Pharmacoinformatics-enabled Interventions Improved Care Coordination and Identified Pharmacy-Related Safety Issues in a Multicultural Medicare Population.

BACKGROUND: Compared to White populations, multicultural older adults experience more gaps in preventive care (e.g., vaccinations, screenings, chronic condition monitoring), social determinants of health barriers (e.g., access to care, language, transportation), and disparities and inequities (e.g., comorbidities, disease burden, and health care costs). OBJECTIVES: This study aims to describe an informatics-based approach used to execute and evaluate results of a member-centric, pharmacoinformatics-informed engagement program to deliver culturally tailored microinterventions to close medication-related gaps in care utilizing multidisciplinary care coordination that leverages the expanded role of the pharmacist. The operational framework will be described, and the influence of the medication use processes will be reported in a multicultural Medicare Advantage cohort. METHODS: A pharmacoinformatics framework was leveraged to conduct a retrospective, observational cohort analysis of the program. Claims data were used to evaluate the influence of medication use process microinterventions from a large Medicare Advantage cohort of members who self-identify as Black and/or Hispanic, and have type 2 diabetes mellitus and/or hypertension, and meet eligibility criteria for multidisciplinary (e.g., nursing and pharmacy) care management (CM) and received pharmacy referral from January 1, 2022, through September 30, 2023. RESULTS: A total of 3,265 Medicare Advantage members (78.3% Black and 21.7% Hispanic) received CM and pharmacy referral. Pharmacovigilance reviews conducted during this timeframe identified 258 acute events that escalated member CM. Provider outreach (n = 185) informed of safety issues (drug duplication, n = 48; drug interactions, n = 21; drug-disease interactions, n = 5; noncompliance and/or dosing issues, n = 27). Outreach to members (n = 160) and providers (n = 164) informed of open quality-related measure gaps for medication adherence. CONCLUSION: The application of pharmacoinformatics by a payor-led multicultural clinical program demonstrated quality improvements in Medicare Advantage member identification including risk stratification, timely outreach for pharmacy-related safety issues, and improved efficiency of multidisciplinary care coordination involving medication use process workflows.

Reliability and Time Course of Postexercise Hypotension during Exercise Training among Adults with Hypertension.

Postexercise hypotension (PEH), or the immediate decrease in blood pressure (BP) lasting for 24 h following an exercise bout, is well-established; however, the influence of exercise training on PEH dynamics is unknown. This study investigated the reliability and time course of change of PEH during exercise training among adults with hypertension. PEH responders (n = 10) underwent 12 weeks of aerobic exercise training, 40 min/session at moderate-to-vigorous intensity for 3 d/weeks. Self-measured BP was used to calculate PEH before and for 10 min after each session. The intraclass correlation coefficient (ICC) and Akaike Information Criterion (AIC) determined PEH reliability and goodness-of-fit for each week, respectively. Participants were obese (30.6 ± 4.3 kg∙m-2), middle-aged (57.2 ± 10.5 years), and mostly men (60%) with stage I hypertension (136.5 ± 12.1/83.4 ± 6.7 mmHg). Exercise training adherence was 90.6 ± 11.8% with 32.6 ± 4.2 sessions completed. PEH occurred in 89.7 ± 8.3% of these sessions with BP reductions of 9.3 ± 13.1/3.2 ± 6.8 mmHg. PEH reliability was moderate (ICC ~0.6). AIC analysis revealed a stabilization of maximal systolic and diastolic BP reductions at 3 weeks and 10 weeks, respectively. PEH persisted throughout exercise training at clinically meaningful levels, suggesting that the antihypertensive effects of exercise training may be largely due to PEH. Further studies in larger samples and under ambulatory conditions are needed to confirm these novel findings.

Comprehensiveness, Accuracy, and Readability of Exercise Recommendations Provided by an AI-Based Chatbot: Mixed Methods Study.

BACKGROUND: Regular physical activity is critical for health and disease prevention. Yet, health care providers and patients face barriers to implement evidence-based lifestyle recommendations. The potential to augment care with the increased availability of artificial intelligence (AI) technologies is limitless; however, the suitability of AI-generated exercise recommendations has yet to be explored. OBJECTIVE: The purpose of this study was to assess the comprehensiveness, accuracy, and readability of individualized exercise recommendations generated by a novel AI chatbot. METHODS: A coding scheme was developed to score AI-generated exercise recommendations across ten categories informed by gold-standard exercise recommendations, including (1) health condition-specific benefits of exercise, (2) exercise preparticipation health screening, (3) frequency, (4) intensity, (5) time, (6) type, (7) volume, (8) progression, (9) special considerations, and (10) references to the primary literature. The AI chatbot was prompted to provide individualized exercise recommendations for 26 clinical populations using an open-source application programming interface. Two independent reviewers coded AI-generated content for each category and calculated comprehensiveness (%) and factual accuracy (%) on a scale of 0%-100%. Readability was assessed using the Flesch-Kincaid formula. Qualitative analysis identified and categorized themes from AI-generated output. RESULTS: AI-generated exercise recommendations were 41.2% (107/260) comprehensive and 90.7% (146/161) accurate, with the majority (8/15, 53%) of inaccuracy related to the need for exercise preparticipation medical clearance. Average readability level of AI-generated exercise recommendations was at the college level (mean 13.7, SD 1.7), with an average Flesch reading ease score of 31.1 (SD 7.7). Several recurring themes and observations of AI-generated output included concern for liability and safety, preference for aerobic exercise, and potential bias and direct discrimination against certain age-based populations and individuals with disabilities. CONCLUSIONS: There were notable gaps in the comprehensiveness, accuracy, and readability of AI-generated exercise recommendations. Exercise and health care professionals should be aware of these limitations when using and endorsing AI-based technologies as a tool to support lifestyle change involving exercise.

Cardiometabolic Biomarkers and Habitual Caffeine Consumption Associate with the Adverse Ambulatory Blood Pressure Response to Strenuous Physical Exertion among Firefighters.

Caffeine has beneficial effects on firefighter job performance reducing fatigue and improving psychomotor vigilance. However, excessive caffeine intake may raise blood pressure (BP) following a bout of acute exercise among adults with elevated BP. The influence of caffeine intake on the ambulatory BP (ABP) response to vigorous physical exertion among firefighters has not been studied. In this sub-study we conducted secondary statistical analyses from a larger clinical trial (NCT04514354) that included examining the influence of habitual caffeine intake, and cardiometabolic biomarkers shown to influence BP, on the ABP response following a bout of sudden vigorous exertion over 19 h among firefighters. Previously, we found high amounts of calcium and sodium intake raised BP following a bout of acute exercise among adults with elevated BP. Thus, other secondary aims were to examine the influence of habitual calcium and sodium intake, and cardiometabolic biomarkers have shown to influence BP, on the ABP response following sudden vigorous exertion over 19 h among firefighters. Firefighters (n = 15) completed a Food-Frequency Questionnaire assessing habitual dietary intake over the past year. They randomly completed a maximal graded exercise stress test (GEST) and non-exercise CONTROL on separate non-workdays leaving the laboratory wearing an ABP monitor for 19 h. Prior to and immediately after the GEST, fasting venous blood was collected to measure lipid-lipoproteins, c-reactive protein, and blood glucose. Height and weight were taken to calculate body mass index. Repeated measures ANCOVA tested if the ABP response differed after GEST vs. CONTROL. Linear mixed models examined the relationships among caffeine, calcium, sodium, cardiometabolic biomarkers, and the ABP response following GEST vs. CONTROL. Firefighters were middle-aged (40.2 ± 9.5 year), overweight (29.0 ± 3.9 kg/m2) men with elevated BP (124.1 ± 10.3/79.6 ± 11.5 mmHg) who consumed 542.0 ± 348.9 mg of caffeine/day, about ~50% more than the dietary reference intake. Unexpectedly, systolic ABP was higher by 18.0 ± 6.7 mmHg and diastolic ABP by 9.1 ± 5.4 mmHg (ps < 0.01) over 19 h following GEST vs. CONTROL. We found 24% of the variance in the adverse ABP response to maximal physical exertion was explained by caffeine intake, and when combined with c-reactive protein, non-high-density lipoprotein-cholesterol, body mass index, blood glucose, and resting heart rate, up to 74% of the variability in the ABP response was explained. Additionally, we found calcium (ps < 0.001) and sodium (p < 0.0001) intake each explained up to 24% of the ABP response. Further investigation is needed in a larger, more diverse sample of firefighters to better establish how caffeine contributes to the adverse BP response to strenuous physical exertion.

Venous thromboemboli associated with acute aerobic exercise: A review of case report commonalities.

Venous thromboembolic (VTE) events such as deep vein thrombosis (DVT) and pulmonary embolism (PE) have been reported in otherwise low-risk healthy athletes following acute bouts of aerobic exercise. PURPOSE: To review case reports and assess the commonalities of athletic individuals with VTE, as well as return-to-play (RTP) recommendations. METHODS: We reviewed 47 reports (20 DVTs, 15 PEs, and 12 DVTs/PEs, 19 women) of trained individuals who were diagnosed with DVT and/or PE following aerobic exercise. We assessed frequency of VTE risk factors, presenting symptoms, and RTP recommendations. RESULTS: The age of women (24.6 ± 7.0 years) was lower (P < .01) than of men (40.6 ± 13.6 years). Of the 19 women, 14 (73.7%) used oral contraceptives. Thirteen cases (27.7%) reported a recent period of prolonged inactivity (>1 hour), and another 12 cases were found to have an antithrombin disorder following testing after diagnosis. The most frequently reported symptoms were muscle pain in 26 of 32 (81.3%) DVT or DVT/PE cases, and dyspnea in 21 of 27 (77.8%) PE or DVT/PE cases. Despite these common symptoms, the estimated time from first report of symptoms to confirmed diagnosis was 56.3 ± 118.7 days and 25 cases (53.2%) were initially misdiagnosed. Twenty-three cases (48.9%) did not report RTP recommendations, and those which did varied widely. CONCLUSIONS: Thirty-two cases (~70%) had at least one of three major risk factors, suggesting that many cases of VTE in athletes may be preventable with better education and awareness. The wide variety of RTP recommendations highlights the need for standardized guidelines in this population.

Links between discrimination and cardiovascular health among socially stigmatized groups: A systematic review.

BACKGROUND: There is a high prevalence of cardiovascular disease across diverse groups in the U.S. population, and increasing research has identified stigma as a potential barrier to cardiovascular disease prevention and treatment. This systematic review examines evidence linking discrimination and cardiovascular health among socially stigmatized groups. STUDY DESIGN: Six databases were systematically reviewed from inception through February 2018 for studies with adult subjects, focusing on cardiovascular health indicators among social groups stigmatized because of their gender, race/ethnicity, age, body weight/obesity, or sexual orientation. The Newcastle-Ottawa Scale was used to evaluate the methodological quality and risk of bias for nonrandomized studies, and the Cochrane Collaboration 7-item domain for randomized controlled and experimental trials. RESULTS: The search identified 84 eligible studies published between 1984 and 2017. Studies retrieved were categorized according to demonstrated links between stigma and cardiovascular disease risk factors including blood pressure (n = 45), heart rate variability (n = 6), blood/saliva cardiovascular biomarkers (n = 18), as well as other indicators of cardiovascular health (n = 15). Based on the findings from included studies, 86% concluded that there was a significant relationship among stigma or discrimination and cardiovascular health indicators among socially stigmatized groups. However, there were varying degrees of evidence supporting these relationships, depending on the type of discrimination and cardiovascular health indicator. The current evidence implies an association between perceived discrimination and cardiovascular health. However, a majority of these studies are cross-sectional (73%) and focus on racial discrimination (79%), while using a wide variety of measurements to assess social discrimination and cardiovascular health. CONCLUSIONS: Future research should include longitudinal and randomized controlled trial designs, with larger and more diverse samples of individuals with stigmatized identities, using consistent measurement approaches to assess social discrimination and its relationship with cardiovascular health.

Using the immediate blood pressure benefits of exercise to improve exercise adherence among adults with hypertension: a randomized clinical trial.

BACKGROUND: A single exercise session evokes immediate blood pressure (BP) reductions that persist for at least 24 h, termed postexercise hypotension (PEH). Self-monitoring of PEH may foster positive outcome expectations of exercise, and thus, enhance exercise adherence among adults with hypertension. PURPOSE: To compare the efficacy of self-monitoring of exercise (EXERCISE) versus exercise and PEH (EXERCISE + PEH) to improve exercise adherence and BP control among adults with hypertension. METHODS: Adults with high BP were randomized to EXERCISE (n = 12) or EXERCISE + PEH (n = 12). Participants underwent supervised, moderate intensity aerobic exercise training for 40-50 min/session, 3 days/week for 12 weeks and encouraged to exercise unsupervised at home at least 30 min/day, 1-2 days/week. EXERCISE + PEH also self-monitored BP before and after exercise. Adherence was calculated as [(no. of exercise sessions performed/no. of possible exercise sessions) × 100%]. BP was measured pre and posttraining. RESULTS: Healthy, middle-aged (52.3 ±â€Š10.8 years) men (n = 11) and women (n = 13) with hypertension (136.2 ±â€Š10.7/85.2 ±â€Š8.9 mmHg) completed exercise training with 87.9 ±â€Š12.1% adherence. EXERCISE + PEH demonstrated greater adherence to supervised training (94.3 ±â€Š6.6%) than EXERCISE (81.6 ±â€Š13.2%; P = 0.007). EXERCISE + PEH performed 32.6 ±â€Š22.5 min/week more unsupervised home exercise than EXERCISE (P = 0.004), resulting in greater exercise adherence (107.3 ±â€Š18.7%) than EXERCISE (82.7 ±â€Š12.2%; P = 0.002). Post versus pretraining BP was reduced -7.4 ±â€Š11.3/-4.9 ±â€Š9.9 mmHg (P < 0.025) with no statistical difference between EXERCISE (-5.2 ±â€Š13.3/-3.6 ±â€Š6.1 mmHg) and EXERCISE + PEH (-9.9 ±â€Š11.3/-6.1 ±â€Š6.9 mmHg; P > 0.344). CONCLUSION: The current study is the first to demonstrate that PEH self-monitoring is an efficacious tool to improve exercise adherence among a small sample of adults with hypertension. Future research among a larger, more diverse sample is needed to confirm these novel findings and determine whether EXERCISE + PEH translates to better BP control relative to EXERCISE self-monitoring alone.

The Influence of Compression Socks During a Marathon on Exercise-Associated Muscle Damage.

CONTEXT: Compression socks have become increasingly popular with athletes due to perceived enhancement of exercise performance and recovery. However, research examining the efficacy of compression socks to reduce exercise-associated muscle damage has been equivocal, with few direct measurements of markers of muscle damage. OBJECTIVE: To examine the influence of compression socks worn during a marathon on creatine kinase (CK) levels. DESIGN: A randomized controlled trial. SETTING: 2013 Hartford Marathon, Hartford, CT. PARTICIPANTS: Adults (n = 20) randomized to control (CONTROL; n = 10) or compression sock (SOCK; n = 10) groups. MAIN OUTCOME MEASURES: Blood samples were collected 24 hours before, immediately after, and 24 hours following the marathon for the analysis of CK, a marker of muscle damage. RESULTS: Baseline CK levels did not differ between CONTROL (89.3 [41.2] U/L) and SOCK (100.0 [56.2] U/L) (P = .63). Immediately following the marathon (≤1 h), CK increased 273% from baseline (P < .001 for time), with no difference in exercise-induced changes in CK from baseline between CONTROL (+293.9 [278.2] U/L) and SOCK (+233.1 [225.3] U/L; P = .60 for time × group). The day following the marathon (≤24 h), CK further increased 1094% from baseline (P < .001 for time), with no difference in changes in CK from baseline between CONTROL (+ 1191.9 [1194.8] U/L) and SOCK (+889.1 [760.2] U/L; P = .53 for time × group). These similar trends persisted despite controlling for potential covariates such as age, body mass index, and race finishing time (Ps > .29). CONCLUSIONS: Compression socks worn during a marathon do not appear to mitigate objectively measured markers of muscle damage immediately following and 24 hours after a marathon.

Coenzyme Q10 as Treatment for Statin-Associated Muscle Symptoms-A Good Idea, but .

3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are extremely well tolerated but are associated with a range of mild-to-moderate statin-associated muscle symptoms (SAMS). Estimates of SAMS incidence vary from <1% in industry-funded clinical trials to 10-25% in nonindustry-funded clinical trials and ∼60% in some observational studies. SAMS are important because they result in dose reduction or discontinuation of these life-saving medications, accompanied by higher healthcare costs and cardiac events. The mechanisms that produce SAMS are not clearly defined. Statins block the production of farnesyl pyrophosphate, an intermediate in the mevalonate pathway, which is responsible for the production of coenzyme Q10 (CoQ10). This knowledge has prompted the hypothesis that reductions in plasma CoQ10 concentrations contribute to SAMS. Consequently, CoQ10 is popular as a form of adjuvant therapy for the treatment of SAMS. However, the data evaluating the efficacy of CoQ10 supplementation has been equivocal, with some, but not all, studies suggesting that CoQ10 supplementation mitigates muscular complaints. This review discusses the rationale for using CoQ10 in SAMS, the results of CoQ10 clinical trials, the suggested management of SAMS, and the lessons learned about CoQ10 treatment of this problem.

The influence of resting blood pressure on muscle strength in healthy adults.

Adverse alterations in the skeletal muscle response to exercise have been noted among adults with hypertension. The influence of resting blood pressure (BP) on muscle strength is unknown. We hypothesized that adults with high BP would exhibit lower muscular strength than adults with normal BP. An isokinetic dynamometer tested 21 measures of isometric and isokinetic muscle strength. BP was measured by auscultation. Patients were categorized into having normal (<120 and <80 mmHg) or high (≥120 and/or ≥80 mmHg) BP. Height (cm) and weight (kg) were measured to calculate BMI (kg/m). Analysis of covariance tested differences in muscle strength between BP groups with sex, age, and height as covariates. Patients [420 (49%) men] were middle-aged (44.1±16.1 years) and overweight (26.4±4.8 kg/m) with 187 having normal (107.7±7.3/68.3±6.3 mmHg) and 233 having high (127.8±9.8/80.8±8.1 mmHg) BP. For upper body, three of five extension measures and five of five flexion measures, as well as handgrip, were greater in the high than the normal BP group (P≤0.05). For lower body, five of five extension measures were greater in the high than the normal BP group, whereas there were no differences between BP groups for the five flexion measures (P>0.05). Contrary to our hypothesis, adults with high BP displayed greater muscle strength than adults with normal BP. Reasons for our findings are unclear, but may be because of shifts in muscle fiber type from type I to type IIb/x and oxidative to glycolytic metabolism; alterations may result in a more strength-adapted phenotype among adults with high BP such as we observed.

The effect of high-dose atorvastatin on neural activity and cognitive function.

BACKGROUND: Functional magnetic resonance imaging (fMRI) has not been used to assess the effects of statins on the brain. We assessed the effect of statins on cognition using standard neuropsychological assessments and brain neural activation with fMRI on two tasks. METHODS: Healthy statin-naïve men and women (48±15 years) were randomized to 80 mg/day atorvastatin (n=66; 27 men) or placebo (n=84; 48 men) for 6 months. Participants completed cognitive testing while on study drug and 2 months after treatment cessation using alternative test and task versions. RESULTS: There were few changes in standard neuropsychological tests with drug treatment (all P>.56). Total and delayed recall from the Hopkins Verbal Learning Test-Revised increased in both groups (P<.05). The Stroop Color-Word score increased (P<.01) and the 18-Point Clock Test decreased in the placebo group (P=.02) after drug cessation. There were, however, small but significant group-time interactions for each fMRI task: participants on placebo had greater activation in the right putamen/dorsal striatum during the maintenance phase of the Sternberg task while on placebo but the effect was reversed after drug washout (P<.001). Participants on atorvastatin had greater activation in the bilateral precuneus during the encoding phase of the Figural Memory task while on-drug but the effect was reversed after drug washout (P<.001). CONCLUSION: Six months of high dose atorvastatin therapy is not associated with measurable changes in neuropsychological test scores, but did evoke transient differences in brain activation patterns. Larger, longer-term clinical trials are necessary to confirm these findings and evaluate their clinical implications.

Can Exercise Improve Cognitive Symptoms of Alzheimer's Disease?

OBJECTIVES: To examine the effects of exercise training on cognitive function in individuals at risk of or diagnosed with Alzheimer's disease (AD). DESIGN: Meta-analysis. SETTING: PubMed, Scopus, ClinicalTrials.gov, and ProQuest were searched from inception until August 1, 2017. PARTICIPANTS: Nineteen studies with 23 interventions including 1,145 subjects with a mean age of 77.0 ± 7.5 were included. Most subjects were at risk of AD because they had mild cognitive impairment (64%) or a parent diagnosed with AD (1%), and 35% presented with AD. INTERVENTION: Controlled studies that included an exercise-only intervention and a nondiet, nonexercise control group and reported pre- and post-intervention cognitive function measurements. MEASUREMENTS: Cognitive function before and after the intervention and features of the exercise intervention. RESULTS: Exercise interventions were performed 3.4 ± 1.4 days per week at moderate intensity (3.7 ± 0.6 metabolic equivalents) for 45.2 ± 17.0 minutes per session for 18.6 ± 10.0 weeks and consisted primarily of aerobic exercise (65%). Overall, there was a modest favorable effect of exercise on cognitive function (d+  = 0.47, 95% confidence interval (CI) = 0.26-0.68). Within-group analyses revealed that exercise improved cognitive function (d+w  = 0.20, 95% CI  = 0.11-0.28), whereas cognitive function declined in the control group (d+w  = -0.18, 95% CI  = -0.36 to 0.00). Aerobic exercise had a moderate favorable effect on cognitive function (d+w  = 0.65, 95% CI = 0.35-0.95), but other exercise types did not (d+w  = 0.19, 95% CI = -0.06-0.43). CONCLUSION: Our findings suggest that exercise training may delay the decline in cognitive function that occurs in individuals who are at risk of or have AD, with aerobic exercise possibly having the most favorable effect. Additional randomized controlled clinical trials that include objective measurements of cognitive function are needed to confirm our findings.

Compression Socks Worn During Flight and Hemostatic Balance in Boston Marathon Runners on Oral Contraceptives.

OBJECTIVE: To investigate the effect of oral contraceptive (OC) use and compression socks on hemostatic activation in women flying cross-country to and from a marathon. DESIGN: Prospective study. SETTING: 2015 Boston Marathon. PARTICIPANTS: Women were divided into non-OC using (CONTROL; n = 12), OC-using (OC; n = 15), and OC-using plus compression sock (OC + SOCK; n = 14) groups. INTERVENTION: Women in OC + SOCK wore compression socks during flights to and from the marathon. MAIN OUTCOME MEASURES: Venous blood samples were collected within 24 hours of arriving in Boston (EXPO), immediately after the marathon (RUN), and within 24 hours after a return flight home (Post-Flight) for analysis of thrombin-antithrombin complex (TAT), d-dimer, and tissue plasminogen activator (t-PA). RESULTS: TAT did not increase with exercise (P = 0.48) and was not affected by group (P = 0.08) or the interaction between these 2 factors (P = 0.80). Group, time, and their interaction were significant for d-dimer (all P < 0.05) such that d-dimer increased with acute exercise to a greater extent (Δ d-dimer from expo to postrace = 909.5 ± 1021.9 ng/mL) in the OC + SOCK group relative to OC (Δ d-dimer = 240.0 ± 178.5 ng/mL; P = 0.02) and CONTROL (Δ d-dimer = 230.3 ± 120.3 ng/mL; P = 0.02). There was a significant effect of time, group, and the interaction on t-PA (all P < 0.01) such that t-PA increased with acute exercise to a greater extent (Δ t-PA from expo to postrace = 19.6 ± 10.0 ng/mL) in the CONTROL group relative to OC (Δ t-PA = 4.0 ± 1.8 ng/mL; P < 0.01) and OC + SOCK (Δ t-PA = 3.3 ± 1.2 ng/mL; P < 0.01). CONCLUSIONS: Female runners using OCs did not exhibit disproportionately increased coagulation. The use of compression socks in women on OCs, surprisingly, resulted in a greater increase in d-dimer after exercise.

Performance of wells score to predict deep vein thrombosis and pulmonary embolism in endurance athletes.

INTRODUCTION: There are an increasing number of reports describing deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in otherwise healthy endurance athletes. The Wells score is the most commonly used clinical prediction rule to diagnose DVT/PE in clinical populations. However, the Wells score may have limited utility for recognition of DVT/PE in athletes, contributing to missed or delayed diagnosis. OBJECTIVE: We performed an analysis of the ability of the Wells score to identify DVT/PE events in athletes through a review of published case reports. METHODS: A systematic search of the literature yielded 11 case reports. RESULTS: The Wells score had a 100% failure rate in identifying athletes with DVT (0/6) and PE (0/5), resulting in a delayed diagnosis for DVT of 20 ± 14 days. Retrospectively removing 'differential diagnosis' from the clinical prediction rule for DVT changed the Wells score median from 0 (range: -1 to 0) to 2 (range: 1 to 2); the threshold for predicting DVT as 'likely'. There were limited clinical characteristics captured in the Wells score for PE that were applicable to athletes, highlighting the need for reappraisal. Although the Wells score failed to accurately triage athletes with known DVT and/or PE, the addition of a D-dimer value (mean: 1566 ± 758ng/dL) to the Wells score correctly identified 9/9 athletes. CONCLUSIONS: The Wells score had a 100% failure rate for triaging athletes with known DVT/PE. When performed, D-dimer adequately facilitated the additional diagnostic testing required for a timely diagnosis of DVT/PE in athletes. Improving awareness of an atypical presentation of thrombotic events in athletes may reduce the widespread underestimation of DVT/PE among athletes and facilitate the additional testing required for a timely diagnosis.

Small Sample Sizes Confound Understanding of Cardiometabolic Responses to Exercise.

Considerable variability exists in the cardiometabolic disease biomarker response to exercise. We propose that a major contributor to this heterogeneity is underpowered studies due to small sample sizes. To test our hypothesis, we conducted a systematic review to identify meta-analyses/reviews of randomized controlled trials (RCT) and RCT that examined the cardiometabolic disease biomarker response to aerobic and resistance exercise.

The antihypertensive effects of aerobic versus isometric handgrip resistance exercise.

BACKGROUND: Aerobic exercise reduces blood pressure (BP) on average 5-7 mmHg among those with hypertension; limited evidence suggests similar or even greater BP benefits may result from isometric handgrip (IHG) resistance exercise. METHOD: We conducted a randomized controlled trial investigating the antihypertensive effects of an acute bout of aerobic compared with IHG exercise in the same individuals. Middle-aged adults (n = 27) with prehypertension and obesity randomly completed three experiments: aerobic (60% peak oxygen uptake, 30 min); IHG (30% maximum voluntary contraction, 4 × 2 min bilateral); and nonexercise control. Study participants were assessed for carotid-femoral pulse wave velocity pre and post exercise, and left the laboratory wearing an ambulatory BP monitor. RESULTS: SBP and DBP were lower after aerobic versus IHG (4.8 ±â€Š1.8/3.1 ±â€Š1.3 mmHg, P = 0.01/0.04) and control (5.6 ±â€Š1.8/3.6 ±â€Š1.3 mmHg, P = 0.02/0.04) over the awake hours, with no difference between IHG versus control (P = 0.80/0.83). Pulse wave velocity changes following acute exercise did not differ by modality (aerobic increased 0.01 ±â€Š0.21 ms, IHG decreased 0.06 ±â€Š0.15 ms, control increased 0.25 ±â€Š0.17 ms, P > 0.05). A subset of participants then completed either 8 weeks of aerobic or IHG training. Awake SBP was lower after versus before aerobic training (7.6 ±â€Š3.1 mmHg, P = 0.02), whereas sleep DBP was higher after IHG training (7.7 ±â€Š2.3 mmHg, P = 0.02). CONCLUSION: Our findings did not support IHG as antihypertensive therapy but that aerobic exercise should continue to be recommended as the primary exercise modality for its immediate and sustained BP benefits.

Influence of Baseline Psychological Health on Muscle Pain During Atorvastatin Treatment.

BACKGROUND: 3-hydroxy-3-methylglutaryl coenzyme A reductase reductase inhibitors (statins) are generally well tolerated, with statin-associated muscle symptoms (SAMS) the most common side effect (~10%) seen in statin users. However, studies and clinical observations indicate that many of the self-reported SAMS appear to be nonspecific (ie, potentially not attributable to statins). OBJECTIVE: Mental health and well-being influence self-perception of pain, so we sought to assess the effect of baseline well-being and depression on the development of muscle pain with 6 months of atorvastatin 80 mg/d (ATORVA) or placebo in healthy, statin-naive adults. METHODS: The Psychological General Well-being Index (n = 83) and Beck Depression Inventory (n = 55) questionnaires were administered at baseline in participants (aged 59.5 ± 1.2 years) from the effect of Statins on Skeletal Muscle Function and Performance (STOMP) trial (NCT00609063). Muscle pain (Short-Form McGill Pain Questionnaire [SF-MPQ]), pain that interferes with daily life (Brief Pain Inventory [BPI]), and pain severity (BPI) were then measured before, throughout, and after treatment. RESULTS: At baseline, there were no differences in well-being (Psychological General Well-being Index), depression (Beck Depression Inventory), or pain measures (SF-MPQ and BPI) (P values ≥ .05) between the placebo and ATORVA groups. Baseline well-being correlated negatively with baseline BPI pain severity (r = -0.290, P = .008). Baseline depression correlated with baseline pain (SF-MPQ; r = 0.314, P = .020). Baseline well-being and depression did not predict the change in pain severity or interference after 6 months among the total sample or between groups (P values ≥ .05). CONCLUSION: Baseline well-being and depression were not significant predictors of pain after 6 months of ATORVA (P values ≥ .05). Thus, they do not appear to increase the risk of SAMS in otherwise healthy adults.

Coming of Age: Considerations in the Prescription of Exercise for Older Adults.

Older adults represent the fastest-growing age demographic of the population. Physiological changes associated with primary aging and concurrent chronic disease adversely impact functional capacity, health outcomes, and quality of life. For these reasons, there is a national emphasis for healthcare providers to improve the health, function, and quality of life of older adults to preserve independent living and psychological well-being. The benefits of regular physical activity or exercise with regard to aging and disease are indisputable, yet many clinicians do not prescribe exercise to older adults. This reluctance may be attributable to a lack of knowledge regarding appropriate exercise prescription for older adults in light of the potential risks and benefits of various doses and types of exercise. In addition, clinicians and patients may have concerns about potential health considerations relevant to older adults such as comprehensive pre-exercise screening and exercise-drug interactions. In light of this, the following review presents (1) guidelines for exercise prescription in older adults and modification of these guidelines for patients with the most common age-associated comorbidities; (2) recommendations for pre-exercise screening prior to initiating an exercise program in older adults; (3) considerations for older adults on one or more medications; and (4) common barriers to adopting and maintaining exercise in an older population. Our goal is to provide a framework that clinicians can follow when prescribing exercise in older adults while considering the unique characteristics and concerns present in this population.

Is Concurrent Training Efficacious Antihypertensive Therapy? A Meta-analysis.

: Aerobic exercise training and, to a lesser degree, dynamic resistance training, are recommended to lower blood pressure (BP) among adults with hypertension. Yet the combined influence of these exercise modalities, termed concurrent exercise training (CET), on resting BP is unclear. PURPOSE: This study aimed to meta-analyze the literature to determine the efficacy of CET as antihypertensive therapy. METHODS: Electronic databases were searched for trials that included the following: adults (>19 yr), controlled CET interventions, and BP measured pre- and postintervention. Study quality was assessed with a modified Downs and Black Checklist. Analyses incorporated random-effects assumptions. RESULTS: Sixty-eight trials yielded 76 interventions. Subjects (N = 4110) were middle- to older-age (55.8 ± 14.4 yr), were overweight (28.0 ± 3.6 kg·m), and had prehypertension (systolic BP [SBP]/diastolic BP [DBP] = 134.6 ± 10.9/80.7 ± 7.5 mm Hg). CET was performed at moderate intensity (aerobic = 55% maximal oxygen consumption, resistance = 60% one-repetition maximum), 2.9 ± 0.7 d·wk for 58.3 ± 20.1 min per session for 19.7 ± 17.8 wk. Studies were of moderate quality, satisfying 60.7% ± 9.4% of quality items. Overall, CET moderately reduced SBP (db = -0.32, 95% confidence interval [CI] = -0.44 to -0.20, -3.2 mm Hg) and DBP (db = -0.35, 95% CI = -0.47 to -0.22, -2.5 mm Hg) versus control (P < 0.01). However, greater SBP/DBP reductions were observed among samples with hypertension in trials of higher study quality that also examined BP as the primary outcome (-9.2 mm Hg [95% CI = -12.0 to -8.0]/-7.7 mm Hg [95% CI = -14.0 to -8.0]). CONCLUSIONS: Among samples with hypertension in trials of higher study quality, CET rivals aerobic exercise training as antihypertensive therapy. Because of the moderate quality of this literature, additional randomized controlled CET trials that examine BP as a primary outcome among samples with hypertension are warranted to confirm our promising findings.