Background:Positive airway pressure (PAP) therapy is prescribed to patients with obstructive sleep apnea (OSA). A commonly used definition for PAP therapy adherence is based upon the minimum requirements to receive Medicare coverage in the US, defined as PAP usage of four or more hours per night on 70 percent of nights for at least 30 consecutive days. However, little evidence exists to support this definition for PAP therapy adherence. Therefore, the present study sought to determine the efficacy of the present definition of PAP therapy adherence on longitudinal outcomes in patients with OSA, using objectively measured PAP device usage time. Methods:An exploratory longitudinal, retrospective, randomized chart review was done to assess clinical outcomes between patients with OSA who were defined as PAP therapy adherent (n=50) and non-adherent (n=50) during an eight-year observation period. Results:No significant differences were shown between groups for mortality, hospitalizations, or development of co-morbidities during the observation period. However, logistic regression showed significantly higher odds of adherence in male patients compared to female patients (OR=8.519; 95%CI=1.301-55.756; p=0.025) and significantly lower odds of adherence in patients with higher normal (OR=0.039; 95%CI=0.005-0.392; p=0.003), mild excessive (OR=0.039; 95%CI=0.003-0.517; p=0.014), and severe excessive (OR=0.088; 95%CI=0.012-0.635; p=0.016) daytime sleepiness compared to patients with lower normal daytime sleepiness. An increasing number of hospitalizations also corresponded with a significant decrease in odds of being adherent (OR=0.741; 95%CI=0.551-0.995; p=0.046). Conclusion:The present study supports a steadily growing body of literature calling for more consideration and evidence to support a definition of PAP therapy adherence that is clinically meaningful.

ObjectivesRegular exercise testing is recommended for people with cystic fibrosis (pwCF), as is the provision and regular review of exercise training programmes. A previous survey on exercise testing and training for pwCF in the UK was conducted over a decade ago. With the landscape of CF changing considerably during this time, this survey aimed to evaluate UK-based exercise testing and training practices for pwCF a decade on.DesignCross-sectional, online survey.ParticipantsA survey was distributed electronically to UK CF clinics and completed by the individual primarily responsible for exercise services. Descriptive statistics and qualitative analyses were undertaken.ResultsIn total, 31 CF centres participated, representing ~50% of UK specialist clinics. Of these, 94% reported using exercise testing, 48% of which primarily use cardiopulmonary exercise testing. Exercise testing mostly occurs at annual review (93%) and is most often conducted by physiotherapists (62%). A wide variation in protocols, exercise modalities, normative reference values and cut-offs for exercise-induced desaturation are currently used. All centres reportedly discuss exercise training with pwCF; 94% at every clinic appointment. However, only 52% of centres reportedly use exercise testing to inform individualised exercise training. Physiotherapists typically lead discussions around exercise training (74%).ConclusionsThese data demonstrate that the majority of respondent centres in the UK now offer some exercise testing and training advice for pwCF, representing a marked improvement over the past decade. However, continued efforts are now needed to standardise exercise practices, particularly regarding field testing practices and the translation of test results into personalised training programmes for pwCF.

Abstract Background Physical activity participation among preschoolers in childcare settings are low, and interventions to increase physical activity levels have produced mixed results. The Physical Literacy in the Early Years (PLEY) project implemented a six-month childcare-based outdoor loose parts play intervention in childcare centres in Nova Scotia, Canada. The purpose of this study was to examine the impact of the PLEY project on the development of domains of physical literacy (physical activity, physical competence, confidence and motivation, knowledge and understanding) in preschoolers attending childcare centres using mixed-methods. Methods Preschoolers (3–5 years) were recruited from 19 childcare centres in Nova Scotia and centres were randomized (parallel design) to the outdoor loose parts play intervention group (n = 11) or control (n = 8) group for 6 months. Participants, early childhood educators, and assessors were not blinded to group assignment. Quantitative and qualitative measures were used to comprehensively assess the impact of the PLEY project on all domains of physical literacy. At 3- and 6-months, early childhood educators participated in focus groups to assess how the intervention supported the development of 4 physical literacy domains: physical activity, physical competence, confidence and motivation, and knowledge and understanding. Physical activity and physical competence were also assessed with accelerometry and the Test of Gross Motor Development-3, respectively. Results Two hundred and nine preschoolers participated in the study (intervention group: n = 115; control group: n = 94). Accelerometer data showed that while baseline physical activity was similar between groups, children in the intervention group had higher physical activity at 3- (F(1,187) = 8.30, p = 0.004) and 6-months (F(1,187) = 9.90, p = 0.002) post-intervention. There was no intervention effect on physical competence scores. Thematic analysis of focus group data revealed that outdoor loose parts play contributed to development in all 4 physical literacy domains, including increased movement repertoires, social development, and enjoyment of physical activity. No adverse events or side effects of the intervention were reported. Conclusions Participation in the PLEY project was associated with increased development of various domains of physical literacy and perceived physical literacy among preschoolers, and outdoor loose parts play may be encouraged as an effective strategy to increase physical literacy in early learning settings. Trial registration Biomed Central (ISRCTN14058106), 20/10/2017.

Increasing rates of physical inactivity and sedentary behaviours among children and the youth are important determinants of chronic disease. Supporting children's participation in organised physical activities like sports has been promoted as a public health strategy to increase physical activity. Evidence shows that successful interventions are family-focused, although research on how parental eating and physical activity behaviours influence children's behaviours is deficient. In this commentary, we argue that interventions for countering physical inactivity and sedentary behaviours should include greater focus on home and social environments, specifically the influence and involvement of parents, siblings, and friends in supporting these health behaviours. We conclude that the design of interventions to prevent chronic diseases in children should also consider more carefully the conditions in which the behaviours of children and their parents occur. This means encouraging parents and children to be active together to address physical inactivity and sedentary behaviours, while being mindful of unintended consequences of focusing on one behaviour over another.

Purpose: This pilot study sought to examine the fundamental movement skills (FMS) and physical literacy (PL) of children with juvenile idiopathic arthritis (JIA) and to explore their relationship with physical activity (PA) and parent perceptions of PA-related risks. Methods: Twenty-five children with JIA and their parents completed questionnaires. Fundamental movement skills were assessed in the laboratory and PA through accelerometry data. Results: Children spent a median of 39.4%, 40.9%, and 18.2% of their day sedentary, in light, and in moderate to vigorous PA, respectively. Fundamental movement skills and PL scores were within the average range, although were related to which joints (upper/lower body) were affected by JIA. Parents who viewed activities such as biking and climbing as risky tended to have children with weaker locomotor skills and lower PL. Conclusion: Children with JIA had age-appropriate PA, FMS, and PL; however, parent perceptions of PA-related risks are related to their child's FMS and PL.

OBJECTIVES:The COVID-19 pandemic has resulted in unprecedent changes to clinical practice, and as the impact upon delivery of exercise services for people with cystic fibrosis (CF) in the United Kingdom was unknown, this was characterised via a national survey.METHODS:An electronic survey was distributed to healthcare professionals involved in the exercise management of CF via established professional networks.RESULTS:In total, 31 CF centres participated. Findings included significant reductions in exercise testing and widespread adaptation to deliver exercise training using telehealth methods. Promisingly, 71% stated that they would continue using virtual methods of engaging patients in future practice.CONCLUSION:These findings highlight adaptation to the COVID-19 pandemic and the need to develop sustainable and standardised telehealth services to manage patients moving forwards.

Purpose Physical activity (PA) and sleep are highly important for those with cystic fibrosis (CF), yet, despite this and suggestions of a bidirectional relationship between these factors in healthy children, their relationship is yet to be investigated. Methods PA, sedentary time (SED), and sleep were objectively derived over seven days in 58 youth (11.9 +/- 2.7 years; 29 CF). Generalized linear latent and mixed models with a random intercept and slope at child-level were adjusted for age, sex, wear-time, type of day, group and mean PA/SED and sleep. Results Every additional 10 min sedentary was associated with 5.6 and 5.0 min less sleep and 10.6 and 12.0 min less wake after sleep onset (WASO) that night, in CF and healthy children, respectively. PA, regardless of intensity, was not associated with total sleep time but every additional 10 min of light PA (LPA) was associated with 3.0 min less WASO in healthy participants. Ten mins more sleep was associated with 3.1 and 1.7 min less SED in CF and healthy children, respectively. In CF, greater sleep time led to less LPA (3.6 min) the following day, whereas, in healthy children, poor sleep quality (greater WASO) was associated with more LPA (1.4 min) and moderate-to-vigorous PA (5.2 min) the following day. Conclusion A bidirectional relationship between SED and subsequent total sleep time was evident, irrespective of group, whereas the relationship between sleep and PA was group dependent. These findings have important implications regarding the reciprocal effects of promoting PA or sleep quantity or quality.

Development of fundamental movement skills in early childhood supports lifelong health. The potential for outdoor play with loose parts to enhance fundamental movement skills has not been investigated. A multi-methods randomized controlled design was used to determine the efficacy of integrating outdoor loose parts play into Nova Scotia childcare centers (19 sites: 11 interventions, 8 control). Movement skills (n = 209, age 3-5 years) were assessed over a 6-month period to investigate changes in fundamental movement skills over time and between groups. Qualitative data was also collected on the educators' perceptions of outdoor loose parts play. Quantitative data (fundamental movement skills) revealed a non-intervention effect, however, educators spoke of outdoor loose parts play providing opportunities to combine/ repeat movements and take risks; supporting physical, cognitive and socio-emotional (holistic) development; and increasing awareness of children's physical development and how to support it. Our findings demonstrate value in outdoor loose parts play for the development of fundamental movement skills in childcare settings.

PURPOSE:Physical activity (PA) predicts important health outcomes in chronic obstructive pulmonary disease (COPD). In the general population, environmental factors have the potential to influence PA; however, data are limited in this clinical population. Therefore, we sought to investigate associations between the environment and PA, sedentary behavior, and self-rated health in COPD. METHODS:Sociodemographic, PA, sedentary behavior, and self-rated health data were collected from a prospective cohort of 418 individuals with COPD (65% female; 58 ± 8 yr), while environmental data were drawn from a national environmental data repository and individually matched to participant postal code. Environmental variables included social and material deprivation, urban form index, surrounding greenness, and air quality (concentrations of air pollution for fine particles, nitrogen dioxide, ozone, and sulphur dioxide). Logistic and multivariate linear regression models were used to investigate the strongest environmental predictors. RESULTS:The models showed a statistically significant negative correlation between PA level and ozone pollution (P = .023; adjusted OR = 0.85: 95% CI, 0.74-0.98). Urban form index was also significantly associated with sedentary behavior (β = 0.113; t value = 1.71; P = .011). Self-rated health was significantly positively correlated with PA level (P = .006; adjusted OR = 2.22: 95% CI, 1.25-3.94), and significantly inversely correlated with sedentary behavior (β = -0.159; t value =-2.42; P = .016). CONCLUSION:These new data may identify barriers to PA and assist clinicians in the prescription of exercise for individuals living with COPD.

Abstract Background The standard first- and second- line chemotherapy backbone regimens for metastatic colorectal cancer (mCRC) are 5-fluorouracil (5-FU)/capecitabine-based with addition of irinotecan or oxaliplatin. Until recently, evidence for optimal sequencing post second-line was sparse. Trifluridine/tipiracil (indicated for mCRC and gastric cancer after standard chemotherapies) was made available to UK patients via a named patient programme (NPP) before receiving marketing authorisation in Europe in 2016, allowing characterisation of UK treatment pathways, and evaluation of trifluridine/tipiracil in a UK non-trial population. Methods Data collected routinely for the NPP were analysed to describe the patient demographics, clinical characteristics and treatment pathways. Patients eligible for the programme were adults (≥18 years) with histologically or cytologically confirmed mCRC who had previously received chemotherapy treatment(s). Results Of the 250 eligible patients enrolled in the NPP, 194 patients received ≥1 dose of trifluridine/tipiracil and 56 patients did not receive trifluridine/tipiracil. The following results are reported first for patients who received trifluridine/tipiracil and second for those who did not receive trifluridine/tipiracil: median (IQR) age was 63.0 (54.0–69.0) and 62.0 (54.8–69.0) years; Eastern Cooperative Oncology Group performance status score was 0 for 28 and 14%, 1 for 65 and 70%, 2 for 7 and 16%. In terms of previous systemic treatments 47 and 43% had 2 prior lines of therapy. FOLFOX-, FOLFIRI- and CAPOX-based therapies were the most common first-line regimens in patients receiving trifluridine/tipiracil (37, 35 and 21%, respectively), and in patients not receiving trifluridine/tipiracil (41, 30 and 20%, respectively). Second-line treatment regimens in patients receiving and not receiving trifluridine/tipiracil were most commonly FOLFIRI-based (48 and 41%, respectively) and FOLFOX-based (19 and 21%, respectively). Patients received a median of 2 cycles of trifluridine/tipiracil with a median treatment duration of 1.8 (95% CI: 1.8–2.4) months. In patients who discontinued treatment due to disease progression, the median progression-free duration was 2.8 (95% CI: 2.4–2.9) months. Conclusions The results highlight the number of treatment pathways used to treat mCRC in routine UK clinical practice prior to the marketing authorisation and National Institute for Health and Care Excellence approval of trifluridine/tipiracil and highlight the lack of clinical guidelines for mCRC.

For a seismically designed concentrically braced frame with hollow structural sections as braces, the typical connection design consists of a slotted brace that is field welded to a gusset plate. During an earthquake, the brace is expected to buckle out-of-plane and the gusset plate is expected to yield. This makes it difficult to repair or replace the brace and connection, and the out-of-plane brace buckling caused by this connection can also damage surrounding walls and cladding, with potential life safety implications. This paper proposes an alternative connection that is expected to result in reduced erection costs by avoiding site welding, and also to simplify structural repairs following a major earthquake by confining all damage to a replaceable brace module. Additionally, the new connection causes the brace to buckle in-plane during a seismic event, reducing the potential for damage to the surrounding walls and cladding. This paper discusses large-scale quasi-static cyclic testing of eight brace modules with two variations of the new connection, one with a single-shear eccentric splice and the other with a double-sided concentric splice. All tested specimens had the desired failure progression and buckled in-plane, as intended. Bolt slip in the connection had very little effect on the overall force-deflection response after the brace compressive strength degraded to less than the slip load. The brace module was replaced after each test without observable damage outside the module. Although both connection variations behaved in a desirable manner, the single-shear eccentric splice was preferred because of the simpler constructability and improved performance. (C) 2019 American Society of Civil Engineers.

Environmental factors like drought impact the quality of biomass entering a bioconversion process. Drought often reduces the sugar content in lignocellulosic biomass, which could have economic impacts, particularly when compounded with losses in dry biomass yield; however, the effects on conversion efficiency are not completely understood. This study investigated how drought may impact biomass composition and sugar yields from dilute-acid pretreatment and enzymatic hydrolysis of Miscanthus, a tall fescue mixture, and switchgrass from Nebraska, Missouri, and Oklahoma, respectively, grown as part of Regional Feedstock Partnership field trials. Samples were grown and harvested in 2010 during non-drought conditions and in 2012 during extreme drought conditions. Non-structural glucose and proline were significantly greater in 2012 compared with 2010 for Miscanthus, which suggests drought stress occurred. Structural glucan and xylan were significantly decreased in 2012 for Miscanthus; however, reactivity and sugar yields from dilute-acid pretreatment and enzymatic hydrolysis were significantly greater in 2012 compared with 2010, suggesting that although structural sugars may decrease during drought conditions, sugar yields and reactivity may increase. For the tall fescue mixture, proline was greater, and structural sugars were lower in 2012, indicating drought stress, but minimal differences were observed in the conversion experiments. Few differences were observed for switchgrass composition and reactivity between years. The observed patterns are likely because of site-specific climatic conditions combined with the tolerance each species may have to drought. As drought occurrence and severity have increased, it is necessary to understand drought impacts to mitigate risks to future bioenergy industry growth.

Tucker and colleagues present an eloquent study investigating the acute pulmonary responses to a single bout of maximal exercise [[1]Tucker M.A. Crandall R. Seigler N. Rodriguez-Miguelez P. McKie K.T. Forseen C. et al.A single bout of maximal exercise improves lung function in patients with cystic fibrosis.J Cyst Fibros. 2017; 16: 752-758Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. The study showed a group mean increase in FEV1 of 0.06 L. Thus, leading the authors to conclude that a single bout of maximal exercise improves lung function. However, an inspection of the scatter plots presented in the article show that eight patients (~25%) responded with a decline in FEV1. A previous study by Stevens et al., [[2]Stevens D. Oades P.J. Williams C.A. Airflow limitation following cardiopulmonary exercise testing and heavy-intensity intermittent exercise in children with cystic fibrosis.Eur J Pediatr. 2015; 174: 251-257Crossref PubMed Scopus (8) Google Scholar] cited in the article, reported that 32% of young cystic fibrosis patients responded to maximal exercise with a fall in FEV1 (L) by 10% or more. A reduction in FEV1 (L) of 10% or greater was used in the study by Stevens et al. as criteria to define airflow limitation [[3]Parsons P.J. Hallstrand T.S. Mastronarde J.G. Kaminsky D.A. Rundell K.W. Hull J.H. et al.An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction.Am J Respir Crit Care Med. 2013; 187: 1016-1027Crossref PubMed Scopus (372) Google Scholar]. The two studies show the variance in the direction and degree of change in airway dynamics between some patients, and the response to maximal exercise appears to be unrelated to conventional measures of disease severity such as FEV1. The work of Tucker and colleagues extends the previous work of Stevens et al. by measuring other pulmonary indices, besides spirometry, in an effort to better elucidate potential mechanisms responsible for changing airway dynamics following a bout of maximal exercise. Tucker and colleagues reported that, while the lung clearance index decreased significantly following a single bout of exercise that may in part explain the corresponding increase in FEV1; airway inflammation as assessed by exhaled nitrate oxide, lung diffusion capacity and impulse oscillometry remained as a whole in the group unchanged [[1]Tucker M.A. Crandall R. Seigler N. Rodriguez-Miguelez P. McKie K.T. Forseen C. et al.A single bout of maximal exercise improves lung function in patients with cystic fibrosis.J Cyst Fibros. 2017; 16: 752-758Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. However, in those patients whose lung function decreased following maximal exercise it would be of interest to determine which of these pulmonary variables are the main drivers causing an adverse response to lung function. Respiratory muscle fatigue may also be a potential mechanism affecting the patient's ability to forcefully expire during spirometry testing following maximal exercise. It has been suggested that in cystic fibrosis, respiratory muscle fatigue caused by an imbalance between workload and work capacity may be a result of airway obstruction due to airway inflammation resulting in high airway resistance and cost of breathing [[4]Pinet C. Cassart M. Scillia P. Lamotte M. Knoop C. Casmir G. et al.Function and bulk of respiratory and limb muscles in patients with cystic fibrosis.Am J Respir Crit Care Med. 2003; 168: 989-994Crossref PubMed Scopus (73) Google Scholar. A significant positive relationship between peak work rate, minute ventilation and the change in FEV1 pre to post maximal exercise is reported by Tucker et al., demonstrating that those patients exercising at a greater work rate and/or higher ventilatory effort showed the largest increases in FEV1. Theoretically, however, any patients in the group with expiratory flow limitation resulting in air trapping during exercise may show a reduction in FEV1 following maximal exercise. In other chronic lung diseases such as COPD, dynamic hyperinflation can manifest when ventilation is increased in the setting of expiratory flow limitation [[5]O'Donnell D.E. Webb K.A. Neder J.E. Lung hyperinflation in COPD: applying physiology to clinical practice.COPD Research and Practice. 2015; 1: 4https://doi.org/10.1186/s40749-015-0008-8Crossref Scopus (51) Google Scholar]. This may acutely reduce forced expiratory measures such as FEV1 following exercise, however, a time course for the lungs to ‘deflate’ is not certain. The prescription of maximal (or near maximal) exercise to acutely improve lung function, therefore, is valid in some patients but not in all. Tucker and colleagues study further emphasizes the importance of assessing the acute physiological responses following exercise testing (i.e., change in airway dynamics), and not just the end points as generally measured in clinical practice (i.e., peak oxygen uptake). This information could better inform clinicians of the advice that they should give to their individual patients regarding exercise and its prescription, as well as presenting a more detailed physiological picture of the patient. However, as Tucker and colleagues suggest, more work needs to be done to improve our knowledge of the potential mechanisms driving these changes and to explain the degree of variability between patients.

>The Systolic Heart failure treatment with the I f inhibitor ivabradine Trial (SHIFT, n=6505) evaluated patients with symptomatic chronic heart failure (CHF), in sinus rhythm with resting heart rate≥70 beats/min and left ventricular ejection fraction (LVEF)≤35%, average age 60±11years. [1] The addition of ivabradine, a selective inhibitor of

INTRODUCTION:Lung hyperinflation is a potential mechanism limiting exercise tolerance. However, available data on the impact of static hyperinflation on exercise performance in adult cystic fibrosis are lacking. Furthermore, the relative contribution of both static and dynamic hyperinflation to exercise performance is unknown.OBJECTIVES:The aim of this study was to determine the impact of static hyperinflation on exercise tolerance and lung dynamics in adult cystic fibrosis.METHODS:Clinical data of 107 adult patients with cystic fibrosis, including pulmonary function, lung volumes and cardiopulmonary exercise from the Toronto Cystic Fibrosis database, were collected and analyzed. Patients were classified as having static hyperinflation with a residual volume to total lung capacity (RV/TLC) ratio of 30% or greater.RESULTS:Patients with static hyperinflation demonstrated a significant reduction in exercise performance [peak oxygen uptake (% predicted) 70 ± 17 vs 80 ± 17; P = .006] and were more likely to experience ventilatory limitation when exercising (Fisher's exact test P < .001). Correlation analysis showed significant relationships between measures of static hyperinflation [RV/TLC ratio (%)] and exercise performance [peak oxygen uptake (% predicted); r = -.38, P < .001] and dynamic hyperinflation (r = -.35, P < .001). Multiple linear regression showed that the contribution of static hyperinflation to exercise performance [peak oxygen uptake (% predicted)] was greater than that of airway obstruction (forced expiratory volume in 1 second).CONCLUSION:Clinicians working with this patient group in a pulmonary rehabilitation or health care setting may wish to consider using measures of static hyperinflation as end points to determine program or treatment efficacy.

Purpose: Dyspnea is a highly distressing symptom of pulmonary disease that can make performing physical activities challenging. However, little is known regarding the strongest predictors of exercise-related dyspnea in adult cystic fibrosis (CF). Therefore, the purpose of the present study was to determine the best clinical model of exercise-related dyspnea in this patient group. Methods: A retrospective analysis of pulmonary function and cardiopulmonary exercise testing data from patients with CF being followed up at the Adult CF Program at St Michael's Hospital, Toronto, Canada, from 2002 to 2008 were used for the analysis. Results: Patients (n = 88) were male 66%; aged 30.4 ± 9.4 years; body mass index (BMI) 23.1 ± 3.3 kg/m2; forced expiratory volume in 1 second (FEV1) 70% ± 19% predicted; and peak oxygen uptake 74% ± 20% predicted. A multivariate linear regression model assessing the effects of age, sex, BMI, airway obstruction (FEV1), perceived muscular leg fatigue, and dynamic hyperinflation explained 54% of the variance in dyspnea severity at peak exercise (P < .01). Relative importance analysis showed that the presence of dynamic hyperinflation and perceived muscular leg fatigue were the largest contributors. Conclusions: Pulmonary rehabilitation programs may consider strategies to reduce dynamic hyperinflation and promote muscular function to best improve exercise-related dyspnea in this patient group.

This study characterised oxygen uptake efficiency (OUE) in children with mild-to-moderate cystic fibrosis (CF). Specifically, it investigated (1) the utility of OUE parameters as potential submaximal surrogates of peak oxygen uptake (\(\dot {V}{{\text{O}}_{2{\text{peak}}}}\)), and (2) the relationship between OUE and disease severity.