Exercise intensity domains determined by heart rate at ventilatory threshold: a comparison of the guideline-directed exercise intensity domains for cardiovascular rehabilitation prescription

Background

Appropriate exercise prescription for cardiovascular diseases patients is a keystone for efficient and safe cardiovascular rehabilitation (CR). Exercise intensity prescribed according to the first and second ventilatory threshold (VT1 and VT2), identified by cardiopulmonary exercise testing (CPET), is considered the gold-standard method. However, because CPET is often not available, percentages of peak heart rate (%HRpeak) or heart rate reserve (%HRR), according to heart rate (HR) response during a conventional exercise test, are very commonly used.

Purpose

To compare the HR at VT1 and VT2 identified by CPET with the recommended exercise intensity prescription domains according to the Brazilian, American, and European CR guidelines/recommendations.

Methods

This retrospective cohort study assessed 1,465 treadmill CPETs from adult patients with stable cardiovascular diseases. Inclusion criteria were available VT1 and VT2 identification, sinus rhythm during exercise, and had reached maximal effort (respiratory exchange rate ≥1.10). HR at VT1 and VT2 were compared with the exercise intensity prescription domains recommended by Brazilian CR Guideline 2020, European Position Statement 2022, and the American College of Sports Medicine Guideline 2017, according to the obtained %HRpeak and %HRR.

Results

After applying the inclusions criteria, a sample of 972 CPETs were included (mean age 57.7±12.0 years, 80.8% males, 81.4% with coronary artery disease, and 26.6% with heart failure). VT1 and VT2 were identified, respectively, at 68.8% (63.8, 74.7) and 89.1 (85.8, 92.2) of the peak HR, and 39.0 (32.9, 45.8) and 78.0 (71.6, 84.5) of the HR reserve, indicating a greater heterogeneity of the latter (Figure 1). We found substantial heterogeneity between the measured %HRpeak and %HRR correspondent to the VT1 and VT2 and the estimated HR exercise intensity domains by compared international recommendations (Figure 2).

Conclusion

The disparities among currently established guideline-directed exercise domains limits the clinical validity of the use of %HRR and %HRpeak, and further strengthens the importance of performing CPET for an accurate exercise intensity prescription in CR. In the absence of CPET, HR values identified in our study at VT1 and VT2 could be used for guiding moderate-intensity exercise prescription for CVD patients, and the suggested range would be 69 to 89% of %HRpeak or 40 to 78% of %HRR. Current established exercise domains limits should be revised to improve HR-based prescription efficiency and safety.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).Conselho Nacional de Desenvolvimento Científico e Tecnolόgico (CNPq).

Effects of adding high- vs low-intensity resistance training to endurance training in patients with heart failure: preliminary results of a randomized controlled trial

Background

In current ESC/EAPC guidelines, adding resistance training to endurance training is advised for patients with heart failure (HF), but the optimal intensity of the resistance training is unknown (40–80% of 1RM is advised).

Purpose

To investigate the effects of high- vs low-intensity resistance training as an adjunct to endurance training on: aerobic capacity (primary outcome), walking capacity, muscle strength and quality of life in patients with HF.

Methods

Forty patients with HF were consecutively recruited in the cardiac rehabilitation center of the Hospital East-Limburg in Belgium. Patients were block-randomized (by age and sex) by an independent researcher to receive maximally 45 supervised sessions (3x/week) of high-intense (HI: 3 exercises, 3x12 repetitions, 55–70%1RM) or low-intense resistance training (LI: 3 exercises, 3x22 repetitions, 35–40%1RM) as an adjunct to endurance training (30 min/session; 50–75% VO2max). The aerobic capacity (VO2max) was measured by a blinded assessor with a ramp cardiopulmonary cycling test (+5–30W/min). Walking distance was assessed with a 6-minute walk test (6MWT), maximal strength with 1RM (leg-press, pull-down and dip), and quality of life with the Minnesota questionnaire. An unpaired t-test, Mann-Whitney U test or ANCOVA were used for between-group analysis, and paired t-test or Wilcox sign-rank test for the within-group analysis.

Results

Both groups had similar baseline characteristics and training adherence (HI vs LI; 20 vs 20 subjects; Age: 62±9 vs 59±13 years; Sex: 76% vs 79%male; BMI: 27±58 vs 29±4 kg/m2; LVEF: 35±10 vs 38±6%; Adherence: 33±10 vs 36±10 sessions; p>0.05). There were no adverse events. Both groups had significant within-group improvements in aerobic and walking capacity (VO2max: LI (n=20) vs HI (n=19), p≤0.010; 6MWT distance: p≤0.007) (Figure 1), but these improvements did not differ between groups (VO2max: p=0.855; 6MWT distance: p=0.854). The LI group improved significantly more in muscle strength than the HI group (dip and leg-press: p<0.001). Although the LI group significantly improved in the quality of life (Minnesota score reduction: p=0.028), the quality of life did not differ between groups (Minnesota score: p=0.756).

Conclusions

Both low-and high-intense resistance training are similarly beneficial for improving aerobic and walking capacity in patients with HF. Surprisingly, low-intense resistance training seems superior to high-intense training in improving muscle strength.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Hasselt University

Early diastolic strain rate and its associations with estimated glomerular filtration rate and albuminuria

Background

The ratio of early diastolic inflow to early diastolic strain rate, E/e'sr, is a novel echocardiographic measure, which has been shown to correlate better with left ventricular (LV) filling pressures than the conventionally used measure, E/e' (1). Additionally, E/e'sr has demonstrated prognostic value in various patient populations (2). Patients with chronic kidney disease (CKD) suffer frequently of diastolic dysfunction and elevated filling pressures (3). We wanted to investigate, how E/e'sr associates with two central measures of kidney function: estimated glomerular filtration rate, eGFR, and urine albumin creatinine ratio, UACR.

Methods

We enrolled a cohort of 825 ambulatory patients with CKD at the Departments of Nephrology of two university hospitals. Participants were examined with echocardiography including tissue doppler imaging. Two-dimensional speckle strain analysis was performed in all three apical standard projections. LV mass index (LVMI), E/e' and global longitudinal strain (GLS) were determined according to guidelines (4,5). Global early diastolic strain rate, e'sr, was calculated as the average of all 18 segments and indexed to early transmittal inflow velocity in order to calculate E/e'sr. Multivariable linear regression models were used to investigate associations between e'sr, E/e'sr, E/e' and kidney parameters. Models were adjusted for eGFR, UACR, LV ejection fraction (LVEF), age, sex, ever smoker, diabetes, hypertension, systolic and diastolic blood pressure (BP), heart rate and body mass index (BMI). We performed sensitivity analysis by excluding patients with known coronary artery disease (CAD) and heart failure (HF).

Results

Seventy-six patients had no measures of E/e'sr available leaving 749 for analysis. Excluding patients with CAD and/or HF (n=88) left 661 patients. For clinical and echocardiographic variables, see table. Patients with lower e'sr were older, had higher blood pressure and lower LVEF and GLS. E'sr was independently associated with eGFR and decreased 0.014 s–1 (95% CI 0.006 to 0.022, p=0.002) pr. 10 mL/min/1.73 m2 decrement of eGFR. Similarly, E/e'sr increased 1.1% (95% CI 0.2% to 19.2%) pr. 10 mL/min/1.73 m2 decrement of eGFR indicating rise in LV filling pressures. Contrary, E/e' was not independently associated with eGFR (p=0.5). Sensitivity analysis did not change the results significantly. None of the three measures were independently associated with UACR. Cubic restricted splines of e'sr, E/e'sr, E/e' over eGFR (figure) showed a non-linear relationship between E/e'sr and eGFR with accelerated increase at eGFR below 40 ml/min/1.73 m2.

Conclusion and perspectives

In patients with CKD, deformation-based e'sr and E/e'sr are independently associated with eGFR, but not with UACR. Repeated measurements and longitudinal follow-up of the cohort will provide information on the prognostic performance of these novel measures compared with conventional measures of LV filling pressure.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): The Capital Region of Denmark

Circadian rhythm of markers of bone turnover in patients with chronic kidney disease

Patients with chronic kidney disease (CKD) have a high risk of bone fractures. A circadian rhythmicity in turnover and mineralization of bone appears to be of importance for bone health. In CKD disturbances in the circadian rhythm of various functions has been demonstrated and indeed the circadian rhythm in the mineral metabolism is disturbed. The aim of the present study was to compare the circadian rhythm of bone turnover markers in ten patients with CKD to ten healthy controls. Bone turnover markers (C-terminal telopeptide of type I collagen, tartrate-resistant acid phosphatase 5b, N-terminal propeptide of type I procollagen, bone alkaline phosphatase and osteocalcin) were measured every third hour for 24 h. All bone turnover markers displayed a significant circadian rhythm in both groups and there were no significant differences in the rhythmicity between the two groups (no group*time interaction). As expected, due to the reduced renal clearance, the overall level of C-terminal telopeptide of type I collagen and osteocalcin was higher in CKD compared to the healthy controls. The present study suggests that disturbances in the circadian rhythm of bone turnover do not explain the metabolic bone disease and increased risk of fractures in CKD.

Personalized remotely guided preventive exercise therapy for a healthy heart: protocol and design of the PRIORITY study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Foundation – Flanders (FWO)

Introduction

Approximately half of the heart failure population has heart failure with preserved ejection fraction (HFpEF), a chronic disease starting with cardiovascular risk factors such as hypertension, diabetes and obesity (stage A) which can further emerge in a structural heart disease without (stage B) or with (stage C) signs or symptoms. Structured exercise therapy is recommended as a Class IA intervention in national and international guidelines and, as such, should be offered to all patients. Yet, in current practice, exercise therapy is often only offered within a secondary prevention program. At present, there exists no comprehensive preventive care program that includes structured exercise for patients in the early stages of heart failure, when cardiovascular risk factors are present, but cardiac remodeling and dysfunction might still be reversible or even preventable.

Purpose

PRIORITY aims to investigate the use of remotely guided exercise therapy as a preventive clinical and cost-effective treatment in the HFpEF continuum. This includes both prevention of progression of asymptomatic diastolic dysfunction towards symptomatic HFpEF (= primary prevention) and delaying progression of symptomatic HFpEF (= secondary prevention).

Methods

A randomized controlled multicenter trial will be conducted in 450 patients (men and women, aged 35-80 years) with heart failure (n = 180 stage A, 180 stage B, 90 stage C). Participants are being recruited from 3 different hospitals and the general population during a 16-month period which started in September 2021. Patients will be randomized (1:1) to usual care or to the PRIORITY exercise intervention (i.e. a combination of supervised with remotely guided home-based training sessions). Training prescription is based on the EXPERT tool and includes person-tailored endurance and dynamic strength training. During one year, participants will receive 18 supervised exercise sessions supplemented with a structured progressive home-based exercise program. Outcomes will be assessed at baseline, 4 months, one and two-years. Primary outcome is the proportion of patients with a clinically relevant improvement in peak oxygen uptake at one-year. Secondary outcomes include vascular health, muscle metabolism, change in electrocardiographic parameters and physical fitness parameters (muscle strength, body composition). Further, big data of physical activity collected during the trial will be used to develop models using machine-learning algorithms which can predict physical activity uptake and changes in fitness to facilitate the creation of more personalized interventions and better tailored exercise prescription.

Conclusion

We anticipate that the PRIORITY study will contribute to better prevention of heart failure thanks to an early easily accessible person-tailored exercise intervention.

Effects of the addition of high- vs. low-intensity resistance training on top of endurance training in patients with heart failure: preliminary results from a randomized clinical trial

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Hasselt University

Background

Adding resistance training on top of endurance training is recommended in the rehabilitation of patients with heart failure. However, it is unknown which intensity of resistance training should be preferred.

Purpose

To compare the effects of the addition of high- vs. low-intensity resistance training on top of endurance training in patients with heart failure.

Methods

Nineteen patients with heart failure were block randomized (by gender and sex) in a combined high-intensity resistance and endurance group (HIG; n=8, age=61±12y, 7 males, LVEF=38±10%) vs. combined low-intensity resistance and endurance group (LIG; n=9, age=68±21y, 8 males, LVEF=38±13%). Patients trained 3x/week for 45 sessions. The resistance exercises were volume-matched between groups and consisted of three sets of leg press, pull down and dip exercises, separated by 30s of rest, done at 55-70% 1RM in HIG vs. 35-40% 1RM in LIG. Both groups did moderate-intense endurance training on a bicycle, cross-trainer, treadmill and arm ergometer for 30 min per training. Maximal oxygen consumption was evaluated with an incremental cardiopulmonary cycling test and muscle strength by 1-RM testing, while quality of life was assessed with the Minnesota questionnaire, and walking distance by a 6-minute walking test. Mann-Whitney U test was used for analyzing differences between groups in all variables and Wilcoxon signed-rank test for evaluating pre-post difference of the entire sample. P values <0,05 (2-tailed) were considered statistically significant.

Results

Training adherence was similar in both groups (LIG vs HIG: 41±6 vs 37±9 sessions, p=0,370; Table 1). Overall, the intervention improved maximal oxygen consumption, walking capacity and muscle strength (p<0,05), but the between-group changes in maximal oxygen consumption (LIG vs HIG: 3±2 vs 3±4 ml/kg/min, p=0,963), quality of life (LIG vs HIG: -8±23 vs -1±5 points, p=0,931) and muscle strength (LIG vs HIG: Dip 34±34 vs 18±20kg, p=0,481; Leg press, 66±87 vs 47±53kg, p=0,486; Pull down, 9±6 vs 9±7kg, p=0,574) were similar.

Conclusion

Adding either high- or low-intensity resistance training on top of endurance training seems equally effective for improving aerobic capacity and walking performance in patients with heart failure. The study is ongoing.

Would be the minute ventilation variability an alternative to the dichotomous diagnosis of exercise oscillatory ventilation?

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): CAPES and FAPERGS.

Background

Exercise oscillatory ventilation (EOV) is an abnormal ventilatory phenomenon observed in chronic heart failure (HF) patients usually defined as EOV-positive or EOV-negative based on a dichotomous diagnosis. Minute ventilation variability (vVE) can quantify the presence of these oscillations and assist the prognosis of patients.

Purpose

To analyse the sensitivity and specificity of vVE to predict 2-year all-causes of death in HF patients.

Methods

Data from 233 cardiopulmonary exercise tests from HF patients performed between 2011 and 2014 at an Italian heart centre were analysed. The vVE was defined by the standard deviation (SD) of VE normalized by the number of respiratory cycles (SD/n) during the exercise tests. The cut-off to predict 2-year mortality was determined by the receiver-operating characteristic (ROC) curve.

Results

Thirty-five deaths were registered at 2-years. The ROC curve indicated ≤ 54.9 as the better cut-off for vVE (32 deaths were registered in follow-up; Figure 1). The relative risk was 3.9 (1.3 to 12.4) with a hazard ratio of 2.7 (1.3 to 5.6) for 2-year mortality.

Conclusion

The vVE appears to be a sensitive alternative to quantify EOV and stratify high-risk cases from 2-year all-cause mortality.

Prevention of heart failure in type 2 diabetes by exercise intervention: protocol and design of the PROTECTION study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): research Foundation - Flanders (FWO)

Introduction

Cardiac dysfunction is highly prevalent in patients with type 2 diabetes mellitus (T2DM), leading to increased risk of cardiac morbidity and premature death. Previous research underscored the high prevalence of a disturbed global longitudinal strain (GLS), a marker to predict this cardiac dysfunction, in both symptomatic and asymptomatic T2DM patients. Exercise-based therapy is recommended in the management of patients with type 2 diabetes. However, it remains unclear i) which type of exercise therapy to have the biggest effect on GLS and ii) which factors modify the effect of exercise therapy on GLS.

Purpose

The PROTECTION study will i) investigate the impact of exercise volume and intensity on GLS to optimize exercise prescription in T2DM and will ii) assess which patient-specific factors influence the change in GLS and physical fitness as a result of exercise intervention in T2DM.

Methods and analyses

The PROTECTION study is composed of two work packages (WP). In WP 1, 100 T2DM adults (50% male, aged 30-75 years) will be randomized to a usual care group or one of the three supervised exercise intervention groups (see Table 1) for a duration of 26 weeks. Outcome measures will be performed at baseline, 13, 26 and 52 weeks of follow-up. The primary outcomes are GLS and cardiac dimensions. Secondary outcomes include health-related physical fitness, blood biomarkers and physical activity behavior. Data will be analyzed by two-way ANOVA repeated measures. A two-tailed P-value <0.05 will be considered statistically significant.

Parallel with the randomized controlled trial, a longitudinal intervention study (WP2) involving 107 adults (50% male, aged 30-75 years) with T2DM will be conducted. All participants will engage in a supervised intervention for 26 weeks, including a high volume of moderate intense physical activity (see Table 1). The main objective of this work package is to define determinants of change in GLS during an exercise intervention. Moreover, the interaction between diet-exercise, habitual physical activity-exercise and phenotype-exercise on change in GLS will be studied in great detail. Patient-specific data will be analyzed by multivariate regression analysis. A two-tailed P-value <0.05 will be considered statistically significant.

Conclusion

It is anticipated that the PROTECTION study will contribute to a better understanding on i) which exercise characteristics are preferred to maximally improve GLS in T2DM and on ii) the determinants of the responsiveness of GLS and physical fitness to exercise in T2DM.

Brain natriuretic peptide levels are associated with cycle length average and are different between Ben-Dov and Corra exercise oscillatory ventilation definitions in heart failure patients

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): CAPES e FAPERGS.

Background

The brain natriuretic peptide (BNP) is a marker of ventricular dysfunction related to severity and prognosis in heart failure patients. Exercise oscillatory ventilation (EOV) is a phenomenon in the ventilatory pattern associated with a worse prognosis in heart failure patients. EOV diagnosis is defined by the interaction among amplitude, cycle length, and the total time of the oscillations. Ben-Dov and Corrà definitions are used to identify EOV-positive cases by different criteria, which may stratify EOV patients with distinct clinical characteristics.

Purpose

To assess the BPN levels in heart failure patients and to test BNP level correlation with amplitude, cycle length, and total oscillation time according to Ben-Dov and Corrà definitions.

Methods

Data from 242 cardiopulmonary exercise tests (CPETs) performed between 2011 and 2014 at an Italian heart centre were screened for EOV identification. CPETs were done in a cycle-ergometer with gas exchange analysed breath-by-breath. EOV cases were identified according to the definitions of Ben-Dov and Corrà. Mann-Whitney test was applied to compare BPN levels between the EOV-positive and negative in each definition and between EOV-positive from Ben-Dov and Corrà definitions. Spearman coefficient (rs) evaluated the association between amplitude and length average of the oscillatory cycle, percentage of total oscillation time, and BNP levels in each EOV definition. The BNP levels from EOV-positive identified by Corrà or Ben-Dov definition alone, and from patients who have met the criteria of both definitions were compared by the Kruskal-Wallis test.

Results

Sixty-seven patients were identified as EOV-positive. From them, 19 were identified exclusively by the Ben-Dov and 26 by Corrà. Twenty-two met the criteria for both definitions. Overall, no difference in EOV prevalence between Ben-Dov and Corrà definitions was found (20.4 vs 24.2%, p = 0.482). EOV-positive identified by the Ben-Dov definition have higher BNP levels than EOV-negative (p < 0.01) and the EOV-positive by Corrà definition (p = 0.025) (Table 1). Spearman correlation showed association just between BNP levels and cycle length average from EOV-positive by the Ben-Dov (rs = 0.566; p < 0.001) and by Corrà (rs = 0.339; p = 0.011) (Figure 1). When analysed by exclusive criteria identification, the BNP levels were higher in EOV-positive identified by Ben-Dov than Corrà (737 [562 to 1,178] vs 276 [221 to 603] pg/mL; p = 0.009). BNP levels in the EOV-positive identified by both definitions (475 [347 to 852] pg/mL) were not different from those identified by the Ben-Dov and Corrà definitions alone.

Conclusion

EOV-positive identified by the Ben-Dov have higher BNP levels than EOV-negative and the EOV-positive identified by Corrà, alone or not. BNP levels also are associated with the cycle length average, with a higher correlation for the Ben-Dov EOV-positive.

The type and dosage of exercise therapy to facilitate the recovery from stroke for balance, walking and quality of life: a systematic review and meta-analysis of randomized controlled trials

Background

Exercise therapy (aerobic or resistance therapy) could have a beneficial effect on balance, walking and quality of life (QoL).

Objective

This systematic review and meta-analysis aimed to quantify the effects of different modes, dosages and setting of exercise therapy on balance, walking capacity and QoL in stroke survivors.

Methods

We searched PubMed, CINHAL and Hinari to identify randomized controlled trials (RCT) that investigated the effects of aerobic (AT) and/or resistance therapy (RT) on balance, walking and QoL in stroke survivors. The treatment effect was computed by the standard mean differences (SMDs).

Results

We included 27 RCT comprising 1,549 chronic stroke survivors. Any modality was effective to improve balance. There was high-level evidence that AT interventions were most effective in improving walking capacity (SMD=0.36 [0.06, 0.66], p=0.02). Both AT, and AT combined with RT were effective to improve QoL (SMD=0.39 [0.09, 0.69], p=0.01). RT programs were not effective to improve walking and QoL. For walking capacity, a lower volume weekly (<60 minutes/session or <3 session/week) and higher intensity (>60% heart rate reserve; rate of perceived exertion (6–20) >14) of AT and RT exercises demonstrated significant higher effect. Hospital located rehabilitation settings trended to improve walking (SMD=0.23 [0.00, 0.45], p=0.05), when compared to home/community and laboratory settings.

Conclusions

In chronic stroke, in particular AT executed in hospital located settings, with a lower volume and high intensity seems more effective strategy to facilitate walking capacity and improve QoL and should thus be incorporated into rehabilitation programs for stroke.

Funding Acknowledgement

Type of funding sources: None.

Risk factors for multi-joint disease in patients with glucocorticoid-induced osteonecrosis

This study investigated risk factors for osteonecrosis involving multiple joints (MJON) among glucocorticoid-treated patients. The best predictor of MJON was cumulative oral glucocorticoid dose. Risk of MJON was 12-fold higher in patients who had a second risk factor for osteonecrosis. Further research is needed into strategies for prevention of MJON.

INTRODUCTION

Osteonecrosis (ON) is a debilitating musculoskeletal condition in which bone cell death can lead to mechanical failure. When multiple joints are affected, pain and disability are compounded. Glucocorticoid treatment is one of the most common predisposing factors for ON. This study investigated risk factors for ON involving multiple joints (MJON) among glucocorticoid-treated patients.

METHODS

Fifty-five adults with glucocorticoid-induced ON were prospectively enrolled. MJON was defined as ON in ≥ three joints. Route, dose, duration, and timing of glucocorticoid treatment were assessed.

RESULTS

Mean age of enrolled subjects was 44 years, 58% were women. Half had underlying conditions associated with increased ON risk: systemic lupus erythematosus (29%), acute lymphoblastic leukemia (11%), HIV (9%), and alcohol use (4%). Mean daily oral dose of glucocorticoids was 29 mg. Average cumulative oral dose was 30 g over 5 years. The best predictor of MJON was cumulative oral glucocorticoid dose. For each increase of 1,000 mg, risk of MJON increased by 3.2% (95% CI 1.03, 1.67). Glucocorticoid exposure in the first 6 months of therapy, peak dose (oral or IV), and mean daily dose did not independently increase risk of MJON. The risk of MJON was 12-fold in patients who had a second risk factor (95% CI 3.2, 44.4).

CONCLUSIONS

Among patients with glucocorticoid-induced ON, cumulative oral dose was the best predictor of multi-joint disease; initial doses of IV and oral glucocorticoids did not independently increase risk. Further research is needed to better define optimal strategies for prevention and treatment of MJON.

Effect of far infrared therapy on arteriovenous fistula maturation, survival and stenosis in hemodialysis patients, a randomized, controlled clinical trial: the FAITH on fistula trial

BACKGROUND

An arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis treatment. After creation many of the AVFs will never mature or if functioning will need an intervention within 1 year due to an AVF stenosis. Studies investigating possible therapies that improves the AVF maturation and survival are scarce. Far infrared therapy (FIR) has shown promising results. In minor single centre and industry supported trials FIR has shown improved AVF maturation and survival. There is a need of a randomized multicentre controlled trial to examine the effect of FIR on the AVF maturation and survival and to explore the possible AVF protective mechanism induced by the FIR treatment.

METHODS

This investigator initiated, randomized, controlled, open-labeled, multicenter clinical trial will examine the effect of FIR on AVF maturation in patients with a newly created AVF (incident) and AVF patency rate after 1 year of treatment in patients with an existing AVF (prevalent) compared to a control group. The intervention group will receive FIR to the skin above their AVF three times a week for 1 year. The control group will be observed without any treatment. The primary outcome for incident AVFs is the time from surgically creation of the AVF to successful cannulation. The primary outcome for the prevalent AVFs is the difference in number of AVFs without intervention and still functioning in the treatment and control group after 12 months. Furthermore, the acute changes in inflammatory and vasodilating factors during FIR will be explored. Arterial stiffness as a marker of long term AVF patency will also be examined.

DISCUSSION

FIR is a promising new treatment modality that may potentially lead to improved AVF maturation and survival. This randomized controlled open-labelled trial will investigate the effect of FIR and its possible mechanisms.

TRIAL REGISTRATION

Clinicaltrialsgov NCT04011072 (7th of July 2019).

Development of a comprehensive frailty test battery including physical, socio-psychological and cognitive domains for patients with cardiovascular disease

Funding Acknowledgements

Type of funding sources: None.

Background

Frailty is an age-related decline in physical, socio-psychological and cognitive function resulting in extreme vulnerability to stressors. In patients with cardiovascular disease (CVD) it remains to be elucidated which tests to select to detect/establish frailty in a comprehensive, valid and feasible manner.

Purpose

1) To compare the frailty prevalence rates using Fried vs. the more comprehensive Vigorito criteria in CVD patients; 2) To establish which tests, from the physical, socio-psychological and cognitive domains, should be selected to be able to detect frailty in patients with CVD; 3) To establish a total score that may represent a valid measurement of frailty severity, and 4) To examine the association of frailty with long-term clinical outcomes.

Methods

Patients (n = 133, mean age 78 ± 7 years) hospitalised for coronary revascularisation or heart failure (HF) were examined by the Fried and Vigorito criteria (Mini Nutritional Assessment (MNA), Katz-scale, 4.6m gait speed, timed up-and-go test (TUG), handgrip strength, Mini Mental State Examination (MMSE), Geriatric Depression Scale (GDS-15), number of medications). Additionally, physical activity, time spent sitting, knee extension and hip flexor muscle strength, timed chair-stand test and fear of falling were measured. Multivariate regression and sensitivity/specificity analyses were performed to assess which tests to adopt to detect frailty in CVD patients. Moreover, hospitalisations and mortality, up to six months after the initial hospital admission were examined.

Results

Any level of frailty was detected in 44% of the patients by the Vigorito criteria and in 65% of the patients by the Fried criteria. However, frailty state may have been overestimated by Fried score as 20% of patients classified as non-frail by Vigorito, were pre-frail by Fried. Furthermore, 10% vs. 38%, respectively, were classified as moderate-frail (by Vigorito) vs. frail (by Fried). Frailty could best be detected (at the earliest stage) by a score from: sex, MNA, Katz-scale, TUG, handgrip strength, MMSE, GDS-15, total number of medications (cut-off score ≥5.56: sensitivity: 1.0, specificity: 0.54, correlation with Vigorito score: r = 0.98, p < 0.001). During the six-month follow-up period, 39% of the patients were readmitted to the hospital (56% of these hospitalisations were attributed to the HF patients) and 7% of the subjects died (89% of them were HF patients). Frailty and specific markers of frailty were significantly associated with mortality and six-month general, urgent, orthopaedic and cardiovascular hospitalisations.

Conclusions

To detect frailty in patients with CVD, even at an earliest stage, sex, MNA, Katz-scale, TUG, handgrip strength, MMSE, GDS-15 and total number of medications play a key role, assessed by a new time- and cost-efficient test battery for frailty.

Validation of frailty assessment batteries in relation to prognosis in older patients with cardiovascular disease

Funding Acknowledgements

Type of funding sources: None.

Background

Frailty is accompanied by, or can be caused by, a combination of several physical, psychosocial and cognitive problems, and is highly prevalent in older patients with cardiovascular disease (CVD). However, different frailty assessment batteries (e.g. Fried and Vigorito) remain to be compared in terms of prognosis, as well as the subcomponents within those batteries.

Purpose

To examine which frailty measurements contribute to the prediction of frailty in CVD patients, and prognosis, and thus should be executed in clinical settings.

Methods

In 133 CVD patients (mean age 78.1 ± 6.7 years) the presence of frailty was examined by the Fried criteria and compared with the outcome from the multi-component frailty assessment tool of Vigorito including the Mini Nutritional Assessment (MNA), Katz-scale, 4.6 m gait speed, Timed Up and Go Test (TUG), handgrip strength, Mini Mental State Examination (MMSE), Geriatric Depression Scale (GDS-15) and number of medications. Additional tests were executed to further enhance the prediction of frailty. Patients were followed to register hospitalisations (general and urgent) and mortality up to 6 months after the frailty assessment. First, it was then analysed whether the Fried or Vigorito test battery would equally predict complications during follow-up, and secondly a new frailty test battery was developed with evaluation towards complication risk predictions.

Results

According to the tool of Vigorito, significantly more CVD patients suffered from minor vs. moderate frailty (34% vs. 10%, p < 0.001) while the Phenotype of Fried did not succeed in detecting any significant difference in the number of pre-frail vs. frail patients (26% vs. 38%, p = 0.11). Moreover, the largest part of the pre-frail patients of Fried seems to be not frail according to Vigorito and the frail patients of Fried seems to be mainly minor frail according to Vigorito.

Significant associations were found between hospitalisations and frailty according to Fried while mortality was significantly associated with frailty according to Vigorito and the newly developed formula (p = 0.013). Finally, based on the multivariate regression model (R2 = 0.95), sex, MNA, Katz scale, TUG, handgrip strength (dominant hand), MMSE, GDS-15, total number of medications and the interaction effect between the Katz-scale and TUG should be assessed to detect frailty.  Based on these  parameters, a new formula to detect frailty was developed (r = 0.95 with Vigorito score, p < 0.001).

Conclusions

In comparison with the frailty assessment tool of Vigorito, the Fried criteria may overestimate frailty and its severity. Moreover, frailty seems to be significantly associated with 6-months hospitalisations as well as with mortality. The newly developed frailty assessment battery has the potential to detect frailty in a multidimensional way, and, moreover, to predict mortality.

The importance of first and second ventilatory thresholds to define aerobic exercise intensity in cardiac patients and in healthy subjects: what is essential can be visible to the eyes

Funding Acknowledgements

Type of funding sources: None.

Background. Although structured exercise training is strongly recommended in cardiac patients, uncertainties exist about the methods for determining exercise intensity (EI) and their correspondence with effective EI obtained by ventilatory thresholds. We aimed to determine the first (VT1) and second ventilatory threshold (VT2) in cardiac patients, sedentary subjects and athletes comparing VT1 and VT2 with EI defined by recommendations.

Methods. We prospectively enrolled 350 subjects (mean age: 50.7 ± 12.9 years; 167 cardiac patients, 150 healthy sedentary subjects, 33 competitive endurance athletes). Each subject underwent ECG, echocardiography, and cardiopulmonary exercise testing. The percentages of peak VO2, peak heart rate (HR), and HR reserve were obtained at VT1 and VT2, and compared with EI definition proposed by the recommendations.

Results. VO2 at VT1 corresponded to high rather than moderate EI in 67.1% and in 79.6% of cardiac patients, applying the definition of moderate exercise by the previous recommendations and the 2020 guidelines, respectively. Most of cardiac patients had VO2 values at VT2 corresponding to very-high rather than high EI (59.9% and 50.3%, by previous recommendations and 2020 guidelines, respectively). A better correspondence between ventilatory-thresholds and recommended EI domains was observed in healthy subjects and in athletes (90% and 93.9%, respectively).

Conclusions. EI definition based on percentages of peak HR and peak VO2 may misclassify the effective EI and the discrepancy between the individually determined and the recommended EI is particularly relevant in cardiac patients. A ventilatory threshold-based rather than a range-based approach is advisable in order to define an appropriate level of EI.

Abstract Figure.

Hippocampal α-synuclein pathology correlates with memory impairment in multiple system atrophy

Recent post-mortem studies reported 22-37% of patients with multiple system atrophy can develop cognitive impairment. With the aim of identifying associations between cognitive impairment including memory impairment and α-synuclein pathology, 148 consecutive patients with pathologically proven multiple system atrophy were reviewed. Among them, 118 (79.7%) were reported to have had normal cognition in life, whereas the remaining 30 (20.3%) developed cognitive impairment. Twelve of them had pure frontal-subcortical dysfunction, defined as the presence of executive dysfunction, impaired processing speed, personality change, disinhibition or stereotypy; six had pure memory impairment; and 12 had both types of impairment. Semi-quantitative analysis of neuronal cytoplasmic inclusions in the hippocampus and parahippocampus revealed a disease duration-related increase in neuronal cytoplasmic inclusions in the dentate gyrus and cornu ammonis regions 1 and 2 of patients with normal cognition. In contrast, such a correlation with disease duration was not found in patients with cognitive impairment. Compared to the patients with normal cognition, patients with memory impairment (pure memory impairment: n = 6; memory impairment + frontal-subcortical dysfunction: n = 12) had more neuronal cytoplasmic inclusions in the dentate gyrus, cornu ammonis regions 1-4 and entorhinal cortex. In the multiple system atrophy mixed pathological subgroup, which equally affects the striatonigral and olivopontocerebellar systems, patients with the same combination of memory impairment developed more neuronal inclusions in the dentate gyrus, cornu ammonis regions 1, 2 and 4, and the subiculum compared to patients with normal cognition. Using patients with normal cognition (n = 18), frontal-subcortical dysfunction (n = 12) and memory impairment + frontal-subcortical dysfunction (n = 18), we further investigated whether neuronal or glial cytoplasmic inclusions in the prefrontal, temporal and cingulate cortices or the underlying white matter might affect cognitive impairment in patients with multiple system atrophy. We also examined topographic correlates of frontal-subcortical dysfunction with other clinical symptoms. Although no differences in neuronal or glial cytoplasmic inclusions were identified between the groups in the regions examined, frontal release signs were found more commonly when patients developed frontal-subcortical dysfunction, indicating the involvement of the frontal-subcortical circuit in the pathogenesis of frontal-subcortical dysfunction. Here, investigating cognitive impairment in the largest number of pathologically proven multiple system atrophy cases described to date, we provide evidence that neuronal cytoplasmic inclusion burden in the hippocampus and parahippocampus is associated with the occurrence of memory impairment in multiple system atrophy. Further investigation is necessary to identify the underlying pathological basis of frontal-subcortical dysfunction in multiple system atrophy.

The Copenhagen chronic kidney disease echo study (COInCYDE)

Background

The cardiovascular mortality of patients with chronic kidney disease (CKD) is 2–10 times higher than in the average population.

Purpose

To estimate the prevalence of abnormal cardiac function or structure across the stages CKD 1 to 5nonD.

Method

Prospective cohort study. Patients with CKD stage 1 to 5 not on dialysis, aged 30 to 75 (n=875) and age-/sex-matched controls (n=173) were enrolled consecutively. All participants underwent a health questionnaire, ECG, morphometric and blood pressure measurements. Blood and urine were analyzed. Echocardiography was performed. Left ventricle (LV) hypertrophy, dilatation, diastolic and systolic dysfunction were defined according to current ESC guidelines.

Results

63% of participants were men. Mean age was 58 years (SD 12.6 years). Mean eGFR was 46.7 mL/min/1,73 m (SD 25.8) for patients and 82.3 mL/min/1,73 m (SD 13.4) for controls. The prevalence of elevated blood pressure at physical exam was 89% in patients vs. 53% in controls. Patients were more often smokers and obese.

Left ventricular mass index (LVMI) was slightly, albeit insignificantly elevated at CKD stages 1 & 2 vs. in kontrols: 3.1 g/m2, CI: −0.4 to 6.75, p-value 0.08. There was no significant difference in LV-dilatation between patients and controls.

Decreasing diastolic and systolic function was observed at CKD stage 3a and later: LVEF decreased 0.95% (CI: −1.5 to −0.2), GLS increased 0.5 (CI: 0.3 to 0.8), and OR for diastolic dysfunction increased 3.2 (CI 1.4 to 7.3) pr. increment CKD stage group.

Conclusion

In accordance to previous studies, we observe in the CPHCKD cohort study signs of early increase of LVMI in patients with CKD stage 1 & 2. Significant decline in systolic and diastolic cardiac function is apparent already at stage 3 CKD.

Figure 1. Estimated GFR vs. GLS & histogram of GLS

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): The Capital Region of Denmark

Novel clinicopathological characteristics differentiate dementia with Lewy bodies from Parkinson's disease dementia

Dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD) known as Lewy body dementias have overlapping clinical and neuropathological features. Neuropathology in both includes combination of Lewy body and Alzheimer's disease (AD) pathology. Cerebral amyloid angiopathy (CAA), often seen in AD, is increasingly recognized for its association with dementia.

AIMS

This study investigated clinical and neuropathological differences between DLB and PDD.

METHODS

52 PDD and 16 DLB cases from the Queen Square Brain Bank (QSBB) for Neurological disorders were included. Comprehensive clinical data of motor and cognitive features were obtained from medical records. Neuropathological assessment included examination of CAA, Lewy body and AD pathology.

RESULTS

CAA was more common in DLB than in PDD (P = 0.003). The severity of CAA was greater in DLB than in PDD (P = 0.009), with significantly higher CAA scores in the parietal lobe (P = 0.043), and the occipital lobe (P = 0.008), in DLB than in PDD. The highest CAA scores were observed in cases with APOE ε4/4 and ε2/4. Survival analysis showed worse prognosis in DLB, as DLB reached each clinical milestone sooner than PDD. Absence of dyskinesia in DLB is linked to the significantly lower lifetime cumulative dose of levodopa in comparison with PDD.

CONCLUSIONS

This is the first study which identified prominent concurrent CAA pathology as a pathological substrate of DLB. More prominent CAA and rapid disease progression as measured by clinical milestones distinguish DLB from PDD.

Fulminant corticobasal degeneration: a distinct variant with predominant neuronal tau aggregates

Corticobasal degeneration typically progresses gradually over 5–7 years from onset till death. Fulminant corticobasal degeneration cases with a rapidly progressive course were rarely reported (RP-CBD). This study aimed to investigate their neuropathological characteristics. Of the 124 autopsy-confirmed corticobasal degeneration cases collected from 14 centres, we identified 6 RP-CBD cases (4.8%) who died of advanced disease within 3 years of onset. These RP-CBD cases had different clinical phenotypes including rapid global cognitive decline (N = 2), corticobasal syndrome (N = 2) and Richardson’s syndrome (N = 2). We also studied four corticobasal degeneration cases with an average disease duration of 3 years or less, who died of another unrelated illness (Intermediate-CBD). Finally, we selected 12 age-matched corticobasal degeneration cases out of a cohort of 110, who had a typical gradually progressive course and reached advanced clinical stage (End-stage-CBD). Quantitative analysis showed high overall tau burden (p = 0.2) and severe nigral cell loss (p = 0.47) in both the RP-CBD and End-stage-CBD groups consistent with advanced pathological changes, while the Intermediate-CBD group (mean disease duration = 3 years) had milder changes than End-stage-CBD (p < 0.05). These findings indicated that RP-CBD cases had already developed advanced pathological changes as those observed in End-stage-CBD cases (mean disease duration = 6.7 years), but within a significantly shorter duration (2.5 years; p < 0.001). Subgroup analysis was performed to investigate the cellular patterns of tau aggregates in the anterior frontal cortex and caudate by comparing neuronal-to-astrocytic plaque ratios between six RP-CBD cases, four Intermediate-CBD and 12 age-matched End-stage-CBD. Neuronal-to-astrocytic plaque ratios of Intermediate-CBD and End-stage-CBD, but not RP-CBD, positively correlated with disease duration in both the anterior frontal cortex and caudate (p = 0.02). In contrast to the predominance of astrocytic plaques we previously reported in preclinical asymptomatic corticobasal degeneration cases, neuronal tau aggregates predominated in RP-CBD exceeding those in Intermediate-CBD (anterior frontal cortex: p < 0.001, caudate: p = 0.001) and End-stage-CBD (anterior frontal cortex: p = 0.03, caudate: p = 0.01) as demonstrated by its higher neuronal-to-astrocytic plaque ratios in both anterior frontal cortex and caudate. We did not identify any difference in age at onset, any pathogenic tau mutation or concomitant pathologies that could have contributed to the rapid progression of these RP-CBD cases. Mild TDP-43 pathology was observed in three RP-CBD cases. All RP-CBD cases were men. The MAPT H2 haplotype, known to be protective, was identified in one RP-CBD case (17%) and 8 of the matched End-stage-CBD cases (67%). We conclude that RP-CBD is a distinct aggressive variant of corticobasal degeneration with characteristic neuropathological substrates resulting in a fulminant disease process as evident both clinically and pathologically. Biological factors such as genetic modifiers likely play a pivotal role in the RP-CBD variant and should be the subject of future research.

Review: Clinical, neuropathological and genetic features of Lewy body dementias

Lewy body dementias are the second most common neurodegenerative dementias after Alzheimer's disease and include dementia with Lewy bodies and Parkinson's disease dementia. They share similar clinical and neuropathological features but differ in the time of dementia and parkinsonism onset. Although Lewy bodies are their main pathological hallmark, several studies have shown the emerging importance of Alzheimer's disease pathology. Clinical amyloid-β imaging using Pittsburgh Compound B (PiB) supports neuropathological studies which found that amyloid-β pathology is more common in dementia with Lewy bodies than in Parkinson's disease dementia. Nevertheless, other co-occurring pathologies, such as cerebral amyloid angiopathy, TDP-43 pathology and synaptic pathology may also influence the development of neurodegeneration and dementia. Recent genetic studies demonstrated an important role of APOE genotype and other genes such as GBA and SNCA which seem to be involved in the pathophysiology of Lewy body dementias. The aim of this article is to review the main clinical, neuropathological and genetic aspects of dementia with Lewy bodies and Parkinson's disease dementia. This is particularly relevant as future management for these two conditions may differ.

Search for CP Violation in Neutrino and Antineutrino Oscillations by the T2K Experiment with 2.2×10^{21} Protons on Target

The T2K experiment measures muon neutrino disappearance and electron neutrino appearance in accelerator-produced neutrino and antineutrino beams. With an exposure of 14.7(7.6)×10^{20} protons on target in the neutrino (antineutrino) mode, 89 ν_{e} candidates and seven anti-ν_{e} candidates are observed, while 67.5 and 9.0 are expected for δ_{CP}=0 and normal mass ordering. The obtained 2σ confidence interval for the CP-violating phase, δ_{CP}, does not include the CP-conserving cases (δ_{CP}=0, π). The best-fit values of other parameters are sin^{2}θ_{23}=0.526_{-0.036}^{+0.032} and Δm_{32}^{2}=2.463_{-0.070}^{+0.071}×10^{-3}  eV^{2}/c^{4}.

Abdominal subcutaneous and visceral adipocyte size, lipolysis and inflammation relate to insulin resistance in male obese humans

Obesity is associated with a disturbed adipose tissue (AT) function characterized by adipocyte hypertrophy, an impaired lipolysis and pro-inflammatory phenotype, which contributes to insulin resistance (IR). We investigated whether AT phenotype in different AT depots of obese individuals with and without type 2 diabetes mellitus (T2DM) is associated with whole-body IR. Subcutaneous (SC) and visceral (V) AT biopsies from 18 lean, 17 obese and 8 obese T2DM men were collected. AT phenotype was characterized by ex vivo measurement of basal and stimulated lipolysis (mature adipocytes), adipocyte size distribution (AT tissue sections) and AT immune cells (flow cytometry). In VAT, mean adipocyte size, CD45⁺ leukocytes and M1 macrophages were significantly increased in both obese groups compared to lean individuals. In SCAT, despite adipocyte hypertrophy, no significant differences in immune cell populations between groups were found. In SCAT, multiple linear regression analysis showed that none of the AT phenotype markers independently contributed to HOMA-IR while in VAT, mean adipocyte size was significantly related to HOMA-IR. In conclusion, beside adipocyte hypertrophy in VAT, M1 macrophage- or B-cell-mediated inflammation, may contribute to IR, while inflammation in hypertrophic SCAT does not seem to play a major role in IR.

The effect of diet or exercise on ectopic adiposity in children and adolescents with obesity: a systematic review and meta-analysis

OBJECTIVE

Ectopic fat depostion in youth with obesity is associated with an increased cardiovascular disease risk. The aim of this meta-analysis was to summarize the evidence for the use of diet and/or exercise on ectopic adiposity in this population.

METHODS

A systematic literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Clinical trials that assessed ectopic fat deposition and included study arms with diet and/or exercise were searched in PubMed, PEDro and the Cochrane database.

RESULTS

Hepatic fat content and intramyocellular lipid content were described in nine studies and three studies, respectively. Most studies included teenagers, and study duration ranged between 3 and 12 months without follow-up. Using random-effects weights, the standardized mean difference of the change in hepatic adiposity (totalling 320 subjects) was -0.54 Hedges' g (95% confidence interval: -0.69 to -0.38 with p < 0.0001). By re-expressing this effect size, it is seen that diet and/or exercise results in an absolute reduction of intrahepatic lipid with 2%, which accords with a relative reduction up to 70%. Although there were significant ameliorations of insulin sensitivity, no significant changes in intramyocellular lipid were observed.

CONCLUSIONS

This meta-analysis showed that diet and/or exercise is effective to reduce hepatic adiposity in youth with obesity.

Natriuretic peptides in the control of lipid metabolism and insulin sensitivity

Natriuretic peptides have long been known for their cardiovascular function. However, a growing body of evidence emphasizes the role of natriuretic peptides in human substrate and energy metabolism, thereby connecting the heart with several insulin-sensitive organs like adipose tissue, skeletal muscle and liver. Obesity may be associated with an impaired regulation of the natriuretic peptide system, also indicated as a natriuretic handicap. Evidence points towards a contribution of this natriuretic handicap to the development of obesity, type 2 diabetes mellitus and cardiometabolic complications, although the causal relationship is not fully understood. Nevertheless, targeting the natriuretic peptide pathway may improve metabolic health in obesity and type 2 diabetes mellitus. This review will focus on current literature regarding the metabolic roles of natriuretic peptides with emphasis on lipid metabolism and insulin sensitivity. Furthermore, it will be discussed how exercise and lifestyle intervention may modulate the natriuretic peptide-related metabolic effects.

Combined Analysis of Neutrino and Antineutrino Oscillations at T2K

T2K reports its first results in the search for CP violation in neutrino oscillations using appearance and disappearance channels for neutrino- and antineutrino-mode beams. The data include all runs from January 2010 to May 2016 and comprise 7.482×10^{20} protons on target in neutrino mode, which yielded in the far detector 32 e-like and 135  μ-like events, and 7.471×10^{20} protons on target in antineutrino mode, which yielded 4 e-like and 66  μ-like events. Reactor measurements of sin^{2}2θ_{13} have been used as an additional constraint. The one-dimensional confidence interval at 90% for the phase δ_{CP} spans the range (-3.13, -0.39) for normal mass ordering. The CP conservation hypothesis (δ_{CP}=0, π) is excluded at 90% C.L.

Measurement of Coherent π^{+} Production in Low Energy Neutrino-Carbon Scattering

We report the first measurement of the flux-averaged cross section for charged current coherent π^{+} production on carbon for neutrino energies less than 1.5 GeV, and with a restriction on the final state phase space volume in the T2K near detector, ND280. Comparisons are made with predictions from the Rein-Sehgal coherent production model and the model by Alvarez-Ruso et al., the latter representing the first implementation of an instance of the new class of microscopic coherent models in a neutrino interaction Monte Carlo event generator. We observe a clear event excess above background, disagreeing with the null results reported by K2K and SciBooNE in a similar neutrino energy region. The measured flux-averaged cross sections are below those predicted by both the Rein-Sehgal and Alvarez-Ruso et al.

Measurement of Muon Antineutrino Oscillations with an Accelerator-Produced Off-Axis Beam

T2K reports its first measurements of the parameters governing the disappearance of ν[over ¯]_{μ} in an off-axis beam due to flavor change induced by neutrino oscillations. The quasimonochromatic ν[over ¯]_{μ} beam, produced with a peak energy of 0.6 GeV at J-PARC, is observed at the far detector Super-Kamiokande, 295 km away, where the ν[over ¯]_{μ} survival probability is expected to be minimal. Using a data set corresponding to 4.01×10^{20} protons on target, 34 fully contained μ-like events were observed. The best-fit oscillation parameters are sin^{2}(θ[over ¯]_{23})=0.45 and |Δm[over ¯]_{32}^{2}|=2.51×10^{-3}  eV^{2} with 68% confidence intervals of 0.38-0.64 and 2.26-2.80×10^{-3}  eV^{2}, respectively. These results are in agreement with existing antineutrino parameter measurements and also with the ν_{μ} disappearance parameters measured by T2K.

172 ANTIVIRAL ACTION OF PROPOLIS AQUEOUS EXTRACT DURING MATURATION OF INFECTED BOVINE OOCYTES

The objective of this study was to evaluate the decrease of virus replication in BoHV-1 (Colorado strain, 106.5 TCID50/mL) after the treatment using propolis aqueous extract (PAE) during in vitro maturation of infected bovine oocytes (24 h). Cow ovaries were obtained from a local slaughterhouse (Nelore breed) and transported to the laboratory. Cumulus-oocyte complexes (COC) were aspirated from follicles and separated into 4 groups (number of replicates for all groups = 6), which were exposed to 20 μL of sterile physiological solution (SPS), 100 μL of the in vitro maturation (IVM) medium [G1 (control), n = 609]; 10 μL of BoHV-1 (106.5 TCID50/mL) virus, 100 μL IVM medium, and 10 μL of SPS (G2, n = 786); 10 μL of PAE in 0.001% in SPS, 100 μL IVM medium, and 10 μL of SPS (G3, n = 819); 10 μL of PAE extract in 0.001% in SPS, 10 μL of BoHV-1 (106.5 TCID50/mL) virus and 100 μL of the IVM medium (G4, n = 734). All groups were kept for 24 h at 38.5°C, 5% CO2 in air. After the IVM, we analysed COC expansion and the presence of a polar body by optical microscope as well as viral replication by titration (Reed and Muench test) after 72 h of co-culture with Madin-Darby bovine kidney (MDBK) cells. The G1, G3, and G4 showed steady expansion of the cumulus cells and ooplasm with uniform appearance. The G2 did not have expansion of the cumulus cells. In contrast, the cytoplasm showed degenerative appearance and an absence of maturity in numerous oocytes. The maturation rates were as follows: G1 = 79% (482/609), G2 = 51% (407/786), G3 = 80% (662/819), and G4 = 76% (565/734). The differences among groups in maturation rates were compared using the chi-squared test (α = 5%) and the average titrations using the Mann–Whitney test (α = 5%). There was a significant difference (P < 0.01) among G1 and G2 evincing the interference of the virus maturation. The extract did not affect maturation as there was no difference among G1 and G3 (P = 0.43). The main step was finding no significant difference between the groups G1 and G4, (P = 17) proving that the extract interferes with viral replication. The titration after co-culturing the oocytes in MDBK demonstrated that G4 (average titrations = 1.63 × 103 titration) showed a lower rate of viral replication, the Mann-Whitney test, when compared to group G2 (average titrations = 6.04 × 107) which has not been subjected to treatment with PAE (P = 0.02). These results indicate that the propolis aqueous extract reduces the rate of viral replication without interfering with the maturation of oocytes and, therefore, it can be a conclusion that the analysis of the action of the molecules of this extract (by proteomics, for example) and future studies should be directed towards identifying the effect of extract on antiviral activity during the assessment of oocyte competence and embryo development.

Ventilatory function during exercise in multiple sclerosis and impact of training intervention: cross-sectional and randomized controlled trial

BACKGROUND

Patients with MS (pwMS) often experience resting ventilatory anomalies. Ventilatory function during exercise and impact of long-term training intervention remains however uncertain.

AIM

The aim of this study was to examine the ventilatory function during exercise and impact of a 6-month training intervention in pwMS.

DESIGN

Combination of a cross-sectional (part 1) and randomized controlled trial (part 2).

SETTING

University rehabilitation facility.

POPULATION

Caucasian patients with MS and healthy controls.

METHODS

In part 1, the ventilatory function during submaximal endurance exercise was compared between pwMS (N.=37) and healthy participants (N.=15). In part 2, pwMS were then randomly assigned to a 6-month training intervention (N.=16) or usual care (N.=11). Following training intervention, ventilatory function during exercise was re-evaluated.

RESULTS

Despite comparable relative exercise testing intensities between groups in part 1, significantly elevated steady-state exercise dead space/tidal volume ratio, O2 uptake and CO2 output equivalent, end-tidal O2 pressure, ratings of perceived exertion and lowered end-tidal CO2 pressure and O2 pulse was observed in pwMS (P<0.05). The degree of ventilatory dysfunction during exercise correlated significantly with ratings of perceived exertion and blood lactate content (P<0.05). In part 2, despite an improved exercise tolerance (based on reductions in heart rate, blood lactate content and ratings of perceived exertion during exercise at similar workload) after a 6-month training intervention, ventilatory dysfunction remained present during endurance exercise (P>0.05).

CONCLUSION

Patients with MS experience a ventilatory dysfunction during endurance exercise, which is related to worse exercise tolerance. This ventilatory anomaly remains present after long-term training intervention.

CLINICAL REHABILITATION IMPACT

Patients with MS experience ventilatory dysfunction during exercise. This dysfunction is related to exercise tolerance and ratings of perceived exertion. Long-term exercise training did not remediate this ventilatory dysfunction. The systematic examination of the pulmonary/cardiovascular system at rest and during exercise is recommended in MS.

[Staffing needs of an intensive care unit in consideration of applicable hygiene guidelines--an exploratory analysis]

The patient burden in intensive care units (ICU) has continually increased worldwide over the past decades. Age, co-morbidities and an increasing complexity of conditions and treatments increase the number of patients who are either colonized or infected with antibiotic-resistant pathogens. To prevent nosocomial infections, hygiene guidelines play an important role. In this paper, we investigate the time needed for nursing of five hypothetical critically ill patients in the intensive care unit. The results show that current staffing is not sufficient under the given hygiene guidelines and that a nurse to patient ratio of one will be necessary to meet the requirements. In a national survey of university hospitals, however, we found that the current nurse to patient ratio is 1: 2.47 in German intensive care units. The apparent staffing shortage is compensated by an extraordinary personal commitment of nurses caring for patients in the ICU.