A systematic review of the effects of acute psychological stress and physical activity on haemorheology, coagulation, fibrinolysis and platelet reactivity: Implications for the pathogenesis of acute coronary syndromes

Potential mechanisms of multimodal prehabilitation effects on surgical complications: a narrative review

Continuous advances in prehabilitation research over the past several decades have clarified its role in improving preoperative risk factors, yet the evidence demonstrating reduced surgical complications remains uncertain. Describing the potential mechanisms underlying prehabilitation and surgical complications represents an important opportunity to establish biological plausibility, develop targeted therapies, generate hypotheses for future research, and contribute to the rationale for implementation into the standard of care. In this narrative review, we discuss and synthesize the current evidence base for the biological plausibility of multimodal prehabilitation to reduce surgical complications. The goal of this review is to improve prehabilitation interventions and measurement by outlining biologically plausible mechanisms of benefit and generating hypotheses for future research. This is accomplished by synthesizing the available evidence for the mechanistic benefit of exercise, nutrition, and psychological interventions for reducing the incidence and severity of surgical complications reported by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). This review was conducted and reported in accordance with a quality assessment scale for narrative reviews. Findings indicate that prehabilitation has biological plausibility to reduce all complications outlined by NSQIP. Mechanisms for prehabilitation to reduce surgical complications include anti-inflammation, enhanced innate immunity, and attenuation of sympathovagal imbalance. Mechanisms vary depending on the intervention protocol and baseline characteristics of the sample. This review highlights the need for more research in this space while proposing potential mechanisms to be included in future investigations.

Physiological reactivity to acute mental stress in essential hypertension-a systematic review

Objective

Exaggerated physiological reactions to acute mental stress (AMS) are associated with hypertension (development) and have been proposed to play an important role in mediating the cardiovascular disease risk with hypertension. A variety of studies compared physiological reactivity to AMS between essential hypertensive (HT) and normotensive (NT) individuals. However, a systematic review of studies across stress-reactive physiological systems including intermediate biological risk factors for cardiovascular diseases is lacking.

Methods

We conducted a systematic literature search (PubMed) for original articles and short reports, published in English language in peer-reviewed journals in November and December 2022. We targeted studies comparing the reactivity between essential HT and NT to AMS in terms of cognitive tasks, public speaking tasks, or the combination of both, in at least one of the predefined stress-reactive physiological systems.

Results

We included a total of 58 publications. The majority of studies investigated physiological reactivity to mental stressors of mild or moderate intensity. Whereas HT seem to exhibit increased reactivity in response to mild or moderate AMS only under certain conditions (i.e., in response to mild mental stressors with specific characteristics, in an early hyperkinetic stage of HT, or with respect to certain stress systems), increased physiological reactivity in HT as compared to NT to AMS of strong intensity was observed across all investigated stress-reactive physiological systems.

Conclusion

Overall, this systematic review supports the proposed and expected generalized physiological hyperreactivity to AMS with essential hypertension, in particular to strong mental stress. Moreover, we discuss potential underlying mechanisms and highlight open questions for future research of importance for the comprehensive understanding of the observed hyperreactivity to AMS in essential hypertension.

The Acute and Chronic Effects of Resistance and Aerobic Exercise in Hemostatic Balance: A Brief Review

Hemostatic balance refers to the dynamic balance between blood clot formation (coagulation), blood clot dissolution (fibrinolysis), anticoagulation, and innate immunity. Although regular habitual exercise may lower the incidence of cardiovascular diseases (CVD) by improving an individual’s hemostatic profile at rest and during exertion, vigorous exercise may increase the risk of sudden cardiac death and venous thromboembolism (VTE). This literature review aims to investigate the hemostatic system’s acute and chronic adaptive responses to different types of exercise in healthy and patient populations. Compared to athletes, sedentary healthy individuals demonstrate similar post-exercise responses in platelet function and coagulatory and fibrinolytic potential. However, hemostatic adaptations of patients with chronic diseases in regular training is a promising field. Despite the increased risk of thrombotic events during an acute bout of vigorous exercise, regular exposure to high-intensity exercise might desensitize exercise-induced platelet aggregation, moderate coagulatory parameters, and up-regulate fibrinolytic potential via increasing tissue plasminogen activator (tPA) and decreasing plasminogen activator inhibitor (PAI-1) response. Future research might focus on combining different types of exercise, manipulating each training characteristic (frequency, intensity, time, and volume), or investigating the minimal exercise dosage required to maintain hemostatic balance, especially in patients with various health conditions.

An exploratory study of hypnosis-induced blood count changes in chronically stressed individuals

Hypnosis is a clinically accepted relaxation technique known for stress reduction. Results from hematological research provide evidence of changes in blood components through hypnosis. However, these hematological effects have been rarely examined. Hence, we exploratively investigated the effect of a single relaxation hypnosis on the hemogram in stressed individuals, assuming a reduction of leukocytes, thrombocytes, and erythrocytes (primary outcomes). Additionally, a reduction in the erythrocyte-related parameters (hemoglobin, hematocrit), and an increase in plasma volume was hypothesized (secondary outcomes). Forty-four either individuals (89 % women) with chronic stress and moderate to high hypnotic suggestibility were randomized to a hypnosis condition (20 min relaxation hypnosis; n = 20) or a control condition (20 min documentary; n = 24). Venous blood was drawn before and after the intervention and used to generate a differential hemogram and determine the plasma volume. The relaxation hypnosis led to a significant reduction in erythrocytes (Cohen's d=0.23) and consequently to a decrease in erythrocyte-related parameters (hemoglobin, d=0.27; hematocrit, d=0.37) as well as to a reduction in thrombocytes (d=0.15) in the hypnosis compared to the control condition. Putatively, this could be the consequence of an increased plasma volume (d=0.10), estimated by the hematocrit concentration and body weight. A hypnosis-induced change in leukocyte count could not be confirmed. Thus, a single session of relaxation hypnosis already alters specific blood count parameters. While relaxation-induced vasodilatation might explain these changes, it is still not completely clear how these changes affect our stress response system.

Effect of virtual group EcoMeditation on psychological conditions and flow states

Background

A plethora of literature has delineated the therapeutic benefits of meditation practice on psychological functioning. A novel meditative practice, EcoMeditation, includes elements of four evidence-based techniques: The Quick Coherence Technique for regulating heart rate variability (HRV), Emotional Freedom Techniques (EFT), mindfulness, and neurofeedback.

Objectives

Changes in psychological symptoms, including anxiety, depression, posttraumatic stress, pain, and happiness were measured following a one-day virtual EcoMeditation training workshop. The current study extended on previous literature by adding measures of transcendent experiences and flow states.

Methods

Participants were drawn from a convenience sample of 151 participants (130 female, 21 male) aged between 26 to 71 years (M = 45.1, SD = 9.19) attending a one-day virtual EcoMeditation workshop. They were assessed pre-workshop, post-workshop, and at 3-months follow-up.

Results

Post-workshop results (N = 111) indicated a significant reduction in anxiety (−42.3%, p < 0.001), depression (−37.5%, p < 0.001), posttraumatic stress (−13.0%, p < 0.001), and pain (−63.2%, p < 0.001) Likert mean scores when compared to pre-workshop. There was also a significant increase in happiness (+111.1%, p < 0.001), flow states (+17.4%, p < 0.001), and transcendent experiences (+18.5%, p < 0.001). At 3-months follow-up, a one-way repeated measures ANOVA (N = 72) found significant decreases in anxiety, depression, and pain symptoms between pre-test and post-test, as well between pre-test and follow-up. Flow, happiness, and transcendent experiences increased significantly between pre-test and post-test, as well as between pre-test and follow-up, with over 71% of participants experiencing clinically significant improvements. Significant reductions in posttraumatic stress and depression symptoms between pre-test and follow-up were also noted.

Conclusion

EcoMeditation is associated with significant improvements in psychological conditions such as anxiety, depression, pain, and posttraumatic stress. EcoMeditation was also shown to enhance flow states and transcendent experiences. The benefits identified were similar to those found in the existing literature and provide support for the use of EcoMeditation as an effective stress reduction method that improves psychological symptoms and enhances transcendent states.

The Use of Compression Stockings to Reduce Water Retention in the Legs During Gaming and Esports: Randomized Controlled Field Study

Background

With the increasing digitalization of daily life, internet-based entertainment such as gaming and streaming has advanced to one of the megatrends of the 21st century. Besides offering a multitude of controversially discussed opportunities for entertainment and social interaction, there is reasonable concern about health issues caused by the absence of physical activity among activities linked to gaming and streaming.

Objective

The aim of this study is to compare the water balance of recreational gamers with and those without compression stockings during a gaming event.

Methods

We measured body composition and water balance with 8-electrode bioelectrical impedance analysis among 46 recreational gamers with an average age of 27.1 (SD 6.5) years (5/46, 11% women and 41/46, 89% men) before and after 24 hours at a gaming event. Of the 46 gamers, 23 (50%) gamers wore compression stockings for the duration of the study.

Results

Our study shows that prolonged gaming and associated behaviors during a 24-hour time frame lead to an increase in total body water (+0.76 L; P<.001) and a decrease of phase angle in the lower extremities (−0.47°; P<.001) but not in the upper extremities (+0.09°; P=.80), when no compression is used. Gamers using compression socks did not show any significant negative effects on their body composition.

Conclusions

Prolonged gaming and streaming are serious risk factors for diseases associated with water retention in the legs, and these risks can be measured by bioelectrical impedance and reduced by wearing compression stockings. We conclude that these findings should be discussed and replicated in larger studies and that there is a considerably large market for compression stockings among gamers and live streamers.

Global thrombosis test for assessing thrombotic status and efficacy of antithrombotic diet and other conditions

Because of the high mortality from myocardial infarction and stroke, there is a great demand for finding novel methods of diagnosis, prevention and treatment of these diseases. Most of the current tests measure important determinants of thrombosis such as platelet function, coagulation and fibrinolysis in isolation; therefore, a global test measuring the actual thrombotic status would be more useful in clinical conditions. We obtained considerable experience by using the global thrombosis test, which determines the actual thrombotic status by taking into account the measured platelet reactivity, coagulation and fibrinolytic activities. In animal experiments, we found significant correlation between the ex vivo global thrombosis test measurements and the in vivo thrombotic status. The published evidence for the benefit of an antithrombotic diet with regular physical exercise is also described.

There is a great concern in the general population how to detect the risk of thrombotic events and prevent the high mortality from stroke, myocardial infarction, sudden death and cancer-associated thrombosis. Our experience on antithrombotic fruits and vegetables intake and regular exercise assessed by the global thrombosis test suggested a potentially unique way of preventing these life-threatening diseases. In addition, global thrombosis testing may offer some benefit in detecting risk of thrombotic of forthcoming thrombotic events in cancer and COVID-19 virus-infected patients.

Physical Exercise as a Modulator of Vascular Pathology and Thrombin Generation to Improve Outcomes After Traumatic Brain Injury

Disruption of the blood-brain barrier and occurrence of coagulopathy after traumatic brain injury (TBI) have important implications for multiple secondary injury processes. Given the extent of post-traumatic changes in neuronal function, significant alterations in some targets, such thrombin (a protease that plays a physiological role in maintaining blood coagulation), play an important role in TBI-induced pathophysiology. Despite the magnitude of thrombin in synaptic plasticity being concentration-dependent, the mechanisms underlying TBI have not been fully elucidated. The understanding of this post-injury neurovascular dysregulation is essential to establish scientific-based rehabilitative strategies. One of these strategies may be supporting physical exercise, considering its relevance in reducing damage after a TBI. However, there are caveats to consider when interpreting the effect of physical exercise on neurovascular dysregulation after TBI. To complete this picture, this review will describe how the interactions established between blood-borne factors (such as thrombin) and physical exercise alter the TBI pathophysiology.

Peripheral white blood cell counts mediated the associations of sleep duration with atherosclerotic cardiovascular disease risk: a cross-sectional study of middle-aged and older Chinese

PURPOSE

To investigate the associations between sleep duration and atherosclerotic cardiovascular disease (ASCVD) risk and the potential mechanism.

METHODS

Overall, 24,471 subjects without ASCVD were included from Dongfeng-Tongji (DFTJ) cohort. Data collection included questionnaires and general medical examinations. We used logistic regression models and generalized linear models to examine the associations between sleep duration, peripheral white blood cell (WBC) counts, and 10-year ASCVD risk. Mediation analyses were further performed to assess the potential role of peripheral WBC counts in the associations between sleep duration and 10-year ASCVD risk.

RESULTS

Increased risk of 10-year ASCVD was observed as sleep duration extended. After adjusting for potential confounders, the odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of 10-year ASCVD were 1.24 (1.11-1.38), 1.12 (1.03-1.22), and 1.21(1.08-1.36) for individuals with nighttime sleeping duration of ≥ 9 h, daytime napping duration of > 30 min, and daily sleep duration of ≥ 9 h, respectively. Peripheral WBC counts mediated 14.1%, 14.5%, and 12.6% in the associations of nighttime sleep duration of ≥ 9 h, daytime napping duration of > 30 min and daily sleep duration of ≥ 9 h with 10-year ASCVD risk, respectively.

CONCLUSIONS

Extended sleep durations are associated with the increased 10-year ASCVD risk, and the associations are partially mediated by peripheral WBC counts.

Circulating neurotrophins and hemostatic risk factors of atherothrombotic cardiovascular disease at baseline and during sympathetic challenge: the SABPA study

Sympathetic activation may trigger acute coronary syndromes. We examined the relation between circulating neurotrophic factors and hemostatic risk factors of atherothrombotic cardiovascular disease at baseline and in response to acute mental stress to establish a brain-heart link. In 409 black and white South Africans, brain-derived neurotrophic factor (BDNF) and fibrinolytic measures were assessed at baseline. Glial cell-derived neurotrophic factor (GDNF), S100 calcium-binding protein (S100B), von Willebrand factor (VWF), fibrinogen and D-dimer were assessed at baseline and 10 min after the Stroop test. Neurotrophins were regressed on hemostatic measures adjusting for demographics, comorbidities, cardiometabolic factors and health behaviors. Higher baseline BDNF was associated with greater stress-induced increase in fibrinogen (p = 0.003) and lower D-dimer increase (p = 0.016). Higher baseline S100B was significantly associated with higher baseline VWF (p = 0.031) and lower fibrinogen increase (p = 0.048). Lower baseline GDNF was associated with higher baseline VWF (p = 0.035) but lower VWF increase (p = 0.001). Greater GDNF (p = 0.006) and S100B (p = 0.042) increases were associated with lower VWF increase. All associations showed small-to-moderate effect sizes. Neurotrophins and fibrinolytic factors showed no significant associations. The findings support the existence of a peripheral neurothrophin-hemostasis interaction of small-to-moderate clinical relevance. The implications for atherothrombotic cardiovascular disease need further exploration.

Brief EcoMeditation Associated With Psychological Improvements: A Preliminary Study

BACKGROUND

A growing body of clinical research attests to the psychological and physiological benefits of meditation. EcoMeditation is a non-pharmacological therapeutic approach used to promote health and well-being, comprising four evidence-based techniques: The Quick Coherence Technique for regulating heart rate variability (HRV), Emotional Freedom Techniques (EFT), mindfulness, and neurofeedback.

OBJECTIVES

This study investigated changes in psychological symptoms of anxiety, depression, posttraumatic stress disorder (PTSD), pain, and happiness following a one-day EcoMeditation training workshop delivered in a large-group format and at 3-months post-intervention.

METHODS

A convenience sample of 208 participants (137 women, 71 men) aged between 21 and 87 years (M = 55.4 years; SD = 12.8 years) attended a one-day EcoMeditation training workshop. Participants completed a pen-and-paper survey pre-workshop and post-workshop, and an online survey three months following the EcoMeditation intervention.

RESULTS

Post-workshop results revealed significant reductions in anxiety (-23.4%, p < .001), depression (-15.8%, p = .011), PTSD (-11.8%, p < .001), and pain (-18.5%, p < .001), while happiness scores increased significantly (+8.9%, p < .001). At 3-month follow-up, one-way repeated-measures ANOVA (N = 65) found significant decreases in anxiety between pre-test and post-test, and pain between pre-intervention and 3-month follow-up. Differences in depression and PTSD scores were not significant over time. Happiness scores significantly increased from pre-test to 3-month follow-up. However, post-hoc analyses suggested that the final sample size was inadequate to detect significant differences between time points.

CONCLUSION

Findings provide preliminary support for EcoMeditation as a brief group-based stress reduction intervention with benefits for improved psychological functioning.

Impact of Acute and Chronic Stress on Thrombosis in Healthy Individuals and Cardiovascular Disease Patients

Psychological stress induces different alterations in the organism in order to maintain homeostasis, including changes in hematopoiesis and hemostasis. In particular, stress-induced hyper activation of the autonomic nervous system and hypothalamic–pituitary–adrenal axis can trigger cellular and molecular alterations in platelets, coagulation factors, endothelial function, redox balance, and sterile inflammatory response. For this reason, mental stress is reported to enhance the risk of cardiovascular disease (CVD). However, contrasting results are often found in the literature considering differences in the response to acute or chronic stress and the health condition of the population analyzed. Since thrombosis is the most common underlying pathology of CVDs, the comprehension of the mechanisms at the basis of the association between stress and this pathology is highly valuable. The aim of this work is to give a comprehensive review of the studies focused on the role of acute and chronic stress in both healthy individuals and CVD patients, focusing on the cellular and molecular mechanisms underlying the relationship between stress and thrombosis.

Associations of long-term exposure to air pollutants, physical activity and platelet traits of cardiovascular risk in a rural Chinese population

BACKGROUND

Long-term exposure to air pollutants relate to increase risk of cardiovascular diseases that may be partially attributable to platelet dysfunction. Physical activity (PA) may attenuate inflammation to modulate platelet function. Thus, this study aimed to evaluate associations of air pollutants and PA with platelet traits of cardiovascular risk.

METHODS

A total of 31,282 participants were obtained from the Henan Rural Cohort (n = 39,259). The concentrations of particulate matter (PM) (PM with an aerodynamic diameter ≤1.0 μm (PM₁), ≤2.5 μm (PM_2.5), or ≤10 μm (PM₁₀)) and nitrogen dioxide (NO₂) were evaluated by using a spatiotemporal model incorporated into satellites data. Independent and combined effects of air pollutants and PA on platelet traits were analyzed by linear mixed models.

RESULTS

Positive associations of PM₁, PM_2.5, PM₁₀ and NO₂ with platelet indices (mean platelet volume (MPV), platelet distribution width (PDW) and platelet large cell ratio (P-LCR), the MPV to platelet counts (PLT) ratio (MPVP)) were observed, whereas negative associations of PM₁₀ and NO₂ with PLT or plateletcrit (PCT) were observed; negative interaction effects of PM_2.5 PM₁₀ and NO₂ and PA on MPV, PDW or P-LCR were found; negative interaction effects of PM₁, PM_2.5 and PM₁₀ and PA on PCT were observed.

CONCLUSIONS

Long-term exposure to air pollutants were related to increase platelet size and these associations were attenuated by increased PA, implying that PA is a costless and affordable method to decrease adverse effects on platelet traits in relation to air pollutants.

Evidence for wall shear stress-dependent t-PA release in human conduit arteries: role of endothelial factors and impact of high blood pressure

Tissue plasminogen activator (t-PA) converts plasminogen into the serine protease plasmin, which in turn degrades fibrin clots. This study assessed whether an increase in shear stress is associated in humans in vivo with the release of t-PA in peripheral conduit arteries, the impact of high blood pressure and the role of NO and CYP450-derived epoxyeicosatrienoic acids (EETs). Local t-PA levels were quantified at baseline and during a sustained increase in radial artery wall shear stress induced by hand skin heating (from 34 to 44 °C) in a total of 25 subjects, among whom 8 were newly diagnosed essential hypertensive patients. The impact of the brachial infusion of NO synthase (L-NMMA) and CYP450 inhibitors (fluconazole) on t-PA release was assessed. The increase in shear stress induced by heating was associated with an increase in local t-PA release (from 3.0 ± 0.5 to 19.2 ± 5.5 ng/min, n = 25, P < 0.01). The magnitude of t-PA release was positively correlated with the increase in shear stress (r = 0.64, P < 0.001) and negatively correlated with mean blood pressure (r = -0.443, P = 0.027). These associations persisted after multiple adjustments for confounding factors. Finally, t-PA release was reduced by L-NMMA and to a larger extent by the combination of L-NMMA and fluconazole without a change in shear stress. The increase in wall shear stress in the peripheral conduit arteries induces a release of t-PA by a mechanism involving NO and EETs. The alteration of this response by high blood pressure may contribute to reducing the fibrinolytic potential and enhancing the risk of arterial thrombosis during exercise.

Coronavirus (COVID-19), Coagulation, and Exercise: Interactions That May Influence Health Outcomes

The proinflammatory cytokine storm associated with coronavirus disease 2019 (COVID-19) negatively affects the hematological system, leading to coagulation activation and endothelial dysfunction and thereby increasing the risk of venous and arterial thrombosis. Coagulopathy has been reported as associated with mortality in people with COVID-19 and is partially reflected by enhanced D-dimer levels. Poor vascular health, which is associated with the cardiometabolic health conditions frequently reported in people with severer forms of COVID-19, might exacerbate the risk of coagulopathy and mortality. Sedentary lifestyles might also contribute to the development of coagulopathy, and physical activity participation has been inherently lowered due to at-home regulations established to slow the spread of this highly infectious disease. It is possible that COVID-19, coagulation, and reduced physical activity may contribute to generate a “perfect storm,” where each fuels the other and potentially increases mortality risk. Several pharmaceutical agents are being explored to treat COVID-19, but potential negative consequences are associated with their use. Exercise is known to mitigate many of the identified side effects from the pharmaceutical agents being trialled but has not yet been considered as part of management for COVID-19. From the limited available evidence in people with cardiometabolic health conditions, low- to moderate-intensity exercise might have the potential to positively influence biochemical markers of coagulopathy, whereas high-intensity exercise is likely to increase thrombotic risk. Therefore, low- to moderate-intensity exercise could be an adjuvant therapy for people with mild-to-moderate COVID-19 and reduce the risk of developing severe symptoms of illness that are associated with enhanced mortality.

Psychotic, Mood, and Anxiety Disorders and Venous Thromboembolism: A Systematic Review and Meta-Analysis

OBJECTIVE

Several studies have shown that psychiatric disorders can be associated with venous thromboembolism (VTE) risk, that is, pulmonary embolism (PE) and/or deep vein thrombosis (DVT). In this study, we provide a systematic review and meta-analyses of the studies addressing this issue.

METHODS

All studies addressing the risk of VTE phenomena (whole VTE, PE, DVT, fatal VTE) in individuals with psychotic, mood, and anxiety disorders published between 1998 and 2019 were reviewed and included in the meta-analyses. Main characteristics of the studies and data concerning VTE risk were extracted. The methodological qualities of the studies were also analyzed. A random-effects meta-analysis model was used. A meta-analysis was conducted separately for each disorder, as well as separately for unadjusted and adjusted studies. Meta-analyses were repeated considering only good-quality studies. Heterogeneity was assessed.

RESULTS

Sixteen studies were reviewed and 15 included in the meta-analyses. Psychotic and bipolar disorders were significantly associated with VTE risk (VTE, DVT, PE, and fatal VTE for psychotic disorder: odds ratios [ORs] between 1.29 and 2.20; VTE, DVT, and PE for bipolar disorder: ORs between 1.22 and 2.14). Depression and anxiety disorders were associated with VTE risk only in adjusted analyses (DVT and PE for depression: ORs = 1.29; VTE and PE for anxiety disorders: ORs between 1.14 and 1.49).

CONCLUSIONS

The risk of VTE among individuals with psychiatric disorders may be explained by hypercoagulability and stasis, with both being related to, and independent of, treatment adverse effects. VTE risk should be taken into consideration in the treatment for people with psychiatric disorders.

mRNA and miRNA profiles in the nucleus accumbens are related to fear memory and anxiety induced by physical or psychological stress

Anxiety is presumably driven by fear memory. The nucleus accumbens involves emotional regulation. Molecular profiles in the nucleus accumbens related to stress-induced fear memory remain elucidated. Fear memory in mice was induced by a paradigm of social defeat. Physical and psychological stress was delivered to an intruder that was attacked by an aggressive resident. Meanwhile, an observer experienced psychological stress by seeing aggressor attacks. The nucleus accumbens tissues from intruder and observer mice that appear fear memory and anxiety as well as control mice were harvested for analyses of mRNA and miRNA profiles by high throughput sequencing. In the nucleus accumbens of intruders and observers with fear memory and anxiety, genes encoding AdrRα, AChRM2/3, GluRM2/8, HrR1, SSR, BDNF and AC are upregulated, while genes encoding DR3/5, PR2, GPγ8 and P450 are downregulated. Physical and/or psychological stress leads to fear memory and anxiety likely by molecules relevant to certain synapses. Moreover, there are differential expressions in genes that encode GABAR_A, 5-HTR1/5, CREB3, AChRM2, RyR, Wnt and GPγ13 in the nucleus accumbens from intruders versus observers. GABAergic, serotonergic and cholinergic synapses as well as calcium, Wnt and CREB signaling molecules may be involved in fear memory differently induced by psychological stress and physical/psychological stress. The data from analyzing mRNA and miRNA profiles are consistent. Some molecules are validated by qRT-PCR and dual luciferase reporter assay. Fear memory and anxiety induced by the mixture of physical and psychological stress or psychological stress appear influenced by complicated molecular mechanisms in the nucleus accumbens.

Current dosing practices for perioperative factor VIII concentrate treatment in mild haemophilia A patients result in FVIII levels above target

BACKGROUND

In patients with haemophilia A (HA) perioperative dosing of factor VIII (FVIII) concentrate is based on body weight, historical FVIII level, in vivo recovery and FVIII level target values. In moderate and severe HA patients, this dosing regimen frequently leads to perioperative FVIII levels below and above target. This has not yet been evaluated in mild HA patients.

OBJECTIVES

To evaluate perioperative FVIII concentrate treatment in mild HA patients and to assess the frequency of FVIII levels below or above target.

PATIENTS/METHODS

This retrospective single-centre study collected data from medical files of mild HA patients undergoing surgery and treated with FVIII concentrate. FVIII levels were compared to their target ranges and predictive factors for levels outside the target ranges were determined by logistic regression.

RESULTS

Fifty surgeries performed in 34 patients were evaluated. Median age was 47 years and median historical FVIII level was 0.14 IU/mL. Preoperative peak FVIII level was above or below the target range in 80% and 6.7% of surgeries, respectively. Postoperatively, the percentages above and below target trough ranges were 55.8% and 12.8%. Patients with blood group 0 had the highest risk on the preoperative peak FVIII level being above target. In addition, patients who had a preoperative baseline FVIII level of >0.10 IU/mL higher than their historical FVIII level had a higher preoperative peak FVIII level than patients without this increase.

CONCLUSIONS

Dosing above FVIII target ranges with FVIII concentrates occurs frequently during perioperative treatment of mild HA patients. These results underline the necessity for better patient-tailored treatment.

The viewing of a 'Bloodcurdling' horror movie increases platelet reactivity: A randomized cross-over study in healthy volunteers

BACKGROUND

Epidemiological studies have suggested an increased risk of cardiovascular events (CVE) during acute stressful and/or frightful moments. A possible explanation for this could be an effect of acute stress on hemostasis. A recent study demonstrated an increase in factor VIII after watching a horror movie. Primary hemostasis, however, is thought to play a more prominent role in the etiology of CVE. The objective of this study was therefore to assess the influence of viewing a 'bloodcurdling' horror movie on platelet reactivity in healthy volunteers.

METHODS

We performed a randomized cross-over study in healthy adults. Subjects were allocated to two movies in random sequence: a horror and a control movie. Blood was drawn at baseline and after 24 min of viewing time. The primary endpoint was the change in Platelet Function Analyzer® Closure Time (Δ PFA-CT) after watching the movie.

RESULTS

In total, 20 participants, aged 18-30 years, completed the study protocol. The delta PFA-CT was statistically significantly shorter with a mean in the delta difference of -9.7 s (SEM 4.0, 95% C.I. -18.0 to -1.3) during the horror movie versus the control movie. The Light Transmission Aggregometry endpoints were in line with the PFA-CT, albeit only the highest level of Arachidonic Acid agonist demonstrated a statistically significant mean difference in the delta of aggregation of 13.15% (SEM 7.0, 95% C.I. 1.6-27.9).

CONCLUSION

A 'blood curdling' horror movie increases platelet reactivity. These data are supportive of a role of platelet reactivity in acute stress induced cardiovascular event risk.

microRNA and mRNA profiles in the amygdala are relevant to fear memory induced by physical or psychological stress

Anxiety is presumably driven by fear memory. Molecular profiles in the amygdala of mice with fear memory induced by psychological and physical stresses remain to be elucidated. Fear memory in mice was induced by a paradigm of social defeat. Physical and psychological stresses (PPS) to an intruder were given by attacks from an aggressive resident. Psychological stress (PS) to an observer was given by the witnessing of aggressor attacks. Amygdala tissues from these mice showing fear memory and anxiety vs. tissues from control mice were harvested to analyze mRNA and microRNA profiles by high-throughput sequencing. In the amygdala of intruders and observers with fear memory, the genes encoding 5-HTR1b, 5-HTR2a, DAR2, AChRM3, and IP3R1 are upregulated, whereas genes encoding GPγ11, GPγ13, GPγT2, RasC3, and P450 are downregulated, indicating that these molecules are involved in fear memory induced by physical/psychological stresses. In the comparison of intruders with observers, the upregulation of genes encoding 5-HTR6, GPγ8, P2R7, NFκ2, CREB3/1, and Itgα9 as well as the downregulation of genes encoding DAR5, 5-HTR1a, and HSP1a are involved in fear memory induced by physical stress. The upregulation of genes encoding DAR1, 5-HTR5a and SSR2/3 as well as the downregulation of AdRα1, CREB3/1, GPγ13 and GPγ8 are involved in fear memory induced by psychological stress. Results obtained by sequencing mRNA and microRNA profiles are consistent with results of quantitative RT-PCR analysis and dual-luciferase reporter assays performed for validation. In conclusion, fear memories and anxiety induced by PPS vs. PS are caused by the imbalanced regulation of different synapses and signaling pathways in the amygdala.NEW & NOTEWORTHY The current study identifies the molecular mechanism underlying fear memory and anxiety induced by psychological stress vs. physical stress, in which the imbalanced expression of microRNA-regulated mRNAs relevant to dopaminergic, adrenergic, and serotonergic synapses in the amygdala plays an important role. This result reveals different molecular profiles for psychological and physical stresses.

Prothrombotic response to norepinephrine infusion, mimicking norepinephrine stress-reactivity effects, is partly mediated by α-adrenergic mechanisms

BACKGROUND

Stress-induced prothrombotic changes are mediated by the sympathetic nervous system and critically involved in mental triggering of acute coronary syndromes, but the underlying psychobiology is not fully understood. We tested the hypothesis that a norepinephrine (NE) infusion to mimic effects of stress-induced NE release on blood coagulation elicits prothrombotic changes and examined to what extent these would be mediated by an alpha-adrenergic mechanism.

METHODS AND RESULTS

In a single-blind placebo-controlled within-subjects design, 24 middle-aged, non-smoking, non-obese and normotensive men participated in three experimental trials with an interval between one and two weeks. Each trial applied two sequential infusions of 1 and 15 min duration with varying substances [i.e., saline as placebo, the non-specific α-blocker phentolamine (2.5 mg/min), and NE (5 μg/min)]: trial 1=saline + saline; trial 2=saline + NE, and trial 3=phentolamine + NE. Plasma levels of clotting factor VIII activity (FVIII:C), fibrinogen, and D-dimer were assessed from blood samples collected immediately before and 1 min and 20 min after infusion procedures. Compared to saline + saline, saline + NE induced increases over time in FVIII:C, fibrinogen, and D-dimer levels. With phentolamine + NE, fibrinogen levels remained increased compared to saline + saline, but changes in FVIII:C and D-dimer levels were no more different. Coagulation changes did not differ between saline + NE and phentolamine + NE.

CONCLUSIONS

NE infusion activates blood coagulation. The resulting prothrombotic state could be one psychobiological mechanism underlying mental triggering of acute coronary syndromes. Blockade of α-adrenergic receptors partly attenuated NE effects on coagulation and could be implied to have preventive potential in susceptible individuals.

Association between beta-adrenoceptor antagonist-induced sympathicolysis and severity of coronary artery disease as assessed by coronary computed tomography angiography (CCTA)

Enhanced sympathetic nervous system activity is associated with increased mortality in many cardiac conditions including heart failure and coronary artery disease (CAD). To ensure adequate image quality of coronary CT angiography (CCTA), pre-scan β-adrenergic blockers (BB) are routinely administered. It is currently unknown whether sensitivity to sympathicolytic compounds is associated with severity of CAD. A total of 2633 consecutive patients (1733 [65.8%] men and 900 [34.2%] women, mean age 56.7 ± 11.5 years) undergoing CCTA for exclusion of significant CAD at our department between 06/2013 and 12/2016 were evaluated. Acute heart rate (HR) responses to BB administration were recorded in all patients. Coronary plaque burden as indicated by segment severity score (SSS), segment involvement score (SIS), and significant CAD (i.e. > 50% luminal narrowing) was higher in weak responders to BB as compared to strong responders to BB (p = 0.001 for SSS and SIS, and p = 0.021 for significant CAD). Accordingly, in a multiple linear regression model adjusted for known risk factors of CAD such as smoking, hypertension, diabetes and dyslipidaemia, as well as age, sex, body mass index (BMI), glomerular filtration rate, and HR during CCTA scan, a strong response to BB was selected as a significant independent negative predictor of coronary plaque burden (beta coefficient - 0.08, p = 0.001). We demonstrate that individuals with a weak acute response to BB administration encounter an increased risk of severe CAD. Taking into account sensitivity to sympatho-inhibition may add complementary information in patients undergoing CCTA for evaluation of CAD.

Sub-Chronic Stress Exacerbates the Pro-Thrombotic Phenotype in BDNFVal/Met Mice: Gene-Environment Interaction in the Modulation of Arterial Thrombosis

Brain-Derived Neurotrophic Factor (BDNF) Val66Met polymorphism has been associated with increased susceptibility to develop mood disorders and recently it has been also linked with cardiovascular disease (CVD). Interestingly, stressful conditions unveil the anxious/depressive-like behavioral phenotype in heterozygous BDNFVal66Met (BDNF^Val/Met) mice, suggesting an important relationship in terms of gene-environment interaction (GxE). However, the interplay between stress and BDNF^Val/Met in relation to CVD is completely unknown. Here, we showed that BDNF^Val/Met mice display a greater propensity to arterial thrombosis than wild type BDNF^Val/Val mice after 7 days of restraint stress (RS). RS markedly increased the number of leukocytes and platelets, and induced hyper-responsive platelets as showed by increased circulating platelet/leukocyte aggregates and enhanced expression of P-selectin and GPIIbIIIa in heterozygous mutant mice. In addition, stressed BDNF^Val/Met mice had a greater number of large and reticulated platelets but comparable number and maturation profile of bone marrow megakaryocytes compared to BDNF^Val/Val mice. Interestingly, RS led to a significant reduction of BDNF expression accompanied by an increased activity of tissue factor in the aorta of both BDNF^Val/Val and BDNF^Val/Met mice. In conclusion, we provide evidence that sub-chronic stress unveils prothrombotic phenotype in heterozygous BDNF Val66Met mice affecting both the number and functionality of blood circulating cells, and the expression of key thrombotic molecules in aorta. Human studies will be crucial to understand whether this GxE interaction need to be taken into account in risk stratification of coronary artery disease (CAD) patients.

Not all plaque ruptures are born equal: an optical coherence tomography study

Aims

Plaque rupture (PR) represents the most common substrate of coronary thrombosis, in at least 50% of cases. Chronic low grade inflammation is a common background for atherosclerosis development; however, increased plaque inflammation may predispose by itself to PR. In the last decade, studies performed by optical coherence tomography (OCT) have allowed to establish the severity of plaque inflammation by assessing macrophage infiltration (MØI). Our retrospective study aimed at assessing the role of plaque inflammation in PR among patients with acute coronary syndrome (ACS) using OCT.

Methods and results

We enrolled 56 patients with ACS exhibiting PR at the site of the culprit stenosis identified by OCT. Patients were divided into two cohorts according to the presence of MØI at OCT analysis, defined as signal-rich, distinct, or confluent punctate regions that exceed the intensity of background speckle noise. Serum high-sensitivity C-reactive protein (CRP) was measured on admission by latex-enhanced immunophelometric assay. Thirty-seven (66%) patients had MØI at the site of PR, whereas 19 (34%) patients had no evidence of MØI. Patients with MØI showed a higher rate of CRP values >3 mg/dL as compared with those without MØI (92% vs. 47%, P = 0.004). In contrast, patients without MØI had a higher prevalence of hypertension compared with those with MØI (89% vs. 59%, P = 0.021). Furthermore, the group with MØI exhibited a significantly higher rate of lipid-rich plaques (86% vs. 50%, P = 0.008), a higher rate of multifocal disease (59% vs. 10%, P < 0.001), and an MØI in both culprit and remote lesions (97% vs. 0%, P < 0.001) compared with those without MØI. At multivariate analysis, CRP value >3 mg/dL was the only independent predictor of MØI in the culprit plaque (OR 8.72, 95% CI 1.78-41.67, P= 0.007).

Conclusions

In conclusion, PR can be caused by predominant inflammatory or non-inflammatory mechanisms, over a common low-grade chronic inflammatory background well known from pathology observations.

Physiological stress response patterns during a blood donation

BACKGROUND

Donating blood is associated with increased psychological stress. This study investigates whether a blood donation induces physiological stress and if response patterns differ by gender, donation experience and non-acute stress.

STUDY DESIGN AND METHODS

In 372 donors, physiological stress [blood pressure, pulse rate, pulse rate variability (PRV)] was measured at seven moments during routine donation. PRV was assessed using time domain [root mean square of successive differences (RMSSD)] and frequency domain [high frequency (HF) and low frequency (LF) power] parameters. Non-acute stress was assessed by questionnaire. Shape and significance of time course patterns were assessed by fitting multilevel models for each stress measure and comparing men and women, first-time and experienced donors, and donors with high and low levels of non-acute stress.

RESULTS

Significant response patterns were found for all stress measures, where levels of systolic blood pressure (F(1,1315) = 24·2, P < 0·001), RMSSD (F(1,1315) = 24·2, P < 0·001), LF (F(1,1627) = 14·1, P < 0·001) and HF (F(1,1624) = 34·0, P < 0·001) increased towards needle insertion and then decreased to values lower than when arriving at the donation centre. Diastolic blood pressure (F(1,1326) = 50·9, P < 0·001) increased and pulse rate (F(1,1393) = 507·4, P < 0·001) showed a U-shaped curve. Significant group effects were found, that is, higher systolic blood pressure/pulse rate in women; higher pulse rate in first-time donors; higher RMSSD at arrival and from screening until leaving in first-time donors; and higher LF and HF in first-time donors.

CONCLUSION

This study shows an increase in physiological stress related to needle insertion, followed by a decrease when leaving the donation centre. Some group effects were also found.

The Interrelated Physiological and Psychological Effects of EcoMeditation

This study investigated changes in psychological and physiological markers during a weekend meditation workshop (N = 34). Psychological symptoms of anxiety, depression, posttraumatic stress disorder (PTSD) and happiness were assessed. Physiological markers included cortisol, salivary immunoglobulin A (SigA), heart rate variability (HRV), blood pressure (BP), and resting heart rate (RHR). On posttest, significant reductions were found in cortisol (-29%, P < .0001), RHR (-5%, P = .0281), and pain (-43%, P = .0022). Happiness increased significantly (+11%, P = .0159) while the increase in SigA was nonsignificant (+27%, P = .6964). Anxiety, depression, and PTSD all declined (-26%, P = .0159; -32%, P = .0197; -18%, P = .1533), though changes in PTSD did not reach statistical significance. No changes were found in BP, HRV, and heart coherence. Participants were assessed for psychological symptoms at 3-month follow-up, but the results were nonsignificant due to inadequate sample size (n = 17). EcoMeditation shows promise as a stress-reduction method.

Procoagulant reactivity to laboratory acute mental stress in Africans and Caucasians, and its relation to depressive symptoms: The SABPA Study

The risk of cardiovascular disease is dramatically increasing in Africans (black). The prothrombotic stress response contributes to atherothrombotic disease and is modulated by depressive symptoms. We examined coagulation reactivity to acute mental stress and its relation to psychological well-being in Africans relative to Caucasians (white). A total of 102 African and 165 Caucasian school teachers underwent the Stroop Color-Word Conflict test. Circulating levels of von Willebrand factor (VWF) antigen, fibrinogen, and D-dimer were measured before and after the Stroop. Cardiovascular reactivity measures were also obtained. All participants completed the Patient Health Questionnaire-9 and the General Health Questionnaire-28 for the assessment of depressive symptoms and total psychological distress, respectively. After controlling for covariates, resting levels of VWF, fibrinogen, and D-dimer were higher in Africans than in Caucasians (all p-values ≤0.006). Depressive symptoms and psychological distress were not significantly associated with resting coagulation measures. Stress reactivity in VWF (p<0.001) and fibrinogen (p=0.016), but not in D-dimer (p=0.27), were decreased in Africans relative to Caucasians with Africans showing greater reactivity of total peripheral resistance (p=0.017). Depressive symptoms, but not general psychological distress, were associated with greater VWF increase (p=0.029) and greater fibrinogen decrease (p=0.030) in Africans relative to Caucasians. In conclusion, Africans showed greater hypercoagulability at rest but diminished procoagulant reactivity to acute mental stress when compared with Caucasians. Ethnic differences in the vascular adrenergic stress response might partially explain this finding. Depressive symptoms were associated with exaggerated VWF reactivity in Africans relative to Caucasians. The clinical implications of these findings for Africans need further study.

Emotional states and future risk of venous thromboembolism

Emotional states of depression and loneliness are reported to be associated with higher risk and optimism with lower risk of arterial cardiovascular disease (CVD) and death. The relation between emotional states and risk of venous thromboembolism (VTE) has not been explored previously. We aimed to investigate the associations between self-reported emotional states and risk of incident VTE in a population-based, prospective study. The frequency of feeling depressed, lonely and happy/optimistic were registered by self-administered questionnaires, along with major co-morbidities and lifestyle habits, in 25,964 subjects aged 25–96 years, enrolled in the Tromsø Study in 1994–1995. Incident VTE-events were registered from the date of inclusion until September 1, 2007. There were 440 incident VTE-events during a median of 12.4 years of follow-up. Subjects who often felt depressed had 1.6-fold (95% CI:1.02–2.50) higher risk of VTE compared to those not depressed in analyses adjusted for other risk factors (age, sex , body mass index, oes-trogens), lifestyle (smoking, alcohol consumption, educational level) and co-morbidities (diabetes, CVD, and cancer). Often feeling lonely was not associated with VTE. However, the incidence rate of VTE in subjects who concurrently felt often lonely and depressed was higher than for depression alone (age-and sex-adjusted incidence rate: 3.27 vs. 2.21). Oppositely, subjects who often felt happy/optimistic had 40% reduced risk of VTE (HR 0.60, 95% CI: 0.41–0.87). Our findings suggest that self-reported emotional states are associated with risk of VTE. Depressive feelings were associated with increased risk, while happiness/ optimism was associated with reduced risk of VTE.

Socioeconomic Factors and Severity of Coronary Artery Disease in Patients Undergoing Coronary Angiography: A Multicentre Study of Arabian Gulf States

INTRODUCTION

Coronary artery disease (CAD) is a leading cause of death worldwide. The association of socioeconomic status with CAD is supported by numerous epidemiological studies. Whether such factors also impact the number of diseased coronary vessels and its severity is not well established.

MATERIALS AND METHODS

We conducted a prospective multicentre, multi-ethnic, cross sectional observational study of consecutive patients undergoing coronary angiography (CAG) at 5 hospitals in the Kingdom of Saudi Arabia and the United Arab Emirates. Baseline demographics, socioeconomic, and clinical variables were collected for all patients. Significant CAD was defined as ≥70% luminal stenosis in a major epicardial vessel. Left main disease (LMD) was defined as ≥50% stenosis in the left main coronary artery. Multi-vessel disease (MVD) was defined as having >1 significant CAD.

RESULTS

Of 1,068 patients (age 59 ± 13, female 28%, diabetes 56%, hypertension 60%, history of CAD 43%), 792 (74%) were from urban and remainder (26%) from rural communities. Patients from rural centres were older (61 ± 12 vs 58 ± 13), and more likely to have a history of diabetes (63 vs 54%), hypertension (74 vs 55%), dyslipidaemia (78 vs 59%), CAD (50 vs 41%) and percutaneous coronary intervention (PCI) (27 vs 21%). The two groups differed significantly in terms of income level, employment status and indication for angiography. After adjusting for baseline differences, patients living in a rural area were more likely to have significant CAD (adjusted OR 2.40 [1.47, 3.97]), MVD (adjusted OR 1.76 [1.18, 2.63]) and LMD (adjusted OR 1.71 [1.04, 2.82]). Higher income was also associated with a higher risk for significant CAD (adjusted OR 6.97 [2.30, 21.09]) and MVD (adjusted OR 2.49 [1.11, 5.56]), while unemployment was associated with a higher risk of significant CAD (adjusted OR 2.21, [1.27, 3.85]).

CONCLUSION

Communal and socioeconomic factors are associated with higher odds of significant CAD and MVD in the group of patients referred for CAG. The underpinnings of these associations (e.g. pathophysiologic factors, access to care, and system-wide determinants of quality) require further study.

The exercise paradox may be solved by measuring the overall thrombotic state using native blood

While exercise is widely believed to prevent atherothrombotic diseases, it occasionally causes sudden death. This exercise paradox may be due to the inadequate testing of the thrombotic and thrombolytic status. A recently developed shear-induced thrombosis/endogenous fibrinolysis test performed with non-anticoagulated blood samples allows the assessment of the thrombotic state of an individual both at rest and after exercise. This sensitive and physiologically relevant test may help to solve the aforementioned exercise paradox.

Experimental protocol of dental procedures In patients with hereditary angioedema: the role of anxiety and the use of nitrogen oxide

Hereditary angioedema (HAE) is a rare disease, little known to the medical and dental community, but with a growing rate of hospitalization over the years. HAE is due to a deficit/dysfunction of C1 esterase inhibitor which leads to an increase in vascular permeability and the appearance of edemas widespread in all body areas. The airways are the most affected and laryngeal swelling, which can occur, it is dangerous for the patient's life, is also a sensitive spot in our daily practice, therefore, it is also important to be aware of all the signs of this disease. Episodes of HAE have no obvious cause, but it can be triggered by anxiety, invasive procedures and trauma. So this disease is a major problem in oral and maxillofacial surgery, ENT, endoscopy, emergency medicine and anesthesia because even simple procedures can cause laryngeal edema. The recommendations on the management of HAE include long- and short-term prophylaxis and treatment for acute attacks, however, the importance of anxiety control during the operating phases is undervalued. The present work suggests an experimental protocol for the surgery management of HAE patients with the help of nitrous oxide, with a brief review of the literature on this topic.

Revisiting the health effects of psychological stress-its influence on susceptibility to ionizing radiation: a mini-review

Both psychological stress (PS) and ionizing radiation (IR) cause varied detrimental effects on humans. There has been no direct evidence so far showing PS alone could cause cancer; however, long-lasting PS may affect our overall health and ability to cope with cancer. Due to their living conditions and occupations, some people may encounter concurrent exposure to both PS and IR to a high extent. In addition to possible health effects resulting directly from exposure to IR on these people, fear of IR exposure is also a cause of PS. The question of whether PS would influence susceptibility to IR, radiocarcinogenesis in particular, is of great concern by both the academic world and the public. Recently, investigations using animal PS models demonstrated that PS could modulate susceptibility to IR, causing increased susceptibility to radiocarcinogenesis in Trp53-heterozygous mice, hematological toxicity in peripheral blood and elevated chromosome aberration (dicentrics) frequency in splenocytes of Trp53-wild-type mice. To actively reduce health risk from exposure to IR, further studies are needed to cumulate more evidence and provide insights into the mechanisms underlying the alterations in susceptibility due to PS modulation. This mini-review gives a general overview of the significance of PS effects on humans and experimental animals, with a special focus on summarizing the latest weight-of-evidence approaches to radiobiological studies on PS-induced alterations in susceptibility in experimental animal models. The susceptibility being investigated is mainly in the context of the impact of the modulatory effect of PS on radiocarcinogenesis; we seek to improve understanding of the combined effects of exposure to both PS and IR in order to facilitate, via active intervention, strategies for radiation risk reduction.

Venous Thromboembolism in Physically Active People: Considerations for Risk Assessment, Mainstream Awareness and Future Research

The global healthcare burden of venous thromboembolism (VTE) and associated comorbidities (e.g., obesity, heart disease and cancer) is significant. Physical activity-especially cardiovascular exercise-is popularly acclaimed for gold-standard prevention. Paradoxically, intensive training can expose athletes to several potentially thrombogenic risk factors (e.g., heat stress, dehydration, blood vessel injury and inflammation). However, awareness regarding the risk of VTE in physically active people is generally lacking. Given that the overall incidence of asymptomatic and/or occult blood clots that resolve spontaneously is uncharted, and because symptoms and sequelae are not always 'textbook', triage evaluation and diagnosis of VTE at large can be challenging. Front-line clinical evaluations, including the major Wells scoring criteria, are (versus the total number of possible factors and diagnoses) comparably reductionist, and the point at which a minor risk might be considered significant in one person-but not in another-is subjective. Considering the popular associations between VTE and inactivity, athletes might be at greater risk of a missed diagnosis quite simply because their cardiovascular conditioning presents as the polar opposite to standard assessment criteria. Undoubtedly, risk factors for VTE associated with exercise are not unique to cardiovascular training or athletes, but the extent to which they might increase the chances of blood clot precipitation in certain participants warrants attention. A multi-agency approach, including research to inform mainstream understanding and awareness about risk factors for VTE in patient groups across age, comorbidity and activity spectra, is required. In this article, the potential for pre-participatory thrombophilia screening, haemostatic monitoring and personalized prophylactic guidelines is discussed.

Longer Sleep Duration and Midday Napping Are Associated with a Higher Risk of CHD Incidence in Middle-Aged and Older Chinese: the Dongfeng-Tongji Cohort Study

STUDY OBJECTIVES

To analyze the independent and combined relations of sleep duration and midday napping with coronary heart diseases (CHD) incidence along with the underlying changes of cardiovascular disease (CVD) risk factors among Chinese adults.

METHODS

We included 19,370 individuals aged 62.8 years at baseline from September 2008 to June 2010, and they were followed until October 2013. Cox proportional hazards models and general linear models were used for multivariate longitudinal analyses.

RESULTS

Compared with sleeping 7- < 8 h/night, the hazard ratio (HR) of CHD incidence was 1.33 (95% CI = 1.10 to 1.62) for sleeping ≥ 10 h/night. The association was particularly evident among individuals who were normal weight and without diabetes. Similarly, the HR of incident CHD was 1.25 (95% CI = 1.05 to 1.49) for midday napping > 90 min compared with 1-30 min. When sleep duration and midday napping were combined, individuals having sleep duration ≥ 10 h and midday napping > 90 min were at a greater risk of CHD than those with sleeping 7- < 8 h and napping 1-30 min: the HR was 1.67 (95% CI = 1.04 to 2.66; P for trend = 0.017). In addition, longer sleep duration ≥ 10 h was significantly associated with increases in triglycerides and waist circumference, and a reduction in HDL-cholesterol; while longer midday napping > 90 min was related to increased waist circumference.

CONCLUSIONS

Both longer sleep duration and midday napping were independently and jointly associated with a higher risk of CHD incidence, and altered lipid profile and waist circumference may partially explain the relationships.

Deep Vein Thrombosis and Pulmonary Embolism in a Mountain Guide: Awareness, Diagnostic Challenges, and Management Considerations at Altitude

High intensity exercise is associated with several potentially thrombogenic risk factors, including dehydration and hemoconcentration, vascular trauma, musculoskeletal injuries, inflammation, long-distance travel, and contraceptive usage. These are well documented in case reports of venous thrombosis in track and field athletes. For mountaineers and those working at high altitude, additional risks exist. However, despite there being a high degree of vigilance for "classic" conditions encountered at altitude (eg, acute mountain sickness, high altitude pulmonary edema, and high altitude cerebral edema), mainstream awareness regarding thrombotic conditions and their complications in mountain athletes is relatively low. This is significant because thromboembolic events (including deep vein thrombosis, pulmonary embolism, and cerebral vascular thrombosis) are not uncommon at altitude. We describe a case of deep vein thrombosis and pulmonary embolism in a male mountain guide and discuss the diagnostic issues encountered by his medical practitioners. Potential risk factors affecting blood circulation (eg, seated car travel and compression of popliteal vein) and blood hypercoagulability (eg, hypoxia, environmental and psychological stressors [avalanche risk, extreme cold]) relevant to the subject of this report and mountain athletes in general are identified. Considerations for mitigating and managing thrombosis in addition to personalized care planning at altitude are discussed. The prevalence of thrombosis in mountain athletes is uncharted, but lowlanders increasingly go to high altitude to trek, ski, or climb. Blood clots can and do occur in physically active people, and thrombosis prevention and recognition will demand heightened awareness among participants, healthcare practitioners, and the altitude sport/leisure industry at large.

Bloodcurdling movies and measures of coagulation: Fear Factor crossover trial

OBJECTIVE

To assess whether, as has been hypothesised since medieval times, acute fear can curdle blood.

DESIGN

Crossover trial.

SETTING

Main meeting room of Leiden University's Department of Clinical Epidemiology, the Netherlands, converted to a makeshift cinema.

PARTICIPANTS

24 healthy volunteers aged ≤30 years recruited among students, alumni, and employees of the Leiden University Medical Center: 14 were assigned to watch a frightening (horror) movie followed by a non-threatening (educational) movie and 10 to watch the movies in reverse order. The movies were viewed more than a week apart at the same time of day and both lasted approximately 90 minutes.

MAIN OUTCOME MEASURES

The primary outcome measures were markers, or "fear factors" of coagulation activity: blood coagulant factor VIII, D-dimer, thrombin-antithrombin complexes, and prothrombin fragments 1+2. The secondary outcome was participant reported fear experienced during each movie using a visual analogue fear scale.

RESULTS

All participants completed the study. The horror movie was perceived to be more frightening than the educational movie on a visual analogue fear scale (mean difference 5.4, 95% confidence interval 4.7 to 6.1). The difference in factor VIII levels before and after watching the movies was higher for the horror movie than for the educational movie (mean difference of differences 11.1 IU/dL (111 IU/L), 95% confidence interval 1.2 to 21.0 IU/dL). The effect of either movie on levels of thrombin-antithrombin complexes, D-dimer, and prothrombin fragments 1+2 did not differ.

CONCLUSION

Frightening (in this case, horror) movies are associated with an increase of blood coagulant factor VIII without actual thrombin formation in young and healthy adults. Trial registration ClinicalTrials.gov NCT02601053.

Differential changes in platelet reactivity induced by acute physical compared to persistent mental stress

Platelets are important in hemostasis, but also contain adhesion molecules, pro-inflammatory and immune-modulatory compounds, as well as most of the serotonin outside the central nervous system. Dysbalance in the serotonin pathways is involved in the pathogenesis of depressive symptoms. Thus, changes in platelet aggregation and content of bioactive compounds are of interest when investigating physiological stress-related mental processes as well as stress-related psychiatric diseases such as depression. In the present study, a characterization of platelet reactivity in acute physical and persistent mental stress was performed (aggregation, serotonin and serotonin 2A-receptor, P-selectin, CD40 ligand, matrix metalloproteinase-2 and -9 (MMP-2 and -9), platelet/endothelial adhesion molecule-1 (PECAM-1), intercellular adhesion molecule-1 (ICAM-1), β-thromboglobulin (β-TG) and platelet factor 4 (PF-4). Acute physical stress increased platelet aggregability while leaving platelet content of bioactive compounds unchanged. Persistent mental stress led to changes in platelet content of bioactive compounds and serotonin 2A-receptor only. The values of most bioactive compounds correlated with each other. Acute physical and persistent mental stress influences platelets through distinct pathways, leading to differential changes in aggregability and content of bioactive compounds.

Depression and risk of venous thromboembolism: a population-based retrospective cohort study

OBJECTIVE

This study investigated the relationship between depression and the risk of subsequent venous thromboembolism (VTE) development.

METHODS

We conducted a population-based retrospective cohort analysis by using data for the period of 2000 to 2011 from the Longitudinal Health Insurance Database 2000 of Taiwan. A depression cohort comprising 35,274 patients and a nondepression cohort comprising 70,548 patients matched according to sex, age, and index year with no history of VTE were evaluated. Cox proportional hazard regression analysis was used to assess the effects of depression and comorbidities, and the Kaplan-Meier method was applied to estimate the cumulative VTE incidence curves.

RESULTS

Compared with individuals without depression, depressed patients had a 1.38-fold greater risk (95% confidence interval = 1.09-1.73) of developing VTE. This risk was significantly higher in male and younger (≤49 years) patients. In addition, patients with comorbidities such as hypertension, diabetes, heart failure, and cancer had a higher risk of depression-associated VTE that was attenuated, although nonsignificantly, by antidepressant use.

CONCLUSIONS

The incidence of VTE in Taiwan is higher in depressed patients than in nondepressed patients. Moreover, men, people 49 years or younger, and patients with comorbidities have a significantly greater risk of VTE after depression.

Resilience to orthostasis and haemorrhage: A pilot study of common genetic and conditioning mechanisms

A major challenge presently is not only to identify the genetic polymorphisms increasing risk to diseases, but to also find out factors and mechanisms, which can counteract a risk genotype by developing a resilient phenotype. The objective of this study was to examine acquired and innate vagal mechanisms that protect against physical challenges and haemorrhages in 19 athletes and 61 non-athletes. These include examining change in heart rate variability (HF-HRV; an indicator of vagus activity) in response to orthostatic challenge, platelet count (PLT), mean platelet volume (MPV), and single-nucleotide polymorphisms in genes that encode several coagulation factors, PAI-1, and MTHFR. Individual differences in PLT and MPV were significant predictors, with opposite effects, of the profiles of the HF-HRV changes in response to orthostasis. Regular physical training of athletes indirectly (through MPV) modifies the genetic predisposing effects of some haemostatic factors (PAI-1 and MTHFR) on vagal tone and reactivity. Individual differences in vagal tone were also associated with relationships between Factor 12 C46T and Factor 11 C22771T genes polymorphisms. This study showed that genetic predispositions for coagulation are modifiable. Its potential significance is promoting advanced protection against haemorrhages in a variety of traumas and injuries, especially in individuals with coagulation deficits.

Predisposing factors to post-operative adhesion development

BACKGROUND

Adhesion development is the most common sequelae of intra-abdominal and pelvic surgery and represents a significant, yet poorly understood, cause of morbidity among post-operative patients. It remains unclear, for example, exactly why adhesions form more frequently in certain tissues and/or patients, or at specific locations within them, as opposed to others. This review contributes to the growing knowledge pool by elucidating factors that potentially predispose to the development of adhesions. Given the strong correlation between a hypofibrinolytic state and adhesion formation, this review article will examine not only those factors that have been shown to directly predispose to adhesion development, but also those that are likely do so indirectly by means of altering the coagulation/fibrinolytic profile.

METHODS

A literature search was performed using the PubMed database for all relevant English language articles up to February 2014. All of the identified articles were reviewed with particular attention to predisposing factors to post-operative adhesion development. In addition, the reference lists of each article were reviewed to identify additional relevant articles.

RESULTS

Various factors have been shown to directly increase the risk of post-operative adhesion development; namely, certain genetic polymorphisms in the interleukin-1 receptor antagonist, increased estrogen exposure, and endometriosis. In addition, numerous factors are known to increase the risk of fibrosis, therefore likely increasing the risk of adhesion development indirectly. These factors include genetic polymorphisms in plasminogen activator inhibitor-1 and thrombin-activatable fibrinolysis inhibitor, diabetes mellitus, metabolic syndrome, hyperglycemia, obesity, depression, binge alcohol consumption, anti-Parkinsonian medications, oral hormone therapy, pregnancy, and cancer.

CONCLUSIONS

The literature reviewed in this paper will help to direct future research aimed at understanding the mechanisms that underlie the association of certain factors with adhesion development. This information will be crucial in the creation of adequate preventative and treatment strategies.

ACUTE MENTAL STRESS AND HEMOSTASIS: WHEN PHYSIOLOGY BECOMES VASCULAR HARM

Stress-induced activation of the sympathoadrenal medullary system activates both the coagulation and fibrinolysis system resulting in net hypercoagulability. The evolutionary interpretation of this physiology is that stress-hypercoagulability protects a healthy organism from excess bleeding should injury occur in fight-or-flight situations. In turn, acute mental stress, negative emotions and psychological trauma also are triggering factors of atherothrombotic events and possibly of venous thromboembolism. Individuals with pre-existent atherosclerosis and impaired endothelial anticoagulant function are the most vulnerable to experience onset of acute coronary events within two hours of intense emotions. A range of sociodemographic and psychosocial factors (e.g., chronic stress and negative affect) might critically intensify and prolong stress-induced hypercoagulability. In contrast, several pharmacological compounds, dietary flavanoids, and positive affect mitigate the acute prothrombotic stress response. Studies are needed to investigate whether attenuation of stress-hypercoagulability through medications and biobehavioral interventions reduce the risk of thrombotic incidents in at-risk populations.

[Development of a stress scale for elderly patients with coronary artery disease]

PURPOSE

The purpose of this study was to develop a scale to evaluate stress in elderly patients with coronary artery diseases (CAD) and to examine validity and reliability of the scale.

METHODS

The development process for the preliminary scale included construction of a conceptual framework and initial items, verification of content analysis, sentence correction, and pilot study. This study was conducted using a questionnaire survey with one-to-one interviews during January and February, 2012. Participants were 240 elderly patients with CAD. Data were analyzed using item analysis, factor analysis, criterion related validity, and internal consistency.

RESULTS

The developed scale consisted of 32 items and 6 factors - aging and disease (7 items), family relations (5 items), anxiety and withdrawal (9 items), management of daily living (3 items), compliance of medical regimen (4 items), poverty and finance (4 items), and explained 68.5% of total variance. The scale had significantly positive correlation with the Korean Perceived Stress Scale (KPSS). Cronbach's alpha was .96, and Guttman split half coefficient was .91.

CONCLUSION

Results indicate that the Stress Scale for Elderly Patients with CAD has validity and reliability, and is a suitable scale in health care settings to assess stress in elderly patients with CAD.

Effects of Hyperbaric and Decompression Stress on Blood Coagulation and Fibrinolysis

Hyperbaric and decompression stress from diving impairs blood coagulation and fibrinolysis. We hypothesized that thromboelastography (TEG) and rotational thromboelastometry (ROTEM) were suitable to characterize the effects of stress on global hemostatic profiles. We thus conducted a comparative study of the hyperbaric effects on human coagulation using TEG and ROTEM. Maximum clot strength (maximum amplitude [MA]) and clot lysis (lysis index at time 30 minutes [LI30]) were reduced as indicated by TEG MA and EXTEM LI30, respectively. The relative changes in coagulation and fibrinolysis by the hyperbaric effects of diving were indicated by reduced TEG reaction time R at 5 hours, MA at 24 hours postdive, and reduced EXTEM coagulation time at 15 minutes postdive as well as decreased fibrinolysis (EXTEM LI30) at all postdiving time points investigated. Comparison of the parameter values and the diving-induced changes in each parameter between TEG and ROTEM showed both differences and correlations. The discrepancies between the 2 systems may be due to the different assay reagents used. Future studies will seek to further elucidate the changes in blood coagulation and fibrinolysis following varying levels of hyperbaric and decompression stress.

Thrombosis formation on atherosclerotic lesions and plaque rupture

Atherosclerosis is a silent chronic vascular pathology that is the cause of the majority of cardiovascular ischaemic events. The evolution of vascular disease involves a combination of endothelial dysfunction, extensive lipid deposition in the intima, exacerbated innate and adaptive immune responses, proliferation of vascular smooth muscle cells and remodelling of the extracellular matrix, resulting in the formation of an atherosclerotic plaque. High-risk plaques have a large acellular lipid-rich necrotic core with an overlying thin fibrous cap infiltrated by inflammatory cells and diffuse calcification. The formation of new fragile and leaky vessels that invade the expanding intima contributes to enlarge the necrotic core increasing the vulnerability of the plaque. In addition, biomechanical, haemodynamic and physical factors contribute to plaque destabilization. Upon erosion or rupture, these high-risk lipid-rich vulnerable plaques expose vascular structures or necrotic core components to the circulation, which causes the activation of tissue factor and the subsequent formation of a fibrin monolayer (coagulation cascade) and, concomitantly, the recruitment of circulating platelets and inflammatory cells. The interaction between exposed atherosclerotic plaque components, platelet receptors and coagulation factors eventually leads to platelet activation, aggregation and the subsequent formation of a superimposed thrombus (i.e. atherothrombosis) which may compromise the arterial lumen leading to the presentation of acute ischaemic syndromes. In this review, we will describe the progression of the atherosclerotic lesion along with the main morphological characteristics that predispose to plaque rupture, and discuss the multifaceted mechanisms that drive platelet activation and subsequent thrombus formation. Finally, we will consider the current scientific challenges and future research directions.