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Treeline position is mainly determined by growth season temperature, but the response of treelines to climate warming is not uniform worldwide. We compared treeline structure, dynamics and thermal profile in nearby areas with different treeline type, species composition and bioclimatic conditions. We performed a detailed survey of different treeline types in three areas of Italian Alps and northern Apennines. Every tree individual was recorded along altitudinal transects from the closed forest to the species limit. Treeline structure and dynamics were described through altitudinal limits of tree height, density and age. Data were elaborated by principal components analysis. Temperature regime of the three sites was assessed from homogeneous historical climatic data. Treeline was different in the three areas for species composition, shape and dynamics. Both Alpine sites showed diffuse treeline, but only one showed advancing dynamics. Apennine treeline was abrupt and static, with higher temperature at the tree limit. Our study showed the variable dynamics of treelines within a relatively restricted area and the connection between treeline shape and dynamics. An important role is played by species composition, determined by bioclimatic and historical features. These factors should be taken into account when modelling future treeline dynamics at global scale. [ABSTRACT FROM AUTHOR]

The global retreat of glaciers is dramatically altering mountain and high-latitude landscapes, with new ecosystems developing from apparently barren substrates 1-4 . The study of these emerging ecosystems is critical to understanding how climate change interacts with microhabitat and biotic communities and determines the future of ice-free terrains 1,5 . Here, using a comprehensive characterization of ecosystems (soil properties, microclimate, productivity and biodiversity by environmental DNA metabarcoding 6 ) across 46 proglacial landscapes worldwide, we found that all the environmental properties change with time since glaciers retreated, and that temperature modulates the accumulation of soil nutrients. The richness of bacteria, fungi, plants and animals increases with time since deglaciation, but their temporal patterns differ. Microorganisms colonized most rapidly in the first decades after glacier retreat, whereas most macroorganisms took longer. Increased habitat suitability, growing complexity of biotic interactions and temporal colonization all contribute to the increase in biodiversity over time. These processes also modify community composition for all the groups of organisms. Plant communities show positive links with all other biodiversity components and have a key role in ecosystem development. These unifying patterns provide new insights into the early dynamics of deglaciated terrains and highlight the need for integrated surveillance of their multiple environmental properties 5 ., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Local anesthetic systemic toxicity (LAST) is a potentially life-threatening complication that may occur after local anesthetic injection. After reaching the systemic circulation, cardiovascular and central nervous system derangements may appear, with potentially fatal complications if left untreated. The pillars for LAST treatment are advanced life support measures, airway and seizure management, and a 20% lipid emulsion intravenous administration. When occurring in the prehospital setting, LAST is difficult to recognize, mostly because of its features overlapping with other acute conditions. Prompt treatment is also challenging because lipid emulsion may not be routinely carried on emergency vehicles. This article reports a case of LAST occurring in a dental ambulatory located in a remote location within the Italian Alps in which effective communication among different components of the same regional health care system (dispatch center, prehospital teams, and hospital network) led to fast lipid emulsion retrieval en route and on-site toxicity resolution. This case can inspire future operational changes, such as antidote networks available to prehospital emergency medicine crews, avoiding unnecessary deployment of antidotes on ambulances or helicopters, which is difficult to preserve without increasing management costs. However, to be established, such a network would need protocols to facilitate antidote retrieval, training focused on toxidromes recognition, and improved communication skills among different professionals involved in prehospital emergency medicine., Competing Interests: Declaration of Competing Interest The author(s) have no relevant disclosures. There was no grant funding or financial support for this manuscript., (Copyright © 2024 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

The development of terrestrial ecosystems depends greatly on plant mutualists such as mycorrhizal fungi. The global retreat of glaciers exposes nutrient-poor substrates in extreme environments and provides a unique opportunity to study early successions of mycorrhizal fungi by assessing their dynamics and drivers. We combined environmental DNA metabarcoding and measurements of local conditions to assess the succession of mycorrhizal communities during soil development in 46 glacier forelands around the globe, testing whether dynamics and drivers differ between mycorrhizal types. Mycorrhizal fungi colonized deglaciated areas very quickly (< 10 yr), with arbuscular mycorrhizal fungi tending to become more diverse through time compared to ectomycorrhizal fungi. Both alpha- and beta-diversity of arbuscular mycorrhizal fungi were significantly related to time since glacier retreat and plant communities, while microclimate and primary productivity were more important for ectomycorrhizal fungi. The richness and composition of mycorrhizal communities were also significantly explained by soil chemistry, highlighting the importance of microhabitat for community dynamics. The acceleration of ice melt and the modifications of microclimate forecasted by climate change scenarios are expected to impact the diversity of mycorrhizal partners. These changes could alter the interactions underlying biotic colonization and belowground-aboveground linkages, with multifaceted impacts on soil development and associated ecological processes., (© 2024 The Authors. New Phytologist © 2024 New Phytologist Foundation.)

The mechanisms underlying plant succession remain highly debated. Due to the local scope of most studies, we lack a global quantification of the relative importance of species addition 'versus' replacement. We assessed the role of these processes in the variation (β-diversity) of plant communities colonizing the forelands of 46 retreating glaciers worldwide, using both environmental DNA and traditional surveys. Our findings indicate that addition and replacement concur in determining community changes in deglaciated sites, but their relative importance varied over time. Taxa addition dominated immediately after glacier retreat, as expected in harsh environments, while replacement became more important for late-successional communities. These changes were aligned with total β-diversity changes, which were more pronounced between early-successional communities than between late-successional communities (>50 yr since glacier retreat). Despite the complexity of community assembly during plant succession, the observed global pattern suggests a generalized shift from the dominance of facilitation and/or stochastic processes in early-successional communities to a predominance of competition later on., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

The worldwide retreat of glaciers is causing a faster than ever increase in ice-free areas that are leading to the emergence of new ecosystems. Understanding the dynamics of these environments is critical to predicting the consequences of climate change on mountains and at high latitudes. Climatic differences between regions of the world could modulate the emergence of biodiversity and functionality after glacier retreat, yet global tests of this hypothesis are lacking. Nematodes are the most abundant soil animals, with keystone roles in ecosystem functioning, but the lack of global-scale studies limits our understanding of how the taxonomic and functional diversity of nematodes changes during the colonization of proglacial landscapes. We used environmental DNA metabarcoding to characterize nematode communities of 48 glacier forelands from five continents. We assessed how different facets of biodiversity change with the age of deglaciated terrains and tested the hypothesis that colonization patterns are different across forelands with different climatic conditions. Nematodes colonized ice-free areas almost immediately. Both taxonomic and functional richness quickly increased over time, but the increase in nematode diversity was modulated by climate, so that colonization started earlier in forelands with mild summer temperatures. Colder forelands initially hosted poor communities, but the colonization rate then accelerated, eventually leveling biodiversity differences between climatic regimes in the long term. Immediately after glacier retreat, communities were dominated by colonizer taxa with short generation time and r-ecological strategy but community composition shifted through time, with increased frequency of more persister taxa with K-ecological strategy. These changes mostly occurred through the addition of new traits instead of their replacement during succession. The effects of local climate on nematode colonization led to heterogeneous but predictable patterns around the world that likely affect soil communities and overall ecosystem development., (© 2023 The Authors. Global Change Biology published by John Wiley & Sons Ltd.)

Ice-free areas are expanding worldwide due to dramatic glacier shrinkage and are undergoing rapid colonization by multiple lifeforms, thus representing key environments to study ecosystem development. It has been proposed that the colonization dynamics of deglaciated terrains is different between surface and deep soils but that the heterogeneity between communities inhabiting surface and deep soils decreases through time. Nevertheless, tests of this hypothesis remain scarce, and it is unclear whether patterns are consistent among different taxonomic groups. Here, we used environmental DNA metabarcoding to test whether community diversity and composition of six groups (Eukaryota, Bacteria, Mycota, Collembola, Insecta, and Oligochaeta) differ between the surface (0-5 cm) and deeper (7.5-20 cm) soil at different stages of development and across five Alpine glaciers. Taxonomic diversity increased with time since glacier retreat and with soil evolution. The pattern was consistent across groups and soil depths. For Eukaryota and Mycota, alpha-diversity was highest at the surface. Time since glacier retreat explained more variation of community composition than depth. Beta-diversity between surface and deep layers decreased with time since glacier retreat, supporting the hypothesis that the first 20 cm of soil tends to homogenize through time. Several molecular operational taxonomic units of bacteria and fungi were significant indicators of specific depths and/or soil development stages, confirming the strong functional variation of microbial communities through time and depth. The complexity of community patterns highlights the importance of integrating information from multiple taxonomic groups to unravel community variation in response to ongoing global changes., (© 2022 The Authors. Molecular Ecology published by John Wiley & Sons Ltd.)

Background: To accommodate and separate the large numbers of patients going to hospital with COVID-19, many EDs had to create new pathways for patients. We describe the outcomes of patients treated in a nurse-led alternate care site (ACS) at our hospital., Methods: This was a retrospective study of outcomes of patients managed at the ACS of 'San Bassiano' Hospital ED, Bassano del Grappa, Italy between 9 March and 16 April 2020. Self-presenting patients aged 5 years and older, suspected of having COVID-19, were initially diverted to the ACS. Patients with a National Early Warning Score ≥5 or with a desaturation ≥4% after the walking test were sent back to the main ED COVID-19 path for further evaluation and medical attention and were not further followed up. In the ACS, patients received a CXR, blood samples and a nasopharyngeal swab to test for SARS-CoV-2, and were sent home. An emergency physician reviewed the results later and called the patient back 5-6 hours later with instructions to return for medical evaluation of abnormal findings, or to seek their general practitioner's attention. Patients received a follow-up phone call 15 days later to learn of their course., Results: A total of 487 patients were fully managed in the ACS and discharged home. Of the 392 (80.5%) patients with no abnormalities after the workup and instructed to stay at home, 29 reattended the ED in the next 15 days, and 13 were admitted. Among the 95 patients asked to return and receive medical attention, 20 were admitted and of those discharged, 3 reattended the ED within 15 days. At 15 days, no patient was deceased or received invasive ventilation; one admitted patient received non-invasive ventilation., Conclusions: A nurse-led ACS diverted a substantial proportion of patients from main ED resources without associated negative clinical outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Since the last glacial maximum, soil formation related to ice-cover shrinkage has been one major sink of carbon accumulating as soil organic matter (SOM), a phenomenon accelerated by the ongoing global warming. In recently deglacierized forelands, processes of SOM accumulation, including those that control carbon and nitrogen sequestration rates and biogeochemical stability of newly sequestered carbon, remain poorly understood. Here, we investigate the build-up of SOM during the initial stages (up to 410 years) of topsoil development in 10 glacier forelands distributed on four continents. We test whether the net accumulation of SOM on glacier forelands (i) depends on the time since deglacierization and local climatic conditions (temperature and precipitation); (ii) is accompanied by a decrease in its stability and (iii) is mostly due to an increasing contribution of organic matter from plant origin. We measured total SOM concentration (carbon, nitrogen), its relative hydrogen/oxygen enrichment, stable isotopic ( 13 C, 15 N) and carbon functional groups (C-H, C=O, C=C) compositions, and its distribution in carbon pools of different thermal stability. We show that SOM content increases with time and is faster on forelands experiencing warmer climates. The build-up of SOM pools shows consistent trends across the studied soil chronosequences. During the first decades of soil development, the low amount of SOM is dominated by a thermally stable carbon pool with a small and highly thermolabile pool. The stability of SOM decreases with soil age at all sites, indicating that SOM storage is dominated by the accumulation of labile SOM during the first centuries of soil development, and suggesting plant carbon inputs to soil (SOM depleted in nitrogen, enriched in hydrogen and in aromatic carbon). Our findings highlight the potential vulnerability of SOM stocks from proglacial areas to decomposition and suggest that their durability largely depends on the relative contribution of carbon inputs from plants., (© 2020 The Authors. Global Change Biology published by John Wiley & Sons Ltd.)

Plant science has been more and more utilized in forensic investigation, although its full potential is still to be reached. Plant macroremains are a powerful tool to link a body or other evidence back to a primary crime scene as they can provide detailed information about its previous ecological and geographic location. However, plant macroremains are often poorly preserved and difficult to identify, as diagnostic elements are seldom present within the assemblage occurring on the scene. Plant fragments most likely to be found are those exposed to the environment and resistant to degradation. The bark of woody plants meets these requirements but the possibility of its identification at species level from small fragments is not known. Starting from a real homicide case, where bark splinters were found on the victim, we aimed to assess the forensic potential of bark identification from small fragments like those likely to occur on a crime scene. Two identification keys were prepared for 16 common lowland tree species from Northern Italy; one key used all the available anatomical traits, the second only those from the outer bark. The second key was not able to discriminate some couples of species unambiguously, but could identify the bark fragments of the homicide as Robinia pseudoacacia, as confirmed from direct comparison with a reference sample. Bark fragments deserve to be included into the macroremains to be analyzed during an investigation, but small samples could easily lack diagnostic traits, and the building of a reference collection should be encouraged., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

This clinical skills review describes the most common cardiac auscultatory findings in adults after heart surgery and correlates them with prognostic indicators. It was written for noncardiologist health care providers who work in outpatient cardiac rehabilitation programs.Mechanical prosthetic valves produce typical closing and opening clicks. Listening to their timing and features, as well as to presence and quality of murmurs, contributes to the awareness of potential prosthesis malfunction before other dramatic clinical signs or symptoms become evident. In patients with biological prostheses, murmurs should be carefully evaluated to rule out both valve malfunction and degeneration. Rubs of post-pericardiotomy pericarditis should prompt further investigation for early signs of cardiac tamponade. Third and fourth heart sounds and systolic murmurs in anemic patients should be differentiated from pathological conditions. Relatively new groups of heart surgery patients are those with chronic heart failure treated with continuous-flow left ventricle assist devices. These devices produce characteristic continuous noise that may suddenly disappear or vary in quality and intensity with device malfunction. After heart transplantation, a carefully performed and regularly repeated cardiac auscultation may contribute to suspicion of impending acute rejection. During cardiac rehabilitation, periodic cardiac auscultation may provide useful information regarding clinical-hemodynamic status and allow detection of heralding signs of possible complications in an efficient and low-cost manner.

During outpatient cardiac rehabilitation after an acute coronary syndrome or after an episode of congestive heart failure, a careful, periodic evaluation of patients' clinical and hemodynamic status is essential. Simple and traditional cardiac auscultation could play a role in providing useful prognostic information.Reduced intensity of the first heart sound (S1), especially when associated with prolonged apical impulse and the appearance of added sounds, may help identify left ventricular (LV) dysfunction or conduction disturbances, sometimes associated with transient myocardial ischemia. If both S1 and second heart sound (S2) are reduced in intensity, a pericardial effusion may be suspected, whereas an increased intensity of S2 may indicate increased pulmonary artery pressure. The persistence of a protodiastolic sound (S3) after an acute coronary syndrome is an indicator of severe LV dysfunction and a poor prognosis. In patients with congestive heart failure, the association of an S3 and elevated heart rate may indicate impending decompensation. A presystolic sound (S4) is often associated with S3 in patients with LV failure, although it could also be present in hypertensive patients and in patients with an LV aneurysm. Careful evaluation of apical systolic murmurs could help identifying possible LV dysfunction or mitral valve pathology, and differentiate them from a ruptured papillary muscle or ventricular septal rupture. Friction rubs after an acute myocardial infarction, due to reactive pericarditis or Dressler syndrome, are often associated with a complicated clinical course.During cardiac rehabilitation, periodic cardiac auscultation may provide useful information about the clinical-hemodynamic status of patients and allow timely detection of signs, heralding possible complications in an efficient and low-cost manner.

Background Erectile dysfunction may predict future cardiovascular events and indicate the severity of coronary artery disease in middle-aged men. The aim of this study was to evaluate whether erectile dysfunction (expression of generalized macro- and micro-vascular pathology) could predict reduced effort tolerance in patients after an acute myocardial infarction. Patients and methods One hundred and thirty-nine male patients (60 ± 12 years old), admitted to intensive cardiac rehabilitation 13 days after a complicated acute myocardial infarction, were evaluated for history of erectile dysfunction using the International Index of Erectile Function questionnaire. Their physical performance was assessed by means of two six-minute walk tests (performed two weeks apart) and by a symptom limited cardiopulmonary exercise test (CPET). Results Patients with erectile dysfunction (57% of cases) demonstrated poorer physical performance, significantly correlated to the degree of erectile dysfunction. After cardiac rehabilitation, they walked shorter distances at the final six-minute walk test (490 ± 119 vs. 564 ± 94 m; p < 0.001); at CPET they sustained lower workload (79 ± 28 vs. 109 ± 34 W; p < 0.001) and reached lower oxygen uptake at peak effort (18 ± 5 vs. 21 ± 5 ml/kg per min; p = 0.003) and at anaerobic threshold (13 ± 3 vs.16 ± 4 ml/kg per min; p = 0.001). The positive predictive value of presence of erectile dysfunction was 0.71 for low peak oxygen uptake (<20 ml/kg per min) and 0.69 for reduced effort capacity (W-max <100 W). Conclusions As indicators of generalized underlying vascular pathology, presence and degree of erectile dysfunction may predict the severity of deterioration of effort tolerance in post-acute myocardial infarction patients. In the attempt to reduce the possibly associated long-term risk, an optimization of type, intensity and duration of cardiac rehabilitation should be considered.

The presence of major depressive symptoms is usually considered a negative long-term prognostic factor after an acute myocardial infarction (AMI); however, most of the supporting research was conducted before the era of immediate reperfusion by percutaneous coronary intervention. The aims of this study are to evaluate if depression still retains long-term prognostic significance in our era of immediate coronary reperfusion, and to study possible correlations with clinical parameters of physical performance. In 184 patients with recent ST-elevated AMI (STEMI), treated by immediate reperfusion, moderate or severe depressive symptoms (evaluated by Beck Depression Inventory version I) were present in 10 % of cases. Physical performance was evaluated by two 6-min walk tests and by a symptom-limited cardiopulmonary exercise test: somatic/affective (but not cognitive/affective) symptoms of depression and perceived quality of life (evaluated by the EuroQoL questionnaire) are worse in patients with lower levels of physical performance. Follow-up was performed after a median of 29 months by means of telephone interviews; 32 major adverse cardiovascular events (MACE) occurred. The presence of three vessels disease and low left ventricle ejection fraction are correlated with a greater incidence of MACE; only somatic/affective (but not cognitive/affective) symptoms of depression correlate with long-term outcomes. In patients with recent STEMI treated by immediate reperfusion, somatic/affective but not cognitive/affective symptoms of depression show prognostic value on long-term MACE. Depression symptoms are not predictors "per se" of adverse prognosis, but seem to express an underlying worse cardiac efficiency, clinically reflected by poorer physical performance.

Aim: To assess the prevalence of depressed heart rate variability (HRV) after an acute myocardial infarction (MI), and to evaluate its prognostic significance in the present era of immediate reperfusion., Methods: Time-domain HRV (obtained from 24-h Holter recordings) was assessed in 326 patients (63.5 ± 12.1 years old; 80% males), two weeks after a complicated MI treated by early reperfusion: 208 ST-elevation myocardial infarction (STEMI) patients (in which reperfusion was successfully obtained within 6 h of symptoms in 94% of cases) and 118 non-ST-elevation myocardial infarction (NSTEMI) patients (percutaneous coronary intervention was performed within 24 h and successful in 73% of cases). Follow-up of the patients was performed via telephone interviews a median of 25 mo after the index event (95%CI of the mean 23.3-28.0). Primary end-point was occurrence of all-cause or cardiac death; secondary end-point was occurrence of major clinical events (MCE, defined as mortality or readmission for new MI, new revascularization, episodes of heart failure or stroke). Possible correlations between HRV parameters (mainly the standard deviation of all normal RR intervals, SDNN), clinical features (age, sex, type of MI, history of diabetes, left ventricle ejection fraction), angiographic characteristics (number of coronary arteries with critical stenoses, success and completeness of revascularization) and long-term outcomes were analysed., Results: Markedly depressed HRV parameters were present in a relatively small percentage of patients: SDNN < 70 ms was found in 16% and SDNN < 50 ms in 4% of cases. No significant differences were present between STEMI and NSTEMI cases as regards to their distribution among quartiles of SDNN ( χ 2 =1.536, P = 0.674). Female sex and history of diabetes maintained a significant correlation with lower values of SDNN at multivariate Cox regression analysis (respectively: P = 0.008 and P = 0.008), while no correlation was found between depressed SDNN and history of previous MI ( P = 0.999) or number of diseased coronary arteries ( P = 0.428) or unsuccessful percutaneous coronary intervention (PCI) ( P = 0.691). Patients with left ventricle ejection fraction (LVEF) < 40% presented more often SDNN values in the lowest quartile ( P < 0.001). After > 2 years from infarction, a total of 10 patients (3.1%) were lost to follow-up. Overall incidence of MCE at follow-up was similar between STEMI and NSTEMI ( P = 0.141), although all-cause and cardiac mortality were higher among NSTEMI cases (respectively: 14% vs 2%, P = 0.001; and 10% vs 1.5%, P = 0.001). The Kaplan-Meier survival curves for all-cause mortality and for cardiac deaths did not reveal significant differences between patients with SDNN in the lowest quartile and other quartiles of SDNN (respectively: P = 0.137 and P = 0.527). Also the MCE-free survival curves were similar between the group of patients with SDNN in the lowest quartile vs the patients of the other SDNN quartiles ( P = 0.540), with no difference for STEMI ( P = 0.180) or NSTEMI patients ( P = 0.541). By the contrary, events-free survival was worse if patients presented with LVEF < 40% ( P = 0.001)., Conclusion: In our group of patients with a recent complicated MI, abnormal autonomic parameters have been found with a prevalence that was similar for STEMI and NSTEMI cases, and substantially unchanged in comparison to what reported in the pre-primary-PCI era. Long-term outcomes did not correlate with level of depression of HRV parameters recorded in the subacute phase of the disease, both in STEMI and in NSTEMI patients. These results support lack of prognostic significance of traditional HRV parameters when immediate coronary reperfusion is utilised., Competing Interests: Conflict-of-interest statement: No author has any conflict of interest to declare.

Background: Depressed heart rate variability (HRV) is usually considered a negative long-term prognostic factor after acute myocardial infarction. Anyway, most of the supporting research was conducted before the era of immediate reperfusion by percutaneous coronary intervention (PCI). Main aim of this study was to evaluate if HRV still retains prognostic significance in our era of immediate PCI., Methods and Results: Two weeks after STEMI treated by primary PCI, time-domain HRV was assessed from 24-h Holter recordings in 186 patients: markedly depressed HRV (SDNN <70ms or <50ms) was present in 16% and in 5% of cases, respectively; patients with left ventricle ejection fraction (LVEF) <40% presented more often SDNN values in the lowest quartile. Physical performance was also assessed, by 6-minute walk tests (6MWT) and by cardiopulmonary exercise test (CPET). After >2years from infarction, occurrence of major clinical events (MCE) was investigated. Cases with or without MCE did not differ by initial HRV parameters; Kaplan-Meier events-free survival curves were similar between patients with lowest quartile SDNN and the remaining ones (χ 2 0.981, p=0.322). By the contrary, events-free survival was worse if patients walked shorter distances at 6MWT (χ 2 6.435, p=0.011), developed poorer ventilatory efficiency at CPET (χ 2 10.060, p=0.002), or presented LVEF <40% (χ 2 7.085, p=0.008)., Conclusions: In primary-PCI STEMI patients, markedly abnormal HRV was found in a small percentage of cases. HRV seems to have lost its prognostic significance, while parameters indicating LV function (LVEF and physical performance) could allow better prognostication in primary-PCI STEMI patients., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: It is known that coronary heart surgery leads to varying degrees of cardiac autonomic derangement, clinically detectable as depression of heart rate variability (HRV) parameters. Few studies report that also surgical replacement of the aortic valve (SAVR) may lead to HRV abnormalities, while very little is known about the autonomic effects obtained after less invasive aortic valve replacement techniques. The study aimed to evaluate HRV after SAVR and to compare it with two less invasive techniques, transapical (TaAVI) and tranfemoral (TfAVI) aortic valve implant., Methods: Time-domain heart rate variability (HRV) parameters have been studied by 24-h Holter ECG in 129 patients after SAVR, in 63 patients after TfAVI and in 19 patients after TaAVI., Results: All HRV parameters were significantly depressed in SAVR, while they were almost completely preserved in TfAVI patients; TaAVI cases showed a somehow intermediate behaviour [(SDNN respectively: 71.0±34.9 vs 95.9±29.5 (p<0.001) vs 84.4±32.6ms (p=ns)]. Mean heart rate during the 24-h Holter was 8% higher in SAVR patients than in both TfAVI and TaAVI patients. The reported results were not correlated with echocardiographic ejection fraction, or presence of abnormal glucose metabolism, or degree of anaemia or treatment with beta-blockers., Conclusions: SAVR leads to profound depression of some cardiac autonomic parameters, while less invasive procedures allow better preservation of HRV. In particular TfAVI does not induce any significant deterioration of HRV parameters and seems to be the strategy of valve implant with less impact on the cardiovascular autonomic system., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

An increasing number of patients with end-stage heart failure are being treated with continuous-flow left ventricular assist devices (cf-LVADs). These patients provide new challenges to the staff in exercise-based cardiac rehabilitation (CR) programs. Even though experience remains limited, it seems that patients supported by cf-LVADs may safely engage in typical rehabilitative activities, provided that some attention is paid to specific aspects, such as the presence of a short external drive line. In spite of initial physical deconditioning, CR allows progressive improvement of symptoms such as fatigue and dyspnea. Intensity of rehabilitative activities should ideally be based on measured aerobic capacity and increased appropriately over time. Regular, long-term exercise training results in improved physical fitness and survival rates. Appropriate adjustment of cf-LVAD settings, together with maintenance of adequate blood volume, provides maximal output, while avoiding suction effects. Ventricular arrhythmias, although not necessarily constituting an immediate life-threatening situation, deserve treatment as they could lead to an increased rate of hospitalization and poorer quality of life. Atrial fibrillation may worsen symptoms of right ventricular failure and reduce exercise tolerance. Blood pressure measurements are possible in cf-LVAD patients only using a Doppler technique, and a mean blood pressure ≤80 mmHg is considered "ideal." Some patients may present with orthostatic intolerance, related to autonomic dysfunction. While exercise training constitutes the basic rehabilitative tool, a comprehensive intervention that includes psychological and social support could better meet the complex needs of patients in which cf-LVAD may offer prolonged survival.

Introduction: Complete denervation of transplanted heart exerts protective effect against postoperative atrial fibrillation; various degrees of autonomic denervation appear also after transection of ascending aorta during surgery for aortic aneurysm., Objective: This study aimed to evaluate if the level of cardiac denervation obtained by resection of ascending aorta could exert any effect on postoperative atrial fibrillation incidence., Methods: We retrospectively analysed the clinical records of 67 patients submitted to graft replacement of ascending aorta (group A) and 132 with aortic valve replacement (group B); all episodes of postoperative atrial fibrillation occurred during the 1-month follow-up have been reported. Heart Rate Variability parameters were obtained from a 24-h Holter recording; clinical, echocardiographic and treatment data were also evaluated., Results: Overall, 45% of patients (group A 43%, group B 46%) presented at least one episode of postoperative atrial fibrillation. Older age (but not gender, abnormal glucose tolerance, ejection fraction, left atrial diameter) was correlated with incidence of postoperative atrial fibrillation. Only among a subgroup of patients with aortic transection and signs of greater autonomic derangement (heart rate variability parameters below the median and mean heart rate over the 75th percentile), possibly indicating more profound autonomic denervation, a lower incidence of postoperative atrial fibrillation was observed (22% vs. 54%)., Conclusion: Transection of ascending aorta for repair of an aortic aneurysm did not confer any significant protective effect from postoperative atrial fibrillation in comparison to patients with intact ascending aorta. It could be speculated that a limited and heterogeneous cardiac denervation was produced by the intervention, creating an eletrophysiological substrate for the high incidence of postoperative atrial fibrillation observed., Competing Interests: No conflict of interest

Background: Cardiac autonomic dysfunction, clinically expressed by reduced heart rate variability (HRV), is present in patients with congestive heart failure (CHF) and is related to the degree of left ventricular dysfunction. In athletes, HRV is an indicator of ability to improve performance. No similar data are available for CHF., Objectives: The aim of this study was to assess whether HRV could predict the capability of CHF patients to improve physical fitness after a short period of exercise-based cardiac rehabilitation (CR)., Patients and Methods: This was an observational, non-randomized study, conducted on 57 patients with advanced CHF, admitted to a residential cardiac rehabilitation unit 32 ± 22 days after an episode of acute heart failure. Inclusion criteria were sinus rhythm, stable clinical conditions, no diabetes and ejection fraction ≤ 35%. HRV (time-domain) and mean and minimum heart rate (HR) were evaluated using 24-h Holter at admission. Patients' physical fitness was evaluated at admission by 6-minute walking test (6MWT) and reassessed after two weeks of intensive exercise-based CR. Exercise capacity was evaluated by a symptom-limited cardiopulmonary exercise test (CPET)., Results: Patients with very depressed HRV (SDNN 55.8 ± 10.0 ms) had no improvement in their walking capacity after short CR, walked shorter absolute distances at final 6MWT (348 ± 118 vs. 470 ± 109 m; P = 0.027) and developed a peak-VO2 at CPET significantly lower than patients with greater HRV parameters (11.4 ± 3.7 vs. an average > 16 ± 4 mL/kg/min). Minimum HR, but not mean HR, showed a negative correlation (ρ = -0.319) with CPET performance., Conclusions: In patients with advanced CHF, depressed HRV and higher minimum HR were predictors of poor working capacity after a short period of exercise-based CR. An individualized and intensive rehabilitative intervention should be considered for these patients.

Axial-flow left ventricular assist devices (LVADs) are increasingly used as destination therapy in end-stage chronic heart failure (CHF), as they improve survival and quality of life. Their effect on exercise tolerance in the early phase after implantation is still unclear. The aim of this study was to evaluate the effect of LVADs on the exercise capacity of a group of CHF patients within 2 months after initiation of circulatory support. Cardiopulmonary exercise test data were collected for 26 consecutive LVAD-implanted CHF patients within 2 months of initiation of assistance; the reference group consisted of 30 CHF patients not supported by LVAD who were evaluated after an episode of acute heart failure. Both LVAD and reference groups showed poor physical performance; LVAD patients achieved lower workload (LVAD: 36.3 ± 9.0 W, reference: 56.6 ± 18.2 W, P < 0.001) but reached a similar peak oxygen uptake (peak VO2 ; LVAD: 12.5 ± 3.0 mL/kg/min, reference: 13.6 ± 2.9 mL/kg/min, P = ns) and similar percentages of predicted peak VO2 (LVAD: 48.8 ± 13.9%, reference: 54.2 ± 15.3%, P = ns). While the values of the O2 uptake efficiency slope were 12% poorer in LVAD patients than in reference patients (1124.2 ± 226.3 vs. 1280.2 ± 391.1; P = ns), the kinetics of VO2 recovery after exercise were slightly better in LVAD patients (LVAD: 212.5 ± 62.5, reference: 261.1 ± 80.2 sec, P < 0.05). In the first 2 months after initiation of circulatory support, axial-flow LVAD patients are able to sustain a low-intensity workload; though some cardiopulmonary exercise test parameters suggest persistence of a marked physical deconditioning, their cardiorespiratory performance is similar to that of less compromised CHF patients, possibly due to positive hemodynamic effects beginning to be produced by the assist device., (Copyright © 2013 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Background: Sub-Saharan Africa (SSA) has the highest burden of HIV in the world and a rising prevalence of cardiometabolic disease; however, the interrelationship between HIV, antiretroviral therapy (ART) and cardiometabolic traits is not well described in SSA populations., Methods: We conducted a systematic review and meta-analysis through MEDLINE and EMBASE (up to January 2012), as well as direct author contact. Eligible studies provided summary or individual-level data on one or more of the following traits in HIV+ and HIV-, or ART+ and ART- subgroups in SSA: body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TGs) and fasting blood glucose (FBG) or glycated hemoglobin (HbA1c). Information was synthesized under a random-effects model and the primary outcomes were the standardized mean differences (SMD) of the specified traits between subgroups of participants., Results: Data were obtained from 49 published and 3 unpublished studies which reported on 29 755 individuals. HIV infection was associated with higher TGs [SMD, 0.26; 95% confidence interval (CI), 0.08 to 0.44] and lower HDL (SMD, -0.59; 95% CI, -0.86 to -0.31), BMI (SMD, -0.32; 95% CI, -0.45 to -0.18), SBP (SMD, -0.40; 95% CI, -0.55 to -0.25) and DBP (SMD, -0.34; 95% CI, -0.51 to -0.17). Among HIV+ individuals, ART use was associated with higher LDL (SMD, 0.43; 95% CI, 0.14 to 0.72) and HDL (SMD, 0.39; 95% CI, 0.11 to 0.66), and lower HbA1c (SMD, -0.34; 95% CI, -0.62 to -0.06). Fully adjusted estimates from analyses of individual participant data were consistent with meta-analysis of summary estimates for most traits., Conclusions: Broadly consistent with results from populations of European descent, these results suggest differences in cardiometabolic traits between HIV-infected and uninfected individuals in SSA, which might be modified by ART use. In a region with the highest burden of HIV, it will be important to clarify these findings to reliably assess the need for monitoring and managing cardiometabolic risk in HIV-infected populations in SSA.

Purpose: In congestive heart failure (CHF) patients, a profound cardiac autonomic derangement, clinically expressed by reduced heart rate variability (HRV), is present and is related to the degree of ventricular dysfunction. Implantation of a left ventricular assist device (LVAD) can progressively improve HRV, associated with an increased circulatory output. Data from patients studied at different times after LVAD implantation are controversial. The aims of this study were to assess cardiac autonomic function in the early phases after axial-flow LVAD implantation, and to estimate the potential relevance of recent major surgical stress on the autonomic balance.
, Methods: HRV (time-domain; 24-h Holter) was evaluated in 14 patients, 44.8 ± 25.8 days after beginning of Jarvik-2000 LVAD support; 47 advanced stage CHF, 24 cardiac surgery (CS) patients and 
30 healthy subjects served as control groups., Inclusion Criteria: sinus rhythm, stable clinical conditions, no diabetes or other known causes of HRV alteration.
, Results: HRV was considerably reduced in LVAD patients in the early phases after device implantation in comparison to all control groups. A downgrading of HRV parameters was also present in CS controls. Circadian oscillations were highly depressed in LVAD and CHF patients, and slightly reduced in CS patients.
, Conclusions: In CHF patients supported by a continuous-flow LVAD, a profound cardiac dysautonomia is still evident in the first two months from the beginning of circulatory support; the degree of cardiac autonomic imbalance is even greater in comparison to advanced CHF patients. The recent surgical stress could be partly linked to these abnormalities.

Aim: HIV infection causes cardiac autonomic neuropathy (CAN); little is known about the relevance of CAN in sub-Sahara African patients, in spite of the highest prevalence of AIDS in that population. The authors assessed prevalence rates of CAN in HIV-positive treatment-naïve African patients and investigated the correlation between degree of immunodeficiency and CAN., Methods: Thirty HIV-positive patients and 11 HIV-negative controls underwent a battery of cardiovascular autonomic function tests; the Ewing-Clarke score was calculated along with the stage of severity of CAN. The patients' immunological status was evaluated by CD4 T-lymphocytes counts., Results: During paced respiration of normal depth, the patients showed shorter baseline RR intervals (739.2+/-136.0 vs 846.2+/-88.7 ms; P<0.05), with an inverse correlation with CD4 counts, and lower heart rate variability (85.3+/-73.0 vs 123.0+/-46.2 ms; P<0.02). Although patients with lower CD4 counts tended to present blunted response to hand-grip and cold-face tests, no linear correlation was found between results of cardiovascular reflex tests and CD4 counts. Eight patients (27%) obtained borderline Ewing-Clarke scores; 9 patients resulted affected by early (6 pts, 20%) or intermediate (3 pts, 10%) stage of CAN., Conclusion: Signs of HIV-related CAN are present in 30% of the African HIV+ patients observed, with no direct correlation to their immunological status. Based on the relevance of the problem and the presence of signs of CAN even in newly diagnosed and treatment-naïve patients, the authors suggest that all HIV-patients should be screened for the presence of the complication, in view of the possible serious events associated with it.

Background: Human immunodeficiency virus (HIV) infection is associated with autonomic neuropathy. The resultant autonomic dysfunction impairs quality of life and can have fatal consequences. Our aim was to clearly define the symptoms of autonomic dysfunction in African HIV-positive patients and determine whether these symptoms were related with (a) autonomic reflex responses (b) the degree of immunosupression., Methods: Thirty-one HIV-positive treatment-naïve African patients (mean CD4 cell count 269.5 +/- 253.4/mm3) and 12 healthy controls completed a detailed questionnaire (Autonomic System Profile, Mayo Clinic, Rochester, MN) relating to specific symptoms of autonomic dysfunction. After completion of the questionnaire, subjects underwent a standard battery of autonomic reflex tests., Results: The autonomic symptom score was higher in the male HIV-positive patients (26.7 +/- 14.7 points) and female patients with CD4 <200/mm3 (24.7 +/- 18.0) than sex-matched controls (male controls, 9.9 +/- 6.8, P < 0.05; female controls, 8.8 +/- 10.1; P < 0.05). Six patients had scores indicative of severe autonomic dysfunction (>43.8 points). The most common autonomic symptoms were: orthostatic intolerance, secretomotor and gastrointestinal dysfunction. There was no relationship between CD4 cell counts and autonomic symptom scores. The blood pressure response to sustained handgrip was blunted, but all other cardiovascular reflex tests were within the normal range or borderline., Conclusion: African HIV-positive patients report symptoms of autonomic dysfunction, despite normal or borderline autonomic reflex responses.