Multi-use physical activity trails in an urban setting and cardiovascular disease: a difference-in-differences analysis of a natural experiment in Winnipeg, Manitoba, Canada.

OBJECTIVE: To determine if expansion of multi-use physical activity trails in an urban centre is associated with reduced rates of cardiovascular disease (CVD). METHODS: This was a natural experiment with a difference in differences analysis using administrative health records and trail-based cycling data in Winnipeg, Canada. Prior to the intervention, each year, 314,595 (IQR: 309,044 to 319,860) persons over 30 years without CVD were in the comparison group and 37,901 residents (IQR: 37,213 to 38,488) were in the intervention group. Following the intervention, each year, 303,853 (IQR: 302,843 to 304,465) persons were in the comparison group and 35,778 (IQR: 35,551 to 36,053) in the intervention group. The natural experiment was the construction of four multi-use trails, 4-7 km in length, between 2010 and 2012. Intervention and comparison areas were based on buffers of 400 m, 800 m and 1200 m from a new multi-use trail. Bicycle counts were obtained from electromagnetic counters embedded in the trail. The primary outcome was a composite of incident CVD events: CVD-related mortality, ischemic heart disease, cerebrovascular events and congestive heart failure. The secondary outcome was a composite of incident CVD risk factors: hypertension, diabetes and dyslipidemia. RESULTS: Between 2014 and 2018, 1,681,125 cyclists were recorded on the trails, which varied ~ 2.0-fold across the four trails (2358 vs 4264 counts/week in summer months). Between 2000 and 2018, there were 82,632 CVD events and 201,058 CVD risk events. In propensity score matched Poisson regression models, the incident rate ratio (IRR) was 1.06 (95% CI: 0.90 to 1.24) for CVD events and 0.95 (95%CI: 0.88 to 1.02) for CVD risk factors for areas within 400 m of a trail, relative to comparison areas. Sensitivity analyses indicated this effect was greatest among households adjacent to the trail with highest cycling counts (IRR = 0.85; 95% CI: 0.75 to 0.96). CONCLUSIONS: The addition of multi-use trails was not associated with differences in CVD events or CVD risk factors, however the differences in CVD risk may depend on the level of trail use. TRIAL REGISTRATION: Trial registration number: NCT04057417 .

Maternal body mass index, offspring body mass index, and blood pressure at 18 years: a causal mediation analysis.

OBJECTIVE: Understanding the natural history of hypertension is key to identifying prevention strategies. Previous work suggests that in utero exposures and offspring anthropometrics may play a role. This study examined the relationship between maternal pre-pregnancy body mass index (BMI) and the mediating role of childhood and adolescent BMI on offspring blood pressure at 18 years. METHODS: We performed multivariable regression and causal mediation analyses within 3217 mother - offspring pairs from the Avon Longitudinal Study of Parents and Children prospective birth cohort. The main exposure was maternal pre-pregnancy BMI, and the outcome was offspring blood pressure at 18 years of age categorized as normal or elevated. Latent trajectory analysis was used to quantify the mediator, offspring BMI trajectories, derived from multiple measurements throughout childhood and adolescence. Mediation analyses were repeated using current offspring BMI at 18 years as a continuous variable. RESULTS: Multivariable logistic regression revealed that for every 1 unit increase in maternal BMI, the risk of elevated blood pressure at 18 years of age increased by 5% (aOR: 1.05, 95% CI: 1.03-1.07; p < 0.001). The strength of this association was reduced after adjusting for offspring BMI trajectory (aOR: 1.03, 95% CI: 1.00-1.05; p = 0.017) and eliminated after adjusting for offspring BMI at 18 years (aOR: 1.00; 95% CI: 0.98-1.03; p = 0.70). Causal mediation analysis confirmed offspring BMI at 18 years as a mediator, where BMI trajectory accounted for 46% of the total effect of maternal BMI on elevated offspring blood pressure and current BMI account for nearly the entire effect. CONCLUSIONS: Maternal pre-pregnancy BMI is associated with an increased risk of elevated blood pressure in offspring at 18 years of age although it appears to be entirely mediated by offspring BMI.

Narcotic tapering in pregnancy using long-acting morphine: an 18-month prospective cohort study in northwestern Ontario.

OBJECTIVE: To document the management of and outcomes for patients receiving narcotic replacement and tapering with long-acting morphine preparations during pregnancy. DESIGN: A prospective cohort study over 18 months. SETTING: Northwestern Ontario. PARTICIPANTS: All 600 births at Meno Ya Win Health Centre in Sioux Lookout, Ont, from January 1, 2012, to June 30, 2013, including 166 narcotic-exposed pregnancies. INTERVENTION: Narcotic replacement and tapering of narcotic use with long-acting morphine preparations. MAIN OUTCOME MEASURES: Prenatal management of maternal narcotic use, incidence of neonatal abstinence syndrome, and other neonatal outcomes. RESULTS: The incidence of neonatal abstinence syndrome fell significantly to 18.1% of pregnancies exposed to narcotics (from 29.5% in a previous 2010 study, P = .003) among patients using narcotic replacement and tapering with long-acting morphine preparations. Neonatal outcomes were otherwise equivalent to those of the nonexposed pregnancies. CONCLUSION: In many patients, long-acting morphine preparations can be safely used and tapered in pregnancy, with a subsequent decrease in observed neonatal withdrawal symptoms.

Incidence of narcotic abuse during pregnancy in northwestern Ontario: three-year prospective cohort study.

OBJECTIVE: To document the incidence and outcomes of narcotic use during pregnancy in northwestern Ontario. DESIGN: Three-year prospective cohort study. SETTING: Sioux Lookout and surrounding communities in northwestern Ontario. PARTICIPANTS: A total of 1206 consecutive births in a catchment area of 28 000 First Nations patients. MAIN OUTCOME MEASURES: Incidence of narcotic use, and maternal and neonatal outcomes. RESULTS: Incidence of narcotic use in pregnancy has risen to 28.6% (P < .001) and incidence of neonatal abstinence syndrome has fallen to 18.0% of narcotic-exposed births (P = .003). Daily intravenous drug use is now a common pattern of abuse. CONCLUSION: Narcotic abuse in pregnancy has dramatically increased in northwestern Ontario. Neonatal outcomes have improved as a result of a family medicine-based prenatal and obstetric program that includes a narcotic replacement and tapering program.

Cardiorespiratory Fitness and Physical Activity in Pediatric Diabetes: A Systemic Review and Meta-Analysis.

Importance: It is unclear whether cardiorespiratory fitness (CRF) and physical activity are lower among youths with type 1 diabetes (T1D) and type 2 diabetes (T2D) compared with youths without diabetes. Objective: To describe the magnitude, precision, and constancy of the differences in CRF and physical activity among youths with and without diabetes. Data Sources: MEDLINE, Embase, CINAHL, and SPORTDiscus were searched from January 1, 2000, to May 1, 2022, for eligible studies. Study Selection: Observational studies with measures of CRF and physical activity in children and adolescents aged 18 years or younger with T1D or T2D and a control group were included. Data Extraction and Synthesis: Data extraction was completed by 2 independent reviewers. A random-effects meta-analysis model was used to estimate differences in main outcomes. The pooled effect estimate was measured as standardized mean differences (SMDs) with 95% CIs. The Preferred Reporting Items for Systematic Review and Meta-Analyses guideline was followed. Main Outcomes and Measures: The main outcomes were objectively measured CRF obtained from a graded maximal exercise test and subjective or objective measures of physical activity. Subgroup analyses were performed for weight status and measurement type for outcome measures. Results: Of 7857 unique citations retrieved, 9 studies (755 participants) with measures of CRF and 9 studies (1233 participants) with measures of physical activity for youths with T2D were included; for youths with T1D, 23 studies with measures of CRF (2082 participants) and 36 studies with measures of PA (12 196 participants) were included. Random-effects models revealed that directly measured CRF was lower in youths with T2D (SMD, -1.06; 95% CI, -1.57 to -0.56; I2 = 84%; 9 studies; 755 participants) and in youths with T1D (SMD, -0.39; 95% CI, -0.70 to -0.09; I2 = 89%; 22 studies; 2082 participants) compared with controls. Random-effects models revealed that daily physical activity was marginally lower in youths with T1D (SMD, -0.29; 95% CI, -0.46 to -0.11; I2 = 89%; 31 studies; 12 196 participants) but not different among youths with T2D (SMD, -0.56; 95% CI, -1.28 to 0.16; I2 = 91%; 9 studies; 1233 participants) compared with controls. When analyses were restricted to studies with objective measures, physical activity was significantly lower in youths with T2D (SMD, -0.71; 95% CI, -1.36 to -0.05; I2 = 23%; 3 studies; 332 participants) and T1D (SMD, -0.67; 95% CI, -1.17 to -0.17; I2 = 93%; 12 studies; 1357 participants) compared with controls. Conclusions and Relevance: These findings suggest that deficits in CRF may be larger and more consistent in youths with T2D compared with youths with T1D, suggesting an increased risk for cardiovascular disease-related morbidity in adolescents with diabetes, particularly among those with T2D. The findings reinforce calls for novel interventions to empower youths living with diabetes to engage in regular physical activity and increase their CRF.

Lower-limb resistance training reduces exertional dyspnea and intrinsic neuromuscular fatigability in individuals with chronic obstructive pulmonary disease.

Skeletal muscle atrophy, dysfunction, and fatigue are important complications of chronic obstructive pulmonary disease (COPD). Greater reliance on glycolytic metabolism and increased type III/IV muscle afferent activity increase ventilatory drive, promote ventilatory constraint, amplify exertional dyspnea, and limit exercise tolerance. To investigate whether muscular adaptation with resistance training (RT) could improve exertional dyspnea, exercise tolerance, and intrinsic neuromuscular fatigability in individuals with COPD (n = 14, FEV1 = 62 ± 21% predicted), we performed a proof-of-concept single-arm efficacy study utilizing 4 wk of individualized lower-limb RT (3 times/wk). At baseline, dyspnea (Borg scale), ventilatory parameters, lung volumes (inspiratory capacity maneuvers), and exercise time were measured during a constant-load test (CLT) at 75% maximal workload to symptom limitation. On a separate day, fatigability was assessed using 3 min of intermittent stimulation of the quadriceps (initial output of ∼25% maximal voluntary force). Following RT, the CLT and fatigue protocols were repeated. Compared with baseline, isotime dyspnea was reduced (5.9 ± 2.4 vs. 4.5 ± 2.4 Borg units, P = 0.02) and exercise time increased (437 ± 405 s vs. 606 ± 447 s, P < 0.01) following RT. Isotime tidal volume increased (P = 0.01), whereas end-expiratory lung volumes (P = 0.02) and heart rate (P = 0.03) decreased. Quadriceps force, relative to initial force, was higher at the end of the stimulation protocol posttraining (53.2 ± 9.1 vs. 46.8 ± 11.9%, P = 0.04). This study provides evidence that 4 wk of RT attenuates exertional dyspnea and improves exercise tolerance in individuals with COPD, which in part, is likely due to delayed ventilatory constraint and reduced intrinsic fatigability. A pulmonary rehabilitation program beginning with individualized lower-limb RT may help mitigate dyspnea before performing aerobic training in individuals with COPD.NEW & NOTEWORTHY This study presents the novel finding that 4-wk resistance training (RT) focused specifically on the lower limbs can reduce exertional dyspnea during constant-load cycling, improve exercise tolerance, and reduce intrinsic fatigability of the quadriceps in individuals with COPD.

Filling gaps in type 1 diabetes and exercise research: a scoping review and priority-setting project.

Our team examined the characteristics of patient engagement (PE) practices in exercise-based randomized trials in type 1 diabetes (T1D), and facilitated T1D stakeholders in determining the top 10 list of priorities for exercise research. Two methodological approaches were employed: a scoping review and a modified James Lind Alliance priority-setting partnership. Published (Medline, Embase, CINAHL and Central databases) and grey literature (www.clinicaltrials.gov) were searched to identify randomized controlled trials of exercise interventions lasting minimum 4 weeks and available in English. We extracted information on PE and patient-reported outcomes (PROs) to identify if patient perspectives had been implemented. Based on results, we set out to determine exercise research priorities as a first step towards a patient-engaged research agenda. An online survey was distributed across Canada to collect research questions from patients, caregivers and healthcare providers. We qualitatively analyzed submitted questions and compiled a long list that a 12-person stakeholder steering committee used to identify the top 10 priority research questions. Of 9962 identified sources, 19 published trials and 4 trial registrations fulfilled inclusion criteria. No evidence of PE existed in any included study. Most commonly measured PROs were frequency of hypoglycemia (n=7) and quality of life (n=4). The priority-setting survey yielded 194 submitted research questions. Steering committee rankings identified 10 priorities focused on lifestyle factors and exercise modifications to maintain short-term glycemic control. Recent exercise-based randomized trials in T1D have not included PE and PROs. Patient priorities for exercise research have yet to be addressed with adequately designed clinical trials.

Physical activity trails in an urban setting and cardiovascular disease morbidity and mortality in Winnipeg, Manitoba, Canada: a study protocol for a natural experiment.

INTRODUCTION: Aspects of the built environment that support physical activity are associated with better population health outcomes. Few experimental data exist to support these observations. This protocol describes the study of the creation of urban trials on cardiovascular disease (CVD)-related morbidity and mortality in a large urban centre. METHODS AND ANALYSIS: Between 2008 and 2010, the city of Winnipeg, Canada, built four, paved, multiuse (eg, cycling, walking and running), two-lane trails that are 5-8 km long and span ~60 neighbourhoods. Linking a population-based health data with census and environmental data, we will perform an interrupted time series analysis to assess the impact of this natural experiment on CVD-related morbidity and mortality among individuals 30-65 years of age residing within 400-1200 m of the trail. The primary outcome of interest is a composite measure of incident major adverse CVD events (ie, CVD-related mortality, ischaemic heart disease, stroke and congestive heart failure). The secondary outcome of interest is a composite measure of incident CVD-related risk factors (ie, diabetes, hypertension and dyslipidaemia). Outcomes will be assessed quarterly in the 10 years before the intervention and 5 years following the intervention, with a 4-year interruption. We will adjust analyses for differences in age, sex, ethnicity, immigration status, income, gentrification and other aspects of the built environment (ie, greenspace, fitness/recreation centres and walkability). We will also assess trail use and trail user profiles using field data collection methods. ETHICS AND DISSEMINATION: Ethical approvals for the study have been granted by the Health Research Ethics Board at the University of Manitoba and the Health Information Privacy Committee within the Winnipeg Regional Health Authority. We have adopted an integrated knowledge translation approach. Information will be disseminated with public and government partners. TRIAL REGISTRATION NUMBER: NCT04057417.

Walking on Water-A Natural Experiment of a Population Health Intervention to Promote Physical Activity after the Winter Holidays.

Background: Very few experimental studies exist describing the effect of changes to the built environment and opportunities for physical activity (PA). We examined the impact of an urban trail created on a frozen waterway on visitor counts and PA levels. Methods: We studied a natural experiment in Winnipeg, Manitoba, Canada that included 374,204 and 237,362 trail users during the 2017/2018 and 2018/2019 winter seasons. The intervention was a 10 km frozen waterway trail lasting 8-10 weeks. The comparator conditions were the time periods immediately before and after the intervention when ~10 kms of land-based trails were accessible to the public. A convenience sample of 466 participants provided directly measured PA while on the frozen waterway. Results: Most trail users were 35 years or older (73%), Caucasian (77%), and had an annual household income >$50,000 (61%). Mean daily trail network visits increased ~four-fold when the frozen waterway was open (median and interquartile range (IQR) = 710 (239-1839) vs. 2897 (1360-5583) visits/day, p < 0.001), compared with when it was closed. Users achieved medians of 3852 steps (IQR: 2574-5496 steps) and 23 min (IQR: 13-37 min) of moderate to vigorous intensity PA (MVPA) per visit, while 37% of users achieved ≥30 min of MVPA. Conclusion: A winter-specific urban trail network on a frozen waterway substantially increased visits to an existing urban trail network and was associated with a meaningful dose of MVPA. Walking on water could nudge populations living in cold climates towards more activity during winter months.

Length of Stay and Achievement of Functional Milestones in a Rural First Nations Population in Northwestern Ontario during Acute-Care Admission after Total Hip Replacement: A Retrospective Chart Review.

PURPOSE: To understand the postoperative acute-care physiotherapy course for First Nations people returning after total hip replacement (THR) to remote communities with limited rehabilitation services and to evaluate length of stay and attainment of functional milestones after THR to determine to what extent an urban-based clinical pathway is transferrable to and effective for First Nations patients in a rural setting. METHODS: Data were collected retrospectively by reviewing charts of patients who underwent THR in the Northwest Ontario catchment area from 2007 through 2012. RESULTS: For the 36 patient charts reviewed, median length of stay (LOS) at the Sioux Lookout Meno Ya Win Health Centre (SLMHC) was 7.5 days (range 2-335); median LOS from time of surgery at the regional hospital (Thunder Bay Regional Health Centre) to discharge from SLMHC was 13.5 days; and median time for mobilizing and stairs was 9 days (range 1-93). CONCLUSION: Commonly accepted urban clinical pathways are not a good fit for smaller rural hospitals from which First Nations patients return to remote communities without rehabilitation services. LOS in a rural acute-care facility is similar to LOS in an urban rehabilitation facility.

Objet: Comprendre le parcours de soins de physiothérapie postopératoires de courte durée pour les membres des Premières Nations qui retournent dans des collectivités éloignées offrant des services de réadaptation limités après une arthroplastie totale de la hanche (ATH); évaluer la durée du séjour et l'atteinte des jalons fonctionnels à la suite d'une ATH afin de déterminer dans quelle mesure et avec quelle efficacité le cheminement clinique de patients des Premières Nations effectué en milieu urbain peut être transféré en milieu rural. Méthodes: Les données ont été recueillies de façon rétrospective en examinant les dossiers de patients qui ont subi une arthroplastie totale de la hanche dans la circonscription hospitalière du nord-ouest de l'Ontario entre 2007 et 2012. Constatations: Pour les 36 dossiers de patient examinés, la durée du séjour (DDS) médiane au centre de santé Meno Ya Win de Sioux Lookout était de 7,5 jours (étendue: de 2 à 335); la DDS médiane à compter du moment de l'intervention chirurgicale à l'hôpital régional (Centre régional des sciences de la santé de Thunder Bay) jusqu'au départ du centre de santé Meno Ya Win de Sioux Lookout était de 13,5 jours; et le temps médian de recouvrement de la capacité à marcher et à monter des escaliers était de 9 jours (étendue: de 1 à 93). Conclusion: Les cheminements cliniques en milieu urbain généralement reconnus ne conviennent pas aux petits hôpitaux ruraux à partir desquels les patients des Premières Nations retournent dans des collectivités éloignées qui n'offrent pas de services de réadaptation. La DDS dans un centre de soins actifs en milieu rural est semblable à la DDS dans un centre de réadaptation en milieu urbain.

Invasive CA-MRSA in northwestern Ontario: a 2-year prospective study.

INTRODUCTION: Northwestern Ontario has a documented high rate of skin and soft-tissue infections due to community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). Recently, invasive illness from this common pathogen has become a serious clinical problem in the region. We sought to better understand this trend of invasive CA-MRSA. METHODS: We prospectively studied cases of positive CA-MRSA bacteremia in 2012 and 2013. We examined genetic typing, comorbidities and outcomes. RESULTS: Twenty-three cases of CA-MRSA bacteremia were treated during the 2-year study period. Intravenous drug use accounted for only 17% of cases. One death and 2 cases of endocarditis occurred. CONCLUSION: High rates of CA-MRSA in skin and soft-tissue infections, combined with poor living conditions and poor access to potable water, may account for most of these cases of CA-MRSA bacteremia. Social determinants of health are relevant when common resistant bacterial isolates become associated with life-threatening illness.

INTRODUCTION: La région du Nord-Ouest de l'Ontario présente un taux élevé et documenté d'infections de la peau et des tissus mous causées par une souche de Staphylococcus aureus méthycillinorésistante d'origine communautaire (SARM-C). La maladie invasive causée par cet agent pathogène commun est récemment devenue un problème clinique grave dans la région. Nous avons voulu mieux comprendre cette tendance du SARM-C invasif. MÉTHODES: Nous avons étudié de manière prospective des cas de bactériémie positive à SARM C en 2012 et 2013. Nous avons analysé le typage génétique, les comorbidités et l'issue des infections. RÉSULTATS: Vingt-trois cas de bactériémie à SARM-C ont été traités au cours de la période de 2 ans. L'utilisation de drogues injectables a pu être incriminée dans seulement 17 % de cas. On a enregistré 1 décès et 2 cas d'endocardite. CONCLUSION: Des taux élevés de SARM-C dans les infections de la peau et des tissus mous alliées à de piètres conditions de vie et à un accès limité à de l'eau potable pourraient expliquer la plupart de ces cas de bactériémie à SARM-C. Il faut tenir compte des déterminants sociaux de la santé lorsque des isolats bactériens communs et résistants deviennent associés à des maladies gravissimes.