Can we screen for heart disease in children at public health centres? A multicentre observational study of screening for heart disease with a risk of sudden death in children.

Sudden cardiac death in children is a rare event, but of great social significance. Generally, it is related to heart disease with a risk of sudden cardiac death (SCD), which may occur with cardiovascular symptoms and/or electrocardiographic markers; thus, a primary care paediatrician (PCP) could detect them. Therefore, we proposed a study that assesses how to put into practice and conduct a cardiovascular assessment within the routine healthy-child check-ups at six and twelve years of age; that reflects cardiovascular signs and symptoms, as well as the electrocardiographic alterations that children with a risk of SCD in the selected population present; and that assesses the PCP's skill at electrocardiogram (ECG) interpretation. In collaboration with PCPs, primary care nurses, and paediatric cardiologists, an observational, descriptive, multicentre, cross-sectional study was carried out in the Balearic Islands (Spain), from April 2021 to January 2022, inclusive. The PCPs gathered patient data through forms (medical record, electrocardiogram, and physical examination) and sent them to the investigator, together with the informed consent document and electrocardiogram. The investigator passed the electrocardiogram on to the paediatric cardiologists for reading, in an identical form to those the paediatricians had filled in. The variables were collected, and a descriptive analysis performed. Three paediatric cardiologists, twelve PCPs, and nine nurses from seven public health centres took part. They collected the data from 641 patients, but 233 patients did not participate (in 81.11% due to the PCP's workload). Therefore, the study coverage was around 64%, representing the quotient of the total number of patients who participated, divided by the total number of patients who were eligible for the study. We detected 30 patients with electrocardiographic alterations compatible with SCD risk. Nine of these had been examined by a paediatric cardiologist at some time (functional murmur in 8/9), five had reported shortness of breath with exercise, and four had reported a family history of sudden death. The physical examination of all the patients whose ECG was compatible with a risk of SCD was normal. Upon analysing to what extent the ECG results of the PCP and the paediatric cardiologist agreed, the percentage of agreement in the final interpretation (normal/altered) was 91.9%, while Cohen's kappa coefficient was 31.2% (CI 95%: 13.8-48.6%). The sensitivity of the ECG interpretation by the PCP to detect an ECG compatible with a risk of SCD was 29% and the positive predictive value 45%.     Conclusions: This study lays the foundations for future SCD risk screening in children, performed by PCPs. However, previously, it would be important to optimise their training in reading and interpreting paediatric ECGs. What is Known: • In Spain at present, there is a programme in place to detect heart disease with a risk of sudden death [1], but it targets only children who are starting on or are doing a physical activity as a federated sport. Implementing such screening programmes has proven effective in several countries [2]. However, several studies showed that the incidence of sudden cardiac death is no higher in children competing in sport activities than in those who do not do any sport [3]. This poses an ethical conflict, because at present, children who do not do any federated sport are excluded from screening. According to the revised literature, so far, only in two studies did they screen the child population at schools, and in both, they successfully detected patients with heart disease associated to the risk of sudden death [4, 5]. We have found no studies where the screening of these features was included within the routine healthy-child check-ups by primary care paediatricians. What is New: • We did not know whether-in our setting, at present-the primary care paediatrician could perform a screening method within the routine healthy-child check-ups, in order to detect presumably healthy children at risk of sudden cardiac death, as they present one of the SCD risks. In this regard, we proposed our project: to assess how to put into practice and conduct a cardiovascular assessment via SCD risk screening in the healthy child population by primary care paediatricians and appraise primary care paediatricians' skills in identifying the electrocardiographic alterations associated with SCD risk. The ultimate intention of this pilot study was to make it possible, in the future, to design and justify a study aimed at universalising cardiovascular screening and achieving a long-term decrease in sudden cardiac death events in children.

The muscle regeneration marker FOXP3 is associated with muscle injury in Duchenne muscular dystrophy.

BACKGROUND: In Duchenne muscular dystrophy (DMD), the immune system cells (ISC) synthesize molecules to regulate inflammation, a process needed to regenerate muscle. The relationship between those molecules and the muscle injury is unknown. Monocytes belonging to ISC are regulated by omega-3 fatty acids (ω-3 LCPUFAs) in DMD, but whether those fatty acids influence other ISC like T-cells is unknown. OBJECTIVE: We analyzed the expression of the muscle regeneration markers (FOXP3 and AREG) in circulating leukocytes of DMD patients with different lower limb muscle functions and whether ω-3 LCPUFAs regulate the expression of those markers, and the populations of circulating T-cells, their intracellular cytokines, and disease progression (CD69 and CD49d) markers. METHODS: This placebo-controlled, double-blind, randomized study was conducted in DMD boys supplemented with ω-3 LCPUFAs (n = 18) or placebo (sunflower oil, n = 13) for six months. FOXP3 and AREG mRNA expression in leukocytes, immunophenotyping of T-cell populations, CD49d and CD69 markers, and intracellular cytokines in blood samples were analyzed at baseline and months 1, 2, 3, and 6 of supplementation. RESULTS: Patients with assisted ambulation expressed higher (P = 0.015) FOXP3 mRNA levels than ambulatory patients. The FOXP3 mRNA expression correlated (Rho = -0.526, P = 0.03) with the Vignos scale score at month six of supplementation with ω-3 LCPUFAs. CD49d + CD8 + T-cells population was lower (P = 0.037) in the ω -3 LCPUFAs group than placebo at month six of supplementation. CONCLUSION: FOXP3 is highly expressed in circulating leukocytes of DMD patients with the worst muscle function. Omega-3 LCPUFAs might modulate the synthesis of the adhesion marker CD49d + CD8 + T-cells, but their plausible impact on FOXP3 needs more research.

Pro-inflammatory monocytes are increased in Duchenne muscular dystrophy and suppressed with omega-3 fatty acids: A double-blind, randomized, placebo-controlled pilot study.

BACKGROUND: Omega-3 long chain polyunsaturated fatty acids (LCPUFA) reduce circulating cytokines produced by monocytes. Nevertheless, whether the omega-3 LCPUFA regulate the monocytes and their cytokines in Duchenne muscular dystrophy (DMD) is unknown. The aim of this study was to evaluate whether circulating pro-inflammatory monocytes are increased and whether omega-3 LCPUFA selectively suppress these monocytes and their cytokines in patients with DMD. METHODS: This was a double-blind, randomized, placebo-controlled pilot study carried out in patients with DMD supplemented with omega-3 LCPUFA (n = 6) or sunflower oils (placebo, n = 6) for 6 months. Monocytes and their cytokines were measured at baseline and after 1, 2, 3, and 6 months of supplementation. RESULTS: The anti-inflammatory monocytes (median, [95% CI]) are increased at month 3 (-0.46 [-13.5-9.5] vs. 8.4 [5.5-12.5], p = 0.05) in the omega-3 LCPUFA group compared with the placebo group. The pro-inflammatory monocytes (-5.7 [-63.8-114.1] vs. -51.9 [-91.2 to -25.4], p = 0.026 and -16.4 [-50.8-50.6] vs. -57.9 [-86.9 to -18.5], p = 0.045 at months 3 and 6, respectively) and their cytokine interleukin 6 (-11.9 [-93.5-148.9] vs. -64.7 [-77.8 to -42.6], p = 0.019 at month 6) decreased in the omega-3 LCPUFA group compared with the placebo group. Pro-inflammatory monocytes decreased and anti-inflammatory monocytes were augmented (p < 0.05) during the 6 months of supplementation with omega-3 LCPUFA. CONCLUSIONS: This pilot study suggests that supplementation with omega-3 LCPUFA could have a selective reductive effect on pro-inflammatory monocytes and their cytokines in patients with DMD. These findings also support the performance of studies in a significant population to explore the role of omega-3 LCPUFA on monocyte populations and their cytokines in patients with DMD. This research was registered at clinicaltrials.gov (NCT018264229).

Circulating markers of oxidative stress are associated with a muscle injury in patients with muscular dystrophy Duchenne.

BACKGROUND: A small number of studies have confirmed the presence of oxidative damage in patients with Duchenne muscular dystrophy (DMD). Nevertheless, it is unknown if there a relationship of circulating markers of oxidative stress with a muscle injury. OBJECTIVE: We evaluated if oxidative damage and anti-oxidant markers are associated with muscle damage in DMD. METHODS: This cross-sectional study included 24 patients with DMD classified in ambulatory and non-ambulatory. Markers of muscle damage (creatine kinase [CK]), oxidative damage (malondialdehyde [MDA], and 8-isoprostane), anti-oxidant function (Thiol and mRNA of NRF2 and NF-κB) and nitric oxide (NO) were quantified in circulation. RESULTS: Total NO, MDA, and 8-isoprostane concentrations were significantly (p < 0.05) higher, and thiol concentration was lower in non-ambulatory than ambulatory patients. A significant correlation (p < 0.05) between muscle injury (evaluated by Vignos scale) with CK (r = -0.382), NO (r = 0.444), MDA (r = 0.503), 8-isoprostanes (r = 0.435) and thiol (r = -0.430) was observed. CONCLUSION: These findings suggest that non-ambulatory have high oxidative damage and low anti-oxidant function than ambulatory patients with DMD. Total nitric oxide and oxidative damage plasma markers increase, but the anti-oxidant marker thiol decreases with a muscle injury in boys with DMD. The findings of this study suggest that these markers could be considered as goods indicators of oxidative damage in longitudinal studies to evaluate the muscle injury during DMD progression. Additionally, these findings add new information about the pathophysiology of DMD.

Transient Disruption of the Inferior Parietal Lobule Impairs the Ability to Attribute Intention to Action.

Although it is well established that fronto-parietal regions are active during action observation, whether they play a causal role in the ability to infer others' intentions from visual kinematics remains undetermined. In the experiments reported here, we combined offline continuous theta burst stimulation (cTBS) with computational modeling to reveal and causally probe single-trial computations in the inferior parietal lobule (IPL) and inferior frontal gyrus (IFG). Participants received cTBS over the left anterior IPL and the left IFG pars orbitalis in separate sessions before completing an intention discrimination task (discriminate intention of observed reach-to-grasp acts) or a kinematic discrimination task unrelated to intention (discriminate peak wrist height of the same acts). We targeted intention-sensitive regions whose fMRI activity, recorded when observing the same reach-to-grasp acts, could accurately discriminate intention. We found that transient disruption of activity of the left IPL, but not the IFG, impaired the observer's ability to attribute intention to action. Kinematic discrimination unrelated to intention, in contrast, was largely unaffected. Computational analyses of how encoding (mapping of intention to movement kinematics) and readout (mapping of kinematics to intention choices) intersect at the single-trial level revealed that IPL cTBS did not diminish the overall sensitivity of intention readout to movement kinematics. Rather, it selectively misaligned intention readout with respect to encoding, deteriorating mapping from informative kinematic features to intention choices. These results provide causal evidence of how the left anterior IPL computes mapping from kinematics to intentions.

Current Therapeutic Options for the Main Monogenic Autoinflammatory Diseases and PFAPA Syndrome: Evidence-Based Approach and Proposal of a Practical Guide.

Monogenic autoinflammatory diseases are rare conditions caused by genetic abnormalities affecting the innate immunity. Previous therapeutic strategies had been mainly based on results from retrospective studies and physicians' experience. However, during the last years, the significant improvement in their genetic and pathogenic knowledge has been accompanied by a remarkable progress in their management. The relatively recent identification of the inflammasome as the crucial pathogenic mechanism causing an aberrant production of interleukin 1ß (IL-1ß) in the most frequent monogenic autoinflammatory diseases led to the introduction of anti-IL-1 agents and other biologic drugs as part of the previously limited therapeutic armamentarium available. Advances in the treatment of autoinflammatory diseases have been favored by the use of new biologic agents and the performance of a notable number of randomized clinical trials exploring the efficacy and safety of these agents. Clinical trials have contributed to increase the level of evidence and provided more robust therapeutic recommendations. This review analyzes the treatment of the most frequent monogenic autoinflammatory diseases, namely, familial Mediterranean fever, tumor necrosis factor receptor-associated periodic fever syndrome, hyperimmunoglobulin D syndrome/mevalonate kinase deficiency, and cryopyrin-associated periodic syndromes, together with periodic fever with aphthous stomatitis, pharyngitis, and cervical adenitis syndrome, which is the most common polygenic autoinflammatory disease in children, also occurring in adult patients. Finally, based on the available expert consensus recommendations and the highest level of evidence of the published studies, a practical evidence-based guideline for the treatment of these autoinflammatory diseases is proposed.

Modulation of corticospinal output during goal-directed actions: Evidence for a contingent coding hypothesis.

Seeing a person perform an action activates the observer's motor system. The present study aimed at investigating the temporal relationship between execution and observation of goal-directed actions. One possibility is that the corticospinal excitability (CSE) follows the dynamic evolution of the pattern of muscle activity in the executed action. Alternatively, CSE may anticipate the future course of the observed action, prospectively extrapolating future states. Our study was designed to test these alternative hypotheses by directly comparing the time course of muscle recruitment during the execution and observation of reach-to-grasp movements. We found that the time course of CSE during action observation followed the time course of the EMG signal during action execution. This contingent coding was observed despite the outcome of the observed motor act being predictable from the earliest phases of the movement. These findings challenge the view that CSE serves to predict the target of an observed action.

The kinematics that you do not expect: Integrating prior information and kinematics to understand intentions.

Expectations facilitate perception of expected stimuli but may hinder perception of unexpected alternatives. Here, we consider how prior expectations about others' intentions are integrated with visual kinematics over time in detecting the intention of an observed motor act (grasp-to-pour vs. grasp-to-drink). Using rigorous psychophysics methods, we find that the processes of ascribing intentions to others are well described by drift diffusion models in which evidence from observed movements is accumulated over time until a decision threshold is reached. Testing of competing models revealed that when kinematics contained no discriminative intention information, prior expectations predicted the intention choice of the observer. When kinematics contained intention information, kinematics predicted the intention choice. These findings provide evidence for a diffusion process in which the influence of expectations is modulated by movement informativeness and informative kinematics can override initial expectations.

Movement kinematics drive chain selection toward intention detection.

The ability to understand intentions based on another's movements is crucial for human interaction. This ability has been ascribed to the so-called motor chaining mechanism: anytime a motor chain is activated (e.g., grasp-to-drink), the observer attributes to the agent the corresponding intention (i.e., to drink) from the first motor act (i.e., the grasp). However, the mechanisms by which a specific chain is selected in the observer remain poorly understood. In the current study, we investigate the possibility that in the absence of discriminative contextual cues, slight kinematic variations in the observed grasp inform mapping to the most probable chain. Chaining of motor acts predicts that, in a sequential grasping task (e.g., grasp-to-drink), electromyographic (EMG) components that are required for the final act [e.g., the mouth-opening mylohyoid (MH) muscle] show anticipatory activation. To test this prediction, we used MH EMG, transcranial magnetic stimulation (TMS; MH motor-evoked potentials), and predictive models of movement kinematics to measure the level and timing of MH activation during the execution (Experiment 1) and the observation (Experiment 2) of reach-to-grasp actions. We found that MH-related corticobulbar excitability during grasping observation varied as a function of the goal (to drink or to pour) and the kinematics of the observed grasp. These results show that subtle changes in movement kinematics drive the selection of the most probable motor chain, allowing the observer to link an observed act to the agent's intention.

The Optimal Load for Maximal Power Production During Upper-Body Resistance Exercises: A Meta-Analysis.

BACKGROUND: External mechanical power is considered to be one of the most important characteristics with regard to sport performance. OBJECTIVE: The purpose of this meta-analysis was to examine the effect of load on kinetic variables such as mean and peak power during bench press and bench press throw, thus integrating the findings of various studies to provide the strength and conditioning professional with more reliable evidence upon which to base their program design. METHODS: A search of electronic databases (MEDLINE, PubMed, Google Scholar, and Web of Science) was conducted to identify all publications up to 31 October 2015. Hedges' g (95 % confidence interval) was estimated using a weighted random-effect model, due to the heterogeneity (I 2) of the studies. Egger's test was used to evaluate possible publication bias in the meta-analysis. A total of 11 studies with 434 subjects and 7680 effect sizes met the inclusion criterion and were included in the statistical analyses. Load in each study was labeled as one of three intensity zones: zone 1 represented an average intensity ranging from 0 to 30 % of one repetition maximum (1RM); zone 2 between 30 and 70 % of 1RM; and zone 3 ≥ 70 % of 1RM. RESULTS: These results showed different optimal loads for each exercise examined. Moderate loads (from >30 to <70 % of 1RM) appear to provide the optimal load for peak power and mean power in the bench press exercise. Lighter loads (<30 % of 1RM) appear to provide the highest mean and highest peak power production in the bench press throw exercise. However, a substantial heterogeneity was detected I 2 > 75 %. CONCLUSION: The current meta-analysis of published literature provides evidence for exercise-specific optimal power loading for upper body exercises.

Long-latency modulation of motor cortex excitability by ipsilateral posterior inferior frontal gyrus and pre-supplementary motor area.

The primary motor cortex (M1) is strongly influenced by several frontal regions. Dual-site transcranial magnetic stimulation (dsTMS) has highlighted the timing of early (<40 ms) prefrontal/premotor influences over M1. Here we used dsTMS to investigate, for the first time, longer-latency causal interactions of the posterior inferior frontal gyrus (pIFG) and pre-supplementary motor area (pre-SMA) with M1 at rest. A suprathreshold test stimulus (TS) was applied over M1 producing a motor-evoked potential (MEP) in the relaxed hand. Either a subthreshold or a suprathreshold conditioning stimulus (CS) was administered over ipsilateral pIFG/pre-SMA sites before the TS at different CS-TS inter-stimulus intervals (ISIs: 40-150 ms). Independently of intensity, CS over pIFG and pre-SMA (but not over a control site) inhibited MEPs at an ISI of 40 ms. The CS over pIFG produced a second peak of inhibition at an ISI of 150 ms. Additionally, facilitatory modulations were found at an ISI of 60 ms, with supra- but not subthreshold CS intensities. These findings suggest differential modulatory roles of pIFG and pre-SMA in M1 excitability. In particular, the pIFG -but not the pre-SMA- exerts intensity-dependent modulatory influences over M1 within the explored time window of 40-150 ms, evidencing fine-tuned control of M1 output.

The Optimal Load for Maximal Power Production During Lower-Body Resistance Exercises: A Meta-Analysis.

BACKGROUND: The development of muscular power is often a key focus of sports performance enhancement programs. OBJECTIVE: The purpose of this meta-analysis was to examine the effect of load on peak power during the squat, jump squat, power clean, and hang power clean, thus integrating the findings of various studies to provide the strength and conditioning professional with more reliable evidence upon which to base their program design. METHODS: A search of electronic databases [MEDLINE (SPORTDiscus), PubMed, Google Scholar, and Web of Science] was conducted to identify all publications up to 30 June 2014. Hedges' g (95% confidence interval) was estimated using a weighted random-effect model. A total of 27 studies with 468 subjects and 5766 effect sizes met the inclusion criterion and were included in the statistical analyses. Load in each study was labeled as one of three intensity zones: Zone 1 represented an average intensity ranging from 0 to 30% of one repetition maximum (1RM); Zone 2 between 30 and 70% of 1RM; and Zone 3 ≥70% of 1RM. RESULTS: These results showed different optimal loads for each exercise examined. Moderate loads (from >30 to <70% of 1RM) appear to provide the optimal load for power production in the squat exercise. Lighter loads (≤30% of 1RM) showed the highest peak power production in the jump squat. Heavier loads (≥70% of 1RM) resulted in greater peak power production in the power clean and hang power clean. CONCLUSION: Our meta-analysis of results from the published literature provides evidence for exercise-specific optimal loads for power production.