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Osteopathic Manipulative Treatment/Myofascial Release Upon The Resistive Index/Blood Pressure in Heart Failure
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Gastroesophageal reflux disease (GERD) is a chronic condition that affects a growing number of people and is currently among the most common disorders seen in clinical practice.
To develop a protocol for the management of GERD with osteopathic manipulative therapy (OMTh) applied to the diaphragm and esophagus, and to evaluate the protocol's effectiveness using the quality of life scale (QS-GERD) for the disease.
In this single-blinded prospective study, an OMTh protocol focusing on the diaphragm and esophagus was applied to a single patient, who had received a diagnosis of GERD 4 years previously. Outcomes were measured using the QS-GERD, which has a total possible score ranging from 0 to 45 (the lower the score, the better the quality of life) and a level of satisfaction from very satisfied to incapacitated. The OMTh protocol was applied at 3 sessions (initial session, second session 1 week after the first, and third session 2 weeks after the second), and the patient completed the QS-GERD 4 times (before the first session, before the third session, and 2 and 4 weeks after the third session).
The OMTh protocol was administered without adverse events, and the patient reported positive outcomes after the third session. The QS-GERD showed a score improvement from 13 of 45 to 4 of 45.
The results in the present report show that OMTh applied to the diaphragm and esophagus may improve symptoms of GERD and should be added to the somatovisceral approach to the care of patients with this condition.
The renal arterial resistance index (RRI) is a measure of renal blood flow obtained by Doppler ultrasonography, which has been demonstrated to reflect both vascular and parenchymal renal abnormalities. The aim of the study was to evaluate clinical correlates and the prognostic relevance of RRI in a group of patients affected by chronic heart failure (CHF).
We enrolled 250 CHF outpatients in a stable clinical condition and receiving conventional therapy. Peak systolic velocity and end-diastolic velocity of a segmental renal artery were obtained by pulsed Doppler flow. Then the RRI was calculated. Standard renal function assessment was obtained by the measurement of creatinine serum levels and the estimation of the glomerular filtration rate (GFR). During follow-up (21.4 ± 11.3 months), 41 patients experienced heart failure progression (hospitalization and/or heart transplantation and/or death due to worsening heart failure). Considered as a continuous variable, RRI was associated with events at univariate [hazard ratio (HR) 1.14; 95% confidence interval (CI) 1.09-1.19; P < 0.001] as well as at multivariate Cox regression analysis (HR 1.08; 95% CI 1.02-1.13; P = 0.004) after correction for independent predictors of the reference model. When the RRI was added to the reference model including GFR, a significant improvement of reclassification according to both category-free net reclassification improvement (NRI, 47%; 95% CI 13-80%; P = 0.006) and integrated discrimination improvement (IDI, 0.034; 95% CI 0.006-0.061; P = 0.016) was observed.
Quantification of arterial renal perfusion provides a new parameter that independently predicts CHF patient outcome, thus strengthening its possible role in current clinical practice in order to better characterize renal function and stratify patients' prognosis.
It remains possible that the benefit from beta-blockers (BBs) in chronic heart failure (CHF) may not entirely be derived from a class-specific effect. Several experimental reports have alluded to the capability of immunomodulation by individual BBs. Given the increasingly recognized importance of the immune system in the pathogenesis of CHF, we studied the effects of BBs on the circulating immune system of these patients. Blood samples from CHF outpatients were prospectively analyzed using flow cytometry and gating software. Results were analyzed against comprehensive clinical details that were recorded during sample donation, including the type of BB administered. 273 blood samples were analyzed from 141 CHF patients, with an average ejection fraction of 31.9% and a mean age of 69.1 years. Patients taking carvedilol had a significantly lower expression of CD107a on cytotoxic T cells compared to bisoprolol (P= 0.001) and nebivolol (P= 0.008). They also had a significantly lower expression of HLA-DR on lymphocytes (P < 0.001 and P= 0.009 for bisoprolol and nebivolol, respectively). Cytotoxic T cells and lymphocytes expressing HLA-DR have been implicated in the pathogenesis of CHF. The fact that carvedilol, but not other commonly used beta-blockers, appears to modulate these important parameters, supports the concept that important differences exist between these agents, which may affect outcomes in CHF.
Overproduction of pro-inflammatory cytokines is a well established factor in the progression of chronic heart failure (CHF). Changes in cellular immunity have not been widely studied, and the impact of standard medication is uncertain. Here we investigate whether a leukocyte redistribution occurs in CHF and whether this effect is influenced by beta-blocker therapy.
We prospectively studied 75 patients with systolic CHF (age: 68+/-11 years, left ventricular ejection fraction 32+/-11%, New York Heart Association class 2.5+/-0.7) and 20 age-matched healthy control subjects (age: 63+/-10 years). We measured the response of cells to endotoxin exposure in vitro, analysed subsets of lymphocytes using flow cytometry, and assessed plasma levels of the pro-inflammatory markers interleukin 1, 6, tumor necrosis factor-alpha, and soluble tumor necrosis factor receptors 1 and 2.
While no differences in the number of leukocytes were noted between patients with CHF and healthy controls, we detected relative lymphopenia in patients with CHF (p<0.001 vs. control), mostly driven by reductions in T helper cells and B cells (both p<0.05). The number of neutrophils was increased (p<0.01). These effects were pronounced in patients who were beta-blocker naïve (32% of all patients with CHF). Increased plasma levels of soluble tumor necrosis receptor-1 correlated with the relative number of lymphocyte subsets.
In patients with CHF, we detected a redistribution of leukocyte subsets, i.e. an increase in neutrophils with relative lymphopenia. These effects were pronounced in patients who were beta-blocker naïve. The underlying mechanism remains to be elucidated.
Chronic heart failure is one of the most serious medical problems in the United States, affecting some 4 million persons. In spite of its common occurrence, and comprehensive literature regarding this condition, no unifying hypothesis has been accepted to explain the signs and symptoms of chronic heart failure. The cardiocirculatory and neurohormonal models place an emphasis on left ventricular ejection fraction and cardiac output and do not provide appropriate explanations for the symptoms of breathlessness and fatigue. The muscle hypothesis supplements these conventional models. It proposes that abnormal skeletal muscle in heart failure results in activation of muscle ergoreceptors, leading to an increase in ventilation and sensation of breathlessness, the perception of fatigue, and sympathetic activation. At least one fourth of patients with chronic heart failure are limited by skeletal muscle abnormalities rather than cardiac output. Cardiac rehabilitation exercise can lead to an increase in exercise capacity that is superior to that gained from digitalis or angiotensin-converting enzyme inhibitors. Exercise tends to reverse the skeletal muscle myopathy of chronic heart failure and reduces the abnormal ergoreflex. Other interventions that have been shown to have a favorable outcome include localized muscle group training, respiratory muscle training, and dietary approaches. The possibility that osteopathic manipulative treatment might be of benefit is an attractive, but untested, possibility.
Osteopathic principles guide treatments, one of which is the rule of the artery is absolute. Objectives of this study were to determine if selected osteopathic techniques (fascial releases along the arterial pathway and balancing of diaphragmatic tensions) were able to influence the vascular supply, dynamic balance, knee range of motion (ROM) and symptoms. Methods: Thirty subjects with radiographic confirmed knee osteoarthritis were randomly assigned to one of two groups: 1) osteopathic evaluation combined with treatment (treatment group); 2) osteopathic evaluation alone (no treatment group). Outcome measures were recorded before and after each osteopathic session: ultrasound/Doppler recordings of the resistive index (RI) of the superficial femoral artery (SFA), active knee flexion ROM, step test for balance and the visual analog scale (VAS) symptom rating. A two factor mixed model Analysis of Variance (ANOVA) for group (evaluation vs. treatment) with repeated measures (pre versus post test) was employed to test for main effects and all interactions for each dependent variable (alpha = 0.05). Results: The RI reduced significantly (p < 0.008) from pre to post test in the treatment group only. Significant pretest/posttest main effects were found for ROM, balance and symptom rating (p < 0.05). Conclusion: The significant difference in RI provides evidence for the benefits of specificity within osteopathic techniques, and reveal the vascular supply to the leg was affected by the fascial releases and will possibly influence some of the pathophysiological factors of an arthritic knee.
The pathophysiology of heart failure (HF) is characterized by hemodynamic abnormalities that result in neurohormonal activation and autonomic imbalance with increase in sympathetic activity and withdrawal of vagal activity. Alterations in receptor activation from this autonomic imbalance may have profound effects on cardiac function and structure. Inhibition of the sympathetic drive to the heart through β-receptor blockade has become a standard component of therapy for HF with a dilated left ventricle because of its effectiveness in inhibiting the ventricular structural remodeling process and in prolonging life. Several devices for selective modulation of sympathetic and vagal activity have recently been developed in an attempt to alter the natural history of HF. The optimal counteraction of the excessive sympathetic activity is still unclear. A profound decrease in adrenergic support with excessive blockade of the sympathetic nervous system may result in adverse outcomes in clinical HF. In this review, we analyze the data supporting a contributory role of the autonomic functional alterations on the course of HF, the techniques used to assess autonomic nervous system activity, the evidence for clinical effectiveness of pharmacological and device interventions, and the potential future role of autonomic nervous system modifiers in the management of this syndrome.
More than 100 years ago AT Still MD founded osteopathic medicine, and specifically described fascia as a covering, with common origins of layers of the fascial system despite diverse names for individual parts. Fascia assists gliding and fluid flow and is highly innervated. Fascia is intimately involved with respiration and with nourishment of all cells of the body, including those of disease and cancer. This paper reviews information presented at the first three International Fascia Research Congresses in 2007, 2009 and 2012 from the perspective of Dr Still, that fascia is vital for organism's growth and support, and it is where disease is sown.
Cardiopulmonary rehabilitation is recognized as a core component of management of individuals with Congestive Heart Failure (CHF) or Chronic Obstructive Pulmonary Disease (COPD) which is designed to improve their physical and psychosocial condition without impacting on the primary organ impairment. This has lead scientific community increasingly to believe that the main effects of cardiopulmonary rehabilitative exercise training are focused on skeletal muscles that are regarded as dysfunctional in both CHF and COPD. Accordingly, following completion of a cardiopulmonary rehabilitative exercise training program there are important peripheral muscular adaptations in both disease entities namely, increased capillary density, blood flow, mitochondrial volume density, fiber size, distribution of slow twitch fibers, and decreased lactic acidosis and vascular resistance. Decreased lactic acidosis at a given level of sub-maximal exercise not only offsets the occurrence of peripheral muscle fatigue leading to muscle task failure and muscle discomfort, but also concurrently mitigates the additional burden on the respiratory muscles caused by the increased respiratory drive, thereby reducing dyspnea sensations. Furthermore in patients with COPD, exercise training reduces the degree of dynamic lung hyperinflation leading to improved arterial oxygen and central hemodynamic responses, thus increasing systemic muscle oxygen availability. In patients with CHF, exercise training has beneficial direct and reflex sympathoinhibitory effects, as well as favorable effects on normalization of neurohumoral excitation. These physiological benefits apply to all COPD and CHF patients independently of the degree of disease severity and are associated with improved exercise tolerance, functional capacity and quality of life.
A theoretical framework for the role that fascia may play in apparently diverse passive manual therapies is presented. The relevant anatomy of fascia is briefly reviewed. Therapies are divided into myofascial ('soft tissue') and manipulative ('joint-based') and comparisons are made between them on a qualitative basis using measures of pain, function and 'autonomic activation'. When these three outcomes are evaluated between therapies it is observed that they are usually comparable in the quality, if not the quantity of the measures. Viewed from a patients' perspective alone the therapeutic benefits are hard to distinguish. It is proposed that a biologically plausible mechanism which may generate a significant component of the observed effects of manual therapies of all descriptions, is the therapeutic stimulation of fascia in its various forms within the body. Such considerations may help explain why diverse therapies apparently give comparable results.
Myofascial Release (MFR) and Fascial Unwinding (FU) are widely used manual fascial techniques (MFTs), generally incorporated in treatment protocols to release fascial restrictions and restore tissue mobility. However, the effects of MFT on pain perception, and the mobility of fascial layers, have not previously been investigated using dynamic ultrasound (US) in patients with neck pain (NP) and low back pain (LBP).
a) To show that US screening can be a useful tool to assess dysfunctional alteration of organ mobility in relation to their fascial layers, in people with non-specific NP or LBP, in the absence of any organ disease; b) To assess, by dynamic US screening, the change of sliding movements between superficial and deep fascia layers in the neck, in people with non-specific NP, before and after application of MFTs c) To assess, by dynamic US screening, the variation of right reno-diaphragmatic (RD) distance and of neck bladder (NB) mobility, in patients with non-specific LBP, before and after application of MFTs d) To evaluate 'if' and 'at what degree' pain perception may vary in patients with NP or LBP, after MFTs are applied, over the short term.
An Experimental group of 60 subjects, 30 with non-specific NP and 30 with non-specific LBP, were assessed in the area of complaint, by Dynamic Ultrasound Topographic Anatomy Evaluation (D.US.T.A.-E.), before and after MFTs were applied in situ, in the corresponding painful region, for not more than 12 min. The results were compared with those from the respective Sham-Control group of 30 subjects. For the NP sub-groups, the pre- to post- US recorded videos of each subject were compared and assessed randomly and independently by two blinded experts in echographic screening. They were asked to rate the change observed in the cervical fascia sliding motions as 'none', 'discrete' or 'radical'. For the LBP sub-groups, a pre- to post- variation of the right RD distances and NB mobility were calculated on US imaging and compared. For all four sub-groups, a Short-Form McGill Pain Assessment Questionnaire (SF-MPQ) was administered on the day of recruitment as well as on the third day following treatment.
The Chi square test has shown a significant correlation (0.915) with a p-Value < 0.0001 between the two examiners' results on US videos in NP sub-groups. The ANOVA test at repeated measures has shown a significant difference (p-Value < 0.0001) within Experimental and Control groups for the a) pre- to post- RD distances in LBP sub-groups, b) pre- to post- NB distances in LBP sub-groups; as well as between groups as for c) pre- to post- SF-MPQ results in NP and LBP sub-groups.
Dynamic US evaluation can be a valid and non-invasive instrument to assess and monitor effective sliding motion of fascial layers in vivo. MFTs are effective manual techniques to release area of impaired sliding fascial mobility, and to improve pain perception over a short term duration in people with non-specific NP or LBP.
The National Institute for Health and Clinical Excellence released its first clinical guideline on heart failure in 2003. This synopsis describes the update of that guideline, which was released in August 2010 and discusses the diagnosis, treatment, and monitoring of heart failure.
Guideline developers considered clinical evidence, health economic analyses, clinical expert opinion, and patient views. Systematic literature searches were performed, and an original decision model assessed the cost-effectiveness of serial measurement of serum natriuretic peptide to monitor patients with chronic heart failure.
First, this guideline update describes the role of serum natriuretic peptide measurement, echocardiography, and specialist assessment in the diagnosis of heart failure. Second, it presents a pathway for pharmacologic treatment, rehabilitation, and pacing therapy (including implantable cardioverter-defibrillator and cardiac resynchronization therapy) for patients with heart failure and left ventricular systolic dysfunction and patients with heart failure and preserved ejection fraction. Finally, it explains the recommendation to monitor patients with heart failure by using serial measurement of serum natriuretic peptide.
Exercise training in patients with systolic heart failure (HF) is an accepted adjunct to an evidence-based management program. This review describes the pathophysiologic features that are thought to be responsible for the exercise intolerance experienced in the HF patient. Significant research has expanded our appreciation of the interplay of hemodynamic, ventilatory, and skeletal myopathic processes in this common, chronic condition. Randomized, controlled exercise trials designed to measure endothelial function, inflammatory markers, sympathetic neural activation, and skeletal muscle metabolism and structure have further defined the pathophysiology, documented the impact of exercise training on these processes, and confirmed the benefit of this therapy. Consistent with prior clinical research and patient experience are the recently published results of the HF-ACTION (Heart Failure-A Controlled Trial Investigating Outcomes of exercise TraiNing), which demonstrated a modest improvement in exercise capacity, reduction of symptoms, and improved self-reported measures of quality of life without adverse events. Consideration is given in this review to the benefits of variable intensity programs and the addition of resistance exercise to a standard aerobic prescription. Despite increasing validation of the role exercise training plays in the modification of exercise intolerance, challenges remain in its routine therapeutic application, including acceptance and use as an adjunctive intervention in the management of the patient with HF, limited insurance coverage for HF patients in cardiac rehabilitation, tailoring of exercise programs to best address the needs of subgroups of patients, and improved short- and long-term adherence to exercise training and a physically active lifestyle.
The objective of our study was to use Doppler sonography to detect the flow characteristics and parameters of the hand arteries that are needed to distinguish between primary Raynaud phenomenon (RP) and secondary RP.
The diameter, resistive index (RI), and flow volume of the digital, ulnar, and radial arteries of patients with primary RP and those with secondary RP were measured at rest and after cold provocation. The flow starting time in the digital artery and the flow normalizing time of all three arteries were also recorded after cold provocation.
At baseline and after cold provocation, the diameters of the radial and digital arteries and the flow volumes of the three arteries were less in patients with secondary RP than in primary RP patients. In primary RP and secondary RP, the flow normalizing times (mean ± SD) were 9.8 ± 3.88 and 25.88 ± 7.14 minutes, respectively, in the radial artery; 11.3 ± 7.43 and 32.15 ± 12.57 minutes in the ulnar artery; and 12.22 ± 6.82 and 32.67 ± 10.76 minutes in the digital artery. A flow normalizing time cutoff in the radial artery of 17 minutes yielded a sensitivity of 90% and specificity of 100%. A flow normalizing time cutoff in the ulnar artery of 23 minutes yielded a sensitivity and specificity of 71% and 100%, respectively. A flow normalizing time cutoff in the digital artery of 23 minutes yielded a sensitivity and specificity of 82.6% and 98%, respectively. The flow starting time of the digital artery was 3.80 ± 3.27 minutes in primary RP and 16.78 ± 9.97 minutes in secondary RP (p < 0.0001). The flow starting time cutoff of the digital artery was 7 minutes (sensitivity, 82.6%; specificity, 95.7%).
The diameter of the radial and distal arteries; flow volume; and flow volume normalizing time of the digital, ulnar, and radial arteries' flow starting time in the digital artery may be helpful in distinguishing between primary RP and secondary RP with high sensitivity and specificity values. These parameters may also facilitate objective follow-up of treatment. The noninvasive nature of Doppler sonography is an additional advantage, and there is no need for extra hardware or software.
Aim of the present study was to investigate the association between osteopathic treatment and hypertension.
The design was a non-randomized trial including consecutive subjects affected by hypertension and vascular alterations, using pre-post differences in intima-media thickness, systolic and diastolic blood pressure as primary endpoints. Statistical analysis was based on univariate t tests and multivariate linear regression.
A total of N = 31 out of N = 63 eligible subjects followed by a single cardiologist received osteopathic treatment in addition to routine care. Clinical measurements were recorded at baseline and after 12 months. Univariate analysis found that osteopathic treatment was significantly associated to an improvement in all primary endpoints. Multivariate linear regression showed that, after adjusting for all potential confounders, osteopathic treatment was performing significantly better for intima-media thickness (delta between pre-post differences in treated and control groups: -0.517; 95% c.i.: -0.680, -0.353) and systolic blood pressure (-4.523; -6.291, -2.755), but not for diastolic blood pressure.
Our study shows that, among patients affected by cardiovascular disorders, osteopathic treatment is significantly associated to an improvement in intima-media and systolic blood pressure after one year. Multicentric randomized trials of adequate sample size are needed to evaluate the efficacy of OMT in the treatment of hypertension.
Stress, whether physical or emotional, is known to challenge the hypothalamus-pituitary-adrenal axis and to induce important changes in the biochemical parameters of organ functions. The fascia is an elastic tissue that envelops the organs and reacts to stress by tightening, thus contributing to the dysfunction of the body. One of the unmistakable aspects of stress is that it induces vasomotor reactions. Both tightening of the fascia and vascular modifications are reversible, but sometimes tensions become embedded in the fascia and gradually begin to hinder specific functions of the body. Here we present the results of a study investigating the effects of a manual therapy (Fasciatherapy Méthode Danis Bois combined with Pulsology Touch) applied to the artery. We have measured the modifications of important parameters contributing to vascular function. Our study shows that this manual approach is able to affect blood shear rate and blood flow turbulence in particular.
This study investigated whether myofascial release techniques performed on upper body connective tissue could mitigate the frequency, duration or pain intensity associated with primary Raynaud's phenomenon.
Five treatments were administered over a 3-week treatment period on a 35-year-old female experiencing primary Raynaud's phenomenon for the past 12 years. A log was kept documenting frequency, duration and severity of pain. The myofascial work targeted the upper back, neck and arms according to hypothetical fascial meridian lines.
Symptom duration was the one characteristic that showed improvement. After the first treatment, the duration of the subject's vasospastic episodes was reduced by almost half and continued to decrease throughout the 3 weeks of treatments. Neither the frequency or number of affected digits varied significantly from the pre-treatment weeks.
The results suggest that by releasing restricted fascia, myofascial techniques may influence the duration and severity of the vasospastic episodes experienced in primary Raynaud's phenomenon.
Peripheral arterial disease (PAD) is a manifestation of systemic atherosclerosis associated with impaired endothelial function and intermittent claudication is the hallmark symptom. Hypothesizing that osteopathic manipulative treatment (OMT) may represent a non-pharmacological therapeutic option in PAD, we examined endothelial function and lifestyle modifications in 15 intermittent claudication patients receiving osteopathic treatment (OMT group) and 15 intermittent claudication patients matched for age, sex and medical treatment (control group). Compared to the control group, the OMT group had a significant increase in brachial flow-mediated vasodilation, ankle/brachial pressure index, treadmill testing and physical health component of life quality (all p<0.05) from the beginning to the end of the study. At univariate analysis in the OMT group there was a negative correlation between changes in brachial flow-mediated vasodilation and IL-6 levels (r=-0.30; p=0.04) and a positive one between claudication pain time and physical function score (r=0.50; p=0.05). In conclusion, despite the relatively few patients in our study, these results suggest that OMT significantly improves endothelial function and functional performance in intermittent claudication patients along with benefits in quality of life. This novel treatment combined with drug and lifestyle modification might be an effective alternative to traditional training based on exercise.
Autonomic regulation of the heart has an important influence on the progression of HF. Although elevated sympathetic activity is associated with an adverse prognosis, a high level of parasympathetic activation confers cardioprotection by several potential mechanisms. These parasympathetic actions on the heart are mediated not only by the direct consequences of cardiac muscarinic receptor stimulation but also by a multitude of indirect mechanisms. Direct vagus nerve stimulation has only recently been investigated in human subjects with HF and could provide new insights into how parasympathetic activation affects disease progression and clinical outcomes.
The objective of this clinical study was to establish normal values for volumetric blood flow in the leg at rest using Doppler ultrasound, and to determine what biophysical factors influence resting volumetric flow. Arterial blood flow was measured at four sites in the legs of 40 healthy subjects using an ATL Ultramark 9 HDI system. All subjects were nonhypertensive nonsmokers with ankle brachial index values greater than 1 and no history of vascular disease. The subjects, 20 of each gender, in age ranging from 20 to 64 y were examined. Blood flow was calculated from the time-averaged, intensity-weighted mean velocity Doppler waveforms and vessel cross-sectional area at the same site. Thigh and calf circumference measurements were used to estimate muscle masses. The mean flow and standard error measured in four arteries in the leg were: 284+/-21 mL/min in the common femoral (CFA); 152+/-10 mL/min in the superficial femoral (SFA); 72+/-5 mL/min in the popliteal; and 3+/-1 mL/min in the dorsalis pedis. Although women tended to have higher time-averaged mean velocities in the CFA and SFA than men (t-test, p < 0.008), their arterial cross-sectional areas tended to be smaller (t-test, p < 0.004) and no statistically significant difference was found between men and women in volumetric flow at any site. No correlation was found between age, weight, height, muscle mass and volumetric flow at all four sites. These estimates of lower extremity volumetric flow in healthy subjects provide a baseline for future studies of flow rates in patients with vascular disease.
The study was conducted to determine if the capillary density of skeletal muscle is a potential contributor to exercise intolerance in class II-III chronic heart failure (CHF).
Previous studies suggest that abnormalities in skeletal muscle histology, contractile protein content and enzymology contribute to exercise intolerance in CHF.
The present study examined skeletal muscle biopsies from 22 male patients with CHF compared with 10 age-matched normal male control patients. Aerobic capacities, myosin heavy chain (MHC) isoforms, enzymes, and capillary density were measured.
The patients with CHF demonstrated a reduced peak oxygen consumption when compared to controls (15.0+/-2.5 vs. 19.8+/-5.0 ml x kg(-1) x min(-1), p <0.05). Using cell-specific antibodies to directly assess vascular density, there was a reduction in capillary density in CHF measured as the number of endothelial cells/fiber (1.42+/-0.28 vs. 1.74+/-0.35, p = 0.02). In CHF, capillary density was inversely related to maximal oxygen consumption (r = 0.479, p = 0.02). The MHC IIx isoform was found to be higher in patients with CHF versus normal subjects (28.5+/-13.6 vs. 19.5+/-9.4, p <0.05).
There was a significant reduction in microvascular density in patients with CHF compared with the control group, without major differences in other usual histologic and biochemical aerobic markers. The inverse relationship with peak oxygen consumption seen in the CHF group suggests that a reduction in microvascular density of skeletal muscle may precede other skeletal muscle alterations and play a critical role in the exercise intolerance characteristic of patients with CHF.
Endothelial function is thought to be an important factor in the pathogenesis of atherosclerosis, hypertension and heart failure. In the 1990s, high-frequency ultrasonographic imaging of the brachial artery to assess endothelium-dependent flow-mediated vasodilation (FMD) was developed. The technique provokes the release of nitric oxide, resulting in vasodilation that can be quantitated as an index of vasomotor function. The noninvasive nature of the technique allows repeated measurements over time to study the effectiveness of various interventions that may affect vascular health. However, despite its widespread use, there are technical and interpretive limitations of this technique. State-of-the-art information is presented and insights are provided into the strengths and limitations of high-resolution ultrasonography of the brachial artery to evaluate vasomotor function, with guidelines for its research application in the study of endothelial physiology.
Although duplex Doppler ultrasonography has been used widely, it still is unknown whether resistive index could be related directly to vascular or tubulointerstitial changes in the kidney.
Thirty-three patients who underwent renal biopsy were included in the present study. Clinical data, including sex; age; time from abnormal urinalysis result to biopsy; serum creatinine level; creatinine clearance; urinary excretion of protein, N-acetyl-beta-glucosaminidase, and urinary beta2-microglobulin; and presence of hypertension, were recorded at biopsy. Histopathologic data, including glomerular sclerosis, interstitial fibrosis/tubular atrophy, interstitial infiltration, and arteriolosclerosis, were evaluated separately by means of a quantitative or semiquantitative method. We examined whether resistive index at biopsy was related to these clinical and histopathologic parameters and, moreover, to renal outcome in patients followed up for more than 2 years.
Age, creatinine clearance, urinary beta2-microglobulin excretion, and all histopathologic parameters showed statistically significant correlations with resistive index. However, stepwise multiple regression analysis showed that only arteriolosclerosis was chosen as an independent risk factor for increased resistive index. During the follow-up period of 57.5 +/- 15.6 months in 29 patients, 8 patients (27.6%) had progression of renal impairment, defined as an increase in serum creatinine level greater than 50%. They had a significantly increased resistive index at biopsy compared with patients without progression.
We show a direct relationship between resistive index and arteriolosclerosis in damaged kidneys. Resistive index at renal biopsy may be useful as one of the prognostic markers for renal outcome.
This review examines the use of cardiac resynchronisation therapy (CRT) for chronic, severe, systolic heart failure. Left ventricular (LV) remodelling is the final common pathway of systolic heart failure and portends a poor prognosis. It is characterised by progressive LV dilatation, deterioration of ventricular contractile function and distortion of LV cavity shape. The LV remodelling process is triggered by prolonged pressure or volume overload, loss of contracting myocytes from myocardial infarction, genetic abnormalities of contractile proteins or exposure to cardiotoxic agents. Current therapeutic strategies for systolic heart failure aim to slow or halt the remodelling process. "Reverse remodelling" is a relatively new concept, where progressive LV dilatation and deterioration in contractile function are not simply arrested, but partially reversed. Cardiac resynchronisation therapy is a novel and effective treatment for systolic heart failure, and is associated with reverse remodelling of the LV.
Traditional explanations for the symptoms of fatigue and breathlessness experienced by patients with chronic heart failure (CHF) focus on how reduced cardiac output on exercise leads to impaired skeletal muscle blood supply, thus causing fatigue, and on how the requirement for a raised left ventricular filling pressure to maintain cardiac output results in reduced pulmonary diffusion owing to interstitial edema, thus causing breathlessness. However, indices of left ventricular function relate poorly to exercise capacity and symptoms, suggesting that the origin of symptoms may lie elsewhere. There is a specific heart failure myopathy that is present early in the condition which may contribute largely to the sensation of fatigue. Receptors present in skeletal muscle sensitive to work (ergoreceptors) are overactive in patients with CHF, presumably as a consequence of the myopathy, and their activity is related both to the ventilatory response to exercise and breathlessness, and to the sympathetic overactivity of CHF. In the present paper, we review the systemic consequences of left ventricular dysfunction to understand how they relate to the symptoms of heart failure.
To evaluate the sensitivity and specificity of Doppler ultrasound (DUS) in diagnosing arthritis in the wrist and hands, and, if possible, to define a cutoff level for our ultrasound measures for inflammation, resistive index (RI), and color fraction.
Using DUS, 88 patients with active RA were selected for study and 27 healthy controls. A total of 419 joints were examined. The synovial vascularization was determined by color Doppler and spectral Doppler estimating the color fraction (the percentage of color pixels inside the synovium was the region of interest) and RI in wrist, metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints. Receiver-operator characteristic (ROC) curves were made for both US measures. Cutoff levels were selected from the ROC curves as the values with the optimum sensitivity and specificity.
Analyses were carried out for small joints (MCP and PIP), wrists, and for all joints (pooled). Pooled joint analysis showed the area under the curve for both RI and color fraction was 0.84. The cutoff level for the color fraction was 0.01 and for RI 0.83. With these cutoff levels, the sensitivity and specificity for the color fraction were 0.92 and 0.73, respectively. For RI a sensitivity of 0.72 and specificity of 0.70 were found. Analysis of small joints and wrist gave very similar results.
DUS may detect vascularization of the inflamed synovium with a high sensitivity and a moderate specificity with selected cutoff levels.
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