ICU-acquired weakness: Critical illness myopathy and polyneuropathy

Critical illness myopathy (CIM) and critical illness polyneuropathy (CIP) are significant complications in intensive care unit (ICU) patients, first identified in the late 20th century. These conditions often present as flaccid paralysis and respiratory muscle weakness, making it challenging for patients to wean off ventilatory support. The incidence of ICU-acquired weakness, which includes CIM and CIP, ranges from 25 % to 84 % among long-term ventilated patients, with higher rates observed in those with sepsis or systemic inflammatory response syndrome. CIM is characterized by muscle wasting and can be confirmed using electromyography and muscle biopsy. The pathogenesis of CIM involves the loss of thick myosin filaments, while the proposed etiology of CIP centers around increased permeability of nerve axons, leading to axonal degeneration. Risk factors for developing these conditions include prolonged ICU length of stay, sepsis, multi-system organ dysfunction, hyperglycemia, as well as exposure to steroids and neuromuscular blocking agents. Emerging diagnostic tools including muscle ultrasound, magnetic resonance imaging (MRI), and biomarkers such as interleukin-6 (IL-6) and growth differentiation factor-15 (GDF-15) show promise in early detection and differentiation of CIM and CIP. Preventative and therapeutic treatment focuses on early mobilization, minimizing sedation, optimizing nutritional support, and use of intensive insulin therapy to prevent prolonged hyperglycemia. Despite these advancements, CIM and CIP continue to pose significant challenges, emphasizing the need for ongoing research to improve patient outcomes and develop effective treatments.

Potential role of large language models and personalized medicine to innovate cardiac rehabilitation

Cardiac rehabilitation is a crucial multidisciplinary approach to improve patient outcomes. There is a growing body of evidence that suggests that these programs contribute towards reducing cardiovascular mortality and recurrence. Despite this, cardiac rehabilitation is underutilized and adherence to these programs has been a demonstrated barrier in achieving these outcomes. As a result, there is a growing focus on innovating these programs, especially from the standpoint of digital health and personalized medicine. This editorial discusses the possible roles of large language models, such as their role in ChatGPT, in further personalizing cardiac rehabilitation programs through simplifying medical jargon and employing motivational interviewing techniques, thus boosting patient engagement and adherence. However, these possibilities must be further investigated in the clinical literature. Likewise, the integration of large language models in cardiac rehabilitation will be challenging in its nascent stages to ensure accurate and ethical information delivery.

Anti-nuclear cytoplasmic antibody-associated vasculitis and kidney cancer: A mini review

This mini review explores the links between anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) and kidney cancer. Several studies suggest an increased incidence of cancer for patients with AAV. Different cancer types have shown different standardized incidence ratios (SIRs) in association with AAV. The SIRs of kidney cancer were found to be between 1.7 and 3.3 as per three retrospective data analyses. This association is likely multifactorial, with increased de novo cancer risks associated with inflammatory diseases; carcinogenic therapies such as cyclophosphamide; and reduced immune surveillance of neoplastic cells in immunocompromised individuals. Some studies have proposed that cancers, including kidney cancer, could be a potential trigger for AAV. Due to variability in SIRs and a lack of multicenter studies looking specifically into the incidence of kidney cancer at AAV diagnosis and on follow-up post initiation of AAV treatment, there remains a lack of evidence to support formal screening for kidney cancer in the AAV patient cohort. Greater awareness on the increased risk of cancer in AAV patients, prompt urological assessment of “red flag” symptoms of kidney cancer, and smoking cessation advice to reduce cancer risk should be standard of care for patients with AAV.

Prospective ultrasonographic evaluation of femoral and vastus intermedius muscles as predictors of ICU-acquired weakness in critically ill patients

PURPOSE

Intensive care unit-acquired weakness (ICU-AW) is associated with poor functional outcomes and increased healthcare costs. This study aimed to evaluate the diagnostic performance of muscular ultrasound (MUS) measurements in predicting ICU-AW and identify potential predictors.

METHODS

Forty-three surgical and medical ICU patients underwent serial MUS measurements of the femoral cross-sectional area (Fcsa) and femoral + vastus intermedius thickness (F + VIth) on days 1, 3 and 5 post-ICU admission. Patients were categorized as having ICU-AW (Medical Research Council (MRC) sum score < 48 at discharge) or not. Univariate and multivariate logistic regression analyses were performed to identify predictors of ICU-AW. The diagnostic performance of MUS measurements was assessed via receiver operating characteristic (ROC) curves. Clinical outcomes (ICU length of stay, ventilator days, extubation failure) were compared between the groups.

RESULTS

Patients with ICU-AW (n = 12, 28%) showed a significant reduction in the Fcsa from Day 1 to Day 5 (p < 0.001). Univariate analysis revealed significant associations between ICU-AW and the Apache II score (OR 1.12, p = 0.03), SOFA score (OR 1.32, p = 0.008), and Day 1 F + VIth score (OR 0.23, p = 0.05). Multivariate analysis confirmed a significant association with the SOFA score (OR 1.35, p = 0.04) and a trend toward an F + VIth score of Day 1 (OR 0.12, p = 0.09). The day 1 Fcsa and F + VIth demonstrated moderate predictive capabilities for ICU-AW (ROC-AUC values of 0.72 and 0.82, respectively). ICU-AW patients experienced longer ICU stays, more ventilator days, and higher extubation failure rates.

CONCLUSION

Preexisting low muscle mass, combined with a high SOFA score, may be a stronger predictor of ICU-acquired weakness than the degree of subsequent muscle loss.

Potential diagnostic tools for intensive care unit acquired weakness: A systematic review

Background

Intensive care unit-acquired weakness is a prevalent complication among critically ill patients, associated with heightened mortality rates, extended durations of mechanical ventilation and hospital stays, as well as diminished mobility and unfavorable prognoses. Early diagnosis of intensive care unit-acquired weakness and identification of its subcategories are essential for early implementation of targeted interventions and care strategies. Nevertheless, there remains a significant gap in the availability of widely accepted, accurate, and user-friendly diagnostic tools for intensive care unit-acquired weakness.

Objective

The aim of this research was to conduct a comprehensive review of pertinent studies on diagnostic tools for intensive care unit-acquired weakness in critically ill patients, summarizing their diagnostic efficacy and constraints to aid healthcare professionals in choosing suitable diagnostic tools for intensive care unit-acquired weakness.

Methods

The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement were utilized to direct the literature search, bias risk assessment and data extraction. The search databases included PubMed, Web of Science, EMBASE, Cochrane Library, and CINAHL. The search period was from the inception of the database to 1 July 2024. Different types of risk bias assessment tools were used for different types of studies. Due to the heterogeneity of the data, solely a narrative synthesis of the intensive care unit-acquired weakness diagnostic tool was performed in this study.

Results

A total of 38 observational studies were included in the study. In the included studies, the gold standard for intensive care unit-acquired weakness diagnosis include the Medical Research Council score, muscle biopsy and electrophysiologic testing, potential diagnostic tools include the manual muscle test, electrophysiologic testing, imaging, serum inflammatory markers, neuromuscular ultrasound, and other parameters. In various studies, the diagnostic accuracy of intensive care unit-acquired weakness diagnostic tools has been inconsistent, with each tool possessing its own set of advantages and disadvantages. At present, no single tool is available for the definitive diagnosis of intensive care unit-acquired weakness, necessitating the combined use of multiple methods, each with inherent limitations. Manual muscle test is inexpensive and straightforward to perform, but it requires the patient to be conscious and cooperative. Muscle biopsy is invasive and rarely utilized. Electrophysiological testing can help differentiate whether intensive care unit-acquired weakness is caused by neural or muscular alterations, thereby aiding in the classification of its subtypes. However, it is moderately invasive, costly, and operator-dependent. Other diagnostic modalities, such as imaging and respiratory parameters, are under ongoing investigation.

Conclusions

The diagnostic tools available in intensive care unit-acquired weakness are varied, each with its own strengths and limitations. This study summarizes the current evidence on potential diagnostic tools for intensive care unit-acquired weakness and identifies possible future directions for these diagnostic tools.

Registration

PROSPERO Registration Number CRD42024573139.

Risk factors for acquired weakness in intensive care unit patients: An umbrella review

OBJECTIVE

This umbrella review aims to summarize and synthesize the evidence on risk factors related to intensive care unit-acquired weakness in systematic reviews to create prevention strategies and intervention measures for intensive care unit-acquired weakness.

METHODOLOGY

Eight databases were searched systematically from inception to 1st November 2023. Two researchers independently screened and extracted data based on predefined inclusion and exclusion criteria. The methodological quality, risk of bias and certainty of evidence of reviews included were evaluated using version 2 of the Measurement Tool for Evaluation System Review (AMSTAR-2) and the Risk of Bias in Systematic Reviews (ROBIS), and the Grading of Recommendations Assessment, Development and Evaluation(GRADE) respectively.

RESULTS

This review included 10 systematic reviews, reporting a total of 42 factors and 22 associations with meta-analysis. Overall, among these associations, the methodological and evidence quality of the majority ofstudies was rated as low or extremely low. Most systematic reviews and/or meta-analyses exhibited a high risk of bias.

CONCLUSION

This umbrella review comprehensively summarized the risk factors related to intensive care unit-acquired weakness and evaluated the methodological quality, risk of bias, and evidence quality of reviews included. Future studies with high-quality research such as cohort studies are needed, to better update and synthesize the risk factors of intensive care unit-acquired weakness.

IMPLICATIONS FOR CLINICAL PRACTICE

Inconsistent or even contradictory findings exist among multiple systematic reviews regarding intensive care unit-acquired weakness. The present study offers a comprehensive and readily comprehensible overview of the risk factors linked to intensive care unit-acquired weakness, which is conducive to develop assessment tools for the condition and identify intervention targets.

The influence of the Big Five inventory on quality of life in people with Parkinson's disease aged 50 and above: A Longitudinal Analysis from the Survey of Health, Aging and Retirement in Europe (SHARE)

BACKGROUND

Parkinson's disease (PD) significantly reduces quality of life (QoL), particularly due to its complex interplay of motor and nonmotor symptoms. While personality traits influence QoL in chronic diseases, their longitudinal effects in people with PD (PwPD) remain underexplored. This study evaluates the longitudinal predictive influence of neuroticism, conscientiousness, and openness on QoL in PwPD over two waves of the Survey of Health, Aging, and Retirement in Europe (SHARE).

METHODS

This study utilized longitudinal data from 100 PwPD participants in waves 7 and 8 of the Survey of Health, Aging, and Retirement in Europe (SHARE). QoL was assessed using the CASP-12 scale, while personality traits were measured with the Big Five Inventory (BFI-10). Linear regressions and generalized estimating equations (GEE) were used to examine cross-sectional and longitudinal associations between personality traits and QoL, controlling for sociodemographic, psychosocial, and health-related variables.

RESULTS

Neuroticism was consistently associated with lower QoL across all analyses. Cross-sectional results showed neuroticism as the strongest predictor of QoL decline in wave 7 (beta = -0.33, p < 0.001), and longitudinal GEE analyses confirmed its predictive effect (beta = -0.03, p = 0.007). Conscientiousness and openness showed limited and inconsistent associations with QoL. Beyond personality traits, depressive symptoms and mobility limitations were found to substantially impact QoL, influencing the effects of neuroticism.

CONCLUSIONS

Neuroticism plays a pivotal role in predicting QoL decline in PwPD, highlighting its utility as a target for psychological interventions aimed at emotional regulation and resilience building. While depressive symptoms and mobility limitations also contribute, integrating personality assessments into care strategies may improve outcomes. These findings advocate for a multidimensional approach to managing PD that addresses both clinical and psychological factors.

Methylprednisolone for Infant Heart Surgery: Subpopulation Analyses of a Randomized Controlled Trial

OBJECTIVES

Evaluate benefits and harms of prophylactic intraoperative methylprednisolone in subpopulations undergoing infant heart surgery.

DESIGN

Subpopulation analyses of The Steroids to Reduce Systemic Inflammation after Infant Heart Surgery (STRESS) trial, a double-blind randomized placebo-controlled trial.

SETTING

Twenty-four congenital heart centers.

PATIENTS

Infants (< 1 yr old) undergoing heart surgery with cardiopulmonary bypass. Patients stratified by Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery (STAT) mortality category, age, gestational age, and presence of chromosomal or syndromic diagnosis (CSD).

INTERVENTIONS

Methylprednisolone (30 mg/kg) vs. placebo administered into cardiopulmonary bypass pump-priming fluid.

MEASUREMENTS AND MAIN RESULTS

Six postoperative outcomes: steroid use, acute kidney injury (AKI), thrombosis, infections, prolonged mechanical ventilation, peak blood glucose levels, and insulin exposure. One thousand two hundred patients received methylprednisolone or placebo. Beneficial effects associated with methylprednisolone included reduced use of postoperative hydrocortisone in neonates (odds ratio [OR], 0.39 [0.25-0.60]), both STAT category groups (1-3: OR, 0.64 [0.46-0.89]; 4-5: OR, 0.57 [0.34-0.97]), term infants (OR, 0.63 [0.47-0.83]), and those without CSD (OR, 0.63 [0.46-0.86]). Methylprednisolone was associated with lower thrombosis occurrence among neonates (OR, 0.37 [0.16-0.87]) and term infants (OR, 0.38 [0.19-0.75]). Adverse associations included increased thrombosis among premature infants (p = 0.005), increased AKI among neonates (OR, 1.55 [1.02-2.37]) and those following STAT category 1-3 operations (OR, 1.34 [1.02-1.75]), and increased peak blood glucose levels and insulin exposure (all subgroups; p < 0.001). No increase in overall infection or reduction in prolonged mechanical ventilation with methylprednisolone.

CONCLUSIONS

Both beneficial and adverse associations were observed with prophylactic methylprednisolone. Reduction in postoperative hydrocortisone administration and absence of increased infection rates are arguments favoring prophylactic methylprednisolone use. Methylprednisolone was associated with increased peak blood glucose levels and a neutral to harmful association with odds of AKI. These data suggest certain subpopulations may benefit from prophylactic intraoperative methylprednisolone without significant harm.

Role of Heart Rate Recovery in Chronic Heart Failure: Results From the MyoVasc Study

BACKGROUND

Cardiac autonomic dysfunction is associated with heart failure (HF). Reduced heart rate recovery (HRR) indicates impaired parasympathetic reactivation after physical activity. Heart rate recovery 60 seconds after peak effort (HRR60) is linked to autonomic dysfunction, but data on its relevance across HF phenotypes are scarce. This study aimed to identify clinical determinants of HRR60 in an HF cohort and assess its relationship with clinical outcomes.

METHODS

Data from the MyoVasc study (NCT04064450; N=3289) were analyzed. Participants underwent standardized clinical phenotyping including cardiopulmonary exercise testing. HRR60 was defined as the heart rate decline 60 seconds after exercise termination. Clinical determinants of HRR60 were evaluated using multivariate regression, whereas Cox regression analyses assessed all-cause death and worsening of HF.

RESULTS

The analysis sample comprised 1289 individuals (median age, 66.0 [interquartile range {IQR}, 58.0-73.0] years, 30.4% women) ranging from stage B to stage C/D according to the universal definition of HF. Age, sex, smoking, obesity, peripheral artery disease, and chronic kidney disease were identified as determinants of HRR60. HRR60 showed a strong association with all-cause death (hazard ratio [HR]HRR60 [10 bpm], 1.56 [95% CI, 1.32-1.85]; P<0.0001) and worsening of HF (HRHRR60 [10 bpm], 1.36 [95% CI, 1.10-1.69]; P=0.0052) independent of age, sex, and clinical profile. Sensitivity analysis showed a stronger association with worsening HF in HF with preserved left ventricular ejection fraction (Pinteraction=0.027).

CONCLUSIONS

HRR60 was associated with clinical outcome in chronic HF. Because it showed a stronger association with outcomes in HF with preserved ejection fraction, future research should consider phenotype-specific differences.

Effects of tiered cardiac rehabilitation on CRP, TNF-α, and physical endurance in older adults with coronary heart disease

Coronary heart disease (CHD) is a highly prevalent disease in the elderly population, with atherosclerosis as its pathology, which can also be viewed as a chronic inflammatory response of the organism. Regular moderate-intensity exercise can direct the immune response toward an anti-inflammatory state, which is beneficial for improving the health and exercise tolerance. In cardiac rehabilitation, attention to the management of inflammatory factors as well as the improvement of exercise endurance is beneficial for the rehabilitation of elderly patients with coronary artery disease. This study investigates the impact of tiered cardiac rehabilitation programs on levels of C-reactive protein (CRP), tumor necrosis factor-alpha (TNF-α), and the capacity for physical exertion in older CHD patients. From March 2020 to April 2022, 94 elderly patients with CHD visiting our institution were recruited and randomly allocated into either a control group or an observation group, each comprising 47 participants. The standard care group participated in traditional rehabilitation exercises, whereas the experimental group received customized, tiered, cardiac rehabilitation interventions. We assessed the variations in CRP and tumor necrosis factor alpha (TNF-α) levels, along with exercise capacity, before and after treatment in both groups. The result shows that significant reductions in CRP and TNF-α levels were seen in the experimental group after 4 and 12 weeks, compared to the standard care group. Analysis showed clear trends in CRP and TNF-α changes over the interventions, with the experimental group showing better results. CRP levels decreased consistently, while TNF-α levels stayed stable. The experimental group also showed improvements in physical endurance measures compared to the control group. Interleukin 6 (IL-6) and fibrinogen (Fib) in the observation group decreased compared with the control group (P < 0.01). After 12 weeks of treatment, CRP and TNF-α showed significant negative correlation with exercise endurance index - 6 min walking test (6 MWT), anaerobic threshold (AT), maximum oxygen consumption (VO2max), and exercise duration (ED); significant positive correlation between cardiac rehabilitation grade and exercise endurance index (6 MWT, AT, VO2max and ED); and both groups experienced cardiovascular adverse events and exercise muscle injury. The analysis shows that the graded nursing of cardiac rehabilitation can effectively reduce the levels of CRP, TNF-α, IL-6, and Fib in elderly patients with CHD and significantly improve the exercise endurance of patients with good safety.

Arteries and Hearts in Motion: Sex Differences in Exercise-Mediated Protection Against Atherosclerotic Cardiovascular Disease Risk

PURPOSE OF REVIEW

This review summarizes the current knowledge on the benefits of various exercise training modalities on subclinical atherosclerotic cardiovascular disease (ASCVD) risk factors (i.e., endothelial dysfunction, large artery stiffening, carotid artery intima-media thickening) across the adult lifespan and the moderating role of biological sex, with the goal of informing/being to inform research gaps and future research directions.

RECENT FINDINGS

Regular exercise is an effective intervention to counter subclinical risk factors for ASCVD. However, sex-specific variation has been observed in exercise training benefits. For example, aerobic exercise improves large artery stiffening in both middle-aged/older men and women and enhances endothelial function in middle-aged/older men; however, similar exercise-mediated improvements in endothelial function are not consistently observed in postmenopausal women Sex differences in exercise benefits may be related to differences in the sex hormone environment across the adult lifespan that influence cellular-molecular mechanisms, disconnecting favorable signaling in the vasculature induced by exercise training. Moreover, differences could be explained by social and/or psychological factors that make women more susceptible, on average, to barriers to exercise training compared to age-matched men.

The broad range of self-management strategies that people with rheumatic and musculoskeletal conditions apply: an online survey using a citizen science approach

Rheumatic and musculoskeletal diseases (RMDs) cause several restrictions in daily living. Self-management is an important aspect of managing RMDs. However, little is known about the self-management strategies that are currently applied in daily life. This study aimed to identify the current self-management strategies that people with RMDs apply through a citizen science approach. An online survey was iteratively developed together with people with RMDs. The survey was distributed among people with all types of RMDs. Survey responses were collected within Qualtrics, and once anonymized, analysed using Atlas.ti. General self-management strategies and motivations to start performing a strategy were deductively coded by two reviewers, after consultations with patient partners. 250 complete surveys were collected. 91.2% of the respondents were female. 1305 self-management strategies were mentioned, and 669 elaborations were given. Most participants applied self-management strategies within the 'physical activity' category in their daily lives (e.g., walking, biking). Motivations to start performing a certain self-management strategy mostly originated from the bodily functioning dimension (e.g., reducing pain). 1275 facilitators to start a self-management strategy were mentioned, which were mostly related to the 'support' category. Barriers (N = 480) were most frequent in the 'condition-related' category. Self-management is an important aspect of managing a person's condition in daily life. People choose one or several strategies based on the challenge they are facing, depending on their feasibility and preferences in line with their personal context. The comprehensive overview of strategies informs both patients and healthcare professionals to support a personalized self-management journey.

Reinstating respiratory heart rate variability improves hemodynamic responses during exercise in heart failure with reduced ejection fraction

Individuals with heart failure have significantly reduced exercise capacity, a critical life-limiting symptom for those living with the disease. Heart failure is negatively correlated with decreased heart rate variability, including the loss of heart rate variability in tune with breathing-termed respiratory heart rate variability (RespHRV). We tested the hypothesis that restoration of RespHRV would improve exercise tolerance. Heart failure was induced in adult female sheep using a microembolization technique, and the sheep were divided into two groups: RespHRV paced and monotonically paced. Following a 1-week baseline recording, the sheep underwent 2 weeks of pacing. Direct recordings of hemodynamic parameters, including arterial pressure, cardiac output, coronary artery blood flow, and heart rate, were taken at rest and during treadmill exercise. Reinstating RespHRV significantly increased resting cardiac output, a change not observed in monotonically paced sheep. Neither group showed a change in resting coronary artery blood flow. During exercise, RespHRV-paced sheep showed increased cardiac output, coronary artery blood flow, cardiac power output, and faster heart rate recovery post-exercise. In contrast, monotonically paced sheep showed no changes in exercise-induced cardiac function. A separate group of heart failure animals were studied to determine if these benefits would persist alongside heart failure medications. RespHRV pacing continued to improve resting cardiac output with concurrent heart failure medications. Our results indicate that reinstating RespHRV may be a novel approach for improving outcomes in heart failure, including exercise capacity.

Cardiac Rehabilitation for Women with Heart Disease

Cardiovascular disease is the leading cause of morbidity and mortality in women globally. Cardiac rehabilitation (CR)-a comprehensive program including supervised progressive exercise, education, support, behavior modification, and nutritional guidance over 36 individual sessions-positively impacts morbidity, mortality, function, and quality of life. Overall, less than 30% of those who qualify are referred and participate in CR-referral and completion rates are significantly less in women compared with men despite evidence supporting equal benefit. Barriers contributing to these disparities have been identified, and CR programs can be modified to enhance the participation of women.

Associations of Intensive Care Unit Acquired Weakness and Postoperative Delirium in Surgical Intensive Care Unit: A Prospective Observation Study

BACKGROUND

To date, studies assessing the relationship between intensive care unit acquired weakness (ICU-AW) and postoperative delirium (POD), two of the most common complications in the intensive care unit (ICU), are lacking.

AIM

To explore the association of the occurrence of POD, POD subtypes and POD duration with ICU-AW in a surgical intensive care unit (SICU).

STUDY DESIGN

This study was a prospective observational study. Four hundred and two postoperative patients in a SICU at a tertiary hospital in Shanghai, China, participated in the study. Data were collected through the electronic medical record system of the hospital between October 2022 and July 2023. POD was assessed using the Richmond agitation-sedation scale (RASS) and the Confusion Assessment Method for the intensive care unit (CAM-ICU). The Medical Research Council score (MRC score) was used to measure ICU-AW. The bivariate logistic regression analysis was used to analyse the relationship between ICU-AW and POD, and further, the influencing factors of ICU-AW.

RESULTS

Of the 402 analysed patients (mean age: 69.2 ± 14.84, 59.7% male), 121 (30.10%) patients developed ICU-AW, and 92 (22.89%) patients developed POD. Of the ICU-AW group, 53 (43.80%) patients screened positive for POD. The occurrence of POD (odds ratio (OR), 0.227 95% CI: 0.052-0.981), hypoactive POD (OR, 4.241 95% CI: 1.490-12.072) and POD duration (OR, 2.649; 95% CI: 1.422-4.935) were independently associated with ICU-AW. Moreover, diabetes (OR, 1.710; 95% CI: 1.036-2.823) and Interleukin-6 (IL-6) (OR, 1.001; 95% CI: 1.000-1.001) were also significantly correlated with ICU-AW.

CONCLUSIONS

ICU-AW was associated with POD, POD subtypes and POD duration in the SICU patients. Screening for hypoactive POD should be used as part of routine risk assessment in the SICU focused on identifying ICU-AW and specifying a timely and targeted plan during the early stages of the postoperative period.

RELEVANCE TO CLINICAL PRACTICE

While closely monitoring ICU patients with high IL-6 levels and diabetes, nurses should assess the type and duration of POD in patients and implement care interventions to prevent the development of ICU-AW.

Risk factors and clinical outcome of postoperative hyperglycemia after cardiac surgery with cardiopulmonary bypass

Background

There is a high incidence of postoperative hyperglycemia (PHG) in cardiac surgery with cardiopulmonary bypass (CPB), as well as increased morbidity and mortality. The purpose of this study was to evaluate the incidence of PHG after cardiac surgery with CPB, the independent risk factors, and its association with clinical outcomes.

Methods

This was a retrospective, observational study of patients who underwent cardiac surgery with CPB between January 2023 and March 2024 in West China Hospital of Sichuan University. A total of 1,008 consecutive postoperative cardiac surgery patients admitted to the cardiac surgery intensive care unit (ICU) were divided into a non-PHG group and a PHG group. Patients' blood glucose levels were evaluated immediately after cardiac surgery and every 3-4 h daily for 10days, until discharge from the ICU. For patients with PHG, intravenous insulin infusion was performed according to the institution's protocol, and perioperative risk factors for hyperglycemia and clinical outcomes were assessed.

Results

PHG, defined as random blood glucose ≥10.0 mmol/L (180 mg/dl) on two occasions within 24 h, occurred in 65.28% of cardiac surgery patients. Multivariable logistic regression analysis identified that age [odds ratio (OR) 1.054, 95% confidence interval (CI) 1.040-1.069; p < 0.001], female sex (OR 1.380, 95% CI 1.023-1.864; p = 0.035), diabetes (OR 13.101, 95% CI 4.057-42.310; p < 0.001), pulmonary infection (OR 1.918, 95% CI 1.129-3.258; p = 0.016), aortic cross-clamp time (OR 1.007, 95% CI 1.003-1.010; p < 0.001), and intraoperative highest glucose (OR 1.515, 95% CI 1.370-1.675; p < 0.001) emerged as independent risk factors for PHG. Moreover, PHG had higher rates of acute kidney injury (12.61% vs. 4.00%; p < 0.001), delirium (9.57% vs. 3.43%; p < 0.001), pulmonary infection (12.01% vs. 5.14%; p < 0.001), longer duration of mechanical ventilation (19 vs. 14 h; p < 0.001), length of ICU stay (74 vs. 58 h; p < 0.001), length of hospitalization (13 vs. 11 days; p < 0.001), and higher rate of self-discharge or death (3.95% vs. 0.57%; p = 0.002) compared with patients with non-PHG.

Conclusions

PHG occurs frequently in patients after cardiac surgery. Age, female, diabetes, pulmonary infection, aortic cross-clamp time, and intraoperative highest glucose were independent risk factors for PHG. PHG is associated with worse clinical outcomes, including a higher rate of acute kidney injury, delirium, and pulmonary infection, greater duration of mechanical ventilation, length of ICU stay, length of hospitalization, and higher rate of automatic discharge or death.

Renal macro- and microcirculatory perturbations in acute kidney injury and chronic kidney disease associated with heart failure and cardiac surgery

Chronic kidney disease (CKD) affects 50% of patients with heart failure. The pathophysiology of CKD in heart failure is proposed to be driven by macrocirculatory hemodynamic changes, including reduced cardiac output and elevated central venous pressure. However, our understanding of renal microcirculation in heart failure and CKD remains limited. This is largely due to the lack of noninvasive techniques to assess renal microcirculation in patients. Moreover, there is a lack of clinically relevant animal models of heart failure and CKD to advance our understanding of the timing and magnitude of renal microcirculatory dysfunction. Patients with heart failure and CKD commonly require cardiac surgery with cardiopulmonary bypass (CPB) to improve their prognosis. However, acute kidney injury (AKI) is a frequent unresolved clinical complication in these patients. There is emerging evidence that renal microcirculatory dysfunction, characterized by renal medullary hypoperfusion and hypoxia, plays a critical role in the pathogenesis of cardiac surgery-associated AKI. In this review, we consolidate the preclinical and clinical evidence of renal macro- and microcirculatory perturbations in heart failure and cardiac surgery requiring CPB. We also examine emerging biomarkers and therapies that may improve health outcomes for this vulnerable patient population by targeting the renal microcirculation.

Relationships between adrenal insufficiency and cardiovascular outcomes in patients with congestive heart failure

BACKGROUND AND AIMS

Patients with adrenal insufficiency (AI) face elevated risks during various hospitalizations including cardiovascular related admissions. Despite this, limited data exist specifically regarding congestive heart failure (CHF) in the context of AI. This investigation leveraged a comprehensive national database to examine the association between AI and cardiovascular outcomes among patients admitted with CHF.

METHODS AND RESULTS

Admissions for CHF were identified in the 2016-2019 National Inpatient Sample. In-hospital outcomes were compared between patients with and without AI. The primary outcome was in-hospital mortality. Secondary outcomes included cardiogenic shock, ventricular tachycardia (VT), acute kidney injury (AKI), vasopressor use, mechanical circulatory support (MCS) use, mechanical ventilation use, hospital length of stay (LOS), and total charges. Multivariable regression models were used to adjust for potential confounders. Among 1,270,784 CHF hospitalizations, 3812 (0.3 %) had a diagnosis of AI. AI was associated with higher odds of in-hospital mortality (aOR 2.6, 95 % CI 2.1-3.7), VT (aOR 1.40, 95 % CI 1.1-1.8), AKI (aOR 1.29, 95 % CI 1.10-1.52), the need for vasopressors (aOR 3.3, 95 % CI 1.9-5.63), mechanical ventilation use (aOR 3.8, 95 % CI 2.9-4.99), cardiogenic shock (aOR 3.08, 95 % CI 2.38-3.98), and MCS (aOR 2.12, 95 % CI 1.14-3.95). Patients with AI also had a longer LOS (8.62 days vs. 5.25 days, p < 0.001) and higher total charges ($103,248 vs. $50,280, p < 0.001).

CONCLUSION

Patients with AI admitted for CHF had higher in-hospital mortality, non-fatal adverse outcomes, and incurred higher hospital charges compared to patients without AI.

Fluorescence-Based Multiplex Western Blot to Simultaneously Detect the Insulin-Like Growth Factor-1 (IGF-1) Isoforms

Insulin-like growth factor-1 (IGF-1) is critical for tissue growth and development. The IGF-1 gene contains six exons and due to alternative splicing three different isoforms might be produced: the IGF-1Ea, Eb, and Ec prohormones (proIGF-1s). These proIGF-1s share the same IGF-1 mature sequence, which is responsible for the IGF-1 receptor binding but differ in their carboxy-terminal extensions called Ea-, Eb-, and Ec-peptides. Several lines of evidence indicate that E-peptides control the intracellular proIGF-1s localization and maturation. Here, we present a multiplex Western blotting system able to simultaneously discriminate and quantify mature IGF-1, proIGF-1s and E-peptides within the same sample. HEK293 cells were transiently transfected with plasmids containing the IGF-1Ea, IGF-1Eb, or IGF-1Ec isoform or an empty vector. Two different primary antibodies, which recognize the mature sequence or the common region of E-peptides, were used to detect IGF-1 isoforms, which were subsequently distinguished with secondary antibodies conjugated to different fluorophores. Our results demonstrate the feasibility of simultaneously detecting different IGF-1 isoforms using two primary antibodies directed against different epitopes of proIGF-1s, combined with fluorescence-conjugated secondary antibodies. Furthermore, this dual-epitope strategy increases the specificity of protein detection, making it a valuable tool for studying the diverse roles of IGF-1 isoforms in biological processes.

Breaking down the recovery of O2 pathway: Peripheral extraction recovery pattern defines exercise capacity and clinical outcomes

Poor recovery pattern of oxygen consumption (V̇O2) post-exercise is associated with adverse clinical outcomes. However, it remains unknown which component of the O2 pathway (Fick principle) defines this prognostic risk, for example, peripheral extraction, stroke volume, heart rate. Retrospective cohort study included 120 participants (heart failure with preserved ejection fraction: HFpEF = 68, pre-capillary pulmonary hypertensio n = 31, non-cardiac dyspnea = 21). Percent recovery metrics were calculated as the percent reduction of each hemodynamic variable from peak exercise to recovery, for example, (exercise-recovery)/exercise ×100%. Overall, the mean age (standard deviation) was 62.6 (14.4) years and 54% were females. Among the three groups (HFpEF, pre-capillary pulmonary hypertension, non-cardiac dyspnea), recovery patterns of O2 pathway components were statistically non-significant. Peripheral extraction recovery (r2 = 0.43, p < 0.001) and heart rate recovery (r2 = 0.25, p < 0.001) correlated with peak V̇O2, but only peripheral extraction recovery remained significant in multivariate analysis (p = 0.01). Peripheral extraction recovery (<41%; median) demonstrated poor one-year survival from mortality and heart failure hospitalizations (HR 2.82; CI 95% 1.38-5.74, p = 0.003). Peripheral extraction recovery pattern is the most significant component of the O2 pathway and defines adverse outcomes. Physiologically, it elucidates the importance of skeletal muscle and peripheral vascular function.

The Effects of Concurrent Training Versus Aerobic or Resistance Training Alone on Body Composition in Middle-Aged and Older Adults: A Systematic Review and Meta-Analysis

Introduction and Aim: The beneficial effects of aerobic training (AT) on preventing excess fat mass, and of resistance training (RT) on skeletal muscle adaptation, are well established. However, the effects of concurrent training (CT) compared to AT or RT alone on body composition in middle-aged and older adults are less understood, and therefore, the focus of this meta-analysis. Methods: Three databases, including PubMed, Web of Science, and Scopus, were searched from inception to March 2024. Randomized trials were included if they compared CT versus either AT or RT, and included body composition measures such as fat mass, body fat percentage, waist circumference, visceral fat mass, lean body mass (LBM), muscle mass/volume, or muscle or muscle fiber cross-sectional area (CSA), in middle-aged (50 to <65 years) and older adults (≥65 years). Weighted mean differences (WMD) or standardized mean differences (SMD) and 95% confidence intervals (CIs) were calculated using random effects models. Results: A total of 53 studies involving 2873 participants were included. Overall, CT increased body weight and LBM significantly more, trending toward significantly larger increases in muscle mass and CSA, compared with AT alone. However, there were no significant differences between CT and RT alone, for body weight, BMI, body fat percentage, fat mass, waist circumference, or visceral fat mass. Conclusions: CT is as effective as AT for decreasing body fat measures and as effective as RT for increasing muscle mass in middle-aged and older adults, and it should be recommended accordingly.

Exploring air insole pressure and walking durations effects on microcirculation in healthy individuals to optimize diabetic foot ulcers prevention

To evaluate the impact of air insole on reducing the risk of diabetic foot ulcers (DFUs) in healthy individuals through microcirculation assessment, which considers blood flow as a critical factor due to the role of peripheral vascular disease in DFU development. The study analyzes the interaction between air insole pressure and walking duration. Repeated-measures design was used to assess the effects of two walking durations (10 and 20 min) and three air insole pressures (80, 160, and 240 mmHg), resulting in six walking conditions tested in 13 healthy participants. The average blood flow in the first metatarsal head (M1) was quantified using data from the last 3 min of the 10 min post-exercise period. The results of one-way ANOVA showed that the 80 mmHg air insole pressure was significantly lower microcirculation than 240 mmHg with 10 min walking duration (129.4 ± 9.1 vs 163.1 ± 12.6 PU, P = 0.035). The paired t-test showed three significant differences in the effects of the walking duration in all air insole pressures. (1) 10 min walking duration was significantly lower compared to 20 min with 80 mmHg air insole pressure (129.4 ± 9.1 vs 203.6 ± 10.1 PU, P = 0.001); (2) 10 min walking duration was significantly lower compared to 20 min with 160 mmHg air insole pressure (142.5 ± 10.6 vs 206.0 ± 12.5 PU, P = 0.001); (3) 10 min walking duration was significantly lower compared to 20 min with 240 mmHg (163.1 ± 12.6 vs 219.1 ± 11.8 PU, P = 0.008). This study highlights that walking with an air insole pressure of 80 mmHg for 20 minutes influences microcirculation at the first metatarsal head, potentially offering important benefits for individuals at risk of pressure-related injuries, such as DFUs.

Orthostatic Heart Rate Changes and Prognostic Outcomes in Patients With Heart Failure

BACKGROUND

Heart rate typically increases during postural changes from a supine to a standing position due to autonomic and hemodynamic factors. Changes in heart rate during orthostasis may reflect the extent of autonomic dysfunction in patients with heart failure (HF). Thus, orthostatic heart rate changes may be useful for evaluating autonomic function and may predict prognosis. This study examined the association between orthostatic heart rate changes and prognosis in patients with HF.

METHODS AND RESULTS

We included 320 patients with HF in sinus rhythm (median age 70 years, 70.9% men) who were admitted to Kitasato University Hospital for HF treatment and whose heart rate was evaluated in the supine and upright positions during the stable period before discharge. We calculated heart rate changes based on supine and upright heart rate. We examined the association of orthostatic heart rate changes with patient prognosis (i.e., a composite of all-cause mortality or rehospitalization for HF). During the follow-up period (median 3.8 years; interquartile range 0.8-7.0 years), 129 events occurred. Orthostatic heart rate changes were associated with low composite event rates (log-rank P=0.015). After adjusting for potential confounders, increasing orthostatic heart rate changes were associated with decreased composite event rates (adjusted hazard ratio 0.954; 95% confidence interval 0.925-0.985; P=0.004).

CONCLUSIONS

In patients with HF, poor orthostatic heart rate changes were associated with a worse prognosis.

Physical exercise and epigenetic modifications in skeletal muscle, brain, and heart

The origins of many diseases can be traced to the dynamic interplay of genetic predispositions and environmental exposures post-birth. Epigenetic modifications have recently gained prominence as a significant mediator between genetic information and environmental factors, influencing the occurrence and progression of disease. There is a burgeoning body of evidence supports that physical exercise, acting as an external environmental stimulus, exerts a discernible impact on major epigenetic modifications, including histone modifications, DNA methylation, RNA methylation, and non-coding RNA. This effect assumes a pivotal role in the pathogenesis of various human diseases. Exploring the epigenetic molecular mechanisms through which physical exercise enhances human health holds the promise of deepening our understanding of how it improves physiological functions, mitigates disease risks, and establishes a theoretical foundation for employing physical exercise as a non-pharmacological intervention in disease prevention and treatment.

Alterations in nailfold videocapillaroscopy among patients with connective tissue diseases combined with pulmonary arterial hypertension: A cross-sectional study

This study examines the correlation between nailfold videocapillaroscopy (NVC) abnormalities and pulmonary hypertension (PH) in connective tissue disease (CTD) patients, evaluating its diagnostic and predictive value for microcirculation alterations. A cross-sectional study included 351 CTD patients and 30 non-CTD healthy people, with NVC assessments conducted qualitatively, semi-quantitatively, and quantitatively by two independent physicians. Clinical and laboratory data were analyzed, comparing CTD patients with pulmonary arterial hypertension (CTD-PAH) and those without (CTD-non-PAH). Among the patients, 16.5% (n = 58) had pulmonary hypertension. CTD-PAH patients showed higher nailfold videocapillaroscopy scores (5.73 ± 3.54 vs. 4.30 ± 2.98, P = 0.001) and larger capillary diameters (17.06 ± 8.22 vs. 14.41 ± 9.25, P = 0.044) compared to CTD-non-PAH patients. Factors significantly influencing the nailfold videocapillaroscopy score included Raynaud's phenomenon, pulmonary hypertension, and the presence of anti-Scl-70 antibody. The ROC analysis yielded an AUC of 0.621 nailfold videocapillaroscopy score for predicting PAH. Additionally, pulmonary artery systolic pressure in CTD-PAH patients was positively correlated with both nailfold videocapillaroscopy score (R = 0.618, B = 3.26, P < 0.001) and capillary diameter (R = 0.541, B = 1.23, P < 0.001). Nailfold videocapillaroscopy abnormalities, such as higher scores and increased capillary diameters, are associated with pulmonary hypertension in patients with connective tissue diseases (CTD). This method demonstrates potential diagnostic and predictive value for detecting microcirculation alterations in these patients.

A Retrospective Analysis of the Effects of Concomitant Use of Intra-Aortic Balloon Pump (IABP) and Veno-Arterial Extracorporeal Membrane Oxygenation (va-ECMO) Therapy on Procedural Brain Infarction

Background/Objectives: Brain ischemia is a frequent complication in patients undergoing veno-arterial extracorporeal membrane oxygenation (va-ECMO) therapy due to hypoperfusion, low oxygenation, and thromboembolism. While concomitant intra-aortic balloon pump (IABP) therapy may improve the perfusion of the supra-aortic branches, it may also favor thromboembolism. This retrospective study aimed to evaluate the effects of combined va-ECMO and IABP therapy on procedural brain infarction compared to va-ECMO therapy alone, with a specific focus on analyzing the types of infarctions. Methods: Cranial computed tomography (CCT) scans of consecutive patients receiving va-ECMO therapy were analyzed retrospectively. Subgroups were formed for patients with combined therapy (ECMO and IABP) and va-ECMO therapy only. The types of infarctions and the potential impacts of va-ECMO vs. combined therapy with IABP on stroke were investigated. Results: Overall, 146 patients (36 female, 110 male, mean age 61 ± 13.3 years) were included, with 69 undergoing combined therapy and 77 patients receiving va-ECMO therapy alone. In total, 14 stroke events occurred in 11 patients in the ECMO-only group and there were 12 events in 12 patients in the ECMO + IABP-group, showing no significant difference (p = 0.61). The majority of infarctions were of thromboembolic (n = 23; 88%) origin, with 14 stroke-events in 12 patients in the ECMO + IABP-group and 9 stroke events in the ECMO-only group. The survival rate within 30 days of treatment was 29% in the ECMO-only group and 32% in the ECMO + IABP group. Conclusions: The results of this retrospective study show that concomitant IABP therapy appears to be neither protective nor more hazardous in relation to ECMO-related stroke. Thus, the indication for additional IABP therapy should be assessed independently from the procedural risk of brain ischemia. Thromboembolic infarctions seem to represent the most common type of infarction in ECMO, especially within the first 48 h of treatment.

Exploring the scope of inspiratory muscle training in difficult weaning: reflections on the multicentre RCT

We commend the authors for their insightful study on inspiratory muscle training (IMT) in mechanically ventilated patients with difficult weaning, highlighting the robust use of maximum inspiratory pressure (MIP) as a key outcome. We suggest that a lower baseline maximum inspiratory pressure cutoff could better target patients with significant inspiratory dysfunction, improving the study's precision. Additionally, alternative imputation techniques, such as multiple imputation, could strengthen the handling of missing data. While the sample size calculation was appropriate, the unbalanced group sizes raise concerns about generalisability. Future research could benefit from subgroup analyses, individual response curves, and further investigation into the unexpected adverse effects observed in the low-intensity group to refine the inspiratory muscle training protocols.

Epigenetic regulation of stress

Stress can have powerful and lasting effects on our bodies and behavior, partly because it changes how our genes work. These processes, such as DNA methylation, histones modifications, and non-coding RNAs, help decide when genes are active or inactive in cells experiencing stress. This can lead to lasting changes in how the cells function. It's important to understand how these changes in our genes affect our response to stress, as they can lead to problems like anxiety, depression, and heart disease. This chapter explores the link between stress and epigenetics. It talks about how our surroundings and lifestyle can impact these processes. It also shows that epigenetic treatments might help with issues created by stress. By looking at how stress affects our genes, we can discover new ways to treat stress and make medicine better for individuals, helping to lessen the bad impact of stress on our health.

Reporting of nutritional screening, status, and intake in trials of nutritional and physical rehabilitation following critical illness: a systematic review

BACKGROUND

Surviving critical illness leads to prolonged physical and functional recovery with both nutritional and physical rehabilitation interventions for prevention and treatment being investigated. Nutritional status and adequacy may influence outcome, but no consensus on which nutritional-related variables should be measured and reported in clinical trials exists.

OBJECTIVES

This study aimed to undertake a systematic review investigating the reporting of nutritional screening, nutritional status, and nutritional intake/delivery in randomized controlled trials (RCTs) evaluating nutritional and/or physical rehabilitation on physical and functional recovery during and following critical illness.

METHODS

Five electronic databases (MEDLINE, Web of Science, EMBASE, CINAHL, and Cochrane) were searched (last update 9 August, 2023). Search terms included both free text and standardized indexed terms. Studies included were RCTs assessing nutritional and/or physical interventions either during or following intensive care unit (ICU) admission in adults (18 y or older) with critical illness, and who required invasive mechanical ventilation for any duration during ICU admission. Study quality was assessed using the Cochrane Collaboration Risk of Bias tool for RCTs and descriptive data synthesis was performed and presented as counts (%). n t RESULTS: In total, 123 RCTs (30 nutritional, 87 physical function, and 6 combined) were included. Further, ≥1 nutritional variable was measured and/or reported in 99 (80%) of the studies including BMI (n = 69), body weight (n = 57), nutritional status (n = 11), nutritional risk (n = 10), energy delivery (n = 41), protein delivery (n = 35), handgrip strength (n = 40), and other nutritional-related muscle variables (n = 41). Only 3 studies were considered to have low risk of bias in all categories.

CONCLUSIONS

Few RCTs of physical rehabilitation measure and report nutritional or related variables. Future studies should measure and report specific nutritional factors that could impact physical and functional recovery to support interpretation where studies do not show benefit. This protocol was preregistered at PROSPERO as CRD42022315122.

CT-guided transthoracic needle biopsy: How we do it

CT-guided transthoracic needle biopsy is a well-established method for diagnosing pulmonary lesions. However, despite extensive literature on the subject, many aspects of the procedure remain unexamined in large controlled trials. Consequently, practices vary across centers due to differences in local facilities, operators' preferences, and experience. This article summarizes the essential steps of CT-guided transthoracic needle biopsy, covering patient selection to technical tips and tricks, complication management, and rapid onsite cytology evaluation. The techniques described here are based on years of clinical practice, research findings, and close collaboration with colleagues from various specialties, aiming to maximize tissue retrieval while minimizing complications. Moreover, given the growing importance of molecular analyses in the diagnosis and management of lung cancer, this article provides a concise and practical guide on proper biopsy specimen handling.

Evaluating the Relationship Between Medication Adherence, Dietary Practices, and Physical Activity in Heart Transplant Recipients

INTRODUCTION

Medication adherence is critical to improve quality of life, reduce transplant-related complications, and increase survival. Nonadherent health behaviors after heart transplantation lead to increased morbidity and mortality, decreased quality of life, increased medical costs, and overuse of healthcare services in heart transplant patients (HTR). This study examined the relationship between heart transplant recipients' medication adherence, dietary practices, and physical activity.

METHODS

This cross-sectional study was conducted at a university hospital's Heart and Lung Transplant Outpatient Clinic. The sample included adult HTR who had undergone transplantation at least 6 months prior. Data were collected using the Basel Assessment of Adherence to Immunosuppressive Medication Scale, a Nutritional Behaviors Questionnaire, and the International Physical Activity Questionnaire Short Form Statistical analyses using SPSS 24.0, with significance set at p < 0.05.

RESULTS

Among 70 participants, 42.85% were non-adherent to immunosuppressive medications. Factors influencing adherence included age and time since transplantation. Dietary assessments revealed that while most patients practiced washing fruits and vegetables, adherence to other food safety measures was low. Physical activity levels indicated that 50% of participants were physically inactive, with high body mass index significantly correlating with lower activity levels. Patients with medication adherence had higher physical activity levels.

CONCLUSION

The study highlights the critical need for targeted interventions to improve medication adherence, dietary practices, and physical activity among HTR. Addressing these factors is essential for enhancing patient outcomes, reducing morbidity and mortality, and improving quality of life posttransplant. Further research is warranted to explore the barriers and facilitators influencing these health behaviors in diverse populations.

Exercise-based cardiac rehabilitation in patients with left ventricular assist devices: an updated systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Data on the efficacy and safety of exercise-based cardiac rehabilitation (EBCR) in patients with left ventricular assist devices (LVAD) remains limited. This study aims to pool evidence on EBCR's efficacy and safety in LVAD patients and compare high-intensity (HIIT) versus moderate-intensity (MIIT) regimens.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) from PubMed, Embase, Cochrane, Scopus, and Web of Science up to January 2024. A fixed-effects model reported dichotomous outcomes using risk ratio (RR) and continuous outcomes using standardized mean difference (SMD) with a 95% confidence interval (CI). The study was registered in PROSPERO under the identifier 'CRD42024506485.'

RESULTS

Six RCTs with 160 patients were included. No significant difference was found between EBCR and usual care for peak VO2 change [p = 0.22] and six-minute walk distance (6-MWD) change [p = 0.16]. Similarly, no significant difference was observed between HIIT and MICT for peak VO2 change [p = 0.52] and 6-MWD change [p = 0.61]. Moreover, there was no significant difference between EBCR and usual care regarding the incidence of adverse events [p = 0.09], and between HIIT and MICT exercise [p = 0.71].

CONCLUSION

The evidence suggests EBCR does not improve functional capacity, measured by peak VO2 or 6-MWD, in LVAD patients. However, EBCR is safe, with similar adverse event rates compared to usual care.

Overcoming antibiotic resistance: the potential and pitfalls of drug repurposing

Since its emergence shortly after the discovery of penicillin, antibiotic resistance has escalated dramatically, posing a significant health threat and economic burden. Drug repositioning, or drug repurposing, involves identifying new therapeutic applications for existing drugs, utilising their established safety profiles and pharmacological data to swiftly provide effective treatments against resistant pathogens. Several drugs, including otilonium bromide, penfluridol, eltrombopag, ibuprofen, and ceritinib, have demonstrated potent antibacterial activity against multidrug-resistant (MDR) bacteria. These drugs can disrupt biofilms, damage bacterial membranes, and inhibit bacterial growth. The combination of repurposed drugs with conventional antibiotics can reduce the required dosage of individual drugs, mitigate side effects, and delay the development of resistance, making it a promising strategy against MDR bacteria such as Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli. Despite its promise, drug repurposing faces challenges such as potential off-target effects, toxicity, and regulatory and intellectual property issues, necessitating rigorous evaluations and strategic solutions. This article aims to explore the potential of drug repurposing as a strategy to combat antibiotic resistance, examining its benefits, challenges, and future prospects. We address the legal, economic, and practical challenges associated with repurposing existing drugs, highlight successful examples, and propose solutions to enhance the efficacy and viability of this approach in combating MDR bacterial infections.

Exercise Training After Myocardial Infarction Enhances Endothelial Progenitor Cells Function via NRG-1 Signaling

Vascular regeneration after myocardial infarction (MI) is essential to improve myocardial ischemia, delay post-infarction ventricular remodeling, and improve the long-term prognosis of MI. Endothelial progenitor cells (EPCs) play important roles in the functional repair and homeostatic maintenance of the vascular endothelium. Exercise training stimulates EPC mobilization and increases the number of circulating EPCs, which has beneficial effects on the restoration of vascular integrity and hemodynamic reconstitution. After post-MI exercise training, cardiac function, the myocardial infarct area, and capillary density in the peri-infarct zone were measured. Bone marrow-derived EPCs were isolated from mice to measure the proliferation, migration, and in vitro angiogenesis of EPCs after myocardial infarction exercise. The expression of NRG-1/ErbB4 signaling factor and related proteins in downstream PI3K/AKT signaling pathway were detected, and the level of autocrine NRG-1 in EPCs was detected. Post-MI resistance training, aerobic exercise training, and combined exercise training increased EPC mobilization and proliferation, migration, and tube-forming capacity, promoted myocardial vascular regeneration, improved cardiac function, and reduced infarct size. Exercise training upregulated NRG-1 expression in EPCs, and NRG-1/ErbB4 signaling activated the downstream PI3K/Akt signaling pathway. Moreover, EPCs may have a positive feedback autocrine loop with NRG-1 to improve the function of EPCs and promote vascular repair and regeneration in mice with MI. Exercise training after MI promotes the function of bone marrow-derived EPCs through NRG-1/ErbB4/PI3K/AKT signaling, thus exerting a role in angiogenesis.

Cardiac Rehabilitation and Heart Failure with Reduced Ejection Fraction: Pathophysiology, Benefits, and Precautions

Heart failure (HF) is a highly comorbid condition associated with significant mortality, despite advances in current medical management. Patients who suffer from HF represent a high needs disease care population in whom structured, long-term chronic disease care delivery models, such as cardiac rehabilitation (CR), have been shown to be highly cost effective in reducing hospitalizations and improving quality of life. HF with reduced ejection fraction affects a growing number of Canadians and health care costs secondary to this condition are increasing, with further increases over the next decade to be expected. CR is a guideline-directed medical therapy for patients living with HF with reduced ejection fraction, and with increasing numbers of HF patients across the world, there is a prescient need to revisit the benefits, safety, and the prescription of this intervention for the health care professionals who treat this condition. Certainly, there is a clinical need for HF practitioners to better understand the pathophysiological benefits of CR with respect to exercise training, as well as the prudent precautions required to facilitate the safe delivery of this highly cost-effective patient intervention.

Challenges faced by cardiac patients prior to coronary artery bypass grafting: a qualitative study

BACKGROUND

Coronary artery bypass grafting (CABG) is one of the most effective treatments for improving the quality of life in patients with severe coronary artery disease. However, these patients face multiple challenges prior to surgery. This study aims to elucidate the challenges faced by cardiac patients before CABG.

METHODS

This qualitative study used a conventional content analysis approach. Data were obtained from 26 interviews with 23 individuals, including patients and their families, physicians, and nurses from hospitals in Bushehr and Hamadan, selected through purposive sampling. Data were collected through semi-structured interviews over ten months and analyzed using MAXQDA20 software.

RESULTS

A total of 575 initial codes were extracted from the interviews and categorized into 16 subcategories based on similarities and differences. After reviewing and comparing the subcategories, five main categories of challenges faced by cardiac patients prior to coronary artery bypass surgery were identified and conceptually named. These categories included psychological and social stress during the waiting period, financial resource management for treatment, quality of information and communication, heightened need for belonging, and spirituality.

CONCLUSIONS

Patients prior to coronary artery bypass grafting encounter psychological, financial, social, and spiritual challenges. A precise understanding of these challenges and the provision of psychological and social counseling to patients and their families, financial support and facilitation of treatment costs, improvement of information quality and communication between patients and the healthcare team, strengthening emotional support from family and friends, and attention to patients' spiritual needs by the healthcare team can facilitate decision-making and enhance the quality of life and surgical outcomes.

Frailty and Heart Failure: Clinical Insights, Patient Outcomes and Future Directions

Frailty is common among heart failure (HF) patients and linked to increased risk of adverse outcomes. Contributing factors include inflammation, sarcopenia and neurohormonal issues which diminish physiological reserves and accelerate the decline of health. Managing frailty in HF requires a multidisciplinary approach to address physical, nutritional and pharmacological needs. Structured exercise and dietary support can improve physical function, while careful medication management, especially with polypharmacy, reduces frailty-related risks. Telemedicine and wearable tech facilitate continuous monitoring and timely intervention, especially for those in remote areas. Future research should develop standardised frailty assessment tools specific to HF, enhancing risk stratification and personalised care. Studies on underlying mechanisms, such as inflammation and mitochondrial dysfunction, could lead to new therapies. Addressing socioeconomic factors can also improve care equity. This review summarises the mechanisms, clinical characteristics and impact of frailty on HF, highlighting challenges in treatment and opportunities for improving patient outcomes.

From surgery to recovery: Measuring success through quality of life and functional improvements after cardiac surgery

Coronary artery disease and aortic valve stenosis are highly prevalent cardiovascular diseases worldwide, resulting in substantial morbidity and mortality. Surgical interventions, such as coronary artery bypass grafting and surgical aortic valve replacement, offer significant therapeutic benefits, including enhanced postoperative quality of life (QoL) and functional capacity, which are key indicators of surgical success. This editorial reviews recent studies on postoperative QoL and functional outcomes in patients undergoing cardiac surgery. Factors such as preoperative health, age, intensive care unit stay duration, surgical risk, and perioperative complications could influence these outcomes. Cardiac rehabilitation is pivotal in enhancing patient function, reducing frailty and improving long-term QoL.

Immediate Effects of Focal Muscle Vibration on Squat Power and Velocity in Amateur Athletes: A Randomized Controlled Trial

Background: Squat exercises are widely recognized for their ability to improve sports performance. Recent advancements in force/velocity profiling have highlighted the importance of power and velocity in explosive movements. While various training methods have been applied to enhance these parameters, their effectiveness remains inconsistent. Focal vibration has emerged as a potential intervention, yet its impact on squat performance has not been extensively explored. The aim was to evaluate the effectiveness of focal vibration with voluntary contractions on power/velocity during a squat exercise in amateur athletes in comparison with voluntary contraction in isolation. Methods: A double-blind, randomized clinical trial with 72 amateur athletes. Velocity, power, muscle activity, perceived effort, and clinical change were measured. The experimental group received focal muscle vibration therapy (100-180 Hz) combined with voluntary contraction, while the sham group underwent identical procedures and focal muscle vibration without the vibrating head, close to the muscle belly but without touching the skin. Results: Statistically significant improvements in the experimental group were found for mean power (p < 0.001; ES = 0.08), peak velocity (p < 0.010; ES = 0.42), and mean velocity (p < 0.001; ES = 0.66) during the squat. Between-group analysis favored the experimental group in peak power (p < 0.049; ES = 0.65), mean power (p < 0.034; ES = 1.42), peak velocity (p < 0.024; ES = 0.095), and mean velocity (p < 0.002; ES = 1.67). Conclusions: Focal muscle vibration (100-180 Hz) combined with active muscle contraction significantly enhances power and velocity during squat exercises in amateur athletes.

Low Phosphatidylserine+ Cells Within the CD34+/CD45dim/CD117(c-kit)+ Subpopulation Are Associated with Poor Outcomes in Metastatic Colorectal Cancer

BACKGROUND

Colorectal cancer is among the most prevalent causes of tumor-related deaths worldwide. Antiangiogenic therapy represents a cornerstone of metastatic CRC treatment, and biomarkers are advocated for the optimization of this therapeutic strategy.

METHODS

In this observational prospective study, we employed an optimized flow cytometry protocol to investigate the prognostic and predictive potential of blood circulating endothelial cells (CECs), circulating endothelial progenitor cells (CEPCs), and related subsets in a cohort of patients with metastatic colorectal cancer (n = 40).

RESULTS

Computational FC analysis revealed a differential enrichment of blood cell clusters with a CD34+/CD45dim/CD117(c-kit)+ phenotype between responders and non-responders both to antiangiogenic and non-antiangiogenic treatments. Intriguingly, our results show that a high percentage of annexin V-negative cells in a putative circulating progenitor population with a CD34+/CD45dim/CD117+ phenotype was correlated with a reduced response to systemic anticancer treatments (p = 0.015) and worse overall survival (log-rank p = 0.03). In addition, we observed increased blood concentrations of CD34+/CD45dim/CD117+/annexin V- cells in patients with a higher number of metastatic sites (p = 0.03).

CONCLUSIONS

Overall, these findings hold promise for the identification of novel circulating biomarkers to develop more personalized treatment approaches in patients with metastatic colorectal cancer.

Physiological Mechanisms Driving Microcirculatory Enhancement: the Impact of Physical Activity

Background

Physical activity induces many beneficial adaptive changes to blood vessel microcirculation, ultimately improving both health and exercise performance. This positions it an effective non-pharmacological therapeutic approach for the rehabilitation of patients with various chronic diseases. Understanding the impact of different types of physical activities on microcirculation and elucidating their physiological mechanisms is crucial for optimizing clinical practice.

Methods

A comprehensive literature search was performed across multiple databases including PubMed, EBSCO, ProQuest, and Web of Science. Following a rigorous screening process, 48 studies were selected for inclusion into the study.

Results

Existing studies demonstrate that various forms of physical activity facilitate multiple positive adaptive changes at the microcirculation level. These include enhanced microvascular dilation-driven by endothelial cell factors and mechanical stress on blood vessels-as well as increased capillary density. The physiological mechanisms behind these improvements involve the neurohumoral regulation of endothelial cell factors and hormones, which are crucial for these positive effects. Physical activity also ameliorates inflammation markers and oxidative stress levels, upregulates the expression of silent information regulator 2 homolog 3, genes for hypoxia-inducible factors under hypoxic conditions, and induces favorable changes in multiple hemodynamic and hemorheological parameters. These structural and functional adaptations optimize myocardial blood flow regulation during exercise and improve both oxygen transport and utilization capacity, which are beneficial for the rehabilitation of chronic disease patients.

Conclusions

Our provides a reference for using physical activity as a non-pharmacological intervention for patients with chronic conditions. This framework includes recommendations on exercise types, intensity, frequency, and duration. Additionally, we summarize the physiological mechanisms through which physical activity improves microcirculation, which can inform clinical decision-making.

Acute Sarcopenia: Systematic Review and Meta-Analysis on Its Incidence and Muscle Parameter Shifts During Hospitalisation

BACKGROUND

Acute sarcopenia is sarcopenia lasting less than 6 months, typically following acute illness or injury. It may impact patient recovery and quality of life, advancing to chronic sarcopenia. However, its development and assessment remain poorly understood, particularly during hospitalisation. This systematic review aimed to elucidate the incidence of acute sarcopenia and examine changes in muscle parameters during hospitalisation.

METHODS

Eighty-eight papers were included in the narrative synthesis; 33 provided data for meta-analyses on the effects of hospitalisation on handgrip strength (HGS), rectus femoris cross-sectional area (RFCSA) and various muscle function tests. Meta-regressions were performed for length of hospital stay (LoS) and age for all meta-analyses; sex was also considered for HGS.

RESULTS

Acute sarcopenia development was assessed in four studies with a pooled incidence of 18% during hospitalisation. Incidence was highest among trauma patients in intensive care (59%), whereas it was lower among medical and surgical patients (15%-20%). Time of development ranged from 4 to 44 days. HGS remained stable during hospitalisation (SMD = 0.05, 95% CI = -0.18:0.28, p = 0.67) as did knee extensor strength. LoS affected HGS performance (θ = 0.04, 95% CI = 0.001:0.09, p = 0.045) but age (p = 0.903) and sex (p = 0.434) did not. RFCSA, reduced by 16.5% over 3-21 days (SMD = -0.67, 95% CI = -0.92:-0.43, p < 0.001); LoS or time between scans did significantly predict the reduction (θ = -0.04, 95% CI = -0.077:-0.011, p = 0.012). Indices of muscle quality also reduced. Muscle function improved when assessed by the short physical performance battery (SMD = 0.86, 95% CI = 0.03:1.69, p = 0.046); there was no change in 6-min walk (p = 0.22), timed up-and-go (p = 0.46) or gait speed tests (p = 0.98). The only significant predictor of timed up-and-go performance was age (θ = -0.11, 95% CI = -0.018:-0.005, p = 0.009).

CONCLUSIONS

Assessment and understanding of acute sarcopenia in clinical settings are limited. Incidence varies between clinical conditions, and muscle parameters are affected differently. HGS and muscle function tests may not be sensitive enough to identify acute changes during hospitalisation. Currently, muscle health deterioration may be underdiagnosed impacting recovery, quality of life and overall health following hospitalisation. Further evaluation is necessary to determine the suitability of existing diagnostic criteria of acute sarcopenia. Muscle mass and quality indices might need to become the primary determinants for muscle health assessment in hospitalised populations.

A Noninvasive Diagnostic Approach for Identifying Spontaneous Coronary Artery Dissection (SCAD) in Young Women: A Case Report and Review of the Literature

A 19-year-old female patient presented with an acute onset of substernal chest pain, accompanied by dyspnea and diaphoresis while walking to the gym. She was able to start her routine, but the pain worsened. She was taken to the emergency room, where an electrocardiogram was performed, and no irregularities were observed, while the troponin test was significantly elevated. Imaging studies, including a Doppler echocardiogram and an emergent CT of the chest to rule out aortic dissection, returned normal results. The pain subsided after two hours, but troponin kept increasing; consequently, spontaneous coronary artery dissection (SCAD) was suspected. In view of the young age of the patient, it was decided to refrain from performing a coronary angiogram, intravascular ultrasound, or optical coherence tomography. A CT coronary angiography scan did not show any anomaly. A cardiac magnetic resonance imaging showed a clear subendocardial enhancement indicative of a myocardial infarction. A diagnosis of SCAD was confirmed, and no further testing was done. The patient was started on aspirin and beta-blockers, and advised to perform only minimal to moderate exercise and to consult a healthcare physician immediately if the episode recurs. CT angiogram ruled out fibrodysplasia of the renal arteries, and plasma metanephrines were normal. This case shows that with the advancement of noninvasive techniques, there is probably no need for invasive measures to diagnose SCAD in stable patients.

The role of extracorporeal membrane oxygenation in thoracic anesthesia

PURPOSE OF REVIEW

Circulatory and respiratory support with extracorporeal membrane oxygenation (ECMO) has gained widespread acceptance during high-end thoracic surgery. The purpose of this review is to summarize the recent knowledge and give an outlook for future developments.

RECENT FINDINGS

A personalized approach of ECMO use is state of the art for monitoring during surgery. Personalization is increasingly applied during anesthesia for high-end surgery nowadays. This is reflected in the point of care testing (POCT) for anticoagulation and cardiac function during surgery on ECMO combining specific patient data into tailored algorithms. For optimizing protective ventilation MP (mechanical power) is a promising parameter for the future. These personalized methods incorporating numerous patient data are promising for the improvement of morbidity and mortality in high-end thoracic surgery. However, clinical data supporting improvement are not available to date but can be awaited in the future.

SUMMARY

Clinical practice during surgery on ECMO is increasingly personalized. The effect of personalization on morbidity and mortality must be examined in the future. Undoubtedly, an increase in knowledge can be expected from this trend towards personalization.

The desat-max in 2-chair test appears to be a worthwhile parameter to identify sickness: An appraisal

Background & objectives The 2-chair test (2CT) has recently been proposed as a cardiopulmonary reserve-specific assessment of post-exercise recovery response. The objective of this study was to find out the most appropriate parameter of 2CT to categorically differentiate between 'normal' and symptomatic diseased population. Methods In a prospective manner, we recruited a random cohort of symptomatic patients attending our outpatient department (OPD) with different respiratory diseases. We also selected another cohort of 'normal' persons from the willing attendants of the patients who had no symptoms and revealed no abnormality on chest X-ray and spirometry. Persons belonging to both groups were requested to mark their 'sickness' on a scale of 0 to 10 ('0' meaning none and '10' meaning maximum possible) under the PPSS (patient-perceived sickness score) and were subjected to perform 2CT. All the test variables related to pulse rate and peripheral capillary oxygen saturation (SpO2) changes were noted for both groups. The 'symptomatic' and 'normal' persons were compared based on the 2CT variables to find the well-performing discriminatory parameter. Results The comparison of 2CT variables of 419 patients and 30 'normal' controls revealed that the PR change max, maximum SpO2, minimum-SpO2, and desat-max can significantly differentiate between the two. However, the desat-max correlated to the PPSS best. The VIP plot, primary component analysis, and pattern-hunter representation further substantiated this. Interpretation & conclusions The desat-max appears to be a sensitive parameter to differentiate the normal from the symptomatic diseased population. Further research in this area is warranted.

Facilitators and barriers to perform physical activity in patients post-heart transplantation: a qualitative study

AIMS

Most patients experience barriers for becoming physical active post-heart transplantation. Therefore, identifying barriers and facilitators can help healthcare professionals in developing physical activity programmes. This study aimed to explore the physical activity experiences, perceived barriers, and facilitators to perform physical activity of patients' post-heart transplantation.

METHODS AND RESULTS

A qualitative study was carried out using in-depth semi-structured interviews on 24 patients post-heart transplantation from October to December 2022. The data were analysed using an inductive strategy for finding emerging themes. NVivo 12.0 software was used to analyse the data. The physical activity experiences included that (i) patients felt that they had to adapt to a new situation after the heart transplantation, (ii) walking was a popular physical activity preferably outdoors, (iii) participants preferred to perform physical activity regularly with others, and (iv) they felt better since they perform physical activity. The facilitators were: (i) desire to live; (ii) experiencing physical benefits; (iii) being physically active with others; (iv) use of mobility assistive devices resources. The barriers were: (i) feeling not being able to perform former physical activity; (ii) complications and experiencing symptoms post-heart transplantation; (iii) unfavourable climate.

CONCLUSION

Patients post-heart transplantation has various facilitators influencing their post-transplant experience to perform physical activity. Key facilitators include the desire to live, physical benefits, social activity, and external support. Yet, they also face barriers like lost abilities, post-transplant complications, and environmental challenges.

Respiratory Muscle Dysfunction and Associated Risk Factors Following COVID-19-Related Hospitalisation

BACKGROUND

Studies have highlighted long-term respiratory muscle dysfunction in COVID-19 survivors, although the underlying risk factors remain unclear. This single-centre study assessed respiratory muscle function and individual associated factors at follow-up in patients hospitalised with COVID-19 and related acute respiratory failure.

METHODS

Data were collected for consecutive patients, aged ≥ 18 years, at the post-COVID outpatient service of Hospital Policlinico in Modena (Italy) in the time frame of 3 to 6 months after discharge. Data were analysed using single and multiple logistic regression models. Correlations among MIP/MEP, hand-grip values, and lung function were further explored.

RESULTS

Out of 223 patients (mean age 67 years, 69% male) 121 (54.3%) exhibited MIP or MEP dysfunction, which was found to be associated with the use of non-invasive ventilation (aOR = 1.91 [1.07-3.49], p = 0.04) and female gender (aOR = 1.76 [1.09-4.16], p = 0.03) as independent risk factors. A positive correlation was observed between MIP dysfunction and hand-grip strength (p = 0.03 and 0.01), whereas both MIP and MEP were significantly associated with FEV1, FVC, TLC, and DLCO.

CONCLUSIONS

Respiratory muscle dysfunction is consistently prevalent and parallels peripheral muscle weakness and the lung function level in patients at follow-up after severe COVID-19. The need for non-invasive ventilation during the acute phase and female gender might represent risk factors. MIP/MEP assessment should be recommended to observe respiratory muscle dysfunction in severe post-COVID survivors.

Exercise Pulmonary Hypertension and Beyond: Insights in Exercise Pathophysiology in Pulmonary Arterial Hypertension (PAH) from Invasive Cardiopulmonary Exercise Testing

Pulmonary arterial hypertension (PAH) is a rare, progressive disease of the pulmonary vasculature that is associated with pulmonary vascular remodeling and right heart failure. While there have been recent advances both in understanding pathobiology and in diagnosis and therapeutic options, PAH remains a disease with significant delays in diagnosis and high morbidity and mortality. Information from invasive cardiopulmonary exercise testing (iCPET) presents an important opportunity to evaluate the dynamic interactions within and between the right heart circulatory system and the skeletal muscle during different loading conditions to enhance early diagnosis, phenotype disease subtypes, and personalize treatment in PAH given the shortcomings of contemporary diagnostic and therapeutic approaches. The purpose of this review is to present the current applications of iCPET in PAH and to discuss future applications of the testing methodology.

Role of physical activity in cardiovascular disease prevention: impact of epigenetic modifications

Cardiovascular disease (CVD) remains the leading cause of death worldwide, imposing a major burden on morbidity, quality of life, and societal costs, making prevention of CVD a top public health priority. Extensive research has pointed out that lack of adequate physical activity in life is one of the key risk factors for heart disease. Indeed, moderate exercise is not only beneficial to the heart in healthy populations, but also exerts a protective effect in pathological states. However, the molecular mechanisms underlying the cardioprotective effects of exercise are still not fully understood. An increasing body of research indicates that variations in the epigenetic system-such as DNA methylation, histone modifications, and production of non-coding RNA-are essential for maintaining heart health and preventing heart disease. Exercise is a potent epigenetic modulator that induces direct and long-lasting genetic changes and activates biological signals associated with cardiovascular health. These changes can be influenced by external stimuli such as physical activity and may even be passed on to offspring, thus providing a mechanism for generating genetic effects through behavioral interventions. Therefore, understanding this relationship can help identify potential biomarkers and therapeutic targets associated with CVD. This study aims to provide an overview of the beneficial effects of exercise on heart health. This information may help guide future research efforts and improve our understanding of epigenetics as a therapeutic, prognostic, and diagnostic biomarker for CVD.