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The purpose of this article is to highlight the importance of considering sleep-disordered breathing (SDB) as a potential confounder to rehabilitation research interventions in spinal cord injury (SCI). SDB is highly prevalent in SCI, with increased prevalence in individuals with higher and more severe lesions, and the criterion standard treatment with continuous positive airway pressure remains problematic. Despite its high prevalence, SDB is often untested and untreated in individuals with SCI. In individuals without SCI, SDB is known to negatively affect physical function and many of the physiological systems that negatively affect physical rehabilitation in SCI. Thus, owing to the high prevalence, under testing, low treatment adherence, and known negative effect on the physical function, it is contended that underdiagnosed SDB in SCI may be confounding physical rehabilitation research studies in individuals with SCI. Studies investigating the effect of treating SDB and its effect on physical rehabilitation in SCI were unable to be located. Thus, studies investigating the likely integrated relationship among physical rehabilitation, SDB, and proper treatment of SDB in SCI are needed. Owing to rapid growth in both sleep medicine and physical rehabilitation intervention research in SCI, the authors contend it is the appropriate time to begin the conversations and collaborations between these fields. We discuss a general overview of SDB and physical training modalities, as well as how SDB could be affecting these studies.

To (1) describe the prevalence of cardiometabolic disease (CMD) at spinal cord injury (SCI) rehabilitation discharge; (2) compare this with controls without SCI; and (3) identify factors associated with increased CMD.Multicenter, prospective observational study.Five National Institute on Disability, Independent Living, and Rehabilitation Research Model SCI Rehabilitation Centers.SCI (n=95): patients aged 18-70 years, with SCI (neurologic levels of injury C2-L2, American Spinal Injury Association Impairment Scale grades A-D), and enrolled within 2 months of initial rehabilitation discharge. Control group (n=1609): age/sex/body mass index-matched entries in the National Health and Nutrition Examination Education Survey (2016-2019) (N=1704).None MAIN OUTCOME MEASURES: Percentage of participants with SCI with CMD diagnosis, prevalence of CMD determinants within 2 months of rehabilitation discharge, and other significant early risk associations were analyzed using age, sex, body mass index, insulin resistance (IR) by fasting glucose and Homeostasis Model Assessment (v.2), fasting triglycerides, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol, total cholesterol, and resting blood pressure (systolic and diastolic).Participants with SCI had significantly higher diastolic blood pressure and triglycerides than those without SCI, with lower fasting glucose and HDL-C. A total of 74.0% of participants with SCI vs 38.5% of those without SCI were obese when applying population-specific criteria (P.05). Low HDL-C was measured in 54.2% of participants with SCI vs 15.4% of those without (P.05). IR was not significantly different between groups. A total of 31.6% of participants with SCI had ≥3 CMD determinants, which was 40.7% higher than those without SCI (P.05). Interplay of lipids and lipoproteins (ie, total cholesterol:HDL-C ratio and triglyceride:HDL-C ratio) were associated with elevated risk in participants with SCI for myocardial infarction and stroke. The only significant variable associated with CMD was age (P.05).Individuals with SCI have an increased CMD risk compared with the general population; obesity, IR, and low HDL-C are the most common CMD risk determinants; age is significantly associated with early CMD.

Many persons with spinal cord injury (SCI) have one or more preventable chronic diseases related to excessive energetic intake and poor eating patterns. Appropriate nutrient consumption relative to need becomes a concern despite authoritative dietary recommendations from around the world. These recommendations were developed for the non-disabled population and do not account for the injury-induced changes in body composition, hypometabolic rate, hormonal dysregulation and nutrition status after SCI. Because evidence-based dietary reference intake values for SCI do not exist, ensuring appropriate consumption of macronutrient and micronutrients for their energy requirements becomes a challenge. In this compressive review, we briefly evaluate aspects of energy balance and appetite control relative to SCI. We report on the evidence regarding energy expenditure, nutrient intake and their relationship after SCI. We compare these data with several established nutritional guidelines from American Heart Association, Australian Dietary Guidelines, Dietary Guidelines for Americans, Institute of Medicine Dietary Reference Intake, Public Health England Government Dietary Recommendations, WHO Healthy Diet and the Paralyzed Veterans of America (PVA) Clinical Practice Guidelines. We also provide practical assessment and nutritional recommendations to facilitate a healthy dietary pattern after SCI. Because of a lack of strong SCI research, there are currently limited dietary recommendations outside of the PVA guidelines that capture the unique nutrient needs after SCI. Future multicentre clinical trials are needed to develop comprehensive, evidence-based dietary reference values specific for persons with SCI across the care continuum that rely on accurate, individual assessment of energy need.

Clinically relevant myopenia accompanies spinal cord injury (SCI), and compromises function, metabolism, body composition, and health. Myostatin, a transforming growth factor (TGF)β family member, is a key negative regulator of skeletal muscle mass. We investigated inhibition of myostatin signaling using systemic delivery of a highly selective monoclonal antibody - muSRK-015P (40 mg/kg) - that blocks release of active growth factor from the latent form of myostatin. Adult female mice (C57BL/6) were subjected to a severe SCI (65 kdyn) at T9 and were then immediately and 1 week later administered test articles: muSRK-015P (40 mg/kg) or control (vehicle or IgG). A sham control group (laminectomy only) was included. At euthanasia, (2 weeks post-SCI) muSRK-015P preserved whole body lean mass and sublesional gastrocnemius and soleus mass. muSRK-015P-treated mice with SCI also had significantly attenuated myofiber atrophy, lipid infiltration, and loss of slow-oxidative phenotype in soleus muscle. These outcomes were accompanied by significantly improved sublesional motor function and muscle force production at 1 and 2 weeks post-SCI. At 2 weeks post-SCI, lean mass was significantly decreased in SCI-IgG mice, but was not different in SCI-muSRK-015P mice than in sham controls. Total energy expenditure (kCal/day) at 2 weeks post-SCI was lower in SCI-immunoglobulin (Ig)G mice, but not different in SCI-muSRK-015P mice than in sham controls. We conclude that in a randomized, blinded, and controlled study in mice, myostatin inhibition using muSRK-015P had broad effects on physical, metabolic, and functional outcomes when compared with IgG control treated SCI animals. These findings may identify a useful, targeted therapeutic strategy for treating post-SCI myopenia and related sequelae in humans.

PURPOSE The purpose of this study was to assess the acute effects of exercise mode and intensity on postprandial macronutrient metabolism. METHODS Ten healthy men age 39 ± 10 yr with chronic paraplegia (13.2 ± 8.8 yr, ASIA A-C) completed three isocaloric bouts of upper-body exercise and a resting control. After an overnight fast, participants completed circuit resistance exercise (CRE) first and the following conditions in a randomized order, separated by >48 h: i) control (CON), ~45-min seated rest; ii) moderate-intensity continuous exercise (MICE), ~40-min arm cranking at a resistance equivalent to ~30% peak power output (PPO); and iii) high-intensity interval exercise (HIIE), ~30 min arm cranking with resistance alternating every 2 min between 10% PPO and 70% PPO. After each condition, participants completed a mixed-meal tolerance test consisting of a 2510-kJ liquid meal (35% fat, 50% carbohydrate, 15% protein). Blood and expired gas samples were collected at baseline and regular intervals for 150 min after a meal. RESULTS An interaction (P < 0.001) was observed, with rates of lipid oxidation elevated above CON in HIIE until 60 min after a meal and in CRE at all postprandial time points up to 150 min after a meal. Postprandial blood glycerol was greater in MICE (P = 0.020) and CRE (P = 0.001) compared with CON. Furthermore, nonesterified fatty acid area under the curve had a moderate-to-strong effect in CRE versus MICE and HIIE (Cohen's d = -0.76 and -0.50, respectively). CONCLUSIONS In persons with paraplegia, high-intensity exercise increased postprandial energy expenditure independent of the energy cost of exercise. Furthermore, exercise combining resistance and endurance modes (CRE) showed the greater effect on postprandial lipid oxidation.

The risks and health hazards of the cardiometabolic syndrome (CMS) are commonly reported in persons with spinal cord injuries (SCIs) and disorders. Overweight/obesity, insulin resistance, hypertension, and dyslipidemia are highly prevalent after SCI. Both the CMS diagnosis and physical deconditioning worsen the prognosis for all-cause cardiovascular disease. Evidence suggests a role for physical activity to address these risks, although intense exercise may be required. A lifestyle plan incorporating both exercise and nutrition represents a preferred approach for health management. Improved surveillance for CMS risks and exercise and nutritional management are essential for the preservation of optimal health and independence.

STUDY DESIGN: Clinical trial OBJECTIVES: We used a single-blind parallel group design to test the feasibility and preliminary efficacy of a telehealth-based physical activity counseling intervention to increase physical fitness in people with SCI. SETTING: Seattle, Washington, United States. METHODS: We recruited under-active, manual wheelchair-using adults at least one-year post-SCI who had at least two cardiometabolic risk factors/diseases. Participants underwent baseline tests of peak cardiorespiratory fitness; lipids, glucose and insulin; muscle and fat mass; self-reported physical activity, depression, pain and other factors. Participants were assigned 1:1 to treatment versus usual care (UC) control conditions via concealed computerized randomization. Treatment was delivered via telephone and adapted from the 16-session Diabetes Prevention Program. All baseline tests were repeated at 6 months. Prespecified feasibility goals were to recruit at least 9 participants/quarter and retain 85% with complete fitness testing at 6 months. Prespecified efficacy goals were to demonstrate at least a medium treatment effect size (0.50) on fitness, self-reported physical activity and other outcomes. RESULTS: Seven participants were randomized to treatment, 8 to UC over 15 months. Maximum recruitment was only 5.4 participants/quarter. Thirteen (87%) of participants were retained. The effects of treatment on fitness and most cardiometabolic risk factors did not meet expectations, whereas the effects on self-reported physical activity, depression, and pain did meet expectations. CONCLUSIONS: The study did not meet key efficacy and feasibility objectives, yet there were some promising effects on self-report measures and lessons to be learned for designing future trials.

A phase 1 open-label, non-randomized clinical trial was conducted to determine feasibility and safety of autologous human Schwann cell (ahSC) transplantation accompanied by rehabilitation in participants with chronic spinal cord injury (SCI). Magnetic resonance imaging (MRI) was used to screen eligible participants to estimate an individualized volume of cell suspension to be implanted. The trial incorporated standardized multi-modal rehabilitation before and after cell delivery. Participants underwent sural nerve harvest, and ahSCs were isolated and propagated in culture. The dose of culture-expanded ahSCs injected into the chronic spinal cord lesion of each individual followed a cavity-filling volume approach. Primary outcome measures for safety and trend-toward efficacy were assessed. Two participants with American Spinal Injury Association Impairment Scale (AIS) A and two participants with incomplete chronic SCI (AIS B, C) were each enrolled in cervical and thoracic SCI cohorts (n = 8 total). All participants completed the study per protocol, and no serious adverse events related to sural nerve harvest or ahSC transplantation were reported. Urinary tract infections and skin abrasions were the most common adverse events reported. One participant experienced a 4-point improvement in motor function, a 6-point improvement in sensory function, and a 1-level improvement in neurological level of injury. Follow-up MRI in the cervical (6 months) and thoracic (24 months) cohorts revealed a reduction in cyst volume after transplantation with reduced effect over time. This phase 1 trial demonstrated the feasibility and safety of ahSC transplantation combined with a multi-modal rehabilitation protocol for participants with chronic SCI.

Background Uptake of HIV self-tests (HIVST) remains low in Europe. We conducted two separate surveys to understand facilitators and barriers to the use of HIVST in two European countries, as part of the EU INTEGRATE Joint Action. In both countries, HIV has been legal since 2016. In Lithuania, where HIVST sales have been low, the survey primarily assessed acceptability whilst in Italy, with better HIVST uptake, usability was the focus. Methods Participants were recruited through community HIV testing sites, and in Lithuania also through social media. In Lithuania, participants self-completed a survey on their testing history, and attitudes toward and experiences with self-testing. In Italy participants performed an HIVST (Mylan Autotest) while being observed by a community health worker (CHW). Both participants and CHW completed a self-administered survey evaluating the experience of the participant. Results In Lithuania, awareness of HIV self-testing (75%) was high among the 138 people who completed the survey. Privacy and confidentiality (70%) was the most common reason to use an HIVST whilst cost was reported as the main barrier by 60%, only 15% were willing to pay the current price. Almost half (42%) were concerned about doing the test incorrectly and 36% preferred that a trained person could discuss their result. Purchasing HIVST at a pharmacy (70%) or online (61%) was favoured and 68% would opt to simultaneously test for other infections. In Italy, 28 people who had never used an HIVST before were observed using one. 43% found the test easy to use but CHWs reported that 36% of participants failed at least one step. The quick result (68%) was the most common reason to use one again, yet the main concerns were the lack of counselling (50%) and reading result alone (32%). Conclusions HIVST are acceptable and usable, however cost is a major barrier. Local and national strategies are needed to increase awareness of and access to HIVST and target HIVST campaigns toward key risk groups such as MSM. Meanwhile, steps can be taken to improve testing instructions and support for self-testers. Offering multiplex testing for other infections would also likely increase uptake.

The authors tested the efficacy of an integrated approach to improving patient experience and physician burnout using a 24-week online training program coupled with a physician engagement strategy. Physicians from different disciplines were randomized to intervention (n = 30) and control (n = 33) groups. Patient experience, physician burnout, and satisfaction data were assessed using patient and provider surveys. Comparisons were made pre and post intervention, and between the groups. Intervention group mean scores increased (+1.40 points) while control group scores dropped (−0.11 points; P = .039). Scores on physician burnout surveys for the intervention group improved in all areas and changes in 2 domains were statistically significant. In all, 73.5% of physicians felt the program was effective. This integrated intervention enhanced patient experience scores and positively affected physicians’ level of burnout, and physicians believed this exercise was useful.

Purpose: To (1) investigate the association between sprint power and aerobic power output (POpeakGXT) during a graded peak exercise test (GXT); and (2) validate the prediction models of POpeakGXT based on sprint power and personal and lesion characteristics. Materials and methods: Wheelchair users with tetraplegia (N = 35) and paraplegia (N = 58) performed a 30 s-Wingate test and GXT on an asynchronous arm-crank ergometer. Data were split into samples to develop and validate the model. Sprint power (POmeanWingate and POpeakWingate, respectively) and POpeakGXT were determined. Regression analyses were performed to develop POpeakGXT prediction models. Candidate independent variables included POmeanWingate or POpeakWingate, age (years), sex, body mass (kg) or BMI (kg/m2), time since injury (TSI, years) and lesion level (tetraplegia/paraplegia). The best model was validated by comparing the predicted POpeakGXT with measured POpeakGXT. Results: The best model (R2 = 0.76) to predict POpeakGXT included POmeanWingate, BMI and all other independent variables. No significant difference was found between measured (68 ± 35 W) and predicted POpeakGXT (68 ± 30 W, p = 0.97). The ICC was excellent (0.89 with 95% confidence intervals: 0.75-0.95). The 95% limits of agreement for the Bland-Altman plots were wide (-30 to 31 W). Conclusions: Strong associations were found between POmeanWingate and POpeakGXT. Although relative agreement was excellent, absolute agreement was low. Implications for rehabilitation There is a strong relationship between peak aerobic power output and sprint power output, both tested on an arm-crank ergometer, in people with spinal cord injury. A prediction model for peak aerobic power output, based on sprint power output and personal and lesion characteristics, showed a high explained variance. The predictive model can give a guideline for choosing the right graded exercise test protocol but should be used with caution.

STUDY OBJECTIVES: The purpose of this study was to determine sleep quality and presence of sleep disorders in participants with spinal cord injury (SCI). METHODS: A web-based survey, available online from February 2011 to July 2013, using validated sleep questionnaires, advertised via the internet and locally through SCI consumer organizations in the United States, Australia, New Zealand, and Canada, was designed to evaluate sleep in adults with self-reported SCI. Demographic characteristics and medical history were obtained from participant self-report. RESULTS: In our study population, 70% of the 304 participants were male with a mean age of 45 ± 13 years. The mean duration of injury was 16 ± 12 years. Cervical injuries were reported by 49% and thoracic injuries noted in 40% of participants. Increased sleep apnea risk was noted in 31% of participants, with 66% reporting snoring. Insomnia symptoms were reported by 54% of the respondents. Almost 40% of participants ranked their sleep quality as “fairly bad” to “very bad” in the previous month, 29% reported “often” or “almost always” waking up because of pain, and 22% had difficulty falling asleep because of leg cramps. In the past year, 27% of the respondents reported daily uncomfortable leg sensations and 28% found these leg symptoms to be “moderately to extremely distressing.” CONCLUSIONS: This study increases the awareness that insomnia, sleep apnea, and poor sleep quality are common in individuals with chronic SCI; often coexisting. There is a need for increased screening for sleep problems by healthcare providers taking care of individuals living with SCI. CITATION: Shafazand S, Anderson KD, Nash MS. Sleep complaints and sleep quality in spinal cord injury: a web-based survey. J Clin Sleep Med. 2019;15(5):719–724.

The 56 Dean Street combination prevention model, a strong engagement with the LGBTQI community and flexible services adapted to users' changing needs led to an 80% drop in HIV diagnoses in gay, bisexual and other men who have sex with men (GBMSM) from 2015 to 2017. We describe the service changes at 56 Dean Street since 2012 which resulted in an increase in the frequency of HIV testing, the introduction of pre-exposure prophylaxis, earlier HIV diagnosis and a shorter time to viral suppression in those living with HIV. This model could be adapted to deliver similar results in those settings of high HIV prevalence among GBMSM and where access to technological innovation in healthcare and engagement with the community can be achieved.

To investigate the feasibility and validity of using the novel axillary:umbilical (A:U) ratio and sustained maximal inspiratory pressure (SMIP) as supplementary measures in the assessment of respiratory function in people with spinal cord injury.Pilot study with a single day of data collection. All measurements were taken with participants in their personal wheelchairs to best represent normal functioning and positioning for each individual.Research institution.A convenience sample of 30 community dwelling volunteers with chronic spinal cord injury (C2-T12, American Spinal Injury Association Impairment Scale A-D) participated.Not applicable.Participants underwent anthropometric measurements (trunk height, abdominal circumference, axillary circumference) and assessment of inspiratory muscle performance, incluidng maximal inspiratory pressure, SMIP, and inspiratory duration, as well as standard pulmonary function tests.The A:U ratio and SMIP were recorded for all participants. The SMIP was significantly related to more respiratory performance measures than the maximal inspiratory pressure (P.05) and the A:U ratio was significantly related to more respiratory performance measures than any other anthropometric measure (P.05). Additionally, an A:U ratio cutoff point detected individuals with a peak expiratory flow ≥ 80% of their predicted value with a sensitivity and specificity of 85.7% and 91.3%, respectively (area under the curve: 0.92).It is feasible to capture the A:U Ratio and SMIP in individuals with spinal cord injury. Further, the strong significant relationships of SMIP and the A:U ratio to respiratory performance measures suggests their clinical importance in the pulmonary assessment and risk stratification of people with chronic spinal cord injury.

The peak rate of fat oxidation (PFO) achieved during a graded exercise test is an important indicator of metabolic health. In healthy individuals, there is a significant positive association between PFO and total daily fat oxidation (FO). However, conditions resulting in metabolic dysfunction may cause a disconnect between PFO and non-exercise FO. Ten adult men with chronic thoracic spinal cord injury (SCI) completed a graded arm exercise test. On a separate day following an overnight fast (≥ 10 h), they rested for 60 min before ingesting a liquid mixed meal (600 kcal; 35% fat, 50% carbohydrate, 15% protein). Expired gases were collected and indirect calorimetry data used to determine FO at rest, before and after feeding, and during the graded exercise test. Participants had “good” cardiorespiratory fitness (VO2peak: 19.2 ± 5.2 ml/kg/min) based on normative reference values for SCI. There was a strong positive correlation between PFO (0.30 ± 0.08 g/min) and VO2peak (r = 0.86, p = 0.002). Additionally, postabsorptive FO at rest was significantly and positively correlated with postprandial peak FO (r = 0.77, p = 0.01). However, PFO was not significantly associated with postabsorptive FO at rest (0.08 ± 0.02 g/min; p = 0.97), postprandial peak FO (0.10 ± 0.03 g/min; p = 0.43), or incremental area under the curve postprandial FO (p = 0.22). It may be advantageous to assess both postabsorptive FO at rest and PFO in those with SCI to gain a more complete picture of their metabolic flexibility and long-term metabolic health.

ImportanceNeutralizing monoclonal antibody (MAB) therapies may benefit patients with mild to moderate COVID-19 at high risk for progressing to severe COVID-19 and/or hospitalization. Studies documenting approaches to deliver MAB infusions as well as demonstrating their efficacy are lacking.ObjectiveWe describe our experience and patient outcomes of almost 3,000 patients who received MAB infusion therapy at Northwell Health, a large integrated health care system in New York.Design, Setting, and ParticipantsThis is a descriptive study of adult patients who received MAB therapy between November 20, 2020, to January 31, 2021, and a retrospective cohort survival analysis comparing patients who received MAB therapy prior to admission versus those who did not. A multivariable Cox model with inverse probability weighting according to the propensity score including covariates (sociodemographic, comorbidities, and presenting vital signs) was used.Main outcomes and measuresThe primary outcome was in-hospital mortality; additional evaluations included ED utilization and hospitalization within 28 days of a positive COVID-19 test for patients who received MAB therapy.ResultsDuring the study period, 2818 adult patients received MAB infusion. Following therapy and within 28 days of COVID-19 test, 123 patients (4.4%) presented to the ED and were released and 145 patients (5.1%) were hospitalized. These 145 patients were compared with 200 controls who were eligible for but did not receive MAB therapy, and were hospitalized. In the MAB group, 16 (11%) patients met the primary outcome of in-hospital mortality, versus 21 (10.5%) in the control group. In an unadjusted Cox model, the hazard ratio (HR) for time to in-hospital mortality for the MAB group was 1.38 (95% confidence interval [95% CI] 0.696-2.719). Models adjusting for demographics (HR 1.1, 95% CI 0.53-2.23), demographics and Charlson Comorbidity Index (CCI) (HR 1.22, 95% CI 0.573-2.59), and with inverse probability weighting according to propensity scores (HR 1.19, 95% CI 0.619-2.29) did not demonstrate significance. The hospitalization rate was 4.4% for patients who received MAB therapy within 0-4 days, 5% within 5-7 days, and 6.1% within ≥8 days of symptom onset (p-value = 0.15).Conclusions and relevanceEstablishing the capability to provide neutralizing MAB infusion therapy requires significant planning and coordination. While this therapy may be an important treatment option for early mild to moderate COVID-19 in high-risk patients, further investigations are needed to define the optimal timing of MAB treatment in order to reduce hospitalization and mortality.

Spinal cord injury (SCI) results in an array of cardiometabolic complications, with obesity being the most common component risk of cardiometabolic disease (CMD) in this population. Recent Consortium for Spinal Cord Medicine Clinical Practice Guidelines for CMD in SCI recommend physical exercise as a primary treatment strategy for the management of CMD in SCI. However, the high prevalence of obesity in SCI and the pleiotropic nature of this body habitus warrant strategies for tailoring exercise to specifically target obesity. In general, exercise for obesity management should aim primarily to induce a negative energy balance and secondarily to increase the use of fat as a fuel source. In persons with SCI, reductions in the muscle mass that can be recruited during activity limit the capacity for exercise to induce a calorie deficit. Furthermore, the available musculature exhibits a decreased oxidative capacity, limiting the utilization of fat during exercise. These constraints must be considered when designing exercise interventions for obesity management in SCI. Certain forms of exercise have a greater therapeutic potential in this population partly due to impacts on metabolism during recovery from exercise and at rest. In this article, we propose that exercise for obesity in SCI should target large muscle groups and aim to induce hypertrophy to increase total energy expenditure response to training. Furthermore, although carbohydrate reliance will be high during activity, certain forms of exercise might induce meaningful postexercise shifts in the use of fat as a fuel. General activity in this population is important for many components of health, but low energy cost of daily activities and limitations in upper body volitional exercise mean that exercise interventions targeting utilization and hypertrophy of large muscle groups will likely be required for obesity management.

Whole body energy expenditure and lipid oxidation (Lox) are upregulated during and after exercise. Persons with spinal cord injury (SCI) generally have a blunted ability to utilize fat during exercise, but it is unknown if their substrate partitioning is affected during recovery from exercise. To determine the effect of a single session of upper body circuit resistance exercise (CRE) on energy expenditure and Lox during exercise recovery in persons with and without SCI. Twenty four persons (3 groups; 7 male and 1 female per group) without paralysis (neurologically intact; N) or with chronic (≥ 1 yr) paraplegia (P) or tetraplegia (T) participated. Energy expenditure and substrate partitioning were assessed via indirect calorimetry before, during, and three times after (up to 120 min after) a single session of CRE, or time-matched seated control (CON). During CRE, all groups experienced a similar relative increase in oxygen consumption (49 ± 13, 55 ± 11, and 48 ± 15% VO2peak for N, P, and T, respectively). The Post0-120 energy expenditure was greater following CRE vs. CON (P

Introduction Cancer is likened to a non-healing wound. There is limited evidence on the expression of wound healing tissue inflammatory markers, CD68(pan-macrophage marker), HO-1(tumour cell marker) and FAP(cancer-associated fibroblast marker) in human breast cancer. Method In 201 invasive breast cancer and 58 DCIS patients, CD68+TAM expression, tumour HO-1 and fibroblast FAP expression, quantified by immunohistochemistry(dichotomised: high/present vs low/absent), was correlated with tumour factors (grade, proliferation(Ki67), ER, HER2); demographic factors, behavioural factors (smoking, alcohol) and survival status(DFS, OS) Result High CD68+macrophage expression was increased in invasive breast cancer, compared to DCIS, and normal tissue distant from the tumour(59%,41%and 6% respectively; p Conclusion Tumour inflammation as assessed by CD68+TAM expression shows utility in identifying aggressive breast cancer sub-types. The association reported between CD68+TAM density and alcohol intake suggests a possible mechanism for alcohol as a risk factor for breast cancer. The prognostic value of HO-1 and FAP expression demonstrated here suggests a functional role of these wound healing markers in breast cancer. HO-1:Heme-oxygenase-1; FAP:Fibroblast activation protein; TAM:Tumour associated macrophage; DCIS: Ductal carcinoma in situ Take-home message Wound healing pathways of inflammation may be implicated in early breast cancer development

Spinal cord injury (SCI) results in disordered fat metabolism. Autonomic decentralization might contribute to dyslipidemia in SCI, in part by influencing the uptake of dietary fats through the gut-lymph complex. However, the neurogenic contributions to dietary fat metabolism are unknown in this population. We present a subset of results from an ongoing registered clinical trial (NCT03691532) related to dietary fat absorption. We fed a standardized (20 kcal⋅kgFFM–1) liquid meal tolerance test (50% carb, 35% fat, and 15% protein) that contained stable isotope lipid tracer (5 mg⋅kgFFM–1 [U-13C]palmitate) to persons with and without motor complete thoracic SCI. Blood samples were collected at six postprandial time points over 400 min. Changes in dietary fatty acid incorporated into the triacylglycerol (TAG) pool (“exogenous TAG”) were used as a marker of dietary fat absorption. This biomarker showed that those with paraplegia had a lower amplitude than non-injured participants at Post240 (52.4 ± 11.0 vs. 77.5 ± 16.0 μM), although this failed to reach statistical significance (p = 0.328). However, group differences in the time course of absorption were notable. The injury level was also strongly correlated with time-to-peak exogenous TAG concentration (r = −0.806, p = 0.012), with higher injuries resulting in a slower rise in exogenous TAG. This time course documenting exogenous TAG change is the first to show a potential neurogenic alteration in SCI dietary fat absorption.

Study design: Randomized crossover. Objectives: To test differences in the duration and magnitude of physiological response to isocaloric moderate intensity continuous (MICE) and high-intensity interval exercise (HIIE) sessions in persons with spinal cord injury (SCI). Setting: Academic medical center in Miami, FL, USA. Methods: Ten adult men (mean ± s.d.; 39 ± 10 year old) with chronic (13.2 ± 8.8 year) paraplegia (T2–T10) completed a graded exercise test. Then, in a randomized order, participants completed MICE and HIIE for a cost of 120 kcal. MICE was performed at 24.6% PO peak. During HIIE, exercise was completed in 2 min work and recovery phases at 70%:10% PO peak. Results: MICE and HIIE were isocaloric (115.9 ± 21.8 and 116.6 ± 35.0 kcal, respectively; p = 0.903), but differed in duration (39.8 ± 4.6 vs 32.2 ± 6.2 min; p < 0.001) and average respiratory exchange ratio (RER; 0.90 ± 0.08 vs 1.01 ± 0.07; p = 0.002). During MICE, a workrate of 24.6 ± 6.7% PO peak elicited a V̇O 2 of 53.1 ± 6.5% V̇O 2peak (10.1 ± 2.2 ml kg −1 min −1). During HIIE, a workrate at 70% PO peak elicited 88.3 ± 6.7% V̇O 2peak (16.9 ± 4.2 ml kg −1 min −1), and 29.4 ± 7.7% of the session was spent at or above 80% V̇O 2peak. During HIIE working phase, RER declined from the first to last interval (1.08 ± 0.07 vs 0.98 ± 0.09; p < 0.001), reflecting an initially high but declining glycolytic rate. Conclusions: Compared with MICE, HIIE imposed a greater physiological stimulus while requiring less time to achieve a target caloric expenditure. Thus, exercise intensity might be an important consideration in the tailoring of exercise prescription to address the cardiometabolic comorbidities of SCI.

Seated balance (SB) is substantially compromised and greatly impacts the function of individuals living with a spinal cord injury (SCI). A clinically applicable criterion standard measure for SB does not exist for this population. Initial validation and reliability analysis of the Function in Sitting Test (FIST) in SCI has been published, but the authors of this study report that modifications to the tool may be necessary. This study aimed to explore the psychometrics and clinical utility of a modified version of the FIST to better measure SCI-specific functional tasks in sitting.The FIST was modified (FIST-SCI) by an expert panel and used by 2 graders to evaluate the SB of individuals with chronic SCI (cSCI) on 2 separate days. The Motor Assessment Scale item 3 (MAS-SCI) was included as a comparison measure.Research facility.Individuals with cSCI longer than 1 year (N=38) participated in the study. Injury levels of individuals participating in this study spanned C1 to T10 (American Spinal Injury Association Impairment Scale A, 17 subjects; B, 12 subjects; and C, 9 subjects). Thirteen individuals required assistance to transfer.Not applicable.Validity, reliability, internal consistency, sensitivity, specificity, and responsiveness.Validity testing found a moderate relationship between the MAS-SCI and the FIST-SCI (ρ, .522; P.05). FIST-SCI scores distinguished individuals requiring assistance to transfer from those who were independent (t=4.51; P.05). Inter- and intra-rater reliability were excellent (intraclass correlation coefficient (2,k)=.985 and .983, respectively) and internal consistency was excellent (α=.94). A FIST-SCI cutoff score of 45 or greater was 92% sensitive and specific in characterizing transfer ability. Standard error of the measure (1.3) and minimal detectable change (3.5) were similar to previous work.Initial validity of the FIST-SCI is reported, but further assessment is required. Reliability is excellent in the cSCI population. FIST-SCI scores provide clinical insight into the seated functional ability of individuals with cSCI.

Purpose of Review Persons with spinal cord injuries (SCI) commonly experience individual risks and coalesced health hazards of the cardiometabolic syndrome (CMS). This review will examinethe role of exercise and nutritional intervention as countermeasures to these disease risks. Recent Findings The CMS hazards of overweight/obesity, insulin resistance, hypertension, and dyslipidemia are strongly associated with physical deconditioning and are common after SCI. Both the CMS diagnosis and physical deconditioning worsen the prognosis for all-cause cardiovascular disease occurring early after SCI. Evidence supports a therapeutic role for physical activity after SCI as an effective countermeasure to these risks and often represents the first-line approach to CMS abatement. This evidence is supported by authoritative systematic reviews and associated guidelines that recommend specific activities, frequencies, and activities of work. In many cases, the most effective exercise programming uses more intense periods of work with limited rest. As SCI is also associated with poor dietary habits, including excessive energy intake and saturated fat consumption, more comprehensive lifestyle management incorporating both exercise and nutrition represents a preferred approach for overall health management. Summary Irrespective of the interventional strategy, improved surveillance of the population for CMS risks and encouraged incorporation of exercise and nutritional management according to recent population-specific guidelines will most likely play an important role in the preservation of activity, optimal health, and independence throughout the lifespan.

The safety and efficacy of pharmacological and cellular transplantation strategies are currently being evaluated in people with spinal cord injury (SCI). In studies of people with chronic SCIs, it is thought that functional recovery will be best achieved when drug or cell therapies are combined with rehabilitation protocols. However, any functional recovery attributed to the therapy may be confounded by the conditioned state of the body and by training-induced effects on neuroplasticity. For this reason, we sought to investigate the effects of a multi-modal training program on several body systems. The training program included body-weight–supported treadmill training for locomotion, circuit resistance training for upper body conditioning, functional electrical stimulation for activation of sublesional muscles, and wheelchair skills training for overall mobility. Eight participants with chronic, thoracic-level, motor-complete SCI completed the 12-week training program. After 12 weeks, upper extremity muscular strength improved significantly for all participants, and some participants experienced improvements in function, which may be explained by increased strength. Neurological function did not change. Changes in pain and spasticity were highly variable between participants. This is the first demonstration of the effect of this combination of four training modalities. However, balancing participant and study-site burden with capturing meaningful outcome measures is also an important consideration.

Background Neutralizing monoclonal antibody (MAB) therapies may benefit patients with mild to moderate COVID-19 at high risk for progressing to severe COVID-19 or hospitalization. Studies documenting approaches to deliver MAB infusions and demonstrating their efficacy are lacking. Objective We describe our experience and the outcomes of almost 3000 patients who received MAB infusion therapy at Northwell Health, a large integrated health care system in New York. Methods This is a descriptive study of adult patients who received MAB therapy between November 20, 2020, to January 31, 2021, and a retrospective cohort survival analysis comparing patients who received MAB therapy prior to admission versus those who did not. A multivariable Cox model with inverse probability weighting according to the propensity score including covariates (sociodemographic, comorbidities, and presenting vital signs) was used. The primary outcome was in-hospital mortality; additional evaluations included emergency department use and hospitalization within 28 days of a positive COVID-19 test for patients who received MAB therapy. Results During the study period, 2818 adult patients received MAB infusion. Following therapy and within 28 days of a COVID-19 test, 123 (4.4%) patients presented to the emergency department and were released, and 145 (5.1%) patients were hospitalized. These 145 patients were compared with 200 controls who were eligible for but did not receive MAB therapy and were hospitalized. In the MAB group, 16 (11%) patients met the primary outcome of in-hospital mortality, versus 21 (10.5%) in the control group. In an unadjusted Cox model, the hazard ratio (HR) for time to in-hospital mortality for the MAB group was 1.38 (95% CI 0.696-2.719). Models adjusting for demographics (HR 1.1, 95% CI 0.53-2.23), demographics and Charlson Comorbidity Index (HR 1.22, 95% CI 0.573-2.59), and with inverse probability weighting according to propensity scores (HR 1.19, 95% CI 0.619-2.29) did not demonstrate significance. The hospitalization rate was 4.4% for patients who received MAB therapy within 0 to 4 days, 5% within 5 to 7 days, and 6.1% in ≥8 days of symptom onset (P=.15). Conclusions Establishing the capability to provide neutralizing MAB infusion therapy requires substantial planning and coordination. Although this therapy may be an important treatment option for early mild to moderate COVID-19 in patients who are at high risk, further investigations are needed to define the optimal timing of MAB treatment to reduce hospitalization and mortality.

Chronic spinal cord injury (SCI) often results in morbidity and mortality due to all-cause cardiovascular disease (CVD) and comorbid endocrine disorders. Several component risk factors for CVD, described as the cardiometabolic syndrome (CMS), are prevalent in SCI, with the individual risks of obesity and insulin resistance known to advance the disease prognosis to a greater extent than other established risks. Notably, adiposity and insulin resistance are attributed in large part to a commonly observed maladaptive dietary/nutritional profile. Although there are no evidence-based nutritional guidelines to address the CMS risk in SCI, contemporary treatment strategies advocate more comprehensive lifestyle management that includes sustained nutritional guidance as a necessary component for overall health management. This monograph describes factors in SCI that contribute to CMS risks, the current nutritional profile and its contribution to CMS risks, and effective treatment strategies including the adaptability of the Diabetes Prevention Program (DPP) to SCI. Establishing appropriate nutritional guidelines and recommendations will play an important role in addressing the CMS risks in SCI and preserving optimal long-term health.

I am a cardiologist. I am also a patient with a potentially life-threatening heart condition. Like millions of other patients, I cannot see the information about my own heart that is being recorded by a cardiac implantable electronic device. The reason I can’t is not based on any technical limitation. It is the result of a choice by the device’s manufacturer to reveal clinical data only to doctors, not to patients. That arrangement is typical, and it is also inappropriate, anachronistic, and dangerous. In my own practice, I have learned the value of engaging patients in their own care. That comes in part from the humbling nature of clinical experience, in which some good outcomes have come from patients ignoring my advice, and some bad outcomes have followed their taking it, and with the recognition that I (and medicine in general) do not have all the answers to patients’ questions. Maturing as a clinician means I recognize that there are few absolutely right or wrong care plans, and that patient preferences, informed by the best medical information available, ought to shape clinical decision making. My journey as a patient started in 2008, when I learned that I have a relatively unusual variant of hypertrophic cardiomyopathy. Although I am asymptomatic, a recent article1 challenged my sense of well-being. It reported that a cohort of patients with findings similar to mine had a prognosis worse than previously appreciated, with a relatively high risk of arrhythmic sudden cardiac death. …

Background Chronic spinal cord injury (SCI) increases morbidity and mortality associated with cardiometabolic diseases, secondary to increases in central adiposity, hyperlipidaemia and impaired glucose tolerance. While upper-body Moderate Intensity Continuous Training (MICT) improves cardiorespiratory fitness, its effects on cardiometabolic component risks in adults with SCI appear relatively modest. The aim of this study is to assess the acute effects of Continuous Resistance Training (CRT), High Intensity Interval Training (HIIT), MICT and rest (CON) on fasting and postprandial systemic biomarkers and substrate utilisation. Methods Eleven healthy, chronic SCI (> 1 year, ASIA A-C) men will be recruited. Following preliminary testing, each will complete four experimental conditions, where they will report to the laboratory following an ~ 10-h overnight fast. A venous blood sample will be drawn and expired gases collected to estimate resting metabolic rate (RMR). In order to ensure an isocaloric exercise challenge, each will complete CRT first, with the remaining three conditions presented in randomised order: (1) CRT, ~ 45 min of resistance manoeuvres (weight lifting) interspersed with low-resistance, high-speed arm-crank exercise; (2) CON, seated rest; (3) MICT, ~ 45 min constant arm-crank exercise at a resistance equivalent to 30–40% peak power output (PPO) and; (4) HIIT, ~ 35 min arm-crank exercise with the resistance alternating every 2 min between 10% PPO and 70% PPO. After each ~ 45-min condition, participants will ingest a 2510-kJ liquid test meal (35% fat, 50% carbohydrate, 15% protein). Venous blood and expired gas samples will be collected at the end of exercise and at regular intervals for 120 min post meal. Discussion This study should establish the acute effects of different forms of exercise on fasting and postprandial responses in chronic SCI male patients. Measures of glucose clearance, insulin sensitivity, lipid and inflammatory biomarker concentrations will be assessed and changes in whole-body substrate oxidation estimated from expired gases. Trial registration ClinicalTrials.gov, ID: NCT03545867. Retrospectively registered on 1 June 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3583-1) contains supplementary material, which is available to authorized users.

To (1) compare energy expenditure during seated rest, standing, and prolonged bionic ambulation or bipedal ambulation in participants with spinal cord injury (SCI) and noninjured controls, respectively, and (2) test effects on postbionic ambulation glycemia in SCI.Two independent group comparison of SCI and controls.Academic Medical Center.Ten participants with chronic SCI (C7-T1, American Spinal Injury Association Impairment Scale A-C) and 10 controls (N=20).A commercial bionic exoskeleton.Absolute and relative (to peak) oxygen consumption, perceived exertion, carbohydrate/fat oxidation, energy expenditure, and postbionic ambulation plasma glucose/insulin.Average work intensity accompanying 45 minutes of outdoor bionic ambulation was40% peak oxygen consumption, with negligible drift after reaching steady state. Rating of perceived exertion (RPE) did not differ between groups and reflected low exertion. Absolute energy costs for bionic ambulation and nonbionic ambulation were not different between groups despite a 565% higher ambulation velocity in controls and 3.3× higher kilocalorie per meter in SCI. Fuel partitioning was similar between groups and the same within groups for carbohydrate and fat oxidation. Nonsignificant (9%) lowering of the area under a glucose tolerance curve following bionic ambulation required 20% less insulin than at rest.Work intensity during prolonged bionic ambulation for this bionic exoskeleton is below a threshold for cardiorespiratory conditioning but above seated rest and passive standing. Bionic ambulation metabolism is consistent with low RPE and unchanged fuel partitioning from seated rest. Bionic ambulation did not promote beneficial effects on glycemia in well-conditioned, euglycemic participants. These findings may differ in less fit individuals with SCI or those with impaired glucose tolerance. Observed trends favoring this benefit suggest they are worthy of testing.

Administrative and financial support provided by Paralyzed Veterans of AmericaReprinted with permission from the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine Clinical Pra...

Spinal cord injury (SCI) triggers an "accelerated aging" process that may include development of hypogonadism, even among younger men with SCI; however, few studies have investigated the prevalence or etiology of hypogonadism in men with SCI. Young men with SCI also are at increased risk for developing metabolic dysfunction after injury, which may be exacerbated by concomitant testosterone (T) deficiency, thus identifying the prevalence and risk factors for T deficiency in men with SCI is important for their long-term health.To investigate the prevalence, risk factors, and etiology of T deficiency (hypogonadism) in otherwise-healthy men with chronic, motor complete SCI.Secondary cross-sectional analysis.Rehabilitation research centers in Washington, DC, and Miami, Florida.Men (n = 58) aged 18-45 years with chronic (≥1 year), motor complete SCI without comorbidities or use of testosterone therapy.Plasma concentrations of hormones were measured with standardized assays. Body composition was assessed with dual-energy x-ray absorptiometry scan.Serum total T and calculated free T.T deficiency was more common in men after SCI than in a matched cohort of similarly-aged men without SCI (25%, SCI versus 6.7%, non-SCI, P.001). The risk of hypogonadism appeared to be increased in men with more extensive injury and with higher percent body fat. The majority of men with SCI with low T had low serum LH levels, suggesting that central suppression of the hypothalamic-pituitary-gonadal axis may be the most common etiology of hypogonadism after SCI.Hypogonadism is more common in young men with SCI than in similarly aged men without SCI, suggesting that SCI should be identified as a risk factor for T deficiency and that routine screening for hypogonadism should be performed in the SCI population.II.

Problems posed by obesity-related endocrine diseases embody a national health crisis. Caloric excess and sedentary lifestyle from which they develop also pose significant challenges for rehabilitation providers. Almost two thirds of the U.S. population are currently overweight or obese, a number that has increased by >10% within the last decade and is expected to grow. An overweight body habitus is strongly associated with clinical hazards, including cardiometabolic syndrome, diabetes hypertension, and coronary artery disease. The component health risks of the cardiometabolic syndrome include coalescing of risk factors that predict a health calamity unless effective interventions can be developed and widely adopted. Obesity by itself is now considered an American Diabetes Association-qualified disability, but it is also disturbingly prevalent in other physical disability groupings of adults and children. This monograph describes successes of the Diabetes Prevention Program (DPP), a National Institutes of Health multisite randomized controlled trial that reported significant weight reduction and a 58% decreased incidence of type-2 diabetes accompanying 1 year of structured lifestyle intervention. This treatment benefit (1) exceeded that of metformin pharmacotherapy, (2) was so powerful that the trial was closed before reaching endpoints, and (3) was judged cost-effective for the patient and society. The DPP roadmap incorporating physical activity, diet, and behavioral approaches has been widely adapted to specific community, faith, racial, ethnic, school, and national populations with excellent outcomes success. The lockstep physical activity approach, activity prescription, and long-term success of the program are described and compared with other programs to illustrate effective countermeasures for the pandemics of obesity and obesity-related cardioendocrine disease. We will illustrate adaptation of the DPP for a cohort of persons with disability from spinal cord injury and the benefits observed.

Patient satisfaction surveys are an increasingly important part of health care, influencing the practice of physicians. Press Ganey has developed tools to assess physician and department performance that are used by 50 percent of hospitals in the United States and over 10,000 health care organizations. The authors sought to evaluate the factors that influence patient satisfaction in plastic surgery patients both locally and nationally.A 24-item Press Ganey survey was distributed to patients of 686 participating plastic surgeons nationwide, including those at the authors' home institution. The responses from January to December of 2016 were analyzed retrospectively with Pearson correlation coefficients. The items "likelihood to recommend provider" and "likelihood to recommend practice" were correlated to all other items of the survey, as these items have been shown to be surrogates for overall satisfaction.There were 411 survey responses from patients in the Northwell Health System and 36,836 responses from patients nationally. Items that were not well correlated (r0.5) with "likelihood to recommend practice" or "provider" were items such as wait time and courtesy of registration staff. The items that were best correlated (r0.8) with "likelihood to recommend practice" or "provider" were the patient's confidence in the care provider and the provider's concern for questions. All correlations were statistically significant (p0.001).In an evolving patient centric culture, the patient's confidence and trust of the provider is more important than perception of the provider's office environment to maintaining patient loyalty and market share.

Objectives Our objective was to present recent trends in the UK HIV epidemic (2007-2016) and the public health response. Methods HIV diagnoses and clinical markers were extracted from the HIV and AIDS Reporting System; HIV testing data in sexual health services (SHS) were taken from GUMCAD STI Surveillance System. HIV data were modelled to estimate the incidence in men who have sex with men (MSM) and post-migration HIV acquisition in heterosexuals. Office for National Statistics (ONS) data enabled mortality rates to be calculated. Results New HIV diagnoses have declined in heterosexuals as a result of decreasing numbers of migrants from high HIV prevalence countries entering the UK. Among MSM, the number of HIV diagnoses fell from 3570 in 2015 to 2810 in 2016 (and from 1554 to 1096 in London). Preceding the decline in HIV diagnoses, modelled estimates indicate that transmission began to fall in 2012, from 2800 [credible interval (CrI) 2300-3200] to 1700 (CrI 900-2700) in 2016. The crude mortality rate among people promptly diagnosed with HIV infection was comparable to that in the general population (1.22 vs. 1.39 per 1000 aged 15-59 years, respectively). The number of MSM tested for HIV at SHS increased annually; 28% of MSM who were tested in 2016 had been tested in the preceding year. In 2016, 76% of people started antiretroviral therapy within 90 days of diagnosis (33% in 2007). Conclusions The dual successes of the HIV transmission decline in MSM and reduced mortality are attributable to frequent HIV testing and prompt treatment (combination prevention). Progress towards the elimination of HIV transmission, AIDS and HIV-related deaths could be achieved if combination prevention, including pre-exposure prophylaxis, is replicated for all populations.

Spinal cord injury (SCI) resulting in paralysis of lower limbs and trunk restricts daily upright activity, work capacity, and ambulation ability, putting persons with an injury at greater risk of developing a myriad of secondary medical issues. Time spent in the upright posture has been shown to decrease the risk of these complications in SCI. Unfortunately, the majority of ambulation assistive technologies are limited by inefficiencies such as high energy demand, lengthy donning and doffing time, and poor gait pattern precluding widespread use. These limitations spurred the development of bionic exoskeletons. These devices are currently being used in rehabilitation settings for gait retraining, and some have been approved for home use. This overview will address the current state of available devices and their utility.

A sedentary lifestyle occurring soon after spinal cord injury (SCI) may be in contrast to a preinjury history of active physical engagement and is thereafter associated with profound physical deconditioning sustained throughout the lifespan. This physical deconditioning contributes in varying degrees to lifelong medical complications, including accelerated cardiovascular disease, insulin resistance, osteopenia, and visceral obesity. Unlike persons without disability for whom exercise is readily available and easily accomplished, exercise options for persons with SCI are more limited. Depending on the level of injury, the metabolic responses to acute exercise may also be less robust than those accompanying exercise in persons without disability, the training benefits more difficult to achieve, and the risks of ill-considered exercise both greater and potentially irreversible. For exercise to ultimately promote benefit and not impose additional impairment, an understanding of exercise opportunities and risks if exercise is undertaken by those with SCI is important. The following monograph will thus address common medical challenges experienced by persons with SCI and typical modes and benefits of voluntary exercise conditioning.

BACKGROUND The superiority of cisplatin and gemcitabine (CisGem) chemotherapy over gemcitabine (Gem) alone in patients with advanced biliary tract cancer (ABC) has been demonstrated in two randomised trials; ABC02 and the Biliary Tract (BT) 22 study. We used a combined dataset from these two trials to investigate the derived neutrophil-to-lymphocyte ratio (dNLR), which is thought to be a prognostic factor associated with clinical outcomes in several solid tumours, including ABC. METHODS White blood cell (WBC) and absolute neutrophil count (ANC) were available for 379 of 410 patients from ABC-02 and all 83 patients in BT-22. The dNLR was calculated as ANC/(WBC-ANC), as previously specified. We examined the association between dNLR and overall survival (OS) and progression-free survival (PFS), as well as comparing the treatment effect in two patient groups defined by their dNLR level. A high dNLR was defined as ≥3.0, which was approximately the upper tertile value. RESULTS A total of 462 individual patient records were analysed, 328 with baseline dNLR

Ischemic preconditioning (IPC) may improve blood flow and oxygen delivery to tissues, including skeletal muscle, and has the potential to improve intense aerobic exercise performance, especially that which results in arterial hypoxemia. The aim of the study was to determine the effects of IPC of the legs on peak exercise capacity (Wpeak), submaximal and peak cardiovascular hemodynamics, and peripheral capillary oxygen saturation (SpO2) in trained males at sea level (SL) and simulated high altitude (HA; 13.3% FIO2, ∼3650 m). Fifteen highly trained male cyclists and triathletes completed 2 Wpeak tests (SL and HA) and 4 experimental exercise trials (10 min at 55% altitude-specific Wpeak then increasing by 30 W every 2 min until exhaustion) with and without IPC. HA resulted in significant arterial hypoxemia during exercise compared with SL (73% ± 6% vs. 93% ± 4% SpO2, p < 0.001) that was associated with 21% lower Wpeak values. IPC did not significantly improve Wpeak at SL or HA. Additionally, IPC failed to improve cardiovascular hemodynamics or SpO2 during submaximal exercise or at Wpeak. In conclusion, IPC performed 45 min prior to exercise does not improve Wpeak or systemic oxygen delivery during submaximal or peak exercise at SL or HA. Future studies must examine the influence of IPC on local factors, such as working limb blood flow, oxygen delivery, and arteriovenous oxygen difference as well as whether the effectiveness of IPC is altered by the volume of muscle made ischemic, the timing prior to exercise, and high altitude acclimatization.

BackgroundObstructive sleep apnoea (OSA) is highly prevalent in people with spinal cord injury (SCI). Polysomnography (PSG) is the gold-standard diagnostic test for OSA, however PSG is expensive and frequently inaccessible, especially in SCI. A two-stage model, incorporating a questionnaire followed by oximetry, has been found to accurately detect moderate to severe OSA (MS-OSA) in a non-disabled primary care population. This study investigated the accuracy of the two-stage model in chronic tetraplegia using both the original model and a modified version for tetraplegia.MethodsAn existing data set of 78 people with tetraplegia was used to modify the original two-stage model. Multivariable analysis identified significant risk factors for inclusion in a new tetraplegia-specific questionnaire. Receiver operating characteristic (ROC) curve analyses of the questionnaires and oximetry established thresholds for diagnosing MS-OSA. The accuracy of both models in diagnosing MS-OSA was prospectively evaluated in 100 participants with chronic tetraplegia across four international SCI units.ResultsInjury completeness, sleepiness, self-reported snoring and apnoeas were included in the modified questionnaire, which was highly predictive of MS-OSA (ROC area under the curve 0.87 (95% CI 0.79 to 0.95)). The 3% oxygen desaturation index was also highly predictive (0.93 (0.87–0.98)). The two-stage model with modified questionnaire had a sensitivity and specificity of 83% (66–93) and 88% (75–94) in the development group, and 77% (65–87) and 81% (68–90) in the validation group. Similar results were demonstrated with the original model.ConclusionImplementation of this simple alternative to full PSG could substantially increase the detection of OSA in patients with tetraplegia and improve access to treatments.Trial registration numberResults, ACTRN12615000896572 (The Australian and New Zealand Clinical Trials Registry) and pre-results, NCT02176928 (clinicaltrials.gov).

BACKGROUND: We previously reported that young men with chronic spinal cord injury (SCI) have a higher prevalence of testosterone deficiency when compared to an age-matched healthy control population. Young men with SCI are also at increased risk for developing cardiometabolic dysfunction after injury. It is unclear whether or not testosterone deficiency is associated with heightened cardiometabolic risk in men with SCI. OBJECTIVE: To investigate associations among levels of testosterone in young men with chronic SCI and surrogate markers of cardiometabolic risk. DESIGN: Secondary cross-sectional analysis. SETTING: Rehabilitation research centers in Washington, DC, and Miami, Florida, USA. PARTICIPANTS: Men (n=58) aged 18–45 with chronic (≥1 year), motor complete SCI without comorbidities or use of testosterone therapy. METHODS: Plasma concentrations of testosterone, lipids, inflammatory markers (CRP and IL-6), HbA1C%, glucose, and insulin were measured in a fasting state using standard assays. A two-hour oral glucose tolerance test (OGTT) and Framingham Risk Score (FRS) were assessed for each subject. Body composition was assessed by DXA scan. MAIN OUTCOME MEASUREMENTS: Surrogate markers of cardiometabolic risk among men based on the level of total testosterone (TT)(≤300, 301–500, or >500 ng/dL) and free testosterone (fT) (≤9 or >9 ng/dL). Comparisons were made between men with normal and low TT or fT. RESULTS: FRS was significantly higher in men with low fT (P.08), were higher in men with low TT or low fT. Men with low TT or low fT had lower high density lipoprotein cholesterol (HDL) levels (P.1) or low density lipoprotein cholesterol (LDL) (P>.07). Men with low TT had higher levels of inflammatory markers CRP (P.8). CONCLUSIONS: In young men with chronic SCI, who undergo an accelerated aging process post-injury, hypogonadism is associated with an unfavorable cardiometabolic risk profile. Further research is needed to determine if a causal relationship exists between hypogonadism and heightened cardiometabolic risk in men with SCI, and whether routine screening for testosterone deficiency is warranted in this population.

Since October 2015 up to September 2016, HIV diagnoses fell by 32% compared with October 2014–September 2015 among men who have sex with men (MSM) attending selected London sexual health clinics. This coincided with high HIV testing volumes and rapid initiation of treatment on diagnosis. The fall was most apparent in new HIV testers. Intensified testing of high-risk populations, combined with immediately received anti-retroviral therapy and a pre-exposure prophylaxis (PrEP) programme, may make elimination of HIV achievable.

This study is a prospective case series analyzing the effects of a comprehensive lifestyle intervention program in three patients with chronic paraplegia having major risks for the cardiometabolic syndrome (CMS). Individuals underwent an intense 6-month program of circuit resistance exercise, nutrition using a Mediterranean diet and behavioral support, followed by a 6-month extension (maintenance) phase involving minimal support. The primary goal was a 7% reduction of body mass. Other outcomes analyzed insulin resistance using the HOMA-IR model, and plasma levels of fasting triglycerides and high-density lipoprotein cholesterol. All participants achieved the goal for 7% reduction of body mass and maintained the loss after the MP. Improvements were observed in 2/3 subjects for HOMA-IR and high-density lipoprotein cholesterol. All participants improved their risk for plasma triglycerides. We conclude, in a three-person case series of persons with chronic paraplegia, a lifestyle intervention program involving circuit resistance training, a calorie-restrictive Mediterranean-style diet and behavioral support, results in clinically significant loss of body mass and effectively reduced component risks for CMS and diabetes. These results were for the most part maintained after a 6-month MP involving minimal supervision.

Background: Injury to the spinal cord produces immediate, adaptive inflammatory responses that can exacerbate the initial injury and lead to secondary damage. Thus far, researchers and clinicians have focused on modulating acute inflammation to preserve sensorimotor function. However, this singular approach risks overlooking how chronic inflammation negatively impacts the broader health of persons with a spinal cord injury (SCI). Objective: The aim of this monograph was to discuss interrelated processes causing persistent inflammatory stress after SCI, along with associated health risks. We review archetypal factors that contribute to a chronic inflammatory state, including response to injury, acute infection, and autonomic dysreflexia. Secondary complications producing and exacerbating inflammation are also discussed, including pain, depression, obesity, and injury to the integumentary and skeletal systems. Finally, we discuss the role of bacteria and the gut microbiome in this process and then conclude with a discussion on how a pro-inflammatory phenotype promotes an elevated risk for cardiovascular disease after injury. Conclusions: Effectively managing chronic inflammation should be a high priority for clinicians and researchers who seek to improve the health and life quality of persons with SCI. Chronic inflammation worsens secondary medical complications and amplifies the risk for cardiometabolic disorders after injury, directly impacting both the quality of life and mortality risk after SCI. Inflammation can worsen pain and depression and even hinder neurological recovery. It is, therefore, imperative that countermeasures to chronic inflammation are routinely considered from the point of initial injury and proceeding throughout the lifespan of the individual with SCI.