Autonomic regulation in different hypertensive phenotypes - the HELIUS study

Background: Hypertension can be classified into different phenotypes based on systolic and diastolic blood pressure (BP) that carry a different prognosis and may therefore be differently associated with sympathetic activity. We assessed the association between cardiac autonomic function determined from continuous finger BP recordings and hypertensive phenotypes. Methods: We included 10,221 individuals aged between 18-70 years from the multi-ethnic HELIUS study. Finger BP was recorded continuously for 3-5 minutes from which cross-correlation baroreflex sensitivity (xBRS) and heart rate variability (HRV) were determined. Hypertension was classified into isolated systolic (ISH; ≥140/<90), diastolic (IDH; <140/≥90) and combined systolic and diastolic hypertension (SDH; ≥140/≥90). Differences were assessed after stratification by age (younger: ≤40, older: >40 years) and sex, using regression with correction for relevant covariates. For xBRS, values were log-transformed. Results: In younger adults with ISH, xBRS was comparable to normotensive individuals in men (ratio 0.92; 95%CI 0.84-1.01) and women (1.00; 95%CI 0.84-1.20), while xBRS was significantly lower in IDH and SDH (ratios between 0.67 and 0.80). In older adults, all hypertensive phenotypes had significantly lower xBRS compared to normotensives. We found a similar pattern for HRV in men, while in women HRV did not differ between phenotypes. Conclusions: In younger men and women ISH is not associated with a shift towards increased sympathetic control, while IDH and SDH in younger and all hypertensive phenotypes in older participants were associated with increased sympathetic control. This suggests that alterations in autonomic regulation could be a contributing factor to known prognostic disparities between hypertensive phenotypes.

Do cool shirts make a difference? The effects of upper body garments on health, fluid balance and performance during exercise in the heat

OBJECTIVES

Due to climate change and major sport events in hot climate, temperature regulation during exercise is gaining relevance in professional and amateur sports. This study compares the effects of an upper body garment with water-soaked inlays, of a synthetic- and of a cotton shirt on health, fluid balance and performance during a high intensity exercise session in the heat.

METHODS

32 healthy participants (age 25 ± 4 years; 15 women) were assigned to one of three upper body garments (cotton-shirt, synthetic-fiber-shirt, cooling-vest with water-soaked inlays) and underwent a high intensity steady state ergometer exercise test (Temperature 30.5 °C, frontal airflow 20 km/h, relative air-humidity 43 ± 13%). Time to exhaustion, physiologic parameters (inner ear temperature, heart rate, relative oxygen uptake, body weight, garment weight) and subjective data (perceived exertion, thermal sensation, skin wettedness, clothing humidity, feeling scale) were assessed. Time to exhaustion was analyzed using a survival time analysis. Other outcomes were evaluated using Kruskal-Wallis Tests and 95%-confidence-intervals.

RESULTS

Time to exhaustion was not different between groups. Cooling-vests were heavier and led to lower inner ear temperature, lower thermal- and higher clothing-humidity-sensation at the start of exercise. Physiologic and subjective parameters showed no group differences at exercise termination.

CONCLUSIONS

In a realistic setting including frontal airflow, synthetic and cotton-fiber shirts reach comparable effects on health and thermoregulation and are perceived as equally comfortable. Although inducing a small pre-exercise cooling effect, a water-soaked garment induces a weight penalty and creates a less comfortable situation.

Southern ocean carbon and heat impact on climate

The Southern Ocean greatly contributes to the regulation of the global climate by controlling important heat and carbon exchanges between the atmosphere and the ocean. Rates of climate change on decadal timescales are therefore impacted by oceanic processes taking place in the Southern Ocean, yet too little is known about these processes. Limitations come both from the lack of observations in this extreme environment and its inherent sensitivity to intermittent processes at scales that are not well captured in current Earth system models. The Southern Ocean Carbon and Heat Impact on Climate programme was launched to address this knowledge gap, with the overall objective to understand and quantify variability of heat and carbon budgets in the Southern Ocean through an investigation of the key physical processes controlling exchanges between the atmosphere, ocean and sea ice using a combination of observational and modelling approaches. Here, we provide a brief overview of the programme, as well as a summary of some of the scientific progress achieved during its first half. Advances range from new evidence of the importance of specific processes in Southern Ocean ventilation rate (e.g. storm-induced turbulence, sea-ice meltwater fronts, wind-induced gyre circulation, dense shelf water formation and abyssal mixing) to refined descriptions of the physical changes currently ongoing in the Southern Ocean and of their link with global climate. This article is part of a discussion meeting issue 'Heat and carbon uptake in the Southern Ocean: the state of the art and future priorities'.

Hospital resource endowments and nosocomial infections: longitudinal evidence from the English National Health Service on Clostridioides difficile between 2011 and 2019

OBJECTIVES

To identify key factors associated with Clostridioides difficile infections (CDIs) in healthcare at the hospital organization level.

DESIGN

Longitudinal study covering the period 2011-2019. Hospital reports were analysed to determine the number of CDIs and several hospital-related environmental factors: financial resources (i.e., cleaning expenditure), spatial resources (i.e., number of single rooms with a private bathroom), human resources (i.e., number of physicians and nursing staff) and cultural resources (i.e., error reporting climate). The relationships between the environmental factors and CDIs were analysed in a hybrid within- and between-hospital random-effect model.

SETTING

A total of 129 general hospital Trusts operating in the English National Health Service (NHS).

PARTICIPANTS

All inpatients in 129 general hospital trusts of the NHS in the years 2011-2019, covering 120,629 cases of CDI.

MAIN OUTCOME MEASURE

Annual number of CDIs per hospital trust.

RESULTS

Single rooms were associated with fewer CDIs at the within-hospital level, but not at the between-hospital level. Similarly, more nursing staff was associated with fewer CDIs at the within-hospital level, but not at the between-hospital level. This effect was not observed for physician staffing. A different picture emerged for the protective effect of cultural resources, with a weakly significant effect of between-hospital differences, but no within-hospital effect. Financial resources were not associated with CDIs either between hospitals or within them over time.

CONCLUSIONS

The present study identified hospital resources with a beneficial influence on CDI rates. Healthcare organizations can use this knowledge for active CDI prevention.

Automated analysis of finger blood pressure recordings provides insight in determinants of baroreflex sensitivity and heart rate variability-the HELIUS study

Sympathovagal balance is important in the pathogenesis of hypertension and independently associated with mortality. We evaluated the value of automated analysis of cross-correlation baroreflex sensitivity (xBRS) and heart rate variability (HRV) and its relationship with clinical covariates in 13,326 participants from the multi-ethnic HELIUS study. Finger blood pressure (BP) was continuously recorded, from which xBRS, standard deviation of normal-to-normal intervals (SDNN), and squared root of mean squared successive difference between normal-to-normal intervals (RMSDD) were determined. A subset of 3356 recordings > 300 s was used to derive the minimally required duration by comparing shortened to complete recordings, defined as intraclass correlation (ICC) > 0.90. For xBRS and SDNN, 120 s and 180 s were required (ICC 0.93); for RMSDD, 60 s (ICC 0.94) was sufficient. We included 10,252 participants (median age 46 years, 54% women) with a recording > 180 s for the regression. xBRS, SDNN, and RMSDD decreased linearly up to 50 years of age. For xBRS, there was a signification interaction with sex, with for every 10 years a decrease of 4.3 ms/mmHg (95%CI 4.0-4.6) for men and 5.9 ms/mmHg (95%CI 5.6-6.1) for women. Using splines, we observed sex-dependent nonlinearities in the relation with BP, waist-to-hip-ratio, and body mass index. Future studies can help unravel the dynamics of these relations and assess their predictive value. Panel 1 depicts automatic analysis and filtering of finger BP recordings, panel 2 depicts computation of xBRS from interpolated beat to beat data of systolic BP and interbeat interval, and (IBI) SDNN and RMSDD are computed directly from the filtered IBI dataset. Panel 3 depicts the results of large-scale analysis and relation of xBRS with age, sex, blood pressure and body mass index.

Linking key husbandry factors to the intrinsic quality of broiler meat

Broiler farming is the fastest-growing animal production sector and broiler meat is the second most-consumed meat in the world. The intensification of broiler production often has a negative impact on the meat quality and carcass characteristics. Consumers, however, expect a quality product from animals reared extensively on farms providing good animal welfare, often intuitively associated with extensive farming practices. Therefore, this literature review investigates how the critical factors contributing to the degree of extensiveness of broiler production affect the quality of meat. We used the data from scientific articles published in the years 2012-2021 to analyze the effect of diet (n = 409), genetics (n = 86), enrichment (n = 25), and stocking density (n = 20) on meat quality and carcass characteristics. Minerals and microelements supplementation in the diet improved all the meat quality aspects: sensory, physical, and chemical in most studies. Minerals and enzymes in the diet had beneficial effects on carcass characteristics, unlike feed restriction and ingredient substitutions. The impact of outdoor access on meat quality and carcass characteristics was most frequently examined, in contrast to the use of perches or effects of litter quality. Overall, enrichment did not affect the meat's sensory or physical parameters, but outdoor access improved its lipid composition. Lower stocking density deteriorated intramuscular fat content, decreased tenderness and juiciness, yet lowered cooking and drip loss, and increased carcass and breast muscle yields. When it comes to genetics, in general, slow growing broiler strains have better meat quality parameters, especially regarding yellowness (b*), redness (a*), cooking and drip loss. Our review shows that the factors which contribute to extensiveness of broiler production systems and birds' welfare also affect meat quality and the carcass characteristics.

Pragmatic Diagnostic and Therapeutic Algorithms to Optimize New Potassium Binder use in Cardiorenal Disease

BACKGROUND

Pivotal randomized trials demonstrating efficacy, safety and good tolerance, of two new potassium binders (patiromer and sodium zirconium cyclosilicate) led to their recent approval. A major hurdle to the implementation of these potassium-binders is understanding how to integrate them safely and effectively into the long-term management of cardiovascular and kidney disease patients using renin angiotensin aldosterone system inhibitors (RAASi), the latter being prone to induce hyperkalaemia.

METHODS

a multidisciplinary academic panel including nephrologists and cardiologists was convened to develop consensus therapeutic algorithm(s) aimed at optimizing the use of the two novel potassium binders (patiromer and sodium zirconium cyclosilicate) in stable adults who require treatment with RAASi and experience(d) hyperkalaemia in a non-emergent setting.

RESULTS

Two dedicated pragmatic algorithms are proposed. The lowest intervention threshold (i.e. 5.1mmol/L or greater) was the one used in the patiromer and sodium zirconium cyclosilicate) pivotal trials, both drugs being indicated to treat hyperkalaemia in a non -emergent setting. Acknowledging the heterogeneity across specialty guidelines in hyperkalaemia definition and thresholds to intervene when facing hyperkalaemia, we have been mindful to use soft language i.e. "it is to consider", not necessarily "to do".

CONCLUSIONS

Providing the clinical community with pragmatic algorithms may help optimize the management of high-risk patients by avoiding the risks of both hyper and hypokalaemia and of suboptimal RAASi therapy.

Reconsidering the Edelman equation: impact of plasma sodium concentration, edema and body weight

BACKGROUND

Guidelines recommend treatment of dysnatremias to be guided by formulas based on the Edelman equation. This equation describes the relation between plasma sodium concentration and exchangeable cations. However, this formula does not take into account clinical parameters that have recently been associated with local tissue sodium accumulation, which occurs without concurrent water retention. We investigated to what extent such clinical factors affect the Edelman equation and dysnatremia treatment.

METHODS

We performed a post-hoc analysis with original data of the Edelman study. Linear regression was used to examine the effect of age, sex, weight, edema, total body water (TBW) and heart and kidney failure on the Edelman equation. With attenuated correction, we corrected for measurement errors of both variables. Using piecewise regression, we analyzed whether the Edelman association differs for different plasma sodium concentrations.

RESULTS

Data was available for 82 patients; 57 males and 25 females with a mean (SD) age of 57 (15) years. The slope of the Edelman equation was significantly affected by weight (p=0.01) and edema (p=0.03). Also, below and above plasma sodium levels of 133 mmol/L the slope of the Edelman equation was significantly different (1.25 x0025vs 0.58x0025, p<0.01).

CONCLUSION

Edelman's equation's coefficients are significantly affected by weight, edema and plasma sodium, possibly reflecting differences in tissue sodium accumulation capacity. The performance of Edelman-based formulas in clinical settings may be improved by taking these clinical characteristics into account.

Associations between gut microbiome, short chain fatty acids and blood pressure across ethnic groups: the HELIUS study

Background

Gut microbiome composition is shaped by a combination of host genetic make-up and dietary habits. In addition, large ethnic differences exist in microbiome composition. Several studies in humans and animals have shown that differences in gut microbiota and its metabolites, including short chain fatty acids (SCFA), are associated with blood pressure (BP). We hypothesized that gut microbiome composition and its metabolites may be differently associated with BP across ethnic groups.

Purpose

To investigate associations of gut microbiome composition and fecal SCFA levels with BP across different ethnic groups.

Methods

We assessed the association between gut microbiome composition and office BP among 4672 subjects (mean age 49.8±11.7 years, 52%F) of 6 different ethnic groups participating in the HELIUS study. Gut microbiome composition was determined using 16S rRNA sequencing. Associations between microbiome composition and blood pressure were assessed using machine learning prediction models. The resulting best predictors were correlated with BP using Spearman's rank correlations. Fecal SCFA levels were measured with high-performance liquid chromatography in an age- and body mass index (BMI)-matched subgroup of 200 participants with either extreme low or high systolic BP. Differences in abundances of best predictors and fecal SCFA levels between high and low BP groups were assessed with Mann-Whitney U tests.

Results

Gut microbiome composition explained 4.4% of systolic BP variance. Best predictors for systolic BP included Roseburia spp. (ρ −0.15, p&lt;0.001), Clostridium spp. (ρ −0.14, p&lt;0.001), Romboutsia spp. (ρ −0.10, p&lt;0.001), and Ruminococceae spp. (ρ −0.15, p&lt;0.001) (Figure 1). Explained variance of the microbiome composition was highest in Dutch subjects (4.8%), but very low in African Surinamese, Ghanaian, and Turkish ethnic groups (ranging from 0–0.77%) Hence, we selected only participants with Dutch ethnicity for the matched subgroup. Participants with high BP had lower abundance of Roseburia hominis (p&lt;0.01) and Roseburia spp. (p&lt;0.05) compared to participants with low BP. However, fecal acetate (p&lt;0.05) and propionate (p&lt;0.01) levels were higher in participants with high BP.

Conclusions

In this cross-sectional study, gut microbiome composition was moderately associated with BP. Associations were strongly divergent between ethnic groups, with strongest associations in Dutch participants. Intriguingly, while Dutch participants with high BP had lower abundances of several SCFA-producing microbes, they had higher fecal SCFA levels. Intervention studies with SCFAs could provide more insight in the effects of these metabolites on BP.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The Academic Medical Center (AMC) of Amsterdam and the Public Health Service of Amsterdam (GGD Amsterdam) provided core financial support for HELIUS. The HELIUS study is also funded by research grants of the Dutch Heart Foundation (Hartstichting; grant no. 2010T084), the Netherlands Organization for Health Research and Development (ZonMw; grant no. 200500003), the European Integration Fund (EIF; grant no. 2013EIF013) and the European Union (Seventh Framework Programme, FP-7; grant no. 278901).

Sex differences in the prevalence and hemodynamic profiles of hypertensive phenotypes: the HELIUS study

Background

Based on systolic (SBP) and diastolic blood pressure (DBP), patients with hypertension can be classified into different phenotypes. Earlier studies have shown clear sex-differences in the relation between phenotype and cardiovascular outcomes, but large studies addressing underlying sex-differences in hemodynamics are lacking.

Purpose

To examine sex differences in the prevalence and underlying hemodynamic profile of different hypertensive phenotypes.

Methods

We used cross-sectional data of 22.112 individuals, 57.8% female, aged between 18–70 years from the HEalthy LIfe in an Urban Setting (HELIUS) study, an ongoing large multi-ethnic prospective cohort study. Based on office BP patients were classified as having: normal (NBP; SBP &lt;140 mmHg and DBP &lt;90 mmHg), isolated systolic hypertension (ISH; SBP ≥140 and DBP &lt;90 mmHg), isolated diastolic hypertension (IDH; SBP &lt;140 and DBP ≥90mmHg) or combined systolic diastolic hypertension (SDH; SBP ≥140 and DBP ≥90 mmHg). We explored sex differences in the prevalence hypertension and the distribution of phenotypes using chi-squared tests after stratification for age (young: &lt;50, old: ≥50 years). In a subgroup of 11.046 participants, continuous non-invasive measurements of cardiac output (CO), stroke volume (SV), systemic vascular resistance (SVR) and mean arterial pressure (MAP) were obtained during 3–5 minutes with finger photoplethysmography in the supine position (Nexfin, Edwards Lifesciences, Irvine, CA, USA). Sex-differences between hemodynamic parameters were assessed using ANOVA tests of linear regression models correcting for age.

Results

In young participants, the overall prevalence of hypertension was significantly higher in men (19.7%) compared to women (11.4%), with a different distribution of phenotypes (both p&lt;0.001). Amongst young hypertensive participants, SDH was the most prevalent phenotype in both men (46%) and women (52%), ISH had a prevalence of respectively 23% in men and 26% in women. In older subjects, overall prevalence of hypertension was 40.2% in men and 35.9% in women (p&lt;0.001), with a different phenotypical distribution (p&lt;0.001). SDH was the most predominant phenotype in men (50%), whilst ISH was the most prevalent phenotype in women (55%). Both young and old participants with ISH showed an elevated cardiac output, ranging from 0.38–0.47 ml/min compared to normotensives. Older men with SDH and IDH had both elevated SVR and CO, while older women had only an elevation in SVR (Figure 1).

Conclusions

There are important age-dependent sex-differences in the prevalence of hypertension, which translate into a different hemodynamic profile. The pattern of cardiac output alterations across phenotypes was different between older men and women, suggesting sex differences in the underlying pathophysiology of elevated blood pressure. These findings contribute to a better understanding of the pathogenesis of hypertension and could impact treatment responses.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): The Academic Medical Center (AMC) of Amsterdam and the Public Health Service of Amsterdam (GGD Amsterdam) provided core financial support for HELIUS. The HELIUS study is also funded by research grants of the Dutch Heart Foundation (Hartstichting; grant no. 2010T084), the Netherlands Organization for Health Research and Development (ZonMw; grant no. 200500003), the European Integration Fund (EIF; grant no. 2013EIF013) and the European Union (Seventh Framework Programme, FP-7; grant no. 278901).

New diagnostic and treatment strategies in renal artery stenosis: a promising pursuit or disappointment foretold?

Clinical management of renal artery stenosis has seen a major shift, after randomised clinical trials have shown no group benefit of endovascular intervention relative to optimal medical control. However, the inclusion criteria of these trials have been criticised for focusing on a subset of patients with atherosclerotic renal artery stenosis where intervention was unlikely to be beneficial. Moreover, new imaging and computational techniques have become available, which have the potential to improve identification of patients that will respond to interventional treatment. This review addresses the challenges associated with clinical decision making in patients with renal artery stenosis. Opportunities for novel diagnostic techniques to improve patient selection are discussed, along with ongoing Dutch studies and network initiatives that investigate these strategies.

[Intramedullary injection with tethered cord : Case report of a rare complication during spinal anesthesia]

Although very rare, severe neurological complications can occur when undergoing spinal anesthesia. This report describes and analyses a case of spinal injury due to an undiagnosed tethered cord (TC) during spinal anesthesia for a cesarean section of a 31-year-old woman expecting twins. As a consequence of spinal dysraphism during embryogenesis, an atypically low conus level can occur and increase the risk of injury during neuraxial anesthesia, especially in the absence of symptoms. Injuries can be caused by mechanical trauma from direct needle injury, hematoma or neurotoxicity from local anesthetics. Special attention should therefore be paid to frequent symptoms, such as a hairy nevus on the back, deformities of the feet or bladder and bowels, voiding and micturition dysfunction in order to reduce the risk of complications.

Associations of blood glucose dynamics with antihyperglycemic treatment and glycemic variability in type 1 and type 2 diabetes

AIMS

The dynamical structure of glucose fluctuation has largely been disregarded in the contemporary management of diabetes.

METHODS

In a retrospective study of patients with diabetes, we evaluated the relationship between glucose dynamics, antihyperglycemic therapy, glucose variability, and glucose exposure, while taking into account potential determinants of the complexity index. We used multiscale entropy (MSE) analysis of continuous glucose monitoring data from 131 subjects with type 1 (n = 18), type 2 diabetes (n = 102), and 11 nondiabetic control subjects. We compared the MSE complexity index derived from the glucose time series among the treatment groups, after adjusting for sex, age, diabetes duration, body mass index, and carbohydrate intake.

RESULTS

In type 2 diabetic patients who were on a diet or insulin regimen with/without oral agents, the MSE index was significantly lower than in nondiabetic subjects but was lowest in the type 1 diabetes group (p < 0.001). The decline in the MSE complexity across the treatment groups correlated with increasing glucose variability and glucose exposure. Statistically, significant correlations existed between higher MSE complexity indices and better glycemic control. In multivariate regression analysis, the antidiabetic therapy was the most powerful predictor of the MSE (β = -0.940 ± 0.242, R ² = 0.306, p < 0.001), whereas the potential confounders failed to contribute.

CONCLUSIONS

The loss of dynamical complexity in glucose homeostasis correlates more closely with therapy modalities and glucose variability than with clinical measures of glycemia. Thus, targeting the glucoregulatory system by adequate therapeutic interventions may protect against progressive worsening of diabetes control.

Effects of aerobic exercise on brain metabolism and grey matter volume in older adults: results of the randomised controlled SMART trial

There is mounting evidence that aerobic exercise has a positive effect on cognitive functions in older adults. To date, little is known about the neurometabolic and molecular mechanisms underlying this positive effect. The present study used magnetic resonance spectroscopy and quantitative MRI to systematically explore the effects of physical activity on human brain metabolism and grey matter (GM) volume in healthy aging. This is a randomised controlled assessor-blinded two-armed trial (n=53) to explore exercise-induced neuroprotective and metabolic effects on the brain in cognitively healthy older adults. Participants (age >65) were allocated to a 12-week individualised aerobic exercise programme intervention (n=29) or a 12-week waiting control group (n=24). The main outcomes were the change in cerebral metabolism and its association to brain-derived neurotrophic factor (BDNF) levels as well as changes in GM volume. We found that cerebral choline concentrations remained stable after 12 weeks of aerobic exercise in the intervention group, whereas they increased in the waiting control group. No effect of training was seen on cerebral N-acetyl-aspartate concentrations, nor on markers of neuronal energy reserve or BDNF levels. Further, we observed no change in cortical GM volume in response to aerobic exercise. The finding of stable choline concentrations in the intervention group over the 3 month period might indicate a neuroprotective effect of aerobic exercise. Choline might constitute a valid marker for an effect of aerobic exercise on cerebral metabolism in healthy aging.

Is remote stretching based on myofascial chains as effective as local exercise? A randomised-controlled trial

Lower limb stretching based on myofascial chains has been demonstrated to increase cervical range of motion (ROM) in the sagittal plane. It is, however, unknown whether such remote exercise is as effective as local stretching. To resolve this research deficit, 63 healthy participants (36 ± 13 years, ♂32) were randomly assigned to one of three groups: remote stretching of the lower limb (LLS), local stretching of the cervical spine (CSS) or inactive control (CON). Prior (M1), immediately post (M2) and 5 min following intervention (M3), maximal cervical ROM was assessed. Non-parametric data analysis (Kruskal-Wallis tests and adjusted post hoc Dunn tests) revealed significant differences between the disposed conditions. With one exception (cervical spine rotation after CSS at M2, P > .05), both LLS and CSS increased cervical ROM compared to the control group in all movement planes and at all measurements (P < .05). Between LLS and CSS, no statistical differences were found (P > .05). Lower limb stretching based on myofascial chains induces similar acute improvements in cervical ROM as local exercise. Therapists might consequently consider its use in programme design. However, as the attained effects do not seem to be direction-specific, further research is warranted in order to provide evidence-based recommendations.

Range of motion and cervical myofascial pain

Several studies investigating myofascial pain syndrome include assessments of range of motion (ROM) as a diagnostic criterion. However, the value of ROM in this context has not yet been evaluated in controlled clinical studies. We aimed to examine whether patients with myofascial pain syndrome display alterations of ROM when compared to healthy subjects. Twenty-two individuals (13 females, 9 males; aged 33.4 ± 13.9 yrs) afflicted with active myofascial trigger points in the upper trapezius muscle as well as 22 age and sex matched healthy controls were included. All subjects underwent an examination of maximal active cervical ROM in flexion/extension assessed by means of a 3D ultrasonic movement analysis system (30 Hz; Zebris CMS 70). In the patients group, pressure pain threshold (PPT) of the trigger points was determined using a pressure algometer. Maximum range of motion in the sagittal plane did not differ between individuals with MTrP (125.9 ± 23.2°, 95% CI: 116.2-135.6°) and asymptomatic subjects (128.2 ± 20.4°, 95% CI: 119.7-136.7°; p > .05). In patients, PPT (1.7 ± .6, 95% CI: 1.5-1.9) was not correlated with cervical mobility (r = -.13; p > .05). Based on these pilot data, range of motion in flexion/extension is not a valid criterion for the detection of myofascial trigger points. Additional research incorporating movement amplitudes in other anatomical planes and additional afflicted muscles should be conducted in order to further delineate the relative impact of MTrP on range of motion.

Appraising the methodological quality of cadaveric studies: validation of the QUACS scale

Although systematic reviews are conducted in the field of anatomical research, no instruments exist for the assessment of study quality. Thus, our objective was to develop a valid tool that reliably assesses the methodological quality of observational cadaveric studies. The QUACS scale (QUality Appraisal for Cadaveric Studies) was developed using an expert consensus process. It consists of a 13-item checklist addressing the design, conduct and report of cadaveric dissection studies. To evaluate inter-rater reliability, a blinded investigator obtained an initial pool of 120 observational cadaveric studies. Sixty-eight of them were selected randomly according to sample size calculations. Three independent researchers rated each publication by means of the QUACS scale. The reliability of the total score was estimated using the intraclass correlation coefficient (ICC). To assess agreement among individual items, margin-free kappa values were calculated. For construct validity, two experts (an anatomist and an experienced physician) categorized the quality of 15 randomly selected studies as 'excellent' (4 points), 'moderate to good' (3 points), poor to moderate' (2 points) or 'poor' (1 point). Kendall's tau rank correlation was used to compare the expert ratings with the scores on the QUACS scale. An evaluation of feasibility was carried out during the reliability analysis. All three raters recorded the duration of quality appraisal for each article. Means were used to describe average time exposure. The ICC for the total score was 0.87 (95% confidence interval: 0.82-0.92; P < 0.0001). For individual items, margin-free kappa values ranged between 0.56 and 0.96 with an agreement of 69-97% among the three raters. Kendall's tau B coefficient of the association between expert ratings and the results obtained with the QUACS scale was 0.69 (P < 0.01). Required rating time per article was 5.4 ± 1.6 min. The QUACS scale is highly reliable and exhibits strong construct validity. Thus, it can confidently be applied in assessing the methodological quality of observational dissection studies.

Short-term effects of acupuncture and stretching on myofascial trigger point pain of the neck: a blinded, placebo-controlled RCT

OBJECTIVES

This trial aimed to evaluate the short-term effectiveness of acupuncture plus stretching to reduce pain and improve range of motion in patients afflicted by cervical myofascial pain syndrome.

DESIGN

Randomized, blinded, placebo-controlled crossover study.

INTERVENTION

Nineteen patients (11 females, eight males, 33 ± 14 years) with myofascial neck pain in randomized order received the following treatments with one week washout between: acupuncture, acupuncture plus stretching, and placebo laser acupuncture.

MAIN OUTCOME MEASURES

Mechanical pain threshold (MPT, measured with a pressure algometer) represented the primary outcome. Secondary outcomes were motion-related pain (Visual Analogue Scale, VAS) and cervical range of motion (ROM, recorded by means of an ultrasonic 3D movement analysis system). Outcomes were assessed immediately prior as well as 5, 15 and 30 min post treatment. Friedman tests with post hoc Bonferroni-Holm correction were applied to compare differences between treatments.

RESULTS

Both acupuncture as well as acupuncture plus stretching increased MPT by five, respectively, 11 percent post treatment. However, only acupuncture in combination with stretching was superior to placebo (p<0.05). There were no significant differences between interventions at 15 and 30 min post treatment. VAS did not differ between treatments at any measurement. Five minutes after application of acupuncture plus stretching, ROM was significantly increased in the frontal and the transversal plane compared to placebo (p<0.05).

CONCLUSIONS

The combination of acupuncture and stretching could represent a suitable treatment option to improve cervical movement behavior and reduce trigger point pain in the short-term. However, additional studies further discriminating the placebo effects are still warranted.

[Sedentary behaviour and health]

Exercise-related public health recommendations and research for increased fitness and health had long focused on vigorous exercise or the lack thereof. Recently scientific interest in possible effects of sedentary behaviour (SB) (sitting) independent of moderate-vigorous intensity exercise has been growing.We conducted a selective literature search in Pubmed and the Sedentary Research Database with the outcomes SB, risk factors, mortality and morbidity in adults. We included only reviews and systematic reviews.Observational studies suggest an association between SB and all-cause and cardiovascular, but not cancer mortality. SB also seems to be associated with diabetes and overweight/weight gain. Evidence for other diseases, such as cardiovascular diseases, hypertension, cancer, and mental diseases is limited also because of the heterogeneity and poor methodology of the -studies. Intervention studies found inconsistent evidence that SB is associated with detrimental effects on markers of cardiometabolic risk.The evidence on the detrimental effects of sedentary behaviour is decreasingly convincing with the endpoints of mortality, -morbidity, and markers of metabolic risk, in that order. Higher TV and screen time, but not total SB seems to be associated with higher all-cause and cardiovascular, but not cancer mortality. Further intervention studies are needed to establish -dose-response relationships and potentially protective effects of cardiorespiratory fitness and physical activity.

Validity of the six-minute walk test in cancer patients

The present study evaluated the validity of the six-minute walk test (6MWT) in cancer patients. 50 subjects (36 f, 14 m; 57.4±10.2 years; during (56%) or off (44%) cancer treatment) performed a 6MWT and a spiroergometry on a cycle ergo-meter (0+25 W, 3 min) to evaluate maximum exercise capacity (VO2peak). A subsample (n=30) completed a retest of the 6MWT within 2-7 days. Patients covered a distance of 594±81 m during 6MWT at an average intensity of 86.3±9.6% of HRmax and achieved a VO2peak of 21.2±4.86 ml · kg - 1 · min - 1 during cycle ergometry. The distance walked correlated significantly (p<0.001) with VO2peak (r=0.67) and perceived physical function (EORTC QLQ-C30 physical function subscale) (r=0.55). Concerning reliability the intraclass correlation coefficient was r=0.93 (95%CI: +0.86;+0.97; p<0.001) and the coefficient of variation 3%. During retest participants walked 3.1% (95%CI: +1.1; +5.2) farther and achieved a higher RPE (+1.0; 95%CI: +0.3;+1.8). Limits of agreement were between - 43.1 and 76.4 m. In cancer patients the 6MWT seems to be as valid and reliable as in healthy elderly, cardiac and pulmonary patients. Thus, it can be recommended for use in cancer patients.

Exercise effects on HRV in cancer patients

The present study evaluated the effects of physical exercise on heart rate variability (HRV) in cancer patients. 3 matched groups of each 15 tumour patients (60.4±8.9 years, 27 male, 18 female) were recruited: Physical exercise group 1 (acute treatment), Physical exercise group 2 (post treatment) and non-intervention group (acute treatment, no exercise). Exercise group patients received counselling for exercise and participated in a Nordic-Walking program. Short-term HRV-recordings, assessments of fatigue and quality of life (QoL) were performed prior to and 16 weeks after the exercise program initiation. MANCOVA revealed group × time differences in total power frequency domain of HRV and QoL (p<0.05). TP follow-up scores [logms(2)] differed significantly between non-intervention and intervention post treatment (2.0±0.5 vs. 2.6±0.5), but not between non-intervention and intervention during acute treatment. QoL follow-up scores differed significantly between non-intervention and intervention during acute treatment (47±15 vs. 64±18) and post treatment (47±15 vs. 69±19). Exercise enhances cardiac autonomic regulation of tumour patients during and after acute treatment. Because of the association of higher HRV-parameters and prolonged survival in cancer patients, improvement in autonomic control may be an important goal of exercise.

The impact of antiproteinuric therapy on the prothrombotic state in patients with overt proteinuria

BACKGROUND

Overt proteinuria is a strong risk factor for thromboembolism, owing to changes in the levels of various coagulation proteins and urinary antithrombin loss. The described coagulation disturbances in these patients are based on outdated studies conducted primarily in the 1970s and 1980s. Whether these coagulation disturbances resolve with antiproteinuric therapy has yet to be studied.

METHODS

A total of 32 patients with overt proteinuria (median, 3.7 g day(-1) ; interquartile range, 1.5-5.6) were enrolled in this intervention crossover trial designed to assess optimal antiproteinuric therapy with sodium restriction, losartan, and diuretics. Levels of various procoagulant and anticoagulant proteins, and parameters of two thrombin generation assays (calibrated automated thrombogram [CAT] and prothrombin fragment 1 + 2) were compared between the placebo period and the maximum antiproteinuric treatment period. As a secondary analysis, coagulation measurements of the placebo period in these patients were compared with those of 32 age-matched and sex-matched healthy controls.

RESULTS

Median proteinuria was significantly lower during the maximum treatment period (median, 0.9 g day(-1) ; interquartile range, 0.6-1.4; P < 0.001) than during the placebo period. Similarly, levels of various liver-synthesized procoagulant and anticoagulant proteins, activated protein C resistance and prothrombin fragment 1 + 2 levels were significantly lower during the maximum treatment period than during the placebo period. However, von Willebrand factor and factor VIII levels were similar. On the basis of the higher levels of procoagulant proteins (fibrinogen, FV, FVIII, and von Willebrand factor) and both thrombin generation assays, patients were substantially more prothrombotic than healthy controls (P < 0.004).

CONCLUSIONS

 Antiproteinuric therapy ameliorates the prothrombotic state. Proteinuric patients are in a more prothrombotic state than healthy controls.