Increased PA participation at CR completion was detected by Fitbit-Flex mean change in step counts . Relative changes for Fitbit-Flex step counts and a 6MWT were consistent with previous research, demonstrating Fitbit-Flex’s potential as an outcome measure. With four days of data, Fitbit-Flex had acceptable ICC values in measuring step counts and MVPA minutes. Fitbit-Flex steps and 6MWT meters are more responsive to changes in PA patterns following exposure to a cardiac rehabilitation program than Fitbit-Flex or PASE-estimated moderate–vigorous PA (MVPA) minutes. Fitbit-Flex step counts provide a useful additional measure for assessing PA outside of the CR setting and accounts for day-to-day variations. Two weekend days and two weekdays are needed for Fitbit-Flex to estimate PA levels more precisely.Concordant assessments of physical activity (PA) and related measures in cardiac rehabilitation (CR) is essential for exercise prescription. This study compared exercise measurement from an in-person walk test; wearable activity tracker; and self-report at CR entry, completion (8-weeks) and follow-up (16-weeks). Forty patients beginning CR completed the Six-Minute Walk Test (6MWT), Physical Activity Scale for the Elderly (PASE), and wore Fitbit-Flex for four consecutive days including two weekend days. The sample mean age was 66 years; 67% were male. Increased exercise capacity at CR completion and follow-up was detected by a 6MWT change in mean distance (39 m and 42 m;  Coronary heart disease (CHD) is a leading cause of death  and lackMeasurement of PA is an essential component of CR programs for determining entry-level functional capacity and PA levels to enable appropriate exercise prescription, and for the evaluation of training and long-term outcomes for CR programs. The conventional in-person Six-Minute Walk Test (6MWT) is commonly recommended to assess exercise capacity, and self-reported surveys or questionnaires are frequently used to assess PA duration and intensity . AlthougModern self-managed measures, including wearable PA trackers such as Fitbit-Flex, offer a novel and real-time approach for objectively measuring the overall PA levels of CR participants . In addiOur validation study  of 48 caHowever, several important questions remain in relation to the measurement of PA using wearable activity trackers such as Fitbit-Flex. For instance, the reliability of Fitbit-Flex for CR patients and its assessment of change during and following CR interventions needs to be established. Evidence of Actigraph reliability demonstrated that in a CR population, two to four days of accelerometer data collection are sufficient to characterize a weekly pattern of PA behavior , but addData from a prospective repeated measures study were used to determine and compare the responsiveness of three different measures: exercise capacity (6MWT), functional activity (PASE) and free-living PA (Fitbit-Flex). This study is part of an ongoing funded trial called “Heart and Mind” designed to investigate the relationship between PA and cognitive function in CR patients. The data presented have not been reported previously.This study recruited a convenience sample from the CR programs at two tertiary hospital sites in Sydney, Australia. Typically, the CR programs within these hospitals involve six to eight weeks of supervised structured aerobic and resistance exercise for one hour, twice a week and a home-based program that aims for an accumulation of 30 min of exercise five days per week. The programs are tailored to the individual’s needs based on exercise capacity (6MWT) and an interview conducted by an exercise physiologist regarding existing exercise habits and barriers. Participants were eligible if they: (1) attended baseline assessment for CR; (2) were admitted for a diagnosis of CHD; (3) could participate in regular PA; (4) had no dementia diagnosis; (5) could understand English language sufficient to provide informed consent and undertake the questionnaires; (6) could participate in the full 16 weeks of the study, and (7) could wear and apply the Fitbit-Flex device. Forty-four participants consented to participate, with four withdrawing prior to commencing the trial due to re-hospitalization or leaving the region. Of the 40 participants who completed the CR entry assessment, 32 completed CR assessment and 26 completed CR follow-up assessment. Ninety percent of participants had completed Fitbit-Flex data collection for the required wear-time for the whole four-day study period at CR entry and 100% had completed data collection for the required wear-time at CR completion and CR follow-up assessments.Assessments were performed at the entry of CR (baseline), the completion of CR (6–8 weeks), and at CR follow-up (16 weeks).Demographic and clinical details including anthropometric measures, medical history, and cardiovascular disease risk factors were collected from the participants and extracted from the CR program patient chart using a data collection form. Due to the small sample size in this study, these data were not used in analysis. Fitbit-Flex; Participants’ PA levels were objectively measured using the Fitbit-Flex activity tracker , a small and light accelerometer worn on the wrist. When initialized to the individual’s height and weight, Fitbit Flex uses a three-dimensional accelerometer to sense user movement to calculate steps walked and moderate–vigorous active minutes. Our validation study  previousThe Physical Activity Scale for the Elderly; The self-reported PASE is a survey designed specifically to assess PA in older people . ParticiSix-Minute Walk Test; Submaximal functional capacity was evaluated through the conventional 6MWT based on standards established by the American Thoracic Society . The tesThe PA and exercise capacity of participants were assessed using three different measures:Patients scheduled to begin CR were invited to participate in this study and informed of the study requirements. After eligibility was confirmed, written informed consent was obtained and the participants completed a self-administered questionnaire to collect socio-demographic information. Data on weight and height were extracted from the CR chart to initialize the Fitbit-Flex device. After initializing the device, each participant was provided with a brief written guide on device placement, wearing time, and how to troubleshoot any problems with the device. Participants were instructed to place the Fitbit-Flex on the non-dominant hand and to wear the device for four consecutive days (two weekend days and two weekdays) during waking hours (at least 10 h) except when showering or swimming. Participants were informed that data collection would be repeated at assessments at 8 and 16 weeks. All assessments took place in the same location as the baseline assessment. All participants were blinded to their Fitbit-Flex data throughout the study.t-tests) among the four measurements  were used to compare change scores of the measures over time. Data were normally distributed, and parametric tests used. If any measures indicated statistically significant changes , then similarity in the responsiveness of the measure was compared using two additional statistical methods. First, comparing the magnitude of change for each measure with the expected magnitude of change due to participating in the CR program to ensure statistical significance was sufficient for clinical significance. Second, comparing the relative change  overlap) to assess whether the measures were similarly responsive or if they measured different PA dimensions. When the units of the measures were similar , data can be examined by comparing their 95% CI. However, to our knowledge, there is currently no guideline available in the literature to examine differences in the responsiveness  for two measures with different units . Thus, we inspected the 95% CIs of (the unitless) relative change for Fitbit-Flex steps and 6MWT meters to compare their change scores. Finally, intra-class correlation coefficients (ICCs) were used to estimate whether four or two days of data collection are needed to achieve acceptable reliability for Fitbit-Flex.Data analyses were performed using the Statistical Package for the Social Sciences, version 22. Mean scores, standard deviations, frequencies, and percentages were used to describe the socio-demographic and clinical characteristics of the sample. Both the relative change scores  ÷ pre-value) and the absolute change scores , and 48% were employed. The sample was highly educated, with 63% of participants holding at least an undergraduate university degree. The most common cardiac diagnoses were myocardial infarction (70%), coronary artery disease (13%), and percutaneous coronary intervention (8%). Arthritis (28%) and asthma (18%) were among the common co-morbidities potentially impacting exercise participation.The sample (N = 40) had a mean age of 66.2 ± 8.2 years and a mean body mass index of 27.9 ± 4.9 kg/mp = 0.015) and the 6MWT detected a statistically significant increase in the mean distance . From the entry of CR to CR follow-up, only the 6MWT detected a sustained change . In contrast, the measure of MVPA minutes estimated by Fitbit-Flex and PASE did not detect statistically significant changes from the entry of CR to completion of CR or from the entry of CR to CR follow-up.All the measures demonstrated positive changes in PA following the CR intervention . HoweverOnly Fitbit-Flex steps and the 6MWT meters had similar change score patterns as they showed statistically significant increases following the CR program and significant relative change score improvements. Furthermore, at the entry of CR to completion of CR, the 95% CI of the relative change for Fitbit-Flex steps and the 6MWT meters did not overlap, suggesting different degrees of responsiveness .When using two days of data (two weekdays vs. two weekend days) at the entry of CR and at the completion of CR, the ICCs for the reliability of Fitbit-Flex  were modTo our knowledge, this is the first study to compare the intervention responsiveness of four widely used PA measurements  among CR participants over three different time periods. Results indicated that, unlike Fitbit-Flex, MVPA minutes and PASE MVPA minutes, the 6MWT meters and Fitbit-Flex steps showed significant and similar patterns of responsiveness to expected changes in PA due to participating in a CR program. Results also implied that the use of activity trackers in cardiac patients is a promising measurement tool for cardiac telerehabilitation. When wearing Fitbit-Flex, four days of measurements including weekend and weekday use, rather than two days only, were required to best determine CR participants’ typical PA levels. Notably, PA improved rapidly during CR program participation but declined relatively quickly once CR was complete.Our findings revealed similar responsiveness between measures of the 6MWT meters and Fitbit-Flex steps from the entry of CR to completion of CR and from the entry of CR to CR follow-up. The increases observed in this study were in line with the 2% to 8% improvement reported by a systematic review  for repeFitbit-Flex steps and the 6MWT meters both measured different PA dimensions. Fitbit-Flex contributes new and clinically relevant information related to the patient’s objectively measured PA changes over time, extending information provided on functional capacity by the conventional in-person 6MWT ,38. FitbNotably, PASE MVPA minutes and Fitbit-Flex MVPA minutes did not show significant responsiveness at the completion of CR nor during CR follow-up. The minutes of MVPA as measured by both Fitbit-Flex and PASE were higher than those reported for cardiac patients in comparable studies. Previous CR studies showed that minutes of MVPA increased from 15 to 25  from theA close reading of the responsiveness of minutes of MVPA for both PASE and Fitbit-Flex at the completion of CR showed that the self-reported PASE response was approximately twice that of the Fitbit-Flex response. To our knowledge, there is no study reporting PASE minutes of MVPA for CR participants. However, our finding is similar to previous interventional studies which highlighted the measurement characteristics of PASE, and which reported an 18% increase in PASE between 3 and 6 months , and a 3Variability in responsiveness was common in all evaluated measures. However, it is noteworthy that heterogeneity will vary depending on the population studied. Therefore, CR patients are not homogenous in regards to change, and it is likely that they change in a different manner . VariatiOur results estimated four monitoring days  using Fitbit-Flex were required to best determine daily PA levels  for CR participants at the entry of CR, completion of CR, and CR follow-up. The results of previous CR studies do not directly allow comparison with the current results because the same measure  was not used. However, Hertzog et al.  used a sAn important issue for CR program coordinators is that changes in PA achieved during CR may depend on participation and may not be sustained from one day to another. Measures of PA indicated that it improved during program participation but rapidly declined when participation ended except for the exercise capacity measure which indicated sustained change. Consistent with our analyses, PA levels—at least in terms of step counts—significantly increase on days patients attend CR compared to non-CR days ,31,36,43We acknowledge that our study had a small sample size and that the participant attrition rate increased across the last two assessment points. The recruitment of a selected sample might also limit the generalizability of the results to other CHD populations. Moreover, a limitation in interpreting the results is that it is increasingly understood that PA increases during CR and decreases again afterward, so the lack of significant change may not be due entirely to the poor responsiveness of the measure. Conversely, the strength of this study was the inclusion of three time-point assessments to accurately compare the responsiveness of Fitbit-Flex, PASE and the 6MWT for CR participants during recovery. Another strength of this study was the inclusion of easily accessible innovative technology (Fitbit-Flex) which is valid, inexpensive, and easy for CR patients to use. Compliance with wearing Fitbit-Flex on CR days compared to non-CR days and variation in wear-time beyond the 10-h/day requested were not taken into account in the analyses and could lead to inconsistent comparisons between participants. Future research should address this issue.Irrespective of whether PA assessment measures are performed conventionally in-person via a 6MWT, by self-report questionnaire, or using an activity tracker, it is important to understand the interrelationships among these measures and their similarities or differences in detecting changes in PA. Moreover, it is important to understand whether these measures appropriately support different models of CR delivery, including telehealth and virtual rehabilitation. The collective information provided by Fitbit-Flex steps and the 6MWT meters better reflect patients’ overall exercise capacity and PA than individual measures alone. The 6MWT meters are most accurate at evaluating changes in functional capacity at the completion of CR and CR follow-up, whereas Fitbit-Flex steps are the best at capturing free-living PA and differentiating it from functional capacity at the completion of CR. This provides an additional measure, step counts, of use to assess outcomes following cardiac rehabilitation programs. The Fitbit-Flex activity tracker and the self-reported PASE estimates of MVPA minutes have limited capacity to differentiate between measurement error and real change. Therefore, we recommend that Fitbit-Flex step counts be used in addition to the conventional 6MWT to provide a more comprehensive understanding of patients’ activities occurring outside of CR. Moreover, data from the present study provide further support of the benefits of Fitbit-Flex steps as a promising tool to track PA levels both in CR settings and for cardiac telerehabilitation programs. This is because it provides continuous PA data which assist clinicians to monitor patients’ adherence to CR guidelines, in personalizing treatment plans, and in initiating timely interventions when needed. For the best estimates of the usual pattern of PA, the use of Fitbit-Flex should include two weekend days and two weekdays.


We introduced enhanced UnaG (eUnaG), a ligand-activatable fluorescent protein, for conventional and super-resolution imaging of subcellular structures in the mammalian cells. eUnaG is a V2L mutant of UnaG with twice brighter bulk fluorescence. We previously discovered the reversible fluorescence switching behavior of UnaG and demonstrated the high photon outputs and high localization numbers in single-molecule localization microscopy (SMLM). In this study, we showed that the fluorescence of eUnaG can be switched off under blue-light illumination, while a high concentration of fluorogenic ligands in the buffer can efficiently restore the fluorescence, as in UnaG. We demonstrated the capacity of eUnaG as an efficient protein label in mammalian cells, as well as for SMLM by utilizing its photoswitchable nature. While cytosolic UnaG proteins showed aggregated patches and fluorescence reduction at high expression levels, eUnaG-labeled protein targets successfully formed their proper structures in mammalian cells without notable distortion from the endogenous structure in the majority of transiently expressing cells. In particular, eUnaG preserved the vimentin filament structures much better than the UnaG. eUnaG provided similarly high single-molecule photon count distribution to UnaG, thus also similarly high resolution in the super-resolution images of various subcellular structures. The sampling coverage analysis of vimentin filaments in SMLM images showed the improvement of labeling efficiency of eUnaG. eUnaG is a high-performance fluorescent protein for fluorescence and single-molecule localization imaging in green emission with minimal labeling artifact. Fluorescent proteins (FPs) are workhorses in live-cell fluorescence microscopy due to the facile and specific labeling of the target proteins . LikewisRecently, we introduced UnaG protein as an efficient SMLM probe for multicolor live-cell imaging . UnaG isHere we investigated the photoswitching nature of enhanced UnaG (eUnaG) protein and its application to SMLM. eUnaG is a single-mutated variant of UnaG, in which Val 2 is substituted with leucine . The sinvia QuikChange site-directed mutagenesis protocol on the UnaG-mCherry construct. eUnaG-mCherry construct was utilized for PCR template for other eUnaG constructs. The primers for PCR amplification contain the sequences for small epitope tags such as HA or Flag. PCR products were digested with restriction enzymes and ligated into cut vectors . For the expression in mammalian cells, the CMV promoter was introduced in all cases. More detailed information about the genetic constructs is summarized in Genetic incorporation using standard restriction enzymes and T4 DNA ligase was performed to construct eUnaG plasmids. eUnaG mutation (V2L) was performed 4 per well. After 24–48 h of transfection, the cells were fixed in 3% paraformaldehyde  with 0.2% glutaraldehyde  for 10 min at room temperature.Cos-7 cells [Korean Collection for Type Cultures (KCTC)] were grown in Dulbecco’s modified Eagle’s medium  containing 10% v/v fetal bovine serum  and 1% v/v antibiotic-antimycotic . The cells were electroporated  during the general subculture, with ∼500 ng of proper plasmid, and seeded on a coverslip-bottomed 8-well chamber  at the density of 5 × 10Photon statistics and super-resolution imaging of eUnaG were performed in imaging buffer based on Tris pH 8  containing NaCl  and β-D-glucose . To reduce the concentration of dissolved oxygen, we added an enzyme-based oxygen scavenging system (GLOX) containing glucose oxidase  and catalase ; 1 μM of external bilirubin  was supplied to the imaging buffer during the SMLM imaging.f = 400 mm, AC508-200-A-ML, Thorlabs, NJ, United States) and a dichroic mirror  to make widefield illumination on the sample plane in epi geometry. The fluorescence was collected by an objective lens  and filtered by an emission filter . A focus maintaining system embedded in the microscope precisely kept the focal plane during the measurement. A back-illuminated scientific CMOS camera  collected the filtered fluorescence signal through the tube lens, resulting in an image pixel size of 110 nm. The acquisition parameters were set to 12-bit sensitive detection mode with no pre- and post-processing.A commercially available spinning-disk confocal system  was used to acquire the confocal images of vimentin filament to compare the expression pattern . A confoFusion, a commercial acquisition software from Andor, was used to acquire confocal images from the DragonFly confocal microscope. SymPhoTime64 from PicoQuant was used to acquire and analyze the fluorescence lifetime. To measure the intensities of UnaG- and eUnaG-fused Sec61β and mCherry, several confocal images containing tens of cells were obtained and analyzed by CellProfiler, an open-source software for cell image processing. An open-source imaging software, μManager, was used to control the sCMOS camera and to acquire the single-molecule images . The rawAlthough UnaG protein has been used for imaging applications of mammalian cells such as local bilirubin quantification , biomolevia aggregation-induced quenching or inhibition of ligand binding. Since the fluorescence lifetimes of UnaG and eUnaG are very similar under the same measurement condition , which are commonly used for the characterization of the oligomerization levels of FPs . We compWe further examined the expression pattern of vimentin filaments labeled with UnaG and eUnaG. Vimentin filaments have been used as a reference structure for evaluating labeling artifacts because the cellular structure is sensitive to the multimeric character of the fused FPs . Most of2), the fluorescence from eUnaG quickly bleached off within 10 s. When we treated the bleached eUnaG proteins with 1 μM of exogeneous bilirubin, the fluorescence recovered in high efficiency, allowing the structure of the endoplasmic reticulum to be clearly visualized again. The on–off switching cycle could be repeated multiple times as observed in UnaG, and the recovery efficiency was quite similar to UnaG during the repetitive switching cycles  as in UnaG, corresponding to the two fluorescent forms of UnaG: less bright conformation that forms immediately after binding to bilirubin, known as UnaG1; brighter conformation (UnaG2) that spontaneously converts from UnaG1 (off1 and koff2 for eUnaG were highly dependent on the concentration of dissolved oxygen, implying the similarity of off-switching mechanism that is mediated by the photo-oxidation of bilirubin molecule under intense 488-nm illumination (This common way of reversible switching indicates that the photoswitching mechanism of eUnaG is similar to that of UnaG. Indeed, when we measured the off-switching rate in different concentrations of dissolved oxygen, there were two different off-switching speeds (kom UnaG1 . Both thmination .2 of illumination intensity, the duty cycle of eUnaG was measured as 0.0015 within ∼7 s, which is comparable to the best-performing SMLM dyes such as Alexa 647 (From the fluorescence intensity trace under off-switching condition, we can measure the on–off duty cycle from the ratio of the equilibrium intensity to the initial, unbleached intensity . With 30lexa 647 .The number of photons during the on-time of each switching cycle determines the localization accuracy in SMLM . The phoAs in UnaG, we obtained SMLM images of Sec61β, Vim, and CLC labeled with eUnaG . These iEven though the fractions of cells with normal expression patterns differ dramatically for UnaG and eUnaG , we coulWe demonstrated the capacity of eUnaG as a potential fluorescent marker for SMLM in the green emission channel. Like UnaG, eUnaG can undergo repetitive fluorescence switching cycles required for SMLM, and the on- and off-switching are mediated by the rebinding and photo-oxidation of bilirubin, respectively. A single eUnaG molecule offers a slightly higher photon number than UnaG, and thus, it can potentially provide the highest spatial resolution among the existing FPs for SMLM. In addition to the unique benefits in SMLM, the clear improvements in labeling artifact of eUnaG make it a much better probe for SMLM as well as conventional diffraction-limited imaging.The slight increase in photon number  may appevia standard genetic incorporation and transient expression in mammalian cells. eUnaG provides better expression patterns than UnaG, especially for proteins like vimentin whose structure can be easily perturbed by protein aggregation. Short peptide tags such as BC2 tag and ALFA tag have shown a similarly low level of labeling artifacts in vimentin fibers (Enhanced UnaG can easily label protein targets n fibers . Howevern fibers . Moreoven fibers  and SMLMn fibers .The lower labeling artifact of eUnaG may be attributed to the stability of the protein and the ligand. The thermal stability of eUnaG was higher than UnaG . Also, tin vivo, thereby revealing the organismal implications in aging and cancer.In fact, eUnaG fused to vimentin may become a valuable tool for investigating proteostasis. Since the discovery of vimentin’s presence at the aggresome , many stWe anticipate that eUnaG’s suppressed labeling artifact and excellent SMLM capabilities would make it a new workhorse in live-cell SMLM imaging.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.S-HS proposed and designed the idea of this work. SK prepared the biological samples, acquired and analyzed the confocal images, evidence of photoswitching, and kinetics information. JK acquired the widefield and SMLM images and analyzed the single-molecule characteristics and sampling coverage. All authors contributed to the writing and manuscript revision.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Recently several alterations of public policy in migration and asylum provision for refugees, were introduced as parts of a new COVID-19-related Russian federal health care legislation. The main of them are 1) Federal Laws No. 58-FZ of 18 March 2020; 63-FZ of 18 March 2020; 134-FZ of 24 April 2020; 209-FZ of 13 June 2020 “About introducing changes to the Federal Law ‘About the citizenship of Russian Federation;’” 2) Decree of the President of the Russian Federation No. 580 of 23 September 2020 “About introducing changes to the Decree of the President no. 274 of 18 April 2020 ‘About temporary measures of regulating legal situation of foreign citizens and persons without citizenship in the Russian Federation in regard to the threat of further spreading the novel coronavirus infection;’” and 3) ordinance of the Government of the Russian Federation No. 1428 of 15 September 2020 “About implementing measures of safety by a foreign citizen or person without citizenship on the territory of the Russian Federation” [These novel legal acts substantially reduce civil rights of working migrants and refugees. New visa restrictions, stricter migration and border control as well as elevated requirements of financial guarantees, have resulted in impaired access of non-Russian citizens, primarily working migrants, to medical care . It is tIn some regions of Russia and within several occupations  the proportion of non-Russian migrants, that predominantly arrive from Central Asia, Middle East, Ukraine, and Moldova, may amount to seventy-eighty per cent of the workforce . Hence, We trust that many of the new legal initiatives may be emotionally-dictated rather than evidence-based and their adoption mainly accounted for by a common belief that migrants represent one of the riskiest epidemiological groups during the COVID-19 pandemic. This belief is widely represented on TV channels, including “official,” government-sponsored channels, and in social networks, both in Russia  and Euro. One may see strong correlation between the level of social support of the new anti-migrant restrictive legislation and the level of using migrants’ labour force in a region. It is likely that negative emotions towards migrants and refugees are mainly caused by social tensions, work competition and psychological antipathy of a considerable part of general population in the regions with the highest level of using migrants’ labour force, not by rational assessment of epidemiological information and expectations. The main most frequent misbeliefs detected during the content analysis of social media are summarised in In October 2020 – March 2021, we performed a content analysis of 1 271 052 open personal accounts of Russian segments of social networks VK, Facebook, Instagram, Odnoklassniki (“School Mates”) and Twitter in regard to misbeliefs about non-Russian working migrants and refugees being the main spreaders of SARS-CoV-2 in Russia. The choice of accounts was randomised. 235 405 accounts (18.5%) contained signals of the account holder’s misbeliefs about non-Russian migrants and refugees being super-spreaders of SARS-CoV-2. Of this set, in 146 204 cases (62.1%) we detected direct social support of anti-migrant and anti-refugee novel legal initiatives related to the COVID-19 pandemic. The content analysis was carried out with the help of proprietary C++-based programme that performed social network screening. The results are presented in IgG test results made in May-December 2020, may offer a different view. Test results of refugee camps in Southern Russia were included (Rostov-on-Don region for refugees from Ukraine and Dagestan for refugees from the recent Armenia-Azerbaijani war in Nagorny Karabakh).The data on SARS-CoV-2 population infection rate within various biosocial strata in Russia, based on our analysis of 45 652 anti-SARS-CoV-2 Demographic data collected included nationality, ethnic origin, race, gender and age. The age range was 12-88 years for the whole set.PIR, %) in the risk groups on the basis of epidemiological data of antibody testing. It may be an appropriate instrument of SARS-CoV-2 transmission comparison in different biosocial groups. In PIR is presented for the groups studied.We investigated the following risk groups: tourists, public transport employees, hospital medical staff, hospital medical staff (“red zone”), social workers, ambulance personnel, working migrants, refugees seeking political asylum, school teachers and schoolchildren. They were chosen on the basis of the works -21. Thes–tPIR ~ a + be, where t is time and a,b are numerical coefficients of proportionality. Growths in the graph may represent an increase in the spread of SARS-CoV-2 infection within respective biosocial groups and/or the introduction of more antibody testing.PIR for the strata of tourists and public transport employees (including airport personnel), whereas for other strata, including working migrants and refugees, such tendency was not observed. The major conclusion deduced from PIR dynamics is between school teachers and ambulance medical personnel, and mainly coincides with PIR dynamics calculated for the stratum of social workers. Point-by-point analysis of the data in the antibody testing set collected in ten Russian regions studied , shows that there is almost no correlation between the refugee/migrant status of a person and probability of his/her being infected with SARS-CoV-2 (average Spearman correlation coefficient C = 0.2716 at P less than 0.4431).In The main contribution to spreading SARS-CoV-2 in Russian population is made by tourists (upper blue line in We suggest that the new Russian COVID-19-related migration legal amendments should be re-considered to support health equity in Russia. These laws create the situation of serious health inequity to non-Russian citizens, mainly working migrants and political refugees, and, from the author’s viewpoint, should be revoked. Introduced as legal instruments to limit the SARS-CoV-2 spread, they may instead contribute to its more dramatic impact on Russian society.What can be done in such a situation to attract the legislators’ attention? The activities of health care-related non-commercial, social and non-governmental organisations may be crucial, they could engage in fundraising and providing basic medical help. Constructing inclusive narratives in the media, including social networks, is also a promising choice, which would counteract the common misbelief about the epidemiological “danger” of migrants and refugees.Several publicly funded social initiatives that would promote health equality to the migrants and refugees during the pandemic, were recently launched in the Russian Centre for Racial and Ethnic Equality created as an interuniversity venue. Shooting documentary films about refugees, recording musical performances, holding art exhibitions, making short video reports for fundraising and placing the complete relevant epidemiological information in Internet websites easily accessible from social networks, are the main goals. The Centre works in collaboration with Teranga project launched and supervised in Italy by Sophia Seymour, Daisy Squires and Lou Marillier .Similar projects may be effectively used to draw the attention of general population, media and policy makers to the unsolved problem of the COVID-19 pandemic-caused victimisation by new migration regulations that place millions of people without Russian citizenship in the situation where they cannot afford to apply for and receive necessary medical help.


We highlighted the 18F-FDG-PET/CT useful approach for therapeutic assessment of TKI in metastatic mutated NSCLC reporting two complete metabolic responses in patients treated with crizotinib for a rearranged ROS1 and a metastatic ALK NSCLC.Crizotinib is a tyrosine kinase inhibitor (TKI) indicated in first-line treatment of rearranged c-ros oncogene 1 (ROS1) and anaplastic lymphoma kinase (ALK) metastatic non-small-cell lung cancer (NSCLC). However, the common response reported after treatment is partial and few complete responses have been reported in PROFILE studies with computed tomography (CT) evaluation. To date, only one case report of complete metabolic response on 2-deoxy-2-[ ROS1(RT-PCR) .ROS1 and ALK receptors have homology, and some ALK TKI have inhibitory activity against ROS1 . Crizoti18F-FDG-PET/CT assessment of tumor responses was more easily undertaken compared to CT with earlier progression detection. Contrary to the CT field of view, it also offers the possibility of detecting progression in the whole body.In metastatic NSCLC, CT is the standard for assessing the response to treatment. However, based on the results of an exploratory study by Kerner et al. , 18F-FDG18F-FDG-PET/CT complete metabolic responses (CMR) have been published concerning patients with NSCLC ROS1-rearrangement treated with crizotinib  might be studied in future clinical trials to find new surrogate survival markers.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.KA and LC provided details of the patient and provided initial draft of submission. CL provided details of the patient. DK and RA provided images, image analysis, and helped draft the initial submission. JC helped draft the initial submission. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Pulmonary rehabilitation (PR), an exercise and education programme for people with chronic lung disease, aims to improve exercise capacity, breathlessness and quality of life. Most evidence to support PR is from trials that use specialist exercise equipment, for example, treadmills (PR-gym). However, a significant proportion of programmes do not have access to specialist equipment with training completed with minimal exercise equipment (PR-min). There is a paucity of robust literature examining the efficacy of supervised, centre-based PR-min. We aim to determine whether an 8-week supervised, centre-based PR-min programme is non-inferior to a standard 8-week supervised, centre-based PR-gym programme in terms of exercise capacity and health outcomes for patients with chronic lung disease.Parallel, two-group, assessor-blinded and statistician-blinded, non-inferiority randomised trial. 436 participants will be randomised using minimisation at the individual level with a 1:1 allocation to PR-min (intervention) or PR-gym (control). Assessment will take place pre-PR (visit 1), post-PR (visit 2) and 12 months following visit 1 (visit 3). Exercise capacity , dyspnoea (Chronic Respiratory Questionnaire (CRQ)-Dyspnoea), health-related quality of life (CRQ), frailty , muscle strength (isometric quadriceps maximum voluntary contraction), patient satisfaction , health economic as well as safety and trial process data will be measured. The primary outcome is change in exercise capacity between visit 1 and visit 2. Two sample t-tests on an intention to treat basis will be used to estimate the difference in mean primary and secondary outcomes between patients randomised to PR-gym and PR-min.London-Camden and Kings Cross Research Ethics Committee and Health Research Authority have approved the study (18/LO/0315). Results will be submitted for publication in peer-reviewed journals, presented at international conferences, disseminated through social media, patient and public routes and directly shared with stakeholders.ISRCTN16196765. This is a parallel, two-group, assessor-blinded and statistician-blinded, non-inferiority randomised trial to assess the primary and secondary outcome measures.The pulmonary rehabilitation intervention is delivered according to national guidelines: British Thoracic Society Guideline on Pulmonary Rehabilitation in Adults.The study includes a 12-month follow-up period to evaluate the long-term effect of the intervention.The study includes a health-economic analysis which aims to understand relative cost-effectiveness which may have implications for NHS commissioning.This is a single-centre study based in northwest London and findings may not be applicable to other populations in different locations.Pulmonary rehabilitation (PR), an evidence-based exercise and education programme, is widely accepted as a cornerstone of management for people with chronic obstructive pulmonary disease (COPD) and other chronic respiratory disorders.2The majority of evidence to support PR has come from trials conducted in hospital or rehabilitation centres that use specialist exercise equipment such as treadmills, cycle ergometers and weights machines (PR-gym).3Apart from improving accessibility, it has been argued that PR-min may have other advantages over PR-gym. Exercise-training using minimal equipment may better reflect activities of daily-living than training using specialist equipment and therefore be easier to replicate and maintain at home following discharge from PR. However, it may be more difficult to prescribe and progress exercise, particularly resistance exercise, without the use of specialist equipment.A systematic review, conducted by Alison and colleagues, identified eight randomised controlled trials that compared outcomes following exercise interventions completed with minimal equipment to usual care without an exercise intervention in patients with COPD.5To our knowledge, no trial has compared supervised centre-based PR using minimal and specialist equipment. A previous National Institute for Health Research Health Technology Assessment-funded randomised 2×2 trial compared PR undertaken in community venues with PR undertaken in a hospital venue, in 240 patients with COPD.The aims of the research are to determine whether an 8-week outpatient supervised PR-min programme is non-inferior to a standard 8-week outpatient supervised PR-gym programme in terms of health benefits for patients with chronic respiratory disease.The primary objective is to determine whether PR-min is non-inferior to PR-gym regarding change in exercise capacity measured using ISWThe secondary objectives are to: (1) determine whether PR-min is non-inferior to PR-gym regarding changes breathlessness (CRQ-D), health-related quality of life (CRQ) and quadriceps strength (isometric quadriceps maximum voluntary contraction) from baseline (visit 1) to post-PR assessment at 8 weeks (visit 2) and from baseline (visit 1) to 12 months after the baseline assessment (visit 3); (2) evaluate the trial process by recording the participant recruitment and retention, participant uptake of PR, PR attendance, PR completion, reasons for PR non-completion and participant satisfaction in each arm of the study, at the appropriate stage of the trial; (3) estimate the cost and cost-effectiveness during the trial period.This study has been approved by the Health Research Authority and London Camden and Kings Cross Research Ethics Committee (reference 18/LO/0315). All participants will provide written informed consent.This is a parallel, two-group, assessor-blinded and statistician-blinded, non-inferiority, randomised trial. Participants will be randomised at the individual level with a 1:1 allocation to either PR-min or PR-gym. Both interventions will comprise two supervised sessions per week for 8 weeks delivered by the same team. Outcome measures will be recorded at baseline assessment for PR (visit 1), following PR at 8 weeks (visit 2) and at 12 months after visit 1 (visit 3). The study schema is outlined in Potential participants will be people referred to Harefield Pulmonary Rehabilitation Unit, Royal Brompton and Harefield Clinical Group, UK who meet the following inclusion criteria (1) adults >18 years of age; (2) physician diagnosis of stable chronic respiratory disease, typically COPD, interstitial lung disease, bronchiectasis, chronic asthma or chest wall disease; (3) referred for PR in line with BTS guidelines ; (4) able to communicate verbally and respond to questions in written English. Potential participants will be excluded if they have (1) any contraindication to moderate intensity physical exercise, for example, unstable cardiovascular disease; (2) progressive cancer or neurological disorder with an expected life expectancy less than 12 months; (3) completed PR within previous 12 months and/or (4) are unable to provide informed consent.Informed consent will be obtained by the nominated researchers as recorded in the Sponsor’s Delegation of Responsibilities Log. All individuals taking informed consent will have received consent training. All participants will provide written consent. Consent to enter this study will be obtained after a full account has been provided of its nature, purpose, risks, burdens and potential benefits, and the patient has had the opportunity to deliberate. The patient will be allowed to specify the time they wish to spend deliberating, usually up to 24 hours. The Investigator or designee will explain that the patients are under no obligation to enter the study and that they can withdraw at any time during the study, without having to give a reason. At each visit, the participant’s willingness to continue in the study will be ascertained and documented in the research notes. A copy of the consent form is in the 10.1136/bmjopen-2020-047524.supp1Supplementary dataFollowing clinical referral, but prior to pre-PR assessment, potential participants will be screened by a member of the PR team for eligibility to the study. The potential participant will be approached by telephone and provided with a participant information sheet. A member of the research team will obtain informed consent following the pre-PR assessment.Consenting participants will be randomised at the individual level with a 1:1 allocation, using an independent web-based system provided by the United Kingdom Clinical Research Collaboration registered King’s Clinical Trials Unit (KCTU), to receive either ‘usual care’ (PR-gym) or intervention (PR-min).Randomisation by minimisation will ensure that participant characteristics are balanced between the groups with respect to previous completion of PR (yes/no), multiple deprivation index . Resistance training will include functional activities such as sit-to-stand and step-ups as well as Theraband based exercises such as sitting knee extension, leg press and hip flexion as well as standing hip extension, squats, chest press and lateral raise. Progression will be through the use of hand/ankle weights and increasing resistant Therabands (from red to black). Exercise training will be individualised and regularly progressed (either in duration or intensity) with targets reviewed at each supervised session. Education will be delivered by a multidisciplinary team as per PR-gym . InformaA list of the scheduled outcomes is outlined in Previous audits of Harefield PR Unit have shown that in participants undergoing PR-gym achieve a mean (SD) change in ISW of 58 (67) m. The null hypothesis is that PR-min is inferior to the standard treatment PR-gym. The alternative hypothesis is that PR-min is not inferior to PR-gym. The non-inferiority margin will be defined as half the known MCID using the fixed-margin method with a preserved effect of 50% as recommended by previous guidance, including from the United States Food and Drug Administration.For baseline data, continuous and categorical variables will be summarised with descriptive statistics. No significance testing will be carried out. The outcome measures will be described by trial arm and at visits 1, 2 and 3 using descriptive statistics.The main statistical analyses will estimate the difference in mean primary and secondary outcomes between patients randomised to PR-gym and PR-min by intention to treat principle from visit 1 to visit 2 (8 weeks following visit 1) and visit 1 to visit 3 (12 months following visit 1). Group difference estimates and associated one-sided 97.5% CI will be reported. The group differences will be compared using one-sided two independent sample t-test or non-parametric equivalent. The significance level is set at one-sided significance level of 0.025.et al.Regarding missing data, the number of baseline variables with complete data will be reported and the primary and secondary outcomes will be analysed as per the recommendations of White Adherence is defined as the number of supervised sessions the participant attends irrespective of the assigned intervention maximum 16). This will be recorded in both intervention arms. As a dichotomous indicator with eight as the cut-off. The following variables will be recorded in a 3×2 table according to allocated intervention: (1) compliers always receive the allocated treatment; (2) complete defiers do the opposite of the allocated treatment, that is, attend no sessions in allocated treatment; (3) partial defiers are all others not falling in the above groups. Dropout cause will be recorded using the MORECARE classification of reason for attrition.. This wiIn addition to the primary intention-to-treat analysis, the effect of actually receiving treatment as defined in the protocol will also be estimated. If non-compliance rate with PR sessions is >10%, a Complier-Average Causal-Effect (CACE) will be estimated.A web based electronic data capture (EDC) system has been designed using the InferMed Macro 4 system and will be maintained by KCTU for the duration of the project. Source data will be entered by recruiting site staff, typically within 1 week of data collection by authorised staff onto the EDC. A full audit trial of data entry and any subsequent changes to entered data will be automatically date and time stamped, alongside information about the user making the entry/changes within the system.The primary investigator (WM) will take overall responsibility for the conduct of MISTER. The trial co-ordinator (CMN) will supervise the day-to-day operation of the project and is responsible for ensuring that Good Clinical Practice guidelines are followed. An unblinded member of the MISTER research team (JAW) will monitor the data and review a random sample of 10% of completed case report forms against clinical records. Monitoring will ensure protocol compliance, proper study management and timely completion of study procedures.A Data Monitoring and Ethics Committee has been appointed. The members of this committee are not members of the applicants’ or sponsors’ institution and include an academic Consultant Respiratory Physician and an independent statistician.The requirement for study monitoring or audit will be based on the Sponsor’s Research Office risk assessment procedure and applicable standard operating procedures. It is the responsibility of the Research Office to determine the monitoring risk assessment and explain the rationale to the study research team.The concept of the research project arose directly from PPI, and the development of this project has included PPI throughout each stage. We have a named PPI coapplicant who will continue to be closely involved in the design and management of the research through membership of the Trial Steering Group that will meet at the beginning of the research period, and then every 6 months throughout the data collection/analysis and dissemination period. This PPI member will be joined by a second representative and will meet the project manager at regular intervals throughout the study. The PPI group will provide input into written material for patients, how results data are presented, particularly to lay audiences and will have a role in dissemination of research findings.A serious adverse event (SAE) is defined as an untoward occurrence that (a) results in death; (b) is life-threatening; (c) requires hospitalisation or prolongation of existing hospitalisation; (d) results in persistent or significant disability or incapacity or (e) is otherwise considered medically significant by the investigator.The Investigator and research team are responsible for reporting events to the Research Office immediately and/or within 24 hours of becoming aware of the event. An SAE occurring to a research participant will be reported to the Research Ethics Committee that gave a favourable opinion of the study.Owing to the COVID-19 pandemic the study was suspended for 13 months between February 2020 and 2021 and, at the date of study suspension, there were 74 recruited and randomised participants waiting to start PR but were unable to receive either intervention due to the pandemic. Accordingly, a substantial amendment to increase the sample size from 362 to 436 and extend the recruitment and follow-up periods by 1 year to 31 March 2022 and 2023, respectively, was submitted to the funders , the Health Research Authority and research ethics committee on 5 February 2021. These amendments were approved on 24 February 2021.Should further substantial amendments be made, a notice of amendment will be submitted to the Health Research Authority for consideration.Participant recruitment started on 15 October 2018 and is expected to end on 31 March 2022. Visit 2 assessments started approximately 8 weeks after visit 1 and visit 3 assessments 12 months after visit 1. The final visit 2 assessment is expected to take place on 31 May 2023. The end date for the study, representing the final visit 3 will be 31 March 2023.We will use a broad strategy to maximise dissemination of our findings: (1) sharing of scientific findings via open-access publication in high impact journals and presentation at international meetings; (2) plain English summaries of findings for public bodies and web-sites  to communicate evidence through a user-friendly interface; (3) online pages about the project on websites of contributing organisations ; (4) social media ; (5) public engagement via talks with service user groups and open public events, so patients and their caregivers can learn about the research; (6) direct sharing of findings with public bodies  and policy makers to whom the applicants have direct access  to facilitate uptake of findings into research strategy and policy; (7) education of commissioners to influence future NHS service delivery.PR is a core strategy in the management for COPD and other chronic respiratory disorders.The strengths of this study include the design: a parallel, two-group, assessor-blinded and statistician-blinded, non-inferiority randomised trial which is the appropriate design to assess the primary and secondary outcome measures. The intervention, PR, is delivered according to national guidelines and the population of interest is people with chronic respiratory disease, both of which mean the results will be generalisable. In addition, study involves a 12-month follow-up period (from visit 1) to evaluate the long-term effect of the intervention and a health-economic analysis which aims to understand the potential cost-effectiveness of the trial which may have implications for the NHS and Clinical Commissioning Groups. A limitation of the study is that it is a single-centre study based in northwest London which may mean that the findings may not be generalisable to other populations in different locations.


Though EBM is essential to advance medicine, we should acknowledge the facts and the limits of the clinical trials.(1) Introduction: Evidence-based medicine (EBM) is necessary to standardize treatments for infections because EBM has been established based on the results of clinical trials. Since entry criteria for clinical trials are very strict, it may cause skepticism or questions on whether the results of clinical trials reflect the real world of medical practice. (2) Methods: To examine how many patients could join any randomized clinical trials for the treatment of community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP). We reviewed all the pneumonia patients in our institute during 2014–2017. The patients were divided into two groups: patients who were eligible for clinical trials (participation-possible group), and those who were not (participation-impossible group). Exclusion criteria for clinical trials were set based on previous clinical trials. (3) Results: A total of 406 patients were enrolled in the present study. Fifty-seven (14%) patients were categorized into the participation-possible group, while 86% of patients belonged to the participation-impossible group. Patients in the participation-possible group had less comorbidities and more favorable outcomes than those with the participation-impossible group. As for the outcomes, there were significant differences in the 30-day and in-hospital mortality rates between the two groups. In addition, the participation-possible group showed a longer overall survival time than the participation-impossible group ( Evidence-based medicine (EBM) aims to assist physicians in making rational decisions in general practices. As EBM is established according to the results of clinical trials, clinical trials are considered one of the essential undertakings and are put at the top of priority among physicians in constructing therapeutic strategies . A randoOur institute is a 900-bed tertiary care center and is located in the countryside at Aichi prefecture in central Japan. For the purpose of how many community-onset pneumonia patients in our institute could join any randomized clinical trials for an antibiotic treatment among pneumonia patients, we reviewed all CAP and HCAP patients who were admitted to our hospital between September 2014 and May 2017. Pneumonia was diagnosed according to the previously published international guidelines . CAP and(1)Age < 18 years, >80 years;(2)Coexisting comorbidities or medical conditions which are difficult to evaluate for pneumonia such as severe liver dysfunction, severe renal dysfunction or HIV/AIDS . Unassessable pulmonary diseases include viral pneumonia, pneumocystis pneumonia ,20, myco(3)Aspiration pneumonia ,22;(4)Receiving immunosuppressive therapy due to any cause;(5)Receiving chemotherapy for malignancy;(6)Receiving hemodialysis due to any cause;(7)Poor activities of daily living (ADL) or requiring any help (Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≥ 3) such as needing tube feeding or home oxygen therapy;(8)Having other complicated infection;(9)Requiring mechanical ventilation and/or requiring treatments in the intensive care unit;(10)Poor prognosis ;(11)Pregnancy.Exclusion criteria commonly used in past ordinary clinical trials are as follows ,17,18; pathogens based on ATS/IDSA guidelines [A sputum sample and two sets of blood were collected from each patient for microbiological examination. Serological tests were performed to detect antibodies against eumoniae  and Chlaeumoniae . Additioeumoniae . Methiciidelines .Antibiotic treatment was classified as appropriate or inappropriate according to whether the identified pathogens were sensitive or resistant, respectively, to the initially prescribed antibiotics. Initial treatment failure was defined as death during the initial treatment or a change in the antibiotic regimen from the initial agents within 72 h after starting the treatment due to a lack of response or clinical deterioration .t test or Mann–Whitney U test to compare continuous variables. Overall survival time (OS) was calculated as from the date of diagnosis until the date of death from any cause. A significance was evaluated by Log-rank test. Missing values were evaluated by the missing analysis of the software. Statistical analyses involved use of SPSS version 26 for Windows . A p-value < 0.05 was considered statistically significant.The data for categorical variables are expressed as percentages and continuous variables as mean ± standard deviation (SD). Chi-squared or Fisher’s exact test (two-tailed) were used to compare categorical variables, and unpaired Student’s p = 0.032). There were no significant differences in the frequency of antipseudomonal agents use as the initial treatment between the two groups. The duration of antibiotics use was longer in patients within the participation-impossible group than in those in the participation-possible group, while there was no difference of duration of admission between the two groups. As for pathogens isolated, MRSA was more frequently seen in participation-impossible group than in the participation-possible group , while Haemophillus influenzae was seen more frequently in the participation-possible group than in the participation-impossible group .A total of 406 patients were enrolled in the present study. p = 0.025), while duration of hospital stay did not differ between the two groups.p = 0.022). There was no differences of 30-day and in-hospital mortality rates in between the two groups. There were no differences in duration of hospital stay or antibiotic treatment between the two groups. As for pathogens isolated, isolation of MRSA and Pseudomonas aeruginosa did not differ between the two groups. On the other hand, H. influenza and Moraxella catarrahis tended to isolate more often in the participation-possible group than in the participation-impossible group.p < 0.001 by Log-rank test), as shown in As for overall survival times, the participation-possible group displayed a longer overall survival times (OSs) than the participation-impossible group   , while tnk test) .In terms of reasons for not being able to join a clinical trial, underlying diseases or conditions which could not be assessed correctly was the most commonly seen in 254 (73%) patients, followed by age in 180 (52%) patients .Patients in the real world are quite different from those who can participate in a clinical trial. We already reported that only 24% of candidemia patients could participate in a clinical trial. Patients who can participate in a clinical trial have better PSs and longer overall survival times than those seen in actual medical practice . Therefop = 0.21). The results of our study also suggest that HCAP patients are likely to have longer duration of antibiotic therapy, lasting 10–14 days, as we expected. The therapeutic strategy for HCAP patients might have to be reconsidered due to the poor general conditions.Outstandingly, the OSs in the participation-impossible group with CAP were significantly shorter than those in the participation-possible group, while 30-day and in-hospital mortality rate did not differ between the two groups. More comorbidities could affect the prognosis among the participation-impossible group. Particularly, more aspiration pneumonia was seen in 65/125 (52%) and 140/223 (63%) patients in the participation-impossible group with CAP and HCAP, respectively. Performance status in patients with aspiration pneumonia are likely to decline, and some of them become bedridden . These pAs for an initial antibiotic therapy among CAP patients, more penicillin and less fluoroquinolones were seen in the participation-impossible group than the participation-possible group. The reasons are that the initial antibiotic selections were based on the patients’ characteristics. The patients who received penicillin had aspiration pneumonia in 31/70 (44.3%) of cases, and those who received fluoroquinolones were younger than 50 years in 7/21 (33.3%). The doctors prescribed penicillin and fluoroquinolones to the patients to cover anerobic bacteria and atypical bacteria, respectively.There are several limitations in our study. First, this is a retrospective study on a small population. Thus, there might be a bias in data selection and analysis, such as the severity of pneumonia, Second, we only evaluated patients who were admitted to our institute. The choice of initial antibiotic therapy, indication of hospitalization, ICU admission and DNAR orders were based on the physicians’ decisions. There might be possibility that patients in this study could not reflect the whole population of pneumonia patients.In conclusion, 14% patients could join the clinical trial, while 86% patients could not. There is a difference in patients’ profiles and outcomes between the real world and the clinical trial. Though EBM is very important and essential to advancing medicine, we should acknowledge the facts and limits of clinical trials. Physicians should not be overconfident in EBM based on the results of a clinical trial.


Local exercise performance was assessed by time to task failure during a knee extensor sustained endurance test. A repeated moderate-intensity cycling test was performed to evaluate dynamics of pulmonary VO2 and muscle deoxygenation. The knee extensor maximal voluntary contraction and quadriceps femoris cross-sectional area measurements were performed to explore the potentiality for strength gain and muscle hypertrophy. The whole-body exercise performance  did not change before and after the intervention . Moreover, the local exercise performance  did not change before and after the intervention . Furthermore, no such changes were observed for all parameters measured using a repeated moderate-intensity cycling test and knee extensor strength and quadriceps femoris size measurements. These findings suggest that a 2-weeks IPC intervention cannot increase whole-body and local exercise performances, corresponding with ineffectiveness on its-related parameters in healthy young adults. However, the statistical analyses of changes in the measured parameters in this study showed insufficient statistical power and sensitivity, due to the small sample size. Additionally, this study did not include control group(s) with placebo and/or nocebo. Therefore, further studies with a larger sample size and control group are required to clarify the present findings.An acute bout of ischemic preconditioning (IPC) has been reported to increase exercise performance. Nevertheless, the ineffectiveness of acute IPC on exercise performance has also been reported. Similarly, the effect of a shot-term intervention of IPC on exercise performance remains controversial in previous studies. In this study, we examined the effects of short-term IPC intervention on whole and local exercise performances and its-related parameters. Ten healthy young males undertook a 2-weeks IPC intervention (6 days/weeks). The IPC applied to both legs with three episodes of a 5-min ischemia and 5-min reperfusion cycle. Whole-body exercise performance was assessed by peak O Nevertheless, a meta-analysis by Salvador et al. (Previous studies have reported that an acute bout of ischemic preconditioning (IPC) increases whole-body and local exercise performances  induced by long-term exercise training may be associated with increased muscle strength and size  further increased by a week after completion of a 1-week IPC intervention compared to 48 h after the completion of this intervention. Their finding suggests that increasing the IPC intervention period  may be effective in enhancing its positive effects. Therefore, in this study, we aimed to determine the effects of a 2-weeks IPC intervention on whole-body and local exercise performances and its-related parameters.Lindsay et al.  found thTen healthy, young males (age: 23 ± 1 years) participated in this study. The subjects were recreationally active, but did not participate in specific physical training program within 3 years. None of the subjects had contraindications to magnetic resonance imaging (MRI). All subjects were informed about the experimental procedures and potential risks and gave written consent to participate in the study. This study was approved by the Ethics Committee of Ritsumeikan University (IRB-2017-034).A schematic representation of the experimental design of this study is shown in On the first experimental day, physical characteristics and quadriceps femoris cross-sectional area (CSA) of the subjects was measured. Then, the subjects performed a ramp-incremental cycling test. Forty-eight hours after the day, in the second experimental day, the subjects performed a repeated moderate-intensity cycling test. Thirty minutes after this test was completed, the knee extensor MVC of the subjects was measured. Thereafter, the subjects performed a sustained knee extensor endurance test.Two days after the second experimental day, the subjects undertook a 2-weeks IPC intervention with 6 days/week, which is a total of 12 sessions. An IPC session of each day comprised of three episodes of a 5-min ischemia and 5-min reperfusion cycle to both legs. Cuffs for IPC were placed proximally around the upper thighs of the subjects in a supine position and inflated to 220 mmHg. The 12 sessions of IPC throughout 2-weeks intervention period in all subjects were performed at approximately the same time (± 1 h) in the morning every day.Forty-eight hours after the final IPC session of the 2-weeks intervention, the subjects repeated same measurements on the first experimental day before this intervention. On the next day, the subjects returned to the laboratory to undergo one IPC session, as aimed to sustain the effect on this IPC intervention. Again, 24 h after the last IPC session, the subjects repeated same measurements on the second experimental day before the IPC intervention.The detailed method of the quadriceps femoris CSA measurement using MRI has been described in our previous studies . The detailed methods for calculating the pulmonary VO2 and muscle deoxygenation dynamics have been described in our previous studies .The repeated moderate-intensity cycling test was consisted of the following protocol; 4-min low-intensity cycling at 30 watts/min , 4-min moderate-intensity cycling at 90% of the gas exchange threshold , 4-min active rest with a low-intensity cycling at 30 watts/min, 4-min low-intensity cycling at 30 watts/min , and 4-min moderate-intensity cycling at 90% of the gas exchange threshold . Subjects were asked to maintain a cadence of 60 rpm throughout this test. During this test, breath-by-breath pulmonary VOThe detailed method of the knee extensor MVC measurement has been described in our previous studies  was calculated to determine the level of statistical power of change in measured variable before and after the intervention. The Cohen's d effect size (ES) was calculated to determine the magnitude of change in measured variable before and after the intervention .Physical characteristics did not change before and after 2-weeks IPC intervention . Additionally, all variables of pulmonary VO2 and muscle deoxygenation dynamics during a repeated moderate-intensity cycling test did not change before and after the intervention . Furthermore, other variables measured during ramp incremental cycling and repeated moderate-intensity cycling tests did not change significantly before and after the intervention . Additionally, endurance  during a sustained knee extensor endurance test did not change before and after the intervention . Other variables measured during this test also did not change significantly before and after the intervention   of IPC increases endothelial function  of blood flow restriction, performed with a similar protocol  to that of IPC, mitigated strength loss and muscle atrophy in subjects with disuse muscle atrophy due to immobilization and orthopedic surgeries  and health state populations  remains unclear. The IPC intervention is generally more required in older individuals and patients with chronic diseases than in healthy young adults due to their deteriorating cardiovascular and musculoskeletal systems, which may be major limiting factors in performing effective exercise training programs to improve exercise performance. Pryds et al.  reportedParadis-Deschênes et al.  reportedThis study had several limitations. First, the statistical values for the measured parameters in this study showed insufficient statistical power and sensitivity. This is mainly associated with small sample size  of this study. A meta-analysis by Salvador et al.  reportedThis study determined that a 2-weeks intervention of IPC did not increase whole-body and local exercise performances, corresponding with ineffectiveness on its-related parameters in healthy young adults. Therefore, we suggest that the short-term IPC intervention may have little or no effect on exercise performance. Nevertheless, because this study has several limitations, further studies may be required to reconfirm the effect of short-term IPC intervention on exercise performance with adequate and rigorous methodology.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee of Ritsumeikan University. The patients/participants provided their written informed consent to participate in this study.DT and TS conceived, designed the experiment, and wrote the manuscript. DT, TS, and KS performed experiments. DT, TS, KS, and TI interpreted results of experiments. TS and TI edited and revised manuscript. All authors have read and approved the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.