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Purpose: Aerobars place a cyclist in a position where the trunk is flexed forward and the elbows are close to the midline of the body. This position is known to improve cycling aerodynamics and time trial race performance compared with upright cycling positions. However, the aggressive nature of this position may have important cardiorespiratory and metabolic consequences. The purpose of this investigation was to examine the respiratory mechanical, ventilatory, metabolic, and sensory consequences of cycling while using aerobars during laboratory-based cycling., Methods: Eleven endurance-trained male cyclists (age, 26 ± 9 yr; V˙O2peak, 55 ± 5 mL·kg·min) were recruited. Visit 1 consisted of an incremental cycling test to determine peak power output. Visit 2 consisted of 6-min bouts of constant load cycling at 70% of peak incremental power output in the aerobar position, drop position, and upright position while grasping the brake hoods. Metabolic and ventilatory responses were measured using a commercially available metabolic cart, and respiratory pressures were measured using an esophageal catheter., Results: Cycling in the aerobar position significantly increased the work of breathing (Wb), power of breathing (Pb), minute ventilation, ventilatory equivalent for oxygen and carbon dioxide, and transdiaphragmatic pressure compared with the upright position. Increases in the Wb and Pb in the aerobars relative to the upright position were strongly correlated with the degree of thoracic restriction, measured as the shoulder-to-aerobar width ratio (Wb: r = 0.80, P = 0.01; Pb: r = 0.69, P = 0.04)., Conclusions: Aerobars significantly increase the mechanical cost of breathing and leads to greater ventilatory inefficiency compared with upright cycling. Future work is needed to optimize aerobar width to minimize the respiratory mechanical consequences while optimizing aerodynamics.

This study sought to develop frailty "identification rules" using population-based health administrative data that can be readily applied across jurisdictions for living and deceased persons. Three frailty identification rules were developed based on accepted definitions of frailty, markers of service utilization, and expert consultation, and were limited to variables within two common population-based administrative health databases: hospital discharge abstracts and physician claims data. These rules were used to identify persons with frailty from both decedent and living populations across five Canadian provinces. Participants included persons who had died and were aged 66 years or older at the time of death (British Columbia, Alberta, Ontario, Quebec, and Nova Scotia) and living persons 65 years or older (British Columbia, Alberta, Ontario, and Quebec). Descriptive statistics were computed for persons identified using each rule. The proportion of persons identified as frail ranged from 58.2-78.1 per cent (decedents) and 5.1-14.7 per cent (living persons).

Objective: Untreated depression among persons with chronic general health conditions (chronic health conditions) affects mortality, functional disability, quality of life, and health care costs. Currently, studies of the association between depression care and chronic health conditions report inconsistent results, and studies of depression care among persons with specific health conditions are rare. This study investigated the association between chronic health conditions and the likelihood of receiving depression care among individuals with depression., Methods: Retrospective data from physician claims, hospital separations, vital statistics, and insurance plan registries were used to identify a cohort of individuals with depression and track 12-month use of health services among those with and without a chronic health condition. Disparities were analyzed by using generalized linear models., Results: Individuals with depression and a chronic health condition had higher use of psychological therapy, higher use of any depression care, greater continuity of care, and better adherence to antidepressant therapy compared with individuals with depression only. However, they were less likely, in general, to be on antidepressant therapy, and individuals with diabetes had fewer visits to general practitioners for a mental health-related reason compared with individuals without diabetes. A trend toward lower use of any depression care was observed among patients with cerebrovascular disease., Conclusions: Use of depression care was generally higher among individuals with chronic health conditions, although there were differences in patterns of use by type of health condition. Some patients with specific health conditions could be at risk of being inappropriately treated for depression.

Recent evidence suggests that surface electromyography of the parasternal intercostals (EMGpara) can be a non-invasive alternative to diaphragmatic EMG (EMGdi) for estimating neural respiratory drive (NRD) during cardiopulmonary exercise testing (CPET). The purpose of this study was to determine if non-respiratory muscles influence EMGpara by having subjects place their hands on (H on ) and off (H off ) the handlebars during cycling-based CPET. Ten healthy adults performed an incremental cycling test until volitional exhaustion. Participants were instrumented with an esophageal electrode catheter to measure EMGdi, and surface electrodes on the 2nd intercostal space to measure EMGpara. Subjects alternated between 30s of H on and 30s H off during each exercise stage. There were no differences in EMGdi across all exercise intensities. However, EMGpara was significantly greater during the H on vs. H off condition at all exercise intensities (p<0.05). These results suggest that EMGpara may not be an appropriate surrogate of NRD during cycle exercise testing due to co-activation of adjacent skeletal muscles., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: The use of physician incentives to improve health care, in general, has been extensively studied but its value in mental health care has rarely been demonstrated. In this study the population-level impact of physician incentives on mental health care was estimated using indicators for receipt of counseling/psychotherapy (CP); antidepressant therapy (AT); minimally adequate counseling/psychotherapy; and minimally adequate antidepressant therapy. The incentives' impacts on overall continuity of care and of mental health care were also examined., Materials and Methods: Monthly cohorts of individuals diagnosed with major depression were identified between January 2005 and December 2012 and their use of mental health services tracked for 12 months following initial diagnosis. Linked health administrative data were used to ascertain cases and measure health service use. Pre-post changes associated with the introduction of physician incentives were estimated using segmented regression analyses, after adjusting for seasonal variation., Results: Physician incentives reversed the downward and upward trends in CP and AT. Five years postintervention, the estimated impacts in percentage points for CP, AT, minimally adequate counseling/psychotherapy, and minimally adequate antidepressant therapy were +3.28 [95% confidence interval (CI), 2.05-4.52], -4.47 (95% CI, -6.06 to -2.87), +1.77 (95% CI, 0.94-2.59), and -2.24 (95% CI, -4.04 to -0.45). Postintervention, the downward trends in continuity of care failed to reverse, but were disrupted, netting estimated impacts of +7.53 (95% CI, 4.54-10.53) and +4.37 (95% CI, 2.64-6.09) for continuity of care and of mental health care., Conclusions: The impact of physician incentives on mental health care was modest at best. Other policy interventions are needed to close existing gaps in mental health care.

Effective management of end stage renal disease for individuals undergoing hemodialysis (HD) requires the acquisition of self-care abilities, which have been shown to improve outcomes. Studies have indicated that educational interventions improve self-care abilities in patients with chronic kidney failure. A self-care coaching intervention was designed to bridge this gap. To evaluate, we utilized a pre-test/post-test quasi-experimental design using the Self Care for Adults on Dialysis (SCAD) tool. This was administered prior to, four months, and one year after the intervention. Results demonstrated improvement in self-care related to vascular access and fluid management, both significant aspects of being HD-dependent., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

No studies of cystic fibrosis (CF) have systematically characterized the evolution of the qualitative dimensions of exertional dyspnea. Adults with CF (n = 25) and control individuals matched for sex, age, and body mass index (n = 25) underwent cardiopulmonary cycle exercise testing with a detailed evaluation of ventilatory and dyspnea responses. The qualitative dimensions of dyspnea were examined during each exercise stage by having subjects select phrases that best described their breathing (i.e., "work/effort," "unsatisfied inspiration," and "unsatisfied expiration"). Subjects also selected phrases that described the quality of their breathing at peak exercise using an established 15-item questionnaire, which was then clustered into different categories. Subjects with CF had greater ventilatory requirements, higher end-inspiratory and end-expiratory lung volumes (% total lung capacity), and an earlier inflection/plateau in tidal volume during exercise compared with control subjects. Increased work/effort was the dominant qualitative descriptor in both groups throughout exercise. Unsatisfied inspiration was selected by 48% of subjects with CF and 40% of controls at some point during exercise. The onset of unsatisfied inspiration in these subjects occurred at a significantly lower relative exercise intensity in subjects with CF vs. controls (72 ± 21 vs. 94 ± 11% Wmax, P < 0.01). Chest tightness was the only qualitative descriptor cluster that was selected more frequently by subjects with CF vs. controls (36 vs. 0%, respectively, P < 0.05) at peak exercise. Therapeutic interventions that reduce ventilatory requirements and improve lung volumes may delay the onset of distressing sensations such as unsatisfied inspiration and chest tightness in adults with CF., (Copyright © 2016 the American Physiological Society.)

Background: Patients with anorexia nervosa exhibit abnormal myocardial repolarization and are susceptible to sudden cardiac death. Exercise testing is useful in unmasking QT prolongation in disorders associated with abnormal repolarization. We characterized QT adaptation during exercise in anorexia., Methods and Results: Sixty-one adolescent female patients with anorexia nervosa and 45 age- and sex-matched healthy volunteers performed symptom-limited cycle ergometry during 12-lead ECG monitoring. Changes in the QT interval during exercise were measured, and QT/RR-interval slopes were determined by using mixed-effects regression modeling. Patients had significantly lower body mass index than controls; however, resting heart rates and QT/QTc intervals were similar at baseline. Patients had shorter exercise times (13.7±4.5 versus 20.6±4.5 minutes; P<0.001) and lower peak heart rates (159±20 versus 184±9 beats/min; P<0.001). The mean QTc intervals were longer at peak exercise in patients (442±29 versus 422±19 ms; P<0.001). During submaximal exertion at comparable heart rates (114±6 versus 115±11 beats/min; P=0.54), the QTc interval had prolonged significantly more in patients than controls (37±28 versus 24±25 ms; P<0.016). The RR/QT slope, best described by a curvilinear relationship, was more gradual in patients than in controls (13.4; 95% confidence interval, 12.8-13.9 versus 15.8; 95% confidence interval, 15.3-16.4 ms QT change per 10% change in RR interval; P<0.001) and steepest in patients within the highest body mass index tertile versus the lowest (13.9; 95% confidence interval, 12.9-14.9 versus 12.3; 95% confidence interval, 11.3-13.3; P=0.026)., Conclusions: Despite the absence of manifest QT prolongation, adolescent anorexic females have impaired repolarization reserve in comparison with healthy controls. Further study may identify impaired QT dynamics as a risk factor for arrhythmias in anorexia nervosa., (© 2016 American Heart Association, Inc.)

Objectives: To characterize patterns of sedentary behavior and physical activity in older adults recovering from hip fracture and to determine characteristics associated with activity., Methods: Community-dwelling, Canadian adults (65 years+) who sustained hip fracture wore an accelerometer at the waist for seven days and provided information on quality of life, falls self-efficacy, cognitive functioning, and mobility., Results: There were 53 older adults (mean age [SD] 79.5 [7.8] years) enrolled in the study; 49 had valid data and demonstrated high levels of sedentary time (median [p10, p90] 591.3 [482.2, 707.2] minutes/day), low levels of light activity (186.6 [72.6, 293.7]), and MVPA (2 [0.1, 27.6]), as well as few daily steps (2467.7 [617.1, 6820.4]). Regression analyses showed that age, gender, gait speed, and time since fracture were associated with outcomes., Conclusions: Older adults have long periods of sedentary time with minimal activity. Results are a call to action to encourage people to sit less and move more.

Objectives: To determine gait characteristics of community-dwelling older adults at different speeds and during a crosswalk simulation. Methods: Twenty-two older adults completed walking trials at self-selected slow, usual, and fast paces, and at a crosswalk simulation, using the GAITRite walkway. These objective measures were complemented by self-report health and mobility questionnaires. Results: Gait speeds at self-selected slow, usual, and fast paces were 98.7 (18.1) cm/s, 140.9 (20.4) cm/s, and 174.0 (20.6) cm/s, respectively, and at simulated crosswalk conditions was 144.2 (22.3) cm/s. For usual pace, right step length variability was 2.0 (1.4) cm and step time variability was 13.6 (7.2) ms, compared with 2.4 (1.3) cm and 17.3 (9.7) ms, respectively, for crosswalk conditions. Discussion: Our sample of healthy older adults walked at a speed exceeding standards for crossing urban streets; however, in response to a crosswalk signal, participants adopted a significantly faster and more variable gait., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Understanding sex differences in the qualitative dimensions of exertional dyspnea may provide insight into why women are more affected by this symptom than men. This study explored the evolution of the qualitative dimensions of dyspnea in 70 healthy, young, physically active adults (35 M and 35 F). Participants rated the intensity of their breathing discomfort (Borg 0-10 scale) and selected phrases that best described their breathing from a standardized list (work/effort, unsatisfied inspiration, and unsatisfied expiration) throughout each stage of a symptom-limited incremental-cycle exercise test. Following exercise, participants selected phrases that described their breathing at maximal exercise from a list of 15 standardized phrases. Intensity of breathing discomfort was significantly higher in women for a given ventilation, but differences disappeared when ventilation was expressed as a percentage of maximum voluntary ventilation. The dominant qualitative descriptor in both sexes throughout exercise was increased work/effort of breathing. At peak exercise, women were significantly more likely to select the following phrases: "my breathing feels shallow," "I cannot get enough air in," "I cannot take a deep breath in," and "my breath does not go in all the way." Women adopted a more rapid and shallow breathing pattern and had significantly higher end-inspiratory lung volumes relative to total lung capacity throughout exercise relative to men. These findings suggest that men and women do not differ in their perceived quality of dyspnea during submaximal exercise, but subjective differences appear at maximal exercise and may be related, at least in part, to underlying sex differences in breathing patterns and operating lung volumes during exercise., (Copyright © 2015 the American Physiological Society.)

Objectives: The purpose of this study was to evaluate the effect of a research training program on clinicians' knowledge, attitudes, and practices related to research and evidence-based practice (EBP)., Background: EBP has been shown to improve patient care and outcomes. Innovative approaches are needed to overcome individual and organizational barriers to EBP., Methods: Mixed-methods design was used to evaluate a research training intervention with point-of-care clinicians in a Canadian urban health organization. Participants completed the Knowledge, Attitudes, and Practice Survey over 3 timepoints. Focus groups and interviews were also conducted., Results: Statistically significant improvement in research knowledge and ability was demonstrated. Participants and administrators identified benefits of the training program, including the impact on EBP., Conclusions: Providing research training opportunities to point-of-care clinicians is a promising strategy for healthcare organizations seeking to promote EBP, empower clinicians, and showcase excellence in clinical research.

Background: Maintaining physical activity is an important goal with positive health benefits, yet many people spend most of their day sitting. Our Everyday Activity Supports You (EASY) model aims to encourage movement through daily activities and utilitarian walking. The primary objective of this phase was to test study feasibility (recruitment and retention rates) for the EASY model., Methods: This 6-month study took place in Vancouver, Canada, from May to December 2013, with data analyses in February 2014. Participants were healthy, inactive, community-dwelling women aged 55-70 years. We recruited through advertisements in local community newspapers and randomized participants using a remote web service. The model included the following: group-based education and social support, individualized physical activity prescription (called Activity 4-1-1), and use of a Fitbit activity monitor. The control group received health-related information only. The main outcome measures were descriptions of study feasibility (recruitment and retention rates). We also collected information on activity patterns (ActiGraph GT3X+ accelerometers) and health-related outcomes such as body composition (height and weight using standard techniques), blood pressure (automatic blood pressure monitor), and psychosocial variables (questionnaires)., Results: We advertised in local community newspapers to recruit participants. Over 3 weeks, 82 participants telephoned; following screening, 68% (56/82) met the inclusion criteria and 45% (25/56) were randomized by remote web-based allocation. This included 13 participants in the intervention group and 12 participants in the control group (education). At 6 months, 12/13 (92%) intervention and 8/12 (67%) control participants completed the final assessment. Controlling for baseline values, the intervention group had an average of 2,080 [95% confidence intervals (CIs) 704, 4,918] more steps/day at 6 months compared with the control group. There was an average between group difference in weight loss of -4.3 [95% CI -6.22, -2.40] kg and reduction in diastolic blood pressure of -8.54 [95% CI -16.89, -0.198] mmHg, in favor of EASY., Conclusions: The EASY pilot study was feasible to deliver; there was an increase in physical activity and reduction in weight and blood pressure for intervention participants at 6 months., Trial Registration: ClinicalTrials.gov identifier: NCT01842061.

Objective: To conduct a systematic review and meta-analysis of published evidence on ethnic or racial disparities in the outpatient use versus non-use of antipsychotics and in the outpatient use of newer versus older antipsychotics., Method: Electronic databases were searched for potentially relevant studies. Two independent reviewers conducted the review in three stages: title review, abstract review and full-text review. Included studies were those that: (a) report measures of disparity in the outpatient use of antipsychotic drugs in clearly defined racial or ethnic groups (b) have a primary focus on ethnic or racial disparities, and (c) have adjusted for factors known to influence medicine use. Odds ratios were pooled following the inverse-variance method of weighting effect sizes. I (2) statistics were calculated to quantify the amount of variation that is likely due to heterogeneity between studies. Funnel plots were produced and Egger's statistic was calculated to assess potential publication bias., Results: No significant differences were found in the odds of using any antipsychotics among African Americans (OR = 1.01, CI = 0.99-1.02) compared with non-African Americans and among Latinos (OR = 0.98, CI = 0.86-1.13) compared with non-Latinos. Small to moderate but statistically non-significant disparities were also noted in other ethnic groups: Asians (OR = 1.10, CI = 0.88-1.36), Maoris (OR = 0.78, CI = 0.53-1.13) and Pacific Islanders (OR = 0.97, CI = 0.84-1.11). Among those who received antipsychotic medication, African Americans (OR = 0.62, CI = 0.50-0.78) and Latinos (OR = 0.77, CI = 0.73-0.81) appeared to have lower odds of receiving newer antipsychotics compared with non-African Americans and non-Latinos., Conclusion: No significant ethnic disparities in the use versus non-use of any antipsychotics were observed, but, among those who received antipsychotic treatment, ethnic minorities were consistently less likely than non-ethnic minorities to be treated with newer antipsychotics.

Objectives: To determine to what extent actual practice as reported in the literature is consistent with clinical guidelines for dementia care., Design: A systematic review of empirical studies of clinical services provided by physicians to older adults with a diagnosis of dementia., Setting: All settings involving primary care physicians in which a diagnosis of dementia is provided., Participants: Physicians providing care to individuals aged 60 and older with a primary or secondary diagnosis of dementia., Intervention: Seven dementia care processes recommended by guidelines: formal memory testing, imaging, laboratory testing, interventions, counseling, community service, and specialist referrals., Measurements: Web of Knowledge, PubMed, Science Direct, MedLine, PsychINFO, EMBASE, and Google Scholar databases were searched for articles in English published before March 1, 2012., Results: Twelve studies met the final inclusion criteria, all of which were self-reported cross-sectional surveys. There was broad variation in the proportion of physicians who reported conducting each dementia care process, with the widest variation in formal memory testing (4-96%). Recently published studies reflected a shift in scope of care, reporting that high proportions of physicians provided interventions, counseling, and referrals to specialist., Conclusion: Despite the availability and dissemination of established best practice guidelines, there is still wide variation in physician practice patterns in dementia care. The quality of currently available studies limits the ability to draw strong conclusions. Better information on practice patterns and their relationship to outcomes for individuals with dementia and their caregivers using more-robust study designs is needed to address the needs of the increasing number of individuals who will require dementia care., (© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.)

The association between social support and mental health across immigrant groups were examined in this study. A population-based sample was extracted from a 2009/10 Canadian community health survey. Self-reported mood or anxiety disorders and a standardized social support scale were used as outcome and explanatory variables. The association between these variables was measured using logistic regression controlling for sex, age, marital status, education, self-rated health and perceived stress. Stratified analyses were performed to test if the strength of association differed by immigrant status. In comparison with individuals who had moderate levels of social support, individuals with low social support had higher odds of reporting mental disorders and this association appeared strongest among recent immigrants. Using the same comparison group, individuals with high social support had lower odds of reporting mental disorders and this association appeared stronger among long-term immigrants. Findings were discussed within the context of immigration stress and acculturation strategies.

Objective: To examine the essential and potentially inappropriate use of antipsychotics across income groups., Method: Linked health, pharmaceutical use, and income data from British Columbia were analyzed to examine antipsychotic use in 2 study cohorts. In the first cohort, the essential use of antipsychotics was assessed among adults who had a recorded diagnosis of schizophrenia in a 2-year period, 2004-2005. In the second cohort, potentially inappropriate use of antipsychotics was examined in people with no recorded diagnosis of schizophrenia or bipolar disorders in 2004-2005. The second cohort was also composed exclusively of seniors with a dementia-related diagnosis who are either in long-term care or living in the community. Income-related differences in antipsychotic use in these 2 cohorts were assessed using logistic regression, controlling for health and sociodemographic characteristics known to influence medicine use., Results: Among adults, the prevalence of essential antipsychotic use was high (85%), with higher odds of use evident among those in the middle-income group. Among seniors, the prevalence of potentially inappropriate antipsychotic treatment is 23%, with prevalence higher in long-term care (56%) than in the community (13%). No income-related differences were found in long-term care; however, in the community, higher odds of use were found in low-income seniors., Conclusion: People from low-income households have slightly lower levels of essential antipsychotic use and are more likely to receive potentially inappropriate antipsychotic treatment.