Effects of Exercise Training in Patients with Chronic Heart Failure and Sleep Apnea

Study Objectives:

To test the effects of exercise training on sleep and neurovascular control in patients with systolic heart failure with and without sleep disordered breathing.

Design:

Prospective interventional study.

Setting:

Cardiac rehabilitation and exercise physiology unit and sleep laboratory.

Patients:

Twenty-five patients with heart failure, aged 42 to 70 years, and New York Heart Association Functional Class I-III were divided into 1 of 3 groups: obstructive sleep apnea (n = 8), central sleep apnea (n = 9) and no sleep apnea (n = 7).

Interventions:

Four months of no-training (control) followed by 4 months of an exercise training program (three 60-minute, supervised, exercise sessions per week).

Measures and Results:

Sleep (polysomnography), microneurography, forearm blood flow (plethysmography), peak VO_2, and quality of life were evaluated at baseline and at the end of the control and trained periods. No significant changes occurred in the control period. Exercise training reduced muscle sympathetic nerve activity (P < 0.001) and increased forearm blood flow (P < 0.01), peak VO₂(P < 0.01), and quality of life (P < 0.01) in all groups, independent of the presence of sleep apnea. Exercise training improved the apnea-hypopnea index, minimum O₂ saturation, and amount stage 3-4 sleep (P < 0.05) in patients with obstructive sleep apnea but had no significant effects in patients with central sleep apnea.

Conclusions.

The beneficial effects of exercise training on neurovascular function, functional capacity, and quality of life in patients with systolic dysfunction and heart failure occurs independently of sleep disordered breathing. Exercise training lessens the severity of obstructive sleep apnea but does not affect central sleep apnea in patients with heart failure and sleep disordered breathing.

Citation:

Ueno LM; Drager LF; Rodrigues ACT; Rondon MUPB; Braga AMFW; Mathias W; Krieger EM; Barretto ACP; Middlekauff HR; Lorenzi-Filho G; Negrão CE. Effects of exercise training in patients with chronic heart failure and sleep apnea. SLEEP 2009;32(5):637-647.     

Natural Treg cells spontaneously differentiate into pathogenic helper cells in lymphopenic conditions

Induction of Forkhead‐box p3 (Foxp3) expression in developing T cells upon peptide‐MHC encountering has been proposed to define a lineage of committed Treg cells. However, sustained expression of Foxp3 is required for Treg function and what maintains Foxp3 expression in peripheral Treg remains obscure. To address this issue, we monitored natural Treg phenotype and function upon adoptive transfer into lymphocyte‐deficient mice. We first show that about 50% of Foxp3‐GFP⁺ Treg isolated from Foxp3^gfp KI animals loose Foxp3 expression in severe lymphopenic conditions. We next evidence that the cytokine IL‐2, either produced by co‐transferred conventional T cells or administrated i.v. prevents Foxp3 downregulation. Moreover, we document that Treg that lost Foxp3 expression upon adoptive transfer produce IL‐2 are not suppressive and promote tissue infiltration and damage upon secondary transfer into alymphoid mice. Our findings that Treg convert into pathogenic Th cells in absence of IL‐2 provide new clues to the success of Treg‐based immune therapies.     

Prevalence of Sexual Problems and Associated Distress in Aging Men Across 4 European Countries

BackgroundAmong older men, comparable cross-cultural investigations of sexual problems and associated distress that also include a multitude of relevant explanatory variables of these sexual problem and related distress are rare in the research literature.AimsTo investigate prevalence rates of sexual problems and associated distress among older men across 4 European countries (Norway, Denmark, Belgium, and Portugal) and assess for associated mental and physical health–related factors.MethodsMultinational cross-sectional questionnaire study using self-report measures.OutcomesPrevalence rates of sexual problems and associated distress levels.ResultsWe found a high prevalence of sexual problems persisting for months or longer across countries, but noted that many affected men experienced minimal or no distress related to these problems. We also found marked cross-cultural differences in reported distress about sexual problems, with southern European men (ie Portugal) reporting significantly more distress related to the majority of sexual problems investigated compared with northern European men (ie Denmark and Norway). Finally, we identified several relational, physical, and mental health problems associated with the reported number of sexual problems and the distress related to these problems.Clinical ImplicationsWe suggest that healthcare professionals also target distress when considering sexual problems among older men and contextualize these considerations within a multifactorial approach to general health in which (other) mental and physical health factors relevant to these patients’ sexual health and function are also jointly considered.Strengths & LimitationsStrengths of this study include the large sample size, inclusion of participants from 4 European countries, assessment of distress associated with sexual problems, and similar research design and method of data collection across the 4 included countries. Limitations of the study include the cross-sectional design, which precludes causal conclusions; the low response rate in the Portuguese sample; the lack of homosexual participants; and the lack of comprehensive assessments of dyadic factors that may be of relevance to sexual problems and associated distress.ConclusionThis study identified a high prevalence of sexual problems persisting for 3 months or longer among older men across 4 European countries, but also found that many of the men with sexual problems experienced minimal or no distress related to these problems.G.M. Hald, C. Graham, A. ?tulhofer, et al. Prevalence of Sexual Problems and Associated Distress in Aging Men Across 4 European Countries. J Sex Med 2019;16:1212–1225.     

Validation of Fetal Medicine Foundation algorithm for prediction of pre-eclampsia in the first trimester in an unselected Brazilian population

Objective: The objective of this study is to evaluate the predictive performance of the Fetal Medicine Foundation (FMF) algorithm for prediction of preeclampsia (PE) between 11 and 14 weeks of gestation in an unselected Brazilian population.

Methods: We conducted a prospective cohort study with 617 singleton pregnancies of unselected risk. Biophysical markers (mean pulsatility index, mean arterial pressure) and biochemical markers (placental growth factor (PLGF) and PAPP-A) were inserted into the FMF software and converted into multiples of the median (MoM). The subjects were divided into five groups: early-onset PE, parturition <34 weeks’ gestation; preterm PE, parturition <37 weeks; PE, parturition at any gestational age; gestational hypertension (GH); and control group. Areas under the receiver operating characteristics curve (AUC) were calculated for the outcomes.

Results: Among 617 patients, seven developed early-onset PE, 18 developed preterm PE (seven early PE plus 11 delivered between 34 and 36?+?6 weeks gestation), 34 developed PE (18 preterm PE plus 16 delivered after 37-week gestation), 12 pregnant women developed GH, and 517 women comprised the control group. The best predictive performance using the FMF algorithm occurred in the early-onset PE group, with AUC?=?0.946 (95% CI 0.919–0.973) and the detection rate of 28.6% and 85.7% for 5% and 10% false-positive (FP), respectively.

Conclusions: The FMF algorithm to predict PE was effective in a Brazilian population, mainly in the early-onset form of the disease at 10% FP.     

Subarachnoid space diameter in chromosomally abnormal fetuses at 11–13 weeks’ gestation

Objectives: To examine the subarachnoid space diameters in chromosomally abnormal fetuses at 11–13 weeks’ gestation.

Methods: Stored three-dimensional (3D) ultrasound volumes of the fetal head at 11–13 weeks’ gestation from 407 euploid and 88 chromosomally abnormal fetuses (trisomy 21, n?=?40; trisomy 18, n?=?19; trisomy 13, n?=?7; triploidy, n?=?14; Turner syndrome, n?=?8) were analyzed. The subarachnoid space diameters, measured in the sagittal and transverse planes of the fetal head, in relation to biparietal diameter (BPD) in each group of aneuploidies was compared to that in euploid fetuses. A total of 20 head volumes were randomly selected and all the measurements were recorded by two different observers to examine the interobserver variability in measurements.

Results: In euploid fetuses, the anteroposterior, transverse and sagittal diameters of the subarachnoid space increased with BPD. The median of the observed to expected diameters for BPD were significantly increased in triploidy and trisomy 13 but were not significantly altered in trisomies 21 and 18 or Turner syndrome. In triploidy, the subarachnoid space diameters for BPD were above the 95th centile of euploid fetuses in 92.9% (13 of 14) cases. The intraclass reliability or agreement was excellent for all three subarachnoid space diameters.

Conclusion: Most fetuses with triploidy at 11–13 weeks’ gestation demonstrate increased subarachnoid space diameters.     

Outcomes in patients with early-onset fetal growth restriction without fetal or genetic anomalies

Objective: Early-onset fetal growth restriction is associated with poor pregnancy outcomes, but frequently is due to fetal structural or chromosomal abnormalities. The objective of this study was to determine outcomes in patients with early-onset fetal growth restriction without diagnosed fetal or genetic anomalies and to identify additional risk factors for poor outcomes in these patients.

Methods: This was retrospective cohort study of singleton pregnancies in women with early-onset growth restriction defined as a sonographic estimated fetal weight <10% diagnosed between 16–28 weeks’ gestation. We excluded all women with a fetal structural or chromosomal abnormality diagnosed prenatally. Data on pregnancy characteristics and outcomes were collected and analyzed for estimated fetal weight <10% and ≤5%. A nested case-control study within the cohort of patients with ongoing pregnancies was then performed to identify risk factors associated with poor pregnancy outcome using chi-squared test.

Results: One hundred forty-two patients were identified who met inclusion and exclusion criteria and 20 patients were found to have fetal structural or chromosomal abnormalities. In the remaining 122 patients, the incidence of intrauterine fetal demise was 5.7% and there were high rates of preterm birth <37 weeks (20%), birth weight <10% (59.3%), and gestational hypertension (14.1%). Later gestational age at diagnosis and the presence of echogenic bowel and abnormal initial umbilical artery Dopplers were associated with poor pregnancy outcome (22.56 versus 20.86 weeks, p?=?.046), (17.4 versus 2.2%, OR 9.68, 95%CI 1.65–56.73), and (35.3 versus 0%, OR 4.46, 95%CI 2.65–7.50) respectively.

Conclusions: Patients with early-onset fetal growth restriction with no fetal structural or genetic abnormality have a high risk of poor pregnancy outcomes. Gestational age at diagnosis and certain ultrasound findings are associated with poor pregnancy outcome.     

Neonatal outcome in preterm deliveries before 34-week gestation – the influence of the mechanism of labor onset

Purpose: To evaluate neonatal outcomes in preterm infants with less than 34?weeks after spontaneous labor, preterm premature rupture of membranes (PPROM) or iatrogenic delivery and to clarify whether the mechanism of labor onset is a risk factor for adverse short-term neonatal outcome.

Methods: We performed a retrospective case-control study, which included 266 preterm newborns with less than 34-week gestation, between 2011 and 2015. Neonatal outcomes were compared according to the mechanism of labor onset. Our primary outcomes were neonatal death, sequelae on hospital discharge and a composite of these two variables (combined neonatal outcome).

Results: Compared to spontaneous preterm labor, iatrogenic preterm newborns were at increased risk of respiratory distress syndrome (RDS) [Odds Ratio (OR) 3.05 (95%CI 1.31; 7.12)], and need of exogenous surfactant administration [OR 3.87 (95%CI 1.60; 9.35)]. PPROM was associated with higher risk of neonatal sepsis [OR 12.96 (95%CI 1.18; 142.67)]. There were no differences regarding the combined outcome for iatrogenic [OR 0.94 (95%CI 0.33; 2.71)] or PPROM [OR 1.11 (95%CI 0.35; 3.49)] groups.

Conclusions: In our study, the different mechanisms of labor onset are associated with different neonatal outcomes. Iatrogenic preterm birth was associated with an increased risk of RDS and a higher need of exogenous surfactant administration than spontaneous group. The rate of neonatal sepsis was significantly higher in PPROM group along with a higher prevalence of histological chorioamnionitis.     

Sexual Dysfunction in Women With Polycystic Ovary Syndrome: Systematic Review and Meta-Analysis

Introduction

Sexual dysfunction occurs in any phase of sexual performance or any period of the sexual response cycle, and polycystic ovary syndrome (PCOS) affects self-image with repercussions on sexuality.