Cognitive-Motor Interference Heightens the Prefrontal Cortical Activation and Deteriorates the Task Performance in Children With Hemiplegic Cerebral Palsy

ObjectiveTo compare the prefrontal cortex (PFC) activation and task performance during single- and dual-task conditions between typically developing (TD) children and children with hemiplegic cerebral palsy (HCP).DesignA prospective, comparative design.SettingResearch laboratory.ParticipantsParticipants (N=21) included 12 TD children (age, 6.0±1.1y) and 9 children with HCP (age, 7.2±3.1).InterventionsNot applicable.Main Outcome MeasuresPFC activation was assessed by measuring the concentration of oxygenated hemoglobin while the children performed a shape-matching task with their more affected arm while sitting on a stable (single task) vs dynamic surface (dual task). The task performance was assessed with the total number of shapes matched, dual-task cost, and reaction time (RT).ResultsFor both conditions, the children with HCP exhibited greater PFC activation, matched a fewer shapes, and had slower RT than the TD children. These differences were accentuated during the dual-task condition and the dual-task cost was greater. An increase in the PFC activation during the dual-task condition was tightly correlated with a higher dual-task cost in children with HCP (r=0.77, P=.01).ConclusionsChildren with HCP appear to have a heightened amount of PFC activity while performing a dual task. The greater cortical activity may be a result of the finite attentional resources that are shared between both the motor as well as cognitive demands of the task. The cognitive-motor interference is likely exacerbated in children with HCP because of the structural and functional brain changes as a result of an insult to the developing brain.     

Falls Efficacy Is Associated With Better Gait and Functional Outcomes After Rehabilitation in Older Patients

ObjectiveTo examine the relationship between falls efficacy and the change in gait speed and functional status in older patients undergoing postacute rehabilitation.DesignProspective cohort study.SettingPostacute rehabilitation facility.ParticipantsPatients (N=180) aged 65 years and older (mean age ± SD, 81.3±7.1y).InterventionsNot applicable.Main Outcome MeasuresData on demographics; functional, cognitive, and affective status; and falls efficacy using a 10-item version of the Falls Efficacy Scale (FES; range, 0-100) were collected upon admission. Data about gait speed and functional status (Barthel Index and Basic Activities of Daily Living [BADL]) were measured at admission and discharge. In addition, BADL performance was self-reported 1 month after discharge.ResultsCompared with admission, all rehabilitation outcomes improved at discharge: gait speed (0.41±0.15 m/s vs 0.50±0.16 m/s; P<.001), Barthel Index score (68.4±16.3 vs 82.5±13.6; P<.001), and BADL (3.5±1.6 vs 4.7±1.3; P<.001). Adjusting for baseline status and other potential confounders, baseline FES independently predicted gait speed (adjusted coefficient: 0.002; 95% confidence interval [CI], 0.000-0.004; P=.025) and Barthel index (adjusted coefficient: 0.225; 95% CI, 0.014-0.435; P=.037) at discharge, with higher confidence at baseline predicting greater improvement. Baseline FES was also independently associated with self-reported BADL performance at the 1-month follow-up (adjusted coefficient: 0.020; 95% CI, 0.010-0.031; P<.001).ConclusionsIn older patients, higher falls efficacy predicted better gait and functional rehabilitation outcomes, independently of baseline performance. These results suggest that interventions aiming at falls efficacy improvement during rehabilitation might also contribute to enhancing gait speed and functional status in patients admitted to this setting.     

Dosage and Effectiveness of Aerobic Training on Cardiorespiratory Fitness,Functional Capacity,Balance, and Fatigue in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis

ObjectivesTo evaluate the benefits of aerobic training (AT) programs on cardiorespiratory fitness, functional capacity, balance, and fatigue in individuals with multiple sclerosis (MS) and to identify the optimal dosage of AT programs for individuals with MS via a systematic review with meta-analysis.Data sourcesTwo electronic databases were searched until March 2020 (PubMed-Medline and Web of Science).Study SelectionStudies examining the effect of AT program on cardiorespiratory fitness, functional capacity, balance, and fatigue were included.Data ExtractionAfter applying the inclusion and exclusion criteria, we included 43 studies. A total sample of 1070 individuals with MS (AT group, n=680; control group, n=390) were analyzed.Data SynthesisThe AT group demonstrated a significant increase in cardiorespiratory fitness (standardized mean difference [SMD], 0.29; P=.002), functional capacity (timed Up and Go Test: SMD, –1.14; P<.001; gait speed: SMD, –1.19; P<.001; walking endurance: SMD, 0.46; P<.001), and balance (SMD, 3.49; P<.001) after training. Fatigue perception also decreased (SMD, –0.45; P<.001). However, no significant differences were observed when compared with the control group in either cardiorespiratory fitness (SMD, 0.14; P=.19) or fatigue perception. Nevertheless, we observed significant differences between the AT and control groups in balance (P=.02), gait speed (P=.02), and walking endurance (P=.03), favoring the participants who performed AT. Regarding the subgroup analysis, no significant differences were observed between subgroups in any of the variables studied except for gait speed, for which a greater increase in posttraining was observed when the AT program applied the continuous method (χ²=7.75; P=.005) and the exercises were performed by walking (χ²=9.36; P=.002).ConclusionsAerobic training improves gait speed, walking endurance, and balance. Cardiorespiratory fitness and fatigue perception also improved after AT, but we found no differences with the control group. In addition, subgroup analysis suggested that training using continuous and walking methods could optimize gait speed.     

Unilateral vs Bilateral Hybrid Approaches for Upper Limb Rehabilitation in Chronic Stroke: A Randomized Controlled Trial

ObjectiveTo investigate the effects of unilateral hybrid therapy (UHT) and bilateral hybrid therapy (BHT) compared with robot-assisted therapy (RT) alone in patients with chronic stroke.DesignA single-blind, randomized controlled trial.SettingFour hospitals.ParticipantsOutpatients with chronic stroke and mild to moderate motor impairment (N=44).InterventionUHT combined unilateral RT (URT) and modified constraint-induced therapy. BHT combined bilateral RT (BRT) and bilateral arm training. The RT group received URT and BRT. The intervention frequency for the 3 groups was 90 min/d 3 d/wk for 6 weeks.Main Outcome MeasuresFugl-Meyer Assessment (FMA, divided into the proximal and distal subscale) and Stroke Impact Scale (SIS) version 3.0 scores before, immediately after, and 3 months after treatment and Wolf Motor Function Test (WMFT) and Nottingham Extended Activities of Daily Living (NEADL) scale scores before and immediately after treatment.ResultsThe results favored BHT over UHT on the FMA total score and distal score at the posttest (P=.03 and .04) and follow-up (P=.01 and .047) assessment and BHT over RT on the follow-up FMA distal scores (P=.03). At the posttest assessment, the WMFT and SIS scores of the 3 groups improved significantly without between-group differences, and the RT group showed significantly greater improvement in the mobility domain of NEADL compared with the BHT group (P<.01).ConclusionsBHT was more effective for improving upper extremity motor function, particularly distal motor function at follow-up, and individuals in the RT group demonstrated improved functional ambulation post intervention.     

Gait Function in Adults Aged 50 Years and Older With Spina Bifida

ObjectiveTo study gait function among individuals with spina bifida (SB) aged 50 years or older.DesignA cross-sectional study conducted in 2017.SettingHome-dwelling participants from all regions in Norway.ParticipantsIndividuals between the ages of 51 and 76 years (N=26; 16 women) categorized as independent walkers (n=9), walkers with aids (n=10) and nonwalkers (n=7).InterventionsNot applicable.Main Outcome MeasuresQuestionnaire, pain assessment, anthropometry, Falls Efficacy Scale International (FES-I), objective gait analysis, 6-minute walk test (6MWT), and timed Up and Go (TUG).ResultsWalking speed correlated with SB severity (ρ=–.59; P=.008). Individuals who walked slower than 0.81 m/s had a higher body mass index (BMI) than those who walked faster (P=.008). Independent walkers walked slower than healthy age-matched walkers (P=.046); spatiotemporal variables showed that this was owing to shorter steps rather than cadence. The mean TUG was 10.6±2.6 seconds in independent walkers and 20.2±6.5 in walkers with aids (P<.01). The mean 6MWT was 504±126 meters in independent walkers and 316±88 in walkers with aids (P<.01). The mean pain intensity (numeric rating scale) was 4.9±2.2 in independent walkers and 4.2±1.6 in walkers with aids, but the difference was not statistically significant. FES-I was significantly lower among independent walkers (mean, 23.6±3.9) than walkers with aids (mean, 31.4±10.0) (P=.042).ConclusionsParticipants commonly experienced an early onset deterioration in gait function, and walking speed was influenced by SB severity and BMI. This highlights the importance of early monitoring and weight management during follow-up for SB.     

Effects of Performance-Based Training on Gait and Balance in Individuals With Incomplete Spinal Cord Injury

ObjectiveTo determine changes in balance and gait following a task-specific, performance-based training protocol for overground locomotor training (OLT) in individuals with motor-incomplete spinal cord injury (iSCI).DesignConvenience sample, prepilot and postpilot study.SettingHuman performance research laboratory.ParticipantsAdults (N=15; 12 men and 3 women; mean age [y] ± SD, 41.5±16.9), American Spinal Injury Association Impairment Scale C or D, >6 months post-spinal cord injury.InterventionsTwo 90-minute OLT sessions per week over 12 to 15 weeks. OLT sessions were built on 3 principles of motor learning: practice variability, task specificity, and progressive overload (movement complexity, resistance, velocity, volume). Training used only voluntary movements without body-weight support, robotics, electrical stimulation, or bracing. Subjects used ambulatory assistive devices as necessary.Main Outcome MeasuresBerg Balance Scale (BBS), Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI) gait parameters, spatiotemporal measures of gait (step length, step width, percent stance, stance:swing ratio) from 7 participants who walked across a pressure-sensitive walkway.ResultsFourteen participants completed the OLT protocol and 1 participant completed 15 sessions due to scheduled surgery. The BBS scores showed a mean improvement of 4.53±4.09 (P<.001). SCI-FAI scores showed a mean increase of 2.47±3.44 (P=.01). Spatiotemporal measures of gait showed no significant changes.ConclusionThis pilot demonstrated improvements in balance and selected gait characteristics using a task-specific, performance-based OLT for chronic iSCI.     

Effect of a Novel Perturbation-Based Pinch Task Training on Sensorimotor Performance of Upper Extremity for Patients With Chronic Stroke: A Pilot Randomized Controlled Trial

ObjectiveTo investigate the effects of perturbation-based pinch task training on the sensorimotor performance of the upper extremities of patients with chronic stroke via a novel vibrotactile therapy system.DesignA single-blinded randomized controlled trial.SettingA university hospital.ParticipantsPatients with chronic stroke (N=19) randomly assigned into either an experimental group or a control group completed the study.InterventionsIn addition to 10 minutes of traditional sensorimotor facilitation, each participant in the experimental group received 20 minutes of perturbation-based pinch task training in each treatment session, and the controls received 20 minutes of task-specific motor training twice a week for 6 weeks.Main Outcome MeasuresThe scores for the primary outcome, Semmes-Weinstein monofilament (SWM), and those for the secondary outcomes, Fugl-Meyer Assessment (FMA), amount of use, quality of movement (QOM) on the Motor Activity Log (MAL) scale, and box and block test (BBT), were recorded. All outcome measures were recorded at pretreatment, post treatment, and 12-week follow-up.ResultsThere were statistically significant between-group differences in the training-induced improvements revealed in the SWM results (P=.04) immediately after training and in the BBT results (P=.05) at the 12-week follow-up. The changes in muscle tone and in the QOM, SWM, and BBT scores indicated statistically significant improvements after 12 sessions of treatment for the experimental group. For the control group, a significant statistical improvement was found in the wrist (P<.001) and coordination (P=.01) component of the FMA score.ConclusionsThis study indicated that the perturbation-based pinch task training has beneficial effects on sensory restoration of the affected thumb in patients with chronic stroke.     

Continuous Renal Replacement Therapy Liberation and Outcomes of Critically Ill Patients With Acute Kidney Injury

ObjectiveTo examine the association between continuous renal replacement therapy (CRRT) liberation and clinical outcomes among patients with acute kidney injury (AKI) requiring CRRT.MethodsThis single-center, retrospective cohort study included adult patients admitted to intensive care units with AKI and treated with CRRT from January 1, 2007, to May 4, 2018. Based on the survival and renal replacement therapy (RRT) status at 72 hours after the first CRRT liberation, we classified patients into liberated, reinstituted, and those who died. We observed patients for 90 days after CRRT initiation to compare the major adverse kidney events (MAKE₉₀).ResultsOf 1135 patients with AKI, 228 (20%), 437 (39%), and 470 (41%) were assigned to liberated, reinstituted, and nonsurvival groups, respectively. The MAKE₉₀, mortality, and RRT independence rates of the cohort were 62% (707 cases), 59% (674 cases), and 40% (453 cases), respectively. Compared with reinstituted patients, the liberated group had a lower MAKE₉₀ (29% vs 39%; P=.009) and higher RRT independence rate (73% vs 65%; P=.04) on day 90, but without significant difference in 90-day mortality (26% vs 33%; P=.05). After adjustments for confounders, successful CRRT liberation was not associated with lower MAKE₉₀ (odds ratio, 0.71; 95% CI, 0.48 to 1.04; P=.08) but was independently associated with improved kidney recovery at 90-day follow-up (hazard ratio, 1.81; 95% CI, 1.41 to 2.32; P<.001).ConclusionOur study demonstrated a high occurrence of CRRT liberation failure and poor 90-day outcomes in a cohort of AKI patients treated with CRRT.     

Crossed Cerebellar Diaschisis Has an Adverse Effect on Functional Outcome in the Subacute Rehabilitation Phase of Stroke: A Case-Control Study

ObjectiveTo investigate whether crossed cerebellar diaschisis (CCD) is associated with functional outcome in the subacute rehabilitation phase of stroke.DesignRetrospective case-control study.SettingHospital-based cohort.ParticipantsThe study enrolled participants who underwent brain single-photon emission computed tomography (N=48). Patients with CCD were identified (n=24). Twenty-four controls were selected for each case-patient by matching age, stroke type (ischemic or hemorrhagic), lesion laterality, and lesion location.InterventionNot applicable.Main Outcome MeasuresThe functional ambulation category (FAC), modified Barthel Index (MBI), and Mini-Mental State Examination (MMSE) were administered at the initial (initiation of rehabilitation therapy) and the follow-up (4wk after rehabilitation therapy) assessments.ResultsThe CCD group had lower MMSE, FAC, MBI, and MMSE scores at the initial assessment (P=.032, .016, and .001, respectively) and lower FAC and MBI scores at the follow-up assessment, than the non-CCD group (P=.001 and .036, respectively). Although CCD was not associated with cognitive impairment, nonambulatory status, and dependent activities of daily living (ADL) at the initial assessment (P=.538, .083, and >.99, respectively), the CCD group had a higher risk of cognitive impairment (adjusted odds ratio [aOR]=4.044; 95% confidence interval [CI], 1.071-15.270; P=.039), nonambulatory status (aOR=7.000; 95% CI, 1.641-29.854; P=.009) and dependent ADL (aOR=13.500; 95% CI, 1.535-118.692; P=.019) at the follow-up assessment.ConclusionsCCD is associated with severe functional impairment and may have an adverse effect on functional outcomes related to cognition, ambulatory function, and ADL during the subacute rehabilitation phase of stroke. This suggests that CCD may be a valuable predictor of functional outcome in the subacute rehabilitation phase of stroke.     

Sex Differences in Outcomes of Patients With Chronic Aortic Regurgitation: Closing the Mortality Gap

ObjectiveTo examine contemporary clinical differences between men and women with hemodynamically significant chronic aortic regurgitation (AR).Patients and MethodsWe retrospectively identified 1072 consecutive patients with moderate to severe or severe AR diagnosed between February 21, 2004, and April 29, 2019. Echocardiographic data, aortic valve surgical intervention (AVS), and all-cause death were analyzed.ResultsAt baseline, the 189 women in the study group were older than the 883 men (mean ± SD age, 64±18 years vs 58±17 years), had more advanced symptoms, and had larger left ventricular end-systolic dimension index (LVESDi) (all P<.001) despite similar AR severity. An LVESDi of greater than 20 mm/m² was noted in 60 of 92 asymptomatic women (65%) vs 225 of 559 asymptomatic men (40%) (P<.001). Median follow-up was 5.6 years (interquartile range, 2.5 to 10.0 years). Female sex was associated with less AVS (P=.009), and overall 10-year survival was better in men (76%±2%) than in women (64%±5%) (P=.004). However, 10-year post-AVS survival was similar between the sexes (P=.86), and women had better left ventricular reverse remodeling than men regarding end-diastolic dimension (P=.02). Multivariable independent predictors of death were age, advanced symptoms, LVESDi, ejection fraction, and AVS (all P≤.03) but not female sex. When compared with the age-matched US population, women exhibited a 1.3-fold increased relative risk of death (P=.0383) while men had similar survival (P=.11).ConclusionIn contemporary practice, women with AR continue to exhibit an overall survival penalty not related to female sex but to late referral markers, including more advanced symptoms, larger LVESDi, and less AVS. Nonetheless, women in our study exhibited outstanding post-AVS left ventricular remodeling and had good post-AVS survival, a step forward toward closing the sex-related mortality gap. The high percentage of LVESDi of 20 mm/m² or greater in asymptomatic women represents a window of opportunity for advanced-symptom prevention and timely AR surgical correction that may close the mortality gap.     

Reductions in Cardiac Structure and Function 24 Months After Spinal Cord Injury: A Cross-Sectional Study

ObjectiveTo determine the alterations in cardiac structure and function that occur in the months after spinal cord injury (SCI).Study DesignCross-sectionalSettingRehabilitation HospitalParticipantsVolunteers (N=29; 4 women, 25 men) between 3 and 24 months after SCI.Main Outcome MeasuresTransthoracic echocardiography was performed on each volunteer. The relationships between time since injury and neurologic and sensory levels of injury to cardiac structure and function were assessed via multiple linear regression.ResultsTime since injury was most strongly associated with reductions in left ventricular end diastolic volume (r²=0.156; P=.034), end systolic volume (r²=0.141; P=.045), and mass (r²=0.138; P=.047). These structural changes were paralleled by reduced stroke volume (r²=0.143; P=.043) and cardiac output (r²=0.317; P=<.001). The reductions in left ventricular structure and systolic function were not differentially affected by neurologic or sensory levels of injury (P=.084-.921).ConclusionsThese results suggest progressive reductions in left ventricular structure and systolic function between 3 and 24 months after SCI that occur independent of neurologic and sensory levels of injury.     

Complications After Hand-Assisted Laparoscopic Living Donor Nephrectomy

ObjectiveTo study the complications of hand-assisted laparoscopic living donor nephrectomy (HALLDN) with an emphasis on complications occurring early after hospital discharge up to 120 days after surgery.Patients and MethodsWe retrospectively categorized complications using the Clavien-Dindo classification in 3002 HALLDNs performed at 1 center from January 1, 2000, through December 31, 2019. In addition to overall summaries, modeling was used to identify correlates of complications before and after living donation.ResultsOf these donors, 87% were White, 59% were female, the mean age was 45 years (range, 18-77 years), 30.3% had a body mass index of at least 30, and 36.3% had previous abdominopelvic surgery. There were no deaths related to the surgery. The incidence of major complications (intraoperative complications plus Clavien-Dindo grade ≥III postoperatively) was 2.5% (n=74). The overall complication rate was 12.4% (n=371), including 15 intraoperative, 76 postoperative before discharge, and 280 after discharge to 120 days. Reoperation was required in 1.8% of patients (n=54), and all but 1 of these were incision-related problems. Seventy-six percent of all complications occurred after discharge, including 85% of the reoperations. For major complications, no risk factor was found. Risk factors for any complication included paramedian incision (hazard ratio [HR], 2.54; 95% CI, 1.49 to 4.34; P<.001); a history of abdominopelvic surgery (HR, 1.37; 95% CI, 1.07 to 1.76; P=.01), male sex (HR, 1.37; 95% CI, 1.07 to 1.76; P=.01), non-White race (HR, 1.40; 95% CI, 1.05 to 1.88; P=.02), and early era of the experience.ConclusionMost major complications of HALLDN occur after discharge, suggesting that close follow-up is warranted and that the current literature may underestimate the true incidence.     

Outcomes and Echocardiographic Follow-up After Surgical Management of Tricuspid Regurgitation in Patients With Transvenous Right Ventricular Leads

ObjectiveTo evaluate outcomes of elective surgical management of tricuspid regurgitation (TR) in patients with transvenous right ventricular leads, and compare results between non–lead-induced and lead-induced TR patients.Patients and MethodsWe studied patients with right ventricular leads who underwent tricuspid valve surgery from January 1, 1993, through December 31, 2015, and categorized them as non–lead-induced and lead-induced TR. Propensity score (PS) for the tendency to have lead-induced TR was estimated from logistic regression and was used to adjust for group differences.ResultsFrom the initial cohort of 470 patients, 444 were included in PS-adjustment analyses (174 non–lead-induced TRs [123 repairs, 51 replacements], 270 lead-induced TRs [129 repairs, 141 replacements]). In PS-adjusted multivariable analysis, lead-induced TR was not associated with mortality (P=.73), but tricuspid valve replacement was (hazard ratio, 1.59; 95% CI, 1.13 to 2.25; P=.008). Five-year freedom from tricuspid valve re-intervention was 100% for non–lead-induced TR and 92.3% for lead-induced TR; rates adjusted for PS differed between groups (P=.005). There was significant improvement in TR postoperatively in each group (P<.001). In patients having tricuspid valve repair, TR grades tended to worsen over time, but the difference in trends was not significantly different between groups.ConclusionLead-induced TR did not affect long-term survival after elective tricuspid valve surgery. In patients with lead-induced TR, tricuspid valve re-intervention was more common. Improvement in TR was achieved in both groups after surgery; however, severity of TR tended to increase over follow-up after tricuspid valve repair.     

Artificial Intelligence–Enabled Electrocardiogram for Atrial Fibrillation Identifies Cognitive Decline Risk and Cerebral Infarcts

ObjectiveTo investigate whether artificial intelligence–enabled electrocardiogram (AI-ECG) assessment of atrial fibrillation (AF) risk predicts cognitive decline and cerebral infarcts.Patients and MethodsThis population-based study included sinus-rhythm ECG participants seen from November 29, 2004 through July 13, 2020, and a subset with brain magnetic resonance imaging (MRI) (October 10, 2011, through November 2, 2017). The AI-ECG score of AF risk calculated for participants was 0-1. To determine the AI-ECG-AF relationship with baseline cognitive dysfunction, we compared linear mixed-effects models with global and domain-specific cognitive z-scores from longitudinal neuropsychological assessments. The AI-ECG-AF score was logit transformed and modeled with cubic splines. For the brain-MRI subset, logistic regression evaluated correlation of the AI-ECG-AF score and the high-threshold, dichotomized AI-ECG-AF score with infarcts.ResultsParticipants (N=3729; median age, 74.1 years) underwent cognitive analysis. Adjusting for age, sex, education, and APOE ?4-carrier status, the AI-ECG-AF score correlated with lower baseline and faster decline in global-cognitive z-scores (P=.009 and P=.01, respectively, non–linear-based spline-models tests) and attention z-scores (P<.001 and P=.01, respectively). Sinus-rhythm-ECG participants (n=1373) underwent MRI. As a continuous measure, the AI-ECG-AF score correlated with infarcts but not after age and sex adjustment (P=.52). For dichotomized analysis, an AI-ECG-AF score greater than 0.5 correlated with infarcts (OR, 4.61; 95% CI, 2.45-8.55; P<.001); even after age and sex adjustment (OR, 2.09; 95% CI, 1.06-4.07; P=.03).ConclusionThe AI-ECG-AF score correlated with worse baseline cognition and gradual global cognition and attention decline. High AF probability by AI-ECG-AF score correlated with MRI cerebral infarcts. However, most infarcts observed in our cohort were subcortical, suggesting that AI-ECG not only predicts AF but also detects other non-AF cardiac disease markers and correlates with small vessel cerebrovascular disease and cognitive decline.     

The Rehabilitation Enhancing Aging Through Connected Health Prehabilitation Trial

ObjectiveTo evaluate the proof of concept of an innovative model of physical therapy Rehabilitation Enhancing Aging through Connected Health (REACH) and evaluated its feasibility and effect on physical function and health care utilization.DesignQuasi-experimental 12-month clinical trial.SettingTwo outpatient rehabilitation centers.ParticipantsCommunity-dwelling older primary care patients with a treatment arm undergoing the intervention (n=75; mean age=77±5.9y; 54% women) and propensity matched controls derived from a longitudinal cohort study (n=430; mean age=71±7.0y; 68% women) using identical recruitment criteria (N=505).InterventionCombined outpatient and home PT augmented with a commercially available app and computer tablet.MeasurementsPrimary outcomes included a feasibility questionnaire, exercise adherence, self-reported function, and the Short Physical Performance Battery (SPPB). Secondary outcomes included the rates of emergency department (ED) visits and hospitalizations.ResultsAmong REACH participants, we observed a 9% dropout rate. After accounting for dropouts, with propensity matching, n=68 treatments and n=100 controls were analyzed. Over the 12-month study duration, 85% of participants adhered to the exercise program an average of 2 times a week and evaluated the treatment experience favorably. In comparison to controls, after 1 year of treatment and within multivariable regression models, REACH participants did not manifest a significant difference in patient reported function (group x time effect 1.67 units, P=.10) but did manifest significant differences in SPPB (group x time effect 0.69 units, P=.03) and gait speed (group x time effect .08m/s, P=.02). In comparison to controls, after 1 year, the rate of ED visits (group x time treatment rate=0.27, P<.004) were significantly reduced, but a significant reduction in hospitalizations was not observed.ConclusionThe REACH intervention is feasible and has proof of concept in preventing functional decline and favorably affecting health care utilization. Evaluation on a larger scale is warranted.     

Prognostic Value of Cardiac Magnetic Resonance Imaging in Acute Coronary Syndrome Patients With Troponin Elevation and Nonobstructive Coronary Arteries

ObjectiveTo define the diagnostic yield of cardiac magnetic resonance (CMR) in differentiating the underlying causes of myocardial infarction with nonobstructive coronary arteries (MINOCA) and to determine the long-term prognostic implications of such diagnoses.MethodsCardiac magnetic resonance evaluation was performed in 227 patients (mean age, 56.4±14.9 years; 120 [53%] female) with a “working diagnosis” of MINOCA as defined by presentation with a troponin-positive acute coronary syndrome (troponin I >0.04 μg/L) and nonobstructed coronary arteries between January 1, 2007, and February 28, 2013. Follow-up was performed to assess the primary composite end point of myocardial infarction, heart failure, and all-cause mortality.ResultsCardiac magnetic resonance identified nonstructural cardiomyopathies in 97 (43%) patients, myocardial infarction in 55 (24%) patients, structural cardiomyopathies in 27 (12%) patients, and pulmonary embolism in 1 patient. No CMR abnormalities were identified in the remaining patients. Kaplan-Meier analysis demonstrated the ability of a CMR diagnosis to predict the risk of the primary composite end point (P=.005) at 5-year follow-up. Worse outcomes were seen among patients with “true” MINOCA and a normal CMR image compared with those with CMR-confirmed myocardial infarction (P=.02). Use of antiplatelets (78% [37/45] vs 95% [52/55]; P=.01), beta blockers (56% [25/45] vs 82% [45/55]; P=.004), and statins (64% [29/45] vs 85% [47/55]; P=.01) was significantly lower in patients with true MINOCA with normal CMR imaging compared with those with CMR-confirmed myocardial infarction.ConclusionsCardiac magnetic resonance carries a high diagnostic yield in patients with MINOCA and predicts long-term prognosis. Patients with MINOCA with normal CMR imaging had an increased rate of major adverse cardiac events and lower use of guideline-recommended myocardial infarction therapy compared with those with CMR-confirmed myocardial infarction.     

Effect of the Renin-Angiotensin System Inhibitors on Inflammatory Markers: A Systematic Review and Meta-analysis of Randomized Controlled Trials

ObjectiveTo synthesize more conclusive evidence on the anti-inflammatory effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs).MethodsPubMed, Scopus, and Embase were searched from inception until March 1, 2021. We included randomized controlled trials (RCTs) that assessed the effect of ACEIs or ARBs, compared with placebo, on any of the following markers: C-reactive protein (CRP), interleukin 6 (IL-6), or tumor necrosis factor α (TNF-α). Mean changes in the levels of these markers were pooled as a weighted mean difference (WMD) with a 95% CI.ResultsThirty-two RCTs (n=3489 patients) were included in the final analysis. Overall pooled analysis suggested that ACEIs significantly reduced plasma levels of CRP (WMD, ?0.54 [95% CI, ?0.88 to ?0.21]; P=.002; I²=96%), IL-6 (WMD, ?0.84 [95% CI, ?1.03 to ?0.64]; P<.001; I²=0%), and TNF-α (WMD, ?12.75 [95% CI, ?17.20 to ?8.29]; P<.001; I²=99%). Moreover, ARBs showed a significant reduction only in IL-6 (WMD, ?1.34 [95% CI, ?2.65 to ?0.04]; P=.04; I²=85%) and did not significantly affect CRP (P=.15) or TNF-α (P=.97) levels. The lowering effect of ACEIs on CRP levels remained significant with enalapril (P=.006) and perindopril (P=.01) as well as with a treatment duration of less than 24 weeks (WMD, -0.67 [95% CI, ?1.07 to -0.27]; P=.001; I²=94%) and in patients with coronary artery disease (WMD, ?0.75 [95% CI, ?1.17 to ?0.33]; P<.001; I²=96%).ConclusionBased on this meta-analysis, ACEIs showed a beneficial lowering effect on CRP, IL-6, and TNF-α, whereas ARBs were effective as a class in reduction of IL-6 only.     

Right Ventricular Enlargement and Dysfunction Are Associated With Increased All-Cause Mortality in Hypertrophic Cardiomyopathy

ObjectiveTo assess whether right ventricular enlargement (RVE) and right ventricular dysfunction (RVD) adversely affect prognosis in hypertrophic cardiomyopathy (HCM).Patients and MethodsData were retrieved from Mayo Clinic’s prospectively collected HCM registry between January 1, 2000, and September 30, 2012. Right ventricle (RV) size and function were semiquantitatively categorized via echocardiography as normal (RV-Norm) versus abnormal (RV-Abn) (RVE or RVD). All-cause mortality was the primary endpoint.ResultsOf 1878 HCM patients studied (mean age 53±15 years; 41.6% female), only 71 (3.8%) had RV-Abn (24 RVE, 28 RVD, 19 combined RVE and RVD). Compared with HCM patients with RV-Norm, RV-Abn patients were older (57±14 vs 53±15 years, P=.02), more symptomatic (New York Heart Association functional class III-IV in 62.0% vs 48.6%, P=.03), had more atrial fibrillation (53.5% vs 17.3%, P<.001), and more prior implantable cardioverter-defibrillator implantation (23.9% vs 11.3%, P=.02). Median follow-up was 9.4 years with 311 deaths. Patients who were RV-Abn had higher all-cause mortality compared with RV-Norm (log-rank P<.001); 24.1% (95% CI, 15.5% to 35.3%) vs 6.1% (95% CI, 5.1% to 7.3%) at 5 years. In multivariable Cox modeling, RV-Abn (hazard ratio, 1.89; 95% CI, 1.18 to 3.03; P=.008) was associated independently with all-cause mortality after adjusting for age, female sex, New York Heart Association functional class, atrial fibrillation, hypertension, coronary artery disease, implantable cardioverter-defibrillator implantation, beta blocker use, prior septal reduction therapy, resting LV outflow tract gradient, maximal LV wall thickness, and moderate or greater tricuspid regurgitation.ConclusionAlthough perturbations in RV size and function were observed in fewer than 5% of patients with HCM, they were associated with nearly two-fold higher all-cause mortality at long-term follow-up.     

Does Unilateral Lower Limb Amputation Influence Ankle Joint Torque in the Intact Leg?

ObjectiveTo investigate ankle torque and steadiness in the intact leg of transtibial and transfemoral unilateral amputees.DesignComparative study.SettingMedical rehabilitation centers.ParticipantsFifteen persons with a unilateral transfemoral amputation, 8 persons with a transtibial amputation, and 14 able-bodied male participants volunteered to participate in this study (N=37).InterventionsNot applicable.Main Outcomes MeasuresMaximal isometric torque performed during ankle plantarflexion and dorsiflexion in the intact limb of amputees and in the dominant limb of able-bodied persons. The coefficient of variation (CV) of the plantarflexion torque was calculated over 5 seconds during a submaximal isometric contraction (15%) in order to assess torque steadiness. Furthermore, electromyographic activity (the root mean square amplitude) of the gastrocnemius medialis and tibialis anterior muscles was analyzed.ResultsPlantarflexion maximal torque was significantly higher for the able-bodied group (115±39 Nm) than for the group with a transfemoral amputation (77±34 Nm) (P<.01), and did not differ between able-bodied group and the group with a transtibial amputation (97±26 Nm) (P=.25). Furthermore, the transfemoral amputee group was 29% less steady than the able-bodied group (P=.01). However, there were no significant differences in torque steadiness between the able-bodied group and transtibial amputee group (P=.26) or between transtibial and transfemoral amputee groups (P=.27). The amputation had no significant effect between groups on dorsiflexion maximal torque (P=.10), gastrocnemius medialis electromyography (EMG) (P=.85), tibialis anterior coactivation (P=.95), and coactivation ratio (P=.75).ConclusionThe present study suggests that as the level of amputation progresses from below the knee to above the knee, the effect on the intact ankle is progressively more negative.