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Background: To compare the acute and chronic effects of frequent, short physical activity (PA) bouts spread throughout the day to a time-matched intervention consisting in a single continuous daily bout of PA on glucose control and potential underlying mechanisms in adults at risk of developing type 2 diabetes (T2D). Methods: BURST2D is a single-center, parallel-group, randomized controlled trial, in which sedentary adults with overweight/obesity and pre-diabetes (18-45 y, BMI: 25-40 kg/m2, fasting glucose: 100-125 mg/dL or 2h glucose: 140-199 mg/dL or HbA1c: 5.7-6.4%) will be randomly assigned to one of two 3-month PA interventions: BREAK, nine bouts of 5-min brisk walking performed every hour for nine consecutive hours (45-min/d total), 5 days/wk; ONE, one continuous 45-min bout of brisk walking, 5 days/wk. Primary outcomes will be daily glycemic mean and variability, fasting glucose and HbA1c, postprandial plasma glucose and insulin, glucose kinetics, and content of skeletal muscle proteins related to insulin signaling and glucose uptake. Secondary outcomes will be whole-body insulin sensitivity, 24-h total substrate oxidation, postprandial triglycerides, daily PA and sedentary behavior (SB) patterns, knowledge and attitude towards PA and SB, barriers and facilitators to intervention compliance, self-perceived appetite, mood, and sleep. Outcomes will be assessed at baseline and after one month and/or three months of intervention. Conclusions: This study will establish the acute and chronic effects of breaking up SB, independent of increases in PA, on glucose control and underlying mechanisms in adults with pre-diabetes. Results will advance the science of T2D prevention. Trial registration: This study is registered with the ClinicalTrials.gov, registry number NTC05041491.

BACKGROUND Physical activity (PA) is a cornerstone of type 2 diabetes mellitus (T2DM) treatment. Sex differences in PA behavior or barriers/facilitators to PA among individuals with T2DM are unclear. PURPOSE To summarize the evidence related to sex differences in participation in PA and barriers/facilitators to PA among individuals with T2DM across the life span. DATA SOURCES Systematic searches (CRD42021254246) were conducted with Ovid MEDLINE, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), APA PsychInfo, and SPORTDiscus. STUDY SELECTION We included studies with assessment of PA, sedentary behaviors (SB), or barriers/facilitators to PA among individuals with T2DM by sex or gender. DATA EXTRACTION Participant characteristics, meeting PA guidelines, participation in PA and SB, and barriers/facilitators to PA were extracted by two independent reviewers. DATA SYNTHESIS A total of 53 articles (65,344 participants) were included in the systematic review and 21 articles in the meta-analysis. Sex differences were not observed in meeting of PA guidelines among adolescents (odds ratio 0.70 [95% CI 0.31, 1.59]), but males were more likely than females to meet PA guidelines among adults (1.65 [1.36, 2.01]) and older adults (1.63 [1.27, 2.09]). Males performed more moderate-to-vigorous PA (MVPA) than females across all age-groups. Common barriers to PA were lack of time (men) and lack of social support and motivation (women). LIMITATIONS Limitations include heterogeneity of measures used to assess PA and lack of stratification of data by sex. CONCLUSIONS Sex differences in meeting PA guidelines were not observed among adolescents but were apparent among adults and older adults with T2DM. Females consistently engaged in less MVPA than males across the life span.

Background: Physical activity (PA) is a cornerstone of type 2 diabetes mellitus (T2DM) treatment. Sex differences in PA behavior or barriers/facilitators to PA among individuals with T2DM are unclear. Purpose: To summarize the evidence related to sex differences in participation in PA and barriers/facilitators to PA among individuals with T2DM across the lifespan. Data Source: Systematic searches (CRD42021254246) were conducted using Ovid Medline, EMBASE, Web of Science, CINAHL, AMED, PsychINFO, and SPORTDiscus. Study Selection: Studies assessing PA, sedentary behaviors (SB) or barriers/facilitators to PA among individuals with T2DM by sex or gender. Data Extraction: Participant characteristics, meeting PA guidelines, participation in PA and SB, and barriers/facilitators to PA were extracted by two independent reviewers. Data Synthesis: Fifty-three articles (65,344 participants) were included in the systematic review; 21 articles in the meta-analysis. Sex differences were not observed in meeting PA guidelines among adolescents (OR [95% CI], 0.70 [0.31, 1.59]), but males were more likely than females to meet PA guidelines among adults (1.65 [1.36, 2.01]) and older adults (1.63 [1.27, 2.09]). Males performed more moderate to vigorous PA (MVPA) than females across all age groups. Common barriers were lack of time (men) and lack of social support and motivation (women). Limitations: Limitations include heterogeneity of measures used to assess PA and lack of stratification of data by sex. Conclusions: Sex differences in meeting PA guidelines were not observed among adolescents, but were apparent among adults and older adults with T2DM. Females consistently engaged in less MVPA than males across the lifespan.

T2D is a global epidemic leading to excess cardiovascular (CV) mortality including heart failure (HF) . Strategies are emerging to prevent HF progression, so early detection is needed. We have identified preclinical cardiac dysfunction associated with central arterial stiffness and decreased cardiorespiratory fitness. We hypothesized that cardiac magnetic resonance (CMR) would identify changes in diabetes. Methods: Age and BMI-similar premenopausal women and men with (n=24) and without (n=30) uncomplicated T2D were studied. CMR for cardiac function, regionally resolved pulse wave velocity (PWV) via 2D phase-contrast MRI assessed proximal arterial stiffness, and carotid to femoral applanation tonometry PWV (C-F PWV) using SphygmoCor assessed global arterial stiffness. The vascular territories covered by SphygmoCor does not include the ascending aorta. Results: CMR showed significant changes consistent with cardiac dysfunction in T2D (Table 1) . PWV was significantly greater with T2D in the ascending and proximal descending aorta (p Conclusions: CMR detects early arterial stiffening in people with uncomplicated T2D and mild cardiac dysfunction. These findings support the use of CMR for detecting central arterial stiffness and incipient CV complications. Disclosure D.Enge: None. M.O.Whipple: None. K.S.Hunter: None. K.J.Nadeau: None. J.G.Regensteiner: None. A.J.Barker: None. J.Reusch: Advisory Panel; Medtronic. M.Schäfer: None. T.Fujiwara: None. E.Clark: None. E.Englund: None. R.L.Scalzo: None. D.Rafferty: None. I.E.Schauer: None. L.Abushamat: None. Funding National Institutes of Health (CX001532) University of Colorado Denver (NCT03419195) National Institutes of Health (R01-DK-124344) National Institutes of Health (K25HL119608)

International audience; The aim of this systematic review was to evaluate the available evidence regarding the acute effects of interrupting/breaking up prolonged sedentary behavior (SB) on vascular health among individuals at elevated risk for type 2 diabetes (T2D). Searches of MEDLINE, Embase, Web of Science, and Cochrane Library databases were conducted on April 7, 2020. Included studies: (1) examined the effect of breaking up prolonged SB in adults with or at elevated risk for T2D and (2) assessed a vascular health outcome, such as blood pressure (BP), flow-mediated dilation (FMD), pulse-wave velocity, or endothelin-1. A total of 20 articles (17 unique studies) were included. Only three studies reported adequate statistical power for the specified vascular outcome. The available evidence suggests that light and moderate intensity activity breaks are effective in acutely lowering BP when compared to prolonged sitting. The small number of studies that included FMD or other vascular outcomes prohibits conclusions regarding the impact of SB breaks on these outcomes. Few studies evaluating the impact of breaking up SB among adults at risk for T2D have included and been adequately powered to examine vascular outcomes, but our preliminary finding, that certain SB breaks improve BP, provides proof-of-concept for this line of inquiry. Future studies should examine both the acute and chronic vascular effects of breaking up SB among individuals most vulnerable to the effects of SB (e.g. older adults, those with T2D), as these individuals are both highly sedentary and at greatest risk of poor health outcomes. PROSPERO ID: CRD42020183423.

KEY POINTS People with type 2 diabetes (T2D) have impaired skeletal muscle oxidative flux due to limited oxygen delivery. In the current study, this impairment in oxidative flux in people with T2D was abrogated with a single-leg exercise training protocol. Additionally, single-leg exercise training increased skeletal muscle CD31 content, calf blood flow and state 4 mitochondrial respiration in all participants. ABSTRACT Cardiorespiratory fitness is impaired in type 2 diabetes (T2D), conferring significant cardiovascular risk in this population; interventions are needed. Previously, we reported that a T2D-associated decrement in skeletal muscle oxidative flux is ameliorated with acute use of supplemental oxygen, suggesting that skeletal muscle oxygenation is rate-limiting to in vivo mitochondrial oxidative flux during exercise in T2D. We hypothesized that single-leg exercise training (SLET) would improve the T2D-specific impairment in in vivo mitochondrial oxidative flux during exercise. Adults with (n = 19) and without T2D (n = 22) with similar body mass indexes and levels of physical activity participated in two weeks of SLET. Following SLET, in vivo oxidative flux measured by 31 P-MRS increased in participants with T2D, but not people without T2D, measured by the increase in initial phosphocreatine synthesis (P = 0.0455 for the group × exercise interaction) and maximum rate of oxidative ATP synthesis (P = 0.0286 for the interaction). Additionally, oxidative phosphorylation increased in all participants with SLET (P = 0.0209). After SLET, there was no effect of supplemental oxygen on any of the in vivo oxidative flux measurements in either group (P > 0.02), consistent with resolution of the T2D-associated oxygen limitation previously observed at baseline in subjects with T2D. State 4 mitochondrial respiration also improved in muscle fibres ex vivo. Skeletal muscle vasculature content and calf blood flow increased in all participants with SLET (P

Objective: To investigate sex-related differences in patients with fibromyalgia (FM) in terms of demographic characteristics and clinical features, including tender point count (TPC), mood disorders, sleep problems, FM symptom severity, fatigue, cognitive dysfunction, and quality of life (QOL). Patients and Methods: We studied 668 consecutive patients with FM (606 women) from May 1, 2012, to November 30, 2013. Validated questionnaires assessed outcomes of depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), sleep problems (Medical Outcomes Study Sleep Scale), FM symptom severity (Revised Fibromyalgia Impact Questionnaire), fatigue (Multidimensional Fatigue Inventory), cognitive dysfunction (Multiple Ability Self-report Questionnaire), and QOL (36-Item Short Form Health Survey). Nonparametric Mann-Whitney U and Pearson χ2 tests were used to compare continuous and categorical outcome measures, respectively, between men and women. Linear regression models were performed for all continuous dependent variables, adjusting for age, body mass index, ethnicity, marital status, and highest education level completed. P

Type 2 diabetes (T2D) is a global epidemic leading to excess cardiovascular (CV) mortality. CV risk factor modification does not prevent progression to non-ischemic heart failure (HF), so early detection and intervention are needed. Our group has identified preclinical cardiac dysfunction associated with central arterial stiffness and decreased cardiorespiratory fitness which is responsive to exercise training (ET) intervention. Cardiac parameters were measured in BMI-similar participants with and without T2D, before and after a 90-day progressive aerobic ET program and compared to lean nondiabetic historical controls. Left ventricular end systolic volume (LV ESV), end diastolic volume (EDV), stroke volume, and cardiac output for both groups pre- and post-exercise training were significantly lower than those of lean controls (Table 1). ESV and EDV increased post-exercise in T2D but not in the control group. While ejection fraction did not differ between groups, decreased heart rate in people with T2D following ET suggests compensation. Pulse wave velocity (PWV) by carotid to femoral tonometry (SphygmoCor) did not change with ET, but thoracic aortic PWV from 4D flow MRI significantly improved with ET across both groups. Cardiac and central arterial function are deleteriously and differently impacted by obesity and T2D. Advanced imaging may be a useful tool to longitudinally assess function and response to intervention. Disclosure D. Enge: None. K. Jarvis: None. T. Fujiwara: None. M. Markl: None. K. S. Hunter: None. A. J. Barker: None. K. J. Nadeau: None. J. G. Regensteiner: None. J. E. Reusch: Advisory Panel; Self; Medtronic. M. Schafer: None. R. L. Scalzo: None. D. Rafferty: None. I. E. Schauer: None. L. Abushamat: None. M. O. Whipple: None. E. Johnson: None. M. B. Scott: None. Funding National Institutes of Health (R01DK124344, R01HL133504)

BACKGROUND: Supervised exercise therapy (SET) is a cornerstone of treatment for improving walking distance for individuals with symptomatic peripheral artery disease and claudication. High quality randomized controlled trials have documented the efficacy of SET as a claudication treatment and led to the recent Centers for Medicare and Medicaid decision to cover supervised exercise therapy (SET). However, to date, the translation of highly controlled, laboratory based SET programs in real world cardiopulmonary rehabilitation settings has been unexplored. METHODS: In this article, we describe our experience integrating SET into existing cardiopulmonary rehabilitation programs, focusing on patient evaluation, exercise prescription, outcome assessments, strategies to maximize program adherence, and transitioning to home and community-based exercise training. RESULTS: Our team has over 3 years experience successfully implementing SET in cardiac rehabilitation settings. The experiences communicated within can serve as a model for rehabilitation therapists to follow as they begin to incorporate SET in their rehabilitation programs. CONCLUSIONS: CMS reimbursement has the potential to change clinical practice and utilization of SET for patients with symptomatic peripheral artery disease. The experience we have gained through implementation of SET programs across the M Health and Fairview Health Systems and in other Minnesota communities, including specific elements in our programs and the lessons learned from our clinical experience, can inform and help to guide development of new programs. BRIEF ABSTRACT: The recent Centers for Medicare and Medicaid decision to cover supervised exercise therapy (SET) for beneficiaries with peripheral artery disease (PAD) has the potential to transform practice. In this article, we describe our experience integrating SET into existing cardiopulmonary rehabilitation programs, which could serve as a model for new programs.

Objective To evaluate the association between smoking and cognitive function in patients with fibromyalgia. Patients and Methods We surveyed 668 patients with fibromyalgia from May 1, 2012 through November 30, 2013 at a major tertiary referral center. Patients were categorized by smoking status. Primary outcome of interest was cognitive function (MASQ questionnaire), and secondary outcomes included fibromyalgia symptom severity (FIQ-R questionnaire), quality of life (SF-36 questionnaire), fatigue (MFI-20 questionnaire), sleep (MOS-sleep scale), anxiety (GAD-7 questionnaire), and depression (PHQ-9 questionnaire). Independent Students' t-tests and χ2 tests were performed for continuous and categorical variables, respectively. Univariate regression analysis identified variables predictive of outcomes, adjusting for age, gender, body mass index, marital status, and educational level. Results Ninety-four (14.07%) patients self-identified as smokers. There was an association of lower education level, unmarried status, and younger age in smokers compared with nonsmokers. In the adjusted univariate regression analysis, fibromyalgia smokers reported greater perceived total cognitive dysfunction (P=.009) and greater subscale scores of perceived difficulty in language (P=.03), verbal memory (P=.003), visual-spatial memory (P=.02), and attention (P=.04) compared with nonsmokers with fibromyalgia. For secondary outcomes, smokers with fibromyalgia reported greater severity of fibromyalgia-related symptoms (P=.006), worse quality-of-life index in the mental component scale (P=.02), greater sleep problems (P=.01), and increased anxiety (P=.001) compared with nonsmokers who had fibromyalgia. Conclusion In patients with fibromyalgia, smoking is a risk factor for cognitive dysfunction. Moreover, smokers with fibromyalgia were more likely to report increased severity of fibromyalgia symptoms, worse quality of life, more sleep problems, and increased anxiety compared with nonsmokers with fibromyalgia.

Low levels of physical activity (PA) are now well recognized as a major public health problem, implicated in cancer, cardiovascular disease (CVD), metabolic syndrome, diabetes, and early mortality (1). PA guidelines (i.e., ≥150 min/week of moderate activity or ≥75 min/week of vigorous activity, collectively referred to as moderate to vigorous physical activity [MVPA]) are globally promoted to protect the population against the risk of developing chronic disease. But is this sufficient to promote metabolic health? The relationship between PA and health appears to be more complex than initially thought, and another component has been attracting attention over the past decade: sedentary behavior (SB). Although they are often used interchangeably, SB is fundamentally different from physical inactivity. While physical inactivity is defined as engaging in less PA than necessary to meet the current guidelines (2), SB describes “any waking behavior characterized by an energy expenditure ≤1.5 metabolic equivalents (METs) while in a sitting or reclining posture” (3). Thus, individuals can be both physically active and highly sedentary (4,5). Increased time spent sitting raises the risk for metabolic syndrome (6), incident CVD, CVD-related risk factors, and early mortality (7,8), even in people who exercise regularly. These observations raise obvious questions: Are the effects of SB independent from those of PA or simply the “other side of the coin”? What is the minimum level of MVPA needed to counteract the adverse health effects of SB? A recent harmonized meta-analysis of data from more than 1 million adults showed that high levels of PA (i.e., about 60–75 min/day of MVPA) are needed to eliminate the effect of 9 h/day of SB on mortality (9). Even if this exceeds the current PA …

Type 2 diabetes (T2D) confers a greater likelihood of heart failure (HF) and hospitalization due to HF. Our group has reported sub-clinical cardiac dysfunction and aortic stiffness in youth and adults with uncomplicated T2D. As aortic stiffening is reported to precede HF and is common in people with uncomplicated T2D, we tested the hypothesis that aerobic exercise training will improve cardiac function and central arterial stiffness in people with T2D compared to participants of similar BMI without T2D. Sedentary adults with (n = 18, age 48±7, 45% female) and without (n = 20, age 45±7, 46% female) T2D, underwent MRI for cardiac function and aortic compliance (aortic relative area change [RAC] and pulse wave velocity [PWV]) before and after 15 weeks of aerobic exercise training. At baseline, both cohorts exhibit subclinical diastolic dysfunction, however, those with T2D had lower end-diastolic volume (EDVN,47.2±9.9 vs. 52.3±9.1 mL/m2) and end-systolic volume (ESVN,21.1±5.4 vs. 23.6±5.2 mL/m2), than controls. The T2D group had higher max thickness of the left ventricular (LV) septal wall (LVMTs, 10.5±1.8 vs. 9.3±1.6 mm) and LV lateral wall (LVMTl, 8.4±1.6 vs. 7.6±1.3 mm) than controls. Those with T2D also had lower RAC (12.7±1.6 vs. 20.2±1.6%) and higher PWV (7.4±1.3 vs. 3.9±0.6 m/s) than controls. Preliminary data in a subset post exercise intervention (n=7 with and n=8 without T2D), revealed increased EDVN(42.8±7.9 to 51.5±11.3 mL/m2) and ESVN(19.7±4.0 to 24.3±6.5 mL/m2) and decreased LVMTs(11.35±1.5 to 9.96±1.3 mm) and LVMTl(8.42±0.81 to 7.74±0.89 mm) in the T2D group, but cardiac endpoints were unchanged in controls. Post-intervention in both groups, ascending aorta RAC increased (control: 16.2±4 % to 18.5±1.7 and T2D: 10.6±1.7 % to 19.6±2.2 %) and PWV decreased (control: 6.3±2.0 to 3.4±0.3 and T2D: 8.0±1.4 to 2.9±0.7). Data from this study in progress suggest that adults with T2D have a greater degree of cardiac dysfunction and arterial stiffness than controls of similar BMI, which improve to a greater degree with exercise than in controls. Disclosure D. Enge: None. J.E. Reusch: None. J.G. Regensteiner: None. M. Schäfer: None. K.S. Hunter: None. A.J. Barker: None. K.J. Nadeau: None. R.L. Scalzo: None. I.E. Schauer: None. L. Abushamat: None. M.O. Whipple: None. D. Rafferty: None. Funding U.S. Department of Veterans Affairs (CX001532)

BACKGROUND: Although supervised exercise therapy (SET) is effective in improving walking distance among adults with symptomatic peripheral artery disease (PAD), some research suggests that individuals with comorbid PAD and type 2 diabetes mellitus (T2DM) may experience a blunted response to SET. It is unknown whether free-living sedentary time changes during SET, and if increases in sedentary time could, in part, explain poor response to SET. OBJECTIVES: The purposes of this pilot study were to: 1) determine if older adults with PAD (with and without T2DM) engaging in SET change their sedentary behavior; and 2) examine the relationship between changes in sedentary behavior and SET outcomes. We hypothesized that decreased sedentary time during SET would be associated with greater improvements in six-minute walk test (6MWT) total distance and other key SET outcomes. METHODS: Participants (n = 44) initiating a 12-week SET program completed the six-minute walk test (6MWT), Short Physical Performance Battery, Walking Impairment Questionnaire, and accelerometer-assessed sedentary behavior at SET initiation, 6 weeks, and 12 weeks. RESULTS: Participants’ mean age was 72.3 (7.1) years, mean ankle-brachial index was 0.71 (0.25), and 47.7% were female. On average, sedentary time did not change following SET, although there was substantial variability (−40% to +38% change in minutes of sedentary time/day). Participants with T2DM experienced greater improvements in claudication onset distance when compared to participants without T2DM (mean 35 m, p = .044, 95% CI 1.6 to 115.4 meters). Neither changes in sedentary time from baseline to 6 weeks (p = .419) nor T2DM (p = .154) predicted changes in 6MWT total distance from baseline to 12 weeks. CONCLUSIONS: As SET availability increases, further examination of factors that may influence SET outcomes will help maximize benefits of this proven therapy.

Although a plethora of evidence supports the benefits of exercise among older adults, a majority of studies have emphasized group differences, while giving little, if any, attention to individual differences. Given the lack of data on variability in response, the present review examined how nonresponse to aerobic exercise has been defined in older adult populations and characteristics associated with nonresponse among older adults. The results of this review suggest that interindividual variability in response of maximal oxygen consumption to aerobic exercise interventions is prevalent among older adults (1.4–63.4%); age, sex, race, and body mass index may not be critical determinants of nonresponse; whereas health status, baseline fitness, and exercise dose appear important. Future intervention studies should evaluate and report the variability in individual response of older adults to exercise; investigators should develop programs that allow for modification of components to assist older adults in achieving optimal benefit from exercise programs.

Fear of falling presents a significant problem for many older adults by reducing physical function and increasing the risk of future falls. Several different types of interventions have improved fear of falling and a summary of efficacious interventions will help clinicians recommend treatment options. Using the Arksey and O’Malley Framework for scoping reviews, the purpose of this review was to identify efficacious interventions for treating fear of falling among community-dwelling older adults in order to provide a list of potential treatment options for care providers. A total of 45 publications were identified for inclusion in this review.

Traditional university learning modalities of lectures and examinations do not prepare students fully for the evolving and complex world of gerontology and geriatrics. Students involved in more active, self-directed learning can develop a wider breadth of knowledge and perform better on practical examinations. This article describes the Evidence in Aging (EIA) study as a model of active learning with the aim of preparing students to be effective interdisciplinary researchers, educators, and leaders in aging. We focus particularly on the experiences and reflections of graduate students who collaborated with faculty mentors on study design, data collection, and analysis. Students acquired new methodological skills, gained exposure to diverse disciplines, built interdisciplinary understanding, and cultivated professional development. The EIA study is a model for innovative student engagement and collaboration, interactive learning, and critical scholarly development. Lessons learned can be applied to a range of collaborative research projects in gerontology and geriatrics education.

Venous thromboembolism (VTE) may complicate the course of Coronavirus Disease 2019 (COVID-19).To evaluate the incidence of VTE in patients with COVID-19.MEDLINE, EMBASE, and PubMed were searched up to 24th June 2020 for studies that evaluated the incidence of VTE, including pulmonary embolism (PE) and/or deep vein thrombosis (DVT), in patients with COVID-19. Pooled proportions with corresponding 95% confidence intervals (CI) and prediction intervals (PI) were calculated by random-effect meta-analysis.3487 patients from 30 studies were included. Based on very low-quality evidence due to heterogeneity and risk of bias, the incidence of VTE was 26% (95% PI, 6%-66%). PE with or without DVT occurred in 12% of patients (95% PI, 2%-46%) and DVT alone in 14% (95% PI, 1%-75%). Studies using standard algorithms for clinically suspected VTE reported PE in 13% of patients (95% PI, 2%-57%) and DVT in 6% (95% PI, 0%-60%), compared to 11% (95% PI, 2%-46%) and 24% (95% PI, 2%-85%) in studies using other diagnostic strategies or patient sampling. In patients admitted to intensive care units, VTE occurred in 24% (95% PI, 5%-66%), PE in 19% (95% PI, 6%-47%), and DVT alone in 7% (95% PI, 0%-69%). Corresponding values in general wards were respectively 9% (95% PI, 0%-94%), 4% (95% PI, 0%-100%), and 7% (95% CI, 1%-49%).VTE represents a frequent complication in hospitalized COVID-19 patients and often occurs as PE. The threshold for clinical suspicion should be low to trigger prompt diagnostic testing.

Although numerous studies have demonstrated the effectiveness of treadmill-based supervised exercise therapy (SET) in improving pain-free and total walking distance and quality of life in individuals with peripheral artery disease (PAD), historically this treatment has not been widely available outside of research settings. Last year’s decision by Centers for Medicare and Medicaid Services (CMS) to cover up to 36 sessions of SET over a 12-week period for beneficiaries with symptomatic PAD (1) has enabled greater implementation of this effective treatment in clinical settings. An additional 36 sessions are available over an extended period with a new referral from a health care provider. At the University of Minnesota, we have been implementing SET in both urban and rural clinical settings since 2015. In this column, we provide examples of two patients who have participated in SET through these programs, highlighting their experiences and tips for those considering implementing SET for individuals with PAD at their own institutions.

Previous studies suggest a myriad of factors prevent individuals from engaging in physical activity; however, less is known about barriers faced by individuals with multiple chronic conditions, such as peripheral artery disease (PAD) and type 2 diabetes, and how these barriers may impact engagement in physical activity. To date, there are no studies that integrate simultaneous assessment of perceived barriers to physical activity and engagement in physical activity in older adults with PAD and diabetes. This integration is key to understanding the implications of barriers to physical activity and to developing strategies to address those barriers. Therefore, this study investigated the unique physical activity experiences of older adults with PAD and diabetes. This study used a concurrent mixed methods design. Ten adults aged 65 years and older with PAD and diabetes completed semistructured interviews about experiences with physical activity, self-reported questionnaires assessing quality of life and fear of falling, and measures of physical function (eg, 6-minute walk test, chair stand, gait speed). Physical activity was measured objectively with accelerometry. Inductive content analysis was used to identify themes, and integrated analysis was performed to evaluate patterns among qualitative and quantitative variables. On average, participants were 74 years old and spent 10% of their time in moderate or vigorous physical activity (range: 3%–18%); 80% of participants were men. Barriers to physical activity identified through qualitative interviews included lack of accessibility, lack of enjoyment of activity, lack of motivation, and pain and physical health. Facilitators to physical activity were social support, accessibility and convenience, and enjoyment of the activity. Participants with more sedentary time and less moderate or vigorous physical activity tended to report greater fear of falling and greater barriers to physical activity and achieved lower distances in 6-minute walk tests. This research provides insight into both the nature of perceived barriers to physical activity and engagement in physical activity among older adults with PAD and diabetes. The integration of self-reported measures and objective measures facilitates our understanding of the lived experiences of individuals with these conditions. Study findings can be used to support further investigation into factors that influence engagement in physical activity in individuals with PAD and diabetes and to assist in the development of strategies to address identified barriers.

Introduction: Evidence supporting the effects of supervised exercise therapy (SET) on alleviating symptoms and improving walking ability for patients with symptomatic peripheral artery disease (PAD) is robust and well recognized. However, little is known about the impact of SET on free-living physical activity (PA). The aim of this study was to examine the relationship between participation in SET and changes in free-living PA among individuals in the the EX ercise Training to Reduce Claudication: Arm ER gometry versus T readmill Walking ( EXERT ) trial. Methods: In this randomized, controlled trial, 104 participants (mean age 68±9; 29% female) were allocated to receive treadmill (TM) exercise (n=41), upper body ergometry (UBE) exercise (n=42), or usual-care (UC) (n=21) for 12 weeks. Exercise participants attended SET three times per week; UC participants met with study staff weekly. PA was measured over 7 days via waist-worn ActiGraph accelerometers at baseline, 6, and 12 weeks. Steps per day was the primary outcome. Secondary outcomes were proportion of time in light and moderate to vigorous physical activity (MVPA), and sedentary time. PA was controlled for in TM participants by using SET logs. Results were analyzed using descriptive statistics, two-sample t-tests, and analysis of variance. Results: Regardless of randomization, average daily steps were low at baseline and 6 weeks (4,013 steps, p =.72; and 3,911 steps, p =.84, respectively), and slightly higher at 12 weeks (4,307 steps; p =.93). Although not statistically significant but perhaps clinically relevant, UBE participants exhibited greater increases in MVPA over 12 weeks (0.9% to 1.3%; F =.48, p =.62) compared to TM (1.2% to 1.3%; F =.35, p =.71) and UC (1.3% to 1.5%, F =.03, p =.97); similarly all participants exhibited reductions in sedentary time and increases in free-living PA between baseline and 12 weeks. Conclusions: These data suggest individuals with PAD attending SET replace sedentary time with light or moderate intensity PA regardless of exercise modality. Despite study participants meeting the recommended daily steps for adults with chronic conditions (3,500-5,500 steps), it is suspected that they did not reach the daily goal of 30 minutes of enhanced PA to reduce health risks. Future research should incorporate activity tracking devices that can provide feedback on PA as an approach to meet daily PA goals. Activity tracking devices used in conjunction with SET may further improve walking distance, symptom management, and quality of life among patients with symptomatic PAD.

Objective To evaluate the association between smoking and cognitive function in patients with fibromyalgia. Patients and Methods We surveyed 668 patients with fibromyalgia from May 1, 2012 through November 30, 2013 at a major tertiary referral center. Patients were categorized by smoking status. Primary outcome of interest was cognitive function (MASQ questionnaire), and secondary outcomes included fibromyalgia symptom severity (FIQ-R questionnaire), quality of life (SF-36 questionnaire), fatigue (MFI-20 questionnaire), sleep (MOS-sleep scale), anxiety (GAD-7 questionnaire), and depression (PHQ-9 questionnaire). Independent Students' t-tests and χ2 tests were performed for continuous and categorical variables, respectively. Univariate regression analysis identified variables predictive of outcomes, adjusting for age, gender, body mass index, marital status, and educational level. Results Ninety-four (14.07%) patients self-identified as smokers. There was an association of lower education level, unmarried status, and younger age in smokers compared with nonsmokers. In the adjusted univariate regression analysis, fibromyalgia smokers reported greater perceived total cognitive dysfunction (P=.009) and greater subscale scores of perceived difficulty in language (P=.03), verbal memory (P=.003), visual-spatial memory (P=.02), and attention (P=.04) compared with nonsmokers with fibromyalgia. For secondary outcomes, smokers with fibromyalgia reported greater severity of fibromyalgia-related symptoms (P=.006), worse quality-of-life index in the mental component scale (P=.02), greater sleep problems (P=.01), and increased anxiety (P=.001) compared with nonsmokers who had fibromyalgia. Conclusion In patients with fibromyalgia, smoking is a risk factor for cognitive dysfunction. Moreover, smokers with fibromyalgia were more likely to report increased severity of fibromyalgia symptoms, worse quality of life, more sleep problems, and increased anxiety compared with nonsmokers with fibromyalgia.

Background Fibromyalgia is a syndrome characterized by chronic pain, fatigue, depression, and sleep disturbances. Its primary cause is unclear. Several studies have reported decreased intracellular magnesium levels in patients with fibromyalgia and have found negative correlation between magnesium levels and fibromyalgia symptoms. Objective To gather preliminary data on whether transdermal magnesium can improve quality of life for women who have fibromyalgia. Design, setting, participants and interventions This is a patient questionnaires and survey in a fibromyalgia clinic at a tertiary medical center. Forty female patients with the diagnosis of fibromyalgia were enrolled. Each participant was provided a spray bottle containing a transdermal magnesium chloride solution and asked to apply 4 sprays per limb twice daily for 4 weeks. Participants were asked to complete the Revised Fibromyalgia Impact Questionnaire, SF-36v2 Health Survey, and a quality-of-life analog scale at baseline, week 2, and week 4. Main outcome measure Questionnaire and survey scores, evaluated through intent-to-treat and per-protocol analyses. Results Twenty-four patients completed the study (mean [SD] age, 57.2 [7.6] years; white, 95%; mean body mass index, 31.3 kg/m 2 ). With intention-to-treat analysis, Revised Fibromyalgia Impact Questionnaire subscale and total scores were significantly improved at week 2 and week 4 (total score, P = 0.001). Per-protocol analysis results were similar: all subscales of the Revised Fibromyalgia Impact Questionnaire were significantly improved at week 2 and week 4 (total score, P = 0.001). Conclusion This pilot study suggests that transdermal magnesium chloride applied on upper and lower limbs may be beneficial to patients with fibromyalgia. Trial registration ClinicalTrials.gov . ldentifier NCT01968772 .

Background Research suggests that disordered autonomic function may be one contributor to deconditioning reported in fibromyalgia; however, no study to date has assessed these variables simultaneously with comprehensive measures. Objective To characterize physical fitness and autonomic function with the use of clinically validated measures and subjective questionnaires between patients with fibromyalgia and healthy controls. Design Cross-sectional, observational, controlled study. Setting Community sample of patients with fibromyalgia and healthy controls. Participants Thirty patients with fibromyalgia and 30 pain and fatigue-free controls. Methods Participants completed a battery of self-report questionnaires and physiological measures, including clinically validated measures of physical fitness and autonomic function. Main Outcome Measurements Six-Minute Walk Test total distance, maximal oxygen consumption as assessed by cardiopulmonary exercise testing, total steps using activity monitor, Composite Autonomic Scoring Scale as assessed by Autonomic Reflex Screen, total metabolic equivalents per week using the International Physical Activity Questionnaire, and self-reported autonomic symptoms via the 31-item Composite Autonomic Symptom Score questionnaire. Results Autonomic function, as assessed by self-report, was significantly different between patients and controls ( P P = .022), and these abnormalities were mild. Self-reported physical activity was not significantly different between patients and controls ( P = .99), but levels of moderate and vigorous physical activity as measured by actigraphy were significantly lower in patients ( P = .012 and P = .047, respectively). Exercise capacity (6-Minute Walk) was poorer in patients ( P = .0006), but there was no significant difference in maximal volume of oxygen consumption ( P = .07). Conclusions Patients with fibromyalgia report more severe symptoms across all domains, including physical activity and autonomic symptoms, compared with controls, but the objective assessments only showed modest differences. Our results suggest that patients with widespread subjective impairment of function have only modest objective measures of autonomic dysfunction. We recommend that the primary treatment goal should be focused on restoration of function, which may also ameliorate symptoms.

The purpose of this study was to implement and evaluate quality outcomes including referral, enrollment, and completion rates of a new peripheral artery disease (PAD)-specific supervised exercise therapy (SET) program within a preexisting clinical exercise wellness program and to evaluate the clinical effectiveness and patient-centered outcomes derived from 12 weeks of PAD-specific SET. Recruited participants completed an individualized, minimally supervised, PAD-specific SET program based on the AHA-ACC guidelines. Exercise workloads (metabolic equivalents of task [METs]) were tracked and evaluated throughout the program. Short Physical Performance Battery, 6-minute walk test (6MWT) Walking Impairment Questionnaire, Short-Form 36 (SF-36), and Peripheral Artery Disease Quality of Life Questionnaire (PADQOL) were assessed before and after the program. Paired t-tests were used to examine differences between baseline and follow-up outcome variables. On average, participants (n = 46) attended 23 (standard deviation [SD] 12.9) out of the possible 36 training sessions, for a 64% attendance rate. Among participants who used treadmill walking as the primary mode of exercise (n = 40), the overall mean MET level just prior to program completion was 3.79 (SD 1.49), which represented an increase of 0.92 (34%) METs compared to baseline (P .001). Total distance on the 6MWT increased 115 (11%) feet (P = .011), which is considered a clinically meaningful improvement. Significant improvements were noted in the PADQOL: symptoms and limitations in physical functioning (P = .007). This study demonstrates that a minimally staffed PAD-specific SET program can improve functional performance in patients with claudication due to PAD and serves as a foundation to help build a clinically effective, Centers for Medicare and Medicaid reimbursed PAD-specific rehabilitation program.

Peripheral artery disease (PAD) represents a serious health issue and is estimated to effect up to 30% of the ~23 million US adults who have diabetes. PAD occurs as the result of the development of plaque in the arteries of the lower limbs. The development of PAD can be attributed to a number of factors such as deleterious lifestyle behaviors (e.g., smoking, inactivity); however diabetes is one of the primary risk factors for developing the disease. Claudication is the most pronounced symptom of PAD and is described by patients as pain, aching, or cramping in the muscles of the legs during exertion that is relieved with rest. Claudication typically limits a patient’s ability to walk which ultimately leads to an exacerbation of poor metabolic control of the patient with diabetes. Patients with both PAD and diabetes who limit ambulatory activity have markedly lower functional ability and poor patient-reported outcomes and have an increased risk of adverse cardiovascular events and premature mortality. Exercise therapy is a cornerstone treatment option for patients who have both diseases, but it is considerably underused. This is attributed to a number of challenges for providing an ideal exercise prescription given the numerous physical limitations of patients. This chapter will provide a synthesis of the available literature using exercise therapy for PAD and diabetes and will propose future directions for treating patients who have both diseases.

This presentation compares and contrasts GSA and IAGG respondents’ views after controlling for discipline and primary activity. The IAGG sample is further divided by country of origin with a cluster, for example, from Africa, from Scandinavian countries, from Western Europe, from UK and Australia, from Asia, and New Zealand and from South American countries and Spain. Although numbers by country are rather small we do expect to see some differences in perspective, and will also analyze qualitative data for further insights. In the IAGG sample, pa large proportion of the same—amounting to at least 1/3, are physicians, perhaps a reflection of the way aging programmatic leadership and research evolves in various parts of the world.

Symptoms of fibromyalgia (FM)--chronic widespread pain, fatigue, unrefreshing sleep, dyscognition etcetera--present with varying degrees of severity in different individuals; however, studies reporting daily estimates of variability of symptoms are sparse. Given the limited literature on the stability and variability of FM symptoms, the purpose of the present study was to determine the feasibility of daily visual analogue, self-report measures to assess daily variability and time trends in core FM symptoms. Ten female patients completed daily assessments of common FM symptoms (pain, fatigue, anxiety, depression, stress, cognitive dysfunction, unrefreshing sleep and lightheadedness) for approximately 90 days. The completion rate was excellent (89.6%). The results demonstrated that average symptom intensity differs markedly across the different symptoms that were measured. Unrefreshing sleep, fatigue and pain are clearly higher in intensity than other symptoms and are followed by memory problems, stress, anxiety and depression. There is also notable average intra-individual change across time (10-15 points on a 100-point scale). Average symptom intensity does not appear to be related to the amount of symptom change within individuals. The results of the present study confirm that intensive longitudinal study, using comprehensive symptom assessment in patients with FM, is both possible and informative, in the sense that a rich description of the daily experience of living with FM can be obtained. Future work, utilizing larger samples, will offer the opportunity to investigate better the causes, consequences and correlates of the daily ups and downs of key symptoms that compromise quality of life in patients with FM.

The purpose of this qualitative study was to assess perspectives on the acceptability and the potential applicability of a forgiveness education in patients with fibromyalgia. The concept and tools of forgiveness were presented to thirteen women (age: 40 - 54 years) with a previous diagnosis of fibromyalgia. Subjects participated in 1 of 2 focus groups following a 90-minute education session in which forgiveness was presented as an emotion-focused coping strategy to deal with interpersonal stressors. Qualitative assessment of focus group discussions reveals 3 themes: 1) forgiveness is healthy and reduces pain, 2) forgiveness is within a patient’s personal control, and 3) forgiveness education is similar to other types of patient education and is well received. Our results suggest that forgiveness education is acceptable and feasible in patients with fibromyalgia. This justifies further exploration of forgiveness as an emotion-focused self- management strategy to decrease psychological distress.

Research demonstrates that patients with fibromyalgia who have higher positive and lower negative affect have lower symptom burden. Affect has been shown to be associated with resilience. This study examined the relationship between affect, resilience and fibromyalgia symptom burden in a clinical sample of patients with fibromyalgia. We hypothesized that (a) positive and negative affect would be associated with fibromyalgia symptom burden; (b) resilience would be associated with positive and negative affect; (c) resilience would be associated with fibromyalgia symptom burden; and (d) the connection between resilience and fibromyalgia symptom burden would be mediated by both positive and negative affect. A sample of 858 patients with fibromyalgia completed questionnaires. Mediation modelling revealed statistically significant direct effects of resilience on fibromyalgia symptom burden (β = −0.10, P

Fibromyalgia is a complex heterogeneous disorder for which a multidisciplinary individualized approach is currently advocated. We executed a 1-week multidisciplinary fibromyalgia clinical program with seven patients, based on our experience with our existing 1.5-day multidisciplinary fibromyalgia program that has demonstrated both short- and long-term benefits. The current expanded program was not designed as a clinical study, but rather as a clinical feasibility assessment, and it was multidisciplinary in nature, with cognitive behavioral therapy, activity pacing, and graded exercise therapy as major components. We assessed changes in individual patients at 1 week and 3 months after the program with the use of validated self-report measures of pain, fatigue, and self-efficacy. All patients indicated at least small improvements in pain and physical symptoms at both 1 week and 3 months, and all but one patient showed improvement in self-efficacy at 1 week and 3 months. Similar trends were observed for fatigue. Based on our early clinical experience, we conclude that the 1-week multidisciplinary fibromyalgia program is logistically feasible and has potential for clinical efficacy. Further research is needed and is planned to test the clinical efficacy of this program and compare it with other interventions.

Fibromyalgia (FM) is a complex illness to diagnose and treat, with symptoms that may be part of, or overlap with other diseases or syndromes. It is also a costly public health problem. Medical costs related to health care utilization and pain-related medications for patients with FM are substantially higher than those for patients without FM (1–4). Therefore, evaluating the prevalence of FM has both clinical and economic relevance. Recognition of FM may not always be straightforward, because FM symptoms may be part of or overlap with other diseases or syndromes. Using the original 1990 American College of Rheumatology (ACR) criteria, Wolfe et al estimated that the prevalence of FM in the US general population is 2% (3.4% in women vs 0.5% in men) (5). Similarly, White et al (6), reporting on the London Fibromyalgia Epidemiology Study in Ontario, Canada, estimated the prevalence of FM at 3.3% (4.9% in women vs 1.6% in men), and Branco et al (7) reported on a multinational study of the prevalence of FM in 5 European countries, estimating it at 4.7%. A separate study, using a method similar to that of the ACR diagnostic criteria estimated the prevalence in Germany at 3.8%, with similar rates in men and women, (8). These differing estimates may reflect differences in study populations, study designs, and measurements. In 2010, the ACR published diagnostic criteria for FM that encompass the chronic widespread pain, fatigue, unrefreshing sleep, cognition, and somatic symptoms considered the hallmarks of this condition (9). These criteria were later modified to allow their use in epidemiologic and survey studies, without the requirement for an examiner to perform a tender point examination (10). The modification involved asking patients to report both pain and tenderness for the widespread pain index, in comparison to the ACR 2010 diagnostic criteria that only asked health care providers to determine areas of pain. Additionally, 3 representative items substituted for the comprehensive list of somatic symptoms that composed the ACR 2010 symptom severity score: 1) the presence or absence of headaches; 2) pain or cramps in the lower abdomen; and 3) depression in the past 6 months. Similar to the 2010 clinical criteria for FM, the modified criteria included a widespread pain index score of ≥7 and a symptom severity score of ≥5. Alternatively, participants are defined as having FM if the widespread pain index is 3 to 6 or the symptom severity score is ≥9. Additionally, symptoms must have been present at a similar level for at least 3 months. Routine use of these criteria in epidemiologic research may improve comparability of FM prevalence in different populations. Our primary objective in this study was to estimate the prevalence of FM in a defined population in 2 different ways. To accomplish this objective, we first estimated the prevalence of diagnosed FM in clinical practice in Olmsted County, Minnesota, using community medical records. We then surveyed a random sample of the population of Olmsted County using the modified 2010 ACR criteria to estimate the percentage of responders who fulfilled criteria.

OBJECTIVE Patients with chronic multisymptom illnesses such as fibromyalgia syndrome (FMS) are experiencing a multitude of physical and mental challenges. Facing such challenges may drain capacity to self-regulate, and research suggests patients with these illnesses may experience self-regulatory fatigue (SRF). This study sought to examine whether SRF can be associated with quality of life (QoL) in patients with FMS. METHODS Patients (N = 258) diagnosed with FMS completed self-report measures related to demographics, SRF (Self-Regulatory Fatigue 18 [SRF-18]), anxiety (Generalized Anxiety Disorder questionnaire [GAD-7]), depression (Patient Health Questionnaire [PHQ-9]), physical fatigue (Multidimensional Fatigue Inventory [MFI]), symptoms related to FMS (Fibromyalgia Impact Questionnaire [FIQ]), and QoL (36-Item Short-Form Health Survey [SF-36]). RESULTS Hierarchical regressions showed higher SRF to be associated with lower QoL in terms of lower overall physical QoL, with subscales related to physical functioning, role limitations-physical, bodily pain, and general health (all P's > 0.001), as well as lower overall mental QoL, with subscales related to vitality, social functioning, role limitations-emotional, and mental health (all P's > 0.001). Including traditional predictors such as anxiety, depression, physical fatigue, and FMS-related symptoms as covariates in the analyses reduced the link between SRF and QoL somewhat, but the associations remained generally strong, particularly for SRF and mental QoL. CONCLUSION This is the first study to show higher SRF relating to lower QoL for patients with FMS. Results suggest that SRF is distinct from anxiety, depression, and fatigue, and predicts QoL above and beyond these traditional factors in the area of chronic multisymptom illnesses such as FMS. SRF may be a "missing link" in understanding the complex nature of chronic multisymptom illnesses.

Autonomic dysregulation is thought to contribute to the pathophysiology and symptoms in patients with fibromyalgia (FM). The majority of studies in FM that have reported autonomic dysregulation have relied on heart rate variability measurement and report increased sympathetic and decreased parasympathetic tone, chronotropic incompetence, and impaired autonomic cardiovascular regulation with blunted sympathetic reactivity to acute stress. 1Y3 These results may have clinical implications as increased sympathetic tone contributes to symptoms such as muscle tension and pain, fatigue, heightened stress response, and unrefreshing sleep, all common patient-reported symptoms in FM. 1,3Y6 The Autonomic Symptom Profile (ASP) is a validated selfreport questionnaire that comprehensively assesses autonomic symptoms across 11 subscales and yields a Composite Autonomic Symptoms Scale (COMPASS) score. 7 The ASP is unique in comparison to other commonly utilized self-report measures in that it assesses both symptoms and functional status. For example, the secretomotor subscale of the ASP assesses secretomotor symptoms such as sweating with vigorous exercise, ability to tolerate heat, and mucosal secretory dysfunction including dry eyes and dry mouth. 8 Similarly, the pupillomotor subscale of the ASP assesses pupillomotor symptoms such as light sensitivity, visual blurring, and dysfunction pupillomotor including trouble focusing eyes and difficulty seeing at night. 8 The ASP also includes a sleep subscale that evaluates presence of sleep disorders such as narcolepsy, obstructive sleep apnea, and abnormal sleeping patterns in addition to assessment of sleep quality. This is relevant as sleep and autonomic function are interdependent by virtue of their common controls, regulatory neurochemicals, and functions, but also because unrefreshing sleep is a predominant complaint in patients with FM. 9,10 There is one previous report utilizing the ASP in patients with FM. In this study, the Spanish version of the ASP was administered to 20 patients with FM, and results were compared with those of 30 patients with rheumatoid arthritis and 30 control subjects. 11 Patients with FM had the highest COMPASS scores in comparison with patients with rheumatoid arthritis and control subjects. In addition, total COMPASS scores correlated with FIQ total scores, suggesting a potential association between FM severity and autonomic dysfunction. 11 Our objective was to assess autonomic symptoms utilizing the ASP and their correlation with the Fibromyalgia Impact QuestionnaireYRevised (FIQ-R) in a large sample of patients with FM. METHODS Participants

Symptoms of post-traumatic stress disorder are common in fibromyalgia patients. This study compared post-traumatic stress disorder symptoms in fibromyalgia patients and healthy controls and determined whether patient-control differences in post-traumatic stress disorder symptoms mediated differences in mental health. In all, 30 patients and 30 healthy controls completed questionnaires assessing symptoms of post-traumatic stress disorder and mental health. Fibromyalgia patients had greater symptoms of post-traumatic stress disorder and mental health than controls. Patient-control differences in mental health symptoms were fully or partially mediated by differences in post-traumatic stress disorder symptoms. Healthcare providers should understand the role of trauma as management of trauma symptoms may be one strategy for improving mental health.