Introduction: Management of Type 1 Diabetes (T1D) poses numerous challenges, especially for young children and their families. Parental care positively influences the outcomes of children with T1D, while there are often criticisms in school environment. The COVID-19 pandemic has forced children and parents to spend many hours at home and diabetes care has returned mainly in the hands of parents. Aim of the study: To evaluate the effectiveness of exclusive return to parental care in preschool and school children with T1D treated with Tandem Basal IQ system during the COVID-19 pandemic. Patients and methods: 22 children (M:F = 14:8) with T1D have been evaluated. We compared insulin and CGM data (TIR, TBR and TAR) of two periods: PRE-COV and IN-COV, in which children have transitioned from normal school attendance to the exclusive care of their parents.Results: During the IN-COV period a significantly (p < 0.001) higher median value of TIR (66,41%) was observed as compared to PRE-COV period (61,45%). Patients also showed a statistically significant difference (p < 0.002) between the IN-COV period and the PRE-COV period as concerning the TAR metric: respectively 29,86 ± 10,6% vs 34,73 ± 12,8%. The difference between the bolus insulin doses was statistically significant (PRE-COV 5,3 IU/day, IN-COV 7,9 IU/day -p < 0.05). Conclusion:Our observational real-life study confirms the positive effect of parental care in T1D very young children and demonstrates that during the COVID-19 pandemic it was possible to obtain a good glycometabolic compensation despite the significant change in lifestyle.

Background Inflammation and mechanical demands play a role in the development of tendon conditions and the dysregulation of tendon healing. In patients with obesity, high levels of pro-inflammatory cytokines and a high mechanical demand promote chronic low-grade inflammation. Although controversial results have been reported, we aimed to summarize current evidence while highlighting the role of obesity in tendinopathy. Questions/purposes (1) Do patients with obesity have a greater risk of tendinopathy, stratified by upper and lower extremity sites, than patients who do not have obesity? (2) Is obesity associated with a higher risk of upper and lower extremity tendon tear and ruptures? (3) Is obesity associated with an increased risk of complications after upper and lower extremity tendon surgery? Methods We performed a systematic review by searching the PubMed, Embase, and Cochrane Library databases, combining the term “tendon” with common terms for tendinopathy and rupture such as “tendon injury OR tendinopathy OR tendon rupture” and “obese” OR “obesity.” We included studies with any level of evidence published from January 2000 to July 10, 2019 in peer-reviewed journals reporting clinical results. After we removed the duplicates, there were 365 records. Two independent authors screened these records and excluded 320 based on abstract and title screening. Of the remaining 45 studies, 23 were excluded because the topic did not address the research questions (n = 19), the article was outdated (n = 3), or because there was a serious risk of bias (n = 1). Finally, we included 22 studies with 49,914 participants (5984 with obesity), 31,100 (1884 with obesity) of whom had upper-extremity tendinopathy, while 18,814 (4010 with obesity) had lower-extremity tendinopathy. Obesity was defined as a BMI ≥ 30 kg/m2 according to the WHO’s criteria. Data were extracted and analyzed critically. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were applied, and the risk of bias (ROBINS tool) of the studies was assessed, as was the methodological quality (Coleman score). The assessment was performed independently by two authors. Inter-rater agreement for the assessments of the risk of bias and methodological quality were 89% and 94%, respectively. All studies were observational, and most were retrospective case-control studies. Any discrepancy was discussed and solved by consensus. The articles had a moderate risk of bias (eight articles) or a low risk of bias (fourteen articles). We excluded one article because of a serious risk of bias. The mean (range) Coleman score was 53.5 (42-74). Results Obesity was associated with a greater risk of upper extremity tendinopathy (rotator cuff: odds ratio 1.25 [95% confidence interval 1.12 to 1.40]; p < 0.001; medial epicondylitis: OR 1.9 [95% CI 1.0 to 3.7]; p < 0.05) and lower-extremity tendinopathy (Achilles tendon: OR 3.81 [95% CI 2.57 to 5.63]; OR 3.77 [95% CI 2.24 to 6.34]; OR 6.56 [95% CI 3.18 to 13.55], for obesity Classes I, II and III, respectively; patellar tendon: OR 1.10 [95% CI 1.05 to 1.90]; p = 0.001; plantar fascia: OR 2.97 [95% CI 1.64 to 5.37]; p = 0.004). Obesity was associated with a greater risk of upper extremity tendon tear (rotator cuff: OR 2.35 [95% CI 1.62 to 3.40]; p < 0.001) and rupture leading to tendon surgery (rotator cuff in men: OR 3.13 [95% CI 1.29 to 7.61]; p < 0.001 and women: OR 3.51 [95% CI 1.80 to 6.85]; p < 0.001). However, no association was found between BMI and lower extremity rupture (Achilles mean BMI: 27.77 kg/m2 [95% CI 26.94 to 28.49] versus control: 26.66 kg/m2 [95% CI 26.06 to 27.27]; p = 0.047). Upper extremity complications (n = 359) after tendon repair surgery had a weighted incidence of 13.27% and 8.13% for rotator cuff surgery in patients with and without obesity, respectively. In the lower extremity (n = 21,152), the weighted incidence for Achilles tendon surgery was 11.28% and 8.6% in patients with and without obesity, respectively. Conclusions Obesity is associated with a higher risk of tendinopathy, tendon tear and rupture, and complications after tendon surgery than non-obesity. However, the high heterogeneity and observational nature of the studies highlight the need to be cautious about the results of our study. We encourage researchers to perform clinical and preclinical studies to explore pathways related to the metabolic state of this population. Level of Evidence Level IV, prognostic study.

Background The wearable defibrillator (WCD) is a useful device to prevent sudden cardiac death (SCD) due to fatal arrhythmias in patients in which an implantable cardioverter defibrillator (ICD) is not currently indicated. Measurement of mean daily heart rate and related variability (HRV) has proved to be useful in identifying patients at increased arrhythmic risk of SCD and in patients with chronic heart failure (CHF), although the specificity and predictive accuracy of fatal arrhythmic events is still relatively limited. We analyzed the mean HR of patients with WCD to determine their impact on the incidence of fatal and non–fatal arrhythmic events. Methods We enrolled 7 patients with WCD and optimal medical therapy by monitoring daily HR and variability over a 30– 90 day follow–up. Monitoring was performed remotely, analyzing both trends acquired by the devices, daily ECG recordings, and telephone surveillance. Results Men constituted 71.4% of the population, with a mean age of 69.1±10.3 yrs, and an ejection fraction of 30.7%±8.7. The devices were worn for 36±24 days, with a daily adherence of 23.8±0.23 hrs. The trend in mean HR showed a progressive, although non–significant reduction (77.5±10.2 bpm vs 66.5±11.9 bpm p=0.08). No fatal arrhythmic events were recorded during monitoring. Two non–fatal arrhythmic events were recorded from patient discharge. Conclusions Mean daily HR is a predictor of cardiac death, independent of other risk factors in patients with cardiovascular disease. Although the small sample size doesn‘t provide a convincing correlation, it is conceivable that reducing mean HR may contribute to a decrease in fatal cardiac arrhythmias. Further studies are needed to confirm these insights.

Background Ablation of the cavotricuspid isthmus (CTI) using contiguous lesions guided by electroanatomical mapping on fluoroscopy assisted by the ablation index (AI) in typical atrial flutter (AFL) is a widely used procedure. Unipolar signal inversion during radiofrequency catheter ablation (RFCA) was found to be a predictive index of transmural lesion, as well as AI–guided strategy showed to be effective in CTI ablation while maintaining an inter–lesion–distance (ILD) ≤ 6mm. Both are related to the block of the CTI, however, it remains unclear how AI is related to the inversion of the negative component of the unipolar signal. The aim of our study is to evaluate the effectiveness of ablation based on unipolar recorded potential inversion and the corresponding AI values. Methods Thirty consecutive patients with AFL diagnosis were enrolled in our Centre to undergo CTI ablation. Patients were randomized 2:1 into the control arm and the experimental arm respectively. Contiguous lesions were performed using current AI standards until values of 500 were reached in the control group. In the experimental group, contiguous lesions were dispensed until inversion of the negative component of the unipolar signal was achieved, while simultaneously recording AI values. After CTI ablation, a 30–minute monitoring was performed to evaluate the efficacy and possible inducibility of AFL. Results A successful ablation procedure was performed in 30 patients. High–density mapping acquired on average 2766±1767 points vs. 2930±2177 (p=0.82), with a mean mapping time of 10.3±4.9 min vs 13.4±5.8 min (p=o.13). The procedural time between the two groups was comparable ( 77.9±27.6 vs 78.3 78.3±22.4 p 0.96). In both arms, the treatment effectively reduced the mean local potential in CTI (2.42±1.09 mV vs 2.71±1.26 mV p=0.51). Compared to the control group, unipolar signal inversion showed significantly lower ablation index values (500 vs 405±41.1 p &lt; 0.0001). Conclusions The inversion of the negative component of the unipolar signal confirms to be an effective strategy in cavotricuspid isthmus ablation. Procedural success can be achieved at significantly lower corresponding ablation index values.

Background Cardiac contractility modulation (CCM) in heart failure (HF) patients with reduced ejection fraction (HFrEF) is an innovative therapy which may contribute to increased exercise capacity and quality of life and reduced hospitalizations. With speckle–tracking echocardiography and global longitudinal strain (GLS), changes in myocardial function can be detected with greater sensitivity than conventional approaches for measuring diastolic and systolic function, including left ventricular ejection fraction. We aim to analyze the usefulness of GLS in detecting improvement in systolic function and response to CCM treatment. Methods We studied 5 patients with CCM referred to our outpatient cardiology clinic. All patients underwent complete echocardiography with evaluation of GLS and ejection fraction. Follow–ups were performed at 1, 3, and 6 months. Results All patients were men (mean age 65.3±15.7 yrs). Mean baseline ejection fraction was 37.1±9.3%, mean GLS was 7.7±3.1%, and patients had mild–to–moderate left ventricular enlargement (mean indexed telediastolic volumes 101.4±8.7 ml/m2). Follow–up performed at the first month showed values similar to baseline values. Between the third and sixth months, a non–significant improvement in ejection fraction and GLS was recorded (EF 40.75±9.6% p=0.51; GLS 8.9±4.2 p=0.62). Indexed telediastolic volumes were reduced (101.4±9.3 ml/m2 vs 89.5±7.4 ml/m2 p=0.05). Conclusions CCM therapy seems to be useful in achieving volumetric remodeling in patients with HFrEF. GLS assessment may be useful in detecting improvement in systolic function. Further studies with larger samples and longer follow–up are needed to confirm these results.

Background The aetiopathogenesis of tendinopathy is uncertain, but inflammation may play a role in the early phase of tendinopathy and in tendon healing response. We investigated the most up-to-date evidence about the association between obesity, high-fat diet and tendinopathy, focusing on the role of adipokines, inflammatory pathways and molecular changes. Sources of data A systematic review was performed searching PubMed, Embase and Cochrane Library databases following the PRISMA guidelines. We included studies of any level of evidence published in peer-reviewed journals. The risk of bias (SIRCLE) was assessed, as was the methodological quality (CAMARADES) of the included studies. We excluded all the articles with a high risk of bias and/or low quality after the assessment. After applying the inclusion and exclusion criteria, we included 14 studies of medium or high quality. Areas of agreement A high-fat diet negatively affects tendon quality, increasing the risk of rupture and tendinopathy. Areas of controversy Controversial evidence exists on both tendon fat infiltration secondary to a dysregulation of the lipid metabolism and of a molecular effect of inflammatory pathways. Growing points The secretion of adipokines is strictly related to fat ingestion and body composition and can potentially act on tendon physiology and injury. Areas timely for developing research Adipokines, low-grade inflammation and fat intake play a role in disrupting tendon healing and setting up tendinopathy. Further high-quality research is needed to better define the molecular pathways involved.

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