Hyperglycemia in Cancer Patients.

Most of the cancer patients have multiple comorbid conditions, commonly diabetes mellitus, hypertension, and coronary vascular diseases. Cancer treatment involves a multidisciplinary approach targeting primary cancer-directed therapy along with optimal management of comorbid conditions as well. Hyperglycemia, which exists prior to cancer therapy initiation or if it develops during or after therapy, is associated with less desirable outcomes like treatment compromise due to increased adverse effects of therapy and higher mortality. Hence, prompt diagnoses and management of hyperglycemia become crucial during therapy. Healthcare providers working in an oncology setting, as well as primary care providers, should be aware of medications that are associated with hyperglycemia and diabetes. This paper will elucidate various cancer-directed therapies associated with hyperglycemia.

CT-Guided Lumbar Sympathectomy as a Last Option for Chronic Limb-Threatening Ischemia of the Lower Limbs: Evaluation of Technical Factors and Long-Term Outcomes.

OBJECTIVE. The purpose of this study was to assess the effects of anatomic and technical factors on the long-term outcome of CT-guided lumbar sympathectomy in patients with chronic limb-threatening ischemia. SUBJECTS AND METHODS. Thirty patients (28 men, two women; mean age, 45.8 years) with chronic limb-threatening ischemia and diffuse tibial arterial disease not amenable to revascularization were included. CT-guided lumbar sympathectomy was performed at the L2-L3 level with a 22-gauge Chiba needle and absolute alcohol. Any periprocedural complication was noted. Numeric pain score (1-10 scale) and skin ulcers were assessed before the procedure and 3 weeks, 3 months, and 1 and 2 years after the procedure. According to spread of alcohol, patients were categorized into those with medial spread and those without medial spread (lateral spread group) with the lateral edge of the vertebral body as the reference point. Treatment results were categorized as improved, unchanged, or worsened on the basis of clinical response. RESULTS. There were 22 (73.3%) patients in the medial spread group and eight (26.7%) in the lateral spread group. The mean volumes of alcohol injected per side were not significantly different (p = .50). One major complication occurred in the group with medial spread. Mean numeric pain scores before the procedure and 3 weeks, 3 months, and 1 and 2 years afterward were 7.31, 2.95, 2.47, 2.10, and 2.04 in the medial spread group and 6.25, 4.13, 4.50, 4.35 and 4.32 in the lateral spread group (p < .001). At 2 years, 16 patients in the medial spread group and two patients in the lateral spread group showed clinical improvement (p < .001), and the limb salvage rates were 100% and 87.5%, respectively. Multivariate analysis showed a trend in improvement with smoking cessation, but the difference was not statistically significant (p = .15). The direction of spread of the neurolytic agent, however, was a major determinant of outcome. CONCLUSION. CT-guided lumbar sympathectomy is a simple, safe, and effective procedure. Ensuring medial spread of the neurolytic agent significantly improves long-term results.

Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part 2: ventricular arrhythmias, channelopathies, and implantable defibrillators.

This paper belongs to a series of recommendation documents for participation in leisure-time physical activity and competitive sports by the European Association of Preventive Cardiology (EAPC). Together with an accompanying paper on supraventricular arrhythmias, this second text deals specifically with those participants in whom some form of ventricular rhythm disorder is documented, who are diagnosed with an inherited arrhythmogenic condition, and/or who have an implanted pacemaker or cardioverter defibrillator. A companion text on recommendations in athletes with supraventricular arrhythmias is published in the European Journal of Preventive Cardiology. Since both texts focus on arrhythmias, they are the result of a collaboration between EAPC and the European Heart Rhythm Association (EHRA). The documents provide a framework for evaluating eligibility to perform sports, based on three elements, i.e. the prognostic risk of the arrhythmias when performing sports, the symptomatic impact of arrhythmias while performing sports, and the potential progression of underlying structural problems as the result of sports.

Return to play with hypertrophic cardiomyopathy: are we moving too fast? A critical review.

The diagnosis of a potentially lethal cardiovascular disease in a young athlete presents a complex dilemma regarding athlete safety, patient autonomy, team or institutional risk tolerance and medical decision-making. Consensus cardiology recommendations previously supported the 'blanket' disqualification of athletes with hypertrophic cardiomyopathy (HCM) from competitive sport. More recently, epidemiological studies examining the relative contribution of HCM as a cause of sudden cardiac death (SCD) in young athletes and reports from small cohorts of older athletes with HCM that continue to exercise have fueled debate whether it is safe to play with HCM. Shared decision-making is endorsed within the sports cardiology community in which athletes can make an informed decision about treatment options and potentially elect to continue competitive sports participation. This review critically examines the available evidence relevant to sports eligibility decisions in young athletes diagnosed with HCM. Histopathologically, HCM presents an unstable myocardial substrate that is vulnerable to ventricular tachyarrhythmias during exercise. Studies support that young age and intense competitive sports are risk factors for SCD in patients with HCM. We provide an estimate of annual mortality based on our understanding of disease prevalence and the incidence of HCM-related SCD in different athlete populations. Adolescent and young adult male athletes and athletes participating in a higher risk sport such as basketball, soccer and American football exhibit a greater risk. This review explores the potential harms and benefits of sports disqualification in athletes with HCM and details the challenges and limitations of shared decision-making when all parties may not agree.

Cardiorespiratory considerations for return-to-play in elite athletes after COVID-19 infection: a practical guide for sport and exercise medicine physicians.

SARS-CoV-2 is the causative virus responsible for the COVID-19 pandemic. This pandemic has necessitated that all professional and elite sport is either suspended, postponed or cancelled altogether to minimise the risk of viral spread. As infection rates drop and quarantine restrictions are lifted, the question how athletes can safely resume competitive sport is being asked. Given the rapidly evolving knowledge base about the virus and changing governmental and public health recommendations, a precise answer to this question is fraught with complexity and nuance. Without robust data to inform policy, return-to-play (RTP) decisions are especially difficult for elite athletes on the suspicion that the COVID-19 virus could result in significant cardiorespiratory compromise in a minority of afflicted athletes. There are now consistent reports of athletes reporting persistent and residual symptoms many weeks to months after initial COVID-19 infection. These symptoms include cough, tachycardia and extreme fatigue. To support safe RTP, we provide sport and exercise medicine physicians with practical recommendations on how to exclude cardiorespiratory complications of COVID-19 in elite athletes who place high demand on their cardiorespiratory system. As new evidence emerges, guidance for a safe RTP should be updated.

Results of a nationally implemented de novo cardiac screening programme in elite rugby players in England.

BACKGROUND/AIM: Screening of young competitive athletes remains a contentious issue. In 2010, a nationwide cardiac screening for all elite rugby players was introduced in England. This provided a unique opportunity to prospectively assess the feasibility and cost-effectiveness of a de novo, ECG-based cardiac screening programme. METHODS: Between 2010 and 2012, 1191 rugby players aged ≥14 years underwent cardiac screening with a health questionnaire, 12-lead ECG and a consultation with a cardiologist. The players with concerning findings on initial evaluation were offered on-site transthoracic echocardiogram (TTE). Athletes were referred for further investigations as deemed necessary. The overall cost of the screening programme was estimated. RESULTS: After initial evaluation, 9.7% of athletes underwent on-site TTE; 8.2% underwent on-site TTE due to ECG anomalies and 1.4% underwent on-site TTE due to concerns on the questionnaire. After TTE, only 2.9% of the total cohort was referred for further evaluation. Two players were diagnosed with potentially serious conditions; one with Wolff-Parkinson-White, who resumed competition after catheter ablation, and one with hypertrophic cardiomyopathy, who withdrew from competition. During a mean follow-up of 52.8±5.5 months, none of the players who were reassured experienced any adverse cardiac events. The total cost of the screening programme was £59 875, which averaged to a cost of £50 per player or £29 938 per condition identified. Application of refined ECG criteria would reduce the ECG false-positive rate to 4.9%. CONCLUSIONS: Preparticipation cardiac screening with 12-lead ECG is feasible. Refinement of the ECG criteria, the use of on-site TTE and expert setting can minimise the burden of unnecessary investigations and reduce costs.

Abnormal electrocardiographic findings in athletes: recognising changes suggestive of cardiomyopathy.

Cardiomyopathies are a heterogeneous group of heart muscle diseases and collectively are the leading cause of sudden cardiac death (SCD) in young athletes. The 12-lead ECG is utilised as both a screening and diagnostic tool for detecting conditions associated with SCD. Fundamental to the appropriate evaluation of athletes undergoing ECG is an understanding of the ECG findings that may indicate the presence of an underlying pathological cardiac disorder. This article describes ECG findings present in cardiomyopathies afflicting young athletes and outlines appropriate steps for further evaluation of these ECG abnormalities. The ECG findings defined as abnormal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.

Abnormal electrocardiographic findings in athletes: recognising changes suggestive of primary electrical disease.

Cardiac channelopathies are potentially lethal inherited arrhythmia syndromes and an important cause of sudden cardiac death (SCD) in young athletes. Other cardiac rhythm and conduction disturbances also may indicate the presence of an underlying cardiac disorder. The 12-lead ECG is utilised as both a screening and a diagnostic tool for detecting conditions associated with SCD. Fundamental to the appropriate evaluation of athletes undergoing ECG is an understanding of the ECG findings that may indicate the presence of a pathological cardiac disease. This article describes ECG findings present in primary electrical diseases afflicting young athletes and outlines appropriate steps for further evaluation of these ECG abnormalities. The ECG findings defined as abnormal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.

Goal-directed fluid therapy guided by Plethysmographic Variability Index (PVI) versus conventional liberal fluid administration in children during elective abdominal surgery: A randomized controlled trial.

BACKGROUND: PVI has been shown to be an accurate predictor of fluid responsiveness in paediatric patients. Evidence regarding the role of PVI to guide intraoperative fluid therapy in paediatric abdominal surgery is lacking. We aimed to assess the effect of PVI-guided fluid therapy on the volume of intraoperative fluids administered and post-operative biochemical and recovery profile in children undergoing elective abdominal surgery. METHODS: 42 children, 6 months-3 years scheduled for elective open bowel surgery were randomised to receive either 'conventional liberal intraoperative fluids' (liberal group) or 'goal-directed intraoperative fluids' (GDT group). PVI <13 was targeted in the GDT group. The primary outcome was the volume of intraoperative fluids administered. Postoperative serum lactate, base excess, hematocrit, recovery of bowel function and duration of postoperative hospital stay were the secondary outcomes. RESULTS: The mean fluid administered intra-operatively was significantly lower in the GDT group as compared to the liberal group (24.1 ± 9.6 mL/kg vs 37.0 ± 8.9 mL/kg, p < 0.001). The postoperative hemoglobin concentration (g%) was significantly lower in the liberal group as compared to the GDT group (8.1 ± 1.3 vs 9.2 ± 1.4, p = 0.008). Recovery of bowel function (hours) was significantly delayed in the liberal group as compared to the GDT group (58.2 ± 17.9 vs 36.5 ± 14.1, p < 0.001). CONCLUSION: Intraoperative PVI-guided fluid therapy significantly reduces the volume of intravenous crystalloids administered to children undergoing open bowel surgery. These children also had faster recovery of bowel function and less hemodilution in the immediate postoperative period, compared to those who received liberal intraoperative fluid therapy. TYPE OF STUDY: Randomized Clinical Trial. LEVEL OF EVIDENCE: Treatment Study (LEVEL 1).

Emergency cardiac care in the athletic setting: from schools to the Olympics.

Medical providers at sporting events must be well-trained in the care of cardiac emergencies. Optimal outcomes are most likely achieved through comprehensive emergency planning that ensures prompt and appropriate care. The diversity of athletic venues, as well as the age and competition level of different athlete populations, present challenges to the provision of appropriate emergency care in sport. An efficient and coordinated medical response to cardiac emergencies requires an established emergency action plan, training of potential first responders in cardiopulmonary resuscitation and use of an automated external defibrillator, coordinating communication and transportation systems, and ensuring access to appropriate medical equipment and supplies. Prompt recognition and early defibrillation are critical in the management of athletes suffering sudden cardiac arrest. This article reviews emergency planning and cardiac care in athletics, with special considerations presented for the school, large arena, mass event and Olympic settings.

Impact of ethnicity upon cardiovascular adaptation in competitive athletes: relevance to preparticipation screening.

Regular participation in intensive physical exercise is associated with several structural and electrophysiological cardiac adaptations that enhance diastolic filling and facilitate a sustained increase in the cardiac output that is fundamental to athletic excellence. Such cardiac adaptations are collectively referred to as the 'Athlete's Heart' and are frequently reflected on the 12-lead ECG and imaging studies. Thorough knowledge relating to exercise-associated cardiovascular adaptation is imperative for the purposes of differentiating physiological adaptation from cardiac pathology, since an erroneous diagnosis of cardiac disease has potentially serious consequences for the athlete's physical, psychological, social and financial well-being. The majority of studies investigating the cardiovascular adaptation to exercise are based on cohorts of Caucasian athletes. However, there is mounting evidence that ethnicity is an important determinant of the objective manifestations of cardiovascular adaptation to exercise. The most pronounced paradigm of ethnically distinct cardiovascular adaptation to exercise stems from athletes of African/Afro-Caribbean descent, who exhibit a significantly higher prevalence of repolarisation anomalies and left ventricular hypertrophy, compared to Caucasian athletes; the differentiation between athlete's heart and hypertrophic cardiomyopathy is particularly challenging in this ethnic group. The extrapolation of ECG and echocardiographic criteria used to diagnose potentially serious cardiac disorders in Caucasian athletes to the African/Afro-Caribbean athlete population would result in an unacceptable number of unnecessary investigations and increased risk of false disqualification from competitive sport. Accurate interpretation of the athlete's ECG and echocardiogram is crucial, particularly when one considers the continuous expansion of preparticipation screening programmes. This review attempts to highlight ethnically determined differences in cardiovascular adaptation to exercise and provides a practical guide for the interpretation of baseline investigations in athletes of diverse ethnic backgrounds.

The London Marathon debate.

Endurance exercise, can you have too much of a good thing?

Cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids in relation to sports: a position statement of the sport cardiology and exercise nucleus of the European Association of Preventive Cardiology.

The use of substances and medications with potential cardiovascular effects among those practicing sports and physical activity has progressively increased in recent years. This is also connected to the promotion of physical activity and exercise as core aspects of a healthy lifestyle, which has led also to an increase in sport participation across all ages. In this context, three main users' categories can be identified, (i) professional and amateur athletes using substances to enhance their performance, (ii) people with chronic conditions, which include physical activity and sport in their therapeutic plan, in association with prescribed medications, and (iii) athletes and young individuals using supplements or ergogenic aids to integrate their diet or obtaining a cognitive enhancement effect. All the substances used for these purposes have been reported to have side effects, among whom the cardiovascular consequences are the most dangerous and could lead to cardiac events. The cardiovascular effect depends on the type of substance, the amount, the duration of use, and the individual response to the substances, considering the great variability in responses. This Position Paper reviews the recent literature and represents an update to the previously published Position Paper published in 2006. The objective is to inform physicians, athletes, coaches, and those participating in sport for a health enhancement purpose, about the adverse cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids, when associated with sport and exercise.

An in vitro evaluation of radicular penetration of hydrogen peroxide from bleaching agents during intra-coronal tooth bleaching with an insight of biologic response.

OBJECTIVES: External root resorption is the complication of intra-coronal bleaching done with 30% H2O2 alone or mixed with sodium perborate but not with sodium perborate mixed with water. The study was done to comparatively evaluate the H2O2 leakage from three H2O2 liberating bleaching agents. STUDY DESIGN: Fifty one single rooted human teeth were used. After root canal therapy gutta percha was removed below cemento-enamel junction. Three bleaching agents: sodium perborate mixed with water, sodium perborate mixed with 30% H2O2 and 30% H2O2 alone were used. Teeth without defect, with cervical root defect and with mid root defect constituted group A, group B and group C. According to various bleaching agents groups were subdivided into subgroup 1, 2 and 3. H2O2 leakage was measured with the help of spectrophotometer RESULTS: Almost all teeth showed H2O2 leakage. It was maximum in B1 followed by C1, B2, A1, A2, C2, B3, A3 and C3. CONCLUSION: Sodium perborate mixed with water was found to be the best bleaching agent.

Impact of baseline clinical features on outcomes of nebulized glycopyrrolate therapy in COPD.

Inhaled bronchodilators are central for the treatment of chronic obstructive pulmonary disease (COPD), as they can provide symptom relief and reduce the frequency and severity of exacerbations while improving health status and exercise tolerance. In 2017, glycopyrrolate (GLY) delivered via the eFlow® closed system (CS) nebulizer (nebulized GLY; 25 µg twice daily), was approved by the US Food and Drug Administration for maintenance treatment of moderate-to-very-severe COPD. This approval was based largely on results from the replicate, placebo-controlled, Phase III clinical trials- GOLDEN 3 and 4. In this review, we summarize key findings from secondary analyses of the GOLDEN 3 and 4 studies, and provide a comprehensive overview that may assist both pulmonologists and primary-care providers in their treatment decisions. Comorbidities are common among patients with COPD in clinical practice and may impact bronchodilator efficacy. This review highlights outcomes among subpopulations of patients with comorbidities (e.g., anxiety/depression, cardiovascular disease), and their impact on the efficacy of nebulized GLY. In addition, the efficacy and safety of nebulized GLY across various demographics (e.g., age, gender) and baseline disease characteristics (e.g., disease severity, rescue medication use) are discussed. Real-world outcomes with nebulized GLY, including device satisfaction, healthcare resource utilization, and exacerbations, are also presented. These secondary analyses and real-world data complement the primary results with nebulized GLY from Phase III studies and support the need for the inclusion of patients representative of real-world clinical practice in RCTs. In addition, these data suggest that RCTs for COPD therapies should be complemented with real-world observational studies.

Preparticipation screening of young competitive athletes for cardiovascular disorders.

The beneficial effects of regular physical exercise on cardiovascular morbidity and mortality are well documented. In rare cases, however, athletes with cardiovascular abnormalities are at increased risk of exercise-related sudden cardiac death (SCD). Paradoxically, most SCDs can be attributed to cardiovascular abnormalities that can be identified during an athlete's life. Such abnormalities can be minimized by several therapeutic strategies, including insertion of an implantable cardioverter-defibrillator. Based on these considerations, the medical and sporting governing bodies recommend preparticipation cardiovascular screening (PPS) in young competitive athletes (aged