Associations between in-hospital daily protein intake and adverse clinical outcomes in older patients with heart failure.

AIMS: The adverse effects of low daily protein intake (DPI) on clinical outcomes in patients with heart failure (HF) are known; however, an optimal DPI to predict event adverse outcomes remains undetermined. Moreover, whether protein restriction therapy for chronic kidney disease is applicable in patients with HF and renal dysfunction remains unclear. METHODS AND RESULTS: In this single-centre, ambispective cohort study, we included 405 patients with HF aged ≥65 years (mean age, 78.6 ± 7.5 years; 50% women). DPI was estimated from consumption over three consecutive days before discharge and normalized relative to the ideal body weight [IBW, 22 kg/m2 × height (m)2]. The primary outcome was a composite of all-cause mortality and HF-related readmission within the 2 year post-discharge period. RESULTS: During an average follow-up period of 1.49 ± 0.74 years, 100 patients experienced composite events. Kaplan-Meier survival curves revealed a significantly lower composite event-free rate in patients within the lowest quartile of DPI than in the upper quartiles (log-rank test, P = 0.02). A multivariate Cox proportional hazards analysis after adjusting for established prognostic markers and non-proteogenic energy intake revealed that patients in the lowest DPI quartile faced a two-fold higher risk of composite events than those in the highest quartile [hazard ratio (HR), 2.03; 95% confidence interval (CI), 1.08-3.82; P = 0.03]. The composite event risk linearly increased as DPI decreased (P for nonlinearity = 0.90), with each standard deviation (0.26 g/kg IBW/day) decrease in DPI associated with a 32% increase in composite event risk (HR, 1.32; 95% CI, 1.10-1.71; P = 0.04). There was significant heterogeneity in the effect of DPI, with the possible disadvantage of lower DPI in patients with HF with cystatin C-based estimated glomerular filtration rate <30 mL/min/1.73 m2. The cutoff value of DPI for predicting the occurrence of composite events calculated from the Youden index was 1.12 g/kg IBW/day. Incorporating a DPI < 1.12 g/kg IBW/day into the baseline model significantly improved the prediction of post-discharge composite events (continuous net reclassification improvement, 0.294; 95% CI, 0.072-0.516; P = 0.01). CONCLUSIONS: Lower DPI during hospitalization is associated with an increased risk of mortality and HF readmission independent of non-proteogenic energy intake, and the possible optimal DPI for predicting adverse clinical outcomes is >1.12 g/kg IBW/day in older patients with HF. Caution is warranted when protein restriction therapy is administered to older patients with HF and renal dysfunction.

Skipping breakfast does not accelerate the hyperglycemia-induced endothelial dysfunction but reduces blood flow of the brachial artery in young men.

PURPOSE: Postprandial hyperglycemia is assumed to have a negative impact on flow-mediated dilation (FMD), an index of endothelial function, and blood flow of the peripheral conduit arteries. This study aimed to determine whether the enhancement of postprandial hyperglycemia by skipping breakfast accelerates endothelial dysfunction and reduces the blood flow in the brachial artery in young men. METHODS: Using a randomized cross-over design, ten healthy men completed two trials: with and without breakfast (Eating and Fasting trials, respectively). Venous blood sampling and brachial FMD tests were conducted before, 30, 60, 90, and 120 min after a 75-g oral glucose tolerance test (OGTT). RESULTS: Skipping breakfast boosted post-OGTT glucose levels than having breakfast (P = 0.01). The magnitude of the decrease in FMD via OGTT did not vary between trials (main effect of trial P = 0.55). Although brachial blood flow tended to decrease after OGTT in both trials (interaction and main effect of time P = 0.61 and P = 0.054, respectively), the decrease in blood flow following OGTT was greater in the Fasting trial than in the Eating trial (main effect of trial, mean difference = - 15.8 mL/min [95%CI = - 25.6 to - 6.0 mL/min], P < 0.01). CONCLUSION: Skipping breakfast did not enhance the magnitude of the decrease in FMD following glucose loading, but did accelerate hyperglycemia-induced reduction in brachial blood flow. Current findings suggest that even missing one breakfast has negative impacts on the blood flow regulation of the peripheral conduit arteries in young men who habitually eat breakfast.

Anthropometric parameters-derived estimation of muscle mass predicts all-cause mortality in heart failure patients.

AIMS: Reduction in appendicular skeletal muscle mass index (ASMI) assessed by dual-energy X-ray absorptiometry (DEXA) has been shown to be independently associated with a higher mortality rate in patients with heart failure (HF). However, DEXA is not suitable for measurement of muscle mass in a daily clinical setting and in large population-based studies. The aim of this study was to determine whether ASMI predicted from anthropometric indicators (predicted ASMI) serves as an alternative to DEXA-measured ASMI for predicting all-cause death in HF patients. METHODS AND RESULTS: Data for 539 HF patients who received a DEXA scan and measurements of calf circumferences (CC) and mid-arm circumferences (MAC) in our hospital were analysed. Predicted ASMI was calculated as we previously reported: predicted ASMI (kg/m2 ) = [0.214 × weight (kg) + 0.217 × CC (cm) - 0.189 × MAC (cm) + 1.098 (male = 1, female = -1) + 0.576]/height2 (m2 ). Low ASMI values were defined as <7.00 kg/m2 and <5.40 kg/m2 for men and women, respectively, according to the criteria of the Asian Working Group for Sarcopenia. The median follow-up period was 1.75 years (interquartile range, 0.96-2.37 years), and 79 patients (15%) died. Kaplan-Meier survival curves showed that patients with low DEXA-measured ASMI and patients with low predicted ASMI had significantly lower survival rates than those for patients with high ASMI. In multivariate Cox proportional hazard analyses adjusted for age, sex, logarithmic B-type natriuretic peptide, cystatin C based-estimated glomerular filtration rate, and gait speed, DEXA-measured ASMI [hazard ratio (HR), 0.982; 95% confidence interval (CI), 0.967-0.998; P = 0.026] and predicted ASMI (HR, 0.979; 95% CI, 0.962-0.996; P = 0.018) were independent predictors of all-cause mortality. Inclusion of predicted ASMI into the adjustment model significantly improved continuous net reclassification improvement (0.338; 95% CI, 0.103-0.572; P < 0.01) and integrated discrimination improvement (0.020; 95% CI, 0.004-0.035; P < 0.05) for predicting mortality after discharge. CONCLUSIONS: Predicted ASMI, as well as DEXA-measured ASMI, can predict all-cause death in HF patients, and calculation of predicted ASMI will be useful for detecting high-risk patients in a daily clinical setting and in large population-based studies.

Posterior shoulder capsule of the dominant arm is stiffer in baseball players than that in nonthrowing population.

BACKGROUND: Posterior shoulder capsule tightness is one of the factors for shoulder injuries in overhead athletes. Recent studies have shown the posterior capsule of the dominant arm to be stiffer than that of the nondominant arm in baseball players. However, whether posterior capsule tightness in the dominant arm is exclusive to overhead athletes remains unknown. This study aimed to investigate whether the posterior shoulder capsule of the dominant arm in baseball players is stiffer than that in nonthrowing population. METHODS: Fifteen male collegiate asymptomatic baseball players (baseball-player group) and fifteen male college students who did not partake in overhead sports (nonthrowing group) participated in this study. We measured the shear moduli of the middle and inferior posterior capsules, superior infraspinatus, inferior infraspinatus, teres minor, and posterior deltoid in the dominant arm by ultrasound shear wave elastography. We compared shear moduli between the two groups using an independent samples t-test and Mann-Whitney test. In addition, we investigated the correlation between the range of glenohumeral internal rotation and each shear modulus in each group using the Pearson correlation coefficient. RESULTS: The shear moduli in the baseball-player group were significantly higher than those in the nonthrowing group in both the middle posterior capsule (baseball-player group: 36.1 ± 5.6 kPa vs. nonthrowing group: 29.0 ± 8.6 kPa; P = .018) and inferior posterior capsule (37.1 ± 9.6 kPa vs. 27.9 ± 6.8 kPa; P = .002). However, no difference in the shear moduli of individual muscle groups was identified. The glenohumeral internal rotation range exhibited a statistically significant negative correlation with the shear modulus of the inferior posterior capsule in the baseball-player group (Pearson correlation coefficient = -0.586, P = .022). CONCLUSION: Our findings suggest that the posterior shoulder capsule of the dominant arm in baseball players is stiffer than that in nonthrowing population.

Time-course changes in active stiffness of the supraspinatus muscle after arthroscopic rotator cuff repair.

PURPOSE: This study aimed to investigate the time-course changes in the active stiffness of the supraspinatus muscle after arthroscopic rotator cuff repair. METHODS: Eight male patients (mean age 61.5 ± 9.4 years) who underwent arthroscopic rotator cuff repair for small to medium tears were recruited for this study. Movement tasks included 30° shoulder isometric abduction and maximal voluntary isometric contraction of shoulder abduction in the scapular plane. The stiffness of the supraspinatus (anterior superficial, anterior deep, posterior superficial, and posterior deep regions), upper trapezius, and middle deltoid muscles in bilateral shoulders was recorded using ultrasound shear wave elastography. For each subject, the measurement was performed preoperatively and 3, 6, and 12 months postoperatively. RESULTS: The stiffness of the affected anterior superficial region of the supraspinatus muscle 12 months postoperatively was significantly higher than that measured preoperatively and 3 months postoperatively (p < 0.05); it was significantly higher at 6 months postoperatively than at 3 months postoperatively (p < 0.05). Further, the maximal voluntary isometric contraction had significantly improved 12 months postoperatively compared to that measured preoperatively and 3 months postoperatively (p < 0.05). The stiffness of the affected upper trapezius and middle deltoid muscles 12 months postoperatively was significantly lower than that preoperatively (p < 0.05). CONCLUSION: The maximal voluntary isometric contraction 12 months postoperatively possibly increased because of improvement in the active stiffness of the anterior superficial region. Active stiffness of the anterior superficial region may improve 6 months rather than 3 months postoperatively because of the different stages of muscle force, structural repair tendon strength, and remodeling.

High-but not moderate-intensity exercise acutely attenuates hypercapnia-induced vasodilation of the internal carotid artery in young men.

PURPOSE: Exercise-induced increases in shear rate (SR) across different exercise intensities may differentially affect hypercapnia-induced vasodilation of the internal carotid artery (ICA), a potential index of cerebrovascular function. We aimed to elucidate the effects of exercise intensity on ICA SR during exercise and post-exercise hypercapnia-induced vasodilation of the ICA in young men. METHODS: Twelve healthy men completed 30 min of cycling at moderate [MIE; 65 ± 5% of age-predicted maximal heart rate (HRmax)] and high (HIE; 85 ± 5% HRmax) intensities. Hypercapnia-induced vasodilation was induced by 3 min of hypercapnia (target end-tidal partial pressure of CO2 + 10 mmHg) and was assessed at pre-exercise, 5 min and 60 min after exercise. Doppler ultrasound was used to measure ICA diameter and blood velocity during exercise and hypercapnia tests. RESULTS: SR was not altered during either exercise (interaction and main effects of time; both P > 0.05). ICA conductance decreased during HIE from resting values (5.1 ± 1.3 to 3.2 ± 1.0 mL·min-1·mmHg-1; P < 0.01) but not during MIE (5.0 ± 1.3 to 4.0 ± 0.8 mL·min-1·mmHg-1; P = 0.11). Consequently, hypercapnia-induced vasodilation declined immediately after HIE (6.9 ± 1.7% to 4.0 ± 1.4%; P < 0.01), but not after MIE (7.2 ± 2.1% to 7.3 ± 1.8%; P > 0.05). Sixty minutes after exercise, hypercapnia-induced vasodilation returned to baseline values in both trials (MIE 8.0 ± 3.1%; HIE 6.4 ± 2.9%; both P > 0.05). CONCLUSION: The present study showed blunted hypercapnia-induced vasodilation of the ICA immediately after high-intensity exercise, but not a moderate-intensity exercise in young men. Given that the acute response is partly linked to the adaptive response in the peripheral endothelial function, the effects of aerobic training on cerebrovascular health may vary depending on exercise intensity.

Energy intake during hospital stay predicts all-cause mortality after discharge independently of nutritional status in elderly heart failure patients.

OBJECTIVE: Malnutrition is associated with an increased risk of mortality in heart failure (HF) patients. Here, we examined the hypothesis that assessment of energy intake in addition to nutritional status improves the stratification of mortality risk in elderly HF patients. METHODS: We retrospectively examined 419 HF patients aged ≥ 65 years (median 78 years, 49% female). Nutritional status was assessed by the Mini Nutritional Assessment Short Form (MNA-SF), and daily energy intake was calculated from intake during 3 consecutive days before discharge. RESULTS: During a median 1.52-year period (IQR 0.96-2.94 years), 110 patients (26%) died. Kaplan-Meier survival curves showed that patients with low tertile of daily energy intake had a higher mortality rate than did patients with high or middle tertile of daily energy intake. In multivariate Cox regression analyses, low daily energy intake was independently associated with higher mortality after adjustment for the model including age, sex, BNP, Charlson Comorbidity Index, history of HF hospitalization, and cachexia in addition to MNA-SF. Inclusion of both MNA-SF and energy intake into the adjustment model improved the accuracy of prediction of the mortality after discharge (continuous net reclassification improvement, 0.355, p = 0.003; integrated discrimination improvement, 0.029, p = 0.003). Results of a fully adjusted dose-dependent association analysis showed that risk of all-cause mortality was lowest among HF patients who consumed 31.5 kcal/kg/day of energy. CONCLUSIONS: Energy intake during hospital stay is an independent predictor of the mortality in elderly HF patients, and its assessment together with established predictors improves the mortality risk stratification.

Effective stretching positions for the posterior shoulder capsule as determined by shear wave elastography.

BACKGROUND: Stretching is often used to prevent and treat posterior shoulder capsule tightness; however, the most effective stretching positions are not clearly defined. The purpose of this study was to identify the stretching positions that specifically applied the greatest passive tension on the posterior shoulder capsule by evaluating the elastic characteristics of posterior capsules and muscles in various stretching positions using ultrasound shear wave elastography (SWE). METHODS: We evaluated 9 fresh-frozen shoulders (mean age 86.6 ± 7.7 years) without osteoarthritis or rotator cuff tears. All posterior shoulder tissues were preserved intact. Shear moduli of the middle and inferior posterior shoulder capsules and the posterior shoulder muscles were evaluated using SWE. We obtained shear modulus measurements in 9 stretching positions using a combination of glenohumeral elevation planes and angles (frontal, sagittal, scapular; -30°, 0°, 30°, 60°, respectively). A 4-Nm torque for shoulder internal rotation or horizontal adduction was applied in each position. We also measured shear moduli in the resting position (0° elevation with neutral shoulder internal/external rotation). We compared the shear moduli of all stretching and resting positions using 1-way repeated measures analysis of variance (P < .05). In addition, we compared the shear modulus in 2 positions (ie, resting and each stretching) among tissues (ie, capsules and muscles) with repeated measures using 2-way analysis of variance (P < .05). RESULTS: Shear modulus values for the middle posterior capsules in "internal rotation at 30° in scapular plane elevation" (28.7 ± 14.3 kPa, P = .01) and in "horizontal adduction at 60° of elevation" (31.1 ± 13.1 kPa, P < .001) were significantly higher than that of the resting position (11.0 ± 7.3 kPa). The shear modulus value for the inferior posterior capsule in "internal rotation at 30° of flexion" was significantly higher than that of the resting position (39.0 ± 17.3 vs. 15.4 ± 13.9 kPa, respectively; P = .004). Additionally, the shear modulus values for the posterior capsules in "internal rotation at 30° in scapular plane elevation and flexion" were significantly higher than that of the posterior shoulder muscles. CONCLUSION: Effective middle posterior shoulder capsule stretching positions were shoulder "internal rotation at 30° of scapular plane elevation" and "horizontal adduction at 60° of elevation." Shoulder "internal rotation at 30° of flexion" was the most effective position for the inferior posterior shoulder capsule. Stretching in these positions could relieve posterior shoulder capsule tightness and contribute to the prevention and treatment of throwing injuries of the shoulder.

Effects of menstrual cycle and menopause on internal carotid artery shear-mediated dilation in women.

This study aimed to elucidate the effects of change in estrogen during the menstrual cycle and menopause on shear-mediated dilation of the internal carotid artery (ICA), a potential index of cerebrovascular endothelial function. Shear-mediated dilation of the ICA and serum estradiol were measured in 11 premenopausal (Pre-M, 21 ± 1 yr), 13 perimenopausal (Peri-M, 49 ± 2 yr), and 10 postmenopausal (Post-M, 65 ± 7 yr) women. Measurements were made twice within the Pre-M group at their early follicular (EF, lower estradiol) and late follicular (LF, higher estradiol) phases. Shear-mediated dilation was induced by 3 min of hypercapnia (target PETCO2 + 10 mmHg from individual baseline) and was calculated as the percent rise in peak diameter relative to baseline diameter. ICA diameter and blood velocity were simultaneously measured by Doppler ultrasound. In Pre-M, shear-mediated dilation was higher during the LF phase than during the EF phase (P < 0.01). Comparing all groups, shear-mediated dilation was reduced across the menopausal transition (P < 0.01), and Pre-M during the LF phase showed the highest value (8.9 ± 1.4%) compared with other groups (Pre-M in EF, 6.4 ± 1.1%; Peri-M, 5.5 ± 1.3%; Post-M, 5.2 ± 1.9%, P < 0.05 for all). Shear-mediated dilation was positively correlated with serum estradiol even after adjustment of age (P < 0.01, r = 0.55, age-adjusted; P = 0.02, r = 0.35). Collectively, these data indicate that controlling the menstrual cycle phase is necessary for the cross-sectional assessments of shear-mediated dilation of the ICA in premenopausal women. Moreover, current findings suggest that a decline in cerebrovascular endothelial function may be partly related to the reduced circulating estrogen levels in peri- and postmenopausal women.NEW & NOTEWORTHY The present study evaluated the effects of the menstrual cycle and menopause stages on the shear-mediated dilation of the ICA, a potential index of cerebrovascular endothelial function, in pre-, peri-, and postmenopausal women. Shear-mediated dilation of the ICA was increased from the low- to high-estradiol phases in naturally cycling premenopausal women and was reduced with advancing menopause stages. Furthermore, lower estradiol was associated with reduced shear-mediated dilation of the ICA, independent of age.

Flexor hallucis longus tendinous slips and the relationship to toe flexor strength.

BACKGROUND: In the general population, the flexor hallucis longus (FHL) often has tendinous slips to lesser toes and the number of FHL slips varies between individuals. The purpose of this study was to investigate the relationship between the number of FHL tendinous slips in an individual foot and its toe flexor strength. METHODS: Forty healthy men were included in the study. The FHL branch test was used to assess each subject for the number of FHL tendinous slips. Toe flexor strength in each toe was measured using a force gauge. A two-way ANOVA was used to compare toe flexor strength between groups classified according to the number of FHL slips. RESULTS: The group of subjects with FHL branching to the second toe was the most common (20/40). The toe flexor strength ratio of the third toe was significantly lower in feet lacking FHL branching to the third toe than in those feet which did have branching to the third toe (P = 0.005). CONCLUSIONS: Toe flexor strength was affected by FHL tendinous slips. Considering the number of the FHL tendinous slips an individual foot has may be useful in clinical practice for rehabilitation or training of toe flexor muscles.

Flexor hallucis longus tendon branch test: Development and validation of a new method to assess anatomical variation of the tendinous slip.

BACKGROUND: The flexor hallucis longus (FHL) muscle often has a tendinous slip with a variable number of branches. We aimed at developing the FHL branch test to determine the number of FHL branches. METHODS: In anatomical validation study, 6 intact cadavers were used. The toe flexion angles were measured while the FHL and flexor digitorum longus (FDL) were manually pulled individually. For electrophysiological studies, 4 healthy men participated. The FHL was electrically stimulated, and electromyography (EMG) of the FHL and FDL were recorded during the FHL branch test. RESULTS: The toe flexion angles' changes in the FHL pulling condition were equivalent with pulling FDL in toes with FHL branching. The electrical stimulation of the FHL produced similar flexion as the FHL branch test. EMG of the FHL was higher than FDL during the FHL branch test (p=0.036). CONCLUSIONS: The FHL branch test could be used to evaluate the number of FHL branches.

Estimation of quadriceps femoris muscle dysfunction in the early period after surgery of the knee joint using shear-wave elastography.

OBJECTIVES: Orthopaedic surgery of the knee joint results in functional deterioration of the quadriceps femoris muscle. However, little is known about quadriceps femoris muscle dysfunction in the early postsurgical period. Therefore, we examined the stiffness of the quadriceps femoris muscle in the early postsurgical period. METHODS: Seven patients and seven healthy controls performed quadriceps contraction exercises. In resting and contraction conditions, the shear modulus, muscle thickness and pennation angle were measured for the vastus medialis (VM), vastus lateralis (VL) and the rectus femoris (RF) using ultrasound elastography. RESULTS: The shear moduli of the VM, VL and RF in the control group did not significantly interact, while the shear moduli in the patient group did show a significant interaction. In the resting condition, there was no difference between the unaffected and affected sides in the patient group, but the shear moduli of the VM and VL in the contraction condition was significantly lower on the affected side than the unaffected side.The contraction ratios between muscles by limbs did not significantly interact. However, there were main effects due to muscle and limb factors. The VM and VL had a significantly higher contraction ratio than the RF, and the control and unaffected limbs had a higher contraction ratio than the affected limb. CONCLUSION: The results demonstrated a decrease in muscle stiffness during contraction in patients with quadriceps femoris dysfunction. Measurement of the shear modulus has potential as a new evaluation index and with high sensitivity to decreases in muscle contraction.