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Background Despite the widely known benefits of exercise and physical activity, adherence rates to these activities are poor. Understanding exercise facilitators, barriers, and preferences may provide an opportunity to personalize exercise prescription and improve adherence. The purpose of this study was to develop the Personalized Exercise Questionnaire (PEQ) to identify these facilitators, barriers, and preferences to exercise in people with osteoporosis. Methods This study comprises two phases, instrument design and judgmental evidence. A panel of 42 experts was used to validate the instrument through quantitative (content validity) and qualitative (cognitive interviewing) methods. Content Validity Index (CVI) is the most commonly used method to calculate content validity quantitatively. There are two kinds of CVI: Item-CVI (I-CVI) and Scale-level CVI (S-CVI). Results Preliminary versions of this tool showed high content validity of individual items (I-CVI range: 0.50 to 1.00) and moderate to high overall content validity of the PEQ (S-CVI/UA = 0.63; S-CVI/Ave = 0.91). Through qualitative methods, items were improved until saturation was achieved. The tool consists of 6 domains and 38 questions. The 6 domains are: 1) support network; 2) access; 3) goals; 4) preferences; 5) feedback and tracking; and 6) barriers. There are 35 categorical questions and 3 open-ended items. Conclusions Using an iterative approach, the development and evaluation of the PEQ demonstrated high item-content validity for assessing the facilitators, barriers, and preferences to exercise in people with osteoporosis. Upon further validation it is expected that this measure might be used to develop more client-centered exercise programs, and potentially improve adherence.

Background To determine the known-group validity, a type of construct validity, and the test-retest reliability of a newly developed tool, the Personalized Exercise Questionnaire (PEQ), that assesses the barriers, facilitators, and preferences to exercise in individuals with low bone mass and osteoporosis. Methods A comparative design was used to assess known-group validity and a test-retest design to examine the reproducibility. Ninety-five participants with low bone mass and osteoporosis were recruited from an outpatient clinic in Hamilton, Ontario. The questionnaire was administered to 95 participants at baseline and a subset of 42 participants completed the survey again one week later. The known-group validity of the PEQ was determined using four hypotheses that compared two known groups based on employment level, age, socioeconomic status, and physical activity level. The reproducibility of individual responses was analyzed using the Kappa Coefficient (κ). Results There was known-group validity for three of the four hypotheses. Test-retest reliability scores ranged from no agreement to almost perfect agreement; seven items had almost perfect agreement (κ: 0.81–1.00), 12 substantial agreement (κ: 0.68–0.74), six moderate agreement (κ: 0.56–0.60), two fair agreement (κ: 0.36–0.40), one slight agreement (κ = 0.23) and one no agreement (κ = − 0.03). Conclusion Preliminary support for the usefulness of the PEQ is indicated since the majority of the items had at least substantial agreement and known-group validity was moderately supported for some items. Trial registration This study was retrospectively registered with ClinicalTrials.gov , NCT03125590, on April 24, 2017.

Background Infliximab is a monoclonal antibody that binds and neutralizes circulating tumor necrosis factor-alpha, a key inflammatory cytokine in the pathophysiology of sarcoidosis. Despite the paucity of randomized clinical trials, infliximab is often considered a therapeutic option for refractory disease. Our study aimed to investigate the effectiveness of infliximab in patients with refractory sarcoidosis. Methods Sarcoidosis patients from three tertiary centres were retrospectively identified by pharmacy records based on treatment with infliximab. Treatment with Infliximab was initiated in patients who failed first and second line immunomodulators as determined by a multidisciplinary team of Respirologists, Dermatologists, ENT specialists, Rheumatologists, and Neurologists. Participants were characterized by the primary organ for which infliximab was initiated and the total number of organs involved. Clinical outcomes were categorized as treatment success versus failure. We defined treatment success as (A) improvement of cutaneous, upper airway, lymph node, gastrointestinal, eye, or joint manifestations; or (B) improvement or no change in central nervous system (CNS) or pulmonary manifestations. Results 33 patients with refractory sarcoidosis were identified. The proportion of treatment success was 100% (95% CI 54.1–100) in CNS, 91.7% (95% CI 61.5–99.8) in cutaneous, 78.6% (95% CI 49.2–95.3) in pulmonary and 71.5% (95% CI 29.0–96.3) in upper airway disease. The use of infliximab was associated with a reduction prednisone dose by 50%. Conclusion Infliximab is possibly an effective therapy for refractory sarcoidosis, with the greatest value in neurologic and cutaneous manifestations. Across all disease presentations, infliximab facilitated a clinically relevant reduction in corticosteroid dose. Relapse is common after discontinuation of infliximab.

The transition from pediatric to adult care for patients with chronic disease is a vulnerable period, with risks of disengagement from care and subsequent complications of inadequately managed disease. This period comes at a time when there are many other transitions occurring in the young person’s life, including changes to vocation, social supports, and to their physiology. The aim of the TRACER study is to assess the feasibility of conducting a multi-center, randomized-controlled trial of a virtual Transition Coach Intervention in youth transferring from pediatric to adult rheumatology care. Patients are being recruited at their last pediatric rheumatology visit from McMaster Children’s Hospital and Children’s Hospital, London Health Sciences Centre in Ontario, Canada. Participants are then randomized to standard of care or to eight transition coaching sessions, covering topics around health management, future planning, and self-advocacy. The primary outcomes of the study are to demonstrate protocol feasibility, including optimal recruitment and consent rates, ≥ 90% coaching session completion, and complete data collection with ≤ 5% missing data. Baseline demographics, transition readiness, global functional assessment, disease activity, and self-efficacy will be collected to characterize the study population. Recruitment has begun and is estimated to last 19 months. This study will inform the design of a robust, multi-centered, randomized-controlled study to investigate the impact of a virtual transition coaching program in supporting the physical, mental, and social well-being of youth with rheumatic disease transitioning into adult care. Clinical trial registration: ClinicalTrials.Gov protocol ID: 14499

The objective was to determine the extent to which the external peak knee adduction moment (KAM) and cumulative knee adductor load explained variation in medial cartilage morphology of the tibia and femur in knee osteoarthritis (OA). Sixty-two adults with clinical knee OA participated (61.5±6.2 years). To determine KAM, inverse dynamics was applied to motion and force data of walking. Cumulative knee adductor load reflected KAM impulse and loading frequency. Loading frequency was captured from an accelerometer. Magnetic resonance imaging scans were acquired with a coronal fat-saturated sequence using a 1.0T peripheral scanner. Scans were segmented for medial cartilage volume, surface area of the bone–cartilage interface, and thickness. Forward linear regressions assessed the relationship of loading variables with cartilage morphology unadjusted, then adjusted for covariates. In the medial tibia, age and peak KAM explained 20.5% of variance in mean cartilage thickness (p<0.001). Peak KAM alone explained 12.3% of the 5th percentile of medial tibial cartilage thickness (i.e., thinnest cartilage region) (p=0.003). In the medial femur, sex, BMI, age, and peak KAM explained 44% of variance in mean cartilage thickness, with peak KAM contributing 7.9% (p<0.001). 20.7% of variance in the 5th percentile of medial femoral cartilage thickness was explained by BMI and peak KAM (p=0.001). In these models, older age, female sex, greater BMI, and greater peak KAM related with thinner cartilage. Models of KAM impulse produced similar results. In knee OA, KAM peak and impulse, but not loading frequency, were associated with cartilage thickness of the medial tibia and femur.

The Medouie Creek wetland complex on Nantucket Island, MA was historically one contiguous salt marsh. Diking in the 1930s caused tidal restriction, creating a freshwater wetland colonized by Phragmites australis . To restore salt marsh habitat, the tidal restriction was removed and tidal salt water hydrology reestablished. Soil pore water salinity increased rapidly through the site with the majority of the marsh exhibiting salt marsh hydrology and higher salinities (25-30 ppt) eight years post-restoration. Extensive dieback of freshwater vegetation facilitated fairly rapid colonization by salt marsh vegetation, particularly adjacent to the culvert and marsh ditches. A non-metric multidimensional scaling (nMDS) analysis demonstrated that vegetation community composition was driven primarily by soil pore water salinity and marsh surface elevation. Eight years post-restoration, areas under 4 m elevation were dominated by salt marsh species while areas over 4 m retained freshwater vegetation. Unlike some other salt marsh restoration projects, salt marsh vegetation communities successfully established at Medouie primarily due to hydrological alteration and without the need for active revegetation or other restoration methods. P. australis stands were also significantly decreased. Given appropriate marsh conditions, altering hydrology alone to mimic functioning salt marsh hydrology may effectively drive vegetation succession and lead to ecologically functional salt marshes.

IntroductionCompared with clinical examination (CE), ultrasonography (US) provides additional and more accurate assessment of inflammation and visualization of structural damage. To better understand the effectiveness of US in metatarsophalangeal joints (MTPJs), we compared disease activity in MTPJs 2–5 assessed by CE and US, with magnetic resonance imaging (MRI) as reference standard.MethodTreatment-naïve adult patients with early RA (ACR criteria, disease duration < 2 years) were consecutively recruited. MTPJs 2–5 were assessed for swelling and tenderness, and imaged by US (Esaote MyLab70). The most symptomatic foot was imaged by peripheral MRI (1.0 Tesla). US was semiquantitatively graded for synovial thickening (ST) and power Doppler (PD) (0–3), and erosions (yes/no). MRI was semiquantitatively graded for bone marrow edema (BME), synovitis, and erosions (OMERACT). Kappa agreement, sensitivity, specificity, and predictive values were analyzed using cut-offs at ST ≥ 2, PD ≥ 1, and MRI synovitis and BME at both ≥ 1 and ≥ 2.ResultsThis study included 39 patients (85% female, mean (SD) age = 51.6 (10.3)). Using MRI synovitis and BME grade ≥ 2 as the reference, PD had superior sensitivity (82%) and kappa agreement (k = 0.43) than swollen joint count (55%, k = 0.20), but similar high specificity (88%, 83%). ST and PD were often observed in clinically asymptomatic MTPJs. US detected very few MRI erosions, but several observed erosions corresponded to grade ≥ 2 MRI erosions.ConclusionClinical swelling and PD are highly specific for active inflammation in the MTPJs. US supplemented CE by allowing observation of subclinical inflammation and structural damage.Key Points• Ultrasonography detected many subclinical synovial inflammations in metatarsophalangeal joints (MTPJs), many confirmed by MRI• Ultrasonography may best be used clinically to supplement clinical examination by assessing non-swollen joints• Ultrasonography provided quick method of visualizing bone erosions that were grade ≥ 2 on MRI

Development of coastal New England has led to the replacement of up to 37% of salt marshes with degraded freshwater wetlands, primarily through tidal restrictions. Removing these restrictions to restore salt marsh ecology would improve water quality, increase flood and storm protection, nutrient filtration, erosion control, and carbon sequestration. However, such restorations replace functional freshwater wetlands and could potentially impact freshwater species. Freshwater-dependent wildlife species such as the spotted turtle (Clemmys guttata), may be especially vulnerable to rapid changes in habitat resulting from tidal reintroduction due to their high site fidelity and limited ability to disperse quickly. Conservation of genetically and physically isolated spotted turtle populations as well as the restoration of salt marshes to mitigate climate change impacts are both high priorities on Nantucket Island. These two priorities conflicted in a project to restore tidal hydrology to an impounded freshwater marsh known to host a robust spotted turtle population. We evaluated changes to spotted turtle home range size and location and habitat use in response to salt marsh restoration over eight years. Home range size did not change but the location of home ranges shifted into bordering wetlands landward of the tidal salt water influence. Spotted turtles selected remaining freshwater marshes and shrub swamps while avoiding developed land and areas of establishing salt marsh within areas that had previously been high quality habitat. This study suggests prioritizing conservation of wetlands adjacent to planned salt marsh restoration to provide habitat for freshwater species to migrate.

Objective The transition from pediatric to adult rheumatology care represents a particularly vulnerable time for patients with juvenile idiopathic arthritis (JIA) and childhood‐onset systemic lupus erythematosus (cSLE). Improving self‐management skills is important in optimizing health care transition. The study’s objectives were to 1) examine variability in transition readiness of adolescents and young adults within and between different ages, sexes, and disease types; 2) determine the association between age and transition readiness; and 3) identify specific challenges to transition readiness for adolescents. Methods Over 1 year, patients 14 to 20 years of age with JIA or cSLE were recruited from pediatric transition and young adult clinics at a single academic institution. Participants completed the 14‐item Transition‐Q at a single time point. Total scores range from 0 to 100; higher scores indicate greater health care self‐management skills as a proxy for transition readiness. Descriptive statistics summarized patient characteristics and Transition‐Q scores for the population. Regression analyses determined the association between age, sex, and disease type and Transition‐Q score. Results Among 70 participants, 61 had JIA and 9 cSLE (mean disease duration 4.6 years). The mean (SD) total Transition‐Q score was 59.8 (14.9). Age was significantly associated with Transition‐Q score (standardized β = 0.372l P = 0.002). The most commonly reported challenges were seeing the physician alone (without parents), making one’s own appointments, picking up prescriptions, and independent transportation for appointments. Conclusion Transition readiness appears to increase with patient age. There is significant variability in Transition‐Q scores between patients of the same age, suggesting that an individualized approach to improving self‐management skills is necessary.

Severe constant and intermittent knee pain are associated with “unacceptable” symptoms in older adults with osteoarthritis (OA) [ 22 ]. We hypothesized that constant and intermittent pain would be independently related to physical function, with intermittent knee pain being a better predictor of future declines in physical function in early symptomatic knee OA. This study included men ( n  = 189) and women ( n  = 133) with radiographic, unilateral knee OA, observed using data from the Osteoarthritis Initiative (OAI). Pain types were measured using the Intermittent and Constant Osteoarthritis Pain (ICOAP) scale. Physical function was measured using the Western Ontario and McMaster Universities Arthritis Index (WOMAC-PF) and Knee Injury and Osteoarthritis Outcome Score (KOOS-FSR) and physical performance tests. High baseline intermittent ( B  = 0.277; p  = 0.001) and constant ( B  = 0.252; p  = 0.001) knee pain were related to poor WOMAC-PF. Increased constant ( B  = 0.484; p  = 0.001) and intermittent ( B  = 0.104; p  = 0.040) pain were related to 2-year decreased WOMAC-PF. High baseline intermittent knee pain predicted poor KOOS-FSR at year 2 ( B  = −0.357; p  = 0.016). Increased constant pain was related to decreased chair stand test performance over 2 years in women ( B  = 0.077; p  = 0.001). High baseline intermittent pain was related to poor performance on repeated chair stands ( B  = 0.035; p  = 0.021), while baseline constant pain was related to poor 400-m walk performance in women ( B  = 0.636; p  = 0.047). Intermittent and constant knee pain were independent factors in self-perceived physical function and were important predictors of future limitations in physical function. Identifying intermittent and constant pain in early symptomatic OA may allow patients to adopt strategies to prevent worsening pain and future declines in physical function.