The influence of hospital and home environments on physical activity and sedentary behaviour: Perceptions of people recovering from fractures.

BACKGROUND: A lack of evidence exists contrasting the factors that influence physical activity and sedentary behaviour in both hospital and home settings before and after discharge from acute hospitalisation for fractures. OBJECTIVE: To describe and compare perceptions of environmental influences on physical activity in hospital and home settings in people recovering from fractures. METHOD: Semi-structured interviews were conducted with patients hospitalised following fractures (hip fracture or multi-trauma), exploring the barriers and enablers to physical activity within hospital and home settings. Interviews were conducted within two weeks of hospital discharge, audio recorded and transcribed prior to thematic analysis via a framework approach. RESULTS: Between December 2022 and May 2023, 12 semi-structured interviews were undertaken with an equal number of participants who sustained an isolated hip fracture or multi-trauma. The median (IQR) age of participants was 60 (52-68) years, with half being male, and the majority sustaining their injuries via transport crashes. Three main themes that influenced physical activity behaviours in hospital and home settings were: having the opportunity, having a reason, and having support and assistance to be active. CONCLUSION: During the period of reduced physical capability following fracture, patients need to be provided with opportunities and motivation to be active, particularly within the hospital setting. Findings from this study will assist clinicians to better support people recovering from fractures via greater engagement in physical activity within hospital and home settings.

Tricuspid and mitral remodelling in atrial fibrillation: a three-dimensional echocardiographic study.

AIMS: Atrial fibrillation (AF) is associated with atrial enlargement, mitral annulus (MA) and tricuspid annulus (TA) dilation, and atrial functional regurgitation (AFR). However, less is known about the impact of AF on both atrioventricular valves in those with normal and abnormal ventricular function. We aimed to compare the remodelling of the TA and MA in patients with non-valvular AF without significant AFR. METHODS AND RESULTS: Ninety-two patients referred for transoesophageal echocardiography were included and categorized into three groups: (i) AF with normal left ventricular (LV) function (Normal LV-AF), n = 36; (ii) AF with LV systolic dysfunction (LVSD-AF), n = 29; and (iii) Controls in sinus rhythm, n = 27. Three-dimensional MA and TA geometry were analysed using automated software. In patients with AF regardless of LV function, the MA and TA areas were larger compared with controls (LVSD-AF vs. Normal LV-AF vs. Controls, end-systolic MA: 5.2 ± 1.1 vs. 4.5 ± 0.7 vs. 3.9 ± 0.7 cm2/m2; end-systolic TA: 5.6 ± 1.3 vs. 5.3 ± 1.3 vs. 4.1 ± 0.7 cm2/m2; P < 0.05 for each comparison with Controls). TA and MA areas were not statistically different between the two AF groups. The TA increase over controls was greater than that of the MA in the Normal LV-AF group (27.7% vs. 15.6%, P = 0.041). Conversely, in the LVSD-AF group, MA and TA increased similarly (35.9% vs. 32.4%, P = 0.660). CONCLUSION: Patients with AF showed dilation of both TA and MA compared with patients in sinus rhythm. In patients with normal LV function, AF was associated with greater TA dilation than MA dilation whereas in patients with LVSD the TA and MA were equally dilated.

Changes in left atrial appendage orifice following percutaneous left atrial appendage closure using three-dimensional echocardiography.

Percutaneous left atrial appendage (LAA) occlusion is increasingly performed in patients with atrial fibrillation and long-term contraindications for anticoagulation. Our aim was to evaluate the effects of LAA occlusion with the Watchman device on the geometry of the LAA orifice and assess its impact on the adjacent left upper pulmonary vein (LUPV) hemodynamics. We included 50 patients who underwent percutaneous LAA occlusion with the Watchman device and had acceptable three-dimensional transesophageal echocardiography images of LAA pre- and post-device placement. We measured offline the LAA orifice diameters in the long axis, and the minimum and maximum diameters, circumference, and area in the short axis view. Eccentricity index was calculated as maximum/minimum diameter ratio. The LUPV peak S and D velocities pre- and post-procedure were also measured. Patients were elderly (mean age 76 ± 8 years), 30 (60%) were men. There was a significant increase of all LAA orifice dimensions following LAA occlusion: diameter 1 (pre-device 18.1 ± 3.2 vs. post-device 21.5 ± 3.4 mm, p < 0.001), diameter 2 (20.6 ± 3.9 vs. 22.1 ± 3.6 mm, p < 0.001), minimum diameter (17.6 ± 3.1 vs. 21.3 ± 3.4 mm, p < 0.001), maximum diameter (21.5 ± 3.9 vs. 22.4 ± 3.6 mm, p = 0.022), circumference (63.6 ± 10.7 vs. 69.6 ± 10.5 mm, p < 0.001), and area (3.1 ± 1.1 vs. 3.9 ± 1.2 cm2, p < 0.001). Eccentricity index decreased after procedure (1.23 ± 0.16 vs. 1.06 ± 0.06, p < 0.001). LUPV peak S and D velocities did not show a significant difference (0.29 ± 0.15 vs. 0.30 ± 0.14 cm/s, p = 0.637; and 0.47 ± 0.19 vs. 0.48 ± 0.20 cm/s, p = 0.549; respectively). LAA orifice stretches significantly and it becomes more circular following LAA occlusion without causing a significant impact on the LUPV hemodynamics.

Bounding the Benefit of Adaptivity in Quantum Metrology Using the Relative Fidelity.

Protocols for discriminating between a pair of channels or for estimating a channel parameter can often be aided by adaptivity or by entanglement between the probe states. This can make it difficult to bound the best possible performance for such protocols. In this Letter, we introduce a quantity that we call the relative fidelity of a given pair of channels and a pair of input states to those channels. Constraining the allowed input states to all pairs of states whose fidelity is greater than some minimum "input fidelity" and minimizing this quantity over the valid pairs of states, we get the minimum relative fidelity for that input fidelity constraint. We are then able to lower bound the fidelity between the possible output states of any protocol acting on one of two possible channels in terms of the minimum relative fidelity. This allows us to bound the performance of the most general, adaptive discrimination and parameter estimation protocols. By finding a continuity bound for the relative fidelity, we also provide a simple confirmation that the quantum Fisher information (QFI) of the output of an N-use protocol is no more than N^{2} times the one-shot QFI.

Understanding the role of left and right ventricular strain assessment in patients hospitalized with COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) can cause cardiac injury resulting in abnormal right or left ventricular function (RV/LV) with worse outcomes. We hypothesized that two-dimensional (2D) speckle-tracking assessment of LV global longitudinal strain (GLS) and RV free wall strain (FWS) by transthoracic echocardiography can assist as markers for subclinical cardiac injury predicting increased mortality. METHODS: We performed 2D strain analysis via proprietary software in 48 patients hospitalized with COVID-19. Clinical information, demographics, comorbidities, and lab values were collected via retrospective chart review. The primary outcome was in-hospital mortality based on an optimized abnormal LV GLS value via ROC analysis and RV FWS. RESULTS: The optimal LV GLS cutoff to predict death was -13.8%, with a sensitivity of 85% (95% CI 55-98%) and specificity of 54% (95% CI 36-71%). Abnormal LV GLS >-13.8% was associated with a higher risk of death [unadjusted hazard ratio 5.15 (95% CI 1.13-23.45), p = 0.034], which persisted after adjustment for clinical variables. Among patients with LV ejection fraction (LVEF) >50%, those with LV GLS > -13.8% had higher mortality compared to those with LV GLS <-13.8% (41% vs. 10%, p = 0.030). RV FWS value was higher in patients with LV GLS >-13.8% (-13.7 ±â€¯5.9 vs. -19.6 ±â€¯6.7, p = 0.003), but not associated with decreased survival. CONCLUSION: Abnormal LV strain with a cutoff of >-13.8% in patients with COVID-19 is associated with significantly higher risk of death. Despite normal LVEF, abnormal LV GLS predicted worse outcomes in patients hospitalized with COVID-19. There was no mortality difference based on RV strain.

Acute changes of left ventricular function during surgical revascularization by 3D speckle tracking.

BACKGROUND: Detecting early impact of coronary artery bypass grafting (CABG) on left ventricular (LV) function is important because such measures may contribute to meaningful improvement in clinical outcomes. We aimed to gain knowledge about acute changes of LV performance during surgical revascularization using three-dimensional speckle tracking echocardiography (3D STE). METHODS: Thirty-five patients scheduled for CABG surgery who underwent intraoperative transesophageal echocardiography (TEE) were enrolled (mean age 68.9 ± 7.3 years). TEE was performed before and after surgery, as well as before and after grafting. 3D LV ejection fraction (LVEF), tissue motion annular displacement (TMAD) of the mitral valves, 3D global longitudinal strain (GLS), global circumferential strain (GCS), twist, and torsion were quantified. Regional longitudinal strain (LS) was calculated based on coronary perfusion territories in a 16-segment LV model. RESULTS: Despite the absence of change in TMAD and 3D LVEF, 3D GLS (-18.6 ± 4.3% at baseline vs -16.0 ± 4.0% after surgery, P = .01) was significantly decreased, followed with no significant effect on GCS, twist, and torsion during surgery. 3D GLS correlated significantly with 3D LVEF (r between -0.34 and -0.51, P < .05 for all) under the whole operation. Territorial LS did not increase immediately after surgery. CONCLUSION: 3D speckle tracking imaging allows for detailed and direct evaluation of myocardial deformation, though impaired LV longitudinal function is still apparent immediately after surgery. GLS is more sensitive to an acute reduction in LV function than conventional parameters, which can be potentially useful for serial monitoring of functional recovery.

Pressure support ventilation in intensive care patients receiving prolonged invasive ventilation.

Background: To our knowledge, the use and management of pressure support ventilation (PSV) in patients receiving prolonged (≥ 7 days) invasive mechanical ventilation has not previously been described. Objective: To collect and analyse data on the use and management of PSV in critically ill patients receiving prolonged ventilation. Design, setting and participants: We performed a multicentre retrospective observational study in Australia, with a focus on PSV in patients ventilated for ≥ 7 days. Main outcome measures: We obtained detailed data on ventilator management twice daily (8am and 8pm moments) for the first 7 days of ventilation. Results: Among 143 consecutive patients, 90/142 (63.4%) had received PSV by Day 7, and PSV accounted for 40.5% (784/1935) of ventilation moments. The most common pressure support level was 10 cmH2O (352/780) observations [45.1%]) with little variation over time, and 37 of 114 patients (32.4%) had no change in pressure support. Mean tidal volume during PSV was 8.3 (7.0-9.5) mL/kg predicted bodyweight (PBW) compared with 7.5 (7.0-8.3) mL/kg PBW during mandatory ventilation (P < 0.001). For 74.6% (247/331) of moments, despite a tidal volume of more than 8 mL/kg PBW, the pressure support level was not changed. Among 122 patients exposed to PSV, 97 (79.5%) received likely over-assistance according to rapid shallow breathing index criteria. Of 784 PSV moments, 411 (52.4%) were also likely over-assisted according to rapid shallow breathing index criteria, and 269/346 (77.7%) having no subsequent adjustment of pressure support. Conclusions: In patients receiving prolonged ventilation, almost two-thirds received PSV, which accounted for 40.5% of mechanical ventilation time. Half of the PSV-treated patients were exposed to high tidal volume and two-thirds to likely over-assistance. These observations provide evidence that can be used to inform interventional studies of PSV management.

Understanding tricuspid valve remodelling in atrial fibrillation using three-dimensional echocardiography.

AIMS: Atrial fibrillation (AF) has been associated with tricuspid annulus (TA) dilation in patients with severe functional tricuspid regurgitation (TR); however, the impact of AF is less clear in patients without severe TR. Our aim was to characterize TA remodelling in patients with AF in the absence of severe TR using 3D transoesophageal echocardiography (TOE). METHODS AND RESULTS: Ninety patients underwent clinically indicated transthoracic and TOE: non-structural (NS)-AF (n = 30); AF with left heart disease (LHD) (n = 30), and controls in sinus rhythm (n = 30). Three-dimensional TOE datasets were analysed to measure TA dimensions using novel dedicated tricuspid valve software. The NS-AF group showed biatrial dilatation and normal right ventricular (RV) size with decreased longitudinal function compared to controls, whereas the LHD-AF group showed biatrial dilatation, RV enlargement, decreased biventricular function, and higher systolic pulmonary artery pressure compared with the other groups. Indexed TA area, minimum diameter, maximum diameter, and total perimeter were significantly larger in the NS-AF group than in controls (measurements in end-diastole: 6.4 ± 1.1 vs. 5.0 ± 0.6 cm2/m2, 1.8 ± 0.3 vs. 1.6 ± 0.2 cm/m2, 2.1 ± 0.3 vs. 1.9 ± 0.2 cm/m2, and 6.6 ± 0.9 vs. 5.9 ± 0.7 cm/m2, respectively, all P < 0.05). There was no significant difference in any indexed TA parameter between AF groups. TA circularity index (ratio between minimum and maximal diameters) and TA fractional area change between end-diastole and end-systole were no different among the three groups. CONCLUSION: AF is associated with right atrial and tricuspid annular remodelling independent of the presence of LHD in patients with intrinsically normal tricuspid leaflets without severe TR.

The feasibility of contrast echocardiography in the assessment of right ventricular size and function.

BACKGROUND: Right ventricle (RV) evaluation requires dedicated imaging to achieve a comprehensive functional and anatomical assessment. Right ventricular imaging could be technically difficult which results in suboptimal visibility and inconsistent assessment between observers. The aim of this study was to assess feasibility and the additive value of contrast enhancement for right ventricular evaluation. METHODS: Eighty patients referred for clinically indicated echocardiography studies were included. Patients with irregular rhythms were excluded. Dedicated RV-focused view was attained; RV dimensions measured, and RV segment visualization and wall motion were assessed with and without contrast enhancement. Paired sample t test was used to compare continuous variables, Wilcoxon signed-rank test to compare segments visualization on enhanced versus (vs) nonenhanced images, and Cohen kappa coefficient to assess the agreement of wall motion between two observers. Reproducibility was measured by the absolute mean difference method. RESULTS: A total of 240 total segments of 80 patients were analyzed, and 178 (74%) were visible on unenhanced while 221 (92%) on enhanced images, P < .05. Further, RV measurements on enhanced images were consistently larger on RV focused, SAX, and RVOT. Inter- and intra-observer reproducibility showed a higher reproducibility with a lower bias on enhanced images. Absolute agreement on RV segmental wall motion between two independent observers was higher on enhanced images. Percent agreement was 78% on UE vs 89% on CE. CONCLUSION: Contrast RV imaging is feasible and improves RV segment visualization and inter-observer agreement. Compared with unenhanced images, RV measurements on contrast images are larger and more reproducible with lower bias.