Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Rehabilitation in post-COVID patients. A single center experience

 

The COVID 19 disease is frequently associated with significant disability related to intensive care unit-acquired weakness, decontitioning, myopathies and neuropathies. However there are no data on the results of a specific rehabilitative treatment in this group of patients.

The aim of our work was to evaluate the effectiveness f a personalized rehabilitative therapy in group of post-COVID patients (A, 47 patients, average age 65.3±11.6 y, 27 M,) comparing the results with a group of post-cardiosurgical patients COVID 19 negative (B, 47 patients, average age 63.5±10.3 y, 29 M) evaluating the degree of clinical complexity (Rehabilitation Complexity Scale, RCS-E V13) and the degree of autonomy recovery (Six-minute walking test SMWT, Barthel Index, BI) pre and post-treatment.

In Group A patients the Rehabilitation program is associated with a significant improvement in autonomy recovery (BI admission 29.7±20 vs discharge 72.7±28.6 p&lt;0.005, SMWT admission 146±25 vs 318±18 m, p&lt;0.005) and in clinical complexity (RCS admission 10.9±1.1 vs discharge 5.3, p&lt;0.05).

At admission the comparison between Group A vs B has show:

1. a reduced pre-rehabilitation hospital stay (days) in Group Vs A (B 8.2±2 vs 31±5 0.005)

2. a similar degrre of clinical complexity (RCS scale A 10.9±1.1 vs 1.6±11.2 p ns)

3. a greater loss autonomy in post-COVID patients (BI scale A 29.7±20 vs B 47.7±19, p 0.05; SMWT A 145±25 m vs B 255±18 m, p 0.05)

After a similar period of rehabilitation (A 29.7±12.8 days vs B 29.6±10 days, p ns) we observed in both Groups:

1. a reduction of clinical complexity ((RCS scale A 5.3±2 vs 6.6±2 p ns

2. an improvement of degree of autonomy recovery ((BI scale A 72.7±28 vs B 47.7±19, p ns; SMWT A 385±18 m vs B 410±25m, p ns)

Conclusions

Post-COVID patients show a greater loss of autonomy than post-cardiosurgery patients. Rehabilitative treatment has proven effective in ensuring adequate functional recovery with similar results to those obtained in the population of cardiological subjects COVID 19 negative.

Funding Acknowledgement

Type of funding sources: None.

Master athletes'ECG and the diagnostic accuracy of contemporary ECG interpretation criteria

Background

Over the last years, several efforts have been made to refine the ECG criteria for interpretation of young (16–35 years) competitive athlete's ECG in order to improve specificity maintaining good sensitivity. However, few data exist about the efficacy of such interpretation criteria in master athletes (over 35 years). We aimed to assess the diagnostic performance of screening based on 2017 International ECG recommendation (2017-International), 2010 European Society of Cardiology recommendation (2010-ESC) and Seattle criteria in a cohort of master athletes competing at regional and national level.

Methods

506 Caucasian master athletes (mean ages 47.9±8.7, 85,6% male, 65% endurance athletes) underwent standardized medical history, physical examination, resting and exercise ECG during their pre-participation screening. ECGs were retrospectively interpreted based on 2010-ESC, Seattle-criteria and 2017-International. For the purpose of the study we included also a transthoracic echocardiography as reference, to calculate the sensibility and specificity, area under the ROC curve (AUC) was estimated as measure of discriminative ability of each ECG criteria. Athletes with abnormalities underwent further examinations according to the European Guidelines.

Results

Twelve athletes (2,3%) were diagnosed with a condition potentially related to SCD (1 hypertrophic cardiomyopathy, 1 Type1 Brugada Syndrome, 4 Chronic Coronary Syndromes, 2 Dilated Cardiomyopathy, 3 Aortic Dilation, 1 Moderate aortic stenosis) during the pre-participation screening. International criteria failed to identify two athletes with DCM and left axis deviation on ECG while no athletes with complete right bundle branch block showed serious structural abnormalities. The most common ECG abnormalities were left axis deviation (7,1%), left atrial enlargement (4,2%) and T wave inversion (3%). 29 athletes (5,7%) exhibited a long QT interval according to 2010-ESC and 1 athlete according to International and Seattle criteria. The false positive ECG rate was 15% for 2017-International based screening, 21,9% for Seattle based screening and 30,40% for 2010-ESC based screening while the diagnostic accuracy for pathologies at risk of SCD was 0,73 (95% CI 0,69–0,77) for 2017 International based screening; 0,81 (95% CI 0,77–0,84) for Seattle Criteria based screening and 0,77 (95% CI 0,73–0,80) for 2010-ESC based screening.

Conclusion

In master athletes the 2017-International ECG criteria showed inferior accuracy compared to the Seattle criteria and 2010-ESC, the least showing a higher false positive rate mostly due to lower cut-off for long QT. Furthermore complete right bundle branch block may be considered a normal finding also in master asymptomatic athletes.

Accuracy of ECG criteria

Funding Acknowledgement

Type of funding source: None

Parental non-compliance--a paediatric dilemma. A medical and psychodynamic perspective

Considerable resources have been directed towards the recognition and management of child physical and sexual abuse and/or neglect. However, the issue of parental non-compliance is less well defined and under recognized. While outwardly seeking advice, non-compliant parents, especially if anxious, are unable or unwilling to comply with the recommendations made. Conflicts of interest between the parent(s)' and the health professionals' perceptions regarding the best interest of the child may arise. Parental non-compliance is centred around the parents' perception of the child's current problems and its relationship to past problems. Such non-compliance may reflect ignorance or misunderstanding of the clinical situation. Ignorance may be readily addressed if the parents are receptive and trusting. However, non-compliance more commonly arises from the parents' inability to cope emotionally with the stresses surrounding the recommended treatment. Parents may be vulnerable to psychological reactions which inhibit rational thinking. Parental anxieties are best understood in terms of psychological constructs, including 'defences' such as 'denial' and 'splitting', 'repetition compulsion' and the need to 'work through' psychological barriers so that the child's best interest is served. Parental non-compliance can serve to protect the parents from overwhelming fears and anxieties, which if addressed may transform parental defensiveness to co-operation. Extreme parental non-compliance may represent a special form of child abuse where, due to parental psychopathology, parents are unable to consider the child's best interest. Clinical vignettes arising from a consultant private and hospital ambulatory setting will focus on management strategies for successful outcomes. Recommendations offered on ways to reduce the risk of parental non-compliance include building trust, eliciting the aid of a parental partner, and organizing a second opinion, thereby improving the chances of a successful outcome.

Group peer review: a questionnaire-based survey

OBJECTIVE

This paper presents the findings from a questionnaire-based survey of psychiatrists designed to elucidate the positive and negative aspects of group peer review and its perceived place in accountability procedures, and to provide information about how accountability through group peer review might be improved.

METHOD

Three hundred and eighty-eight psychiatrists were surveyed via mailout questionnaire. Demographic data, details of groups, and perceptions of beneficial and detrimental effects of group peer review were sought from group participants and non-participants. Attitudes of participants were compared with those of non-participants. Features of groups related to satisfaction in participants were examined.

RESULTS

The majority of the 170 respondents participating in groups regarded peer review as a means of maintaining and improving skills, sharing ideas and methods, receiving constructive criticism and feedback, of educational benefit and an important source of professional accountability. Non-participants, while less positive overall, responded equally that participation in peer review groups would be an effective response to accountability procedures. Potential detrimental effects and problems with the functioning of peer review groups were elucidated.

CONCLUSIONS

Group peer review contributes significantly to professional accountability and education in well-functioning groups. Further strategies for the facilitation of group functioning and for the processing of problems arising in group peer review need to be developed to optimise its contribution to the maintenance and improvement of professional standards.

The rights of the child in psychotherapy

A brief historical perspective on the development of the concept of children's rights provides the background from which to delve into their rights when in psychotherapy. After centuries of the systematic ill-treatment of children, the emergence of an empathic ethos that pervaded Western society in the eighteenth century ushered in a new attitude of social reform. Social progress over the next two centuries culminated in the United Nations Convention on the Rights of the Child. The modern concept of the rights of the child and application of the best-interest-of-the-child standards in child care is evident in four areas of child psychotherapy: informed consent; recognition of the difference between the child's withdrawal of consent to further therapy and resistance in therapy; the need to distinguish between "difficult to treat" and "unsuitable for treatment" cases; and empathic listening. However, mounting evidence that dysfunctional families cause increasing vulnerability of the child to future mental disorder places an obligation on the therapist to recognize the interlocking psychopathology and needs of both parents and children for therapy. Finally, the effect on child psychotherapy of "managed care" in the United States, which threatens to transform a best-interest-of-the-child standard to a "minimum-interest-of-the-child" one as a socially regulated form of restrictive care, contravenes the child's right to optimal care. Principles relating to the well-being of the child in psychotherapy are offered to counter this trend.

Growth and physical outcome of children conceived by in vitro fertilization

OBJECTIVE

To determine the growth and physical outcome at 2 years of age for children born after assisted reproductive techniques in the state of Victoria.

DESIGN

Using a case-matched control study between January 1991 and July 1993, 314 children (196 singletons, 47 sets of twins, 8 sets of triplets) conceived after in vitro fertilization (IVF) and related techniques at the Monash IVF and Royal Women's Hospital Reproductive Biology Unit and 150 control children (113 singletons, 17 sets of twins, 1 set of triplets) randomly selected from the general population using the Victorian Perinatal Data Collection Unit records were enrolled to be examined for minor dysmorphic and major organ abnormalities. Singleton and twin cases were matched for plurality and gestation and date of birth. Triplets were not matched.

RESULTS

IVF status was not a significant independent factor for physical outcomes, including malformation rates, nor for days of hospitalization postdischarge and operations. There was no significant interaction between IVF status and mean percentiles for weight and head circumference. The IVF group had a greater mean length percentile. Twins in both groups had significantly poorer physical outcomes than singletons on some measures.

CONCLUSION

This study did not demonstrate an independent IVF effect on the growth and physical outcome of children at 2 years of age when matched for plurality and gestation. The poor outcomes where noted were related to the effects of multiple births. These findings must be viewed in context of the response rates and therefore representativeness of the data. The need for longitudinal studies is demonstrated.

Clinical practice beyond science: debunking the scientific myth

The theme of the RANZCP 28th Conference questioned the science of clinical practice. This question is explored in the light of prevailing paradigms of 20th century psychiatry and recent claims by scientism, especially biologism, that assumes an organic causation for all abnormal behaviour. It is argued that a paradigm of objective science is necessary to understanding many aspects of mental illness, but not sufficient to explain certain essential phenomena, such as altered states of consciousness and empathy, encounted daily in clinical practice. Discarding these phenomena in the name of "science" runs the risk of clinical practice becoming "mindless". The "reconquest of the subjective" is offered as a way to extend clinical practice beyond objective science.

A 13 year follow-up of child psychiatry training

The graduates from two child psychiatry training programmes over a 13 year period responded to a questionnaire designed to elicit their retrospective evaluations of various aspects of their educational experience. Information is presented about areas of knowledge judged important, specific experiences which were helpful and unhelpful, and current patterns of practice of these graduates. Their attitudes toward supervision and supervisors are discussed, as are implications for recruitment of future trainees and teachers/faculty.

Death related themes in anorexia nervosa: a practical exploration

On the basis of an extensive literature review, Jackson and Davidson (1986) suggested that the theme of death may constitute an integral part of the psychodynamic aetiology of anorexia nervosa. This paper describes an attempt to explore this contention using a structured questionnaire in a group of adolescent patients to examine experiences, concepts of and attitudes concerning death. Comparison of the responses of this group with those of age matched school student controls and recovered patients revealed qualitative and quantitative differences which lent some support to the hypothesis. It is concluded that death related themes are of significance in the understanding and management of this illness.