Functional improvements of patients admitted to an inpatient rehabilitation facility after bilateral lung transplant due to severe COVID-19 pulmonary disease.

BACKGROUND: Coronavirus disease (COVID-19) has introduced a new subset of patients with acute end-stage lung damage for which lung transplantation has been successfully performed. OBJECTIVE: To describe the inpatient rehabilitation course of patients who underwent bilateral lung transplant due to severe COVID-19 pulmonary disease. DESIGN: Retrospective chart review. SETTING: Free-standing, academic, urban inpatient rehabilitation hospital. PARTICIPANTS: Seventeen patients aged 28-67 years old (mean 53.9 ± 10.7) who developed COVID-19 respiratory failure and underwent bilateral lung transplant. INTERVENTIONS: Patients participated in a comprehensive inpatient rehabilitation program including physical, occupational, and speech therapy tailored to the unique functional needs of each individual. MAIN OUTCOME MEASURES: Primary outcome measures of functional improvements, include mobility and self-care scores on section GG of the Functional Abilities and Goals of the Improving Post-Acute Care Transformation Act, as defined as quality measures by the Centers for Medicare and Medicaid Services. Other functional measures included 6 minute walk test, Berg balance scale, Mann Assessment of Swallowing Ability (MASA), and Cognition and Memory Functional Independence Measure (FIM) scores. Wilcoxon signed rank sum test was used to evaluate statistical significance of change between admission and discharge scores. RESULTS: Fourteen patients completed inpatient rehabilitation. Self-care (GG0130) mean score improved from 20.9 to 36.1. Mobility (GG0170) mean score improved from 30.7 to 70.7. Mean 6-minute walk distance improved from 174.1 to 467.6 feet. Mean Berg balance scores improved from 18.6/56 to 36.3/56. MASA scores improved from 171.3 to 182.3. All functional measures demonstrated statistically significant improvements with p value ≤ .008, except for cognition and memory FIM scores, which did not show a statistically significant difference. A majority (76%) of patients discharged home. CONCLUSION: This new and unique patient population can successfully participate in a comprehensive inpatient rehabilitation program and achieve functional improvements despite medical complications.

Outcomes of Acute Inpatient Rehabilitation of Patients With Left Ventricular Assist Devices and Subsequent Stroke.

OBJECTIVE: The aim of the study was to examine the functional outcomes and medical complications of patients with left ventricular assist device implantation and subsequent stroke during comprehensive inpatient rehabilitation. DESIGN: Retrospective cohort study of 21 patients admitted to an inpatient rehabilitation facility between 2009 and 2015. Main outcome measurements include admission and discharge Functional Independence Measure, length of stay, and Functional Independence Measure efficiency. RESULTS: The study included 17 male and 4 female patients aged 32-75 yrs. Eleven patients (52%) required transfer to an acute care hospital for evaluation. Fifteen patients completed inpatient rehabilitation with median [interquartile range] length of stay 26 [13.5-34] days (range = 7-59 days), median [interquartile range] Functional Independence Measure gain of 18 [12.5-32], and median [interquartile range] Functional Independence Measure efficiency of 1.0 [0.6-1.44]. Patients who required transfer to acute care during their course but ultimately completed inpatient rehabilitation (n = 5) demonstrated larger median [interquartile range] Functional Independence Measure gain (40 [23-42]) and longer median [interquartile range] length of stay (35 [35-42]) compared with patients who completed inpatient rehabilitation without transfer (Functional Independence Measure gain = 15 [9.25-26.5]; length of stay = 14.5 [11.5-26.25]). CONCLUSIONS: Patients with left ventricular assist device implantation and subsequent stroke demonstrate functional gains during acute inpatient rehabilitation programs. A large percent of patients required transfer to acute care.

Presenting characteristics of patients undergoing cardiac troponin measurements in the emergency department.

INTRODUCTION: Not all patients with suspected acute coronary syndrome (ACS) receiving cardiac troponin (cTn) testing present to the emergency department (ED) with cardiac chest pain. Since elderly patients (age ≥70) have increased morbidity and mortality associated with ACS, complaints other than cardiac chest pain may justify cTn testing. Our primary objective was to characterize the population of ED patients who receive cTn testing. The secondary objective was to determine if elderly patients underwent cTn testing for different presenting complaints than their younger counterparts. METHODS: We created an electronic database including Canadian Emergency Department Information Systems (CEDIS) presenting complaints, age, sex, disposition, and Canadian Triage Acuity Scale (CTAS) score, for patients who received cTn testing in three Canadian EDs during 2011. We analyzed the data for patient characteristics and sorted by age (<70 and ≥70) for further analysis. RESULTS: In the 15,824 included patients, the average age was 66 (51%<70; 51% female). The most common presenting complaints were cardiac chest pain (n=3,267) and shortness of breath (n=2,266). The elderly underwent cTn testing for significantly (p<0.0001) different complaints than their younger counterparts. They more commonly presented with generalized weakness (n=898), whereas younger patients more frequently had abdominal pain (n=576). CONCLUSIONS: Cardiac chest pain and shortness of breath are presenting complaints in one-third of patients undergoing ED cTn testing. The majority of patients undergoing cTn testing did not have typical ACS symptoms. Half of all cTn testing in the ED is on the elderly, who present with different complaints than their younger counterparts.

Prior heat stress: effect on subsequent 15-min time trial performance in the heat.

UNLABELLED: The impact of prior heat stress on subsequent aerobic exercise-heat performance has not been studied. PURPOSE: To determine whether prior heat stress degrades subsequent aerobic exercise performance in the heat. METHODS: Eighteen nonheat acclimated males were trained (four practice trials) on an aerobic exercise performance test in 22 degrees C and then divided into two (n = 8) groups. One group (EUHPH; (.)VO2peak = 44 +/- 7 mL x kg x min(-1)) was tested after 90 min of recovery (in 22 degrees C) from 3 h of intermittent light-intensity (<30% (.)VO2peak) exercise-heat (50 degrees C) stress, where sweat losses were matched with fluid intake (3.5 +/- 0.5 L) to maintain euhydration. The other group (EUH; (.)VO2peak = 45 +/- 5 mL x kg x min(-1)) was tested while euhydrated without prior exercise-heat stress. Aerobic performance was determined from a 30-min cycling preload (50% (.)VO2peak) followed by a 15-min time trial in 40 degrees C. Total work during the 15-min performance time trial in EUH and EUHPH was compared, as were the percent changes from the best practice trials. RESULTS: Volunteers were euhydrated (plasma osmolality < 290 mOsm x kg(-1)) and normothermic before each exercise-heat trial. Heart rate and core temperature were not different (P > 0.05) between groups at any time point during exercise. Total work was not different (P > 0.05) at baseline or between EUH (150.5 +/- 28.3 kJ; 2.0 +/- 0.3 kJ x kg(-1)) and EUHPH (160.3 +/- 24.0 kJ; 1.8 +/- 0.2 kJ x kg(-1)). The percent change in total work relative to baseline was not different (P > 0.05) between EUH (-18.7% +/- 9.2%) and EUHPH (-15.0% +/- 7.8%). CONCLUSIONS: If hydration and body temperatures recover, prior exercise-heat stress does not result in a greater degradation in aerobic time trial performance in the heat compared with heat exposure alone.

Influence of sensor ingestion timing on consistency of temperature measures.

PURPOSE: The validity and the reliability of using intestinal temperature (T int) via ingestible temperature sensors (ITS) to measure core body temperature have been demonstrated. However, the effect of elapsed time between ITS ingestion and T int measurement has not been thoroughly studied. METHODS: Eight volunteers (six men and two women) swallowed ITS 5 h (ITS-5) and 29 h (ITS-29) before 4 h of varying intensity activity. T int was measured simultaneously from both ITS, and T int differences between the ITS-5 and the ITS-29 over the 4 h of activity were plotted and compared relative to a meaningful threshold of acceptance (+/-0.25 degrees C). The percentage of time in which the differences between paired ITS (ITS-5 vs ITS-29) were greater than or less than the threshold of acceptance was calculated. RESULTS: T int values showed no systematic bias, were normally distributed, and ranged from 36.94 degrees C to 39.24 degrees C. The maximum T int difference between paired ITS was 0.83 degrees C with a minimum difference of 0.00 degrees C. The typical magnitude of the differences (SE of the estimate) was 0.24 degrees C, and these differences were uniform across the entire range of observed temperatures. Paired T int measures fell outside of the threshold of acceptance 43.8% of the time during the 4 h of activity. CONCLUSIONS: The differences between ITS-5 and ITS-29 were larger than the threshold of acceptance during a substantial portion of the observed 4-h activity period. Ingesting an ITS more than 5 h before activity will not completely eliminate confounding factors but may improve accuracy and consistency of core body temperature.

Serum S-100beta response to exercise-heat strain before and after acclimation.

UNLABELLED: Exercise alone or in combination with environmental heat stress can elevate blood S-100beta protein concentrations. However, the explanatory power of exercise with marked environmental heat stress on the appearance of S-100beta is questionable. It is possible that the process of heat acclimation might afford additional insight. PURPOSE: Determine the S-100beta response to moderate-intensity exercise with heat strain before and after heat acclimation. METHODS: Nine healthy male volunteers completed 10 consecutive days of heat acclimation consisting of up to 100 min of treadmill walking (1.56 m x s(-1), 4% grade) in the heat (45 degrees C, 20% relative humidity). Changes in HR, rectal temperature (T(re)), and sweat rate (SR) were examined to determine successful acclimation. Area under the curve (AUC) for T(re) greater than 38.5 degrees C was calculated to assess cumulative hyperthermia. Blood samples were taken before and after exercise on days 1 and 10 and were analyzed for serum osmolality and S-100beta concentration. RESULTS: All subjects displayed physiological adaptations to heat acclimation including a significant (P < 0.05) reduction in final HR (161 to 145 bpm) and T(re) (39.0 to 38.4 degrees C), as well as a modest (approximately 10%) increase in SR (1.10 to 1.20 L x h(-1); P = 0.09). No differences were observed in pre- to postexercise serum S-100beta concentrations on day 1 or 10, and no differences were observed in S-100beta values between days 1 and 10. No significant correlations were found between S-100beta values and any variable of interest. CONCLUSIONS: S-100beta concentrations do not necessarily increase in response to exercise-heat strain, and no effect of heat acclimation on S-100beta could be observed despite other quantifiable physiological adaptations.

Efficacy of body ventilation system for reducing strain in warm and hot climates.

This study determined whether a torso-vest forced ambient air body ventilation system (BVS) reduced physiological strain during exercise-heat stress. Seven heat-acclimated volunteers attempted nine, 2-h treadmill walks at 200 W m(-2) in three environments, -40 degrees C, 20% rh (HD), 35 degrees C, 75% rh (HW), and 30 degrees C, 50% rh, (WW) wearing the Army Combat Uniform, interceptor body armor (IBA) and Kevlar helmet. Three trials in each environment were BVS turned on (BVS(On)), BVS turned off (BVS(Off)), and no BVS (IBA). In HD, BVS(On) significantly lowered core temperature (T (re)), heart rate (HR), mean skin temperature (T (sk)), mean torso skin temperature (T (torso)), thermal sensation (TS), heat storage (S), and physiological strain index (PSI), versus BVS(Off) and IBA (P < 0.05). For HW (n = 6), analyses were possible only through 60 min. Exercise tolerance time (min) during HW was significantly longer for BVS(On) (116 +/- 10 min) versus BVS(Off) (95 +/- 22 min) and IBA (96 +/- 18 min) (P < 0.05). During HW, BVS(On) lowered HR at 60 min versus IBA, T (sk) from 30 to 60 min versus BVS(Off) and IBA, and PSI from 45 to 60 min versus BVS(Off) and at 60 min versus IBA (P < 0.05). BVS(On) changes in T (re) and HR were lower in HD and HW. During WW, BVS(On) significantly lowered HR, T (sk), and T (torso) versus BVS(Off) and IBA (P < 0.05) during late exercise. Sweating rates were significantly lower for BVS(On) versus BVS(Off) and IBA in both HD and WW (P < 0.05), but not HW. These results indicate that BVS(On) reduces physiological strain in all three environments by a similar amount; however, in hot-dry conditions the BVS(Off) increases physiological strain.

Impact of a protective vest and spacer garment on exercise-heat strain.

Protective vests worn by global security personnel, and weighted vests worn by athletes, may increase physiological strain due to added load, increased clothing insulation and vapor resistance. The impact of protective vest clothing properties on physiological strain, and the potential of a spacer garment to reduce physiological strain, was examined. Eleven men performed 3 trials of intermittent treadmill walking over 4 h in a hot, dry environment (35 degrees C, 30% rh). Volunteers wore the US Army battledress uniform (trial B), B + protective vest (trial P), and B + P + spacer garment (trial S). Biophysical clothing properties were determined and found similar to many law enforcement, industry, and sports ensembles. Physiological measurements included core (T (c)), mean skin (T (sk)) and chest (T (chest)) temperatures, heart rate (HR), and sweating rate (SR). The independent impact of clothing was determined by equating metabolic rate in all trials. In trial P, HR was +7 b/min higher after 1 h of exercise and +19 b/min by the fourth hour compared to B (P < 0.05). T (c) (+0.30 degrees C), T (sk) (+1.0 degrees C) and Physiological Strain Index were all higher in P than B (P < 0.05). S did not abate these effects except to reduce T (sk) (P > S) via a lower T (chest) (-0.40 degrees C) (P < 0.05). SR was higher (P < 0.05) in P and S versus B, but the magnitude of differences was small. A protective vest increases physiological strain independent of added load, while a spacer garment does not alter this outcome.

Evaluation of the limits to accurate sweat loss prediction during prolonged exercise.

Sweat prediction equations are often used outside their boundaries to estimate fluid requirements and generate guidance. The limitations associated with these generalized predictions have not been characterized. The purposes of this study were to: (1) evaluate the accuracy of a widely used sweat prediction equation (SHAP) when widening it's boundaries to include cooler environments (2 h) and very prolonged exercise (8 h), (2) determine the independent impact of holding skin temperature constant (SHAP36), and (3) describe how adjustments for non-sweat losses (NSL) and clothing saturation dynamics affect prediction accuracy. Water balance was measured in 39 volunteers during 15 trials that included intermittent treadmill walking for 2 h (300-600 W, 15-30 degrees C; n=21) or 8 h (300-420 W, 20-40 degrees C; n=18). Equation accuracy was assessed by comparing actual and predicted sweating rates (211 observations) using least-squares regression. Mean and 95% confidence intervals for group differences were compared against a zone of indifference (+/-0.125 l/h). Sweating rate variance accounted for by SHAP and SHAP36 was always high (r2>0.70), while the standard error of the estimate was small and uniform around the line of best fit. SHAP errors were >0.125 l/h during 2 and 8 h of exercise. SHAP36 errors were <0.125 l/h for 2 h conditions but were higher at 8 h in three of the six warmest trials. Adjustments for NSL and clothing saturation dynamics help explain SHAP errors at 2 and 8 h, respectively. These results provide a basis for future development of accurate algorithms with broader utility.