Fetal heart rate tracings associated with eclamptic seizures.

BACKGROUND: Although there is a well-known association between fetal bradycardia and maternal eclampsia, the characteristics of fetal heart rate tracings after an eclamptic seizure have not previously been thoroughly described. Fetal heart rate changes are thought to be related to maternal lactic acidemia caused by vasospasm and uterine hyperactivity leading to placental hypoperfusion and fetal hypoxia. The decision to intervene in the case of an abnormal fetal heart rate tracing after an eclamptic seizure is often difficult; however, maternal resuscitation should be the primary focus. OBJECTIVE: This study aimed to quantify and characterize fetal heart rate changes associated with a maternal eclamptic seizure. Moreover, we sought to document subsequent obstetrical management following these seizures complicated by fetal heart rate decelerations. STUDY DESIGN: This was a retrospective study of fetal heart rate tracings associated with eclampsia during a 13-year period at a single institution. Eclampsia was diagnosed following the 2013 Executive Summary of the American College of Obstetricians and Gynecologists criteria. Tracings were independently reviewed and classified by 3 physicians using the National Institute of Child Health and Human Development Criteria. Hospital records were reviewed to ascertain obstetrical management after the eclamptic seizure. RESULTS: A total of 107 women were diagnosed with eclampsia from January 2009 to December 2021. Of these women, 31 experienced 34 intrapartum seizures during which time electronic fetal heart rate monitoring was ongoing. During the 34 seizures, fetal heart rate decelerations were documented in 79% of cases. The mean duration of bradycardia was 5.80±2.98 minutes with a range of 2 to 15 minutes. Fetal heart decelerations occurred, on average, 2.7±1.6 minutes after the onset of the eclamptic seizure. In half of the fetuses with fetal heart rate changes, fetal tachycardia followed, and in 48% of cases, there was minimal variability noted. As a result of the fetal heart rate tracings and clinical findings, 4 women underwent an emergent cesarean delivery, including 2 that were diagnosed with placental abruption. In this cohort, there were 4 cases of abruption. The mean duration from the seizure to delivery was 299±353 minutes. The mean neonatal cord pH was 7.20±0.11 with a mean base excess of -8.6±4.4 mmol/L. There was no perinatal death. CONCLUSION: After an eclamptic seizure, 79% of fetuses demonstrated prolonged decelerations, and half of the fetuses developed fetal tachycardia after recovery from the episode of bradycardia. Despite these periods of fetal heart rate decelerations associated with eclampsia, prioritization of maternal support and stabilization resulted in a favorable perinatal outcome without immediate operative intervention in more than two-thirds of cases.

Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR): a randomized, placebo-controlled, double-blinded trial.

AIMS: Cardiosphere-derived cells (CDCs) are cardiac progenitor cells that exhibit disease-modifying bioactivity in various models of cardiomyopathy and in previous clinical studies of acute myocardial infarction (MI), dilated cardiomyopathy, and Duchenne muscular dystrophy. The aim of the study was to assess the safety and efficacy of intracoronary administration of allogeneic CDCs in the multicentre, randomized, double-blinded, placebo-controlled, intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR) trial. METHODS AND RESULTS: We enrolled patients 4 weeks to 12 months after MI, with left ventricular ejection fraction (LVEF) ≤45% and LV scar size ≥15% of LV mass by magnetic resonance imaging (MRI). A pre-specified interim analysis was performed when 6-month MRI data were available. The trial was subsequently stopped due to the low probability of detecting a significant treatment effect of CDCs based on the primary endpoint. Patients were randomly allocated in a 2:1 ratio to receive CDCs or placebo in the infarct-related artery by stop-flow technique. The primary safety endpoint was the occurrence, during 1-month post-intracoronary infusion, of acute myocarditis attributable to allogeneic CDCs, ventricular tachycardia- or ventricular fibrillation-related death, sudden unexpected death, or a major adverse cardiac event (death or hospitalization for heart failure or non-fatal MI or need for left ventricular assist device or heart transplant). The primary efficacy endpoint was the relative percentage change in infarct size at 12 months post-infusion as assessed by contrast-enhanced cardiac MRI. We randomly allocated 142 eligible patients of whom 134 were treated (90 to the CDC group and 44 to the placebo group). The mean baseline LVEF was 40% and the mean scar size was 22% of LV mass. No primary safety endpoint events occurred. There was no difference in the percentage change from baseline in scar size (P = 0.51) between CDCs and placebo groups at 6 months. Compared with placebo, there were significant reductions in LV end-diastolic volume (P = 0.02), LV end-systolic volume (P = 0.02), and N-terminal pro b-type natriuretic peptide (NT-proBNP) (P = 0.02) at 6 months in CDC-treated patients. CONCLUSION: Intracoronary infusion of allogeneic CDCs in patients with post-MI LV dysfunction was safe but did not reduce scar size relative to placebo at 6 months. Nevertheless, the reductions in LV volumes and NT-proBNP reveal disease-modifying bioactivity of CDCs. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01458405.

Update on COVID-19 Myocarditis.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) gained worldwide attention at the end of 2019 when it was identified to cause severe respiratory distress syndrome. While it primarily affects the respiratory system, we now have evidence that it affects multiple organ systems in the human body. Cardiac manifestations may include myocarditis, life threatening arrhythmias, acute coronary syndrome, systolic heart failure, and cardiogenic shock. Myocarditis is increasingly recognized as a complication of Coronavirus-19 (COVID-19) and may result from direct viral injury or from exaggerated host immune response. The diagnosis is established similar to other etiologies, and is based on detailed history, clinical exam, laboratory findings and non-invasive imaging studies. When available, cardiac MRI is the preferred imaging modality. Endomyocardial biopsy may be performed if the diagnosis remains uncertain. Current management is mainly supportive with the potential addition of interventions recommended for severe COVID-19 disease, such as remdesivir, steroids, and convalescent plasma. In the setting of cardiogenic shock and refractory, life-threatening arrhythmias that persist despite medical therapy, advanced mechanical circulatory support devices should be considered. Ultimately, early recognition and aggressive intervention are key factors in reducing morbidity and mortality. Our management strategy is expected to evolve further as we learn more about COVID-19 disease and the associated cardiac complications.

Teaching clinical skills in pre-registration nurse education: value and methods.

This article explores the value of teaching clinical skills in pre-registration nurse education. It touches on stages of competence and the knowledge necessary to enable the learner to meet the standards of proficiency expected of registered nurses. Some contemporary issues around clinical skills teaching are discussed. How clinical skills can be taught and learnt as well as common problems encountered by learners and by educators are highlighted. This article also aims to stimulate discussion around the Nursing and Midwifery Council's new standards of proficiency for registered nurses. It discusses how learners will be prepared to undertake all nursing procedures outlined in these standards within a changing healthcare education landscape and an increasingly complex health and social care environment.

Heart rate informed artificial pancreas system enhances glycemic control during exercise in adolescents with T1D.

OBJECTIVE: To evaluate the safety and performance of using a heart rate (HR) monitor to inform an artificial pancreas (AP) system during exercise among adolescents with type 1 diabetes (T1D). MATERIALS AND METHODS: In a randomized, cross-over trial, adolescents with T1D age 13 - 18 years were enrolled to receive on separate days either the unmodified UVa AP (stdAP) or an AP system connected to a portable HR monitor (AP-HR) that triggered an exercise algorithm for blood glucose (BG) control. During admissions participants underwent a structured exercise regimen. Hypoglycemic events and CGM tracings were compared between the two admissions, during exercise and for the full 24-hour period. RESULTS: Eighteen participants completed the trial. While number of hypoglycemic events during exercise and rest was not different between visits (0.39 AP-HR vs 0.50 stdAP), time below 70 mg dL -1 was lower on AP-HR compared to stdAP, 0.5±2.1% vs 7.4±12.5% (P = 0.028). Time with BG within 70-180 mg dL -1 was higher for the AP-HR admission vs stdAP during the exercise portion and overall (96% vs 87%, and 77% vs 74%), but these did not reach statistical significance (P = 0.075 and P = 0.366). CONCLUSIONS: Heart rate signals can safely and efficaciously be integrated in a wireless AP system to inform of physical activity. While exercise contributes to hypoglycemia among adolescents, even when using an AP system, informing the system of exercise via a HR monitor improved time <70 mg dL -1 . Nonetheless, it did not significantly reduce the total number of hypoglycemic events, which were low in both groups.

Evaluation and management of thyroid nodules in children.

PURPOSE OF REVIEW: The review is focused on new information about the presentation and management of thyroid nodules in children and adolescents. RECENT FINDINGS: Palpable thyroid nodules are uncommon in children but many children have nodules detected by radiologic imaging. How to evaluate them, when to suspect thyroid cancer, and how best to follow apparently benign nodules has become an area of great interest. The American Thyroid Association recently published treatment guidelines for children with thyroid nodules and cancers but much has been learned since that publication. SUMMARY: Personal and family history, ultrasound features, and fine needle aspiration cytology are used to determine the risk of cancer in thyroid nodules, which are then managed according to cancer risk.

Atrial fibrillation and heart failure: intersecting populations, morbidities, and mortality.

Heart failure (HF) and atrial fibrillation (AF) are the only two cardiovascular disorders that continue to increase in magnitude in the United States. The purpose of this brief overview is to provide a description of these two cardiovascular epidemics of HF and AF as they interact, and to provide additional information regarding the emerging influence of genetics and environment in the development of AF in the HF setting. These two modern epidemics are highly interactive and highly age-dependent. The development of new AF in a patient with either HF with preserved ejection fraction or HF with reduced ejection fraction possesses challenging management issues for practicing physicians. Control of heart rate is always prudent though still not precisely defined. The need to restore normal sinus rhythm is highly patient-dependent and strategies will vary. Elderly patients derive the most benefit from anticoagulation, but are also more prone to falls and bleeding complications. Today, we know much more about AF and HF and how they interact. The extent of AF/HF challenge is now widely recognized. It is inevitable that as people age, they will develop structural and functional changes in the cardiovascular system, some of which will predispose to the development of HF and AF. Not every case of HF or AF is preventable. Nevertheless, it is only throughout careful observations and further studies that we will be able to better manage these two Goliaths.

Changes in body anthropometry and composition in obese adolescents in a lifestyle intervention program.

PURPOSE: Impact of lifestyle modification on obesity control during adolescence, a period of significant physical growth and development, is less quantitatively evaluated. Therefore, we investigated the impact of changes in reported energy intake and physical activity on anthropometrics and body composition in adolescents. METHODS: Participants were obese adolescents aged 11-18 years. All of them have a body mass index (BMI) ≥ 95th percentile specific for age and gender according to the 2000 CDC Growth Charts. The intervention consists of supervised physical activity, structured nutrition education and dietary modification, and behavioral support in 6 months. Hundred and forty-five obese adolescents completed the study. RESULTS: Compared to baseline, significant reductions in body weight (-1.4 kg, p < 0.001) and BMI (-0.1 kg/m(2), p < 0.001) were observed at 6 months. When compared to expected growth trajectories on the 2000 CDC Growth Charts, body weight and BMI were reduced by 3.6 kg and 1.5 kg/m(2), respectively, in boys and 5.6 kg and 1.9 kg/m(2) in girls. Age was inversely associated with changes in weight (ß = -1.48 kg, p < 0.01) and BMI (ß = -0.32 kg/m(2), p = 0.03). There was a dose-response relationship between reduction in energy intake and weight loss. A decrease of 100 kcal/day was significantly associated with reductions in body weight 0.30 kg, BMI 0.09 kg/m(2), and BMI Z score 0.01 (all p < 0.01). Physical activity was not significantly associated with changes in anthropometrics or body composition. CONCLUSIONS: Reduction in energy intake was a significant predictor of obesity reduction in these adolescents. A quantitative evaluation of adolescent weight loss programs should account for natural growth and development.

Fetal right-ventricular hypertrophy with pericardial effusion and maternal untreated hyperthyroidism.

Uncontrolled/untreated maternal hyperthyroidism has been associated with fetal tachycardia. We report a case of right-ventricular (RV) hypertrophy with pericardial effusion related to untreated maternal Graves' disease. A 33-year-old G4P1021 woman with uncontrolled Graves' disease presented at 29 weeks gestation with abdominal pain and vaginal bleeding. Fetal echocardiogram showed severe RV hypertrophy and a pericardial effusion. The infant was born prematurely, and initial transthoracic echocardiogram showed severe RV hypertrophy and a small pericardial effusion. The infant had clinical findings consistent with congenital thyrotoxicosis and was treated for this. Follow-up imaging at 4 weeks showed improvement of the cardiac hypertrophy and pericardial effusion. This article describes the presentation of fetal RV hypertrophy with congenital thyrotoxicosis and underscores the importance of screening for this prenatally in mothers with uncontrolled or untreated hyperthyroidism.

Psychological treatment improves hemoglobin A1c outcomes in adolescents with type 1 diabetes mellitus.

UNLABELLED: Adolescents diagnosed with Type 1 Diabetes Mellitus often exhibit reduced adherence to their medical regimen and poor glycemic control. A retrospective study examined longitudinal hemoglobin A1c (HgbA1c) outcomes for adolescent patients referred to the psychology service embedded within an endocrinology clinic. Three patient groups were examined: (1) TREATMENT: 59 adolescents referred who engaged in psychotherapy; (2) No TREATMENT: 40 adolescents referred yet failed to initiate psychotherapy; (3) CONTROL: 58 adolescents not referred for treatment and matched on demographics to the two treatment groups. Over 1 year, the TREATMENT group had a sustained decrease in HgbA1c while the No TREATMENT and CONTROL groups had an overall increase in HgbA1c. At study end, the TREATMENT group had HgbA1c values that were not significantly different from patients who were not considered in need of psychological treatment (CONTROL). Adolescents that utilized the pediatric psychology service saw decreased HgbA1c values over time.

Effect of Angiotensin-converting enzyme inhibitors and Angiotensin receptor antagonists in atherosclerosis prevention.

Atherosclerosis is a highly complex biological process that has become the scourge of modern civilization. Endothelial dysfunction is the first step in the development of atherosclerosis. The renin-angiotensin-aldosterone system (RAAS) plays an important role in the development of endothelial dysfunction and atherosclerosis. Several studies have shown that in vitro blockade of the RAAS is associated with improvement in markers of endothelial dysfunction and inflammation. Many clinical trials have demonstrated a clear benefit of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) manifested by a reduction of cardiovascular events. These findings suggest that ACEIs and ARBs can play an important role in prevention of atherosclerosis and in the delay of its progression. In this review we focus on the importance of RAAS blockade to prevent or delay progression of atherosclerosis and its impact on reduction of cardiovascular events.

ß-blockers in stage B: a precursor of heart failure.

ß-blockers are an important treatment of heart failure (HF) and are useful in reducing the progression of the syndrome. They should be considered for patients with asymptomatic left ventricular (LV) dysfunction. Evidence-based ß-blocker therapy (bisoprolol, carvedilol, or metoprolol succinate) in combination with standard therapy is a mainstay of treatment of all symptomatic patients with LV systolic dysfunction. Patients in stage B also benefit from the early introduction of ß-blockers, but there are no large randomized clinical trials to support this strategy. Whether there is a role for ivabradine in the treatment of HF is not clear.

Treatment of hypothyroidism in infants, children and adolescents.

In 2014, treatment guidelines from the American Thyroid Association reflected the general consensus that levothyroxine (LT4), adjusted to maintain a normal thyrotropin (TSH) level, is the preferred method for treatment of hypothyroidism. Although this is generally applicable to children, there are subsets of children for whom the diagnosis and treatment of hypothyroidism are problematic. These include children with congenital hypothyroidism (CH), low birth weight (LBW) and very low birth weight (VLBW), Down syndrome (DS), subclinical hypothyroidism, and obesity. In this Review, we focus on the progress and remaining pitfalls in diagnosis and treatment of hypothyroidism in these and other groups.

Thyroid nodules of indeterminate cytology in Hispanic/Latinx patients.

BACKGROUND: Behavior of differentiated thyroid cancer (DTC) varies among ethnic groups. Recommended management of thyroid nodules with indeterminate cytology (TN-IC) is based on molecular analysis from predominantly non-Hispanic white patients. We hypothesized that TN-IC in Hispanic/Latinx patients would have different features, management, and outcomes and that molecular testing might perform differently in Hispanic/Latinx patients. METHODS: Retrospective chart review was performed on 127 TN-IC analyzed with Afirma. Patient characteristics were compared using linear model ANOVA and Fisher's exact test. RESULTS: Out of 127 TN-IC, 71 (56%) were Hispanic/Latinx. Hispanic/Latinx had a greater prevalence of diabetes, but Afirma results (benign or suspicious) were similar between ethnic groups. Fourteen patients had malignant pathology. Their management and outcomes were similar across groups. The negative predictive value for our cohort (97.9%) was similar to published data. CONCLUSIONS: Data from our predominantly-Hispanic/Latinx cohort suggest that Afirma performs similarly in Hispanic/Latinx and non-Hispanic white patients with TN-IC.

Hypotension on cardiopulmonary stress test predicts 90 day mortality after LVAD implantation in INTERMACS 3-6 patients.

AIMS: Cardiopulmonary stress test (CPX) is routinely performed when evaluating patient candidacy for left ventricular assist device (LVAD) implantation. The predictive value of hypotensive systolic blood pressure (SBP) response during CPX on clinical outcomes is unknown. This study aims to determine the effect of hypotensive SBP response during to clinical outcomes among patients who underwent LVAD implantation. METHODS AND RESULTS: This was a retrospective single center study enrolling consecutive patients implanted with a continuous flow LVAD between 2011 and 2022. Hypotensive SBP response was defined as peak exercise SBP below the resting value. Multivariable Cox-regression analysis was performed to evaluate the relationship between hypotensive SBP response and all-cause mortality within 30 and 90 days of LVAD implantation. A subgroup analysis was performed for patients implanted with a HeartMate III (HM III) device. Four hundred thirty-two patients underwent LVAD implantation during the pre-defined period and 156 with INTERMACS profiles 3-6 met our inclusion criteria. The median age was 63 years (IQR 54-69), and 52% had ischaemic cardiomyopathy. Hypotensive SBP response was present in 35% of patients and was associated with increased 90 day all-cause mortality (unadjusted HR 9.16, 95% CI 1.98-42; P = 0.0046). Hazard ratio remained significant after adjusting for age, INTERMACS profile, serum creatinine, and total bilirubin. Findings were similar in the HM III subgroup. CONCLUSIONS: Hypotensive SBP response on pre-LVAD CPX is associated with increased perioperative and 90 day mortality after LVAD implantation. Additional studies are needed to determine the mechanism of increased mortality observed.