Risultati per: Linee Guida per le cure post-parto

Objectives
The interim Foundation Year 1 (FiY1) post was created in response to the COVID-19 pandemic to help bolster the workforce and manage increased clinical pressures. This study aimed to assess the impact of the FiY1 post on medical graduates’ self-reported confidence in common tasks, core skills, competencies and procedures prior to starting FY1, as a measure of increasing preparedness for practice.

Setting
A longitudinal survey was performed at a tertiary teaching hospital in the South East of England. FiY1 posts ran from June to July 2020.

Participants
Questionnaires were sent to 122 medical graduates from a single medical school (recipients included FiY1s and non-FiY1s) and to 69 FiY1s at a single Teaching Hospital NHS Trust, irrespective of medical school attended. Initial and follow-up questionnaires had 86 and 62 respondents, respectively. Of these, 39 graduates were matched; 26 were FiY1s and 13 non-FiY1s. The 39 matched results were analysed.

Primary outcome measures
Confidence levels in common FY1 tasks, core procedures and competencies were gathered before and after the FiY1 post through online questionnaires. Change in confidence comparing FiY1s and non-FiY1s was measured and analysed using linear regression.

Results
On a 5-point scale, the FiY1 post increased overall confidence in starting FY1 by 0.62 (95% CI 0.072 to 1.167, p=0.028). The FiY1 post increased confidence in performing venepuncture by 0.32 (95% CI 0.011 to 0.920, p=0.045), performing intravenous cannulation by 0.48 (95% CI 0.030 to 1.294, p=0.041) and recognising, assessing and initiating the management of the acutely ill patient by 0.32 (95% CI 0.030 to 1.301, p=0.041).

Conclusions
The COVID-19 pandemic FiY1 post improved confidence in core skills and competencies. These findings may help guide future educational interventions in conjunction with further larger scale studies, ultimately aiding to bridge the transition gap between being a medical student and a doctor.

Annals of Internal Medicine, Ahead of Print.

This Viewpoint proposes a solution to better safeguard reproductive health information in patient records that are now more complete owing to the interoperability of health information exchange networks.

This cohort study analyzes self-reported data from 3 large ongoing studies to determine whether high levels of psychological distress before SARS-CoV-2 infection are associated with increased risk of developing post–COVID-19 conditions, sometimes called long COVID.

Circulation, Volume 146, Issue Suppl_1, Page A14439-A14439, November 8, 2022. Introduction:Post-transcatheter aortic valve replacement (TAVR) outcome of patients is an important research topic. To accurately assess post-TAVR mortality, we examined a family of new echo-parameters (augmented systolic blood pressure (AugSBP) and arterial mean pressure parameters (AugMAP)) derived from blood pressure and aortic valve gradient (Figure 1).Methods:Patients in the Mayo Clinic National Cardiovascular Diseases Registry-TAVR database who underwent TAVR between January 1, 2012, and June 30, 2017, were identified to retrieve baseline clinical, echocardiographic, and mortality data. The median of AugSBP and AugMAP were used to stratify patients in Kaplan-Meier analysis.Results:The final cohort contained 974 patients with a mean age of 81.4±8.3 years old, and 56.6% were male. The mean Society of Thoracic Surgeons risk score was 8.2±5.2. The median follow-up duration was 354 days, and the one-year all-cause mortality rate was 14.2%. Detailed characteristics are summarized inTable 1.AugMAP1 < 102.5 mmHg (median) was associated with a 3-fold risk of all-cause mortality post-TAVR at 1 year (hazard ratio 3.0, 95%confidence interval 2.0-4.5, p

Circulation, Volume 146, Issue Suppl_1, Page A12876-A12876, November 8, 2022. Introduction:Heart failure (HF) is characterized by a switch from predominantly fatty acid (FA) to glucose metabolism, but the molecular pathways involved in this switch are not totally understood. Identification of novel pathways regulating cellular metabolism could facilitate the development of new therapies. Tristetraprolin (TTP) is a tandem zinc finger protein that binds to AU-rich elements (AREs) in the 3’ untranslated region (UTR) of mRNA molecules and causes their degradation. Its expression is regulated by mTOR, a key protein involved in cellular metabolism. Our preliminary data suggested a link between TTP and FA metabolism in the heart. Thus, we hypothesized that TTP regulates cardiac FA metabolism and that its deletion prevents the development of HF by increasing FA uptake and metabolism in the heart.Results:TTP downregulation in cultured cardiomyocytes resulted in higher palmitate uptake and oxidation, while its overexpression had the opposite effect. Since TTP regulates its targets at the mRNA level, we studied the mRNA levels of ARE-containing genes involved in lipid metabolism, and found that only PPARα mRNA to be significantly increased with TTP downregulation. Furthermore, we demonstrated that TTP physically interacts with PPARα mRNA, and the activity of a luciferase reporter harboring full-length PPARα 3’UTR is increased with TTP downregulation. Additionally, PPARα mRNA is stabilized with TTP knockdown. We then studied the role of TTP in cardiac FA metabolism using mice with cardiac-specific (cs) TTP knockout (KO). Consistent with our in vitro data, cs-TTP KO mice displayed higher fatty acid utilization compared to littermate controls but maintained normal cardiac function at baseline. We also demonstrated a significantly higher TTP levels in failing human and mouse cardiac samples, suggesting that TTP levels are altered in HF.Conclusion:Our results demonstrate that TTP is a novel regulator of cardiac FA metabolism through its effect on PPARα, and that its levels are increased in HF. Thus, modulation of TTP may be a viable therapeutic approach for HF.

Circulation, Volume 146, Issue Suppl_1, Page A14479-A14479, November 8, 2022. Introduction:Reducing mitochondrial ROS (mito-ROS) has been a novel approach for improving cardiac function. Here, we evaluated the effect of prolonged decrease in EC-specific mito-ROS on post-acute myocardial infarction (AMI) coronary angiogenesis and cardiac function.Hypothesis:We hypothesized that a prolonged decrease in EC-specific mito-ROS contributes to mitochondrial dysfunction in coronary EC resulting in post-AMI maladaptive cardiac remodeling.Methods:We used an EC-specific, tetracycline-controlled, transgenic MnSOD overexpression (MnSOD-OE) model. After 16 weeks of MnSOD-OE, mice underwent ligation of left anterior coronary artery (AMI). 28 days post-AMI, ejection fraction (EF), fractional shortening (FS), and left ventricle (LV) mass were determined by echocardiography (n=8/group). Isolated mouse heart ECs (MHEC) were evaluated by Seahorse for mitochondrial function and by western blot for cell signaling. Data were analyzed by Student’s t test. Ap-value ≤0.05 was considered statistically significant.Results:MnSOD-OE mice showed 33% decrease (44.4±2.3 vs. 29.7±3.5) in EF and 35% decrease (21.7±1.2 vs. 14.2±1.7) in FS, compared to control. LV mass was increased by 51% (76.4±1.8 vs. 115.1±12.33 mg) in MnSOD-OE heart. LV end systolic and diastolic areas were increased in MnSOD-OE, by 2-fold (5.8±0.4 vs. 12.6±1.8) and 1.7-fold (9.8±0.5 vs. 16.8±1.6 mm2), respectively. MnSOD-OE MHEC showed a reduction in mitochondrial maximal and spare respiration capacities, and decreased activation of Akt by 25% and ERK by 23%.Conclusions:Prolonged MnSOD-OE impaired mitochondrial respiration and inhibited Akt and ERK signaling in MHEC. These changes were associated with maladaptive remodeling post-AMI, including cardiac hypertrophy, LV dilatation, and systolic dysfunction. Together, these findings suggest that prolonged decrease in mito-ROS has detrimental effects on coronary EC resulting in maladaptive post-AMI cardiac remodeling.

Circulation, Volume 146, Issue Suppl_1, Page A12100-A12100, November 8, 2022. Case Presentation:49-year-old male without known cardiovascular history presented with three days of atypical chest discomfort. 12-lead EKG revealed ST-segment elevations in II-III-aVF and depression in V1 suggestive of an acute infero-posterior MI (A), Troponin T at 6.85 ng/mL. Following administration of DAPT and heparinization, emergent coronary angiography proved a dominant RCA with proximal 60% and middle 100% occlusion (B), 80% focal stenosis at mid-LAD and 70% focal stenosis at prox-LCx (C). PCI with intra-aortic balloon pump support was performed, with two DES deployed in the RCA, use of a trans-venous pacemaker was required for complete AV block, and two defibrillations required for ventricular fibrillation. Following further hemodynamic compromise unexplained by his hemodynamic parameters, TEE was performed, demonstrating a large mid/distal infero-septum ventricular septal defect with left to right shunt (D, E and F), as well as a basal/mid infero-septum large pseudo-aneurysm (PSA) cavity (contained rupture) (G: low velocity Doppler flow from LV to PSA cavity, H and I show intact septum). The patient continued to decompensate requiring escalation to temporary mechanical circulatory support with VA-ECMO. Heart transplantation was initially considered, family decided to withdraw care due to multi-organ failure and poor prognosisDiscussion:Due to widespread availability of primary percutaneous coronary intervention with early reperfusion, mechanical complications post MI are less common in current days. Following transmural MI, persistent hypotension and cardiogenic shock should alert for complications such as VSD or PSA. While VSD may be amenable to percutaneous or surgical closure, PSA is associated with very high mortality even if surgery is attempted. Given the presence of both a VSD and PSA, mechanical support with VA-ECMO allowed us to support the patient for several days as a bridge to decision regarding heart transplantation

Circulation, Volume 146, Issue Suppl_1, Page A14461-A14461, November 8, 2022. Background:Transcatheter aortic valve replacement (TAVR) is indicated in patients with severely reduced left ventricular ejection fraction (LVEF) and can restore left ventricular (LV) function. However, mortality outcomes in this unique subset of patients has been studied only in limited cohorts.Methods:Extensive search on PubMed and Google Scholar yielded 1069 reports meeting inclusion criteria. These studies were independently evaluated by 2 physicians. Nine studies comparing all-cause mortality in patients undergoing TAVR with and without severely reduced LVEF (30% was considered an indicator of statistical heterogeneity among the studies. A Mantel-Haenszel Random effects model was used to calculate the Odds Ratio for homogeneous endpoints. A p value

Circulation, Volume 146, Issue Suppl_1, Page A14602-A14602, November 8, 2022. Background:Cancer treatment induced cardiotoxicity, can be a devastating outcome of cancer therapy. It is possible that a patient can survive cancer but develop cardiovascular disease (CVD).Aim:to determine whether there are differences in the characteristics of cancer patients who received potentially cardiotoxic cancer therapy and subsequently developed CVD and those who did not.Methods:This epidemiological study will comprise a retrospective analysis of de-identified linked health data sets, including the Integrated Activity Collection (ISAAC) of Hospital Separations, South Australian Cancer Registry (SACR), Northern Territory Cancer Registry (NTCR) and mortality (Births Deaths and Marriage Registry Data) and NT Hospital Separation data. The total population will be segregated in two distinct groups namely ‘Cancer with no HF’ and ‘Cancer with HF’ to compare the between group differences by demographic factors and medical history.Results:Of the (n=17,389) patients who received chemotherapy cancer treatment between July 2001-June 2017, 49% (8,530) were diagnosed with HF post cancer treatment( median age at cancer diagnosis 65 years; 58% male); crude mortality was 73% within the HF and cancer group; cause of death within this group was HF related 14%; cancer related 63%; other 22% compared to the non HF and cancer group ( median age at cancer diagnosis 58 years; 53% male) who had a mortality rate of 46%; 6.2% CVD related; 68.8% cancer related and 25% other.Conclusion:After adjusting for age, sex, tumour grade, cancer site and CVD admissions prior to cancer diagnosis patients with CVD and cancer had poorer outcomes.

Circulation, Volume 146, Issue Suppl_1, Page A12809-A12809, November 8, 2022. Background:Major adverse cardiac events (MACE) are a leading cause of morbidity and mortality after orthotopic liver transplantation (OLT). Cirrhotic cardiomyopathy (CCM) is relatively common and a source of MACE in patients after OLT. Initial diagnostic criteria based on transthoracic echocardiogram (TTE) were described in 2005 and revised in 2019 with echocardiographic advancements (Table 1). We sought to identify CCM related predictors of MACE at 13 months post-OLT.Methods:This is a retrospective study of adult patients who underwent OLT between 2009-2019. All patients had TTE’s within one year pre-OLT and one month to 13 months post-OLT. We excluded TTE’s within one-month post-OLT to reduce contributions from stress cardiomyopathy. Patients with a left ventricular ejection fraction less than 50% pre-OLT were excluded. MACE was defined as death, MI, CHF hospitalization, or cardiac arrest. Multivariable Cox regression was used to identify independent predictors of MACE.Results:Of 568 OLT patients screened, 131 met inclusion criteria for this study. There were 103 and 23 patients who met 2005 and 2019 criteria, respectively. During the 13 month follow up period, 42 patients had MACE. Compared to those without MACE, patients with MACE had more ascites (93 vs 70%, p 0.003), hepatorenal syndrome (HRS) (17 vs 4%, p 0.019), delayed OLT >10 days after admission (19 vs 7%, p 0.033), pre-OLT CCM per 2005 criteria (90% vs 73%, p 0.023), and lower diastolic blood pressure (60.81 vs 66.88, p 0.014). There was no difference in pre-OLT CCM per 2019 criteria (19 vs 17%, p 0.758) or MELD-Na score (21.24 vs 19.40, p 0.166). In multi-variable cox regression analysis adjusted for diastolic blood pressure, HRS, ascites, and OLT timing during admission, CCM per 2005 criteria remained significant as seen in Figure 1 (Hazard Ratio = 3, p 0.038).Conclusion:CCM per 2005 criteria is an independent predictor of MACE at 13 months post-OLT while CCM per 2019 criteria is not.

Circulation, Volume 146, Issue Suppl_1, Page A12070-A12070, November 8, 2022. Introduction:The majority of patients resuscitated from cardiac arrest (CA) present in coma or with an altered level of consciousness. Although CA survivors are routinely sedated during targeted temperature management, the effects of sedation on CA outcomes remain to be determined.Hypothesis:Post-CA sedation would modulate cerebral physiology and improve neurological outcomes in mice.Methods:Adult C57BL/6J mice of both sexes were subjected to potassium chloride-induced CA and thereafter resuscitated with manual chest compression. Starting at return of spontaneous circulation (ROSC) or at 60 minutes after ROSC, mice received intravenous infusion of propofol at 40 mg · kg-1· h-1, dexmedetomidine at 1 μg · kg-1· h-1, or normal saline for 2 hours. Body temperature was lowered and maintained at 33°C during sedation. Cerebral blood flow was measured for 4 hours after ROSC. Telemetric electroencephalogram (EEG) was recorded in freely moving mice from 3 days before up to 7 days after CA.Results:Sedation with propofol or dexmedetomidine starting at ROSC attenuated brain injury and improved survival in hypothermia-treated post-CA mice (propofol [13/16] vs. no sedation [4/16],P= 0.008; dexmedetomidine [14/16] vs. no sedation [4/16],P= 0.002). Mice that were not sedated after ROSC exhibited cerebral hyperemia immediately after resuscitation and EEG power in all frequency bands remained less than 20% of the baseline in the first 4 hours after ROSC. Administration of propofol or dexmedetomidine starting at ROSC attenuated cerebral hyperemia and induced slow-wave (0.5-4 Hz) EEG activity that reached near baseline levels during and early after sedation. Increased EEG activity within 6 hours after ROSC was associated with improvement in neurological outcomes at 24 hours post-CA. In contrast, delayed sedation starting at 60 minutes after ROSC failed to improve outcomes, without attenuating cerebral hyperemia and inducing slow-wave EEG activity.Conclusions:Post-CA sedation with propofol or dexmedetomidine improved neurological outcomes and survival in mice resuscitated from CA and treated with hypothermia. The beneficial effects of sedation were accompanied by attenuation of the cerebral hyperemic response and induction of EEG slow-wave activity.

Circulation, Volume 146, Issue Suppl_1, Page A15008-A15008, November 8, 2022. Introduction:Myocardial infarction (MI) is a leading cause of death worldwide. Although available treatments improve prognosis post-MI, they do not remediate cardiomyocyte death and loss of cardiac vasculature, resulting in chronic maladaptive remodeling and subsequently, heart failure. Extracellular vesicles (EVs) derived from endothelial colony-forming cells (ECFCs) show therapeutic potential, facilitating adaptive cardiac remodeling post-MI. However, ECFCs function is compromised in patients with type-2 diabetes, a common risk factor for MI, limiting the applicability of autologous cell-based therapies. Therapeutic administration is a further challenge, as current strategies present difficulties regarding invasiveness, retention, and efficacy.Hypothesis:We hypothesized that the minimally invasive intra-pericardial (IP) injection of ECFCs-EVs within a hydrogel would improve cardiac retention and promote sustained therapeutic release, facilitating cardiac repair in a murine model of MI. We anticipated that this repair would be greater with the use of EVs derived from wildtype mice than from diabetic mice.Methods:The impact of wildtype and diabetic ECFCs-EVs was evaluated on both in vitro EVs retention and angiogenesis. In a murine model of MI, the left anterior descending coronary artery was ligated while the pericardium was preserved. We evaluated whether IP injection is an effective and safe method of delivering hydrogels containing ECFCs-EVs, in addition to its long-term effects on cardiac morphology and function.Results:Our findings indicate that hydrogel use facilitates sustained EVs release. Besides that, the administration of ECFCs-EVs increased coronary endothelial cell proliferation, migration, and vascularization in vitro, and reduced maladaptive cardiac remodeling, improving cardiac contractility and function in vivo. These effects appear to be more pronounced with the administration of wildtype ECFCs-EVs.Conclusions:Collectively, our results underscore the therapeutic promise of ECFCs-EVs to improve cardiac repair after MI.

Circulation, Volume 146, Issue Suppl_1, Page A13992-A13992, November 8, 2022. Introduction:Transcatheter Aortic Valve Replacement (TAVR) is a widely used minimally invasive treatment for severe aortic stenosis. Though the procedure is safe and effective, patients are still at risk for ischemic and hemorrhagic events after this intervention. The post-procedure antithrombotic management in these patients continues to be a source of debate, particularly in patients who do not have a preexisting or concurrent comorbidity which requires long-term anticoagulation therapy.Methods:We performed a systematic review and meta-analysis to compare Direct Oral Anticoagulants (DOACs) versus antiplatelet therapy after TAVR in patients without previous indication for chronic oral anticoagulation. PubMed, EMBASE, and Cochrane databases were searched for randomized controlled trials (RCTs). Risk ratio (RR) with P value < 0.05 were considered statistically significant. The primary endpoints of interest were death, obstructive valve thrombosis and major bleeding. No time for follow-up was limited.Results:Three studies involving 2922 patients undergoing TAVR were included. Of the participants, 1459 received antiplatelets and 1463 received DOACs. Antiplatelets were associated with significantly lower all-cause mortality (RR 1.68 [1.22-2.30], 95%IC; p=0.001). Major bleeding did not differ significantly between groups, but DOACs had a higher risk of bleeding when compared to antiplatelet drugs (RR 1.44 [0.90-2.32]; 95%IC, p=0.13). The antiplatelet group had a significantly higher risk of valve thrombosis than the DOACs group (RR 0.27 [0.14-0.51]; 95%IC; p

Circulation, Volume 146, Issue Suppl_1, Page A10006-A10006, November 8, 2022. Background:In the DECLARE-TIMI 58 trial, involving patients with type 2 diabetes at high cardiovascular (CV) risk, dapagliflozin reduced the risk for heart failure hospitalization and adverse kidney outcomes, compared to placebo. Whether dapagliflozin lowers the risks for the broader outcome of adverse event (AE)-related hospital admissions is unknown.Methods:The DECLARE-TIMI 58 trial randomized 17,160 subjects with type 2 diabetes and a high risk for or established CV disease, to receive dapagliflozin or placebo (1:1). Dapagliflozin effect on AE-related hospital admissions was assessed overall and by baseline cardiovascular and kidney subgroups. Investigator reported system organ class classification was used to evaluate dapagliflozin’s effects on admissions due to different etiologies.Results:Over a median follow up of 4.2 years, dapagliflozin reduced the risk of AE-related hospital admissions by 11% (32.4% vs. 35.4% of participants, HR 0.89 [95% CI 0.85, 0.94]; p