Cardiopulmonary and metabolic responses during a 2-day CPET in myalgic encephalomyelitis/chronic fatigue syndrome: translating reduced oxygen consumption to impairment status to treatment considerations.

BACKGROUND: Post-exertional malaise (PEM), the hallmark symptom of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), represents a constellation of abnormal responses to physical, cognitive, and/or emotional exertion including profound fatigue, cognitive dysfunction, and exertion intolerance, among numerous other maladies. Two sequential cardiopulmonary exercise tests (2-d CPET) provide objective evidence of abnormal responses to exertion in ME/CFS but validated only in studies with small sample sizes. Further, translation of results to impairment status and approaches to symptom reduction are lacking. METHODS: Participants with ME/CFS (Canadian Criteria; n = 84) and sedentary controls (CTL; n = 71) completed two CPETs on a cycle ergometer separated by 24 h. Two-way repeated measures ANOVA compared CPET measures at rest, ventilatory/anaerobic threshold (VAT), and peak effort between phenotypes and CPETs. Intraclass correlations described stability of CPET measures across tests, and relevant objective CPET data indicated impairment status. A subset of case-control pairs (n = 55) matched for aerobic capacity, age, and sex, were also analyzed. RESULTS: Unlike CTL, ME/CFS failed to reproduce CPET-1 measures during CPET-2 with significant declines at peak exertion in work, exercise time, V ˙ e, V ˙ O2, V ˙ CO2, V ˙ T, HR, O2pulse, DBP, and RPP. Likewise, CPET-2 declines were observed at VAT for V ˙ e/ V ˙ CO2, PetCO2, O2pulse, work, V ˙ O2 and SBP. Perception of effort (RPE) exceeded maximum effort criteria for ME/CFS and CTL on both CPETs. Results were similar in matched pairs. Intraclass correlations revealed greater stability in CPET variables across test days in CTL compared to ME/CFS owing to CPET-2 declines in ME/CFS. Lastly, CPET-2 data signaled more severe impairment status for ME/CFS compared to CPET-1. CONCLUSIONS: Presently, this is the largest 2-d CPET study of ME/CFS to substantiate impaired recovery in ME/CFS following an exertional stressor. Abnormal post-exertional CPET responses persisted compared to CTL matched for aerobic capacity, indicating that fitness level does not predispose to exertion intolerance in ME/CFS. Moreover, contributions to exertion intolerance in ME/CFS by disrupted cardiac, pulmonary, and metabolic factors implicates autonomic nervous system dysregulation of blood flow and oxygen delivery for energy metabolism. The observable declines in post-exertional energy metabolism translate notably to a worsening of impairment status. Treatment considerations to address tangible reductions in physiological function are proffered. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, retrospectively registered, ID# NCT04026425, date of registration: 2019-07-17.

Factorial validity and gender invariance of the Patient Health Questionnaire (PHQ-9) in student-athletes.

BACKGROUND/PURPOSE: Depressive symptoms are prevalent in student-athletes. Evidence for the factorial validity of measures assessing depressive symptoms in student-athletes is presently absent from the literature. This study examined the best fitting factorial structure and invariance across sexes of the PHQ-9. METHODS: Data were collected from 1,524 student-athletes from institutions in the North-Eastern United States. Confirmatory factor analyses of 4 factorial structures of the Patient Health Questionnaire-9 (PHQ-9) were conducted, followed by invariance analyses across sexes. RESULTS: All tested models showed an excellent fit for all tested models and a unidimensional model of the PHQ-9 was chosen for further analyses. Metric and scalar invariance for the identified model across sexes was supported. The participants in this study reported an unusually low (3.13%) prevalence of elevated depressive symptoms, which may indicate underreporting of symptoms. CONCLUSION: Using a unidimensional, composite score via the PHQ-9 is a valid assessment of depressive symptoms in male and female student-athletes.

Validation and Clinical Utility of the Patient Health Questionnaire-9 and Center for Epidemiologic Studies Depression Scale as Depression Screening Tools in Collegiate Student-Athletes.

CONTEXT: The National Athletic Trainers' Association recommends including mental health screening measures as part of the preparticipation examination for all student-athletes (SAs). Despite this recommendation, most mental health screening tools have not been validated in the SA population. OBJECTIVE: To validate and examine the clinical utility of 2 depression screening tools in the collegiate SA population. DESIGN: Cross-sectional mixed-methods study. SETTING: Two Northeastern United States university athletics programs. PATIENTS OR OTHER PARTICIPANTS: A total of 881 (men = 426, 48.4%; women = 455, 51.6%; mean age = 19.7 ± 1.4 years) National Collegiate Athletic Association Division II collegiate SAs completed the Patient Health Questionnaire-9 (PHQ-9) and Center for Epidemiologic Studies Depression Scale (CES-D); 290 SAs participated in a Mini-International Neuropsychiatric Interview. MAIN OUTCOME MEASURE(S): Depression symptoms were measured using 2 self-report depression screening tools, the PHQ-9 and CES-D, during the fall preparticipation examination. The SAs were selected using a random stratified sampling technique to participate in a Mini-International Neuropsychiatric Interview as the reference standard comparison for the receiver operating characteristic analysis. RESULTS: A cutoff score of 6 on the PHQ-9 corresponded to 78% sensitivity, 75% specificity, 17.3% positive predictive value, 98.1% negative predictive value (NPV), 3.2 positive likelihood ratio (+LR), and 0.3 negative likelihood ratio (-LR). A cutoff score of 15 on the CES-D corresponded to 83% sensitivity, 78% specificity, 19.7% positive predictive value, 98.6% NPV, 3.7 +LR, and 0.22 -LR. CONCLUSIONS: This was the first study to validate depression screening tools in the collegiate SA population. The results suggest cutoff scores on the PHQ-9 and CES-D in SA may need to be lower than those recommended for the general population and provide strong evidence for use as screeners to rule out depression. Referral and confirmatory testing should be implemented to confirm the presence of depression for SAs scoring at or above the cutoff thresholds. Given its brevity, inclusion of a suicidality or self-harm question and evidence of -LR and NPV strength, the PHQ-9 is a practical and effective screener for the SA population.

Game Changers: A participatory action research project for/with students with disabilities in school sport settings.

Introduction: Although school communities may be required to provide physical education opportunities for all students-including for those with disabilities-the same is not generally true with respect to school sport (i.e., participation in interscholastic or intramural sport programs). Hence, opportunities for inclusive school sport participation are consequently limited. Recognizing the need for continued attention and action in this area, we recently developed and piloted Game Changers-a participatory action research project. Together, 27 students with various cognitive and/or intellectual disabilities (i.e., student-participants), their schools' six physical education teachers and learning support teachers (i.e., champion-participants), four university researchers (i.e., researcher-participants), and two community partners [i.e., Physical and Health Education (PHE) Canada, Special Olympics Nova Scotia] engaged in the Game Changers project with three idealized goals: (a) to bring to the fore para/adapted/inclusive sport opportunities for all students; (b) to provide an empowering opportunity for students with disabilities to participate, make choices, and act as leaders in the development of sport programming; and (c) to engage youth with disabilities in sport as participants, leaders, mentors, and role models. Methods: Utilizing a mixed-methods design, data were collected from a variety of sources before the implementation of the Game Changers program, during its implementation, and once it was complete. These four data sources included the following: pre- and post-program survey for student-participants, pre- and post-program focus group interviews for student-participants, pre- and post-program focus group interviews for champion-participants, and school/sport observations. Results: The first cycle of this participatory action research project has yielded positive and informative findings. Strictly positive findings, among others, relate to the following: improving upon students' perceived competence and autonomy, inviting student voice, identifying and responding to sport participation barriers, and creating genuine sport opportunities within school settings. More undesirable yet informative findings, among others, relate to the following: unachieved intrinsic motivation and belonging, (un)sustainability of sport programs without "interventions" like Game Changers, recreation/leisure as "substitutes" for sport, and a continued want for authentic leadership and mentorship opportunities. Discussion: With these findings, we offer insights for future iterations of Game Changers (and programs like it) in similar school communities.

Feasibility and efficacy of a remotely delivered fall prevention exercise program for community-dwelling older adults with cancer: Protocol for the STABLE trial.

Falls are a major issue in older adults with cancer due to the effects of cancer and its treatments. Ample evidence in the general population of older adults has demonstrated the effectiveness of strength and balance training in reducing fall rates in older adults. However, data on effective fall prevention interventions in the oncology setting are lacking. The objective of this study is to evaluate the feasibility and efficacy of a remotely delivered, partially-supervised, resistance and balance training program on lower body strength, balance, and falls in community-dwelling older adults with cancer. The proposed study is an observer-blinded, parallel group (intervention group vs. control group) randomized controlled trial (ClinicalTrials.gov Identifier: NCT04518098). This study will recruit 74 eligible community-dwelling older adults with cancer from a comprehensive cancer centre. Intervention includes a remotely delivered exercise program for 3 months. Outcome measures include feasibility measures, lower body strength, balance, and fall rates. Research ethics approval has been granted by the Biomedical Research Ethics Boards of the University of Saskatchewan. If found effective, findings from this study will inform a subsequent, phase III definitive trial, with the ultimate goal to reduce falls and reduce impact on cancer treatment. Study findings will be disseminated through presentation at community level and scientific conferences, and in scientific journals. Trial registration: ClinicalTrials.gov identifier: NCT04518098.

The effectiveness of 3D multiple object tracking training on decision-making in soccer.

BACKGROUND: Soccer requires athletes to make quick decisions in dynamic environments. Several off-court technology-based interventions have been developed to train these perceptual cognitive skills. However, the evidence for training transfer using technologies to athletic performance has been sparse. Previous research found 3-dimensional multiple object tracking (3D MOT) training to cause a significant increase in quality of passing decision-making. Limitations to the research warrant further investigation of this association. PURPOSE: To re-examine the effectiveness of 3D MOT on training decision-making. METHODS: Thirty-one NCAA Division III soccer players (female n = 16) were randomized to 3D MOT training or a control task. The experimental group received 10 training sessions over a span of 4 weeks. RESULTS: The manipulation check indicated a significant training effect in 3D MOT performance for the intervention but not the control group (F(1,29) = 21.46, p < .001, np2 = .43). Non-significant changes with small effect sizes (np2 = .01-.03) in decision-making and measures of near-transfer were found. CONCLUSION: The findings challenge the association between 3D MOT training and increased quality of decision-making in soccer.

Effectiveness of Three-Dimensional Multiple-Object Tracking in Patients with Multiple Sclerosis: A Pilot Trial.

BACKGROUND: Computerized cognitive training remains an attractive supplemental modality to enhance rehabilitation in multiple sclerosis (MS). The objective of the present study was to assess the usability of three-dimensional multiple-object tracking (3D-MOT) in patients with MS. METHODS: In this pilot study, 16 patients with relapsing-remitting MS and nine age-matched controls participated in four 30-minute training sessions of 3D-MOT. Computerized neuropsychological tests, including driving readiness (ie, Useful Field of View) and cognitive function (ie, Stroop Color and Word Test, Paced Visual Serial Addition Test, Symbol Digit Modalities Test) were conducted at baseline and at the conclusion of training. RESULTS: Although scoring lower in 3D-MOT, the MS group improved their 3D-MOT scores in similar magnitude as the control group. The 3D-MOT training led to significant improvements in driving readiness in the MS group. Taken together, 3D-MOT training showed similar effectiveness in patients with MS as in age-matched controls. CONCLUSIONS: Training with 3D-MOT may be an accessible and remotely administrable supplement to cognitive rehabilitation protocols for patients with MS.

Compendium of Health and Wellness Coaching: 2019 Addendum.

The 2019 Addendum, in conjunction with the original health and wellness coaching (HWC) Compendium, organizes HWC literature with the aim of assisting researchers while providing a resource for practitioners. The 2019 Addendum to the HWC Compendium extends the initial work by adding HWC-related literature published in the past 2 years. The 2019 Addendum divides articles retrieved into 8 categories, including a new miscellaneous section complementing categories examining HWC effects on cancer, cholesterol, diabetes, heart disease, hypertension, obesity, and wellness. The 2019 Addendum again provides in-depth information about the nature, quality, and results from each article in a detailed spreadsheet provided as an electronic appendix. The 2019 Addendum contributes another 104 peer-reviewed coaching-related articles to the HWC Compendium. This most recent research again describes HWC as a favorable intervention with treatment potential in all categories, though only 3 new cancer articles were included in the 2019 Addendum. Trends in HWC (ie, e-coaching and group coaching) are identified, and there is also discussion of future research needs. In conclusion, the field of HWC continues to grow, as does the research describing this clinical practice; the 2019 Addendum to the Compendium of HWC organizes and assists understanding of this literature.

A retrospective analysis of postrehabilitation outcomes following total knee arthroplasty.

BACKGROUND AND PURPOSE: Total knee arthroplasty (TKA) is one of the most frequently performed orthopaedic procedures in Canada. Despite the frequency at which TKAs are performed, few studies have examined the association between postoperative outcomes and long-term functional outcomes following group-based rehabilitation in Canada. The primary objective of the present study was to examine changes in flexion and extension from intake to discharge from rehabilitation in patients in Saskatchewan, Canada. A secondary objective was to explore the demographic and medical predictors of range of motion in TKA patients, and treatment duration. METHODS: A retrospective chart review from an outpatient rehabilitation clinical database was conducted between September 2014 and December 2016, and assessed demographic and medical variables. RESULTS: A total of 672 patient charts were included in the study. Significant improvements (p < 0.001) were noted from intake to discharge from rehabilitation for flexion and extension. Right-side TKA, flexion at intake and the length of treatment predicted flexion at discharge from rehabilitation (R2  = 0.23). Gender, right side TKA, extension at intake and the length of treatment predicted extension at discharge from rehabilitation (R2  = 0.23). Lastly, age, flexion at intake and extension at intake predicted length of treatment in the rehabilitation programme (R2  = 0.21). CONCLUSIONS: Patients who participated in rehabilitation following TKA experienced improvements in flexion and extension. Those with decreased flexion and extension after TKA may be less likely to experience a desirable range of motion, indicating a need for more intensive targeted rehabilitation in this group, and adjustments in hospital and community care.

Compendium of the Health and Wellness Coaching Literature.

Health and wellness coaching (HWC) for lifestyle behavior change is emerging as a practice, role, and profession, in diverse health care, employee wellness, and community settings. Health care professionals apply HWC as a behavior change methodology for the prevention and treatment of diabetes, hypertension, hyperlipidemia, heart disease, cancer, and other chronic disorders. The purpose of this systematic review was to provide a comprehensive and organized compendium of HWC literature. To date, extant HWC literature remains scattered with no meaningful summary accessible. Lack of comprehensive summary stems from lack of consensus on HWC definition and standards. We applied a recently proposed, standardized definition of HWC to determine compendium inclusion criteria for peer-reviewed, data-based literature from relevant search engines (ie, PubMed, PsychInfo, and CINAHL). A systematic review process was executed and ultimately yielded 219 articles meeting HWC inclusion criteria. Of these, 150 were data-based and the remainder were expert opinion or review-style articles. A summary of results generally reveals HWC as a promising intervention for chronic diseases though further research is needed in most categories. The resulting HWC compendium organizes and describes the quantity and quality of available literature for the use and benefit of HWC practitioners and researchers.

Long-term pharmacodynamic effects of Ticagrelor versus Clopidogrel in fibrinolytic-treated STEMI patients undergoing early PCI.

The long-term pharmacodynamic effects of Ticagrelor versus Clopidogrel in patients undergoing early percutaneous coronary intervention (PCI) after fibrinolytic therapy is unknown. From May 2014 to August 2016, 212 patients undergoing PCI within 24 h of Tenecteplase (TNK), Aspirin, and Clopidogrel for ST-elevated myocardial infarction (STEMI) were randomized at four Canadian sites to receive additional Clopidogrel or Ticagrelor initiated prior to PCI. The platelet reactivity units (PRU) were measured with the VerifyNow Assay before study drug administration (baseline), at 4 and 24 h post PCI, and follow-up appointment. A mixed-model analysis with time as the repeated measure and drug as the between-subjects factor was calculated using 2 separate 1 × 4 ANOVAs, with students t-tests used to compare drugs within each time point. Complete clinical follow-up data (median 115.0 days; IQR 80.3-168.8) was available in 50 patients (23.6%) randomized to either Clopidogrel (n = 23) or Ticagrelor (n = 27). Analyses revealed significant decreases in PRU from baseline to 4 h (261.4 vs. 71.7; Mdiff = - 189.7; p < 0.001) to 24 h (71.7 vs. 27.7; Mdiff = - 44.0; p < 0.001) to end of follow-up (27.7 vs.17.9; Mdiff = - 9.9. p = 0.016) for those randomized to Ticagrelor and significant decreases in PRU only from baseline to 4 h (271.3 vs. 200.8; Mdiff = - 70.5, p = < 0.001) in patients receiving Clopidogrel, and a significantly greater proportion of patients with adequate platelet inhibition (PRU < 208) on long-term follow-up (Clopidogrel, 82.6% vs. Ticagrelor, 100.0%; p = 0.038). Our results demonstrate that in patients undergoing PCI within 24 h of fibrinolysis for STEMI, Ticagrelor provides prolonged platelet inhibition compared with Clopidogrel.

Effects of ticagrelor versus clopidogrel on platelet function in fibrinolytic-treated STEMI patients undergoing early PCI.

OBJECTIVES: Patients undergoing PCI early after fibrinolytic therapy are at high risk for both thrombotic and bleeding complications. We sought to assess the pharmacodynamic effects of ticagrelor versus clopidogrel in the fibrinolytic-treated STEMI patients undergoing early PCI. METHODS AND RESULTS: Patients undergoing PCI within 24 hours of tenecteplase (TNK), aspirin, and clopidogrel for STEMI were randomized to receive additional clopidogrel 300 mg followed by 75 mg daily or ticagrelor 180 mg followed by 90 mg twice daily. The platelet reactivity units (PRU) were measured with the VerifyNow Assay before study drug administration (baseline) at 4 and 24 hours post-PCI. The primary end point was PRU ≤208 at 4 hours. A total of 140 patients (74 in ticagrelor and 66 in clopidogrel group) were enrolled. The mean PRU values at baseline were similar for the 2 groups (257.8±52.9 vs 259.5±56.7, P=.85, respectively). Post-PCI, patients on ticagrelor, compared to those on clopidogrel, had significantly lower PRU at 4 hours (78.7±88 vs 193.6±86.5, respectively, P<.001) and at 24 hours (34.5±35.0 and 153.5±75.5, respectively, P<.001). The primary end point was observed in 87.8% (n=65) in the ticagrelor-treated patients compared to 57.6% (n=38) of clopidogrel-treated patients, P<.001. CONCLUSION: Fibrinolysis-treated STEMI patients who received clopidogrel and aspirin at the time of fibrinolysis and were undergoing early PCI frequently had PRU >208. In this high-risk population, ticagrelor provides more prompt and potent platelet inhibition compared with clopidogrel (Funded by Astra Zeneca; NCT01930591, https://clinicaltrials.gov/ct2/show/NCT01930591).

Can Multiple Object Tracking Predict Laparoscopic Surgical Skills?

OBJECTIVE: The purpose of this study was to examine the relationship between multiple object tracking (MOT) and simulated laparoscopic surgery skills. METHODS: A total of 29 second-year medical students were recruited for this study. The participants completed 3 rounds of a three-dimensional MOT and a simulated laparoscopic surgery task. Averages of the performance on the tasks were calculated. Descriptive variables (i.e., age, hours of sleep, caffeine, and video game use) were measured via questionnaires. Data were analyzed using hierarchical regression models with surgical performance as the outcome variable. Predictor variable was the multiple objects tracking score and the descriptive variables. RESULTS: The regression models revealed a significant prediction of simulated laparoscopic surgical skills by the multiple objects tracking score. In particular, 29% of the variance of time to completion and 28% of the average surgical arm movement were explained. In both regressions, the MOT score was the only significant predictor. CONCLUSION: This study demonstrates the potential implications of perceptual-cognitive training for future surgeons. Along with motor skill practice, MOT may aid to better prepare health care professionals for the complex cognitive demands of surgery.

Factorial validity and gender invariance of the center for epidemiological studies depression in cardiac rehabilitation patients.

PURPOSE: To find a best-fitting factor structure of the Center for Epidemiological Studies Depression (CES-D) and test whether this structure is invariant across gender in a cardiac rehabilitation population. METHODS: We examined the data from 920 participants of a cardiac rehabilitation exercise program. Fourteen confirmatory factor analyses were conducted to examine existing factor solutions from the literature. The best-fitting model was tested for invariance across gender. RESULTS: The data fit best to a 3-factor solution, which has 14 items and 3 factors (ie, somatic symptoms, negative affect, and anhedonia). The goodness-of-fit indices showed an acceptable fit. The invariance analysis revealed that the factor structure is equivalent across gender. CONCLUSIONS: While a fitting factor solution was found, rehabilitation practitioners and researchers need to be aware of the psychometrical shortcomings of the CES-D and consider using other scales as alternative measures of depressive symptoms.