Exacerbated hemodynamic response during exercise in cancer patients prior to autologous hematopoietic stem cell transplantation.

PURPOSE: Chemotherapy treatment can lead to cardiovascular toxicity and physical impairment prior to autologous hematopoietic stem cell transplantation (auto-HSCT). Cardiovascular adjustments during exercise and the exercise capacity remain unknown in patients prior to auto-HSCT. Thus, the hemodynamic responses during exercise and exercise capacity were evaluated using a novel effort test in patients prior to auto-HSCT. METHODS: Thirty patients prior to auto-HSCT (BMT group: 44.6 ± 14.1 years) and 23 control participants (CON group: 43.9 ± 16.6 years) performed the 6-Minute Step Test (6MST) to assess their exercise capacity and the hemodynamic responses during exercise. Systolic and diastolic blood pressure (SBP and DBP), heart rate (HR), and oxygen saturation (SpO2) were measured during the test. Rate-pressure product (RPP) was calculated multiplying SBP by HR. The highest HR value recorded during the test was compared with the maximum HR predicted by age and was used as % of maximum HR (%HRmax). RESULTS: The number of steps up and down performed by the BMT group was lower than CON (108.8 ± 25.3 vs. 127.5 ± 34.4 steps, P = 0.02). The BMT group showed a higher magnitude of increase in SBP and RPP during the 6MST when compared to CON (ΔSBP: 18.5 ± 11.45 vs. 8.30 ± 18.46 mmHg, P = 0.01; and ΔRPP: 8197.3 ± 3829.1 vs. 6170.9 ± 3568.9 mmHg beats min-1, P = 0.05). The BMT group exhibited higher SpO2 and HR values throughout the protocol (P < 0.05), reaching a higher %HRmax than CON group (76.9 ± 9.6 vs. 66.4 ± 8.9%, P < 0.01). CONCLUSIONS: Patients with indication for auto-HSCT have exacerbated chronotropic and pressor responses during exercise and reduced exercise capacity in the 6MST.

Safety and feasibility of inspiratory muscle training for hospitalized patients undergoing hematopoietic stem cell transplantation: a randomized controlled study.

PURPOSE: Patients undergoing hematopoietic stem cell transplantation (HSCT) usually experienced respiratory muscle weakness. Inspiratory muscle training (IMT) at HSCT has not been studied yet. Thus, it is important to evaluate the safety, feasibility, and preliminary effectiveness of IMT for hospitalized patients undergoing HSCT with an unstable and acute clinical condition. METHODS: This is a randomized controlled feasibility study. Thirty-one hospitalized patients undergoing HSCT were randomized to the conventional physical rehabilitation (CON) or to the IMT group (conventional physical rehabilitation + IMT). IMT was carried out at 40% of maximal inspiratory pressure (MIP), 5 sessions weekly, 10-20 min/session. Primary outcomes were safety and feasibility (recruitment, adherence, and attrition rates) of IMT. Secondary outcomes were respiratory strength, respiratory rate, oxygen saturation, and frequency of patients with oxygen desaturation, bleeding, dyspnea, and acute pulmonary edema. RESULTS: Patients were allocated to the IMT (N = 15; 43.6 years) or to the CON group (N = 16; 46.6 years). The recruitment rate was 100%, the adherence rate was 91%, and attrition was 13% to IMT. Two events were observed in 126 IMT sessions (1.5%). MIP increased in the IMT group (P < 0.01). No differences were observed in respiratory rate and oxygen saturation between groups. Trends to negative outcomes were observed in the CON in comparison to IMT group for a need of oxygen therapy (18% vs. 6%), bleeding (12% vs. 6%), dyspnea (25% vs. 13%), and acute pulmonary edema (6% vs. 0%). CONCLUSIONS: IMT is safe, feasible, and improves the inspiratory muscle strength in hospitalized patients undergoing HSCT. TRIAL REGISTRATION: Clinical trial registration: NCT03373526.

Baroreflex gain and vasomotor sympathetic modulation in resistant hypertension.

PURPOSE: The aim of this study was to determine the gain and latency of arterial baroreflex control of heart rate in patients with resistant hypertension compared to patients with essential hypertension and normotensive subjects. METHODS: Eighteen patients with resistant hypertension (56 ± 10 years, mean of four antihypertensive drugs), 17 patients with essential hypertension (56 ± 11 years, mean of two antihypertensive drugs), and 17 untreated normotensive controls (50 ± 15 years) were evaluated by spectral analysis of the spontaneous fluctuations of arterial pressure (beat-to-beat) and heart rate (ECG). This analysis estimated vasomotor and cardiac autonomic modulations, respectively. The transfer function analysis quantified the gain and latency of the response of output signal (RR interval) per unit of spontaneous change of input signal (systolic arterial pressure). RESULTS: The gain was similarly lower in patients with resistant hypertension and patients with essential hypertension in relation to normotensive subjects (4.67 ± 2.96 vs. 6.60 ± 3.30 vs. 12.56 ± 8.81 ms/mmHg; P < 0.01, respectively). However, the latency of arterial baroreflex control of heart rate was significantly higher only in patients with resistant hypertension when compared to patients with essential hypertension and normotensive subjects (-4.01 ± 3.19 vs. -2.91 ± 2.10 vs. -1.82 ± 1.09 s; P = 0.04, respectively). In addition, the index of vasomotor sympathetic modulation was significantly increased only in patients with resistant hypertension when compared to patients with essential hypertension and normotensive subjects (4.04 ± 2.86 vs. 2.65 ± 1.88 vs. 2.06 ± 1.70 mmHg2; P < 0.01, respectively). CONCLUSIONS: Patients with resistant hypertension have reduced gain and increased latency of arterial baroreflex control of heart rate. These patients also have increased vasomotor sympathetic modulation.

High-dose Chemotherapy Impairs Cardiac Autonomic Control of Hospitalized Cancer Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation.

BACKGROUND: Autologous hematopoietic stem cell transplantation (HSCT) patients have intermediary and late cardiac autonomic dysfunction, which is an independent mortality predictor. However, it is unknown when this HSCT-related autonomic dysfunction begins during hospitalization for HSCT and whether cardiac autonomic control (CAC) is related to cardiotoxicity in these patients. PATIENTS AND METHODS: CAC was assessed in 36 autologous-HSCT inpatients (HSCT group) and 23 cancer-free outpatients (CON group) using heart rate variability analysis. The HSCT group was assessed at five time-points from admission to hospital discharge during hospitalization period. The CON group was assessed once. The severity of cardiotoxicity (CTCAE 5.0) and cardiac troponin I were recorded. RESULTS: The CAC was significantly reduced after high-dose chemotherapy (HDC) (reduction of MNN, SDNN, RMSSD, LFms2 and HFnu, and increase of LFnu and LF/HF; P<0.05). At the onset of neutropenia, pNN50 and HFms2 were also reduced (P<0.05) compared to the admission ones. Although both groups were similar regarding CAC at hospital admission, the HSCT patients showed impaired CAC at hospital discharge (P<0.05). The LF/HF was positively associated with cardiac troponin I and RMSSD was inversely associated with the severity of cardiotoxicity (P≤0.05). CONCLUSION: CAC worsened during hospitalization for autologous-HSCT, mainly after HDC. In addition, it seems associated to early signs of cardiotoxicity in these patients.

Embedding Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease in the Home and Community Setting: A Rapid Review.

This paper presents a rapid review of the literature for the components, benefits, barriers, and facilitators of pulmonary rehabilitation for chronic obstructive pulmonary disease (COPD) people in-home and community-based settings. seventy-six studies were included: 57 home-based pulmonary rehabilitation (HBPR) studies and 19 community-based pulmonary rehabilitation (CBPR) studies. The benefits of HBPR on exercise capacity and health-related quality of life were observed in one-group studies, studies comparing HBPR to usual care, and studies comparing to hospital-based pulmonary rehabilitation, although the benefits were less pronounced in the latter. HBPR reduced hospital admissions compared to usual care and was more cost-effective than hospital pulmonary rehabilitation. Most HBPRs were designed with low-density or customized equipment, are minimally supervised, and have a low intensity of training. Although the HBPR has flexibility and no travel burden, participants with severe disease, physical frailty, and complex comorbidities had barriers to complying with HBPR. The telerehabilitation program, a facilitator for HBPR, is feasible and safe. CBPR was offered in-person supervision, despite being limited to physical therapists in most studies. Benefits in exercise capacity were shown in almost all studies, but the improvement in health-related quality of life was controversial. Patients reported the benefits that facilities where they attended the CBPR including social support and the presence of an instructor. They also reported barriers, such as poor physical condition, transport difficulties, and family commitments. Despite the minimal infrastructure offered, HBPR and CBPR are feasible, safe, and provide clinical benefits to patients with COPD. Home and community settings are excellent opportunities to expand the offer of pulmonary rehabilitation programs, as long as they follow protocols that ensure quality and safety following current guidelines.

Functional Capacity Change Impacts the Quality of Life of Hospitalized Patients Undergoing Hematopoietic Stem Cell Transplantation.

OBJECTIVE: The aim of the study was to compare the quality of life (QOL) of patients undergoing hematopoietic stem cell transplantation who improved their functional capacity during hospitalization (increased functional capacity group) with that of patients who maintained or decreased functional capacity during hospitalization (decreased functional capacity group). DESIGN: This observational, longitudinal study included 27 hospitalized patients undergoing hematopoietic stem cell transplantation. Patients were divided into increased functional capacity group (16 patients) and decreased functional capacity group (11 patients). Functional capacity (6-min step test), peripheral muscle strength (sit-to-stand test and handgrip strength), and QOL (European Organization for Research and Treatment of Cancer) were assessed at admission and at hospital discharge. RESULTS: Increased functional capacity patients had increased functional capacity and peripheral muscle strength of the lower and upper limbs at hospital discharge (P < 0.01, <0.01, and 0.02, respectively). The patients in the increased functional capacity group demonstrated an increase in global health and reduced symptoms at discharge (P = 0.02 and 0.03, respectively). No significant differences were observed between groups in the functional domain. CONCLUSIONS: Patients undergoing hematopoietic stem cell transplantation, who have improved functional capacity at discharge, also experience an improved QOL, with no such improvement noted among patients who have stable or reduced functional capacity. We recommend that the treatment protocol for hospitalized patients undergoing hematopoietic stem cell transplantation include an exercise program aimed at improving functional capacity.