Electrocardiogram and CMR to differentiate tachycardia-induced cardiomyopathy from dilated cardiomyopathy in patients admitted for heart failure.

In patients admitted for heart failure (HF) with reduced left ventricular ejection fraction (LVEF) and a concomitant supraventricular tachyarrhythmia (SVT) it is a challenge to predict LVEF recovery and differentiate tachycardia-induced cardiomyopathy (TIC) from dilated cardiomyopathy (DCM). The role of the electrocardiogram (ECG) and cardiac magnetic resonance (CMR) and in this acute setting remains unsettled. Forty-three consecutive patients admitted for HF due to SVT and LVEF < 50% undergoing CMR in the acute phase, were retrospectively included. Those who had LVEF > 50% at follow up were classified as TIC and those with LVEF < 50% were classified as DCM. Clinical, CMR and ECG findings were analyzed to predict LVEF recovery. Twenty-five (58%) patients were classified as TIC. Patients with DCM had wider QRS (121.2 ± 26 vs 97.7 ± 17.35 ms; p = 0.003). On CRM the TIC group presented with higher LVEF (33.4 ± 11 vs 26.9 ± 6.4%; p = 0.019) whereas late gadolinium enhancement (LGE) was more frequent in DCM group (61 vs 16%; p = 0.004). On multivariate analysis, QRS duration ≥ 100 ms (p = 0.027), LVEF < 40% on CMR (p = 0.047) and presence of LGE (p = 0.03) were independent predictors of lack of LVEF recovery. Furthermore, during follow-up (median 60 months) DCM patients were admitted more frequently for HF (44 vs 0%; p < 0.001) than TIC patients. In patients with reduced LVEF admitted for HF due to SVT, QRS ≥ 100 ms, LVEF < 40% and LGE are independently associated with lack of LVEF recovery and worse clinical outcome.

Predictive value of computed tomography scoring systems evolution in adults with cystic fibrosis.

OBJECTIVES: To assess whether the evolution of two consecutive high-resolution computed tomography (HRCT) scores in patients with cystic fibrosis (CF) has prognostic value. METHODS: A longitudinal retrospective study was performed to research adult patients with CF. Two consecutive HRCT studies were scored using Bhalla and Brody II scoring scales by two senior radiologists. Annual scoring changes for each scale were calculated and correlated with annual FEV1% decline, with pulmonary exacerbations and number of antibiotic treatments. RESULTS: We selected sixty-four adult patients. The median interval between the two HRCTs was 3.88 ± 1.59 years. The mean spirometric values showed dynamic lung volumes lower than the general population; globally, there was a worsening of respiratory function over time. The change in the annual HRCT scores was positive on both scales, indicating a worse structural situation over time. The Brody II scale annual change showed a significant statistical correlation with a decline in the annual FEV1%, exacerbations and number of oral antibiotic treatments. In contrast, for the Bhalla scale, the relationship was moderately inverse with exacerbations and with the number of oral treatments. No statistically significant relationships were found for the change in the annual FEV1% and exacerbations or number of antibiotic treatments. The interobservational and intraobservational agreements were very strong in both scales. CONCLUSIONS: The annual evolution of the Brody II HRCT scoring system demonstrated a predictive value and correlated with FEV1% decline, pulmonary exacerbations and oral antibiotic treatments. KEY POINTS: • HRCT evolution has prognostic value in cystic fibrosis. • Temporal evolution for the Brody II score is useful for clinical follow-up. • Brody II score changes correlate with FEV1% decline, pulmonary exacerbations and number of antibiotic treatments.

Changes in structural lung disease in cystic fibrosis children over 4 years as evaluated by high-resolution computed tomography.

OBJECTIVES: To compare the worsening of structural lung disease on high-resolution computed tomography (HRCT) with changes in spirometry results in cystic fibrosis (CF) patients, and analyse factors associated with the worsening of structural lung disease over time. METHODS: A total of 31 CF subjects (mean age 11.03 ± 3.67 years old) were prospectively evaluated by two HRCT and spirometry tests performed 4 years apart. HRCT abnormalities were scored using the Bhalla scoring system. Comparisons between changes on HRCT and spirometry were made for all patients, and also for groups categorized by age, sex, genotypic alterations and lung obstruction. RESULTS: The mean HRCT Bhalla scoring, forced expiratory volume in 1 s (FEV1 %pred.) and forced vital capacity (FVC %pred.) were 7.92 ± 3.59, 87.76 ± 20.52 and 96.54 ± 15.12, respectively. There was a significant deterioration in the Bhalla score (p < 0.01) and in certain categories: severity of bronchiectasis, peribronchial thickening, mucous plugging and bronchial divisions. Females had a more pronounced worsening of the Bhalla score than males (p = 0.048). No change over time was found in FEV1 and FVC. Only sex was associated with a deterioration in HRCT. CONCLUSIONS: HRCT Bhalla scoring changes statistically significantly over 4 years, but spirometry results do not. Worsening on HRCT is more evident in females. KEY POINTS: • HRCT Bhalla scoring changes significantly over 4 years, spirometry results do not. • Females experience faster respiratory deterioration than males. • Spirometry results are not associated with deterioration in HRCT.

Intracoronary thrombus assessment with cardiac computed tomography angiography in a deferred stenting strategy: the MATURE prospective study (MSCT to Assess ThrombUs REsolution).

BACKGROUND: Cardiac computed tomography angiography (CCTA) is precise in noninvasive coronary atherosclerosis characterization but its value in the diagnosis of intracoronary thrombus remains unknown. Therefore, our aim was to evaluate CCTA for intracoronary thrombus and stenosis detection in patients with acute coronary syndromes with high thrombus burden selected for a deferred stenting strategy. METHODS: We systematically performed a CCTA in consecutive patients following a deferred stenting strategy, 24 h before the scheduled repeated coronary angiography including optical coherence tomography (OCT) imaging. Intracoronary thrombus and residual stenosis were blindly and independently evaluated by both techniques. Agreement was determined per lesion using the weighted Kappa ( K ) coefficient and absolute intraclass correlation coefficient (ICC). A stratified analysis according to OCT-detected thrombus burden was also performed. RESULTS: Thirty lesions in 28 consecutive patients were analyzed. Concordance between CCTA and repeated coronary angiography in thrombus detection was good ( K = 0.554; P < 0.001), but both showed poor agreement with OCT. CCTA needed >11.5% thrombus burden on OCT to obtain adequate diagnostic accuracy. The lesions detected by angiography were more frequently classified as red thrombus (76.5 vs. 33.3%; P = 0.087) on OCT. CCTA showed an excellent concordance with coronary angiography in diameter measurement (ICC = 0.85; P < 0.001) and was able to identify all the patients with severe residual stenosis. CONCLUSIONS: Although CCTA showed just a good concordance with angiography in intracoronary thrombus detection, the agreement in residual stenosis was excellent. Thus, in patients with a high-thrombus burden selected for a deferred stenting strategy CCTA may substitute repeat angiography.

Usefulness of Tissue Tracking by Cardiac Magnetic Resonance to Predict Events in Patients With Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HC) is the most common cardiovascular inherited disease, and it is associated with arrhythmic events, heart failure, and death. Strain analysis by tissue tracking (TT) techniques on cardiac magnetic resonance (CMR) is a novel noninvasive diagnostic tool. However, the usefulness of CMR-TT to identify patients with HC at risk of adverse outcomes remains unknown. CMR strain parameters by CMR-TT were prospectively measured in a cohort of 136 consecutive patients with HC. Clinical (death or readmission for heart failure) and arrhythmic (any ventricular tachycardia) events during follow-up were prospectively recorded. Global radial systolic strain rate and global radial diastolic strain rate showed the best area under the receiver operating characteristic curve (ROC curve) to predict adverse clinical events. On Cox multivariate regression models, a global radial systolic strain rate value <1.4/s and a global radial diastolic strain rate value ≥ -1.38/s were independently associated with clinical events at follow-up (adjusted hazard ratio 6.57, 95% confidence interval [CI] 2.01 to 21.49, p = 0.002; adjusted hazard ratio 5.96, 95% CI 1.79 to 19.89, p = 0.004, respectively). Regarding arrhythmic events, global radial peak strain <27% showed the best area under the ROC curve and remained independently associated with ventricular tachycardia after adjustment for confounders (odds ratio 7.33, 95% CI 1.07 to 50.41, p = 0.043). CMR strain parameters by TT predict clinical and arrhythmic events in patients with HC.

Efficacy of short-course colchicine treatment in hospitalized patients with moderate to severe COVID-19 pneumonia and hyperinflammation: a randomized clinical trial.

Some patients with COVID-19 pneumonia develop an associated cytokine storm syndrome that aggravates the pulmonary disease. These patients may benefit of anti-inflammatory treatment. The role of colchicine in hospitalized patients with COVID-19 pneumonia and established hyperinflammation remains unexplored. In a prospective, randomized controlled, observer-blinded endpoint, investigator-initiated trial, 240 hospitalized patients with COVID-19 pneumonia and established hyperinflammation were randomly allocated to receive oral colchicine or not. The primary efficacy outcome measure was a composite of non-invasive mechanical ventilation (CPAP or BiPAP), admission to the intensive care unit, invasive mechanical ventilation requirement or death. The composite primary outcome occurred in 19.3% of the total study population. The composite primary outcome was similar in the two arms (17% in colchicine group vs. 20.8% in the control group; p = 0.533) and the same applied to each of its individual components. Most patients received steroids (98%) and heparin (99%), with similar doses in both groups. In this trial, including adult patients with COVID-19 pneumonia and associated hyperinflammation, no clinical benefit was observed with short-course colchicine treatment beyond standard care regarding the combined outcome measurement of CPAP/BiPAP use, ICU admission, invasive mechanical ventilation or death (Funded by the Community of Madrid, EudraCT Number: 2020-001841-38; 26/04/2020).

Association of CHA2DS2-VASc Score With Remodeling of Left Atrial Appendage Assessed by Cardiac Computed Tomography.

BACKGROUND: CHA2DS2-VASc score (congestive heart failure; hypertension; ages ≥ 74 years (2 points); diabetes; stroke, transient ischemic attack, or systemic embolism (2 points); vascular disease; ages 65 - 74 years; sex (female)) is a widely used clinical scale to estimate the risk of stroke in patients with non-valvular atrial fibrillation (AF). However, the relationship between the increase in CHA2DS2-VASc score and atrial remodeling remains unsettled. METHODS: Twenty-five consecutive patients undergoing cardiac computed tomography (CT) were recruited. The systolic and diastolic volumes of left atrium and left atrial appendage (LAA) were measured. Risk of stroke was estimated using the CHA2DS2-VASc score. The relationship of the CHA2DS2-VASc score with morphological and functional variables was analyzed by Pearson's correlation. RESULTS: A positive correlation was documented between the CHA2DS2-VASc score and systolic (r = 0.419, P = 0.037) and diastolic (r = 0.415, P = 0.039) LAA volumes. Atrial volumes and left atrial ejection fraction showed no significant correlations with CHA2DS2-VASc. CONCLUSIONS: This study shows, for the first time, a positive correlation between CHA2DS2-VASc score and LAA remodeling.

Mid term results after bone marrow laser revascularization for treating refractory angina.

BACKGROUND: To evaluate the midterm results of patients with angina and diffuse coronary artery disease treated with transmyocardial revascularization in combination with autologous stem cell therapy. METHODS: Nineteen patients with diffuse coronary artery disease and medically refractory class III/IV angina were evaluated between June 2007 and December 2009 for sole therapy TMR combined with intramyocardial injection of concentrated stem cells. At the time of surgery, autologous bone marrow (120cc) was aspirated from the iliac crest. A cardiac MRI and an isotopic test were performed before and after the procedure. Follow-up was performed by personal interview. RESULTS: There were no perioperative adverse events including no arrhythmias. Mean number of laser channels was 20 and the mean total number of intramyocardially injected cells per milliliter were: total mononuclear cells(83.6 × 10(6)), CD34+ cells(0.6 × 10(6)), and CD133+ cells(0.34 × 10(6)). At 12 months mean follow-up average angina class was significantly improved (3.4 ± 0.5 vs 1.4 ± 0.6; p = 0.004). In addition, monthly cardiovascular medication usage was significantly decreased (348 ± 118 vs. 201 ± 92; p = 0.001). At six months follow up there was a reduction in the number of cardiac hospital readmissions (2.9 ± 2.3 vs. 0.5 ± 0.8; p < 0.001). MRI showed no alterations regarding LV volumes and a 3% improvement regarding ejection fraction. CONCLUSIONS: The stem cell isolator efficiently concentrated autologous bone marrow derived stem cells while the TMR/stem cell combination delivery device worked uneventfully. An improvement in clinical status was noticed in the midterm follow-up. Images test showed no morphological alterations in the left ventricle after the procedure.

Sex differences in cardiac magnetic resonance features in patients with hypertrophic cardiomyopathy.

Whether sex differences exist in cardiac magnetic resonance (CMR) findings in patients with hypertrophic cardiomyopathy (HCM) remain unknown. We sought to assess and compare CMR characteristics in male and female patients with HCM. From January-2006 to October-2017, 165 consecutive HCM patients evaluated with CMR were included. All clinical and complementary test information was prospectively collected. At the time of CMR evaluation women were older (70 [57-75] vs. 61 [47-72] years, p = 0.02) and more symptomatic in terms of dyspnea (New York Heart Association class II-IV 47.2 vs. 24.1%, p = 0.003) and palpitations (19.6 vs. 4.6%, p = 0.006) and received more frequently treatment with diuretics (49.1% vs. 23.4%, p = 0.001). On echocardiographic examination more women had obstructive physiology (45.1 vs. 20.6%, p = 0.002). On CMR evaluation, women showed smaller left ventricular end-systolic volume index (13 [10-15] vs. 16 [13-21] ml/m2, p < 0.001), higher left ventricular ejection fraction (77 [74-80] vs. 72 [66-78]%, p = 0.004), more marked left ventricular outflow tract acceleration (54.7 vs. 26.4%, p < 0.001) and mitral regurgitation (33.3 vs. 12.7%, p = 0.002). In multivariable analysis, female sex [OR 2.44 (1.04-5.73), p = 0.04] and left ventricular end-systolic volume index [OR 1.60 (1.08-2.38), p = 0.018] were independently associated with obstructive physiology. Women with HCM have more frequently obstructive physiology, a finding that could be related to the smaller left ventricular end-systolic volume.

[Necrotic lipoma of the posterior mediastinum]. / Lipoma infartado del mediastino posterior.

Lipomas are well-differentiated, encapsulated masses composed of adipocytes. Intrathoracic lipomas are rare, but found most commonly in the pleura or anterior mediastinum. Computed tomography shows fatty, homogenous content of the mass and will establish the diagnosis. Areas with a higher fat density are suggestive of liposarcoma. We describe a case of lipoma in the posterior mediastinum that contained solid areas on computed tomography. Histology showed that these areas were fat necrosis.

Helical distribution of hypertrophy in patients with hypertrophic cardiomyopathy: prevalence and clinical implications.

Recently a novel pattern of helical distribution of hypertrophy has been described in patients with hypertrophic cardiomyopathy (HCM). Our aim was to determine its prevalence and potential implications in an unselected cohort. One-hundred- and eight consecutive patients diagnosed with HCM by cardiac magnetic resonance (CMR) were included (median clinical follow up of 1718 days). All clinical and complementary test information was prospectively collected. The presence of a helical pattern was assessed by a simple measurement of the maximal left ventricle (LV) wall thickness (LVWT) for each of the 17 classical LV segments and it was classified in one of three types according to its extension. A helical distribution was detected in 58% of patients, and was associated to a higher incidence of left ventricular outflow tract obstruction (LVOT; 35% vs. 10%; p = 0.005) and systolic anterior motion of the mitral valve (SAM; 30% vs. 13%, p = 0.053). No significant difference in the maximal LVWT was observed. However, the presence of a helical pattern showed a significant association with non sustained ventricular tachycardia (NSVT; 22% vs. 7%; p = 0.029) and was associated to a higher risk of sudden cardiac death (SCD) calculated with the European society of cardiology (ESC) calculator (p = 0.006). Notably, patients with a more extense spiral had a higher incidence of heart failure (75% vs. 34%, p = 0.012) and all-cause death (21 vs. 3%, p = 0.049). A helical pattern is frequent in HCM and can be readily assessed on CMR standard cine sequences. In conclusion, a helical pattern carries negative clinical implications and is associated to a higher estimated risk of SCD.

Atrioventricular Septum Pseudoaneurysm As Late Complication After Repeated Mitral Valve Replacement.

We report the case of a pulsatile mass found in a patient who presented for a routine echocardiogram. The mass turned out to be an exceedingly rare mitral-subannular pseudoaneurysm involving the membranous atrioventricular septum with systolic expansion protruding into right atrium, discovered late after repeated multiple valve replacement surgery. Although these pseudoaneurysms may present asymptomatically, surgical intervention might be indicated because of the risk of rupture. This report describes this rare finding, discusses possible pathophysiological mechanisms, and underscores the importance of multimodality imaging to achieve correct identification and delimitation to guide surgical intervention in such cases.

Early gadolinium enhancement in hypertrophic cardiomyopathy: a potential premature marker of myocardial damage.

Early gadolinium enhancement (EGE), one CMR diagnostic criteria in acute myocarditis, has been related with hyperemia and capillary leakage. The value of EGE in hypertrophic cardiomyopathy (HCM) remains unknown. Our aim was to determine the prevalence of EGE in patients with HCM, and its relation with late gadolinium enhancement (LGE). The association of EGE with morphological and clinical parameters was also evaluated. Sixty consecutive patients with HCM and CMR from our center were included. All the clinical and complementary test information was collected prospectively in our HCM clinic. Left ventricular (LV) measurements were calculated from cine sequences. EGE and LGE were quantified with a dedicated software. Clinical events were collected from medical records. A slow wash-out pattern on EGE was detected in up to 68 % of the patients, being an isolated finding without LGE in 10 (16 %). This cohort showed a greater maximal LV wall thickness (20.1 ± 4 vs. 18.1 ± 3.5 mm, p = 0.010) and asymmetry ratio (1.86 ± 0.42 vs. 1.62 ± 0.46; p = 0.039). The percentage of EGE/slice and the difference with the percentage LGE/slice demonstrated a significant positive correlation with the maximal LV wall thickness (Rho 0.450 and 0.386 respectively). EGE also correlated with number of segments with LVH (LV hypertrophy) and the asymmetry ratio. Neither EGE nor LGE were associated with classical risk factors, the risk score for sudden cardiac death, or with major clinical events. EGE was a frequent finding in HCM, even in absence of LGE. This phenomenon showed a positive correlation with morphological markers of disease burden.

[EFFECTS OF WEIGHT LOSS AFTER BARIATRIC SURGERY ON PULMONARY FUNCTION TESTS AND OBSTRUCTIVE SLEEP APNEA IN MORBIDLY OBESE WOMEN]. / EFECTO DE LA PÉRDIDA DE PESO TRAS LA CIRUGÍA BARIÁTRICA SOBRE LA FUNCIÓN RESPIRATORIA Y EL SÍNDROME DE APNEAS-HIPOPNEAS DEL SUEÑO EN MUJERES CON OBESIDAD MÓRBIDA.

INTRODUCTION: obesity impacts on respiratory function and also it acts as a risk factor for obstructive sleep apnea (OSA). AIMS: to study the effects of bariatric surgery on pulmonary function tests and on OSA in morbidly obese women over 4 years. METHODS: fifteen morbidly obese women (mean body mass index [BMI] 50.52 ± 12.71 kg.m-2, mean age 40.13 ± 10.06 years) underwent pulmonary function tests (PFT) in two opportunities (before and after weight loss surgery). PFT included spirometry, body plethysmography and measure of maximal inspiratory mouth pressure (PImax) and of tension-time index for inspiratory muscles. Also, in both opportunities, resting arterial blood gas tensions were evaluated and a full night sleep register was performed. RESULTS: BMI significantly decreased after bariatric surgery (-44.07 kg.m-2 [CI 95% -38.32 - -49.81]). Also, there was a significantly increase in forced expiratory volume in 1 second (FEV1) (p < 0.01), forced vital capacity (FVC) (p < 0.01), expiratory reserve volume (ERV) (p = 0.040), functional residual capacity (FRC) (p = 0.009) and a decline in airways resistance (Raw) (p = 0.018). Concerning sleep registers, apnea hypopnea index (p = 0.001) and desaturation index (p = 0.001) were also reduced after weight loss. Improve in ERV had a significant correlation with weight loss (r = 0.774, p = 0.024). Conclussions: pulmonary function tests and apnea hypopnea index improve after bariatric surgery in mor bidly obese women. Improvement of ERV is well correlated with weight loss.

Introducción: la obesidad afecta a la función respiratoria e incrementa el riesgo de síndrome de apneas-hipopneas del sueño (SAHS). Objetivo: evaluar el efecto de la cirugía bariátrica, en mujeres con obesidad mórbida, sobre la función respiratoria y sobre el índice de apneas-hipopneas (IAH) tras dos años de seguimiento. Métodos: se incluyeron 15 mujeres (índice de masa corporal [IMC] medio 50,52 ± 12,71 kg.m-2, edad media 40,13 ± 10,06 años). Los enfermos fueron analizados en dos fases: previo a la cirugía bariátrica y tras dos años de la misma. En cada visita se valoraron las medidas antropométricas y se realizaron pruebas de función respiratoria consistentes en espirometría, pletismografía, medida de la presión inspiratoria máxima y del índice de tensión-tiempo de los músculos inspiratorios, así como análisis de gases arteriales. Por último, también se efectuó una poligrafía cardiorrespiratoria durante el sueño. Resultados: tras la cirugía bariátrica el IMC disminuyó en 44,07 kg.m-2 (IC 95% 38,32 ­ 49,81). De igual forma, se observaron incrementos significativos en el volumen espiratorio forzado al primer segundo (FEV1) (p < 0,01), la capacidad vital forzada (FVC) (p < 0,01), el volumen de reserva espiratorio (ERV) (p = 0,040), la capacidad funcional residual (FRC) (p = 0,009) y la resistencia de las vías aéreas (Raw) (p = 0,018). Por otra parte, el IAH (p = 0,001) y el índice de desaturación de oxígeno (p = 0,001) disminuyeron tras la cirugía. Se observó una correlación significativa entre el grado de pérdida de peso y el incremento del ERV (0,774, p = 0,024). Conclusiones: tras dos años desde la cirugía bariátrica se siguen observando mejorías significativas en la función respiratoria y en la gravedad del SAHS. La mejoría del ERV estaría en relación directa con los niveles de peso perdido.

Rapid D-dimer test combined a clinical model for deep vein thrombosis. Validation with ultrasonography and clinical follow-up in 383 patients.

An optimal approach to the diagnosis of deep vein thrombosis (DVT) in lower limbs in the emergency department is still unknown. In this prospective cohort study, we aimed to evaluate the accuracy of the widely available plasma D-dimer test (VIDAS) and establish the usefulness of combining D-dimer testing with a clinical model to reduce the need for serial ultra-sonographies and improve the diagnostic strategy of DVT. We performed a cohort study in 383 consecutive outpatients referred to the emergency department of Hospital La Princesa, with clinical suspicion of DVT. The patients were stratified into three pre-test probability categories using an explicit clinical model (Wells score), and underwent a quantitative automated ELISA D-dimer assay (VIDAS D-Dimer bioMérieux). Patients were managed according to the diagnostic strategy based on clinical probability and compression ultrasonography (CU). Patients for whom DVT was considered a high pre-test probability with negative ultrasonographic findings in the initial CU, returned the following week for repeat ultrasonography. All patients with DVT excluded did not receive anticoagulant therapy, and were followed up for three months to monitor the development of venous thromboembolic complications. DVT was confirmed in 102 patients (26.6%): 95 in the initial test, four in the second test, and three who developed venous thromboembolic complications in the three-month follow-up period. The calculated D-dimer cut-off level was 1 micro g/ml. One hundred patients (98%) with DVT had positive D-dimer. D-dimer had a sensitivity of 98% and a negative predictive value of 98.6%. Among the high-probability patients with positive D-dimer tests and initial negative CU, 9.75% had DVT on repeat CU at one week. The study results suggest that the addition of VIDAS D-dimer to this diagnostic algorithm could improve the management of patients with suspected DVT in daily practice. A diagnostic approach of DVT based on D-dimer (cut-off > or =1 microg/ml) as the first diagnostic tool for the exclusion of DVT, and the clinical probability model as the tool that identifies those patients requiring a second ultrasonography is useful and suitable for daily medical practice.

The upper airway and obstructive sleep apnea in morbidly obese women.

STUDY OBJECTIVES: We are currently carrying out a study on the changes of the upper airway in morbidly obese women and the relationship of the upper airway with the severity of obstructive sleep apnea syndrome (OSAS). This study is similar to the study by Fogel RB et al, which appeared in Sleep 2003;2:150-5. DESIGN: Patients underwent a cardiorespiratory polygraphic sleep study, respiratory function test (spirometry, plethysmography, arterial blood gas analysis), and computed tomographic studies of the upper airway. PATIENTS: Thirteen morbidly obese women being evaluated for weight-reduction surgery. RESULTS: OSAS was present in all the patients. We found a positive correlation between the uvula diameter and age (r = 0.63, P = .02) and a negative correlation between the area of the oropharynx at the end of maximal expiration and the number of desaturations greater than 4% per hour (r = -0.58, P = .03). In the subgroup of patients with severe OSAS (7 cases), the area of the oropharynx at maximal inspiration had a negative correlation with the apnea-hypopnea index (r = -0.78, P = .03). The resistances of the airway positively correlated with apnea-hypopnea index (r = 0.89, P = .003), apnea index (r = 0.90, P = .03), and desaturation index (r = 0.91, P = .02). The Pao2 had a negative correlation with apnea-hypopnea index (r = -0.63, P = .02), apnea index (r = -0.65, P = .02), and desaturation index (r = -0.66, P = .02). CONCLUSIONS: Our results confirm that, in morbid obese women, airway resistance is higher in those patients with OSAS. We propose that airway resistance and Pao2 can also constitute a good predictor of apnea severity and that a reduction in the cross-sectional area of the airway at the level of the nasopharynx could be related to the severity of OSAS.

[Deep venous thrombosis of lower extremities in an Emergency Department. Utility of a clinical diagnosis model]. / Trombosis venosa profunda en miembros inferiores en un servicio de urgencias. Utilidad de un modelo clínico de estratificación de riesgo.

BACKGROUND: Deep vein thrombosis (DVT) is a difficult to diagnostic disease. The aim of this study was to determine the utility and accuracy of a risk stratification questionnaire and a diagnostic strategy, which were applied to patients with suspected DVT on lower extremities in an emergency department. PATIENTS AND METHOD: A prospective cohort study was performed in 569 outpatients with clinical suspected DVT during 14 months. The applied questionnaire stratified patients into three pre-test probability categories. Items included signs, symptoms, risk factors and potential alternative diagnosis, which were based on a modified Wells clinical model. DVT was diagnosed by the combined use of clinical model, compression ultrasonography (CUS) and follow-up CUS one week later in those moderate-high risk patients with an initial normal test. These patients were followed over three months for the development of venous thromboembolic complications. RESULTS: Two hundred three (35.7%) patients were classified as having a low, 186 (32.7%) moderate and 180 (31.6%) high clinical probability. Overall, DVT was diagnosed in 153 patients (26%; CI95%, 23.2-30.7%): 144 (96%) at the initial CUS, 6 (3.5%) at the second testing and 3 over the 3-month follow-up period. 22 patients had a low pretest probability (11%; CI95%, 7-16%), 43 (23%; CI95%, 17-30%) moderate, and 88 (49%; CI95%, 41-56%) high pretest probability. The difference in the prevalence of DVP among risk categories was significant (p < 0.00001). When the high and moderate groups were joined, the model had a 86% sensitivity, a 90% negative predictive value and a 43% specificity for diagnosis of DVT. CONCLUSIONS: The clinical model used in this study is accurate and feasible, though it is not enough to take clinical decisions. The diagnostic strategic used is effective but not efficient.