Change in Shoulder Function in the Early Recovery Phase after Breast Cancer Surgery: A Prospective Observational Study

Breast cancer surgery significantly affects the shoulder’s range of motion (ROM) and strength. However, the extent of shoulder impairment, as well as patterns of recovery immediately after surgery, is not fully understood. Therefore, we aimed to investigate shoulder ROM and strength during the early recovery phase after surgery. Thirty-two breast cancer patients were observed five times: the day before surgery, discharge day (postoperative day 1 (POD1) or (POD2)), first outpatient visit (POD7–10), second outpatient visit (POD14–20), and third outpatient visit (POD21–30). We assessed shoulder passive ROM and strength for both affected and unaffected arms at each observation. ROM decreased in both affected and unaffected sides post-surgery. ROM on the affected side did not recover to the pre-surgery level until the third outpatient visit (POD24). In contrast, the ROM on the unaffected side recovered to the pre-surgery level by the first outpatient visit (POD10). The shoulder strength of both arms declined and did not recover to pre-surgery levels. Shoulder strength in the affected arm significantly decreased immediately after surgery (52.9% of the pre-surgery levels) and did not recover until the third outpatient visit (62.5% of the pre-surgery levels), whereas that in the unaffected arm decreased gradually (83.1 ± 2.3 at POD 1 and 78.9 ± 2.9 at POD 24). Descriptively, patterns of recovery in ROM may vary according to types of surgery while patterns of recovery in shoulder strength did not: shoulder strength significantly decreased and did not recover notably regardless of types of surgery. Both shoulder ROM and strength reduced during the early recovery phase after breast cancer surgery regardless of types of surgery, although the degree of reduction was greater in shoulder strength than ROM. Our findings suggest that rehabilitation exercises should be implemented in both upper limbs.

Significance of Exercise‐Related Ventricular Arrhythmias in Patients With Brugada Syndrome

Background Sinus tachycardia during exercise attenuates ST‐segment elevation in patients with Brugada syndrome, whereas ST‐segment augmentation after an exercise test is a high‐risk sign. Some patients have premature ventricular contractions (PVCs) related to exercise, but the significance of exercise‐related PVCs in patients with Brugada syndrome is still unknown. The objective of this study was to determine the significance of exercise‐related PVCs for predicting occurrence of ventricular fibrillation (VF) in patients with Brugada syndrome. Methods and Results The subjects were 307 patients with Brugada syndrome who performed a treadmill exercise test. We evaluated the occurrence of PVCs at rest, during exercise and at the peak of exercise, and during recovery after exercise (0–5 minutes). We followed the patients for 92±68 months and evaluated the occurrence of VF. PVCs occurred in 82 patients (27%) at the time of treadmill exercise test: PVCs appeared at rest in 14 patients (4%), during exercise in 60 patients (20%), immediately after exercise (0–1.5 minutes) in 28 patients (9%), early after exercise (1.5–3 minutes) in 18 patients (6%), and late after exercise (3–5 minutes) in 12 patients (4%). Thirty patients experienced VF during follow‐up. Multivariable analysis including symptoms, spontaneous type 1 ECG, and PVCs in the early recovery phase showed that these factors were independently associated with VF events during follow‐up. Conclusions PVCs early after an exercise test are associated with future occurrence of VF events. Rebound of vagal nerve activity at the early recovery phase would promote ST‐segment augmentation and PVCs in high‐risk patients with Brugada syndrome.

Coingestion of protein and carbohydrate in the early recovery phase, compared with carbohydrate only, improves endurance performance despite similar glycogen degradation and AMPK phosphorylation

Endurance athletes competing consecutive days need optimal dietary intake during the recovery period. We report that coingestion of protein and carbohydrate soon after exhaustive exercise, compared with carbohydrate only, resulted in better performance the following day. The better performance after coingestion of protein and carbohydrate was not associated with a higher rate of glycogen synthesis or activation of anabolic signaling compared with carbohydrate only. Importantly, nitrogen balance was positive after coingestion of protein and carbohydrate, which was not the case after intake of carbohydrate only, suggesting that protein synthesis contributes to the better performance the following day.

Compromised Glutamine - Glutamate Metabolism in a Pseudomonas Aeruginosa Induced Hyperdynamic Sepsis-Recovery Pig Model During an Anabolic Nutritional Intervention

Objectives Optimal feeding in patients recovering from sepsis is critical to preserve muscle mass. In sepsis, glutamine (Gln) is considered a conditional essential amino acid and low plasma level of its precursor glutamate (Glu), is associated with higher mortality. An essential amino acid (EAA) mixture restores protein anabolism in the early recovery phase of acute septicemia in the pig. However, it is unclear whether interorgan Glu-Gln kinetics is also improved. Therefore, we measured the interorgan kinetics of Glu-Gln during a nutritional intervention with a balanced free amino acid (TAA) or EAA mixture in the early recovery phase of acute septicemia in the pig. Methods In catheterized pigs (±25 kg), acute septicemia was present for 6 hours (Pseudomonas aeruginosa: 3e,8 CFU/ml/h IV). At t = 6 h, recovery was started by a single dose gentamycin (5 mg/kg) and intra-gastric continuous feeding of a balanced free TAA or EAA mixture (pig muscle profile, 31 mg N/kg bw/h, 30% daily intake and dextrose 781 mg/kg bw/h) for 6 hours. We studied 3 groups (Healthy: H-TAA n = 12; Sepsis: S-TAA n = 13, S-EAA n = 12) over the last 3 hours of the intervention by measuring arterial and venous plasma concentrations (expressed as mean[low, high 95%CI]) and organ net balances of the portal drained viscera (PDV), liver, kidneys and hindquarter (HQ, muscle). Statistics: Net balances were tested with Wilcoxon Signed Rank Test. Group comparisons with ANOVA. Significance: P < 0.05. Results Plasma concentrations : Gln was increased only in S-EAA (23 [14,32]%) group. In contrast, Glu substantially decreased in S-TAA and S-EAA (32[25,40]; 35[28,43]%) groups. Net PDV balance:Increased Gln uptake in S-EAA (P = 0.0020), but zero balance of Glu. Net HQ balance: Gln release was higher in S-TAA and S-EAA(P = 0.0028;0.0143). However, no changes in Glu uptake. Net liver balance: Gln uptake was higher in S-TAA and S-EAA (P = 0.0155;0.0056). Reduced Glu release in S-TAA (P = 0.0250). Net kidney balance: Zero balance for Gln, Glu uptake decreased in S-TAA (P = 0.0403). Conclusions In the present model of an early recovery of septicemia, interorgan Glu-Gln metabolism and Glu plasma levels are not restored by anabolic intervention, suggesting additional supplementation needs. Funding Sources NIH R01GM084447 and S10RR027047.

Abstract 17270: Prognostic Impact of Ventricular Ectopy During the Recovery Phase of Stress Testing: A Meta-Analysis

Introduction: Ventricular ectopy after exercise, due to parasympathetic activity, predicts an increased risk of death in population-based cohorts. We sought to examine the composite risk of all cause mortality in patients with premature ventricular contractions (PVCs) in the early recovery phase of stress testing. Methods: PubMed, Medline & EMBASE were queried for all English language articles from 1993 to 2017. The primary outcome was incidence of all cause mortality in patients with frequent PVCs during recovery phase (RPV) of stress testing. Frequent PVCs were defined as the presence of seven or more ventricular premature beats/min, frequent ventricular couplets, ventricular bigeminy or trigeminy, or any other form of ventricular tachycardia or ventricular fibrillation. Meta-analysis of the main outcome was performed using a weighted random effects model. Results: A total of four observational studies including 38765 patients were retrieved. Data for 2065 patients with RPV was pooled. A comparative analysis of PVC vs Infrequent/Non-PVC group showed a calculated risk ratio for all cause mortality of 1.8 (95% CI 1.36-2.38; p=0.001). I 2 statistic for heterogeneity testing was 82.8% (Fig.1). Conclusion: Frequent premature ventricular contractions during early recovery phase of stress testing are associated with increased all cause mortality as compared to patients with infrequent or no PVCs.

Nurses’ Perception of a Tailored Web-Based Intervention for the Self-Management of Pain After Cardiac Surgery

Background Cardiac surgeries rank among the most frequent surgical procedures and present a risk of chronic postsurgical pain (CPSP). A continuum approach is required to prevent the development of CPSP. As a first step, a tailored web-based intervention was developed and successfully tested to tackle pain management during hospitalization. Before proceeding to further development, preliminary acceptability of the intervention including the postdischarge phase must be evaluated. Purpose The purpose of this study was to examine nurses’ perception of a tailored Web-based intervention for pain management in the early recovery phase. The objectives were to evaluate intervention’s acceptability and to identify ways to enhance its acceptability. Methods A parallel mixed methods approach was used to assess the acceptability of the intervention in the early recovery phase (first month after surgery). Results In total, 249 participants completed the online survey and 10 participants were individually interviewed. Overall, the intervention was rated as acceptable. No difference was found in acceptability ratings by demographics. The intervention was rated as appropriate to very much appropriate by 79% of participants. Although nurses seemingly would recommend it to their patients, they did not perceive that their patients would be as highly willing to use it. Interviews highlighted several strengths of the intervention, such as postoperative pain awareness, customization of content, and flexible dosage and schedule. However, the main weakness was related to patient adherence. Opting for a hybrid format and integrating individual preferences could enhance the coaching experience. Conclusion The innovative intervention was judged as acceptable for pain management in the early recovery phase. Considering that the intervention has demonstrated positive effects on the pain experience in the first week after cardiac surgery, it seems logical to explore its potential impact after discharge on the transition to CPSP.