Benefits of Preserving Residual Urine Output in Patients Undergoing Maintenance Haemodialysis

Introduction

Chronic kidney disease is a widespread medical problem that leads to higher morbidity, mortality, and a decrease in the overall well-being of the general population. This is especially expressed in patients with end-stage renal disease (ESRD) undergoing maintenance haemodialysis. Several variables could be used to evaluate those patients' well-being and mortality risk. One of them is the presence of residual urine output.

Materials and Methods

The study was conducted on 485 patients treated with maintenance haemodialysis. After enrollment in the study, which consisted of medical history, physical examination, hydration assessment, and blood sampling, each patient was followed up for 24 months. We used residual urine output (RUO) as a measure of residual renal function (RRF). The entire cohort was divided into 4 subgroups based on the daily urinary output (<=100mL per day, >100mL to <=500mL, >500mL to <=1000mL and >1000mL).

Results

The data show that the mortality rate was significantly higher in groups with lower RUO, which was caused mainly by cardiovascular events. Also, patients with higher RUO achieved better sodium, potassium, calcium, and phosphate balance. They were also less prone to overhydration and had a better nutritional status. Preserved RRF also had a positive impact on markers of cardiovascular damage, such as NT-proBNP as well as TnT.

Conclusion

In conclusion, preserving residual urine output in ESRD patients undergoing maintenance haemodialysis is invaluable in reducing their morbidity and mortality rates and enhancing other favourable parameters of those patients.

Mechanical power of ventilation and driving pressure: two undervalued parameters for pre extracorporeal membrane oxygenation ventilation and during daily management?

The current ARDS guidelines highly recommend lung protective ventilation which include plateau pressure (P_plat < 30 cm H₂O), positive end expiratory pressure (PEEP > 5 cm H₂O) and tidal volume (V_t of 6 ml/kg) of predicted body weight. In contrast, the ELSO guidelines suggest the evaluation of an indication of veno-venous extracorporeal membrane oxygenation (ECMO) due to hypoxemic or hypercapnic respiratory failure or as bridge to lung transplantation. Finally, these recommendations remain a wide range of scope of interpretation. However, particularly patients with moderate-severe to severe ARDS might benefit from strict adherence to lung protective ventilation strategies. Subsequently, we discuss whether extended physiological ventilation parameter analysis might be relevant for indication of ECMO support and can be implemented during the daily routine evaluation of ARDS patients. Particularly, this viewpoint focus on driving pressure and mechanical power.

Can Overnutrition Lead to Wasting?-The Paradox of Diabetes Mellitus in End-Stage Renal Disease Treated with Maintenance Hemodialysis

Background: The population of end-stage renal disease (ESRD) patients with diabetes mellitus (DM) may be at increased risk of protein energy wasting (PEW). The aim of the study was to investigate the impact of DM on selected indicators of PEW in the ESRD population that was undergoing maintenance hemodialysis (MHD). Methods: A total of 515 MHD patients were divided into two subgroups with and without DM. The evaluation of diet composition, Charlson Comorbidity Index (CCI), SGA, and laboratory and BIS analyses were performed. All-cause and cardiovascular mortality was recorded. Results: DM patients had lower albumin (3.93 (3.61–4.20) vs. 4.10 (3.80–4.30) g/dL, p < 0.01), total cholesterol (158 (133–196) vs. 180 (148–206) mg/dL, p < 0.01), and creatinine (6.34 (5.08–7.33) vs. 7.12 (5.70–8.51) mg/dL, p < 0.05). SGA score (12.0 (10.0–15.0) vs. 11.0 (9.0–13.0) points, p < 0.001), BMI (27.9 (24.4–31.8) vs. 25.6 (22.9–28.8) kg/m², p < 0.001), fat tissue index (15.0 (11.4–19.6) vs. 12.8 (9.6–16.0) %, p < 0.001), and overhydration (2.1 (1.2–4.1) vs. 1.8 (0.7, 2.7) L, p < 0.001) were higher in the DM group. Increased morbidity, reflected in the CCI and mortality—both all-cause and cardiovascular—were observed in DM patients. Conclusions: Hemodialysis recipients with DM experience overnutrition with a paradoxically higher predisposition to PEW, expressed by a higher SGA score and lower serum markers of nutrition. This population is also more comorbid and is at higher risk of death, including from cardiovascular causes.

Risk Factors for Catheter-Related Thrombosis in Multiple Myeloma Patients Undergoing Autologous Stem Cell Transplantation

Background and Objectives: Cancer associated thrombosis (CAT) is a common complication of neoplasms. Multiple myeloma (MM) carries one of the highest risks of CAT, especially in the early phases of treatment. Autologous stem cell transplantation (ASCT) as the standard of care in transplant-eligible patients with MM carries a risk of catheter-related thrombosis (CRT). The aim of this study was identification of the risk factors of CRT in MM patients undergoing ASCT in 2009–2019. Materials and Methods: We retrospectively analyzed patients with MM undergoing ASCT. Each patient had central venous catheter (CVC) insertion before the procedure. The clinical symptoms of CRT (edema, redness, pain in the CVC insertion area) were confirmed with Doppler ultrasound examination. We examined the impacts of four groups of factors on CRT development: (1) patient-related: age, gender, Body Mass Index (BMI), obesity, Charlson comorbidity index, hematopoietic stem cell transplantation comorbidity index, renal insufficiency, and previous thrombotic history; (2) disease-related: monoclonal protein type, stage of the disease according to Salmon–Durie and International Staging System, number of prior therapy lines, and MM response before ASCT; (3) treatment-related: melphalan dose, transplant-related complications, and duration of post-ASCT neutropenia; (4) CVC-related: location, time from placement to removal. Results: Symptomatic CRT was present in 2.5% (7/276) of patients. Univariate analysis showed an increased risk of CRT in patients with a catheter-related infection (OR 2.4, 95% CI; 1.109–5.19, p = 0.026), previous thrombotic episode (OR 2.49, 95% CI; 1.15–5.39, p = 0.021), previous thrombotic episode on initial myeloma treatment (OR 2.75, 95% CI; 1.15–6.53, p = 0.022), and gastrointestinal complications of ASCT such as vomiting and diarrhea (OR 3.87, 95% CI; 1.57–9.53, p = 0.003). In multivariate analysis, noninfectious complications were associated with higher CRT incidence (OR 2.75, 95% CI; 1.10–6.19, p = 0.031). Conclusions: The incidence of symptomatic CRT in ASCT in MM was relatively low. Previous thrombotic events, especially during the induction of myeloma treatment, increased CRT risk during ASCT. Dehydration following gastrointestinal complications may predispose to higher CRT incidence.

Overhydration as a modifiable cardio-vascular risk factor in patients undergoing hemodialysis

Introduction  Cardio-vascular mortality in end-stage renal disease patients remains high despite advancement in dialysis techniques. This can be attributed to a number of traditional and non-traditional risk factors. Overhydration seems to be one of the promising non-traditional cardio-vascular risk factors to target in order to improve the survival. Objectives     The aim of this study was to assess the influence of chronic overhydration and its dynamic changes on cardio-vascular and all-cause morbidity and mortality in the group of hemodialyzed patients. Patients and methods          The study has been conducted on a total number of 511 patients. Hydration was assessed with whole-body bioimpedance spectroscopy. The entire cohort has been divided into 4 subgroups according to initial hydration value. Additionally, patients with at least 2 observation visits (n = 277) have been assigned to 4 subgroups created with respect to hydration change-over-time. Results           Statistical analysis showed that male gender (P <0.001), diabetes (P <0.001), heart insufficiency (P < 0.001), smoking (P = 0.049) and cerebrovascular incidents (P = 0.007) were significant risk factors for overhydration. Cardiovascular toxicity of overhydration was reflected with elevated levels of NT-proBNP (P <0.001) and cTnT (P <0.001). Albumin and total cholesterol values were the lowest in highly overhydrated subgroups (P <0.001) showing the prevalence of malnutrition. Mortality rate was significantly lower in groups of normal hydration and mild overhydration (P <0.001), as well as of patients with stable low or descending overhydration levels (P = 0.002). Conclusion    We can state that the degree of overhydration of hemodialyzed patients is significantly associated with the incidence of cardiovascular complications and affects the prognosis in end-stage renal disease.

Is Preptin a New Bone Metabolism Parameter in Hemodialysis Patients?

BACKGROUND

Preptin is a bone-anabolic pancreatic peptide hormone. Its role in bone metabolism has been studied in rats and in patients with diabetes, but its levels and significance in bone metabolism in hemodialyzed (HD) patients is unknown.

METHODS

The relationships between preptin and anthropometric and biochemical parameters related to bone metabolism were studied in 73 patients on chronic hemodialysis (48 males, 25 females; mean age of 57 years; HD vintage of 69.7 months). Of these subjects, 36 patients had diabetes or impaired glucose tolerance (DM/IGT), and 37 patients had normal glucose tolerance (NGT). Dual-energy X-ray absorptiometry of the femoral neck and lumbar spine were also performed.

RESULTS

No differences were observed in preptin levels between DM/IGT and NGT HD patients. Preptin was positively correlated with HD vintage (r = 0.312, p = 0.007). Negative correlations between preptin and bone mineral density (BMD), T-score, and Z-score in the lumbar spine (L2-L4) were observed (r = -0.319, p = 0.009; r = -0.341, p = 0.005; r = -0.375, p = 0.002). Preptin was positively correlated with parathormone (PTH) levels (r = 0.379, p < 0.001) and osteocalcin levels (r = 0.262, p = 0.027).

CONCLUSIONS

The results indicate that preptin may reflect on bone and mineral metabolism disturbances seen in HD patients. The significant correlation of preptin with PTH and osteocalcin suggests that preptin may be important in indirect measurement of bone turnover in HD patients.

Adropin and irisin: New biomarkers of cardiac status in patients with end-stage renal disease? A preliminary study

BACKGROUND

The new polypeptide hormones adropin and irisin have a broad impact on human metabolism and energy homeostasis. They could be potential biomarkers of cardiac injury. In end-stage renal disease (ESRD), the clinical importance of adropin and irisin is yet to be investigated.

OBJECTIVES

The aim of this study was to determine the relationship between these peptides and cardiac status in ESRD patients.

MATERIAL AND METHODS

Seventy-nine ESRD patients on hemodialysis (HD), peritoneal dialysis (PD) or after renal transplantation (Tx), and 40 healthy, ageand sex-matched controls (CON) were included in this study. Serum concentrations of adropin and irisin were measured with enzyme-linked immunosorbent assay (ELISA). Cardiac status was estimated by transthoracic echocardiography and the plasma concentration of N-terminal pro-brain natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT).

RESULTS

The levels of irisin were significantly lower in HD patients as compared to CON. During HD sessions, the concentrations of adropin did not change significantly, whereas the concentrations of irisin increased with borderline significance. Positive correlations were evident between adropin concentration and cTnT as well as NT-proBNP. Adropin was also correlated with left ventricular systolic internal diameter (LVIDs) (r = 0.375, p = 0.045) and relative wall thickness (RWT) (r = -0.382, p = 0.034). Irisin was correlated with right ventricular diameter (RVd) (r = -0.363, p = 0.045). No correlations were found between irisin and adropin, and blood pressure (BP) measurements.

CONCLUSIONS

Adropin could be a new candidate marker of cardiac dysfunction in HD patients. The cause of low levels of irisin found in HD patients is still unclear. These 2 myokines should be further investigated as potential prognostic markers of cardiac status in HD patients.

L-2-oxothiazolidine-4-carboxylic acids slow down dialysate-induced senescence in human peritoneal mesothelial cells

Peritoneal dialysis induces an intraperitoneal inflammatory reaction, which in the long term may cause deterioration of the peritoneal structure and function as the dialysis membrane. We studied the effect of the overnight effluent dialysate from patients on chronic peritoneal dialysis on aging of the human peritoneal mesothelial cells in an in vitro model of replicative cellular senescence. In the control group cells were cultured in the standard medium and in the studied groups in culture medium mixed 1:1 v/v with the dialysate ± L-2-oxothiazolodine-4-carboxylic acid 1 mmol/L (OTZ). OTZ was used as the precursor for the synthesis of glutathione in these cells. Dialysate accelerated senescence of the mesothelial cells as reflected by elongation of their population doubling time, reduced expression of KI-67 gene, and increased β-galactosidase activity. Also, expression of the genes regulating the production of the inflammatory mediators (interleukin-6, monocyte chemoattractant protein-1, metalloproteinase-2, hyaluronan), proangiogenic (VEGF) and profibrotic (fibronectin) factors was increased in that group. At the same time, these cells secreted more inflammatory mediators. Simultaneous treatment of the cells with the dialysate and OTZ slowed down their senescence, whose intensity was similar to that in the control group. The results presented in this manuscript prove that the intraperitoneal inflammatory reaction induced by repeated infusions of the dialysis fluid accelerates the senescence of the mesothelial cells, which may result in fibrosis and neoangiogenesis within the peritoneum. Simultaneous supplementation of the cells with a glutathione precursor (OTZ) may prevent the development of these pathological changes.

Dialysis vintage stratified comparison of body composition, hydration and nutritional state in peritoneal dialysis and hemodialysis patients

INTRODUCTION

Body mass decomposition and hydration state imbalances affect patients on maintenance dialysis. We compared body composition, hydration and nutritional state of patients on peritoneal dialysis (PD) and hemodialysis (HD) based on dialysis vintage (DV).

MATERIAL AND METHODS

Three hundred and fifty-nine prevalent patients on HD (n = 301) and PD (n = 58) were divided into 3 subgroups depending on DV: < 2 years HD (n = 41) and PD (n = 28), 2-4 years HD (n = 111) and PD (n = 17), > 4 years HD (n = 149) and PD (n = 13). Bioimpedance analysis delivered data including overhydration (OH), Lean (LTM) and adipose lipids mass (FAT). Other measurements included daily diuresis (DD), subjective global assessment (SGA) and serum albumin (alb), C-reactive protein (CRP) and total cholesterol (TChol), and hemoglobin (Hb).

RESULTS

Dialysis vintage < 2 years. Hemodialysis patients were older (65.5 ±18.5 vs. 50.9 ±17.1; p < 0.01) with a higher mortality (28 vs. 1; p < 0.01) and OH (8.0 ±4.3 vs. 1.6 ±3.1; p < 0.001). Hemoglobin (10.6 ±1.5 vs. 11.8 ±1.7; p < 0.05), TChol (180.2 ±47.0 vs. 211.7 ±46.3; p < 0.05), DD (871 ±729 vs. 1695 ±960; p < 0.001) and LTM (46.5 ±12.9 vs. 53.8 ±14.4; p < 0.05) were lower on HD. Dialysis vintage 2-4 years: when compared to PD, HD patients had higher OH (11.7 ±5.9 vs. 2.1 ±3.2; p < 0.001) and lower Hb (10.8 ±1.5 vs. 11.9 ±1.4; p < 0.01). Dialysis vintage > 4 years: compared to PD, HD patients had higher LTM (44.3 ±11.7 vs. 38.6 ±7.9; p < 0.05) and lower FAT (34.4 ±11.1 vs. 42.8 ±6.4; p < 0.01).

CONCLUSIONS

Dialysis patients' body composition depends on dialysis modality and DV. Dialysis vintage < 2 years is associated with better hydration, nutritional state, and survival in PD patients, but longer DV reduces these benefits. Dialysis vintage > 4 years associated with similar hydration and mortality in both PD and HD while body composition was better on HD.

Dialysis vintage and cardiovascular injury as factors influencing long-term survival in peritoneal dialysis and hemodialysis

BACKGROUND

Cardiovascular (CV) incidents are the major cause of mortality in maintenance dialysis (MD) patients undergoing peritoneal dialysis (PD) or hemodialysis (HD). CV injury indicators may be useful to investigate the dialysis modality influence on survival.

OBJECTIVES

The aim of this study was to compare selected laboratory and echocardiographic (ECHO) markers of CV injury in terms of dialysis vintage (DV), CV-related mortality and all-cause mortality.

MATERIAL AND METHODS

The study involved 301 patients on HD (n = 301) and PD (n = 58), who were divided into subgroups according to DV. The subjects' medical histories included diabetes mellitus (DM), myocardial infarction (MI), stroke, CV deaths and deaths from non-CV causes. Their CV parameters were measured with ECHO for the left ventricle ejection fraction (EF), posterior wall (LVW) and interventricular septum (IVS). Serum analyses of cardiac troponin T (TnT) and N-terminal pro-brain natriuretic peptide (BNP) were also carried out.

RESULTS

In the subgroup with a DV of 4 years, the PD and HD patients were of a similar age, and had similar mortality and morbidity rates and CV markers, except for thicker IVS in the HD patients.

CONCLUSIONS

Focusing on the data analysis based on mortality, and both laboratory and echocardiographic markers of cardiovascular injury, PD seems to be a more favorable method of dialysis. The advantage of PD was noted in subjects with a DV < 2 years. HD showed no outcome benefit over PD in longer DV.

Adropin and irisin levels in relation to nutrition, body composition, and insulin resistance in patients with end-stage renal disease on chronic hemodialysis and peritoneal dialysis

INTRODUCTION    Newly discovered myokines, adropin, and irisin, are regulators of energy homeostasis and metabolism in humans. In end-stage renal disease (ESRD), the significance and role of irisin and adropin as metabolism regulators are still unclear. OBJECTIVES    The aim of this study was to evaluate serum adropin and irisin levels and establish their relation to insulin resistance, nutritional status, and hydration status in patients on chronic hemodialysis (HD) and on peritoneal dialysis (PD). PATIENTS AND METHODS    The study consisted of 71 subjects, including 48 patients (18 women, 30 men; median age, 56.5 years; range, 26-84 years) either on HD (n = 41) or PD (n = 7) and 36 healthy controls matched for age and sex. We measured the serum levels of adropin, irisin, creatinine, albumin, glucose, and insulin, as well as the plasma levels of lipids. The bioimpedance method was used to evaluate the body composition and overhydration in patients with ESRD. RESULTS    Irisin levels were significantly lower in patients with ESRD compared with controls, but there were no differences in adropin levels between both study groups. Adropin levels were inversely correlated with body mass, lean tissue mass, total, intracellular, and extracellular water, and albumin concentrations in patients with ESRD. Irisin levels were positively correlated with glucose levels and homeostasis model assessment of insulin resistance. No significant correlations were observed between adropin and irisin concentrations and overhydration. CONCLUSIONS    Adropin may be considered as a new marker of nutritional status in patients with ESRD. The significance and cause of low irisin levels characteristic for these patients are still unclear. Adropin and irisin should be further investigated as possible markers of cachexia and insulin resistance in patients with ESRD.

Effective PEGylation of gold nanorods

Standard procedures to coat gold nanorods (AuNR) with poly(ethylene glycol) (PEG)-based ligands are not reliable and high PEG-grafting densities are not achieved. In this work, the ligand exchange of AuNR with PEGMUA, a tailored PEG-ligand bearing a C10 alkylene spacer, is studied. PEGMUA provides AuNR with very high stability against oxidative etching with cyanide. This etching reaction is utilized to study the ligand exchange in detail. Ligand exchange is faster, less ligand consuming and more reproducible with assisting chloroform extraction. Compared to PEG ligands commonly used, PEGMUA provides much higher colloidal and chemical stability. Further analyses based on NMR-, IR- and UV/Vis-spectroscopy reveal that significantly higher PEG-grafting densities, up to ∼3 nm(-2), are obtained with PEGMUA. This demonstrates how the molecular structure of the PEG ligand can be used to dramatically improve the ligand exchange and to synthesize PEGylated AuNR with high chemical and colloidal stability and high PEG grafting densities. Such AuNR are especially interesting for applications in nanomedicine.

Cardiac Troponin T and Hydration Status as Prognostic Markers in Hemodialysis Patients

This study aimed to assess cardiac troponin T (cTnT) and hydration state as cardiovascular (CV) risk markers in hemodialysis (HD) patients. Two hundred and forty one patients were divided according to HD vintage into two groups: SV (HD ≤24 months) and LV. Water balance was assessed with overhydration (OH%; bioimpedance analysis) and daily diuresis (DD); CV dysfunction with cTnT and heart ultrasound; nutrition with subjective global assessment (SGA), cholesterol (TC) and albumin. SV had lower OH% (2.8 vs. 3.5, p < 0.05) and higher DD (1,161 vs. 637 ml, p < 0.001), while LV had higher cTnT (0.1 ± 0.04 vs. 0.1 ± 0.07 ng/ml, p < 0.05) and lower interventricular septum thickness (IVS; 13.4 vs. 14.5 mm, p < 0.05). Nutritional state as reflected by lower TC was worse in LV (184.7 vs. 169.5 mg/dl, p < 0.05). Mortality was higher in patients in the LV group (15 vs. 27 deaths, p < 0.05). OH% correlated inversely with albumin (r = -0.36, p < 0.001), TC (r = -0.31, p < 0.001) and cTnT (r = -0.4, p < 0.001). cTnT correlated positively with IVS (r = 0.39, p < 0.001), SGA (r = 0.23, p = 0.001) and mortality rate (r = 0.21, p < 0.01), and negatively with DD (r = -0.34, p < 0.001) and albumin (r = -0.25, p < 0.001). Longer dialysis vintage associates with CV dysfunction, overhydration and increased mortality, which may be predicted with OH% and cTnT. Video Journal Club ‘Cappuccino with Claudio Ronco' at http://www.karger.com/?doi=376603.

N‑terminal pro‑B-type natriuretic peptide as a marker of hypervolemia and predictor of increased mortality in patients on hemodialysis

INTRODUCTION

N‑terminal pro‑B‑type natriuretic peptide (NT‑proBNP) is an established biomarker of heart failure in the general population. However, its diagnostic value is unclear in hemodialysis (HD) patients owing to renal insufficiency.

OBJECTIVES

The aim of the study was to establish the usefulness of NT‑proBNP for hydration assessment and the relation of NT‑proBNP to the nutritional state and prognosis of survival.

PATIENTS AND METHODS

In 321 HD patients (206 men; mean age, 65.1 ±21.4 years), we assessed NT‑proBNP levels, overhydration (OHBIA), and the indices of the nutritional state (using a bioimpedance analysis [BIA]) in relation to cardiac troponin T (cTnT), hemoglobin, albumin, total cholesterol (TC), and C‑reactive protein (CRP) levels. The efficacy of HD was assessed using Kt/V, weekly HD dose, and HD session ultrafiltration. The cohort was divided into NT‑proBNP quartiles. Patients with 2 NT‑proBNP measurements were categorized also into change‑over‑time subgroups. A follow‑up lasted for a median period of 23.8 ±26.3 months.

RESULTS

Relative OHBIA increased across the NT‑proBNP quartiles (Q1/Q2/Q3/Q4, 1.31% ±2.56%/2.06% ±2.35%/2.92% ±2.97%/4.62% ±4.22%; P <0.0001). NT‑proBNP was also closely associated with other OH parameters. In addition, there was a significant correlation between NT‑proBNP and cTnT (r = 0.55; P <0.0001). Body mass index (BMI) and fat tissue index (FTI) decreased across the quartiles (BMI, 28.5 ±7.7/26.0 ±6.6/25.8 ±5.4/23.7 ±5.5 kg/m2; FTI, 14.4 ±9.0/14.1 ±7.3/12.3 ±6.8/11.6 ±6.1; P <0.001). The highest albumin level was present in Q1 (4.10 ±0.63/3.99 ±0.51/3.90 ±0.62/3.97 ±0.78 g/dl; P = 0.006). The TC level was the lowest in Q4 (190 ±60/169 ±56/173 ±51/153 ±56 mg/dl; P = 0.002). The hemoglobin level decreased across the quartiles (11.44 ±1.25/11.15 ±2.50/10.79 ±1.51/10.45 ±1.67 g/dl; P = 0.0006). The differences in CRP levels and HD‑related parameters were nonsignificant. During the follow‑up, 97 deaths were recorded (11/26/21/39, P <0.0001).

CONCLUSIONS

NT‑proBNP seems to be a useful biomarker of hypervolemia in HD patients. Nevertheless, it has to be interpreted with regard to the patient's individual residual renal function and cardiovascular status.

Clinical relevance of fascial tissue and dysfunctions

Fascia is composed of collagenous connective tissue surrounding and interpenetrating skeletal muscle, joints, organs, nerves, and vascular beds. Fascial tissue forms a whole-body, continuous three-dimensional viscoelastic matrix of structural support. The classical concept of its mere passive role in force transmission has recently been disproven. Fascial tissue contains contractile elements enabling a modulating role in force generation and also mechanosensory fine-tuning. This hypothesis is supported by in vitro studies demonstrating an autonomous contraction of human lumbar fascia and a pharmacological induction of temporary contraction in rat fascial tissue. The ability of spontaneous regulation of fascial stiffness over a time period ranging from minutes to hours contributes more actively to musculoskeletal dynamics. Imbalance of this regulatory mechanism results in increased or decreased myofascial tonus, or diminished neuromuscular coordination, which are key contributors to the pathomechanisms of several musculoskeletal pathologies and pain syndromes. Here, we summarize anatomical and biomechanical properties of fascial tissue with a special focus on fascial dysfunctions and resulting clinical manifestations. Finally, we discuss current and future potential treatment options that can influence clinical manifestations of pain syndromes associated with fascial tissues.

Percolation on fitness-dependent networks with heterogeneous resilience

The ability to understand the impact of adversarial processes on networks is crucial to various disciplines. The objects of study in this article are fitness-driven networks. Fitness-dependent networks are fully described by a probability distribution of fitness and an attachment kernel. Every node in the network is endowed with a fitness value and the attachment kernel translates the fitness of two nodes into the probability that these two nodes share an edge. This concept is also known as mutual attractiveness. In the present article, fitness does not only serve as a measure of attractiveness, but also as a measure of a node's robustness against failure. The probability that a node fails increases with the number of failures in its direct neighborhood and decreases with higher fitness. Both static and dynamic network models are considered. Analytical results for the percolation threshold and the occupied fraction are derived. One of the results is that the distinction between the dynamic and the static model has a profound impact on the way failures spread over the network. Additionally, we find that the introduction of mutual attractiveness stabilizes the network compared to a pure random attachment.