Diabetic cardiomyopathy: from the pathophysiology of the cardiac myocytes to current diagnosis and management strategies

Diabetic cardiomyopathy (DCM), although a distinct clinical entity, is also a part of the diabetic atherosclerosis process. It may be independent of the coexistence of ischemic heart disease, hypertension, or other macrovascular complications. Its pathological substrate is characterized by the presence of myocardial damage, reactive hypertrophy, and intermediary fibrosis, structural and functional changes of the small coronary vessels, disturbance of the management of the metabolic cardiovascular load, and cardiac autonomic neuropathy. These alterations make the diabetic heart susceptible to ischemia and less able to recover from an ischemic attack. Arterial hypertension frequently coexists with and exacerbates cardiac functioning, leading to the premature appearance of heart failure. Classical and newer echocardiographic methods are available for early diagnosis. Currently, there is no specific treatment for DCM; targeting its pathophysiological substrate by effective risk management protects the myocardium from further damage and has a recognized primary role in its prevention. Its pathophysiological substrate is also the objective for the new therapies and alternative remedies

Neurology of Covid-19

The authors will present a comprehensive account of the neurological aspects of SARS-CoV-2 infection. The aim is to provide a practical clinical book which will serve as a guide for clinicians from all specialties involved in the management of COVID-19 patients. The authors share the extensive clinical experience gained in major hospitals in Lombardy, the first European region to face the COVID-19 emergency in 2020. All are recognized international experts in their respective fields and have been involved in the management of COVID-19 cases from the very beginning of the Italian SARS-CoV-2 outbreak. The text begins with a description of pathobiological and pathophysiological aspects related to the involvement of the nervous system, moving on to the discussion of the neurological complications observed in COVID-19 patients; these range from central to peripheral symptoms, and can occur in the acute or post-acute phases of the disease. Further topics are: neuropathology, seizures and EEG, neuroimaging, delirium, encephalomyelitis, stroke, psychopathology and psychiatry, neuropsychology and cognitive impairment, neuromuscu-lar disorders, and the impact of COVID-19 on other pre-existing neurological disorders. In addi-tion, the book will discuss the new developments in teleneurology approaches, which have been a direct response to the ongoing pandemic. Finally, the possible neurological complications of the COVID-19 vaccines and the neurological complications in children will be considered.Each chapter will present a critical review of the existing literature concerning the specific subject matter, followed by practical clinical recommendations, as well as personal considerations based on the experience gained by each author during the course of the COVID-19 pandemic. Neurology of COVID-19 will be an original and innovative reference book for clinicians of all the specialties involved in the management of patients with SARS-CoV-2 infection.illustrato

New Technologies for the Treatment of Coronary and Structural Heart Diseases

There has been significant progress in the field of interventional cardiology, from the development of newer devices to newer applications of technology, resulting in improved cardiovascular outcomes. The goal of this Special Issue is to update practicing clinicians and provide a comprehensive collection of original articles, reviews, and editorials. To this end, we invited state-of-the-art reviews, including reviews of new technology and therapeutics, as well as original research in this area to be considered for inclusion in this issue. Examples include the history and evolution of interventional techniques, reviews of specific devices and technologies for coronary artery disease (i.e., stent technology, atherectomy devices, coronary physiology, intracoronary imaging, and robotics), structural heart diseases (i.e., ASD: atrial septal defect; LAAC: left atrial appendage closure; MC: MitraClip; PFO: patent foramen ovale; TAVI: transcatheter aortic valve implantation), advances in the management of challenging coronary anatomy, new biomarkers of cardiovascular disease (noncoding RNAs, etc.), and interventional techniques in the management of heart failure, peripheral arterial diseases, and pulmonary embolism. This Special Issue presents the most recent advances in the field of coronary and structural heart diseases as well as their implications for future patient care

Awakenings: An Equine Assisted Learning Research Project

Objective. The purpose of this pilot study was to determine if and how the Awakenings Equine Assisted Learning program was effective at improving the professionalism, confidence, communication skills and adaptability of students preparing for careers as Anesthesiologist Assistants. Background. Equine Assisted Learning (EAL) is a rapidly growing experiential model that utilizes horses to enhance participants\u27 awareness of their own non-verbal language, communication styles, projection of self-confidence and competence, and problem-solving abilities (Chandler, 2012; Green, 2012, 2013; Kane, 2012; Trotter, 2012). Methods. As a part of their regular educational and clinical rotations, first year students in the Anesthesiologist Assistant (AA) program participated in a 6- week training that included weekly, 2 -hour Equine Assisted Learning (EAL) sessions. Each session, the AA students participated in a 2- hour experiential equine assisted activity, specifically designed to address a certain target area necessary for their development as professionals in this field. The participants completed a pre and post assessment with 93 items that measured development as they relate to the EAL sessions. Results. The data was analyzed using t-tests, exploratory factor analysis, and qualitative self-reports. Confidence, empathy, awareness, and communication were the most significant factors. Conclusion. The qualitative data reinforced the quantitative findings that showed significant improvement in the objective factors as a result of the EAL sessions

Neurology of Covid-19

The authors will present a comprehensive account of the neurological aspects of SARS-CoV-2 infection. The aim is to provide a practical clinical book which will serve as a guide for clinicians from all specialties involved in the management of COVID-19 patients. The authors share the extensive clinical experience gained in major hospitals in Lombardy, the first European region to face the COVID-19 emergency in 2020. All are recognized international experts in their respective fields and have been involved in the management of COVID-19 cases from the very beginning of the Italian SARS-CoV-2 outbreak. The text begins with a description of pathobiological and pathophysiological aspects related to the involvement of the nervous system, moving on to the discussion of the neurological complications observed in COVID-19 patients; these range from central to peripheral symptoms, and can occur in the acute or post-acute phases of the disease. Further topics are: neuropathology, seizures and EEG, neuroimaging, delirium, encephalomyelitis, stroke, psychopathology and psychiatry, neuropsychology and cognitive impairment, neuromuscu-lar disorders, and the impact of COVID-19 on other pre-existing neurological disorders. In addi-tion, the book will discuss the new developments in teleneurology approaches, which have been a direct response to the ongoing pandemic. Finally, the possible neurological complications of the COVID-19 vaccines and the neurological complications in children will be considered.Each chapter will present a critical review of the existing literature concerning the specific subject matter, followed by practical clinical recommendations, as well as personal considerations based on the experience gained by each author during the course of the COVID-19 pandemic. Neurology of COVID-19 will be an original and innovative reference book for clinicians of all the specialties involved in the management of patients with SARS-CoV-2 infection.Publishe

Pacing with restoration of respiratory sinus arrhythmia improved cardiac contractility and the left ventricular output: a translational study

Introduction: Respiratory sinus arrhythmia (RSA) is a prognostic value for patients with heart failure and is defined as a beat-to-beat variation of the timing between the heart beats. Patients with heart failure or patients with permanent cardiac pacing might benefit from restoration of RSA. The aim of this translational, proof-of-principle study was to evaluate the effect of pacing with or without restored RSAon parameters of LV cardiac contractility and the cardiac output

Novel Biomarkers for Heart Disease

Cardiac biomarkers such as troponins and natiuretic peptides have made a great impact on clinical decision making as well as improving our understanding of molecular mechanisms of different disease conditions. However, the biomarkers that are currently in use do not reflect all the multiple disease pathways that are involved in a broad spectrum of cardiac disease conditions ranging from acute coronary syndrome, to heart failure (and heart failure with preserved ejection fraction, HFpEF), to pulmonary hypertension or arrhythmias. In this Special Issue, we will provide an overview of the current developments in the field of biomarker research, beginning with research on molecular pathways and cellular communication (e.g., microRNA) up to the clinical use of biomarkers

Exercise and peripheral vascular function in health and disease

“Chronic disease will never reach its clinical horizon to compromise health if it is attacked at its origin” [1]. Knowledge that one’s risk for cardiovascular events is related to the severity of endothelial dysfunction, and evidence that exercise training can improve endothelial function, has prompted speculation that measures of vascular function may serve as a “barometer” for cardiovascular health. This dissertation consists of three experiments intended to study vascular function and the manner in which it may influence or may be influenced by physical function. Project one examined the influence of high and low volume circuit weight training on forearm vascular function. Thirty-five individuals participated in a program consisting of 3 sessions/week for 5 weeks. Results indicated significant but similar strength gains in both groups (Hand Grip: Ä15.55%, Knee Extension: Ä21.00%, Bench Press: Ä35.31%; p\u3c0.05). Reactive hyperemic responses, a measure of vascular function, only changed in those individuals with the lowest pre-training vascular measures, independent of group assignment. Project two examined the link between vascular and physical function in peripheral neuropathy patients. Reactive hyperemic responses were significantly related to the time up and go test (r=-0.31, p=0.02) and the 6-minute walk distance (r=0.37, p=0.007). These data suggest a link between measures of vascular and physical function in these patients, indicating that those with better vascular function have greater physical function. Project three examined the effects of an acute bout of exercise on nitric oxide, oxidative stress and anti-oxidants, and brachial vasoreactivity, before, at peak exercise, and in recovery, in trained individuals. The results indicated a significant increase in reactive oxygen species and peroxynitrite, and a decrease in the anti-oxidant glutathione peroxidase at peak exercise. Brachial vasoreactivity was significantly lower immediately after exercise, but returned to pre-exercise levels at 20 minutes into recovery. These findings suggest an acute bout of exercise contributes to a significant rise in oxidative stress, which can in part be buffered by anti-oxidants systems, but may cause temporary blunting of arterial reactivity. Collectively, these findings indicate the importance of examining vascular function, and its controllers, and may extend the current understanding of preserving and/or maintaining vascular health

Cerebral Autoregulation-Based Blood Pressure Management In The Neuroscience Intensive Care Unit: Towards Individualizing Care In Ischemic Stroke And Subarachnoid Hemorrhage

The purpose of this thesis is to review the concept of cerebral autoregulation, to establish the feasibility of continuous bedside monitoring of autoregulation, and to examine the impact of impaired autoregulation on functional and clinical outcomes following subarachnoid hemorrhage and ischemic stroke. Autoregulation plays a key role in the regulation of brain blood flow and has been shown to fail in acute brain injury. Disturbed autoregulation may lead to secondary brain injury as well as worse outcomes. Furthermore, there exist several methodologies, both invasive and non-invasive, for the continuous assessment of autoregulation in individual patients. Resultant autoregulatory parameters of brain blood flow can be harnessed to derive optimal cerebral perfusion pressures, which may be targeted to achieve better outcomes. Multiple studies in adults and several in children have highlighted the feasibility of individualizing mean arterial pressure in this fashion. The thesis herein argues for the high degree of translatability of this personalized approach within the neuroscience intensive care unit, while underscoring the clinical import of autoregulation monitoring in critical care patients. In particular, this document recapitulates findings from two separate, prospectively enrolled patient groups with subarachnoid hemorrhage and ischemic stroke, elucidating how deviation from dynamic and personalized blood pressure targets associates with worse outcome in each cohort. While definitive clinical benefits remain elusive (pending randomized controlled trials), autoregulation-guided blood pressure parameters wield great potential for constructing an ideal physiologic environment for the injured brain. The first portion of this thesis discusses basic autoregulatory physiology as well as various tools to interrogate the brain’s pressure reactivity at the bedside. It then reviews the development of the optimal cerebral perfusion pressure as a biological hemodynamic construct. The second chapter pertains to the clinical applications of bedside neuromonitoring in patients with aneurysmal subarachnoid hemorrhage. In this section, the personalized approach to blood pressure monitoring is discussed in greater detail. Finally, in the third chapter, a similar autoregulation-oriented blood pressure algorithm is applied to a larger cohort of patients with ischemic stroke. This section contends that our novel, individualized strategy to hemodynamic management in stroke patients represents a better alternative to the currently endorsed practice of maintaining systolic blood pressures below fixed and static thresholds