Clinical Exercise Stress Testing in Adults (2014).

This position paper provide guidelines on the minimum requirements of both personnel and equipment for the safe performance of clinical exercise electrocardiography, and for the adequate interpretation and assessment of results. This document was originally developed by Professor Ben Freedman and members of the Rehabilitation, Exercise and Prevention Working Group in 1996. It has been recently reviewed by a Working Group chaired by Associate Professor David Colquhoun. The resulting, revised Statement was considered by the Continuing Education and Recertification Committee and ratified at the CSANZ Board meeting held on 1st August 2014.

The impact of dementia on rehabilitation outcomes following hip fracture.

Objective: To compare clinical outcomes between patients for whom their participation in inpatient rehabilitation was and was not impacted by dementia through matching patients reporting dementia (dementia group) with those not reporting dementia (non-dementia group). Methods: Prospectively collected data held by the Australasian Rehabilitation Outcome Centre (AROC) were analyzed for patients aged 65 years or older receiving inpatient rehabilitation in public hospitals in Australia following a hip fracture and discharged between July 1, 2014, and June 30, 2019. Patients reported as having dementia impacting their rehabilitation program were matched to patients not reporting dementia based on age, admission motor Functional Independence Measure (FIM) score, and accommodation prior to rehabilitation. The matched cohorts were compared in relation to clinical outcomes (motor and cognitive FIM improvement, FIM efficiency, length of stay, and discharge destination) following participation in hospital-based rehabilitation using univariate analysis. Results: Patients with dementia had significantly lower cognitive FIM scores on commencing rehabilitation (17.6 and 26.9, respectively, P < 0.001) and their median length of stay was 2 days shorter than those without dementia (21 and 23 days, respectively, P < 0.001). Relative change in FIM score and FIM efficiency (per week) were lower in the dementia group [relative FIM score change of dementia vs non-dementia, respectively, 26.2% vs. 44.0% (P < 0.001) and FIM efficiency, 6.5 vs. 8.9 (P < 0.001)]. Discharge destination between the two groups was statistically different, with 35.7% of patients with dementia being discharged to residential aged care facilities (RACFs) compared to 21.7% of those without dementia (P < 0.001). More patients with dementia had carers in their private residence in the post-rehabilitation phase, 82.2% vs. 57.6% (P < 0.001). Conclusion: Patients with dementia who sustain a fractured hip benefit from inpatient rehabilitation, although their clinical outcomes are not as good as those without dementia. FIM change and FIM efficiency were lower in the dementia group. Length of stay in the hospital for patients with dementia was shorter due to earlier recognition for the need for placement in either an RACF or at home with carer support. The need for placement in an RACF or carer support in a private residence was significantly greater in the dementia group.

Comparison of patterns of drug levels in head and body hair for medico-legal and workplace testing.

This paper presents concentration ranges and positivity rates for the common drugs, alcohol markers, new psychoactive substances (NPS) and anabolic steroids tested in head hair (n = 138,352) and body hair (n = 9532) on samples of hair from medico-legal (n = 112,033) and workplace (n = 35,851) sectors tested in our laboratory. Statistically significant higher levels were found more often in the various types of body hair when compared with head hair, but fewer cases exhibited lower levels. For example, statistically significant higher levels were detected in leg hair for cannabinol, THC, methadone and EtG and in beard hair for THC, THC-COOH and 6-acetylmorphine. In contrast, significantly lower levels were detected in axilla hair for cannabinol, THC and for EDDP, but median levels of mephedrone and DHEA were higher. Overall, higher medium levels were detected in head hair samples tested in the UK when compared with those previously published for samples tested in Germany, indicating geographical differences in drug consumption. Recommendations are, firstly, that hair testing laboratories use the results of their own compiled previous positive results for guidance when interpreting hair testing results and, secondly, that laboratories periodically share and combine their accumulated data with other testing laboratories. The latter could be used to establish reference ranges associated with specific technical procedures which would improve interlaboratory comparability and improve laboratory testing services when interpreting hair testing results.

Testing venous carbohydrate-deficient transferrin or capillary phosphatidylethanol with concurrent ethyl glucuronide and ethyl palmitate hair tests to assess historical and recent alcohol use.

Hair biomarkers, ethyl glucuronide (EtG) and ethyl palmitate (EtPa), together with blood biomarker tests, carbohydrate-deficient transferrin (CDT) or phosphatidylethanol (PEth), are commonly used in identifying patterns of alcohol consumption as they possess different windows of detection. The detection of EtG in hair samples is mainly used in combination with EtPa when hair cosmetic treatments such as hair colouring and bleaching affect EtG levels. The main purpose of our study was to investigate the differences in frequency distribution of positive CDT and PEth results indicating alcohol had been used, when EtG and EtPa were not detected, where evidence of abstinence is paramount. Of the total 602 cases, for 179 (29.7%), neither EtG nor EtPa markers were detected. Of these, 0.5% of the cases produced positive CDT. However, 18.6% produced positive PEth, a significantly higher proportion. A similar pattern emerges when results are evaluated according to whether hair had been either cosmetically treated or untreated. When hair was untreated, one case produced positive CDT, and 19.3% were positive for PEth (median of 51 ng/ml). No cases of positive CDT results, but 20.8% of PEth were positive (median of 106.5 ng/ml) when hair samples had been cosmetically treated. Whether EtG or EtPa markers were detected or not, significantly higher proportions of PEth than CDT were seen. The results of this study substantiate the case for using hair EtG in conjunction with a PEth test, rather than CDT test, for efficient monitoring of recent and historical alcohol consumption.

The Effect of Prolonged Storage Time on the Stability of Fatty Acid Ethyl Esters in Hair Samples.

The advantages of analysis of drugs in hair samples are recognized for the long window of detection, alongside easy sampling and long stability after sample collection. Alcohol markers, ethyl glucuronide (EtG) and total fatty acid ethyl esters (FAEEs) in hair, are widely used for monitoring alcohol consumption for clinical and forensic purposes. Although stability of drugs and EtG in hair samples is documented to a certain extent, stability of FAEEs in hair samples after collection has not been reported. This study covered hair samples that had been tested for FAEEs on the day of arrival at the laboratory and retested between 4 and 80 months later. The statistical analysis of the data set reveals significant lower FAEEs levels including ethyl palmitate (EtPa) ester levels when samples were retested for the second time after 6 days of storage under ideal conditions. Specifically, the results suggest that when measuring total FAEEs or solely EtPa in hair samples, the elapsed time between sample collection and analysis of the sample needs to be considered when interpreting the results. The recommendation is that whenever hair samples need to be tested for total FAEEs or EtPa, the analytical procedure needs to be performed within 1 week after collection in order to obtain meaningful results. The study results substantiate the case for the use of hair samples solely for the analysis of EtG, in conjunction with other measurements such as full blood count, carbohydrate-deficient transferrin test, liver function test or phosphatidylethanol alongside clinical assessment for a more effective evaluation of alcohol consumption.

Hair analysis when external contamination is in question: A review of practical approach for the interpretation of results.

Despite having been extensively discussed over the last decade, the differentiation between systemic exposure and external contamination still continues to be one of the limitations of hair testing for drugs. For this reason, we consider it worthwhile to re-state some basic principles in this short review. Various studies investigating a diversity of wash protocols, most using artificially contaminated hair with cocaine, have been valuable in evaluating wash efficacy and in understanding the incorporation of drugs in hair. However, assessments of wash efficacy made with real hair samples, as opposed to artificially contaminated samples, provide a different perspective, and demonstrate how rarely external contamination affects the interpretation of results. Data from a large number of hair samples from crack cocaine users, confirmed the usefulness of our protocol to remove most of the externally deposited cocaine. The data showed that hair levels of cocaine and benzoylecgonine in crack cocaine users were overall high with ratio of benzoylecgonine to cocaine in all samples above 0.1. The wash residue concentrations of cocaine ranged from not detected to 21ng/mg with a median of 0.5ng/mg. Cocaine was detected in the wash residue in 105 out of 138 samples. The wash to hair cocaine ratio ranged from not detected to 0.36 with a median of 0.02. The wash to hair cocaine ratios were below 0.07 in 133 cases. The five cases that produced wash to hair ratios above 0.1, one sample was at 0.11, three at 0.13 and one at 0.36, possibly because these cases were at the lower end of cocaine levels, however, we could not rule out that the hair was contaminated. Whilst it is not possible to differentiate between the drug extracted from the hair and the drug attached to the outside of the hair, we can compare levels of drug in the wash residue with levels detected in the hair sample. In addition, further diagnostic criteria must be applied to minimise potential misdiagnosis of external contamination. When drugs are detected in hair, individuals have clearly been in an environment where drugs are present, but it is only on rare occasions that it is unclear whether this is the result of drug use or of external contamination, and, in those cases, the results of testing need to be interpreted in the light of corroborating evidence from clinical data or social context.

How Accurate Is the Prediction of Maximal Oxygen Uptake with Treadmill Testing?

BACKGROUND: Cardiorespiratory fitness measured by treadmill testing has prognostic significance in determining mortality with cardiovascular and other chronic disease states. The accuracy of a recently developed method for estimating maximal oxygen uptake (VO2peak), the heart rate index (HRI), is dependent only on heart rate (HR) and was tested against oxygen uptake (VO2), either measured or predicted from conventional treadmill parameters (speed, incline, protocol time). METHODS: The HRI equation, METs = 6 x HRI- 5, where HRI = maximal HR/resting HR, provides a surrogate measure of VO2peak. Forty large scale treadmill studies were identified through a systematic search using MEDLINE, Google Scholar and Web of Science in which VO2peak was either measured (TM-VO2meas; n = 20) or predicted (TM-VO2pred; n = 20) based on treadmill parameters. All studies were required to have reported group mean data of both resting and maximal HRs for determination of HR index-derived oxygen uptake (HRI-VO2). RESULTS: The 20 studies with measured VO2 (TM-VO2meas), involved 11,477 participants (median 337) with a total of 105,044 participants (median 3,736) in the 20 studies with predicted VO2 (TM-VO2pred). A difference of only 0.4% was seen between mean (±SD) VO2peak for TM- VO2meas and HRI-VO2 (6.51±2.25 METs and 6.54±2.28, respectively; p = 0.84). In contrast, there was a highly significant 21.1% difference between mean (±SD) TM-VO2pred and HRI-VO2 (8.12±1.85 METs and 6.71±1.92, respectively; p<0.001). CONCLUSION: Although mean TM-VO2meas and HRI-VO2 were almost identical, mean TM-VO2pred was more than 20% greater than mean HRI-VO2.

Rate and amplitude of adaptation to two intensities of exercise in men aged 65-75 yr.

PURPOSE: To test the hypothesis that in males aged 65-75 yr when the total amount of work completed is similar in endurance training three times per week for 12 wk at either 50% or 70% peak oxygen uptake (VO2(peak)), there will be no significant difference in time course and amplitude of selected responses. METHODS: Subjects were randomly assigned to three groups: 70% VO2(peak), N = 19; 50% VO2(peak), N = 16; or control group, N = 19. Subjects underwent a maximal cycle exercise test and blood volume (Evans Blue) determination at 0, 4, 8, and 12 wk. A submaximal exercise test (50 W) was conducted at weeks 0 and 12 where cardiac output was determined. The exercise groups maintained the same exercise relative intensity throughout the 12 wk and completed a similar total amount of work. RESULTS: There were significant and similar increases in peak VO2, power and heart rate (HR) for both exercise groups. Linear models best described the time course for peak power and HR in both exercise groups. In the 70% VO2(peak) group, a quadratic model for VO2 and a linear model for VE were the best fit. There were no significant changes in blood or plasma volume for any groups over the 12 wk. Significant increases in stroke volume and significant decreases in HR at 50 W were found in both exercise groups after training. CONCLUSION: Moderate-intensity cycle exercise (50% VO2(peak)) to achieve 180-200 kJ per session, three times a week for 12 wk is a safe and effective stimulus for healthy asymptomatic men aged 65-75 yr to improve functional capacity in a primarily linear manner.

Personality assessment in neuropsychology: the nonspecificity of MMPI-2 neurocorrection methods.

Three established methods of neurocorrection claim to improve Minnesota Multiphasic Personality Inventory (MMPI)/MMPI-2 validity with closed-head injury (CHI) patients. These methods (which suggest removing "neurological" items from scoring) were employed here comparing 35 CHI patients with 35 psychiatric patients with elevated profiles. The 14-item correction changed 2-point codes for 41% of CHI and 31% of psychiatric profiles, the 30-item system changed 77% of CHI and 71% of psychiatric profiles, whereas the 37-item system changed 80% of CHI and 71% of psychiatric profiles. There were no significant differences between the two groups in number of profiles changed or number of neurocorrective items endorsed. Using each of the three correction systems, the following percentage of profiles remained elevated: 99%, 87%, and 89%, respectively.

Differentiation between consumption and external contamination when testing for cocaine and cannabis in hair samples.

It is possible for hair to be externally contaminated by drugs like cannabis or cocaine, which are smoked or snorted. Three steps are commonly employed to minimize the chance of external contamination causing misinterpretation of the results of a hair test. The first consists of decontamination of hair samples by washing the hair before analysis, the second is the use of cut-off levels, and the third is the detection of both the parent drugs and appropriate levels of their metabolite(s) in the hair sample. We propose an additional step for the assessment of drug use using hair samples combined with decontamination data. Hair samples from 186 drug users were analyzed along with their wash residues by liquid chromatography-tandem mass spectrometry (LC-MS/MS). The results of the hair analysis of the 140 samples for cocaine showed that 85.5% (N=89) of the samples passed 'cocaine use' criteria for metabolites ratios and 12.5% (N=13) for wash residue criteria (<10% of cocaine in the wash residue) leading to conclusive interpretation. Only two cases (1.9%) had an uncertain conclusion of drug consumption because cocaine levels in the wash residue were >10% of the levels in the hair. The results of the cannabis set of samples (N=46) were not as clear-cut, as a comparatively large number of samples (15.2%) had relatively high levels of THC in the wash residues. To use this approach, it is important that laboratories testing drugs in hair samples can demonstrate that the method utilized does not generate significant levels of the cocaine metabolites.

Evidence that changes in social cognitions predict changes in self-reported driver behavior: Causal analyses of two-wave panel data.

Previous research on the theory of planned behavior (TPB) is characterized by cross-sectional tests of the model's proposed causal relationships. In the absence of effective experimental techniques for changing the TPB's cognitive antecedents, the present research aimed to provide a stronger non-experimental test of the model, using causal analyses of two-wave panel data. Two studies of driver behavior were conducted in which naturally occurring within-participant changes in TPB constructs were measured over time, and used to predict corresponding within-participant changes in both intentions and behavior. A two-wave panel design was used in both studies. Study 1 had a one-month gap between baseline and follow-up. At both waves, a convenience sample comprising predominantly university students (N=135) completed questionnaire measures of all TPB cognitions and behavior (compliance with speed limits in urban areas). Cross-lagged multiple regressions and bootstrapping procedures for testing multiple mediators supported all of the relationships proposed by the TPB. These findings were extended in study 2 using a large, non-student sample of speed limit offenders (N=1149), a six-month gap between baseline and follow-up, and a larger number of cognitive antecedents. Participants completed postal questionnaires at both waves to measure all cognitions proposed by the two-component TPB, along with moral norm, anticipated regret, self-identity and speeding on urban roads, country roads, and fast dual carriageways or motorways. Changes in instrumental and affective attitude, descriptive norm, self-efficacy, moral norm, anticipated regret and self-identity predicted changes in intention to speed. Changes in intention and self-efficacy predicted behavior-change. Injunctive norm and perceived controllability did not predict intention or behavior-change. Additionally, direct (unhypothesized) relationships with behavior were found for affective attitude, descriptive norm and anticipated regret. The implications of the findings for theory and the development of effective behavior-change interventions are discussed.

Workplace drug testing, different matrices different objectives.

Drug testing is used by employers to detect drug use by employees or job candidates. It can identify recent use of alcohol, prescription drugs, and illicit drugs as a screening tool for potential health and safety and performance issues. Urine is the most commonly used sample for illicit drugs. It detects the use of a drug within the last few days and as such is evidence of recent use; but a positive test does not necessarily mean that the individual was impaired at the time of the test. Abstention from use for three days will often produce a negative test result. Analysis of hair provides a much longer window of detection, typically 1 to 3 months. Hence the likelihood of a falsely negative test using hair is very much less than with a urine test. Conversely, a negative hair test is a substantially stronger indicator of a non-drug user than a negative urine test. Oral fluid (saliva) is also easy to collect. Drugs remain in oral fluid for a similar time as in blood. The method is a good way of detecting current use and is more likely to reflect current impairment. It offers promise as a test in post-accident, for cause, and on-duty situations. Studies have shown that within the same industrial settings, hair testing can detect twice as many drug users as urine testing.

HR index--a simple method for the prediction of oxygen uptake.

PURPOSE: Energy expenditure measured in METs is widely used in cardiovascular medicine, exercise physiology, and nutrition assessment. However, measurement of METs requires complex equipment to determine oxygen uptake. A simple method to predict oxygen uptake on the basis of HR measurements without requirement for gas analysis, movement-recording devices, or exercise equipment (treadmills, cycle ergometers) would enable a simple prediction of energy expenditure. The purpose of this study was to determine whether HR can be used to accurately predict oxygen uptake. METHODS: Published studies that reported a measured resting HR (HR(rest)), a measured activity HR (HR(absolute)), and a measured oxygen uptake (mL O(2)·kg(-1)·min(-1)) associated with the HR(absolute) were identified. A total of 220 data sets were extracted from 60 published exercise studies (total subject cohort = 11,257) involving a diverse range of age, pathophysiology, and the presence/absence of ß-blocker therapy. Net HR (HR(net) = HR(absolute) - HR(rest)) and HR index (HR(index) = HR(absolute)/HR(rest)) were calculated from the HR data. A regression analysis of oxygen uptake (expressed as METs) was performed against HR(absolute), HR(net), and HR(index). RESULTS: Statistical models for the relationship between METs and the different HR parameters (HR(absolute), HR(net), and HR(index)) were developed. A comparison between regression analyses for the models and the actual data extracted from the published studies demonstrated that the best fit model was the regression equation describing the relationship between HR(index) and METs. Subgroup analyses of clinical state (normal, pathology), testing device (cycle ergometer, treadmill), test protocol (maximal, submaximal), gender, and the effect of ß-blockade were all consistent with combined data analysis, demonstrating the robustness of the equation. CONCLUSIONS: HR(index) can be used to predict energy expenditure with the equation METs = 6HR(index) - 5.

Differentiation between drug use and environmental contamination when testing for drugs in hair.

The differentiation between systemic exposure and external contamination for certain drug groups has been frequently referred to as one of the limitations of in drug testing in hair. When hair samples are used, three steps are usually employed in order to minimise the possibility of external contamination causing a misinterpretation. The first consists of decontaminating hair samples by washing the hair before analysis, the second is the detection of the relevant metabolites in the hair samples and the third is the use of cut-off levels. Difficulty in the interpretation arises when metabolites are not detected either due to external contamination of the hair or low doses of the drugs used. A wash protocol needs to be practical and ideally remove any drug deposited on the external portion of the hair. We propose an additional step that helps considerably in the interpretation of the results with the aim to establish a consensus: the analysis of the wash residue (W) and its comparison with the levels detected in hair (H). The wash residue is the remainder of a quick wash with methanol which is dried and reconstituted in buffer before analysis. The detection of small quantities of analytes that are not susceptible to external contamination in the wash residue, such as metabolites or drugs such as dihydrocodeine, indicates that the washing procedure is in fact able to remove drugs from the hair shaft. Where the W/H ratio is less then 0.1 or null, it would tend to indicate drug use as opposed to environmental contamination. Where the W/H ratio is above 0.1 but less than 0.5, it is likely to indicate possible use possibly combined with a level of external contamination. A W/H ratio greater than 0.5 is likely to indicate that the source of most of the drug in the wash residue is from external contamination. In this last case, the source of levels detected in the hair is questionable, as it is not possible to be absolutely sure that all external contamination was removed, and so use cannot be confirmed. Two hundred and sixteen hair samples from a population where external contamination could be expected (Police Investigations on drug related cases) and their wash residue were analysed. The W/H ratios of 891 results were evaluated over 13 analytes. Between 74 and 100% of the analytes studied produced W/H ratios less than 0.5, in particular in cannabis (93%) and cocaine (95%), where external contamination is more likely because of the way the drug is used. The data do show that while it is very important to always be aware of alternative explanations for test results, the likelihood of external contamination confounding the interpretation of hair tests can be reduced to manageable proportions.

Patterns in drug use in the United Kingdom as revealed through analysis of hair in a large population sample.

This paper presents an overview of the most common sectioning patterns utilised in the analysis of hair for drug use; report on the major user groups (sectors) that currently make use of hair analysis in the United Kingdom (UK); present the results for the different drug groups analysed in samples of hair samples analysed at TrichoTech between 2001 and 2005. A total of 186,084 tests on 34,626 hair samples were performed for the commonly requested drug groups. There were 145,799 enzyme-linked Immunosorbent positive screening tests (ELISA), which were subsequently confirmed by gas chromatography equipped with mass spectrometry detection (GC-MS). The two major sectors were the Medico-Legal sector (65%) and Workplace (20%). Police (Forensics), Clinical Monitoring, Schools, Research and Insurance accounted together for the remaining 15% of the samples. Combinations of several sections patterns were requested covering periods from the most recent month up to 24 months. The most common sectioning pattern was one single section measuring 3 cm, to cover the most recent 3 months (44%), which in some cases was complemented by a further 3 cm to cover together 6 months (13%). The second most common sectioning pattern was the analysis of three sections of 1cm each to cover the most recent 3 months (28%), when a more detailed evaluation of drug use pattern was relevant. Samples collected from other areas of the body such as axilla, pubic, chest, beard and leg, constituted 6% of the samples. The analysis of monthly sections plays an important role in the evaluation and interpretation of drug use, particularly in certain Medico-Legal cases. The sectors with the highest rates of positive results were Police (Forensics) (78%), Medico-Legal (62%) and Clinical (54%). The common drugs in each group were cannabinol (27%), cocaine (25%), morphine (17%), amphetamine (13%) and diazepam (15%). The positive rate for the Workplace sector was 10%. The most common drugs detected in the Workplace samples in each group were: THC (4%), codeine (2%), cocaine (2%), MDMA (0.5%) and diazepam (0.1%). The concentration levels of drugs found in samples from the workplace were lower than in the other sectors (95% of cases). The exceptions were for dihydrocodeine and MDMA, where levels were 170 and 143% higher, respectively. However, the maximum levels detected in the Workplace samples were lower. The Medico-Legal sector is the most prevalent sector using hair analysis in the UK but the rate of Workplace sector use of hair testing is increasing. One in 10 workplace hair tests detected the presence of at least one drug, which is twice the rate of detection using urine, which is a 1 in 20 urine sample. This means that the chances of identifying people on drugs in the workplace by testing hair samples are twice as likely than urine samples.