Evaluating the Effectiveness of Expert Modeling Videos on Nursing Student Competency Behaviors.

BACKGROUND: Expert modeling videos (EMVs) have shown promise in improving students' performance in simulation. However, research evaluating the impact of EMVs is limited to major performance areas, lacking exploration into specific student competency behaviors. PURPOSE: This study evaluated the effect of an EMV intervention on undergraduate nursing students' behavioral competencies as measured by the Creighton Competency Evaluation Instrument (CCEI). METHODS: Using a quasi-experimental pragmatic evaluation design, students in a medical surgical nursing course (n = 160) viewed either an expert model demonstration video (experimental) or expert model discussion video (control). Students' behavioral competencies were measured and compared between groups using the CCEI. RESULTS: Students who viewed an expert model demonstration video performed at a higher level of competency in 11 of the 18 CCEI behaviors. CONCLUSION: Using EMVs in nursing simulation may improve students' ability to achieve clinical competency in nursing specific behaviors.

A Short Form for Measuring Anxiety in Nursing Education.

Background and purpose: Nursing education lacks an easily accessible, valid, and reliable short instrument to support researchers and instructors in quickly assessing student anxiety. The purpose of this research was to respond to this need by assessing the reliability and validity of a short-form anxiety instrument adapted from psychology which could measure state and trait anxiety. Methods: Using a one-group, repeated measures design, 51 sophomore level undergraduate nursing students had their state and trait anxiety levels measured at three time points over the course of a semester. Results: Results showed that the anxiety instrument was valid and reliable for use in nursing education with Cronbach's α ranging from .65 to .88. Conclusion: Future nurse researchers and educators should consider using the short-form anxiety instrument when a quick differentiation is needed to measure state and trait anxiety.

Actinium-225-PSMA radioligand therapy of metastatic castration-resistant prostate cancer (WARMTH Act): a multicentre, retrospective study.

BACKGROUND: Actinium-225 (225Ac) prostate-specific membrane antigen (PSMA) radioligand therapy (RLT) is a novel therapy for metastatic castration-resistant prostate cancer (mCRPC). We aimed to report the safety and antitumour activity of 225Ac-PSMA RLT of mCRPC in a large cohort of patients treated at multiple centres across the world. METHODS: This retrospective study included patients treated at seven centres in Australia, India, Germany, and South Africa. We pooled data of consecutive patients of any age and Eastern Cooperative Oncology Group performance status with histopathologically confirmed adenocarcinoma of the prostate who were treated with one or more cycles of 8 MBq 225Ac-PSMA RLT administered intravenously for mCRPC. Previous lines of mCRPC treatment included taxane-based chemotherapy, androgen-receptor-axis inhibitors, lutetium-177 (177Lu) PSMA RLT, and radium-223 dichloride. The primary outcomes were overall survival and progression-free survival. FINDINGS: Between Jan 1, 2016, and May 31, 2023, 488 men with mCRPC received 1174 cycles of 225Ac-PSMA RLT (median two cycles, IQR 2-4). The mean age of the patients was 68·1 years (SD 8·8), and the median baseline prostate-specific antigen was 169·5 ng/mL (IQR 34·6-519·8). Previous lines of treatment were docetaxel in 324 (66%) patients, cabazitaxel in 103 (21%) patients, abiraterone in 191 (39%) patients, enzalutamide in 188 (39%) patients, 177Lu-PSMA RLT in 154 (32%) patients, and radium-223 dichloride in 18 (4%) patients. The median follow-up duration was 9·0 months (IQR 5·0-17·5). The median overall survival was 15·5 months (95% CI 13·4-18·3) and median progression-free survival was 7·9 months (6·8-8·9). In 347 (71%) of 488 patients, information regarding treatment-induced xerostomia was available, and 236 (68%) of the 347 patients reported xerostomia after the first cycle of 225Ac-PSMA RLT. All patients who received more than seven cycles of 225Ac-PSMA RLT reported xerostomia. Grade 3 or higher anaemia occurred in 64 (13%) of 488 patients, leukopenia in 19 (4%), thrombocytopenia in 32 (7%), and renal toxicity in 22 (5%). No serious adverse events or treatment-related deaths were recorded. INTERPRETATION: 225Ac-PSMA RLT shows a substantial antitumour effect in mCRPC and represents a viable therapy option in patients treated with previous lines of approved agents. Xerostomia is a common side-effect. Severe bone marrow and renal toxicity are less common adverse events. FUNDING: None.

Generative AI Backstories for Simulation Preparation.

BACKGROUND: Developing engaging presimulation learning materials that provide contextualized patient information is needed to best prepare students for nursing simulation. One emerging strategy that can be used by educators to create visual images for storytelling is generative artificial intelligence (AI). PURPOSE: The purpose of this pilot study was to determine how the use of generative AI-created patient backstories as a presimulation strategy might affect student engagement and learning in nursing simulation. METHODS: A qualitative cross-sectional survey with content analysis was completed with undergraduate nursing students following an acute care simulation. RESULTS: Student surveys point to positive pedagogical outcomes of using AI image generation as a strategy to prepare for simulation such as decreased anxiety in simulation, increased preparatory knowledge, and increased emotional connection with the patient's story. CONCLUSIONS: Images created with generative AI hold promise for future research and transforming nursing education.

Correlation between [68Ga]Ga-FAPI-46 PET Imaging and HIF-1α Immunohistochemical Analysis in Cervical Cancer: Proof-of-Concept.

Hypoxia leads to changes in tumor microenvironment (upregulated CAFs) with resultant aggressiveness. A key factor in the physiological response to hypoxia is hypoxia-inducible factor-1alpha (HIF-1α). [68Ga]Ga-FAPI PET imaging has been demonstrated in various cancer types. We hypothesized that [68Ga]Ga-FAPI PET may be used as an indirect tracer for mapping hypoxia by correlating the image findings to pathological analysis of HIF-1α expression. The [68Ga]Ga-FAPI PET/CT scans of women with cancer of the cervix were reviewed and the maximum and mean standardized uptake value (SUVmax and SUVmean) and FAPI tumor volume (FAPI-TV) were documented. Correlation analysis was performed between PET-derived parameters and immunohistochemical staining as well as between PET-derived parameters and the presence of metastasis. Ten women were included. All patients demonstrated tracer uptake in the primary site or region of the primary. All patients had lymph node metastases while only six patients had distant visceral or skeletal metastases. The mean SUVmax, SUVmean, and FAPI-TV was 18.89, 6.88, and 195.66 cm3, respectively. The average FAPI-TV for patients with additional sites of metastases was higher than those without. Immunohistochemistry revealed varying intensities of HIF-1α expression in all tested samples. There was a positive correlation between the presence of skeletal metastases and staining for HIF-1α (r=0.80;p=0.017). The presence of skeletal metastasis was correlated to the HIF-1⍺ staining (percentage distribution). Furthermore, the FAPI-TV was a better predictor of metastatic disease than the SUVmax.

Measuring Nursing Student Development Through Computer-Based Simulation Activities.

BACKGROUND: New nurse attrition jeopardizes patient safety, devastates career plans, and negatively impacts costs to hospitals and patients. Employers and educators recognize the widening transition-to-practice gap in meeting expectations for practice-ready, resilient nurses. PURPOSE: The purpose of this study was to test the use of computer-based simulation activities (CBSAs) to measure processes in Aller's Development of Decision-Making and Self-Efficacy Model (ADD-SEM). METHODS: BSN students (N = 50) in a multisite, cross-sectional study used CBSAs to provide data on decision making (Virtual Patient Lasater's Clinical Judgment Rubric), psychological capital (Nursing Anxiety and Self-Confidence in Decision-Making Scale©), and reflection. RESULTS: Repeated-measures analysis of variance and reflexive thematic analysis revealed that decision-making (DM) scores were highest in noticing and lowest in interpreting with significant differences in cohorts (DM) (juniors: P < .001; seniors: P = .013) and self-confidence/anxiety ( P < .001). CONCLUSION: The CBSAs are an effective means of measuring student development of DM and psychological capital needed to retain resilient nurses.

225Ac-PSMA-617 radioligand therapy of de novo metastatic hormone-sensitive prostate carcinoma (mHSPC): preliminary clinical findings.

PURPOSE: 225Ac-PSMA-617 has demonstrated good anti-tumor effect as a treatment option for metastatic castration-resistant prostate cancer (mCRPC) patients. No study has previously assessed treatment outcome and survival following 225Ac-PSMA-617 treatment of de novo metastatic hormone-sensitive prostate carcinoma (mHSPC) patients. Based on the potential side effects that are known and explained to the patients by the oncologist, some of the patients refused the standard treatment and are seeking alternative therapies. Thus, we report our preliminary findings in a retrospective series of 21 mHSPC patients that refused standard treatment options and were treated with 225Ac-PSMA-617. METHODS: We retrospectively reviewed patients with histologically confirmed de novo treatment-naïve bone ± visceral mHSPC that were treated with 225Ac-PSMA-617 radioligand therapy (RLT). Inclusion criteria included an Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 2, treatment-naive bone ± visceral mHSPC, and patients refusal for ADT ± docetaxel, abiraterone acetate, or enzalutamide. We evaluated the response to treatment using prostate-specific antigen (PSA) response and the progression-free survival (PFS) and overall survival (OS) as well as the toxicities. RESULTS: Twenty-one mHSPC patients were included in this preliminary work. Following treatment, twenty patients (95%) had any decline in PSA and eighteen patients (86%) presented with a PSA decline of ≥ 50% including 4 patients in whom PSA became undetectable. A lower percentage decrease in PSA following treatment was associated with increased mortality and shorter progression-free survival. Overall, administration of 225Ac-PSMA-617 was well tolerated. The commonest toxicity seen was grade I/II dry mouth observed in 94% of patients. CONCLUSIONS: Given these favorable results, randomized prospective multicenter trials assessing the clinical value of 225Ac-PSMA-617 as a therapeutic agent for mHSPC administered either as monotherapy or administered concomitant with ADT are of interest.

Learning From Non-Practicing Registered Nurses.

One way to increase the number of RNs during a global nursing shortage is to recruit those currently not working in health care to rejoin the workforce. The goal of this project was to assess the attitudes and perceived learning needs of nurses who are not working in health care. An online survey was distributed via social media nursing groups to a self-selected sample of nurses not working in health care for the previous 2 years. Although the response rate was low (n = 18), there was interesting discussion on re-entry to nursing practice. Top reasons stated for not re-entering the workforce included burnout/stress, workplace conditions, lack of education/skills, and pay. Pharmacology, skills, and technology were the top three self-identified learning needs of the participants. Limited programs offer education for re-entry to practice. Nurse educators should develop learning materials to meet the needs of this special population. [J Contin Educ Nurs. 2022;53(11):486-490.].

68 Ga-nitroimidazole PET/CT imaging of hypoxia in tuberculosis: A case series.

Tuberculosis (TB) lesions in humans have been proven to be severely hypoxic with hypoxia leading to latency and dormancy of disease. Dormant TB lesions become less susceptible to standard TB treatment regimens with varying responses to treatment but may have increased susceptibility to nitroimidazole drugs. This in turn implies that positron emission tomography / computed tomography (PET/CT) imaging with radiolabelled nitroimidazoles may identify patients who will benefit from treatment with antimicrobial agents that are active against anaerobic bacteria. This case series aims to highlight the hypoxic uptake and retention of a novel 68 Ga-labelled hypoxia-seeking agent in TB lesions at different time points during anti-TB therapy using PET/CT imaging. Patients with confirmed TB underwent whole-body PET/CT after administration of a 68 Ga-nitroimidazole derivative at baseline and follow-up. Images were analysed both qualitatively and semi-quantitatively. Hypoxic uptake and change in uptake over time were analysed using lesion-to-muscle ratio (LMR) and lesion-to-blood ratio (LBR). 68 Ga-nitroimidazole avid lesions were demonstrated most frequently in the upper lobes of the lung. Low-grade hypoxic uptake was visualised in areas of consolidation, cavitation, nodules and lymph nodes. From baseline to follow-up imaging, the LMR increased with persistent hypoxic load despite morphologic improvement. This case series highlights the dynamic hypoxic microenvironment in TB lesions. From these initial data, it appears that 68 Ga-nitroimidazole is a promising candidate for monitoring hypoxic load in patients diagnosed with TB. Such imaging could identify patients who would benefit from individualised therapy targeting other mechanisms in the TB microenvironment with the intention to predict or improve treatment response.

The prevalence of comorbidity in rheumatoid arthritis: a systematic review and meta-analysis.

This systematic review and meta-analysis estimates the prevalence of common comorbid health disorders in adults with rheumatoid arthritis (RA). A multi-database search strategy was undertaken. Screening, data extraction and quality assessment were carried out by two independent reviewers. A meta-analysis and meta-regression were used to generate a pooled prevalence estimate and identify relevant moderators. After study selection, 33 studies (74633 participants) were included in the meta-analysis. Some 31 studies were judged to be of low risk of bias, and two studies were judged to be at moderate risk of bias. The three most common comorbidities in RA were anxiety disorders (62.1%, 95% Cl: 43.6%; 80.6%), hypertension (37.7%, 95% Cl: 29.2%; 46.2%) and depression (32.1%, 95% Cl: 21.6%; 42.7%). There was substantial statistically significant heterogeneity for all comorbidities (I2 ≥77%). Meta-regression identified that the covariate of mean age (unit increase) had a statistically significant effect on the prevalence of hypertension (+2.3%, 95% Cl: 0.4%; 4.2%), depression (-0.5%, 95% Cl: -0.6%; -0.4%) and cancer (0.5%, 95% Cl: 0.2%; 0.8%) in adults with RA. A country's income was identified to have a statistically significant effect on the prevalence of depression, with low-to moderate-income countries having 40% (95% Cl: 14.0%; 66.6%) higher prevalence than high-income countries. No studies consider health inequalities. It is concluded that comorbidities are prevalent among people with RA, particularly those associated with mental health and circulatory conditions. Provision of health services should reflect the importance of such multimorbidity and the consequences for quality and length of life.

Hematologic toxicity profile and efficacy of [225Ac]Ac-PSMA-617 α-radioligand therapy of patients with extensive skeletal metastases of castration-resistant prostate cancer.

PURPOSE: Actinium-225-labeled prostate-specific membrane antigen ([225Ac]Ac-PSMA-617) is safe and effective in the treatment of metastatic castration-resistant prostate cancer (mCRPC). No study has specifically assessed its safety in patients with extensive skeletal metastases of mCRPC. We aimed to investigate the hematologic toxicity and efficacy of [225Ac]Ac-PSMA-617 therapy in patients with extensive skeletal metastases of mCRPC. METHODS: We retrospectively reviewed the medical record of patients treated with [225Ac]Ac-PSMA-617 for mCRPC. We included patients with a superscan pattern of skeletal metastases and those with 20 or more multifocal sites of skeletal metastases on baseline [68 Ga]Ga-PSMA-11 PET/CT. We reviewed the levels of hemoglobin, white blood cell (WBC), and platelet prior to each cycle of treatment and determined the presence of impaired bone marrow function at baseline and the grade of toxicity in the hematologic parameters induced by treatment. We evaluated the predictors of hematologic toxicity using binary logistic regression analysis. We also determined the presence of renal dysfunction before or during treatment. We assessed response to treatment using prostate-specific antigen response and the progression-free survival (PFS) and overall survival (OS). RESULTS: A total of 106 patients were included. Skeletal metastasis was in the superscan pattern in 34 patients (32.1%) and multifocal in 72 patients (67.9%). The median treatment cycle was 4 (range = 1-9). Ninety-eight patients (92.5%) had abnormal baseline hematologic parameters. One patient had grade 4 thrombocytopenia. Grade 3 anemia, leukopenia, and thrombocytopenia were seen in 1 (0.9%), 3 (2.8%), and 2 (1.9%) patients, respectively. Age, the number of treatment cycles, and the presence of renal dysfunction were significant predictors of hematologic toxicity. Eighty-five patients (80.2%) achieved PSA response. The median PFS and OS of the study population were 14:00 (95%CI: 8.15-19.86) months and 15.0 (95%CI: 12.8-17.2) months, respectively. CONCLUSIONS: [225Ac]Ac-PSMA-617 induces a good anti-tumor effect in about 80% of patients with extensive skeletal metastases of mCRPC with a rare incidence of severe hematologic toxicity. Age, number of treatment cycles, and the presence of renal dysfunction were significant risk factors for hematologic toxicity of [225Ac]Ac-PSMA-617 therapy.

A Prospective Investigation of Tumor Hypoxia Imaging with 68Ga-Nitroimidazole PET/CT in Patients with Carcinoma of the Cervix Uteri and Comparison with 18F-FDG PET/CT: Correlation with Immunohistochemistry.

Hypoxia in cervical cancer has been associated with a poor prognosis. Over the years 68Ga labelled nitroimidazoles have been studied and have shown improved kinetics. We present our initial experience of hypoxia Positron Emission Tomography (PET) imaging in cervical cancer with 68Ga-Nitroimidazole derivative and the correlation with 18F-FDG PET/CT and immunohistochemistry. Twenty women with cervical cancer underwent both 18F-FDG and 68Ga-Nitroimidazole PET/CT imaging. Dual-point imaging was performed for 68Ga-Nitroimidazole PET. Immunohistochemical analysis was performed with hypoxia inducible factor-1α (HIF-1α). We documented SUVmax, SUVmean of the primary lesions as well as tumor to muscle ratio (TMR), tumor to blood (TBR), metabolic tumor volume (MTV) and hypoxic tumor volume (HTV). There was no significant difference in the uptake of 68Ga-Nitroimidazole between early and delayed imaging. Twelve patients had uptake on 68Ga-Nitroimidazole PET. Ten patients demonstrated varying intensities of HIF-1α expression and six of these also had uptake on 68Ga-Nitroimidazole PET. We found a strong negative correlation between HTV and immunohistochemical staining (r = -0.660; p = 0.019). There was no correlation between uptake on PET imaging and immunohistochemical analysis with HIF-1α. Two-thirds of the patients demonstrated hypoxia on 68Ga-Nitroimidazole PET imaging.

The Utility of Metabolic Parameters on Baseline F-18 FDG PET/CT in Predicting Treatment Response and Survival in Paediatric and Adolescent Hodgkin Lymphoma.

Lymphoma is the third most common paediatric cancer. Early detection of high-risk patients is necessary to anticipate those who require intensive therapy and follow-up. Current literature shows that residual tumor avidity on PET (Positron Emission Tomography) following chemotherapy corresponds with decreased survival. However, the value of metabolic parameters has not been adequately investigated. In this retrospective study, we aimed to evaluate the prognostic value of metabolic and other parameters in paediatric and adolescent Hodgkin lymphoma. We recorded tMTV (total Metabolic Tumor Volume), TLG (Total Lesion Glycolysis), and SUVmax (maximum Standard Uptake Value) on baseline PET, as well the presence of bone marrow or visceral involvement. HIV (human immunodeficiency virus) status and baseline biochemistry from clinical records were noted. All patients received stage-specific standard of care therapy. Response assessment on end-of-treatment PET was evaluated according to the Deauville criteria. We found that bone marrow involvement (p = 0.028), effusion (p < 0.001), and treatment response (p < 0.001) on baseline PET, as well as HIV status (p = 0.036) and baseline haemoglobin (p = 0.039), were significantly related to progression-free survival (PFS), whereas only effusion (p = 0.017) and treatment response (p = 0.050) were predictive of overall survival (OS). Only baseline tMTV predicted treatment response (p = 0.017). This confirms the value of F-18 FDG PET/CT (Fluoro-deoxy-glucose Positron Emission Tomography/Computed Tomography) in prognostication in paediatric and adolescent Hodgkin lymphoma; however, further studies are required to define the significance of metabolic parameters.

Gaming and anxiety in the nursing simulation lab: A pilot study of an escape room.

BACKGROUND: Anxiety accompanying educational simulations is a complex issue impacting nursing students and their learning. Research has provided evidence that some pre-simulation activities can increase student comfort with the simulation environment and may also reduce anxiety. Studies have also provided evidence of promising outcomes for gaming use in nursing education. PURPOSE: This pilot study explored a medical-surgical escape room game as an introductory simulation experience for nursing students, particularly focused on determining student anxiety levels, and both faculty and student perception of the experience. METHODS: A quasi-experimental one group pretest-posttest design was used with a convenience sample to explore student anxiety levels and perceived enjoyment of the game. RESULTS: Student anxiety levels significantly decreased (p = .013); however, anxiety levels remained high at posttest. Students reported high enjoyment of the game and provided positive comments. CONCLUSION: Escape rooms can provide an engaging, interactive way to teach nursing concepts in the simulation environment.

Barriers and facilitators to deprescribing in primary care: a systematic review.

BACKGROUND: Managing polypharmacy is a challenge for healthcare systems globally. It is also a health inequality concern as it can expose some of the most vulnerable in society to unnecessary medications and adverse drug-related events. Care for most patients with multimorbidity and polypharmacy occurs in primary care. Safe deprescribing interventions can reduce exposure to inappropriate polypharmacy. However, these are not fully accepted or routinely implemented. AIM: To identify barriers and facilitators to safe deprescribing interventions for adults with multimorbidity and polypharmacy in primary care. DESIGN & SETTING: A systematic review of studies published from 2000, examining safe deprescribing interventions for adults with multimorbidity and polypharmacy. METHOD: A search of electronic databases: MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature (CINHAL), Cochrane, and Health Management Information Consortium (HMIC) from inception to 26 Feb 2019, using an agreed search strategy. This was supplemented by handsearching of relevant journals, and screening of reference lists and citations of included studies. RESULTS: In total, 40 studies from 14 countries were identified. Cultural and organisational barriers included: a culture of diagnosing and prescribing; evidence-based guidance focused on single diseases; a lack of evidence-based guidance for the care of older people with multimorbidities; and a lack of shared communication, decision-making systems, tools, and resources. Interpersonal and individual-level barriers included: professional etiquette; fragmented care; prescribers' and patients' uncertainties; and gaps in tailored support. Facilitators included: prudent prescribing; greater availability and acceptability of non-pharmacological alternatives; resources; improved communication, collaboration, knowledge, and understanding; patient-centred care; and shared decision-making. CONCLUSION: A whole systems, patient-centred approach to safe deprescribing interventions is required, involving key decision-makers, healthcare professionals, patients, and carers.

Barriers and facilitators to primary health care for people with intellectual disabilities and/or autism: an integrative review.

BACKGROUND: Globally, people with intellectual disabilities and/or autism experience health inequalities. Death occurs at a younger age and the prevalence of long-term morbidities is higher than in the general population. Despite this, their primary healthcare access rates are lower than the general population, their health needs are often unmet, and their views and experiences are frequently overlooked in research, policy, and practice. AIM: To investigate the barriers and facilitators reported by individuals with intellectual disabilities, autism, or both, and/or their carers, to accessing and utilising primary health care for their physical and mental health needs. DESIGN & SETTING: An integrative review was undertaken, which used systematic review methodology. METHOD: Electronic databases MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane were searched for relevant studies (all languages) using a search strategy. Two researchers independently screened the results and assessed the quality of the studies. RESULTS: Sixty-three international studies were identified. Six main themes relating to barriers and facilitators emerged from an analysis of these studies. The main themes were: training; knowledge and awareness; communication; fear and embarrassment; involvement in healthcare decision-making; and time. All the themes were underpinned by the need for greater care, dignity, respect, collaborative relationships, and reasonable adjustments. Opposing barriers and facilitators were identified within each of the main themes. CONCLUSION: Adolescents and adults with intellectual disabilities and/or autism experience several barriers to accessing and utilising primary health care. The findings highlight the reasonable adjustments and facilitators that can be implemented to ensure that these individuals are not excluded from primary health care.

Gaming in Nursing Education: Recent Trends and Future Paths.

BACKGROUND: Game-based learning has attracted much attention in education in recent years due to its ability to increase student motivation and engagement in learning. This study reviewed the literature to answer the research questions: What learning outcomes have been linked to games in nursing education? What are potential gaps in the field's knowledge regarding games in nursing education? METHOD: A systematic literature search was completed in CINAHL and Google Scholar from 2009-2019 with the keywords of games, gaming, and nursing education. RESULTS: A total of 49 papers were identified; of these, 34 were excluded, and 15 empirical studies were evaluated. The majority reported beneficial learning outcomes, such as increased knowledge, higher test scores, and positive student comments. Several methodological weaknesses were noted, such as small sample sizes, convenience samples, and lack of control groups or randomization. CONCLUSION: Games have the potential to prepare new nurses for improved clinical decision making. More robust research methodologies are needed to confirm best practices for educators. [J Nurs Educ. 2020;59(7):375-381.].

A scoping review of determinants of performance in dressage.

As a first step in achieving an evidence-based classification system for the sport of Para Dressage, there is a clear need to define elite dressage performance. Previous studies have attempted to quantify performance with able-bodied riders using scientific methods; however, definitive measures have yet to be established for the horse and/or the rider. This may be, in part, due to the variety of movements and gaits that are found within a dressage test and also due to the complexity of the horse-rider partnership. The aim of this review is therefore to identify objective measurements of horse performance in dressage and the functional abilities of the rider that may influence them to achieve higher scores. Five databases (SportDiscuss, CINAHL, MEDLINE, EMBASE, VetMed) were systematically searched from 1980 to May 2018. Studies were included if they fulfilled the following criteria: (1) English language; (2) employ objective, quantitative outcome measures for describing equine and human performance in dressage; (3) describe objective measures of superior horse performance using between-subject comparisons and/or relating outcome measures to competitive scoring methods; (4) describe demands of dressage using objective physiological and/or biomechanical measures from human athletes and/or how these demands are translated into superior performance. In total, 773 articles were identified. Title and abstract screening resulted in 155 articles that met the eligibility criteria, 97 were excluded during the full screening of articles, leaving 58 included articles (14 horse, 44 rider) involving 311 equine and 584 able-bodied human participants. Mean ± sd (%) quality scores were 63.5 ± 15.3 and 72.7 ± 14.7 for the equine and human articles respectively. Significant objective measures of horse performance (n = 12 articles) were grouped into themes and separated by gait/movement. A range of temporal variables that indicated superior performance were found in all gaits/movements. For the rider, n = 5 articles reported variables that identified significant differences in skill level, which included the postural position and ROM of the rider's pelvis, trunk, knee and head. The timing of rider pelvic and trunk motion in relation to the movement of the horse emerged as an important indicator of rider influence. As temporal variables in the horse are consistently linked to superior performance it could be surmised that better overall dressage performance requires minimal disruption from the rider whilst the horse maintains a specific gait/movement. Achieving the gait/movement in the first place depends upon the intrinsic characteristics of the horse, the level of training achieved and the ability of the rider to apply the correct aid. The information from this model will be used to develop an empirical study to test the relative strength of association between impairment and performance in able-bodied and Para Dressage riders.