Chlorpheniramine, an Old Drug with New Potential Clinical Applications: A Comprehensive Review of the Literature

Chlorpheniramine Maleate (CPM), also known as chlorphenamine, is a potent alkylamine first-generation H1 antihistamine that has been used since the 1950s. CPM is a widely popular drug commonly used to treat allergic conditions, given its antihistamine properties. Although mainly used in over-the-counter treatment for cough and colds, various studies discuss a wide range of CPM's clinical uses, such as treating asthma, plasma cell gingivitis, chronic urticaria, and depression, among others. This antihistamine is usually taken orally; however, intravenous, intramuscular, and subcutaneous routes have been documented. Intranasal routes of this drug have recently been explored, especially due to its antiviral properties against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Accordingly, given CPM's extensive medical and safety profile, the present review explores this versatile drug's current and potential clinical applications. Although it is widely used mainly for treating common colds and aforementioned allergic conditions, CPM can be used for other clinical indications. The repurposing of CPM for other clinical indications, such as COVID-19, needs to be further explored through more extensive studies.

Noninvasive central hemodynamic monitoring in the primary care setting: improving prevention and management of cardiovascular diseases

Background

Although cardiovascular disease (CVD) has markedly declined since the early 1960s due to medical advances and better management, this condition persists as the most critical and preventable cause of death in the US. For that reason, the identification and application of more sensitive, specific, validated, and noninvasive biomarkers of cardiovascular functioning in the primary care setting for the early identification of CVD risk at the subclinical level are warranted.

Aim

The goal of the present review is twofold: first, to familiarize the primary care practitioner with noninvasive aortic hemodynamic parameters, including how these could be integrated into primary care services and patient management, and second, to propose a model for earlier detection of CVD based on the noninvasive hemodynamic parameters in the primary care setting.

Relevance for Patients

Implementation of noninvasive hemodynamic monitoring in a primary care setting could help in the identification of heart disease risk at the early onset thus preventing the need for expensive treatment or death at later stages.

The acute, systemic effects of aerobic exercise in recently concussed adolescent student-athletes: preliminary findings

OBJECTIVES

Examine the acute effects (pre-, during, post-intervention) of two different intensities of aerobic exercise or rest on autonomic, oculomotor, and vestibular function and symptom burden in patients with a recent sport-related concussion (SRC) and compare their responses to sex-matched, age-stratified, non-concussed (HEALTHY) student-athletes.

METHODS

Student-athletes between the ages of 13 and 18 that presented to the sports medicine clinic within Day 3-7 post-SRC and from local schools were recruited for a randomized controlled trial (RCT). The participants were administered the Vestibular/Ocular Motor Screening (VOMS), King-Devick (K-D), and Post-Concussion Symptom Scale (PCSS) before and after the intervention. Heart rate variability (HRV) and mean arterial pressure (MAP) were collected before, during, and after the intervention. The intervention was either a single, 20-min session of treadmill walking at 40% (40HR) or 60% of age-predicted max heart rate (60HR), or seated, rest (NOEX).

RESULTS

30 participants completed the intervention with the SRC group treated 4.5 ± 1.3 days post-injury. Pre-exercise HRV and MAP were significantly different (p's < 0.001) during treatment but returned to pre-exercise values within 5 min of recovery in both the SRC and HEALTHY groups. Both the SRC and HEALTHY groups exhibited similar reductions pre- to post-intervention for symptom severity and count (p's < 0.05), three VOMS items (p's < 0.05) but not K-D time.

CONCLUSIONS

To date, this is the first adolescent RCT to report the acute, systemic effects of aerobic exercise on recently concussed adolescent athletes. The interventions appeared safe in SRC participants, were well-tolerated, and provided brief therapeutic benefit.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT03575455.

Minimizing transrectal prostate biopsy-related infections; A prospective randomized trial of povidone-iodine intrarectal cleaning versus formalin needle disinfection

Introduction:

Transrectal prostate biopsies are associated with post biopsy infection and sepsis. We compared the efficacy of povidone-iodine rectal disinfection versus formalin needle disinfection in preventing post biopsy infection among patients undergoing transrectal ultrasound-guided prostate biopsy.

Methods:

Patients scheduled to undergo ultrasound-guided transrectal prostate biopsy (n = 621) over 20 months were randomized into 2 groups to receive either povidone-iodine intrarectal disinfection or formalin disinfection of needle after each core. These were compared to assess which methodology better prevented postprocedure infection. Statistical analysis were used to identify independent factors promoting infections.

Results:

Two hundred and ninety-eight patients from povidone-iodine intrarectal disinfection were compared with 300 from formalin needle disinfection group. Formalin needle disinfection was associated with significantly more infections (P = 0.02). Escherichia coli was the dominant pathogen, with >50% of cases being quinolone resistant. Type of disinfection (P = 0.002), BMI (P = 0.001), chronic prostatitis (P = 0.002), and diabetes mellitus (P = 0.01) were independent predictors of infections. BMI at 28.95 kg/m² provided the best predictive cut-off point for infections, irrespective of method of disinfection. Area under the curve for all these parameters together was 0.91.

Conclusions:

We conclude that along with oral cephalosporin prophylaxis, povidone-iodine intrarectal disinfection is a superior to formalin needle disinfection alone in preventing post biopsy infection. Patients with BMI >28.95 kg/m² should be considered at a higher risk for infections.

Variances in BCG protection against COVID-19 mortality: A global assessment

The BCG vaccine is known to impart nonspecific immunological benefits alongside conferring protection to tuberculosis in endemic regions. It is also known to protect against bladder cancer and other respiratory tract infections. During the coronavirus disease 2019 (COVID-19) pandemic, the BCG vaccine has gained attention due to its role in conferring protective immunity. We demonstrate the potential immunological protective mechanisms that play a role against COVID-19. We conduct a global assessment of the countries that have the highest and lowest mortality rates determined by an a priori methodology. Lastly, we discuss the potential limitations of incorporating BCG vaccines as potential strategies against COVID-19 and provide recommendations regarding their use in ongoing and future epidemics.

The Safety and Efficacy of Anakinra, an Interleukin-1 Antagonist in Severe Cases of COVID-19: A Systematic Review and Meta-Analysis

This study aims to assess anakinra's safety and efficacy for treating severe coronavirus disease 2019 (COVID-19). Numerous electronic databases were searched and finally 15 studies with a total of 3,530 patients, 757 in the anakinra arm, 1,685 in the control arm were included. The pooled adjusted odds ratio (OR) for mortality in the treatment arm was 0.34 (95% confidence interval [CI], 0.21 - 0.54, I² = 48%), indicating a significant association between anakinra and mortality. A significant association was found regarding mechanical ventilation requirements in anakinra group compared to the control group OR, 0.68 (95% CI, 0.49 - 0.95, I² = 50%). For the safety of anakinra, we evaluated thromboembolism risk and liver transaminases elevation. Thromboembolism risk was OR, 1.59 (95% CI, 0.65 - 3.91, I² = 0%) and elevation in liver transaminases with OR was 1.35 (95% CI, 0.61 - 3.03, I² = 76%). Both were not statistically significant over the control group. Anakinra is beneficial in lowering mortality in COVID-19 patients. However, these non-significant differences in the safety profile between the anakinra and control groups may have been the result of baseline characteristics of the intervention group, and further studies are essential in evaluating anakinra's safety profile.

Effective Nasal Disinfection as an Overlooked Strategy in Our Fight against COVID-19

Although the recent advent of a vaccine and other therapeutic aids in our fight against COVID-19 has brought us a step closer to controlling the pandemic, our fight is far from over. Handwashing, masks, and social distancing practices are considered reasonable measures to control the spread of the disease have been well accepted by government officials and public health officials despite scarce and conflicting scientific evidence. Taking into consideration the aforementioned measures, there is an additional perhaps overlooked practice that warrants our attention-nasal disinfection and hygiene.

Effectiveness of Mavrilimumab in Viral Infections Including SARS-CoV-2 Infection - A Brief Review

Hyperinflammation and cytokine storm has been noted as a poor prognostic factor in patients with severe pneumonia related to coronavirus disease 2019 (COVID-19). In COVID-19, pathogenic myeloid cell overactivation is found to be a vital mediator of damage to tissues, hypercoagulability, and the cytokine storm. These cytokines unselectively infiltrate various tissues, such as the lungs and heart, and nervous system. This cytokine storm can hence cause multi-organ dysfunction and life-threatening complications. Mavrilimumab is a monoclonal antibody (mAb) that may be helpful in some cases with COVID-19. During an inflammation, Granulocyte-macrophage colony-stimulating factor (GM-CSF) release is crucial to driving both innate and adaptive immune responses. The GM-CSF immune response is triggered when an antigen attaches to the host cell and induces the signaling pathway. Mavrilimumab antagonizes the action of GM-CSF and decreases the hyperinflammation associated with pneumonia in COVID-19, therefore strengthening the rationale that mavrilimumab when added to the standard protocol of treatment could improve the clinical outcomes in COVID-19 patients, specifically those patients with pneumonia. With this review paper, we aim to demonstrate the inhibitory effect of mavrilimumab on cytokine storms in patients with COVID-19 by reviewing published clinical trials and emphasize the importance of extensive future trials.

Patient Throughput Times for Supplemental Breast Cancer Screening Exams

Background: To optimize screening abbreviated breast MRI (ABMR) operations, patient throughput times of ABMR were compared to breast ultrasound (US) and full protocol breast MRI (FPMR).Methods: Patient throughput times (mean ± standard error) and its subcomponents were analyzed for 95 ABMRs, 90 breast US exams, and 50 FPMRs. Total patient throughput was measured from registration time to the time of the last acquired image. Actual exam time was time difference between the first and last acquired images and pre-examination time was the calculated difference between throughput and actual exam times. Results: ABMR total patient throughput time was shorter than FPMR (55.7 ± 1.7 vs. 63.1 ± 2.0 min; difference, 7.4 min, 13%; p<0.001), but longer than breast US (39.1 ± 1.3 min; difference, 16.6 min, 30%; p<0.001). ABMR had shorter actual scan times than FPMR (13.4 ± 0.14 vs. 18.6 ± 0.25 min; p<0.001), but longer than US (9.6 ± 0.46 minutes; p<0.001). There was no difference in the pre-examination times between ABMR and FPMR (42.3 ± 1.7 vs. 44.6 ± 1.9 min; p = 0.357); pre-examination times were longer for both MR exam types compared to US (29.5 ± 1.3 minutes; p<0.001). Conclusion: ABMR patient throughput times are faster than FPMR, but these gains are limited as they have no impact on pre-examination activities which comprise the lengthiest components of the patient flow process. US patient flow currently remains faster than ABMR; however, comparable ABMR times could be achieved by further omitting certain sequences and optimizing pre-examination processes.

Human Adaptations to Multiday Saturation on NASA NEEMO

Human adaptation to extreme environments has been explored for over a century to understand human psychology, integrated physiology, comparative pathologies, and exploratory potential. It has been demonstrated that these environments can provide multiple external stimuli and stressors, which are sufficient to disrupt internal homeostasis and induce adaptation processes. Multiday hyperbaric and/or saturated (HBS) environments represent the most understudied of environmental extremes due to inherent experimental, analytical, technical, temporal, and safety limitations. National Aeronautic Space Agency (NASA) Extreme Environment Mission Operation (NEEMO) is a space-flight analog mission conducted within Florida International University’s Aquarius Undersea Research Laboratory (AURL), the only existing operational and habitable undersea saturated environment. To investigate human objective and subjective adaptations to multiday HBS, we evaluated aquanauts living at saturation for 9–10 days via NASA NEEMO 22 and 23, across psychologic, cardiac, respiratory, autonomic, thermic, hemodynamic, sleep, and body composition parameters. We found that aquanauts exposed to saturation over 9–10 days experienced intrapersonal physical and mental burden, sustained good mood and work satisfaction, decreased heart and respiratory rates, increased parasympathetic and reduced sympathetic modulation, lower cerebral blood flow velocity, intact cerebral autoregulation and maintenance of baroreflex functionality, as well as losses in systemic bodyweight and adipose tissue. Together, these findings illustrate novel insights into human adaptation across multiple body systems in response to multiday hyperbaric saturation.

Suicidal Behavior and Medication Adherence in Schizophrenic Patients

Suicide is one of the potential complications in the Schizophrenic patient population. This review article deals with the significance of antipsychotic medication compliance in decreasing suicidal behavior and hospitalizations in Schizophrenic patients. The medication adherence with second-generation antipsychotics (SGA) like clozapine and long-acting injectables (LAIs) like paliperidone is associated with decrease suicidal behavior and all-cause mortality in Schizophrenic patients. Concomitant treatment of depression and substance abuse disorder in this patient population is also associated with decreasing all-cause mortality and hospitalizations. On the other hand, long-term benzodiazepine use is associated with increase mortality in Schizophrenic patients. We also discuss some important physician intervention strategies to improve medication adherence in Schizophrenic patients like motivational interviewing (MI), behavioral tailoring (BT), and psychosocial interventions like cognitive behavior therapy (CBT).

Forgiveness: protecting medical residents from the detrimental relationship between workplace bullying and wellness

Bullying of medical residents is associated with numerous negative psychological and physiological outcomes. As bullying within this demographic grows, there is increased interest in identifying novel protective factors. Accordingly, this research investigated whether interpersonal forgiveness buffers the relationship between two forms of workplace bullying and indices of well-being. Medical residents (N = 134, 62% males) completed measures assessing person and work-related bullying victimization, dispositional forgiveness, and depressive symptoms and underwent a series of cardiovascular assessments during which cardiovascular reactivity was induced by a 3-min serial subtraction math task. It was hypothesized that the tendency to forgive would be negatively related to bullying victimization and that forgiveness would reduce the association of bullying with psychological distress (i.e. depressive symptoms), cognition errors (i.e. incorrect serial subtraction computations), and exaggerated cardiovascular reactivity and recovery. Findings show that forgiveness reduced the harmful relationship between the two forms of workplace bullying and depressive symptoms, serial subtraction errors, and cardiovascular reactivity and recovery for systolic blood pressure (SBP). Study results suggest that forgiveness may serve as an effective means for reducing the outcomes of bullying for medical residents. Implications for forgiveness interventions are discussed. Lay summary This research demonstrated that forgiveness reduced the harmful relationship between bullying victimization and negative outcomes (i.e. depressive symptoms, subtraction errors, and exaggerated cardiovascular reactivity and recovery for SBP) in medical residents. This study suggests that forgiveness may serve as a protective factor and provide an effective means for reducing the negative association between workplace bullying and negative outcomes.

Potential Role of Xylitol Plus Grapefruit Seed Extract Nasal Spray Solution in COVID-19: Case Series

The SARS-CoV-2 virus has created an unprecedented impact on healthcare globally. Being a novel virus, several treatments have been explored against COVID-19. During the early stages of the disease, treatment is mainly supportive. While several studies have suggested different treatment modalities, there is still no definitive treatment against COVID-19. Re-purposing already established medications, with excellent safety profiles, is a possible approach for treating the disease in its early stage. Having a mode of transmission as a droplet mode, several studies have supported how the nose can contain the primary route of entry of SARS-CoV-2. Hence, we postulated that re-purposing a commercially available nasal spray containing xylitol and grapefruit seed extract (GSE), namely Xlear Nasal Spray® (Xlear, Inc., American Fork, USA) could be used as an adjunct treatment of COVID-19. With a well-established safety profile, the components of this nasal spray have been studied and have been shown to have potential efficacy against viral pathogens, including coronavirus, and may potentially regulate pathways important in the initial entry of infection, replication, and systemic response to SARS-CoV-2. We present a series of three mild-moderate risks, symptomatic, COVID-19 patients, treated with the intranasal combination, as an adjuvant to their ongoing treatment, with rapid clinical improvement and shorten time to negativization on repeat intranasal swab test via PCR. No safety issues were noted during the course of treatment. Xlear nasal spray, containing xylitol plus GSE, given its established safety profile and compelling clinical results described here, could be a potential adjunct treatment option in mild-moderate COVID-19 cases.

A Pathophysiological Perspective on COVID-19's Lethal Complication: From Viremia to Hypersensitivity Pneumonitis-like Immune Dysregulation

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the coronavirus responsible for our recent coronavirus disease 2019 pandemic, is driving a lung immunopathology that strongly resembles a severe form of hypersensitivity pneumonitis (HP). A review of recent Severe acute respiratory syndrome-related coronavirus (SARS-CoV) and SARS-CoV-2 medical reports, as well as described characteristics of HP, lead us to postulate a theory for SARS-CoV-2 severe disease. We propose that the novel SARS-CoV-2 can act as a trigger and substrate of an HP-like severe immune reaction especially in genetically vulnerable individuals in addition to those with immune senescence and dysregulation. Accordingly, the purpose of our letter is to shift the emphasis of concern surrounding immune activity from viral infection to an HP-like severe immune reaction. We review similarities in disease presentation between infection and allergy, relevant immunopathology, and outline phases of SARS-CoV-2 disease with perspectives on therapy and critical care. Altogether, the favored course is to begin treatments that address the disease at the earliest phase before immune dysregulation leading to uncontrolled pulmonary inflammation.

Abbreviated Screening Breast MRI in Women at Higher-than-Average Risk for Breast Cancer with Prior Normal Full Protocol MRI

OBJECTIVE

To compare the performance of abbreviated screening breast MRI (ABMR) versus full protocol MRI (FPMR) in women at higher-than-average risk for breast cancer with a prior normal FPMR.

METHODS

ABMR was performed on higher-than-average-risk women who had a prior normal FPMR. ABMR protocol consisted of short inversion time inversion recovery imaging, precontrast, and two early postcontrast sequences acquired in under 10 minutes. Retrospective review of ABMR examinations performed from July 2016 to July 2018 was compared with a control group who underwent routine screening with FPMR who had a prior normal FPMR performed from July 2014 to June 2016. Screening outcome metrics were calculated and compared, adjusting for differences in patient demographics.

RESULTS

The study cohort included 481 ABMR examinations, while the control group included 440 FPMR studies. There was no significant difference in the abnormal interpretation rate (AIR) or cancer detection rate (CDR) for the ABMR versus the FPMR group (AIR 6.0% vs 6.8% respectively, odds ratio (OR) 0.91, 95% confidence interval (CI): 0.53-1.5, P = 0.73; CDR 8.3 vs 11 cancers detected per 1000 examinations respectively, OR 0.73, 95% CI: 0.20-2.7, P = 0.64). The PPV2 and PPV3 for the ABMR group was 19% and 21% versus 16% and 16% for the FPMR group, with no statistical difference. Sensitivity was 100% in each group with no interval cancers. There was no difference in specificity between the ABMR and FPMR groups, 93% versus 94%, respectively (P = 0.73).

CONCLUSION

ABMR may be used to screen higher-than-average-risk women with a prior normal FPMR as outcome metrics are equivalent to FPMR.

Retrospective Cohort Analysis from a High-Volume Center of Prognostic Factors Affecting Biochemical Relapse in Patients with Encapsulated, Margin-Negative, Isolated Seminal Vesicle Invasion After Robot-Assisted Laparoscopic Prostatectomy: A Novel Study

Purpose: Specimen pathology findings collectively impact the long-term outcomes of robot-assisted laparoscopic prostatectomy. Since seminal vesicle invasion (SVI) is an important independent predictor of biochemical recurrence (BCR), this study was designed to evaluate the influence of isolated SVI in the absence of capsular/margin invasion on BCR. Material and Methods: Pathology reports of 2009 robot-assisted laparoscopic prostatectomy specimens were analyzed retrospectively excluding capsular breach and/or margin-positive cases to include 1409 patients in the study. Factors predicting SVI and BCR in this select group of patients were assessed and statistically analyzed. Survival analysis for PSA (prostate-specific antigen) failure probability and binomial regressions for variable predictability were performed. Results: The African American race was associated with SVI (p < 0.05). PSA had a directly proportional correlation with the occurrence of SVI and BCR. SVI was found to be an independent predictor of BCR, leading to higher odds of BCR at 5 years (odds ratio [OR] 8.2, 95% confidence interval [CI] 4.5-14.6, p < 0.0001). When the seminal vesicle was invaded, the specimen Gleason grade group (SGGG; OR 1.9, 95% CI 1.02-3.7, p = 0.04), PSA (OR 1.2, 95% CI 1.01-1.4, p = 0.03), and BMI (body mass index) (OR 1.2, 95% CI 1.04-1.5, p = 0.01) predicted BCR. Seminal vesicle involvement was not found in SGGG 1. Risk stratification of significant predictors of BCR with isolated SVI identified a subgroup with BMI ≤27.9 kg/m², PSA ≤8.6 ng/mL, and SGGG 2, which had a significantly better prognosis (p = 0.029, log-rank test). Conclusions: Seminal vesicles are infrequently involved with SGGG 1. Select groups of patients with isolated SVI who have low-grade disease with relatively lower PSA and BMI do not have an aggressive biological behavior and are unlikely to have a BCR, thereby circumventing unnecessary adjuvant therapy with its attendant side effects. The BMI significantly predicted PSA failures and should be considered as an additional risk assessment tool.

Safety and Efficacy of Ultrasound-Guided Cryoablation for Benign Breast Fibroepithelial Lesions

OBJECTIVE

The purpose of this study is to evaluate the safety and efficacy of cryoablation for benign breast fibroepithelial lesions (FELs) that otherwise warrant surgical excision, including symptomatic fibroadenomas, growing fibroadenomas, and cellular FELs.

METHODS

All patients from 2016-2018 who had ultrasound-guided cryoablation of a symptomatic and/or growing fibroadenoma or cellular fibroepithelial lesion were reviewed. The electronic medical record was reviewed for any procedure-related complications and reduction in mass volume by ultrasound and was recorded to assess for efficacy. Patients were surveyed using a seven-point Likert scale to assess satisfaction with the procedure and a ten-point visual analog pain scale to assess level of discomfort.

RESULTS

Twenty-four women (average age 37.1 years, range 19-57 years) with 26 FELs were treated with no adverse events and 100% technical success. Thirteen cellular FELs and 13 symptomatic and/or growing fibroadenomas were ablated. Twenty-two patients had an average imaging follow-up of 11.7 months (range 5-23 months), and 18 patients completed the follow-up survey. There was 92% (22/24) clinical success, defined as a greater-than-50% reduction in mass volume. Average reduction in mass volume was 86% overall. Eighty-five percent (17/20) would recommend the procedure to others and reported pain during the procedure to be minimal (average 2.4 out of 10) with overall satisfaction rating of 6.2 out of 7. Twelve symptomatic masses demonstrated a significant reduction in pain after cryoablation (P = 0.01).

CONCLUSION

Cryoablation is a safe and efficacious minimally invasive nonsurgical alternative for the treatment of benign breast FELs.

Electronic Health Record Implementation: A Review of Resources and Tools

Implementing an electronic health record (EHR) can be a difficult task to take on and planning the process is of utmost importance to minimize errors. Evaluating the selection criteria and implementation plan of an EHR system, intending interoperability, confidentiality, availability, and integrity of the patient health information data, while ensuring timely, accurate, and regulatory compliant generation of reports is a critical task.

This article discusses the selection and implementation plan that will primarily consist of assessing existing institutional workflows for each department, and it outlines the necessities and inclinations of the institution to include in the EHR system for the organization to function properly. Resources and tools are included to assist in the selection of the product as well as ideas on how to train staff and evaluate staff readiness. Regulatory requirements are also included for consideration during the initial process.

EHR increases the logistic productivity of workflows and offers a safer way to care for patients. To ensure efficiency, there is a series of steps the provider’s staff must follow to ensure proper implementation and handling of the EHR system. Before using the implemented EHR, it is recommended to have a testing protocol in place to ensure areas of possible staff confusion are identified and controlled. Using a proper implementation strategy for a new EHR system can facilitate success, minimize delays, and increase health care worker’s satisfaction and decrease the chances of usability being compromised.

Simultaneous robotic assisted laparoscopic prostatectomy (RALP) and inguinal herniorrhaphy (IHR): proof-of-concept analysis from a high-volume center

PURPOSE

Inguinal hernia (IH) is detected in approximately 33% of RALP's either pre or intraoperatively wherein all are repaired during RALP to circumvent future herniorrhaphy (Fukuta et al., Urology 68(2):267-271, 2006; Nielsen, Urology 66(5):1034-1037, 2005). Some debate this policy by quoting the potential risk of mesh lying close to the vesicourethral anastomosis leading to infections and adhesions. The current study was initiated to elucidate the feasibility and outcomes of simultaneous inguinal herniorrhaphy (IHR) during RALP.

METHODS

Historic analysis of prospectively maintained data of 1224 RALP patients, as per inclusion criteria, between 2012 and 2017 was done, among whom 143 patients had a concurrent IHR using 3DmaxTM polypropylene monofilament mesh. Patients were then compared for demographics, peri-operative features, and outcomes.

RESULTS

The mean age and AUA score were significantly different (p < 0.002, p < 0.01 respectively) between patients undergoing only RALP and RALP with IHR. BMI was not significantly different. One hundred forty-three patients (11.6%) underwent IHR at 155 hernial sites, 12 sites being bilateral. One hundred and one sites (65.2%) were diagnosed intraoperatively. The mean console time was 67.4 ± 11.5 min for RALP which increased by 6.9 ± 10.7 min in unilateral and by 10.7 ± 8.6 min in bilateral IHR. There were no mesh-associated or Clavien Dindo class II-V complications. Mean follow-up was 36 ± 1.4 months with no recurrences.

CONCLUSION

This study reiterates the feasibility and advisability of repairing most inguinal hernias encountered during RALP as it is without any significant alteration of peri-operative morbidity, is associated with excellent post-operative outcomes, and obviates the need for a future surgical procedure.

Self-regulatory biofeedback training: an intervention to reduce school burnout and improve cardiac functioning in college students

With the detrimental relationship between school burnout and physiological and cognitive functioning now well documented, interventions to ameliorate school burnout symptomology are needed. This study examined the effectiveness of a self-regulatory biofeedback intervention program (Heart Rate Variability Coherence Biofeedback Training [HRVCB]) in contrast to a protocol demonstrated to produce cognitive and physiological improvements (a high intensity interval training protocol [HIIT]) as well as a wait-list control condition at decreasing school burnout in an American collegiate sample (N = 90). Intervention training was conducted over a 4-week span (three sessions per week) with accompanying baseline and post-intervention assessments. In addition to measurements of school burnout and negative affect (depression and anxiety), intervention influences on cognition (via a serial subtraction task) and physiology (hemodynamics, electrocardiography, and a submaximal cardiorespiratory fitness test) were explored. Findings indicate HRVCB training significantly decreased school burnout and increased mathematical performance from pre- to post-intervention measurement. These changes did not occur for HIIT or waitlist participants. Brachial and aortic systolic blood pressure decreased pre to post-intervention for HRVCB but not HIIT or waitlist participants. Cardiovascular fitness (VO_2max) improved pre to post-intervention for HIIT but not HRVCB or waitlist participants. Also, both HRVCB and HIIT training participants decreased heart rate from pre to post-intervention but not waitlist participants. Finally, all participants decreased cardiac sympathovagal tone from pre to post-intervention. These findings provide evidence that HRVCB training programs can decrease school burnout as well as improve components associated with cardiac health. Study limitations and directions for future research are discussed.

School burnout and heart rate variability: risk of cardiovascular disease and hypertension in young adult females

Emerging research documents the relationship between school burnout and some indicators of increased cardiovascular risk. Indicators of cardiovascular functioning assessed via ambulatory blood pressure and heart rate variability (HRV) have not been thoroughly explored in this research domain. Therefore, the current study examined relationships between school burnout and indicators of cardiac functioning via 24 h ambulatory blood pressure (BP) and electrocardiogram monitoring in a sample of young adult female undergraduates (N = 88). Two hypotheses were tested: (1) that independent of related negative affective symptomology (depression and anxiety), increased school burnout would be related to greater systolic and diastolic BP, higher low frequency (LF) HRV and lower very low frequency (VLF) HRV, and (2) that lower VLF would be related to greater school burnout independently of LF HRV. Hierarchical multiple regression analyzes showed that school burnout was significantly related to elevated ambulatory BP (systolic and diastolic) and HRV markers of increased cardiac sympathovagal tone. These findings support the hypotheses and suggest that school burnout might be implicated in the development of pre-hypertension or early cardiovascular disease. Study limitations and the need for future longitudinal research are discussed.

Rehabilitation Outcomes for Total Knee Arthroplasties: Continuous Adductor Canal Block Versus Continuous Femoral Nerve Block

Objective

To determine whether any strength, range of motion (ROM), or functional improvement exists in the adductor canal block (ACB) group after completion of inpatient rehabilitation and following the removal of the continuous block.

Design

Retrospective cohort.

Setting

Inpatient rehabilitation at discharge and outpatient orthopedic clinic for follow-up.

Participants

Two hundred forty-six consecutive primary total knee arthroplasties (TKAs; N = 221 patients) performed by a single surgeon in a single institution between July 2013 and August 2015 for a diagnosis of osteoarthritis.

Interventions

All TKA cases received a continuous femoral nerve block (FNB) from July 2013 to August 2014 for postoperative pain control. From August 2014 through August 2015, all TKAs received a continuous ACB.

Main Outcome Measures

Manual muscle tests (MMTs; 0-5 scale) of the quadriceps and passive ROM of the knee were assessed at 3 time periods (hospital discharge [HD], 1-2 weeks, and 1 month). Patient-oriented outcomes and clinical knee scores were examined preoperatively and postoperatively at 3 and 6 months.

Results

63.6% of FNB cases had an MMT less than 3 at HD and 36.4% of FNB cases had an MMT of 3 or greater at HD. Conversely, 46% of ACB cases had an MMT less than 3 at HD and 54% had an MMT of 3 or greater at HD. There were no statistically significant differences in all postoperative variables at all tested time periods.

Conclusions

This study showed no short-term postoperative advantages in the ACB group after catheter removal. The superior inpatient rehabilitation course in the continuous ACB group is likely not long enough to translate into any maintained benefit following catheter removal. Nevertheless, the trend toward greater strength in the ACB group in the immediate short term at HD warrants further investigation.

Respiratory Rate Variability as a Prognostic Factor in Hospitalized Patients Transferred to the Intensive Care Unit

Introduction

Increasing mortality rates within the intensive care unit (ICU) is an ever growing problem, ultimately leading to increases in the cost of healthcare expenditures. Currently, there are attempts to use guidelines in the hospital setting to predict overall mortality in critically ill patients. However, a predictor of subsequent ICU admissions remains to be explored. Recent data has shown the importance of monitoring respiratory rate variability (RRV) as a useful predictor of the deterioration of patients. Respiratory rate, in comparison to blood pressure or pulse rate, is deemed as the better determinant in identifying high-risk patients.

Aim

Our study aims to assess the role of RRV monitoring as a potential prognostic marker predictive of ICU admission.

Results

There was a significant (p = 0.009) increase in RRV between the third and fourth set of respiratory rates prior to ICU admission, such that coefficient of variation percentage (CV%) increased from 0.3% (95% confidence interval (CI): 0.09 - 0.42) to 0.7% (95% CI: 0.04 - 0.9) about 12 hours before admission to the ICU independent from diagnosis.

Conclusion

Using elevated RRV as a signal may be a useful prognostic tool in providing early intervention, thus reducing the incidence of subsequent morbidity and mortality in patients that might necessitate an ICU admission.

Influence of Acute Antipsychotic Treatment on Cardiorespiratory Coupling and Heart Rate Variability

A major contributing factor associated with increased cardiac mortality in patients with schizophrenia (SCZ) seems to be a dysfunction of the autonomic nervous system (ANS). The link between ANS dysfunction and SCZ is multifactorial, but some reports suggest that the use of antipsychotics could be implicated. This case illustrates the time course of autonomic improvement in response to antipsychotic treatment in an inpatient with SCZ in acute psychosis. To this end, we documented markers of autonomic function during hospitalization. Heart rate variability (HRV; cardiac autonomic modulation) analysis showed an increased variability over time (from Day 1 to Day 3), with strongest reaction at Day 3. The respiration analysis showed an increased respiratory variability over time (from Day 1 to Day 3) suggesting improved autonomic modulation in response to the pharmacotherapy. Cardiorespiratory coupling (CRC; surrogate of cardiorespiratory synchrony and cardiovagal modulation) showed an increasing influence of heart rate on respiration and increased from Day 1 to Day 3. The concurrent improvement of psychosis and autonomic function in response to antipsychotic treatment in this patient suggest a potential cardio protective role of antipsychotics in the acute setting. Prospective trials aimed at examining the cardiovascular implications of acute psychosis treatment in patients with schizophrenia are warranted.

Acupuncture therapy improves vascular hemodynamics and stiffness in middle-age hypertensive individuals

Acupuncture (ACU) is becoming a more common practice among hypertensive individuals. However, the reported therapeutic effects of ACU in lowering brachial blood pressure (BP) are ambiguous. Therefore, evaluating more sensitive markers of arterial functioning might unveil the protective effects of ACU on hypertension. We examined the effects of an 8-week ACU therapy intervention on vascular hemodynamics and stiffness in middle-age hypertensive individuals. Participants were randomly assigned to either ACU (n = 23) or a control group (n = 22). Brachial and aortic BP, wave reflection (AIx) and arterial stiffness (SI) were measured before and after 8 weeks. There was a significant group x time interaction (P < 0.05) for brachial and aortic BP, AIx and SI which significantly decreased (P < 0.05) following ACU but not after control. ACU led to reductions in brachial and aortic BP, wave reflection and arterial stiffness in middle-age hypertensive individuals. ACU might be effective in the prevention and treatment of hypertension.

Acute Changes in Mentation in a Patient with Hepatic Cirrhosis Treated with High Doses of Dexamethasone

Despite the anti-inflammatory benefits of steroids in the management of multiple medical conditions, they are associated with undesired metabolic and psychiatric side effects. We present a case of a 57-year-old Hispanic man with hepatic cirrhosis due to hepatitis C and no past medical history of psychiatric illnesses who became delirious after treatment with high doses of intravenous Dexamethasone. The patient presented to Larkin Community Hospital, USA with complaints of lower back pain requiring treatment with steroids for severe lumbar central canal stenosis. After three days of treatment, the patient became disoriented to time and place, grossly psychotic with auditory hallucinations and disorganized behavior, manic, aggressive, combative, restless, hard to redirect, and unable to follow commands. He met the criteria for a diagnosis of substance-induced psychotic disorder according to Diagnostic and Statistical Manual of Mental Disorders (DSM) V. Furthermore, the patient had worsening hepatic profile, a high ammonia level of 125 umol/L, and clinical findings consistent with West Haven classification grade 2 encephalopathy. Head computed tomography (CT) scan was normal. He was treated with discontinuation of steroids, lactulose, and Haloperidol returning to baseline mental status after 48 hours. The patient's hospitalization was complicated with a prolonged hospital stay after lumbar surgery. This case illustrates that treatment with high doses of Dexamethasone in a patient with hepatic cirrhosis can cause acute changes in mental status by (i) inducing delirium, and (ii) precipitating hepatic encephalopathy.

Pathogenesis of depression- and anxiety-like behavior in an animal model of hypertrophic cardiomyopathy

Cardiovascular dysfunction is highly comorbid with mood disorders, such as anxiety and depression. However, the mechanisms linking cardiovascular dysfunction with the core behavioral features of mood disorder remain poorly understood. In this study, we used mice bearing a knock-in sarcomeric mutation, which is exhibited in human hypertrophic cardiomyopathy (HCM), to investigate the influence of HCM over the development of anxiety and depression. We employed behavioral, MRI, and biochemical techniques in young (3-4 mo) and aged adult (7-8 mo) female mice to examine the effects of HCM on the development of anxiety- and depression-like behaviors. We focused on females because in both humans and rodents, they experience a 2-fold increase in mood disorder prevalence vs. males. Our results showed that young and aged HCM mice displayed echocardiographic characteristics of the heart disease condition, yet only aged HCM females displayed anxiety- and depression-like behaviors. Electrocardiographic parameters of sympathetic nervous system activation were increased in aged HCM females vs. controls and correlated with mood disorder-related symptoms. In addition, when compared with controls, aged HCM females exhibited adrenal gland hypertrophy, reduced volume in mood-related brain regions, and reduced hippocampal signaling proteins, such as brain-derived neurotrophic factor and its downstream targets vs. controls. In conclusion, prolonged systemic HCM stress can lead to development of mood disorders, possibly through inducing structural and functional brain changes, and thus, mood disorders in patients with heart disease should not be considered solely a psychologic or situational condition.-Dossat, A. M., Sanchez-Gonzalez, M. A., Koutnik, A. P., Leitner, S., Ruiz, E. L., Griffin, B., Rosenberg, J. T., Grant, S. C., Fincham, F. D., Pinto, J. R. Kabbaj, M. Pathogenesis of depression- and anxiety-like behavior in an animal model of hypertrophic cardiomyopathy.

Preserving brain function in a comatose patient with septic hyperpyrexia (41.6 °C): a case report

Background

Pyrexia is a physiological response through which the immune system responds to infectious processes. Hyperpyrexia is known to be neurodegenerative leading to brain damage. Some of the neurotoxic effects of hyperpyrexia on the brain include seizures, decreased cognitive speed, mental status changes, coma, and even death. In the clinical management of hyperpyrexia, the goal is to treat the underlying cause of elevated temperature and prevent end organ damage.

Case presentation

This case illustrates a 39-year-old white American man referred from another medical facility where he had undergone an upper gastrointestinal tract diagnostic procedure which became complicated by blood aspiration and respiratory distress. During hospitalization, he developed a core body temperature of 41.6 °C (106.9 °F) leading to cognitive decline and coma with a Glasgow Coma Score of 3. Levetiracetam and amantadine were utilized effectively for preserving and restoring neurocognitive function. Prior studies have shown that glutamate levels can increase during an infectious process. Glutamate is an excitatory neurotransmitter that is utilized by the organum vasculosum laminae terminalis through the neuronal excitatory system and causes an increase in body temperature which can lead to hyperpyrexia. Similar to neurogenic fevers, hyperpyrexia can lead to neurological decline and irreversible cognitive dysfunction. Inhibition of the glutamate aids a decrease in excitatory states, and improves the brain’s regulatory mechanism, including temperature control. To further improve cognitive function, dopamine levels were increased with a dopamine agonist.

Conclusions

We propose that a combination of levetiracetam and amantadine may provide neuroprotective and neurorestorative properties when administered during a period of hyperpyrexia accompanied by any form of mental status changes, particularly if there is a decline in Glasgow Coma Score.

Preserving brain function in a comatose patient with septic hyperpyrexia (41.6 °C): a case report

BACKGROUND

Pyrexia is a physiological response through which the immune system responds to infectious processes. Hyperpyrexia is known to be neurodegenerative leading to brain damage. Some of the neurotoxic effects of hyperpyrexia on the brain include seizures, decreased cognitive speed, mental status changes, coma, and even death. In the clinical management of hyperpyrexia, the goal is to treat the underlying cause of elevated temperature and prevent end organ damage.

CASE PRESENTATION

This case illustrates a 39-year-old white American man referred from another medical facility where he had undergone an upper gastrointestinal tract diagnostic procedure which became complicated by blood aspiration and respiratory distress. During hospitalization, he developed a core body temperature of 41.6 °C (106.9 °F) leading to cognitive decline and coma with a Glasgow Coma Score of 3. Levetiracetam and amantadine were utilized effectively for preserving and restoring neurocognitive function. Prior studies have shown that glutamate levels can increase during an infectious process. Glutamate is an excitatory neurotransmitter that is utilized by the organum vasculosum laminae terminalis through the neuronal excitatory system and causes an increase in body temperature which can lead to hyperpyrexia. Similar to neurogenic fevers, hyperpyrexia can lead to neurological decline and irreversible cognitive dysfunction. Inhibition of the glutamate aids a decrease in excitatory states, and improves the brain's regulatory mechanism, including temperature control. To further improve cognitive function, dopamine levels were increased with a dopamine agonist.

CONCLUSIONS

We propose that a combination of levetiracetam and amantadine may provide neuroprotective and neurorestorative properties when administered during a period of hyperpyrexia accompanied by any form of mental status changes, particularly if there is a decline in Glasgow Coma Score.

Dispositional self-control: relationships with aerobic capacity and morning surge in blood pressure

The psychological, behavioral and psychosocial implications of self-control are well established, but relatively little is known about its implications for physical health. This study examined the association between self-control and two important indicators of cardiovascular risk: morning blood pressure surge (MBPS) and maximum oxygen consumption (VO_2max). Undergraduate students (N = 78) completed a measure of dispositional self-control (Brief Self-Control Scale), participated in a 24-h ambulatory assessment of heart rate (HR) and blood pressure (BP), and completed the YMCA Cycle Ergometer Submaximal Test. Regression analyzes yielded a significant positive relationship between self-control and VO_2max. Results also indicated a significant negative association between self-control and MBPS, independent of average 24-h blood pressure and VO_2max scores. These findings expand our understanding of the relationship between dispositional self-control and MBPS. Study limitations and directions for future research are discussed.

Impact of a motivated performance task on autonomic and hemodynamic cardiovascular reactivity

Motivated performance (MP) tasks include mental stressors characterized by a high degree of motivation, individual engagement, and sympathetic overstimulation. It is therefore important to document the independent influence of motivation apart from engagement on markers of cardiovascular autonomic modulation, including vasomotor tone (low-frequency systolic blood pressure, LFSBP), blood pressure homeostasis (baroreflex sensitivity, BRS), and myocardial oxygen consumption (rate pressure product, RPP). Accordingly, an arithmetic task (AT) was used to manipulate motivation to evaluate its impact on cardiovascular reactivity. Forty-two young adults (Mage = 20.21 years, SD = 2.09) qualified for the study. After a 10-min resting period, electrocardiogram and finger beat-to-beat blood pressure were recorded at three distinct 5-min stages: baseline (BASE), AT, and recovery (REC). Prior to AT initiation, participants were randomized into two groups based on directions stating that the AT task was either designed to be entertaining and fun (low MP, LMP) or a test diagnostic of one's intelligence (high MP, HMP). Independent of task engagement ratings, motivation to complete the AT task as well as solution success was significantly greater in the HMP than the LMP condition. Regarding physiological parameters, two (LMP vs. HMP) × three (BASE, AT, REC) repeated measures ANOVAs revealed no significant baseline differences but a significant higher order interaction indicating that in comparison to LMP, individuals in the HMP condition had significantly higher vasomotor tone and myocardial oxygen consumption but not BRS. Greater motivation during a performance task may provide the substrate for the development of adverse cardiovascular events by increasing sympathetic activity and ultimately increasing myocardial oxygen demand which could lead to acute coronary syndromes.

Understanding the physiology of mindfulness: aortic hemodynamics and heart rate variability

Data were collected to examine autonomic and hemodynamic cardiovascular modulation underlying mindfulness from two independent samples. An initial sample (N = 185) underwent laboratory assessments of central aortic blood pressure and myocardial functioning to investigated the association between mindfulness and cardiac functioning. Controlling for religiosity, mindfulness demonstrated a strong negative relationship with myocardial oxygen consumption and left ventricular work but not heart rate or blood pressure. A second sample (N = 124) underwent a brief (15 min) mindfulness inducing intervention to examine the influence of mindfulness on cardiovascular autonomic modulation via blood pressure variability and heart rate variability. The intervention had a strong positive effect on cardiovascular modulation by decreasing cardiac sympathovagal tone, vasomotor tone, vascular resistance and ventricular workload. This research establishes a link between mindfulness and cardiovascular functioning via correlational and experimental methodologies in samples of mostly female undergraduates. Future directions for research are outlined.

In Vivo Analysis of Troponin C Knock-In (A8V) Mice: Evidence that TNNC1 Is a Hypertrophic Cardiomyopathy Susceptibility Gene

BACKGROUND

Mutations in thin-filament proteins have been linked to hypertrophic cardiomyopathy, but it has never been demonstrated that variants identified in the TNNC1 (gene encoding troponin C) can evoke cardiac remodeling in vivo. The goal of this study was to determine whether TNNC1 can be categorized as an hypertrophic cardiomyopathy susceptibility gene, such that a mouse model can recapitulate the clinical presentation of the proband.

METHODS AND RESULTS

The TNNC1-A8V proband diagnosed with severe obstructive hypertrophic cardiomyopathy at 34 years of age exhibited mild-to-moderate thickening in left and right ventricular walls, decreased left ventricular dimensions, left atrial enlargement, and hyperdynamic left ventricular systolic function. Genetically engineered knock-in (KI) mice containing the A8V mutation (heterozygote=KI-TnC-A8V(+/-); homozygote=KI-TnC-A8V(+/+)) were characterized by echocardiography and pressure-volume studies. Three-month-old KI-TnC-A8V(+/+) mice displayed decreased ventricular dimensions, mild diastolic dysfunction, and enhanced systolic function, whereas KI-TnC-A8V(+/-) mice displayed cardiac restriction at 14 months of age. KI hearts exhibited atrial enlargement, papillary muscle hypertrophy, and fibrosis. Liquid chromatography-mass spectroscopy was used to determine incorporation of mutant cardiac troponin C (≈ 21%) into the KI-TnC-A8V(+/-) cardiac myofilament. Reduced diastolic sarcomeric length, increased shortening, and prolonged Ca(2+) and contractile transients were recorded in intact KI-TnC-A8V(+/-) and KI-TnC-A8V(+/+) cardiomyocytes. Ca(2+) sensitivity of contraction in skinned fibers increased with mutant gene dose: KI-TnC-A8V(+/+)>KI-TnC-A8V(+/-)>wild-type, whereas KI-TnC-A8V(+/+) relaxed more slowly on flash photolysis of diazo-2.

CONCLUSIONS

The TNNC1-A8V mutant increases the Ca(2+)-binding affinity of the thin filament and elicits changes in Ca(2+) homeostasis and cellular remodeling, which leads to diastolic dysfunction. These in vivo alterations further implicate the role of TNNC1 mutations in the development of cardiomyopathy.

School burnout: increased sympathetic vasomotor tone and attenuated ambulatory diurnal blood pressure variability in young adult women

Two studies examined autonomic and cardiovascular functioning that may link school burnout to cardiovascular risk factors in young healthy adult females. Study 1 (N = 136) investigated whether school burnout was related to resting values of blood pressure (BP) and blood pressure variability (BPV) through laboratory beat-to-beat BP assessment. Study 2 (N = 94) examined the link between school burnout and diurnal BPV through ambulatory BP monitoring. Controlling for anxiety and depressive symptomatology, school burnout demonstrated strong positive relationships with indices of cardiac sympathovagal tone, sympathetic vasomotor tone, inefficient myocardial oxygen consumption, increased 24-h ambulatory heart rate and BP, blunted BP diurnal variability, and increased arterial stiffness. These studies establish cardiovascular biomarkers of school burnout and suggest that even in a seemingly healthy sample school burnout may predispose females to increased cardiovascular risk. Several future lines of research are outlined.

Effect of anger and trait forgiveness on cardiovascular risk in young adult females

High trait anger is linked to adverse cardiovascular outcomes. A potential antidote to the cardiotoxic influence of anger is trait forgiveness (TF), as it has shown associations with improved blood pressure (BP) and cardiovagal tone regulation in cardiac patients. However, it has yet to be determined if anger and forgiveness independently predict cardiovascular parameters. Trait anger (State-Trait Anger Expression Inventory-2) and TF (Tendency to Forgive Scale) were evaluated in 308 (M = 21.11years ± SD = 2.52) healthy female volunteers allocated to 3 related, yet distinct, studies. Hierarchical multiple regressions tested the incremental contribution of TF after accounting for anger. Study 1 assessed autonomic modulation through beat-to-beat BP and spectral analysis to examine sympathovagal balance and baroreflex functioning. Study 2 used tonometry and pulse wave analysis for aortic hemodynamics. Study 3 assessed 24-hour ambulatory BP and ambulatory arterial stiffness index. Hierarchical models demonstrated that anger was significantly associated with increased sympathovagal tone, increased hemodynamic indices, high ambulatory BPs, and attenuated BP variability and baroreflex. In contrast, TF was associated with more favorable hemodynamic effects (i.e., decreased ventricular work and myocardial oxygen consumption). In conclusion, these results demonstrate divergent cardiovascular effects of anger and forgiveness, such that anger is associated with a more cardiotoxic autonomic and hemodynamic profile, whereas TF is associated with a more cardioprotective profile. These findings suggest that interventions aimed at decreasing anger while increasing forgiveness may be clinically relevant.

Long term ablation of protein kinase A (PKA)-mediated cardiac troponin I phosphorylation leads to excitation-contraction uncoupling and diastolic dysfunction in a knock-in mouse model of hypertrophic cardiomyopathy

The cardiac troponin I (cTnI) R21C (cTnI-R21C) mutation has been linked to hypertrophic cardiomyopathy and renders cTnI incapable of phosphorylation by PKA in vivo. Echocardiographic imaging of homozygous knock-in mice expressing the cTnI-R21C mutation shows that they develop hypertrophy after 12 months of age and have abnormal diastolic function that is characterized by longer filling times and impaired relaxation. Electrocardiographic analyses show that older R21C mice have elevated heart rates and reduced cardiovagal tone. Cardiac myocytes isolated from older R21C mice demonstrate that in the presence of isoproterenol, significant delays in Ca(2+) decay and sarcomere relaxation occur that are not present at 6 months of age. Although isoproterenol and stepwise increases in stimulation frequency accelerate Ca(2+)-transient and sarcomere shortening kinetics in R21C myocytes from older mice, they are unable to attain the corresponding WT values. When R21C myocytes from older mice are treated with isoproterenol, evidence of excitation-contraction uncoupling is indicated by an elevation in diastolic calcium that is frequency-dissociated and not coupled to shorter diastolic sarcomere lengths. Myocytes from older mice have smaller Ca(2+) transient amplitudes (2.3-fold) that are associated with reductions (2.9-fold) in sarcoplasmic reticulum Ca(2+) content. This abnormal Ca(2+) handling within the cell may be attributed to a reduction (2.4-fold) in calsequestrin expression in conjunction with an up-regulation (1.5-fold) of Na(+)-Ca(2+) exchanger. Incubation of permeabilized cardiac fibers from R21C mice with PKA confirmed that the mutation prevents facilitation of mechanical relaxation. Altogether, these results indicate that the inability to enhance myofilament relaxation through cTnI phosphorylation predisposes the heart to abnormal diastolic function, reduced accessibility of cardiac reserves, dysautonomia, and hypertrophy.

School burnout and cardiovascular functioning in young adult males: a hemodynamic perspective

This study investigated aortic and brachial hemodynamic functioning that may link school burnout to cardiovascular risk factors. Methodological improvements from previous research were implemented including (1) statistical control of depressive and anxiety symptoms (2) resting, stress-induced and cardiac recovery condition comparisons and (3) use of pulse wave analysis. Forty undergraduate young adult males completed self-report measures of school burnout, trait anxiety and depressive symptoms. Participants then completed a protocol consisting of a 10-min seated rest, 5-min baseline (BASE), 3-min cold pressor test (CPT) and a 3-min recovery period (REC). Indices of brachial and aortic hemodynamics were obtained by means of pulse wave analysis via applanation tonometry. Controlling for anxiety and depressive symptoms, planned contrasts identified no differences in cardiovascular parameters at BASE between participants in burnout and non-burnout groups. However, negative changes in hemodynamic indices occurred in burnout participants at CPT and REC as evidenced by increased aortic and brachial systolic and diastolic blood pressures, increased left ventricular work and increased myocardial oxygen consumption. Findings suggest that school burnout symptoms are associated with cardiac hyperactivity during conditions of cardiac stress and recovery and therefore may be associated with the early manifestations of cardiovascular disease. Future studies are suggested to reveal underlying autonomic mechanisms explaining hemodynamics functioning in individuals with school burnout symptomatology.

Sympathetic vasomotor tone is associated with depressive symptoms in young females: a potential link between depression and cardiovascular disease

BACKGROUND

Although increased sympathetic nervous system (SNS) activity is commonly associated with major depressive disorder (MDD) and cardiovascular disease (CVD), a biomarker linking these two entities remains elusive. We therefore evaluated the relationship between depressive symptoms and cardiovascular modulation by heart rate variability (HRV), brachial blood pressure (BP), ambulatory BP (ABP), and low frequency component of systolic BP variability (LFSBP), a surrogate of sympathetic vasomotor tone. We hypothesized that LFSBP would be the strongest predictor of depressive symptoms compared with HRV and BP measurements.

METHODS

Eighty young healthy female subjects (20.51 ± 2.82 years) were evaluated for depressive symptoms using the Center for Epidemiologic Studies Depression Scale (CES-D). Data collection was conducted after a 10-minute resting period. Beat-to-beat BPs were recorded for 5-minute at baseline (BASE) followed by a 3-minute cold pressor test (CPT). ABP was obtained for 24 hours.

RESULTS

Hierarchical multiple regression analyses indicated that LFSBP at BASE was a stronger predictor of CES-D variance than BP and HRV indices, with LFSBP uniquely accounting for 8.1% of variance in CES-D scores during laboratory beat-by-beat BP assessments and 44.7% in ABP assessments. Individuals with acute depression scores (n = 12; CES-D ≥ 16) had significantly higher (P < 0.001) mean LFSBP values (6.66 ± 2.54 mm Hg(2)) than the remaining sample (3.32 ± 2.2 mm Hg(2)), whereas no other significant differences were detected in any of the other cardiovascular variables. Cardiovascular responses to CPT did not predict CES-D scores.

CONCLUSIONS

These findings suggest that LFSBP could be a biomarker of neurovascular functioning with potential clinical implications for understanding the interaction between MDD and CVD.

Depressive symptoms contribute to increased wave reflection during cold pressor test in young adult men

BACKGROUND

Major depressive disorder (MDD) is associated with increased cardiovascular risk. Although cardiovascular hyperactivity to stressors (e.g., cold pressor test (CPT)) is common in those with MDD, the aortic hemodynamic (AH) responses to sympatho-stimulation in healthy individuals with higher depressive scores (HDS) are not well understood. We hypothesized that individuals with HDS, compared with those with low depressive scores (LDS), would have greater changes in AH during the CPT.

METHODS

Thirty-five male participants (mean age, 22.3±0.7 years) completed a self-report measure of depressive symptoms and were classified as having an HDS or LDS. Radial waveforms were then obtained by means of applanation tonometry. The testing protocol consisted of a 10-minute seated rest, 5 minutes of baseline measurements, a 3-minute CPT, and a 3-minute recovery period.

RESULTS

At baseline, no differences were found between the LDS (n=16) and HDS (n=19) groups on any variables studied. During CPT, there was a significant group-by-time interaction for aortic mean blood pressure (HDS vs. LDS = 107±3mm Hg vs. 96±3mm Hg; P = 0.008); augmentation index (HDS vs. LDS =19% ± 3% vs. 11% ± 2%; P = 0.02), a surrogate of wave reflection; and systolic time interval (HDS vs. LDS = 2295±78mm Hg/s.min(-1) vs. 1919±74mm Hg/s.min(-1); P = 0.001), a marker of myocardial work, such that the HDS group had significantly higher responses than the LDS group.

CONCLUSIONS

HDS may be associated with cardiac hyperactivity during sympatho-stimulation, contributing to increased central blood pressure, wave reflection, and myocardial work. Prospective studies to unveil mechanisms explaining increased AH in healthy individuals with high depressive symptomatology are warranted.

Cold exposure attenuates post exercise cardiovagal reactivation and sympathetic withdrawal

In a crossover design we investigated cardiac autonomic responses (heart rate variability, HRV) to isometric handgrip exercise (IHG) in cold (4°C) and temperate (24°C, temp) conditions in 20 men that assumed the supine position for 30 min in an environmental chamber. After a 5 min rest, subjects performed 3 min of IHG followed by a 3 min recovery period (REC). During REC, the low frequency of HRV was lower while the high frequency and the square root of the mean squared differences of successive NN intervals were higher (P<0.05) than the rest in the temp compared to a full recovery in the cold. In conclusion, recovery from concurrent cold exposure and exercise impairs cardiovagal modulation which may precipitate cardiac events.

Acute exercise with whole-body vibration decreases wave reflection and leg arterial stiffness

AIM

Whole-body vibration exercise (WBV) acutely decreases brachial-ankle pulse wave velocity (baPWV), an index of systemic arterial stiffness. However, the effect of WBV on segmental PWV and aortic hemodynamics is unknown. We examined the acute effects of WBV on arterial function.

METHODS

Fifteen young men performed ten 1-min sets of static squat with WBV (40 Hz, 1 mm, 5.37 G) and without WBV (no-WBV). Brachial and aortic blood pressure (BP), heart rate (HR), augmentation index (AIx), baPWV, carotid-femoral PWV (cfPWV), and femoral-ankle (faPWV), were recorded before and 5, 15, and 30 min after both trials.

RESULTS

Brachial and aortic SBP (P < 0.01), and HR (P < 0.01) were increased only at 5 min after both exercise trials. AIx was elevated through the recovery after no-WBV while decreased at 15 and 30 min after WBV exercise. FaPWV was decreased (P < 0.01) at 5 min after both trials, but returned to baseline at 15 min after no-WBV exercise and was maintained decreased at 15 and 30 min after WBV exercise. There were no significant changes in brachial and aortic diastolic BP, cfPWV and baPWV after both trials.

CONCLUSIONS

Our findings indicate that regardless of WBV, static squat causes a small transient increase in hemodynamic responses during early recovery. WBV counteracts the increase in AIx induced by static squat and reduces wave reflection magnitude through a local effect on arterial stiffness.