A Simple Exercise Program for Patients With End-Stage Kidney Disease to Improve Strength and Quality of Life: Clinical Research Protocol.

Background: Most patients with end-stage kidney disease (ESKD) appreciate the importance of exercise and would like to increase their physical activity; however, they report a few key barriers, including (1) lack of physician advice to do so, (2) lack of safe and convenient programs (ie, appropriate for home or neighborhood), and (3) cost. Importantly, patients indicated in a previous survey that they would prefer an exercise program that improves muscle strength and symptoms, and are less interested in cardiovascular disease prevention. Objective: To test the feasibility of a simple, prescribed exercise program using Nordic walking poles in patients with ESKD treated with dialysis. Design: Randomized multicenter pilot trial of an exercise intervention that includes Nordic walking poles, personalized physician exercise prescriptions, pedometers, and access to exercise videos, compared with standard of care, in patients being treated with maintenance dialysis. Setting: Multicenter tertiary care centers in Canada. Patients: Ambulatory adult patients with ESKD treated with peritoneal dialysis or hemodialysis (HD) for at least 6 months at participating sites are potentially eligible. Inclusion criteria include ability to use Nordic walking poles (either de novo or in place of mobility aid) and to provide informed consent in English or in French. Exclusion criteria include (1) any absolute contraindication to exercise, (2) baseline step count >8000 steps/day, (3) planned living donor kidney transplant, and (4) participation in another interventional trial that may affect the results of this study. Methods: This is a randomized multicenter pilot trial of an exercise intervention that consists of a prescription to exercise using Nordic walking poles, a pedometer to track activity, and access to exercise videos, with the comparator of standard of care (dialysis unit staff encouragement to exercise) in patients being treated with maintenance dialysis. Randomization is concealed and uses a 1:1 ratio for group assignment. Our specific aims are to determine the feasibility of patient recruitment, adherence to the exercise program (verified by step counts), and efficacy of the intervention on patient-important outcomes that were assessed as a priority by patients in a prior survey-specifically strength, fatigue, and sleep. We record days spent in hospital and loss of independent living to inform sample size calculations for a definitive trial of exercise in patient with ESKD treated with dialysis. Adverse events are closely monitored. Outcomes: Primary: Our recruitment goal is 90 to 150 patients over 27 months; adherence success will be defined if >75% of randomized patients, excluding those who are transplanted or deceased, achieve >80% of their prescribed steps at 6 and 12 months. Secondary Efficacy Outcomes: (1) strength-hand grip strength and 5 times sit to stand, (2) energy-Short Form (SF)-36 vitality subscale, and (3) sleep-Pittsburg Sleep Quality Index will be assessed at baseline, 6, and 12 months. Results: Trial recruitment started before the COVID-19 pandemic and the pandemic led to many interruptions and delays. Online exercise Web sites and a tailored video were added to the protocol to encourage activity when participants were unable or reluctant to walk in public places. Limitations: This trial was designed to include ambulatory patients with ESKD and does not address the burden of disease in patients with very restricted mobility. Trial Registration: NCT03787589.

Contexte: La plupart des patients atteints d'insuffisance rénale terminale (IRT) comprennent l'importance de l'exercice physique et souhaitent augmenter leur niveau d'activité. Ils signalent toutefois quelques obstacles, notamment 1) le manque de conseils médicaux pour le faire; 2) le manque de programmes sécuritaires et faciles (c.-à-d. pouvant être suivis à la maison ou dans le quartier); et 3) les coûts. Il convient de noter que les patients avaient indiqué dans une enquête précédente préférer un programme d'exercices améliorant la force musculaire et les symptômes liés à la maladie, et être moins intéressés par la prévention des maladies cardiovasculaires. Objectif: Dans une population de patients atteints d'IRT traités par dialyse, tester la faisabilité d'un programme prescrit et simple à suivre d'exercices impliquant l'utilisation de bâtons de marche nordique. Conception: Essai pilote randomisé multicentrique mené chez des patients traités par dialyse d'entretien. L'essai compare les soins habituels à une intervention comprenant des exercices avec bâtons de marche nordique, un programme personnalisé prescrit par un médecin, un podomètre et l'accès à des vidéos d'exercices. Cadre: Plusieurs centres de soins tertiaires au Canada. Sujets: Tous les patients adultes ambulatoires atteints d'IRT traités par dialyse péritonéale ou hémodialyse depuis au moins 6 mois dans les sites participants sont potentiellement admissibles. Pour être inclus, les patients doivent pouvoir utiliser des bâtons de marche nordique (de novo ou en remplacement de l'aide à la mobilité) et fournir un consentement éclairé en anglais ou en français. Les critères d'exclusion sont : 1) toute contre-indication absolue à l'exercice; 2) le fait de marcher déjà au moins 8 000 pas/jour; 3) avoir une transplantation rénale d'un donneur vivant prévue; 4) la participation à un autre essai interventionnel susceptible d'affecter les résultats de la présente étude. Méthodologie: Il s'agit d'un essai pilote randomisé multicentrique examinant une intervention en matière d'activité physique. L'intervention consiste en une prescription d'activité physique à l'aide de bâtons de marche nordique, elle donne accès à un podomètre pour suivre l'activité, ainsi qu'à des vidéos d'exercices; le comparateur est la norme de soins (encouragement par le personnel de l'unité de dialyse à pratiquer une activité physique) pour les patients traités par dialyse d'entretien. La randomisation est masquée et utilise un ratio de 1:1 pour l'affectation aux groupes. Nous examinons la faisabilité du recrutement des patients, l'observance du programme d'exercices (vérifiée par le nombre de pas) et l'efficacité de l'intervention sur les résultats de santé ayant été jugés comme importants et prioritaires par les patients dans une enquête précédente ­ plus précisément la force, la fatigue et le sommeil. Nous enregistrons le nombre de jours passés à l'hôpital et la perte de vie autonome afin d'éclairer les calculs de la taille de l'échantillon d'un essai définitif qui portera sur l'activité physique en contexte d'HD. Les événements indésirables sont étroitement surveillés. Mesures: Primaires : nous souhaitons recruter 90 à 150 patients sur une période de 27 mois; l'observance sera jugée comme un succès si plus de 75 % des patients randomisés (excluant les patients transplantés ou décédés) atteignent plus de 80 % de leur prescription de nombres de pas/jour après 6 et 12 mois. Paramètres secondaires d'efficacité : 1) Force ­ mesure de la force de préhension et 5 fois l'exercice de se lever d'une position assise; 2) Énergie ­ sous-échelle du test de vitalité SF-36; et 3) Sommeil ­ mesure de l'Indice de la qualité du sommeil Pittsburg à l'inclusion et après 6 mois et 12 mois. Résultats: Le recrutement s'est amorcé avant la pandémie de COVID-19, puis celle-ci a entraîné de nombreuses interruptions et retards. Des sites d'exercices en ligne et une vidéo personnalisée ont été ajoutés au protocole afin d'encourager les patients à continuer de faire de l'activité physique lorsqu'ils ne pouvaient pas marcher dans des lieux publics ou étaient réticents à le faire. Limites: Cet essai a été conçu pour inclure des patients ambulatoires atteints d'IRT, il ne traite pas du fardeau de la maladie chez les patients à mobilité très restreinte.

Prevalence, Perceptions, and Patterns of Cannabis Use Among Cardiac Inpatients at a Tertiary-Care Hospital: A Cross-Sectional Survey.

Background: Cannabis use may adversely affect cardiovascular health. Patterns of use by cardiac patients are unknown. We evaluated the prevalence, perceptions, and patterns of cannabis use among cardiac inpatients. Methods: A consecutive cross-section of cardiac inpatients, hospitalized between November 2019 and May 2020, were surveyed in-person or via telephone. Descriptive statistics and logistic regression were used to examine the characteristics of cannabis use. Results: The prevalence of past-12-month cannabis use was 13.8% (95% confidence interval [CI]: 11.8%-16.0%). Characteristics independently associated with cannabis use were as follows: age < 64 years (< 44 years, odds ratio [OR] = 3.96 [95% CI: 1.65-9.53]; age 45-64 years, OR = 2.72 [95% CI: 1.65-4.47]); tobacco use in the previous 6 months (OR = 1.91 [95% CI: 1.18-3.07]); having a cannabis smoker in one's primary social group (OR = 4.17 [95% CI: 2.73-6.38]); and a history of a mental health diagnosis (OR = 1.82 [95% CI: 1.19-2.79]). Among those using cannabis, 70.5% reported smoking or vaping it; 47.2% reported daily use. Most did not know the tetrahydrocannabinol (THC; 71.6%) or cannabidiol (CBD; 83.3%) content of their cannabis, or the dose of cannabis in their edibles (66.7%). As defined by Canada's Lower Risk Cannabis Use Guidelines, 96.7% of cannabis users reported ≥ 1 higher-risk use behaviour (mean = 2.3, standard deviation = 1.2). Over 60% of patients expressed no intention to quit or reduce cannabis use in the next 6 months. Conclusions: Cannabis use appears prevalent among cardiac patients. Most users demonstrated higher-risk use behaviours and low intentions to quit. Further work is needed to understand the impacts of cannabis use on the cardiovascular system and to develop guidelines and educational tools relating to lower-risk use, for cardiac patients and providers.

Contexte: L'utilisation du cannabis peut nuire à la santé cardiovasculaire, mais les habitudes d'utilisation des patients atteints de troubles cardiaques ne sont pas connues. Nous avons évalué la prévalence, les perceptions et les habitudes d'utilisation du cannabis chez des patients hospitalisés présentant des troubles cardiaques. Méthodologie: Une analyse transversale a été réalisée en interrogeant en personne ou au téléphone des patients hospitalisés consécutivement entre novembre 2019 et mai 2020 et présentant des troubles cardiaques. Des statistiques descriptives et une régression logistique ont été utilisées pour examiner les caractéristiques liées à l'utilisation du cannabis. Résultats: La prévalence de l'utilisation du cannabis au cours des 12 mois précédents était de 13,8 % (intervalle de confiance [IC] à 95 % : 11,8 % à 16,0 %). Les caractéristiques indépendamment associées à l'utilisation du cannabis étaient les suivantes : âge < 64 ans (< 44 ans, rapport de cotes [RC] = 3,96 [IC à 95 % : 1,65 à 9,53]; âge de 45 à 64 ans, RC = 2,72 [IC à 95 % : 1,65 à 4,47]); tabagisme dans les six mois précédents (RC = 1,91 [IC à 95 % : 1,18 à 3,07]); présence d'un consommateur de cannabis au sein du cercle social principal (RC = 4,17 [IC à 95 % : 2,73 à 6,38]); et diagnostic antérieur lié à la santé mentale (RC = 1,82 [IC à 95 % : 1,19 à 2,79]). Parmi les utilisateurs de cannabis, 70,5 % d'entre eux ont rapporté qu'ils fumaient ou vapotaient et 47,2 % ont déclaré en consommer quotidiennement. La plupart ne connaissaient pas le contenu en tétrahydrocannabinol (THC; 71,6 %) ou en cannabidiol (CBD; 83,3 %) du cannabis consommé, ou la dose contenue dans les aliments à base de cannabis consommés (66,7 %). Au total, 96,7 % des utilisateurs de cannabis ont rapporté ≥ 1 comportement(s) à risque élevé (moyenne = 2,3, écart-type = 1,2) selon les Recommandations canadiennes pour l'usage du cannabis à moindre risque. Par ailleurs, plus de 60 % des patients n'ont exprimé aucune intention d'interrompre ou de diminuer leur consommation de cannabis au cours des six prochains mois. Conclusions: L'utilisation du cannabis semble courante chez les patients qui présentent des troubles cardiaques. La plupart des utilisateurs ont démontré des comportements à risque élevé, et une faible intention de mettre fin à leur consommation. D'autres études sont requises pour caractériser les répercussions de l'utilisation du cannabis sur l'appareil cardiovasculaire et élaborer des lignes directrices et des outils éducatifs à l'intention des patients atteints de troubles cardiaques et des professionnels de la santé en vue de favoriser un usage à moindre risque.

Nicotine replacement therapy 'gift cards' for hospital inpatients who smoke: a prospective before-and-after controlled pilot evaluation.

INTRODUCTION: A common barrier identified by individuals trying to quit smoking is the cost of cessation pharmacotherapies. The purpose of this evaluation was to: (1) Assess the feasibility of offering nicotine replacement therapy (NRT) 'gift cards' to hospitalised smokers for use posthospitalisation; and, (2) Estimate the effect of providing NRT gift cards on 6-month smoking abstinence. METHODS: A prospective, quasi-experimental, before-and-after controlled cohort design with random sampling was used to compare patients who had received the Ottawa Model for Smoking Cessation (OMSC) intervention ('control') with patients who received the OMSC plus a $C300 Quit Card ('QCI'), which they could use to purchase any brand or form of NRT from any Canadian pharmacy. RESULTS: 750 Quit Cards were distributed to the three participating hospitals of which 707 (94.3%) were distributed to patients. Of the cards received by patients, 532 (75.2%) were used to purchase NRT. A total of 272 participants completed evaluation surveys (148 control; 124 QCI).Point prevalence abstinence rates adjusted for misreporting among survey responders were 15.3% higher in the QCI group, compared with controls (44.4% vs 29.1%; OR 1.95, 1.18-3.21; p=0.009). Satisfaction was high among participants in both groups, and among staff delivering the QCI. QCI participants rated the intervention as high in terms of motivation, ease of use and helpfulness. CONCLUSIONS: The NRT gift card appears to be a feasible and effective smoking cessation tool that removes a primary barrier to the use of evidence-based smoking cessation pharmacotherapies, while motivating both patients and health providers.

Sustained Effects of Different Exercise Modalities on Physical and Mental Health in Patients With Coronary Artery Disease: A Randomized Clinical Trial.

BACKGROUND: Twelve-week high-intensity interval training (HIIT), moderate-to-vigorousintensity continuous training (MICT), and Nordic walking (NW) have been shown to improve functional capacity, quality of life (QoL), and depression symptoms in patients with coronary artery disease. However, their prolonged effects or whether the improvements can be sustained remains unknown. In this study we compared the effects of 12 weeks of HIIT, MICT, and NW on functional capacity, QoL, and depression symptoms at week 26. METHODS: Patients with coronary artery disease were randomized to a 12-week HIIT, MICT, or NW program followed by a 14-week observation phase. At baseline, and at weeks 12 and 26, functional capacity was measured with a 6-minute walk test (6MWT); QoL was assessed using the HeartQoL and Short Form-36; and depression severity using the Beck Depression Inventory-II. Prolonged (between baseline and week 26) and sustained (between weeks 12 and 26) effects were assessed using linear mixed models with repeated measures. RESULTS: Of 130 participants randomized, 86 (HIIT: n = 29; MICT: n = 27; NW: n = 30) completed week 26 assessments. There were significant improvements in 6MWT distance, QoL, and depression symptoms from baseline to week 26 (P < 0.05); NW increased 6MWT distance (+94.2 ± 65.4 m) more than HIIT (+59.9 ± 52.6 m; interaction effect P = 0.025) or MICT (+55.6 ± 48.5 m; interaction effect P = 0.010). Between weeks 12 and 26, 6MWT distance and physical QoL increased significantly (P < 0.05). CONCLUSIONS: Twelve weeks of HIIT, MICT, and NW have positive prolonged effects on functional capacity, QoL, and depression symptoms. However, NW conferred additional benefits in increasing functional capacity. The effects of the 12-week exercise programs were sustained at week 26.

The effects of high-intensity interval training, Nordic walking and moderate-to-vigorous intensity continuous training on functional capacity, depression and quality of life in patients with coronary artery disease enrolled in cardiac rehabilitation: A randomized controlled trial (CRX study).

BACKGROUND: Coronary artery disease (CAD) patients undergoing revascularization procedures often experience ongoing, diminished functional capacity, high rates of depression and markedly low quality of life (QoL). In CAD patients, studies have demonstrated that high-intensity interval training (HIIT) is superior to traditional moderate-to-vigorous intensity continuous training (MICT) for improving functional capacity, whereas no differences between Nordic walking (NW) and MICT have been observed. Mental health is equally as important as physical health, yet few studies have examined the impact of HIIT and NW on depression and QoL. The purpose of this randomized controlled trial (RCT) was to compare the effects of 12 weeks of HIIT, NW and MICT on functional capacity in CAD patients. The effects on depression severity, brain-derived neurotrophic factor (BDNF) and QoL were also examined. METHODS: CAD patients who underwent coronary revascularization procedures were randomly assigned to: (1) HIIT (4 × 4-min of high-intensity work periods at 85%-95% peak heart rate [HR]), (2) NW (resting HR [RHR] + 20-40 bpm), or (3) MICT (RHR + 20-40 bpm) twice weekly for 12 weeks. Functional capacity (six-min walk test [6MWT]), depression (Beck Depression Inventory-II [BDI-II]), BDNF (from a blood sample), and general (Short-Form 36 [SF-36]) and disease-specific (HeartQoL) QoL were measured at baseline and follow-up. Linear mixed-effects models for repeated measures were used to test the effects of time, group and time × group interactions. RESULTS: N = 135 CAD patients (aged 61 ± 7 years; male: 85%) participated. A significant time × group interaction (p = 0.042) showed greater increases in 6MWT distance (m) for NW (77.2 ± 60.9) than HIIT (51.4 ± 47.8) and MICT (48.3 ± 47.3). BDI-II significantly improved (HIIT: -1.4 ± 3.7, NW: -1.6 ± 4.0, MICT: -2.3 ± 6.0 points, main effect of time: p < 0.001) whereas BDNF concentrations did not change (HIIT: -2.5 ± 9.6, NW: -0.4 ± 7.7, MICT: -1.2 ± 6.4 ng/mL, main effect of time: p > 0.05). Significant improvements in SF-36 and HeartQoL values were observed (main effects of time: p < 0.05). HIIT, NW and MICT participants attended 17.7 ± 7.5, 18.3 ± 8.0 and 16.1 ± 7.3 of the 24 exercise sessions, respectively (p = 0.387). CONCLUSIONS: All exercise programmes (HIIT, NW, MICT) were well attended, safe and beneficial in improving physical and mental health for CAD patients. NW was, however, statistically and clinically superior in increasing functional capacity, a predictor of future cardiovascular events.

Work-related factors predict changes in physical activity among nurses participating in a web-based worksite intervention: A randomized controlled trial.

BACKGROUND: Despite the numerous benefits associated with physical activity (PA), most nurses are not active enough and few interventions have been developed to promote PA among nurses. A secondary analysis of raw data from a single-centre, three-arm parallel-group randomized controlled trial was conducted to assess whether work-related characteristics and general mood states predict changes in total weekly moderate-to-vigorous intensity PA (MVPA) and average daily step-count among nurses participating in a 6-week web-based worksite intervention. METHODS: Seventy nurses (meanage: 46.1 ± 11.2 years) were randomized to an individual-, friend-, or team-based PA challenge. Participants completed questionnaires pre- and post-intervention assessing work-related characteristics (i.e., shift schedule and length, number of hours worked per week, work role) and general mood states (i.e., tension, depression, anger, confusion, fatigue, vigour). Participants received a PA monitor to wear before and during the 6-week PA challenge, which was used to assess total weekly MVPA minutes and average daily step-count. Data were analyzed descriptively and using multilevel modeling for repeated measures. RESULTS: Change in total weekly MVPA minutes, but not change in average daily step-count, was predicted by shift schedule (rotating vs. fixed) by time (estimate = - 17.43, SE = 6.18, p = .006), and work role (clinical-only vs. other) by time (estimate = 18.98, SE = 6.51, p = .005). General mood states did not predict change in MVPA or change in average daily step-count. CONCLUSIONS: Given that nurses who work rotating shifts and perform clinical work showed smaller improvements in MVPA, it may be necessary to consider work-related factors/barriers (e.g., time constraints, fatigue) and collaborate with nurses when designing and implementing MVPA interventions in the workplace. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04524572 . August 24, 2020. This trial was registered retrospectively. This study adheres to the CONSORT 2010 statement guidelines.

The INITIATE trial protocol: a randomized controlled trial testing the effectiveness of a "quit card" intervention on long-term abstinence among tobacco smokers presenting to the emergency department.

BACKGROUND: Smoking cessation interventions implemented in emergency department (ED) settings have resulted in limited success, owing to factors such as lack of time, motivation, and incentives. A dynamic yet simple and effective approach that addresses the fast-paced nature of acute-care ED settings is needed. This study proposes a multi-center randomized controlled trial (RCT) to compare the effectiveness of an easy to deliver proactive, multi-component tobacco treatment intervention to usual care in the ED setting. METHODS: This will be a prospective four-site, single-blind, blinded-endpoint (PROBE) RCT. Participants will be recruited directly in the ED and will be approached strictly in order of arrival time. Those randomized to the Quit Card Intervention (QCI) group will receive a "quit kit" which will include: a "Quit Card" worth $300 that can be used at any Canadian pharmacy to purchase any form of nicotine replacement therapy (NRT); a self-help booklet; and proactive enrolment in 6 months of telephone follow-up counseling. The usual care (UC) group will receive a "quit kit" which will include a brochure for a local smoking cessation program. Quit kits for both groups will be delivered in opaque, sealed envelopes, and identical in size and weight so to conceal group allocation from the blinded research coordinator. Randomization will be stratified by site and by the Canadian Triage Acuity Scale (CTAS), a value assigned to each ED patient based on the severity of the condition. An equal number of quit kits will be prepared for each CTAS level. The primary outcome will be bio-chemically verified smoking abstinence at 26 weeks. Secondary outcomes include smoking behavior at weeks 4, 52, and 104 as well as mortality and health care utilization outcomes. Investigators, outcome assessors, and data analysts will be blinded to group allocation until after primary analyses are completed. It is hypothesized that the QCI group will have higher a abstinence rate, improved health outcomes, and decreased healthcare utilization. DISCUSSION: There are few examples of hospital EDs in Canada that systematically initiate tobacco cessation interventions for patients who smoke. Given the high smoking prevalence among ED patients and the relation of tobacco smoking to the majority of ambulatory care sensitive conditions, EDs are a missed opportunity in the initiation of tobacco treatment interventions. We have designed and will test an evidence-based tobacco treatment intervention that is simple and highly scalable. TRIAL REGISTRATION: ClinicalTrials.gov NCT04163081 . Registered on November 14, 2019.

Performance Obligations to Improve Delivery of Hospital-Initiated Smoking Cessation Interventions: A Before-and-After Evaluation.

INTRODUCTION: This study evaluated whether introducing performance obligations (a policy intervention) to service agreements between hospitals (n = 15) and their local health authority: (1) improved provision of an evidence-based tobacco cessation intervention (the "Ottawa Model" for Smoking Cessation) and (2) changed the quality of the cessation intervention being delivered. METHODS: Interrupted time series analysis was used to evaluate the change in the proportion of smoker patients provided the Ottawa Model 3 years before and 3 years after introducing the performance obligations. Changes in secondary outcomes related to program quality were described using mean differences, risk differences, and risk ratios, as appropriate. RESULTS: The proportion and number of patients provided the Ottawa Model doubled in the 3-year period following introduction of the new policy-from 3453 patients (33.7%) in the year before to 6840 patients (62.8%) in the final assessment year. This resulted in a signification slope change (+9.2%; 95% confidence interval [CI] 4.5%, 13.9%; p = .01) between the pre- and post-obligation assessment periods, signifying the policy had a positive impact on performance. Quality and effectiveness of the in-hospital intervention remained steady. CONCLUSIONS: Implementation of performance obligations by a healthcare funder increased delivery of an evidence-based smoking cessation intervention across multiple hospitals. Given the known health and economic impacts of smoking cessation interventions, health authorities and hospitals should consider pairing adoption of systematic interventions, like the Ottawa Model, with policy to enhance reach and impact. IMPLICATIONS: • The hospital-based Ottawa Model for Smoking Cessation (OMSC) intervention has been shown to increase smoking abstinence, while reducing mortality and healthcare utilization.• The uptake of systematic, evidence-based interventions, like the OMSC, by hospitals has been relatively low despite the known positive impacts.• The introduction of smoking cessation performance obligations by a healthcare funder resulted in more patients receiving an OMSC intervention while in hospital, with no corresponding change in intervention quality or effectiveness.• Healthcare funders and hospitals should consider pairing the adoption of effective, systematic interventions, like the OMSC, with policy to enhance reach and impact.

A Randomized Controlled Trial of an Exercise Maintenance Intervention in Men and Women After Cardiac Rehabilitation (ECO-PCR Trial).

BACKGROUND: Exercise maintenance interventions are needed for cardiac rehabilitation (CR) graduates to maintain moderate and vigorous-intensity physical activity (MVPA). We tested an exercise facilitator intervention (EFI) to promote exercise maintenance compared with usual care (UC) separately in men and women. METHODS: This was a 3-site, randomized (1:1), parallel-group, superiority trial (ECO-PCR). CR graduates were stratified by site and sex and randomly allocated (concealed). EFI participants received a face-to-face introductory session, 5 small-group counseling teleconferences, and 3 personal calls from a trained facilitator over 50 weeks. In-person assessments were undertaken at baseline and 26 and 52 weeks after randomization. The primary outcome was weekly minutes of MVPA, measured by accelerometer. Secondary outcomes were exercise capacity, risk factors, quality of life, and enrollment in community-based exercise programs. Effects were tested with the use of linear mixed models. RESULTS: A total of 449 CR graduates (135 women, 314 men) were randomised (n = 226 EFI, n = 223 UC). In the intention-to-treat analysis for men and for women, there were no significant effects for treatment or time on MVPA. In a planned secondary analysis that considered only those adherent to EFI (completed ≥ 66% of sessions; per-protocol), bouted MVPA (ie, in sustained bouts of ≥ 10 min) was higher in women in the EFI group (mean = 132.6 ± 135.2 min/wk at 52 weeks) compared with UC (111.8 ± 113.1; P = 0.013). Regarding secondary outcomes, in women, a treatment group main effect was observed for blood pressure (P = 0.011) and exercise capacity (P = 0.019; both per-protocol) favouring EFI; no other differences were observed. CONCLUSIONS: In this trial of CR completers, an EFI showed promise for women, but was ineffective in men.

Meeting the Canadian strength training recommendations: Implications for the cardiometabolic, psychological and musculoskeletal health of nurses.

AIM: To examine the proportion of nurses meeting the strength training recommendation and its associated cardiometabolic, psychological and musculoskeletal benefits. BACKGROUND: Strength training targets poor physical and mental health often reported by nurses; however, it is unknown whether nurses are meeting the strength training guidelines. METHODS: Nurses from 14 hospitals completed a 7-day physical activity log. Nurses were considered meeting the recommendation if they reported ≥2 strength training sessions per week. Cardiometabolic, psychological and musculoskeletal health, and levels of motivation were compared between nurses meeting and not meeting the guidelines. RESULTS: Of the 307 nurses (94% female; age: 43 ± 12 years), 29 (9.4%) met the strength training recommendation. These nurses had lower body mass index (24.1 ± 2.6 vs. 27.3 ± 5.5 kg/m2 , p = .007) and waist circumference (73.8 ± 8.3 vs. 81.1 ± 11.7 cm, p = .017); and higher vigour-activity (18.0 ± 5.8 vs. 15.6 ± 6.5 points, p = .046) and self-determined motivation (relative autonomic index: 54.9 ± 20.3 vs. 45.0 ± 23.8 points, p = .042) scores than nurses not meeting the recommendation. CONCLUSION: While the proportion of nurses meeting the strength training recommendation was small (<10%), they had lower body mass and waist circumference, and higher vigour-activity. IMPLICATIONS FOR NURSING MANAGEMENT: Strategies to increase the strength training engagement may improve the cardiometabolic health and increase vigour among nurses.

Using the 6-min Walk Test to Monitor Peak Oxygen Uptake Response to Cardiac Rehabilitation in Patients With Heart Failure.

PURPOSE: We examined the agreement between peak oxygen uptake (V˙o2peak), estimated using prediction equations from the 6-min Walk Test (6MWT), and V˙o2peak measured using a cardiopulmonary exercise test (CPX) to estimate change in V˙o2peak in patients with heart failure (HF) enrolled in cardiac rehabilitation (CR). METHODS: This was secondary analysis of 54 (including 9 women) patients with HF who completed a clinical CR program. Four previously published equations using 6MWT distance were used to estimate V˙o2peak and were compared with a CPX at baseline, follow-up, and change using the standard and modified Bland-Altman method. Analyses were repeated for quartiles of cardiorespiratory fitness (CRF) based on measured V˙o2peak from the CPX. RESULTS: Bland-Altman plots revealed proportional bias between all prediction equations and the measured V˙o2peak. The difference between methods varied by the level of CRF, with overestimation of prediction equations at greater levels of CRF and underestimation at lower levels of CRF. This poor agreement remained when comparisons were made between the estimated and measured V˙o2peak values at quartiles of CRF, indicating prediction equations have limited ability to predict V˙o2peak at any level of CRF. CONCLUSION: Estimated V˙o2peak using 6MWT distance demonstrated poor agreement with measured V˙o2peak from a CPX. While distance ambulated on the 6MWT remains an important measure of physical performance in patients with HF, prediction equations using 6MWT distance are not appropriate to monitor changes in V˙o2peak following CR in patients with HF.

Motivation Predicts Change in Nurses' Physical Activity Levels During a Web-Based Worksite Intervention: Results From a Randomized Trial.

BACKGROUND: Low physical activity levels can negatively affect the health of nurses. Given the low physical activity levels reported by nurses, there is a clear need for brief and economical interventions designed to increase physical activity levels in this population. We developed a web-based intervention that used motivational strategies to increase nurses' physical activity levels. The intervention provided the nurses with feedback from an activity monitor coupled with a web-based individual, friend, or team physical activity challenge. OBJECTIVE: In this parallel-group randomized trial, we examine whether nurses' motivation at baseline predicted changes in objectively measured physical activity levels during the 6-week intervention. METHODS: The participants were 76 nurses (n=74, 97% female; mean age 46, SD 11 years) randomly assigned to 1 of 3 physical activity challenge conditions: (1) individual, (2) friend, or (3) team. The nurses completed a web-based questionnaire designed to assess motivational regulations for physical activity levels before the intervention and wore a Tractivity activity monitor before and during the 6-week intervention. We analyzed data using multilevel modeling for repeated measures. RESULTS: The nurses' physical activity levels increased (linear estimate=10.30, SE 3.15; P=.001), but the rate of change decreased over time (quadratic estimate=-2.06, SE 0.52; P<.001). External and identified regulations (ß=-2.08 to 11.55; P=.02 to .04), but not intrinsic and introjected regulations (ß=-.91 to 6.29; P=.06 to .36), predicted changes in the nurses' physical activity levels. CONCLUSIONS: Our findings provide evidence that an intervention that incorporates self-monitoring and physical activity challenges can be generally effective in increasing nurses' physical activity levels in the short term. They also suggest that drawing solely on organismic integration theory to predict changes in physical activity levels among the nurses participating in web-based worksite interventions may have been insufficient. Future research should examine additional personal (eg, self-efficacy) and occupational factors (eg, shift length and shift type) that influence physical activity levels to identify potential targets for intervention among nurses. TRIAL REGISTRATION: ClinicalTrials.gov NCT04524572; https://clinicaltrials.gov/ct2/show/NCT04524572.

Personalized dosing of nicotine replacement therapy versus standard dosing for the treatment of individuals with tobacco dependence: study protocol for a randomized placebo-controlled trial.

BACKGROUND: Medications for smoking cessation are currently only effective in helping a minority of smokers quit. Drug development is slow and expensive; as such, there is much interest in optimizing the effectiveness of existing treatments and medications. Current standard doses of nicotine replacement therapy are not effective for many smokers, and in many cases, the amount of nicotine provided is much less than when a smoker is smoking their usual number of cigarettes. The proposed study will test if titrating the dose of the nicotine patch (up to 84 mg) will improve quitting success compared to those receiving a 21-mg nicotine patch with increasing doses of placebo patch. METHODS: This is a multicenter, pragmatic, two-arm, placebo-controlled, block randomized controlled trial. We will recruit participants who smoke at least 10 cigarettes daily and are interested in making a quit attempt. After 2 weeks of usual treatment with a 21-mg patch, participants who fail to quit smoking (target n = 400) will be randomized to receive escalating doses of a nicotine patch vs matching placebo patches for an additional 10 weeks or up to a maximum dose of 84 mg per day. Those who stop smoking during the first 2 weeks of usual treatment will continue with 21 mg patch treatment for 10 weeks and will form an additional comparison arm. In addition to the medication, participants will receive brief behavioral counseling at each study visit. The primary outcome will be biochemically confirmed continuous abstinence from smoking during the last 4 weeks of treatment (weeks 9 to 12). DISCUSSION: Research evidence supporting the effectiveness of personalized doses of nicotine replacement therapy could change current practice in a variety of healthcare settings. Given the evidence that quitting smoking at any age diminishes the risk of tobacco-related morbidity and mortality, even small increases in absolute quit rates can have a substantial population-level impact on reducing smoking-related disease, mortality rates, and associated healthcare costs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03000387 . Registered on 22 December 2016.

Physical activity, sedentary time and sleep and associations with mood states, shift work disorder and absenteeism among nurses: an analysis of the cross-sectional Champlain Nurses' Study.

BACKGROUND: Research has suggested ideal combinations of sleep, physical activity (PA) and sedentary time (ST) (i.e., optimal sleep/high PA/low ST) are associated with better overall health. Previous research has shown nurses spend more than half their day sedentary, do not generally meet PA guidelines and have difficulty obtaining adequate sleep. There has been no known work to examine how combinations of sleep, PA and ST relate to the work performance and mental health of nurses. Our objective was to assess the associations of sleep, PA and ST with absenteeism, mood states and shift work disorder (SWD) in a sample of Canadian nurses. METHODS: A total of 342 nurses from the Champlain Nurses' Study (mean age ± SD = 43 ± 12 years, 94% women) wore an ActiGraph GT3X accelerometer for ≥ 4 days for ≥ 10 h/day to derive time spent in moderate-to-vigorous intensity physical activity (MVPA) and ST and reported sleep time for ≥ 4 days using daily activity logs. Behavioural patterns were categorized into four groups for comparison based on opposing combinations of sleep, MVPA and ST (e.g., optimal sleep/high MVPA/low ST vs. non-optimal sleep/low MVPA/high ST). Self-reported absenteeism, mood states and SWD as measured by the Profile of Mood States (POMS) and Shift Work Disorder Screening questionnaires, respectively, were compared across combinations of high versus low MVPA and ST, and optimal vs. non-optimal sleep. RESULTS: Nurses spent an average of 444 ± 11 min/day sedentary, 14 ± 15 min/day in bouts ≥ 10 minutes of MVPA (23% met PA guidelines) and reported an average of 8 h and 39 min ± 1 h 6 min of sleep/24-h. Significant associations between behaviour groups and the POMS score and its vigor subscale, as well as SWD were observed, however, none were observed for absenteeism. The healthiest behaviour group had a significantly lower mood disturbance compared to 2/3 unhealthy behaviours and greater vigor compared to 2/3 and 3/3 unhealthy behaviours. SWD trended toward being higher amongst the group with 2/3 unhealthy behaviours. Meeting PA guidelines was associated with significantly lower total mood disturbance versus not meeting guidelines (median [IQR] = 0.4 [4.5] vs. 1.3 [4.4], Z =  - 2.294, df = 1, p = 0.022), as well as lower anger, higher vigor and lower fatigue. Low ST was associated with lower POMS total mood disturbance scores versus higher ST (0.6 [4.4] vs. 1.4 [4.3], Z = 2.028, df = 1, p = 0.043), as well as higher vigor and lower fatigue. CONCLUSIONS: In this sample of hospital nurses, the combined effects of sleep, PA and ST are associated with total mood disturbance and SWD. Achieving the recommended levels in all three behaviours may be beneficial in decreasing total mood disturbance and minimizing the effects of SWD. Future work is needed to address the low PA and high ST levels of nurses and to better understand how these behaviours can be improved to optimize the mental health of the health workforce.

Patterns and predictors of exercise behavior during 24 months of follow-up after a supervised exercise program during breast cancer chemotherapy.

BACKGROUND: Understanding the longer-term exercise behavior of patients with breast cancer after chemotherapy is important to promote sustained exercise. The purpose of the current study was to report the longer-term patterns and predictors of exercise behavior in patients with breast cancer who exercised during chemotherapy. METHODS: In the Combined Aerobic and Resistance Exercise (CARE) Trial, 301 patients with breast cancer were randomized to three different exercise prescriptions during chemotherapy. Exercise behaviors after chemotherapy were self-reported at 6-, 12-, and 24-month follow-up. Exercise patterns were identified by categorizing patients according to which exercise guideline they were meeting (neither, aerobic only, resistance only, or combined) at each of the three follow-up timepoints (64 possible patterns). Predictors of longer-term exercise behavior included physical fitness, patient-reported outcomes, and motivational variables from the theory of planned behavior assessed at postintervention (postchemotherapy). Univariate and multivariate stepwise multinomial logistic regression and linear regression were used for statistical analyses. RESULTS: A total of 264 (88%) participants completed all three follow-up exercise behavior assessments and exhibited 50 different exercise patterns. Postintervention aerobic fitness was the most consistent predictor of longer-term exercise behavior at all three timepoints. For example, higher aerobic fitness (per 1 ml/kg/min) predicted better adherence to the "aerobic only" (OR = 1.09; p = 0.005) and "combined" (OR = 1.12; p < 0.001) guidelines compared to "neither" guideline at 6-month follow-up. Additionally, higher postintervention muscular strength (per 1 kg) was associated with better adherence to the "resistance only" (OR = 1.07; p = 0.025) and "combined" (OR = 1.08; p < 0.001) guidelines compared to "neither" guideline at 24-month follow-up. Finally, lower perceived difficulty (per 1 scale point) was associated with better adherence to the "combined" (OR = 0.62; p = 0.010) and "aerobic only" (OR = 0.58; p = 0.002) guideline compared to the "neither" guideline at the 24-month follow-up. CONCLUSIONS: Our study is the first to show that the longer-term exercise patterns of patients with breast cancer who exercised during chemotherapy are diverse and predicted by physical fitness and motivational variables after chemotherapy. Our novel implications are that improving physical fitness during chemotherapy and applying motivational counseling after chemotherapy may improve longer-term exercise behavior in patients with breast cancer. TRIAL REGISTRATION: (NCT00249015).

Effects of exercise dose and type during breast cancer chemotherapy on longer-term patient-reported outcomes and health-related fitness: A randomized controlled trial.

The Combined Aerobic and Resistance Exercise (CARE) Trial compared different types and doses of exercise performed during breast cancer chemotherapy. Here, we report the longer-term follow-up of patient-reported outcomes, health-related fitness and exercise behavior at 6, 12 and 24 months postintervention. A multicenter trial in Canada randomized 301 breast cancer patients initiating chemotherapy to thrice weekly, supervised exercise consisting of a standard dose of 25-30 min of aerobic exercise (STAN; n = 96), a higher dose of 50-60 min of aerobic exercise (HIGH; n = 101) or a combined dose of 50-60 min of aerobic and resistance exercise (COMB; n = 104) performed for the duration of chemotherapy (median of 17 weeks). Primary outcomes were patient-reported outcomes including quality of life, cancer-related symptoms and psychosocial outcomes. Secondary outcomes were objective health-related fitness (assessed at 12 months only) and self-reported exercise behavior. A total of 269 (89.4%) participants completed patient-reported outcomes at all three follow-up time points and 263 (87.4%) completed the health-related fitness assessment at 12-month follow-up. COMB was significantly superior to (i) STAN for sleep quality at 6-month follow-up (p = 0.027); (ii) HIGH for upper body muscular endurance at 12-month follow-up (p = 0.020); and (iii) HIGH for meeting the resistance exercise guideline at 6-month follow-up (p = 0.006). Moreover, self-reported meeting of the combined exercise guideline during follow-up was significantly associated with better patient-reported outcomes and health-related fitness. Performing combined exercise during and after breast cancer chemotherapy may result in better longer-term patient-reported outcomes and health-related fitness compared to performing aerobic exercise alone.

Smoking behaviour among nurses in Ontario: cross-sectional results from the Champlain Nurses' Study.

OBJECTIVE: Nurses comprise the largest professional group within the Canadian health care workforce. We aimed to assess the prevalence and correlates of smoking among nurses. METHODS: The Champlain Nurses' Study was a multi-centre, observational study that evaluated the physical activity levels and health of hospital-based nurses. Participants completed a series of self-report questionnaires addressing a variety of health indicators including smoking status and smoking history. Multi-level modelling was used to examine variability in smoking status across hospital sites and to identify correlates of current smoking. RESULTS: A total of 406 nurses, from 14 urban and rural hospitals, were included in this analysis. On average, the nurses were 42.9 (standard deviation (SD), 11.9) years old, had a waist circumference of 78.7 (95% confidence interval (CI): 77.5, 80.2) cm and body mass index of 25.9 (95% CI: 25.3, 26.5) kg/m2, worked in urban hospitals (81.3%), and had either a university bachelor's (46.9%) or college (39.6%) education. Most participants (92.0%) reported that they are not current smokers, 4.0% reported that they currently smoke occasionally, and 4.0% reported that they are current daily smokers. Smokers were more likely to be working in rural hospitals than urban hospitals (34.4% versus 17.4% respectively, p = 0.018), associated with having a higher waist circumference (mean difference = 4.5 (SD, 2.1), p = 0.035), a college but not university education (71.9% versus 36.9%, respectively, p < 0.001), lower scores for the Barriers Specific Self-Efficacy Scale (mean difference = - 9.7 (SD, 4.6), p = 0.038), and higher scores for the Profile of Mood States scale (mean difference = 2.0 (SD, 3.3), p = 0.007). The only correlate that remained statistically significant in the final, multivariate model was marital status; however, this analysis may be underpowered. CONCLUSIONS: The prevalence of nurse smokers in our population is lower than previous estimates, and consistent with global declines in cigarette smoking. However, smoking was still prominent and associated with several other risk factors. Given the important relationship between smoking and health, and the critical role that nurses play in health care delivery, they should be an important focus for smoking cessation initiatives and other health education initiatives.

What Motivates Nurses to Exercise? Determinants of Physical Activity Among Canadian Nurses Using Self-Determination Theory.

BACKGROUND: Nurses' suboptimal physical activity (PA) levels place them at high risk for cardiovascular diseases. Little is known about the motivational factors that influence their PA behavior. PURPOSE: This study drew on the Self-Determination Theory (SDT) to investigate whether associations between nurses' levels of mood disturbance, psychological need satisfaction (competence, autonomy, and relatedness), and self-determined motivation predict levels of objectively assessed PA. METHODS: A total of 363 nurses recruited from 14 hospitals in the Champlain region of Ontario, Canada, wore ActiGraph GT3X accelerometers and completed standardized questionnaires assessing sociodemographic and work characteristics, mood disturbance, and SDT variables. Levels of moderate-to-vigorous intensity PA (MVPA) were measured in minutes/week in bouts ≥10 min. Data were analyzed using path analysis and multiple mediational model. RESULTS: The model predicting MVPA showed good fit to the data, χ 2 (4, n = 363) = 7.82, p = .10; comparative fit index = .991; Tucker-Lewis Index = .967; root mean square error of approximation = .051. Higher mood disturbance was associated with lower perceived competence (ß = -.29, p = .002), autonomy (ß = -.29, p = .002), and relatedness (ß = -.19, p = .002). Lower perceived competence (ß = .46, p = .003) and autonomy (ß = .14, p = .011), as well as higher mood disturbance (ß = -.16, p = .016), were associated with less self-determined motivation for PA. Lower self-determined motivation was associated with lower levels of MVPA among nurses. CONCLUSIONS: Interventions targeting low mood, as well as perceived competence and autonomy in exercise, may promote MVPA among nurses and reduce cardiac risk.