Reflex and Tonic Autonomic Markers for Risk Stratification in Patients With Type 2 Diabetes Surviving Acute Myocardial Infarction

OBJECTIVE Diabetic postinfarction patients are at increased mortality risk compared with nondiabetic postinfarction patients. In a substantial number of these patients, diabetic cardiac neuropathy already preexists at the time of the infarction. In the current study we investigated if markers of autonomic dysfunction can further discriminate diabetic postinfarction patients into low- and high-risk groups. RESEARCH DESIGN AND METHODS We prospectively enrolled 481 patients with type 2 diabetes who survived acute myocardial infarction (MI), were aged ≤80 years, and presented in sinus rhythm. Primary end point was total mortality at 5 years of follow-up. Severe autonomic failure (SAF) was defined as coincidence of abnormal autonomic reflex function (assessed by means of heart rate turbulence) and of abnormal autonomic tonic activity (assessed by means of deceleration capacity of heart rate). Multivariable risk analyses considered SAF and standard risk predictors including history of previous MI, arrhythmia on Holter monitoring, insulin treatment, and impaired left ventricular ejection fraction (LVEF) ≤30%. RESULTS During follow-up, 83 of the 481 patients (17.3%) died. Of these, 24 deaths were sudden cardiac deaths and 21 nonsudden cardiac deaths. SAF identified a high-risk group of 58 patients with a 5-year mortality rate of 64.0% at a sensitivity level of 38.0%. Multivariately, SAF was the strongest predictor of mortality (hazard ratio 4.9 [95% CI 2.4–9.9]), followed by age ≥65 years (3.4 [1.9–5.8]), and LVEF ≤30% (2.6 [1.5–4.4]). CONCLUSIONS Combined abnormalities of autonomic reflex function and autonomic tonic activity identifies diabetic postinfarction patients with very poor prognoses

The role of agonist and antagonist muscles in explaining isometric knee extension torque variation with hip joint angle.

PURPOSE: The biarticular rectus femoris (RF), operating on the ascending limb of the force-length curve, produces more force at longer lengths. However, experimental studies consistently report higher knee extension torque when supine (longer RF length) compared to seated (shorter RF length). Incomplete activation in the supine position has been proposed as the reason for this discrepancy, but differences in antagonistic co-activation could also be responsible due to altered hamstrings length. We examined the role of agonist and antagonist muscles in explaining the isometric knee extension torque variation with changes in hip joint angle. METHOD: Maximum voluntary isometric knee extension torque (joint MVC) was recorded in seated and supine positions from nine healthy males (30.2 ± 7.7 years). Antagonistic torque was estimated using EMG and added to the respective joint MVC (corrected MVC). Submaximal tetanic stimulation quadriceps torque was also recorded. RESULT: Joint MVC was not different between supine (245 ± 71.8 Nm) and seated (241 ± 69.8 Nm) positions and neither was corrected MVC (257 ± 77.7 and 267 ± 87.0 Nm, respectively). Antagonistic torque was higher when seated (26 ± 20.4 Nm) than when supine (12 ± 7.4 Nm). Tetanic torque was higher when supine (111 ± 31.9 Nm) than when seated (99 ± 27.5 Nm). CONCLUSION: Antagonistic co-activation differences between hip positions do not account for the reduced MVC in the supine position. Rather, reduced voluntary knee extensor muscle activation in that position is the major reason for the lower MVC torque when RF is lengthened (hip extended). These findings can assist standardising muscle function assessment and improving musculoskeletal modelling applications

Medication adherence among diabetic and hypertensive patients in Al-Qassim region of Saudi Arabia

Non-adherence to medication is often an unrecognized risk factor that contributes to failure of the therapeutic plan. The purpose of the study was to identify factors related to high, medium and low medication adherence among adult Saudi patients with hypertension and diabetes mellitus. This study is designed as a descriptive cross sectional survey and was conducted in three tertiary care hospitals of Al-Qassim province of Saudi Arabia. The data was collected using the 8-item Morisky Medication Adherence Scale (MMAS-8) and analyzed by SPSS. Three levels of adherence were considered based on the following scores: 0 to <6 (low); 6 to <8 (medium); 8 (high). Of the 396 patients interviewed, 52% reported low adherence to prescribed medication. Multinomial logistic regression analysis was conducted. Gender, age, literacy level, duration of illness and type of chronic disease were negatively associated with medication adherence. The study shows very high proportion of low and medium adherence on long term medication, which may be responsible for the failure of achieving therapeutic outcome. Further investigation is required to evaluate the applicability of MMAS-8 as a tool of measuring medication adherence among Saudi patients with chronic diseases. Adherence enhancing strategies should also be evaluated in separate patients group

Age-Related Changes in Strength, Joint Laxity, and Walking Patterns: Are They Related to Knee Osteoarthritis?

Aging is associated with musculoskeletal changes and altered walking patterns. These changes are common in people with knee osteoarthritis (OA) and may precipitate the development of OA. We examined age-related changes in musculoskeletal structures and walking patterns to better understand the relationship between aging and knee OA

Reductions in co-contraction following neuromuscular re-education in people with knee osteoarthritis

Background Both increased knee muscle co-contraction and alterations in central pain processing have been suggested to play a role in knee osteoarthritis pain. However, current interventions do not target either of these mechanisms. The Alexander Technique provides neuromuscular re-education and may also influence anticipation of pain. This study therefore sought to investigate the potential clinical effectiveness of the AT intervention in the management of knee osteoarthritis and also to identify a possible mechanism of action. Methods A cohort of 21 participants with confirmed knee osteoarthritis were given 20 lessons of instruction in the Alexander Technique. In addition to clinical outcomes EMG data, quantifying knee muscle co-contraction and EEG data, characterising brain activity during anticipation of pain, were collected. All data were compared between baseline and post-intervention time points with a further 15-month clinical follow up. In addition, biomechanical data were collected from a healthy control group and compared with the data from the osteoarthritis subjects. Results: Following AT instruction the mean WOMAC pain score reduced by 56% from 9.6 to 4.2 (P<0.01) and this reduction was maintained at 15 month follow up. There was a clear decrease in medial co-contraction at the end of the intervention, towards the levels observed in the healthy control group, both during a pre-contact phase of gait (p<0.05) and during early stance (p<0.01). However, no changes in pain-anticipatory brain activity were observed. Interestingly, decreases in WOMAC pain were associated with reductions in medial co-contraction during the pre-contact phase of gait. Conclusions: This is the first study to investigate the potential effectiveness of an intervention aimed at increasing awareness of muscle behaviour in the clinical management of knee osteoarthritis. These data suggest a complex relationship between muscle contraction, joint loading and pain and support the idea that excessive muscle co-contraction may be a maladaptive response in this patient group. Furthermore, these data provide evidence that, if the activation of certain muscles can be reduced during gait, this may lead to positive long-term clinical outcomes. This finding challenges clinical management models of knee osteoarthritis which focus primarily on muscle strengthening

Clinical Features Of Familial Hypercholesterolemia In Children And Adults In EAS-FHSC Regional Centre For Rare Diseases In Poland.

Background: Familial hypercholesterolemia (FH) is a genetic autosomal co-dominant metabolic disorder leading to elevated circulating concentrations of low-density lipoprotein cholesterol (LDL-C). Early development of atherosclerotic cardiovascular disease (ASCVD) is common in affected patients. We aimed to evaluate the characteristics and differences in the diagnosis and therapy of FH children and adults. Methods: All consecutive patients who were diagnosed with FH, both phenotypically and with genetic tests, were included in this analysis. All patients are a part of the European Atherosclerosis Society FH-Study Collaboration (FHSC) regional center for rare diseases at the Polish Mother’s Memorial Hospital Research Institute (PMMHRI) in Lodz, Poland. Results: Of 103 patients with FH, there were 16 children (15.5%) at mean age of 9 ± 3 years and 87 adults aged 41 ± 16; 59% were female. Children presented higher mean levels of total cholesterol, LDL-C, and high-density lipoprotein cholesterol (HDL-C) measured at the baseline visit (TC 313 vs. 259 mg/dL (8.0 vs. 6.6 mmol/L), p = 0.04; LDL 247 vs. 192 mg/dL (6.3 vs. 4.9 mmol/L), p = 0.02, HDL 53 vs. 48 mg/dL (1.3 vs. 1.2 mmol/L), p = 0.009). Overall, 70% of adult patients and 56% of children were prescribed statins (rosuvastatin or atorvastatin) on admission. Combination therapy (dual or triple) was administered for 24% of adult patients. Furthermore, 13.6% of adult patients and 19% of children reported side effects of statin therapy; most of them complained of muscle pain. Only 50% of adult patients on combination therapy achieved their treatment goals. None of children achieved the treatment goal. Conclusions: Despite a younger age of FH diagnosis, children presented with higher mean levels of LDL-C than adults. There are still urgent unmet needs concerning effective lipid-lowering therapy in FH patients, especially the need for greater use of combination therapy, which may allow LDL-C targets to be met in most of the patients

Empowering stroke survivors beyond inpatient rehabilitation: the STRIDE program

ObjectiveThe timeframe from hospital discharge to the commencement of outpatient therapies represents a crucial yet often overlooked period in post-stroke recovery. We designed an eight-week post-stroke management program (STRIDE, Stroke Management Training and Inpatient Rehabilitation Discharge Education) targeting individuals discharging from an inpatient rehabilitation facility to home. The primary aims of this pilot study were to determine STRIDE feasibility and participant engagement.MethodsParticipants with first or recurrent stroke were enrolled. Each week, participants monitored and recorded their daily activity, completed a 15-min educational module and quiz, and partook in weekly and biweekly communication with a fellow participant and STRIDE coordinator, respectively. Feasibility was evaluated by successful initiation of STRIDE and enrollment of the target population. We also assessed participant adherence and conducted semi-structured exit interviews.ResultsOf the 99 individuals screened, 20 individuals were enrolled (7 females, 28.6 ± 15.7 days post-stroke). Several participants were unable to begin the program (n = 6) or complete the program (n = 4). Overall, participants completing at least 1 week of STRIDE (n = 14) demonstrated adherence with education module and quiz completion and communication with the STRIDE coordinator. Participant feedback from interviews was largely positive, underscoring the value of STRIDE during early post-stroke recovery.ConclusionsThese findings support the feasibility of an initiated multi-faceted stroke management program. Participant dropout was a limitation and serves as a consideration when designing future iterations of STRIDE. With the long-term goal of promoting autonomy and investment in one's continued recovery beyond the inpatient setting, STRIDE bridges the transition from hospital to home

Empowering stroke survivors beyond inpatient rehabilitation: the STRIDE program

Objective The timeframe from hospital discharge to the commencement of outpatient therapies represents a crucial yet often overlooked period in post-stroke recovery. We designed an eight-week post-stroke management program (STRIDE, Stroke Management Training and Inpatient Rehabilitation Discharge Education) targeting individuals discharging from an inpatient rehabilitation facility to home. The primary aims of this pilot study were to determine STRIDE feasibility and participant engagement. Methods Participants with first or recurrent stroke were enrolled. Each week, participants monitored and recorded their daily activity, completed a 15-min educational module and quiz, and partook in weekly and biweekly communication with a fellow participant and STRIDE coordinator, respectively. Feasibility was evaluated by successful initiation of STRIDE and enrollment of the target population. We also assessed participant adherence and conducted semi-structured exit interviews. Results Of the 99 individuals screened, 20 individuals were enrolled (7 females, 28.6 ± 15.7 days post-stroke). Several participants were unable to begin the program (n = 6) or complete the program (n = 4). Overall, participants completing at least 1 week of STRIDE (n = 14) demonstrated adherence with education module and quiz completion and communication with the STRIDE coordinator. Participant feedback from interviews was largely positive, underscoring the value of STRIDE during early post-stroke recovery. Conclusions These findings support the feasibility of an initiated multi-faceted stroke management program. Participant dropout was a limitation and serves as a consideration when designing future iterations of STRIDE. With the long-term goal of promoting autonomy and investment in one's continued recovery beyond the inpatient setting, STRIDE bridges the transition from hospital to home

Regional differences in physicians’ behavior and factors influencing the intensity of PCSK9 inhibitor therapy with alirocumab: a subanalysis of the ODYSSEY APPRISE study

BackgroundDespite better accessibility of the effective lipid-lowering therapies, only about 20% of patients at very high cardiovascular risk achieve the low-density lipoprotein cholesterol (LDL-C) goals. There is a large disparity between European countries with worse results observed for the Central and Eastern Europe (CEE) patients. One of the main reasons for this ineffectiveness is therapeutic inertia related to the limited access to appropriate therapy and suitable dosage intensity. Thus, we aimed to compare the differences in physicians’ therapeutic decisions on alirocumab dose selection, and factors affecting these in CEE countries vs. other countries included in the ODYSSEY APPRISE study.MethodsODYSSEY APPRISE was a prospective, single-arm, phase 3b open-label (≥12 weeks to ≤30 months) study with alirocumab. Patients received 75 or 150 mg of alirocumab every 2 weeks, with dose adjustment during the study based on physician's judgment. The CEE group in the study included Czechia, Greece, Hungary, Poland, Romania, Slovakia, and Slovenia, which we compared with the other nine European countries (Austria, Belgium, Denmark, Finland, France, Germany, Italy, Spain, and Switzerland) plus Canada.ResultsA total of 921 patients on alirocumab were involved [modified intention-to-treat (mITT) analysis], including 114 (12.4%) subjects from CEE countries. Therapy in CEE vs. other countries was numerically more frequently started with lower alirocumab dose (75 mg) at the first visit (74.6 vs. 68%, p = 0.16). Since week 36, the higher dose was predominantly used in CEE patients (150 mg dose in 51.6% patients), which was maintained by the end of the study. Altogether, alirocumab dose was significantly more often increased by CEE physicians (54.1 vs. 39.9%, p = 0.013). Therefore, more patients achieved LDL-C goal at the end of the study (&lt;55 mg/dl/1.4 mmol/L and 50% reduction of LDL-C: 32.5% vs. 28.8%). The only factor significantly influencing the decision on dose of alirocumab was LDL-C level for both countries’ groups (CEE: 199.2 vs. 175.3 mg/dl; p = 0.019; other: 205.9 vs. 171.6 mg/dl; p &lt; 0.001, for 150 and 75 mg of alirocumab, respectively) which was also confirmed in multivariable analysis (OR = 1.10; 95% CI: 1.07–1.13).ConclusionsDespite larger unmet needs and regional disparities in LDL-C targets achievement in CEE countries, more physicians in this region tend to use the higher dose of alirocumab, they are more prone to increase the dose, which is associated with a higher proportion of patients reaching LDL-C goals. The only factor that significantly influences decision whether to increase or decrease the dose of alirocumab is LDL-C level

The feasibility of measuring the activation of the trunk muscles in healthy older adults during trunk stability exercises

<p>Abstract</p> <p>Background</p> <p>As the older adult population increases, the potential functional and clinical burden of trunk muscle dysfunction may be significant. An evaluation of risk factors including the impact of the trunk muscles in terms of their temporal firing patterns, amplitudes of activation, and contribution to spinal stability is required. Therefore, the specific purpose of this study was to assess the feasibility of measuring the activation of trunk muscles in healthy older adults during specific leg exercises with trunk stabilization.</p> <p>Methods</p> <p>12 asymptomatic adults 65 to 75 years of age were included in the study. Participants performed a series of trunk stability exercises, while bilateral activation of abdominal and back extensor muscles was recorded by 24 pairs of Meditrace™ surface electrodes. Maximal voluntary isometric contractions (MVIC) were performed for electromyographic (EMG) normalization purposes. EMG waveforms were generated and amplitude measures as a percentage of MVIC were calculated along with ensemble average profiles. 3D kinematics data were also recorded, using an electromagnetic sensor placed at the left lateral iliac crest. Furthermore, a qualitative assessment was conducted to establish the participant's ability to complete all experimental tasks.</p> <p>Results</p> <p>Excellent quality abdominal muscle activation data were recorded during the tasks. Participants performed the trunk stability exercises with an unsteady, intermittent motion, but were able to keep pelvic motion to less than 10°. The EMG amplitudes showed that during these exercises, on average, the older adults recruited their abdominal muscles from 15–34% of MVIC and back extensors to less than 10% of MVIC. There were similarities among the abdominal muscle profiles. No participants reported pain during the testing session, although 3 (25%) of the participants reported delayed onset muscle soreness during follow up that was not functionally limiting.</p> <p>Conclusion</p> <p>Older adults were able to successfully complete the trunk stability protocol that was developed for younger adults with some minor modifications. The collected EMG amplitudes were higher than those reported in the literature for young healthy adults. The temporal waveforms for the abdominal muscles showed a degree of synchrony among muscles, except for the early activation from the internal oblique prior to lifting the leg off the table.</p