Physiological Basis of Fatigue

The Biological Rationale for Integrating Intrinsic Capacity Into Frailty Models

The assessment and management of two function-centered clinical care models, frailty and intrinsic capacity decline have been proposed to achieve healthy aging. To implement these two care models, several different guidelines have been advocated by different health organizations, which has resulted in confusion and cost-ineffective results in healthcare practice. Although there are various operational definitions and screening tools of frailty, the most accepted operational definitions are based on the recognition of frailty phenotypes or deficit accumulation-based frailty indexes. Intrinsic capacity, referred to as the total physical and mental capacities for individual to undertake daily tasks in everyday life, is another care model, including five domains. Similar or identical instruments have been used to assess frailty and intrinsic capacity. In the present narrative review, we outlined the biological rationale for integrating intrinsic capacity into frailty models and highlighted the hierarchical and energy-dependent order of the intrinsic capacity domains. The vitality domain or energy metabolism-related capacity, is the highest order dimension and the basis of other intrinsic capacity domains. Vitality vulnerability manifests as a pre-frailty status in function-centered healthy aging. We provided a conceptual framework of frailty phenotypes and frailty indexes based on the hierarchical and energy-dependent order of the intrinsic capacity domains, particularly vitality capacity. To facilitate the clinical translation of the framework, some potential energy metabolism-related biomarkers have also been proposed as critical components for assessing and screening vitality capacity in older age. The integrating framework not only provides testable theoretical hypotheses, particularly about vitality as a foundational element in aging, but could serve as a starting point for further research to unravel the mechanisms of frailty. It also improves cost-effectiveness for optimizing aging interventions in clinical healthcare and public health policies of healthy aging.

The effect of Gyrokinesis exercise on fatigue and sleep quality in female office workers

Fatigue is a state of difficulty maintaining voluntary activity. Cortisol, which is essential for stress regulation, can cause tissue damage when elevated for long periods of time, which is a common problem for office workers in stressful environments. Sleep quality is important for health and cognitive function, while sleep deprivation increases the risk of physical and mental health disorders. Gyrokinesis combines circular, spiral, and wave movements influenced by yoga, tai chi, and ballet to provide a calming effect on the sympathetic nervous system. This study investigated the effects of Gyrokinesis exercise on lower extremity edema, muscle strength, fatigue, and sleep quality in sedentary office workers. Twenty-seven adult women aged 20-40 years were randomly assigned to a Gyrokinesis exercise group (n=14) or a control group (n=13). The exercise group participated in 60-min Gyrokinesis sessions twice a week for 8 weeks, while the control group used elastic compression stockings during their working hours. Results showed a significant decrease in fatigue and an improvement in sleep quality in the exercise group. Cortisol and serotonin levels showed a significant between-group interaction effect, with within-group changes observed only in the exercise group. Sleep quality indices improved significantly over time. In conclusion, Gyrokinesis exercise has the potential to improve physical and psychological well-being in sedentary office workers by positively influencing fatigue, sleep quality, and related hormone levels.

Development of air therapy as a novel therapeutic branch in the field of rehabilitation

BACKGROUND AND PURPOSE

Developing technology in the field of rehabilitation is vital to accelerate recovery and decrease the side effects of current modalities. Rehabilitation is a challenging science in which the main challenge is not just treating the patient but also to shorten the rehabilitation time and avoid harmful effects. Thus, this review demonstrates the possible design and effects of air therapy as a novel treatment branch besides hydrotherapy, electrotherapy, and manual therapy in the field of rehabilitation.

METHODS

The search was conducted over clinical trials, literature reviews, and systematic reviews on the possible effects of treatments that may have similar effects to the newly developed air therapy. This search was conducted in the Web of Science, Scopus, EBSCO, and Medline databases.

RESULTS

Air therapy could be used to improve the function of mechanoreceptors, improve circulation and microcirculation, decrease pain, the release of trigger points, regain the elasticity of soft tissues, treat acute and chronic inflammations, decrease muscle cramps and spasticity, strengthen muscle, and decrease muscle fatigue and Decreasing muscle fatigue and delayed muscle soreness.

CONCLUSION

Air therapy is a novel treatment modality that can be used effectively in the field of rehabilitation. Air therapy could be a valuable and safe treatment in rehabilitation.

The Application of Digital Frailty Screening to Triage Nonhealing and Complex Wounds

OBJECTIVE

We investigated the association between the complexity of diabetic foot ulcers (DFUs) and frailty.

RESEARCH DESIGN AND METHODS

Individuals (n = 38) with Grade 2 Wagner DFU were classified into 3 groups based on the Society for Vascular Surgery risk-stratification for major limb amputation as Stage 1 at very low risk (n = 19), Stage 2 at low risk (n = 9), and Stage 3 to 4 at moderate-to-high risk (n = 10) of major limb amputation. Frailty status was objectively assessed using a validated digital frailty meter (FM). The FM works by quantifying weakness, slowness, rigidity, and exhaustion over a 20-second repetitive elbow flexion-extension exercise using a wrist-worn sensor. FM generates a frailty index (FI) ranging from 0 to 1; higher values indicate progressively greater severity of frailty. Skin perfusion pressure (SPP), albumin, and tissue oxygenation level (SatO2) were also measured. One-way analysis of variance (ANOVA) was used to identify group effect for wound complexity. Pearson's correlation coefficient was used to assess the associations with frailty and clinical endpoints.

RESULTS

Frailty index was higher in Stage 3 and 4 as compared to Stage 1 (d = 1.4, P < .01) and Stage 2 (d = 1.2, P < .01). Among assessed frailty phenotypes, exhaustion was correlated with SPP (r = -0.63, P < .01) and albumin (r = -0.5, P < .01).

CONCLUSION

Digital biomarkers of frailty may predict complexity of DFU and thus triage individuals who can be treated more simply in their primary clinic versus higher risk patients who require prompt referral to multidisciplinary, more complex care.

Exercise therapy as a digital therapeutic for chronic disease management: consideration for clinical product development

Digital exercise therapies (DET) have the potential to bridge existing care gaps for people living with chronic conditions. Acting as either a standalone, embedded within multi-modal lifestyle therapy, or adjunct to pharmacotherapy or surgery, evidence-based DETs can favorably impact the health of a rapidly growing population. Given the nascent nature of digital therapeutics, the regulatory landscape has yet to mature. As such, in the absence of clear guidelines clinical digital product developers are responsible for ensuring the DET adheres to fundamental principles such as patient risk management and clinical effectiveness. The purpose of this narrative review paper is to discuss key considerations for clinical digital product developers who are striving to build novel digital therapeutic (DTx) solutions and thus contribute towards standardization of product development. We herein draw upon DET as an example, highlighting the need for adherence to existing clinical guidelines, human-centered design and an intervention approach that leverages the Chronic Care Model. Specific topics and recommendations related to the development of innovative and scalable products are discussed which ultimately allow for differentiation from a basic wellness tool and integration to clinical workflows. By embodying a code of ethics, clinical digital product developers can adequately address patients' needs and optimize their own future digital health technology assessments including appropriate evidence of safety and efficacy.

Cardiovascular adverse effects associated with the use of anti-HER2 in breast cancer treatment

Background: Cancer represents an important public health problem with increasing incidence, prevalence, and mortality, affecting the entire Western population, especially in developed and developing countries. The use of monoclonal antibodies has revolutionized the treatment of cancer, but this treatment can cause adverse cardiovascular effects (AE). Objective: The objective of this paper is to identify and classify AE in breast cancer patients in the use of Trastuzumab in two health institutions. Methods: Retrospective study of medical records of patients with breast cancer Her 2+ submitted the therapy with trastuzumab in early and advanced stage of the disease. Review conducted in a university hospital and a private clinic, both located in Rio de Janeiro State, Brazil. Results: Cardiovascular events were late for trastuzumab, with predominance of moderate reactions. There was a predominance of dyspnea, increased blood pressure, fatigue and reduced left ventricular ejection. Conclusion: The results resemble similarities in the pattern of the institutions' reactions. Identify possible AE and know the toxicity profile of trastuzumab can contribute to a safer therapy.

Sexual Dimorphism of Skeletal Muscle in a Mouse Model of Breast Cancer: A Functional and Molecular Analysis

Breast cancer incidence in men is statistically rare; however, given the lack of screening in males, more advanced stages at initial diagnosis result in lower 5-year survival rates for men with breast cancer compared to women. A sexual dimorphism, with respect to the effect of tumor growth on cachexia incidence and severity, has also been reported across cancer types. The purpose of this study was to examine the sexual dimorphism of breast cancer as it pertains to skeletal muscle function and molecular composition. Using female and male transgenic PyMT mice, we tested the hypothesis that the isometric contractile properties and molecular composition of skeletal muscle would be differentially affected by breast tumors. PyMT tumor-bearing mice of each sex, corresponding to maximal tumor burden, were compared to their respective controls. RNA sequencing of skeletal muscle revealed different pathway alterations that were exclusive to each sex. Further, differentially expressed genes and pathways were substantially more abundant in female tumor mice, with only minimal dysregulation in male tumor mice, each compared to their respective controls. These differences in the transcriptome were mirrored in isometric contractile properties, with greater tumor-induced dysfunction in females than male mice, as well as muscle wasting. Collectively, these data support the concept of sexually dimorphic responses to cancer in skeletal muscle and suggest that these responses may be associated with the clinical differences in breast cancer between the sexes. The identified sex-dependent pathways within the muscle of male and female mice provide a framework to evaluate therapeutic strategies targeting tumor-associated skeletal muscle alterations.

Sexual Dimorphism of Skeletal Muscle in a Mouse Model of Breast Cancer: A Functional and Molecular Analysis

Breast cancer incidence in men is statistically rare; however, given the lack of screening in males, more advanced stages at initial diagnosis results in lower 5-year survival rates for men with breast cancer compared to women. A sexual dimorphism, with respect to the effect of tumor growth on cachexia incidence and severity, has also been reported across cancer types. The purpose of this study was to examine the sexual dimorphism of breast cancer as it pertains to skeletal muscle function and molecular composition. Using female and male transgenic PyMT mice, we tested the hypothesis that isometric contractile properties and molecular composition of skeletal muscle would be differentially affected by breast tumors. PyMT tumor-bearing mice of each sex, corresponding to maximal tumor burden, were compared to their respective controls. RNA-sequencing of skeletal muscle revealed different pathway alterations that were exclusive to each sex. Further, differentially expressed genes and pathways were substantially more abundant in female tumor mice, with only minimal dysregulation in male tumor mice, each compared to their respective controls. These differences in the transcriptome were mirrored in isometric contractile properties, with greater tumor-induced dysfunction in females than male mice, as well as muscle wasting. Collectively, these data support the concept of sexually dimorphic responses to cancer in skeletal muscle and suggest these responses may be associated with the clinical differences in breast cancer between the sexes. The identified sex-dependent pathways within muscle of male and female mice provide a framework to evaluate therapeutic strategies targeting tumor-associated skeletal muscle alterations.

Which Exercise Approaches Work for Relieving Cancer-Related Fatigue? A Network Meta-analysis

OBJECTIVE: To determine the most effective exercise modalities for managing cancer-related fatigue during and after cancer treatment. DESIGN: Network meta-analysis (NMA) of randomized controlled trials. LITERATURE SEARCH: Seven electronic databases were systematically searched from inception to January 2022. STUDY SELECTION CRITERIA: Randomized controlled trials testing the effects of exercise on relieving cancer-related fatigue in adult patients with cancer. DATA SYNTHESIS: An NMA of 56 studies was conducted, and the PRISMA-NMA guidelines were followed when reporting results. To determine the most effective interventions, the surface under the cumulative ranking curve (SUCRA) value was calculated for each exercise modality. RESULTS: Combined aerobic and resistance exercise (standardized mean difference [SMD], 1.57; credible interval [CrI], 1.03-2.10), yoga (SMD, 1.02; CrI: 0.44, 1.60), and regular physical activity (SMD, 1.07; CrI: 0.21, 1.92) could significantly alleviate cancer-related fatigue compared to control groups (usual care, wait-list, and regular physical activity). Combined aerobic and resistance exercise (SUCRA, 97.2%) had the highest probability of efficacy, followed by yoga (SUCRA, 75.5%) and regular physical activity (SUCRA, 74.1%). During cancer treatment, combined aerobic and resistance exercise (SUCRA, 94.5%) ranked first in efficacy, followed by regular physical activity (SUCRA, 82.1%) and yoga (SUCRA, 73.8%). After cancer treatment, only combined aerobic and resistance exercise (SMD, 0.99; CrI: 0.13, 1.84) had a significant effect on cancer-related fatigue. CONCLUSION: Combined aerobic and resistance exercise, yoga, and regular physical activity were the most effective exercise modalities for alleviating cancer-related fatigue. Combined aerobic and resistance exercise is recommended during and after cancer treatment. J Orthop Sports Phys Ther 2023;53(6):1-10. Epub: 23 March 2023. doi:10.2519/jospt.2023.11251.

Handling shifts during an overnight sailing regatta: Comparison between sleep management strategies

The study aims to investigate the association between different sleep management strategies and the final ranking during a one-night sailing race. A large sample of 190 teams participating in the overnight sailing regatta (151 Miglia) were included in the study. The experimental design consisted of two surveys, administered one before the start of the race and the other after the arrival. The questionnaires provided general information on the sailboat, its crew, and the strategy adopted to manage sleep during the race. In this one-night regatta, the self-management of sleep/wake timing emerged as the most successful strategy. Among participants who adopted a shift-based racing strategy, a short night shift duration (i.e., 2 h) significantly predicted a better placement. These findings confirmed the relevance of sleep management in sport performance and provided new insights into the most suitable sleep management strategy during a relatively short offshore regatta. The conclusions might apply also to similar continuous-cycle activities. Further investigations are needed to explore best sleep management strategy in team regattas of longer duration.

Malnutrition screening and treatment in pediatric oncology: a scoping review

BACKGROUND

Malnutrition and cachexia during pediatric cancer treatment worsen toxicity and quality-of-life. Clinical practice varies with lack of standard malnutrition definition and nutrition interventions. This scoping review highlights available malnutrition screening and intervention data in childhood cancer and the need for standardizing assessment and treatment.

METHODS

Ovid Medline, CINAHL, and Cochrane Library were searched for studies containing malnutrition as the primary outcome with anthropometric, radiographic, or biochemical measurements. Secondary outcomes included validated nutritional assessment or screening tools. Two authors reviewed full manuscripts for inclusion. Narrative analysis was chosen over statistical analysis due to study heterogeneity.

RESULTS

The search yielded 234 articles and 17 articles identified from reference searching. Nine met inclusion criteria with six nutritional intervention studies (examining appetite stimulants, nutrition supplementation, and proactive feeding tubes) and three nutritional screening studies (algorithms or nutrition support teams) each with variable measures and outcomes. Both laboratory evaluations (albumin, prealbumin, total protein) and body measurement (weight loss, mid-upper arm circumference) were used. Studies demonstrated improved weight, without difference between formula or appetite stimulant used. Screening studies yielded mixed results on preventing weight loss, weight gain, and survival.

CONCLUSION

Our review demonstrated a paucity of evidence for malnutrition screening and intervention in pediatric cancer treatment. While a variety of malnutrition outcomes, interventions, and screening tools exist, nutritional interventions increased weight and decreased complications. Screening tools decreased malnutrition risk and may improve weight gain. Potential age- and disease-specific nutritional benefits and toxicities also exist, further highlighting the benefit of standardizing malnutrition definitions, screening, and interventions.

Vulnerability to chronic stress and the phenotypic heterogeneity of presbycusis with subjective tinnitus

Age-related functional reserve decline and vulnerability of multiple physiological systems and organs, as well as at the cellular and molecular levels, result in different frailty phenotypes, such as physical, cognitive, and psychosocial frailty, and multiple comorbidities, including age-related hearing loss (ARHL) and/or tinnitus due to the decline in auditory reserve. However, the contributions of chronic non-audiogenic cumulative exposure, and chronic audiogenic stress to phenotypic heterogeneity of presbycusis and/or tinnitus remain elusive. Because of the cumulative environmental stressors throughout life, allostasis systems, the hypothalamus-pituitary-adrenal (HPA) and the sympathetic adrenal-medullary (SAM) axes become dysregulated and less able to maintain homeostasis, which leads to allostatic load and maladaptation. Brain-body communication via the neuroendocrine system promotes systemic chronic inflammation, overmobilization of energetic substances (glucose and lipids), and neuroplastic changes via the non-genomic and genomic actions of glucocorticoids, catecholamines, and their receptors. These systemic maladaptive alterations might lead to different frailty phenotypes and physical, cognitive, and psychological comorbidities, which, in turn, cause and exacerbate ARHL and/or tinnitus with phenotypic heterogeneity. Chronic audiogenic stressors, including aging accompanying ontological diseases, cumulative noise exposure, and ototoxic drugs as well as tinnitus, activate the HPA axis and SAM directly and indirectly by the amygdala, promoting allostatic load and maladaptive neuroplasticity in the auditory system and other vulnerable brain regions, such as the hippocampus, amygdala, and medial prefrontal cortex (mPFC). In the auditory system, peripheral deafferentation, central disinhibition, and tonotopic map reorganization may trigger tinnitus. Cross-modal maladaptive neuroplasticity between the auditory and other sensory systems is involved in tinnitus modulation. Persistent dendritic growth and formation, reduction in GABAergic inhibitory synaptic inputs induced by chronic audiogenic stresses in the amygdala, and increased dendritic atrophy in the hippocampus and mPFC, might involve the enhancement of attentional processing and long-term memory storage of chronic subjective tinnitus, accompanied by cognitive impairments and emotional comorbidities. Therefore, presbycusis and tinnitus are multisystem disorders with phenotypic heterogeneity. Stressors play a critical role in the phenotypic heterogeneity of presbycusis. Differential diagnosis based on biomarkers of metabonomics study, and interventions tailored to different ARHL phenotypes and/or tinnitus will contribute to healthy aging and improvement in the quality of life.

Perception of Swallowing-Related Fatigue Among Older Adults

PURPOSE

Although fatigue is recognized as clinically relevant to swallowing performance, its prevalence and significance in dysphagic and nondysphagic adults have not been sufficiently examined. In this study, an online survey was used to examine swallowing- and eating-related fatigue (SERF) symptoms, the relationship between perceived SERF and other dysphagia-related health outcomes, and whether perceived SERF predicts risk for dysphagia or malnutrition.

METHOD

An online survey of older adults (aged 60 years or older) was conducted. A novel 12-item scale was developed to capture perceived SERF. Previously validated scales were used to measure dysphagia risk, sarcopenia, general fatigue, malnutrition risk, and quality of life. Logistic regression was used to examine whether SERF predicted risk for dysphagia and/or malnutrition.

RESULTS

Complete responses were collected from 417 community-dwelling adults (M _age = 70.6 years, SD = 4.9; 263 women); 75% (n = 312) reported at least some degree of SERF. SERF was significantly correlated with dysphagia risk, sarcopenia, general fatigue, malnutrition risk, and quality of life. SERF was a significant predictor of dysphagia risk while controlling for age, gender, and other health outcomes (odds ratio [OR] = 1.2, 95% confidence interval [CI; 1.16, 1.27], p < .001). For every unit increase in SERF score, the odds of being at risk for dysphagia were associated with an increase of 22%. Significant predictors for malnutrition risk included SERF (OR = 0.94, 95% CI [0.91, 0.98]), general fatigue (OR = 0.95, 95% CI [0.92, 0.99]), and quality of life (OR = 1.04, 95% CI [1.0, 1.1]).

CONCLUSIONS

Fatigue during swallowing and mealtimes is experienced by community-dwelling older adults and predicted dysphagia risk and malnutrition risk. Further research is needed to refine and validate a patient-reported outcome measure for SERF and examine the effects of fatigue on swallowing function and physiology under imaging.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20405835.

The effects of operating height and the passage of time on the end-point performance of fine manipulative tasks that require high accuracy

Sustained shoulder abduction, which results from an inappropriate worktable height or tool shape and long task hours, leads to an accumulation of muscle fatigue and subsequent work-related injuries in workers. It can be alleviated by controlling the table height or ergonomic tool design, but workers who are doing some types of work that require a discomfortable posture, such as minimally invasive surgery, cannot avoid these situations. Loads to the shoulder joint or muscles result in several problems, such as muscle fatigue, deterioration of proprioception or changing movement strategies of the central nervous system, and these are critical to work that requires a high accuracy of the upper extremities. Therefore, in this paper, we designed and conducted an experiment with human participants to discuss how an inappropriate height of the work-table affects the task performance of workers who are performing a fine manipulative task that requires high accuracy of the end point. We developed an apparatus that can control the height and has four touch screens to evaluate the end-point accuracy with two different heights. Eighteen adults (9 women and 9 men) participated in the experiments, and the electromyography of their shoulder muscles, their movement stability, and task performance were measured for the analysis. We found that inappropriate height of a table brings about muscle fatigue, and time elapsed for conducting tasks accelerated the phenomenon. Task performance deteriorated according to increased fatigue, and improved movement stability is not enough to compensate for these situations.

Exploring the prevalence, impact and experience of cardiac cachexia in patients with advanced heart failure and their caregivers: A sequential phased study

BACKGROUND

Cardiac Cachexia is a wasting syndrome that has a significant impact on patient mortality and quality of life world-wide, although it is poorly understood in clinical practice.

AIM

Identify the prevalence of cardiac cachexia in patients with advanced New York Heart Association (NYHA) functional class and explore its impact on patients and caregivers.

DESIGN

An exploratory cross-sectional study. The sequential approach had two phases, with phase 1 including 200 patients with NYHA III-IV heart failure assessed for characteristics of cardiac cachexia. Phase 2 focussed on semi-structured interviews with eight cachectic patients and five caregivers to ascertain the impact of the syndrome.

SETTING/PARTICIPANTS

Two healthcare trusts within the United Kingdom.

RESULTS

Cardiac Cachexia was identified in 30 out of 200 participants, giving a prevalence rate of 15%. People with cachexia had a significantly reduced average weight and anthropometric measures (p < 0.05). Furthermore, individuals with cachexia experienced significantly more fatigue, had greater issues with diet and appetite, reduced physical wellbeing and overall reduced quality of life. C-reactive protein was significantly increased, whilst albumin and red blood cell count were significantly decreased in the cachectic group (p < 0.05). From qualitative data, four key themes were identified: (1) 'Changed relationship with food and eating', (2) 'Not me in the mirror', (3) 'Lack of understanding regarding cachexia' and (4) 'Uncertainty regarding the future'.

CONCLUSIONS

Cardiac cachexia has a debilitating effect on patients and caregivers. Future work should focus on establishing a specific definition and clinical pathway to enhance patient and caregiver support.

Oxaloacetate Treatment For Mental And Physical Fatigue In Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) and Long-COVID fatigue patients: a non-randomized controlled clinical trial

BACKGROUND

There is no approved pharmaceutical intervention for Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (ME/CFS). Fatigue in these patients can last for decades. Long COVID may continue to ME/CFS, and currently, it is estimated that up to 20 million Americans have significant symptoms after COVID, and the most common symptom is fatigue. Anhydrous Enol-Oxaloacetate, (AEO) a nutritional supplement, has been anecdotally reported to relieve physical and mental fatigue and is dimished in ME/CFS patients. Here, we examine the use of higher dosage AEO as a medical food to relieve pathological fatigue.

METHODS

ME/CFS and Long-COVID patients were enrolled in an open label dose escalating "Proof of Concept" non-randomized controlled clinical trial with 500 mg AEO capsules. Control was provided by a historical ME/CFS fatigue trial and supporting meta-analysis study, which showed average improvement with oral placebo using the Chalder Scale of 5.9% improvement from baseline. At baseline, 73.7% of the ME/CFS patients were women, average age was 47 and length of ME/CFS from diagnosis was 8.9 years. The Long-COVID patients were a random group that responded to social media advertising (Face Book) with symptoms for at least 6 months. ME/CFS patients were given separate doses of 500 mg BID (N = 23), 1,000 mg BID (N = 29) and 1000 mg TID (N = 24) AEO for six weeks. Long COVID patients were given 500 mg AEO BID (N = 22) and 1000 mg AEO (N = 21), again over a six-week period. The main outcome measure was to compare baseline scoring with results at 6 weeks with the Chalder Fatigue Score (Likert Scoring) versus historical placebo. The hypothesis being tested was formulated prior to data collection.

RESULTS

76 ME/CFS patients (73.7% women, median age of 47) showed an average reduction in fatigue at 6 weeks as measured by the "Chalder Fatigue Questionnaire" of 22.5% to 27.9% from baseline (P < 0.005) (Likert scoring). Both physical and mental fatigue were significantly improved over baseline and historical placebo. Fatigue amelioration in ME/CFS patients increased in a dose dependent manner from 21.7% for 500 mg BID to 27.6% for 1000 mg Oxaloacetate BID to 33.3% for 1000 mg TID. Long COVID patients' fatigue was significantly reduced by up to 46.8% in 6-weeks.

CONCLUSIONS

Significant reductions in physical and metal fatigue for ME/CFS and Long-COVID patients were seen after 6 weeks of treatment. As there has been little progress in providing fatigue relief for the millions of ME/CFS and Long COVID patients, anhydrous enol oxaloacetate may bridge this important medical need. Further study of oxaloacetate supplementation for the treatment of ME/CFS and Long COVID is warranted. Trial Registration https://clinicaltrials.gov/ct2/show/NCT04592354 Registered October 19, 2020. 1,000 mg BID Normalized Fatigue Data for Baseline, 2-weeks and 6-weeks evaluated by 3 Validated Fatigue Scoring Questionnaires.

Fatigue is associated with disease activity in some, but not all, patients living with rheumatoid arthritis: disentangling "between-person" and "within-person" associations

Background

Previous research has shown an unclear and inconsistent association between fatigue and disease activity in patients with rheumatoid arthritis (RA). The aim of this study was to explore differences in “between-person” and “within-person” associations between disease activity parameters and fatigue severity in patients with established RA.

Methods

Baseline and 3-monthly follow-up data up to one-year were used from 531 patients with established RA randomized to stopping (versus continuing) tumor necrosis factor inhibitor treatment enrolled in a large pragmatic trial. Between- and within-patient associations between different indicators of disease activity (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], swollen and tender joint count [ SJC and TJC], visual analog scale general health [VAS-GH]) and patient-reported fatigue severity (Bristol RA Fatigue Numerical Rating Scale) were disaggregated and estimated using person-mean centering in combination with repeated measures linear mixed modelling.

Results

Overall, different indices of disease activity were weakly to moderately associated with fatigue severity over time (β’s from 0.121 for SJC to 0.352 for VAS-GH, all p’s < 0.0001). Objective markers of inflammation (CRP, ESR and SJC) were associated weakly with fatigue within patients over time (β’s: 0.104–0.142, p’s < 0.0001), but not between patients. The subjective TJC and VAS-GH were significantly associated with fatigue both within and between patients, but with substantially stronger associations at the between-patient level (β’s: 0.217–0.515, p’s < 0.0001). Within-person associations varied widely for individual patients for all components of disease activity.

Conclusion

Associations between fatigue and disease activity vary largely for different patients and the pattern of between-person versus within-person associations appears different for objective versus subjective components of disease activity. The current findings explain the inconsistent results of previous research, illustrates the relevance of statistically distinguishing between different types of association in research on the relation between disease activity and fatigue and additionally suggest a need for a more personalized approach to fatigue in RA patients.

Trial registration Netherlands trial register, Number NTR3112.

Relationship of Cachexia with Self-Care Agency and Quality of Life in Cancer Patients: The Case of Turkey

Objective:

This study aims to determine the effects of cachexia, causing major problems in the world and Turkey, on self-care agency and quality of life in cancer patients.

Methods:

The population of this cross-sectional and relationship-seeking study consisted of cancer patients in Turkey from April 1 to April 20, 2021. Using the snowball sampling method, 174 patients were sampled. “Patient Information Form,” “The European Organization for Research and Treatment of Cancer C30 Cancer Quality of Life Scale,” and “Exercise of Self-Care Agency Scale” were used as data collection tools.

Results:

In the study, 52 patients (29.9%) were found to have cachexia. Function, general well-being, symptom (except insomnia), and self-care agency, which are subdimensions of the quality-of-life scale, were found to be significantly lower in patients with cachexia than patients without cachexia (P < 0.001). It was determined that there was a significant negative correlation between the cachexia status of the patients and the five basic functions in the functional scale (physical, role, emotional, cognitive, and social function), general well-being, and self-care agency, and there was a significant positive correlation between the cachexia status of the patients and the symptom scale (P < 0.001). According to the results of multiple linear regression analysis, it was found that the factor that significantly affected the cachexia status of the patients was their self-care agency (P < 0.001).

Conclusions:

It was determined that cachexia caused significantly lower self-care agency and quality of life in cancer patients. Furthermore, quality of life was related to self-care agency.

Mild parkinsonian signs, energy decline, and striatal volume in community-dwelling older adults

BACKGROUND

Mild Parkinsonian Signs (MPS), highly prevalent in older adults, predict disability. It is unknown whether energy decline, a predictor of mobility disability, is also associated with MPS. We hypothesized that those with MPS had greater decline in self-reported energy levels (SEL) than those without MPS, and that SEL decline and MPS share neural substrates.

METHODS

Using data from the Health, Aging and Body Composition Study, we analyzed 293 Parkinson's Disease-free participants (83±3 years old, 39% Black, 58% women) with neuroimaging data, MPS evaluation by Unified Parkinson Disease Rating Scale in 2006-2008, and ≥ 3 measures of SEL since 1999-2000. Individual SEL slopes were computed via linear mixed models. Associations of SEL slopes with MPS were tested using logistic regression models. Association of SEL slope with volume of striatum, sensorimotor, and cognitive regions were examined using linear regression models adjusted for normalized total gray matter volume. Models were adjusted for baseline SEL, mobility, demographics, and comorbidities.

RESULTS

Compared to those without MPS (n=165), those with MPS (n=128) had 37% greater SEL decline in the prior eight years (p=0.001). Greater SEL decline was associated with smaller right striatal volume (adjusted standardized β=0.126, p=0.029). SEL decline was not associated with volumes in other regions. The association of SEL decline with MPS remained similar after adjustment for right striatal volume (adjusted OR=2.03, 95% CI: 1.16 - 3.54).

CONCLUSION

SEL decline may be faster in those with MPS. Striatal atrophy may be important for declining energy but does not explain the association with MPS.

Influence of Self-managed Rehabilitation on Work Efficiency in Active Duty Military With a Knee Injury

INTRODUCTION

Knee injuries associated with intense physical training are one of the most frequent injuries associated with medical encounters for military members. The purpose of this study was to evaluate four approaches to physiotherapy rehabilitation and their effects on work efficiency in active duty military with a knee injury. The four groups included neuromuscular electrical stimulation (NMES), walking with a weighted vest (WALK), combined NMES/Walk, and standard physiotherapy rehabilitation. All groups received standard physiotherapy rehabilitation.We have previously reported that quadriceps muscle strength improved over 18 weeks in the study for the three interventions relative to standard rehabilitation alone. This report presents results from an examination of work efficiency as evaluated during a step test while measuring oxygen utilization.

METHODS

A randomized controlled trial was conducted, with repeated outcome measures of work efficiency assessed at baseline, 3, 6, 12, and 18 weeks. The sample consisted of 67 active duty service members between the ages of 18 and 50 years with a knee injury. Participants were randomized to one of the four approaches to physiotherapy rehabilitation: (1) NMES was applied to the quadriceps muscle four times per week, for 30 minutes (15 minutes to each leg), consisting of 15 quadriceps muscle contractions per leg; (2) graduated strength walking using a weighted vest (WALK) was for 30 minutes, 3 to 4 days a week; (3) combined NMES with strength walking received both the NMES therapy and the weighted vest walking; and (4) standard physiotherapy consisted of progressive exercise with the number and type of sessions not controlled by the study. All four groups received the standard physiotherapy for a knee injury. The primary outcome was work efficiency, as measured by oxygen utilization during a 2-minute self-paced step test over 18 weeks. The primary analysis used repeated measures, linear mixed-effects models with a random effect for subject.

RESULTS

Both the number of steps performed and gross work efficiency improved during the study for all three intervention groups. For gross work efficiency, standard rehabilitation improved 12%, WALK showed a 19% improvement, NMES increased by 24%, and the NMES/Walk group improved by 40%.

CONCLUSIONS

All groups showed improved submaximal exercise efficiency based on oxygen utilization, with the intervention groups showing a greater improvement in work efficiency as compared to standard rehabilitation. Knee injuries can be problematic for active duty members because of reduced mobility leading to deconditioning and associated declines in work efficiency. Rehabilitative programs, including those described in this study, may minimize loss of work efficiency and fitness and promote a quicker recovery.

Nutritional Status of Pediatric Cancer Patients at Diagnosis and Correlations with Treatment, Clinical Outcome and the Long-Term Growth and Health of Survivors

Malnutrition is caused either by cancer itself or by its treatment, and affects the clinical outcome, the quality of life (QOL), and the overall survival (OS) of the patient. However, malnutrition in children with cancer should not be accepted or tolerated as an inevitable procedure at any stage of the disease. A review of the international literature from 2014 to 2019 was performed. Despite the difficulty of accurately assessing the prevalence of malnutrition, poor nutritional status has adverse effects from diagnosis to subsequent survival. Nutritional status (NS) at diagnosis relates to undernutrition, while correlations with clinical outcome are still unclear. Malnutrition adversely affects health-related quality of life (HRQOL) in children with cancer and collective evidence constantly shows poor nutritional quality in childhood cancer survivors (CCSs). Nutritional assessment and early intervention in pediatric cancer patients could minimize the side effects of treatment, improve their survival, and reduce the risk of nutritional morbidity with a positive impact on QOL, in view of the potentially manageable nature of this risk factor.

Impact of musculoskeletal degradation on cancer outcomes and strategies for management in clinical practice

The prevalence of malnutrition in patients with cancer is one of the highest of all patient groups. Weight loss (WL) is a frequent manifestation of malnutrition in cancer and several large-scale studies have reported that involuntary WL affects 50-80% of patients with cancer, with the degree of WL dependent on tumour site, type and stage of disease. The study of body composition in oncology using computed tomography has unearthed the importance of both low muscle mass (sarcopenia) and low muscle attenuation as important prognostic indications of unfavourable outcomes including poorer tolerance to chemotherapy; significant deterioration in performance status and quality of life (QoL), poorer post-operative outcomes and shortened survival. While often hidden by excess fat and high BMI, muscle abnormalities are highly prevalent in patients with cancer (ranging from 10 to 90%). Early screening to identify individuals with sarcopenia and decreased muscle quality would allow for earlier multimodal interventions to attenuate adverse body compositional changes. Multimodal therapies (combining nutritional counselling, exercise and anti-inflammatory drugs) are currently the focus of randomised trials to examine if this approach can provide a sufficient stimulus to prevent or slow the cascade of tissue wasting and if this then impacts on outcomes in a positive manner. This review will focus on the aetiology of musculoskeletal degradation in cancer; the impact of sarcopenia on chemotherapy tolerance, post-operative complications, QoL and survival; and outline current strategies for attenuation of muscle loss in clinical practice.

[Anemia increases mortality risk associated with frailty or disability in older adults. The FRADEA Study]

OBJECTIVE

To analyze if anemia increases 10-year mortality risk associated to frailty and disability in older adults.

DESIGN

Substudy of the FRADEA population-based concurrent cohort study (Frailty and dependence in Albacete), with a 10-year follow-up (2007-2017) in people older than 69years.

SETTING

Albacete city, Spain.

PARTICIPANTS

Of the 993 participants included in the first wave, 790 were selected with valid data on function (frailty and disability), anemia and vital status at 10years.

MAIN MEASUREMENTS

Anemia was defined according to the criteria of the World Health Organization (hemoglobin <13g/dL in men and <12g/dL in women). A functional classification variable was created, including frailty and disability, identifying four progressive functional levels: robust, prefrail, frail and disabled in basic activities of daily life, using frailty phenotype and Barthel index respectively. A new eight categories variable was constructed combining the four functional groups with the presence or absence of anemia. The association with mortality was determined by Kaplan-Meier and Cox proportional hazards analysis adjusted for age, sex, comorbidity, polypharmacy, institutionalization and creatinine.

RESULTS

Mean age was 79years and 59.6% were women. 393 participants (49.7%) died during the follow-up period. The median survival was 98.4months (interquartile range 61). The risk of mortality increased from the levels with better functionality to those with worse functionality, and for each subgroup it was higher in the participants with anemia. Prefrail without anemia HR [hazard ratio] 1.59 (95%CI 1.07-2.36) and with anemia HR 2.37 (95%CI 1.38-4.05). Frail without anemia HR 3.18 (95%CI 1.68-6.02) and with anemia HR 4.42 (95%CI 1.99-9.84). Disabled without anemia HR 3.81 (95%CI 2.45-5.84) and with anemia HR 5.48 (95%CI 3.43-8.76).

CONCLUSION

Anemia increases the risk of mortality associated with frailty and disability in older adults.

Burden of fatigue among adults living with HIV/AIDS attending antiretroviral therapy in Ethiopia

BACKGROUND

Fatigue is one of the most common and devastating Human Immuno-deficiency Virus (HIV) - related symptoms, with a varying prevalence in different study areas. In Ethiopia, there is a paucity of information on the magnitude and factors associated with fatigue among HIV/Acquired Immune Deficiency Syndrome (AIDS) patients. This may lead to under-diagnosis and eventually under-management of the symptom.

METHODS

Institution based cross-sectional study design was conducted among 609 HIV/AIDS patients who were selected by using a systematic random sampling method. Data were collected by using interviewer administered structured questionnaire. Level of fatigue was measured by Fatigue Severity Scale.

RESULTS

The prevalence of fatigue was found to be 51.7%. The factors associated with fatigue were: Parity [AOR = 2.01; 95% CI: 1.09-3.71], CD4 count 200-499 cells/mm3 [AOR = 2.81; 95% CI: 1.58-4.99], anemia [AOR = 4.90 95% CI: 2.40-9.97], co-morbidities [AOR = 3.65; 95% CI: 1.71-7.78], depression [AOR = 3.68 95% CI: 1.99-6.79], not being physically active [AOR = 3.20 95% CI: 1.50-6.81], clinical stage II or IV HIV [AOR = 3.11; 95% CI: 1.51-6.40] and [AOR = 4.08; 95% CI: 1.37-12.14], respectively.

CONCLUSION

The finding of this study revealed that fatigue is a common health problem among adult People Living with HIV (PLHIV). Factors associated with fatigue included: Parity, CD4 count 200-499 cells/mm3, Clinical Stage II or IV HIV, anemia, co-morbidities, depression, and not being physically active. The health care service needs to address the predisposing factors by provision integrated care including timely detection and treatment of comorbidities, mental health problems, and promote physical activity to slow down disease progression and then reduce exposure to fatigue.

Oral Bioavailability Enhancement and Anti-Fatigue Assessment of the Andrographolide Loaded Solid Dispersion

Andrographolide (AG), a major diterpene lactone isolated from Andrographis paniculata (Burm. f.) Nees (Acanthaceae), possesses a wide spectrum of biological activities. However, its poor water solubility and low bioavailability limit its clinical application. Therefore, this study aimed to develop a solid dispersion (SD) formulation to increase the aqueous solubility and dissolution rate of AG. Different drug-polymer ratios were used to prepare various SDs. The optimized formulation was characterized for differential scanning calorimetry, Fourier transform infrared spectroscopy, and powder X-ray diffraction. The analysis indicated that the optimized SD enhanced AG solubility and dissolution rates by changing AG crystallinity to an amorphous state. The dissolution behaviors of the optimum SD composed of an AG-polyvinylpyrrolidone K30-Kolliphor EL ratio of 1:7:1 (w/w/w) resulted in the highest accumulated dissolution (approximately 80%). Pharmacokinetic studies revealed that C_max/dose and the AUC/dose increased by 3.7-fold and 3.0-fold, respectively, compared with AG suspension. Furthermore, pretreatment using the optimized AG-SD significantly increased the swimming time to exhaustion by 1.7-fold and decreased the plasma ammonia level by 71.5%, compared with the vehicle group. In conclusion, the optimized AG-SD formulation appeared to effectively improve its dissolution rate and oral bioavailability. Moreover, the optimized AG-SD provides a promising treatment against physical fatigue.

Energy Cost During the 6-Minute Walk Test and Its Relationship to Real-World Walking After Stroke: A Correlational, Cross-Sectional Pilot Study

BACKGROUND

After experiencing stroke, individuals expend more energy walking than people who are healthy. However, among individuals who have experienced stroke, the correlation between the energy cost of walking, as measured by validated tests (such as the 6-minute walk test), and participation in walking, as measured by more sensitive tools (such as an ambulatory activity monitor), remains unknown.

OBJECTIVE

The main objective of this study was to determine whether the energy cost of walking is correlated with participation in walking.

DESIGN

This study was a correlational, cross-sectional pilot study.

METHODS

Data from 23 participants who had experienced chronic stroke were analyzed. On the first day, data on oxygen uptake were collected using a portable metabolic system while participants walked during the 6-minute walk test. Then, the ambulatory activity monitor was placed on the participants' nonparetic ankle and removed 9 days later. The energy cost of walking was calculated by dividing the mean oxygen uptake recorded during the steady state by the walking speed.

RESULTS

The energy cost of walking was correlated with the following: the number of steps (Spearman rank correlation coefficient [rs] = -0.59); the percentage of time spent in inactivity (rs = 0.48), low cadence (rs = 0.67), medium cadence (rs = -0.56), high cadence (rs = -0.65), and the percentages of steps taken at low cadence (rs = 0.65) and high cadence (rs = -0.64).

LIMITATIONS

Individuals who were physically inactive, convenience sampling, and a small sample size were used in this study.

CONCLUSIONS

Higher energy costs of walking were associated with fewer steps per day and lower cadence in real-world walking in individuals who had experienced stroke.

An exploration of the prevalence and experience of cardiac cachexia: protocol for a mixed methods cross-sectional study

BACKGROUND

Cachexia is a complex and multifactorial syndrome defined as severe weight loss and muscle wasting which frequently goes unrecognised in clinical practice [1]. It is a debilitating syndrome, resulting in patients experiencing decreased quality of life and an increased risk of premature death; with cancer cachexia alone resulting in 2 million deaths per annum [2]. Most work in this field has focused on cancer cachexia, with cardiac cachexia being relatively understudied - despite its potential prevalence and impact in patients who have advanced heart failure. We report here the protocol for an exploratory study which will: 1. focus on determining the prevalence and clinical implications of cardiac cachexia within advanced heart failure patients; and 2. explore the experience of cachexia from patients' and caregivers' perspectives.

METHODS

A mixed methods cross-sectional study. Phase 1: A purposive sample of 362 patients with moderate to severe heart failure from two Trusts within the United Kingdom will be assessed for known characteristics of cachexia (loss of weight, loss of muscle, muscle mass/strength, anorexia, fatigue and selected biomarkers), through basic measurements (i.e. mid-upper arm circumference) and use of three validated questionnaires; focusing on fatigue, quality of life and appetite. Phase 2: Qualitative semi-structured interviews with patients (n = 12) that meet criteria for cachexia, and their caregivers (n = 12), will explore their experience of this syndrome and its impact on daily life. Interviews will be digitally recorded and transcribed verbatim, prior to qualitative thematic and content analysis. Phase 3: Workshops with key stakeholders (patients, caregivers, healthcare professionals and policy makers) will be used to discuss study findings and identify practice implications to be tested in further research.

DISCUSSION

Data collected as part of this study will allow the prevalence of cardiac cachexia in a group of patients with moderate to severe heart failure to be determined. It will also provide a unique insight into the implications and personal experience of cardiac cachexia for both patients and carers. It is hoped that robust quantitative data and rich qualitative perspectives will promote crucial clinical discussions on implications for practice, including targeted interventions to improve patients' quality of life where appropriate.

Effects of weight loss and sarcopenia on response to chemotherapy, quality of life, and survival

It has frequently been shown that patients with cancer are one of the largest hospital patient groups with a prevalence for malnutrition. Weight loss is a frequent manifestation of malnutrition in patients with cancer. Several large-scale studies over the past 35 y have reported that involuntary weight loss affects 50% to 80% of these patients with the degree of weight loss dependent on tumor site and type and stage of disease. The aim of this review was to determine the consequences of malnutrition, weight loss, and muscle wasting in relation to chemotherapy tolerance, postoperative complications, quality of life, and survival in patients with cancer. The prognostic impact of weight loss on overall survival has long been recognised with recent data suggesting losses as little as 2.4% predicts survival independent of disease, site, stage or performance score. Recently the use of gold-standard methods of body composition assessment, including computed tomography, have led to an increased understanding of the importance of muscle abnormalities, such as low muscle mass (sarcopenia), and more recently low muscle attenuation, as important prognostic indicators of unfavourable outcomes in patients with cancer. Muscle abnormalities are highly prevalent (ranging from 10-90%, depending on cancer site and the diagnostic criteria used). Both low muscle mass and low muscle attenuation have been associated with poorer tolerance to chemotherapy; increased risk of postoperative complications; significant deterioration in a patients' performance status, and poorer psychological well-being, overall quality of life, and survival.

Human Breast Cancer Xenograft Model Implicates Peroxisome Proliferator-activated Receptor Signaling as Driver of Cancer-induced Muscle Fatigue

PURPOSE

This study tested the hypothesis that a patient-derived orthotopic xenograft (PDOX) model would recapitulate the common clinical phenomenon of breast cancer-induced skeletal muscle (SkM) fatigue in the absence of muscle wasting. This study additionally sought to identify drivers of this condition to facilitate the development of therapeutic agents for patients with breast cancer experiencing muscle fatigue.

EXPERIMENTAL DESIGN

Eight female BC-PDOX-bearing mice were produced via transplantation of tumor tissue from 8 female patients with breast cancer. Individual hind limb muscles from BC-PDOX mice were isolated at euthanasia for RNA-sequencing, gene and protein analyses, and an ex vivo muscle contraction protocol to quantify tumor-induced aberrations in SkM function. Differentially expressed genes (DEG) in the BC-PDOX mice relative to control mice were identified using DESeq2, and multiple bioinformatics platforms were employed to contextualize the DEGs.

RESULTS

We found that SkM from BC-PDOX-bearing mice showed greater fatigability than control mice, despite no differences in absolute muscle mass. PPAR, mTOR, IL6, IL1, and several other signaling pathways were implicated in the transcriptional changes observed in the BC-PDOX SkM. Moreover, 3 independent in silico analyses identified PPAR signaling as highly dysregulated in the SkM of both BC-PDOX-bearing mice and human patients with early-stage nonmetastatic breast cancer.

CONCLUSIONS

Collectively, these data demonstrate that the BC-PDOX model recapitulates the expected breast cancer-induced SkM fatigue and further identify aberrant PPAR signaling as an integral factor in the pathology of this condition.

Dysregulation of metabolic-associated pathways in muscle of breast cancer patients: preclinical evaluation of interleukin-15 targeting fatigue

BACKGROUND

Breast cancer patients report a perception of increased muscle fatigue, which can persist following surgery and standardized therapies. In a clinical experiment, we tested the hypothesis that pathways regulating skeletal muscle fatigue are down-regulated in skeletal muscle of breast cancer patients and that different muscle gene expression patterns exist between breast tumour subtypes. In a preclinical study, we tested the hypothesis that mammary tumour growth in mice induces skeletal muscle fatigue and that overexpression of the cytokine interleukin-15 (IL-15) can attenuate mammary tumour-induced muscle fatigue.

METHODS

Early stage non-metastatic female breast cancer patients (n = 14) and female non-cancer patients (n = 6) provided a muscle biopsy of the pectoralis major muscle during mastectomy, lumpectomy, or breast reconstruction surgeries. The breast cancer patients were diagnosed with either luminal (ER⁺ /PR⁺ , n = 6), triple positive (ER⁺ /PR⁺ /Her2/neu⁺ , n = 5), or triple negative (ER^- /PR^- /Her2/neu^- , n = 3) breast tumours and were being treated with curative intent either with neoadjuvant chemotherapy followed by surgery or surgery followed by standard post-operative therapy. Biopsies were used for RNA-sequencing to compare the skeletal muscle gene expression patterns between breast cancer patients and non-cancer patients. The C57BL/6 mouse syngeneic mammary tumour cell line, E0771, was used to induce mammary tumours in immunocompetent mice, and isometric muscle contractile properties and fatigue properties were analysed following 4 weeks of tumour growth.

RESULTS

RNA-sequencing and subsequent bioinformatics analyses revealed a dysregulation of canonical pathways involved in oxidative phosphorylation, mitochondrial dysfunction, peroxisome proliferator-activated receptor signalling and activation, and IL-15 signalling and production. In a preclinical mouse model of breast cancer, the rate of muscle fatigue was greater in mice exposed to mammary tumour growth for 4 weeks, and this greater muscle fatigue was attenuated in transgenic mice that overexpressed the cytokine IL-15.

CONCLUSIONS

Our data identify novel genes and pathways dysregulated in the muscles of breast cancer patients with early stage non-metastatic disease, with particularly aberrant expression among genes that would predispose these patients to greater muscle fatigue. Furthermore, we demonstrate that IL-15 overexpression can attenuate muscle fatigue associated with mammary tumour growth in a preclinical mouse model of breast cancer. Therefore, we propose that skeletal muscle fatigue is an inherent consequence of breast tumour growth, and this greater fatigue can be targeted therapeutically.

Self-Nanoemulsifying Drug Delivery System for Resveratrol: Enhanced Oral Bioavailability and Reduced Physical Fatigue in Rats

Resveratrol (RES), a natural polyphenolic compound, exerts anti-fatigue activity, but its administration is complicated by its low water solubility. To improve RES bioavailability, this study developed a self-nanoemulsifying drug delivery system (SNEDDS) for RES and evaluated its anti-fatigue activity and rat exercise performance by measuring fatigue-related parameters, namely lactate, ammonia, plasma creatinine phosphokinase, and glucose levels and the swimming time to exhaustion. Through solubility and emulsification testing, the optimized SNEDDS composed of Capryol 90, Cremophor EL, and Tween 20 was developed; the average particle size in this formulation, which had favorable self-emulsification ability, was approximately 41.3 ± 4.1 nm. Pharmacokinetic studies revealed that the oral bioavailability of the optimized RES-SNEDDS increased by 3.2-fold compared with that of the unformulated RES-solution. Pretreatment using the RES-SNEDDS before exercise accelerated the recovery of lactate after exercise; compared with the vehicle group, the plasma ammonia level in the RES-SNEDDS group significantly decreased by 65.4%, whereas the glucose level significantly increased by approximately 1.8-fold. Moreover, the swimming time to exhaustion increased by 2.1- and 1.8-fold, respectively, compared with the vehicle and RES-solution pretreatment groups. Therefore, the developed RES-SNEDDS not only enhances the oral bioavailability of RES but may also exert anti-fatigue pharmacological effect.

Antifatigue Functions and Mechanisms of Edible and Medicinal Mushrooms

Fatigue is the symptom of tiredness caused by physical and/or psychological stresses. As fatigue is becoming a serious problem in the modern society affecting human health, work efficiency, and quality of life, effective antifatigue remedies other than pharmacological drugs or therapies are highly needed. Mushrooms have been widely used as health foods, because of their various bioactive constituents such as polysaccharides, proteins, vitamins, minerals, and dietary fiber. This paper reviews the major findings from previous studies on the antifatigue effects, the active components of mushrooms, and the possible mechanisms. Many studies have demonstrated the antifatigue effects of edible and medicinal mushrooms. These mushrooms probably mitigate human fatigue through effects on the functional systems, including the muscular, cardiovascular, hormone, and immune system. The bioactive constituents that contribute to the antifatigue effects of mushrooms may include polysaccharides, peptides, nucleosides, phenolic compounds, and triterpenoids. Further research is still needed to identify the active ingredients and to investigate their mechanism of action on the antifatigue effects. Since most previous studies have been carried out in animal models, more human trials should be performed to verify the antifatigue function of edible and medicinal mushrooms.

Causes and consequences of fatigue in rheumatoid arthritis

PURPOSE OF REVIEW

To review current information on the causes, treatments, and consequences of fatigue in rheumatoid arthritis.

RECENT FINDINGS

Disease activity (inflammation, pain, joint symptoms) is associated with greater fatigue. However, disease activity per se accounts for only a small portion of fatigue, and rheumatoid arthritis medications that reduce disease activity have small effects on fatigue. Instead, factors outside the direct effects of rheumatoid arthritis, such as obesity, physical inactivity, sleep disturbance, and depression, explain the majority of variation in fatigue. Some of these factors may be indirect effects of disease (e.g. pain can lead to sleep disturbance). Rheumatoid arthritis has significant effects on the quality of life of individuals with rheumatoid arthritis. The most effective approaches to reducing rheumatoid arthritis fatigue appear to be behavioral, such as increasing physical activity, or cognitive, such as cognitive behavioral interventions.

SUMMARY

Fatigue in rheumatoid arthritis appears to be largely because of factors outside the direct effects of the disease, such as behavioral and psychological factors. In spite of the tremendous impact of fatigue on patient health and quality of life, effective treatments remain elusive, but existing data show that behavioral and cognitive approaches may be most effective.

Relationship between cardiopulmonary responses and isokinetic moments: the optimal angular velocity for muscular endurance

Most protocols for testing and rehabilitation for recovery and improvement of muscular endurance have been set at 180°/sec, 240°/sec, and 300°/sec. These protocols can cause confusion to clinical providers or other researchers. This study was aimed at investigating the optimal isokinetic angular speed for measuring or developing muscular endurance after assessing the relationship between cardiopulmonary responses and isokinetic moments. This study was conducted with 31 male and female college students. Graded exercise test and body composition were measured as well as the isokinetic moments of the knee muscles at three angular speeds: 180°/sec, 240°/sec, and 300°/sec. The specific isokinetic moments of knee muscles that were measured included: peak torque (PT) and total work (TW) on extensor (e) and flexor (f) of knee joints, which were denoted as ePT180, fPT180, eTW180, fTW180, ePT240, fPT240, eTW240, fTW240, ePT300, fPT300, eTW300, and fTW300 according to the three angular speeds. Spearman correlation test was used to examine the relationship between the sum means of cardiopulmonary responses and the variables of isokinetic moments. This study confirmed that the optimal angular speed for testing or training for muscular endurance was 180°/sec, which showed a stronger relationship between cardiopulmonary responses and isokinetic moments. Therefore, this angular speed is recommended for testing and training for muscular endurance of the knee joints.

Docetaxel-related fatigue in men with metastatic prostate cancer: a descriptive analysis

PURPOSE

Fatigue is a prevalent and debilitating side effect of docetaxel chemotherapy in metastatic prostate cancer. A better understanding of the kinetics and nature of docetaxel-related fatigue may provide a framework for intervention.

METHODS

This secondary analysis was performed using the MOTIF database, from a phase III, randomised, double-blind, placebo-controlled study of modafinil (200 mg/day for 15 days) for docetaxel-related fatigue in men with metastatic prostate cancer [1]. The pattern of fatigue was analysed using the MDASI (MD Anderson Symptom Inventory) score. The impact of modafinil, cumulative docetaxel exposure, age and smoking status on fatigue kinetics were explored. Fatigue-related symptoms were assessed using the SOMA6 (fatigue and related symptoms) subset of the SPHERE (Somatic and Psychological Health Report). Mood was tracked using the short form 36 health survey questionnaire (SF-36).

RESULTS

Across four docetaxel cycles, fatigue scores were higher in the first week and decreased over weeks two and three. Whilst men randomised to modafinil had reduced fatigue scores, cumulative docetaxel had little impact. Younger men (55-68 years) had significantly reduced fatigue scores, whereas current and ex-smokers had higher scores. There was no significant change in mood status or haemoglobin across treatment cycles. Men described both 'somnolence' and 'muscle fatigue' contributing significantly to their symptom complex.

CONCLUSIONS

Assessment and management of docetaxel-related fatigue remains an important challenge. Given the complex, multifactorial nature of fatigue, identification through structured interview and interventions targeted to specific 'at risk' groups may be the most beneficial. Understanding the temporal pattern (kinetics) and nature of fatigue is critical to guide this process.

Anti-Fatigue Effect of Green Tea Polyphenols (-)-Epigallocatechin-3-Gallate (EGCG)

BACKGROUND

(-)-Epigallocatechin-3-gallate (EGCG) is the most abundant of the green tea polyphenols that exhibit a variety of bioactivities. The objective of this study was to evaluate the anti-fatigue effect of EGCG by forced swimming exercise.

MATERIALS AND METHODS

The mice were divided into one control group and three EGCG-treated groups. The control group was administered with distilled water and EGCG-treated groups were administered with different dose of EGCG (50, 100, and 200 mg/kg) by oral gavage for 28 days. On the last day of experiment, the forced swimming exercise was performed and corresponding biochemical parameters were measured.

RESULTS

The data showed that EGCG prolonged exhaustive swimming time, decreasing the levels of blood lactic acid, serum urea nitrogen, serum creatine kinase and malondialdehyde, which were accompanied by corresponding increase in liver and muscle glycogen contents, and superoxide dismutase, catalase, and glutathione peroxidase activities.

CONCLUSIONS

This study indicated that EGCG had an anti-fatigue effect.

SUMMARY

EGCG significantly prolonged exhaustive swimming time and decreased the levels of BLA, SUN, SCK and MDA, which were accompanied by corresponding increases in liver and muscle glycogen contents, and SOD, CAT, and GPx activities.EGCG can be used to design nutraceutical supplements aimed to facilitate recovery from fatigue and attenuate exhaustive exercise-induced oxidative damage. Abbreviations used: EGCG: (-)-Epigallocatechin-3-gallate, ROS: reactive oxygen species, BLA: blood lactic acid, SUN: serum urea nitrogen, SOD: superoxide dismutase, GPx: glutathione peroxidase, CAT: catalase, SCK: serum creatine kinase, MDA: malondialdehyde, C: control, LET: Low-dose EGCG-treated, MET: Middle-dose EGCG-treated, HET: High-dose EGCG-treated, GTE: green tea extract.

Impaired muscle force production and higher fatigability in a mouse model of sickle cell disease

Skeletal muscle function has been scarcely investigated in sickle cell disease (SCD) so that the corresponding impact of sickle hemoglobin is still a matter of debate. The purpose of this study was to investigate muscle force production and fatigability in SCD and to identify whether exercise intensity could have a modulatory effect. Ten homozygous sickle cell (HbSS), ten control (HbAA) and ten heterozygous (HbAS) mice were submitted to two stimulation protocols (moderate and intense) to assess force production and fatigability. We showed that specific maximal tetanic force was lower in HbSS mice as compared to other groups. At the onset of the stimulation period, peak force was reduced in HbSS and HbAS mice as compared to HbAA mice. Contrary to the moderate protocol, the intense stimulation protocol was associated with a larger decrease in peak force and rate of force development in HbSS mice as compared to HbAA and HbAS mice. These findings provide in vivo evidence of impaired muscle force production and resistance to fatigue in SCD. These changes are independent of muscle mass. Moreover, SCD is associated with muscle fatigability when exercise intensity is high.

Assessment of fatigability of older women during sit-to-stand performance

BACKGROUND

Fatigability of older adults is relevant with regard to physical performance, falls and physical activity. Objective and inexpensive assessment tools for testing fatigability in the persons' home environment are not available.

AIMS

The aim of this study was to develop a protocol to objectively measure fatigability during repeated sit-to-stand performance in older persons.

METHODS

Decrease of maximum velocity of performance during repeated sit-to-stand transfers and the number of repetition when achieving a 10, 15, and 20 % fatigue threshold were measured in 49 community-dwelling older women using a linear encoder.

RESULTS

Mean maximum velocity of the sit-to-stand performance was 1.12 m/s (SD 0.17 m/s) with an estimated change of velocity per repetition of -0.0037 m/s (95 % CI -0.0039 to -0.0035) during the test. The mean number of repetitions representing 10, 15, and 20 % fatigue threshold was 8.1, 13.8, and 21, respectively.

DISCUSSION

This simple test protocol provides objective information about the decrease of performance of a daily task in older adults.

CONCLUSION

Fatigability of the sit-to-stand performance can be measured objectively by measuring the decrease of maximum velocity of consecutive repetitions and the repetition number achieving a 20 % fatigue threshold.

Low Adherence to Immunosuppressants Is Associated With Symptom Experience Among Kidney Transplant Recipients

PURPOSE

The purpose of this study was to investigate the relationship between immunosuppressant-related symptom experience (SE) and adherence to immunosuppressant regimens among kidney transplant (KT) recipients.

METHODS

A total of 239 KT recipients on an immunosuppressant regimen who were followed up after transplantation participated in this study. Data was collected through a self-reported questionnaire survey (medication adherence, SE, and quality of life) and medical record review.

RESULTS

Low adherence in the immunosuppressant group was associated with longer time since KT, less comorbidity (<3), and a higher rehospitalization rate. Low adherence among KT recipients showed significantly greater overall symptom occurrence (P = .001) and symptom distress (P = .002) levels than patients with high or medium adherence after adjusting for a number of covariates. The most common symptom both in terms of occurrence (96.4%) and distress (91.1%) among poorly adherent KT recipients was tiredness.

CONCLUSION

Low adherence to an immunosuppressant regimen was significantly associated with high SE among KT recipients. Strategies to decrease immunosuppressant-related SE are needed to improve adherence to immunosuppressants.

Role of Sleep Disturbance, Depression, Obesity, and Physical Inactivity in Fatigue in Rheumatoid Arthritis

OBJECTIVE

Fatigue is a major concern for individuals with rheumatoid arthritis (RA). However, in order to treat fatigue adequately, its sources need to be identified.

METHODS

Data were collected during a single home visit (number of participants = 158). All participants had physician-diagnosed RA. Assessments of self-reported sleep quality, depression, physical activity, RA disease activity, muscle strength, functional limitations, and body composition were made. Information on demographics, medications, and smoking was collected. The Fatigue Severity Inventory (FSI; measuring average fatigue over the past 7 days) was used as the primary outcome. Analyses were first conducted to evaluate bivariate relationships with fatigue. Correlations among risk factors were examined. Multivariate analyses identified independent predictors of fatigue.

RESULTS

The mean ± SD age was 59 ± 11 years, the mean ± SD disease duration was 21 ± 13 years, and 85% of subjects were female. The mean ± SD FSI rating was 3.8 ± 2.0 (range 0-10). In multivariate analyses, self-reported disease activity, poor sleep, depression, and obesity were independently associated with fatigue. Physical inactivity was correlated with poor sleep, depression, and obesity. Mediation analyses indicated that physical inactivity had an indirect association with fatigue, mediated by poor sleep, depression, and obesity.

CONCLUSION

This cross-sectional study suggests that fatigue may not be solely a result of RA disease activity, but may result from a constellation of factors that includes RA disease activity or pain, but also includes inactivity, depression, obesity, and poor sleep. The results suggest new avenues for interventions to improve fatigue in individuals with RA, such as increasing physical activity or addressing depression or obesity.

Cancer-associated malnutrition, cachexia and sarcopenia: the skeleton in the hospital closet 40 years later

An awareness of the importance of nutritional status in hospital settings began more than 40 years ago. Much has been learned since and has altered care. For the past 40 years several large studies have shown that cancer patients are amongst the most malnourished of all patient groups. Recently, the use of gold-standard methods of body composition assessment, including computed tomography, has facilitated the understanding of the true prevalence of cancer cachexia (CC). CC remains a devastating syndrome affecting 50-80 % of cancer patients and it is responsible for the death of at least 20 %. The aetiology is multifactorial and complex; driven by pro-inflammatory cytokines and specific tumour-derived factors, which initiate an energy-intensive acute phase protein response and drive the loss of skeletal muscle even in the presence of adequate food intake and insulin. The most clinically relevant phenotypic feature of CC is muscle loss (sarcopenia), as this relates to asthenia, fatigue, impaired physical function, reduced tolerance to treatments, impaired quality of life and reduced survival. Sarcopenia is present in 20-70 % depending on the tumour type. There is mounting evidence that sarcopenia increases the risk of toxicity to many chemotherapy drugs. However, identification of patients with muscle loss has become increasingly difficult as 40-60 % of cancer patients are overweight or obese, even in the setting of metastatic disease. Further challenges exist in trying to reverse CC and sarcopenia. Future clinical trials investigating dose reductions in sarcopenic patients and dose-escalating studies based on pre-treatment body composition assessment have the potential to alter cancer treatment paradigms.

Rehabilitation of patients with glioma

Disabling sequelae occur in a majority of patients diagnosed with brain tumor, including glioma, such as cognitive deficits, weakness, and visual perceptual changes. Often, multiple impairments are present concurrently. Healthcare staff must be aware of the "biographic disruption" the patient with glioma has experienced. While prognostic considerations factor into rehabilitation goals and expectations, regardless of prognosis the treatment team must offer cohesive support, facilitating hope, function, and quality of life. Awareness of family and caregiver concerns plays an important role in the overall care. Inpatient rehabilitation, especially after surgical resection, has been shown to result in functional improvement and homegoing rates on a par with individuals with other neurologic conditions, such as stroke or traumatic brain injury. Community integration comprises a significant element of life satisfaction, as has been shown in childhood glioma survivors. Employment is often affected by the glioma diagnosis, but may be ameliorated, when appropriate, by addressing modifiable factors such as depression, fatigue, or sleep disturbance, or by workplace accommodations. Further research is needed into many facets of rehabilitation in the setting of glioma, including establishing better care models for consistently identifying and addressing functional limitations in this population, measuring outcomes of various levels of rehabilitation care, identifying optimal physical activity strategies, delineating the long-term effects of rehabilitation interventions, and exploring impact of rehabilitation interventions on caregiver burden. The effective elements of cognitive rehabilitation, including transition of cognitive strategies to everyday living, need to be better defined.

Factors Associated with Fatigue among Men Aged 45 and Older: A Cross-Sectional Study

Background and Purpose: Fatigue is one of the most common symptoms reported in several studies; but few studies have concentrated on the male population, especially for the middle-aged and older men who are exposed to greater fatigue risk. The purpose of this study was to explore the prevalence of fatigue and identify the risk factors of fatigue among men aged 45 and older in China. Methods: This study was part of a cross-sectional study on community health in Shunde (Guangdong Province, China). A total sample of 1158 men aged 45 and older were included. Sociodemographic characteristics, health and lifestyle factors and the Chalder Fatigue Scale (CFS) were measured by structured questionnaires through face-to-face interviews. Multivariate logistic regression was applied to determine the risk factors of fatigue. Results: Approximately 30% of participants experienced fatigue. Older age (≥75 years: adjusted OR 3.88, 95% CI 2.09–7.18), single marital status (1.94, 1.04–3.62), unemployed status (1.68, 1.16–2.43), number of self-reported chronic diseases (≥2 chronic diseases: 2.83, 1.86–4.31), number of individuals’ children (≥4 children: 2.35, 1.33–4.15), hospitalization in the last year (1.61, 1.03–2.52) were all significantly associated with increased risk of fatigue, while regular exercise (0.46, 0.32–0.65) was a protective factor against fatigue. Conclusions: Fatigue was usual in males and several factors were associated with the fatigue. These findings may have implication in risk assessment of fatigue and help in developing and implementing targeted interventions in middle-aged and elderly males.

Pharmacological treatments for fatigue associated with palliative care

BACKGROUND

This review updates the original review, 'Pharmacological treatments for fatigue associated with palliative care' and also incorporates the review 'Drug therapy for the management of cancer-related fatigue'.In healthy individuals, fatigue is a protective response to physical or mental stress, often relieved by rest. By contrast, in palliative care patients' fatigue can be severely debilitating and is often not counteracted with rest, thereby impacting daily activity and quality of life. Fatigue frequently occurs in patients with advanced disease (e.g. cancer-related fatigue) and modalities used to treat cancer can often contribute. Further complicating issues are the multidimensionality, subjective nature and lack of a consensus definition of fatigue. The pathophysiology is not fully understood and evidence-based treatment approaches are needed.

OBJECTIVES

To evaluate the efficacy of pharmacological treatments for fatigue in palliative care, with a focus on patients at an advanced stage of disease, including patients with cancer and other chronic diseases.

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO and EMBASE, and a selection of cancer journals up to 28 April 2014. We searched the references of identified articles and contacted authors to obtain unreported data. To validate the search strategy we selected sentinel references.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) concerning adult palliative care with a focus on pharmacological treatment of fatigue compared to placebo, application of two drugs, usual care or a non-pharmacological intervention. The primary outcome had to be non-specific fatigue (or related terms such as asthenia). We did not include studies on fatigue related to antineoplastic treatment (e.g. chemotherapy, radiotherapy, surgical intervention). We also included secondary outcomes that were assessed in fatigue-related studies (e.g. exhaustion, tiredness).

DATA COLLECTION AND ANALYSIS

Two review authors (MM and MC) independently assessed trial quality and extracted data. We screened the search results and included studies if they met the selection criteria. If we identified two or more studies that investigated a specific drug with the same dose in a population with the same disease and using the same assessment instrument or scale, we conducted meta-analysis. In addition, we compared the type of drug investigated in specific populations, as well as the frequent adverse effects of fatigue treatment, by creating overview tables.

MAIN RESULTS

For this update, we screened 1645 publications of which 45 met the inclusion criteria (20 additional studies to the previous reviews). In total, we analysed data from 18 drugs and 4696 participants. There was a very high degree of statistical and clinical heterogeneity in the trials and we discuss the reasons for this in the review. There were some sources of potential bias in the included studies, including a lack of description of the methods of blinding and allocation concealment, and the small size of the study populations. We included studies investigating pemoline and modafinil in participants with multiple sclerosis (MS)-associated fatigue and methylphenidate in patients suffering from advanced cancer and fatigue in meta-analysis. Treatment results pointed to weak and inconclusive evidence for the efficacy of amantadine, pemoline and modafinil in multiple sclerosis and for carnitine and donepezil in cancer-related fatigue. Methylphenidate and pemoline seem to be effective in patients with HIV, but this is based only on one study per intervention, with only a moderate number of participants in each study. Meta-analysis shows an estimated superior effect for methylphenidate in cancer-related fatigue (standardised mean difference (SMD) 0.49, 95% confidence interval (CI) 0.15 to 0.83). Therapeutic effects could not be described for dexamphetamine, paroxetine or testosterone. There were a variety of results for the secondary outcomes in some studies. Most studies had low participant numbers and were heterogeneous. In general, adverse reactions were mild and had little or no impact.

AUTHORS' CONCLUSIONS

Based on limited evidence, we cannot recommend a specific drug for the treatment of fatigue in palliative care patients. Fatigue research in palliative care seems to focus on modafinil and methylphenidate, which may be beneficial for the treatment of fatigue associated with palliative care although further research about their efficacy is needed. Dexamethasone, methylprednisolone, acetylsalicylic acid, armodafinil, amantadine and L-carnitine should be further examined. Consensus is needed regarding fatigue outcome parameters for clinical trials.

Malnutrition is associated with worse health-related quality of life in children with cancer

Purpose

Malnutrition in childhood cancer patients has been associated with lower health-related quality of life (HRQOL). However, this association has never actually been tested. Therefore, we aimed to determine the association between nutritional status and HRQOL in children with cancer.

Methods

In 104 children, aged 2–18 years and diagnosed with hematological, solid, or brain malignancies, nutritional status and HRQOL were assessed at diagnosis and at 3, 6, and 12 months using the child- and parent-report versions of the PedsQL 4.0 Generic scale and the PedsQL 3.0 Cancer Module. Scores on both scales range from 0 to 100.

Results

Undernourished children (body mass index (BMI) or fat-free mass < −2 standard deviation score (SDS)) reported significantly lower PedsQL scores compared with well-nourished children on the domains physical functioning (−13.3), social functioning (−7.0), cancer summary scale (−5.9), and nausea (−14.7). Overnourished children (BMI or fat mass >2 SDS) reported lower scores on emotional (−8.0) and cognitive functioning (−9.2) and on the cancer summary scale (−6.6), whereas parent-report scores were lower on social functioning (−7.5). Weight loss (>0.5 SDS) was associated with lower scores on physical functioning (−13.9 child-report and −10.7 parent-report), emotional (−7.4) and social functioning (−6.0) (child-report), pain (−11.6), and nausea (−7.8) (parent-report). Parents reported worse social functioning and more pain in children with weight gain (>0.5 SDS) compared with children with stable weight status.

Conclusions

Undernutrition and weight loss were associated with worse physical and social functioning, whereas overnutrition and weight gain affected the emotional and social domains of HRQL. Interventions that improve nutritional status may contribute to enhanced health outcomes in children with cancer.

Effects of acupressure on fatigue and depression in hepatocellular carcinoma patients treated with transcatheter arterial chemoembolization: a quasi-experimental study

This study was to examine the effects of acupressure on fatigue and depression in HCC patients undergoing TACE. A quasiexperimental study design was used. Patients were evaluated at five time points: before treatment (T1) and 2, 3, 4, and 5 days after treating TACE (T2, T3, T4, and T5). Fatigue and depression were assessed by a VAS fatigue scale and a VAS depression scale at each time point. TFRS and BDI were administered at T1 and T5. Patients' fatigue and depression were significantly higher at T5 than at T1 in two groups. Fatigue and depression increased in both the experimental and control groups' patients over the five days of hospitalization during which TACE and chemotherapy were administered. The experimental group had significantly less fatigue than the control group, with lower subscale scores on physical, psychosocial, daily, and overall fatigue. There were no differences between the groups on depression. At posttest, the experimental group experienced lower physical, psychosocial, daily, and overall fatigue than the control group. Acupressure can improve fatigue in HCC patients during treatment with TACE but did not alleviate depression. Discharge planning should include home care for management of fatigue and depression.