Adapting, restarting, and terminating a randomised control trial for people with cystic fibrosis: Reflections on the impact of the COVID-19 pandemic upon research in a clinical population

Background

Habitual physical activity (PA) and exercise form a cornerstone of the management of cystic fibrosis (CF), a genetically inherited pulmonary and digestive condition - whereby telehealth platforms have been proposed as a mechanism to engage remotely people with CF in PA and exercise.

Methods

To test this, in early 2020, the 'ActivOnline: Physical Activity in Cystic Fibrosis Trial' (ActiOn PACT) randomised control trial was established to examine whether an online intervention was effective at increasing PA in adolescents and adults with CF.

Results

The emergence of the COVID-19 pandemic in 2020 forced this trial to be paused and modified, with the adoption of online recruitment and remote assessment of outcome measures. Despite such adaptations in accord with frameworks developed by the National Institute for Health Research, this trial failed to recruit and was subsequently terminated.

Conclusions

This article details the authors reflections upon the proposed reasons for lack of recruitment, including improved technology and medications for people with CF, and contextualises this finding in relation to the wider issue of non-reporting of trial results in clinical research.

Parental recommendations and exercise attitudes in congenital hearts

BACKGROUND

Children and young people with CHD benefit from regular physical activity. Parents are reported as facilitators and barriers to their children's physical activity. The aim of this study was to explore parental factors, child factors, and their clinical experience on physical activity participation in young people with CHD.

METHODS

An online questionnaire was co-developed with parents (n = 3) who have children with CHD. The survey was then distributed in the United Kingdom by social media and CHD networks, between October 2021 and February 2022. Data were analysed using mixed methods.

RESULTS

Eighty-three parents/guardians responded (94% mothers). Young people with CHD were 7.3 ± 5.0 years old (range 0-20 years; 53% female) and 84% performed activity. Parental participation in activity (X2(1) = 6.9, P < 0.05) and perceiving activity as important for their child were positively associated with activity (Fisher's Exact, P < 0.05). Some parents (∼15%) were unsure of the safety of activity, and most (∼70%) were unsure where to access further information about activity. Fifty-two parents (72%) had never received activity advice in clinic, and of the 20 who received advice, 10 said it was inconsistent. Qualitative analysis produced the theme "Knowledge is power and comfort." Parents described not knowing what activity was appropriate or the impact of it on their child.

CONCLUSION

Parental participation and attitudes towards activity potentially influence their child's activity. A large proportion of young people performed activity despite a lack and inconsistency of activity advice offered by CHD clinics. Young people with CHD would benefit from activity advice with their families in clinics.

Cardiopulmonary Exercise Testing Provides Prognostic Information in Advanced Cystic Fibrosis Lung Disease

Rationale: Cardiopulmonary exercise testing (CPET) provides prognostic information in cystic fibrosis (CF); however, its prognostic value for patients with advanced CF lung disease is unknown. Objectives: To determine the prognostic value of CPET on the risk of death or lung transplant (LTX) within 2 years. Methods: We retrospectively collected data from 20 CF centers in Asia, Australia, Europe, and North America on patients with a forced expiratory volume in 1 second (FEV1) ⩽ 40% predicted who performed a cycle ergometer CPET between January 2008 and December 2017. Time to death/LTX was analyzed using mixed Cox proportional hazards regression. Conditional inference trees were modeled to identify subgroups with increased risk of death/LTX. Results: In total, 174 patients (FEV1, 30.9% ± 5.8% predicted) were included. Forty-four patients (25.5%) died or underwent LTX. Cox regression analysis adjusted for age, sex, and FEV1 revealed percentage predicted peak oxygen uptake ([Formula: see text]o2peak) and peak work rate (Wpeak) as significant predictors of death/LTX: adjusted hazard ratios per each additional 10% predicted were 0.60 (95% confidence interval, 0.43-0.90; P = 0.008) and 0.60 (0.48-0.82; P < 0.001). Tree-structured regression models, including a set of 11 prognostic factors for survival, identified Wpeak to be most strongly associated with 2-year risk of death/LTX. Probability of death/LTX was 45.2% for those with a Wpeak ⩽ 49.2% predicted versus 10.9% for those with a Wpeak > 49.2% predicted (P < 0.001). Conclusions: CPET provides prognostic information in advanced CF lung disease, and Wpeak appears to be a promising marker for LTX referral and candidate selection.

Process evaluation of school-based high-intensity interval training interventions for children and adolescents: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Several systematic reviews have been published to investigate the effectiveness of high-intensity interval training (HIIT) in schools. However, there has been limited attention given to understanding the functioning of the intervention processes, which is of paramount importance for interpreting and translating the intervention effectiveness. The aim of this systematic review is to determine the extent to which process evaluation is measured in school-based HIIT interventions and to explore the effects of process evaluation and intervention characteristics on cardiorespiratory fitness (CRF), body composition, muscular strength, and blood pressure.

METHODS

A comprehensive search was conducted in SPORT Discus (EBSCOhost), Web of Science, Scopus, Medline (Ovid) and Cochrane Central Register of Controlled Trials. The extent to which process evaluation is measured was narratively reported, alongside with the guidance of process evaluation of complex interventions by UK Medical Research Council. Meta-analyses and meta-regressions were conducted to determine the effects of process evaluation and intervention characteristics to the intervention outcomes.

RESULTS

The literature search identified 77 studies reporting on 45 school-based HIIT interventions. In total, five interventions reported process evaluation in a section or in a separate study, and only one intervention adopted a process evaluation framework. On average, 6 out of 12 process evaluation measures were reported in all interventions. Subgroup analyses did not indicate any beneficial treatment effects for studies with process evaluation group, whereas all pooled data and studies without process evaluation group showed significant improvement for CRF and body composition.

CONCLUSION

Process evaluation is frequently omitted in the literature of school-based HIIT in children and adolescents. Although reporting of process evaluation measures may not directly associate with better intervention outcomes, it allows accurate interpretation of intervention outcomes, thereby enhancing the generalisability and dissemination of the interventions.

The Role of Speckle-Tracking Echocardiography in Predicting Mortality and Morbidity in Patients With Congenital Heart Disease: A Systematic Review and Meta-analysis

BACKGROUND

Speckle-tracking echocardiography (STE) is now routinely included in cardiac evaluations, but its role in predicting mortality and morbidity in congenital heart disease (CHD) is not well described. We conducted a systematic review to evaluate the prognostic value of STE in patients with CHD.

METHODS

The EMBASE, Medline, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception to January 2023 for terms related to all CHD, STE, and prognosis. Meta-analysis of association of right ventricle and left ventricle strain (RV Sl and LV Sl, respectively) with major adverse cardiovascular events (MACEs) was performed in atrial switch transposition of the great arteries (asTGA)/congenitally corrected TGA (ccTGA), tetralogy of Fallot (ToF), and congenital aortic stenosis (cAS)/bicuspid aortic valve (BAV). P-value combination analysis was additionally performed for all CHD groups.

RESULTS

A total of 33 studies (30 cohorts, n = 8,619 patients, children, and adults) were included. Meta-analysis showed the following parameters as being associated with MACE: RV Sl in asTGA/ccTGA (hazard ratio [HR] = 1.1/%; CI, [1.03; 1.18]), RV Sl and LV Sl in ToF (HR = 1.14/%; CI, [1.03; 1.26] and HR = 1.14/%; CI, [1.08; 1.2], respectively), and LV Sl in cAS/BAV (HR = 1.19/%; CI, [1.15; 1.23]). The RV Sl and strain rate were associated with outcomes also in single ventricle/hypoplastic left heart syndrome (at all palliation stages except before Norwood stage 1) and LV Sl in Ebstein's anomaly.

CONCLUSIONS

This systematic review and meta-analysis showed that biventricular strain and strain rate were associated with outcomes in a variety of CHD, highlighting the need for updated recommendations on the use of STE in the current guidelines, specific to disease types.

The effect of the Mid-Day Meal programme on the longitudinal physical growth from childhood to adolescence in India

The study aims to examine the effect of the world's largest school-feeding programme, the Mid-Day Meal (MDM) programme, on the changes in the underweight prevalence among school-children in India. Data from the Indian Human Development Survey (IHDS) Rounds 1 (2004-05) and 2 (2011-12) were utilized. The sample included individual-level information of children aged 6 to 9 years in IHDS-1 who then turned 13 to 16 years in IHDS-2. The sample was categorised into four groups based on their MDM consumption history (Group 1: no MDM support in IHDS-1 and IHDS-2, Group 2: MDM support in IHDS-1, Group 3: MDM support in IHDS-2, Group 4: persistent MDM support in IHDS-1 and IHDS-2). The dependent variable was underweight status as defined by the World Health Organisation Child Growth Standards Body Mass Index for age (BMI Z-score) < -2 SD of the median. Bivariate analysis was used to examine the prevalence of underweight and establish associations between underweight status and socio-demographic characteristics. Logistic regression was performed to assess the strength of the association of socio-demographic characteristics and MDM consumption patterns with underweight across poor and non-poor asset groups. The findings suggest that early and persistent MDM support among respondents reduced the likelihood of low BMI Z-scores compared to those without MDM support. Respondents from the poor asset group who received MDM support in at least one of the two survey rounds had higher odds of being underweight in comparison with those who did not receive MDM support at all. Girls and adolescents residing in the Eastern region of India were less likely to be underweight. The study shows that the MDM programme was effective in reducing the rate of underweight among school children. However, continuous programme upscaling with a special focus on children from poor households will significantly benefit India's school-aged children.

Validation and Calibration for Embedding Rating of Perceived Exertion Into High-Intensity Interval Exercise in Adolescents: A Lab-Based Study

PURPOSE

Rating of perceived exertion (RPE) is a convenient and cost-effective tool that can be used to monitor high-intensity interval exercise (HIIE). However, no methodological study has demonstrated the validity of RPE in this context. Therefore, the aim of this study was to validate and calibrate RPE for monitoring HIIE in adolescents.

METHODS

RPE, heart rate (HR), and oxygen uptake (V˙O2) data were retrospectively extracted from 3 lab-based crossover studies, with a pooled sample size of 45 adolescents, performing either cycling-based or running-based HIIE sessions. Within-participant correlations were calculated for RPE-HR and RPE-V˙O2, and receiver operator characteristic curve analysis was used to establish RPE cut points.

RESULTS

The results showed that RPE-HR demonstrated acceptable criterion validity (r = .53-.74, P < .01), while RPE-V˙O2 had poor validity (r = .40-.48, P < .01), except for HIIE at 100% peak power (r = .59, P < .01). RPE cut points of 4 and 5 were established in corresponding to HR/V˙O2 based thresholds.

CONCLUSION

RPE has some utility in evaluating intensity during lab-based running or cycling HIIE in adolescents. Future studies should expand the validation and calibration of RPE for prescribing and monitoring HIIE in children and adolescents in field-based contexts.

The utility of the reperfusion rate of tissue oxygen saturation as a measure of vascular endothelial function in adolescents: reliability, validity and sensitivity

Introduction: The near-infrared spectroscopy (NIRS)-derived reperfusion rate of tissue oxygen saturation (slope 2 StO2) may provide a surrogate measure of vascular function, however, this has yet to be examined in a paediatric population. This study investigated in adolescents: 1) the between-day reliability of NIRS-derived measurements; 2) the relationship between slope 2 StO2 and macro- (flow-mediated dilation, FMD) and microvascular (peak reactive hyperaemia, PRH) function; and 3) the effect of high-intensity interval exercise (HIIE) on slope 2 StO2, FMD, and PRH. Methods: Nineteen boys (13.3 ± 0.5 y) visited the laboratory on two occasions, separated by ∼ 1 week. On visit 1, participants underwent simultaneous assessment of brachial artery FMD and slope 2 StO2 and PRH on the internal face of the forearm. On visit 2, participants completed a bout of HIIE with slope 2 StO2, FMD and PRH measured pre-, immediately post- and 1.5 h post-exercise. Results: Slope 2 StO2 showed no mean bias (p = 0.18) and an intraclass correlation coefficient of 0.67 (p = 0.003) between visits. No significant correlation between slope 2 StO2 and FMD or PRH was observed on visit 1 (r = -0.04, p = 0.89 and r = -0.30, p = 0.23, respectively) or visit 2 pre-exercise (r = -0.28, p = 0.25 and r = -0.31, p = 0.20, respectively). Compared to pre-exercise, FMD decreased immediately post-exercise (p < 0.001) and then increased 1.5 h post-exercise (p < 0.001). No significant change was detected for slope 2 StO2 (p = 0.30) or PRH (p = 0.55) following HIIE. Conclusion: In adolescents, slope 2 StO2 can be measured reliably, however, it is not correlated with FMD or PRH and does not follow the acute time course of changes in FMD post-exercise. Hence, the use of slope 2 StO2 as a surrogate measure of vascular function in youth must be refuted.

The efficacy of virtual reality interventions compared with conventional physiotherapy in improving the upper limb motor function of children with cerebral palsy: a systematic review of randomised controlled trials

PURPOSE

Cerebral palsy (CP) is the commonest motor disability affecting children. This study reviewed the evidence for virtual reality (VR) intervention compared with conventional physiotherapy in upper limb function of children with CP.

METHODS

Searches were undertaken in MEDLINE, EMBASE, PEDro, CENTRAL, Web of Science, CINAHL, ERIC, ICTRP, EU-CTR, ClinicalTrials.gov and EThOS databases. Only randomised-controlled trials (RCTs) were included. Two reviewers independently screened the search results, assessed full-text articles, extracted data and appraised the methodological quality by using the Cochrane collaboration's risk of bias (RoB2) tool. Albatross plots were used to synthesise the data.

RESULTS

Seven RCTs, examining motor function in a total of 202 children with CP, included. Four trials used the Quality of Upper Extremity Skills Test (QUEST) as an outcome measure, and three trials used grip strength. These outcome measures were utilised to develop two Albatross plots. Data from the plots showed contradictory findings of the included studies.

CONCLUSIONS

The effect of VR in the upper limb rehabilitation of children with CP remains unclear. All included studies used commercial non-immersive VR games. Future high-quality clinical research is needed to explore the extent to which non-immersive and immersive VR is feasible and effective with children and adolescents.IMPLICATIONS FOR REHABILITATIONThe current evidence supporting the use of VR as a rehabilitative tool is weak and uncertain.The current use of VR relies only on commercial non-immersive VR (off-shelf) games, which are not adjustable to meet the demands and goals of therapy programmes.Future research is needed to study the therapeutic feasibility of immersive VR with children and adolescents.

Exploring the role of socioeconomic status and psychological characteristics on talent development in an English soccer academy

Social factors and psychological characteristics can influence participation and development in talent pathways. However, the interaction between these two factors is relatively unknown. The aim of this study was to investigate the implications of socioeconomic status and psychological characteristics in English academy soccer players (n=58; aged 11 to 16 years). To assess socioeconomic status, participants' home postcodes were coded according to each individual's social classification and credit rating, applying the UK General Registrar Classification system and Cameo^TM geodemographic database, respectively. Participants also completed the six factor Psychological Characteristics for Developing Excellence Questionnaire (PCDEQ). A classification of 'higher-potentials' (n=19) and 'lower-potentials' (n=19) were applied through coach potential rankings. Data were standardised using z-scores to eliminate age bias and data were analysed using independent sample t-tests. Results showed that higher-potentials derived from families with significantly lower social classifications (p=0.014) and reported higher levels for PCDEQ Factor 3 (coping with performance and developmental pressures) (p=0.007) compared to lower-potentials. This study can be used to support the impetus for researchers and practitioners to consider the role of social factors and psychological characteristics when developing sporting talent. For example, facilitating player-centred development within an academy and, where necessary, providing individuals with additional support.

Citizen Science to improve healthy and active living among adolescents in four European countries: a protocol of the cluster randomised controlled trial of the Science Engagement to Empower aDolescentS (SEEDS) project

INTRODUCTION

Improving healthy lifestyles of adolescents is challenging. Citizen Science is a way to engage them in the design and delivery of interventions, and may also increase their interest in science, technology, engineering and mathematics (STEM). The Science Engagement to Empower aDolescentS (SEEDS) project aims to use an equity-lens, and engage and empower boys and girls from deprived areas by designing and cocreating interventions to promote healthy lifestyles, and to seed interest in STEM.

METHODS AND ANALYSIS

SEEDS is a cluster randomised controlled trial in four countries (Greece, the Netherlands, Spain and the UK). Each country will recruit six to eight high schools from lower socioeconomic neighbourhoods. Adolescents aged 13-15 years are the target population. High schools will be randomised into intervention or control group. Each country will select 15 adolescents from intervention schools called ambassadors, who will be involved throughout the project.In each country, focus groups with ambassadors and stakeholders will focus on physical activity, snacking behaviour and STEM. The input from focus groups will be used to shape Makeathon events, cocreation events where adolescents and stakeholders will develop the interventions. The resultant intervention will be implemented in the intervention schools during 6 months. In total, we aim to recruit 720 adolescents who will complete questionnaires related to healthy lifestyles and STEM outcomes at baseline (November 2021) and after the 6 months (June 2022).

ETHICS AND DISSEMINATION

The four countries obtained approval from their corresponding Ethics Committees (Greece: Bioethics Committee of Harokopio University; the Netherlands: The Medical Research Ethics Committee of the Erasmus Medical Center; Spain: The Drug Research Ethics Committee of the Pere Virgili Health Research Institute; UK: Sport and Health Sciences Ethics Committee of the University of Exeter). Informed consent will be collected from adolescents and their parents in line with General Data Protection Regulation legislation. The findings will be disseminated by conference presentations, publications in scientific peer-reviewed journals and during (local) stakeholders and public events. Lessons learnt and the main results will also be used to provide policy recommendations.

TRIAL REGISTRATION NUMBER

NCT05002049.

Systematic review and meta-analysis: Associations of vitamin D with pulmonary function in children and young people with cystic fibrosis

BACKGROUND

Increasing evidence suggests that vitamin D is associated with pulmonary health, which may benefit children and young people diagnosed with Cystic Fibrosis (cypCF). Therefore, the aim of this systematic review was to evaluate primary research to establish associations between 25OHD and pulmonary health in cypCF.

METHODS

Electronic databases were searched with keywords related to CF, vitamin D, children/young people and pulmonary function. Included studies were cypCF (aged ≤21 years) treated in a paediatric setting. The primary outcome was lung function [forced expiratory volume in 1 s (FEV₁% predicted)] and secondary outcomes were rate of pulmonary exacerbations, 25OHD status and growth. Evidence was appraised for risk of bias using the CASP tool, and quality using the EPHPP tool. A Meta-analysis was performed.

RESULTS

Twenty-one studies were included with mixed quality ratings and heterogeneity of reported outcomes. The Meta-analysis including 5 studies showed a significantly higher FEV₁% predicted in the 25OHD sufficiency compared to the deficiency group [FEV₁% predicted mean difference (95% CI) was 7.71 (1.69-13.74) %; p = 0.01]. The mean ± SD FEV₁% predicted for the sufficient (≥75 nmol/L) vs. deficient (<50 nmol/L) group was 94.7 ± 31.9% vs. 86.9 ± 13.2%; I² = 0%; χ² = 0.5; df = 4). Five studies (5/21) found significantly higher rate of pulmonary exacerbations in those who were 25OHD deficient when compared to the sufficient group and negative associations between 25OHD and FEV% predicted. The effects of vitamin D supplementation dosages on 25OHD status (10/21) varied across studies and no study (12/21) showed associations between 25OHD concentration and growth.

CONCLUSION

This systematic review suggests that 25OHD concentration is positively associated with lung function and a concentration of >75 nmol/L is associated with reduced frequency of pulmonary exacerbations, which may slow lung function decline in cypCF. Future randomised clinical trials and mechanistic studies are warranted.

The effect of 4 weeks of high-intensity interval training and 2 weeks of detraining on cardiovascular disease risk factors in male adolescents

NEW FINDINGS

What is the central question of this study? What is the effect of 4 weeks of high-intensity interval training (HIIT) and 2 weeks of detraining on vascular function and traditional cardiovascular disease (CVD) risk factors in male adolescents? What is the main finding and its importance? Four weeks of HIIT improved macrovascular function in adolescents. However, this training period did not measurably change microvascular function, body composition or blood biomarkers. Following 2 weeks of detraining, the improvement in flow-mediated dilatation (FMD) was lost. This highlights the importance of the continuation of regular exercise for the primary prevention of CVD.

ABSTRACT

High-intensity interval training (HIIT) represents an effective method to improve cardiometabolic health in adolescents. This study aimed to investigate the effect of 4 weeks of HIIT followed by 2 weeks of detraining on vascular function and traditional cardiovascular disease (CVD) risk factors in adolescent boys. Nineteen male adolescents (13.3 ± 0.5 years) were randomly allocated to either a training (TRAIN, n = 10) or control (CON, n = 9) group. Participants in TRAIN completed 4 weeks of HIIT running with three sessions per week. Macro- (flow-mediated dilatation, FMD) and microvascular (peak reactive hyperaemia, PRH) function, body composition (fat mass, fat free mass, body fat percentage) and blood biomarkers (glucose, insulin, total cholesterol, high- and low-density lipoprotein, triacylglycerol) were assessed pre-, 48 h post- and 2 weeks post-training for TRAIN and at equivalent time points for CON. Following training, FMD was significantly greater in TRAIN compared to CON (9.88 ± 2.40% and 8.64 ± 2.70%, respectively; P = 0.036) but this difference was lost 2 weeks after training cessation (8.22 ± 2.47% and 8.61 ± 1.99%, respectively; P = 0.062). No differences were detected between groups for PRH (P = 0.821), body composition (all P > 0.14) or blood biomarkers (all P > 0.18). In conclusion, 4 weeks of HIIT improved macrovascular function; however, this training period did not measurably change microvascular function, body composition or blood biomarkers. The reversal of the FMD improvement 2 weeks post-training highlights the importance of the continuation of regular exercise for the primary prevention of CVD.

Expert guidelines on exercise and physical activity for people with cystic fibrosis

Research has shown that there is a lack of confidence and understanding in how to use exercise for managing cystic fibrosis. This editorial discusses the key points of a consensus statement that highlights what is and is not known about the relationship between cystic fibrosis and exercise.

Protecting the stars of tomorrow: do international cardiovascular preparticipation screening policies account for the paediatric athlete? A systematic review and quality appraisal

OBJECTIVE

(1) Identify and review current policies for the cardiovascular screening of athletes to assess their applicability to the paediatric population and (2) evaluate the quality of these policy documents using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool.

DESIGN

Systematic review and quality appraisal of policy documents.

DATA SOURCES

A systematic search of PubMed, MEDLINE, Scopus, Web of Science, SportDiscus and CINAHL.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

An article was included if it was a policy/position statement/guideline/consensus or recommendation paper relating to athletes and cardiovascular preparticipation screening.

RESULTS AND SUMMARY

Of the 1630 articles screened, 13 met the inclusion criteria. Relevance to paediatric athletes was found to be high in 3 (23%), moderate in 6 (46%) and low in 4 (31%), and only 2 provide tailored guidance for the athlete aged 12-18 years. A median 5 related citations per policy investigated solely paediatric athletes, with study designs most commonly being retrospective (72%). AGREEII overall quality scores ranged from 25% to 92%, with a median of 75%. The lowest scoring domains were rigour of development; (median 32%) stakeholder involvement (median 47%) and Applicability (median 52%).

CONCLUSION

Cardiac screening policies for athletes predominantly focus on adults, with few providing specific recommendations for paediatric athletes. The overall quality of the policies was moderate, with more recent documents scoring higher. Future research is needed in paediatric athletes to inform and develop cardiac screening guidelines, to improve the cardiac care of youth athletes.

Heart Rate Variability in Individuals with Down Syndrome: A Scoping Review with Methodological Considerations

Individuals with Down syndrome (DS) present similar heart rate variability (HRV) parameters at rest but different responses to selected movement maneuvers in comparison to individuals without DS, which indicates reduced vagal regulation. The present study undertakes a scoping review of research on HRV in individuals with DS, with special attention paid to the compliance of the studies with standards and methodological paper guidelines for HRV assessment and interpretation. A review was performed using PubMed, Web of Science and CINAHL databases to search for English language publications from 1996 to 2020 with the MESH terms "heart rate variability" and "down syndrome", with the additional inclusion criteria of including only human participants and empirical investigations. From 74 studies, 15 were included in the review. None of the reviewed studies met the recommendations laid out by the standards and guidelines for providing the acquisition of RR intervals and necessary details on HRV analysis. Since authors publishing papers on this research topic do not adhere to the prescribed standards and guidelines when constructing the methodology, results of the research papers on the topic are not directly comparable. Authors need to design the study methodology more robustly by following the aforementioned standards, guidelines and recommendations.

Validity and repeatability of cardiopulmonary exercise testing in interstitial lung disease

BACKGROUND

Cardiopulmonary exercise testing (CPET), and its primary outcome of peak oxygen uptake (VO_2peak), are acknowledged as biomarkers in the diagnostic and prognostic management of interstitial lung disease (ILD). However, the validity and repeatability of CPET in those with ILD has yet to be fully characterised, and this study fills this evidence gap.

METHODS

Twenty-six people with ILD were recruited, and 21 successfully completed three CPETs. Of these, 17 completed two valid CPETs within a 3-month window, and 11 completed two valid CPETs within a 6-month window. Technical standards from the European Respiratory Society established validity, and repeatability was determined using mean change, intraclass correlation coefficient and typical error.

RESULTS

Every participant (100%) who successfully exercised to volitional exhaustion produced a maximal, and therefore valid, CPET. Approximately 20% of participants presented with a plateau in VO₂, the primary criteria for establishing a maximal effort. The majority of participants otherwise presented with secondary criteria of respiratory exchange ratios in excess of 1.05, and maximal heart rates in excess of their predicted values. Repeatability analyses identified that the typical error (expressed as percent of coefficient of variation) was 20% over 3-months in those reaching volitional exhaustion.

CONCLUSION

This work has, for the first time, fully characterised how patients with ILD respond to CPET in terms of primary and secondary verification criteria, and generated novel repeatability data that will prove useful in the assessment of disease progression, and future evaluation of therapeutic regimens where VO_2peak is used as an outcome measure.

Scaling Peak Oxygen Consumption for Body Size and Composition in People With a Fontan Circulation

Background Peak oxygen consumption (peak V̇O2$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$) is traditionally divided ("ratio-scaled") by body mass (BM) for clinical interpretation. Yet, it is unknown whether ratio-scaling to BM can produce a valid size-independent expression of peak V̇O2$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$ in people with a Fontan circulation. Furthermore, people with a Fontan circulation have deficits in lean mass, and it is unexplored whether using different measures of body composition may improve scaling validity. The objective was to assess the validity of different scaling denominators (BM, stature, body surface area, fat-free mass, lean mass, and appendicular lean mass using ratio and allometric scaling). Methods and Results Eighty-nine participants (age: 23.3±6.7 years; 53% female) with a Fontan circulation had their cardiorespiratory fitness and body composition measured by cardiopulmonary exercise testing and dual-energy x-ray absorptiometry. Ratio and allometric (log-linear regression) scaling was performed and Pearson correlations assessed scaling validity. Scaling denominators BM (r=-0.25, P=0.02), stature (r=0.46, P<0.001), and body surface area (0.23, P=0.03) were significantly correlated with their respective ratio-scaled expressions of peak V̇O2$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$, but fat-free mass, lean mass, or appendicular lean mass were not (r≤0.11; R²=1%). Allometrically expressed peak V̇O2$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$ resulted in no significant correlation with any scaling denominator (r=≤0.23; R²=≤4%). Conclusions The traditional and accepted method of ratio-scaling to BM is invalid because it fails to create a size-independent expression of peak V̇O2$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$ in people with a Fontan circulation. However, ratio-scaling to measures of body composition (fat-free mass, lean mass, and appendicular lean mass) and allometric techniques can produce size-independent expressions of peak V̇O2$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$ in people with a Fontan circulation.

Normal reference values for aerobic fitness in cystic fibrosis: a scoping review

Objective

The importance of aerobic fitness (VO2peak) in cystic fibrosis (CF) is well established, and regular exercise testing is recommended. To standardise VO2peak, a ‘percentage of predicted’ (%pred) derived from normative reference values (NRV), as promoted by the 2015 European Cystic Fibrosis Society Exercise Working Group (ECFS EWG), can be reported. However, the NRVs used in CF and their relative frequency is unknown.

Method

A scoping review was performed via systematic database searches (PubMed, Embase, Web of Science, SciELO, EBSCO) and forward citation searches for studies that include people with CF and report VO2peakas %pred. Studies were screened using Covidence, and data related to patient demographics, testing modality and reference equations were extracted. Additional analyses were performed on studies published in 2016–2021, following the ECFS EWG statement in 2015.

Results

A total of 170 studies were identified, dating from 1984 to 2022, representing 6831 patients with CF, citing 34 NRV. Most studies (154/170) used cycle ergometry, 15/170 used treadmills, and the remainder used alternative, combination or undeclared modalities. In total, 61/170 failed to declare the NRV used. There were 61 studies published since the ECFS EWG statement, whereby 18/61 used the suggested NRV.

Conclusion

There is a wide discrepancy in NRV used in the CF literature base to describe VO2peakas %pred, with few studies using NRV from the ECFS EWG statement. This high variance compromises the interpretation and comparison of studies while leaving them susceptible to misinterpretation and limiting replication. Standardisation and alignment of reporting of VO2peakvalues are urgently needed.

Diagnosing low-mode (ℓ < 6) and mid-mode (6 ≤ ℓ ≤ 60) asymmetries in the post-stagnation phase of laser-direct-drive deuterium-tritium cryogenic implosions on OMEGA

Low- and mid-mode perturbations are possible candidates for performance limitations in cryogenic direct-drive implosions on the OMEGA laser at the Laboratory of Laser Energetics. Simulations with a 3D hydrocode demonstrated that hotspot imagers do not show evidence of the shell breakup in the dense fuel. However, these same simulations revealed that the low- and mid-mode perturbations in the dense fuel could be diagnosed more easily in the post-stagnation phase of the implosion by analyzing the peak in the x-ray emission limb at the coronal-fuel interface than before or at the stagnation phase. In experiments, the asymmetries are inferred from gated images of the x-ray emission of the implosion by using a 16-pinhole array imager filtered to record x-ray energies >800 eV and an x-ray framing camera with 40-ps time integration and 20-μm spatial resolution. A modal analysis is applied to the spatial distribution of the x-ray emission from deuterium and tritium cryogenic implosions on OMEGA recorded after the bang time to diagnose the low- and mid-mode asymmetries, and to study the effect that the beam-to-target ratio (R_b/R_t) has on the shell integrity.

Incorporating movement breaks into primary school classrooms; a mixed methods approach to explore the perceptions of pupils, staff and governors

BACKGROUND

Public health guidelines for children advocate physical activity (PA) and the restriction of continuous sedentary time. Schools offer an attractive setting for health promotion, however school-based interventions to increase PA typically fail, and primary school children may spend most of the school day sitting down. Classroom movement breaks have been identified as an attractive opportunity to address this concern and may positively influence behaviour, but little is known about the barriers to implementing movement within lessons from a multi stakeholder perspective. The purpose of this study was to explore (1) the perceptions of primary school pupils, staff members and governors regarding classroom movement breaks, and (2) their perceived barriers and facilitators to implementing PA into the classroom.

METHODS

Thirty-four pupils (Key Stages 1 and 2, ages 5-7 y) took part in a focus group discussion. Sixty-four staff members and twenty governors completed a questionnaire and an optional follow up semi-structured telephone interview. Qualitative data were analysed using thematic analysis.

RESULTS

Pupils, staff members and governors expressed an enthusiasm for movement breaks provided that they were short, simple, pupil-guided and performed at the discretion of the teacher. Time and concerns regarding transitioning back to work following a movement break were identified as key barriers by pupils and staff. Governors and some staff expressed that favourable evidence for movement breaks is needed to facilitate their adoption, particularly regarding the potential for improvements in cognitive functioning or classroom behaviour.

CONCLUSION

There is a wide appeal for classroom-based activity breaks, when delivered in a manner that is not disruptive. Future research which examines the potential benefits of such activity breaks is warranted.

A Multidisciplinary Investigation into the Talent Development Processes at an English Football Academy: A Machine Learning Approach

The talent development processes in youth football are both complex and multidimensional. The purpose of this two-fold study was to apply a multidisciplinary, machine learning approach to examine: (a) the developmental characteristics of under-9 to under-16 academy players (n = 98; Study 1), and (b) the characteristics of selected and deselected under-18 academy players (n = 18; Study 2). A combined total of 53 factors cumulated from eight data collection methods across two seasons were analysed. A cross-validated Lasso regression was implemented, using the glmnet package in R, to analyse the factors that contributed to: (a) player review ratings (Study 1), and (b) achieving a professional contract (Study 2). Results showed non-zero coefficients for improvement in subjective performance in 15 out of the 53 analysed features, with key findings revealing advanced percentage of predicted adult height (0.196), greater lob pass (0.160) and average dribble completion percentage (0.124), more total match-play hours (0.145), and an older relative age (BQ1 vs. BQ2: -0.133; BQ1 vs. BQ4: -0.060) were the most important features that contributed towards player review ratings. Moreover, PCDEQ Factor 3 and an ability to organise and engage in quality practice (PCDEQ Factor 4) were important contributing factors towards achieving a professional contract. Overall, it appears the key factors associated with positive developmental outcomes are not always technical and tactical in nature, where coaches often have their expertise. Indeed, the relative importance of these factors is likely to change over time, and with age, although psychological attributes appear to be key to reaching potential across the academy journey. The methodological techniques used here also serve as an impetus for researchers to adopt a machine learning approach when analysing multidimensional databases.

A knock-on deuteron imager for measurements of fuel and hotspot asymmetry in direct-drive inertial confinement fusion implosions (invited)

A knock-on deuteron imager (KoDI) has been implemented to measure the fuel and hotspot asymmetry of cryogenic inertial confinement fusion implosions on OMEGA. Energetic neutrons produced by D-T fusion elastically scatter ("knock on") deuterons from the fuel layer with a probability that depends on ρR. Deuterons above 10 MeV are produced by near-forward scattering, and imaging them is equivalent to time-integrated neutron imaging of the hotspot. Deuterons below 6 MeV are produced by a combination of side scattering and ranging in the fuel, and encode information about the spatial distribution of the dense fuel. The KoDI instrument consists of a multi-penumbral aperture positioned 10-20 cm from the implosion using a ten-inch manipulator and a detector pack at 350 cm from the implosion to record penumbral images with magnification of up to 35×. Range filters and the intrinsic properties of CR-39 are used to distinguish different charged-particle images by energy along the same line of sight. Image plates fielded behind the CR-39 record a 10 keV x-ray image using the same aperture. A maximum-likelihood reconstruction algorithm has been implemented to infer the source from the projected penumbral images. The effects of scattering and aperture charging on the instrument point-spread function are assessed. Synthetic data are used to validate the reconstruction algorithm and assess an appropriate termination criterion. Significant aperture charging has been observed in the initial experimental dataset, and increases with aperture distance from the implosion, consistent with a simple model of charging by laser-driven EMP.

Reliability and validity of using the global school-based student health survey to assess 24 hour movement behaviours in adolescents from Saudi Arabia

This study aimed to examine the reliability and validity of Global School-based Student Health Survey (GSHS) to measure 24-hour movement behaviours (moderate-to-vigorous physical activity - MVPA; sedentary behaviour in the form of recreational screen time - ST; and sleep) in Saudi Arabian youths. A total of 120 (50% female) participants aged 12-15 years old were recruited from eight Saudi public middle schools. Participants completed GSHS survey twice and wore GENEActiv accelerometers for seven consecutive days and completed a diary log. ICC indicated moderate reliability in all 24-hour movement behaviours (ICC = 0.41 - 0.60), whereas ST and sleep were strongly reliable for females only (ICC = 0.61 - 0.80). Kappa agreements for all 24-hr movement behaviours were moderate (k = 0.41 - 0.60), but fair in MVPA and ST for males only (k = 0.21 - 0.40). Spearman's indicated low validity (r = 0.1 - 0.3) in MVPA and sleep between GSHS and GENEActiv. However, kappa test results indicated poor-to-slight agreements (k = <0.00 - 0.2) in MVPA and sleep, but fair in MVPA for males only (k = 0.21 - 0.4). GSHS provided good reliability for single items of 24-hour movement behaviours, and the validity was acceptable and in line with other comparable questionnaires.

Exercise training in paediatric congenital heart disease: fit for purpose?

Exercise and physical activity (PA) have been shown to be effective, safe and feasible in both healthy children and children with congenital heart disease (CHD). However, implementing exercise training as an intervention is still not routine in children with CHD despite considerable evidence of health benefits and well-being. Understanding how children with CHD can safely participate in exercise can boost participation in PA and subsequently reduce inactivity-related diseases. Home-based exercise intervention, with the use of personal wearable activity trackers, and high-intensity interval training have been beneficial in adults' cardiac rehabilitation programmes. However, these remain underutilised in paediatric care. Therefore, the aims of this narrative review were to synthesise prescribed exercise interventions in children with CHD, identify possible limitation to exercise training prescription and provide an overview on how to best integrate exercise intervention effectively for this population into daily practice.

Non-invasive MR imaging techniques for measuring femoral arterial flow in a pediatric and adolescent cohort

Magnetic Resonance Imaging (MRI) is well‐suited for imaging peripheral blood flow due to its non‐invasive nature and excellent spatial resolution. Although MRI is routinely used in adults to assess physiological changes in chronic diseases, there are currently no MRI‐based data quantifying arterial flow in pediatric or adolescent populations during exercise. Therefore the current research sought to document femoral arterial blood flow at rest and following exercise in a pediatric‐adolescent population using phase contrast MRI, and to present test‐retest reliability data for this method. Ten healthy children and adolescents (4 male; mean age 14.8 ± 2.4 years) completed bloodwork and resting and exercise MRI. Baseline images consisted of PC‐MRI of the femoral artery at rest and following a 5 × 30 s of in‐magnet exercise. To evaluate test‐retest reliability, five participants returned for repeat testing. All participants successfully completed exercise testing in the MRI. Baseline flow demonstrated excellent reliability (ICC = 0.93, p = 0.006), and peak exercise and delta rest‐peak flow demonstrated good reliability (peak exercise ICC = 0.89, p = 0.002, delta rest‐peak ICC = 0.87, p = 0.003) between‐visits. All three flow measurements demonstrated excellent reliability when assessed with coefficients of variance (CV’s) (rest: CV = 6.2%; peak exercise: CV = 7.3%; delta rest‐peak: CV = 7.1%). The mean bias was small for femoral arterial flow. There was no significant mean bias between femoral artery flow visits 1 and 2 at peak exercise. There were no correlations between age or height and any of the flow measurements. There were no significant differences between male and female participants for any of the flow measurements. The current study determined that peripheral arterial blood flow in children and adolescents can be evaluated using non‐invasive phase contrast MRI. The MRI‐based techniques that were used in the current study for measuring arterial flow in pediatric and adolescent patients demonstrated acceptable test‐retest reliability both at rest and immediately post‐exercise.

A Compositional Analysis of Physical Activity, Sedentary Time, and Sleep and Associated Health Outcomes in Children and Adults with Cystic Fibrosis

This study sought to investigate the association of light physical activity (LPA), moderate-to-vigorous physical activity (MVPA), sedentary time (SED), and sleep with lung function in children and adults with CF. In total, 86 children (41 females; 13.6 ± 2.8 years; FEV₁%_predicted: 86 ± 1%) and 43 adults (21 females; 24.6 ± 4.7 years; FEV₁%_predicted: 63 ± 21%) with CF participated in this study. Wrist-worn accelerometery was used to assess PA, SED and sleep. Compositional linear regression models were conducted following normalisation via isometric log-ratio transformations. Sequential binary partitioning was applied to investigate the impact of reallocating 10 to 30 min between each behaviour on FEV₁%_predicted. A decline in FEV₁%_predicted was predicted with the reallocation of 30 min from MVPA to SED or LPA or sleep to any other behaviour in children (−3.04–−0.005%) and adults (−3.58–−0.005%). Conversely, improvements in FEV₁%_predicted were predicted when 30 min was reallocated to MVPA from LPA or SED in children (0.12–1.59%) and adults (0.77–2.10%), or when 30 min was reallocated to sleep from any other behaviour in both children (0.23–2.56%) and adults (1.08–3.58%). This study supports the importance of MVPA and sleep for maintaining and promoting lung function in people with CF.

The impact of COVID‐19 upon the delivery of exercise services within cystic fibrosis clinics in the United Kingdom

Objectives

The COVID‐19 pandemic has resulted in unprecedent changes to clinical practice, and as the impact upon delivery of exercise services for people with cystic fibrosis (CF) in the United Kingdom was unknown, this was characterised via a national survey.

Methods

An electronic survey was distributed to healthcare professionals involved in the exercise management of CF via established professional networks.

Results

In total, 31 CF centres participated. Findings included significant reductions in exercise testing and widespread adaptation to deliver exercise training using telehealth methods. Promisingly, 71% stated that they would continue using virtual methods of engaging patients in future practice.

Conclusion

These findings highlight adaptation to the COVID‐19 pandemic and the need to develop sustainable and standardised telehealth services to manage patients moving forwards.

The Effect of Dysglycaemia on Changes in Pulmonary and Aerobic Function in Cystic Fibrosis

Cross-sectional studies have reported lower pulmonary and aerobic function during exercise in people with cystic fibrosis-related diabetes (CFRD) compared to non-CFRD counterparts. However, this association has yet to be longitudinally investigated. Therefore, this study examines these differences over time between people with cystic fibrosis (CF) of differing glycaemic status. Annual review data, including cardiopulmonary exercise tests and pulmonary function tests, were retrospectively analysed at baseline (T0, n = 82) and at a one-year follow-up (T1, n = 54). Data was analysed in three groups: normal glucose tolerance (NGT), impaired glucose tolerance (IGT), and CFRD. Further analyses were undertaken, with a dichotomous split of NGT and a combined IGT/CFRD group. At baseline, a significant reduction in the majority of variables, including forced expiratory volume in one second (FEV₁) and maximal oxygen uptake (VO_2max), was observed in the CFRD (n = 19) group compared to NGT (n = 58). At follow-up, no significant differences were observed, and no interaction effect between CFRD status and time was identified. FEV₁ and VO_2max presented with varying directions and magnitudes of change within patients. In summary, patients with CFRD have a reduced aerobic and pulmonary function compared to non-CFRD counterparts, although such changes disappeared at follow up. Varying responses for FEV₁ and VO_2max highlight the need to consider both variables as independent markers of function in CF.

The role of segmental speckle tracking echocardiography in characterising right ventricle dilation patterns: a multicentre study on healthy adolescent athletes

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): UK Research and Innovation - Medical Research Council GW4 Studentship

Background

Right ventricle inflow (RV) dilation is a common adaptation to training in professional athletes, but how this impacts myocardial mechanics is yet unclear. Previous studies in athletes have found changes in segmental longitudinal strain (Sl), namely mid segment Sl, compared to normal controls, and have proposed RV dilation as a possible explanation. Whether different patterns of RV dilation are found in athletes, and if these influence regional RV mechanics is not known.

Purpose

To describe the patterns of RV dilation in healthy adolescent athletes and their relationship to segmental myocardial mechanics.

Methods

A total of 346 healthy athletes (&lt;18 years) screened at 3 sports academies between 2014 and 2019 with measurements for RV Sl, RV basal and RV apical diameters were included. Four groups were defined based on the basal and apical RV diameters size relative to the whole group distribution: No RV dilation (both basal and apical RV diameter under the 25th percentile), basal dilation (only basal RV above the 75th percentile), apical dilation (only apical RV above the 75th percentile) and global dilation (both the basal and apical RV above the 75th percentile). The segmental Sl was compared between the groups using a one-way ANOVA test with Bonferroni correction.

Results

The mean (SD) age was 14.5 (1.6) years, with athletes coming from various ethnic (55% arab, 22% white and 22% black) and sports backgrounds (75% mixed, 11% power, 8% endurance and 6% skill). Based on the RV diameters, the following groups were defined: no dilation (n = 35), basal dilation (n = 53), apical dilation (n = 51) and global dilation (n = 33). There were variations in dilation pattern by ethnicity and practised sports (Figure 1).

RV free wall Sl was less negative ("lower") in the apical and global dilation groups compared to the no dilation group (-26.7% and -26.4% vs -28.6%, p = 0.04 and 0.03, respectively). Mid segment Sl was consistently lower in all 3 dilation pattern groups, compared to the no dilation group (Figure 2, *denotes p &lt; 0.05). Basal Sl was lower in the global dilation group compared to those with no dilation (p = 0.05). There were also differences between the basal and apical dilation groups: basal Sl was lower (p = 0.01) and apical Sl higher (p = 0.02) the apical dilation group.

Conclusions

RV dilation in healthy athletes can be global, predominately basal or predominately apical. Apical and global dilation were more prevalent in non-white ethnicity, endurance and power sports. Lower mid segment Sl values were observed in all 3 dilation patterns, but FW Sl was only lower in the apical and global dilation groups. This suggests that there are different patterns of RV remodelling in athletes, which can be further characterised using segmental strain analysis. Abstract Figure. RV dilation by ethnicity and sport  Abstract Figure. RV segmental strain by RV dilation

Monitoring Postmatch Fatigue During a Competitive Season in Elite Youth Soccer Players

CONTEXT

Countermovement jump (CMJ) and perceived wellness measures are useful for monitoring fatigue. Fatigue indicators should simultaneously show sensitivity to previous load and demonstrate influence on subsequent physical output; however, these factors have not been examined.

OBJECTIVE

To explore the efficacy of CMJ and wellness measures to both detect postmatch fatigue and predict subsequent physical match output in elite youth soccer players.

DESIGN

Cross-sectional study.

PATIENTS OR OTHER PARTICIPANTS

Sixteen soccer players (18 ± 1 years) from 36 English Football League Youth Alliance League fixtures.

MAIN OUTCOME MEASURE(S)

Physical match outputs (total distance, high-speed running, very high-speed running, and accelerations and decelerations [AD]) were recorded using a 10-Hz global positioning system and 200-Hz accelerometer device during competitive match play. The CMJ height and perceived wellness were assessed weekly and daily, respectively, as indirect indicators of fatigue. Four subunits of wellness (perceived soreness, energy, general stress, and sleep) were measured using customized psychometric questionnaires.

RESULTS

Simple linear regression showed that match AD predicted energy (R2 = 0.08, P = .001), stress (R2 = 0.09, P < .001), and total wellness (R2 = 0.06, P = .002) at 2 days postmatch. The CMJ (R2 = 0.05, P = .002), stress (R2 = 0.08, P < .001), sleep (R2 = 0.03, P = .034), and total wellness (R2 = 0.05, P = .006) measures at 5 days prematch predicted AD during the subsequent match.

CONCLUSIONS

The CMJ and wellness measures may be useful for detecting postmatch fatigue. Wellness scores, but not CMJ, at 5 days prematch influenced subsequent match output and therefore may be used to plan and periodize training for the upcoming microcycle.

The Exeter Activity Unlimited statement on physical activity and exercise for cystic fibrosis: methodology and results of an international, multidisciplinary, evidence-driven expert consensus

Background

The roles of physical activity (PA) and exercise within the management of cystic fibrosis (CF) are recognised by their inclusion in numerous standards of care and treatment guidelines. However, information is brief, and both PA and exercise as multi-faceted behaviours require extensive stakeholder input when developing and promoting such guidelines.

Method

On 30^th June and 1^st July 2021, 39 stakeholders from 11 countries, including researchers, healthcare professionals and patients participated in a virtual conference to agree an evidence-based and informed expert consensus about PA and exercise for people with CF. This consensus presents the agreement across six themes: (i) patient and system centred outcomes, (ii) health benefits, iii) measurement, (iv) prescription, (v) clinical considerations, and (vi) future directions. The consensus was achieved by a stepwise process, involving: (i) written evidence-based synopses; (ii) peer critique of synopses; (iii) oral presentation to consensus group and peer challenge of revised synopses; and (iv) anonymous voting on final proposed synopses for adoption to the consensus statement.

Results

The final consensus document includes 24 statements which surpassed the consensus threshold (>80% agreement) out of 30 proposed statements.

Conclusion

This consensus can be used to support health promotion by relevant stakeholders for people with CF.

Exercise intolerance in cystic fibrosis-the role of CFTR modulator therapies

Exercise intolerance is common in people with CF (pwCF), but not universal among all individuals. While associated with disease prognosis, exercise intolerance is not simply a reflection of the degree of lung disease. In people with severe CF, respiratory limitations may contribute more significantly to impaired exercise capacity than in those with mild-moderate CF. At all levels of disease severity, there are peripheral factors e.g., abnormal macro- and micro-vascular function that impair blood flow and reduce oxygen extraction, and mitochondrial defects that diminish metabolic efficiency. We discuss advances in understanding the central and peripheral mechanisms underlying exercise intolerance in pwCF. Exploring both the central and peripheral factors that contribute to exercise intolerance in CF can help inform the development of new therapeutic targets, as well as help define prognostic criteria.

The role of cardiopulmonary exercise testing in predicting mortality and morbidity in people with congenital heart disease: a systematic review and meta-analysis

AIMS

The role of cardiopulmonary exercise testing (CPET) in predicting major adverse cardiovascular events (MACE) in people with congenital heart disease (ConHD) is unknown. A systematic review with meta-analysis was conducted to report the associations between CPET parameters and MACE in people with ConHD.

METHODS AND RESULTS

Electronic databases were systematically searched on 30 April 2020 for eligible publications. Two authors independently screened publications for inclusion, extracted study data, and performed risk of bias assessment. Primary meta-analysis pooled univariate hazard ratios across studies. A total of 34 studies (18 335 participants; 26.2 ± 10.1 years; 54% ± 16% male) were pooled into a meta-analysis. More than 20 different CPET prognostic factors were reported across 6 ConHD types. Of the 34 studies included in the meta-analysis, 10 (29%), 23 (68%), and 1 (3%) were judged as a low, medium, and high risk of bias, respectively. Primary univariate meta-analysis showed consistent evidence that improved peak and submaximal CPET measures are associated with a reduce risk of MACE. This association was supported by a secondary meta-analysis of multivariate estimates and individual studies that could not be numerically pooled.

CONCLUSION

Various maximal and submaximal CPET measures are prognostic of MACE across a variety of ConHD diagnoses. Further well-conducted prospective multicentre cohort studies are needed to confirm these findings.

Injuries and Training Practices in Competitive Adolescent Distance Runners: A Retrospective Cross-Sectional Study

Background: Distance running is one of the most popular sports around the world. The epidemiology of running-related injury (RRI) has been investigated in adults, but few studies have focused on adolescent distance runners. Objectives: (1) To provide descriptive epidemiology of RRI (risks, rates, body regions/areas, and severity) and examine the training practices (frequency, volume, and intensity) of competitive adolescent distance runners (13-18 years) in England, and (2) to describe potential risk factors of RRI. Methods: A cross-sectional study design was used. Adolescent distance runners (n = 113) were recruited from England Athletics affiliated clubs. Participants voluntarily completed an online questionnaire between April and December 2018. At the time of completion, responses were based on the participant's previous 12-months of distance running participation. Incidence proportions (IP) and incidence rates (IR) were calculated. Results: The IP for "all RRI" was 68% (95% CI: 60-77), while the IR was 6.3/1,000 participation hours (95% CI: 5.3-7.4). The most commonly injured body areas were the knee, foot/toes, and lower leg; primarily caused by overuse. The number of training sessions per week (i.e., frequency) significantly increased with chronological age, while a large proportion of participants (58%) self-reported a high level of specialisation. Conclusions: RRI is common in competitive adolescent distance runners. These descriptive data provide guidance for the development of RRI prevention measures. However, analytical epidemiology is required to provide better insight into potential RRI risk factors in this specific population.

The impact of physical activity and exercise interventions for physical health in people with cystic fibrosis: protocol for a systematic review

BACKGROUND

Cystic fibrosis (CF) is a genetically inherited, life-limiting condition, affecting ~90,000 people globally. Physical activity (PA) and exercise form an integral component of CF management, and have been highlighted by the CF community as an area of interest for future research. Previous reviews have solely focused on PA or structured exercise regimens independent of one another, and thus a comprehensive assessment of the physical health benefits of all PA, including exercise, interventions, is subsequently warranted. Therefore, the purpose of this review is to evaluate the effects of both PA and exercise upon outcomes of physical health and healthcare utilisation in people with CF.

METHODS

A systematic review has been registered and reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analysis-P guidelines. This will include randomised control trials on the effects of PA and exercise, relative to usual treatment, upon people with CF. Primary outcomes will include variables associated with fitness, PA, lung health, inflammation, body composition, glycaemic control and patient-reported outcomes. Secondary outcomes will include adverse events and healthcare utilisation. Searches will be undertaken in Ovid MEDLINE, OVID EMBASE, PsychINFO, ERIC, SPORTDiscus, ASSIA, CCTR, CINHAL and Web of Science databases, and will be searched from date of inception onwards. Two reviewers will independently screen citations and abstracts, and full-texts, for inclusion and data extraction, respectively. Methodological quality will be assessed using the Cochrane Risk of Bias-2 tool. If feasible, random-effects meta-analyses will be conducted where appropriate. Additional analyses will explore potential sources of heterogeneity, such as age, sex, and disease severity.

DISCUSSION

This systematic review will build on previous research, by comprehensively assessing the impact of both PA and exercise upon physical health and healthcare utilisation in people with CF. Results of this review will be utilised to inform discussions that will ultimately result in a consensus document on the impact of physical activity and exercise for people with CF.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020184411.

Can left ventricular speckle tracking imaging be used in left ventricular non-compaction cardiomyopathy screening? A study of healthy paediatric athletes with and without echocardiographic criteria

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): The study was support by a contractual research partnership between the University of Bristol and Canon Medical Systems UK

Background

Left ventricular non-compaction (LVNC) is a rare cardiomyopathy, with hypertrabeculation often observed in athletes. In confirmed LVNC, LV systolic strain and rotational mechanics have been shown to be abnormal. Whether healthy athletes meeting echocardiographic LVNC criteria exhibit abnormal myocardial mechanics is not known.

Purpose

The aim of this study is to evaluate the prevalence of healthy paediatric athletes meeting the Jenni criteria for LVNC and how this relates to LV systolic function and rotational mechanics.

Methods

Professional athletes under 18 years undergoing comprehensive pre-participation screening (2014-2017) at two sports academies were included. Jenni criteria for LVNC were assessed from short axis LV views. Global and segmental peak systolic longitudinal (Sl) and circumferential strain (Sc), basal rotation (basal Rot) and apical rotation (apical Rot) were calculated using speckle tracking imaging.

Results

A total of 201 boys (11.9-18 years, median 15.1 years) were included, with diverse ethnicity (47.7% Arab, 28.5% Black, 21.8% White, and 2% other) and sports background (60% football, 21.2% athletics, 18.8% other).

Of these n = 16 (8%) met the Jenni criteria for LVNC and were more likely to be of Black ethnicity than Arab or White (12.7% vs 4.4% or 9.5%). There were no differences in global, lateral or septal Sl, basal, mid or apical Sc, basal Rot or apical Rot between participants with or without Jenni criteria for LVNC (Table 1).

Conclusions

In healthy paediatric athletes, those meeting the criteria for LVNC (8%) do not have abnormal longitudinal, circumferential strain and rotational mechanics, compared to those without LVNC criteria. This finding supports the use of speckle tracking echocardiography as a tool in differentiating pathological changes reported in LVNC from exercise associated adaptations observed in athletes during preparticipation screening.

LV mechanics Jenni criteria presence With Jenni criteria Median (IQR) Without Jenni criteria Median (IQR) p value Global LV Sl -18.6% (-19.1;-17.7) -18.6% (-19.7;-17.8) 0.7 Lateral Sl -18.3% (-18.8;-17.2) -18.5% (-19.8;-17.6) 0.5 Septal Sl -18.6% (-20.6;-17.3) -18.7% (-20.1;-17.7) 0.7 Basal LV Sc -23% (-24.6;-21.6) -23.3% (-25.7;-21.6) 0.7 Mid LV Sc -24.9% (-27.1;-23.2) -25.1% (-27.1;-22.5) 0.9 Apical LV Sc -27.8% (-32.3;-24.8) -26% (30.5;-22.4) 0.2 Basal Rot -4o (-4.7;-2.5) -3.8o (-5.3;-2.5) 0.9 Apical Rot 6.4o (5.2;7.1) 4.4 (2.9;7.1) 0.2

Can right ventricular speckle tracking imaging be used in arrhytmogenic cardiomyopathy screening? A study of healthy paediatric athletes with and without echocardiographic modified task force criteria

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): The study was support by a contractual research partnership between the University of Bristol and Canon Medical Systems UK.

Background

Arrhytmogenic cardiomyopathy (ACM) is a major cause of sudden cardiac death among young athletes. Screening these individuals can be challenging due to right ventricular (RV) exercise-related remodelling, particularly right ventricular outflow tract (RVOT) dilation. Recent studies have also shown that peak RV longitudinal strain (Sl) measured by speckle tracking echocardiography (STE) is reduced in adolescents with definite and borderline ACM. The prevalence of RV changes meeting ACM criteria in healthy paediatric athletes, and whether these changes are associated with abnormal RV strain values is not known.

Purpose

The aim of this study is to evaluate the prevalence of healthy paediatric athletes meeting the ACM echocardiographic modified Task Force Criteria (mTFC) for RVOT dilation, and how this relates to RV longitudinal systolic function.

Methods

Athletes under 18 years old undergoing comprehensive pre-participation screening (2014-2017) at two sports academies were included. Global (RV-Sl) and free wall peak systolic strain (FW-Sl) were calculated using STE. Three groups were defined: meeting the major mTFC for RVOT size (M-mTFC), meeting the minor mTFC (m-mTFC) and not meeting the mTFC (no-mTFC). RV-Sl and FW-Sl were compared using the Kruskall Wallis test.

Results

A total of 247 boys (11.1-18 years, median 14.6 years) were included, with diverse ethnicity (53.1% Arab, 27.6% Black, 17.6% White, and 1.7% other) and sports background (50.6% football, 27.9% athletics, 21.5% other).

Of these n = 22 were in the M-mTFC group (8.9%), n = 93 in the m-mTFC group (37.7%) and n = 132 in the no-mTFC group (53.4%). No regional RV wall motion abnormalities were observed. There were no differences in RV-Sl or FW-Sl by mTFC Group (Table 1).

Conclusions

In healthy paediatric athletes, 9% met the major mTFC, and 38% met the minor mTFC for RVOT size. RV longitudinal strain was found to be similar between those who met the mTFC and those who did not. This highlights the probable non-pathological adaptations reflected by RVOT dilation in these individuals, as opposed to those seen in ACM. The results of this study suggest that STE can be a valuable tool in ACM screening in paediatric athletes, especially in cases where RV remodelling is present.

RV peak longitudinal strain by mTFC All M-mTFC n = 22 m-mTFC n = 93 no-mTFC n = 132 p value for between group comparison Global RV Sl (median, IQR) -23.3% (-25.2;-21.7) -23.3% (-25.5;-21.7) -23.4% (-25;-21.7) -23.3% (-25.5;-21.7) p = 0.8 Free wall RV Sl (median, IQR) 27.7% (-30;-25.2) -27.6% (-29.3;-25.2%) -28.1% (-29.7;-25) -27.5 (-30.5;-25.4) p = 0.9

Prevalence and burden of health problems in competitive adolescent distance runners: A 6-month prospective cohort study

To describe all health problems (injuries and illnesses) in relation to type, location, incidence, prevalence, time loss, severity, and burden, in competitive adolescent distance runners in England. Prospective observational study: 136 competitive adolescent distance runners (73 female athletes) self-reported all health problems for 24-weeks between May and October 2019. Athletes self-reported health problems using the Oslo Sports Trauma Research Centre Questionnaire on Health Problems. The incidence of running-related injury per 1,000 hours of exposure was markedly higher, compared to previous research. At any time, 24% [95% Confidence Intervals (CI): 21-26%] of athletes reported a health problem, with 11% [95% CI: 9-12%] having experienced a health problem that had substantial negative impact on training and performance. Female athletes reported noticeably more illnesses, compared to male athletes, including higher prevalence, incidence, time loss, and severity. The most burdensome health problems, irrespective of sex, included lower leg, knee, and foot/toes injuries, alongside upper respiratory illnesses. The mean weekly prevalence of time loss was relatively low, regardless of health problem type or sex. Competitive adolescent distance runners are likely to be training and competing whilst concurrently experiencing health problems. These findings will support the development of injury and illness prevention measures.

The acute effect of high- and moderate-intensity interval exercise on vascular function before and after a glucose challenge in adolescents

NEW FINDINGS

What is the central question of this study? What is the effect of high-intensity and moderate-intensity interval running on macro- and microvascular function in a fasted state and following a glucose challenge in adolescents? What is the main finding and its importance? Both macro- and microvascular function were improved after interval running independent of intensity. This finding shows that the intermittent exercise pattern and its associated effect on shear are important for vascular benefits. In adolescents, macrovascular function was enhanced after an acute glucose load. However, the effect of chronic glucose consumption on vascular function remains to be elucidated.

ABSTRACT

Interventions targeting vascular function in youth are an important strategy for the primary prevention of cardiovascular diseases. This study examined, in adolescents, the effect of high-intensity interval running (HIIR) and moderate-intensity interval running (MIIR) on vascular function in a fasted state and postprandially after a glucose challenge. Fifteen adolescents (13 male, 13.9 ± 0.6 years) completed the following conditions on separate days in a counterbalanced order: (1) 8 × 1 min HIIR interspersed with 75 s recovery; (2) distance-matched amount of 1 min MIIR interspersed with 75 s recovery; and (3) rest (CON). Macro- (flow-mediated dilatation, FMD) and microvascular (peak reactive hyperaemia, PRH) function were assessed immediately before and 90 min after exercise/rest. Participants underwent an oral glucose tolerance test (OGTT) 2 h after exercise/rest before another assessment of vascular function 90 min after the OGTT. Following exercise, both HIIR and MIIR increased FMD (P = 0.02 and P = 0.03, respectively) and PRH (P = 0.04, and P = 0.01, respectively) with no change in CON (FMD: P = 0.51; PRH: P = 0.16) and no significant differences between exercise conditions. Following the OGTT, FMD increased in CON (P < 0.01) with no changes in HIIR and MIIR (both P > 0.59). There was no change in PRH after the OGTT (all P > 0.40). In conclusion, vascular function is improved after interval running independent of intensity in adolescents. Acute hyperglycaemia increased FMD, but prior exercise did not change vascular function after the OGTT in youth.

A multidisciplinary investigation into "playing-up" in academy football according to age phase

In an attempt to facilitate more appropriate levels of challenge, a common practice in academy football is to play-up talented youth players with chronologically older peers. However, the context of playing-up in academy football is yet to be empirically explored. Thus, the purpose of this study was to examine the multidimensional factors that differentiated players who play-up from those who do not. Ninety-eight participants from a single football academy were examined within their age phase: Foundation Development Phase (FDP; under-9 to under-11; n = 40) and Youth Development Phase (YDP; under-12 to under-16; n = 58). Drawing upon the FA Four Corner Model, 27 factors relating to Technical/Tactical, Physical, Psychological, and Social development were assessed. Following MANOVA analysis within both the FDP and YDP, significant differences were observed for Technical/Tactical and Social sub-components (P < 0.05). Further differences were observed for Physical and Psychological sub-components (P < 0.05) within the YDP. In sum, Technical/Tactical and Social characteristics appeared to differentiate those who play-up compared to those who do not within the FDP. In the YDP however, there were measures representing all sub-components from the FA Four Corner Model. Subsequently, it is suggested coaches and practitioners consider these holistic factors when playing-up youth football players within relevant age-phases.

Test-Retest Reliability of Handgrip Strength Measurement in Children and Preadolescents

The reliability of handgrip strength (HGS) measurement has been confirmed in adults but has been sparsely addressed in pediatric populations. The aims of this study are twofold: to determine whether sex, age and/or hand-dominance influence the test–retest differences and to establish the reliability level of the HGS measurement in typical developing pediatric participants. A total of 338 participants aged 7–13 years were tested using a digital handgrip strength (HGS) dynamometer (Jamar Plus+ Dynamometer) by the same rater on two testing trials separated by a one-day interval between sessions. The HGS testing was conducted according to the American Society of Hand Therapists recommendations. Relative and absolute reliability statistics were calculated. Age influenced the test–retest difference of the HGS measurement as children compared to preadolescents had lower intraclass correlation coefficients (0.95 vs. 0.98), standard error of measurement (SEM) (0.74 vs. 0.78 kg), smallest detectable difference (SDD) (2.05 vs. 2.16 kg) and higher values of the percentage value of SEM (5.48 vs. 3.44%), normalized SDD (15.52 vs. 9.61%) and a mean difference between the test and retest values (0.50 vs. 0.02 kg) for the dominant hand. The results indicate that the protocol using the Jamar digital handgrip dynamometer is a reliable instrument to measure HGS in participants aged 7–13 years with typical development. Clinicians and researchers therefore can have confidence in determining the minimally clinical effect for HGS.

Physical activity interventions for people with congenital heart disease

BACKGROUND

Congenital heart disease (ConHD) affects approximately 1% of all live births. People with ConHD are living longer due to improved medical intervention and are at risk of developing non-communicable diseases. Cardiorespiratory fitness (CRF) is reduced in people with ConHD, who deteriorate faster compared to healthy people. CRF is known to be prognostic of future mortality and morbidity: it is therefore important to assess the evidence base on physical activity interventions in this population to inform decision making.

OBJECTIVES

To assess the effectiveness and safety of all types of physical activity interventions versus standard care in individuals with congenital heart disease.

SEARCH METHODS

We undertook a systematic search on 23 September 2019 of the following databases: CENTRAL, MEDLINE, Embase, CINAHL, AMED, BIOSIS Citation Index, Web of Science Core Collection, LILACS and DARE. We also searched ClinicalTrials.gov and we reviewed the reference lists of relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCT) that compared any type of physical activity intervention against a 'no physical activity' (usual care) control. We included all individuals with a diagnosis of congenital heart disease, regardless of age or previous medical interventions.  DATA COLLECTION AND ANALYSIS: Two review authors (CAW and CW) independently screened all the identified references for inclusion. We retrieved and read all full papers; and we contacted study authors if we needed any further information. The same two independent reviewers who extracted the data then processed the included papers, assessed their risk of bias using RoB 2 and assessed the certainty of the evidence using the GRADE approach. The primary outcomes were: maximal cardiorespiratory fitness (CRF) assessed by peak oxygen consumption; health-related quality of life (HRQoL) determined by a validated questionnaire; and device-worn 'objective' measures of physical activity.

MAIN RESULTS

We included 15 RCTs with 924 participants in the review. The median intervention length/follow-up length was 12 weeks (12 to 26 interquartile range (IQR)). There were five RCTs of children and adolescents (n = 500) and 10 adult RCTs (n = 424). We identified three types of intervention: physical activity promotion; exercise training; and inspiratory muscle training. We assessed the risk of bias of results for CRF as either being of some concern (n = 12) or at a high risk of bias (n = 2), due to a failure to blind intervention staff. One study did not report this outcome. Using the GRADE method, we assessed the certainty of evidence as moderate to very low across measured outcomes. When we pooled all types of interventions (physical activity promotion, exercise training and inspiratory muscle training), compared to a 'no exercise' control CRF may slightly increase, with a mean difference (MD) of 1.89 mL/kg^-1/min^-1 (95% CI -0.22 to 3.99; n = 732; moderate-certainty evidence). The evidence is very uncertain about the effect of physical activity and exercise interventions on HRQoL. There was a standardised mean difference (SMD) of 0.76 (95% CI -0.13 to 1.65; n = 163; very low certainty evidence) in HRQoL. However, we could pool only three studies in a meta-analysis, due to different ways of reporting. Only one study out of eight showed a positive effect on HRQoL. There may be a small improvement in mean daily physical activity (PA) (SMD 0.38, 95% CI -0.15 to 0.92; n = 328; low-certainty evidence), which equates to approximately an additional 10 minutes of physical activity daily (95% CI -2.50 to 22.20). Physical activity and exercise interventions likely result in an increase in submaximal cardiorespiratory fitness (MD 2.05, 95% CI 0.05 to 4.05; n = 179; moderate-certainty evidence). Physical activity and exercise interventions likely increase muscular strength (MD 17.13, 95% CI 3.45 to 30.81; n = 18; moderate-certainty evidence). Eleven studies (n = 501) reported on the outcome of adverse events (73% of total studies). Of the 11 studies, six studies reported zero adverse events. Five studies reported a total of 11 adverse events; 36% of adverse events were cardiac related (n = 4); there were, however, no serious adverse events related to the interventions or reported fatalities (moderate-certainty evidence). No studies reported hospital admissions.

AUTHORS' CONCLUSIONS

This review summarises the latest evidence on CRF, HRQoL and PA. Although there were only small improvements in CRF and PA, and small to no improvements in HRQoL, there were no reported serious adverse events related to the interventions. Although these data are promising, there is currently insufficient evidence to definitively determine the impact of physical activity interventions in ConHD. Further high-quality randomised controlled trials are therefore needed, utilising a longer duration of follow-up.

Speed of Thought and Speed of Feet: Examining Perceptual-Cognitive Expertise and Physical Performance in an English Football Academy

The world’s greatest professional football players are able to execute effective tactical decisions as well as fulfil various physical demands. However, the degree to which both are associated with greater potential in a football academy is unknown. Therefore, the aim of this study was to investigate decision-making skill and physical performance as contributing factors to coach potential rankings in an English football academy. Ninety-eight outfield academy players (Foundation Development Phase [FDP] under-9 to under-11 n = 40; Youth Development Phase [YDP] under-12 to under-16 n = 58) participated in the study. They engaged in 45 film-based simulations at two occlusion phases (e.g., the visual display is cut-off at a precise time during an action), firstly “during” and secondly “post” execution, to examine decision-making skill. Participants also completed four fitness tests to examine physical performance. A classification of “higher-potentials” (top third) and “lower-potentials” (bottom third) were applied through coach rankings. Independent t-tests compared the decision-making and physical performance tests. Higher-potentials made significantly more accurate decisions within the “post” phase within the FDP (P < 0.05) and the “during” phase within the YDP (P < 0.05). Additionally, higher-potentials were significantly faster for the 0–30 m sprint in both the FDP and YDP (P < 0.05), with higher-potentials within the YDP also significantly faster in the 0–10 m sprint (P < 0.05) and jumped significantly higher in the countermovement jump (P < 0.05). These findings indicated that greater football potential may be associated with superior perceptual-cognitive expertise and quicker sprint ability in both academy age phases, with a greater discriminatory function within the older cohort.