Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training.

BACKGROUND: Health care routinely fails Indigenous peoples and anti-Indigenous racism is common in clinical encounters. Clinical training programs aimed to enhance Indigenous cultural safety (ICS) rely on learner reported impact assessment even though clinician self-assessment is poorly correlated with observational or patient outcome reporting. We aimed to compare the clinical impacts of intensive and brief ICS training to control, and to assess the feasibility of ICS training evaluation tools, including unannounced Indigenous standardized patient (UISP) visits. METHOD: Using a prospective parallel group three-arm randomized controlled trial design and masked standardized patients, we compared the clinical impacts of the intensive interactive, professionally facilitated, 8- to10-h Sanyas ICS training; a brief 1-h anti-bias training adapted to address anti-Indigenous bias; and control continuing medical education time-attention matched to the intensive training. Participants included 58 non-Indigenous staff physicians, resident physicians and nurse practitioners from family practice clinics, and one emergency department across four teaching hospitals in Toronto, Canada. Main outcome measures were the quality of care provided during UISP visits including adjusted odds that clinician would be recommended by the UISP to a friend or family member; mean item scores on patient experience of care measure; and clinical practice guideline adherence for NSAID renewal and pain assessment. RESULTS: Clinicians in the intensive or brief ICS groups had higher adjusted odds of being highly recommended to friends and family by standardized patients (OR 6.88, 95% CI 1.17 to 40.45 and OR 7.78, 95% CI 1.05 to 58.03, respectively). Adjusted mean item patient experience scores were 46% (95% CI 12% to 80%) and 40% (95% CI 2% to 78%) higher for clinicians enrolled in the intensive and brief training programs, respectively, compared to control. Small sample size precluded detection of training impacts on clinical practice guideline adherence; 100% of UISP visits were undetected by participating clinicians. CONCLUSIONS: Patient-oriented evaluation design and tools including UISPs were demonstrated as feasible and effective. Results show potential impact of cultural safety training on patient recommendation of clinician and improved patient experience. A larger trial to further ascertain impact on clinical practice is needed. TRIAL REGISTRATION: Clinicaltrials.org NCT05890144. Retrospectively registered on June 5, 2023.

Uncovering SARS-COV-2 vaccine uptake and COVID-19 impacts among First Nations, Inuit and Métis Peoples living in Toronto and London, Ontario.

BACKGROUND: First Nations, Inuit and Métis Peoples across geographies are at higher risk of SARS-CoV-2 infection and COVID-19 because of high rates of chronic disease, inadequate housing and barriers to accessing health services. Most Indigenous Peoples in Canada live in cities, where SARS-CoV-2 infection is concentrated. To address gaps in SARS-CoV-2 information for these urban populations, we partnered with Indigenous agencies and sought to generate rates of SARS-CoV-2 testing and vaccination, and incidence of infection for First Nations, Inuit and Métis living in 2 Ontario cities. METHODS: We drew on existing cohorts of First Nations, Inuit and Métis adults in Toronto (n = 723) and London (n = 364), Ontario, who were recruited using respondent-driven sampling. We linked to ICES SARS-CoV-2 databases and prospectively monitored rates of SARS-CoV-2 testing, diagnosis and vaccination for First Nations, Inuit and Métis, and comparator city and Ontario populations. RESULTS: We found that SARS-CoV-2 testing rates among First Nations, Inuit and Métis were higher in Toronto (54.7%, 95% confidence interval [CI] 48.1% to 61.3%) and similar in London (44.5%, 95% CI 36.0% to 53.1%) compared with local and provincial rates. We determined that cumulative incidence of SARS-CoV-2 infection was not significantly different among First Nations, Inuit and Métis in Toronto (7364/100 000, 95% CI 2882 to 11 847) or London (7707/100 000, 95% CI 2215 to 13 200) compared with city rates. We found that rates of vaccination among First Nations, Inuit and Métis in Toronto (58.2%, 95% CI 51.4% to 64.9%) and London (61.5%, 95% CI 52.9% to 70.0%) were lower than the rates for the 2 cities and Ontario. INTERPRETATION: Although Ontario government policies prioritized Indigenous populations for SARS-CoV-2 vaccination, vaccine uptake was lower than in the general population for First Nations, Inuit and Métis Peoples in Toronto and London. Ongoing access to culturally safe testing and vaccinations is urgently required to avoid disproportionate hospital admisson and mortality related to COVID-19 in these communities.

A Comparison of On-Ice External Load Measures Between Subelite and Elite Female Ice Hockey Players.

ABSTRACT: Douglas, AS, Rotondi, MA, Baker, J, Jamnik, VK, and Macpherson, AK. A comparison of on-ice external load measures between subelite and elite female ice hockey players. J Strength Cond Res 36(7): 1978-1983, 2022-This study quantified and examined differences in measures of on-ice external load for subelite and elite female ice hockey players. External load variables were collected from subelite (N = 21) and elite (N = 24) athletes using Catapult S5 monitors during the preseason. A total of 574 data files were analyzed from training and competition during the training camp. Significant differences between groups were found across all variables. Differences in training between the 2 groups ranged from trivial (forwards PlayerLoad, p = 0.03, effect-size [ES] = 0.18) to large (forwards Explosive Efforts [EEs], p < 0.001, ES = 1.64; defense EEs, p < 0.001, ES = 1.40). Match comparisons yielded similar results, with differences ranging from small (defense Low Skating Load [SL], p = 0.05, ES = 0.49; Medium SL, p = 0.04, ES = 0.52) to very large (forwards PlayerLoad, p < 0.001. ES = 2.25; PlayerLoad·min-1, p < 0.001, ES = 2.66; EEs, p < 0.001, ES = 2.03; Medium SL, p < 0.001, ES = 2.31; SL·min-1, p < 0.001, ES = 2.67), respectively. The differences in external load measures of intensity demonstrate the need to alter training programs of subelite ice athletes to ensure they can meet the demands of elite ice hockey. As athletes advance along the development pathway, considerable focus of their off-ice training should be to improve qualities that enhance their ability to perform high-intensity on-ice movements.

A systematic review and meta-analysis of the effect of treadmill desks on energy expenditure, sitting time and cardiometabolic health in adults.

BACKGROUND: As the health risks of sedentary working environments become more clear, greater emphasis on the implementation of walking interventions to reduce sitting time is needed. In this systematic review and meta-analysis, we investigate the role of treadmill-desk interventions on energy expenditure, sitting time, and cardiometabolic health in adults with sedentary occupations. METHODS: Relevant studies published in English were identified using CINAHL, EMBASE, MEDLINE, Web of Science, Scopus, and PubMed databases up to December 2020. Random effects meta-analysis models were used to pool study results. RESULTS: Thirteen relevant studies (six workplaces and seven laboratories) were found with a total of 351 participants. Pooled analysis of laboratory studies showed a significant increase in energy expenditure (105.23 kcal per hour, 95% confidence interval [CI]: 90.41 to 120.4), as well as metabolic rate (5.0 mL/kg/min, 95% CI: 3.35 to 6.64), among treadmill desk users compared to sitting conditions. No evidence of significant differences in blood pressure were found. In workplace studies, we observed a significant reduction in sitting time over a 24-h period (- 1.73 min per hour, 95% CI: - 3.3 to - 0.17) among users of treadmill desks, compared to a conventional desk. However, there were no evidence of statistically significant changes in other metabolic outcomes. CONCLUSIONS: Treadmill desks offer a feasible and effective intervention to increase energy expenditure and metabolic rate and reduce sitting time while performing work-related tasks. Future studies are needed to increase generalizability to different workplace settings and further evaluate their impact on cardiometabolic health.

Standardized serum 25-hydroxyvitamin D concentrations are inversely associated with cardiometabolic disease in U.S. adults: a cross-sectional analysis of NHANES, 2001-2010.

BACKGROUND: Previously reported associations between vitamin D status, as measured by serum 25-hydroxyvitamin D [25(OH)D] concentrations, and cardiometabolic risk factors were largely limited by variability in 25(OH)D assay performance. In accordance with the Vitamin D Standardization Program, serum 25(OH)D measurement was recently standardized in the National Health and Nutrition Examination Survey (NHANES) to reduce laboratory and method related differences in serum 25(OH)D results. We evaluated the overall and ethnic-specific associations between the newly standardized serum 25(OH)D concentrations and cardiometabolic risk in U.S. adults. METHODS: This study examined standardized 25(OH)D data from five cycles of the NHANES (2001-2010). The total sample included 7674 participants (1794 Mexican-Americans, 4289 non-Hispanic whites, and 1591 non-Hispanic blacks) aged ≥ 20 years who were examined in the morning after overnight fasting. Serum 25(OH)D was directly measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) in 2007-2010, and was predicted from LC-MS/MS equivalents for 2001-2006. Serum 25(OH)D levels were categorized into quartiles (<43.4, 43.4-58.6, 58.7-74.2, ≥74.3 nmol/L). Cardiometabolic risk was defined by the homeostatic model assessment of insulin resistance (HOMA-IR), metabolic syndrome (MetS), and Framingham cardiovascular disease (CVD) risk. Prevalence ratios and 95% confidence intervals were calculated using modified Poisson regression. RESULTS: After full adjustment for confounders, serum 25(OH)D ≥74.3 nmol/L was associated with lower cardiometabolic risk compared to 25(OH)D <43.4 nmol/L in the overall sample [HOMA-IR: 0.70 (0.59, 0.84); MetS: 0.82 (0.74, 0.91); CVD risk: 0.78 (0.66, 0.91)]. These associations remained significant in Mexican-Americans [HOMA-IR: 0.54 (0.35, 0.82); MetS: 0.73 (0.55, 0.96)], non-Hispanic whites [HOMA-IR: 0.81 (0.68, 0.96); MetS: 0.84 (0.73, 0.95); CVD risk: 0.78 (0.64, 0.93)]; and in non-Hispanic blacks [HOMA-IR: 0.67 (0.45, 0.99); MetS: 0.75 (0.56, 0.97); CVD risk: 0.58 (0.41, 0.81)]. CONCLUSIONS: Low vitamin D status is a significant risk factor for cardiometabolic disease in U.S. adults based on standardized serum 25(OH)D results, irrespective of ethnic background. Future studies using standardized 25(OH)D data are needed to confirm these results, particularly amongst U.S. blacks with 25(OH)D concentrations above 75 nmol/L.

Formulation of evidence-based messages to promote the use of physical activity to prevent and manage Alzheimer's disease.

BACKGROUND: The impending public health impact of Alzheimer's disease is tremendous. Physical activity is a promising intervention for preventing and managing Alzheimer's disease. However, there is a lack of evidence-based public health messaging to support this position. This paper describes the application of the Appraisal of Guidelines Research and Evaluation II (AGREE-II) principles to formulate an evidence-based message to promote physical activity for the purposes of preventing and managing Alzheimer's disease. METHODS: A messaging statement was developed using the AGREE-II instrument as guidance. Methods included (a) conducting a systematic review of reviews summarizing research on physical activity to prevent and manage Alzheimer's disease, and (b) engaging stakeholders to deliberate the evidence and formulate the messaging statement. RESULTS: The evidence base consisted of seven systematic reviews focused on Alzheimer's disease prevention and 20 reviews focused on symptom management. Virtually all of the reviews of symptom management conflated patients with Alzheimer's disease and patients with other dementias, and this limitation was reflected in the second part of the messaging statement. After deliberating the evidence base, an expert panel achieved consensus on the following statement: "Regular participation in physical activity is associated with a reduced risk of developing Alzheimer's disease. Among older adults with Alzheimer's disease and other dementias, regular physical activity can improve performance of activities of daily living and mobility, and may improve general cognition and balance." The statement was rated favourably by a sample of older adults and physicians who treat Alzheimer's disease patients in terms of its appropriateness, utility, and clarity. CONCLUSION: Public health and other organizations that promote physical activity, health and well-being to older adults are encouraged to use the evidence-based statement in their programs and resources. Researchers, clinicians, people with Alzheimer's disease and caregivers are encouraged to adopt the messaging statement and the recommendations in the companion informational resource.

Application of the McKenzie system of Mechanical Diagnosis and Therapy (MDT) in patients with shoulder pain; a prospective longitudinal study.

OBJECTIVES: The primary objective was to determine if the pain and function response to the McKenzie system of Mechanical Diagnosis and Therapy (MDT) differs by MDT classification category at two and four weeks following the start of MDT treatment for shoulder complaints. The secondary objective was to describe the frequency of discharge over time by MDT classification. METHODS: International, MDT-trained study collaborators recruited 93 patients attending physiotherapy for rehabilitation of a shoulder problem. The Numeric Pain Rating Scale (NPRS) and the Upper Extremity Functional Index (UEFI) were collected at the initial assessment and two and four weeks after treatment commenced. A two-way mixed model analysis of variance with planned pairwise comparisons was performed to identify where the differences between MDT classification groups actually existed. RESULTS: The Derangement and Spinal classifications had significantly lower NPRS scores than the Dysfunction group at week 2 and week 4 (p < 0.05). The Derangement and Spinal classifications had significantly higher UEFI scores than the Dysfunction group at week 2 and week 4 (p < 0.05). The frequency of discharge at week 2 was 37% for both Derangement and Spinal classifications, with no discharges for the Dysfunction classification at this time point. The frequency of discharge at week 4 was 83, 82 and 15% for the Derangement, Spinal and Dysfunction classifications, respectively. DISCUSSION: Classifying patients with shoulder pain using the MDT system can impact treatment outcomes and the frequency of discharge. When MDT-trained clinicians are allowed to match the intervention to a specific MDT classification, the outcome is aligned with the response expectation of the classification.Level of Evidence: 2b.

A meta-analysis of prospective studies on the role of physical activity and the prevention of Alzheimer's disease in older adults.

BACKGROUND: The incidence of Alzheimer's disease is increasing as the global population ages. Given the limited success of pharmaceuticals in preventing this disease, a greater emphasis on non-pharmaceutical approaches is needed. The aim of this study was to quantify the association between Alzheimer's disease and physical activity in older adults over the age of 65 years. METHODS: A meta-analytic approach was used to determine if physical activity reduced the risk of Alzheimer's disease in individuals 65 years or older. Some evidence indicates that physical activity may improve cognitive function in older adults, while other evidence is inconclusive. The purpose of this study was to examine if prevention of Alzheimer's disease is possible if started at a later age. The precise brain changes that occur with the onset of Alzheimer's disease are not fully known, and therefore may still be influenced by preventative measures even in advancing age. Determining if physical activity can inhibit the onset of the disease at any age may motivate individuals to adopt an "it's never too late" mentality on preventing the onset of this debilitating disease. Longitudinal studies of participants who were 65 years or older at baseline were included. A total of 20,326 participants from nine studies were included in this analysis. RESULTS: The fixed effects risk ratio is estimated as 0.61 (95% CI 0.52-0.73) corresponding to a statistically significant overall reduction in risk of Alzheimer's disease in physically active older adults compared to their non-active counterparts. CONCLUSION: Physical activity was associated with a reduced risk of Alzheimer's disease in adults over the age of 65 years. Given the limited treatment options, greater emphasis should be paid to primary prevention through physical activity amongst individuals at high-risk of Alzheimer's disease, such as those with strong genetic and family history.

Transition to injection drug use: the role of initiators.

Data are limited about the role of initiators in the transition to injection drug use. We examined the prevalence and predictors of giving someone their first injection using baseline data from a study involving 98 injection drug users (IDUs) in Toronto, Canada. Participants were recruited in 2011 using respondent-driven sampling. Findings revealed that 27.4 % (95 % CI 14.7-42.2) of IDUs had ever given anyone their first injection. In the logistic regression analysis, being unemployed and having ever spoken positively about injecting to a non-injector were associated with giving someone their first injection. Furthermore, the odds of initiating non-IDUs increased with the number of years that IDUs had been injecting. Our results provide support for interventions that aim to reduce the initiation of non-IDUs; however, further research is needed to shed light on the link between unemployment and initiation of non-injectors.

Towards the estimation of effect measures in studies using respondent-driven sampling.

Respondent-driven sampling (RDS) is an increasingly common sampling technique to recruit hidden populations. Statistical methods for RDS are not straightforward due to the correlation between individual outcomes and subject weighting; thus, analyses are typically limited to estimation of population proportions. This manuscript applies the method of variance estimates recovery (MOVER) to construct confidence intervals for effect measures such as risk difference (difference of proportions) or relative risk in studies using RDS. To illustrate the approach, MOVER is used to construct confidence intervals for differences in the prevalence of demographic characteristics between an RDS study and convenience study of injection drug users. MOVER is then applied to obtain a confidence interval for the relative risk between education levels and HIV seropositivity and current infection with syphilis, respectively. This approach provides a simple method to construct confidence intervals for effect measures in RDS studies. Since it only relies on a proportion and appropriate confidence limits, it can also be applied to previously published manuscripts.

Identifying persons at risk for developing type 2 diabetes in a concentrated population of high risk ethnicities in Canada using a risk assessment questionnaire and point-of-care capillary blood HbA1c measurement.

BACKGROUND: Amidst the growing health care burden created by diabetes, this study aimed to assess the utility of a prediabetes/type 2 diabetes risk questionnaire in high risk ethnic communities in Toronto Canada. METHODS: Participants (n = 691) provided questionnaire responses and capillary blood tests collected via fingerstick and results were analysed for HbA1c using the Bio-Rad in2it point-of-care device. The Bland-Altman method was used to compare point-of-care HbA1c analysis (Bio-Rad, boronate affinity chromatography) to that using high performance liquid chromatography. ANOVA and linear regression were performed to investigate the relationship between questionnaire and blood data. RESULTS: Mean (± SD) HbA1c was 5.99% ± 0.84 and the Bland-Altman analysis revealed no significant biases HbA1c (bias = 0.039, 95% limits of agreement = -1.14 to 1.22). ANOVA showed that with increasing risk classification based on questionnaire answers (with the exception of "moderate"-to-"high"), there was a significant increase in mean HbA1c (Welch Statistic 30.449, p < 0.001). Linear regression revealed that the number of high risk parents, age category, BMI, physical activity participation and previous diagnosis of high blood sugar were significant contributors (p < 0.05) to the variance in HbA1c. CONCLUSIONS: Though not a substitute for established diagnostic protocols, the use of a risk questionnaire can be an accurate, low cost, educational and time efficient method for assessment of type 2 diabetes risk. The early detection of prediabetes and type 2 diabetes is vital to increased awareness and opportunity for intervention with the goal of preventing or delaying the progression of type 2 diabetes and the known associated complications.

Inter-examiner reliability of diplomats in the mechanical diagnosis and therapy system in assessing patients with shoulder pain.

OBJECTIVE: To investigate the inter-examiner reliability of Mechanical Diagnosis and Therapy (MDT)-trained diplomats in classifying patients with shoulder disorders. The MDT system has demonstrated acceptable reliability when used in patients with spinal disorders; however, little is known about its utility when used for appendicular conditions. METHODS: Fifty-four clinical scenarios were created by a group of 11 MDT diploma holders based on their clinical experience with patients with shoulder pain. The vignettes were made anonymous, and their clinical diagnoses sections were left blank. The vignettes were sent to a second group of six international McKenzie Institute diploma holders who were asked to classify each vignette according to the MDT categories for upper extremity. Inter-examiner agreement was evaluated with kappa statistics. RESULTS: There was 'very good' agreement among the six MDT diplomats for classifying the McKenzie syndromes in patients with shoulder pain (kappa = 0.90, SE = 0.018). The raw overall level of multi-rater agreement among the six clinicians in classifying the vignettes was 96%. After accounting for the actual MDT category for each vignette, kappa and the raw overall level of agreement decreased negligibly (0.89 and 95%, respectively). DISCUSSION: Using clinical vignettes, the McKenzie system of MDT has very good reliability in classifying patients with shoulder pain. As an alternative, future reliability studies could use real patients instead of written vignettes.

Cumulative meta-analysis for genetic association: when is a new study worthwhile?

OBJECTIVES: In this paper, we address the questions: how large a sample size would be required to show genome-wide significance between a single nucleotide polymorphism (SNP) and a genetic trait in a meta-analysis of a newly planned study together with the existing ones? Or alternatively: will a planned study of size n be able to provide evidence of a genetic association when this study is combined with a current meta-analysis? METHODS: We examine the potential impact of a newly planned genetic study on an existing meta-analysis through the use of a simulation-based algorithm. The proposed approach provides an empirical estimate of the power of the updated meta-analysis to detect genome-wide significance (p<5.0×10(-8)) of a complex trait and each of a set of specific SNPs of interest or the expected p value of the updated meta-analysis including the current and proposed studies. RESULTS: This technique is illustrated in the context of an updated meta-analysis of case-control studies in Paget's disease. A second example illustrates the impact of adding a newly planned study to a large meta-analysis of SNP associations with human height. CONCLUSIONS: The proposed algorithm is particularly useful for the design of studies to assess a selected set of high-priority SNP associations that are 'nearly' significant in meta-analysis of existing studies. The results may help investigators decide whether an updated meta-analysis is likely to achieve genome-wide significance.

Population-Level Impact and Cost-effectiveness of Continuous Glucose Monitoring and Intermittently Scanned Continuous Glucose Monitoring Technologies for Adults With Type 1 Diabetes in Canada: A Modeling Study.

OBJECTIVE: Maintaining healthy glucose levels is critical for the management of type 1 diabetes (T1D), but the most efficacious and cost-effective approach (capillary self-monitoring of blood glucose [SMBG] or continuous [CGM] or intermittently scanned [isCGM] glucose monitoring) is not clear. We modeled the population-level impact of these three glucose monitoring systems on diabetes-related complications, mortality, and cost-effectiveness in adults with T1D in Canada. RESEARCH DESIGN AND METHODS: We used a Markov cost-effectiveness model based on nine complication states for adults aged 18-64 years with T1D. We performed the cost-effectiveness analysis from a single-payer health care system perspective over a 20-year horizon, assuming a willingness-to-pay threshold of CAD 50,000 per quality-adjusted life-year (QALY). Primary outcomes were the number of complications and deaths and the incremental cost-effectiveness ratio (ICER) of CGM and isCGM relative to SMBG. RESULTS: An initial cohort of 180,000 with baseline HbA1c of 8.1% was used to represent all Canadians aged 18-64 years with T1D. Universal SMBG use was associated with ∼11,200 people (6.2%) living without complications and ∼89,400 (49.7%) deaths after 20 years. Universal CGM use was associated with an additional ∼7,400 (4.1%) people living complications free and ∼11,500 (6.4%) fewer deaths compared with SMBG, while universal isCGM use was associated with ∼3,400 (1.9%) more people living complications free and ∼4,600 (2.6%) fewer deaths. Relative to SMBG, CGM and isCGM had ICERs of CAD 35,017/QALY and 17,488/QALY, respectively. CONCLUSIONS: Universal use of CGM or isCGM in the Canadian T1D population is anticipated to reduce diabetes-related complications and mortality at an acceptable cost-effectiveness threshold.

On-Ice Physical Demands of World-Class Women's Ice Hockey: From Training to Competition.

PURPOSE: To compare on-ice external and internal training loads in world-class women's ice hockey during training and competition. METHODS: On-ice training loads were collected during 1 season from 25 world-class ice hockey players via wearable technology. A total of 105 on-ice sessions were recorded, which consisted of 61 training sessions and 44 matches. Paired and unpaired t tests compared training and competition data between and across playing positions. RESULTS: For training data, there was a difference between positions for PlayerLoad (P < .001, effect size [ES] = 0.32), PlayerLoad·minute-1 (P < .001, ES = 0.55), explosive efforts (P < .001, ES = 0.63), and training impulse (P < .001, ES = 0.48). For the competition data, there were also differences between positions for PlayerLoad (P < .001, ES = 0.26), PlayerLoad·minute-1 (P < .001, ES = 0.38), explosive efforts (P < .001, ES = 0.64), and training impulse (P < .001, ES = 1.47). Similar results were found when positions were viewed independently; competition had greater load and intensity across both positions for PlayerLoad, training impulse, and explosive efforts (P < .001, ES = 1.59-2.98) and with PlayerLoad·minute-1 (P = .016, ES = 0.25) for the defense. CONCLUSIONS: There are clear differences in the volume and intensity of external and internal workloads between training and competition sessions. These differences were also evident when comparing the playing positions, with defense having lower outputs than forwards. These initial results can be used to design position-specific drills that replicate match demands for ice hockey athletes.

On-Ice Measures of External Load in Relation to Match Outcome in Elite Female Ice Hockey.

The aim of this study is to investigate the differences between select on-ice measures using inertial movement sensors based on match outcome, and to determine changes in player movements across three periods of play. Data were collected during one season of competition in elite female ice hockey players (N = 20). Two-factor mixed effects ANOVAs for each skating position were performed to investigate the differences in match outcome, as well as differences in external load measures during the course of a match. For match outcome, there was a small difference for forwards in explosive ratio (p = 0.02, ES = 0.26) and percentage high force strides (p = 0.04, ES = 0.50). When viewed across three periods of a match, moderate differences were found in skating load (p = 0.01, ES = 0.75), explosive efforts (p = 0.04, ES = 0.63), and explosive ratio (p = 0.002, ES = 0.87) for forwards, and in PlayerLoad (p = 0.01, ES = 0.70), explosive efforts (p = 0.04, ES = 0.63), and explosive ratio (p = 0.01, ES = 0.70) for defense. When examining the relevance to match outcome, external load measures associated with intensity appear to be an important factor among forwards. These results may be helpful for coaches and sport scientists when making decisions pertaining to training and competition strategies.

A cross-sectional analysis of the relationship between diabetes and health access barriers in an urban First Nations population in Canada.

OBJECTIVE: This study explores the relationship between health access barriers and diabetes in an urban First Nations population in Canada. DESIGN: Data from a self-identified urban First Nations population were collected using respondent-driven sampling (RDS). As no clear approach for regression modelling of RDS data is available, two logistic regression modelling approaches, including survey-based logistic and generalised linear mixed models, were used to explore the relationship between diabetes and health barriers of interest, including access to healthcare, food, housing and socioeconomic factors. SETTING: Hamilton, Ontario, Canada. PARTICIPANTS: This cross-sectional study used data collected from the Our Health Counts study, in partnership with the De dwa da dehs nye>s Aboriginal Health Centre, which recruited 554 First Nations adults living in Hamilton using RDS. RESULTS: After adjusting for covariates, multivariable regression techniques showed a statistically significant relationship between a self-reported diagnosis of diabetes and a lack of culturally appropriate care among urban First Nations peoples (OR: 12.70, 95% CI 2.52 to 57.91). There was also a trend towards a relationship between diabetes and not having a doctor available in the area, feeling that healthcare provided was inadequate and a lack of available healthcare services in the area. CONCLUSIONS: Urban First Nations peoples who felt the health service they received was not culturally appropriate were more likely to have diabetes, compared with those who did not feel the service they received was culturally inappropriate. Establishing more healthcare services that integrate First Nations cultures and traditions could improve access to care and the course of treatment for urban First Nations peoples living with diabetes.

Consistency of commonly used orthopedic special tests of the shoulder when used with the McKenzie system of mechanical diagnosis and therapy.

BACKGROUND: Shoulder Orthopedic Special Tests (OSTs) are used to assist with diagnosis in shoulder disorders. Issues with reliability and validity exist, making their interpretation challenging. Exploring OST results on repeated testing within Mechanical Diagnosis and Therapy (MDT) shoulder classifications may offer insight into the poor performance of these tests. OBJECTIVES: To investigate in patients with shoulder complaints, whether MDT classifications affect the agreement of OST results over the course of treatment. METHODS: An international group of MDT clinicians recruited 105 patients with shoulder problems. Three commonly used OSTs (Empty Can, Hawkins-Kennedy, and Speed's tests) were utilized. Results of the OSTs were collected at sessions 1, 3, 5 and 8, or at discharge from an MDT classification-based treatment. The Kappa statistic was utilized to determine the agreement of the OST results over time for each of the MDT classifications. RESULTS: The overall Kappa values for Empty Can, Hawkins-Kennedy and Speed's tests were 0.28 (SE = 0.07), 0.28 (SE = 0.07) and 0.29 (SE = 0.07), respectively. The highest level of agreement was for Articular Dysfunction for the Empty Can test (0.84, SE = 0.19). For shoulder Derangements, there was no agreement for any of the OSTs (P values > 0.05). CONCLUSION: The lack of agreement when the OSTs were consecutively tested in the presence of the MDT Derangement classification contrasted with the other MDT classifications. The presence of Derangement was responsible for reducing the overall agreement of commonly used OSTs and may explain the poor consistency for OSTs.

Clinical utility of serum 25-hydroxyvitamin D in the diagnosis of insulin resistance and estimation of optimal 25-hydroxyvitamin D in U.S. adults.

AIMS: To assess the clinical utility of measuring serum 25-hydroxyvitamin-D [25(OH)D] along with traditional risk factors in the diagnosis of insulin resistance (IR) and to estimate the optimal 25(OH)D level associated with normal glucose and insulin homeostasis. METHODS: A cross-sectional analysis of 6868 adults aged≥20years without diagnosed diabetes in the National Health and Nutrition Examination Survey, with available standardized 25(OH)D data (2001-2010). IR was defined by the homeostatic-model-assessment of insulin resistance (HOMA-IR; ≥75th percentile, sex-specific: 3.9 in men or 3.6 in women). Using logistic regression, two risk models were developed to estimate the risk of IR: Model 1 included established risk factors, and Model 2 additionally included serum 25(OH)D. Predictiveness curves and decision-curve analysis were used to assess differences in IR detection among models. Receiver-operating-characteristic curves were used to estimate the lower threshold for 25(OH)D. Results were validated in a testing sample. RESULTS: Model 2 marginally improved detection of IR: at a risk threshold of 0.2, adding 25(OH)D would identify an additional 2 to 4 cases per 1000 people. Overall, the lower 25(OH)D threshold was estimated at 60nmol/L, however, the threshold differed by ethnicity (Mexican-Americans: 54nmo/L, non-Hispanic whites: 68nmol/L, and non-Hispanic blacks: 41nmol/L). CONCLUSION: Addition of serum 25(OH)D to traditional risk factors provided small incremental improvement in detection of IR in asymptomatic adults. The optimal 25(OH)D threshold was estimated to be at least 60nmol/L, however, the threshold may differ by ethnic-background. Further research is needed to validate these results in other populations.