Effects of Blood Flow Restriction Resistance Training on Autonomic and Endothelial Function in Persons with Parkinson's Disease.

Background: Autonomic dysfunction precedes endothelial dysfunction in Parkinson's disease (PD) and causes blood pressure and circulation abnormalities that are highly disruptive to one's quality of life. While exercise interventions have proven helpful for motor symptoms of PD, improving associated non-motor symptoms is limited. Low-intensity resistance training with blood flow restriction (LIRT-BFR) improves autonomic dysfunction in non-PD patients and high-intensity resistance training (HIRT) is recommended for motor symptom improvements for people with PD (PwPD). Objective: To determine the effects of LIRT-BFR and HIRT on homocysteine and autonomic and endothelial function in PwPD and to determine the hemodynamic loads during LIRT-BFR and HIRT in PwPD using a novel exercise protocol. Methods: Thirty-eight PwPD were assigned LIRT-BFR, HIRT or to a control (CNTRL) group. The LIRT-BFR and HIRT groups exercised three days per week for four weeks. The LIRT-BFR protocol used 60% limb occlusion pressure (LOP) and performed three sets of 20 repetitions at 20% of the one-repetition maximum (1RM). The HIRT group performed three sets of eight repetitions at 80% 1RM. The CNTRL group was asked to continue their normal daily routines. Results: LIRT-BFR significantly improved orthostatic hypotension (p = 0.026), homocysteine levels (p < 0.001), peripheral circulation (p = 0.003), supine blood pressure (p = 0.028) and heart rate variability (p = 0.041); LIRT-BFR improved homocysteine levels (p < 0.018), peripheral circulation (p = 0.005), supine blood pressure (p = 0.007) and heart rate variability (p = 0.047) more than HIRT; and hemodynamic loads for LIRT-BFR and HIRT were similar. Conclusions: LIRT-BFR may be more effective than HIRT for autonomic and endothelial function improvements in PwPD and hemodynamic loads may be lessened in LIRT-BFR protocols using single-joint exercises with intermittent blood flow restriction. Further research is needed to determine if non-motor symptoms improve over time and if results are sustainable.

Acceptability and use of waist-worn physical activity monitors in Jamaican adolescents: lessons from the field.

OBJECTIVE: We report our experience with a validated waist-worn activity monitor in Jamaican adolescents attending urban high schools. Seventy-nine adolescents from the Global Diet and Activity Research (GDAR) study, recruited from 5 urban Jamaican high schools (two coeducational (n = 37), two all-female schools (n = 32) and one all-boys school (n = 10)) were asked to wear Actigraph wGT3X-BT accelerometers for 7 days (24-h), removing the device only when bathing or swimming. They also logged wake up and bed times in an activity diary. Accelerometry was considered valid if at least 4 days with ≥ 10-h monitor wear were recorded. Validity was compared by adolescent demographic and school characteristics. We also reviewed the students' written feedback on objective physical activity measurement. RESULTS: Participants, 80.5% female, had a mean age of 15.5 ± 0.8 years with 60% attending schools in low-income communities. Accelerometer return rates were > 98% with 84% providing valid data. Validity did not vary by age group, sex and school setting. While participants were excited about participating in the accelerometer sub-study, commonly reported challenges included monitor discomfort during sleep and maintaining the study diary. Objective measurement of physical activity using 24-h waist-worn accelerometers is feasible and acceptable in Jamaican adolescents.

Understanding the Role of Support in Digital Mental Health Programs With Older Adults: Users' Perspective and Mixed Methods Study.

BACKGROUND: Digital mental health interventions have the potential to increase mental health support among isolated older adults. However, the older adult population can experience several barriers to accessing and using digital health resources and may need extra support to experience its benefits. OBJECTIVE: This paper aimed to understand what older adults experience as an important aspect of support during engagement in a digital mental health program. The program entailed 3 months of staff support to participate in digital literacy training and engage with the digital mental health platform myStrength, which offers support for a range of mental health challenges, including depression and anxiety. METHODS: A total of 30 older adults participated in surveys and interviews to assess their experience of participating in a digital mental health program provided by county mental health services. As part of the program, participants attended 4 classes of digital literacy training, had access to the digital mental health platform myStrength for 2 months with staff support (and 10 months after the program without support), and received support from program staff during the entire 3-month program. Survey data were analyzed using descriptive statistics, and interview data were analyzed using thematic analysis. RESULTS: A thematic analysis of the interview data revealed that participants valued ongoing support in 3 main areas: technical support to assist them in using technology, guided support to remind them to use myStrength and practice skills they had learned, and social support to enable them to connect with others through the program. Furthermore, participants reported that social connections was the most important aspect of the program and that they were mainly motivated to participate in the program because it was recommended to them by trusted others such as a community partner or because they believed it could potentially help others. CONCLUSIONS: Our findings can be used to inform the design of future digital mental health programs for older adults who may have unique support needs in terms of dedicated technical support and ongoing guided support to use technology and social support to increase social connectedness.

Development of a position statement for Australian critical care nurse education.

Position statements are used by large organisations such as the Australian College of Critical Care Nurses to publically present an official philosophy or beliefs and to propose recommendations. Position statements are increasingly used by health departments and healthcare facilities to allocate resources and to guide and audit nursing practice, yet there are limited resources on the process of their development. A position statement should help readers better understand the issue, communicate solutions to problems, and inform decision-making. It should be supported by the highest level of evidence available and reflect the organisation's governing objectives and goals. In this article, we describe the structured approach used to develop a position statement for Australian critical care nurse education. The formation of an expert advisory panel, synthesis of available evidence using Whittemore and Knafl's integrative review methodology, use of Donabedian's structure-process-outcomes quality framework as a theoretical approach, and multiple layers of consensus building and consultation enabled the development of an important critical care document and informed an implementation plan. The framework and processes we have outlined in this discussion article may provide a useful starting point for other professional organisations wishing to develop similar position statements.

Structures, processes and outcomes of specialist critical care nurse education: An integrative review.

OBJECTIVES: The objective of this study was to review and synthesise international literature to reveal the contemporary structures, processes, and outcomes of critical care nurse (CCN) education. METHOD: An integrative review on specialist critical care education was guided by Whittemore and Knafl's integrative review steps: problem identification; literature search; and data evaluation, analysis, and presentation. Donabedian's Quality Framework (Structure-Process-Outcome) provided a useful analytical lens and structure for the reporting of findings. RESULTS: (1) Structures for CCN education incorporated transition-to-practice and ongoing education programs typically offered by hospitals and health services and university-level graduate certificate, diploma, and masters programs. Structural expectations included a standard core curriculum, clinically credible academic staff, and courses compliant with a higher education framework. Published workforce standards and policies were important structures for the practice learning environment. (2) Processes included incremental exposure to increasing patient acuity; consistent and appropriately supported and competent hospital-based preceptors/assessors; courses delivered with a flexible, modular approach; curricula that support nontechnical skills and patient- and family-centred care; stakeholder engagement between the education provider and the clinical setting to guide course planning, evaluation and revalidation; and evidence-based measurement of clinical capabilities/competence. (3) Outcomes included articulation of the scope and levels of graduate attributes and professional activities associated with each level. The role of higher degree research programs for knowledge creation and critical care academic leadership was noted. CONCLUSIONS: Provision of high-quality critical care education is multifaceted and complex. These findings provide information for healthcare organisations and education providers. This may enable best practice structures and processes for critical care specialist training that meets the needs of industry and safely supports developing CCN expertise. There is an acknowledged tension between the expectations of governing bodies for policies, standards, and position statements to enhance quality and reduce care variance and the availability of high-quality evidence to underpin these across international contexts.

Metastatic pleomorphic adenoma to the supraspinatus muscle: a case report and review of a rare aggressive clinical entity.

We report a case of a 65-year-old female with a recurrent right parotid pleomorphic adenoma (PA) 24 years after initial surgical excision. Positron-emission tomography (PET) and computed tomography (CT) demonstrated an unusual suspicious FDG-avid erosive rim enhancing mass centered in the right supraspinatus muscle. Cytology from CT-guided aspiration of the mass was consistent with a histologically benign PA, and the patient was diagnosed with metastatic pleomorphic adenoma (MPA). The patient later developed diffuse pulmonary metastases and died within 3 months. MPA, although rare, is recognised as a potentially lethal malignant complication of recurrent or longstanding benign PA. As no biochemical or genetic parameters are predictive of malignant change, patients presenting with recurrent PA should be considered for screening for metastatic disease.

Dietary supplementation with aromatic amino acids increases protein synthesis in children with severe acute malnutrition.

Although 2 earlier studies reported that aromatic amino acid (AAA) supplementation of children with severe acute malnutrition (SAM) improved whole-body protein anabolism during the early postadmission (maintenance) phase of rehabilitation, it is not known whether this positive effect was maintained during the catch-up growth and recovery phases of treatment. This study aimed to determine whether supplementation with an AAA cocktail (330 mg · kg(-1) · d(-1)) vs. isonitrogenous Ala would improve measures of protein kinetics in 22 children, aged 4-31 mo, during the catch-up growth and recovery phases of treatment for SAM. Protein kinetics were assessed by measuring leucine, phenylalanine, and urea kinetics with the use of standard stable isotope tracer methods in the fed state. Supplementation started at the end of the maintenance period when the children were clinically/metabolically stable and continued up to full nutritional recovery. Three experiments were performed: at the end of maintenance (at ∼13 d postadmission), at mid-catch-up growth (at ∼23 d post- admission when the children had replenished 50% of their weight deficit), and at recovery (at ∼48 d postadmission when they had achieved at least 90% weight for length). Children in the AAA group had significantly faster protein synthesis compared with those in the Ala group at mid-catch-up growth (101 ± 10 vs. 72 ± 7 µmol phenylalanine · kg(-1) · h(-1); P < 0.05) and better protein balance at mid-catch-up growth (49 ± 5 vs. 30 ± 2 µmol phenylalanine · kg(-1) · h(-1); P < 0.05) and at recovery (37 ± 8 vs. 11 ± 3 µmol phenylalanine · kg(-1) · h(-1); P < 0.05). We conclude that dietary supplementation with AAA accelerates net protein synthesis in children during nutritional rehabilitation for SAM.

Ditch blocking, water chemistry and organic carbon flux: evidence that blanket bog restoration reduces erosion and fluvial carbon loss.

The potential for restoration of peatlands to deliver benefits beyond habitat restoration is poorly understood. There may be impacts on discharge water quality, peat erosion, flow rates and flood risk, and nutrient fluxes. This study aimed to assess the impact of drain blocking, as a form of peatland restoration, on an upland blanket bog, by measuring water chemistry and colour, and loss of both dissolved (DOC) and particulate organic carbon (POC). The restoration work was designed to permit the collection of a robust experimental dataset over a landscape scale, with data covering up to 3 years pre-restoration and up to 3 years post-restoration. An information theoretic approach to data analyses provided evidence of a recovery of water chemistry towards more 'natural' conditions, and showed strong declines in the production of water colour. Drain blocking led to increases in the E4:E6 ratio, and declines in specific absorbance, suggesting that DOC released from blocked drains consisted of lighter, less humic and less decomposed carbon. Whilst concentrations of DOC showed slight increases in drains and streams after blocking, instantaneous yields of both DOC and POC declined markedly in streams over the first year post-restoration. Attempts were made to estimate total annual fluvial organic carbon fluxes for the study site, and although errors around these estimates remain considerable, there is strong evidence of a large reduction in aquatic organic carbon flux from the peatland following drain-blocking. Potential mechanisms for the observed changes in water chemistry and organic carbon release are discussed, and we highlight the need for more detailed information, from more sites, to better understand the full impacts of peatland restoration on carbon storage and release.

Visiting all hours: a focus group study on staff's views of open visiting in a hospice.

St Columba's Hospice, Edinburgh, is a busy specialist palliative care unit with 30 inpatient beds. A previous publication reported the first strand of a qualitative exploratory study evaluating the impact of open visiting on patients at the hospice. This paper reports on the second strand, which sought to elicit the views of the hospice staff through focus group interviews. The main themes identified were valuing the family and friends as visitors, involving the family as part of the care team, patient powerlessness over visiting, shared rooms and their impact on visitors and patients, and the staff role as advocates or gatekeepers. Several strategies for developing a flexible and 'patient-controlled' visiting policy were identified, including quiet times without visitors, restriction of visitor numbers in shared rooms, and encouraging breaks from visiting. Since the study was completed, the hospice's visiting policy has been modified to ensure that it is patient-centred and meets the needs of patients and families.

Early repeated 18F-FDG PET scans during neoadjuvant chemoradiation fail to predict histopathologic response or survival benefit in adenocarcinoma of the esophagus.

UNLABELLED: This study evaluated the role of (18)F-FDG PET as an early predictor of histopathologic response to neoadjuvant chemoradiotherapy and overall survival in patients with adenocarcinoma of the esophagus undergoing multimodal therapy. METHODS: Thirty-seven patients with locally advanced adenocarcinoma of the esophagus underwent pretreatment and an intratreatment (18)F-FDG PET scan in the second week of a 6-wk regimen of neoadjuvant chemoradiotherapy. Histopathologic response and overall survival were correlated with percentage change in (18)F-FDG uptake (%Δmaximum standardized uptake value [%ΔSUVmax]). RESULTS: In 16 patients (43%), treatment induced a histopathologic response (<10% viable tumor cells), which was associated with a significant (P < 0.05) survival benefit. The optimal reduction in (18)F-FDG uptake, which separated histopathologic responders and nonresponders, was a -26.4% ΔSUVmax (receiver-operating-characteristic curve analysis). At this separation, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy (area under the receiver operating characteristic curve) were 62.5%, 71.4%, 62.5%, 71.4%, and 67.4%, respectively, for intratreatment (18)F-FDG PET scans. Kaplan-Meier survival analysis of (18)F-FDG PET responders (>26.4% reduction in SUVmax), compared with (18)F-FDG PET nonresponders (<26.4% reduction in SUVmax), revealed no survival benefit for responders (P = 0.6812). CONCLUSION: The %ΔSUVmax during the second week of induction chemoradiation did not correlate either with histopathologic response or with survival. Our results show that, in contrast to published reports on neoadjuvant chemotherapy, combined chemoradiotherapy in patients with adenocarcinoma of the esophagus lowers the predictive accuracy of early repeated (18)F-FDG PET in identifying histopathologic responders and those with chances for increased survival below clinically applicable levels.

Clinical implication and prognostic significance of standardised uptake value of primary non-small cell lung cancer on positron emission tomography: analysis of 176 cases.

OBJECTIVE: We sought to assess the clinical implication and prognostic significance of maximum standardised uptake value (SUV(max)) of primary non-small cell lung cancer (NSCLC) staged by integrated PET-CT. METHODS: A retrospective review was carried out on 176 consecutive patients with histologically proven NSCLC who underwent staging with integrated PET-CT prior to curative intent surgical resection. SUV(max) of primary NSCLC were measured and correlated with tumour characteristics, lymph node involvement, surgical stage, type of surgical resection and survival following resection. RESULTS: SUV(max) was significantly higher in centrally located tumours, tumours > or =4.0 cm, squamous cell subtype, poorly differentiated tumours, advanced T stage, advanced nodal stage, pleural invasion, and patients requiring complex surgical resection. SUV(max) value of 15 was the best discriminative cut-off value for survival generated by log-rank test. When patients were stratified based on this value, those with SUV(max) >15 were more likely to have centrally located tumours, squamous cell subtype, advanced T stage, advanced nodal stage, advanced American Joint Committee on Cancer (AJCC) stage, larger tumour size and required more advanced surgical resections than a simple lobectomy. Overall survival was significantly longer for patients with SUV(max) < or =15 than those with SUV(max) >15. Furthermore, nodal stage specific survival following resection (i.e. non-N2 and N2) were significantly better in patients with SUV(max) < or =15 than SUV(max) >15. CONCLUSION: SUV(max) correlates with tumour characteristics, surgical stage and prognosis following resection. SUV(max) may be a useful preoperative tool, in addition to other known prognostic markers, in allocating patients with potentially poor prognosis preoperatively to neoadjuvant chemotherapy prior to resection in order to improve their overall survival. Prospective and randomised trials are warranted.

Mediastinal lymph node staging by means of positron emission tomography is less sensitive in elderly patients with non-small-cell lung cancer.

PURPOSE: We sought to identify the impact of age on the sensitivity and specificity of integrated positron emission tomography/computed tomography (PET-CT; CT) on mediastinal lymph node staging of patients with non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: We conducted a retrospective review of 206 consecutive patients with histologically proven NSCLC who underwent resection and/or mediastinoscopy in our center between September 2004 and January 2007. All of these patients had preoperative staging with integrated PET-CT as an adjunct to chest CT before resection and/or mediastinoscopy. Diabetic patients and patients who received neoadjuvant chemotherapy were excluded. The pathologic results of all of these cases were reviewed and correlated with those on CT and integrated PET-CT. RESULTS: The sensitivity and positive predictive values (PPV) of PET-CT in mediastinal nodal staging were significantly lower in elderly patients (age>or=65 years; sensitivity, 42%; PPV, 66%) than in younger patients (age<65 years; sensitivity, 52%; PPV, 74%). Specificity and negative predictive values were similar in both groups. CONCLUSION: PET-CT staging of the mediastinum is less sensitive in elderly patients with NSCLC who have a lower PPV. Positive mediastinal uptake on PET-CT should be verified by mediastinoscopy, irrespective of age. Elderly patients with positive mediastinal uptake should not be refuted a curative intent surgical resection on the basis of positive mediastinal uptake alone.

Pattern and predictors of occult mediastinal lymph node involvement in non-small cell lung cancer patients with negative mediastinal uptake on positron emission tomography.

OBJECTIVE: We sought to assess the incidence, pattern and predictors of occult mediastinal lymph node involvement (N2) in non-small cell lung cancer patients with negative mediastinal uptake of 2-deoxy-2-[(18)F]-fluoro-d-glucose ((18)FDG) on integrated positron emission tomography-computerised tomography (PET-CT). METHODS: All patients who underwent surgical resection in our unit over a 30-month period were reviewed (n=215). All patients had preoperative PET-CT prior to lung resection as an adjunct to a dedicated chest CT. Diabetic patients, patients who received neoadjuvant chemotherapy and those with positive mediastinal nodes on PET-CT (N2/N3) were excluded from this study. The population of interest was 153 non-small cell cancer patients (NSCLC), all of which had no FDG uptake in the mediastinum. No preoperative mediastinoscopy was carried out in this group and all underwent curative intent surgical resection. The pathological results were retrospectively reviewed and correlated with CT and integrated PET-CT findings. RESULTS: The incidence of occult N2 disease in NSCLC patients with negative mediastinal uptake of (18)FDG on PET-CT was 16% (25 of 153). The highest incidence of occult N2 involvement was in American thoracic society (ATS) 7 (16 of 25 patients, 64%) followed by ATS 4 (seven patients of 25, 28%). In univariate analysis, the following were significant predictors of occult N2 disease: centrally located tumours (P=0.049), right upper lobe tumours (P=0.04), enlarged lymph nodes (>1cm) on CT (P=0.048) and PET positive uptake in N1 nodes (P=0.006). In multivariate analysis, the following were independent predictors of occult N2 disease: centrally located tumours, right upper lobe tumours and PET positive uptake in N1 nodes (P<0.05). CONCLUSIONS: In NSCLC patients who are clinically staged as N2/N3 negative in the mediastinum by integrated PET-CT, 16% will have occult N2 disease following resection. Patients with the following: centrally located tumours, right upper lobe tumours and positive N1 nodes on PET should have preoperative cervical mediastinoscopy to rule out N2 nodal involvement, especially in ATS stations 7 and 4 as the incidence of occult nodal metastasis in these nodes is high. This study has potential implications in decision-making and planning best treatment approach.

Lymph node staging by means of positron emission tomography is less accurate in non-small cell lung cancer patients with enlarged lymph nodes: analysis of 1,145 lymph nodes.

BACKGROUND: Despite documented superiority of integrated positron emission tomography-computerized tomography (PET-CT) over computerized tomography (CT) in lymph node staging in non-small cell lung cancer, little is known about the sensitivity, specificity and accuracy of integrated PET-CT among enlarged lymph nodes. We sought to assess if PET-CT is uniformly accurate among enlarged and non-enlarged lymph nodes. METHODS: A retrospective review of 206 consecutive patients with histologically proven non-small cell lung cancer who underwent resection and/or mediastinoscopy in our centre over 30 months period was carried out. All these patients had pre-operative staging with integrated PET-CT as an adjunct to chest CT prior to resection and/or mediastinoscopy. Diabetic patients (BM>or=8.0 mmol/l) and those who received neo-adjuvant chemotherapy were excluded. The pathological results of all these cases were reviewed and correlated with those on CT and integrated PET-CT. RESULTS: The sensitivity, specificity, accuracy, positive and negative predictive values were higher in integrated PET-CT than CT alone in all lymph nodes, whether N1 or N2. When lymph nodes were stratified by size, the sensitivity of PET-CT was significantly higher among enlarged (>1cm) than non-enlarged (1cm) should be with caution as the specificity of PET-CT is lower and its ability to detect truly negative nodes become reduced. NSCLC patients with enlarged nodes by CT criteria who are PET-CT negative may require cervical mediastinoscopy to rule out metastatic spread to these nodes. Prospective studies are warranted.

Factors causing inaccurate staging of mediastinal nodal involvement in non-small cell lung cancer patients staged by positron emission tomography.

Despite documented superiority of positron emission tomography over other investigative modalities in the preoperative staging of non-small cell lung cancer, a proportion of patients will have an inaccurate staging of their mediastinal nodes. The aim of this retrospective review is to analyse the clinicopathological factors responsible for inaccurate nodal staging by integrated PET-CT. A total of 100 consecutive patients with histologically proven non-small cell lung cancer underwent staging with PET-CT prior to lung resection. Thirty-three patients, inaccurately staged by PET-CT, were analysed. Univariate analysis identified the following as significant in causing inaccurate nodal staging: history of tuberculosis (P=0.039) and non-insulin dependant diabetes (P=0.014). In multivariate analysis, we have identified the following as independent factors in causing inaccurate staging of mediastinal lymph nodes: rheumatoid arthritis, non-insulin dependent diabetes, history of tuberculosis, presence of atypical adenomatous hyperplasia and pneumonia (P<0.05). The highest rate of inaccuracy in mediastinal nodal staging was in nodal station 4 (11%, P=0.01) followed by station 7 (10%, P=0.02) and station 9 (3.5%, P=0.01). Interpretation of PET-CT staging of the mediastinum in patients with a history of the above should be with caution, as the incidence of false upstaging and down staging in these subgroups is high. Vigilance of such factors may improve the accuracy of PET-CT in staging mediastinal lymph nodes. Histological confirmation should always be sought.

Primary mediastinal synovial sarcoma.

Synovial sarcoma occurs predominantly in the soft tissues of the extremities, but is exceedingly rare in the mediastinum. It has overlapping histological and immunophenotypic features with other tumours in the differential diagnosis. We report a case of a patient who had an incidental finding of such a tumour. Because of the rarity of this tumour in the mediastinum, optimal therapy is unknown and the prognosis remains guarded.