A Visual Case-Oriented Analysis of Stress-Related Symptoms in Caregivers of Allogeneic Bone Marrow Transplantation Recipients.

OBJECTIVES: To describe trends in caregiver stress and stress-related symptoms (anxiety, depression, fatigue, and sleep disturbance) across 12 weeks post-transplantation. SAMPLE & SETTING: 11 caregivers were recruited from a National Cancer Institute-designated comprehensive cancer center's bone marrow transplantation (BMT) outpatient clinic in the southeastern United States. METHODS & VARIABLES: A visual case-oriented analysis was conducted on data from 11 caregivers' weekly self-reported data to identify trends after allogeneic BMT. RESULTS: The authors identified three primary trends as follows: U-shaped (highest symptoms at start of transplantation and end of study; n = 3), negatively sloped (highest symptoms at beginning of transplantation and decreasing over time; n = 2), and V-shaped predischarge (highest symptoms at start of transplantation and right before discharge home; n = 4). Two caregivers did not have postdischarge data because of patient death prior to study completion. IMPLICATIONS FOR NURSING: Caregivers may benefit from additional support to manage their stress-related symptoms at the start of transplantation and just before discharge.

Using TENS to Enhance Therapeutic Exercise in Individuals with Knee Osteoarthritis.

Transcutaneous electrical nerve stimulation (TENS) facilitates quadriceps voluntary activation in experimental settings. Augmenting therapeutic exercise (TE) with TENS may enhance the benefits of TE in individuals with knee osteoarthritis (KOA) and quadriceps voluntary activation failure (QVAF). PURPOSE: This study aimed to determine the effect of TENS + TE on patient-reported function, quadriceps strength, and voluntary activation, as well as physical performance compared with sham TENS + TE (Sham) and TE alone in individuals with symptomatic KOA and QVAF. METHODS: Ninety individuals participated in a double-blinded randomized controlled trial. Everyone received 10 standardized TE sessions of physical therapy. TENS + TE and Sham groups applied the respective devices during all TE sessions and throughout activities of daily living over 4 wk. The Western Ontario and McMaster University Osteoarthritis Index (WOMAC), quadriceps strength, and voluntary activation, as well as a 20-m walk test, chair-stand test, and stair-climb test were performed at baseline, after the 4-wk intervention (post 1) and at 8 wk after the start of the intervention (post 2). Mixed-effects models were used to determine between-group differences between baseline and post 1, as well as baseline and post 2. RESULTS: Improvements in WOMAC subscales, quadriceps strength, and voluntary activation, 20-m walk times, chair-stand repetitions, and stair-climb time were found at post 1 and post 2 compared with baseline for all groups (P < 0.05). WOMAC Pain and Stiffness improved in the TENS + TE group compared with TE alone at post 1 (P < 0.05); yet, no other between-group differences were found. CONCLUSIONS: TE effectively improved patient-reported function, quadriceps strength, and voluntary activation, as well as physical performance in individuals with symptomatic KOA and QVAF, but augmenting TE with TENS did not improve the benefits of TE.

Effects of Citrulline Malate and Beetroot Juice Supplementation on Energy Metabolism and Blood Flow During Submaximal Resistance Exercise.

The ergogenic effects of citrulline malate (CitMal) and beetroot juice (BEET) have been widely studied, but their effects on physiological outcomes related to resistance exercise are not fully understood. The purpose of this randomized, double-blind, crossover study was to investigate the effects of CitMal (8 g) and BEET (400 mg nitrate) on blood pressure (BP), blood flow, and energy efficiency during submaximal leg extension. Recreationally active males (n = 27; age: 22 ± 4 yrs) completed familiarization, followed by three testing visits. Supine and standing BP were measured upon arrival, followed by supplement ingestion, a 2-h rest period, postsupplement BP measurement, and a bout of repeated submaximal isotonic leg extensions at 25% of maximal voluntary contraction torque. Diameter (aDIAM) and blood flow (aBF) of the superficial femoral artery, and cross-sectional area (CSA) and echo intensity (EI) of the vastus lateralis, were measured before and after exercise via ultrasonography. Muscle blood flow (mBF) and oxygen consumption (mVO2), along with whole-body energy expenditure (EE) and respiratory exchange ratio (RER), were measured before and during exercise via indirect calorimetry and near-infrared spectroscopy. Baseline RER values differed among treatments (p = 0.01); BEET was higher than CitMal (p = 0.01) but not PLA (p = 0.58); CitMal and PLA were not significantly different (p = 0.12). No other measurements were significantly affected by treatment (all p > 0.05). Results suggest that neither CitMal nor BEET significantly influence resting BP, blood flow, or metabolic efficiency during submaximal leg extension in recreationally active males.

Effects of Citrulline Malate and Beetroot Juice Supplementation on Blood Flow, Energy Metabolism, and Performance During Maximum Effort Leg Extension Exercise.

Trexler, ET, Keith, DS, Schwartz, TA, Ryan, ED, Stoner, L, Persky, AM, and Smith-Ryan, AE. Effects of citrulline malate and beetroot juice supplementation on blood flow, energy metabolism, and performance during maximum effort leg extension exercise. J Strength Cond Res 33(9): 2321-2329, 2019-Citrulline malate (CitMal) and beetroot juice (BEET) are increasingly popular ergogenic aids, but few studies have rigorously investigated their effects on resistance exercise performance and underlying mechanisms. The current randomized, double-blind, crossover study evaluated the effects of CitMal and BEET supplementation on blood flow, metabolic efficiency, and performance during maximal isokinetic leg extension exercise. After familiarization, 27 recreationally active men (age: 22 ± 4 years) completed 3 visits in which subjects ingested a treatment beverage (CitMal [8 g], BEET [400-mg nitrate], or placebo [PLA]), followed by a 2-hour rest period, warm-up, and 5 sets of 30 concentric leg extensions. Before and after exercise, ultrasound was used to measure diameter (aDIAM) and blood flow (aBF) of the superficial femoral artery, along with cross-sectional area and echo intensity of the vastus lateralis. Plasma analytes (lactate, nitrate/nitrite [NOx], and urea nitrogen [BUN]) were also assessed at these times, and indirect calorimetry was used to measure energy expenditure and respiratory exchange ratio before and during exercise. Resting NOx values were higher in BEET (233.2 ± 1.1 µmol·L) compared with CitMal (15.3 ± 1.1, p < 0.0001) and PLA (13.4 ± 1.1, p < 0.0001). Postexercise NOx values, adjusted for resting differences, were higher in BEET (86.3 ± 1.2 µmol·L) than CitMal (21.3 ± 1.1, p < 0.0001) and PLA (18.1 ± 1.1, p < 0.0001). No other variables were affected by treatment (all p > 0.05). While BEET increased NOx, neither treatment was found to enhance performance, blood flow, metabolic efficiency, nor the hormonal response to leg extension exercise.

Acute Effects of Citrulline Supplementation on High-Intensity Strength and Power Performance: A Systematic Review and Meta-Analysis.

BACKGROUND: Citrulline is an increasingly common dietary supplement that is thought to enhance exercise performance by increasing nitric oxide production. In the last 5 years, several studies have investigated the effects of citrulline supplements on strength and power outcomes, with mixed results reported. To date, the current authors are unaware of any attempts to systematically review this emerging body of literature. OBJECTIVE: The current study sought to conduct a systematic review and meta-analysis of the literature describing the effects of citrulline supplementation on strength and power outcomes. METHODS: A comprehensive, systematic search of three prominent research databases was performed to find peer-reviewed, English language, original research studies evaluating the effects of citrulline supplementation on indices of high-intensity exercise performance in healthy men and women. Outcomes included strength and power variables from performance tests involving multiple repetitive muscle actions of large muscle groups, consisting of either resistance training sets or sprints lasting 30 s or less. Tests involving isolated actions of small muscle groups or isolated attempts of single-jump tasks were not included for analysis due to differences in metabolic requirements. Studies were excluded from consideration if they lacked a placebo condition for comparison, were carried out in clinical populations, provided a citrulline dose of less than 3 g, provided the citrulline dose less than 30 min prior to exercise testing, or combined the citrulline ingredient with creatine, caffeine, nitrate, or other ergogenic ingredients. RESULTS: Twelve studies, consisting of 13 total independent samples (n = 198 participants), met the inclusion criteria. Between-study variance, heterogeneity, and inconsistency across studies were low (Cochrane's Q = 6.9, p = 0.86; τ2 = 0.0 [0.0, 0.08], I2 = 0.0 [0.0, 40.0]), and no funnel plot asymmetry was present. Results of the meta-analysis identified a significant benefit for citrulline compared to placebo treatments (p = 0.036), with a small pooled standardized mean difference (SMD; Hedges' G) of 0.20 (95% confidence interval 0.01-0.39). CONCLUSION: The effect size was small (0.20), and confidence intervals for each individual study crossed the line of null effect. However, the results may be relevant to high-level athletes, in which competitive outcomes are decided by small margins. Further research is encouraged to fully elucidate the effects of potential moderating study characteristics, such as the form of citrulline supplement, citrulline dose, sex, age, and strength versus power tasks.

Blood docosahexaenoic acid and eicosapentaenoic acid in vegans: Associations with age and gender and effects of an algal-derived omega-3 fatty acid supplement.

BACKGROUND & AIMS: Several studies have demonstrated that vegetarians and vegans have much lower plasma concentrations of omega-3 fatty acids (i.e., docosahexaenoic and eicosapentaenoic acids) when compared to those who eat fish. The purposes of this study were 1) to define the age and/or sex-specific docosahexaenoic plus eicosapentaenoic acids levels in red blood cell membranes (expressed as a percent of total fatty acids; hereafter the omega-3 index) in long-term vegans, and 2) to determine the effects of a vegetarian omega-3 supplement (254 mg docosahexaenoic plus eicosapentaenoic acids/day for 4 months) on the omega-3 index. METHODS: A sample (n = 165) of vegans was recruited, and their omega-3 index was determined using a dried blood spot methodology. A subset of 46 subjects with a baseline omega-3 index of <4% was given a vegetarian omega-3 supplement for 4 months and then retested. RESULTS: The mean ± SD omega-3 index was 3.7 ± 1.0% which was similar to that of a cohort of omnivores (deployed US soldiers) from a recently-reported study. Among the vegan cohort, the index was significantly higher in females than males (3.9 ± 1.0% vs. 3.5 ± 1.0%; p = 0.026) and was directly related to age (p for trend = 0.009). The omega-3 index increased from 3.1 ± 0.6% to 4.8 ± 0.8% (p = 0.009) in the supplementation study. CONCLUSIONS: We conclude that vegans have low baseline omega-3 levels, but not lower than omnivores who also consume very little docosahexaenoic and eicosapentaenoic acids. The vegans responded robustly to a relatively low dose of a vegetarian omega-3 supplement.

Cost-effectiveness of alternative treatments for depression in low-income women.

BACKGROUND: Low-income mothers are more likely to experience depressive symptoms than their higher income counterparts, but they are less likely to receive treatment. One way to overcome common barriers to care for low-income women is to do therapy in the mother's home. AIMS OF THE STUDY: The objective of this study was to compare the cost-effectiveness of in-home interpersonal therapy (IPT) to two standard therapies for depression treatment: office based cognitive behavioral therapy (CBT) and psychotropic medication. METHODS: This cost utility analysis used a Markov model with a 3-year time horizon to compare the cost-effectiveness of the alternate therapies from the public payer perspective. We followed a hypothetical cohort of 1,000 women age 19 to 35 years with depressive symptoms who had an income level at or below 200% of the federal poverty level. Costs were based on the number of women who completed the therapy. We used data from published literature on clinical trials with low-income minority women to determine the completion rates, duration, and effectiveness of each type of therapy. Additionally, costs for in-home IPT were calculated from unpublished trial data. Costs were determined using 2011 North Carolina Medicaid reimbursement rates; utility weights were taken from published literature. The endpoint was the total outpatient medical cost (therapy and outpatient medical visits). The study outcomes were depression free days (DFD), which were translated into quality of adjusted life years (QALY). We calculated the incremental cost-effectiveness ratio (ICER) of each therapy based on the number of QALYs gained. We conducted deterministic and probabilistic sensitivity analyses to determine how robust the results were to uncertainty in the parameters. RESULTS: Treating patients with IPT resulted in an ICER of USD 13,479/QALY and USD 29,309/QALY as compared to CBT and medications, respectively. The results were most sensitive to the efficacy of IPT. Simulations showed that, with a threshold of USD 50,000/QALY, IPT was cost-effective 95% and 78% of the time as compared to CBT and medications, respectively. If policy makers were willing to pay USD 50,000 per QALY, IPT had a 0.586 probability of being the cost-effective option relative to medication and in-office CBT. DISCUSSION: Due to higher completion rates, in-home IPT cost more but resulted in more QALYs gained than the other therapies. Our results indicated that in-home IPT was cost-effective as compared to office-based CBT and at least as cost-effective as medication therapy. The analysis was based on limited data because there have been few randomized, controlled studies on treatments for depression in low-income women, however; additional studies are needed to improve the accuracy of the model. IMPLICATIONS FOR HEALTH POLICY: In coming years, the number of low-income women covered by public insurance should increase due to the Affordable Care Act. Given the high prevalence of depression in this population, it will be important to consider the value of potential resources spent on depression treatments. This study found that both in-home IPT and medication could be cost-effective treatments for depression. The results of this study support public payers reimbursing for in-home services.