Physical rehabilitation of patients suffering from chronic heart failure

A BENEFICIAL METHOD: Heart failure combines with peripheral vascular and muscular abnormalities that can be effectively improved by rehabilitation. The data in the literature appears to demonstrate the efficacy and excellent tolerance of such exercise. Regarding functional results and improved quality of life, rehabilitation is as equally efficient as the medical treatment that it completes. It can currently be proposed to the majority of patients exhibiting left ventricular systolic dysfunction and who are are only partially improved with medical treatment alone. MODALITIES: The rehabilitation of heart failure must, optimally, be set-up in ambulatory settings, notably within the context of a health care network. Its modalities remain to be specified in on-going studies and its impact on prognosis has to be determined.     

The epigenetic promise to improve prognosis of heart failure and heart transplantation

Heart transplantation is still the only possible life-saving treatment for end-stage heart failure, the critical epilogue of several cardiac diseases. Epigenetic mechanisms are being intensively investigated because they could contribute to establishing innovative diagnostic and predictive biomarkers, as well as ground-breaking therapies both for heart failure and heart transplantation rejection. DNA methylation and histone modifications can modulate the innate and adaptive immune response by acting on the expression of immune-related genes that, in turn, are crucial determinants of transplantation outcome. Epigenetic drugs acting on methylation and histone-modification pathways may modulate Treg activity by acting as immunosuppressive agents. Moreover, the identification of non-invasive and reliable epigenetic biomarkers for the prediction of allograft rejection and for monitoring immunosuppressive therapies represents an attractive perspective in the management of transplanted patients. MiRNAs seem to fit particularly well to this purpose because they are differently expressed in patients at high and low risk of rejection and are detectable in biological fluids besides biopsies. Although increasing evidence supports the involvement of epigenetic tags in heart failure and transplantation, further short and long-term clinical studies are needed to translate the possible available findings into clinical setting.     

Significant benefits after renal transplantation in patients with chronic heart failure and chronic kidney disease

Background: Chronic heart failure (CHF) and chronic kidney disease (CKD) are serious medical conditions with significant morbidity and mortality and often coexist. Because of perioperative risks in these patients, they may not be considered a candidate for renal transplantation (RTx).

Material and methods: We compare retrospectively RTx outcomes [graft/patient survival, rejection rates and adverse cardiac events] in study group [low left ventricular ejection fraction (LVEF) ≤45% by echocardiogram, n?=?63] and control group [normal LVEF ≥50%, n?=?537] from a developing country.

Results: The mean EF was 35?±?5.6 and 57?±?3% for the study and control groups, respectively (p?Conclusion: RTx may play a role in reversing LV systolic dysfunction. Once thought by many to be a contraindication for renal transplantation, this appears not to be the case. The outcomes between the 2 groups are comparable and transplant is an option for even low EF patients.     

Treating chronic pain in patients suffering from addictive disorders: The psychodynamics

The substance abuse understood from a self-psychological perspective is the patient’s marked inability to tolerate frustration and other intense negative and positive affects. Therapy is directed toward teaching the patient about the inevitability of ambivalence and other unpleasant but existential realistic limitations and imperfections of being human. Additionally, the patient is taught to ventilate his intense feelings, to understand and to utilize the concept of ego boundaries, and to gain the capacity to separate all that is inside one’s body from that which is outside the skin and the ability to separate the childhood pain of the past from that of the present and future.The contents of consciousness distinguish between feelings, thoughts, judgments, and actions.³⁰ Psychodynamic intervention for addicted patients struggling with co-occurring pain management issues can provide a unique pathway to understanding these complex feelings, thoughts, and actions. Contemporary practice strives to integrate insights derived from drive theory, ego psychology, object relations, self-psychology, relational and attachment theories, and intersubjectivity to claim a more thorough understanding of the antecedents of the addictive symptoms.³¹ Placing emphasis on the unique personal history of the individual and finding a safe haven in which to process that history are cornerstones of psychodynamic treatment embraced by each of these schools of thought.In closing, it is interesting to consider that when the powerlessness over pain that must be accepted by the patient who suffers both addiction and chronic pain is rejected, they may have entered the realm of denial amenable to Control-Mastery theory. This theory, proposed by Joseph Weiss, states that psychopathology is caused by pathogenic beliefs, ideas about oneself and the world which interfere with healthy functioning.³² The acceptance that a person is powerless may seem impossible when one has believed since infancy that one can make anything happen. This dynamic has kept many an addict from “taking the first step” and admitting powerlessness. Control-Mastery theory allows the psychotherapist the ability to intervene on such unconscious beliefs and open the patient to the help that is available.Contemporary psychoanalysis aims to be more “user-friendly” for patients, referral sources, and therapist alike. This article has emphasized the importance of creating a safe space for these patients to speak, processing the most salient affects that arise in the therapeutic dyad, assessing potential transference and counter-transference paradigms, and assisting these patients in mastering symptomatic behaviors by making healthier identifications with their therapists. Psychodynamic theory, infant and developmental studies, and in-depth outcomes research are shaping the way that psychoanalytically informed treatments are performed. Although the topics selected here merely sketch how psychodynamic treatment may impact the practice of pain management, it is hoped that a more sustained inquiry and more frequent and earlier referrals to psychodynamically oriented practitioners will follow in its wake.     

The red blood cell deformability in patients suffering from end stage renal failure on hemodialysis or continuous ambulatory peritoneal dialysis

Anemia is the main problem for patients suffering from end stage renal disease (ESRD). This study aimed to determine whether the index of rigidity (IR), that shows red blood cells (RBCs) deformability and the possible IR disturbances can provide an explanation about the cause of anemia, in patients undergoing maintenance hemodialysis (HD) or on peritoneal dialysis. The IR was determined in 39 hemodialyzed patients, who were already in dialysis for a period of time ranging from 16 to 120 months (mean+/-SD=41.8 +/-24.1) (Group A). Furthermore, the IR was measured in 32 patients on continuous ambulatory peritoneal dialysis (CAPD), who were in CAPD for a period of time ranging from 6 to 60 months (mean+/-SD = 10.7+/-9.9) (Group B). Finally, the IR was determined in 17 normal individuals (group C). The RBCs IR was measured twice in group A (before and after the end of a hemodialysis session) and once in groups B and C. The IR was determined by hemorrheometry (method of filtration), using special equipment. In group A the IR was increased in comparison to the control group (C) (17.9+/-6.2 vs. 10.2+/-1.8, p<0.0001). This increase was even higher in the measurement at the end of the hemodialysis session (paired t-test, p < 0.0001). The RBCs IR in CAPD patients was significantly lower than that of HD patients (12+/-3.8 vs. 17.9+/-6.2, p<0.0001) and was not statistically different from the control group (12+/-3.8 vs. 10.2+/-1.8, p=0.068). It is concluded from the study that: 1) in HD patients occur disturbances in the deformability of the RBCs, that are worsened by the hemodialysis session; 2) the index of rigidity of RBCs is significantly higher in the HD patients than in CAPD patients; 3) in patients on CAPD, the disturbance of deformability of the RBCs was less in comparison to the control group, which however does not reach the statistically significant levels.     

Mild chronic anemia following heart transplantation: a syndrome with prognostic relevance?

The clinical relevance of mild chronic anemia in patients after heart transplantation (HTX) has not yet been demonstrated. Forty-five outpatients who had undergone HTX 2–99 months prior to investigation and who had not received blood transfusions or erythropoietin (EPO) before data acquisition were observed over a period of 37 months. Anemia was found in 36 of the 45 patients and was normocytic, normochromic, and slightly anisocytotic (coefficient of variation = 16 ± 2, normal 11.5–14.5). Anemic patients showed elevated EPO levels, whereas in nonanemic patients EPO levels were normal. Survival after HTX differed significantly in anemic and nonanemic patients (P < 0.02), with 100 % survival in the nonanemic and 85 % in the anemic group. Chronic anemia in patients after HTX shows a typical pattern. Even when mild, anemia in patients after HTX seems to be of prognostic value and thus might be an indicator of chronic disorders. Received: 9 March 1998 Received after revision: 20 May 1998 Accepted: 26 June 1998     

The effect of beta-adrenergic blockers on the prognostic value of peak exercise oxygen uptake in patients with heart failure.

OBJECTIVES: Our aim was to determine the effect of beta-adrenergic blockade on the prognostic value of peak oxygen consumption testing in patients with heart failure. BACKGROUND: Peak oxygen consumption has been shown to be a useful prognostic tool in patients with heart failure. However, studies demonstrating the utility of peak oxygen consumption were conducted before beta-blocker therapy became widespread. Thus, our objective was to determine the effect of beta-blockers on the prognostic value of peak oxygen consumption in patients with heart failure. METHODS: Actuarial, anthropomorphic, hemodynamic and exercise ventilatory data were collected from 369 patients with heart failure. Death and orthotopic heart transplants were the events tracked. Patients were divided into those taking beta-blockers and those not taking them. Event-free survival days were calculated. RESULTS: One hundred ninety-nine patients on beta-blockers and 170 not on beta-blockers were studied. There were 40 orthotopic heart transplants and 82 deaths during follow-up. Peak oxygen consumption (milliliters per kilogram per minute) trended toward being an independent predictor of event-free survival (p = 0.055). In patients on and not on beta-blockers, a peak oxygen consumption of >14 ml/kg.min was associated with a 1-year event rate of approximately half of that associated with a peak oxygen consumption 相似文献   

Pulmonary function in chronic heart failure. Changes after heart transplantation.

To investigate the impact of chronic heart failure on pulmonary function in heart transplant recipients, pulmonary function was evaluated in 41 consecutive patients (mean age 43 years, range 15-57 years) before and 6 months after successful heart transplantation. The pulmonary function tests included measurements of forced vital capacity [FVC], forced expiratory volume in 1.s [FEV1], FEV1/FVC ratio, total lung capacity [TLC], and diffusion capacity for carbon monoxide [TLCO] and KCO [TLCO per l alveolar volume]. Compared to pretransplant values, spirometry after transplantation revealed modest improvements in FVC (from 77 +/- 16 to 88 +/- 21% of predicted [%pred]; p < 0.001) and FEV1 (from 75 +/- 16 to 85 +/- 22%pred; p < 0.001), whereas the FEV1/FVC ratio was unchanged (81% +/- 11 and 80% +/- 10; p = NS). A slight but statistically significant increase in TLC (from 78 +/- 15 to 86 +/- 18%pred, p < 0.001) was also observed. Prior to transplantation the mean TLCO was 76 +/- 17%pred; 7 of the patients had a TLCO below 60%pred (mean 51% pred). In 33 of the 41 patients a reduction in TLCO was observed after transplantation; for all 41 patients the mean fall in TLCO was 14% of the predicted value (SD 12%pred) (p < 0.0001). Likewise, a significant reduction in KCO was noted (p < 0.0001). Multiple regression analysis revealed that high pretransplant TLCO %pred (p = 0.02) and FVC %pred (p = 0.04) were associated with a less favorable outcome concerning posttransplant TLCO %pred. Although normalization of FEV1, FVC and TLC can be anticipated after correction of severe chronic left ventricular failure by heart transplantation, the pronounced concomitant decline in diffusion capacity observed in this study may be explained by underlying pulmonary disease caused by factors other than long-standing heart failure. Our findings support the notion that pulmonary function abnormalities attributable to chronic heart failure should not preclude consideration for heart transplantation.     

慢性心力衰竭患者自我同情状况及影响因素分析

目的探讨慢性心力衰竭患者自我同情状况及影响因素,为开展针对性心理干预提供参考。方法便利选取293例慢性心力衰竭患者,采用一般资料调查问卷和自我同情量表进行调查。结果慢性心力衰竭患者自我同情评分为(57.99±8.74)分。多元线性回归分析显示,年龄、婚姻状况、NYHA心功能分级、病程是慢性心力衰竭患者自我同情的主要影响因素(均P<0.01),可解释总变异的40.70%。结论慢性心力衰竭患者自我同情处于中等偏低水平,医护人员需针对影响因素对慢性心力衰竭患者进行心理干预,以提高其自我同情水平,增强患者的积极心理力量。     

The relationship of systemic hemodynamics and oxygen consumption to early allograft failure after liver transplantation

The early postoperative hemodynamic data of 88 patients who underwent primary liver transplantation between July 1989 and October 1990 at the University Health Center of Pittsburgh were analyzed to establish the relationship of systemic hemodynamics and oxygen consumption to perioperative allograft function. The 15 patients whose allografts failed within the 1 st month following transplantation were designated as group 1, while 73 patients who retained adequate graft function constituted group 2. Although the cardiac index and oxygen delivery did not differ significantly between the groups, group 1 consistently demonstrated a lower mean arterial pressure, oxygen consumption, arteriovenous oxygen content difference, and arterial ketone body ratio. The etiology of reduced oxygen consumption in group 1 patients is speculative, but the data support the notion that oxygen consumption is a useful, predictive indicator for liver allograft function after transplantation.     

Changes in intraoperative total oxygen consumption in patients during liver transplantation

The changes in O2-uptake (VO2) during 110 liver transplantations (LTX) were studied using Fick's principle (O2-uptake = cardiac index x arteriovenous O2-content difference). During each of the three operative periods [a dissecting period before clamping of the hepatic vessels (1), the anhepatic phase (2), and after reperfusion of the new liver (3)], two measurements (A and B) were taken. After removal of the liver (2A) the VO2 decreased about 11.4%, and increased after reperfusion (3A) about 44.0%; these changes were significant (P less than 0.001). To evaluate the influence of the various indications for LTX on the course of intraoperative VO2, the following patient groups were compared: patients with hepatic tumors (n = 17), patients with cirrhosis following hepatitis (n = 14), patients with primary biliary cirrhosis (n = 17), patients with cirrhosis plus tumor (n = 11), and patients in a hepatic coma (n = 20), regardless of the underlying liver disease. Groups with less than ten subjects were not considered. The drop of VO2 in the anhepatic period (1B----2A) was between -26.7% (patients with tumors) and -7.3% (patients with cirrhosis plus tumor). The patients with cirrhosis following hepatitis showed a special feature: their VO2 increased about 13.4% after cross-clamping the hepatic vessels. After revascularization, the VO2 increased in all groups between +37.2% and +69.8%. In all groups the level of VO2 was higher after reperfusion (3A) than in the dissecting period (1B), ranging from +5.3% in patients with tumors to +61.6% in patients with cirrhosis following hepatitis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Acute renal failure in a patient suffering from chronic alcoholism.

Introduction Urinary tract infections (UTI) are common in adults and areknown to cause deterioration in renal function in patients withchronic renal impairment, solitary kidneys and renal transplants.Acute non-obstructive pyelonephritis is rarely considered inthe differential diagnosis of acute renal failure (ARF), especiallyin patients with little or no evidence of previous kidney disease.Diagnosis is particularly difficult if the infection is asymptomatic.Chronic alcohol abuse increases the risk of ARF in unobstructedacute pyelonephritis [1] and is a rare cause of renal papillarynecrosis [2,3]. We present an unusual case of asymptomatic acute pyelonephritisin combination with renal papillary necrosis in an otherwisewell individual with a history of substantial alcohol abuse. Case A 62-year-old man was admitted to another hospital with an 8week history of increasing dyspnoea and lower limb oedema. Hehad no