Diaphragmatic Ultrasound Predictors of High-Flow Nasal Cannula Therapeutic Failure in Critically Ill Patients With SARS-CoV-2 Pneumonia.

OBJECTIVES: High flow nasal cannula (HFNC) is frequently used in patients with acute respiratory failure, but there is limited evidence regarding predictors of therapeutic failure. The objective of this study was to assess diaphragmatic ultrasound criteria as predictors of failure to HFNC, defined as the need for orotracheal intubation or death. METHODS: Prospective cohort study including adult patients consecutively admitted to the critical care unit, from July 24 to October 20, 2020, with respiratory failure secondary to SARS-CoV-2 pneumonia who required HFNC. After 12 hours of HFNC initiation we measured ROX index (ratio of SpO2 /FiO2 to respiratory rate), excursion and diaphragmatic contraction speed (diaphragmatic excursion/inspiratory time) by ultrasound, both in supine and prone position. RESULTS: In total, 41 patients were analyzed, 25 succeeded and 16 failed HFNC therapy. At 12 hours, patients who succeeded HFNC therapy presented higher ROX index in supine position (9.8 [9.1-15.6] versus 5.4 [3.9-6.8], P < .01), and higher PaO2 /FiO2 ratio (186 [135-236] versus 117 [103-162] mmHg, P = .03). To predict therapeutic failure, the supine diaphragmatic contraction speed presented sensitivity of 89% and a specificity of 57%, while the ROX index presented a sensitivity of 92.8% and a specificity of 75%. CONCLUSIONS: Diaphragmatic contraction speed by ultrasound emerges as a diagnostic complement to clinical tools to predict HFNC success. Future studies should confirm these results.

Unmasking an acute coronary occlusive myocardial infarction in patients with right ventricular paced rhythm.

Electrocardiographic recognition of an acute myocardial infarction in the setting of a right ventricular paced rhythm (VPR) represents a unique diagnostic challenge. The classical ST-segment patterns of myocardial ischemia can become obscured by the abnormal repolarization changes caused by a right VPR. Consequently, longer door-to-balloon reperfusion times and a higher mortality have been reported among these patients mostly due to a delayed diagnosis. In this population, the use of the modified Sgarbossa Criteria (SC) can aid the clinician in the diagnosis of an acute coronary occlusive myocardial infarction (OMI), as an ST-segment elevation myocardial infarction (STEMI) equivalent. However, there are only a few validating studies and no specific guidelines endorsing their use in patients with VPR. We present three cases with right VPR in which the use of the modified SC was diagnostic of OMI, as well as predictive of the occluded coronary vessel. Our review of the current evidence favors that identification of at least one modified SC in patients with right VPR represents an OMI finding with a similar accuracy as when these are used in patients with LBBB.

Connected Elbow Exoskeleton System for Rehabilitation Training Based on Virtual Reality and Context-Aware.

Traditional physiotherapy rehabilitation systems are evolving into more advanced systems based on exoskeleton systems and Virtual Reality (VR) environments that enhance and improve rehabilitation techniques and physical exercise. In addition, due to current connected systems and paradigms such as the Internet of Things (IoT) or Ambient Intelligent (AmI) systems, it is possible to design and develop advanced, effective, and low-cost medical tools that patients may have in their homes. This article presents a low-cost exoskeleton for the elbow that is connected to a Context-Aware architecture and thanks to a VR system the patient can perform rehabilitation exercises in an interactive way. The integration of virtual reality technology in rehabilitation exercises provides an intensive, repetitive and task-oriented capacity to improve patient motivation and reduce work on medical professionals. One of the system highlights is the intelligent ability to generate new exercises, monitor the exercises performed by users in search of progress or possible problems and the dynamic modification of the exercises characteristics. The platform also allows the incorporation of commercial medical sensors capable of collecting valuable information for greater accuracy in the diagnosis and evolution of patients. A case study with real patients with promising results has been carried out.

Agent-Based Intelligent Interface for Wheelchair Movement Control.

People who suffer from any kind of motor difficulty face serious complications to autonomously move in their daily lives. However, a growing number research projects which propose different powered wheelchairs control systems are arising. Despite of the interest of the research community in the area, there is no platform that allows an easy integration of various control methods that make use of heterogeneous sensors and computationally demanding algorithms. In this work, an architecture based on virtual organizations of agents is proposed that makes use of a flexible and scalable communication protocol that allows the deployment of embedded agents in computationally limited devices. In order to validate the proper functioning of the proposed system, it has been integrated into a conventional wheelchair and a set of alternative control interfaces have been developed and deployed, including a portable electroencephalography system, a voice interface or as specifically designed smartphone application. A set of tests were conducted to test both the platform adequacy and the accuracy and ease of use of the proposed control systems yielding positive results that can be useful in further wheelchair interfaces design and implementation.

Architecture to Embed Software Agents in Resource Constrained Internet of Things Devices.

Sensing systems in combination with treatment tools and intelligent information management are the basis on which the cities and urban environments of the future will be built. Progress in the research and development of these new and intelligent scenarios is essential to achieve the objectives of efficiency, integration, sustainability, and quality of life for people who live in cities. To achieve these objectives, it is essential to investigate the development of cheaper, more accurate, and smarter hardware devices, which will form the basis of the intelligent environments of the future. This article focuses on an approach based on intelligent multi-agent systems that are integrated into basic hardware devices for the Internet of Things (IoT). A multi-agent architecture is proposed for the fast, efficient, and intelligent management of the generated data. A layer of services adapted to the needs of the new intelligent environments is built on this architecture. With the aim of validating this architecture, a case study based on electric vehicles of the e-bike type is proposed.

Cutaneous Metastases From Malignant Mesothelioma of the Tunica Vaginalis Testis.

Mesotheliomas are uncommon tumors arising from mesothelial cells lining the serous membranes of the pleura, pericardium, peritoneum, and tunica vaginalis testis. Less than 100 cases arising from the tunica vaginalis testis have been published and, to our knowledge, only 5 cases of cutaneous involvement from these tumors have been reported. We report an additional case with fatal outcome. A 93-year-old man presented with multiple polypoid nodules on the left scrotum. Ulceration was also present, and a firm 5-cm palpable testicular mass was also found. The patient had been exposed to asbestos for 40 years. Histologic examination of a skin biopsy from one of the nodules showed diffuse dermal infiltration of markedly atypical cuboidal cells, with polymorphous and hyperchromatic nuclei. Mitotic figures were common. These cuboidal cells lined clefts, forming a tubular and micropapillary pattern throughout papillary and reticular dermis. Immunohistochemical study showed strong nuclear and cytoplasmic positivity for calretinin, epithelial membrane antigen (cytoplasmic), and cytokeratin-7 (cytoplasmic) and nuclear positivity for Wilms tumor-1. These findings were consistent with cutaneous infiltration from malignant mesothelioma of the tunica vaginalis testis. Treatment of this rare tumor remains challenging because there are currently no recommended guidelines, but radical inguinal orchiectomy is an optimal choice.

Infectious salmon anaemia virus (ISAV) in Chilean Atlantic salmon (Salmo salar) aquaculture: emergence of low pathogenic ISAV-HPR0 and re-emergence of virulent ISAV-HPR∆: HPR3 and HPR14.

ABSTACT: Infectious salmon anaemia (ISA) is a serious disease of marine-farmed Atlantic salmon (Salmo salar) caused by ISA virus (ISAV), which belongs to the genus Isavirus, family Orthomyxoviridae. ISA is caused by virulent ISAV strains with deletions in a highly polymorphic region (HPR) of the hemagglutinin-esterase (HE) protein (designated virulent ISAV-HPR∆). This study shows the historic dynamics of ISAV-HPR∆ and ISAV-HPR0 in Chile, the genetic relationship among ISAV-HPR0 reported worldwide and between ISAV-HPR0 and ISAV-HPR∆ in Chile, and reports the 2013 ISA outbreak in Chile. The first ISA outbreak in Chile occurred from mid-June 2007 to 2010 and involved the virulent ISAV-HPR7b, which was then replaced by a low pathogenic ISAV-HPR0 variant. We analyzed this variant in 66 laboratory-confirmed ISAV-HPR0 cases in Chile in comparison to virulent ISAV-HPR∆ that caused two new ISA outbreaks in April 2013. Multiple alignment and phylogenetic analysis of HE sequences from all ISAV-HPR0 viruses allowed us to identify three genomic clusters, which correlated with three residue patterns of ISAV-HPR0 (360PST362, 360PAN362 and 360PAT362) in HPR. The virus responsible for the 2013 ISAV-HPR∆ cases in Chile belonged to ISAV-HPR3 and ISAV-HPR14, and in phylogenetic analyses, both clustered with the ISAV-HPR0 found in Chile. The ISAV-HPR14 had the ISAV-HPR0 residue pattern 360PAT362, which is the only type of ISAV-HPR0 variant found in Chile. This suggested to us that the 2013 ISAV-HPR∆ re-emerged from ISAV-HPR0 that is enzootic in Chilean salmon aquaculture and were not new introductions of virulent ISAV-HPR∆ to Chile. The clinical presentations and diagnostic evidence of the 2013 ISA cases indicated a mixed infection of ISAV with the ectoparasite Caligus rogercresseyi and the bacterium Piscirickettsia salmonis, which underscores the need for active ISAV surveillance in areas where ISAV-HPR0 is enzootic, to ensure early detection and control of new ISA outbreaks, as it is considered a risk factor. This is the first report of ISA linked directly to the presence of ISAV-HPR0, and provides strong evidence supporting the contention that ISAV-HPR0 shows a strong relationship to virulent ISAV-HPR∆ viruses and the possibility that it could mutate to virulent ISAV-HPR∆.

An Unexpected Cause of Chest Pain While Self-Pleasuring: A Ripping Doom Excitement.

Acute aortic dissection (AD) involves the tearing of the aortic intima by shearing forces, resulting in a false lumen, which, depending on its location and extent, may lead to hemodynamic compromise, hypoperfusion of vital organs, or even rupture of the aorta. The classical presentation is a sudden chest or back pain described as sharp or ripping in quality. We present a 60-year-old male with a history of hypertension, Liddle's syndrome, obstructive sleep apnea, and chronic cannabis use for insomnia who arrived at a non-PCI hospital complaining of severe retrosternal chest pain lasting several hours in evolution that started upon masturbation. The pain was ripping in character, starting retrosternally and radiating to his neck and back. After evidence of rising troponin values, he was initially diagnosed with non-ST segment elevation myocardial infarction (NSTEMI), managed with dual antiplatelet therapy with full anticoagulation, and subsequently transferred to our institution for further care. Shortly after his arrival at our hospital, he suddenly deteriorated with recurrent chest pain and hypotension, which triggered an emergent bedside echocardiogram evaluation. This revealed a hemodynamically significant pericardial effusion, moderate to severe aortic valve regurgitation (AR), and an intimal flap visualized on the ascending and descending aorta, suggestive of an extensive AD. A computerized tomographic angiogram confirmed the diagnosis of a Stanford type A AD that required an emergent surgical pericardiotomy, ascending aorta with partial arch replacement, and aortic valve repair. Often, AD may mimic an acute coronary syndrome (ACS) or even present with an acute myocardial infarction (AMI). The appropriate diagnostic imaging evaluation prior to the initiation of anticoagulation therapy should be done in patients with higher-risk clinical criteria for AD to reduce adverse treatment outcomes. The use of a simple three-step diagnostic algorithm for acute aortic syndromes (AAS) may decrease diagnostic delays, misdiagnosis, and inappropriate therapies.

Successful Treatment of Severe Paravalvular Leak by Repositioning a Self-Expandable Percutaneous Aortic Valve Bioprosthesis (Evolut PRO+) Using the "Double Snare" Technique.

Significant (moderate or severe) paravalvular leak (PVL) after transcatheter aortic valve replacement (TAVR) remains a common phenomenon and has been associated with decrease survival and quality of life. Transcatheter valve embolization and migration (TVEM) is a rare post-TAVR complication that can occur in 1% of cases and has been associated with worse patient outcomes. Valve embolization or migration into the left ventricle can result in significant PVL causing hemodynamic instability, shock, heart failure, and hemolytic anemia. Although this complication most commonly occurs in the acute setting (90%) within 4 hours of TAVR, it can also present late (4 hr-43 days later) in 10% of cases. There are no clear guidelines as to how this condition should be managed; however, several percutaneous bailout techniques exist that can ultimately spare the patient from emergent cardiovascular surgery. We present a rare case of late ventricular transcatheter aortic valve migration 3 days after TAVR causing severe PVL and heart failure symptoms that was successfully treated using the percutaneous "double snare" technique.

Close temporal coupling of neuronal activity and tissue oxygen responses in rodent whisker barrel cortex.

Neuronal activity elicits metabolic and vascular responses, during which oxygen is first consumed and then supplied to the tissue via an increase in cerebral blood flow. Understanding the spatial and temporal dynamics of blood and tissue oxygen (To2) responses following neuronal activity is crucial for understanding the physiological basis of functional neuroimaging signals. However, our knowledge is limited because previous To2 measurements have been made at low temporal resolution (>100 ms). Here we recorded To2 at high temporal resolution (1 ms), simultaneously with co-localized field potentials, at several cortical depths from the whisker region of the somatosensory cortex in anaesthetized rats and mice. Stimulation of the whiskers produced rapid, laminar-specific changes in To2. Positive To2 responses (i.e. increases) were observed in the superficial layers within 50 ms of stimulus onset, faster than previously reported. Negative To2 responses (i.e. decreases) were observed in the deeper layers, with maximal amplitude in layer IV, within 40 ms of stimulus onset. The amplitude of the negative, but not the positive, To2 response correlated with local field potential amplitude. Disruption of neurovascular coupling, via nitric oxide synthase inhibition, abolished positive To2 responses to whisker stimulation in the superficial layers and increased negative To2 responses in all layers. Our data show that To2 responses occur rapidly following neuronal activity and are laminar dependent.

"Teaching Them That Pain Exists": Dilemmas Regarding Memory Transmission and Entrepreneurship in Adult Children of Former Political Prisoners 40 Years After the Coup D'Etat in Chile.

The present study sought to identify and understand the memory transmission and entrepreneurship processes conducted by children of victims of politically motivated imprisonment and torture during Chile's civilian-military dictatorship. A qualitative methodology was adopted, with an exploratory and analytic-relational design being used. Twelve children of former political prisoners, seven men and five women, participated in the study. Focus groups were selected as a data production technique. A content analysis was conducted following Grounded Theory guidelines. Results suggest that the adult sons and daughters of survivors have taken up memory transmission and entrepreneurship based on their parents' memories of political imprisonment and torture. They engage in memory transmission and entrepreneurship by constructing exemplary memories about their parents' experiences. They transmit these memories to peers and to their own children once they reach adulthood, given the increased openness of Chilean society regarding these discussions.

Electrocardiographic Recognition of Unprotected Left Main ST-Segment Elevation Myocardial Infarction: Looking Beyond aVR.

ST-segment elevation in aVR has traditionally been used for electrocardiographic identification of left main coronary artery (LM) myocardial infarction. We present two ST-segment elevation myocardial infarction (STEMI) cases with acute total occlusion of the LM without aVR ST-segment elevation. This report reviews the different electrocardiographic discriminators suggestive of unprotected LM STEMI. (Level of Difficulty: Intermediate.).

Lactococcus garvieae: An Uncommon Human Pathogen Causing Infective Endocarditis in a Valve-in-Valve Transcatheter Aortic Valve Replacement.

Lactococcus garvieae is a fish pathogen and an uncommon cause of human infections. There is a growing body of evidence showing its potential for causing endocarditis especially in those with prior valve surgery. In this case report, we present what we believe is the first case of endocarditis by L. garvieae affecting a valve-in-valve transcatheter aortic valve replacement that was successfully treated. Specific guidelines for the management of these patients are lacking. Our experience can contribute to the current knowledge regarding this life-threatening infection as well as to the future care of these patients. We aim to emphasize that despite not being recognized as a typical endocarditis microorganism by the Duke Criteria, the possibility of endocarditis needs to be highly entertained in patients with L. garvieae bacteremia, especially when prosthetic valves are present. Consequently, clinicians should pursue further this diagnosis with transesophageal echocardiogram and/or alternative imaging modalities (e.g., PET-CT scan and MRI) regardless of an initial negative transthoracic echocardiogram. Reaching a diagnosis of L. garvieae endocarditis led us to the decision of prolonging the antibiotic course for 6 weeks with successful results. Ultimately, surgery was not required owing to the absence of prosthetic aortic valve dysfunction and paravalvular extension of the infection.

Memories of Boys, Girls, and Adolescent Victims of Political Prison and Torture by the Chilean Military-Civilian Dictatorship.

This article reconstructs and analyzes the memories of victims of political prison and torture during the Chilean Military-Civilian Dictatorship who were minors when they experienced this violence. Participants in the study were 11 adults, six women and five men from the region of Valparaíso, who were victims of State terrorism during childhood and adolescence. The information production technique used was the focus group. A textual analysis was performed, based on interdisciplinary contributions from interpretation theory and discourse theories. The analysis of the information identified distinctive elements in the traumatic memories according to the sex-gender system associated with the private/public and passivity/agency dimensions. The results of this study reveal the urgent need to recognize boys, girls, and adolescents as people with rights who should be protected by both adults and States. Moreover, these results emphasize the need to implement early intervention programs in people affected by psychosocial traumas and disasters of different types, and improve their quality of life.

The Effects of the 2016 Copa América Centenario Victory on Social Trust, Self-Transcendent Aspirations and Evaluated Subjective Well-Being: The Role of Identity With the National Team and Collective Pride in Major Sport Events.

Following a neo-Durkheimian perspective, major sporting events such as the World Cup or the America's Cup differ from other collective rituals because they promote interest throughout the nation due to their massiveness and international character. In order to increase the scientific knowledge related to these type of rituals, the aim of this study was to observe the effects that the Chilean victory in the 2016 Copa América Centenario had on social variables such as trust, self-transcendent aspirations, and evaluated subjective well-being (SWB) of both fans and non-fans. In addition, two longitudinal structural equation models (SEMs) were performed to estimate the effect of identity with the national team before the final match on evaluated SWB, trust, and self-transcendent aspirations post-final. A total of 648 Chilean participants (mean age = 38.58; SD = 10.96) answered the questionnaire before the final match. Out of these, 409 completed our measures after the final. The results show that fans presented higher scores in many of the studied variables before and after the final compared to non-fans. Identification with the national team (before the final) prospectively and significantly predicted pride in the national team and pride in the country (after the final). In addition, these two forms of collective pride mediated the relationship between identification with the national team (before the final) and evaluated SWB (after the final). The results are discussed emphasizing the importance of these kinds of specific massive rituals and their effects.

An Uncommon Cause of ST-Segment Elevation Myocardial Infarction: Intramural Coronary Artery Hematoma After Blunt Chest Trauma.

Intramural coronary hematoma (IMCH) is a rare cause of acute myocardial infarction (MI). We aim to review the current knowledge and share our experience with the diagnosis and management of a patient presenting with traumatic IMCH leading to an acute ST-segment elevation MI. (Level of Difficulty: Intermediate.).

Localization of Small Neoplastic Lesions in Colonoscopy by Estimating Edge, Texture and Motion Saliency.

Early screening in Colorectal Cancer consists in finding and removing small precancerous masses or neoplastic lesions developed from the mucosa, usually lesions smaller than 10 mm. Localization of small neoplastic lesions is a very challenging task since colon exploration is highly dependent on the expert training and colon preparation. Several strategies have attempted to locate neoplasias, but usually they are huge lesions that a trained gastroenterologist could hardly miss. This work presents a saliency-based strategy to localize polypoid and non-polypoid neoplastic lesions smaller than 10 mm in colonoscopy videos by combining spatio-temporal descriptors. For doing so, a per-frame-multi-scale representation is computed and edge, texture and motion features are extracted. Each of these features is used to construct a primary saliency map which are then combined to obtain a coarse saliency map. Finally, the neoplasia is localized as the bounding box of a circular region, approximated by the Hough transform, with the largest salience. The proposed approach was evaluated in 8 short colonoscopy videos obtaining an average of Annotated Area Covered of 0.75 and a precision of 0.82.

The Reciprocal Relationship Between Gratitude and Life Satisfaction: Evidence From Two Longitudinal Field Studies.

Gratitude and life satisfaction are associated with several indicators of a good life (e.g., health, pro-social behavior, and relationships). However, how gratitude and life satisfaction relate to each other over time has remained unknown until now. Although a substantial body of research has tested the link from gratitude to life satisfaction, the reverse association remains unexplored. In addition, recent cross-cultural research has questioned the link between gratitude and subjective well-being in non-Western countries, suggesting that the benefits of gratitude may only prevail in Western societies. However, previous cross-cultural studies have only compared western (e.g., American) and eastern (e.g., Asian) cultures, but this simple contrast does not adequately capture the diversity in the world. To guide further theory and practice, we therefore extended previous cross-sectional and experimental studies, by testing the bi-directional longitudinal link between gratitude and life satisfaction in a Latin American context, aiming to establish temporal precedence. We assessed two adult samples from Chile, using three-wave cross-lagged panel designs with 1 month (Study 1, N = 725) and 3 months (Study 2, N = 1,841) between waves. Both studies show, for the first time, that gratitude and life satisfaction mutually predict each other over time. The reciprocal relationships suggest the existence of a virtuous circle of human well-being: higher levels of gratitude increase life satisfaction, which in turn increases gratitude, leading to a positive spiral. Key theoretical and practical implications for the dynamics of human flourishing and field of positive psychology are discussed.

Diagnostic accuracy of uroflowmetry parameters to predict infravesical obstruction / Exactitud diagnóstica de los parámetros de la flujometría para predecir la obstrucción infravesical

Objective: to evaluate the performance statistics of average flow (Qave), voiding time (Vtime), and time to maximum flow (TQmax), in addition to maximum flow (Qmax), for diagnosis of infravesical obstruction. Methods: we reviewed urodynamic studies performed in men > 40 years. Obstruction was considered a grade 3-6 in the Schäfer nomogram. Sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR-), and the receiver operator characteristic (ROC) curve were calculated for the different components of free uroflowmetry. Results: we analyzed 432 studies. Patients with obstruction had lower values of Qmax and Qave, and higher values of Vtime and TQmax. Considering different thresholds, Qmax had sensitivity, specificity, LR + and LR- values of 12-83%, 50-97%, 1.7-4.46 and 0.32-0.9, respectively; Qave had sensitivity, specificity, LR + and LR- values of 65-95%, 21-66%, 1.22-1.94 and 0.19-0.53, respectively; Vtime had sensitivity, specificity, LR + and LR- values of 49-85%, 26-67%, 1.15-1.54, and 0.57-0.74, respectively; TQmax had a sensitivity, specificity, LR + and LR- of 36-81%, 22-72%, 1.04-1.33 and 0.85-0.87, respectively. The areas under the ROC curves for Qmax, Qave, Vtime and TQmax were 0.75 (95% CI = 0.71-0.79, p < 0.001), 0.71 (95% CI = 0.66-0.75, p < 0.001), 0.62 (95% CI = 0.57-0.67, p < 0.001) and 0.55 (95% CI = 0.5-0.6, p = 0.03), respectively. Conclusions: Qave, Vtime, and TQmax showed a statistically significant discriminatory capacity to predict infravesical obstruction, and therefore they have clinical value as a complement to the information provided by Qmax.

Objetivo: evaluar las estadísticas de desempeño del flujo promedio (Qave), el tiempo de evacuación (Vtime) y el tiempo hasta el flujo máximo (TQmax), además del flujo máximo (Qmax), para el diagnóstico de obstrucción infravesical. Métodos: revisamos urodinamias realizadas en hombres > 40 años. La obstrucción se consideró un grado 3-6 en el nomograma de Schäfer. Se calcularon la sensibilidad, la especificidad, la razón de verosimilitud positiva (LR +), la razón de verosimilitud negativa (LR-) y la curva característica operativa del receptor (ROC) para los diferentes componentes de la flujometría libre. Resultados: analizamos 443 estudios. Los pacientes con obstrucción tenían valores más bajos de Qmax y Qave, y valores más altos de Vtime y TQmax. Considerando diferentes umbrales, el Qmax tuvo valores de sensibilidad, especificidad, LR + y LR- de 12-83%, 50-97%, 1.7-4.46 y 0.32-0.9, respectivamente; Qave tuvo valores de sensibilidad, especificidad, LR + y LR- de 65-95%, 21-66%, 1.22-1.94 y 0.19-0.53, respectivamente; Vtime tuvo valores de sensibilidad, especificidad, LR + y LR- de 49-85%, 26-67%, 1.15-1.54 y 0.57-0.74, respectivamente; TQmax tuvo una sensibilidad, especificidad, LR + y LR- de 36-81%, 22-72%, 1.04-1.33 y 0.85-0.87, respectivamente. Las áreas bajo las curvas ROC para Qmax, Qave, Vtime y TQmax fueron 0,75 (95% CI = 0.71-0.79, p < 0,001), 0.71 (95% CI = 0.66-0.75, p < 0,001), 0.62 (95% CI = 0.57-0.67, p < 0,001) y 0.55 (95% CI = 0.5-0.6, p = 0.03), respectivamente. Conclusiones: Qave, Vtime y TQmax mostraron una capacidad discriminatoria estadísticamente significativa para predecir la obstrucción infravesical, por lo que tienen valor clínico como complemento de la información proporcionada por el Qmax.

Utilidad de la midodrina para controlar el síncope vasovagal: ¿la recomienda la evidencia? / Usefulness of Midodrine for the Control of Recurrent Vasovagal Syncope: Does the Evidence Recommend it? / Utilidade da midodrina no controle da síncope vasovagal: as evidencias a recomendam?

Introducción:El síncope vasovagal es la principal causa de pérdida transitoria de la conciencia, y es un motivo de consulta cada vez más frecuente en pediatría y medicina del adulto. La midodrina es un agonista de los recepto-res alfa, de acción periférica, empleada principalmente en el manejo de la hipotensión ortostática; sin embargo, también se ha evaluado en el síncope vasovagal, con resultados prometedores.Objetivo:Analizar la evidencia más reciente sobre la utilidad de la midodrina para el control y la prevención del síncope vasovagal.Materiales y métodos: Se realizó una búsqueda bibliográfica utilizando términos de búsqueda como Vasovagal Syncope y Midodrine, así como sinónimos, que se combinaron con operadores booleanos, en cinco bases de datos, hasta octubre del 2022. Se incluyeron estudios originales, revisiones sistemáticas y metanálisis, publicados tanto en inglés como en español.Resultados:Ensayos controlados aleatorizados y revisiones sistemáticas y metanálisis difieren ligeramente entre resultados, pero estos demuestran un efecto global protector. La evidencia más reciente y completa indica que utilizar este agente reduce significativamente la positividad al realizar la prueba de la mesa inclinada y que previene la aparición de episodios sincopales.Conclusiones:Aunque la evidencia actual sobre la eficacia de la midodrina respecto a la prevención y control del síncope vasovagal es limitada, se observa un efecto protector significativo, porque disminuye el riesgo de sufrir un episodio sincopal, aproximadamente hasta en un 50 %.Palabras clave: midodrina; síncope vasovagal; síncope; adrenérgicos; medicina basada en la evidencia

Introduction: Vasovagal syncope is the main cause of transient loss of consciousness, being an in-creasingly frequent reason for consultation in pediatrics and adult medicine. Midodrine, a periphe-rally acting alpha-receptor agonist, is mainly used in the management of orthostatic hypotension. However, it has also been evaluated in vasovagal syncope, with promising results. Objective: To analyze the most recent evidence on the usefulness of midodrine for the control and prevention of vasovagal syncope. Materials and Methods: A literature search was performed using search terms such as "Vasovagal Syncope" and "Midodrine," as well as synonyms, which were combined with Boolean operators, in 5 databases until October 2022. Original studies, systematic reviews and meta-analyses, published in both English and Spanish, were included. Results: Randomized controlled trials and systematic reviews and meta-analyses differ slightly between results, but these demonstrate an overall protective effect. The most recent and complete evidence shows that using this agent significantly reduces the probability of positivity when performing the tilt table test and prevents the occurrence of syncopal episodes. Conclusions: Although current evidence on the efficacy of midodrine with respect to the prevention and control of vasovagal syncope is limited, a significant protective effect is observed, reducing the risk of suffering syncopal episode by approximately up to 50%

Introdução: a síncope vasovagal é a principal causa de perda transitória de consciência e é um motivo cada vez mais comum de consulta em pediatria e medicina de adultos. A midodrina é um agonista do receptor alfa de ação periférica usado principalmente no tratamento da hipotensão ortostática; no entanto, ela também foi avaliada na síncope vasovagal, com resultados promissores. Objetivo: Revisar as evidências mais recentes sobre a utilidade da midodrina para o controle e a pre-venção da síncope vasovagal. Materiais e métodos: Foi realizada uma pesquisa na literatura usando termos de pesquisa como Va-sovagal, Syncope e Medodrine, bem como sinônimos, que foram combinados com operadores boo-leanos, em cinco bancos de dados, até outubro de 2022. Foram incluídos estudos originais, revisões sistemáticas e metanálises, publicados em inglês e espanhol. Resultados: Os ensaios clínicos randomizados, as revisões sistemáticas e as metanálises diferem ligei-ramente entre os resultados, mas demonstram um efeito protetor geral. As evidências mais recentes e abrangentes indicam que o uso desse agente reduz significativamente a positividade no teste de inclinação da mesa e evita a ocorrência de episódios de síncope. Conclusões: Embora as evidências atuais sobre a eficácia da midodrina em relação à prevenção e ao controle da síncope vasovagal sejam limitadas, observa-se um efeito protetor significativo, pois ela diminui o risco de sofrer um episódio sincopal em aproximadamente 50%