Effectiveness of exercise modalities on breast cancer patient outcomes: a systematic review and meta-analysis.

BACKGROUND: The effects of exercise in patients with breast cancer (BC), has shown some profit, but consistency and magnitude of benefit remains unclear. We aimed to conduct a meta-analysis to assess the benefits of varying types of exercises in patients with BC. METHODS: Literature search was conducted across five electronic databases (MEDLINE, Web of Science, Scopus, Google Scholar and Cochrane) from 1st January 2000 through 19th January 2024. Randomized controlled trials (RCTs) assessing the impact of different types of exercise on outcomes related to fitness and quality of life (QOL) in patients with BC were considered for inclusion. Outcomes of interest included cardiorespiratory fitness (CRF), health-related quality of life (HRQOL), muscle strength, fatigue and physical function. Evaluations were reported as mean differences (MDs) with 95% confidence intervals (CIs) and pooled using random effects model. A p value < 0.05 was considered significant. RESULTS: Thirty-one relevant articles were included in the final analysis. Exercise intervention did not significantly improved the CRF in patients with BC when compared with control according to treadmill ergometer scale (MD: 4.96; 95%Cl [-2.79, 12.70]; P = 0.21), however exercise significantly improved CRF according to cycle ergometer scales (MD 2.07; 95% Cl [1.03, 3.11]; P = 0.0001). Physical function was significantly improved as well in exercise group reported by 6-MWT scale (MD 80.72; 95% Cl [55.67, 105.77]; P < 0.00001). However, exercise did not significantly improve muscle strength assessed using the hand grip dynamometer (MD 0.55; 95% CI [-1.61, 2.71]; P = 0.62), and fatigue assessed using the MFI-20 (MD -0.09; 95% CI [-5.92, 5.74]; P = 0.98) and Revised Piper scales (MD -0.26; 95% CI [-1.06, 0.55] P = 0.53). Interestingly, exercise was found to improve HRQOL when assessed using the FACT-B scale (MD 8.57; 95% CI [4.53, 12.61]; P < 0.0001) but no significant improvements were noted with the EORTIC QLQ-C30 scale (MD 1.98; 95% CI [-1.43, 5.40]; P = 0.25). CONCLUSION: Overall exercise significantly improves the HRQOL, CRF and physical function in patients with BC. HRQOL was improved with all exercise types but the effects on CRF vary with cycle versus treadmill ergometer. Exercise failed to improve fatigue-related symptoms and muscle strength. Large RCTs are required to evaluate the effects of exercise in patients with BC in more detail.

Genotype and Phenotype of Transthyretin Cardiac Amyloidosis: THAOS (Transthyretin Amyloid Outcome Survey).

BACKGROUND: Transthyretin amyloidosis (ATTR) is a heterogeneous disorder with multiorgan involvement and a genetic or nongenetic basis. OBJECTIVES: The goal of this study was to describe ATTR in the United States by using data from the THAOS (Transthyretin Amyloidosis Outcomes Survey) registry. METHODS: Demographic, clinical, and genetic features of patients enrolled in the THAOS registry in the United States (n = 390) were compared with data from patients from other regions of the world (ROW) (n = 2,140). The focus was on the phenotypic expression and survival in the majority of U.S. subjects with valine-to-isoleucine substitution at position 122 (Val122Ile) (n = 91) and wild-type ATTR (n = 189). RESULTS: U.S. subjects are older (70 vs. 46 years), more often male (85.4% vs. 50.6%), and more often of African descent (25.4% vs. 0.5%) than the ROW. A significantly higher percentage of U.S. patients with ATTR amyloid seen at cardiology sites had wild-type disease than the ROW (50.5% vs. 26.2%). In the United States, 34 different mutations (n = 201) have been reported, with the most common being Val122Ile (n = 91; 45.3%) and Thr60Ala (n = 41; 20.4%). Overall, 91 (85%) of 107 patients with Val122Ile were from the United States, where Val122Ile subjects were younger and more often female and black than patients with wild-type disease, and had similar cardiac phenotype but a greater burden of neurologic symptoms (pain, numbness, tingling, and walking disability) and worse quality of life. Advancing age and lower mean arterial pressure, but not the presence of a transthyretin mutation, were independently associated with higher mortality from a multivariate analysis of survival. CONCLUSIONS: In the THAOS registry, ATTR in the United States is overwhelmingly a disorder of older adult male subjects with a cardiac-predominant phenotype. Val122Ile is the most common transthyretin mutation, and neurologic phenotypic expression differs between wild-type disease and Val122Ile, but survival from enrollment in THAOS does not. (Transthyretin-Associated Amyloidoses Outcome Survey [THAOS]; NCT00628745).

Initial description of cerebral oximetry measurement in heart failure patients.

Cerebral oximetry is a noninvasive technology using near-infrared spectroscopy (NIRS) to monitor regional cerebral tissue oxygen saturation (SctO(2)). NIRS has been widely used for assessing cerebral tissue oxygenation in a variety of populations including the fields of neonatology, anesthesiology, neurology, and cardiac surgery.However, little information has been reported on cerebral oximetry in heart failure (HF) patients. In this observational study, we enrolled 30 patients (15 men) aged 23 to 82 years (mean 67 years) with stage C HF. All patients had New York Heart Association (NYHA) functional class I to III. All patients were on stable HF medical therapy. SctO(2) measurements were recorded from the left and right forehead simultaneously, using FORE-SIGHT cerebral oximeter (CAS Medical Systems Inc, Branford, CT). Feasible associations with SctO(2) risk factors, known to correlate with HF, were recorded. The mean SctO(2) value was 67.4% (range, 47.6%-76.3%), while the mean peripheral tissue saturation (SpO(2)) was 97% (range, 92%-100%). The mean difference between cerebral and peripheral tissue oxygenation (SpO(2)-SctO(2)) was 29.2% (range, 19.2%-51.4%). There was also a significant positive correlation between SctO(2) and mean arterial blood pressure (0.55, P<.01). Statistically significant lower SctO(2) values were observed in patients with diabetes (P=.026; confidence interval [CI], 0.006-0.090) and in patients with dyslipidemia (P=.007; CI, 0.018-0.103). In this initial description of SctO(2) in patients with stage C HF, we noted a wide range of SctO(2) measurements. For most patients, there was a profound SpO(2)-SctO(2) difference, despite near-normal peripheral oxygen saturations. The authors suggest that SctO(2) is a potentially important biomarker to measure in HF patients and may be a useful marker of target organ perfusion.

Symptomatic calcific constrictive pericarditis presenting years after presumed resolved inflammatory heart disease.

Inflammatory heart diseases are characterized as a focal, diffuse, or sparse inflammatory process of the myocardium and its adjacent structures. In adults, inflammatory heart disease often progresses to symptomatic dilated cardiomyopathy and heart failure. We report the case of a 42-year-old woman who was diagnosed with right-sided heart failure, presumably secondary to inflammatory heart disease, after the acute onset of exercise intolerance. Nine years after the initial diagnosis, she developed clinical symptoms of calcified constrictive pericarditis. Pericardiectomy was performed and the patient resumed normal functional capacity. In conclusion, close monitoring and careful evaluation of patients with presumed inflammatory heart disease is warranted because of the potential for late-occurring chronic constrictive sequelae.

Management of anemia in heart failure.

PURPOSE OF REVIEW: Anemia is a relatively common finding in heart failure. Anemia in heart failure patients has been independently associated with reduced exercise tolerance, increased heart failure hospitalizations and increased all-cause mortality. Anemia would appear to be a reasonable treatment target for patients with heart failure. The review will discuss the potential causes of anemia in heart failure patients and give an up-to-date overview of treatment trials. RECENT FINDINGS: Studies assessing the pathophysiology of anemia in heart failure patients have recently demonstrated the potential importance of iron deficiency, abnormal iron metabolism and hemodilution. Treatment studies have focused on the use of erythropoiesis-stimulating agents, with recent trials showing mixed results. SUMMARY: Despite initial studies indicating a possible beneficial effect of erythropoiesis-stimulating agents in the treatment of anemic heart failure patients, clinical trial data, to date, have failed to show convincing evidence for morbidity or mortality benefit, and information on the long-term safety is lacking. Ongoing large-scale trials will have the potential to provide such information in the future.

Impact of center volume on outcomes of left ventricular assist device implantation as destination therapy: analysis of the Thoratec HeartMate Registry, 1998 to 2005.

BACKGROUND: More than 400 patients with end-stage heart failure underwent left ventricular assist device (LVAD) implantation of LVAD as destination therapy (DT) after the US Food and Drug Administration approval of DT in 2002. Because most of these patients had surgeries at hospitals that were newly accredited, we sought to examine the impact of LVAD center volume on the outcomes of DT. METHODS AND RESULTS: From July 1998 through December 2005, a total of 377 patients underwent implantation of HeartMate I LVAD as DT at 68 centers in the United States. Using data from the Thoratec DT Registry, we examined the association between LVAD center volume at the time of surgery and 1-year survival with DT. Of the studied 377 DT recipients, 53% underwent device implantation at centers that performed 9th DT implant; P=0.009). However, the DT center volume was not an independent predictor of 1-year survival with DT when adjusted for the preoperative DT Risk Score, suggesting that other factors, such as improved candidate selection, may have accounted for the institutional learning curve. CONCLUSIONS: The institutional experience with DT may have a significant impact on outcomes of this therapy. Better selection of candidates, systemic approach to surgical and postoperative care, as well as the long-term medical management most likely all contribute to these improvements.

Low incidence of neurologic events during long-term support with the HeartMate XVE left ventricular assist device.

Neurologic events during left ventricular assist device (LVAD) support are associated with significant morbidity and death. To evaluate this problem, we analyzed neurocognitive function and the frequency and incidence of neurologic events in 21 consecutive patients who were undergoing long-term support with the HeartMate XVE LVAD (Thoratec Corporation; Pleasanton, Calif). The mean duration of LVAD support was 531 days (range, 55-1, 309 d); the cumulative support time was 11,188 days (30.7 yr). No patients received anticoagulant therapy, and most received aspirin. None experienced strokes or transient ischemic attacks. Twenty patients were discharged from the hospital; 2 were later readmitted because of transient changes in neurologic status (metabolic encephalopathy) that ultimately resolved. Neurologic function, as measured by the National Institutes of Health Stroke Scale (NIHSS) and the Modified Rankin Score (MRS), was abnormal before LVAD implantation but normal 6 and 12 months after (mean NIHSS, 23.6 before vs 0 after; mean MRS, 0.68 before vs 0.18 after). Neurocognitive function, as evaluated by the Boston Naming Test, Trail Making Test part B, and Block Design Test, also improved during LVAD support. Together, these findings indicate that few neurologic events occur during long-term HeartMate XVE LVAD support in the absence of anticoagulation therapy. They also suggest that modifications made to the HeartMate LVAD since the REMATCH trial have resulted in fewer complications, and that better patient selection and supportive care have improved outcomes.

Outcomes of left ventricular assist device implantation as destination therapy in the post-REMATCH era: implications for patient selection.

BACKGROUND: The landmark Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial first demonstrated that implantation of left ventricular assist devices (LVADs) as destination therapy (DT) can provide survival superior to any known medical treatment in patients with end-stage heart failure who are ineligible for transplantation. In the present study, we describe outcomes of DT in the post-REMATCH era in the United States. METHODS AND RESULTS: The present study included 280 patients who underwent HeartMate XVE LVAD implantation between November 2001 and December 2005. A preoperative risk score for in-hospital mortality after LVAD implantation was established in 222 patients with complete data. All patients were followed up until death or December 2006. The 1-year survival after LVAD implantation was 56%. The in-hospital mortality after LVAD surgery was 27%. The main causes of death included sepsis, right heart failure, and multiorgan failure. The most important determinants of in-hospital mortality were poor nutrition, hematological abnormalities, markers of end-organ or right ventricular dysfunction, and lack of inotropic support. Stratification of DT candidates into low (n=65), medium (n=111), high (n=28), and very high (n=18) risk on the basis of the risk score calculated from these predictors corresponded with 1-year survival rates of 81%, 62%, 28%, and 11%, respectively. CONCLUSIONS: Appropriate selection of candidates and timing of LVAD implantation are critical for improved outcomes of DT. Patients with advanced heart failure who are referred for DT before major complications of heart failure develop have the best chance of achieving an excellent 1-year survival with LVAD therapy.

The natriuretic peptide system: kidney and cardiovascular effects.

PURPOSE OF REVIEW: The natriuretic peptide (NP) system is primarily an endocrine system that maintains fluid and pressure homeostasis by modulating cardiac and renal function. The physiologic functions of the NP system in healthy humans and in patients with cardiovascular disease are not fully understood. NP levels are elevated in patients with heart failure (HF) and other cardiac diseases; measurement of NPs may be used in the clinical setting to aid diagnosis and prognosis. In addition, synthetic NPs such as nesiritide are available for use in management of patients with acutely decompensated congestive HF. RECENT FINDINGS: Not only do NPs modulate volume and pressure homeostasis, but they also exert important anti-proliferative, anti-fibrotic effects in the heart. Thus, NPs may prove useful for prevention of remodeling after myocardial infarction and in advanced HF. BNP is emerging as an important biomarker in patients with HF and other cardiovascular diseases, such as pulmonary hypertension and atherosclerotic vascular disease. Elevated NP levels may serve as an early warning system to help to identify patients at high risk for cardiac events. Recombinant human ANP (carperitide) and BNP (nesiritide) are useful for management of acutely decompensated HF; these drugs are also being investigated for myocardial and renal protection in the setting of cardiac surgery and for prevention of cardiac remodeling. SUMMARY: The clinical application of NPs is expanding rapidly. Recent basic science and clinical research findings continue to improve our understanding of the NP system and guide use of ANP and BNP as biomarkers and as therapeutic agents.

Systemic hypertension among women with uterine leiomyomata: potential final common pathways of target end-organ remodeling.

The uterus and the heart share a common structure and may remodel in a similar fashion, albeit temporally distinct. The authors investigated the prevalence of systemic hypertension in women with uterine leiomyomata (fibroids) and compared the prevalence in women undergoing hysterectomy for other reasons as well as in age-matched women from the National Health and Nutrition Examination Survey III (NHANES III). A total of 584 women, 205 with leiomyomata in 1999 (group A) and 379 who underwent hysterectomy for a variety of reasons in 2000 (group B) at Advocate Christ Medical Center were included. Presence of leiomyomata was confirmed by pathology. Hypertension was defined as blood pressure > or = 140/90 mm Hg or history of hypertension with or without medication use. The prevalence of hypertension in group A and B patients with leiomyomata compared with NHANES III overall was 48.6% vs. 24% (p<0.001), in African Americans 55.5% vs. 32.4% (p<0.001), and in Caucasians 51.1% vs. 23.3% (p<0.001). Leiomyomata were more frequent among hypertensive than normotensive women (57% vs. 27%). Caucasian and African-American women with leiomyomata were significantly younger and more likely to use hormone replacement therapy than others. Thus there appears to be an association between leiomyomata and hypertension, which needs to be explored in future prospective trials.

Percutaneous closed reduction of fracture-dislocation of the shoulder.

A technique using a cannulated tap in a percutaneous manner allows for easy reduction of the dislocated humeral head with minimal soft-tissue trauma and presents a useful alternative to repeated attempts at open or closed reduction.

Efficacy of nonsteroidal anti-inflammatory medications for prevention of atrial fibrillation following coronary artery bypass graft surgery.

This study was designed to test whether nonsteroidal anti-inflammatory medications could reduce the frequency of atrial fibrillation after coronary artery bypass graft surgery. The study was designed as an open-label, randomized trial. Patients undergoing first-time coronary artery bypass graft surgery were considered eligible. Patients with a history of atrial fibrillation, serum creatinine >2.0 mg/dL, on antiarrhythmic treatment, and those undergoing concomitant valvular surgery were excluded. The study was conducted in a single, university-affiliated community hospital. The researchers' role in the study was restricted to randomizing the patients and collecting data. The primary clinical care team made all decisions regarding patient care. One hundred patients were randomized to two groups: one received 30 mg ketorolac intravenously every 6 hours until able to take oral medications, at which point the patients were switched to 600 mg ibuprofen orally three times a day; the other group received conventional treatment. The primary end point of the study was incidence of atrial fibrillation in the immediate postoperative period. Atrial fibrillation occurred in 14 patients (28.6%) in the conventional treatment group vs. five patients (9.8%) in the ibuprofen group (p<0.017). Nonsteroidal anti-inflammatory medications were relatively safe and effective in significantly reducing the incidence of atrial fibrillation after coronary artery bypass graft surgery.

High incidence of elevated B-type natriuretic peptide levels and risk factors for heart failure in an unselected at-risk population (stage A): implications for heart failure screening programs.

Only early detection and treatment is likely to stem the current epidemic of heart failure (HF). Several common cardiovascular and metabolic conditions increase the risk of developing symptomatic HF, but its detection by a simple and reliable screening method has proved elusive. HF screening sessions were conducted in September and November 2001. Members of the community with HF risk factors (e.g., hypertension, coronary artery disease, diabetes mellitus, hyperlipidemia) were invited--all specifically without a history of HF. The screening included a history review, health history questionnaire, measurement of blood pressure and pulse, as well as a measurement of B-type natriuretic peptide (BNP) level. A total of 233 individuals attended these two sessions: 108 men and 125 women (mean age, 63 years). Of the 233 subjects screened, the majority (92%) had >or=1 risk factor with an average of 2.8 risk factors for HF. The most common risks included hyperlipidemia (112), hypertension (112), age >65 years (105), cigarette smoking (105), coronary artery disease (60), and diabetes mellitus (54). Many subjects also had symptoms consistent with HF, with most (182, 82%) recording >or=1 symptom. Blood pressure measurements revealed a mean systolic of 139 mm Hg and mean diastolic of 79 mm Hg; on the screening days, 48% and 59% of subjects demonstrated either systolic or diastolic blood pressures above normal, respectively. BNP levels ranged from 0-479 pg/mL with an average of 40 pg/mL. A total of 24 subjects (10.3%) had a BNP level >100 pg/mL, and a total of 32 subjects (13.7%) had a level >80 pg/mL. The follow-up data showed that all 24 subjects saw their physician within 6 months after the screening. By 12 months following the initial screening program, 21 of the 24 subjects with elevated BNP levels (88%) underwent further testing and 18 of the 24 (67%) had changes in their medications. BNP screening identifies subjects at high risk for developing HF. Most subjects at risk have multiple risk factors and abnormal blood pressure. Approximately 10% of this population tested with an abnormal level of BNP, higher than the Food and Drug Administration-assigned cut-point diagnostic for HF. Increased public and physician awareness and information are needed to transform screening opportunities into a strategic approach to improve health care and HF prevention.

Current and potential applications of left ventricular assist devices.

The syndrome of heart failure is epidemic, causing increased hospital admissions, poor survival rates, and a dismal quality of life. Treatment choices include pharmacologic, psychological, and surgical interventions. Recent data suggest that mechanical heart pumps, or assist devices, are viable additions or alternatives to transplantation in management of advanced heart failure. A ventricular assist device (VAD) can support the circulation when the natural heart is unable to maintain adequate perfusion. Although its use continues to be explored, VADs can be used in three ways: as a bridge to transplantation, as a destination therapy (or implanted permanently), or as a bridge to recovery. As VAD science advances, nurses will needs to understand its practice implications.