The Eruptive Fevers at Sixes and Sevens.

Sixth Disease (roseola infantum) and its primary causative agent, HHV-6, share names that numerically concur. This article examines and answers the question of whether that correspondence is by design or coincidental by briefly reviewing the history and nomenclature of the HHV viruses and the classic febrile rashes of childhood while highlighting some clinical and microbiologic features of HHV-6 infection.

The AI Future of Emergency Medicine.

In the coming years, artificial intelligence (AI) and machine learning will likely give rise to profound changes in the field of emergency medicine, and medicine more broadly. This article discusses these anticipated changes in terms of 3 overlapping yet distinct stages of AI development. It reviews some fundamental concepts in AI and explores their relation to clinical practice, with a focus on emergency medicine. In addition, it describes some of the applications of AI in disease diagnosis, prognosis, and treatment, as well as some of the practical issues that they raise, the barriers to their implementation, and some of the legal and regulatory challenges they create.

Resistance Training and Weight Loss in Older Adults: A Scoping Review.

Resistance training (RT) is one of the most effective interventions available to older adults wishing to slow the progressive loss of muscle size and strength known to occur with age. Less is known about the ability of RT to resist the onset of an equally problematic condition related to increased age: obesity. The objective of this scoping review was to characterize current research associated with RT and weight loss in older adults, including protocols, feasibility, and gaps in current knowledge. We searched six databases using variations of the terms "resistance training," "weight loss," and "older adults" for experimental or quasi-experimental studies published in the year 2009 or later. Studies were included if they featured at least one treatment group with a mean age of > 65 years that engaged in an RT-only exercise protocol with no aerobic or high-intensity interval component. Of the 6102 references identified by the initial database search, 24 were retained for analysis. Older women and older adults with obesity or sarcopenic obesity were the most studied groups (n = 13), followed by healthy community-dwelling older adults (n = 11) and studies involving older adults and some aspect of either dietary control or pharmaceutical intervention (n = 8). Significant between-study heterogeneity was observed in the RT characteristics researchers thought optimal for improving body composition measures in older adults. Changes in body composition, rather than total body mass, were found to be the essential variables to consider when evaluating the effectiveness of an RT intervention aimed at reducing chronic disease in older adults. Weight loss alone appears to be an incomplete and problematic outcome measure for older adults, with changes in body composition (ratio of fat mass to lean mass) being the more appropriate variable to emphasize in this population. However, it is important to note that only one study, showing questionably reproducible findings, found a significant lean body mass gain. The lack of abundant high-quality evidence demonstrating combined RT and a healthy diet can lead to significant fat loss and lean body mass gain, coupled with high attrition rates observed in many of the studies reviewed, highlight the need for further rigorous research.

Social Prescribing Outcomes for Trials (SPOT): Protocol for a modified Delphi study on core outcomes.

PURPOSE: This is a study protocol to co-create with knowledge users a core outcome set focused on middle-aged and older adults (40 years+) for use in social prescribing research. METHODS: We will follow the Core Outcome Measures in Effectiveness Trials (COMET) guide and use modified Delphi methods, including collating outcomes reported in social prescribing publications, online surveys, and discussion with our team to finalize the core outcome set. We intentionally center this work on people who deliver and receive social prescribing and include methods to evaluate collaboration. Our three-part process includes: (1) identifying published systematic reviews on social prescribing for adults to extract reported outcomes; and (2) up to three rounds of online surveys to rate the importance of outcomes for social prescribing. For this part, we will invite people (n = 240) who represent the population experienced in social prescribing, including researchers, members of social prescribing organizations, and people who receive social prescribing and their caregivers. Finally, we will (3) convene a virtual team meeting to discuss and rank the findings and finalize the core outcome set and our knowledge mobilization plan. CONCLUSION: To our knowledge, this is the first study designed to use a modified Delphi method to co-create core outcomes for social prescribing. Development of a core outcome set contributes to improved knowledge synthesis via consistency in measures and terminology. We aim to develop guidance for future research, and specifically on the use of core outcomes for social prescribing at the person/patient, provider, program, and societal-level.

Hockey Fans in Training (Hockey FIT): Rationale, design, and baseline characteristics from a cluster randomized controlled trial in men with overweight or obesity.

BACKGROUND: Previous research highlights the need for effective lifestyle interventions for men. Hockey Fans in Training (Hockey FIT) was developed as a pragmatic healthy lifestyle program tailored to men with overweight or obesity. This paper overviews the rationale, program details, and design of a recently completed cluster randomized controlled trial (RCT) of Hockey FIT. Participant engagement and baseline characteristics are also described. METHODS: The RCT evaluated the effectiveness, cost-effectiveness, and implementation of Hockey FIT. Forty-two sites in Canada and the United States were randomized to either the Hockey FIT intervention group or wait-list control group. Participants were men, aged 35-65 years, with a body mass index (BMI) ≥27 kg/m2. Hockey FIT is a group-based, off-ice, in-person healthy lifestyle program, including both a 3-month active phase and a 9-month minimally-supported phase. Outcomes were assessed at baseline, 3, and 12 months. The primary outcome was weight loss at 12 months. RESULTS: The design of the cluster RCT incorporates evaluations of participant health outcomes, program implementation, and broader healthcare system impact. In the RCT, 1397 participants were assessed for eligibility and 997 were enrolled. Most participants heard about the program through social media or hockey team emails. Participants averaged 49 years of age, had BMI values of 35.3 kg/m2, were predominately white, and had varying levels of education. CONCLUSION: The intended audience for Hockey FIT was recruited successfully, however, targeted recruitment to better engage diverse populations is warranted. This paper affords a useful outline for evaluating future lifestyle interventions tailored to men. This trial was registered on August 17, 2018 with ClinicalTrials.gov (identifier: NCT03636282).

Older adults and social prescribing experience, outcomes, and processes: a meta-aggregation systematic review.

OBJECTIVE: Social prescribing is a complex care model, which aims to address unmet non-medical needs and connect people to community resources. The purpose of this systematic review was to synthesize available evidence from qualitative methods (e.g. interviews or focus groups) on experience, outcomes, and processes for social prescribing and older adults (from the person or provider level). STUDY DESIGN: This was a systematic review using the Joanna Brigg's meta-aggregative approach. METHODS: We searched multiple online databases for peer-reviewed studies, which included older adults aged ≥60 years (group mean age) and social prescribing experience, outcomes, or processes. We included all qualitative or mixed methods designs from all years and languages. Date of the last primary search was March 24, 2022. Two authors used online software to conduct the screening independently and then decided on the final list of included studies via notes and online discussion. RESULTS: We screened 376 citations (after duplicates) and included eight publications. There were 197 older adult participants (59% women), and many people were living with chronic health conditions. Few details were provided for participants' ethnicity, education, and related factors. We created five synthesized findings related to (1) the approach of social prescribing; implementation factors such as (2) relationships, (3) behavior change strategies, and (4) the environment; and (5) older adults' perceived health and psychosocial outcomes. CONCLUSIONS: Despite the limited number of available studies, data provide an overview of people and processes involved with social prescribing, identified research and practice gaps, and possible next steps for implementing and evaluating social prescribing for older adults in primary care.

Changes in Cognition and Brain Function After 26 Weeks of Progressive Resistance Training in Older Adults at Risk for Diabetes: A Pilot Randomized Controlled Trial.

OBJECTIVES: Type 2 diabetes is associated with deficits in cognition and brain health. Individuals with at least 1 risk factor for diabetes (i.e. obesity, prediabetes) already experience some neurocognitive impairment and are at risk for further decline. One way to combat these deficits is through exercise, but it is unknown whether resistance exercise can improve these functions in this at-risk group. METHODS: This study was a pilot randomized controlled trial. Participants were 60 to 80 years of age and had prediabetes (fasting capillary glucose 6.1 to 6.9 mmol/L) and/or were living with overweight or obesity (body mass index ≥25 kg/m2). Participants completed resistance training or balance and stretching exercises (control) thrice weekly for 6 months. Neuropsychological tests were used to assess cognitive ability, whereas functional magnetic resonance imaging was used to examine brain activation patterns. RESULTS: Resistance training led to improvements in task-switching, attention, and conflict resolution, as well as improved patterns of brain activation that may mimic healthy older adults. CONCLUSIONS: Resistance exercise may serve as an effective behavioural strategy to improve neurocognition in older adults at risk for type 2 diabetes. A large-scale powered trial is needed to further explore these findings.

Early Osteoarthritis Questionnaire (EOAQ): a tool to assess knee osteoarthritis at initial stage.

Background: Early stage of osteoarthritis (OA) is characterized by joint stiffness and pain as well as by subclinical structural changes that may affect cartilage, synovium, and bone. At the moment, the lack of a validated definition of early osteoarthritis (EOA) does not allow to make an early diagnosis and adopt a therapeutic strategy to slow disease progression. Also, no questionnaires are available to evaluate the early stage, and therefore this remains an unmet need. Objective: Therefore, the purpose of the technical experts panel (TEP) of 'International Symposium of intra-articular treatment' (ISIAT) was to create a specific questionnaire to evaluate and monitor the follow-up and clinical progress of patients affected by early knee OA. Design: The items for the Early Osteoarthritis Questionnaire (EOAQ) were identified according to the following steps: items generation, items reduction, and pre-test submission. Methods: During the first step, literature has been reviewed and a comprehensive list of items about pain and function in knee EOA was drafted. Then, during the ISIAT (5th edition 2019), the draft has been discussed by the board, which reformulated, deleted, or subdivided some of the items. After the ISIAT symposium, the draft was submitted to 24 subjects affected by knee OA. A score based on the importance and the frequency was created and the items with a score ⩾0.75 were selected. After intermediate evaluation made by a sample of patients, the second and final version of the questionnaire EOAQ was submitted to the whole board for final analysis and acceptance in a second meeting (29 January 2021). Results: After an exhaustive elaboration, the final version of the questionnaire contains two domains (Clinical Features and Patients Reported Outcome) with respectively 2 and 9 questions, for a total of 11 questions. Questions mainly explored the fields of early symptoms and patients reported outcomes. Marginally, the need of the symptoms treatment and the use of painkillers were investigated. Conclusions: Adoption of diagnostic criteria of early OA is strongly encouraged and a specific questionnaire for the whole management of the clinical features and patients' outcome might really improve the evolution of OA in the early stages of the disease, when the treatment is expected to be more effective.

Identifying Personality Characteristics and Indicators of Psychological Well-Being Associated With Attrition in the Motivation Makes the Move! Physical Activity Intervention: Randomized Technology-Supported Trial.

BACKGROUND: Data attrition has been a common problem in longitudinal lifestyle interventions. The contributors to attrition in technology-supported physical activity interventions have not been thoroughly studied. OBJECTIVE: The present study examined the roles of personality characteristics and indicators of psychological well-being in data attrition within a technology-supported, longitudinal intervention study with overweight adults. METHODS: Participants (N=89) were adults from the Motivation Makes the Move! intervention study. Data attrition was studied after a 3-month follow-up. Participants' personality characteristics were studied using the Short Five self-report questionnaire. Psychological well-being indicators were assessed with the RAND 36-item health survey, Positive and Negative Affect Schedule, and Beck Depression Inventory. Logistic regression analyses were conducted to assess the risk of discontinuing the study. The analyses were adjusted for sex, age, study group, and educational status. RESULTS: At the 3-month follow-up, 65 of 89 participants (73% of the initial sample) had continued in the study. Participants' personality characteristics and indicators of psychological well-being were not associated with the risk of dropping out of the study (all P values >.05). The results remained the same after covariate controls. CONCLUSIONS: Participant attrition was not attributable to personality characteristics or psychological well-being in the Motivation Makes the Move! study conducted with overweight adults. As attrition remains a challenge within longitudinal, technology-supported lifestyle interventions, attention should be paid to the potentially dynamic natures of personality and psychological well-being, as well as other elements beyond these. TRIAL REGISTRATION: ClinicalTrials.gov NCT02686502; https://clinicaltrials.gov/ct2/show/NCT02686502.

Systematic review of social prescribing and older adults: where to from here?

OBJECTIVE: Social prescribing is a person-centred model of care with emphases on lessening the impact of unmet social needs, supporting the delivery of personalised care, and reducing non-medical resource use in the primary care setting. The purpose of this systematic review was to synthesise the effect of social prescribing for older adults within primary care. DESIGN: We followed standard systematic review guidelines, including protocol registration, screening studies (title/abstract and full text) and assessing the study quality. ELIGIBILITY AND INFORMATION SOURCES: We searched multiple online databases for studies that included older adults 60+ years (group mean age), an intervention defined and called social prescribing (or social prescription) via health provider referrals to non-medical services, and quantitative physical and psychosocial outcomes and/or health resource use. We included experimental and observational studies from all years and languages and conducted a narrative synthesis. The date of the last search was 24 March 2022. RESULTS: We screened 406 citations (after removing duplicates) and included seven studies. All studies except one were before-after design without a control group, and all except one study was conducted in the UK. Studies included 12-159 participants (baseline), there were more women than men, the group mean (SD) age was 76.1 (4.0) years and data collection (baseline to final) occurred on average 19.4 (14.0) weeks apart. Social prescribing referrals came from health and social providers. Studies had considerable risk of bias, programme implementation details were missing, and for studies that reported data (n=6) on average only 66% of participants completed studies (per-protocol). There were some positive effects of social prescribing on physical and psychosocial outcomes (eg, social participation, well-being). Findings varied for health resource use. These results may change with new evidence. CONCLUSIONS: There were few peer-reviewed studies available for social prescribing and older adults. Next steps for social prescribing should include co-creating initiatives with providers, older people and communities to identify meaningful outcomes, and feasible and robust methods for uptake of the prescription and community programmes. This should be considered in advance or in parallel with determining its effectiveness for meaningful outcomes at multiple levels (person, provider and programme).

High-Intensity Interval Training in Older Adults: a Scoping Review.

High-intensity interval training (HIIT) is an increasingly popular form of aerobic exercise which includes bouts of high-intensity exercise interspersed with periods of rest. The health benefits, risks, and optimal design of HIIT are still unclear. Further, most research on HIIT has been done in young and middle-aged adults, and as such, the tolerability and effects in senior populations are less well-known. The purpose of this scoping review was to characterize HIIT research that has been done in older adults including protocols, feasibility, and safety and to identify gaps in the current knowledge. Five databases were searched with variations of the terms, "high-intensity interval training" and "older adults" for experimental or quasi-experimental studies published in or after 2009. Studies were included if they had a treatment group with a mean age of 65 years or older who did HIIT, exclusively. Of 4644 papers identified, 69 met the inclusion criteria. The average duration of training was 7.9 (7.0) weeks (mean [SD]) and protocols ranged widely. The average sample size was 47.0 (65.2) subjects (mean [SD]). Healthy populations were the most studied group (n = 30), followed by subjects with cardiovascular (n = 12) or cardiac disease (n = 9), metabolic dysfunction (n = 8), and others (n = 10). The most common primary outcomes included changes in cardiorespiratory fitness (such as VO2peak) as well as feasibility and safety of the protocols as measured by the number of participant dropouts, adverse events, and compliance rate. HIIT protocols were diverse but were generally well-tolerated and may confer many health advantages to older adults. Larger studies and more research in clinical populations most representative of older adults are needed to further evaluate the clinical effects of HIIT in these groups.

The Benefits of High-Intensity Interval Training on Cognition and Blood Pressure in Older Adults With Hypertension and Subjective Cognitive Decline: Results From the Heart & Mind Study.

Background: The impact of exercise on cognition in older adults with hypertension and subjective cognitive decline (SCD) is unclear. Objectives: We determined the influence of high-intensity interval training (HIIT) combined with mind-motor training on cognition and systolic blood pressure (BP) in older adults with hypertension and SCD. Methods: We randomized 128 community-dwelling older adults [age mean (SD): 71.1 (6.7), 47.7% females] with history of hypertension and SCD to either HIIT or a moderate-intensity continuous training (MCT) group. Both groups received 15 min of mind-motor training followed by 45 min of either HIIT or MCT. Participants exercised in total 60 min/day, 3 days/week for 6 months. We assessed changes in global cognitive functioning (GCF), Trail-Making Test (TMT), systolic and diastolic BP, and cardiorespiratory fitness. Results: Participants in both groups improved diastolic BP [F (1, 87.32) = 4.392, p = 0.039], with greatest effect within the HIIT group [estimated mean change (95% CI): -2.64 mmHg, (-4.79 to -0.48), p = 0.017], but no between-group differences were noted (p = 0.17). Both groups also improved cardiorespiratory fitness [F (1, 69) = 34.795, p < 0.001], and TMT A [F (1, 81.51) = 26.871, p < 0.001] and B [F (1, 79.49) = 23.107, p < 0.001]. There were, however, no within- or between-group differences in GCF and systolic BP at follow-up. Conclusion: Despite improvements in cardiorespiratory fitness, exercise of high- or moderate-intensity, combined with mind-motor training, did not improve GCF or systolic BP in individuals with hypertension and SCD. Clinical Trial Registration: ClinicalTrials.gov (NCT03545958).

Systolic blood pressure dipping may be associated with mobility impairment and brain volume in community-dwelling older adults: An exploratory study.

OBJECTIVE: We investigated whether systolic blood pressure (SBP) dipping is associated with mobility outcomes and brain volume in older adults without dementia. METHODS: We conducted an exploratory analysis of data from 345 community-dwelling older adults (mean age [SD]: 69.9 [7.1], 60% women) who underwent 24-h BP measurement and mobility assessment. Mobility measures included usual and dual-task (DT) gait velocity, step length, and variability. For DT assessment, participants performed naming animals (NA) and serial sevens (S7) tasks. A subsample of participants (N = 32) also underwent magnetic resonance imaging to estimate total grey matter, white matter, and hippocampal brain volumes. We conducted hierarchical regression models to examine the association between SBP dipping and mobility outcomes, after adjusting for age, years of education, sex, Montreal Cognitive Assessment score, body mass index, hypertension, diabetes, other cardiovascular diseases, musculoskeletal conditions, and study cohort. Similar models were conducted to investigate associations between SBP dipping and brain volumes. RESULTS: SBP dipping significantly predicted gait velocity and step length under usual and both DT conditions. The R2 change was the highest for usual gait velocity (Fchange = 7.8, p = 0.005, R2change = 0.019), and lowest for step length during the NA task (Fchange = 4.4, p = 0.037, R2change = 0.01), suggesting a deleterious effect of SBP dipping on gait regardless of task complexity. For brain volumes, SBP dipping significantly predicted right hippocampal volume (Fchange = 5.4, p = 0.029, R2change = 0.12), and total hippocampal volume (Fchange = 5.1, p = 0.033, R2change = 0.1). CONCLUSIONS: Our findings suggest that SBP dipping, as a marker of cardiovascular disease in older adults, impacts mobility performance and hippocampal volume. SBP dipping could be targeted in future therapeutic interventions in older adults at risk for mobility and cognitive impairment.

Perspectives and Impact of a Parent-Child Intervention on Dietary Intake and Physical Activity Behaviours, Parental Motivation, and Parental Body Composition: A Randomized Controlled Trial.

Adults and children in Canada are not meeting physical activity guidelines nor consuming sufficient nutrient-rich foods. High engagement in these unhealthy behaviours can lead to obesity and its associated diseases. Parent-child interventions aimed at obesity prevention/treatment have assisted families with making positive changes to their nutrition and physical activity behaviours. Given that the home environment shapes early health behaviours, it is important to target both parents and children when addressing diet and physical activity. One method that has been shown to improve health outcomes is co-active coaching. The current study explored the impact of a three-month co-active coaching and/or health education intervention on the dietary intake and physical activity behaviours of parents with overweight/obesity and their children (ages 2.5-10; of any weight). Body composition (i.e., body mass index [BMI] and waist circumference), changes in parental motivation with respect to physical activity and dietary behaviours, and parental perceptions of program improvements were collected. A concurrent mixed methods study comprised of a randomized controlled trial and a descriptive qualitative design was utilized. Fifty parent-child dyads were recruited and randomly assigned to the control (n = 25) or intervention (n = 25) group. Assessments were completed at baseline, mid-intervention (six weeks), post-intervention (three months), and six-month follow-up. A linear mixed effects model was utilized for quantitative analysis. Inductive content analysis was used to extract themes from parent interviews. No significant results were observed over time for the dependent measures. Parents in both control and intervention groups reported varied program experiences, including developing changes in perspective, increased awareness of habits, and heightened accountability for making positive changes in themselves, and consequently, their families. Parents also shared barriers they faced when implementing changes (e.g., time, weather, stress). Qualitatively, both groups reported benefitting from this program, with the intervention group describing salient benefits from engaging in coaching. This research expands on the utility of coaching as a method for behaviour change, when compared to education only, in parents with overweight/obesity and their children.

A Scoping Review of Multiple-modality Exercise and Cognition in Older Adults: Limitations and Future Directions.

The effects of multiple-modality exercise (MME) on brain health warrants further elucidation. Our objectives were to report and discuss the current evidence regarding the influence of MME on cognition and neuroimaging outcomes in older adults without dementia. We searched the literature for studies investigating the effects of MME on measures of cognition, brain structure, and function in individuals 55 years or older without dementia. We include 33 eligible studies. Our findings suggested that MME improved global cognition, executive functioning, processing speed, and memory. MME also improved white and gray matter and hippocampal volumes. These findings were evident largely when compared with no-treatment control groups but not when compared with active (e.g., health education) or competing treatment groups (e.g., cognitive training). MME may improve brain health in older adults without dementia; however, because of possible confounding factors, more research is warranted.

Memory Function and Brain Functional Connectivity Adaptations Following Multiple-Modality Exercise and Mind-Motor Training in Older Adults at Risk of Dementia: An Exploratory Sub-Study.

BACKGROUND: Multiple-modality exercise improves brain function. However, whether task-based brain functional connectivity (FC) following exercise suggests adaptations in preferential brain regions is unclear. The objective of this study was to explore memory function and task-related FC changes following multiple-modality exercise and mind-motor training in older adults with subjective cognitive complaints. METHODS: We performed secondary analysis of memory function data in older adults [n = 127, mean age 67.5 (7.3) years, 71% women] randomized to an exercise intervention comprised of 45 min of multiple-modality exercise with additional 15 min of mind-motor training (M4 group, n = 63) or an active control group (M2 group, n = 64). In total, both groups exercised for 60 min/day, 3 days/week, for 24 weeks. We then conducted exploratory analyses of functional magnetic resonance imaging (fMRI) data collected from a sample of participants from the M4 group [n = 9, mean age 67.8 (8.8) years, 8 women] who completed baseline and follow-up task-based fMRI assessment. Four computer-based memory tasks from the Cambridge Brain Sciences cognitive battery (i.e. Monkey Ladder, Spatial Span, Digit Span, Paired Associates) were employed, and participants underwent 5 min of continuous fMRI data collection while completing the tasks. Behavioral data were analyzed using linear mixed models for repeated measures and paired-samples t-test. All fMRI data were analyzed using group-level independent component analysis and dual regression procedures, correcting for voxel-wise comparisons. RESULTS: Our findings indicated that the M4 group showed greater improvements in the Paired Associates tasks compared to the M2 group at 24 weeks [mean difference: 0.47, 95% confidence interval (CI): 0.08 to 0.86, p = 0.019]. For our fMRI analysis, dual regression revealed significant decrease in FC co-activation in the right precentral/postcentral gyri after the exercise program during the Spatial Span task (corrected p = 0.008), although there was no change in the behavioral task performance. Only trends for changes in FC were found for the other tasks (all corrected p < 0.09). In addition, for the Paired Associates task, there was a trend for increased co-activation in the right temporal lobe (Brodmann Area = 38, corrected p = 0.07), and left middle frontal temporal gyrus (corrected p = 0.06). Post hoc analysis exploring voxel FC within each group spatial map confirmed FC activation trends observed from dual regression. CONCLUSION: Our findings suggest that multiple modality exercise with mind-motor training resulted in greater improvements in memory compared to an active control group. There were divergent FC adaptations including significant decreased co-activation in the precentral/postcentral gyri during the Spatial Span task. Borderline significant changes during the Paired Associates tasks in FC provided insight into the potential of our intervention to promote improvements in visuospatial memory and impart FC adaptations in brain regions relevant to Alzheimer's disease risk. CLINICAL TRIAL REGISTRATION: The trial was registered in ClinicalTrials.gov in April 2014, Identifier: NCT02136368.

Heart failure management insights from primary care physicians and allied health care providers in Southwestern Ontario.

BACKGROUND: It remains to be determined whether collaborative strategies to improve and sustain overall health in patients with heart failure (HF) are currently being adopted by health care professionals. We surveyed primary care physicians, nurses and allied health care professionals in Southwestern Ontario regarding how they currently manage HF patients and how they perceive limitations, barriers and challenges in achieving optimal management in these patients. METHODS: We developed an online survey based on field expertise and a review of pertinent literature in HF management. We analyzed quantitative data collected via an online questionnaire powered by Qualtrics®. The survey included 87 items, including multiple choice and free text questions. We collected participant demographic and educational background, and information relating to general clinical practice and specific to HF management. The survey was 25 min long and was administered in October and November of 2018. RESULTS: We included 118 health care professionals from network lists of affiliated physicians and clinics of the department of Family Medicine at Western University; 88.1% (n = 104) were physicians while 11.9% (n = 14) were identified as other health care professionals. Two-thirds of our respondents were females (n = 72) and nearly one-third were males (n = 38). The survey included mostly family physicians (n = 74) and family medicine residents (n = 25). Most respondents indicated co-managing their HF patients with other health care professionals, including cardiologists and internists. The vast majority of respondents reported preferring to manage their HF patients as part of a team rather than alone. As well, the majority respondents (n = 47) indicated being satisfied with the way they currently manage their HF patients; however, some indicated that practice set up and communication resources, followed by experience and education relating to HF guidelines, current drug therapy and medical management were important barriers to optimal management of HF patients. CONCLUSIONS: Most respondents indicated HF management was satisfactory, however, a minority did identify some areas for improvement (communication systems, work more collaborative as a team, education resources and access to specialists). Future research should consider these factors in developing strategies to enhance primary care involvement in co-management of HF patients, within collaborative and multidisciplinary systems of care.

Are we missing the target? Are we aiming too low? What are the aerobic exercise prescriptions and their effects on markers of cardiovascular health and systemic inflammation in patients with knee osteoarthritis? A systematic review and meta-analysis.

OBJECTIVES: We systemically reviewed published studies that evaluated aerobic exercise interventions in patients with knee osteoarthritis (OA) to: (1) report the frequency, intensity, type and time (FITT) of exercise prescriptions and (2) quantify the changes in markers of cardiovascular health and systemic inflammation. DATA SOURCES: PubMed, CINAHL, Scopus; inception to January 2019. ELIGIBILITY CRITERIA: Randomised clinical trials (RCT), cohort studies, case series. DESIGN: We summarised exercise prescriptions for all studies and calculated effect sizes with 95% CIs for between-group (RCTs that compared exercise and control groups) and within-group (pre-post exercise) differences in aerobic capacity (VO2), heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and inflammatory markers (interleukin-6 (IL-6), tumour necrosis factor-alpha). We pooled results where possible using random effects models. RESULTS: Interventions from 49 studies were summarised; 8% (4/49) met all FITT guidelines; 16% (8/49) met all or most FITT guidelines. Fourteen studies (10 RCTs) reported at least one marker of cardiovascular health or systemic inflammation. Mean differences (95% CI) indicated a small to moderate increase in VO2 (0.84 mL/min/kg; 95% CI 0.37 to 1.31), decrease in HR (-3.56 beats per minute; 95% CI -5.60 to -1.52) and DBP (-4.10 mm Hg; 95% CI -4.82 to -3.38) and no change in SBP (-0.36 mm Hg; 95% CI -3.88 to 3.16) and IL-6 (0.37 pg/mL; 95% CI -0.11 to 0.85). Within-group differences were also small to moderate. CONCLUSIONS: In studies of aerobic exercise in patients with knee OA, very few interventions met guideline-recommended dose; there were small to moderate changes in markers of cardiovascular health and no decrease in markers of systemic inflammation. These findings question whether aerobic exercise is being used to its full potential in patients with knee OA. PROSPERO REGISTRATION NUMBER: CRD42018087859.

Treat-to-target strategy for knee osteoarthritis. International technical expert panel consensus and good clinical practice statements.

BACKGROUND: In this work, we aimed to establish a clinical target in the management of knee osteoarthritis (KOA) and to propose good clinical practice (GCP) statements for carrying out a treat-to-target strategy. METHODS: A steering committee of seven experts had formulated a provisional set of recommendations that were exposed for discussion and modification to a technical expert panel (TEP) of 25 multidisciplinary experts from Europe, North America, South America and Asia. The level of evidence and strength of each recommendation was discussed. The TEP formulated overarching principles and GCP statements based on the level of agreement for each item with a vote using a 10-point numerical scale. RESULTS: Two overarching principles and 10 GCP statements were formulated by the TEP. These GCP statements suggest: treatment should achieve clinical improvement bringing the patient to the Patient Acceptable Symptom State (PASS); pharmacological and nonpharmacological treatment should begin as early as possible, with an early diagnosis of symptomatic KOA; the patient should be evaluated every 3-6 months; risk factors of KOA progression should be identified and managed with patients at the beginning of the treatment and monitored regularly; treatment should be adapted according to patient phenotype and disease severity; healthy lifestyle must be promoted and monitored. The level of agreement average ranged from 8.7 to 9.6 on scale. CONCLUSIONS: The proposed overarching principles and GCP statements have the aim of involving patients, general practitioners and multidisciplinary specialists in sharing a therapeutic treat-to-target strategy for KOA management based on the best evidence and expert opinions.

Lessons Learned in the Implementation of HealtheSteps: An Evidence-Based Healthy Lifestyle Program.

HealtheSteps is a pragmatic, evidence-based lifestyle prescription program aimed at reducing the rates of chronic disease, in particular, type 2 diabetes. A process evaluation was completed to assess the feasibility of the implementation of HealtheSteps in primary care and community-based settings across Canada. Key informant interviews (program providers and participants) were conducted to identify facilitators and barriers to implementation and opportunities for future program adaptation and improvement. Forty-three interviews were conducted across five regions in Canada (15 sites ranging from remote, rural, suburban, and urban). Transcripts were analyzed using a qualitative naturalistic inquiry approach with several facilitating factors identified: pragmatic program design, in-line goals with sites' mandates, and access to ongoing support. Barriers were related to administrative challenges such as booking space, personnel changeovers, and scheduling participants. Findings from this analysis revealed insights on program delivery, design, and importance of site champions. Key lessons learned focused on two areas: infrastructure support and program implementation. The application of these learnings from the HealtheSteps program may inform the development of strategies that can optimize program adaptation and support while reducing real and perceived barriers experienced, thus increasing the success of translation of the evidence-based diabetes program to different points of care.