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  • Lung Health of Early COPD (LHEC): A Multi-center Cohort Study——rat

    Lung Health of Early COPD (LHEC): A Multi-center Cohort Study——rat

    Background

    Chronic obstructive pulmonary disease (COPD) is the most prevalent chronic respiratory disease in China. According to the most recent epidemiological study in China,1 the overall prevalence of spirometry-defined COPD is 8.6%, accounting for 99.9 million people in China.

    The disease burden of COPD in the young population is also high; the prevalence of COPD is 7.1% and 2.9% in men and women aged 40–49 years, respectively, and 3.9% and 2.0% in men and women aged 30–39 years, respectively.1 Studies focusing on lung function in early adulthood (25–40 years) showed that 9.6% of these individuals had poor lung function (forced expiratory volume in one second [FEV1] <80% predicted)2 and were associated with earlier incidence of respiratory, cardiovascular, and metabolic abnormalities.

    A number of people have shown lung function abnormalities but still cannot be diagnosed with COPD. Moreover, COPD patients with mild lung function impairment (GOLD stage I) also account for a large proportion of all COPD patients.1 The gap between normal lung function and severe COPD is substantial. However, individuals within this gap may possess certain characteristics that remain unidentified but contribute to disease progression.

    Recently, to stop the progression of COPD at an early stage to decrease the heavy economic and social burdens it causes, researchers have paid more attention to the pre- and mild stages of the disease. We defined pre- or mild COPD as Early COPD (as described in the Methods section). Early COPD has been studied for a long time; however, there has been no consensus on its definition. Researchers have identified some clues regarding patients with early COPD, such as special risk factors, early symptoms, lung function characteristics, and early signs on computed tomography (CT). However, these studies mostly excluded nonsmokers and focused on younger patients, who cannot represent all people in this stage of COPD.3,4

    We aim to characterize individuals with early COPD, both smokers and nonsmokers, to determine unknown risk factors, changes in lung function and CT findings, and biomarkers.

    Materials and Methods

    Objectives

    The major objectives of this study are as follows:

    1. Characterizing pre- and mild-COPD patients in China and exploring their risk factors in smokers and nonsmokers.

    2. Describing descending lung function in early COPD and identifying groups of people with different changing curves of lung function.

    3. Recording the disease process of early COPD, including lung function, CT findings, symptoms, and treatment.

    4. Exploring new indicators of early COPD, such as lung function parameters, CT characteristics, and biomarkers, that can help identify individuals who are most likely to develop COPD.

    Design

    This is a multicenter, observational, prospective cohort study with two follow-up periods of 2 years as the initial stage, external follow-up will be planned later.

    Participants

    We aim to enroll men and women aged 35–75 years, with post-bronchodilator spirometry FEV1/forced vital capacity (FVC) <0.8 and forced expiratory volume in one second percent predicted (FEV1%pred) ≥80%, who are willing to participate in this study and sign the consent form. The exclusion criteria are as follows: (1) diseases that may cause lung function abnormalities, such as lung cancer, bronchiectasis, interstitial lung disease, and previous chest surgery; (2) body mass index >35 kg/m2; (3) mental disease or cognitive disorders; (4) pregnancy or lactation; (5) participation in other interventional clinical studies; (6) heart attack in the last 3 months (eg, angina pectoris, myocardial infarction, malignant arrhythmia); (7) hospitalized for heart disease within the last 1 month; (8) receiving anti-tuberculosis drugs or having active tuberculosis; (9) Malignancy diagnosed recently or treated; (10) disease that researchers consider inappropriate for pulmonary function tests; and (11) inability to provide written informed consent.

    Participants enrolled will be further divided into four groups named and defined as follows (Table 1). Group A: Pre-COPD smokers, defined as a population with 0.7≤ FEV1/FVC <0.8 (post-bronchodilator) and >10 pack-years of smoking. Group B: Mild-COPD smokers, defined as a population with FEV1/FVC<0.7 (post-bronchodilator) and >10 pack-years of smoking. Group C: Pre-COPD nonsmokers, defined as a population with 0.7≤ FEV1/FVC <0.8 (post-bronchodilator) who never smoked or smoked fewer than 10 pack-years. Group D: Mild-COPD nonsmokers, defined as a population with FEV1/FVC<0.7 (post-bronchodilator) who never smoked or smoked < 10 pack-years.

    Table 1 Grouping of the Subjects into 4 Groups

    We plan to enroll 1500 participants, with 375 patients in each group. We will also enroll 50 individuals with normal pulmonary function as healthy controls, defined as FEV1/FVC ≥0.8 and FEV1%pred ≥80%. Participants will be enrolled from hospitals located throughout China, mainly in outpatient departments.

    Distribution of Research Centers

    This study was led by the China–Japan Friendship Hospital in Beijing, with 23 other sub-research centers located in different provinces of China distributed throughout the country (Figure 1).

    Figure 1 Distribution of research centers of this study located in China. Red: provinces with research centers located. Yellow star: research centers.

    Baseline and Follow-Up Assessments

    Visit 1: Baseline Assessment

    After enrollment, we will conduct a face-to-face baseline assessment of the participants, which will include questionnaires, physical examination, pulmonary function tests, high-resolution CT, blood tests, and biological sample collection.

    Baseline questionnaires include demographic data, respiratory symptoms, tobacco use, biomass and environmental exposure, personal and family disease history, physical activity, diet, psychological status, quality of life, complications, and medical assessments.

    The modified Medical Research Council (mMRC) and COPD Assessment Test (CAT) questionnaires were employed to assess symptom severity, the EQ-5D questionnaire was utilized to quantify quality of life (QoL), and the Short Form-12 (SF-12) was applied to evaluate psychological status.

    Physical examinations include blood pressure, height, weight, and fingertip oxygen saturation measurements.

    Pulmonary function tests include pre- and post-diastolic pulmonary function, diffusing capacity of the lung for carbon monoxide (DLCO), tomography, and pulse oscillation.

    CT including breathing biphasic chest high-resolution CT.

    A regular blood test is required.

    Biological sample collection, wherein blood and urine are collected for further investigation.

    Visit 2: 12-Month Telephone Follow-Up

    We will make a 10-min phone call with the participants in the 12th month after enrollment, employing an easy questionnaire, including respiratory symptoms, tobacco use, biomass, and environmental exposure, as well as medical visits in the past 12 months.

    Visit 3: 24-Month Face-to-Face Follow-up

    During the 24-month visit, we will perform a face-to-face follow-up that will include questionnaires, physical examinations, pulmonary function tests, high-resolution CT, blood tests, and biological sample collection.

    Twenty-four-month questionnaires include respiratory symptoms, tobacco use, biomass and environment exposure, as well as medical visits in the past 12 months. Pulmonary function tests, high-resolution CT, blood tests, and biological sample collection are the same as those performed at baseline.

    The overall study design and data collection at each visit are shown in Figure 2.

    Figure 2 Study design and visits. The red box includes all the data that will be collected in visit 1, which is the baseline assessment. The green box shows data collected in visit 2 as the first follow-up in Month 12. The blue box shows data collected in visit 3 as the second follow-up in Month 24.

    Management of Follow-up and Loss to Follow-Up

    At enrollment, all participants provided contact information for themselves and their primary contacts. The telephone follow-up in this study was designed with brief interview duration. During the predefined one-month window before and after each scheduled follow-up time point, researchers will attempt to contact the participant at three distinct time slots over three days. If all three attempts fail, the participant will be classified as lost to follow-up. For individuals lost to follow-up at the 12-month assessment, additional attempts will be made during the 24-month follow-up window to re-establish contact.

    All instances of loss to follow-up will be documented, including reasons for attrition, to evaluate whether missingness adheres to the missing completely at random (MCAR) assumption. Primary analyses will employ complete case analysis (CCA) to ensure validity in trajectory modeling. Should the overall attrition rate exceed 10%, a multiple imputation approach via iterative chained equations will be implemented to generate a complete dataset.

    Outcome

    The primary outcomes of this study are decline in pulmonary function (eg, FEV1, FVC, DLCO) and changes of high-resolution CT in early and mild COPD. The secondary outcomes of this study are changes in the quality of life and symptoms reflected through the changes in the scale scores.

    Sample Size

    Based on a consensus discussion by five respiratory specialists, the probability of high-risk individuals developing early-stage COPD was estimated at 20%. With α=0.05 (significance level) and β=0.10 (statistical power), a survival analysis using a cohort study design indicated a minimum required sample size of 677 participants. To enhance statistical robustness and account for potential attrition, this study plans to enroll 1500 individuals.

    To ensure adequate representation of the target subgroups (including non-smoking individuals and the pre-COPD subgroup), we implemented a balanced allocation strategy to maintain equal participant numbers across all groups.

    Ethics and Registration

    The project protocol, informed consent, and questionnaires were approved by the Institutional Review Board of China–Japan Friendship Hospital (Beijing, PR China; approval number 2022-KY-141). The program has been registered at ClinicalTrials.gov with the identifier NCT05466396. All the participants will be required to provide written informed consent. The trial will comply with the Declaration of Helsinki.

    Planned Statistical Analysis

    Continuous variables (eg, age, FEV1, FVC, tobacco use, biomass exposure, physical activity, and DLCO) will be summarized as the number of observed values, number of missing values, mean and standard deviation, or median, minimum, and maximum. Categorical data (eg, sex, complications, and disease history) will be summarized as the number of observed values, number of missing values, and numbers and percentages in each category.

    For statistical comparison between study groups, when continuous data are normally distributed, the Student’s t-test will be used. The Mann–Whitney U-test will be used for non-normally distributed data. Categorical data will be compared using χ2 or the Fisher exact test.

    To control covariates in this study, primary analyses will adjust for covariates via linear/logistic mixed-effects models (eg, adjusting for age, sex, smoking status as fixed effects; study site as random effect). For exposure-outcome analyses (eg, air pollution effects), inverse probability weighting (IPW) will be applied to minimize selection bias.

    Imaging data will be analyzed using the Digital Lung platform to quantify metrics such as emphysema extent, lung volume, and pulmonary nodules. Longitudinal statistical analyses will be performed to assess temporal changes in these quantitative parameters.

    Biomarker analysis in this study primarily encompasses multi-omics profiling. Biological samples will undergo genomic, proteomic, and metabolomic analyses. Differential protein expression will be screened using t-tests, ANOVA (for multi-group comparisons), or non-parametric tests (eg, Mann–Whitney U-test), while population genomic analyses will employ linear/logistic regression models (eg, PLINK).

    Differentially expressed molecules will undergo pathway enrichment analysis via databases such as Gene Ontology (GO), KEGG, and Reactome (utilizing tools like clusterProfiler) to identify COPD-associated pathways, including inflammation, oxidative stress, and fibrosis. Multi-omics integration will be conducted using Weighted Gene Co-expression Network Analysis (WGCNA) or Data Integration Analysis for Biomarker discovery using Latent variable methods (DIABLO) to identify cross-omics co-expression modules or biomarker combinations. Classification models based on random forest, support vector machines (SVM), or deep learning architectures (eg, convolutional neural networks) will be developed to predict early COPD risk.

    Data Management

    In this study, the data will be collected and processed by each research center following general data protection rules. The data will be further analyzed in a leading research center. Chest CT images will undergo quantitative CT analysis via the Dexin-FACT software (Dexin-FACT-V1.0, China) integrated into the Digital Lung measurement platform, generating CT-derived metrics specific to chronic obstructive pulmonary disease (COPD), including emphysema index, airway wall thickness, and parenchymal texture parameters, etc. Biological samples will be collected and roughly processed at each research center and then transported to the China–Japan Friendship Hospital for further processing and analysis. A research data management plan was developed to provide further operational details and procedures.

    Discussion

    This study aims to investigate the initial stages of COPD based on a national cohort, record the natural disease history at this stage, and clinically and biologically define early COPD.

    COPD is a heterogeneous collection of diseases associated with different genetic backgrounds, environmental exposures, and physiological effects. People with FEV1/FVC<0.7 are likely to be diagnosed with COPD, and as the underlying causes of COPD have not been fully investigated, there is considerable interest in the initial stages of the disease. Studies on the lung function trajectory of COPD have shown that FEV1 declines faster at the early stage of COPD than at the terminal stage.5 Owing to the lack of awareness in identifying early stage COPD, many patients are first diagnosed in moderate to severe stages, missing the optimal period for intervention.1,6,7 The concept of early COPD was proposed quite some time ago, and its definition has been continuously updated over the past 20 years. GOLD 0 stage was introduced by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) in 2001,8 which is thought to be the origin of the concept of early COPD. GOLD 0 was defined as patients without airflow limitation on spirometry, but with risk factors and persistent respiratory symptoms. However, GOLD 0 has always been questioned because of its vague definition and unconfirmed clinical relevance, especially because of the lack of evidence that these patients will eventually develop COPD.9–12 In 2006, the definition of GOLD 0 was removed from the GOLD guidelines because of the high heterogeneity of the defined population and insufficient evidence supporting the progression of the GOLD 0 population to stage 1.13

    It has become increasingly evident that individuals classified as GOLD 0 experience a higher incidence of COPD exacerbations, greater respiratory impairment, poorer quality of life, and shorter 6-min walk distances compared to never-smokers.14,15 Additionally, 42.3% of patients in the GOLD 0 group already exhibit CT evidence of emphysema or airway thickening. Consequently, the question of whether GOLD 0 should be reintegrated into the COPD staging system has sparked an ongoing debate since 2016. Many researchers have argued that a new definition of “early COPD” should be established.16 In an effort to reduce confusion and support future research, the 2022 GOLD statement clarified the concept of “early COPD”,17 defining “early” as “near the beginning of a process” which should only be used to discuss the “biological early” stage when appropriate. The aim is to promote the development of effective preventive interventions to halt these processes, thereby reducing the risk of COPD-related mortality.18

    Currently, the majority of cohorts established for research on early COPD focus on smokers, with minimal attention given to nonsmokers.19–21 These research cohorts are partially dedicated to patients classified as GOLD I–II, whereas others have adopted the definition of GOLD 0 as part of the early COPD definition. Furthermore, some studies have focused specifically on young individuals with COPD. However, research has demonstrated that factors other than smoking, such as biomass exposure, may be the predominant causes of early COPD. Moreover, GOLD 0 is not an optimal method for defining early COPD. There is a need for a more accurate definition of early COPD that encompasses both pre-COPD and mild COPD.

    Our study has two notable strengths. First, it employs a narrower range of lung function thresholds to define pre-COPD and mild COPD. According to our preliminary studies (unpublished data), people with a FEV1/FVC of 0.7–0.8 have a higher probability of becoming COPD patients in 2 years, therefore we set this range for our study. This approach facilitates the identification of true COPD cases within a shorter timeframe. By focusing on a more precise range, we can more effectively distinguish between pre-COPD and mild-COPD. Observing patients at both ends of the initial disease stage allows for a deeper investigation of this particular phase. Second, the study included a significant proportion of nonsmokers. By excluding smoking, which is a prominent risk factor, we can better understand the true contributions of other risk factors and identify new ones. Additionally, we plan to utilize the collected biological samples for a variety of analyses, including various omics approaches, and employ large-scale biological models to track changes in biomarkers. This will enable us to identify truly meaningful indicators. This approach could potentially revolutionize the definition of COPD.

    Our study has several limitations. First, the follow-up period may be insufficient to fully investigate the progression of early COPD. Given that COPD is a chronic condition, significant changes may not be observable within a 2-year timeframe. However, this study focuses on the early stage of the disease, which is meaningful to get a closer view, and we designated the initial 2 years as the first stage of this cohort. Following the completion of this initial follow-up phase, we will develop a subsequent follow-up plan for the cohort. Second, no interventions have been included. This investigation is designed as an observational study to better understand the natural processes of the disease, with the implementation of interventions being a crucial next step.

    Abbreviations

    BMI, body mass index; COPD, chronic obstructive pulmonary disease; CT, computed tomography; DLCO, diffusing capacity of the lung for carbon monoxide; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; GOLD, Global Initiative for Chronic Obstructive Lung Disease.

    Patient and Public Involvement

    No patient and/or the public were involved in the design of this study.

    Acknowledgments

    Thanks to all the researchers in every sub-research center who work hard in enrollment and follow-ups for this study.

    Author Contributions

    All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

    Funding

    This study is supported by Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (CIFMS) (2021-I2M-1-049); Noncommunicable Chronic Diseases-National Science and Technology Major Project (2023ZD0506003, 2023ZD0506306); National Natural Science Foundation of China, No.82100044; Elite Medical Professionals Project of China-Japan Friendship Hospital (ZRJY2021-QM10); CAMS Innovation Fund for Medical Sciences (CIFMS) (2022-I2M-C&T-B-107).

    Disclosure

    The authors report no conflicts of interest in this work.

    References

    1. Wang C, Xu J, Yang L, et al. Prevalence and risk factors of chronic obstructive pulmonary disease in China (the China Pulmonary Health [CPH] study): a national cross-sectional study. Lancet. 2018;391(10131):1706–1717.

    2. Agusti A, Noell G, Brugada J, et al. Lung function in early adulthood and health in later life: a transgenerational cohort analysis. Lancet Respir Med. 2017;5(12):935–945. doi:10.1016/S2213-2600(17)30434-4

    3. Sundeep S, Salvi PJB. Chronic obstructive pulmonary disease in non-smokers. Lancet. 2009;374:733–743. doi:10.1016/S0140-6736(09)61303-9

    4. Yang IA, Jenkins CR, Salvi SS. Chronic obstructive pulmonary disease in never-smokers: risk factors, pathogenesis, and implications for prevention and treatment. Lancet Respir Med. 2022;10(5):497–511. doi:10.1016/S2213-2600(21)00506-3

    5. Tantucci C, Modina D. Lung function decline in COPD. Int J Chron Obstruct Pulmon Dis. 2012;7:95–99. doi:10.2147/COPD.S27480

    6. Wang C, Qi W, Yang T, et al. The care cascade of chronic obstructive pulmonary disease in China: a cross-sectional study of individual-level data at enrolment into the national “happy breathing programme”. EClinicalMedicine. 2024;74:102597. doi:10.1016/j.eclinm.2024.102597

    7. Rennard SI, Drummond MB. Early chronic obstructive pulmonary disease: definition, assessment, and prevention. Lancet. 2015;385(9979):1778–1788. doi:10.1016/S0140-6736(15)60647-X

    8. Pauwels RA, Buist A, Calverley P, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop summary. Am J Respir Crit Care Med. 2001;163(5):1256–1276. doi:10.1164/ajrccm.163.5.2101039

    9. Vestbo J, Lange P. Can GOLD stage 0 provide information of prognostic value in chronic obstructive pulmonary disease? Am J Respir Crit Care Med. 2002;166(3):329–332. doi:10.1164/rccm.2112048

    10. Mannino DM. GOLD stage 0 COPD: is it real? Does it matter? Chest. 2006;130(2):309–310. doi:10.1016/S0012-3692(15)51839-4

    11. de Marco R, Accordini S, Cerveri I, et al. An international survey of chronic obstructive pulmonary disease in young adults according to GOLD stages. Thorax. 2004;59(2):120–125. doi:10.1136/thorax.2003.011163

    12. Ekberg-Aronsson M, Pehrsson K, Nilsson J-Å, et al. Mortality in GOLD stages of COPD and its dependence on symptoms of chronic bronchitis. Respir Res. 2005;6(1):98. doi:10.1186/1465-9921-6-98

    13. Vestbo J, Hurd SS, Agustí AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013;187(4):347–365. doi:10.1164/rccm.201204-0596PP

    14. Regan EA, Lynch DA, Curran-Everett D, et al. Clinical and radiologic disease in smokers with normal spirometry. JAMA Intern Med. 2015;175(9):1539–1549. doi:10.1001/jamainternmed.2015.2735

    15. Woodruff PG, Barr RG, Bleecker E, et al. Clinical significance of symptoms in smokers with preserved pulmonary function. N Engl J Med. 2016;374(19):1811–1821. doi:10.1056/NEJMoa1505971

    16. Celli BR, Agusti A. COPD: time to improve its taxonomy? ERJ Open Res. 2018;4(1):00132–2017. doi:10.1183/23120541.00132-2017

    17. Global initiative for chronic obstructive lung disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. cited October 3, 2022. 2022.

    18. Yang W, Li F, Li C, et al. Focus on early COPD: definition and early lung development. Int J Chron Obstruct Pulmon Dis. 2021;16:3217–3228. doi:10.2147/COPD.S338359

    19. Curtis JL, Bateman LA, Murray S, et al. Design of the SPIROMICS study of early COPD progression: SOURCE study. Chronic Obstr Pulm Dis. 2024;11(5):444–459. doi:10.15326/jcopdf.2023.0490

    20. Borras-Santos A, Garcia-Aymerich J, Soler-Cataluña JJ, et al. Determinants of the appearance and progression of early-onset chronic obstructive pulmonary disease in young adults. a case-control study with follow-up. Arch Bronconeumol. 2019;55(6):312–318. doi:10.1016/j.arbr.2019.04.003

    21. Vrbica Z, Labor M, Gudelj I, et al. Early detection of COPD patients in GOLD 0 population: an observational non-interventional cohort study – MARKO study. BMC Pulm Med. 2017;17(1):36. doi:10.1186/s12890-017-0378-6

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  • Characteristics of eclampsia not preceded by hypertensive disorders of pregnancy: a case control study | BMC Pregnancy and Childbirth

    Characteristics of eclampsia not preceded by hypertensive disorders of pregnancy: a case control study | BMC Pregnancy and Childbirth

  • Fishel Bartal M, Sibai BM. Eclampsia in the 21st century. Am J Obstet Gynecol. 2022;226(2S):S1237–53.

    CAS 
    PubMed 

    Google Scholar 

  • Watanabe K, Matsubara K, Nakamoto O, Ushijima J, Ohkuchi A, Koide K, et al. Outline of the new definition and classification of “Hypertensive Disorders of Pregnancy (HDP)”; a revised JSSHP statement of 2005. Hypertens Res Pregnancy. 2018;6(2):5.

    Google Scholar 

  • Ghulmiyyah L, Sibai B. Maternal mortality from preeclampsia/eclampsia. Semin Perinatol. 2012;36(1):56–9.

    PubMed 

    Google Scholar 

  • Thornton C, Dahlen H, Korda A, Hennessy A. The incidence of preeclampsia and eclampsia and associated maternal mortality in Australia from population-linked datasets: 2000–2008. Am J Obstet Gynecol. 2013;208(6):476.e1-5.

    PubMed 

    Google Scholar 

  • Zhang J, Meikle S, Trumble A. Severe maternal morbidity associated with hypertensive disorders in pregnancy in the United States. Hypertens Pregnancy. 2003;22(2):203–12.

    PubMed 

    Google Scholar 

  • Liu S, Joseph KS, Liston RM, Bartholomew S, Walker M, León JA, et al. Incidence, risk factors, and associated complications of eclampsia. Obstet Gynecol. 2011;118(5):987–94.

    PubMed 

    Google Scholar 

  • Hitti J, Sienas L, Walker S, Benedetti TJ, Easterling T. Contribution of hypertension to severe maternal morbidity. Am J Obstet Gynecol. 2018;219(4):405-e1-.e7.

    Google Scholar 

  • Shields LE, Wiesner S, Klein C, Pelletreau B, Hedriana HL. Early standardized treatment of critical blood pressure elevations is associated with a reduction in eclampsia and severe maternal morbidity. Am J Obstet Gynecol. 2017;216(4):415-e1-.e5.

    Google Scholar 

  • Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol. 2012;120(5):1029–36.

    PubMed 

    Google Scholar 

  • Schaap TP, Knight M, Zwart JJ, Kurinczuk JJ, Brocklehurst P, van Roosmalen J, et al. Eclampsia, a comparison within the International Network of Obstetric Survey Systems. BJOG. 2014;121(12):1521–8.

    CAS 
    PubMed 

    Google Scholar 

  • Knight M, UKOSS. Eclampsia in the United Kingdom 2005. BJOG. 2007;114(9):1072–8.

    CAS 
    PubMed 

    Google Scholar 

  • Jaatinen N, Ekholm E. Eclampsia in Finland; 2006 to 2010. Acta Obstet Gynecol Scand. 2016;95(7):787–92.

    PubMed 

    Google Scholar 

  • Cooray SD, Edmonds SM, Tong S, Samarasekera SP, Whitehead CL. Characterization of symptoms immediately preceding eclampsia. Obstet Gynecol. 2011;118(5):995–9.

    PubMed 

    Google Scholar 

  • Miguil M, Chekairi A. Eclampsia, study of 342 cases. Hypertens Pregnancy. 2008;27(2):103–11.

    CAS 
    PubMed 

    Google Scholar 

  • Ratsiatosika AT, Razafimanantsoa E, Andriantoky VB, Ravoavison N, Andrianampanalinarivo Hery R, Boukerrou M, et al. Incidence and natural history of preeclampsia/eclampsia at the university maternity of Antananarivo, Madagascar: high prevalence of the early-onset condition. J Matern Fetal Neonatal Med. 2019;32(19):3266–71.

    PubMed 

    Google Scholar 

  • Vousden N, Lawley E, Seed PT, Gidiri MF, Goudar S, Sandall J, et al. Incidence of eclampsia and related complications across 10 low- and middle-resource geographical regions: secondary analysis of a cluster randomised controlled trial. PLoS Med. 2019;16(3):e1002775.

    PubMed 
    PubMed Central 

    Google Scholar 

  • Eke AC, Ezebialu IU, Okafor C. Presentation and outcome of eclampsia at a tertiary center in South East Nigeria–a 6-year review. Hypertens Pregnancy. 2011;30(2):125–32.

    PubMed 

    Google Scholar 

  • Moodley J. Hypertensive emergencies in pregnancies in underresourced countries. Curr Opin Obstet Gynecol. 2008;20(2):91–5.

    PubMed 

    Google Scholar 

  • Sibai BM. Disparity in the rate of eclampsia and adverse pregnancy outcome from eclampsia: a tale of two countries. Obstet Gynecol. 2011;118(5):976–7.

    PubMed 

    Google Scholar 

  • Amburgey OA, Chapman AC, May V, Bernstein IM, Cipolla MJ. Plasma from preeclamptic women increases blood-brain barrier permeability: role of vascular endothelial growth factor signaling. Hypertension. 2010;56(5):1003–8.

    CAS 
    PubMed 

    Google Scholar 

  • Schreurs MP, Houston EM, May V, Cipolla MJ. The adaptation of the blood-brain barrier to vascular endothelial growth factor and placental growth factor during pregnancy. FASEB J. 2012;26(1):355–62.

    CAS 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Shiozaki A, Matsuda Y, Hayashi K, Satoh S, Saito S. Comparison of risk factors for major obstetric complications between Western countries and Japan: a case-cohort study. J Obstet Gynaecol Res. 2011;37(10):1447–54.

    PubMed 

    Google Scholar 

  • Watanabe K, Suzuki Y, Yamamoto T. Incidence of eclampsia in Japanese women. Hypertens Res Pregnancy. 2013;1(1):4. https://doi.org/10.14390/jsshp.1.31.

    Article 

    Google Scholar 

  • Abi-Said D, Annegers JF, Combs-Cantrell D, Frankowski RF, Willmore LJ. Case-control study of the risk factors for eclampsia. Am J Epidemiol. 1995;142(4):437–41.

    CAS 
    PubMed 

    Google Scholar 

  • Maraschini A, Salvi S, Colciago E, Corsi E, Cetin I, Lovotti M, et al. Eclampsia in Italy: a prospective population-based study (2017–2020). Pregnancy Hypertens. 2022;30:204–9.

    PubMed 

    Google Scholar 

  • Stella CL, Jodicke CD, How HY, Harkness UF, Sibai BM. Postpartum headache: is your work-up complete? Am J Obstet Gynecol. 2007;196(4):318.e1-7.

    PubMed 

    Google Scholar 

  • Hastie R, Brownfoot FC, Cluver CA, Walker SP, Hesselman S, Tong S, et al. Predictive value of the signs and symptoms preceding eclampsia: a systematic review. Obstet Gynecol. 2019;134(4):677–84.

    PubMed 

    Google Scholar 

  • Sperling JD, Dahlke JD, Huber WJ, Sibai BM. The role of headache in the classification and management of hypertensive disorders in pregnancy. Obstet Gynecol. 2015;126(2):297–302.

    PubMed 

    Google Scholar 

  • Douglas KA, Redman CW. Eclampsia in the United Kingdom. BMJ. 1994;309(6966):1395–400.

    CAS 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Mattar F, Sibai BM. Eclampsia. VIII. Risk factors for maternal morbidity. Am J Obstet Gynecol. 2000;182(2):307–12.

    CAS 
    PubMed 

    Google Scholar 

  • Friedman A, Kaufer D, Heinemann U. Blood-brain barrier breakdown-inducing astrocytic transformation: novel targets for the prevention of epilepsy. Epilepsy Res. 2009;85(2–3):142–9.

    CAS 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Johnson AC, Tremble SM, Chan SL, Moseley J, LaMarca B, Nagle KJ, et al. Magnesium sulfate treatment reverses seizure susceptibility and decreases neuroinflammation in a rat model of severe preeclampsia. PLoS ONE. 2014;9(11): e113670.

    PubMed 
    PubMed Central 

    Google Scholar 

  • Oby E, Janigro D. The blood-brain barrier and epilepsy. Epilepsia. 2006;47(11):1761–74.

    CAS 
    PubMed 

    Google Scholar 

  • Uzun H, Benian A, Madazli R, Topçuoğlu MA, Aydin S, Albayrak M. Circulating oxidized low-density lipoprotein and paraoxonase activity in preeclampsia. Gynecol Obstet Invest. 2005;60(4):195–200.

    CAS 
    PubMed 

    Google Scholar 

  • Arifin R, Kyi WM, Che Yaakob CA, Yaacob NM. Increased circulating oxidised low-density lipoprotein and antibodies to oxidised low-density lipoprotein in preeclampsia. J Obstet Gynaecol. 2017;37(5):580–4.

    CAS 
    PubMed 

    Google Scholar 

  • Itabe H. Oxidative modification of LDL: its pathological role in atherosclerosis. Clin Rev Allergy Immunol. 2009;37(1):4–11.

    CAS 
    PubMed 

    Google Scholar 

  • van Veen TR, Panerai RB, Haeri S, Griffioen AC, Zeeman GG, Belfort MA. Cerebral autoregulation in normal pregnancy and preeclampsia. Obstet Gynecol. 2013;122(5):1064–9.

    PubMed 

    Google Scholar 

  • Jones-Muhammad M, Warrington JP. Cerebral blood flow regulation in pregnancy, hypertension, and hypertensive disorders of pregnancy. Brain Sci. 2019. https://doi.org/10.3390/brainsci9090224.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

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  • Bollywood star Shah Rukh Khan takes medical leave after on-set injury

    Bollywood star Shah Rukh Khan takes medical leave after on-set injury

    Entertainment Desk

    19 July 2025, 02:01 PM IST

    Shah Rukh Khan suffers muscle injury during `King` filming, seeks treatment in US. Expected one-month recovery.

    shah rukh khan

    Mumbai: Bollywood superstar Shah Rukh Khan has reportedly sustained a muscular injury while shooting for Siddharth Anand’s upcoming action film King in Mumbai.

    According to sources cited by multiple media outlets, the actor has flown to the United States for medical attention. While the exact nature of the injury remains undisclosed, it is said to be related to previous muscle damage from years of performing action stunts.

    Though not considered serious, doctors have advised Shah Rukh to take a one-month break to fully recover before resuming work on the film.

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    Disclaimer: Kindly avoid objectionable, derogatory, unlawful and lewd comments, while responding to reports. Such comments are punishable under cyber laws. Please keep away from personal attacks. The opinions expressed here are the personal opinions of readers and not that of Mathrubhumi.

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  • Harmanpreet Singh says Indian hockey team ‘got punished for lack of balance’ at FIH Pro League

    Harmanpreet Singh says Indian hockey team ‘got punished for lack of balance’ at FIH Pro League

    The international hockey federation (FIH) offers several routes to qualify for Blue Riband tournaments like the World Cup and the Summer Olympics.

    At this stage, the Indian men’s hockey team, having finished second-last among nine teams in the recently concluded FIH Pro League 2024-25, are not looking too far ahead and focusing on the upcoming Asia Cup in Bihar, said skipper Harmanpreet Singh in an exclusive interview to Olympics.com.

    To cut a long story short, the Indian hockey team has two objectives in front of them. First, to dethrone the Republic of Korea in home conditions and win the Asia Cup, which will be played from August 27 to September 7. Victory will ensure a berth in the FIH World Cup in the Netherlands and Belgium in 2026.

    Second, find a balanced squad for the Asian Games next year. Gold in Aichi-Nagoya in Japan will give India a berth at the LA 2028 Olympics.

    Indian hockey seems to be at an exploratory stage. “The FIH Pro League has been a lesson. We have lost matches by narrow margins. If we can’t defend well and score goals, we will get punished,” said Harmanpreet, adding that only a good “balance” will give the results India desires. India won six and lost 10 matches in the FIH Pro League 2024-25.

    Having conceded (38 goals) more than they scored (34) at the FIH Pro League, questions about India’s defence line and the solidity of goalkeeping in the post-PR Sreejesh era are bound to surface and they did so during the conversation with Harmanpreet at India’s training camp at the Sports Authority of India’s high-performance centre in Bengaluru.

    “Sreejesh has been one of the world’s best goalkeepers but we have faith in the current crop. We have to own up as a team. The forward line, midfield and the defence are collectively responsible for the team’s success or failure. We certainly have to be tighter in defence and not allow soft goals,” said Harmanpreet.

    In the FIH Pro League 2023-24 season, India scored 38 goals and conceded three fewer to finish seventh among nine countries.

    India have generally relied on a counterattacking strategy to surprise the opposition. While the inclusion of young players should have helped raise the overall stamina level, Harmanpreet pointed out that consistency in focus and intensity in all four quarters needs to be improved.

    “While we have lost matches by close margins, performance-wise, we are struggling a bit in the third quarter. We made some strategic changes to play our counterattacking game but we have to have the energy to convert the opportunities. We have to keep these things in mind and be more impactful in the next tournament.

    “Like we start very well, we should be able to finish equally well. We trained very hard in the camps but seven straight defeats in the FIH Pro League were tough. Having said that, it was a great learning that should help us in the future,” said Harmanpreet.

    The 29-year-old Indian captain remains the biggest hope in the side. In the FIH Pro League, Harmanpreet missed five matches due to injury and his absence was felt. Five of the seven straight defeats came at that stage.

    Harmanpreet, who was the top scorer in the Paris 2024 Olympics, was India’s best man (overall joint 10th) in the Pro League with six goals, four from penalty corners and two from penalty strokes. By contrast, 35-year-old Tom Boon of Belgium was the League’s highest scorer with 21 goals – 13 field goals, six from PCs and two from the spot.

    “Injuries are part of the game. When the ball is coming, you must position your body to defend and protect the goal. So I will take the injuries, no matter how frustrating they are. Last match against Belgium, I got a chance to come back and we finished on a winning note (4-3),” said Harmanpreet.

    For now, all attention is on the Asia Cup in Rajgir in Bihar. It remains to be seen if India will play its usual “full press” game or alter the Pro League strategy to inject more balance and remain impact throughout the four quarters.

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  • Australia v British & Irish Lions: first Test – live | Lions tour 2025

    Australia v British & Irish Lions: first Test – live | Lions tour 2025

    Key events

    24 mins. From the scrum way back in the Aus half, Gibson-Park goes blind to Freeman who attempts a chip and chase into the corner but the winger can only watch as the ball drifts into touch.

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  • Apple’s latest AirPods models are still at their lowest price ever – get them while the deal lasts

    Apple’s latest AirPods models are still at their lowest price ever – get them while the deal lasts

    Jada Jones/ZDNET

    Amazon Prime Day may be over, but you can still find Apple’s AirPods 4 at their lowest price yet at Walmart. The AirPods 4 with active noise cancellation (ANC) are currently retailing for $120, or $60 off their sale price. If you want the AirPods 4 without ANC, you can buy that pair for $90.

    Also: The best earbuds you can buy: Expert tested

    Apple released the AirPods 4 last September. The ANC-enabled pair is fitted with Apple’s impressive noise cancellation, adaptive noise cancellation, spatial audio, and an IP54 rating for dust and water resistance. The charging case includes Qi-certified wireless charging and a speaker that plays a pinging noise when you’re trying to locate it in Find My Devices. Additionally, the earbuds’ advanced H2 chip promises clear voice calling, improved noise-canceling performance, and clearer audio. 

    The AirPods 4 without ANC are also a solid option for people who want AirPods without advanced features. They don’t have noise cancellation or adaptive noise cancellation, but they do have spatial audio, Find My compatibility, Siri integration, and a wireless charging case, just like the ones with ANC.

    If you don’t need the beefed-up performance of the premium AirPods Pro 2 but don’t want to try your luck with Apple’s older models, the AirPods 4 lineup is a great place to start. The AirPods 4 with ANC are perfect for people who want noise cancellation and improved voice quality without the tighter, in-canal fit of the AirPods Pro 2.

    Also: My favorite Bose products are on sale plus an extra 25% discount – if you buy refurbished

    The AirPods 4 without ANC are great for people who don’t require noise cancellation, but still want great audio, spatial audio, and a pair of earbuds that pair perfectly with their iPhone.

    Looking for the next best product? Get expert reviews and editor favorites with ZDNET Recommends.

    How I rated this deal

    Based on ZDNET’s deal rating system, these deals received a 4 out of 5 rating because they’re currently at their lowest price ever. Additionally, these AirPods are newer models, and it’s typically harder to find recent released at such low prices. Finally, we’ve tested and recommended the AirPods 4 with and without ANC, and concluded that they are a high-performing pair of earbuds for iOS users, making now the best time to purchase them.

    Deals are subject to sell out or expire at any time, though ZDNET remains committed to finding, sharing, and updating the best product deals for you to score the best savings. Our team of experts regularly checks in on the deals we share to ensure they are still live and obtainable. We’re sorry if you’ve missed out on this deal, but don’t fret — we’re constantly finding new chances to score savings and sharing them with you at ZDNET.com. 

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    We aim to deliver the most accurate advice to help you shop smarter. ZDNET offers 33 years of experience, 30 hands-on product reviewers, and 10,000 square feet of lab space to ensure we bring you the best of tech.

    In 2025, we refined our approach to deals, developing a measurable system for sharing savings with readers like you. Our editor’s deal rating badges are affixed to most of our deal content, making it easy to interpret our expertise to help you make the best purchase decision.

    At the core of this approach is a percentage-off-based system to classify savings offered on top-tech products, combined with a sliding-scale system based on our team members’ expertise and several factors like frequency, brand or product recognition, and more. The result? Hand-crafted deals chosen specifically for ZDNET readers like you, fully backed by our experts.

    Also: How we rate deals at ZDNET in 2025

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  • Simulated Success: Impact of a Preclinical Elective on Medical Student

    Simulated Success: Impact of a Preclinical Elective on Medical Student

    Danielle M Sawka, Mark C Kendall, Matthew S Diorio, Nardin O Derias, Arezoo Rajaee, Chao Ji, Shyamal R Asher

    Correspondence: Shyamal R Asher, Anesthesiology, Rhode Island Hospital, 593 Eddy Street, Davol 129, Providence, RI, 02903, USA, Tel +1 401-527-4775, Email [email protected]

    Introduction: Preclinical medical students often have minimal exposure to topics within the field of anesthesiology. As efforts to expand clinical exposure in the preclinical curriculum are increasing, there remains an unawareness of which education topics are still undervalued. This study is the first application of an anesthesiology simulation in the medical student population that incorporates objective performance evaluation that aims to identify key areas of clinical learning growth and gaps within anesthesiology following a semester-long elective.
    Methods: Our study population consisted of 14 first- and 2 second-year medical students interested in a career in anesthesiology and enrolled in an anesthesia preclinical elective at a single-institution. The students were tested on the same clinical scenario graded based on a standardized rubric prior to and after the completion of the anesthesia preclinical elective. Differences in individual simulation scores were analyzed using t-test, or Wilcoxon signed-rank test for paired samples.
    Results: The students had a statistically significant increase in individual total scores (p < 0.001), with the strongest improvements in basic induction skills (p < 0.001) and response to hemodynamic changes (p < 0.001) after completion of the elective. There was no significant improvement in PACU management skills (p = 0.184) after completion of the elective, although the small sample size limits statistical power.
    Conclusion: This first application of anesthesia-based simulation training with performance scoring in medical students highlights the possible need for targeted early intervention in post-operative management for medical students interested in a career in anesthesiology.

    Introduction

    With only 20% of medical schools requiring an anesthesiology rotation,1 medical student exposure to topics within anesthesiology is unfortunately limited. Previous studies at our institution have demonstrated that a preclinical anesthesia elective enhances written knowledge acquisition2 and that the creation of a new anesthesiology residency program has been associated with an increase in anesthesiology match rates in affiliated medical schools.3 Despite the beneficial influences of these initiatives to enhance preclinical medical education, there remains a strong need to understand which specific domains of clinical skills are being adequately learned by preclinical medical students.

    Simulation-based training is an indispensable tool in assessing such clinical skills, especially for more procedural specialties such as anesthesiology. It appears, however, that most simulation studies of anesthesia skills are applied to residents and attendings,4–7 not medical students, while the published literature shows a remarkable integration of medical student simulation training in other specialties such as internal medicine and obstetrics and gynecology.8–12 These simulations frequently employ objective measurements of performance improvement rather than subjective participant attitudes, a potentially more valuable measure when assessing a simulation’s clinical impact. This study provides a model for filling this gap. In one study of medical students actually performing anesthesia-related skills, the focus is limited to hands-on technical performance of maneuvers such as intubation with no simulation modeled after a clinical scenario and no testing of the crucial higher-order cognitive skills and knowledge learned in anesthesia training;13 our present study again addresses this gap.

    Investigating student learning through clinical simulation training has the additional benefit of clearly isolating and testing understanding of specific content areas. The Accreditation Council for Graduate Medical Education (ACGME) program requirements for anesthesiology residents define broad domains of expected competency such as “airway management techniques” and management of “patients immediately after anesthesia, including direct care of patients in the post-anesthesia care unit, and responsibilities for management of pain, hemodynamic changes, and emergencies related to the post-anesthesia care unit”.14 This single institution prospective study aims to explore which anesthesia contents, as derived from ACGME core domains, are learned by preclinical medical students interested in anesthesia after a semester of exposure to the field of anesthesiology. Medical student clinical anesthesia performance in these domains will be assessed through a low fidelity simulation scenario before and after taking the elective. This study importantly uses objective assessments of participant performance and real-time applied knowledge, a desired and currently lacking objective in the currently sparse research on medical student simulations in anesthesia.

    Methods

    Study Participants

    The students enrolled in the anesthesiology preclinical elective volunteered to participate in an identical clinical simulation scenario before the start (September 5, 2023) and upon completion of the elective (November 14, 2023). Participation in the simulation was not required to obtain credit for the elective and did not affect participation in the elective. Participants received an introduction letter describing the study. Their completion of the simulation indicated willingness to participate in the study. The demographics of study participants who completed the post-elective simulation are reported in Table 1. Highlights from Table 1 are that the majority of participants (88%) were first-year medical students, there was a roughly equal gender ratio (7 males and 9 females), and most (81%) students considered anesthesiology a top three specialty interest although three-quarters had not had prior exposure to the field.

    Table 1 Study Participant Demographics

    Study Context

    The anesthesiology preclinical elective, BIOL 6704: “Anesthesia: Much More than Putting you to Sleep”, is a one-credit course held annually throughout the fall semester at The Warren Alpert Medical School of Brown University. This course has previously been shown to significantly increase medical students’ understanding of anesthesiology fundamentals in airway management, anesthetic pharmacology, ultrasound basics, and residency training.3 This pass/fail elective is open to all first- and second-year medical students during the fall semester. The sessions and learning objectives are presented in Table 2. Students participate in both didactics as well as shadowing experiences in the operating theaters.

    Table 2 Introduction to Anesthesia Preclinical Elective Syllabus Overview

    Ethical Clearance

    Per the Rhode Island Hospital Institutional Review Board, this study was exempt from Human Subjects Research under 45 Code of Federal Regulations 46.104(d) requirements and did not require consent documentation (IRB2083944-3).

    Simulation Design

    The clinical anesthesiology simulation scenario was adapted, with permission, from a Vital Anesthesia Simulation Training (VAST) case.15 VAST is a low fidelity simulation course designed for trainees and practitioners in low resource settings that has been shown to improve trainee Anesthetists’ Non-Technical Skills (ANTS) scores16 and team coordination in cardiopulmonary resuscitation.17 In the latter study, the performance based measures were evaluated using a self-designed checklist similar in construction to ours that was tested to have good reliability and validity.18 The case involved a 19-year-old male, represented by an airway mannequin, presenting for a laparoscopic appendectomy after one day of abdominal pain, nausea, and vomiting. An iPad with the Sim-Mon app (Castle+Anderson ApS; Copenhagen, Denmark) was used to display a monitor screen with vital signs that could be changed in real time requiring live interpretation by the student as the simulation progressed. Following the case presentation, the student was cued to enter the simulation and act as the primary anesthesia provider.

    Data Collection

    The simulation facilitators included a senior anesthesia resident and an attending anesthesiologist who assessed performance in five key domains, called “stages”, and assigned numerical points based on a standardized rubric. The standardized rubric was designed to have binary responses and explicit unambiguous criteria for scoring in order to eliminate the need for training or the concerns of interrater variability. Stage (a) assessed basic induction knowledge, Stage (b) airway management, Stage (c) reaction to hemodynamic changes, Stage (d) emergence and postoperative pain control, and Stage (e) PACU management. In all five stages, the student acted as a supervisor for the anesthesia resident. The anesthesia resident is a scripted role undertaken by the resident simulation facilitator, and the attending (S.R.A.) assessed the students competency; thus a single scorer was used to minimize interrater variability. The detailed simulation scenario and scoring rubric are included in Appendix 1. Figure 1 is an illustrated schematic of the rubric and includes key tasks students had to initiate to receive credit. All data collected were de-identified.

    Figure 1 Rubric illustrating an optimal series of steps that can be taken during the simulation scenario. A skilled anesthesiologist observed each student and awarded points in real-time based on actions completed. Each box represents 1 point that can be earned – 0.5 points were awarded if the student correctly named the class of drug, 1 point if the student answered with a correct drug name. The total points for Stages (a-e) were 6, 3, 3, 4, 4 respectively, for a maximum score of 20 points. As the scenario progressed from Stages (a-e), facilitators manipulated the situation according to the arrows. Drawings by D. M. Sawka.

    Statistical Analysis

    Only results from participants who completed both simulations were analyzed. The few students who completed the pre-simulation but not post-simulation were assumed to be Missing at Random and thus excluded from the analysis. The mean and standard deviation were computed for the five stages. Individual differences in pre- and post-scores were calculated for each section. The group of differences were assessed for normality using the Shapiro–Wilk test, then analyzed using paired t-test or Wilcoxon signed-rank test for paired samples. Alpha threshold for significance was selected to be 0.05. Post hoc power analysis was performed with G*Power 3, a free and publicly available software package19 (Henrich Heine Universität Düsseldorf) published in the literature.20 This software transforms input variables of type of statistical test (set as Means: Difference between two dependent means (matched pairs), number of tails (two), effect size calculated from group means and standard deviations, alpha, and total sample size) to an output parameter of study power.

    Results

    A total of 18 students enrolled in the elective and completed the pre-course simulation. These were all preclinical students with minimal exposure to simulation and no previous exposure to this particular simulation case. Out of this cohort, 2 students withdrew from the elective over the course of the semester, and the remaining 16 students participated in the post-course simulation (88.9%) and were included in the final analysis (Table 2 for demographics). These students represented 14 medical students in their first year and 2 in their second.

    The total rubric scores for each individual are summarized in Figure 2. Thirteen of the 16 students had an improved performance on the second iteration of the simulation after taking the anesthesia preclinical elective, with a maximum score improvement of 10 points on the 20-point rubric.

    Figure 2 Graded total simulation scores across Stages (a-e) for preclinical medical students enrolled in anesthesia elective, performed at the start and end of the elective. The maximum score possible was 20 points.

    A detailed breakdown of aggregate scores for each stage are presented in Table 3. In general, participants significantly improved in 4 of the 5 stages with the exception of Stage (e): PACU Management. The average total score for the first simulation attempt was 4.3 ± 4.2 points. The average total score for the second simulation attempt following clinical exposure was 8.8 ± 2.8 points (p < 0.001). Figure 3 highlights this expected global improvement in clinical performance.

    Table 3 Summary Scores of 16 Preclinical Medical Students in an Anesthesia Simulation Scenario Performed Before and After a Preclinical Elective

    Figure 3 Distributions of total scores (sum of all 5 stages) for preclinical medical students in the standardized anesthesia simulation scenario pre- and post- elective. (i) are the initial total scores of the 16 students, and (ii) are the follow-up scores. Bins are structured as [0,1), [1,2), etc.

    Stage (d): Emergency and Post-operative Pain had the lowest mean pre-score at 0.3, while Stages (b): Airway Management and (e): PACU Management had the highest mean pre-score at 1.3 points. Following several weeks of the elective, Stage (d) remained with the lowest mean post-score at 0.9, while Stage (a): Basic Induction had the highest mean post-score at 2.4 points. Interestingly, Stages (a) and (c): Hemodynamic changes had the strongest significant improvements (p < 0.001), Stages (b) and (d) had weaker but still significant improvements (p = 0.021 and p = 0.048 respectively), and Stage (e) had no significant improvement (p = 0.184). Performances widely varied among participants, as reflected by large standard deviations.

    Discussion

    There is a notable gap in the literature for simulation studies of medical students in the field of anesthesia that are objective and performance based, as most literature is on medical student simulations in other specialties8–12 or anesthesia simulations limited to residents and attendings.4–7 This single-center prospective study aimed to help fill this gap and to identify specific anesthesia content areas, if any, needing more future emphasis in the learning of preclinical medical students interested in anesthesia after a full semester anesthesia elective. Although conclusions are narrowed by study limitations detailed shortly, our findings do suggest the need for early intervention in the education of postoperative care management for medical students given the lack of better clinical performance after the semester (p = 0.184). Interestingly, prior studies of resident and attending anesthesia simulations have notably excluded evaluations of emergence and PACU preparation skills altogether,5–7 which indicates that perhaps this is a far-reaching education gap across the specialty. PACU management is a critically important part of perioperative care with potential for significant risk. An analysis of claims brought against US anesthesiologists for harm occurring in the PACU frequently reported respiratory injuries, nerve injuries, and airway injuries. Over half of cases resulting in patient death cited missed or delayed diagnoses in the PACU as a causative factor.21 Techniques such as airway management and regional anesthesia are considered synonymous with anesthesiology education leaving little time dedicated towards postoperative care management. In a multi-study analysis, with over 70% of included studies involving residents, education surrounding an integral part of PACU management – anesthesiologist handoffs – is suboptimal.22 Theoretical implications of our finding of lack of post-elective PACU skill management are a possible lack of student enthusiasm for the topic and inadequate exposure; practically, this result implies that while intraoperative patient care might improve with learner experience, postoperative patient outcomes might disproportionately stagnate unless our preclinical elective (and anesthesia didactics broadly) are redesigned to include more postoperative exposure and instruction. Understanding this bias can allow medical educators to specifically target postoperative care education through workshops or dedicated time towards learning this important phase of care.

    The simulation was modeled after what is expected of residents in their training. In this study, multiple skills were assessed, such as identifying appropriate medications, recognizing and correcting improper airway management, responding to emergent vital sign changes, and transitioning the patient to PACU. This differs from the assessment tools used in a previously reported anesthesia simulation study conducted among medical students. In that case, third- and fourth-year students interacted with a mannequin in three realistic simulations that included malignant hyperthermia and pulmonary embolism. Despite the quality of the clinical scenarios, evaluation measures were limited to self-assessments. Details and results of the assessments were not provided.23 In another study involving first- and second-year medical students in 14 simulation cases, the study design similarly lacked real-time performance evaluation and instead, relied on participants’ self-completed multiple-choice pre- and post-test grades on knowledge-based questions.24 Based on our literature review, the sole study of student performance resulting from anesthesia simulation training was conducted with veterinary, not medical, students.25 Our study uniquely presents a quality simulation scenario with objective performance metrics excluded from participant self-bias through the use of an external assessor, metrics that are fully transparent to colleagues for future study reproducibility. Since the main purpose of medical simulation training is to enhance learner competency in performing given tasks, it is essential to use such objective metrics to evaluate the real-time application of participants’ knowledge.

    This study has limitations including a small sample size that was limited by the number of students enrolled in the preclinical elective. Our post-hoc power analysis shows a limited power for analyses without strong (p < 0.001) statistical significance, especially for PACU emergence in which true differences between pre- and post-elective may exist. In addition, the lack of a control group limits causal inference of the impact of the preclinical elective itself on performance improvement but is reasonably attributed given our institution’s lack of anesthesia-related core curriculum. In addition, the simulation facilitators were not blinded thereby adding an element of bias in the post-course scoring. There is also a degree of selection bias in our sample as the students volunteered to enroll into the elective and all students were from a single institution. It is unclear in what direction and magnitude, if any, this selection bias would have on the results. Despite the construction of the rubric for easy incorporation elsewhere, this study’s results cannot be readily generalized beyond our single institution. Finally, the simulation performed was a low fidelity simulation with a prepared scenario, an airway mannequin and a simulated monitor but was conducted in a classroom rather than a mock operating room that reduces the level of realism for the student.

    This novel study demonstrates the successful implementation of an objective performance-based evaluation of medical students using an anesthesiology simulation after a preclinical anesthesiology elective. Specific anesthesia content domains that may need additional instructional support from educators are identified.

    Conclusion

    Anesthesiology simulations are a popular and high-impact educational tool for anesthesiology training and a valuable tool for assessing clinical performance. This study demonstrates that a clinical anesthesiology simulation can help identify relative specific strengths and weaknesses in preclinical medical student clinical performance after a preclinical anesthesiology elective. Future initiatives for early medical student exposure to the field of anesthesia should be developed with a suggested greater emphasis on learning postoperative management.

    Data Sharing Statement

    All study data will be publicly shared at request.

    Ethical Considerations

    This student underwent a review by the Rhode Island Hospital Institutional Review Board (IRB2083944-3).

    Consent to Participate

    Per the Rhode Island Hospital Institutional Review Board, this study was exempt from Human Subjects Research under 45 Code of Federal Regulations 46.104(d) requirements and did not require consent documentation (IRB2083944-3).

    Acknowledgments

    The authors thank the Warren Alpert Medical School of Brown University and its preclinical elective student participants.

    Funding

    This study was not funded and the authors report no financial disclosures pertaining to this manuscript.

    Disclosure

    The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

    References

    1. Ly EI, Catalani BS, Boggs SD, McGreevey KE, Updegraff AB, Steadman JL. The anesthesiology clerkship: a requisite experience in medical education. Ochsner J. 2020;20(3):250–254. doi:10.31486/toj.20.0094

    2. Walsh KL, Yadav A, Cradeur M, et al. Impact of a preclinical medical student anesthesiology elective on the attitudes and perceptions of medical students regarding anesthesiology. Adv Med Educ Pract. 2023;14:1347–1355. doi:10.2147/AMEP.S427974

    3. Sawka D, Yadav A, Kendall M, Diorio M, Asher SR. The impact of a new anesthesiology residency program on the number of medical students matching into anesthesiology at a single institution: a retrospective longitudinal study. Cureus. 2023;15(12):e50677. doi:10.7759/cureus/50677

    4. Klein MR, Schmitz ZP, Adler MD, Salzman DH. Simulation-based mastery learning improves emergency medicine residents’ ability to perform temporary transvenous cardiac pacing. West J Emerg Med. 2022;24(1):43–49. doi:10.5811/westjem.2022.10.57773

    5. Weinger MB, Banerjee A, Burden A, et al. Simulation-based assessment of the management of critical events by board-certified anesthesiologists. Anesthesiology. 2017;127(3):475–489. doi:10.1097/ALN0000000000001739

    6. Murray DJ, Boulet JR, Avidan M, et al. Performance of residents and anesthesiologists in a simulation-based skill assessment. Anesthesiology. 2007;107(5):705–713. doi:10.1097/01.anes.0000286926.01083.9d

    7. Abrahamson S, Denson J, Wolf R. Effectiveness of a simulator in training anesthesiology residents. Qual Saf Health Care. 2004;13(5):395–397. doi:10.1136/qhc.13.5.395

    8. McInerney N, Nally D, Khan MF, Heneghan H, Cahill RA. Performance effects of simulation training for medical students – a systematic review. GMS J Med Educ. 2022;39(5):Doc51. doi:10.3205/zma001572

    9. Alluri RK, Tsing P, Lee E, Napolitano J. A randomized controlled trial of high-fidelity simulation versus lecture-based education in preclinical medical students. Med Teach. 2016;38(4):404–409. doi:10.3109/0142159X.2015.1031734

    10. DeWaay DJ, McEvoy MD, Kern DH, Alexander LA, Nietert PJ. Simulation curriculum can improve medical student assessment and management of acute coronary syndrome during a clinical practice exam. Am J Med Sci. 2014;347(6):452–456. doi:10.1097/MAJ.0b013e3182a562d7

    11. Kern DH, Mainous AG, Carey M, Beddingfield A. Simulation-based teaching to improve cardiovascular exam skills performance among third-year medical students. Teach Learn Med. 2011;23(1):15–20. doi:10.1080/10401334.2011.536753

    12. Dayal AK, Fisher N, Magrane D, Goffman D, Bernstein PS, Katz NT. Simulation training improves medical students’ learning experiences when performing real vaginal deliveries. Simul Healthc. 2009;4(3):155–159. doi:10.1097/SIH.0b013e3181b3e4ab

    13. Long S, Sorrels C, Cook R, et al. Early exposure to anesthesiology: a summer preceptorship program for first-year medical students. Proc. 2024;37(2):274–276.

    14. ACGME Program Requirements for Graduate Medical Education in Anesthesiology. ACGME 2022. Available from: https://www.acgme.org/globalassets/pfassets/programrequirements/040_anesthesiology_2022.pdf. Accessed June 17, 2024.

    15. Mossenson A. Airway management. VAST Scenario Bank. Available from: https://www.dropbox.com/sh/uks5o0s15mhee50/AADrkB5DvCzoMVYFKk_RFH_ga/Airway%20management?dl=0&subfolder_nav_tracking=1. Accessed November. 27, 2023.

    16. Mossenson AI, Tuyishime E, Rawson D, et al. Promoting anesthesia providers’ non-technical skills through the vital anaesthesia simulation training (VAST) course in a low-resource setting. Br J Anaesth. 2020;124(2):206–213. doi:10.1016/j.bja.2019.10.022

    17. Tuyishime E, Mossenson A, Livingston P, et al. Resuscitation team training in Rwanda: a mixed method study exploring the combination of the VAST course with advanced cardiac life support training. Resusc Plus. 2023;15:100415. doi:10.1016/j.resplu.2023.100415

    18. Andersen PO, Jensen MK, Lippert A, Østergaard D, Klausen TW. Development of a formative assessment tool for measurement of performance in multi-professional resuscitation teams. Resuscitation. 2010;81(6):703–711. doi:10.1016/j.resuscitation.2010.01.034

    19. G*Power; statistical power analyses for mac and windows. Heinrich Heine Universität Düsseldorf. Available from: https://www.psychologie.hhu.de/arbeitsgruppen/allgemeine-psychologie-und-arbeitspsychologie/gpower. Accessed July 16, 2025.

    20. Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods. 2007;39(2):175–191. doi:10.3758/bf03193146

    21. Kellner DB, Urman RD, Greenberg P, Brovman EY. Analysis of adverse outcomes in the post-anesthesia care unit based on anesthesia liability data. J Clin Anesth. 2018;50:48–56. doi:10.1016/j.jclinane.2018.06.038

    22. Riesenberg LE, Davis R, Heng A, Vong Do Rosario C, O’Hagan EC, Lane-Fall M. Anesthesiology patient handoff education interventions: a systematic review. Jt Comm J Qual Patient Saf. 2023;49(8):394–404. doi:10.1016/j.jcjq.2022.12.002

    23. Jenkins KD, Stroud JM, Bhandary SP, et al. High-fidelity anesthesia simulation in medical student education: three fundamental and effective teaching scenarios. Int J Acad Med. 2017;3(1):66–71. doi:10.4103/IJAM.IJAM_45_17

    24. Jabaay MJ, Marotta DA, Aita SL, et al. Medical simulation-based learning outcomes in pre-clinical medical education. Cureus. 2020;12(12):e11875. doi:10.7759/cureus.11875

    25. Jones JL, Rinehart JJ, Englar RE. The effect of simulation training in anesthesia on student operational performance and patient safety. J Vet Med Educ. 2019;46(2):205–213. doi:10.3138/jvme.0717-097r

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  • How it gave me my independence back

    How it gave me my independence back

    Jennifer Wilson

    BBC Scotland News

    Easterhouse Phoenix Tony Deeney sits on a dual side by side tandem bike with his wife, Teresa. Tony holds onto the handlebars wearing a grey t-shirt with a grey helmet. He is smiling while looking at the camera. Teresa has short brown hair wears a cream jumper and holds onto the handlebars. She is smiling at the camera. Easterhouse Phoenix

    Tony and Teresa Deeney enjoy the cycling sessions

    Tony Deeney was diagnosed with Parkinson’s at just 38 and the degenerative condition gradually left him feeling isolated and with little enthusiasm for life.

    But after two decades struggling with the condition, he says cycling has helped him rediscover a sense of independence.

    Tony says he first knew something was wrong when he struggled to strum a tune on his guitar.

    He was a keen guitarist but suddenly his fingers would not move to find the different notes.

    Soon after, the father of two young children was diagnosed with Parkinson’s, a condition in which parts of the brain become progressively damaged over many years.

    It can cause tremors, balance problems and slow movement.

    Tony was told he might only have between five and eight “good” years left before his symptoms would worsen.

    In the end, with advancements in medication and support from his colleagues, it was 11 years before Tony had to retire from his job as a physics teacher.

    Easterhouse Phoenix Tony Deeney stands next to his wife, Teresa. Tony is wearing a grey t-shirt and black square glasses to the right of the image. He is smiling while looking at the camera. Teresa has short brown hair wears a cream jumper and stands to the left of the image. She is smiling at the camera. Easterhouse Phoenix

    Tony and his wife Teresa attend Parkinson’s cycling together

    It was when he retired that he noticed a drop in his enjoyment for life.

    “It’s the dark side of Parkinson’s,” Teresa says.

    “There is a loss that is almost depressive.”

    Tony, who can now only manage a few words, calls it “apathy”.

    He would often stay in the house watching television and sometimes couldn’t be bothered to shower.

    The couple say Parkinson’s can be isolating because of the way symptoms present themselves.

    It was almost 10 years after his retirement that Tony discovered the benefits of exercise for people with Parkinson’s.

    “It became a real game-changer for him,” Teresa says.

    He started playing table tennis as well as “walking football”, aimed at Parkinson’s suffers.

    It was when he tried chair yoga that a friend encouraged him to attend a cycling club.

    ‘Transformative is an understatement’

    Tony was apprehensive and almost refused to go but Teresa convinced him to try it.

    “To say it was transformative is an understatement,” she says.

    She says she was close to tears when Tony’s face lit up during his first class.

    “From day one, the joy and freedom he has experienced has been life-changing for him – he can cycle on his own,” she says.

    “This cycling club has given Tony his independence back.”

    Tony agrees that the club has given him a “sense of independence” but he says he still has to rely on his wife.

    Teresa says Tony’s confidence has improved because it is something he is able to do on his own. He’s now even got his own scooter.

    “It’s opened up the outside world for him again,” Teresa says.

    “We went for a walk and he was in [the scooter]. I can’t remember the last time we did that.”

    “It’s such an ordinary thing that people take for granted and don’t even notice, but for us, that’s major.”

    A close up of a side by side tandem tricycle made by Van Raam. There are two seats at the back of the bike with two wheels underneath. There are two handle bars with a basket in between them and one wheel underneath them. Below the double seats you can see the battery for the power assist.

    The cycling club uses side-by-side tandem bikes made by Van Raam

    Community and support

    The Parkinson’s Cycling sessions are run twice a month by the Phoenix Community Centre in Easterhouse, on the outskirts of Glasgow.

    They use specially designed tricycles for people with a disability made by the Dutch company Van Raam.

    Some of their features include power assisted cycling, a moving chair for accessibility and dual control so that someone can cycle with a partner.

    The Phoenix Centre also has a pop up café at the side of the sports hall to encourage connection and community.

    Director Caroline Cumming says: “Even if you only wanted to have a short cycle. You can sit down have a chat, have a cup of tea or a coffee.”

    “You don’t even have to cycle.”

    Teresa and Tony said maintaining a connection was very important for people with Parkinson’s.

    They say groups for people with the disease help to ease their worry because they don’t have to explain why they struggle to speak or walk.

    Teresa says that everyone supports each other and create a positive space.

    Caroline sits to the right of the image on one of the tandem bikes. She has shoulder length hair wearing a green zip-up hoodie and a white t-shirt. She's looking off to the right of the camera. In the background there is a the selection of bikes. To the right there is a couple who are on a tandem side by side bike blurred out.

    Caroline is keen to encourage community throughout her classes

    Exercise as medicine

    Parkinson’s symptoms arise after substantial loss of the dopamine-producing cells in an area of the brain known as the substantia nigra.

    Amanda Mckay, from Parkinson’s UK, said that there are over 40 different types of symptoms and “no two people are the same.”

    As people live longer with the condition, symptoms can become more aggressive and debilitating – which can impact mobility and stability significantly.

    Ms McKay says: “I think the key is to encourage people with Parkinson’s to be active, that’s a prescription in itself.”

    She says it is important for people to find something they enjoy doing because then they are likely to do it more often.

    Physiotherapist lecturer David Hegarty says exercise has similar benefits to medicine for Parkinson’s patients without the side effects.

    People build stronger muscles and better cardiovascular fitness, which in turn reduces symptoms, he says.

    And Teresa Deeney agrees.

    “The independence, joy and fitness it gives my husband is a tonic to his health and mental wellbeing,” she says.

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  • Tour de France 2025: Stage 15 preview – Sunday 20 July

    Tour de France 2025: Stage 15 preview – Sunday 20 July

    Stage 15 route of the 2025 Tour de France – Sunday 20 July

    As the peloton moves on from the Pyrenees, the 169.3 km stage begins in Muret, south of Toulouse, with 70 km of flat terrain interrupted by a few small rises, none exceeding 250 metres in elevation.

    Most of the total 2,400m of climbing is concentrated in the second half of the route: the first categorised ascent of the day is the Côte de Saint-Ferréol (Category 3, 1.7 km at 7%). Around 10 km earlier, sprinters chasing the green jersey will have the opportunity to contest the intermediate sprint at Saint-Félix-Lauragais.

    The route then enters the Haut-Languedoc Regional Natural Park, where two more climbs feature: the Côte de Sorèze (Category 3, 6.2 km at 5.5%) and the steeper Pas du Sant (Category 2, 2.9 km at 10.2%).

    A long descent towards the south leads to a flat finish in Carcassonne, a familiar Tour destination. It was there in 2021 that Mark Cavendish matched Eddy Merckx’s all-time record for stage wins, claiming the 34th victory of his Tour de France career. The Manxman would go on to break the Belgian’s long-standing record on Stage 5 of last year’s race.

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  • Australia vs British & Irish Lions first Test live: score, commentary, updates

    Australia vs British & Irish Lions first Test live: score, commentary, updates

    An excellent game for Tom Curry, who now potters off (Will Kelleher writes). He never quite had the series he could have in 2021, so that has been his best game for the Lions in his fourth consecutive Test. Ben Earl now comes on to add some energy.

    You feel Australia have to score soon, to keep their heads up and themselves in this game.

    No try. It’s similar to the Jones incident before… Suaalii needed to release the ball but failed to do so, and we’re back to 24-5 to the Lions.

    TRY! Australia 10-24 Lions

    They needed that! Suaalii runs a sturdy line off a scrum under the posts, clatters into Ben Earl and his mates help shunt him over. The Wallabies may just have a glimmer.

    Sione Tuipulotu enjoyed that one…

    After a bit of to and fro about his nationality and eligibility for the Lions in the country of his birth, the Scotland centre didn’t hold back on his celebrations after scoring the first try of the series.

    Rugby Union - Australia vs British and Irish Lions 1st Test

    The referees are checking a clear out by Tadhg Furlong… there’s no card but it will be a penalty for shoulder to head contact, but there’s mitigation in the fact that Len Ikitau, the centre, was on his way up.

    Not everything needs to end in the bin

    Re Curry. He would have been unlucky to receive yellow (Stuart Barnes writes). Sometimes penalties are just penalties. No malice, good reffing.

    Replacements will make the difference

    The usual form on this tour is that it is tight-ish and then the Lions bench blows the Australian team away (Will Kelleher writes). With Andrew Porter, Ronan Kelleher. Will Stuart, Ollie Chessum and Ben Earl to come on in the pack, that could well make the difference here again.

    Speaking to the Australian journalists, one of them said what else would you expect, really, when the Lions can combine four (three) high-ranked nations. Their point was it would be like South Africa, New Zealand and Australia combining to tour Scotland, and then everyone being surprised when they battered them.

    I hope for the sake of the series that this stays tight right until the end. Nothing like some Test match drama.

    A scathing assessment of the Wallabies at half-time from Christy Doran, the rugby editor of the Australian publication the Roar…

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    TRY! Australia 5-24 Lions

    What a game Tom Curry is having (Owen Slot writes). He just stole the lineout and then gave the offload for the Dan Sheehan try on the opposite touchline. Wow, he is playing well. And really, in my opinion, he shouldn’t be on the pitch.

    Russell’s conversion is good and the Lions take a 19-point lead.

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    Why the Lions means so much

    Watching on in Brisbane today is a group of mates for whom this tour means an awful lot…

    Read Owen Slot’s piece on the tour that became a homage to an old friend.

    Stuart Barnes

    Half time, Lions 7/10, Australia 3/10. Lions in control and impressive in some ways but a way to go before we herald the “greatest” ever Lions. Loving the two Tadhg’s.

    Is Tom Curry a lucky boy?

    Tom Curry was probably lucky not to be yellow carded there (Will Kelleher writes). Certainly the Australians in the crowd and on the pitch were livid it wasn’t a sin bin for taking Tom Lynagh out in the air.

    Then a mild debate ensues, as Lynagh’s penalty was caught on the plane of touch by Finn Russell. Usually a penalty can be kicked to touch and then play continues after the hooter has gone, but the referees thought Russell’s act had ended the half.

    Tadhg Beirne has gone off for a head injury assessment. He took a heavy blow a few minutes before half-time, and is being checked during the break.

    Australia v British & Irish Lions: 1st Test Match

    DAVID ROGERS/GETTY IMAGES

    Half-time: Australia 5-17 Lions

    Such a dominant half from the Lions (Owen Slot writes). They have a 17-5 lead but it feels like more. The Wallabies have actually done well to get their five points because their attack is going nowhere.

    Their try came from one up and under. Nothing else has worked for them. The Lions have been so dominant in the collisions and we know how close they were to finishing one or two more tries themselves.

    The Wallabies are badly missing Will Skelton and Rob Valetini, who both failed to prove their fitness in time (Alex Lowe writes). Joe Schmidt said he would have played them if this was the third Test. If they were that close, he should have played them today.

    Try and win the first Test and then worry about the rest of the series. Without them, the Wallabies are losing the physical battle. They cannot stop the Lions momentum and cannot generate enough of their own.

    TRY! Australia 5-17 Lions

    The Lions fail to score four times from close range: Huw Jones, Joe McCarthy, James Lowe and then Maro Itoje being held up (Alex Lowe writes). Eventually, Tom Curry crashes over after a series of heavy-duty carries eventually cracks the Wallabies.

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    Finn Russell’s cross field kick just evades… Joe McCarthy? The big lock has found himself on the wing and can’t quite reach it for an easy score in the corner. Russell will be disappointed with that.

    We’re cooking with gas now

    You have to say that that try is brilliant for the game (Will Kelleher writes). There was a danger that the Lions were going to pull away, but Max Jorgensen has just fired up the Wallaby response, with lightning pace down the right wing, after that spilled high-ball from Hugo Keenan.

    Game back on. Now how do the Lions respond? Tasty stuff so far!

    TRY! Australia 5-10 Lions

    The 20-year old wing Max Jorgensen gets Australia right back in it! It’s not out of very much – the wing contests a kick with Keenan, nicks it off him and finds the corner after escaping the attentions of Finn Russell.

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    A good game for the selectors so far. Tadhg Beirne and Tom Curry — two players who hadn’t hit top form on this tour but in whom the selectors put their faith — they’ve both been outstanding (Owen Slot writes). The power of the Lions defence has stopped the Wallabies runners thus far. These two right in the middle of everything.

    There’s the first bit of needle. A late clear out after the whistle and it boils over a bit with a few players getting to know each other. The referee gives both captains a stern talking to, and we have a scrum inside the Aussie half. The home side have a penalty, and need something to get their game going.

    That’s the first scrum penalty the Lions have conceded all tour.

    That is a massive let-off for Australia who are on the brink of being out of this game inside 25 minutes (Alex Lowe writes). They were carved open far too easily. Lions lineout on halfway. Conan carries up the middle. From the breakdown, Gibson-Park goes left and with one fend from Lowe on Jorgenson, the Lions are in behind. Huw Jones should have finished that. Australia have not fired a shot yet.

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    This might not stand. Jones doesn’t release the ball after being tackled, so has to release the ball before getting back up, which he doesn’t do. It’s ruled out. There’s boos around the stadium, but that’s probably the right call. We’re back to 10-0 Lions.

    TRY! Australia 0-15 Lions

    Huw Jones is over for his fourth try of the tour. Strong running from James Lowe, who finds Jones inside him. He’s tackled but is going with enough momentum to roll over and smash it down.

    The pitch markings are in Wallaby gold. The stands are in Lions red. And they are all on their feet to celebrate some magic touches from Finn Russell — a kick in behind that forced Harry Potter to concede a lineout; a delayed pass through the tackle and then a floated ball over the top for the try (Alex Lowe writes).

    It was reminiscent of that ball he threw for Huw Jones against England, except this time it was five metres from the Wallabies line. The platform was built on huge carries from Dan Sheehan and Ellis Genge, and a Lions ability to keep the ball alive and play what they see.

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    Here’s a shock, hot-take. Finn Russell is really, really good (Will Kelleher writes). Two incredible passes in that move — one delay and pop for Dan Sheehan, and then a skip-three for Sione Tuipulotu to score. He had a penalty advantage, but still, what a ball!

    RUGBYU-AUS-LIONS

    DAVID GRAY/AFP VIA GETTY IMAGES

    Tuipulotu goes over! A wonderful score from the centre, who latches on to a beautiful missed pass from his Scotland team-mate Finn Russell, who converts easily.

    The Lions look in great nick here — fast, fit and hungry. The Wallabies can’t live with it.

    Potter can’t get it under his spell

    Harry Potter, the Australian wing, fluffs his lines to give the Lions a lineout inside the Aussie 22. The first chance to show their set piece prowess. Smart hands from the backs but there’s a penalty won by Fraser McReight for the Wallabies.

    Penalty! Australia 0-3 Lions

    Yeah, the Lions didn’t pick their jackalling back-row… and then Tadhg Beirne wins a jackal turnover within 50 seconds for the first penalty!

    Finn Russell bangs it over and we are away.

    Ally McCoist’s favourite song Hell’s Bells draws to a close, Finn Russell has the ball in hand, and we are off.

    Who makes your Lions team?

    Andy Farrell’s selection for the first Test has been locked in for a couple of days now… but if you were the big fella from Wigan, who would you pick?

    Use our interactive selector tool to compare your picks with those of our writers.

    Huw Jones — the failed U11s coach and enthusiastic cricket umpire who became a Test starter

    After initially failing to make it as a pro, the Scotland centre got his break in South Africa, and lines up for his first Lions Test match tonight.

    Read Will Kelleher’s article on the centre’s unusual path to the top of international rugby.

    Huw Jones scoring a try for the British & Irish Lions.

    Jones’s excellent tour has earned him a Test jersey today

    DAVID GIBSON/FOTOSPORT

    Players Alex Lowe is excited to see this evening (in no particular order):

    Joseph-Aukuso Suaalii. He carved up England at Twickenham last November and then got into a scrap with Sione Tuipulotu at Murrayfield and told him, “See you next time”. Next time is now.

    Rugby players interacting on the field.

    The maverick centre and Tuipulotu clashed at Murrayfield

    Tom Curry. Welsh fans are fuming that he was picked ahead of Jac Morgan, although I rather feel that Tadhg Beirne was picked ahead of Morgan because the question was not whether curry played but which jersey. He is a big game player. Made for this stage. He will go around smashing people for 80 minutes.

    Finn Russell. Always a great talent. At Racing 92 he was encouraged to be a risk taker. That club is about a highlights reel. Over the last two years at Bath, Russell has become a brilliant all-court fly half, capable of playing any style of game. His risk-reward ratio has a better balance to it — but he is not afraid to throw the pass if it’s on, or launch the cross kick.

    Fraser McReight. The best poaching open-side flanker in the world and a legit successor to George Smith, David Pocock and Michael Hooper. The Lions thought they had issues at the breakdown in the tour matches. Things could be about to get a whole lot tougher.

    Really interesting watching Owen Farrell during the warm-up (Owen Slot writes). Completely and utterly a team man. Always talking, communicating. Helping Finn Russell earlier with his kicking practice. Happy in a bib, holding tackle bags. Smile on his face. He’s not playing, he’s not in the 23. But he really relishes this environment.

    Blimey, that’s a lot of red shirts behind the goal…

    Welshmen once dominated Lions sides — now the proud 126-year run is over

    For all the selection debates, there is one glaring omission for the Lions today — a Welshman.

    Ten Wales players started last time out against Australia in 2013. The absence of any in a Test for the first time since 1896 is the saddest sign yet of nation’s decline.

    More from Elgan Alderman here.

    Away from all the hullabaloo in Brisbane, something quite special happened for a former captain. Alun Wyn Jones, who led the Lions to South Africa in 2021, was made honorary colonel of the 3rd Battalion of the Royal Welsh recently, a position personally approved by the King.

    Here he is at Maindy barracks (he’s on the right).

    Former Wales Rugby Captain Is Made Honorary Colonel Of The 3rd Battalion The Royal Welsh

    MATTHEW HORWOOD/GETTY IMAGES

    We have heard from our sources on the ground here that the Lions coaching staff are really nervous (Will Kelleher writes). That lies in contrast to the bullishness we have heard on the record from the players and Andy Farrell — perhaps it comes from the weight of expectation. The Lions are ten-point favourites with the bookies, but the game is not played on a betting slip, is it?

    I have some sort of feeling we might get a red card in this series — not necessarily tonight, as there will be so much of a focus on tackle height. Remember we have 20-minute reds, so if we see one the player will be replaced after 20 minutes, after a “bunker” check — unless it’s a horrendous act of foul play.

    Joe Schmidt saving the best tricks for Wallabies bench to scare unproven Lions

    Andy Farrell’s side seem intent on blasting their way to a physical victory, but if the Wallabies can stay in the match today, they have an ace up their sleeve in the electric Tate McDermott.

    Read more from Stuart Barnes here.

    Australia v British & Irish Lions: Game 1

    DAVID ROGERS/GETTY IMAGES

    Strange pre-match emotions, unlike any other I’ve ever known before a Lions game (Owen Slot writes). I don’t actually care who wins. I’m a massive Lions lover and I want the Lions to win the series. But the greater fear is the Lions running away with it by 15+ points and killing this series dead before it’s even got going.

    You can weigh up the arguments either way, the strengths and weaknesses of each team, but on paper the Lions are way ahead. I just hope we don’t see that on the pitch.

    No Coldplay drama here…

    Judging by the number of red jerseys on Caxton Street — and those starting to fill up the stands — there will be more than 50 percent Lions fans in the Suncorp Stadium (Alex Lowe writes).

    They appear to have survived the kiss-cam section of the big match build-up without outing any affairs.

    Dan Sheehan: We’re talking about staying true to who we are

    Speaking to Will Greenwood on Sky Sports, the Lions starting hooker said: “It’s been a special week. The buzz around the city and in the stadium has a really special feel about it.

    On the shirt presentation ceremony: “That was something special. The opportunity for my dad to present me with my jersey was pretty special.”

    On the atmosphere in the dressing room: “Trying my best to stay level-headed. We’re talking about staying calm, and staying true to who you are.”

    Itoje: We’re looking forward to it

    On the occasion of his 100th Test cap, the Lions captain told Sky Sports: “This is something myself and the whole team are massively excited for. The opportunity to perform is great and one we’re looking forward to.

    Asked about his final message to his team-mates: “I haven’t thought that far ahead.”

    Lions fans are giving the pubs on Caxton Street plenty of cash as the atmosphere keeps building…

    Australia v British & Irish Lions - 1st Test
    Australia v British & Irish Lions - 1st Test
    Australia v British and Irish Lions - Qatar Airways Lions Tour 2025 - Suncorp Stadium

    When asked by Sky Sports about the bookmakers having the Lions as heavy favourites, the Wallabies head coach: “For us we focus on what we can do, we can’t influence the bookies!

    “There’s a quiet resolve in the team, sometimes you don’t want too much energy, because that can burn out pretty quickly. They’re ready to build their way into kick-off.

    “They’ve prepared well and I think they will step up tonight.

    On Tom Lynagh: “Tom knows this stadium, he’s played here a lot. He’s a good example of the calm you need in the midst of the storm.”

    Earlier this week, Andy Farrell warned the Lions not to take the Australian underdogs too lightly despite their injuries, but urged his players to embrace the pressure of the favourites tag.

    Farrell: ‘Nothing focuses the mind like the Lions’

    Speaking to Sky Sports, the Lions head coach said it was a “great day to walk around town and see tens of thousands of Lions fans. What a privilege to be part of this.

    “We’ve had a good preparation, the longer weeks helps. We want to deliver when it matters most.

    “Most things need to go right for us against a desperate Australia side — it means a lot to them and it means a lot to us. Nothing focuses the mind like a Lions series.”

    Why Ellis Genge will be key today

    The England prop bulldozed Michael Hooper for England in 2022. He returns three years later, two stone heavier, with one big responsibility — to be the “emotional driver” of a team built to outmuscle the Wallabies.

    Tap here to read Alex Lowe’s article on the prop’s vital importance.

    DAVID ROGERS/GETTY IMAGES

    Elsewhere in the Pacific…

    There’s been another Test match on this morning, an absolute ding dong between the All Blacks and France in Hamilton. Despite some fantastic defending from France on their own lines, including holding up the All Blacks three times, a 29-19 victory for New Zealand completes the series clean sweep.

    Will we see more iconic tries in Brisbane?

    The capital of Queensland has seen some fantastic action in past tours, not least from Jason Robinson at the Gabba 24 years ago.

    Will Kelleher went to find out just how difficult it would be to stop such a great player at full tilt… and ended up in a heap.

    TIMES PHOTOGRAPHER MARC ASPLAND

    Sam Warburton: Dad asked me to write my ambition at 14 — my answer was ‘Lions legend’

    Read the two-time captain’s thoughts on the honour of wearing the red jersey.

    Sam Warburton of the British & Irish Lions during a rugby match.

    Warburton captained the Lions in 2013 in Australia, and 2017 in New Zealand

    MATT ROBERTS/GETTY IMAGES FOR HSBC

    Roving reporter Will Kelleher on the ground in Brisbane

    More than two hours before kick-off and the streets of Brisbane are absolutely heaving. Will Kelleher gets amongst it…

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    What’s Andy Farrell’s game plan?

    After watching Sonny Bill Williams in an exhibition boxing match against Paul Gallen, an old rugby league rival, the Lions head coach felt inspired. He wants his side to fight like the dogged boxers in the ring, tough and relentlessly physical — but braced and ready for a punch in the face from the underdog Wallabies.

    Read Alex Lowe’s full preview here.

    It’s a depleted Australia side up against the Lions tonight, with players like Will Skelton, Rob Valetini and Noah Lolesio all missing through injury.

    Tom Lynagh, the Surrey-educated son of Michael who took the plunge with a move down under, starts at fly half at the tender age of 22. Talk about in at the deep end.

    You can read Owen Slot’s article from earlier this week on why Lynagh’s selection is such a gamble here.

    Australia team for first Test

    Tom Wright; Max Jorgensen, Joseph-Aukuso Suaalii, Len Ikitau, Harry Potter; Tom Lynagh, Jake Gordon; James Slipper, Matt Faessler, Allan Alaalatoa, Nick Frost, Jeremy Williams, Nick Champion de Crespigny, Fraser McReight, Harry Wilson (capt).
    Replacements Billy Pollard, Angus Bell, Tom Robertson, Tom Hooper Carlo Tizzano, Tate McDermott, Ben Donaldson, Andrew Kellaway.

    It’s buzzy and lively around the Suncorp Stadium with 100-person queues out of the doors of the pubs on Caxton Street (Will Kelleher writes). This is the first time on this tour so far that we’ve had a sense of the massive away support. They’ve all turned up at last! It is a much younger crowd too than for the tour games.

    Will Skelton is outside the ground signing jerseys — what a shame he’s not playing today, and nor is the powerful back-row Rob Valetini. The Lions surely will look to overpower the Wallabies now those two aren’t playing.

    Don’t forget the Aussies too…

    The gold certainly stands out.

    Australia v British and Irish Lions - Qatar Airways Lions Tour 2025 - Suncorp Stadium

    You can tell it’s the first Lions tour in front of fans for eight years, after the rather damp squib atmosphere-wise in South Africa thanks to Covid four years ago.

    The streets of Brisbane are awash with red. Groups of mates, young and old, having a few beers in the sun before a great sporting occasion. Looks a pretty rubbish way to spend a Saturday night, really…

    Australia v British and Irish Lions - Qatar Airways Lions Tour 2025 - Suncorp Stadium
    Australia v British and Irish Lions - Qatar Airways Lions Tour 2025 - Suncorp Stadium
    Australia v British & Irish Lions: Game 1

    DAVID ROGERS/GETTY IMAGES

    A reminder of Andy Farrell’s Lions 23 for the first Test…

    G’day and welcome to the main event

    Good morning and welcome along to the Times’ live coverage of the first Test between the British & Irish Lions and Australia in Brisbane.

    Stay right up to date with all the build-up action, analysis and updates from our team of writers at the Suncorp Stadium.

    Australia v British & Irish Lions: Game 1

    CAMERON SPENCER/GETTY IMAGES

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