Contemporary Considerations in the Evolution of Wearable Technology for Arrhythmia Detection.

Arrhythmias are an increasingly common cause of hospital admissions worldwide. Late detection of arrhythmias is associated with a significantly increased risk of cardiovascular complications. Early identification and management of life-threatening arrhythmias is paramount to reduce mortality. Wearable technologies are now widespread among the general population, providing a continuous output of healthcare data. However, this data are not routinely integrated into clinical practice. Here, we begin by outlining the current landscape in wearable technology for aiding arrhythmia detection; we then consider the clinical impact of wearable technology for both clinicians and patients; we further highlight the latest and emerging trials in wearable technology for arrhythmia detection and finally postulate the wider implications of the expansion of such cardiac devices.

Percutaneous approach for reducing outflow tract obstruction in hypertrophic obstructive cardiomyopathy.

Hypertrophic obstructive cardiomyopathy (HOCM) affects approximately 1 in 500 people globally. The condition results in hypertrophy of the interventricular septum and thickening of the left ventricular wall. Surgical management to resect the thickened myocardium or septal alcohol ablation are currently considered the mainstay treatment option for HOCM refractory to pharmacological therapy. In this special report we aim to highlight the current landscape of septal mass reduction in HOCM. Next, we describe the evolving discipline of minimally invasive techniques for reducing outflow tract obstruction in patients with HOCM. We further consider future options and outline a possible percutaneous approach for septal myectomy with a novel device.

Gene Mutations in Cushing's Syndrome.

Background: Prolonged exposure to glucocorticoids can result in the development of Cushing's syndrome. Excess serum cortisol can occur due to several factors including exogenous steroids, pituitary and adrenal adenoma, and ectopic ACTH secretion. Summary: The last 2 decades have seen significant progress in identifying new genetic and molecular mechanisms underlying hypercortisolemia. This has implicated mutations seen in a multitude of aberrant pathways that underpin the pathophysiology of Cushing's syndrome. Key Messages: There is much overlap between the different, with mutations affecting well-understood molecular pathways such as the cAMP/PKA/MAPK and Wnt signalling systems. Further work should delineate the exact involvement of specific mutations in Cushing's syndrome and the effect of epigenetic/microenvironmental interactions. This could have implications for screening, as the identification of specific mutations may lead to earlier identification and subsequently improved prognosis.

Trends in the incidence and mortality of infective endocarditis in high-income countries between 1990 and 2019.

BACKGROUND: Infective endocarditis (IE) remains a life-threatening disease with high morbidity and mortality. OBJECTIVES: To describe temporal trends in IE incidence, mortality and survival over the last 30 years. METHODS: Nineteen high-income countries (the 'EU 15+') were included. Age-standardised and sex-stratified incidence rates (ASIRs) and mortality rates (ASMRs) for IE were extracted from the Global Burden of Disease (GBD) database between 1990 and 2019, and mortality to incidence ratios (ASMIRs) were calculated. Trends were analysed using Joinpoint regression analysis. RESULTS: ASIRs were higher in males than females and increased in both sexes in all countries between 1990 and 2019. A recent steep rise in ASIRs was noted in several countries including the UK, the USA and Germany. ASMRs increased for both sexes in all countries except Finland and Austria. The largest increase in ASMR was observed in females in Italy (+246%). ASMIRs were generally higher in females compared to males, with large increases in ASMIRs (indicating worsening survival) at the end of the 20th century, but more recent stabilisation or decline across the study cohort. CONCLUSIONS: While the incidence and mortality of IE have increased over the last 30 years, recent data suggest that these trends have plateaued or reversed in most countries studied. However, a recent surge in incidence in several countries (including the USA and UK) is of concern, while unfavourable outcomes in females also merit attention. More encouragingly, this analysis provides the first indication of improving IE survival at population level, supporting recent advances in diagnosis and treatment.

Temporal trend analysis of rheumatic heart disease burden in high-income countries between 1990 and 2019.

AIMS: To assesses trends in rheumatic heart disease (RHD) burden in high-income, European Union 15+ (EU15+) countries between 1990 and 2019. METHODS AND RESULTS: Cross-sectional analysis of the incidence and mortality of RHD was conducted using data from the Global Burden of Disease Study (GBD) database. Age-standardized incidence rates (ASIRs) and age-standardized mortality rates (ASMRs) were extracted for EU15 + countries per sex for each of the years from 1990-2019, inclusive, and mortality-to-incidence indices (MII) were computed. Joinpoint regression analysis was used for the description of trends. Over 29 years, an overall declining trend in RHD incidence and mortality across EU 15 + nations were observed. There was significant variability in RHD incidence and mortality rates across high-income countries. However, both RHD incidence and mortality were higher among females compared to males across EU15 + countries over the observed period. The most recent incidence trend, starting predominantly after 2014, demonstrated a rise in RHD incidence in most countries for both sexes. The timing of this RHD resurgence corresponds temporally with an influx of migrants and refugees into Europe. The recent increasing RHD incidence rates ranged from + 0.4% to + 24.7% for males, and + 0.6% to + 11.4% for females. CONCLUSIONS: More than half of EU15 + nations display a recent increase in RHD incidence rate across both sexes. Possible factors associated with this rise are discussed and include increase in global migration from nations with higher RHD prevalence, host nation factors such as migrants' housing conditions, healthcare access and migrant health status on arrival.

Recent Updates and Technological Developments in Evaluating Cardiac Syncope in the Emergency Department.

Syncope is a commonly encountered problem in the emergency department (ED), accounting for approximately 3% of presenting complaints. Clinical assessment of syncope can be challenging due to the diverse range of conditions that can precipitate the symptom. Annual mortality for patients presenting with syncope ranges from 0-12%, and if the syncope is secondary to a cardiac cause, then this figure rises to 18-33%. In ED, it is paramount to accurately identify those presenting with syncope, especially patients with an underlying cardiac aetiology, initiate appropriate management, and refer them for further investigations. In 2018, the European Society of Cardiology (ESC) updated its guidelines with regard to diagnosing and managing patients with syncope. We highlight recent developments and considerations in various components of the workup, such as history, physical examination, investigations, risk stratification, and novel biomarkers, since the establishment of the 2018 ESC guidelines. We further discuss the emerging role of artificial intelligence in diagnosing cardiac syncope and postulate how wearable technology may transform evaluating cardiac syncope in ED.

Catastrophic case of suppurative, embolic and fistulating infective endocarditis causing complete heart block.

Complete heart block, aortic root abscess and aortic valve regurgitation are well-recognized complications of infective endocarditis of the aortic valve. Splenic abscess and aorto-cavitary fistula are rarer phenomena and are indicative of calamitous infection. The authors present the case of an otherwise healthy 61-year-old man presenting with a 2-month history of non-specific symptoms, who developed suppurative endocarditis with a fistulating aortic root abscess, combined with severe sepsis, splenic embolization and complete heart block. Staphylococcus lugdunensis was the causative bacterium identified. The combination of these sequelae in the same patient is sparsely reported, is exceedingly rare and carries a significant risk of mortality.

Infective endocarditis is a condition caused by bacteria invading the body and damaging the heart, especially the heart valves. Usually, the infection is diagnosed relatively swiftly by blood tests and images of the heart. Rarely, if this condition isn't managed promptly, the infection can progress to cause further damage to the heart and can spread to other organs and lead to a plethora of complications. Here, the authors report a case of a single patient who sought medical attention after 2 months of feeling unwell. It transpired that the patient had infective endocarditis that had spread to the spleen, which caused a defect in the cardiac tissue and impaired its ability to maintain an adequate circulation.

Diabetes, Heart Failure and Beyond: Elucidating the Cardioprotective Mechanisms of Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors.

Approximately 5 million individuals in the US are living with congestive heart failure (CHF), with 650,000 new cases being diagnosed every year. CHF has a multifactorial etiology, ranging from coronary artery disease, hypertension, valvular abnormalities and diabetes mellitus. Currently, guidelines by the American College of Cardiology advocate the use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, ß-blockers, diuretics, aldosterone antagonists, and inotropes for the medical management of heart failure. The sodium glucose cotransporter 2 (SGLT2) inhibitors are a class of drug that have been widely used in the management of type 2 diabetes mellitus that work by inhibiting the reabsorption of glucose in the proximal convoluted tubule. Since the EMPA-REG OUTCOME trial, several studies have demonstrated the benefits of SGLT2 inhibitors in reducing cardiovascular risk related to heart failure. While the cardiovascular benefits could be explained by their ability to reduce weight, improve glycemic index and lower blood pressure, several recent trials have suggested that SGLT2 inhibitors exhibit pleiotropic effects that underlie their cardioprotective properties. These findings have led to an expansion in preclinical and clinical research aiming to understand the mechanisms by which SGLT2 inhibitors improve heart failure outcomes.

Current and Emerging Classes of Pharmacological Agents for the Management of Hypertension.

Cardiovascular disease accounts for more than 17 million deaths globally every year, of which complications of hypertension account for 9.4 million deaths worldwide. Early detection and management of hypertension can prevent costly interventions, including dialysis and cardiac surgery. Non-pharmacological approaches for managing hypertension commonly involve lifestyle modification, including exercise and dietary regulations such as reducing salt and fluid intake; however, a majority of patients will eventually require antihypertensive medications. In 2020, the International Society of Hypertension published worldwide guidelines in its efforts to reduce the global prevalence of raised blood pressure (BP) in adults aged 18 years or over. Currently, several classes of medications are used to control hypertension, either as mono- or combination therapy depending on the disease severity. These drug classes include those that target the renin-angiotensin-aldosterone system (RAAS) and adrenergic receptors, calcium channel blockers, diuretics and vasodilators. While some of these classes of medications have shown significant benefits in controlling BP and reducing cardiovascular mortality, the prevalence of hypertension remains high. Significant efforts have been made in developing new classes of drugs that lower BP; these medications exert their therapeutic benefits through different pathways and mechanism of actions. With several of these emerging classes in phase III clinical trials, it is hoped that the discovery of these novel therapeutic avenues will aid in reducing the global burden of hypertension.

Vasospasm induced myocardial ischaemia secondary to sumatriptan use.

Certain medications have been implicated in causing acute myocardial infarctions (AMI). Sumatriptan, a medication usually prescribed for acute migraine and cluster headaches has been documented as potentially causing coronary vasospasm, thereby leading to MI. This is usually seen in patients with strong risk factors for coronary artery disease (CAD) or in those with established CAD. Most cases thus far have been reported in patients using the subcutaneous preparation of sumatriptan. Here, we present a case of a patient without prior risk factors for CAD and angiographically unremarkable coronary arteries who presented with evidence of an AMI after oral sumatriptan use for migraines.

Training in Interventional Radiology: A Simulation-Based Approach.

Innovations in medical technology have revolutionised both medical and surgical practice. Indeed, with such innovations, training for specific specialties has become more advanced and streamlined. However, despite these novel approaches to train students and specialist trainees, training for interventional radiology (IR) is lagging. While the reason for this lag remains contentious, one of the primary reasons for this issue may be the lack of standardisation for IR training due to a scarcity of specific guidelines for the delivery of IR procedural training. Interventional radiologists manage a vast array of conditions and perform various procedures. However, training for each procedure is largely dependent on the centre and access to a range of cases. Recently, the use of simulation technology has allowed this issue to be addressed. Simulation technology allows trainees to participate in a range of procedures regardless of their centre and availability of cases. Specialties such as cardiology and vascular surgery have already adopted simulation-based technology for trainees and have commented positively on this approach. However, simulation-based training is still lacking in the IR training pathway. Here, we evaluate why IR training can benefit from a more simulation-based approach. We further consider the cost-effectiveness of implementing simulation-based training nationally. Finally, we outline the potential pitfalls that may arise of introducing simulation-based training for IR trainees. We conclude that despite its disadvantages, simulation training will prove to be more cost-efficient and allow standardisation of IR training.

Role of AYUSH Therapies in Modern Medicine: A Qualitative Study to Explore the Awareness and Attitudes of Doctors Towards the Utilization of Alternate System of Medicine for Diabetes Mellitus.

OBJECTIVE: To understand doctors' attitude to and awareness of AYUSH therapies for the treatment of diabetes mellitus (DM). METHODS: This qualitative study, using a usage-and-attitude survey, was conducted in secondary centers across Mumbai, India. The study surveyed 77 physicians, including those specializing in diabetes. RESULTS: The majority of doctors were aware of Ayurveda (69%) and Homeopathy (52%). Some doctors were aware of Unani (34%) and Siddha (32%). Most doctors (60%) thought that Ayurveda was effective in some way. Almost all doctors (97%) thought that allopathic medicine was effective for DM. The majority of doctors (68%) had not recommended AYUSH therapies as an adjunct to modern medicines. Approximately half of the doctors (52%) believed that AYUSH therapies posed a safety concern for patients and 46% thought that AYUSH therapies could not be used to manage any form of DM. A large group of doctors thought that the main barrier preventing AYUSH therapies from being integrated into current allopathic management of DM was the lack of strong scientific evidence and clinical trials. CONCLUSION: The majority of doctors are aware to some degree of Ayurveda and homeopathic forms of treatment. The majority believe that AYUSH therapies pose a safety concern for patients and have no role in treatment for any form of DM. The most common barrier preventing AYUSH therapies from becoming a mainstream treatment option for DM is the lack of scientific evidence. From this sample, it seems that greater efforts are required to conduct research into the efficacy and safety of AYUSH therapies to ensure that doctors are able to provide holistic care for patients with DM.

Evaluating the effectiveness of anti-Nogo treatment in spinal cord injuries.

As humans, we cannot regenerate axons within the central nervous system (CNS), therefore, making any damage to it permanent. This leads to the loss of sensory and motor function below the site of injury and can be crippling to a person's health. Spontaneous recovery can occur from plastic changes, but it is minimal. The absence of regeneration is due to the inhibitory environment of the CNS as well as the inherent inability of CNS axons to form growth cones. Amongst many factors, one of the major inhibitory signals of the CNS environment is the myelin-associated Nogo pathway. Nogo-A, Nogo-B and Nogo-C (Nogo), stimulate the Nogo receptor, inhibiting neurite outgrowth by causing growth cones to collapse through activation of Rho Kinase (ROCK). Antibodies can be used to target this signalling pathway by binding to Nogo and thus promote the outgrowth of neuronal axons in the CNS. This use of anti-Nogo antibodies has been shown to upregulate CNS regeneration as well as drastically improve sensory and motor function in both rats and primates when coupled with adequate training. Here, we evaluate whether the experimental success of anti-Nogo at improving CNS regeneration can be carried over into the clinical setting to treat spinal cord injuries (SCI) and their symptoms successfully. Furthermore, we also discuss potential methods to improve the current treatment and any developmental obstacles.

Challenges In Widening Participation Outreach: Is Enough Being Done To Tackle The Under-Representation Of Low-Income Students In Medicine?

Widening Participation (WP) in medicine refers to all theory, activities and policy concerned with removing barriers to entering medical school for students from lower income and under-represented backgrounds. Medical schools and other institutions including; the Medical Schools Council, the Office for Fair Access, the Higher Education Funding Council for England, have been committed to improving Widening Participation for more than a decade. As senior medical students and academics, we have been actively involved with WP work at our respective medical schools and in conjunction with the British Medical Association (BMA) and the Medical Schools Council (MSC). Yet, we have observed over the years that the pace of change seems sometimes stuttering and stagnated. Here, we have investigated the reasons why there is still such a significant under-representation of students from lower income backgrounds in medicine. In order to make the medical student intake representative of the general population, the number of applications from lower income students would need to increase five-fold. This would require a great scaling up of WP outreach work. Critical analysis demonstrates that medical schools and the other key institutions in medical education have made many nominal commitments to WP, but have yet to make any commitments that are truly binding. This may be due to the institutions lack of belief in their own capacity to scale up WP Outreach sufficiently to achieve success. Ultimately binding commitments will be needed to secure a representative intake of medical students. In order for institutions to be willing to move towards such commitments, evidence-based success in WP must first be demonstrated through collaboration on specific projects that are scalable, sustainable and impactful.

What are the links between hypoxia and Alzheimer's disease?

Alzheimer's disease (AD) is the most common neurodegenerative disease. Histological characterization of amyloid plaques and neurofibrillary tangles in the brains of AD patients, alongside genetic studies in individuals suffering the familial form of the disease, has fueled the accumulation of the amyloid-ß protein as the initial pathological trigger of disease. Association studies have recently showed that cerebral hypoxia, via both genetic and epigenetic mechanisms, increase amyloid-ß deposition by altering expression levels of enzymes involved in the production/degradation of the protein. Furthermore, hypoxia has also been linked to neuronal and glial-cell calcium dysregulation through formation of calcium-permeable pores, dysregulated glutamate signaling, and intracellular calcium-store dysfunction. Hypoxia has also been strongly linked to neuroinflammation; however, this relationship to AD has not been thoroughly discussed in the literature. Here, we highlight and organize critical research evidence showing that in both hypoxic and AD brains, there are similarities in terms of 1) the substances mediating/modulating the neuroinflammatory environment and 2) the immune cells that drive the formation of these substances.

Current perspective on the role of insulin and glucagon in the pathogenesis and treatment of type 2 diabetes mellitus.

According to the World Health Organization, 422 million adults worldwide live with diabetes mellitus (DM), a significant portion of whom have type 2 diabetes. The discovery of insulin as a key regulator of glucose metabolism has revolutionized our understanding of DM and provided several therapeutic avenues. Most studies have so far predominantly focused on the role of insulin in type 2 diabetes. However, the balance between insulin and glucagon is essential in ensuring glucose homeostasis. In this review, we begin by evaluating the principal differences between insulin and glucagon with regard to their mechanism and control of their secretion. Next, we discuss their mode of action and effects on metabolism. We further explore how the two hormones impact the natural history of type 2 diabetes. Finally, we outline how current and emerging pharmacological agents attempt to exploit the properties of insulin and glucagon to benefit patients with type 2 diabetes.

Not Just a Medical Student: Delivering Medical Education Through a Short Video Series on Social Media.

"Not Just a Medical Student" is an innovative bite-size medical education video series founded and hosted on social media. Its primary aim is to inspire tomorrow's doctors to be creative while engaging and informing them with the latest innovations, technology, and conferences within various specialties. To our knowledge, these themes are scarcely covered in the structured medical curriculum. Created and launched in August 2017, "Not Just a Medical Student" quickly gained traction; with over 1000 followers on Facebook and a rapidly increasing number of views, it reached the medical community across the globe. The video series features a trailblazer in virtual reality surgery and its potential impact on the evolution of medical education, reviewing future medical technology apps, such as Touch Surgery, and reporting on the latest medical education and health apps. The series engaged in topical medico-politics at the British Medical Association House and reported on global health issues and innovations at the Royal Society of Medicine Conference. The video series has further received several national awards including the Association and Study of Medical Education (ASME) Educator Innovator 2017 award, runner up to the Zeshan Qureshi Outstanding Contribution to Medical Education Award, and the Alternative Docs National Social Media Influencer award. The concept has been presented at international conferences (eg, the Healthcare Leadership Academy conference) and gained international recognition upon personal invitation at the Norwegian Annual Junior Doctors Conference. With the rise of the social media generation, innovative methods to inspire, engage, and inform students contributing to the continuous evolution of medical education should be encouraged and further explored.