Thursday, October 10, 2024

Why isometric exercises are so good for everyone.

 

Exercise is great for improving heart health. But the thought of hitting the gym or going for a jog might put some people off from doing it. And, if you have a heart condition already, such dynamic exercises may not be safe to do.

The good news is, you don't necessarily need to do a vigorous workout to see heart benefits. You can even improve your heart health by holding still and trying really hard not to move.

Isometric training, as this is called, is becoming increasingly popular as a way of reducing blood pressure and hypertension, and improving strength and muscle stability.

Normally, to build strength and force, our muscles need to change length throughout a movement. Squats and bicep curls are good examples of exercises that cause the muscle to change length throughout the movement.

But isometric training involves simply contracting your muscles, which generates force without needing to move your joints. The harder a muscle is contracted, the more forceful it becomes (and the more forceful a muscle is, the more powerfully we can perform a movement).

If you add weight to an isometric exercise, it causes the muscle to contract even harder. A wall sit and a plank are examples of isometric contractions.

Isometric exercises are associated with a high degree of "neural recruitment", because of the need to maintain the contraction. This means these exercises are good at engaging specialized neurons in our brain and spinal cord, which play an important role in all the movements we do—both voluntary and involuntary. The greater this level of neural activation, the more muscle fibers are recruited—and the more force generated. As a result, this can lead to strength gains.

Isometric exercises have long been of interest to strength and power athletes as a means of preparing their muscles to generate high forces by activating them. But research also shows isometric exercises are beneficial for other areas of our health—including reducing hypertension and promoting better blood flow.

There are a couple reasons why isometric exercises are so good for the heart.

When a muscle is contracted, it expands its size. This causes it to compress the blood vessels supplying this muscle, reducing blood flow and raising the blood pressure in our arteries—a mechanism known as the "pressor reflex".

Then, once the contraction is relaxed, a sudden surge of blood flows into the blood vessels and muscle. This influx of blood brings more oxygen and (crucially) nitric oxide into the blood vessels—causing them to widen. This in turn reduces blood pressure. Over time, this action will reduce stiffness of the arteries, which may lower blood pressure.

When blood flow is reduced during an isometric movement, it also reduces the amount of available oxygen that cells need to function. This triggers the release of metabolites, such as hydrogen ions and lactate, which stimulate the sympathetic nervous system—which controls our "fight of flight" response. In the short term, this leads to an increase in blood pressure.

But when an isometric exercise is done repeatedly over many weeks, there's a reduction in sympathetic nervous system activity. This means blood pressure is lowered and there's less strain on the cardiovascular system—which makes these exercises good for the heart.

Isometric exercises may be even more beneficial for heart health than other types of cardiovascular exercise. A study which compared the benefits of isometric exercise versus high-intensity interval training found isometrics led to significantly greater reductions in resting blood pressure over the study period of between two and 12 weeks.

How to use isometric exercise

If you want to use isometric training to reduce blood pressure, it's recommended that you should do any isometric contraction for two minutes at around 30-50% of your maximum effort. This is enough to trigger physiological improvements.

You can start by doing this four times a day, three-to-five times per week—focusing on the same exercise. As you progress, you can start to vary the exercises you do, add weights to the exercise, or add in more than one isometric exercise.

Some good isometric exercises to begin with include a static squat, a wall sit or a plank. Even during these small bouts of exercise, your heart rate, breathing and arterial pressure will all increase—the same responses that occur during more conventional whole-body exercises, such as cycling and running.

The beneficial improvements in blood pressure start to manifest around 4-10 weeks after starting isometric training—though this depends on a person's health and fitness levels when starting out.

Isometric training appears to be a simple, low-intensity mode of exercise that offers big benefits for cardiovascular health—all while requiring little time commitment compared with other workouts.


 

Delays in Emergency Care Linked To Higher Death Rates and Longer Hospital Stays For Hip Fracture Patients

 

A study links delays over four hours in emergency care for hip fracture patients to higher death rates and more extended hospital stays, highlighting the critical need for prompt treatment. These delays also add significant healthcare costs.

A recent study published in the Emergency Medicine Journal linked waiting over four hours in emergency care to increased death rates and prolonged hospital stays for patients with hip fractures. The study analyzed records of 3,266 patients aged 50 and above admitted between January 2019 and June 2022.

The average patient, aged 81, spent nearly four hours in emergency care, but over one-third waited longer. These delays were often associated with winter admissions, more complex fractures, and higher surgical risks. Findings revealed that patients who waited longer had a 90-day survival rate of 93%, compared to 96% for those treated sooner. This difference equates to one additional death per 36 patients waiting over four hours.

Extended delays before surgery were also linked to a 14% higher risk of death at 90 days. A wait of more than four hours was associated with a 29% increase in death risk at 60 days, 36% at 90 days, and 15% at final follow-up. Patients facing delays also spent an extra day in the hospital, costing the center an estimated £770,000 (Rs 8,45,22,669), underscoring the urgent need for timely emergency care for hip fracture patients.


(Source:https://medicalxpress.com/news/2024-10-hour-emergency-linked-heightened-death.html )

Sunday, October 6, 2024

ACOG Guidance for Medication Abortion: Evaluation, Dosing and Follow-Up

 

ACOG has reaffirmed guidance related to medication abortion up until 70 days of gestation. This guidance impacts multiple aspects of gynecologic care. Approximately 60% of abortions will occur before 10 weeks with current data suggesting that medication abortion constitutes 39% of all abortions. Combined mifepristone-misoprostol regimens are preferred due to increased effectiveness vs misoprostol only. Mifepristone is a selective progesterone receptor modulator and misoprostol is a prostaglandin E1 analogue.

Use in Patients with Prenatal and Medical Conditions

  • May be used in patients with comorbidities but may require monitoring  
  • Anemia
    • Risk for excessive bleeding is low but there may be more bleeding vs procedural abortion
  • Asthma
    • Not contraindicated
    • Misoprostol does not cause bronchoconstriction
  • Multiple gestation
    • Not contraindicated  
    • Treat twins like singleton

Evaluation Prior to Medication Abortion

Confirm Pregnancy and Estimate Gestational Age

  • Regular menstrual cycles | Certain LMP within the prior 56 days | No signs, symptoms, or risk factors for ectopic pregnancy
    • Clinical examination or ultrasound examination is not necessary
    • If ultrasound is clinically indicated, transabdominal approach can be used  

Rh Testing

  • Unknown Rh Status
    • Perform testing and Rh D immunoglobulin as indicated
  • Rh testing and Rh D immunoglobulin administration are not available or will cause significant delay
    • Shared decision making is advised

Other Laboratory Evaluations

  • Not routinely indicated clinically but may be a local or state requirement
  • Suspected Anemia: Obtain hemoglobin or hematocrit

Medication Abortion Regimen

Preferred

  • Combination FDA approved
    • Mifepristone: 200 mg | OralMisoprostol: 800 micrograms | Buccal
    • Interval between drugs: 24 to 48 hours
  • Combination WHO recommended
    • Mifepristone: 200 mg oralMisoprostol: 800 micrograms | Buccal, vaginal, sublingual
    • Interval between drugs: 24 to 48 hours

Alternative: Mifepristone unavailable   

  • Misoprostol: 800 micrograms | Buccal, vaginal, sublingual
  • Repeat every 3 hours for up to 3 doses

Follow-Up

Counsel Patients Regarding the Following

  • Bleeding and cramping may be more severe than menses
  • Potential adverse effects (typically following misoprostol)
    • Nausea | Diarrhea | Headache | Dizziness | Thermoregulatory effects (e.g., fever, warmth, hot flushes, chills)
  • Contact clinician
    • Heavy bleeding: Soaking >2 maxi pads per hour for 2 consecutive hours
    • <1% of patients will require intervention (e.g., aspiration) for excessive bleeding
    • Seek care at the nearest facility of care if emergency situation arises
  • Routine in-person follow-up not necessary
    • If patient wishes clinical follow-up: Medical history | Clinical examination | Serum hCG
    • If ultrasound performed: “…sole purpose is to determine whether the gestational sac is present or absent. The measurement of endometrial thickness or other findings do not predict the need for subsequent uterine aspiration”

Medication Failure

Need for Uterine Aspiration Due to Ongoing Pregnancy or Retained Tissue

  • Incomplete
    • Repeat dose of misoprostol or
    • Uterine aspiration or
    • Expectant management
  • Ongoing pregnancy
    • Repeat dose of misoprostol or
  • Uterine aspiration

Note: Management choices based on clinical situation and patient preference

Teratogenicity 

  • Misoprostol in a teratogen associated with Möbius’ syndrome (facial paralysis)
    • Counsel regarding teratogenicity prior to providing medication abortion
  • In case of unsuccessful medication abortion
    • Counsel regarding teratogen risk and all pregnancy options
  • If patient opts to continue pregnancy
    • Monitor expectantly

KEY POINTS:

  • Counseling prior to procedure  
    • Medication abortion failure rates requiring aspiration increase toward 10 week gestation (approximately 3 % ongoing pregnancy) but is still low
    • Contraception  
      • Can be initiated on day 1 (mifepristone intake) except for IUD and permanent contraception
      • All contraceptive methods are considered safe after successful medication abortion
      • Use of DMPA on day 1 may increase the risk of ongoing pregnancy
    • Medication abortion does not impact future fertility or pregnancy outcomes  
  • Any clinician that can screen and provide follow-up can provide medication abortion
  • Mifepristone can be taken at home and can be self-administered by patients
    • Medication abortion can be provided via telemedicine services
  • Prophylactic antibiotics are not required
  • Use NSAIDS for pain management

IMPORTANT LINES: All other previous mifepristone REMS requirements remain in effect, including the need for prescriber certification and completion of Prescriber and Patient Agreement Forms

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