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Cardiac Troponins in Kidney Disease.
Get PDFCardiovascular disease is a major cause of morbidity and mortality in individuals with kidney disease. In recent years, biomarkers such as cardiac troponins have become indispensable to the diagnosis and prognosis of cardiac disease, such as MI and heart failure. However, these biomarkers behave differently in the general population compared with people with kidney disease, who may have higher baseline levels and reactions to acute disturbance due to a combination of reduced renal clearance of biomarker molecules and increased production due to concurrent cardiovascular disease and cardiorenal syndrome. Three decades of research into cardiac biomarkers have produced a range of literature investigating their applications in different patient groups and healthcare settings. This review explores the evidence surrounding measurement and interpretation of cardiac troponin levels in people who have chronic kidney disease, and have had dialysis and/or kidney transplantation, with reference to baseline levels and changes over time, their relationship to incident cardiovascular morbidity and mortality, and their application in acute settings
Breast Cancer Myths, Mysterious Miracles and Mistrust among Rural Womenfolk in Sarawak
Get PDFBACKGROUND: Sarawak hospitals report high rates of advanced cancer among women in remote rural areas. Cultural beliefs, low awareness, socio-economic challenges, geographical barriers, and the lack of specialist cancer care contribute to late diagnoses, particularly in breast cancer, exacerbating disparities in access to timely treatment. OBJECTIVE: This study aimed to explore cultural beliefs, barriers, and healthcare access challenges influencing breast cancer awareness and screening among Sarawak's indigenous and rural communities. METHODS: This qualitative study explores how rural Sarawakian women perceive breast cancer and their access to healthcare. Twenty women from three main geographical terrains in Borneo-coastal, riverine, and highland areas participated in the study. After informed consent was obtained, semi-structured interviews were conducted. Data was coded and thematically analyzed to identify cultural nuances affecting their knowledge. RESULTS: The study found a strong link between cancer and negative beliefs rooted in sociocultural backgrounds. Myths varied, but most associated cancer with death, a fatalistic culture relying on spiritual faith for healing. Participants delayed seeking medical help until "the pain is unbearable," often using oils and herbs first. Lack of knowledge and lack of access to information about cancer are two main findings from the study. Although the majority of the respondents were not equipped with adequate information, they expressed interest in learning about breast screening programs and attending breast cancer awareness campaigns. CONCLUSION: The findings will be used to design behavioral intervention modules to educate rural Sarawak populations about the importance of breast self-examination (BSE) practices, early detection, and screening
Targeting Recipient Dendritic Cells with Sialic Acid-Modified Donor Alloantigen Prolongs Skin Transplant Survival
Get PDFMature dendritic cells (DCs) are known to activate effector immune responses, whereas steady state immature DCs can induce tolerance. Several studies have targeted immature murine quiescent DCs in vivo with antigen, including donor alloantigens, for the induction of tolerance. Receptors expressed by specific DC subsets have been also targeted with antibodies linked with antigens to induce tolerance; for instance, in vivo targeting of the DCIR2+ DC subset with donor alloantigen resulted in long-term survival of heart and skin transplants. DCs also express sialic acid immunoglobulin-like lectin (Siglec) receptors, and these have been successfully targeted with myelin oligiodendrocyte glycoprotein (MOG) antigen to induce tolerance in experimental autoimmune encephalomyelitis (EAE). We investigated, in a mismatched model of skin transplant (B6Kd into B6 recipient mice), whether targeting a sialylated alloantigen Kd (Sia-Kd) to Siglecs on recipient DCs promoted transplant survival. The injection of α2,3 Sia-Kd into B6 recipient mice prior to B6Kd skin transplantation, by binding to Batf3 dependent DCs, resulted in prolonged skin graft survival and an increase in CD4+CD62L+Foxp3+ Tregs. Targeting Siglecs on DC subsets in vivo represents a novel way of improving transplant survival
Recent-onset atrial fibrillation: challenges and opportunities
Get PDFAtrial fibrillation (AF) is increasingly diagnosed early, close to its first occurrence due to: (i) increased public awareness with self-screening; (ii) health care initiatives including population screening and opportunistic case finding; and (iii) increased use and surveillance of implantable cardiac devices. At its onset, AF is often low burden, and cardiovascular co-morbidities may be absent or at an early stage. Thus, the management of recent-onset AF has become an issue of growing importance. Professional guidelines have traditionally focused on anticoagulant thromboprophylaxis, generally recommending a cautious approach to rhythm control, and priority has been given to rate control to alleviate symptoms. In recent guidelines, the importance of managing lifestyle and co-morbidities has increased. The AF-SCREEN collaboration proposes that a vigorous approach to active management of recent-onset AF may be warranted. This includes addressing co-morbidities and promoting healthy lifestyles to prevent the emergence or progression of AF and associated cardiovascular disease, as well as the initiation of active rhythm control ± anticoagulation to prevent AF-related morbidity and mortality, including stroke and heart failure (HF). Intuitively, intervention early after AF onset would be beneficial since lifestyle and co-morbidity management, plus rhythm control and anticoagulation, are important contributors to improved outcomes in patients with established AF, but robust evidence is lacking for recent-onset AF. There is a delicate balance between achieving favourable outcomes such as preventing strokes, HF and AF progression vs the complications and potential adverse effects of interventions. Given the serious long-term consequences, innovative approaches are necessary to determine the value and risks of initiating active therapy very early in the course of AF. More data are needed to guide the best management of recent-onset AF, bearing AF burden in mind. Long-term studies using large national databases linked to electronic medical records and rhythm monitoring devices offer excellent opportunities. Shorter-term studies focusing on reducing AF burden to slow AF progression and studies focusing on outcomes such as HF could be used in both randomized clinical trials and observational cohort studies
Atrial cardiomyopathy: From healthy atria to atrial failure. A clinical consensus statement of the Heart Failure Association of the ESC
Get PDFThe importance of atrial cardiomyopathy (AtCM) as a specific clinical entity is increasingly recognized. Past definitions have varied, and the lack of consistent cut‐offs for imaging parameters and biomarkers have limited clinical utility to diagnose and track AtCM progression. While research has mainly focused on AtCM in the context of atrial fibrillation, emerging evidence underscores its relevance in remodelling and development of heart failure. The aim of this consensus document was to provide a contemporary framework for AtCM, evolve the definitions of AtCM and atrial failure for more widespread clinical use, and help to direct emerging research and future clinical trials. Supporting the work of early career researchers, this consensus document evaluates diagnostic markers and summarizes the underpinning mechanisms, clinical characteristics and prognostic impact of AtCM. Our objective was to bring together new translational scientific progress, catalyse future research and enable clinical application to facilitate better management, for example in patient groups where aggressive control of risk factors or comorbidities could prevent AtCM progression. We redefined AtCM as a graded disorder that includes electrical dysfunction of the atria along with evidence of either mechanical atrial dysfunction, atrial enlargement and/or atrial fibrosis. Atrial failure is the end‐stage manifestation of AtCM, characterized by progressive structural, electrophysiological and functional changes. Earlier identification, risk stratification and ongoing research into therapeutic options have the potential to prevent the clinical consequences of AtCM and atrial failure, including adverse patient outcomes and poor quality of life associated with atrial fibrillation and heart failure
Awareness, access, and adoption of natriuretic peptides for diagnosis of heart failure
Get PDFAims
This survey investigates natriuretic peptide (NP) testing in community and hospital settings, assessing awareness, accessibility, and utilization.
Methods and results
This investigator‐initiated survey, conceived within the HFA of the European Society of Cardiology, comprised 14 questions. It underwent validation and pilot testing to ensure question readability and online system functionality. The survey was accessible for 87 days, from 5 April 2023 to 1 July 2023 via a web platform. There were 751 healthcare professionals across 99 countries who responded. Of them, 92.5% had access to NPs testing in hospital whereas 34.3% had no access to NTproBNP in community settings. Access to point of care NP testing was uncommon (9.6%). Public insurance fully covered NPs testing in 31.0% of cases, with private insurance providing coverage in 37.9%. The majority (84.0%) of participants believed that the medical evidence supporting NPs testing was strong, and 54.7% considered it cost‐effective. Also, 35.8% found access, awareness, and adoption to be in favour of NPs testing both in hospital and community settings. Strategies to optimize NP testing involved regular guideline updates (57.9%), prioritizing NPs testing for dyspnoea assessment (36.4%), and introducing clinician feedback mechanisms (21.2%). Notably, 40% lacked a community‐based HF diagnostic pathway for referring high‐NP patients for echocardiography and cardiology evaluation.
Conclusions
This survey reveals NP awareness, access, and adoption across several countries. Highlighting the importance of community‐based early heart failure diagnosis and optimizing HF diagnostic pathways remains a crucial, unmet opportunity to improve patient outcomes
Elastic intramedullary nailing: a viable solution to stabilise adult humeral diaphyseal fractures? A systematic review
No full textPURPOSE: Conservatively managed diaphyseal humeral fractures have demonstrated higher non-union rates than previously reported and there are drawbacks to functional bracing. There is a growing trend towards operative management of these injuries, yet there are several complications associated with current operative methods. This systematic review aimed to evaluate the role of elastic stable intramedullary nailing (ESIN) as a solution to mitigate these risks. METHODS: A systematic review and meta-analysis was performed using PubMed, EMBASE, MEDLINE and Cochrane databases. Methodology followed the Preferred Reporting Items for Systematic Reviews. Papers were screened using the screenatron SR software. Any differences of opinion regarding study inclusion were resolved through consultation with senior authors DT and AT. Data and outcomes were synthesised by two independent reviewers, and papers were assessed for bias and quality. RESULTS: Nine studies encompassing 264 patients, at a mean age of 40 years old were analysed with a mean follow-up of 17 months. The majority of these studies were of level four evidence (with only one study being level three). Two elastic nails were retrogradely inserted in most cases. Two hundred fifty-eight (98%) of patients achieved union, the average time to union was 14 weeks. Studies demonstrated satisfactory, if not 'good to excellent' results across all, albeit heterogenous, measured outcomes. A low rate of complications such as radial nerve palsy and infection were found. CONCLUSION: Current evidence supports the potential for increased use of ESIN for humeral shaft fracture management in adults. However, this study would encourage the further investigation of its efficacy through the development of a formalised surgical technique and the promotion of more high-quality comparative studies
Prevalence, trends and outcomes from smoking in elective surgical systems: a secondary analysis of a prospective observational cohort study across 442 hospitals from 29 countries across Europe
Get PDFBACKGROUND: Smoking remains a significant public health issue in Europe, with elective surgery offering a key opportunity for intervention. Knowledge gaps exist around its prevalence and the optimal timing for preoperative cessation to improve outcomes, despite current guidelines recommend smoking cessation up to six weeks prior to surgery. This study aims to address this gap in a large observational prospective cohort study of patients undergoing abdominal surgery across Europe. METHODS: We performed a pre-planned secondary analysis of a prospective, international cohort study of patients undergoing elective abdominal surgery between January 24, and May 03, 2022. The primary measure was smoking status and secondary measures were prevalence by age, gender, and number of long-term conditions. Multilevel logistic regression was used to explain the relationship between preoperative smoking status on postoperative overall (primary outcome) and major (secondary outcome) complications. Three-level models were constructed with patients nested within hospitals and countries. FINDINGS: 16,327 patients from 442 hospitals across 29 countries were included. 3179 patients (19.5%, 95% confidence interval (CI): 18.9%-20.1%) were current smokers, ranging from 8.3% to 31.7% across the included countries. Rates of current smokers were higher in younger patients (18-40 vs 41-60 vs 61-80 vs ≥ 81 years: 26.8% [95% CI: 24.8%-28.9%] vs 25.3% [95% CI: 24.2%-26.4%] vs 15.1% [95% CI: 14.3%-16.0%] vs 5.2% [95% CI: 4.0%-6.8%]), male patients (compared to females: 22.1% [95% CI: 22.0%-23.1%] vs 17.2% [95% CI: 16.5%-18.0%]) and healthy adults (compared to one or two long-term conditions: 24.6% [95% CI: 23.2%-25.9%] vs 19.6% [95% CI: 18.6%-20.7%] vs 16.6% [95% CI: 15.8%-17.5%]). 30-day overall complications were higher across current (OR: 1.14; 95% CI: 1.03-1.27), ex-smoker 1 year (1.13, 1.02-1.26) compared to never smokers. No difference was seen for 30-day major complications across these groups. INTERPRETATION: The high prevalence of smoking among elective surgical patients, especially in younger, healthy patients, expose a need to strengthen preoperative cessation strategies. Although uncertainty exist around perioperative outcomes, smoking cessation in the perioperative window is a good opportunity to reach people for long-term health promotion. Embedding high-value strategies into elective surgical systems may serve as a model for broader healthcare reforms, leading to more efficient, preventive care across the entire health system. FUNDING: The Student Audit and Research in Surgery collaborative is supported with a Strategic Partnership with BJS Society. SKK was funded by the NIHR Doctoral Research Fellowship (NIHR303288)
Functional Capacity Evaluation and Rehabilitation Strategies in Cardiac Amyloidosis: A Comprehensive Review
Get PDFCardiac amyloidosis (CA) is an increasingly recognized cause of restrictive cardiomyopathy characterized by amyloid fibril deposition in the heart, leading to severe functional impairments and poor prognosis. This review aims to provide a comprehensive overview of the pathophysiology of CA, emphasizing the mechanisms underlying functional capacity limitations and highlighting the importance of precise physiological assessment tools. We focus on objective measures such as cardiopulmonary exercise testing, field-based functional tests, and frailty evaluations that are vital for prognosis and tailoring patient care. With recent advances in disease-modifying therapies extending survival, maintaining and improving functional status through multidisciplinary rehabilitation emerges as a crucial therapeutic target. Evidence suggests that structured aerobic and resistance training can enhance exercise tolerance, strength, and quality of life in CA patients, although further research is needed to optimize rehabilitation protocols. By integrating clinical, physiological, and rehabilitative insights, this review underscores the value of a patient-centered approach aimed at preserving functional capacity and improving outcomes in this complex and systemic disease
Current antibiotic and prophylactic antifungal drug policies in UK neonatal intensive care units: a national survey
Get PDFObjectives
To survey the current antibiotic and antifungal drug practices of UK neonatal intensive care units (NICUs), and to identify antibiotic preferences and policies for treatment of early- and late-onset sepsis (EoS and LoS), meningitis, and antifungal prophylaxis.
Methods
Between January and May 2024, we contacted all 53 tertiary-level UK NICUs via telephone and/or e-mail. We requested a copy of each unit’s guidelines for antibiotic treatment of EoS and LoS, and antifungal prophylaxis.
Results
We obtained guidelines from 53/53 (100%) units. A penicillin and aminoglycoside combination was the consistent first-line recommendation for EoS in 51/53 (96%) units. Only a minority (11/53; 21%) units specified any second-line antibiotic regimen for EoS, though most (44/53; 83%) specifically recommended amoxicillin for suspected listeriosis. For LoS, almost all NICUs (52/53; 98%) provided specific guidance on empirical first-line antibiotic treatment, with empirical narrow-spectrum antibiotics as first-line LoS treatment for term neonates in 42/53 (79%) NICUs and for preterm neonates in 41/53 (77%) NICUs. Fifty-four percent (29/53) of units included specific LoS recommendations for neonates with indwelling central venous catheters. Sixty-six percent (35/53) of NICUs included cefotaxime in their empirical meningitis regimens. Eighty-five percent (45/53) of units had clear guidelines for antifungal prophylaxis.
Conclusions
While EoS treatment was consistent across units, there remained wide variation in antibiotic regimens used for LoS and meningitis, and for neonates with indwelling central venous catheters. Guidelines specific to preterm neonates were limited. The practice of routine antifungal prophylaxis has been more prevalent since the last UK survey in 2006–07 but is still neither universal nor consistent
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