Medical Bulletin 07/ August/ 2024
Here are the top medical news for the day:
New Study Reveals Link Between Obesity and Increased Risk of Heart Failure
A recent study led by Johns Hopkins Medicine researchers and published in the journal Nature Cardiovascular Research revealed the impact of obesity on muscle structure in patients having a form of heart failure called heart failure with a preserved ejection fraction (HFpEF).
Over half of patients with heart failure have a preserved ejection fraction, a syndrome with substantial morbidity/mortality and few effective therapies. Its dominant comorbidity is now obesity, which worsens disease and prognosis.
Myocardial data from patients with morbid obesity and heart failure with a preserved ejection fraction show depressed myocyte calcium-stimulated tension and disrupted gene expression of mitochondrial and lipid metabolic pathways abnormalities shared by human HF with a reduced EF but less so in heart failure with a preserved ejection fraction without severe obesity.
The impact of severe obesity on human heart failure with a preserved ejection fraction myocardial ultrastructure remains unexplored. Here the researchers assessed the myocardial ultrastructure in septal biopsies from patients with heart failure with a preserved ejection fraction using transmission electron microscopy.
They observed sarcomere disruption and sarcolysis, mitochondrial swelling with cristae separation and dissolution, and lipid droplet accumulation that was more prominent in the most obese patients with heart failure with a preserved ejection fraction and not dependent on comorbid diabetes.
Therefore, myocardial proteomics revealed associated reduction in fatty acid uptake, processing and oxidation and mitochondrial respiration proteins, particularly in very obese patients with heart failure with a preserved ejection fraction.
Ref: Meddeb, M., Koleini, N., Binek, A. et al. Myocardial ultrastructure of human heart failure with preserved ejection fraction. Nat Cardiovasc Res (2024). https://doi.org/10.1038/s44161-024-00516-x
Diet and Exercise Found to Be as Effective as Therapy in Treating Depression, Study Reveals
Depression is the leading cause of disability worldwide and is associated with disruptions to several brain and psychological processes, including impaired learning and memory.
A recent trial shows improving diet and doing more physical activity can be as effective as therapy with a psychologist for treating low-grade depression. Previous studies have found “lifestyle” therapies are effective for depression. But they have never been directly compared with psychological therapies.
The research targeted people with elevated distress, meaning at least mild depression but not necessarily a diagnosed mental disorder. Typical symptoms included feeling down, hopeless, irritable or tearful. After partnering with local mental health service, the authors recruited 182 adults and provided group-based sessions. All participants took part in up to six sessions over eight weeks, facilitated by health professionals.
Half were randomly assigned to participate in a program co-facilitated by an accredited practicing dietitian and an exercise physiologist. That group – called the lifestyle program – developed nutrition and movement goals: -eating a wide variety of foods -choosing high-fibre plant foods -including high-quality fats -limiting discretionary foods, such as those high in saturated fats and added sugars doing enjoyable physical activity.
The second group took part in psychotherapy sessions convened by two psychologists. The psychotherapy program used cognitive behavioural therapy (CBT), the gold standard for treating depression in groups and when delivered remotely.
The results showed that over eight weeks, the self reported mental health scores showed symptoms of depression reduced for participants in the lifestyle program by 42 per cent and the psychotherapy program by 37 per cent. That difference was not statistically or clinically meaningful. People in the lifestyle program improved their diet, while those in the psychotherapy program felt they had increased their social support – meaning how connected they felt to other people – compared to at the start of the treatment.
Therefore, it was concluded that Lifestyle therapies can be combined with psychology sessions for multi-disciplinary care. But diet and exercise therapies could prove particularly effective for those on waitlists to see a psychologist, who may be receiving no other professional support while they wait.
Ref: Adrienne O’Neil, Joahna Perez et al, Clinical and cost-effectiveness of remote-delivered, online lifestyle therapy versus psychotherapy for reducing depression: results from the CALM non-inferiority, randomised trial; The Lancet Regional Health - Western Pacific 2024;▪: 101142, DOI:https://doi.org/10.1016/j.lanwpc.2024.101142
Study shows SGLT2i or Finerenone Added to RAAS Inhibitors Offers Kidney and Heart Protection for Diabetics with CKD
Type 2 diabetes (T2D) is the leading cause of end-stage kidney disease (ESKD) globally. The presence of both T2D and CKD poses a major public health challenge because patients are at an increased risk of cardiovascular (CV) events and related mortality compared with patients with either condition alone. Accroding to a new research published in BMC nephrology, add on SGLT2i or finerenone to RAAS inhibitor may provide kidney and CV protection in diabetics with CKD.
Given the substantial burden of chronic kidney disease associated with type 2 diabetes, an aggressive approach to treatment is required. Despite the benefits of guideline-directed therapy, there remains a high residual risk of continuing progression of chronic kidney disease and of cardiovascular events.
Historically, a linear approach to pharmacologic management of chronic kidney disease has been used, in which drugs are added, then adjusted, optimized, or stopped in a stepwise manner based on their efficacy, toxicity, effects on a patient’s quality of life, and cost. However, there are disadvantages to this approach, which may result in missing a window of opportunity to slow chronic kidney disease progression. Instead, a pillar approach has been proposed to enable earlier treatment that simultaneously targets multiple pathways involved in disease progression.
Combination therapy in patients with chronic kidney disease associated with type 2 diabetes is being investigated in several clinical trials. Inclusion of either an SGLT2i or finerenone to a maximum tolerated dose of a RAAS inhibitor provides supportive phase 3 evidence of a pillar approach. The pillar approach if adopted in routine clinical practice in CKD would enable drugs of different classes to be combined and taken earlier in the disease course, which may have greater benefit as the extent of pathophysiologic damage is likely to be lower at an early CKD stage.
Reference: Khan, M.S., Lea, J.P. Kidney and cardiovascular-protective benefits of combination drug therapies in chronic kidney disease associated with type 2 diabetes. BMC Nephrol 25, 248 (2024). https://doi.org/10.1186/s12882-024-03652-5
Study Finds Venous Thromboembolism Prophylaxis Effective in Pediatric Trauma Patients
The indications, safety, and efficacy of chemical venous thromboembolism prophylaxis (cVTE) in pediatric trauma patients remain unclear. A set of high-risk criteria to guide chemical venous thromboembolism prophylaxis use was recently recommended; however, these criteria have not been evaluated prospectively.
Therefore the present study was conducted to examine high-risk criteria and cVTE use in a prospective multi-institutional study of pediatric trauma patients.
This cohort study was completed in 8 free-standing pediatric hospitals were the participants were pediatric trauma patients younger than 18 years who met defined high-risk criteria on admission.
The results showed that among 460 high-risk pediatric trauma patients, the median age was 14.5 years, out of which 68% were male and 32% were females. A total of 54.5% patients received cVTE; 13.5% received cVTE within 24 hours of admission. Patients who received cVTE after 24 hours had more high-risk factors. The most common reason for delayed cVTE was central nervous system bleed. VTE occurred in 1 of 62 patients receiving cVTE within 24 hours, 13 of 189 patients receiving cVTE after 24 hours, and 11 of 209 who had no cVTE.
Based on the results, the authors concluded that in this prospective study, use of cVTE based on a set of high-risk criteria was safe and did not lead to bleeding complications. Delay to initiation of cVTE was significantly associated with development of VTE. Quality improvement in pediatric VTE prevention may center on timing of prophylaxis and barriers to implementation.
Ref: Witte AB, Van Arendonk K, Bergner C, et al. Venous Thromboembolism Prophylaxis in High-Risk Pediatric Trauma Patients. JAMA Surg. Published online July 31, 2024. doi:10.1001/jamasurg.2024.2487
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