Left Ventricle Size Correlates with Peak Exercise Capacity in Pediatric Cancer Survivors Exposed to Anthracycline Chemotherapy.

Cancer survivors exposed to anthracycline chemotherapy are at risk for developing cardiomyopathy, which may have delayed clinical manifestation. In a retrospective cross-sectional study, we evaluated the utility of cardiopulmonary exercise testing (CPET) for detecting early cardiac disease in 35 pediatric cancer survivors by examining the associations between peak exercise capacity (measured via percent predicted peak VO2) and resting left ventricular (LV) function on echocardiography and cardiac magnetic resonance imaging (cMRI). We additionally assessed the relationships between LV size on resting echocardiography or cMRI and percent predicted peak VO2 since LV growth arrest can occur in anthracycline-exposed patients prior to changes in LV systolic function. We found reduced exercise capacity in this cohort, with low percent predicted peak VO2 (62%, IQR: 53-75%). While most patients in our pediatric cohort had normal LV systolic function, we observed associations between percent predicted peak VO2 and echocardiographic and cMRI measures of LV size. These findings indicate that CPET may be more sensitive in manifesting early anthracycline-induced cardiomyopathy than echocardiography in pediatric cancer survivors. Our study also highlights the importance of assessing LV size in addition to function in pediatric cancer survivors exposed to anthracyclines.

Everolimus for cardiac rhabdomyomas in children with tuberous sclerosis. The ORACLE study protocol (everOlimus for caRdiac rhAbdomyomas in tuberous sCLErosis): a randomised, multicentre, placebo-controlled, double-blind phase II trial.

INTRODUCTION: Tuberous sclerosis complex is a rare genetic disorder leading to the growth of hamartomas in multiple organs, including cardiac rhabdomyomas. Children with symptomatic cardiac rhabdomyoma require frequent admissions to intensive care units, have major complications, namely, arrhythmias, cardiac outflow tract obstruction and heart failure, affecting the quality of life and taking on high healthcare cost. Currently, there is no standard pharmacological treatment for this condition, and the management includes a conservative approach and supportive care. Everolimus has shown positive effects on subependymal giant cell astrocytomas, renal angiomyolipoma and refractory seizures associated with tuberous sclerosis complex. However, evidence supporting efficacy in symptomatic cardiac rhabdomyoma is limited to case reports. The ORACLE trial is the first randomised clinical trial assessing the efficacy of everolimus as a specific therapy for symptomatic cardiac rhabdomyoma. METHODS: ORACLE is a phase II, prospective, randomised, placebo-controlled, double-blind, multicentre protocol trial. A total of 40 children with symptomatic cardiac rhabdomyoma secondary to tuberous sclerosis complex will be randomised to receive oral everolimus or placebo for 3 months. The primary outcome is 50% or more reduction in the tumour size related to baseline. As secondary outcomes we include the presence of arrhythmias, pericardial effusion, intracardiac obstruction, adverse events, progression of tumour reduction and effect on heart failure. CONCLUSIONS: ORACLE protocol addresses a relevant unmet need in children with tuberous sclerosis complex and cardiac rhabdomyoma. The results of the trial will potentially support the first evidence-based therapy for this condition.

Association Between Serial B-Type Natriuretic Peptide Levels, Vasoactive Drug Weaning, and Adverse Cardiovascular Outcomes in Pediatric Heart Failure.

BACKGROUND: Children hospitalized with acute decompensated heart failure (ADHF) frequently require intravenous vasoactive (IVV) support drugs and are at risk for adverse cardiovascular (ACV) outcomes. We wished to assess whether serial changes in B-type natriuretic peptide (BNP) levels are associated with successful weaning off IVV support and/or prespecified ACV outcomes in children hospitalized with ADHF. METHODS AND RESULTS: Children hospitalized with ADHF from 2005 to 2021 at our institution were assessed for serial changes in BNP, weaning off of IVV support, and ACV outcomes. Changes in BNP level were evaluated using linear mixed-effects modeling. Bonferroni correction was used to adjust for multiple hypothesis testing. In 131 hospitalizations of children with ADHF, the median age was 4.8 years, with 74% receiving IVV support. ACV outcomes occurred in 62 children. IVV support was associated with lower admission left ventricular ejection fraction (26.7% versus 32%, P=0.002), more severe left ventricular dilation (left ventricular internal diastolic dimension Z score 5.9 versus 3.1, P=0.021) moderate or more mitral regurgitation (41.3% versus 20.6%, P=0.038), and qualitative right ventricular systolic dysfunction (in 45.4% versus 11.8%, P<0.001). Decline in BNP levels was more rapid in patients who were successfully weaned from IVV support (-0.20 versus -0.03 2log pg/mL per day, P<0.001) and in the non-ACV group (-0.17 versus -0.03 2log pg/mL per day, P<0.001). Right ventricular systolic dysfunction was an independent risk factor for ACV (odds ratio, 2.49; P=0.045). CONCLUSIONS: The declining rate of serial BNP levels was associated with weaning from IVV support and no ACV outcomes in children hospitalized with ADHF. Right ventricular systolic dysfunction was associated with ACV outcomes.

The impact of education level and socioeconomic status on the association between depressive symptoms and memory in an older population in Latin America: An exploratory analysis from the Brazilian Longitudinal Study of Aging (ELSI-BRAZIL).

Purpose: The globally increasing older population raises concerns about age-related conditions, including cognitive impairment and depressive symptoms. In Latin America, nearly one-third of the population is affected by either of these conditions. However, data investigating the association between cognitive impairment and depressive symptoms, particularly in Brazil, are limited to small-scale studies that have not carefully examined the critical effects of variables such as education level and socioeconomic status on this relationship. We aimed at exploring this association in a representative population-based cohort. Methods: We used the Brazilian Longitudinal Study of Aging (ELSI-BRAZIL) database to examine the relationship between depressive symptoms and cognitive impairment in Brazilian older adults, adjusted for potential confounders. Direct acyclic graphs and multivariable linear regression were used to build our model. Depressive symptoms were measured using a short version of the Center for Epidemiologic Studies Scale (CES D-8), and combined memory recall test as a surrogate of cognitive impairment. Results: The study included 8280 participants. Only education level was identified as a confounder for the relationship between memory loss and depressive symptoms. After adjusting for age, sex, and education level, there was strong evidence for a negative association between depressive symptoms and memory performance. For every 5-unit increase in the CES D-8 score, there was a reduction in memory capacity, translating to a loss of approximately one word in the combined words recall test (mean - 0.18, 95% CI -0.22; -0.15, P < 0.001). In addition, we found strong evidence for an interaction between socioeconomic status and depressive symptoms. Subjects belonging to medium socioeconomic status (SES) showed more pronounced memory decline, when compared to those with lower SES (mean - 0.28, 95% CI -0.42 to -0.14, P < 0.001). Conclusions: In adults aged over 50, after adjusting for sex, age, and educational level, a 5-unit increase in CES D-8 score is associated with loss of one point in the combined memory recall test. This association seems to be confounded by educational level and significantly modified by socioeconomic status.

Observational Studies: Specific Considerations for the Physical and Rehabilitation Medicine Physician.

ABSTRACT: The development of high-quality research is desired in all healthcare fields. Experimental and nonexperimental designs are used to investigate the effect or association of an intervention and clinical or surrogate outcome. The aims of these methods are to improve knowledge and to develop new strategies to manage a disease or condition. Randomized clinical trials are considered one of the standard methods to test the efficacy of a new drug or intervention; however, they are costly, have reduced generalizability, and cannot be feasible in all scenarios. Well-designed observational studies can provide valuable information regarding exposure factor and the event under investigation. In physical and rehabilitation medicine, where complex procedures and multiple risk factors can be involved in the same disease, the use of observational study must be planned in detail and a priori to avoid overestimations. In this article, we will give an overview of the methods used for observational design studies in physical and rehabilitation medicine using clinical examples to illustrate each method. We will describe when it is appropriate and how to use the observational studies in different scenarios explaining how to deal with potential bias and confounders using the adequate design and statistical plan for the situation.

Recent and Upcoming Drug Therapies for Pediatric Heart Failure.

Pediatric heart failure (HF) is an important clinical condition with high morbidity, mortality, and costs. Due to the heterogeneity in clinical presentation and etiologies, the development of therapeutic strategies is more challenging in children than adults. Most guidelines recommending drug therapy for pediatric HF are extrapolated from studies in adults. Unfortunately, even using all available treatment, progression to cardiac transplantation is common. The development of prospective clinical trials in the pediatric population has significant obstacles, including small sample sizes, slow recruitment rates, challenging endpoints, and high costs. However, progress is being made as evidenced by the recent introduction of ivabradine and of sacubitril/valsartan. In the last 5 years, new drugs have also been developed for HF with reduced ejection fraction (HFrEF) in adults. The use of well-designed prospective clinical trials will be fundamental in the evaluation of safety and efficacy of these new drugs on the pediatric population. The aim of this article is to review the clinical presentation and management of acute and chronic pediatric heart failure, focusing on systolic dysfunction in patients with biventricular circulation and a systemic left ventricle. We discuss the drugs recently approved for children and those emerging, or in use for adults with HFrEF.