Insulin Resistance and Left Ventricular Mass in Non-Diabetic Hemodialysis Patients

Background

Insulin resistance (IR) is frequently recognized in patients with uremia, and it is thought that IR has a basic role in the pathogenesis of cardiovascular disease.

Objective

To evaluate the effect of IR on cardiovascular risk in non-diabetic patients receiving hemodialysis (HD).

Methods

We performed a cross-sectional observational study that comprised 186 non-diabetic patients receiving HD (95 men; mean [SD] age, 46.4 [10.8] years; age range, 35–60 years) who had been receiving HD for 7.3 (3.5) years. Demographic variables and laboratory values were recorded. Insulin resistance was determined using the Homeostatic Model Assessment (HOMA), and the left ventricular mass index (LVMI) was calculated via echocardiography.

Results

According to HOMA-IR levels, patients were categorized as having IR (HOMA-IR score ≥2.5; n = 53) or not having IR (HOMA-IR score <2.5; n = 133). Insulin resistance was determined in 28.4% of study patients. Compared with the non-IR group, the IR group had been receiving HD longer; had greater body mass index; and had higher serum creatinine, uric acid, triglyceride, insulin, and C-reactive protein concentrations, leukocyte count, and LVMI (P < 0.05). Patients with increased LVMI had significantly higher body mass index, systolic blood pressure, serum cholesterol and C-reactive protein concentrations, and HOMA score. At multivariate analysis, systolic blood pressure (β = 0.22; P = 0.03) and HOMA score (β = 0.26; P = 0.01) affected LVMI.

Conclusions

Insulin resistance and hypertension are independent risk factors for left ventricular hypertrophy in non-diabetic patients with uremia who are receiving HD. Further studies are needed to indicate the benefits of improving IR for cardiovascular mortality in this subgroup of patients with uremia.     

Fluvastatin attenuates severe hemorrhagic shock-induced organ damage in rats

Objectives

Multiple organ dysfunction resulting from hemorrhagic shock (HS) and subsequent resuscitation was mediated by several inflammatory factors such as tumor necrosis factor-α (TNF-α) and interleukin-10 (IL-10). The present study was designed to investigate the protective effects of fluvastatin on these mediators after HS in rats.

Methods

The experimental rats were randomly divided into three groups. The vehicle group received only vitamin K without HS, the HS-control group received vitamin K and HS, and the HS-experimental group received both vitamin K and fluvastatin (1 mg/kg) before HS. HS was produced by bleeding from a femoral arterial catheter to remove 60% of total blood volume (6 ml/100 g BW) over 30 min. The mean arterial pressure (MAP) and heart rate (HR) were monitored continuously for 12 h after the start of blood withdrawal. The biochemical parameters, including arterial blood gas, glutamic oxaloacetic transaminase (GOT), glutamic pyruvic transaminase (GPT), blood urea nitrogen (BUN), creatinine (Cre), lactic dehydrogenase (LDH), creatine phosphokinase (CPK), and lactate were obtained at 30 min before induction of HS and at 0, 1, 3, 6, 9 and 12 h after HS. Equal volume of normal saline was given to replace blood volume loss. Cytokine levels including TNF-α and IL-10 in serum were measured at 1 h after HS. Kidney, liver, lung and small intestine were removed for pathology examination at 48 h after HS.

Results

HS significantly increased HR, blood GOT, GPT, BUN, Cre, LDH, CPK, lactate, TNF-α and IL-10 levels, and also induced metabolic acidosis and decreased MAP in rats. Pre-treatment with fluvastatin was found to improve survival rate, preserved MAP, decreased the markers of organ injury, suppressed the release of TNF-α and increased IL-10 after HS in rats.

Conclusion

Pre-treatment with fluvastatin can suppress the release of serum TNF-α and can also increase serum IL-10 level to protect HS-induced multi-organ damage in rats.     

Plasma mitochondrial DNA levels in patients with trauma and severe sepsis: Time course and the association with clinical status

Purpose

This study aimed to investigate the serial changes in plasma levels of mitochondrial DNA (mtDNA) in patients with trauma and severe sepsis and the mechanism of increase in mtDNA levels and the association between the levels and severity.

Materials and Methods

We conducted a prospective observational study of patients with trauma having injuries with an Abbreviated Injury Scale score of 3 or higher (n = 37) and patients with severe sepsis (n = 23). The mtDNA concentrations in clarified plasma were measured using real-time quantitative polymerase chain reaction.

Results

Concentrations of mtDNA peaked on the day of admission (day 1) in patients with trauma, whereas they increased on day 1 and remained constant until day 5 in patients with sepsis. The mtDNA levels on day 1 correlated with the maximal levels of creatinine phosphokinase in patients with trauma (R² = 0.463, P < .05) but not in patients with sepsis (R² = 0.028, P = .43). The mtDNA levels on day 1 were significantly higher in nonsurvivors compared with survivors of trauma (P < .05) but not sepsis.

Conclusions

The levels of mtDNA were elevated during traumatic injury and severe sepsis, although time course and prognostic significance differed between the groups, suggesting that the mechanisms of mtDNA release into plasma differ.     

Blood levels of glutamate oxaloacetate transaminase are more strongly associated with good outcome in acute ischaemic stroke than glutamate pyruvate transaminase levels

Ischaemic stroke is associated with an excessive release of glutamate in brain. GOT (glutamate-oxaloacetate transaminase) and GPT (glutamate-pyruvate transaminase) are two enzymes that are able to metabolize blood glutamate facilitating the lowering of extracellular levels of brain glutamate. Our aim was to study the association between blood levels of both enzymes and stroke outcome in patients with acute ischaemic stroke. We prospectively studied 365 patients with first ischaemic stroke<12 h. Glutamate, GOT and GPT levels were determined in blood samples obtained at admission. We considered functional outcome at 3 months [good outcome: mRS (modified Rankin Scale)≤2; poor outcome mRS >2], END (early neurological deterioration) in the first 72 h [increment ≥4 points in NIHSS (National Institutes of Health Stroke Scale)] and infarct volume [CT (computed tomography) at 36-72 h] as end points. We have found an inverse correlation between GOT and GPT levels and blood glutamate levels. Patients with poor outcome showed lower levels of GOT (11.9±8.2 compared with 22.7±10.2 m-units/ml, P<0.0001) and GPT (19.5±14.3 compared with 24.7±20.3 m-units/ml; P=0.004). A negative correlation has been found between GOT (Pearson coefficient=-0.477, P<0.0001) and GPT (Pearson coefficient=-0.116; P=0.027) levels and infarct volume. Patients with END showed higher levels of blood glutamate (381.7±97.9 compared with 237.6±114.0 μmol/l, P<0.0001) and lower levels of GOT (10.8±6.7 compared with 18.1±10.8 m-units/ml; P<0.0001). This clinical study shows an association between high blood GOT and GPT levels and good outcome in ischaemic stroke patients, this association being stronger for GOT than GPT levels.     

Life-Space Assessment and Physical Activity Scale for the Elderly: Validity of Proxy Informant Responses

Objective

To validate the administration of the Life-Space Assessment (LSA) and Physical Activity Scale for the Elderly (PASE) surveys to proxy informants, as would be necessary when measuring long-term outcomes in acutely ill, hospitalized older adults who are initially incapacitated but eventually return to the community.

Design

Cross-sectional study.

Setting

General community.

Participants

Convenience sample of dyads (N=40) composed of an ambulatory older adult and a familiar companion.

Interventions

Dyads completed the LSA and PASE surveys on 1 occasion. Companions based their responses on the recent mobility and physical activity of the older adult.

Main Outcome Measures

Paired total scores for each instrument.

Results

At a group level, the difference between older adult and companion mean scores for each instrument was not significant (P>.05). Standardized mean difference values were small (d<0.1). Paired scores were significantly yet moderately associated: intraclass correlation coefficient(1,1)=.84 to .88; P<.01. Difference in scores was not associated with time spent together (P>.05) or older adult gait speed (P>.05). At an individual level, older adults and companions agreed more closely on the LSA than on the PASE. However, disagreement in excess of estimated measurement error occurred in 40% of the dyads for the LSA and in none of the dyads for the PASE.

Conclusions

Older adults and companions collectively provided similar responses on each instrument. Nonetheless, varying levels of agreement within individual dyads suggested that proxy responses should be considered carefully. Implications for clinical research and practice research are discussed.     

Troponin-I as a prognosticator of mortality in severe sepsis patients

Purpose

The purpose of this retrospective study was to evaluate cardiac troponin-I (cTnI) as a 28-day mortality prognosticator and predictor for a drotrecogin alfa (activated) (DrotAA) survival benefit in recombinant human activated Protein C Worldwide Evaluation in Severe Sepsis patients.

Methods

Cardiac troponin-I was measured using the Access AccuTnI Troponin I assay (Beckman Coulter, Fullerton, CA). There were 598 patients (305 DrotAA, 293 placebo) with baseline cTnI data (cTnI negative [<0.06 ng/mL], n = 147; cTnI positive [≥0.06 ng/mL], n = 451).

Results

Cardiac troponin-I–positive patients were older (mean age, 61 vs 56 years; P = .002), were sicker (mean Acute Physiology and Chronic Health Evaluation II, 26.1 vs 22.3; P < .001), had lower baseline protein C levels (mean level, 49% vs 56%; P = .017), and had higher 28-day mortality (32% vs 14%, P < .0001) than cTnI-negative patients. Elevated cTnI was an independent prognosticator of mortality (odds ratio, 2.020; 95% confidence interval, 1.153-3.541) after adjusting for other significant variables. Breslow-Day interaction test between cTnI levels and treatment was not significant (P = .65).

Conclusion

This is the largest severe sepsis study reporting an association between elevated cTnI and higher mortality. Cardiac troponin-I elevation was not predictive of a survival benefit with DrotAA treatment.     

Functional Outcomes Associated With Adaptive Seating Interventions in Children and Youth With Wheeled Mobility Needs

Objective

To determine the parent-reported functional outcomes associated with adaptive seating devices for wheeled mobility devices used by young people aged 1 to 17 years.

Design

Longitudinal case series.

Setting

Homes of participating parents.

Participants

Parents (N=70, 63 mothers, 6 fathers, 1 grandmother) who had children with adaptive seating needs.

Intervention

Adaptive seating system for wheeled mobility devices.

Main Outcome Measure

Family Impact of Assistive Technology Scale for Adaptive Seating (FIATS-AS).

Results

All parents completed the FIATS-AS 4 times—2 times before and 2 times after their child received a new adaptive seating system. Mixed-design analysis of variance did not detect significant mean differences among the FIATS-AS scores measured at baseline and 2 and 8 months after receiving the seating system (F_2,134=.22, P=.81). However, the FIATS-AS detected a significant interaction between age cohort and interview time (F_4,134=4.5, P<.001, partial η²=.16). Post hoc testing confirmed that 8 months after receiving the seating system was associated with a large improvement in child and family functioning for children <4 years, maintenance of functioning for children between 4 and 12 years, and a moderate decline in functioning for youth between 13 and 17 years.

Conclusions

Adaptive seating interventions for wheeled mobility devices are associated with functional changes in the lives of children and their families that interact inversely with age. Future controlled longitudinal studies could provide further empirical evidence of functional changes in the lives of children and their families after the introduction and long-term use of specific adaptive seating interventions.     

Outcome of Percutaneous Osseointegrated Prostheses for Patients With Unilateral Transfemoral Amputation at Two-Year Follow-Up

Objective

To report outcomes regarding general and specific physical health-related quality of life of treatment with percutaneous osseointegrated prostheses.

Design

Prospective 2-year case-control study.

Setting

University hospital.

Participants

Individuals (N=39; mean age, 44±12.4y) with unilateral transfemoral amputation as a result of trauma (n=23), tumor (n=11), or other cause (n=5). At baseline, 33 of the 39 participants used socket-suspended prostheses.

Intervention

Osseointegrated prosthesis.

Main Outcome Measures

Questionnaire for Persons with Transfemoral Amputation (Q-TFA), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical functioning (PF) and physical component summary (PCS), SF-6D, and Physiological Cost Index (PCI).

Results

At 2 years postimplantation, 6 of 7 Q-TFA scores improved (P<.0001) compared with baseline (prosthetic use, mobility, problem, global, capability, walking habits). The walking aid subscore did not improve (P=.327). Of the 39 participants, increased prosthesis use was reported by 26, same amount of use by 11, and less use by 2. Improvement was reported in 16 of the 30 separate problem items (P<.05). Unchanged items included problems regarding phantom limb pain and pain from the back, shoulders, and contralateral limb. The PF, PCS, and SF-6D improved a mean of 24.1±21.4 (P<.0001), 8.5±9.7 (P<.0001), and .039±.11 (P=.007) points, respectively. Walking energy cost decreased (mean PCI at baseline, .749; mean PCI at follow-up, .61; P<.0001).

Conclusions

Two years after intervention, patients with a unilateral TFA treated with an OPRA implant showed important improvements in prosthetic function and physical quality of life. However, walking aids used and the presence of phantom limb pain and pain in other extremities were unchanged. This information is valuable when considering whether percutaneous osseointegrated prostheses are a relevant treatment option.     

Waist Circumference Provides an Indication of Numerous Cardiometabolic Risk Factors in Adults With Cerebral Palsy

Objective

To report the prevalence of cardiometabolic risk factors in a cohort of adults with cerebral palsy (CP) and to investigate the ability of anthropometric measures to predict these factors.

Design

Cross-sectional study.

Setting

Testing took place in a laboratory setting.

Participants

Adults with CP (N=55; mean age, 37.5±13.3y; Gross Motor Function Classification System levels, I–V) participated in this study.

Interventions

Not applicable.

Main Outcome Measures

Total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, glucose, insulin, and C-reactive protein levels were measured from a fasting venous blood sample. Insulin resistance was calculated using the Homeostasis Model Assessment (HOMA-IR) index. Blood pressure, body mass index (BMI), waist circumference (WC), waist-hip ratio, and waist-height ratio were also measured. The metabolic syndrome (MetS) was defined according to the 2009 Joint Interim Statement.

Results

The prevalence of the MetS was 20.5% in ambulatory adults and 28.6% in nonambulatory adults. BMI was associated with HOMA-IR only (β=.451; P<.01). WC was associated with HOMA-IR (β=.480; P<.01), triglycerides (β=.450; P<.01), and systolic blood pressure (β=.352; P<.05). Receiver operating characteristic curve analysis revealed that WC provided the best indication of hypertensive blood pressure, dyslipidemia, HOMA-IR, and the presence of multiple risk factors (area under the curve, .713–.763).

Conclusions

A high prevalence of the MetS was observed in this relatively young sample of adults with CP. WC was a better indicator of a number of risk factors than was BMI and presents as a clinically useful method of screening for cardiometabolic risk among adults with CP.     

Endotoxin activity levels as a prediction tool for risk of deterioration in patients with sepsis not admitted to the intensive care unit: A pilot observational study

Purpose

The aim of this prospective observational study was to evaluate in patients with sepsis not requiring intensive care unit admission the relationship between the levels of endotoxin activity assay (EAA) early after sepsis recognition and the risk of development of organ dysfunction (OD).

Methods

Endotoxin activity assay levels were drawn immediately after sepsis identification (baseline) and at 6, 24, and 48 hours postbaseline in 50 patients with signs of sepsis of a duration of less than 24 hours. An EAA 0.60 units or greater was considered as highly elevated.

Results

Logistic regression showed independent association between EAA levels at baseline and the appearance of new OD (adjusted odd ratio, 2.41; 95% confidence interval, 1.18-4.90; P < .05). Fifteen patients (30%) who developed new OD after baseline had at least 1 EAA level 0.60 or greater. The adjusted linear regression analysis showed that across the 4 time points, EAA levels were significantly higher in patients who developed new OD (0.11; 95% confidence interval, 0.01-0.20; P < .05).

Conclusions

Endotoxin activity assay levels 0.60 or greater early after sepsis diagnosis in patients not requiring intensive care unit admission predict risk of development of new organ dysfunction. High EAA levels in the first 48 hours of recognition of sepsis are also predictive of risk of deterioration.     

Pulsed Electromagnetic Field and Exercises in Patients With Shoulder Impingement Syndrome: A Randomized,Double-Blind,Placebo-Controlled Clinical Trial

Objective

To evaluate the effects of pulsed electromagnetic field (PEMF) and exercises in reducing pain and improving function and muscle strength in patients with shoulder impingement syndrome (SIS).

Design

Double-blind, randomized controlled trial with a 3-month posttreatment follow-up.

Setting

Outpatient rehabilitation of a public hospital.

Participants

Patients (N=56) between 40 and 60 years of age, with a diagnosis of SIS, were randomly assigned to receive active PEMF (n=26; mean age, 50.1y) or placebo PEMF (n=30; mean age, 50.8y).

Interventions

After 3 weeks of active or placebo PEMF, both groups performed the same program of exercises that focused on shoulder strengthening.

Main Outcome Measures

A visual analog scale, the University of California/Los Angeles shoulder rating scale, the Constant-Murley shoulder score, and handheld dynamometry for muscle strength were used as outcome measures at baseline (pretreatment), at 3 weeks (after active or placebo PEMF), at 9 weeks (postexercise), and at 3 months posttreatment.

Results

Patients in the active PEMF group had a higher level of function and less pain at all follow-up time frames compared with baseline (P<.05). However, the placebo PEMF group had increased function and reduced pain only at the 9-week and 3-month follow-ups (P<.05)—that is, after performing the associated exercises. For the shoulder dynamometry, the active PEMF group had increased strength for lateral rotation at 9 weeks (P<.05), and increased strength for medial rotation at 9 weeks and 3 months (both P<.05) when compared with baseline. There was no significant difference for shoulder strength in the placebo PEMF group (P>.05), as well as no significant differences (P>.05) for all outcome measures.

Conclusions

The combination of PEMF and shoulder exercises is effective in improving function and muscle strength and decreasing pain in patients with SIS. However, these results should be carefully interpreted because of the lack of differences between groups.     

Participation in and Impact of a Depression Care Management Program Targeting Low-Income Minority Patients in an Urban Community-Based Clinic

Background

African American people experience disproportionately higher rates of chronic depression, and among those affected, the condition is less likely to be detected and treated than in non-Hispanic white people.

Objective

To address this disparity in our primary care clinic, we introduced a validated framework for detecting and managing depression.

Methods

Over a 5-year period, there were 146 patients diagnosed as having depression and enrolled in a depression care management program. We evaluated the feasibility and effectiveness of that program using baseline and follow-up screening data from the Patient Health Questionnaire-9.

Results

The mean baseline severity score of 20.60 was reduced to 15.89 at 6 months (P < 0.001) and to 16.62 at 12 months. Patients achieved their best score, a mean of 12.93, 10.14 months after baseline (P < 0.001). The last mean severity score, after 15.47 months, was 14.60, a significant difference compared with baseline (P < 0.001). Although baseline severity scores for both groups were similar (P = 0.534), patients who remained engaged with the program demonstrated better scores and achieved greater severity score reductions from baseline to the last measure (P < 0.001). This study did not find any differences between the sexes when comparing PHQ-9 scores at baseline (P = 0.074), 6 months (P = 0.303), and 12 months (P = 0.429) and best (P = 0.875) and last (P = 0.640) scores.

Conclusions

Most of the improvement was witnessed in the first 10 months of treatment. Patients with more medical comorbidities participated longer in the study than patients with fewer comorbidities. Further research could elicit the relationship between improvement in mental health and medical conditions.     

Effect of Interferential Current Stimulation in Management of Hemiplegic Shoulder Pain

Objective

To study the immediate effects of interferential current stimulation (IFC) on shoulder pain and pain-free passive range of motion (PROM) of the shoulder in people with hemiplegic shoulder pain (HSP).

Design

Double-blind, placebo-controlled clinical trial.

Setting

Institutional physical therapy clinic, neurologic rehabilitation center.

Participants

A population-based sample of people with HSP (N=30) was recruited.

Intervention

Participants were divided into 2 groups—an IFC group and a placebo group—by using a match-paired method (age, sex, and Brunnstrom motor recovery stage). In the IFC group, participants received IFC for 20 minutes with an amplitude-modulated frequency at 100Hz in vector mode. The current intensity was increased until the participants felt a strong tingling sensation.

Main Outcome Measures

Pain intensity and pain-free PROM of the shoulder until the onset of pain were measured at baseline and immediately after treatment.

Results

Participants reported a greater reduction in pain during the most painful movement after treatment with IFC than with placebo (P<.05). The IFC group showed a greater improvement in posttreatment pain-free PROM than the placebo group in shoulder flexion (P<.01), abduction (P<.01), internal rotation (P<.01), and external rotation (P<.01).

Conclusions

This study provides evidence that IFC is effective for the relief of pain during movement and also increases the pain-free PROM of the shoulder in people with HSP.     

Association between early glycemic control and improvements in markers of coagulation and fibrinolysis in patients with septic shock–induced stress hyperglycemia

Purpose

The purpose of this study is to evaluate the coagulation and inflammatory profiles in septic shock patients with baseline hyperglycemia under glycemic control.

Methods

Prospective, observational study conducted in an intensive care unit of a university hospital, including 41 septic shock nondiabetic patients with hyperglycemia (n = 21) or normoglycemia (n = 20) profiles at baseline. Hyperglycemic patients received a glucose control protocol (target glycemia, < 150 mg/dL). Metabolic, inflammatory, and coagulation markers were measured at baseline and after 24 hours.

Results

Median glycemic values between groups were different at baseline but not after 24 hours. Baseline coagulation profile was similar in both groups with elevated levels of coagulation markers, reduced factor VII, protein C, and antithrombin activities and fibrinolysis impairment. Normoglycemic patients had unchanged coagulation markers after 24 hours. After treatment, previously hyperglycemic patients exhibited increased plasminogen concentrations (P = .03) and reduced levels of plasminogen activator inhibitor 1 (P = .01) and tissue plasminogen activator (P = .03) as compared with baseline. They also had higher factor VII (P = .03), protein C (P = .04), and antithrombin (P = .04) activities than normoglycemic patients. Inflammatory markers were elevated in both groups and improved after 24 hours, independently of the glycemic profile.

Conclusions

Glycemic control during septic shock is associated with improvements in coagulation and fibrinolysis parameters compared with baseline and normoglycemic patients.     

Alternations of galectin levels after renal transplantation

Objectives

Galectins (gals), a growing family of β-galactoside-binding animal lectins, have been implicated in a variety of biological processes including fibrosis, angiogenesis, and immune activation, all of which are involved in hemodialysis (HD) and renal transplantation (RTx). In this study, we aimed to investigate serum gal levels in HD and RTx recipients.

Design and methods

41 normal subjects, 41 RTx recipients and 32 HD patients were recruited for this study. RTx recipients were evaluated before transplantation as well as 3 months afterwards. Serum gals-1, 2, 3, 4, 8, and 9 were measured both at baseline and 3 months later in each group.

Results

At baseline, there were no differences in gals-1, 2, 3, 4, 8, and 9 between the RTx and HD groups. However, the levels of gals-1, 2, 3, 8, and 9 in the RTx and HD groups were higher than that of normal subjects. In paired analyses, gals-1, 2, and 3 were significantly decreased in RTx patients (P < 0.0001) at 3 months, while there was no change in the HD group. However, levels of gals-4, 8, and 9 did not significantly change in either the HD or RTx group.

Conclusion

Gal-1, 2, and 3 levels were high in maintenance HD patients. Kidney transplantation improved gal-1, 2, and 3 levels.     

Hemodynamic and Catecholamine Changes after Recurrent Ventricular Fibrillation

Background

Patients with recurrent ventricular fibrillation (VF) have a high mortality rate, which may be partly due to hemodynamic instability.

Objectives

The aim of this study was to simulate spontaneous recurrent VF by repeated induction of VF in pigs, and to evaluate the subsequent changes in heart rate (HR), blood pressure (BP), and serum catecholamine levels.

Methods

VF was induced four times in each of eight female pigs. Defibrillation was first attempted at 30 s after induction of each episode of VF. Circulation was allowed to stabilize for 30 min after return of spontaneous circulation (ROSC) before induction of the next episode of VF. HR and BP were measured before each induction of VF and at 1 min after each ROSC, and venous blood was drawn at the same times to measure serum catecholamine levels.

Results

VF was induced a total of 32 times. Serum epinephrine (EPI) and norepinephrine (NE) levels decreased (p all < 0.05) and dopamine (DA) levels gradually increased (p < 0.05) with repeated episodes of VF. Compared with baseline values before each episode of VF, BP increased significantly at 1 min after ROSC (p all < 0.05) and then gradually returned to baseline values. HR increased significantly after the first ROSC and stayed elevated. No significant correlations were found between catecholamine levels and HR or BP.

Conclusion

With repeated episodes of VF, BP increased transiently and then gradually returned to baseline values, but HR stayed elevated. Serum DA levels increased, EPI and NE levels gradually decreased.     

Interdisciplinary Cardiovascular and Neurologic Outpatient Rehabilitation in Patients Surviving Transient Ischemic Attack or Stroke With Minor or No Residual Deficits

Objective

To evaluate the feasibility and effectiveness of a comprehensive outpatient rehabilitation program combining secondary prevention and neurorehabilitation to improve vascular risk factors, neurologic functions, and health-related quality of life (HRQOL) in patients surviving a transient ischemic attack (TIA) or stroke with minor or no residual deficits.

Design

Prospective interventional single-center cohort study.

Setting

University hospital.

Participants

Consecutive consenting patients having sustained a TIA or stroke with 1 or more vascular risk factors (N=105) were included.

Interventions

Three-month hospital-based secondary prevention and neurorehabilitation outpatient program with therapeutic and educational sessions twice a week. Patients were evaluated at entry and program end.

Main Outcome Measures

Impact on vascular risk factors, neurological outcome, and HRQOL.

Results

A total of 105 patients entered the program and 95 patients completed it. Exercise capacity (P<.000), smoking status (P=.001), systolic (P=.001) and diastolic (P=.008) blood pressure, body mass index (P=.005), low-density lipoprotein cholesterol (P=.03), and triglycerides (P=.001) improved significantly. Furthermore, the 9-Hole-Peg-Test (P<.000), Six-minute Walking Test (P<.000), and One Leg Stand Test (P<.011) values as well as HRQOL improved significantly. The program could be easily integrated into an existing cardiovascular prevention and rehabilitation center and was feasible and highly accepted by patients.

Conclusions

Comprehensive combined cardiovascular and neurologic outpatient rehabilitation is feasible and effective to improve vascular risk factors, neurologic functions, and HRQOL in patients surviving TIA or stroke with minor or no residual deficits.     

Pilot Study: Elevated Circulating Levels of the Proinflammatory Cytokine Macrophage Migration Inhibitory Factor in Patients With Chronic Spinal Cord Injury

Objective

To test the hypothesis that the proinflammatory cytokine macrophage migration inhibitory factor (MIF) is elevated in the circulation of patients with chronic spinal cord injury (SCI) relative to uninjured subjects, and secondarily to identify additional immune mediators that are elevated in subjects with chronic SCI.

Design

Prospective, observational pilot study.

Setting

Outpatient clinic of a department of physical medicine and rehabilitation and research institute in an academic medical center.

Participants

Individuals with chronic (>1y from initial injury) SCI (n=22) and age- and sex-matched uninjured subjects (n=19).

Interventions

Not applicable.

Main Outcome Measures

Plasma levels of MIF, as determined by a commercially available multiplex suspension immunoassay. The relationship between MIF levels and clinical/demographic variables was also examined. As a secondary outcome, we evaluated other cytokines, chemokines, and growth factors.

Results

Plasma MIF levels were significantly higher in subjects with chronic SCI than in control subjects (P<.001). Elevated MIF levels were not correlated significantly with any one clinical or demographic characteristic. Subjects with SCI also exhibited significantly higher plasma levels of monokine induced by interferon-gamma/chemokine C-X-C motif ligand 9 (P<.03), macrophage colony stimulating factor (P<.035), interleukin-3 (P<.044), and stem cell growth factor beta (SCGF-β) (P<.016). Among subjects with SCI, the levels of SCGF-β increased with the time from initial injury.

Conclusions

These data confirm the hypothesis that MIF is elevated in subjects with chronic SCI and identify additional novel immune mediators that are also elevated in these subjects. This study suggests the importance of examining the potential functional roles of MIF and other immune factors in subjects with chronic SCI.     

Association between sympathoadrenal activation,fibrinolysis, and endothelial damage in septic patients: A prospective study

Purpose

The purpose of this study is to investigate potential associations between sympathoadrenal activation and/or vasopressor/inotropic therapy and endothelial activation, damage, and coagulopathy in septic patients.

Materials and methods

Septic patients included in the Scandinavian Starch for Severe Sepsis/Septic Shock trial who were expected not to receive catecholamines at screening preintervention (baseline) and had baseline blood sampled. Clinical, outcome data, and measurements of plasma concentration (p-) biomarkers reflecting sympathoadrenal activation, endothelial activation and damage, natural anticoagulation, fibrinolysis, cell damage, and platelet activation.

Results

Sixty-seven patients were included, of whom 14 turned out to receive noradrenaline infusion at blood sampling. These 14 patients had p-noradrenaline 5-fold higher than patients not receiving catecholamines (n = 53), whereas no other baseline preintervention biomarkers differed. In the 53 patients not receiving catecholamines at blood sampling, endogenous p-noradrenaline correlated positively with adrenaline, syndecan 1, soluble vascular endothelial growth factor receptor 1, soluble CD40 ligand, tissue-type plasminogen activator, and plasminogen activator inhibitor 1 (PAI-1) and negatively with PAI-1/tissue-type plasminogen activator ratio (all P < .05) and was independently associated with syndecan 1, soluble vascular endothelial growth factor receptor 1, and PAI-1 (all P < .05), and 28- and 90-day mortality (P < .05).

Conclusions

In septic patients, endogenous noradrenaline was independently associated with biomarkers of endothelial activation, damage, fibrinolysis and mortality, comparable with findings in trauma and myocardial infarction patients. The catecholamine surge in critical illness may contribute to balance endothelial damage and procoagulation with hypocoagulability and hyperfibrinolysis in the circulating blood.     

Consecutive thrombelastography clot strength profiles in patients with severe sepsis and their association with 28-day mortality: A prospective study

Purpose

The aim of this study was to assess associations between consecutive thrombelastography (TEG) profiles and standard coagulation tests and disease severity and mortality in patients with severe sepsis.

Materials and Methods

This was a prospective observational study of adults with severe sepsis admitted to the intensive care unit (ICU). Clinical scores/variables, infection, TEG, biochemistry, therapy, and overall mortality were recorded.

Results

Fifty patients (60% men, median age 62 years, 28-day mortality 24%) were included. At admission, 22%, 48%, and 30% had a hypocoagulable, normocoagulable, and hypercoagulable TEG clot strength (maximum amplitude [MA]), respectively. Hypocoagulable patients had higher Sequential Organ Failure Assessment and disseminated intravascular coagulation scores compared with hypercoagulable patients and higher 28-day mortality compared with normocoagulable patients (all P < .05). Most patients (73%-91%) displayed a TEG MA comparable with the admission profile during the initial 4 ICU days or until death/discharge. Patients progressing to hypocoagulable MA had a high early mortality (80%) and hypocoagulable MA independently predicted 28-day mortality (adjusted odds ratio, 4.29 [95% confidence interval, 1.35-13.65], P = .014). In hypocoagulable and hypercoagulable patients, only fibrinogen (P = .041 and P < .001, respectively) contributed independently to clot strength, whereas both platelets (P < .001) and fibrinogen (P < .001) contributed independently to clot strength in normocoagulable patients.

Conclusions

The ICU admission TEG MA remained constant for several days in patients with severe sepsis and hypocoagulable MA independently predicted 28-day mortality.