Spontaneous coronary artery dissection: A review of diagnostic methods and management strategies

Spontaneous coronary artery dissection (SCAD) is a rare non-atherosclerotic cause of acute coronary syndromes defined as non-iatrogenic, non-traumatic separation of the coronary artery wall. The most common profile is a middle-aged woman between 44 and 53 years with few cardiovascular risk factors. SCAD is frequently linked with predisposing factors, such as postpartum, fibromuscular dysplasia or other vasculopathies, connective tissue disease and hormonal therapy, and it is often triggered by intense physical or emotional stress, sympathomimetic drugs, childbirth and activities increasing shear stress of the coronary artery walls. Patients with SCAD usually present at the emergency department with chest discomfort, chest pain, and rapid heartbeat or fluttery. During the last decades, the most common problem of SCAD was the lack of awareness about this condition which has led to significant underdiagnosis and misdiagnosis. However, modern imaging techniques such as optical coherence tomography, intravascular ultrasound, coronary angiography or magnetic resonance imaging have contributed to the early diagnosis of the disease. Treatment of SCAD remains controversial, especially during the last years, where invasive techniques are being used more often and in more emergent cardiac syndromes. Although conservative treatment combining aspirin and beta-blocker remains the recommended strategy in most cases, revascularization could also be suggested as a method of treatment in specific indications, but with a higher risk of complications. The prognosis of SCAD is usually good and long-term mortality seems to be low in these patients. Follow-up should be performed on a regular basis.

Immunostimulation and Coagulopathy in COVID-19 Compared to Patients With H1N1 Pneumonia or Bacterial Sepsis

BACKGROUND/AIM

Multiple reports from all over the world link COVID-19 with endothelial/coagulation disorders as well as a dysregulated immune response. This study tested the hypothesis that immunostimulation will be greater in COVID-19 patients than in patients with H1N1 infection or bacterial sepsis. Also, whether an increase in immune stimulation will be accompanied by a more severely affected endothelium/coagulation system was examined.

PATIENTS AND METHODS

Twenty-three septic patients, admitted in the Intensive Care Unit (ICU), were enrolled (9 with SARS-CoV-2, 5 with H1N1 pneumonia, 9 with bacterial sepsis). Myeloperoxidase (MPO) activity along with certain endothelial/coagulation factors were assessed on admission (time point 1) and at either improvement or deterioration (time point 2).

RESULTS

MPO levels were significantly higher in COVID-19 patients compared to both other groups. Furthermore, in patients with COVID-19, vWF levels did not differ significantly, fVIII levels were lower while ADAMTS-13 activity was higher compared to patients with H1N1 pneumonia and bacterial sepsis (a trend in the latter).

CONCLUSION

Increased immunostimulation was noted in COVID-19 patients compared to other septic patients; however, this was not accompanied by greater disturbance of the clotting system and/or more severe endothelial injury.

Modalities of Exercise Training in Patients with Extracorporeal Membrane Oxygenation Support

The aim of this qualitative systematic review is to summarize and analyze the different modalities of exercise training and its potential effects in patients on extracorporeal membrane oxygenation (ECMO) support. ECMO is an outbreaking, life-saving technology of the last decades which is being used as a gold standard treatment in patients with severe cardiac, respiratory or combined cardiorespiratory failure. Critically ill patients on ECMO very often present intensive care unit-acquired weakness (ICU-AW); thus, leading to decreased exercise capacity and increased mortality rates. Early mobilization and physical therapy have been proven to be safe and feasible in critically ill patients on ECMO, either as a bridge to lung/heart transplantation or as a bridge to recovery. Rehabilitation has beneficial effects from the early stages in the ICU, resulting in the prevention of ICU-AW, and a decrease in episodes of delirium, the duration of mechanical ventilation, ICU and hospital length of stay, and mortality rates. It also improves functional ability, exercise capacity, and quality of life. Rehabilitation requires a very careful, multi-disciplinary approach from a highly specialized team from different specialties. Initial risk assessment and screening, with appropriate physical therapy planning and exercise monitoring in patients receiving ECMO therapy are crucial factors for achieving treatment goals. However, more randomized controlled trials are required in order to establish more appropriate individualized exercise training protocols.

Acute Cardiorespiratory Responses to Different Exercise Modalities in Chronic Heart Failure Patients-A Pilot Study

The purpose of this study was to compare the acute cardiorespiratory responses and time spent above different %VO_2peak intensities between three "iso-work" protocols: (a) a high intensity interval training protocol (HIIT), (b) a higher intensity continuous protocol (CON₇₀) and (c) a lower intensity continuous protocol (CON₅₀) in patients with chronic heart failure (CHF). Ten male CHF patients (aged 55.1 ± 16.2 years) performed in separate days a single session of a HIIT protocol consisted of 4 sets × 4 min cycling at 80% VO_2peak with 3 min of recovery at 50% VO_2peak, a CON₇₀ protocol corresponding to 70% VO_2peak and a CON₅₀ protocol corresponding to 50% VO_2peak. Cardiopulmonary data were collected by an online gas analysis system. The HIIT and CON₇₀ elicited higher cardiorespiratory responses compared to CON₅₀ with no differences between them (p > 0.05). In HIIT and CON₇₀, patients exercised longer at >80% and >90% VO_2peak. The completion rate was 100% for the three protocols. Not any adverse events were observed in either protocol. Both HIIT and CON₇₀ elicited a stronger physiological stimulus and required shorter time than CON₅₀. Both HIIT and CON₇₀ also induced comparable hemodynamic responses and ventilatory demand.

Exercise training in heart transplantation

Heart transplantation remains the gold standard in the treatment of end-stage heart failure (HF). Heart transplantation patients present lower exercise capacity due to cardiovascular and musculoskeletal alterations leading thus to poor quality of life and reduction in the ability of daily self-service. Impaired vascular function and diastolic dysfunction cause lower cardiac output while decreased skeletal muscle oxidative fibers, enzymes and capillarity cause arteriovenous oxygen difference, leading thus to decreased peak oxygen uptake in heart transplant recipients. Exercise training improves exercise capacity, cardiac and vascular endothelial function in heart transplant recipients. Pre-rehabilitation regular aerobic or combined exercise is beneficial for patients with end-stage HF awaiting heart transplantation in order to maintain a higher fitness level and reduce complications afterwards like intensive care unit acquired weakness or cardiac cachexia. All hospitalized patients after heart transplantation should be referred to early mobilization of skeletal muscles through kinesiotherapy of the upper and lower limbs and respiratory physiotherapy in order to prevent infections of the respiratory system prior to hospital discharge. Moreover, all heart transplant recipients after hospital discharge who have not already participated in an early cardiac rehabilitation program should be referred to a rehabilitation center by their health care provider. Although high intensity interval training seems to have more benefits than moderate intensity continuous training, especially in stable transplant patients, individualized training based on the abilities and needs of each patient still remains the most appropriate approach. Cardiac rehabilitation appears to be safe in heart transplant patients. However, long-term follow-up data is incomplete and, therefore, further high quality and adequately-powered studies are needed to demonstrate the long-term benefits of exercise training in this population.

Epigenetic effects following acute and chronic exercise in cardiovascular disease: A systematic review

INTRODUCTION

Acute exercise and exercise training may confer epigenetic modifications in healthy subjects. Epigenetic effects after exercise have been showed in patients with cardiovascular disease. The aim of this systematic review was to summarize the evidence from available clinical trials that study epigenetic adaptations after exercise in patients with cardiovascular disease.

METHODS

The search strategy was performed in PubMed and CENTRAL databases on articles published until September 2020. Studies with titles and abstracts relevant to exercise epigenetic modification applied to cardiovascular patients were fully examined. Inclusion and exclusion criteria were utilized for studies screening. Quality assessment with PEDro scale and evaluation by two independent reviewers was performed.

RESULTS

Of the 1714 articles retrieved, 88 articles were assessed for eligibility criteria and 8 articles matched our search criteria and finally included in the systematic analysis. The acute exercise epigenetic (miRNAs) effects were assessed in three studies and the chronic exercise training effects (miRNAs and DNA methylation) in six studies. The results have shown that there is possibly an acute significant exercise effect on epigenetic targets which is more evident after chronic exercise training.

CONCLUSIONS

By the present systematic review, we provide preliminary evidence of beneficial epigenetic adaptations following acute and chronic exercise in patients with cardiovascular disease. More controlled studies are needed to confirm such evidence.

Endothelial progenitor cells mobilization after maximal exercise according to heart failure severity

BACKGROUND

Vascular endothelial dysfunction is an underlying pathophysiological feature of chronic heart failure (CHF). Patients with CHF are characterized by impaired vasodilation and inflammation of the vascular endothelium. They also have low levels of endothelial progenitor cells (EPCs). EPCs are bone marrow derived cells involved in endothelium regeneration, homeostasis, and neovascularization. Exercise has been shown to improve vasodilation and stimulate the mobilization of EPCs in healthy people and patients with cardiovascular comorbidities. However, the effects of exercise on EPCs in different stages of CHF remain under investigation.

AIM

To evaluate the effect of a symptom-limited maximal cardiopulmonary exercise testing (CPET) on EPCs in CHF patients of different severity.

METHODS

Forty-nine consecutive patients (41 males) with stable CHF [mean age (years): 56 ± 10, ejection fraction (EF, %): 32 ± 8, peak oxygen uptake (VO₂, mL/kg/min): 18.1 ± 4.4] underwent a CPET on a cycle ergometer. Venous blood was sampled before and after CPET. Five circulating endothelial populations were quantified by flow cytometry: Three subgroups of EPCs [CD34⁺/CD45^-/CD133⁺, CD34⁺/CD45^-/CD133⁺/VEGFR₂ and CD34⁺/CD133⁺/vascular endothelial growth factor receptor 2 (VEGFR₂)] and two subgroups of circulating endothelial cells (CD34⁺/CD45^-/CD133^- and CD34⁺/CD45^-/CD133^-/VEGFR₂). Patients were divided in two groups of severity according to the median value of peak VO₂ (18.0 mL/kg/min), predicted peak VO₂ (65.5%), ventilation/carbon dioxide output slope (32.5) and EF (reduced and mid-ranged EF). EPCs values are expressed as median (25th-75th percentiles) in cells/10⁶ enucleated cells.

RESULTS

Patients with lower peak VO₂ increased the mobilization of CD34⁺/CD45^-/CD133⁺ [pre CPET: 60 (25-76) vs post CPET: 90 (70-103) cells/10⁶ enucleated cells, P < 0.001], CD34⁺/CD45^-/CD133⁺/VEGFR₂ [pre CPET: 1 (1-4) vs post CPET: 5 (3-8) cells/10⁶ enucleated cells, P < 0.001], CD34⁺/CD45^-/CD133^- [pre CPET: 186 (141-361) vs post CPET: 488 (247-658) cells/10⁶ enucleated cells, P < 0.001] and CD34⁺/CD45^-/CD133^-/VEGFR₂ [pre CPET: 2 (1-2) vs post CPET: 3 (2-5) cells/10⁶ enucleated cells, P < 0.001], while patients with higher VO₂ increased the mobilization of CD34⁺/CD45^-/CD133⁺ [pre CPET: 42 (19-73) vs post CPET: 90 (39-118) cells/10⁶ enucleated cells, P < 0.001], CD34⁺/CD45^-/CD133⁺/VEGFR₂ [pre CPET: 2 (1-3) vs post CPET: 6 (3-9) cells/10⁶ enucleated cells, P < 0.001], CD34⁺/CD133⁺/VEGFR₂ [pre CPET: 10 (7-18) vs post CPET: 14 (10-19) cells/10⁶ enucleated cells, P < 0.01], CD34⁺/CD45^-/CD133^- [pre CPET: 218 (158-247) vs post CPET: 311 (254-569) cells/10⁶ enucleated cells, P < 0.001] and CD34⁺/CD45^-/CD133^-/VEGFR₂ [pre CPET: 1 (1-2) vs post CPET: 4 (2-6) cells/10⁶ enucleated cells, P < 0.001]. A similar increase in the mobilization of at least four out of five cellular populations was observed after maximal exercise within each severity group regarding predicted peak, ventilation/carbon dioxide output slope and EF as well (P < 0.05). However, there were no statistically significant differences in the mobilization of endothelial cellular populations between severity groups in each comparison (P > 0.05).

CONCLUSION

Our study has shown an increased EPCs and circulating endothelial cells mobilization after maximal exercise in CHF patients, but this increase was not associated with syndrome severity. Further investigation, however, is needed.

Life-threatening antineutrophil cytoplasmic antibody-associated vasculitis after influenza A H1N1 infection requiring veno-venous extracorporeal membrane oxygenation

INTRODUCTION

Antineutrophil cytoplasmic autoantibody-associated vasculitis is an immune-mediated necrotizing vasculitis, affecting small- and medium-sized vessels.

CASE REPORT

A 22-year-old female patient with free medical history presented with life-threatening pulmonary hemorrhage due to antineutrophil cytoplasmic autoantibody-associated vasculitis, temporarily associated with influenza A H1N1 infection. Due to rapidly worsening respiratory failure, despite conventional management, veno-venous peripheral extracorporeal membrane oxygenation was initiated and continued for 26 days, with subsequent renal replacement therapy.

DISCUSSION

We present a case of severe antineutrophil cytoplasmic autoantibody-associated pulmonary vasculitis, managed with veno-venous extracorporeal membrane oxygenation at the initial phase. Despite the significant challenges raised with the use of extracorporeal membrane oxygenation in pulmonary hemorrhage cases, extracorporeal membrane oxygenation may have a significant impact on outcome in this setting, by providing adequate time for a successful immunosuppressive treatment.

Sonographic muscle mass assessment in patients after cardiac surgery

BACKGROUND

Patients undergoing cardiac surgery particularly those with comorbidities and frailty, experience frequently higher rates of post-operative morbidity, mortality and prolonged hospital length of stay. Muscle mass wasting seems to play important role in prolonged mechanical ventilation (MV) and consequently in intensive care unit (ICU) and hospital stay.

AIM

To investigate the clinical value of skeletal muscle mass assessed by ultrasound early after cardiac surgery in terms of duration of MV and ICU length of stay.

METHODS

In this observational study, we enrolled consecutively all patients, following their admission in the Cardiac Surgery ICU within 24 h of cardiac surgery. Bedside ultrasound scans, for the assessment of quadriceps muscle thickness, were performed at baseline and every 48 h for seven days or until ICU discharge. Muscle strength was also evaluated in parallel, using the Medical Research Council (MRC) scale.

RESULTS

Of the total 221 patients enrolled, ultrasound scans and muscle strength assessment were finally performed in 165 patients (patients excluded if ICU stay < 24 h). The muscle thickness of rectus femoris (RF), was slightly decreased by 2.2% [(95% confidence interval (CI): - 0.21 to 0.15), n = 9; P = 0.729] and the combined muscle thickness of the vastus intermedius (VI) and RF decreased by 3.5% [(95%CI: - 0.4 to 0.22), n = 9; P = 0.530]. Patients whose combined VI and RF muscle thickness was below the recorded median values (2.5 cm) on day 1 (n = 80), stayed longer in the ICU (47 ± 74 h vs 28 ± 45 h, P = 0.02) and remained mechanically ventilated more (17 ± 9 h vs 14 ± 9 h, P = 0.05). Moreover, patients with MRC score ≤ 48 on day 3 (n = 7), required prolonged MV support compared to patients with MRC score ≥ 49 (n = 33), (44 ± 14 h vs 19 ± 9 h, P = 0.006) and had a longer duration of extracorporeal circulation was (159 ± 91 min vs 112 ± 71 min, P = 0.025).

CONCLUSION

Skeletal quadriceps muscle thickness assessed by ultrasound shows a trend to a decrease in patients after cardiac surgery post-ICU admission and is associated with prolonged duration of MV and ICU length of stay.

Safety of Percutaneous Dilatational Tracheostomy During Veno-Venous Extracorporeal Membrane Oxygenation Support in Adults With Severe Respiratory Failure

OBJECTIVES

To investigate the safety of percutaneous dilatational tracheostomy in severe respiratory failure patients during veno-venous extracorporeal membrane oxygenation support.

DESIGN

A single-center, retrospective, observational cohort study.

SETTING

Tertiary referral severe respiratory failure center, university teaching hospital.

PATIENTS

Severe respiratory failure patients consecutively admitted and supported with veno-venous extracorporeal membrane oxygenation between January 2010 and December 2015.

INTERVENTION

A bronchoscopy-guided percutaneous dilatational tracheostomy was performed in all cases.

MEASUREMENTS AND MAIN RESULTS

Sixty-five veno-venous extracorporeal membrane oxygenation patients (median [interquartile range] age, 47 yr [interquartile range, 35-59 yr]; 39 males; Acute Physiology and Chronic Health Evaluation-II score, 18 [interquartile range, 17-22] Sequential Organ Failure Assessment score, 10 [interquartile range, 7-16]) underwent percutaneous dilatational tracheostomy. Ten patients (15%) developed one or more major complications. Of these, seven (11%) had major bleeding, and three of these also required circuit change due to extracorporeal membrane oxygenation circuit dysfunction. Two more patients (3.1%) presented with isolated extracorporeal membrane oxygenation circuit dysfunction requiring circuit change, and one developed bilateral pneumothoraces (1.5%) requiring intercostal drain insertion. Patients who developed complications had significantly lower extracorporeal membrane oxygenation postoxygenator PO2 prior to percutaneous dilatational tracheostomy (45.8 kPa [interquartile range, 36.9-56.5 kPa] vs 57.9 kPa [interquartile range, 45.1-64.2 kPa]; p = 0.019]. On multivariate analysis, including demographic, clinical, biochemical, hematologic variables, and extracorporeal membrane oxygenation circuit functional variables, extracorporeal membrane oxygenation postoxygenator PO2 was the only independent variable associated with major complications following percutaneous dilatational tracheostomy (beta = -0.09; odds ratio, 0.9; 95% CI, 0.84-0.99; p = 0.03).

CONCLUSIONS

Percutaneous dilatational tracheostomy is associated with a considerable complication rate in veno-venous extracorporeal membrane oxygenation patients. Preprocedure circuit performance as indicated by extracorporeal membrane oxygenation postoxygenator PO2 is an independent predictor of major complications following percutaneous dilatational tracheostomy.

Variation of endothelium-related hemostatic factors during sepsis

OBJECTIVE

The thrombomodulin/protein C and VWF/ADAMTS-13 pathways are disturbed in sepsis and have been implicated in the coagulation disorders that characterize the septic syndrome. We aimed to assess the variation of these endothelial parameters during sepsis and their putative association with outcome, in critically ill, septic patients.

METHODS

We monitored 34 septic patients, 23 of whom improved (group A) while 11 deteriorated (group B). We assessed ADAMTS-13 levels, VWF activity, soluble thrombomodulin, and protein C activity upon admission to the ICU (time point 0) and at the time of a change in the clinical condition (remission or deterioration, time point 1).

RESULTS

In group A, thrombomodulin and VWF increased at time point 1 compared to time point 0 (P = 0.011, P = 0.028, respectively). In group B, protein C and ADAMTS-13 significantly decreased (P = 0.023, P = 0.026, respectively), while VWF, VWF/ADAMTS-13 ratio, and the thrombomodulin/protein C ratio increased (P = 0.02, P = 0.002, P = 0.01, respectively). Protein C (> or ≤17%) and ADAMTS-13 percentage difference (> or ≤22%) were independently associated with sepsis outcome among the endothelial variables tested.

CONCLUSIONS

An ongoing endothelial/hemostatic disorder was established during sepsis, observed even at clinical improvement. Among the variables tested, protein C and ADAMTS-13 change were associated with outcome.

Muscle microcirculation alterations and relation to dipping status in newly diagnosed untreated patients with arterial hypertension-A pilot study

OBJECTIVE

The importance of abnormalities observed in the microcirculation of patients with arterial hypertension (AH) is being increasingly recognized. The authors aimed to evaluate skeletal muscle microcirculation in untreated, newly diagnosed hypertensive patients with NIRS, a noninvasive method that evaluates microcirculation.

METHODS

We evaluated 34 subjects, 17 patients with AH (13 males, 49±13 years, BMI: 26±2 kg/m² ) and 17 healthy controls (12 males, 49±15 years, BMI: 25±3 kg/m² ). The thenar muscle StO₂ (%) was measured by NIRS before, during and after 3-minutes vascular occlusion to calculate OCR (%/min), EF (%/min), and RHT (minute). The dipping status of hypertensive patients was assessed.

RESULTS

The RHT differed between AH patients and healthy subjects (2.6±0.3 vs 2.1±0.3 minutes, P<.001). Dippers had higher EF than nondippers (939±280 vs 710±164%/min, P=.05).

CONCLUSIONS

The study suggests an impaired muscle microcirculation in newly diagnosed, untreated AH patients.

Exercise training improves characteristics of exercise oscillatory ventilation in chronic heart failure

Background Exercise oscillatory ventilation in chronic heart failure has been suggested as a factor related to adverse cardiac events, aggravated prognosis and higher mortality. Exercise training is well known to affect exercise capacity and mechanisms of pathophysiology beneficially in chronic heart failure. Little is known, however, about the exercise training effects on characteristics of exercise oscillatory ventilation in chronic heart failure patients. Design and methods Twenty (out of 38) stable chronic heart failure patients exhibited exercise oscillatory ventilation (age 54 ± 11 years, peak oxygen uptake 15.0 ± 5.0 ml/kg per minute). Patients attended 36 sessions of high intensity interval exercise. All patients underwent cardiopulmonary exercise testing before and after the programme. Assessment of exercise oscillatory ventilation was based on the amplitude of cyclic fluctuations in breathing during rest and exercise. All values are mean ± SD. Results Exercise training reduced ( P < 0.05) the percentage of exercise oscillatory ventilation duration (79.0 ± 13.0 to 50.0 ± 25.0%), while average amplitude (5.2 ± 2.0 to 4.9 ± 1.6 L/minute) and length (44.0 ± 10.9 to 41.0 ± 6.7 seconds) did not change ( P > 0.05). Exercise oscillatory ventilation patients also increased exercise capacity ( P < 0.05). Conclusions A rehabilitation programme based on high intensity interval training improved exercise oscillatory ventilation observed in chronic heart failure patients, as well as cardiopulmonary efficiency and functional capacity.

Effects of High-Intensity Interval Exercise Training on Skeletal Myopathy of Chronic Heart Failure

BACKGROUND

It remains controversial which type of exercise elicits optimum adaptations on skeletal myopathy of heart failure (HF). Our aim was to evaluate the effect of high-intensity interval training (HIIT), with or without the addition of strength training, on skeletal muscle of HF patients.

METHODS AND RESULTS

Thirteen male HF patients (age 51 ± 13 years, body mass index 27 ± 4 kg/m²) participated in either an HIIT (AER) or an HIIT combined with strength training (COM) 3-month program. Biopsy samples were obtained from the vastus lateralis. Analyses were performed on muscle fiber type, cross-section area (CSA), capillary density, and mRNA expression of insulin-like growth factor (IGF) 1 isoforms (ie, IGF-1Ea, IGF-1Eb, IGF-1Ec), type-1 receptor (IGF-1R), and binding protein 3 (IGFBP-3). Increased expression of IGF-1Ea, IGF-1Eb, IGF-1Ec, and IGFBP-3 transcripts was found (1.7 ± 0.8, 1.5 ± 0.8, 2.0 ± 1.32.4 ± 1.4 fold changes, respectively; P < .05). Type I fibers increased by 21% (42 ± 10% to 51 ± 7%; P < .001) and capillary/fiber ratio increased by 24% (1.27 ± 0.22 to 1.57 ± 0.41; P = .005) in both groups as a whole. Fibers' mean CSA increased by 10% in total, but the increase in type I fibers' CSA was greater after AER than COM (15% vs 6%; P < .05). The increased CSA correlated with the increased expression of IGF-1Ea and IGF-1Εb.

CONCLUSIONS

HIIT reverses skeletal myopathy of HF patients, with the adaptive responses of the IGF-1 bioregulation system possibly contributing to these effects. AER program seemed to be superior to COM to induce muscle hypertrophy.

Neuromuscular electrical stimulation acutely mobilizes endothelial progenitor cells in critically ill patients with sepsis

BACKGROUND

Endothelial progenitor cells (EPCs) have been suggested to constitute a restoration index of the disturbed endothelium in ICU patients. Neuromuscular electric stimulation (NMES) is increasingly employed in ICU to prevent comorbidities such as ICU-acquired weakness, which is related to endothelial dysfunction. The role of NMES to mobilize EPCs has not been investigated yet. The purpose of this study was to explore the NMES-induced effects on mobilization of EPCs in septic ICU patients.

METHODS

Thirty-two septic mechanically ventilated patients (mean ± SD, age 58 ± 14 years) were randomized to one of the two 30-min NMES protocols of different characteristics: a high-frequency (75 Hz, 6 s on-21 s off) or a medium-frequency (45 Hz, 5 s on-12 s off) protocol both applied at maximally tolerated intensity. Blood was sampled before and immediately after the NMES sessions. Different EPCs subpopulations were quantified by cytometry markers CD34(+)/CD133(+)/CD45(-), CD34(+)/CD133(+)/CD45(-)/VEGFR2 (+) and CD34(+)/CD45(-)/VEGFR2 (+).

RESULTS

Overall, CD34(+)/CD133(+)/CD45(-) EPCs increased from 13.5 ± 10.2 to 20.8 ± 16.9 and CD34(+)/CD133(+)/CD45(-)/VEGFR2 (+) EPCs from 3.8 ± 5.2 to 6.4 ± 8.5 cells/10(6) enucleated cells (mean ± SD, p < 0.05). CD34(+)/CD45(-)/VEGFR2 (+) EPCs also increased from 16.5 ± 14.5 to 23.8 ± 19.2 cells/10(6) enucleated cells (mean ± SD, p < 0.05). EPCs mobilization was not affected by NMES protocol and sepsis severity (p > 0.05), while it was related to corticosteroids administration (p < 0.05).

CONCLUSIONS

NMES acutely mobilized endothelial progenitor cells, measures of the endothelial restoration potential, in septic ICU patients.

Use of Ventilator Bundle and Staff Education to Decrease Ventilator-Associated Pneumonia in Intensive Care Patients

BACKGROUND

Ventilator-associated pneumonia (VAP), one of the most common hospital-acquired infections, has a high mortality rate.

OBJECTIVES

To evaluate the incidence of VAP in a multidisciplinary intensive care unit and to examine the effects of the implementation of ventilator bundles and staff education on its incidence.

METHODS

A 24-month-long before/after study was conducted, divided into baseline, intervention, and postintervention periods. VAP incidence and rate, the microbiological profile, duration of mechanical ventilation, and length of stay in the intensive care unit were recorded and compared between the periods.

RESULTS

Of 1097 patients evaluated, 362 met the inclusion criteria. The baseline VAP rate was 21.6 per 1000 ventilator days. During the postintervention period, it decreased to 11.6 per 1000 ventilator days (P = .01). Length of stay in the intensive care unit decreased from 36 to 27 days (P = .04), and duration of mechanical ventilation decreased from 26 to 21 days (P = .06).

CONCLUSIONS

VAP incidence was high in a general intensive care unit in a Greek hospital. However, implementation of a ventilator bundle and staff education has decreased both VAP incidence and length of stay in the unit.