Long-term impact of SARS-CoV-2 infection on cardiorespiratory fitness: a meta-analysis.

Background: Despite surviving Coronavirus disease 2019 (COVID-19), its long-term impact is of concern. Low cardiorespiratory fitness is a strong predictor of all-cause mortality, and likely affected by multisystem impairments following COVID-19 infection. Accumulating evidence has identified the impact of COVID-19 on cardiorespiratory fitness level. However, the findings have been controversial. Conclusive evidence is still needed. Objectives: This review aimed to systematically summarize and synthesize whether the SARS-CoV-2 infection diminishes cardiorespiratory fitness in COVID-19 survivors. Design: The study design was a systematic review and meta-analysis. Methods: A search was carried out using PubMed, CINAHL, Scopus, Embase and the Cochrane Library, together with reference lists (searching from their inception to January 2023). Observational studies investigating the impact of COVID-19 on outcomes relevant to cardiorespiratory fitness (i.e., peak oxygen uptake) were included. Weighted mean difference (WMD) and 95% confidence interval (CI) were used to identify a pooled effect estimate. Use of a random effects model was considered as the main method. Grading of Recommendation Assessment, Development and Evaluation approach was employed to determine the certainty of evidence. This meta-analysis was registered with PROSPERO (registration number: CRD42023393108). Results: Seven eligible studies (4 cross-sectional, 2 cohort, and 1 case-control studies) involving 4,773 participants were included in this meta-analysis. A pooled effect estimates showed that patients in the surviving COVID-19 group had a significant reduction in peak oxygen uptake when compared to their counterparts in the non-COVID-19 group (WMD -6.70, 95%CI -9.34 to -4.06, low certainty). A subgroup analysis by age found that COVID-19 survivors in the young- to middle-aged and middle- to older-aged subgroups had significant reductions in peak oxygen uptake when compared to their counterparts in the non-COVID-19 group (WMD -5.31, 95%CI -7.69 to -2.94, low certainty; WMD -15.63, 95%CI -28.50 to -2.75, very low certainty, respectively). Subgroup analyses by symptom found that patients with moderate to severe symptoms in the surviving COVID-19 group had significantly lower peak oxygen uptake than their counterparts in the non-COVID-19 group (WMD -15.63, 95%CI -28.50 to -2.75, very low certainty). Conclusion: The current meta-analysis concluded that patients in the COVID-19 survivors had poorer cardiorespiratory fitness than their counterparts in the non-COVID-19 group, but there is considerable uncertainty of evidence. Poorer cardiorespiratory fitness is likely to be more pronounced in COVID-19 survivors who are getting older and had severe symptoms, but it is uncertain whether such finding has a valuable in clinical context. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, CRD42023393108.

Influences of age and gender on operative risks following carotid endarterectomy: A systematic review and meta-analysis.

OBJECTIVES: This review aims to undertake a comprehensive review of the literature and investigate associations of age and gender on 30 days post carotid endarterectomy (CEA) and up to 5 years post CEA stroke, death, and combined stroke and death. DESIGN: A systematic review and meta-analysis. METHODS: Three main electronic databases including the Cochrane Library, MEDLINE, and Embase were searched from their inception to July 2022. Studies examining operative risks (i.e., stroke, death, and combined stroke and death following CEA) linked to age or gender were included. Two independent reviewers were responsible for study selection, quality assessment, and data extraction. Odds ratio (OR) and 95% confidence interval (CI) of all outcomes were calculated. RESULTS: 44609 studies were retrieved from the search. There were 127 eligible studies (80 studies of age, 72 studies of gender, 25 studies of age and gender) for pooling in the meta-analysis. With regards to stroke and death risks within 30 days post CEA; patients aged ≥75 had higher death (OR 1.38; 95% CI 1.10-1.75) than patients aged <75. Patients aged ≥80 had higher stroke risk (OR 1.17; 95% CI 1.07-1.27) and death risk (OR 1.85; 95% CI 1.48-2.30) particular in asymptomatic patients (OR 2.4; 95% CI 1.56-3.81). Pooled effect estimates by gender, at 30 days post CEA, showed that female was associated with increased risk of stroke (OR 1.28; 95% CI 1.16-1.40), with more risk in asymptomatic female patients (OR 1.51; 95% CI 1.14-1.99). CONCLUSIONS: This meta-analysis highlights that older people is associated with increased stroke risk, particularly asymptomatic octogenarians who had higher likelihood of death within 30 days post CEA. In addition, female especially those with asymptomatic carotid stenosis had greater likelihood of stroke within 30 days post CEA surgery.

The Effect of Standard Compression Adjuvant with a Tailored Exercise Training Program on Health-Related Quality of Life Outcomes in Treating Adults with Venous Leg Ulcer: A Randomized Controlled Trial.

Exercise training adjuvant to standard compression is considered to improve calf muscle pump dysfunction in venous leg ulcer (VLU) and subsequent healing. The objectives of this trial were to assess the effectiveness of a tailored exercise training intervention in addition to standard compression therapy on health-related quality of life and anticipating wound healing. Twenty-four VLU participants were recruited and randomly divided into 2 groups. The control group was prescribed conventional compression, and the intervention group received compression plus progressive tailored exercise training. The 14-item chronic venous disease quality of life questionnaire (CIVIQ-14) was used to assess improvement after treatment over time (0, 6, and 12 weeks). Intervention and control groups achieved wound closure for 11 (92%) and 7 (58%) patients. After adjusting for age, sex, and wound size at baseline, the exercise intervention group had 2 times the probability of complete wound healing in 12 weeks than those in the control group (risk ratio = 1.98, 95% CI= 1.01-3.72, P = .047). The primary outcome was the difference in CIVIQ-14 score in 3 dimensions and global index score per visit. The outcomes were evaluated by independent assessors. Demographic, comorbidities, and wound assessments were collected on enrollment. The overall adherence to exercise protocol was 71%. After adjusting age, sex, size of VLU, and CIVIQ score at baseline, the participants in the intervention group had the average global index scores and psychological scores increase at week 12 than those in the control group (21.2; 95% CI= 7.1-35.2, P = .005, and 13.5; 95% CI = 2.9-24.2, P = .044, respectively). Both groups showed similar improvement in the mean change in physical and pain scores within-group over time. Patients with combined conventional compression therapy with exercise training appeared to have a higher quality of life score in psychological and global scores than those with compression therapy alone.

Association of cardio-ankle vascular index and future major adverse cardiovascular events in older adults living with HIV.

ABSTRACTIncreased arterial stiffness is an indicator of cardiovascular disease (CVD) and death in the general population. The cardio-ankle vascular index (CAVI) is a novel method for measuring arterial stiffness. This study investigated the utility of CAVI as a prognostic indicator of CVD and death in older adults living with HIV(OALHIV). Patients aged ≥50 taking antiretroviral treatment with no history of cardiovascular events enrolled from multiple centers in Chiang Mai, Thailand. Participants (N = 347) who underwent CAVI were followed up for five years. The primary endpoint was major adverse cardiovascular events (MACE): a composite of total deaths and hospitalizations due to myocardial infarction, coronary revascularization, stroke, and heart failure. Cox regression analysis determined between normal (<8) and high (≥8) CAVI against the incidence of MACE. Forty-five participants (13.0%) were diagnosed with MACE. The risk of MACE was more significant in high CAVI than normal CAVI (adjusted HR = 2.11, 95% confidence interval 1.06-4.20, p = 0.033). In OALHIV, CAVI was an independent prognosis of MACE, in addition to conventional CVD risk factors. CAVI-assisted to help identify high-risk patients showed the benefit of further evaluation and more intensive therapy to prevent CVD and death.

Immediate Effects of Aerobic Exercise and Whole-Body Vibration on Fat Oxidation, Lipid Mobilization, and Cardiovascular Response in Individuals with Obesity.

Among obesity, cumulative fat and poor physical activity are risk factors for cardiovascular disease. Due to the limit in performing aerobic exercise (AER), whole-body vibration (WBV) as a passive form of exercise is an alternative therapeutic strategy. Herein, this study aimed to compare the immediate effects of AER and WBV on metabolic and cardiovascular responses, and dyspnea level in obesity. Forty-nine eligible obesities performed both AER and WBV, with a random order assignment (age = 28.94 ± 11.39 years). Fat oxidation, cardiovascular parameters (i.e., heart rate (HR) and blood pressure (BP)), and dyspnea level (i.e., rating perceived exertion (RPE)) were measured during exercise, while lipid mobilization (i.e., triglycerides) was collected pre- and post-exercise. Fat oxidation rate in AER was significantly higher than in WBV. Significantly increased fat oxidation rates were shown in both groups (within-group analyses) (also shown in females aged 20-45). Triglyceride levels between AER and WBV were similar. A significant decrease in triglyceride levels was only observed in WBV (within-group change). HR and RPE in AER were significantly higher than in WBV (p < 0.05). HR and RPE were significantly increased throughout both AER and WBV, while systolic blood pressure was only significantly elevated in AER (whining-group analyses). WBV may facilitate fat oxidation (particularly in females aged below 45), induce lipid mobilization, and reduce interference on cardiovascular parameters in obesity.

Associations between maternal plasma zinc concentrations in late pregnancy and LINE-1 and Alu methylation loci in the young adult offspring.

BACKGROUND: In animal models, prenatal zinc deficiency induced epigenetic changes in the fetus, but data in humans are lacking. We aimed to examine associations between maternal zinc levels during pregnancy and DNA methylation in LINE-1 and Alu repetitive sequences in young adult offspring, as well as anthropometry and cardiometabolic parameters. METHODS: Participants were 74 pregnant women from the Chiang Mai Low Birth Weight cohort, and their offspring followed up at 20 years of age. Maternal plasma zinc concentrations were measured at approximately 36 weeks of gestation. DNA methylation levels in LINE-1 and Alu repetitive sequences were measured in the offspring, as well as anthropometry and cardiometabolic parameters (lipid profile, blood pressure, and glucose metabolism). RESULTS: Over half of mothers (39/74; 53%) were zinc deficient (<50 µg/dL) during their third trimester of pregnancy. Maternal zinc concentrations during pregnancy were associated with LINE-1 DNA methylation levels in adult offspring. Specifically, lower prenatal zinc concentrations were associated with: 1) lower levels of total LINE-1 methylation; 2) lower levels of LINE-1 hypermethylation loci; and 3) higher levels of LINE-1 partial methylation loci. Prenatal zinc concentrations were not associated with Alu methylation levels, nor with any anthropometric or cardiometabolic parameters in adult offspring. However, we observed associations between Alu and LINE-1 methylation patterns and cardiometabolic outcomes in offspring, namely total cholesterol levels and diastolic blood pressure, respectively. CONCLUSIONS: Lower maternal zinc concentrations late in gestation were associated with changes in DNA methylation in later life. Thus, zinc deficiency during pregnancy may induce alterations in total LINE-1 methylation and LINE-1 hypermethylation loci. These results suggest a possible epigenetic link between zinc deficiency during pregnancy and long-term outcomes in the offspring.

Upper limb exercise for arteriovenous fistula maturation in people requiring permanent haemodialysis access.

BACKGROUND: The failure of arteriovenous fistulas (AVF) to mature is a major problem in patients with kidney failure who require haemodialysis (HD). Preoperative planning is an important factor in increasing functional AVF. Upper limb exercise has been recommended to gain AVF maturation. Studies of pre- and post-operative upper limb exercises in patients with kidney failure patients have been reported; however, the optimal program for this population is unknown due to inconsistent results among these programs. OBJECTIVES: We aimed to determine if upper limb exercise would be beneficial for AVF maturation (prior to and post AVF creation) in patients with kidney failure and to improve AVF outcomes. This review also aimed to identify adverse events related to upper limb exercise. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 15 March 2022 through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov, and other resources (e.g. reference list, contacting relevant individuals, and grey literature). SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs, comparing upper limb exercise training programs with no intervention or other control programs before or after AVF creation in patients with kidney failure. Outcome measures included time to mature, ultrasound and clinical maturation, venous diameter, blood flow in the inflow artery, dialysis efficacy indicator, vascular access function (functional AVF), vascular access complications, and adverse events. DATA COLLECTION AND ANALYSIS: Study selection and data extraction were taken by four independent authors. Bias assessment and quality assessment were undertaken independently by two authors. The effect estimate was analysed using risk ratio (RR) with 95% confidence intervals (CI) for dichotomous data, or mean difference (MD) or standardised mean difference (SMD) for continuous data. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: Nine studies (579 participants) were included, and seven studies (519 participants) conducting post-operative exercise training could be meta-analysed. Three comparisons were undertaken: (i) isotonic exercise training versus no intervention; (ii) isometric versus isotonic exercise training; and (iii) isotonic (high volume) versus isotonic exercise training (low volume). Due to insufficient data, we could not analyse pre-operative exercise training. Overall, the risk of bias was low for selection and reporting bias, high for performance and attrition bias, and unclear for detection bias. Compared to no intervention, isotonic exercise training may make little or no difference to ultrasound maturation (2 studies, 263 participants: RR 1.09, 95% CI 0.94 to 1.25; I² = 0%; low certainty evidence), but may improve clinical maturation (2 studies, 263 participants: RR 1.14, 95% CI 1.02 to 1.27; I² = 0%; low certainty evidence). Compared to isotonic exercise training, isometric exercise training may improve both ultrasound maturation (3 studies, 160 participants: RR 1.56, 95% CI 1.21 to 2.00; I² = 22%; low certainty evidence) and clinical maturation (3 studies, 160 participants: RR 1.80, 95% CI 1.18 to 2.76; I² = 53%; low certainty evidence). Venous diameter (3 studies, 160 participants: MD 0.84 mm, 95% CI 0.45 to 1.23; I² = 0%; low certainty evidence) and blood flow in the inflow artery (3 studies, 160 participants: MD 140.62 mL/min, 95% CI 38.72 to 242.52; I² = 0%; low certainty evidence) may be greater with isometric exercise training. It is uncertain whether isometric exercise training reduces vascular access complications (2 studies, 110 participants: RR 2.54, 95% CI 0.38 to 17.08; I² = 47%; very low certainty evidence). It is uncertain whether high volume isotonic exercise training improves venous diameter (2 studies, 93 participants: MD 0.19 mm, 95% CI -0.75 to 1.13; I² = 34%; very low certainty evidence) or blood flow in the inflow artery (1 study, 15 participants: MD -287.70 mL/min, 95% CI -625.99 to 60.59; very low certainty evidence) compared to low volume isotonic exercise training. None of the included studies reported time to mature, dialysis efficacy indicator, vascular access function, or adverse events. AUTHORS' CONCLUSIONS: Our findings suggest that the current research evidence examining upper limb exercise programs is of low quality, attributable to variability in the type of interventions used and the overall low number of studies and participants.

Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting).

BACKGROUND: Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. The shunt may improve the outcome. This is an update of a Cochrane review originally published in 1996 and previously updated in 2002, 2009, and 2014. OBJECTIVES: To assess the effect of routine versus selective or no shunting, and to assess the best method for selective shunting on death, stroke, and other complications in people undergoing carotid endarterectomy under general anaesthesia. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched April 2021), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2021, Issue 4), MEDLINE (1966 to April 2021), Embase (1980 to April 2021), and the Science Citation Index Expanded (SCI-EXPANDED) (1980 to April 2021). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform, and handsearched relevant journals, conference proceedings, and reference lists. SELECTION CRITERIA: Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in people undergoing carotid endarterectomy. DATA COLLECTION AND ANALYSIS: Three independent review authors performed data extraction, selection, and analysis. A pooled Peto odds ratio (OR) and 95% confidence interval (CI) were computed for all outcomes of interest. Best and worse case scenarios were also calculated in case of unavailable data. Two authors independently assessed risk of bias, and quality of evidence using GRADE. MAIN RESULTS: No new trials were found for this updated review. Thus, six trials involving 1270 participants are included in this latest review: three trials involving 686 participants compared routine shunting with no shunting, one trial involving 200 participants compared routine shunting with selective shunting, one trial involving 253 participants compared selective shunting with and without near-infrared refractory spectroscopy monitoring, and the other trial involving 131 participants compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. Only three trials comparing routine shunting and no shunting were eligible for meta-analysis. Major findings of this comparison found that the routine shunting had less risk of stroke-related death within 30 days of surgery (best case) than no shunting (Peto odds ratio (OR) 0.13, 95% confidence interval (CI) 0.02 to 0.96, I2 not applicable, P = 0.05, low-quality evidence), the routine shunting group had a lower stroke rate within 24 hours of surgery (Peto odds ratio (OR) 0.15, 95% CI 0.03 to 0.78, I2 = not applicable, P = 0.02, low-quality evidence), and ipsilateral stroke within 30 days of surgery (best case) (Peto OR 0.41, 95% CI 0.18 to 0.97, I2 = 52%, P = 0.04, low-quality evidence) than the no shunting group. No difference was found between the groups in terms of postoperative neurological deficit between selective shunting with and without near-infrared refractory spectroscopy monitoring. However, this analysis was inadequately powered to reliably detect the effect. There was no difference between the risk of ipsilateral stroke in participants selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared with pressure assessment alone, although again the data were limited. AUTHORS' CONCLUSIONS: This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy when performed under general anaesthesia. Large-scale randomised trials of routine shunting versus selective shunting are required. No method of monitoring in selective shunting has been shown to produce better outcomes.

The Ability of Clinical Decision Rules to Detect Peripheral Arterial Disease: A Narrative Review.

Peripheral arterial disease (PAD) is a common cause of lower extremity wound. Consequently, PAD leads to a cause of leg amputation nowadays, especially in diabetic patients. In general practice (GP), confrontation with PAD prevention is a challenge. In general, ankle-brachial index (ABI) measurement can be used as a PAD diagnostic tool, but this takes some time. The tool is not generally available and this need to train healthcare workers to perform. Multiple independent predictors developed the diagnostic prediction model known as clinical decision rules (CDRs) to identify patients with high-risk PAD. This might therefore limit the number of patients (only high-risk patients) to refer for ABI evaluation. This narrative review summarized existing CDRs for PAD.

A randomized controlled trial of the effect of postoperative hand exercise training on arteriovenous fistula maturation in patients with chronic kidney disease.

OBJECTIVE: Immature arteriovenous fistula (AVF) is a critical problem in patients with chronic kidney disease (CKD) after creation. Exercise with 30% maximum voluntary contraction (MVC) encourages vascular functions in other populations. It is unknown which exercise type is superior on maturation in the CKD population. We compare effects of isometric (ISM) and isotonic (IST) hand exercise training, both at 30% MVC, on AVF maturation and grip strength in patients with CKD. METHODS: Fifty patients with CKD were randomized into the ISM program or IST program (25 per group). Each group performed exercise program at intensity of 30% MVC every day for 10 weeks. Cephalic vein (CV) and brachial artery diameters, brachial blood flows, and grip strength were measured at weeks 0, 2, 6, and 10 of the program. The number of patients meeting clinical and ultrasound maturation were evaluated at weeks 2, 6, and 10. RESULTS: At weeks 6 and 10 of the programs, the ISM group had greater CV diameters (week 6, 7.1 ± 1.2 vs 6.2 ± 1.0 mm; week 10, 7.1 ± 1.0 vs 6.2 ± 1.1 mm) than the IST group. Compared with the IST group, the ISM group had a higher number of patients meeting ultrasound maturation at weeks 2 (IST/ISM, 8/2), 6 (IST/ISM, 16/8), and 10 (IST/ISM, 21/12), and clinical maturation at week 10 (IST/ISM, 25/18). No adverse events were observed throughout the study. CONCLUSIONS: At 30% MVC, ISM is more effective at promoting increases in CV diameter and maturation than IST. Both exercise types are feasible and safe for patients with CKD after AVF creation.

Effectiveness of combined conventional treatment with a tailored exercise training program on wound healing in patients with venous leg ulcer: A randomized controlled trial.

INTRODUCTION: Venous leg ulcer (VLU) is a therapeutic challenge. The mainstay of care is compression therapy and wound care. Exercise is also recommended for facilitating wound healing. This study aimed to determine whether adding tailored exercise training to conventional treatment would be superior on wound healing, ankle mobility, calf muscle function, and functional ability compared to those with the conventional treatment alone. METHODS: A randomized controlled trial, single-blinded was conducted. VLU patients were randomized to the conventional treatment plus tailored exercise training (intervention group) and the conventional treatment alone (control group) (12/group). The conventional treatment contained foam dressing and short-stretch bandage, while the tailored exercise training consisted of stretching, resistive, and aerobic exercise sessions (3-day/week, for 12-week). Primary outcomes included healing rate and wound size parameters. Secondary outcomes were ankle range of motion (ROM), calf circumference, calf muscle endurance and strength, and functional ability. All outcomes were assessed at baseline, 6-, and 12-week intervention. RESULTS: The intervention group had a higher trend of healing rate after 12-week training than those in the control group, but this trend was not significantly different (92% versus 58%, p = 0.06). After training, the intervention group had significantly decreased wound size. The intervention group had significantly higher ankle ROM and dorsiflexor muscle strength after 6- and 12-week training than those in the control group. CONCLUSION: Adding the tailored exercise training incorporated with the conventional treatment may provide a greater tendency on wound healing and have the potential to improve ankle mobility than the conventional treatment alone. TRIAL REGISTRATION NUMBER: TCTR20170405002.

Agreement between physical and ultrasound examination for arteriovenous fistula maturation diagnostics in Thai hemodialysis patients.

INTRODUCTION: Physical examination (PE) is used to determine if arteriovenous fistula (AVF) meets criteria for first hemodialysis (HD) cannulation in chronic kidney disease (CKD) with HD patients. Three ultrasound (US) based criteria are adopted to investigate maturation: (i) Rule of Six: blood flow ⩾600 milliliters per minute (mL/min), vein diameter ⩾6 millimeters (mm), vein depth ⩽6 mm); (ii) Rule of Five: blood flow ⩾500 mL/min, vein diameter ⩾5 mm, vein depth ⩽6 mm; and (iii) Rule of Four: blood flow ⩾500 mL/min, vein diameter ⩾4 mm, vein depth ⩽6 mm. In Thai, no study determined optimal US criteria for predicting AVF maturation measured by PE before first cannulation. This study examined the significance of these US criteria on the physical AVF maturation in Thai. METHODS: Fifty CKD patients, operated brachiocephalic AVF, were enrolled and examined on the operative day and 6 weeks afterwards. PE was evaluated by an experienced vascular surgeon, and US measurements were obtained by an experienced US technologist. Matching mature number between US criteria and PE was computed using McNemar test. Agreement between US criteria and PE was measured using Kappa. Mature and immature discrimination were evaluated by the Receiver Operator Characteristics (ROC) curve and Youden index. RESULTS: Rule of Six and Rule of Five had higher non-mature matching number than Rule of Four (p < 0.001 both). Regarding Kappa statistics, Rule of Six and Rule of Five agreed with the PE (p < 0.01 both). The ROC curve of Rule of Six and Rule of Five were 0.75 and 0.74, respectively (p <0.01 both). Youden index (maturity and immaturity discriminating performance) of both rules was 0.5 and 0.47, respectively. CONCLUSION: Rule of Six and Rule of Five agreed with the PE, with the highest performance of the Rule of Six to predict first successful cannulation in Thai.

Exercise Training as an Adjunctive Therapy for Chronic Venous Insufficiency Patients: Evidence from Research to Practice.

Chronic venous insufficiency, which is defined as a condition relevant to persistent ambulatory venous hypertension, is a common cause of venous leg ulcers. Compression therapy is commonly used to relieve ambulatory venous hypertension and heal leg ulcers. Exercise is considered as adjunctive therapy, targeting calf muscle pump function, to additionally favor the compression treatment for facilitating the healing process. Different exercise training regimens for promoting wound healing and its relevant outcomes are reviewed and discussed in this study.

Local versus general anaesthesia for carotid endarterectomy.

BACKGROUND: Carotid endarterectomy may significantly reduce the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks that may be minimised by performing the operation under local rather than general anaesthetics. This is an update of a Cochrane Review first published in 1996, and previously updated in 2004, 2008, and 2013. OBJECTIVES: To determine whether carotid endarterectomy under local anaesthetic: 1) reduces the risk of perioperative stroke and death compared with general anaesthetic; 2) reduces the complication rate (other than stroke) following carotid endarterectomy; and 3) is acceptable to individuals and surgeons. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and two trials registers (to February 2021). We also reviewed reference lists of articles identified. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing the use of local anaesthetics to general anaesthetics for people having carotid endarterectomy were eligible. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted data, assessed risk of bias, and evaluated quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool. We calculated a pooled Peto odds ratio (OR) and corresponding 95% confidence interval (CI) for the following outcomes that occurred within 30 days of surgery: stroke, death, ipsilateral stroke, stroke or death, myocardial infarction, local haemorrhage, and arteries shunted. MAIN RESULTS: We included 16 RCTs involving 4839 participants, of which 3526 were obtained from the single largest trial (GALA). The main findings from our meta-analysis showed that, within 30 days of operation, neither incidence of stroke nor death were significantly different between local and general anaesthesia. Of these, the incidence of stroke in the local and general anaesthesia groups was 3.2% and 3.5%, respectively (Peto odds ratio (OR) 0.91, 95% confidence interval (CI) 0.66 to 1.26; P = 0.58; 13 studies, 4663 participants; low-quality evidence). The rate of ipsilateral stroke under both types of anaesthesia was 3.1% (Peto OR 1.03, 95% CI 0.71 to 1.48; P = 0.89; 2 studies, 3733 participants; low-quality evidence). The incidence of stroke or death in the local anaesthesia group was 3.5%, while stroke or death incidence was 4.1% in the general anaesthesia group (Peto OR 0.85, 95% CI 0.62 to 1.16; P = 0.31; 11 studies, 4391 participants; low-quality evidence). A lower rate of death was observed in the local anaesthetic group but evidence was of low quality (Peto OR 0.61, 95% CI 0.35 to 1.06; P = 0.08; 12 studies, 4421 participants). AUTHORS' CONCLUSIONS: The incidence of stroke and death were not convincingly different between local and general anaesthesia for people undergoing carotid endarterectomy. The current evidence supports the choice of either approach. Further high-quality studies are still needed as the evidence is of limited reliability.

A systematic review with meta-analysis of the effects of arm exercise training programs on arteriovenous fistula maturation among people with chronic kidney disease.

This study systematically reviewed the evidence and quantified the effectiveness of arm exercise training programs, before and after arteriovenous fistula (AVF) operation on AVF maturation, among people with chronic kidney disease. Scopus, CINAHL, PubMed, Science Direct, Cochrane Library, and reference lists were searched. Experimental studies that investigated the effect of arm exercise before and post-operation on AVF maturations were included. Screened and extracted data were administered by two independent reviewers. Seven studies with preoperative exercise were included in a systematic review, while five studies were analyzed in a meta-analysis. Preoperative exercise significantly increased vessel diameters and grip strength after training. Postoperative exercise had higher clinical and ultrasonographic (US) maturation rates and arterial blood flow than controls (risk ratio [RR], 1.44; 95% confidence interval [CI], 1.23-1.69; RR, 1.27; 95% CI, 1.02-1.57; weight mean difference, 166.03; 95% CI, 27.58-304.49, respectively). Subgroup analysis showed that isometric exercise training promoted clinical and US maturations (RR, 2.40; 95% CI, 1.51-3.82; RR, 1.53; 95% CI, 1.02-2.30, respectively), whereas isotonic exercise promoted clinical maturation (RR, 1.18; 95% CI, 1.03-1.34). Grip strength had a greater trend in the intervention group than controls (standardized mean difference, 0.59; 95% CI, -0.06 to 1.25). In conclusion, arm exercise training improves vascular function, which is essential before surgery. The meta-analysis suggested that arm exercise training promotes AVF clinical and US maturations after surgery. Subgroup analysis suggested that isometric-arm exercise training may have a larger effect on AVF maturation. However, more studies are needed to draw a solid conclusion.