Diaphragm Dysfunction after Cardiac Surgery: Insights from Ultrasound Imaging during Cardiac Rehabilitation.

Diaphragm dysfunction is common after cardiac surgery and can be evaluated with ultrasonography (US). We aimed at assessing with US the incidence of diaphragmatic dysfunction and the impact of cardiovascular rehabilitation (CR) on its recovery. A single-center cohort study was performed. Patients were enrolled after cardiac surgery. The 6-min walking test (6MWT) and diaphragm US were performed at CR admission and after 10 rehabilitative sessions. One hundred eighty-five patients were eligible for final analysis. One hundred thirty-one patients (70.8%) were found to have diaphragm dysfunction (excursion <2 cm). After CR, 68 patients regained normal diaphragmatic function; those with persistent dysfunction had a lower level of functional performance on the 6MWT (metabolic equivalents of tasks: 3.3 vs. 3.6, p = 0.013). The patients who underwent combined surgery (adjusted odds ratio [aOR] = 4.09, p = 0.001) and those with post-operative pneumothorax (aOR = 3.02, p = 0.042) were at increased risk of failure to improve diaphragmatic excursion. US parameters were more powerful tools in predicting diaphragmatic evolution compared with the 6MWT indexes: baseline diaphragm excursion and thickening fraction were associated with complete diaphragmatic functional recovery after CR (aOR = 9.101, p < 0.001, and aOR = 1.058, p = 0.020 respectively). US is a valuable tool for the assessment of post-operative diaphragmatic dysfunction and can identify patients at risk of diaphragmatic recovery failure.

Lung Ultrasound in COVID-19 A Role Beyond the Acute Phase?

OBJECTIVES: Coronavirus disease 2019 (COVID-19) is a viral illness caused by severe acute respiratory syndrome coronavirus 2. With the increasing number of improved and discharged patients with COVID-19, the definition of an adequate follow-up strategy is needed. The purpose of this study was to assess whether lung ultrasound (LUS) is an effective indicator of subclinical residual lung damage in patients with COVID-19 who meet discharge criteria. METHODS: We prospectively enrolled 70 consecutive patients with COVID-19 who had a prolonged hospitalization with inpatient rehabilitation between April 6 and May 22, 2020. All of the patients underwent an LUS evaluation at discharge. Data of patients with more severe disease during the acute phase (ie, required ventilatory support) were compared to those of patients with milder disease. RESULTS: Among the 70 patients with COVID-19 (22 women and 48 men; mean age ± SD, 68 ± 13 years), the LUS score before discharge was still frankly pathologic and higher in patients who had more severe disease during the acute phase compared to patients with milder disease (median [interquartile range], 8.0 [5.5-13.5] versus 2.0 [1.0-7.0]; P < .001), even when both categories met internationally defined discharge criteria. CONCLUSIONS: Lung ultrasound can identify the persistence of subclinical residual lung damage in patients with severe COVID-19 even if they meet discharge criteria. Considering the low cost, easy application, and lack of radiation exposure, LUS seems the ideal tool to be adopted in outpatient and primary care settings for the follow-up of patients with COVID-19.

Rehabilitative of COVID-19 patients with acute lower extremity Ischemia and amputation.

OBJECTIVE: To evaluate the clinical characteristics and rehabilitation management of patients who undergo amputation for COVID-19-associated coagulopathy. METHODS: Clinical and laboratory data for 3 patients were analysed and their rehabilitative management discussed. RESULTS: The medical records of 3 patients who had undergone amputation due to acute lower extremity ischaemia and who were provided with rehabilitation in our COVID-19 unit were reviewed. CONCLUSION: Coagulation changes related to SARS-CoV-2 may complicate recovery from this devastating disease. The rehabilitation management of amputated patients for COVID-19 acute lower extremity ischaemia is based on a multilevel approach for clinical, functional, nutritional and neuropsychological needs. Based on this limited experience, a dedicated programme for this specific group of patients seems advantageous to warrant the best functional outcome and quality of life.

COVID-19 rehabilitation units are twice as expensive as regular rehabilitation units.

OBJECTIVE: The COVID-19 pandemic has caused significant motor, cognitive, psychological, neurological and cardiological disabilities in many infected patients. Functional rehabilitation of infectious COVID-19 patients has been implemented in the acute care wards and in appropriate, ad hoc, multidisciplinary COVID-19 rehabilitation units. However, because COVID-19 rehabilitation units are a clinical novelty, clinical and organizational benchmarks are not yet available. The aim of this study is to describe the organizational needs and operational costs of such a unit, by comparing its activity, organization, and costs with 2 other functional rehabilitation units, in San Raffaele Hospital, Milan, Italy. METHODS: The 2-month activity of the COVID-19 Rehabilitation Unit at San Raffaele Hospital, Milan, Italy, which was created in response to the emergency need for rehabilitation of COVID-19 patients, was compared with the previous year's activity of the Cardiac Rehabilitation and Motor Rehabilitation Units of the same institute. RESULTS: The COVID-19 Rehabilitation Unit had the same number of care beds as the other units, but required twice the amount of staff and instrumental equipment, leading to a deficit in costs. DISCUSSION: The COVID-19 Rehabilitation Unit was twice as expensive as the 2 other units studied. World health systems are organizing to respond to the pandemic by expanding capacity in acute intensive care and sub-intensive care units. This study shows that COVID-19 rehabilitation units must be organized and equiped according to the clinical and rehabilitative needs of patients, following specific measures to prevent the spread of infection amongs patients and workers.

Role of Rehabilitation Department for Adult Individuals With COVID-19: The Experience of the San Raffaele Hospital of Milan.

The rapid evolution of the health emergency linked to the spread of severe acute respiratory syndrome coronavirus 2 requires specifications for the rehabilitative management of patients with coronavirus disease 2019 (COVID-19). The symptomatic evolution of patients with COVID-19 is characterized by 2 phases: an acute phase in which respiratory symptoms prevail and a postacute phase in which patients can show symptoms related to prolonged immobilization, to previous and current respiratory dysfunctions, and to cognitive and emotional disorders. Thus, there is the need for specialized rehabilitative care for these patients. This communication reports the experience of the San Raffaele Hospital of Milan and recommends the setup of specialized clinical pathways for the rehabilitation of patients with COVID-19. In this hospital, between February 1 and March 2, 2020, about 50 patients were admitted every day with COVID-19 symptoms. In those days, about 400 acute care beds were created (intensive care/infectious diseases). In the following 30 days, from March 2 to mid-April, despite the presence of 60 daily arrivals to the emergency department, the organization of patient flow between different wards was modified, and several different units were created based on a more accurate integration of patients' needs. According to this new organization, patients were admitted first to acute care COVID-19 units and then to COVID-19 rehabilitation units, post-COVID-19 rehabilitation units, and/or quarantine/observation units. After hospital discharge, telemedicine was used to follow-up with patients at home. Such clinical pathways should each involve dedicated multidisciplinary teams composed of pulmonologists, physiatrists, neurologists, cardiologists, physiotherapists, neuropsychologists, occupational therapists, speech therapists, and nutritionists.

A decomposition approach for the combined master surgical schedule and surgical case assignment problems.

This research aims at supporting hospital management in making prompt Operating Room (OR) planning decisions, when either unpredicted events occur or alternative scenarios or configurations need to be rapidly evaluated. We design and test a planning tool enabling managers to efficiently analyse several alternatives to the current OR planning and scheduling. To this aim, we propose a decomposition approach. More specifically, we first focus on determining the Master Surgical Schedule (MSS) on a weekly basis, by assigning the different surgical disciplines to the available sessions. Next, we allocate surgeries to each session, focusing on elective patients only. Patients are selected from the waiting lists according to several parameters, including surgery duration, waiting time and priority class of the operations. We performed computational experiments to compare the performance of our decomposition approach with an (exact) integrated approach. The case study selected for our simulations is based on the characteristics of the operating theatre (OT) of a medium-size public Italian hospital. Scalability of the method is tested for different OT sizes. A pilot example is also proposed to highlight the usefulness of our approach for decision support. The proposed decomposition approach finds satisfactory solutions with significant savings in computation time.

Validation of the treadmill Six-Minute Walk Test in people following cardiac surgery.

BACKGROUND: The Six-Minute Walk Test (6MWT) often is used to measure exercise capacity in people with cardiopulmonary diseases but has some disadvantages. The 6MWT administered on a treadmill (Tr6MWT) requires less physical space and allows for easier monitoring of vital parameters than the traditional 6MWT. OBJECTIVE: The objectives of this study were: (1) to analyze the validity of the Tr6MWT in people who underwent cardiac surgery; (2) to compare the reliability, responsiveness, and people's tolerance of the Tr6MWT with those of the 6MWT; and (3) to evaluate the agreement between the 2 tests. DESIGN: This study was designed to assess reliability and validity. METHODS: Twenty-six participants who were inpatients were assessed before a 2-week rehabilitation program. Twenty of them also were assessed after rehabilitation. All participants performed 3 Tr6MWT trials and 3 6MWT trials that were randomly assigned on 2 consecutive days. RESULTS: The Pearson r correlation coefficient between the Tr6MWT and the 6MWT was .72, indicating satisfactory concurrent validity. The Tr6MWT was as well tolerated as the 6MWT. The Tr6MWT produced reproducible results after 2 practice tests, whereas the 6MWT did so after only 1 practice test. Both tests showed high test-retest reliability (intraclass correlation coefficient of >.94; standard errors of measurement of 23 m for the Tr6MWT and 18.5 m for the 6MWT). The Tr6MWT showed better responsiveness than the 6MWT (effect sizes of 0.9 for the Tr6MWT and 0.6 for the 6MWT). The distance covered during the Tr6MWT was significantly shorter (X=62 m, SD=91) before rehabilitation but not after rehabilitation. LIMITATIONS: A crossover randomized procedure could have improved the reliability of the Tr6MWT in people who performed the 6MWT first. CONCLUSIONS: The Tr6MWT appears to be an instrument with adequate concurrent validity and to be tolerable, reliable, and responsive for the evaluation of exercise capacity in people after cardiac surgery even though it is not interchangeable with the 6MWT.

Reduction of mitral valve regurgitation caused by acute papillary muscle ischemia.

BACKGROUND: A 67-year-old man was admitted to a coronary care unit for non-ST-segment elevation myocardial infarction with complicating acute heart failure. Severe mitral regurgitation was detected by echocardiography at presentation. Repeat echocardiography carried out during another ischemic episode revealed a marked reduction in the patient's mitral regurgitation that was related to decreased apical traction of the valve leaflets. INVESTIGATIONS: Physical examination, electrocardiography, laboratory tests, coronary angiography, chest radiography, echocardiography. DIAGNOSIS: Mitral regurgitation associated with acute coronary syndrome. MANAGEMENT: Early revascularization by percutaneous coronary intervention, supported by pharmacological therapy to decrease left ventricular filling pressure.

One year of clinical experience in postdilution hemofiltration with online reinfusion of regenerated ultrafiltrate.

BACKGROUND/AIMS: Hemofiltrate reinfusion (HFR) is characterized by the use of regenerated ultrafiltrate as replacement fluid. We set up a new technique, postdilution HFR (PD-HFR), aiming at increasing purification efficiency, treatment tolerance and at reducing inflammatory states. METHODS: We performed PD-HFR in 6 uremic patients during 1 year. Dialysis efficacy, dialyzer blood loss and the behavior of cytokines were evaluated. RESULTS: No pyrogenic reactions or other adverse events were recorded. Treatment tolerance was excellent. We observed high urea extraction rates and optimal Kt/V values, high beta2-microglobulin (beta2m) extraction rates and a decrease in dialyzer blood loss; also IL-6 and TNF-alpha decreased significantly. CONCLUSIONS: Inversion of the standard HFR configuration has allowed us to improve the removal of both urea and beta2m, and to decrease dialyzer blood loss, with an optimal tolerance. Moreover, the decrease in cytokine levels might attenuate the uremic microinflammatory state.

Adequate protein dietary restriction in diabetic and nondiabetic patients with chronic renal failure.

OBJECTIVE: To evaluate whether a dietary protein restriction is useful for slowing the progression of chronic renal failure (CRF) in diabetic and nondiabetic patients and to analyze the possible risk of malnutrition after such a dietary regimen. DESIGN: Prospective, randomized case-control clinical trial. SETTING: Nephrology outpatients. PATIENTS AND OTHER PARTICIPANTS: A total of 169 patients, 89 affected with CRF and chronic hypertension and 80 affected with overt diabetic nephropathy (24 suffering from type 1 and 56 from type 2 diabetes) and chronic hypertension. INTERVENTION: Diabetic patients and nondiabetic patients were randomly divided into 2 groups: 40 diabetic patients received a low-protein diet (0.8 g/kg/day) and 40 were maintained on a free protein diet; similarly, 44 nondiabetic patients received a low-protein diet (0.6 g/kg/day) and 45 were maintained on a free protein diet. The investigation lasted 1 year. MAIN OUTCOME MEASURE: Renal function and nutritional status. RESULTS: At the end of the study, there were no statistically significant differences in renal function between treated and nontreated diabetic patients, whereas treated nondiabetic patients showed a lower decrease in renal function compared with the nontreated group. In both diabetic and nondiabetic patients, the mean body weight and obesity index decreased significantly in treated patients compared with nontreated ones. Serum albumin and prealbumin were stable in all patients during the whole study time, and there were no other signs of malnutrition. CONCLUSION: An adequate dietary protein restriction is accepted by patients, and it is well tolerated during a 12-month follow-up. Without any sign of malnutrition, it is possible to get near the ideal body weight and to reduce the obesity index and the body mass index, which are both well-established risk factors for developing cardiovascular pathology. In nondiabetic patients only, we observed a significant slowing of the progression of renal damage.

A case report of plasma exchange therapy in non-paraneoplastic cerebellar ataxia associated with anti-Yo antibody.

A 71-year-old-woman was admitted to the S. Eugenio Hospital for a history of progressively impaired standing and gait. Anamnesis revealed systemic hypertension, gastric polyposis and juvenile pulmonary tuberculosis. Neurological examination showed a severe truncal and gait ataxia, without any sensory-motor impairment. Motor and somato-sensory evoked potentials were normal. Brain Magnetic Resonance Imaging (MRI) showed minimal signs of chronic ischemia only at a supratentorial level. Cerebral Single Photon Emission Computed Tomography, spinal MRI, total body computed tomography, Esophagogastroduodenoscopy, and finally total body Positron Emission Tomography resulted negative for neoplasms. Oncological serum markers were negative. Serum antibody against Purkinje's cells (Anti-Yo) was detected and titer was 1:80, while normally it should be undetectable. Other autoantibodies (Anti-Hu, Anti-Ri) were undetectable. Two sessions of plasma exchange (PE) were thus performed, leading to a rapid, marked and durable improvement of standing and gait and to a reduction of the autoantibody, which became undetectable. No serious adverse effect was noted. Although no definite therapy for autoimmune cerebellar ataxia has been established, PE should be considered as one of the main therapeutic choices.

Arachidonate cascade, apoptosis, and vitamin E in peripheral blood mononuclear cells from hemodialysis patients.

BACKGROUND: Lipid peroxidation and oxidative stress are enhanced in peripheral blood mononuclear cells (PBMCs) from hemodialysis (HD) patients because of upregulation of the 5-lipoxygenase pathway of the arachidonate cascade. 5-Lipoxygenase activity is specifically inhibited by vitamin E both in vitro and in vivo regardless of its administration route. METHODS: The effect of arachidonate cascade enzymes and vitamin E on oxidative stress and apoptosis was investigated in PBMCs from 16 maintenance HD patients treated for at least 6 months with cuprammonium rayon membranes in a two-step crossover study: after a 4-week treatment with vitamin E-coated cuprammonium rayon membranes and again after a 4-week treatment with oral vitamin E. Control PBMCs were obtained from 16 healthy volunteers. RESULTS: Membrane lipoperoxidation, cellular luminescence, membrane fluidity, and leukotriene B(4) content were significantly greater in PBMCs from HD patients; lipoxygenase was upregulated, but prostaglandin H synthase (PHS) was not affected. Regardless of administration route, vitamin E partially controlled lipid peroxidation and oxidative stress through direct inhibition of 5-lipoxygenase. Cultured PBMCs from HD patients showed a significant increase in apoptotic cells compared with controls. Vitamin E markedly reduced cell luminescence, membrane fluidity, and apoptosis, whereas the PHS inhibitor indomethacin was ineffective. Similar results were obtained with control PBMCs induced to apoptosis by hydrogen peroxide. CONCLUSION: Reported data suggest that the 5-lipoxygenase branch of the arachidonate cascade is only responsible for membrane peroxidation, oxidative stress, and apoptosis of PBMCs of HD patients, and administration of vitamin E may be helpful in the control of oxidative stress-related disease in these subjects.

Severe dietary protein restriction in overt diabetic nephropathy: benefits or risks?

OBJECTIVE: To evaluate whether restricting protein intake may delay the progression of chronic renal failure caused by overt diabetic nephropathy and also whether this increases the risk of malnutrition. DESIGN: Prospective clinical trial. SETTING: Nephrology outpatients. PATIENTS: Sixty-nine patients (32 affected by type 1 and 37 by type 2 diabetes, all treated with insulin) affected by both overt diabetic nephropathy and hypertension. INTERVENTION: The study was started once hypertension and glycemia had been under control for at least 3 months. Two groups of patients, matched for similar mean glomerular filtration rate value and nutritional status, were studied: a low-protein diet (0.6 g/kg/d) was randomly prescribed to 35 patients, whereas in the other 34 patients a free diet intake was maintained for 12 months. MAIN OUTCOME MEASURE: Renal function and nutritional status. RESULTS: The protein intake was significantly different in the 2 groups of patients, whereas the average decline of glomerular filtration rate during the follow-up was comparable. In the low-protein diet group, serum prealbumin concentration significantly decreased after 9 months, whereas serum albumin decreased at the end of the study. CONCLUSION: Severe dietary protein restriction does not seem to delay the progression of renal disease in patients with overt diabetic nephropathy, whereas it may induce malnutrition.