Are "Carbon Dots" Always Carbon Dots? Evidence for their Supramolecular Nature from Structural and Dynamic Studies in Solution and in the Pure Solid.

A model for the morphology (size, shape, and crystallinity) of carbon dots (CDs) in the solid state consistent with the observed photoluminescence in solution is proposed herein. Overwhelming evidence has been collected that links the data coming from solid-state analysis (high-resolution transmission electron microscopy (HRTEM), atomic force microscopy (AFM), and matrix-assisted laser desorption/ionization (MALDI) mass spectrometry (MS)) to that of solution (pulsed-field gradient (PFG)-NMR spectroscopy, time-resolved fluorescence anisotropy (TRFA), and steady-state/time-resolved fluorescence), allowing the establishment of an overall structural model for CDs. According to this model, the so-called carbon dots, observed under HRTEM imaging, are in fact supramolecular organized structures dynamically assembled from small to medium-sized molecular species when the solvent is removed to give the solid form. In this way, the imaged nanoparticles (TEM/AFM) are not covalently bound entities formed during the synthetic process, but instead supramolecular entities formed by noncovalent interactions. These particles, if at all present in solution, have the form of loose associations of relatively small molecules. This study was conducted on CDs obtained from the hydrothermal carbonization (HTC) of a biomass waste (olive wet pomace).

Are "Carbon Dots" Always Carbon Dots? Evidence for Their Supramolecular Nature from Structural and Dynamic Studies in Solution and in the Pure Solid.

Invited for the cover of this issue are José Prata and co-workers at Instituto Superior de Engenharia de Lisboa and Instituto Superior Técnico. The image depicts a model for the supramolecular nature of carbon dots. Read the full text of the article at 10.1002/chem.202302955.

Gender-inclusive language in midwifery and perinatal services: A guide and argument for justice.

Effective communication in relation to pregnancy and birth is crucial to quality care. A recent focus in reproductive healthcare on "sexed language" reflects an ideology of unchangeable sex binary and fear of erasure, from both cisgender women and the profession of midwifery. In this paper, we highlight how privileging sexed language causes harm to all who birth-including pregnant trans, gender diverse, and non-binary people-and is, therefore, unethical and incompatible with the principles of midwifery. We show how this argument, which conflates midwifery with essentialist thinking, is unstable, and perpetuates and misappropriates midwifery's marginalized status. We also explore how sex and gender essentialism can be understood as colonialist, heteropatriarchal, and universalist, and therefore, reinforcing of these harmful principles. Midwifery has both the opportunity and duty to uphold reproductive justice. Midwifery can be a leader in the decolonization of childbirth and in defending the rights of all childbearing people, the majority of whom are cisgender women. As the systemwide use of inclusive language is central to this commitment, we offer guidance in relation to how inclusive language in perinatal and midwifery services may be realized.

Polyprenylated Benzophenones from Brazilian Red Propolis: Analytical Characterization and Anticancer Activity.

The present work describes the extraction of a polyprenylated benzophenone-rich extract from Brazilian red propolis (ERPB), the development and validation of an RP-HPLC-UV method to characterize it, and its evaluation against breast cancer cell lines MCF-7 and MDA-MB-231, as well as the normal counterpart MCF-10 A. A mixture of gutifferone E and xanthochymol (1+2), and isolated oblongifolin B (3) were used as chemical standards for ERPB and were also evaluated. The concentrations of 1+2 and 3 corresponded to 16.68 % and 42.25 % of the total content of the extract, respectively, and the validation parameters evaluated were satisfactorily met. The cytotoxic effects of ERPB were assessed, and the obtained IC50 values were 19.58 µg/mL (MCF-10 A), 11.56 µg/mL (MCF-7), and 5.22 µg/mL (MDA-MB-231). In conclusion, ERPB exhibits promising cytotoxic effects on the tested breast cell lines. However, further investigation to elucidate its potential therapeutic applications and safety profile should be conducted.

Correction: Miranda et al. Anion Binding by Fluorescent Ureido-Hexahomotrioxacalix[3]arene Receptors: An NMR, Absorption and Emission Spectroscopic Study. Molecules 2022, 27, 3247.

In the original publication [...].

Maximal Exercise Improves the Levels of Endothelial Progenitor Cells in Heart Failure Patients.

The impact of exercise on the levels of endothelial progenitor cells (EPCs), a marker of endothelial repair and angiogenesis, and circulating endothelial cells (CECs), an indicator of endothelial damage, in heart failure patients is largely unknown. This study aims to evaluate the effects of a single exercise bout on the circulating levels of EPCs and CECs in heart failure patients. Thirteen patients with heart failure underwent a symptom-limited maximal cardiopulmonary exercise test to assess exercise capacity. Before and after exercise testing, blood samples were collected to quantify EPCs and CECs by flow cytometry. The circulating levels of both cells were also compared to the resting levels of 13 volunteers (age-matched group). The maximal exercise bout increased the levels of EPCs by 0.5% [95% Confidence Interval, 0.07 to 0.93%], from 4.2 × 10-3 ± 1.5 × 10-3% to 4.7 × 10-3 ± 1.8 × 10-3% (p = 0.02). No changes were observed in the levels of CECs. At baseline, HF patients presented reduced levels of EPCs compared to the age-matched group (p = 0.03), but the exercise bout enhanced circulating EPCs to a level comparable to the age-matched group (4.7 × 10-3 ± 1.8 × 10-3% vs. 5.4 × 10-3 ± 1.7 × 10-3%, respectively, p = 0.14). An acute bout of exercise improves the potential of endothelial repair and angiogenesis capacity by increasing the circulating levels of EPCs in patients with heart failure.

Exercise training decreases the load and changes the content of circulating SDS-resistant protein aggregates in patients with heart failure with reduced ejection fraction.

BACKGROUND: Heart failure (HF) often disrupts the protein quality control (PQC) system leading to protein aggregate accumulation. Evidence from tissue biopsies showed that exercise restores PQC system in HF; however, little is known about its effects on plasma proteostasis. AIM: To determine the effects of exercise training on the load and composition of plasma SDS-resistant protein aggregates (SRA) in patients with HF with reduced ejection fraction (HFrEF). METHODS: Eighteen patients with HFrEF (age: 63.4 ± 6.5 years; LVEF: 33.4 ± 11.6%) participated in a 12-week combined (aerobic plus resistance) exercise program (60 min/session, twice per week). The load and content of circulating SRA were assessed using D2D SDS-PAGE and mass spectrometry. Cardiorespiratory fitness, quality of life, and circulating levels of high-sensitive C-reactive protein, N-terminal pro-B-type natriuretic peptide (NT-proBNP), haptoglobin and ficolin-3, were also evaluated at baseline and after the exercise program. RESULTS: The exercise program decreased the plasma SRA load (% SRA/total protein: 38.0 ± 8.9 to 36.1 ± 9.7%, p = 0.018; % SRA/soluble fraction: 64.3 ± 27.1 to 59.8 ± 27.7%, p = 0.003). Plasma SRA of HFrEF patients comprised 31 proteins, with α-2-macroglobulin and haptoglobin as the most abundant ones. The exercise training significantly increased haptoglobin plasma levels (1.03 ± 0.40 to 1.11 ± 0.46, p = 0.031), while decreasing its abundance in SRA (1.83 ± 0.54 × 1011 to 1.51 ± 0.59 × 1011, p = 0.049). Cardiorespiratory fitness [16.4(5.9) to 19.0(5.2) ml/kg/min, p = 0.002], quality of life, and circulating NT-proBNP [720.0(850.0) to 587.0(847.3) pg/mL, p = 0.048] levels, also improved after the exercise program. CONCLUSION: Exercise training reduced the plasma SRA load and enhanced PQC, potentially via haptoglobin-mediated action, while improving cardiorespiratory fitness and quality of life of patients with HFrEF.

Spin-polarized electronic properties of naphthylene-based carbon nanostructures.

The 2D naphthylene-ß structure is a theoretically proposed sp2 nanocarbon allotrope based on the assembly of naphthalene-based molecular building blocks, which features metallic properties. We report that 2D naphthylene-ß structures host a spin-polarized configuration which turns the system into a semiconductor. We analyze this electronic state in terms of the bipartition of the lattice. In addition, we study the electronic properties of nanotubes obtained from the rolling up of 2D naphthylene-ß. We show that they inherit the properties of the parent 2D nanostructure, such as the emergence of spin-polarized configurations. We further rationalize the results in terms of a zone-folding scheme. We also show that the electronic properties can be modulated using an external transverse electric field, including a semiconducting-to-metallic transition for sufficiently large field strength.

Adherence, safety, and satisfaction of a cardio-oncology rehabilitation program framework versus community exercise training for cancer survivors: findings from the CORE trial.

PURPOSE: To assess safety, satisfaction, and overall adherence of a center-based cardiac rehabilitation (CBCR) program for cancer survivors at increased cardiovascular (CV) risk, compared to community-based exercise training (CBET). METHODS: The CORE study was a single-center, prospective, randomized controlled trial enrolling cancer survivors exposed to cardiotoxic cancer treatment and/or with previous CV disease. Participants were randomized to an 8-week CBCR program or CBET, twice a week. Overall feasibility (consent, retention, and completion rates), intervention adherence (percentage of exercise sessions attended), and safety were assessed. Adverse events (AEs) were registered, and participants' satisfaction was measured at the end of the study. RESULTS: Eighty out of 116 potentially eligible individuals were included; consent rate was 72.4%, and 77 (96.2%) started the study (retention rate 100% in CBCR vs 92.5% in CBET); completion rate was 92.5%. Intervention adherence was higher in CBCR (90.3 ± 11.8% vs 68.4 ± 22.1%, p < 0.001). Exercise-related AEs were mainly related to musculoskeletal conditions in both groups (7 in CBCR vs 20 in CBET, p < 0.001), accounting for exercise prescription modification in 47 sessions (18 (3.3%) in CBCR vs 29 (7.2%) in CBET, p = 0.006), none motivating exercise discontinuation. No participants reported major CV events. Overall, the satisfaction with the different aspects of the programs (e.g., expectations, monitoring) was higher in the CBCR. CONCLUSION: This exploratory analysis of the CORE trial suggests that both exercise-based interventions are feasible and safe in this setting. The higher intervention adherence and patient satisfaction in CBCR suggest that this comprehensive approach could be of interest in this population.

Toxicological and chemoprevention studies of Brazilian brown propolis from Araucaria sp.

Brazilian brown propolis (BBP) is a natural product derived predominantly from the south region of Brazil, where Araucaria forests are dominant. Despite its potential as a source of bioactive compounds with leishmanicidal, anti-inflammatory, nociceptive, and antimicrobial properties, BBP has not been comprehensively studied compared to green propolis. Therefore, this study aimed to determine the safety and chemopreventive potential of BBP. The cytotoxicity attributed to BBP was assessed using two different assays, while the Salmonella/microsome assay was employed to evaluate mutagenicity. The acute toxicity attributed to BBP was determined using a zebrafish model, while the chemopreventive potential was investigated utilizing Chinese hamster lung (V79) cell lines. Data demonstrated that BBP exerted cytotoxic effects at concentrations greater than or equal to 10 µg/ml and did not exhibit mutagenicity in Salmonella typhimurium strains TA98 and TA100. However, at the highest concentration tested (4000 µg/plate), BBP induced a significant increase in revertant colonies in S. typhimurium TA102 strain. The LC50 equivalent to 8.83 mg/L was obtained in the acute toxicity evaluation in zebrafish. BBP also showed antigenotoxic effect by significantly reducing chromosomal damage induced by the mutagen doxorubicin in V79 cell cultures at a concentration of 2.5 µg/ml. Compared to Brazilian green and red propolis, BBP exhibited greater toxicity. On the other hand, at lower concentrations, BBP displayed chemopreventive potential, which may be associated with the antioxidant capacity of the extract. These findings contribute to a better understanding of the biological properties and potential applications of BBP in treating various diseases.

Effects of Exercise on Circulating Extracellular Vesicles in Cardiovascular Disease.

The evidence that physical exercise has multiple beneficial effects and is essential to a healthy lifestyle is widely accepted for a long-time. The functional and psychological changes promoted by exercise improve clinical outcomes and prognosis in several diseases, by decreasing mortality, disease severity, and hospital admissions. Nonetheless, the mechanisms that regulate the release, uptake, and communication of several factors in response to exercise are still not well defined. In the last years, extracellular vesicles have attracted significant interest in the scientific community due to their ability to carry and deliver proteins, lipids, and miRNA to distant organs in the body, promoting a very exciting crosstalk machinery. Moreover, increasing evidence suggests that exercise can modulate the release of those factors within EVs into the circulation, mediating its systemic adaptations.In this chapter, we summarize the effects of acute and chronic exercise on the extracellular vesicle dynamics in healthy subjects and patients with cardiovascular disease. The understanding of the changes in the cargo and kinetics of extracellular vesicles in response to exercise may open new possibilities of research and encourage the development of novel therapies that mimic the effects of exercise.

Phase-Resolved Optical Coherence Elastography: An Insight into Tissue Displacement Estimation.

Robust methods to compute tissue displacements in optical coherence elastography (OCE) data are paramount, as they play a significant role in the accuracy of tissue elastic properties estimation. In this study, the accuracy of different phase estimators was evaluated on simulated OCE data, where the displacements can be accurately set, and on real data. Displacement (∆d) estimates were computed from (i) the original interferogram data (Δφori) and two phase-invariant mathematical manipulations of the interferogram: (ii) its first-order derivative (Δφd) and (iii) its integral (Δφint). We observed a dependence of the phase difference estimation accuracy on the initial depth location of the scatterer and the magnitude of the tissue displacement. However, by combining the three phase-difference estimates (Δdav), the error in phase difference estimation could be minimized. By using Δdav, the median root-mean-square error associated with displacement prediction in simulated OCE data was reduced by 85% and 70% in data with and without noise, respectively, in relation to the traditional estimate. Furthermore, a modest improvement in the minimum detectable displacement in real OCE data was also observed, particularly in data with low signal-to-noise ratios. The feasibility of using Δdav to estimate agarose phantoms' Young's modulus is illustrated.

Critical Analysis of Association Constants between Calixarenes and Nitroaromatic Compounds Obtained by Fluorescence. Implications for Explosives Sensing.

The binding behaviour of two ureido-hexahomotrioxacalix[3]arene derivatives bearing naphthyl (1) and pyrenyl (2) fluorogenic units at the lower rim towards selected nitroaromatic compounds (NACs) was evaluated. Their affinity, or lack of it, was determined by UV-Vis absorption, fluorescence and NMR spectroscopy. Different computational methods were also used to further investigate any possible complexation between the calixarenes and the NACs. All the results show no significant interaction between calixarenes 1 and 2 and the NACs in either dichloromethane or acetonitrile solutions. Moreover, the fluorescence quenching observed is only apparent and merely results from the absorption of the NACs at the excitation wavelength (inner filter effect). This evidence is in stark contrast with reports in the literature for similar calixarenes. A naphthyl urea dihomooxacalix[4]arene (3) is also subject to the inner filter effect and is shown to form a stable complex with trinitrophenol; however, the equilibrium association constant is greatly overestimated if no correction is applied (9400 M-1 vs 3000 M-1), again stressing the importance of taking into account the inner filter effect in these systems.

Home Based Rehabilitation in Children and Adolescents with Cystic Fibrosis: A Systematic Review with Meta-Analysis and Grade Recommendations.

OBJECTIVE: The objective of this study is to elucidate the effectiveness of home based rehabilitation (HBR) and compare its results with those obtained in conventional rehabilitation (CR) programs, carried out in clinics and/or outpatient clinics. METHODS: Searches were conducted in five databases of randomized clinical trials. Study selection, data extraction, and assessment of the methodological quality of included studies were conducted independently by two reviewers, with discrepancies resolved by a third reviewer. RESULTS: The results demonstrate post-intervention values favorable to the use of HBR when compared to control group in the outcomes of forced expiratory volume in 1 second (FEV1) (MD = 14% CI: 5.42 to 22.58, p = 0.001), forced vital capacity (FVC) (MD = 8.00% CI: 0.83 to 15.17, p = 0.03) and quality of life by the Cystic Fibrosis Questionnaire - revised in the categories (Child version score" (MD= 0.71%CI: 0.15 to 1.27, p = 0.01) and "Parent version score" (MD= 0.67%CI: 0.11 to 1.23, p = 0.02). Furthermore, we noticed an increase in the distance covered in the 6-minute walk test (MD= 34.75%CI: -8.00 to 77.50, p = 0.14), in favor of HBR. CONCLUSIONS: We found that supervised or partially supervised HBR promotes improvements in FEV1, FVC and related quality of life in children and/or adolescents with cystic fibrosis.

Physical activity and exercise training in heart failure with preserved ejection fraction: gathering evidence from clinical and pre-clinical studies.

Conventional treatments for heart failure have failed to improve survival in heart failure with preserved ejection fraction (HFpEF). The current therapy recommendations highlight the importance of symptom management and improvement of patient's well-being or other health-related outcomes. Physical activity/exercise training might be an adjuvant treatment option, since several studies in HFpEF patients reported beneficial effects on exercise intolerance, which is the main symptom associated with this disease. In addition, exercise training was shown to improve quality of life and, in some studies, to improve cardiac function. However, the mechanisms behind these effects are not completely known. The objective of this narrative review is to summarize the main clinical findings regarding the role of physical activity/exercise training in several outcomes, such as hospitalization and mortality, exercise capacity, quality of life, and cardiac function and remodeling. In addition, we will briefly discuss the findings provided by pre-clinical studies. In conclusion, while the impact of physical activity/exercise training on exercise intolerance and quality of life is already well known, its effect on mortality and hospitalization is not well documented, and whether it benefits diastolic function needs further investigation. Some clinical studies showed that exercise training can improve diastolic function, and evidences from pre-clinical studies suggest that this effect is mediated through reduced myocardial stiffness.

Exercise training counteracts the cardiac metabolic remodelling induced by experimental pulmonary arterial hypertension.

Exercise training provides several cardiovascular benefits in both physiological and pathological conditions; however, its use as a therapeutic tool for pulmonary arterial hypertension (PAH) has been poorly explored. This study aimed to extend the comprehension of the cardioprotective effects of exercise training in the set of PAH focusing on the metabolic changes promoted by exercise in the right ventricle (RV). The monocrotaline animal model of PAH was used and male Wistar rats were submitted to two weeks of treadmill exercise training (5 days/week, 60 min/day, 25 m/min) following disease establishment. Trained rats showed an improved diastolic function (lower end-diastolic pressure and tau) despite the presence of cardiac overload (increased peak systolic pressure, end-diastolic pressure and arterial elastance). This enhanced hemodynamic response was paralleled by an increased uptake of glucose to cardiomyocytes through glucose transporter type 4 (GLUT4) followed by increased lactate dehydrogenase (LDH) activity. Exercise did not reverse the decrease of fatty acid oxidation related to PAH but increased the content of the transcription factors peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α) and peroxisome proliferator-activated receptor gamma (PPAR-γ). Two weeks of exercise did not modulate the changes in amino acid metabolism secondary to PAH. Our work suggests that continuous aerobic exercise of moderate intensity, despite its short-term duration and application in a late stage of the disease, supports the RV response to PAH by promoting a shift in the cardiac metabolic phenotype.

Time-dependent evolution of IgG antibody levels after first and second dose of mRNA-based SARS-CoV-2 vaccination in haemodialysis patients: a multicentre study.

BACKGROUND: Vaccination programs are essential for the containment of the coronavirus disease 2019 pandemic, which has hit haemodialysis populations especially hard. Early reports suggest a reduced immunologic response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines in dialysis patients, in spite of a high degree of seroconversion. We aimed to identify risk factors for a reduced efficacy of an mRNA vaccine in a cohort of haemodialysis patients. METHOD: In a multicentre study, including 294 Portuguese haemodialysis patients who had received two doses of BNT162b2 with a 3-week interval, immunoglobulin G-class antibodies against the SARS-CoV-2 spike protein were determined 3 weeks after the first dose (M1) and 6 weeks after the second dose (M2). The threshold for seroconversion was 10 UR/mL. Demographic and clinical data were retrieved from a quality registry. Adverse events were registered using a questionnaire. RESULTS: At M2, seroconversion was 93.1% with a median antibody level of 197.5 U/mL (1.2-3237.0) and a median increase of 180.0 U/mL (-82.9 to 2244.6) from M1. Age [beta -8.9; 95% confidence interval (95% CI) -12.88 to -4.91; P < 0.0001], ferritin >600 ng/mL (beta 183.93; 95% CI 74.75-293.10; P = 0.001) and physical activity (beta 265.79; 95% CI 30.7-500.88; P = 0.03) were independent predictors of SARS-CoV-2 antibody levels after two vaccine doses. Plasma albumin >3.5 g/dL independently predicted the increase of antibody levels between both doses (odds ratio 14.72; 95% CI 1.38 to 157.45; P = 0.03). Only mild adverse reactions were observed in 10.9% of patients. CONCLUSIONS: The SARS-CoV-2 vaccine BNT162b2 is safe and effective in haemodialysis patients. Besides age, iron status and nutrition are possible modifiable modulators of the immunologic response to SARS-CoV-2 mRNA vaccines. These data suggest the need for an early identification of populations at higher risk for diminished antibody production and the potential advantage of the implementation of oriented strategies to maximize the immune response to vaccination in these patients.

In vivo schistosomicidal activity of (±)-licarin A-loaded poly(ε-caprolactone) nanoparticles.

Schistosomiasis mansoni is an infectious parasitic disease caused by worms of the genus Schistosoma, and praziquantel (PZQ) is the medication available for the treatment of schistosomiasis. However, the existence of resistant strains reinforces the need to develop new schistosomicidal drugs safely and effectively. Thus, the (±)-licarin A neolignan incorporated into poly-Ɛ-caprolactone (PCL) nanoparticles and not incorporated were evaluated for their in vivo schistosomicidal activity. The (±)-licarin A -loaded poly(ε-caprolactone) nanoparticles and the pure (±)-licarin A showed a reduction in the number of worm eggs present in spleens of mice infected with Schistosoma mansoni. In addition, the (±)-licarin A incorporated in the concentration of 20 mg/kg and 200 mg/kg reduced the number of worms, presenting percentages of 56.3% and 41.7%, respectively.

Brazilian green propolis reduces worm burden and hepatic granuloma formation in a Schistosoma mansoni experimental murine model.

Characterized as an acute and chronic parasitic disease, schistosomiasis mansoni has as its central pathology the formation of hepatic granulomas in response to the parasite's eggs trapped in the host's liver. In recent years, research on propolis has grown; however, there is little anthelmintic work on this bee product. In the propolis scenario, Brazilian ones receive attention, with green and red propolis standing out. This study aims to evaluate in vivo the standardized extract of Brazilian green propolis (Pex) against Schistosoma mansoni. The in vivo antiparasitic activity of Pex was conducted in female BALB/c mice infected with S. mansoni and of the three groups treated with Pex (300 mg/kg); G2 (35th to 42nd dpi) reduced the total worm burden by 55.32%, followed by G3 (42nd to 49th dpi) and G4 (49th to 56th dpi), with about 46%. Furthermore, G2 significantly reduced the total egg load in the ileum (59.33%) and showed an increase in the dead eggs. Similarly, histological analysis of the livers showed a significant reduction in the number and diameter of the granulomas. Based on these results, there is an interesting schistosomicidal activity of Pex and its potential against the formation of hepatic granulomas, paving the way for more detailed studies of propolis in the animal model of schistosomiasis mansoni.

Standardized exercise training is feasible, safe, and effective in pulmonary arterial and chronic thromboembolic pulmonary hypertension: results from a large European multicentre randomized controlled trial.

AIMS: This prospective, randomized, controlled, multicentre study aimed to evaluate efficacy and safety of exercise training in patients with pulmonary arterial (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). METHODS AND RESULTS: For the first time a specialized PAH/CTEPH rehabilitation programme was implemented in 11 centres across 10 European countries. Out of 129 enrolled patients, 116 patients (58 vs. 58 randomized into a training or usual care control group) on disease-targeted medication completed the study [85 female; mean age 53.6 ± 12.5 years; mean pulmonary arterial pressure 46.6 ± 15.1 mmHg; World Health Organization (WHO) functional class II 53%, III 46%; PAH n = 98; CTEPH n = 18]. Patients of the training group performed a standardized in-hospital rehabilitation with mean duration of 25 days [95% confidence interval (CI) 17-33 days], which was continued at home. The primary endpoint, change of 6-min walking distance, significantly improved by 34.1 ± 8.3 m in the training compared with the control group (95% CI, 18-51 m; P < 0.0001). Exercise training was feasible, safe, and well-tolerated. Secondary endpoints showed improvements in quality of life (short-form health survey 36 mental health 7.3 ± 2.5, P = 0.004), WHO-functional class (training vs. control: improvement 9:1, worsening 4:3; χ2P = 0.027) and peak oxygen consumption (0.9 ± 0.5 mL/min/kg, P = 0.048) compared with the control group. CONCLUSION: This is the first multicentre and so far the largest randomized, controlled study on feasibility, safety, and efficacy of exercise training as add-on to medical therapy in PAH and CTEPH. Within this study, a standardized specialized training programme with in-hospital start was successfully established in 10 European countries.