Bringing gut microbiota into the spotlight of clinical research and medical practice

Despite the increasing scientific interest and expanding role of gut microbiota(GM)in human health,it is rarely reported in case reports and deployed in cli-nical practice.Proteins and metabolites produced by microbiota contribute to im-mune system development,energy homeostasis and digestion.Exo-and endoge-nous factors can alter its composition.Disturbance of microbiota,also known as dysbiosis,is associated with various pathological conditions.Specific bacterial taxa and related metabolites are involved in disease pathogenesis and therefore can serve as a diagnostic tool.GM could also be a useful prognostic factor by predicting future disease onset and preventing hospital-associated infections.Ad-ditionally,it can influence response to treatments,including those for cancers,by altering drug bioavailability.A thorough understanding of its function has per-mitted significant development in therapeutics,such as probiotics and fecal trans-plantation.Hence,GM should be considered as a ground-breaking biological parameter,and it is advisable to be investigated and reported in literature in a more consistent and systematic way.

Safety and effectiveness of neuromuscular electrical stimulation in cardiac surgery:A systematic review

BACKGROUND Lack of mobilization and prolonged stay in the intensive care unit(ICU)are major factors resulting in the development of ICU-acquired muscle weakness(ICUAW).ICUAW is a type of skeletal muscle dysfunction and a common complication of patients after cardiac surgery,and may be a risk factor for prolonged duration of mechanical ventilation,associated with a higher risk of readmission and higher mortality.Early mobilization in the ICU after cardiac surgery has been found to be low with a significant trend to increase over ICU stay and is also associated with a reduced duration of mechanical ventilation and ICU length of stay.Neuromuscular electrical stimulation(NMES)is an alternative modality of exercise in patients with muscle weakness.A major advantage of NMES is that it can be applied even in sedated patients in the ICU,a fact that might enhance early mobilization in these patients.AIM To evaluate safety,feasibility and effectiveness of NMES on functional capacity and muscle strength in patients before and after cardiac surgery.METHODS We performed a search on Pubmed,Physiotherapy Evidence Database(PEDro),Embase and CINAHL databases,selecting papers published between December 2012 and April 2023 and identified published randomized controlled trials(RCTs)that included implementation of NMES in patients before after cardiac surgery.RCTs were assessed for methodological rigor and risk of bias via the PEDro.The primary outcomes were safety and functional capacity and the secondary outcomes were muscle strength and function.RESULTS Ten studies were included in our systematic review,resulting in 703 participants.Almost half of them performed NMES and the other half were included in the control group,treated with usual care.Nine studies investigated patients after cardiac surgery and 1 study before cardiac surgery.Functional capacity was assessed in 8 studies via 6MWT or other indices,and improved only in 1 study before and in 1 after cardiac surgery.Nine studies explored the effects of NMES on muscle strength and function and,most of them,found increase of muscle strength and improvement in muscle function after NMES.NMES was safe in all studies without any significant complication.CONCLUSION NMES is safe,feasible and has beneficial effects on muscle strength and function in patients after cardiac surgery,but has no significant effect on functional capacity.

Latest updates on structure and recommendations of cardiac rehabilitation programs in chronic heart failure

Chronic heart failure(HF)is a clinical syndrome with high morbidity and mor-tality worldwide.Cardiac rehabilitation(CR)is a medically supervised program designed to maintain or improve cardiovascular health of people living with HF,recommended by both American and European guidelines.A CR program con-sists of a multispecialty group including physicians,nurses,physiotherapists,trainers,nutritionists,and psychologists with the common purpose of improving functional capacity and quality of life of chronic HF patients.Physical activity,lifestyle,and psychological support are core components of a successful CR program.CR has been shown to be beneficial in all ejection fraction categories in HF and most patients,who are stable under medication,are capable of participating.An individualized exercise prescription should be developed on the basis of a baseline evaluation in all patients.The main modalities of exercise training are aerobic exercise and muscle strength training of different intensity and frequency.It is important to set the appropriate clinical outcomes from the beginning,in order to assess the effectiveness of a CR program.There are still significant limitations that prevent patients from participating in these programs and need to be solved.A significant limitation is the generally low quality of research in CR and the presence of negative trials,such as the rehabilitation after myocardial infarction trial,where comprehensive rehabilitation following myocardial infraction had no important effect on mortality,morbidity,risk factors,or health-related quality of life or activity.In the present editorial,we present all the updated knowledge and recommendations in CR programs.

Overcoming geographical and socioeconomic limitations in colorectal cancer screening

Despite colorectal cancer’s(CRC)high global incidence,residents of low-and middle-income countries,as well as low-income minorities in advanced economies have low screening rates.Observational studies demonstrate that in these groups higher incidence of CRC is observed,yet screening rates remain low for consistent reasons.Low income,low educational background,and lack of awareness in combination with inadequate social security of certain population groups impede access and compliance rates to CRC screening.On the other hand,despite the global availability of multiple screening approaches(colonoscopy,sigmoidoscopy,faecal occult blood test,faecal immunochemical test,computed tomography-colonography,etc.)with proven diagnostic validity,many low-income countries still lack established screening programs.The absence of screening guidelines in these countries along with the heterogeneity of guidelines in the rest of the world,demonstrate the need for global measures to tackle this issue comprehensively.An essential step forward is to develop a global approach that will link specific elements of screening with the incidence and available resources in each country,to ensure the achievement of at least a minimum screening program in low-income countries.Utilizing cheaper,cost-effective techniques,which can be carried out by less specialized healthcare providers,might not be equivalent to endoscopy for CRC screening but seems more realistic for areas with fewer resources.Awareness has been highlighted as the most pivotal element for the effective implementation of any screening program concerning CRC.Moreover,multiple studies have demonstrated that outreach strategies and community-based educational programs are associated with encouraging outcomes,yet a centrally coordinated expansion of these programs could provide more consistent results.Additionally,patient navigator programs,wherever implemented,have increased CRC screening and improved follow-up.Therefore,global coordination and patient education seem to be the main areas on which policy making needs to focus.

Quality of life and functional capacity in patients after cardiac surgery intensive care unit

Coronary heart disease and aortic stenosis are prevalent cardiovascular diseases worldwide,leading to morbidity and mortality.Coronary artery bypass grafting(CABG)and surgical aortic valve replacement(SAVR)have therapeutic benefits,including improved postoperative quality of life(QoL)and enhanced patient functional capacity which are key indicators of cardiac surgery outcome.In this article,we review the latest studies of QoL outcomes and functional capacity in patients who underwent cardiac surgery.Many standardized instruments are used to evaluate QoL and functional conditions.Preoperative health status,age,length of intensive care unit stay,operative risk,type of procedure,and other pre-,intra-,and postoperative factors affect postoperative QoL.Elderly patients experience impaired physical status soon after cardiac surgery,but it improves in the following period.CABG and SAVR are associated with increases of physical and mental health and functional capacity in the immediate postoperative and the long long-term.Cardiac rehabilitation improves patient functional capacity,QoL,and frailty following cardiac surgery.

Recognizing and preventing complications regarding bioresorbable scaffolds during coronary interventions

The evolution of coronary intervention techniques and equipment has led to more sophisticated procedures for the treatment of highly complex lesions.However,as a result,the risk of complications has increased,which are mostly iatrogenic and often include equipment failure.Stent dislodgement warrants vigilance for the early diagnosis and a stepwise management approach is required to either expand or retrieve the lost stent.In the era of bioresorbable scaffolds that are not radiopaque,increased caution is required.Intravascular imaging may assist in detecting the lost scaffold in cases of no visibility fluoroscopically.Adequate lesion preparation is the key to minimizing the possibility of equipment loss;however,in the case that it occurs,commercially available and improvised devices and techniques may be applied.

Recent advances in the diagnostic methods and therapeutic strategies of transthyretin cardiac amyloidosis

Cardiac amyloidosis is a progressive disease characterized by the buildup of amyloid fibrils in the extracellular space of the heart.It is divided in 2 main types,immunoglobulin light chain amyloidosis and transthyretin amyloidosis(ATTR),and ATTR amyloidosis is further divided in 2 subtypes,non-hereditary wild type ATTR and hereditary mutant variant amyloidosis.Incidence and prevalence of ATTR cardiac amyloidosis is increasing over the last years due to the improvements in diagnostic methods.Survival rates are improving due to the development of novel therapeutic strategies.Tafamidis is the only disease-modifying approved therapy in ATTR amyloidosis so far.However,the most recent advances in medical therapies have added more options with the potential to become part of the therapeutic armamentarium of the disease.Agents including acoramidis,eplontersen,vutrisiran,patisiran and anti-monoclonal antibody NI006 are being investigated on cardiac function in large,multicenter controlled trials which are expected to be completed within the next 2-3 years,providing promising results in patients with ATTR cardiac amyloidosis.However,further and ongoing research is required in order to improve diagnostic methods that could provide an early diagnosis,as well as survival and quality of life of these patients.

Interdepartmental miscommunication regarding radiology:Addressing chronic challenges and exploring solutions

Effective communication and collaboration among healthcare professionals are crucial for delivering high-quality patient care.Interdepartmental miscommunication poses a significant challenge to healthcare systems,potentially undermining the quality of healthcare services provided.In the same manner,communication barriers between referring physicians and radiologists can specifically affect radiology services and patient outcomes.This article attempts to put the spotlight on the ever-present chronic challenges of this issue and prompt readers to recognize the relevant potential pitfalls in their daily clinical practice.Practical solutions are explored and proposed,which should be tailored to the specific needs and issues that each individual institution may face.

Effects of combined aerobic,resistance and inspiratory training in patients with pulmonary hypertension:A systematic review

BACKGROUND Pulmonary hypertension(PH)is a serious progressive disorder of the modern world,characterized by endothelial dysfunction and impaired vasoreactivity.Patients with PH usually present exercise intolerance from the very early stages and reduced exercise capacity.Exercise training has been shown to have beneficial effects in patients with cardiovascular comorbidities.However,data regarding the effects of combined exercise training programs in patients with PH still remains limited.AIM To investigate the effects of combined exercise training programs on exercise capacity and quality of life in patients with PH.METHODS Our search included all available randomized controlled trials(RCTs)regarding combined aerobic,resistance and inspiratory training programs in patients with PH in 4 databases(Pubmed,PEDro,Embase,CINAHL)from 2012 to 2022.Five RCTs were included in the final analysis.Functional capacity,assessed by peak VO_(2)or 6-min walking test(6MWT),as well as quality of life,assessed by the SF-36 questionnaire,were set as the primary outcomes in our study.RESULTS Peak VO_(2)was measured in 4 out of the 5 RCTs while 6MWT was measured in all RCTs.Both indices of functional capacity were significantly increased in patients with PH who underwent combined exercise training compared to the controls in all of the included RCTs(P<0.05).Quality of life was measured in 4 out of 5 RCTs.Although patients improved their quality of life in each group,however,only 2 RCTs demonstrated further improvement in patients performing combined training compared to controls.CONCLUSION By this systematic review,we have demonstrated that combined aerobic,resistance and inspiratory exercise training is safe and has beneficial effects on aerobic capacity and quality of life in patients with PH.Such exercise training regimen may be part of the therapeutic strategy of the syndrome.

Gut microbiome in alcohol use disorder:Implications for health outcomes and therapeutic strategies-a literature review

Alcohol use disorder(AUD)represents a major public health issue which affects millions of people globally and consist a chronic relapsing condition associated with substantial morbidity and mortality.The gut microbiome plays a crucial role in maintaining overall health and has emerged as a significant contributor to the pathophysiology of various psychiatric disorders.Recent evidence suggests that the gut microbiome is intimately linked to the development and progression of AUD,with alcohol consumption directly impacting its composition and function.This review article aims to explore the intricate relationship between the gut microbiome and AUD,focusing on the implications for mental health outcomes and potential therapeutic strategies.We discuss the bidirectional communication between the gut microbiome and the brain,highlighting the role of microbiotaderived metabolites in neuroinflammation,neurotransmission,and mood regulation.Furthermore,we examine the influence of AUD-related factors,such as alcohol-induced gut dysbiosis and increased intestinal permeability,on mental health outcomes.Finally,we explore emerging therapeutic avenues targeting the gut microbiome in the management of AUD,including prebiotics,probiotics,and fecal microbiota transplantation.Understanding the complex interplay between the gut microbiome and AUD holds promise for developing novel interventions that could improve mental health outcomes in individuals with AUD.

Burril-Bernard Crohn(1884-1983)and the disease which bears his name

Background:Crohn’s disease,described by Dr.Burrill Crohn and his colleagues in 1932,continues to be of great research and clinical interest.It was initially perceived as a distinct condition and it has evolved since into a complex disease,with debates still going regarding its classification and etiology.Even though more that 80 years of research have passed,numerous significant questions regarding the disease’s causes and best possible treatment strategies still remain.Methods:This article reviews both historical and contemporary perspectives on Crohn’s disease,including its initial description,the research developments that happened in the years to follow,as well as the way it is regarded nowadays.It refers to notable contributions from medical figures,such as Dr.Crohn and his colleagues,examines related advances made in medical research and mentions the challenges and the treatment strategies that are still being discussed.Results:This article highlights the evolution of Crohn’s disease from a distinct condition to a more heterogeneous one.Furthermore,it refers to advancements made in medical research,such as the identification of CARD15(NOD2)gene mutations and the role of dysbiosis,and it examines current therapeutic approaches.Conclusion:Even though significant progress has been made since the initial description of Chron’s disease,there is no definitive cure,even though it has been determined that genetic and environmental factors are of great importance.The ongoing research could possibly lead to future discoveries and therefore aid in the discovery of efficient management and treatment of Crohn’s disease.

Irreversible electroporation for the management of pancreatic cancer: Current data and future directions

Pancreatic cancer is currently the seventh leading cause of cancer death(4.5%of all cancer deaths)while 80%-90%of the patients suffer from unresectable disease at the time of diagnosis.Prognosis remains poor,with a mean survival up to 15 mo following systemic chemotherapy.Loco-regional thermal ablative techniques are rarely implemented due to the increased risk of thermal injury to the adjacent structures,which can lead to severe adverse events.Irreversible electroporation,a promising novel non-thermal ablative modality,has been recently introduced in clinical practice for the management of inoperable pancreatic cancer as a safer and more effective loco-regional treatment option.Experimental and initial clinical data are optimistic.This review will focus on the basic principles of IRE technology,currently available data,and future directions.

Liver replacement therapy with extracorporeal blood purification techniques current knowledge and future directions

Clinically,it is highly challenging to promote recovery in patients with acute liver failure(ALF)and acute-on-chronic liver failure(ACLF).Despite recent advances in understanding the underlying mechanisms of ALF and ACLF,standard medical therapy remains the primary therapeutic approach.Liver transplantation(LT)is considered the last option,and in several cases,it is the only intervention that can be lifesaving.Unfortunately,this intervention is limited by organ donation shortage or exclusion criteria such that not all patients in need can receive a transplant.Another option is to restore impaired liver function with artificial extracorporeal blood purification systems.The first such systems were developed at the end of the 20th century,providing solutions as bridging therapy,either for liver recovery or LT.They enhance the elimination of metabolites and substances that accumulate due to compromised liver function.In addition,they aid in clearance of molecules released during acute liver decompensation,which can initiate an excessive inflammatory response in these patients causing hepatic encephalopathy,multiple-organ failure,and other complications of liver failure.As compared to renal replacement therapies,we have been unsuccessful in using artificial extracorporeal blood purification systems to completely replace liver function despite the outstanding technological evolution of these systems.Extracting middle to high-molecular-weight and hydrophobic/protein-bound molecules remains extremely challenging.The majority of the currently available systems include a combination of methods that cleanse different ranges and types of molecules and toxins.Furthermore,conventional methods such as plasma exchange are being re-evaluated,and novel adsorption filters are increasingly being used for liver indications.These strategies are very promising for the treatment of liver failure.Nevertheless,the best method,system,or device has not been developed yet,and its probability of getting developed in the near future is also low.Furthermore,little is known about the effects of liver support systems on the overall and transplant-free survival of these patients,and further investigation using randomized controlled trials and meta-analyses is needed.This review presents the most popular extracorporeal blood purification techniques for liver replacement therapy.It focuses on general principles of their function,and on evidence regarding their effectiveness in detoxification and in supporting patients with ALF and ACLF.In addition,we have outlined the basic advantages and disadvantages of each system.

Inherited arrhythmias and gene therapy: Are there any ethical considerations to take into account?

Interventional electrophysiology represents a relatively recent subspecialty within the field of cardiology.In the past half-century,there has been significant advan-cement in the development and implementation of innovative ablation treatments and approaches.However,the treatment of arrhythmias continues to be inade-quate.Several arrhythmias,such as ventricular tachycardia and atrial fibrillation,pose significant challenges in terms of therapeutic efficacy,whether through interventional procedures or the administration of antiarrhythmic drugs.Cardio-logists are engaged in ongoing research to explore innovative methodologies,such as genome editing,with the purpose of effectively managing arrhythmias and meeting the growing needs of patients afflicted with rhythm disturbances.The field of genome editing has significant promise and has the potential to serve as a highly effective personalized therapy for rhythm disorders in patients.However,several ethical issues must be considered.

Cardiac arrest and cardiopulmonary resuscitation in“hostile”environments:Using automated compression devices to minimize the rescuers’danger

Mechanical automated compression devices are being used in cardiopulmonary resuscitation instead of manual,“hands-on”,rescuer-delivered chest compressions.The-theoretical-advantages include high-quality non-stop compressions,thus freeing the rescuer performing the compressions and additionally the ability of the rescuer to stand reasonably away from a potentially“hazardous”victim,or from hazardous and/or difficult resuscitation conditions.Such circumstances involve cardiopulmonary resuscitation(CPR)in the Cardiac Catheterization Laboratory,especially directly under the fluoroscopy panel,where radiation is well known to cause detrimental effects to the rescuer,and CPR during/after land or air transportation of cardiac arrest victims.Lastly,CPR in a coronavirus disease 2019 patient/ward,where the danger of contamination and further serious illness of the health provider is very existent.The scope of this review is to review and present literature and current guidelines regarding the use of mechanical compressions in these“hostile”and dangerous settings,while comparing them to manual compressions.

Incidence and peri-operative risk factors for development of acute kidney injury in patients after cardiac surgery:A prospective observational study

BACKGROUND Patients admitted to intensive care unit(ICU) after cardiac surgery develop acute kidney injury(AKI) immediately post-operation. We hypothesized that AKI occurs mainly due to perioperative risk factors and may affect outcome.AIM To assess peri-operative risk factors for AKI post cardiac surgery and its relationship with clinical outcome.METHODS This was an observational single center, tertiary care setting study, which enrolled 206 consecutive patients, admitted to ICU after cardiac surgery. Patients were followed-up until ICU discharge or death, in order to determine the incidence of AKI, perioperative risk factors for AKI and its association with outcome.Univariate and multivariate logistic regression analysis was performed to assess predictor variables for AKI development.RESULTS After ICU admission, 55 patients(26.7%) developed AKI within 48 h. From the logistic regression analysis performed, high EuroScore Ⅱ(OR: 1.18;95%CI: 1.06-1.31, P = 0.003), white blood cells(WBC) pre-operatively(OR: 1.0;95%CI: 1.0-1.0, P = 0.002) and history of chronic kidney disease(OR: 2.82;95%CI: 1.195-6.65, P = 0.018) emerged as independent predictors of AKI among univariate predictors. AKI that developed AKI had longer duration of mechanical ventilation [1113(777–2195) vs 714(511–1020) min, P = 0.0001] and ICU length of stay [70(28–129) vs 26(21–51) h, P = 0.0001], higher rate of ICU-acquired weakness(16.4% vs 5.3%, P =0.015), reintubation(10.9% vs 1.3%, P = 0.005), dialysis(7% vs 0%, P = 0.005), delirium(36.4% vs 23.8%, P = 0.001) and mortality(3.6% vs 0.7%, P = 0.046).CONCLUSION Patients present frequently with AKI after cardiac surgery. EuroScore Ⅱ, WBC count and chronic kidney disease are independent predictors of AKI development. The occurrence of AKI is associated with poor outcome.

COVID-19 and liver injury in individuals with obesity

Coronavirus disease 2019 is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 that manifests as a variety of clinical manifestations,including liver damage commonly detected by a hepatocellular pattern from liver function tests.Liver injury is associated with a worse prognosis overall.Conditions associated with the severity of the disease include obesity and cardiometabolic comorbidities,which are also associated with nonalcoholic fatty liver disease(NAFLD).The presence of NAFLD,similarly to obesity,is associated with an unfavourable impact on the coronavirus disease 2019 outcome.Individuals with these conditions could present with liver damage and elevated liver function tests due to direct viral cytotoxicity,systemic inflammation,ischemic or hypoxic liver damage or drug side effects.However,liver damage in the setting of NAFLD could also be attributed to a pre-existing chronic low-grade inflammation associated with surplus and dysfunctional adipose tissue in these individuals.Here we investigate the hypothesis that a pre-existing inflammatory status is exacerbated after severe acute respiratory syndrome coronavirus 2 infection,which embodies a second hit to the underestimated liver damage.

Diabetes mellitus and atrial fibrillation-from pathophysiology to treatment

Type 2 diabetes mellitus(T2DM)is a leading risk factor for cardiovascular complications around the globe and one of the most common medical conditions.Atrial fibrillation(AF)is the most common supraventricular arrhythmia,with a rapidly increasing prevalence.T2DM has been closely associated with the risk of AF development,identified as an independent risk factor.Regarding cardiovascular complications,both AF and T2DM have been linked with high mortality.The underlying pathophysiology has not been fully determined yet;however,it is multifactorial,including structural,electrical,and autonomic pathways.Novel therapies include pharmaceutical agents in sodium-glucose cotransporter-2 inhibitors,as well as antiarrhythmic strategies,such as cardioversion and ablation.Of interest,glucose-lowering therapies may affect the prevalence of AF.This review presents the current evidence regarding the connection between the two entities,the pathophysiological pathways that link them,and the therapeutic options that exist.

Effectiveness of high intensity interval training on cardiorespiratory fitness and endothelial function in type 2 diabetes:A systematic review

BACKGROUND Type 2 diabetes mellitus(T2DM)is a chronic metabolic syndrome characterized by insulin resistance and hyperglycemia that may lead to endothelial dysfunction,reduced functional capacity and exercise intolerance.Regular aerobic exercise has been promoted as the most beneficial non-pharmacological treatment of cardiovascular diseases.High intensity interval training(HIIT)seems to be superior than moderate-intensity continuous training(MICT)in cardiovascular diseases by improving brachial artery flow-mediated dilation(FMD)and cardiorespiratory fitness to a greater extent.However,the beneficial effects of HIIT in patients with T2DM still remain under investigation and number of studies is limited.AIM To evaluate the effectiveness of high intensity interval training on cardiorespiratory fitness and endothelial function in patients with T2DM.METHODS We performed a search on PubMed,PEDro and CINAHL databases,selecting papers published between December 2012 and December 2022 and identified published randomized controlled trials(RCTs)in the English language that included community or outpatient exercise training programs in patients with T2DM.RCTs were assessed for methodological rigor and risk of bias via the Physiotherapy Evidence Database(PEDro).The primary outcome was peak VO_(2 ) and the secondary outcome was endothelial function assessed either by FMD or other indices of microcirculation.RESULTS Twelve studies were included in our systematic review.The 12 RCTs resulted in 661 participants in total.HIIT was performed in 310 patients(46.8%),MICT to 271 and the rest 80 belonged to the control group.Peak VO_(2 ) increased in 10 out of 12 studies after HIIT.Ten studies compared HIIT with other exercise regimens(MICT or strength endurance)and 4 of them demonstrated additional beneficial effects of HIIT over MICT or other exercise regimens.Moreover,4 studies explored the effects of HIIT on endothelial function and FMD in T2DM patients.In 2 of them,HIIT further improved endothelial function compared to MICT and/or the control group while in the rest 2 studies no differences between HIIT and MICT were observed.CONCLUSION Regular aerobic exercise training has beneficial effects on cardiorespiratory fitness and endothelial function in T2DM patients.HIIT may be superior by improving these parameters to a greater extent than MICT.

Understanding the Importance of Effective Third-Party Risk Management on Data Governance

With a view to adopting to the globalized business landscape,organizations rely on third-party business relationships to enhance their operations,expand their capabilities,and drive innovation.While these collaborations offer numerous benefits,they also introduce a range of risks that organizations must carefully mitigate.If the obligation to meet the regulatory requirements is added to the equation,mitigating the third-party risk related to data governance,becomes one of the biggest challenges.