John J. Votto

Venous hemodynamics of the lower extremities in response to electrical stimulation

OBJECTIVE To evaluate the calf muscle pump function using an air plethysmograph (APG) applied to the lower leg of subjects during three different tiptoe exercises. DESIGN A controlled trial design was selected to compare the hemodynamic effects of three exercise conditions on a group of able-bodied, healthy patients. SETTING Testing was performed in an outpatient clinic at a rehabilitation hospital. SUBJECTS Patient groups were selected from a convenience sample of 10 healthy volunteers with normal venous capacitance and no reflux, determined through impedance pleythysmography before the study. INTERVENTIONS Three exercise conditions undertaken by each subject consisted of loaded and unloaded lower leg muscle contractions produced by (1) voluntary contraction (VOL), (2) electrical stimulation of the gastocnemius-soleus and tibialis anterior muscles (ES), and (3) combined ES and VOL (ES/VOL). MAIN OUTCOME MEASURE Hemodynamic measurements of venous filling index upon standing from the supine (VFI), ejection fraction (EF), ejection volume (EV), residual volume (RV), and residual volume fraction (RVF) were recorded after each protocol. These results were used to compare the lower leg hemodynamic effects of the treatments. RESULTS Combined ES/VOL single tiptoe exercise produced the highest EV (97.8mL), followed by VOL (80.6mL) and ES (51.7mL) (p < .0008). The EF was also highest for combined ES/VOL (73.1%), followed by VOL (64.5%) and ES (37.8%) (p < .0001). Ten tiptoe ES exercises produced the highest RV (96.2mL), followed by ES/VOL (44.7mL) and VOL (28.2mL) (p < .0001). RVF was also highest in the ES group (71%), followed by ES/VOL (33.4%) and VOL (22.8%) (p < .0001). CONCLUSION Periodic single ES-induced calf muscle contractions produced significant muscle pump function and could be used to improve venous blood flow and reduce stasis in the lower leg. Continuous ES-induced contractions, on the other hand, could improve lower leg peripheral perfusion while eliciting the physiologic venous muscle pump. Higher RV and RVF after 10 ES-induced contractions in this sample of healthy subjects with normal VFI may be caused by an increase in arterial blood perfusion after repeated ES-induced contractions.

Short-Stay Comprehensive Inpatient Pulmonary Rehabilitation for Advanced Chronic Obstructive Pulmonary Disease

OBJECTIVE To evaluate the effectiveness of short-term, comprehensive inpatient pulmonary rehabilitation in severe chronic obstructive pulmonary disease (COPD). DESIGN Retrospective analysis of several outcome measures. SETTING Inpatient pulmonary rehabilitation unit. PARTICIPANTS Thirty-eight consecutive adult patients with advanced COPD referred to our inpatient pulmonary rehabilitation program between January 1 and December 31, 1994. All but one were referred from acute care hospitals. The mean forced expiratory volume in 1 second (FEV1) was .69L; 79% required supplemental oxygen. MAIN OUTCOME MEASURES (1) Discharge status; (2) timed walk, with measurements of distance and exertional dyspnea; and (3) functional status. RESULTS All patients were able to be discharged home after a mean length of stay of 9.9 days. The 12-minute walk distance increased by 66%, from 416 +/- 282 feet to 690 +/- 337 feet (p < .001). Dyspnea during the walk testing also improved: the resting score decreased from 2.87 to .97, the 6-minute score from 7.84 to 3.05, and postwalk score from 8.53 to 3.51 (all p < .001). All patients showed improvement in the Pulmonary Function Status Scale (PFSS), with the functional activities subsection increasing by 39%, the dyspnea score by 65%, and psychosocial score by 35% (all p < .001). CONCLUSION Short-term improvement in multiple areas can be accomplished with comprehensive pulmonary rehabilitation of short duration. This is particularly relevant to the current health care environment that dictates shorter in-hospital lengths of stay.

An analysis of clinical outcomes and costs of a long term acute care hospital.

Abstract Objective: Compare clinical outcomes and costs in a study group of long-term acute care hospital (LTCH) patients with a control group of LTCH-eligible patients in an acute care hospital. LTCHs were created to provide post-acute care services not available at other post-acute settings. This is based on the premise that these patients would otherwise have stayed at acute care hospitals as high-cost outliers. The LTCH hospital is intended to deliver care to patients more efficiently, however, there are little documented clinical and financial data regarding the comparative clinical outcomes and costs for patients. Methods: Retrospective medical and billing record review of patients from the following groups: (1) LTCH study comprising patients admitted directly from an acute care hospital to the study LTCH and discharged from the LTCH from September 2004 through August 2006; (2) a control group of LTCH-eligible, medically complex patients treated and discharged from an acute care hospital in FY 2002. The control group was selected from approximately 500 patients who had at least one of the ten most common principle diagnosis DRGs of the study LTCH with >30-day length of stay at the referring hospital and met NALTH admitting guidelines. Results: Discharge disposition is an important outcome measure of the quality of care of medically complex patients. The in-hospital mortality rate trended lower and home discharge was 3 times higher for the LTCH study group than for the control group. As a possible result, SNF discharge of LTCH patients was approximately half that of the control group. Both mean patient cost per day and mean total cost per patient were significantly higher in the control group than in the LTCH study group. Conclusions: The patients in the LTCH study group had both better clinical outcomes and lower cost of care than the control group.

Inhaled Sodium Pyruvate Improved FEV1 and Decreased Expired Breath Levels of Nitric Oxide in Patients with Chronic Obstructive Pulmonary Disease

Exogenously administered sodium pyruvate has a variety of biological effects including antioxidant/anti-inflammatory effects. Chronic obstructive pulmonary disease (COPD) is an inflammatory disease of the airways mediated in part by reactive oxygen species (ROS) and reactive nitrogen species (RNS). The current therapies for COPD have limited efficacy. This study was designed to test the safety and therapeutic efficacy of inhaled pyruvate in COPD patients. Subjects were randomized to receive either sodium pyruvate or placebo three times per day over a 6-week period. Long-term efficacy was evaluated by spirometry and expired breath nitric oxide (NO) levels taken at baseline, 3 days, 1 week, 2 weeks, 4 weeks, and 6 weeks. In addition, acute assessments (1 h pre- and 1 h postinhalation of compound) were made at day 0 and at 4 weeks. Subjects receiving inhaled pyruvate showed significant (p < 0.02) improvement of approximately 11% in forced expiratory volume in 1 sec (FEV(1)) at 6 weeks, whereas subjects receiving placebo did not. The inhalation of pyruvate or placebo had no significant effect on expired breath NO levels at any of the long-term outcome time points; measurements were made 12 h after the last inhalation of the compound. In contrast, acute assessments (1 h pre-and 1 h postinhalation of compound) of expired breath NO made at 4 weeks demonstrated that inhalation of pyruvate resulted in a significant (p </= 0.01) decrease (-22.7 +/- 6%) in expired breath NO compared to placebo (5.0 +/- 7%). Inhalation of pyruvate was well tolerated and was associated with improvement in FEV(1) and expired breath NO, and was considered clinically important in COPD. These beneficial effects of inhaled pyruvate in COPD may be optimized with adjustments in both dose and length of treatment.