Diagnostic patterns of serum inflammatory protein markers in children with Lyme neuroborreliosis.

Definite diagnosis of Lyme neuroborreliosis (LNB) requires investigation of serum and cerebrospinal fluid (CSF). Thus, lumbar puncture is necessary, and requires administration of sedating drugs in children. This study aimed to investigate if a pattern of different inflammatory biomarkers in serum could contribute to the selection of children for lumbar puncture in suspected LNB. Patients were included from a cohort of children who was previously investigated for LNB including serum and CSF sampling during the years 2010-2014. The multiplex proximity extension assay (PEA) inflammation panel Target 96 (Olink Bioscience, Uppsala, Sweden) was used to examine 92 biomarkers in serum. Based on the presence of CSF pleocytosis and Borrelia-specific antibodies, patients were divided into a definite LNB group (n=61) and a non-LNB control group (n=58). Following PEA and statistical analysis with multivariate logistic regression, five biomarkers remained significant (p < 0.001), which were included in a calculation of protein index. The index biomarkers were CST5, IL-15RA, CXCL10, DNER and CX3CL1. A receiver operating characteristic curve was constructed from the index, which showed an 80 % sensitivity and 81 % specificity. Area under the curve was 0.889. We offer evidence that, with further refinements, patterns of serum biomarkers might help identify those children more or less likely to have LNB, perhaps ultimately decreasing the need for lumbar punctures.

Cell-Mediated Proteomics, and Serological and Mucosal Humoral Immune Responses after Seasonal Influenza Immunization: Characterization of Serological Responders and Non-Responders.

Immunization against influenza through vaccination is the most effective method with which to prevent infection. To assess protection after immunization, analysing humoral response with a hemagglutinin inhibition assay is the gold standard, but cell-mediated immune response has been shown to better correlate with protection in the elderly. Our aim was to explore the influenza-specific cell-mediated and mucosal humoral responses in serologically defined responders and non-responders. We analysed sera for total immunoglobulins (Ig) A, G, and M and nasal swab samples for influenza-specific IgA. Peripheral blood mononuclear cells were stimulated with trivalent influenza vaccine VaxiGripTetra, and supernatants were analysed for influenza-specific responses with the Olink Immune-Oncology panel using a proximity extension assay. We included 73 individuals, of which 69 completed the study with follow-up sampling at one and six months post-vaccination. Of the 73, 51 (70%) were found to be serological responders and 22 (30%) were non-responders. We did not find any significant differences in sex or mucosal humoral response between responders and non-responders; however, a higher IFNγ/IL-10 ratio in individuals ≤65 years of age indicates an enhanced cell-mediated immune response in this age group. Characteristics of the non-responders were found to be higher levels of IgM, Granzyme B and Interleukin 12, and lower levels of C-X-C motif chemokine 13 compared with those of the responders. In conclusion, our results did not show any correlation between serological response and age. Furthermore, the majority of influenza-specific cell-mediated immune markers did not differ between responders and non-responders; the immune marker profile of the non-responders and its contribution to protection is of interest but needs to be further explored.

Estimated glomerular filtration rate as a tool for early identification of patients with insufficient exposure to beta-lactam antibiotics in intensive care units.

BACKGROUND: Only about 50% of intensive care unit (ICU) patients reach a free trough concentration above MIC (100% fT > MIC) of beta-lactam antibiotics. Although dose adjustments based on therapeutic drug monitoring (TDM) could be beneficial, TDM is not widely available. We investigated serum creatinine-based estimated GFR (eGFR) as a rapid screening tool to identify ICU patients at risk of insufficient exposure. METHOD: Ninety-three adult patients admitted to four ICUs in southeast Sweden treated with piperacillin/tazobactam, meropenem, or cefotaxime were included. Beta-lactam trough concentrations were measured. The concentration target was set to 100% fT > MICECOFF (2, 4, and 16 mg/L based on calculated free levels for meropenem, cefotaxime, and piperacillin, respectively). eGFR was primarily determined via Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) and compared to three other eGFR equations. Data was analysed using logistic regression and receiver operative characteristic (ROC) curves. RESULTS: With intermittent standard dosing, insufficient exposure was common in patients with a relative eGFR ≥48mL/min/1.73m2 [85%, (45/53)], particularly when treated with cefotaxime [96%, (24/25)]. This eGFR cut-off had a sensitivity of 92% and specificity of 82% (AUC 0.871, p < 0.001) in identifying insufficient exposure. In contrast, patients with eGFR <48mL/min/1.73m2 had high target attainment [90%, (36/40)] with a wide variability in drug exposure. There was no difference between the four eGFR equations (AUC 0.866-0.872, cut-offs 44-51 ml/min/1.73m2). CONCLUSION: Serum creatinine-based eGFR is a simple and widely available surrogate marker with potential for early identification of ICU patients at risk of insufficient exposure to piperacillin, meropenem, and cefotaxime.

Associations between self-care advice and healing time in patients with venous leg ulcer- a Swedish registry-based study.

BACKGROUND: Venous leg ulcers take time to heal. It is advocated that physical activity plays a role in healing, and so does the patient's nutritional status. Additionally, malnutrition influences the inflammatory processes, which extends the healing time. Therefore, the staff's advising role is important for patient outcomes. Thus, this study aimed to investigate the associations between given self-care advice and healing time in patients with venous leg ulcers while controlling for demographic and ulcer-related factors. METHODS: The sample consisted of patients registered in the Registry of Ulcer Treatment (RUT) which includes patient and ulcer-related and healing variables. The data was analyzed with descriptive statistics. Logistic regression models were performed to investigate the influence of self-care advice on healing time. RESULTS: No associations between shorter healing time (less than 70 days) and the staff´s self-care advice on physical activity was identified, whilst pain (OR 1.90, CI 1.32-2.42, p < 0.001) and giving of nutrition advice (OR 1.55, CI 1.12-2.15, p = 0.009) showed an association with longer healing time. CONCLUSIONS: Neither self-care advice on nutrition and/or physical activity indicated to have a positive association with shorter healing time. However, information and counseling might not be enough. We emphasize the importance of continuously and systematically following up given advice throughout ulcer management, not only when having complicated ulcers.

Exercise Systolic Blood Pressure Response During Cycle Ergometry is Associated with Future Hypertension in Normotensive Individuals.

AIMS: We aimed to investigate the association between the exercise systolic blood pressure (SBP) response and future hypertension (HTN) in normotensive individuals referred for cycle ergometry, with special regard to reference exercise SBP values, and exercise capacity. METHODS: In this longitudinal cohort study, data from 14,428 exercise tests were cross-linked with Swedish national registries on diagnoses and medications. We excluded individuals with a baseline diagnosis of cardiovascular disease or HTN. The peak exercise SBP (SBPpeak) was recorded and compared to the upper limit of normal (ULN) derived from SBPpeak reference equations incorporating age, sex, resting SBP and exercise capacity. To evaluate the impact of exercise capacity, three SBP to work rate slopes (SBP/W-slopes), were calculated, relative to either supine or seated SBP at rest or to the first exercise SBP. Adjusted hazard ratios (HRadjusted [95% Confidence interval, CI]) for incident HTN during follow-up, in relation to SBP response metrics, were calculated. RESULTS: We included 3,895 normotensive individuals (49±14 years, 45% females) with maximal cycle ergometer tests. During follow-up (median 7.5 years) 22% developed HTN. Higher SBPpeak and SBPpeak>ULN were associated with incident HTN (HRadjusted 1.19 [1.14-1.23] per 10 mmHg, and 1.95 [1.54-2.47], respectively). All three SBP/W-slopes were positively associated to incident HTN, particularly the SBP/W-slope calculated as supine-to-peak SBP (HRadjusted 1.25 [1.19-1.31] per 1 mmHg/10W). CONCLUSION: Both SBPpeak>ULN based on reference values and high SBP/W-slopes were associated with incident HTN in normotensive individuals and should be considered in the evaluation of the cycle ergometry SBP response.

We examined the systolic blood pressure response during maximal bicycle exercise testing in individuals without hypertension or established cardiovascular disease, and found that: When applying reference values for peak systolic blood pressure during cycling exercise, accounting for age, sex, resting blood pressure and exercise capacity, exceeding the upper limit of normal was associated with twice as high relative risk of future hypertension, compared to having a peak systolic blood pressure within normal limits. A steep increase in exercise blood pressure in relation to the increase in work rate was also associated with future hypertension but did not always coincide with elevated peak systolic blood pressure.

Identification of potential biomarkers in active Lyme borreliosis.

OBJECTIVES: Lyme serology does not readily discriminate an active Lyme borreliosis (LB) from a previous Borrelia infection or exposure. Here, we aimed to investigate a large number of immunological protein biomarkers to search for an immunological pattern typical for active LB, in contrast to patterns found in healthy blood donors, a proportion of whom were previously exposed to Borrelia. METHODS: Serum samples from well-characterised adult patients with ongoing LB and healthy blood donors were included and investigated using a proximity extension assay (provided by Olink®) by which 92 different immune response-related human protein biomarkers were analysed simultaneously. RESULTS: In total, 52 LB patients and 75 healthy blood donors were included. The blood donors represented both previously Borrelia exposed (n = 34) and not exposed (n = 41) based on anti-Borrelia antibody status. Ten of the examined 92 proteins differed between patients and blood donors and were chosen for further logistic regression (p<0.1). Six proteins were statistically significantly different between LB patients and blood donors (p<0.05). These six proteins were then combined in an index and analysed using receiver-operating-characteristic curve analysis showing an area under the curve of 0.964 (p<0.001). CONCLUSIONS: The results from this study suggest that there is an immunological protein pattern that can distinguish a present Borrelia infection from a previous exposure as well as anti-Borrelia antibody negative blood donors. Although this method is not adapted for routine clinical use at this point, the possibility is interesting and may open new diagnostic opportunities improving the laboratory diagnostics of LB.

Prognostic value of peak work rate indexed by left ventricular diameter.

Left ventricular diameter (LVEDD) increases with systematic endurance training but also in various cardiac diseases. High exercise capacity associates with favorable outcomes. We hypothesized that peak work rate (Wpeak) indexed to LVEDD would carry prognostic information and aimed to evaluate the association between Wpeak/LVEDDrest and cardiovascular mortality. Wpeak/LVEDDrest (W/mm) was calculated in patients with an echocardiographic examination within 3 months of a maximal cycle ergometer exercise test. Low Wpeak/LVEDDrest was defined as a value below the sex- and age-specific 5th percentile among lower-risk subjects. The association with cardiovascular mortality was evaluated using Cox regression. In total, 3083 patients were included (8.0 [5.4-11.1] years of follow-up, 249 (8%) cardiovascular deaths). Wpeak/LVEDDrest (W/mm) was associated with cardiovascular mortality (adjusted hazard ratio (HR) 0.28 [0.22-0.36]), similar to Wpeak in % of predicted, with identical prognostic strength when adjusted for age and sex (C-statistics 0.87 for both). A combination of low Wpeak/LVEDDrest and low Wpeak was associated with a particularly poor prognosis (adjusted HR 6.4 [4.0-10.3]). Wpeak/LVEDDrest was associated with cardiovascular mortality but did not provide incremental prognostic value to Wpeak alone. The combination of a low Wpeak/LVEDDrest and low Wpeak was associated with a particularly poor prognosis.

Reference equations for breathlessness during incremental cycle exercise testing.

Background: Exertional breathlessness is commonly assessed using incremental exercise testing (IET), but reference equations for breathlessness responses are lacking. We aimed to develop reference equations for breathlessness intensity during IET. Methods: A retrospective, consecutive cohort study of adults undergoing IET was carried out in Sweden. Exclusion criteria included cardiac or respiratory disease, death or any of the aforementioned diagnoses within 1 year of the IET, morbid obesity, abnormally low exercise capacity, submaximal exertion or an abnormal exercise test. Probabilities for breathlessness intensity ratings (Borg CR10) during IET in relation to power output (%predWmax), age, sex, height and body mass were analysed using marginal ordinal logistic regression. Reference equations for males and females were derived to predict the upper limit of normal (ULN) and the probability of different Borg CR10 intensity ratings. Results: 2581 participants (43% female) aged 18-90 years were included. Mean breathlessness intensity was similar between sexes at peak exertion (6.7±1.5 versus 6.4±1.5 Borg CR10 units) and throughout exercise in relation to %predWmax. Final reference equations included age, height and %predWmax for males, whereas height was not included for females. The models showed a close fit to observed breathlessness intensity ratings across %predWmax values. Models using absolute W did not show superior fit. Scripts are provided for calculating the probability for different breathlessness intensity ratings and the ULN by %predWmax throughout IET. Conclusion: We present the first reference equations for interpreting breathlessness intensity during incremental cycle exercise testing in males and females aged 18-90 years.

Loss of pulp vitality correlated with the duration of the interim restoration and the experience of the dentist: A retrospective study.

STATEMENT OF PROBLEM: The second most common biological complication in fixed prosthodontics is loss of pulp vitality, which may lead to restoration loss. While reasons for loss of pulp vitality are unclear, 2 potential contributing factors, duration of the interim restoration and operator experience, have not been fully investigated. PURPOSE: The purpose of this retrospective study was to investigate whether the duration of the interim restoration or the experience of the dentist was correlated with loss of pulp vitality. MATERIAL AND METHODS: Fixed prosthetic restorations placed between 2005 and 2012 were retrospectively analyzed. Abutment teeth supporting single-unti or multiunit restorations were evaluated regarding loss of pulp vitality. The Mann-Whitney U test and simple logistic regression were used, with α=.05 for the subsequent multiple logistic regression. The experience of dental professionals was defined by the number of treatments performed and coupled with failure rate by using an analysis of variance. RESULTS: One hundred seventy-four dentists made 15 879 restorations, of which 1136 failed during the observation period, a failure rate of 7.2%. Two hundred fifty restorations were randomly selected from the failed restorations, and a corresponding 250 restorations were randomly selected from nonfailed restorations for the control group. Increased duration with interim replacement was linked to a higher risk of loss of pulp vitality (P<.001). Failure rate in the dentist group varied from 0% to 100%. No significant differences in failure rate were found among dentists who did few restorations and those who performed larger numbers of restorations. CONCLUSIONS: The results of the present study suggest that operator experience does not affect failure rate. However, extended time with an interim restoration was a contributing factor to the loss of pulp vitality.

Treatment with CoreTherm in 570 patients with prostate volumes of 80-366 ml: an evaluation of short- and long-term retreatment risk.

INTRODUCTION: CoreTherm (ProstaLund AB, Lund, Sweden) is an outpatient treatment option in men with lower urinary tract symptoms and catheter-dependent men with chronic urinary retention caused by benign prostatic obstruction (BPO). CoreTherm is high-energy transurethral microwave thermotherapy with feedback technique. Modern treatment with CoreTherm includes transurethral intraprostatic injections of mepivacaine and adrenaline via the Schelin Catheter (ProstaLund AB, Lund, Sweden) and is often referred to as the CoreTherm Concept. OBJECTIVES: The aim of this study was to evaluate the short- and long-term retreatment risk in men with large prostates and BPO or chronic urinary retention, all primarily treated with CoreTherm. MATERIAL AND METHODS: All men from the same geographical area with prostate volumes ≥ 80 ml treated 1999-2015 with CoreTherm and having BPO or were catheter-dependent due to chronic urinary retention, were included. End of study period was defined as December 31, 2019. RESULTS: We identified and evaluated 570 men treated with CoreTherm, where 12% (71 patients) were surgically retreated during the follow-up. Mean follow-up was 11 years, and maximum follow-up was 20 years. The long-term retreatment rate in our study was 23%. A majority of these could be retreated with CoreTherm or TURP, with only 3% requiring open surgery. CONCLUSION: We conclude that CoreTherm is a suitable outpatient treatment option in patients with profoundly enlarged prostates, regardless of age, prostate size, and reason for treatment.

The relationship between six-minute walked distance and health-related quality of life in patients with chronic heart failure.

Objectives. To assess the relationship between the six-minute walk test (6MWT) and health-related quality of life (HRQL) in patients with chronic heart failure. Methods. Forty-six patients (37 men and 9 women) with chronic heart failure, mean age 68 (SD 9), NYHA II-III and EF 29 (9) % were included. They performed 6MWT and assessed HRQL using two tools, a Swedish version of the 36-item Short Form (SF-36) and the Minnesota Living with Heart Failure Questionnaire (MLHFQ). This was performed repeatedly during a study period of one year. Results. Patients with a walking distance lower than median experienced a lower HRQL than the higher performing half of the cohort, in four dimensions of the SF-36 and the summary of physical and mental components, but not in the dimensions of MLHFQ. Conclusion. Patients with heart failure with a short walking distance assessed their quality of life as inferior in half of the dimensions in the SF-36 but not in the dimensions measured with the MLHFQ. Thus, different aspects of the symptomatology are uncovered using the 6MWT and the different HRQL tools.

Detection of Neoehrlichia mikurensis DNA in blood donors in southeastern Sweden.

BACKGROUND: The tick-borne bacterium Neoehrlichia mikurensis can cause persistent asymptomatic bloodstream infections, but transfusion-mediated transmission has not been reported. This study aimed to investigate the prevalence of N. mikurensis in blood donors, and recipients of blood components from N. mikurensis-positive donors were traced. METHODS: In 2019 and 2021, 1007 blood donors were recruited. Participants completed a questionnaire and additional blood samples were collected during blood donation. Detection of N. mikurensis was performed by PCR followed by sequencing. Positive donors were interviewed and retested. Look-back was performed on positive donations and on all subsequent donations. RESULTS: N. mikurensis was detected in 7/1006 (0.7%) donors. A total of 380/1005 (38%) donors reported at least one noticed tick bite during the current season. The questionnaire could not detect any differences between negative and positive N. mikurensis-donors. Two of the positive donors were still positive on days 318 and 131 after the index donation, respectively. One donor with persistent N. mikurensis in blood experienced slight fatigue. All other had no symptoms attributable to neoehrlichiosis. Look-back included ten donations and 20 blood components. Eight components were discarded, and 12 recipients of N. mikurensis-positive donations were identified. PCR was negative in seven recipients. Five recipients had died, but their medical records gave no evidence for neoehrlichiosis. CONCLUSIONS: Although N. mikurensis was found in 0.7% of blood donors, transfusion-mediated infection was not detected, despite several recipients being at high risk for severe neoehrlichiosis. The results warrant further studies as well as raised clinical awareness.

Prognostic implications of structural heart disease and premature ventricular contractions in recovery of exercise.

Premature ventricular contractions (PVCs) during recovery of exercise stress testing are associated with increased cardiovascular mortality, but the cause remains unknown. We aimed to evaluate the association of PVCs during recovery with echocardiographic abnormalities, and their combined prognostic performance. Echocardiographic abnormalities [reduced left ventricular (LV) ejection fraction, valvular heart disease, LV dilatation, LV hypertrophy, or increased filling pressures] and PVCs during recovery were identified among patients having undergone both echocardiography and exercise stress test. Among included patients (n = 3106, age 59 ± 16 years, 55% males), PVCs during recovery were found in 1327 (43%) patients, among which the prevalence of echocardiographic abnormalities was increased (58% vs. 43%, p < 0.001). Overall, PVCs during recovery were associated with increased cardiovascular mortality (219 total events, 7.9 [5.4-11.1] years follow-up; adjusted hazard ratio (HR [95% confidence interval]) 1.6 [1.2-2.1], p < 0.001). When analyzed in combination with either presence or absence of echocardiographic abnormalities, PVCs during recovery were associated with increased risk when such were present (HR 3.3 [1.9-5.5], p < 0.001) but not when absent (HR 1.5 [0.8-2.8], p = 0.22), in reference to those with neither. Our findings provide mechanistic insights to the increased CV risk reported in patients with PVCs during recovery.

Peak exercise SBP and future risk of cardiovascular disease and mortality.

OBJECTIVES: This study aimed to evaluate the risk of all-cause mortality and incident cardiovascular disease associated with peak systolic blood pressure (PeakSBP) at clinical exercise testing. METHODS: Data from 10 096 clinical exercise tests (54% men, age 18-85 years) was cross-linked with outcome data from national registries. PeakSBP was compared with recently published reference percentiles as well as expressed as percentage predicted PeakSBP using reference equations.Natural cubic spline modelling and Cox regression were used to analyse data stratified by sex and baseline cardiovascular risk profile. RESULTS: Median [IQR] follow-up times were 7.9 [5.7] years (all-cause mortality) and 5.6 [5.9] years (incident cardiovascular disease), respectively. The adjusted risk of all-cause mortality [hazard ratio, 95% confidence interval (95% CI)] for individuals with PeakSBP below the 10th percentile was 2.00 (1.59-2.52) in men and 2.60 (1.97-3.44) in women, compared with individuals within the 10th--90th percentile. The corresponding risk for incident cardiovascular disease was 1.55 (1.28-1.89, men) and 1.34 (1.05-1.71, women). For males in the upper 90th percentile, compared with individuals within the 10th--90th percentile, the adjusted risks of all-cause death and incident cardiovascular disease were 0.35 (0.22-0.54) and 0.72 (0.57-0.92), respectively, while not statistically significant in women. Spline modelling revealed a continuous increase in risk with PeakSBP values less than 100% of predicted in both sexes, with no increase in risk more than 100% of predicted. CONCLUSION: Low, but not high, PeakSBP was associated with an increased risk of mortality and future cardiovascular disease. Using reference standards for PeakSBP could facilitate clinical risk stratification across patients of varying sex, age and exercise capacity.

Moderately trained male football players, compared to sedentary male adults, exhibit anatomical but not functional cardiac remodelling, a cross-sectional study.

BACKGROUND: Elite athletes have been the subject of great interest, but athletes at an intermediate level of physical activity have received less attention in respect to the presence of cardiac enlargement and/or hypertrophy. We hypothesized that playing football, often defined as demanding less endurance components than running or cycling, would still induce remodelling similar to sports with a dominating endurance component. METHODS: 23 male football players, age 25+/- 3.9 yrs. underwent exercise testing, 2D- and 3D- echocardiography and cardiac magnetic resonance (CMR). The results were compared with a control group of engineering students of similar age. The athletes exercised 12 h/week and the control subjects 1 h/week, p < 0.001. RESULTS: The football players achieved a significantly higher maximal load at the exercise test (380 W vs 300 W, p < 0.001) as well as higher calculated maximal oxygen consumption, (49.7 vs 37.4 mL x kg- 1 x min- 1, p < 0.001) compared to the sedentary group. All left ventricular (LV) volumes assessed by 3DEcho and CMR, as well as CMR left atrial (LA) volume were significantly higher in the athletes (3D-LVEDV 200 vs 154 mL, CMR-LVEDV 229 vs 185 mL, CMR-LA volume 100 vs 89 mL, p < 0.001, p = 0.002 and p = 0.009 respectively). LVEF and RVEF, LV strain by CMR or by echo did not differentiate athletes from sedentary participants. Right ventricular (RV) longitudinal strain, LA and right atrial (RA) strain by CMR all showed similar results in the two groups. CONCLUSION: Moderately trained intermediate level football players showed anatomical but not functional cardiac remodelling compared to sedentary males.

Age- and gender-specific upper limits and reference equations for workload-indexed systolic blood pressure response during bicycle ergometry.

BACKGROUND: Guidelines recommend considering workload in interpretation of the systolic blood pressure (SBP) response to exercise, but reference values are lacking. DESIGN: This was a retrospective, consecutive cohort study. METHODS: From 12,976 subjects aged 18-85 years who performed a bicycle ergometer exercise test at one centre in Sweden during the years 2005-2016, we excluded those with prevalent cardiovascular disease, comorbidities, cardiac risk factors or medications. We extracted SBP, heart rate and workload (watt) from ≥ 3 time points from each test. The SBP/watt-slope and the SBP/watt-ratio at peak exercise were calculated. Age- and sex-specific mean values, standard deviations and 90th and 95th percentiles were determined. Reference equations for workload-indexed and peak SBP were derived using multiple linear regression analysis, including sex, age, workload, SBP at rest and anthropometric variables as predictors. RESULTS: A final sample of 3839 healthy subjects (n = 1620 female) were included. While females had lower mean peak SBP than males (188 ± 24 vs 202 ± 22 mmHg, p < 0.001), workload-indexed SBP measures were markedly higher in females; SBP/watt-slope: 0.52 ± 0.21 versus 0.41 ± 0.15 mmHg/watt (p < 0.001); peak SBP/watt-ratio: 1.35 ± 0.34 versus 0.90 ± 0.21 mmHg/watt (p < 0.001). Age, sex, exercise capacity, resting SBP and height were significant predictors of the workload-indexed SBP parameters and were included in the reference equations. CONCLUSIONS: These novel reference values can aid clinicians and exercise physiologists in interpreting the SBP response to exercise and may provide a basis for future research on the prognostic impact of exercise SBP. In females, a markedly higher SBP in relation to workload could imply a greater peripheral vascular resistance during exercise than in males.