentially harmful effects and the roles of presenter- and coach-specific effects need to be investigated further with a representative sample of coaches and more children before the workshop is recommended for implementation.