Exercise intolerance associated with impaired oxygen extraction in patients with long COVID.

OBJECTIVE: Chronic mental and physical fatigue and post-exertional malaise are the more debilitating symptoms of long COVID-19. The study objective was to explore factors contributing to exercise intolerance in long COVID-19 to guide development of new therapies. Exercise capacity data of patients referred for a cardiopulmonary exercise test (CPET) and included in a COVID-19 Survivorship Registry at one urban health center were retrospectively analyzed. RESULTS: Most subjects did not meet normative criteria for a maximal test, consistent with suboptimal effort and early exercise termination. Mean O2 pulse peak % predicted (of 79 ± 12.9) was reduced, supporting impaired energy metabolism as a mechanism of exercise intolerance in long COVID, n = 59. We further identified blunted rise in heart rate peak during maximal CPET. Our preliminary analyses support therapies that optimize bioenergetics and improve oxygen utilization for treating long COVID-19.

Increasing Rates of Prone Positioning in Acute Care Patients with COVID-19.

BACKGROUND: Prone positioning improves mortality in patients intubated with acute respiratory distress syndrome and has been proposed as a treatment for nonintubated patients with COVID-19 outside the ICU. However, there are substantial patient and operational barriers to prone positioning on acute floors. The objective of this project was to increase the frequency of prone positioning among acute care patients with COVID-19. METHODS: The researchers conducted a retrospective analysis of all adult patients admitted to the acute care floors with COVID-19 respiratory failure. A run chart was used to quantify the frequency of prone positioning over time. For the subset of patients assisted by a dedicated physical therapy team, oxygen before and after positioning was compared. The initiative consisted of four separate interventions: (1) nursing, physical therapy, physician, and patient education; (2) optimization of supply management and operations; (3) an acute care prone positioning team; and (4) electronic health record optimization. RESULTS: From March 9, 2020, to August 26, 2020, 176/875 (20.1%) patients were placed in prone position. Among these, 43 (24.4%) were placed in the prone position by the physical therapy team. Only 2/94 (2.1%) eligible patients admitted in the first two weeks of the pandemic were ever documented in prone position. After launching the initiative, weekly frequency peaked at 13/28 (46.4%). Mean oxygen saturation was 91% prior to prone positioning vs. 95.2% after (p < 0.001) in those positioned by physical therapy. CONCLUSION: A multidisciplinary quality improvement initiative increased frequency of prone positioning by proactively addressing barriers in knowledge, equipment, training, and information technology.

Adherence and Exercise Capacity Improvements of Patients With Adult Congenital Heart Disease Participating in Cardiac Rehabilitation.

Background As the number of adults with congenital heart disease increases because of therapeutic advances, cardiac rehabilitation (CR) is increasingly being used in this population after cardiac procedures or for reduced exercise tolerance. We aim to describe the adherence and exercise capacity improvements of patients with adult congenital heart disease (ACHD) in CR. Methods and Results This retrospective study included patients with ACHD in CR at New York University Langone Rusk Rehabilitation from 2013 to 2020. We collected data on patient characteristics, number of sessions attended, and functional testing results. Pre-CR and post-CR metabolic equivalent task, exercise time, and maximal oxygen uptake were assessed. In total, 89 patients with ACHD (mean age, 39.0 years; 54.0% women) participated in CR. Referral indications were reduced exercise tolerance for 42.7% and post-cardiac procedure (transcatheter or surgical) for the remainder. Mean number of sessions attended was 24.2, and 42 participants (47.2%) completed all 36 CR sessions. Among participants who completed the program as well as pre-CR and post-CR functional testing, metabolic equivalent task increased by 1.3 (95% CI, 0.7-1.9; baseline mean, 8.1), exercise time increased by 66.4 seconds (95% CI, 21.4-111.4 seconds; baseline mean, 536.1 seconds), and maximal oxygen uptake increased by 2.5 mL/kg per minute (95% CI, 0.7-4.2 mL/kg per minute; baseline mean, 20.2 mL/kg per minute). Conclusions On average, patients with ACHD who completed CR experienced improvements in exercise capacity. Efforts to increase adherence would allow more patients with ACHD to benefit.

Rehabilitation Using Mobile Health for Older Adults With Ischemic Heart Disease in the Home Setting (RESILIENT): Protocol for a Randomized Controlled Trial.

BACKGROUND: Participation in ambulatory cardiac rehabilitation remains low, especially among older adults. Although mobile health cardiac rehabilitation (mHealth-CR) provides a novel opportunity to deliver care, age-specific impairments may limit older adults' uptake, and efficacy data are currently lacking. OBJECTIVE: This study aims to describe the design of the rehabilitation using mobile health for older adults with ischemic heart disease in the home setting (RESILIENT) trial. METHODS: RESILIENT is a multicenter randomized clinical trial that is enrolling patients aged ≥65 years with ischemic heart disease in a 3:1 ratio to either an intervention (mHealth-CR) or control (usual care) arm, with a target sample size of 400 participants. mHealth-CR consists of a commercially available mobile health software platform coupled with weekly exercise therapist sessions to review progress and set new activity goals. The primary outcome is a change in functional mobility (6-minute walk distance), which is measured at baseline and 3 months. Secondary outcomes are health status, goal attainment, hospital readmission, and mortality. Among intervention participants, engagement with the mHealth-CR platform will be analyzed to understand the characteristics that determine different patterns of use (eg, persistent high engagement and declining engagement). RESULTS: As of December 2021, the RESILIENT trial had enrolled 116 participants. Enrollment is projected to continue until October 2023. The trial results are expected to be reported in 2024. CONCLUSIONS: The RESILIENT trial will generate important evidence about the efficacy of mHealth-CR among older adults in multiple domains and characteristics that determine the sustained use of mHealth-CR. These findings will help design future precision medicine approaches to mobile health implementation in older adults. This knowledge is especially important in light of the COVID-19 pandemic that has shifted much of health care to a remote, internet-based setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT03978130; https://clinicaltrials.gov/ct2/show/NCT03978130. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/32163.

Effects of Biophilic Nature Imagery on Indexes of Satisfaction in Medically Complex Physical Rehabilitation Patients: An Exploratory Study.

OBJECTIVE: Exposure to nature has been shown to influence various dimensions of human experience in the healthcare environment. This mixed method study explores the effects of the presence of biophilic, nature-based imagery on patient perceptions of their hospital room and aspects of their experience in rehabilitation. BACKGROUND: In settings where patients have high degrees of medical acuity and infection control is a major concern, exposure to the benefits of real nature may be precluded. This is also true in many older healthcare facilities which were not designed with salutatory nature exposure in mind. In these settings, the presence of nature imagery may provide benefits which positively impact patient experience. METHOD: Seventy-six physical rehabilitation patients on a medically complex/cardiopulmonary rehabilitation unit filled out questionnaires assessing their perceptions of their room and various indexes of patient satisfaction. Data were collected from 47 patients in enhanced room containing nature imagery and 29 patients in standard rooms which served as controls. RESULTS: Scores on the Environmental Assessment Scale (EAS) indicated a significant difference between experimental and control group in the rating of their rooms (p = .0071). Ratings of quality of room, quality of stay, quality of sleep, and overall care trended in the direction of the hypothesis but were not significant. Data from qualitative questionnaires supported the results of the EAS. CONCLUSION: We conclude that the presence of biophilic nature imagery in the hospital rooms had a significant effect on patients' room ratings and positively influenced indexes of patient satisfaction.

Acceptability of capnography-assisted respiratory therapy: a new mind-body intervention for COPD.

Dyspnoea self-management is often suboptimal for patients with COPD. Many patients with COPD experience chronic dyspnoea as distressing and disabling, especially during physical activities. Breathing therapy is a behavioural intervention that targets reducing the distress and impact of dyspnoea on exertion in daily living. Using a qualitative design, we conducted interviews with 14 patients after they participated in a novel mind-body breathing therapy intervention adjunct, capnography-assisted respiratory therapy (CART), combined with outpatient pulmonary rehabilitation. Comprehensive CART consisted of patient-centred biofeedback, tailored breathing exercises, a home exercise programme and motivational interviewing counselling. We assessed participants' perceptions and reported experiences to gauge the acceptability of CART and refine CART based on feedback. Constant comparative analysis was used to identify commonalities and themes. We identified three main themes relating to the acceptability and reported benefits of CART: (1) self-regulating breathing; (2) impact on health; and (3) patient satisfaction. Our findings were used to refine and optimise CART (i.e. its intensity, timing and format) for COPD. By addressing dysfunctional breathing behaviours and dysregulated interoception, CART offers a promising new paradigm for relieving dyspnoea and related anxiety in patients with COPD.

Mobile health and cardiac rehabilitation in older adults.

With the ubiquity of mobile devices, the availability of mobile health (mHealth) applications for cardiovascular disease (CVD) has markedly increased in recent years. Older adults represent a population with a high CVD burden and therefore have the potential to benefit considerably from interventions that utilize mHealth. Traditional facility-based cardiac rehabilitation represents one intervention that is currently underutilized for CVD patients and, because of the unique barriers that older adults face, represents an attractive target for mHealth interventions. Despite potential barriers to mHealth adoption in older populations, there is also evidence that older patients may be willing to adopt these technologies. In this review, we highlight the potential for mHealth uptake for older adults with CVD, with a particular focus on mHealth cardiac rehabilitation (mHealth-CR) and evidence being generated in this field.

Early Termination of Cardiac Rehabilitation Is More Common With Heart Failure With Reduced Ejection Fraction Than With Ischemic Heart Disease.

PURPOSE: Despite known benefits of cardiac rehabilitation (CR), early termination (failure to complete >1 mo of CR) attenuates these benefits. We analyzed whether early termination varied by referral indication in the context of recent growth in patients referred for heart failure with reduced ejection fraction (HFrEF). METHODS: We reviewed records from 1111 consecutive patients enrolled in the NYU Langone Health Rusk CR program (2013-2017). Sessions attended, demographics, and comorbidities were abstracted, as well as primary referral indication: HFrEF or ischemic heart disease (IHD; including post-coronary revascularization, post-acute myocardial infarction, or chronic stable angina). We compared rates of early termination between HFrEF and IHD, and used multivariable logistic regression to determine whether differences persisted after adjusting for relevant characteristics (age, race, ethnicity, body mass index, smoking, hypertension, chronic obstructive pulmonary disease, and depression). RESULTS: Mean patient age was 64 yr, 31% were female, and 28% were nonwhite. Most referrals (85%) were for IHD; 15% were for HFrEF. Early termination occurred in 206 patients (18%) and was more common in HFrEF (26%) than in IHD (17%) (P < .01). After multivariable adjustment, patients with HFrEF remained at higher risk of early termination than patients with IHD (unadjusted OR = 1.73, 95% CI, 1.17-2.54; adjusted OR = 1.53, 95% CI, 1.01-2.31). CONCLUSIONS: Nearly 1 in 5 patients in our program terminated CR within 1 mo, with HFrEF patients at higher risk than IHD patients. While broad efforts at preventing early termination are warranted, particular attention may be required in patients with HFrEF.

The Wearable Cardioverter Defibrillator: A Case Study Illustrating Physical Therapy Implications and Management in the Inpatient Setting.

Background and Purpose: Sudden cardiac death causes an estimated 200,000 to 450,000 deaths per year in the USA. Although permanent implantation of an internal cardiac defibrillator offers a preventive intervention, the required assessment period for determining need creates vulnerability for patients who will benefit from this protection. The use of a wearable cardioverter defibrillator (WCD) for interim protection is rapidly increasing. There are no rehabilitation guidelines for patients wearing a WCD. This article reviews the WCD's purpose, considers implications and current challenges for use during rehabilitation, and illustrates this with a case report. Case Description: A 51-year-old male with coronary artery disease following prolonged hospitalization was fitted with a WCD during evaluation for an internal cardiac defibrillator. During inpatient rehabilitation, the therapy plan required unique considerations because of the presence of the WCD. Outcomes: Recapitulating the patient's rehabilitation course illustrates the WCD's challenges, the benefits to exercise progression, and the safety measures used. The patient gained functional independence, with uninterrupted care, in the presence of the WCD. Discussion: Knowledgeable clinicians, attention to safety, and sufficient patient/caregiver education are essential for uninterrupted and successful rehabilitative care for WCD-wearing patients. Because of increasing clinical prevalence of WCDs in rehabilitation, it is critically important to share clinical experience and eventually conduct a systematic assessment.

Functional assessment of pharmacological telomerase activators in human T cells.

Telomeres are structures at the ends of chromosomes that shorten during cell division and eventually signal an irreversible state of growth arrest known as cellular senescence. To delay this cellular aging, human T cells, which are critical in the immune control over infections and cancer, activate the enzyme telomerase, which binds and extends the telomeres. Several different extracts from the Astragalus membranaceus root have been documented to activate telomerase activity in human T cells. The objective of this research was to compare two extracts from Astragalus membranaceus, TA-65 and HTA, for their effects on both telomerase and proliferative activity of human CD4 and CD8 T cells. Our results demonstrate that, TA-65 increased telomerase activity significantly (1.3 to 3.3-fold relative to controls) in T cell cultures from six donors tested, whereas HTA only increased telomerase levels in two out of six donors. We also demonstrate that TA-65 activates telomerase by a MAPK- specific pathway. Finally, we determine that during a three-day culture period, only the T cells treated with the TA-65 extract showed a statistically significant increase in proliferative activity. Our results underscore the importance of comparing multiple telomerase activators within the same experiment, and of including functional assays in addition to measuring telomerase activity.