Richard Crevenna

MuSCLE WASTING IN INTENSIVE CARE PATIENTS: uLTRASouND oBSERVATIoN oF THE M. QuADRICEPS FEMoRIS MuSCLE LAYER

OBJECTIVE Patients in intensive care exhibit a high degree of loss of muscle mass. Appropriate instruments are needed to document muscle wasting in these patients. The aim of this pilot study was to describe muscle wasting in patients in the intensive care unit. DESIGN Two-fold study setting: prospective longitudinal and cross-sectional single-blind. PATIENTS A total of 118 patients in the intensive care unit (length of stay 1-98 days; male:female ratio 88:30; age 55 +/- 17 years) were included in a two-fold study setting. METHODS Muscle layer thickness of the M. quadriceps femoris was documented using ultrasound measurement at well-defined points. Seventeen pilot-patients were measured twice; at baseline and after 28 days. In another group of 101 patients, muscle layer thickness was determined once after a random length of stay. The results of both groups were compared and correlated. RESULTS In both groups, M. quadriceps femoris thickness showed a significant negative correlation with length of stay in the intensive care unit (p < 0.01). Furthermore, muscle wasting in intensive care patients could be described using a logarithmic function. CONCLUSION Loss of muscle mass shows a negative correlation with length of stay, and seems to be higher during the first 2-3 weeks of immobilization/intensive care unit stay. Ultrasound is a valid and practical measurement tool for documenting muscle mass (e.g. muscle layer thickness) as part of the daily routine at an intensive care unit.

Muscle strength as a predictor of long‐term survival in severe congestive heart failure

The objective of the study was to test the relationship between isolated muscle strength and outcome, and its significance in the context of other exercise variables.

Sleep attacks in patients taking dopamine agonists: review

Abstract Objectives: To assess the evidence for the existence and prevalence of sleep attacks in patients taking dopamine agonists for Parkinsons disease, the type of drugs implicated, and strategies for prevention and treatment. Design: Review of publications between July 1999 and May 2001 in which sleep attacks or narcoleptic-like attacks were discussed in patients with Parkinsons disease. Results: 124 patients with sleep events were found in 20 publications. Overall, 6.6% of patients taking dopamine agonists who attended movement disorder centres had sleep events. Men were over-represented. Sleep events occurred at both high and low doses of the drugs, with different durations of treatment (0-20 years), and with or without preceding signs of tiredness. Sleep attacks are a class effect, having been found in patients taking the following dopamine agonists: levodopa (monotherapy in 8 patients), ergot agonists (apomorphine in 2 patients, bromocriptine in 13, cabergoline in 1, lisuride or piribedil in 23, pergolide in 5,) and non-ergot agonists (pramipexole in 32, ropinirole in 38). Reports suggest two distinct types of events: those of sudden onset without warning and those of slow onset with prodrome drowsiness. Conclusion: Insufficient data are available to provide effective guidelines for prevention and treatment of sleep events in patients taking dopamine agonists for Parkinsons disease. Prospective population based studies are needed to provide this information.

Effects of neuromuscular electrical stimulation on muscle layer thickness of knee extensor muscles in intensive care unit patients: a pilot study.

OBJECTIVE It is known that patients in the intensive care unit show an enormous loss of muscle mass. Neuromuscular electrical stimulation is effective in enhancing strength and endurance in immobilized patients. The aim of this study was to evaluate the effects of neuromuscular electrical stimulation on muscle layer thickness of knee extensor muscles in intensive care unit patients. DESIGN Randomized, controlled, double-blind, pilot trial. PATIENTS Thirty-three patients, male to female ratio 26:7, mean age 55 years (standard deviation 15). METHODS After enrolment in the study, intensive care unit patients (main diagnoses: polytrauma, cardiovascular diseases, transplantation, pneumonia, cancer) were stratified (based on the length of their stay in hospital) into 2 groups: 17 acute patients (< 7 days) and 16 long-term patients (> 14 days). Both groups were randomized to a stimulation group or a sham-stimulation group. Neuromuscular electrical stimulation was applied to knee extensor muscles for a period of 4 weeks (session time 30-60 minutes, 5 days/week). Ultrasound measurements were performed before and after the stimulation period to quantify muscle layer thickness of knee extensor muscles. RESULTS Only stimulated long-term patients (+4.9%) showed a significant (p = 0.013) increase in muscle layer thickness compared with sham-stimulated patients (-3.2%). CONCLUSION Neuromuscular electrical stimulation appears to be a useful adjunct to revert muscle wasting in intensive care unit long-term patients; however, larger studies with a larger sample size are needed to confirm these promising, but preliminary, results.

Non-invasive neuromuscular electrical stimulation in patients with central nervous system lesions: an educational review.

The aim of this educational review is to provide an overview of the clinical application of transcutaneous electrical stimulation of the extremities in patients with upper motor neurone lesions. In general two methods of electrical stimulation can be distinguished: (i) therapeutic electrical stimulation, and (ii) functional electrical stimulation. Therapeutic electrical stimulation improves neuromuscular functional condition by strengthening muscles, increasing motor control, reducing spasticity, decreasing pain and increasing range of motion. Transcutaneous electrical stimulation may be used for neuromuscular electrical stimulation inducing repetitive muscle contraction, electromyography-triggered neuromuscular electrical stimulation, position-triggered electrical stimulation and subsensory or sensory transcutaneous electric stimulation. Functional electrical stimulation provokes muscle contraction and thereby produces a functionally useful movement during stimulation. In patients with spinal cord injuries or stroke, electrical upper limb neuroprostheses are applied to enhance upper limb and hand function, and electrical lower limb neuroprostheses are applied for restoration of standing and walking. For example, a dropped foot stimulator is used to trigger ankle dorsiflexion to restore gait function. A review of the literature and clinical experience of the use of therapeutic electrical stimulation as well as of functional electrical stimulation in combination with botulinum toxin, exercise therapy and/or splinting are presented. Although the evidence is limited we conclude that neuromuscular electrical stimulation in patients with central nervous system lesions can be an effective modality to improve function, and that combination with other treatments has an additive therapeutic effect.

PHYSICAL PERFORMANCE AND HEALTH-RELATED QUALITY OF LIFE IN MEN ON A LIVER TRANSPLANTATION WAITING LIST

Twenty-six men on a liver transplant waiting list (12 had alcoholic cirrhosis, 8 suffered from posthepatitic cirrhosis, and 6 from cirrhosis of other etiologies) were eligible for this observation. Nineteen subjects underwent exercise testing to determine oxygen uptake at anaerobic threshold. In all patients dynamometry was performed to determine isokinetic muscle strength of knee extensor muscles, and handgrip. Quality of life was evaluated in all patients with the MOS SF-36 questionnaire. Child-Pugh A patients showed 54 +/- 8%, Child-Pugh B patients 36 +/- 2%, and Child-Pugh C patients 31 +/- 4% of VO2 max predicted at the anaerobic threshold (Kruskal-Wallis ANOVA, p < 0.05). Isokinetic muscle strength of the quadriceps femoris (left/right) was 149 +/- 20/134 +/- 14 Nm in Child-Pugh A, 108 +/- 16/114 +/- 19 Nm in Child-Pugh B, and 89 +/- 10/81 +/- 11 Nm in Child-Pugh C patients (Kruskal-Wallis ANOVA, p < 0.05). MOS-SF36 revealed a Child-Pugh class dependent reduced functional status (Kruskal-Wallis ANOVA, p < 0.05). No significant differences in target parameters were found when analysed according to the etiology of cirrhosis. Patients on the liver transplant waiting list do have a stage dependent reduction in physical health. These data are the basis for longitudinal studies measuring the effects of preoperative rehabilitation programs in these patients.

AEROBIC CAPACITY, MUSCLE STRENGTH AND HEALTH-RELATED QUALITY OF LIFE BEFORE AND AFTER ORTHOTOPIC LIVER TRANSPLANTATION: PRELIMINARY DATA OF AN AUSTRIAN TRANSPLANTATION CENTRE

OBJECTIVE Patients before orthotopic liver transplantation usually show a reduced physical performance status, which impacts on their daily life and social participation. This pilot study aimed to evaluate endurance capacity, muscle strength, and quality of life before and after orthotopic liver transplantation in patients in an Austrian transplantation centre. SUBJECTS Fifteen patients (male/female = 10:5) were included in the pilot study. METHODS Exercise testing, strength testing of knee extensor muscles and of handgrip, and quality of life (SF-36 health survey) were assessed before and after orthotopic liver transplantation (after 1-2 months). RESULTS The oxygen uptake at the anaerobic threshold (VO2AT) and isokinetic strength testing of quadriceps femoris muscle did not change significantly from baseline, before transplantation to follow-up after orthotopic liver transplantation. Before orthotopic liver transplantation, quality of life was hampered concerning functional status, emotional role, vitality, and general health perception. Significant improvements of social functioning (p=0.032), vitality (p=0.006), mental health (p=0.004) and general health perception (p=0.002) could be found for this study population after orthotopic liver transplantation. CONCLUSION The results of this pilot study including a population of an Austrian transplantation centre indicate deficits of physical performance as well as reduced quality of life in patients before and after orthotopic liver transplantation.

Effect of ischemic preconditioning in skeletal muscle measured by functional magnetic resonance imaging and spectroscopy: a randomized crossover trial

BackgroundNuclear magnetic resonance (NMR) imaging and spectroscopy have been applied to assess skeletal muscle oxidative metabolism. Therefore, in-vivo NMR may enable the characterization of ischemia-reperfusion injury. The goal of this study was to evaluate whether NMR could detect the effects of ischemic preconditioning (IPC) in healthy subjects.MethodsTwenty-three participants were included in two randomized crossover protocols in which the effects of IPC were measured by NMR and muscle force assessments. Leg ischemia was administered for 20 minutes with or without a subsequent impaired reperfusion for 5 minutes (stenosis model). IPC was administered 4 or 48 hours prior to ischemia. Changes in 31phosphate NMR spectroscopy and blood oxygen level-dependent (BOLD) signals were recorded. 3-Tesla NMR data were compared to those obtained for isometric muscular strength.ResultsThe phosphocreatine (PCr) signal decreased robustly during ischemia and recovered rapidly during reperfusion. In contrast to PCr, the recovery of muscular strength was slow. During post-ischemic stenosis, PCr increased only slightly. The BOLD signal intensity decreased during ischemia, ischemic exercise and post-ischemic stenosis but increased during hyperemic reperfusion. IPC 4 hours prior to ischemia significantly increased the maximal PCr reperfusion signal and mitigated the peak BOLD signal during reperfusion.ConclusionsIschemic preconditioning positively influenced muscle metabolism during reperfusion; this resulted in an increase in PCr production and higher oxygen consumption, thereby mitigating the peak BOLD signal. In addition, an impairment of energy replenishment during the low-flow reperfusion was detected in this model. Thus, functional NMR is capable of characterizing changes in reperfusion and in therapeutic interventions in vivo.Trial RegistrationClinicalTrials.gov: NCT00883467

mTOR inhibition by everolimus counteracts VEGF induction by sunitinib and improves anti-tumor activity against gastric cancer in vivo.

VEGF receptor blockage has been reported to increase serum VEGF. We hypothesized that mTOR inhibition by everolimus counteracts VEGF induction by sunitinib resulting in an improved anti-tumor activity of sunitinib. In vitro, sunitinib in combination with everolimus did not outperform the respective monotherapies. In vivo, monotherapies reduced tumor growth by 60%, whereas the combination of sunitinib and everolimus led to an almost complete tumor growth inhibition. This superior anti-tumor activity coincided with attenuation of VEGF peaks. In conclusion mTOR inhibition by everolimus counteracts VEGF induction by sunitinib and results in significant reduction of tumor burden and long-lasting tumor growth control.

Extracorporeal shockwave treatment is effective in calcific tendonitis of the shoulder. A randomized controlled trial.

SummaryBackgroundCalcific tendonitis of the shoulder is often associated with chronic pain and impairment of function. Extracorporeal Shockwave therapy (ESWT) is considered to be a treatment option. We compared the effects of two different ESWT regimens.Methods43 patients (57 shoulders) with symptomatic calcific tendonitis of the shoulder for more than six months were included in a double-blinded study. Thirty-one shoulders were treated at the area of maximum pain with application of 2×2000 impulses of 0.28mJ/mm2 at an interval of two weeks (treatment group) and 26 shoulders with 2×2000 impulses of <0.07mJ/mm2 at an interval of two weeks (control group), without pretreatment analgesia. Shoulder function (Constant score) and pain (visual analogue scale, VAS) were assessed before treatment and at one week, three months and seven months after treatment. Shoulder X-rays were performed at the 3- and 7-month follow-up visits.ResultsImprovement in Constant score was significantly higher in the treatment group at all follow-up visits (p<0.05). Seven months post-treatment, calcifications dissolved completely in 19% of the treatment group and 8% of the control group, and a >50% reduction was observed in 19% and 8% respectively. With regard to reduction of pain, there was significant improvement in the treatment group compared with the control group at the 1-week follow-up (p<0.05). However, at the 3-month and 7-month visits, no significant between-group difference in pain could be detected.ConclusionAs applied, ESWT with an energy flux density of 0.28mJ/mm2 led to a significantly greater improvement in shoulder function and a slightly higher, nonsignificant, rate of > 50% disintegration of calcific deposits compared with the control group. However, this did not result in reduction of pain.