Track 1: Surgery, anaesthesia and intensive care

Surgery, anaesthesia and intensive care

Characterization and Clinical Management of Dilated Cardiomyopathy

Dilated cardiomyopathy (DCM) is a particular phenotype of non-ischemic systolic heart failure, frequently recognizing a genetic background and affecting relatively young patients with few comorbidities. Nowadays, long-term survival of DCM patients has been markedly improved due to an early diagnosis and uninterrupted and tailored follow-up under constant optimal medical and non-pharmacological evidence-based treatments. Nevertheless, DCM is still one of the most common causes of heart transplantation in the western world. Clinical management requires an integrated and systematic use of diagnostic tools and a deeper investigation of the basic mechanisms underlying the disease. However, several emerging issues remain debated. Specifically, the genotype–phenotype correlation, the role of advanced imaging techniques and genetic testing, the lack of appropriate risk stratification models, the need for a multiparametric and multidisciplinary approach for device implantation, and a continuous reclassification of the disease during follow-up remain challenging issues in clinical practice. Therefore, the aim of this Special Issue is to shed the light on the most recent advancements in characterization and clinical management of DCM in order to unveil the conundrum of this particular disease

Exercise therapy and cardiac, autonomic and systemic function in patients with chronic heart failure

Background Exercise training is now accepted as a safe, adjunct therapy in stable heart failure patients. Acceptance of exercise training or therapy within this population is due to the benefits that have been demonstrated over the past three decades in trials and data syntheses presented in systematic reviews and meta-analyses. As new concepts emerge and with an increase in the number of trials comes the challenge of keeping up-to date with all the information, deciphering what's relevant, deciding how to interpret and apply the findings and what should happen next. Fortunately, the research methodologies of systematic review and meta-analysis provide a suitable platform for collecting, analysing and critically appraising studies. Methods An initial evidence mapping exercise identified the current level of research activity in regard to the synthesis of evidence focusing on the broad question of the benefits and/or effects of exercise training in heart failure patients. The objective of the exercise was to identify gaps in research synthesis and areas in which research synthesis would be valuable. A series of research syntheses were then conducted based on the identified gaps, using systematic reviews as the research methodology, and applying the statistical technique of meta-analysis where possible. Results While some of the effects of exercise training are now well established, e.g., improved functional capacity and quality of life, new trials and new concepts continue to emerge. Evidencing mapping highlighted a number of areas in which research synthesis was limited or out dated. The identified areas addressed the effect of exercise training on specific areas of cardiac, autonomic and systemic inflammatory markers in chronic heart failure patients; all associated with the pathogenesis and progression of heart failure. Evidence from systematic reviews and meta-analyses demonstrated that exercise training/therapy resulted in statistically significant improvements in: 1) endothelial function (FMD and EPCs), 2) direct (MSNA) and indirect (HRR, HRV) measures of autonomic function, 3) cardiac biomarkers (BNP, NT-proBNP) and 4) diastolic function, measured as E/E’. However, the evidence for improvements in a number of inflammatory markers was inconclusive, and limited evidence is currently available to allow for any conclusion to be drawn on the effect of exercise on emerging heart failure biomarkers. Conclusion This thesis utilised systematic reviews and meta-analyses as the research methodology to answer questions in relation to exercise training in heart failure patients. This work adds to the current evidence base by providing a robust synthesis of data in regard to effects of exercise training and therapy on endothelial function, autonomic function, inflammatory markers, biomarkers and diastolic function in heart failure patients

Smoking and Second Hand Smoking in Adolescents with Chronic Kidney Disease: A Report from the Chronic Kidney Disease in Children (CKiD) Cohort Study

The goal of this study was to determine the prevalence of smoking and second hand smoking [SHS] in adolescents with CKD and their relationship to baseline parameters at enrollment in the CKiD, observational cohort study of 600 children (aged 1-16 yrs) with Schwartz estimated GFR of 30-90 ml/min/1.73m2. 239 adolescents had self-report survey data on smoking and SHS exposure: 21 [9%] subjects had “ever” smoked a cigarette. Among them, 4 were current and 17 were former smokers. Hypertension was more prevalent in those that had “ever” smoked a cigarette (42%) compared to non-smokers (9%), p\u3c0.01. Among 218 non-smokers, 130 (59%) were male, 142 (65%) were Caucasian; 60 (28%) reported SHS exposure compared to 158 (72%) with no exposure. Non-smoker adolescents with SHS exposure were compared to those without SHS exposure. There was no racial, age, or gender differences between both groups. Baseline creatinine, diastolic hypertension, C reactive protein, lipid profile, GFR and hemoglobin were not statistically different. Significantly higher protein to creatinine ratio (0.90 vs. 0.53, p\u3c0.01) was observed in those exposed to SHS compared to those not exposed. Exposed adolescents were heavier than non-exposed adolescents (85th percentile vs. 55th percentile for BMI, p\u3c 0.01). Uncontrolled casual systolic hypertension was twice as prevalent among those exposed to SHS (16%) compared to those not exposed to SHS (7%), though the difference was not statistically significant (p= 0.07). Adjusted multivariate regression analysis [OR (95% CI)] showed that increased protein to creatinine ratio [1.34 (1.03, 1.75)] and higher BMI [1.14 (1.02, 1.29)] were independently associated with exposure to SHS among non-smoker adolescents. These results reveal that among adolescents with CKD, cigarette use is low and SHS is highly prevalent. The association of smoking with hypertension and SHS with increased proteinuria suggests a possible role of these factors in CKD progression and cardiovascular outcomes