Effect of COVID-19 on Continuing Education Activities and Learner Interactions: Report from Six Accreditation Systems.

The COVID-19 pandemic has had disruptive effects on all parts of the health-care system, including the continuing education (CE) landscape. This report documents, what has happened in six different CE accreditation systems to CE activities as well as learners. Complete lockdown periods in the first part of the COVID-19 pandemic have inevitably led to reductions in numbers of the then predominant format of education, i.e. onsite in-person meetings. However, with impressive speed CE providers have switched to online educational formats. With regard to learner interactions this has compensated, and in some systems even overcompensated, the loss of in-person educational opportunities. Thus, our data convincingly demonstrate the resilience of CPD in times of a global health crisis and offer important insights in how CPD might become more effective in the future.

Association for European Paediatric and Congenital Cardiology recommendations for basic training in paediatric and congenital cardiology 2020.

The recommendations of the Association for European Paediatric and Congenital Cardiology for basic training in paediatric and congenital cardiology required to be recognised as a paediatric cardiologist by the Association for European Paediatric and Congenital Cardiology are described below. Those wishing to achieve more advanced training in particular areas of paediatric cardiology should consult the training recommendations of the different Association for European Paediatric and Congenital Cardiology Working Groups available on the Association for European Paediatric and Congenital Cardiology website (www.aepc.org) and the respective publications 1-6. The development of training requirements is the responsibility of the Educational Committee and the Association for European Paediatric and Congenital Cardiology Council in collaboration with the Working Groups of the Association for European Paediatric and Congenital Cardiology. Trainees should be exposed to all aspects of general paediatric and congenital cardiology from fetal life to adolescence and adulthood. Centres performing generalised and specialised work in paediatric and congenital cardiology should be committed to deliver postgraduate training. At each training institute, trainers should be appointed to supervise and act as mentors to the trainees. Association for European Paediatric and Congenital Cardiology will provide basic teaching courses to supplement the training process.

The future of accreditation of continuing medical education (CME)-continuing professional development (CPD) in Europe: harmonisation through dialogue and consensus.

In Europe, there are currently some 30 different jurisdictions and no overarching legislation regarding CME-CPD accreditation, since legislative competency related to national health-care systems lies with national authorities. Thus, public demonstration of professional agreement regarding the principles, rules and practice of CME-CPD as well as its accreditation is a highly desirable professional and political objective in Europe, where free movement and freedom to offer professional (medical) services is a key feature of the EU vision of the single market. The newly formed association of independent European accreditors, Continuing Medical Education - European Accreditors (CME-EA) is committed to offering a platform for dialogue between individuals and organisations involved in definition of professional codes in general, and accreditation of CME-CPD in particular on the national level. The aim is to reach a European consensus on principles and rules applied in planning and delivery of CME-CPD. This includes consensus on constituent characteristics of accreditors as well as principles and practice of accreditation.

Embarazo y enfermedad cardiaca / Pregnancy and cardiac disease

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Functional Recovery of a Human Neonatal Heart After Severe Myocardial Infarction.

RATIONALE: Cardiac remodeling and subsequent heart failure remain critical issues after myocardial infarction despite improved treatment and reperfusion strategies. Recently, cardiac regeneration has been demonstrated in fish and newborn mice after apex resection or cardiac infarctions. Two key issues remain to translate findings in model organisms to future therapies in humans: what is the mechanism and can cardiac regeneration indeed occur in newborn humans? OBJECTIVE: To assess whether human neonatal hearts can functionally recover after myocardial infarction. METHODS AND RESULTS: Here, we report the case of a newborn child having a severe myocardial infarction due to coronary artery occlusion. The child developed massive cardiac damage as defined by serum markers for cardiomyocyte cell death, electrocardiograms, echocardiography, and cardiac angiography. Remarkably, within weeks after the initial ischemic insult, we observed functional cardiac recovery, which translated into long-term normal heart function. CONCLUSIONS: These data indicate that, similar to neonatal rodents, newborn humans might have the intrinsic capacity to repair myocardial damage and completely recover cardiac function.

Indications for cardiovascular magnetic resonance in children with congenital and acquired heart disease: an expert consensus paper of the Imaging Working Group of the AEPC and the Cardiovascular Magnetic Resonance Section of the EACVI.

This article provides expert opinion on the use of cardiovascular magnetic resonance (CMR) in young patients with congenital heart disease (CHD) and in specific clinical situations. As peculiar challenges apply to imaging children, paediatric aspects are repeatedly discussed. The first section of the paper addresses settings and techniques, including the basic sequences used in paediatric CMR, safety, and sedation. In the second section, the indication, application, and clinical relevance of CMR in the most frequent CHD are discussed in detail. In the current era of multimodality imaging, the strengths of CMR are compared with other imaging modalities. At the end of each chapter, a brief summary with expert consensus key points is provided. The recommendations provided are strongly clinically oriented. The paper addresses not only imagers performing CMR, but also clinical cardiologists who want to know which information can be obtained by CMR and how to integrate it in clinical decision-making.

Six-minute walk distance in overweight children and adolescents: effects of a weight-reducing program.

OBJECTIVE: To assess the significance of consecutive six-minute walk tests (6MWTs) during a weight reduction program. STUDY DESIGN: Overweight children and adolescents (n = 113; mean ± standard deviation age, 12.9 ± 2.0 years; 64 girls) performed a standardized 6MWT at the beginning and end of an in-patient weight reduction program consisting of exercise, diet, and educational and psychological support. Their 6-minute walk distance (6MWD) was compared with age- and sex-matched normal-weight children (n = 353). RESULTS: Preintervention 6MWD averaged 93% of control subjects (631 ± 88 m versus 675 ± 70 m, P < .001) and increased significantly to 667 ± 90 m (P < .001) after 27 ± 7 days of intervention (99% of control subjects; P = .260). Participants reduced their body weight from 80.9 ± 19.8 kg to 75.6 ± 19.0 kg, body mass index (BMI) percentile from 98.2 ± 2.1% to 96.8 ± 3.8%, and BMI-standard deviation score from 2.37 ± 0.6 to 2.13 ± 0.6 (P < .001 for each variable). BMI-standard deviation score, height, and the change in heart rate during the 6MWT were significant independent predictors of the 6MWD at preintervention and at post intervention time points (P < .001 each). CONCLUSIONS: The 6MWD increases during a weight reduction program, indicating improvement of physical fitness and decreased metabolic demand during daily activities in overweight children. The 6MWT represents a practical and reliable assessment tool for exercise performance in overweight children and adolescents.

Intravenous tezosentan and vardenafil attenuate acute hypoxic pulmonary hypertension.

Excessive hypoxic pulmonary hypertension imposes right ventricular strain by increasing afterload that may lead to right heart failure and death. Increased phosphodiesterase activity, as well as increased levels of endothelin-1, has been discussed as molecular mechanisms. We investigated the hemodynamic and intrapulmonary effects of the intravenous dual endothelin A and B receptor blocker tezosentan, and of the phosphodiesterase-5 (PDE-5) antagonist vardenafil in a pig model of acute normobaric hypoxic pulmonary hypertension. Eighteen 4-week-old ventilated white farm pigs were exposed to normobaric hypoxia (FiO2 12%) and randomly assigned to three groups (n = 6) in order to receive either intravenous tezosentan or vardenafil or to serve as control. Arterial alveolar oxygen differences were the same with both drugs. After 90 min of treatment, pulmonary artery pressure and vascular resistance were significantly lower in both treatment groups when compared to controls (p < 0.001). Cardiac index increased significantly with vardenafil alone (2.8 l x min(-1) x m2 +/- 0.7 to 4.2 l x min x m2 +/- 0.7, p = 0.0003). Intravenous tezosentan, as well as vardenafil equipotently attenuate acute hypoxic pulmonary hypertension without afflicting pulmonary gas exchange. However, cardiac index increases with vardenafil only.

Prolonged but successful weaning from left ventricular assist device after cardiac decompensation due to late-recognized coarctation of the aorta in a toddler.

A 2-year-old boy was presented with late-recognized coarctation of the aorta and pulmonary hypertension due to left ventricular failure. The coarctation was corrected at the day of admission with a good postoperative result. However, weaning from the respirator failed despite multiple drug support due to left ventricular failure. Consequently, a left ventricular assist device (LVAD) was implanted 22 days later. The further course was complicated by systemic hypertension and ongoing pulmonary hypertension requiring extensive antihypertensive therapy. The first attempt to wean from LVAD failed and the left ventricle was left completely unloaded for additional 4 weeks. The second weaning attempt, using a very smooth weaning protocol, led to a recovered left ventricle and facilitated the removal of the assist device after a total of 120 days. The patient was discharged with normal cardiac function, but he still requires antihypertensive therapy. We believe that the slow reduction of the LVAD support was the key measure that leads to the successful weaning of the patient, thereby avoiding heart transplantation.

Diminished response to tick-borne encephalitis vaccination in thymectomized children.

In order to analyze the clinical impact of immunological alterations in thymectomized children after exposure to a new antigen (tick-borne encephalitis virus (TBEV) vaccine), 17 thymectomized children completed a three-dose immunization regimen. Thymectomized children showed significantly lower TBEV IgG antibody levels after the second vaccination when compared to healthy age-matched controls (n=30) (p=0.03), but a normal response after the third vaccination. Age at thymectomy correlated significantly with the TBEV IgG antibody levels (p=0.04). Thymectomized children also showed significantly lower total counts and percentages for naïve T cells correlating with time after thymectomy (p=0.02), than observed for controls. These changes in T cell subsets and the decreased ability to respond to new antigens in thymectomized children, as observed here, may precede more striking effects such as higher infection rates or autoimmune conditions as they age.

Intravenous tezosentan improves gas exchange and hemodynamics in acute lung injury secondary to meconium aspiration.

OBJECTIVE: Meconium aspiration induces acute lung injury (ALI) and subsequent pulmonary arterial hypertension (PAH) which may lead to right ventricular failure. Increase of endothelin-1, thromboxane-A, and phosphodiesterases are discussed molecular mechanisms. We investigated the intrapulmonary and hemodynamic effects of the intravenous dual endothelin A and B receptor blocker tezosentan and inhalational iloprost in a model of ALI due to meconium aspiration. DESIGN: Animal study. SETTING: University-affiliated research laboratory. SUBJECTS: White farm pigs. INTERVENTIONS: Acute lung injury was induced in 24 pigs by instillation of meconium. Animals were randomly assigned to four groups to receive either intravenous tezosentan, inhalational iloprost, or combined tezosentan and iloprost, or to serve as controls. MEASUREMENTS AND RESULTS: After meconium aspiration-induced lung injury each treatment increased oxyhemoglobin saturations (TEZO: 88 +/- 6% (p = 0.02), ILO: 85 +/- 13% (p = 0.05), TEZO-ILO: 89 +/- 6% (p = 0.02), control: 70 +/- 18%). TEZO but not ILO significantly decreased pulmonary arterial pressure and pulmonary vascular resistance (both p < 0.01). ILO alone decreased intrapulmonary shunt blood flow (p < 0.01). Compared with control, TEZO-ILO yielded the highest arterial partial pressure of oxygen (70 +/- 6 torr vs.49 +/- 9 torr, p = 0.04), although it decreased arterial blood pressure (change from 71 +/- 13 mmHg to 62 +/- 12 mmHg vs.85 +/- 14 mmHg to 80 +/- 11 mmHg (p = 0.01). CONCLUSIONS: Intravenous TEZO improves pulmonary gas exchange and hemodynamics in experimental acute lung injury secondary to meconium aspiration. Inhaled ILO improves gas exchange only, thereby reducing intrapulmonary shunt blood flow. Combination of TEZO and ILO marginally improves pulmonary gas exchange at the disadvantage of pulmonary selectivity.

The pediatric mechanical circulatory support program in Innsbruck, Austria, and the impact of such programs on lack of donor hearts in Europe.

Strategy and results of the Innsbruck Mechanical Circulatory Support Program are presented, and the impact of such programs on pediatric heart transplantation (HTX) in Europe is discussed. Venoarterial extracorporeal membrane oxygenation (vaECMO) and ventricular assist devices (VADs) were used in 21 pediatric patients (median age 3.3 years, 2 days to 17 years) for acute heart failure (AHF) following a bridge or bridge-to-bridge strategy. Twelve patients were treated with vaECMO: eight were weaned after 2-10 days, two died, and two were switched to a VAD. Of the last, one was weaned 47 days later and the other underwent HTX 168 days later. In nine patients, VAD was implanted without preceding vaECMO. One such patient died (cerebral hemorrhage) after 236 days; of the remaining eight patients three were weaned and five underwent HTX. Waiting time for HTX (high-urgency status) varied from 4 to 372 days. Fifteen patients were discharged (follow up: 2-74 months); 14 are doing very well (New York Heart Association (NYHA) Functional Classification Class I, neurologically normal), whereas one suffers from severe neurologic damage, presumably from resuscitation before vaECMO. Data from Eurotransplant on pediatric HTX in 2004, 2005, and 2006 (33, 49, and 34 transplanted hearts, respectively; recipients <16 years of age) are discussed. Mechanical circulatory support (MCS) substantially improves survival with AHF in pediatric patients. Medium-term support (up to 400 days in our patients) is possible and outcome of survivors is excellent. Wide spread use of MCS might slightly aggravate the lack of donor organs, which could result in longer support times.

Six-minute walk test in children and adolescents.

OBJECTIVE: To evaluate the 6-minute walking distance (6MWD) for healthy Caucasian children and adolescents of a population-based sample from the age of 3 to 18 years. STUDY DESIGN: Two hundred and eighty boys and 248 girls completed a modified test, using a measuring wheel as incentive device. RESULTS: Median 6MWD increased from the age of 3 to 11 years in boys and girls alike and increased further with increasing age in boys (from 667.3 m to 727.6 m), whereas it essentially plateaued in girls (655.8 m to 660.9 m). After adjusting for age, height (P = .001 in boys and P < .001 in girls) remained independently correlated with the 6MWD. In the best fitting and most efficient linear and quadratic regression models, the variables age and height explained about 49% of the variability of the 6MWD in boys and 50% in girls. CONCLUSION: This modified 6-minute walk test (6MWT) proved to be safe, easy to perform, and highly acceptable to children. It provides a simple and inexpensive means to measure functional exercise capacity in children, even of young age, and might be of value when conducting comparable studies.

NT-proBNP concentrations indicate cardiac disease in pediatric patients.

OBJECTIVE: To test the performance of N-terminal pro B-type natriuretic peptide to distinguish from cardiac and non-cardiac disease in the pediatric patient population. METHOD: NT-proBNP concentrations were retrospectively analysed in 102 pediatric patients (median age: 5.96 years; 0-18 years) with cardiac diseases comprising left-to-right-shunt lesions (n=42), left heart lesions (n=47) and right heart lesions (n=13) and in 65 pediatric patients (median age: 3.37 years; 0.03-18 years) with acute infection, minor trauma or neurological disorder. RESULTS: NT-proBNP levels between patients without heart disease and patients with heart disease differed significantly with a median NT-proBNP value of 224.9 ng/l, 108.7 ng/l-945.6 ng/l (25th-75th percentile) versus 76.7 ng/l, 35.0 ng/l-122.4 ng/l, p<0.0001. The diagnostic performance of NT-proBNP to differentiate between patients with and without cardiac diseases was high with an area under curve of 0.81 (95% confidence intervals 0.75-0.87). At a cut-off value of 134 ng/l the specificity was 83% (95% CI: 74-92%). The presence of heart failure (p<0.0001) had a significant impact on NT-proBNP concentrations. CONCLUSIONS: NT-proBNP measurement is a helpful addition to identify pediatric patients with heart disease.

A multi-platform approach to image guided radiation therapy (IGRT).

Siemens Medical Solutions, Oncology Care Systems Group (SMSOCSG) is supporting the development of several technologies that enable image acquisition and decision making processes required for IGRT in various clinical settings. Four such technologies are presented including: (i) the integration of a traditional multi-slice computed tomography (CT) scanner "on rails" with a C-arm gantry linear accelerator; (ii) the development of a high sensitivity, fast, megavoltage (MV) electronic portal imaging device capable of clinical MV Conebeam CT (MVCBCT) reconstruction and fluoroscopy mounted on a C-arm gantry linear accelerator; (iii) the modification of a mobile C-arm with flat panel kilovoltage (kV) diagnostic imager; and (iv) the development of an in-line megavoltage and kilovoltage flat panel imaging system that has the potential to image both anatomical and dosimetric information in "real-time" utilizing the traditional C-arm gantry linear accelerator geometry. Each method of IGRT has unique as well as complementary qualities which are discussed from both a clinical and technical perspective.