PURPOSE:Evaluate the clinimetric properties and clinical utility of the Short Physical Performance Battery (SPPB) in survivors of critical illness up to 6 months post-hospital discharge. MATERIALS AND METHODS:Clinimetric analysis of three international datasets (n = 488 ICU survivors) from the United States and Australia. RESULTS:At hospital discharge, the SPPB demonstrated moderate-to-excellent construct validity with the six-minute walk test (rho = 0.81, p < 0.001), Timed Up and Go (TUG) (rho = -0.87, p < 0.001), and dual TUG (rho = -0.75, p < 0.001); and fair-to-moderate construct validity with handgrip and quadriceps strength. At hospital discharge it predicted minimal to mild limitations (score 7-12) at 6 months post (AUC 0.78 [0.72-0.84]). Responsiveness was observed, with the largest effect size (0.72) between hospital discharge and 3 months. Minimal clinical difference (from distribution-based methods) ranged from 1.21 to 1.43 out of 12 across timepoints. Floor effects were present at hospital discharge (18.8%) and ceiling effects at 3- and 6-months post (26.5% and 28.1%). At 3 months post, participants with moderate-to-severe limitations (score 0-6) performed worse on physical and strength-based measures. CONCLUSIONS:The SPPB is a valid tool that can be used to monitor physical function recovery. It may have the potential for prediction of physical limitations particularly at hospital discharge, however further validation is required.

OBJECTIVE: To explore if patient characteristics (pre-existing comorbidity, age, sex, and illness severity) modify the effect of physical rehabilitation (intervention vs control) for the coprimary outcomes health-related quality of life (HRQoL) and objective physical performance using pooled individual patient data from randomized controlled trials (RCTs).DATA SOURCES: Data of individual patients from four critical care physical rehabilitation RCTs.STUDY SELECTION: Eligible trials were identified from a published systematic review.DATA EXTRACTION: Data sharing agreements were executed permitting transfer of anonymized data of individual patients from four trials to form one large, combined dataset. The pooled trial data were analyzed with linear mixed models fitted with fixed effects for treatment group, time, and trial.DATA SYNTHESIS: Four trials contributed data resulting in a combined total of 810 patients (intervention n = 403, control n = 407). After receiving trial rehabilitation interventions, patients with two or more comorbidities had HRQoL scores that were significantly higher and exceeded the minimal important difference at 3 and 6 months compared with the similarly comorbid control group (based on the Physical Component Summary score (Wald test p = 0.041). Patients with one or no comorbidities who received intervention had no HRQoL outcome differences at 3 and 6 months when compared with similarly comorbid control patients. No patient characteristic modified the physical performance outcome in patients who received physical rehabilitation.CONCLUSIONS: The identification of a target group with two or more comorbidities who derived benefits from the trial interventions is an important finding and provides direction for future investigations into the effect of rehabilitation. The multimorbid post-ICU population may be a select population for future prospective investigations into the effect of physical rehabilitation.

Current literature yields unequivocal results regarding the effect of body composition on physical function in patients with chronic obstructive pulmonary disease and disproportionately includes a majority of males. The purpose of this study was to determine whether specific body composition measures are significantly associated with physical function and exercise capacity in patients with chronic obstructive pulmonary disease with equal representation of males and females. Independent variables included sex, total body mass, total body lean and fat mass, appendicular total mass, and appendicular lean and fat mass. Dependent variables included peak oxygen consumption, 6-minute walk distance and self-reported physical function. Patients (n = 170) with dual-energy X-ray absorptiometry data, 6-minute walk distance, and self-reported physical function were used for these analyses. A sub-set of 145 of these patients with peak oxygen consumption data were also analysed. Hierarchical multiple regression analysis was used to determine if sex and body composition measures correlated with physical function and exercise capacity and if they explained additional variance after controlling for disease severity. After controlling for disease severity, appendicular lean mass, total body fat mass, and sex explained an additional 16.5% of the variance in peak oxygen consumption (p < 0.001). Appendicular lean mass explained an additional 8.9% of the variance in 6-minute walk distance (p < 0.001) and an additional 2.5% of the variance in self-reported physical function (p = 0.057). Body composition measures may further predict exercise capacity, 6-minute walk distance, and self-reported physical function in patients with chronic obstructive pulmonary disease.

BackgroundMobile health interventions for weight loss frequently use automated messaging. However, this intervention modality appears to have limited weight loss efficacy. Furthermore, data on users’ subjective experiences while receiving automated messaging–based interventions for weight loss are scarce, especially for more advanced messaging systems providing users with individually tailored, data-informed feedback. ObjectiveThe purpose of this study was to characterize the experiences of individuals with overweight or obesity who received automated messages for 6-12 months as part of a behavioral weight loss trial. MethodsParticipants (n=40) provided Likert-scale ratings of messaging acceptability and completed a structured qualitative interview (n=39) focused on their experiences with the messaging system and generating suggestions for improvement. Interview data were analyzed using thematic analysis. ResultsParticipants found the messages most useful for summarizing goal progress and least useful for suggesting new behavioral strategies. Overall message acceptability was moderate (2.67 out of 5). From the interviews, 2 meta-themes emerged. Participants indicated that although the messages provided useful reminders of intervention goals and skills, they did not adequately capture their lived experiences while losing weight. ConclusionsMany participants found the automated messages insufficiently tailored to their personal weight loss experiences. Future studies should explore alternative methods for message tailoring (eg, allowing for a higher degree of participant input and interactivity) that may boost treatment engagement and efficacy. Trial RegistrationClinicalTrials.gov NCT05231824; https://clinicaltrials.gov/study/NCT05231824

Beetroot juice is a food high in nitrate and is associated with cardiometabolic health benefits and enhanced exercise performance through the production of nitric oxide in the nitrate–nitrite–nitric oxide pathway. Since various food components influence this pathway, the aim of this trial was to study the effect of beetroot juice alone and in conjunction with vitamin C or protein on the acute response to plasma nitrate and nitrite levels in healthy middle- to older-aged adults. In this cross-over trial, each participant received, in a randomized order, a single dose of Beet It Sport® alone; Beet It Sport®, plus a 200 mg vitamin C supplement; and Beet It Sport® plus 15 g of whey protein. Plasma levels of nitrate and nitrite were determined prior to and at 1 and 3 h after intervention. Log plasma nitrate and nitrite was calculated to obtain data that were normally distributed, and these data were analyzed using two-way within-factors ANOVA, with time and treatment as the independent factors. There were no statistically significant differences for log plasma nitrate (p = 0.308) or log plasma nitrite (p = 0.391) values across treatments. Log plasma nitrate increased significantly from pre-consumption levels after 1 h (p < 0.001) and 3 h (p < 0.001), but plasma nitrate was lower at 3 h than 1 h (p < 0.001). Log plasma nitrite increased from pre to 1 h (p < 0.001) and 3 h (p < 0.001) with log values at 3 h higher than at 1 h (p = 0.003). In this cohort, we observed no differences in log plasma nitrate and nitrite at 1 h and 3 h after co-ingesting beetroot juice with vitamin C or a whey protein supplement compared to beetroot juice alone. Further research needs to be undertaken to expand the blood-sampling time-frame and to examine factors that may influence the kinetics of the plasma nitrate to nitrite efficacy, such as differences in fluid volume and osmolarity between treatments employed.

Introduction: Level one evidence supports improvement in physical function at hospital discharge following rehabilitation for critically ill adults. The effect beyond hospital discharge is unclear.

Introduction: Level one evidence shows physical function improves at hospital discharge following rehabilitation, the longer-term effect is unclear. Aims and Objectives: Explore if patient characteristics of critically ill adults modify rehabilitation outcomes using individual patient data from randomized trials. Methods: The interaction between treatment group, four patient characteristics (comorbidity, age, sex and illness severity) and patient outcomes were examined. Co-primary outcomes were physical function at hospital discharge, three and six months and health-related quality of life (HRQoL) measured with the SF-12 or SF-36 at three, six and 12 months. Analyses were performed by fitting linear mixed models with fixed effects for treatment group, time and trial. Results: Four trials from United States (n=2), United Kingdom (n=1) and Australia (n=1) contributed data totaling 810 patients. Comorbidities modified the outcome of rehabilitation for the Physical Component Summary (PCS) score of HRQoL. Patients with two or more comorbidities (Functional Comorbidity Index score ≥2) had PCS scores below normative values (mean 50±10) which improved following the intervention at three (effect estimate (95% CI) intervention vs control 36.2 (34.4, 38.1) vs 30.4 (28.3, 32.6)) and six months (38.3 (36.4, 40.1) vs 32.5 (30.4, 34.6)) but not 12 months. No other patient characteristic modified the outcome of rehabilitation for HRQoL or physical function. Conclusions: This is the first study to identify a target group of critically ill patinets in who rehabilitation impacts physical recovery. These findings are important clinically and provide direction for future research.

Abstract Long-term consumption of beetroot juice on efficacy of converting dietary nitrate to plasma nitrate and nitrite was investigated. Adults were randomized to consume either beetroot juice with 380 mg of nitrate (BR) or a beetroot juice placebo (PL) for 12-weeks. Plasma nitrate and nitrite were measured before and 90-minutes after consuming their intervention beverage. Percent change in nitrite across the 90 min was greater in BR (273.2 ± 39.9%) vs. PL (4.9 ± 36.9%). Long-term consumption of nitrate containing beetroot juice increased fasting nitrate and nitrite plasma levels compared to baseline.

The COVID-19 pandemic was a monumental exogeneous shock to the Colorado economy. Prior to the pandemic’s onset the state reported historically low unemployment alongside robust growth in personal income levels and state revenue. While the negative economic effects of the pandemic were sharp, the state’s economic recovery is outpacing what many economists previously projected. The General Assembly was compelled to impose major cuts to last year’s budget, many of which were restored with the enactment of the budget for the 2021–2022 fiscal year. The General Fund budget of $13.6 billion proposed by Democratic Governor Jared Polis represented a substantial spending increase of 20 percent from the prior year. The enacted $13.1 billion General Fund budget received nearly unanimous approval among Democrats and modest Republican support. Policymakers ultimately sought to balance competing priorities across many issue areas, while also preparing for the future with a major investment of $1.5 billion to the state’s reserve fund.

Abstract Pain catastrophizing is prominent in chronic pain conditions such as fibromyalgia and has been proposed to contribute to the development of pain widespreadness. However, the brain mechanisms responsible for this association are unknown. We hypothesized that increased resting salience network (SLN) connectivity to nodes of the default mode network (DMN), representing previously reported pain-linked cross-network enmeshment, would be associated with increased pain catastrophizing and widespreadness across body sites. We applied functional magnetic resonance imaging (fMRI) and digital pain drawings (free-hand drawing over a body outline, analyzed using conventional software for multivoxel fMRI analysis) to investigate precisely quantified measures of pain widespreadness and the associations between pain catastrophizing (Pain Catastrophizing Scale), resting brain network connectivity (Dual-regression Independent Component Analysis, 6-minute multiband accelerated fMRI), and pain widespreadness in fibromyalgia patients (N = 79). Fibromyalgia patients reported pain in multiple body areas (most frequently the spinal region, from the lower back to the neck), with moderately high pain widespreadness (mean ± SD: 26.1 ± 24.1% of total body area), and high pain catastrophizing scale scores (27.0 ± 21.9, scale range: 0-52), which were positively correlated (r = 0.26, P = 0.02). A whole-brain regression analysis focused on SLN connectivity indicated that pain widespreadness was also positively associated with SLN connectivity to the posterior cingulate cortex, a key node of the DMN. Moreover, we found that SLN-posterior cingulate cortex connectivity statistically mediated the association between pain catastrophizing and pain widespreadness (P = 0.01). In conclusion, we identified a putative brain mechanism underpinning the association between greater pain catastrophizing and a larger spatial extent of body pain in fibromyalgia, implicating a role for brain SLN-DMN cross-network enmeshment in mediating this association.

Objective: Limited data exist on the quantification of activity levels and functional status in critically ill patients as they transition from the intensive care unit (ICU) to the wards and, subsequently, back into the community. The physical activity of critically ill patients from their ICU stay until 7 days after hospital discharge was characterized, as well as correlate physical activity levels with an objective measure of physical function. Methods: This prospective observational study of previously independent adults aged 55 or older, undergoing mechanical ventilation for up to 7 days, recruited participants at the time of spontaneous breathing trials or less than 24 hours after extubation. Participants received an accelerometer at enrollment to wear until 1 week after discharge. Results: Twenty-two participants received accelerometers; 15 were suitable for analysis. Participants had a mean (SD) age of 68 (9.6) years; 47% were female. Mean step counts were 95 (95% CI = 15-173) in the 3 days before ICU discharge, 257 (95% CI = 114-400) before hospital discharge, 1223 (95% CI = 376-2070) in the first 3 days at home, and 1278 (95% CI = 349-2207) between day 4 and 6 post-hospital discharge. Physical activity was significantly higher post- compared with pre-hospital discharge. Short Physical Performance Battery scores were poor at ICU and hospital discharge; however, they correlated moderately with physical activity levels immediately upon return home. Conclusions: Physical activity remained low as survivors of critical illness transitioned from ICU to hospital wards, but significantly increased upon return to the community. Despite poor Short Physical Performance Battery scores at both ICU and hospital discharge, participants were significantly more active immediately after discharge than in their last 3 days of hospitalization. This may represent rapid functional improvement or, conversely, constrained physical activity in hospital. Impact: This study highlights the need for further evaluation of physical activity constraints in hospital and ways to augment physical activity and function upon discharge. Lay Summary: Physical activity (step counts) increased modestly as survivors of critical illness transitioned from ICU to hospital wards, but significantly increased upon return to the community. This study highlights the need for further evaluation of physical activity constraints in the hospital setting and ways to augment physical activity and function postdischarge.

ABSTRACT State legislatures in the United States began using the legislative veto in 1939 to block rules issued by state agencies. At present, 25 state legislatures possess some form of independent legislative veto authority. This study uses a transaction cost theoretical approach to analyse factors expected to influence the adoption and expansion of legislative veto oversight. Results indicate that such measures are more likely in non-Southern states when a single party controls the state legislature, while legislative size and professionalisation do not substantially affect legislative veto reforms. Empirical analysis differentiating veto power according to whether legislators can nullify or suspend rules shows some differences in the factors affecting the imposition of each oversight type. The most consistent finding is that empowering legislatures with legislative veto authority is more likely to occur with a Republican governor in office.

PURPOSE: Nitrate (NO3-), through its conversion to nitrite (NO2-) and nitric oxide, has been shown to increase exercise tolerance in healthy younger adults and older diseased patients. Nitrate’s effect in well-trained middle to older-aged adults has not been studied. Therefore, the purpose of this investigation was to examine the effects of a NO3- rich beverage on submaximal constant work rate exercise time in well-trained middle to older-aged adults. METHODS: Fifteen, 41-64 year-old, well-trained middle to older-aged adults were assigned to receive one of two treatments (NO3- rich beverage then placebo or placebo then NO3- rich beverage), after which an exercise test at 75 percent of the subject’s maximal work rate was completed. RESULTS: The NO3- rich beverage increased plasma NO3- and NO2- levels by 270 μM and 0.81 μM, respectively (p<0.001). Exercise time was not significantly different (p=0.31) between the NO3- rich versus placebo conditions (1130±151 vs 1060±132 sec, respectively). Changes in exercise time between the two conditions ranged from a 55% improvement to a 40% decrease with the NO3- rich beverage. Oxygen consumption and rating of perceived exertion were not significantly different between the two conditions. CONCLUSIONS: In middle to older-aged well-trained adults, NO3- supplementation has non-significant, albeit highly variable, effects on exercise tolerance.

Nitrate rich beetroot juice (BRJ) can enhance nitric oxide signaling, leading to improved physical function in healthy and diseased populations, but its safety and biologic efficacy have not been evaluated in a critically ill population. We randomized 22 previously functional acute respiratory failure patients to either BRJ or placebo daily until day 14 or discharge. We measured blood nitrate and nitrite levels and quantified strength and physical function at intensive care unit (ICU) and hospital discharge. Participants were predominantly male (54%), aged 68.5 years with an APACHE III score of 62. BRJ increased plasma nitrate (mean 219.2 μM increase, p = 0.002) and nitrite levels (mean 0.144 μM increase, p = 0.02). We identified no adverse events. The unadjusted and adjusted effect sizes of the intervention on the short physical performance battery were small (d = 0.12 and d = 0.17, respectively). In this pilot trial, administration of BRJ was feasible and safe, increased blood nitrate and nitrate levels, but had a small effect on physical function. Future studies could evaluate the clinical efficacy of BRJ as a therapy to improve physical function in survivors of critical illness.

INTRODUCTION:The number of inconclusive physical rehabilitation randomised controlled trials for patients with critical illness is increasing. Evidence suggests critical illness patient subgroups may exist that benefit from targeted physical rehabilitation interventions that could improve their recovery trajectory. We aim to identify critical illness patient subgroups that respond to physical rehabilitation and map recovery trajectories according to physical function and quality of life outcomes. Additionally, the utilisation of healthcare resources will be examined for subgroups identified. METHODS AND ANALYSIS:This is an individual participant data meta-analysis protocol. A systematic literature review was conducted for randomised controlled trials that delivered additional physical rehabilitation for patients with critical illness during their acute hospital stay, assessed chronic disease burden, with a minimum follow-up period of 3 months measuring performance-based physical function and health-related quality of life outcomes. From 2178 records retrieved in the systematic literature review, four eligible trials were identified by two independent reviewers. Principal investigators of eligible trials were invited to contribute their data to this individual participant data meta-analysis. Risk of bias will be assessed (Cochrane risk of bias tool for randomised trials). Participant and trial characteristics, interventions and outcomes data of included studies will be summarised. Meta-analyses will entail a one-stage model, which will account for the heterogeneity across and the clustering between studies. Multiple imputation using chained equations will be used to account for the missing data. ETHICS AND DISSEMINATION:This individual participant data meta-analysis does not require ethical review as anonymised participant data will be used and no new data collected. Additionally, eligible trials were granted approval by institutional review boards or research ethics committees and informed consent was provided for participants. Data sharing agreements are in place permitting contribution of data. The study findings will be disseminated at conferences and through peer-reviewed publications. PROSPERO REGISTRATION NUMBER:CRD42019152526.

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Pulmonary arterial hypertension (PAH) is characterized by impaired pulmonary vascular structure and function and is commonly associated with symptoms of dyspnea, fatigue, and potentially syncope. With chronic exposure to elevated pulmonary pressures, dramatic right ventricular dysfunction is common, thereby compromising cardiorespiratory fitness and increasing the risk of mortality. Collective investigative efforts, both at the preclinical and clinical levels, have established the safety and efficacy of regular exercise training in improving quality of life, cardiorespiratory fitness, and the physiologic profile of patients with PAH. Although the total volume of exercise training studies in patients with PAH pales in comparison with other chronic conditions, evidence for the optimal training recommendations is emerging. This review aims to provide a synopsis of the current exercise training literature in patients with PAH and provide preliminary training recommendations that can be implemented in rehabilitation programs.

During the final year of Governor John Hickenlooper's second term as governor the General Assembly passed a state budget including $11.42 billion in General Fund spending that increased funding for nearly every state department. Governor Hickenlooper prioritized increased spending for education and the criminal justice system as Colorado residents also considered tax increases for education and transportation. Colorado’s economic trajectory remains generally positive, and recent budgetary reform has allowed policymakers to make greater investments in key issue areas.

PURPOSE:To examine relationships between self-report and performance-based measures of physical function in ICU patients randomized to standardized rehabilitation therapy (SRT) or usual care (UC).METHODS:Physical function was assessed in 257 ICU patients using self-report (physical functioning scale of the SF-36 (SF-36 PFS)) and the functional performance inventory-short form (FPI-SF) as well as performance-based measures (Short Physical Performance Battery (SPPB)) and muscular strength (MS). Assessments were at hospital discharge, 2, 4, and 6 months.RESULTS:Correlations between self-report and performance-based measures were not significantly different between the two groups. When examining the entire cohort, a significant, but weak, correlation (r = 0.286) was found between the SF-36 PFS and the SPPB. At 2 months, moderate correlations were found between self-report and performance-based measures. The SF-36 PFS and FPI were significantly correlated with the SPPB (r = 0.536 and 0.553, respectively) and muscular strength (r = 0.413 and 0.431, respectively). Similar associations were seen at 4 and 6 months in both groups.CONCLUSION:Self-report and performance-based measures of physical function appear to assess different constructs at hospital discharge. Following recovery, these measures converge, but indicate different constructs are being assessed. As such, both self-report and performance-based measures of physical function should be used with ICU patients.

PURPOSE:Patients with acute respiratory failure (ARF) show changes in skeletal muscle structure and strength. The purpose of this study was to examine the relationship between muscle thickness, echogenicity, and strength in patients with ARF. METHODS:Thirteen (6 females, 7 males) patients with ARF participated in the study. Knee extensor strength was measured via a handheld dynamometer and quadriceps images were obtained via ultrasonography at hospital discharge. The ultrasonograms were used to obtain muscle thickness and both mean ± SD echogenicity of the rectus femoris, vastus lateralis, and vastus medialis. Partial correlations, controlling for age, body mass index, and fluid intake were used to describe the relationships among knee extensor strength and echogenicity and muscle thickness. RESULTS:Knee extensor strength and vastus lateralis SD echogenicity were significantly correlated when controlling for age, body mass index, and fluid intake (r = 0.69, P = .029). Knee extensor strength and vastus lateralis echogenicity were 19.1 ± 8.0 kg and 19.8 ± 5.4 units, respectively. No other correlations between strength and ultrasound measures were found to be significant. CONCLUSION:These results show skeletal muscle echogenicity to be significantly correlated with skeletal muscle strength in patients with ARF. As such, it may be useful in identifying muscle weakness in these patients when they are unable or unwilling to perform voluntary strength testing.