Ventricular arrhythmias in cardiac amyloidosis : a review of current literature

Cardiac Amyloidosis is an infiltrative cardiomyopathy which occurs secondary to deposition of mis-folded protein in the myocardium, with the two most common subtypes being AL amyloidosis and TTR amyloidosis. The pathogenesis of the disease is multifaceted and involves a variety of mechanisms including an inflammatory response cascade, oxidative stress and subsequent separation of myocyte fibrils. Cardiac Amyloidosis frequently results in congestive cardiac failure and arrhythmias, from a disruption in cardiac substrate with subsequent electro-mechanical remodelling. Disease progression is usually demonstrated by development of progressive pump failure, which may be seen with a high arrhythmic burden, usually portending a poor prognosis. There is a paucity of literature on the clinical implications of ventricular arrhythmias in the context of cardiac amyloidosis. The important diagnostic investigations for these patients include transthoracic echocardiography, cardiac magnetic resonance imaging and an electrophysiology study. Whilst there are no robust management guidelines, studies have indicated benefits from contemporary pharmacological therapy and case-by-case catheter ablation. There are novel directed therapies available for TTR amyloidosis that have shown to improve overall survival. The role of ICD therapy in cardiac amyloidosis is controversial, with benefits seen predominantly in early phases of the disease process. The only definitive surgical therapy includes heart transplantation, but is largely indicated for progressive decompensated heart failure (Figure 1). Further large-scale studies are required to better outline management paradigms for treating ventricular arrhythmias in cardiac amyloidosis

A qualitative exploration of influences on the process of recovery from personal written accounts of people with anorexia nervosa

Less than half of people with anorexia nervosa achieve full recovery. Previous qualitative research has identified a "tipping point" for change in people who have experienced recovery. The present study's goal was to explore factors that might contribute to this time in personal published accounts, an alternate source for understanding lived experience. Using the 5-stage framework approach for thematic analysis, 31 individual (29 female) accounts were explored. These were purposively sampled from autobiographical accounts (during 1999-2011). In all the accounts a "tipping point" or change in the person's attitude toward treatment and recovery did appear. We identified four main themes: desire for recovery, positive experiences in treatment, an aspect of life outside work or study, and positive and helpful experiences with new or renewed relationships. The themes were a mix of internal and external themes, as well as themes independent of a treatment experience. The findings support other research that indicates experiences, such as personal and spiritual relationships, in addition to specific psychotherapies or treatments, are important in recovery. Further research into how to facilitate and integrate these external factors with formal treatment is indicated in order to improve understanding of outcomes in anorexia nervosa

Melanomas and stress patterns on the foot : a systematic review and meta-analysis

Most melanomas are associated with UV radiation exposure.1 However, melanomas can emerge on sun-shielded skin such as the plantar surfaces. The pathogenesis of these melanomas is largely unknown.2 One hypothesis is that repetitive mechanical stress contributes to their formation. We performed a systematic review and meta-analysis to investigate the location of plantar and subungual melanoma lesions to examine a possible correlation with pressure areas of the foot

Persistent pathology of the patent foramen ovale : a review of the literature

A patent foramen ovale (PFO) is an interatrial shunt, with a prevalence of 20–34% in the general population. While most people do not have secondary manifestations of a PFO, some reported sequelae include ischaemic stroke, migraine, platypnoea–orthodeoxia syndrome and decompression illness. Furthermore, in some cases, PFO closure should be considered for patients before neurosurgery and for patients with concomitant carcinoid syndrome. Recent trials support PFO closure for ischaemic stroke patients with high risk PFOs and absence of other identified stroke mechanisms. While PFOs can be associated with migraine with auras, with some patients reporting symptomatic improvement after closure, the evidence from randomised controlled trials is less clear in supporting the use of PFO closure for migraine treatment. PFO closure for other indications such as platypnoea–orthodeoxia syndrome, decompression illness and paradoxical embolism are based largely on case series with good clinical outcomes. PFO closure can be performed as a day surgical intervention with high procedural success and low risk of complications

Chatbot-mediated learning of cardiac auscultation

Previous research suggested cardiac auscultation is underdeveloped in physicians-in-training. Developing proficiency requires wide exposure to signs, practice and feedback, which may not regularly occur in clinical environments. Our novel pilot study using a mixed-methods approach (n = 9) suggests chatbot-mediated learning of cardiac auscultation is accessible and possesses unique advantages, including immediate feedback, helping in the management of cognitive overload and facilitating deliberate practice

Medical student changes in self-regulated learning during the transition to the clinical environment

Background: Self-regulated learning (SRL), which is learners’ ability to proactively select and use different strategies to reach learning goals, is associated with academic and clinical success and life-long learning. SRL does not develop automatically in the clinical environment and its development during the preclinical to clinical learning transition has not been quantitatively studied. Our study aims to fill this gap by measuring SRL in medical students during the transitional period and examining its contributing factors. Methods: Medical students were invited to complete a questionnaire at the commencement of their first clinical year (T0), and 10 weeks later (T1). The questionnaire included the Motivated Strategies for Learning Questionnaire (MSLQ) and asked about previous clinical experience. Information about the student’s background, demographic characteristics and first clinical rotation were also gathered. Results: Of 118 students invited to participate, complete paired responses were obtained from 72 medical students (response rate 61%). At T1, extrinsic goal orientation increased and was associated with gender (males were more likely to increase extrinsic goal orientation) and type of first attachment (critical care and community based attachments, compared to hospital ward based attachments). Metacognitive self-regulation decreased at T1 and was negatively associated with previous clinical experience. Conclusions: Measurable changes in self-regulated learning occur during the transition from preclinical learning to clinical immersion, particularly in the domains of extrinsic goal orientation and metacognitive self–regulation. Self–determination theory offers possible explanations for this finding which have practical implications and point the way to future research. In addition, interventions to promote metacognition before the clinical immersion may assist in preserving SRL during the transition and thus promote life-long learning skills in preparation for real-world practice

Exploration of cardiology patient hospital presentations, health care utilisation and cardiovascular risk factors during the COVID-19 pandemic

Objectives: COVID-19 and the lockdowns have affected health care provision internationally, including medical procedures and methods of consultation. We aimed to assess the impact of COVID-19 at two Australian hospitals, focussing on cardiovascular hospital admissions, the use of community resources and cardiovascular risk factor control through a mixed methods approach. Methods: Admissions data from the quaternary referral hospital were analysed, and 299 patients were interviewed from July 2020 to December 2021. With the admissions data, the number, complexity and mortality of cardiology hospital admissions, prior to the first COVID-19 lockdown (T0=February 2018–July 2019) were compared to after the introduction of COVID-19 lockdowns (T1=February 2020–July 2021). During interviews, we asked patients about hospital and community health resource use, and their control of cardiovascular risk factors from the first lockdown. Results: Admission data showed a reduction in hospital presentations (T0=138,099 vs T1=128,030) and cardiology admissions after the lockdown period began (T0=4,951 vs T1=4,390). After the COVID-19-related lockdowns began, there was an increased complexity of cardiology admissions (T0=18.7%, 95% CI 17.7%–19.9% vs T1=20.3%, 95% CI 19.1%–21.5%, chi-square test: 4,158.658, p<0.001) and in-hospital mortality (T0=2.3% of total cardiology admissions 95% CI 1.9%–2.8% vs T1=2.8%, 95% CI 2.3%–3.3%, chi-square test: 4,060.217, p<0.001). In addition, 27% of patients delayed presentation due to fears of COVID-19 while several patients reported reducing their general practitioner or pathology/imaging appointments (27% and 11% respectively). Overall, 19% reported more difficulty accessing medical care during the lockdown periods. Patients described changes in their cardiovascular risk factors, including 25% reporting reductions in physical activity. Conclusion: We found a decrease in hospital presentations but with increased complexity after the introduction of COVID-19 lockdowns. Patients reported being fearful about presenting to hospital and experiencing difficulty in accessing community health services