To Improve the Initial Inpatient Management of Adolescents Admitted with Severe Anorexia Nervosa: A Narrative Review and a Convenient Protocol

Inadequate nutritional rehabilitation of severely malnourished adolescents with Anorexia Nervosa (AN) increases the risk of medical complications. There is no consensus on best practices for inpatient nutritional rehabilitation and medical stabilization for severe AN. This study aimed to elaborate an admission protocol for adolescents with severe AN based on a comprehensive narrative review of current evidence. A Pubmed search was conducted in July 2017 and updated in August 2020, using the keywords severe AN or eating disorders (ED), management guidelines and adolescent. Relevant references cited in these guidelines were retrieved. A secondary search was conducted using AN or ED and refeeding protocol, refeeding syndrome (RS), hypophosphatemia, hypoglycemia, cardiac monitoring or cardiac complications. Evidence obtained was used to develop the admission protocol. Selective blood tests were proposed during the first three days of nutritional rehabilitation. Higher initial caloric intake is supported by evidence. Continuous nasogastric tube feeding was proposed for patients with a BMI < 12 kg/m2. We monitor hypoglycemia for 72 h. Continuous cardiac monitoring for bradycardia <30 BPM and systematic phosphate supplementation should be considered. Developing protocols is necessary to improve standardization of care. We provide an example of an inpatient admission protocol for adolescents with severe AN.

Atrial Fibrillation Detected After Stroke and Transient Ischemic Attack: A Novel Clinical Concept Challenging Current Views

Atrial fibrillation (AF) can be newly detected in approximately one-fourth of patients with ischemic stroke and transient ischemic attack without previously recognized AF. We present updated evidence supporting that AF detected after stroke or transient ischemic attack (AFDAS) may be a distinct clinical entity from AF known before stroke occurrence (known atrial fibrillation). Data suggest that AFDAS can arise from the interplay of cardiogenic and neurogenic forces. The embolic risk of AFDAS can be understood as a gradient defined by the prevalence of vascular comorbidities, the burden of AF, neurogenic autonomic changes, and the severity of atrial cardiopathy. The balance of existing data indicates that AFDAS has a lower prevalence of cardiovascular comorbidities, a lower degree of cardiac abnormalities than known atrial fibrillation, a high proportion (52%) of very brief (<30 seconds) AF paroxysms, and is more frequently associated with insular brain infarction. These distinctive features of AFDAS may explain its recently observed lower associated risk of stroke than known atrial fibrillation. We present an updated ad-hoc meta-analysis of randomized clinical trials in which the association between prolonged cardiac monitoring and reduced risk of ischemic stroke was nonsignificant (incidence rate ratio, 0.90 [95% CI, 0.71–1.15]). These findings highlight that larger and sufficiently powered randomized controlled trials of prolonged cardiac monitoring assessing the risk of stroke recurrence are needed. Meanwhile, we call for further research on AFDAS and stroke recurrence, and a tailored approach when using prolonged cardiac monitoring after ischemic stroke or transient ischemic attack, focusing on patients at higher risk of AFDAS and, more importantly, at higher risk of cardiac embolism.

South Asian-Specific MYBPC3Δ25bp Deletion Carriers Display Hypercontraction and Impaired Diastolic Function Under Exercise Stress

Background: A 25-base pair (25bp) intronic deletion in the MYBPC3 gene enriched in South Asians (SAs) is a risk allele for late-onset left ventricular (LV) dysfunction, hypertrophy, and heart failure (HF) with several forms of cardiomyopathy. However, the effect of this variant on exercise parameters has not been evaluated.Methods: As a pilot study, 10 asymptomatic SA carriers of the MYBPC3Δ25bp variant (52.9 ± 2.14 years) and 10 age- and gender-matched non-carriers (NCs) (50.1 ± 2.7 years) were evaluated at baseline and under exercise stress conditions using bicycle exercise echocardiography and continuous cardiac monitoring.Results: Baseline echocardiography parameters were not different between the two groups. However, in response to exercise stress, the carriers of Δ25bp had significantly higher LV ejection fraction (%) (CI: 4.57 ± 1.93; p &lt; 0.0001), LV outflow tract peak velocity (m/s) (CI: 0.19 ± 0.07; p &lt; 0.0001), and higher aortic valve (AV) peak velocity (m/s) (CI: 0.103 ± 0.08; p = 0.01) in comparison to NCs, and E/A ratio, a marker of diastolic compliance, was significantly lower in Δ25bp carriers (CI: 0.107 ± 0.102; p = 0.038). Interestingly, LV end-diastolic diameter (LVIDdia) was augmented in NCs in response to stress, while it did not increase in Δ25bp carriers (CI: 0.239 ± 0.125; p = 0.0002). Further, stress-induced right ventricular systolic excursion velocity s' (m/s), as a marker of right ventricle function, increased similarly in both groups, but tricuspid annular plane systolic excursion increased more in carriers (slope: 0.008; p = 0.0001), suggesting right ventricle functional differences between the two groups.Conclusions: These data support that MYBPC3Δ25bp is associated with LV hypercontraction under stress conditions with evidence of diastolic impairment.

Preliminary Analysis of a Wireless and Wearable Electronic-Textile EASI-Based Electrocardiogram

Background: With cardiovascular disease continuing to be the leading cause of death and the primary reason for hospitalization worldwide, there is an increased burden on healthcare facilities. Electronic-textile (e-textile)-based cardiac monitoring offers a viable option to allow cardiac rehabilitation programs to be conducted outside of the hospital.Objectives: This study aimed to determine whether signals produced by an e-textile ECG monitor with textile electrodes in an EASI configuration are of sufficient quality to be used for cardiac monitoring. Specific objectives were to investigate the effect of the textile electrode characteristics, placement, and condition on signal quality, and finally to compare results to a reference ECG obtained from a current clinical standard the Holter monitor.Methods: ECGs during different body movements (yawning, deep-breathing, coughing, sideways, and up movement) and activities of daily living (sitting, sitting/standing from a chair, and climbing stairs) were collected from a baseline standard of normal healthy adult male using a novel e-textile ECG and a reference Holter monitor. Each movement or activity was recorded for 5 min with 2-min intervals between each recording. Three different textile area electrodes (40, 60, and 70 mm2) and electrode thicknesses (3, 5, and 10 mm) were considered in the experiment. The effect of electrode placement within the EASI configuration was also studied. Different signal quality parameters, including signal to noise ratio, approximate entropy, baseline power signal quality index, and QRS duration and QT intervals, were used to evaluate the accuracy and reliability of the textile-based ECG monitor.Results: The overall signal quality from the 70 mm2 textile electrodes was higher compared to the smaller area electrodes. Results showed that the ECGs from 3 and 5 mm textile electrodes showed good quality. Regarding location, placing the “A” and “I” electrodes on the left and right anterior axillary points, respectively, showed higher signal quality compared to the standard EASI electrode placement. Wet textile electrodes showed better signal quality compared to their dry counterparts. When compared to the traditional Holter monitor, there was no significant difference in signal quality, which indicated textile monitoring was as good as current clinical standards (non-inferior).Conclusion: The e-textile EASI ECG monitor could be a viable option for real-time monitoring of cardiac activities. A clinical trial in a larger sample is recommended to validate the results in a clinical population.

Discrete Wavelet Transforms-Based Analysis of Accelerometer Signals for Continuous Human Cardiac Monitoring

Measuring cardiac activity from the chest using an accelerometer is commonly referred to as seismocardiography. Unfortunately, it cannot provide clinically valid data because it is easily corrupted by motion artefacts. This paper proposes two methods to improve peak detection from noisy seismocardiography data. They rely on discrete wavelet transform analysis using either biorthogonal 3.9 or reverse biorthogonal 3.9. The first method involves slicing chest vibrations for each cardiac activity, and then detecting the peak location, whereas the other method aims at detecting the peak directly from chest vibrations without segmentation. Performance evaluations were conducted on signals recorded from small children and adults based on missing and additional peaks. Both algorithms showed a low error rate (15.4% and 2.1% for children/infants and adults, respectively) for signals obtained in resting state. The average error for sitting and breathing tasks (adults only) was 14.4%. In summary, the first algorithm proved more promising for further exploration.

Commercially-available heart rate monitor repurposed into a 9-gram standalone device for automatic arrhythmia detection with snapshot electrocardiographic capability: a pilot validation.

Background: The usefulness of opportunistic arrhythmia screening strategies, using an electrocardiogram (ECG) or other methods for random snapshot assessments is limited by the unexpected and occasional nature of arrhythmias, leading to a high rate of missed-diagnosis. We have previously validated a cardiac monitoring system for AF detection pairing simple consumer-grade Bluetooth low-energy (BLE) heart rate (HR) sensors with a smartphone application (RITMIA, Heart Sentinel srl, Italy). In the current study we test a significant upgrade to the abovementioned system, thanks to the technical capability of new HR sensors to run algorithms on the sensor itself and to acquire (and store on-board) single-lead ECG strips, if asked to do so. Methods and Results We have reprogrammed a HR monitor intended for sports use (Movensense HR+) to run our proprietary RITMIA algorithm code in real-time, based on RR analysis, so that if any type of arrhythmia is detected it triggers a brief retrospective recording of a single-lead ECG, providing tracings of the specific arrhythmia for later consultation. We report the initial data on the behavior, feasibility and high diagnostic accuracy of this ultra-low weight customized device for standalone automatic arrhythmia detection and ECG recording, when several types of arrhythmias were simulated, under different baseline conditions. Conclusions This customized device was capable to detect all types of simulated arrhythmias and correctly triggered an visually interpretable ECG tracing. Future human studies are needed to address real-life accuracy of this device.

Cardiac Pacing in Cardioinhibitory Reflex Syncope: Clinical Use of Closed-loop Stimulation

Cardiac pacing has been studied extensively in patients with reflex syncope over the past two decades. The heterogeneity of the forms and clinical manifestations of reflex syncope explain the controversial results of older randomised clinical trials. New evidence from recent trials has changed medical practice, now leading to clear indications for pacing in patients with asystolic syncope documented during carotid sinus massage, implantable cardiac monitoring or tilt testing. Given that recent trials in reflex syncope have been performed using the closed-loop stimulation algorithm, the authors will briefly discuss this pacing mode, review hypotheses about the mechanisms underlying its activation during syncope and provide practical instructions for programming and troubleshooting.